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Contributors
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Contributors
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1 Orthoplastic Reconstruction of the Arms and Legs L. Scott Levin
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Limb Salvage LZ ]VkZ aZVgcZY V \gZVi YZVa VWdji a^bW hVakV\Z XdbeVgZY id ^bbZY^ViZ VbejiVi^dc ^c i]Z ^c_jgZY aZ\# LZ ]VkZ XaZVg ^cY^XVidgh WVhZY dc Xa^c^XVa VhhZhhbZci VcY hXdg^c\ hnhiZbh i]Vi lZ XVc h]VgZ l^i] eVi^Zcih WZ[dgZ lZ VbejiViZ# ;dg ZmVbeaZ! V a^bW i]Vi ]Vh bjai^eaZ Xdbb^cj" i^dch! dg Vc ZaYZgan eVi^Zci l^i] V Y^hgjei^kZ edh" iZg^dg i^W^Va cZgkZ! dg Vc ^eh^aViZgVa Xgjh] id i]Z i^W^V VcY [ddi! XVccdi WZ hVakV\ZY ;^\jgZ &"& # EVi^Zcih i]Vi ]VkZ egdigVXiZY eZg^dYh d[ ^hX]" Zb^V l^i] cZgkZ Y^hgjei^dc Vahd bV`Z a^bW hVakV\Z jc[ZVh^WaZ# LZ bjhi Vkd^Y i]Z ig^jbe] d[ ÅiZX]cdad\n dkZg gZVhdc#Æ 6 XaZVg jcYZghiVcY" ^c\ ^h cZZYZY d[ i]Z egdhi]Zi^X VaiZgcVi^kZh [dg VbejiZZh! eVgi^XjaVgan Vh i]Zn gZaViZ id i]Z cZl iZX]cdad\^Zh! hjX] Vh XVgWdc ÑWZg! e^adch! ZcZg\n"VWhdgW^c\ Vc`aZ Vgi^XjaVi^dch! VcY heZX^Va bViZg^Vah i]Vi Vaadl i]Z egdhi]Zh^h id WZ XdjeaZY Xdb[dgiVWan id i]Z ZmigZb^in VcY i]Vi l^aa gZbV^c YjgVWaZ# I]Z jhZ d[ egdhi]ZhZh! hjX] Vh i]Z bndZaZXig^X egdhi]Zh^h VcY i]Z ÅJiV] VgbÆ [dg eVi^Zcih jcYZg\d^c\ h]djaYZg Y^hVgi^XjaVi^dc
Tissue Surgery
Figure 1-1. Flailed bilateral lower extremities not amenable to salvage.
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Orthoplastic Reconstruction of the Arms and Legs
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Figure 1-2. a) Standard below-knee prosthesis on the left, an energy-absorbing ankle on the left. b) An upper extremity myoelectric prosthesis.
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c Figure 1-3. a–c) Examples of foot filet flaps in below-knee amputation.
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Tissue Surgery
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b Figure 1-4. A transmetatarsal amputation augmented with a lateral arm free flap.
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Orthoplastic Reconstruction of the Arms and Legs
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d
e Figure 1-5. a–e) An example of aesthetic considerations using tissue expansion to remodel soft tissue after limb salvage.
6
Tissue Surgery
a c
b
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Figure 1-6. a–d) One-stage reconstruction illustrated with solid fixation of bone with Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Osteosynthesis) principles and free tissue transfer combined.
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Figure 1-7. The osteocutaneous fibula in lower extremity tibia reconstruction.
Figure 1-8. The use of external ring fixation combined with soft tissue reconstruction.
Orthoplastic Reconstruction of the Arms and Legs
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7
egdXZhh! Vh ^c ijbdg hjg\Zgn! i]Z igZVibZci djiXdbZh [dg adc\"hiVcY^c\ dhiZdbnZa^i^h XVc WZ egZY^XiZY#)' I]Z igZVibZci Va\dg^i]b ^ckdakZh i]Z Xd" deZgVi^dc d[ Wdi] i]Z hd[i"i^hhjZ VcY WdcZ hjg\Zdch# ;^ghi! gVY^XVa cZXgZXidbn VcY hZfjZh" igZXidbn ^h eZg[dgbZY dc Vaa cdck^VWaZ i^hhjZ VcY ^beaVcih# 6 ]ZVai]n ldjcY VcY ]ZVai]n WdcZ VgZ i]Zc ZhiVWa^h]ZY# I]^h egdXZhh d[iZc ^ckdakZh gZbdk^c\ ^beaVcih0 XgZVi^c\ Vcdi]Zg hiVWaZ XdchigjXi! hjX] Vh jhZ d[ i]Z >a^oVgdk dg ZmiZgcVa ÑmVi^dc0 igZVi^c\ YZVY heVXZ l^i] hd[i i^hhjZ iZX]c^fjZh! hjX] Vh [gZZ ÒVeh0 VcY hjWhZfjZcian gZXdchigjXi^c\ i]Z WdcZ ;^\jgZ &". # =neZg" WVg^X dmn\Zc ^h cdi ^bedgiVci ^c igZVi^c\ dhiZd" bnZa^i^h! ^ih XjggZci gdaZ ^c ZmigZb^in hVakV\Z WZ^c\ id Vj\bZci i]Z egdYjXi^dc d[ \gVcjaVi^dc i^hhjZ hd i]Vi Vcn i]gZViZcZY YnhkVhXjaVg a^bWh d[ Y^VWZi^X eVi^Zcih i]Vi VgZ cdi XVcY^YViZh [dg b^XgdgZXdchigjXi^dc dg bVXgdgZXdchigjXi^dc XVc WZ gZhjg[VXZY l^i] h`^c \gV[ih#)(!)) HdbZ eVi^Zcih jcYZg\d ViiZbeiZY a^bW hVakV\Z l^i] egdeZg eaVcc^c\ VcY ZmZXji^dc!
a
c b Figure 1-9. a–c) Osteomyelitis of the tibia with filling of the dead space with a free muscle flap after adequate sequestrectomy and split-thickness skin grafting.
8
Tissue Surgery
dcan id gZhjai ^c [V^ajgZ Vh V gZhjai d[ X]gdc^X hZeh^h! ^cigVXiVWaZ eV^c! dg aVX` d[ eVi^Zci YZh^gZ id Xdci^cjZ i]Z hVakV\Z egdXZYjgZh# >c XVhZh l]ZgZ XdbeaZm gZXdchigjXi^dc ]Vh WZZc jcYZg" iV`Zc id hVkZ i]gZViZcZY a^bWh! V XdcigVXi h]djaY WZ bVYZ l^i] i]Z eVi^Zci VcY i]Z [Vb^an ^cY^XVi" ^c\ i]Vi ^[ i]Z a^bW XVccdi WZ hVkZY Wn V XZgiV^c YViZ! VbejiVi^dc h]djaY WZ eZg[dgbZY# A^bW hVakV\Z ^c eVi^Zcih l^i] Y^VWZiZh ^h ZheZX^Vaan X]VaaZc\^c\! ^c i]Vi V ]^\] eZgXZciV\Z d[ Y^VWZi^Xh ZmeZg^ZcXZ cZjgdeVi]n VcY higjX" ijgVa X]Vc\Zh XVjhZY Wn cZjgdeVi]^X X]Vc\Zh ^c i]Z [ddi! gZhjai^c\ ^c VWcdgbVa higZhh id i]Z [ddi VcY aZVY^c\ id jaXZgVi^dc VcY h`^c WgZV`Ydlc#)* I]^h egdXZhh d[iZc gZhjaih ^c YZZe ^c[ZXi^dch ^c i]Z WdcZ VcY hd[i i^hhjZ! VcY WZXVjhZ Y^VWZiZh ^c]^W^ih ]ZVa^c\! i]ZhZ ^c[ZX" i^dch VgZ d[iZc gZh^hiVci id XdckZci^dcVa igZVi" bZci# I]Z Ñghi YZiZgb^cVi^dc [dg a^bW hVakV\Z ^c V Y^VWZi^X eVi^Zci ^h id YZiZgb^cZ ^cÒdl! V [VXi d[iZc dkZgadd`ZY Wn eg^bVgn XVgZ egdk^YZgh VcY ZkZc Wn dgi]deZY^hih# D[iZc! _jhi h^beaZ hiZci^c\ dg kVhXjaVg WneVhh egdXZYjgZh XVc Vj\bZci WaddY Òdl id i]Z a^bW! gZhjai^c\ ^c ]ZVa^c\ dg egdbdi^c\ ldjcY WZYh hj^iVWaZ [dg h^beaZ hdaji^dch! hjX] Vh h`^c \gV[ih dg adXVa ÒVeh#)+!), >[ aVg\Z VgZVh d[ i^hhjZ VgZ YZhigdnZY! gZhjai^c\ ^c YZVY heVXZ! dg ^[ aVg\Z VgZVh cZZY gZhjg[VX^c\! [gZZ i^hhjZ igVch[Zgh XVc WZ Xdch^Y" ZgZY! ^c Xdc_jcXi^dc l^i] dg V[iZg kVhXjaVg WneVhh egdXZYjgZh#)- I]Z VbejiVi^dc gViZ d[
a
a^bWh ^c Y^VWZi^Xh XVc WZ Vh ]^\] Vh *% Vi * nZVgh0 i]jh! Vaa ViiZbeih h]djaY WZ bVYZ id hVakV\Z i]Zb#).
