Functional muscular transfer of lateral femoral muscle superficial region in emergency reconstruction of traumatic defects of dynamical muscle: A report of preliminary clinical study / 中华显微外科杂志

Objective:To explore the feasibility and clinical effect of emergency lateral thigh muscle transfer in functional reconstruction of major traumatic muscle defects.Methods:Emergency surgeries for 8 patients(7 males and 1 female) with muscle defects were carried out subject to emergently reconstruct the power of lateral femoral muscle superficial region, between March 2020 and December 2021, in the Department of Hand and Foot Microsurgery Hospital, Xi'an Fengcheng Hospital. The 8 patients were 23 to 52 years old with an average of 37.6 years old. Five patients injured by machine crush, 2 by heavy object crush and 1 by traffic accident. Five patients were in Gustilo III B injury in forearm, including 2 with flexor muscle group defects, 2 with extensor muscle group defects and 1 with defect of dorsal metacarpal flexor muscle and extensor muscle. Among the 5 patients, 2 patients had the defects in left forearm and 3 in right forearm. One patient had defect of right 1st metacarpal bone and skin and thenar muscle. One patient suffered a complete right upper arm detachment with musculocutaneous nerve being drawn out from the bicipital muscle. One patient had Gustilo III C injury in the right calf with defects of extensor hallucis longus and extensor digitorum. The areas of soft tissue defect were 10.0 cm×8.0 cm-36.0 cm×11.0 cm and the size of flaps was 12.0 cm×6.0 cm-38.0 cm×12.0 cm with the volumes of excised muscle at 18.0 cm×9.0 cm×1.5 cm-10.0 cm×2.0 cm×1.0 cm. The anatomical cross-section and length of the corresponding muscle on the healthy side were measured by musculoskeletal ultrasound. The chimeric tissue flap was designed on the anterolateral side of the thigh. The flap was designed according to the size of the wound and the corresponding flap. Then 1 or 2 muscle tissue blocks were designed and cut from the superficial region of the lateral femoral muscle according to the condition of the muscle defect, to cover the wound and reconstruct the muscle power. Postoperative follow-ups were conducted by scheduled hospital visit. The contents of follow-up included dynamic observation, evaluation and record through musculoskeletal ultrasound, electromyography and strength of muscle.Results:For the 8 patients who were subject to a muscle reconstruction, the transferred muscles and flaps survived in stage-one without vascular event. Postoperative follow-ups lasted for 10 to 32 months with an average of 19.6 months. The strength of muscle was evaluated according to the M 4 strength of muscle. Strength of muscle restored to M 4 or above in 7 patients who could lift, hook or push a heavy object in 5-30 kg of weight, with free joint movement. One patient restored the strength of muscle to M 3+. Muscle contraction was detected 2-4 months after surgery by musculoskeletal B ultrasound. The average ratio of contraction to resting cross sectional area in 5 cases was 1.45±0.42. The shape of limb was bilaterally symmetrical. There was no discomfort in the donor site and knee joint. The flaps were soft and glossy, with protective sensation restored. Conclusion:Muscle transfer from the lateral femoral muscle superficial region in emergency surgery for functional reconstruction of traumatic muscle defects is feasible and effective with a good clinical effect.

Analysis of emergency reconstruction of forearm Gustilo III B and III C fracture with complex tissue defect: outcomes and related factors / 中华显微外科杂志

