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Objective:To investigate the techniques of digit-tip replantation with anastomosis of superior digital arch artery in children and to evaluate the clinical effects.Methods:From January 2020 to September 2022, 62 children (62 digits) with completely severed digit-tips were admitted to the Department of Paediatric Orthopaedics, Suzhou Ruihua Orthopaedic Hospital. All the injury planes were distal to the nail root. All arterial dissections were distal to the digital arterial arch with the vessel calibre from 0.15 mm to 0.35 mm. The superior arch arteries of the digital arterial arch were successfully anastomosed. After surgery, a significant blood flux to the replanted digit body were observed. Postoperative necroses or failures were analysed for the causes. All children with survived digit-tips were entered into scheduled follow-ups through a combination of visit of outpatient clinics or via WeChat and telephone reviews. Postoperative follow-up included digit body fullness, motion of distal interphalangeal joint, nail growth, scarring, and response of the replanted digit-tips to needling. Clinical outcomes were evaluated according to the evaluation criteria for finger replantation function.Results:Of the 62 replanted digit-tips, 56 survived after replantation. Two digits had wound infection after surgery, and survived by dressing change and applying sensitive antibiotics. Necrosis occurred in 6 replanted digit-tips, of which 2 necrotic digit bodies were amputated, and the stumps at the distal interphalangeal joint were repaired. The other 4 necrotic digits were healed after dressing change under the scab due to a smaller digit body. A total of 52 children (including 2 survivals from postoperative infection after dressing changes and 4 survivals with healing underneath-eschar after necrosis) and with 10 lost during follow-up (including 2 with stump repairs after necrosis). The follow-up period ranged from 2 to 30 months, with an average of 6 months. The shape and function of replanted digit-tips recovered well. According to the evaluation criteria for finger replantation function, 44 digits were of excellent, 6 of good, and 2 of fair.Conclusion:In children, the superior arch arteries of digital arterial arches of the digit-tips are small in diameter. However, the vessels in smaller calibres can be anastomosed, should proper surgical techniques are applied. Therefore, due to the satisfactory outcomes, microsurgeons should try the best efforts to replant a digit severed at the plane of digit-tip.
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Objective:To summarise the clinical application and results of superficial peroneal artery perforator flaps in tiled reconstruction of thumbs and fingers.Methods:From June 2020 to June 2022, 8 patients with finger or thumb defects (4 thumbs, 2 index fingers and 2 middle fingers) received digit reconstruction in the Department of Hand Surgery, Suzhou Ruihua Orthopaedic Hospital. Two thumbs (2 patients) were reconstructed with a free partial hallux nail flap combined with a free perforator flap of superficial peroneal artery and an iliac bone graft, 1 thumb was reconstructed with a free partial hallux nail flap combined with a free perforator flap of superficial peroneal artery, 1 thumb and 2 middle fingers were reconstructed with free perforator flaps of superficial peroneal artery combined with iliac bone grafts, and 2 index fingers were reconstructed with lobulated free perforator flaps of superficial peroneal artery. The sizes of the flaps were 1.8 cm×3.2 cm-4.0 cm×10.0 cm. Lengths of iliac crest were 1.5-4.0 cm. The donor sites were directly sutured in 5 patients, skin grafts in 2 and superficial peroneal artery perforator flap reconstruction in 1 patient. Postoperative observations included survival of the digits and healing of the bone grafts. Monthly scheduled postoperative follow-ups were conducted at outpatient clinics and via telephone or WeChat reviews, covering function and appearance of the reconstructed digits, impact on the function and appearance of donor sites as well as the satisfaction of patients.Results:All 8 reconstructed digits survived in one stage and all the 5 bone grafts healed at 3 to 4 months after surgery. The mean postoperative follow-up period was 10 months, ranged 4 to 20 months. The texture of the reconstructed digits was close to that of the recipient site and good in elasticity, without purplish while in cold, nor ulceration, obvious bloating and pigmentation. Sensation of the digit pulps was recovered to S 2 to S 3, and the sensation in touch, pain and temperature were restored. TPD was not checked. There was no noticeable hyperplasia nor pain in the recipient and donor sites. There was no obvious hyperplasia or pain at the donor sites for the hallux nail flap, and the skin grafts or flaps in the donor sites survived well without ulceration or pain and the function of the donor feet were not affected. Functions of the reconstructed digits were assessed according to the Functional Assessment Criteria for Thumb and Finger Reconstruction of the Society for Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 4 patients achieved in excellent and 4 in good. According to the University of Michigan Hand Profile Questionnaire (MHQ), patient satisfaction was found very satisfied with 4 patients and satisfied with the other 4 patients. Conclusion:The superficial peroneal artery perforator flap has advantages of thin and large area with pleasant texture, better sensation recovery and less damage to the donor site. It is an ideal flap for reconstruction of thumbs and fingers.
