Jiun-Ting Yeh

Free Functioning Muscle Transfer for Lower Extremity Posttraumatic Composite Structure and Functional Defect

Background: Traumatized lower extremities may present not only composite soft-tissue defects but also flexor and/or extensor loss. Free functioning muscle transfer can provide composite structural and functional restoration. Methods: From 1996 to 2004, 19 patients with lower extremity injuries whose lesions exhibited composite soft-tissue damage, with or without bone defects, and certain accompanying functional disabilities were allocated to study groups on the basis of impression, as follows: group I, open fracture IIIB (n = 10); group II, neglected compartment syndromes [open IIIB (n = 4) and open IIIC (n = 1)]; and group III, crush injuries (n = 4). Free flap resurfacing was indicated for these lesions. Fifteen patients underwent free functioning muscle transfer; source muscles were the rectus femoris (n = 3), rectus femoris with anterolateral thigh flap (n = 5), and gracilis (for ankle dorsiflexion) (n = 7). Two patients underwent composite rectus femoris and vascular iliac crest for ankle dorsiflexion and segmental tibial defect reconstruction. Two received rectus femoris muscle and anterolateral thigh flaps for posterior compartment defect and quadriceps defect reconstruction, individually. Results: Two patients required reexploration; salvage was successful in only one, with below-knee amputation necessary in the other. Skin grafts were needed for partial skin paddle necrosis (n = 3) or remaining skin defect (n = 2). Functioning muscle reinnervation failed in four cases, with one individual undergoing ankle fusion, two people electing ambulation with stiff ankles, and one person using an orthosis. In the sample population, range of motion varied and was related to the severity of injury and the extent of skin grafting on the distal musculotendinous portion. Less function was exhibited in the compartment syndrome group (group II). Conclusion: Functioning muscle transfer can be performed posttraumatically in lower limbs with composite soft-tissue and motor-unit defects, resulting in acceptable functional results and reliable limb salvage.

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.

Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects : An evaluation of functional outcomes

Background: Peripheral nerve injuries in the upper extremity often require interposition of sural nerve grafts for reconstruction. Due to the poor donor-site appearance with standard techniques, and the potential for trauma to the nerve because of poor visualization during the harvest when the stepladder technique is used, the endoscope has been employed for nerve harvest. Methods: From January of 1997 until December of 2003, 15 patients with an average age of 27.5 years with posttraumatic upper limb nerve defects of the ulnar, median, or posterior interosseous nerves (crush, cutting, or avulsion injuries) underwent reconstruction with endoscopically harvested sural nerve. The nerves were harvested using atraumatic techniques under video monitor visualization. The functional results of sensation and motor function were assessed using British Medical Research Council scales. Results: All patients regained at least cutaneous pain and tactile sensibility, with most regaining two-point discrimination (nine patients achieved S3+). Two patients achieved complete recovery (S4). The 11 patients with motor nerve involvement achieved between M1+ and M5 after the initial reconstruction. Eight patients required a total of one immediate and nine secondary procedures to achieve the final outcome. The procedures included tenolysis (three patients), intrinsic tendon transfers (four patients), and opponensplasty (three patients). At the 4-year mean follow-up, grip power was M5 in 13 patients (86.7 percent) and M4 in two patients (13.3 percent). Conclusions: Upper extremity sensory and motor nerve defects can be reconstructed with interposition of endoscopically harvested sural nerve grafts. The procedure is reliable, quick, and atraumatic, and results in reasonable motor and sensory recovery.

