Severe Traumatic Defects of the Upper Limb
Severe Traumatic Defects of the Upper Limb
Edited by Alain C Masquelet Professor of Orthopaedics and Traumatology Hopital Avicenne Bobigny France Acacio C Ferreira Director, Servico de Chirurgia Plastica Hospital Santa Maria Lisbon Portugal
LONDON AND NEW YORK
© 2003 Martin Dunitz, an imprint of Taylor & Francis Group First published in the United Kingdom in 2003 by Martin Dunitz, an imprint of Taylor and Francis Group, 11 New Fetter Lane, London EC4P 4EE Tel.: +44 (0) 20 7583 9855 Fax.: +44 (0) 20 7842 2298 E-mail:
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CONTENTS Contributors
viii
INTRODUCTION 1
What is a severe defect? Alain C Masquelet
1
SOFT TISSUE REPAIR: FLAP TECHNIQUES 2 3 4 5
Pedicled fasciocutaneous and adipofascial flaps José Amarante
4
Pedicled muscle and musculocutaneous flaps Christoph Heitmann and L Scott Levin
24
Free flaps Horacio Costa
35
Emergency free flaps for the reconstruction of open injuries of the upper limb Maurizio Calcagni and Giorgio Pajardi
56
BONE RECONSTRUCTION 6
7
8 9
Bone auto-and allografts in post-traumatic reconstruction of the upper limb Olivier Barbier and Jean-Jacques Rombouts Massive bone defects of the upper limb: reconstruction by vascularized bone transfer Michael B Wood Loss of the post-traumatic infected substance of the upper limb Ferdinando Da Rin, Mauro Ciotti and Alain Gilbert Bone substitutes Norbert Passuti, Lawrence Bigotte, Sophie Touchais, Joël Delécrin and François Gouin
64
85 100
120
JOINT RECONSTRUCTION 10
Joint transfers and joint reconstruction Luc Téot
132
11 12
Joint replacement as a secondary procedure John K Stanley and Ian A Trail
142
Joint fusion in severe traumatic defects of the upper limb Giorgio A Brunelli
152
NERVE DEFECT REPAIR 13 14 15
Nerve grafts Michel Merle and Aymeric Lim
167
Bridging nerve defects: the role of tissue interpositioning Göran Lundborg
189
End-to-side neurorrhaphy: an alternative method for reinnervation in cases with long nerve defects Manfred Frey and Pietro Giovanoli
209
TENDON DEFECT REPAIR 16
17
Conventional tendon grafting Antonio Landi, Giuseppe Caserta, Norman Della Rosa and Andrea Leti Acciaro When to use vascularized tendon transfers and how is the digital flexion sliding system supposed to work? Jean C Guimberteau
224
293
COMPOUND TRANSFERS 18 19 20
Composite tissue transfer in the upper extremity Günter Germann and Simone Brüner
312
Free functioning muscle transfer Alain Gilbert and Vittore Costa
323
Combined soft tissue and tendon reconstruction: the dorsum and thenar regions Francisco del Piñal
334
GENERAL INDICATIONS 21
Principles of emergency reconstruction Abel Nascimento
352
22
23 24
25
Principles or repair of a compound defect as a secondary procedure: the multiple stages approach Alain C Masquelet Surgical management of infection Manuel Llusa, Xavier Mir and Xavier Flores Reconstruction of large defects of the upper limb in children Massimo Ceruso, Filippo M Sènés, Giuseppe Checcucci, Prospero Bigazzi, Alessandra Allegra and Gloria Taliani Future advances in hand and upper limb surgery: application of tissue engineering and biotechnology Panayotis N Soucacos Index
365 377
388
400 411
CONTRIBUTORS Andrea Leti Acciaro Unit of Hand Surgery and Microsurgery Azienda Ospedaliera Policlinico of Modena Italy Alessandra Allegra 2a UO Anestesia e Rianimazione Azienda Ospedaliera Careggi Firenze Italy José Amarante Plastic Surgery Department São João University Hospital Porto Portugal Olivier Barbier Hand and Orthopaedic Surgeon St-Luc University Hospital 1200 Brussels Belgium Prospero Bigazzi UO Chirurgia della Mano e Microchirurgia Ricostruttiva Azienda Ospedaliera Careggi Firenze Italy Laurence Bigotte Clinique Chirurgicale Orthopédique CHU Nantes France Giorgio A Brunelli University of Brescia Medical School Brescia Italy
Simone Brüner Department of Hand, Plastic and Reconstructive Surgery Burn Center BG Trauma Center and Ludwig-Guttmann-Strasse 13 67071 Ludwigshafen Germany Maurizio Calcagni Department of Hand Surgery Policlinico MultiMedica Institute of Plastic and Reconstructive Surgery University of Milan Via Milanese, 300 Sesto San Giovanni Milan I-20099 Italy Giuseppe Caserta Unit of Hand Surgery and Microsurgery Azienda Ospedaliera Policlinico of Modena Italy Massimo Ceruso UO Chirurgia della Mano e Microchirurgia Ricostruttiva Azienda Ospedaliera Careggi Firenze Italy Giuseppe Checcucci UOC Chirurgia della Mano e Microchirurgia Ricostruttiva Azienda Ospedaliera Careggi Firenze Italy Mauro Ciotti Istituti Codivilla-Putti Cortina Italy Horacio Costa Plastic Surgery Department
Hospital Vila Nova de Gaia Portugal Vittore Costa Institut de la Main Clinique Jouvenet 6 square Jouvenet F-75016 Paris France Joël Delécrin Clinique Chirurgicale Orthopédique CHU Nantes France Xavier Flores Department of Trauma and Orthopaedic Surgery Hospital de Traumatología Vall D’Hebron Barcelona Spain Manfred Frey MD Professor of Plastic Surgery Head, Division of Plastic and Reconstructive Surgery Department of Surgery Medical School University of Vienna Währinger Gürtel 18-20 A-1090 Austria Günter Germann Professor of Hand and Plastic Surgery University of Heidelberg and Professor of Surgery and Chief, Department of Hand, Plastic and Reconstructive Surgery Burn Center BG Trauma Center and Ludwig-Guttmann-Strasse 13 67071 Ludwigshafen Germany Alain Gilbert Institut de la Main
Clinique Jouvenet 6 square Jouvenet F-75016 Paris France Pietro Giovanoli Professor of Plastic Surgery Head, Division of Plastic and Reconstructive Surgery Department of Surgery Medical School University of Vienna Währinger Gürtel 18-20 A-1090 Austria François Gouin Professor, Clinique Chirurgicale Orthopédique CHU Nantes France Jean C Guimberteau Chirurgie de la Main Microchirurgie, Chirurgie Plastique, Reconstructrice et Esthetique 54 rue Huguerie Bordeaux 330000 France Christoph Heitmann Professor of Plastic and Orthopaedic Surgery Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery Duke University Medical Center, Box 3945 Durham, NC 27710 USA Antonio Landi Unit of Hand Surgery and Microsurgery Policlinico of Modena Italy L Scott Levin Professor of Plastic and Orthopaedic Surgery Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery
Duke University Medical Center, Box 3945 Durham, NC 27710 USA Aymeric Lim Consultant, Department of Hand and Reconstructive Microsurgery National University Hospital Singapore Manuel Llusa Department of Trauma and Orthopaedic Surgery Hospital de Traumatología Vall D’Hebron Barcelona Spain Göran Lundborg Department of Hand Surgery Malmö University Hospital SE-205 02 Malmö Sweden Alain C Masquelet Professor of Orthopaedics and Traumatology Hopital Avicenne 125, route de Stalingrad 93009 Bobigny France Michel Merle Head, Institut Européen de la Main 54320 Maxeville-Nancy France Xavier Mir Department of Trauma and Orthopaedic Surgery Hospital de Traumatología Vall D’Hebron Barcelona Spain Abel Nascimento Department of Orthopaedic Surgery University Hospital Coimbra Portugal
Giorgio Pajardi Department of Hand Surgery Policlinico MultiMedica Institute of Plastic and Reconstructive Surgery University of Milan Milan Italy Norbert Passuti Professor, Clinique Chirurgicale Orthopédique CHU Nantes France Francisco del Piñal Head, Section of Hand-Wrist and Plastic Reconstructive Surgery Hospital Mutua Montañesa and Director, Instituto de Chirugía de la Mano y Plástica-Reparadora Calderón de la Barca 16-entlo E-39002 Santander Spain Ferdinando Da Rin Istituti Codivilla-Putti Cortina Italy Jean-Jacques Rombouts Dean, School of Medicine Université Catholique de Louvain and Professor of Orthopaedic Surgery St-Luc University Hospital 1200 Brussels Belgium Norman Della Rosa Unit of Hand Surgery and Microsurgery Azienda Ospedaliera Policlinico of Modena Italy Filippo M Sènés 1a UO Ortopedia e Traumatologia Istituto Scientifico Giannina Gaslini Genova Italy
Panayotis N Soucacos Professor and Chairman Department of Orthopaedic Surgery University of Ioannina School of Medicine 45110 Ioannina Greece John Stanley Centre for Hand and Upper Limb Surgery Wrightington Hospital for Joint Diseases Wigan UK Gloria Taliani Clinica Malattie Infettive Università degli Studi di Firenze Italy Luc Téot Burns and Plastic Unit Lapeyronie Hospital Montpellier France Sophie Touchais Clinique Chirurgicale Orthopédique CHU Nantes France Ian A Trail Centre for Hand and Upper Limb Surgery Wrightington Hospital for Joint Diseases Wigan UK Michael B Wood Mayo Foundation Rochester, MN USA
Introduction
1 What is a severe defect? Alain C Masquelet
When can a defect be considered as severe? This is not a mild question because the answer is inevitably arbitrary. I propose the following answer: a defect is severe when the restoration of the injured structure cannot be performed without employing a palliative procedure. A limited bone or joint defect can be neglected. For instance, a small defect of cartilage in a joint will not have an effect on function. In case of soft tissue limited defect, direct restoration of the continuity can be obtained owing to the suppleness of the involved tissue which can be sutured. This is also the case for skin, arteries, nerves, muscles and tendons. In other cases, direct suturing is not possible and the defect cannot be neglected without an inacceptable functional impairment. The aim of this textbook is to provide some answers to the following questions: • How to repair a severe defect of a tissue of the upper limb? • What are the surgical procedures and what are their respective indications according to the features of the defect? • How to reconstruct a long bone defect? • How to perform a joint fusion when there is a bone defect? • What are the possible methods to restore the skin envelope, the continuity of nerves and tendons, etc.? All the answers to these questions require a good knowledge of conventional procedures, state-of-the-art advances in bioengineering and imagination. The course includes surgical precedures and general indications. The upper limb is an assembly of structures and tissues devoted to supporting the prehensile function of the hand. The initial trauma may lead to a variety of associated lesions of several tissues. A limited defect of the skin envelope can be combined with a severe defect of a long bone. In this situation we only consider the severe defect of the bone. But if a severe defect involves two or more structures, we call it a compound defect. A compound defect is the combination of several severe defects with varying degrees of involvement of the skin, muscles, bone, joints, tendons, nerves, arteries, etc. Thus we can give some definitions. • A defect always implies a defect of a particular tissue which is a component of the musculoskeletal system. • A severe defect cannot be treated without a palliative procedure of replacement. • A compound defect is the combination of several severe defects. Another important question is: How to repair a compound defect?
Severe traumatic defects of the upper limb
2
In this book two possibilities are considered: the replacement of each isolated tissue or the use of a compound transfer which allows the repair in a one-stage procedure. The aim is to provide an holistic view of all possibilities including the latest advances in bioengineering. The replantation of amputated segments of the upper limb and the severe injuries of the fingers will not be discussed.
Soft tissue repair: flap techniques
2 Pedicled fasciocutaneous and adipofascial flaps José Amarante
Introduction The forearm island flaps are probably, at present, one of the surgical techniques utilized most fre
Figure 1 (a) A dorsal hand lesion. (b) The final result after a distally pedicled radial forearm flap.
Pedicled fasciocutaneous and adipofascial flaps
5
quently for reconstructive surgery of the hand. These flaps are based on the arteries and veins of the forearm and their septocutaneous branches. Their main advantages include the use of fasciocutaneous or adipofascial areas of reasonable dimensions, ease of reinnervation and their possible use as composite flaps. The last option allows the execution of cutaneous, tendinous and osseous reconstructions in the same operating time. The forearm radial flap (Fig. 1) was first described in plastic surgery literature as a free flap (Yang et al 1981) and later as a distally pedicled flap for hand reconstruction. It was used in cutaneous reconstructions (Stock et al 1981), reinnervation of the reconstructed area (Schoofs et al 1983) as well as in tendocutaneous (Reid and Moss 1983) and osteocutaneous reconstructions (Biemer and Stock 1983, Schoofs et al 1983). This flap can also be utilized as an adipofascial flap (Fig. 2) or as a purely fascial flap (Reyes and Burkhalter 1988). Presently it is one of the flaps that is used more frequently in reconstruction of the hand or as a free flap in diverse anatomical areas such as the oral cavity (Boyd et al 1994), the leg (Muhlbauer et al 1982) and the penis (Gottieb and Levine 1993). Some technical modifications have been recently published: an adipofascial flap pedicled in a single distal perforator artery preserving the radial artery (Weinzweig et al 1994, Koshima et al 1995) and also a radial forearm flap without the fascia for lowering the morbidity of the donor area (Lutz et al 1999). The ulnar forearm flap (Fig. 3) was initially described as a free flap (Lovie et al 1984) but is also used with a distal pedicle in reconstructive surgery of the hand (Elliot et al 1988, Glasson et al 1988, Guimberteau et al 1988). As a free flap
Figure 2 (a) Planning an adipofascial radial forearm flap. (b) The dissection of the adipofascial radial forearm flap. (c) The adipofascial flap. (d) An aspect of the final result.
Severe traumatic defects of the upper limb
6
and in a way similar to the radial forearm flap, it has surgical applications in various areas, namely the face, penis and leg (Christie et al 1994). It can be used as a cutaneous flap but also as a composite flap with tendons or bone from the ulna (Christie et al 1994). It is centred in the forearm in a position symmetrical to the radial flap and, as its name implies, is supplied by the ulnar artery and its septal branches. A large area of skin and subcutaneous cellular tissue of the anterior region of the forearm can be used in this type of flap. The radial and the ulnar forearm flaps, when utilized with a distal pedicle, are vascularized inversely to the normal flow secured by various existing anastomoses between the radial and ulnar arteries. Another flap that has identical vascularization when pedicled distally is the posterior interosseous flap (Fig. 4) (Zancolli and Agrigiani 1986). In this case, the circulation is assured by the existing anastomosis between the two interosseous arteries localized normally in the distal third of the forearm (Penteado et al 1986). This flap is almost exclusively used in reconstructive hand surgery (Masquelet and Penteado 1987, Maillard and Meredith 1991, Angrigiani et al 1993) as an osteocutaneous flap (Costa et al 1988) although some clinical cases have been described with reconstructions in other areas using this flap as a proximally pedicled flap (Nakajima et al 1986) or as a free flap (Tonkin and Stern 1989).
Figure 3 (a) A lesion located on the dorsum of the hand. (b) Planning an ulnar forearm flap. (c) The dissection of the flap. (d) The final result.
Pedicled fasciocutaneous and adipofascial flaps
7
Figure 4 (a) Planning a posterior interosseous flap to reconstruct a dorsal hand lesion. (b) The final result.
Figure 5 (a) A dorsal lesion on the hand. (b) The final result after an ulnodorsal septocutaneous flap reconstruction. Contrary to the flaps already described, the ulnodorsal septocutaneous flap (distal ulnar artery island flap) (Becker and Gilbert 1988a, 1991) and the median flaps (Niranjan and Shibu 1994) are supplied with a blood flow in the normal direction: the former through a distal branch from the ulnar artery (Fig. 5) (Becker and Gilbert 1991, HolevichMadjarova et al 1991, Niranjan and Shibu 1994) and the latter through a branch from the median artery. The median flap is rarely used in clinical practice as the median artery is rarely identified. For reconstructions in the elbow area it is possible to use flaps based on the recurrent radial or ulnar arteries with reverse flow (Figs 6 and 7). The recurrent radial artery has been used in a musculocutaneous flap based on the brachioradial muscle (Lai et al 1981) while the collateral radial artery is the base of a free flap (Song et al 1982, Katsaros et al 1984). The use of these two arteries for the execution of the inverted flow flap was first described by Maruyama (Maruyama and Takeuchi 1986) and later more clinical cases were described (Culberston and Mutimer 1987). Several authors described the execution of free flaps in the medial arm area (Daniel et al 1975, Dolmann et al 1979); the execution of the island flap with a proximal pedicle has also been described (Budo et al 1984). Maruyama was the
Severe traumatic defects of the upper limb
8
Figure 6 (a) The area demanding reconstruction. (b) The final result with the recurrent ulnar flap. first to describe an inverted flow flap based on the recurrent ulnar artery and the collateral superior ulnar artery united by their anastomoses (Maruyama et al 1987). Kadry has also presented some clinical cases using this flap (Kadry et al 1989). All the flaps described can be used as fasciocutaneous or adipofascial flaps. For adipofascial flaps and before starting the true dissection of the flap, it is necessary to lift the skin from both margins of a longitudinal incision located in the long axis of the flap. It is obvious that the flap must include the main artery supplying the flap and the local fascia. Other flaps like the anterior interosseous (Hu et al 1994) and the neurocutaneous (Bertelli 1993, Bertelli and Pagliei 1998) are not large enough to reconstruct large defects so they are not discussed in this chapter.
Pedicled fasciocutaneous and adipofascial flaps
9
Figure 7 (a) A recurrent radial flap for reconstruction of the anterior surface of the elbow. (b) A recurrent ulnar flap already dissected. (c) The final result. (d) The donor areas. Still another option for hand reconstruction is to execute venous flaps in the forearm which, as the name indicates, avoids the use of arteries for the cutaneous blood supply (Amarante et al 1987, Thatte and Thatte 1987, Amarante et al 1988).
Severe traumatic defects of the upper limb
10
Radial forearm flap The radial flap (see Fig. 1), which can be dissected from a vast area of the anterior region of the forearm, is based on the radial artery and its septal branches as they pass at the proximal level between the brachioradialis and flexor carpi radialis muscles and at the distal level between the flexor carpi radialis and the flexor digitorum superficialis muscles. If necessary, it is possible to use a musculocutaneous composite flap once the radial artery supplies the flexor carpi radialis, brachioradialis and palmaris longus muscles. Analogically, fragments of the radius could also be used given the fact that they are vascularized by the radial artery either directly or indirectly through the periosteal branches of the insertions of the flexor pollicis longus and pronator quadratus. The flap could be resensitized utilizing either the lateral or the medial cutaneous nerves of the forearm. The venous drainage of the flap is effected through the superficial venous system which communicates with the deep veins, satellites of the radial artery, the blood flowing posteriorly contrary to the normal flow. Surgical technique Before surgery, the permeability of the arteries of the hand must be evaluated by Allen’s test. The flap must be designed on the forearm centred on the trajectory of the radial artery. Next, an incision is made on the ulnar edge of the flap which must include the skin, subcutaneous tissue and fascia (easily identifiable at this level). The flap is raised from its bed with the exposure of the forearm muscles, which is achieved by sectioning the intermuscular septa that run from the deep surface of the fascia to the subjacent muscles. Maintaining this plane of dissection assures the connection of the radial artery to the flap once this is localized in the lateral intermuscular septa. The sectioning of the periosteal insertion of the lateral septum allows the liberation of the radial artery and the two satellite veins. With these vessels already referred to, the incision can proceed to the radial margin of the flap followed by its dissection in the subfascial plane. The retraction of the brachioradialis muscle permits the exposure of the superficial branch of the radial nerve which must be kept intact. After ligation of the proximal end of the radial artery and the two satellite veins, the flap can be lifted out progressively dissecting the pedicle towards the distal end. In the event that the intention is the reinnervation of the flap, one can proceed with the identification and isolation of a nerve in the cutaneous area of the flap. Normally the arc of rotation of the flap reaches the hand, that is the fingers, though one can substantially increase that arc of rotation by dissecting out the pedicle of the flap at the level of the anatomical snuff box in a manner that facilitates the passage between the abductor pollicis longus and extensor pollicis brevis muscles.
Pedicled fasciocutaneous and adipofascial flaps
11
If the intention is to include a bone fragment with the flap, the insertion of the lateral intermuscular septum in the periosteum of the radius must be preserved intact. In this case, the dissec tion of the flap must be done more deeply through the flexor pollicis longus and the pronator quadratus muscles until the radius is reached. The donor area of the flap is usually closed with a dermo-epidermic graft, care being taken to first cover the tendons of the flexor carpi ulnaris and brachioradialis muscles and the superficial branch of the radial nerve. This is achieved by suturing the flexor digitorum superficialis to the flexor pollicis longus muscle.
Ulnar forearm flap The ulnar forearm flap (see Fig. 3) is based upon the ulnar artery and its septal branches which reach the fascia by passing between the flexor carpi ulnaris and flexor digitorum superficialis muscles. The venous drainage of the island pedicle flap occurs through the satellite veins of the ulnar artery. This flap can be resensitized using the medial cutaneous nerve of the forearm. The flap can also include muscles (flexor carpi ulnaris and palmaris longus) as well as a bone fragment from the ulna. Surgical technique Before raising the flap and because an important artery supplying the hand is going to be ligated, Allen’s test must be done to confirm the permeability of the radial artery. Once the permeability of the arterial vessels is verified, the flap is designed on the forearm, beginning the intervention by the identification of the ulnar artery at the distal end. The lateral edge of the flap is then incised up to the fascia, the flap being separated previously from the flexor digitorum superficialis muscle. If necessary the palmaris longus muscle or part of the flexor carpi ulnaris muscle could be included. The flap separation is continued at this level until the fascial septum separating the flexor digitorum superficialis muscle and flexor carpi ulnaris muscle is exposed. In this phase of the intervention, the septal branches of the ulnar artery are quite visible. The incision is concluded along the periphery of the flap, ligating, if necessary, some superficial veins and identifying the medial cutaneous nerve of the forearm in case the intention is to resensitize the flap. After the separation from its bed, the flap must now be progressively separated from the ulnar nerve. Next proceed with the sectioning of the ulnar artery and its satellite veins immediately after it gives rise to the common trunk of the interosseous arteries in such a way as to permit the transposition of the flap. Usually it is necessary to dissociate the vascular pedicle of the flap from the ulnar nerve at the distal end level and to ligate some arterial muscular branches. The donor area of the flap can be closed directly if it is of reduced dimensions otherwise it is necessary to use a dermo-epidermic graft.
Severe traumatic defects of the upper limb
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The posterior interosseous forearm flap The posterior interosseous flap (see Fig. 4) is based on the artery of the same name and its septal branches. The flap is located on the posterior region of the forearm where the artery emerges at this level in the deep face of the supinator muscle. The point of emergence is approximately at the union of the superior third with the median third of a line that unites the epicondylus lateralis to the processus styloideus of the ulna. At the level of emergence of the artery on the posterior face of the forearm, it is accompanied by the posterior interosseous nerve. The nerve gives rise to a small branch that accompanies the artery in its distal trajectory. These two structures accompanied by the two satellite veins of the artery pass into the fascial septum situated between the extensor carpi ulnaris and extensor digiti minimi muscles. Surgical technique The surgery begins by drawing a line that unites the epicondylus lateralis to the processus styloideus of the ulna, corresponding to the trajectory of the posterior interosseous artery. The line must be drawn with the forearm in complete pronation and with the elbow flexed. The flap must be designed on the posterior region of the forearm so as to include the emergence of the posterior interosseous artery. Before the flap is raised at the distal level, the anastomosis between the two interosseous arteries must be confirmed. Then the incision into the skin and afterwards into the fascia can be done in such way as to preserve the anastomosis. After the verification, the incision of the flap proceeds at its periphery separating it from the muscular bed on both sides of the intermuscular septum until the emergence of the interosseous artery can be seen. In this phase it is crucial not to damage the posterior interosseous nerve. After the artery is ligated proximally the flap can be completely separated from the muscular bed and after the distal dissection of the arteriovenous pedicle, it can be transposed to the hand. If the flap is of small dimensions, one can close the donor area of the flap directly, otherwise it is necessary to apply a skin graft.
Ulnodorsal septocutaneous flap (distal ulnar artery island flap) This flap uses the distal branches of the ulnar artery in the forearm (see Fig. 5), which run directly to the forearm fascia passing the posterior surface of the flexor carpi ulnaris muscle. After ramifying and anastomosing at the level of the fascia with other branches of the septal arteries these distal ulnar branches are going to supply a localized area at the ulnar edge of the forearm extending between the trajectory of the palmaris longus and the extensor indicis muscles.
Pedicled fasciocutaneous and adipofascial flaps
13
Surgical technique The flap is drawn on the ulnar edge of the forearm and is centred largely on the anterior region. It axis of rotation is located in the plane of emergence of the most distal septocutaneous artery, which is situated about 3–4 cm from the pisiform bone. Eventually a second perforating artery about 7–8 cm from the pisiform bone can also be included. Usually, one proceeds with raising the flap from proximal to distal, incising the skin, the subcutaneous tissue and the fascia. This structure, in the area of the flexor carpi radialis muscle is thinner and difficult to dissociate from the muscle. It the flap is raised by proceeding distally one is able to see the first perfusing artery located about 7 cm from the pisiform bone, which can also be included in the flap. During the dissection at the distal level, damage to the dorsal branch of the ulnar nerve must be avoided. Then the flap is completely separated from its bed, remaining attached only by its artery and vein, which permits easy transposition to the dorsal or the palmar regions of the hand. The donor area of the flap, if it is of reduced size, can be closed directly. In the case of large flaps, a skin graft easily closes the donor area.
Recurrent radial flap (lateral arm flap with inverted flux) This flap is located on the external margin of the arm and is based on the recurrent radial artery which is usually a branch of the radial artery. This artery, after giving rise to some muscular arterial branches to the supinator and brachial muscles leads proximally anastomosing with the collateral radial artery. Surgical technique The shape of the flap is drawn on the outside of the arm centred on a line that unites the lateral epicondyle to the inferior edge of the deltoid muscle. The incision, normally initiated at the anterior edge of the flap, must include skin, subcutaneous tissue and brachial fascia up to the muscular plane. The flap is then progressively raised from its bed, allowing the identification of the recurrent radial artery that is dissected in a manner to maintain its link with the flap through the septal prolongation of the fascia. The incision is afterwards completed on the whole periphery of the flap, which is completely raised from its bed, remaining attached at the distal end by the recurrent radial artery and its satellite veins after they are proximally ligated. Depending on the width necessary for the flap, the closure of the donor area may or may not require a skin graft.
Severe traumatic defects of the upper limb
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Recurrent ulnar flap (medial arm flap with inverted flow) This flap is found, as the name indicates, on the internal face of the arm (see Fig. 6) and is centred on the vascular axis constituted by the recurrent ulnar artery and the collateral ulnar arteries joined by their respective anastomoses. The recurrent ulnar artery divides after its origin into two arterial branches, one anterior and the other posterior, the latter having the greater calibre and an ascending trajectory between the bundles of the flexor carpi radialis. This branch artery with the greater dimension passes in its proximal trajectory along with the ulnar nerve behind the humeral epicondyle in order to anastomose with the superior collateral ulnar artery. Surgical technique After drawing the flap on the medial face of the arm, between the anterior and posterior medial lines, the incision is made into the skin, subcutaneous tissue and the brachial fascia in the anterior margin of the flap. Afterwards the flap is raised from its bed exposing the fascial septum between the triceps brachii and brachial muscle, which is incised longitudinally, care being taken not to injure the ulnar nerve. During this phase of the dissection, the recurrent blood vessels are normally identifiable.
Clinical cases A total number of 246 forearm island flaps were performed, of which 117 were radial forearm flaps, 6 were ulnar forearm flaps, 43 were posterior interosseous flaps and 80 were ulnodorsal septocutaneous flaps. Two radial forearm flaps were performed in direct flow. There were 157 male and 99 female patients, ranging in age from 1 year to 74 years. All the flaps were done by bloodless technique with the patients under endovenous anaesthesia, brachial plexus block or general anaesthesia. Of the cases, 111 were treated as a result of burns, 135 as result of emergency hand trauma and 11 were reconstructions following neoformation treatment. The dorsal region of the hand was the area treated most frequently (Table 1). The complications are shown in Table 2. We had difficulty in closing the donor area in some cases as a result of the skin graft revascularization, which had the inconvenience of prolonging the recovery period. Oedema was found in some flaps, a complication which was easily resolved in the majority of cases using an elastic bandage. Only in the case of one radial forearm flap did the oedema persist beyond 3 months. The difficulty of extension of the fifth finger was observed in four cases, in which the posterior interosseous flap was used.
Pedicled fasciocutaneous and adipofascial flaps
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Table 1 Reconstructed areas and flaps used. Radial Ulnar Post Ulnodor Radial recur Ulnar recur inter Hand dorsum 44 3 28 36 Hand palmar 21 3 4 12 Hand ulnar 8 20 border 1st web space 19 3 12 Fingers 10 Hand + fingers 21 Elbow 2 3 10 TOTAL 117 6 43 80 3 10 Radial, radial forearm flap; Ulnar, ulnar forearm flap; Post inter, posterior interosseous flap, Ulnodor, ulnodorsal septocutaneous flap, Radial recur, recurrent radial flap, ulnar recur, recurrent ulnar flap. Table 2 Complications of the different flaps used. Partial Oedema Nervous necrosis complications Radial forearm 4 33 11 Ulnar forearm 2 5 Ulnodorsal 3 8 1 Posterior 3 9 2 interosseous Radial recurrent 1 Ulnar recurrent 1 TOTAL 12 52 19
Muscle complications
4
4
Transient paraesthesia was noted in three patients in the area reinnervated by the ulnar nerve at the level of the hand, which disappeared completely about 3 weeks after surgery. Thirteen patients had dysaesthesia. Considering the recurrent radial and ulnar flaps, ten recurrent ulnar and three recurrent radial flaps were performed in nine men and four women, between 22 and 36 years old. We preferred the recurrent ulnar flap since its donor area is easier to conceal. All the donor areas, except four cases, were directly sutured. In those four cases we used skin grafts to close the donor area. Both these flaps were used to reconstruct the anterior region of the elbow and in two cases we had to use both flaps (see Fig. 7) to accomplish the goal as the areas that demanded reconstruction were of large dimensions.
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Total necrosis was not observed in any of the flaps. Partial necrosis on the periphery of two of the flaps was observed.
Discussion The flaps described are safe and in general easy to execute and can be used as fasciocutaneous or adipofascial flaps. We must consider several issues in the choice of antebrachial flaps: the anatomical variations; the point of rotation of the pedicle; the vascular disadvantages; and the scar in the donor area. Anatomical variations of the radial and ulnar arteries are rarely impediments to the raising of this flap (McCormack et al 1953, Coleman and Anson 1961, Amarante 1990). For example, the presence of the superficial ulnar artery, which occurs in 2–3% of the cases (McCormack et al 1953, O’Rahilly 1986), was initially considered to be an obstacle for the use of this flap (Fatah et al 1985), although clinical practice shows that its presence facilitates the raising of this flap (Glasson and Lovie 1988, Reis et al 1994). In every case and prior to the dissection, the viability of the hand circulation after the occlusion of either the radial or ulnar arteries must be verified by Allen’s test or by Doppler fluxometer (Gelberman and Blasingame 1981, Emerson et al 1985). Nevertheless, a negative Allen’s test is not an impediment to the execution of this flap (McGregor 1987a). So if one persists in raising the flap, during the operation the artery to be ligated must be clamped prior to raising the flap, which will permit the evaluation of the circulation of the hand (McGregor 1987b). This precaution is particularly important in traumatic injuries since the circulation can be interrupted in one of the main axes of the arm or in the vascular arcs of the hand. However this situation is rarely verified given that the anastomoses between the radial and ulnar arteries at the distal end are through the palmar and dorsal arcs, which usually permit raising the flap even in the presence of local lesions at the carpal level. The posterior interosseous flap, like the radial and ulnar flaps, is irrigated in inverted flow through the anastomoses between the interosseous arteries, which requires confirmation of its presence prior to the complete raising of the flap. In our work with 50 forearm dissections we verified that the anastomotic system was absent in one case and bilaterally absent in another case (Amarante 1990) although some authors reported after 100 upper arm dissections that only in 50% of the cases is there a real interosseous system (Huelin et al 1978, Barreiro and Huelin 1980). Penteado reported the absence of the same anastomosis in one of 70 cases studied (Penteado et al 1986) contrary to another study in 50 cases in which the anastomosis was always encountered between the two interosseous arteries (Costa et al 1991). The absence of the artery in the middle of the forearm, which also makes the execution of the flap unfeasible, was verified in four, two and one of 80, 36 and 70 arms, respectively (O’Rahilly 1986, Maillard and Meredith 1991, Angrigiani et al 1993). The absence of the same artery at the distal end in one clinical case was reported (Angrigiani et al 1993) and we have also observed in a clinical case bilateral disappearance of the artery in the middle third of both forearms preventing the use of the posterior interosseous flap. The patient was a 46-year-old man with a severe bilateral Dupuytren
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contracture with involvement of the skin (Costa et al 1991). Considering all the anatomical data presented, prior to the execution of the posterior interosseous flap and consequently the proximal sectioning of the artery, it is necessary to confirm its presence at the distal level and the anastomosis with the anterior interosseous artery. Relative to the distal septal branch of the ulnar artery, its absence was report in one (Becker and Gilbert 1991) and in three (Amarante 1990) of 50 cases studied, so it is advisable to confirm its presence prior to raising the flap. During the execution of the ulnodorsal septocutaneous flap (Becker and Gilbert 1988a,b), we always try to include, whenever it is possible, a second septal artery which is normally located about 7 cm from the pisiform bone—which was regularly encountered in 50 dissections (Amarante 1990) and the superficial forearm fascia because we think this forearm flap is identical to the posterior septocutaneous tibial flap in the leg (Amarante et al 1986), both having a vast vascular network at the fascial level between the septocutaneous arteries, making it possible to raise a flap of appreciable dimensions based on one or two perforating arteries. Other flaps like these can be dissected in the arm using the fasciocutaneous arteries located by Doppler flowmeter (Bertelli 1993, Bertelli and Pagliei 1998). The chances of execution of the median flap are very uncertain owing to its anatomical characteristics. The median artery is reported to be constantly present (Huelin et al 1978) but the fact is that it has a reasonable calibre in only 8% of cases (Niranjan and Shibu 1994). Even in these one must confirm the presence of the perforating cutaneous artery which is absent in the great majority of cases. In the utilization of inverted flux flaps, the position of the rotation point of the pedicle can influence the selection, consonant with the area to be reconstructed. That point is related to the existing anastomosis between the two arteries which supply the flap. In the case of the ulnodorsal septocutaneous flap, its point of rotation is located at the level of origin of the most distal septocutaneous artery from the ulnar artery. The anatomical characteristics of the radial and ulnar forearm flaps permit reconstructions including the fingers and areas of the hand distal to the metacarpophalangeal joints where using either a posterior interosseous flap or an ulnodorsal septocutaneous ulnar flap was not indicated. An important factor in the choice of the flap is the vascular inconvenience resulting from the arterial ligation, as it will have repercussions in the forearm and hand blood supply. The ulnodorsal septocutaneous flap and other flaps based on the fasciocutaneous or neurocutaneous arteries (Bertelli 1993, Bertelli and Pagliei 1998) are, in this aspect, the ones with fewer vascular repercussions if the arterial branches utilized are almost exclusively cutaneous. The large calibre ulnar and radial flap arteries will be ligated at the proximal end in the forearm when the flap is completed. The interruption of any of these large arteries at the forearm level has negative repercussions, most of all, on the muscular and nervous vascularization. At the muscular level in the forearm, the ulnar artery practically supplies the flexor digitorum superficialis (Parry et al 1988, Parry and Mathes 1989, Revol et al 1991). The radial artery has only one muscular branch of significance to the pedicle of the flexor carpi radialis muscle (Parry et al 1988, Parry and Mathes 1989, Revol et al 1991). This muscular branch is found quite proximally and is not usually sectioned in the execution of the radial forearm flap. In contrast to the arteries already referred to, the interosseous arteries are of great importance at the forearm level, namely the posterior interosseous artery which supplies practically all the muscles of the
Severe traumatic defects of the upper limb
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posterior compartment of the forearm (Parry et al 1988, Parry and Mathes 1989, Revol et al 1991): extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, supinator and extensor indicis. This fact could explain the difficulty in effecting the extension of the fifth finger—verified in four patients on whom we executed this flap—the extensor digiti minimi is practically exclusively supplied by the posterior interosseous artery. Of great importance and also deserving mention is the contribution of the arteries of these flaps to the blood supply of the main nerves of the forearm. The ulnar nerve is mostly supplied by the ulnar artery while the superficial branch of the radial nerve, a sensory nerve, is supplied by the radial artery while its motor branch is supplied by the posterior interosseous artery (Bellinger and Smith 1980, Pinal and Taylor 1990). The paraesthesias reported by some authors (Christie et al 1994, Amarante 1990), resulting from the execution of the ulnar flap, are probably, to a greater extent, related to the minor trauma verified during the dissection of the flap than a diminution of the vascular flow, as recuperation from this complication is usually fast. Relative to the repercussions of the diminution of the blood supply at the level of the hand owing to the utilization of these flaps, it must be said that the perfusion by the distal septocutaneous ulnar artery as well as by the posterior interosseous artery contributes minimally to the vascularization of the hand through their anastomoses with the palmar and dorsal arcs. The major importance of the ulnar artery relative to the radial artery in the hand circulation is noted in the references (Barreiro and Huelin 1980). Therefore, it must be emphasized that the radial artery contributes significantly to the blood supply of the thumb and index finger (Coleman and Anson 1961, Mutz 1972, Braun 1977, Parks et al 1978). The importance of these arteries in the circulation of the hand was the main reason to perform venous bridges (Soutar et al 1983, Lovie et al 1984) but later it was reported that those venous bridges soon became occluded (Gelberman et al 1982, Boorman and Sykes 1987, Meland et al 1993). Recently, a study was published which compared the vascular status of one hand where a free radial forearm flap had been harvested without radial artery reconstruction, with the vascular status of the contralateral normal hand and the authors concluded that the vascular repercussions were not significant (Meland et al 1993). When using flaps based on the radial, ulnar and interosseous arteries we must consider the sequelae not only in the hand but also in the forearm. Another factor to consider when selecting the type of flap to use is related to the donor area. Whenever the execution of large flaps requires skin grafts, they take better in ulnar and interosseous flap donor areas once the graft is applied over the muscle mass with good vascularization (Glasson and Lovie 1988). When raising a large or a distally localized radial forearm flap there will be tendons exposed with deficient blood supply making revascularization of the graft difficult and prolonging the recovery period. This problem is more frequently encountered when using large free flaps. Several techniques have been described to avoid this inconvenience (Soutar et al 1983, Fenton and Roberts 1985, McGregor 1987b, Bardsley et al 1990, Masser 1990, Liang et al 1994). Another subsequent complication is the appearance of painful neuromas in the donor area of the flap due to sectioning of sensory nerves (Boorman and Sykes 1987, Timmons et al 1986).
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It is also important to consider the appearance of the donor area. Flaps of identical dimensions raised from the anterior region of the forearm are less visible than those raised from the dorsal region. The more visible scar is therefore a result of a flap raised from the posterior interosseous artery. From among the forearm flaps which produce less visible donor scars, the first choice should be the ulnodorsal septocutaneous flap since it is raised on the ulnar edge of the forearm—an area little exposed in the functional position. The scar from raising a radial forearm flap on the radial side of the forearm is, compared to similar areas, more visible than a scar resulting from raising an ulnar flap. Any one of these flaps, if executed with reduced dimensions, which will permit the direct closing of the donor area, will cause fewer visible scars. The recurrent radial and ulnar flaps are useful for the reconstruction of areas in the elbow and it is important to point out the fact that the arteries that nourish these flaps are dispensable. When the flaps have small dimensions, it is possible to suture directly the donor area minimizing the aesthetic sequelae more so, with the recurrent ulnar flap as its donor scar is more concealed. For the reconstruction of large defects in the elbow it is possible to use both flaps simultaneously.
Conclusion In surgery of the hand, to reconstruct large cutaneous areas or in the case of simultaneous cutaneous, osseous and tendinous reconstructions we prefer to use the radial forearm flap as a fasciocutaneous, adipofascial or as a composite flap. For small areas localized proximally in the hand and not over the metacarpophalangeal joints, we opt for the ulnodorsal septocutaneous flap in which no important artery is sectioned. This flap produces, from an aesthetic point of view, fewer donor scars in the forearm. Given the importance of the ulnar artery in hand circulation and its proximity to the ulnar nerve, ulnar forearm flaps are used only in selected cases in spite of the scars in the donor areas being less visible. The posterior interosseous flap uses an artery that supplies almost all muscles in the posterior compartment of the forearm. This is why the use of this flap must be carefully thought out. The scar in the donor area of this flap is located in the dorsal region of the forearm and, of all the flaps described, is the most visible amongst those found in identical areas. We prefer to use the radial forearm flap and, for smaller areas, the ulnodorsal septocutaneous flap. For reconstruction of the elbow we prefer the recurrent ulnar flap if its donor scar will be less visible. If we need to reconstruct large areas we use both the recurrent ulnar and the recurrent radial flaps.
References Amarante J (1990) Retalhos Septocutâneos de Fluxo Invertido Contribuição Para o seu Estudo a Nivel Distal dos Membros. Tese de doutoramento da Universidade do Porto: Porto. Amarante J, Costa H, Reis J, Soares R (1986) A new distally based fasciocutaneous flap of the leg, Br J Plast Surg 39:338–40.
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Amarante J, Costa H, Reis J, Soares R, Carvalho F (1987) Um novo conceito em cirurgia plástica e reconstrutiva: retalhos venosos, (Prémio Pfizzer 1986), J Soc Cien Med Lisboa 5:229–54. Amarante J, Costa H, Reis J, Soares R (1988) Venous skin flaps: an experimental study and report of two clinical distal island flaps, Br J Plast Surg 41:132–7. Angrigiani C, Grilli D, Dominikow D, Zancolli E (1993) Posterior interosseous reverse forearm flap. Experience with 80 consecutive cases, Plast Reconstr Surg 92:285–93. Bardsley A, Soutar O, Elliot D, Batchelor G (1990) Reducing morbidity in the radial forearm flap donor site, Plast Reconstr Surg 86:287–92. Barreiro J, Huelin J (1980) Etude à l’aide de la radioanatomie de la vascularisation de l’avantbras et de la main acquisitions récentes In: Tubiana R, ed. Traité de Chirurgie de la Main. Vol 1. Masson: Paris, 332–49. Becker C, Gilbert A (1988a) Le Lambeau cubital, Ann Chir Main 7:136–42. Becker C, Gilbert A (1988b) Der Ulnaris-lappen, Handchir Mikrochir Plast Chir 20:180– 3. Becker C, Gilbert A (1991) Lambeau des branches distales de l’artére cubitale et son utilisation dans les récidives du canal carpian . In: Tubiana R, ed. Traité de Chirurgie de la Main. Vol 4. Masson: Paris, 527–32. Bellinger C, Smith J (1980) La vascularisation des nerfs du membre supérier. In: Tubiana R, ed. Traité de Chirurgie de la Main. Vol 1. Masson: Paris, 371–5. Bertelli JA (1993) Neurocutaneous axial island flaps in the forearm: anatomical, experimental and preliminary clinical results, Br J Plast Surg 46:489–96. Bertelli JA, Pagliei A (1998) The neurocutaneous flap based on the dorsal branches of the ulnar artery and nerve: a new flap for extensive reconstruction of the hand, Plast Reconstr Surg 101:1537–43. Biemer X, Stock W (1983) Total thumb reconstruction: a one stage reconstruction using an osteo-cutaneous forearm flap, Br J Plast Surg 36:55–9. Boorman J, Sykes P (1987) Morbidity in the forearm flap donor arm, Br J Plast Surg 40:207–12. Boyd B, Mulhollande S, Gullane P et al (1994) Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction. Are we making sense?, Plast Reconstr Surg 93:1350–9. Braun F (1977) Le Lambeau antebrachial en ilot en chirurgie de la main. A propos d’une série de 23 cas. Thése pour le Doctorar en Medicine. Université de Strasburg: Strasburg. Buchler U, Frey H (1991) Retrogade posterior interosseous flap, J Hand Surg 16A:283– 4. Budo J, Finucan T, Clarke J (1984) The inner arm fasciocutaneous flap, Plast Reconstr Surg 73:629–32. Christie D, Duncan G, Glasson D (1994) The ulnar artery free flap. The first 7 years, Plast Reconstr Surg 93:547–51. Coleman S, Anson B (1961) Arterial patterns in the hand based upon a study of 650 specimens, Surg Gynecol Obst 113:409–24. Costa M, Smith R, McGrouther DA (1988) Thumb reconstruction by the posterior interosseous osteocutaneous flap, Br J Plast Surg 41:228–30.
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Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J (1991) Further experience with the posterior interosseous flap, Br J Plast Surg 44:449–55. Culbertson J, Mutimer K (1987) The reverse lateral upper arm flap for elbow coverage, Ann Plast Surg 18:62–8. Daniel R, Terzis J, Schwarz G (1975) Neurovascular free flaps. A preliminary report, Plast Reconstr Surg 56:13–20. Dolmann S, Guimberteau J, Baude J (1975) The upper arm flap, J Microsurg 1:162. Elliot D, Bainbridge L (1988) Ulnar fasciocutaneous flap of the wrist, J Hand Surg 13B:311–15. Emerson J, Sprigg A, Page R (1985) Some observations on the radial artery island flap, Br J Plast Surg 38:107–12. Fatah F, Nancarrow J, Murray D (1985) Raising the radial artery forearm flap: the superficial ulnar artery trap, Br J Plast Surg 38:394–5. Fenton O, Roberts J (1985) Improving the donor site of the radial forearm flap, Br J Plast Surg 38:504–7. Gelberman R, Blasingame J (1981) The timed Allen test, J Trauma 21:477–9. Gelberman R, Nunley J, Koman L et al (1982) The results of radial and ulnar arterial repair in the forearm, J Bone Joint Surg 64A:383–5. Glasson D, Lovie M (1988) The ulnar island flap in hand and forearm reconstruction, Br J Plast Surg 41:349–53. Gottieb L, Levine L (1993) A new design for the radial forearm free-flap phallic construction, Plast Reconstr Surg 92:276–83. Guimberteau J, Goin J, Panconi B, Schmacher B (1988) The reverse ulnar artery forearm island flap in hand surgery: 54 cases, Plast Reconstr Surg 81:925–32. Holevich-Madjarova B, Paneva-Holevich E, Tjkarov V (1991) Island flap supplied by the dorsal branch of the ulnar artery, Plast Reconstr Surg 87:562–6. Hu W, Martin D, Foucher G, Baudet J (1994) Anterior interosseous flap, Ann Chir Plast Esthet 39:290–300. Huelin J, Barreiro F, Barcia E (1978) Etude radioanatomique des artéres interosseuses, Acta Anat 102:147–58. Kadry H, Hassan A, Tewfik O, Ismail M (1985) Recent fasciocutaneous flaps for repair of post-burn neck, axillary and elbow contractures, Ann Medit Burns Club 2:89. Katsaros J, Shusterman M, Bejju M (1984) The lateral upper arm flap anatomy and clinical applications, Ann Plast Surg 6:489. Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H (1995) The radial artery perforator based adipofascial flap for hand coverage, Ann Plast Surg 35:474–9. Lai M, Krishna B, Pelly A (1981) The brachioradialis myocutaneous flap, Br J Plast Surg 34:431. Liang M, Swartz W, Jones N (1994) Local full-thickness skin-graft coverage for the radial forearm flap donor site, Plast Reconstr Surg 93:621–5. Lovie M, Duncan M, Glasson D (1984) The ulnar artery forearm free flap, Br J Plast Surg 37:486–92. Lutz BS, Wei FC, Chang SC et al (1999) Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 cases, Plast Reconstr Surg 103:132–7.
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Maillard G, Meredith P (1991) Bilateral pinch reconstruction. Versatility of the Masquelet–Zancolli flap and the Wilkki operation, Plast Reconstr Surg 87:165–71. Maruyama Y, Takeuchi S (1986) The radial recurrent fasciocutaneous flap: reverse upper arm flap, Br J Plast Surg 39:458–61. Maruyama Y, Onishi K, Iwahira Y (1987) The ulnar fasciocutaneous island, Plast Reconstr Surg 79:381. Masquelet A, Penteado C (1987) The posterior interosseous flap, Ann Chir Main 2:131– 9. Masser M (1990) The preexpanded radial free flap, Plast Reconstr Surg 86:295–302. McCormack L, Cauldwell E, Auson B (1953) Brachial and antebrachial arterial patterns, Surg Gynecol Obstet 96:43–54. McGregor A (1987a) The Allen test—an investigation of its accuracy by fluorescein angiography, J Hand Surg 12B:82–5. McGregor A (1987b) The free radial forearm flap. The management of the secondary defect, Br J Plast Surg 40:83–5. Meland N, Core Tg, Hoverman V (1993) The radial forearm flap donor site: should we vein graft the artery? A comparative study, Plast Reconstr Surg 91:865–70. Muhlbauer W, Herndl E, Stock W (1982) The forearm flap, Plast Reconstr Surg 70:336– 41. Mutz S (1972) Thumb web contracture, Hand 4:236–9. Nakajima H, Fujino T, Adachi S (1986) A new concept of vascular supply to the skin and classification of the skin flaps according to their vascularization , Ann Plast Surg 16:1–11. Niranjan N, Shibu M (1994) The median forearm flap, Br J Plast Surg 47:272–4. O’Rahilly R (1986) Anatomy: A Regional Study of Human Structure. In: Gardner, Gray, O’Rahilly, eds. WB Saunders Company: Philadelphia. Parks B, Arbelaez J, Homer R (1978) Medical and surgical importance of the arterial blood supply of the thumb, J Hand Surg 3B:383–5. Parry S, Mathes S (1989) Blood supply of the upper extremity muscle as related to functional tendon transfers, Clin Plast Surg 3:531–6. Parry S, Ward J, Mathes S (1988) Vascular anatomy of the upper extremity muscles, Plast Reconstr Surg 81:357–60. Penteado C, Masquelet A, Chevrel J (1986) The anatomic basis of the posterior interosseous artery, Surg Radiol Anat 8:209–15. Pinal F, Taylor G (1990) The venous drainage of nerves. Anatomical study and clinical implications, Br J Plast Surg 43:511–20. Reid C, Moss A (1983) One-stage flap repair with vascularised tendon graft in a dorsal hand injury using the ‘Chinese’ forearm flap, Br J Plast Surg 36: 473–9. Reis J, Malheiro E, Santa Comba A, Amarante J (1994) The ulnar superficial forearm free flap. An alternative technique to the radial forearm flap. Proceedings of the 2nd Congress Federation of European Society for Microsurgery, Copenhagen. Revol M, Lantieri L, Loys S, Guerin-Surville H (1991) Vascular anatomy of the forearm muscles. A study of 50 dissections, Plast Reconstr Surg 88:1026–33. Reyes FA, Burkhalter WE (1988) The fascial radial arm flap, J Hand Surgery Am 13:432–7.
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Schoofs M, Bovet J, Panconi B, Amarante J, Daoud G, Baudet J (1983) Le Lambeau Chinois antebrachial technique et applications, Lille-Chirurgical 1:21–4. Song R, Song Y, Yu Y, Song K (1982) The upper arm free flap, Clin Plast Surg 9:27–35. Soutar D, Scheker L, Tanner N, McGregor I (1983) The radial forearm flap: a versatile method for intra-oral reconstruction, Br J Plast Surg 36:1–8. Stock W, Muhlbauer W, Biemer E (1981) Der neurovaskulare unterarm-insel-lappen, Zeitschript Plastische Chirurgie 5:158–163. Thatte R, Thatte M (1987) Cephalic venous flaps, Br J Plast Surg 40:16–19. Timmons M, Missotten F, Poole M, Davies D (1986) Complications of radial forearm flap donor sites, Br J Plast Surg 39:176–8. Tonkin M, Stern H (1989) The posterior interosseous artery free flap, J Hand Surg 14B:215–20. Yang G, Chen B, Gao Y (1981) Forearm free skin flap transplantation, Nat Med J China 61:139–42. Weinzweig N, Chen L, Chen Z-W (1994) The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical approach, Plast Reconstr Surg 94:675–84. Zancolli E, Agrigiani C (1986) Colgajo dorsal de antebrazo, Rev Assoc Argent Ortop Traumatol 51:161–8.
3 Pedicled muscle and musculocutaneous flaps Christoph Heitmann and L Scott Levin
It was Sterling Bunnell who said that trauma to the limb involves all types of tissue, irrespective of the divisions of surgical specialties that perform upper extremity surgery (Bunnell 1970). Therefore we believe, among others, that the combination of specialties, as represented in the orthoplastic approach, permits the best possible outcome in the treatment of the mangled upper extremity (Green 1994, Gopal et al 2000). The orthoplastic approach combines the best of two surgical specialists: the orthopedic surgeon with training and practice traditionally dedicated to the care of bone and joint injuries and the reconstructive plastic surgeon with expertise in soft tissue coverage and resurfacing (Levin 1993). Many recent advantages in reconstructive surgery have permitted greater salvage and more rapid restoration of the structure and function of injured upper extremity (Vasconez 1993). Stabilization, fixation and distraction of bony segments have been a key element in improving results. No less important has been the demonstration that rapid and optimal soft tissue reconstruction has a direct impact on the treatment of the limb as a whole. The primary goal of upper extremity reconstruction is to provide key functions such as sensory contact with the environment and the ability to manipulate objects. Described as the extension of the brain, the hand is the focus of reconstructive efforts and because the shoulder, arm and forearm permit the hand to accomplish all of its complex tasks, it is important to maintain or restore their function. The mangled upper extremity is a combination of injury to bones, joints, nerves and soft tissues. Skeletal stability is the basis for all other reconstruction, the initial management of the fracture sets the stage for subsequent events. It is beyond the scope of this chapter to go through all methods of fracture stabilization. Regardless what type of fixation is used, the importance of stable bone fixation must be emphasized, because the vascular, functional and soft tissue reconstruction depend on a stable skeleton. This chapter is limited to soft tissue coverage and reconstruction of the shoulder and brachium because the focus is on pedicled muscle and musculocutaneous flaps. The optimal timing of the soft tissue reconstruction in the severely traumatized upper extremity remains controversial. The argument favoring staged procedures is the need for a second look debridement (Gustilo et al 1990). If there is uncertainty about traumatized and devascularized tissue, a second look is done to allow more adequate debridement. The main argument for early reconstruction is to reduce the nosocomial contamination and secondary necrosis of exposed tissues. Late soft tissue reconstruction is associated with a significantly higher infection and flap complication rate when compared with early (within 72 hours) soft tissue coverage (Hertel et al 1999). We
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believe, that the overall timing of the soft tissue reconstruction should ideally be immediate or as soon as possible. In questionable cases we use Godinas’s principles, a second look and soft tissue reconstruction within 72 hours past the injury (Godina 1986). Although various pedicled muscle and musculocutaneous flaps have been described for soft tissue reconstruction of the shoulder and brachium (Palmer and Miller 1988, Vasconez and Oishi 1993), we found almost all wounds to be manageable by either the pedicled latissimus dorsi flap or its anterior homologue, the pectoralis major muscle flap. There are certainly other choices, but these two flaps were found to have dependable and consistent anatomy, long vascular pedicles, providing reliable and predictable results and therefore becoming the workhorses of reconstructions for severe injuries to the shoulder and brachium (Dowden and McCraw 1980, Stern and Carey 1988, Minami et al 1990). Apart from traumatic soft tissue loss they are very useful in contaminated wounds of the shoulder and in wounds caused by radiation. Ger, Chang and Mathes demonstrated the value of muscle flaps in the treatment of osteomyelitis, which are more resistant to bacterial infection and rapidly recover from inoculation with bacterial suspension (Ger 1977, Chang and Mathes 1982, Mathes et al 1982). This suggests that muscle flaps in general are ideally suited for the treatment of osteomyelitic lesions. In addition, the transposition of the latissimus dorsi has been used to restore flexion or extension of the elbow (Hovnanian 1956, Zancolli and Mitre 1973). Furthermore, we have used transfer of the latissimus and pectoralis major musculocutaneous flaps as an adjunct in the treatment of patients who had chronic osteomyelitis and septic arthritis of the shoulder.
Surgical anatomy Pedicled latissimus dorsi flap Extensive experience with the latissimus dorsi has shown it to be perhaps the most reliable and versatile of known flaps. It is the largest muscle in the body and is roughly quadrangular in shape, originating from the lumbar fascia and posterior part of the pelvis and inserting on the posterior aspect of the intertubercular groove of the humerus. Using the latissimus dorsi flap has resulted in no major demonstrable functional deficit. Its vascular supply is derived from the subscapular artery that bifurcates into the scapular circumflex and thoracodorsal arteries. The thoracodorsal artery continues posteriorly and inferiorly, giving off branches to the serratus anterior muscle. It enters the latissimus muscle together with the thoracodorsal nerve and vein at a well-defined neurovascular hilus, 2–3 cm medial to the lateral edge of the latissimus dorsi muscle and about 5 cm distal to the inferior scapular border. A secondary blood supply comes from several small perforator vessels along the spinous origin of the latissimus dorsi muscle. Based on the thoracodorsal artery, the rotation point is predictably located near the apex of the axilla posteriorly. This rotation point gives the flap an arc that allows it to reach the entire shoulder posteriorly and the upper arm. When the latissimus is used for reconstruction of the area of the upper arm and shoulder, the patient is placed in the lateral decubitus position and the entire hemithorax and the area of the arm that is to be reconstructed are prepared. The arm is left free to facilitate exposure and mobilization of the flap. Every soft tissue reconstruction starts
Severe traumatic defects of the upper limb
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with a thorough debridement and removal of all devitalized tissues from the area to be reconstructed. After the debridement it can be decided whether a functional muscle transfer, a muscle flap plus split thickness skin graft or musculocutaneous latissimus dorsi flap is best suited for the existing defect. Horizontal incisions can be used to gain access to the muscle, but a vertical incision is more direct and expedient. The incision begins on the posterior aspect of the posterior axillary fold and is carried further parallel to the main axis of the muscle fibers. The skin on either side is dissected off the muscle. After the muscle is exposed, dissection is carried onto its undersurface, starting at the axilla, with care taken to preserve the thoracodorsal artery on the undersurface of the muscle. The latissimus dorsi muscle is elevated off the chest wall. It is best to first cut distally along the iliac crest, which then gives better exposure for dividing the attachments to the thoracolumbar fascia and scapula. After the muscle has been fully elevated, the humeral insertion as well as the branch of the thoracodorsal artery to the serratus muscle needs to be divided if the full arc of rotation is required. For flap inset the latissimus dorsi muscle can be passed anteriorly to the upper arm or the shoulder through a tunnel. If the tunnel is felt to be too tight full extension of the incision to the defect is required to rule out compromise or torque of the pedicle. When a flexorplasty is performed to restore elbow flexion, either the coracoid or the acromion process is exposed by a deltopectoral incision, and the biceps tendon is exposed by a separate incision distally. Both incisions are connected by means of a subcutaneous tunnel situated on the anterior aspect of the arm. The former origin of the latissimus dorsi muscle is passed through the tunnel and is sutured into the biceps tendon. Next, the humeral insertion of the latissimus is fixed proximally to the coracoid or the acromion. The upper extremity is immobilized with the elbow in 100° flexion and full supination for 6 weeks in a posterior plaster splint. At this juncture active motion of the shoulder motion and elbow is initiated. The latissimus dorsi muscle can as well be utilized to restore elbow extension in cases of triceps palsy or traumatic loss of the triceps muscle. The humeral insertion is left intact and the origin is sutured to the triceps tendon, the periosteum of the olecranon and the connective tissue muscle septa on the extensor surface of the forearm. Pedicled pectoralis major flap The pectoralis major muscle is located in the anterior chest wall and in many ways matches the characteristics of the latissimus dorsi muscle. The pectoralis major is particularly useful for the repair of anterior shoulder defects. The pectoralis can be dissected out from beneath the skin, rotated into position, and split skin applied to its exposed surface, or it can be used as a myocutaneous flap. The pectoralis muscle receives its main blood supply from the thoracoacromial artery, a branch of the subclavian artery. This main vascular axis runs on the undersurface of the pectoralis major muscle and can be identified by Doppler preoperatively. In addition there are numerous perforating vessels from the internal mammary artery. For use in reconstruction of shoulder defects, the muscle can survive solely on the thoracoacromial axis and the chest wall perforators can be safely divided. When elevated upon the thoracoacromial axis, whether as a myocutaneous flap or as a muscle flap alone, the pectoralis major has as its rotation axis a point 2 cm below and slightly medial to the
Pedicled muscle and musculocutaneous flaps
27
coracoid process. Swinging upon this axis, the tip of the flap can completely cover the acromion, or head of the humerus. For flap harvest an oblique incision is marked from the coracoid down to either side of the nipple. The skin on either side is then elevated off the fascia of the pectoralis muscle. Once the entire muscle is exposed, dissection proceeds around its lateral margin on the chest wall. Care is taken to leave the pectoralis minor muscle and clavipectoral fascia intact. The fibers of origin of the pectoralis major are dissected bluntly off the chest wall, dividing the perforating branches of the internal mammary artery. When the pectoralis has been dissected free from the chest wall, it can be elevated and rotated into place. The effective length and reach of the flap is improved by dividing the insertion of the pectoralis major muscle. The pectoralis major muscle is quite vascular and accepts a skin graft readily. The donor wound can be closed primarily. If a skin component is incorporated we prefer situating the skin island above the pectoralis muscle. The pectoralis can also be used for biceps reconstruction, but requires lengthening of fascia to reach the biceps tendon.
Illustrative case reports Case 1 A 54-year-old patient presented with right elbow osteomyelitis and concomitant brachial plexus palsy after a gun shot wound (Fig. 1a). The patient underwent repeated irrigation and debridement including bony debridement with a high-speed burr until punctuate bleeding (the socalled paprika sign) as an indication for healthy bone was obtained. The soft tissue coverage was performed with a pedicled latissimus dorsi island flap (Fig. 1b– d). Case 2 A 36-year-old female patient was admitted for treatment of deep shoulder infection after radiotherapy, chemotherapy and partial resection of the scapula, resection of the proximal humerus and lateral clavicle (Tikhoff–Linberg resection) for a malignant ossifying fibromyxoid tumor (Fig. 2a). During the tumor resection there was also involvement of the brachial plexus, which had to
Severe traumatic defects of the upper limb
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Figure 1 (a) Chronic right elbow osteomyelitis. (b) Flap design of a pedicled latissimus dorsi flap. (c) Intraoperative view after transposition of the latissimus dorsi island flap to the elbow. (d) Result 6 months postoperatively. be partially sacrificed. The shoulder wound was open for 6 months and the patient suffered from constant pain. After thorough debridement the soft tissue defect at the shoulder measured 5 × 12 cm and was closed with a pedicled latissimus dorsi island flap. The patient is disease free since 18 months, shows no sign of infection and her pain status was classified as mild (Fig. 2b).
Pedicled muscle and musculocutaneous flaps
29
Figure 2 (a) Deep right shoulder infection. (b) Result 18 months after transposition of a pedicled latissimus dorsi island flap providing stable soft tissue coverage. Case 3 A 44-year-old patient had a severe, fulminant infection of the superficial fascia and subcutaneous tissue known as necrotizing fasciitis of the right upper extremity. The initial surgical incision revealed the pathognomonic liquefactive necrosis of the subcutaneous tissue and fascia with the characteristic appearance of grayish, watery and foul smelling fluid often referred to as ‘dishwater pus’. Immediate radical debridement was carried out well beyond the margins of the cellulitis. Repeated debridement including resection of the triceps muscle was warranted on a 12–24 hour
Severe traumatic defects of the upper limb
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Figure 3 (a) Right upper extremity after repeated debridement in a case of necrotizing fasciitis. (b,c) Result 6 months postoperatively after restoration of the elbow extension with a pedicled latissimus dorsi island flap. basis until the infection was controlled and healthy muscle and fascia were reached (Fig. 3a). For functional restoration of the elbow extension a pedicled myocutaneous latissimus dorsi flap was used. The residual defects have been addressed with split thickness skin grafts (Fig. 3b,c).
Pedicled muscle and musculocutaneous flaps
31
Case 4 A 66-year-old male patient sustained a deep shoulder infection after rotator cuff repair. The patient showed active drainage from an infected glenohumeral joint (Fig. 4a). After debridement, the patient was left with a soft tissue defect located at the anterior aspect of the shoulder, which was closed using a pectoralis major island flap (Fig. 4b). The flap was harvested from distally to proximally and the skin island on top of the muscle was rotated into the shoulder defect (Fig. 4c–f). Postoperatively the range of motion of the shoulder was limited (Fig. 4g). The patient achieved 40° forward elevation, 30° lateral elevation and 30° external rotation. However, 7 years after the operation the patient showed stable wound coverage, there was no sign of infection and the patient was pain free.
Figure 4(a,b) (a) Infected right glenohumeral joint. (b) Flap design of a pedicled pectoralis major flap.
Severe traumatic defects of the upper limb
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Figure 4(c,d) (c) Cranially reflected pectoralis major muscle with arrows indicating the thoracoacromial pedicle and the pectoral nerve. (d) Transposition of the island flap into the shoulder defect.
Pedicled muscle and musculocutaneous flaps
33
Figure 4(e,f,g) (e) Transposition of the island flap into the shoulder defect. (f,g) Functional outcome 12 months postoperatively.
Conclusion Each year, millions of persons sustain injuries of varying degrees of severity to the upper extremity. Orthopedic and plastic surgeons are frequently called on to treat these injuries. Injuries to the upper extremity should be treated acutely, definitively, and comprehensively. Collaboration between the orthopedic and plastic surgeons in the treatment plan is essential if the patient is to obtain the best result. The transfer of the pedicled latissimus dorsi flap and pectoralis major flap prove to be useful not only to restore elbow flexion and extension but also provide regional coverage of the soft tissue about the shoulder and brachium. In addition, we have successfully used both muscle flaps as an adjunct in the management of chronic osteomyelitis and septic arthritis of the shoulder and elbow.
References Bunnell S (1970) Surgery of the Hand. JB Lippincott: Philadelphia. Chang N, Mathes SJ (1982) Comparison of the effect of bacterial inoculation in musculocutaneous and random pattern flaps, Plast Reconstr Surg 70:1–10.
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Dowden RV, McCraw JB (1980) Muscle flap reconstruction of shoulder defects, J Hand Surg 5A:382–90. Ger R (1977) Muscle transposition for treatment and prevention of chronic post-traumatic osteomyelitis of the tibia, J Bone Joint Surg 59A:784–91. Godina M (1986) Early microsurgical reconstruction of complex trauma of the extremities, Plast Reconstr Surg 78:285–92. Gopal S, Majumder S, Batchelor AG, Knight AL, De Boer P, Smith RM (2000) Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia, J Bone Joint Surg 82B:959–66. Green AR (1994) The courage to co-operate: the team approach to open fractures of the lower limb, Ann R Coll Surg Engl 76:365–6. Gustilo RB, Merkow RL, Templeman D (1990) Current concepts review: the management of open fractures, J Bone Joint Surg 72A:299–304. Hertel R, Lambert SM, Muller S (1999) On the timing of soft tissue reconstruction for open fractures of the lower leg, Arch Orthop Trauma Surg 119:7–12. Hovnanian AP (1956) Latissimus dorsi transplantation for loss of flexion or extension of the elbow. A preliminary report on technic, Ann Surg 143:493–9. Levin LS (1993) The reconstructive ladder. An orthoplastic approach, Orthop Clin North Am 24: 393–409. Mathes SJ, Alpert BS, Chang N (1982) Use of muscle flaps in chronic osteomyelitis: experimental and clinical correlation, Plast Reconstr Surg 69:815–29. Minami A, Ogino T, Ohnishi N, Itoga H (1990) The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopedic surgery, Clin Orthop 260:201–6. Palmer RS, Miller TA (1988) Anterior shoulder reconstruction with pectoralis minor muscle flap, Plast Reconstr Surg 81:437–42. Stern P, Carey JP (1988) The latissimus dorsi flap for reconstruction of the brachium and shoulder , J Bone Joint Surg 70A:526–35. Vasconez HC, Oishi S (1993) Soft tissue coverage of the shoulder and brachium, Orthop Clin North Am 24:435–48. Zancolli E, Mitre H (1973) Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases, J Bone Joint Surg 55A:1265–75.
4 Free flaps Horacio Costa
Introduction The anatomy of the upper limb allows the surgeon to design a variety of local, pedicle or island flaps to cover small and median defects. For larger defects, it is necessary to use flaps from distant donor sites. The past two decades have seen major changes in reconstructive surgery of the upper extremity (Buncke and Schulz 1966, Bunck et al 1966, Cobbett JR 1969, Ikuta et al 1976, Yang and Gu 1979). The most important changes have been the timing of the reconstruction and the quality of transferred tissues available. Following the description of axial pattern flaps, the traditional teaching of length to breadth ratio in flap design became obsolete (McGregor and Morgan 1973, Cormack and Lamberty 1984). Large defects could thus be resurfaced immediately, but the hand still had to be attached to the body. For many patients, this resulted in unnecessary joint immobilization, stiffness and tenodesis. The advantages of the free flap over the distant pedicle in upper limb reconstruction are well documented. Free tissue transfers usually require only one operation and often allow all other reconstructive procedures to be done in a single stage (Höpfner 1903, Lapchinsky 1960, Komatsu and Taimai 1968, Biemer 1977a, Biemer and Duspira 1982, Costa 1994). Free flaps bring new blood supply to the reconstructed area, whereas the distant pedicle flap is parasitic on the recipient site after division of the pedicle. Free flaps also allow elevation of the hand and immediate motion. Physical therapy is started as soon as the patient recovers from anaesthesia, and reduces postoperative oedema and stiffness. None of this is possible when pedicle flaps are used, as they restrict the mobility of the hand and all joints proximal to the site of injury. Pedicle flaps still play an important part in the reconstruction of the hand that is, to provide extra skin cover. The groin flap fulfils an important role as a skin provider prior to toe transfer in cases of extensive soft tissue loss on the hand. As a pedicle flap it does not require dissection around the main arteries of the hand, which thus may be saved for use when the toe or toes are subsequently transferred. Its donor site is inconspicuous, thus it is a first choice in females. The distally based posterior interosseous fasciocutaneous island flap also has all these advantages, except the donor site is not inconspicuous. It is the author’s first choice for hand skin resurfacing (Fig. 1) (Costa and Soutar 1988, Costa et al 1988, 1991, 1996, Costa 1994).
Severe traumatic defects of the upper limb
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Principles of management A complex injury to the upper limb can be defined as one that involves two or more tissues of the limb and which jeopardizes upper limb function or survival. There are two major dangers, which arise in the immediate post trauma phase. The first is devascularization, which leads to necrosis and threatens the local survival of a particular structure. The second is oedema and its inevitable sequela, stiffness, which may severely impair the final functional result (Burke 1971, Robson et al 1974, Janzekovic 1975, Nylen and Carlsson 1980). Microsurgery has proved to be a powerful tool in the treatment of these two complications, by allowing arterial repair and hence revascularization and also venous repair to improve circulatory return and help combat oedema. The overall beneficial effects of improved vascularization include a favourable influence on the healing of skin, bone, tendon, nerve and other structures (Costa 1994).
Figure 1(a–f)
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Figure 1(g,h) (a,b) Defect before and after debridement with exposed bones. (c) Drawing of the distally based island flap. (d) The flap is raised based on the septum between the extensor carpi ulnaris and extensor digiti minimi. (e) The distally based posterior interosseous island flap has been transposed. (f) Postoperative appearance at 2 months (proximal to injury zone, the radial artery is uninjured and is available for late toe transfer). (g) Drawing of the second toe transfer on the right foot. (h) The thumb reconstruction after 3 months. Reproduced with permission of the Editor, Eur J Plast Surg 1996; 19:92–6. Immediate skin cover is preceded by thorough debridement of all dead tissue (Janzekovic 1975, Guofan et al 1981). The simplest method of obtaining skin cover is to use skin grafts but this requires a vascularized bed and immobilization to allow a satisfactory graft to take. Regional arm and forearm flaps have revolutionized skin cover of the upper extremity and form part of the reconstructive armamentarium. The main indications for a free flap in upper extremity reconstruction are where no local or regional flap can be used, extensive lesions of the arm, forearm and hand. Where specific large tissue losses are present the free flaps can be used as functional muscle, tendons, nerves, bone and fingers (Costa 1994). Many free flaps are available for use in reconstruction of the upper extremity. Choosing a flap with minimum donor site morbidity is a primary consideration in reconstructive surgery. With the current variety of free flaps, coverage may be tailored to the needs of the upper extremity recipient site, matching soft tissue, skin thickness, texture and colour. Thus, the defect to be reconstructed must be assessed for its need for bulk and surface cover. The selection of the flap will be governed, in part, by this assessment. In general, muscle flaps are used when defects require a relatively large volume flap and fascial and fasciocutaneous flaps are used to provide less bulky surface cover or a functional reconstruction.
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Muscle and musculocutaneous flaps (Table 1) These have the advantage that they can be placed between structures, thus filling what otherwise would be dead space. They well vascularize the areas in which they are placed and are helpful in treating both acute defects and defects left by debridement of bone following chronic osteomyelitis (Mathes and Nahai 1982). The muscle tissue is also quite useful for transfer as a functioning unit when microneurovascular anastomoses are performed (Fig. 2f–h) (Ikuta et al 1976, Manktelow and McKee 1978, Schenk 1978, Mathes and Nahai 1982).
Fascial and fasciocutaneous flaps (Table 2) These are excellent for coverage of large surfaces, although they lack the bulk to fill dead space. They result in minimal donor site morbidity and do not restrict range of motion in the
Table 1 Musculocutaneous free tissue transfers. Site Latissimus Serratus Rectus dorsi anterior abdominis Muscle size 25 × 35 12 × 10 5 × 20 (cm) Skin territory 30 × 40 12 × 5 14 × 25 (cm) Pattern of Dominant Two Two blood supply pedicle and dominant dominant secondary pedicles pedicles segment pedicles Vessel Thoracodorsal Lateral Superior artery and vein thoracic/ epigastric/ thoracodorsal inferior epigastric Pedicle length (cm) Calibre (mm) Sensory nerve
9.3
8/9.3
3.5/4
2.7
2.5/2.7
2/2.2
Segmental Segmental intercostal, T2– intercostal, T6 T2–T4
Tensor fascia lata 5×5 8 × 30 Dominant pedicle
Gracilis 6 × 30 8 × 15 Dominant pedicle and minor pedicle
Lateral Medial circumflex circumflex branch of femoral profunda artery femoris 6 5 1.8
Segmental Lateral femoral cutaneous
1.5 Medial cutaneous of thigh
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Motor nerve Thoracodorsal Long thoracic Segmental Superior gluteal Nerve length (cm) Osseous territory Accessibility Donor site function loss Donor site appearance
12.3
10
5
None
6th, 7th ribs
None
Anterior branch of obturator 5
Iliac crest
Good Fair Fair Good Not important Adduction of Abdominal Minimal scapula wall strength Good to fair Good Good Fair
None Good Not important Good
Table 2 Fasciocutaneous free tissue transfers. Site Temporal Scapular Lateral Radial Dorsalis fascia arm forearm pedis Skin territory (cm)
7 × 7 (deep 12 × 8 fascia), 14 × 12 (superficial fascia) Pattern of Dominant Dominant blood supply pedicle cutaneous pedicle
Vessel
10 × 6
20 × 10
First web Second toe space of foot 6 × 9 (11 6 × 3 (14 5 × 6 (length × 9) × 7.5) and circumference of toe)
Dominant Dominant Cutaneous and pedicle pedicle secondary (flowcutaneous through) pedicle (flowthrough) Superficial Circumflex Profunda Radial Dorsalis temporal scapular brachii artery pedis artery (posterior artery radial collateral) 2.5 6 5 10 15
Pedicle length (cm) Calibre 1.6 (mm) Sensory None nerve
1.8
1.5
2.5
Segmental Posterior Medial intercostal cutaneous and
1.5
Cutaneous Two pedicle cutaneous pedicles
First First dorsal dorsal metatarsal metatarsal and plantar artery digital arteries 7.4 7.4/3 1.3
1.3/1.2
Superficial Deep Superficial peroneal peroneal and deep
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of arm
Osseous territory
None
Accessibility Good Donor site None function loss Donor site Good appearance
lateral cutaneous of forearm Lateral Lateral Distal Second None border of aspect of radius metatarsal scapula humerus (10 × 1 (10 × 1 cm) cm) Good Good Good Good Good None None None Minimal Minimal
Good
Fair
Fair
Fair
Good
peroneal, plantar digital
Toe phalanges
Good Sport activities, long walks Good
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Figure 2 (a) Crush-degloving injury, involving the anterior aspect of the left forearm, with loss of skin, flexor muscles, radial and ulnar arteries, median and ulnar nerves and an ischaemic hand. (b) Marking of the flow-through radial flap. (c) Raised flap, including palmaris longus (PL) tendon. (d) Transposed flap after proximal and distal arterial and venous anastomoses have been performed. The arrow points to the thrombosed interpositional reversed
Severe traumatic defects of the upper limb
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saphenous graft to the ulnar artery. (e) Appearance at 4 months after surgery illustrating viability of the flap and the hand. (f,g) Drawing and harvesting of the free functional muscle transfer. (h) Appearance at 7 months after surgery. Already the patient has a useful grip capacity. Reproduced with permission of the Editor, Eur J Plast Surg 1991; 44:533–7. majority of cases (Fig. 3) (Lamberty and Cormarck 1983, Cormarck and Lamberty 1984). Osteomyofasciocutaneous flaps These have specific indications for reconstruction of bone defects in the upper limb. These include the length of the defect, quality of surrounding soft tissue, malignancy (where chemotherapy or irradiation may be considered postoperatively and it is essential to maintain bone support while awaiting union and hypertrophy) and a record of prior failed conventional bone grafting techniques. Any long bone defect exceeding 8–10 cm in the upper limb should be considered for reconstruction by vascularized bone transfer. Shorter defects may warrant consideration if there are additional factors such as a poor surrounding soft tissue milieu due to prior infection or multiple surgical procedures. Management of extraarticular long bone defects in the upper extremity may be amenable to a variety of reconstructive measures including shortening, cancellous or corticocancellous autografts, synostosis, bone transport, vascularized bone grafts, diaphyseal allografts and metallic prosthetic replacement. Shortening and bone grafting in some form are the most widely applied techniques (Allien et al 1981, Dell and Sheppard 1984). The choice of the bone free flap is not a difficult task, since for the overwhelming majority of upper limb bone defects (for which a microvascular bone graft is indicated) the fibula is the preferred donor bone. A number of factors favour the fibula. A length of up to 30 cm can be obtained and the diameter of the fibula approximates that of the radius and ulna. For humerus reconstruction the fibular diameter permits intramedullary placement and demonstrates the ability to hypertrophy to the size of the diaphysis of the humerus. The cortical structure of the fibula permits excellent internal fixation potential with plates and/or screws. For radius and ulnar reconstructions, the fibula has a similar diameter to the diaphyses of the forearm bones. Frequently, for radius reconstruction the distal fibula end may be impaled into the distal radius metaphyseal flare (Pho 1979, Weiland et al 1979, Wood 1987, Zhong-Jia 1987). The anterior iliac crest based on the deep circumflex iliac vessels may occasionally be useful for reconstruction near the distal metaphysis of long bones or for reconstruction of a bony defect in the carpus. The author has encountered a situation of extensive carpal osteomyelitis where, after total bone carpal removal, a vascularized anterior iliac crest free flap was successfully transferred.
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Emergency free flaps The concept of emergency free tissue transfer was developed by Marko Godina (1986). In a series of 134 upper and lower limb traumatic injuries, 80% of the flaps were transferred immediately following the patient’s admission to hospital and 20% within 72 hours after injury, so defining the group of early free flaps. Lister and Scheker (1988) defined the emergency free flap as the flap transferred for coverage of soft tissue defects at the time of the first surgical procedure and during the first 24 hours after injury. The idea that the probability of failure of free tissue transfer is greater if done as an emergency procedure, still exists. Godina’s experience clearly demonstrated the opposite—his failure rate in 134 emergency and early free flaps transfers was 0.75%, compared with a 12% failure rate observed in his series of 167 delayed reconstructions (Godina 1986). Lister and Scheker (1988) reported 6.05% failure rate in 31 emergency free flaps; Arnez (1993) reinforced the concept with his 3% failure rate in 100 emergency free flaps. Costa et al (1997a) report a series of nine acute free flaps in head, upper and lower limb injuries with no postoperative infections and no failures, definitively confirming the reliability of the free flap concept. Combined orthopaedic and plastic surgery teams dealing with major trauma must follow strict principles of management to develop the most efficient approach for extensive wounds with large zones of injury. The first aim is to control infection and the principle is radical debridement (Janzekovic 1975, Haury et al 1978). Infection is present in granulation tissue which is poorly penetrated by systemic antibiotics (Burke 1971, Robson et al 1974). Nylen and Carlsson’s study, on upper extremity trauma treated with a conservative approach and serial debridement, had a 52% infection rate, while Godina reported a 17.5% infection rate during treatment of 167 grade III traumatic injuries on both lower and upper extremities (Nylen and Carlsson 1980, Godina 1986). The infection rate in 134, 31, 100 and 9 patients dropped drastically to 1.5% (Godina 1986), 9.7% (Lister and Scheker 1988), 2% (Arnez 1993) and 0% (Costa et al 1997a) respectively when these authors analysed their series of radical debridement and emergency free flap reconstructions.
