Management strategies for complex wounds following total knee arthroplasty

Complex wounds following total knee arthroplasty can result in loss of the prosthesis or limb. We report our experience with 32 patients (33 knees) with complex wounds following total knee arthroplasty. Wound assessment includes size, location, depth, presence of infection, quality of tissue, and exposure of bone or prosthetic components. Management options include debridement and closure, local wound care, skin graft, fasciocutaneous flap, local muscle flap, and free tissue transfer. Postoperative outcome is based on complications and clinical evaluation using the Knee Society Score. Successful salvage of the total knee prosthesis was obtained in 28 of 33 knees (85%). Secondary procedures were necessary in ten knees and consisted of soft tissue revision in six knees, removal of prosthetic components in three knees, and both soft tissue revision and removal of prosthetic components in one knee. Our algorithm for management includes early plastic surgery consultation, control of infection, aggressive debridement, and early soft tissue coverage. Received: 25 May 1999 / Accepted: 13 July 1999     

The gracilis free flap for reconstruction of parotidectomy defects

Summary Total parotidectomy causes a significant postoperative concave deformity in the retromandibular, preauricular, and infra-auricular regions of the face; many patients are concerned about this defect. Frey's syndrome (gustatory sweating) is also a well-recognized postoperative entity following parotid surgery. The incidence of Frey's syndrome ranges from 10–90%, depending on the type and complexity of the investigation used to diagnose it [5, 11]. Numerous methods have been described to correct these problems. Patients requiring total parotidectomy were recently offered the option of immediate reconstruction of the contour defect with microvascular transfer of a tailored gracilis muscle flap. Four patients are included in this preliminary series; all are extremely satisfied with the postoperative result. The defect following total parotidectomy can be reconstructed immediately with gratifying cosmetic results, a hidden donor site scar, and to date no operative morbidity.     

Use of a free gracilis flap for coverage of medium size defects over the ankle and foot

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

The gracilis flap revisited

The gracilis muscle or myocutaneous flap is a Mathes and Nahai neurovascular flap type II. It can be used either as a pedicled flap, or as a free flap. Since 1983, 21 gracilis muscle flaps were used in 19 patients at this department; 15 were pedicled while six were free flaps. Two pedicled flaps were lost, possibly due to an intraoperative spasm of the feeding artery. The indications for using the gracilis muscle are discussed, and the results with an average follow-up of more than a decade are presented. Received: 6 December 1999 / Accepted: 7 June 2000     

带腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

目的探讨带腓肠神经营养血管蒂逆行岛状皮瓣临床应用效果.方法在小腿后侧设计带腓肠神经营养血管蒂逆行岛状皮瓣,转位修复10例小腿下段及足跟周围皮肤缺损病例;皮瓣面积最大11.0cm×8.0cm,最小4.0cm×5.0cm.结果 10例皮瓣全部存活,无皮瓣坏死及血管危象的发生.结论带腓肠神经营养血管蒂逆行岛状皮瓣的血供可靠、充分,操作安全、简便,可以修复小腿下段踝部及足跟周围的软组织缺损.     

带血管蒂的趾短伸肌瓣的临床应用解剖研究

作者对130例小腿标本进行了趾短伸肌瓣及相应血供的应用解剖研究,发现下列血管是恒定的:足背动脉(管经2.95mm±0.32);腓动脉穿支(0.87mm±0.34);外踝前动脉(1.02mm±0.28);支配趾短伸肌瓣的外侧动脉弓(0.97mm±1.9);跗外侧动脉(1.50mm±0.22);外侧动脉弓(0.97mm±1.9)和跗外侧动脉(1.50mm+1.22)形成的血管网,设计了带血管蒂的趾短伸肌瓣,并于1995年应用于临床,修复足部软组织缺损。本研究提示:该肌瓣具有知名血管,解剖位置恒定,血运丰富,技术操作简便,成活率高,是修复足部软组织缺损的一种理想方法。     

应用节段性兔股薄肌肌皮瓣重建阴茎勃起功能的研究

目的 设计应用节段性兔股薄肌肌皮瓣构建再造阴茎、重建勃起功能的动物模型.方法 依据肌亚部原则,近似二等分纵向完全劈开兔股薄肌,以前部肌束作为功能单位和皮瓣血供来源,植入硅胶假体作为支撑,构建阴茎再造的动物模型.应用多道生理信号采集处理系统刺激再造阴茎活动,并同步检测复合肌肉动作电位.结果 通过电刺激兔再造阴茎根部的神经,可使前部肌束收缩,引起阴茎形态的相应改变,当肌束发生强直收缩时,再造阴茎上翘幅度最大,并可维持翘起状态数秒,较满意地模拟了阴茎的勃起动作.结论 应用节段性兔股薄肌肌皮瓣构建的再造阴茎动物模型,较满意地重建了阴茎勃起功能,达到了兼顾改善阴茎外观与保留肌肉收缩功能的要求,具有较好的临床应用前景.     

