The purpose of this study was to report the clinical results of interfascicular neurolysis for anterior interosseous nerve palsy (AIN) and posterior interosseous nerve palsy (PIN) with hourglass-like constrictions. Interfascicular neurolysis was performed in 3 patients (including 1 patient with bilateral involvement) with PIN palsy and 1 patient with AIN palsy. Mean age at the time of treatment was 41 years (range, 18-52 years). All patients were initially treated conservatively, but showed no signs of recovery. Surgeries were performed at a mean of 3.8 months after onset (range, 2-7 months). Hourglass constrictions were found in both PIN and AIN. All patients achieved relief from pain or tenderness around the elbow. Finally, all patients showed recovery of muscle strength to better than grade 3 on the manual muscle test after surgery. In cases of AIN and PIN palsy with pain or tenderness around the elbow, interfascicular neurolysis of an hourglass-like constriction of the nerve may be a valid option.
Postoperative blood flow monitoring of free transferred tissue after reconstruction of head and neck cancer surgery is important. We retrospectively analyzed the accuracy of postoperative clinical flap monitoring after head and neck reconstruction. Our clinical assessment of postoperative blood flow of transferred tissue involved evaluation of flap appearance, capillary refill, warmness, and the pin prick test. During October 2004 to May 2008, 544 free flaps with skin islands were transferred in 520 patients. Of these, twelve patients who had suspected blood flow insufficiency were evaluated. The appearance of 12 flaps was congestive in 7 and pale in 5 cases. Seven congestive flaps revealed venous thrombosis in 4 cases, perforator trouble in 2 cases, and one case was false positive. Five pale flaps showed arterial thrombosis in 4 cases and a kinked pedicle in one case. Vascular re-anastomosis could be carried out in 5 cases and the salvage rate was 27.3%. The total flap success rate was 98.5%. The sensitivity of our clinical assessment procedure was 100% and the false positive rate was 0.2%. Although our clinical assessment showed a slightly poor salvage rate, a satisfactory sensitivity and specificity were obtained compared with other postoperative blood flow monitoring methods. Based on these outcomes, our clinical method is safe, easy and appropriate to assess the state of postoperative free flaps.
In patients who undergo reconstruction after resection of malignant tumors around the knee joint, proper flap selection and choice of recipient vessels are important considerations. We report our experience with reconstruction using free or pedicle flaps for malignant tumors around the knee joint. This report details the results from 11 patients. There were four cases of malignant fibrous histiocytoma, four cases of osteosarcoma of the proximal tibia, and one case each of liposarcoma, synovial sarcoma and malignant myxofibroma. Reconstruction was performed at the same time as tumor resection in six cases, and reconstruction was performed after operation due to complications with wound healing in five cases. Though all flaps survived, there were two cases of surgical site infection that required reoperation. In patients with large soft tissue defects and when prosthetic material is considered in the reconstruction, we believe that latissimus dorsi musculocutaneous flaps are a suitable method of reconstruction. On the other hand, in patients with small defects, we typically select a proximally-based sural artery flap. Proper selection of recipient vessels is crucial, as is selection of flaps. Our first choice is the descending genicular vessels because of the presence of genicular vessels of adequate size that are generally reliable and constant.
Breast reconstruction with autologous tissue or implant after mastectomy is becoming popular in Japan. We also perform breast reconstruction mainly using perforator flaps, because perforator flaps reduce the donor site morbidity. The aim of this report is to explain our strategy for bilateral breast reconstruction with free perforator flaps. We performed bilateral breast reconstruction mainly using free perforator flaps in 9 cases after bilateral total mastectomy in the past five years. There were ten flaps with DIEP flap, one flap with SIEA flap, four flaps with IGAP flap and two flaps with PMT flap. The complications included one case of partial flap necrosis and two cases of wound dehiscence at the donor site. There was no abdominal bulging, and good results were obtained in almost all patients. We choose the optimal flap, including DIEP flap, SIEA flap, SGAP flap, IGAP flap and PMT flap, for breast reconstruction according to the background of each patient. The timing of breast reconstruction at each side sometimes causes trouble when choosing the flap. Therefore, familiarity with various flaps for breast reconstruction with autologous tissue is necessary to perform reconstruction in various conditions.