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Figure 3 (a) Crush-degloving injury involving the dorsum of the left hand, with loss of skin and extensor tendons of the index, middle, ring and little fingers with tangential bone losses of the 2nd and 3rd metacarpal bones in a dental surgeon. (b) Marking of the tendofasciocutaneous dorsalis pedis flap on the dorsum of the left foot. (c) Raised flap, including long extensor tendons of the 2nd, 3rd, 4th and 5th toes, great saphenous vein, dorsalis pedis vessels and superficial peroneal nerve. (d–f) Appearance at 13 months after surgery. Good functional result of extension and flexion of the fingers. Good cosmetic result due to the similarities of the skin between the dorsum of the foot and hand. Open wounds are subject to further loss of tissues and extension of the zone of injury due to bone and tendon desiccation and formation of granulation tissue (Godina 1986,
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Lister and Scheker 1988, Arnez 1993, Costa et al 1997a). The best surgical exposure of the whole wound is possible immediately after radical debridement, when there is no tissue fibrosis, friability or granulation, no anatomical structures displacement by wound contracture and no retraction of recipient blood vessels which still have integrity of their walls. For these reasons the success rate is higher in all series of emergency and early free flap transfers compared with the series of serial debridement and delayed wound closure. Nowadays, free tissue transfer is not a lengthy and unpredictable procedure. The entire initial procedure, which always includes debridement and frequently bone fixation, tendon repair, revascularization and even nerve grafting, should average under 5 hours for small defects, under 8 hours for medium defects and under 12 hours for large defects (Lister 1988, Lister and Scheker 1988). In our series, the longest procedures were all related to the flow-through radial midforearm flaps for coverage–revascularization and coverage–reimplantation, taking on average 10 hours. The total operating time per patient is in fact reduced, since the main reconstruction is accomplished in a single big operative procedure. Our shortest operative procedures took 7 hours (Costa et al 1997a). Cost effectiveness should also be considered. In Godina’s series the average length of hospital stay was 27 days and the average number of operations was 1.3 per patient (Godina 1986). In Lister and Scheker’s (1988) series of upper extremity injuries the average hospital stay was 11.8 days and 27 out of 31 patients returned to work, 18 of them to their previous employment. In Arnez’s (1993) series of 100 emergency free flaps the hospitalization ranged between 14 to 25 days. In our series the average hospital stay was 27.8 days (range 20–44 days) and the average number of operations was 2 per patient (Costa et al 1997a). Age is not a contraindication for the use of acute free flaps as clearly demonstrated by Lister (1988); the youngest patient on whom this author has performed an early free flap was 2.5 years old, the oldest was 76 and both did well. This point is also reinforced by our series in which the youngest patient was 4 years old and the oldest 65 (Costa et al 1997a). Thus, emergency free flaps have proved to be a more reliable technique than delayed wound closure, offering the patient an effective method of reconstruction with significant advantages in postoperative form and function. One-stage coverage and revascularization of traumatized limbs by a flowthrough radial mid-forearm free flap On analysing all the described axial flaps, one finds that few have the capacity to allow a flowthrough circulation. The theoretical idea of flow-through circulation was suggested by Soutar et al (1983) for head and neck reconstruction, that is, establishing an uninterrupted arter ial flow through a flap between the external carotid and distal facial artery. It was also suggested by Cormack and Lamberty (1984) with the use of Siamese or sister flaps in which a flap could be attached onto the end of another flap. Lamberty and Cormack (1983) reported one clinical case of head and neck reconstruction in which they used an antecubital fasciocutaneous free flap to reconstruct an excisional defect after removal of a squamous cell carcinoma, involving the left pinna and external auditory meatus. The proximal end of the divided facial artery was
Severe traumatic defects of the upper limb
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anastomosed to the proximal end of the radial artery and the distal end of the radial artery was looped back to be anastomosed to the distal end of the facial artery. The flaps which were considered suitable for this were the antecubital forearm flap (Lamberty and Cormack 1983) and the radial forearm flap (Lamberty and Cormack 1983, Soutar et al 1983). Costa et al (1991b) described the practical use of this concept in two clinical cases (hand and foot) in which uninterrupted arterial and venous flow was established through the radial mid-forearm fasciocutaneous flap, allowing revascularization of the ischaemic extremity (Fig. 4). The clinical importance of this concept is paramount. Exposure of deep structures, like tendons, nerves and/or bone with vascular damage which often accompanies major trauma of the extremities, may warrant flap cover with its own blood supply. If the clinical situation is complicated by ischaemia of the distal segment (hand or foot), we are dealing with a double problem of coverage and revascularization. In this type of situation, the choice of soft tissue reconstruction is not just dependent on the immediate problem of wound closure, the quality of the soft tissue cover or the possibilities of subsequent reconstruction, but we must also consider the vascular pattern of the flap to be used, allowing a flow-through circulation to achieve a one-stage technique of soft tissue coverage and distal revascularization, without having to resort to an interpositional reversed vein graft to bridge the vascular gap (see Fig. 2). The radial forearm flap is based on the radial artery which is included in a condensation of the deep fascia, called the lateral intermuscular septum of the forearm. The radial mid-forearm flap combines the advantages of easy dissection, is hairless, has thin skin and provides a suitable bed for grafting, inclusion of bone and, most importantly, the possibility to dissect proximal and distal vascular pedicles allowing a flowthrough circulation to be established. Another advantage is that either the venae comitantes or a superficial vein, or both, may be used to drain the flap and the distal revascularized segment of the extremity; this double venous drainage system of the flap links the superficial and deep venous systems of the reconstructed extremity. We believe that this technique achieves, possibly, the most physiological reconstruction in these clinical situations. The antecubital fasciocutaneous flap based on the inferior cubital artery, a branch of the radial artery, has been described by Lamberty and Cormack (1983); it was classified as a type B modified fasciocutaneous flap (Cormack and Lamberty 1984). Its essential characteristic is the T-junction between the pedicle and the radial artery which enables a much longer distal arterial pedicle to be dissected; another advantage is that the length of the pedicle is independent of the flap length whereas in the radial forearm flap the length of the pedicle is inversely related to the size of skin flap. However, two major draw
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Figure 4 Diagram showing the anatomical and dynamic concept of a flowthrough fasciocutaneous free radial mid-forearm flap; a, superficial vein; b, venae comitantes; c, radial artery; and d, lateral fascial intermuscular septum of the forearm. backs exist with this flap: the absence of a significantly sized inferior cubital artery and the type C variety of this flap in which the vessel arises from the radial recurrent artery which has its point of origin from the brachial artery. Other axial flaps may be used to put this dynamic concept of flow-through circulation into practice. The lateral arm flap is based on the posterior radial collateral artery, which is a branch of the profunda brachii artery and has been described by Song et al (1982) and Katsaros et al (1984). This flap has a shorter and thinner pedicle, particularly distally where its artery anastomoses with the recurrent interosseous artery, and its elevation is more difficult compared with the radial forearm flap. While it would probably be possible to use this flap as a flowthrough flap, this has not been reported to our knowledge. The ulnar forearm flap is based on the segment of the ulnar artery distal to the common interosseous branch and has been described by Lovie et al (1984); many of its properties are shared with the radial flap although with some advantages: less hairy territory, less obvious donor site and, more importantly, when the flexor carpi ulnaris muscle is included in the flap, it may be used to fill cavities. On the other hand, disadvantages are also present, such as a slightly more difficult dissection and the danger of devascularization of the ulnar nerve. In conclusion, the flow-through concept is of considerable use in the field of major trauma of the extremities where compound tissue losses are combined with devascularization of the distal segment. The free flaps which offer adequate characteristics for this vascular achievement are the radial forearm, the ulnar forearm, the antecubital forearm and the lateral arm fasciocutaneous flap, although we believe the advantages of the mid-forearm radial flap outweigh those of the other flaps. The flow-through free flap in reimplantation surgery Reimplantation and revascularization of extremities continue to be demanding tasks for the plastic and reconstructive surgeons. Their need increases in proximal, total or subtotal amputations, because of loss of length. If we are dealing with avulsion type injuries, the
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major pitfall is the extent of vessel damage both in the proximal amputated stump, and in the distal amputated part. Consequently, vascular anastomosis must be performed as far proximally and distally, requiring greater bone shortening or longer interposition vein grafts. Biemer (1993) defined replantation as the operative reconstruction of amputation injuries, including the reconnection of various structures, including the blood vessels which will guarantee the viability of the amputated part. Since the introduction of vein grafts by Biemer (1977b), replantation and revascularization has become possible in avulsion and heavy combined crushing injuries allowing re-anastomosis through a
Figure 5 Diagram showing the anatomical and dynamic concepts of flowthrough fasciocutaneous free flaps in replantation. bridge over and out of the zone of trauma. Nowadays, they play a major role in replantation surgery. However, this useful technique does not have soft tissue coverage capacity which is paramount in certain types of replants. Costa et al (1997b) described the practical use of the flowthrough free flap concept in hand replantation (Fig. 5). Considering the main vascular pedicles, we have two kinds of situation: (1) the absence of major longitudinal losses of the vessel ends, allowing end to end anastomosis with some bone shortening and (2) the presence of major longitudinal losses of the vessel ends making techniques for their reconstruction the key point for re-establishment of blood flow. Bone shortening is limited, particularly in the lower limb to a maximum of 5–6 cm and can be performed either proximally in the amputated stump or distally in the amputated part. Interpositional vein grafts are the method of choice to bridge the vascular gaps and are usually harvested from the great and small saphenous, cephalic and basilic veins or their tributaries, depending on the length of the vascular defect and the diameter of the vessels. Biemer and Duspiva (1982) list the following indications for vein grafts. • vessel defects (arterial and venous) • difficult anastomoses with short vessel stumps • to bypass bifurcation and tributaries
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• tension at the site of anastomosis • differing vessel calibres. In major trauma of the extremities, including total and subtotal amputations, flap cover is desirable when exposure of deep structures like tendons, nerves and/or bone is present (ZhongJia 1987, Costa et al 1997a). In these clinical situations the flow-through free flap concept is the method of choice (Costa 1991). There are two types of free flap which allow the clinical application of this concept in replantation surgery. 1. The flow-through free fasciocutaneous flap for arterial supply and venous drainage of the replant (Fig. 6). 2. The flow-through free venous flap for venous drainage of the replant (Fig. 7). The flow-through free fasciocutaneous flap is a one-stage technique of soft tissue cover and distal revascularization. This technique has other important advantages: • Reconstruction of the arterial defect by another artery. • Reconstruction of the superficial and deep venous systems by the superficial and deep veins of the flap. • Anatomical link between superficial and deep venous systems through the flap. • Maintenance of the collateral vessels in the traumatic defect by the flap tissue. • No major discrepancies in the microvascular anastomosis. The flow-through venous flap also is an interesting and evolutionary concept. Baek et al (1985) and Amarante et al (1988) presented experimental work in the dog, testifying the viability of the flow-through venous saphenous flap. Successful clinical cases have been reported and Honda et al (1984) have used skin and subcutaneous tissue as free venous carriers for digital replants, including dorsal skin losses with success in two out of five cases (Dell and Sheppard 1984, Honda et al 1984, Chavoin et al 1987, Thatte and Thatte 1987, Amarante et al 1988). A recent finding must be brought into the discussion about the survival of these flowthrough venous flaps. The experimental work of Noreldin et al (1992) has confirmed the importance of the
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Figure 6 (a,b) Oblique transcarpometacarpal amputation of the left hand (palmar and dorsal aspects). (c) The crush-degloving injury of the amputated stump. (d) Bone fixation of the amputated part without bone shortening. The segmental injury of the radial vessels is shown between arrows. (e) Marking of the flow-through fasciocutaneous radial flap. (f,g) Harvesting of the free flap. (h) Appearance at 4 months after surgery. Already, the patient has a useful grip capacity. Reproduced with permission of the Editor, Eur J Plast Surg 1997; 20:181–5.
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Figure 7 (a) Transmetacarpal amputation of right hand. (b) Dorsal aspect of the amputated stump with skin loss and absence of dorsal veins. (c) Palmar aspect of the amputated stump with skin incisions for dissection of the radial artery and harvesting of the basilic vein graft. (d) The free dermal flow-through venous flap. (e) Immediate postoperative result with split graft applied over the flap. (f–h) Appearance at 5 months after surgery. A good range of motion was achieved with a useful grasp. Reproduced with permission of the Editor, Eur J Plast Surg 1997; 20:181–5.
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perivenous areolar tissue in perfusion of the skin island in the rat inferior epigastric venous flap. Shalaby and Saad (1993) presented histological studies of the pedicles of long and short saphenous and cephalic venous flaps in fresh human cadavers and in two clinical cases, showing that one or two arterioles and multiple capillaries were present in the perivenous areolar tissue. Lenoble et al (1993) showed experimentally the incapacity for a vein to nourish a flap in the epigastric and thoraco-abdominal flow-through venous flaps of the rat, if the vein was meticulously cleaned of the perivenous areolar tissue. The authors concluded that the survival observed in clinical reports could be explained by the simultaneous preservation of arterial microcirculation in the perivenous fat, augmentation of blood flow and pressure and by exchanges with the recipient bed. This challenges the concept that these flaps are purely venous. These explanations seem to be supported by Chow et al (1992). Sequentially linked free flaps are a very interesting and useful concept. The complex threedimensional nature of composite head and neck defects after tumour extirpation may challenge the ability of any single osteocutaneous flap to adequately reconstruct all aspects of the resultant defect. Sequentially linked free flap reconstructions, consisting of one free flap linked to the second, have become a preferred method of reconstruction for complex composite head and neck defects when there is limited recipient site vascularity (Sanger et al 1990, Wells et al 1994).
Acknowledgement The author would like to thank his wife, Fernanda Zenha for her help and encouragement to accomplish this work, and for typing the manuscript and the line drawings.
References Allien Y, Gomis R, Yoshimura M, Dimeglio A, Bonnel F (1981) Congenital pseudarthrosis of the forearm. Two cases treated by free vascularised fibular graft, J Hand Surg 6:475–81. Amarante J, Costa H, Reis J, Soares R (1988) Venous skin flaps: an experimental study and report of two clinical distal island flaps, Br J Plast Surg 41:132–7. Arnez ZM (1993) Acute free flaps. In: Soutar D, ed. Microvascular Surgery and Free Tissue Transfer. Edward Arnold: London, 140–51. Baek SM, Weinberg H, Song Y, Park CG, Biller HF (1985) Experimental study of the survival of venous island flaps without arterial inflow, Plast Reconstr Surg 75:88–95. Biemer E (1977a) II. Zehentransplantation. Vortrg auf Third Congress of European Section of the International Confederation for Plastic and Reconstructive Surgery: The Hague, May 22–27. Biemer E (1977b) Vein grafts in microvascular surgery, Br J Plast Surg 30:197–201. Biemer E (1993) Current status of replantation surgery. In: Soutar D, ed. Microvascular Surgery and Free Tissue Transfer. Edward Arnold: London, 43–53. Biemer E, Duspiva W (1982) Reconstructive Microvascular Surgery. Springer-Verlag: Berlin.
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Buncke HJ, Schulz WB (1966) Total ear reimplantation in the rabbit utilizing microminiature vascular anastomoses, Br J Plast Surg 10:15–22. Buncke HJ, Buncke CM, Schulz WB (1965) Experimental digital amputation and reimplantation, Plast Reconstr Surg 36:62. Buncke HJ, Buncke CM, Schulz WB (1966) Immediate Nicoladoni procedure in the Rhesus monkey, or halluxto-hand transplantation, utilizing microminiature vascular anastomoses, Br J Plast Surg 19:332–7. Burke JF (1971) Effects of inflammation on wound repair, J Dent Res 50:296–302. Chavoin JP, Rouge D, Vachand M, Boccalon H, Costaglioga M (1987) Island flaps with an exclusively venous pedicle. A report of eleven cases and a preliminary haemodynamic study, Br J Plast Surg 40:149–54. Chow SP, Chen DZ, Gu YD (1992) A comparison of arterial and venous flaps, J Hand Surg 17B:359–64. Cobbett JR (1969) Free digital transfer: report of a case of transfer of a great toe to replace an amputated thumb, J Bone Joint Surg 51B:677–9. Cormack GC, Lamberty BGH (1984) A classification of fasciocutaneous flaps according to their patterns of vascularisation, Br J Plast Surg 37:80–7. Costa H (1994) Estudo anatómico e aplicações clínicas de retalhos livres microcirúrgicos, Tese de Doutoramento, Universidade do Porto. Costa H, Soutar DS (1988) The distally based island posterior interosseous flap, Br J Plast Surg 41:221–7. Costa H, Smith R, McGrouther DA (1988) Thumb reconstruction by the posterior interosseous osteocutaneous flap, Br J Plast Surg 51:228–33. Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J (1991a) Further experience with the posterior intereosseous flap, Br J Plast Surg 44:449–55. Costa H, Guimarães I, Cardoso A, Malta A, Amarante J, Guimarães F (1991b) Onestaged coverage and revascularisation of traumatised limbs by a flow-through radial mid-forearm free flap, Br J Plast Surg 44:533–7. Costa H, Cunha C, Silva A, Malheiro E, Luz M, Guimarães I, Conde A, Cardoso R (1996) One real advantage of the distally based posterior interosseous island flap, Eur J Plast Surg 19:92–6. Costa H, Cunha C, Cardoso A, Bardsley A (1997a) Emergency free tissue transfer, Eur J Plast Surg 20:122–6. Costa H, Cunha C, Conde A, Barsdley A, McGrouther DA (1997b) The flow-through free flap in reimplantation surgery: a new concept, Eur J Plast Surg 20:181–5. Dell PC, Sheppard JE (1984) Vascularised bone grafts in the treatment of infected forearm non unions, J Hand Surg 9:653–8. Foucher G, Norris RW (1988) The venous dorsal digital island flap or the neutral flap, Br J Plast Surg 41:337–43. Godina M (1986) Early microsurgical reconstruction of complex trauma of the extremities, Plast Reconstr Surg 78:285–92. Guofan Y, Baoqui C, Yuzhi G (1981) Forearm free skin flap transplantation, Natl Med J China 61:139. Haury B, Rodeheaver G, Vensko J et al (1978) Debridement: an essential component of traumatic wound care, Am J Surg 135:238–42.
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Honda T, Nomura S, Yamanchi S, Shimamura K, Yoshimura M (1984) The possible applications of a composite skin and subcutaneous vein graft in the replantation of amputated digits, Br J Plast Surg 37:607–12. Höpfner E (1903) Über GefäBnaht, GefäBtransplantation und Reimplantation von amputierten Extremitäten, Arc Klin Chir 70:417–22. Ikuta W, Kubo T, Tsuge K (1976) Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture, Plast Reconstr Surg 58: 407–11. Janzekovic A (1975) The burn wound from a surgical point of view, J Trauma 15:42–6. Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD (1984) The lateral upperarm flap: anatomy and clinical applications. Ann Plast Surg 12:489–500. Komatsu S, Taimai S (1968) Successful replantation of a completely cut-off thumb, Plast Reconstr Surg 42:374. Lamberty BGH, Cormack GC (1983) The antecubital fasciocutaneous flap, Br J Plast Surg 36:428–33. Lapchinsky AG (1960) Recent results of experimental transplantation of preserved limbs and kidneys and possible use of this technique in clinical practice, Ann NY Acad Sci 64:539. Lenoble E, Foucher G, Voisin MC, Maurel A, Gontallier D (1993) Observations on experimental flow-through venous flaps, Br J Plast Surg 46:378–83. Lister G (1988) Emergency free flaps. In: Green DP, ed. Operative Hand Surgery, 2nd edn. Churchill Livingstone: Edinburgh, 1127–49. Lister G, Scheker L (1988) Emergency free flaps to the upper extremity, J Hand Surg 13A:22–9. Lister GD, Kalisman M, Tsai TM (1983) Reconstruction of the hand with free microneuro-vascular toe-to-hand transfer: experience with 54 toe transfers, Plast Reconstr Surg 71:372–86. Lovie MJ, Duncan G, Glasson DW (1984) The ulnar artery forearm free flap, Br J Plast Surg 37:486–92. Manktelow RT, McKee NH (1978) Free muscle transplantation to provide active finger flexion, J Hand Surg 3:416–26. Mathes SJ, Nahai F (1982) Clinical Applications for Muscle and Musculocutaneous Flaps. CV Mosby Company: St Louis. May JW, Chait LA, Cohen BE, O’Brien B McC (1977) Free neurovascular flaps from the first web of the foot in hand reconstruction, J Hand Surg 2:387–93. McGregor IA, Morgan G (1973) Axial and randompattern flaps, Br J Plast Surg 26:202– 13. Muhlbaeur W, Herndl E, Stock W (1982) The forearm flap , Plast Reconstr Surg 70:336– 44. Noreldin AA, Fukuta K, Jackson IT (1992) Role of perivenous areolar tissue in the viability of venous flaps: an experimental study on the inferior epigastric venous flap of the rat, Br J Plast Surg 45:18–22. Nylen S, Carlsson B (1980) Time factor, infection frequency and quantitative microbiology in hand injuries, Scand J Plast Reconstr Surg 14:185–9. O’Brien BM, Morrison WA, Ishida H, MacLeod AM, Gilbert A (1974) Free flap transfers with microvascular anastomoses, Br J Plast Surg 27:220–30.
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Ohmori K, Harii K (1976) Free dorsalis pedis sensory flap to the hand with microneurovascular anastomoses, Plast Reconstr Surg 58:546–54. Pho RWH (1979) Free vascularised fibular transplant for replacement of the lower radius, J Bone Joint Surg 61B:362–5. Robinson DW (1976) Microsurgical transfer of the dorsalis pedis neuro-vascular island flap, Br J Plast Surg 29:209–13. Robson MC, Edstron LE, Krizek TJ, Groskin MG (1974) The efficacy of systemic antibiotics in the treatment of granulating wounds, J Surg Res 16:299–306. Sanger JR, Matloub HS, Yousif NJ (1990) Sequential connection flaps: a logical approach to customized mandibular reconstruction. Ann J Surg 160:402–4. Schenck RR (1978) Rectus femoris muscle and composite skin transplantation by microneuro-vascular anastomosis for avulsion of forearm muscles, J Hand Surg 3:60– 9. Shalaby HA, Saad MA (1993) The venous island flap: is it purely venous? Br J Plast Surg 46:285–7. Song R, Gao Y, Song Y, Yu Y, Song Y (1982) The forearm flap, Clin Plast Surg 9:21–6. Soutar DS, Scheker LM, Tanner NSB, McGregor IA (1983) The radial forearm flap: a versatile method for intra-oral reconstruction, Br J Plast Surg 36:1–8. Taylor GI, Townsend P (1979) Composite free flap and tendon transfer: an anatomical study and a clinical technique, Br J Plast Surg 32:170–83. Thatte RL, Thatte MR (1987) Cephalic venous flap, Br J Plast Surg 40:16–19. Weiland AJ, Kleinert HE, Kutz JE, Daniel RK (1979) Free vascularised bone in surgery of upper extremity, J Hand Surg 4:129–44. Wells MD, Luce EA, Edwards AL, Vasconez HC, Sadove RC, Bouzaglou S (1994) Sequentially linked free flaps in head and neck reconstruction, Clin Plast Surg 21:59– 67. Wood MB (1987) Upper extremity reconstruction by vascularised bone transfer: results and complications, J Hand Surg 12:422–7. Yang DY, Gu YD (1979) [Thumb reconstruction utilizing second toe transplantation by microvascular anastomosis: report of 78 cases], Chinese Med J 92:295. (Translation by Khoo Boo-Chai: Plast Reconstr Surg 1980;65:704.) Zhong-Jia Y (1987) Microsurgical composite free tissue transfer for extremity trauma, Plast Reconstr Surg 79:222–33.
5 Emergency free flaps for the reconstruction of open injuries of the upper limb Maurizio Calcagni and Giorgio Pajardi
Introduction Currently, debridement of all necrotic and contaminated tissues followed by immediate soft tissue coverage in order to obtain primary healing is the standard approach to all open injuries of the extremities. In 1977, Foucher et al introduced for the first time, the concept of immediate treatment at one time of all injured tissues in complex trauma of the upper limb. A similar approach to injuries of the lower extremity was documented in the works of Byrd et al (1981, 1985) and Godina (1986), who demonstrated the superiority of early closure of complex lesions with free flaps so as to reduce risk of infection and hospital stay and to improve flap survival rate. The final goal of this therapeutic approach called ‘Tout en un temps et mobilisation precoce’ (all-in-one stage and early motion) is early postoperative mobilization of the hand and of the whole upper extremity (Foucher et al 1977). Delay in treatment will lead to higher risk of infection, granulation tissue formation and extended fibrosis, reduced flap survival rate, longer hospital stay, late rehabilitation and eventually poor function. Similar conclusions were later reported by other authors who demonstrated the feasibility of immediate free flap closure with free flaps of contaminated open wounds of the upper limb (Lister and Scheker 1988, Breidenbach 1989). In the 1990s some papers further supported this concept sharing some common considerations: the need for appropriate debridement and for immediate (or early) coverage with flaps of all open wounds with exposed vital structures and/or high risk of infection (Chen et al 1992, Chick et al 1992, Ninkovic et al 1995a, McCabe and Breidenbach 1999). Some points of discussion about early closure of open wounds are still controversial: the most appropriate timing for wound closure; indications for early free flaps; and possible disadvantages of this kind of surgery.
Timing The timing of early closure of wounds has been described with different and sometimes confusing definitions. Lister and Scheker (1988) called the procedure an emergency free flap all transfers performed within 24 hours of the trauma. Godina (1986) defined early free flaps as all procedures done within 72 hours. Acute flaps have been defined as those transferred within 5 days by Byrd et al (1981, 1985). Breidenbach (1989) used the term emergency free flaps for all flaps used to cover a soft tissue defect within 24 hours of the injury. Ninkovic et al (1995a,b) proposed the terms primary closure (within 24 hours), delayed primary closure (within 7 days) and delayed closure with free flaps.
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In our opinion the nomenclature proposed by Breidenbach (1989) better classifies the timing of reconstruction of upper extremity open wounds (Table 1). Relevance of timing has been stressed in many papers but the evidence is contradictory. Some
Table 1 Definition of timing of reconstruction of open wounds of the upper extremity according to Breidenbach (1989). Definition Timing Emergency closure Within 24 hours of injury Early closure From 24 hours to 7 days after injury Delayed primary From 1 week or prior to formation of extensive closure granulation tissue Delayed closure Secondary closure of a wound authors advocate immediate closure with emergency free tissue transfer, others argue that delayed closure after 5 days can be detrimental, while others state that such a delay does not affect results. Godina (1986) divided patients who underwent a microsurgical reconstruction of the extremities into early, delayed and late groups. The early group was treated within 72 hours of the injury and showed the lowest infection rate and percentage of flap failure, and bone healing time and hospital stay were markedly reduced as compared to delayed and late groups. Lister and Scheker published two papers (Scheker et al 1987, Lister and Scheker 1988) supporting the advantages of immediate reconstruction with emergency free flaps showing a very low percentage of complications (two flaps lost out of 31). Similar results were demonstrated in later papers (Chen et al 1992, Chick et al 1992, Ninkovic et al 1995 a,b, Schwabegger et al 1999). In the last 2 years we have treated all complex injuries of the upper extremity in emergency, but in the past this was not the case and a delay of 2–3 days was the rule. Flap survival and infection rate were similar. Hospital stay conversely was longer in patients treated in the early period compared to those treated in emergency.
Indications Free flaps are needed when the loss of substance is too large, or too deep, or too complex to be closed with a local or regional flap, and where a skin graft would be inappropriate because of poor bed conditions, or because it would endanger function or further reconstructions. The first absolute indication is an exposed vital structure. Vital structures are those that will rapidly undergo desiccation and necrosis if not covered by adequate soft tissue. The most important among these are the vein grafts reconstructing the arterial circulation of a limb or its major vessel (Breidenbach 1989, Chen et al 1992). Other vital structures that, if left exposed will get desiccated and eventually infected are nerves, joints, denuded bone and tendons (Fig. 1) (McCabe and Breidenbach 1999). These structures can stand a short period of time of exposure (better when covered with some sort of temporary skin
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substitute), but need to be adequately covered as soon as possible to retain useful function. High risk of infection, which is one of the most function-threatening factors in open injuries, is also a major indication. Infection means further loss of previously vital tissue (and possibly of the flap too) and it reduces functional recovery and eventually can endanger limb survival. Debridement is the first and most important step in the treatment of contaminated wounds and the use of free tissue transfer may allow for an increased freedom in performing a true radical debridement (Ninkovic et al 1995a, McCabe and Breidenbach 1999) with the possibility of more complex and extended reconstructions. Two different techniques of debridement are available: serial and radical. When the serial approach is chosen the patient is taken to the operating room several times over the first 2–3 days and the tissue is allowed to demarcate itself over time and coverage is accomplished only at the end of the process. This approach (also called ‘wait and see’) is problematic when vital structures are exposed, as already discussed, and it is incompatible with emergency free tissue coverage. The principle of radical debridement is to make an incision through normal, healthy tissue to be sure that all non-viable tissue is eliminated, (Ninkovic et al 1995a), all longitudinal vital structures (vessels, nerves, bones and tendons) if not completely devitalized are preserved. This tech
Figure 1 (a) Friction avulsion of all soft tissues of the dorsum of the hand with bone and carpometacarpal joint exposure. (b) Debridement, joint stabilization and tendon grafting. (c) An omolateral lateral arm flap is planned. (d) Early result at 10 days with viable flap and start of rehabilitation.
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nique requires excision not only of all clearly non-viable tissue, but also of all tissue that is at all questionable. This approach may lead to removal of normal tissue, but allows for safer immediate closure of the wound. In these cases free flaps are often the only mean to obliterate all dead spaces and achieve complete skin closure. Ninkovic et al (1995a) proposed a very early second look operation and definitive coverage (within 24 hours from injury) trying to overcome the risk of misjudgements of an inexperienced or exhausted team. In addition, choice of recipient vessels is fundamental in immediate free flap transfer. The vessels should be well out of the crushed zone and should be checked under high magnification for intima damage. During debridement the disrupted vessels can be clamped and, after release of the tourniquet, their health can be easily determined (Chen et al 1992) without risk of overresection and thus reducing the need for long vein grafts. Other indications for emergency free flaps are flow-through flaps and salvage flaps. The first is not a recent concept (Foucher et al 1984, Partecke and Buck-Gramko 1984) and has several advantages: the need for a separately harvested vascular graft is avoided, the type of vascular conduit is a better match (artery-to-artery) than vein grafts and the number of anastomoses is reduced (Brandt et al 1996). Salvage flaps are harvested from nonreplantable parts in order to preserve stump length, decrease amputation level (Chen et al 1992) and preserve as much residual function as possible. In this case timing is not questionable and the flap has to be transferred in emergency. Relative indications are all the reconstructions with special features. This is the case of digital or web reconstruction with flaps from the foot (Fig. 2). In these situations early definitive reconstruction is fundamental for a fast functional recovery and return to work. Finally, in some patients, aesthetic concerns can make free flaps preferable in order to minimize the donor site morbidity. This is also true in special cases like extensive burns where healthy donor sites are greatly reduced.
Disadvantages There are some disadvantages of immediate free tissue transfer. Free flap surgery performed in emergency by inexperienced surgeons and in less than optimal conditions may lead to a higher rate of complications. There are some steps in the planning of this type of surgery where experience is crucial: assessment of the general condition of the patient; assessment of the remaining function of the injured limb; assessment of the adequacy of wound debridement; and assessment of health of the recipient vessels. Careful assessment of the systemic condition of the patient should be carried out before choosing an emergency free tissue transfer. In case of multiple trauma saving the patient’s life always precedes limb salvage. An often lengthy and complex procedure like a free flap transfer may not be indicated in patients with associated life-threatening injuries. The wound should be inspected and complex reconstruction should be undertaken only when good remaining function of the limb is expected (Chen et al 1992). It is unwise, and also disadvantageous for the patients, to perform aggressive surgery on a limb that will be amputated secondarily (Breidenbach 1989, Chen et al 1990).
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Wound debridement is the first and probably most important step in successful treatment of open injuries of the extremities (Lister and Scheker 1988). Insufficient debridement may lead to infection and eventually to flap necrosis and/or limb ischaemia (Breidenbach 1989, Chen et al 1992). In all cases where a clean wound (bacterial count below 104 in quantitative cultures (Breidenbach 1989, Chen et al 1990) is not obtainable further debridement should be carried out and free flap reconstruction postponed. It is our opinion that a delay of 24–48 hours has no adverse effects on success rate and that, in all cases, when experienced judgement is not available it is better to postpone the reconstruction in the early period.
Flap choice There is no fixed rule in choosing a flap. In our department large defects are covered with latissimus dorsi muscle free flap and split thickness skin grafts. Smaller defects are often treated with island flaps (mainly the reverse posterior interosseous island flap). When the lesion is not amenable to closure with a regional flap the free flap is chosen according to the specific requirements.
Conclusions The advantages of an emergency free flap reconstruction are salvage of exposed vital structures, reduction of bacterial colonization and immediate reconstruction of all damaged structures in the first surgical procedure. Furthermore this approach allows early rehabilitation, reduces hospital stay and eventually leads to better functional recovery. In the absence of life-threatening injuries the absolute indication for an emergency free flap is exposure of a reconstructed vessel and/or of the main artery of the limb. Other absolute indications are salvage free flaps harvested from nonreplantable amputated parts and the flowthrough flaps used for limb revascularization.
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Figure 2 (a) High voltage injury of the thumb. (b) Debridement of all non-viable tissues. (c) A cutaneous flap from the pulp of great toe is planned. (d) Immediate result. (e) Result at 3 months. The golden period for free tissue transfer is the first 24 hours after injury. In the literature there is evidence that 3 days and even 5 days are of no detriment to final outcome if debridement is accurate and bacterial load low. Longer delay is consistently associated with higher infection rate, flap failure, multiple secondary procedures, longer hospital stay and eventually poor function. The disadvantage of emergency free flaps is the need for an experienced surgeon capable, first of all, of careful assessment of the general condition of the patient and of the remaining function of the affected limb. Further critical points are the extent of the debridement and the choice of the receiving vessels. A definitive closure should be undertaken only when a surgically clean wound is obtained. In our opinion there are multiple methods available to close a complex wound of the extremities and the surgeon should choose the technique that offers the best chance of
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success at the lowest risk for the patient. Free flaps do not exclude local or regional ones, but offer greater flexibility in size, shape and tissue composition without adding donor site morbidity to the already injured limb.
References Brandt K, Khouri RK, Upton J (1996) Free flaps as flowthrough vascular conduits for simultaneous coverage and revascularization of the hand or digit, Plast Reconstr Surg 98:321–7. Breidenbach WC (1989) Emergency free tissue transfer for reconstruction of acute upper extremity wounds, Clin Plast Surg 16:505–14. Byrd S, Cierny GI, Tebbets J (1981) The management of open tibial fractures with associated soft tissue loss: external pin fixation with early flap coverage, Plast Reconstr Surg 68:73–82. Byrd H, Spicer T, Cierney GI (1985) Management of open tibial fractures, Plast Reconstr Surg 76:719–30. Chen S, Wei FC, Tsai YC, Gau YL (1990) Emergency free flaps to the type IIIC tibial fracture, Ann Plast Surg 25:223–8. Chen SH, Wei FO, Chen HC, Chuang CC, Noordhoff MS (1992) Emergency free-flap transfer for reconstruction of acute complex extremity wounds, Plast Reconstr Surg 89:882–8; discussion 889–90. Chick RL, Lister GD, Sowder L (1992) Early free-flap coverage of electrical and thermal burns, Plast Reconstr Surg 89:1013–21. Foucher G, Merle M, Michon J (1977) Traitement ‘Tout en un Temps’ des traumatismes complexes de la main avec mobilisation précoce , Ann Chir 31:1059–63. Foucher G, Van Genechten F, Merle M, Michon J (1984) A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap, Br J Plast Surg 37:139–48. Godina M (1986) Early microsurgical reconstruction of complex trauma of the upper extremity, Plast Reconstr Surg 78:285–92. Lister G, Scheker L (1988) Emergency free flaps to the upper extremity, J Hand Surg (Am) 13:22–8. McCabe SJ, Breidenbach WC (1999) The role of emergency free flaps for hand trauma, Hand Clin 15:275–88, viii–ix. Ninkovic M, Deetjen H, Ohler K, Anderl H (1995a) Emergency free tissue transfer for severe upper extremity injuries, J Hand Surg (Br) 20:53–8. Ninkovic M, Hussl H, Hefel L, Anderl H (1995b) [Timing of management of severe injuries of the upper extremity by free flap-plasty], Handchir Mikrochir Plast Chir 27:297–306. Partecke BD, Buck-Gramko D (1984) Free forearm flap for reconstruction of soft tissue defects concurrent with improved peripheral circulation, J Reconstr Microsurg 1:1–6. Scheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer to ipsilateral hand defects, J Hand Surg (Am) 12:665–72. Schwabegger AH, Anderl H, Hussl H, Ninkovic MM (1999) [Complex hand injuries. Importance of primary repair with free flaps], Unfallchirurg 102:292–7.
Bone reconstruction
6 Bone auto- and allografts in post-traumatic reconstruction of the upper limb Olivier Barbier and Jean-Jacques Rombouts
In cases of severe lesions involving multiple tissues, the basic principles of early debridement, stabilization, cover with vascularized soft tissue and osseous reconstruction remain central to management. The treatment of post-traumatic skeletal conditions such as delayed unions, nonunions, malunions and other problems of bone loss is challenging. In many cases, adjunctive measures such as bone grafting are required to stimulate bone healing and fill bone defects.
The receiver site In the case of a non-vascularized bone graft, the process of incorporation is primarily the function of the recipient bed and depends on close contact with viable tissue (Nather et al 1990). A considerable amount of autogenous cancellous bone graft, with an adequate soft tissue coverage like a healthy muscle (Lukash et al 1974), can accomplish the osseous reconstruction in large diaphyseal defects (Christian et al 1989). Muscle also offers better control of subflap bacterial levels and may improve delivery of antibiotics to the bone (Mathes 1982). In open fractures, because of the risk of infection, bone grafts are rarely applied initially with the exception of type I and type II intraarticular fractures when bone is necessary to fill defects for obtaining reduction and stability. In type III open fractures, bone grafting is generally delayed until after the soft tissues have recovered from the acute trauma. This is generally about 6 weeks after injury. Bone grafting done too early might allow the graft to become infected, whereas too long a delay would result in greater atrophy and fibrosis of the soft tissues and would jeopardize the other reconstructive procedures (Grace and Eversmann 1980). In general, the absence of any clinical or radiographic evidence of progression of fracture healing for 2–3 months after the expected time period for healing constitutes a non-union (Chapman 2001). Devascularization and excessive motion at the fracture site are the most common causes of non-union. Oligotrophic nonunions and all of the avascular non-unions (Weber and Cech 1976) require bone grafting. In the case of infected non-union, the infection has first to be controlled. All necrotic and infected bone as well as implants are removed. The bone is stabilized with external fixation. After debridement, antibiotherapy is administered according to the cultures. Local or free flaps may be necessary to revascularize the site of non-union. If the wound has been clean for about 6 weeks, a bone graft is applied.
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Bone auto- and allografts Biological properties Autograft An autologous bone graft allows healing and remodelling to proceed through physiologic mechanisms. The initial process is always vascular invasion. The graft remodels by osteoclastic degradation and osteoblastic new bone formation. This resorption and apposition was called as ‘creeping substitution’ in the English literature. It differs from the process of incorporation of a bone graft with microvascular anastomosis (Dell et al 1985). The autograft contains the mineral, protein and cellular elements of normal bone tissue, arranged in a physiologic matrix. The matrix provides a scaffold for new bone formation and has osteoconductive properties. The osteoinductive properties of the graft influence immigrant cells possessing the pluripotential characteristics of primitive mesenchyme to undergo differentiation into osteoblasts (Lacroix 1947). Some surviving bone cells (Gray and Elves 1979), along with the structural and regulatory matrix proteins (Mundy 1996), make autograft osteogenic, or having the intrinsic potential to form new bone at non-skeletal sites. Cancellous bone graft has the greatest osteogenic potential. Allograft Allogeneic bone, with variable biologic properties, is available in many preparations: cancellous or corticocancellous frozen or freeze-dried pieces, osteochondral frozen grafts and demineralized bone matrix. Large frozen allografts are essentially osteoconductive Union between the allograft and the host takes place at the cortical junctions by external callus advancing from the host. Internal repair is confined to the surface and involves only 20% of the graft by 5 years (Enneking and Mindell 1991). Experimental data suggest that the revitalization of the graft increases by perforating the cortical bone which augments the interface between living soft tissues of the host and the allografted bone (Delloye et al 2002). The majority of the immune stimulation of a bone allograft is derived from cell surface glycoprotein antigens controlled by the major histocompatibility complex. The antigen–antibody response to allografts varies considerably in reported series (Stevenson et al 1996). Bone graft immunogenicity is influenced by the manipulation for the purpose of preservation. Frozen bone is less immunogenic than fresh bone and freeze-dried bone is even less reactive (Friedlaender et al 1976). The inclusion of cryoprotectant, while necessary to maintain the integrity of chondrocytes, also has been shown to protect cells in general from the effects of freezing, including the surface antigens (Mazur 1984). In intact cartilage frozen with a cryopreservative (dimethylsulphoxide), approximately 10–30% of chondrocytes will survive (Tomford et al 1986). But there is a severe loss and lack of proteoglycans several months after transplantation (Tomford et al 1984). Analysis of the articular cartilage of retrieved human allografts revealed no evidence of chondrocytes having survived (Enneking and Mindell 1991). A freeze-dried tissue has no cell survival and does not elicit a humoral immune response. This graft has only osteoconductive properties.
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Demineralized bone matrix (Urist et al 1967) shows osteoinductive activity attributable to proteins and various growth factors present in the extracellular matrix and made available to the host environment by the demineralization process. Structural properties Successful bone grafts must be well matched to the structural demands of a particular clinical situation. Bone consists of hydroxyapatite, a calcium phosphate salt, deposited on a matrix of type I collagen. The mineral component confers rigidity. The organic matrix provides a scaffolding for bone formation and contributes tensile strength. Autograft The biomechanical strength of the bone transplant can be correlated with the process of its repair. Cancellous transplants are first strengthened by the addition of new bone. Thereafter, when the old, necrotic bone is removed, the mechanical strength of transplanted areas tends to return to normal. Conversely, osteoclastic resorption of the bone within the haversian system takes place before apposition in the repair of transplanted cortical bone (Enneking et al 1975). Clinical experience permits to predict that a human autogenous cortical transplant will develop its maximal weakness from 12 weeks to at least 48 weeks and then return to its original strength by 2 years (Springfield 1987). The rate of creeping substitution is dependent on the speed of revascularization. It takes years for autogenous cortical grafts to hypertrophy in relation to the presence of mechanical stress (Wilson 1972). Although a cancellous graft does not provide immediate structural support, it incorporates quickly and ultimately achieves strength equivalent to that of a cortical graft after 6–12 months (Gazdag et al 1995). Allograft The ability of the graft to withstand the loads to which it is subjected is largely determined by the original properties of bone at the time of donation. Bone tissues tend to be strongest between 20 and 40 years of age. Little change in the bending, torsional or compressive strength has been noted after freezing (Pelker et al 1984). Decalcified allografts repair at a faster rate than those that are only frozen but, initially, they are mechanically weaker (Oikarinen 1982). Freeze-drying and gamma irradiation, commonly used for preservation and sterilization in bone banking, add their negative effects to the mechanical resistance (Cornu et al 2000). Choice of bone graft The first step in matching the graft to the clinical problem is to examine whether the problem is a lack of osteoinduction and/or osteogenesis or one of structural bone loss requiring a loadbearing graft.
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For segmental defects which require immediate structural support, autologous cortical bone grafts are good choices (Grace and Eversmann 1980). Reconstruction of traumatic defects up to 20 cm with a fibular cortical autograft is possible at the level of the radius (Miller and Phalen 1947). The advantages of autologous bone grafts are their excellent success rate, low risk of transmitting disease and histocompatibility. However, there is a limited quantity of autologous bone graft and the potential for donor site morbidity. Cortical allografts are best reserved for use in areas with an excellent vascular supply. Bone transport may also be an option in large defects (Green 1994). In small diaphyseal defects (< 6 cm), autologous cancellous bone used with stable internal fixation is adequate (Nicoll 1956). Demineralized bone matrix is useful for filling stable, well-contained bone defects. A percutaneous procedure utilizing demineralized bone matrix and autologous bone marrow could be considered (Tiedeman et al 1991) although there is no definitive evidence of clinical success. Well-contained, stable, metaphyseal defects with a good vascular supply are well suited for osteoconductive bone grafts like frozen or freezedried (Fig. 1) corticocancellous allografts that can resist compressive forces. If a non-union is present and a stimulus for new bone formation is needed, an autologous cancellous graft is ideal. Severe soft tissue injuries frequently accompany the bony trauma, and many of the wounds have been previously infected. Morcellized bone grafts appear to incorporate faster than large segmental grafts (Coutelier et al 1984) and bacteria are much less likely to survive in these small, rapidly revascularized pieces.
How to obtain a bone graft? Autograft The iliac crest is the most common donor site because of easy access, relatively low morbidity, and availability of large quantities of both cortical and cancellous bone. Harvesting from the anterior iliac crest is usually more convenient because the patient is typically in a supine position for most operations involving the extremities. An incision lateral to the iliac wing is made 2 cm dorsal to the anterior superior iliac spine in order to avoid injuring the lateral femoral cutaneous nerve and to avoid predisposing the iliac spine to an avulsion fracture. The tubercle, being the widest part of the crest, contains the largest amount of corticocancellous bone. The apex of the crest is incised longitudinally, between the abdominal and gluteus muscles. The iliacus is dissected from the inner
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Figure 1 Freeze-dried allograft of an unstable epihyseal fracture of the distal radius in a 19-year-old boy. (a,b) Epiphyseal fracture with dorsal displacement. (c) Secondary dorsal displacement under a cast due to posterior comminution at 2 weeks after initial reduction. (d) New reduction stabilized by a freeze-dried corticocancellous allograft (high density in the epiphysis on the radiograph), two pins and a cast. (e,f) At 3 months—fracture consolidation with integration of the allograft.
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Figure 2 Abdominal hernia through a defect in the iliac wing after bone removal for a graft. (a) The computerized tomography scan shows the left iliac hernia. (b) AP (anteroposterior) radiograph of the left iliac wing. wall of the ilium. To avoid injuring the abductor muscles only harvest the inner table. Thereafter, the abdominal muscles are meticulously closed to the abductor musculature to minimize the risk of hernia (Fig. 2). A bicortical graft can be harvested from just below the iliac tubercle, including both outer and inner cortical tables. The continuity of the crest is preserved. A small graft can be harvested by using a trephine forceps (Saleh 1991). To harvest the posterior bone grafts, an almost vertical incision is made slightly lateral to the posterior iliac spine. A transverse incision is dangerous for the cluneal nerves (Finkemeier 2002), more likely to result in dehiscence and can be painful if it lies along the belt line. The cluneal nerves which cross the iliac crest beyond approximately 8 cm anteriorly from the posterior midline provide sensation to the region of the posterior iliac crest and the cephalad portion of the buttock. The patient is usually prone but can also be placed in a lateral position. The gluteal fascia is incised along the crest. The gluteus can be elevated off the outer wall of the ilium down to the level of the sciatic notch. Injury to the superior gluteal nerve and vessels and penetration of the sacroiliac joint are avoided. Bleeding is controlled with a collagen product placed on the donor site. The use of bone wax should be discontinued as it may elicit a foreign body reaction (Verborgt et al 2000). Depending on the quantity of the procured bone, a bone allograft can be implanted to reshape the defect. The use of an anaesthetic regimen at the donor site could overcome the problem of pain at the wound site (Puri et al 2000). Other potential areas for harvesting cancellous bone include metaphyseal regions of the skeleton, such as Gerdy’s tubercle, the proximal tibial and the greater trochanter (Finkemeier 2002). For upper extremity procedures obtaining a bone graft from the olecranon or distal radius allows the surgical procedure to be limited to the involved extremity. The primary disadvantage of local upper extremity graft is the limited amount of bone available (Bruno et al 2001). The distal radius seems structurally inferior and has lower bone turnover compared with the iliac crest. However, the difference is of minimal clinical significance when the bone is used as graft material (Biddulph 1999). The radius is approached between the first and second dorsal compartments. A section of cortex is
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outlined with multiple drill holes. Cancellous bone is resected with a curette. The ulna below the elbow is approached through an incision to either side of the donor site along the dorsal subcutaneous ulnar ridge. The graft is taken below the olecranon, to avoid weakness over the elbow joint, and well distal to the epiphysis (McCrath and Watson 1981). The fibula is the most common bone used for long cortical autogenous grafts. The fibula is exposed through a lateral approach, between the soleus and peroneal muscles. The periosteum is stripped with an elevator. Patients younger than 9 years of age can develop a valgus ankle if the fibula is removed and does not regenerate. It is recommended leaving the distal 8–10 cm of fibula to avoid changes at the ankle. Removal of the fibular head will not lead to knee instability by suturing the biceps tendon and fibular collateral ligament to the soft tissue attached to the tibia. For maximum osteocyte survival, bone grafts should be kept in chilled blood or a sponge moistened with chilled saline and not exposed to air (Berggren et al 1981). Autologous red bone marrow, usually obtained by aspiration in adults from the axial skeleton, contains a small but significant number of pluripotential mesenchymal stem cells and inductive factors that have been used to treat non-unions (Tiedeman et al 1991). Allograft Human bones available from the bank attached to our department of orthopaedic surgery are essentially in frozen and freeze-dried forms. Allografts come from living donors having hip replacements or from cadavers. Selection of a donor presenting minimal risk of transmitting disease to a recipient is one of the major responsibilities of the tissue bank (Delloye 2000). Bone allografts have transmitted hepatitis B and C, HIV-1 and tuberculosis (Tomford 1995). Donors are excluded if they present a suspicion of central nervous disease, a risk for HIV or hepatitis B or C. They are also excluded in cases of connective tissue disease or malignant disease. Several serological tests are performed on the donor (hepatitis B and C, HIV, syphilis). Risk is associated with a seronegative window during which a viruscontaminated donor can transmit the virus while the serum still remains negative for antibodies. The risk of a ‘window donation’ is one per 166 000 for HIV and one per 6100 for hepatitis C (Lelie et al 1996). The risk of a window donation can be lowered by additional safety measures like the amplification of the viral genome that has been intercalated into the patient’s DNA (polymerase chain reaction). For a living donor, serological tests are repeated. Rhesus matching is necessary for a Rhesus negative female patient with child-bearing potential because a Rhesus positive allograft is able to sensitize a Rhesus negative recipient (Johnson et al 1985). HLA (human leucocyte antigen) histocompatibility group matching does not appear necessary to achieve a successful allograft (Stevenson et al 1996). The bone is explanted in sterile conditions. A sample, representative of the tissue, is cultured. Then the bone is immersed in a solution containing rifampicin. Deep-freezing (–80°C) is the most convenient and widespread method of tissue preservation. Water contained in the tissue is converted into ice and is therefore no longer available for further chemical reaction. The process of freeze-drying removes water from the tissue by chemical agents such as acetone or ether. These agents are able to inactivate coated viruses such as HIV and
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hepatitis B and C (Anastasescou et al 1998). However, penetration into the core of the tissue might take longer depending on the nature of the tissue, the thickness of the sample and the quantity of fat bone marrow. For prion disease, contamination through a musculoskeletal tissue has not yet been demonstrated. However, an effective treatment with sodium hydroxide or sodium hypochlorite is applied (WHO 1992). Dehydration is completed when the tissue has less than 5% residual humidity. Lyophylization is then performed by sublimation of ice which requires freezing and vacuum conditions. Numerous different demineralized bone allograft preparations are now available (Finkemeier 2002). The decalcification process with HCl appears to inactivate and eliminate HIV (Prewett et al 1992).
Applications of bone grafts All the grafts must be appropriately protected during incorporation by adequate internal or external fixation and/or external bracing. Scapular girdle In a comminuted fracture, the glenoid rim can be reconstructed with a block of iliac crest (Goss 1992). Treated non-operatively, the vast majority of middle-third clavicle fractures, which account for approximately 80% of all clavicle fractures, heal uneventfully. Malunion and non-union are rarely functional or clinically significant problems. Indications for surgical treatment of clavicular nonunion are: pain attributable to the non-union; shoulder girdle dysfunction; and neurovascular compromise (Barbier et al 1997). Plate fixation with the use of autogenous bone grafting is an excellent method of treatment for these injuries (Mullaji and Jupiter 1994). Plates fit best on the superior clavicle. At the clavicle, like for other inter calated bone grafts, it is recommended (Davey and Simonis 2002) to chamfer the cut ends of the receiver bone and the bone graft in order to increase the area of contact and to allow the graft to be wedged securely in place. The cortical surface of the graft is positioned opposite the plate to allow firm compression without crushing (Fig. 3).
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Figure 3 Peroperative view of an intercalated bone graft in a long bone (clavicle). The cut ends of the graft and the receiver bone are chamfered (arrows). The plate is on the superior side of the clavicle, opposite to the cortical surface of the graft. Shoulder There are few surgical options for reconstruction of an osteoarticular loss at the shoulder level. Vascularized or non-vascularized fibula transfer has been used, but this does not offer an anatomical joint surface. In the replacement of the joint, fixation of soft tissue remains a major concern with potential subsequent instability and restricted motion. An osteoarticular allograft resolves the problem of soft tissue fixation and consequently of joint stabilization. However, no patient regains normal abduction despite an anatomical reconstruction (Delloye et al 1991). The necrotic cartilage of the allograft can maintain good architecture for several years. Two clinical circumstances appeared to be associated with this phenomenon: a good anatomical fit of the graft and satisfactory stability of the joint that had been engendered by a good soft tissue repair (Enneking and Mindell 1991). Another interesting option is a combination of a structural allograft and a joint prosthesis. Arm Unlike the lower limb, some shortening and/or rotation is tolerated by the arm as long as function of the hand and the ability to position the hand in space is maintained. An autogenous reconstruction of the humerus using two fibulae is advisable (Springfield 1987). The use of a locked nail and cementing the inner part of a diaphyseal allograft are some means to prevent mechanical failure. The observation of retrieved human allografts
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shows that where bone cement had been used to fix a prosthetic stem or an intramedullary rod to the allograft, there was no evidence of resorption of bone or loosening of the device (Enneking and Mindell 1991). A combination of auto- and allografts is also advisable. Half of an allograft shaft is used with morcellized autogeneic bone packed around it. This approach has two advantages: it maximizes the morcellized graft material, and it decreases the volume of cortical bone that might distend the already shrunken surrounding soft tissue (Chapman and Rodrigo 2001). Non-union seems best treated by rigid internal fixation and bone grafting (Foster et al 1985) (Fig. 4). Union rates for non-unions treated with intramedullary fixation and plates are nearly equivalent (Wu and Shih 1992). At the proximal third, a tension band can fix the rotator cuff and proximal fragment to the remainder of the shaft
Figure 4 Autogenous bone graft and nail fixation of delayed union in an unstable humerus. (a) Radiograph of Gustilo IIIC open fractures of the arm and the forearm. (b) Absence of bone consolidation at 3 months after a forearm amputation and unstable humeral fixation as initial treatment. (c) Immediate postoperative radiograph of stable fixation with a locked nail. Autogenous iliac bone graft was placed at the fracture sites (arrows). (d) Consolidation of the humerus at 1 year.
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(Healy et al 1990). All fibrous tissue is removed from between the bone ends. The medullary canals are open. The cortex is petalled with a small osteotome for a distance at least equal to the diameter of the cortex at that point on the proximal and distal fragment. The aim is to augment the surface of living bone and hence its osteogenic capacity, by creating several chips of cortical bone that remain vascularized through their periosteum and soft tissues (Judet et al 1992). A layer of autograft is applied along this exposed surface. When bone stock is a major problem, use of a split autologous fibula or an allograft to provide a backup to the plate on the opposite cortex for screw fixation can be useful. Symptoms from lateral condylar non-union are most often attributable to tardy ulnar nerve palsy, cubitus valgus deformity or both. Osteosynthesis with iliac crest bone grafting eventually associated with anterior transposition of the ulnar nerve and a corrective osteotomy can lead to a pain-free elbow (Inoue and Tamura 1993). Elbow In complex fractures involving the trochlea and capitulum, their reconstruction is the most important step in internal fixation. If there is a defect after reconstruction, it must be filled with autologous cancellous bone (Helfet and Schmeling 1993). The most common defects are caused by comminution in the metaphyseal portion of the olecranon fossa, fragmentation of the supracondylar ridge or loss of the midsubstance of the trochlea. The superior margin of the iliac crest provides the ideal graft for replacing these deficiencies. The general categories of treatment for intraarticular and extraarticular non-unions of the distal humerus are osteosynthesis, total elbow arthroplasty and allograft replacement (Gallay and McKee 2000). Decortication, autogenous iliac crest bone grafting, and internal fixation leads to union in more than 90% of cases. However, unless the soft tissue trauma associated with this injury is considered, a successful result cannot be achieved (McKee et al 1994). For olecranon fracture and non-union, depending on the size of the proximal fragment, whether the articular cartilage is preserved and the quality of the bone, the treatment is fragment excision, prosthesis or osteosynthesis (Papagelopoulos and Morrey 1994). If there is segmental comminution in the fracture, tension band wiring is contraindicated because it will narrow the fossa of the olecranon and produce an incongruous joint. These require an intercalary bone graft and plate fixation. The use of joint allografts remains a salvage procedure for massive bone loss of the elbow joint. Since the allograft is avascular and bulky, adequate skin must be present to allow wound closure without tension. The results are generally poor with a high complication rate (70%) including infection, instability and graft resorption— necessitating removal of the graft in 25% of the cases (Dean et al 1997). Although useful function can be obtained at an early stage (Urbaniak and Aitken 1987), the complications indicate that this option for treatment should at present remain experimental. We now consider that in patients with deficient bone stock, the allografts re-establish bone mass to permit a potential arthrodesis or prosthetic arthroplasty. Before being implanted, the allograft is thawed at 40 °C for at least 30 minutes in preheated saline containing antibiotics. Autografting with cancellous bone procured from the iliac crest is performed
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at the junction. Callus develops slowly with union achieved at around 6 months to 1 year (Fig. 5) (Delloye et al 1991). In fracture of the radial head, periosteal connections between the fragments should be preserved. Depressed areas must be reduced and the resultant defects filled with cancellous bone graft. It can be taken from the nearby epicondyle. If the reconstruction of the radial head is definitively not adequate, resection of the head or prosthetic replacement is considered (Ring and Jupiter 1998). Frozen bone allografts have been used to replace the proximal radius (Delloye et al 1991, Szabo et al 1997). Our longterm experience with allografts in this situation revealed a high rate of complications. Forearm In case of severe fracture of bones of the forearm, the osteosynthesis can be improved biologically with an additional autologous cancellous bone graft. The graft should be placed away from the interosseous border to avoid formation of radio-ulnar bridging callus (Vince and Miller 1987). However, in two studies on comminutive forearm fractures treated with plates with or without bone graft, the union rate was 98% (Chapman et al 1989, Wright et al 1997). Most areas of bone loss in the forearm can be managed with standard bone grafting techniques (Miller and Phalen 1947, Nicoll 1956, Grace and Eversmann 1980). The host tissues into which the transplant is made must have a good blood supply, since osteogenesis can occur only if the graft has intimate contact with an active circulation. All sclerotic bone ends must be removed. Procedures used in the reconstruction of segmental defects of both bones of the forearm should, whenever possible, preserve forearm pronation and supination. Most reports of such reconstructions, however, describe the creation of a single-bone forearm by radio-ulnar fusion. Attempts to bridge large defects are fraught with problems of delayed or nonunion of the graft–host junction, as well as stress fractures and resorption of the graft; these may explain
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Figure 5 Bone allograft and joint prosthesis with flap coverage in the treatment of a largely open fracture of the elbow with loss of the joint. (a) Gustilo IIIB open fracture of the elbow with large soft tissue defect in front of an open joint. (b) AP radiograph of the elbow showing loss of distal humerus and olecranon. (c) AP radiograph of the elbow during the initial phase of treatment with an external fixator as stabilizer and cement with antibiotics in the joint as spacer.
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(d) AP radiograph at 4 years. In a second phase, at 5 weeks after the injury, a prosthesis had been cemented through an allograft of the distal part of the humerus. A callus formed at the junction between the humerus and the allograft (arrow). (e) The elbow had been covered in the initial phase with a pedicled fasciocutaneous radial forearm flap. the infrequency with which these procedures have been carried out successfully (Haddad and Drez 1974) and reported. In cases of massive bone loss, infections or recalcitrant non-union, vascularized bone grafts could be more suitable (Kumar et al 1988). Wrist Several investigators have shown improved anatomical and functional outcomes with the use of autologous bone graft to reconstruct the radial metaphysis (Fernandez and Jupiter 1996). Autologous bone graft can be used to fill depressed articular surfaces, in association with internal fixation (Axelrod and McMurtry 1990). Another surgical tactic is based on external fixation in conjunction with placement of autogenous cancellous bone in the metaphyseal defect that is always present following reduction of the comminuted unstable fractures (Leung et al 1990). However, bone graft substitutes or allografts may be interesting in these cases to avoid donor site morbidity. Union with deformity continues to be the most common complication following fracture of the distal end of the radius. The most commonly observed cause of an extraarticular malunion is secondary displacement of the initial fracture reduction due to deficient cancellous bone in the metaphysis (McQueen and Caspers 1988). If there is no marked osteoporosis and advanced carpal lesions, malunion is treated by osteotomy, distraction, bone graft and plate stabilization. Fractures of the distal radius that demonstrate either delayed healing or the development of an atrophic or synovial non-union can be treated with surgical realignment, stable internal fixation and autogenous iliac crest bone grafting (Fernandez et al 2001). In case of severe bone loss, an autogenous transplantation of the proximal fibula or an osteochondral allograft could maintain some flexion–extension of the wrist and prosupination. This has been demonstrated in tumoral reconstruction (Noellert and Louis 1985, Delloye et al 1991). Arthrodesis of the wrist using bone graft seems a more predictable solution (Freeland et al 2000). Hand Large crush injuries or wounds, can cause segmental defects of several metacarpals. In many cases, autogenous (Bruner 1957) or allogenous (Smith and Brushart 1985) bone grafts can be used to reconstruct these deficits. Allogeneic bone satisfies the requirements for reconstruction when there is a need for osteochondral grafts, strong cortical grafts to allow secure fixation and early motion, and small tubular grafts that meet the demands of minimizing bulk in the hand.
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Complications and limitations of bone grafts The graft Auto- and allografts have particular advantages and disadvantages. Compared with autografts, allografts have less osteogenic potential, variable quality and theoretical possibility of disease transmission. Bone allograft can fail under repetitive constraint; this is referred to as fatigue failure. Until the transplanted grafts become vascularized, they do not have the potential to repair subfailure damage. Thereafter, fracture healing can occur because of a new host bone and periosteum encompassing the allograft. Moreover, infection, non-union, cartilage deterioration and bone resorption are serious complications. To limit allograft infection, the most important factor is the presence of healthy skin and subcutaneous tissue. Osteochondral allografts preserved by current techniques are thought to be low in immunogenicity. However, important radiographic changes are noted on radiographic follow-up evaluations (Urbaniak and Aitken 1987). This may also be a result of decreased cartilage viability, incongruity (Highgenboten et al 1989) and lack of joint innervation (O’Connor et al 1985). The analysis of retrieved allografts confirms that cartilage erosions depend on the congruity of the joint (Enneking and Mindell 1991). An epiphyseal autograft without microvascular anastomosis has no potential for growth in a child (Brown et al 1983). The donor site At the iliac crest, complications seem 10 times more frequent after anterior harvesting (25%) than after posterior harvesting (Ahlmann et al 2002). Amongst the complications associated with the anterior bone graft donor sites are haematoma, numbness over the distribution of cutaneous nerves (Wechel and Halsal 1977, Smith et al 1984), vascular injuries (Lim et al 1996, Neo et al 2000), fracture of the iliac wing, visceral and ureteral injuries (Escalas and DeWald 1977), and infection and pelvic instability (Coventry and Tapper 1972). A 10% rate of difficulty ambulating 3 months postoperatively is reported in patients with grafts obtained from the lateral cortex of the iliac crest (Keller and Triplett 1987). Herniation of the abdominal contents through the wing of the ilium following the removal of bone from that site for grafting is a relatively rare complication (Cowley and Anderson 1983). The most common symptoms attributable to the donor site are pain and sensory disturbances. Variation in the position of the lateral femoral cutaneous nerve is a contributing factor associated with injury of that nerve (Murata et al 2000). In children, splitting of the iliac crest can lead to premature growth arret of the ilium, usually with only minor cosmetic prejudice (Rossillon et al 1999). Tenderness at the distal dorsal radius donor site has been reported in one of 78 patients (McCrath and Watson 1981). There are also isolated reports of pathologic fracture following olecranon and distal radius harvest (Mirly et al 1995).
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Conclusions and future directions Advances made in the techniques of soft tissue treatment, modern methods of stable fixation, bone reconstitution by the way of grafts and early postoperative rehabilitation have largely improved the surgeon’s ability to treat the complex problems of severe traumatic skeletal lesions. New biological methods are now being investigated to accelerate and augment skeletal reconstitution. Undifferentiated stem cells are characterized by the ability to differentiate along various cell lines (Connolly et al 1989). They replace cells that are lost by senescence or injury. These cells are procured from the bone marrow, isolated and cultured, so that they will grow with an osteoblastic phenotype. They could be used alone or in association with a structural graft (Delloye 2001). The existence of osteo-inductive proteins was demonstrated many decades ago (Lacroix 1945). Growth factors are proteins that induce stem cells to proliferate or to differentiate into osteoblast-like cells. Three recombinant osteogenic proteins have been particularly studied: OP-1; BMP-2; and BMP-4. Research and clinical trials on these inductive factors are being performed (Friedlaender et al 2001).
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Chapman MW (2001) Principles of treatment of nonunions and malunions. In: Chapman M, ed. Chapman’s Orthopaedic Surgery, 3rd edn. Lippincott Williams & Wilkins: Philadelphia, 847–85. Chapman MW, Rodrigo JJ (2001) Bone grafting, bone graft substitutes, and growth factors. In: Chapman M, ed. Chapman’s Orthopaedic Surgery, 3rd edn. Lippincott Williams & Wilkins: Philadelphia, 181–215. Chapman MW, Gordon JE, Zissimos AG (1989) Compression plate fixation of acute fractures of the diaphysis of the radius and ulna, J Bone Joint Surg 71A:159–69. Christian EP, Bosse MJ, Robb G (1989) Reconstruction of large diaphyseal defects, without free fibular transfer, in grade-IIIB tibial fractures, J Bone Joint Surg 71A:994– 1004. Connolly J, Guse R, Lippiello L, Dehne R (1989) Development of an osteogenic bonemarrow preparation, J Bone Joint Surg 71A:684–91. Cornu O, Banse X, Docquier PL, Luyckx S, Delloye C (2000) Effect of freeze-drying and gamma irradiation on the mechanical properties of human cancellous bone, J Orthop Res 18:426–31. Coutelier L, Delloye C, De Nayer P, Vincent A (1984) Aspects microradiographiques des allogreffes osseuses massives chez l’homme, Rev Chir Orthop 70:581–8. Coventry MB, Tapper EM (1972) Pelvic instability: a consequence of removing iliac bone grafting, J Bone Joint Surg 54A:83–101. Cowley SP, Anderson LD (1983) Hernias through donor sites for iliac-bone grafts, J Bone Joint Surg 65A:1023–5. Davey PA, Simonis RB (2002) Modification of the Nicoll bone-grafting technique for nonunion of the radius and/or ulna, J Bone Joint Surg 84B:30–3. Dean GS, Holliger IV EH, Urbaniak JR (1997) Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results, Clin Orthop 341:12–22. Dell PC, Burchardt H, Glowczewskie FP Jr (1985) A roentgenographic, biomechanical, and histological evaluation of vascularized and non-vascularized segmental fibular canine autografts, J Bone Joint Surg 67A:107–12. Delloye C (2000) Bone banking in orthopaedic surgery. In: Dupore J, ed. Surgical Techniques in Orthopaedics and Traumatology. Editions Scientifiques et Médicales Elsevier SAS: Paris. Delloye C (2001) Bone grafts using tissue engineering (in French), Bull Mem Acad R Med Belg 156:418–26. Delloye C, De Nayer P, Vincent A (1991) Osteochondral allografts in arm and forearm surgery, Acta Orthop Belg 57(Suppl II):75–83. Delloye C, Simon P, Nyssen-Behets C, Banse X, Bresler F et al (2002) Perforations of cortical bone allografts improve their incorporation, Clin Orthop 396:240–7. Enneking WF, Mindell ER (1991) Observations on massive retrieved human allografts, J Bone Joint Surg 73A:1123–42. Enneking WF, Burchardt H, Puhl JJ, Piotrowski G (1975) Physical and biological aspects of repair in dog cortical bone transplants, J Bone Joint Surg 57A:237–52. Escalas F, DeWald RL (1977) Combined traumatic arteriovenous fistula and ureteral injury: a complication of iliac bone grafting, J Bone Joint Surg 59A:270–1. Fernandez DL, Jupiter JB (1996) Fractures of the Distal Radius. A Practical Approach to Management. SpringerVerlag: New York.
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Lacroix P (1947) Organizers and the growth of bone, J Bone Joint Surg 29:292–6. Lelie PN, Zaaijer HL, Cuypers HT (1996) Risk of virus transmission by tissue, blood and plasma products Transplant Proc 28:2939. Leung KS, Shen WY, Tsang HK et al (1990) An effective treatment of comminuted fracture of the distal radius, J Hand Surg 15A:11–17. Lim EVA, Lavaia WT, Robert JM (1996) Superior gluteal artery injury during iliac bone grafting for spinal fusion; a case report and literature review, Spine 21:2376–8. Lukash FN, Zingaro EA, Salig J (1974) The survival of free nonvascularized bone grafts in irradiated areas by wrapping in muscle flaps, Plast Reconstr Surg 74:783–8. Mathes SJ (1982) The muscle flap for management of osteomyelitis, N Engl J Med 306:294–5. Mazur P (1984) Freezing of living cells: mechanisms and implications, Am J Physiol 247:C125–42. McCrath MH, Watson KH (1981) Late results with local bone graft donor sites in hand surgery, J Hand Surg 6:234–7. McKee M, Jupiter J, Toh CL et al (1994) Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults, J Bone Joint Surg 76B:614–21. McQueen M, Caspers J (1988) Colles’ fracture: Does the anatomic result affect the final function?, J Bone Joint Surg 70B:649–51. Miller RC, Phalen GS (1947) The repair of defects of the radius with fibular bone grafts, J Bone Joint Surg 29:629–36. Mirly HL, Manske PR, Szerzinski RN (1995) Distal radius bone graft in surgery of the hand and wrist, J Hand Surg 20A:623–7. Mullaji AB, Jupiter JB (1994) Low-contact dynamic compression plating of the clavicle, Injury 25:41–5. Mundy GR (1996) Regulation of bone formation by bone morphogenetic proteins and other growth factors, Clin Orthop 324:24–8. Murata Y, Takahashi K, Yamagata M, Shimada Y, Moriya H (2000) The anatomy of the lateral femoral cutaneous nerve, with special reference to the harvesting of iliac bone graft, J Bone Joint Surg 82A:746–7. Nather A, Balasubramaniam P, Bose K (1990) Healing of non-vascularized diaphyseal bone transplants. An experimental study, J Bone Joint Surg 72B:830–4. Neo M, Matsushita M, Morita T, Nakamura T (2000) Pseudoaneurysm of the deep circumflex iliac artery: a rare complication at an anterior iliac bone graft donor site, Spine 25:848–51. Nicoll EA (1956) The treatment of gaps in long bones by cancellous insert grafts, J Bone Joint Surg 38B: 70–82. Noellert RC, Louis DS (1985) Long-term follow-up of non-vascularized fibular autografts for distal radial reconstruction, J Hand Surg 10A:335–40. O’Connor B, Palmoski M, Brandt K (1985) Neurogenic acceleration of degenerative joint lesions, J Bone Joint Surg 67A:562–72. Oikarinen J (1982) Experimental spinal fusion with dccalcified bone matrix and deep frozen allogeneic bone in rabbits, Clin Orthop 162:210–18. Papagelopoulos PJ, Morrey BF (1994) Treatment of nonunion of olecranon fractures, J Bone Joint Surg 76B:627–35.
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7 Massive bone defects of the upper limb: reconstruction by vascularized bone transfer Michael B Wood
Introduction The use of free microvascular bone segment transfer has become an accepted and, in many instances, the preferred technique for reconstructing massive defects of bone. This is true in either the upper or the lower limb. The advantages of this technique are suggested to be more rapid bone union, more rapid bone hypertrophy and fewer instances of late stress fracture or osteolysis. In addition, some authors suggest that microvascular autografts may be used under adverse surgical conditions including a septic field or in an irradiated field. The disadvantages of this technique are that microvascular bone transfer is a technically demanding procedure and requires a donor site that may result in some degree of morbidity. This chapter will focus on the indications and technique of microvascular bone transfers in the upper limb, with illustrative case examples.
History The suggestion of at least partial sustained viability of cellular elements within bone segments transferred with an intact soft tissue vascular pedicle dates to at least a century ago. Huntington in 1905 described the successful healing of a large tibial defect by a pedicled shift of the ipsilateral fibula (Huntington 1905). Bone segments based on an intact vascularized soft tissue pedicle lacked widespread clinical application, however, because they were limited by the arc of rotation of the donor bone segment. It was not until the clinical feasibility of microvascular anastomosis was demonstrated in the early 1960s that the concept of free vascularized bone grafting emerged. The earliest experimental work using the rib as the model was by McCulloch in 1973 (McCulloch and Fredrickson 1973). This was followed by the more comprehensive work of Östrup and Fredrickson (1974). Several investigators subsequently confirmed earlier findings of at least partial preservation of intraosseous cellular elements, a mechanism of bone union more similar to fracture union than non-vascularized autograft incorporation and more rapid bone remodeling (Doi et al 1977, Haw et al 1978, Berggren et al 1982, Arata et al 1984, Goldberg et al 1987, DeBoer and Wood 1989, Siegert and Wood 1990). Even today, however, there remains a controversy about what the most important advantage of a microvascular bone transfer is—whether it is retained intraosseous cellular viability or
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whether it is the immediate re-establishment of intraosseous blood flow which permits immediate reseeding of the bone segment with osteoprogenitor cells. Clinical applications of microvascular bone transfer have been reported over the past three decades. For long bone reconstruction, the fibula is clearly the preferred donor site. Taylor is credited with the first report of a successful fibula transfer in 1975 (Taylor et al 1975). However, Ueba reported in 1983 what seems to be the first actual successful clinical application (Ueba and Fuyikawa 1983). Regardless of who was the first to carry out free fibular transfer, in the past 20 years, numerous large series have been reported that have confirmed the value of this technique for reconstructing massive bone defects (Gilbert 1979, Weiland et al 1979, 1983, Weiland 1981, Taylor 1983, Osterman and Bora 1984, Dell and Sheppard 1984, Wood and Cooney 1984, Wood et al 1984, 1985, Pho et al 1985, Wood 1986, 1987, Gidumal et al 1987). The author’s personal series, reported by Han et al (1992), resulted in an overall primary union rate of 61% and a secondary union rate of 81%, with the best results occurring in non-septic reconstructions with a union rate of 84%.
Upper limb bone defect—indications for vascularized bone transfer In general, most authors suggest that the strongest indications for the use of vascularized bone graft include situations that are prone to failure or complications with technically less demanding techniques such as non-vascularized bone autografts or allografts. These situations in general include massive defects and/or an unfavorable surrounding soft tissue milieu related to prior bone grafting failure, infection, radiation or other causes of extensive scarring. Specific indications Recipient site considerations In the upper limb, humerus reconstruction probably represents the most compelling indication for the use of vascularized fibula transfer. This is because, other than massive allografts, there are few techniques available to reconstruct a large missing segment of the humeral shaft. Although large defects of the radius and ulna may also be excellent indications for reconstruction by vascularized bone transfer, the option of forearm salvage by a one-bone forearm conversion (Fig. 1) always merits consideration (Peterson et al 1995). Moreover, more limited defects of the proximal radius or distal ulna may be consistent with an acceptable level of upper limb function.
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Figure 1 One-bone forearm reconstruction for en bloc resection of proximal radius. Large bone defects The precise length of a bony defect which would lead one to select a vascularized bone graft for reconstruction is not particularly well established. Many authors (Taylor et al 1975, Weiland 1981, Osterman and Bora 1984, DeBoer and Wood 1989, Han et al 1992) have suggested that a 6 cm gap is the point where vascularized bone reconstruction
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should be chosen in place of a non-vascularized autograft. However, it is important to recognize that with sufficient mechanical protection over several months, and when dealing with a well vascularized surrounding soft tissue milieu, bone defects exceeding 10 cm may heal with cancellous autograft (Nicoll 1956) or non-vascularized cortical bone segments (Enneking et al 1980). Moreover massive allografts may be a suitable option for reconstructing very lengthy defects (Mankin et al 1987). However, it should be recognized that massive allografts have limited ability to be revascularized and hence a limited capacity to be replaced by ‘creeping substitution’ of host osteoprogenitor cells (Phemister 1914). In general, the author believes that for a defect as short as 6 cm in the presence of a poor surrounding soft tissue bed and for all defects greater than 10 cm, the selection of vascularized bone transfer for reconstruction is justifiable. Prior bone reconstruction failures Bone defects in the upper limb, without regard to length, which have failed to heal with nonvascularized autograft may be candidates for a vascularized bone graft. This is particularly the case when there is no readily apparent explanation for the initial failure (i.e. inadequate bone graft material, inadequate stabilization, use of allograft or xenograft, etc.). Infected bone defects The use of vascularized bone grafts for reconstructing infected bone defects is particularly attractive for a number of reasons. Probably the most important fact is that such bone grafts are inherently a vehicle for local blood supply (Dell and Sheppard 1984, Wood and Cooney 1984). However, also of importance is the fact that a vascularized fibula is a generous source of bone length and it makes little difference from the technical perspective if one transfers a 6 cm or 16 cm graft segment. Thus, a more aggressive debridement of infected bone ends may be carried out with less concern about creating a larger bone defect than can be reconstructed. Non-unions associated with bone radionecrosis Bone non-union that is associated with radiation osteonecrosis is a particularly challenging problem that responds poorly to conventional bone grafting techniques (Duffy 2000). This is because three adverse circumstances exist in the presence of localized radiation changes: (1) impaired intraosseous blood supply; (2) impaired blood supply of the surrounding soft tissue; (3) periosteal and intraosseous cell death. These adverse circumstances are directly addressed by the transfer of vascularized bone segment obtained from a site well distant to the irradiated field. Donor sites The focus of this chapter is repair of large bone defects of the upper limb. For all practical purposes, for these types of defects, the fibula is the preferred donor bone. Rarely is the fibula unavailable—for example, if both were previously harvested for bone
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grafting or in unique patients with osteogenesis imperfecta. The technique of vascularized fibula isolation has been well described (Gilbert 1979, Wood 1985) and will not be repeated here. In the rare patient where the fibula is unavailable, one can consider other vascularized bone donor sites for example, iliac crest, scapula, rib, radius, metatarsal or any bone segment from a paralyzed or useless limb.
Surgical technique Scapulo/humeral defects Scapulohumeral defects most typically result from extraarticular resections of malignant bone lesions of the proximal humerus. This situation presents significant technical challenges in
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Figure 2 (a) Parosteal osteogenic sarcoma of the proximal humerus. (b) Immediate postoperative radiograph following extraarticular resection of tumor and reconstruction with massive proximal humerus allograft and side-by-side vascularized fibular autograft bridging between scapula and distal humerus. (c) Radiograph 7 years postoperatively: note allograft, partial resorption and progressive fibular hypertrophy. Solid scapulohumeral union.
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securing adequate fixation between the end of the transferred fibula and the remaining scapula. The author has successfully used a compression plate and screws bridging from the remaining scapular spine to the proximal segment of the fibula. However, due to the cancellous nature of the scapula and small diameter of the fibula, such fixation requires the additional use of external fixation using a shoulder spica cast. Because of the problems associated with immobilization of this type of construct, the author prefers to combine fibula transfer in this location with a proximal humerus allograft (Fig. 2). Such a construct better ensures scapula to allograft and allograft to the remaining humerus fixation by the use of larger screws and plates. The fibula
Figure 3 (a) Immediate postoperative radiograph following en bloc resection of mid-humerus for chondrosarcoma and transfer of revascularized fibular autograft. (b) Radiograph 13 months postoperatively. Note union and hypertrophy of fibular segment to nearly the same diameter of normal humerus.
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is placed parallel to the allograft with contact proximally into the neck of the scapula and distally to the remaining humerus, using a transosseous screw at each end. The author prefers to revascularize the fibula in most patients by end-to-side anastomosis of the donor bone peroneal artery to the recipient site brachial artery. Venous anastomoses are usually end-to-end between peroneal venae comitantes and either brachial venae comitantes or the cephalic vein. It is much easier to perform the vascular anastomoses and to isolate the recipient vessels more distally in the upper limb. Thus, the fibular segment should be positioned in a retrograde manner in order to position its vascular pedicle closer to the elbow.
Figure 4 (a) Radiograph of atrophic non-union of humerus—prior gunshot wound with extensive bone loss. (b) Immediate postoperative radiograph of vascularized fibula transfer. Note internal fixation with proximal and distal compression plates.
