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Objective:To introduce the concept and procedures of precise flap surgery in construction of knee defects and to report the preliminary clinical outcomes.Methods:The data of 16 patients with knee defects at 17 sides were retrospectively analyzed who had been treated under the guidance of the concept of precise flap surgery at Department of Orthopedic Surgery, The 920th Hospital of Joint Logistic Support Force of PLA from August 2014 to March 2022. There were 12 males and 4 females, aged 44(34, 54) years. The wounds were at the left side in 8 cases, at the right side in 7 ones and at bilateral sides in one, and their sizes ranged from 5 cm×3 cm to 15 cm×11 cm. The time from injury to surgery was 8.5(6.0, 13.0) days. Optimal repair protocols were chosen after the donor and recipient sites were evaluated according to the methods of precise flap surgery: a retrograde anterolateral thigh flap in 7 sides, a descending genicular artery perforator flap in 3 ones, a saphenous artery flap in 2 ones, and a superior genicular lateral artery perforator flap, a popliteal artery perforator flap, a medial sural perforator propeller flap, a peroneal artery perforator propeller flap, and a randomized flap in one, respectively. The flap sizes ranged from 10 cm×6 cm to 15 cm×15 cm. The outcomes and complications of skin flap repair, and functional recovery of the affected limb were recorded.Results:All the flaps at 17 sides survived after surgery; 3 cases developed distal edge necrosis which responded to dressing change. The follow-ups for the 16 patients were 14.5(10.0, 28.0) months. All the flaps presented with good color, texture and contour. Flap bulking, local osteomyelitis, and scar ulcer was found in one case respectively. According to the revascularization assessments in the digital replantation criteria by Hand Surgery Society, Chinese Medical Association, all the flaps at 17 sides were excellent. Accoding to the knee functional evaluation of Hospital for Special Surgery (HSS) at the last follow-up, the 17 affected limbs scored 86(80,91) points, yielding 9 excellent, 7 good and 1 fair sides.Conclusion:Although the defects and donor sites around the knee vary greatly, precise flap surgery may lead to effective control of the variations, choice of an optimal reconstruction protocol, and precise wound repair.
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Objective:To introduce the concept and procedure of CTA guided precision flap surgery and report the preliminary clinical application.Methods:The theory of CTA guided precision flap surgery is: based on CTA high-throughput data, comprehensively evaluate the wound and potential donor sites, and select the best plan for wound repair. This article reviews 177 patients treated under the guidance of CTA guided precision flap surgery from August 2014 to December 2018. Among them, 131 were males and 46 were females; they were 7-72 years old, with an average age of 39.5 years. The tissue defects were: 74 cases of foot and ankle, 64 cases of wrist, 15 cases of calf, 11 cases of forearm and upper arm, 7 cases of thigh and perineum, 5 cases of face and neck, and 1 case of abdomen. The size of the defect was 2 cm×1 cm to 65 cm×50 cm. The recipient and donor sites were assessed based on CTA guided precision flap surgery, then choose the optimal flap to repair the defect. The flap types, outcomes and complications were recorded. The visual analogue scale (VAS), British Medical Research Council sensory rating scale, and revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association was used to assess clinical results.Results:All flaps were uneventfully harvested as planned according to the CTA guided precision flap surgery concept.A total number of 181 flaps were harvested, including 125 free flaps and 56 pedicled flaps. The flap area rangedfrom 4 cm×3 cm to 40 cm×8 cm. After surgery, 165 cases were survival completely, 7 cases were total necrosis, 9 cases were partial necrosis. A total of 174 cases of flaps survived. The mean follow-up was 9.2 months (range, 6-60 months). After surgery 53 flaps were bulky, and 7 cases with other complications.At the last follow-up, only 6 patients had mild pain, the VAS score was 1-3. The sensation of the flaps recovered partially. According to the British Medical Research Council sensory rating scale: 68 cases were grade S2 and 106 cases were grade S3. According to the revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association, 171 cases were excellent and 3 cases were good.Conclusion:The concept of precision flap surgery based on CTA can effectively guide flap surgery and achieve precise wound repair.
