When Julius H. Jacobson II, M.D., took up the posts of Associate Professor of Surgery and Director of Surgical Research at the University of Vermont College of Medicine in October 1959, an investigator from the Department of Pharmacology inquired how the murine carotid artery could be completely denervated. Dr. Jacobson attempted to transect / reanastomose the artery under an operating microscope used for ear surgery. This was the start of his investigations into microvascular anastomosis. It proved a challenging task as all the instruments and suture materials available at that time were too bulky for use under magnification. Thereafter, he ordered a two-person operating microscope from the Carl Zeiss Co. and prepared several instruments for performing microvascular anastomoses as well as fine suture materials. Jacobson and Suarez published a short article entitled “Microsurgery in Anastomosis of Small Vessels” in Surgical Forum 11 : 243-245, 1960, which has been called the “Bible of Microsurgery”. This technique has been introduced in the fields of brain-neurosurgery, coronary surgery, peripheral neurosurgery, orthopedic and plastic surgery. In particular, in reconstructive surgery it was applied to limb / digit replantation and several composite tissue transplantation procedures from the beginning of the 1970s.
This study evaluated the factors affecting the survival of digital replants using univariate and multivariate analyses. A cohort of 49 patients with 63 digital replants ( mean age : 46.8 years ; range, 18-81 years ) were enrolled in this study. The data collected included information about age, sex, smoking history, the injury zone, preoperative time, the amputated digit, the mechanism of injury, the level of surgical expertise, the method and number of anastomosed vessels, and the bone fixation technique. The survival rate of the replanted digits was 76%. The univariate analysis showed that avulsion injuries and a greater number of anastomosed arteries have significant negative impacts on the survival rate of digital replants. The multivariate analysis revealed that avulsion injuries ( odds ratio [OR], 73.7 ; 95% confidence interval [CI], 7.19-756 ) and zone I injuries ( according to Tamai's classification ) ( OR, 24.9; 95% CI, 1.29-480 ) significantly reduce the survival rate of amputated digital replants. A zone I injury indicates a technical problem, whereas a greater number of anastomosed arteries is primarily attributed to the extent of damage of the amputated digit. Therefore, these results suggest that avulsion injuries might be the main risk factor for replantation failure.
Prior to free flap transplantation, we evaluated various blood vessels using Doppler ultrasonography and then decided which of them should be used as recipient vessels for anastomosis. The facial artery and vein, superior thyroid artery and vein, and transverse cervical artery and vein were evaluated as potential recipient vessels. Concerning the items assessed during the vascular waveform analysis, the vascular diameter, F-V, maximum systolic velocity, resistance index, pulsatility index, and acceleration time were measured based on arterial waveforms. The diameters of the target veins were also measured. In all cases, the candidate vessels for anastomosis exhibited normal preoperative waveforms, indicating that there were no problems with their blood flow. During the subsequent surgery, we only had to gain access to the recipient vessel and so were finished within a short period of time. Due to the effects of neck dissection, the planned recipient vessel was not available in one patient, but the anastomosis was performed as planned in all other cases. Doppler ultrasonography can be used to obtain detailed blood flow information, such as about the distribution of the vascular network, vascular diameter, flow velocity, flow volume, and arterial waveform. For this reason, we suggest that it should be performed routinely prior to surgery.
The effectiveness of using a sensory flap to reconstruct soft tissue defects in the plantar area remains unknown. We performed reconstruction procedures using the sensory free anterolateral thigh flap in four male patients with soft tissue defects of the plantar area from 2013 to 2015. Sensory nerve coaptation was carried out in all cases. The mean age of the four patients was 44.3 years ( range, 24-66 years ), the mean defect size was 147.9 cm2 ( range, 84-198 cm2 ), and the mean follow-up period was 16 months ( range, 9-24 months ). All of the flaps survived. The restoration of sensation allowed the patients to start performing activities of daily living relatively quickly. The patients were able to walk without support two months after the surgery, and none of them experienced acute pain, tylomas, or ulceration. In two cases, perception disappeared from the affected region during treatment with anticancer medication. The results of our study showed that sensory reconstruction should be performed if possible.