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Humeral diaphyseal defect A large defect of the diaphysis of the humerus is probably the ideal application of vascularized fibula transfer, because when successful it results in a functioning shoulder and elbow joint. Typically defects of the humerus shaft result from penetrating trauma, infected non-unions, tumor resection or radiation necrosis. Fixation of these constructs is usually easier than with scapulohumeral defects. Preferentially, and when there is an adequate remaining length of the proximal and distal humerus, a compression plate or transosseous screws at each end is employed (Figs 3–5). If a compression plate is used at each end screw fixation to at least six cortices (three screws, each with two cortex purchase) should be obtained on either side of the osteosynthesis site. A single plate spanning the entire construct should be avoided as it may act as a stress-shield and inhibit appropriate fibular hypertrophy after healing. Even with compression plate fixation, the additional protection of a shoulder spica cast should be considered for the first 2 postoperative months. As was mentioned for the scapulohumeral reconstructions, retrograde positioning of the fibula should be done to facilitate access to the vascular pedicle for anastomoses. Preferentially end-to-side arterial and end-to-end venous anastomoses are employed as discussed previously. Radius/ulna diaphyseal defect Large defects of either radius or ulna most commonly result from penetrating trauma, infected non-union or tumor resection. Based on size and shape considerations, the fibula is a near perfect match for the diaphyseal segment of radius or ulna. Because of their similarity, post-union hypertrophy of the fibular segment is usually not a significant issue. Fixation may employ a compression plate and screws at each end or a single long spanning plate may be utilized. If the latter technique is selected, however, it is important to avoid screw placement in the central portion of the fibula or near the nutrient foramen. Moreover, six-cortex fixation is required in both the distal and proximal forearm bone segments whether one or two plates are used. For reconstruction requiring fixation to the distal metaphyseal flare of the radius, it is preferable to dowel the fibula well into the metaphysis of the radius (Fig. 6). Internal fixation by any method should be additionally protected by the use of a long arm cast or splint for 6–8 weeks postoperatively. The fibular segment may be placed orthograde or retrograde depending upon the most convenient vascular access site. Anastomoses usually employ end-to-end coaptation to either radial or ulnar arteries, provided the second vessel is patent and the superficial palmar arterial arch permits adequate flow to all digits with the selected recipient artery occluded. As a final comment, whenever one is considering the use of free vascularized fibula for reconstructing a defect of either radius or ulna, the possibility of developing a rather refractory radio-ulnar synostosis should be weighed—especially if the simpler approach of a one-bone forearm construct is considered a viable option for the patient’s functional needs and expectations.
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Forearm-carpal defects Forearm-carpal defects most often result from either penetrating trauma or aggressive tumors, especially recurrent giant cell tumor of the distal radius. In this situation the usual goal is to obtain a stable wrist arthrodesis (Fig. 7). The technique of vascularized bone transfer in this area is essentially identical to that of reconstructing forearm defects, with the exception of distal osteosynthesis fixation. It can be technically challenging to obtain secure fixation to either the carpal bones or the metacarpals and the selection of the best form of internal fixation will thus differ with the unique circumstances of each patient. The author has utilized mini-plate fixation, screws alone, Kirschner wires and cerclage wiring. In all patients firm cast support is recommended until union is confirmed.
Conclusion Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for
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Figure 5 (a) Radiograph of chronic non-union associated with radionecrosis of humeral diaphysis for Ewing’s sarcoma. (b) Immediate postoperative radiograph following resection of radionecrotic humerus and transfer of vascularized fibula autograft. (c) Radiograph of healed humerus reconstruction 58 months postoperatively. Note hypertrophy and absence of radionecrosis of humerus.
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Figure 6 (a) Radiograph of radius—recurrent adamantinoma post curettage at another institution. (b) Immediate postoperative radiograph of en bloc resection of portion of radius and transfer of vascularized fibula autograft. Note intramedullary placement into metaphysis of radius. (c) Radiograph 3 months postoperatively demonstrating union of fibular autograft proximally and distally. (d) Radiograph 38 months post fibular transfer and 30 months post internal fixation plate removal demonstrating fibula incorporation identical to normal appearing radius.
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Figure 7 (a) Radiograph of recurrent aggressive giant cell tumor of distal radius invading proximal carpal row. (b) Immediate postoperative radiograph following extraarticular en bloc resection for aggressive, recurrent giant cell tumor of the distal radius. Note distal fixation with multiple Kirschner wires. (c) Radiograph 13 months postoperatively with union proximally and distally and modest fibular hypertrophy.
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reconstructing massive bone defects in the upper limb or in patients with especially challenging conditions, such as infected non-unions and nonunions associated with radionecrosis of bone. It is especially indicated for the humerus and shoulder region with more selected applications in the forearm or wrist. Though technically challenging, the outcomes of this procedure justify consideration along with alternative methods for major reconstructions of the upper limb.
References Arata MA, Wood MB, Cooney WP (1984) Revascularized segmental bone transfers in the canine. An analysis of viability, J Reconstruct Microsurg 1: 11–19. Berggren A, Weiland AJ, Dorfman H (1982) The effect of prolonged ischemia time on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses, Plast Reconstr Surg 69:290–8. DeBoer NH, Wood MB (1989) Bone changes in the vascularized fibula graft, J Bone Joint Surg 71B:374–8. Dell PC, Sheppard JE (1984) Vascularized bone grafts in the treatment of infected forearm nonunions, J Hand Surg 9A:653–8. Doi K, Tominaga S, Shubata T (1977) Bone grafts with microvascular anastomoses of vascular pedicles: an experimental study in dogs, J Bone Joint Surg 59: 809–15. Duffy GP, Wood MB, Rock MG, Sim FH (2000) Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy, J Bone Joint Surg 82A:544–54. Enneking WF, Gady GL, Burchardt H (1980) Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects, J Bone Joint Surg 62A: 1039–58. Gidumal R, Wood MB, Sim FH et al (1987) Vascularized bone transfer for limb salvage and reconstruction after resection of aggressive bone lesions, J Reconstr Microsurg 3:183–8. Gilbert A (1979) Vascularized transfer of the fibular shaft, Int J Microsurg 1:100–2. Goldberg VM, Shaffer JW, Field G, Davy DT (1987) Biology of vascularized bone grafts, Orthop Clin North Am 18:197–205. Han CS, Wood, MB, Bishop AT, Cooney WP (1992) Vascularized bone transfer, J Bone Joint Surg 74A: 1441–9. Haw CS, O’Brien B Mc, Kurata T (1978) The microsurgical revascularization of resected segments of tibia in the dog, J Bone Joint Surg 60:266–9. Huntington TW (1905) Case of bone transference. Use of a segment of fibula to supply a defect in the tibia, Ann Surg 41:249. Mankin HJ, Gebhardt MC, Tomford WW (1987) Use of frozen cadaveric allografts in the management of patients with bone tumors of the extremities, Orthop Clin North Am 18:275–89. McCulloch DW, Fredrickson JM (1973) Neovascularized rib grafts to reconstruct mandibular defects, Can J Otolaryngol 2:96–100. Nicoll GA (1956) The treatment of gaps in long bones by cancellous insert grafts, J Bone Joint Surg 38B:70–82.
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Osterman AL, Bora FW (1984) Free vascularized bone grafting for large-gap nonunion of long bones. Orthop Clin North Am 15:131–42. Östrup LT, Fredrickson JM (1974) Distant transfer of a free living bone graft by microvascular anastomosis: an experimental study, Plast Reconstr Surg 54:274–85. Peterson CA, Maki S, Wood MB (1995) Clinical results of the one-bone forearm, J Hand Surg 20A:609–18. Phemister DB (1914) The fate of transplanted bone and regenerative powers of its various constituents, Surg Gynecol Obstet 19:303–33. Pho RW, Levack B, Satku K, Patradul A (1985) Free vascularized fibula graft in the treatment of congenital pseudarthrosis of the tibia, J Bone Joint Surg 67B:64–70. Siegert JJ, Wood MB (1990) Blood flow evaluation of vascularized bone transfers in a canine model, J Orthop Res 8:291–6. Taylor GI (1983) The current status of free vascularized bone grafts, Clin Plast Surg 10:185–209. Taylor GI, Miller GDH, Ham FJ (1975) The free vascularized bone graft: a clinical extension of microvascular techniques, Plast Reconstr Surg 55:533–44. Ueba Y, Fuyikawa S (1983) Nine years follow-up of a vascularized fibular graft in neurofibromatosis: a case report and literature review, Orthop Trauma Surg 26:595. Weiland AJ (1981) Current concepts review. Vascularized free bone transplants, J Bone Joint Surg 63A:166–9. Weiland AJ, Kleinert HE, Kutz JE, Daniel RK (1979) Free vascularized bone grafts in surgery of the upper extremity, J Hand Surg 4:129–44. Weiland AJ, Moore JR, Daniel RK (1983) Vascularized bone autografts: experience with 41 cases, Clin Orthop 174:87–95. Wood MB (1986) Free vascularized bone transfers for nonunion, segmental gaps, and following tumor reconstruction, Orthopedics 9:810–16. Wood MB (1987) Upper extremity reconstruction by vascularized bone transfers: results and complications, J Hand Surg 12A:422–7. Wood MB (1990) Free osseous tissue transfer. In: Atlas of Reconstructive Microsurgery. Aspen Publications: Rockville, 65–91. Wood MB, Cooney WP (1984) Vascularized bone segment transfers for management of chronic osteomyelitis, Orthop Clin North Am 15:461–72. Wood MB, Cooney WP, Irons GB (1984) Posttraumatic lower extremity reconstruction by vascularized bone graft transfer, Orthopedics 7:255–62. Wood MB, Cooney WP, Irons GB (1985) Skeletal reconstruction by vascularized bone transfer. Indications and results, Mayo Clin Proc 60:729–34.
8 Loss of the post-traumatic infected substance of the upper limb Ferdinando Da Rin, Mauro Ciotti and Alain Gilbert
Introduction The authors institute specializes in the treatment of chronic infected forms of pseudoarthrosis and therefore of generally infected pseudoarthrosis. The institution was set-up in 1932 by Professor Vittorio Putti, who wanted it for this purpose, in collaboration with the Rizzoli Institute of Bologna. It remained in partnership until 1980 when it was taken over by the Veneto Region remaining, however, an important referral centre for infected pathologies. For the treatment of septic forms we introduced a therapeutic scheme some time ago, based on the use of immuno-stimulation (Savoini 1972, 1975, Savoini et al 1980), a necessary development following the continuously increasing resistance to antibiotics. This therapy does not substitute and is used in association with the antibiotic treatment.
Figure 1 Pandiaphytes of ulna bone in an 11-year-old treated only with ITBS and antibiotic therapy.
ITBS and antibiotic therapy The ITBS (immuno therapy for specific bacteria) is based on the use of inactive staphylococcus which stimulates the so-called aspecific immunity (Ciotti et al 1992)— macrophages and lymphocyte helper cells stimulating the capacity for opsonization (Figs
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1 and 2) and consists of subcutaneous injections, of gradually increasing doses for a period of 3 months, that the patients can carry out by themselves at home. We have verified a multitude of outcomes following the combined use of ITBS and antibiotics. These can be summarized as follows: • Spontaneous elimination of sequestrum. • Demarcation and resorption of the area surrounding the focus of infection. • Toning of the secretion. • Tendency for the fistula to close. • Reduction of the phenomenon of congestion.
Figure 2 1 year later: complete reconstruction of the ulna. • • • •
Reduction of the new acute phase. Reduced articulation stiffness. Stimulation of bone repair. Improvement of the immunological condition with increase in the phagocytic activity of macrophages and polymorphonucleated cells. • Desensibilization of the bacterial proteins. Along with this therapy we carry out local cleansing with antibiotics. A surgical clean-up is always done following the ITBS. The antibiotic therapy is carried out according to the antibiogram or culture where the bacteria can be identified. Where the microorganism cannot be identified, we use high doses of wide spectrum antibiotics.
Pseudoarthrosis The loss of the bone substance or pseudoarthrosis, was defined according to the parameters of
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Figure 3 The typical atrophic form of pseudoarthrosis. Weber and Cech (1989), as an absent consolidation after 6–8 months of the fracture. A nonresolution of the fracture before this period is defined as a ‘delay of consolidation’. Currently, the concept of pseudoarthrosis is different according to the location and the anatomical–pathological characteristics of the type of bone interruption, and therefore this is a statistical data and can change considerably. For this reason it is defined by location and the radiological aspect of the injury (McKee 2000). Once the pseudoarthrosis is established (nonunion) it may present in the following forms: • with or without loss of substance between the stumps of fracture • with fragments of fracture (atrophic) (Fig. 3) • with fragments of fracture (hypertrophic (Fig. 4) This simple but practical classification allows us to consider some opportunities which are provided by the fragmental characteristics of the
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Figure 4 The hypertrophic form (the gap among the fragments is important). pseudoarthrosis and in fact, our treatment philosophy is based on these considerations: 1. A hypertrophic pseudoarthrosis without a gap between the fragments can be treated by simple compression. In fact, the peculiar characteristic of this type of pathology is its large regenerative potential, and that its stabilization alone can certainly result in recovery. 2. An atrophic pseudoarthrosis, but with the fragments close to each other will certainly need between and after stabilization. 3. In case there is a gap between the two fragments that does not exceed 5 cm, we will consider approximation with compression using the apparatus of Ilizarov. 4. In the case of fragments separated by more than 5 cm, the solution is the transfer of vascularized fibula.
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Figure 5 Infected pseudoarthrosis of the right humerus with a massive sequestrum and a gap between the fragments of about 5 cm. The surgical treatment in pseudoarthrosis must be immediate, because of the need to stabilize the lesion. The antibiotic treatment and ITBS are started during the operation. In septic forms without continuity, we can wait until the effect of the ITBS therapy. Stability is our primary objective concomitantly with the treatment of the infection. The loss of muscle and skin, nerve injury and associated tendon injury, are discussed elsewhere in this book.
Treatment considerations of the various forms of pseudoarthrosis Hypertrophic pseudoarthrosis with a gap less than 3–5 cm is treated with the Ilizarov method. If the gap measures 3 cm, we apply immediate compression to the focus of the infection, because as described previously: ‘the infection burns at the firing of the compression’. We use Ilizarov’s apparatus because usually we are dealing with a case of poor alignment which must be corrected more than once and this apparatus permits us to do so. When the gap exceeds 5 cm (shortening is well tolerated by both the apparatus and the patient), the compression is applied gradually, 3–4 mm each day, following an initial
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compression which we do while in the operating theatre (Figs 5–7) for surgical cleaning and removal of the sequestrum. If the focus of infection is oblique, it is necessary to use the olive (Figs 8 and 9).
Figure 6 Application of the Ilizarov apparatus.
Figure 7(a,b) After 15 days the contact between the fragments of the pseudoarthrosis is seen and after 6 months the apparatus was removed. This is the result 6 months after the removal.
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Figure 8 Radiograph of Ilizarov’s apparatus and the olive for the compression–stabilization of the focus while distraction is taking place.
Obviously, this type of immediate compression can be applied for the pseudoarthrosis of both bones of the forearm or of the humerus. If only one bone of the forearm is affected a compacto tomy is performed and the and bone is moved to close the area of bone loss. If the pseudoarthrosis is hypertrophic we do the compression and then some days later (15– 20 days) we do distraction of 1 mm of the same focus of pseudoarthrosis each day. Both these techniques are used in the presence of a shortened bone (Figs 8–11).
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Figure 9 Radiograph after 4 months of treatment shows correction of the ulnar plus. The proximal compactotomy technique with gradual distraction and compression of the focus is shown in Figures 12–16. We must consider that the compression can or better, must, take place very quickly. In fact, experience with lower limbs has shown, the longer we take to put the fragments of pseudoarthrosis into contact, the higher the risk of further consolidation, resulting in another operation to revitalize the fragments, mostly with the use of cancellous bone graft
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Figure 10 A pseudoarthrosis (infected) of the radius of a 43-year-old patient: the outcome of an open fracture. (a) Radiographic evidence of proximal migration of the radius (metry of about 3 cm) with ulnar plus. (b) Following 7 months of treatment, he has a fistula and laboratory tests show there is an infection (VES: 55; PCR: 15; fibrinogen: 600).
Figure 11 Radiographs of the apparatus in compression, after 15–20 days of distraction of 1 mm per day. . Figures 17–19 show another case where we executed a simple compression followed by gradual filling of the gap. This was preceded by a surgical cleaning and removal of a
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sequestrum. We must also consider a system which is defined as ‘hybrid’ used for the arm made up of rings in association with proximal fiches, like those used for the common fixators (Fig. 17). This design
Figure 12 50-year-old male patient with an infected non-union following an open fracture.
Figure 13 A model which shows the assembly required with the use of a proximal compactotomy at the ends of the gap between the fragments of pseudoarthrosis.
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became obligatory after an initial use of the rings in proximity which was less tolerated by the patient, as the rings occupied the medial side of the arm, preventing adduction and producing painful subluxation of the shoulder.
Figure 14 Radiographs following application of Ilizarov apparatus, the position of the compactotomy can be seen.
Figure 15 Radiograph of the contact of the fragments with the evident formation of regenerated bone, and the closing of the gap of about 5 cm. In pseudoarthrosis with loss of substance, a gap of 5 cm for an upper limb is the limit for direct compression of the focus. Exceeding this limit can lead to ischaemic phenomena, especially on the distal side, due to an excessive kinking of vessels. This was also demonstrated in Ilizarov’s work of 1959 (Ilizarov 1959, Dell and Sheppard 1984). With an atrophic or hypertrophic loss of substance larger than 5 cm, we prefer to use the vascularized fibula, which is considered the best method for bone reconstruction in the upper limb (Dell and Sheppard 1984). We use the vascularized fibula technique, because in the presence of septic pathology
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Figure 16 Radiographic result after about 2 months of removal of the apparatus.
Figure 17 Drawing representing the assembly called ‘hybrid’.
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Figure 18 The skin incision. there is a lack of vascularization, not just of the bone, but of the whole organ. Thus the endoperiosteal vascularization of the fragment is compromised. The vascularization of soft tissues is also compromised, since an infection above all results in hypoxaemia. The focus of infection also tends to create isolating barriers, so that the antibiotics cannot reach it. If a non-vascularized graft is put into this environment, the survival of the graft itself will be compromised. It may survive but after a long period, in which the defences against possible intensification of the infection will be low and easily overcome by microorganisms with low virulence. It is like being on a raft in the middle of the sea— with (vascularized) or without (graft) provisions. We follow the technique of Gilbert for this procedure, (1979, 1981, 1997) (Figs 18 and 19). We don’t use a particular technique if not the fixation of the focus, searching a bayonet cap fixed with screws and eventually supported by an external fixer. A particular method of using the fibula is to dissect the fibula, maintaining its vascularization (Figs 20–22). Before using the fibula, we do a first-step operation, using a spacer of cement with an antibiotic because it is impossible to clean up the infection focus properly. In fact, sometimes an infection with sequestration of the inserted fibula can occur (Fig. 23) when the fibula is inserted immediately after the surgical cleaning. We must con-
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Figure 19 Dissection of pedicle and section.
Figure 20 A particular case of the use the vascularized fibula in the non-union of the distal humerus. sider the difficulty in overcoming infection; thus the protocol adopted for this condition consists of two steps. In the first step we do surgical cleaning and apply a spacer with an antibiotic, which will be removed after 3–4 weeks after checking the local, general and laboratory parameters. If these are still altered, we will substitute the spacer with another spacer (Tripel 1986, McNally et al 1993, Tsukayama et al 1996). After the removal of the spacer, in the second step we will transfer the vascularized fibula.
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Figure 21 The cut in the middle of the fibula, without interruption of its vascularization.
Figure 22 Reconstruction of the distal humerus. The spacer serves many functions: • it prevents adhesion between the fragments • it maintains the correct length • it contributes to the healing of the septic focus, maintaining high local concentration of the antibiotic. For a long time we used self mixed cements, which were composed of low toxicity powdered antibiotics, but we noticed that these became porous (immediately leaching the antibiotic) and fragile (Ghisellini and Ceffa 1997).
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Figure 23 Infection of a fibula graft inserted immediately after surgical cleaning. We resolved the situation by doing surgical cleaning and applying Ilizarov’s apparatus. Recently, cements have appeared on the market which are composed of two readymixed antibiotics with a wide spectrum of action (Fig. 24) and have better biomechanical properties. These cements are used especially in septic prosthesis replacements.
Complications We have reported an intolerance to the Ilizarov device in a case where the ‘non-hybrid’ system has been utilized. The same also happened when the Ilizarov technique was utilized for bone reconstruction, building up the gap after compactotomy. Rare complications observed during limb ‘transfixation’ were lesions of a blood vessel, a nerve or a tendon, all completely resolved after removal and substitution of Kirschner wires. In one case a late brachial artery aneurysm needed a surgical repair of the damaged vessel. In another case a forearm compartment syndrome resolved after the removal of the Ilizarov device. The eventual instability of the assembly needs periodic evaluation; also the ‘distraction’ of a bony fragment, if present, needs to be checked frequently since, in the
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fibrous tissue, it could be blocked or deviated in its axis of descent. In this event an incision must be performed along the wires or some corrective systems must be applied. Tissue lysis and secretion around the wires is often seen. Usually it is a superficial inflam-
Figure 24 Spectrum of action of a cement with gentamicin + clindamicin.
Figure 25(a,b) 54-year-old patient—result of open fracture of the forearm and wrist.
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Figure 26 Fistulography.
Figure 27 Debridement and application of the spacer with external fixator. matory reaction that benefits from maintaining good hygiene of the device. A patient must learn how to maintain hygiene.
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Sometimes we have observed a flexion of the wrist or fingers, which can be avoided by the use of splints attached to the Ilizarov device; this type of inconvenience resolves completely after the removal of the device and some rehabilitation therapy. The shortening of bone, mainly the humerus (even of 5 cm) was not followed by any major functional defect. Better results were obtained with the ‘twostep’ technique, mainly in the incidence of relapse that reduced from 30% to 5%. In the use of vascularized fibular graft for bone reconstruction, besides the difficulty of harvesting, special attention must be given to the synthesis. For this to be made in the safest and most stable way: we usually consider the use of synthesis screws together with an external monoaxial fixator. In case of large bone loss the use of multihole plates should be considered. No com
Figure 28 Removal of the spacer fibula microvascular graft with arthrodesis of the wrist. After 4 months: removal of the fixator. Radiograph after 2 more months. plication has been reported in adult patients from graft sampling: in very few cases some transient limitation of hallus abduction underwent spontaneous recovery. A plexiform vascularization of the fibular vein could complicate the graft procedure, requiring specific skills in vascular microsurgery for vascular calibre reduction. If possible, the ligation of the receiving radial vessel should be avoided, performing two termino-terminal sutures, proximal and distal, using the fibular artery as a bypass. In elderly patients with history of cigarette-smoking and arteriopathy, microsurgery is contraindicated.
References Ciotti M, Argazzi M, Bergami PL (1992) La vaccinoterapia nell’ osteomielite cronica, Atti SERTOT 34(Fasc II).
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Dell PC, Sheppard JE (1984) Vascularized bone graft in the treatment of infected forearm nonunions, J Hand Surg 9A:653. Ghisellini F, Ceffa R (1997) Trattamento Delle Infezioni di Protesi Articolari. La Moderna: Novara. Gilbert A (1979) Vascularized transfer of the fibula shaft, Int J Microsurg 1:100–9. Gilbert A (1981) Free vascularized bone graft. Int Surg 66:27. Gilbert A (1997) Fibular transfer, In: Wood MB, Gilbert A eds. Microvascular Bone Reconstruction. Martin Dunitz: London. Ilizarov GA (1959) Compression osteosynthesis with the author’s apparatus in clinics (in Russian), Final Scientific Session of the Institutes of Traumatology and Orthopedics of Ministry of Health of the RSFSR. Leningrad, pp. 68–70. McKee MD (2000) Aseptic non-union. In: AO Principles of Fracture Management. Thieme: Stuttgart. McNally MA, Small JO, Tofighi HG, Mollan RAB (1993) Two stage management of chronic osteomyelitis of the long bones. The Belfast Technique, J Bone Joint Surg 75B:375–80. Savoini E (1972) Sulla cura dell’osteomielite cronica, COM 60:547–69. Savoini E (1975) Moderne Richtungen in der Behandlung der Chronischen Osteomyelitis, Z Orthop 113:344–56. Savoini E, Capanna R, Gherlinzoni F (1980) Immunità umorale ed osteomielite cronica, COM 66:511–15. Tripel SB (1986) Antibiotic-impregnate cement in total joint arthroplasty, J Bone Joint Surg 68A:1297–302. Tsukayama DT, Estrada R, Gustillo RB (1996) Infection after total hip arthroplasty, J Bone Joint Surg 78A: 512–23. Weber BG, Cech O (1989) Pseudoartrosi. Piccin: Padova.
9 Bone substitutes Norbert Passuti, Laurence Bigotte, Sophie Touchais, Joël Delécrin and François Gouin
Introduction Bone grafting has a well recognized role in orthopaedic surgery for the treatment of nonunion, bridging diaphyseal defects and filling metaphyseal defects. However, it is associated with postoperative pain and morbidity (Summers and Eisenstein 1989, Younger and Chapman 1989). When extensive grafting is required (as in spinal arthrodesis and the management of large bony defects) adequate amounts of autologous bone may not be available. Allograft bone has been used as an alternative but it has low osteogenicity, increased immunogenicity and resorbs more rapidly than autogenous bone and the transmission of disease remains a concern. Autogenous bone graft is osteogenic, osteoinductive, osteoconductive and completely biocompatible. These characteristics should also be present in the ideal substitute. Osteogenic materials have the capacity to form bone, that is they have living cells such as osteoblasts capable of producing it. Osteoconductive materials have no capability to form bone or induce its formation.
Osteoconductive materials Osteoconductive materials have been available for longer than osteoinductive or osteogenic substitutes. These inert materials resemble the mineral phase of bone and are biocompatible. They provide a structure or scaffold, which can form a close interface with adjacent bone. The cellular elements can grow into the material and gradually regenerate normal bone. They are generally used as a material to fill bone defects which require mechanical support. However, some have a role in extending autogenous bone graft, and more recently have been evaluated as carrier materials for osteoinductive proteins. Coralline hydroxyapatite This material is derived from the calcium carbonate of sea corals. The pore structure of coralline calcium phosphate produced by certain species is similar to human cancellous bone, making it a suitable material for an osteoconductive substitute for bone graft. The pore size required for bone ingrowth varies from 100 to 500 µm. Coralline bone substitutes may be natural or manufactured. For the natural substitute the calcium carbonate skeleton is harvested directly from the natural habitat, cleaned and sterilized.
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The manufactured substitute is coralline hydroxyapatite, which is produced from natural coralline calcium carbonate by substitution of the carbonate components with phosphates. The material is commercially available and is marketed with mean pore sizes of 200 or 500 µm. It has high compressive strength but is brittle with low tensile strength. It has been used in the management of fractures of the tibial plateau as a filler material and the results have been comparable to those obtained with autogenous bone graft (Bucholz et al 1989). The main disadvantages have been the variable strength and rates of resorption. More recently, coralline hydroxyapatite has been used as a carrier for some growth factors. In a canine model, it has been used as a carrier for bone morphogenetic proteins (BMP) with success and in a rabbit model as a carrier for transforming growth factors and fibroblast growth factors (Miller et al 1991, Ashby et al 1996). Calcium sulphate This material is familiar to orthopaedic surgeons as plaster-of-Paris and is perhaps the oldest osteoconductive material available. In a review of the history of the material, Tay et al (1999) describe reports of it being used to fill bony defects in the last century. Its main drawback is the chemical reaction which occurs during setting, and which results in a very variable crystalline structure with consequent inconsistencies in the material properties of the final product. It also resorbs very rapidly at a rate which may exceed the capacity of surrounding bone to regenerate. At present, it has been superseded by more reliable osteoinductive materials although it may still have a future role as a carrier for BMP. Ceramics When naturally occurring mineral salts are subjected to very high temperatures in a process known as sintering, highly crystalline materials termed ceramics are produced. Some of these materials are biocompatible and osteoconductive. Their structure is quite distinct from the poorly crystalline configuration of normal bone and for this reason they are resorbed very slowly. The most popular ceramics have been tricalcium phosphate and the derived ceramic hydroxyapatite. The latter is a biocompatible ceramic, which is produced in a high temperature reaction and is a highly crystalline form of calcium phosphate. It is very stable and resorbs very slowly. Coralline hydroxyapatite, which has already been discussed, was one of the first ceramics to be used as an osteoconductive material. The main drawbacks of ceramics are the slow resorption and the difficulty in developing a material with favourable handling characteristics and which is easy to use clinically. Ceramics have been used in spinal surgery to extend autogenous bone graft in the long fusion necessary for adolescent scoliosis. Le Huec et al (1997) compared the use of tricalcium phosphate ceramic mixed with autogenous bone (24 patients) with a mixture of allograft and autogenous bone (30 patients). No pseudoarthrosis occurred in either group. Ransford et al (1998) carried out a randomized trial in 341 patients, comparing the use of a synthetic porous ceramic with autogenous bone for spinal fusion in idiopathic scoliosis. The results were comparable in both groups, but complications occurred in relation to the donor site of the bone graft. The authors concluded that the ceramic was a safe and
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effective substitute for autograft. The use of ceramic hydroxyapatite in the management of fractures has been more limited. Itokazu et al 1996 found that in 17 patients with fractures of the tibial plateau, the material was safe with no evidence of post-traumatic arthritis at a mean follow-up of 2 years and 6 months. The poor bioresorption and difficulties in the handling of ceramics have stimulated research to develop materials which resemble the mineral phase of bone more closely. This further has led to the development of calcium phosphate cements. Calcium phosphate ceramics are widely used as bone graft substitutes for filling bone defects because of their chemical composition which is similar to the mineral part of bone and their excellent biocompatibility. They undergo a resorption/bone substitution process, particularly when they are macroporous, and form a strong bond with the host bone (Daculsi et al 1989b, 1990a). This property is known as bioactivity and has been described by several authors (Daculsi et al 1989a). Bioactivity includes biodegradation/dissolution of the ceramic and biological apatite precipitation. Many factors influence the degradation/ dissolution process: physical form, composition and crystallinity. The process of degradation/ dissolution results in physical changes (loss of mechanical strength) and chemical changes (pH reduction in the implant environment causing notably partial dissolution of the material). Dissolution provokes an elevation of the calcium and phosphate ion concentrations in the microenvironment, leading to the precipitation of a biological apatitic phase. The new microcrystals were observed regardless of the site of implantation (osseous or non-osseous). However, no work has clearly demonstrated the presence of ‘true bone’ in a non-osseous site and thus the osteoinductivity of calcium phosphates. Differences in features between implants from osseous and nonosseous sites. To determine if physico-chemical changes participate in the modification of the mechanical properties of macroporous biphasic calcium phosphate (MBCP), cylinders were implanted in a bone site (rabbit femurs) where physicochemical changes and bone ingrowth take place, and in muscle where only physico-chemical transformation occurs. The presence of a new calcium phosphate phase and an organic matrix was observed by FTIR (Fourier Transform Infrared) spectroscopy in both osseous and nonosseous site. This new mineral phase was assumed to consist of bone apatite-like crystals. At the same time compressive strength of MBCP, not only in bone but also in muscle increased linearly with duration of implantation. Mechanical improvement of the MBCP implanted in a human simultaneously with biological apatite precipitation was also demonstrated. Factors that might explain this enhancement are decrease in microporosity and precipitation of needle-like crystals, but transmission electron microscopy and histological observations still have to be done to check that carbonated apatite precipitates are the major changes in MBCP after implantation in muscle (Legeroz 1988). Our results suggest that two types of multinucleated cells are elicited by contact with the biomaterials implanted in bone site. The first type consists of large cells containing more than 20 nuclei and resembling giant cells. These cells have neither TRAP (tartrate resistant acid phosphatase) activity nor a ruffled border, but some have vacuoles or vesicles with crystals, suggesting phagocytosis of the biomaterial. Similar cells have also been observed with subcutaneous bone implants in rabbits. These multinucleated giant cells do not have the specific enzymatic activity, cell surface aspects and functional features of osteoclasts. The second type consists of multinucleated cells with some
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characteristics similar to those of osteoclasts. These cells are smaller, contain less than 10 nuclei and are TRAP+. The enzyme activity of the cells appears to provoke extracellular dissolution of the implant as demonstrated by the TRAP+ reaction and structural modification in the biomaterials subjacent to the multinucleated cells. Electron microscopy reveals that these cells have a clear zone and some cytoplasmic membrane infolding resembling a ruffled border, was observed (Basle et al 1993). The calcium phosphate ceramics HA (hydroxyapatite) and β-TCP (tricalcium phosphate) are used clinically for bone reconstruction in periodontal, orthopaedic and maxillofacial surgery. Biphasic calcium phosphate ceramic, being a mixture of HA and βTCP 1 is resorbable to a degree that is a function of the HA to β-TCP ratio. An animal study showed that the biological performance of MBCP ceramics improved when they were used in connection with repair of defects due to bone loss. Previous studies in which we used non-commercial MBCP, consisting of HA-β-TCP in various proportions, confirmed that the mixture of an equal amount of HA and β-TCP was particularly effective. This explains why in both the experiments on animals and in this clinical study, macroporous granules consisting of 60% HA and 40% β-TCP were used (Passuti et al 1989). The histological results revealed bioactivity and osteoconduction in MBCP ceramics. The granules became smaller with time; hence, resorption was taking place according to the degree of β-TCP bioactivity and the stability of the HA. Following the biodegradation and healing of the implanted site, the osteoblasts of the bone that received the implant invaded the macropores and the spaces between the MBCP granules. True bone— characterized by osteocytes, a mineralized bone matrix, and, because of remodelling, a haversian-type system—appeared between the pores. We observed that in general the newly formed bone appeared first on the surface area of the MBCP granules and that it was made up mainly of lamellar bone and ‘scarcely woven’ bone. In other human applications (spine fusion, long bone filling) we have noticed the same results. According to our previous studies, it seems that 2 or 3 months are needed before the new bone starts to look like normal bone (Trecant et al 1994).
Clinical experience The initial Food and Drug Administration (FDA) monitored trial with Pro-Osteon (Interpore Cross International, Irvine, CA, USA) consisted of 174 defects (137 acute fractures, 26 delayed unions, 11 cysts) in 167 patients (Shors 1998). The inclusion of patients with multiple aetiologies made data analysis difficult. More focused clinical series have shown the efficacy of interporous hydroxyapatite (Bucholz et al 1989, Ladd and Pliani 1999, Wolfe et al 1999). In a randomized study of 40 patients with split depression tibial plateau fractures, hydroxyapatite implants were compared with autograft in their ability to buttress articular fragments and prevent postoperative loss of reduction (Bucholz et al 1989). Blocks of hydroxyapatite implants were milled to fit the different shapes and volumes of defects encountered at surgery. No significant differences in the clinical results were seen between hydroxyapatite implants and autograft. No radiographic evidence of bioresorption of the implant was seen, even at long-term followup. Similarly, in a study of 15 patients with severe distal radius fractures treated with
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external fixation, supplemental Kirschner wires and limited open fixation, hydroxyapatite implants were used to buttress depressed articular fragments (Wolfe et al 1999). The goal of maintaining articular congruency was achieved. Intraarticular extrusion of hydroxyapatite granules into the radio-carpal joint in one patient had no apparent adverse effect on longterm wrist function. In a review of bone graft alternatives for complex distal radius fractures, Ladd and Pliani (1999) concluded that hydroxyapatite implants are useful, effective fillers. Interporous hydroxyapatite has been used extensively in anterior and posterior spinal arthrodesis. The FDA does not approve it for spinal use, and the series with spinal applications are small (Thalgott et al 1999). Because of their weak mechanical properties, granular hydroxyapatite implants are used primarily as bone graft extenders for long posterior spinal arthrodesis with rigid instrumentation (Daculsi et al 1990b, Thalgott et al 1999)
Clinical applications for upper limb Few publications describe specific applications of bone substitutes for traumatic defects in the upper limb. Very often macroporous calcium phosphate ceramics are used for filling bone defects (Gouin et al 1995) or for specific hand lesions as noted by Schernberg et al (1992). They used a bovine derived ceramic substitute (Pyrost, Osteo AG, Selzach, Switzerland) for 104 cases and suggested that this biomaterial can be applied for bone defects in hand and wrist traumatology. In the case of acute fractures prospective studies have been performed. A randomized clinical trial was concurrently conducted at 18 medical centres to compare the safety and efficacy of two types of graft material for the treatment of fractures of long bones: autogenous bone graft obtained from the iliac crest and a composite material composed of purified bovine collagen, a biphasic calcium phosphate ceramic and autogenous marrow. Two hundred and thirteen patients were followed for a minimum of 24 months to monitor healing and occurrence of complications. They observed no significant differences between the two treatment groups with respect to rates of union or functional measures. Twelve patients, who were treated with a synthetic graft had positive antibody titres to bovine collagen. The authors concluded that for traumatic defects of long bones the use of the composite graft material could be justified on the grounds of safety, efficacy (avoids the increased operative time) and risk involved in obtaining an autogenous graft from the iliac crest (Chapman et al 1997). For fractures of the distal radius some authors used bone cement (Sanchez-Sotelo et al 2000). They performed a prospective, randomized study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with a bone cement (Norian skeletal repair system (SRS), Stratec Medical, Germany) and immobilization in a cast for 2 weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The authors concluded that injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provided better radiological results than conventional treatment (Wolfe et al 1999). Hence traumatic bone defects can be filled with granules or blocks of macroporous biphasic calcium phosphate ceramics mixed with bone marrow cells.
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Example of a case A 30-year-old female patient presented with a benign lesion of the first metacarpal bone (Fig. 1). We filled the chondroma with macroporous biphasic calcium ceramic mixed with bone marrow cells. After 13 months we observed
Figure 1 a satisfactory osteointegration of the bone substitute with consolidation (Figs 2 and 3).
Indications and future directions Although interporous hydroxyapatite is only approved by the FDA for traumatic metaphyseal defects, it has been used in the treatment of a spectrum of bone defect problems including spinal arthrodesis, iliac crest donor site filler, delayed unions, nonunions, bone cysts and tumors, and revision arthroplasties. The implant must be shielded from major loading forces wherever it is applied. To date, all research and clinical applications confirm it to be a biocompatible, osteoconductive, porous implant on which bone has a propensity to grow (Bucholz et al 1989, Shors 1998, Wolfe et al 1999). A resorbable form of the interporous hydroxyapatite called Pro-Osteon 500R (Interpore Cross International, Irvine, CA, USA) has been devel-
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Figure 2
Figure 3 An aspect of the bone rehabitation inside the macropores of a calcium phosphate ceramic: biopsy done 2 years after implantation. Ceramic in white, bone in grey (differentiated bone inside the pores). oped recently. By terminating the thermochemical reaction before completion, the coral carbonate interior of the Goniopora coral is preserved with only the outer 4 µm of the surface converting to hydroxyapatite. Experimental data suggest that osteoblasts can degrade the coral carbonate much more rapidly with resorption of most of the implant by 6 months. Although the mechanical
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properties are similar to the original Pro-Osteon 500, the rapid resorption of Pro-Osteon 500R permits more complete bone remodelling. An autologous gel prepared from a patient’s blood comprising of serum, serum-derived proteins and growth factors, and platelets has been promoted and used as an adjuvant to form a composite graft with osteoconductive interporous hydroxyapatite granules. No clinical series have been published on the use of resorbable implants or plateletderived growth factor. Biomaterials such as calcium phosphate ceramics appear to be suitable alternatives to bone grafts. Calcium phosphate ceramics are known to be biocompatible and osteoconductive: that is, they are able to promote new bone formation on contact (Daculsi et al 1990b, Trecant et al 1994). Biphasic calcium phosphate (BCP) ceramics, composed of a mixture of hydroxyapatite and 13-tricalcium phosphate, are considered to be more bioactive (Daculsi et al 1999) and more efficient than hydroxyapatite alone for the repair of periodontal defects (Ellinger et al 1986), certain orthopaedic applications (Daculsi and Passuti 1990), and maxillofacial and ear, nose, and throat surgery. The macroporous form of BCP can promote bone formation by osteoconduction and has a degradation rate adapted to bone ingrowth kinetics (Ellinger et al 1986, Daculsi and Passuti 1990). However, these ceramics possess no intrinsic osteogenic (osteoinduction) properties. Therefore, they are inadequate for the filling of large bone defects or lesions, especially since they have little contact with bone, which means that clinical applications may have to be restricted to small bone defects or to regions with large bone contact. The association of osteogenic cells with calcium phosphate ceramics has shown osteogenic potential in vivo, as illustrated in a rat model of bone marrow cells and calcium phosphate ceramic that induced bone formation in extraosseous sites (Nade et al 1983) and also potentiated bone ingrowth in osseous sites (Benayahu et al 1991). Bone marrow contains various cell populations involved in both bone homoeostasis and renewal of peripheral mature blood cells. Thus, in addition to osteoprogenitors, bone marrow contains various mesenchymal cells, including fibroblasts, adipocytes, endothelial cells, smooth muscle cells and reticular cells (Benayahu et al 1991). The osteogenic potential of the mesenchymal stem cell compartment has been demonstrated by Friedenstein et al (1968). It differentiated to form an ossicle in association with active haematopoietic tissue when grafted under the kidney capsule. In vitro, human and animal mesenchymal stem cells have differentiated into osteogenic cells, giving rise to bone-like tissues (Maniatopoulos 1988). These results suggest that bone marrow cells are good candidates for improving the osteoinductive capacity of biomaterials. Moreover, bone marrow can be obtained much more easily from patients than can autologous bone. We cultured bone marrow mesenchymal stem cells on biomaterials in order to obtain a ‘hybrid material’ with osteogenic potential. The proliferation of mesenchymal stem cells and their differentiation in calcium phosphate ceramic, leading to in vitro autologous bone formation, should allow the use of this material in many new clinical applications.
Conclusions Bone graft substitutes of two main types are now available. Osteoinductive materials incorporate a BMP in a carrier material, which, after implantation, induces local tissue to form bone. Osteoconductive materials are an inert scaffold which allows bony ingrowth
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from local osseous tissue. Some of these products have compressive strengths similar to that of cancellous bone. Many are still being evaluated experimentally. There is increasing interest in combining an osteoinductive protein in an osteoconductive carrier medium with more desirable structural properties. It is probable that a second generation of products with these characteristics will appear in the foreseeable future. At present, osteoconductive materials have been shown to be effective in the treatment of defects in metaphyseal bone in association with some fractures, notably in the distal radius, the tibial plateau and the calcaneum. Osteogenic proteins have met with some success in the treatment of bone defects and non-union, but more work is needed to define the most effective protein and the optimum local dose required. Autologous bone grafting will, for the moment, continue to play an important role in the treatment of non-union. In the future, however, it seems likely that the requirement for this treatment will diminish and with the development of more effective alternatives it may eventually become obsolete.
References Ashby ER, Rudkin GH, Ishida K, Miller TA (1996) Evaluation of a novel osteogenic factor, bone cell stimulating substance in a rabbit cranial defect model, Plast Reconstr Surg 98:420–6. Basle MF, Chappard D, Grizon F et al (1993) Osteoclastic resorption of Ca-P biomaterials implanted in rabbit bone, Calcif Tissue Int 53:348–56. Benayahu D, Fried A, Zipori D, Weintroub S (1991) Subpopulation of marrow stromal cells share a variety of osteoblastic markers, Calcif Tiss Int 49:202–7. Bucholz RW, Carlton A, Holmes RE (1989) Interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures, Clin Orthop Rel Res 240:53–62. Chapman MW, Bucholz R, Cornell CH (1997) Treatment of acute fractures with a collagen-calcium phosphate graft material: a randomized clinical trial, J Bone Joint Surg (Am) 79A:495–502. Daculsi G, Passuti N (1990) Effect of the macroporosity for osseous substitution of calcium phosphate ceramics, Biomaterials 11:86–7. Daculsi G, Legeros G, Nery E et al (1989a) Transformation of biphasic calcium phosphate ceramics in vivo: ultrastructural and physicochemical characterization, J Biomed Mater Res 23:883–94. Daculsi G, Passuti N, Martin S, Le Nihouanen JC, Brulliard V, Delécrin J (1989b) Etude comparative des céramiques biocalciques en phosphate de calcium après implantation en site spongieux chez le chien, Rev Chir Orthop 75:65–71. Daculsi G, Legeros RZ, Heughebaert M, Barbieux I (1990a) Formation of carbonate apatite crystals after implanatation of calcium phosphate ceramics. Calcif Tissue Int 46:20–7. Daculsi G, Passuti N, Martin S et al (1990b) Macroporous calcium phosphate ceramic for long bone surgery in humans and dogs. Clinical and histological study, J Biomed Mater Res 24:379–96.
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Ellinger RF, Nery EB, Lynch KL (1986) Histological assessments of periodontal osseous defects following implantation of hydroxyapatite and biphasic calcium phosphate ceramics. A case report, Int J Periodont Restor Dent 3:223. Friedenstein AJ, Petrakova KV, Kurolesova AI et al (1968) Heterotopic transplants of bone marrow. Analysis of precursor cells for osteogenic and hematopoietic tissues, Transplantation 6:230–47. Gouin F, Delécrin J, Passuti N et al (1995) Comblements osseux par céramique phosphocalcique biphasée macroporeuse. A propos de 23 cas , Rev Chir Orthop 81:59–65. Itokazu M, Matsunaga T, Ishii M, Kusakabe H, Wyni Y (1996) Use of arthroscopy and interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures, Acta Orthop Traum Surg 115:45–8. Ladd A, Pliani N (1999) Use of bone graft substitutes in distal radius fractures, J Am Acad Orthop Surg 7:279–90. Legeros RZ (1988) Calcium phosphate materials in restorative dentistry: a review, Adv Dent Res 2:164–80. Le Huec JC, Lespirt E, Delavigne C et al (1997) Tricalcium phosphate ceramics and allografts as bone substitutes for spinal fusion in idiopathic scoliosis: comparative results at four years, Acta Orthop Belg 63:202–11. Maniatopoulos C, Sodek S, Melcher AH (1988) Bone formation in vitro by stroma cells obtained from bone marrow of young adult rats, Cell Tiss Res 254: 317–30. Miller TA, Ishida K, Kobayashi M et al (1991) The induction of bone by an osteogenic protein and the conduction of bone by porous hydroxyapatite: a laboratory study in the rabbit, Plast Reconstr Surg 87:87–95. Nade S, Armstrong L, McCartney E, Baggaley B (1983) Osteogenesis after bone and bone marrow transplantation. The ability of ceramic materials to sustain osteogenesis from transplanted bone marrow cells: preliminary studies, Clin Orthop 181:255–63. Passuti N, Daculsi G, Rogez JM et al (1989) Macroporous calcium phosphate ceramic performance in human spine fusion, Clin Orthop Rel Res 248: 169–76. Ransford AO, Morley T, Edgar MA et al (1998) Synthetic porous ceramic compared with autograft in scoliosis surgery: a prospective randomized study of 341 patients, J Bone Joint Surg (Br) 80B:13–18. Sanchez-Sotelo J, Munuera L, Madero R (2000) Treatment of fractures of distal radius with a remodellable bone cement: a prospective randomised study using Norian SRS, J Bone Joint Surg (Br) 82B: 856–63. Schernberg F, Costa-Foru B, Magnien C (1992) Utilisation d’un substitut osseux (Pyrost) au niveau de la main. Résultats préliminaires à 3 ans. Communication à la Société Française de Chirurgie de la Main, Montpellier. Shors E (1998) Bone graft substitutes: clinical studies using coralline hydroxyapatite biomaterials in surgery. In: Walenkamp GHIM, Bakker FC, eds. Georg Thieme Verlag: Stuttgart, 83–9. Summers BN, Eisenstein SM (1989) Donor site pain from the ilium: a complication of lumbar spine fusion, J Bone Joint Surg (Br) 71B:677–80. Tay B, Patel VV, Bradford DS (1999) Calcium sulphate and calcium phosphate-based bone substitutes: mimicry of the mineral phase of bone, Orthop Clin North Am 30:615–23.
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Thalgott S, Fritts K, Guiffre J, Timlin M (1999) Anterior interbody fusion of the cervical spinal with coralline hydroxyapatite. Spine 24:1295–9. Trecant M, Delecrin J, Royer J, Daculsi G (1994) Mechanical changes in macroporous calcium phosphate ceramics after implantation in bone, Clin Mater 15:233–40. Wolfe S, Pike L, Slade J, Katz L (1999) Augmentation of distal radius fracture fixation with coralline hydroxyapatite bone graft substitute, J Hand Surg 24A:816–27. Younger EM, Chapman MW (1989) Morbidity at bone graft donor sites, J Orthop Trauma 3:192–5.
Joint reconstruction
10 Joint transfers and joint reconstruction Luc Téot
Introduction Joints which have lost normal movements consequent to traumatic arthrodesis or congenital malformations are candidates for surgical reconstruction. Several techniques have been proposed to restore movement in joints using different types of transfer like partial or complete replacement of joints by allografts or epiphyseal replacements using pedicled apophysis on growing bones. Limitations of these techniques include the anatomical scarcity of donor sites (autografts, allografts) and the poor scientific evidence of the revascularization of the transplanted structure. However, clinical results have confirmed that these surgical techniques can improve the movements in reconstructed joints.
Fundamental aspects Two different types of osteochondral transfer can be performed, that is bone allografts without preservation of the vascularization and free epiphyseal partial reconstruction using vascularized growing structures. Both these techniques are based on a specific behaviour, linked to the cellular events occurring in the transplanted zone. Bone allografts are subject to the immunogenicity of the patient and its long-term effects on graft preservation (Friedlaender 1987). Bone incorporation can be divided into several stages. First, the inflammatory response is predominant, initiated by the antigen reactions and surgery, leading to an infiltration of lymphocytes (T cells). Then the graft is surrounded by fibrovascular tissue which leads to the revascularization of the graft. The rejection process is observed mostly over the surface of the cortical bone. Osteolysis and osteogenesis must proceed in delicate balance, in order to prevent a rapid rejection and to enhance the repopulation of osteoblasts from the recipient. When the rejection process is more pronounced, the bone is weakened (Friedlaender 1983). The immune response is not a significant factor in a patient with chronic resorption and increased susceptibility to infection (Enneking and Mindell 1991). Burchardt (1987) proposed a scheme to differentiate the three types of bone reaction after allograft bone transplantation. • type I—(20%), the bone behaves like an autograft • type II—(60%), the bone is slowly resorbed • type III—(20%), rapid resorption of the bone graft is observed.
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In most cases, the rejection process is limited to several millimetres of the depth of the bone. Cartilage allografts follow the same principles as bone allografts but some additional requirements are: • Histological and biomechanical characteristics of the recipient bed must be respected. The homology of the situation is important, an elbow replacing an elbow. Osmotic exchanges and cartilage nutrition are favoured, certainly by a correct cartilage massage (Poitout 1996). • The cartilage matrix must be intact, as immunological reactions are favoured by any surface alteration. The modality of cryo-preservation is important to obtain living chondrocytes.
Joint transfer Non-pedicled allografts Several authors have suggested the use of nonvascularized allografts, with or without simultaneous soft tissue flap coverage (Mastorakos et al 2002) after tumour resection. Flap coverage can be done immediately or can be delayed. In Mastorakos et al’s series, 12 patients had such a technique after resection of a tumour involving the upper limb. The overall limb salvage rate for the bone allograft and soft tissue flap coverage was 95%. Alman (1995) used massive allografts to reconstruct the epiphysis. In a series of 26 patients, 12 had allografts placed in the upper limb. Sixtynine per cent of the total patients had a good result in spite of a 77% complication rate and 54% had a fracture at the site of the allografted bone. Slow resorption is frequently observed and fractures and non-union are not rare. Movements of flexion–extension can be usefully restored, with some limitation in the full range of motion. Allograft elbow transfer seems to be done more than any other upper limb joint transfer. Indications are rare, and most of them are posttraumatic situations where the joint was completely destroyed. Preparation of the recipient site can be problematic. In some cases, the skin can be severely retracted. Skin expanders are often necessary to progressively enlarge the recipient cavity before transfer. The skin can be a source of problems when incisions or retractile adherent scars cross the elbow area. In these cases, a large muscle flap like the latissimus dorsi pedicled flap will protect the transferred joint against exposure and provide good vascularization to the skin. Some authors stress the importance of the muscular envelope, and insist on a large vascularized muscle flap, when the muscles surrounding the allografted transfer seem inadequate. Skin volume also has to be checked before transfer in order not to limit the freedom of movements. Composite tissue allografts for the human hand are a subject of controversy, and very few studies have measured precisely the exact range of motion of the transplanted joints included in the hand transfer. Some information was recently put forward by Siemionow and Ozer (2002). Urbaniak et al (1987) described the results in their series of elbow allografts to be poor. However, Marck (2001) reported recently on the experience of two
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different French units of 12 complete allografts of the elbow. Indications for elbow allograft were discussed and compared to arthrodesis, arthroplastic resection and prosthetic arthroplasty. The author concluded that allogeneic arthroplasty can be proposed for large losses of osteocartilaginous substance. The rate of complications, especially the rate of sepsis, is high (more than 50% of joint destruction). Plans to overcome the anticipation of the skin problems must be made carefully. The mean follow-up was 9 years in their series. In the
Figure 1 long term the transfer is marked by a chronic dislocation (mechanical, immunological) of the joint partially compensated by the muscles surrounding the joint. Functional results were good, in spite of poor radiological findings (Fig. 1). Conclusions were positive, specially concerning the restoration of bone around the cartilage in case of large defects. Other proposals were put forward from these studies, particularly the possibility of combining bone allografts with prosthetic replacement of the cartilaginous surfaces.
Epiphyseal transfer Non-pedicled epiphyseal autograft Maruthainar et al presented in 2002 a series of 13 patients with large tumour of the lower radial epiphysis (giant cell tumours, osteosarcoma, chondrosarcoma and Ewing’s sarcomas) where the upper fibula was transferred without its own vascularization. Results were satisfactory in terms of function. Pedicled epiphysis Three areas can be considered as potential donor sites for epiphyseal transfers: the lower scapular apophysis, the iliac crest (anterior or posterior) and the upper fibula (Figs 2 and 3).
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The upper fibular epiphysis is mostly used in adults to reconstruct significant defects of the radius, especially following resection of giant cell tumours, and was proposed by several authors to reconstruct the upper humerus after malignant tumour resections. Pho et al (1988) and Innocenti et al (1998) used the upper fibular
Figure 2
Figure 3
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Figure 4 epiphysis as a vascularized transplant to replace the upper humerus and the distal radius after tumour resection (Fig. 4). The iliac crest was used for the reconstruction of the lower femoral epiphysis and the acetabular rim area, and in congenital malformations of the radius. Studies carried out during the past 20 years lead to new information on physiology and behaviour of the transplanted growth area. In congenital malformations, growth of the transplanted structure approximates the deficient growth of the malformed limb, especially when the transfer is placed in apposition to the abnormal epiphysis. In complete replacements of an absent growth plate the expected growth cannot be compared to the normal contralateral side (Fig. 5). In a recent series published by Gilbert and Mathoulin (2000), indications for epiphyseal replacements were summarized as follows: fibula can be proposed in upper limb reconstruction and iliac crest for lower limb growth plate replacement. The lower scapular apophysis has been used in different indications of radial club hand. Téot et al (1992) published a series where the scapular apophysis was used as an appositional graft to increase the volume and the surface of some epiphyses in congenital malformations. In the upper limb, the vascularized scapular apophysis was used in apposition to the distal ulna in a radial club hand. The result after a 19-year follow-up, shows the amount growth compared to the growth of the malformed ulna (Fig. 6). Hemitransfers were proposed by Harpf (2002) to rebuild the normal shape of the great toe and increase the web size after vascularized transplantation in five adult patients. The technique used the fibular part of the great toe and its adjacent soft tissue and the first web space. Results showed an improvement of the pinch up to 90% of the strength of the normal contralateral side.
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Discussion The choice of the technique in joint transfer or joint reconstruction is dependent on different factors such as the anatomical location, the aetiology of the joint destruction or loss of movements, the softness and pliability of the skin surrounding the joint and the quality of the muscles. When dealing with reconstruction of the wrist, most authors will choose pedicled transfer coming from the upper fibula if the defect is long and the scapular crest or the iliac crest if the
Figure 5 defect is limited. For reconstruction of the elbow allografts are preferred. The upper humeral epiphysis can be replaced either by vascularized fibular transplantation or allograft. The elbow joint is difficult to replace, due to the shape of the bone extremities
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and the specificites of the two different types of joint. In this case, the discussion of the options with the patient must be comprehensive and include the choices of prosthetic replacement and allograft reconstruction.
Figure 6 Absence of movement can either be the consequence of an extensive epiphyseodiaphyseal resection; or of limited trauma involving the cartilage, leading to a spontaneous arthrodesis (where a limited osteochondral graft can provide enough tissue to restore the movement); or of congenital malformations (where movement has never been possible due to simultaneous limitations of the tendon’s course. The surrounding tissues influence the results. Joint replacement under fibrous tissue or scarred adherent skin will lead to a poor result. Replacement of these tissues before or during the joint reconstruction is necessary. Some authors recommended the association of an allograft transfer to a vascularized autograft, especially for shoulder and knee replacements to enhance muscular ambience and to provide a better protection against infection (Zinberg et al 1985).
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Autologous transfers have been used since Judet in 1908. Large series (Elderlyi) of nonvascularized autologous transfers were instructive in term of biological data. As for bone transfers, the sequence of revascularizationrejection was observed. Movement is necessary to prevent ankylosis of the joint, but would be deleterious if excessive before complete revascularization. Experimental studies on pigs (Yoshuzi) could compare partially vascularized joint transfers to completely devascularized transfers. A destruction of the cartilage is observed in most of the devascularized group, contrary to the vascularized group. Results of transplantations of small joints seemed completely dependent on the revascularization process, contrary to what is observed after large joint transplantations. Epiphyseal transfers including a growing structure have been developed since 1976, with the confirmation that the preservation of the epiphyseal vessels was mandatory to expect normal growth. Experimental transplantation and replantation of complete and partial epiphysis were carried out by Brown et al, Zaleske et al, and Téot (Zaleske et al 1982, Brown et al 1983). Results showed good preservation of growth when the complete epiphyseal vascularization was maintained during the transfer, and that growth plate physiology was complex and cellular events quite different in the peripheral part compared to the central part of the structure. Anatomical studies concerning the lower scapula (Téot et al 1981), the upper fibular epiphysis and the iliac crest (Téot 1982) were carried out in child cadavers using injection techniques.
Conclusion Joint transfer and joint reconstruction have demonstrated their usefulness and their technical reliability. Problems remain concerning donor sites, immunologic control and revascularization. The future of allocartilage transplantation, combined with the progress in resorbable biomaterials could open new possibilities in joint reconstruction.
References Allieu Y, Chammas M, Desbonnet P (2000) Elbow allograft and their long term results. In: Hand Arthroplasties. Martin Dunitz: London. Bugbee WD (2002) Fresh osteochondral allografts, J Knee Surg 15:191–5. Brown K, Marie P, Lyskakowski T, Daniel R, Cruess R (1983) Epiphyseal growth after free fibular transfer with and without anastomoses, J Bone Joint Surg 65B:493. Burchardt H (1987) Biology of bone transplantation, Orthop Clin North Am 18:187–96. Chow SP, Chan KC, Tang SC, Billett (1986) Reconstruction of the lateral tibial condyle by a pedicled vascularized fibular graft after en bloc resection of giant cell tumour, Int Orthop 10:239–43. Enneking WF, Mindell ER (1991) Observations on massive retrieved human allografts, J Bone Joint Surg 73A:1123–42. Entin MA, Alger JR, Baird RM (1962) Experimental and clinical transplantation of autogenous whole joints, J Bone Joint Surg 44A:1518.
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Friedlaender GE (1983) Immune response to osteochondral allografts: current knowledge and future directions, Clin Orthop 174:58–68. Friedlaender GE (1987) Bone grafts: the basic science rationale for clinical applications, J Bone Joint Surg 69A:786–90. Germain MA, Dubousset J, Mascard E, Kalifa C (2000) Vascularized peroneal reconstruction after bloc resection of tumors or congenital malformations of the upper limb in children, Bull Acad Natl Med 184: 1671–84. Getty PJ, Peabody TD (1999) Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus, J Bone Joint Surg (Am) 81:1138–46. Gilbert A, Mathoulin C (2000) Vascularized bone grafts in children. Specifics and indications, Ann Chir Plast Esthet 45:309–2. Herndon GH, Chase W (1952) Experimental studies in the transplantation of whole joints, J Bone Joint Surg 34A:564. Innocenti M, Ceruso M, Manfrini M et al (1998) J Reconstr Microsurg 14:137–43. Marck G (2001) Les allogreffes totales de l’articulation du coude Etude à long terme a propos de 12 cas. Thèse Marseille. Maruthainar N, Zambakidis C, Harper G, Calder D, Cannon SR, Briggs TW (2002) Functional outcome following excision of tumours of the distal radius and reconstruction by autologous non-vascularized osteoarticular fibula grafting, J Hand Surg (Br) 27: 171–4. Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey JH, Cordeiro PG (2002) Softtissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction, Plast Reconstr Surg 109:1567–73. Minami A, Kato H, Iwasaki N (2002) Vascularized fibular graft after excision of giantcell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis, Plast Reconstr Surg 110:112–17. Nagoya S, Usui M, Wada T, Yamashita T, Ishii S (2000) Reconstruction and limb salvage using a free vascularised fibular graft for periacetabular malignant bone tumours, J Bone Joint Surg (Br) 82:1121–4. Pho RW, Patterson MH, Kour AK, Kumar VP (1988) Free vascularized epiphyseal transplantation in upper extremity reconstruction, J Hand Surg (Br) 13:440–7. Poitout DG (1996) Avenir des allogreffes osseuses dans les résections osseuses massives pour tumeur, Presse Med 25:527–30. Rodl RW, Ozaki T, Hoffmann C, Bottner F, Lindner N, Winkelmann W (2000) Osteoarticular allograft in surgery for high-grade malignant tumours of bone, J Bone Joint Surg (Br) 82:1006–10. Shea KG, Coleman DA, Scott SM, Coleman SS, Christianson M (1997) Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor resection, J Pediatr Orthop 17:424–3. Shigetomi M, Hickey MJ, Hurley JV, Riccio M, Niazi ZB, Ohta I (1996) Orthotopic vascularized osteochondral allografts in an immunosuppressed rat model, J Reconstr Microsurg 12:113–19. Siemionow M, Ozer K (2002) Advances in composite tissue allograft transplantation as related to the hand and upper extremity, J Hand Surg (Am) 27:565–80.
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Téot L (1982) Les transferts osseux libres vascularisés de cartilage de croissance, Rev Chir Orthop 61(Suppl 2):40–2. Téot L, Bossé JP, Mouffarège R, Papillon J (1981) The scapular bone crest pedicled bone graft, Int J Microsurg 3:257. Téot L, Bossé JP, Dussault RG, Gilbert A (1983) Pedicled iliac crest epiphysis transplantation, Clin Orthop 180:286–93. Téot L, Souyris F, Bossé JP (1992) Pedicle scapular apophysis transplantation in congenital limb malformations. Ann Plast Surg 29:332–40. Urbaniak JR et al (1987) Clinical use of bone allograft in the elbow, Orthop Clin North Am 18:311–21. Wada T, Usui M, Isu K, Yamawakii S, Ishii S (1999) Reconstruction and limb salvage after resection for malignant bone tumour of the proximal humerus. A sling procedure using a free vascularised fibular graft, J Bone Joint Surg (Br) 81:808–13. Zaleske PJ, Ehrlich MG, Piliero C, May J, Mankin H (1982) Growth plate behavior in whole joint replantation in the rabbit, J Bone Joint Surg 64A:249. Zinberg EM, Wood MB, Brown ML (1985) Vascularized bone transfer: evaluation of viability by postoperative bone scan, J Reconstr Microsurg 2:13–19.
11 Joint replacement as a secondary procedure John K Stanley and Ian A Trail
Joint replacement for traumatic bone loss at the elbow Fractures around the elbow are quite common but those that involve loss of bone substance are relatively rare. Fractures, in which there is a loss of bone, may be divided into three main categories: 1. The closed grossly comminuted fracture and non-union. 2. The pathological fracture. 3. The side-swipe or gunshot wound. There is no doubt that the alternatives for treatment of significant traumatic bone loss at the elbow are limited, consisting basically of the five ‘As’: • Autograft • Allograft • Arthroplasty • Arthrodesis • Amputation. The closed fracture In situations in which it is impossible to reconstruct the fracture (or where the fracture has a very low chance of healing such as in the elderly) and fragments are discarded at the time of surgery, the potential benefits and risks of a primary joint replacement must be assessed. This most commonly occurs when there is a complex comminuted fracture of the radial head associated with medial collateral ligament injury and a fracture of the coronoid process. The grossly unstable situation requires a sound radial head that is achieved with primary radial head replacement and fixation of the coronoid fragment. If there is a significant axial compression element to the injury the Essex-Lopresti lesion (Essex-Lopresti 1951) may exist (fracture of the radial head and rupture of the radio-ulna interosseous membrane). It is then imperative to restore axial length to the radius to prevent proximal migration of the radius leading to increased ulna plus variance and ulna abutment syndrome. If the radial head is not reconstructable, radial head replacement is indicated. The choice of implant is a matter of personal experience. Currently viable implants are manufactured from cobalt-chrome, stainless steel, pyrolytic carbon and titanium, pyrolytic carbon alone and titanium alone. The implants may be modular or
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monobloc; cemented or uncemented. However, whichever implant is chosen must be rigid and not deformable such as those made from silicone rubber. The indications for primary total elbow replacement in the management of fractures are well outlined by Morrey and others (Figgie et al 1989, Morrey and Adams 1992, Garcia et al 2002) and may be summarized as (1) elderly patients with low transverse or ‘Y’ shaped intercondylar fractures which have a poor reputation for healing in these patients, and (2) those who have already gone on to delayed or non-union (Figgie et al 1989, Morrey and Adams 1992). The lower age limit is a matter for judgement but in the absence of any significant comorbidity patients under the age of 70 years would require further justification, in addition to age and the type of fracture. Morrey cites rheumatoid arthritis and other inflammatory joint disease as two of the conditions, which if present, would tilt the
Figure 1 (a) Loss of bone at 1 year following a low humeral fracture in an elderly woman. The lower humerus was barely a shell at operation with no ligamentous support and with a painful non-union. (b) Stability was restored with a linked modular implant (c,d) Range of pain-free motion at 3 months.
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balance in favour of total arthroplasty rather than open reduction and internal fixation. In his series the youngest patient was 40 years old and had concomitant rheumatoid disease. The choice of implant in these circumstances will be determined by the surgeon’s preference and by the state of the remaining bone and restraining ligaments. In general a linked ‘sloppy hinge’ the so-called semi-constrained implant, for example the Acclaim (DePuy) or Coonrad– Morrey (Zimmer), is necessary to provide stability in joints in which the soft tissue envelope cannot provide sufficient support for a resurfacing implant. In the event that there is sufficient soft tissue restraint, it is possible to use a resurfacing implant and Acclaim (DePuy), Kudo (Biomet), GSBIII (Sultzer), Souter/Strathclyde (Stryker-Howmedica) are examples of implants available in this configuration. It is for more reliable to treat these comminuted fractures conservatively with a plaster followed by an orthosis and to consider the options at leisure than to rush to perform an arthroplasty. However, individual treatment decisions depend on each patient’s unique requirements and primary surgery is more likely in the older, more frail patient (Fig. 1). The pathological fracture If a traumatic event precipitates a fracture through an area where the tumour or disease has destroyed the bone structure in such a way that reconstruction with autograft is impossible or, that the reconstruction would be so complex that only in the very young adult would one consider such a procedure, then implant arthroplasty should be considered (Morrey 1985). In these circumstances a custom implant is indicated (Venable 1952). In the majority of patients a linked ‘sloppy hinge’ is the implant of choice. Periprosthetic fracture in the rheumatoid osteoporotic patient is an example of a benign condition causing significant bone loss. In the absence of infection a combination of a distal humeral allograft and a long-stemmed linked ‘sloppy hinge’ is a realistic although a very challenging procedure even for the greatly experienced elbow surgeon. David Stanley (Sheffield, UK) cautiously reports early success with this technique. With the advent of more extensive ranges
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Figure 2 (a) Massive bone loss due to a periprosthetic fracture. (b) Stabilization with a linked snap fit revision prosthesis. of stem size and length, considerable defects in the humerus can be bridged with an implant but on occasion a custom implant may be necessary. The nature of the pathology causing the defect has a significant influence upon the decision to proceed with an implant arthroplasty, particularly in the younger patient. For example, neoplasia with poor prognosis would shift the balance toward a replacement rather than a major reconstructive procedure (Fig. 2). The side-swipe or gunshot wound This is a situation where the bone is lost at the time of the traumatic event and is not recoverable. Five common complications of these serious injuries increase the difficulty of the management: • the fractures are often compound and contaminated • there are often significant neurological injuries • there is commonly a vascular injury • large soft tissue defects may be present
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• significant skin loss is often present. In the hours immediately following these injuries the treatment is often determined by the extent of the vascular injury and the urgency of repair and restoration of adequate perfusion of the forearm and hand. The stabilization of the humerus to the radius and ulna is necessary to protect the anastomoses. Therefore it is necessary to consider extensive open reduction and internal fixation at this time. Primary total joint replacement is contraindicated. However, an external fixator can be applied although such a device would introduce potential pin track contamination and increase the risk of infection and stiffness. Nicholas et al (1993) and Brannon et al (1995) advise early removal of such devices. The place of joint replacement in the treatment of these injuries is very small indeed because of proven bush wear from the linked prostheses (Brannon et al 1995) and the potential for fracture of the implant in the younger age group (< 60 years) who invariably have higher demands. However, there are special circumstances such as the case of a 39year-old soldier quoted by Jupiter and Morrey (2000). He had severe bilateral elbow injuries with an amputation on one side and arthrodesis on the other, grossly impaired function and severe disability. An elbow arthroplasty was performed and the soldier’s function improved dramatically with the caveat that some form of rebushing or revision some time in the future would almost certainly be required.
Joint replacement for traumatic bone loss at the shoulder The use of shoulder arthroplasty to manage the sequelae of trauma at the shoulder has been undertaken for some time (Neer et al 1982). The development of pain and stiffness together with secondary osteoarthritis following three and four part fracture of the shoulder is well known, being seen particularly where the fracture heals in malunion or where there is avascular necrosis. Occasionally fractures at this site can go on to nonunion. Traditionally ‘monobloc’ type prosthesis such as the Neer has been used. More recently however with the advent of modular prosthesis implants designed specifically for use in trauma or post trauma have become available (Global, FX, Aequalis, Polaris). Whilst, undoubtedly, these new prostheses have facilitated the procedure at this time there is no evidence that they have improved the outcome. The latter is related to a number of factors primarily the severity of the initial injury, the delay between the injury and the insertion of an arthroplasty as well as the age of the patient. There is no doubt that if surgery is undertaken primarily the results are generally more favourable. In light of this it is of paramount importance to make the correct operative decision at the time of injury. Generally for three or four part fractures of the humeral head, the choice lies between either some form of internal fixation or arthroplasty. For a displaced four part fracture, particularly fracture dislocation, in the older patient it would seem sensible to proceed directly to arthroplasty. For the younger patient whilst internal fixation obviously offers more potential advantages, much depends on the quality of the fixation, the requirement for bone graft and the vascularity of the fragments, etc.
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Figure 3 (a) Bone collapse due to osteoporosis with a four part fracture. (b) Treatment with a hemi-arthroplasty. Again if this proves difficult speedy conversion to arthroplasty may be an option. The preoperative planning can be aided considerably by a CT scan, which gives more detailed information of the severity of the injury, particularly the number and position of fragments. If an arthroplasty is planned this should be undertaken in the standard fashion taking all routine precautions to limit the complication of infection. Of particular difficulty when undertaking arthroplasty in this situation is the assessment of the correct rotation of the humeral component, its height above the fracture line and finally fixation of both tuberosities to either the implant, the humeral shaft or both. With regard to rotation most surgeons would use the elbow and forearm as a guide allowing the implant to be inserted in 30° of retroversion. With regard to the height with the shoulder reduced the inferior border of the humeral head should lie at the same horizontal level as the lower border of the glenoid without undue tension. The newer implant designs provide a ‘jig’ system, which facilitates this part of the procedure. Once the correct humeral component has been chosen it should be cemented into place. Generally the use of methylmethacrylate is recommended, as this is the only means of obtaining a secure fixation to the humeral shaft. The authors would also recommend an advanced cementing technique where possible. The next step with modular systems is to choose the correct head size. A good guide for this is the humeral head that has been removed. Most systems contain a measuring guide, which allows this to be done. It is important however, that the head size used is not too large as this can cause postoperative stiffness—more specifically, with the trial head in situ, the shoulder laxity should be as close to normal as possible; that is the head should translate to the rim of the glenoid both posteriorly and inferiorly and be stable on external rotation to 60°. Generally a glenoid component is not inserted unless there is significant change in the glenoid articular surface. The final and most difficult step however, is reattachment of the tuberosities particularly the greater tuberosity. Several systems are now available and involve the use
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of either wire or strong suture passed through bone or the rotator cuff and sutured down on to the prosthesis, humerus or both. On many occasions there is an obvious gap between the tuberosity and the humeral shaft. Within this area it is important to minimize cement and, if appropriate, de-bulk the tuberosity. The latter allows it to sit better onto the shaft; the defect is then bridged by a bone graft taken from the excised humeral head. With regard to the immediate postoperative period many surgeons will immobilize the shoulder in an abduction splint, this is analogous to the position following a rotator cuff repair and certainly would de-tension the tuberosity repair. Otherwise passive mobilization is started immediately. Neer et al (1982) drew attention to the specific difficulties in treating patients who had suffered sequelae of trauma to the shoulder. These difficulties were related to the presence of contracture and scarring of the muscles, the presence of nerve injuries and shortening of the humeral shaft. If the malunited tuberosity required osteotomy the rehabilitation programme was slowed and recovery prolonged. Further to this Huten and Duparc (1986) reported their experience with 22 old injuries of the shoulder in which they used a Neer prosthesis. The mean age of the patients was 66 years. They reported a number of complications which included dislocation, secondary displacement of fragment and loosening of the glenoid component: some of these requiring further surgery. Movements were limited with less than half achieving flexion to 90°. Radiologically, as well as loosening of the glenoid component, a number of humeral components were subluxated proximally indicating rupture of the rotator cuff. Overall the authors concluded that the results in acute situations were better than in chronic situations. Frich et al (1991) reported a similar series, reporting unpredictable pain relief in the delayed group with only 22% of this group having a good result as evaluated by the modified Neer scoring system. Again, there were a number of cases of persistent instability particularly when the arthroplasty followed failed osteosynthesis. Norris et al (1995) reported their results in 23 patients with failed treatment of three and four part proximal humeral fractures subsequently treated with prosthetic arthroplasty. They were able to show a reduction in pain level, and an increase in active forward elevation from 68° to 92° and in active external rotation from 6° to 27°. Whilst this resulted in an improvement for most patients’ functional activities, they did note that late surgery is technically difficult and the results are inferior to those for acute humeral head replacement. Nevertheless they recommended that late arthroplasty is a satisfactory reconstruct option. Bosch et al (1998) reported somewhat better results although they again found a significant correlation between the outcome and the length of time between the injury and arthroplasty. Boileau et al (2001) reported their multicentre study of 71 cases. In their series the average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of radiographical examination they developed a classification system which found: 1. Humeral head collapse or necrosis with minimal tuberosity malunion. 2. Locked dislocations or fracture dislocations. 3. Non-union of the surgical neck. 4. Severe malunions of the tuberosities.
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Overall the postoperative Constant score was good to excellent in 42% of cases; patient satisfaction was generally good. The limiting factor in functional outcome was whether a greater tuberosity osteotomy had been done. Specifically, they felt that if the greater tuberosity was left in situ rather than undergoing an osteotomy the results were better. Further basic research was undertaken by Frankle et al (2001) who showed in the laboratory situation that if the greater and lesser tuberosities were replaced in an anatomical position the outcome was superior than if they were placed or left in a nonanatomical position. Work from the authors’ institution shows that over the past 10 years 36 patients have undergone shoulder arthroplasty as a result of the sequelae of trauma. The majority of these patients were over 60 years of age. In most cases the fracture system (Global FX) was used. At review the visual analogue score for pain was reduced from a preoperative value of 7.3 to 2.7 at follow-up. Abduction improved from 43° to 84° and flexion from 49° to 94° and external rotation also improved from 7° to 35°. As a result func
Figure 4 (a) Fracture with avascular necrosis, rotator cuff failure and glenoid deficiency. (b) Total joint replacement with a high riding humeral head. tion (as measured by the American Shoulder and Elbow Society and Constant scoring systems) was improved. The overall survival at 10 years was 69%. A number of revisions have been undertaken for various complications: loosening of the glenoid, dislocation, infection and superior migration as a result of rotator cuff tuberosity failure (Fig. 4). As a result of this it is our view that whilst arthroplasty undoubtedly has a valuable role in the treatment of sequelae of trauma the results are not as good as those of arthroplasty in primary osteoarthritis. Added to this is a significant complication rate; many of the complications requiring further surgery.
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Non-union of the humeral fracture can also be treated by arthroplasty. Results of this treatment were reported by Antuna et al (2002) who evaluated the outcome of 25 replacement with a 6-year follow-up. Most patients had experienced significant pain relief and improvement in active elevation from 41° to 88° and in external rotation from 22° to 38° Overall the modified Neer scoring system showed that there were 12 satisfactory and excellent results.
References Antuna SA, Sperling JW, Sanchez-Sotelo J, Cofield RH (2002) Shoulder arthroplasty for proximal humeral nonunions, J Shoulder Elbow Surg 11:114–21. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R (2001) Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus, J Shoulder Elbow Surg 10:299–308. Bosch U, Skutek M, Fremerey R, Tscherne H (1998) Outcome after primary and secondary hemiathroplasty in elderly patients with fractures of the proximal humerus, J Shoulder Elbow Surg 7:479–84. Brannon JK, Woods C, Chandran RE, Hansrai KK, Reyes CS (1995) Gunshot wounds to the elbow, Orthop Clin North Am 26:75–84. Cooney WP (2000) Reconstructive procedures of the elbow. In: Morrey BF, ed. The Elbow and its Disorders, 3rd edn. 583–601. Essex-Lopresti P (1951) Fractures of the radial head with distal radio-ulnar dislocation, J Bone Joint Surg 33B:244. Figgie MP, Inglis AE, Mow CS, Figgie HE (1989) Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty, J Bone Joint Surg 71A:1058–65. Frankle MA, Greenwald DP, Markee BA, Ondrovic LE, Lee WE (2001) Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humeral fractures, J Shoulder Elbow Surg 10:321–6. Frich LH, Sojbjerg JO, Sneppen O (1991) Shoulder arthroplasty in complex acute and chronic proximal humeral fractures, Orthopedics 14:949–54. Galatz LM, Iannotti JP (2000) Management of surgical neck nonunions, Orthop Clin North Am 31:51–61. Garcia JA, Mykula R, Stanley D (2002) Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment, J Bone Joint Surg (Br) 84:812–16. Huten D, Duparc J (1986) Prosthetic arthroplasty for acute and old injuries to the shoulder, Rev Chir Orthop 72:517–29. Jupiter J, Morrey BF (2000) Fractures of the distal humerus in adults. In: Morrey BF, ed. The Elbow and its Disorders, 3rd edn. 325. Morrey BF (1985) Reconstructive procedures of the elbow. In: Morrey BF, ed. The Elbow and its Disorders, 1st edn. 570–81. Morrey BF, Adams RA (1992) Semi-constrained total elbow replacement for distal humeral non-union, J Bone Joint Surg 77B:67–72.
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Neer CS, Watson KC, Stantont PJ (1982) Recent experience in total shoulder replacement, J Bone Joint Surg 64A3:319–37. Nicholas RM, Barr RJ, Mollan RA (1993) Paramilitary punishment in Northern Ireland: a macabre irony, J Trauma 34:90–5. Norris TR, Green A, McGuigan FX (1995) Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures, J Shoulder Elbow Surg 4:271–80. Siegel JA, Dines DM (2000) Proximal humerus malunions, Orthop Clin North Am 31:35–49. Venable CS (1952) An elbow and an elbow prosthesis: case of complete loss of the lower third of the humerus, Am J Surg 83:271.
12 Joint fusion in severe traumatic defects of the upper limb Giorgio A Brunelli
Joint fusion (arthrodesis) is tantamount to a confession of the surgeon that he is not able to perform effective reconstructive surgery of that joint (i.e. reconstruction or replacement of the joint or restitution of the motors) (Botteri 1960). In arthrodesis, any movement of the joint is abolished and the damaged, useless, painful joint is transformed to a rigid painless lever. By the suppression of the normal movement of a joint, arthrodesis provides a stable connection of the bones that constituted that joint, removes pain and allows the patient to exploit the movements of nearby joints and the remaining muscles. Arthrodesis is not a common operation. Generally, sacrificing a joint repulses the surgeon, but it is a matter of ‘propitiatory sacrifice’ offered to obtain active movement of an irretrievable joint, especially the glenohumeral joint. Joint fusions have strict indications and require perfect surgical technique and expertise during both the operation and the postoperative treatment. Indications for joint fusion are as follows: • loss of bony components of the joint • comminuted fractures of the bone heads • severe, irreparable ruptures of the ligaments and instability • painful arthritis (idiopathic or post-traumatic) • severe infections of the joint (resistant to medical treatment, especially after open fractures) • paralysis of the motors of the joint • necessity of doing heavy work • refusal or impossibility of joint replacement. The contraindications of joint fusion are: old age and a person’s psychological refusal of treatment of a stiff joint and/or of the loss of movement. Arthrodesis may be classified as extraarticular, intraarticular or mixed. It can be simple or modelled, i.e., performed in such a way so as to give particularly favourable positions postoperatively. It can be done by decortication alone or with the addition of bone grafts. Numerous types of arthrodesis have been suggested, and the positions of the arthrodesis of the shoulder, the elbow and the wrist have been discussed in the literature for a long time.
