Although vascular thrombosis following digital replantation is most likely to occur within the first 72 hours, a significant risk still exists up to 2 weeks after surgery. We discuss circulatory insufficiency after digital replantation based on 13 patients and 15 replantations over a 5-year period. The level of amputation included one digit in zone I, five digits in zone II, seven digits in zone III, and two digits in zone IV. The types of injury included clean-cut (one case), crush (three cases), compression (six cases), and avulsed (three cases). Arterial thrombosis occurred within the first 7-111 hours, and venous thrombosis within the first 5-115 hours. This difference was not significant (P>0.05). Approximately 53% of the circulatory insufficiencies occurred between 3:00 and 7:00 in the morning. Thrombosis in smokers (eight patients) occurred within the first 5-115 hours, and thrombosis in nonsmokers (five patients) occurred within the first 6-68 hours. A strong association was observed between smoking and the risk of late circulatory insufficiency. Our findings suggest that close monitoring for 72 hours following replantation is important and probably sufficient; however, smokers should be monitored longer than nonsmokers.

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The second dorsal metacarpal (SDMC) flap has been used for soft tissue reconstruction of the dorsal side of the hand. However, it is difficult to identify the depth, path, and branches of the second dorsal metacarpal artery (SDMA) perforators only using an ultrasound Doppler stethoscope. The purpose of this study was to evaluate the efficacy of color Doppler ultrasonography to detect the perforators to help design the SDMC flap. Twenty healthy volunteers (forty hands) were examined using color Doppler ultrasonography and an ultrasound Doppler stethoscope. The SDMA and its perforators were mapped at all points where the perforators seemed to penetrate through the fascia of the interosseous muscle. The average number of SDMA perforators was found to be 2.7 branches per hand using color Doppler ultrasonography, while it was 1.8 branches per hand using the ultrasound Doppler stethoscope. The perforators were found in all cases by the color Doppler ultrasonography. Most perforators were found to be around the distal 1/4 and proximal 1/3 of the second metacarpal. It is concluded that color Doppler ultrasonography can identify perforators and help in making the assessment of vascularity for an SDMC flap.

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As a treatment for traumatic soft tissue defects of the foot, amputation results in a deteriorated quality of life because of a shortened leg. From April 2008 to March 2010, we performed reconstructions using free pedicled flaps based on the subscapular artery vasculature for three male patients with soft tissue defects of the foot. The mean age of the three patients was 52.0 years (range, 32-77 years). We used scapular flaps for two cases and a latissimus dorsi myocutaneous flap with scapular bone for one case. All flaps survived the procedure. After reconstruction, all patients could walk bearing their full weight. None of the patients showed any signs of skin trouble on the flap, such as ulceration or occurrence of clavi. Because of discrepancies in subcutaneous tissue thickness between donor and recipient tissue and difficulty with sensory reconstruction, only a few reports have found these types of flaps useful for foot reconstruction. In our cases, the patients were able to walk wearing normal shoes without developing any ulcers or clavi. We therefore conclude that scapular or latissimus dorsi myocutaneous flaps could be useful for soft tissue reconstruction of injured feet.

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A well-perfused soft tissue envelope prevents infection, promotes fracture healing and restores extremity function. Important considerations in surgical management include surgical timing, the fixation technique and soft tissue coverage. We treated 3 cases with bone and soft-tissue injuries in the lower extremities using a deep inferior epigastric perforator (DIEP) flap. There were two Gustilo type III B fractures and 1 type IIfracture. Radical debridement and temporal external fixation were performed on the day of injury, and soft tissue reconstruction was performed from 14 to 28 days after injury. One flap failed completely. The flap choice in our case was determined by the extent of the soft-tissue defect. A DIEP flap provides large, thin soft tissue to cover extensive defects, consistent vascular anatomy and a long vascular pedicle. We conclude that DIEP flap transfer is a useful reconstructive option for open fractures of the lower extremities.

