Emergency thumb reconstruction for traumatic thumb amputation with bone and tendon from the amputated part without replantation condition / 第二军医大学学报

Objective To investigate the feasibility of emergency thumb reconstruction for traumatic thumb amputation with bone and tendon from the amputated part, when the soft tissue is severely damaged and the amputated thumb is not replantable. Methods When the soft tissues of the amputated thumb was severely damaged and replantation was not applicable, thumb reconstruction as phase one emergency management was proceeded. The skin and nail bed of the amputated thumb was removed. The bone was in situ replanted, and the tendon was repaired. The nail flap from the ipsilateral toe was grafted and the bone and tendon was wrapped around to reconstruct the thumb. Results A total of 5 patients underwent surgical treatment. All reconstructed thumbs survived with an appearance similar to the contralateral sides. The patients were followed up for 10 months on average (range, 4 to 18 months). The result of two-point discrimination test was 10.1 mm on average (range, 9.2-12.0 mm). The preserved joints possessed partial function. The average range of motion of the metacarpophalangeal joint was 69.6° (range, 20° to 90°). The range of motion of interphalangeal joint was 15° and 20° in 2 patients, respectively. No infection or bone resorption occurred. The injury was healed successfully in 4 patients, and delayed union occurred in one patient. Conclusion Complete bone and tendon from the nonreplantable amputated part combined with wrap-around flap can be used for emergency thumb reconstruction and it can achieve good clinical results.

Repair of the donor defect after wrap-around flap transfer with free thinned innervated anterolateral thigh perforator flap / 中国修复重建外科杂志

Objective: To explore the feasibility of harvesting free thinned innervated anterolateral thigh (ALT) perforator flap for repairing the donor defect after wrap-around flap transfer.

Bilateral big toe wrap-around flap for reconstruction of the defects of the finger / 中华显微外科杂志

Objective To investigate the therapeutic effect of bilateral combined flap transfer in reconstruction and repairation of thumb and finger defects.Methods A partial fibular side wrap-around flap was harvested from both big toes.The flaps were tailored and designed based on measurements taken from the finger of the intact side.These two flaps were combined to reconstruct the defects of the finger.From March,2008 to December,2015,a total of 9 fingers (9 cases) which had defect degrees range from Ⅰ ° to Ⅲ° underwent reconstruction surgeries in this way.Appearance,sensation and function of the thumb and foot flap were followed-up.Simultaneously how to improve the outcoming and success rate were explored and investigated.Results All 9 thumbs and fingers in 9 cases with these procedures were survived.No vascular crisis happened.All patients were followed up from 3 to 24 months.The reconstructed thumbs and fingers were all with abundant blood supply,having similar shape to the normal thumbs and fingers,good pain and temperature sensation,with two-point discrimination of 4-8 mm.All patients were satisfied with the thumb and finger shape,regained life and work ability as before.The donor sites had no obvious discomfort,and walking and weight-bearing function remained normal.Judged by the tentative evalution standard of function of upper limb,which was made by Chinese Medical Association for Surgery of the Hand.The results were excellent in 6,good in 2,fair in 1.Conclusion There is less damage on foot and most hand function recovery using bilateral combined flap transplantation to repair multiple fingers defect.

Subemergency reconstruction of grade Ⅲ and Ⅳ thumb defect by great toe wrap-around flap combined with the tissue flap of second toe / 中华显微外科杂志

Objective To explore the surgical technique and clinical effect of combined great toe wraparound flap and second toe tissue flap transfer for subemergency reconstruction of grade Ⅲ and Ⅳ thumb defect.Methods From July,2011 to March,2014,12 patients of grade Ⅲ and Ⅳ thumb defect were treated by transfering combined great toe wrap-around flap and second toe tissue flap transfer.The second toe tissue flap was carried out to cover donor site defect of the big toe.Results All the 12 transplants survied and were followed up for 6 to 24 months.The reconstructed thumbs had near nomal appearace and good fuction,2-point discrimination ranged from 0.6 cm to 0.8 cm.According to the trial standard of upper limb part of functional assessment of the Hand Surgery Branch of Chinese Medical Association,among the 12 eases,there were excellent in 9,good in 3.Impact on the donor foot was minor with limited complications.The patients were able to weight-bearing walking after one months of operation.For long-term follow-up,no case had successive ulces,obvious pain and claudication.Conclusion The reconstructed thumbs by great toe wrap-around flap combined with the tissue flap of second toe had near nomal appearace and good fuction.