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Techniques of joint fusion A joint fusion may be done by: • Resecting the articular cartilage and the cortical bone beneath, moulding the bone ends to obtain a good congruence, putting them in contact with each other and forcing and maintaining the contact by means of plasters, compression plates, screws (Richards et al 1963) or combination of both, nails or external fixators (Charnley 1966, Johnson et al 1986, Nagano 1989). • Adding bony grafts to this moulding (either corticocancellous bone blocks or corticocancellous chips or better of a cancellous bone ‘paste’ (Brunelli 1972) obtained by pounding cancellous bone). • Turning aside or sliding corticocancellous flaps from one of the involved bones (Brille 2001). • Putting extraarticular bone grafts (rare option today). • Performing a free microvascular bone graft when the loss of bone is excessive or the recipient bed is sclerotic and avascular. • All these methods may be used with specific alterations for the different joints of the upper limb.
Shoulder Among the joint fusions of the upper limb, the arthrodesis of the shoulder gives the best results provided it is done properly and the motors of the scapula function. It is the joint fusion that does better than the others. By suppressing the movement of the joint it restitutes the movement to the arm. The first shoulder arthrodesis was probably done by Albert in 1879. The shoulder joint may require arthrodesis for the following indications: • comminuted fractures • traumatic loss of the humeral head in compound fractures • surgical removal of the humeral head (tumours, infections) • failures of shoulder replacement • palsy of the motors of the shoulder due to brachial plexus lesions. Pre-requiste conditions for arthrodesis of the shoulder joint are: • Good function of thoracoscapular muscles: trapezium, levator scapulae, rhomboid and particularly serratus anterior. • The function of the pectoralis major must also be satisfactory because its presence is fundamental for the thoracobrachial grip. • Good function of the distal arm. It is of no use to perform a shoulder arthrodesis if the hand is completely paralysed and flail. • Integrity of the other joints of the shoulder (acromioclavicular, sternoclavicular and scapulothoracic joints). Stiffness of these joints following joint fractures or adhesion
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of the scapula to thorax impairs or annuls the result. It is therefore very important to take care to avoid any involvement of the acromioclavicular joint during surgery. Joints which substitute for the glenohumeral articulation are subject to extra work and may undergo deterioration and degenerative arthritis
Figure 1 The ideal position to be given to a shoulder arthrodesis. (a) 20° of internal rotation (to allow the patient to touch the abdomen). (b) 20° of abduction (60° if calculated from the external edge of the scapula and humerus shaft). This fixed abduction will allow the arm to dangle close to the thorax and to abduct up to 70° by the movements of the scapula. (c) 45° of anteposition. with time; the muscles also undergo extra stress, sometimes reacting by undergoing hypertrophy and sometimes with exhaustion and atrophy. It is mandatory to choose the best position tailored for the requirements of the patient. After shoulder fusion we must obtain an abduction sufficient to position the hand on the working plane yet not to prevent an efficient active adduction for the thoracobrachial
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plyers which must be strong enough to hold an object under the axilla. (Hawkins and Neer 1987, Harryman et al 1993). Furthermore, too much abduction will cause muscle fatigue. I believe that the arm must be put in 20–40° of abduction from the thorax. Radiographs should show an angle of 60–80° between the lateral border of the scapula and the medial border of the humerus. With this angle, the active movement of the scapula will allow the arm abduction of 60– 80° while still allowing the contact with the thorax (Fig. 1). Anteposition should be 45° which will permit an active anteposition of the arm of 65–75° as well as a vertical resting position. Rotation must be such as to allow the hand to touch the abdomen, to reach the mouth and to enter the lateral pocket of the trousers (25°) The above mentioned angles may be slightly modified to suit the special needs of a patient. There are numerous surgical techniques which differ in the surgical approach, the type of fusion, the type of fixation and the type of bone graft (Fig. 2). Today, shoulder fusion is generally done by intraarticular techniques but in unique cases with big loss of bone the ancient extraarticular fusion techniques may still be used. It is mandatory to remove both the cartilage and the subchondral cortical bone to obtain bleeding cancellous surfaces to put in contact with each other. Fixation may be obtained in various ways: multiple screws, plates of various types, external fixators or plasters. Bone grafts of different types and sizes are added according to the needs of the case: solid corticocancellous pieces taken from the iliac bone shaped according to the amount of bone loss, corticocancellous chips or cancellous bone paste. My preferred surgical approach is an angulated one, running above the spine of the scapula and continuing onto the lateral aspect of the deltoid region. The deltoid muscle is divided longitudinally and its insertion on the spine and clavicle partially detached. The rotator cuff is also divided exposing the capsule which, in turn, is also opened and widely removed to provide a wide operating field. The periosteum of the spine must be cut longitudinally and retracted. This region is rich in vessels and the surgeon must proceed with careful, progressive haemostasis. Then the head of the humerus is dislocated. Decortication of both the humeral head and the glenoid is performed by chisels. At this point the head of the humerus is pushed into the cavity of the glenoid. The arm is put in the above mentioned position which is temporarily fixed by means of two long screws, one from the humerus and one from the acromion. A long plate (12 or 14 holes) is bent up to the desired angle and then secured to the spine of the scapula by means of five screws and to the metadiaphysis of the humerus by means of four more (longer) screws (Fig. 3). To avoid excessive prominence of the plate under the skin, the acromion can be partially removed, taking care to spare the acromioclavicular joint. It is advisable to add a bony graft. My preferred method of grafting is to harvest cancel
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Figure 2 (a) Arthrodesis of shoulder by means of screws and iliac bone graft (posterior approach). (b) Fixation by means of an external fixation. The joint has been decorticated with addition of bone chips or bone ‘paste’. (c) Arthrodesis by decortication of the bony heads, addition of cancellous bone paste and fixation by means of a long bent plate and screws.
Figure 3 Radiograph of a shoulder arthrodesis done by means of plate and screws.
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Figure 4 The cancellous bone taken from the proximal metaepiphysis of the tibia is pounded to reduce it to a ‘paste’.
Figure 5 A good position of the shoulder arthrodesis allows the patient both to reach the mouth and to hold something with the thoracobrachial pliers. lous bone from the proximal metaepiphysis of the tibia by means of a ‘curette’. The bone is then pounded to obtain a ‘paste’ which is able to fill in all the recesses of the joint (Fig. 4). This paste is easily and quickly revascularized and revitalized as it has no cortical bone (which requires creeping substitution). Since 1963 I have performed 61 shoulder arthrodeses. I will discuss only the last 22 cases which have been operated on with the above described technique (the previous cases were immobilized only by screws and plaster and resulted in some non-unions). In the last 22 cases healing was obtained, on an average, in 4.5 months (range 3–8 months). Evaluation is shown in Table 1. Sixteen of the cases could be classified as very good and
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six as good. All of them acheived satisfactory final results and were able to do all daily activities (Figs 5 and 6). I did not encounter pseudoarthrosis (which is the commonest complication in series of other authors) but one case which was not fused at 7 months was cured by a second operation—inserting a corticocancellous wedge graft into the anterior opening of the joint. Nor did I encounter fractures of the humerus (another common complication reported in literature): probably because of the modest abduction. One case
Table 1 Evaluation of the results of shoulder fusion. Abduction Fork to the Thoracobrachial (active) mouth pliers Very 60° or more Yes Yes good Good 45°–60° Long fork Yes Fair 30°–45° Very long Weak fork Poor 30° or less No No
Manual work Yes
Daily activity Yes
+/– No
Yes +/–
No
No
Figure 6 20° of abduction allows both vertical position of the arm (and the thoracobrachial pliers) and abduction to 70°. healed in 7 months (delayed union). In two cases the plate led to decubitus ulcers of the skin which were cured by local skin flaps. In three cases, after bone consolidation, I had to remove the plate because it protruded under the skin in the acromion region. In two more cases I had to remove two screws which were coming out. The position in internal rotation obviously leads to a lack of external rotation and difficulty in reaching the back of the neck but is very useful to access trousers’ pockets. Almost all the patients were not
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able to sleep on the side of their fused shoulder. From the subjective point of view all the patients were satisfied.
Elbow Fusion of the elbow is more disabling than that of the shoulder because it is difficult to fulfill or to compensate the requirements of this joint, i.e. enough extension to work, enough flexion to eat and prono-supination. If the elbow is fused at an angle greater than 90° the hand will not reach the head nor get to the mouth with a spoon whereas if the angle is smaller (70° or less) it will be difficult for the hand to reach distant objects on the desk, to enter the pocket and so on. A compromise which is very useful, and I use in elbow reimplantations, is fusing the elbow at an angle of 100° after shortening the humerus so that even with this angle the mouth can be reached. Indications for elbow fusion are as follows: • open comminuted fractures • reimplantations at elbow level • surgical removal of bony heads (for various reasons) • severe rheumatoid arthritis • severe painful arthrosis • infections. The approach depends upon the traumatic wound or scar. If it is possible, a posteromedial approach is preferred. The ulnar nerve must be atraumatically isolated and protected. In recent wounds all the other structures must be simultaneously repaired. In case of amputation– reimplantation the amount of shortening depends upon various factors: the amount of crush and contamination, the necessity for suturing vessels and nerves without tension and the functional needs of the patient (Fig. 7) If the articular bony heads are widely resected the stumps are made up of cortical compact bone which requires longer time to fuse and, therefore, some special techniques or tricks should be used: one is to preserve and elevate wide flaps of periosteum to be then sutured over the arthrodesis; another one is to put a sleeve of cancellous bone paste around the bony heads and under the periosteal flaps. These techniques give firm and quicker consolidation.
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Figure 7 Arthrodesis of the elbow in case of amputation– reimplantation at the level of the elbow. Fixation may be obtained by means of a plate that allows at least three screws on the humerus and three more on the ulna. Depending on the presence or absence of prono-supinator muscles the head of the radius may be resected or spared in order to allow pronosupination or the radius may be involved in the fusion in a working position (mild pronation, 40°). My series of elbow fusion is limited to only nine cases. All of them involved reimplantation at elbow level. In general, amputations at this level are considered, by many surgeons, a contraindication to reimplantation. On the contrary, my nine cases have fairly good function of the hand and of the whole arm.
Wrist The wrist joint may also benefit from arthrodesis either for traumatic or surgical loss of bone or for any type of disease destroying the bony heads or making the joint painful or paralytic (Dick 1982). In the past wrist fusion was very often used in poliomyelitis, spastic palsies and tuberculosis. In many cases, the choice can be between arthrodesis or another operation (replacement, arthroplasty, first row resection, denervation) but in patients doing heavy work or requiring a steady wrist, joint fusion remains the best option. When deciding to do a wrist arthrodesis a further choice should be made between a radioulno-carpal or a radio-carpal fusion (sparing the distal radio-ulnar joint or resecting the head of the ulna in order to preserve prono-supination). Another option is between the fusion of the forearm bone(s) with the first row or with the base of the metacarpals (second and third). By
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fusing the radius with the first row (which is generally done only in wrist reimplantations) some movement of the wrist in extension and flexion could theoretically be preserved but this solution is generally discarded in other cases due to both the degeneration or loss of the first row bones or to the secondary medio-carpal arthritis. Hence when speaking of wrist arthrodesis, we refer to a radio-metacarpal fusion. Indications for wrist fusion are as follows. • destruction of the radio-carpal joint (posttraumatic or infectious) in patients whose work involves heavy labour. • reimplantation at the wrist level (Cannon and Urbaniak (2001) • loss of bone (traumatic or iatrogenic (tumours)) • failure of joint replacement • paralysis not likely to improve with tendon transfers • spastic palsy with flexion deformity. In the elderly patient with light occupation wrist replacement will be the first choice as well for a rheumatoid wrist when stabilization methods are still useful. The main contraindication is the young patient with an open epiphyseal plate in the distal radius. The approach for a wrist fusion is mostly dorsal unless the traumatic wound allows another approach. The lateral approach is also indicated especially if the ulna is spared and can be used as a graft (Fig. 8a). Most of the techniques use a corticocancellous graft taken from the ilium (Fig. 8b) (Debeyre and Goutallier 1970). The graft I prefer is a corticocancellous stick advanced from the dorsal aspect of the distal radius under a bridge and slipped under two splinters elevated from the base of the 2nd and 3rd metacarpals with addition of cancellous bone paste taken from the upper metaepiphysis of the tibia (Fig. 8c). Fixation is obtained by means of there strong Kirschner wires: two in the fashion of St Andrew’s cross and one transversally across the radius and the ulna (Fig. 8d). If a bone graft has to be taken from elsewhere, in general, the donor site is the ilium. The bone graft can be inserted into a trench dug in the radius and in the carpus or laid over the bones after having elevated on both sides two lateral flaps taking the periosteum and the cortical surface of the bones. If the loss of the bone is large the iliac graft should be bicortical and shaped according to the needs (see Fig. 8a) (Larsons 1974, Field Herbert and Roner 1996). If the loss of the radius is significant a free microvascular fibula graft may be used, putting the epiphysis distally (Fig. 8d).
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Figure 8
• • • •
(a) Technique of removal of a bicortical cancellous graft from ilium avoiding cosmetic defects. (b) Wrist arthrodesis by medial approach. The distal ulna is removed, decorticated and pushed (upside down) into a trench dug in the radius, carpus and base of the 5th metacarpal. (c) Arthrodesis of the wrist by means of the author’s own method. A corticocancellous stick is slid from the dorsal aspect of the distal radius (under a distal bone bridge) on the decorticated bones of the carpus and pushed under two bony flaps elevated from the bone of the 2nd and 3rd metacarpal. Cancellous bone paste is added. Fixation is obtained by means of three Kirschner wires (see text for details). (d) Wrist arthrodesis by means of a vascularized peroneal graft in case of big loss of bone—traumatic or iatrogenic (tumour). (1) fibula; (2) the shaft of fibula introduced into the radius; (3) periosteal flap of the fibula sutured to the periosteum of radius; (4) end-to-side anastomosis of the peroneal and radial artery; (5) addition of cancellous bone paste. Fixation varies depending on the surgeon’s preference. It can be done by: a plate and screws (modelled to the bony surface) (Fig. 9b) by one Rush rod with two or more staples (Fig. 9c) by external fixator by Kirschner wires.
All these methods of fixation (except the external fixation) are generally combined with plaster immobilization for some weeks. The position to be given to a wrist arthrodesis has been widely discussed. I have done hundreds of goniometric measurements of the position of the wrist when at work or in sports or when doing hobbies. These measurements have been made on photographs of actors, sportsmen, politicians or heavy workers on numerous occasions. The result of these measurements is that the main position, in any occasion, is 32° of extension and 15° of ulnar deviation (Fig. 10). For certain jobs only or when both the wrists are to be fused,
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one wrist can be arthrodesed in a slight flexion and supination for personal hygiene activities. Several complications are reported in literature, haematoma, infection, non-union, reflex
Figure 9 Four different types of wrist arthrodesis. (a) Radio-carpal fusion with Darrach procedure. (b) Radio-carpal fusion with plate and screws preserving the prono-supination. (c) Radio-carpal fusion with Rush rod and staples preserving the prono-supination. (d) Radio-ulno-carpal fusion in semipronation with sliding of a radial stick and three Kirschner wires. sympathetic dystrophy, carpal tunnel syndrome and distal ulnar impingement. I have recently reviewed 18 cases (out of many operated over 50 years). Fourteen of them had also had a Darrach procedure whereas four had radio-ulnocarpal fusion in working position (i.e. 30° of extension, 15° of ulnar deviation and 60° of pronation). Five of them were done for reimplantation at the wrist level. Regarding pain all of them where satisfied with the result, having no pain on any occasion. Except for the reimplanted patients, the other nine also had good strength and were able to do heavy work.
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Figure 10 A careful research based on the measurement of the angles of the wrist on photographs of hundreds of people (actors, sportsmen, heavy workers, politicians) demonstrated that the average working position is 32° of extension and 15° of ulnar deviation.
References Botteri G (1960) Arthrodesi. In: Mezzari A, ed. La Poliomielite. Napoli: Idelson, 197–9. Brunelli GA (2001) Artrodesi o artroplastica del polso. In: Brunelli La Mano, Manuale di Chirurgia. Micom: Milan, 390–4. Brunelli GA (1972) Soft cancellous grafts for non-union and joint fusion, International Congress of SICOT. Excerpta Medica, Amsterdam, 952–4. Cannon DL, Urbaniak JR (2001) Transcarpal and radio carpal wrist amputation and reimplantation, In: Watson HK, ed. The Wrist Lippincot Williams & Wilkins: Weinzweig, 269–76. Charnley J, Houston JK (1966) Compression arthrodesis of the shoulder, J Bone Joint Surg 46B:614–20. Debeyre J, Goutallier D (1970) L’artrodese du poignet par greffon iliaque intracarpien, Presse Med 78:1993–4. Dick HM (1982) Wrist and intercarpal arthrodesis. In: Green DP, ed. Operative Hand Surgery. Churchill Livingstone: New York, 127–39. Field Herbert T, Roner R (1996) Total wrist fusion: a functional assessment, J Hand Surg (Br) 21:429–33.
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Harryman II DT Walker EP, Harris SL et al (1993) Residual motion and function after glenohumeral or scapulothoracic arthrodesis , J Shoulder Elbow Surg 2:275–85. Hawkins RJ, Neer CS (1987) A functional analysis of shoulder fusions, Clin Orthop 223:65–76. Johnson CA Okinaga S, Ochiai N et al (1986) External fixation of shoulder arthodesis, Clin Orthop 211: 219–23. Larsons S 1974 Compression arthrodesis of the wrist, Clin Orthop 99:146–53. Nagano A Healy WL, Krackow KA et al (1989) Shoulder arthrodesis by external fixation, Clin Orthop 247: 97–100. Richards RR, Beaton D, Hudson AR (1963) Shoulder arthrodesis plate fixation: functional outcome analysis, J Shoulder Elbow Surg 2:225–39.
Nerve defect repair
13 Nerve grafts Michel Merle and Aymeric Lim
Repair of nerve defects by grafts was first attempted by Phillipeaux and Vulpian in 1870 and then by Albert (1876). However, later it was abandoned because of inconclusive results. It was not until 1972 that Millesi validated the fascicular nerve grafting method of repair by reporting good results (Millesi et al 1972). In 1974, the first vascularized nerve graft performed by Taylor seemed to provide a solution for clinical situations with long segmental losses and poorly vascularized beds unfavourable for the take of conventional grafts (Taylor and Ham 1976). Over time, however, vascularized grafts have not proved their superiority over conventional grafts and their early promise has not been borne out due to the scarcity of suitable donor sites. The reconstruction of long segment peripheral nerve defects or brachial plexus injuries requires the use of long grafts. The difficulty in finding donor sites of sufficient length motivated us to experiment with vascularized allografts in the rabbit (Bour and Merle 1989). Cyclosporine was used during the period of nerve regeneration. Stopping the immunosuppressive treatment inevitably led to rejection of the graft. Mackinnon preferred to use a method which involved pretreating the allografts to minimize rejection after cessation of the immunosuppressive treatment (Mackinnon et al 1984). The first allograft hand transplantations have shown that it is possible to recover sensory and motor functions aided by a combination of immunosupressants. Among these, is tacrolimus which, while promoting nerve regeneration, also unfortunately causes neurotoxic side effects. Lundborg first demonstrated that it is possible for a nerve to regenerate in a silicone chamber (Lundborg and Hansson 1981). The concept of nerve tubes was further developed by Restrepo et al (1985b), Madison et al (1988), Fields et al (1989), Mackinnon and Dellon (1990a), and Archibald et al (1991). It is now accepted that an artificial or biological tube is able to sustain nerve regeneration over a distance of less than 15 mm. Before the advances in microsurgical techniques led to the application of the principle of direct primary suture, nerve grafting was considered to be the only option in the repair of peripheral nerve lesions. Currently, no well conducted study has been able to prove that nerve grafting, when possible, is superior to primary or secondary suture. Grafts are thus indicated solely for the repair of nerve gaps.
Different types of graft The choice of graft is important because it directly affects the results of the repair. The repair of digital nerves requires similar sized nerve grafts harvested from the medial
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antebrachial cutaneous nerve and more infrequently, vascularized grafts. For defects in larger nerve trunks, sural nerve grafts are the most appropriate. A non-vascularized trunk graft may be chosen when the decision has been made to sacrifice a major nerve. There are problems with the vascularization of this volume of nerve tissue, however, and when axonal regrowth occurs within the graft, it is often necrosed and sclerosed in its centre. It is preferable to transform the nerve trunk into fascicles by intraneural dissection. Trunk grafts are only indicated if vascularized. Strange (1947) was the first to propose the concept of a two-stage repair of the median nerve with a vascularized ulnar nerve and Taylor and Ham (1976) were the first to perform a free vascularized nerve graft using microvascular sutures. The concept of fascicular nerve grafting is impractical as, for the median nerve, it would entail the use of one fascicle each for each of the 16–20 fascicles that compose the nerve. All our laboratory experience with nonvascularized and vascularized allografts has not been applied clinically because of poor results. We have demonstrated that it is possible to reestablish the continuity of a nerve over a short distance with an empty tube of perineurium (Restrepo et al 1985b). For gaps of less than 15 mm, silicone, polypropylene, collagen and polyglycolic acid tubes have been used. Despite numerous appeals in favour of the role of tropism in this technique, we remain convinced that the best method for nerve repair lies in the improvement of the technique of direct coaptation.
Fascicular grafts This is the most commonly used graft for the repair of nerve defects. The choice of donor nerve The sural nerve (Fig. 1) We usually use this nerve. It is harvested from distal to proximal. A 6 cm retromalleolar incision localizes the terminal two branches of division. A second transverse incision 16 cm proximal to the lateral malleolus (as described by Gilbert et al 1986) allows extraction of the distal part of the sural nerve as well as identification of its junction with the accessory sural nerve originating from the common peroneal nerve. Harvesting both nerves is useful for large defects or the simultaneous repair of multiple nerves. In young children, harvesting should be done via a single incision because of the abundance of fatty tissue and fascia surrounding the nerve. The medial antebrachial cutaneous nerve For small defects of digital nerves, we prefer to harvest this nerve from the distal aspect of the arm. An oblique incision is made from the hollow on the medial aspect of the biceps tendon
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Figure 1 Technique to harvest the lateral saphenous nerve and its accessory branches. (a) The sural nerve arises from the tibial nerve at the level of the popliteal fossa where the superficial peroneal nerve also arises which takes its origin on the common peroneal nerve and which travels subcutaneously. (b) It is always necessary to perform an additional incision at the junction of the top and middle third in order to harvest both branches of the sural nerve. to 5 cm proximal to the medial epicondyle. The basilic vein is retracted and anterior and posterior branches of this nerve are exposed. The lateral antebrachial cutaneous nerve We have stopped using this nerve, the terminal branch of the musculocutaneous nerve, as there is significant morbidity from scarring and loss of sensation at the donor site. It is a donor nerve of last resort.
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Technique The technique of nerve grafting follows some general principles: the incision should be some distance from the nerve; it should be extensile and allow excision of scar tissue; it should allow transfer of healthy tissue to improve the vascularity of the bed; and finally, it should permit the simultaneous repair of any major vessels. There are two methods of grafting. The classically described method is that of Millesi et al (1972), which involves the preparation of a fascicular group and the suture of every fascicle within. The second technique, which we learned from Narakas, focuses on the nerve trunk. A monobloc of fascicles with similar diameter to the nerve to be grafted is assembled with tissue glue. The nerve should be resected until healthy nonindurated tissue is obtained so as to minimize a fibroblastic reaction. Meyer’s instrumentation is best for the secondary resection of a nerve. The technique of Millesi (Fig. 2) The nerves are resected until healthy tissue is obtained. Methylene blue applied to the nerve
Figure 2 Fascicular graft according to Millesi. After a partial epineurectomy and trimming of the fascicular groups, the fascicular grafts are adjusted and sutured with 10/0 nylon. ends then reveals the fascicular arrangement. Rarely monofascicular or oligofascicular but most often polyfascicular, they are arranged in groups or independently. If the organization is monofascicular or polyfascicular, multiple nerve segments are apposed to the large diameter fascicle. In polyfascicular nerves, one graft is coapted to one fascicle. Grafting of mono-or oligofascicular nerves does not necessitate intraneural dissection or resection of the epineurium. For polyfascicular distributions, however, Millesi recommends staggering the repair zones so as to avoid having all the coaptations in the same plane. Although apparently logical, this method may be injurious to the nerve; resecting the epineurium alters the blood supply and dissociating the fascicles increases the risk of fibrosis and collagen invasion. Finally, staggered resection of fascicles can only be done with curved scissors with consequent crushing of the nerve and a natural evolution towards necrosis.
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Each nerve segment is fixed with one or two sutures of Ethilon 9 or 10-0 while trying to respect the correspondence between the proximal and distal nerve segments, which is not always obvious. We were very impressed with the time Millesi spent while performing a nerve grafting operation, drawing with India ink on a sterile cardboard, the fascicular organization of nerve ends separated by a few centimetres. Intraneural dissection can create the illusion of fascicular correspondence over a certain distance. But the work
Figure 3 Fascicular nerve graft of the median nerve at the level of the carpal tunnel. of Sunderland (Sunderland 1945, Sunderland et al 1959) describing the changes in direction in intraneural fascicular topography over 4–5 cm segments destroyed the illusion that nervous anatomy could be accurately restored by grafting. On the other hand, Jabaley et al (1980) demonstrated that, over a significant distance in the same quadrant, were to be found the same fascicular groups linked by numerous ramifications. In summary, it may be concluded that one should always try to restore the general orientation of a nerve so that grafting may reflect the correspondence of the quadrants. To look for a correlation at fascicular level remains an illusion. One must note that there are certain levels at which it is possible to find a very marked fascicular organization; for example the radial nerve at the elbow joint where one perceives a distinct organization of the fascicles before actual division into posterior interosseous nerve and superficial sensory branch. It is also the case for the ulnar nerve at the wrist where one finds separation of the fascicular groups destined for the interossei and for the skin. In these situations, the anatomy allows efficient interfascicular grafting; any topographical error would send the motor nerves into cutaneous territory and vice versa. The course of the graft is not necessarily the shortest between the two nervous extremities. It is sometimes necessary to elongate the graft so as to place it in a healthy bed favourable for its revascularization. Thus, when one would like to avoid returning via the palmar approach to a multi-operated digit, it is possible to re-establish the continuity of the digital nerve by placing the graft in a dorsolateral course with sutures in healthy tissue. The length of the graft should be calculated by placing the operated limb or digit in maximal extension so as to avoid all tension at the suture sites.
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The technique of Narakas (Fig. 4) This technique has the advantages of being simple, less invasive and fast whilst respecting the major principles of reconstructive surgery. Narakas resects the nerves out of the fibrotic zone with the aid of Victor Meyer forceps. The nerve ends are stained with methylene blue and are primarily oriented using the epineural vascularization as a guide and secondarily the fascicu
Figure 4 Fascicular graft according to Narakas. (a) The nerve defect is measured by extending the neighbouring joints. (b) The sural nerve graft cleaned from its connective tissue is fitted so as to have the same diameter as that of the nerve to be grafted; they are joined at each end with Tissucol. (c) Trimming of the nerve graft is performed with a ‘guillotine’ clamp of V. Meyer. (d) The graft is jointed to the nerve stumps with Tissucol. lar distribution if the defect is only of a few centimetres. The gap is measured carefully with the limb in maximal extension and recognizing that this distance is always longer than the real nerve loss, 1–2 cm are added depending on the course of the graft. The sural and, if necessary, the accessory sural nerve are harvested with multiple stab incisions and then cleaned under the microscope of all fat and connective tissue leaving only two or three fascicular groups. The sural nerve is then laid out on a block of polyethylene and folded on itself until the aggregate diameter approximates that of the nerve to be grafted. The ends are bunched together like a bundle of firewood, glued with Tissucol (Baxter, USA) and trimmed with Victor Meyer forceps. The middle of the graft is left free for the nerve segments to spread in the bed. This technique avoids all intraneural dissection. Glue replaces suture material which always causes a foreign body reaction. The graft also has the advantage of being ‘made to measure’. It is, however, less precise with respect to fascicular groups and some nerve segments may be wasted by coaptation with non-neuronal epineural tissue (Fig. 5). We have used this technique satisfactorily since 1987. Our results are comparable with those of Millesi with the added advantage of simplicity of technique. The use of glue does not impose a barrier to nervous regeneration (Merle 1992).
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Figure 5 Ulnar nerve graft at the level of the wrist. (a) The nerve is trimmed to a healthy area using the V. Meyer clamp. (b) The sural nerve is fitted as the same diameter as the ulnar nerve. (c) Both extremities of the nerve graft are glued with Tissucol. (d) Trimming of the nerve graft using freezing technique. (e) Gluing of the nerve graft to the ulnar nerve using Tissucol. Postoperative care All grafts must be immobilized postoperatively. When the length of the grafts has been calculated with the wrist in mild extension, it suffices to immobilize the wrist in that position for 3 weeks. For digital nerves, the metacarpophalangeal joints are immobilized
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in 60° flexion for 3 weeks while allowing early mobilization of the proximal and distal interphalangeal joints. Indications Grafts are indicated in all nerve defects which cannot be repaired directly without tension despite the methods of mobilization, transposition and bone shortening. The natural separation of a nerve after section is linked to its elasticity. This can range from 1 cm to 2 cm for a lesion at the wrist to 5 cm at the level of the arm. Mobilization of the nerve by extensive dissection with mild flexion of the wrist allows primary repair in most cases. If, however, the resection of a neuroma creates a gap of 4 cm or more in the wrist or the forearm, grafting is indicated. Narakas’ technique is the simplest and one must not hesitate to elongate the graft so to as to allow a course in a healthier bed. Results Grafting of nerve defects is reserved for the most severe injuries. This explains the mediocrity of our results (Dumontier et al 1990). Despite the introduction of microsurgical techniques, in 10 years we have not observed any significant improvement in useful results which have ranged from 23% to 25%. We find ourselves in conflict with the multicentric study performed by Frykman and Gramyk (1991) who observed 81% useful motor results and 79% useful sensory results after grafting. Superior to the best results of primary repair, these figures are difficult to understand, especially given all the known problems with grafting. It is, however possible that many of their patients may have benefited from direct repair if they had been subject to our indications. Finally, the superiority of their results may be due in part to the young age of the patients—less than 20 years old in 45% of the cases. We have demonstrated that after primary repair, useful results were found in 88% of patients less than 10 years old (Merle et al 1984). The accurate evaluation of results demands specificity for each nerve. The functional result of the ulnar nerve needs to take into account the strength of grip, while useful results for a median nerve would essentially reflect the return of sensory function. The age of the patient, the nature of the injury and associated lesions are determinant factors in the prognosis.
Vascularized nerve grafts History (Table 1) Large nerve defects, i.e. more 10 cm, have an uncertain outcome when they are repaired by conventional fascicular free grafting techniques. Therefore, Taylor aroused great interest when he described the use of a radial nerve to graft an extensive loss of substance in a median nerve lesion (Taylor and Ham 1976). During the following decade, many experimental studies were undertaken and this new technique was applied
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Table 1 Review of vascularized graft techniques. Authors Year Technique Reconstruction of the median by the pedicled ulnar in Strange 1947 two procedures Reconstruction of the tibial nerve by the pedicled McCarty 1951 peroneal nerve Taylor and Ham 1976 Superficial radial to median Bonney et al 1984 Ulnar nerve in the forearm Townsend and Sural nerve with its arterialized vein 1978 Taylor Fachinelli et al 1981 Sural nerve and superficial sural artery Comtet et al 1981 Medial cutaneous nerve Ulnar nerve in the arm and proximal ulnar collateral Lebreton et al 1983 artery Oberlin et al 1985 Pedicled common peroneal nerve Internal branch of the anterior tibial nerve and dorsalis Rose 1985 pedis Anterior interosseous nerve and anterior interosseous Merle and Dautel 1991 artery clinically. However, with the lack of suitable donor sites and results that did not appear to be better than those with conventional grafts, enthusiasm and interest subsided. The principle of the vascularized nerve graft goes back to Strange who described the possibility of grafting the median nerve by staged transposition of the ulnar nerve; he obtained his first success in 1948 (Strange 1947, 1948). The same principle of pedicled grafting was applied by McCarty to repair the tibial nerve (McCarty 1951). Microsurgery revived interest in the technique of nerve repair by vascularized grafting. Taylor used the superficial branch of the radial nerve, 24 cm long, vascularized by the radial artery to repair a defect of the median nerve. This technique is acceptable in patients presenting multiple trauma of the limbs, because sequelae at the donor site are minimal. However, the sensory loss would be unacceptable in the patient presenting with only a single injury. Taylor (1978) classified vascularization of peripheral nerves into five types—the first three of which could be used for free vascularized transfers (Fig. 6). Taylor’s work in the field of donor sites was taken up by others. Bonney et al (1977) suggested use of the antebrachial portion of the ulnar nerve. Comtet et al (1981) described the vascularization of the internal cutaneous nerve and Fachinelli et al (1981) described the superficial sural artery which vascularizes the sural nerve. Lebreton et al (1983) described the vascularization of the ulnar nerve in the arm and Oberlin and Alnot (1985) described the pedicled common peroneal nerve. Rose (1985) repaired digital nerve defects using the internal branch of the deep peroneal nerve lifted with the dorsalis pedis artery: later, he came to use only a vena comitans which he arterialized. This arterialization technique was described by Townsend and Taylor (1984) for the sural nerve and was also
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developed by Gu et al (1985). Recently, Dautel used the anterior interosseous nerve taken with the anterior interosseous artery (Merle and Dautel 1991). Our clinical experience summarizes the problems encountered in the upper limb, i.e. avulsions of the brachial plexus, extensive loss of substance with poor tissue environment (Volkmann, crush) and defects of digital nerves. Vascularized grafts for extensive loss of substance of the brachial plexus In cases of intraspinal avulsion of C8 and T1 roots, it is legitimate to use the brachial or antebrachial portion of the ulnar nerve to bridge an extensive gap, from C5/C6 to the upper trunk or even to the posterior cord. We used the brachial portion of the ulnar nerve in five cases, five times as a free vascularized transfer and four times as a pedicled graft. By the use of free vascularized grafts measuring about 16.5 cm, it was possible to bridge gaps averaging 14.4 cm in length. Usually, vascular anastomoses
Figure 6 Five types of vascularization of peripheral nerve described by I. Taylor. Types a, b, c, could be used for free vascularized transfers. of the proximal ulnar pedicle were made with one of the cervical or thoracic branches of the subclavian artery. Four out of the five vascularized transfers remained viable. The Tinel sign progressed distally at an average of 3 mm per day in the first 6 months after operation. Contractions of the biceps were first observed clinically and electromyographically in the ninth month after operation whereas the same result would be observed 12 months after nonvascularized fascicular grafts. The one observed failure was caused by early thrombosis of the arterial and venous anastomoses and since extrinsic neovascularization of whole nerve trunk grafts is poor or delayed, the grafted nerve underwent ischaemic necrosis. Functional failure was complete in this case. In the four cases where we used the pedicled brachial segment of the ulnar nerve, we observed recovery of the biceps graded M3+ (three patients) and M4 (one patient). In this
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situation, there is no risk of thrombosis but the length of the graft is a major concern. It is imperative to dissect the ulnar nerve as far as 6 cm distal to the medial epicondyle of the humerus. This is necessary in order to mobilize the ulnar nerve upwards and suture it to the C5 or C6 root without tension. In this short series, it is worth noting the consistency of results of biceps function when the vascular anastomoses remain patent. Yet, when the patients were examined after 3 years or more, functional results were no better than those obtained with successful conventional fascicular grafts; progress of the Tinel sign, which occurred through the vascularized graft at above average speed during the first 6 months (3 mm per day), later stabilized at 1.5 mm per day. Our results were similar to those obtained by Bonney et al (1984) (two failures out of 12 cases), and Alnot (1988, one failure out of 10), who used the ulnar nerve with its artery. We avoided using the antebrachial portion of the ulnar nerve so as not to sacrifice the dominant artery of the hand. Vascularized nerve grafts for extensive loss of nerve substance in the forearm Severe trauma of the forearm (crush and avulsion injuries, Volkmann’s contracture) necessitate the restoration of at least sensory function of the median nerve. The tissue environment is usually poor and cannot support free fascicular grafts. Grafting the median nerve with the vascularized brachial segment of the ulnar nerve seems to be a good choice (Fig. 7). We have used this technique on three occasions, two of these for Volkmannn’s ischaemic contracture. The first two cases failed: early thrombosis of the vascular anastomoses resulted in necrosis of the grafts and no functional recovery was observed. This emphasizes the uncertainty of microsurgical techniques applied to
Figure 7 Ulnar vascularized nerve graft to repair median nerve at the level of the wrist. (a) Sequelae from a median and an ulnar nerve injury in a 60-year-old patient. Total anaesthesia of the hand. (b) Design of the free compound flap: the skin flap is vascularized by its ulnar artery which also vascularized the ulnar nerve. (c) The free compound flap. (d) Result after 1 year, protective sensitivity has returned in the territory of the median nerve.
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recipient vessels severely damaged by the initial trauma. Grafts of digital nerve The published results of conventional digital nerve grafts vary widely. One can only admire the results of Mackinnon and Delton (1988) who reported 31 cases of discriminating sensitivity out of 33 operations, i.e. a 93% success rate. Tenny and Lewis (1984) obtained discriminating sensitivity in 32 cases out of 42. In our experience, Dumontier et al (1990) observed discriminating sensitivity in three out of 16 patients. These disappointing results led us to investigate vascularized grafts. At first, we used Rose’s (1985) technique: the internal branch of the deep peroneal nerve is harvested with a vena comitans that is used to bridge the digital artery. Later, we switched to the technique of Dautel using the anterior interosseous nerve and its artery (Merle and Dautel 1991). Our prospective study included nine patients. The average length of the graft was 35 mm. In the first five cases, the donor site used was the one described by Rose, i.e. the internal branch of the deep peroneal nerve and the vena comitans adjacent to the dorsalis pedis artery. In the last four cases, the segment of the anterior interosseous nerve distal to the origin of the flexor pollicis longus nerve was used as a donor site. The vascular anastomoses were end-to-end except in two cases where the proximal anastomosis was an end-toside suture. Immediate patency was judged at tourniquet release with a patency test done distal to both proximal and distal vascular anastomoses. All our grafts were found to be patent. No further monitoring was done in the first days after operation. Long-term vascular results were assessed using Allen’ test; in the first six cases, the results of the test were compared with arteriographic data obtained in the third month after operation. Since the results were consistently concurrent, no arteriography was done in the last three cases. Thrombosis was observed in six of the grafts at the time of control; out of the three remaining patent grafts, two were those cases where the proximal vascular anastomosis was end-to-side. Assessment of sensory results was done with the static and dynamic two-point discrimination tests. No selective block of the healthy contralateral nerve was used to study the sensory result. However, care was taken to test precisely the area of the pulp that was innervated solely by the grafted nerve. Sensory results observed in these nine clinical cases were as follows: three cases were considered failures since static discrimination was equal to, or worse than, 15 mm. No patient had a static two-point discrimination better than 10 mm. Even though this series was too small for statistical analysis, it seems that long-term sensation was not influenced by graft patency. The vascular results obtained in this series demonstrated the difficulties of late reconstruction of digital vascular axes when the contralateral axis is patent. Since there was no long-term postoperative monitoring, the exact time at which thrombosis occurred is not known. The sensory results of the six cases with long-term thrombosis were not different from those of the three cases where vessels remained patent. Thus, there is an important difference between vascularized nerve graft involving small nerves, such as digital nerves, and those involving large nerve trunks. When secondary thrombosis occurs, small calibre nerves, such as the internal branch of the deep peroneal nerve or the anterior interosseous nerve, are probably revascularized from their tissue environment as
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conventional non-vascularized nerve grafts would be. Our results are not in agreement with those of Rose et al (1989). Discussion Our clinical experience of vascularized grafts indicates that the results, i.e. sensory and motor functional recovery, were not significantly enhanced. This was true for both the brachial portion of the ulnar nerve and small nerve trunks. The only guaranteed benefit, observed in cases of brachial plexus lesion, was the consistent recovery of biceps function at M3+ or M4 when the graft remained patent. However, when there was thrombosis of the anastomosis, necrosis of the graft ensued and functional failure was complete. This risk is not negligible in surgery of the brachial plexus and must be weighed against the relative safety of conventional fascicular grafts. The experimental work of Daly and Wood (1985) and of Lux et al (1988) on the dog, demonstrated that blood supply of conventional nonvascularized grafts was superior to that of vascularized grafts on day 4 to day 6, provided the tissue bed was healthy. This is the case with brachial plexus lesions, where the tissue bed is usually satisfactory and conducive to revascularization of free nerve grafts. Claims of superiority of vascularized nerve grafts have been based mostly on optimistic forecasts during the first month after operation, when the Tinel sign progresses through the graft at a rate of 3 mm per day. This may be due to rapid phagocytosis of myelin sheaths and enhanced activity of Schwann cells. The fact remains that vascularized grafts have less tendency to sclerose than conventional grafts. The latter are subjected to ischaemia for several days; although Penkert et al (1988) have shown that rabbit Schwann cells can survive ischaemia for 6–7 days, there is little doubt that the ischaemia hinders Schwann cell activity. Axonal regrowth seems to be optimal in the vascularized graft. However, at the proximal and distal suture sites and when the nerve divides into collateral branches, axonal sprouts meet with the same obstacles as in conventional grafts. This may explain why the final results are similar with both techniques. These clinical results are not as good as the results of animal experimentation. Restrepo et al (1985a), and Shibata et al (1988) demonstrated in the rabbit that the number and diameter of fibres, along with the thickness of myelin sheaths, were greater in vascularized than in non-vascularized grafts. Pho et al (1985) found no histological difference between vascularized and non-vascularized grafts in the rat. All donor sites are not equally good. The trunk of the ulnar nerve is better because it has both arterial supply and venous return. This is not the case with grafts of the internal branch of the deep peroneal nerve or of the anterior interosseous nerve, where a vena comitans is arterialized but no venous return is reconstructed. In these conditions, the nerve cannot be considered to be physiologically vascularized. It is probable that the nerve soon suffers from venous stasis, leading to oedema or even thrombosis. This insufficiency of venous return probably explains the disappointing sensory results we have observed after grafting digital nerves with Rose’s technique. The donor sites that we have listed in Table 1 are few in number.
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Even when nerves are of sufficient diameter and vessels are of appropriate calibre, these sites are rarely useful; the avulsions of C8 and T1 roots that justify their use are not a frequent occurrence. The technical obstacles might be overcome in the future: at present, they restrict the surgeon’s choices. We prefer to ameliorate the quality of the tissue bed rather than to continue transplanting rare vascularized grafts. Giving a new surface to sclerosed tissue beds through the use of free or pedicled flaps will guarantee rapid revascularization of conventional fascicular grafts. This option is all the more justifiable in cases of complex trauma; the associated procedures on bone and tendons also benefit from a satisfactory tissue bed.
Nerve allografts The successful experience of immunosuppressive treatment for heart, renal, liver and now hand transplants along with extensive experimental evidence encouraged the use of nerve allografts. Freezing grafts and adjuvant immunosuppressants allow application of these techniques in humans but there are unresolved technical and ethical problems, which have limited clinical usage to the present time. History The concept of nerve allografts is not new and it is interesting to note that the clinical case done by Albert in 1885 preceded by 5 years the work of Forsmann (1898) who performed a ‘successful’ allograft in a rabbit. This was followed by numerous experimental works until 1945, on dogs, cats and monkeys with results ranging from failure to success. After a gap of 20 years subsequent work by Dos Gupta et al (1967), Zalewski (1971), Pollard and Fitzpatrick (1973), Chung and Chung (1974), Comtet and Revillard (1979) and Levinthal et al (1978) between 1967 and 1981 showed constant failure in the rat and pig. From 1982 onwards, Mackinnon et al (1984), Bain et al (1987), Evans et al (1994) and others demonstrated that nerve allografts in the mouse only work if they are refrigerated in Belzer’s solution (University of Wisconsin Cold Storage Solution, Evans et al 1999) for a minimum of 7 days with small doses of cyclosporin A. They also proved that the immunosuppressive effect of monoclonal antibodies prevented rejection of the graft and allowed good regeneration of the nerve (Nakao et al 1995). Experimental work was also done in the rabbit and the rat to determine the feasibility of vascularized allografts (Best et al 1993). We evaluated brachial plexus repair in the rabbit and the dog with massive vascularized allograft. These grafts, which were only preserved for a few hours in Ringer’s solution before revascularization, did not undergo any refrigeration. The rabbits were then treated with cyclosporin A and signs of regeneration were obvious during immunosuppressive therapy, however when the treatment was stopped all the rabbits developed a massive rejection reaction with loss of function (Bour and Merle 1989). Best et al (1993) compared vascularized autograft and vascularized allograft with and without immunosuppressive therapy in the rat. They proved that vascularized allograft gave equivalent results when compared to vascularized autograft. On the other hand,
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vascularized allograft without immunosuppression was subject to an acute and massive rejection, with vascular thrombosis possibly accelerated by direct contact with recipient antibodies. Concurrently, we have developed the clinical use of vascularized autografts. However, we realized after a few years follow-up that the functional results were not superior to conventional non-vascularized autografts when the surrounding tissue bed was healthy permitting revascularization of the grafts. The clinical results of vascularized autografts have not been remarkable, which explains the small number of studies on this topic (Merle and Dautel 1991). Experimental data in favour of non-vascularized allografts Numerous studies, mostly on the rat, rabbit and goat, have demonstrated the value of graft pretreatment with and adjuvant immunosuppressive treatment with or without monoclonal antibodies. Pretreatment of grafts Preservation at 5°C in Belzer’s solution (University of Wisconsin Cold Storage Solution, Evans et al 1999) for a period of 7 days does not diminish the number of Schwann cells but reduces the immunogenicity. Lower doses of cyclosporin are thus required (Mackinnon et al 1992). This period of preservation allows the recipient to be progressively immunosuppressed, making allograft nerve grafting an elective operation unlike other allograft procedures. In addition, the number of myelinated fibres during regeneration and the conduction velocity are increased. This effect is particularly evident when FK 506 (tacrolimus) is used as the immunosuppressor. Injection of recipient Schwann cells into the allograft also contributes to the protection of the graft from rejection. Immunosuppressive treatments The benefits of immunosuppression with cyclosporin A have been well demonstrated in the rat (Bain et al 1987, Mackinnon et al 1992, Strasberg et al 1996). The allograft allows axonal regeneration in the host to proceed. The number of donor Schwann cells diminishes while the recipient Schwann cells colonize the allograft. Without immunosuppression however the rejection reaction is very rapid and the allograft becomes a fibrous cord obstructing any nerve regeneration. Atchabahian et al (1998) have demonstrated that immunosuppression can be stopped without detriment to neurological function as long as nerve regeneration has reached the sensory and motor end organs. Generally, at this stage, recipient Schwan cells have finished colonizing the allograft. Cases of rejection have to be detected early so as to reinforce the immunosuppressive treatment. It is possible to salvage an allograft which is being rejected if FK 506 is added within 15 days (Feng et al 2001).
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Monoclonal antibodies The usefulness of monoclonal antibodies in antirejection therapy for organ transplantation has been well demonstrated. In the rat, different combinations have been shown to protect the allograft from rejection while permitting a decrease in the dose of cyclosporin A. This is the case for ICAM-1, LFA-1 (Nakao et al 1995) and CD4 (RIB502) (Doolabh and Mackinnon 1999). They are thus useful when there are adverse effects from the immunosuppressive therapy, allowing a decrease in dose while protecting the graft. FK 506 (tacrolimus) and nerve regeneration Lyons et al (1994) showed that in cell cultures, FK 506 increases the rate of axonal growth. Since then, numerous studies have confirmed this capability. It has also been reported that weak doses of FK 506 on treated allografts allow better functional results in allografts than in autografts (Doolabh et al 1999). The accumulation of all this experimental data encouraged clinicians to apply the technique of non-vascularized allografts in humans. Mackinnon’s clinical series (Mackinnon et al 2001) Mackinnon successfully performed the first case in June 1988; a sciatic nerve to posterior tibial nerve defect in an 11-year-old boy was repaired using a 10-strand allograft 23 cm long. After 2 years and 2 months of immunosuppressive treatment (cyclosporin A), the patient recovered some sensation but no useful motor function. Between 1988 and 1998, Mackinnon carried out seven allografts on four women and three men for the following indications: three severe median nerve defects, two associated with ulnar nerve defects; one radial nerve defect; one sciatic nerve defect and two posterior tibial nerve defects. To facilitate revascularization of the allografts, the nerves were stripped into fascicular groups and all fat was removed. They were also placed under the skin to monitor better for rejection. The mean age of the subjects was 15 years. The mean length of the allografts was 190 cm. In the first two patients only allograft nerve was used for repair, while the five subsequent patients also benefited from autograft sural nerve. The mean time of immunosuppression was 18 months. Five patients were treated with cyclosporin A and two with FK 506. Immunosuppression was stopped 6 months after the Tinel sign was detected distal to the allograft with objective signs of return of sensation and muscular function. The immunosuppressive treatment was as follows: • cyclosporin A 200–300 ng/ml or FK 506 5–15 ng/ml • azathioprine 1–1.5 mg/kg/day • prednisolone 0.25–0.5 mg/kg/day for 5–8 weeks. One graft was rejected after 4 months. The rejection reaction did not however affect the autograft which was partially grafting the ulnar nerve. Long-term follow-up verified a return of protective sensibility in six patients, with a two-point discrimination of 3 mm in
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one patient who had grafting of the ulnar nerve. There was useful motor recovery in three cases. Discussion Currently, the technique used by all microsurgical teams for repairing nerve defects is interfascicular autografting. Useful functional results, however, rarely occur in more than 60% of the patients in any series (Millesi et al 1972). Though vascularized autografts have been useful in large defects, their use is limited by the donor site morbidity and the fact that the functional results are not significantly superior to conventional fascicular autografts (Merle and Dautel 1991). Indications for nerve allografts do exist as shown in Mackinnon’s series (2001); in 10 years, she found 10 suitable cases but only seven were operated upon. While the sensory results are encouraging, the motor recovery has been poor but one should note that most of the limbs involved in this series were destined for a total amputation. There are many arguments in favour of allografts; they are certainly an elegant solution for grafting large nerve defects. The problems associated with the immunosuppressive treatment are in part resolved by the limited duration of 18 months on average. Rejection reactions, which do not affect the concurrently placed autografts, are monitored better by placing the grafts subcutaneously. Nervous regeneration definitely benefits from FK 506 (tacrolimus) (Lyons et al 1994). The main disadvantage is the risk of infection with viruses or even prions. Is it ethical to subject a patient to these risks in the hope of obtaining a purely functional benefit? Long-term follow-up and a detailed analysis of the secondary effects of the immunosuppressive drugs would clear any ambiguity about their use. Even if Mackinnon’s experience is unique, she had the great merit of basing her work on a large body of experimental work, systematically resolving all the problems encountered between 1967 and 1981. She was able to overcome them by cold treatment of the grafts for 7 days at 5°C. It was also with better immunosuppression protocols and in particular the addition of FK 506 that the first clinical cases were possible. The caution observed by microsurgical teams with regard to allografts will diminish when the principles of allograft nerve regeneration are better known, the adverse effects of immunosuppressive therapy are diminished and the risks of viral or prion infection are addressed.
Nerve tubes Lundborg’s work using silicone artificial regeneration chambers demonstrates the role of trophism for nerve fibre regeneration (Lundborg and Hansson 1981). The silicone chamber was also an excellent experimental tool for the evaluation of the maximal gap that a nerve can bridge when both ends are fixed to such a tube. The concept of a neurotube, a substitute for autografts, had already been proposed by Weiss in 1943. With Restrepo, we evaluated in the rabbit the use of an empty perineural tube to successfully repair sciatic nerve defects of 15 mm. These results had been confirmed in humans with the repair of digital nerve defects (Restrepo et al 1985b). Since then, numerous biomaterials have been used to make a neurotube. Dellon and Mackinnon proposed a
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polyglycolic acid tube then evolved to trimethylene glycolide carbonate (Maxon) and finally experimented with collagen (Mackinnon and Dellon 1990b). All these experimental studies demonstrated the capacity of the nerve to regenerate if the gap is between 5 mm and 15 mm. Reported complications range from kinking to complete rejection while observing excessive foreign body reactions when the absorbable biomaterial used is polyglycolic acid. Merle et al (1989) have described a chronic neuritis resulting from a fibrous sleeve formed within a silicone tube causing ischaemia to the nerve. Lundborg has rejected this type of complication and justifies its use in humans by reporting the success obtained in seven patients with median or ulnar nerve defects of 3–5 mm (Dahlin et al 2001). Archibald et al (1995) have proposed the utilization of collagen tubes. The results obtained in eight monkeys in which a gap of 5 mm in 15 median nerves and 1 ulnar nerve were repaired with such a tube have demonstrated a functional result equivalent to conventional grafting or direct suture. Other teams have looked for resorbable materials with low inflammatory potential. Using a tube made out of poly-3-hydroxybutyrate (PHB), Young et al (2002) reported nerve regeneration in a rabbit over a distance of 4 cm. The use of a vein filled with muscle (Fornaro et al 2001) encourages the migration of Schwann cells, the indispensable guide to nerve regeneration. The work published by the Italian team of Battiston confirms other similar works. The clinical application has been disappointing as the vein tends to fibrose and sometimes becomes totally obstructed. The bed that hosts this composite graft (vein and muscle) has to very good to support its revascularization. The accumulation of numerous experimental works confirms that nerve regeneration in a ‘neurotube’ is possible over a distance of 5–15 mm. It is enhanced by using an inert material and a tube cavity that facilitates the migration of Schwann cells. The integration, within the tube of Schwann cells, of ‘nerve growth factor’ and of resorbable filaments would probably improve this concept.
Conclusions The solution for the repair of nerve defects has not been found despite the multiple therapeutic options. The fascicular autograft remains the best technique in most cases. Vascularized nerve grafts have been disappointing and they should be reserved for use only in cases involving very large defects and when the recipient bed is of poor quality (crush injuries, Volkmann’s ischaemic contractures). It has not been proved that allografts with an immunosuppressive treatment that is stopped after reinnervation can provide a useful functional result for the patient. In addition, the ethics of using immunosuppressive drugs for a purely functional gain is questionable. For gaps of less than 15 mm, the utilization of a neurotube is justifiable but only time will tell if it is better to use a biotube made with the patient’s own tissues or a tube manufactured with resorbable materials and sown with Schwann cells and filled with growth factor.
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References Albert E (1885) Eirige operationen au nerven, Wien Med Presse 26:1285. Alnot JY (1988) The use of ulnar nerve as a vascularised nerve graft in some peculiar conditions and particularly in total palsies of the brachial plexus C7, C8, D1 avulsions. In: Brunelli G, ed. Textbook of Microsurgery. Masson: Milan, 637–9. Archibald SJ, Shefner J, Krarup C, Madison RD (1995) Monkey median nerve repaired by nerve graft or collagen nerve guide tube, J Neurosci 15:4109–23. Atchabahian A, Mackinnon SE, Doolabh VB, Yu S, Hunter DA, Fly MW (1998) Indefinite survival of peripheral nerve allografts after temporary cyclosporin A immunosuppression. Res Neurol Neurosci 13:129. Bain JR, Mackinnon SE, Hudson AR, Falk RE, Hunter DA (1987) Evaluation of nerve regeneration across nerve allografts in rats immunosuppressed with cyclosporin A, Surg Forum 38:515–17. Best TJ, Mackinnon SE, Bain JR, Makino A, Evans JE (1993) Verification of a free vascularized nerve graft model in the rat with application to the peripheral nerve allograft, Plast Reconstr Surg 92:516–25. Bonney G, Birch R, Jamieson AM, Eames RA (1984) Experience with vascularized nerve grafts, Clin Plast Surg 11:137–42. Bour C, Merle M (1989) Les allogreffes nerveuses et les problèmes immunologiques, Ann Chir Main 8:334–5. Chung PKC, Chung SKY (1974) Evaluation of Imuran and Locke’s solution in peripheral nerve homografts, Exp Neurol 42:41. Comtet JJ, Revillard JP (1979) Peripheral nerve allografts. Distinctive histological features of nerves degeneration and immunological rejection, Transplantation 28:103. Comtet JJ, Bertrand HG, Moyen B, Condamine JL (1981) Greffe nerveuse vascularisée utilisant le branchial cutané interne transplanté avec un pédicule vasculaire. Lyon Chir 77:62–3. Dahlin LB, Anagnostaki L, Lundborg G (2001) Tissue response to silicone tubes used to repair human median and ulnar nerves, Scand J Plast Reconstr Hand Surg 35:29–34. Daly PJ, Wood MB (1985) Endoneural and epineural blood flow evaluation with free vascularized and conventional nerve grafts in the canine, J Reconstr Microsurg 2:45– 9. Doolabh VB, Mackinnon SE (1999) FK 506 accelerates functional recovery following nerve grafting in a rat model, Plast Reconstr Surg 103:1928. Doolabh VB, Motoyama K, Mackinnon SE, Flye MW (1998) Long term tolerance to peripheral nerve allografts with donor antigen and anti-CD4 monoclonal antibody (RIB 5/2) pretreatment, Ann Coll Surg Forum 49:633. Dos Gupta TK (1967) Mechanism of rejection of peripheral nerve allografts, Surg Gynecol Obstet 125: 1058–68. Dumontier C, Kloos M, Dap F, Merle M (1990) Greffes nerveuses des collatéraux digitaux. A propos d’une serie de 16 cas revus, Rev Chir Orthop 76:311–16.
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Evans PJ, Midha R, Mackinnon SE (1994) The peripheral nerve allograft: a comprehensive review of regeneration and neuroimmunology. Prog Neurobiol 43:187–233. Evans PJ, Mackinnon SE, Midha R et al (1999) Regeneration across cold preserved peripheral nerve allografts, Microsurgery 19:115–27. Fachinelli A, Masquelet AC, Restrepo Y, Gilbert A (1981) The vascularized sural nerve, Int J Microsurgery 3:57–62. Feng FY, Ogden MA, Myckatyn TM et al (2001) FK 506 rescues peripheral nerve allografts in acute rejection, J Neurotrauma 18:217. Fields RD, Le Beau JM, Longo FM, Ellisman MH (1989) Nerve regeneration through artificial tubular implants, Prog Neurobiol 33:87–134. Fornaro M, Tos P, Geuna S, Giacobini-Robecchi MG, Battiston B (2001) Confocal imaging of Schwann-cell migration along muscle-vein combined grafts used, to bridge nerve defects in the rat, Microsurgery 21:153–5. Forssman J (1898) Uber den uraschen, welche die wachstrums richtung der peripheren nerven fasern beider regeneration bestimmern, Biet Path Anat, 24:56. Frykman GK, Gramik K (1991) Results of nerve grafting in operative nerve repair and reconstruction. In: Gelberman RH, ed. Operative Nerve Repair and Reconstruction. JP Lippincott: Philadelphia 553–67. Gilbert A, De Moura W, Salar R, Grossman J (1986) Le prélèvement des greffes nerveuses. In: Tubiana R, ed. Traité de Chirurgie de la Main. Vol III Masson: Paris, 451–7. Gu Y, Zheng Y, Li H, Zu Y (1985) Arterialized venous free sural nerve grafting, J Plast Surg 15:332–8. Jabaley ME, Wallace WH, Heckler FR (1980) Internal topography of major nerves of the forearm and hand: a current review, J Hand Surg 5:1–18. Lebreton E, Bourgeon Y, Lascombes P, Merle M, Foucher G (1983) Vascularisation de la portion brachiale du nerf ulnaire, Ann Chir Main 2:211–18. Levinthal R, Brown J, Ran RW (1978) Fascicular nerve allograft. Evaluation. Part 1: Comparison with autografts by light microscopy, J Neurosurg 48:423–7. Lundborg G, Hansson HA (1981) Nerve lesions with interruption of continuity. Studies on the growth pattern of regenerating axons in the gap between the proximal and distal nerve ends. In: Gorio A, Millesi H, Mingrino S, eds. Posttraumatic Nerve Regeneration. Raven Press: New York, 229–39. Lux P, Breidenbach W, Firelli J (1988) Determination of temporal changes in blood flow in vascularized and non vascularized nerve grafts in the dog, Plast Reconstr Surg 82:133–44. Lyons WE, George EB, Dawson TM, Steiner JP, Snyder SH (1994) Immunosuppressant FK 506 promotes neurite out growth in cultures of PC 12 cells and sensory ganglia, Proc Natl Acad Sci USA 91:3191. Mackinnon SE, Dellon AC (1988) Surgery of the Peripheral Nerve. Thieme Medical Publishers: New York, 89–130. Mackinnon SE, Dellon AL (1990a) Clinical nerve reconstruction with a bioabsorbable polyglicolic acid tube, Plast Reconstr Surg 85:419–24.
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Mackinnon SE, Dellon AL (1990b) A study of nerve regeneration across synthetic (Maxon) and biologic (collagen) nerve conduits for nerve gaps up to 5 cm in the primate, J Reconstr Microsurg 6:117–21. Mackinnon SE, Hudson AR, Falk RE, Kline D, Hunter DA (1984) Peripheral nerve allograft: an immunological assessment of pretreatment methods, J Neurosurg 14:167–71. Mackinnon SE, Midha R, Bain J, Hunter D, Wade J (1992) An assessment of regeneration across nerve allografts in rats receiving short courses of cyclosporin A immunosuppression, Neuroscience 46:585–93. Mackinnon SE, Doolabh VB, Novak CB, Trulock EP (2001) Clinical outcome following nerve allograft transplantation, Plast Reconstr Surg 107:1419–29. Madison RD, Da Silva CF, Dikkes P (1988) Entubulation repair with protein additives increases the maximum nerve gap distance successfully bridged with tubular prostheses, Brain Res 447:325–34. McCarty C (1951) Two stage autograft for repair of extensive damage to sciatic nerve, J Neurosurg 8:318–22. Merle M (1992) Lésions nerveuses. In: Merle M, Dautel G, eds. La Main Traumatique, Tome 1: L’urgence. Masson: Paris. Merle M, Dautel G (1991) Vascularised nerve grafts, J Hand Surg 16B:483–8. Merle M, Amend PH, Foucher G, Michon J (1984) Plaidoyer pour la réparation primaire microchirurgicale des nerfs périphériques: Etude comparative de 150 lésions du nerf médian et cubital avec un recul supérieur à 2 ans, Chirurgie 110:761–71. Merle M, Dellon AL, Campbell JN, Chang PS (1989) Complications from silicone polymer intubation of nerves, Microsurgery 10:130–3. Millesi M, Meissl G, Berger A (1972) The interfascicular nerve-grafting of the median and ulnar nerves, J Bone Joint Surg 54A:727–50. Nakao Y, Mackinnon SE, Strasberg SR et al (1995) Immunosuppressive effect of monoclonal antibodies to ICAM 1 and LFA-1 on peripheral nerve allograft in mice, Microsurgery 16:612–20. Oberlin CH, Alnot JY (1985) Utilisation du nerf sciatique poplité externe comme greffe vascularisée, Rev Chir Orthop 71 (Suppl II):94–8. Penkert G, Bini W, Samii M (1988) Revascularization of nerve grafts: An experimental study, J Reconstr Microsurg 4:319–25. Pho RWH, Lee YS, Rujiwetpongstorn V, Pang M (1985) Histological studies of vascularized nerve graft and conventional nerve graft, J Hand Surg 10B:45–8. Pollard JD, Fitzpatrick L (1973) An ultrastructural comparison of peripheral nerve allografts and autografts, Acta Neuropathol (Berl) 23:. Restrepo Y, Merle M, Michon J, Foliguet B, Barrat E (1985a) Free vascularized nerve grafts: an experimental study in the rabbit, Microsurgery 6:78–84. Restrepo Y, Merle M, Petry D, Michon J (1985b) Empty perineurial tube graft used to repair a digital nerve: a first case report, Microsurgery 6:73–7. Rose EH (1985) Restoration of sensibility to anesthetic scarred digits with free vascularized nerve grafts from the dorsum of the foot, J Hand Surg 10A:593–602. Rose EH, Kowalski TA, Norris MS (1989) The reversed venous arterialized nerve graft in digital nerve reconstruction across scarred beds, Plast Reconstr Surg 83:593–602.
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Shibata M, Tsai TM, Firelli J, Breidenbach WC (1988) Experimental comparison between vascularized and non vascularized nerve grafting, J Hand Surg 13A: 358–65. Strange FGS (1947) An operation for nerve pedicle grafting, Br J Surg 34:423–5. Strange FGS (1948) The pedicle nerve graft, Br J Surg 35:331–3. Strasberg SR, Hertl MC, Mackinnon SE et al (1996) Peripheral nerve allograft preservation improves regeneration and decreases systemic cyclosporin A requirements, Exp Neurol 139:306–16. Sunderland S (1945) The intraneural topography of the radial, median and ulnar nerves, Brain 68:243. Sunderland S, Marshall RD, Swaney WE (1959) The intraneural topography of the circumflex, musculocutaneous and obturator nerve , Brain 82:116. Taylor GI (1978) Nerve grafting with simultaneous microvascular reconstruction, Clin Orthop Rel Res 133:56–70. Taylor GI, Ham F (1976) The free vascularized nerve graft, Plast Reconstr Surg 57:413– 26. Tenny JR, Lewis RC (1984) Digital nerve grafting for traumatic defects, J Bone Joint Surg (Am) 66:1375–9. Townsend PLG, Taylor GI (1984) Vascularized nerve grafts using composite arterialized neuro-venous system, Br J Surg 37:1–17. Weiss P (1943) Nerve regeneration in the rat following tubular splicing of severed nerves, Arch Surg 46: 525–47. Young RC, Wiberg M, Terenghi G (2002) Poly-3-hydroxyburate (PHB): a resorbable conduit for long-gap repair in peripheral nerves, Br J Plast Surg 55:235–40. Zalewski AA (1971) The effect of AgB locus. Compatibility and incompatibility on neuron survival in transplanted sensory ganglia in rats, Exp Neurol 33: 576.
14 Bridging nerve defects: the role of tissue interpositioning Göran Lundborg
Bridging a defect in nerve continuity is a very demanding reconstructive surgical procedure. Several problems are added on top of the difficulties associated with primary nerve repair. The defect has to be bridged by a conduit capable of guiding regenerating axons from the proximal to the distal nerve segment. The axons have to pass two suture lines with the risk of misdirection or loss of axons at both levels. The conduit which bridges the defect should offer a permissive and stimulating environment for the traversing nerve fibres (Lundborg 1988). In clinical practice, the most effective conduit used today is an autologous nerve graft (Millesi 2000). However, a nerve grafting procedure requires sacrifice of healthy nerves. It is therefore not surprising that extensive research is on going—aimed at development of alternatives to nerve grafts. The aim of this chapter is to review the biological principles for a regenerationcompetent nerve conduit and to present various types of tissue interpositioning which are used experimentally and clinically to bridge nerve defects.
The ideal nerve conduit: a theoretical model Nerve fibres, traversing a defect, need (1) a matrix/scaffold offering contact guidance and a framework for the regenerating axons; (2) cells incorporated in the matrix, with capacity to produce growth factors and to provide a physiological local environment; (3) growth factors to stimulate the axonal growth, synthesized by cells in the local environment or supplied locally by other means in experimental systems. When discussing the construction of a nerve conduit these three factors should be considered— separately or together (Fig. 1). An interposed conduit of biological or synthetic material may be tissueengineered to offer these three components in varying proportions and extent. A matrix/scaffold can be constructed of synthetic or biological material (Lundborg 1988, 2000, Fields et al 1989, Doolabh et al 1996). A synthetic matrix can consist of tubes, fibres or other materials of varying topographical shapes and dimensions. It can be resorbable or nonresorbable. Tubes can be filled with gels containing cells or factors supporting axonal growth. Among biological matrices basal membranes from nerve and muscle have been frequently used. Vessels and collagen are examples of other types of biological material which can be used for tubular structures. Cells are needed for interaction with the local environment and support of axonal growth by producing neurotrophic substances. Schwann cells are believed to be the main
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source of such factors, but macrophages provided by leaking blood vessels in the nerve stumps are also important components of the regeneration process (Lundborg 2000). Cultured Schwann cells have been added to the matrix in many experimental systems. Cells added to the matrix may be of autologous origin or they may be gene-manipulated to make them competent to produce specific growth stimulating factors. Addition of stem cells to the matrix is another promising possibility for the future. Growth stimulating factors can be added directly to the matrix. In experimental systems such factors may be provided by, for example
Figure 1 Principles of tissue engineering nerve conduits for bridging nerve defects. A conduit should consist of a scaffold/ matrix acting in concert with cells and growth factors. The scaffold/matrix can be biological or non-biological in nature; resorbable or non-resorbable. It can be of varying topographical nature such as tubes, fibres or sponges. Schwann cells are needed for production of growth factors. Such cells can be precultured in vitro, they may be incorporated in gels or seeded on longitudinal filament structures. Cells can be gene-engineered to acquire competence to produce neutrophic factors. In the future, stem cells may have a potential to differentiate into Schwann cells or other types of growth promoting cell. Neurotrophic factors can be added to the system by slow release from a bioactive matrix or they can be added from extrinsic sources. osmotic pumps or by slow release from a bioactive stroma.
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Thus, the ideal conduit for bridging a nerve gap should provide a matrix/scaffold as well as cells and growth factors. Naturally, the ultimate solution is an autologous nerve graft since such a graft provides all three components: a matrix constituted by endoneurial tubes/Schwann cell basal laminae incorporated in connective tissue sheaths and cells (mainly Schwann cells) producing neurotrophic factors. The autologous nerve graft therefore is currently the gold standard for bridging nerve defects. However, since nerve grafting requires sacrifice of healthy nerves, and since large amounts of graft material occasionally may be needed, there is a strong need for development of alternatives to nerve grafts. In the search for such alternatives the aim should be to develop a guide providing the components which are illustrated in Figure 1.
Nerve grafts Autologous nerve grafts (isografts) The concept of using autologous nerve grafts for bridging nerve defects was popularized by Millesi more than 40 years ago (Millesi et al 1972, 1976, Millesi 2000) and is still the gold standard in nerve reconstruction. To date no other alternative has proved superior to the use of autologous nerve grafts. Autologous nerve grafts provide a scaffold which contains Schwann cells basal laminae as well as Schwann cells producing growth factors, thereby fulfilling the criteria for an ideal nerve conduit as discussed above. The importance of laminin and fibronectin in the basal lamina scaffolds of nerve grafts has been emphasized by several investigators (Baron-van Evercooren et al 1982, Wang Nerve conduits and tissue engineering Proximal nerve segment axons et al 1992, Bailey et al 1993) and these have been found to be ideal to support advancement of regenerating axons. The Schwann cells in a nerve graft will survive on diffusion, provided the graft is thin enough, until it is revascularized. Various types of manipulation can be used to increase the regeneration potential of autologous nerve grafts, for instance predegeneration (Danielsen et al 1994, Gulati 1996, Dahlin and Lundborg 1998). The regeneration potential of autologous grafts has been experimentally improved by non-invasive techniques also such as vibration exposure of the donor’s hind limb (Bergman et al 1995), and treatment with hyperbaric oxygen (Zamboni et al 1995, Haapaniemi et al 1998).
Tubes: experimental background The use of tubes for experimental nerve repair was introduced in the late 1970s as an interesting model to study nerve regeneration (Lundborg and Hansson 1979, 1980). In the first studies mesothelial tubes were used for bridging experimental defects in nerve continuity (Lundborg and Hansson 1979, 1980), but in the early 1980s a silicone tube model was introduced as an important tool for studying basic biological mechanisms of nerve regeneration and to analyse effects of manipulating the microenvironment at the repair site (Lundborg et al 1982a). The concept of tubular repair was based on that nerve regeneration would be favoured by minimizing surgical trauma, and a short gap between
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the nerve ends, encased in a tube, would allow accumulation of the neurotrophic factors that are normally synthesized in a damaged nerve trunk, with good possibility of the neurotrophic and neurotropic mechanisms regulating axonal growth to act. When a 10 mm gap was left between proximal and distal ends of a severed rat sciatic nerve and when the repair side was encased in a tube a very typical and standardized regeneration process followed: there was, within 4 weeks, a spontaneous formation of a new nerve structure of more or less normal appearance bridging the defect. The nature and quality of this nerve structure was directly related to the length of the gap and to the presence of a distal segment: with a gap length less than 10 mm in a rat sciatic nerve regeneration always occurred but with gaps exceeding 10–15 mm there was no or inferior regeneration (Lundborg et al 1982b). The tube model was therefore regarded as an interesting ‘all/or/nothing’ model for axonal growth presenting interesting possibilities to study, in a simple way, effects of modifying the experimental situation on nerve regeneration, e.g. supply of various exogenous substances. The cellular and chemical events occurring in a regeneration chamber follow a specific pattern. Within hours there is accumulation of fluid inside the chamber containing neurotrophic factors and various inflammatory cells. At least two types of neurotrophic activity have been defined in the chamber fluid: Nerve Growth Factor (NGF) and ciliary neuro trophic factor (CNTF) (Lundborg et al 1982a, Danielsen and Varon 1995). A major peak in the occurrence of neurotrophic factors has been observed as soon as 3–6 hours after nerve injury (Danielsen and Varon 1995). The fluid contains neurotrophic factors as well as various inflammatory cells and cytokines (Longo et al 1983a, b, Danielsen et al 1993). Cells with a pattern characteristic of an ordinary inflammatory response also accumulate in the tube (Danielsen et al 1993). The neurotrophic factors in the fluid address sensory, motor and sympathetic neurons. Within weeks there is a well-organized fibrin matrix being formed inside the tube bridging the two nerve ends. Laminin as well as fibronectin have been demonstrated early in the matrix (Longo et al 1984). The fibrin matrix is invaded early by various types of macrophages (Danielsen et al 1993, Zhao et al 1993, Dahlin et al 1995). The fibrin orients itself in longitudinal strands. Schwann cells, fibroblasts and microvessels invade the fibrin matrix from both ends, and the new structure soon becomes revascularized (Podhajsky and Myers 1994). Axons regenerate into the matrix from the proximal side, and within months there is an overgrowth of axons into the distal nerve segment. The matrix is at that time well organized, resembling a normal well vascularized nerve structure. Many materials have been used in tube experiments (Fields et al 1989). Tubes may be permeable or non-permeable to nutrients, cells and vessels, and they may be bioresorbable or nonresorbable. Although permeable tubes with holes may allow diffusion of nutrients and ingrowth of vessels (Jenq and Coggeshall 1985) silicone tubes with holes do not seem to stimulate axonal ingrowth as compared to tubes with no holes when applied around a zone of crush injury (Danielsson et al 1996). Several factors like the interstump gap, the tube lumen area and the microstructure of the inner surface of the tube lumen are of importance for organization of the axonal growth and for the final outcome (Lundborg 1988, Aebischer et al 1990, Kim et al 1993, Butí et al 1996, Navarro et al 1996, ValeroCabré et al 2001).
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Manipulation/modification of tube contents for improvement of regeneration The regeneration potential of a tube system has been experimentally improved by various modifications, for example, by varying the size of the chamber or filling it with dialyzing plasma (Williams 1987). Introduction of laminin, collagen, fibrin and fibronectin into tubes has been shown to have a positive influence on regeneration (Madison et al 1985, 1987, 1988, Müller et al 1987, Valentini et al 1987, Rosen et al 1990, Kljavin and Madison 1991, Bailey et al 1993, Tong et al 1994, Zeng et al 1995, Labrador et al 1998, Rodriguez et al 2000). Stimulation of regeneration by the introduction of testosterone, gangliosides (Müller et al 1987), Matrigel (Guénard et al 1992) or hyalyron (Seckel et al 1995) as well as cultured adult Schwann cells into the tube has also been attempted (Guénard et al 1992, Kim et al, 1994, Ansselin et al 1997, Levi et al 1997). In addition, neurotrophic factors such as NGF (Rich et al 1989) and fibroblast growth factor (FGF) (Danielsen et al 1988, Rich et al 1989) have been used to stimulate the regeneration process. Longitudinal synthetic filaments introduced inside silicone tubes have been used to increase the regeneration competence of such conduits. Defects of 15 mm in rat sciatic nerve, which can not be bridged by a tube alone, were successfully bridged by the use of such ‘bioartificial nerve grafts’ (Lundborg and Kanje 1996, Lundborg et al 1997b). In this model filaments made of polyamide or polyglactin helped to stabilize the fibrin matrix which is formed inside the tube, and regenerating axons together with Schwann cells and microvessels advanced inbetween the filaments (Fig. 2) (Lundborg and Kanje 1996, Lundborg et al 1997b, Terada et al 1997a,b,c, Dahlin and Lundborg 1999, Arai et al 2000). Silicone tubes have been successfully used in the situation clinical for repair of median and ulnar nerves in the human forearm (Lundborg et al 1991, 1994, 1997a). In a randomized prospective clinical study the outcome was compared between routine microsurgical repair and a tubular repair where the nerve ends were intentionally left 3–4 mm apart inside the tube. At follow-up, 12 months later, there was no difference in the outcome regarding sensory or motor function (Lundborg et al 1997a). Also, at followup 5 years postoperatively the functional outcome was the same in the two groups although the tubular group showed less cold intolerance (Lundborg et al, in press).
Biodegradable polymer tubes Tubes consisting of various biodegradable materials, such as polyglycolic acid (PGA) have been successfully used both experimentally and clinically for bridging nerve defects (Reid et al 1978, Molander et al 1982, 1983, Dellon and Mackinnon 1988, Mackinnon and Dellon 1990a). PGA tubes were shown to support successfully regeneration across 3 cm defects in the ulnar nerves of monkeys (Dellon and Mackinnon 1988). In other experiments in monkeys glycolide trimethylene carbonate (Maxon) conduits were used to bridge 2 cm nerve gaps with good results (Mackinnon and Dellon 1990b). These conduits supported some regeneration even across defects as long as 5 cm. PGA tubes were successfully used in patients to bridge digital nerve gaps of 0.5–3.0 cm (mean 1.7 cm) (Mackinnon and Dellon 1990a). A randomized prospective multicentre
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study on the use of PGA conduits for human digital nerve construction was performed by Weber et al (2000). PGA conduits were found useful and compared well to nerve grafts and end-to-end repair in conduit repair for nerve gaps of 4 mm or less. PGA tubes have also been successfully used to reconstruct a 25 mm defect in the right inferior alveolar nerve (Crawley and Dellon 1992). At
Figure 2 A type of bioartificial nerve graft based on synthetic material. (a) Longitudinal synthetic filaments are introduced into a silicone tube. The filaments can be nonresorbable, e.g. polyamide, or resorbable, e.g. polyglactin. The filaments help to stabilize the fibrin matrix as illustrated in the insert; (b) There is vigorous growth of myelinated axons in the fibrin matrix inbetween the filaments. Asterix indicates polyamide filament. (c) The same area in higher magnification. Scale: bar = 25 µm. Reproduced with permission from Lundborg and Kanje 1997b.
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2 years follow-up the perception of pressure and vibration at the nerve reconstruction was similar to the contralateral side of the lip. Navarro and co-workers have performed extensive studies on the use of nerve guides in mice with special reference to tube material and tube contents (Navarro et al 1994, 1996, 2001, Butí et al 1996, Gomez et al 1996, Rodriguez et al 1999, 2000, Valero-Cabré et al 2001). They used a mouse sciatic nerve model in which various types of tubular conduit were used to bridge a nerve gap of 6 mm. They found resorbable guides made of collagen or polylactate caprolactone (PLC) superior to non-resorbable guides such as silicone, Teflon or Polysylfone. Cultured Schwann cells suspended in Matrigel, introduced in the tubes, were important factors contributing to successful nerve regeneration (Rodriguez et al 2000).
Collagen tubes Collagen tubes have been used for bridging nerve defects in mice (Gomez et al 1996, Navarro et al 1996), rabbits (Kim et al 1993) and primates (Mackinnon and Dellon 1990b, Li et al 1992, Archibald et al 1995, Madison and Archibald 1996). Krarup et al performed extensive studies on factors that influence peripheral nerve regeneration through collagen tubes in monkeys (Krarup et al 2002). Nerve gap distances of various lengths were repaired with collagenbased nerve guides, and extensive neurophysiological investigations were performed postoperatively over a period of 3–4 years. It was found that nerve gap distance and the type of repair strongly influenced the time to the earliest muscle reinnervation. Nerve gaps up to 5 cm were successfully bridged by the collagenbased nerve guide tube (Krarup et al 2002).
Longitudinally oriented suture material Longitudinal sutures alone, without an artificial tube, can support regeneration across defects in the rat sciatic nerve. Scherman et al (2000a,b, 2001a) bridged 7–15 mm gaps in the rat sciatic nerve by parallel strands of 8–0 sutures of either polyglactin or polyamide (Fig. 3). It was found that the sutures served as an effective scaffold for generation of a new nerve structure across the gap. A matrix containing capillaries, fibroblast-like cells and mononuclear cells were rapidly formed in the tissue inbetween the sutures. Axons, advancing between the longitudinal suture strands were organized in minifascicles and, with time, became surrounded by a perineurium-like structure. No difference in axonal counts or degree of myelination was observed between polyamide and polyglactin. For bridging of 7 mm gaps the suture model showed no difference in regeneration capacity as compared to conventional nerve grafts. In the 15 mm gap group, axonal regeneration across a 15 mm gap was significantly enhanced when a short interposed nerve segment was attached to the sutures halfway (a ‘stepping-stone’ procedure). The interposed nerve segment acted as a Schwann cell resource in this model. Pretreatment of the sutures with triiodothyronine (T3) enhanced the myelination process in the regenerating nerve structure (Scherman et al 2001b). It was concluded that conventional longitudinally oriented sutures bridging a defect may be sufficient to support regeneration across short
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gaps in peripheral nerves, a method which may be of considerable potential clinical value (Scherman et al 2000a,b, 2001a).
