Reconstruction of pulp defects of two neighbouring digits with free great toe fibular flaps of both feet: a study on 7 cases / 中华显微外科杂志

Objective:To explore the clinical effect of using great toe fibular flaps of both feet on reconstruction of pulp defects of two neighbouring digits.Methods:A total of 14 digit pulp defects in 7 cases were repaired in Zhoukou Huaihai Hospital using great toe fibular flaps of both feet from August 2020 to January 2023. Of the 7 cases, there were 4 males and 3 females, with an average of 28 years old, ranging from 19 to 45 years old. Meanwhile, there were 4 cases in left hand and 3 cases in right hand. There were 3 cases of digit pulp defects in index and middle fingers, 2 in middle and ring fingers, and 2 in thumb and index fingers. The area of soft tissue defect in 1.2 cm×1.5 cm-3.0 cm×2.5 cm, and flap was 1.5 cm ×1.8 cm-3.2 cm×2.8 cm. Furthermore, 1 case underwent emergency surgery and 5 were repaired in elective surgery. The donor site of the flap was closed directly, and an intermediate-thickness skin graft was prepared from the medial plantar area for transfer in the case of high suture tension at the wound edge. After surgery, patients received postoperative by outpatient clinic and WeChat to observe the appearance, sensation, functional recovery and flap contracture of digits, as well as the movement of the great toes of both feet.Results:After the surgery, all flaps in the 7 cases survived smoothly and the donor sites healed. All patients entered scheduled follow-ups postoperatively for 6 months to 2 years, with an average of 9 months. The flap showed an aesthetic appearance and excellent sensation, with a TPD of 3-6 mm, and satisfactory digit function. The donor site of the great toe fibular flap left linear scars only, without abnormality in range of motion and gait in walking. In addition, there were 5 in excellent and 2 in good according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association.Conclusion:Application of great toe fibular flaps of both feet is an ideal option for the simultaneous repair of pulp defects of two neighbouring digits, which can achieve good reconstructive results.

Transfer of polyfoliate perforator flap of fibular hallux in reconstruction of multiple digit-tip defects / 中华显微外科杂志

Objective:To evaluate the clinical effectiveness of the reconstruction of multiple digit-tip defects with transfer of polyfoliate perforator flaps of the fibular hallux.Methods:From January 2019 to June 2022, 15 patients had undergone reconstruction surgery for multiple digit-tip defects using polyfoliate perforator flaps of ipsilateral fibular hallux, with the first dorsal metatarsal artery as the pedicle, in the Department of Upper Limb Repair and Reconstruction Surgery, Guizhou Hospital of Beijing Jishuitan Hospital. The patients were 10 males and 5 females and aged 20 to 45 years old. Eight patients had the defects of thumbs and index fingers, 4 of thumbs and middle fingers, 2 of thumb, index and middle fingers and 1 of thumb, index and ring fingers. All the 15 digit injuries had nail bed defects to which reconstructive surgery were required. For the flaps of dorsal artery, flaps were 1.8 cm×2.0 cm-2.0 cm×3.1 cm in size and for those of plantar artery, the flaps sized 1.5 cm×2.0 cm-2.5 cm×3.0 cm. Donor site defects in the hallux were reconstructed with free superficial circumflex iliac perforator flaps. Postoperative follow-up lasted until 30th June 2023 and included visits to the outpatient clinic, WeChat and telephone reviews to assess the appearance, function and sensation recovery of the digits.Results:All the 15 flaps survived. During the 6 to 24 months (16 months in average) of postoperative follow-up, the appearance and texture of all flaps were found close to the healthy digits, with good nail growth and without deformity. TPD were found between 8.0 mm and 12.0 mm. The donor sites on the great toes that reconstructed with superficial circumflex iliac artery flaps were all survived well, and the incisions were satisfactorily healed without the functions of walking, running or jumping being significantly affected.Conclusion:The use of polyfoliate perforator flaps of fibular hallux for reconstruction of multiple digit-tip defects is an ideal surgical method due to the consistency of vascular anatomy, ease with flap harvest, similarity in the normal digital skin texture, and the capability to include a nail bed with the flap. A single donor from the hallux can simultaneously reconstruct two defects of digit-tip, making it an excellent treatment in the reconstruction of small-to medium-sized composite tissue defects in multiple digits.

Comparison of two types of pedicled homodigital flap in reconstruction of thumb-tip or thumb-pulp defects / 中华显微外科杂志

