【Abstract】 Objective To report cl inical experience in the use of temporary intravascular shunts (TIVS) for quickrestoration of perfusion to the extremity with major vascular injury. Methods Between August 2009 and March 2011, TIVSwas applied temporarily to restore blood perfusion to the extremity in 6 patients with major extremity vascular structure injury secondary to trauma (4 patients) or tumor resection (2 patients), who would received vascular transplantation and underwent long ischemia. The patterns of vascular shunts included external carotid artery-subclavian artery, axillary artery-axillary artery, axillary vein-subclavian vein, brachial artery-brachial artery, brachial vein-brachial vein, brachial artery-radial artery, femoral artery-popliteal artery, and popliteal artery-posterior tibial artery. After TIVS, extensive debridement, fracture fixation, or tumor excision was performed. Then the shunted tubes were removed, and the vessels were repaired definitly. Six vessels were repaired by transplanting the great saphenous veins; one vessel was anastomosed directly without tension; and one vessel was repaired by artificial vascular graft. Results All shunted tubes were successfully established within 5 to 10 minutes (mean, 8.2 minutes). The duration of bypass ranged from 67 to 210 minutes. After establishment of TIVS, blood perfusion to the affected limb was improved. When shunted tubes were removed, thrombosis and partial obstruction occurred in one who accepted amputation, and the others kept patency. No loosening of tubes and haemorrhage occurred. At 2-15 months of follow-up, affected limbs had good blood supply. Conclusion TIVS is rapid and simple, which can quickly restore blood perfusion to the extremity with major vascular injury and shorten the ischemic time of the affected extremity.
ObjectiveTo investigate the effectiveness of delayed replantation of degloving skin preserved at 4℃ in treatment of limb degloving injuries. Methods Between October 2020 and October 2023, 12 patients with limb degloving injuries were admitted. All patients had severe associated injuries or poor wound conditions that prevented primary replantation. There were 7 males and 5 females; age ranged from 29 to 46 years, with an average of 39.2 years. The causes of injury included machine entanglement in 6 cases, traffic accidents in 5 cases, and sharp instrument cuts in 1 case. Time from injury to hospital admission was 0.5-3.0 hours, with an average of 1.3 hours. Injury sites included upper limbs in 7 cases and lower limbs in 5 cases. The range of degloving skin was from 5 cm×4 cm to 15 cm×8 cm, and all degloving skins were intact. The degloving skin was preserved at 4℃. After the patient’s vital signs became stable and the wound conditions improved, it was trimmed into medium-thickness skin grafts for replantation. The degloving skin was preserved for 3 to 7 days. At 4 weeks after replantation, the viability of the degloving skin grafts was assessed, including color, elasticity, and sensation of pain. The Vancouver Scar Scale (VSS) was used to assess the scars of the skin grafts during follow-up. Results At 4 weeks after replantation, 8 cases of skin grafts completely survived and the color was similar with normal skin, with a survival rate of 66.67%. The elasticity of skin grafts (R0 value) ranged from 0.09 to 0.85, with an average of 0.55; moderate pain was reported in 4 cases, mild pain in 3 cases, and no pain in 5 cases. All patients were followed up 12 months. Over time, the VSS scores of all 12 patients gradually decreased, with a range of 4-11 at 12 months (mean, 6.8). Conclusion For limb degloving injuries that cannot be replanted immediately and do not have the conditions for deep low-temperature freezing preservation, the method of preserving the degloving skin at 4℃ for delayed replantation can be chosen.
ObjectiveTo explore the effectiveness of free lobed perforator flaps in repairing of complex wounds of limbs. Methods Between January 2018 and January 2021, 10 patients with complex wounds of limbs were admitted. There were 7 males and 3 females, aged from 32 to 64 years, with an average age of 45 years. There were 4 cases of traffic accident injuries, 3 cases of machine strangulation injuries, 1 case of machine crush injury, and 2 cases of heavy object crush injuries. There were 5 cases of upper limb wounds and 5 cases of lower limb wounds. The size of wounds ranged from 11 cm×10 cm to 25 cm×18 cm. The wounds were repaired with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery in 7 cases, four-lobed flaps in 2 cases, and with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery combined with oblique branch in 1 case. The size of flaps ranged from 12.0 cm×10.5 cm to 28.0 cm×12.0 cm. The donor sites were sutured directly in 9 cases and repaired with superficial iliac circumflex artery perforator flap in 1 case. ResultsSinus formed at the edge of the flap in 1 patient, which healed after dressing change and drainage; other flaps survived well, and the wounds healed by first intention. The skin flap at donor site survived, and the incisions healed by first intention. All patients were followed up 6-24 months (mean, 11 months). All flaps had good appearance and function, and linear scars were left at the donor site without obvious complications. ConclusionFree lobed perforator flap is an alternative method to repair complex wounds of limbs with high safety, good effectiveness, and less complications.