Basal laminin as scaffolds Basal membranes from muscle or nerve can provide a matrix in a nerve guide. It was demonstrated about 20 years ago that basal laminae tubes from muscle tissue could serve as guiding structures for growing axons (Ide et al 1983). Muscle basal laminae contain laminin and fibronectin and may thereby support axonal ingrowth (for a review see Hall 1997). Based on this concept coaxial frozen and thawed muscle grafts have been used for bridging gaps in nerve continuity (Keynes et al 1984, Fawcett and Keynes 1986, Glasby et al 1986a,b, 1992, Gschmeissner et al 1988, Feneley et al 1991, Glasby 1991). Regeneration is limited by the length of such grafts: in rabbit common peroneal nerve a 5 cm gap could be successfully bridged while in more extensive defects regeneration was impaired compared to nerve grafts (Hems and Glasby 1993). Introduction of a small nerve segment in the middle of a muscle graft (‘sandwich graft’) can increase the regeneration capacity (Calder and Green 1995, Whitworth et al 1995c). Besides freezing and thawing, muscle grafts also can be made acellular by chemical extraction by Triton x-100 (Packard, USA) (Arai et al 2001, Xiao-Lin et al 2001). Such grafts show good regeneration competence when used for bridging defects in rat sciatic nerve. In clinical trials coaxial autografts of freeze-thawed skeletal muscle have been used to repair injured digital nerves (Norris et al 1988). At follow-up 3–11 months after the operation all but one patient showed an excellent level of recovery. Precultured Schwann cells, added to frozen and thawed muscle grafts have been shown to improve the regeneration competence of the graft (Fansa et al 1999, Nishiura et al, 2001a,b).
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Figure 3 Longitudinal sutures alone, bridging a gap, can serve as a framework for generation of a new nerve structure. (a) Principles for longitudinal suture arrangement: I, 7 mm gap, no conduit; II, continuous longitudinal sutures bridging a 7 mm gap as compared to a standard nerve autograft on the contralateral side; III, 15 mm gaps bridged by sutures alone or a 2 mm interposed nerve segment threaded onto the sutures on the contralateral side. (b) Axons are advancing in the tissue space inbetween the longitudinal suture material. There are numerous large minifascicles containing numerous axons after 12 weeks. Reproduced with permission from Scherman et al 2001a. Besides muscle basal laminae, basal laminae from nerves may also serve as nerve guides in experimental systems. Nerve allografts, made acellular through chemical
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extraction, have been used to bridge 10 mm defects in rat sciatic nerves. Such grafts were found to support outgrowth of axons and migration of Schwann cells which reoccupy the empty basal lamina tubes without excessive signs of inflammation (Sondell et al 1998). Vascular endothelial growth factor (VEGF), when added to such grafts, had neurotrophic activity and stimulated Schwann cell proliferation as well as axonal outgrowth (Sondell et al 1999).
Veins Veins have been used successfully for bridging nerve gaps (Chiu et al 1982, FoidartDessalle et al 1997). An original observation (Chiu et al 1982, 1988) that a 10 mm gap of rat sciatic nerve could successfully be bridged by autologous vein grafts evolved from an experimental idea to a clinical reality showing successful reconstruction of peripheral nerves with a nerve gap of less then 3 cm in patients (Chiu and Strauch 1990, Chiu 1999).
Vein–muscle conduits Combined vein–muscle nerve conduits have been used by Battiston et al to bridge 1–2 cm gaps in rat sciatic nerve. The principle was that a piece of fresh muscle inside the vein would expand the vessel, and that the muscle basal lamina would help to support axonal overgrowth (Battiston et al 2000a,b, Geuna et al 2000a,b, Tos et al 2000, Fornaro et al 2001). In the Battiston experimental model these conduits serve well as guides for axonal overgrowth, and the principle has been applied in more than 20 clinical cases followed for more than 1 year with encouraging results (Battiston et al 2000a).
Autologous tendons as graft Collagen fibres have been used as a matrix for regenerating axons in rats, bridging gaps up to 30 mm (Yoshii et al 2001, 2002). Collagen fibres from rat tail tendon were used by Brandt et al to bridge defects of varying lengths in the sciatic nerve of rats (Brandt et al 1999a,b, 2002a). In these models the tendon was either used in its original shape or was teased and subsequently rolled to form a loose collagen roll which was used to bridge defects of 10–15 mm (Fig. 4). Such tendon structures served as effective conduits for axonal growth and were found to be comparable to freeze-thawed muscle grafts (Brandt et al 2002a). In vitro colonization of Schwann cells in tendon autografts prior to grafting was found to enhance significantly the regeneration process (Brandt et al 2002b). It was also shown that acutely dissociated Schwann cells, from the ends of a previously severed nerve, when seeded in a tendon autograft for bridging nerve defects in rats, increased the regeneration competence of the conduit (Brandt 2002).
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Fibronectin and laminin grafts Conduits made out of laminin (Kauppila et al 1993) have been used to bridge defects in nerve continuity in rats, and fibronectin mats have been successfully used as conduits for bridging 10 mm gaps in rat sciatic nerves (Whitworth et al 1995a, 1996). It has been demonstrated that the addition of neurotrophic factors such as NGF can enhance nerve regeneration (Whitworth et al 1995b, 1996) and can also decrease post-traumatic nerve cell body death in dorsal root ganglia in rats (Rich et al 1987) and monkeys (Ahmed et al 1999, Wiberg et al 1999). Also neurotrophin-3 (NT-3) delivered locally via fibronectin mats has been shown to increase peripheral nerve regeneration in rats (Sterne et al 1997).
Alginate conduits Freeze-dried alginate gels covered with a polyglycolic acid mesh have been used successfully to bridge 50 mm gaps in cat sciatic nerves with good functional results (Suzuki et al 1999). Alginates have been used experimentally for facial nerve repair also. In cats alginate sponges were used to bridge 5 mm gaps in the dorsal ramus of the facial nerve with good behavioural, electrophysiological and histological results after 4 months (Wu et al 2002).
Polyhydroxybutyrate Poly-3-hydroxybutyrate (PHB) is a natural biological polymer used as a bacterial storage product, and manufactured as bioresorbable sheaths. PHB has been successfully used to bridge long nerve gaps (up to 4 cm) in a rabbit common peroneal nerve injury model (Young et al 2002). PHB, wrapped around a nerve repair site, has been successfully used as an alternative to nerve suture in rats (Hazari et al 1999a) and cats (Hazari 1999b, Ljungberg et al 1999). Addition of allogeneic Schwann cells to the PHB conduits increased their regeneration competence (Mosahebi et al 2002).
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Figure 4 Tendon used as nerve graft. (a) A rat tail tendon can be teased to a membrane exposing numerous parallel collagen fibres. Such a membrane can be rolled to form a tube and can also be co-cultured with Schwann cells in vitro. Reproduced with permission from Brandt 2002c. (b) When a tendon is used as a conduit for bridging a nerve gap myelinated axons can be seen advancing inbetween the collagen components after 4 weeks. Scale: bar = 100 µm. (c) The same area at higher magnification. Scale: bar = 50 µm. (Reproduced with courtesy of Dr J Brandt.)
Conclusions The ideal nerve conduit consists of a matrix favouring axonal advancement and acting in concert with Schwann cells producing neurotrophic factors. Although autologous nerve grafts offering these components constitute the gold standard, evolving tissue engineering techniques have already provided alternative conduits with a regeneration competence approaching the competence of nerve grafts in experimental animal systems. Synthetic tubular structures have already been used clinically for bridging short defects in digital nerves as well as ulnar and median nerves in the human forearm. Various types of biological systems as well as various synthetic structures, tissue-engineered to contain appropriate cells and growth factors, may in the future be an important alternative to autologous nerve grafts.
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Acknowledgements Research on nerve injury and repair at our department is supported by the Medical Research Council; Faculty of Medicine, Lund University; and Malmö University Hospital.
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15 End-to-side neurorrhaphy: an alternative method for reinnervation in cases with long nerve defects Manfred Frey and Pietro Giovanoli
Introduction The results of surgical reconstruction by proximal nerve repair or with long nerve grafts are often not satisfying clinically. Recovery of motor and sensory function depends on a critical number of axons reaching the target organ and on reinnervating muscle fibres and sensory receptors within a critical period after denervation. In limited cases, like in avulsion injuries, where no donor nerve or nerve transfer is available for direct end-toend suture, or in cases where extremely long distances have to be overcome by the regenerating axons and limited functional results are to be expected, end-to-side suture of the distal part of the injured nerve to an uninjured nerve in the neighbourhood may offer a practical solution. The technique of end-to-side neurorrhaphy was first used by Depres in 1876, in a median nerve injury. He inserted the distal portion of the nerve between the fibres of the ulnar nerve, as reported by Sherren (1906). At the beginning of the twentieth century several reports of clinical application followed. Ballance et al (1903) published their experience with end-to-side neurorrhaphy in the operative treatment of chronic facial palsy of peripheral origin. In the same year Harris and Low (1903) reported on crossunions of nerve roots to treat Erb’s palsy and infantile paralysis of the upper extremity. Kennedy discussed as early as in 1901 the interchange of function of the cerebral cortical centres during restoration of coordinated movement after nerve crossing. He sutured the distal end of the facial nerve end-to-side into the accessory nerve dividing a significant part of this nerve. At that time partial neurotomy of the donor nerve caused significant morbidity and the clinical outcome of end-to-side neurorrhaphy was below an acceptable limit. This technique of nerve reconstruction was forgotten until the early 1990s, when Viterbo (Viterbo et al 1992, 1994a,b) reported on a successful experimental series in rats. This optimistic revival of the end-to-side nerve suture stimulated many international centres to perform research work predominantly in the rat and to develop experience in clinical application. In the past 10 years almost 40 scientific papers have been published, the majority being experimental studies. The few clinical publications are limited to case reports that are usually poorly documented. Over all, the majority of authors conclude that end-to-side neurorrhaphy is a successful tool for reinnervation: experimentally and clinically. Our research group studied end-to-side neurorrhaphy in rabbits, a larger animal more comparable to human conditions, and reported excellent functional results without
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downgrading the donor nerve (Giovanoli et al 2000). Besides this, detailed nerve fibre distribution was studied for the first time in all cross-sections on different levels: proximal, within and distal to the end-toside nerve suture. We found that the regenerative stimulus of the distal nerve segment is not limited to the contact zone. These results as well as the technique used, that is fenestrating the epineurium and leaving the perineurium intact, was of important influence on our clinical work. In this chapter we report that end-to-side neurorrhaphy achieves clinically efficient results and that, on the basis of this reliability, end-to-side neurorrhaphy for reinnervation of a free functional muscle transplant is justified in selected cases.
Methods Since our first clinical end-to-side neurorrhaphy in a replantation case of an avulsed thumb on 9 September 1995, we have used end-to-side nerve repair for motor or sensory reinnervation in the upper extremities of nine patients (Table 1). In three patients primary nerve repair using end-toside neurorrhaphy was performed in an avulsion injury of a finger (n = 2) or in a replantation at upper arm level (n = 2). In three brachial plexus reconstructions end-to-side nerve repair was used after tumour resection. A free functional muscle graft was reinnervated by an end-to-side neurorrhaphy in three patients after tumour resection (n = 1) and Volkmann’s contracture (n = 1) and in a brachial plexus lesion (n = 1). Surgical technique Having identified the distal nerve stump and missing corresponding proximal nerve stump usually because of avulsion trauma to the nerve, end-to-side neurorrhaphy is indicated as primary nerve repair. A synergistic nerve next to the distal nerve stump is selected for end-to-side nerve suture. This is important for a clinically useful result, because antagonistic co-contractions would limit the regained function in the case of motor reinnervation, and sensory perception would be difficult to be re-localized from a completely different dermatome. A window of similar size to the cross-section of the distal nerve stump is cut into the epineurium of the donor nerve with microsurgical technique under the microscope. Trauma to the nerve fibres themselves should be kept to a minimum. In our opinion traumatic preconditioning is not a presupposition for adequate sprouting of the nerve fibres into the distal nerve segment brought in end-to-side contact. The epineurium of the distal stump is sutured to the margins of the epineurial window using four to six 10-0 nylon interrupted sutures. If mixed stem nerves are used as donors, known dominance of motor or sensory fibres in the different fascicles of the thicker nerve is considered corresponding to the target to be reinnervated; especially in multifascicular nerves this may be more important than in a monofascicular nerve branch. Intraoperative, selective electric stimulation is very helpful to localize fascicles containing predominantly motor fibres along the circumference of the nerve and to identify the muscle or muscle group reacting. Trains of pulses with a low amplitude of 1–2 mA are used for submaximal stimulation (Neurostimulator, Aesculap® type GN 015).
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In the case of irreversible loss of the muscle target by direct trauma, ischaemia, tumour resection or irreversible atrophy as a consequence of longstanding paralysis, replacement of the muscle target has to be performed by free muscle transplantation with microneurovascular anastomoses. If this problem is combined with that of a missing proximal source for reinnervation, end-to-side neurorrhaphy of the muscle nerve to a synergistic intact or sufficiently regenerated donor nerve is indicated. Distal end-to-side neurorrhaphy of a nerve graft to a nerve with some remaining function may be useful for reinforcement of clinically insufficient muscle function. If this technique does not result in an acceptable functional improvement, the distal end of the nerve graft can still be used for an additional muscle transplant with end-to-end nerve suture. So far, we have used this technique in two cases of incomplete facial paralysis, but not in the upper extremity.
Results Sensory recovery was obtained in the two patients with lesions of a digital nerve. The static two-point discrimination was 3.0 mm and the dynamic two-point discrimination was 2–3 mm in the areas of the fingers reinnervated by the endto-side neurorrhaphy, compared to 2 mm for static and dynamic two-point discrimination in the area supplied by the ‘donor’ nerve. The stem of the median nerve served as a donor for the ulnar side of the replanted thumb of a 12-yearold girl (Fig. 1), and the radial finger nerve for the avulsed ulnar finger nerve in a 42-year-old man after a circular saw injury.
Table 1 Clinical cases of end-to-side neurorrhaphy in the upper limb. Patient Age Sex Diagnosis (lesion) Reconstruction Follow- Result number (years) up (months) 1 12 F Avulsion/amputation Replantation, end-to- 48 Static 2-point left thumb side neurorrhaphy of discrimination avulsed ulnar digital 3 mm nerve to median nerve Dynamic 2point discrimination 2–3 mm 2 42 M Avulsion right ring Revascularization, 37 Static 2-point finger end-to-side discrimination neurorrhaphy of 3 mm avulsed ulnar to radial Dynamic 2digital nerve point discrimination 2–3 mm Replantation, end-to- 18 Protective 3 10 M Amputation left sensibility in upper arm, avulsion side neurorrhaphy of
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roots C8 and T1, lower trunk to root comminuted fracture C7, open reduction, left forearm internal fixation radius and ulna M Soft tissue sarcoma Resection/amputation, 8 proximal right upper replantation by arm shortening
4
43
5
34
F
Recurrence of malignant nerve sheath tumour right thoracic wall
6
41
F
Chondrosarcoma right humeral head
7
28
M Osteosarcoma left elbow
Resection (including 4 root T1), soft tissue reconstruction using latissimus dorsi myocutaneous flap, end-to-side neurorrhaphy root T1 to C8 Resection, including 3 posterior cord and musculocutaneous nerve; anatomic reconstruction of posterior cord and motor branch to biceps muscle (nerve grafts), end-to-side neurorrhaphy lateral cutaneous antebrachial nerve to median nerve Resection, elbow joint 29 prosthesis, latissimus dorsi musculocutaneous flap for soft tissue coverage and to reconstruct wrist and finger extension, endto-side neurorrhaphy
all fingers, no motor function
Progression Tinel sign to elbow level, patient died 11 months postoperatively from lung metastases Time since reconstruction too short for clinical signs of reinnervation
Time since reconstruction too short for clinical signs of reinnervation
Wrist and finger extension M3– 4
End-to-side neurorrhaphy
Patient Age Sex Diagnosis number (years) (lesion) 8
29
F
Longstanding brachial plexus lesion right side (part, C7, avulsion C8/T1)
9
32
M Volkmann’s contracture left forearm
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of muscle nerve to radial nerve Reconstruction
Follow- Result up (months) Free functioning 13 Thumb gracilis muscle and finger transfer to reconstruct flexion finger flexion, end-toM3 side neurorrhaphy of muscle nerve to median nerve (branch to pronator muscle) Free functioning 38 Excellent latissimus dorsi wrist and muscle transfer to finger reconstruct wrist and flexion (M4) finger flexion, end-toside neurorrhaphy to median nerve, neurolysis of median nerve
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Figure 1 Sensory reinnervation of the ulnar pulp of a replanted thumb by end-to-side neurorrhaphy of the avulsed finger nerve to the median nerve in a 12-year-old girl. (a) Amputation of the left thumb by the bridle while falling from the back of a horse. (b) Full functional recovery 4 years after replantation (c). Ninhydrin test shows good recovery of sudomotor function on both sides of the replanted left thumb (right finger print), compared to the normal right thumb (left finger print). (d) Potential deducted after electric stimulation at the ulnar side of the thumb (R4, orthodromic sensory conduction of finger nerves, stimulus application to the finger nerves percutaneously, recording at the wrist, 16 signals averaged) shows good sensory nerve function equal to the result after reinnervation by end-toend suture of the radial thumb nerve (R2). Because of the extremely long distances involved in the nerve regeneration, the results of two of the patients are not available 8 months and 18 months after replantation at the upper arm level. In both the replanted arms progression of the Tinel sign has been observed, and in the case of the 10-year-old boy useful sensory and motor reinnervation could be observed 18 months after replantation. In major limb replantations and in cases of reconstruction of the brachial plexus it is difficult to identify the part of reinnervation resulting from end-to-side neurorrhaphy through the avulsed roots of the plexus, if endto-end coaptation of disrupted parts of the plexus has been performed at the same time.
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However, the patients did not suffer any disadvantages by the additional end-to-side neurorrhaphies. One latissimus dorsi myocutaneous flap for functional reconstruction after tumour resection—end-to-side to the radial nerve for improvement of elbow, wrist and finger extension
Figure 2(a–d)
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Figure 2(e–h) Reconstruction, with soft tissue coverage of an elbow prosthesis and of motor function for elbow, wrist and finger extension, by a free myocutaneous latissimus dorsi flap with end-to-side neurorrhaphy of the thoracodorsal nerve to the radial nerve. (a) Soft tissue deficit at the left elbow in a 22-year-old man, who had a radical resection of an osteosarcoma and implantation of an elbow prosthesis. (b) The extensor function was not enough to extend the elbow against weight or to open the hand for grip (maximal extension). (c) Myocutaneous latissimus dorsi flap with the neurovascular anastomoses completed (white loop around the radial nerve). (d) Detail of the end-to-side neurorrhaphy of the muscle nerve to the radial nerve. (e,f) Good soft tissue coverage of the left elbow and good extensor function at the elbow, wrist and fingers 2 years after the operation. (g,h) Significant improvement of the extensor function with opening of the hand for the grip. (Fig. 2)—resulted in a clinically useful function with contraction against gravity and resistance graded M3 to M4 (muscle power graded M0-M5 using the Highet scale adopted by the British Medical Research Council, Tubiana and Masquelet, 1988). Hence a functional upgrading of the region of tumour resection could be achieved besides a stable soft tissue coverage. The gracilis muscle transplant in a 32-year-old woman and the latissimus dorsi muscle transplant in a 28-year-old man (Fig. 3), both reinnervated by end-to-side neurorrhaphy to
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the median nerve showed good restoration of finger flexion after complete loss by Volkmann’s contracture (M3 and M4).
Discussion Our growing experience with the clinical application of end-to-side neurorrhaphy shows clearly that this technique is reliable and clinically useful results can be expected for motor as well as for
Figure 3 Successful reinnervation of a myocutaneous latissimus dorsi flap in a 32-year-old man by end-to-side neurorrhaphy. (a) Ischaemic contracture of the left lower arm, the fingers fixed in a severe flexion contracture. (b,c)
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2 years after muscle transplantation and endto-side suture of the thoracodorsal nerve of the muscle graft to the median nerve. The blockade of extension had been removed (b), and strong finger flexion became possible by a well contracting muscle transplant (c). Reproducible, polyphasic motor unit potential and stable late component corresponding to a reinnervation potential in an MNC record of the transplanted muscle reinnervated by end-toside neurorrhaphy. Duration 27 msec, amplitude 360 µV, latency for 10 cm between stimulation site at the median nerve and recording site 2.8 msec. sensory reinnervation. Considering the fact that we have been using end-to-side neurorrhaphy so far in situations where a proximal nerve stump was not available for nerve reconstruction, the results obtained mean a significant improvement of the overall functional outcome of nerve reconstructions. This additional option is going to change fundamentally the concepts of recon structive surgery of the peripheral nerves (Frey et al 1998) and broadening the indications for end-to-side neurorrhaphy might show results that compete with end-to-end coaptation or endto-end nerve graft interpositioning. In literature, the reported results of the end-toside neurorrhaphy vary between complete failure (Kayikcioglu et al 2000) and excellent reinnervation (Franciosi et al 1998, Kostakoglu 1999, Mennen 1999, Rapp et al 1999, Yoleri et al 2000). The majority of reports are now positive. Yoleri et al (2000) performed end-to-side neurorrhaphy of the facial nerve to the hypoglossal nerve in four patients with varying success. Sensory reinnervation by end-to-side neurorrhaphy of the palmar digital nerves of thumb and index finger to the superficial branch of the radial nerve could be achieved by Rapp et al (1999) This study also includes cases with end-to-end suture of the donor and recipient nerves, and did not show superiority of the end-to-end technique compared to the end-toside technique. In contrast, Santamaria et al (1999) found better results by end-to-end nerve suture compared to end-to-side nerve suture, when they connected the sensory nerve of the radial forearm flap to the lingual nerve. Some useful protective sensibility is reported for a median nerve by Kostakoglu (1999), when the distal part was put end-toside to the ulnar nerve because of a 35 cm defect in the median nerve. The positive role of end-toside nerve reconstructions in brachial plexus lesions is difficult to evaluate in the overall functional end result. When Viterbo et al (1995) described a promising case of brachial plexus reinnervation by nerve grafts sutured end-to-side to the phrenic nerve and end-to-end to C5 and C6 in 1995, Dellon (1996) criticized the unscientific follow-up of this case report. In the meantime, the number of publications on successful applications of the end-to-side neurorrhaphy in brachial plexus reconstructions continues to grow (Franciosi et al 1998, Mennen 1999). Although some important questions on endto-side neurorraphy can be answered by several experimental studies, many questions remain: How does the end-to-side neurorrhaphy function? Is an epineurial window enough, or could better results be obtained by cutting a perineurial window? What are the decisive factors during the selection of the donor nerve? What is the role of the target? And is the spinal cord level of the donor and the recipient nerve of any importance?
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Our own experimental studies (Giovanoli et al 2000) showed that end-to-side neurorrhaphy is accompanied by a significant increase of the total number of the peripheral donor nerve fibres. The end-to-side contact seems to be a strong stimulus for collateral sprouting in the area of the end-to-side nerve suture. Because the number of nerve fibres remained constant in the distal donor nerve segment and there was no functional deficit measured in the muscles innervated by the donor nerve, in our opinion, retraction of the donor nerve fibres from their targets is not a precondition for a successful functional contact of the sprouting fibre with its new and additional target. Our findings are supported by Kanje et al (2000) who showed double-labelled sensory and motor neurons after end-to-side suture. This indicated that collateral sprouting was induced by a nerve segment sutured end-toside to the intact rat sciatic nerve. Tham and Morrison (1998) considered the severed proximal nerve as a source for fibre growth into the endto-side connection. This mechanism might be relevant in our clinical cases with avulsed nerves, but the aim of an excellent clinical result was met anyway, independently from the origin of the regenerating fibres. Cutting a perineurial window means trauma to at least some of the nerve fibres of the donor nerve and should ideally be prevented. From our experimental studies as well as from clinical experience we know that an epineurial window is satisfactory and preservation of the perineurium does not prevent acheivement of excellent results with end-to-side nerve suture. A comparative study of Viterbo et al (1998) did not show any difference between the two techniques, although Okajima and Terzis (2000) and alQuattan and al-Thunyan (1998) stress the necessity of a perineurial window. In experimental studies in rats Lutz et al (2000a) demonstrated the importance of the preference of agonistic nerves as donors to prevent co-contractions. The authors could show that concentration of end-to-side reinnervation to a single muscle is more effective than reinnervation of a group of different muscles (Lutz et al 2000b). Their experimental findings correlate well with our clinical experience (Frey et al 1998, Frey 2000). Further considerations arise from the results of an experimental study of Zhang et al (1998) They showed that end-to-side neurorrhaphy is unsuccessful if donor and recipient nerves are originating at different spinal cord levels. Further possibilities for clinical application of the end-to-side nerve suture were presented by Viterbo et al in 2000 in cross-face nerve grafting with end-to-side neurorraphy on the healthy and the paralysed side. Improvement of mimic function in nine of 10 cases is difficult to believe, if one considers the fact that all patients suffered from a palsy lasting more than 1 year which can be rarely reanimated by the end-to-end cross-face nerve grafting technique without the need of an additional free muscle transplant. A further group of 14 patients showed some successful recovery of sensory function after an ‘embracing suture’ of the rectus abdominis nerve to the fourth intercostal nerve during breast reconstruction with a TRAM flap. Fifty per cent of the patients achieved a reasonable degree of sensation in the flap. Finally the authors reported a case of successful reinnervation of the sacral region in a paraplegic patient by nerve grafts connected end-to-side to the eleventh intercostal nerve. We could include the results of three patients after motor reconstruction by a free functional muscle transplant reinnervated by end-to-side neurorrhaphy in this chapter. To our knowledge, this is the first report on the clinical application of end-to-side neurorrhaphy for reinnervation of a free muscle transplant. In one case radical tumour
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resection included a functional group of muscles leaving a nerve with some peripheral function behind. Two other patients had lost the majority of flexor function in the lower arm by ischaemic contracture. The remaining function was not clinically relevant (M2), but should certainly not be reduced by the operation. We used end-to-side neurorrhaphy to the main trunk of the nerve originally responsible for the absent motor function. By that we could retain the remaining partial motor and sensory function of the nerve. Combining muscle transplantation with end-to-side neurorrhaphy the motor function was upgraded in all three patients. Having achieved a clinically relevant motor function of M3 or M4 in all muscle transplants and having done no harm to any of the donor nerves, we are thinking of using the end-to-side technique more frequently for reinnervation of a muscle graft.
Conclusions Although the indications for the end-to-side nerve suture are still limited to cases with otherwise poor prognosis, these are described more clearly: • Proximal avulsion leaving the main nerve trunk in continuity. • Missing proximal nerve stumps. • Partial recovery after nerve reconstruction. • Shortening of long distances necessary to be covered by the regenerating nerve axons. • Prevention of long nerve grafts in proximal lesions. • Functional muscle transplantation. The degree of restoration of motor or sensory function by end-to-side neurorrhaphy depends on some crucial factors like selection of the proper agonistic donor nerve, minimizing donor nerve trauma by cutting only an epineurial window into the nerve, and an attempt to be highly selective with respect to sensorimotor and topographic differentiation. The results of our study show that end-to-side neurorrhaphy is an efficient method of motor or sensory reinnervation. Especially, this technique is reliable in combination with a free functional muscle transplantation and leads the way for new possibilities for neuromuscular reconstruction even in cases when useful function cannot be achieved by nerve reconstruction alone.
Acknowledgements The authors wish to thank Dr Doris Burg, neurologist at the Division of Reconstructive Surgery at the University Hospital at Zurich, and Dr Tatjana Paternostro-Sluga, specialist in electroneurodiagnostic follow-up studies, at the Department of Physical Medicine and Rehabilitation at the University of Vienna, for their detailed electroneurodiagnostic studies in our patients. Through their work an objective evaluation of the results of endto-side neurorrhaphy became possible independently from the surgeons treating the patients. Mag Susanne Friedl was very helpful in preparing the manuscript, for which we would like to thank her.
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Our research work on experimental muscle transplantation using end-to-side neurorrhaphy was possible because of the sponsorship of the Oesterreichische Nationalbank (Grant Number 7791). The laboratory for picture and movement analysis at our department is dedicated to objective evaluation of regained motor function after reconstructive surgery. Our work is supported by a generous research grant by the Austrian Federal Ministry of Education, Science and Culture (Project Number GZ 308.974/4-III/2a99), for which we are most grateful. This grant supports multicentre studies and further developments within the International Registry for Neuromuscular Reconstruction in the Face.
References al-Qattan MM, al-Thunyan A (1998) Variables affecting axonal regeneration following end-to-side neurorrhaphy, Br J Plast Surg 51:238–42. Ballance CA, Ballance HA, Stewart P (1903) Remarks on the operative treatment of chronic facial palsy of peripheral origin, BMJ 1:1009. Dellon AL (1996) Nerve grafting and end-to-side neurorrhaphies connecting phrenic nerve to the brachial plexus, Plast Reconstr Surg 98:905. Franciosi LF, Modestti C, Mueller SF (1998) Neurotization of the biceps muscle by endto-side neurorrhaphy between ulnar and musculocutaneous nerves. A series of five cases, Chir Main, 17:362–7. Frey M (2000) Avulsion injuries to the brachial plexus and the value of motor reinnervation by ipsilateral nerve transfer, J Hand Surg (Br) 25:323–4. Frey M, Girsch W, Giovanoli P (1998) [Possibilities for reconstruction in brachial plexus paralysis: neurotization], Langenbecks Arch Chir Suppl Kongressbd 115:550–3. Giovanoli P, Koller R, Meuli-Simmen C et al (2000) Functional and morphometric evaluation of end-to-side neurorrhaphy for muscle reinnervation, Plast Reconstr Surg 106:383–92. Harris W, Low VW (1903) On the importance of accurate muscular analysis in lesions of the brachial plexus; and treatment of Erb’s palsy and infantile paralysis of the upper extremity by cross-union of the nerve roots, BMJ 2:1035. Kanje M, Arai T, Lundborg G (2000) Collateral sprouting from sensory and motor axons into an end-to-side attached nerve segment, Neuroreport 11:2455–9. Kayikcioglu A, Karamursel S, Agaoglu G, Kecik A, Celiker R, Cetin A (2000) End-toside neurorrhaphies of the ulnar and median nerves at the wrist: report of two cases without sensory or motor improvement, Ann Plast Surg 45:641–3. Kennedy R (1901) On the restoration of coordinated movement after nerve crossing, with interchange of function of the cerebral cortical centers, Philos Trans R Soc Lond B Biol Sci 194:127. Kostakoglu N (1999) Motor and sensory reinnervation in the hand after an end-to-side median to ulnar nerve coaptation in the forearm, Br J Plast Surg 52:404–7. Lutz BS, Chuang DC, Hsu JC, Ma SF, Wei FC (2000a) Selection of donor nerves—an important factor in endto-side neurorrhaphy, Br J Plast Surg 53:149–54.
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Lutz BS, Ma SF, Chuang DC, Wei FC (2000b) Role of the target in end-to-side neurorrhaphy: reinnervation of a single muscle vs multiple muscles, J Reconstr Microsurg 16:443–8. Mennen U (1999) End-to-side nerve suture—a technique to repair peripheral nerve injury, S Afr Med J 89:1188–94. Okajima S, Terzis JK (2000) Ultrastructure of early axonal regeneration in an end-to-side neurorrhaphy model, J Reconstr Microsurg 16:313–23; discussion 323–6. Rapp E, Lallemand S, Ehrler S, Buch N, Foucher G (1999) Restoration of sensation over the contact surfaces of the thumb-index pinch grip using the terminal branches of the superficial branch of the radial nerve, Chir Main 18:179–83. Santamaria E, Wei FC, Chen IH, Chuang DC (1999) Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction by using different recipient nerves, Plast Reconstr Surg 103:450–7. Sherren J (1906) Some points in the surgery of peripheral nerves, Edinb Med J 20:297. Tham SK, Morrison WA (1998) Motor collateral sprouting through an end-to-side nerve repair, J Hand Surg (Am) 23:844–51. Tubiana R, Masquelet AC (1988) Functional classification of the upper limb paralyses, Hand Clin 4:557–62. Viterbo F, Trindade JC, Hoshino K, Mazzoni Neto A (1992) Latero-terminal neurorrhaphy without removal of the epineurial sheath. Experimental study in rats, Rev Paul Med 110:267–75. Viterbo F, Trindade JC, Hoshino K, Mazzoni A (1994a) Two end-to-side neurorrhaphies and nerve graft with removal of the epineural sheath: experimental study in rats, Br J Plast Surg 47:75–80. Viterbo F, Trindade JC, Hoshino K, Mazzoni Neto A (1994b) End-to-side neurorrhaphy with removal of the epineurial sheath: an experimental study in rats, Plast Reconstr Surg 94:1038–47. Viterbo F, Franciosi LF, Palhares A (1995) Nerve graftings and end-to-side neurorrhaphies connecting the phrenic nerve to the brachial plexus, Plast Reconstr Surg 96:494–5. Viterbo F, Teixeira E, Hoshino K, Padovani CR (1998) End-to-side neurorrhaphy with and without perineurium, Rev Paul Med 116:1808–14. Viterbo F, Sanches J, RW (2000) In: Frey M, Giovanoli P, Koller R, eds. Fifth International Muscle Symposium. Vienna, pp. 151. Yoleri L, Songur E, Yoleri O, Vural T, Cagdas A (2000) Reanimation of early facial paralysis with hypoglossal/facial end-to-side neurorrhaphy: a new approach, J Reconstr Microsurg 16:347–55; discussion 355–6. Zhang F, Cheng C, Chin BT et al (1998) Results of termino-lateral neurorrhaphy to original and adjacent nerves, Microsurgery 18:276–81.
Tendon defect repair
16 Conventional tendon grafting Antonio Landi, Giuseppe Caserta, Norman Della Rosa and Andrea Leti Acciaro
History A clear distinction between tendons and nerves was made at the end of the nineteenth century. In ancient Greek culture the word ‘neuron’ was attributed both to nerves and to tendons and its heritage might occasionally explain why, even in contemporary times, tendons might be erroneously connected to nerves in the emergency setting. Apparently Heuck (1881), a general surgeon, was the first to perform a tendon graft to repair the extensor pollicis longus (EPL). Soon after, at the Surgical Society of Paris, Peyrot (1886) reported a case of ‘transplantation’ of a tendon of a dog in a man to replace the flexor tendon of the middle finger. The related experimental work was extensively carried out in Germany at the beginning of the twentieth century by Lange (1900). Mayer (Mayer 1916a–c, Mayer and Ransohoff 1936), who had worked in Munich under the supervision of Lange, published several articles on tendon transplantation. His clinical experience was mainly confined to the lower limbs and the corresponding pioneering work on the upper limb was initiated by Sterling Bunnell in San Francisco and summarized in his first article on tendon repair in fingers published in 1918 (Bunnell 1918). Tendon allografts have been routinely used in Europe by Iselin (1975) and by several European surgeons who had their training in Nanterre. For many years, in fact, Iselin has advocated the use of acellular grafts preserved in a mercurial solution of 1 g of Cialit in 5 l of sterile water (Iselin 1975, Tubiana 1997). This technique maintained its popularity for quite a long while and was finally banned within the Common Market of the European Community. Reconstruction of the pseudo-sheath in presence of severe tendon damage is based on the earlier work of Biesalski (1910). Mayer and Ransohoff (1936) used celloidin tubes as implants and stainless steel implants were introduced by Milgram (1960); Carrol and Bassett (1963) were able to show that a flexible silicone rubber rod could be safely implanted in a scarred tendon bed to reconstruct the flexor tendons of the hand. In the early 1950s tendon grafting was the elective procedure for flexor tendon lesions in ‘no-man’s land’ as a consequence of relinquishment to proceed to primary repair within this anatomical boundary. Bunnell’s (1918) advice to close the skin, wait for the wound to heal, and then perform secondary grafting become a dogma for generations of surgeons (Graham 1947, Littler 1947, Boyes 1950, Pulvertaft 1956, Tubiana 1960). The state of the art of this commonly shared surgical attitude was summarized in the outstanding presentation delivered by JH Boyes on February 15, 1950 at the American Academy of Orthopedic Surgeons in New York (Boyes 1950). Out of a total of 138
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grafts, although nearly 90% of the cases in the ‘good’ group achieved flexion to within one inch of the distal palmar crease, less then half of those having stiff joints and only a quarter of the ‘cicatrix’ group obtained such a good degree of flexion (Boyes 1997). Technical advancement would soon also improve the outcome even in these less favourable groups. In 1965, and later in 1971 along with Salisbury, Hunter first published his personal experience with a tendon implant (Hunter and Salisbury 1971, Schneider 1997a,b). In a staged technique the severely damaged flexor tendons were excised and the flexor apparatus reconstructed with a new sheath prepared around a silicone Dacron reinforced implant. This paper is considered a milestone in the field of flexor tendon reconstruction, and the corresponding procedure has thereafter been universally attributed to Hunter. The pedicled tendon graft was described by Paneva-Holevich from Sofia in 1965 (Paneva 1987). This procedure was apparently first done in Bulgaria in April 1964 in a male patient with a complex lesion involving the skin and flexor apparatus of the index and middle fingers. Skin coverage was accomplished by a pedicled flap and the proximal stump of superficial and profundus flexor tendons were sutured to each other. Two months later the superficialis flexor tendon was transferred as a pedicled graft to replace the sublimis function whilst fusing the distal interphalangeal (DIP) joint. The same technique had already been extensively used by DM Brooks at the Royal National Orthopaedic Hospital in London, but was never published. The Hunter active tendon prosthesis, which allows the transformation of a two-stage technique into a potentially one-stage technique, might be considered a further step forward, but it has not gained sufficient acceptance and consensus for any conclusions to be drawn (Hunter and Salisbury 1997, Hunter et al 1997). A further attempt to reduce the length of a staged procedure was made by the introduction of the vascularized tendon graft, which is not adversely influenced by the unfavourable condition of the recipient bed and might therefore be utilized as a single stage procedure.
Repair of flexor tendon defects Severe post-traumatic defects of tendons are usually associated with complex lesions in the upper limb. Preliminary ancillary interventions on skin or contiguous anatomical structures (bones, joints) have usually been anticipated to attempt, at a later stage, to reestablish the active motion of the finger (Landi et al 1997 a,b, 2002). Secondary reconstruction is also indicated when primary tendon repair has failed or has been delayed due to infection (Bishop et al 1996). Exposure of the tendon per se has detrimental effects on tendon metabolism and adds to the risk of contamination (Landi 1973). Clinical examination of the affected hand is mandatory as, in presence of still unresolved problems (neuroma, sensation deficit, joint stiffness), adequate treatment prior to tendon grafting is essential. Furthermore, the nature of the associated joint contracture (flexion or extension contracture) has to be clearly defined. In fact, one might have to deal with stiffness in the presence of a radiologically preserved single joint, derangement of a limited sector of one joint surface, derangement of an entire joint surface, or
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complete disruption of the joint. The presence of joint stiffness will deeply influence further decisions (Landi et al 1997b, 2002). In the presence of irreversibly damaged DIP joint, reconstruction of the flexor digitorum profundus is unnecessary and the flexor superficialis finger should be considered as a salvage procedure (Schneider et al 1987). Prerequisites Fractures need to be well reduced and healed, and non-union already treated with restoration of passive mobility of digital joints before tendon grafting can be considered (Bishop et al 1996, Landi et al 1997a). Circulation must be adequate, even more so when profundus tendon grafting is to be carried out in replanted fingers or hands. Before the operation it is advisable to obtain a Doppler study on the patency of the sutured vessels. Moreover, the original surgical notes must be carefully consulted, any available drawings examined and particular attention paid to ascertain if vessel shifting has been carried out (Landi et al 1985, 1997a). Flexor tendon grafting in replanted fingers that have had vascular complications but finally survived, usually do not have favourable outcomes (Landi et al 1985). Sensation must be adequate and at least one digital nerve must have been repaired. Neuroma must be treated by conventional nerve or interposed vein grafting as a painful digit will poorly exploit restored mobility. Flexion deformity of the proximal interphalangeal (PIP) joint and metacarpophalangeal (MP) joint or at the wrist joint level might be caused by both intrinsic and extrinsic factors. A fixed deformity might be caused by soft tissue contracture due to thermal injury or a deep infection following flexor tendon repair. Joint release before tendon grafting can result in a skin defect. Therefore, the surgical approach to the extrinsic or intrinsic structures of a joint varies according to the condition of the overlying skin. In the presence of hypomobile skin, or longitudinally contracted skin a Z plasty or V–Y advancement flap is sufficient (Landi et al 1997a,b, 2002). When a skin gap ≥1 cm is anticipated a lateral transposition flap is often sufficient (Bruser et al 1999). In more extensive skin defects we tend to select the flap described by Malek or a similar version described by Kleinman (1996). Cross-finger flaps, or flaps from the neighbouring digits are only performed in the presence of a significant skin defect when a volar release has to precede a staged flexor tendon reconstruction. Flexion deformity of the MP joint, when caused by skin scarring or contracture, in most cases can be treated with full thickness skin grafts. When subcutaneous padding is absent a flap must be considered. We agree with Foucher (1997) that there is no standard flap for the palm which provides a supple and thin skin. A fascial flap plus grafting might be a reasonable compromise. Flexion contracture at the wrist usually requires release and coverage by a regional, axial flap (based on perforator flap) or a free flap (Landi et al 1980b). The level of injury of the flexor tendons is also important (Fig. 1). Flexor tendon grafting might be performed for injuries which have occurred from zone I (the area distal to the insertion of the flexor digitorum superficialis (FDS)) to zone V, where the main nerves and feeding vessels to the hand are concentrated. Age and compliance with postoperative rehabilitation are also crucial. In younger patients any secondary procedure on the tendon should be postponed until the child is
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capable of playing a more active role (Bishop et al 1996, Osterman and Paksima 1997). The best results are obtained between the ages of 10 and 30 years (Bishop et al 1996, Boyes 1997). In our view, flexor tendon grafting is therefore not indicated under the age of 10 years with the exception of the FPL.
Figure 1 Classification of cases In order to select the most appropriate technique for tendon grafting and to provide reliable outcome studies the following criteria have been suggested by Boyes (1997) and have been universally adopted (Hunter and Salisbury 1971, 1997, Paneva 1987, Sakellarides 1987, Hunter et al 1997). 1. Good: This represents the ideal group, with minimal scarring of the skin and soft tissue, good supple joints, no ligamentous or capsular contractures, and no major trophic changes due to nerve damage. The loss of function of one digital nerve is not considered detrimental. 2. Cicatrix: This group includes cases in which there was scarring after injury or because of incorrect incisions, or in which a deep cicatrix followed infection after attempted primary repair. The contractures usually result from deep scar tissue rather
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than from joint stiffness. In a few instances a preliminary Z plasty is performed or a pedicle flap is applied to repair the soft tissue damage before tendon reconstruction is carried out. 3. Joint damage: Cases are classed in this group when the range of passive motion of an interphalangeal (IP) joint is restricted. Rehabilitation is mandatory and free passive motion, as far as possible, must be obtained before the tendon is reconstructed. 4. Nerve damage: This represents a small group, limited to those cases in which damage to the major nerve trunk caused trophic changes in the fingers and results in shiny skin and secondary stiffness of the joints. In some instances the major nerve damage is repaired, and the tendon is reconstructed after nerve regeneration has taken place. 5. Multiple damage: When tendon damage is not confined to one digit, an attempt is made to reconstruct all the damaged tendons in one operation. Many of these cases are complicated by other factors, such as cicatrix and joint stiffness. Selection of the reconstructive procedure Several options are available to repair a severe tendon defect. The following criteria and considerations are applicable both to extensor and to flexor tendons. Intercalated tendon graft Intercalated tendon graft between the distal stump and the corresponding muscle can be accomplished provided that free gliding is present in the entire unit and no irreversible changes, such as myostatic contracture are present. This is more likely in proximal lesions (zone V of flexor tendons; Fig. 1) and zones VI and VII of extensor tendons (Fig. 2), where retain
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Figure 2 ing structures such as vincula, junctura tendinum, intertendinous connections are absent. Static and dynamic sonography are usually helpful to locate the proximal stump and assess the corresponding excursion. Selection of a neighbouring motor This routinely applies to flexor tendon reconstruction in ‘no-man’s land’, when both the superficialis and profundus tendons have been injured. Only one tendon will be reconstructed and the proximal connection is usually made at the palm and wrist to the corresponding profundus.
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Figure 3 The end to side suture This is a sort of compromise but can provide excellent outcomes. It implies that the distal tendon is sutured to an intact neighbouring one. This technique is often selected for multiple pathological ruptures linked to inflammatory diseases, such as rheumatoid arthritis, but is also indicated in older patients who may not tolerate staged reconstructive procedures. The suture can be successfully placed for the flexor tendon both in the palm and the wrist. For the extensor tendon this procedure is more frequently carried out on the dorsum of the hand (Fig. 3). Tendon transfer When the injury has occurred in the palm or wrist, transfer of an adjacent FDS might be considered as an alternative to grafting as this involves only a single tendon suture (Bishop et al 1996). In large tendon defects mainly on the dorsum of the hand, the tendon transfer—usually extensor indicis proprius (EIP) and extensor digiti minimi (EDM)— might not reach the recipient tendon and should be extended with a tendon graft (see Case 1 Figs. 1-8, 1-9 later in this chapter).
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Tendon prosthesis Hunter has pioneered the idea of an active tendon prosthesis fixed distally by bone ingrowth and proximally to a musculotendinous unit with the aim of providing active motion of the corresponding digit within a reasonable span of time. The implant is constructed of silicone rubber with a Dacron core ending proximally in a loop and distally in a small plate. This will potentially remain as a permanent prosthesis (Bishop et al 1996, Hunter and Salisbury 1997, Hunter et al 1997). Tendon allograft or xenograft No consolidated clinical experiences support the routine application of tendon allograft and xenograft (Bishop et al 1996, Tubiana 1997). Selection of the graft Many factors affect selection of the graft: locally available material (Boyes 1997), required tendon length, calibre, facilities for harvesting, anaesthesiological implications, anatomical variations (Bishop et al 1996), possibility and adequate skills for harvesting vascularized grafts and use of a synovial versus extrasynovial tendon (Seiler and Gelberman 1997). Biological considerations • The following conclusions have been drawn from experimental data emerging from research conducted in the rabbit intrasynovial flexor tendon: • Blood flow in flexor tendons is related to metabolic activity and young animals possess a higher lactate dehydrogenase (LDH) activity as compared to tenocytes from the adult animal. • The tendon transplanted in the knee joint possesses intrinsic capacities for healing (Lundborg 1976). • The repaired tendon might survive in the knee joint as a floating structure, but to function properly blood supply is crucial except for some anatomical areas of the tendon, such as on the volar aspect where the synovial nutritional pattern might prevail (Landi et al 1980a, 1997a). • In the canine model extrasynovial (peroneus longus) and intrasynovial (flexor digitorum profundus (FDP)) tendon grafts to replace injured flexor tendons were compared (Seiler and Gelberman 1997). Intrasynovial grafts were completely incorporated with preservation of the gliding surface. In contrast, tenocyte necrosis and obliteration of the gliding surface from peripherally ingrown adhesions were observed in the extrasynovial graft. DNA content and intravital staining using calcium-AM and ethidium-bromide clearly showed survival of the original tenocytes only in the intrasynovial specimen. • Light microscopy and ultrastructural morphology of the normal chicken and human flexor tendon sheath unit (Salamon 1997) confirmed the presence of two types of
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synovial cells: type A presenting at a different level of the synovium with phagocytic activity; and type B with the features of secretory cells. The same findings have been confirmed in specimens taken from the pseudo-sheath 6 weeks after replacing silicone implants by autologous tendon grafts. Thus, the cumulative evidence suggests that the intrasynovial flexor tendons are best replaced by intrasynovial tendon grafts (Gelberman et al 1992, Seiler and Gelberman 1997). Sources of tendon grafts Palmaris longus: Easily harvested from the ipsilateral forearm, this represents the most frequent choice for palm to finger grafts. Its presence (85% of individuals) should be verified preoperatively by asking the patient to simultaneously flex the wrist and oppose the thumb to the small finger. Harvesting can be achieved through a short incision at the wrist areas using a Brand tendon stripper (Bishop et al 1996) (Fig. 4). Care should be taken to maintain the appropriate
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Figure 4 tension and ascertain the correct direction so as to avoid premature detachment. Plantaris longus: Present in more or less the same percentage of individuals as the palmaris longus. Unlike the palmaris, it cannot be clinically assessed preoperatively but can be identified by ultrasonography (Wilson 1985). The plantaris, which can reach a length of 18 cm, is harvested through an incision made on the medial border of the Achilles tendon (Tubiana 1965). The same precautions as for the palmaris longus should be taken when using a long Brand tendon stripper. According to Hunter, it can be harvested under local anaesthesia and sedation (Hunter and Salisbury 1997, Hunter et al 1997). Extensor digitorum longus of the toes: The long extensors of the central toes are routinely used when the palmaris longus and plantaris longus tendons are absent. They are usually harvested through multiple transverse incisions made distal to the level of the MP joint, and proximal to the conjunction with the corresponding extensor digitorum
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brevis (EDB) tendon (see Case 2 Figs 2-7, 2-8 later in this chapter). This is usually lacking for the fifth toe. Therefore, when needed, up to four grafts can be taken. The use of a tendon stripper might be dangerous at this level because of the numerous intertendinous connections. It is preferable to approach the graft by adding a transverse incision on the foot and a longitudinal incision proximal to the extensor retinaculum where each single tendon can be separated after dissection has been facilitated by passively flexing and extending the ankle. Flexor digitorum superficialis: This has been utilized as a pedicled graft by PanevaHolevich since 1965 (Paneva 1987). Its application as an intercalary profundus graft was routinely considered by Boyes (1997) and Tubiana (1997). The related work by Gelberman and Seiler (Gelberman et al 1992, Seiler and Gelberman 1997), in addition to improvement of tendon juncture techniques will probably create new interest for the use of this intrasynovial tendon, especially through the vascularized and pedicled version. Extensor proprius tendons: We do not usually consider these when selecting grafts but it should not be discounted because at least a good portion of the graft is intrasynovial (Bishop et al 1996). Flexor tendon grafting in zone II (Fig. 1) The standard technique of flexor tendon grafting Surgical exposure depends on previous scars and surgical approach. Whenever possible, a lateral incision is selected at a site less relevant for tactile function (Fig. 5, Tubiana 1965, Bishop et al 1996). When a Bruner incision was used in previous surgery this can be followed (Fig. 6a). When grafting procedures are undertaken in a replanted finger we use a mini-Bruner incision on the opposite site whenever a single artery repair was carried out (Fig. 6b). In the failed primary flexor tendon repair in zone II a curvilin-
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Figure 6a
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ear approach is made on the palm in such a way that the proximal suture of the graft does not coincide with the line of incision. At the wrist a curvilinear incision is made on the radial aspect for the grafting procedure of the flexor pollicis longus (FPL) and on the ulnar site for the FDP of the long fingers (Fig. 5). The incision through the subcutaneous tissue should be made exactly in the middle of the finger to avoid the repaired nerves and vessels with particular caution if arterial repositioning was carried out during the previous procedure (Landi et al 1997a). Tendon sheath isolation: From the centre the sheath can be easily isolated. Its damaged portion should be removed and release of flexors should then be started distally and proximally to converge in the damaged area. It is crucial to assess the condition of the superficialis. This might be intact, adherent, partially damaged or interrupted. In the presence of continuity accurate tenolysis should then be undertaken. Wherever possible, the sublimis might also be considered per se as a source for pulley reconstruction and tendon grafting (Paneva 1987, Bishop et al 1996, Boyes 1997, Tubiana 1997). Preservation of the number, location and width of the remaining annular pulleys is mandatory.
Figure 6b Assessment of the proximal stump is made through the palmar incision. The lumbrical muscles should be separated and the corresponding myotendinous unit mobilized. A passive excursion (average 3 cm) is sufficient to consider the proximal stump adequate for immediate or future attachment of the graft. When local conditions, due to inadequate skin padding, scarred bed, stiff proximal stump etc., are considered unfavourable, a staged procedure should be taken into consideration and the site of the proximal suture moved to the distal forearm. Distal fixation: In 1992, we mailed a detailed questionnaire regarding surgeons’ criteria for treating acute tendon lesions. The majority of surgeons considered the
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difficulty of repair of the extensor tendons of the fingers in ‘no-man’s land’ to be equal to that of the flexor tendons (Landi et al 1997a). A similar majority of surgeons from all continents indicated that the Bunnell pull-out suture, using wire as suture material, was the technique of choice for distal flexor tendon attachment. In adults this suture is performed first after the graft has been passed through the pulleys and the remnants of the sheath. The distal part of the profundus might be split into two parts. A small
Figure 7 cortical window is made just distal to its insertion. An oblique tunnel is prepared in the direction of the proximal third of the nail complex. Dorsal cortical penetration by the drill should be avoided. A 3-0 crisscrossed Bunnell monofilament type of suture is placed in the distal graft using a double long straight needle which will be passed through the tunnel to allow a suture to be placed through the nail bed distal to the lunula. When a monofilament is used the pull-out is not mandatory as when wire is selected as suture material (Boyes 1997). Additional 5-0 absorbable sutures are added to improve the tendon to bone and periosteum contact. Alternatively, distal attachment can be achieved without interfering with the nail bed with a bone anchoring device which still allows an end to end suture between the residual flexor tendon stump and the distal part of the tendon graft (Fig. 7). In children, one should bear in mind that, whilst the extensor tendon attaches to the epiphysis in both PIP and DIP joints, the flexor tendon attaches to the metaphysis and this is the anatomical area where the distal repair should be placed. The technique differs from the one adopted in adults in three basic ways: the bone tunnel is to be avoided, bone anchoring devices are contraindicated and any external device such as a felt pad and button should not be used. The graft is secured to the distal stump by a Bunnell type of suture using 5-0 synthetic braided material (Osterman and Paksima 1997). Side reinforcement is obtained by 6-0 or 7-0 extra sutures (Fig. 8). The graft is then passed along the palmar surface. The tendon will be cut flush with the skin and secured to it by rapid, absorbable 4-0 or 5-0 nylon suture. The pulp fixation method is now completed. The distal suture is performed first even in children. Proximal fixation: This type of repair is strictly related to the size of the donor graft. No differences in technique are required in children as compared to adults apart from the size of the suture material. A grasping suture is recommended for direct end to end repair. This is usually the case when the sublimis is selected both as a free (Boyes 1997) or pedicled tendon graft (Paneva 1987). The Pulvertaft weave technique is the most frequently utilized proximal repair (Paneva 1987,
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Figure 8
Figure 9 Schneider and Hunter 1993, Bishop et al 1996, Boyes 1997, Hunter and Salisbury 1997). It is the best method when a discrepancy exists in terms of size between the graft and recipient tendon. Palmaris longus, plantaris and toe extensors are the mostly commonly used tendon grafts. The stump is fish mouthed and the graft is usually double passed
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using a sharp tendon retriever. Proximal suture is secured by a synthetic braided suture (Fig. 9). There is unanimous consensus that tension, both in adults and in children, should be adjusted so that each finger is slightly more flexed than its radial neighbour (Paneva 1987, Bishop et al 1996, Boyes 1997, Osterman and Paksima 1997, Tubiana 1997). Preservation and reconstruction of the pulley system: The pulley system plays an important role in controlling the overall tendon excursion in the ideal, uninjured setting. The pulley system serves to prevent bow-stringing of the tendon across the volar aspect of the joint in flexion. The residual or reconstructed pulleys should not only be located appropriately, but should also be of the proper diameter to resist attenuation or breakdown (Schneider and Hunter 1993). At least two pulleys, A2 and A4, need to be retained or reconstructed (Bishop et al 1996, Nishida et al 1999) (see Case 3 Fig. 3-5 later in this chapter). In agreement with Schneider (1997a,b) we believe that, when possible, a three
Figure 10 or four pulley system should be aimed for (Fig. 10). As a general rule, since the reconstructed pulleys might interfere with volar plate or collateral ligament function, these should not be placed in correspondence with the MP and PIP joints. Ideally, one pulley should be placed proximally and distally to each joint requiring reconstruction (see Case 2 Fig. 2-3 later in this chapter). Weak pulleys should always be reinforced by a crisscrossed suture secured to the fibrous rim of the sheath. Pulley disruption might be encountered, especially during a single stage grafting procedure, since considerable forces act across pulleys. A 3 N (newtons) force at the fingertip may in fact create a 107 N force on a pulley (Hume et al 1991). Besides the number and location of the pulleys other factors are also important when considering pulley reconstruction, such as the tension and intrinsic structure of the grafting material and related biomechanics (Bishop et al 1996, Nishida et al 1999). The recommended proximal to distal width of a reconstructed pulley is
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Figure 11a approximately 5 mm (Doyle and Blythe 1975). Wider pulleys add strength that will allow earlier postoperative motion. Lin et al (1989) evaluated three methods of pulley reconstruction. The fibrous rim described by Weilby (1968), the palmar plate belt-loop described by Karev (1984), and the triple loop method described by Okutsu et al (1987) (Fig. 11a). Only the triple loop could withstand as much load (520 N) before failure as a normal pulley. The pulleys should also have adequate tension as they tend to loosen over time (Bishop et al 1996) without interfering with tendon gliding. As the flexor tendon–tendon sheath interaction is influenced by the nature of the graft (intrasynovial tendons producing, at least in vitro, less excursion resistance than extrasynovial tendons (Nishida et al 1999), the pulley reconstruction is deeply influenced by the nature of the grafting material. In vitro intrasynovial tissue sources (extensor retinaculum, volar plate and flexor superficialis tendon) have produced less excursion resistance than extrasynovial tissue sources (extensor digitorum and palmaris longus) (Nishida et al 1999).
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Figure 11b All the above factors should be considered before selecting the method of pulley reconstruction. Methods of pulley reconstruction Pulleys based on remnants: This is usually the first option when there is generally sufficient tendon material available to construct pulleys by free tendon grafts. These can be sutured to the rim or the periosteum. This type of pulley employs a suture on both sides—therefore, the folding residual anatomical structure should be equally reliable (Fig. 11b)(see Case 4 Fig. 4-1 later in this chapter). FDS tail: If FDS insertion remains intact (and this is often the case), this remnant can be utilized to reconstruct part of the A4 or A3 pulley. The tail must be securely fixed, and we prefer the criss
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Figure 12a cross type of suture using braided non-absorbable material anchored to the bone in a safe area, distally (for A4 reconstruction) (Fig. 11b) or proximally to the PIP joint (for A3 reconstruction). The single or multiple loop technique: The loop technique may be single, one and a half, double or triple. The graft encircles the phalanx and is secured to the sheath remnants or to bone by a bone anchor. An adequate length of tendon graft must be harvested since approximately 6–8 cm of tendon is required for reconstruction of one loop (Schneider and Hunter 1993). The loop will be placed underneath the extensor tendon and extensor retinacular system, both at the distal metaphysis of the metacarpal and at the proximal phalanx (Fig. 11a). The double or triple loop should be placed around the tendon or rod and secured with 3-0 multiple non-absorbable suture. To reconstruct the A4 pulley the graft is placed dorsal to the extensor mechanism at the base of
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Figure 12b the middle phalanx (Fig. 12). Under ideal circumstances a three-pulley system can be entirely rebuilt using palmaris longus as a graft in the following way: A2 using the double or triple loop technique; A3 using the FDS tail technique; and A4 using the single loop technique at the base of the middle phalanx. The extensor retinaculum: Lister (1979) popularized the use of the extensor retinaculum in place of the traditional tendon graft. It has a width of 10 mm, which is adequate for a pulley, and leaves sufficient retinaculum to avoid bow-stringing of the extensor tendons. The smooth undersurface of the retinaculum provides the best gliding surface for the flexor graft (Nishida 1999). It can either pass around a phalanx as one loop or be fixed to the rim remnant or to the bone by bone anchors. The drawbacks are the limited length and poor cosmesis of the donor area. The beltloop method uses the volar plate (Karev et al 1987) to reconstruct the A3 pulley. Whenever available, we prefer the FDS tail for this purpose. Furthermore, the most critical A2 and A4 pulleys are not reconstructed and adjunctive procedures are therefore needed. We introduced the ‘running pulley’ in cases of complex tenolysis with unsightly and disturbing bow-stringing in the palm following multiple flexor procedures. A2 and A4 pulleys are reconstructed following the same rules of the loop technique but in a continuous fashion. The two tails of the graft are secured to the phalanx or metacarpal bone by bone anchors (Fig. 12a, b). This technique allows early motion (Landi et al
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1997a, 2002) and leads to good functional results. It is now being used during the first phase of the flexor tendon grafting technique when the pulley system is extensively damaged. The wide availability of biological materials obviates the need for artificial materials to reconstruct the flexor retinacular system (Schneider 1997b). Techniques for flexor tendon grafting The single stage tendon grafting technique This is best indicated when the pulley system is preserved and the flexor sheath is minimally scarred. These criteria are usually met by the good group of Boyes’ classification (Boyes 1997, see above). In the clinical setting, single stage grafting is indicated in cases of unrepaired flexor tendons in ‘no-man’s land’, in cases of secondary rupture of partially lacerated flexor tendons, and in well-selected cases of delayed treatment for flexor profundus avulsion (see Case 5 Figs 5-1–5-3 later in this chapter). The surgical techniques for the distal and proximal repairs follow the guidelines described above. Rehabilitation: Rehabilitation is routinely started 10 days after surgery, when the skin has started to heal, minimizing the risks of skin dehiscence and infection. An extensive block splint is used for 4 weeks placing the hand in a safe position. A resting static splint both to prevent MP joint contracture and rupture of the graft at the attachment sites is worn while sleeping. During day time the scheduled exercise programme will follow both the Kleinert and Duran principles. The daily dynamic splint is removed at 4 weeks and rubber bands are connected to an armlet placed over the flexion crease for an additional 2 weeks. The resting splint is still worn at night. From the eighth week place-holding and active exercises start in sequence. Strengthening is allowed after 12 weeks. Early complications: Early breakdown at the proximal or distal attachments of the graft have been reported (Paneva 1987, Bishop et al 1996, Schneider 1997a). When rupture of a graft attachment is recognized promptly the procedure can often be salvaged by early reoperation. Ultrasound evaluation will facilitate locating the site of rupture. This complication occurs more commonly at the distal attachment, and, if the tendon cannot be advanced to the original site of attachment, to avoid the flexion deformity of DIP joint that inevitably follows, the end of the graft can be inserted into the middle phalanx creating the ‘superficialis finger’. A proximal attachment disruption is usually represented by slippage of the graft interweave in the distal forearm. Reattachment and salvage are often possible. Pulley breakdown is another issue and is diagnosed on reduction of the acquired range of motion with bow-stringing of the tendon graft. Blocking support by external pulleys might be helpful (Schneider 1997a) Late complications: Adhesions of the tendon graft will interfere with the potential overall excursion. Clinically the tenodesis site can be located only by flexing in sequence the wrist and the other joints (Landi et al 1997a,b) or by dynamic ultrasound. Tenolysis of the graft should then be considered and undertaken 6 months after the primary grafting procedure. It is advisable, when dealing with tendon grafting procedures, to describe them as staged procedures, and it should be clearly mentioned in the consent form
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presented to the patient that subsequent interventions might be required to achieve the best possible outcome. The staged tendon grafting techniques The flexor tendon sequelae of the ‘cicatrix’ and joint and nerve damage groups of the Boyes’ classification are amenable to treatment using the staged techniques of tendon grafting. As a prerequisite, any soft tissue problem, nerve and joint contracture should be addressed before embarking on such a demanding procedure, which is usually carried out in two stages. Two types of staged technique are followed at present: the Hunter (Hunter and Salisbury 1997) and the Paneva-Holevich (Paneva 1987) techniques. According to Boyes’ classification, for both options the patients should have undergone a complete rehabilitation programme and the best possible local condition should have been obtained. Joint and soft tissue contractures should be dealt with before carrying out the first stage of the procedure. Relevant sensory deficits and painful neuromas are the only conditions which might be treated during the first phase, as nerve grafting is compatible with the rehabilitation procedures required during stage one. Stage one: This is performed following the surgical step already described. It is important at this stage to leave a stump (0.5 cm) of the flexor tendon attached to the distal phalanx and to excise the scarred lumbrical to prevent the paradoxical motion occasionally seen after tendon grafting, which causes the finger to extend rather than flex as the patient attempts to flex the finger completely (the lumbrical plus sign is described by Parkes 1971). During this phase the tendon silicone implant is inserted after it has been passed through the retinacular system to re-establish a new functional tendon sheath. A precaution needs to be observed at this time: because silicone rubber is highly electrostatic and attacks airborne particles it should be kept immersed in saline on removal from the package and handled with atraumatic instruments. A ‘no touch’ policy must be adopted and, in any case, gloves should be washed intraoperatively with aseptic solution. Since the staged technique can seldom be performed in cooperative children to overcome growth retardation caused by non-use of a digit, a variety of rods ranging from 2 mm to 6 mm is available. The implant is passed through the residual sheath in a proximal to distal direction. The distal end of the prosthesis is sutured beneath the stump of the profundus (see Case 2 Fig. 2-3 later in this chapter). A figure-of-eight suture of monofilament on atraumatic taper-cut needle is used. Careful assessment at the palm or distal forearm has to be made so that the implants glide freely without binding or buckling (Hunter and Salisbury 1997) by passively flexing and extending the fingers (see Case 2 Fig. 2-4 later in this chapter). The short rod is selected for an unscarred palm, otherwise a long rod should be inserted through the carpal canal to glide freely in the proximal area. Following skin closure a standard postoperative dressing is applied with the MP joint (40°) and PIP joint (20°) in moderate flexion. When a long rod is selected the wrist should be also be immobilized in a neutral position for 10 days to allow skin healing.
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The same precautions should be undertaken for implant surgery as for prosthetic surgery. Prevention of infection should be made by a minimum 48 hour preoperative administration of a first generation cephalosporin. Rehabilitation following stage one: Passive flexion exercises start as soon as complete wound healing has been achieved (about 10 days). Until then, immobilization and splinting in the safe position are indicated. Flexion exercises are carried out on a regular basis and buddy-taping will allow exercise of the digit under control of the adjacent finger. The rehabilitation target during stage one is to gradually restore full passive range of motion which is the prerequisite for stage two. Premature and overzealous rehabilitation might provoke aspecific synovitis and infections. Complications in stage one: Aspecific synovitis is a commonly recorded complication in about 15–20% of cases (Paneva 1987, Bishop et al 1996, Hunter and Schneider 1997). It is characterized by pain in the finger tip, swelling along the volar surface of the finger, and swelling and erythema at the incision sites. This serious complication is not necessarily followed by less unfavourable results. It is more frequent in children, and this supports the argument to reserve the staged procedure for older patients. Cultures for bacteria in the fluid found within these sheaths have consistently shown no growth. The following precautions should be taken during the surgical phase: observation of the ‘no touch’ technique, and multiple and careful cleansing of the surgeon’s gloves. When synovitis is observed the patient’s exercise programme must be interrupted for 1 week. In order to prevent bacterial contamination antibiotics are also prescribed again as a prophylactic measure. Dynamic ultrasound might reveal an underlying mechanical cause, such as buckling of the prosthesis which might, in fact, underlie the fascial block. In the vast majority this complication subsides. When synovitis does not respond to the proposed therapeutic regime (although we do not know whether the new sheath will be structurally or functionally modified as a consequence of this complication), a stage two procedure might be performed earlier or when synovitis subsides and removal and deferral of stage one to a latter time considered (Hunter and Schneider 1997). Real infection has occurred in 2–3% to 15% in three series (Wehbe et al 1986, Amadio et al 1988). In this case implant removal and appropriate antibiotic therapy are required (see Case 4 Fig. 4-3 later in this chapter). Stage two: The interval between stages one and two should be 2–6 months. Incisions are very limited and the aim is to expose fully the proximal and distal attachment sites. Leaving the distal end of the prosthesis attached to the distal phalanx, the rod with the attached selected tendon graft is pulled distally through the new tendon sheath. The sequence of sutures is placed according to the guidelines described above in a distal to proximal direction, to set the appropriate tension of the graft. Rehabilitation guidelines and complication rates following stage two do not substantially differ from those already described for the single stage grafting technique. Pedicled staged tendon grafting technique: This operation has been described by PanevaHolevich in 1965 (Paneva 1987). The procedure involves the use of the flexor superficialis of the same finger as a pedicled graft after it has been sutured in an earlier stage to the flexor profundus usually at the level of the lumbrical muscle (See case 4 Fig.
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4-2 later in this chapter). In the presence of a coexisting scar in the palm the preliminary suture is carried out at the wrist level. The same area is selected for secondary reconstruction of the flexor pollicis longus (FPL). In this case, the preliminary suture is placed between the corresponding muscular tendon unit and the palmaris longus. No earlier than 1 month after the first stage, the superficialis tendon is exposed and cut at the level of musculotendinous junction. The tendon loop is then passed beneath the pulley system and sutured to the distal phalanx. The method of suturing does not differ from that suggested for the free tendon graft technique. The technique differs significantly from the Hunter staged technique during the rehabilitation process. After stage two, the wrist and fingers are immobilized in moderate flexion for only 5 days. Soon after the splint is removed and the patient is encouraged to perform active exercises on a daily basis. A splint is worn between the exercises and overnight for 25 days. From this point on the rehabilitation schedule does not differ from that followed for the single stage grafting technique. For the most unfavourable cases this procedure might be employed alongwith the Hunter twostage technique (Tubiana 1997; see Case 4 later in this chapter). The loop technique has several advantages. Grafting of the flexor superficialis, an intrasynovial tendon, has the related biological advantages (Nishida et al 1998, 1999). Furthermore, one repair has already healed when the second is undertaken. Chaplin (1973) has also experimentally proved the presence of a microcirculation in the pedicled tendon graft. The size of the superficialis tendon is wider than the usual extrasynovial tendon graft. A better tendon graft–pulleys relationship is then re-established when the original retinacular system is preserved. The superficialis tendon will then glide within an appropriate and competent pulley system. When the Paneva-Holevich technique is followed with preliminary insertion of a tendon rod, the ideal setting of a unique tendinous distal suture is acheived. Early rehabilitation can be undertaken with positive effect on outcome (Bishop et al 1996). In the presence of a severely damaged flexor tendon sheath necessitating extensive pulley reconstruction, the Hunter technique might be preferable. Complications after stage two: These are the same as those encountered during the single stage grafting technique, apart from breakdown, which for the Paneva-Holevich technique is confined to the distal repair. Results of flexor tendon grafting: These are favourable in the ‘good’ group of Boyes’ classification in 95.48% of cases. In the ‘cicatrix’ group only 40% of the patients (reported by Boyes) achieved flexion to within 2 cm of the distal crease of the palm. When comparing the single to the staged technique for the ‘scarred’, ‘joint stiffness’ and ‘multiple lesions’ groups, Hunter and Salisbury (1997) reported a significant improvement when the latter was carried out. The results obtained in ‘unfavourable’ cases were also graded by Paneva-Holevich (Paneva 1987). Overall ‘very good’ and ‘good’ results were obtained in 63.73% of the series, and the outcomes were significantly better when the Hunter modification was added to the original technique. Other tendon grafting procedures The ‘flexor superficialis finger’: The concept of a superficialis finger was initially introduced and described by Osborne (1960, 1975) from Liverpool, England, as the ‘redemption operation’. A different name, for this technique ‘the proximal
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interphalangeal joint motored finger’ was proposed by Schneider (1997a) but it undoubtedly sounds less biblical. This procedure is based on the premise that 85% of the arc of motion is achieved by full MP joint and PIP joint flexion. The technique is indicated for the following circumstances: • When flexor injury is associated with DIP joint damage or with distal disruption of the extensor tendon insertion or with unreliable skin at this level (see Case 6 later in this chapter). • In case of rupture of the distal attachment of a tendon graft when the graft cannot be reattached under acceptable tension to the distal phalanx. • In the case of A2 or A4 pulley failure with bow-stringing of the tendon graft; in this case simultaneous A2 reconstruction might be accomplished by the triple loop technique. • When the digit is graded 4–5 on Boyes’ scale. This procedure can be undertaken as a salvage procedure or planned as a staged procedure wherever active flexion of DIP joint cannot be re-
Figure 13
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established (Fig. 13). The Hunter active tendon has also been used to implement the flexor superficialis finger. This procedure is best for elderly patients or those in whom the local tissue conditions would make a traditional tendon graft unlikely to function. Isolated flexor digitorum profundus injury: In this situation treatment by tendon grafting should carefully be considered on an individual basis when strict criteria are met (Schneider 1997a,b). This technique is usually performed in young patients with supple joints and with minimal scarring especially at the DIP joint level. Occupational needs have to be ascertained after the digit acts as a ‘superficialis finger’ for certain period of time but the performance is not felt to be adequate by the patient (see Case 5 later in the chapter). We agree entirely with Schneider (1997a,b) that this grafting procedure is better indicated for the ring and little finger where power grasp demands are greater and stronger flexion is required as compared to the index and long fingers, where loss of FDP function will be missed less in daily activities. Surgical technique: The FDS might be fully functional from the beginning. In this case a single stage grafting technique is carried out possibly through or around the superficialis decussation. In the presence of adhesions of the FDS, tenolysis is carried out to restore the possibility of PIP joint active flexion. In this case a staged tendon grafting procedure is preferred. The postoperative phase starts after 1 week when wound healing is acceptable. Active exercises are carried out at the PIP joint and passive exercises at the DIP joint, on a daily basis. In summary, a single stage technique for isolated FDP reconstruction is rarely indicated; Schneider used it on 25 occasions in nearly 30 years. We used it, always as a staged technique, in six patients over the same period of time. In two cases aspecific synovitis had to be dealt with, but in all cases the final outcome was good. A secondary tenolysis was performed in 14 out of 25 tendon grafts in the Schneider series, and this procedure finally re-established an excellent function at the DIP joint. Late sequelae of flexor tendon grafting: The sequelae can be classified in relationship to the underlying condition of the joints. In presence of a functional range of passive motion tenolysis of the graft might be carried out. However, when dealing with a fixed posture different salvage procedures should be considered (Landi et al 1997a,b) Tenolysis after staged reconstruction has been performed in 16–45% of patients following staged reconstruction (Amadio et al 1988, LaSalle and Strickland 1983). Overall, 54% had good or excellent results—although only 19% had final TAM (total active motion) greater than 180°. Factors associated with poor results included patients younger than 10 years of age (Osterman and Paksima 1997) and those with ‘multiple damage’ according to Boyes’ classification. In these cases finger adhesion can extend the full length of the grafts especially in the presence of poor circulation. In the replanted finger low oxygen tension would inevitably provoke adhesion formations to enable survival of the graft (Hunter and Salisbury 1997, Landi et al 1985, 1997a). In this group staged flexor grafting should therefore be considered from the start. Fixed deformity: Skin and flexion contracture often coexist at the DIP and PIP joints level following multiple interventions to the flexor tendons. The options for treating the hook deformity range from a supplemental tenolysis of the flexor and release of the volar plate to arthrodesis in a more extended position of one of the two IP joints or to digit amputation.
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Saffar, in 1978, introduced the total anterior teno-arthrolysis (TATA) (Landi et al 1997a). The surgical technique includes the following surgical procedures: access through the lateral surface from the middle of the proximal phalanx to the distal phalanx, incision of the subcutaneous tissue to the bone and dissection of the periosteum with a straight rougine or scalpel from the diaphysis of the first two phalanges. Then the volar fibres of the collateral ligament are incised, removing the volar plate that becomes continuous with the previously detached periosteum (see Case 7 Fig. 7-1 later in the chapter). This surgical procedure is performed both at the PIP and DIP joints so that all elements of the volar surfaces of the two phalanges are detached from the bone. Sectioning of the collateral ligaments proceeds from volar to dorsal side, sparing the most dorsal fibres. At times, part of the collateral ligaments of the DIP joint must also be sectioned. If an attempt is made to extend the finger and extension is possible at the expense of flexion of the DIP joint, the FDP must be sectioned closed to the periosteal insertion, leaving the tendon attached to the surrounding tissue. The degree of gliding is proportional to the severity of the hook deformity. It is not always necessary to obtain a complete extension of the digit. If a small area of skin remains uncovered, it can be left to heal by secondary intention or covered with a local flap (Landi et al 1997a, 2002). Flexor tendon graft in zone III (Fig. 1) In zone III the common digital nerve needs to be sutured. Ideally, both the superficialis and profundus flexors should be also repaired. Practically only the FDP is reconstructed and the FDS is used as a graft source. The scarred lumbrical muscles should be removed. We prefer to use the minigraft technique instead of long grafts that reach the tips of the fingers (see Case 8 Fig 8-2 later in the chapter). When the minigraft technique is chosen this will require a localized fasciectomy since the distal segment of the graft usually borders the A2 pulley and adhesions might occur. The possibility of tenolysis has to be explained to the patients. Great attention should be paid while doing this operation as the digital nerves or digital nerve grafts can adhere to the skin. Flexor tendon graft in zone IV (Fig. 1) Zone IV represents an area of crowded anatomical structures which pass through the carpal tunnel. Extensive tendon loss in this area carries a high risk of development of extensive adhesions. Simultaneous damage to the median nerve requires secondary repair by nerve grafting. The following guidelines should be observed: • The superficialis tendon should be removed. • The flexor tendons of long fingers and FPL should be repaired by tendon grafting. If graft sources are insufficient an end to side suture can be considered between the deep flexor of the little and ring fingers. • The flexor retinaculum should be excised, and a secondary tendon transfer by the best rerouting to the abductor pollicis brevis should be planned at this early stage.
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The suture technique is based on personal preference. We prefer, at this level, the single core loop technique suture with 3-0 braided nonabsorbable filament in adults, as described by Tsuge (1998), reinforced by a separated epitendinous repair with 5-0 monofilament (see Figs 17a, b). Flexor tendon graft in zone V (Fig. 1) Tendon grafts are usually required following complex lesions especially due to trauma, physical or chemical agents, where hand survival and soft tissue skin coverage are at the top of the priority list. Following soft tissue repair, when needed, a secondary new repair is done by traditional nerve grafting. Direct interpositional tendon grafting cannot be undertaken due to both the extensive scarred bed and the proximal damage to the myotendinous unit. Tendon transfers, usually BR (brachioradialis) to FPL and ECRL (extensor carpi radialis longus) to FDP, represent the usual alternatives (Tsuge 1988; Fig. 14a,b). One-stage reconstruction of postelectrical burns for forearm and hand defects might be accomplished by using microsurgical transfer of an ulnar neuromyotenocutaneous unit, which has been suggested as a unique treatment in a difficult setting. To prevent adhesions, or in association with secondary tenolysis, a locally reabsorbable gel composed of gelatine and carbohydrate polymer buffered in phosphate (Adcon-TN, Glyatech, Cleveland, USA) might be added (Landi et al 1997a, 2002) When tenolysis of the tendon grafts is required, both at the palm and wrist, great attention should be paid so as not to damage nerves or nerve grafts.