The Future of Orthoplastic Surgery I]Z [jijgZ d[ dgi]deaVhi^X hjg\Zgn l^aa WZ WVhZY dc i]Z edhh^W^a^in d[ i^hhjZ igVcheaVciVi^dc# H]dgi d[ i]^h! i]Z jhZ d[ WdcZ Vaad\gV[ih Xdb" W^cZY l^i] hd[i i^hhjZ gZXdchigjXi^kZ iZX]c^fjZh ]VkZ WZZc Z[[ZXi^kZ ^c hVakV\^c\ a^bWh# Di]Zg dgi]deaVhi^X YdbV^ch ^cXajYZ gZXdchigjXi^c\ i]Z bVcY^WaZ l^i] g^\^Y ÑmVi^dc VcY kVhXjaVg^oZY WdcZ \gV[ih# I]^h gZXdchigjXi^dc egdWaZb ^h h^b^aVg id i]Vi XgZViZY Wn dhiZdbnZa^i^h ^c i]Z ZmigZb^i^Zh# D[iZc gVY^Vi^dc"^cYjXZY dhiZdcZ" Xgdh^h! dg ijbdgh l^i] adXVa^oZY h`^c ^c[ZXi^dc! gZfj^gZ ijbdg Zmi^geVi^dc! i^hhjZ YWg^YZbZci! bVcY^WjaVg hiVW^a^oVi^dc! VcY hd[i i^hhjZ XdkZg" V\Z# I]ZhZ egdXZYjgZh XVc WZ YdcZ Vh i]Zn VgZ ^c i]Z ZmigZb^i^Zh# 6cdi]Zg YdbV^c d[ dgi]deaVhi^X hjg\Zgn i]Vi ]Vh WZZc jcgZVa^oZY ^h i]Z cZZY [dg dgi]deaVhi^X hjg\Zgn d[ i]Z X]Zhi lVaa#*% 6ai]dj\] hd[i i^hhjZ egdXZYjgZh VgZ YZh^\cZY id igZVi bZY^Vhi^c^i^h VcY id ]Zae gZXdchigjXi i]Z X]Zhi lVaa! higjXijgVa ^chiVW^a^i^Zh! hjX] Vh hiZgcVa cdcjc^dc VcY X]gdc^X eV^c WVhZY dc hiZgcVa ^chiVW^a^in! XVc WZ igZViZY l^i] YZk^XZh hjX] Vh Xjhidb eaViZh ;^\jgZ &"&% #
b Figure 1-10. a–c) Sternal instability treated with custom plates.
c
Orthoplastic Reconstruction of the Arms and Legs
9
Conclusion B^c^bVaan ^ckVh^kZ dgi]deaVhi^X hjg\Zgn ]Vh WZZc lZaa YZkZadeZY# 8jggZci iZX]c^fjZh [dg i^hhjZ ZmeVch^dc VgZ gZaViZY id WVaaddc"Vhh^hiZY ZcYdhXde^X i^hhjZ ZmeVch^dc#*& ;gZZ"ÒVe egZ[VW" g^XVi^dc jh^c\ ZcYdhXde^X eaVXZbZci d[ i^hhjZ ZmeVcYZgh ]Vh WZZc lZaa ZhiVWa^h]ZY VcY gZYjXZh i]Z i^bZ cZZYZY [dg XdbeaZm a^bW gZXdchigjX" i^dc# L^i] b^c^bVaan ^ckVh^kZ hjg\Zgn VcY di]Zg iZX]cdad\^Zh! iZX]cdad\^Zh ^c hZVgX] d[ hjg\^XVa egdXZYjgZh l^aa cdi hZaa VcY WZ ]Zae[ja# I]Z [jijgZ d[ dgi]deaVhi^X hjg\Zgn ^h [jgi]Zg ^ciZ\gV" i^dc l^i] XdcXZeih ^c hd[i i^hhjZ VcY WdcZ iZX]" cdad\n VcY [jgi]Zg YZkZadebZci d[ a^bW hVakV\Z VcY gZXdchigjXi^dc#
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Tissue Surgery )(# e IN! 6edciZ G! @d\Zg @:!
2 Clinical Application of Composite Tissue Allografts Maria Z. Siemionow, Sakir Unal and Galip Agaoglu
Introduction 8dbedh^iZ i^hhjZ Vaad\gV[ih 8I6h Xdch^hi d[ i^hhjZh YZg^kZY [gdb ZXidYZgb VcY bZhdYZgb VcY ine^XVaan XdciV^c h`^c! [Vi! bjhXaZ! cZgkZh! anbe] cdYZh! WdcZ! XVgi^aV\Z! a^\VbZcih! VcY WdcZ bVggdl# 6ai]dj\] Åcdck^iVaÆ id a^[Z! i]ZhZ i^hhjZh VgZ higjXijgVaan! [jcXi^dcVaan! VcY VZh" i]Zi^XVaan ^bedgiVci id eVi^Zcih l]d cZZY [jcX" i^dcVa gZhidgVi^dc d[ bjhXjadh`ZaZiVa YZ[ZXih# 6jidad\djh i^hhjZ ^h i]Z bdhi Xdbbdcan jhZY bViZg^Va [dg gZXdchigjXi^c\ hZkZgZ Wjgc VcY igVjbVi^X ^c_jg^Zh dg XVcXZg VWaVi^dc hjg\Zg^Zh# :kZc l]Zc Zcdj\] Vjidad\djh i^hhjZ ^h VkV^aVWaZ id gZXdchigjXi aVg\Z YZ[ZXih! [jcXi^dcVa VcY VZh" i]Zi^X gZXdkZgn ^h cdi ValVnh ^YZVa! VcY bjai^eaZ hjg\Zg^Zh bVn WZ cZXZhhVgn# >c VYY^i^dc! Ydcdg h^iZ bdgW^Y^in XVc WZ V egdWaZb ^c Vjidad\djh i^hhjZ \gV[i^c\# Egdhi]Zi^X bViZg^Vah VgZ Vcdi]Zg igZVibZci dei^dc [dg aVg\Z YZ[ZXih! Wji i]Zn ]VkZ Vaa i]Z bV_dg YgVlWVX`h d[ cdck^iVa bViZg^Va# 8dbedh^iZ i^hhjZ Vaad\gV[ih i]jh ]VkZ \gZVi ediZci^Va [dg gZXdchigjXi^c\ kVg^djh eVgih d[ i]Z WdYn# 8dbedh^iZ i^hhjZ ^h bdgZ ^bbjcd\Zc^X i]Vc igVcheaVciZY hda^Y dg\Vch# 6ai]dj\] XVgi^aV\Z! a^\VbZcih! VcY [Vi ]VkZ adl Vci^\Zc^X^in VcY WdcZ! bjhXaZh! cZgkZh! VcY kZhhZah ]VkZ bdYZgViZ Vci^\Zc^X^in! h`^c YZkZadeh i]Z bdhi hZkZgZ gZ_ZX" i^dc WZXVjhZ d[ i]Z VWjcYVcXZ d[ YZcYg^i^X XZaah ^c i]Z Ze^YZgb^h VcY YZgb^h#&
Clinical Composite Tissue Allotransplants 6YkVcXZh ^c igVcheaVciVi^dc ^bbjcdad\n ]VkZ deZcZY Y^hXjhh^dc dc i]Z gdji^cZ Xa^c^XVa Veea^" XVW^a^in d[ Xdbedh^iZ i^hhjZ Vaad\gV[ih# 6h d[ ?VcjVgn &! '%%*! bdgZ i]Vc *% Xdbedh^iZ i^hhjZ Vaad\gV[i igVcheaVcih ]VkZ WZZc eZg[dgbZY
ldgaYl^YZ! ^cXajY^c\0 ]VcY! VWYdb^cVa lVaa! `cZZh! ÒZmdg iZcYdc VeeVgVijh! cZgkZ! aVgncm! h`ZaZiVa bjhXaZ! idc\jZ! VcY igVX]ZV IVWaZ '"& #
Hand Transplants I]Z Ñghi ]VcY igVcheaVciVi^dc lVh eZg[dgbZY WZ[dgZ i]Z XnXadhedg^cZ ZgV d[ ^bbjcdhjeegZh" h^dc ^c &.+(#' I]Z eVi^Zci gZXZ^kZY hiZgd^Yh VcY VoVi]^deg^cZ ^bbjcdhjeegZhh^kZ igZVibZci# I]Z ]VcY lVh gZ_ZXiZY ( lZZ`h V[iZg igVcheaVciVi^dc# H^cXZ i]Z Ñghi hjXXZhh[ja ]VcY igVcheaVciVi^dc ^c &..-! ^c Andc(! '* igVcheaVcih + W^aViZgVa ^c &. eVi^Zcih ]VkZ WZZc gZedgiZY0 - + eVi^Zcih [gdb 8]^cV! * ( eVi^Zcih [gdb ;gVcXZ! ) ' eVi^Zcih [gdb 6jhig^V! ( [gdb >iVan! ' [gdb i]Z JH6! & [gdb 7Za\^jb! VcY & [gdb BVaVnh^V IVWaZ '"' #) >c HZeiZbWZg &..-! V iZVb ^c Andch! ;gVcXZ! eZg[dgbZY i]Z Ñghi hjXXZhh[ja ]jbVc ]VcY VaadigVcheaVci#( I]Zn igVcheaVciZY i]Z g^\]i ]VcY VcY Y^hiVa [dgZVgb [gdb V WgV^c"YZVY Ydcdg id V )-"nZVg"daY bVc l]dhZ dlc g^\]i ]VcY VcY Y^hiVa [dgZVgb ]VY WZZc VbejiViZY ^c V &.-. VXX^YZci# I]Z ^cYjXi^dc ^bbjcdhjeegZhh^kZ egdidXda Xdch^hiZY ^c^i^Vaan d[ Vci^i]nbdXniZ \adWja^c ,* b\$YVn [dg &% YVnh ! iVXgda^bjh VY_jhiZY id bV^ciV^c WaddY XdcXZcigVi^dch WZilZZc &% c\$bA VcY &* c\$bA Yjg^c\ i]Z Ñghi bdci]! bnXde]ZcdaViZ bd[Zi^a BB; ' \$ YVn ! VcY hiZgd^Yh egZYc^hdcZ! '*% b\ dc YVn & VcY gVe^Yan iVeZgZY id '% b\$YVn # 89'* bdcd" XadcVa Vci^WdYn lVh \^kZc dc YVn '+ VcY YVn &%%# BV^ciZcVcXZ i]ZgVen ^cXajYZY iVXgda^bjh id bV^ciV^c hZgjb XdcXZcigVi^dch WZilZZc * VcY &% c\$bA ! BB; ' \$YVn ! VcY egZYc^hdcZ '% b\$YVn Vi ( bdci]h! &* b\$YVn Vi + bdci]h #( 6i +"bdci] [daadl"je! egd\gZhh^dc d[ bdidg VcY hZchdgn [jcXi^dc lVh hVi^h[VXidgn# >c ?VcjVgn &...! hjg\Zdch ^c Adj^hk^aaZ! @ZcijX`n! eZg[dgbZY i]Z Ñghi ]jbVc ]VcY
