自体腓骨移植重建骨巨细胞瘤破坏的桡腕关节

目的总结桡骨远端骨巨细胞瘤瘤段切除后,采用自体腓骨近段移植行腕关节部分融合术（腓骨一舟月骨融合）的临床效果。方法2008年5月至2010年1月,收治7例桡骨远端Ⅱ、Ⅲ级（Campanacci分级）骨巨细胞瘤患者。男4例,女3例;年龄19～45岁,平均32．8岁。病程1-18个月,平均8个月。其中2例采用带血管的腓骨近端移植融合部分腕关节,5例采用不带血管的腓骨近端移植融合部分腕关节。术后功能评价包括腕关节活动度、前臂旋转功能及MSTS评分。结果术后切口均Ⅰ期愈合。7例均获随访,随访时间2．2—3．8年,平均3．1年。X线片检查示移植腓骨均顺利成活,带血管组骨愈合时间为12—16周,不带血管组骨愈合时间18-30周。随访期间肿瘤无复发,取腓骨侧膝关节未见明显骨关节炎表现。腕关节活动范围：背伸28°～40°,平均33．8°;掌屈16°-30°,平均23．8°;前臂旋前55°-80°,平均72°;前臂旋后38°-75°,平均55．4°,平均握力为对侧的76％。MSTS评分平均为85．71％。所有患者腕关节稳定性良好,无活动性疼痛,能够胜任日常生活、工作。结论采用自体腓骨近段移植行腕关节部分融合重建腕关节,能保留一定的腕关节功能,是桡骨远端骨巨细胞瘤安全、有效的治疗方法之一。     

Improved free vascular graft survival in an irradiated surgical site following topical application of rVEGF

PURPOSE: Wound healing disorders following surgery in preirradiated tissue are clinically well known and may even become more crucial with the increasing use of neoadjuvant chemoradiation protocols. Both the expression of vascular endothelial growth factor (VEGF) and endoglin (CD105) play a key role in neovascularization and wound healing after soft tissue grafts in irradiated and nonirradiated tissue. Modulation of neovascularization through the application of recombinant VEGF (rVEGF) may be a therapeutic option to reduce wound healing disorders in irradiated tissue. An experimental in vivo model was used to study the possible role of rVEGF for reduction of wound healing disorders and the promotion of neovascularization. METHODS AND MATERIALS: A free myocutaneous gracilis flap was transplanted from the groin into the neck region of Wistar rats (weight 300-500 g) with and without previous irradiation of the neck region with 40 Gy: Group 1 (n = 7) radiotherapy alone; Group 2 (n = 14) flap transplantation alone and rVEGF; Group 3 (n = 14) radiotherapy, transplantation, and rVEGF. Time interval between irradiation and grafting was 10 +/- 1 day. 1.0 micro g rVEGF/500 microL phosphate-buffered saline was applied s.c. intraoperatively and on Days 1 through 7. Neovascularization (CD105) and endogenous VEGF expression were analyzed by means of immunohistochemistry on Days 3, 5, 7, 14, and 28 postoperatively and quantified as labeling indices (LI). RESULTS: After irradiation there was a continuous significant reduction of the cytoplasmic VEGF expression (MEAN LI: 0.018 +/- 0.048) compared with the nonirradiated control (mean LI: 0.042 +/- 0.006) (p < 0.001). VEGF expression after flap transplantation without irradiation after VEGF application was at a constantly higher level from Day 3 (mean LI: 0.044 +/- 0.01) to Day 28 postoperatively compared with the control group (Day 3, mean LI: 0.028 +/- 0.006) (p < 0.001). As an indication of increased neovascularization after the local application of rVEGF, a significantly increased expression of CD105 was found in the transition area and graft bed from Day 7 on (p < 0.001). After irradiation and grafting there was a significant overall increase in the VEGF- and CD105-expression throughout Day 28 after rVEGF in the transition area (p < 0.001). CONCLUSION: Whereas irradiation alone led to a downregulation of the endogenous VEGF expression, rVEGF application resulted in an increased expression and in a CD105 associated neovascularization after soft tissue grafting in irradiated tissues. Application of rVEGF may enable modulation of wound healing by influencing neovascularization. This could indicate a possible clinical approach for reducing fibrosis and chronic wound healing disorders in irradiated tissues.     

