ObjectiveTo introduce the surgical method and effectiveness of repairing skin and soft tissue defect in the palm or dorsum of the hand and forearm with epigastric bilobed flap. MethodsBetween October 2010 and December 2013, 4 male patients with skin and soft tissue defect in the palm or dorsum of the hand and forearm were treated, aged from 36 to 62 years. Of them, 3 cases had degloving injury caused by machines and 1 case had necrosis of fingers and skin after surgery of crush injury. The time from injury to hospitalization was from 3 hours to 15 days. Among the 4 cases, the size of palmar defect was 7 cm×4 cm to 16 cm×6 cm, and the size of dorsal defect was 10 cm×7 cm to 20 cm×10 cm. The epigastric bilobed flap was designed based on the axial vessel which was formed by inferior epigastric artery, superior epigastric artery, and intercostals arteries. The size of flap ranged from 12 cm×4 cm to 18 cm×6 cm in the vertical direction, 15 cm×8 cm to 22 cm×11 cm in the oblique direction. The donor site was directly closed. The pedicles were cut at 22 to 24 days after repairing operation. ResultsAll the flaps survived well with the wound healing by first intention. Four patients were followed up 3 months to 1 year and 2 months. The other flaps had good appearance and texture except 1 bulky flap. The flap sensation basically restored to S2-S3. The function of the hands recovered well. ConclusionSkin and soft tissue defect in the palm or dorsum of the hand and forearm can be repaired with the epigastric bilobed flap, because it has such advantages as big dermatomic area and adequate blood supply. Besides, the operation is practical, safe, and simple.
Objective To investigate the operative method and effectiveness of repairing defects at medial malleolus in children with vascularized fibular head composite flap. Methods Between November 2008 and January 2011, 8 children with bone and soft tissue defects at the medial malleolus were treated. There were 5 boys and 3 girls, aged 2-9 years (mean, 4.6 years). Injuries were caused by machine twisting in 2 cases and by wheel twisting in 6 cases. Soft tissue defect area ranged from 3.5 cm × 3.0 cm to 7.0 cm × 4.5 cm; defect was total in all medial malleolus. The disease duration from injury to admission was 2-8 hours (mean, 4.5 hours). Defects were repaired with vascularized fibular head composite flap carrying the skin around the head of the fibula in 5 cases, and with vascularized fibular head composite flap and skin flap above the medial malleolus in 3 cases having too large defect (gt; 5 cm × 4 cm). The donor sites were repaired with direct suture in 2 cases and with skin graft in 6 cases. Results All 8 fibular head composite flaps and 3 skin flaps above the medial malleolus survived completely. Wounds healed by first intention; the skin grafts at donor sites survived in the other cases except 1 case having local necrosis, with healing of incision by first intention. The patients were followed up 10 months to 3 years (mean, 22 months). The color and elasticity of the flaps were good. All the children had equal leg length. Of 8 cases, 6 had no joint valgus; 2 cases had progressive ankle varus after 1 year of operation. The ankle flexion and extension function returned to normal in 5 cases, and was slightly limited in 3 cases; horizontal side, forward and backward movements had no difference compared with normal side. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, and good in 3 cases at 10 months after operation. X-ray film showed that the ankle hole gap development of both sides was similar; no premature closure of the epiphysis or bone bridge formation of the medial malleolus was observed in 6 cases, and bone bridge formed in 2 cases after 1 year of operation. Conclusion The satisfactory short-term effectiveness can be obtained in repairing children medial malleolus and soft tissue defects by vascularized fibular head composite flap, and the reconstructed medial malleolus can develop with the growth of children. Long-term effectiveness still need more follow-up study.
