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

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

Vascularized Ribs in the Treatment of Posterior Instrumentation Infection after Thoracic Vertebrectomy. Case Report.

Isolated vertebral mestastases can be successfully treated by surgical removal of the affected vertebral body and stabilization with alloplastic material. The bone union between the upper and lower vertebra is expected, yet a relatively high rate of a non-union has been reported. In case of infection, bone consolidation is altered, and removal of alloplastic material is recommended, which decreases spinal stability and is a devastating complication. This case report of delayed infection and exposure of posterior hardware after thoracic vertebrectomy without an interbody osseous union, authors present a successful treatment with vascularized rib flaps through an anterior approach followed by hardware removal.

Facial Nerve Reconstruction with Free Vascularized Composite Nerve Flap from Intrapetrous Portion to Terminal Branches-Case Report.

The case presented here is a delayed reconstruction of a facial nerve defect after radical parotidectomy without a useful nerve stump at the stylomastoid foramen. A composite free flap was used to reconnect the nerve's intrapetrous portion to the peripheral branches and reconstruct the soft-tissue deficit.

Abdominal Wall Reconstruction with a Free Fibula Flap after Internal Extended Hemipelvectomy.

Major pelvic resections for malignant tumors are infrequent and have significant morbidity and mortality, for instance, incisional hernias are postoperative complications uncommonly reported probably because most cases are overshadowed by more serious complications. Reconstruction depends on the extent of the resection and overall prognosis of the patient. A case of a late complex hypogastric and femoral incisional hernia after extended hemipelvectomy for recurrent osteosarcoma treated with distal abdominal wall fixation into a free fibula flap is reported.

Total Nasal Reconstruction With Prefabricated and Prelaminated Free Flap.

Nasal reconstruction is a complex staged procedure. When optimal donor areas are unavailable, flap prefabrication and prelamination techniques can be used for total nasal reconstruction. A technique of total nasal reconstruction using neovascularization of the supraclavicular skin from a skin free flap used for internal lining, along with prelamination of the cartilage framework and surgical delays, is described in 2 patients with adverse anatomical conditions.

Treatment of Hand Macrodactyly With Resection and Toe Transfers.

Macrodactyly is an uncommon congenital hand condition that can be difficult to treat and that can have a profound negative impact on patients and their families. Although many treatments have been described, results tend to be inconsistent. The authors report a case in which a combination of ray resection, partial finger resection, and toe transfer resulted in a 4-digit hand with acceptable function and cosmesis.

Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes.

PURPOSE: Ischemia time has been traditionally considered a critical factor in replantation survival rate. The objective of this study was to compare the survival rate between immediate and overnight-delayed digital replantation. METHODS: We performed a retrospective cohort study of all digital replantations performed at our clinic between 2005 and 2016. The survival rate was compared between the immediate digital replantation group (immediate replantation group) and those that were replanted the morning after they were admitted to the hospital (overnight-delayed replantation group). The decision to delay the replant was made in cases admitted in the evening with less than 12 hours of previous ischemia time and without farm-related contamination. RESULTS: Five hundred ninety-seven digital replantations (456 patients) were analyzed. One hundred eighty-five (31%) digital replantations were performed the following day (delayed replantation group) and 412 (69%) digital replantations were performed the same day that they were admitted to the hospital (immediate replantation group). The overall survival rate was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2% (376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185). There were no statistically significant differences between the immediate and the delayed replantation groups with respect to age, zone of amputation, or presence of multiple amputations. CONCLUSIONS: Our study suggests that overnight delay is a safe approach for digital replantation when performed by experienced microsurgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion.

PURPOSE: To report a series of 6 radiocarpal avulsion amputations in 5 patients. METHOD: We replanted 6 radiocarpal amputations in 5 patients with proximal musculotendinous and nerve avulsion between 2005 and 2013 and reviewed them retrospectively. All 5 patients were men, age range from 21 to 32 years. Functional results were evaluated through total active motion (TAM) of the fingers, 2-point discrimination, monofilament test, grip strength, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Follow-up was 4 to 10 years. RESULTS: All replanted parts survived without systemic complications. No infections or major wound complications occurred despite the preservation of presumably avascular tendons. The functional results of the right side in patient 1 who suffered bilateral amputations, were very modest, with only 360° of TAM (about 30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This was the only hand in which the tendons were not reinserted primarily. The other hands achieved TAM between 590 and 820°, which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and mean of 10-kg grip force. CONCLUSIONS: Radiocarpal amputation with proximal musculotendinous avulsion is an infrequent pattern of injury in which replantation with tendon reinsertion can yield functional results comparable with those reported for sharp wrist-level amputations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Simplified Posterior Interosseous Flap.

Several technical modifications have been described to avoid complications and simplify dissection. The authors describe some technical tips that make posterior interosseous flap dissection safer and more straightforward.

Urethra reconstruction with a prelaminated pedicled anterolateral thigh flap: a case report.

We present a case report of urethral reconstruction with a pedicled anterolateral thigh flap prelaminated with bladder mucosa in sex reassignment. The successful outcome may make this technique worthy to be considered in the secondary reconstruction of urethra in difficult cases. To the best of the authors' knowledge, no similar case has been previously described.

Late nail lesions rejection in a stable bilateral forearm allograft at 60 months posttransplantation.

We present a case of late nail lesions rejection in a stable and compliant bilateral forearm allograft at 60 months posttransplantation, confirming that rejection features in vascularized composite tissue allotransplantation are more heterogeneous with multiple clinical implications, despite apparently appropriate immunosuppressive treatment. Our observations may help to better characterize and to fully understand the onset and dynamics of skin rejection after human hand allotransplantation; nevertheless, further investigations are required, and careful monitoring of the grafts by direct inspection is advisable in all patients to start rapidly appropriate and effective treatment.

