足部一蒂多瓣同时修复手部多处皮肤缺损

目的 介绍足部一蒂多瓣同时修复手部多处皮肤缺损的临床效果.方法 对8例19处手部创面采用一蒂多瓣的方法进行修复,其中以第一跖底动脉为蒂的第一、二趾侧方皮瓣修复5例12处;以足背动脉为蒂的跗外侧皮瓣及第一、二趾侧方皮瓣修复1例3处;以足背动脉为蒂的足背皮瓣及(足母)趾趾腹皮瓣修复2例4处.结果 术后8例19块皮瓣全部存活,随访时间为3～ 36个月,皮瓣外形逼真,两点分辨觉为5～11 mm,有排汗功能,术后供区植皮创面Ⅰ期愈合.结论 足部一蒂多瓣是同时修复手部多个创面的理想方法,它简化了手术步骤,缩短了手术时间,但应根据损伤类型、面积选择最合适的皮瓣.     

双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤

目的 探讨应用组合组织移植修复全手皮肤套脱伤的方法.方法 对3例全手皮肤套脱伤患者,分别采用一侧足部以胫前动脉为蒂的带踝前皮瓣、足背皮瓣、足内侧皮瓣和足外侧皮瓣的拇甲皮瓣再造拇指,修复桡侧手掌手背及虎口区皮肤缺损;另一侧足部带以上相同皮瓣的第二趾甲皮瓣再造示指(或中指),修复尺侧手掌及手背皮肤缺损.结果 术后3例,除一再造示指坏死外,其余组织瓣全部存活.术后随访3～12个月,修复后手部外形和捏、握、抓等功能基本恢复.皮瓣及再造拇、示指(或中指)感觉恢复至S2～S4.结论 双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤是一种有效的治疗方法.     

The use of combined latissimus-serratus free flap for soft tissue coverage in the hand

Summary A case report is presented on the successful use of a combined latissimus-serratus free muscle transfer in a farmer whose hand was degloved in corn husking bin. There have been no previous reports of the use of such a flap for soft tissue coverage on the hand. The patient was transferred eight days post-injury with an infected wound, a gangrenous thumb and viable fingers. Flap coverage was undertaken four days later. The latissimus dorsi and the lower four slips of the serratus anterior muscle were anastomosed via a common vascular pedicle to the radial artery. The post-operative course was uneventful and donor site morbidity minimal.     

Coverage of defect over toes after failure of microsurgical replantation with medial sural artery perforator flap: A case report

In this report, we present a case of toe reconstruction with a medial sural artery perforator free flap after failure of replantation. A 35‐year‐old male suffered a crush injury from a heavy object falling over the left 1st, 2nd, and 3rd toes and underwent microsurgical replantation of the toes at an outside facility. Over the next 2 weeks, ischemic necrosis of all the toes developed. This condition was very frustrating for the patient who had very high expectations of preserving the toes, and also for the surgeon to determine the optimal method to reconstruct the distal foot and toes. After debridement of non‐viable tissues, the defect over the toes was resurfaced using a medial sural artery perforator free flap and full thickness skin graft. Subsequently, several minor operations, including interdigitation, excision of neuromas, and defatting procedure were performed to complete his reconstruction. Eighteen months later, the patient had very aesthetically pleasing and fully functional toes. A medial sural artery perforator free flap may be used to repair the soft tissue defect on the toes after failed replantation, and provides sufficient skin. © 2015 Wiley Periodicals, Inc. Microsurgery 36:161–164, 2016.     

Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

Reconstruction of traumatic absence of the thumb by microvascular free tissue transfer from the foot.

