We reviewed 30 cases of brachial plexus palsy (11 complete palsies, 19 upper palsies), with reconstruction of the shoulder abduction and elbow flexion using nerve transfer and/or graft. Clinical outcomes and surgical effectiveness were evaluated. The average age at surgery was 25.2 years, the average period from injury to surgery was 3.4 months, and minimum follow-up was 1 year, averaging 3.7 years. Regarding shoulder reconstruction, accessory nerve transfer to suprascapular nerve was performed in 16 cases (combined with axillary nerve reconstruction in 6 upper palsies). Nerve graft was performed in 6 cases. For elbow reconstruction, intercostal nerve transfer to the motor branch of the biceps muscle was performed in 17 cases. Oberlin procedure (in 9 cases) and partial median nerve transfer (in 3 cases) were performed for upper palsy. Nerve graft procedures were not satisfactory in shoulder reconstruction. However, accessory nerve transfer with axillary nerve reconstruction achieved favorable results, with muscle strength recovery to MMT 3 or greater in shoulder abduction. Intercostal nerve transfer achieved favorable result in younger patients. The Oberlin procedure achieved better elbow function in the short term. However, in C5 - 7 root injury cases, the Oberlin procedure was less effective. Median/ulnar funiculus transfer should be selected following confirmation by electronic stimulation during operation.
The principles that guide treatment methods for bone and soft-tissue defects after emergency surgery for severe finger trauma remain a matter of debate. In particular, methods to treat severe damage of the middle part of a finger or reconstruction following failed replantation or degloving injury are challenging. Here, we retrospectively reviewed 5 cases of finger reconstruction using a vascularized corticoperiosteal flap from the medial femoral trochlea (VCMFT). For all cases, bone union and soft-tissue coverage was achieved within 3 months. The iliac bone, costal osteochondral graft and phalanx removed from the injured finger were used and wrapped by the VCMFT. The union between the bone matrix and the VCMFT was evaluated by serial X-rays or Computed tomography (CT), which allowed for visualization of bone matrix remodeling through the VCMFT. In one case, bone resorption at the fingertip was observed, requiring additional surgery. When preparing vascular anastomosis of the VCMFT at the recipient site in the injured finger, the distal end of the recipient digital artery may be used as a drainage vein. Thus, VCMFT is a useful treatment technique.
Reconstructive surgeries for volar oblique amputation of the fingertip generally involve advancement flaps and reverse digital artery flaps. However, some advancement flaps cause flexion contracture of the PIP joint. The purpose of this study was to report the surgical outcome of venous flaps containing a Y-shaped vein for reconstruction following volar oblique fingertip amputation, focusing on PIP joint contracture. Seven fingers of five patients were enrolled in this study. All fingers underwent volar oblique amputation distal to the DIP joint. Venous flaps containing a Y-shaped subcutaneous vein were harvested from the ipsilateral forearm. Two efferent veins were anastomosed to the radial and ulnar digital arteries at the DIP joint level. The afferent vein was coagulated. Six flaps survived. Four flaps became congested, and were treated with medical leeches. The average total active motion was 237 degrees, average flexion of the PIP joint was 99.2 degrees, and the average extension of the PIP joint was −3.3 degrees. Our method for reconstruction of the volar oblique fingertip using a venous flap containing a Y-shaped vein was useful and caused less flexion contracture of the PIP joint.
We report two cases of free flap transfer combined with titanium mesh plate for craniofacial reconstruction. The flaps drooped and thinned over more than 8 years of follow-up. In one case, the titanium mesh plate was exposed from the top of the latissimus dorsi M-C flap. Gravity may affect thinning of the flap. The edges of the titanium mesh led to breakdown of thin portions of the flap. Fortunately, the titanium mesh prevented abscess spreading under the mesh plate. There was no need for total removal of the titanium mesh plate, and only the exposed side was cut followed by coverage with a local flap. In the other case, the titanium plate was not exposed from the forearm flap. This case was treated with palmaris longus tendon grafting between the flap and the titanium mesh plate. This tendon prevented drooping of the forearm flap and exposure of the titanium mesh. Smooth margins of the titanium mesh plate and flap suspension, and coverage of the titanium edges by free tendon graft may be effective in preventing exposure of the titanium mesh plate in craniofacial reconstruction for the long term.
