This study aimed to evaluate the risk factors affecting the survival rate of replantation for an amputated digit caused by avulsion injury. A cohort of 20 patients with 27 digital replants from avulsion injuries and mean age of 46.5 years (range, 6-79 years) were enrolled in this study. The data collected included age, sex, smoking history, zone of injury, preoperative time, the amputated digit, level of surgical expertise, method and number of anastomosed vessels, and the bone fixation technique. The survival rate of replanted digits was 52%. Arterial thrombosis occurred in 6 digits within the first 0-86 hours, and venous thrombosis in 11 digits within the first 0.5-108 hours. On univariate analysis, there were no risk factors affecting survival rate of replantation. Based on the examination of circulatory insufficiency after replantation, adequate reconstruction of the arterial flow may be especially important for survival of the amputated digit caused by avulsion injury. To improve the survival rate of finger avulsion injuries, we believe that it is also necessary to record and collect more information about the arterial damage state and reconstruction method of the artery during replantation.
The reverse posterior interosseous flap is useful for skin coverage of the hand. However, the reliability of this flap has been questioned, and it has not been decided if the range of the flap extends to the lateral condyle of the humerus. The limit of the proximal range of the flap varies in whether to include the perforator of the proximal third of the forearm. In general, the motor branch of the extensor carpi ulnaris nerve is frequently on the posterior interosseous artery. In these cases, the perforator of the proximal third cannot be included in the flap. We designed the flap to include 1 cm distal to the mid-point of the forearm and used only the middle forearm perforator. We performed this reverse flap in 10 cases. The size of the flap was 9 cm × 4 cm ~ 13 cm × 4 cm. The average range of the proximal edge of the flap to the lateral condyle of the humerus was 3.8 cm. The flap survived in all cases. We concluded that the posterior interosseous flap is a reliable and safe flap with only the middle forearm perforator within the range of 2 ~ 4 cm from the lateral condyle of the humerus.
Background : The fibula free flap is a useful option in head and neck reconstructive surgery. The donor site is often closed with skin grafts. There have been some reports describing skin grafts fixed by negative pressure dressing ( NPD ) instead of conventional pressure dressing and splint ( CPD ). Methods : Between 2007 and 2015, 56 fibula flap donor sites were covered with split-thickness skin grafts immobilized with either CPD ( n=42 ) or NPD ( n=14 ). We evaluated the operating time, postoperative walking rehabilitation day, wound complications ( graft take rate, infection ), re-operation for donor, length of hospital stay, healing time and total treatment costs in the hospital. Results : There were no significant differences in median operating time, graft take rate, donor infection, median length of hospital stay or healing time between the two groups. Median postoperative walking rehabilitation day was day 7 and day 4 for CPD and NPD, respectively; the difference was significant. However, CPD was found to be significantly more cost efficient than NPD. Conclusion : There was no significant difference in the outcomes in relation to wound healing. The NPD group demonstrated the benefits of early ambulation improvement, although the treatment is expensive.
A 62-year-old woman exhibited a Gustilo type IIIc open fracture of the right humerus with a long defect of the brachial artery. The injury was due to the patient's upper extremity protruding through a window during a motor vehicle rollover. The patient's overall health status was stable, and reconstruction was attempted. After debridement and external fixation of the humerus, the brachial artery was reconstructed with a reverse great saphenous vein graft of 220 mm in length. The duration of ischemia was 6.5 hours. Graft patency was demonstrated by ultrasonography 10 months after the injury. Most of the brachial artery injuries were caused by puncture wounds to the upper extremity. Our case involved a “hand-out-the-window” injury during a traffic accident. Although there was good collateral circulation around the elbow joint, the patient had a large soft-tissue injury including the brachial artery and its branches; therefore, revascularization with a vein graft was needed for limb salvage.
Recently, indocyanine green ( ICG ) fluorescence angiography imaging is often used in many kinds of surgical cases for a variety of purposes, but it is rarely used to evaluate digital blood flow. In this report, we demonstrate the usefulness of ICG fluorescence for evaluation of blood flow in a case of impaired digital circulation in a 31-year old man. The impaired circulation occurred during revision surgery for multiple finger amputation injury. Although it was difficult to judge the need for immediate revascularization, we could diagnose the clinical blood flow condition by ICG fluorescence. As a result, emergency surgery for revascularization was performed, and the finger was saved. Conventional methods for evaluation of finger blood flow require comprehensive judgement based on many clinical factors, such as skin color, skin temperature, elasticity, capillary refilling, and the pin prick test, but this comprehensive judgment is sometimes difficult because it is impossible to quantify these clinical findings. ICG fluorescence can visualize blood flow directly, which gives it an advantage over other visualization methods. However, because ICG infusion is invasive, its use for monitoring blood flow should be limited. In addition, when we evaluate finger blood flow, the affected limb should be kept elevated.
There are many therapeutic difficulties when treating post-traumatic pyogenic osteomyelitis of the tibia. Many surgical techniques, such as free vascularized flaps and pedicled flaps, have been developed and reported. Here, we describe the case of a 58-year-old male with tibia fracture by traffic accident seven years ago. He had severe diabetes mellitus and had undergone operation using external fixation for the tibia fracture. One year after trauma, the tibia fracture was healed with sufficient union on X-ray. However, he developed pyogenic osteomyelitis of the tibia seven years after the first operation. We performed curettage, debridement of the tibia bone marrow, and applied cement beads containing antibiotics two times. Furthermore, the proximally pedicled medial gastrocnemius muscle was transferred to fill the dead space of the bone marrow. The pedicled flap technique is safe and easy, and is a useful method for treatment of post-traumatic pyogenic osteomyelitis of the tibia without non-union.
Free rectus abdominus myocutaneous ( RAMC ) flaps are generally nourished by the deep inferior epigastric artery ( DIEA ) and deep inferior epigastric vein ( DIEV ). There are few cases with anatomical anomalies regarding the DIEA and DIEV, and no reports refer to anomalous venal drainage of the RAMC flap or deep inferior epigastric perforator ( DIEP ) flap with DIEA and DIEV. Therefore, free RAMC and DIEP flaps are widely used to reconstruct tissue defects. DIEA and DIEV are anastomosed to recipient vessels as a matter of course. We experienced an anomaly of venous drainage in a free RAMC flap. The flap we harvested had normal DIEA and DIEV; however, drainage via the DIEV was not observed. Main venous drainage was observed through a different path, which led to the intraperitoneum. This unusual drainage was adequate and the flap was completely viable post-surgery. Identifying the feeding and drainage vessels as soon as possible, as well as continuous observation of flap color to monitor for ischemia or congestive conditions is critical. If complications are seen, then the decision must be made to select some other vessel for anastomosis.
We encountered a patient with a soft tissue defect after forearm open fracture accompanied by distal radio-ulnar joint instability, in whom the wound was closed with a free groin flap and the postoperative course could be followed for 4 years. The patient was a 72-year-old female who fell, causing open fracture of the left forearm. An emergency operation was performed, but skin defects appeared. The second surgery ( re-osteosynthesis of the ulna, repair of the triangular fibrocartilage complex, and free groin flap ) was performed 14 days after the first surgery at our hospital. The flap was engrafted without problems and bone union was achieved. As of 4 years after surgery, it does not interfere with her daily life, and the flap has maintained a favorable condition. This case required functional evaluation of the wrist joint for a prolonged period because distal radio-ulnar joint instability was treated, which allowed us to follow-up the free groin flap for 4 years. Based on this long-term follow-up, we consider the free groin flap to be a useful reconstruction method for skin soft tissue defects of the forearm.
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