Repairing donor site after harvested of wrap-around flap of toe by peroneal artery perforator flap / 中华显微外科杂志

Objective To investigate the prothetic effect of free grafting of microvascular anastomotic peroneal artery perforator flap when used to repair the donor tissue defects of wrap-around flap of toe.Methods From January 2008 to March 2013,twenty-six cases thumb avulsion at proximal and distal phalanx level with skin and nail bed defect caused by trauma were admitted to our hospital.After incising wrap-around flap of toe to repair the thumb defects,microvascular anastomotic peroneal artery perforator flap was transplanted freely to repair the donor site of it.Results The skin flaps of 26 cases all successfully survived.After a followed-up of 3 months to 4 years,the length of donor toes were the same as before.The appearance of skin flaps were no fat and clumsy and the abradability of their skin were well.Algesia,thalposis and thigmesthesia were partially recovery.Two point discrimination reached to 5-10 mm.There were no obvious uncomfortableness in donor feet when standing and walking except wearing flip-flops.Conclusion Free grafting of peroneal artery perforator flap is a good method to repair the donor defect caused by incising wrap-around flap of toe.

Application of combined wrap-around flap from the big toe and flap from the opposite foot in treating degloving injuries of the whole thumb / 中华显微外科杂志

Objective To explore the new operation method and clinical effect of treating degloving injuries of the whole thumb.Methods Nine cases of the whole thumb degloving injury caused by machine were treated with free wrap-around flap from the big toe and the flap from the opposite foot.The phalanges,joints and tendons of all injured thumbs were integral relatively,except that the interphalangeal joints in 3 cases were destroyed and the flexor and extensor pollicis longus were ruptured.The size of the dorsal tissue defects varied from 4.8 cm × 2.9 cm to 6.2 cm × 3.4 cm,and the volar tissue defects ranged from 4.7 cm × 3.2 cm to 6.1 cm × 4.0 cm.The area of the wraparound flap from the big toe harvested was from 5.0 cm × 3.2 cm to 6.7 cm × 3.9 cm.The flap from the opposite foot was tibial flap with dorsalis pedis flap from the opposite second toe,and the area of the flap was from 5.0 cm × 3.5 cm to 6.6 cm × 4.5 cm.Results All 9 combined flaps survived.The wound healed primarily.Skin grafts in the donor sites of the foot also survived.Postoperative follow-up ranged from 6 to 20 months,with an everage of 9 months.The pulp of the thumb was well-stacked.Sensory recovery ranged from S3 to S3 +.Thumb nail grew well.Thumbs performed good functions as grabbing,grasping and nipping.The range of motion of the MP joints of the reconstructed thumb was normal.The motion of interphalangeal joints were acceptable in 6 cases,but worse than the normal thumb.The interphalangeal joint in 3 cases destroyed was fused.There was no obvious influence on the function of the foot.Conclusion Applying combined wrap-around flap from the big toe with the tibial flap and dorsalis pedis flap from the opposite foot in treating degloving injuries of the whole thumb is a new operation method,which could achieve good appearance and function,but have a small influence on the donor site.It is worthy being used widely in clinical.