Objective:To compare the clinical effects between the homodigital radial flap of the dorsal cutaneous branch of radial palmar proper digital artery (PPDA) and the homodigital reverse island flap of the ulnar dorsal digital artery (DDA) on reconstruction of defects in thumb-tip or thumb-pulp.Methods:The retrospective case-control study method was used. From January 2016 to August 2022, a total of 65 thumb-tip or thumb-pulp defects were treated in the Department of Hand Surgery of the Second Hospital of Tangshan. Thirty-five defects of thumbs were reconstructed with the homodigital radial flap pedicled with dorsal cutaneous branch of radial PPDA (PPDA group) and the other 30 thumbs were treated by the homodigital ulnar reverse island flap pedicled with ulnar DDA (DDA group). Sizes of the wounds and flaps in PPDA group were 1.9 cm×1.5 cm to 2.9 cm×2.4 cm and 2.1 cm× 1.7 cm to 3.1 cm×2.6 cm, respectively, and the dimensions of the wounds and flaps in DDA group were 2.0 cm× 1.7 cm to 2.9 cm×2.5 cm and 2.2 cm×1.9 cm to 3.2 cm×2.8 cm, respectively. The wounds of donor site in both groups were all directly closed. Survival of the flaps and wound healing of donor sites were observed in both groups. The time of surgery and duration of follow-up of the 2 groups were recorded. Postoperative follow-up included outpatient clinic visits, telephone reviews and WeChat video-clips. At the final follow-up, record of total active motion (TAM) of the injured thumbs, angle of first web of the affected hands, static TPD of the flaps, patient satisfaction of the appearance of flaps and donor sites were taken. According to the Michigan Hand Function Questionnaire (MHQ) evaluation criteria, the patient satisfaction of the appearance of flaps and donor sites were evaluated. The measurement and count data acquired from both groups were compared by independent sample t-test and χ2 tests or Fisher's exact test, respectively. P<0.05 was considered statistically significant. Results:All 35 flaps in PPDA group and 26 flaps in DDA group survived primarily, except 4 flaps in the DDA group that showed blisters and healed with dressing changes. The primary survival rate of flap in PPDA group (100%) was higher than that of DDA group (87%), and the difference was statistically significant ( P<0.05). Donor sites of both groups healed primary. The time of surgery and duration of follow-up in PPDA and DDA groups were 59.11 minutes±5.42 minutes and 15.37 months±3.32 months, and 61.27 minutes±5.96 minutes and 16.17 months±3.60 months, respectively. There was no statistically significant difference between the 2 groups ( P>0.05). At the final follow-up, the thumb TAM and angle of thumb web in PPDA and DDA groups were 135.14°±10.04° and 90.29°±4.36° and 132.17°±11.04° and 89.00°±4.81°, respectively. There was no statistically significant differences between the 2 groups ( P>0.05). The static TPD, patient satisfaction of the appearance of flaps and donor sites in PPDA group were 7.11 mm±1.21 mm, 4.69 point±0.47 point and 4.43 point±0.50 point, which were better than DDA group [8.20 mm±1.47 mm, 4.40 point±0.50 point and 4.13 point±0.57 point, respectively] with a statistically significant difference ( P<0.05). Conclusion:The homodigital radial flap of the dorsal cutaneous branch of radial PPDA and the homodigital ulnar reverse island flap of the ulnar DDA are both suitable for reconstruction of defects in thumb-tip or thumb-pulp. Compared with the homodigital reverse island flap with the DDA, a homodigital radial flap with the dorsal cutaneous branch of PPDA has advantages in higher primary survival rate, better flap sensation and appearance at both of recipient and donor sites.

A modified procedure for replantation of severed digit-tips in Tamai zones I - II and the clinical effects / 中华显微外科杂志

Objective:To explore the clinical effect of a modified surgical procedure for replantation of severed digit-tips in Tamai zones I-II.Methods:From November 2019 to October 2022, the Department of Hand and Foot Microsurgery of the First Affiliated Hospital of Bengbu Medical College employed a modified procedure (to abandon the anatomically labelling of blood vessels and nerves after naked-eye debridement and fracture fixation, then perform the microscopic dissections and anastomoses of blood vessels and nerves, and the anastomosis of dorsal veins though an auxiliary small incision by the lateral nail fold of the severed digit-tip) to replant severed digit-tips in Tamai zones I-II of 26 patients (29 digits). The patients were 20 males (23 digits) and 6 females (6 digits), aged 3-66 years old, with mean age at 28 years old. Nineteen digit-tips were severed in Tamai zone I and 10 in Tamai zone II. The severed digit-tips were 7 of thumbs, 9 of index fingers, 5 of middle fingers, 5 of ring fingers and 3 of little fingers. Causes of injury were 12 of cut, 8 of crush and 6 of avulsion. Postoperative management included infection prevention, antispasmodic for 3 days and keeping in bed for 5 days. The time of surgery was recorded on all patients. Postoperative follow-ups were conducted at outpatient clinics for 6 to 12 months to observe the survival of digit-tips and the appearance, recovery of sensation and motor functions, strength of digits and patient satisfaction.Results:(1)The surgical time was about 1.0 hour for replantation of a severed digit-tip in Tamai zone I, while it took about 1.5 hours for those in Tamai zone II. (2)Survival rate and appearance: all 29 replanted digit-tips survived, except 2 in Tamai zone I which encountered venous occlusion and survived after small incision for bloodletting. Twenty-two digit-tips gained pulp fat pads with full digit pulps. Four avulsed digit-tips had mild atrophy of pulp. The 15 digit-tips severed in Tamai zone I were about 2 mm shorter than the healthy sides, but without deformity. One digit-tip had poor nail appearance due to preoperative fungal infection of nail bed. (3)Sensory recovery: with the British Medical Research Council (BMRC), 23 digit-tips recovered to S 3+, and 2 digit-tips of avulsion and 1 digit-tip of crush recovered to S 3. TPD of the replanted digit-tips were: 4-7 mm in those of cut injury; 6-8 mm in those of crush and 9-11 mm in those of avulsion. (4)Motion and digit strength: results of functional assessment according to the total active mobility standard promoted by China's Society for Surgery of the Hand were: 21 cases of excellent and 5 of good, without pain in digit pulp when pinching and griping. The mobility of the digits with replanted digit-tips of both Tamai zones I and II were close to that of the healthy sides. The motions of the digits with replanted digit-tips in Tamai zone I were close to the healthy sides and the 5 of those in Tamai zone II had 0° in extension and 2°-3° in flexion, due to the severed plane at distal interphalangeal joint. (5)Patient satisfaction: 25 patients were satisfied, however 1 patient was dissatisfied to the poor function of the distal interphalangeal joint due to the severed thumb-tip in Tamai zone II. Conclusion:Modified replantation procedure for severed digit-tip in Tamai zones I-II has significant achievement in cutting down the surgical time through a modified procedure of debridement and fracture fixation (tendon suture) by naked-eyes operation first, followed by dissections and anastomoses of the blood vessels and nerves under the surgical microscope. The auxiliary small incision by the lateral nail fold of digit-tip in Tamai zone I facilitates an exposure of a constant, healthy lateral nail fold vein. It enables the anastomosis with a high-quality vein, hence improves the success rate of replantation. The appearance and function of the replanted digit-tip are found better in the severed digit-tips of cut injury than those with injuries of avulsion and crush.