Objective To evaluate the effect of internal fixation on the stability of pedicled fascial flap and the osteogenesis of exceed critical size defect (ECSD) of bone so as to provide theory for the clinical application by the radiography and histology observation. Methods The ECSD model of the right ulnar midshaft bone and periosteum defect of 1 cm in length was established in 32 New Zealand white rabbits (aged 4-5 months), which were divided into group A and group B randomly (16 rabbits in each group). The composite tissue engineered bone was prepared by seeding autologous red bone marrow (ARBM) on osteoinductive absorbing material (OAM) containing bone morphogenetic protein and was used repair bone defect. A pedicled fascial flap being close to the bone defect area was prepared to wrap the bone defect in group A (control group). Titanium miniplate internal fixation was used after defect was repair with composite tissue engineered bone and pedicled fascial flap in group B (experimental group). At 2, 4, 6, and 8 weeks, the X-ray films examination, morphology observation, and histology examination were performed; and the imaging 4-score scoring method and the bone morphometry analysis was carried out. Results All rabbits survived at the end of experiment. By X-ray film observation, group B was superior to group A in the bone texture, the space between the bone ends, the radiographic changes of material absorption and degradation, osteogenesis, diaphysis structure formation, medullary cavity recanalization. The radiographic scores of group B were significantly higher than those of group A at different time points after operation (P lt; 0.05). By morphology and histology observation, group B was superior to group A in fascial flap stability, tissue engineered bone absorption and substitution rate, external callus formation, the quantity and distribution area of new cartilage cells and mature bone cells, and bone formation such as bone trabecula construction, mature lamellar bone formation, and marrow cavity recanalization. The quantitative ratio of bone morphometry analysis in the repair area of group B were significantly larger than those of group A at different time points after operation (P lt; 0.05). Conclusion The stability of the membrane structure and the bone defect area can be improved after the internal fixation, which can accelerate bone regeneration rate of the tissue engineered bone, shorten period of bone defect repair, and improve the bone quality.
Objective To explore the effects of natural hirudin on the survival of dorsal random flap after early pedicle division in rats. Methods Thirty-eight adult Wistar rats, male or female, weighing 220-280 g, were selected and randomly divided into natural hirudin group (experimental group, n=19) and normal saline group (control group, n=19). The dorsal random flap of 9 cm × 3 cm in size was prepared on the back of the rats. Six symmetrical injection points were selected at 2, 4, and 8 cm from the pedicle, 0.5 mL (3 ATU) natural hirudin and equivalent normal saline were injected in experimental group and control group respectively every day to the end of the experiment. After 4 days, the pedicles were cut. The flap was observed, and the ratio of flap survival area was measured at 7 days after pedicle division. At immediately after flap preparation, at 1 day before pedicle division, and at 3 and 7 days after pedicle division, the specimens were harvested for histological staining, immunohistochemical staining, microvessel density (MVD) measurement, and detection of vascular endothelial growth factor (VEGF) mRNA expression by fluorescent quantitative RT-PCR. Results All rats of 2 groups survived to the completion of the experiment. After pedicle division, the flap necrosis area of experimental group was smaller than that of control group; at 7 days, the ratio of flap survival area in experimental group was 85.366% ± 2.872%, and was significantly higher than that in control group (75.252% ± 3.455%) (t=7.117, P=0.000). Histological staining showed that no significant difference was found in the number of capillaries between 2 groups at immediately after flap preparation; at 1 day before pedicle division and at 3 and 7 days after pedicle division, the capillary number of experimental group was significantly more than that of control group. Immunohistochemical staining showed that CD34 positive cells were observed in 2 groups; MVD of experimental group was significantly higher than that of control group at 1 day before pedicle division, and at 3 and 7 days after pedicle division (P lt; 0.05). At 7 days after pedicle division, the VEGF mRNA expression was 7.122 ± 0.503 in experimental group, and was 5.655 ± 1.174 in control group, showing significant difference (t=3.633, P=0.003). Conclusion Natural hirudin can promote the formation of new blood vessels, improve the blood supply of the flap, and increase the survival of random flap after early pedicle division by increasing VEGF expression.