经皮踝外侧韧带复合体重建治疗慢性踝外侧不稳

[目的]探讨经皮功能重建踝关节外侧韧带复合体治疗慢性踝关节不稳的临床疗效。[方法]2014年1月~2018年2月,符合纳入标准的47例慢性踝关节不稳患者随机分为两组,其中,切开组23例采用常规切开术式重建距腓前韧带(ATFL)和跟腓韧带(CFL),经皮组24例采用超声定位,经皮建立骨隧道重建ATFL和CFL。比较两组间手术时间、围术期并发症、踝背伸-跖屈活动度(ROM)、AOFAS评分、VAS评分,应力位影像测量距骨前移度和倾斜度。[结果]术中切开组2例出现腓浅神经损伤。经皮组手术时间、切口总长度显著小于切开组,差异有统计学意义(P<0.001)。切开组术后4例切口边缘处坏死,而经皮组1例切口渗液。两组患者随访26~30个月,平均(27.39±2.51)个月。术后6个月时,经皮组ROM显著大于切开组(P<0.05)。随时间推移两组患者AOFAS评分均显著增加,而VAS评分显著减少(P<0.001),但是两组相同时间点AOFAS评分和VAS评分的差异均无统计学意义(P>0.05)。应力位X线测量方面,术后两组患者距骨前移距度和距骨倾斜角均较术前显著减少(P<0.001)。但是两组相同时间点在距骨前移距度和距骨倾斜角的差异均无统计学意义(P>0.05)。[结论]经皮踝关节外侧韧带复合体重建治疗慢性踝关节不稳的效果与常规开放手术相当,但具有手术时间短、创伤小、并发症少的优点。     

Microvascular reconstruction of complex craniofacial defects.

Many large vault or skull base tumours are best treated by wide surgical excision and primary reconstruction using a microvascular free tissue transfer (free flap). We report 23 patients who were reconstructed using free flaps, eight having been previously treated surgically elsewhere and seven of whom had recurrent disease after radiotherapy. There was one flap failure and a local recurrence rate of 16% (3/19). The outcome at a mean follow-up period of 29 months, was 19 patients alive and four deaths.     

Composite cervicofacial flap for reconstruction of complex cheek defects.

The authors present the reconstructive technique for complex cheek defects using the composite cervicofacial flap and study the possibilities, advantages, disadvantages, and results that can be expected. The design follows the classic outline of Mustardé's flap. The skin is undermined for 2 cm anterior to the ear, then after incision of the superficial musculoaponeurotic system (SMAS), undermining is continued below the plane of the SMAS, level with the facial nerve branches. It is continued forward to the facial vessels, which give rise to branches that ensure the blood supply of this composite flap and contribute to its high reliability. In the cervical region, undermining is done beneath the platysma, which is transected transversely in the lower cervical region to allow good upward mobility and satisfactory transposition of the flap. The flap is adapted to the defect and the medial suture line is placed as near as possible to the medial limit of the cheek aesthetic unit. The authors carried out a retrospective study of 7 patients with complex facial reconstruction after excision of malignant lesions. The defects measured from 4x4 cm to 9x7 cm. In 4 patients excision included the periosteum, and in 1 patient excision involved the entire thickness and removed the entire anterior half of the cheek. In 4 patients reconstruction involved the cheek and eyelid. In spite of the advanced age of the patients (88, 69, 91, 67, 70, 82, and 59 years), there was no distal edge necrosis. The only complication was a single case of facial paresis, which resolved spontaneously. The results were considered very good in all 7 patients. The authors conclude that the composite flap increases the possibilities of the cervicofacial flap. It is more mobile, more reliable, thicker, and more adaptable. It can be used in complex cheek defects that involve the periosteum, or even in full-thickness defects. The quality of the results obtained using this flap represents a considerable advance in facial reconstruction.     

