Markus V. Küntscher

the Concept of Fillet Flaps: Classification, Indications, and Analysis of Their Clinical Value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the “spare parts” concept. By definition, fillet flaps are axial‐pattern flaps that can function as composite‐tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects. From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps). Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytrens contracture, and two with high‐voltage electrical injuries). Thirty‐six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above‐knee or below‐knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet‐of‐thigh or entire‐limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper‐arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet‐of‐sole flap. In another case, wound infection required revision and above‐knee amputation with removal of the flap. Nine free plantar fillet flaps were performed—five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper‐arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one aboveknee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery. Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients. On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor‐site morbidity and facilitate stump‐length preservation or limb salvage. (Plast. Reconstr. Surg. 108: 885, 2001.)

Suprathel, a New Skin Substitute, in the Management of Partial-thickness Burn Wounds: Results of a Clinical Study

Objective:A prospective, randomized, bicentric, nonblinded, clinical study was conducted to evaluate the impact on wound healing of Suprathel in partial-thickness burn injuries. Suprathel represents an absorbable, synthetic wound dressing with properties of natural epithelium. Methods:Thirty patients suffering from second-degree burn injuries were included in the study, with a mean of age 40.4 years old. Burn injuries were randomly selected, partly treated with Omiderm and partly treated with Suprathel. The first gauze change was applied the fifth day postoperatively, followed by regular wound inspection until complete reepithelization. The study focused on patient pain score, healing time, analysis of wound bed, ease of care, and treatment costs. Results:There was no significant difference between the 2 materials tested regarding healing time and reepithelization. There was a significant lower pain score for patients treated with Suprathel (P = 0.0072). Suprathel becomes transparent when applied, thus allowing close monitoring of wound healing. In contrast to Omiderm, Suprathel shows better attachment and adherence to wounds. During the course of healing, it detaches smoothly, without damaging the reepithelized wound surface. Moreover, it reduces the frequency of dressing changes required. Ease of care of Suprathel has been rated outstanding by patients and healthcare professionals. When interviewed, patients reported Suprathel as their treatment preference. As dressing material, Omiderm is more cost-effective than Suprathel. Conclusion:Suprathel represents a reliable epidermal skin substitute, with a good impact on wound healing and pain reduction in partial-thickness burn injuries. Although it is less cost-effective than Omiderm, the significant increase of patient comfort makes this material represent a reliable and solid treatment alternative when dealing with partial-thickness burn injuries. Further studies with this synthetic dressing on other types of wounds are warranted.

Sprayed Cultured Epithelial Autografts for Deep Dermal Burns of the Face and Neck

The objective of this study was the assessment of clinical results after sprayed application of cultured epithelial autograft (CEA) suspensions onto deep dermal burn wounds of the face and neck. Nineteen patients with deep dermal burns of the face and neck were included into a prospective study. The average total body surface area burn was 15.1% (7%–46%; median: 13%). The average Abbreviated Burn Severity Index (ABSI) was 6.7 points (4–12 points; median: 7 points). The application of sprayed CEA suspension was performed onto an average body surface area of 2% (0.5–5%; median: 2%). Thirteen patients were recruited for clinical follow-up after an average of 10 months (3–18 months). The average Vancouver Scar Scale score at follow-up was 2.4 ± 2.2 points (range, 0–8 points), and the average Donnersmarck and Hörbrand score was 9.3 ± 6.8 points (range, 0–22). Four patients had less than 9 months’ follow-up. Excluding these patients from the analysis resulted in an average Vancouver Scar Scale score of 1.3 ± 0.9 points (range, 0–3 points) and an average Donnersmarck and Hörbrand score of 8.0 ± 7.4 points (range 0–22) for the remaining 9 patients. Our data show that enzymatic and careful surgical debridement and consecutive application of CEA suspensions using a spray technique results in excellent cosmetic outcomes compared with any other method.

Transcardiopulmonary vs Pulmonary Arterial Thermodilution Methods for Hemodynamic Monitoring of Burned Patients.

