Forearm Defects Research Articles

Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

Successful salvage of upper extremity following severe crush injury associated with vascular compromise using a supra thin free anterolateral thigh flap

Traumatic injuries of the upper limbs can often result in serious and challenging wounds involving multiple compartments such as skin, bone, tendons and neurovascular structures. These type of injuries of the upper extremity pose several challenges to the plastic surgeon. The main difficulty is to provide a stable, long lasting and aesthetically acceptable coverage that enables joints excursion so that patient can return to work at the earliest. Here, we present a case of 45 years old gentlemen who sustained severe crush injury associated with avulsed radial and ulnar artery of left upper limb following road traffic accident. At presentation, there was no pin prick in his hand and hand was pale. At first surgery, hand was revascularized using a vein graft in radial artery and skin grafting was done over the forearm defect as a temporary cover. After 12 hours, when the viability of hand was reassured, the defect was covered with free supra thin anterolateral thigh (ALT) flap. Patient’s hand and flap both survived and he was discharged in a satisfactory condition.

Pedicled SCIA and SIEA Mega Groin Flap-A Staged Reconstructive Approach for Large Forearm Defects

Pedicled SCIA and SIEA Mega Groin Flap-A Staged Reconstructive Approach for Large Forearm Defects

Optimising oral cancer reconstruction: a retrospective cohort study on the modified radial forearm free flap technique to eliminate the need for a secondary donor site

The radial forearm free flap (RFFF) is commonly used in the reconstruction of oral cancer patients. Traditional RFFF (TRFFF) techniques, which often require a secondary donor site to repair the forearm defect, may result in a scar extending to the dorsal hand. This can lead to significant functional and aesthetic concerns in the forearm. We designed a modified RFFF (MRFFF) that incorporates a glasses-shaped flap and features deep venous drainage. To evaluate its effectiveness we conducted a retrospective chart review of 105 patients with oral squamous cell carcinoma who underwent reconstructive surgery between 2018 and 2022. These patients were treated either with a TRFFF (n = 60) or the newly developed MRFFF (n = 45). Our inclusion criteria, guided by preliminary surgical experience prior to initiating the study, stipulated that single oral defects should be no larger than 6 × 6 cm2, and adjacent double defects no larger than 3 × 6 cm2. Flap size, pedicle length, harvesting duration, and anastomosis during the surgical procedure were compared between the two techniques. Preoperative and postoperative oral function, recurrence, mortality, and dorsal scarring were recorded. One-week, one-month, and six-month postoperative subjective aesthetics assessments, and self-reported postoperative donor hand function, were measured using the Michigan hand questionnaire (MHQ). There were no significant differences between the groups in terms of flap size, pedicle length, harvesting time, anastomosis time, postoperative oral function, recurrence, and mortality. However, patients with a MRFFF did not require a second donor graft site and did not have scars extending to the dorsal forearm. They also had significantly improved postoperative aesthetic outcomes (1 week: 70.6%, 1 month: 62.2%) and donor hand function (1 week: 54.6%, 1 month: 40.4%) compared with the TRFFF group (p < 0.001). The MRFFF eliminates the need for secondary donor sites and improves primary donor site outcomes. It is versatile and can be employed for either single or composite oral defects. Through extensive case studies, we have defined its specific scope: it is suitable for single defects measuring no more than 6 × 6 cm2, or for composite defects no larger than 3 × 6 cm2. Furthermore, it does not compromise the functional recovery of the recipient site, and should be widely adopted for all qualifying patients.

