Tissue Defects In Limbs Research Articles

Clinical application of digital technology in the use of anterolateral thigh lobulated perforator flaps to repair complex soft tissue defects of the limbs.

It is challenging to repair wide or irregular defects with traditional skin flaps, and anterolateral thigh (ALT) lobulated perforator flaps are an ideal choice for such defects. However, there are many variations in perforators, so good preoperative planning is very important. This study attempted to explore the feasibility and clinical effect of digital technology in the use of ALT lobulated perforator flaps for repairing complex soft tissue defects in limbs. Computed tomography angiography (CTA) was performed on 28 patients with complex soft tissue defects of the limbs, and the CTA data were imported into Mimics 20.0 software in DICOM format. According to the perforation condition of the lateral circumflex femoral artery and the size of the limb defect, one thigh that had two or more perforators from the same source vessel was selected for 3D reconstruction of the ALT lobulated perforator flap model. Mimics 20.0 software was used to visualize the vascular anatomy, virtual design and harvest of the flap before surgery. The intraoperative design and excision of the ALT lobulated perforator flap were guided by the preoperative digital design, and the actual anatomical observations and measurements were recorded. Digital reconstruction was successfully performed in all patients before surgery; this reconstruction dynamically displayed the anatomical structure of the flap vasculature and accurately guided the design and harvest of the flap during surgery. The parameters of the harvested flaps were consistent with the preoperative parameters. Postoperative complications occurred in 7 patients, but all flaps survived uneventfully. All of the donor sites were closed directly. All patients were followed up for 13-27months (mean, 19.75months). The color and texture of each flap were satisfactory and each donor site exhibited a linear scar. Digital technology can effectively and precisely assist in the design and harvest of ALT lobulated perforator flaps, provide an effective approach for individualized evaluation and flap design and reduce the risk and difficulty of surgery.

Single-stage microsurgical reconstruction of large complex tissue defects of the lower extremities with two vascularized flaps

The purpose of this study was to explore the effectiveness of combined one-stage reconstruction of extensive complex defects of lower limb tissues and to analyze postoperative complications.Material and methods. The research involved 25 patients with bone and soft tissue defects of lower extremities. The first group included 16 patients, where the replacement of bone and soft-tissue defects of the lower leg was carried out with one complex bone-skin graft. The second group consisted of 9 patients who, along with major defects of the tibia, had concomitant extensive damage of soft tissues. To replace bone and soft-tissue limb defects, the autotransplantation technique of 2 free flaps, bone and soft-tissue (combined) was used.Results and discussion. In our study, we analyzed early and late postoperative complications, as well as the average time of fusion of the graft with the recipient bed and restoration time of the lower limb supportability. In the second group of patients, we did not observe any critical complications in the early postoperative period that would affect the results of patient`s treatment. The increase in the incidence of vascular complications is not statistically significant. In the late postoperative period (30 days or more), stress fractures of the fibular graft, traumatic fracture of the fibular graft, delayed consolidation of the graft ends with the recipient bone lasting more than 6 months were observed in both groups of patients. The incidence of these complications was comparable in both groups, there were no statistically significant differences. The average time of fusion of the graft with the recipient bed and the time of restoration of the lower limb supportability did not have statistically significant differences.Conclusion. One-stage reconstruction of extensive deep limb tissue defects by using an appropriate combination of two vascularized complex grafts (bone and soft tissue) provides a complete reconstruction of complex limb tissue defects without increasing the time of bone consolidation and the frequency of occurrence of critical complications in the postoperative period (total necrosis of vascularized flaps and deep wound infection process).

Clinical effects of bilateral overlength anterolateral femoral perforator flaps connected in series or parallel in repairing large area of wounds in limbs