The objective of this study was to validate a new method of transcardiopulmonary thermodilution for assessment of cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI) and additional parameters such as intrathoracic blood volume index and extravascular lung water index (EVLWI) by comparison with conventional pulmonary artery catheter values in a severely burned population. The pulmonary artery measurements were performed continuously with the Vigilance system, and the transcardiopulmonary thermodilution with the PiCCO(R) system. One hundred thirteen measurements with each system on up to six consecutive days were taken in 14 severely burned patients (average TBSA, 49.6%; average ABSI, 10.3), aged 21 to 61 years (mean, 42.2 years) and compared intraindividually. An excellent correlation between the two methods was shown for CI (r = 0.80) and its derived parameters SVI and SVRI in states of low to normal cardiac output. The correlation was poor for cardiac indices greater then 5.5 up to their maximum values (r = 0.46). No correlation between index of oxygenation (PaO2/FiO2) vs EVLW I was observed. There was no difference between survivors and nonsurvivors, and between patients with and without inhalation injury in EVLWI. The method of transcardiopulmonary thermodilution is suitable to assess SVI, CI and SVRI under the special pathophysiologic condition of a major burn for low to normal cardiac output states. It is less reliable when cardiac output is high. The lower cost and less invasive nature are the advantages of the system compared with use of the pulmonary artery catheter. The role of intrathoracic blood volume index and EVLWI in cardiopulmonary monitoring of severely burned patients remains to be further determined.

Late remote ischemic preconditioning in rat muscle and adipocutaneous flap models

The purpose of this study was to determine whether remote ischemic preconditioning can be induced by a late mechanism. The rat cremaster flap model was used for assessment of ischemia–reperfusion injury. In the control group (N = 9), 2 hours of flap ischemia was induced after preparation of the cremaster muscle. Ten minutes of ischemia of the contralateral hind limb was induced 24 hours before flap ischemia in the late remote ischemic preconditioning group (LRIP) (N = 8). In vivo microscopy was performed after 1 hour of flap reperfusion in each animal. The epigastric adipocutaneous flap model was used for the second part of the experiment. Three hours of flap ischemia was induced in the control group (N = 8). A similar late remote ischemic preconditioning protocol as in the LRIP group was used for the second late remote ischemic preconditioning group (N = 8). A significantly higher muscle red blood cell velocity in the capillaries, first-order arterioles, and venules, and a higher capillary flow as well as a decreased number of “stickers” were observed in the late remote ischemic preconditioning group compared with the first control group (p < 0.05). Average flap necrotic area was not significantly different within the second control group and the second late remote ischemic preconditioning group in the adipocutaneous flaps. These data show that late remote ischemic preconditioning attenuates ischemia–reperfusion injury in muscle flaps, whereas it is ineffective in adipocutaneous flaps.

Measures to prevent complications of distally based neurovascular sural flaps.

Several publications in recent years have proven unbroken popularity of superficial sural artery flaps for the coverage of defects of the lower leg and proximal foot. However, complications are being discussed rarely. The realistic complication rate is up to 59%, given corresponding comorbidities, risk factors, or performance errors. Twelve distally based neurovascular sural flaps were used for reconstruction of heel, ankle, and lower-leg defects between 2003 and 2005. The following pre- and postoperative procedures were performed as a routine: An additional arteriography was done preoperatively to prove the patency of the peroneal artery. Acoustic Doppler ultrasound was used to identify the lesser saphenous vein and the concomitant vessels (perforators of the peroneal artery) of the sural nerve. An enlarged skin paddle with a tail of skin over the pedicle at the point of rotation was harvested intraoperatively to take pressure off the vessels and facilitate primary closure. Postoperatively, external fixation provides strict immobilization of the affected leg. Following these measures, no flap loss was observed in the presented series, and only few minor complications occurred.

Transcardiopulmonary thermal dye versus single thermodilution methods for assessment of intrathoracic blood volume and extravascular lung water in major burn resuscitation

The purpose of this study was to compare the approximated values for intrathoracic blood volume (ITBV) and extravascular lung water (EVLW) obtained from a single indicator dilution to the exact data measured by double-indicator dilution. Eighteen patients with an average TBSA of 46.3% (range, 26 to 67%) and an average abbreviated burn severity index of 8.7 (range, 7 to 11) were included into a intraindividual comparative prospective study over a 20-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain both the exact measurements, as well as the estimated values for ITBV and EVLW. Two hundred ninety intraindividually comparative measurements were performed during the first 4 days after the burn injury. A good correlation between both techniques was shown for ITBVI (0.77; P <.01) for the overall measurements. However, the overall bias demonstrated a standard deviation higher than the mean value (-87.4 +/- 136 ml/m2), and precision for the estimated values for ITBVI was poor (-491 to 783 ml/m2). Additional analyses demonstrated a poor but significant correlation for low states of ITBV (r =.37; P <.01), but no significant correlations were found between the techniques for normal and high ITBV states. Thus, the approximated ITBV obtained from single thermodilution should not be used to guide volume therapy in major burn resuscitation. Furthermore, the EVLW is neither suitable for diagnostic use nor for therapeutic decisions because it is calculated on the basis of the poorly estimated values for ITBV in single thermodilution. Transcardiopulmonary single thermodilution is not suitable to assess intrathoracic blood volume and extravascular lung water in burn shock. However, the method is suitable to assess cardiac output and its derived parameters in burn resuscitation as shown in previous studies. It still must be proven whether the exactly measured ITBV obtained from transcardiopulmonary double-indicator dilution is superior to the commonly used parameters to guide major burn resuscitation.