RECURRENT FIBROUS DYSPLASIA ON RADIUS TREATED WITH VASCULARIZED FIBULAR GRAFT: A CASE REPORT

Introduction: Fibrous Dysplasia is a benign intramedullary fibro-osseous lesion that are reported to represent approximately 5%-7% of benign bone tumor. Treatment of fibrous dysplasia include bisphosphonates therapy and surgical procedures. Case Report: A 9-year-old girl presented with a mass on her left forearm 2 years ago. Primary resection by curettage was performed and patient did not and one year after the surgery, the mass recurred and patient complaint about lump and deformity on her left forearm. A limb salvage surgery by intercalary resection was performed to remove the tumor and the defect was filled with vascularized fibular graft from the right leg. Seven- month follow up show no sign of recurrence and patient underwent surgery to remove the implant. Discussion: Fibrous dysplasia represents a dysplastic disorder of bone characterized by solitary or multifocal polyostotic intramedullary lesion composed of proliferation of fibroblastic spindle cells. Treatment of fibrous dysplasia include conservative treatment and surgical procedures may be required for correction of deformity, prevention of pathologic fracture and/or eradication of symptomatic lesion. The free vascularized fibular graft is particularly suited for reconstruction of large forearm defects because the fibula matches the radius and ulna in size and shape with studies that shown healing rate of 89%. Conclusion: Fibrous Dysplasia is a benign intramedullary fibro-osseous lesion that are reported to represent approximately 5%-7% of benign bone tumor. The most common clinical symptom is swelling or deformity of the affected site. Treatment of fibrous dysplasia using vascularized fibular graft may be an effective option.

Immediate tendon transfer for functional reconstruction of a dorsal forearm defect after sarcoma resection

In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

ИСПОЛЬЗОВАНИЕ ЛОСКУТА ШИРОЧАЙШЕЙ МЫШЦЫ СПИНЫ ПРИ ПОСТТРАВМАТИЧЕСКОЙ ФУНКЦИОНАЛЬНОЙ НЕСОСТОЯТЕЛЬНОСТИ ВЕРХНЕЙ КОНЕЧНОСТИ

Objective: To improve the outcomes of surgical correction of upper limb dysfunction (ULD) using the latissimus dorsi flap (LDF). Methods: ULD occurred in 76 patients with Volkmann's ischemic contracture (VIC), post-traumatic soft tissue defects, and brachial plexitis in 57, 11, and 8 cases, respectively. Out of 57 patients with VIC, in 30 cases, a skin defect was observed along with severe degenerative changes in soft tissues, neurovascular bundles (NVBs) and tendons. Post-traumatic forearm defects (n=11) in 5 cases were accompanied by damage to the NVBs and tendons. In brachial plexitis, isolated injury to the musculocutaneous nerve occurred in 6 patients, and a combination of nerve lesions with radial nerve palsy – in 2 patients. Results: Transposition of LDF to the biceps brachii for the treatment of brachial plexitis, free muscle transplantation for the treatment of VIC and forearm soft tissue defects were performed in 8, 57, and 11 cases, respectively. Active forearm flexion after the muscle flap transposition was noted after 4 weeks. In contrast, after graft transplantation in VIC, the grip function restoration began after 6 months and improved within 1 year and beyond. Conclusion: Using the LDF in surgical correction of post-traumatic ULD allowed restoring the lost functions of the crushing grip and forearm flexion. For the forearm, only free flap transplantation with a relatively long period of limb function recovery is possible. In contrast, the traspositioned LDF to the biceps allows achieving the desired functional outcomes in the shortest possible time. Keywords: Upper limb, latissimus dorsi flap, Volkmann's contracture, soft-tissue defect, brachial plexitis.

Treatment of diaphyseal forearm defects caused by infection using Ilizarov segmental bone transport technique

BackgroundThe Ilizarov segmental bone transport technique can be applied in the reconstruction of the bone defects with less invasive fashion and more versatility compared to other methods, while most studies were focused on the lower extremity. The purpose of this study was to evaluate the effectiveness of the Ilizarov segmental bone transport technique in the treatment of diaphyseal forearm bone defects caused by infection.MethodsThis study included 12 patients with diaphyseal forearm bone defects caused by infection, who underwent bone transport procedures using the monolateral external fixator at our institution from January 2010 to January 2018, including 10 males and 2 females with a mean age of 39 years (range 23–57 years). Patient’s demographic data and clinical outcomes at least two years follow-up after removing the external fixator were collected and retrospectively analyzed. The functional results were evaluated by the questionnaire of Disability of Arm, Shoulder and Hand (DASH) and the modified Mayo wrist score (MWS) at the final follow-up.ResultsThere were 10 radii and 2 ulnae bone transport procedures collected. The average defect size was 5.1 cm (4-6.5 cm). All patients were successfully followed up with a mean period of 28.2 months (24 to 36 months) and achieved infection-free union. There was no recurrence of infection observed. The mean external fixation time was 232.6 days (182 to 276 days), and the mean external fixation index was 46.3 days/cm (40.9 to 61.8 days/cm). The mean DASH score was 30.6(18 to 49) preoperative, while 13.8 (5 to 26) at the final follow-up. The average modified MWS improved from 68.8 (55 to 80) pre-operatively to 83.8 (65 to 90) at the final follow-up. All the differences between the preoperative and final scores were statistically significant (p < 0.05). Almost all the patients achieved satisfactory clinical outcomes and were able to perform activities of daily living.ConclusionsIlizarov segmental bone transport technique is an alternative and effective method for the treatment of diaphyseal forearm bone defects caused by infection, and this method acquired satisfactory clinical outcomes.