Objective:To discuss outcomes of emergency repairing for Gustilo III B and III C fractures of forearm with complicated tissue defects and the related influence factors.Methods:From January 2014 to Feburary 2022, data of 98 cases of Gustilo III B and III C fractures with large compound defects of soft tissue, blood vessel, bone, tendon or muscle from elbow to wrist were collected. Primary debridement, bone fixation, wound coverage by free flap, bone transfer(or bone cement filling) or dynamic reconstruction of muscle were completed with emergency surgery in Department of Hand and Foot Microsurgery, Xi'an Fengcheng Hospital. Postoperative follow-ups were conducted through outpatient clinic visits, telephone and WeChat reviews. Video clips, questionnaires and the latest information of patients were also analysed. Rank sum test and Chi-square test were used to examine the relationship between independent variables such as general condition, disease condition and surgical procedures of chimeric tissue transfer group and simple flap transfer group, together with dependent variables such as limb salvage, number of surgery, wound healing, function scores, and complications. P<0.05 were further included in the regression equation to discover the relationship between multiple independent variables and dependent variables. Results:Follow-up lasted for 6-96 months, with an average of 71.1 months. In the chimeric group, the limb salvage rate was at 95.1%, with an infection rate of 8.50% and an average number of surgery was 2.13±0.89. In the simple flap transfer group, the limb salvage rate was at 87.5%, with an infection rate of 15.38% and an average number of surgery was 2.62±0.64. The good rate of Anderson score was 65.3% and the average score of Disability of the Arm, Shoulder and Hand(DASH) was 32.9(0-60) points for all the patients. There were significant differences in dependent variables of limb salvage and infection rate between the 2 groups ( P<0.05). Ischemia time and method of bone fixation led to significant differences in number of surgery ( P<0.05). Methods of bone fixation and the types of flap made significant differences in wound healing ( P<0.05). Underlying disease, bonedefect, Gustilo classification and method of bone fixation all contributed to the significant differences in function score ( P<0.05 or P<0.01) . Conclusion:Emergency surgery for repair of serious injury of forearm has a relatively high limb salvage rate and good functional effects. The limb salvage rate is not correlated with independent variables such as severity of injury, Mangledextremity Severity Score (MESS) and ischemia time, while transfer of a simple flap or a chimeric flap is significantly correlated with the limb salvage rate, infection and wound healing. The severity of injury, ischemia time and bone defect are correlated with functional assessment, number of surgery and bone healing.

Preliminary study on anatomy and clinical significance of the superficial region of lateral femoral muscle / 中华显微外科杂志

Objective:To explore the feasibility in reconstruction of the muscular power with the superficial part of lateral femoral muscle through anatomical study on the superficial region of lateral femoral muscle.Methods:Studies on 4 sides of lower limbs of 2 cadaver specimen were conducted in the Department of Hand and Foot Microsurgery of Xi'an Fengcheng Hospital. Intraoperative observations and measurements were further carried out on 21 sides of 21 patients. Muscular fascia in superficial region, muscular gross morphology, thickness, length and width of muscles, length of muscle fibres and pinnate angles of muscle surface were observed and measured. Both blood vessels and nerves in the muscle were separated to measured.Results:The superficial region of lateral femoral muscle was in a shape of fusiform and started from the greater trochanter and ended at the patella and rectus femoris, with the fascia at proximal end and the muscle of distal end. The inferior muscle fibres of the fascia were arranged in sequence and ended at the deep fascia from proximal to distal. Mean muscle thickness was measured at 1.96 cm±0.48 cm, and mean pinnate angle was of 18.9°±3.3°. The superficial region was found being distributed by the descending branches of lateral circumflex femoral artery(LCFA) and the second branch of femoral nerve, and they accompanied each other. At 5.0 cm from the point of entry to the muscle, the diameter of the vessels was measured at 2.39 mm±0.52 mm, and the diameter of nerves was at 2.64 mm±0.61 mm. Both of arteries and nerves further branched out anteriorly and posteriorly in 1.0-1.5 cm intervals after having entered the muscle. At 0 - 2.5 cm away from the muscle entry point, a larger branch was often running posteriorly into the muscle, and this branch appears on all 4-sided specimens. While the occurrence rate in the 21 sides of patients observed in operations was of 90.5%, with a transverse diameter at 1.23 mm±0.28 mm.Conclusion:The superficial region of lateral femoral muscle is dominated by independent vessels and nerves and there are many branches from superior vessels and nerves, which form an anatomical basis for one or more muscular flaps.

