Extraanatomic lateral reconstruction to the popliteal vessels.

OBJECTIVES: To describe the lateral approach to the popliteal artery in reconstructions after soft tissue sarcoma resection in the thigh. DESIGN: Case reports. Subjects Four patients with soft tissue sarcoma. METHODS: Extraanatomic reconstruction of the resected artery and vein in the medial part of the thigh was performed. Vessel reconstruction was performed before tumor resection to avoid leg ischemia. RESULTS: In all four patients the artery was replaced by using the contralateral saphenous vein, while the femoral vein was replaced in two cases using e-PTFE. Post-operative complications included one large lymphatic collection and a deep wound infection. Arterial primary graft patency was 100% after 1-7 years. Patency of the e-PTFE-venous graft was 0% without further consequences. CONCLUSIONS: The extraanatomic lateral replacement of the vessels in the thigh is an elegant method in difficult vascular reconstructions after soft tissue sarcoma resection or debridement for deep vascular infections.     

Combined turnover vastus lateralis and lateral gastrocnemius flaps as a salvage option for soft tissue reconstruction of the knee

Infection with subsequent wound breakdown and soft tissue deficit represents the most devastating complication after total knee arthroplasty. Although microsurgical reconstruction is increasingly being performed in this setting, several factors may preclude its use. We present a case of a 52-year-old female patient who presented with a complex right anterior knee wound resulting from a complicated clinical course following total knee arthroplasty. Initial reconstructive efforts included coverage with a superiorly based fasciocutaneous thigh flap as well as a medial gastrocnemius flap. Persistence of infection and necrosis of the distal aspect of the fasciocutaneous flap eventually required salvage by means of a vastus lateralis turnover muscle flap augmented by a lateral gastrocnemius muscle flap. The combination of these two fairly straightforward muscle flaps provided stable wound coverage with well-vascularized tissue without the use of sophisticated microsurgical expertise. Level of Evidence: V, therapeutic study     

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects.Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle.All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction.Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.     

Free flow‐through anterolateral thigh flap for complex knee defect including the popliteal artery

Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft‐tissue coverage should be performed simultaneously for limb salvage. We present the one‐stage reconstruction of a complex knee defect including the popliteal artery using a free flow‐through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flow‐through ALT flap enables simultaneous leg revascularization and soft‐tissue coverage with a single free flap. The lateral circumflex femoral arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries. © 2015 Wiley Periodicals, Inc. Microsurgery 35:485–488, 2015.     

带血管蒂肌瓣转移用于胫腓骨骨肉瘤保肢术

目的 报告四肢恶性肿瘤广泛切除保肢手术,应用带血管蒂肌瓣修复和重建软组织成功的经验。方法 广泛切除小腿骨肉瘤及瘤周软组织,得用人工假体或吻合血管游离腓骨和移植等方法重建骨骼,局部转移带血管蒂的腓骨肌或比目鱼肌肌瓣,欠组织缺损。结果 临床应用７例,带血管蒂的肌瓣成活良好,无切口并发症,膝关节活动度提高,假体表面皮肤移动性良好。结论 带血管蒂的肌瓣在胫腓骨恶性肿瘤的保肢术中,对于重建软组织缺损和保证切     

闭式灌洗法在组织瓣修复皮肤软组织缺损伴伤口感染中的应用

目的：探讨降低组织瓣修复软组织缺损并感染创面后感染复发率的方法。方法 A组38例经组织瓣修复的皮肤软组织缺损伴创面感染者,伤口采用温盐水闭式灌洗法;B组29例为组织瓣修复的皮肤软组织缺损伴创面感染者,伤口采用半胶管或胶管负压引流,比较两组术后创面感染复发及皮瓣坏死率。结果术后随访9～12个月,A组出现创面感染复发率为5.26%,皮瓣部分坏死率为18.42%;B组出现创面感染复发率为20.69%,皮瓣部分坏死率为27.59%。两组创面感染复发率差异有统计学意义（P＜0.05）,但两组的皮瓣坏死率差异无统计学意义（P＞0.05）。结论闭式灌洗法能有效降低伤口感染复发率,但对组织瓣的成活无明显影响。     

腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝软组织缺损

目的探讨腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝软组织缺损的临床效果。方法采用回顾性病例系列研究分析2013年6月至2019年6月,上海交通大学医学院附属新华医院(崇明)收治的9例腘窝软组织缺损患者临床资料,男6例,女3例,年龄25~73岁,平均49.6岁,腘窝缺损创面为6.5 cm×3.5 cm~17.0 cm×8.5 cm。根据解剖学基础,结合腘窝缺损创面的位置、大小、形状,设计并切取腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝缺损创面,皮瓣面积最大为18.0 cm×10.0 cm,最小为7.5 cm×4.5 cm。根据皮瓣成活、感染控制、弹性色泽、外观形态、供区瘢痕、皮肤感觉、膝关节活动功能、患者认可度等情况,对患者术后疗效进行综合评价。结果 9例皮瓣术后全部顺利成活,供、受区伤口一期愈合,其中2例皮瓣远端发生皮缘坏死,给予换药处理后完全愈合。术后均获6~60个月随访,平均33个月,皮瓣成活优良,形态满意,色泽、弹性、质地与周围正常皮肤接近,供区瘢痕较小。疗效评价:满意8例,一般1例,无不满意。膝关节功能优7例,良1例,可1例。皮瓣肿胀评级,早期:Ⅰ度6例,Ⅱ度2例,Ⅲ度1例,Ⅳ度0例;后期:Ⅰ度8例,Ⅱ度1例,Ⅲ度0例,Ⅳ度0例。结论腘窝直接皮动脉穿支蒂螺旋桨皮瓣移位修复腘窝缺损创面方法简便、安全可靠、损伤较小,易于推广,是修复腘窝皮肤软组织缺损的理想方法之一。     

内侧腓肠肌肌(皮)瓣在小腿近端恶性肿瘤手术中的应用

目的探讨采用内侧腓肠肌肌(皮)瓣修复小腿近端恶性肿瘤切除后缺损的方法及临床疗效。方法自2015年10月至2019年1月,对6例小腿近端恶性肿瘤切除后的胫前软组织缺损患者分别采用内侧腓肠肌肌(皮)瓣转移修复、内侧腓肠肌肌瓣转移联合人工网状补片重建伸膝功能,并于术后3个月对切口的愈合情况、肢体功能以及肿瘤控制情况进行评价。结果本组共6例患者,术后获随访11~34个月,平均(13.3±3.2)个月。5例切口一期愈合(占83.3%);1例皮瓣边缘发生部分坏死,经换药后愈合。1例于术后12个月因肿瘤肺转移而死亡;1例于术后3个月时肿瘤局部复发接受了二次手术治疗;其余4例肿瘤无复发,效果较满意。患者术后3个月MSTS评分为17~29分,平均(26.2±4.8)分;评定下肢功能的优良率为83.3%(5/6)。结论采用内侧腓肠肌肌(皮)瓣转移修复小腿近端恶性肿瘤切除后的软组织缺损,以及联合人工网状补片行伸膝功能重建,其方法简单易行,可获得较满意的临床效果。     

Trauma centre experience: flap reconstruction of traumatic lower limb injuries

BACKGROUND: Decision-making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study was to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in-hospital complications and outcomes related to timing, choice of flap and pre-existing complications. METHODS: Retrospective review of all lower limb flap reconstructions carried out by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital from 1 July 2001 to 20 October 2005 (51-month period) was carried out. RESULTS: Sixty-four patients had 83 flap reconstructions (35 free and 48 local) of 70 separate lower limb injuries. Internal skeletal fixation was followed by earlier soft tissue coverage and lower deep metal infection rates. Twenty-seven flaps (32.5%) developed soft tissue infections, and 16 fixation devices (25.8%) were complicated by deep metal infection. There were six (12.5%) local flap partial necrosis and four (11.4%) free flap failures. Limbs in which flaps were carried out after day 5 were more likely to develop deep metal infection (P = 0.04) and suffer free flap failure or local flap partial necrosis (P = 0.02). Three patients underwent secondary amputation during their initial admission. CONCLUSIONS: The current study presented our experience with flap reconstruction of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) were associated with lower infection rates and optimal outcomes.     

