Treatment possibilities of reverse-flow sural flap in covering the defects of lower extremities.

UNLABELLED: Soft tissue defects of the lower extremity pose an important surgical challenge, often because of inviability of primary covering. Therapeutic modalities of choice comprise of local perforator flaps, as well as of free flaps created with the use of microsurgical skills. However, these methods cannot be applied in patients with important comorbidities, and it is in such cases where the reverse sural flap proves to be the best solution. THE AIM OF THE STUDY: To present the results of treating lower extremity defects with various modifications of the reverse sural flap. MATERIAL AND METHODS: Sixteen patients, males aged 17-56 years, were operated on from 2007 to 2013. Diabetes with multiple complications, disseminated atheromatosis, and extensive soft tissue trauma involving the arteries crucial for microsurgica anastomoses were the most common reason disqualifying from the free and perforator-based flap techniques. RESULTS: All of the patients achieved very good results; in two cases distal and marginal flap necrosis was observed which, once exiced, covered with granulation, and was successfully covered with a partial-thickness skin graft. CONCLUSIONS: The reverse sural flap, technically easy, offers a viable, low-risk alternative to free and perforator-based flaps.

Surgical treatment of hemangiomas and arteriovenous malformations in upper extermity.

UNLABELLED: Hemangiomas belong to one of the most common type of tumors occurring in childhood. They are benign and often do not require any treatment, with the tendency to. frequently disappearing spontaneously at the age of 5-7 years. The tumors usually develop in the head and neck area, whereas vascular malformations (AVMs) are rare congenital anomalies, which may occur anywhere. In upper limb, they may amount to 30-60% of cases. It is common for these changes not to require any surgical treatment. In case they do, the main indications for such treatment of upper limb AVMs may be as follows: signs of compression of the peripheral nerves, limited mobility of the fingers because of the tumor, which entails difficulties in the functioning of the whole arm, pain and aesthetic considerations. AIM OF THE STUDY: was to present the results of surgical treatment of vascular tumors (hemangiomas and AVMs) in the upper limb that was applied in our department, as well as a broader discussion on epidemiology, diagnosis, and treatment of these changes. MATERIAL AND METHODS: In 2003-2011 period we treated 11 patients aged 24-39, suffering from vascular tumors (hemangiomas / vascular malformations) in the upper limb; the group included 3 men and 8 women. In this group we diagnosed 2 cases with arm hemangiomas, 2 cases of intramuscular hemangiomas of the forearm, 2 cases of hemangiomas in metacarpal area, 2 cases of AVMs of the finger and metacarpal area, and 4 cases of isolated vascular malformations (mainly arteriovenous malformations) of the fingers. All preparations were examined histologically. RESULTS: No complications or recurrence were found in 7 cases, recurrences of AVMs were observed in 4 patients with finger changes. In one patient with AVMs of the index finger, we observed a treble recurrence, which severely impaired functioning of his hand. We eventually suggested to him the finger amputation, to which the patient agreed. CONCLUSIONS: Upper extremity is a rare location of hemangiomas and other vascular malformations requiring surgery. hemangiomas are more common in women, and the occurrence of AVMs in both males and females is similar. Surgical treatment of hemangiomas and AVMs of the upper extremities is doubtlessly an arduous task, which calls for great microsurgical skills.

[An example of multi-stage reconstruction of a full-thickness abdominal wall defect]. / Przyklad wieloetapowej rekonstrukcji pelnej grubosci ubytku sciany jamy brzusznej.

Abdominal wall reconstruction is a highly complex procedure that may requires a multiple stages surgical operations. The aim of a such reconstruction is to close the abdominal wall defect and to create a support for the internal organs. It's a challenge for both general and reconstructive surgery. An incomplete thickness defects of the abdominal wall are so much easier to challenge than complete ones. Also the size of the primary defect determines the way and stages of the operation. Such defects can occur in necrotizing fasciitis of the abdominal wall, after abdominal walls tumors removal, in traffic accidents or after "open abdomen" procedures (acute severe pancreatitis). In this paper the authors present a case of 62-yo patient which was operated because of large intestine perforation with various complications of which the most serious was the abdominal wall defect.

Result of arm-level upper-limb transplantation in two recipients at 19- and 30-month follow-up.