Challenging Difficulties of Flap Reconstruction in the Hand

In reconstructive hand surgery, flaps and therefore microsurgical techniques are inevitable to provide the best functional and aesthetic results. There are various complications of defect repair with microsurgical methods. We aimed to classify subacute and late unexpected complications that develop after defect repair by microsurgical methods and to present the management. Patients who underwent microvascular flap surgery for upper extremity tissue defects between 2014-2018 were included in the study. Complications other than total flap loss were retrospectively investigated and recorded. 8 patients (6 Male, 2 Female) were included to the study. 5 left and 3 right hand defects were detected. 3 fingers, 3 hand dorsum, 1 wrist and 1 forearm defects were detected. 2 marginal necrosis, 2 partial flap loss, 1 venous insufficiency, 1 nonunion, 1 skin contracture and 1 burn were the determined complications. Most defects present with different traumas in hand. The trauma zone is almost always close to the area of microvascular repair, moreover the recipient artery may not always be intact. How the bone fixation is performed is very important, covering the bone should be provided with well-blooded tissues. While providing all these, this coverage should not be bulk and should not restrict the range of motion in the hand. Having grasping function necessitates a repair that puts the function in the foreground compared to other areas in the body. Subclinical infections of hand in patients presenting with post-traumatic defects may cause nutritional problems, which may impair wound healing. Such a problem can also be confused with the arterial deprivation of the flap. The absolute sense requirement distinguishes the hand area from the reconstruction of many areas. All these are challenging difficulties in choosing flap for defects in the hand.

The Superficial Inferior Epigastric Artery Based Abdominal Flap for Reconstruction of Extensive Defects of the Hand and Forearm: A Modified Design With Primary Closure of the Donor Site.

The reconstruction of the hand and forearm targets the restoration of their function and aesthetic appearance. Inferiorly based abdominal flaps are reliable and versatile flaps that can cover large defects of the forearm and hand. Here we present a modified abdominal flap design based exclusively on the superficial inferior epigastric artery (SIEA) to reconstruct the hand and forearm's extensive defects. The donor site is closed primarily. This is a retrospective study of the patients who underwent reconstruction of hand and forearm defects with SIEA flap from 2006 to 2018. The flap was designed on the ipsilateral hemiabdomen with a narrow pedicle based on the SIEA. We describe the anatomical basis and the outcomes of SIEA flap for reconstruction of the hand and forearm's extensive defects. Forty-eight soft tissue defects of the hand and forearm were reconstructed with the SIEA-based abdominal flap. Twenty-nine (60.41%) dorsal defects, 4 (8.33%) volar defects, 4 (8.33%) circumferential defects, 6 (12.5%) hand amputation stump, and 5 (10.41%) finger and thumb defects were covered using the SIEA flap. Forty-seven (97.91%) flaps had complete survival, whereas 1 (2.08%) flap had distal necrosis at the time of division. One (2.08%) flap had marginal necrosis, and 1 (2.08%) flap had distal necrosis after the division. The donor site was closed primarily in all patients. One (2.08%) patient had wound dehiscence at the abdominal donor site. All flaps gave excellent coverage with a satisfactory contour. Abdominal flap based on SIEA is a safe, reliable, and versatile flap for the reconstruction of extensive soft-tissue defects of the hand and forearm. An ability to provide a large amount of skin and soft tissue and the abdominal donor site's primary closure make it a favorable option for upper limb reconstruction in regions with limited resources and technical expertise.

Management of complex forearm defects: A multidisciplinary approach

Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.