We report the 9-year clinical course of a patient who underwent pedicled posterior interosseous artery adipofascial flap treatment for post-traumatic elbow stiffness caused by proximal radioulnar synostosis resulting from post-traumatic heterotopic ossification (HO). A 66-year-old woman was diagnosed with radial neck fracture and medial collateral ligament injury, and underwent open reduction and internal fixation with plate and ligament suture. Postoperatively, joint contracture of the elbow resulting from HO occurred. We removed the plate from the radial neck, performed posterior release of the lateral collateral ligament, release of the posterior oblique bundle of the medial collateral ligament, proximal radioulnar bone bridge resection, and inserted a pedicled posterior interosseous artery adipofascial flap. During 9 years of follow-up examinations, there was no recurrence of HO or proximal radioulnar synostosis, and the range of motion on physical examination was excellent (extension 0°, flexion 140°, supination 90°, pronation 45°). Post-traumatic HO impedes the progress of treatment for proximal radioulnar bone bridge formation, and the optimal duration from the diagnosis of HO to commencement of this treatment is unclear. We were able to insert the pedicled adipofascial flap without sacrificing the major arteries and prevented the recurrence of bone bridge formation.
We used a contralateral digital artery as a graft vessel for finger amputation in an infant. This artery graft may be harvested from the same finger, and the difference in diameter between the donor and recipient vessels is less than that for a vein graft from other areas. In cases with difficulties in harvesting a vein graft, such as in an infant, this method is useful for finger replantation. A 4-month-old girl had her left index finger amputated at the distal interphalangeal joint by scissors and finger replantation was performed. We required a graft vein for the arterial anastomosis, but there was no suitable vein on the body surface. A radial digital artery was harvested 3 mm from the amputated edge as a graft vessel for anastomosis of the ulnar digital artery. The replantation surgery was successful.
Ischial pressure sores are often observed in paraplegic patients due to spinal cord injury and are of concern. Surgical treatment is one option, and several local flaps, including fasciocutaneous flaps and musculocutaneous flaps, may be used for wound closure. However, the recurrence of ischial pressure sores is more common than that of any other pressure sores even if local flaps have already been used. Therefore, free flaps may be the next method. Several free flaps have been reported for the treatment of pressure sores such as medial plantar flaps, sole foot flaps, medial gastrocnemius flaps and latissimus dorsi musculocutaneous flaps. In our experience, the free latissimus dorsi musculocutaneous flap has sufficient volume to cover large focal defects after surgical debridement of pressure sores, and the thickness of the flap is appropriately durable. Here, we report two cases of successful closure of ischial pressure sores with a free latissimus dorsi musculocutaneous flap, and discuss the patient selection, surgery plan and advantages of this method.
A 66-year-old female developed avascular necrosis and infection of the quadriceps femoris muscle after resection of a malignant tumor in the thigh, resulting in a severe soft-tissue defect measuring 200×50 mm on the front of the thigh. Reconstructive surgery was performed using a free latissimus dorsi musculocutaneous flap approximately two months after the resection. We used the deep inferior epigastric artery as a recipient vessel because no appropriate local recipient vessels were available due to marked adhesion. The concomitant deep inferior epigastric perforator flap was used to cover the site of vascular anastomosis between the deep inferior epigastric artery and the latissimus dorsi musculocutaneous flap. The clinical course after reconstruction was satisfactory, and there was no evidence of recurrence of infection during the 2 years of follow-up. Free latissimus dorsi musculocutaneous flaps using the deep inferior epigastric artery as a recipient vessel are an effective option for reconstruction of severe soft-tissue defects in the thigh.