In general, skin incisions made in the fingers are midlateral or zigzag incisions, but there is no consensus on the difference in their usefulness in flaps. Therefore, we investigated postoperative flexion contracture due to differences in skin incisions in 9 cases of digital artery island flaps. As a result, flexion contracture of the PIP joint developed in 1 case in which the zigzag incision was performed in a reverse digital artery island flap and in 1 case in which the zigzag incision was performed in a heterodigital finger island flap. Thus, the zigzag incision may cause postoperative flexion contracture more often than the midlateral incision in digital artery island flaps.
Localized-type tenosynovial giant cell tumors are common in the fingers and have a high recurrence rate even though they are benign. Among 38 cases of tenosynovial giant cell tumor, neurovascular bundles were involved in 16. There were 5 cases of circumferential lesions, 2 in the peripheral two-thirds, 6 in the peripheral one-half, and 3 in the peripheral one-third. Although adhesion and involvement were observed around the neurovascular bundle, the tumor was removed without damaging it using a microscope. The extent of the tumor was confirmed via the I-shaped incision on the dorsal side and the W-shaped incision on the volar side, and the neurovascular bundle and vein were preserved.
We performed a retrospective review of 60 free tissue transfers for head and neck reconstruction in our department between September 2015 and May 2019. The patients were 44 males and 15 females with a mean age of 60.6 years. The reconstructed sites were the oral cavity（18 cases）, hypopharynx（18 cases）, oropharynx（11 cases）, maxillary（5 cases）, and mandible（5 cases）. The number and type of free tissue transfer performed were as follows: free jejunal flap: 18 cases, radial forearm flap: 13 cases, anterolateral thigh flap: 9 cases, rectus abdominis flap: 8 cases, and groin flap: 6 cases. We mainly used the superior thyroid artery（35 cases）, cervical transverse artery（17 cases）, internal jugular vein（69 cases）, and external jugular vein（16 cases）as recipient vessels. There were 3 cases of flap failure and 4 cases of partial flap necrosis, resulting in an overall flap survival of 95.0%. We also considered the causes in cases with unfavorable results.
Traumatic toe amputation has been rarely reported because of the limited number of cases, difficulty of the operative procedure and fewer problems with the absence of toes than fingers. We report toe amputation in 2 children. Case 1: A 15-year-old girl with crush type, Ishikawa classification subzoneⅡ, incomplete amputation of the first toe underwent revascularization with a vein graft. Skin necrosis was observed at the crush zone, and skin grafting was required after debridement and artificial dermis transplant. Case 2: A 7-year-old girl with crush type, Ishikawa classification subzoneⅡ, incomplete amputation of the fifth toe underwent revascularization. Skin necrosis was observed at the tip of the toe and the distal phalanx was resorbed partially, but the toe survived.
In the case of vascularized bone graft for bone defects of the proximal ulna, there are several options for recipient vessels. However, the radial artery, ulnar artery, and interosseous recurrent artery were reported to have problems. Therefore, we focused on the posterior radial collateral artery at the bifurcation of the profunda branchii artery. We report 3 cases of bone defects of the proximal ulna: two cases of nonunion following high-energy trauma, and 1 of intractable bone cyst treated using the posterior reversed radial collateral artery as the recipient vessel. Bone union was observed in both nonunion cases 6 months after surgery and at 5 months after surgery in the other case. The posterior radial collateral artery was anatomically stable and used as a recipient vessel of the lateral upper arm flap. We conclude that the reversed posterior radial collateral artery is a useful option for the treatment of bone defects of the proximal ulna.
A 48-year-old man sustained a cut on his right forearm after falling into a glass door. An emergency doctor performed the clinical examination and sutured the skin. However, on the following day, he was unable to dorsiflex his wrist and was referred to our department. We observed a 5-cm sutured wound on the volar aspect of the right proximal forearm and wrist drop on the affected side, with no sensory disturbance. During surgery, we observed a 50% brachioradialis tear, and complete tear of both the extensor carpi radialis longus and brevis and the posterior interosseous nerve（PIN）. Microscopic neurorrhaphy and myorrhaphy were performed. The patient was able to dorsiflex his wrist normally five months after surgery and extend his fingers after one year. There are only six previous reports of isolated PIN tears due to non-iatrogenic penetrating trauma. PIN tears are usually initially overlooked during primary assessment; therefore, non-specialists have to perform the clinical examination carefully. However, even if a specialist performs the primary assessment, the muscle tear may initially be more conspicuous. This case illustrates the importance of careful neurological evaluation and sufficient anatomical knowledge for predicting the site of traumatic injury.
The author reports a case of pathological fracture due to intraosseous ganglion at the carpal scaphoid. A 53-year-old female presented with intermittent pain in her left wrist. Her symptoms had been present for 2 years without prior trauma. Plain radiography and computed tomography demonstrated a well-demarcated cyst in the proximal one-third of the scaphoid associated with peripheral fracture. For surgical treatment, the proximal one-third of the scaphoid was visualized through the dorsal approach. The scaphoid exhibited an egg-shell-like appearance and jelly-like fluid was found during curettage of the lesion. The free bone tip from the radial styloid process and vascularized bone graft（size, 7×6×6 mm）pedicled on the dorsal intercarpal artery from the second metacarpal base were rigidly secured at the curetted region. Postoperatively, her wrist was immobilized in a cast for 2 months. At 6 months, she successfully returned to work. Postoperative radiography and computed tomography at 6 months revealed sufficient healing at the proximal scaphoid.
Reconstruction is necessary for chest wall defects from wide resection of malignant tumors. As the resection time is long, the time required for reconstruction must be as short as possible. We focused the time of reconstruction for large chest wall defects using a pedicled latissimus dorsi flap. We report four cases of pedicled latissimus dorsi flaps for chest wall defects. The clinical course and findings are presented. Case 1 was for a defect after resection of chondrosarcoma in a 50-year-old man. Case 2 was for a defect after resection of a recurrent malignant peripheral nerve sheath tumor in a 73-year-old man. Case 3 was for a defect after resection of myxofibrosarcoma in a 70-year-old man. Case 4 was for a defect after resection of leiomyosarcoma in a 66-year-old man. The mean time of resection was 349.8 min and the size of defects was 197.8 cm2 on average. All flaps survived and no skin graft was required for the donor site. We conclude that pedicled latissimus dorsi flaps are useful for large chest wall defects and the time of reconstruction is shorter using these flaps. Moreover, skin grafting was not needed at donor sites in our cases.
Basal cell carcinoma（BCC）is usually found and treated when it is small, whereas the giant type is rare and difficult to treat. We present one case of giant BCC that was reconstructed using the anterolateral thigh flap（ALT）. A 60-year-old man presented with giant BCC on his face. The tumor was 70×65 mm, and covered the right lower eyelid, cheek, nose and upper lip. Wide resection of the tumor involving the nose cartilage, nasal bone, maxillary bone and zygomatic bone partially was performed first. Secondary reconstruction using the ALT was carried out after pathological analysis, which confirmed margin-free status. The outer cheek skin and inner nasal lining were covered with a partially de-epithelized flap. Microvascular anastomosis between the pedicle of the flap and the right facial vessels was performed in an end-to-end manner. Six months after reconstructive surgery, revisional surgery was performed. The flap-in-flap technique was used according to the facial aesthetic unit concept. Costal cartilage grafting between the outer skin and inner lining was effective to prevent the lack of nasal ventilation. There were no signs of tumor recurrence at 30 months of follow-up, and the patient was satisfied with his appearance and function.