BACKGROUND: Arm transplantation (ATx) is a novelty in the field of upper-limb transplantation, with only 7 procedures performed world-wide. CASE REPORT: In this paper we report on early results of unilateral arm transplantation recipients. Patient 1, a 30-year-old man, examined 30 months post-transplant, is able to actively flex the elbow, has 160 degree of ROM in the fingers of the grafted limb, and scored 92 points in the DASH questionnaire and 62 points in the Comprehensive Functional Score System (CFSS). The post-transplant period was complicated with 1 acute rejection episode due to CMV infection, and delayed bony union. Patient 2, a 55-year-old woman, examined 19 months post-transplant, is able to actively flex the elbow, has 180 degree of ROM in the fingers of the grafted limb, and scored 89 points in the DASH questionnaire and 64 points in the Comprehensive Functional Score System (CFSS). CONCLUSIONS: The post-transplant period was complicated with a delayed bony union. The ATx seems to be a valuable reconstructive therapeutic modality.

First Polish forearm transplantation - final report (outcome after 4 years).

BACKGROUND: Hand transplantation (HTx) presents an exceptional reconstructive solution for hand amputees. Relatively few patients qualify for such an operation - generally healthy patients suffering from a serious disturbance of body integrity. CASE REPORT: We present a patient 48 months after unilateral transplantation of an allogenic forearm. Clinical course, laboratory results, function of the graft, and quality of life of the patient are analyzed. These findings are compared with those achieved by 2 other patients - recipients of allograft forearm transplanted on the same zone in Lyon 2002, and Louisville 2001. The patient suffered no post-transplantation infections, had 1 episode of rejection - I degrees . Except for mild diabetes, no disturbances of internal organs were observed. Total active motions of fingers (TAM) equaled 53% of fingers of unaffected hand. The functional evaluation by SF 36 is 53; by DASH - 92; Chen's score system rates our patient as II (good); CFSS score system - 84 points (excellent result). His functional result is similar to that achieved by 2 others mid-forearm recipients. CONCLUSIONS: The upper limb transplant performed on a functionally unfavorable zone of the mid-forearm has greatly increased patient's quality of life.

Unsuccessful attempt of forearm transplantation--case report.

BACKGROUND: The technique of hand transplantation is similar to that of hand replantation. Although the rate of failure of hand replantation tantamount to 15% on average, depending mostly on mechanism of amputation, until now no data have been published concerning the failure of attempts of hand transplantation. CASE REPORT: A 42-year-old male is presented who was the recipient of a hand transplant. The patient had an amputation of his left, dominant forearm (result of a circular-saw accident) 8 years prior to the transplantation. He was generally healthy, very dedicated to the operation. The limb was obtained in another hospital from a 49-year-old woman, victim of an accident and multi visceral donor.The donor was matched for blood group (0 positive), bone size, texture, with the recipient. There was 4 HLA antigen mismatch; the lymphocytotoxic cross-match was negative. The operation was performed in a sequence as follows: bones--muscles--nerves--veins--arteries--skin. The induction IT consisted of Simulect, Prograff, Cell-Cept, and steroids; the pharmacotherapy was standard as for a forearm replantation. The cold ischemia time was 9 hours. Soon after the transplantation the disturbances of blood circulation in the transplanted forearm were to be seen. High doses of macromolecular heparin were applied resulting in temporary improvement. During following hours despite various precautions the symptoms of ischemia of the hand up to 1/3 distal part of the forearm dramatically increased. The revision (performed 12 hrs after completing the transplantation) proved a massive thrombosis of hand arteries, and a large clot of the radial artery in locus of it's cannulation for invasive blood pressure measurement. The limb had to be re-amputated. As it came clear the arterial catheter was removed 6 hours prior to procurement. CONCLUSIONS: The hand transplant are not free from non-immunological typical vascular complications. The arterial catheters should not be applied in limbs destined for procurement.

Hand transplant - outcome after 6 months, preliminary report.

