Neurovascular Flap Research Articles

Repair of distal finger soft-tissue defects with free fibular great toe neurovascular flaps

BackgroundThis work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap.MethodFrom April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated.ResultAll flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve.ConclusionThe free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6–8 months.

“Flap-in-Flap” Technique: Double V-Y Flap in Fingertip Injury Management

Abstract Background Fingertip injuries with amputation are one of the common hand injury problems. Several reconstructive options are available for fingertip injury. V-Y advancement flap is one of the common flaps. In some cases, their advancement capacities are not sufficient to cover the whole defect, resulting in flexion deformity of the distal interphalangeal (DIP) joint, loss of finger pulp shape, or hooked deformity. The double V-Y flap consists of harvesting two cutaneous flaps on the same neurovascular digital palmar bundle. The first V-Y flap is raised as a neurovascular flap and the second flap is an advancement V-Y plasty. Objectives This article evaluates the outcomes of the double V-Y advancement flap for the fingertip reconstruction. Materials and Methods This is a prospective study on 19 patients with zone II and III fingertip amputation tip defects between December 2021 and June 2023. The majority were workplace injuries. Results There were 16 males and 3 females. The average static two-point discrimination was 6 mm. Average advancement of first flap is 8.5 mm and the average advancement of second flap is 4.3 mm. The average total advancement of a double V-Y flap is 12.94 mm (10–15 mm). All of them had “good” total active motion with movement > 210. One patient had flexion deformity at the DIP joint without causing any functional disturbance. All the flaps settled well except for one patient who had superficial partial necrosis of flap which was managed conservatively. Conclusion This is simple and safe for the reconstruction of zone II and III fingertip amputations with the advantage of like-for-like tissue with near-normal sensation. The second flap increased the advancement of the proximal flap, restoring the pulp shape, and thereby reconstructing a functional and aesthetic fingertip.

Modified Bilhaut–Cloquet procedure for Wassel type III–IV polydactyly

BackgroundTo investigate the functional and aesthetic results of a new modified Bilhaut–Cloquet procedure for the treatment of Wassel type III–IV thumb polydactyly.MethodsThirteen patients with Wassel type III–IV thumb polydactyly who visited the Department of Orthopedics of Hebei Provincial Children's Hospital from 2019 to 2022 were selected. The surgical procedure involved a modified Bilhaut–Cloquet surgery, where two-thirds of the distal part of the dominant finger was retained as the p body of the reconstructed thumb. The triangular bone block of the ablated distal thumb that did not contain the epiphysis and articular cartilage was sutured and fixed, and the neurovascular flap of the ablated distal thumb was used as an augmenting segment of the reconstructed thumb, with the nail bed and nail matrix exquisitely sutured. The evaluation performed according to the Japanese Society for Surgery of the Hand (JSSH) system.ResultsAll 13 children showed bone healing, no wound infection, nonunion, or deformity healing. None of the children showed a significant reduction in the active and passive mobility of the thumb postoperatively compared with preoperatively. Postoperative evaluation was performed based on the JSSH score, with a mean of 17.15 points (14–19 points), with 11 children rated as excellent and two as good. No severe nail ridges, nail gaps, or nail split deformities of the thumb were observed postoperatively. Postoperative metacarpophalangeal and interphalangeal joint movements were not reduced compared with preoperative movements. All parents were satisfied with the appearance and function of the reconstructed thumb.ConclusionThe modified Bilhaut–Cloquet procedure designed in this study was satisfactory for Wassel type III–IV thumb polydactyly without affecting the stability of the interphalangeal joints and preserving joint mobility. The postoperative thumb has a comparable circumference and nail width and was cosmetically and functionally satisfactory, especially for the asymmetric two thumbs, which achieved favorable results.