The posterior calf fasciocutaneous island flap in the covering of infected traumatic defects of the knee

Our experience with the posterior calf fasciocutaneous island flap in the treatment of 12 traumatic knee lesions is presented. The wide vascular fascial pedicle provided a good blood inflow and all the flaps survived. The postoperative complications were mild, and the functional result was satisfactory even in cases associated with ligament tissue loss.Presented at the 15th annual meeting of the European Association of Plastic Surgeons (EURAPS), Genoa, Italy, 27–29 May 2004.     

逆行及顺行腓肠神经营养血管皮瓣的临床应用

目的探讨腓肠神经营养血管皮瓣逆行转移修复足背、足跟及踝部组织缺损,顺行转移修复膝部组织缺损的临床应用效果。方法在应用解剖及对成人小腿和足背长度测量基础上,设计带筋膜蒂的腓肠神经营养血管岛状皮瓣,逆行应用修复足背、足跟、足底及踝部软组织缺损,顺行应用修复膝部软组织的缺损。同时观察皮瓣的可切取范围、血液供应及静脉回流情况、营养血管在外踝上与腓动脉穿通支的位置及血管蒂隧道的处理方案。结果临床应用23例,其中修复足背组织缺损11例、足跟软组织缺损5例、膝软组织缺损3例、足底软组织缺损1例及外踝及足背联合缺损3例。皮瓣最大面积16cm×10cm,全部成活。结论腓肠神经营养血管皮瓣血液循环丰富,成活率高,是修复足背、足跟、踝部、足底及膝部软组织缺损的理想皮瓣。     

带肌肉的远端蒂腓肠神经营养血管皮瓣的临床应用

目的探讨带肌肉的远端蒂腓肠神经营养血管皮瓣修复特殊病例的踝足部软组织缺损。方法2004年2月以来应用带肌肉的远端蒂腓肠神经营养血管皮瓣修复踝足部软组织缺损7例,其中胫骨下段软组织缺损伴慢性骨髓炎1例,足后跟软组织缺损伴死腔3例,足底软组织缺损伴跟骨表层骨质缺失(长度为5~8mm)3例,皮瓣切取的面积为16cm×12cm~10cm×7cm,切取的腓肠肌厚度为1~4cm,肌瓣的面积比相应的皮瓣面积小。结果术中观察15~20min,切取肌皮瓣的肌肉面活跃渗血,血液循环良好,皮瓣均成活,所有病例均经2~6个月以上随访,骨髓炎治愈,肌皮瓣外形满意,大部分恢复感觉,行走负重良好。结论带肌肉的远端蒂腓肠神经营养血管皮瓣可以成活,该手术操作简便,系特殊病例的踝足部软组织缺损需行肌皮瓣修复的良好供区。     

筋膜蒂逆行皮瓣在四肢电烧伤修复中的应用

目的　探讨Ⅰ期修复四肢电烧伤创面又不损伤其主要动脉的方法。方法　采用四肢筋膜蒂逆行皮瓣，皮瓣面积最小为５ｃｍ ×３ｃｍ ，最大为１８ｃｍ ×８ｃｍ（ 包括蒂长），筋膜蒂宽为１－５ ～４ｃｍ ，长为３ ～６ｃｍ 不等，皮瓣最小长宽比例为１－６ ：１ ，最大为４－５ ：１ ，皮瓣可旋转１８０°，移转不呈现“猫耳朵”皱襞。结果　临床应用２０ 例３６ 个皮瓣，除个别皮瓣出现散在水泡，轻度肿胀外全获成功。结论　经１ 年以上随访，功能与外形均获得了较满意疗效     

Reconstruction of a defect after harvesting a radial forearm flap using a narrow pedicled paraumbilical perforator-based subdermal vascular network (super-thin) flap

The radial forearm flap is one of the most reliable flaps, but it has serious cosmetic donor site morbidity. We therefore reconstruct the defect after harvesting a radial forearm flap using a narrow pedicled paraumbilical perforator-based subdermal vascular network (super-thin) flap to overcome this problem.     