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Objective:To estimate the preliminary result of circumflex scapular perforator propeller flap in reconstruction of axillary scar contractures.Methods:From January 2016 to June 2021, circumflex scapular perforator propeller flaps were used in 7 cases for reconstruction of soft tissue defect after axillary scar contractures. Patients were 5 males and 2 females. Age ranged from 23 to 38 years old, mean age of 27.7 years old. According to Kurtzman and Stern classification of axillary scar contractures, there were 1 case with type 1a, 1 with type 1b, 2 with type 2, and 3 with type 3. The preoperative range of motion of the shoulder joint were 40°-85°, with an average of 63.7°. All the patients were underwent scar release and circumflex scapular perforator propeller flap transfer. All flaps were transferred as the manner of perforator propeller flap. All the donor sites were closed directly. The defects after releasing ranged from 5.0 cm×7.0 cm to 11.0 cm×9.0 cm, and the flaps ranged from 16.0 cm×7.0 cm to 24.0 cm×9.0 cm. Flap survival, complications of donor site and recipient site were recorded after surgery. The range of motion of the shoulder joint, donor and recipient sites were reviewed in outpatient clinic.Results:All flaps survived uneventfully after surgery, besides 1 case complicated with distal venous congestion. The follow-up time ranged from 6 to 23 months, with an average of 12 months. The texture and contour of the flaps were good in all. At last follow-up, the range of motion of the shoulder joints were 90°-120°, with an average of 107°. Mild scar hyperplasia occurred in 2 cases.Conclusion:The circumflex scapular perforator propeller flap is an effective protocol in reconstruction of axillary scar contractures.
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Objective:To investigate the preliminary clinical effect of posterior interosseous artery propeller flap in the repair of dorsal of wrist and hand wounds.Methods:From March, 2015 to December, 2019, 9 cases of dorsal of wrist and hand wounds were repaired with posterior interosseous artery propeller flap, including 6 cases of dorsal hand defect and 3 cases of dorsal wrist defect. Defect area: 6 cm × 4 cm-3 cm × 3 cm; There were 3 cases of metacarpal fracture, 1 case of phalangeal fracture and 1 case of tendon rupture. According to the size and shape of the wound, the posterior interosseous artery propeller flap was designed to transfer and repair the soft tissue defect wound. The size of the flap: 20 cm × 5 cm-12 cm × 3 cm, the size of posterior interosseous artery propeller flap was recorded and the surgical characteristics were summarized; The survival of the flap, donor and recipient complications were observed and followed-up.Results:All flaps were cut smoothly and the donor areas were sutured directly. The flap survived completely in 8 cases and partial necrosis in 1 case; One case complicated with wound infection. The follow-up ranged from 6 to 31 months, with an average of 14 months. The texture and shape of the flap were good; The last DASH score was 3-18, with an average of 9.3; There were 2 cases of mild scar hyperplasia in the donor area and 1 case of mild scar hyperplasia at the edge of the flap.Conclusion:Posterior interosseous artery propeller flap may be an effective method to repair small and medium-sized wounds of dorsal of wrist and hand.
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Objective:To investigate the efficacy of induced membrane technique combined with anterolateral thigh flap transfer in treating composite foot defect.Methods:A retrospective case series study was performed for 7 patients with composite foot defect treated at 920th Hospital of Joint Logistic Support Force of PLA from February 2014 to December 2018. There were 5 males and 2 females, with the age of 20-73 years [(38.9±16.3)years]. The composite defect located at the forefoot in 5 patients, midfoot in 1, and hindfoot in 1. There were 9 metatarsal bone defects, 1 medial cuneiform bone defect, and 1 calcaneus bone defect. The size of soft tissue defect varied from 6 cm×5 cm to 70 cm×35 cm. At stage I, the anterolateral thigh flap transfer and vancomycin loaded cement implantation were performed. The flap survival and complications were recorded. At stage II, the cement was removed and autogenous bone was grafted into the induced membrane. The duration of two-stage operation, bone union time, and complications were recorded. The postoperative function was assessed using Maryland foot score system before operation and at the last follow-up and postoperative compications were documented.Results:All patients were followed up for 22-54 months [(33.8±9.7)months]. At stage I, flaps survived in all patients, and bulking of the flap was seen in 3 patients. One patient with calcaneus bone defect had repeated infection after operation, and received debridement. At stage II, 6 patients received bone grafting surgery. The duration of two-stage operation was 2-4 months [(2.8±0.9)months]. The bone union time was 3 and 7 months [(4.7±1.2)months]. At the last follow-up, the Maryland foot function score was 63-92 points [(82.1±8.7)points], significantly different from 0 point before operation ( P<0.01). The results were excellent in 1 patient, good in 5, and fair in 1. Except for one nonunion of metatarsal bone, all the other 8 sites were with bone union uneventfully. Conclusion:The induced membrane technique combined with anterolateral thigh flap transfer is an effective protocol for composite foot defect, which can well repair soft tissue and bone defect, and restore walking.