Shunt-Restricted Arterialized Venous Flaps Mimicking Arterial Flaps in Microcirculation: Observations in Sprague-Dawley Rats

Introduction: An arterialized venous flap is not a physiologic flap which is nourished through arterial system. Several surgical techniques have been reported to improve the flap survival, but venous congestion and inadequate peripheral perfusion were frequently encountered which limited the generalization of flap. Suzuki ligated the arterialized central vein of the rabbit ear to investigate the influence of the competent ”valve”. They did not extrapolate the mechanism of flap survival. Aim and objectives: Our hypothesis is interruption of the flow-through arterialized vein not only makes the arterial flow circumventing the clamp to perfuse the peripheral area but also decreases venous pressure for better drainage. In this study, we conducted a rat experiment to compare the microcirculation of abdominal adipofascial arterialized venous flaps with and without restriction of the arterialized vein. Materials and methods: Six male Sprague-Dawley rats were used for microcirculation observation. Each adipofascial flap based on left thoracoepigastric vascular system was prepared and observed following the sequence of arterial flap, shunt-restricted arterialized venous flap, and flow-through arterialized venous flap. Microcirculation was observed and recorded under vital microscope with a 100X-magnification, which is composed of a Nikon microscope MM-22 and a Sony Trinitron video monitor. Results: In the flow-through arterialized venous flap, the flow in the flap was slowly to-and-fro in both arterioles and venules without a dominant direction. In the shunt-restricted arterialized venous flaps: at the proximal flap, the flow in the smaller vessels was constant and slow and the flow in the trunk vessels ran swiftly and stopped intermittently towards the periphery of the flap; at the middle flap, the flow moved slowly and constantly from proximal toward distal flap in both arterioles and venules; at the distal flap, the directions of the flow within the arterial and venous networks were similar to the flow observed in an arterial flap. Conclusion: In rat abdominal adipofascial arterialized venous flap model, we observed the interruption of arteriovenous shunting not only made the blood flow circumventing the ligated site to nourish distal part of flap, but also made the flow of arterial and venous system of the arterialized venous flap directionally moving from proximal toward distal part of flap.

Treatment of a High-Flow Facial and Mandibular Arteriovenous Malformation by Direct Transosseous Puncture-A Case Report

Extensive high-flow facial and mandibular arteriovenous malformation (AVM) is a potentially life-threatening vascular pathology. We report a case of right facial, scalp and mandibular high-flow AVM in a 16 years-old male. He was treated successfully by direct transosseous embolization with platinum coils following insufficient transarterial embolization. There has been no clinical or radiographic relapse for a follow-up period of 16 months. Transosseous embolization may be utilized to prevent extensive bleeding from high-flow AVM in the head and neck region following any surgical procedure on or near the vicinity of these lesions.

Traumatized Index Finger Ray Pollicization Accompanied with Various Reconstructive Procedures for Post-traumatic Thumb Loss Proximal to Metacarpophalangeal Joint

Purpose: In the situation of thumb amputations proximal to metacarpophalangeal joints or extensive composite first ray defect, toe transfer may has the limitation of adequate functional length reconstruction Pollicization will be an alternative. Materials and Methods: Seven patients underwent index finger pollicization for their thumb loss proximal to the metacarpophalangeal joint level. While three were reconstructed at chronic stage (7, 13, 15 months) after previous primary surgeries with inadequate basic hand functional restoration, four patient received pollicization at acute stage (within 1 week). Several tendon transfers including opponensplasty, intrincis tendon reconstruction were performed simultaneously. Four free flaps (3 anterolateral thigh flaps, 1 fibular flap) were transferred in acute reconstruction, and 2 local flaps and 1 groin flap in chronic stage reconstruction. Thee of four acute reconstruction require index finger revascularization during pollicization. Results: One revascularized index ray failed and was lost. The other six patients achieved a basic hand functional reconstruction and have adequate opposition as Kapandji categories 5-8, abduction angle 58.3 degrees (40-80), and circumduction angle 103.3 degrees (90-110) to allow prehensile integration between the neo-thumb and 2-5th fingers. The tripod pinch was around 20% of the contralateral hand. Conclusion: With the application of microsurgical technique and tendon transfers, pollicization using a traumatized and functional impaired index finger is a good alternative option for thumb loss proximal to MPJ, especially in the situation when toe-to-thumb transfer can not provide an adequate functional restoration.