Objective: To explore the clinical effects of bilateral overlength anterolateral femoral perforator flaps connected in series or parallel in repairing large area of wounds in limbs. Methods: From January 2017 to July 2019, 9 patients with large area of skin and soft tissue defects in limbs were admitted to the Departments of Hand Surgery and Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 8 males and 1 female, aged 36 to 63 years. The retrospective cohort study was conducted. The wound areas of patients after debridement were 20 cm×15 cm to 30 cm×25 cm, and the wounds were repaired with bilateral overlength anterolateral femoral perforator flaps. One main artery defect in the receiving area of 4 patients was repaired with bilateral flaps connected in series. Two main artery defects in the receiving area of 5 patients were repaired with bilateral flaps connected in parallel. A total of 18 flaps were excised, and the area of a single flap ranged from 20 cm×8 cm to 46 cm×9 cm. The donor sites of 17 flaps were sutured directly, and the donor site of 1 flap was repaired with free full-thickness skin graft from hypogastrium. Harvesting time of flaps, survival condition of flaps after surgery, and wound healing time, and flap observation, two-point discrimination distance of flaps, functional recovery of joint and appearance of recipient site, and recovery of donor site during follow-up were recorded. Results: In this group of 9 patients, the flap harvesting time was 1.0 to 4.5 hours, and all the 18 flaps survived. The wound healing time of recipient site was 18 to 72 days after flap transplantation. They were followed up for 6 to 34 months. The shape of the recipient site was satisfactory, with no deep tissue infection such as osteomyelitis. Four flaps in 2 patients were bloated and were thinned in 6 months after operation; 4 flaps in 2 patients had skin pigmentation on the edge of the flap; the flap of one patient was scalded but healed by dressing change, with patchy scar being observed during follow-up. The rest of the flaps were soft, elastic, and painless with good blood supply. All the flaps restored with protective sensation, with only one point in two-point discrimination. Only linear scars remained in the donor sites of 17 flaps. All the limbs had good blood supply in the distal end of donor sites, and no restriction occurred in range of motion of knee joint and quadriceps muscle strength. Conclusions: The bilateral overlength anterolateral femoral perforator flaps connected in series or parallel have constant anatomy, reliable blood supply, and flexible combination. It is an ideal surgical method for repairing large area of skin and soft tissue defects in limbs at one time.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb: 11 cases report

Objective To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb. Methods Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years. The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator. Postoperative regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System. Results All 11 flaps survived. No vascular crisis happened. All 11 cases were followed-up for 3 to 12 (average, 5) months. The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case. The Enneking system was used to assesse the lower limbs recovery. The average score was 21, an average of 70% of limb function restored. Conclusion The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method. It helps a safer and successful operation with optimal outcome. Key words: 3D-CTA; Anterolateral thigh perforator flap; Lobulated flap; Repair; Limb

Sequential chimeric deep circumflex iliac artery perforator flap and flow-through anterolateral thigh perforator flap for one-stage reconstruction of complex tissue defects

Simultaneous reconstruction of composite bone and large soft-tissue defect areas is challenging for reconstructive surgeons. This study presents a microsurgical sequential chimeric flap composed of a flow-through anterolateral thigh perforator (ALTP) flap and a deep circumflex iliac artery perforator (DCIAP) chimeric flap for one-stage reconstruction of a complex tissue defect in limbs. A retrospective analysis was performed among patients who underwent reconstruction of bone composite and large soft-tissue defect areas in limbs using a sequential chimeric flap. A flow-through ALTP flap and a DCIAP chimeric flap were microsurgically fabricated as sequential chimeric flaps. Ten patients were successfully treated with the sequential chimeric flaps. All components of the flaps survived in all patients. Primary closure of the donor site was achieved in all cases. The sizes of the flow-through ALTP flaps ranged from 16 × 6 cm to 27 × 8 cm. The size of the cutaneous portion of the DCIAP chimeric flap ranged from 11 × 4 cm to 20 × 9 cm, and bone flap sizes ranged from 1 × 3 × 2 cm to 2.5 × 8 × 3 cm. A vascular compromise was observed postoperatively in one case. Only one case suffered minor wound-edge necrosis. Mean follow-up time was 13.1 months. Most cases showed a satisfactory contour, and no fracture of transferred iliac segments occurred. The sequential chimeric ALTP-DCIAP flap is a valuable alternative for one-stage reconstruction of composite bone and large soft-tissue defects in limbs. This approach is flexible and provides a large cutaneous area with primary closure of the donor site.

Reconstruction of the soft tissue defects of limbs using the free thoracodorsal artery perforator flaps

Objective To investigate the clinical effects of reparing the complicated soft tissue defects of limbs with free thoracodorsal artery perforator(TDAP) flaps. Methods From April, 2009 to March, 2014, 19 limbs (including 8 upper limbs and 11 lower limbs) soft tissue defects with bone and tendon exposure were repaired with free TDAP flaps in the secondary stage. There were 12 thoracodorsal artery perforator flaps, 5 polyfoliate perforator flaps, 1 chimeric muscle flap, and 1 chimeric muscle polyfoliate flap. The sizes of the flaps ranged from 5.0 cm×6.0 cm-20.0 cm×11.0 cm. Seventeen wounds of the dornor site were closed directly, and the other 2 were closed with skin grafts. Results Sixteen flaps survived successfully. Two flaps had venous congestion and survived at last after taking the stitches out. One flap had partial necrosis and repaired by skin graft finally. The clinical results were satisfactory after 12-18 months following-up, and the scars of the dornor sites of all but 3 patients were not obvious. All the shoulder function were normal. Conclusion The TDAP flap has dependable blood supply, good texture, less dornor site morbility. The polyfoliate TDAP flap can be used for repairing irregular defect. The chimeric latissimus TDAP flap can be used for the function reconstruction. The free TDAP flap is suited for repairing soft tissue defects of the limbs. Key words: Thoracodorsal artery perforator flap; Polyfoliate flap; Limbs; Soft tissue defect; Transplantation

Editorial upper and lower limb reconstruction following trauma.

