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11.2 VASCULARIZED MUSCULAR AND MUSCULOCUTANEOUS FLAPS AND VASCULARIZED BONE SEGMENT TRANSFER FOR MANAGEMENT OF CHRONIC OSTEOMYELITIS
ARTICLE IN PRESS 52
11.1 VASCULARIZED BONE BLOCKS FROM THE TOE PHALANX TO SOLVE COMPLEX INTERCALATED DEFECTS IN THE FINGERS
F. Del Pin˜al, F. J. Garcı´ a-Bernal, J. Delgado Martinez, J. Regalado Bilbao, M. Sanmartin Ferna´ndez and L. Cagigal Instituto de Cirugı´a Pla´stica y de la Mano, Spain Background: Whereas large vascularized bone grafts have become a standard procedure in reconstructive surgery, the use of small bone segments for reconstruction of bone loss in the hand has been sparsely reported. In part, this is due to the fact that keeping small bony segments vascularized on a pedicle is challenging. Purpose: To present a cohort of patients with an intercalated compound bony defect in fingers who were reconstructed with a vascularized toe phalanx. Patients and methods: Eight patients with a complex bony defect of the finger were treated with an intercalated vascularized bone graft that included a part of the proximal phalanx (three cases), most of the middle phalanx (four cases), or a portion of each phalanx (one case) of a second toe (totalling nine bone blocks). There was associated loss of soft tissue in each case, which was reconstructed simultaneously with a cutaneous flap from the toe. The flaps were pedicled on the proper digital artery (six cases) or a segment of the first dorsal metatarsal artery (two cases). The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was resolved by soft-tissue arthroplasty or fusion. Results: A mean length of 12.2 mm (range 6–19 mm) of vascularized bone was transferred. Arterial anastomosis was carried out, in every case, to a proper digital artery endto-end. Similarly, end-to-end anastomosis of a subcutaneous vein was performed on the digital web. Bleeding from all the bone surfaces was observed once the tourniquet was released. Radiological bony union was evident at 4 to 6 weeks in all but one patient, who achieved bony union at 10 weeks. In every case the skin flaps fully survived. Conclusion: The toe phalanx has reliably maintained its vascularization after harvesting. We were able to solve compound osteocutaneous defects in the fingers in a single stage by transferring vascularized toe phalanges. Donor site morbidity has been minimal. 10.1016/j.jhsb.2006.03.040
THE JOURNAL OF HAND SURGERY VOL. 31B No. S1 JUNE
2006
11.2 VASCULARIZED MUSCULAR AND MUSCULOCUTANEOUS FLAPS AND VASCULARIZED BONE SEGMENT TRANSFER FOR MANAGEMENT OF CHRONIC OSTEOMYELITIS
S. Ghahremani Iran Medical Science University, Iran Background: Chronic osteomyelitis though treated medically and surgically, recurs within less than 2 years because of numerous reasons including sequesters, poor blood supply, residual dead space and resistant microorganisms. Recovery from this disease essentially involves the following treatment approaches: (1) long-term administration of various antibiotics; (2) effective surgery. Antibiotic treatment will not prove successful until dead, osseous and soft fibrotic tissue excision is complete. Meanwhile, wide debridement of wound and fibrotic tissue excision makes direct closure of tissue unfeasible. Today rotational and free flap procedures make direct closure of wounds possible on complete debridement and removal of soft fibrotic tissue. Methods: Our clinical experiences in the recent 10 years indicate the success of these techniques in treatment of upper and lower limb osteomyelitis following removal of sequesters along with antibiotic therapy. The remarkable effectiveness of vascularized flaps is accounted for increased blood supply, oxygen and the defense mechanism of the infected area. Discussion: Our experiences indicate that to manage upper limb osteomyelitis, the rotational musculocutaneous flap followed by vascularized free fibula has been more successful. However, for the lower limb, the muscular or musculocutaneous free flap has been more effective. The various management and treatment of chronic osteomyelitis by rotational, island and free flap procedures will be presented. 10.1016/j.jhsb.2006.03.041
