Vascular reconstruction is an absolutely critical step in finger replantation. The purpose of this study was to assess the success rate of replantation surgery in our institution, where the surgeon basically applied vein grafts for vascular reconstruction intraoperatively and continuous intravenous administration of heparin postoperatively. We retrospectively reviewed the records of patients undergoing digital replantation surgery in our institution from May 2011 to April 2014. Twenty-one patients and 27 digits exhibiting complete or incomplete amputation, accompanying arterial and/or venous disorder, were included in the study. Their injury mechanisms were 10 blunt cuts, 5 crush injuries, and 6 avulsion injuries. We interposed vein grafts in 40 out of 41 arterial reconstructions and 23 out of 26 venous reconstructions at replantation surgeries, and continuously administered heparin intravenously for 2 weeks postoperatively. The success rate was 92.6% ( 25 digits survived and 2 were lost ). Vascular patency after replantation surgery presumably depends on two factors ; technique of vascular anastomosis and damage of vascular endothelium in the replanted finger. Endothelial damage cannot be managed by surgical manipulation, and should be left to recover spontaneously. To minimize the effects of posttraumatic endothelial damage on vascular patency, it is recommended to replace the possibly damaged parts of digital vessels, along with postoperative systemic heparinization.
Special Feature Article : Mastering finger replantation
The purpose of this study was to report the clinical results and problems of replantation and reconstruction surgeries for polydigit amputation. Sixty polydigit amputations of 21 patients who had more than one digit proximal to Tamai's zone III amputation were retrospectively reviewed. The complete survival rate of replantation was 87% ( 45 of 52 digits ). The %TAM of digits of zone IV was significantly lower than that of other zones ( mean 28%, p<0.01 ). At the final follow-up for patients who underwent second toe transfer for finger reconstruction, the %TAM and grip strength of the finger proximal to the proximal interphalangeal ( PIP ) joint was significantly lower than those of the finger distal to the PIP joint ( %TAM ; 72% : 28%, p<0.05, grip strength ; 70% : 21% of normal side, p< 0.05 ). The success rate of polydigit replantation was comparable with that of the single finger replantation; however, clinical outcomes were poor, especially in zone IV. In the second toe transfer for finger defects, better clinical results were achieved for the finger distal to the PIP joint than for the finger proximal to the PIP joint.
Background : Popliteo-posterior thigh fasciocutaneous island flap ( PPT flap ), nourished from the direct branches of the popliteal artery for the repair of skin defects around the knee, was reported in 1989. However, there are few reports regarding anatomical information of this branch and PPT flap. Methods : Eight fresh cadaveric lower extremities were dissected following injection of silicon compounds into the femoral artery. We investigated the number, location, and diameter of the direct branches of the popliteal artery, as well as location of cutaneous perforators to the PPT flap. Results : The mean number of direct branches from the popliteal artery was 2.0, with a mean diameter of 0.9 mm and mean pedicle length of 5.2 cm, which were located an average of 4.5 cm proximal to the bicondylar line. At least one branch consistently nourished the PPT flap. All branches passed through the fat of the septal plane between the hamstrings and ran along the posterior femoral cutaneous nerve. The most distal branch was always located at the junction of the small saphenous vein and the popliteal vein. The skin perforators were mostly found in the lower and middle thirds of the posterior thigh. Conclusion : The PPT flap should be included in the posterior femoral cutaneous nerve for good blood supply and this flap can be used as a NAF flap ( neuro-accompanying artery fasciocutaneous flap ).
Although perforator based-propeller flaps have become recently popular in the reconstruction for several soft tissue defects, the usefulness in traumatic tissue problems has not been clarified. We investigated 8 cases with traumatic soft tissue defects in the lower leg treated using posterior tibial artery perforator-based propeller flap ( PTPF ) in our hospital. The average patient age was 58 years old. Most of the original diagnoses were distal tibial fractures ( including 2 open fractures ). The average duration from soft tissue damage to flap operation was 44 days. We could not use the perforators identified by preoperative ultrasound examination in three cases because of scar formation and diffuse edema. The flap survived in 6 cases. One flap exhibited partial necrosis and 1 flap was completely necrotic, and those 2 cases needed additional free flap operations for soft tissue coverage. In addition, there was soft tissue necrosis around the transferred flaps in 2 cases, infection in 2 cases, and delayed bone union in 3 cases. Although PTPF is thought to be useful in traumatic cases, we should pay more attention to the zone of injury surrounding the defects, as well as make a detailed plan for selection of proper perforator, flap design, and fracture management.