Free transverse carpal flap of superficial palmar branch of radial artery in reconstruction of soft tissue defect of digit: a report of 17 cases / 中华显微外科杂志

Objective:To explore the surgical procedure and clinical effect of a free transverse carpal flap based on the superficial palmar branch of radial artery in reconstruction of soft tissue defect of digits.Methods:From February 2014 to May 2022, 17 cases of soft tissue defects with tendon or phalanges in digits were treated in the Department of Hand and Foot Surgery, Hainan Zhongde Orthopaedic Hospital. All 17 cases were treated by the free transverse carpal flap based on the superficial palmar branch of radial artery. The flap size was 2.0 cm×2.0 cm-4.5 cm×2.0 cm. The anastomosed artery was digital artery or common digital artery, and the vein was the accompanying vein or superficial subcutaneous vein. All donor sites were directly sutured. Preventive measures of anti-infection, anticoagulation, anti-vasospasm and symptomatic treatment were given after surgery. After discharge of patients, scheduled follow-ups were conducted through outpatient clinic, telephone or WeChat interviews to observe the clinical effects. According to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, hand functional recovery was good in 14 cases and good in 1 case.Results:All 17 flaps had survived with 16 completed the postoperative follow-up. Follow-ups ranged from 6 to 18 months, with a mean of 14 months. At the last follow-up, the flaps were good in shape, soft texture, in normal flexion and extension and with good protective sensation. Two-point discrimination (TPD) was 8-12 mm, with an average of 8 mm. There was no other adverse effect in the donor sites except a linear scar.Conclusion:Application of transverse carpal flap based on the superficial palmar branch of radial artery from same limb to restore the digit function is feasible. It is an ideal surgical procedure of flap transfer.

Reconstruction of soft tissue defects in distal segment of dorsal fingers with a perforator(joint branch) flap of proper palmar digital artery combined with dorsal metacarpal artery flap / 中华显微外科杂志

Objective:To explore the surgical procedure and effect of reconstruction of soft tissue defects in the distal segment of dorsal finger with a perforator(joint branch) flap of proper palmar digital artery combined with a dorsal metacarpal artery flap.Methods:From January 2019 to June 2022, 9 patients with soft tissue defects in distal dorsal finger, mostly with avulsion at the extensor tendon insertion point, were treated in Department of Hand and Foot Microsurgery, the Affiliated Hospital of Qingdao University. The defect areas were 1.0 cm×1.0 cm-2.5 cm×2.0 cm. Steel wires were used to reconstruct the extensor tendon insertion point. The defects were reconstructed by a perforator(joint) flap of proximal phalanx artery and a dorsal metacarpal artery flap was used to repair the donor site for proximal flap. Postoperative follow-up and evaluation included flap survival, flap appearance, scars and function of interphalangeal and metacarpophalangeal joints, through outpatient clinical, WeChat and so on.Results:The flap of digital artery perforator (joint branch) and the fasciocutaneous flap of dorsal metacarpal artery all survived. One flap of the digital artery perforator(joint branch) appeared purple and tension blisters after surgery. The stitches of the pedicle of the flap were partially dismantled at 36-48 hours after surgery. The flap was then turned to ruddy in colour 7 days after surgery. The wounds of the distal finger joint and nail bed healed well without redness and infection. The postoperative follow-up lasted for 5 to 12 months, 9 months in average. The appearance, colour and texture of the skin at distal finger were similar to those at the dorsal proximal finger and dorsal palm. Sensation recovered well, all flaps exceeding S 3. The two-point resolution (TPD) was 8-10 mm, with an average of 9.5 mm. According to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 5 cases were in excellent and 4 in good. Conclusion:The perforator(joint branch) flap of proper palmar digital artery combined with a dorsal metacarpal artery flap is simple and safe treatment. It has a fast functional recovery with an aesthetic appearance in reconstruction of the soft tissue defect in distal segment of dorsal finger.