High Pressure Injury of the Hand: An Emergent Condition

Purpose: High-pressure injection injury has wide extent of injury although it initially presents with a small and harmless puncture of the finger or the hand. This study is to emphasize that prompt treatment is important to avoid mutilating and function-threatening complications. Materials and Methods: During the past 8 years (from January 1997 to January 2005), 15 patients suffered from high-pressure injection injury and obtained soft tissue defect after debridement. Results: Four cases were treated with amputation within nine days after injury. Three cases received cross finger flap or V-Y advancement flap to cover the finger tip defect and one case was treated by free flap for the extensive defect of the dorsal hand. Three cases received tendon reconstruction surgery. Conclusions: Ignoring high-pressure injection injury may result in gangrene and amputation of affected fingers. Recognition of the injury with adequate treatment is crucial for successful outcome. (J Plast Surg Asso R.O.C. 2006; 15:251~258)

Life-Threatening Intratumor Hemorrhage in Plexiform Neurofibroma: A Case Report and Literatures Review

Plexiform neurofibromas is a common feature of neurofibromatosis 1 (NF1). This benign soft tissue tumor can cause different kinds of complications, depend on their size and location. Some of the complications demand prompt and aggressive surgical intervention, such as massive intratumor hemorrhage, which is potentially life-threatening if not treated adequately and can result in hypovolemic shock or compression of vital structures. We report a case of trunk plexiform neurofibromas with spontaneous massive intratumor hemorrhage, which could not be controlled under conservative management and resulted in chest wall compression, respiratory insufficiency as well as hypovolemic shock 18 hours after the episode. Urgent surgical intervention was performed and totally 6,000 ml blood clot and hematoma were evacuated from the tumor. He received angiography and selective embolization as an adjuvant therapy for further hemostasis. A huge skin defect developed over the fragile and myxomatous tumor-tissue secondary to ischemic change, which was successfully treated by vacuum-assisted wound closure system (VAC) followed by skin graft. The patient was doing well at 1-year follow-up.

Endoscopically Assisted Removal of Frontal Hardware and Sequestrum

Osteosynthesis using plates and screws in treatment of craniofacial disorder is well established. The implant may then be regarded as a foreign body once its role is completed. Potential complications such as infection, delay union, as well as palpable plates or screws may follow after insertion of the hardware. The inherent properties of magnification and illumination of endoscope provide an ideal environment for removal of forehead hardware and sequestrum when causing symptoms. A consecutive 9 patients (5 male and 4 female including 4 children)received the endoscopically assisted procedure for removal of frontal hardware (8) and sequestrum (1). The average of time interval between initial reconstructive surgery and secondary endoscopic procedure was 9.8 months. All patients had smooth course of removal of the hardware and sequestrum without conversion to traditional open methods. Complications were not seen during the period of follow-up. The patients and their families were happy with their forehead contour and cosmetic results. The endoscope assisted method allows magnified vision, avoidance of neurovascular bundles injury, minimal tissue disturbance, and better convalescence. It provides a good alternative method for removal of hardware and sequestrum in the frontal region.

Release of Finger Flexion Contracture with a Glabrous Free Tissue Transfer

Flexion contracture of a finger is an inconvenient morbidity, which may interfere the function of other digits in a hand and occasionally induce joint pain in some strict cases. When the contracture is severe with shortage of skin, the scar cannot be lengthened with z-plasties alone, and there is no available local flap for covering the exposed tendon and neurovascular bundles, flaps from toe and medial plantar foot were introduced for reconstruction. Two cases were reported in this article. Indications for the hemipulp flap and the medialis pedis flap transfers are elaborated. Both flaps provide a glabrous skin, which is characterized as durability, stability and sensibility. The flap dimensions are appropriate for finger reconstruction after release of contracture. For fingers with fingertip involvement in flexion contracture, a hemipulp tissue transfer will be the best option. For those without a fingertip involvement, a medialis pedis flap can suffice the requirement of durability, stability and sensibility of a finger reconstruction.