Reconstruction of muscular dynamics with partial superficial vastus of lateral thigh: a preliminary study / 中华显微外科杂志

Objective:To explore the feasibility of functional reconstruction of muscle power in treatment of traumatic muscle defects by transferring part of superficial vastus of lateral thigh.Methods:From March 2020 to March 2023, reconstruction of muscle power with transfer of superficial lateral thigh muscle was performed on 9 patients in the Department of Hand and Foot Microsurgery of Xi'an Fengcheng Hospital. Nine patients were assigned in a study group. A total of 48 patients who previously had the surgery of chimerically grafted superficial vastus of lateral thigh were recruited as the "previous surgery group" and another group of 71 staff volunteers from our hospital were recruited as the "healthy control group". Of the study group, 5 patients had Gustilo type ⅢB injury in forearm (two with defects of flexor muscle group and 3 with extensor muscle group, 2 with the defects in the left and 3 in the right), one had defect of both flexor and extensor muscle groups in dorsal hand, one had defect of right 1st metacarpal with defects of soft tissue and thenar muscle, one had a completely severed right upper arm with a withdrawn musculocutaneous nerve from the biceps brachii and one had Gustilo ⅢC injury in right calf with defects of tibialis anterior, extensor longus and extensor phalangeal muscle. In the emergency surgery, part of the superficial muscles of lateral thigh were taken to reconstruct the muscular power for the defected traumatic muscles. During the surgery, the excessed nerve with a length of 3.0 cm proximally was removed at 3.0 cm from the point where the nerve entered the muscle. In the transfer of superficial chimeric muscle of lateral thigh, a 3.0 cm of sample nerve tissue was taken for HE staining to find out the number of nerve fibers. Musculoskeletal ultrasonography, electromyography and muscle strength test were performed in the postoperative follow-up for observations and evaluations of the effects of surgery. Average length and thickness of muscle were taken from the 48 patients in the "previous surgery group". The measurement was compared with the length of muscle fibers and the number of nerve fibers in the gracilis muscle of the 9 patients in study group. The cross-sectional areas (SCA) at contraction state (C) and resting state (R) of the superficial vastus of lateral thigh were taken from the 71 volunteers in the healthy control group, and the C/R ratio was calculated (CR value). All the 9 patients were included in the postoperative follow up by outpatient visits and via telephone or internet reviews to observe the recovery of muscle strength of the reconstruction of muscle dynamics.Results:In the study group, the number of nerve fibers shown by immunohistochemical HE staining was 1 088±213, with the CR value of graft muscle measured by musculoskeletal ultrasonography at 1.44±0.17. The wound healed smoothly without complication. The average time of postoperative follow-up for the 9 patients was 22.6 (10-38) months. Recovery of muscle strength was found at M5 in 6 patients and M4 in 3 patients. The appearance of the joints was normal. In the previous surgery group, the average muscle thickness of the superficial vastus lateralis muscle was 1.74 cm±0.35 cm and the length of muscle fiber was 8.86 cm±1.59 cm. In the healthy control group, the CR value of the superficial muscle vastus of lateral thigh was found at 1.17±0.12.Conclusion:Reconstruction of muscular power with partial muscle transfer of the superficial vastus of lateral thigh is proposed in this study.

Emergency one-stage transfer of Flow-through chimeric anterolateral thigh perforator tissue flap in repair of Gustilo III C wrist injury of a child: A case report / 中华显微外科杂志

In September 2020, a child with open wrist fracture and severe soft tissue injury was admitted in the Department of Hand and Foot Microsurgery, Xi'an Fengcheng Hospital. In the emergency surgery, the fracture was fixed, the vascular, nerve and tendon were repaired, and Flow-through chimeric anterolateral thigh perforator tissue flap was used to cover the wound. The chimeric tissue flap and the wrist survived in first stage as well as the wound healing. At 1 year of follow-up, the flap was not bloated and the protective sensation was restored. The flexion and extension and the rotation of left wrist were good. The pinch, flexion and extension of all digits of the left hand recovered well.

Treatment and follow-up of a scapular girdle avulsion in a 7-year-old child: A case report / 中华显微外科杂志

In November 2011, a 7-year-old child with shoulder avulsion was treated in the Department of Hand and Foot Microsurgery, Xi’an Fengcheng Hospital with debridement, transfer of free anterolateral thigh flap(ALTF) and decompression with forearm incision. After operation the limb survived. Six months after surgery, the function of right shoulder abduction was reconstructed by transposition of trapezius muscle. At the 11 years after surgery, the length of the limb on the affected side was slightly shorter than that of the healthy side. The circumference of forearm was slightly less than that of the healthy side. The pain, touch and temperature sensations were recovered. The TPD was 15-20 mm, and the skin temperature on both sides of the limb was normal. The shoulder abduction reached 30°. The muscle strength of elbow and wrist flexions reached grade Ⅴ with the recovered wrist pronation and all digit flexions. The affected limb can cooperate with the healthy limb to complete all daily duties.