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Objective To localise and evaluate the precise position of the shank perforators preoperatively with the CTA and hand-held color Doppler (HHD),then evaluate the clinical efficacy of the method.Methods From April,2013 to June,2017,designed 36 propeller perforator flaps in 36 patients by following methods.Firstly,the CTA test was performed to calculate the parameters of perforator vessel positioning.Secondly,a HHD was typically used to verify the location of perforators found on preoperative CTA.At last,according to the "like with like" principle,the propeller perforator flaps were accurately designed.The regular followed-up was performed.Results All patients were followed-up for 3-24 months after operation.Thirty-six propeller perforator flaps survived,and 3 cases among them showed partial epidermal necrosis and healed after skin grafting.Donor sites were closed primarily in 24 cases,and skin grafting were performed in 12 cases.The skin graft sites survived without necrosis,and the average time of cutting flaps was 45 min.Conclusion By the methods of mapping the perforator propeller flaps with CTA and HHD,the perforator vessel can be positioned more accurately and quickly.The operation time was shortened,and the clinical efficiency can be achieved with the good clinical application values.
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Objective To explore how to overcome the difficulties during two paddle anterolateral thigh flap harvest. Methods From January, 2009 to December, 2015, the harvest of two paddle anterolateral thigh flap was encountered difficulties during surgery in 8 cases, which were 7 males and 1 female. The age was ranged from 16 to 48 years old, with averaged of 32.8. Six patients presented with one defect, and 2 patients presented with two defects. The skin defects ranged from 60-247 cm2. The number of the flap perforator, vascular source, flap pattern and out-comes was recorded. All patiants were followed-up at regular intervals. Results All of 8 flaps were converted suc-cessfully during surgery. Only 1 perforator was found in 4 cases. The flap was converted to sigle perforator flap. The dornor site was covered by skin graft. Two perforators from different origins were found in 2 cases, and the flap was converted to sequential chimeric flap. Two perforators from descending branch and transverse branch respectively were found in 1 case, and the flap was converted to combined anterolateral thigh and tensor fascia lata flap. Only 1 perfora-tor was found in 1 case, which the distal defect was small sized, the flap was converted to deepithelialized two paddle flap. The flap ranged from 78-288 cm2. Venous compromise was happened in 1 case, and the flap survived after reex-ploration surgery. Local infection was found in 2 cases, and cured with wound dressing. Other flaps were survived un-eventfully. At donor site, 1 case wound dehiscence and 1 case local infection, both of which underwent debridement and healed. All patiants were followed-up for 7-21(mean, 11.5)months. The flaps had satisfactory appearance and soft texture. Conclusion When it is difficult to harvest two paddle anterolateral thigh flap during surgery, the flap need to be converted rationally based on the characteristics of the defect, the number of the flap perforator, and the vascular origins.
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Objective To investigate the effect and characteristics of anterolateral thigh flap in repair of extremity wound in children.Methods A retrospective case series study was conducted to analyze the clinical data of 69 patients with limb soft tissue defects admitted to Kunming General Hospital of PLA from January 2008 to December 2016.There were 57 boys and 12 girls,aged 2-15 years (mean,6.7 years).There were 56 cases of lower extremity wounds and 13 cases of upper limb wounds.The wound areas ranged from 3 cm ×4 cm to 14 cm × 15 cm,with an average of 52.4 cm2.All wounds were repaired with the anterolateral thigh flap.The type of flap,number of perforators,type of perforation,closure of donor site,healing of the flap,complications,and reoperation were recorded.Results Seventy anterolateral thigh flaps were harvested in 69 children,including 42 musculocutaneous flaps and 28 perforator flaps.Intraoperative visualization identified 76 perforators,including 14 septocutaneous and 62 musculocutaneous perforators.The donor site was closed primarily in 52 cases,and a split-thickness skin graft was required in 18 cases.After operation,vascular crisis occurred in four cases.After exploration,one flap survived,and partial necrosis was found in three flaps.Except for one flap with total necrosis because of infection,the rest of the flaps survived.Other postoperative complications included flap edge necrosis in six cases,local infection in six,and wound dehiscence in three.The follow-up ranged from 6 to 33 months,averaged 14.9 months.Hypertrophic scar occurred at donor site in 27 children.The number of reoperation was 46,including 23 debulking procedures,seven skin grafts,four debridements,and 12 others.Conclusions The anterolateral thigh flap is a safe,reliable option for reconstruction of soft tissue defects in extremities of children.The anterolateral thigh musculocutaneous flap is used commonly in children.However,hypertrophic scar at donor site occurs more often after flap surgery,with high rate of reoperations.