OBJECTIVE: To summarize the application of simple skin traction technique in repair of soft tissue defect of limb. METHODS: From 1999, 42 cases of soft tissue defect of limbs were repaired by simple skin traction technique instantly; the defect area ranged from 2.5 cm x 2.0 cm to 8.0 cm x 6.5 cm. RESULTS: The soft tissue defect less than 8.0 cm can be sutured instantly. All of the wound achieved primary healing without infection and necrosis of skin edge, the circulation and sensation of limbs were normal; healing time was 10 days to 16 days, 12.8 days on average. Thirty-two cases were followed up for 6 months; the shape and function recovered well. CONCLUSION: Simple skin traction technique is a good option to repair the soft tissue defect of limbs.
OBJECTIVE: To summarize the importance of surgical management to repair vascular injury in limbs salvage, and to analyze the influence factors in the management. METHODS: From 1993 to 2000, 42 cases of 58 vascular injuries were reviewed; there were 37 males and 5 females, aging from 12 to 70 years old. Emergency operations were performed in 38 cases and selective operations in 4 cases from 1 hour to 45 days after injury. There were 22 cases of complete rupture in 32 blood vessels, 5 cases of partial rupture in 6 blood vessels, and 15 cases of vascular defect in 20 blood vessels, with 5 cm to 10 cm defect. The operation management included end-to-end anastomosis in 22 cases, side-to-end anastomosis in 1 case, vascular repair in 5 cases and vascular grafting in 14 cases. All of the cases were followed up for 6 months to 7 years. RESULTS: In those received emergency operations, it was successful in 35 cases, with amputation in the other 3 cases; after operation, there were 5 cases of post-operative angio-crisis, 1 case of hematoma and 1 case of pseudoaneurysm. In those received selective operation, all succeeded but 1 case of post-operative angio-crisis. After the follow-up, except for 3 cases of amputation, the other limbs survived; and function of the survived limbs recovered satisfactorily after operation except poor recovery in 7 cases of replantation of the limbs. CONCLUSION: To repair vascular injury immediately, to manage angio-crisis and to remove influence factors is the key to save the injured limbs and to maintain the function of them.
Objective To evaluate the effectiveness of anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap for repairing extremities soft tissue defect. Methods Between January 2014 and January 2017, 24 patients with extremities soft tissue defects were treated by anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. There were 15 males and 9 females, with a median age of 33.5 years (range, 5-64 years). Wounds located in upper limb in 8 cases, complicated with radial styloid fracture in 1 case, extensor tendon exposure in 3 cases, and brachioradialis muscle tendon exposed in 1 case. Wounds located in lower extremity in 16 cases, complicated with calcaneal or metatarsal, phalangeal fractures in 4 cases, Achilles tendon departure in 1 case, toe long extensor tendon and flexor digitorum longus tendon exposed in 8 cases. The wound area ranged from 8 cm×5 cm to 18 cm×12 cm. According to wound size, anterolateral thigh perforators were detected by conventional ultrasound Doppler (2-5 perforators). The irregular wounds were decomposed into multiple parts and the leaf number (2-4 leaves) of polyfoliate flap depended on the part number of the wound. The flap area ranged from 9 cm×6 cm to 20 cm×14 cm, and the largest area of single leaf was 24 cm×6 cm. The vascular pedicle length ranged from 7 cm to 12 cm. The foliate flap area with protecting pedicle ranged from 5 cm×3 cm to 7 cm×5 cm. Results All the flaps survived, and no vascular crisis occurred. All the patients were followed up 2-28 months (mean, 9 months). Sinus occurred in 1 case of calcaneal fracture after flap repair, and the sinus was healed after 3 months by conventional dressing. All the flaps were thin and had a good texture. Healing of soft tissue was found in 5 patients with fracture. The wrist and ankle plantar flexion and dorsiflexion function of recipient site were normal in all patients. Conclusion It is safe and reliable to repair the extremities soft tissue defect with anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. And it is one of the ways to reduce the vascular crisis of the anterolateral thigh free perforator flap.