Chung-Chen Hsu

Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers.

Venous insufficiency is the most common cause of re-exploration in free-tissue transfers to the lower extremity. There is currently no consensus regarding the best approach to recipient vein selection. This study was designed to evaluate whether the type of venous system or the number of recipient veins would impact flap outcomes after microsurgical lower-extremity reconstruction. A retrospective study was conducted in 362 free-tissue transfers for lower-extremity reconstruction between 2003 and 2008. Flap outcomes were evaluated according to the selection of recipient vein system and number of veins. The deep venous system (80.4%) was more frequently selected than the superficial venous system (12.1%) or the combination of both systems (7.5%). In addition, one vein (65.5%) was more commonly used for anastomosis than two veins (34.5%). A total of 26 flaps (7.2%) presented with postoperative venous insufficiency. Male patients, composite defects including bones and the use of bone flaps presented higher rates of venous insufficiency with statistical significance. However, no significant differences were found among the different groups related to the age of patients, co-morbidities, aetiology, location of the defects or timing of reconstruction after trauma. The superficial venous system group was associated with a higher rate of venous insufficiency and partial flap loss compared with the deep venous system group (p = 0.036 and 0.018, respectively). One-vein-anastomosis flaps were associated with statistically significant fewer complete flap failure in comparison with two-vein-anastomosis flaps (p = 0.014). In conclusion, the assessment of recipient vein parameters by surgeons experience is the best predictor of flap outcome in lower-extremity reconstruction. In our cohort of patients, the deep venous system was more reliable than the superficial venous system, but the use of more than one vein for anastomosis did not correlate with better flap outcomes.

The medial sural artery perforator flap: a versatile donor site for hand reconstruction.

BACKGROUND The challenge of modern hand reconstruction goes beyond simple coverage. Thanks to the advances of microsurgery, there are ever-improving standards of functional and esthetic outcomes in hand reconstruction. The versatile donor site of the medial sural artery perforator flap can fulfill this purpose. MATERIALS Between June 2006 and October 2008, we used free medial sural artery perforator flaps for hand reconstruction in 14 cases. The sites of reconstruction included digits (n=7), dorsal hand (n=3), palmar hand (n=2), and wrist (n=2). Associated tendon and nerve defects were found in five patients. The plantaris tendon (n=4), split Achilles tendon (n=1), saphenous nerve (n=1), and sural nerve (n=1) were harvested for reconstructive purpose from the same donor site in this series. RESULTS The proximal perforator of the medial sural artery emerged 8 cm to 13 cm from the midpoint of the popliteal crease, correlating with the axis of the medial sural artery. Twelve flaps were raised with a single perforator. One flap failed because of perioperative vasospasm. The donor defect could be closed without skin grafts when the flap width was <6 cm. CONCLUSION The free medial sural artery perforator flap transfer is appropriate for small- to medium-sized hand defect reconstruction. The donor site not only supplies a thin fasciocutaneous flap but also provides the option to harvest a segment of tendon or nerve graft through the same incision for composite tissue reconstruction in a single stage.

Fingertip replantation without venous anastomosis.

Background Replantation of amputated fingertips is a technical challenge, as many salvage procedures fail because no suitable vein in the fingertip is available for anastomosis. In this study, we examined our experience in fingertip replantation in cases without venous anastomosis with our established fingertip replantation treatment protocol. Methods Between August 2002 and August 2010, a retrospective study examined all patients who had undergone fingertip replantation at Chang-Gung Memorial Hospital. All the patients (n = 24) suffered from complete digital amputations at or distal to the interphalangeal joint of the thumb, or distal to distal interphalangeal joint of the fingers. A total of 30 fingertips that were salvaged by microsurgical anastomosis of the digital arteries but not of digital veins were included in this study. On satisfactory arterial anastomosis, a 2-mm incision was made over the fingertip with a number 11 Scalpel blade, and 0.1 to 0.2 mL heparin (5000 IU/mL) was injected subcutaneously around the incision immediately and once per day thereafter to ensure continuous blood drainage from the replanted fingertip. None of the replanted nail plate was removed, and no medical leeches were used. The perfusion of the replanted digits and patient’s hemoglobin level were closely monitored. The wound bleeding was maintained until physiologic venous outflow was restored. Results Of 30 fingertips, 27 (90%) replanted fingertips survived. The average length needed for maintaining external bleeding by chemical leech was 6.8 days (range, 5–10 days). Twelve patients (including a 2-year-old child) received blood transfusions. The average amount of blood transfusion in the 23 adults was 4.0 units (range, 0–16 units) for each patient or 3.29 units (range, 0–14 units) for each digit. A 2-year-old child received 100 mL blood transfusion or 50 mL for each digit. Conclusions This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.