VERSATILITY OF PARAUMBILICAL PERFORATOR FLAP FOR UPPER LIMB RECONSTRUCTION

Background Microvascular flap and groin flap are the most commonly used flaps for upper limb reconstruction. Microvascular flap can not be done in certain situations and groin flap is not convenient for coverage of forearm defect and elbow defect. Paraumbilical perforator (pup) flaps can provide a large amount of tissue for coverage of forearm , elbow defects and mitigates the side effects of groin flap. Material and method A retrospective study was conducted for reconstruction of soft tissue defects from finger tip to elbow between January 2016 to December 2019 with PUP flaps .Demographic data, size of the defect, etiology ,flap design and flap complication were analysed . Result The age of the patients ranged from 12 years to 56 year with mean age of 29.85 years and SD = 11.073. Male to female ratio was 1.5 : 1 (M=12 , F= 8). Size of the defect varied between 20 cm2 to 288cm2 with mean of 88.1 cm 2 and SD = 29.69 .No of cases with flap dimension &lt; 100 cm 2 (n= 13), and &gt; 100 cm2 (n= 7) . Aetiology of injury included vehicular accidents in 10 patients, machine injury in 2 patients, electrical burns in 6 patients post snake bite ulcer 2 patients. The location of the defect included hands, forearm and the elbow, and fingers.Flap was directed Superolaterally in 18 patients , inferolaterally in one case , and combined medially and laterally in one case. There was no case of complete flap failure. Conclusion Paraumbilical perforator flap can be a safe and reliable option for soft tissue reconstruction in varied areas of upper limb.

One-bone forearm reconstruction and distal radioulnar joint fusion for emergency one-stage operation in traumatic major bone defect of forearm

BackgroundMajor bone defects in forearm caused by severe trauma is a real challenge for orthopedic surgeons. This study aimed to evaluate the role of one-bone forearm (OBF) reconstruction combined with distal radioulnar joint fusion (DRUJF) as a rescue option under this difficult situation. MethodsIn total, 18 patients with major bone defects in forearm caused by severe trauma were selected from 2003 to 2017 and followed up for 2 to 16 years. All patients were managed in the Emergency Department and received emergency one-stage OBF combined with DRUJF. In addition, patient demographics, surgical techniques, clinical outcomes and complications were collected from the medical records. ResultsThe mean age of patients was 41.5 years (ranging from 23 to 58 years), with 11 males and 7 females. The mean time to union was 5.8 months; 17 patients had complete union, and 1 patient had infection with nonunion requiring secondary procedures. According to the criteria of Chen, 3 patients had a grade-I functional outcome, 14 patients had a grade-II functional outcome, and 1 patient had a grade-III functional outcome. Based on the Peterson scoring system, the outcome was excellent for 3 patients, good for 13 patients, fair for 1 patient, and poor for 1 patient. ConclusionOBF reconstruction combined with DRUJF was an alternative surgical procedure as the emergency stage-one intervention for the treatment of traumatic major bone defects in forearm, which may be more functionally and cosmetically superior than forearm amputation.

Two Perforators Improve the Extent and Reliability of Paraumbilical Flaps for Upper Limb Reconstruction.

BACKGROUNDComplex defects of the forearm and arm are best reconstructed with free flaps. Free flaps are however not universally available. They require long operative time and may be contraindicated in patients with extensive injuries due to a lack of good recipient vessels. The alternatives to free flaps are distant flaps such as groin flaps, random abdominal flaps, thoracoepigastric flaps and paraumbilical perforator flaps. These are axial flaps that are limited by the angiosomes supplied by a given perforator or blood vessel. To improve the extent and reliabilities of the paraumbilical flaps, we incorporated two perforators in the flap.METHODSA total of 17 patients with extensive forearm defects were managed by two vessel paraumbilical perforator flaps between January 2013 and December 2018. The perforators were identified by a hand-held Doppler and the flap was fashioned with the perforators at the base. RESULTSThe mean length of the flap raised was 19.5 cm and width was 8.3 cm. The median age was 39 years. All the flaps were successful with no incidence of flap necrosis and no dehiscence.CONCLUSIONTwo vessel perforator flaps improved the reliability of the paraumbilical perforator flap, allowing for a bigger flap to be harvested and thus ensuring a cover of larger defects. The flaps were easy to raise and were easily tolerated by the patients.

A Bilobed Pedicled Groin Flap for Reconstruction of Forearm Skin Defects following Replantation.