Repair of the extensor tendon defects Late reconstruction of the extensor tendons can be as difficult as for flexor tendons. Functioning
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Figure 14a
Figure 14b of the extensor tendon assembly has been defined by Littler as a ‘fugue of movement’ (Burton and Melchior 1982) The retinacular system, although structurally very thin, plays a relevant role in the functional chain as the dynamic system of the extensor apparatus is harmoniously interrelated. An imbalance at one joint will trigger a predictable deformity in the next adjacent joint. Contracture of the oblique retinacular system will lead to the fixed ‘boutonniere deformity’ (Fig. 15). A fixed swan-neck deformity is maintained by contrac
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Figure 15 ture of the triangular lamina. In addition, the extensor mechanism has far less tolerance than the flexor system in relation to changes in tendon length (Burton and Mechior 1982) Injuries proximal to the juncturae tendinum will lead to contracture of the motor unit. This precludes the possibility for direct secondary repair in the vast majority of cases. The following myostatic muscle contracture creates a gap between the disrupted tendon stumps. Direct repair of an irreversibly contracted motor unit will prevent finger flexion due to the extensor tenodesis effect. These are the basic principles underlying the more frequent use of tendon transfers for late reconstruction of the extensor tendons. Joint contractures are often associated and should be released before embarking on extensor tendon grafting procedures at any level. The dorsal skin of the hand is thin and pliable to allow flexion of the underlying joint. This skin is not easily replaceable, and certainly the only possible replica can be provided by skin from the dorsum of the foot by means of a dorsalis pedis composite flap (Landi et al 1980b, Caroli et al 1993). The thin elastic skin of the dorsum of the hand, when damaged, lacks a priori the subcutaneous padding that
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allows secondary tendon procedures to be carried out. The methods of repair and technique of tendon grafting are strictly related to the level of injury (see Fig. 2). Repair or secondary reconstruction of the extensor retinacular system is also a relevant issue. Tendon reconstruction of the extensor hood deficit is mandatory at the MP joints when dislocation of the tendons on the groove causes friction and pain. This is also applicable in the presence of painful sequelae of release of the first dorsal compartment (Rozmaryn and Rockville 1995, Ramesh and Britton 2000). Similar to a zone V injury of the flexor tendons, where the flexor retinaculum is not repaired, in zone VII injury of the extensor tendons the extensor retinaculum should not be reconstructed to prevent de certo adhesions in this area. In any case, a natural tenodesis effect is provided by flexion of the wrist. Release of the contracted retinacular system has been introduced as adjuvant therapy for the fixed deformity of the fingers sustained by the imbalance of extensor tendon mechanism (Fowler 1959, Dolphin 1965) (Fig. 15). Single stage tendon grafting can be considered for large defects on the dorsum of the fingers and hand only when ideal conditions of the overlying soft tissues exist (Cautilli and Schneider 1995). The braided plantaris tendon has been suggested as an extensor tendon graft source for this (Baker 1995). The staged technique has been used in a potentially scarred bed. It has been used after chronic burn wounds or infection treated by free tissue transfer (Tomaino and Plakseychuck 2000). Limited experience has been reported with the use of vascularized extensor tendon grafts. The extensor indicis proprius (EIP) appears to be the only appropriate local source (Vermeylen and Monballiu 1991). Tendon transfers are routinely used for chronic lesions of the EPL (extensor pollicis longus), or EDC (extensor digitorum communis), whenever EIP or EDM are available. Composite tissue transfers allow one-stage reconstruction of simultaneous skin and extensor tendon loss by means of a regional vascularized flap, namely the radial forearm flap, including vascularized tendons (Hiroshi et al 1996, Sukkar et al 2002). Under ideal conditions composite free tissue transfer can also be considered from different sources (Ichioka et al 1994). The upper lateral arm has been used by Hou (Hou and Liu 1993), and the dorsum of the foot by Taylor (Taylor and Townsend 1979) and Landi (Landi et al 1995). The cost–benefit assessment of the procedure, especially for the latter, should take into account donor site morbidity (these aspects are dealt with elsewhere in this book). Consideration of donor site morbidity is often associated with cosmetic considerations, which are based both on individual perceptions and on cultural background (Hirochi et al 1996). More precise guidelines in terms of repairs of defects of the extensor tendons can be drawn in relationship to the affected anatomical area. Zones III and IV (Fig. 2) The most frequent lesions that afflict the extensor apparatus and frequently the skeletal system occur in zones III and IV, usually in the work place but also during recreational activities. Skin resurfacing is the main issue. Reproduction of the dorsal interrelated system might not be realistically achievable. Therefore, some general guidelines should be followed. Preliminary soft tissue resurfacing is strictly related to involvement of a single
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digit or multiple digits. When dealing with a single digit, some local flaps are for the most part of historical interest but can occasionally be used, such as the flag flap (Iselin 1973) and the digital arterialized lateral finger flap (Russel et al 1981). Other flaps have more recently been introduced, and we believe that the reverse adipofascial turnover flap, for complicated dorsal skin defects both at the level of the digits and hand, is worth considering (Lai et al 1991). It usually has a base to length ratio of 1:1.0–1:1.5. Dissection of the flap has to be stopped in the finger about 1.0 cm before the edge of the defect is reached. A full or split thickness graft is applied to the raw area of the turnover flap. When dealing with multiple digits, dorsal skin defect free flaps, such as the lateral arm flap, should be considered whenever possible, keeping in mind that no regional flap will be able to cover such an extensive area, apart from the radial forearm flap. Traditional reconstructive techniques can be used, depending on the centre and surgeon’s experience, with the provision that thin or defatted skin should ultimately be provided. For the extensor apparatus, in a complex lesion DIP joint control is usually left to the retinacular system and the central band is reconstructed by means of one of two widely accepted techniques: the reverse central tendon pedicled graft as suggested by Snow (1973) (Fig. 15) or the tendon graft suggested by Fowler (1959) (Fig. 16). We prefer the former technique. Distal attachment is usually secured by a bone anchor. As for any extensor grafting procedure, immobilization is maintained in the safe position for 3 weeks. A tailored rehabilitation programme will then be started, taking care to avoid stretching of the sutured graft during the following weeks. Zones V and VI (Fig. 2) These zones are also frequently affected. The corresponding lesions at T III or T IV in the thumb are less common. The overall surgical strategy depends on various factors. In the emer
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Figure 16 gency setting, the reconstructive procedures for skin damage or loss are strictly governed by the anatomical area and corresponding extension. Limited loss to one ray in zone III can be treated by a reverse dorsal hand flap (Quaba and Davison 1990) Approximately one-third of the dorsum of the hand in zone IV and of the dorsum of the thumb can be resurfaced by the posterior interosseous flap (Landi et al 1991). The adipofascial turnover flap can also be considered (Lai et al 1991) Secondary reconstruction of extensor tendon defects can be achieved with minigrafts taken from the various sources available just as for flexor tendons reconstruction (Fig. 17). This procedure can be used for the thumb to reconstruct EPL at the T III level. At the T IV level, proximal contracture of EPL usually occurs, and EIP is transferred to reconstitute active extension of the thumb. We prefer the suture technique proposed by Tsuge (1988). Regarding the technique for suturing the extensor tendons grafts, the core suture is achieved by applying a looped braided non-absorbable suture (3-0 in adults) reinforced by a supplementary epitendinous suture using 6-0 monofilament (Fig. 17). When the entire dorsum of the hand has been severely damaged in a young motivated patient, surgeons who are acquainted with the dorsum of the foot as a donor area for reconstructive procedures can opt for the composite dorsalis pedis flap. Experience in this field is still minimal and prevention of donor site morbidity relies on preservation of EDB innervation and strict immobilization of the foot to guarantee taking of the graft (Landi et al 1980b). When confronted with skin defects in the order of 10 × 6 cm, the radial forearm flap, which may include vascularized tendons (the duplicated palmaris longus, flexor carpi
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radialis, and brachioradialis (Haroshi et al 1996; see Case 9 later in this chapter) has a good indication in a situation where microvascular procedures are contraindicated. We use it in older patients as an alternative to distant flaps. Caution should be taken to place the suture of the graft at a distance from the skin suture. Dealing with an almost circular flap, a trapdoor effect is foreseeable and secondary tenolysis should be anticipated (Hiroshi et al 1996). Among the complications that can occur exposition of the suture with secondary infection and breakdown can be prevented by including part of the flexor carpi radialis muscle in the flap (Sukkar et al 2002). As a third option, just skin coverage can be accomplished in the emergency setting. Secondary minigrafts to the extensor tendon can be performed by elevating half of the flap and defatting as needed. Simultaneous tendon transfer can also be accomplished (see Case 10 later in the chapter). The staged extensor tendon reconstruction remains the last resort and should be done through small proximal and subcutaneous tunnelling of the silicone rods. This technique has been used even under split thickness skin grafts (Bevin and Hothem 1978) Zone VII (Fig. 2) The wrist extensors are also damaged in this zone. The ECRL tendon is usually used as a free graft to reconnect the ECRB (extensor carpi radi-
Figure 17 alis brevis) to the corresponding metacarpal (see Case 1 Fig. 1-2 later in the chapter).
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Tendon grafts to the long fingers are usually intercalated with the provision that EDC myostatic contracture has not developed. In this case BR is usually transferred to the EPL and FCU (flexor carpi ulnaris) to the EDC (Fig. 18). The extensor retinaculum is discarded. Zone VIII (Fig. 2) For extensive skin losses in the acute phase the anterolateral thigh flap based on perforators has recently gained renewed interest (Javaid and Cormack 2003). By exploiting the chimeric flap principle it can also be used to revascularize the hand and thanks to its dimension (20 × 10 cm) it might cover the entire dorsum of the hand and distal forearm. For late extensor tendon reconstruction no other options besides tendon transfers occasionally prolonged by tendon grafting can be considered (Burton and Melchior 1982, Javaid and Cormack 2003). The late sequelae of extensor tendon grafting: Similar to the flexor tendons, the extensor tendon grafts can adhere to the floor in the neutral zones, especially at the dorsum of the hand. In the presence of supple joints, a simple tenolysis is required after 6 months of the preliminary procedure. The four cases that we have treated were confined to zone III–zone V. The range of motion gained ranged from 45° to 90° (Landi et al 2002). Teno-arthrolysis of the dorsal apparatus (TADA) becomes necessary when adhesions and joint
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Figure 18 stiffness occur as sequelae of infection, inflammatory reactions, closed trauma, and tenorraphy or tendon grafting of the extensors at the dorsum of the hand and fingers. TADA can be accomplished via two modalities, depending on whether tenolysis is required following tenorraphy and tendon grafting of the extensor apparatus or closed trauma of the fingers and hand. In the former, tenolysis extends in both directions from the site of anatomic fixation, and involves clearcut surgical steps, because at the PIP joint
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the central band must be isolated from the lateral bands, and at the MP joint, the extensor hood is almost inevitably sacrificed. The sagittal bands are usually the only retinacular structures that are preserved. However, extrinsic stiffness is often associated with an intrinsic stiffness of the MP and PIP joints. In this case, one proceeds with a dorsal capsulotomy at the MP or PIP joint. The traditional hesitation as regards secondary tenolysis of the extensor tendon graft should be reevaluated in the light of contemporary techniques of hand rehabilitation (Landi et al 1997a, 2002). In conclusion, flexor and extensor tendon defects are usually linked to severe traumatic events. The priority list which includes survival of the limb, resurfacing skin defects and simultaneous or secondary reconstruction of tendon defects deserves, in our experience, equal attention on both the volar and the dorsal aspects of the hand.
Case 1 CG: 25-year-old male. Open lesion at the dorsum of the left hand initially treated elsewhere.
Figure 1-1 The patient was unable to actively extend the wrist and long fingers.
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Figure 1-2 Postoperative radiographs: extensor carpi radialis longus (ERLC) has been reconstructed by a tendon graft taken from extensor carpi radialis brevis (ERBC). The graft has been anchored to the third metacarpal by an anchoring device.
Figure 1-3 The stiffness of the MP joint of the index finger was due to an unrecognized fracture dislocation.
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Figure 1-4 Corresponding X-ray.
Figure 1-5 The joint has been replaced by a pyrocarbon prosthesis.
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Figures 1-6, 1-7 At 1 year follow-up, the patient is unable to actively extend the index finger.
Figures 1-8, 1-9 One slip of EDM has been tranferred to the extensor apparatus of the index finger. The transfer has been prolonged by a tendon graft harvested from palmaris longus.
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Case 2 MIG: 12-year-old-female. Crush injury at little finger of the right hand. Lesion of flexor profundus was left untreated during the emergency setting.
Figure 2-1 Preoperative clinical picture.
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Figure 2-2 Extensive fibrosis of the flexor apparatus.
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Figure 2-3 The silicone rod has been inserted and the retinacular system reconstructed by three pulleys.
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Figure 2-4 Intraoperative passive range motion.
Figures 2-5, 2-6 Clinical follow-up at 3 years.
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Figures 2-7, 2-8 The active extension of toes is within the normal range and is provided by EDB.
Case 3 CG: 36-year-old male. Crush injury of the left hand. A Swanson spacer was used in the emergency setting to replace the MP joint.
Figure 3-1 Clinical picture showing the impossibility of flexing the finger.
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Figure 3-2 Preoperative X-ray.
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Figure 3-3 Intraoperative picture showing extensive damage of the tendon sheath.
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Figure 3-4 Interruption of the flexor apparatus required a staged flexor tendon repair.
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Figure 3-5 The silicone rod has been inserted and A2–A4 pulleys reconstructed.
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Figures 3-6, 3-7 Favourable outcome at 2 months.
Case 4 DA: 30-year-old male. Lesion of the flexor apparatus of the index finger of the right hand.
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Figure 4-1 Intraoperative finding
Figure 4-2 A preliminary suture was carried out in the palm between the flexor superficialis and the corresponding flexor profundus.
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Figure 4-3 The wound became contaminated by Micrococcus sp. during the rehabilitation phase.
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Figure 4-4 The staged flexor grafting procedure was completed according to the Paneva–Holevich technique.
Case 5 DR: 11-year-old male. Subcutaneous rupture of flexor profundus of the middle finger of the right hand.
Figure 5-1 Preoperative clinical picture.
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Figures 5-2, 5-3 Positive outcome following a single stage tendon grafting procedure to the profundus through the intact sublimis. Palmaris longus was used as a graft source.
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Case 6 MM: 26-year-old male. Crush injury of the right hand treated elsewhere.
Figures 6-1, 6-2 Subankylosis of DIP joint was present in association with disruption of the flexor apparatus of the long finger.
Figure 6-3 Stage one of the technique as described by Hunter has been carried out. A two pulley system has been reconstructed. The initial purpose was to simply reestablish a ‘superficialis finger’.
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Figures 6-4, 6-5 Follow-up at 1 year showed an unpredictably favourable result as active flexion of the DIP joint was obtained. The joint stiffness was overcome by the active motion of the tendon graft.
Case 7 DRL: 52-year-old female. Sequelae of crush injury of the left hand. A two-stage technique flexor tendon reconstruction has been carried out. A fixed ‘hook deformity’ was finally established.
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Figure 7-1 Pre-generative clinical finding.
Figure 7-2 Complete passive motion of the little finger can be achieved.
Figure 7-3 The technique of TATA.
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Figure 7-4 Intraoperative flexion of the little finger.
Figures 7-5, 7-6 Follow-up at 1 year.
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Figure 8-1 Preoperative picture. Case 8 PG: 20-year-old male. Sequelae of a sharp injury in the palm. The patient, a policeman, was unable to flex the index finger of the dominant hand.
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Figure 8-2 Intraoperative finding: a flexor tendon minigraft to the flexor profundus was harvested from the corresponding superficialis.
Figures 8-3, 8-4 At 1-year follow-up the patient was able to resume all the previous vocational and other activities.
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Case 9 BS: 36-year-old male. RTA with exposed metacarpal fractures (right hand) initially treated elsewhere.
Figure 9-1 Infection and secondary rupture of the extensor tendons.
Figure 9-2 Preoperative radiograph.
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Figure 9-3 Release of the MP joint was carried out.
Figure 9-4 A forearm composite flap including PL and FRC was performed.
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Figures 9-5, 9-6 Follow-up after 5 months. The donor site was unsightly and a limited (~40°) active range of motion was recorded.
Figure 9-7 Clinical outcome at 10 years. Complete independence in DLA was accomplished.
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Case 10 MG: 54-year-old female. Thermal injury with a crush component at the dorsum of the hand. The wound was debrided and skin resurfaced with a groin flap.
Figures 10-1, 10-2 Preoperative clinical picture.
Figure 10-3 ECRB to EDC (2nd–3rd) and ECU to EDC (4th–5th) tendon transfers have been carried out.
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Sukkar SM, Saulis AS, Dumainian GA (2002) Radial forearm skin with flexor carpi radialis muscle: a useful composite free flap, Ann Plast Surg 49:486–9. Taylor GI, Townsend P (1979) Composite free flap and tendon transfer: an anatomical study and a clinical technique, Br J Plast Surg 32:170. Tomaino NM, Plakseychuk A (2000) Two-stage extensor tendon reconstruction after composite tissue loss from the dorsum of the hand, Am J Orthop 29: 122–4. Tsuge K (1988) A Comprehensive Atlas of Hand Surgery. McGraw-Hill: Milan. Tubiana R (1960) Greffes des tendon flechisseurs des doigts et du pouce. Technique et resultats , Rev Chir Orthop 46:191–214. Tubiana R (1965) Incision and technics in tendon grafting, Am J Surg 109:339–45. Tubiana R (1997) Tendon grafting: A historical perspective, In: Tendon and Nerve Surgery in the Hand. Hunter JM, Schneider LH, Mackin EJ, eds. CV Mosby: USA, 397–9. Vermeylen J, Monballiu G (1991) The use of the extensor indicis proprius as a vascularised tendon graft. A preliminary report, J Hand Surg 16(B):185. Wehbe MA, Mawr B, Hunter JM (1986) Two-stage flexor-tendon reconstruction: tenyear experience, J Bone Joint Surg 68(A):752–61. Weilby A (1968) Flexor tendon grafts: results in 95 cases, Acta Orthop Scand 39(3):369– 75. Wilson RL (1985) Flexor tendon grafting, Hand Clin 1:97–105.
17 When to use vascularized tendon transfers and how is the digital flexion sliding system supposed to work? Jean C Guimberteau
Introduction In classes III, IV, or V of Boyes’ classification are patients who have already undergone multiple operations with skin scarring, joint stiffness and severe flexion contracture deformity. Treatment of such problems has consisted of amputation, distal arthrodesis or tendon grafting, often in two stages. The latter approach, however, allows neither adequate nutrition to the graft (leading to repeated failures) nor results in consistently satisfactory function, and even then, the ultimate range of active movement requires a minimum of 6 months to achieve. Fifteen years ago, we abandoned this traditional approach in favour of a more rapid and physiologic technique in which the tendon is regarded not as a simple string to transmit forces but as a living organ. The single stage operation using an island vascularized flexor tendon transfer allows earlier discharge return to home and to work and reduces the cost in socioeconomic terms. However, before we adopted this approach we had to modify our outlook towards tendon physiology and anatomy. Armed with new information from dissections on fresh treated cadavers and more than 300 reverse ulnar flaps, the time has come to confirm some anatomical truths and to finally discard certain preconceived ideas. Some traditional basic concepts seem to be at variance with anatomical reality and should be changed. Physiological conclusions There is no histological difference between the paratendon and the carpal sheath. The ancient term—paratenon—thus includes the whole of the peripheral sliding system called multimicrovascular collagenic dynamic absorbing system (MCDAS) made of billions of microvacuoles and a fibrous frame. The MCDAS is the proximal histological continuation of the perimysium profundus layer and it differentiates functionally to become the digital sheath (Fig. 1). In fact it is the same structure but viewed differently from different aspects under different mechanical circumstances. As soon as an external or internal factor increases internal pressure,
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Figure 1
Figure 2 the distribution changes in a megavacuole with a selective blood pedicle in protected areas. The notion of a piston machine mechanism is false and obsolete. This analytical concept must be replaced by a systemic concept. Contrary to the holistic aspect there is no difference between the vascular system in tendons and a peripheral synovial vascular system without communication. Anatomical conclusions Vascularization is continuous and permanent (Fig. 2). There is no area without blood supply. Tendon, epitenon and MCDAS are supplied by the same vascular system. Tendons are not hypovascular. The digital canal is an efficient adaptation of the MCDAS as a megavacuole with vincula system. So the digital and carpal sheaths do not have the same sliding system. All these observations are innovative in that they introduce a new concept. The SLIDING UNIT composed of the tendon and its surrounding sheaths (Fig. 3). From now on, Potenza’s principle, tendon adhesions and reconstruction of the digital sheath using a silicone rod should give way to newer principles. • A tendon only has optimal functional value when it is surrounded by its original
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sliding sheath and its vascular supply.
Figure 3 • A tendon only adheres when it is artificially separated from its own sliding sheath, or when the harmony between the tendon and the sheath has been interrupted. • A tendon is only one of the intervening elements in the transmission of a force through the sliding unit.
The method of natural replacement for secondary flexor tendon salvage The new principles of tendon physiology introduce a completely new approach to the problem of reconstruction: 1. The concept of the tendon-sheath couple and the major role of tendon vascularization with peripheral collagen organization is emphasized. 2. The transfer of a sliding unit composed of a flexor tendon and its surrounding sheaths in reverse island pedicle manner in one single operation, thus avoiding the two-stage procedure for secondary repair is proposed, inspired by biological consequences (Fig. 4). This new technique is used today in clinical cases for the reconstruction of finger flexor systems in grades III and IV of Boyes’ classification.
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Figure 4 Basic principles 1. The tendon can only be conceived as vascularized. 2. The tendon can only be conceived as an element in association with its surrounding sheaths to form a sliding unit. In order to conform with these two basic principles, the proposed new technique must satisfactorily answer three basic questions. Technical questions 1. Which sliding zone must be used to replace zones I and II, subject to so many problems and complications? The mesotenon and its vascular branches provide vascularization of the flexor tendon and the sliding carpal sheath both extrinsically and intrinsically. The structure thus transferred is a real sliding structure which already exists in a natural state in zones III, IV and V. The principle is to replace the digital sliding zones I and II, the most frequently reconstructed zone, by the natural sliding zone of the wrist and the palm, i.e. zones III, IV and V. Because the tendon used for the reconstruction is transferred with its own sheath, it does not need to adhere to the neighbouring tissue to survive, and any adhesion formation is reduced, leading to improved functional results. Potenza’s basic principle of the absolute necessity for adhesion can thus be discarded and the twostage procedure is now considered obsolete. Furthermore, the transferred tendon is a real flexor tendon with all its original qualities of resistance and flexibility. Technically, the sutures are placed outside the ‘no man’s land’ and the sliding unit, composed of the tendon and the carpal sheath, is inserted between pulleys A1 and A4. 2. What will be the method of vascularization of the flexion replacement structure? Vascularization is ensured by a preretinacular mesotenon, with branches issuing from the ulnar artery.
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Anatomical reminder At the inferior third of the wrist, just before the flexor retinaculum carpi or the annular ligament, the ulnar artery gives off two or three branches around 1 mm in diameter. These branches pass through the common carpal sheath towards the superficial flexor tendons, especially those of the middle finger, the ring finger and the little finger, by way of a fine transparent mesotenon, which acts as a mesentery. This vascular approach to the flexor system and the common carpal sheath is made distal to the tendon–muscle junction, thus permitting the adaptation of the concept of retrograde island transfers to purely tendinous structures. This vascularization is one of the principal differences from the radial artery based flap because it is developed in the tendon zone and not in the muscle zone. Purely tendinous transfers can be developed founded on the concept of vascularized tendon island transfers. This certainly represents a fundamental change in the concept of tendon reconstruction. According to the same principle and using the same surgical technique, it is possible to carry out not only pure tendinous vascular transfers (most often with the superficial flexor tendon of the ring finger), but also a cutaneo-tendinous transfer, and even the triple transfer of skin, tendon and bone. 3. How will this sliding unit be placed into ‘no man’s land’? Nowadays, the technique of island retrograde forearm transfer is used, to transfer a forearm or wrist structure which is pedicled on an arterial axis. For retrograde vascularized tendon transfer, only the ulnar based pedicle is suitable owing to its distally based palmar point of rotation and to its branch transmission at an exclusively tendinous level. Technique The basie procedure consists of the transfer of the flexor superficialis tendon of the ring finger to repair any type of tendon defect. Preoperative evaluation includes Allen’s and Doppler tests to ascertain that the radial artery provides adequate blood supply to the hand. Angiography of the arm is also advisable (Fig. 5). A bayonet-shaped incision is first traced and then made on the medial side of the forearm, the axis of the incision overlying the lateral border of the flexor carpi ulnaris. The cutaneous branches between the ulnar artery and the skin, emerging from the volar aspect of the pedicle and which are the principal components of the ulnar forearm flap, are then carefully isolated. These branches should be divided only when skin transfer is not required. The ulnar pedicle is then separated from the ulnar nerve on its dorsal
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Figure 5 aspect along its whole length from the lower third of the forearm to Guyon’s canal. Reflection of flexor carpi ulnaris and the ulnar nerve ulnarward and the skin of the volar surface in a radial direction exposes the preretinaculum area and the carpal tunnel, which is opened. The small vascular branches running from the anterolateral side of the ulnar pedicle to the flexor superficial tendons of the fourth and fifth rays are identified through the transparency of the large mesotendon which begins just before the carpal tunnel and continues into the common carpal sheath with vascular connections. The flexor superficialis tendons of the third and fifth fingers are drawn aside, and all mesotendinous structures and carpal sheath surrounding these two tendons are carefully dissected free and preserved to accompany the future tendon transfer. A mesotendinous structure composed of the flexor superficialis of the ring finger is raised, with its carpal sheath (to permit slight sliding) and its vascular connections from the ulnar pedicle. These connections, usually comprising two or three small branches on the anterolateral side and measuring, on average, 0.2–0.5 mm in diameter, are found just before the proximal edge of the flexor retinaculum. By means of an incision of the volar digital surface, the flexor superficialis of the ring finger is divided at the level of the chiasma tendinum. The tendon is divided proximally at the muscle junction. The tourniquet is released, and a clamping test of the ulnar pedicle is performed to establish that there is a satisfactory blood supply to the hand through the radial artery and to the tendon transfer by retrograde flow in the superficial palmar arcade. After proximal ligature of the ulnar pedicle, a composite mesotendinous island transfer 20 cm long is raised, as with any reversed forearm flap, and transferred to the distal part of the hand to provide a complete flexor tendon unit for any finger from the pulp to the wrist. Like any reversed forearm flap, the transferred unit is pliable and plastic, and in addition, the blood supply that bathes its intrinsic and extrinsic components is readily visualized throughout. The rest of the operation follows conventional principles of tendon surgery. The tendon area wrapped in the common carpal sheath is laid into the ‘no man’s land’ beneath the A2 and Ag pulleys, which must be carefully preserved or solidly reconstructed, since the tendon transfer exposes them to much greater strain than a simple tendon graft. The transfer is inserted first into the distal phalanx by means of a ‘barbed wire’ suture.
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Proximal suture with the distal extremity of the relevant flexor profundus is performed using Pulvertaft’s method. The tension on the suture is easy to assess and should be slightly overcorrected in comparison with the other fingers. On completion of the procedure, a dynamic Kleinerttype splint is applied to allow early movement. Combined flexor tendon and skin transfer (Fig. 6) In some cases when the overlying skin is extremely scarred and of poor quality, particularly at the base of P1 or P2, it would be impossible to replace the flexor tendon and achieve early motion. Skin of this sort inevitably breaks down or necroses, compromising the functional result, and therefore, it should be replaced. In the lower third of the forearm, the ulnar pedicle not only sends branches to the flexor superficialis tendons but also to the skin. These branches, constantly of excellent calibre, are easily identified, being close to the mesotenon branches, and allow simultaneous composite transfer of skin and tendon. Generally the skin island lies proximal to the mesotenon position. However, due to the pliability and flexibility of these cutaneous branches, the transfer can be rotated and positioned on the digital surface
Figure 6 without changing the physiologic direction of tendon fibres. This is of fundamental importance in achieving a good functional result. Case reports Case 1 A 40-year-old agricultural worker had undergone two previous operations after complete division of the flexor superficialis and flexor profundus of the fifth left finger. These procedures included secondary suture and tenolyses. No pulley reconstruction. Island reverse vascularized tendon transfer with the flexor superficialis of the fourth finger was performed. This patient had an
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Figure 7
Figure 8
Figure 9 excellent functional result within 45 days. Although preoperatively there was no active range of movement in flexion, the functional result was a total recovery of motion. The patient returned to work within 3 months (Figs 7–9).
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Case 2 A 33-year-old woman had undergone two former surgical procedures, including two tenolyses and a palmaris brevis tendon graft, resulting in a fixed flexion deformity of the little finger at 90°
Figure 10
Figure 11
Figure 12
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Figure 13 of flexion in the proximal interphalangeal joint and bowstringing secondary to pulley collapse. Because of a large skin defect, a composite skin and tendon transfer was performed. After 50 rehabilitation sessions and application of a night extension splint for 3 months, the functional result was very good (Figs 10–13). Discussion The new technique, which is now our standard procedure for cases in Boyes’ class III or IV, using a mesovascular tendon island, is likely to set the trend for future flexor tendon surgery because the requisite tendon reconstruction can be carried out in one operation. As compared with all other tendon graft techniques, the advantages of this techniques are as follows. It makes use of a living tendon island on a thin mesotenon with vascular branches, providing a perfect blood supply to all areas, both extrinsic and intrinsic. It thus avoids adhesions and improves the vascularity of the surrounding tissues. Since the transfer is a real flexor tendon and not a simple myotendinous structure, it retains flexibility, pliability and resistance, and allows the correct tension to be achieved. Because vascularization is preserved, all sheaths are retained. The paratenon and in particular the carpal sheath (which is transposed into ‘no man’s land’) retain the unrestricted gliding movement of the tendon. The length of the tendon transfer is approximately 18–20 cm. This allows easy reconstruction of any type of flexor tendon defect from the pulp to the carpal area. Thus the tendon anastomoses are not under tension and lie outside ‘no man’s land’. Because of the very distal rotation point and the mesotenon plasticity and versatility, the placement and anchoring need attention but can be performed without difficulty. The operation is performed in the same way as a classic reverse flow radial or ulnar forearm flap. The mesotendinous vascular branches are anatomically constant, and the dissection will take approximately the same amount of time as a reverse flow forearm skin flap (approximately 90 minutes). This is a one-stage procedure allowing retention of all gliding surfaces, which means that recipient bed preparation by a pseudosynovial sheath using a silicone rod is unnecessary. However, all pulleys have to be repaired carefully because it has been found
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that the traction exerted by this type of tendon is greater because the resistance is less. Compared with the other forearm transfers and their potential for composite transfers, the only one that allows simultaneous transposition of skin, bone and tendon is the radial forearm flap. However, this type of flap does not allow transfer of the common carpal sheath and the flexor tendon because the radial pedicle supplies them only at the myotendinous level and its rotation point is too proximal. The new technique of composite transfer described in this chapter is specifically confined to the ulnar vascular system and may conveniently be knows as the ULNAR TRAIL SYSTEM. The main disadvantage of our technique is the need to transect the ulnar pedicle. However, in our experience with more than 450 cases of all varieties of ulnar transfers, no undesirable longterm effects such as paraesthesia or functional deficits have been encountered 1 year after surgery. It is nevertheless preferable to restore arterial continuity by either a venous graft or a vascular prosthesis 2 mm in diameter. Results It is very difficult to evaluate the results after complex tendon reconstruction operations because the variables involved are too numerous (age of the patient, procedures used, type of injury, accompanying nerve, bone, or vascular injuries, and especially associated skin problems). Many systems of evaluation have been proposed. We prefer the Tubiana system because it is based on methodology centred on proximal interphalangeal joint movement, which in our opinion displays the principal effects of the flexor tendon transfer. The arithmetical addition of degrees between extension and flexion compared with the hypothetical maximum amplitude, while not distinguishing between metacarpophalangeal joint and proximal interphalangeal or distal interphalangeal joints, would seem inadequate for this sort of salvage situation. There is rarely a significant alteration of metacarpophalangeal joint movement. It is obvious that in these cases the principal aim is to restore effective and useful function, including grip, and especially to attain recovery of good proximal interphalangeal joint movement. The Tubiana evaluation gives specific evaluation of proximal interphalangeal joint function, which is readily assessed by comparing P2 position to the metacarpal bone in the same digit. In this study, all patients were classified into four groups preoperatively, and the criteria used were largely based on Boyes’ classification (modified by Tubiana) though more importance was given to preoperative skin condition. Our strategy is defined by the skin quality. Since there is early mobilization (3 days postoperatively), it is very necessary is to avoid skin dehiscence or necrosis. Our study was divided into two series: Series A: 21 patients, all previously operated on at least twice (excluding emergency procedures) and corresponding to class II (3 cases), class III (8 cases) and class IV (10 cases) in whom flexor superficialis transfers were performed. Series B: 25 patients corresponding to class IV in whom composite skin flap and flexor superficialis transfers were performed. In series A, 21 patients were analysed according to the Tubiana classification, four excellent (1 group II, 2 group III, 1 group IV), six very good (4 group III, 2 group IV), six good (2 group II, 2 group III, 2 group IV), three medium (2 group IV) and two poor (2 group IV). Great improvement was achieved in 76% of patients.
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In series B, 25 patients were analysed, five very good, 11 good, three medium and six poor. The results show that 66% of these extreme salvage flexor tendon situations were greatly improved. The technique also produces favourable trophic changes. Finger skin becomes more supple and sensitive, joints are less stiff and are mechanically active, and flexion is improved. All this testifies good biologic recovery. Overall, 15 patients (64%) achieved an excellent, very good, or good result; this compares with an average figure of 55% in results published for similar cases in series using the two-stage procedure with or without a silicone rod. What is definite is that our results have improved by a better understanding of the flexor tendon biology and the restored gliding mechanism. This new technique seems to give better functional performance and reduces time off from work. Conclusions We present a completely new approach to flexor tendon reconstruction for major salvage surgery. Use of island flexor tendon, vascularized by ulnar mesotenon, with all its gliding surfaces intact, seems to be a major advance in dealing with adhesions and has the added merit of being a one-stage procedure. These types of ulnar vascularized tendon or tendon and skin transfers with multiple applications and good functional results could set a trend in tendon reconstructive surgery.
Toe-to-finger free flexor tendon transfer for digital flexion reconstruction (In collaboration with J. Bakhach) Based on this ‘idea’ of pedicled tendon transfer, which however may not be useful in cases with extended injury of the entire flexion mechanism, we have transferred the flexor mechanism of the second toe as a free composite flap and repaired ‘en bloc’ and in a single operation, the flexor
Figure 14
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tendons, digital theca and palmar plates of a long finger. According to our technique, this composite flap is based on the medial plantar vessels and contains both flexor tendons of the second toe with their digital sheaths and pulleys. The results of an anatomical study which was carried out describe the different types of vascular basis of the flap and confirm the safety of the transfer (Figs 14–17).
Figure 15
Figure 16
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Figure 17 Human allotransplant of a digital flexion system vascularized on the ulnar pedicle In light of this experience, the idea of a simultaneous tendon and pulley vascularized allotransplant gradually developed, especially since several clinical cases using nonvascularized entire flexor tendon complex homografts, originally performed by E Peacock, were reported previously to produce conflicting functional results. These can be explained, doubtlessly, by an immunologic response to tendon cell components although there is little or no antigenicity to the collagen tendon structure. These tendon homografts were non-vascularized, taken from cadavers and either stored by deep freezing or preserved in Cialit. Introduction of cyclosporine in 1980 changed the indications and improved success rates of allovascularized transplantations with the use of low, non-toxic maintenance doses for these relatively weak antigenicity response organs. Ideas regarding tissue compatibility have led to more simplified techniques over the past few years. Specific characteristics of the anatomical structure of the ulnar vascular network, previous experience in homotendon grafts, the use of low dose cyclosporine, and the necessity to improve functional results have all combined to produce a successful human vascularized allotransplant of a complete digital system by microsurgery. Transplantation technique (from a cadaver) The original procedure, based on our knowledge of the ulnar blood supply of the flexor superficialis, especially of the ring finger, is described. Preoperative preparation. The donor is in a dorsal position. The arm is in hyperabduction to facilitate cooperation with the other surgical teams. A tourniquet is put on just before aorta clamping. First, the heart and liver are removed. These procedures take at least 2 hours. Then the nephrectomy can be accomplished, and during this period, the hand surgeon can perform this procedure.
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Dissection. The incision proceeds longitudinally along the forearm, starting above the anterior edge of the flexor carpi ulnaris and turning 90° along the fold of the wrist before following the interthenar fold and adopting a zigzag pattern across the palm, according to the Brunner technique, as far as the digital extremity. The different branches of the ulnar pedicle in the forearm are identified. Those supplying the skin and connected with the forearm anterior superficial venous network (usually two or three of differing calibre situated on the anterior side of the pedicle) and the tendons (usually three on the lateral side, one at the tendon-muscle junction of the flexor digitorum sublimis of the fourth finger, and two others of approximately 0.3 mm diameter at the entrance to Guyon’s canal) are then selected. The two branches supplying the joint and the cubital bone, as well as the hypothenar and dorsal branches are ligated. The flexor digitorum sublimis of the finger is separated from the flexors digitorum sublimis of the middle finger and the small finger and is dissected at the tendon-muscle junction. All the tendon-nourishing pedicles coming from the ulnar pedicle, as well as all adjacent mesotenons, are carefully preserved. The carpal tunnel and Guyon’s canal are opened, and the ulnar pedicle is separated from the ulnar nerve as far as the motor branch. All vascular and nerve structures on the ulnar side of the palm are identified and dissected, particularly the fourth common palmar digital artery. Vascular ligatures or clamps are placed at the point of division on the ulnar pedicle of the false deep branch, the deep branch, and the collateral branch of the fifth artery on the ulnar and radial sides while conserving the collateral branch of the fourth artery on the ulnar side. The superficial palmar arcade is then clamped and transected between the third and fourth opened, especially near the volar, surface of the interphalangeal joints. On the radial side of the ring finger, the procedure is the same. We also leave the collateral pedicle on the radial side in the transplant. To avoid opening the sheath and thus inducing tendon adhesions, we leave the flexor profundus in place. The use of ulnar veins to ensure venous return has been abandoned, and the veins of the superficial forearm network, which are more suitable for microsurgery, are preferred. At the wrist, the largest of the ulnar arterio-venous skin branches is dissected as well as a 3-cm segment of a superficial vein connected to it. This vein will provide venous return if the ulnar veins are inadequate. The only remaining link between the structure to be transplanted and the donor’s hand is now the ulnar pedicle itself. The tourniquet is released, and vascularization is immediate. The functional unit composed of the profundus and superficialis tendon flexors and the entire pulley system is then separated from the digital bone skeleton using a medialside access and passing behind the vascular nerve collateral branch, which must be included in the transplant. This dissection is made in the subperiosteal plane along the skeleton of P1, P2 and P3, but the tendon sheath is not opened. The ulnar pedicle is then ligated above the branch supplying the skin, and the transplant is placed in a sterile plastic container containing refrigerated serum at 40°C. Implantation. Preparation of the recipient site. The site is cleared of any sclerotic tendinous structures and all traces of the pulleys. Only the collateral vasculonervous pedicles are retained. The incision is enlarged at the ulnar pedicle and is dissected at the wrist, and the artery and ulnar veins are well individualized. A vein from the anterior side
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of the forearm is dissected, and the proximal end of the flexor digitorum profundus of the finger to be repaired is identified. Insertion of the transplant. This insertion is performed by means of barbed wire sutures integrating the lateral structures of the transplant into the periosteal edge of the recipient bed on both sides at the base of P1, the head of P1, the base of P2 and the head of P2. At P3, the anchorage is to the bone. Perioperatively, it is easy to check the functioning of the transplant by applying traction to the proximal end of the flexor digitorum sublimis. Anastomoses. The proximal extremity of the flexor digitorum sublimis and profundus is passed under the superficial palmar arch of the recipient hand to avoid vascular compression before being sutured to the distal end of the recipient flexor digitorum profundus as described by Pulvertaft. Extremities of the ulnar artery were anastomosed end-to-side. The dorsal ulnar veins are also anastomosed with recipient anterior forearm veins. Total ischaemia time was 3 hours in our case. Functional results In our case, a very good functional result was obtained 4 months later. The wrist swelling disappeared little by little, and since the patient had no active motion preoperatively, the functional result with a range of motion in flexion of 80° in the proximal interphalangeal joint and no extension defect and a range of motion in flexion of
Figure 18
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Figure 19
Figure 20
Figure 21 55° in the distal interphalangeal joint with an extension defect of 35° was considered excellent (Figs 18–20). The average total active flexion almost equalled the available range of passive motion. This finger is now very functional and perfectly adapted. Conclusions This technique is a step towards a new type of reconstruction in hand surgery. It can be used not only for the flexion system, but also for bone and joints. For the moment, medicolegal constraints are severe, and exacting criteria must be met before any transplant can be performed. Such constraints may diminish over time, and techniques of repair and reconstruction such as those described here will be able to develop freely for use in selected patients. Despite the success of this technique, it should be reserved for complex cases where conventional techniques are not possible.
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References Boyes JH (1950) Flexor tendon grafts in the fingers and thumb: an evaluation of end results, J Bone Joint Surg 32A:489. Guimberteau JC, Panconi, B (1990) Recalcitrant nonunion of the scaphoid treated with a vascularized bone graft on the ulnar artery, J Bone Joint Surg 72:88. Guimberteau JC, Goin JL, Panconi B, Schumacher B (1988) The reverse ulnar artery forearm island flap in hand surgery: About 54 cases, Plast Reconstr Surg 81:925. Guimberteau JC, Goin JL, Panconi B, Schumacher B (1989) Tendon ulnar artery island flap in hand surgery: technique, indications, Eur J Plast Surg 12:12. Guimberteau JC, Baudet J, Panconi B, Boileau R, Potaux L (????) Human allotransplant of a digital flexion system vascularized on the ulnar pedicle: A preliminary report and 1 year follow-up of two cases, Plast Reconstr Surg 89:11–35. Guimberteau JC, Kleinert H, Verdan CI (2001) New Ideas in Hand Surgery. Island Vascularized Flexor Tendons Transfers, The Sliding System. Aquitaine Domaine Forestier Hunter JM (1985) Tendon salvage and the active tendon implant: A perspective. Symposium on flexor tendon surgery, Hand Clin 1:J8J. Littler JW (1947) Free tendon grafts in secondary flexor tendon repair, Am J Surg 74:315. Lundborg G, Holm S, Myrhage R (1980) The role of the synovial fluid and tendon sheath for flexor tendon nutrition , Scand J Plast Reconstr Surg 14:99. Paneva Holevitch E (1972) Résultats du traitement des lésions multiples des tendons fléchisseurs des doigts pargreffe effectuée en deux temps, Rev Chir Orthop Repar 58:481. Potenza AD (1963) Critical evaluation of flexor-tendon healing and adhesion formation within artificial digital sheath, J Bone Joint Surg 45A:1217. Strickland JW (1989) Flexor tendon surgery: 2. Free tendon graft and tenolysis, J Hand Surg J4B:358. Tubiana R (1986) Traité de la Chirurgie de la Main, vol. 3. Masson: Paris. Verdan CE (1975) The decades of tendon surgery. In: American Academy of Orthopedic Surgeons Symposium on Tendon Surgery. Mosby: St Louis.
Compound transfers
18 Composite tissue transfer in the upper extremity Günter Germann and Simone Brüner
Introduction Compound defects in the upper extremity are most frequently caused by high impact injuries such as contusion trauma or gun-shot injuries. Rare causes are tumour resections, necrotizing infections or tissue necrosis following extravasation of cytostatic agents or irradiation. Most severe injuries involving vascular trauma can threaten survival of the upper limb (Pulcini et al 2000). Before the introduction of microsurgical techniques into the clinical routine, complex defects frequently ended in amputation. Although microvascular repair and the introduction of free tissue transfer had already improved the survival rate of severely injured upper extremities, major advances occurred when the concepts of ‘onestage reconstruction’, ‘emergency free flaps’ and ‘chimeric free flaps’ were introduced into clinical practice (Germann et al 1999, Koshima 2001, Nisanci et al 2002, Rogachefsky et al 2002). There is no generally used classification system for complex tissue defects in the upper extremity. For the purpose of this chapter, we have designed a simple descriptive classification system: 1. Extended skin and soft tissue defects—Type A defect. 2. Skin and soft tissue defects involving muscles and tendons—Type B defect. 3. Skin and soft tissue defects involving neurovascular structures—Type C defect. 4. A–C + segmental bone defects—Type D defect. The introduction of free tissue transfer into plastic surgery opened the door to an entirely new world of reconstructive procedures. Large defects could be resurfaced with a single procedure thereby reducing treatment time, treatment cost and patient morbidity. The latissimus dorsi muscle either as a pure muscle or as a myocutaneous flap soon became the workhorse of reconstructive procedures, because of its large surface area, reliable anatomy and large vascular calibre (Rogachefsky et al 2002). A wide variety of free flaps were introduced in the years following, including myocutaneous flaps such as the tensor fascia lata flap (TFL); pure cutaneous flaps such as the scapular flap; fascio-cutaneous flaps such as the lateral arm flap or the dorsalis pedis flap; and muscle flaps such as the gracilis flap or the rectus abdominus flap. Increasing knowledge about the anatomical properties of the flaps led to the introduction of new concepts. Nerve reconstructions of muscle flaps facilitated functional muscle transfer to replace lost muscles or nerve function. Harvesting side branches of vascular pedicles
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allowed ‘flow-through flaps’ with the reconstruction of vascular defects (Germann et al 1999, Horch et al 1999, Pulcini et al 2000, Chun and Sterry 2001, Koshima 2001, Sauerbier et al 2001, Tropet et al 2001, Fairbanks and Hallock 2002, King et al 2002, Nisanci et al 2002, Rogachefsky et al 2002, Wei et al 2002a, Yang et al 2002). Prefabrication of flaps either by implantation of arterio-venous fistulae under defined skin territories, or by prefabrication via vascularized fascia transfer and pre-expansion were the next step in tailoring the reconstructive strategies to specific requirements of the defects. Pre-expanded flaps were introduced to increase the surface area of commonly used flaps. The variety of refinements and modifications resulted in the most recent development, the so-called chimeric or designer flaps. These flaps include several components of tissue raised on one vascular pedicle, and are customized to the requirements of the defect. These flaps are frequently used as osteocutaneous flaps in facial reconstruction. The introduction of these type of flap into the treatment strategies for complex upper and lower extremity defects have promoted the concept of ‘onestep reconstruction’ (Koshima et al 1993, Fairbanks and Hallock 2002).
Reconstructive strategy Traditionally, compound defects either caused by tumour resection or by trauma, were reconstructed in a multistage approach. After the defect was reconstructed with appropriate means (pedicle flap, free flap), functional structures were reconstructed in several stages. Nerve grafts were usually planned after an interval of 6 weeks to 4 months. Tendon transfers were frequently performed at even later stages. Bony defects were reconstructed by multiple graft procedures, with usually the first procedure carried out at the time of nerve reconstruction. This concept led to prolonged duration of treatment, multiple hospital stays and delayed social and professional reintegration (Germann et al 1999, Tropet et al, 2001). After Marco Godina’s pioneering work on the lower extremity, there was clear evidence that early reconstruction, ideally within 5–7 days post trauma, resulted in superior treatment results. The concept was quickly adopted by leading hand and plastic surgery centres. The reconstructive concept fundamentally changed from delayed staged reconstruction to ‘as early and as complete as possible’. Alternately the concept of ‘emergency free flap’ was introduced, originally meaning immediate soft tissue reconstruction after appropriate debridement (Tropet et al 2001). The terminology in the literature is confusing, since free flaps performed within 48 hours postadmission are also called immediate free flaps by some authors. Summarizing the literature, a one-stage reconstruction following trauma consists of: • radical debridement at the time of admission • preserving all functional structures whenever possible • removal of all tissue of questionable viability • immediate reconstruction—as far as infrastructure, logistics, availability of microsurgical teams, situation of the patient, etc. allow • scheduled second look 48 hours post trauma with immediate one-stage reconstruction, if indicated.
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In selected cases of severe contusion injuries or necrotizing infections, consecutive second looks may be scheduled. Several reasons justify a scheduled second look with concomitant reconstruction: 1. No study to date has shown that immediate reconstruction yields superior results compared to scheduled early post primary reconstruction. 2. These injuries are typically admitted after regular hours when limited manpower is available, even in large units. 3. Busy hand and microsurgical units frequently have a load of other emergency cases. 4. The surgeons already have a full working day behind them and are not in ‘top shape’. 5. Operating theatre capacity may be limited. 6. Best results can be expected with a well rested team and a patient in a perfect condition, i.e. all potential morbidities are excluded as far as possible.
Selection of flaps Type A and B defects As mentioned above, flap selection depends largely on the type of defect and availability of flaps. This also includes the position of the patient, i.e. some flaps cannot be harvested in certain patient positions. Extensive soft tissue defects involving large surface areas or resulting in deep cavities together with superficial defects are usually reconstructed with chimeric flaps containing several cutaneous or muscle flaps based on the same vascular pedicle. A frequently used combination is the latissimus dorsi muscle combined with the serratus muscle or the serratus fascia (Chun and Sterry 2001). Alternatively,
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Figure 1 (a) Soft tissue defect of the dorsum of the hand after abrasion injury. The paratenon was lost and the extensor tendons exposed. Destruction of the metapopharyngeal joint of the little finger. (b) Soft tissue reconstruction with a scapular skin flap and a parascapular fascia extension to serve as new gliding tissue for the extensor tendons. the subscapular arterial system offers several more options for cutaneous flaps, such as the parascapular flap, the scapular flap or the myocutaneous latissimus dorsi flap. There are various combinations possible, which fulfil most of the requirements (Germann et al 1999, Chun and Sterry 2001, Fairbanks and Hallock 2002). Another situation where only soft tissue components are required is when the transfer of gliding tissue together with skin territories is indicated, as is sometimes encountered in defects of the dorsum of the hand with exposed tendons or following tendon reconstructions (Fig. 1). Several options are available for these situations, such as a combined deep and superficial temporal artery flap (TPF), a combined serratus and serratus fascia flap, a skin flap from the scapular system including a fascial extension, or for larger defects any combination of a flap from the subscapular arterial system with a portion of the serratus fascia. In extensive soft tissue defects, multicomponent flaps are occasionally required. The selection of the components mostly depends on the size of the defect. As in the examples discussed above, the most frequently used source of large combined flaps is the subscapular system where the individual components of the flap can be customized to
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match the length and the width of the defect. (Germann et al 1999) Alternatively, the lateral circumflex femoral artery system can be used. This system allows inclusion of the TFL, the vastus lateralis, the rectus femoris and the anterolateral perforator skin flaps. In defects with concomitant segmental loss of nerve or vascular structures ‘one-flap’ reconstructions are still possible in selected cases (Type C defects). Several flaps can be used as flow-through flaps for simultaneous arterial reconstruction. The classic example is the radial forearm flap with its large calibre vessel, but flaps from the subscapular system can also be
Figure 2 Type B defect: (a) compound soft tissue defect with loss of superficial flexor muscles and third degree open ulnar fracture—medial aspect. (b) Lateral aspect showing the severe crush defect of the extensor muscle group. (c) Despite the open fracture, plate osteosynthesis for stable internal fixation under well-vascularized soft tissue coverage is performed. (d,e) Soft tissue reconstruction with a large muscular latissimus dorsi flap plus skin graft after tendon repair and osteosynthesis. The flap was the best solution in this case due to the large surface area required. The residual function was very satisfying.
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used when the branch to the serratus muscle or the circumflex scapular artery is harvested with the pedicle, and is of sufficient calibre (Fig. 2) (Germann et al 1999, Chun and Sterry 2001, Fairbanks and Hallock 2002) Type C defects The repair of neural defects with vascularized components of chimeric flaps is rarely possible. Neural structures that are suitable to bridge gaps
Figure 3 Type C defect: (a) Severe high-voltage injury with loss of the soft tissue envelope of both forearms, muscle substance and tendons, and bilateral involvement of median and ulnar nerves. (b) Parascapular flap to the right forearm with transfer of remaining tendons to achieve residual function; partial nerve reconstruction. (c,d) Function of both hands approximately 3 months after parascapular flap to the left hand. (e) Thermoplastic splint for dynamic motion protocols after tendon transfer.
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in the ulnar or the medial nerve are not part of the commonly used compound tissue transfers, where usually only small calibre cutaneous nerves are included. However, in microsurgically transferred fillet flaps from amputated body parts, a major nerve may be occasionally included. Soft tissue defects with simultaneous loss of tendon structures (Type B, C defects) have been occasionally treated in the past with a dorsalis pedis flap as a tendocutaneous unit. However, the donor site morbidity with respect to the aesthetic appearance and the functional impairment led to a significant decline in the use of this flap. Complex tendon–cutaneous defects are, at present, usually reconstructed by soft tissue reconstruction, and a free non-vascularized transfer of the long extensor tendon system from the dorsum of the foot (Fig. 3). Tendon strips for the repair of isolated tendon defects can be included into many conventional free flaps, for example the lateral arm flap, the anterior thigh flap, and the TFL flap (Saleh et al 1999, Omokawa et al 2001, Wei et al 2002b).
Type D defects Several options are available for defects involving skeletal structures. The size of the cutaneous defect and the length of the bony gap determine the type of flap. The combination of a short bony defect with a large soft tissue deficit is usually an indication for a flap from the subscapular system including a segment of the medial or lateral scapular rim (Fig. 4). Longer defects of the radius or the ulna are an indication for an osteocutaneous fibula flap. The fibula is the ideal bone for the reconstruction of a tubular bone such as the radius. Bony consolidation occurs within 6–8 weeks, and after several years there will be almost no radiological difference between the transplanted fibula and the original radius. However, it has to be emphasized that the cutaneous island that can be raised with the fibula is limited in size. Soft tissue volume can be increased by simultaneously harvesting the soleus muscle, but this makes the dissection significantly longer and more tedious (Küntscher et al 2001). In cases of large soft tissue defects with a long segmental osseous defect two free flaps are probably the procedure of choice.
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Figure 4(d–g) Type D defect: (a) Severe crush injury with segmental bone loss, laceration of median nerve, loss of radial artery and severe semicircular soft tissue loss. (b) Intraoperative situation after nerve and tendon repair and vascular interposition vein graft to the radial artery. (c) Raised multicomponent scapular/parascapular flap with a segment of the scapula. (d) Plate osteosynthesis for stable internal fixation. (e) Flap is wrapped around the wrist and forearm. Vascular anastomosis to ulnar artery and cephalic vein. (f,g) Satisfactory function after approximately 6 weeks.
Segmental defects These are the most severe types of defects. Although, depending on the level of injury, many functional structures may be involved, one-stage reconstruction with a composite tissue transfer may still offer a solution. Free tendon or nerve grafts can be incorporated into soft tissue bone and muscle reconstruction, and have high success rate under stable, well vascularized soft tissue coverage. Stable internal or external fixation allows for early rehabilitation, and yields significantly better long-term results than primary amputation or multistage reconstruction where many secondary or tertiary procedures have to be performed in scarred tissue (Saleh et al 1999, Tropet et al 2001, Fairbanks and Hallock 2002).
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Conclusion The concept of one-stage reconstruction has revolutionized reconstructive strategy following trauma or tumour resection. The development of composite tissue transfer with the option of including all types of tissue required has facilitated this quantum leap in reconstruction procedures. Today, almost all defects can be reconstructed in a single operation, as long as debridement or tumour resection is sufficient. The wide variety of flaps available permits the reconstruction of most complex defects while simultaneously limiting donor site morbidity. Profound knowledge of the anatomy and of the possible options of combinations provide the reconstructive microsurgeon with a large armamentarium of flaps that allows customized treatment for the individual patient.
References Chun JK, Sterry TP (2001) Latissimus dorsi musculocutaneous flap based on the serratus branch with microvascular venous augmentation, J Reconstr Microsurg 17:95–8. Fairbanks GA, Hallock GG (2002) Facial reconstruction using a combined flap of the subscapular axis simultaneously including separate medial and lateral scapular vascularized bone grafts, Ann Plast Surg 49:104–8; discussion:108. Germann G, Bickert B, Steinau HU, Wagner H, Sauerbier M (1999) Versatility and reliability of combined flaps of the subscapular system, Plast Reconstr Surg 103:1386–99. Horch RE, Stark GB (1999) The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects, Plast Reconstr Surg 103:1421–7. King TW, Gallas MT, Robb GL, Lalani Z, Miller MJ (2002) Aesthetic and functional outcomes using osseous or soft-tissue free flaps, J Reconstr Microsurg 18:365–71. Koshima I (2001) A new classification of free combined or connected tissue transfers: introduction to the concept of bridge, siamese, chimeric, mosaic, and chain-circle flaps, Acta Med Okayama 55: 329–32. Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H (1993) Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle, Plast Reconstr Surg 92:411–20. Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G (2001) The concept of fillet flaps: classification, indications, and analysis of their clinical value, Plast Reconstr Surg 108:885–96. Nisanci M, Selcuk I, Duman H (2002) Flow-through use of the osteomusculocutaneous free fibular flap, Ann Plast Surg 48:435–8. Omokawa S, Mizumoto S, Fukui A, Inada Y, Tamai S (2001) Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction, Plast Reconstr Surg 107:152–4. Pulcini G, Ottaviani GM, Lancini GP, Biasca F, D’Adda F, Pouche A (2000) Vascular trauma of the upper extremities, G Chir 21:394–8. Rogachefsky RA, Aly A, Brearley W (2002) Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction, Orthopedics 25:403–8.
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Saleh M, Yang L, Sims M (1999) Limb reconstruction after high energy trauma. Br Med Bull 55:870–84. Sauerbier M, Erdmann D, Bickert B, Wittemann M, Germann G (2001) Defect coverage of the hand and forearm with a free scapula-parascapula flap, Handchir Mikrochir Plast Chir 33:20–5. Tropet Y, Garbuio P, Obert L, Jeunet L, Elias B (2001) One-stage emergency treatment of open grade IIIB tibial shaft fractures with bone loss, Ann Plast Surg 46:113–19. Wei FC, Celik N, Chen HC, Cheng MH, Huang WC (2002a) Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects, Plast Reconstr Surg 109:45–52. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH (2002b) Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps, Plast Reconstr Surg 109:2219–26; discussion:2227–30. Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC (2002) Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures, Plast Reconstr Surg 110:39–46.
19 Free functioning muscle transfer Alain Gilbert and Vittore Costa
In cases of severe muscle paralysis or destruction there are often few surrounding muscles left for tendon transfers. These are the most common indications for microsurgical muscle transplantations. Muscle transfers have been used for a long time for the coverage of large or infected defects. Although the addition of function in muscle transfer seems logical, it is not easy as several factors complicate the procedure such as the presence/absence of a good donor nerve and the tension of the muscle belly. Tamai et al (1970) had experimentally proved in dogs that the muscle transplant could remain vital and functioning. Following this, reports of clinical cases were published in several parts of the world (Shanghai 1976, Ikuta et al 1976, Harii et al 1976, Manktelow and McKee 1978, O’Brien 1977, Gilbert, 1981). However, even 25 years later, there are very few large series with long follow-up. This may be due to few indications and a certain scepticism regarding this technique.
Muscles used for free functioning transfer For transplantation of a muscle several conditions need to be fulfilled: 1. The defect created by removal should be easily filled. 2. It should be a rather long muscle with, if possible, a tendon on each extremity. 3. It should have only one neurovascular hilus or at least a major one. 4. The excursion of the muscle should be as long as possible, to obtain maximum movement. 5. Its cross-section should be thick enough to produce sufficient force (the maximum tension in mammals is 4 kg/cm2 of cross-sectional area; Carlson, 1974). Several muscles have been used: Gracilis This muscle is most frequently used. It is long (30–40 cm), with a strong terminal tendon. It is not too bulky and can be fitted into a limb without additional skin cover. It has a single proximal motor nerve, coming from the obturator nerve, that measures 6–8 cm. The only drawback is its vascular supply: there is a dominant proximal pedicle but also a secondary pedicle going to the middle part of the muscle and a small distal pedicle; since this distal pedicle is never necessary, there may sometimes be problems when the middle pedicle is
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Figure 1 The gracilis muscle. The main proximal neurovascular pedicle. ligated. If, after this ligation, the distal part of the muscle becomes dark (congested), it may be necessary to anastomose the vein from the middle pedicle. This was necessary in two cases out of 20. Pectoralis major This is a large muscle with a single vascular pedicle, but it has several motor nerves, is very bulky, and its removal creates a severe defect. Pectoralis minor This is small and weak and has been used only in facial reconstruction. It is difficult to raise, as it is deep to pectoralis major but can be isolated on one or two pedicles. Latissimus dorsi This is a very well known muscle, long, strong, with a single vascular and motor pedicle. Its removal does not create a severe defect. However, some techniques of lengthening the latissimus dorsi with the gluteal aponeurosis allow its transplantation up to the fingers. There are few indications for using a free latissimus dorsi muscle transfer in the upper extremity. Gastrocnemius This is a very strong muscle (the strongest in the body), easy to raise, with a proximal neurovascular pedicle. The sural nerve as a vascularized nerve graft (useful in Volkmann’s contracture) and/or the overlying skin can be raised at the same time. The defect created is compensated by the soleus. Its main drawbacks are its bulk and very short excursion.
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Other muscles that have been used are rectus femoris (it has several vascular hila); extensor carpi radialis brevis (too small); extensor digitorum brevis from the foot (whose vascularization is very delicate and has been used mainly for the face).
Figure 2 In some cases, it is necessary to use the second pedicle.
Surgical technique The surgical technique for gracilis transfer for elbow flexion is as follows. With the patient lying supine, the thigh is prepared including the pubis area. The muscle can be felt, at least in thin patients, by feeling its contraction during flexion–extension of the knee. This positioning is important if a combined muscle and skin flap is to be used: the area covering the muscle is very narrow and if the skin incision is not precisely positioned, the vitality of the skin flap may be impaired. Finding the muscle is not always easy as all the adductor muscles have the same direction and size. However, among these muscles, the gracilis is relatively thin and has a large proximal pedicle. Once the muscle is found, dissection is easy. On the medial aspect, the three pedicles can be found: • The distal pedicle is small and systematically sacrificed. • The middle pedicle is cut but with the vessels kept long, in order to be accessible if needed. • The proximal major pedicle is dissected carefully. The vascular pedicle is followed until the trunk of the perforator where the diameter of the artery is 1.5 mm. The nerve has an upward direction towards the inguinal ligament. It originates from the obturator nerve.
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Figure 3 (a) A 6-year-old patient. The arm was previously replanted. The biceps is destroyed. (b) The gracilis is transplanted with neurovascular anastomoses. The nerve from the biceps is used. (c,d) Active elbow flexion after 8 months. This motor nerve gives one or two branches to the muscle before the main hilus. The existence of these branches that provoke separate contraction of some groups of muscle fibres has led some authors (Mankletow 1988) to suture them separately and expect an individual contraction to reconstruct a different movement (thumb + fingers).
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Figure 4 (a) Proximal long standing paralysis of the brachial plexus. (b) Gracilis transplantation on the intercostal nerves. (c) Strong elbow flexion, lifting 2 kg. Once the pedicle is dissected (6–8 cm for vessels, 8–10 cm of nerve), the muscle can be detached; before detaching it, it is important to mark the length with regular stitches, in order to fix it with the exact tension. At this moment it is useful to inject the patient with a muscle relaxant to avoid contraction, once it is be detached. The distal tendon is cut and, protecting the pedicle, the proximal fibrous attachment to the pubis. It is then possible to cut the pedicle and transfer the muscle to the upper extremity. The muscle is placed in the arm which is widely exposed. It will be fixed proximally to the coracoid process or to the pectoralis major aponeurosis. The nerve is sutured to the donor nerve, usually the sural nerve placed 1 year before (taken from the pectoralis major nerve on the contralateral side). The size matches well and there should be no tension. The artery is sutured usually with a branch of the profundus humeral artery; the venous suture connects the vein to a superficial vein. The revascularization of the muscle is assessed, particularly the venous drainage of the distal third. If after 10–15 minutes it is dark and seems congested, the vein from the middle pedicle is sutured. Then the distal tendon is fixed with the elbow in acute flexion, using the stitches placed before to control the tension. It is usually fixed to the biceps tendon. After closure, the elbow is immobilized in flexion for 6 weeks.
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Surgical technique for transplantation in the forearm after Volkmann’s contracture There are some differences in the forearm. • The gracilis is usually too long. It is possible to use another shorter muscle (gastrocnemius, latissimus) or fix the gracilis higher in the arm. • The distal fixation is different. The tendon is sutured to the deep flexors and a special technique allows simultaneous positioning of the thumb. • It is usually possible to use a local nerve. The anterior interosseus nerve is often separated at its origin and can be used.
Figure 5 (a) Volkmann’s contracture with destruction of the flexor muscles in a 10-year-old child. (b) Transplantation of the medial gastrocnemius with the sural nerve. (c,d) Limited flexion–extension.
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• A flap may be needed as the forearm is often scarred.
Personal series Between 1977 and 2001, 39 free muscle transplantations were done in 38 patients, for various aetiologies. Only 31 were done following traumatic destruction or paralysis of muscles. One patient had a postoperative haematoma and necrosis of the muscle; he subsequently had a second gracilis transfer to the arm. Twenty-four cases were followed-up for a maximum of 12.4 years and a minimum of 11 months (average 4.7 years). The aetiologies of these were traumatic brachial plexus (n = 15); obstetrical brachial plexus (n = 3); and Volkmann’s contracture (n = 6). Gracilis was used most often (20 times) but we used also gastrocnemius (three times) and extensor carpi radialis brevis (once) in the forearm. There were 15 reconstructions of elbow flexion, seven reconstructions of finger flexion and 2 extensor reconstructions. The criteria used for assessment were: joint ROM and MMT, and the modified scale for endresult evaluation (Dellon et al 1974, Mackinnon and Dellon 1988). The results showed that 12 patients had muscle function >M3 and 12 <M3. The results are easier to assess in the arm for an elbow reconstruction secondary to paralysis than in a forearm after Volkmann’s contracture. In the latter case, the associated nerve paralysis, intrinsic wasting, and stiffness will have a deleterious
Figure 6 (a) Young paraplegic with complete brachial plexus. The gracilis is transferred using cross-chest pectoralis major nerve neurotization. (b) Elbow flexion after 1 year.
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effect on the result, even with excellent muscle contraction. For elbow flexion reconstruction, the donor nerve used was the upper pectoralis nerve from the contralateral side (13 times) and twice the sternomastoid nerve from the same side. Both of the latter had poor results with weak muscle contraction and no function. The contralateral pectoralis nerve was used in two stages. In the first stage, the upper nerve was isolated and sutured to the end of the sural nerve. The nerve was passed subcutaneously, anterior to the chest to the upper arm. At this level, a small incision allowed us to find the nerve end and mark it with a metal clip. After 3 weeks of immobilization, the progression of nerve regeneration was followed with the Tinel sign. When tapping the nerve over the chest the patient felt a slight tingling over the thorax on the donor site. Usually, after 1 year, the regeneration was considered complete and the second stage of muscle transplantation was possible. For reconstruction of finger flexion or extension, the anterior interosseus nerve was used seven times and twice a contralateral graft from the pectoralis nerve was used.
Discussion Since the first reports on clinical muscle transplantation in 1976, few series have been published. In 1988, Manktelow, using mostly gracilis, reported the results of his first 12 transfers for the forearm. Ten of these cases had good results. Akasaka et al in 1991 showed that in 17 cases of rectus femoris transplantation for elbow flexion, eight of the 11 cases assessed had resulting function >M3. In wrist extension surgery, they had performed 29 transfers in conjunction with elbow flexion. They found that nine cases had regained M3 function after 1 year. Chuang et al (1993) stated that in a series of 17 patients, using intercostal nerve transfers, seven had good results (>M3). Groting et al (1990), used gracilis and tensor fascia lata in 12 patients with satisfactory results (M4) in 11 cases. Berger and Brenner (1995) used a free latissimus dorsi (8 times) for elbow reconstruction after brachial plexus paralysis. They found an average of 1–2 kg of power against resistance. Doi et al (1993) suggested using free muscle transfers for the combined reconstruction of two functions, i.e. elbow flexion and fingers flexion or elbow flexion and wrist extension. They operated 46 patients (58 muscles) of which 31 had had post-traumatic loss. The donor nerves were the accessory nerve or intercostal nerves. They claimed that with a double muscle transfer or a double function, single muscle transfer, the results are good, allowing useful function in completely paralysed patients. Ercetin (1994) showed that in transplanting gracilis muscle for Volkmann’s contracture, he could obtain active flexion of the fingers in 23 cases out of 28. Although these series are few in number, they all demonstrate the feasibility of vascularized muscle transfer. The results vary from 40% to 70%. Useful results were acheived depending on various factors such as: • A good donor nerve is necessary. In cases of brachial plexus paralysis, authors have used several extraplexal neurotizations (sternomastoid nerve, intercostal nerves, contralateral C7 or pectoralis nerve). These nerves cannot bring axonal influx of the same quality as an anterior interosseus nerve, or a musculocutaneous nerve.
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• Sensation in the hand is very important, not for recovery of the motor nerve but for its use. • Associated nerve lesions can impair the result. In finger flexors reconstruction, the addition of an ulnar nerve paralysis, with claw and lack of thumb adduction will not allow good function. Provided these problems can be avoided, the procedure is reliable and can give some very good results.
References Akasaka Y, Hara T, Takahashi M (1991) Free muscle transplantation combined with intercostals nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries, Microsurgery 12:346–51. Al-Qattan M (2001) Severe traumatic soft-tissue loss in the antecubital fossa and proximal forearm associated with radial and/or median nerve palsy: nerve recovery after coverage with a pedicle latissimus dorsi muscle flap, Ann Plast Surg 46:125. Berger A, Brenner P (1995) Secondary surgery following brachial plexus injuries, Microsurgery 16:43. Brooks M, Seddon HJ (1959) Pectoral transplantation for paralysis of the flexor of the elbow , J Bone Joint Surg (Br), 41B:36. Bunnell S (1951) Restoring flexion to the paralytic elbow, J Bone Joint Surg (Am) 33A:566. Carlson, FD, Wilkie DR (1974) Muscle Physiology. Prentice Hall: Englewood Cliffs, WJ. Carroll RE, Kleinman WB (1979) Pectoralis major transplantation to restore elbow flexion to the paralytic limb, J Hand Surg 4:501–7. Chinese Medical Journal (1976) Free muscle transplantation by microsurgical neurovascular anastomoses, Chin Med J 2:47–50. Chuang DC, Epstein MD, Yen MC et al (1993) Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injuries), J Hand Surg (Am) 18:285. Chuang DC, Carver N, Wei FC (1996) Results of functioning free muscle transplantation for the elbow flexion, J Hand Surg (Am) 21:1071–7. Clark JM (1946) Reconstruction of biceps brachii by pectoral muscle transplantation, Br J Surg 34:180. Dellon AL, Curtis RM, Edgerton MT (1974) Reeducation of sensation in the hand after nerve injury and repair, Plast Reconstr Surg 53:297–305. Doi K, Sakai K, Ihara K et al (1993) Reinnervated free muscle transplantation for extremity reconstruction, Plast Reconstr Surg 91:872. Doi K, Marumatsu K, Hattori Y et al (2000) Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results, J Bone Joint Surg (Am) 82:652–66. Ercetin O, Akinci M (1994) Free muscle transfer in Volkmann’s ischaemic contracture, Ann Chir Main 13: 5–12.
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Eggers IM, Mennen U, Matime AM (1992) Elbow flexorplasty: a comparison between latissimus dorsi transfer and Steindler flexorplasty, J Hand Surg (Br) 17:522. Gilbert A (1981) Free muscle transfers, Int Surg 66:33–5. Gordon L, David G et al (1993) The serratus anterior free-muscle transplant for reconstruction of the injured hand: an analysis of the donor and recipient sites, Plast Reconstr Surg 92:97. Gousheh J, Arab H, Gilbert A (2000) The extended latissimus dorsi muscle island flap for flexion or extension of the fingers, J Hand Surg (Br and Eur) 22B:160–5. Groting JC, Bunckle HJ et al (1990) Functional restoration in the upper extremity using free muscle transplantation. Ann Hand Upper Limb Surg 9:98–106. Gutowski KA, Orestein HH (2000) Restoration of elbow flexion after brachial plexus injury: the role of nerve and muscle transfers, Plast Reconstr Surg 106:1348. Harii K, Ohmori K, Torii S et al (1976) Free gracilis muscle transplantation by microvascular anastomoses Plast Reconstr Surg 57:133–43. Hohmann G (1918) Ersatz des gelahmten Bizeps brachii durch den Pectoralis major , Munchen Wchnschr 65:1240. Ikuta Y, Kubo T, Tsuge K (1976) Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture, Plast Reconstr Surg 76:413–26. Ikuta Y, Yoshioka K, Tsuge K (1979) Free muscle graft applied to brachial plexus injury—case report and experimental study, Ann Acad Med Singapore 8:454–8. Lange F (1930) Die Epidemische Kinderlahmung. JF Lehmanns Verlag: Munchen. Lim AYT, Pereira BP, Eng B et al (2001) The long head of the triceps brachii as a free functioning muscle transfer, Plast Reconstr Surg 107:1746–52. Mackinnon SE, Dellon AL (1988) Results of nerve repair and grafting. In: Mackinnon SE, Dellon AL, eds Surgery of Peripheral Nerve, Thieme Medical Publishers: New York, 117–18. Manktelow RT (1988) Functioning microsurgical muscle transfer , Hand Clin 4:289. Manktelow RT, McKee NH (1978) Free muscle transplantation to provide active finger flexion, J Hand Surg 3:416–26. Manktelow RT, McKee NH, Vettese T (1980) An anatomical study of the pectoralis major muscle as related to functioning free muscle transplantation, Plast Reconstr Surg 65:610. Manktelow RT, Zuker RM, McKee NH (1984) Functioning free muscle transplantation, J Hand Surg 9(A):32. Marshall RW, Williams DH, Birch R, Bonney G (1988) Operation to restore elbow flexion after brachial plexus injuries, J Bone Joint Surg (Br) 70B:577–82. Morris SF, Yang D (1999) Gracilis muscle: arterial and neural basis for subdivision, Ann Plast Surg 42: 630–3. O’Brien BMc (1977) Microvascular Reconstructive Surgery . Churchill Livingstone: Edinburgh, 290–305. Pierce TD, Tomaino MM (2000) Use of the pedicled latissimus muscle flap for upperextremity reconstruction, J Am Acad Orthop Surg 8:324–31. Schenck RR (1977) Free muscle and composite skin transplantation by microsurgical neurovascular anastomoses, Othop Clin North Am 8:367–75. Songcharoen P (1995) Brachial plexus injuries in Thailand: a report of 520 cases, Microsurgery 16:35–9.
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Spira E (1957) Replacement of biceps brachii by pectoralis minor transplant: report of a case, J Bone Joint Surg (Br) 39B:126–7. Steindler A (1918) A muscle plasty for the relief of fail elbow infantile paralysis. Interstate Med J 32:235. Tamai S, Komatsu S, Sakamoto H et al (1970) Free muscle with neurovascular anastomoses, Plast Reconstr Surg 46:219–25. Terzis JK, Dykos RW, Williams HB (1978) Recovery of function in free muscle transplants by microsurgical neurovascular anastomoses, J Hand Surg 3:37–59. Terzis JK, Vekris MD, Soucacos PN (1999) Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis, Plast Reconstr Surg 104:1221. Zancolli E, Mitre H (1973) Latissimus dorsi transfer to restore elbow flexion: an appraisal of eight cases, J Bone Joint Surg (Am) 55A:1265–75. Zukowski M, Lord J, Ash K et al (1988) The gracilis free flap revisited: a review of 25 cases of transfer to traumatic extremity wounds, Ann Plast Surg 40:141–4.
20 Combined soft tissue and tendon reconstruction: the dorsum and thenar regions Francisco del Piñal
Introduction Soft tissue defects that require tendon and skin reconstruction are not uncommon at the hand level. This chapter focuses on reconstructing combined defects at two locations: the dorsum of the hand and the thenar area. In the former, the skin, the tendon and, at times, the bones are destroyed by frictional or crushing forces. A lack of extension at the metacarpophalangeal joint is the main limitation. In the thenar area destruction of the abductor, the opponens and the superficial head of the flexor pollicis brevis by avulsing forces or burns poses a challenge to the hand surgeon as there is a need to restore cover and to re-establish opposition.
Compound tendon loss on the dorsum of the hand Complex dorsal hand injuries where skin and subcutaneous tissue loss is combined with extensor tendon defects have been traditionally handled by multistaged procedures: skin grafting or flap coverage followed by tendon grafting or transfer to restore extensor function at a later stage. However, transfer of compound flaps that include skin and tendon would provide, in a single stage, a solution to this complex problem. Multiple donor sites can be ‘found’ if one considers the arterial and venous distribution throughout the body, where any given pedicle supplies a tridimensional block of tissue (Taylor and Palmer 1987). However, only two have stood the test of time. Dorsalis pedis tendinocutaneous flap Taylor and Townsend (1979) showed that injecting the dorsalis pedis with India ink stained the paratenon of the extensor digitorum tendons and even ‘within the infrastructure of the tendon’ the ink was detected under the microscope. They concluded that the dorsalis pedis flap (McCraw and Furlow 1975) could be expanded to include several of the extensor tendons and presented a case report of an acute reconstruction. VilaRovira et al (1985) in corrosion studies further delineated the blood supply to the extensor digitorum tendons and the skin of the dorsum of the foot. They presented two cases in which the reconstruction was done secondarily. After those publications other
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papers have appeared in the literature (Hentz and Pearl 1987, Shen 1989, Caroli et al 1993, Lee et al 1994, Desai et al 1995, Osaka et al 1996, Cho et al 1998). The flap’s blood supply is based on tiny branches that emerge from the dorsalis pedis artery and first dorsal metatarsal artery (FDMA) (Man and Acland 1980). The presence of both is a precondition to ensure reliable nutrition to the flap. Absence of the dorsalis pedis artery is rare, but anomalies in its course are quite frequent (Cormack and Lamberty 1994) and should be taken into consideration at the time of planning. Additionally, the presence of a superficial type of FDMA should also be ascertained prior to flap elevation. If the FDMA can not be included because it lies too deep or is absent (in approximately 20% of cases) (Gilbert 1976, May et al 1977) there is major risk of necrosis of the distal part of the flap (McCraw and Furlow 1975, Taylor and Townsend 1979, Man and Acland 1980, Cho et al 1999). Angiographic studies are not routinely recommended to assess the arterial tree because of related morbidity (Upton 1998), and are reserved for situations where damage or malformations are suspected. Nevertheless, the surgeon can have a rough idea of the location of the FDMA by using the technique of Banis (1988), in which the Doppler probe is leant laterally and medially over the first web. We have found this artifice useful (although not infallible) while raising toe transfers (Piñal et al 2000). The flap is outlined in the dorsum of the foot centred over the course of the dorsalis pedis and first dorsal metatarsal arteries. The saphenous vein or any other major subcutaneous vein is marked to be included with the flap. Dissection commences distally, by ligating the FDMA. After this the tendons of the extensor hallucis brevis and/or the appropriate extensor digitorum longus are cut and tagged. Great care should be taken as the dissection proceeds proximally to include the peritenon and areolar tissues to protect the blood supply of the harvested tendons, and, at the same time, to preserve the peritenon of the extensor hallucis longus and the left out tendons, as otherwise the bed would not be graftable. Particular attention should be paid to the most proximal aspect of the first web where the FDMA may take off from the deep plantar branch of the dorsalis pedis instead of from the dorsalis pedis artery proper. If the dissection is carried out from the sides there is a real risk of severing the FDMA at this level, endangering full flap survival. To overcome this problem we have found it useful to keep the FDMA under visual control at all times while dissecting the flap from distal to proximal, and maintaining the plane of dissection immediately under the artery. Once this difficulty is overcome the dissection is terminated by cutting the tendons proximally and isolating the dorsalis pedis–anterior tibial axis in the cleft between the extensor digitorum and hallucis longus tendons. Finally the flap is transferred to the hand where tendon tensioning and revascularization are performed in a standard manner. The bed on the dorsum of the foot is closed with an intermediate thickness skin graft and a tie-over dressing. A posterior splint and strict leg elevation is obligatory to ensure a full take. Cho et al (1999) devised a variant to spare the dorsalis pedis, the flap was nourished by means of an A-V (arterio-venous) shunt montage. There are several concerns with this modification including marginal blood supply, and the need for a ‘delay’ operation that will quite probably not make it popular. In addition, the main drawback of the dorsalis pedis tendinocutaneous flap, that is, the need for skin grafting the dorsum of the foot, remains unchanged.
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Radial artery forearm flap Reid and Moss (1983) and Foucher et al (1984) introduced a modification of the reverse flow radial forearm flap (Song et al 1982, Biemer and Stock 1983) in which the tendons of the palmaris longus, flexor carpi radialis and brachioradialis were included on the radial forearm flap. The anatomical relationship of the radial artery and venae comitantes to the lateral intermuscular septum made this combination feasible. The lateral intermuscular septum is a fascial condensation attached to the undersurface of the deep fascia of the forearm bordered by the tendons of the flexor carpi radialis medially and by the brachioradialis laterally. The vessels from the radial artery travel through this mesentery to the deep fascia where they form a rich plexus. The palmaris longus which is located in a duplication of the deep fascia receives its blood supply from this plexus. Prior to raising the forearm tendinocutaneous flap, the surgeon should confirm the presence of an intact ulnar artery and adequate blood supply to the hand by Allen’s test. Consideration should be paid to the possibility of a superficial ulnar artery, as unawareness of that variant may endanger the blood supply to the hand (Fatah et al 1985). The presence of a palmaris longus tendon should also be checked. Preoperative angiography is necessary only in those cases where damage to the superficial arch is suspected: reverse flow to the radial artery through the deep palmar arch or other secondary arches can still permit the use of the ‘Chinese’ flap (Cavanagh and Pho 1992). Once the defect of the dorsum of the hand is appropriately debrided, a template of the defect is transposed to the volar forearm. The radial pedicle is identified proximally and distally and the flap outlined. Care should be taken to include the loose areolar tissue around the tendons and to include the deep fascia to protect the tiny vessels that supply the tendons. The pedicle is dissected distally up to the palmar branch of the radial artery, but if more pedicle length is required Foucher (Foucher and Merle 1992) has shown that the palmar branch can be safely ligated and the dissection carried further distally under the tendons of the anatomical snuff box up to the first web space where the radial artery communicates with the deep palmar arch. The venous drainage of this flap occurs through the radial venae comitantes, which unfortunately, have valves that block the reverse flow. The number of valves is reduced by crossconnections among the venae comitantes as Lin and co-workers (1984) have shown. However, these connections are not enough and we have found that the areolar tissue around the pedicle is important to improve the venous return of the flap; the surgeon should not skeletonize the pedicle distally to avoid damage to the tiny vessels that act as an alternative pathway to the venous drainage of this flap (Piñal and Taylor 1993). After ligating the pedicle proximally the flap is transposed to the dorsum of the hand, the tendons sutured in the standard fashion and a split thickness skin graft applied to the donor site. In reconstruction of combined extensor and skin defects, the flap has gained some popularity (Yajima et al 1996, Tamai et al 1999) mainly because it is quick to raise, is located in the same area as the defect, and does not require microsurgery. Unfortunately it does have some disadvantages: first, the main blood supply to the hand is sacrificed (Kleinert et al 1989); second, donor aesthetics are poor; and third, the combined reconstruction tends to be chunky, due in part to the thickness of the flap itself, and in part to secondary oedema due to insufficient venous drainage that, as stated above, relies
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on a complex mechanism (Piñal and Taylor 1993, Nakajima et al 1997). To improve the latter some surgeons have suggested including just the fascia (Jin et al 1985) and the vascularized tendons, but the logical approach is to restore normal haemodynamics by anastomosing a vena comitans to a local subcutaneous vein (Piñal and Taylor 1993). Decision making for complex losses on the dorsum of the hand Severe avulsion injuries to the dorsum of the hand where skin and extensor tendon have been lost creates a significant functional deficit and a major aesthetic challenge: the dorsum of the hand is, after the face, the most exposed part of the body. The surgeon should, apart from restoring extensor function at the metacarpophalangeal joint, provide a cover as close as possible to the anatomical normal: thin pliable skin, with minimal subcutaneous tissue. A chunky flap (musculocutaneous or otherwise) has no role in dorsal hand injuries, as ‘aesthetics is an important part of function’. It is conceded that, without grafting, some extension, at times, will be recovered because of spontaneous regeneration (Quaba et al 1988). The predictability of this regeneration is unreliable, however, and it is generally believed that these severe injuries require tendon reconstruction as well as flap coverage. It is possible to reconstruct the skin and subcutaneous tissue with a pedicle—or free— flap, and secondarily to place the tendon grafts. In severe cases an intermediate stage for Silastic® (Wright Medical, Arlington, TN, USA) rod placement has been recommended (Cautilli and Schneider 1995), but this multistage procedure has been associated with longer periods off work, longer recovery time and more operations as compared to single stage procedures (Sundine and Scheker 1996). Taylor and Townsend (1979) introduced the vascularized skin tendon compound free flap. The greatest advantage of using a combined tendon-skin flap is that the tendons are better vascularized and need not rely on an extrinsic blood supply to heal (Singer et al 1989). Although the concept is appealing, the fact is that similar results have been reported by simpler procedures—in single or multiple stages (Bevin and Hothem 1978, Scheker et al 1993, Cautilli and Schneider 1995, Sundine and Scheker 1996). Furthermore, the donor site can be a source of major unfavourable sequelae. In the case of the dorsalis pedis there could be delayed healing of the donor site (Fig. 1) and hyperkeratosis, fissuring, and chronic ulcers with regular shoe wear (Morrison et al 1979, Tamai and Sakamoto 1993, Babu et al 1994, Lee et al 1994, Balakrishnan 1995, Samson et al 1998). This prevents its widespread use and the present experience is limited to few cases by few authors (Vila-Rovira et al 1985, Hentz and Pearl 1987, Caroli et al 1993, Lee et al 1994, Desai et al 1995, Osaka et al 1996, Cho et al
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Figure 1 Donor site 1 month after raising a compound dorsalis pedis flap. Exposure and partial necrosis of the extensor hallucis as well as the tarsal bones are evident. 1998, Ian Taylor personal communication 2002). The donor site of the forearm flap is ugly, for men and women alike, and it requires sacrificing the major blood supply to the hand (Kleinert et al 1989), which is not desirable particularly after a severe injury to the hand. The lateral arm free flap (Katsaros et al 1984, 1991) has been extensively used in hand reconstruction by the Louisville group (Scheker et al 1987) with impressive results for combined dorsal injuries such as those we are discussing in this chapter (Scheker et al 1993). In Scheker’s protocol the skin is replaced by a lateral arm flap and in a single stage the tendons (and if required the bones) are reconstructed. The latter are woven through the fat of the lateral arm flap, and the patient is put into an immediate protected mobilization programme. I have no doubt that at present the best results are obtained with Scheker’s protocol, and I wholeheartedly recommend it. However, I am not entirely satisfied with the lateral arm flap as it is at times too bulky particularly in obese, women, and when not harvested directly over the epicondyle. To overcome this problem we prefer to use a fascial flap, as it fulfils the requirement of being extra thin, with minimal donor site complications, and
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robust blood supply. We have found the lateral arm fascial flap (Yousif et al 1990) most useful or even the anterolateral thigh fascial flap (Song et al 1984, Gu et al 1991, Wei et al 2002), but as stated above any fascial flap is appropriate. In patients who want hidden donor site scars alternative flaps are the dorsalis pedis myofascial flap (Ismail 1990, Piñal and Herrero 2000), and the temporalis fascial flap (Smith 1980, Brent et al 1985). Unfortunately, fascial flaps are not thick enough to harbour the extensor tendon grafts within their substance. As a compromise, we place the tendon grafts under the flap where the fascia has a gliding surface, recognizing that the ideal position is the fat layer. A medium thickness or full thickness skin graft from the groin is placed on top of the fascia (Fig. 2). Finally, we would stress that, in our experience, to achieve a good functional result the important point has been, whether the debridement was radical and the reconstruction immediate (or in few days) and not which flap we selected. Sundine and Scheker (1996) have shown this beautifully and I cannot agree with them more.