Reconstruction of the hypopharynx with the free jejunum transfer

Microsurgical techniques have revolutionized pharyngolaryngeal reconstruction. Free flap reconstruction with the free jejunal flap enables one stage reconstruction with minimal morbidity and mortality. This review will examine indications, operative technique, postoperative management, and expected outcomes for the hypopharyngeal reconstruction with the free jejunum flap. This procedure allows for maintenance of oral sections and rapid return of per-oral feeds and swallowing. The vast majority of patients resume swallowing and can maintain adequate nutrition without the need for supplemental enteral feeding via a tube. The free jejunal transfer can be rapidly harvested in most instances and transplanted to the hypopharyngeal region with a greater than 95% success rate. The jejunum fee flap is most useful for circumferential defects of the hypopharynx, but can also be used for partial defects. The most common local complications are stricture and fistula formation. A history of preoperative radiation therapy increases the risk of local complications.     

Early and late complications in the reconstructed mandible with free fibula flaps

Background and Objectives

Evaluation of mandibular reconstructions with free fibula flaps. Identification of factors associated with major recipient site complications, that is, necessitating surgical intervention under general anaesthesia.

Methods

Seventy‐nine reconstructions were included. The following factors were analyzed: fixation type, number of osteotomies, site of defect (bilateral/unilateral), surgeon, sex, ASA classification, continuous smoking, pathological N‐stage, age, defect size, flap ischemic time, and postoperative radiotherapy. Proportional hazards regression was used to test the effect on the time between reconstruction and intervention.

Results

Sixty‐nine (87%) of the 79 fibula flaps were successful at the last follow‐up. Forty‐eight major recipient site complications occurred in 41 reconstructions. Nineteen complications required surgical intervention within six weeks and were mostly vascular problems, necessitating immediate intervention. These early complications were associated with defects crossing the midline, with an estimated relative risk of 5.3 (CI 1.1‐20, P = 0.01). Twenty‐nine complications required surgical intervention more than 6 weeks after the reconstruction. These late complications generally occurred after months or years, and were associated with smoking, with an estimated relative risk of 2.8 (CI 1.0‐8.3, P = 0.05).

Conclusions

Fibula flaps crossing the midline have a higher risk of early major recipient site complications than unilateral reconstructions. Smoking increases the risk of late complications.     

Reconstruction of scalp defects with the radial forearm free flap

Background

Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.

Patients and methods

A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.

Results

The patients were primarily male (n = 34), with a mean age of 67 years (25?C91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).

Conclusion

Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.     

Reconstruction of maxillectomy and midfacial defects with free tissue transfer

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.     

桡骨远端骨巨细胞瘤切除术后自体腓骨移植与异体骨移植腕关节重建的对比研究

骨巨细胞瘤好发于长骨骨端,是一种具有侵袭性的原发性骨肿瘤,局部手术后容易复发,复发率为2096～50﹪,瘤段切除复发率为6.3﹪[1].桡骨远端是骨巨细胞瘤的好发部位之一,仅次于股骨远端及胫骨近端,也是骨巨细胞瘤局部容易复发的部位.     

游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损

目的 探讨吻合血管的游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损的疗效。方法 对27例胫骨骨纤维结构不良患，行病灶彻底切除，所遗骨缺损以吻合血管的游离腓骨移植重建。移植腓骨长6cm～26cm，平均14．2cm。术后随访2年～12年，平均6．6年。结果 移植的腓骨术后平均4．2个月(3～8个月)达到骨性愈合，双下肢等长，功能接近正常。结论 吻合血管的游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损，可最大限度地恢复患肢功能，是行之有效的方法。     

应用折叠型游离股前外侧皮瓣修复面颊贯通性缺损12例

目的：探讨折叠型游离股前外侧皮瓣在修复面颊贯通性缺损中的临床应用效果。方法：2010年1月至2014年10月,在中山大学附属肿瘤防治中心应用折叠型游离股前外侧皮瓣修复12例面颊贯通性缺损的患者。分析获取游离股前外侧皮瓣的手术过程、血管吻合技巧以及皮瓣存活率。结果：11例皮瓣存活,1例因术后静脉血栓形成而坏死。在12例患者中,游离股前外侧皮瓣的供区均一期缝合,供区的线性瘢痕隐蔽性好,且供区大腿的功能不受影响。结论：游离股前外侧皮瓣具有良好的可塑性,折叠后可同时修复面颊贯通性缺损的内侧及外侧,具有供区并发症少、外观易接受及患者满意率高的优点。     

Hemiarthroplasty of the elbow with a vascularized fibular graft after excision of Ewing's sarcoma of the proximal ulna: a case report

