Which instrument should we use to assess hand function after digital replantation?

The functional recovery of a replanted body part is as important as its viability. We compared four instruments frequently used for the evaluation of hand function after digital replantation. The functional results of 17 patients at least one year after replantation of a total digital amputation between 2004 and 2007 were evaluated according to the Tamai, Ipsen, Chen and Disabilities of the Arm, Shoulder and Hand questionnaires. Scores of each patient for each test were calculated and intra-individual comparisons were made. Correlation was significant at the 0.05 level (two tailed) for all tests. A high correlation (>0.71) was found between the Ipsen, Tamai and DASH tests. The Chen test had a moderate correlation with the other tests. We determined that Ipsen, Tamai and DASH tests have similar effectiveness in assessing hand function after replantation.

Evaluation of an educational programme in Ege University, Turkey: medical student's home visits with midwife preceptors.

OBJECTIVE: to evaluate the efficiency of the midwife preceptors in teaching comprehensive health care for women and their families through exploring how they perceive their roles as educators and from the perspectives of medical students; to assess the number of educational goals achieved. DESIGN: for midwives, a quantitative method was used for pre- and post-evaluation of a 'Medical Students' Home Visits with Midwife Preceptors' course. Focus-group interviews were used to gather qualitative data. Students were evaluated after undertaking home visits with the midwives. SETTING: urban health centres in Western Turkey and Ege University Faculty of Medicine. PARTICIPANTS: a sample of four clusters of second year medical students (130 out of 284) and all midwives (n=32) linked with the health centres participated in the programme. FINDINGS: in general, both the midwives and the medical students found the programme useful. Students declared that they achieved their learning objectives and midwives stated that they had contributed to this achievement. Scores of eight of the 20 learning objectives significantly increased in the midwives' post-test evaluation. Midwives and students valued the effective communication they had with each other. All midwives participated in focus-group interviews, and reported that the course before the home visits was useful to them. Nearly all of the midwives suggested that the home visits course should be longer, repeated, or both. It was difficult to organise home visits for all of the medical students, and access to some households to enable students to gain training experience was refused. CONCLUSIONS: this programme encouraged the medical students to adopt broad public health approaches in assessing the health needs of defined communities. It also increased their awareness of the importance of multi-professional teamwork and comprehensive health care for women and their families. At the same time, the programme improved the professional knowledge of midwives, and they were able to appreciate their roles and functions in primary health care, and enhance their self-esteem. The findings also indicated that this programme is an effective way of promoting multi-professional education in medical schools.

Primary one-stage reconstruction of cheek defect after a shotgun blast to the face: use of the latissimus dorsi musculocutaneous free flap for soft-tissue repair and facial reanimation.

The authors describe a case of a shotgun blast injury to the face in which early definitive repair of both facial soft tissues and facial reanimation was accomplished in one stage using a free flap. The trauma occurred 2 days before presentation via a hunting rifle fired at a short range. On examination, a 8 x 5-cm cheek defect was evident, involving the full thickness of the perioral facial mimetic muscles as well. A free latissimus dorsi musculocutaneous flap was transferred to the defect, with the thoracodorsal nerve coapted to an ipsilateral, severed buccal branch of the facial nerve. Postoperatively, the flap survived completely, with its skin paddle excised subsequently in two stages. Good muscle movement was obtained, providing resting symmetry and a pleasant smile. Other than soft-tissue and bony defects resulting from shotgun injuries, ablation of the facial nerve or facial mimetic muscles may be an important component of the defect that needs further consideration. The authors conclude that the current technique of one-stage, early definitive repair of soft tissues and facial reanimation in such cases of facial shotgun blast injury offers the advantages of achieving both goals with one flap and accomplishing the procedure primarily in one stage.

Cephalic vein-pedicled arterialized anteromedial arm venous flap for head and neck reconstruction.

