Role of perforator flaps in leg and foot reconstruction.

INTRODUCTION: Lower extremity wounds have always been a challenge for the reconstructive surgeons. Free perforator flaps are considered to be the best option for this problem but require the complexity of microsurgery. So, pedicled perforator flaps have emerged as an alternative option. PATIENTS AND METHODS: Prospective study was conducted in 40 patients with traumatic soft tissue defects in the leg and foot. The free flaps included the anterolateral thigh flap (ALT) and medial sural artery perforator flap (MSAP). In pedicled perforator flaps group, 10 cases were designed as propeller flaps while the other 10 flaps were designed as perforator plus flaps. RESULTS: Free flaps were mainly used for large-sized defects; we had one case of partial flap loss and one case of complete flap necrosis.  MSAP flap was the first option for coverage of large-sized defects on foot and ankle as it is a thin and pliable flap, while ALT flap was used for coverage of larger defects on the leg. Pedicled perforator flaps were used mainly for small to medium-sized defects, especially in the lower third of the leg; we had three cases of flap loss in propeller flap design while we had no cases of flap loss in perforator plus flap. CONCLUSION: Perforator flaps have become a reasonable solution for soft tissue defects of the lower extremity. Careful assessment of the dimensions, location, patient comorbidities, availability of surrounding soft tissue and presence of adequate perforators are mandatory for proper perforator flap selection.

Which MR imaging sequences are necessary in determining the need for radiation therapy for cord compression? A prospective study.

BACKGROUND AND PURPOSE: To determine which MR imaging sequences are necessary to assess for spinal metastases. METHODS: Hypothetical MR imaging interpretations and management plans were made prospectively for consecutive adult cases acquired retrospectively. Standardized MR imaging protocols were independently interpreted by 2 neuroradiologists. MR imaging protocol types varied: 1) T1-weighted images only; 2) T1-weighted and T2-weighted images; 3) T1-weighted and postcontrast T1-weighted images; and 4) T1- and T2-weighted images and postcontrast T1-weighted images. Hypothetical management plans were created by 2 radiation oncologists. Logit model was used to investigate the effect of MR imaging protocol type on the probability of recommending radiation therapy (RT). Mixed effect models were used to investigate whether median spinal level or total number of spinal levels of planned RT was associated with MR imaging protocol type. RESULTS: Thirty-one subjects were evaluated, each with multiple scan interpretations. Logit model showed that neither MR imaging protocol type nor neuroradiologist reader affected the probability that the oncologist would recommend RT (all P > .50). Mixed models showed that neither ML nor NL was affected by MR imaging protocol type or by neuroradiologist reader (all P > .12). CONCLUSION: Although MR imaging is known to be the most useful diagnostic test in suspected spinal cord compression, which particular MR images are necessary remain unclear. Compared with T1-weighted images alone, the additional use of T2-weighted and/or postcontrast T1-weighted sequences did not significantly affect the probability that RT would be recommended or the levels that would be chosen for RT in our study. Our data suggest that unenhanced T1-weighted images may be sufficient for evaluation of possible cord compression.

Economy of donor site incisions: multiple free flaps of the subscapular family for extensive extremity wounds and bilateral foot defects.

One of the most important goals of modern microsurgical reconstruction is to decrease donor site morbidity as much as possible. With free flaps for lower limb reconstruction, economy of donor sites was designed and performed in 39 patients. Among these 39 patients, 17 had multiple flaps raised from a single incision for reconstruction of multiple defects in one or both lower extremities. Microvascular reconstruction of multiple defects is a challenging problem, particularly if it is to be performed simultaneously. The patients were followed for more than 3 years. Immediate complications and long-term disabilities were analyzed. From the data we conclude that this method has the following advantages: (1) economy of donor site incisions, (2) less harvest time, and (3) availability of any composite tissue for transfer. Donor site morbidity can be reduced by good planning, careful dissection, meticulous hemostasis, and adequate postoperative management.

Cerebrospinal fluid fistula: detection with MR cisternography.

PURPOSE: Our goal was to assess the role of MR cisternography in the examination of patients with suspected CSF rhinorrhea. METHODS: MR cisternography was performed as a heavily T2-weighted fast spin-echo study with fat suppression and video reversal of the images in 37 patients over a 3-year interval. Twenty-four of the patients subsequently had exploratory surgery for fistula. Statistical analysis of the surgical results was compared with the findings at MR cisternography. RESULTS: MR cisternography showed significant correlation with surgical findings, with sensitivity, specificity, and accuracy of 0.87, 0.57, and 0.78, respectively. CONCLUSION: MR cisternography proved to be an accurate diagnostic imaging technique in the evaluation of suspected CSF rhinorrhea.

