Darrell Brooks

Arterialized venous flaps: A review of the literature

The arterialized venous flaps are highly regarded in microsurgical and reconstructive surgeries based on advantages of ease of design and harvest without the need to perform deep dissection, no sacrifice of a major artery at the donor site, no limitation of the donor sites, and less donor‐site morbidity. Many experimental investigations and clinical applications have been reported. However, their survivals are still inconsistent, and survival mechanisms remain controversial. In this review, we update the existing problems, experimental studies for survival mechanisms, clinical practices, and methods developed to improve their survivals.

Use of the venous flap for salvage of difficult ring avulsion injuries

Ring avulsion can lead to soft tissue compromise resulting in eventual digit failure or restriction of motion. The authors present use of the venous flow through flap for simultaneous soft tissue and digital vessel reconstruction in severe ring avulsion injury. A retrospective review of ring avulsion injuries treated with transplantation of an arterialized (A‐V‐A) venous flap between 1999 and 2006 was conducted. Indications included digits which were debrided and required soft tissue and digital artery reconstruction. Eight venous flaps were transplanted for 3 Urbaniak class II and 5 Urbaniak class III ring avulsions. Average size of the venous flap was 6 cm2. All flaps and digits survived without partial necrosis. The soft tissue envelope was supple in all cases. Total active motion (TAM) ranged from 160 to 210°. The arterialized venous flow‐through flap is a reliable solution for the complex ring avulsion injury which requires simultaneous soft tissue and digital vessel reconstruction.

Management of exposed total knee prostheses with microvascular tissue transfer

Introduction: Exposure of a knee endoprosthesis represents a limb‐threatening condition, requiring long‐term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three‐dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re‐sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. Methods: We treated 11 complex wounds with exposed total knee arthroplasty prostheses with free tissue transfer. Three of 11 patients had failed previous local muscular rotation flap coverage. Five latissimus dorsi muscle flaps and 6 rectus abdominis muscle flaps were used in our series. Wounds were closed after aggressive surgical debridement, antibiotic irrigation, and intravenous antibiosis. Results: Eleven of 11 free flaps were successful (100%), and we achieved limb salvage in 11/11 limbs (100%) and prosthesis salvage in 10/11 knees (91%), with one prosthesis removed at an outside facility followed by knee arthrodesis. Conclusion: The advantages of microvascular tissue transfer are well suited to the treatment of exposed knee endoprostheses. The reliable rectus and latissimus flaps provide robust local perfusion to the wound, fill complex three‐dimensional contour defects around knee implants, and lead to a high rate of salvage of both limbs and prostheses.

Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience.

Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin–twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss.

Partial muscle harvest: Our first 100 cases attempting to preserve form and function at the donor site†

The authors report their first 100 partial muscle flaps as a strategy to preserve form and function of the donor site in muscle transplantation. Between 2003 and 2007, 62 partial superior latissimus (PSL) flaps and 38 partial medial rectus (PMR) flaps were transplanted for head and neck, upper and lower extremity, and chest wall reconstruction. All flaps survived. There were hematomas at the donor sites in two PMR cases. Form and function were preserved at the donor site in all cases. The PSL provided comparable muscle volume and pedicle length to the entire rectus abdominis muscle. An additional benefit was its use as a functional muscle. The PMR flap provided comparable muscle volume to the gracilis muscle. An additional benefit was a much longer vascular pedicle. Small to moderate sized flaps can be harvested from the fabric of the latissimus dorsi and rectus abdomenis muscles and be reliably transplanted. When positioned at the superior edge of the latissimus or medial edge of the rectus muscle, adequate blood flow and innervation to the residual muscle result in preservation of form and function at the donor site. The benefits of muscle transplantation can be realized without the associated morbidity of muscle harvest.

Index finger salvage with replantation and revascularization: Revisiting conventional wisdom

Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty‐eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty‐three replants/revascularizations survived (100%). Total active motion was 170° in zone 1, and 133° for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided.

Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

We report a case of a 24‐year‐old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6‐months follow‐up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.

Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle.

Limb salvage techniques of traumatized extremities using free‐tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6–28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and returned to independent ambulation. When performing free tissue transfer about the ankle, temporary spanning with a circular fixator is effective in preventing equinus deformity and provides a stable mechanical construct protecting the flap.

Creation of a four-joint-digit after second toe to digit transplantation: Restoration of form and function†

The authors describe the non‐orthotopic insertion of an Ascension two‐piece pyrocarbon proximal interphalangeal joint at the osteosynthesis level of bilateral toe‐to‐digit transplantations in an attempt to restore both anatomic length and composite fist formation after traumatic multidigit loss. The non‐orthotopic joints provided an additional 30 and 35 degrees of stable flexion to the reconstructed index and longs digits enabling the patient to form a composite fist. There was no evidence of joint instability or loosening. Total active motion was 240 and 235 degrees at the index and long fingers, respectively. Creation of two four joint fingers by the addition of non‐orthotopic joints in toe‐to‐digit reconstructions successfully restored form and function after multidigit loss.