Figure 2 (a) Friction injury to the dorsum of the hand with loss of extensors to the 2nd, 3rd, 4th and common to the 5th in a 54-year-old. The index was destroyed and only the ulnar part could be preserved and filleted. (b) Reconstruction of
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the extensor tendon and sagittal bands with nonvascularized flexor tendon grafts taken from the amputated index. (c) Harvested free anterolateral thigh fascial flap. Notice the gliding surface underneath the fascia. A skin graft would be placed directly on top of the fascia. (Inset: flap design on the thigh, and marked perforators.) (d) Result 3 months later. (P, descending branch of the lateral femoral circumflex artery and vein. K, knee arrow points to the anterosuperior iliac spine.)
Compound thenar mass losses When a traumatic agent primarily acts on the thenar eminence the damage usually follows a classic progressive pattern (Fig. 3). In stage 1 there is destruction of the superficial thenar muscles—abductor pollicis, superficial head of the flexor pollicis. In stage 2 the opponens pollicis is destroyed too. The adductor pollicis and deep head of the flexor pollicis are usually spared in this intermediate stage, as the first metacarpal and trapezium act as a barrier to the progression of the traumatizing agent. However, if the injuring agent continues to act there will be destruction of the first web muscles—stage 3, and, at times, thumb amputation—stage 4. In the first stage (superficial damage) the appropriate treatment is debridement of the necrotic tissues and application of a skin graft directly over the healthy muscles (or a local flap). There would be minimal functional impairment as other muscles (opponens pollicis, abductor pollicis longus) would compensate the loss of the abductor pollicis brevis and/or flexor pollicis brevis. In the second stage the abductor pollicis longus compensates (in part) for the absence of the abductor pollicis brevis but no other muscle would give palmar abduction and pronation to the thumb. The clinical scenario would be similar to a median nerve palsy but complicated by the lack of cover. Closure by means of a skin graft cannot be a definitive treatment as no tendon
Figure 3 Classification of thenar injuries (see text for details).
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will glide under a scarred bed. The surgeon has to provide a cover stable enough to resist shearing forces, and at the same time pliable and well vascularized to provide an unscarred bed to serve as a gliding path for a tendon transfer. There are many available sources of motors for opponensplasty (Davies and Barton 1999) and flaps to restore thenar muscles function, and this is probably the usual way to proceed. Under certain circumstances a free functioning muscle transplant (FFMT) may be a good alternative: it provides cover and function at the same time, does not require reeducation (the motor branch of the median nerve will reinnervate the transfer), and adds to the damaged limb (sparing donor motors). The serratus (Mathes and Alpert 1988), the extensor digitorum brevis (Tamai et al 1983, Zhu et al 1985, Mitz 1986) and the abductor hallucis (lbaraki and Kanaya 1995) all have been used to reconstruct the thenar muscles. The size of the serratus and the need to apply a skin graft directly over the muscle has not made it popular. Similarly, the extensor digitorum brevis has fallen into disrepute after several papers reported lack of strength and excursion in facial reanimation (Terzis and Mersa 2001). The abductor hallucis is a good replacement for the thenar mass and is covered by fixed glabrous skin. Abductor hallucis Ibaraki and Kanaya (1995) first introduced the concept of thenar mass reconstruction with the abductor hallucis (AH) flap. Others have presented promising results with this flap (l ik et al 1997, Piñal et al 2002b). The muscle extends from the medial calcaneal tubercle to the medial sesamoid. It receives its blood supply from the medial plantar vessels located in the cleft between the flexor digitorum brevis (FDB) and the AH. The innervation comes from the medial plantar nerve which sends two or more dominant branches (Hua et al 1995). The cutaneous portion of the flap is delineated over the muscle, and although a flap of considerable dimensions can be harvested, we try to keep the skin flap as small as possible to avoid the risk of donor site problems. The muscle limits are easily identified except its distal portion where, on the lateral aspect, it is joined by the flexor hallucis brevis. To avoid any possibility of confusion we begin on the medial aspect going deep to the muscle and above the periosteum of the navicular and cuneiforms. The deep branch of the medial plantar artery is ligated and the dissection carried out until the medial plantar pedicle is located at the lateral edge of the muscle. It is surprising, when beginning to dissect the flap, how deep the pedicle is located. The surgeon should remember that there is safety in carefully following the undersurface of the muscle, there is no structure that may be damaged until the medial plantar pedicle is located in the cleft between the FDB and AH. The tendon is identified distally and the fibres of the flexor hallucis brevis dissected out. Muscle harvesting proceeds quickly now by cutting on the outer limits of the flap and ligating the vascular pedicle on its distal aspect. At this stage the nerve branches to the muscle are dissected from the medial plantar nerve by intraneural dissection, and tracked proximally until a single nerve trunk of sufficient length for late suturing is obtained. The medial plantar nerve proper need not be sacrificed as recommended by Hua and colleagues, as this unnecessarily increases the morbidity in the donor site. Finally the AH is freed from its proximal insertion and the medial plantar artery and vein are
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dissected up to the posterior tibial vessels (Fig. 4a). The lateral plantar vessels are ligated and the AH is pedicled on the posterior tibial vessels ready for transfer (Hua et al 1995, Ibaraki and Kanaya 1995, I ik et al 1997, Piñal et al 2002b). In an attempt to minimize morbidity in our most recent case we have directly used as donor the medial plantar artery, which is large enough for a safe end-to-side anastomosis to the ulnar artery. The veins can be dissected further proximally, continuing with the posterior tibial venae comitantes and thus have a venous pedicle of 4 or 5 cm, long enough to go to the dorsal aspect of the wrist, escaping from the area of injury (Fig. 4b). The tourniquet is now released and the muscle should be left for at least 20 minutes to recover. As shown by Manktelov, functioning muscle has a poor ischaemic tolerance and hence the hand should be fully prepared prior to severing the pedicle. The motor branch of the median nerve should be dissected proximal to the carpal tunnel for a straightforward neurorraphy to the motor branch of the AH (Fig. 4c). Once the muscle is transferred to the hand the nerve is repaired first, then the medial plantar artery is anastomosed end to side to the ulnar artery in Guyon’s canal (or the posterior tibial artery to the ulnar artery proximally). The muscle is anchored to the pisiform-medial fascia of the hypothenar region with resorbable sutures. The tendon of the AH is split and sutured under tension to the medial aspect of the metacarpophalangeal joint and to the extensor apparatus as recommended by Brand (Davies and Barton 1999). Finally the venous anastomoses are completed to any local healthy vein (Fig. 4d). Donor site closure deserves special attention. The medial plantar nerve is protected by the flexor digitorum brevis which is mobilized medially and sutured with absorbable sutures to the periosteum. To assure full take on the donor site we prefer to delay skin grafting for several days. A posterior splint and rest are advised until full take of the graft. A compressive stockinet is prescribed for 3 months. Decision making for complex thenar mass losses Massive soft tissue destruction of the thenar eminence poses a phenomenal reconstructive challenge. The surgeon has to use classic techniques such as tendon transfers and ‘newer’ ones such as free flaps, toe to hands, etc. In stage 2 the decision has to be made between a flap + tendon transfer or an FFMT. For this decision we take into consideration several factors: the most important being age, associated trauma, available motors, and fitness. Disappointing results have been reported when using FFMT in brachial plexus surgery in patients older than 40 years (Doi et al 2000, Nagano 2001). However, this limitation may not apply in thenar reconstruction where a pure motor nerve is joined to another pure motor nerve, in fact, good results have been presented in free functioning muscle transfer for facial palsy in patients up to 70 years old (Harii et al 1998). Probably it would be reasonable to avoid functioning muscle transfer above 55 years. Our experience is, however, limited to young patients. The more associated damage to the hand, the more we
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Figure 4 (a) Operative picture while harvesting the abductor hallucis. Arrows point to nerve branches to the muscle isolated in a common trunk after intraneural dissection of the medial plantar nerve (*). A hollow arrow points to the medial plantar artery. (Inset: corresponding panoramic view.) (b) Harvested abductor hallucis myocutaneous free flap. (c) Prepared bed in a type 2 thenar injury for an abductor hallucis transfer. The motor branch of the median nerve has been isolated by intraneural dissection for easy nerve coaptation proximal to the carpal canal. The ulnar artery has been isolated at Guyon’s canal for end-to-side anastomosis to the medial plantar artery. A branch of the basilic vein has been tagged at the dorsum of the wrist (arrow), direct anastomosis to the posterior tibial vein will be possible. (d) Flap inset. (VC, vena comitantes of the posterior tibial artery; A, medial plantar artery; N; motor nerve to the abductor hallucis.) prefer a FFMT. The indication of an abductor hallucis should not be taken lightly however, any FFMT is more involved than a ‘normal’ free flap, and the muscle tolerance to ischaemia is lower if function is to be expected from the transfer (Manktelov 1988, Chuang 1997). Besides this, the abductor is difficult to harvest, and a skin graft has to be placed on the sole.
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In contrast to the abductor hallucis the tendon transfer is a simpler operation, particularly if it can be combined with a local flap so as not to require microsurgery. Several tendons can be used as motors: EIP (extensor indicis proprius) to APB (abductor pollicis brevis) tendon, or FDS IV (flexor digitorum superficialis) to abductor tubercle using a pulley at the palmar edge of the carpal canal or on a loop at the flexor carpi ulnaris as recommended by Bunnell being among the most popular (Davis and Barton 1999). If the surgeon decides to use a tendon transfer and there is major loss of soft tissue, I believe that it should be combined with a free flap rather than a local flap: a free flap provides the best tissue in the ideal place, with a first class blood supply and the ability to heal with minimal scarring. Management of stage 3 is much more complex. The deficient thumb, as in a combined low median-ulnar nerve palsy, is unable to oppose and lacks strength and stability on side pinch (plus a massive soft tissue defect). FFMT have been reported to restore the adductor pollicis (Zhu et al 1985) but the results have been disappointing. Zancolli (1979) recommends an opposition transfer only if the metacarpophalangeal joint of the thumb is stable (Zancolli plan 1), and an opponensplasty plus an adductorplasty if the surgeon wants to provide a strong and more stable thumb (Zancolli plan 2). Again the opposition can be restored by a FFMT or a tendon transfer. Stage 4 injury can be managed by pollicization or by adding a toe to the strategy referred above for stage 3. Pollicization is, in our opinion, the best operation when there has been damage to the trapezio-metacarpal joint and/or to the index. Pollicization has to be combined with some kind of flap (a posterior interosseus (Zancolli and Angrigiani 1988, Masquelet 1998) or a free flap) as the soft tissue loss is always extensive (Binhamer and Lister 1997). Under certain circumstances (young patient, index spared, work that requires five digits) a toe to hand transfer can be considered, transforming the situation to a stage 3 (Fig. 5). Management of severe trauma to the thenar eminence deserves three additional considerations: 1. Ideally the reconstruction should be done early, in the acute phase. The results are better then, in our experience, than for the traumatized hand in general (Gupta et al 1999). 2. Major trauma to the thenar eminence is frequently accompanied by silent acute compartment syndrome involving neighbouring compartments, not directly released by the injury, that may be responsible for adverse sequelae. The surgeon should be aware that compartment syndrome of the hand may occur with minimal signs and symptoms (Piñal et al 2002a). Low threshold to measure the compartmental pressure is the only way to prevent further damage. 3. Lastly, any major trauma to the thumb inexorably evolves to first web contracture unless a programme of early serial casting or splints is started soon after the injury. Established first web contracture unnecessarily complicates the reconstructive plan and is (nearly) always preventable if the surgeon takes the appropriate measures.
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References Babu V, Chittaranjan S, Abraham G, Korula RJ (1994) Single-stage reconstruction of soft-tissue defects including the Achilles tendon using the dorsalis pedis arterialized flap along with the extensor digitorum brevis as bridge graft, Plast Reconstr Surg 93: 1090–4. Balakrishnan C (1995) Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction (letter), Plast Reconstr Surg 95:1335–6. Banis C (1988) Thin cutaneous flap for intraoral reconstruction: the dorsalis pedis free flap revisited, Microsurgery 9:132–9. Bevin AG, Hothem AL (1978) The use of silicone rods under split-thickness skin grafts for reconstruction of extensor tendon injuries, Hand 10:254–8. Biemer E, Stock W (1983) Total thumb reconstruction: a one-stage reconstruction using an osteo-cutaneous forearm flap, Br J Plast Surg 36:52–5. Binhamer P, Lister G (1997) Pollicization. In: Foucher G, ed. Reconstructive Surgery in Hand Mutilation. Martin Dunitz: London, 29–39. Brent B, Upton J, Acland RD et al (1985) Experience with the temporoparietal fascial free flap, Plast Reconstr Surg 76:177–88. Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina PB (1993) Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction, Plast Reconstr Surg 92:1326–30.
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Figure 5 (a) Type 4 thenar injury after a combined burn-crush. Debridement included all thenar and first web muscles. Only the ulnar hemipulp of the thumb remained viable (and innervated). Reconstruction was performed 72 hours later. (b) Intraoperative view highlighting the tendons used to motorize the first ray: (1) The FDS IV has been retrieved distal to the carpal ligament and ulnar to the palmar fascia that will act as the pulley for the opponensplasty as recommended by Royle–Thompson (Davis and Barton 1999). A silastic® rod (2) follows the path of the adductorplasty as recommended by Edgerton– Omer (modification of Smith transfer: ECRB-third web space–abductor tubercle) (Omer 1999). The rod will be used in a second stage to guide a tendon graft and avoid dangerous dissection around vital nerves and vessels (artifice suggested by May (1990)). The radial half of the trapezi-metacarpal joint was lost as was the abductor pollicis longus (3). The latter will be reconstructed by an
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interposition tendon graft. A segment of non-vascularized humerus restored the dorsal two thirds of the metacarpal. Arrows point to the proximal stumps of the FPL and EPL to be sutured to the flexor and extensor hallucis longus respectively. (c) The thumb has been reconstructed with a custom made (Foucher et al 1980) trimmed-toe transfer (Wei et al 1988) in such a way that the innervated ulnar thumb’s pulp was used to cover the ulnar portion of the toe. Coverage of the dorsum and the thenar eminence will be achieved by a split lateral arm free flap (*). Notice that the silastic® rod has been sutured around the rebuild first ray metacarpal to provide not only adduction but pronation (Edgerton in Omer 1999). The tension provided to the APL and the opponensplasty transfer spontaneously places the first ray in a physiologic palmar abducted stance. (d) Result at 6 months. (e) Thumb motion and pinch power at 6 months (the bottle is full). Cautilli D, Schneider LH (1995) Extensor tendon grafting on the dorsum of the hand in massive tendon loss, Hand Clin 11:423–9. Cavanagh S, Pho RWH (1992) The reverse radial forearm flap in the severely injured hand: an anatomical and clinical study, J Hand Surg 17B:501–3. Cho BC, Lee JH, Weinzweig N, Baik BS (1998) Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction, Ann Plast Surg 40:268–76. Cho BC, Byun JS, Baik BS (1999) Dorsalis pedis tendocutaneous delayed arterialized venous flap in hand reconstruction, Plast Reconstr Surg 104:2138–44. Chuang DCC (1997) Functioning free-muscle transplantation for the upper extremity, Hand Clin 13:279–89. Cormack GC, Lamberty BG (1994) The ankle and foot. In: Cormack GC, Lamberty BG, eds. The Arterial Anatomy of Skin Flaps, 2nd edn. Churchill Livingstone: Edinburgh, 258–67. Davies TRC, Barton NJ (1999) Median nerve palsy. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery, Vol 2, 4th edn. Churchill Livingstone: New York, 1497–525. Desai SS, Chuang DC, Levin LS (1995) Microsurgical reconstruction of the extensor system, Hand Clin 11:471–82. Doi K, Muramatsu K, Hattori Y et al (2000) Restoration of prehension with the double free muscle transfer following complete avulsion of the brachial plexus: indications and long-term results, J Bone Joint Surg Am 82A:652–66. Fatah MF, Nancarrow JD, Murray DS (1985) Raising the radial artery forearm flap: the superficial ulnar artery ‘trap’, Br J Plast Surg 38:394–5. Foucher G, Merle M (1992) The radial forearm island flap in hand surgery. In: Gilbert A, Masquelet A, Hentz VR, eds. Pedicle Flaps of the Upper Limb. Martin Dunitz: London, 89–99. Foucher G, Merle M, Maneaud M, Michon J (1980) Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases, Plast Reconstr Surg 65:616–26.
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Foucher G, Van Genechten F, Merle N, Michon J (1984) A compound radial artery forearm flap in hand surgery: An original modification of the Chinese forearm flap, Br J Plast Surg 37:139–48. Gilbert A (1976) Composite tissue transfer from the foot: anatomic basis and surgical technique. In: Daniller AJ, Strauch B, eds. Symposium on Microsurgery. Mosby: St Louis, 230–42. Gupta A, Shatford RA, Wolff TW, Tsai TM, Scheker LR, Levin LS (1999) Treatment of the severely injured upper extremity, J Bone Joint Surg (Am) 81A: 1628–51. Harii K, Asato H, Yoshimura K, Sugawara Y, Nakatsuka T, Ueda K (1998) One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative, Plast Reconstr Surg 102:941–51. Hentz VR, Pearl RM (1987) Hand reconstruction following avulsion of all dorsal soft tissues. A cutaneo-tendinous free tissue transfer, Ann Chir Main 6:31–7. Hua J, En-tan G, Zheng-lun J, Ming-li J, Van L (1995) One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis, Plast Reconstr Surg 96:78–85. Ibaraki K, Kanaya F (1995) Free vascularized medial plantar flap with functioning abductor hallucis transfer for reconstruction of thenar defects, Plast Reconstr Surg 95:108–13. I ik S, Sezgin M, Öztürk S, Selmanpakoğlu N, Kütükçü Y (1997) Free musculofascicutaneous medial plantar flap for reconstruction of thenar defects, Br J Plast Surg 50:116–20. Ismail TIA (1990) The dorsalis pedis myofascial flap, Plast Reconstr Surg 86:573–6. Jin YT, Guan WX, Shi TM, Quian YL, Xu LG, Chang TS (1985) Reverse island forearm fascial flap in hand surgery, Ann Plast Surg 15:340–7. Katsaros J, Schusterman M, Beppu M et al (1984) The lateral upper arm flap: anatomy and clinical applications, Ann Plast Surg 12:489–500. Katsaros J, Tan E, Zoltie N, Barton M, Venkataramakrishnan, Venugopalsrinivasan (1991) Further experience with the lateral arm free flap, Plast Reconstr Surg 87:902– 10. Kleinert JM, Fleming SG, Abel CS, Firrell J (1989) Radial and ulnar artery dominance in normal digits, J Hand Surg (Am) 14A:504–8. Lee KS, Park SW, Kim HY (1994) Tendocutaneous free flap transfer from the dorsum of the foot, Microsurgery 15:882–5. Lin SD, Lai CS, Chiu CC (1984) Venous drainage in the reverse forearm flap, Plast Reconstr Surg 74:508–12. McCraw JB, Furlow LT Jr (1975) The dorsalis pedis arterialised flap: a clinical study, Plast Reconstr Surg 55:177–87. Man D, Acland R (1980) The microarterial anatomy of the dorsalis pedis flap and its clinical applications, Plast Reconstr Surg 65:419–23. Manktelov RT (1988) Free muscle transfer. In: Green DP, ed. Operative Hand Surgery, 2nd edn. Churchill Livingstone: New York, 1215–44. Masquelet AC (1998) The posterior interosseous flap in surgery of the hand, Atlas Hand Clin 3:109–18. Mathes SJ, Alpert BS (1988) Free skin and composite flaps. In: Green DP, ed. Operative Hand Surgery. Churchill Livingstone: New York, 1151–213.
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May JW Jr (1990) Microvascular great toe to hand transfer for reconstruction of the amputated thumb. In: McCarthy JG, May JW Jr, Littler JW, eds. Plastic Surgery, Vol 8. WB Saunders: Philadelphia, 5153–85. May JW, Chait LA, Cohen BE, O’Brien BMc (1977) Free neurovascular flap from the first web of the foot in hand reconstruction , J Hand Surg 2:387–93. Mitz V (1986) Second toe to thumb transfer with extensor digitorum brevis opponensplasty, Ann Plast Surg 17:259–62. Morrison WA, O’Brien B, MacLeod A (1979) The foot as a donor site in reconstructive microsurgery, World J Surg 3:43–52. Nagano A (2001) Intercostal nerve transfer for elbow flexion. Tech Hand Upp Extr Surg 5:136–40. Nakajima H, Imanishi N, Aiso S, Fujino T (1997) Venous drainage of the radial forearm and anterior tibial reverse flow flaps: anatomical and radiographic perfusion studies, Br J Plast Surg 50:389–401. Omer GE Jr (1999) Ulnar nerve palsy. In Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery, Vol 2, 4th edn. Churchill Livingstone: New York, 1526–41. Osaka S, Hoshi M, Sano S, Nozaki M, Yamamoto M (1996) Description of new composite tissue transfer for salvage of a complex hand defect, Clin Orthop 328:91–3. Piñal F del, Taylor G (1993) The deep venous system and the reverse flow flaps, Br J Plast Surg 46:652–64. Piñal F del, Herrero F (2000) Extensor digitorum brevis free flap: anatomic study and further clinical applications, Plast Reconstr Surg 105:1347–56. Piñal F del, Herrero F, Jado E, Fuente M, García Cabeza JM (2000) Transplantes de dedo de pie a mano. Análisis de las anomalías arteriales, la disección del pie y la revascularización, Cir Plast lberlatinamer 26:309–17. Piñal F del, Herrero F, Jado E, García-Bernal JF, Cerezal L (2002a) Acute hand compartment syndromes after closed crush: a reappraisal, Plast Reconstr Surg 110: 1232–9. Piñal F del, Herrero F, Jado E, Oteo JA, García-Bernal JF (2002b) Salvage and functional rehabilitation of a massively crushed hand with two sequential free flaps. Case report, J Trauma 53:980–3. Quaba AA, Elliot D, Sommerlad BC (1988) Long term hand function without long finger extensors: a clinical study, J Hand Surg (Br) 13B:66–71. Reid CD, Moss ALH (1983) One-stage flap repair with vascularized tendon grafts in a dorsal hand injury using the ‘Chinese’ forearm flap, Br J Plast Surg 36:473–9. Samson MC, Morris SF, Tweed AEJ (1998) Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr Surg 102:1549–59. Scheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer for ipsilateral hand defects, J Hand Surg (Am) 12A:665–72. Scheker LR, Langley SJ, Martin DL, Julliard KN (1993) Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps, J Hand Surg (Br) 18B: 568– 75. Shen Z (1989) Vascularized tendon grafting from the dorsum of the foot: a functional anatomic study and clinical experience (abstract), J Reconstr Microsurg 5:90.
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Singer DI, Morrison WA, Gumley GJ et al (1989) Comparative study of vascularized and nonvascularized tendon grafts for reconstruction of flexor tendons in zone 2: an experimental study in primates, J Hand Surg (Am) 14A:55–63. Smith RA (1980) The free fascial scalp flap, Plast Reconstr Surg 66:204–9. Song R, Gao Y, Song Y, Yu Y, Song Y (1982) The forearm flap, Clin Plast Surg 9:21–6. Song YG, Chen GZ, Song YL (1984) The free thigh flap: a new free flap concept based on the septocutaneous artery, Br J Plast Surg 37:149–59. Sundine M, Scheker LR (1996) A comparison of immediate and staged reconstruction of the dorsum of the hand, J Hand Surg (Br) 21B:216–21. Tamai S, Sakamoto H (1993) Free sensory skin flap transfers to the hand. In: Tubiana R, ed. The Hand, Vol 4. WB Saunders: Philadelphia, 795–810. Tamai S, Fukui A, Shimizu T, Yamaguchi T (1983) Thumb reconstruction with an iliac bone graft and a dorsalis pedis flap transplant including the extensor digitorum brevis muscle for restoring opposition: A case report, Microsurgery 4:81–6. Tamai S, Yajima H, Inada Y (1999) Secondary reconstruction of the extensor tendons and overlying soft tissue deficiency, Hand Clin 15:555–61. Taylor GI, Townsend P (1979) Composite free flap and tendon transfer: an anatomical study and clinical technique, Br J Plast Surg 32:170–83. Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: experimental study and clinical applications, Br J Plast Surg 40:113–41. Terzis JK, Mersa B (2001) Facial reanimation. In: Goldwyn RM, Cohen MN, eds: The Unfavourable Result in Plastic Surgery. Avoidance and Treatment. Lippincott Williams & Wilkins: Philadelphia, 597–610. Upton J (1998) Direct visualization of arterial anatomy during toe harvest dissections: clinical and radiological correlations, Plast Reconstr Surg 102:1988–92. Vila-Rovira R, Ferreira BJ, Guinot A (1985) Transfer of vascularized extensor tendons from the foot to the hand with a dorsalis pedis, Plast Reconstr Surg 76:421–7. Wei FC, Chen HC, Chuang CC, Noordhoff MS (1988) Reconstruction of the thumb with a trimmed-toe transfer technique, Plast Reconstr Surg 82:506–13. Wei FC, Jain V, Celik N, Chen HC, Chuang DCC, Lin HC (2002) Have we found an ideal soft tissue flap? Experience with 672 anterolateral thigh flaps, Plast Reconstr Surg 109:2219–26. Yajima H, Inada Y, Shono M, Tamai S (1996) Radial forearm flap with vascularized tendons for hand reconstruction, Plast Reconstr Surg 98:328–33. Yousif NJ, Warren R, Matloub HS, Sanger JR (1990) The lateral arm fascial free flap: its anatomy and use in reconstruction, Plast Reconstr Surg 86:1138–45. Zancolli E (1979) Intrinsic paralysis of the ulnar and median nerves. In: Zancolli EA, ed Structural and Dynamic Bases of Hand Surgery. Lippincott: Philadelphia, 207–28. Zancolli EA, Angrigiani C (1988) Posterior interosseous island forearm flap, J Hand Surg (Br) 13B:130–5. Zhou G, Qiao Q, Chen GY, Ling YC, Swift R (1991) Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations, Br J Plast Surg 44:91–6. Zhu SX, Zhang BX, Yao JX, Li ZY, Wang XL, Fu ZG (1985) Free musculocutaneous flap transfer of extensor digitorum brevis muscle by microvascular anastomosis for restoration of function of thenar and adductor pollicis muscles, Ann Plast Surg 15:481–8.
General indications
21 Principles of emergency reconstruction Abel Nascimento
Introduction During the past 25 years, there has been a major advance in plastic reconstruction of the limbs. However, we cannot ignore the pioneering studies of Manchot (1883–88) and Salmon (1933–36) on human cutaneous vascularization (Manchot 1983, Salmon 1936). Gillies, in spite of his vast amount of work in reconstructive surgery during and after the second world war, did not achieve the expected results since he was unaware of the studies of Manchot and Salmon (Gillies and Millard 1957). It was only in the late 1970s and in the early 1980s, that knowledge of the anatomical details of limb vascularization (bone, muscle and skin) nerve cartography and flap standardization increased tremendously. The concepts of septal and subfascial vascularization, as well as direct and inverted flow flap vascularization (haemodynamic concept), were described at this time (Ponten 1981). Simultaneously, there have been major developments in experimental animal surgery, leading to a considerable increase in knowledge and the experience of general concepts of microsurgical techniques. The author has been involved in the study and standardization of several flaps (1982–83), performing research in more than 200 fresh cadavers in Paris (Nascimento 1983a, b, 1984, 1994). After an initial experimental phase of free flap application, standardization has been achieved of well defined plastic reconstructive techniques, using, whenever possible, pediculated vicinity flaps, both direct and inverted flow. Although it is a basic concept, the importance of high standards of planning and experience of the surgeon in emergency is emphasized. The hand surgeon’s knowledge should cover several surgical disciplines to obtain good results. In our opinion, they must have ‘the five fingers knowledge’ to perform hand surgery: anatomy, orthopaedics and plastic, vascular and nerve surgery. We do not advocate multidisciplinary teams to perform reconstructive surgery of the limbs. A team of hand surgeons should treat complex upper limb trauma. This team should be organized to ensure an emergency service roundthe-clock (SOS Hand University Hospital of Coimbra and Institute of Reconstructive Surgery). The treatment of complex trauma in emergency should be preceded by stabilization of vital signs with general cardiorespiratory, haemodynamic and neurologic balance. Only after a general evaluation of the trauma (cranial, thoracic and abdominal), stabilization and treatment planning can we consider the treatment of the limbs. It is obvious that, at
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the first opportunity, the limbs should be daced in the correct axial orientation. Vascular and nerve injuries should be evaluated in order to attain haemodynamic stability and protected from incurring further damage from bony splinters. Evaluation of a limb from the perspective of reconstruction is extremely important, since one should only reconstruct a limb segment in which necrosis and infections are not anticipated. As function is the ‘primum movens’ of reconstruction, the latter without a functional purpose ought to be carefully considered. Single surgical procedures, even though of great extent, should not be implemented without a strict, serious and very well defined protocol in order to recover function. Cost-benefit analysis, age, profession of the patient, etc. are important factors to consider when planning the most convenient surgical procedure to reconstruct a severely traumatized upper limb. The principle ‘primum non nocera’ should always be present in the mind of the surgeon. The vast array of surgical techniques at their disposal should not obscure good and practical clinical sense (Nascimento 1989). The strategy for emergency reconstruction of upper limb bone, muscles, vessels, nerves and skin must envisage these structures as a whole. This is a very important postulate, since reconstruction of one of these cannot be considered individually, if our goal is to obtain a good anatomical, aesthetic and functional recovery. The main principles for the reconstruction of these structures are now discussed.
Bone Bone reconstruction, in an avulsion injury or linear amputation, should follow general orthopaedic principles. The osteosynthesis should be performed using stabilization with a diaphyseal, metaphyseal intramedullary nail or fragmentary compression type plate low contact-distraction compression plate (LC-DCP). In joint trauma, if osteosynthesis for functional recovery is not possible, arthrodesis (shoulder, elbow, wrist) or replacement with a prosthesis should be considered. One of the essential rules for all avulsion injuries, due to risk of infection, is to perform debridement of dead tissue, together with thorough washing under pressure and scrubbing (including the bone), since preserving nonvascularized fragments is extremely dangerous. Bone shortening is of vital importance for the success of the surgery. One should not hesitate to shorten the bone several centimetres; besides providing a stable osteosynthesis it will avoid prolonged surgery for the repair of the other structures. We have defended this principle in several international meetings and demonstrated this to be one of the most important factors contributing to the success of macroreimplantations and sphacelus reconstruction (Nascimento 1994). The shortening of the bone should be done to enable direct suturing of vascular and nerve structures (whenever possible); musculo-tendinous anatomical reconstruction without gaps; fasciocutaneous sutures without tension; vascularization of the structures without deficit; and also to avoid the use of covering flaps. It is better to have a short functional limb than one with normal length but presenting nerve, vascular and functional abnormalities. Later on, if necessary, the reconstructed limb can be elongated using one of the several methods of bone distraction. There are cases of sphacelus/tearing away of the entire upper limb, with only the uncovered humerus remaining. Glenohumeral or even omothoracic disarticulation should
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be avoided, preserving the glenohumeral joint, either by osteosynthesis or by arthrodesis and a myofasciocutaneous flap (usually with the latissimus dorsi) (Fig. 1).
Muscles In a muscular sphacelus of the upper limb we should bear in mind several extremely important principles of surgical evaluation and planning in emergency. Muscle is a tissue that easily becomes necrotic and oedematous. Its fibres remain highly contracted and retracted and have a poor regenerative power. If the injury reaches the neuromotor plates there will be a high probability of decrease/loss of function. Nevertheless, muscles are very useful as local pediculated flaps or as free flaps for plastic reconstruction of soft tissue loss. The time to treatment of a
Figure 1 (a) Avulsion of the upper limb. Plastic reconstruction with a pediculated latissimus dorsi flap. (b) Eight days after surgery. sphacelus with major muscular involvement is short, due to the irreversible necrosis/metabolic acidosis of the destroyed or avascular muscular mass. The urgency of the repair increases as we go from the distal to the proximal portion of the upper extremity—in some situations, a distal sphacelus/amputation could wait for several hours, while a proximal one should be treated within 2–3 hours. We should always bear in mind, that repair of a proximal sphacelus/amputation with revascularization can be life threatening for the patient (the so-called revascularization syndrome, shock kidney and lung). In a forearm and arm reconstruction, the arterial part should always be done first, leaving the vein to drain freely to preclude the precipitation of the above mentioned syndrome (myoglobinuria). One of the major complications in major trauma of the forearm and the arm is the compartment syndrome. This syndrome may occur even in fractures without major injuries to other structures. Basically it starts as a haematoma of the arm, forearm (higher incidence) and hand compartments, which compromise muscle, nerve and vessel viability. It is an emergency situation which should be constantly monitored and requires decompressive fasciectomies, in order to protect the vitality of the limb and to avoid later complications (Volkmann’s contracture). In this context, in major sphacelus/amputations we perform an elementarectomy (Fig. 2) (Brunelli et al 1985). Every devitalized muscle as well as all the muscles and tendons
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that can be discard should be removed, enabling survival of the structures inside the fasciocutaneous involucre without compression from the oedema that occurs immediately. This oedema starts to decrease by the fifteenth day post surgery. This procedure is of great importance in major sphacelus/amputations, as it will avoid vascular compression in regard to the superficial venous drainage. This same procedure justifies the success of our macroreimplantations compared with international series. In forearm sphacelus/ amputations, superficial muscles and flexor tendons, as well as some muscles distal to their innervation and vascularization are discarded to achieve this aim. As we will refer to later in reconstruction by regions, the upper limb, thorax and scapular girdle muscles are very important for reconstruction, preservation and motorization in the surgical emergency protocol.
Vessels A reconstructive surgeon should have very detailed knowledge of the arterial, venous and lymphatic networks, both macro- and microcirculation, to be able to plan the ideal treatment protocol in emergency for major trauma of the upper limb. Macro- and microvascular techniques should be routine for this surgeon. As we already mentioned, we should perform, as much as possible, an end-to-end reconstruction in sphacelus/ amputation situations, even if we have to shorten a bone by several centimetres. Vascular grafts are used in lesser injuries with skeletal integrity. Bones, tendons and muscles should be the first structures to be repaired to achieve a stable vascular suture. In a brachial plexus injury with a proximal lesion of the subclavicular or axillary arteries or in presence of an omothoracic high energy distension, there is a rule which is rarely followed: reconstruction with a saphenous vascular graft of the arteries should be used as a bypass to avoid the anatomical field of the brachial plexus, so that it can subsequently be repaired free of fibrotic involvement. In our opinion this vascular reconstruction should be
Figure 2 (a) Complete amputation/sphacelus of the right forearm. Shortening of the bones and reconstruction of all structures with gracilis muscle transfer post-elementarectomy. (b) Flexion 1 year after surgery. done by the hand surgeon/microsurgeon and not by the vascular surgeon to provide the best brachial plexus recovery.
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As it is well known, there are two concomitant veins for each artery, besides the superficial fasciocutaneous veins. We emphasize the importance of the reconstruction of the concomitant veins for the success of a great sphacelus/reimplantation, even if one or two superficial veins of considerable calibre are reconstructed. Our extensive animal experimental work on amputation/reimplantation of dog’s hind limb (more than 100)—to study oedema formation and tissue regeneration, specially of lymphatic vessels—enhanced our knowledge and supports these axioms (Nascimento 1983b, 1987, 1994). That is why we insist that reconstruction of deep vascular axes accounts for success of major reconstruction/reimplantation. Well functioning veins, in the first days after reconstruction, can occlude due to decrease in speed of flow and reduction in calibre by compression from the acute oedema and hypertension. Lymphatic vessels are extremely significant in post-traumatic resolution of oedema of the upper limb. The lymphatic network, although of great importance, is almost unknown to the great majority of surgeons. Around 10 years ago, we performed thorough research (Nascimento 1994)—using experimental animal surgery and injection/dissection of fresh cadavers—to study the role of capillaries, small and great lymphatic vessels in limb injuries, namely sphacelus, amputations and fasciocutaneous flaps. We will not describe the results of these investigations in detail, but we will refer to some of the conclusions that might be useful to understand the different phases of oedema. Following an injury/trauma, the body releases different kinds of cells (macrophages, lymphocytes, platelets, etc.). These cells release chemotactic and growth factors to initiate immediate tissue regeneration. Following use of histochemical-enzymatic methods for optical microscopy, scanning microscopy, anatomical microsurgical dissection, gelatine/China ink, epoxy resin/corrosion and barium sulphate selective injection, digital arterio- and venography, direct and indirect lymphography and direct and indirect lymphoscintigraphy in dog’s hind limb amputation/reimplantation as well as after applying some of these methodologies to fresh cadavers and clinical cases of total limb reimplantations and flaps we reached the following conclusions. (1) Muscle, arterial, venous and lymphatic capillaries start regenerating immediately; (2) blood vessel reorganization begins around the third day; (3) on the seventh day there is a true reorganization/regeneration of the venous system, which markedly contributes to drainage of oedema; (4) lymphatic capillaries and afferents remain open below and above the lesion, draining the lymph to the interface; (5) only lymphatic capillaries and very small afferents can regenerate; (6) in the connective tissue of the drainage area a connection is established between the distal and proximal lymphatic afferents (lymphatic lakes); (7) as is well known, the lymphatic system removes macromolecules (>40 KDa), cleansing the interstitium distal to the wound. Although there is no regeneration of the great lymphatics, they play an important role in acute and subacute drainage of oedema in a sphacelus/reimplantation/flap. We also concluded that the venous system regenerates around the seventh day and plays an active part in the initial hypertension phase of posttraumatic acute oedema. Nevertheless the lymphatics, in a passive way, help the drainage of the fluid as they remain open for a while. A gentle massage during the initial phase helps to drain the interstitial fluids, mainly macromolecular components of the fluids. An intempestive massage is not advised, since it destroys the tissue regenerative linkage of all structures, mainly lymphatic. High doses of heparin enhance draining of the system.
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Our studies confirmed the doubtful existence of venolymphatic communications due to high pressure. Following selective injection of different coloured resins (experimental study) into the venous and lymphatic systems we observed mixing of colours at certain points. We proved, for the first time, that both systems communicate regularly at capillary and lymph node levels (Nascimento 1994). This is due to the intricacy of both the venous and the lymphatic system, sharing the same embryologic origin. Thus, based upon well defined and structured scientific data, we can conclude that in spite of suturing one, two or three veins in a sphacelus/amputation, without reconstruction of lymphatic afferents, the oedema disappears in the second and
Figure 3 (a) Arteriography at 10 days. (b) Venography at 10 days. (c) Lymphography at 20 days. third weeks, as the venous and lymphatic drainage occurs all around the interface. The same principle applies to flaps, even random ones, 3 weeks after surgery. This knowledge also leads us to recommend bone shortening in a sphacelus/amputation; anatomical positioning and suture of all structures; deep suture of vascular trunks to juxtapose lymphatic afferents enhancing drainage and muscle fibroconnection to improve its poor regeneration (Fig. 3).
Nerves Besides the already referred to purposes, shortening of structures enables an end-to-end nerve suture without tension, which is vital for motor and sensory recovery of the injured limb. Any tense nerve suture will cause a neuroma. Nerve sutures should always be done in emergency whenever there is a linear cut and an epiperineural suture is possible without tension. Sometimes it is necessary to dissect, both distally and proximally, the nerve (obviously without destroying its vascularization) to achieve a good suture. When there is nerve tissue loss larger than 1–2 cm, it will not be possible to do a suture without tension, even after performing nerve dissection; we will then use a graft in scheduled surgery. Nevertheless, following the above guidelines we obtained almost total nerve recovery (even in reimplantations). Using nerve grafts will not lead to as good results as direct sutures in emergency. We emphasize that, when necessary, it is better to do bone shortening and a direct suture than to use a graft in scheduled surgery. Another great
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negative factor of secondary nerve reconstruction is that a second approach/dissection will destroy the reorganization of blood and lymphatic vessels. In addition, when there are large nerve injuries in sphacelus/amputation at the elbow and arm levels associated with complete brachial injury, indications for limb preservation are reduced or absent.
Skin Cutaneous coverage of tissue loss in upper limb trauma is one of the most demanding and satisfying procedures for the hand surgeon. The surgeon must be familiar with all the techniques necessary to perform simple and composite, pedicled direct and indirect flow, septal and free flaps (Mathes and Nahai 1979, 1981, 1982, Cormack and Lamberty 1984a,b, 1987, Foucher et al 1984, Nascimento 1984, 1994, Cormack et al 1986, Masquelet and Penteado 1987; Costa and Soutar 1988; Gilbert et al 1990). Principles of plastic reconstruction by regions Shoulder: Depending on the structures injured, the shoulder can be reconstructed using pedicled flaps: latissimus dorsi (myofasciocutaneous) flap, pectoralis major flap, proximal pedicled lateral external flap of the arm, brachial internal flap and free flap (following the preference and experience of the surgeon). Arm: Latissimus dorsi (myofasciocutaneous) flap, lateral external flap of the arm, brachial internal flap (function of the injured area), free flap. Elbow: Latissimus dorsi flap, lateral external flap of the arm, proximal flow antebrachial radial flap (Chinese), brachio radialis flap, carpi ulnaris flexor flap, proximal flow interosseous dorsal flap, free flap. Forearm: Distal pedicled lateral external flap of the arm, interosseous dorsal flap, antebrachial radial flap, antebrachial cubital flap (as a last choice), McGregor flap, accessory cubital flap (Becker’s), free flap (Figs 4–8).
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Figure 4 (a) Seen in emergency 5 days after an accident with a sphacelus of the distal forearm and wrist, without vascularization of the hand. Thrombosis of the radial and ulnar arteries with infection. Escharectomy (skin, nerves, tendons, vessels), reconstructionusing vessel grafts and tendon spacers and plastic reconstruction with a free flap (lateral forearm flap) in emergency. (b) Perioperative view showing tendon spacers. (c) Free flap application (lateral forearm flap). Wrist, back of the hand and palmar area: Coverage of the back of the hand and of the palmar area are planned separately, due to the different composition of the skin. The dorsal face of the hand can receive a simple skin graft when the epitenon is preserved. Nevertheless, reverse flow pediculate flaps such as the interosseous dorsal, the antebrachial radial (Chinese), Becker’s flap, the flap based upon the arteries of the intermetacarpal spaces, the pediculated McGregor’s flap and free flaps are the best options for reconstruction of the dorsal aspect of the hand, according to the experience of the surgeon and the type
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Figure 5 (a) Forearm cutaneous sphacelus caused by a shot gun: flexor digitorum profundus destruction with partial finger extensor digitorum communis. Gracilis muscle transfer for digital motorization/flexion with tendon transfer at the extensor level. (b) Post-surgical motor function (extension). (c) Post-surgical motor function (flexion).
Figure 6 (a) Sphacelus of the wrist and dorsal aspect of hand, with avulsion of the proximal insertion of extensor tendon. Complete destruction of the carpal bones and metacarpal and phalangeal fractures. Cubital and radial arteries and median and ulnar nerve lesions. Forearm bone fractures and circumferential trauma of the soft tissues. (b) Radiological image. (c) Reconstruction of all the structures (tendons, arteries, veins, nerves) with arthodesis of the wrist and McGregor flap: post-surgical function.
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Figure 7 (a) Traumatic sphacelus/amputation at elbow and proximal forearm levels in a train accident. (b) Shortening (several cm) of the upper limb and arthrodesis of the elbow. Artery and vein reconstruction with grafts, elementarectomy. Biceps and brachialis muscle transfer for flexor digitorum profundus; brachioradialis muscle transfer for extensor pollicis longus; triceps muscle (three fascicles) for the extensor tendons. Flexor carpi radialis and flexor carpi ulnaris tenodesis along with extensor carpi radialis brevis and extensor carpi radialis longus tenodesis. Median, ulnar and superficial radial nerves reconstruction.
Figure 8 (a) Post-surgical function 1 year and 6 months later (same case as in Fig. 7). Thenar and hypothenar recovery. Extension of the digits. (b) Active finger flexion. of injury. In bone, tendon and skin injuries of the back of the hand it is possible to plan an anatomical reconstruction of all the structures at the same time, either using bone grafts followed by coverage with tendinofasciocutaneous composite flaps (Chinese flap) or leaving tendons spacers for subsequent reconstruction (Fig. 9).
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Figure 9 (a) Soft tissue and bone sphacelus of the wrist and dorsal aspect of the hand, with oil injection into the bones. Reconstruction of the bones and a composite. Chinese flap with tendons. (b) Post-surgical flexion.
Figure 10 (a) Avulsion of the palmar skin of the hand and reconstruction with the Chinese flap in emergency. (b) Result after aesthetic lipotomy. The palmar region requires reconstruction with a fasciocutaneous flap. A free skin graft can never be used due to the texture and mechanical demands of the area during daily and professional activity (Fig. 10). We can use the antebrachial radial flap with deep sutures and subsequent aesthetic lipotomy, McGregor’s flap as a last choice and free flaps, from which we suggest the internal plantar flap (with similar texture). Obviously, a bone and tendon reconstruction can be done in one or two operations to re-establish motor function of the hand. One of the most challenging and satisfying areas, accounting for a great number of cases, is probably the reconstruction in emergency of a finger’s amputation stumps— using ‘bank fingers’ with the associated flap, fourth contralateral hand finger transfer, toe-to-hand finger transfer for thumb reconstruction, fasciocutaneous pediculated digital flaps—whose multiplicity only ends where the surgeons’s imagination stops. This is a very interesting subject but it was not included in this chapter.
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References Brunelli G, Vigasio A, Brunelli F (1985) L’elementarisation musculaire dans les reimplantations et les revascularisations. ‘Limite’ de l’avant-bras, Ann Chir Main 4:337–9. Cormack GC, Lamberty BGH (1984a) A classification of fasciocutaneous flap according to their patterns of vascularization, Br J Plast Surg 37:80–7. Cormack GC, Lamberty BGH (1984b) Fasciocutaneous vessels in the upper arm: application the design of new fasciocutaneous flaps, Plast Reconstr Surg 74:244–9. Cormack GC, Lamberty BGH (1987) The Arterial Anatomy of Skin Flaps. Churchill Livingstone: New York. Cormack GC, Duncan MJ, Lamberty BGH (1986) The blood supply to the bone component of the compound osteo-fasciocutaneous radial artery forearm flap, Br J Plast Surg 39:173–5. Costa H, Soutar DS (1988) The distally based island posterior interosseous flap, Br J Plast Surg 41:228–33. Foucher G, Gilbert A, Merle M, Jacob Y (1984) Lambeau radial ‘chinois’. In: Tubiana R, ed. Traité de Chirurgie de la Main, vol II. Masson: Paris, 244–9. Gilbert A, Masquelet AC, Hentz RV (1990) Les Lambeaux Artériels Pédiculés du Membre Supérieur. Expansion Scientifique Française: Paris:17. Gillies H, Millard DR (1957) The Principles and Art of Plastic Surgery. Little Brown & Co: Boston. Manchot C (1983) The Cutaneous Arteries of the Human Body. (Translation of Die handarterien des menschlichen Körpers (1889)). Springer-Verlag: New York. Masquelet AC, Penteado CV (1987) Le lambeau interosseux postérieur. Ann Chir Main 6:131–9. Mathes SJ, Nahai F (1979) Clinical Atlas of Muscle and Musculocutaneous Flaps. CV Mosby: St Louis. Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation, Plast Reconstr Surg 67:177–87. Mathes SJ, Nahai F (1982) Clinical Application for Muscle and Musculocutaneous Flaps. CV Mosby: St Louis. Nascimento A (1983a) Anatomie Chirurgicale des Muscles Jumeaux et Vascularization de la Peau du Mollet. Mémoire d’Assistant Etranger de la Faculté de Médecine René Descartes: Université de Paris, Paris. Nascimento A (1983b) Homotransplant du Genou Vascularisé du Rat. Mémoire présentée au Laboratoire de Chirurgie Expérimentale de Paris (‘Fer-à-Moulin’). Nascimento A (1984) Etude anatomo-chirurgicale d’un nouveau lambeau sensible: le lambeau externe du bras. Société d’Anatomie de Paris, Musée Orfila, March 2. Nascimento A (1987) Transplante vascularizado do joelho do rato com e sem ciclosporina A, Rev Ortop Traum 1B:56–62. Nascimento A (1989) Reconstructive microsurgical techniques in the upper limb. In: Carolli A, Zanassi S, eds. Proceedings of the 1st European Congress of Hand Surgery. Modenna: Italy, 180–3.
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Nascimento A (1994) Reconstruction plastique du membre supérieur—Investigation anatomique et application chirurgicale et régénération lymphatique en réimplantations et lambeaux vascularisés dans la chirurgie expérimentale et clinique. European PhD Thesis, UFR Biomédicale Saints-Pères, Université René Descartes, Paris V. Ponten B (1981) The fascio-cutaneous flap, its use in soft tissue defects of the lower leg, Br J Plast Surg 34: 215–20. Salmon M (1936) Les Artères de la Peau. Masson et Cie: Paris.
22 Principles of repair of a compound defect as a secondary procedure: the multiple stages approach Alain C Masquelet
A secondary procedure implies that a compound injury is not recent and that the treatment is not performed in emergency. Most of time, the treatment of a complex injury of the upper limb in emergency is based on the principle of repairing all the injuries in a ‘one-stage procedure’ (Michon et al 1977, Lister and Schecker 1988). When the injury is treated secondarily one should be prepared for complications or adverse sequelae and the ‘one-stage procedure’ cannot be applied safely, especially when the defect involves several structures. The repair of a compound defect comes under the field of reconstructive surgery. Obviously, a compound defect involves several kinds of tissue but the final goal of the treatment is not necessarily to restore all structures in their entirety. The goal of treatment is to restore function of the upper limb to an acceptable level compatible with the initial lesions and the possibilities provided by reconstructive surgery. A compound defect of the upper limb requires an holistic view of the musculoskeletal system. This system can be defined according to anatomical regions, functional entities or types of tissues. From these different points of view, the upper limb comprises the shoulder girdle, the arm, the elbow, the forearm, the wrist and the hand. The primary aim of the upper limb is to support the function of prehension which involves the positioning of the hand in space. The upper limb is made of several kinds of tissue including skin and adipo-fascial tissue, muscles and tendons units, bones and joints, and nerves and vessels. A compound defect involves at least two differents kind of tissue (or more) and any combination is possible. There are four important points for a reconstructive surgeon to reflect upon: 1. Assess the lesions and define the final goal of the treatment. 2. Decide a general strategy. 3. Determine tactics. 4. Choose the surgical techniques.
Assess the lesions and define the final goal of the treatment The assessment should consider the function and the defect of the particular tissues which contribute to the functional impairment. Obviously, the status of the impairment and the
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extent of injuries influence the final goal of the treatment. Ideally the aim of the treatment is the ‘restitutio ad integrum’ of the function of the upper limb and hand. However, in several cases, the initial impairment is so severe and the possibilities so limited that the aim of the treatment can only be to improve the function, or to provide palliative function. This means that the first step (assessment and goal of the treatment) is the most important one, since it requires vast experience to determine what one can hope from the treatment. A much too ambitious goal may lead to complete failure and to a final prejudiciable result. A good example of compound sequelae is the Volkmann syndrome which is defined as the final and definitive evolution of a non-treated compartment syndrome. The function of the hand should be assessed as well as the function of the whole upper limb. Then each component should be assessed and the evaluation of each tissue can be done starting from the skin surface to the depth of the bone: 1. Skin envelope: note the presence of defects, skin grafts, contractures, scars; etc. 2. Muscles: evaluate the degree of atrophy or fibrous transformation. 3. Tendons: assess the importance of destruction or adherences. 4. Nerves: are there disturbances in sensory function or paralysis? Can some nerves be used for neurotization? 5. Joints: assess stiffness, active and passive motions. 6. Bone: is there malunion, non-union, bone defects? One of the most important issues is the presence or absence of an infection involving the bone and soft tissues. The assessment may require examinations like MRI (magnetic resonance imaging) to evaluate muscle dystrophy, standard radiographs and bone scans for the bone, arthrograms to evaluate the chondral surface of the joints, arteriograms for the arterial network, echo Doppler for the veins and EMG (electromyography) or evoked potentials for evaluation of nerve and muscle functions. After the assessment of the lesions the final goal of the treatment is defined. Will it be possible to restore all the functions or is it better to restore one particular function that will be useful for the patient? For example, in some cases of Volkmann syndrome the muscle lesions are so important and definitive that it is preferred to restore a key pinch than to restore a true opposition of the first column.
The general strategy of reconstructive surgery The general strategy of reconstructive surgery is defined by what we have called the three Rs. • Repair of the soft tissue envelope. • Reconstruction of bone and joints. • Restoration of function. Reconstructive surgery is devoted to the restoration of living structures and involves a high degree of specificity, which can be understood when we compare reconstructive surgery to ship-building. There is a great difference between these two activities. Ship-
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building begins at the keel, ribs and floor frame which can be compared to the bony skeleton; the keel is often compared to the spine. The second step of ship-building is planking which is the equivalent of the skin envelope of the human body. Finally, the construction of the mess and decks is like the restoration of function. The difference is that for building a ship we are obliged to begin from the ‘skeleton’ while in reconstructive surgery nothing can be undertaken without restoring the skin envelope. Thus, I do believe that, when faced with a compound defect, we should begin by repairing the soft tissue envelope. Then the reconstruction of the bones and joint system will be possible and finally, a healthy envelope, a healed skeleton and mobile joints allow the restoration of function; that means to restore active motion. The presence of an infection is an indication for large debridement and a radical excision of all infected tissues prior to the repair of the envelope and the bone.
Tactics Tactics can be defined as the different combinations in timing of the three components of the strategy: • Repair of the soft tissue envelope. • Reconstruction of bone and joints. • Restoration of function. Generally speaking, if each step of reconstructive surgery is performed separately it requires a simple palliative procedure. When treating a compound defect it is possible to begin by repairing the soft tissue envelope: then in a second procedure the bone and joint are reconstructed. The restoration of active function is undertaken in a third step (see Case 1 below). However, we may perform the repair of the soft tissue and the reconstruction of bone in a one-stage procedure. For example, we may perform, in the same operative procedure, a conventional bone graft to restore the continuity of a bone and a fascio-cutaneous flap to repair the envelope. In other cases a compound flap may be used. Scapula and latissimus dorsi, fibula and soleus muscle, iliac crest and groin flaps allow the reconstruction of a compound defect in a one-stage procedure. The restoration of function will be done when bone is healed and the soft tissues repaired. In some cases, the compound defect may involve only skin and tendons without the bone, and we can use a compound skin and tendon transfer. So the tactical possibilities allow us to
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Figure 1 The defect involved the skin envelope, the radius and the extensor tendons of the wrist and fingers. Radial artery was avulsed but the hand was well vascularized by the ulnar artery. The median nerve was intact. decide whether to perform the reconstructive surgery in one, two or three stages according to the clinical requirements. It should be understood that to decide on the tactics a precise assessment of the defect and knowledge of all the technical possibilities is required. Case 1 (Figures 1–5) This is a case of gun-shot injury in a 25-year-old man. Treatment in emergency comprised of debridement and bone fixation. The patient was transferred 3 weeks later with an infected wound.
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Figure 2 The first stage after radical excision consisted of the soft tissue repair by a free serratus anterior muscle flap. A cement spacer was placed in the bone defect.
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Figure 3 (a) Two months later, the cement spacer was removed and the radius was reconstructed by autologous fresh cancellous bone graft. (b) The external device was replaced by a plate 2 months later. Bone healing was complete at 4 months.
Surgical techniques The choice of the surgical technique is the last step in the surgeon’s reflection of a compound defect. It depends on the importance and the nature of the defect and the tactics chosen. Reciprocally, the surgical procedures available determine the tactics. Advances in techniques also influence the tactics. The techniques comprise all the procedures to reconstruct the injured tissues in a compound defect of the musculoskeleton system: skin envelope repair, bone and joint reconstruction and restoration of function. All procedures range on a ladder from the most simple (which is also the easiest procedure) to the most sophisticated (which is, most often, the most technically demanding procedure). The repair of the soft tissue envelope The procedures to repair the soft tissue envelope are as follows: spontaneous healing, plasties, vacuum-assisted closure, skin expansion, skin graft, local flap, island pedicled
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flap, free flap, etc. Obviously, the procedure that will be employed depends on the size of the defect, the local conditions and the time of reconstruction.
Figure 4 The restoration of the function required two stages. (a) In a first stage silicone rods were placed beneath the flap. (b) In a second stage, the continuity of the extensors of the wrist was restored by a fascia lata graft (flexor carpi ulnaris). Finger extension was restored at the same time by a transfer of the FCU tendon.
Figure 5 (a,b) Clinical result. For example, skin expansion is not advocated in an emergency, but it is suitable when there is a retractile scar. In our opinion, when a flap is required, the tendency should be to use a pedicle flap as far as possible since it is a more reliable and quicker procedure than a free flap. Bone and joint system reconstruction When a long bone and an adjacent joint are involved it is better to undertake the reconstruction in two stages. As a matter of fact, the bone should have healed before commencing with the restoration of joint motion or performing joint fusion.
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Procedures for reconstruction of the bone • Cortical or cancellous bone graft, bone substitutes, vascularized bone transfer, bone transport, large allograft. • Large defects can be reconstructed with conventional cancellous bone grafts provided a cement spacer has been inserted prior to the graft procedure to induce a foreign body membrane which prevents the resorption of the graft (Masquelet et al 2002). • Techniques of bone fixation should be considered according to the length of the defect, the quality of soft tissue and the procedure of bone reconstruction. Procedures for reconstruction of the joints The reconstruction of the joints does not necessarily mean to restore motion. Joint fusion should be considered as a particular case of joint reconstruction. Obviously joint fusion with a bone defect raises difficult problems of reconstruction. Procedures to reconstruct a joint can be summarized as follows: arthrolysis, joint fusion, arthroplasties. Arthroplasties constitute a vast subject which comprises prosthetic replacements, bone extremities remodelling, tissue interposition, etc. The restoration of function This is the final goal of treatment once the skin envelope is repaired and bone stability and joint motion have been achieved.
Figure 6 Skin and tendon necrosis by a chemotherapeutic agent in a 65-year-old patient. The MP (metacarpophalangeal) joints were stiff. Function involves the muscles, the tendons and the nerves. A tendon transfer cannot be performed before having repaired the skin envelope and restoring joint motion. In most cases, tendon grafting and tendon transfers should be prepared by setting silicone rods to induce a gliding sheath according to Hunter’s technique (Case 2) (Hunter and Jaeger 1977). However, in some cases, procedures on nerves must be performed very early in the plan of reconstructive surgery. For instance, in a case of Volkmann
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syndrome, the first procedure to be undertaken is the release of the nerves to obtain recovery of sensory function. Procedures on nerves include: neurolysis, conventional nerve grafts, vascularized nerve grafts, nerve allografts, special techniques (nerve expansion, end-to-side anastomosis). Procedures on tendons include: tenolysis, tendon graft, artificial tendons. Procedures for restoring active motion (in case of paralysis) include: muscle tendon unit transfer and free muscle transfer. It is to be noted that when we use a free muscle transfer, the soft tissue defect is treated in the same stage as the functional impairment. Case 2 (Figures 6–10) This is a compound defect of the dorsum of the hand involving the skin envelope and extensor tendons.
Figure 7 Prior to reconstruction several iterative debridements and excisions were undertaken. Extensor tendons of the fingers were excised.
Figure 8
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The first stage involved soft tissue repair. This was by a distally based radial forearm flap which has the advantage of improving the blood supply of the recipient site.
Figure 9 (a,b) The second stage consisted of the release of the MP joints associated with the setting of silicone rods under the flap according to Hunter’s technique.
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Figure 10 (a) The final stage was tendon grafting by using extensor tendons of the toes. (b) Clinical result.
Conclusion Reconstructive surgery of a compound defect which involves functional impairment is based on the following points: • A precise assessment of the tissue injuries and functional impairment. • The final function that we can hope to obtain after surgery. • The planning of the reconstruction. • The choice of surgical techniques. Reconstructive surgery requires maximal cooperation between the surgeon and the patient.
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References Hunter JM, Jaeger SH (1977) Tendon implants: primary and secondary usage, Orthop Clin North Am 8:473–89. Lister G, Schecker L (1988) Emergency free flaps to the upper extremity, J Hand Surg 13A:22–8. Masquelet AC, Fitoussi F, Begue T, Muller GP (2002) Reconstruction des os longs par membrane induite et autogreffe spongieuse, Ann Chir Plast Esthet 45: 346–53. Michon J, Foucher G, Merle M (1977) Traumatismes complexes de la main. Traitement ‘tout en un temps’ avec mobilisation précoce, Chirurgie 103:956–64.
23 Surgical management of infection Manuel Llusa, Xavier Mir and Xavier Flores
Introduction Management of severe traumatic defects of the upper limb presents an important challenge to orthopaedic and plastic surgeons. Recent advances in reconstructive microsurgery have made it possible to transfer free cutaneous, muscle, myocutaneous, fasciocutaneous, bone and osteocutaneous flaps to solve a wide spectrum of posttraumatic defects. All of these complex techniques, and even the more simple surgeries require a previously clean wound to obtain a good result. Ideally, infection should be avoided but the kind of high-energy trauma that results in fractures and soft tissue injuries with high wound contamination make it difficult to prevent infection. Management protocols for acute situations begin with irrigation, debridement and stabilization of the fractures as soon as possible. Infected fractures require similar radical treatment. In fact, all patients with open fractures should be considered as being infected.
Irrigation and debridement Predebridement cultures are taken and gross debris cleaned by irrigating the wound profusely with sterile saline solution (up to 10 litres of normal saline). The majority of authors recommend a mechanical irrigating system with pulsating or jet lavage (Gustilo 1989, Johnson 1989). After the initial cultures, intravenous antibiotic therapy is begun depending on the prophylactic protocol (see Antibiotic treatment at the end of the chapter). With open fractures bacterial contamination is present 65–75% of the time. It should be emphasized that emergency cultures have little correlation with organisms isolated from infected wounds (Gustilo 1990, Seekamp et al 2000). Wound cultures should be taken from the deeper part of the wound. Cultures taken superficially or from inside the sinus tract, in chronic cases, can be misleading and bear no relation to the infecting organism inside the deep part of the wound (Gustilo 1989). The most significant infecting organisms in highenergy fractures are Gram-negative rods (75%) or the same along with Gram-positive organisms (24%) (Johnson 1989). Following initial irrigation the draping of the extremity is changed and debridement is performed. Generally tourniquet is not applied in order to distinguish between viable and nonviable tissue. Debridement must be radical including all devitalized tissues and devascularized bone fragments with the exception of intraarticular fragments with cartilage, if possible, to
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preserve future joint function. Some authors suggest that debridement must be very aggressive, such as when ablating tumours (Tomaino 1999). However, we think that the debridement must be radical but functional, trying to conserve at least the basic elements for future movement if possible. The real soft tissue injury is usually more extensive than initially appreciated. Serial debridements repeated every 48–72 hours permit the surgeon to define the real extent of the wound (Weiland and Yaremchuck 1990). On other occasions, severe and frank infections make it obligatory to perform a one-stage wide and radical debridement with composite tissue loss—combination of soft tissue, tendon, nerve and bone (Fig. 1). Extensive bone fragmentation should be carefully evaluated. Devascularized bone fragments with no soft tissue attachments should be
Figure 1 Severe infection of the dorsum of the hand and wrist affecting soft tissue, tendons, muscle and bones— composite tissue loss. removed without hesitation. Currently the availability of cancellous or free bone grafting (microvascular fibular or iliac crest) or bone transport gives the surgeon confidence that the bone defects can be reconstructed later (Wood and Gilbert 1977, Gerwin and Weiland 1992).
Fracture stabilization Once final debridement is completed fracture stabilization is performed. It has been demonstrated that early fracture stabilization reduces wound infection rates (Anderson and Meyer 1993). External fixation devices can be used in the majority of cases. They are easy to apply, allow daily wound care and serial debridements, and permit secondary procedures such as skin closure and plastic surgery procedures for wound coverage when infection has been eradicated (Fig. 2) (Wild et al 1982, Soucacos et al 1995). The techniques used to achieve fracture stability in upper extremity fractures differ from those for lower extremity fractures. Primary internal fixation, by plating or intramedullary nailing, can be used in diaphyseal fractures, in cases with low risk of infection due to the rich blood supply and abundant soft tissue envelope, especially in
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humerus and forearm fractures (Tomaino 1999). Plating is a good option in fractures around epiphyseometaphyseal bone. At the level of the
Figure 2 Fracture stabilization with external fixation facilitates skin coverage and plastic procedures. hand Kirschner wires are a fast and safe option (Tomaino 1999). In the presence of infection, if the internal fixation device is loose and the fracture becomes unstable, it should be removed and changed to external fixation after wide debridement. But if the internal fixation provides rigid fracture stability it can be maintained even if it is exposed (Gustilo 1990). Internal fixation has the advantage of permitting easy care for soft tissue problems, and avoids the risk of pin track sepsis often seen with external devices. If there is any doubt we prefer to apply an external fixation and later change to internal fixation as soon as possible (when signs and symptoms of infection have subsided) to avoid pin track infection (Figs 3–5).
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Figure 3 Elbow open fracture grade IIIC with severe bone loss. Ipsilateral fracture of the radius and ulna.
Figure 4 Temporary external fixation application as an emergency treatment after debridement. Brachial artery reconstruction was needed. When pin sepsis occurs changes to secondary plating or intramedullary nailing have a high risk of infection (Gustilo 1990). Antibiotic therapy and a delay of 48–72 hours after external fixation removal is recommended. Some authors do not recommend intramedullary reaming because of the risk of pandiaphyseal osteomyelitis, and others use unreamed intramedullary nails, especially in the humerus (Gustilo 1990). If any kind of osteosynthesis is in place and functioning properly, without any sign of loosening, it should be left in place and an aggressive debridement carried out. Radical excision of necrotic skin, non-viable tissues and debride
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Figure 5 Early elbow arthrodesis due to wide soft tissue loss. Options such as elbow allograft or elbow prosthesis should be considered. This patient refused these options. ment of necrotic bone are performed until viable tissue and a clean wound are obtained. This step should be done without a tourniquet.
Defect coverage Initially no attempt to close the wound should be made, unless the surgeon’s experience recommends the contrary. Generally it is very difficult to assess, during the initial treatment, the degree of contamination and vascularization of the injured area. We prefer to perform a second look and several debridements, especially in polytraumatic patients, because of the high infection rates. Surgically induced wounds may be closed if there is no tension on the soft tissue. However, the wound in the area of the open fracture should not be closed (Johnson 1989). Timing of wound closure depends on several factors but generally it is possible within the first few days to a fortnight; the management varies from delayed primary or secondary closure to local flaps or microvascular free flaps (Soucacos et al 1995). In
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cases with unprotected neurovascular structures additional procedures should be done in order to cover the vital nerves and vessels (Varecka 1989). Initially the wound is left wide open or packed with polymethylmethacrylate beads impregnated with gentamicin sulphate to fill dead space. Recently, biodegradable delivery systems have been used (Klemm 1993). The technique of open healing by secondary intention results in a densely fibrotic wound, increasing the susceptibility to ischaemic complications and decreasing the functionality of the affected extremity. The technique of Papineau is not recommended except in very special situations (Weiland and Yaremchuk 1990). There is a consensus that generally it is better to proceed to early or delayed primary wound closure or coverage with local, or even better, with free muscle transfer within the first week (Gerwin and Weiland 1992). The dead space is filled with polymethylmethacrylate beads (Klemm 1987) or, as has been proposed, with an antibiotic-impregnated cement block (Masquelet et al 2000), not only to deliver antimicrobial agents but also to provide some restoration of integrity and stability. Ideally free muscle flap (latissimus dorsi or rectus abdominis) is adapted to cover the wound and fill the rest of the dead space. The muscle flap is covered with a meshed split thickness skin graft. Cutaneous or fasciocutaneous flaps are not used because of their inability to adapt and fill dead space. The muscle provides a rich vascular supply and creates an induced membrane over the polymethylmethacrylate cement block (Masquelet et al 2000). After a period of 4–6 weeks the cement block is removed and, if the wound is clean without any sign of infection, bone grafting is performed. Stevanovic et al (1999) recommend autogenous cancellous bone in small or moderate defects and microvascular bone transfer in cases of segmental defects greater than 6 cm. The recipient site should be explored prior to obtaining the bone graft to remove any occult infection. The increase in blood supply brought by the microvascular muscle transfer aids in the control of infection and in the rapid incorporation of the cancellous bone graft. Chan et al (2000) suggest that antibiotic-impregnated autogenous bone grafting is an effective and safe method for the management of small bone defects and it does not have any adverse effects on bone graft incorporation. Simultaneous cancellous bone grafting and muscle flap closure should be avoided because of the risk of bacterial contamination at the time of closure and possible reinfection. In some situations one-stage soft tissue reconstruction with a free osteomyocutaneous flap has been suggested by some authors (Godina 1986). A practical point to remember is to get in touch with the plastic surgeon as soon as possible when a free soft tissue flap is indicated, so that it can be planned in advance. This should be within the first 3–7 days of injury, when the wound is in optimal condition. In some special situations creation of a one bone forearm may be indicated. This technique sacrifices prono-supination. Reported results indicate a less than ideal outcome but it should be borne in mind when treating a difficult combination of bone and soft tissue injury with loss of the distal radio-ulnar joint (Stevanovic et al 1999). In Figures 6– 10 we summarize some of the
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Figure 6 A young male with an open grade IIIC ulna and radius fracture. Severe infection was present with bone and soft tissue loss. Serial debridements were performed. Cultures isolated Clostridium perfringens.
Figure 7 Radiographs of the same case as in Fig. 6.
Figure 8 Radical debridement, free latissimus dorsi transfer and reapplication of the external fixation.
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basic concepts of the surgical management of infection in a severe post-traumatic case.
Antibiotic treatment The most satisfactory prophylactic procedure to prevent infection in open fractures is prompt, adequate surgical debridement and antibiotics are no substitute for this (Johnson 1989). Theoretically, prophylactic antibiotic therapy should not be initiated until surgical debridement and samples for cultures have been taken. However, due to the high frequency of bacterial contamination, the use of antibiotics for a conta
Figure 9 Four weeks later there were no signs of infection and bone grafting and osteosynthesis were performed with creation of a one bone forearm.
Figure 10 Final appearance with resolution of the infection, even though prono-supination was lost. minated wound is defined as active therapy and not as prophylaxis (Johnson 1999). Appropriate therapy should be selected according to the organisms cultured in each specific case.
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The following empirical recommendations can be made for antibiotic treatment of open fractures and soft tissue injuries, depending on the degree and type of contamination: • Minimally contaminated soft tissue injuries and type I and type II open fractures should be treated with a first generation cephalosporin (usually cefazolin) or a combination of amoxicillin and clavulanate. • Severely contaminated soft tissue injuries and contaminated type II fractures and all type III open fractures should be treated with a combination of a first generation cephalosporin with an intravenous aminoglycoside (gentamicin or tobramycin). The use of a third generation cephalosporin, such as cefotaxime, is a good option. This antibiotic is very effective against Gram-negative organisms and also against Grampositive organisms compared with other third generation cephalosporins. Its use avoids the risks and side effects of aminoglycosides. However, it should be remembered that most of the third generation cephalosporins do not cover Pseudomonas spp. as well as the aminoglycosides. Currently, the use of amoxicillin/clavulanate is also considered a good choice in empirical antibiotic treatment of type III open fractures, except in cases with risk of Pseudomonas contamination or infection. In such a situation gentamicin must be part of the antibiotic therapy. Generally prophylactic antibiotics are administred for 48–72 hours. In severe cases with generalized sepsis a penicillinase-resistant synthetic penicillin (cloxacillin 2 gm every 4 hours iv) in combination with an antipseudomonal aminoglycosidic antibiotic (gentamicin or tobramycin, 80 mg every 8 hours iv) plus clindamycin (900 mg every 8 hours iv) should be administered. Generally these complex cases are managed by intensive care unit specialists. In postoperative infections, after fracture reduction and internal fixation, Staphylococcus aureus, Enterobacteriaceae or Pseudomonas spp. are usually isolated. In these cases a combination of cloxacillin (2 gm every 4 hours iv) with ciprofloxacin (750 mg every 12 hours po) should be considered or a combination of ciprofloxacin (750 mg every 12 hours po) with rifampicin (300–600 mg every 8 hours po). When Staphylococcus epidermidis is isolated the appropriate antibiotic is vancomycin (1 gm every 12 hours iv) and all foreign bodies such as sutures, hardware or osteosynthesis must be removed. Once the infection has resolved antibiotic therapy should be restarted as a prophylactic measure for the following circumstances: • During delayed primary or secondary wound closure, including free flap transfers. • When internal fixation or open reduction and osteosynthesis are performed. • When external fixation is changed to internal fixation (plates or intramedullary nailing). In most cases, patients are already on broadspectrum antibiotic treatment because of previous signs and symptoms of infection, prior to microorganism identification and are then put on specific treatment adapted to their indivdual situation. At this point, we recommend collaborating with an infectious disease specialist in complex cases with antibiotic-resistant microorganisms or in cases with severe medical problems. These situations demand wide experience in systemic antibiotic management.
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Antibiotic therapy is recommended until adequate soft tissue healing has been achieved; usually this may take from 3–6 weeks.
References Anderson LD, Meyers FN (1993) Management of infected implants. In: Chapman MW, Madison M, eds. Operative Orthopaedics, 2nd edn. JB Lippincott: Philadelphia, 3385–407. Chan Y, Ueng SW, Wang C et al (2000) Antibioticimpregnated autogeneic cancellous bone grafting is an effective and safe method for the management of small infected tibial defects. A comparison study, J Trauma 48:246–55. Gerwin M, Weiland AJ (1992) Vascularized bone grafts to the upper extremity. Indications and technique , Hand Clin 8:509–23. Gilbert DN, Moellering RC, Sande MA (1999) Terapéutica antimicrobiana empírica. Fármacos antimicrobianos de elección frente a microorganismos. In: Sanford JP, ed. Guía de Terapéutica Antimicrobiana. Ediciones Díaz de Santos SA: Madrid, 4–61. Godina M (1986) Early microsurgical reconstruction of complex trauma of the extremities, Plast Reconstr Surg 78:285–92. Gustilo RB (1989) Management of open fractures. In: Gustilo RB, ed. Orthopaedic Infection. Diagnosis and Treatment. WB Saunders: Philadelphia, 87–117. Gustilo RB (1990) Management of infected fractures. In: Evarts CM, ed. Surgery of the Musculoskeletal System. Churchill Livingstone: New York, 4429–54. Johnson K (1989) Management of open fractures and infections. In: D’Ambrosia RD, Marier RL, eds. Orthopaedic Infections. Slack Incorporated: New Jersey, 517–28. Klemm KW (1993) Antibiotic bead chains, Clin Orthop 295:63–6. Klemm K (1997) Clinical applications of gentamicinPMMA beads. In: Coombs R, Fitzgerald RH, eds. Infection in the Orthopaedic Patient. Butterworths: London, 167– 77. Kumar VP, Satku K, Helm R, Pho RW (1988) Radial reconstruction in segmental defects of both forearm bones, J Bone Joint Surg 70B:815–17. Masquelet AC, Fitoussi F, Begue T, Muller GP (2000) Reconstruction of the long bones by the induced membrane and spongy autograft, Ann Chir Plast Esthet 45:346–53. Seekamp A, Köntopp H, Schandelmaier P, Krettek C, Tscherne H (2000) Bacterial cultures and bacterial infections in open fractures, Eur J Trauma 26:131–8. Soucacos PN, Beris AE, Xenakis TA, Malizos KN, Vekris MD (1995) Open Type IIIB and IIIC fractures treated by an orthopaedic microsurgical team, Clin Orthop 314:59– 66. Stevanovic M, Gutow AP, Sharpe F (1999) The management of bone defects of the forearm after trauma, Hand Clin 15:299–318. Tomaino MM (1999) Treatment of composite tissue loss following hand and forearm trauma, Hand Clin 15:319–33.
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Varecka TF (1989) Soft tissue coverage in open fractures. In: Gustilo RB, ed. Orthopaedic Infection. Diagnosis and Treatment. WB Saunders: Philadelphia, 118– 22. Weiland AJ, Yaremchuk MJ (1990) Management of traumatic osteocutaneous defects in the lower extremity. In: Evarts CM, ed. Surgery of the Musculoskeletal System. Churchill Livingstone: New York, 4525–55.
24 Reconstruction of large defects of the upper limb in children Massimo Ceruso, Filippo M Sènés, Giuseppe Checcucci, Prospero Bigazzi, Alessandra Allegra and Gloria Taliani
Introduction Severe post-traumatic defects in the upper limbs of children are rather rare. Literature on the subject is scarce and it is difficult to conduct an exhaustive review because of the heterogeneity of the reported series. While there is reasonable agreement on indications and surgical strategies, data on complications and failures are quite diverse (Canales et al 1991, Raimondi et al 2000, Romaña et al 2000, Yücel et al 2001). Furthermore, the special consideration for anaesthesia and pharmacological treatment of the young patient are rarely discussed (Bell et al 1992, Mollit 2002). In fact, the differences in the anatomy of a child compared to an adult and their growth must be taken into consideration while planning any reconstructive treatment in children.
Aetiopathogenesis The incidence, characteristics and effects of highenergy trauma are different in the growing individual than in the adult. Severe post-traumatic defects of the upper limb in adults are mostly related to work, traffic, or sports-related accidents. In children, these types of injury occur less frequently and when they happen they are caused by catastrophic events (e.g. explosions or collapse of buildings) or serious traffic accidents in which children are involved either as passengers in a vehicle, or as pedestrians hit by a vehicle. Domestic accidents may cause lesions from crushing and avulsion. In these instances, owing to the small size of the limbs, the traumatizing agent often damages the tissues, transforming a sharp cut into a crush injury. In high-energy trauma, the child is more vulnerable to injuries in multiple areas of the body. Limb injuries are frequently associated with visceral involvement (cranio-encephalic, spleen and kidney lesions), which often make lifesaving procedures a higher priority than reconstructive procedures. There is, therefore, a distinction between the patient with multiple trauma, which is relatively frequent, and the isolated severe lesion of the upper limb, which is rather rare. Upper limb lesions are frequently observed in conjunction with trauma at the level of the trunk; in traffic accidents this happens owing to both the seated position in the back seat and the upper limb being generally close to the thorax and thus more easily compressed or injured by parts of the vehicle’s cab.
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Extensive burns are also one of the more frequent causes of lesions in children and occur especially because of thermal injuries to the upper limb, whereas electric or caustic burns are almost exclusively limited to the hand. Severe soft tissues lesions can be isolated or associated with neurovascular lesions and/or exposed fractures (with or without loss of bone substance); the latter are more frequently observed (Fried et al 1978, Holmes and Reyes 1984, Mazurek 1991, Ramenofsky and Moulton 1995, Weinberg et al 1999, Moulton 2000, Fagelman et al 2002).