The latissimus dorsi muscle can be used for functional reconstruction and as a musculocutaneous flap to cover a large soft tissue defect. We describe application of a pedicled unipolar latissimus dorsi flap to reconstruct finger extension. The patient had massive defects in the radial nerve and extensor musculature as well as weakness of the flexor muscles due to a crush and de-gloving injury at the elbow. As a result, finger extension could not be restored by local tendon transfer. In harvesting the latissimus dorsi, we continued the dissection down to the gluteal fascia and across the periosteum on the iliac crest. A 50-cm-length latissimus dorsi flap was prepared, which enabled the fascial end of the flap to be sutured to the tendinous portion of the extensor digitorum without overstretching. A pedicled unipolar latissimus dorsi flap does not require a microsurgical procedure, which may promote early functional recovery.
A 53-year-old male received an electric saw injury, resulting in complete amputation at the level of the wrist. Replantation was successful, but hand stiffness remained ; consequently, several secondary surgeries were performed. After flexor tenolysis, flexor tendon rupture of the pinky finger occurred. Resection of the hook of hamate and tendon graft were performed. At the same time, an Ilizarov minifixator was attached to widen the first interdigital space. One year after replantation, a coler Doppler echocardiogram detected ruptures of the fourth and fifth extensor tendons ; subsequently, tenosuture and tendon transfer were performed. As a result, the following scores were achieved : the percentage of total active motion ( %TAM ) of all fingers, 66-80% ; Disabilities of Arm, Shoulder and Hand ( DASH ) score, 43.1 ; Chen grade scale, III ; and Tamai score, 61. Although the intrinsic muscles do not exhibit good function, the patient can tie strings and write letters. Several secondary surgeries and rehabilitation using a dynamic splint were important for achieving functional improvement in this case.
We report two cases with massive skin defects of the forearm treated with a free tensor fascia lata flap. Case 1 was a 31-year-old male with contracture of the elbow, wrist, and thumb after a free skin graft for a counter incision due to compartment syndrome. The free skin graft causing contracture was converted to a free tensor fascia lata flap with a size of 40 × 10 cm. The flap survived well and the contracture was released. Case 2 was a 55-year-old male with open fractures of the elbow and wrist. The skin on the volar side of the forearm became totally necrotic. A tensor fascia lata flap ( size 35 × 14 cm ) was placed after thorough debridement of the necrotic tissue and once the distal one-sixth became partially necrotic. He returned to daily activity after a necrotomy and secondary suture. Although we have to pay attention to distal partial necrosis if we use a full length flap, the tensor fascia lata free flap was useful for massive skin defects on the forearm because most of the flap survived without infection.
In certain acute situations, amputated digits may be needed for a replantation and normal function to be restored, but the medical services available to perform this operation at any one time are often rarely available. The most likely reason for this is a shortage of qualified microsurgeons, for example, because the microsurgeon may already be in the operating room with another patient when the ambulance crew brings in a patient with digit amputation. To address this problem, we implemented a “hotline for amputated digits” service, which is available 24 hours a day, 365 days a year, and answered directly by a plastic surgeon. An advantageous feature of the hotline is that it can streamline decision making regarding whether or not a patient needs to be admitted, without needing to coordinate with other services such as the bed managers or operating rooms. The hotline contributed to regional medicine, but had several limitations including a shortage of microsurgeons and medical institutions equipped to support digit replantation. To resolve these problems, there is a need for improved coordination between the regional surgeons qualified in performing microsurgery and those medical institutions that are equipped to host these emergency procedures.
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