Selection strategy of pedicled axial flaps for repairing high-voltage electric burn wounds in foot and ankle

Objective: To explore the selection strategy of pedicled axial flaps for repairing high-voltage electric burn wounds in foot and ankle. Methods: The retrospective observational research method was used. From January 2017 to December 2022, 16 patients with skin and soft tissue defects in foot and ankle after high-voltage electric burns were treated in General Hospital of Eastern Theater Command, including 11 cases of unilateral defect and 5 cases of bilateral defect. All patients were male, aged from 25 to 75 years. After thorough debridement, the area of the defect to be repaired with the flap was 5.0 cm×4.0 cm to 12.0 cm×8.0 cm. Before operation, the color Doppler ultrasound, computed tomography angiography, or digital subtraction angiography was used to fully evaluate the degree of vascular injury in the affected limb and to identify the distribution and traffic anastomosis of vascular network. Pedicled axial flaps with reliable blood supply were used to repair the wounds as soon as possible, and the area of flaps ranged from 3.0 cm×2.0 cm to 13.0 cm×8.0 cm. The wound in the donor area of flaps was repaired with split-thickness skin graft from head or medium-thickness skin graft from thigh. The flap repair of wounds in various areas of the ankle and foot was recorded. The postoperative survivals of the flaps and skin grafts were observed after surgery. The postoperative appearance of flaps and walking function of patients were followed up. At the last follow-up, the foot and ankle function was evaluated and rated using the American Association of Foot and Ankle Surgeons Ankle Posterior Foot Scoring System. Results: Two wounds in toe area were repaired with reverse dorsal pedis flaps, 3 wounds in medial ankle area and 2 wounds in heel area were repaired with medial plantar flaps, 2 wounds in anterior plantar area combined with toe area were repaired with reverse medial plantar flaps, 2 wounds in anterior plantar area combined with toe area and 5 wounds in anterior plantar area were repaired with reverse medial pedis flaps, 1 wound in toe area was combined with proper plantar digital artery flap, 1 dorsal pedis wound and 1 lateral malleolus wound were repaired with lateral supramalleolar perforator flaps, and 1 lateral malleolus wound and 1 dorsal pedis wound were repaired with sural neurovascular flap. One flap had venous reflux disorder after surgery and survived after treatment, while the other flaps and skin grafts survived completely after surgery. During the follow-up of 6 to 24 months after operation, the appearance of the flaps was good, and the walking function of patients was normal. At the last follow-up, the functional score of foot and ankle was 76 to 95, which was evaluated as excellent in 11 cases and good in 5 cases. Conclusions: According to the condition of high-voltage electric burn in foot and ankle, early and thorough debridement, preoperative imaging examination to evaluate blood vessels of the affected limb, and selection of pedicled axial flap with reliable blood supply are good methods for wound repair and related functional reconstruction of high-voltage electric burn in foot and ankle.

DORSALIS PEDIS NEUROVASCULAR FLAP, OUR EXPERIENCE.

Analyze the donor site morbidity of the dorsalis pedis neurovascular flap in traumatic injuries with hand tissue loss. The study involved dorsalis pedis neurovascular flaps that were used to reconstruct the hands of eight male patients, between 1983 and 2003, aged between 21 and 53 years (mean 34.6, SD ± 10.5 years). The size of the lesions ranged from 35 to 78 cm2 (mean 53, SD ± 14.4 cm2). Surgical procedures were performed two to 21 days after the injuries had occurred. The patients were followed up for an average of 10.3 years (ranging 8-14, SD ± 2.1 years). Regarding the donor site, in one case there was hematoma formation, which was drained; in another case, the skin graft needed to be reassessed. All patients experienced delayed healing, with complete healing from 2 to 12 months after the surgery (mean 4.3, SD ± 3.2 months). Despite the advantages of the dorsalis pedis neurovascular flap, we consider that the sequelae in the donor site is cosmetically unacceptable. Nowadays, this procedure is only indicated and justified when associated with the second toe transfer. Level of Evidence IV; Case series .