The tropical diabetic hand syndrome: a surgical perspective.

Tropical diabetic hand syndrome (TDHS) is an aggressive type of hand sepsis that results in significant morbidity and mortality among patients with diabetes in the tropics. This study set out to establish a protocol for the holistic management of TDHS to improve digit/hand salvage and function at AIC Kijabe Hospital. This prospective study examined the following demographics of patients presenting to the authors institution between October 2009 and September 2010 with TDHS: their sex, age, comorbidities, length of in-hospital stay, surgical and medical treatment, total cost of treatment, and immediate postdischarge outcomes. A total of 10 patients (3 men and 7 women) were presented with TDHS during the study period. Surgical procedures included a thorough debridement of the hand at initial presentation, followed by procedures aimed at preserving length and hand function, with digit or hand amputation when there was no possibility of salvage. Three hands were salvaged, without the need for an amputation; 2 of these, however, developed severe stiffness with resultant poor function. Fifty percent of the patients developed considerable disability; 3 of these patients had disabilities of the arm, shoulder, and hand, (DASH) scores of >90 at 6 months after treatment. TDHS appears to be more aggressive in some patients than in others; a multidisciplinary approach, with early involvement of the surgical team, and a radical surgical debridement are essential to improved outcomes. Although the goal of medical treatment (ie, glycemic control) is simple and easily achieved, surgical goals (salvage of limb or life, preservation of hand function) are more complex, costly, and difficult to achieve. Educating health care workers, diabetic patients, and their relatives on hand care is an important preventive measure. Diligence in taking antidiabetic medicine, early presentation, and appropriate care of TDHS are required for meaningful improvement in outcomes of patients with diabetes who develop hand sepsis in the tropics.

Lymphedema after upper limb transplantation: scintigraphic study in 3 patients.

Lymphatic vasculature is known to spontaneously reconnect after hand replantation. Nonetheless, lymphatic outflow has not been specifically studied in hand transplantation.Lymphedema was studied clinically and scintigraphically in 3 bilateral upper limb transplants performed in Valencia, Spain, since 2006. Case 1 was a radiocarpal level, case 2 midforearm and proximal forearm, and case 3 was a transhumeral transplantation. Follow-up was 5, 4, and 3 years, respectively. Clinically, in case 1, there was a left-sided moderate lymphedema, case 2 was normal, and a right-sided moderate lymphedema was present in case 3. Lymphoscintigraphy results were consistent with the clinical findings. It was normal in the 4 nonedematous limbs. In the 2 affected limbs, there were scintigraphic findings of lymphatic block and lymphangiectasia.The study demonstrates objectively that lymphatic circulation can reconnect spontaneously in hand transplantations, although not in a homogeneously efficient way.

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

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

Radiocarpal Joint Reconstruction with a Double Free Metatarsophalangeal Joint Transfer.

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

Pedicled fasciocutaneous anterolateral thigh flap for the reconstruction of a large postoncologic abdominal wall resection defect: a case report.

The anterolateral thigh (ALT) flap has been used to cover defects between the proximal third of the leg and lower abdomen, and with modification, may cover epigastric defects. We used the ALT flap to cover a full-thickness defect of over half the anterior abdominal wall. We conclude that abdominal wall defects of large sizes can be successfully reconstructed using an appropriately designed ALT flap; a simple, single-stage effective reconstruction.

Surgical aspects of a lower face, mandible, and tongue allotransplantation.

Face transplantation is a novel treatment for the reconstruction of massive facial defects. To date 13 cases have been performed. The technical aspects of a composite lower face transplantation including the tongue, floor of the mouth, and most of the mandible are detailed. The transplantation was performed in August 2009 in an HIV-positive, postoncologic patient. A preparatory surgery for nerve identification was performed. Facial composite tissue was procured after cardiac cessation. Revascularization was performed to the right subclavian artery with an internal shunt between the internal carotid arteries. At 16 months posttransplantation the patient is swallowing, without evidence of malignancy recurrence or HIV replication.

Unusual Late Complication of Latissimus Dorsi Free Flap Donor Site: Elastofibroma Dorsi.

In existing literature about elastofibroma dorsi (ED), no cases reported ED arising after latissimus dorsi flap harvest. Concretely, we present a patient who developed an ED at latissimus dorsi free flap donor site 10 years after harvesting. After our research, we found the occurrence of ED after thoracotomy surgery, stressing the importance of previous local trauma. Latissimus dorsi flap harvest is also a local traumatic episode, although its association with ED has not been previously reported. Thus, ED should be considered in the differential diagnosis of deep soft tissue lumps after latissimus dorsi harvest.

Monitor selection according to the defect location in the medial femoral condyle flap.

BACKGROUND: Medial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods. METHODS: Twenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted. RESULTS: There were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38-68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm3 and 1.36 cm3, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05) CONCLUSION: MFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.

Arteriovenous Vascular Loop Using a Bifurcated Greater Saphenous Vein.

High-energy lower limb trauma may result in complex defects with extensive vascular damage. Free flap reconstruction in these cases may require vein grafts to reach healthy proximal recipient vessels. Vascular loops are an increasingly popular technique in managing recipient vessels in reconstructive microsurgery, especially in the lower limb. The use of an entire omega segment of the greater saphenous vein had not been described before but offered two advantages: the caliber match for arterial repair was better using one of the limbs of the omega compared with the parent greater saphenous vein, and it allowed two venous anastomoses instead of one. A case report of a fully bifurcated segment of the greater saphenous vein as a vascular loop for microvascular reconstruction in the lower limb is presented. To the best of the authors' knowledge, no similar case has been reported previously.