The development of microvascular surgical techniques during the last quarter century has advanced the ability of the hand surgeon to reconstruct the traumatically amputated thumb. The use of tissue from the foot has become the mainstay of therapy for this previously exceedingly difficult reconstructive problem. Although numerous minor variations of thumb reconstruction with use of the toes from the foot are available, three main techniques--the complete great toe transfer, wraparound flap, and second toe transfer--provide a predictable outcome. With multiple donor sites available, the surgeon can choose a procedure based on the needs of the patient as well as the particular preferences of the individual surgeon involved. The uniform goal in thumb reconstruction is to provide a cosmetically acceptable, stable, mobile, and sensible thumb that can be used in opposition and pinch maneuvers. Transfer of the great toe can provide excellent reconstruction in the selected patient. This transfer may be the procedure of choice in the child who requires continued epiphyseal growth of the transferred digit. The esthetic appeal of this transfer is somewhat dependent on individual patient variation and the appearance of the toe relative to that of the contralateral uninjured thumb. In patients with a narrow great toe, the transfer can provide an ideal esthetic result. Disadvantages of this transfer are that it is less esthetic when the toe is very bulbous in appearance and that the resultant defect and morbidity in the donor foot may be significant, possibly affecting activities of daily living. The wraparound flap provides the unique ability to customize the thumb reconstruction. The final esthetic outcome of the thumb can be altered in nail size, circumference, and length. Use of the wraparound flap permits a greater portion of the great toe to be left with the foot in an attempt to preserve more normal gait and function postoperatively. This type of transfer does not permit interphalangeal joint motion and may not permit metacarpophalangeal joint motion. Therefore, the requirements of a normal carpometacarpal joint with excellent thenar musculature so that the postoperative thumb can be put through a functional arc of motion are essential. Transferring a portion of the distal phalanx in the wraparound flap permits the intercalary iliac crest graft to have viable bone on both the distal and proximal aspects, thereby reducing postoperative osteopenia of the iliac crest graft itself.(ABSTRACT TRUNCATED AT 400 WORDS)     

Present technique and long-term results of toe-to-antebrachial stump transplantation.

Complete hand amputation has been considered conventionally as an indication for the use of mechanical prosthetic devices in order to regain some hand like function. A microsurgical option to create a new pinching ability after wrist amputation has been used in a series of 13 patients. The actual operation technique is presented in detail. It was designed by the senior author in 1981 and applied into clinical use in 1983. In order to evaluate the functional results and patient satisfaction in long-term, a questionnaire was sent to 12 patients and 11 patients were interviewed, examined clinically and studied with a hand function scoring test according Sollerman. The operated series consist of 12 adults with posttraumatic distal antebrachial or wrist amputations and 1 adolescent boy with a congenital wrist level amputation. There were 3 females and 10 males in the series. The satisfaction to achieved result was generally good. The ADL section of Tamai score and the one we used correlated well with each other and patient satisfaction. Sollerman hand function test gave worse results in two blind patients and same occurred in two short antebrachial stump patients. However the satisfaction was much better in Tamai score among blind patients, with wrist amputation level amputations. In our opinion this single toe transfer method gives an acceptable pinch reconstruction for hand amputation patients. We measured pinch strength and total active motion. They averaged about half of the normal values. The reconstruction is suitable to the patients, who are not willing to donate multiple toes or who are aware and concerned about the risks of human hand transplantation, which necessarily will need a life-long immunosuppressive medication to prevent from rejection.     

Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot

IntroductionThe aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not.Patients and MethodsNinety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively.ResultsIn 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints.ConclusionMultiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.     

Reconstruction of adactyly for 4th and 5th toes: the study of foot pressure.

Analysis of foot pressures in cases of reconstructed adactyly of the lateral toes is presented. Two cases with adactyly of the 4th and 5th toes in which new toes were created by cross-knee tubed pedicle flap were chosen and foot pressures of both the operated foot and the contralateral normal foot were measured postoperatively. The results did not indicate any functional disturbance after this method of reconstruction.     

Temporary ectopic digital implantation: a clinical series of eight digits

This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted onto the foot, while in the second patient the four amputated digits were implanted onto the opposite forearm. After stump reconstruction, the digits were microsurgically transferred to the hand, restoring a functional pinch. One digit suffered a venous congestion and necrosis in the ectopic site caused by a haematoma and another experienced a no-reflow phenomenon. In conclusion, temporary ectopic implantation remains a procedure that can be used to salvage amputated digits.     

Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand.