Burn contractures of the elbow joint can cause severe dysfunction. Such contractures are difficult to treat, as they result in the formation of cicatricial tissue and an insufficient blood supply. Many surgical techniques for treating burn contractures, including Z-plasties, skin grafting, and flap transfers, have been described. Reconstruction using a free flap makes it possible to improve severe and wide contractures. However, secondary operations are often required to revise bulky flaps. Here, we describe the case of a 28-year-old male with severe burn contractures of the bilateral upper extremities. After releasing the contracture using the bilateral Y-shaped incision technique, a free flap transfer was performed using thin superficial circumflex iliac artery perforator ( SCIP ) flaps ( thin-SCIP flap ). After surgery, the range of motion of the affected joints was markedly increased, and the patient was soon able to return to social activities and did not suffer any re-contracture. The thin-SCIP flap can be safely elevated above the superficial fascia and dissected under a microscope. It makes it possible to achieve one-stage reconstruction, provides elastic motion, and reduces the risk of re-contracture.
Introduction : The use of headless screws ( HS ) is recommended during internal fixation in cases of scaphoid nonunion, but it is difficult to treat scaphoid nonunion with HS fixation after the failure of internal fixation. Therefore, we used a locking plate system to achieve internal fixation in a case of scaphoid nonunion after a failed operation. We report two cases of postoperative nonunion after attempted fixation with HS. The patients underwent a vascularized bone graft transfer from the distal radius and internal fixation with a locking plate system. Case : The patients were 19 and 47 years old, respectively, and were both male. The previous operative procedures included percutaneous screw fixation, and a free bone graft combined with screw fixation. The time between the first and second procedures was 12 and 22 months, respectively. In each case, preoperative X-rays showed that bone union had not been achieved, and bone defects were present around the proximal or distal screw. We harvested the flap from the dorsal part of the distal radius using the Zaidemberg method after removing the screw, placed a vascularized grafted bone on the radial side of the scaphoid bone, and inserted a locking plate on the volar side. Results : Bone union was successfully achieved in both cases, and the clinical results were good ( the mean Mayo wrist score was 82.5 points ). Conclusion : Our combined surgical procedure involving vascularized bone grafting and locking plate fixation is useful for treating scaphoid nonunion after HS fixation.
Four patients underwent pedicled extensor digitorum brevis ( EDB ) muscle flap surgery for soft tissue defects of the foot. All of the patients were male, and their mean age was 46.5 years. The soft tissue defects had been caused by injuries sustained whilst operating machinery in two patients, skin necrosis in one patient, and a cellulitis-induced ulcer in the remaining patient. The EDB muscle flaps used included a reverse muscle flap, turnover EDB muscle flap, and a reverse EDB muscle flap of the lateral tarsal artery. Skin grafts were transferred to all of the muscle flaps, and complete coverage was obtained in all cases. We found that the use of an appropriately vascularized reverse EDB muscle flap is useful for reconstructing skin defects of the fore foot and toe. Furthermore, turnover EDB muscle flaps can be used to address skin defects of the medial dorsum pedis and preserve the dorsalis pedis artery. Similarly, reverse EDB muscle flaps of the lateral tarsal artery can be used to treat defects of the lateral dorsum pedis. Such flaps are also useful for treating dorsalis pedis artery insufficiency. In summary, EDB muscle flaps can be used and adapted to treat many skin defects of the foot.
I report the treatment outcomes of four patients with ring avulsion injuries who required microsurgery. On the basis of the classification by Adani et al., one patient had class II, two patients had class III, and one patient had class IV injuries. The class II patient underwent venous repair and skin grafting with a venous flap, and the two class III patients and the class IV patient underwent replantation. One class III patient underwent the end-to-end anastomosis of an artery and a vein. Although the latter patient experienced postoperative venous thrombosis, the finger survived after a reoperation. The other class III patient underwent the anastomosis of two arteries and two veins with vein grafting and exhibited an uneventful postoperative course. The class IV patient underwent the anastomosis of two arteries with vein grafts and four veins with end-to-end anastomosis, and did not suffer any complicating postoperative vascular disorders. Ring avulsion injuries are a special type of degloving injury with a poor functional prognosis. Replantation is indicated for amputations distal to the insertion of the flexor digitorum superficialis ; however, its postoperative outcomes are not necessarily favorable. To improve the postoperative outcomes of such procedures, rehabilitation should be performed as soon as possible, and a precise microsurgical technique and primary wound healing are desirable in such cases.
