CC BY
17
Журнал Национального научного центра хирургии им. А.Н. Сызганова
21
The use of vascularized radial flap in patients with defects and scar deformations of hand soft tissue
Muradov MI, Sike PY, Shomanova DS
National Research Center of Surgery, named after A.N Syzganov, Almaty, Republic of Kazakhstan
Actuality
Hand's damage on frequency, complexity of treatment, material costs and causes of disability occupy one of the first places among the injuries of the musculoskeletal system. The necessity for soft tissue reconstruction after surgical treatment of hand injury occurs in 46 - 55%. Insufficient perfection of traditional methods of skin plastics lead to a 30 - 47% of consequences of hand injury, caused by thermal and mechanical factors, after recovery of the skin in need of repetitive reconstructive surgeries.
The purpose of the work
Improved functional and aesthetic results of surgical treatment of patients with defects and deformations of soft tissue scar of the hand.
Material and methods
In National Scientific Center of Surgery named after A.N Syzganov in the department of Plastic and Aesthetic Reconstructive Microsurgery for 2008-2013y. treated 45 patients with various types of soft tissue defects of the hand: men - 29, women - 11 children - five of them men and women of working age.
Nature of hand damage in four cases were long-term consequences of hand's burns, received in childhood, and in one case - the traumatic injury. In all cases, soft tissue defects were large areas and depth of the lesion, which required the closure by perfused flap. Survey of patients was complex and, besides clinical methods, determine the condition of the peripheral circulation, used Doppler ultrasound, contrast necessary vessels.
The purpose of this research was the scrutiny the experience of treatment of patients with deep and extensive defects of hand soft tissue by applying vascularized radial flap. When treating patients with extensive and deep defects and scar deformations of hand's soft tissue we adhered next principles: total excision of the scar tissue, a one-time replacement of soft tissue defects compound flaps with axial type of blood supply and early rehabilitation of the affected limb. This tactic allows you to maximize and fully achieve aesthetic and functional outcomes.
All operations were performed under the optical zoom from 2.5 to 8.5-fold, using microsurgical instruments and atraumatic suture material is 3.0 to 11.0.
Clinical example
Patient Cheche-oglu F. 20 years, was admitted with the diagnosis: Long-term effects of thermal burns of the right hand. Mixed tendon and desmogenius flexion contracture of I, II, III, IV, V fingers.
Complaints on admission: scar deformation of the palmar surface of the right hand, limiting the extension movements
I, II, III, IV, V fingers.
Anamnesis morbi: According to the patient received a thermal burn at 8 months of age with boiling water. She was treated conservatively in the CRH. When the wound has healed formed hypertrophied deforming scar of right hand. Addressed to the National Scientific Center of Surgery named after A.N Syzganov. Was counseled with microsurgeon, hospitalized for tertiary care.
Status localis: On the inner surface of the lower third of the right forearm with the transition to the palmar surface of the hand there is a postburn, hypertrophic, deforming the contours of the hand scar, sharply limiting the extensor movements of I, II, III, IV, V fingers. Active flexion movements of I, II, III, IV,
V fingers of the right hand not in full, extension movements are absent.
Operation is performed under magnification 2,5krat: The elimination of the defect cover tissues palmar surface of the right hand via transposition of vascularized radial flap, metalosteosynthesis of IV finger via Kirschner wires.
Course of the operation: Endotracheal anesthesia. The position of the patient on her back. Desinfection of the right upper extremity solution of Povidone four times. On the inner surface of the lower third of the right forearm with the transition to the palmar surface of the hand there is a postburn, hypertrophic, deforming the contours of the hand scar, sharply limiting the extensor movements of I, II, III, IV,
V finger, excised, opened skin, underlying tissues. The audit revealed: pronounced scar-adhesive process, involving a single conglomerate of all the anatomical structures. Made MOS of IV finger of the right hand via Kirschner wires. The resulting defect is covered with a fabric cover transposition radial flap on the vascular pedicle, taken according to the size of the defect, the inner surface of the middle third of the forearm. Hemostasis during surgery. The seams on the wound. Drainages. Asseptic bandage. Plaster splint.
Postoperatively, a course of antibiotic, anti-inflammatory, analgesic therapy. Postoperative wound healed by first intention, sutures are removed on the 10th day. Mixed tendon and desmogenius flexion contracture eliminated, flexion, extension movements of I, II, III, IV, V fingers of the right hand may be full. The patient was discharged on day 11 with the recovery.
Results and discussion
All operated patients with soft tissue defects and scar contractures of the hand began to improve the form and function of the hand. We noted that the closure of soft tissue defects via vascularized (functional completeness) skin flaps significantly reduces the time of treatment, prevents the development of serious complications such as the formation of scar contractures and deformities.
Achieve improved outcomes in patients with hand's soft tissue defects is possible only by a differentiated approach to
22
Вестник хирургии Казахстана №4, 2014
5. The condition of of the hand and the donor area after 1 year.
2. Excision tightening scars palm redressation of hand joints, marking the radial flap.
3. Isolation of radial flap.
the treatment of various clinical forms of damage. The position of the active operational tactics vascularized skin and fascial flaps now need to be addressed at a remote and late periods of treatment as the most defensible way in such cases. Since this treatment strategy produces better results: significantly reduced residence time of the patient in a hospital bed, terms of disability, disability, patients get rid of the need to wear cumbersome plaster and orthopedic corsets, repetitive, and numerous reconstructive surgeries.
Conclusions
Skin-fascial flap of the forearm on the basis of the radial artery enables you to replace the soft tissue defects on almost any area of the hand. This skin-fascial flap is technically simple enough for the "fence" and relatively "safe" to use.
The use of vascularized flaps with the deep and extensive defects and scar deformities of hand, improving biomechanics by accelerating the process of restructuring graft allows for favorable cosmetic and functional results.
6. The condition of of the hand and the donor area after 1 year.
Literature
1. Plastic hand tissue defects with radial forearm flap /
A.E.Belousov, SA Myslin, VV Jurkiewicz et al. // Vestnik. of Surgery. II Grekova.- 1986.- T.137, № 11.
2. Slesarenko SV, Badyul PA, Prokopenko, AN The use of flaps based on perforating vessels at the close of the deep wound defects //Materials of "IV international scientific congress Ukraine surgeons". - 2010. - V.2.
3. Oleinik GA Grigorieva TG, Fedak BS et al. Burns and frostbite. Atlas / guide for practitioners. - Kharkov: IPP "Contrast". - 2009.
4. Friedrich JB, Pederson WC, Bishop AT, Galaviz P, Chang J. New workhorse flaps in hand reconstruction. Hand (N Y). 2012 Mar; 7 (1): 45-54. doi: 10.1007 /s11552-011-9385-x. Epub 2012 Jan 4.
5. Bruner TW, Hanasono MM, Skoracki RJ. Radial forearm free flap morbidity: A rare case of a normal preoperative arteriogram and acute intraoperative handischemia. Can J Plast Surg. 2011 Fall; 19 (3): 102-4.
6. Sinclair CF, Gleysteen JP, Zimmermann TM, Wax MK, Givi
B, Schneider D, Rosenthal EL. Assessment of donor site morbidity for free radial forearm osteocutaneous flaps. Microsurgery. 2012 May; 32 (4): 255-60. doi: 10.1002/micr.21950. Epub 2012 Mar 31.
7. Engelhardt TO, Rieger UM, Schwabegger AH, Pierer G. Functional resurfacing of the palm: flap selection based on defect analysis. Microsurgery. 2012 Feb; 32 (2): 158-66. doi: 10.1002 / micr.20951. Epub 2011 Nov 28.