Immediate Emergency Free Anterolateral Thigh Flap Transfer for the Mutilated Upper Extremity

Background: Immediate emergency free flaps are defined as flaps performed directly following emergency surgery due to the exposure of major reconstructed arteries, major nerves, bones, and tendons. The authors document their experience in using free anterolateral thigh flaps in the immediate reconstruction of complex upper extremity injuries. Methods: From January of 2000 to October of 2006, 12 patients ranging from 10 to 59 years old with complicated upper extremity traumatic injuries were treated with immediate emergency free anterolateral thigh flap transfers. These flaps were performed to cover the exposed vital structures. Flap sizes ranged from 30 × 15 to 8 × 6 cm2. A variety of flap designs were used, including six flow-through flaps for upper limb revascularization and three tensor fasciae latae components for gliding planes of exposed repaired tendons. The operative times ranged from 7.2 to 12.1 hours, with an average operative time of about 9.6 hours. The hospital stay was from 13 to 34 days, with average stay of about 27.7 days. Results: All of the flaps survived. No re-exploration was required. Partial flap necrosis occurred in only one case. Traumatized wound infection occurred in three patients. Conclusions: The anterolateral thigh flap has been popularized as the versatile flap for soft-tissue reconstruction. It has many advantages, including long pedicle length, large skin territory, flow-though and chimeric concept design, a two-team approach, and no need for changing the position. Thus, it is suitable as the immediate emergency flap for upper extremity salvage.

Reply: Algorithmic Approach to Anterolateral Thigh Flaps Lacking Suitable Perforators in Lower Extremity Reconstruction.

Leila Harhaus, M.D. Fig. 1. An extended skin defect in a patient suffering from a fourth-degree burn of the dorsum of the hand requires a large, thin, fasciocutaneous flap for soft-tissue reconstruction and coverage of the exposed extensor tendons. the only relevant perforator of the anterolateral thigh flap (*) is located distally and is of small caliber. It would not have been sufficient for perfusion of the whole 26 × 12-cm flap. to harvest the thin, pliable anterolateral thigh flap with reliable perfusion, one perforator, which pierced the tensor fasciae latae muscle (#), is dissected (above). (Below) the in-flap anastomosis (°) is performed between the tensor fasciae latae perforator and the descending branch (+) distal to the anterolateral thigh perforator (ethilon 10-0; ethicon, Inc., somerville, N.J.) (above and below). the distal portion of the anterolateral thigh, which was significantly thinner, was essential for adequate, nonbulky soft-tissue coverage including the fascia in this case. the entire flap was well perfused after anastomosis, and the further clinical course was uneventful. ulrich kneser, M.D. Department of Hand, Plastic, and Reconstructive Surgery Burn Center University of Heidelberg BG Trauma Center Ludwigshafen Ludwigshafen, Germany

The distally based, venous supercharged anterolateral thigh flap

The distally‐based anterolateral thigh flap is an attractive option for proximal leg and knee coverage but venous congestion is common. Restoration of antegrade venous drainage via great saphenous vein supercharge to the proximal flap vein is proposed. The purpose of this study was to evaluate and compare outcomes of 18 large, distally‐based anterolateral thigh flaps with and without venous augmentation on the basis of flap size, venous congestion, and clinical course. The average age of 12 men and 6 women was 35.9‐year old (range, 16–50 years old). Wounds resulting from trauma, burn sequela, sarcoma, and infection were localized to the knee, proximal leg, knee stump and popliteal fossa. The mean defect was 17.6 × 9.4 cm2 (range, 6 × 7 cm2 to 22 × 20 cm2). The mean flap size was 21.4 × 8.8 cm2 (range, 12 × 6 to 27 × 12 cm2). There were 14 cases in the venous supercharged group and 4 cases in the group without supercharge. The mean size of flaps in the venous supercharged group was significantly larger than that in the group without supercharge (22.6 ± 3.8 × 9.1 ± 1.7 cm vs. 17.5 ± 4.4 × 7.8 ± 1.7 cm, P = 0.03). Venous congestion occurred in all four flaps without supercharge that lasted 3–7 days and partial flap loss occurred in two cases. There was no early venous congestion and partial flap loss in supercharged flaps but venous congestion secondary to anastomotic occlusion developed in two cases. Early exploration with vein grafting resolved venous congestion in one case. Late exploration in the other resulted in flap loss. Preventive venous supercharge is suggested for the large, distally‐based anterolateral thigh flap.

Secondary reconstructive surgery following major upper extremity replantation.

Background: Little literature currently exists on reconstructive strategies following successful upper extremity replantation. The authors hypothesized that the type of secondary surgery would vary predictably depending on mechanism and amputation level. Methods: The authors performed a retrospective review of upper extremity replantations performed at their institution between 2003 and 2012. The mean follow-up period was 3 years. Patient, injury, and surgical demographics, as well as replantation survival rates and secondary surgical procedures, were recorded. Results: Forty-five upper extremity replantations met inclusion criteria and the survival rate was 89 percent (n = 40). In 40 cases of successful replantation, the average number of secondary surgical procedures was three per patient (range, zero to seven). The most common reconstructive procedures were soft-tissue coverage (n = 24), tenolysis (n = 24), free functioning muscle transfer (n = 18), and tendon transfer (n = 14). For upper arm replantations, soft-tissue coverage was the most common secondary surgery; free functioning muscle transfer was the most common for amputations between the elbow and mid-forearm; tenolysis was the most common secondary procedure performed for amputations of the distal forearm to wrist. Conclusions: Proximal-level amputations commonly required soft-tissue coverage. Amputations through the proximal forearm and elbow often underwent free functioning muscle transfer, and tenolysis was the most common secondary surgery following distal forearm and wrist amputations. Secondary surgery could be predicted based on the anatomic levels of injury.