Dual-Perforator Flap With Wide Pedicle Versus Sural Neurocutaneous Flap With Peroneal Artery Perforator in the Treatment of Soft Tissue Defects of Foot and Ankle

How to deal with large soft tissue defects around the foot and ankle is still controversial. The aim of this study was: (1) to display a new pedicled flap, also named the dual-perforator flap with wide pedicle (DPFWP), and (2) to compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. According to different surgical methods, 82 patients were divided into 2 groups: the DPFWP group (42 cases) and the SNFPAP group (40 cases). All cases underwent a flap surgery after radical debridement. The 2 groups were homogeneous in terms of age, sex, body mass index (BMI), etiology, location, and follow-up duration. Operation indexes were compared, including flap length, flap width, operation time and blood loss. Complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed. The DPFWP group had larger flap length (24.5 ± 4.6 cm vs 16.3 ± 3.8 cm), and flap width (10.5 ± 2.7 cm vs 7.8 ± 1.7 cm) than the SNFPAP group. In postoperative follow-up, DPFWP group showed a lower complication rate and better cosmetic, functional outcomes than SNFPAP group. In conclusion, this study showed that a DPFWP flap brought better results than a SNFPAP flap in terms of complications, cosmetic appearance, and functional outcomes for patients undergoing reconstruction of foot and ankle defects.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique.

ObjectiveTo describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.MethodsA pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty‐five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo–Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5–8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria.ResultsTwenty‐five patients were followed up for an average of 28.96 (Range, 15–48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5–9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.ConclusionsThe combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.

Analysis of the therapeutic effect of artificial leather embedding combined with fascial sleeve flap transplantation on chronic wounds of lower limbs with bone and plate exposure

BackgroundAfter severe trauma of lower limbs, bone, tendon or plate graft exposure is common. The traditional repair method is to use a variety of skin flap transplantation to cover the exposed part, but the wound often can not heal after operation, or the wound is cracked, ulcer, sinus, bone and steel plate are exposed again after wound healing. The reason for this result is that when the flap is covered, the space around the bone plate is not well closed, forming a dead cavity, blood and exudate accumulation, hematoma formation or infection, and finally the wound ruptures again. In addition, due to the swelling and contracture of the flap after operation, the suture tension between the flap and the receiving area becomes larger, the skin becomes thinner and broken, and then the wound is formed. In order to solve the above problems, we carried out the study of artificial true skin embedding combined with fascial sleeve flap transplantation in the treatment of chronic bone plate exposed wounds of lower limbs.MethodsIn this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion, removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1–2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in nine cases and the lateral superior malleolar artery perforator flap in two case.ResultsThe flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation.ConclusionsArtificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture. It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs.

Salvage Procedures for Facial Reanimation With Neurovascular Flaps When Previous Surgeries Failed: Is Homolateral Vessel or Nerve Depletion a Contraindication?

Facial paralysis reconstruction can be difficult in extensive defects after complex facial or cranial base tumor resection and radiotherapy or when primary smile reanimation attempt has failed. The surgical challenge is more complicated when defects are associated with recipient vessels or nerves depletion. This scenario has not been well described in the literature, and the present article will address the alternatives that plastic surgeons may use in these circumstances. Seventy-five patients operated in the Hospital Gregorio Marañon between 2008 and 2020, for dynamic reconstruction of facial paralysis, were retrospectively evaluated, collecting data about previous facial nerve surgeries, radiotherapy, chemotherapy, recipient nerve for motor restoration and vessels used for free flaps, type of neurovascular free flap (NVFF), and functional score before and after the facial reanimation surgery. Patients presenting recipient vessel and/or nerve depletion after several facial surgeries requiring a variation from the common NVFF surgical protocol were included in this study. Six cases (8%) with facial paralysis and absent recipient homolateral vessels or nerves after severe cranial base surgery, parotid malignancies, or schwannoma surgery were included. Two patients had an immediate functional reconstruction during the oncologic resection surgery, and 4 patients had a delayed reconstruction. Three patients had previous reconstruction with free flaps, and the vascular pedicles of previous flaps were used for the new NVFF. In the other 3 cases, interposition vein grafts to the contralateral recipient vessels were required to perform NVFF. Masseteric nerve in 4 cases, hypoglossal nerve and posterior branch of the deep temporal nerve in 1 case each, were used as recipient nerves. House-Brackmann score improved in all patients after surgery. Neurovascular free flap can be successfully performed to restore facial motion after depletion of homolateral recipient vessels or nerves after previous facial or cranial base surgeries. In these cases, interposition vascular grafts or the pedicle of previous flaps are essential to provide vascularization as well as an optimal orientation of flaps, to reach recipient nerves in a 1-step procedure.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel.

