Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers.

BACKGROUND: Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results. METHODS: A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years). RESULTS: One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes. CONCLUSIONS: Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.

Reconstruction of the Flexor Pollicis Longus Tendon with Vascularized Tendon with Ulnar Artery Preservation.

Reconstruction of the flexor pollicis longus tendon using staged grafting yields modest results. A modification of the pedicled vascularized flexor digitorum superficialis transfer, without division of the ulnar artery, was used in five patients. Methods: The flexor digitorum superficialis and its gliding tissue were transferred in five patients, based on a branch of the ulnar artery without division of the ulnar vessels. Functional results were evaluated using a total active range of motion and Buck-Gramko score at 10 months by an independent hand therapist. Results: The mean total active motion of the interphalangeal joint was 49 degrees, with a Buck-Gramko score of excellent in three cases and good in two. No complications were recorded. Conclusion: Reconstruction of the flexor pollicis longus tendon with single-staged vascularized FDS transfer without ulnar artery division yielded good results in a small cohort of five cases.

Radiocarpal Joint Reconstruction with a Double Free Metatarsophalangeal Joint Transfer.

Background: Destruction of the radiocarpal and midcarpal joints causes loss of wrist motion, pain, and reduced grip strength. A novel technique for radiocarpal reconstruction is presented. Methods: Two patients who had radiocarpal and midcarpal destruction and osteoarthritis underwent reconstruction using simultaneous bilateral microvascular second metatarsophalangeal joint transfer. The insetting was performed, inverting the distal-proximal orientation of both metatarsophalangeal joints and fixing them with two 2.0 screws in proximal and Kirschner wires in distal. Results: Radiocarpal extension and flexion without pain were preserved after a minimum of 4 years follow-up. Both patients could return to recreational activities. No secondary procedures were needed. Conclusions: This technique could be an alternative for radiocarpal reconstruction, although longer follow-up and more cases are needed.