In order to complete the treatment of mangled hand injury, it is necessary to use the orthoplastic approach, which requires knowledge and skills in orthopedic surgery, plastic surgery, and hand surgery. It is difficult to treat mangled hand injuries without appropriate goal setting. On the other hand, the frequency of such mangled hand injuries has been decreasing in Japan in recent years as the safety of various machines has improved; thus, opportunities for young microsurgeons to gain treatment experience are limited. In this article, we present our approach to the treatment of mangled hand injury, as understanding of treatment concepts and strategies is equally or even more important than surgical skill. The author then discusses how young microsurgeons can gain experience and keep progressing into the future as well as the future prospects of this field in Japan.

  Emergency free flaps are performed directly following emergency surgery for coverage of exposed bones and tendons. Four emergency free flaps for finger injuries were performed at our institution between 2012 and 2022. We performed two venous flaps: one using the superficial palmar branch of the radial artery, and another using scavenged tissue for reconstruction of an injured hand. Venous flaps were applied for the reconstruction of the digital artery and soft tissue defects of the palmar region of the finger at the same time, and the superficial palmar branch of radial artery flap and scavenged tissue were applied for the reconstruction of soft tissue defects of the palmar region of the hand and finger. One of the four flaps became completely necrotic; however, no postoperative infections occurred in any of the cases. The reason for the necrosis was due to the lack of adequate outflow in an A-V-A-type venous flap without venous anastomosis. Although the emergency free flap is technically demanding and requires a longer operating time, the procedure may be useful for the reconstruction of soft tissue defects when considering the propensity for vascular fibrosis and vasospasm in delayed operations.

  Eleven adult patients who underwent surgical treatment for trauma with brachial artery injury were reviewed. The patients were nine males and two females with a mean age of 58.4 years. The causes of injury were six upper extremity avulsion injuries, three blunt injuries, and two glass puncture injuries. The injury types were seven complete/incomplete amputations, two sharp injuries, and two blunt injuries. Injury levels were proximal in three, central in four, and distal in four. The length of defect of the brachial artery on preoperative enhanced CT was 2 to 6 cm.
  In the nine cases where limb salvage was possible, the revascularization methods were three end-to-end anastomoses, two end-to-end anastomoses after bone shortening, one bridging vein graft, and three bypasses from the subclavian artery. The mean inhibition time was 6 hours. For sharp injuries or distal injuries, anastomosis could be achieved by end-to-end technique or anastomosis after bone shortening or vein grafting. Proximal avulsion injuries often involve endovascular injuries to the brachial artery and axillary artery, requiring bypass from the subclavian artery to the brachial artery. It is necessary to evaluate the extent of endovascular injury as well as the length of the defect on enhanced CT.

  Hemophilia is a hereditary recessive disease that causes a coagulation disorder. Pseudoaneurysm of upper limb is rare, and there are few studies in hemophilia patients. Herein, we describe a 32-year-old man without any treatable illness. He accidentally cut his distal volar forearm by a kitchen knife. At the first consultation, pulsating bleeding was seen, and it was immediately stopped by compression. Four weeks after, the patient complained of a growing pulsating mass around the scar. Contrast-enhanced tomography showed it had enhanced and unenhanced parts beside the ulnar artery. We diagnosed pseudoaneurysm and made a surgical plan. Preoperative laboratory data showed APTT was 51.8 seconds. An additional test showed clotting factor level was 10%, which diagnosed mild hemophilia A. With a perioperative infusion of factor Ⅷ, we excised the mass with the attached ulnar artery and performed end-to-end anastomosis. At fourteen months follow-up, ultrasound showed good patency of the vessel and no recurrence. Our findings suggest unindicated mild hemophilia is a risk factor for pseudoaneurysm.

  Painful neuroma of the finger may cause spontaneous pain, paresthesia, numbness, cold intolerance, and tapping pain (Tinel sign) , and may result in significant disability of activities of daily living. We experienced two cases with painful neuromas of the fingers that were reconstructed with innervated flaps after neuroma resection. Case 1 had painful neuromas in bilateral digital nerves of the index finger. The patient was treated with an innervated crossed finger flap from the middle finger as an active/reconstructive technique. Case 2 had a painful neuroma in the digital nerve of the thumb. The patient was treated with a first dorsal metacarpal artery flap as a passive/ablative technique. Both patients had good pain relief and preservation of sensation of their fingers. Our findings suggest that innervated flap reconstruction after neuroma resection is a useful procedure for painful neuroma of the finger.

  Extensive degloving injuries of the hand are usually treated with a groin flap. However, the reconstructed hand has no perception, and the outcome is not always cosmetically and functionally satisfactory. We report a case of extensive degloving injury of the hand, that was reconstructed with wrap-around flap and toe transfer. A 19-year-old male with severe obesity sustained an extensive degloving injury of his right hand caused by a confectionery roller. The skin beyond the wrist was almost completely degloved. Revascularization of the degloved skin was performed on the day of injury; however, the entire skin was necrotized. All digits were amputated at the base of the proximal phalanx and covered with a unilateral pedicled groin flap. Subsequently, the thumb was reconstructed using a wrap-around flap. This allowed side pinch. To better improve hand function and appearance, a toe transfer was performed to the index finger. Active flexion range of the index finger was improved by flexor tenolysis eight months after the toe transfer. A toe graft provides good perception and appearance with a nail plate; however, a reduction in the number of fingers and loss of the toes are inevitable.

  In general, patients with thyroid cancer invading multiple organs have a poor prognosis. In particular, thyroid cancer that has invaded the trachea may require resection of a wide section of the trachea, which often makes tracheal reconstruction difficult. Despite numerous reports on tracheal reconstruction, no standard technique has been established.　
  We performed a two-stage tracheal reconstruction after initial tracheal wall reconstruction using transplantation of costal cartilage and a free forearm flap in a patient with tracheal invasion from thyroid cancer who had undergone partial tracheal resection. This resulted in a good outcome with no narrowing of the tracheal lumen after reconstruction and excellent cosmetic results. Our findings suggest that this reconstruction method is safer and more reliable than other reconstruction methods for patients with tracheal invasion of thyroid cancer.

  Purpose: The availability of reliable and suitably sized veins is limited for creating free flaps to treat severe trauma and infection, and it is important to manage vessel size discrepancy between the recipient and flap veins. We evaluated the clinical outcomes of free flaps with large-to-small venous end-to-side anastomoses using the microscopic parachute end-to-side (MPETS) anastomosis in soft tissue defects in the extremities. This procedure comprises mainly a wide-slit venotomy and parachute procedure at the heel.　
  Methods: We examined 24 free flaps in 23 patients given a large-to-small venous anastomosis using the MPETS technique. Patient demographics, details of vessel anastomoses, and flap outcomes and complications were obtained from medical records.　
  Results: Two veins were anastomosed in six flaps. Thirty anastomosed veins were assessed, and 24 deep veins, all of which accompanied main arteries, were chosen as recipient veins. The mean diameters were 1.5 mm in the recipient veins and 2.7 mm in the flap veins, and the mean vessel size discrepancy was 1.8 fold (range 1.3-3.3 fold) . Because of the presence of venous valves at the anastomotic site, trimming of venous cusps was performed in six veins. All flaps survived, although one venous thrombosis occurred because of pedicle kinking in a case with a short pedicle.　
  Conclusions: The MPETS technique is simple, reliable, and useful for performing various types of venous anastomoses regardless of a vessel size discrepancy and the presence of a venous valve. This may be a good option for large-to-small venous anastomosis in free flaps.