ObjectiveTo summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.MethodsA total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.ResultsAfter surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3–44 months) and the two-point discrimination of 5–14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.ConclusionThe repair method should be selected according to the“5-zone method”: The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6–10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

Utility of "reposition-flap" in the reconstruction of the avulsed thumb.

Injuries that result in thumb amputation cause a loss of 50% of hand function. Microsurgical replantation remains the gold standard of thumb reconstruction techniques. The non-microsurgical technical variants of thumb reconstruction described so far aim to create a neo-thumb of adequate length, stable, opposable, sensitive, and last but not least esthetically pleasing appearance. Avulsion of the distal phalanx and the absence of the nail will determine a functional deficit but also an unesthetic appearance. When replantation is not possible or the patient refuses to “sacrifice” another anatomical region for thumb reconstruction, the “reposition-flap” technique can be used. Although often controversial, this surgical technique deserves proper attention and should be used in some cases. We studied a group of 32 patients with distal thumb amputations. In patients with amputations in zone II according to Tamai, with interphalangeal joint preservation, the thumb was reconstructed using “reposition-flap” with an O’Brien flap in 15 cases. In the remaining 17 cases where the amputation was at the level of the interphalangeal joint, we used the same technique, but the thumb neopulp was reconstructed with the Littler heterodigital neurovascular flap harvested from the ulnar border of the middle finger in 11 cases or radial border of the ring finger in 6 cases. The results were evaluated from a functional (Kapandji score), sensitive (2-point discrimination, Semmes-Weinstein test) but also esthetically (patient satisfaction) point of view. Donor site morbidity, cold intolerance, the presence of nail dystrophy, and bone resorbtion were also assessed. The disabilities of the arm, shoulder and hand score was evaluated for each patient. Although various surgical and microsurgical techniques for thumb reconstruction are described, when choosing the technique to use we must first consider patient's wishes. A well-informed patient will be able to make, with the surgeon, the best decision for him concerning the reconstruction option.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair

Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

Restoration of Neck Extension after Severe Oncological Surgery of the Posterior Cervical Trunk.

SummaryReconstruction of posterior cervical trunk defects secondary to tumor resection carries significant morbidity when vertebral hardware or the spinal cord is exposed, and neck extension is interrupted. Complete reconstruction includes the coverage and obliteration of dead spaces, but functional outcomes are necessary to prevent the head dropping. This report documents the first known technique, using a free latissimus dorsi neurovascular flap to provide neck extension after ablative oncological surgery affecting trapezium and paraspinal muscles of the neck. The author explains the method by using a branch of the accessory nerve as the donor nerve. While keeping the head in a neutral position, the tendinous part of the neurovascular flap was firmly attached to the occipital periosteum and to the cephalad remnants of the trapezius, splenius capitis, and semispinalis muscles. At the caudal portion of the defect, cardinal notches were used to set the muscle at rest, avoiding excessive fiber tension. The maximal length of the muscle at rest was measured before flap elevation, calculated via the anatomical 3D print model. The thoracodorsal nerve was stimulated until the muscle shortened its length to 50%. Head extension was tested several times via neurostimulation and electromyographic control. The described procedure may provide neck extension and circumvent the problem with donor nerve providing synergy to the desired function.

Indications, selection, and effect of flap application in repairing scar carcinoma in the lower leg and ankle