11
12 Table 2-1. Number and Type of Composite Tissue Allografts Transplanted as of January 1, 2005, Worldwide Hand 13 unilateral, 6 bilateral Abdominal wall 9 Knee 3 femoral diaphysis, 5 whole knee Flexor tendon apparatus 2 Nonvascularized nerve 7 Larynx 1 Muscle 1 Tongue 1 Trachea 2
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Table 2-2. Cases of Hand Transplantation as of January 1, 2005, Worldwide Date Location Transplant Type 1963 Ecuador Unilateral September 1998 Lyon (France) Unilateral January 1999 Louisville (KY, USA) Unilateral September 1999 Guangzhou (China) Unilateral September 1999 Guangzhou (China) Unilateral January 2000 Lyon (France) Bilateral January 2000 Guangxi (China) Unilateral January 2000 Guangxi (China) Unilateral March 2000 Innsbruck (Austria) Bilateral May 2000 Kuala Lumpur (Malaysia) Unilateral October 2000 Guangzhou (China) Bilateral August 2000 Monza (Italy) Unilateral January 2001 Harping (China) Bilateral February 2001 Louisville (KY, USA) Unilateral October 2001 Monza (Italy) Unilateral June 2002 Brussels (Belgium) Unilateral November 2002 Milan (Italy) Unilateral February 2003 Innsbruck (Austria) Bilateral May 2003 Lyon (France) Bilateral Total 19 patients 25 hands
Clinical Application of Composite Tissue Allografts
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13
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14
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Tissue Surgery
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Clinical Application of Composite Tissue Allografts
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15
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Muscle Transplants >c &..-! kVhXjaVg^oZY h`ZaZiVa bjhXaZ Vaad\gV[i^c\ lVh YdcZ id XdkZg V aVg\Z YZ[ZXi ^c i]Z hXVae d[ V gZcVa igVcheaVci eVi^Zci l]d lVh dc X]gdc^X ^bbjcdhjeegZhh^kZ i]ZgVen 8h6 VcY egZYc^" hdcZ #'% 6[iZg i]Z hZXdcY XVYVkZg^X gZcVa igVch" eaVci! hfjVbdjh XZaa XVgX^cdbV YZkZadeZY ^c i]Z hXVae# I]Z ijbdg lVh ZmX^hZY! VcY i]Z YZ[ZXi lVh gZXdchigjXiZY l^i] V XVYVkZg^X kVhXjaVg^oZY gZXijh [Zbdg^h bjhXaZ ÒVe# I]Z eVi^Zci gZXZ^kZY bZi]naegZYc^hdadcZ! & \! VcY gVWW^i Vci^i]nbdXniZ \adWja^c! &#* b\$`\ >K! WZ[dgZ gZkVhXjaVg^oVi^dc# =Z lVh gZijgcZY ^bbZ" Y^ViZan id ]^h WVhZa^cZ ^bbjcdhjeegZhh^kZ gZ\^bZc d[ egZYc^hdcZ VcY 8h6#6 bjhXaZ W^dehn ' lZZ`h V[iZg igVcheaVci gZkZVaZY eZg^kVhXjaVg anbe]dXni^X ^cÑaigVi^dc! VcY BB; &%%% b\ ED W#^#Y# lVh VYb^c^hiZgZY! VcY i]Z YdhZ d[ 8h6 lVh ^cXgZVhZY# 6i &- lZZ`h! BB; lVh hideeZY! VcY i]Z eVi^Zci lVh `Zei dc X]gdc^X 8h6 VcY egZYc^hdcZ# I]^h eVi^Zci ^h hi^aa jcYZg ^bbjcd" hjeegZhh^dc [dg `^YcZn igVcheaVci l^i] cd gZedgiZY Xdbea^XVi^dch#
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16
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Tissue Surgery
Immunosuppressive Drugs Currently Used in Composite Tissue Allograft Transplants 8jggZcian! ^bbjcdhjeegZhh^kZ Ygj\h VgZ jhZY id ^cYjXZ! bV^ciV^c! VcY igZVi VXjiZ Ze^hdYZh d[ \gV[i gZ_ZXi^dc IVWaZ '"( # 6aa XjggZci ^bbjcd" hjeegZhh^kZ Ygj\h iVg\Zi VXi^kVi^dc d[ I XZaah! egd" YjXi^dc d[ Xnid`^cZh! XadcVa ZmeVch^dc! dg V XdbW^cVi^dc d[ Vaa i]ZhZ [VXidgh IVWaZ '")0 ;^\jgZ '"& #'+
Immunosuppression Induction Protocols I]Z V^b d[ ^cYjX^c\ ^bbjcdhjeegZhh^dc V[iZg igVcheaVciVi^dc ^h id hjeegZhh i]Z ^bbjcZ hnhiZb [dg V h]dgi eZg^dY ' lZZ`h id gZYjXZ i]Z edh" h^W^a^in d[ ]neZgVXjiZ l^i]^c &% YVnh V[iZg igVch" eaVci VcY VXjiZ gZ_ZXi^dc l^i]^c ( bdci]h V[iZg i]Z igVcheaVci #'+ Table 2-3. Immunosuppressive Therapy Regimens Used in Transplanting Composite Tissue Allografts Maintenance Transplant Induction Therapy Therapy Hand ATG Tacrolimus Anti-CD25 MoAb MMF Tacrolimus Prednisone MMF Basiliximab Prednisone Abdominal wall Anti-CD52 MoAb Tacrolimus (alemtuzumab) Daclizumab Vascularized bone ATG CsA CsA Azathioprine Azathioprine Prednisone Nonvascularized CsA or tacrolimus CsA or tacrolimus nerve Azathioprine Azathioprine Prednisone Prednisone Vascularized tendon CsA CsA Nonvascularized CsA CsA trachea MMF MMF Larynx OKT3 CsA or tacrolimus CsA MMF MMF Prednisone Muscle ATG CsA Prednisone ATG antithymocyte globulins MMF mycophenolate mofetil CsA cyclosporine A OKT3 anti-CD3 antibody
Clinical Application of Composite Tissue Allografts
17
