The medial plantar artery flap: a series of cases over 14 years.

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity.

The posterior tibial island flap for coverage in complex injuries of the lower extremity.

The lower third of the leg poses a surgical challenge in patients with complex injuries requiring reconstruction of soft tissue defects. The posterior tibial island fasciocutaneous flap is recognized as a suitable option for coverage of these defects, and provides a versatile solution for a complex problem. A retrospective audit was conducted at our institution from 1996 to 2008 including all patients who underwent this procedure. Patient's demographics, clinical features, outcome, and complications were noted. The study population was 24 patients (23 males, one female) with age ranging from 11 to 60 years. Mechanism of injury was road traffic accident in 20 patients and firearm injury in 4. The defect was located in the lower half of the leg in all cases. Tibial fracture was present in 15 patients, treated by external fixation in 13 and internal fixation in two patients. Fasciocutaneous flap from the medial aspect of leg was raised based on a perforator of the posterior tibial artery and rotated distally. Average length of the flaps was 12.3 cm. Patients were followed for an average of 11 months (minimum 3 months). Clinical outcome was graded as good in 19 patients, fair in four patients, and poor in one patient. Posterior tibial island flap appears to be a safe and reliable option for coverage of complex wounds in lower third of the leg.

Hand involvement in Navajo neurohepatopathy: a case report.

We report a case of Navajo neurohepatopathy with severe involvement of the hands. It is a progressive sensorimotor neuropathy with distal weakness, areflexia, and reduced sensation in the extremities associated with acral mutilation. The role of possible surgical intervention is demonstrated in this case.

One-stage osteoplastic reconstruction of the thumb.

One-stage osteoplastic reconstruction of the thumb is based on a reverse-flow forearm osteocutaneous flap. It is indicated in traumatic loss of the thumb at or around metacarpophalangeal joint level in situations where replacement with a toe is not feasible or patient desires against such a transfer. It is relatively an easier method of thumb reconstruction and does not require microsurgical expertise. Donor-site morbidity is small. Complications include delayed wound healing at donor site, radius fracture, and venous congestion. This technique is a useful reconstruction option for traumatic loss at the middle-third level of the thumb.

The distally based sural artery flap for ankle and foot coverage.

The sural artery flap is a distally based fasciocutaneous flap that has many advantages to offer for coverage in the foot and ankle area. It has the largest arc of rotation of all the regional flaps and does not require sacrifice of any major artery, and moderate-to-large-sized defects can be covered adequately. The dissection technique is simple, and donor site morbidity is minimal. We report our experience with 17 cases. Age range was from 13 to 56 years. Ten (59%) defects were posttraumatic, 3 (17%) were related to reconstructive surgery of the foot or tendon Achilles', 2 (11%) resulted from tumor resection, and 1 each were from infection and gunshot wound. The smallest flap was 6 x 4 cm and the largest was 15 x 12 cm, with the average size being 11 x 7.5 cm. In 5 cases, the donor site was closed primarily, and in other cases, split-thickness skin graft was needed. The short saphenous vein was included in the pedicle in all cases. There was no incidence of complete flap necrosis. Follow-up ranged from 3 to 30 months. Two cases (12%) developed partial superficial necrosis. In 1 case, there was partial wound dehiscence that needed debridement and repair. Another case had postoperative discharge, which subsided after removal of the calcaneal plate. None of the patients complained of any functional problem related to loss of sensation along the lateral border of the foot. The sural island flap is a reliable, safe, and easy method of providing soft tissue coverage in the area of the foot and ankle.

Reverse-flow posterior interosseous flap-a review of 68 cases.

We are reporting our 10-year experience with 68 patients. Sixty-six flaps were of fasciocutaneous type and two were of osteofasciocutaneous type. These flaps were used for volar and dorsal traumatic hand defects, first web space reconstruction, thumb reconstruction, and repair of congenital anomalies. Sixty flaps (88.24%) had complete uneventful take-up. Four flaps developed partial necrosis, whereas four flaps suffered complete necrosis. The single most important factor for flap survival in our experience has been inclusion of at least two perforators to supply the skin pedal. The proximal flap dissection has a learning curve and all of our poor results were in the early part of our experience. We believe that posterior interosseous fasciocutaneous flap (PIF) is a versatile and reliable option for the challenging problems of hand soft-tissue coverage.

Biomechanic comparison of 3 tendon transfers for supination of the forearm.

PURPOSE: Flexion-pronation of the hand and the forearm is a common deformity when the upper extremity is affected by cerebral palsy. Solutions used to improve the pronation deformity and increase supination include transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis, pronator teres rerouting, and brachioradialis rerouting. The purpose of this study was to compare the biomechanic efficacy of these 3 tendon transfers in simulated supination in cadaveric forearms. METHODS: Ten fresh-frozen adult cadaveric above-elbow upper extremities were used. In each specimen the 3 tendon transfers were performed sequentially in random order and were loaded in increments of 4 N (1 lb) to a maximum of 36 N (8 lb). Measurements were recorded from the starting point of 90 degrees of pronation. Statistical analysis of the data included the Student t test with the Bonferoni correction. RESULTS: For all transfers, supination increased in a nonlinear manner as the load was increased in a nonlinear manner. For the flexor carpi ulnaris transfer, the forearm reached its neutral position at a load of 9 N (2 lb). The forearm continued to rotate to up to 84 degrees of supination with 36 N (8 lb) of load. With the brachioradialis transfer, the forearm reached its neutral position at 13 N (3 lb) of load and continued to rotate to up to 33 degrees of supination with 36 N of load. With the pronator teres transfer, the forearm never reached the neutral position. Under a maximum load of 36 N, only 55 degrees of rotation from full pronation was obtained. CONCLUSIONS: Transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis proved to be the most effective transfer for producing supination in cadavers. The brachioradialis transfer was second best. The pronator teres rerouting was the least effective transfer in effecting simulated supination in this experiment.

Measurement of rotation of the first metacarpal during opposition using computed tomography.

PURPOSE: Opposition is an important movement of the hand and rotation of the first metacarpal is the essential component. There is no agreement on the exact magnitude of rotation of the first metacarpal during opposition. This study used computed tomography to describe rotation measurement of the first metacarpal in the hands of a group of healthy individuals. METHODS: The rotation of the first metacarpal was measured with reference to the fixed unit of the hand. Computed tomographic images were taken of the hands of 10 healthy individuals with the thumb in retroposition, resting position, and opposition to the index, middle, ring, and small fingers. On each image a tangential line was drawn along the dorsal margin of the second and third metacarpals. A second line was drawn through the head of the first metacarpal at the level of the sesamoids. The angle between the 2 lines was measured as the angle of rotation of the first metacarpal in different thumb positions. RESULTS: The mean angle of rotation of the first metacarpal in retroposition was 54 degrees+/-10 degrees with reference to the fixed unit of the hand. In the resting position the angle of rotation of the first metacarpal changed to 74 degrees+/-10 degrees. In the position of opposition to the index, middle, ring, and small fingers the angle of rotation of the first metacarpal increased to 100 degrees+/-7 degrees , 103 degrees+/-6 degrees, 105 degrees+/-6 degrees, and 110 degrees+/-7 degrees, respectively. CONCLUSIONS: The first metacarpal rotates 56 degrees when it moves from retroposition to the position of opposition to the small finger.