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Objective:To explore the feasibility of an "ABC" three line perforator locating method in design and harvest of free anterolateral perforator flap of calf.Methods:Between March 2021 and November 2021, 42 patients with 62 wounds on hand and foot were treated in the Department of Hand Surgery, Suzhou Ruihua Orthopaedic Hospital. The "ABC" three line perforator locating method was applied to determine the location and source of perforating branch before operation and to guide the design and harvest of flap during operation in wound reconstruction. Among the 42 patients, 24 had the injury of single digit, 7 had the injuries with 2 digits, 4 with 3 digits, 1 with 4 digits, 1 of the first web, 1 in the wrist, 2 of the great toe, 1 of second toe and 1 in dorsal foot. The sizes of soft tissue defect were 1.5 cm×2.0 cm-3.0 cm×14.0 cm. The sizes of the flaps were 2.0 cm×2.5 cm-3.5 cm×15.0 cm. All donor sites were sutured directly. In the follow-up, sensations of flaps were evaluated following the sensory function evaluation standard of British Medical Research Council(BMRC), and the recovery of the donor and recipient sites was evaluated by the flap comprehensive evaluation scale. Regular follow-up were scheduled at outpatient clinic.Results:A total of 162 perforators were located before operation. There were 95 perforating branches being explored in the operation, of which 5 patients had 1 extra perforating branch than that located before surgery. Seventy-six perforating branches were found consistent with preoperative localisation, with a coincidence rate of 84.4%(76/90). Sixty-four perforating branches were found consistent with the preoperative source with an accuracy rate of 84.2%(64/76). All the 62 flaps survived without a vascular compromise. Follow-up lasted for 6-10(mean 7.1) months. The colour and texture of the flaps were excellent. The flaps were thin and wear-resistant. The sensory function of the flaps was evaluated at S 1-S 3 by BMRC. Comprehensive evaluation scale of flap was excellent in 38 patients and good in 4 patients. Conclusion:"ABC" three line perforator locating method in design of free anterolateral calf flap is a feasible and an ideal auxiliary method in surgical practice. It combines anatomical knowledge, clinical experience and Doppler ultrasound localisation as well as accurately guides the location and source prediction of perforator before surgery.
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Objective:To explore the surgical method and clinical effect of harvesting 2 ipsilateral free pedicled perforator flaps from a single donor site of superficial peroneal artery in reconstruction of 2 defects in same or adjacent digits.Methods:From November 2017 to August 2021, 12 patients with 2 defects in same or adjacent digits were treated in the Department of Hand Surgery, Suzhou Ruihua Orthopaedic Hospital with 2 ipsilateral free pedicled perforator flaps from a single donor site of superficial peroneal artery. Among the patients, 1 had the defect in dorsal and palmar of index finger, 1 in thumb and index finger, 6 in index and middle fingers, 3 in middle and ring fingers, and 1 in ring and little fingers. The size of digit defects was 1.5 cm×0.8 cm-6.0 cm×3.5 cm. The size of flaps was 2.0 cm× 1.2 cm-8.0 cm×4.0 cm. All the patients were included in postoperative monthly follow-up to assess the recovery of recipient and donor sites at outpatient service, by telephone or WeChat.Results:All 24 flaps in 12 patients survived without vascular compromise and achieved 100% of survival rate. The follow-up period ranged from 4 to 18 months, with an average of 10 months. Six patients were treated with additional flap thinning and plastic surgery at 4 months after the primary surgery due to slightly bloated flaps. Otherwise, all the flaps in the recipient site had neither pigmentation, obvious hyperplasia nor scar pain. All flaps gained the protective sensations, however the assessment of TPD was not conducted. The flaps were wear-resist and had no ulceration. The texture of the flaps was soft with good elasticity, and the flap did not turn to purple or swelling when in cold. The functional recovery of 23 digits in 12 patients was evaluated according to the total active mobility (TAM) of the digits. It achieved excellent in 3 digits, good in 15 digits, and fair in 5 digits, with an excellent and good rate of 78.26%. A linear scar appeared at the donor site without obvious hyperplasia or scar pain. There were normal sensations around the scar and at the digit-tips. The blood supply to the digit-tips was normal.Conclusion:Harvest of multiple free pedicled perforator flaps from a single donor site of superficial peroneal artery is an effective method in reconstruction of 2 defects in same or adjacent digits at the same time. It has advantages of being a simple surgery procedure by sacrificing only one donor site. It achieves a minimal damage to the donor site and a reliable blood supply of the flap.
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Objective:To explore the surgical procedure and clinical effect of the free Flow-through superficial peroneal artery flap for repairing the digit injury with defect of proper palmar digital artery.Methods:From June, 2015 to December, 2019, free Flow-through superficial peroneal artery flap was used to repair the digit injury and to bridge the proper digital artery in 7 digits of 7 patients. There were 2 thumbs, 3 index fingers and 2 middle fingers. The size of defects on digits ranged from 2.5 cm×3.0 cm to 5.0 cm×7.0 cm. The defects of digit proper artery were 1.0 to 3.0 cm. The size of flaps was from 3.0 cm×3.5 cm to 5.5 cm×8.0 cm. The donor areas of the flap were directly sutured or covered with skin graft. Postoperative supportive treatments were given, such as infection prevention, antispasmodic, anticoagulant, analgesia and fluid infusion. The patients were kept in bed for 1 week after surgery. Monthly follow-up review were conducted and the patients were kept with the rehabilitation exercises under medical guidance.Results:All the patients entered postoperative followed-up for 6 to 18 months, with an average of 8 months. All flaps survived without any adverse event. All wounds achieved stage-one-healing. The flaps appeared in good colour, texture, elasticity and the plumps of the digit without obvious bloating. There was no obvious swelling and atrophy of the digits. The skin temperature was normal. According to the Standard for Evaluation of Upper Limb Function by the Hand Surgery Society of Chinese Medical Association, 3 digits were excellent and 4 were good. There was no obvious scar at the donor site of shank. The donor site had a good appearance and the limb function was not affected.Conclusion:The free Flow-through superficial peroneal artery flap is an ideal material to repair the defect of digit with the defect of proper digital artery. It has the advantages of simple surgical procedure, reliable blood supply and satisfactory appearance. The defect of proper digit artery can be repaired at the same time of the surgical procedure. The blood supply, appearance and function of the digits could be well recovered and the donor site is not affected.