Indications It is agreed that indications for surgical reconstruction of severe post-traumatic defects in children, as well as for replantation of amputated segments, are wider than in adults because of the expected lifespan of the patient, for the aesthetic and social value of the reconstruction and finally because the prospects of functional recovery are higher (Paul et al 1997, Raimondi et al 2000). Obviously, more generalized indications for reconstructive surgery lead to a greater incidence of complications and failures. The success rate of replantations in adults is reported to be higher than 80%, whereas in children it is lower than 70% (Urbaniak and Foster 1992). Conflicting data are found in the articles specifically dedicated to microsurgical flaps in children (Iwaya et al 1982, Banic and Wulf 1986, Shapiro et al 1989, Canales et al 1991). In view of improved surgical and anaesthesiological techniques, more recent reviews suggest rates of success closer to those for adults (95%, Yücel et al 2001).
Anaesthetic considerations A child is not simply a small adult: their anatomy, physiology, and pharmacokinetics are completely different. Therefore, paediatric anaesthesia may be very difficult and requires special skills. Orthopaedic lesions are frequent in children and severe trauma is the leading cause of death and disability in children older than 12 months. Severe crush injuries to the limb may be life threatening for the associated blood loss can lead to cardiovascular collapse. The initial care of the child patient is organized systematically and is based on the paediatric advanced life support (PALS) and advanced trauma life support (ATLS) protocols. A complete examination in a minimally stabilized patient can be made before establishing the surgical therapeutic strategy. As soon as temporary haemostasis has been achieved by the surgical team, fluid volume replacement must be initiated by means of an intravenous line. It is always easier and less time consuming to insert a short catheter in the early stages of progressive shock. Intraosseous infusion is recommended for emergency vascular access in advanced paediatric trauma life support protocols: it allows perfusion of crystalloid solutions, blood products and even emergency drugs into the marrow space of the proximal tibia, when attempts to establish other routes have failed. Once vital functions are stable, we need to ensure that the child is calm and cooperative
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to perform a complete examination of the lesion. An anxious patient complicates the assessment. Preoperative anxiety also activates the human stress response, leading to increased serum cortisol and epinephrine; it is associated with arterial pressure alterations, likelihood of vasospasm, susceptibility to infection and delayed wound healing. Children are particularly vulnerable to the general surgical stress response. Premedication with oral midazolam seems to decrease the incidence of negative behavioural changes during the first week after surgery. This may be particularly significant for children undergoing repeated surgical procedures. Parental presence during induction of anaesthesia and during recovery should be allowed to minimize postoperative behavioural disturbances (McCann and Kain 2001). Finally, alleviating parental anxiety will alleviate child anxiety. Once light general anaesthesia is induced, a nerve block can provide most of the analgesia. In the perioperative period, it is mandatory to keep tissue perfusion constant, particularly when microsurgical flaps or a replantation are being performed. Vasoconstriction may occur because of many reasons like hypothermia, crying, pain, so the child must be kept warm, calm and pain free. It is useful to consider a continuous brachial plexus anaesthetic block with an axillary catheter. This produces pain control and induces a pharmacological sympathetic paralysis during and after surgery, and can be used therapeutically for improving perfusion. Electrical stimulation of nerves can be used to help while giving the nerve block. Temperature control is important during anaesthesia, especially in small children. They have a larger surface area to weight ratio than adults and consequently cool down more rapidly. There is a tendency to progressive heat loss during an operation, especially if large areas of the body are exposed. Therefore, in children the use of a warming blanket, warmed perfusion solution and warmed, humidified gases is beneficial. An interesting cause of body temperature variation is (if being used) the tourniquet: the exposed limb below the tourniquet becomes cool from contact with air. When the tourniquet is released, blood circulates through the cold limb resulting in a fall of body temperature over the next 5 minutes, which can induce peripheral vasoconstriction. Intraoperative blood loss must be carefully evaluated because hypovolemia may lead to decreased tissue perfusion. The total blood volume is estimated to be about 70 ml/kg for a child and 80 ml/kg for an infant. Whenever haemorrhage occurs, children maintain adequate arterial blood pressure by efficient compensatory sympathetic-mediated vasoconstriction and tachycardia. Signs of shock are initially subtle and are evident clinically only when the compensatory mechanisms begin to fail. Red cell transfusion is required to meet tissue oxygen demands and maintain the metabolic rate; in any case a moderate normovolemic haemodilution is useful to improve microcirculatory flow, by reducing the haematocrit while maintaining intravascular volume to ensure adequate cardiac output. Blood viscosity is reduced as a consequence of the fall in haematocrit, and results in decreased systemic vascular resistance, increased blood flow and increased systemic oxygen transport. It is generally agreed that it is necessary to maintain a haematocrit above 30% for the infant and 26% for the older child.
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Surgical treatment Soft tissue defects Some anatomical peculiarities of children’s tissues affect the technique of harvesting vascularized flaps and may influence long-term results of microsurgical reconstructions. The subcutaneous fat tissue is trophic and abundant in infants; moreover, it is scarcely vascularized and fragile. An atraumatic technique is necessary to avoid ischaemia of the fat layer, which may lead to necrosis and infection. Furthermore, the dissection of composite flaps is more difficult than in adults because of the tendency of the subcutaneous layer to separate from the underlying muscle or fascia. Cutaneous and composite flaps tend to be thicker in children; this should be kept in mind while deciding which flap to use for the reconstruction of the overall defect. Such flaps tend to increase in volume during childhood growth (allegedly owing to their rich vascularization), whereas muscular flaps tend to retract and become fibrotic with time. Consequently, skin flaps are preferred in reconstructions of articular or paraarticular areas so as not to interfere with joint motion, whereas muscular flaps should be chosen to cover non-mobile areas, such as the diaphyseal segment of a limb (Romaña et al 2000). The latissimus dorsi flap is most frequently used to reconstruct large upper limb defects. It can be used both as a pedicled flap—for reconstructions in the shoulder area— or as a free flap in larger distal defects. Furthermore it may be used as a functional muscle transfer, keeping its motor nerve intact, to reconstruct an avulsed or paralysed deltoid or biceps muscle. The scapular and parascapular flaps are good options for medium-sized reconstructions. Their major drawback is a rather short vascular pedicle which quite frequently shows anatomical variations. Moreover, in the donor area, the aesthetics are poor as the scar worsens with time because of the progressive stretching due to childhood growth. The radial forearm flap has few or no indications because it requires the sacrifice of the radial artery, which in the child takes on greater significance in later life. It can be considered in special cases, such as in the form of a flowthrough composite flap to replant or revascularize an ischaemic distal segment through an arterial graft. The posterior interosseous flap poses greater difficulties in terms of harvesting technique, especially in smaller children. It can be used as a direct flow pedicle flap for proximal defects or, more commonly, as a reverse flow flap for distal upper limb reconstructions. Becker’s ulnar flap has more limited indications, although it leaves less scarring. Becker and Gibert (1990) report the possibility of using it as a free flap which is based on a pedicle that includes a short segment of the ulnar artery. This can later be reanastomosed owing to its elasticity. The lateral arm flap may also be a possible choice for the reconstructive surgery. It has a constant and long vascular pedicle and can be chosen for the reconstruction of thick medium-sized defects. The dorsalis pedis flap still is useful for smallto-medium reconstructions of the wrist and hand when a thin and elastic flap is needed. It is particularly useful as a composite flap including the vascularized toe extensor tendons, or as an osteocutaneous flap that
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includes one of the metatarsals. The donor site scarring is not as bad as commonly described if the flap is properly designed and the thickness of the split skin graft used for the secondary reconstruction is adequate. An innervated gracilis muscle transfer is indicated in severe forearm muscular tissue loss, as well as in sequelae of Volkmann’s syndrome. It can be harvested as a pure muscular or a myocutaneous flap. Its motor reinnervation allows the recovery of a functional grip depending on different reconstructive options. Finally, when a free microsurgical flap is not feasible, the possibility of using more traditional axial flaps can be still be considered. In particular, McGregor’s groin flap allows the covering of the distal forearm; wrist and dorsal or volar aspects of the hand, with minimal aesthetic damage in the donor area. This remains, however, a second option because of the discomfort of immobilizing the small patient with a bandage or cast for several weeks and the necessity of changing the wound dressing frequently. Bone and articular defects Extensive skeletal lesions of the upper limb can affect bone growth by damaging the epiphyseal plates, or thwarting their growth potential leading to secondary axial deviations or, paradoxically, to hypergrowth due to excessive stimulus of the physis. These all are conditions peculiar to the paediatric patient. A vascularized epiphyseal transfer, together with a variable length of the diaphyseal segment, makes it possible to restore the axial growth of the bones of young patients whose epiphysis has been destroyed by trauma, infections, or tumour resection. The proximal fibula is particularly well suited to reconstruction of the proximal humerus and of the distal radius because of the similarities in size and shape. Furthermore, a vascularized bone graft has greater resistance to infection because of its inherent blood supply. The choice of the vascular pedicle in epiphyseal fibula transfers has been a subject of discussion. Some authors utilize the peroneal artery, isolated or in association with the geniculate inferior lateral artery (Tsai et al 1986, Gilbert and Mathoulin 2000), whereas others prefer the anterior tibial pedicle. The latter is able to vascularize both the proximal epiphysis and the proximal two-thirds of the diaphysis (Taylor et al 1988). Our clinical experience has convinced us that the anterior tibial pedicle permits a predictable growth of the graft (Fig.1) (Innocenti et al 1998). Articular reconstructions as well should be planned taking skeletal growth into account. Temporary restoration of skeletal length of the limb is obtained through external fixation. Associated soft tissue reconstruction is through
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Figure 1 Reconstruction of the distal radius with a vascularized fibula graft in a 7-year-old child after bone sarcoma resection. The transfer was based on the anterior tibial vascular pedicle. (a) Radiograph at 4 months. (b) After 3 years the graft growth was 2.5 cm (growth rate per year: 0.9 cm). pedicled or free vascularized flaps. Coexisting nerve or vascular lesions are also repaired. Large bone defects can be treated by immediate microsurgical composite osteocutaneous flaps. As an alternative, temporary cement spacers with antibiotics can be used. The wrist and the digital joints may be treated with immediate arthrodesis supported with cancellous bone grafts. Elbow joint reconstruction poses greater functional problems because rigidity leads to a severe functional impairment. In these instances, a vascularized transplant of the first metatarsophalangeal joint has proved to be effective (Ceruso et al 2000). A stable joint with a functional range of motion can be achieved (Fig. 2). Similarly, in multiple digit trauma, there may be an indication for a vascularized metatarsophalangeal joint transfer to restore the mobility of at least one of the digital rays. Peripheral nerve lesions ‘Recovery in children is far better than adults and there should, therefore, be no hesitation in embarking on the repair of proximally situated
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Figure 2 Septic arthritis of the elbow joint. (a) Radiograph showing secondary elbow dislocation and bone deformity at the age of 14. (b,c) AP and lateral views after reconstruction with a vascularized metatarsophalangeal joint transfer from the big toe. (d) Range of motion of the reconstructed elbow at 5-year follow-up. (e) First metatarsal ray reconstruction with an iliac bone graft. (f) The donor foot at 5 years.
Figure 3 (a) Traumatic left arm amputation in a 7-year-old child. (b–d) The progression of nerve regeneration and complete intrinsic muscle recovery. lesions in the young’ (Seddon 1975). More recent studies also support the view that peripheral nerve repair in children is always aided by favourable biological factors (Birch
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and Achan 2000). Nerve regeneration occurs in considerably shorter time in comparison to adult patients; excellent sensory recovery can be expected and motor reinnervation of the intrinsic muscles of the hand can be achieved (Fig. 3). Furthermore, in children we observe neither hypersensitivity to cold nor posttraumatic neuralgia or the painful hypersensitivity that accompanies regeneration of a trunk nerve. Finally, causalgia and reflex sympathetic dystrophy are scarcely ever seen in a paediatric patient (Stevenson and Zucker 1986). Therefore, immediate exploration and repair of the nerve lesion, through direct microscopic suture or grafts, should always be performed even in proximal avulsion injuries. In some instances it may be difficult to perform an adequate evaluation of the extent and complexity of nerve lesions in children and treatment could be delayed owing to an erroneous belief in spontaneous recovery. It must be kept in mind that nerve lesions interfere with the growth of the limb and may lead to secondary osteoarticular deformities owing to the alteration of muscular balance. After repair, nerve regeneration may go on for an unusually long time. Therefore, secondary palliative operations, such as tendon transfers, must be delayed longer than in the adult.
Antibiotic treatment Infection is the most frequently recognized cause of morbidity in severely injured children. However, it should not be considered as an inevitable consequence of injury. Exogenous, environmental or endogenous pathogens can be involved and polymicrobial aetiology accounts for nearly half of the infections. Among the paediatric trauma patients the overall incidence of infections is nearly 10% and approximately 1% of deaths are related to sepsis (Bell et al 1992). These figures are low compared to those reported among adults. Different factors contribute to the risk of infection, including disruption of cutaneous barriers, devitalization of tissue by trauma, reduction of chemotaxis, impairment of reticuloendothelial function and intracellular killing, and alteration of T and B cell responses. These factors act in conjunction with bacterial contamination by foreign debris and/or bacterial overgrowth due to intestinal and urinary stasis (Mollit 2002). In traumatically wounded children antibiotic treatment cannot be considered prophylactic, since tissue injury and contamination have already occurred at the time the antibiotic therapy is started. Its role is, therefore, to control infection, particularly in the presence of severe contamination, widespread tissue damage, abundant local flora and delay in surgical and medical treatment. In fact, all these factors favour the onset of infection. The recommended route of administration of the antibiotic therapy is the intravenous route which allows better efficacy with shorter duration of treatment. In presence of sharp, penetrating trauma or complex blunt injuries involving only skin and/or soft tissue, a latent period of approximately 4 hours exists before bacterial growth and tissue invasion occurs and at least 6–8 hours are necessary for infection to develop. In these instances, provided that the intervention is timely (unless an animal bite is responsible for the wound) a single dose of an antistaphylococcal agent may be sufficient for prophylaxis of infection. In the case of bite wounds, in which Staphylococcus aureus,
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streptococci, anaerobes and Pasteurella spp. are usually involved, intravenous treatment with amoxicillin-clavulanate or ampicillin-sulbactam is recommended for at least 48–72 hours (American Academy of Pediatrics 2000). When stretch, compression or crush injuries are associated with open fractures, contamination with skin flora and/or other pathogens derived from clothes, soil or debris occurs immediately. These injuries are therefore at risk of soft tissue infection and of osteomyelitis. The most commonly involved pathogens are Staphylococcus, Gramnegative rods, Pseudomonas and Clostridium. Antibiotic treatment is administered according to the extent of the tissue wound, crushing and vascular injury. In particular, in children, when the tissue wound is greater than 1 cm and crushing injury with or without massive contamination or vascular injury are also present, an aminoglycoside is added and the treatment is continued for longer than 72 hours. In the presence of an extensive crush injury or soil or faecal contamination, which increase the risk of clostridial infection, penicillin is also given (Table 1) (Behrens 1998). Tetanus prophylaxis is indicated in all children with any soft tissue injuries.
Complications The smaller dimensions of the vessels in children are generally cited as one of the unfavourable elements for the success of a microsurgical reconstructive procedure. In spite of the improvement of microsurgical techniques, there remain objective limits to performing reliable anastomosis of vessels below 0.8 mm in diameter (Romaña et al 2000). It must be noted however, that there is a favourable relationship between the overall dimensions of the injured limb and the diameter of the vessels, since the vessels and nerves of children are proportionally larger than in the adult, the level of lesion being similar. Favourable prognostic factors are reported to be the decreased tendency for spasm and vascular thrombosis because risk factors such as diabetes, arterial hypertension, associated cardiovascular pathologies, smoking, are absent or rare (Parry et al 1998). Nevertheless, the percentage
Table 1 Paediatric doses of selected antibiotics. Doses in mg/kg at frequency indicated Body weight < Body weight > Drug 2000 gm 2000 gm 0–7 days 8–28 0–7 days 8–28 > 28 days days days Amikacin 7.5 q 18– 7.5 q 18– 10 q 12h 10 q 12h 10 q 8h 24h 24h Gent/tobra 2.5 q 18– 2.5 q 18– 2.5 q 12h 2.5 q 12h 2.5 q 8h 24h 24h Cefazolin 20 q 12h 20 q 12h 20 q 12h 20 q 8h 20 q 8h Ampicillin 50 q 12h 50 q 8h 50 q 8h 50 q 6h 50 q 6h
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Ampicillin/sulb Amoxicillin
30 div bid
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100–300 div q 6h 25–50 div tid
Amoxi-clav
For 875/125 formulations, 45 div bid Penicillin G IV 50 000 U 75 000 U 50 000 U 50 000 U 50 000 U q 6h q 12h q 8h q 8h q 6h Clindamycin 5 q 12h 5 q 8h 5 q 8h 5 q 6h 7.5 q 6h 5–6 q 8h Vancomycin 40–60 div q 6h Gent, gentamicin; tobra, tobramycin; sulb, sulbactam; amoxi, amoxicillin, clav, clavalunate.
Figure 4 (a) Hypertrophic scar of the donor site after harvesting of a latissimus dorsi flap. (b) Parascapular flap donor area showing stretching of the scar. (c) The dystrophic aspect of the donor area of a dorsalis pedis flap, covered with an inadequate split thickness skin graft. of failed microsurgical operations is rather higher in infancy because of the wide indications for operation (Canales et al 1991). Scar retraction and hypertrophy in both the traumatized areas and the donor areas have been observed (Fig. 4). As already emphasized, these cause aesthetic and functional problems for they interfere with tissue sliding and range of articular motion. Moreover a scar may induce secondary alterations during the growth of the limb. An adequate planning of the incision is mandatory and a more limited skin paddle should be considered whenever a large composite musculo- or fasciocutaneous flap is required. Pressure garments and silicone tapes should be used to reduce the tendency of scars to hypertrophy. Infections are less frequent than in adults (Canales et al 1991). The better perfusion of tissues and the immunological status of children are favourable factors in preventing
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bacterial growth and make it possible to eradicate the infecting agent with greater ease Conversely, septic damage to the growing structures is responsible for severe secondary deformities and length discrepancies.
Conclusions Reconstructive surgery for severe post-traumatic defects of the upper limb has broad indications in children, considering the greater lifespan and good long-term results characterized by a better functional recovery. The technical knowledge required for the treatment of paediatric lesions is not substantially different from that for microsurgery in adult patients. Nevertheless, paediatric surgery based on a specific knowledge of the peculiar characteristics of the young patient leads to better patient care and to a more suitable choice of reconstructive procedures in terms of functional and aesthetic results. An injured child requires an organized team approach for the best possible care. Anaesthesiological requirements, for instance, do not end with surgery, but continue into the postoperative period for long-term control of pain and anxiety, given the close link between these two factors and limb perfusion. To accomplish this, physicians from all specialties must cooperate and be knowledgeable about the up-to-date paediatric treatment techniques.
References American Academy of Pediatrics (2000) Bites. In: Pickering LK, ed. Red Book: Report of the Committee of Infectious Diseases, 2 5th edn. Elk Grove Village, Illinois, 155–9. Banic A, Wulf K (1986) Latissimus dorsi free flaps for total repair of extensive lower leg injuries in children, Plast Reconstr Surg 79:769. Becker C, Gilbert A (1990) Lambeau antébrachial des branches distales de I’artère cubitale. In: Gilbert A, Masquelet AC, Hentz RV, eds. Les Lambeaux Artériels Pédiculées du Membre Supérieur. Expansion Scientifique Francaise: Paris. Behrens FF (1998) Fractures with soft tissue injuries. In: Green NE, Swiontkowsky MS, eds. Skeletal Trauma in Children, vol 3, 2nd edn. WB Saunders: Philadelphia, 103–19. Bell LM, Baker MD, Beatty D et al (1992) Infections in severely traumatized children, J Pediatr Surg 27: 1394–8. Birch R, Achan P (2000) Peripheral nerve repairs and their results in children, Hand Clin 16:579–95. Canales F, Lineaweaver WC, Furnas H et al (1991) Microvascular tissue transfer in paediatric patients: analysis of 106 cases, Br J Plast Surg 44:423–7. Ceruso M et al (2000) Elbow joint reconstruction with a vascularized metatarsophalangeal joint transfer from the great toe. VII Congress of the FESSH: Barcelona, Spain, 21–24 June. Fagelman MF, Epps HR, Rang M (2002) Mangled extremity severity score in children, J Pediatr Orthop 22:182–4.
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Fried G, Salerno T et al (1978) Management of extremity with combined neurovascular and muscoloskeletal trauma, J Trauma 18:481–6. Gilbert A, Mathoulin C (2000) Vascularized bone grafts in children. Specifics and indications, Ann Chir Plast Esthet 45:309–22. Holmes MJ, Reyes HM (1984) A critical review of urban pediatric trauma, J Trauma 24:253–5. Innocenti M, Ceruso M, Manfrini M et al (1998) Free vascularized growth-plate transfer after bone tumor resection in children, J Reconstr Microsurg 14:137–43. Iwaya T, Harii K, Yamada A et al (1982) Microvascular free flaps for the treatment of avulsion injuries of the feet in children, J Trauma 22:15. Mazurek A (1991) Pediatric trauma: overview of the problem, J Post Anesthiol Nurs 6:331–5. McCann ME, Kain ZN (2001) The management of preoperative anxiety in children: an update, Anesth Analg 93:98–105. Mollit DL (2002) Infection control: avoid the inevitable, Surg Clin North Am 82:365–78. Moulton S (2000) Early management of the child with multiple injuries, Clin Orthop Rel Res 376:6–14. Parry SW, Toth BA, Elliot LF (1998) Microvascular freetissue transfer in children, Plast Reconstr Surg 44:423. Paul O, Jouglet T, Camboulives J (1997) Les traumatismes severes de I’enfant, Arch Pediatr 4:443–59. Raimondi PL, Petrolati M, Delaria G (2000) Replantation of large segments in children, Hand Clin 16:547–61. Ramenofsky ML, Moulton SL (1995) The pediatric trauma center, Semin Pediatr Surg 4:128–34. Romaña C, Goubier JN, Gilbert A, Masquelet AC (2000) Coverage of large skin defects of the pediatric upper extremity, Hand Clin 16:563–71. Seddon HJ (1975) Results of repairs of nerves. In: Surgical Disorders of Peripheral Nerves, 2nd edn. Churchill Livingstone: Edinburgh, 312. Shapiro J, Akbarnia BA, Hanel DP (1989) Free tissue transfer in children, J Pediatr Orthop 9:590–5. Stevenson JH, Zucker RM (1986) Upper limb motor and sensory recovery after multiple proximal nerve injury in children: a long term review of five patients, Br J Plast Surg 39:109–13. Taylor GI, Wilson KR, Rees MD et al (1988) The anterior tibial vessels and their role in epiphyseal and diaphyseal transfer of the fibula: experimental study and clinical applications, Br J Plast Surg 41:451–69. Tsai TM, Ludwig L, Tonkin M (1986) Vascularized fibular epiphyseal transfer, Clin Orthop 210:228–34. Urbaniak JR, Foster JS (1992) Reimplantation in children. In: Microsurgical Procedures. Churchill Livingstone. Weinberg A, Mosheiff R et al (1999) Amputated lower limbs as a bank of organs for other organ salvage, Injury 30(Suppl 2):B34–8. Yücel A, Aydin Y, Yazar S, Altintas F, Senyuva C (2001) Elective free-tissue transfer in pediatric patients, J Reconstr Microsurg 17:27–36.
25 Future advances in hand and upper limb surgery: application of tissue engineering and biotechnology Panayotis N Soucacos
Introduction Advances in the fields of biotechnology and tissue engineering offer new possibilities in the repair or regeneration of tissue loss in disease or injury. Although biotechnology and tissue engineering have broad applications in several medical disciplines, a major portion of the research effort has focused on applications in orthopedics with emphasis on the development of techniques for developing bone, articular cartilage, ligaments, tendons and nerves. Biotechnology and tissue engineering represent a multidisciplinary approach to solving some of the most demanding medical problems, particularly the creation of new tissues similar to those in the living organism. These technical approaches include strategies using new synthetic polymer formulations, biologic constructs as well as various alternatives in tissue regeneration. This chapter will examine the fundamental issues of tissue engineering, such as scaffold formation, cell cultures and cell signals. The possible impact of bimolecular medicine in areas critical to the future of hand surgery, including tissue replacement, tissue regeneration, wound healing, and bone, tendon, cartilage, ligament and nerve repair will be discussed.
Tissue replacement and tissue regeneration In the past, orthopaedic surgeons have been applying the principles of tissue engineering clinically in tendon and bone transplantation. In these procedures, a scaffold (tendon (collagen) or bone) is inserted for structural support with or without living cells in recipient graft sites which have been prepared to promote remodelling and tissue restoration. An autograft is the best option for replacing defects, but the problem of donor site defects (structural or functional) in the host has never been overcome. Although the development of immune suppressing agents expanded the allograft era, the number of donors with perfectly matching recipient HLA (human leucocyte antigen) is still limited. As a result of these inherent difficulties, the possibility of replacing tissue defects with biochemically functioning materials instead of auto- or allografts has been the focus of recent investigations. The ultimate goal is to regenerate normal tissue. Bone under most conditions is capable of regeneration; however, tissues such as tendon, cartilage and ligament repair themselves with organized scar tissue. Thus, for these tissue types
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strategies have been developed to modify normal tissue repair with scar formation to the regeneration of normal tissue. With the recent progress in the new technologies of cell modulation, extracellular matrix fabrication and synthesis of polymers that mimic body structures, selfregeneration of body defects by host tissue cannot be considered a possibility. Conventionally, tissue replacement focused on the use of non-biologic and nonviable materials, such as metals, ceramics and synthetic polymers. Restoration of defects was usually limited to re-establishing support for mechanical functions of the skeletal and circulatory systems or to the replacement of morpho-logical defects with bioinert materials. Recently, research focusing on constructing artificial tissues by combining modulated cells with extracellular matrix-hybridized synthetic polymers has produced exciting results with biologically functioning artificial tissues (Suh 2000). The increase in knowledge of cell biology and embryology has slowly shifted the focus from tissue restoration to tissue regeneration or generation of site-specific normal tissue as it occurs in embryonic development. Embryonic tissue is characterized by a high concentration of pluripotent and progenitor cells and relatively little matrix. Embryonic and mesenchymal stem cells have become attractive resources because of the potential for differentiation into various tissue types in response to signal transduction mediated by various circulating chemical factors such as cytokines (Suh 2000). Embryonic pluripotential stem cells and adult human stem cells have the potential to differentiate into various cells types (Thomason et al 1998, Pittenger et al 1999).
Components of tissue engineering All tissues consist of cells, extracellular matrix and ionic body fluid. The extracellular matrix plays a fundamental role in providing a suitable living environment for cells and in maintaining the tissue’s structure. By hybridizing the extracellular matrix with polymers, cultured cells can then be introduced, resulting in a biomimicking material with biological properties appropriate for tissue replacement. Thus, three essential components are required for tissue engineering: • scaffold or matrix • cells • cellular signals in the form of growth factors or transfected genes. The scaffold or matrix A scaffold or matrix that provides a construct for the cells to grow in is a crucial component of tissue engineering. A scaffold can be an artificial construct of polymers. Human tissues are comprised of biologically and structurally complex acellular fabrics that provide a supportive scaffold or matrix for cellular growth and have biologically important chemical properties that profoundly affect cell growth and differentiation. Initially, the scaffolds or matrices were developed from biodegradable polymers which supported the initial growth and differentiation of cells. These, however, had inherent properties that allowed them to degrade over time, thus allowing the cells themselves to produce the matrix components specific to that particular tissue. Amongst the new
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polymers developed, polyactic acid, polyglycolic acid and polypropyl fumarate have exhibited not only novel biomechanical properties, but, in particular, the ability to promote growth of tissue. As our awareness of the extracellular matrix constituents increases, more tissue-specific scaffolds can be developed. An important future direction in the development of new scaffolds includes the incorporation of cellular signals that enhance cell growth and differentiation. The cells Although tissues are complex structures comprised of various cell types, most investigators in tissue engineering have used only fully differentiated cells, such as osteoblasts, chondrocytes or others. For example, skin is composed of multiple differentiated cell populations including keratinocytes, melanocytes, neural cells, fibroblasts, adipocytes, smooth muscle cells, endothelial cells, etc. To engineer an anatomically precise tissue would entail the use of numerous differentiated cell types such as those described for skin. In light of the knowledge that new cells in any tissue differentiate from a quiescent population of stem cells, which are responsible for maintaining the long-term integrity of the tissue, research has recently focused on cells that are undifferentiated (Solter and Gearhart 1999). The advantage of using stem cells is that they can differentiate into individual specific cell types and also reproduce themselves so as to maintain the population of stem cells. Recently, investigators have proposed methods to obtain autologous stem cells, embryonic stem cells or cloning (Pennisi 1997, Ferber 1999). The cellular signals The regulation of cellular processes that occurs during tissue repair is complex, and growth factors and cytokines play a central role. Advances in molecular biology have given us a clearer picture of how growth factors influence repair through receptor activation, signal transduction and changes in target gene expression. These, in turn, alter cell proliferation, migration, as well as other cellular metabolic activities. It is very likely that during the twenty-first century new treatment paradigms will entail adding or subtracting growth factors to ultimately induce changes in cell function. Various growth factors have a prominent role in the regulation of wound healing (Breuing et al 1997). They are released predominantly by various activated cells at the wound site. Recently, healing rates in normal wounds were found to be accelerated by adding exogenous TGF (transforming growth factor)-beta, PDGF (platelet derived growth factor), IGF (insulin-like growth factor)-1, or FDF-2 (Cromack et al 1990). In addition, these growth factors also augment repair in organisms with impaired wound healing conditions, for example chronic steroid use or diabetes (Cromack et al 1991).
Biomaterials Several important requirements must be adhered to in the development of biomaterials for orthopaedic applications. These include biocompatibility, appropriate mechanical
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properties, promotion of tissue formation, ease of material sterilization, as well as ease of handling. It is important that any biomaterial used in hand surgery must be biocompatible. In other words, the material must not elicit extreme immunogenic or cytotoxic responses. Because most of these materials are designed to degrade in vivo, it is also important that the degradation products are biocompatible (Thomson et al 1995). The initial mechanical properties of a biomaterial that is implanted must be as close as possible to those of the tissue that is to regenerate. Appropriate mechanical properties ensure proper support in early healing stages, as well as a graded load transfer later in the process during the creation of replacement tissue that is identical to the original (Yaszeski et al 1996). Several mechanical properties need to be considered for materials to be used in orthopaedics, including compression, tension and torsion. In general compressive properties are an important consideration for cancellous bone, while tensile properties are important for cortical bone. Properties such as amount of void space and degradation time are selected to encourage tissue growth and vascularization within the material (Thomson et al 1995). It should be relatively easy to sterilize the biomaterial to help prevent infection (Yaszeski et al 1996) and it should be easy to handle (Temenoff and Mikos 2000).
Bone In the past, bone tissue engineering has focused primarily on repairing bony defects with polymeric materials and ceramics. Ceramics, such as calcium phosphate hydraulic cement, have often been selected to aid fracture fixation and filling of bony defects, as they promote bony ingrowth, are biocompatible and harden in situ (Ikenga et al 1998). Despite considerable focus on cements that are quickly resorbed, many existing calcium phosphate materials degrade relatively slowly, which can lead to decreased bone regeneration at the site of the implant (Frankenburg et al 1998). While these cements show good biocompatibility and perform well in compression, tensile strengths are still below that of natural bone (Constanz et al 1995, Frankenburg et al 1998). In an effort to address these concerns, researchers have focused on polymeric materials. Polymers are injectable and harden in situ. Although polymers may be less biocompatible and more difficult to sterilize than ceramic cements, mechanical properties and degradation times are more easily tailored, giving them several distinct advantages for use in orthopaedic surgery. A promising candidate for clinical application is poly(propylene fumarate) (PPF) which shows versatility and excellent mechanical properties (Temenoff and Mikos 2000). The ultimate mechanical properties of PPF can vary greatly according to the method of synthesis and the cross-linking agents used in its formulation. Its degradation time is dependent on polymer structure and other components that comprise the composite material. Although initially a mild inflammatory response is observed and a fibrous capsule formed around the implant, PPF does not exhibit a deleterious longterm inflammatory response when implanted subcutaneously in rats (Peter et al 1998). Recent in vitro studies have shown that the PPF/betaTCP construct has significant osteoconductive properties. In addition, these studies indicated that the composite encourages attachment, proliferation and differentiation of osteoblastic functions of rat
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marrow stromal cells (Peter et al 2000). Moreover, recent studies indicate that the initial mechanical properties can be improved significantly by directing cell migration and differentiation within the material with the use of growth factors, for example TGF-beta 1 (Lu et al 2000). The periosteum has osteogenic properties through the release of periosteum-derived osteoblasts. As a result, several investigators have attempted to use periosteum to generate bone. Periosteal grafts have been successfully applied to induce new bone formation, with vascularized periosteum showing a constant or even increasing level of osteogenic capacity over time (Ritsila et al 1972, Ishida et al 1996). Bone formation by endochondral ossification can be induced when periosteum is placed directly onto a polyglycolic acid polymer, resulting in the migration of the periosteal cells from the tissue and their attachment and spreading on the polymer (Isogali et al 1999).
Cartilage The principles and requirements of cartilage tissue engineering differ significantly from those of bone tissue engineering. The biomaterials used for cartilage engineering are, like bone, required to withstand compressive loads. However, cartilage must provide frictionless movement at the joints. Thus, important considerations for appropriate cartilage biomaterials include the ability to withstand shear forces at the joint surface. Both naturally derived and synthetic polymers have been used in cartilage repair with notable differences in their biocompatibility and in their ability to promote tissue formation. Transplanted chondrocytes on a polyglycolic acid polymer mesh have been shown to regenerate cartilage (Vacanti et al 1991). Of the naturally derived polymers, fibrin glues and alginate gels have been widely studied for injectable cartilage applications. Several investigators have explored the application of a degradable fibrin mesh produced by injecting fibrinogen and thrombin as a scaffold for chondrocytes (Sims et al 1998). The advantage of this method is that the patient’s own fibrinogen and thrombin can be used, thus eliminating concerns about biocompatibility, sterility and temperature changes during setting. Recent experiments show that when the cell-fibrinogen-thrombin mixture was injected into defects, a hyalinelike cartilage was formed with more glycosaminoglycan and type II collagen than in untreated defects (Hendrickson et al 1994). Alginate is a liquid derivative of seaweed that can be cross-linked with calcium and injected into the cartilaginous defect. Histologic evaluation showed the architecture of the newly formed tissue induced by alginate to be similar to that of the native cartilage. However, there was little evidence of degradation of the alginate biomaterial. There was also some evidence that it may be immunogenic (Paige et al 1996).
Tendons Tendon defects are a major concern in hand surgery because of the limited availability of appropriate tissue sources for tendon grafting. In many cases, unfavourable results can be attributed to the lack of ideal graft material, rather than the surgical technique used.
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Although autografts are considered ideal for repairing tendon defects, there are limited donor sites and harvesting an autologous tendon often leads to minor functional disabilities at the donor site. On the other hand, tendon allografts are generally unsuitable because of immune rejections. Most prosthetic replacements (e.g. carbon fibres, silastic sheets, Dacron grafts, etc.) fail to achieve satisfactory long-term results, as they are unable to heal properly with the tendon tissue and they are unable to sustain the mechanical forces required for normal movement (Milthorpe 1994). Compared to other tissue types such as bone and cartilage, tendon engineering has not been studied extensively. To date several studies have tested the feasibility of engineering tendon tissues with autologous tenocytes to bridge the tendon defects (Cao et al 1994, 2002, Young et al 1998, Awad et al 1999). One of the pioneer experiments in tendon engineering was performed in nude mice. The results demonstrated for the first time that tendon tissue could be engineered using polyglycolic acid fibres seeded with tenocytes (Cao et al 1994). However, because an immunodeficient animal model was used, there was no information forthcoming regarding the biocompatibility of polyglycolic acid with host tissues and seed cells. In addition, this study did not address the effects of mechanical loading on the engineered tendons. More recently, the same research team presented results of experiments using a hen model and nicely demonstrated that tendon tissue could be engineered in vivo to bridge the tendon defect (Cao et al 2002). Moreover, their findings showed that the engineered tendons resembled natural tendons in their gross appearance (structure, colour and texture), and their histologic structure was also similar to that of natural tendons as regards collagen bundle alignment and cell-tocollagen ratio. Unlike their earlier study, the hen model study also assessed the mechanical properties of the in vivo formed tendon. An important finding was that the strength of the engineered tendons was about 83% of the normal tendon breaking strength. Moreover, the engineered tendon appeared to gain tensile strength gradually over the entire period of tissue construction, indicating similar biomechanical properties to natural tendons (Cao et al 2002). Two research teams have investigated the effectiveness of mixing bone marrow stromal cells with collagen gel to repair tendon defects in a rabbit model (Young et al 1998, Awad et al 1999). Although the biomechanical properties were improved when compared to the control tissue, the engineered tissues did not display a histologic structure similar to that of normal tendons. Critical evaluation of the results of these studies underscores two fundamental elements in tissue engineering: the biomaterial applied and the seed cell. The biomaterial applied as the scaffold material used is of primary importance. In the hen model, the scaffold material used consisted of unwoven polyglycolic acid fibres which otherwise are unable to sustain any tension. To provide additional mechanical strength, the investigators wrapped the fibres with a biomembrane of intestinal submucosa, and allowed the severed ends to retract to a set degree to avoid overloading. The seed cell is the second key element. In the study by Cao et al (2002) tenocytes were selected as seed cells to engineer the tendon tissue. The disadvantage of using tenocytes for tendon construction is the need to harvest autologous tendon tissue, which may not be practical clinically. Moreover, tenocytes from other mammalian sources (e.g. pigs) are difficult to culture and grow. Thus, it becomes clear that a remaining important
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step for the future success of tendon engineering is the ability to identify an alternative source of seed cells, such as dermal fibroblasts. A common clinical problem is adhesion of the repaired tendon to surrounding tissues. Generally, it is believed that preservation of paratenon tissue helps reduce adhesion. The tendons engineered in these studies were not surrounded by paratenon, and therefore adhered strongly to the surrounding tissues. In this regard, future studies must also focus on means of engineering a composite tendon tissue that includes a paratenon. In the past few years, several groups have been interested in applying methods of cell culture and molecular biology to flexor tendon research. Banes and colleagues (1988) developed a method to separate and propagate chicken fibroblast/tenocyte populations from the synovium (epitenon) and the internal tendon. It is also apparent that a third cell line composed of fibroblasts derived from the surrounding tendon sheath can be cultured. Growth factors, such as TGF-beta 1, have been implicated in the process of tendon wound healing.
Vessels Polyvinylchloride (PVC) was first used to restore dissected vessels in 1952. Since then, synthetic polymers have been regarded as one of the most important biomaterials, mostly because of their malleable chemical and physical characteristics. To protect against the formation of thrombosis from blood plasma proteins adhering to the polymer surface of the artificial blood vessels, chemical modifications of the lumen with hydrophilichydrophobic phase segregation or grafting protein repellant on the polymer surface have been attempted with encouraging results (Wesolowski et al 1963, Lee et al 1999). Neovascularization appears to be dependent on both angiogenesis and increased vascular permeability (Berse et al 1992). Both of these processes are endogenously stimulated by vascular endothelial growth factor (VEGF) (Zhang et al 2001). VEGF is produced by a variety of different cells in the human body and its receptors are found on endothelial cells (Berse et al 1992). VEGF sets off a cascade of events which lead to increased vascular permeability. This in turn, stimulates the migration of endothelial cells through the extracellular matrix. By effecting these two processes, VEGF is believed to improve angiogenesis (Taub et al 1999).
Nerves Current issues in peripheral nerve surgery include improvement of regeneration and creation of alternative sources of donor nerves. Several advances have been made in the surgical technique, including introduction of end-toside neurorrhaphy and baby-sitter nerve anastomoses (Zhang et al 2000). Biotechnological advances include allotransplantation of nerves, growth factors and artificial nerve conduits (Malizos et al 1997). Nerve allografts or xenografts are considered a good alternative for nerve conduits if immunosuppression is found to be safe and efficacious. Nerve allotransplantation has already been performed in patients with adequate sensory reinnervation (Mackinnon et al
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1992). Neurotrophic factors play an important role in nerve regeneration and as a result, there is great clinical interest in addressing whether they can supplement damaged nerve and nerve repairs to enhance sensory or motor recovery, or alternatively to avoid excessive tissue inflammation and scarring. Tissue engineering of peripheral nerves has focused on means to create either natural or synthetic tubular nerve guidance channels as alternatives to nerve autografts. The various options for guidance channels include synthetic substances, such as lactate polymer, polyglactin mesh, polyethylene, silicone and siliconepolymer tubes, as well as biologic conduits including autologous collagen, arterial grafts, veins and acellular muscle grafts (Fansa et al 1999). These are selected for their ability to help direct axon sprouting from the regenerating nerve end, to provide a conduit for diffusion of neurotropic and neurotrophic factors secreted by the damaged nerve stumps and minimize infiltration of fibrous tissue (Hudson et al 2000). Good axonal regeneration has been observed with the use of autologous vein grafts, and vein conduits have been used clinically to bridge short digital nerve gaps (Malizos et al 1997, Strauch et al 1997). Acellular muscle has been used for the repair of digital nerves, but because of the lack of viable Schwann cells there was failure of regeneration (Fawcett and Keynes 1986). As Schwann cells play a crucial role in regeneration of peripheral nerves due to their neurotrophic and neurotropic influence (Bunge 1993), recent studies have been aimed at evaluating the possibility of creating tissue engineered nerve grafts from biologic matrices combined with viable Schwann cells (Fansa et al 2001). Schwann cells produce and accumulate trophic factors for regenerating axons and thus are essential for axonal regeneration, particularly for long gaps (Ide 1996). Schwann cells produce basal lamina components, such as collagen type IV, which provide the extracellular matrix for attachment of the regenerating axons. More importantly, the Schwann cells form a column of cells, the band of Bungner, within the basal lamina tube after wallerian degeneration has taken place. This cell column serves as the pathway for the regenerating axons to reach their target (Gulati et al 1995). Recent studies have found several advantages of the application of acellular muscle in combination with cultured Schwann cells for nerve regeneration. This combination provides the advantage of large basal lamina tubes which can serve as pathways for the regenerating axons and the necessary effects of viable Schwann cells (production and accumulation of neurotrophic and neurotropic factors) to support early axonal regeneration (Fansa et al 2001).
Conclusions Biotechnology and tissue engineering represent a multidisciplinary approach to solving some of the most demanding medical problems, particularly the creation of new tissues similar to those in the living organism. These new technical approaches include strategies using new synthetic polymer formulations, biologic constructs as well as various alternatives in tissue regeneration. Fundamental issues in tissue engineering include scaffold formation, cell cultures and cell signals. The application of tissue engineering techniques in areas critical to the future of hand surgery, including tissue replacement, tissue regeneration, and bone, tendon, cartilage, ligament and nerve repair has met with
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promising results. Today, cell transplantation on artificial matrices is rapidly being applied successfully to form several specific tissue types (bone, cartilage, tendon, nerve, etc.). On the other hand, the construction of anatomical units, such as an entire joint, present special challenges in tissue engineering. These anatomical units are composed of multiple cell–tissue types, each with its tissue-specific extracellular matrices. The next challenge in biotechnology and tissue engineering will be to combine the formation of several musculoskeletal tissue components into a functional anatomical unit. Recent studies have presented the application of three different cell types (periosteum, cartilage and tendon) to form an entire phalangeal joint with a predetermined shape and composition (Isogali et al 1999).
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Index A A2-A4 pulley extensor 192–3 abdominal hernia, through defect iliac wing, after bone removal 63 active extension of toes, normal range, EDB provided 211 acute compartment syndrome 269 acute flaps, definition 51 adductorplasty 269, 271 adipofascial radial forearm flap 7–8 procedure stages 8 adipofascial turnover flap 204 aggressive giant cell tumor of distal radius, proximal carpal row invasion 81, 84 AH (abductor hallucis) 266–7 harvesting operative picture 267–8 myocutaneous free flap, harvest 267–8 transfer, type 2 thenar injury 268 alginate conduits 160–1 Allen tests 230, 262 long term vascular results 145 permeability confirmation, radial artery 13, 16 allogeneic arthroplasty 110 allograft bone transplantation, bone reaction types 109 allograft nerve grafting, pre-treatment 147 allografts 60–2, 64–5, 113 allovascularized transplantation, indications and improved successes 235–6 anaesthetic considerations, in children, as difficult and specialist skill 304–5 antebrachial flaps, issues of choice 16 anterior bone graft donor sites, complications 70 anterior interossoeus nerve 255 anterior surface of elbow reconstruction, recurrent radial flap, procedure stages 10–11 anterolateral thigh fascial flap harvested free 265 results after 3 months 265 antibiotic (examples), paediatric doses 309–10 antibiotic treatment 299–300 APB (abductor pollicis brevis) tendon 268 arm see autogenous reconstruction, humerus arthrodesis, see also joint fusion arthrodesis of the elbow amputation-reimplantation 130 and shortening of the upper limb 283 arthrodesis of shoulder ideal position 126 joint fusion 126–9 methods 127 plate and screws, radiograph 128 position 128 pre-requisite conditions 126 arthrodesis of wrist 130–2
Index
412
author’s method 130–1 complications 131–2 indications 130 main position of 30 degrees and 15 degrees ulnar deviation 131–2 medial approach 131 types 132 using bone graft 69 vascularized peroneal graft, traumatic tumour 131 ATLS (advanced trauma life support) 304 atrophic non-union of humerus, prior gunshot wound, extensive bone loss 80–1 auto- and allografts, combination benefits 65 autogenous bone graft and nail fixation consolidated humerus 66 delayed union bone consolidation, absence 66 stable fixation with nail 66 unstable humerus 66 autogenous reconstruction, humerus 65 autogenous transplantation proximal fibula, severe bone loss 69 autograft 59–64, 313 autologous cortical bone grafts, advantages 61 autologous fresh cancellous bone graft cement spacer removal and radius reconstruction 290 external device replacement by a plate, complete healing at 4 months 290 silicone rod placement, under flap 291 autologous nerve grafts (isografts) 154–5 autologous tendons as graft 160–1 autologous vein grafts 160 avascular necrosis fracture, rotator cuff failure and glenoid deficiency 123 avulsion of the upper limb 278 B Battiston experimental model, conduit guides for axonal growth 160 bioartificial nerve graft, synthetic material base 157 biocortical cancellous graft from ilium, technique for removal 130–1 biodegradable polymer tubes 156–8 bone auto- and allografts advantages/disadvantages 69–70 biological properties 59–60 bone allograft and joint prosthesis 68 in post-traumatic reconstruction 59–70 receiver site 59 structural properties 60–1 bone collapse, due to osteoporosis 121 bone defect, infection 77 bone formation induction, extraosseous sites 104 bone free flap 39 bone grafting applications 64–9 arthrodesis of wrist 69 complications and limitations 69–70
Index
413
followed by coverage with tendinofasciocutaneous composite flaps 283–4 graft choice 61 and shortening 39 sourcing donor site 61–4 bone and joint system reconstruction 291–3 bone marrow, content examples 104 bone morphogenic proteins (BMP) 99–100 bone radionecrosis, non-union associated 77 bone reconstruction 278 procedures 291–2 spacer, functional purposes 94 bone regeneration evidence, closing of gap, with fragments contact 92 bone shortening 278 sphacelus amputation; anatomical suturing 280–1 bone substitutes 99–104 clinical applications 102–3 clinical experience 101–2 indications and future directions 103–4 bone wax, usage 63 ‘boutonierre deformity’ 202 Boyes’ classification 234 grade III and IV finger flexor system, as new technique 228–9 BR, EPL (extensor pollicus longus) transferred 205 BR (brachioradialis) 200 brachial plexus, proximal long standing paralysis 254 brachial plexus injury 279–80 braided suture, synthetic 192 breast reconstruction, successful recovery sensory function, ‘embracing suture’ rectus abdominis nerve, TRAM flap 178 bridging nerve defects: role of tissue interpositioning 153–61 Brunner technique 236 Bunnell, type of suture 191 burn-crush thenar injury, type (4) 270–1 C calcium phosphate ceramics, biocompatible and osteoconductive 104 calcium sulphate 100 cancellous transplants 60 cancellous/corticocancellous autografts 39 capitulum reconstruction 67–9 cartilage allografts, allograft bone transplantation, principles and additional differences 109–10 catastrophic events, post-traumatic defects in children 303 cement with gentamicin and clindamicin, spectrum of action 95–7 ceramic hydroxyapatite 100 ceramics 100 chemotherapy 39 chimeric flap principle 205 chondroma, macroporous biphasic calcium ceramic filled 102–3 chondrosarcoma and revascularized fibular autograft, immediate/postoperative by 13 months 79–80 chronic dislocation of joint, partial compensation, by muscles surrounding joint 111
Index
414
chronic osteo-myelitis, following debridement of bone 35 chronic right elbow osteomyelitis and comcomitant brachial plexus palsy, gun shot wound 25–6 Cialit preservation 235 ciproflexacin 300 clindamycin 300 closed fracture, and primary joint replacement option 117–19 cloxacillin 300 collagen fibres 160 collagen tubes 158 combined flexor tendon and skin transfer 231 combined low median-ulnar nerve palsy 269 combined tendon-skin flap 263 compartment syndrome 279 complex injury (upper limb), definition 33 complex tendon-cutaneous defects, soft tissue reconstruction option, free non-vascularized transfer, long extensor tendon system 245–6 complex tenolysis, ‘running pulley’ introduction 195 composite skin-tendon free flap web of foot 3 months recovery 55 aesthetic flap integration 55 web of foot planning, and result 55 composite tissue transfer upper extremity 241–7 reconstructive strategy 242 compound defect, factors enabling 289 compound defect as secondary procedure, repair principles 287–93 compound dorsalis pedis flap, donor site-after 1 month, exposure and partial necrosis of extensor hallucis and tarsal bones evidence 264 compound thenar mass losses 266–9 compound tissue transfers, segmental defects 247 compression apparatus ‘hybrid’ 93 removal at 2 months 93 concomitant rheumatoid disease 118 consequent follow-up requirement, reasons with concomitant reconstruction 242 contracted retinacular system 202 contracted retinacular system release 202 contracting muscle transplant, strong finger flexion enablement 176 conventional tendon grafting 183–222 classification of cases cicatrix category 186 ‘good’ category 185–6 joint damage 186 multiple damage 186 nerve damage 186 historical background 183–4 coralline hydroxyapatite 99–100 corrective osteotomy 66 cortical allografts, excellent vascular supply necessity 61 ‘creeping substitution, ‘ resorption and apposition 60 crush component, at dorsum of hand, preoperative clinical pictures 222 crush injury left hand finger flexing impossibility 211
Index
415
preoperative radiographs 211 tendon sheath, with extensive damage 212 left hand a sequelae 218 follow-up at 1 year 218 intraoperative flexion of little finger 218 passive motion of little finger achieved 218 TATA technique 218 little finger right hand, lesion of flexor profundus, preoperative picture 209 right hand clinical follow-up at 3 years 210 intraoperative passive range motion 210 silicone road insertion, retinacular system reconstruction by pulleys 210 to hand 69 crush-degloving injury amputated stump 44 anterior aspect of left forearm 38–9 dorsum of left hand 40 post-surgical appearance 39 cubitus valgus deformity 66 cutaneous coverage of tissue, upper limb trauma 281 cyclosporine 235 D debridement non-viable tissues, high voltage injury, web of hand 55 techniques 52 debridement and application of spacer with external fixator 97 defect coverage 297–9 delayed staged reconstruction vs. ‘as early and as complete as possible’ 242 dermo-epidermic graft 13 diaphyseal allografts 39 digital flexion reconstruction, toe-to-finger free flexor tendon transfer 234–5 digital flexion sliding system technique 227–38 digital nerve grafts 145 ‘dishwater pus’, pathognomonic liquefactive necrosis 27 distal humerus and olecranon loss, AP radiograph, elbow 68 reconstruction 94 distal humerus and olecranon loss, AP radiograph, elbow, recovery stages 68 distal interphalangeal (DIP) joint 184 distal phalangeal joint, extension defect of 35 degrees 237–8 distal radius fractures 102 delayed healing, surgical realignment 69 distal radius with a vascularized fibula graft reconstruction, child 7 years 306–7 distal sphacelus/amputation 279 distal ulnar artery island flap see ulnodorsal septocutaneous flap distally based posterior interosseous island flap, transposition, and procedure stages 34–5 distally based radial forearm flap 293 donor site, iliac crest 70 Doppler fluxometer 16 Doppler tests 230
Index
416
dorsal hand lesion example 7 post distally pedicled radial forearm flap 7 dorsal pedis myofascial flap 264 dorsalis pedis 37 dorsalis pedis artery, absence as rarity 261–2 dorsalis pedis tendinocutaneous flap 261–2 dorsum of hand compound tendon loss 261–2 decision making for complex losses 263–5 dorsum lesion, ulnar forearm flap procedure stages 9 dorsum and thenar regions, combined soft tissue and tendon reconstruction 261–9 E early free flaps, definition 51 ECRB to EDC and EDU to EDC, tendon transfer completion 222 ECRL (extensor carpiraialis longus) 200 EIP (extensor indicis longus) 203 EIP (extensor indicis proprius) 268 EIP (extensor oligitonum communis) 203 elbow joint reconstruction, greater functional problems, in children 307 elbow prosthesis, soft tissue coverage in reconstruction 175 emergency free flaps 39–47 definitions 51 delayed closure 51 delayed primary closure 51 introduction 242 open injuries reconstruction disadvantages 54 flap choice 54 indications 52–4 timing 51–2 upper limb 51–5 primary closure 51 emergency free tissue transfer, concept 39 emergency reconstruction, principles 277–84 end-to-end cross-face nerve grafting 178 end-to-side neurorrhaphy alternative reinnervation long nerve defects 169–78 methods 170 results 170–5 surgical technique 170 clinical cases 171–2 as technique, reliable and clinicallly useful 175–6 enterobacteriaceae 300 epiphyseal transfer 111–12 donor site examples 111 EPL (extensor pollicies longus) 203 reconstruction 204 tendon graft repair 183
Index
417
ERLC reconstruction by tendon graft taken from ERBC 207 escarectomy reconstruction using vessel grafts and tendon spacers and plastic reconstruction 282 etiopathogenesis 303 Ewings sarcoma 111 radionecrosis of humeral diaphysis, radiograph 82 extensive epiphyseo-diaphyseal resection, consequences 114 extensive fibrosis of flexor apparatus 209 intraoperative passive range of motion 210 solicone rod insertion and retinacular system, reconstruction by pulleys 210 extensor hood deficit, reconstruction 202 extensor retinaculum 195 extensor tendon, infection and secondary rupture 220 extensor tendon defects repair 200, 202, 204 secondary reconstruction 204 extensor tendon grafting, late sequelae 205 extensor tendon reconstruction, sagittal bands, non-vascularized flexor tendon grafts from amputated index 265 extensor tendons zone VI and VII, absent structures, dynamic sonography are usually helpful, proximal stump location 186 F fascial and fasciocutaneous flaps 35, 37 fascial flap plus grafting 185 fascicular graft according Narakas 140 fascicular nerve grafting concept 138 donor nerve 138–9 of median nerve, carpal tunnel level 139–40 fasciocutaneous flap reconstruction, palmar region 284 fasciocutaneous free tissue transfers 37 FCU transfer, finger extension restoration 291 FCW (fleuro carpi wraris) 205 FDB (flexor digitorum brevis) 266–7 FDS (flexor digitorum superficialis) 268 IV, retrieval distal to carpal ligament, ulnar to the palmar fascia, as acting pulley for oppensplasty 271–2 surgical technique issues 199 FDS (flexor digitorum superficialis) tail 194 FFMT (free flap muscle transfer) 267–9 FFMT (free functioning muscle transplant) 269 fibronectin and laninin grafts 160 fibronectin mats, as conduits 160 fibula graft infection 95 inserted immediately after surgical cleaning 95 fibula (middle) cut, without interruption to vascularization 94 first dorsal metatarsal artery (FDMA) 261–2 first metacarpal bone benign lesion 102–3 first web space, of foot, free tissue transfers 37 fistulography 96 fixation, surgeon’s preference 131 fixed flexion deformity 232
Index
418
FK506 (tacrolimus) and nerve regeneration 148 flap selection and type A and B defects 242–5 type B defect, compounds soft tissue defect with loss of superficial flexor muscles and 3rd degree open ulnar fracture 244 and type C defects 245–6 and type D defects 246–7 flex tendon repair at 2 months favourable outcome 213 flexor apparatus interruption, staged repair 212 silicone rod insertion, with A2-A4 pulleys reconstructed 213 flexor apparatus, extensive fibrosis 209 flexor apparatus lesion 214 intraoperative finding 214 Micrococcus spp. wound contamination, rehabilitation phase 214 preliminary suture between flexor superficialis and flexor profundus 214 staged flexor grafting procedure Paneva-Holevich technique 215 flexor digitorum sublimis, finger 236 flexor digitorum superficialis 268 flexor pollicis, pedicled graft 197 flexor profundus 197, 231 flexor superficialis 231 flexor superficialis finger 197 flexor tendon defects 184–200 prerequisites 184–5 flexor tendon graft in zone III, IV, V 200 flexor tendon graft in zone VII 204–5 flexor tendon graft in zone VIII 205 flexor tendon graft in zones III and IV 203–4 flexor tendon graft in zones V and VI 203–4 flexor tendon grafting 185, 195–6 zone 1-5, area distal to flexor digitorum superficialis (FDS) 185 in Zone II 189 flexor tendon grafting results 199 flexor tendon reconstruction 204–5 two stage technique 218 flow-through fasciocutaneous free flaps, anatomy and dynamic concepts, in replantation 43 flow-through fasciocutaneous radial flap, marking 44 flow-through flaps, advantages 54 flow-through free fasciocutaneous flap, as single stage technique 44 flow-through free flap concept, as method of choice 44 flow-through free flap in reimplantation surgery 43–7 flow-through radial flap, marking guides 38–9 flow-through radial mid-forearm free flap anatomy and dynamic concept 42 one-stage coverage, revasculized limbs 41–3 Food and Drug Administration (FDA) 101 forearm clinical outcome after 10 years complete independence, DLA accomplished 222 forearm composite flap including PL and FRC performed 221 forearm cutaneous sphacelous as shot gun injury 282 post-surgical motor function (extension) 282
Index
419
post-surgical motor function (flexion) 282 forearm follow-up after 5 months, donor sites as unsightly with limited active range 222 forearm MP joint release 221 forearm-carpal defects 81 FPL (flexor pollicis longus), secondary reconstruction 197 fracture stabilization 296–7 with external fixation 296 free dermal flow-through venous flap 44, 46–7 free flaps 33–47 disadvantages 54 management principles 33–9 see also distally pedicled radial forearm flap; ulnar forearm flap free functioning muscle transfer 251–7 muscles utilised 251–2 free muscle transplantations 256–7 free serratus anterior muscle flap, soft tissue repair, post radical incision, showing cement spacer 289 free vascularized nerve graft, microvascular sutures 137–8 freeze dried allograft, unstable epihyseal fracture, distal radius, repair stages 62 friction avulsion dorsum of hand with bone and carpometacarpal joint exposure 53 debridement, joint stabilization and grafting 53 early result 53 friction injury to dorsum of hand, loss of extensors 2nd 3rd and 4th and common to 5th 265 FTIR (Fourier Transform Infrared) spectroscopy 101 function restoration 292 fusion of the elbow, indications 129 fusion of wrist, approach 130 G gastrocnemius muscle 252 gastronemius muscle 255 generalised sepsis, treatment option 300 gentamicin 95, 300 giant cell tumours 111 Gilbert’s procedure, skin incision, non-vascularized graft 93 glenohumeral joint, infection 28 glenoid rim, reconstruction 64 Godina’s principles 23 gracilis muscle 36, 255 distal-middle and proximal pedicles 252–4 as main proximal neurovascular pedicle 251–2 transfer for elbow flexion, surgical technique 252 transplantation on the intercostal nerves 254 gracilis muscle transfer post-elementarectomy, bone shortening 279 gun-shot injury emergency treatment composition 289–90 secondary treatment 290 Gustilo IIIB open fracture, elbow with large soft tissue defect 68
Index
420
H hemi-arthroplasty, treatment 121 high riding humeral head, total joint replacement 123 high voltage injury, web of hand 55 Highet scale, muscle power grade M0-M5, British Medical Council 175 HLA (human leucocyte antigen) 313 ‘hook deformity,’ fixed 218 human allotransplant of a digital flexion system vascularized on the ulnar pedicle 235–8 human vascularized allotransplant, digital system by microsurgery 236 humeral diaphyseal defect 81 humerus, autogenous reconstruction 65 humerus reconstruction, recipient site considerations 76 Hunter active tendon prosthesis 184 Hunter two-stage technique 197, 217, 293 hydroxyapatite implants 102 I ideal nerve conduit, theoretical model 153–4 idiopathic scoliosis 100 iliac crest, as common donor site 61–4, 70 immunosuppressive treatments 147 implant arthroplasty, pathological fracture 119–20 index finger 1 year follow up, unable to actively extend finger 208 MP joint stiffness, unrecognised fracture dislocation 207 infection, surgical management 295–300 initial fracture to shoulder arthroplasty, classification system 122 injury assessment and evaluation of tissue, from skin surface to depth of bone 288 intercalated bone graft, peroperative view, clavicle 65 intercalated tendon graft 186 interfascicular autografting 148 interpositional tendon graft 270–1 intraarticular and extraarticular non unions, general categories 67 irrigation and debridement 295–6 ischaemic contracture, left lower arm, fingers fixed, severe flexion contracture 176 isolated flexor digitorum profundus injury 199 ITBS (immuno therapy for specific bacteria) 87–8 iterative debridements and excisions, prior to reconstruction 292 J ‘jig’ system, with newer implant design 121 joint allografts, as salvage procedure 67 joint fusion indications 125 severe traumatic defects 125–32 techniques 125–6 joint reconstruction, choice of technique 112–13 joint replacement as secondary procedure 117–23 for traumatic bone loss at the elbow 117–20 joint replacement for traumatic bone loss at the shoulder 120–3
Index
421
joint transfer 110–11 choice of technique 112–13 joint transfers and joint reconstruction 109–15 fundamental aspects 109 joints reconstruction procedures 292 L large bone defects, donor sites 76–7 large defects reconstruction in children 303–10 antibiotic treatment 308–9 complications 309–10 indications 304 nerve regeneration and complete intrinsic muscle recovery 308 peripheral nerve lesions 307–8 septic arthritis of the elbow joint 307 surgical treatment bone and articular defects 306–7 soft tissue defects 305–6 traumatic arm amputation, child 7 years 308 late sequelae of flexor tendon grafting 199 lateral antebrachial cutaneous nerve 138–40 lateral arm flap with inverted flux see recurrent radial flap lateral fascial intermuscular septum, forearm 42 lateral forearm flap 282 lateral saphenous nerve, technique to harvest 138 latissimus dorsi island flap 36 after tumour resection, end-toside radial nerve, elbow improvement 173–5 transposed, intraoperative view 26 latissimus dorsi muscle 252 lesions assessment and definition, final goal of treatment definition 287–8 llizarov apparatus application 89, 95 and compactotomy radiographs 92 olive for compressionstabilization of focus while distraction is taking place 90 local upper extremity graft, disadvantages 63 long cortical autogenous grafts, fibula bone 63 long fingers and inability to extend the wrist 206 long nerve defects, end-to-side neurorrhaphy: as alternative reinnervation 169–78 longitudinally oriented suture material 158 loop technique, advantages 197 low humeral fracture bone loss range of pain-free motion 118–19 stability restoration with linked modular implant 118–19 bone loss at 1 year 118–19 low median-ulnar nerve palsy 269 lymphatic network 280 M McGregor’s flap 284 Mackinnon’s clinical series 148 macroporous biphasic calcium phosphate (MBCP) 101
Index
422
macroporous calcium phosphate ceramics 102 malignant ossifying fibromyxoid tumor 25, 27 MCDAS (multimicrovascular collagenic dynamic absorbing system) 227–8 medial antebrachial cutaneous nerve 138 medial gastrocnemius with the sural nerve 255 metallic prosthetic replacement 39 methylmethacrylate, usage 121 microvascular graft with arthrodesis of the wrist, spacer removal 97 middle of a muscle graft (‘sandwich graft’) basal laminae scaffolds 158–9 Millesi technique, nerve grafting 139–40 monoclonal antibodies, antirejection therapy 147–8 MP(metacarpophalyngeal) joints 292–3 associated release, silicone rods under flap, Hunter’s technique 293 multicomponent flaps 243 muscle and musculocutaneous flaps 35–6 muscle transplantation and end-toside suture of thoracodorsal nerve os mucle graft to median nerve 176 muscular sphacelous, of upper limb, significance of surgical evaluation 278 muscular sphacelus (tearing away of the entire upper limb) 278 musculocutaneous free tissue transfers 36 myocutaneous latissimus dorsi flap, successful innervation, by end-to-side neurorrhaphy 176 myoglobinuria 279 myostatic contracture 205 N Narakas technique 140 Neer prosthesis 122 neighbouring motor selection 186 nerve allografts 146–9, 159–60 history 146–7 nerve defect repair, veins 160 nerve gap distance, and repair type influenced time to earliest reinnervation 158 nerve grafting 137–49 different types 137–8 indications 141–2 postoperative care 141 results 142 technique and methods 139 tendon used as nerve graft 161 procedural stages 161 nerve grafts 154–5 nerve regeneration, ‘neurotube’ 149 nerve sutures as procedure, in emergency 281 nerve tubes 149 neurotrophic factor, example 160 non-pedicled allografts 110–11 non-pedicled epiphyseal autograft 111 non-vascularized allografts, experimental data in favour 147–8 non-vascularized trunk graft 137
Index
423
O oblique transcarpometacarpal amputation 4 months post-surgery appearance 44–5 bone fixation of amputated part, without shortening 44 free flap harvesting 44 left hand 44–5 olecranon fracture and non-union 67 omolateral lateral arm flap, planning 53 omothbracic disarticulation 278–9 one bone arm creation bone grafting and osteosynthesis 299 infection resolution, pro-supination was lost 299 one bone forearm, pronosupination sacrificed 298 one-stage reconstruction, with composite tissue transfer 247 open fracture infected non-union 92 plate osteosynthesis for stable internal fixation, well vascularized soft tissue coverage 244 open fracture of elbow, grade IIIC, with severe bone loss: ipsilateral fracture of radius and ulna 297 open fracture of forearm and wrist, result 96 open grade IIIC fracture serial debridements 298 radiographs 299 open grade IIIC ulna and radius fracture, severe infection with bone and soft tissue loss 298 opponensplasty 269, 271 osteoarticular allograft 65 osteoarticular loss, at shoulder level 65 osteochondral allograft, flexion-extension of wrist maintenance, with pro-supination 69 osteoconductive materials 99–101 osteocutaneous fibula flap 246 osteomyofasciocutaneous flaps 39 osteosarcoma 111 P palmaris brevis tendon graft 232 palmaris longus tendon 262 PALS (paediatric advanced life support) 304 pandiaphytes of ulna bone complete reconstruction of ulna 87 post ITBS and antibiotic therapy 87 Paneva-Holevich technique 198 Papineau technique 298 paprika sign 25 parascapular flap to left hand, function testing 3 months later 245 parascapular flap to the right forearm with transfer of remaining tendons to achieve residual function; partial nerve reconstruction 245 parosteal osteogenic sarcoma, proximal humerus, procedure and recovery stages 78 Pasteurella spp. 309 pathognomonic liquefactive necrosis, ‘dishwater pus’ 27 pathological fracture, implant arthroplasty 119–20 pectoralis major muscle 252
Index
424
pectoralis minor muscle 252 pedicellate fasciocutaneous radial forearm flap 68 pedicle dissection and section 94 pedicled epiphysis 111–12 pedicled fasciocutaneous and adipofascial flaps 7–19 pedicled latissimus dorsal island flap transposition 18 months post, deep right shoulder infection 27 shoulder defect 30 outcome postoperatively 30 pedicled latissimus dorsi flap 24–6 right upper extremity, repeated debridement, necrotizing fasciitis 27 pedicled latissmus dorsal island flap, transposition, shoulder defect 29 pedicled muscle and musculocutaneous flaps 23–9 pedicled myocutaneous latissimus dorsi flap 28 pedicled pectoralis major flap 25 design 28 pedicled staged tendon grafting technique 197–8 pedicled tendon graft 184 pediculated latissismus dorsi flap, plastic reconstruction 278 periprosthetic fracture massive bone loss 119 stabilization linked snap fit revision prosthesis 119 PL (palman’s longus) tendon, raised flap 38–9 plaster-of-Paris see calcium sulphate plastic reconstruction, by regions, principles 281–4 plate fixation, by autogenous bone grafting 64–5 pollicization operation, trapeziometacarpal joint 269–70 poly-3-hydroxbutyrate (PHB) 149, 161 polyglycolic acid (PGA) tubes 156 polyhydroxybutyrate 161 polylactate caprolactone (PLC) 158 polymethylmethacrylate beads impregnated with gentamicin sulphate 298 post-traumatic infected substance loss 87–104 complications 95–7 posterior bone graft, harvesting 63 posterior interosseous flap 305 complications 16 pedicled distally, inverse vascularization 8–9 planning and completion example 9 posterior interosseous forearm flap 13 surgical technique 13–14 Potenza’s principle 228 preservation and reconstruction of the pulley system 192 primary total elbow replacement, indications 117–18 prior bone reconstruction failures 77 Pro-Osteon 500R, interporous hydroxyapatite 103–4 prosthetic arthroplasty 122 large loss linked 110 proximal fixation, Pulver weave technique 191–2 proximal humerus allograft 78–9 ‘proximal interphalangeal joint motored finger,’ circumstances for use 198 proximal interphalangeal joint (PIP) 184–5 proximal metaepiphysis of the tibia, cancellous bone removal 128
Index
425
proximal migration of radius with ulnar plus 91 proximal sphacelus/amputation 279 proximal suture, synthetic braided suture 192 pseudoarthrosis 88–95 atrophic form 88 hypertrophic form 88 infected, stability as goal 89 infected radius: outcome of open fracture 91 infected right humerus 89 proximal compactotomy assembly required model 92 recovery stages 89–90 treatment philosophy 89 ulnar plus, post 4 months treatment 90 various forms, treatment considerations 89–95 Pseudomonas spp. 300 pulley reconstruction based on remnants 194 methods 194–5 single or multiple loop technique 194 Pulvertaft’s method, weave technique 231 pyrocarbon prosthesis, as joint replacement 208 R radial artery blood supply contribution, to thumb and index finger 18 radial artery forearm flap 262–3 radial flap transposition, post proximal/distal arterial, venous anastomoses 38–9 radial forearm flap 7, 37 complications 16 with large calibre vessel 244 surgical technique 12–13 radial recurrent flap, complications 16 radial and ulnar arteries thrombosis, with infection 282 radial/ulnar forearm flaps, with distal pedicle, inverse vascularization 8 radical debridement infection control 41 principle 52 radical debridements, free latissimus dorsi transfer, external fixation reapplication 299 radio-carpal fusion with Darrach procedure 132 radio-carpal fusion with plate and screws preserving prono-supination 132 radio-ulnar bridging callus 67–8 radio-ulno-carpal fusion in semipronation with sliding of a radial stick and 3 Kirschner wires 132 radius-recurrent adamantinoma post curettage 81–2 radius/ulna diaphyseal defect 81 rat sciatic nerve, long sutures, bridging gap, generation of new nerve structure 158–9 reconstruction areas and flaps used 15 reconstructive procedure, selection, in tendon defect repair 186 reconstructive surgery general strategy and components 288 greater salvage and speedier restoration, structure and function 23 rectus abdominis 36 recurrent radial flap 14
Index
426
surgical technique 14–15 recurrent ulnar flap reconstruction area, and procedure result 10–11 surgical technique 15–16 replantation of arm biceps destroyed gracilis transplantation with neurovascular anastomoses 253 active elbow flexion after 8 months 253 revascularization syndrome 279 reverse flow pedicle flap 282 rifampicin 300 rigid internal fixation and bone grafting, as non-union procedure 65–6 road-traffic accident MP joint release, and follow-up 221 preoperative radiographs 221 Rose’s technique, nerve grafting 145 rotator cuff repair, post-surgical shoulder infection 28 RTA (road-traffic accident) 220 metacarpal fractures exposed 220 S salvage free flaps 54 saphenous vascular graft 279 scapular free tissue transfer 37 scapular girdle 64–5 scapulohumeral defects, surgical technique 77–80 scapulohumeral reconstructions 81 Scheker’s protocol 264 Schwann cells basal laminae 154–5 Matrigel suspension, introduction to tubes, successful nerve regeneration factor 158 ‘nerve growth factor, ‘ with resorbable filaments 149 second toe of foot, free tisssue transfer 37 secondary flexor tendon salvage, natural method 228 serratus anterior 36 severe bilateral Dupuytren contracture 17 severe contusion injuries or necrotizing injuries, consequent follow-up requirement 242 severe crush defect of the extensor muscle group 244 severe crush injury intraoperative situation after nerve, and tendon repair and vascular interposition, vein graft to radial artery 247 segmental bone loss, median nerve laceration, radial artery loss, severe semicircular soft tissue loss 247 severe defect, definitions 3 severe fractures forearm 67–9 severe high-voltage injury with loss of soft tissue envelope of forearms, muscle substance and tendons, bilateral involvement of median and ulnar nerves 245 severe infection of the dorsum, of hand and wrist affecting soft tissue 296 severe tendon damage, pseudo-sheath reconstruction 183 shap injury sequelae of palm 1 year follow-up 220
Index
427
intraoperative finding: flexor tendon minigraft to flexor profundus corresponding superficialis harvested 219 unable to flex index finger, dominant hand 219 shoulder arthroplasty 120–3 shoulder fusion 20 degree of abduction 129 results evaluation 129 shoulder infection, post rotator cuff repair 28 shoulder level, osteoarticular loss 65 Siamese (sister) flaps 42 side-swipe or gunshot wound, common complications 120 silicone artificial regeneration chambers 149 simultaneous arterial reconstruction, several flaps used in conjunction as flow-through flaps 244 single or multiple loop technique, tendon defect repair 194–5 single stage tendon grafting technique 195 skeleton stability, significance 23 skin envelope, radius and extensor tendons of wrist and fingers, vascularization by ulnar artery 289 skin grafts 35 skin and tendon necrosis, by chemotherapeutic agent 292 sliding unit, tendon and surrounding sheaths 228 soft tissue defect of the dorsum of the hand after abrasion injury 243 soft tissue envelope repair 290–1 soft tissue reconstruction with a large muscular latissimus dorsi flap plus skin graft after tendon repair and osteosynthesis 244 late, higher infection and flap complication rate 23 surgical anatomy 24–5 soft tissue reconstruction with a scapular skin flap and a parascapular fascia extension, extensor tendon, new gliding tissue 243 soft tissue volume increase, with simultaneous harvesting of soleus muscle 246 SOS Hand (round-the-clock) 277 sphacelous of the distal forearm and wrist 282 sphacelous of the wrist and dorsal aspect of hand with avulsion of proximal insertion of extensor tendon 283 radiographical image 283 reconstruction of all structures 283 sphacelous/amputation complete flexion 1 year after surgery 279 right forearm and complete right forearm 279 spinal surgery, ceramics 100–1 SRS (Norian skeletal repair system) 102 stability in joints, ‘sloppy hinge,‘ and semi-constrained implant 118 staged tendon grafting techniques rehabilitation following stage one 196 stage two, complications 198 Staphylococcus aureus 300, 309 Staphylococcus epidermis 300 strong elbow flexion, lifting 2kg 254 subankylosis of DIP joint, in association to disruption of the flexor apparatus of long finger 216 subcutaneous rupture of flexor profundus middle finger, right hand 215
Index
428
palmaris longus, as graft source 215 preoperative clinical picture 215 single stage tendon grafting procedure to the profundus through intact sublimis, positive outcome 215 subscapular system: indication for flap from, including a segment of medial or lateral scapular rim 246 superficial ulnar artery 16 ‘superficialis finger’ 195 ‘superficialis finger’ ‘follow-up at 1 year, active flexion at DIP joint, with stiffness overcome by active motion’ 217 ‘re-established’ 217 sural nerve 138 sural nerve grafts 137 surgical techniques, as last step in surgeon’s methodology 290–2 suturing technique, extensor tendon grafts 204 swan-neck deformity 202 T tactics, defined 288–9 TADA 205–6 TAM (total active motion) 199 tardy ulnar nerve palsy 66 temporal fascia free tissue transfer 37 temporary external fixation application, emergency treatment post debridement: brancial artery reconstruction 297 tendofasciocutaneous dorsalis pedis flap 13 months post-surgery 40 dorsum left foot 40 raised flap, anatomy 40 tendon, optimal functional value when it is surrounded by its original sliding 228 tendon allografts 183 tendon defect repair anatomical conclusions 228 neighbouring motor selection 186 technique 230 transplantation technique 236–7 tendon grafting 203–5 distal fixation 190 end-to-side suture 187 fixed deformity 199–200 flexor tendon grafting, standard technique 189–90 graft selection 187–8 biological considerations 187–8 graft sources extensior proprius tendons 189 extensor digitorum longus of the toes 189 flexor digitorum superficialis 189 palmaris longus 188–9 plantaris longus 189 longer fingers, FCU (fleuro carpi wraris) 205 proximal fixation 191–2
Index
429
tendon allograft (xenograft) 187 tendon prosthesis 187 tendon sheath isolation 190 tendon transfer 187 using extensor tendons of the toes, and clinical result 293 tendon physiology, new physiology 228 tendon reconstruction, postsurgical repair 243 tendon sheath couple concept 228 tendon spacers, perioperative view 282 tendon vascularization with peripheral collagen 228 tensor fascia lata 36 tensor fascia lata flap (TFL) 241 tetanus prophylaxis, for children 309 thenar eminence, severe trauma, management considerations 269 thenar injury, type 4, combined burn-crush 271 thermal injuries in children 303 thermal injury with crush component at dorsum of hand, debridement and skin resurfacing with groin flap 222 thermoplastic splint for dynamic motion protocois after tendon transfer 245 thoracoacromial pedicle and pectoral nerve, cranially reflected pectoralis major muscle 28–9 Tikhoff-Linberg resection 25–6 timing of reconstruction open wounds, upper extremity, Breidenbach (1989) definition 52 terms 51 Tinel sign, nerve grafting 144 tissue engineering and biotechnology, hand and upper limb surgery advances 313–18 tissue engineering and biotechnology application 313–18 tissue engineering components 314–15 biomaterials 315 bone 315–16 cartilage 316 cells 314 cellular signals 315 nerves 318 scaffold or matrix 314 tendons 316–17 vessels 317–18 tissue engineering nerve conduit, for bridging nerve defects 154 tissue replacement and regeneration 313–14 tobramycin 300 total elbow arthroplasty 67 total limb reimplantations, conclusions associated 280–1 total recovery of motion and return to work 231–2 TPF (temporal artery flap) 243 transmetacarpal amputation 5 months post-surgery 46–7 dorsal aspect of stump 46–7 immediate post-operative result 46–7 palmar aspect of stump 46–7 right hand 47 transplantation technique (from a cadaver) 236, 237 TRAP (tartrate resistant acid phosphatase) 101
Index
430
trapezio-metacarpal joint, and pollicization operation 269–70 traumatic sphacelous/amputation at elbow and proximal forearm levels 11 years 2 months later 283 active finger flexion 283 train accident 283 trephine forceps 63 tricalcium phosphate 100 trochlea reconstruction 67–9 trunk grafts 137 tube contents manipulation/modification, regeneration improvement 156 tubes: experimental background 155–6 tubular repair 155 U ulnar forearm flap 7, 9 complications 16 surgical technique 9, 13 ulnar nerve graft, wrist level, procedural stages 141 ulnar pedicle 236 ulnar pulp sensory reinnervation replanted thumb electric stimulation ulnar side of thumb 173 end-to-side neurorrhaphy avulsed finger nerve to median nerve 173 full functional recovery 4 years 173 Nihydrin test showing good recovery 173 ulnar recurrent, complications 16 ulnar trail system see ulnar vascular system ulnar vascularization, specific characteristics 235–6 ulnar vascularized nerve graft to repair median nerve, wrist level, procedural stages and result 144 ulnodorsal septocutaneous flap 17 complications 16 reconstruction for dorsal hand lesion 10 surgical technique 14 upper extremity reconstruction, primary goal 23 upper fibular epiphysis, as vascularized transplant, upper humerus replacement, with distal radius tumour resection 112 V vancomycin 300 vascular basis of the flap, confirming safety of the transfer 234–5 vascular pedicles problematic factors 44 vascularized tendon transfers, results 233–4 vascularization, continuous/and permanent 228 vascularized bone transfer 39 indication, upper limb bone defect 76–7 reconstruction
Index
431
massive bone defects 75–81 historical background 75–6 specific indications, bone defect 76–7 vascularized fibula non-union distal humerus 94 transfer, postoperative radiograph 80 vascularized fibula transfer, technique 92 vascularized grafting, clinical experience 145–6 vascularized nerve grafts extensive loss of substance of branchial plexus 143–4 techniques with historical review 142–3 types 143 vascularized tendon transfer discussion 233 transplantation technique (from a cadaver) 236–7 transplantation techniques, functional results 237–8 vascularized tendon transfers anatomical reminder 229–30 basic principles 229 as method of choice anatomical conclusions 228 physiological conclusions 227–8 technical questions 229 vasculization improvement, benefits 33–4 vasculized bone graft, large bone defects, reconstruction issue 77 vein-muscle conduits 160 vena comitantes (VC), posterior tibial artery, flap inset 268 venous anastomoses 80 venous drainage of the island pedicle flap, satellite veins 13 vessels (arterial, venous, lymphatic) networks 279–81 Volkmann’s contracture 252, 279, 287–8 transplantation in the forearm, surgical technique 255–6