Determine a surgical procedure for diabetic foot with chronic refractory wound / 中华显微外科杂志

Objective:To evaluated the options in selection of surgical procedures for treatment of the patients suffering from diabetic feet with chronic refractory wounds.Methods:From January 2020 to June 2021, 23 patients with diabetic feet complicated with refractory wounds were treated in Department of Hand Surgery, Shunde Heping Surgical Hospital. The patients were 15 males and 8 females, aged 51-86 years old and with an average age of 65 years old. All the patients had Type-II diabetes for over 5 - 22 years. Average blood glucose of the patients was found at 15.6 mmol/L on admission. Free anterolateral thigh perforator flaps (ALTPF) were used for reconstruction of the wound of diabetic feet in 19 patients, 2 patients received vascular bypass surgery and 2 had amputations. Regular outpatient follow-up were conduct on all patients after surgery.Results:Follow-up time lasted for 8 to 30 months, 12 months in average. At the last follow-up, the donor and recipient sites healed well in the 19 patients who received flap reconstruction, without an infection, necrosis and wound recurrence. Pains were significantly relieved after the surgery in the 2 patients who received vascular bypass surgery, and wounds all healed well after symptomatic treatment and dressing change without recurrence of wounds at the last follow-up. Average Maryland score of foot function was 84 for the patients who had limb salvage, and 2 patients were in excellent and 19 in good at the last follow-up. The 2 patients who had amputation successfully survived through the perioperative period, and the wounds healed well at the last follow-up.Conclusion:The treatment is complicated in the patient suffering from diabetic foot with chronic refractory wounds due to factors such as advanced age, co-existing and complicated underlying diseases together with the complex wounds. Most patients can achieve good prognosis in wound treatment of free flap transfer or vascular bypass surgery. However, a limb salvage is recommended with caution for the patients who have severe infections and dry gangrene.

Application of mixed reality technology in reconstruction of soft tissue defect in extremities with anterolateral thigh flap / 中华显微外科杂志

Objective:To investigate the application value of mixed reality (MR) technology in reconstruction of soft tissue defect of extremities with free anterolateral thigh flap(ALTF).Methods:From December 2019 to November 2021, a retrospective analysis was performed on 10 patients who had undergone ALTF reconstruction of soft tissue defects in extremities in Department of Orthopaedics, the First People's Hospital of Yunnan Province. Four patients had the defects in hand and 6 patients in foot and ankle. For the 6 patients in emergency surgery, the time from injury to admission was 4.0-15.0 hours, with an average of 7.3 hours. Four patients with soft tissue defects caused by chronic infection and ulcers were given debridement, and the soft tissue defects were reconstructed by flap transfer at the second stage. The defect area were from 8.0 cm×5.0 cm to 22.0 cm×8.0 cm. Preoperatively, 3D bone-vessel-flap model was established based on the lower extremity CTA scans. Intraoperatively, MR technology was used to project the 3D model on the flap donor site to observe the virtual profile of vessel shape in real time, to locate the perforator and the course of the perforator, and observe the consistency between the virtual image and the actual anatomy of the perforator. The appearance, texture and colour of the flap were recorded at the last follow-up. Hand function was evaluated by the total activity movement (TAM), and foot and ankle function was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS).Results:The position location and course of perforator vessels were reconstructed successfully in all patients before surgery. The MR technology was used to locate the perforator, and the course of the virtual perforator was consistent with the actual anatomy, and the matching reached 100%. The length of vascular pedicle measured before surgery was at 11.02 cm±1.37 cm. And that measured during surgery was at 11.21 cm±1.23 cm ( P=0.748, t=-0.326). The difference was not statistically significant ( P>0.05). The flap area was at 9.0 cm×6.0 cm to 23.0 cm×9.0 cm. The donor site was sutured directly in one stage. All patients were entered postoperative followed-up for 1 to 24 months, with an average of 13.5 months. All the flaps survived after surgery. The flap with good appearance, colour and texture, and only one linear scar was left in the donor site. According to the TAM of the hand function, 3 cases were excellent and 1 was fair. Foot and ankle function were evaluated according to the AOFAS, 5 cases were in excellent and 1 was good. Conclusion:MR technology applied to the surgery of ALTF can locate the course of the flap vessels in real time, guide the operation, improve the operation efficiency and reduce the risk in surgery.

Reconstruction of thumb degloving injury with hallux nail flap combined with 3D printing: a report of 16 cases / 中华显微外科杂志

Objective:To explore the effect of hallux nail flap design assisted with 3D printing in reconstruction of thumb defect in degloving injury.Methods:From January 2020 to March 2022, 16 patients with thumb defect caused by degloving injury with intact digit flexor and extensor tendons were treated. The patients were 11 males and 5 females, aged 20 to 52 years old, with an average age of 31 years old. The injured patient's hands were firstly scanned by CT and the 3D models were created to map the profile of the tissues required for reconstruction. Photopolymer templates for the defects in thumb were then 3D printed. The printed templates were put on the great toes and accordingly the hallux nail flaps were designed and harvested. The degloving wound of thumb was repaired by the hallux nail flap. Donor sites were repaired with artificial dermis in 6 patients and with ilioinguinal flaps in 10 patients. The effect of surgery was observed at outpatient clinic during postoperative follow-up. The survival of the hallux nail flap and the recovery of the donor site were observed. Function recovery were evaluated according to the Evaluation Standard of Finger Replantation and Reconstruction of Hand Surgery Society of Chinese Medical Association.Results:All the harvested hallux nail flaps matched with the profiles of recipient sites. All the hallux nail flaps survived over 4 to 30 months of follow-up, in an average of 16 months. Appearance of all hallux nail flaps was similar to normal thumbs, with good fingerprint and nails. Sensation recovery were S 3-S 4, with TPD at 4-7 mm. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 15 thumbs were excellent and 1 was good. Conclusion:Application of 3D printing assisted hallux nail flap transfer in reconstruction of defect of thumb in degloving injury can precisely design and harvest the required tissue and minimise a damage to the donor great toe. It improves the appearance of thumb as well as patient satisfaction. It is practical in reconstruction of the defect of thumb in degloving injury.