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Objective:To investigate the blood supply pattern and characteristics of bilobate anterolateral thigh flaps, and to summarize the clinical experience.Methods:Date of 102 cases of limb wounds repaired by bilateral anterolateral thigh perforator flaps from March 2014 to July 2019 were retrospectively analyzed. There were 80 males and 22 females with an average age of 40.7 years (range, 9-66 years). All of the patients suffered from limb trauma with complex tissue defects, among which 29 cases had two adjacent and discontinuous wound surfaces on the same limb, and the area ranged from 5 cm×5 cm to 30 cm×18 cm, while the other 73 cases remained a single wound with the area ranged from 12 cm×11 cm to 27 cm×15 cm. Ultrasonic Doppler was used to locate the perforating branches. According to different patterns of blood supply, flaps of different types were designed and applied respectively. For those who with perforating branches of common trunk type or fascial type, the wound surface can be covered by the flap directly; for those who with perforating branches of double trunks type or mixed type, the turbocharging technique was performed after dissection of the pedicles of the flap, while the wound was repaired by reconnection. All the donor sites were sutured directly.Results:Total of 105 bilobed flaps were designed in 102 patients, including 43 flaps of common trunk type, 30 flaps of double trunks type, 24 flaps of fascial type and 8 flaps of mixed type. The single harvested flap area ranged from 6 cm×5 cm to 20 cm×9 cm. One patient's one piece of the bilobed flap repairing two wounds suffered an arterial crisis at 17 h after surgery. The surgery confirmed there was an intractable arterial spasm and the crisis was relieved after a vein trans-plantation. Then about 4 cm×3 cm superficial necrosis appeared in the most distal part of the flap and healed in secondary after dressing changes. Two cases with single wounds suffered from a vein crisis at 48 h after operation. After removing the suture and blood letting, the flaps survived a week later. The average healing time was 19 days (range, 8-83 days). All the thigh donor sites healed by first stage. All the cases were followed-up for an average period of 16 month (range, 6-70 months). The latest follow-up showed that the flaps were of good color and texture, and the sensation of the flaps recovered partially. According to the British Medical Research Council sensory rating scale: 21 cases were grade S2 and 81 cases were grade S3. According to the revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association, the results were excellent in 91 cases, good in 11 cases, with excellent and good rate of 100%. Linear scars were left in most donor sites and the VAS scores were all zero. 5 cases had a large scar area which the width was more than 3 cm, but there was no scar contracture or pain. 9 cases had an abnormal sensation in the donor area in the early stage and recovered gradually 3 months later without any movement disorder.Conclusion:The use of the bilobed anterolateral femoral perforator flap with different blood supply patterns to repair the wounds of extremities could overcome the lack or deficiency of blood supply caused by perforators with different sources. To clarify the blood supply types is conducive to the flap cutting and leaf splitting during the operation, which greatly improves the survival rate of the flap.
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Objective:To investigate the clinical effect of the first dorsal metatarsal-dorsal phalangeal artery flap in repairing large area of soft tissue defect on the palmar side of finger.Methods:From February, 2016 to June, 2018, 11 fingers of 11 patients (7 males and 4 females, aged 19-46 years old with an average of 32.5 years old) with large area of soft tissue defect on the palmar side of the finger were repaired with the first dorsal metatarsal-dorsal phalangeal artery flap. These included 3 with the first dorsal metatarsal-first dorsal phalangeal artery blood supply, and 8 with the first dorsal metatarsal-second dorsal phalangeal artery blood supply. In which 3 with retained finger pulp was for repairing the defects and bridging arteries, including 1 flexor tendon defect repaired by the extensor digitorum brevis tendon of the second toe with the flap. The type of blood vessel was Gilbert I detected by CDU before surgery. The area of the flaps was from 1.5 cm×5.0 cm to 3.0 cm×8.0 cm. The donor area of the flaps was compressed with full thickness skin grafts of the shank. The follow-up data was collected by outpatient clinic visits and telephone interviews.Results:All the 11 flaps survived and were followed-up for an average of 14 months, ranged from 6 months to 24 months. The colour and texture of the flaps were good. Sensing of temperature, pain and touch restored, without swelling. Function of the fingers was well restored. The range of motion of distal and proximal interphalangeal joints was closed to normal. The TPD of the flaps was 5-11 mm, with an average of 8 mm. Ten had primary wound healing in the donor sites of foot. One case had necrosis of the proximal toe of the skin graft and healed after dressing change. Long-term follow-up of the skin grafting area was wear-resistant, and does not hinder walking without rupture.Conclusion:Application of the first dorsal metatarsal-dorsal toe artery flap to repair large area of soft tissue defect on the palmar side of finger has number of advantages such as it, covers the wound and carry the tendons, bridges the arteries at the same time, plus delivers satisfactory outcome.