Die plastisch-chirurgische Deckung osteocutaner Defekte der Sternumregion mit dem Vertikalen und Transversalen Rectus Abdominis Muskel (VRAM/TRAM)-Lappen

Zusammenfassung. Langstreckige osteocutane Defekte der Sternumregion mit Einbeziehung des caudalen Sternumdrittels wurden in einem Zeitraum von 3 Jahren bei 15 Patienten mit dem „Vertikalen (VRAM)- und dem Transversalen Rectus Abdominis Muskel“ (TRAM)-Lappen plastisch-chirurgisch rekonstruiert. In der überwiegenden Zahl der Fälle handelte es sich um eine Sternumosteitis nach kardiochirurgischer Intervention und um ventrale Thoraxwanddefekte nach Therapie eines Mammacarcinoms. Drei der VRAM/TRAM-Lappenplastiken erfolgten primär frei mit mikrovaskulärem Anschluß in der Axillaregion. Bei 9 von 12 gestielten VRAM- oder TRAM-Lappen wurde eine zusätzliche mikrochirurgische Anastomose wegen drohender venöser oder arterieller Insuffizienz durchgeführt (sog. „Supercharging“). Daher ist der technische und zeitliche Aufwand der gestielten und primär freien VRAM/TRAM-Lappenplastik bei der Deckung langstreckiger Defekte der Sternumregion vergleichbar. Eine primäre Defektdeckung und Infektsanierung konnte in 11 Fällen mit dem VRAM/TRAM erzielt werden. Bei 2 Patienten mußte eine Revision mit partieller sekundärer Defektdeckung erfolgen. Zwei männliche Patienten verstarben postoperativ aufgrund einer vorbestehenden Grunderkrankung.Abstract. Longitudinal osteocutaneous defects of the sternal region including the caudal third were reconstructed in 15 patients during a 3-year period by using the “vertical (VRAM)- and transverse rectus abdominis muscle” (TRAM) flap. The majority of the defects resulted from chronic osteomyelitis after previous cardiothoracic surgery or were due to former therapy of breast cancer. Three VRAM/TRAM flaps were primarily transferred as free flaps with microvascular anastomosis in the axilla region. Nine out of 12 pedicled VRAM or TRAM flaps required an additional microvascular anastomosis because of imminent venous or arterial insufficency (“supercharging”). Therefore, operative technique and operating time of the pedicled and free flap for reconstruction of longitudinal sternal defects are comparable. Adequate reconstruction and rehabilitation was achieved in 11 cases. In 2 patients revision and partial secondary defect coverage was required. Two male patients died postoperatively due to their preexisting condition.

Use of a free jejunal graft for oesophageal reconstruction following perforation after cervical spine surgery: case report and review of the literature.

Study design: Single-subject (male, 16 years of age) case.Objectives: To demonstrate a suitable method for oesophageal repair after perforation as a complication of anterior spinal fusion in an individual with quadriplegia, and to review the literature on oesophageal perforation and repair.Setting: University hospital, large trauma centre with departments for spinal injuries and reconstructive surgery in Germany.Methods: A free jejunal graft used for oesophageal reconstruction in a post-traumatic situation after a complicated treatment course in a C6 quadriplegic patient.Results: A protuberant loose screw of the titanium plate after anterior spinal fusion perforated the oesophagus. Imbricating sutures and a fascia lata patch were insufficient to repair the oesophageal leakage. An 8 cm long segment of the cervical oesophagus including a fistula had to be excised, and a free microsurgical jejunal flap was used for restitution of continuity. The jejunal vessels were connected to the superior thyroid artery and external jugular vein. At 1 week after the oesophageal repair, an enteral contrast study showed a small amount of contrast medium leaking at the oesophago-pharyngeal anastomosis. A percutaneous gastric tube was inserted, and oral feeding was limited to tea and still water for 4 weeks. The further course was uneventful.Conclusions: Oesophageal perforation is a rare but recognized complication after cervical spine surgery, which can mostly be managed using secondary suture techniques. The free jejunal flap is a reliable and innovative tool in the particularly complex situation of a segmental oesophageal loss. It should be considered in similar cases to reconstruct oesophageal continuity or to treat stricture and fistula formations.