Table 2-4. Immunosuppressive Drugs used in Transplanting Composite Tissue Allografts Drug Mechanism of Action Lymphocyte-Depleting Agents Antithymocyte globulins/Antilymphocyte globulin (ATG/ALG) Binds multiple antigens on lymphocytes and causes complement mediated lysis and opsonization Anti-CD3 antibody (OKT3) Blocks T-cell CD3 receptor and causes complement mediated lysis and opsonization Interleukin-2 Receptor Antagonists Daclizumab Binds Interleukin-2 receptor and down-regulates Basiliximab Binds Interleukin-2 receptor and down-regulates Cytokine Gene Expression Blockers Steroids Blocks the transcription of cytokine genes Nonspecific actions to decrease immune reactivity Calcineurin Inhibitors Cyclosporine Inhibits calcineurin, and Interleukin-2 production Tacrolimus (FK-506) Inhibits calcineurin, and Interleukin-2 production Antiproliferative Agents Mycophenolate mofetil (MMF) Blocks de novo purine synthesis Azathioprine Blocks synthesis TOR (Target of Rapamycin) Inhibitor Sirolimus Blocks IL-2–induced cell cycle progression
OKT3
Sirolimus
TCR-CD3 Engagement to APC Glucocorticoids
Antigen Presenting Cell
X
IL-2 receptor expression
X on T cells
CsA/Tacrolimus IL-2 binding to IL-2 receptor
X
X IL-1, IL-6 release
T cell G0 phase
IL-2 release
T cell G1 phase IL-2 receptor signal
ATG
X
X
X
T cell depletion T cell M phase
T cell differentiation
X MMF/AZA
T cell G2 phase
T cell S phase T cell proliferation
X MMF/AZA
Figure 2-1. Mechanisms and sites of action of different immunosuppressive drugs
Basiliximab Daclizumab
Sirolimus
18
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20
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References &# AZZ LE!NVgZbX]j` B?! EVc N8! Zi Va# GZaVi^kZ Vci^\Zc^X" ^in d[ XdbedcZcih d[ V kVhXjaVg^oZY a^bW Vaad\gV[i# EaVhi GZXdchig Hjg\# &..&0-,/)%&Ã)&&# '# <^aWZgi G# IgVcheaVci ^h hjXXZhh[ja l^i] V XVYVkZg [dgZVgb# BZY Ig^W BZY CZlh# &.+)0*# (# 9jWZgcVgY ?B! DlZc :! =ZgoWZg\
Tissue Surgery .# AZk^ 9B! IoV`^h 686B"& VcY XaVhh B=8 Vci^\Zch# ? GZXdchig B^Xgdhjg\# &...0&*/(%,Ã (&&# &*# :kVch E?! BVX`^ccdc H:! AZk^ 69! Zi Va# 8daY egZhZgkZY cZgkZ Vaad\gV[ih/ X]Vc\Zh ^c WVhZbZci bZbWgVcZ! k^VW^a^in! ^bbjcd\Zc^X^in! VcY gZ\ZcZgVi^dc# BjhXaZ CZgkZ#&..-0'&/&*%,Ã&*''# &+# =VgZ bbjcdhje" egZhh^kZ V\Zcih ^c igVcheaVciVi^dc/ bZX]Vc^hbh d[ VXi^dc VcY XjggZci Vci^"gZ_ZXi^dc higViZ\^Zh# B^Xgdhjg" \Zgn# '%%%0'%/)'%Ã)'.#
Clinical Application of Composite Tissue Allografts ',# A^j ?! ;VgbZg ?9 ?g! AVcZ LH! Zi Va# 8VaX^cZjg^c ^h V Xdbbdc iVg\Zi d[ XnXade]^a^c"XnXadhedg^cZ 6 VcY ;@7E";@*%+ XdbeaZmZh# 8Zaa# &..&0++/-%,Ã-&*# '-# 7dgZa ?;# 8nXadhedg^cZ"6ÄegZhZci ZmeZg^bZciVa hiVijh# IgVcheaVci EgdX# &.-&0&(/())Ã()-# '.# <]VhZb^Vc HG! A^\]i ?6! 8jgg^Zg 8! Zi Va# IVXgda^bjh kh CZdgVa ^c gZcVa VcY gZcVa$eVcXgZVh igVcheaVciVi^dc# 8a^c IgVcheaVci# &...0&( &! ei ' /&'(Ã&'*# (%# 8ZcYVaZh A! =VgYn B6# >bbjcdad\^X Xdch^YZgVi^dch ^c Xdbedh^iZ i^hhjZ igVcheaVciVi^dc/ dkZgk^Zl# B^Xgdhjg" \Zgn# '%%%0'%/)&'Ã)&.# (&# HeZcXZg 8B!
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d[ i]Z Ñghi [djg Xa^c^XVa XVhZh#B^Xgdhjg\Zgn# '%%%0'%/(+%Ã (,&# @V]Vc 79! EdYW^Zah`^ ?! CVeda^ @A! Zi Va# >bbjcdhje" egZhh^kZ Z[[ZXih VcY hV[Zin d[ V h^gda^bjh$XnXadhedg^cZ XdbW^cVi^dc gZ\^bZc [dg gZcVa igVcheaVciVi^dc# IgVch" eaVciVi^dc# &..-0++/&%)%Ã&%)+# 6aa^hdc 68! :j\j^ :B# >bbjcdhjeegZhh^kZ VcY di]Zg Z[[ZXih d[ bnXde]Zcda^X VX^Y VcY Vc ZhiZg egdYgj\! bnXde]ZcdaViZ bd[Zi^a# >bbjcda GZk# &..(0&(+/*Ã'-# K^cXZci^ ;! @^g`bVc G! A^\]i H! Zi Va# >ciZgaZj`^c"'" gZXZeidg WadX`VYZ l^i] YVXa^ojbVW id egZkZci VXjiZ gZ_ZXi^dc ^c gZcVa igVcheaVciVi^dc# 9VXa^ojbVW Ig^eaZ I]ZgVen HijYn
3 Advanced Concepts in Vascularized Tissue Transfer in the Hand Holger Engel and Günter Germann
Introduction Hd[i i^hhjZ YZ[ZXih ^c i]Z ]VcY l^i] ZmedhZY iZcYdch! WdcZh! dg _d^cih d[iZc egZhZci Y^[ÑXjai gZXdchigjXi^kZ egdWaZbh#&Ã&* I]ZhZ egdWaZbh VgZ jhjVaan gZaViZY id i]Z a^b^iZY VkV^aVW^a^in d[ adXVa ÒVeh VcY id i]Z iZX]c^XVaan YZbVcY^c\ Y^h" hZXi^dch d[ i]Z^g YZa^XViZ kVhXjaVijgZ#&+Ã') B^Xgd" hjg\^XVa Y^hhZXi^dc iZX]c^fjZh VcY V egZX^hZ `cdlaZY\Z d[ VcVidbn VgZ gZfj^gZY id hjXXZhh" [jaan gZaZVhZ i]ZhZ ÒVeh# GZY^hXdkZgn d[ VcVidb" ^XVa hijY^Zh Wn HeVaiZ]dao! BVcX]di! VcY HVabdc'&!''!'* egdk^YZY i]Z ^beZijh [dg bdYZgc VcVidb^XVa hijY^Zh d[ i]Z kVhXjaVijgZ d[ i]Z ]VcY#'+Ã(' I]ZhZ hijY^Zh ^c ijgc aZY id V cZl \Zc" ZgVi^dc d[ ÒVeh ^c V l^YZ kVg^Zin d[ h^oZh VcY [gdb V l^YZ kVg^Zin d[ Ydcdg h^iZh# Bdhi d[ i]ZhZ ÒVeh VgZ [gdb i]Z Ydghd"aViZgVa VheZXi d[ i]Z ]VcY VcY Y^\^ih0 dcan V [Zl VgZ gV^hZY Vi i]Z eVabVg VheZXi#((Ã(. >c i]^h X]VeiZg! lZ gZk^Zl hdbZ VYkVcXZY XdcXZeih d[ igVch[Zgg^c\ ^cig^c" h^X ÒVeh d[ i]Z ]VcY! ^cXajY^c\ XdbeaZm gZXdc" higjXi^dc l^i] bjai^eaZ"XdbedcZci X]^bZg^X ÒVeh#
Venous and Arterial Anatomy of the Hand and Fingers I]ZgZ VgZ ild kZcdjh hnhiZbh ^c i]Z ]VcY/ V YZZe hnhiZb l^i] hbVaa! ]VgYan k^h^WaZ XdcXdb^" iVci kZ^ch gjcc^c\ l^i] i]Z VgiZg^Zh0 VcY V bdgZ hjeZgÑX^Va! aVg\Z"XVa^WgZ XjiVcZdjh hnhiZb#)%Ã)( KZcdjh kVakZh VgZ Xdch^hiZcian [djcY ^c kZ^ch l^i] V XVa^WgZ d[ %#' bb dg aVg\Zg# I]Z dcan ^bedgiVci ZmXZei^dc XdcXZgc^c\ i]Z egZhZcXZ d[ i]ZhZ kVakZh hZZbh id WZ i]Z kZcdjh VgX]Zh