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Objective:To investigate the feasibility and clinical efficacy of the bilobed anterolateral femoral perforator flap pidicled with the oblique branch of lateral femoral circumflex artery in repair of the wounds in extremities.Methods:A study was conducted on 36 patients with complex limb wounds from December, 2014 to May, 2020. Thirty patients had single-wound sized from 10.0 cm×10.0 cm to 23.0 cm×17.0 cm, and 6 patients had 2 adjacent and discontinuous wounds sized from 4.0 cm×5.0 cm to 11.0 cm×9.0 cm. A total of 78 perforators were identified in routine preoperative CDU examination, and 67 perforators were confirmed. According to the actual requirement of the perforator confirmed in surgery, 19 flaps were designed with completely split up into bilobed flaps and 17 bilobed fascial flaps were designed with segmented skin and deep fascia. The blood supply of flaps relies on the anastomosis of oblique branch with the recipient vessels, therefore bridged blood Flow-through anastomosis was performed in 8 flaps. All thigh donor sites were sutured directly. Regular follow-up were made after surgery.Results:In this group, 35 cases of bilobed flaps survived successfully. Venous crisis was found in 1 case of flap repairing 2 wounds after the operation and was relieved 7 days later by remove some stitches and bloodletting. The donor sites healed by first intension, and the wound healing time was 11-83 days. All patients were followed-up for 6-39 months. The flaps had good colour and texture with S 2-S 3 sensory. All the donor sites left linear scars except 1 where left with a large scar without contracture and pain. Conclusion:The repair of the wounds in extremities by bilobed anterolateral thigh perforator flaps pedicled with the oblique branch of the lateral femoral circumflex artery could obtain a more concealed donor site. It acts as a beneficial supplement when a bilobed flap cannot be harvested on the descending branch of the lateral femoral circumflex artery.
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Degloving injury of distal thumb is common in hand surgery. Generally, the degloving tissue is severely damaged without conditions for replantation. It is often treated by methods of stump revision, local flap coverage, free second toe reconstruction, and so on. It inevitably leads to a shortening of distal phalanx, sacrifice of the whole toe and poor appearance after repair. The hallux nail flap is considered to be the best to treat this kind of injury. However, the traditional wrap-around flap excises the toe in a large range and has many complications in the donor site. In April, 2010, a case of degloving injury of the distal thumb was repaired with a combined wrap-around flap of the hallux nail flap and the tibial flap of the second toe. The patient was followed-up for 10 years in our hospital. Both of the appearance and function of the patient's thumb are well recovered.
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Objective:To investigate the clinical efficacy of external fixators combined with anterolateral thigh musculocutaneous flap for treatment of Gustilo type IIIB/C open tibiofibular fractures.Methods:A retrospective case series study was conducted to analyze clinical data of 15 patients with Gustilo type IIIB/C open tibiofibular fractures admitted to Ruihua Hospital of Soochow University from March 2016 to June 2019. There were 11 males and 4 females, with the age of (48.5±12.6)years (range, 22-67 years). All patients underwent emergency debridement in stage I, the major blood vessels, nerves and tendons were inspected and repaired, and the fracture ends were fixed by external fixator. There were different degrees of wounds necrosis, infection and bone defect after operation. After debridement in stage II, the soft tissue defects with the dimension of 10.0 cm×5.0 cm to 30.0 cm×8.0 cm were repaired with anterolateral thigh musculocutaneous flaps whose areas ranged from 10.5 cm×5.5 cm to 30.5 cm×8.5 cm. All donor areas of the musculocutaneous flaps were sutured directly in stage I. The healing of the donor areas and musculocutaneous flaps were observed within 2 weeks after operation. At the last follow-up, the shape and sensory recovery of the flap, healing of fractures and related complications were observed. The lower extremity functional scale (LEFS) was used to evaluate the injured limb function.Results:All patients were followed-up for 12-32 months [(22.0±5.8)months]. All donor areas were healed by first intention, leaving only linear scars. The musculocutaneous flaps survived completely in all patients. Partial necrosis of large area of musculocutaneous flap occurred in 2 patients, and healed after debridement and skin grafting. Another patient had vascular crisis after musculocutaneous flap operation and survived after the embolized vein repaired by contralateral great saphenous. At the last follow-up, the shape of flap recovered well, and the feeling partially recovered with the two-point discrimination of 18-26 mm. All fractures healed well, and there were no serious infection-related complications such as osteomyelitis. The LEFS score was 47-69 points [(59.0±9.5)points].Conclusion:Theexternal fixator combined with anterolateral thigh musculocutaneous flaps for treatment of Gustilo type IIIB/Copen tibiofibular fractures can better restore the appearance of soft tissue defect of the lower leg, and can effectively reduce the occurrence of severe infection-related complications.