Reconstruction of multiple metatarsus and soft tissue defects with fibular flap and fibular artery chimeric: A case report / 中华显微外科杂志

In May 2019, a patient who suffered with multiple foot metatarsus injury with soft tissues defect was treated in the Hand and Foot Microsurgery of Xi'an Fengcheng Hospital, by using chimeric peroneal artery for phase-1 reconstruction of metatarsus with folded fibular flap, foot cross arch and soft tissue defects. After 2 years, the arch of foot as intact without collapse. There was no arthritic lesions. The height, arc and width of metatarsus were very close to the healthy side. The flap and plantar were smooth without abrasion and ulceration. The patient could walk, run and stand with single-foot stand, and able to carry out heavy physical work continuously.

Double chimeric bone flap with double Flow-through anastomosis in emergency repair of segmental forearm defects in the one-stage surgical procedure: A case report / 中华显微外科杂志

The peroneal artery chimeric bone flap combined with chimeric flap of lateral femoral circumflex artery was applied in the repair of a case defects of both ulna and radius arteries combined with large extensive ring-like soft tissue defects of forearm in November, 2018, causing no blood supply to the hand. In the one-stage surgical procedure, anastomosis of the ulnar and radial arteries with the pedicle of the 2 flaps by Flow-through anastomosis were performed and the blood supply of the forearm and hand was restored. Six months after the surgery, the rotation functions of forearm, wrist joint and fingers were recovered. The patient was able to carry out daily activities and some of precision tasks.

Emergency repair of Gustillo III C limb extremities with free Flow-through chimeric anterolateral thigh perforator flap / 中华显微外科杂志

Objective:To explore the clinical effects of a single stage reconstruction and revascularization using a free Flow-through chimeric anterolateral thigh perforator (ALTP) flap in Gustillo III C limb injuries.Methods:From January, 2010 to December, 2017, 17 patients with Gustillo III C injury of extremities were repaired with Flow-through chimeric ALTP in emergency surgeries. The patients were 16 males and 1 female with mean age of 32.4 (19-55) years. The size of wounds ranged from 16 cm×8 cm-45 cm×30 cm. The injured arteries were Flow-through anastomosed with the descending branch of the lateral circumflex femoral artery to regain blood flow. The deep dead space was filled with vastus lateralis flap, and the skin flap and fascia flap were used for superficial covering. The donor site was closed directly in 6 patients, simultaneous skin grafts were applied in 11 patients.Results:The followed-up time ranged 5 to 60 (average 21.8) months, and conducted by clinic visits and by telephone or WeChat interviews. Fifteen flaps survived, and 2 flaps failed with limb amputated. Six patients were repaired with skin and fascia flaps and 11 patients received flaps comprising the skin, fascia and vastus lateralis muscle. Four flaps healed in stage I. Partial necrosis were observed in 11 flaps. Of which, 1 healed by change of dressing and 10 healed by skin grafting. No complications occurred in donor site in all patients.Conclusion:The Flow-through chimeric ALTP flap can be used in stage I reconstruction of the blood supply of limbs and meanwhile achieve the 3-D repair of defects. It is one of the reliable methods in the reconstruction of Gustillo III C injuries in the extremities.

