ObjectiveTo explore a new improved technique and its effectiveness to repair dorsal thumb composite tissue defects including interphalangeal joint by transplantation of modified hallux toe-nail composite tissue flap. MethodsThe hallux toe-nail composite tissue flap carrying distal half hallux proximal phalanx, extensor hallucis longus, and interphalangeal joint capsule were designed and applied to repair the dorsal skin, nails, and interphalangeal joint defect of thumb in 14 cases between January 2007 and June 2013. They were all males, aged from 19 to 52 years (mean, 30 years). The time from injury to hospital was 0.5-2.0 hours (mean, 1.2 hours). The area of the thumb nail and dorsal skin defects ranged from 2.5 cm×1.5 cm to 5.0 cm×2.5 cm. The dorsal interphalangeal joint had different degrees of bone defect, with residual bone and joint capsule at the palm side. The length of bone defect ranged from 2.5 to 4.0 cm (mean, 3.4 cm). The hallux nail flap size ranged from 3.0 cm×2.0 cm to 6.0 cm×3.0 cm. The donor sites were repaired by skin grafting in 5 cases, and retrograde second dorsal metatarsal artery island flap in 9 cases. ResultsAfter operation, arterial crisis occurred in 1 case and the flap survived after relieving pressure; the other flaps survived, and wounds healed by first intention. Liquefaction necrosis of the skin grafting at donor site occurred in 3 cases, and the other skin grafting and all retrograde second dorsal metatarsal artery island flaps survived. The follow-up ranged from 9 months to 3 years and 6 months (mean, 23 months). The secondary plastic operation was performed in 4 cases at 6 months after operation because of slightly bulky composite tissue flaps. The other composite tissue flaps had good appearance, color, and texture. The growth of the nail was good in 12 cases, and slightly thickened in 2 cases. At last follow-up, X-ray examination showed that bone graft and proximal phalanx of the thumb had good bone healing in 12 cases. Good bone healing was obtained at the donor site. According to the Hand Surgical Branch of Chinese Medical Association standard for thumb and finger reconstruction function, the results were excellent in 12 cases and good in 2 cases, and the excellent and good rate was 100%. No pain at donor site was observed, with normal gait. ConclusionTransplantation of modified hallux toe-nail composite tissue flap to repair dorsal thumb composite tissue defects including interphalangeal joint can effectively improve the appearance and function of the impaired thumb.
Objectives To investigate the curative effect of skin flap and allogenic tendon in reconstructing l imbs function of complex soft-tissue defect. Methods From May 2001 to December 2007, 43 cases of complex soft-tissue defect of l imbs were repaired by pedicled skin flaps, free skin flaps, cutaneous nerve nutrient vessel skin flaps and arterial island skin flaps for primary stage, then the function of the l imbs were reconstructed with allogeneic tendon after 2-3 months of skin flapoperation. There were 31 males and 12 females, aged 5-53 years(mean 25 years). Injury was caused by machine in 28 cases, by traffic accident in 14 cases and others in 1 case. There were 27 cases in upper l imb, 16 cases in lower l imb. Twenty-six cases compl icated by bone fracture, dislocation and bone defect, the most of bone defect were cortical bone defect. The sizes of skin and parenchyma defect were 9 cm × 4 cm to 37 cm × 11 cm, the length of tendon defect was 6 to 26 cm. The sizes of skin flaps were 10 cm × 5 cm to 39 cm × 12 cm. Allogeneic tendons were used 2-6 strips(mean 4 strips). Results Forty-three cases were followed up for 5-56 months (16 months on average), all flaps survived. The donor area healed by first intention, the incision healed by first intention in second operation, and no tendon rejection occurred. The cl inical heal ing time of fracture was 3-8 months, and the cl inical heal ing time of allograft was 6-8 months. Six cases were given tenolysis for adhesion of tendon after 3-5 months of tendon transplantation. The postoperative flexion of wrist joint was 20-50°, the extension was 20-45°. Articulatio metacarpophalangea and articulatio interphalangeae could extend completely. The flexion of articulatio metacarpophalangea of thumb was 20-45°, the flexion of articulatio interphalangeae was 30-70°. The flexion of articulatio metacarpophalangea and articulatio interphalangeae of the other fingers was 60-90°. The postoperative ankle can extend to neutral position, the neutral position of ankle was 30-50°. The flexion of articulatio metatarsophalangeae and articulatio interdigital was 20-40°. Theextension of articulatio metatarsophalangeae was 30-60°. Conclusion Through designing systematically treatment plan,practicing operation by stages, preventing adhesion of tendon actively and exercising function reasonably, the functions of l imbs reconstructed by allogenic tendon and skin flap can leads to satisfactory effect.