i]Vi Vaadl Z^i]Zg gVY^Va"jacVg dg eVabVg"YdghVa YgV^cV\Z! hjX] Vh kZ^ch XadhZ id Vaa _d^cih VcY hjWYZgbVa kZ^ch dc i]Z YdghVa! eVabVg! VcY aViZgVa hjg[VXZh d[ i]Z ]VcY VcY Ñc\Zgh# ;^cVaan! i]Z dg^ZciVi^dc d[ i]Z kZcdjh kVakZh ^cY^XViZh i]Vi i]Z Y^gZXi^dc d[ i]Z kZcdjh Òdl \ZcZgVaan ^h [gdb i]Z eVabVg id i]Z YdghVa h^YZ d[ i]Z ]VcY! VcY [gdb i]Z hjeZgÑX^Va id i]Z YZZe kZ^c hnhiZb# 6aa VgiZg^Zh d[ i]Z ]VcY VcY Ñc\Zgh dg^\^cViZ [gdb i]Z bV^c [dgZVgb kZhhZah/ i]Z gVY^Va! jacVg! VcY VciZg^dg VcY edhiZg^dg ^ciZgdhhZdjh VgiZg^Zh# I]ZhZ VgiZg^Zh VgZ i]Z ig^WjiVg^Zh id i]Z kVhXjaVg" ^in d[ i]Z lg^hi! l]^X] VeeZVgh id WZ i]Vi d[ ild eVabVg hjeZgÑX^Va eVabVg VcY YZZe eVabVg VgX] VcY i]gZZ YdghVa XVgeVa VgX]Zh WVhVa bZiVXVgeVa VgX]! YdghVa ^ciZgXVgeVa VgX]! YdghVa gVY^dXVgeVa VgX]0 ;^\jgZh ("&V VcY ("&W #))Ã), I]Z Xdbbdc Y^\^iVa VgiZg^Zh jhjVaan WgVcX] d[[ i]Z hjeZgÑX^Va eVabVg VgX] id Y^k^YZ ^cid i]Z gVY^Va VcY jacVg egdeZg Y^\^iVa VgiZg^Zh Vi i]Z aZkZa d[ i]Z bZiVXVgeVa ]ZVY# I]Z eVabVg bZiV" XVgeVa VgiZg^Zh VgZ [ZY Wn i]Z YZZe eVabVg VgX]# 6[iZg gjcc^c\ Vh V h^c\aZ kZhhZa! ZVX] eVabVg bZiVXVgeVa VgiZgn Y^k^YZh ^cid ild VcY Zm^ih aVi" ZgVaan [gdb jcYZg i]Z eVabVg eaViZ id XgVYaZ i]Z bZiVXVgeVa ]ZVY dg id XdccZXi l^i] V Xdbbdc Y^\^iVa VgiZgn# I]Z [djg YdghVa bZiVXVgeVa VgiZg^Zh VgZ WVhZY dc i]Z i]gZZ YdghVa XVgeVa VgX]Zh#(' >bedgiVci [dg jcYZghiVcY^c\ i]Z \gZVi kZghV" i^a^in d[ ^cig^ch^X ÒVeh WVhZY dc i]^h cZildg` ^h i]Z [VXi i]Vi ZVX] VgiZgn XdccZXih l^i] i]Z eVabVg VgiZg^Va hnhiZb! Wdi] egdm^bVaan VcY Y^hiVaan# I]Z bV^c XdccZXi^c\ kZhhZa ^h i]Z eVabVg eZg[dgVidg ^c i]Z lZW heVXZ! jhjVaan [dgb^c\ i]Z [ZZY^c\ kZhhZa [dg i]Z YdghVa bZiVXVgeVa VgiZgn ÒVe ;^\jgZh ("&V VcY ("&W #('
23
24
Tissue Surgery
Radial artery to index
Common palmar digital arteries
Dorsal metacarpal arteries
Thumb artery Superficial palmar arch Dorsal carpal branch of ulnar artery
Palmar intercarpal arch
Ulnar artery Anterior interosseous
Basal metacarpal arch
Deep palmar arch
Dorsal intercarpal arch Dorsal radiocarpal arch Ulnar artery
Radial artery Retinacular and compartmental collateral branches
Radial artery
a
b
Posterior division of anterior interosseous artery
Figure 3-1. (a) Arterial anatomy of the palm. (b) Dorsum of the hand.
Principles of Intrinsic Flap Design I]Z gVe^Y Zkdaji^dc d[ hjg\^XVa VcY iZX]c^XVa ZmeZgi^hZ VcY ^cXgZVh^c\ VcVidb^XVa VcY Xa^c^XVa `cdlaZY\Z ]Vh aZVY id V ]^\] hiVcYVgY d[ hd[i i^hhjZ gZXdchigjXi^dc d[ i]Z ]VcY# >c XdcigVhi id igVY^i^dcVa Y^hiVci eZY^XaZ ÒVeh! ^cig^ch^X ÒVeh eZgb^i ^bbZY^ViZ ldjcY XadhjgZ VcY ZVgan VXi^kZ bdW^a^oVi^dc VcY e]nh^XVa i]ZgVen# I]^h dcZ"hiV\Z XdcXZei Vkd^Yh i]Z YgVlWVX`h d[ Y^hiVci eZY^XaZ ÒVeh! hjX] Vh bjai^eaZ egdXZ" YjgZh! ZmiZcYZY ^bbdW^a^oVi^dc! egdadc\ZY i^bZ d[[ ldg`! VcY ^cXgZVhZY igZVibZci Xdhi# 7Zh^YZh V hdjcY `cdlaZY\Z d[ i]Z VcVidbn! gZXdchigjXi" ^c\ YZ[ZXih ^c i]Z ]VcY gZfj^gZh Vc Va\dg^i]b^X VeegdVX] id hZaZXi i]Z ^YZVa ÒVe ^c i]Z eVgi^XjaVg Xa^c^XVa h^ijVi^dc# 6 i]dgdj\] VcVanh^h d[ i]Z YZ[ZXi ^h i]Z Ñghi hiZe ^c i]Z gZXdchigjXi^dc Va\d" g^i]b VcY ]Vh id egZXZYZ i]Z hZaZXi^dc d[ Vcn gZXdchigjXi^kZ egdXZYjgZ# 9ZX^h^dch VgZ WVhZY dc i]Z ZkVajVi^dc d[ & i]Z h^oZ d[ i]Z YZ[ZXi! ' i]Z adXVi^dc d[ i]Z YZ[ZXi! ( Vcn b^hh^c\ i^hhjZ Xdb" edcZcih! ) i]Z YZ\gZZ d[ hZchVi^dc gZfj^gZY! * igZVibZci dei^dch! + XdcigV^cY^XVi^dch id igZVi" bZci! VcY , i]Z eZghdcVa egdÑaZ d[ i]Z eVi^Zci# 6aa [VXidgh cZZY id WZ VhhZhhZY id YZiZgb^cZ l]Zi]Zg i]Z YZ[ZXi XVc WZ gZXdchigjXiZY Wn adXVa bZVch dg l]Zi]Zg V Y^hiVci eZY^XaZ ÒVe! dg ZkZc
V [gZZ ÒVe! ^h ^cY^XViZY# ;aVe X]d^XZ Vahd YZeZcYh bdgZ dc i]Z eVi^ZciÈh egdÑaZ i]Vc dc i]Z X]VgVX" iZg^hi^Xh d[ i]Z YZ[ZXi# L]ZcZkZg edhh^WaZ! i]Z eVi^ZciÈh YZh^gZh VcY ZmeZXiVi^dch h]djaY WZ Y^h" XjhhZY WZ[dgZ hjg\Zgn id Vkd^Y aViZg egdWaZbh l^i] jch^\]ian Ydcdg h^iZh! ^beV^gZY bdW^a^in d[ Y^\^ih! dg di]Zg edhh^Wan jceaZVhVci gZhjaih# >c VYY^i^dc id Va\dg^i]b^X egdWaZb hdak^c\! ZkZgn hjg\Zdc ]Vh id Xdch^YZg i]Z iZX]c^XVa VheZXih ^c YZh^\c^c\ ÒVeh ^c i]Z ]VcY VcY Ñc\Zgh# I]Z [daadl^c\ eg^cX^eVah bVn VeeZVg ig^k^Va! Wji bVcn ÒVe [V^ajgZh XVc WZ igVXZY WVX` id Vc Zggdg ^c eaVcc^c\ i]Z ÒVe ;^\jgZ ("' / &# 6YZfjViZ ÒVe h^oZ0 '# 6YZfjViZ aZc\i] VcY VgX d[ gdiVi^dc i]Vi ^h! cd iZch^dc dg `^c`^c\ d[ i]Z eZY^XaZ 0 (# 6YZfjViZ egdiZXi^dc d[ eZg[jh^dc cd ^cVe" egdeg^ViZ iZch^dc dc i]Z eZY^XaZ ÒVeh 0 )# I]Z adXVi^dc d[ V h`^c ^haVcY ^c Vc Vm^Va ^haVcY dg ^c YdghVa bZiVXVgeVa ÒVeh0 VcY *# I]Z adXVi^dc d[ eZg[dgVidgh ^c Vm^Va ^haVcY ÒVeh# I]Z fj^X`Zhi! ZVh^Zhi! VcY hV[Zhi bZi]dYh WZhi hj^iZY [dg i]Z eVi^Zci h]djaY WZ jhZY id dWiV^c i]Z WZhi edhh^WaZ djiXdbZ# I]Z ^YZVa hdaji^dc ^h Xdch^YZgZY id WZ V ÒVe i]Vi & bZZih i]Z
Advanced Concepts in Vascularized Tissue Transfer in the Hand
Size Location What is missing?
Reconstruction with local means possible
Yes
No Free flaps Distant pedicle flaps
Flap characteristics: Qualities of tissue needed in the flap Size of the flap, etc.