The application of prophylactic abdominal aorta balloon occlusion with Fogarty catheter in treating patients with pernicious placenta previa / 介入放射学杂志

Objective To discuss the clinical effect of prophylactic abdominal aorta balloon occlusion with Fogarty catheter before cesarean section in treating delivery woman with pernicious placenta previa.Methods The clinical data of 12 delivery women with pernicious placenta previa,who received prophylactic abdominal aorta balloon occlusion with Fogarty catheter before cesarean section,were retrospectively analyzed.The curative effect was evaluated.Results The average intraoperative blood loss in the 12 patients was (1256±318) ml.The uterus was successfully retained in 9 patients.Hysterectomy had to be carried out in 3 patients because of refractory hemorrhage;one of them had to receive total hysterectomy together with bladder repair as the placenta had penetrated into the bladder wall.After delivery no complications,such as infection,delayed hemorrhage,lower limb thrombosis,etc.,occurred.All 12 neonates were born smoothly.Conclusion Prophylactic abdominal aorta balloon occlusion with Fogarty catheter before cesarean section can effectively reduce intraoperative blood loss and help save the uterus.Therefore,it is a safe and effective therapeutic means for delivery woman with pernicious placenta previa before the performance of cesarean section.

Application of lateral femoral circumflex artery perforator flaps and fit together for limbs complex wound surface / 中华显微外科杂志

Objective To evaluate the feasibility and clinical efficacy of lateral femoral circumflex artery perforator flaps and fit together in the treatment of limbs complex wound surface.Methods From January 2010 to March 2012,use the characteristics that the descending branch of lateral femoral circumflex artery extend its branches over the flap,fascia and skin,to form lenticulostriate arteries,which contain 2 to 3 different species tissues fits together,flaps cover the important tissues such as vessel,nerves and bones.Fascia covers the tendinous tissues etc.Muscle can not only cover the tissues,but also fill in the space,and followed by skin grafting.This research was to perform the treatment for 4 cases of lacking limbs ring tissue,three cases of multiple wound surface,six cases of hand avulsion injury of skin and 9 cases of Gustilo grade-Ⅲ C.Results As for the 22 cases in the research,nineteen cases of flaps survived,the other 3 cases were necrosis with length of 1cm to 2 cm at distal and self-healed later.During 6 months to 2 years followed-up of 18 cases,external flaps were satisfactory,skin grafting over the fascia layers develops very well,smooth with great elasticity,no recoil,and no color change.Conclusion Lateral femoral circumflex artery is one of effective restoration methods for limbs with complex wound surface.

Half hallux toenail flap transplantation to repair the distal segment finger defect / 中华显微外科杂志

Objective To discuss the treatment of half hallux toenail flap transplantation for reconstruction of the distal segment finger defect. Methods Based on using the first plantar/dorsal metatarsal artery, or toe artery as pedicle to cut off partial toenail together with toe abdomen flap or partial toenail to repair 64 cases which include 69 fingers with distal segment complete and partial defect,the distal skin avulsion,skin tube in postoperative plastic,replantation failure and so on.Depending on the size of the donor foot wound use the first dorsal metatarsal artery,second toe artery,the perforating branch of peroneal artery or plantar metatarsal artery flap to cover the wound, and then observe the appearance of the finger and foot donor site after operation. Results The finger pulp was full and elastic,nail bed of the toe was well healing,nail groove which originated from the reconstructed nail fold was shallow,the appearance wos realistic,all feelings were recover,two-point discrimination was 4 to 5 millimeter,the donor toe was plump like the original one in appearance,patients were all satisfied with the reconstructed finger and the toe shape,after a follow-up from 3 month to 4 years. Conclusion Half hallux toenail flap transplantation is an effective way to repair the distal segment finger defect.

Multi-method transplantation of fibula and flap to the repair of limb bone and soft tissue defects / 中华显微外科杂志

Objective To investigate the effect of vascularized fibula with fibular flap to repair limb bones and soft tissue defects.Methods Transpositional fibulas were used to repair tibiae defects in 4 cases.Free fibular transplantation was used in 6 cases,including folded fibular transplantation in 3 cases distal femur repair in 2 cases,calcaneus repair in I case.Hole fibular transplantation was used in 11 cases to repair tibia radius and metatarsal bones.Semi-fibular transplantation was used to repair metacarpal bone defects in 2 cases.All transplanted bones were together with the flap to repair bones and soft tissue defects.Results Twenty cases were all survived,with bone healing time of 6 to 10 weeks,and weight bearing time of 3 to 6 months,fifteen cases were followed up for 6 months to 4 years,and the results showed that their transplanted bones became thicker,their lower limbs recovered to normal walking,hand grip function recovered,the transplanted flaps were elastic.Conclusion Vascularized fibula and fibular flaps transplantation was an effective way to repair limb bones and soft tissue defects.

