Zone of injury: a critical review of the literature.

The response of tissue to trauma is difficult to define. The zone of injury is an area surrounding a wound that, though traumatized, may not appear nonviable at initial debridement. Because of this, a policy of repeated debridements has been followed to monitor tissues for viability before final tissue coverage. Appreciation of the zone of injury has led to a controversy in the literature about how to define and approach the management of traumatic injuries requiring free-tissue coverage. This review examines the current literature with regard to the definition of the zone of injury, and seeks to establish a consensus statement about the application of free flaps to traumatized wounds. We have investigated the literature supporting the use of free flaps relying on proximally or distally based recipient vessels. Critical appraisal of this literature includes study design, determination of the power of the study, subject classification, inclusion and exclusion criteria, follow-up, and outcomes (free flap success). There has been little attempt in the literature to fully and objectively define the zone of injury. All studies to date have been observational alone. Although it would be impossible to rid a definition of the zone of injury of subjectivity entirely, a more objective, reproducible definition is vitally needed. Without a clear definition of what the zone of injury is, there can only be anecdotal, technique reports of the placement of free flap anastomoses. In this time of rising costs and lower reimbursements, this is one area that could provide vital information to improve care for patients, lessen costs, and further medical knowledge.

Free muscle flap reconstructions using interpositional vein grafts vs. local anastomosis: a 5-year experience at a rural tertiary care center.

BACKGROUND: The use of free muscle or myocutaneous flaps is well established as a means for reconstructing tissue defects over nearly any part of the body. This free tissue transfer is based on the availability of a robust blood supply in the recipient wound. The reliability of native blood supplies within the zone of injury is suspect even in the best of conditions. There are several causes of flap failure however; one of the most common is vascular compromise. Though refinements in the technique of vascular anastomosis have lessened the risk, it is still significant, especially when dealing with an area of injury at the recipient site. The mechanisms of scar formation and healing that occur within the zone of injury often limit the potential for viable anastomotic targets. This often leads to delay in wound coverage and exposes the patient to all of the risks associated with having an open wound. Free flap failure can be devastating for patients, even leading to the loss of limbs. Therefore, it is vital that all measures possible to ensure the survival of the transferred tissue be employed. METHODS: We will examine interpositional vein grafts versus local anastomoses in the context of free tissue transfer for wound coverage in the traumatized and reconstructed patient. We will retrospectively review the case histories of free tissue transfers preformed at West Virginia University Hospital over a 5-year period (2001-2006). We will examine data including the demographics of our patient population, type and locations of the free flaps, length of stay in the hospital, time interval between injury and repair, and the Success and failure rate. RESULTS: The overall success rate was 38 out of 45 or 84%. Success was defined as a healthy flap and preservation of the limb and/or successful wound coverage at time of discharge. Flap success was present in 18 of 23 (78%) of the vein interposition grafts, and flap failure occurred in 5 (22%). In patients with local anastomoses, 20 out of 22 flaps survived (91%) with 2 failures (9%). GOALS: We will demonstrate that the use of interpositional vein grafts for free tissue transfer is a viable option in the wound coverage. We will demonstrate that this is especially 'true in the patient population that exists in rural America.

Overuse-related vascular injury of the hand--hypothenar hammer syndrome: a case report.

Although rare, vascular insufficiency is a well-recognized cause of hand pain, making a significant impact in the athletic and labor industry. Surgically correctable lesions are important to recognize since definitive treatment may alter the course of the disease and affect outcomes. Hypothenar hammer syndrome (HHS) results from anatomic predisposition and exposure to acute and chronic stress. Arteriography is the gold standard of diagnosis and severe symptomatic cases are treated with surgical resection and re-establishment of blood flow. We report such a case of HHS, its clinical course and management.