Objective: To explore the indications, selection, and effect of flap application in repairing scar carcinoma in the lower leg and ankle. Methods: A retrospective cohort study was conducted. From June 2008 to December 2018, six male patients with scar carcinoma in the lower leg and ankle were treated in Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, aged 48-64 years, with the area of lesion ranging from 3 cm×2 cm to 15 cm×6 cm. After extended resection, the defect area ranged from 8 cm×5 cm to 22 cm×9 cm, with tissue of tendon or bone exposed. Free anterolateral thigh perforator flap, latissimus dorsi myocutaneous flap, or pedicled sural neurovascular flap was selected to repair the wound according to the location of wound in the lower extremity, selection of operation position, the location of the anastomotic vessels in the recipient area, and whether there was good skin and soft tissue available in the lower leg. The size of flap was 11 cm×8 cm-26 cm×10 cm. The donor site of free flap or myocutaneous flap was closed directly by suturing in 5 cases, and the donor site of pedicled flap was repaired with full-thickness skin graft in 1 case. The blood supply and survival of flap, quality of skin graft survival, and complication were observed postoperatively. During the follow-up period, the recurrence and metastasis of scar carcinoma, and the appearance and function of donor and recipient sites were observed. Results: All the patients completed the operation successfully, all the transplanted flaps survived with good blood supply, and the skin graft in one donor site survived well. The wounds in the donor and recipient sites of all the patients healed well without infection, effusion, or dehiscence, etc. All the patients were followed up for 1-5 years. No local recurrence or distant metastasis of scar carcinoma was found. The quality of the transplanted flaps was good. The shape of the recipient area was quite good, and the function of the affected limb was fine. The appearance of the donor area was good without dysfunction. Conclusions: Flap transplantation is suitable for the patients with tendon and bone exposure after the excision of scar carcinoma in the lower leg and ankle. The flap can be selected according to the location of scar carcinoma, operation position, the location of anastomotic vessels in the recipient area, and whether there is good skin and soft tissue available in the lower leg. The free anterolateral thigh perforator flap or latissimus dorsi myocutaneous flap is an ideal choice for repair, which can be obtained in a large area, and the donor site can be directly sutured without affecting the function.

Exploration on clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries

Exploration on clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries

Clinical effects of anterograde sural neurovascular flap in repairing skin and soft tissue defect around the knee

Objective: To explore the clinical effects of anterograde sural neurovascular flap in repairing skin and soft tissue defect around the knee. Methods: Nine patients with skin and soft tissue defect around the knee admitted to Beijing Fengtai YouAnMen Hospital from May 2011 to December 2018, were included in this retrospective descriptive study, including 8 males and 1 female, aged 16 to 65 years. The wound area after debridement ranged from 8 cm×5 cm to 18 cm×10 cm. Anterograde sural neurovascular flap was used to repair the wounds in 9 patients, with the area ranging from 9 cm×6 cm to 20 cm×12 cm. The donor sits of flaps in 2 patients were closed and sutured directly, and the donor sits of flaps in 7 patients were repaired with medial split-thickness skin graft of the ipsilateral thigh. The flap survival, complications, and follow-up after operation were recorded. Results: The flaps survived and the blood supply was good in 8 patients and the wounds were closed. One patient developed skin ischemic necrosis which was cured after three weeks of dressing change. All the skin grafts in the donor site of flap in 7 patients survived. In 6 months to 5 years of follow-up after surgery, the skin flap had good texture, color, and shape, and normal sensation. Except for one patient whose knee had poor recovery of function, the knee joint function of the other patients recovered well. Conclusions: The anterograde sural neurovascular flap has the advantages of high survival rate, satisfactory appearance and functional recovery post surgery, and is an ideal flap for repairing the skin and soft tissue defect around the knee.

Repair of Small-Size Wound With Achilles Tendon Exposure With Proximal Pedicled Cutaneous Neurovascular Flap.

To investigate the clinical outcomes associated with repairing of small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap in the dorsolateral foot. After thorough debridement, 16 cases with small-sized wounds of Achilles tendon exposure were repaired by proximal pedicled cutaneous neurovascular flap of the dorsolateral foot, and their clinical outcomes were observed. All the flaps in the 16 cases survived completely, excluding the marginal part necrosis in 1 case, and all the wounds were healed. The 2-point discrimination of the flaps was 14.53 ± 1.55 mm (range, 12-17 mm) in patients without sural nerve injury after 3 to 18 months follow-up. No discomfort was felt in wearing normal shoes by all the 16 patients. It is reasonable to repair the small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap of dorsolateral foot due to its effective repair of the wound, relatively uncomplicated surgery, and had satisfactory healing recovery.