The authors describe a case of transfer of an arterialized cephalic venous flap from the anteromedial arm region to the neck with the cranial limb of the cephalic vein serving as the drainage vein and a pedicle. The burn scar contracture of a 45-year-old man was released and repaired with a venous flap based on the cephalic vein in the anteromedial arm. After dissection of the cranial end of the cephalic vein as a drainage vein in the deltopectoral groove, until the flap could be transposed easily to the neck defect pedicled on the dissected cranial limb of the cephalic vein, the flap was arterialized by anastomosing the caudal end of the cephalic vein to a recipient artery in the neck The donor defect was skin grafted and the flap survived completely. The neck contracture improved substantially.

Coverage of a thumb wound and correction of a first web space contracture using a longitudinally split reverse radial forearm flap.

The authors describe a new design for a reverse-flow radial forearm flap. A total thumb amputation by severe avulsion was salvaged by microsurgical replantation and a reverse-flow radial forearm flap with a modified design to allow repair of two separate hand defects concomitantly. This newly described flap design for the reverse radial forearm flap offers a refined technique for simultaneous reconstruction of multiple defects in the hand.

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site.

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.

A new flap model in rats: iliac osteomusculocutaneous flap.

Although osteomusculocutaneous flaps are used frequently in clinical practice to repair defects involving soft tissue and bone, there are still many questions that remain to be answered regarding their basic physiology. To accomplish such basic science studies, simple and reliable animal osteomusculocutaneous flap models are needed. The purpose of this study was to describe a new flap model in rats--namely, the iliac osteomusculocutaneous flap. Thirty adult Wistar rats weighing 200 to 250 g were used in this experiment. In 15 rats, the vascular anatomy of the iliolumbar vessels and their relation with adjacent soft tissues and the iliac bone was determined by anatomic dissection. Based on this anatomic study, the iliac osteomusculocutaneous flap model was created in rats. The flap is comprised of a skin island (3 x 3 cm) in the flank region, a 1 x 1-cm segment of iliac bone, and an abdominal wall muscle cuff. In 10 rats, the flap was raised as an island flap based on its vascular pedicle of iliolumbar vessels, and was replaced in situ. In the remaining 5 rats, the flap was transferred to the groin region as a free flap. Direct observation on postoperative day 7 revealed that the skin island of all the flaps was completely viable. Bone scintigraphy performed on postoperative day 3 in free flaps demonstrated radionuclide uptake, indicating viability of the bony segment. The dye injection study revealed ink staining within blood vessels of the bone, confirming its viability. Microangiography of the flap demonstrated vascularity of each component of the flap by the iliolumbar vessels, including a distinct branch to the iliac bone. The authors conclude that the iliac osteomusculocutaneous flap of the rat is a simple and reliable flap model that offers the following advantages: (1) It is a true osteomusculocutaneous flap, (2) it can be used as a free flap without the need for an isogeneic rat, (3) the vascular pedicle is consistent, and (4) it is harvested from a small-animal species.

Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis.

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days.

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.

A rat musculocutaneous flap model: the biceps femoris musculocutaneous flap.

The purpose of this study was to describe a new musculocutaneous flap model in the rat. A total of 25 Wistar rats weighing 200 to 280 g were used in this experiment. In 15 rats, the vascular anatomy of the biceps femoris muscle and the cutaneous blood supply of its overlying posterior thigh skin were studied by anatomic dissection, dye injection, and microangiography using 5 rats in each group. The anatomic studies revealed that the main axial vessel supplying the biceps femoris muscle was the caudal femoral branch of the popliteal vessels. The posterior thigh skin overlying the biceps femoris muscle received a consistent musculocutaneous perforator at the center of the mid-posterior line of the posterior thigh. Based on the caudal femoral-popliteal vascular pedicle, the biceps femoris musculocutaneous flap was created in the rat, comprised of the whole muscle and its overlying posterior thigh skin. The skin paddle was designed as an ellipse with its longitudinal axis paralleling that of the extremity, generally measuring 4 x 2 cm. Island flaps were raised as described and replaced either in situ (N = 5) or transposed to a sacral defect (N = 5). Results showed that the cutaneous islands of all the flaps survived completely. Tetrazolium blue stain used to indicate muscle survival revealed that the average muscle viability was 86.7+/-3.4%. The authors conclude that the biceps femoris musculocutaneous flap is a reliable and true musculocutaneous flap model for future biological and pharmacological studies. It offers the following advantages: It has a consistent vascular pedicle and a musculocutaneous perforator, it supports a relatively large skin island, and there is no risk of autocannibalization of the flap because the flap is located dorsally.