Free fibula osteoseptocutaneous graft for reconstruction of segmental femoral shaft defects.

Seventeen major reconstructions of the femoral shaft using vascularized fibula osteoseptocutaneous grafts were performed from August 1984 to September 1993. Patients were 14 males and 3 females, with an average age of 34 years. All patients had sustained high-energy trauma in motor vehicle crashes and had bone defects averaging 10 cm. The skeletal defect was primary attributable to bone loss at the time of injury (2 cases) or secondary after infection and sequestrectomy (15 cases). Vascularized fibular transfer was performed at an average of 6 months after trauma. The fibular graft was inserted as a single strut in 10 cases and as a double-barrel composite in 7 cases. Patients were evaluated at an average of 43 months after surgery. All grafts eventually united, and no patient showed evidence of recurrent or persistent infection. The average time to radiologic union was 8 months, and the average time to full weight bearing was 14 months. Secondary bone grafting and internal fixation were required in five cases because of delayed union, stress fracture, or screw loosening. All cases of delayed union and stress fracture were in those reconstructed by single-strut fibular graft. Four cases (24%) required quadriceps plasty and arthrolysis. The final average arc of active knee motion was from 0 to 80 degrees. Limb length discrepancy ranged from 0 to 7 cm (average, 3 cm). Five cases (29%) had varus deformity averaging 30 degrees. The fibular graft hypertrophied to 100% of the femoral circumference in cases followed for 3 years. Donor site morbidity was negligible. At the time of final follow-up, 13 patients had returned to their original jobs, two were permanently disabled because of below-knee amputation, and two were retired. The study suggests that vascularized fibula osteoseptocutaneous transfer is a valuable procedure for reconstruction of large, previously infected femoral shaft defects.

Cross-leg free flaps for difficult cases of leg defects: indications, pitfalls, and long-term results.

BACKGROUND: Cross-leg free flaps have been described for reconstruction of leg defects in cases of trauma with no suitable recipient vessels in the vicinity of the defect. The pitfalls, however, have not been well documented in the literature. The technique of transfer and the length of time required before pedicle division depend on the nature of the flap and the contact surface. METHODS: Eight cross-leg free flap reconstructions were performed on seven patients between 1986 and 1993. These included three latissimus dorsi muscle flaps, three fibula osteomyocutaneous flaps, one tensor fascia lata myocutaneous flap, and one posterolateral thigh flap. The important technical considerations are outlined. RESULTS: One latissimus dorsi flap failed, whereas the rest of the flaps completely survived. The morbidity of the recipient and donor sites are listed. CONCLUSION: We conclude that the technique offers the possibility of salvaging limbs that are, otherwise, nonreconstructable. It is useful for young patients. When the flap is long, it can function as a nutrient flap for the distal limb even though the pedicle has been divided. It is a backup procedure in an urgent situation of re-exploration in which reestablishment of circulation should take place as soon as possible.

Toe-to-hand transfer for traumatic digital amputations in children and adolescents.

In the period from July of 1990 to August of 1994, 45 toe or toe tissue transfers were performed in 28 children and adolescents with traumatic amputation of digits. The average age at the time of transfer was 12 years (range, 3 to 16 years), and the median age was 10 years. The methods of reconstruction included transfer of 6 trimmed great toes, 2 great toe pulps, 24 second toes, 1 vascularized metatarsophalangeal joint from the second toe, 2 third toes, 4 combined second and third toes. and 1 combined third and fourth toes. All of the transferred toes, except one second toe, ultimately survived. Exploration and reanastomosis were required in three cases owing to arterial insufficiency. Partial pulp loss occurred in two digits. Follow-up ranged from 1 to 5 years (average, 3 years). Bony union occurred uneventfully in all patients. Two-point discrimination averaged 5 mm (static) and 6 mm (moving). Active range of the motion averaged 69, 38, and 13 degrees at the metaphalangeal proximal interphalangeal and distal interphalangeal joints of the reconstructed fingers, respectively, and 15 degrees at the interphalangeal joint of the reconstructed thumbs. None of the children required subsequent tenolysis. Pulp plasty was performed in nine digits in seven patients. Radiologically, the transferred phalanges showed the some growth as the non-transferred ones. Trimming the great toe before transfer did not result in premature physeal closure or growth retardation. The donor foot maintained a satisfactory appearance. None of the patients complained of difficulty in running or jumping. Toe-to-hand transfer in children, performed meticulously, can provide a valuable option for reconstruction of traumatic digit loss.