Reconstruction of the extensor mechanism after proximal tibia endoprosthetic replacement

The proximal tibia is a difficult area in which to perform a wide resection of a bone tumor. This difficulty is due to the intimate relationship of tumor in this location to the nerves and blood vessels of the leg, inadequate soft tissue coverage after endoprosthetic reconstruction, and the need to reconstruct the extensor mechanism. Competence of the extensor mechanism is the major determinant of functional outcome of these patients. Between 1980 and 1997, 55 patients underwent proximal tibia resection with endoprosthetic reconstruction for a variety of malignant and benign-aggressive tumors. Reconstruction of the extensor mechanism included reattachment of the patellar tendon to the prosthesis with a Dacron tape, reinforcement with autologous bone-graft, and attachment of an overlying gastrocnemius flap. All patients were followed for a minimum of 2 years; 6 patients (11%) had a transient peroneal nerve palsy, 4 patients (7.2%) had a fasciocutaneous flap necrosis, and 2 patients (3.6%) had a deep wound infection. Full extension to extension lag of 20 degrees was achieved in 44 patients, and 8 patients required secondary reinforcement of the patellar tendon. Function was estimated to be good to excellent in 48 patients (87%). Reattachment of the patellar tendon to the prosthesis and reinforcement with an autologous bone-graft and a gastrocnemius flap are reliable means to restore extension after proximal tibia endoprosthetic reconstruction.     

封闭负压引流联合腓肠肌肌皮瓣治疗胫前软组织缺损

目的探讨封闭负压引流(VSD)联合腓肠肌肌皮瓣治疗胫前软组织缺损的效果。方法对16例胫前中上2/3软组织缺损患者应用VSD联合腓肠肌肌皮瓣治疗。结果 16例均获随访,时间3个月～3年。1例患者行岛状肌皮瓣转移时,因皮瓣血运差改行肌瓣转移+植皮术,全部成活;1例患者出现内固定物排异反应,去除内固定物后伤口愈合。余14例患者皮瓣均成活,伤口一期愈合,对患肢膝、踝关节功能无明显影响。结论一期应用VSD覆盖创面,后行腓肠肌肌皮瓣转移治疗胫前不同平面软组织缺损,操作简单,效果满意。     

Optimizing the use of local muscle flaps for knee megaprosthesis coverage

Primary muscle flap cover of megaprostheses following limb salvage surgery for tumors around the knee serves to decrease infection rates, provide additional soft tissue cover over the implant, and act as a bed for split-skin grafting. The purpose of this study is to demonstrate the role of supplementary muscle flaps such as the hemisoleus, gracilis, and semimembranosus in augmenting coverage provided by gastrocnemius muscle flaps. Between August 1999 and August 2006, 10 patients underwent resection of distal femur (n = 5) or proximal tibia (n = 5) sarcomas, followed by bone reconstruction with a modular megaprosthesis and soft tissue coverage with local pedicled flaps. The average age was 31 years (range, 13 to 47), with pathologic diagnoses inclusive of osteosarcoma (n = 7), chondrosarcoma (n = 2), and recurrent giant cell tumor (n = 1). For proximal tibial tumors, both bellies of the gastrocnemius with hemisoleus for additional soft tissue cover were used. For distal femoral tumors, 1 gastrocnemius belly sutured to the extensor mechanism and gracilis or semimembranosus provided adequate soft tissue cover. All flaps survived without complications, all wounds healed well, and all patients were ambulant after surgery. The role of supplementary muscle flaps was demonstrated in specific situations, where coverage of the subcutaneous area of the midtibia was deficient and where a significant amount of the vastus medialis or gastrocnemius has been resected. Technical refinements included primary skin grafting to relieve tension during skin closure and excision of the aponeurosis over the gastrocnemius and hemisoleus to increase the reach and surface area of the muscle flap.     