Treatment of the donor site after wound healing of semi-toe nail flap / 中华显微外科杂志

Objective To explore the wound healing of semi-toe nail flap donor site after transplantation. Methods To repair small wounds,on 13 toes the first metatarsal dorsal flaps were applied,and on 7 toes the second toe digital flaps were applied.While,to repair large wounds,free flaps were applied,including foot inside flaps on 3 toes,peroneal artery perforator flaps on 5 toes,tarsal lateral artery flaps on 2 toes,and phil bowel artery inside branch flaps on 3 toes.Wounds remaining on semi-toe nail flaps of 7 toes were all covered with fibular island flaps of the first toes. Results Twenty cases were followed up,and the rang between 6 months to 5 years.The nail margin was exposed out of the lateral flaps in 2 cases.The first toes and the second toes appeared nearly normal in the other 18 cases.The flaps appeared smooth,flexible appearance with nice color and no ulceration.Seven cases applied with free flaps recovered protective sensibility with no complaint. Conclusion To cover wounds on semi-toe nail flaps of the first toes and the second toes with flaps is an ideal treatment method.The method of free flap transplantation is superior to vascular pedicle flap graft.

Treatment of the donor site after wrap around flap from toe / 中华显微外科杂志

Objective To investigate the methods to cover the donor site of wrap around flap from toe. Methods In 34 cases, 8 thumbs reconstructed with wrap around flap from great toe, 8 thumbs and 14 fingers reconstructed with half nail flap from fibular side of second toe, and 4 fingers reconstructed with dorsal nail flap from second toe. The donor site were covered with pedicle flap (first metatarsal dorsal flap, second toe digital flap, neighbor flap from dorsal of second toe, and lateral tarsus flap) or free flap (medical plantar flap, fibular artery flap, and lateral tarsus flap). Results Twelve cases were followed up after 2 months, normal gait were found, 6 cases were followed up after 4 months, (4 cases for first metatarsal dorsal flap, one for fibular artery flap and one for internal volar flap). 2 cases recovered defend sensibility and showed a bit dark, the cases which reconstructed with medical plantar flap and second toe digital flap had nearly normal sensibility. The outward appearance of the donor site were chubbiness, flexible, and no complaint were found. Conclusion Covered the donor site of wrap around flap from toe with these flaps can avoid complications like pain and ulcerate, and have a satisfactory appearance.

Microsurgical repairment of finger-tip defection / 中华显微外科杂志

Objective To investigate the methods to repair the defection of finger tip.Methods During Feb.2004 to July 2008,in 98 cases,23 fingers were reconstructed with 2nd toe transfer which was reformed with digital flap or trilobed flap from 2nd toe,33 fingers were coverd with wrap around flap or half wrap around flap from great toe,or combined wrap around flap from great with pulp flap from 2nd toe,28fingers were repaired with fabular flap from great toe combined with tibial flap from 2nd flap,and 27 fingers were repaired with nail flap or enlarged nail flap from great toe. Results Vessel articulo took place in 5 cases,and all cases recovered with wonderful outward appearance Conclusion Microsurgical technic is an ideal method to repair the finger-tip defection.

Reconstruction of finger with reshaped second toe / 中华显微外科杂志

@#Objective To improve the outward appearanee in toe-to-hand transfer,a reshaped procedure of second toe was studied. Methods In reconstructing a finger with second toe transfer,a piece of flap from the fibular side of the second toe,or/and a H-shaped flap from the tibial of great toe were designed and transferred to the volar side in order to obliterate the constriction below the toe pulp. Results In 17 patients,22 fingers reconstructed with these procedure,ouly one rotation flap necrosis partly.The appearance of the newly reconstructed thumbs and fingers were improved,the pulp of reconstructed finger was similar to a natural finger, the narrow neck of second toe was well-stacked,and the interpbalangeal joint was straighten. Conclusion Reconstructed finger with this reshaped second toe is similar to a normal finger.