Free transfer of the radial forearm flap with preservation of the radial artery.

One of the main disadvantages of the radial forearm flap is the sacrifice of a major artery. To overcome this drawback the authors describe a technique of free transfer of the flap with preservation of the radial artery. The flap is elevated as a distal row perforator-based fasciocutaneous flap with a very short segment of the radial artery included in the inverted-T-shaped arterial pedicle. The venous outflow of the flap is provided by the cephalic vein, with accompanying veins of the radial artery left behind. Although the donor radial artery is repaired primarily, the flap is transferred to reconstruct a soft-tissue defect resulting from the release of a neck contracture after radiotherapy in a 42-year-old patient who had previous excision of a mandibular osteosarcoma. The arterial anastomosis was performed end to end between the superior thyroid artery and one limb of the arterial pedicle, with the other limb ligated. The venous anastomosis was performed end to end between the cephalic vein and the external jugular vein. The flap survived completely and a satisfactory result was obtained. The radial artery is demonstrated to be patent long after surgery, both with Allen's test and with a Doppler examination. Considering the possible sequelae of the sacrifice of the radial artery, this technique is obviously advantageous to such patients, even with a nonsatisfactory preoperative Allen's test. This perforator-based radial forearm flap is very easy to raise and to transfer, with anastomoses of large-diameter vessels.

End-to-side microvascular anastomosis using an external metal ring.

Enthusiasm for developing safer and faster anastomotic techniques and complementary devices continues. We report on a new microvascular end-to-side anastomosis technique using a silver ring around the anastomotic circumference. The purpose of this study was to compare the effectiveness of this technique with conventional end-to-side vessel anastomosis. Forty Sprague-Dawley rats were divided into two groups. Twenty rats were used to assess the external ring method in end-to-side anastomosis between carotid arteries and anterior jugular veins and the remaining 20 formed the control group with conventional end-to-end anastomosis. The anastomosis time was 26.4 min for standard suture anastomosis and 18.4 min for the external ring technique (P< 0.01). Patency was 95% with standard technique and 100% using the external ring (P> 0.05). The external ring technique of end-to-side microvascular anastomosis is a safe and reliable method and may reduce the operation time. Its clinical applicability should be further evaluated.

Osteocutaneous flap prefabrication based on the principle of vascular induction: an experimental and clinical study.

Conventional osteomyocutaneous flaps do not always meet the requirements of a composite defect. A prefabricated composite flap may then be indicated to custom create the flap as dictated by the complex geometry of the defect. The usual method to prefabricate an osteocutaneous flap is to harvest a nonvascularized bone graft and place it into a vascular territory of a soft tissue, such as skin, muscle, or omentum, before its transfer. The basic problem with this method is that the bone graft repair is dependent on the vascular carrier; the bone needs to be revascularized and regenerate. The bone graft may not be adequately perfused at all, even long after the transfer of the prefabricated flap. This study was designed to prefabricate an osteocutaneous flap where simply the bone nourishes the soft tissues, in contrast to the conventional technique in which the soft tissue supplies a bone graft. This technique is based on the principle of vascular induction, where a pedicled bone flap acts as the vascular carrier to neovascularize a skin segment before its transfer. Using a total of 40 New Zealand White rabbits, two groups were constructed as the experimental and control groups. In the experimental group, a pedicled scapular bone flap was induced to neovascularize the dorsal trunk skin by anchoring the bone flap to the partially elevated skin flap with sutures in the first stage. After a period of 4 weeks, the prefabricated composite flaps (n = 25) were harvested as island flaps pedicled on the axillary vessels. In the control group, nonvascularized scapular bone graft was implanted under the dorsal trunk skin with sutures; after 4 weeks, island composite flaps (n = 15) were harvested pedicled on the cutaneous branch of the thoracodorsal vessels. In both groups, viability of the bony and cutaneous components was evaluated by means of direct observation, bone scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results demonstrated that by direct observation on day 7, the skin island of all of the flaps in the experimental group was totally viable, like the standard axial-pattern flap in the control group. Bone scintigraphy revealed a normal to increased pattern of radionuclide uptake in the experimental group, whereas the bone graft in the control group showed a decreased to normal pattern of radioactivity uptake. The biodistribution studies revealed that the mean radionuclide uptake (percent injected dose of 99mTc methylene diphosphonate/gram tissue) was greater for the experimental group (0.49+/-0.17) than for the control group (0.29+/-0.15). The difference was statistically significant (p<0.01). By microangiography, the cutaneous component of the prefabricated flap of the experimental group was observed to be diffusely neovascularized. Histology demonstrated that although the bone was highly vascular and cellular in the experimental group, examination of the bone grafts in the control group revealed necrotic marrow, empty lacunae, and necrotic cellular debris. Circulation to the bone in the experimental group was also demonstrated by India ink injection studies, which revealed staining within the blood vessels in the bone marrow. Based on this experimental study, a clinical technique was developed in which a pedicled split-inner cortex iliac crest bone flap is elevated and implanted under the medial groin skin in the first stage. After a neovascularization period of 4 weeks, prefabricated composite flap is harvested based on the deep circumflex iliac vessels and transferred to the defect. Using this clinical technique, two cases are presented in which the composite bone and soft-tissue defects were reconstructed with the prefabricated iliac osteomyocutaneous flap. This technique offers the following advantages over the traditional method of osteocutaneous flap prefabrication. Rich vascularity of the bony component of the flap is preserved following transfer (i.e. (ABSTRACT