Vascular access becomes useless after a successful renal transplantation. We report a 59-year-old male, kidney recipient, who presented with pain in the left index finger two weeks after radiocephalic arteriovenous fistula (RCAVF) ligation. The tip of the index finger was white and the skin perfusion pressure was 20 mmHg. The Doppler sound of the radial artery around the RCAVF was weak, suggesting an occlusion of the radial artery. Angiogram showed filling defect corresponding to the occluded segment of the radial artery around the RCAVF. Arterial reconstruction of the radial artery was performed using a cephalic vein as a vein graft. The cephalic vein of the RCAVF was ligated at 2 cm proximal from the radial artery and was found to be filled with a thrombus. This suggested that the radial artery thrombosis was due to turbulent flow at that site. The ischemia resolved gradually. After a follow-up of 17 months, the patient remained asymptomatic. When we need to occlude AVF after kidney transplantation, an appropriate ligation site should be considered to avoid turbulent flow and constriction of the radial artery.
Here, we discuss 2 patients who had crush syndrome and deep complex tissue injuries in multiple fingers with extremely poor prognoses. One patient showed symptoms suggestive of post-traumatic stress disorder. The patients had sequestrums and skin ulcers that required 4 months to heal. Both patients were in their 70s, and they lacked awareness of the need and motivation to undergo rehabilitation. In conclusion, in patients with crushed hands, adequate debridement and early wound healing are crucial; in addition, it is necessary to correctly evaluate the severity of the condition and carefully design a plan for rehabilitation/reconstruction depending on the severity of the syndrome. Moreover, elderly patients may show a decline in basal physical activity, motivation for rehabilitation, and awareness of the need for rehabilitation. Therefore, it is important to set a treatment goal as early as possible for patients with crushed hands.
Replantation was performed for the treatment of rupture and crush injuries on a left forearm that was believed to be a candidate for amputation. The exposed vessels ruptured following surgery, leading to massive bleeding. However, vein grafting, and combined therapy with intra-wound continuous negative pressure, irrigation treatment was initiated after affixing an artificial dermis on to the exposed vascular graft. A bulbil was formed on the vascular graft, and the injury was successfully treated using local flaps and skin grafting. This method is therefore considered to be a useful treatment modality when exposed vessels cannot be covered by either local flaps or free flaps.
To accomplish free vascularized tissue transfer, both arterial and venous anastomosis between recipient vessels and nutrient vessels of the grafts are usually necessary. We have successfully performed free vascularized fibular grafting in spite of failure of venous anastomosis in 2 patients. In the 2 patients, vascularized fibula with a skin flap was grafted to segmental bony defects of the contralateral tibia in an inlay fashion. Venous thrombosis at the anastomosis site occurred repeatedly in each patient after the surgery, and venous drainage was abandoned. The skin flaps were congested, but the flaps and fibulas survived. Postoperative radiographs demonstrated bone union and hypertrophy of the grafted fibulas. It can be presumed that venous drainage of the grafted fibula occurred by intraosseous circulation of the tibia at the recipient site. The results suggest that vascularized fibular grafting can be accomplished with only arterial anastomosis when intraosseous venous drainage occurs at the recipient site.
Free tissue transfer is seldom used for reconstruction of the buttock because of the absence of appropriate recipient vessels in the gluteal area and difficulties in postoperative care in the prone position to prevent impairment of the anastomosed pedicles. We present a patient who underwent treatment for a recurrent radiation ulcer in the sacroiliac joint using free latissimus dorsi musculocutaneous flap nourished by the inferior gluteal vessels. A 77-year-old woman who had suffered from uterine cancer and osteogenic sarcoma in the pelvis, and had undergone surgical resection and radiation therapy, presented with a radiation ulcer on her right buttock. The ulcer reached the retroperitoneum through the sacroiliac joint, and osteomyelitis was observed. Numerous scars caused by the previous operations were seen around the ulcer. First we tried to treat the ulcer using a split gluteus maximus muscle flap, but it failed due to insufficient obliteration of the dead space. We therefore used a free LD m-c flap supplied by the inferior gluteal vessels in the revision surgery. The patient had to stay in the prone position for two weeks, and the ulcer healed subsequently. In conclusion, a free LD m-c flap supplied by the inferior gluteal vessels is useful to treat radiation ulcers involving the sacroiliac joint.