The transverse upper gracilis flap: Efficiencies and design tips

The transverse upper gracilis free flap is a well-described option for breast reconstruction. The technique is a secondary choice for autologous breast reconstruction because the abdomen remains the primary donor site for breast reconstruction. However, in appropriately selected patients, the authors believe that the transverse upper gracilis flap remains a reliable flap for breast reconstruction. Its consistent anatomy, potentially reasonable donor site scar, limited functional morbidity and simultaneous two-team surgical approach make this flap a viable option for many patients. The technique, however, is not without drawbacks – known numbness of the medial thigh and the potential for chronic lymphedema of the lower leg, contour deformities of the medial thigh, and widening of the medial thigh scar need to be considered.The current article presents a harvest technique that is reliable, rapid and addresses each of the above-mentioned limitations with specific changes in the traditional technique. The article provides video documentation of the modified harvest technique using only monopolar cautery for the dissection.     

筋膜蒂逆行皮瓣在四肢电烧伤修复中的应用

目的探讨Ⅰ期修复四肢电烧伤创面又不损伤其主要动脉的方法。方法采用四肢筋膜蒂逆行皮瓣,皮瓣面积最小为5cm×3cm,最大为18cm×8cm(包括蒂长),筋膜蒂宽为1.5～4cm,长为3～6cm 不等。皮瓣最小长宽比例为1.6:1,最大为4.5:1,皮瓣可旋转180°,移转不呈现“猫耳朵”皱襞。结果临床应用20例36个皮瓣,除个别皮瓣出现散在水泡,轻度肿胀外全获成功。结论经1年以上随访,功能与外形均获得了较满意疗效。     

Reconstruction with distally based dorsalis pedis fasciocutaneous flap for the coverage of distal toe-plantar defects

Reconstruction of small defects in the distal portion of the foot has always been a difficult problem. A case involving a young man with a deep electric burn of the distal lateral side of the big toe, successfully treated with a distally based dorsalis pedis fasciocutaneous flap, is presented. The donor site area of the dorsum of the foot was grafted, and deambulation was reassumed three weeks later. Advantages, limits and anatomical consideration regarding the viability of the flap are also discussed.     

小腿后外侧逆行筋膜蒂岛状瓣修复足部缺损

目的　探讨小腿后外侧逆行筋膜蒂岛状瓣在同侧足部缺损修复中的应用。方法　以小腿外踝及跟腱之间踝关节血管网向上穿支血管及筋膜为蒂 ,形成上达窝下方、前后达小腿内外侧中线的小腿后外侧逆行筋膜蒂岛状皮瓣 ,修复同侧足跟及足背等皮肤软组织深度缺损。结果　应用 6例 ,皮瓣全部成活 ,其中 2例分别为 5岁及 6岁的患儿。结论　该法具有操作简单 ,供瓣面积大 ,血运安全可靠 ,不牺牲主要血管等优点 ,对于小腿中下部、足跟、内外踝及足背部等处较大软组织深度缺损的修复 ,是一种较理想的方法。     

Knee salvage procedures: The indications,techniques and outcomes of large osteochondral allografts

The overall incidence of osteochondral defect in the general population is estimated to be 15 to 30 per 100000 people. These lesions can become symptomatic causing pain, swelling and decreased function of the knee, and may eventually progress to osteoarthritis. In the young and active population, partial or total knee arthroplasty (TKA) is rarely the treatment of choice due to risk of early failure. Osteochondral allograft transplantation has been demonstrated to be a safe and effective treatment of large osteochondral and chondral defects of the knee in appropriately selected patients. The treatment reduces pain, improves function and is a viable limb salvage procedure for patients, especially young and active patients for whom TKA is not recommended. Either large dowels generated with commercially available equipment or free hand shell allografts can be implanted in more posterior lesions. Current recommendations for fresh allografts stored at 4C advise implantation within 21-28 d of procurement for optimum chondrocyte viability, following screening and testing protocols. Higher rates of successful allograft transplantation are observed in younger patients, unipolar lesions, normal or corrected malalignment, and defects that are treated within 12 mo of symptom onset. Patients with bipolar lesions, uncorrectable malalignment, advanced osteoarthritis, and those over 40 tend to have less favourable outcomes.