11.1 VASCULARIZED BONE BLOCKS FROM THE TOE PHALANX TO SOLVE COMPLEX INTERCALATED DEFECTS IN THE FINGERS
F. Del Pin˜al, F. J. Garcı´ a-Bernal, J. Delgado Martinez, J. Regalado Bilbao, M. Sanmartin Ferna´ndez and L. Cagigal Instituto de Cirugı´a Pla´stica y de la Mano, Spain Background: Whereas large vascularized bone grafts have become a standard procedure in reconstructive surgery, the use of small bone segments for reconstruction of bone loss in the hand has been sparsely reported. In part, this is due to the fact that keeping small bony segments vascularized on a pedicle is challenging. Purpose: To present a cohort of patients with an intercalated compound bony defect in fingers who were reconstructed with a vascularized toe phalanx. Patients and methods: Eight patients with a complex bony defect of the finger were treated with an intercalated vascularized bone graft that included a part of the proximal phalanx (three cases), most of the middle phalanx (four cases), or a portion of each phalanx (one case) of a second toe (totalling nine bone blocks). There was associated loss of soft tissue in each case, which was reconstructed simultaneously with a cutaneous flap from the toe. The flaps were pedicled on the proper digital artery (six cases) or a segment of the first dorsal metatarsal artery (two cases). The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was resolved by soft-tissue arthroplasty or fusion. Results: A mean length of 12.2 mm (range 6–19 mm) of vascularized bone was transferred. Arterial anastomosis was carried out, in every case, to a proper digital artery endto-end. Similarly, end-to-end anastomosis of a subcutaneous vein was performed on the digital web. Bleeding from all the bone surfaces was observed once the tourniquet was released. Radiological bony union was evident at 4 to 6 weeks in all but one patient, who achieved bony union at 10 weeks. In every case the skin flaps fully survived. Conclusion: The toe phalanx has reliably maintained its vascularization after harvesting. We were able to solve compound osteocutaneous defects in the fingers in a single stage by transferring vascularized toe phalanges. Donor site morbidity has been minimal. 10.1016/j.jhsb.2006.03.040
THE JOURNAL OF HAND SURGERY VOL. 31B No. S1 JUNE
2006
11.2 VASCULARIZED MUSCULAR AND MUSCULOCUTANEOUS FLAPS AND VASCULARIZED BONE SEGMENT TRANSFER FOR MANAGEMENT OF CHRONIC OSTEOMYELITIS
S. Ghahremani Iran Medical Science University, Iran Background: Chronic osteomyelitis though treated medically and surgically, recurs within less than 2 years because of numerous reasons including sequesters, poor blood supply, residual dead space and resistant microorganisms. Recovery from this disease essentially involves the following treatment approaches: (1) long-term administration of various antibiotics; (2) effective surgery. Antibiotic treatment will not prove successful until dead, osseous and soft fibrotic tissue excision is complete. Meanwhile, wide debridement of wound and fibrotic tissue excision makes direct closure of tissue unfeasible. Today rotational and free flap procedures make direct closure of wounds possible on complete debridement and removal of soft fibrotic tissue. Methods: Our clinical experiences in the recent 10 years indicate the success of these techniques in treatment of upper and lower limb osteomyelitis following removal of sequesters along with antibiotic therapy. The remarkable effectiveness of vascularized flaps is accounted for increased blood supply, oxygen and the defense mechanism of the infected area. Discussion: Our experiences indicate that to manage upper limb osteomyelitis, the rotational musculocutaneous flap followed by vascularized free fibula has been more successful. However, for the lower limb, the muscular or musculocutaneous free flap has been more effective. The various management and treatment of chronic osteomyelitis by rotational, island and free flap procedures will be presented. 10.1016/j.jhsb.2006.03.041