带感觉的上臂外侧皮瓣游离移植修复手部皮肤缺损

目的游离上臂外侧穿支感觉皮瓣修复手部皮肤缺损。方法2008年7月-2010年5月．急诊或择期行同侧上臂外侧穿支感觉皮瓣修复手部皮肤缺损11例．其中单纯皮肤缺损5例．合并肌腱伤或骨折6例。皮瓣切取面积为6．5cm×4．5cm-11cm×6．5cm,皮瓣包括上臂外侧皮神经．移至受区重建皮瓣感觉。结果术后皮瓣全部成活。随访5～12个月．皮瓣外观及弹性良好,单纯皮肤缺损行皮瓣移植后手部各关节主被动活动正常者5例,合并肌腱伤或骨折行皮瓣移植后手部各关节主动活动有不同程度影响者6例。按中华医学会手外科学会断指再植功能评定标准评定：优7指,良4指。结论带感觉上臂外侧皮瓣游离移植是修复手部皮肤缺损的一种较好方法。     

The extended Abbe flap in the reconstruction of complex midfacial defects

The Abbe flap is most commonly used to repair full-thickness defects of the lip that do not involve the commissure. This well-perfused axial flap is based on the labial branches of the facial artery. The inferior labial vessels have been shown to support a cutaneous territory, including the entire lower lip, chin, and submental skin. Defects extending beyond the confines of the upper lip may be reconstructed with an extended lip switch flap that is based on the inferior labial artery. This "extended" Abbe flap allows functional and cosmetically acceptable repair of the upper lip, medial cheek, columella, and nasal sill. Case presentations illustrate the technique and outcome.     

Delayed reconstruction of lateral complex structures of the ankle

Lateral ankle instability is one of the most common and well-recognized conditions presenting to foot and ankle surgeons. It may exist as an isolated entity or in conjunction with other concomitant pathology, making it important to appropriately diagnose and identify other conditions that may need to be addressed as part of treatment. These associated conditions may be a source of chronic pain, even when the instability has been appropriately treated, or may lead to failure of treatment by predisposing the patient to ankle inversion injuries. The primary goal of this editorial is to provide a brief summary of the common techniques used in the delayed reconstruction of lateral ankle ligamentous injuries and present a method we have successfully employed for over 15 years. We will also briefly discuss the diagnosis and treatment of the more common associated conditions, which are important to identify to achieve satisfactory results for the patient. We present the outcomes of 250 consecutive reconstructions performed over the last 10 years and describe our operative technique for addressing lateral ankle ligamentous injuries.     

Combined reconstruction of complex defects of the chest wall

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex®) mesh, and Marlex® mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex® mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.     

单隧道悬吊固定解剖重建外侧韧带复合体治疗慢性踝关节外侧不稳

目的:探讨单隧道悬吊固定解剖重建外侧韧带复合体术治疗慢性踝关节外侧不稳的临床疗效.方法:回顾性分析2016 年 1 月至2018 年12 月行单隧道悬吊固定踝外侧韧带复合体解剖重建的23 例慢性踝关节外侧不稳患者的临床资料,其中男7 例,女16 例;年龄17～33(26.0±4.3)岁;Kellgren-Lawrenc...     

Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects

BACKGROUND: Tumors of the lateral skull base are best treated with surgery plus or minus radiation therapy. Surgical ablation may involve cutaneous structures, the auricle, the parotid, and the lateral temporal bone. These composite soft tissue defects are best reconstructed with composite tissue. Multiple pedicled flaps have been used to reconstruct these defects. Free flaps have been shown to provide the best tissue for these reconstructions. We review our experience and present an algorithm for their reconstruction. METHODS: A case series of consecutive patients treated between 1999 and 2006 at 2 tertiary care institutions, Oregon Health and Science University and University of Alabama at Birmingham were reviewed. There were 73 patients who had periauricular defects requiring 74 free tissue transfers in this retrospective chart review. All defects had extensive cutaneous loss and underwent some form of parotidectomy. There were 57 lateral temporal bone defects and 16 periauricular defects where the external auditory canal was preserved. The majority of patients had nonmelanoma skin malignancies (65%). Eighty percent of patients had undergone previous treatment (radiation therapy, surgery, or a combination therof). RESULTS: Early on, reconstruction was performed using a radial forearm (RFFF, n=29), evolving to lateral arm (n=6), rectus (n=11), and finally an anterolateral thigh (ALT, n=28) free flap. The average hospital stay was 6 days, and the overall complication rate was 22%. The rectus flap needed debulking in 34% of patients, and the anterolateral thigh in 9%. Periauricular defects were classified based on preservation of the external auditory canal (class I), lateral temporal bone resection with preservation of the auricle (class II), or lateral temporal bone with total auriculectomy (class III). CONCLUSION: Class I defects were best managed by RFFF reconstruction, class II defects were managed well with the ALT flap, and class III defects required the ALT or rectus flap.     