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Objective:To investigate the clinical effect of the anterolateral thigh myocutaneous flap combined with sequential fibular flap to repair complex tissue defects of the foot.Methods:A retrospective case series study was conducted to analyze the clinical data of 6 patients with complex tissue defects of the foot admitted to Ruihua Hospital of Soochow University from March 2017 to March 2019. There were 5 males and 1 females,aged 33-54 years[(41.4±10.2)years]. The area of the skin and soft tissue defects of the foot was from 12 cm×7 cm to 19 cm×9 cm. First metatarsal defect occurred in 3 patients,4-5th metatarsal defects in 2,and 4-5th metatarsal combined with lateral cuneiform and cuboid defects in 1. The length of bone defects was 6-14 cm,and partial extensor tendon defects were found in all patients. The anterolateral thigh myocutaneous flap was used to cover the wound in the first stage,and the sequential fibula flap was used to repair the complex bone defects. The myocutaneous flap survival,wound healing,fibular bone flap healing and donor site recovery were detected. The appearance and sensory recovery of myocutaneous flap and related complications were observed at the last follow-up. The foot function was evaluated by the Maryland foot function score before operation,at postoperative 1 month,at postoperative 6 months and at the last follow-up.Results:All patients were followed up for 9-33 months[(17.8±5.2)months]. All musculocutaneous flaps survived at postoperative 2 weeks. One patient sustained sinus tract formation due to partial necrosis of the residual metatarsal bone,which healed 3 weeks after re-debridement,while the wounds of other patients healed smoothly. The surgical incision healed two weeks after fibular flap surgery,with no signs of local infection. A small amount of callus formed between the transplanted fibula and the fractured end of the bone in the recipient area was observed 6 weeks after the fibular flap operation. Primary bone healing was found in all patients,with the fibular flap healing time of 12-18 weeks[(14.5±4.3)weeks]. The donor sites of the myocutaneous flap and fibular flap also showed primary healing with only linear scars left. Three patients had numbness in the lower and outer side of the donor sites of the thigh but were gradually recovered to the normal 6 months after the repair of the fibula. The joint function of the knee and ankle at the donor sites of the fibular flap recovered well. There showed slight swelling appearance of the flap,a protective feeling of the myocutaneous flap and sound healing of the bone flaps,at the last follow-up,with no complications such as resorption or osteomyelitis of the fibula flap. The Maryland foot function evaluation score was increased from(23.5±5.2)points preoperatively to(44.3±5.3)points at postoperative 1 month,(52.1±7.4)points at postoperative 6 months,and(84.5±11.1)points at the last follow-up( P<0.05),with statistically significant difference at each time point after operation( P<0.05). The foot function was excellent in 3 patients,good in 2,and fair in 1. Conclusion:For complex tissue defects of the foot,the anterolateral femoral myocutaneous flap and subsequent fibular flap can effectively repair the wound of the foot,reduce the occurrence of serious infection-related complications,ensure the healing of bone defects,restore the shape of the foot,reduce the occurrence of serious infection-related complications and promote the functional recovery of the affected limb.
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Objective:To investigate the clinical effect of flow-through anterolateral thigh perforator flap with fascia lata for repairing dorsal wounds of the hand and foot with extensor tendon defects.Methods:A retrospective case series study was conducted to analyze the clinical date of 14 patients with hand and foot wounds associated with extensor tendon defects admitted to Ruihua Affiliated Hospital of Soochow University from January 2015 to December 2019. There were 13 males and 1 female,aged 10-57 years[(39.2±13.4)years]. The wounds were all single with the area of 10 cm×4 cm to 23 cm×12 cm,including 8 wounds on the back of the hand and 6 wounds on the back of the foot. There was 1 patient accompanied with 1 tendon defect,10 with 4 tendon defects and 3 with 5 tendon defects,with the length of tendon defects ranging from 2.0 to 6.0 cm[(3.8±1.4)cm]. The dimension of flaps ranged from 12 cm×5 cm to 23 cm×13 cm,with the fascia lata from 11 cm×5 cm to 20 cm×7 cm. The deficient extensor tendons were repaired with the fascia lata and vascular pedicles were anastomosed by flow-though. A bilobed flap was harvested in 3 patients and a single flap in 11 patients. Donor sites were sutured directly. The survival of the flap and healing of the donor area were detected after operation. The extremity revascularization and shape and sensation recovery of the flap were measured at the last follow-up. The upper extremity functional evaluation standard set up by Hand Surgery Society of the Chinese Medical Association and Maryland foot functional score were used to evaluate the hand and foot function before operation and at the cast follow-up,respectively. The donor site complications and performance of tendon release or flap thinning in the second stage were recorded.Results:All patients were followed up for 8-30 months[(15.3±6.2)months]. All flaps survived successfully,with wounds and thigh donor areas healed by first intension. No significant effect of revascularization was observed on recipient sites,and acceptable cosmetic outcomes and sensation recovery of the flap were achieved at the final follow-up. For patients with dorsal wounds of the hand,the extensor function recovered in different degrees,and the flexion activities of the fingers were not limited. The total active movement was 180°-250°[(226.3±21.7)°]at the last follow-up,compared to preoperative 110°-170°[(145.6±13.2)°]( P<0.01). According to the upper extremity functional evaluation standard,the function was excellent in 4 patients,good in 2 and fair in 2. For patients with wounds of the foot,the flexion and extension function was good,with no obvious deformity of toes,and the Maryland foot functional score ranged from 60 to 92 points[(76.0±12.7)points]at the last follow-up,significantly improved from preoperative 18-45 points[(27.4±7.8)points]( P<0.01),including excellent results in 2 patients,good in 3 and fair in 1. Only linear scars were left in the thigh donor area,and there was no discomfort such as scar contracture or pain. Four patients underwent skin flap thinning at 4-8 months after operation and none underwent a tenolysis. Conclusion:Repair of dorsal wounds with extensor tendon defects of the hand and foot by flow-through anterolateral thigh perforator flap with fascia lata can reduce interference to recipient sites and repair wounds and extensor tendons simultaneously,which can obtain good flexion and extension function and minor damage to the donor area.