We report an 8-year-old girl with a Ewing's sarcoma in the right proximal ulna. The patient presented with pain in her right elbow, and plain radiographs showed destructive changes with a periosteal reaction in the proximal third of the ulna. A biopsy confirmed the diagnosis of Ewing's sarcoma. For preoperative chemotherapy, the patient received two courses of vincristine, doxorubicin and cyclophosphamide alternating with high-dose ifosfamide. MRI and angiography demonstrated that the chemotherapy was effective and therefore the patient underwent wide local excision of the tumor and reconstruction of the elbow joint using a vascularized fibular graft. Pathological examination of the resected specimen showed no evidence of viable tumor cells. After surgery, the patient received three courses of chemotherapy consisting of the same agents as those for the preoperative chemotherapy. Four years after surgery, there is no evidence of local recurrence or distant metastasis. Furthermore, the grafted bone is extending favorably and the patient has excellent function with active movement of the elbow.     

Reconstruction surgery for patients with musculoskeletal tumor,using a pasteurized autogenous bone graft

Background The pasteurized autogenous bone graft (PABG) is a new method to reuse resected and diseased autogenous bones after heat treatment at a comparatively low temperature (60°C–65°C).Methods The subjects of this study were ten patients with musculoskeletal tumor who underwent surgery with a PABG in the 6 years between 1995 and 2000.Results The pasteurized bone developed into bone union in all patients, except for the elderly patients who required repeat surgery. There were no infected patients. The PABG was performed by three different types of reconstruction, a segmental method, an intercalary method, and a combination method with an artificial joint as a spacer. No local recurrence of tumor the pasteurized bone was observed from in any patient.Conclusion The PABG appears to be a comparatively easy, safe, inexpensive, and effective reconstruction method for musculoskeletal tumors.     

Reconstruction of oral defects using free revascularized jejunum transfer

Reconstruction of the oral cavity after extended surgery poses many difficult problems. The vital functions of the oral cavity, especially swallowing, mastication and breathing, are seriously impaired by resection of the tongue, floor of the mouth, gingiva or jaw bone. We have used the free revascularized jejunal transfer for reconstruction of the oral cavity in 10 patients and have had good functional and cosmetic results. The advantages of this method are as follows: 1) it is a one-stage operation; 2) the flexibility of the graft preserves maximal tongue function; 3) the graft can be applied to difficult anatomic sites, and 4) the mucosal defect is covered with jejunal mucosa and induration is minimum. Our success rate with this procedure has been 90%. In our experience, this transfer is useful for reconstruction of a massive defect in the oral cavity.     

血管化骨组织瓣在下颌骨放射性骨坏死临床治疗中的应用研究*

目的：探讨血管化骨组织瓣在治疗下颌骨放射性骨坏死中的应用。方法：对2003 年1 月到 2015 年1 月上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科采用血管化骨组织瓣修复下颌骨放射性骨坏死术后缺损的53 例患者临床资料进行回顾性分析。结果：在53 例下颌骨放射性骨坏死血管化骨组织瓣修复中,血管化腓骨瓣应用48 例（90 .57 %）,血管化髂骨瓣5 例（9.43 %）。术后5 例（10 .42 %）腓骨瓣出现并发症（4 例静脉栓塞,1 例动脉危象）,经探查后 3 例皮瓣恢复正常,2 例改用胸大肌皮瓣修复创面。而髂骨瓣 2 例（40 .00 %）出现术后并发症（1 例静脉栓塞,1 例动脉危象）,最后植入髂骨因坏死被取出,局部清创缝合。皮瓣供区均未出现明显并发症。平均随访时间28 （5～60 ）个月,经过血管化骨组织瓣治疗后88 .57 % 患者骨坏死得到有效控制,85 .71 % 患者张口度在 2～3 指,85 .72 %的患者能进软食或半流质,80 .00 %的患者言语可识别度较好。另外,在随访时还发现,通过术中牵引钉或术后斜面导板等使用,髁状突保留与否与患者术后张口、面型等关系不大,但髁状突保留的患者颞下颌关节区不适感明显比髁状突去除者少。结论：血管化骨组织瓣应用于下颌骨放射性骨坏死术后缺损的修复,虽然存在一定的风险,但只要适应证选择恰当、术中操作精细及术后并发症控制良好,仍是目前手术治疗下颌骨放射性骨坏死最好的方法。血管化骨组织瓣首推血管化腓骨瓣。