Using modified great toe wrap-around flap to reconstruct degloved thumb and fingers / 中华显微外科杂志

Objective To explore the clinical outcome of using modified great toe wrap-around flap to reconstruct degloved thumb and fingers.Methods Eighteen patients were involved.Based on different types of injury,four procedures were carried on for reconstructing degloved thumb and fingers:①Unilateral modified great toe wrap-around flap to reconstruct 9 degloved thumbs of distal proximal level and 3 degloved fingers of proximal interphalangeal joint level.②Unilateral modified great toe wrap-around flap with second toe medial flap to reconstruct 2 total degloved fingers.③Bilateral modified great toe wrap-around flap to reconstruct 2 thumbs.④Bilateral modified great toe wrap-around flap and second toe medial flap with neurolized super thin anterolateral thigh flap to reconstruct 12 degloved fingers.This wrap-around flap carried with entire nail.A triangle flap was reserved at medial plantar of great toe.Results All free flaps were survived in one stage.Fifteen patients were followed up for 8 to 25 months.The contour of reconstructed digit was as same as contralateral digit with satisfactory motion arc and sensation.There was no extensive scar in donor toe.The width of medial plantar triangle flap increased significantly.All patients could walking,running,jumping without restricted.Conclusions With reconstructed by modified great toe wrap-around flap,degloved thumb or finger can be promised with excellent contour and function outcome.In the meantime,the loss of donor foot can be expected to minimal.This procedure is one of the best ways for reconstructing degloved thumb and finger.

Resurfacing of the donor defect after wrap-around toe transfer using the Y-V vascular pedicle lengthening technique / 中华显微外科杂志

Objective To explore the methods of Y-V vascular pedicle lengthening technique for cover-age of the defect of great toe after wrap-around flap transfer, and decrease the morbidity of donor site in great toes. Methods Fifteen patients received three kinds of flap for immediate resurfacing of donor defect of the great toes during wrap-around flap transfer, all flaps were harvested with Y-V vascular pedicle lengthening technique. Among them, 9 cases received the free lateral tarsal flaps transplantation for coverage of defect in donor great toes, 5 cases was repaired by medial tarsal flaps, and only one was treated by the medial plantar flap. Results All the flaps survived postoperatively. The medial plantar flap encountered the venous crisis in postoperative 3 days, and regained the normal blood supply after continuous bleeding for 2 days. All patients were satisfied with cosmetic and functional outcome in average 10- month follow-up. The appearance and sensory function of donor toe repaired by medial tarsal flaps was best among three ones. Conclusion Depending on the Y-V vascular pedicle lengthening technique, the local pedical flaps of foots are enlarged scope for coverage of great toe after wrap-around flap harvest, which can decrease the complication of donor site at the most.

Staged Reconstruction of the Mangled Hand with the Combined Use of Pedicled Groin Flap and Free Wrap Around Flap

PURPOSE: Despite the free tissue transfer using microsurgical technique being the current trend of soft tissue reconstruction of the hand, the pedicled groin flap has the advantage to provide coverage for the mangled hand without necessitating the use of a damaged arterial system and also providing the benefit of saving the arterial system for later free tissue transfer. This report presents the author's experience using pedicled groin flap in four cases of mangled hands with massive bone and soft tissue defects requiring later thumb reconstruction with the free wrap around flap. MATERIALS AND METHODS: The patients' age ranged from 30 to 51 years; three patients were male and one was female. The causes of mangled hand included two machinery crush injuries, one laboratory explosion and one motor vehicle accident. While evaluating the post-operative results, factors like flap survival, complications, stability in opposition, pinch power and 2 point discrimination were taken into account. RESULTS: All massive soft tissue defects of the hands were completely covered with pedicled groin flap successfully. The reconstructed thumb using free wrap around flap did not have any limitation in opposition. There was no occurrence of post-operative infection and all the flaps survived completely. The average pinch power was 70% of the contralateral intact thumb and average 2 point discrimination was 10 mm. CONCLUSION: The pedicled groin flap for the reconstruction of the massive soft tissue defects of the hand with subsequent reconstruction of the thumb with a wrap around flap is a very useful procedure. The combined use of pedicled groin flap and wrap around flap allows adequate coverage of sizable soft tissue defects and functional thumb opposition in cases of reconstruction of the mangled hands.