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Objective:The morphological characteristics of the oblique branch of lateral circumflex femoral artery (LCFA) were observed by digital subtraction angiography (DSA) in order to provide imaging basis in the application of the ALTF pedicled with the oblique branch of LCFA.Methods:Between February, 2020 and December,2020, for the patients who were requested to repair the wound with ALTF, a DSA radiography was performed before operation. A total of 197 sides of selective DSA were analysed in 113 patients. The occurrence rate, origin and course of the oblique branch of LCFA were observed. Relationships between the oblique branch of LCFA and the upper cutaneous branch, descending branch and transverse branch were analysed. In addition, in order to verify the accuracy of conventional DSA data in describing the morphological characteristics of oblique branches, 10 sites of 10 patients were randomly selected to perform rotational DSA three-dimensional imaging.Results:Femoral artery, deep femoral artery, LCFA and the branches of LCFA were clearly identified on DSA images. The oblique branch appeared in 190 sites, with a occurence rate of 96%. Among them, 1 oblique branch originated from the femoral artery, 2 from the deep femoral artery, and other 187 from LCFA. The oblique branches were found in 10 sites from rotational DSA three-dimensional imaging, which was consistent with conventional DSA imaging.Conclusion:The occurrence rate and morphological characteristics of the oblique branch of LCFA can be directly analysed by DSA. The oblique branch is not a variant branch as reported in the literatures, as it always appears. It may serve the main blood supply artery of the anterolateral thigh flap.
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Objective:To explore the clinical effect of bilobate anterolateral thigh flaps with turbocharging technique in repairing limb wounds.Methods:A retrospective case series study was conducted to analyze the clinical data of 29 patients with complex wounds of limbs admitted to Ruihua Hospital Affiliated to Soochow University from March 2014 to July 2019. There were 26 males and 3 females, aged 22-60 years [(41.9±11.1)years]. A total of 24 patients had single-wounds with the dimension of 12 cm×10 cm to 38 cm×27 cm, and 5 patients had two adjacent and discontinuous wounds with the area from 7 cm×4 cm to 13 cm×9 cm. The bilobate anterolateral thigh flaps with turbocharging technique were used. All the donor sites were directly sutured by primary closure. Routine treatment was given after operation. The origin artery of perforators, time of flap harvesting and operation time were recorded. The survival of the flap, healing of the donor area, long-term shape of the flap and donor area, sensory recovery and complications were observed.Results:All patients were followed up for 6-64 months [(19.0±12.7)months]. A total of 30 bilobed flaps were designed for the 29 patients. The time of flap harvesting ranged from 25 to 60 minutes [(46.6±20.2)minutes]. The operation time was 4-11 hours [(6.4±1.8)hours]. All flaps survived except one piece of a bilobed flap suffered from a vein crisis, which healed well after conservative treatment. These wounds' healing time ranged from 11 to 53 days [(18.5±9.9)days], and all the donor sites healed by first intention. Four patients underwent skin flap thinning operation 4 to 8 months later due to the bloated appearance of flaps. Acceptable cosmetic outcomes, soft and elastic skin, and sensation recovery were achieved at the final follow-up. All patients 'donor area left linear scars. One patient had large scar area, but there was no scar contracture and pain. Two patients had an abnormal sensation in the incision area in the early stage and recovered gradually 3 months later without any other serious complications.Conclusions:Repair of limb wounds with bilobed anterolateral thigh flaps with turbocharged technique can overcome the limitation that the bilobed flap can not be designed if the perforators do not share the same trunk and expand the application scope of the bilobed flaps. The design of bilobate flaps reduces the width of the donor site, which can effectively avoid the complications of the donor site.
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Objective:To explore the clinical effects in repairing dorsal complex tissue defect of finger with the flap based on superficial palmar branch of radial artery (SPBRA) with palmaris longus tendon.Methods:From May, 2011 to October, 2017, dorsal complex tissue defects of 15 fingers and thumbs in 15 patients were treated by the flaps which were based on SPBRA with palmaris longus tendon. There were 10 males and 5 females, in an average of 35.8 (19-51) years. All the defects (3 thumbs, 5 index, 2 middle and 5 ring fingers) were dorsal complex tissue defects and all had extensor tendon defects. The areas of soft tissue defect measured 2.0 cm×1.5 cm to 4.0 cm×2.0 cm. The lengths of tendon defect measured 2.0-4.0 cm. All patients received emergency surgery. The time before the surgery was 1.5-3.0 hours. The surgery time was 3.0-4.5 hours, 3.6 hours in an average. Postoperative regular follow-up.Results:All of the wounds healed in stage I and all flaps survived. Texture of the flaps was soft with rosy color. No obvious swelling occurred. All the donor sites healed in stage I. The patients were followed-up for 4-18 months, 8 months in an average. The appearance and function of the repaired fingers and thumbs were satisfactory. The pain, temperature and touch sensations were good. The color of flaps was similar to the normal finger without swelling. The wear resistance of the flaps was good. Thin-line scars were in the wrist donor sites without contracture. The range of motion of active palmar flexion of the wrist was from 0° to 80° and active hyperextension was from 0° to 70°. No obvious limitation was found.Conclusion:It is able to achieve a satisfactory clinical effects by using the flap that is based on SPBRA with palmaris longus tendon in repairing the dorsal complex tissue defect of hand. The advantages of the technique are that the donor site is concealed. The wound is small, and the flap is easy to be harvested and anastomosed.