Availability of flap options Personal profile Donor site considerations
Flap selection
Design of the flap Figure 3-2. Algorithm for analyzing a defect before designing any flap.2
gZfj^gZbZcih d[ i]Z eVi^Zci! ' ]Vh VXXZeiVWaZ Ydcdg"h^iZ bdgW^Y^in! VcY ( ^h i]Z aZVhi iZX]c^" XVaan Y^[ÑXjai#
Classification of Intrinsic Flaps >cig^ch^X ÒVeh! VcY ÒVeh ^c \ZcZgVa! XVc WZ XaVh" h^ÑZY VXXdgY^c\ id & kVhXjaVg VcVidbn! ' i]Z^g bZi]dY d[ jhZ! ( i]Z i^hhjZ XdbedcZcih i]Zn ^cXajYZ! ) i]Z eZg[jh^dc eViiZgc VciZ\gVYZ dg gZigd\gVYZ ! dg * i]Z adXVi^dc d[ i]Z Ydcdg h^iZ# ;aVeh VgZ \ZcZgVaan Y^k^YZY ^cid gVcYdb" eViiZgc ÒVeh VcY Vm^Va"eViiZgc ÒVeh# 7ZXVjhZ d[ i]Z g^X] kVhXjaVg cZildg` YZhXg^WZY VWdkZ! ÒVeh XVc WZ WVhZY dc egdm^bVa dg Y^hiVa eZY^XaZh# Egdm^bVaan WVhZY ÒVeh VgZ XVaaZY ÅVciZ\gVYZ ÒVeh#Æ ;aVeh i]Vi VgZ cdjg^h]ZY Wn Y^hiVa ^cÒdl VgZ XVaaZY ÅgZigd\gVYZ ÒVeh#Æ
25
Xgdhh"Ñc\Zg ÒVe dg i]Z i]ZcVg ÒVe0 VcY Vm^Va" eViiZgc ÒVeh! i]Z egdidineZh d[ l]^X] lZgZ i]Z A^iiaZg ÒVe dg i]Z =^a\Zc[ZaYi ÒVe aViZg YZhXg^WZY Wn ;djX]Zg Vh i]Z Å`^iZ ÒVeÆ ! Wdi] jhZY Vh ]Zi" ZgdY^\^iVa ÒVeh [dg gZXdchigjXi^c\ i]Z ejae d[ i]Z i]jbW# Dc i]Z WVh^h d[ i]ZhZ XaVhh^X YZhXg^ei^dch VcY dc VYY^i^dcVa VcVidb^X hijY^Zh! bdY^ÑXV" i^dch! VcY gZÑcZbZcih! cZl ineZh d[ ÒVeh ]VkZ WZZc YZkZadeZY VcY VgZ YZhXg^WZY ^c bdgZ YZiV^aZY WZadl#
Cross-Finger Flaps I]Z XaVhh^X ÅXgdhh"Ñc\ZgÆ ÒVe ]Vh WZZc bdY^ÑZY ^cid hZkZgVa [dgbh# 6aa i]ZhZ [dgbh VgZ eg^cX^" eVaan Xdch^YZgZY id WZ gVcYdb"eViiZgc ÒVeh! Vai]dj\] hbVaa Vm^Va XjiVcZdjh WgVcX]Zh bVn WZ ^cXajYZY ^c hdbZ bdY^ÑXVi^dch! Vh [dg ZmVbeaZ ^c i]Z 8"g^c\ ÒVe! l]^X] XdciV^ch YZÑcZY kZhhZah id Zc]VcXZ ^ih kZghVi^a^in VcY bdW^a^in#(+ I]Z 8" g^c\ ÒVe ^h Z^i]Zg V egdm^bVaan dg Y^hiVaan WVhZY ÒVe i]Vi Xdch^hih d[ i]Z hZb^"X^gXjb[ZgZcXZ d[ i]Z Y^\^i ;^\jgZ ("( #)I]Z ÅXgdhh"Ñc\ZgÆ ÒVe XVc XdkZg aVg\Zg XdbeaZm YZ[ZXih ^c i]Z Y^hiVa b^YYaZ e]VaVcm VcY XVc Vahd WZ gZ"^ccZgkViZY! Wji ^ih VgX d[ gdiVi^dc ^h a^b^iZY WZXVjhZ d[ i]Z h]dgi eZY^XaZ# I]ZgZ[dgZ! i]Z bdhi ^bedgiVci eg^cX^eaZ ^c eaVcc^c\ V Xgdhh"Ñc\Zg ÒVe ^h id hfjVgZ i]Z YZ[ZXi VcY id VY_jhi i]Z aZkZa d[ i]Z YZ[ZXi ^c i]Z Y^\^i id i]Z Proximally based C-ring flap
Palmar digital nerve Digitally based C-ring flap
Traditional Flaps HZkZgVa ^cig^ch^X ÒVeh ]VkZ WZZc jhZY ^c gZXZci YZXVYZh# 6bdc\ i]Z bdgZ [gZfjZcian ZbeadnZY VgZ gVcYdb"eViiZgc ÒVeh! l]^X] VgZ i]Z XaVhh^X
Digital nerve Figure 3-3. Steps in elevating the C-ring digital flap.
26
Tissue Surgery
aZkZa d[ i]Z ÒVe id Vkd^Y iZch^dc dc i]Z ÒVe# HdbZ iZbedgVgn ÒZm^dc d[ i]Z Ydcdg dg gZX^e^" Zci Ñc\Zg bVn WZ cZXZhhVgn id gZYjXZ iZch^dc dc i]Z ÒVe# I]Z aVg\Zhi ÒVe XVc WZ gV^hZY dc i]Z b^YYaZ e]VaVcm# I]Z eVgViZcdc bjhi WZ egZ" hZgkZY id hZXjgZ \gV[i^c\ Vi i]Z Ydcdg h^iZ# 9dcdg h^iZ bdgW^Y^in XVc WZ Xdch^YZgVWaZ ^[ i]Z hZb^" X^gXjb[ZgZcXZ d[ i]Z Y^\^i ^h gV^hZY#
I]Z iZX]c^fjZ [daadlh i]Z ÅdeZc i]Z Yddg" XadhZ i]Z YddgÆ eg^cX^eaZ# 6[iZg ZaZkVi^c\ i]Z h`^c d[ i]Z Ydcdg h^iZ Vh V eZY^XaZY kVhXjaVg^oZY YZgbVa ÒVe ÅdeZc i]Z YddgÆ ! i]Z hjWXjiVcZdjh i^hhjZ ^h ZaZkViZY ^c i]Z deedh^iZ Y^gZXi^dc Wn eaVX^c\ ^ih WVhZ VY_VXZci id i]Z gZX^e^Zci Ñc\Zg! egZhZgk^c\ i]Z eVgViZcdc# I]Z hjWXjiVcZdjh ÒVe ^h i]Zc Ò^eeZY dkZg a^`Z i]Z eV\Z d[ V Wdd` VcY hjijgZY ^cid i]Z YZ[ZXi# 6[iZg i]Z hjWXjiVcZ" djh ÒVe ^h ^chZi! i]Z eZY^XaZY kVhXjaVg^oZY YZgbVa ÒVe ^h hZlc WVX` ^cid ^ih WZY ÅXadhZ i]Z YddgÆ ! VcY V i^Z"dkZg YgZhh^c\ ^h Veea^ZY# 6 hea^i"i]^X`cZhh h`^c \gV[i HIH< ^h Veea^ZY id i]Z gZkZghZY hjg[VXZ d[ i]Z gZkZghZY hjWXjiV" cZdjh ÒVe# HZXjg^c\ i]Z ÒVe l^i] hjijgZh! WjYYn iVe^c\! dg `"l^gZ ÑmVi^dc ^h bVcYVidgn ;^\jgZ (") #
Reverse Cross-Finger Flaps GZkZghZ Xgdhh"Ñc\Zg ÒVeh VgZ jhZY id gZeV^g YdghVa Ñc\Zg YZ[ZXih d[ i]Z VY_VXZci Ñc\Zg#). I]Z X]d^XZ d[ i]Z Ydcdg Ñc\Zg VcY i]Z Ydcdg gZ\^dc ^h WVhZY dc i]Z hVbZ Xdch^YZgVi^dch Vh ^c i]Z igVY^i^dcVa iZX]c^fjZ#
Reversed flap covering recipient defect and reconstructing avulsed eponychial defect
Intact skin island
Defect Thin fullthickness skin graft
Elevated thin full-thickness skin flap
a c
Elevated full-thickness subcutaneous flap with intact skin island
Originally elevated thin full-thickness skin flap covering donor defect
b
No tie-over dressing on skin graft covering reversed surface of reverse cross finger flap
d
e
Tie-over dressing on donor area skin coverage
Figure 3-4. Reversed cross-finger flap.3
Advanced Concepts in Vascularized Tissue Transfer in the Hand
27
Dorsal tissue loss Cleland’s ligament Areas of pedicle release
Grayson’s ligament Dermo-epidermal flap
a
Subcutaneous flap
b Split thickness skin graft
c Figure 3-5. Homodigital adipofascial palmar flap. (Voche P, Merle M. The homodigital subcutaneous flap for cover of dorsal finger defects. Br J Plast Surg. 1994;47(6): 435–439. Copyright (1994), with permission from The British Association of Plastic Surgeons.)
