Different surgical procedures for reconstruction of soft-tissue defects around the ankle.

INTRODUCTION: Management of soft tissue defects around the ankle is a difficult and challenging situation for all reconstructive surgeons. A microsurgical free flaps coverage can solve this problematic situation especially with large defects that is not available in all trauma centers. Moreover, long operating time and suitable operative demands are considered obstacles. MATERIALS AND METHOD: Eighty five patients having soft tissue defects around ankle were included in this study. They underwent various reconstructions in our specialized hand and reconstructive microsurgery unit from 2015 to 2019. Fifty two were males and thirty three patients were females. Road traffic accident was the main cause of injury in 66 patients followed by implant exposure in 15 patients and chronic osteomyelitis in 4 patients. Distally based superficial sural artery flap was used to reconstruct the defects in 21 cases, free flap was used in 32 cases, Rotational local flap was used in 8 cases, contralateral distally based superficial sural artery flap was used in 2 cases, full or partial skin flaps were used in 10 cases and Propeller flap was used in 12cases. RESULTS: All flaps survived except for one modified sural flap with 98% success rate and average follow up of 48 months. All patients were satisfied with the functional capacity of operated limbs. Average time of bone healing postoperative was 3 months with gradual return to original work with acceptable degrees for cosmotic appearance of the limbs. CONCLUSION: Many treatment options are available to cover defects around the ankle. Propeller and rotational flaps are fast and easy but cover small defects, distally-based modified sural artery flap is an excellent reliable flap. Microsurgical free flaps provide good contour, color, texture and cover large defects but require microsurgery facilities to execute.

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects.

OBJECTIVE: Management of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. PATIENTS AND METHODS: Thirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6-33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. RESULTS: All the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. CONCLUSION: Skin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft.

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.

Anterior shoulder release and tendon transfer as 1-stage procedure for treatment of internal rotation contracture deformity in obstetric brachial plexus injuries.

PURPOSE: Children who had internal rotation contracture deformities of the shoulder secondary to obstetric brachial plexus palsy were studied. The outcomes of anterior shoulder release and tendon transfer in 1-stage procedure were analyzed. METHODS: Anterior shoulder release and tendon transfer in 2 separate incisions as 1 procedure were performed in 76 patients for improvement of shoulder function. Anterior shoulder release was performed through the deltopectoral incision, starting with the coracoid process that extended 5 cm caudally. Osteotomy of the coracoid process subperiosteally with retaining the pectoralis minor attached to the periosteum. Z-plasty of the subscapularis and resuturing of the pectoralis minor short head of biceps and coracobrachialis to their original position were performed in all cases. A separate second incision in the posterior axillary fold was carried out to perform rerouting of the latissimus dorsi and teres major tendons with a mean follow-up of 5.6 years (range, 1-7 years). RESULTS: The average active external rotation with the arm at the side increased from -26 + 15 degrees preoperatively to 67 + 17 degrees postoperatively (average gain, 85 degrees). The average shoulder abduction increased from 46 + 22 degrees preoperatively to 130 + 32 degrees postoperatively (average gain, 75 degrees). Mallet score improved from 12.3 to 22.6. CONCLUSIONS: Anterior shoulder release combined with latissimus dorsi and teres major rerouting significantly improved global shoulder function.

Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique.

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

Functional outcomes of nonunion scaphoid fracture treated by pronator quadratus pedicled bone graft.

Between 1998 and 2007, a pronator quadratus pedicled bone graft was performed for 45 patients of ununited scaphoid fracture. One of them had bilateral ununited scaphoid fracture. There were 29 men and 16 women with a median age at operation of 24 (16-32) years. The affected side was the right side (dominant hand) in 32 patients whereas 13 patients had fracture of the nondominant left side. There had been 32 proximal pseudoarthrosis (through or proximal to the junction of the proximal and middle thirds of the bone) and 14 of the middle third of the scaphoid. The original fractures were caused by motor cycle accidents in 23 patients, falling on outstretched hand in 15 patients, and sport injuries in the remaining 7 patients. Surgery was indicated from 5 months to 6 years after injury (average 43 months) because of complaints of pain on heavy work. The fracture has been missed at the initial examination in 23 patients whereas cast immobilization was done for 6 weeks and 3 months in 15 and 7 cases, respectively, that had failed to result in union. There were no preoperative osteoarthritic changes, but in 25 cases, there were avascular necrosis of the proximal fragment of the scaphoid. Forty-three patients showed radiographic union after an average of 14 weeks (12-16 weeks). One patient had dislodgement of the graft and refused to do it again. The average range of movement of wrist improved after operation. Taken as a percentage of the normal range, dorsiflexion increased from 69% to 80%, palmar flexion from 66% to 76%, radial deviation from 45% to 70%, and ulnar deviation from 67% to 84%. Grip strength improved from 82% to 92% of normal. All the patients have been able to return to their former activities with no pain.

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results.

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle

Repeated upper limb salvage in a case of severe traumatic soft-tissue and brachial artery defect.

We present the case of a 9-year-old male patient who suffered a gunshot injury to the right arm. The patient arrived in shock, his right arm severely traumatized, with soft-tissue loss involving the anterior surface and both sides of the right arm. The humerus was exposed. There was brachial artery defect and damage to the lateral fibers of the median nerve. The mangled extremity severity score (MESS) was 8 points. The patient was treated with general resuscitation, blood transfusion, and debridement. A venous graft, 12 cm in length, to bridge the brachial artery defect, and tendon transfer, triceps to the biceps, was performed in one step. Postoperatively, there was a normal radial pulse, normal skin color, normal temperature, and normal movement of the fingers without pain. Unfortunately, the patient then sustained a second trauma to the right arm 3 weeks later, rupturing the graft. This time he lost 1,500 cc of blood. After another blood transfusion, we performed a second reverse saphenous vein graft. The patient stayed at the hospital for 3 weeks. At follow-up 12 months later, the limb has good function and, except for the presence of a scar and skin graft, is equal in appearance to the left side.