Results of the application of neurovascular homodigital flaps on the cutaneous defects of the digital fingertip

Introduction: the traumatic injuries of the hand are in the top of the list of industrial working accidents. The treatment of these injuries has as goal to restore the function of the fingertip, improving the life quality of the patients. Objective: to evaluate results of the application of neurovascular homodigital flaps on the cutaneous defects of the digital fingertip of the large fingers of the hand. Method: it was perform an observational and descriptive type investigation, in a case chain of 33 patients on the Hermanos Ameijeiras Hospital in the period of October 2013 up to January 2015, were it was apply neurovascular homodigital flaps with direct circulation (17 patients) or indirect circulation (16 patients). Results: male sex was more affected, with a higher frequency between 36 and 41 years old and also over 41 years old. There was confirmed 4 complications representing the 12%. It was obtained a 72.7% of good and excellent results with the application of these surgical techniques getting an appropriate protector sensibility and a satisfactory cutaneous covering. The patients were satisfied in a 93.9% of the cases with the application of these procedures. Conclusions: it was demonstrated the efficiency of the application of neurovascular homodigital flaps on the cutaneous defects of the digital fingertip of the large fingers of the hand.

Nerve vascularity in free vascularized nerve flaps.

The blood supply of peripheral nerves consists of a complex internal vessels' network, feeding external vessels and the interlinking vasa nervorum. Patients with nerve damage may require nerve substitution. While the commonly performed avascular nerve grafts obtain vascularization only from random and slow inosculation into the vasa nervorum, their insufficient revascularization causes loss of the graft's potential due to central necrosis. This gets more relevant with the larger diameter of nerves injured. Examples for neurovascular flaps are the lateral femoral cutaneous nerve vascularized via the superficial circumflex iliac artery perforator (LFCN-SCIP) flap or the iliohypogastric nerve graft vascularized via the superficial inferior epigastric artery (SIEA). LFCN-SCIP shows a well concealed donor scar site with a maintained vascularization and a minor donor site morbidity. Therefore, the guaranteed axial nerve vascularity in LFCN-SCIP makes it a preferred autologous vascularized nerve therapy for peripheral nerve defects. A further option example is the anterior lateral thigh (ALT) flap with the LFCN.

Clinical application of 3 types of the medial shank island flaps

Objective To compare the application and results in repairing wounds on shank and medial malleolus by perforator pedicled middle and lower third of posterior tibial flap, saphenous neurovascular flap and posterior tibial artery perforator plus saphenous neurovascular (double blood supply) flap. Methods Clinical data of 60 patients with wounds on shank and medial malleolus and treated between August, 2015 and December, 2018 were analyzed. Among the patients, 25 were treated with perforator pedicled middle and lower third of posterior tibial flaps, 15 with saphenous neurovascular flaps, and 20 with double blood supply flaps. The data of surgery, survival of the flaps, texture and swelling of the flaps, patient satisfaction and scores set by American Orthopaedic Foot and Ankle Society(AOFAS) were collected. Statistic analysis was carried out to compare observations among the 3 groups. Results Postoperative followed-up was 6 to 24(average 13.4) months. One flap suffered insufficient blood supply in the group of perforator pedicled middle and lower third of posterior tibial flaps, 2 flaps suffersd necrosis and skin graft was carried out in reverse saphenous nerve neurocutaneous flaps group. In double blood supply flaps group, 2 flaps appeared purple after surgery, and improved after removing the pedicle sutuer, and flaps became swelling and received secondary repair. All AOFAS scores (93.8, 93.3 and 92.8, respectively) and patient satisfaction were high in all 3 groups. Conclusion All 3 types of flap are able to be used in repairing the soft tissue defect on shank and medial malleolus. The inclusive of saphenous nerve should be determined in intraoperation according to the presence and size of the perforator. If artery perforation is reliable, the use of posterior tibial artery perforator flap in wound repairing will deliver satisfactory outcomes in terms of blood supply and appearance of the flap. For the wider area of wound, a flap with double blood supply is preferred. Key words: Shank; Posterior tibial artery perforator flap; Saphenous neurovascular flap; Repair; Microsurgical technique