A self-designed wound measurement grid in design of lobulated perforator flap / 中华显微外科杂志

Objective:To explore the clinical effect of a self-designed wound measurement grid on the design of lobulated perforator flap.Methods:From January 2019 to December 2022, soft tissue defects in limbs of 9 patients were reconstructed by lobulated perforator flaps in the Department of Orthopaedics and Traumatology of Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine. The patients were 7 males and 2 females aged 21-55 years old with 40.3 years old in average. There were 6 upper limb defects and 3 lower limb defects. Self-designed wound measuring grids were applied to guide the design and excision of lobulated perforator flaps during surgery. Five patients were treated by lobulated perforator flap pedicled with the descending branch of lateral circumflex femoral artery and 4 by perforator flaps pedicled with dorsal interosseous artery. The areas of soft tissue defect were 4.0 cm×1.5 cm-26.0 cm×8.0 cm, and the sizes of the flaps were 4.5 cm×1.8 cm-22.0 cm×10.0 cm. After surgery, the blood supply of flaps, flap survival and wound healing were monitored. Flap survival, donor site recovery and limb function were observed at outpatient clinic over the postoperative follow-up, and the limb function was evaluated by the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association and Lower Extremity Measure(LEM).Results:In this study, a total of 17 of 18 lobes of the lobulated perforator flaps survived after surgery. One flap had venous occlusion and after exploration and further treatment, a necrosis occurred in 1 lobe of the lobulated flap and then a free flap transfer was performed again. All the wounds achieved stage-I healing. Postoperative follow-up lasted for 3-18 months with 8.6 months in average. All flaps had good colour and texture, satisfactory appearance and only linear scars remained in the donor sites, without pain and scar contracture. The reconstructed upper extremity defect were evaluated according to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, with 4 patients were in excellent and 2 in good. The reconstructed lower extremity defects were evaluated according to the LEM, and 2 patients were in excellent and 1 in good.Conclusion:The self-designed wound measurement grid was successfully applied in the design of lobed perforator flaps. It can accurately measure a wound surface and quickly extract a wound profile, and it is more convenient and intuitive to guide the design of flaps. It has a good effect in clinical application and further clinical trials are required.

Reconstruction of the donor site of hallux nail flap with free superficial circumflex iliac artery perforator flap / 中华显微外科杂志

Objective:To investigate the efficacy of free superficial circumflex iliac artery perforator flap (SCIAPF) in reconstruction of the donor site of hallux nail flap.Methods:From December 2015 to December 2022, Section Ⅲ of Department of Hand Surgery of Hangzhou Plastic Surgery Hospital conducted thumb reconstruction surgery with free hallax nail flaps for 12 patients with traumatic defects of thumbs. Six patients had degloving injuries of thumb with intact bone scaffold and extensor-flexor tendon. Among the other 6 patients with thumb defects, 3 had grade I defect, 2 had grade II defect and 1 had grade Ⅲ defect, according to Gu Yudong's classification. Free SCIAPFs were used to reconstruct the donor sites of hallux nail flaps. Sizes of the flaps were 3.0 cm× 6.5 cm-9.0 cm ×7.0 cm. All donor sites in the abdomen were directly sutured. After surgery, functional evaluations of the reconstructed thumb were conducted through follow-ups at outpatient clinics and(or) by WeChat interviews, according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, and the functional evaluation of donor feet was conducted according to the Maryland foot function evaluation standard.Results:Successful survival of the 9 cases of flap in the donor site of hallux nail flap. One patient had venous occlusion of flap and survived after timely surgical exploration. One flap had partial necrosis at the tip of flap, and the wound was eliminated with local transfer of a flap. One patient had necrosis over most of the flap with the base of the flap survived, and the wound was repaired by a stage-II skin grafting. The donor sites at groin healed in stage-I in all of 11 patients with a linear scar. One patient who had haematoma at the donor site was cured by removal of the haematoma and a re-suture. All the patients received a 3 to 24 months of postoperative follow-up. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 10 patients were in excellent and 2 in good. All of the great toes remained with original length and recovered normal flexion and extension. No patient suffered pain while walking and running. According to the Maryland foot function evaluation standard, 10 patients were in excellent and 2 in good. All SCIAPFs were satisfactory in colour and texture. Five patients had bloated flaps and underwent Hacks in the stage-Ⅱ.Conclusion:Application of a free SCIAPF in reconstruction of the donor site for hallux nail flap can effectively preserve the appearance and function of the donor site. Meanwhile, the scar in the donor site of groin is concealed with little damage, therefore the groin meets the requirements as a donor site of a flap.

Surgical approaches and clinical outcomes of endoscopic endonasal resection for trigeminal schwannomas / 中华显微外科杂志