1) The ortho-plastic approach to soft tissue management in trauma 2) Flap decisions and options in soft tissue coverage of the upper limb 3) The Development and Future of Reconstructive and Microvascular Surgery of the Hand 4) Flap decisions and options in soft tissue coverage of the lower limb 5) Pilon Fracture: A case report of a 45 year old dental technician 6) Orthopaedic approaches to proximal humeral fractures following trauma This series provides a concise overview of the management of trauma. Trauma is an evolving speciality involving a wide range of emergency, medical and surgical teams. Although this series should not be used as a definitive guide, it highlights many key aspects in the treatment of a trauma patient, especially those involving the extremities and the reconstructive surgeon. Trauma management has long been debated and although presentations of trauma do vary the initial approach and later decision making have become more standardised with time. This series covers the choices that need to be made when a trauma case presents, including the initial management of open fractures, as well as the range of options available for flap reconstruction of both the upper and lower limb. The history, and future, of traumatic hand surgery and the development of the microsurgical field are dissected and we also look at the much documented treatment of the complex fractures involving the proximal humerus and those described as a pilon fracture. In our first paper, Jordan et al. review the management of the commonly presenting open fracture. Current guidance laid out by the British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons, which is widely accepted as the gold level of therapy is reviewed alongside other management options in these scenarios. Griffin et al. describe the options available in soft tissue deficiency of the upper limb, seen in events involving trauma, burns, infection and tumour excision. The ultimate soft tissue coverage is dependent on the size and site of the wound, the complexity of the injury and the status of the surrounding tissue and patient health. Local, regional and free flap choices are discussed, highlighting the benefits and challenges associated with the different approaches. Malahias et al. proceed to discuss the specifics involved with the management of the distal upper limb when they review the current literature as well as the history of hand reconstruction. The hand is often thought of as a key discriminator in what makes a human ‘human’. The hand is both intricate and fascinating in its design and function, and allows a person to interact with both their surroundings, and other people. Due to its use, damage to the hand is common and injuries can have a profound, physical, psychological, financial and socially crippling effect. From the first successful arm replantation in 1962, and the myriad of autologous free flaps of varying composition discovered since, the amount of trauma to the patient and their family after an injury has become less devastating. The decisions in flap reconstruction are again echoed when Jordan et al. discuss the management of lower limb tissue defects. Essentially, reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and then the restoration of form and function. The reconstructive ladder is reviewed, and the key points of management highlighted which incorporate a multidisciplinary approach to optimise both surgeon and patients outcomes. Proximal humeral fractures have been a topic of discussion since the 3rd century BC, and Mafi et al. take a systematic review of the literature on this topic. Being the most common humerus fracture, both conservative and surgical approaches are discussed, in particular whether one choice is better in what is an increasingly presenting injury in our ageing population. The pilon fracture is both complex and difficult to treat. Mafi et al. aim to summarise current understanding and describe why initial external fixation is crucial, as well as evaluating its merits and drawbacks in managing this high impact injury. In this paper, a case report highlights the pilon fracture injury, and discuss ways to reduce the complications associated with external fixation of open intra-articular distal tibial fractures. We hope that all emergency and trauma physicians and surgeons find this issue useful, as well as general practitioners and therapists who may not be exposed to the initial injuries but are involved in the later rehabilitation.

The application of strands of anterolateral flap in the treatment of soft tissue defect in limbs

Objective To explore the methods and clinical effect of strands of anterolateral flap in the treatment of soft tissue defect in limbs.Methods 17 patients with soft tissue defect in limbs accepted strands of anterolateral flap treatment.The damage area was 8 cm × 11 cm to 14 cm × 29 cm,an average of 10.78 cm × 19.32 cm.Results All flaps of 17 cases survived completely after operation.Good effect was obtained after 1 ～ 2 years.However,flap bloated was found in 3 cases,which was improved after flap cut thin plastic.Most of the flap recovered gradually in the following six months after surgery.Conclusion The strands of anterolateral flap is proved to be constant,large,rich in blood,beautiful and easy to moderate,what is the effective method to repair soft tissue defect in limbs. Key words: Strands of anterolateral flap; Limbs; Soft tissue defect; Repair