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Objective:To investigate clinical effect of the descending genicular periosteal free flap combined with bone graft in the treatment of tibial nonunions.Methods:From January, 2014 to June, 2018, 15 cases of tibial nonunions were treated with the descending genicular corticoperiosteal free flaps combined with bone graft after soft tissue coverage. All patients had Gustilo III C fracture. In 6 cases, the descending genicular artery of periosteal flap was anastomosed with the branch of anterior tibia artery, 6 cases anastomosed with the branch of posterior tibia artery, other 3 cases had Flow-through anastomosis with the main trunk of anterior tibia artery. The accompanying vein of descending geniculate artery was anastomosed with the vein of anterior tibia or posterior tibia artery. Routine treat- ment, step-by-step functional recovery exercises, monthly X-ray examination were conducted together with close ob- servation of the healing of fracture.Results:All cases were followed-up from 6 to 29 (average, 11) months. Bone u- nion was achieved in 14 cases with the averager time of healing in 5 months. According to the evaluation criteria of Paley fracture healing, 12 cases were excellent, 2 were good and 1 was poor. Fourteen cases were able to take daily normal activities, and 1 case failed to take the daily activities because the fracture was not healed. Six months later, according to the results of Paley functional evaluation, 2 cases were scored excellent, 12 scored good and 1 scored poor.Conclusion:The method of the descending genicular periosteal free flap combined with bone graft in the treatment of tibial nonunions can effectively improve the fracture union rate and reduce the patient treatment time with hidden donor area and simplicity of operation. It is helpful for the patients to take early exercises for the recovery of functions.
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Objective@#To investigate the clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of ankle and foot wounds.@*Methods@#From March 2014 to October 2018, 16 patients with foot and ankle injuries were admitted to our hospital and left large area of wounds on foot and ankle after emergency treatment. There were 13 males and 3 females, with age of 27 to 60 years. The area of the wounds ranged from 14 cm×10 cm to 40 cm×17 cm. The wounds were repaired with extra-long lateral femoral supercharged perforator flaps. The widths of flaps in 8 patients were longer than 8 cm, and the bilobed flaps were designed to repair the wounds. The area of the flaps ranged from 12 cm×5 cm to 40 cm×9 cm. During the operation, 54 perforators were detected, with an average of 3.2 perforators in each flap, and 36 source arteries of perforators were detected. The blood vessel trunk of 15 patients was descending branch of the lateral femoral circumflex artery, and their supercharged mode was anastomosis of the bulky perforator of descending branch of the lateral femoral circumflex artery with the oblique branch of the lateral femoral circumflex artery and/or medial femoral circumflex artery or the descending branch of superficial illiac circumflex artery. The blood vessel trunk of 1 patient was oblique branch of the lateral femoral circumflex artery, and the supercharged mode of the patient was anastomosis of the oblique branch of the lateral femoral circumflex artery with the bulky perforator of the descending branch of the lateral femoral circumflex artery. The wounds were covered with the flaps after supercharged blood vessel anastomosis, and blood vessels in the donor sites were anastomosed with those in the recipient sites. The donor site was sutured directly. The survival of the flap after the operation and healing time of the wound, and the flap condition, the two-point discrimination distance of flap in patients who were reconstructed with sensation, the recovery of the ankle function, and the appearance of the donor site during follow-up were recorded.@*Results@#A total of 17 flaps in 16 patients were designed, including 8 bilobed flaps and 9 non-lobulated flaps. Sixteen flaps in 15 patients survived. Vascular crisis occurred in the flap of one patient, and the flap survived when the vascular crisis was relieved by the second operation. The healing time of foot and ankle wounds ranged from 12 to 90 days. All the lateral femoral donor sites healed completely. During follow-up of 8 to 48 months, flaps in 2 patients were slightly bloated and were trimmed in 6 months after the operation. The other flaps were with good appearance, soft texture, good elasticity, and no rupture or ulceration. The two-point discrimination distances of flaps ranged from 7 to 16 mm in 8 patients who were reconstructed with sensation, and the other flaps recovered protective sensation. The flexion and extension function of ankle joint recovered well, and the walking function was not affected significantly. All donor sites formed linear scar, with no deep tissue infection such as osteomyelitis.@*Conclusions@#The application of extra-long lateral femoral supercharged perforator flaps to repair the large area of wounds in foot and ankle can significantly reduce damage to donor sites and has advantages of rich blood supply and good safety, thus it has satisfactory clinical effects.