The versatility of a pedicled groin flap can be further increased by raising it in a bilobed fashion. This allows the flap to cover both the volar and dorsal surfaces of a hand or forearm defect. A 48-year-old man sustained an avulsion amputation of his right forearm by a rolling machine in a workplace accident. Replantation of the right forearm was performed, and the postoperative course was uneventful. Unfortunately, the wound healing was complicated by circumferential marginal skin necrosis, which was confined to the distal forearm. A bilobed pedicled groin flap was performed for the wound coverage because reconstruction with a free flap would be very risky as the vessels were avulsed from the proximal part of the forearm. A good functional recovery of the hand and fingers was noted at 12 months' follow-up. The advantages of a bilobed pedicle groin flap are that it allows coverage of both the volar and dorsal surfaces at one setting and primary closure of the donor site is possible. Furthermore, a long tube-shaped pedicle in this flap can reduce the patient discomfort and prevent finger stiffness by allowing a range of motion exercise. In conclusion, the bilobed pedicled groin flap is a useful option to cover soft tissue defects involving both the volar and dorsal surfaces over the mid- to distal forearm, especially when the free flap is contraindicated.

Osteosynthesis of Postosteomyelitic Forearm Defects in Children Using a Modified Bone Grafting Technique: The Fibular Intramedullary Bridging Bone and Additional Grafting (FIBBAG).

Background: There are many options to treat post osteomyelitic gaps in forearm bones. We report a pediatric series with postosteomyelitic forearm segmental defects reconstructed with fibular only graft: the non vascular fibular intramedullary bridging bone and additional grafting (FIBBAG) and the results thereof. Methods: Outcomes in 8 patients treated with fibular strut and overlay matchstick grafts were retrospectively assessed. The clinical results were expressed as forearm shortening, range of motion at elbow and wrist joint. The radiological evaluation included time to union, presence of fractures and recurrence of infection, if any. Results: The average patient age was 6 years (range, 3-12 years). The radius was involved in 6 and ulna in 2. Union occurred in all patients. The average intraoperative gap to be spanned was 5.86 cm (range, 3-14 cm). The average time for union was 6.63 months (range, 2-14 months). Two patients required additional bone grafting procedures. No graft fatigues/fractures were noted in available follow up. There was no recurrence of infection in any case. A positive ulnar variance was seen in 3 patients at follow up. Forearm shortening was a major cosmetic limitation following the procedure. Conclusions: Fibular strut and additional bone grafting (FIBBAG) is one of the viable options for reconstruction of post osteomyelitic forearm defects in children with low procedural complication rate.

Donor-site morbidity after harvesting of radial forearm free flaps—comparison of vacuum-assisted closure with conventional wound care: A randomized controlled trial

IntroductionRadial forearm free flaps (RFFF) are often used to replace tissue removed in head and neck surgery. In recent years, many attempts have been made to reduce donor-site morbidity and to prevent common complications such as infection, skin-graft necrosis, tendon exposure and subsequent impairment of hand function. One promising option is the use of vacuum-assisted-closure wound therapy (VAC). The objective of this study was to evaluate the effectiveness of VAC compared with a conventional bolster dressing (CBD). Material and methodsA randomized controlled trial was enrolled. Our study was prospective in design and included patients with a skin-grafted forearm defect after harvesting of RFFF. Patients who met the inclusion criteria were randomly assigned into two study arms. The predictor variable was the type of wound therapy (VAC therapy compared with CBD) and the outcome variables were (1) the size of the wound area, (2) wrist movement and (3) grip strength. Outcome variables were assessed 12 days, three weeks and eight weeks after surgery. ResultsFifty patients (33 males, mean age 61.7 years [SD 15.5]; 17 females, mean age 54.7 years [SD 10.5]) were included consecutively in the study. Patients in the VAC group experienced a faster postsurgical reduction of wound area and had better wrist movement; nonetheless, the differences between the VAC group and CBD group did not reach statistical significance. In contrast, the recovery of postsurgical grip strength was significantly faster in the VAC group. ConclusionsOur study failed to prove that VAC therapy is significantly superior to CBD for all the variable studied. Because VAC therapy has some positive effects, however, we recommend further development of this negative-pressure wound treatment, rather than the termination of its use.

Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects

Background: The reverse radial forearm perforator flaps are useful in softtissue reconstruction of the hand and forearm. Certain modifications in the flap and usage of hyperbaric oxygen therapy as an adjunct in reconstruction could aid in better outcome of the surgical procedure. The conventional reverse radial artery forearm flap incorporates the radial artery along with its venae commitants along with the flap providing less chances of venous congestion. The per-foratoronly flap may cause a twist in a pedicle which may not affect the artery much, but a small increase in pressure may obstruct the tiny veins running along with the perforator resulting in chances of venous congestion which is a common problem in propeller or perforator flaps. This can be overcome by designing a flap with adequate venous outflow and reducing the postoperative inflammatory edema to prevent pressure to the tiny perforators with arterial and venous components. Aims and Objectives: To focus on flap harvest in a perforator plus model to increase the venous outflow and use of hyperbaric oxygen therapy as an adjunct to prevent the inflammatory edema on the perforator vessels. Materials and Methods: Reverse radial artery perforator plus flaps used for the reconstruction of hand and forearm soft-tissue loss in a series of patients due to electrical burns. We used hyperbaric oxygen therapy as an adjunct for reconstruction. Results: No flap related complication in the series. One patient developed venous congestion at the distal tip region which settled without any further intervention. Conclusion: Defects of the hand and forearm due to the electrical burns could be effectively managed with radial forearm perforator plus flap with allowing adequate venous outflow, and hyperbaric oxygen therapy as an adjunct in electrical burns.

Repair of soft tissue defects in finger, thumb and forearm: less invasive methods with similar outcomes.

We review recent developments in using occlusive dressings, dermal templates, and venous flaps for less invasive approaches to treat soft tissue defects of the forearm and fingers. Occlusive dressings can be used for thumb tip or fingertip trauma with soft tissue defects of small or moderate sizes. They permit skin regeneration without use of skin graft or a flap transfer. This is currently a popular way to treat tip soft tissue defects in European countries. Extensive soft tissue defects in the thumb, fingers, hand and forearm require flap transfers traditionally, but in recent years, surgeons use dermal templates to cover the defect site to allow regeneration of subcutaneous tissues, over which a skin graft is used in lieu of a flap. Transfer of a venous flap is currently a reliable procedure and is less invasive compared with conventional flaps, which usually damage a named artery in the donor. We advocate that less invasive methods should be considered for soft tissue defects in the hand and forearm.

Application of perforators positioning technique in anterolateral thigh perforator sub lobe flap transplantation for reconstructing soft tissue defects of forearm or hand

Objective To assess the clinical efficacy of perforators positioning technique in anterolateral thigh perforator sub lobe flap transplantation for reconstructing soft tissue defects of forearm or hand. Methods A retrospective case series study was performed to analyze 24 patients with forearm and hand soft tissue defects admitted from January 2013 to August 2017. There were 18 males and six females, aged 31-68 years (mean, 52.3 years). The wound defect areas ranged from 11 cm×10 cm to 18 cm×14 cm. The anterolateral thigh sub lobe perforator flaps were used for repair. CT angiography (CTA) combined with color Doppler ultrasound (CDS) was used to determine the perforator position before operation. After the appropriate thigh side was selected according to the perforator position and the wound area, the lobed flaps were designed to ensure all the flaps for the stage I suture after the length was converted into width. All patients obtained stage II repair, and the repair time was 5-29 days, with an average of 13 days. The accuracy of perforation positioning was observed during operation (the error was not more than 1 cm for accurate positioning). The flap survival and complications were recorded within 2 weeks after operation. Follow-up was performed using the seven indicators of flap function to evaluate the efficacy. Results The positioning accuracy rate was 99%. One case was seen necrosis about 2 cm at the proximal end of flap. Two cases had arterial crisis after flap operation and survived after active exploration. In two nonunion cases because of wound infection around the flap, one case was healed after dressing change, and another case was healed after debridement. The donor site of the flap obtained stage I direct suture, and one case was seen obvious scar hyperplasia at the donor site. Flaps were made thinner in two patients with hand defects at the later stage. All 24 patients were followed up for 7-33 months, with an average of 18.3 months. According to the seven indexes of the flap function, the results were excellent in seven cases, good in 13, fair in three, and poor in onee, with an excellent and good rate of 83%. The flaps appeared soft with good color at the last follow-up. Conclusions In the treatment of soft tissue defects of forearm or hand using anterolateral thigh flap, conversion from length to width and direct suture of donor site can cover the wound well and reduce complications. Perforators positioning technique can facilitate precise preoperative planning and intraoperative accurate cutting. Key words: Soft tissue injuries; Surgical flaps; Surgery, computed tomography; Anterolateral thigh flap