Objective:To investigate the surgical approaches and clinical outcomes of endoscopic endonasal approaches (EEA) for trigeminal schwannomas(TSs).Methods:Clinical data, surgical videos and outpatient follow-up notes of 41 patients with TSs and underwent EEA between January 2013 to October 2022 in the Department of Neurosurgery of the First Affiliated Hospital of Nanchang University were retrospectively studied. The patients were 19 males and 22 females, with an average age of 45.3 (22-63) years old. Twenty-four patients had TSs on the left and 17 on the right. According to Jeong's classification, for 6 TSs with type MP, 2 tumours were resected by trans-Meckel's cave approach (TMCA) alone, and the remaining 4 TSs were resected by combined transclival approach (TCA). For the 4 tumours that involved infratemporal fossa(2 of type E3, 1 of type mE3 and 1 of type Mpe3), the surgery were performed via a trans-prelacrimal recess approach(TPRA), of which the operation for type Mpe3 was combined with a TMCA. The trans-laminal papyracea approach (TLPA) was applied to remove 2 tumours of type E1. The rest of 29 patients received the surgery by TMCA alone to remove tumours including 15 of types M, 10 of type Mp, 1 of type ME2, 2 of type E2 and 1 of type MpE2. Gross total tumour resection was achieved in 40 patients(97.6%), with only 1 patient (2.4%) had a subtotal tumour resection.Results:A total of 40 patients had completed the long-term follow-up, with 1 patient lost in follow-up. The average follow-up period was 34(3-101) months; No tumour recurrence or progression was observed over follow-up. After the surgery, preoperative symptoms were improved in 34 patients(89.5%). The main improved symptoms were: facial numbness(78.9%), facial pain(70.0%), headache(88.2%), mastication weakness (50.0%), poor vision (60.0%), diplopia (83.3%), and abducens nerve palsy (100%). Transient and permanent neurological deficits occurred in 8 (19.5%) and 9 (22.0%) patients, respectively. Cerebrospinal fluid leakage and internal carotid artery injury occurred in 1 patient each.Conclusion:According to the location of a tumour, an appropriate EEA should be selected and satisfactory results can be achieved for all types of tumours, except the TSs that has the main body of the tumour located in the posterior cranial fossa.

Application of superficial peroneal artery perforator flap in tiled reconstruction of thumbs and fingers / 中华显微外科杂志

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.

Transfer of anteriolateral thigh flap with partial iliotibial tract in reconstruction of composite tissue defect in dorsal wrist and hand / 中华显微外科杂志

Objective:To investigate the curative effect of transfer of free anteriolateral thigh flap (ALTF) with partial iliotibial tract on reconstruction of composite tissue defects in dorsal wrist/hand.Methods:Ten patients who were admitted in the Department of Hand Surgery of Yongkang Orthopaedic Hospital from March 2018 to August 2022 were entered in the study due to extensive composite tissue defects in dorsal wrists and hands. The patients were 24-48 (37 in average) years old. All patients had tendon defects in 3 or more digits with 35 digits in total. The length of the tendon defects were 5.0-11.0 cm in various digits. The soft tissue defects ranged from 6.0 cm×8.0 cm to 11.0 cm×21.0 cm in size. Six patients had defects accompanied with metacarpal and phalangeal bone fracture and joint capsule. In emergency surgery, all patients received thorough debridement and VSD coverage after internal fixation for combined fractures. At 3-5 days after the primary surgery, free ALTF transfer with partial iliotibial tract was employed to reconstruct the defects on dorsal wrists and hands and the digit extension function. The size of flap was 6.0 cm×9.0 cm-9.0 cm×17.0 cm, and the rest of defect wound was covered by skin graft. All the donor sites were sutured directly, except 1 that received abdominal skin graft. Patients had the follow-ups in outpatient clinics, or via telephone or Wechat, to observe the sensation and appearance of the flap, and the healing of the donor site. The recovery of the extension function of the hand was evaluated according to the totle active motion (TAM) system.Results:All flaps survived except one that had vascular compromise after the surgery and it survived after two explorations and a vascular transfer. Postoperative follow-ups lasted for 6 to 24 months, with 13 months in average. At the last follow-up, a all the flaps were found soft in texture and slightly swollen in appearance. There was no obvious pigmentation or rupture of skin and extensor tendon. Sensory recovery achieved to S 2 in 7 patients and S 3 in 3 patients. The hand function was evaluated according to TAM system and rated as excellent for 3 digits, good for 18 digits, fair for 9 digits and poor for 5 digits. There were linear scars in the donor sites. Conclusion:Free ALTF transfer with partial iliotibial tract in the reconstruction of composite tissue defect of dorsal wrists and hands can not only reconstruct the wound surface, but also the extension of digits, which cuts short the course of treatment.

Inherit, innovate and correctly position the clinical application of microsurgery technology: Celebrate the 60th anniversary of successful replantation of severed limbs in China / 中华显微外科杂志

In 1963, the successful replantation of severed limbs in China was firstly reported in the world, and it opened a new era of microsurgery. In the past 60 years, Chinese microsurgery scholars had created numerous world firsts. Microsurgery is an advantage and characteristic clinical subject in China. We should continue to innovate and correctly position the clinical application of microsurgery technology, constantly expand the business space, serve the grass-roots level, educate new people, develop technologies and techniques, improve skills, strengthen communication.

Pedicled latissimus dorsi flap in reconstruction of large soft tissue defect around elbow: An efficacy evaluation / 中华显微外科杂志