BACKGROUND: Hand transplant still remains a partly experimental procedure because of the small number of patients and short follow-up (not longer than 10 years). Most hand transplantations have been performed at the distal forearm level. MATERIAL AND METHOD: The transplant recipient was a 29-year-old man who had lost his dominant right hand 3 years before in a milling machine accident; the donor was a 52-year-old woman. The procurement and transport of the limb were performed according to standard procedures. Preparation of the donor limb and the patient's stump was performed simultaneously by two surgical teams. Anastomoses were done in the following order : bones-tendons-nerves-veins-artery. The radial artery and 3 large veins were anastomosed. The operative wound was closed without a skin graft. Ischemia time was 9 hours. Pharmacological treatment was similar to that usually administered to replantation patients; immunotherapy consisted of Simulect, Prograf, Cell-Cept, and steroids. Physiotherapy was started on the second postoperative day; it consisted of early protective active motion (EPM), continuous passive motion (CPM), splinting, and sensory stimulation. The function of internal organs was monitored; the early outcome was evaluated at 6 months after the transplantation. RESULTS: The function of internal organs remained undisturbed, no rejection episodes were observed. Bony union was achieved after 11 weeks and progressed steadily, as did the range of motion and reinnervation. On the day of the preliminary assessment, the active range of motion was 200 degrees , 2PD exceeded 15 mm, and electromyography demonstrated temperature sensation and hypothenar muscle function. Functional assessment according to the DASH questionnaire was rated at 67 points, and a quality of life evaluation with the SF-36 questionnaire produced a score of 110 points. CONCLUSION: The distal third of the forearm is a replantation zone promoting early functional recovery.

[Finger transfer from contra lateral hand on metacarpal hand--case illustration]. / Transfer palca reki przeciwstawnej na reke bezpalcowa--ilustracja przypadku.

A case of reconstruction of metacarpal hand by means of ring finger transfer from contra lateral hand is presented. The patient did not accept the option of a toe transfer. The finger was implanted on the third ray. The unification of bones was done by headless AO screw resulting in an excellent bony union. The result was assessed after 11 months. Sensitivity of the transferred finger is excellent; 2-points discrimination test: 8 mm, range of motion is small--65. The cosmesis of the recipient and donor hands are excellent. No diminishing of grasp strength or of the range of finger motion of the donor hand was observed. As the result of the transfer the patient is able to perform many activities which he was unable to do preoperatively.

[Bilateral transversal humeral defect accompanied by defects of lower limbs--an attempt of improvement of upper limb's function by a reconstructive procedure, a case illustration]. / Obustronny ubytek poprzeczny ramion wspólistniejacy z niedorozwojem konczyn dolnych --próba poprawy funkcji konczyny górnej poprzez operacje rekonstrukcyjna, ilustracja przypadku.

Motor system is the most common localization of congenital defects. Disturbances of limb formation resulting in a total defect of a limb fragment are most difficult to treat. Transversal defects within the arm are usually unilateral and rarely accompanied by other congenital mutilations. The exceptional case is presented of a child with bilateral humeral transversal defect accompanied by transversal defect of a right thigh, and bilateral hip joint dysplasion. The etiology of the mutilation is unknown. The child was able to move on a wheel-chair as well as thanks to well innervated arm-stumps and a single foot to perform many activities of daily life, although some of them with a serious difficulty. The commonly stated decision was taken to operate the child aiming at improvement of limb's function. That was achieved by a reconstructive procedure creating a pincer-like enlargement of arm-stump's ending. Arm lengthening seems to be necessary in the near future.

[Transfer of the distal phalange of the ring finger as a method of reconstruction of the partially amputated thumb--preliminary report]. / Transfer dystalnego paliczka palca serdecznego jako sposób rekonstrukcji czesciowo amputowanego kciuka--doniesienie wstepne.

Loss of a thumb accounts for 60% decrease of functional value of the hand, thus any attempt of it's reconstruction is a priority in the field of hand surgery. Optimal reconstructive solution for subtotal thumb amputations has not been settled. The results of partial pollicization of ring finger in 5 adult men is presented. Four patients sustained distal subtotal thumb amputation (MCP joint level), one total amputation. In three patients the distal phalange of the ring finger was transferred with the DIP joint, FDP tendon and a fragment of extensor tendon. An effective movement of a newly created thumb's IP joint was achieved in two patients. In one patient with a total thumb amputation the transfer was followed by a pollicization of the second metacarpal with remnants of proximal phalange. The postoperative course was uneventful in all of the patients. The sensitivity tested on the pulp of the transferred finger equalized to the preoperative value, the hand strength was not diminished. The cosmetic result was excellent.

[Observation of healing process of operative wound in the first Polish upper limb transplant]. / Obserwacja procesu gojenia rany operacyjnej pierwszego polskiego przeszczepu konczyny górnej.