OBJECTIVE: To assess the utility of toe-to-finger transfers (TFTs) for post-traumatic reconstruction of the fingerless hand. DESIGN: A case series. SETTING: A regional trauma centre. PATIENTS: Eight men, mean age was 36 years (range from 25-59 yr), who had lost all the fingers from a hand due to a crush-degloving injury (6 patients), frostbite (1 patient) or a burn injury (1 patient). INTERVENTION: TFT. Twelve TFTs were cone and the mean time from injury to reconstruction was 17.2 months. MAIN OUTCOME MEASURES: Objective (range of motion, moving 2-point discrimination, grip strength, key pinch, Jebsen-Taylor hand assessment, return to work) and subjective (activities of daily living and a questionnaire) measures. RESULTS: Eleven of the 12 transfers survived. Six of the 7 in whom the transfer was successful were available for follow-up (mean 45 mo). Range of motion was 10 degrees at the distal interphalangeal joint, 18 degrees at the proximal interphalangeal joint and 59 degrees at the metacarpophalangeal joint. Sensation was protective in all. Grip strength and key pinch were 26.1% and 70.2% of the contralateral hand respectively. Jebsen-Taylor assessment indicated that basic activities were possible but slowed. All 6 patients returned to work and could perform 92.6% of the activities of daily living unassisted. Hand and foot symptoms were mild. Two-thirds were appearance conscious, 5 of the 6 went on to altered vocations and all reported overall satisfaction as high. CONCLUSION: This study supports TFT for reconstruction of the fingerless hand in that, although transferred toe function may be poorer than a normal finger, the hand is restored to a useful, sensate and versatile functional unit, such that global hand and patient function, as well as patient satisfaction, are very good.     

Incisional lumbar hernia after the use of a lumbar artery perforator flap for breast reconstruction

Abstract

Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has been described as a good alternative for autologous breast reconstruction. The LAP flap is a perforator flap based on a single pedicle. This flap is easy to harvest, with minimal donor-site morbidity. We present a case of a lumbar incisional hernia after LAP flap breast reconstruction in a 53-year-old patient. The patient had been treated with a bilateral mastectomy for cancer. Secondary breast reconstruction was performed with a bilateral DIEP flap. Reoperation was necessary because of a failed DIEP flap at the left side. Reconstruction was performed with a free LAP flap. The patient was referred for a right lumbar incisional hernia at the donor-site of the LAP flap. Open repair was performed with a retroperitoneal mesh. The thoracolumbar fascia was closed in with a running suture. Lumbar artery perforator is a perforator flap based on a single pedicle. Although it does not sacrifice any muscle and seems to be associated with minimal donor-site morbidity, we present the first report of a lumbar incisional hernia repair after LAP flap breast reconstruction treated using an open retroperitoneal mesh repair.     

Combined free-tissue transfer for primary reconstruction of radial part of the hand

This paper presents 14 cases of primary reconstruction of radial-part hand defect by combined free-tissue transfer. The thumb was reconstructed by wraparound flap or second-toe transfer, while a lateral upper-arm flap or anterolateral thigh flap was transferred to cover the soft-tissue defect of the radial part of the hand. The arteries of the toe and flap were anastomosed and cascaded with the radial artery in an anatomical "snuffbox." Fourteen toes and 13 flaps survived in 14 cases. Only one flap was lost. Two-point discrimination of thumb tips was between 4-8 mm. The results suggest that combined free-tissue transfer appears to be a promising way of reconstructing a defect of the radial part of the hand.     

Distally based perforator sural flaps for foot and ankle reconstruction

Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chain-linked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.     

Hand reconstruction for multiple amputations by double microsurgical toe transplantation

Double microvascular toe transplant procedures were used to restore function in 16 mutilated hands. In eight hands, both opposing surfaces were reconstructed with the great toe or second toe used for the thumb and the contralateral second toe for the ulnar side of the hand. In eight hands in which the thumb was still present, two fingers were reconstructed with a second toe from each foot. All 33 transplanted toes survived. In all patients, hand function was substantially improved, with an average of 9.15 pounds of pinch strength between the transplanted opposing digits or the transplanted digit and a normal thumb. Adequate sensibility was restored. The two transplant procedures were done sequentially in six patients, while the two transplantations were performed simultaneously in 10 patients. Simultaneous reconstruction proved time- and cost-effective.     