Lymphatic malformation causing intractable chylorrhagia.

Lymphatic malformation is a developmental error usually noticed at birth or in early childhood. Lesions of the upper leg and lower trunk are the most difficult to remove, because they are often the largest ones encountered and also because they tend to extend proximally into the retroperitoneal tissues. Chyle reflux, usually associated with lymphedema of the extremity, has not been reported to be caused by lymphatic malformation. We report a case of intrapelvic retroperitoneal lymphatic malformation with an extension of gluteal-thigh soft-tissue involvement causing intractable chylorrhagia. The tumor was subtotally excised, and the defect was closed by a distally based, peninsular latissimus dorsi myocutaneous flap. The flap served both as a filling material and as a "bridge" between the residual tumor, including abnormal lymphatics, and normal lymph flow.

Perioperative dilation for vessel-size discrepancy using a percutaneous transluminal angioplasty catheter.

The problem of vessel-size discrepancy is still unsolved in microvascular-free tissue transfers. In an effort to develop a technique perioperatively to dilate smaller vessel diameters, the authors utilized a catheter customarily used in coronary angioplasties, the percutaneous transluminal coronary angioplasty (PTCA) catheter. Twenty New Zealand rabbits were divided into two groups: Group 1 consisted of 14 experimental animals; Group 2 of six control animals. In both groups, a segmental defect of 2 cm was created in the proximal portion of the femoral artery just below the inguinal ligament, where the vessel diameter is 2.0+/-0.1 mm. In Group 1 animals, an arterial graft was harvested from the superficial femoral artery in the contralateral lower extremity, where the vessel diameter is 1.0+/-0.1 mm. The arterial graft along its entire length was dilated, using a PTCA catheter up to 2 mm in diameter. The duration of dilation was 3 min with pressure applied at 2.5 atm. Before and following dilation, sections were obtained from both ends of the graft for histologic comparison. The grafts were then interposed within the defect and microvascular anastomoses were performed. In the control group, an arterial graft of the same length as in the experimental group was harvested from the contralateral upper femoral region, where the vessel diameter is 2.0+/-0.1 mm. These grafts were then interposed within the defect and microsurgically anastomosed. Seven days later, the patency of the anastomoses was evaluated in both groups. In 13 of 14 rabbits in the experimental group, the anastomoses were patent and the arterial grafts maintained their dilated diameters (2 mm). In all six control animals, the anastomoses were patent. A statistical comparison of vessel patency using Fischer's exact chi-square test showed no significant differences between the experimental and control groups (p = 0.7). Histologically, the dilated arteries demonstrated intact endothelial layers.