During the surgical treatment of vascular malformations, it is important to reconstruct any skin and soft tissue defects caused by wide resection. In addition, donor-recipient matching is critical during reconstructive surgery, especially in procedures involving the hand. Herein, we describe the case of a 37-year-old female who underwent the resection of a vascular malformation located within the ulnar side of the palm, followed by the coverage of the resultant defect using a superficial palmar branch of the radial artery ( SPBRA ) flap. The superficial palmar artery and cutaneous vein of the forearm were anastomosed to the common digital artery and the dorsal digital vein of the hand, respectively. The SPBRA flap completely survived and exhibited a good cosmetic appearance. Furthermore, the donor site was primarily closed without any morbidities, such as limited wrist motion, occurring.
Scaphoid nonunion combined with avascular necrosis of the proximal pole remains a challenging problem in wrist reconstructive surgery. We report the case of a 40-year-old female who presented with right wrist pain, a restricted range of wrist motion, and grip weakness. Radiographic and computed tomography images showed scaphoid nonunion together with fragmentation of the proximal pole and a dorsal intercalated segment instability ( DISI ) deformity without any obvious osteoarthritic changes. Magnetic resonance imaging demonstrated low signal intensity in the proximal pole on both T1- and T2-weighted images, which was indicative of avascular necrosis. The proximal pole was unsalvageable ; therefore, excision of the proximal scaphoid fragment and reconstruction with a vascularized medial femoral trochlea ( MFT ) osteocartilaginous flap were performed. At 17 postoperative months, the patient’s pain had reduced, and her range of wrist motion and grip strength had improved. Radiographs confirmed that the reconstructed scaphoid bone had healed and the patient was free from DISI deformities. The vascularized MFT osteocartilaginous flap is a valuable surgical option for unsalvageable proximal pole scaphoid nonunion.
We report a case in which a free vascularized fibular head transfer was performed using reverse flow anterior tibial vessels to reconstruct the distal radius. The patient was a 59-year-old female. She was diagnosed with a giant cell tumor of the right distal radius. Previously, she had undergone tumor resection followed by vascularized fibular transfer. After the operation, the patient experienced bone resorption and subluxation. Her wrist pain and joint restriction continued, so we completed a free vascularized fibular head transfer. We used reverse flow anterior tibial vessels so anastomoses were created between the distal portions of the anterior tibial vessels and the proximal portions of radial vessels without vein grafting. Eleven years after the operation, the patient's total range of wrist joint motion was 100 degrees of flexion-extension, and she was able to clench her hand powerfully. There have not been any complications, including fractures or collapse of the fibula head graft, in this case.
Vascularized fibular grafts ( VFG ) are usually harvested based on the peroneal artery and is useful for reconstructing long bone defects. Most of the branching patterns of the popliteal artery are normal, and providing the surgeon performs the dissection meticulously VFG flaps can be harvested safely together with the peroneal artery. However, our knowledge regarding variations in vascular anatomy is based on angiographic and cadaveric studies. In patients scheduled to undergo VFG transfer procedures, it is important to be aware of vascular abnormalities preoperatively to be able to preserve the arterial supply to the foot as well as the fibular circulation. In this report, we describe the case of a patient who sustained a 15-cm bone defect due to the removal of osteomyelitic bone after the open reduction and internal fixation of a tibial fracture. During preoperative computed tomography angiography ( to plan for a VFG transfer procedure ), a rare vascular variant was identified ; i.e., the foot was solely nourished by dominant peroneal artery because the anterior and posterior tibial arteries were hypoplastic.
Background : Periarterial sympathectomy ( PAS ) is used to improve blood flow in patients with Raynaud's disease, but the ideal site for PAS and the optimal extent of the procedure remain unknown. We hypothesized that improvements in blood flow occur soon after PAS. Methods : We performed PAS in a 46-year-old female with Raynaud's disease without scleroderma. She had experienced pain in her index finger for several years, and it had proved refractory to conservative treatment. A laser Doppler perfusion imager ( LDPI ) was used to assess the patient's blood flow preoperatively and intra-operatively after sequential PAS of the digital arteries followed by PAS of the radial and ulnar arteries. Results : A significant ( P<0.01 ) improvement in blood flow was seen at 10 minutes after the digital artery in the affected finger was subjected to PAS. PAS of the radial and ulnar arteries ( at the wrist ) did not lead to significant changes in blood flow. The patient reported that her pain had improved at three days after surgery, and it had completely resolved by one postoperative month. Discussion : This study showed that blood flow improves quickly after PAS and that such changes can be detected by LDPI intraoperatively in a non-invasive manner. LDPI might be an effective tool for determining the optimal site and extent of PAS intraoperatively.