The goal of this paper was to present the healing process of the operative wound of the hand transplant. The recipient was a man, 32 years of age who lost his right dominant hand 14 years ago, as a result of an accident. The transplant was made at the level of the halves of a forearm. The total ischemia time was 10.5 hrs. The recipient was qualified by a tedious process of preparation, he was thoroughly informed about all of the risks involved. The wound was primarily closed with loose sutures, without a skin graft. The healing process was complicated by creation of a large hematoma, wound dispersal and candida infection. The granulation process was very slow. Only traditional dressings were applied. The secondary wound closure was performed with a skin graft, the healing was ended after 64 days. Within this period neither general infection nor rejection symptoms were observed.

[Second-toe transfer on forearm stump as an alternative to Krukenberg's operation--case illustration]. / Transfer II palca stopy na kikut przedramienia sposobem Vilkkiego jako alternatywa operacji metoda Krukenberga--ilustracja przypadku.

The result of gripping ability reconstruction by Vilkki's method in a patient after a total wrist amputation is presented. The achieved range of motion makes possible gripping of objects of 3.5 cm in diameter; patient's hand function improved which depicts the drop of 8 points according to DASH questionnaire. The patient is highly satisfied with this result.

[Management of soft tissue defects in the region of finger PIP joints by means of pedicular skin flaps taken from abdomen]. / Zaopatrywanie niewielkich ubytków skórnych powierzchni dloniowej okolicy stawów PIP palców reki za pomoca platów uszypulowanych z powlok brzucha.

Management of soft tissue defects in the region of finger PIP joints makes a serious operative problem. Commonly recommended skin plastics require a wide experience in hand surgery. There is also lack of a comprehensive doctrine of surgical therapy depending on the extent of the mutilations. The paper presents the results of treatment of 17 mutilated fingers of 11 patients (8 men, 3 females) treated over the period of 2 years (2002-2004). The method applied was pediculated skin flaps taken from an abdomen. According to the extent of lesions three groups of patients were created. Eight patients were treated as emergencies, three appeared from 4 to 11 weeks after the accident. Flaps were cut off after 20.4 days on average. The secondary plastic was performed after the following 9.5 weeks. In 2 patients tendon plastics were performed. Fingers were mobilized during the whole period of the therapy. No complications in healing of the flaps were observed. The functional results were assessed 6 months on average after the primary operation. The average TAM and TPM were evaluated as follows: group I (no, or minor tendon lesions) TAM--186 degrees, group II.

[Assessment of results of opponensplasty by transfer of flexor digitorum superfitcialis tendon of the ring finger]. / Wyniki odtwarzania opozycji kciuka za pomoca transferu sciegna zginacza powierzchownego palca obraczkowego.

This study is the review of 16 hands in the same number of patients (15 men, 1 female) in whom ring finger flexor digitorum superficialis opponensplasty was performed. The patients were operated on during the period of 6 years. The lack of thumb opposition was a result of traumatic nerve leasions (5 median, 11 median and ulnar). The operation was performed 7.2 months (on average) after the nerve reconstruction. The outcome was assessed by scoring the finger to which the thumb could obtain a pinch grip (Kapandji's test), measuring the gap between thumb and little finger MCP joints, the patient's satisfaction. The sensitivity on the pulps of ring and little finger were also tested. Two patients were reoperated for loosening the transferred tendon, two patients developed minor dysfunction of the donor finger. The results were evaluated 41 weeks after an operation. As a result of the operation the "opposition gap" was diminished by 22 mm on average; the patients scoring by Kapandji's test was improved by 2 points. Eight patients assessed the improvement of the hand function as excellent, six as good, two were dissatisfied with the result.

[The problems in replantation of limbs amputated through the arm region]. / Problemy replantacji konczyn amputowanych na poziomie ramienia.

The problems in replantation of arms were analysed on the ground of nine such replantations performed in Center of Replantations of Limbs in Trzebnica in the same number of patients (7 men, 2 children, 1 woman) during the seven year period 1993-2000. The range of age of the patients was from 12 to 62 years (35.5 on average). Among the problems discussed were such as qualification for the operation, operative technique (limb shortening, perfusion of vessels, half-open anastomosis of veins, neurotisation of remaining nerves) evaluation scale. Eight of the amputations were the results of crush-avulsion mechanism, one was guillotine-type. The patients required 15 secondary operations; all of them were able to perform an arm abduction and active flexion of the elbow joint. They all had at least protective sensibility on the palm. The results were rated (acc. to Chen-Yu scale) III(o)--four patients, IV(o)--four patients (one patient did not appear for control check-up). Despite of such a poor evaluation, all of the patients are satisfied with the operation.