The lateral arm fascial free flap for resurfacing of the hand and fingers.

The lateral arm free flap can be harvested as a fascial flap or fasciocutaneous flap. In this report we describe the use of the lateral arm fascial flap for degloving injuries of the fingers and for skin loss on the dorsum of the hand with exposure of tendons and bones. Concomitant reconstruction of a missing phalanx with a portion of the distal humerus is also described. The use of the fascial flap allows a large area of tissue to be harvested, and still, the donor site can be closed primarily. The fascia is thin and pliable and so conforms well to the contour of the fingers. Its bulk does not interfere with finger motion, and its undersurface creates a gliding surface for tendons. Complications in the reported cases were negligible.

Metacarpal hand: classification and guidelines for microsurgical reconstruction with toe transfers.

Metacarpal hand refers to the hand that has lost its prehensile ability through amputation of all fingers with or without amputation of the thumb. Functional restoration can be achieved by a wide variety of microvascular toe transfer techniques. When deciding which procedure should be used, careful consideration must be given to the level of amputation of the fingers as well as the functional status of the remaining thumb. In this article we propose a classification for the various patterns of the metacarpal hand along with guidelines for selection of the proper toe transfer procedure.

Microvascular reconstruction of the distal digits by partial toe transfer.

Advances in microsurgery have provided multiple options for reconstruction of distal digital deficit using various parts of the finger. These relatively minor microsurgical procedures always lead to a great patient satisfaction both in function and appearance.

Magnetic resonance cisternography and thin coronal computerized tomography in the evaluation of cerebrospinal fluid rhinorrhea.

In recent years cerebrospinal fluid (CSF) rhinorrhea has been managed successfully with transnasal endoscopic techniques. The most important and often most difficult step is the precise localization of the fistula. Computerized tomographic and radionuclide cisternography are two commonly used techniques for preoperative identification of the CSF fistula when it cannot be seen clearly with nasal endoscopy. Each of these requires a lumbar puncture, and the intrathecal placement of contrast material has been associated with transient neurotoxicities. Magnetic resonance cisternography (MRC) is a noncontrast study that does not require a lumbar puncture and has been used recently in the diagnosis of spontaneous and traumatic CSF leaks. Magnetic resonance cisternography utilizes a fast spin-echo sequence with fat suppression and video image reversal that highlights CSF. This allows precise localization of the fistula in both coronal and sagittal planes. Thin section coronal computed tomography (TCCT) is another noninvasive technique that can be helpful in localizing CSF leaks. The technique of MRC and TCCT and the results of 16 CSF leaks in 15 patients are reported. There was good correlation between MRC, TCCT, and intraoperative findings. Magnetic resonance cisternography and thin coronal computerized tomography appear to be accurate and complementary, noninvasive radiographic studies that should be considered in the evaluation CSF rhinorrhea.

Current concepts of toe-to-hand transfer: surgery and rehabilitation.

Optimal functional recovery after toe-to-hand transfer depends on skillful surgery as well as aggressive motor and sensory rehabilitation. The patient should be well motivated and willing to incorporate the involved hand in daily living and carry out the rehabilitation program on a daily basis. This article presents the current recommendations for the different toe-to-hand transfers and their postoperative rehabilitation programs.

Toe-to-hand transfer. Current concepts, techniques, and research.

The current status of toe-to-hand transfer at the Chang Gung Memorial Hospital is presented. Various combinations of toe-to-hand transfers have been used routinely for reconstruction of lost digits as well as parts of the digits distal to the sublimis insertion. Early, one-stage reconstruction is recommended in patients with clean wounds when replantation is not feasible. The decision of which technique to be used in certain patients is highly individualized. Technical refinements have been introduced aimed at simplifying the technique of toe harvesting and improving the function and appearance of the reconstructed digits as well as donor sites. Aggressive motor rehabilitation and sensory re-education are essential for optimal functional recovery. Current research projects involve evaluation of patients using the computerized work simulator, gait analysis, and somatosensory evoked potentials. Morphometric studies of the digital nerves in the fingers and toes have been performed to determine the effect of neurotization upon the degree of sensory recovery.

MR myelography of the cervical spine.