Versorgung proximaler Kahnbeinpseudarthrosen und -frakturen mit der Mini-Herbert-Schraube über einen dorsalen Zugang

ZusammenfassungEs wurden 32 Patienten im Alter von 16–49 Jahren über einen dorsalen Handgelenkzugang mit der Mini-Herbert-Schraube versorgt. Die Indikation zur Operation waren 5 Frakturen (Typ B3 nach Herbert), 2 verzögerte Frakturheilungen (Typ C nach Herbert) und 25 Pseudarthrosen (Typ D1 bis D3 nach Filan u. Herbert). Bei 6 Patienten wurde keine Spongiosa transplantiert, in 19 Fällen Radiusspongiosa, in 4 Fällen ein Beckenkammblock und in 3 Fällen ein vaskularisierter Radiusspan eingesetzt. Die durchschnittliche Ruhigstellungsdauer betrug 9 Wochen. 26 Patienten konnten nach einem durchschnittlichen Zeitraum von 14,5 Monaten klinisch nachuntersucht werden. Radiologisch wurde das Ergebnis von 30 Patienten (94%) erfasst.26 Skaphoide (100% der Frakturen, 84% der Pseudarthrosen) zeigten radiologisch eine knöcherne Konsolidierung. Dabei fielen in jeweils 3 Fällen Lockerungszeichen bzw. ein Vorschub der Schraube in das Radiokarpalgelenk auf. Eine “Humpback”-Deformität wurde in 4 Fällen beobachtet. Bei 4 Patienten persistierte die Pseudarthrose, wobei es in einem Fall zu einer straffen Pseudarthrose kam. 6 Patienten zeigten eine beginnende periskaphoidale Arthrose.Die Kraftmessung (JAMAR II) ergab für den Kraftgriff 91%, für den Dreifingergriff 94% und für den Seitgriff 95% der Gegenseite. Der durchschnittliche Schmerzwert auf der visuellen Analogskala lag in Ruhe bei einem, bei Bewegung bei 11 und unter Belastung bei 33 Punkten. Das Bewegungsausmaß betrug für die Extension/Flexion 79% und die Radial-/Ulnardeviation 83% der Gegenseite. Der durchschnittliche DASH-Wert ergab 15 Punkte.Die Ergebnisse zeigen, dass sich die Mini-Herbert-Schraube in der Versorgung sowohl von Frakturen als auch Pseudarthrosen des proximalen Skaphoid-Drittels als Standardverfahren etabliert hat.Abstract32 patients, aged 16 to 49 years, were treated by osteosynthesis using the Herbert mini screw. The indications were five fractures (type B3, Herbert classification), two delayed unions (type C) and 25 nonunions (type D1 to D3, Filan and Herbert classification). Six patients received no bone grafts, 19 received cancellous bone graft from the radius. An interpositional iliac crest bone graft was used in four, and a vascularized bone graft from the distal radius in three cases respectively. The average postoperative immobilisation in a forearm splint was nine weeks. 26 patients could be recruited for clinical follow-up at an average of 14,5 months. The radiological results were assessed in 30 cases (94%).Bony consolidation was achieved in 26 cases (100% of the fractures, 84% of the nonunions). In three cases a loosening of the screw, and in three further cases a dislocation into the radiocarpal joint were observed. A humpback deformity was present in four cases. Three patients showed a persisting nonunion, one patient a fibrous union. Early degenerative changes of the radiocarpal joint were observed in six cases.The clinical follow up examination showed an average grip strength of 91% (JAMAR II), 94% for the three finger, and 95% for the pinch grip compared to the contralateral side. The mean postoperative pain score on the visual analog scale was one for resting conditions, eleven for motion and 33 under stress. The range of motion was 79% of the opposite side for extension/flexion and 83% for radial/ulnar deviation. The average DASH-score reached 15 points.The Herbert mini screw has proven to be a reliable implant for reconstruction of proximal pole fractures and nonunions of the scaphoid.