This study assessed the problems that should be resolved during replantation surgery for an amputated thumb. A cohort of 23 patients with 23 thumb replants and a mean age of 47.4 years was enrolled. The survival rate of replanted thumbs was 82.6%. For arterial repair, end-to-end methods were applied in 16 thumbs, whereas vein grafts were anastomosed end-to-end to the branch of the radial artery in the anatomical snuff box in seven thumbs or to the proximal stump of the digital artery at the proximal phalanx level in one. Veins were mainly repaired by end-to-end methods. Avulsion of the flexor pollicis longus (FPL) and extensor pollicis longs (EPL) (nine thumbs), digital nerve (three thumbs), and an injured thenar muscle (one thumb) were considered unrepairable. The interphalangeal joint was primarily fused in four thumbs because both the EPL and FPL tendons were unable to be repaired, and no other primary reconstruction was carried out. The use of vein grafting is beneficial for successful replantation of avulsed thumbs. Rather than attempting direct repair of avulsed tendons, primary arthrodesis of the interphalangeal joint may be a useful procedure during replantation in the distal area from zone Ⅲ.
Gustilo type ⅢB and ⅢC lower extremity fractures require reconstruction of the damaged soft tissue free flap during the early stages of fracture. Congestion is an early complication of free flap surgery. To detect congestion due to venous thrombosis, it is necessary to evaluate flap blood flow. The purpose of this study was to detect congestion early and save free flaps. The measurements were compared between patients who presented with congestion and those without congestion. The 17 limbs with open lower leg and foot fractures included in this study had their fracture sites covered by the free flap. Our approach involved performing a pinprick test, and measuring blood glucose and lactate levels using a portable instrument. We identified 11 flaps without congestion and 6 flaps with congestion. The 6 flaps with congestion had a low mean capillary blood glucose measurement index of 0.57 (range 0.79 to 0.3) in their congested flaps and an increased mean lactate level of 11.4 mmol/L (range 8.3 to 17.9 mmol/L). The 6 flaps survived. Monitoring both flap blood glucose and lactate levels enables the early detection of congestion.
(objective) A case report of a free vascularized fibular graft (FVFG) for hand reconstruction for a defect at the metacarpal region. (case) A 21-year-old male was injured in a traffic accident and brought to another hospital by ambulance. The diagnoses were open multiple fractures of carpal bones and phalanges. Five days after injury, he was referred to our hospital. He was unable to move his fingers or wrist joints. We immediately performed Ilizarov external fixation. After the first operation, he became able to move his fingers actively and the wrist joint passively. Two weeks after the first operation, we performed FVFG bridging from the lunate bone to the 4th and the 5th metacarpal heads, and tendon transfers from the 4th and 5th EDC to the 3rd EDC. (result) Nine months after FVFG, bone fusion was complete. The range of motion of the little finger and wrist joint remained limited, but he returned to work. (discussion) As the fibular bone used was strong, rehabilitation began earlier than if another method had been used. The final result was good.
A 53-year-old woman presented with complete left index finger amputation in zone Ⅳ caused by a dog bite. The finger was replanted; two digital arteries and two veins were sutured after thorough debridement and irrigation. The patient started receiving prostaglandin E1 after the surgery; however, her finger turned from a pinkish color to a whitish color because of vasospasm within the first 10 hours. In order to treat brachial plexus block, we administered 1% lidocaine. As it was sufficiently effective to stabilize microvascular anastomosis, continuous brachial plexus blockade was performed for 4 days after the surgery. The color of the finger was stable during this treatment and it was then successfully replanted without infection. There are several reports of the advantages of brachial plexus blockade; it increases blood flow in replanted digits by preventing neutrally mediated spasms, but pain and agitation may increase the risk of vasospasm. Our case demonstrated its effectiveness at preventing highly damaged tissue due to an animal bite from developing infection and microvascular anastomosis from vasospasm.
The Masquelet technique is gaining popularity in reconstructive procedures for large bone defects. However, surgery timing and required quantity of graft bone remain topics of discussion. In patients who sustain traumatic injuries, reconstructive surgery using a free vascularized fibula graft (FVFG) should be performed as soon as possible to avoid vasospasm and adhesion complications. In contrast, the second stage of the Masquelet procedure is usually performed approximately 6 weeks after the first stage. We report the case of a patient who simultaneously underwent the Masquelet technique and FVFG reconstructive surgery for a large bone defect in the femur. A 54-year-old man injured his left thigh in a motorcycle accident. X-ray examination revealed an open fracture with a 17-cm length bone defect in his left femur. The bone defect was considered too long to treat by either the Masquelet technique or FVFG alone. He underwent surgery that combined the Masquelet and FVFG techniques. He was able to walk 7 months after the surgery. We consider the combination of the Masquelet technique and FVFG reconstruction to be a useful method for complete recovery, especially for injures resulting in severe fracture with a large bone defect.
We report the use of a free flap with the Masquelet technique to cover a soft tissue and bone defect of the leg. A 52-year-old man was injured in a motorcycle accident. He was diagnosed with open fracture of the left leg. The wound was debrided and the free-floating bone fragments were removed. There was a large soft tissue defect and tibial defect of 9 cm in length. A free latissimus dorsi flap was used to cover the open wound. The bone defect was treated using the Masquelet technique. There were no signs of postoperative infection and bone union was achieved. After 1 year and 3 months, the patient was able to walk with a cane. His left knee range of motion was 140 degrees for flexion and 0 degrees for extension. The use of a free latissimus dorsi flap with the Masquelet technique was effective for treating a large bone and soft tissue defect.
In the following report, we present our experience with the use of the pedicled vascularized fibula graft through a posterior approach for reconstruction of tibial non-union in a patient who achieved successful bony union in nine months. The advantages of a pedicled vascularized fibula graft are that time-consuming microvascular anastomosis is not required and distant donor-site morbidity, which can occur with free fibular grafts, can be avoided. The disadvantage of utilizing a pedicled vascularized fibula graft is the possible loss of mechanical support, which can cause the leg to be more unstable than if a free vascularized fibula graft is used from the contralateral side. Thus, the pedicled vascularized fibula graft was confirmed to be a useful option for the reconstruction of tibial non-union, and a posterior approach is especially useful in trauma cases. The advantages of using the posterior approach include entering through healthy skin, good tissue planes for dissection, and full visualization of the fibula and peroneal vessels. However, it should be noted that a pedicled vascularized fibula graft is more difficult to harvest in an injured leg or at the site of infection where scar tissue surrounds the vascular pedicle.
The patient was a 34-year-old man whose left foot was severely injured by a one-ton boiler. He was diagnosed with a Gustilo type ⅢB open fracture from the forefoot to midfoot and calcaneus fracture. We observed a degloving injury and laceration of the pedal artery at the dorsum of his left foot. We performed guillotine amputation and negative-pressure wound therapy for the amputation stump. At 22 days after initial surgery, we performed definitive reconstruction. First, we fixated the calcaneus fracture using headless compression screws. Second, we performed Chopart’s amputation, and the extensor tendons and plantar fascia were sutured together to prevent equinovarus foot. Third, we elevated a latissimus dorsi flap and covered the amputation stump. We anastomosed the thoracodorsal artery to the pedal artery and their respective accompanying veins to each other. At 28 months after injury, the patient is able to ambulate inside the house. He is also able to move around outdoors using his orthosis. We were able to avoid limb length discrepancy using a combination of Chopart’s amputation, suturing of extensor tendons and plantar fascia, and a free latissimus dorsi flap.