Objective To summarize the method and the cl inical outcome of repairing both toe extensor tendon and dorsal foot wounds with anterolateral thigh flap. Methods Between February 2007 and May 2009, 11 patients with toe extensor tendon and dorsal foot defect were treated with anterolateral thigh flap. There were 8 males and 3 females with a medianage of 45 years (range, 10-60 years). The causes of injury were sharp injury in 3 cases, machine crush injury in 3 cases, and traffic accident injury in 5 cases, including 7 cases of fresh wounds with a disease duration of 2-8 hours and 4 cases of old wounds with a disease duration of 3-15 days. The size of wound ranged from 6 cm × 5 cm to 25 cm × 15 cm. All cases compl icated by toe extensor tendon defect, which were located at the 2nd-5th toes in 1 case, 3rd-5th toes in 1 case, 2nd-4th toes in 2 cases, 2nd and 3rd toes in 3 cases, 1st and 2nd toes in 1 case, and 1st toe in 3 cases. In the first stage, the anterolateral thigh flap ranged from 8 cm × 7 cm to 27 cm × 15 cm was used to repair defect and fascia lata was used to bridge two ends of digitorum longus tendon; the donor site was sutured or repaired with the skin graft. The second stage was performed after 2-3 months, tenolysis for tendon was performed, and fascia lata was spl it into tendon-l ike shape; and the toe functional exercises were done. Results All flaps survived completely after the first stage, wounds healed by first intention; the donor skin graft survived and incisions healed by first intention. At 7 days after the second stage, marginal necrosis occurred in 3 flaps (0.5-2.0 cm in width), and healed after 15-20 days of dressing change; the other flaps survived, and incisions healed by first intention. Eight patients were followed up 12-18 months (mean, 15 months). Excepts 4 sl ight bulky flaps, the other flaps had satisfactory appearance and soft texture with two points discrimination of 1-3 cm. During the follow-up, part of the dorsiflexion function recovered in 5 patients (5-40°), andflexion function was normal; 3 dorsiflexion function disappeared without effect on the function of toe flexion, and the patients could walk normally. No toe ptosis occurred. Conclusion Appl ication of the anterolateral thigh flap can repair toe extensor tendon and dorsal foot wounds with short treatment time and less damage at the donor site, so it can avoid toe ptosis after surgery and achieve excellent cl inical results.
Objective To investigate the clinical application and effectiveness of the composite tissue flaps pedicled with perforating branch of posterior tibial artery for repairing distal leg defects. Methods Between September 2014 and August 2017, 12 patients with skin and bone defects of distal leg were repaired with the composite tissue flaps pedicled with perforating branch of posterior tibial artery. There were 8 males and 4 females with an average age of 41.3 years (range, 25-66 years). The causes of injury included traffic accident injury in 7 cases, heavy crushing injury in 2 cases, tibial osteomyelitis with soft tissue ulcer and necrosis in 2 cases, and bone and soft tissue defect after resection of bone tumor in 1 case. Eight patients underwent primary repair, and 4 patients underwent second-stage repair. The size ranged from 6 cm×4 cm to 10 cm×7 cm in skin flap, from 4.0 cm×2.5 cm to 8.0 cm×6.0 cm in muscle flap, and from 4 cm×2 cm×2 cm to 5 cm×4 cm×4 cm in tibial bone flap. Tibial defects of the donor region were repaired by autologous iliac bone grafting, and the wounds were sutured directly in 7 cases and repaired by autologous skin grafting in 5 cases. Results All composite tissue flaps survived and both the recipient and the donor wounds healed primarily. All patients were followed up 6-12 months, with an average of 10.8 months. The appearance, color, texture of the composite tissue flaps and ankle function were satisfactory. X-ray films showed that the bone flap at the tibia defect and the ilium graft at the donor site both healed well at 6 months after operation. Conclusion The composite tissue flaps pedicled with perforating branch of posterior tibial artery has abundant blood, and it is a good donor region for repairing the distal leg defects combined with circumscribed bone defect.