Objective:To evaluate the efficacy of pedicled latissimus dorsi flaps in reconstruction of large soft tissue defects around elbow.Methods:From January 2012 to January 2022, 12 patients with large soft tissue defects around elbow received reconstructive surgery with pedicled latissimus dorsi flaps in Department of Microreconstructive Surgery, The First Affliliated Hospital of Xinjiang Medical University. Partial latissimus dorsi flaps were employed to reconstruct The soft tissue defects around the posterolateral side of elbow in 6 patients. Functional reconstruction of anteromedial soft tissue defect around elbow with functional latissimus dorsi myocutaneous flap combined with biceps muscle dynamic reconstruction was performed on other 6 patients. All patients were males and aged 18 to 57 years old, at 31.4 years old in average. Causes of injury: machine strangulation in 5 patients, traffic accident in 4 patients, machine crush in 2 patients, and fall from height in 1 patient. Injured sites: 5 patients had injury on right elbow and 7 on the left. The size of soft tissue defect ranged from 18.0 cm×10.0 cm to 51.0 cm×13.0 cm. The size of the flaps were at 30.0 cm×7.0 cm-55.0 cm×14.0 cm. The wounds at donor site were directly sutured. Follow-up included postoperative reviews via telephone, WeChat and visit to outpatient clinic. Mayo elbow performance scores(MEPS) at the last follow-up were recorded.Results:All 12 flaps survived, and all donor and recipient sites healed at stage I. The follow-ups lasted for 3 months to 2 years for all patients, with 18 months in average. Three months after operation, 1 patient underwent additional surgery for flap reduction due to a bloated flap and poor appearance. Six patients who received dynamic reconstruction myocutaneous flaps achieved grade IV in elbow flexion. Six patients with lateral elbow repaired with partial latissimus dorsi myocutaneous flap showed that the appearance of the flap was not bulky and had no effect on the flexion and extension function of the elbow joint. All flaps survived well at the last follow-up, with soft texture and colour close to the surrounding normal skin. All donor sites healed well, leaving only linear scars. Motion of all elbows was good. The MEPS at the final follow-up was(90.6±6.4), with 10 patients in excellent and 2 in good.Conclusion:According to the location of elbow joint soft tissue defect, different types of latissimus dorsi myocutaneous flaps are used for reconstruction, which can achieve good clinical results.

Calf tissue flap combined with artificial bone of antibiotics loaded calcium sulphate in treatment of tibia osteomyelitis / 中华显微外科杂志

Objective:To observe the surgical method and clinical efficacy of applying calf tissue flap combined with artificial bone of antibiotics loaded calcium sulphate in treatment of tibia osteomyelitis.Methods:From July 2018 to January 2021, calf tissue flaps combined with artificial bone of antibiotics loaded calcium sulphate (or mixed with iliac bone) were applied to treat 16 cases with tibia osteomyelitis in the Department of Hand and Microsurgery of Baoji Third Hospital. There were 10 males and 6 females, aged 15 to 64 years old, with a mean age of 41 years old. For the 5 cases with acute osteomyelitis caused by wound infection, local dressing changes and drainage or VSD wound management were applied after debridement, together with primary systemic anti-infection treatment. After the acute infection period had been under control and stabilised, the wounds were then thoroughly exposed and cavities were filled and covered with the surgical reconstruction procedure with antibiotics-loaded artificial bone of calcium sulphate in combination with calf tissue flaps. For the 11 cases with chronic and hypotoxicity osteomyelitis, calf tissue flaps combined with antibiotics-blended artificial bone of calcium sulphate were applied to fill the cavity and cover the wound in phase I surgical reconstruction after thorough debridement. For the 7 cases with large bone defects or larger cavities after debridement, a mixed bone grafts of antibiotics-loaded artificial bone of calcium sulphate and autologous iliac bone were employed, with muscle flaps or myocutaneous flaps for an embedding repair. Sizes of the tissue flaps were 2.0 cm×3.5 cm to 12.0 cm×23.0 cm. Clinical outcomes were evaluated through follow-ups at outpatient clinic. The therapeutic effect was evaluated by the method described by McKee et al.Results:Except for 1 case of distal necrosis of tissue flap and survived after dressing change, the other tissue flap survived successfully. Postoperative follow-ups lasted for 12 to 40(mean 18) months. All the osteomyelitis were successfully cured, except 1 that had recurrence of osteomyelitis 1 year later, and treated with antibiotics-loaded artificial bone of calcium sulphate combined with autologous iliac bone implants after thorough debridement, and then healed well. The shape and texture of flaps were good. Protective sensations were restored to vary levels after 6 months. The calf regained weight-bearing and walking functions at 1 year after surgery. According to McKee et al., the therapeutic effect was evaluated: 11 cases were cured, 4 cases were improved, and 1 case relapsed, with an effective rate of 93.8%.Conclusion:Application of calf tissue flap combined with antibiotics-loaded artificial bone of calcium sulphate in the treatment of tibia osteomyelitis has a high cure rate and remarkable efficacy. It can significantly reduce the number of surgeries and shorten the course of disease.

Clinical efficacy of free deep inferior epigastric artery perforator flap in repair of large wounds in upper limb / 中华显微外科杂志

Objective:To summarise the clinical efficacy of free deep inferior epigastric artery perforator flap (DIEPF) in repairing large wounds in upper limb.Methods:From June 2016 to March 2022, free DIEPF repair surgery were performed for 9 cases with large defects in elbow, forearm and wrist in the Department of Hand Surgery, Xuzhou Renci Hospital. The patients were 3 males and 6 females at 36-65(average 50) years old. The sizes of defect ranged from 6.0 cm×7.0 cm to 25.0 cm×33.0 cm. Seven defects combined with radius-ulnar fracture, 4 with wrist fracture, 4 with metacarpal fracture and 1 with humerus fracture. All defects had various degrees of injuries of tendon, blood vessel and nerve. A total of 10 flaps were harvested, and the size of flaps were 7.0 cm×8.0 cm-12.0 cm×35.0 cm. Vessels in 7 flaps of 6 patients were anastomosed with unilateral vascular pedicles and 3 with bilateral vascular pedicles. End-to-end arterial anastomosis was performed on 1 flap, and the other 9 flaps of 8 patients had end-to-side arterial anastomoses. End-to-end vein anastomoses were performed on all flaps. Umbilical reconstruction was performed at the abdominal donor site for 3 patients, and all donor site wounds were closed in stage I surgery. Scheduled outpatient and WeChat follow-up were made after surgery.Results:Nine flaps in 8 patients survived successfully. Partial skin necrosis occurred in 1 flap and repaired by skin grafting. Follow-up lasted for 6 to 60 months(12 months in average). At the last follow-up, the colour of the flaps was found being similar to the surrounding skin with mildly bloated and soft in texture. Sensation of the flaps recovered to S 2 in 5 patients, and not detected in 4 cases. Conclusion:The free DIEPF has a relatively constant perforator and the flap can be used for repairing a large area of defect. The donor site wound can be closed in Ⅰ stage surgery. Free DIEPF is suitable for repair of large upper limb wounds.