Bipedicle flap reconstruction for complex longitudinal dorsal tissue defects of the digits

Achieving coverage after digital injury is crucial, because simple skin defects can expose essential structures such as tendons or bones. This is particularly true on the dorsal surfaces of the digits, where the skin provides the only protection for the tendons. However, longitudinal skin defects of the digit have not been specifically identified in the literature and there have been few reports focusing on longitudinal dorsal skin defects. Here we report on the use of a bipedicle flap for reconstruction of complex longitudinal dorsal tissue defects of the digits, including those associated with tendon or bone damage.     

The visor ear flap: a new method for reconstruction of upper helical defects

Helical defects in the upper pole of the ear have been traditionally reconstructed by a variety of techniques. However, some of these techniques decrease the length of the ear while others produce a bulky helix. This paper describes a new technique in which a visor flap is raised from the medial aspect of the ear to form the soft tissue cover of the helical rim. A rotation flap is subsequently raised to cover the donor defect of the visor flap and a conchal cartilage graft taken from underneath the rotation flap is used to construct the helical cartilage. This method has the advantage of being a single-staged procedure, avoids reduction in the length of the ear and provides acceptable cosmetic result. The visor ear flap should be a valuable tool in the armamentarium of reconstructive procedures for upper helical defects.     

Combined reconstruction of complex defects of the chest wall.

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex) mesh, and Marlex mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.     

Two modifications of the radial forearm flap for reconstruction of complex facial defects

The free radial forearm flap has been one of the most common free flaps of recent decades. This flap is employed predominantly in head and neck reconstruction. The possibility of combining bone, muscle, and nerves with the fasciocutaneous flap greatly enhanced reconstructive options. However, the frequently unsightly donor site and the development of other readily available free flaps have led to a decline in the use of the radial forearm flap. Nevertheless, for reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, the radial forearm flap still remains a prime choice. Two modifications of the standard forearm flap are presented. The first patient had two large defects at the nose and mental area after radical resection of a basal-cell carcinoma. Soft-tissue reconstruction was achieved with a conventional forearm flap and a second additional skin island based on a perforator vessel originating proximally from the pedicle. Both skin islands were independently mobile and could be sutured tension-free into the defects after tunneling through the cheek, with vascular anastomosis to the facial vessels. The second patient required additional volume to fill the orbital cavity after enucleation of the eye due to an ulcerating basal-cell carcinoma. In this case, the body of the flexor carpi radialis muscle was included in the skin flap to fill the defect. The skin island was used to reconstruct the major soft-tissue defect.     

Recent advances in the reconstruction of complex Achilles tendon defects

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.     

A method for reconstruction of large full-thickness defects of the bony thorax

Wide resection in 12 cases of malignant or potentially malignant lesions of the chest wall resulted in full-thickness loss of skeleton and frequently of overlying soft tissues (defect greater than or equal to 15 cm in its smallest diameter or at least 90% of the sternum resected). In reconstruction of the defect, steel bars were used to replace lost ribs and a double layer of Marlex mesh for intercostal spaces. Soft-tissue coverage and primary closure were accomplished with current plastic surgical procedures and good stability of the chest wall was achieved. Protracted respiratory support was required in only one case. Postoperative pain was managed with epidural anesthesia and routine analgesics. Functionally and cosmetically satisfactory long-term results were obtained, with no infection and no need for removal of prosthetic material. The overall 5-year and 10-year actuarial survival rates were 60% and 37.5%. If lesions are radically resectable, the extent of thoracic wall resection need not be restricted because of inability to close the defects.