Variations of Random-Pattern Flaps 6cdi]Zg dei^dc id XdkZg V YdghVa YZ[ZXi d[ i]Z Ñc\Zg ^h V ]dbdY^\^iVa VY^ed[VhX^Va eVabVg ÒVe! Vh YZhXg^WZY Wn KdX]Z VcY BZgaZ ;^\jgZ ("* #(&!*% >c VcVidb^X hijY^Zh! i]Zn YdXjbZciZY i]Z kVh" XjaVg hjeean d[ i]Z eVabVg hjWXjiVcZdjh i^hhjZ! VcY i]Zn jhZ i]^h aVnZg Vh V ijgcdkZg ÒVe id XdkZg YdghVa YZ[ZXih# I]^h ÒVe YZÑc^iZan ]Vh ediZci^Va! Wji kZgn YZa^XViZ Y^hhZXi^dc ^h gZfj^gZY id egZ" hZgkZ i]Z eVgViZcdc d[ i]Z ÒZmdg iZcYdch VcY id Vkd^Y ^c_jg^c\ i]Z cZjgdkVhXjaVg WjcYaZ#
Flaps With Axial-Pattern Perfusion 6m^Va"eViiZgc ÒVeh VgZ X]VgVXiZg^hi^XVaan WVhZY dc V YZÑcZY kZhhZa i]Vi ^cYZeZcYZcian eZg[jhZh i]Z VgZV d[ i]Z ÒVe! Z^i]Zg Y^gZXian dg i]gdj\] eZg[dgVi^c\ WgVcX]Zh# I]Z YZh^\c d[ Vm^Va ^haVcY ÒVeh! bdhi [gZfjZcian jhZY Vh Y^\^iVa dg YdghVa bZiVXVgeVa ÒVeh! kVg^Zh hjWhiVci^Vaan [gdb i]Vi d[ V adXVa igVchedh^i^dc ÒVe# I]Z h^oZ d[ i]Z ÒVe
h]djaY bViX] i]Z h^oZ d[ i]Z YZ[ZXi! l^i] dcan V ha^\]i dkZgXdggZXi^dc# Bdhi hjg\Zdch YZh^\c i]Z h`^c ^haVcY ha^\]ian aVg\Zg id Vkd^Y Vcn iZch^dc dc i]Z ÒVe# I]^h ^h jhjVaan idaZgViZY Wn i]Z ÒVe# ;aVeh i]Vi VgZ idd aVg\Z [dg i]Z YZ[ZXi bVn gZhjai ^c kZcdjh Xdc\Zhi^dc gVi]Zg i]Vc ^c VYY^i^dcVa hV[Zin id i]Z ÒVe# I]Z VgX d[ gdiVi^dc! l]^X] ^h YZiZgb^cZY Wn i]Z aZc\i] d[ i]Z eZY^XaZ! ^h d[ jibdhi ^bedgiVcXZ [dg i]Z hjXXZhh d[ Vc Vm^Va ^haVcY ÒVe# >i ^h ZkZc bdgZ ^bedgiVci ^c gZkZghZ eZY^XaZ ÒVeh# 6ciZ\gVYZ ÒVeh jhjVaan Yd cdi ZmXZZY Vc VgX d[ gdiVi^dc d[ .% id &'%! l]^X] \gZVian gZYjXZh i]Z g^h` d[ `^c`^c\# GZkZghZ eZY^XaZ ÒVeh [gZfjZcian ]VkZ VgXh d[ gdiVi^dc d[ &-%# >c i]ZhZ ÒVeh! ^[ i]Z eZY^XaZ ^h cdi adc\ Zcdj\] id Vaadl V l^YZ VgX! `^c`^c\ d[ i]Z eZY^XaZ XVc _ZdeVgY^hZ kZcdjh djiÒdl# 6YY^c\ &% id &* bdgZ aZc\i] id i]Z eZY^XaZ! Vkd^Y^c\ i]Z jhZ d[ cVggdl ijccZah [dg i]Z eZY^XaZ! VcY jh^c\ V addhZ XadhjgZ d[ i]Z ldjcY! h]djaY WZ ^cXajYZY ^cid i]Z ÒVe YZh^\c id Vkd^Y i]ZhZ Xdbea^XVi^dch#
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Tissue Surgery
Antegrade and Retrograde Homodigital Artery Flaps =dbdY^\^iVa ^haVcY ÒVeh! VciZ\gVYZ dg gZkZghZ! XVc WZ ZbeadnZY id gZeV^g kVg^djh ineZh d[ YZ[ZXih [gdb XdbeaZm ^c_jg^Zh d[ i]Z ]VcY! ZheZ" X^Vaan l]Zc ZVh^Zg iZX]c^fjZh! hjX] Vh Xgdhh" Ñc\Zg ÒVeh! VgZ cdi edhh^WaZ Vh V gZhjai d[ hZkZgZ bjai^eaZ Ñc\Zg ^c_jg^Zh# I]ZhZ ÒVeh gZan dc dcZ d[ i]Z Y^\^iVa VgiZg^Zh dg dc V eZg[dgVidg WgVcX]^c\ d[[ i]ZhZ kZhhZah! id\Zi]Zg l^i] i]Z^g XdcXdb^iVci kZ^ch! l]^X] VgZ egdiZXiZY dc i]Z eVabVg h^YZ Wn i]Z E Y^hiVa ^ciZge]VaVc\ZVa dg E>E egdm^bVa ^ciZge]VaVc\ZVa aZkZa!(*!**Ã*, l]ZgZ V eVabVg VgX] gjch WZilZZc i]Z ÒZmdg iZcYdc h]ZVi] VcY i]Z WdcZ ;^\jgZ ("+ #*- I]Z ^ciZ\g^in d[ i]ZhZ igVchkZghZ Y^\^iVa VgX]Zh ^h ZhhZci^Va [dg V hjXXZhh[ja ÒVe# I]Z kVhXjaVg eZY^XaZ ^h gZa^VWaZ! VcY i]Z VgX d[ gdiVi^dc ^h l^YZ Zcdj\] id gZVX] i]Z E>E VcY 9>E _d^cih0 i]ZgZ[dgZ! i]ZhZ ÒVeh VgZ ^cY^XViZY [dg Y^hiVa ]dbd"Y^\^iVa YdghVa YZ[ZXih! ZheZX^Vaan dkZg ZmedhZY _d^cih VcY Ñc\Zgi^e ^c_jg^Zh! l^i] VXXZeiVWaZ Ydcdg h^iZ bdgW^Y^in# 6 [jaa"i]^X`cZhh h`^c \gV[i [dg i]Z Ydcdg h^iZ ^h gZfj^gZY#
Heterodigital Island Flaps =ZiZgdY^\^iVa VgiZg^Va^oZY ÒVeh VgZ jhZ[ja [dg gZhjg[VX^c\ aVg\Z YZ[ZXih ^c i]Z ]VcY! Vh lZaa Vh i]Z eVabVg! YdghVa! VcY aViZgVa VheZXih d[ VY_VXZci Ñc\Zgh i]Vi VgZ idd W^\ [dg adXVa igVch" edh^i^dc ÒVeh# I]Z ÒVeh VgZ i]^c VcY ea^VWaZ! VcY i]Z bdgW^Y^in id i]Z Ydcdg Ñc\Zg ^h
Retrograde pedicle design (Homodigital island flap) Figure 3-6. Design of a reverse homodigital artery flap.1
b^c^bVa# I]Z ÒVe ^h WVhZY dc i]Z Y^\^iVa VgiZgn d[ Vc VY_VXZci Ñc\Zg! VcY ^c hdbZ XVhZh ^cXajYZh V kZ^c [gdb i]Z Ydghjb d[ i]Z Ñc\Zg# I]^h kZ^c ^begdkZh ÒVe ]ZbdYncVb^Xh VcY egZkZcih kZcdjh Xdc\Zhi^dc ^c i]Z ÒVe! l]^X] XVc dXXjg ^c ^haVcY ÒVeh [gdb i]Z Ñc\Zgh i]Vi YZeZcY hdaZan dc i]Z kZcVZ Xdb^iVciZh d[ i]Z Y^\^iVa VgiZgn#*. >[ V adc\Zg gZVX] ^h gZfj^gZY! i]Z ]ZiZgdY^\^iVa VgiZg^Va^oZY ÒVe XVc WZ ZmiZcYZY Wn Y^k^Y^c\ i]Z YdghVa kZ^c# DcXZ i]Z ÒVe ]Vh WZZc igVch[ZggZY! i]Z kZcdjh eZY^XaZ d[ i]Z ÒVe XVc WZ gZXdccZXiZY b^Xgdhjg\^XVaan#+% 8a^c^XVa XVhZh gZedgiZY Wn IV^ Zi Va# h]dlZY XdbeaZiZ ÒVe hjgk^kVa l^i] cd edhideZgVi^kZ kZcdjh ÒVe Xdc\Zhi^dc VcY cdgbVa hZchVi^dc ^c i]Z Ydcdg Ñc\Zg ejae ;^\jgZ (", #