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Objective@#To explore the clinical effect of bilateral anterolateral thigh flaps in repairing complex wounds of foot and ankle.@*Methods@#From April 2014 to June 2017, 16 patients with complex foot and ankle wounds were treated in Ruihua Hospital Affiliated to Soochow University. There were 15 males and 1 female, aged from 12 to 73 years. Two of them had two wounds for each, the area of which was from 4 cm ×5 cm to 6 cm×10 cm. Fourteen cases were single-wounds, the area of which ranged from 11 cm×8 cm to 42 cm×15 cm. According to the wound surfaces, the wide wound cloth was divided into two pieces of cloth with a width less than 8 cm. The double-leaf skin flap was designed at the point of the perforating branch of the skin flap located by B-ultrasound on the iliac-patellar connecting line of the donor area. The course of the origin artery of the skin perforating branch of the skin flap was observed by DSA image. If the perforating branch of the double-leaf skin flaps was the common origin artery, the two adjacent wounds would be repaired directly. If the perforator of the double-leaf skin flaps is not the common artery, the double-leaf skin flaps were cut separately. After the pedicle division, the perforator vessels of the high perforator skin flaps were anastomosed with the distal end of the medial circumflex lateral femoral artery of the low perforator skin flaps to form a new parallel double-leaf skin flaps, which were then assembled or lobed to the recipient area. Flap donor sites were sutured directly.@*Results@#11 cases were repaired with parallel bilateral anterolateral thigh flaps with double perforators, and 5 cases were repaired with new parallel bilateral thigh flaps formed by anastomotic bridging of perforator vessels. The area of the flaps ranged from 5 cm×6 cm to 8 cm×22 cm. All the 16 flaps survived and the donor site wounds healed in one stage. Five cases underwent internal fixation removal and skin flap thinning 6 to 10 months after operation. Follow-up for 6 to 18 months showed that the skin flaps were of good color and texture, and the sensation of the flaps ranged from S1 to S3. Linear scars were left in all donor sites and lower limb movements were normal.@*Conclusions@#It is a good method to repair complex foot and ankle wounds with bilateral anterolateral thigh flaps, and it has the advantages of flexible design, less damage to donor site and good blood supply of the flap.
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Objective To investigate the clinical effects of irrigation sequential Flow-through type anterolat eral thigh chimeric myocutaneous flap in the treatment of chronic tibial osteomyelitis.Methods From January,2012 to December,2017,trench grooved sequential Flow-through anterolateral femoral chimeric flaps were u sed to treat chronic tibial osteomyelitis.On the basis of sensitive antibiotics,bone grooving and VSD grooved sequential Flow-through anterolateral thigh chimeric flaps were used to fill the bone cavity and cover the wound.The patients received the follow-up care in outpatient office and telephone regularly after hospital discharge.Results Among the 18 cases in this group,2 cases were positive and 16 cases were negative in secondary bacteriological detection.The flaps and donor sites survived in one stage.Fifteen cases healed in one stage,and extravasate occurred in 3 cases after operation.After dressing change,the wounds healed in 25 days,32 days and 43 days after flap operation,respectively.All the patients were followed-up for 12 to 30 months,with an average of 25 months.Local low toxicity infection symptom occurred again in 1 case with delayed healing 6 months after operation.After 1 week of antibiotic treatment,the symptom subsided.After 1 more week of antibiotic use,the patient was discharged from hospital.And followed-up for 1 year,no recurrence occurred.During the follow-up period,no recurrence of infection and no fracture occurred after primary fracture healing in other 17 cases.One year after the second operation,there was no obvi ous stenosis in the bridged vessels examined by Doppler ultrasonography and the blood flow velocity was the same as that of the contralateral limbs.Conclusion The application of irrigation and sequential Flow-through type anterolateral thigh chimeric myocutaneous flap for treatment of chronic tibial osteomyelitis can achieve good therapeutic effect and is worth popularizing.
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To investigate the clinical efficacy of using the posterior tibial artery and peroneal artery perforator flaps to repair the heel wounds. Methods From January, 2011 to May, 2018, heel soft tissue de-fect caused by trauma in 18 cases were treated by posterior tibial artery and peroneal artery perforator flaps respec-tively. The posterior tibial artery perforator flap was used in 11 cases, and the peroneal artery perforator flap was used in 7 cases. The area of flaps ranged from 5.0 cm×3.0 cm to 11.0 cm×9.0 cm. The length of the vascular pedicle was from 10.0 cm to 16.0 cm.After operation, the patients were followed-up regularly.The time of wound healing, appear-ance and texture of the flap, and function of ankle joint were observed. Results After the operation, 13 flaps sur-vived uneventfully. The wound achieved primary healing. Partial necrosis occurred in the distal of posterior tibial artery perforator flap in 2 cases, and repaired by skin graft 1 or 2 months later.Marginal necrosis occurred in posterior tibial artery perforator flap in 2 cases and in peroneal artery perforator flap in 1 case. And scar healing occurred in these 3 cases finally.All the 18 patients were followed-up for 3 to 60 months, with an average of 10 months. Fracture healing time was from 3-6 months, with an average of 4 months. Flap was soft with satisfied appearance in 16 cases. Obvious scar formation occurred in 2 cases. There was no obvious scar contracture in donor sites. There was no obvi-ous limitation of the flexion and extension function of the ankle joint in 18 cases. According to the American Or-thopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, there was excellent in 16 cases, and good in 2 cases. Conclusion As for the characteristics of the heel wound, it is a simple and practical method to use leg perforator flap to repair.The flap is based on a long vascular pedicle.And the clinical effect is satisfied.