In previous studies, magnetic resonance (MR) myelography was not effective in the cervical region. However, effective cervical MR myelography is possible with a modified fast spin-echo sequence (8,000/360 [repetition time msec/effective echo time msec], four signals averaged, echo train length of 24). In a clinical study of this protocol, MR myelography was performed as an additional sequence following conventional MR imaging; composite images were obtained with a maximum-intensity projection algorithm. The MR myelographic sequence added only 8.5 minutes to the total imaging time and yielded information not provided by MR imaging in 13% of patients. MR myelography was especially valuable in demonstrating abnormal intraspinal vascularity and in guiding patient treatment by providing detailed preoperative information about intradural masses and posttraumatic and postoperative diverticulum and meningocele. This MR myelographic technique is a useful adjunct to MR imaging, especially in cases in which the more detailed information provided will be helpful in the analysis of complex intraspinal disease.

Early bilateral radiation-induced optic neuropathy with follow-up MRI.

Most documented cases of radiation-induced optic neuropathy are unilateral and occur more than 1 year after radiotherapy to the sellar region. We describe a patient with bilateral radiation optic neuropathy 3 months following the completion of radiotherapy. MRI 13 months after the onset of visual failure showed bilateral optic atrophy with residual gadolinium enhancement.

MR myelography: imaging findings.

MR myelography, heavily T2-weighted fast spin-echo imaging with fat suppression, enhances the signal intensity of CSF with subtraction of the surrounding background signal. Krudy [1], who first described the technique, used multiple projections per examination. We illustrate the findings in 80 patients who were examined with a modified MR imaging technique that provides increased spatial resolution and uses a single coronal sequence after the conventional MR study. This report illustrates the usefulness of MR myelography in cases of spinal stenosis or spinal block, in both the lumbar and thoracic regions.

MR cisternography: initial experience in 41 cases.

PURPOSE: To present our initial experience with MR cisternography, an application of fast spin-echo MR with fat suppression, and compare it with routine MR cranial studies in the evaluation of the subarachnoid cisterns and their contents. METHODS: MR cisternography is a heavily T2-weighted fast spin-echo technique with high spatial resolution; it uses fat suppression and video reversal of the images. A small number of individual sections (two to four) are compressed into a composite image by a maximum-intensity projection algorithm, providing better depiction of anatomy in three dimensions. MR cisternography enhances the signal intensity of the cerebrospinal fluid (CSF) with suppression and subtraction of the background. A total of 41 patients were examined during a period of 6 months. MR cisternography was performed as an additional one (n = 31) or two (n = 10) sequences after conventional MR study. RESULTS: Twenty-one cases of disease were examined by MR cisternography, including 8 neoplasms, 4 CSF fistulas, and 3 large intracranial aneurysms. MR cisternography provided information unavailable by conventional MR studies in 17 cases. These included visualization of fistulous tracks in patients with CSF rhinorrhea, origin of a large suprasellar aneurysm, an additional loculus of a posterior fossa aneurysm and its relation to surrounding structures, and proper location of three tumors (intraaxial versus extraaxial). Clear depiction of the pituitary gland separate from the cavernous sinus was noted in 60% of the cases, and a new observation of a CSF sleeve around the third nerve in the posterior cavernous sinus was made in 85% of the cases. CONCLUSION: MR cisternography is superior to conventional MR studies in depicting anatomic structures within the subarachnoid spaces. This technique is recommended in the evaluation of cranial CSF fistulas and suprasellar and posterior fossa masses and in diagnosis of intraaxial versus extraaxial location of intracranial tumors.

Anatomy of the oblique retinacular ligament of the index finger.

The available literature includes conflicting descriptions of the anatomy and function of the oblique retinacular ligament. We have studied this ligament in the index finger to better define its presence, configuration, points of attachment, length, and relationship to the proximal interphalangeal joint axis. Twenty fresh frozen index fingers were dissected. Five additional specimens were decalcified, mounted, sectioned transversely at 1 mm intervals and studied under the microscope. An oblique retinacular ligament was identified on the radial side of the index finger in 95% and on the ulnar side in 90% of the specimens. The radial oblique retinacular ligament was usually longer and more developed than the ulnar oblique retinacular ligament. Proximally, the ligament arose from the middle third of the proximal phalanx and the A-2 pulley whereas, distally, it inserted into the lateral extensor band with a fan-shaped expansion centered 4 to 6 mm distal to the proximal interphalangeal joint line. In 70% of the specimens, the oblique retinacular ligament was supplemented by a contribution from the proximal cruciform pulley (C-1). Histologic cross sections also confirmed the presence of the oblique retinacular ligament but not the supplemental contribution arising from the C-1 pulley. The relationship of the oblique retinacular ligament to the proximal interphalangeal joint axis is dependent on the proximal interphalangeal joint position; the ligament lies palmar to the proximal interphalangeal joint axis only when the proximal interphalangeal joint is flexed.