Double toe transfers

Ten double toe transfers for mutilating hand injuries have been studied. In two patients with total loss of all digits, pincer pinch was restored by the transfer of two separate toes, one to each side of the stump. Seven patients had survival of the thumb and a three-point chuck pinch was provided by transfer of a second toe plus a wrap-around flap over a bone graft to create a third, but stiff digit. One patient required three fingers and was treated by one single toe transfer and one double toe transfer.     

Conjoined legs: Sirenomelia or caudal regression syndrome?

Presence of single umbilical persistent vitelline artery distinguishes sirenomelia from caudal regression syndrome. We report a case of a12-year-old boy who had bilateral umbilical arteries presented with fusion of both legs in the lower one third of leg. Both feet were rudimentary. The right foot had a valgus rocker-bottom deformity. All toes were present but rudimentary. The left foot showed absence of all toes. Physical examination showed left tibia vara. The chest evaluation in sitting revealed pigeon chest and elevated right shoulder. Posterior examination of the trunk showed thoracic scoliosis with convexity to right. The patient was operated and at 1 year followup the boy had two separate legs with a good aesthetic and functional results.     

拇趾毁损伤的再造

目的介绍逆行足内、外侧双岛状瓦合皮瓣加髂骨植骨再造足拇趾外伤性缺损的临床经验。方法对拇趾及踌、第2趾毁损且跖趾关节完好者,采用以足背动脉跖底深支为蒂,以内踩前或跗内侧血管、外踝前或跗外侧血管为分支的足内、外侧分叶皮瓣瓦合加髂骨植骨再造足拇趾。结果术后皮瓣顺利成活,经6～18个月随访,再造足拇趾外形满意,皮瓣两点辨别觉6-8mm,X线示髂骨与残端趾骨骨性愈合,髂骨未见吸收征象．拇趾跖趾关节背伸达40°,屈曲达30°。结论采用逆行足内、外侧分叶瓦合皮瓣加髂骨植骨再造拇趾是一种简单有效的方法。     

五块游离复合组织修复全手套状撕脱伤的长期随访

目的 通过对患手功能的恢复情况以及足部供区切取组织后功能情况进行长期随访,来评价应用5块游离组织移植一期修复全手撕脱伤的疗效.方法 对7例采用5块游离组织移植一期修复全手撕脱伤的患者进行长期随访,随访离手术时间为3～12年,平均5.8年.对再造手和供足的评价方法:主观指标[DASH评分、Michigan手功能评价、足部Maryland评分(FPCS)];客观指标(捏力、握力、虎口距离、拇手指的关节活动度、再造指的两点分辨觉);采用中华医学会手外科学会拇、手指再造功能评定试用标准评定优良率.结果 主观指标:再造手DASH评分平均为(21.60±16.58)分.Michigan手功能评价(平均):其中整体手功能(67.50±24.05)%,日常活动(99.69±32.58)%,工作情况(49.57±25.45)%,疼痛(24.00±21.38)%,外观(48.20±7.11)%,满意度为(78.40±12.65)%.供足Maryland评分平均为(84.56±2.44)分.客观指标:再造拇掌指关节活动度平均为(56.00±20.77)°,示指掌指关节活动度平均为(78.00±10.33)°,中指掌指关节活动度平均为(76.00±9.00)°;再造手平均握力达健侧的46.70%;拇、示指平均捏力为健侧的66.52%,拇、中指平均捏力为健侧的61.30%;拇指指端两点分辨觉平均为(8.47±0.68)mm,再造手指指端两点分辨觉平均为(10.59±0.82)mm;手掌、手背感觉为S3-;供足除2例患者有色素沉着和少许瘢痕增生外,无疼痛等后遗症.按中华医学会手外科学会上肢部分功能评定试用标准评定:再造手功能优2例、良4例、可1例,优良率为85.71%.结论 用5块游离组织组合移植修复全手套状撕脱伤,恢复了较好的手功能,且随着术后时间的延长,手功能的恢复越好,对供足功能仅有轻微的影响.