Primary free functioning muscle transfer for fingers with accompanying tendon transfer for thumb provide one-stage upper extremity composite reconstruction in acute open wound.

BACKGROUND: Upper limb trauma may present as both soft tissue and muscle defects necessitating a free skin flap to effect a repair. The limbs core (basic) functionality can be returned with a secondary tendon transfer or a functioning muscle transfer. A functioning muscle flap can provide for soft tissue repair and functional restoration in a single procedure, but the success of such procedures requires further clarification. MATERIAL: From 1997 to 2006, nine patients underwent free functioning muscle transfer performed for upper extremity composite structure and functional defects, including four flexor digitorum profundus muscle and three extensor digitorum comminis muscle defects. Seven thumb tendon defects were managed with simultaneous tendon and free functioning muscle transfer. In addition, two opponensplasties and one thumb basal joint arthrodesis were performed for thumb function revision. RESULT: In all nine patients, procedures were completed without complications, the flaps surviving, enabling the patients to achieve opposable hand function. The muscle strength accomplished M4.2 (M3–5). The grip power was 41.7, and pinch power 55.3%, when compared with the other hand. CONCLUSION: Primary functioning muscle transfer can provide a one-stage composite functional restoration in an open wound. The thumb can be reconstructed with tendon transfer followed by opponensplasty to achieve a satisfactory range of opposable function.

Vascularised toe proximal interphalangeal joint transfer in posttraumatic finger joint reconstruction: The effect of skin paddle design on extensor lag *

UNLABELLED Vascularised joint transfer (VJT) from the toe proximal interphalangeal joint (PIPJ) has been criticised for providing a limited range of motion (ROM) and significant extensor lag in reconstructed digits. The original technique includes the dorsal skin of toe PIPJ as a marker of joint viability, while a modified technique uses the skin flap of the great toe and the dorsal foot. This systematic review aimed to assess vascularised toe-to-finger PIPJ transfers with respect to functional outcomes, and in particular, whether a modified skin paddle design can improve extensor lag. METHODS A MEDLINE search was performed. Studies were included if they present five or more vascularised toe-to-finger PIPJ transfers for posttraumatic reconstruction, and with the functional outcome data available. RESULTS Seven studies including 92 VJTs met the inclusion criteria. The overall survival rate was 93.5%. Among the successful 86 VJTs, mean single-joint ROM was 37.4 ± 21.1°, with a mean extension lag of 31.8 ± 18.8° and a mean flexion of 69.2 ± 22.8°. The traditional group with the skin paddle taken from the dorsum of the toe PIPJ had a statistically significantly greater extensor lag than the modified group with the skin paddle harvested from the great toe and dorsal foot (37.8° vs. 17.1°, p < 0.001). The secondary variable of interest was age of the patient at time of transfer (children vs. adults). There was no significant difference in ROM between younger (≤16 years) and older patients (>16 years). CONCLUSIONS This systematic review suggests that extensor lag may be improved by using the modified skin paddle design by harvesting it from the great toe and the dorsal foot. This effect may be mediated by the preservation of the native extensor tendon apparatus in the finger.

Heterotopic Vascularized Joint Transfer in Mutilating Hand Injuries.

BackgroundIn cases of mutilating hand injuries, the primary goal is recovery of prehensile function. This is particularly true in the case of joints, which are extremely difficult to replace or reconstruct adequately when damaged. Heterotopic vascularized joint transfer is indicated when salvageable joints are available for transfer to a more functionally optimal position on the hand. Materials and MethodsSeven cases of mutilating hand injuries treated with heterotopic vascularized joint transfers from 2003 to 2012 were retrospectively identified. All patients sustained severe metacarpophalangeal joint (MPJ) or proximal interphalangeal joint (PIPJ) damage that threatened recovery of optimal hand function. All patients were men, with an average age of 34.7 years. Operative, perioperative, and postoperative details including final active range of motion were collected and analyzed. ResultsSeven joints were taken from nonsalvageable amputated digits: 4 from the amputated parts, and 3 from the proximal stumps. Five joints were transferred as free flaps requiring microvascular anastomosis, and 2 were transferred on neurovascular pedicles. One joint was lost due to vasospasm. Average active range of motion was 68.3° for homojoint transfers (MPJ to MPJ, PIPJ to PIPJ), and 35° for heterojoint transfers. All but 1 patient were able to achieve tripod pinch; the remaining patient achieved only side-to-side pinch. ConclusionsHeterotopic vascularized joint transfer is a useful technique to consider in cases of mutilating hand injuries. Improved recovery of prehensile function can be achieved with thoughtful design and execution, followed by proper patient education and rehabilitation.