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.

How to cover the defect of great toe after the wrap-around flap transfer / 中华显微外科杂志

Objective To explore the methods for coverage of the defect of great toe after the wrap-a- round flap transferand decrease the morbidity of donor site in great toes.Methods Twenty-five patients received three kinds of procedure for immediate resurfacing of donor defect of the great toes during wrap-around flap transferAmong them9 cases received the free flaps for coverage of defect in donor great toes12 cases was repaired by local pedieled dorsal or plamarpedis flapsand the other cases were treated by the nail-flap of second toe.Results All the flaps were survivalTwo patients received the flap thinning procedure in 6 months laterall patients were satisfied with cosmetic and functional outcomeThe appearance and sensory function of donor toe repaired by second toe nail-flap was best among three methods.Conclusion Accord- ing the detect situation of great toesthree kinds of flap were selected for immediate coverage of donor site, which can decrease the complication of donor great toe at the most.

Thumb Reconstruction with a Free Neurovascular Wrap / 대한정형외과학회잡지

On the length, strength, free lateral motion, and perfect mobility of the thumb, depends the power of the human hand. The thumb is called pollex because of its strength and that strength is necessary to the power of the hand being equal to that of all the fingers."So stated Sir Chales Bell in the fourth Bridgewater Treatise, first published in 1833. Morrison and O'Brien advocated reconstruction of the thumb with a free wrap around flap from the big toe to recreate a stable, sensate and functional digit including the nail in 1980. From March, 1982 to July, 1988, Twelve thumb reconstructions were performed using the wrap around procedure at Hanyang University Hospital;12 successful thumb reconstructions were reviewed at an average of 16 months after surgery. There were several complications;these included skin necrosis(4), malunion(1), resorption of the bone graft(7). We considered that cosmesis and function were good;pinch grip averaged 68% of normal, sensibility returned in all patients as assessed by two-point discrimination(average 9.5mm). Over all the results are as follows. 1. The wrap around technic provides a good method of reconstruction. 2. The wrap around technic is one stage operation and can be used in the level of metacarpal amputation. 3. The surgeon should be familiar with microsurgical technic.

Avulsed Index Finger Reconstruction with a Free Neurovascular Flap from the Big Toe / 대한정형외과학회잡지

Degloving injuries of the fingers result in avulsion of skin and subcutaneous tissue from the underlying deep fascia, the arterial supply is embarrassed and necrosis may result. Theoretically primary microvascular replantation may be a complete solution, however, the prognosis in terms of both immediate and long term function following avulsed digits is poor. The ideal reconstruction aims at retension of mobility and restoration of a skin cover that is adherent, has a sensibility approaching the norm, and is free from pain. A method of finger reconstruction for an avulsion injury using a free neurovascular wrap-around flap from the big toe may be a choice of treatment for both esthetic and functional aspects.

Thumb Reconstruction with a Free Neurovascular Wrap / 대한정형외과학회잡지

This article introduces a new method of thumb reconstruction with the use of an iliac bone graft and a free neurovascular wrap-around flap from the big toe, previously reported by Morrison et al. in 1980. Using this method it is possible to reconstruct a thumb similar to the missing part without total sacrifice of the toe. There is no mobile portion in the reconstructed thumb and motion is provided only by intact joint of traumatized thumb. In thumb reconstruction, it is possible to preserve the nail and its pulp, thus preventing swivelling of the nail and loss of pulp sensation as well as ensuring continued nail growth. This is achieved by free tissue transfer from the 1st web space of the foot, innervated by the deep peroneal nerve and supplied by the dorsalis pedis artery with relatively large diameter. Three cases of thumb reconstruction were performed with this method. Follow up was done for an average of 11.3 months; the rate of viability was 100% with excellent appearance; the 2-point discrimination averaged 8.3 mm.