Optimizing functional upper extremity reconstruction—Simultaneous free anterolateral thigh flap and tendon transfers—A case report

Composite upper extremity defects involving muscle–tendon units are amongst the most formidable reconstructive challenges and mandate functional restoration in addition to stable soft‐tissue coverage. Here, the authors present a case of a composite defect involving the extensor muscle–tendon units of the forearm resulting from surgical resection of a recurrent Merkel cell cancer. Functional restoration was achieved via multiple tendon transfers followed by soft tissue coverage with a free anterolateral thigh (ALT) flap. No donor‐ or recipient‐site complications were encountered and complete flap survival was noted. Following a 6‐week period of immobilization, physical therapy and range of motion exercises were initiated. Excellent functional outcome and high patient satisfaction were noted at 8 weeks postoperatively. In summary, simultaneous tendon transfers and microsurgical tissue transfer may provide a potentially superior approach for upper extremity reconstruction in complex composite defects. © 2014 Wiley Periodicals, Inc. Microsurgery 37:71–74, 2017.     

Managing skin necrosis and prosthesis subluxation after total knee arthroplasty

Skin necrosis and prosthetic subluxation are dreaded complications after total knee arthroplasty. It can result in deep infection with subsequent failure of prosthesis. The incidence of infection in patients with rheumatoid arthritis who undergo knee arthroplasty is high when compared to patients with primary osteoarthritis. The gastrocnemius muscle flap has been described for cover of proximal tibia and tendon loss because of malignancy and has been used as a bridge graft in trauma patients with patellar tendon loss. We describe a patient with total knee arthroplasty with anterior knee skin necrosis and prosthesis subluxation because of attenuation and loss of continuity of patellar tendon. This was managed by using gastrocnemius bridge grafting. Here, the gastrocnemius bridge graft was used as a soft tissue cover as well as a dynamic anterior stabilizer for the prosthesis.     

Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.     

Use of nasolabial flap for mouth floor reconstruction

SUBJECT: Oral cavity cancers represent 30% of the cephalic extremity tumors. Their resection requires in the majority of the cases a reconstruction by soft tissue. The reconstruction must be simple by bringing some reliable, hairless, thin, resistant tissue to radiation therapy, with a limited morbidity and an acceptable scar ransom. PURPOSE: The purpose of our study is to define the place and the limits of nasolabial flap in the reconstruction of the anterior floor of the mouth after tumoral resection compared to the other surgical and microsurgical techniques. MATERIAL AND METHOD: We retrospectively studied patients with oral cancerous lesions of the anterior floor of the mouth reconstructed by nasolabial flap between 1997 and 2002. The patients benefited from a surgical resection of the tumor by respecting the safety margins, with an immediate reconstruction allowing the restoring of the oral functions. We tried to describe the limits of this flap and discussed its modalities of vascularization. RESULTS: Fifty-three flap procedures were performed on 47 patients; forty-one have received a unilateral and 6 a bilateral nasolabial flap. The majority of tumors were squamous cell carcinomas (50 cases). The average age of patients were 64.8 years (45-78 years) with 40 men (75%) and 13 women (25%). A radical neck lymph nodes dissection with facial artery ligation was realized for 21 patients (15 ipsilateral and 3 bilateral) without affecting the outcome. As complications, we noted one complete necrosis and two partial necrosis of the flap, two postoperative wound complications with dehiscence as well as a massive local recurrence of initial tumor in one patient. CONCLUSION: The nasolabial flap represents a simple functional and morphological option to other pedicled or microsurgically anastomosed flaps for the reconstruction of intermediate-sized mouth floor defects.     