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 Introduction: We report our results of treating nonunion of the leg bones with vascularized bone grafts.
 Methods: Between November 2003 and July 2010, we placed 9 vascularized bone grafts (6 free flaps, 3 pedicled flaps) in 9 patients (7 men; mean age, 63 years; range, 23 to 92 years). The nonunion site was in the femur in 3 patients and the tibia in 6. Bone defects ranged from 0.5 to 10 cm long (mean, 4.4 cm). Grafts came from 6 fibula, 2 ilea and 1 medial femoral condyle. External fixators were used in 6 patients, intramedullary nails in 2, and a plate in 1.
 Results: All flaps survived and bone union was acquired in all patients. One patient had skin and soft tissue necrosis in the donor site for harvesting fibula, which was treated with a free latissimus dorsi myocutaneous flap. Another suffered postoperative recalcitrant pneumonia and died 5 months later.
 Conclusion: Vascularized bone grafts can treat nonunion in the leg bones, but can cause surgical stress and major complications. Optimal results depend on preoperatively evaluating the vascularization of both donor and recipient bones; choosing a simple procedure (a reliable flap or a pedicled graft) ; and assessing the patient's general health, risks associated with past illnesses, and possible complications.

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The optimal reconstruction procedure after wide resection of sarcoma in lower extremities, remains controversial. We reviewed the outcomes of 8 recycled intercalary autogenous bone grafts combined with an osteocutaneous free fibula flap for bone and soft tissue sarcoma in the lower extremities. There were five males and three females, between 11 and 49 years of age who were followed up for at least 14 months (average, 38 months). The recycled bone graft was treated by liquid nitrogen in three cases, and by pasteurization procedure in five cases. Bony union was seen in seven patients (88%) an average of 11 months after the operation. In the remaining patient, bone union was not achieved due to infection. Postoperative complications included deep infection and two fractures. There were two local recurrences of sarcomas. The Musculoskeletal Tumor Society score was 70% on average in 4 patients without complications. Our results suggest a recycled autogenous bone graft combined with an osteocutaneous free fibula flap could be a useful reconstruction method in selected patients with large bone defects after wide resection of sarcoma in the lower extremities. Using reliable internal fixation (e.g. a locking plate system) could improve the clinical results and reduce the incidence of fracture of the grafted bone.

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 Free flap transfer is generally used in head and neck reconstruction surgeries, and many advantages of this procedure have been reported. The availability of reliable recipient vessels for free flap transfer may be limited in cases of prior neck dissection or radiation therapy. It is important that reconstruction is performed by safely using a vein graft or a bridge flap. Herein, we report a case in which venous return was performed using other vessels since the perfusion of the recipient vein was unsatisfactory.
 A 74-year-old man presented with recurrence of hypopharyngeal cancer. We performed reconstruction by using free jejunum transfer with an omental flap as a bridge flap. Although the omental flap collapsed because of necrosis, the artery survived, and since the veins were anastomosed to another variety, the jejunal flap distal to the bridge flap completely survived. It is necessary to choose a good recipient vessel from among the limited number of vessels that are functional after 2 or more operations, radiation therapy, or chemotherapy. We believe that perioperative evaluation is important when the condition of the recipient vessel is bad.

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A 25-year-old male sustained an injury to his hand, resulting in amputation from the base of the little finger, as well as skin loss at the dorsoulnar aspect of the hand. Radiographs showed a defect of the proximal phalanx in the little finger. The patient and his family were eager for replantation even if the finger had to be shortened. The replantation of the little finger was performed by temporarily implanting the middle phalanx on the neck of the metacarpus. Secondary reconstruction was then performed, with the base of the finger fused with an iliac bone graft and the skin loss covered with a reversed posterior interosseous flap. As a result, the right finger, which was fused, was shorter than the left one by 3cm; however, the patient was satisfied with the results and returned to his work as a carpenter. Replantation with a defect of the proximal phalanx may not be the best choice to save hand function, but we believe that it can play a role as it affords the option of secondary reconstruction.

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