Replantation of severed midfoot with pedicled perforator flap around ankle for repair traumatic defect: Report of 4 cases / 中华显微外科杂志

Objective:To discuss the pedicled perforator flap around ankle in complicated replantation of severed traumatic midfoot.Methods:From May 2017 to December 2020, a total of 4 patients with severed midfoot combined with severely traumatic soft tissue defects were treated in the Department of Micro-orthopaedics, The Second Affiliated Hospital of Luohe Medical Collage. The patients were all males and aged from 22 to 53 (mean, 44) years old. Two patients had left foot injured and 2 in right foot. Causes of injuries: One patient was injured by strangulation of a corn harvester belt, and 3 were crushed by a heavy steel bar. Three patients had the severed sites at the level of intertarsal joint and 1 at the base of metatarsus. The time from injury to admission was 2.0-5.0(mean, 3.5) hours. The severed feet were replanted by anterograde method. Pedicled perforator flaps around ankle were used to repair the soft tissue defects of feet in emergency surgery or post first-stage surgery. The sizes of the flaps were 7.5 cm×8.0 cm-9.0 cm×19.0 cm. Scheduled follow-ups were arranged at outpatient clinic or by online reviews. Appearance, texture, colour, blood supply and sensory-motor function of the replanted feet and flaps were observed. The function of the foot and ankle was evaluated according to the American Orthopaedic Foot Ankle Association (AOFAS).Results:All 4 patients engaged follow-ups lasted for 13-36(mean, 19.5) months. Three replantations survived after surgery. In the other case, a chronic necrosis of the broken foot was caused by skin necrosis, wound infection, and vascular embolism. And then the necrotic forefoot was released, and the wound was later repaired with a flap based medial supramalleolar branches. A total of 5 flaps in 4 patients survived. All flaps were in good appearance with good texture and colour. All flaps healed primarily, and all skin grafts survived. All of the 4 patients could walked without assistance. Sensation restored to S 3. The patient with a failed replantation had left with a mild claudication. According to AOFAS, 2 patients were in excellent, 1 in good and 1 in fair at the last follow-up. Conclusion:Replantation of severed midfoot with an early application of pedicled perforator flap around ankle for reconstruction of severely traumatic defect is an effective and feasible treatment strategy.

Repair of finger pulp defect with free thenar perforator flap / 中华显微外科杂志

Objective:To investigate the effect of free thenar perforator flap on repair of finger pulp defect.Methods:From September 2019 to November 2021, 79 cases of finger injuries complicated with defects in the pulp of fingers received free thenar perforator flap transfer surgery for reconstruction of finger pulps in the Department of Hand and Foot Surgery, Taizhou Hospital, Zhejiang Province. The patients were 51 males and 28 females, aged from 17 to 52(37.5±5.2) years old. There were 34 finger-pulp defects of index fingers, 15 of middle fingers, 26 of ring fingers and 4 of little fingers. All patients were treated with free thenar perforator flaps sized 2.0 cm×2.5 cm-3.0 cm×3.5 cm. All thenar perforator flaps were pedicled with the perforator artery and subcutaneous superficial vein in the thenar region, and the vessels were anastomosed with the proper palmar digital artery and dorsal digital vein, respectively. At the same time, subcutaneous nerve and proper palmar digital nerve were sutured to reconstruct the sensation of flaps. During the operation, the dominant perforating branch of thenar was found being originated from the superficial palmar branch of radial artery in 27 cases, from the superficial palmar arch in 21 cases, from the perforating branch of metacarpophalangeal proper artery of thumb in 11 cases, from the radial artery in 10 cases and from the main artery of thumb in 10 cases. The origins of nerves within the flaps were found from the superficial branch of radial nerve(24 cases), the terminal branch of lateral cutaneous nerve of forearm(22 cases) and the palmar branch of median nerve(33 cases). The operation time was (96.7±10.7) minutes. The donor site for the flap was closed directly without skin grafting. Most of the follow-up were conducted through the visit of outpatient clinic and the patients from other regions were reviewed via telephone or WeChat.Results:All perforator flaps survived completely and the flap donor sites healed smoothly. Follow-up lasted for (20.5±3.8) months. The reconstructed finger pulp was not bulky and the texture was satisfactory. TPD of the flaps was (5.6±0.9) mm. Only a linear scar left in the flap donor sites without significant affect on thenar function.Conclusion:The vascular anatomy of thenar perforator flap is constant, which helps to regain sensations of the flap. The texture and thickness of the flap are similar to those of the finger. It is ideal for reconstruction of defect of finger pulp.