Omental free flap reconstruction in complex head and neck deformities

BACKGROUND: Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. This article reviews our 25-year experience with omental free tissue transfers. METHODS: All patients who underwent free omental transfer to the head and neck region were reviewed. RESULTS: Fifty-five patients were included with omental transfers to the scalp (25%), craniofacial (62%), and neck (13%) region. Indications were tumor resections, burn wound, hemifacial atrophy, trauma, and moyamoya disease. Average follow-up was 3.1 years (range, 2 months-13 years). Donor site morbidities included abdominal wound infection, gastric outlet obstruction, and postoperative bleeding. Recipient site morbidities included partial flap loss in four patients (7%) total flap loss in two patients (3.6%), and three hematomas. CONCLUSIONS: The omental free flap has acceptable abdominal morbidity and provides sufficient soft tissue coverage with a 96.4% survival. The thickness \and versatility of omentum provide sufficient contour molding for craniofacial reconstruction. It is an attractive alternative for reconstruction of large scalp defects and badly irradiated tissue.     

Blunt popliteal artery trauma: one hundred consecutive injuries

An institutional experience with 100 consecutive blunt popliteal artery injuries over a 20-year period was reviewed. The overall amputation rate was 15%; however, during the past 7 years this has declined from 23% to 6%. Minimizing delay in the revascularization of ischemic limbs, routine systemic heparinization, primary arterial repair when possible, repair of popliteal venous injuries, aggressive wound debridement, and early soft tissue coverage have contributed to improved limb salvage during the 1980s.     

Brachytherapy tubes and free tissue transfer after soft tissue sarcoma resection

Irradiation commonly is used after resection of soft tissue sarcomas to decrease the local recurrence rate. Brachytherapy spares more normal tissue than external beam irradiation and permits irradiation to the tumor bed in the immediate postoperative period. After vascular anastomosis and irradiation, flap survival can be affected by vascular coagulation in the immediate postoperative period and later by vascular fibrosis secondary to irradiation effects. The purpose of the current retrospective study was to evaluate the survival of free tissue transfer when combined with brachytherapy after resection of soft tissue sarcomas. Thirty-six patients had wide resection of extremity tumors, free flap coverage, and brachytherapy 5 days after surgery. Followup averaged 54 months. There were three major and four minor complications. The major complications included two patients with free flaps who required revision of anastomosis before radiation therapy (they had brachytherapy 5 days after the second surgery without additional complications) and one patient who had a deep wound infection develop 2 months after the index procedure and required a second flap. Minor complications included one hematoma, one partial skin graft loss, and two superficial infections. Brachytherapy can be done safely at the site of microvascular anastomosis in the immediate postoperative period.     

Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries

The benefits of free flap transfers in the acute burn injury are early wound closure, early mobility, reduced hospitalization, and possibly limb salvage. This retrospective study will attempt to provide principles to the use of free fasciocutaneous flap for the reconstruction of acute burned-hand injuries. Between 1995 and 2004, 5521 patients were admitted to the burn unit at Linkou Chang Gung Memorial Hospital. Of these, 38 patients (0.7%) patients received free fasciocutaneous flap transfers. Each patient's chart was reviewed the following data: age, gender, burn injury type, percentage of the burned area to total body surface area, flap type, operations prior to free flap coverage, the size and location of recipient area, timing of free flap coverage, operative time, duration of hospital stay, complications, flap survival and returning to work. All 38 free flaps survived and healed well. Three flaps with partial necrosis due to wound infections required subsequent debridement and skin grafting. Arterial thrombosis occurred in one patient and was salvaged successfully. Minimal donor-site morbidity with no intraoperative mortality was observed. Free fasciocutaneous flap transfer is a safe, efficacious one-stage reconstruction for acute burned-hands with satisfactory aesthetic and functional outcomes. Flap survival is not affected neither by the etiologies of burn nor the timing of free flap coverage.