Heterodigital, Reversed Neurovascular Island Flaps =ZiZgdY^\^iVa! gZkZghZY cZjgdkVhXjaVg ^haVcY ÒVeh VgZ YZh^\cZY dc i]Z Ydghd"aViZgVa VheZXi d[ i]Z b^YYaZ e]VaVcm d[ i]Z VY_VXZci jc^c_jgZY Ñc\Zg# I]Zn VgZ ^cY^XViZY [dg gZeV^g^c\ ZmiZc" h^kZ YZ[ZXih ^c Ñc\Zgh i]Vi XVccdi WZ gZXdc" higjXiZY jh^c\ di]Zg ÒVeh VcY Vh Vc VaiZgcVi^kZ id b^Xgdhjg\^XVa gZXdchigjXi^dc# I]Z aZc\i] d[ i]Z kVhXjaVg eZY^XaZ Vaadlh V l^YZ VgX d[ igVch" edh^i^dc [dg XdkZg^c\ YZ[ZXih ^c i]Z b^YYaZ VcY ^cYZm Ñc\Zgh# 6 Y^\^iVa 6aaZcÈh iZhi VcY 9deeaZg ZmVb^cVi^dc bjhi XdcÑgb i]Z eViZcXn d[ i]Z Y^\^iVa VgiZg^Zh d[ i]Z ^c_jgZY VcY VY_VXZci Ydcdg Ñc\Zgh egZdeZgVi^kZan# >[ V cZjgdkVhXjaVg ÒVe ^h id WZ XgZViZY! V YdghVa hZchdgn WgVcX] d[ i]Z Y^\^iVa cZgkZ XVc WZ Y^hhZXiZY VcY ViiVX]ZY id i]Z ÒVe# 6[iZg Y^hhZXi^c\ i]Z Xdbbdc Y^\^iVa VgiZgn WZilZZc i]Z ^c_jgZY Ñc\Zg VcY i]Z ÒVe"Ydcdg Ñc\Zg! i]Z VgiZgn ^h igVchZXiZY WZ[dgZ ^ih W^[jgXV" i^dc0 VcY i]Z Y^\^iVa VgiZgn ^h ^YZci^ÑZY je id ^ih W^[jgXVi^dc ^c i]Z eVab#I]Z XdckZg\^c\ WgVcX]Zh VgZ bdW^a^oZY Vh V Xdci^cjdjh kVhXjaVg eZY^XaZ [dg i]Z ÒVe! hd i]Vi kVhXjaVg^oVi^dc ^h egdk^YZY Wn V gZkZghZ Òdl i]gdj\] i]Z egdm^bVa igVch" kZghZ Y^\^iVa eVabVg VgX] d[ i]Z ^c_jgZY Ñc\Zg#+& 9Zhe^iZ i]Z edhh^W^a^in d[ dcZ"hiV\Z gZXdchigjX" i^dc! ZVgan edhideZgVi^kZ bdW^a^oVi^dc! \ddY [jcXi^dcVa gZXdkZgn! VcY hVi^h[VXidgn XdhbZi^X VcY hZchdgn gZhjaih! i]^h iZX]c^fjZ ]Vh Y^hVYkVc" iV\Zh! l]^X] ^cXajYZ i]Z hVXg^ÑXZ d[ i]Z Xdbbdc Y^\^iVa VgiZgn! Vh lZaa Vh i]Z cZZY id k^daViZ V ]ZVai]n Ñc\Zg#
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Figure 3-7. (above) Preoperative injury. Extensive injury to the radial side of the palm with damage to the radial digital artery of the index finger precludes harvesting the heterodigital arterialized flap from the ulnar side of the index finger, as this would risk necrosis of the donor finger. As the flap came from the noncontiguous side of the ring finger, vein division was necessary to facilitate transfer of
the flap. (below) Postoperative healing. Both the flap and the full-thickness skin graft have healed well. (Tay SC, Teoh LC, Tan SH, et al. Extending the reach of the heterodigital arterialized flap by vein division and repair. Plast Reconstr Surg. 2004;114(6):1450–1456.)
Thenar Flaps Based on the Superficial Palmar Branch of the Radial Artery
d[ i]Z i]ZcVg [VhX^V VcY Xdch^hiZcian \^kZh eZg[d" gVi^c\ WgVcX]Zh id i]Z i]ZcVg [VhX^dXjiVcZdjh VgZV# I]Z eVabVg VheZXi d[ i]Z i]ZcVg Zb^cZcXZ ^h Xdch^hiZcian ^ccZgkViZY Wn i]Z XjiVcZdjh WgVcX] d[ i]Z bZY^Vc cZgkZ! VcY i]Z gVY^Va VheZXi ^h ^ccZgkViZY Wn i]Z hjeZgÑX^Va WgVcX] d[ i]Z gVY^Va cZgkZ VcY i]Z aViZgVa VciZWgVX]^Va XjiVcZdjh cZgkZ#&&!,)!,*!,, <^kZc i]Z VcVidbn YZhXg^WZY VWdkZ! V [VhX^d" XjiVcZdjh ÒVe XVc WZ gV^hZY i]Vi XVc Vahd WZ jhZY Vh Vc ^ccZgkViZY ÒVe#,*!,, I]Z aVg\Z Y^VbZiZg d[ i]Z kZhhZah Vaadlh ^ih jhZ Vh V [gZZ ÒVe#&&!,'Ã,*!,,!,>c eVgi^XjaVg YZ[ZXih! hjX] Vh bVhh^kZ eVabVg YZ[ZXih VcY YZ\adk^c\ ^c_jg^Zh! V ÒVe WVhZY dc i]Z hjeZgÑX^Va eVabVg WgVcX] d[ i]Z gVY^Va VgiZgn XVc WZ XdbW^cZY l^i] V gVY^Va [dgZVgb ÒVe Wn ZmiZcY^c\ i]Z kVhXjaVg eZY^XaZ id i]Z gVY^Va VgiZgn#,, >c VWdji +% d[ Vaa eZdeaZ! V Y^hiVa Xdc" cZXi^dc l^i] i]Z hjeZgÑX^Va eVabVg VgX] ZcVWaZh
I]Z XaVhh^X i]ZcVg ÒVe Vh V gVcYdb"eViiZgc ÒVe [dg gZXdchigjXi^c\ YZ[ZXih d[ i]Z ejae ^h lZaa `cdlc VcY ]Vh WZZc YZhXg^WZY Wn cjbZg" djh Vji]dgh#'!&&!&)!+)Ã,& >c &..(! @VbZ^ Zi Va# ^cigd" YjXZY i]Z Å[gZZ i]ZcVg ÒVeÆ WVhZY dc i]Z hjeZgÑX^Va eVabVg WgVcX] d[ i]Z gVY^Va VgiZgn#,' I]^h ^cigdYjXi^dc lVh [daadlZY Wn kVg^djh kVh" XjaVg VcY cZjgd"VcVidb^XVa hijY^Zh ;^\jgZ ("- #&&!,(Ã,+ I]ZhZ hijY^Zh Xdch^hiZcian h]dlZY i]Vi i]Z hjeZgÑX^Va eVabVg WgVcX] d[ i]Z gVY^Va VgiZgn ]Vh Vc VkZgV\Z Y^VbZiZg d[ &#) bb VcY hjeea^Zh V XdchiVci VgZV d[ h`^c dkZg i]Z egdm^bVa eVgih d[ i]Z VWYjXidg edaa^X^h WgZk^h VcY deedcZch edaa^X^h bjhXaZh# 6[iZg \^k^c\ d[[ V cjig^Zci WgVcX] id i]Z i]ZcVg bjhXaZ! i]Z hjeZgÑX^Va eVabVg VgiZgn WgVcX] gjch i]gdj\] i]Z WVhZ
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Tissue Surgery
a
b
c
Figure 3-8. Variations of the superficial palmar branch of the radial artery. (Schmidt HM, Lanz U. Chirurgische Anatomie der Hand, New York: Georg Thieme Verlag, 2003.)
i]Z XgZVi^dc d[ gZkZghZ"Òdl ^haVcY ÒVeh [gdb i]Z i]ZcVg VgZV [dg gZXdchigjXi^c\ i]Z i]jbW dg [dg XdkZg^c\ eVabVg YZ[ZXih V[iZg gZhZXi^c\ 9jejnigZcÈh XdcigVXijgZ ;^\jgZ (". #&&
Superficial palmar arch Superficial palmar branch Radial artery
Ulnar artery
Figure 3-9. Schematic drawing of a reverse flap from the thenar area.The superficial palmar branch of the radial artery connects to the superficial palmar arch, which enables reverse-flow island flaps to cover palmar defects.
Hypothenar Flaps Based on the Ulnar Palmar Digital Artery I]Z h`^c dkZg i]Z ]nedi]ZcVg Zb^cZcXZ ^h cdjg" ^h]ZY Wn bjhXjadXjiVcZdjh dg [VhX^dXjiVcZdjh eZg[dgVidg VgiZg^Zh! l]^X] eVhh i]gdj\] i]Z ]nedi]ZcVg bjhXaZh dg [VhX^V# I]Z Y^hiVa ]Va[ d[ i]Z ]nedi]ZcVg Zb^cZcXZ ]Vh V XdchiVci kVhXj" aVg hjeean [gdb i]Z jacVg eVabVg Y^\^iVa VgiZgn d[ i]Z a^iiaZ Ñc\Zg# >ccZgkVi^dc d[ i]^h VgZV ^h [gdb YdghVa dg eVabVg XjiVcZdjh WgVcX]Zh d[ i]Z jacVg cZgkZ ;^\jgZ ("&% #&%!,.Ã-& I]Z jacVg ]nedi]ZcVg ÒVe ^h YZh^\cZY dkZg i]Z jacVg VheZXi d[ i]Z Y^hiVa ]Va[ d[ i]Z ]nedi]" ZcVg Zb^cZcXZ! l]^X] ^h adXViZY dkZg i]Z VWYjX" idg Y^\^i^ b^c^b^ bjhXaZ# I]Z ÒVe XVc ^cXajYZ bjai^eaZ [VhX^dXjiVcZdjh eZg[dgVi^c\ kZhhZah i]Vi Vg^hZ [gdb i]Z jacVg eVabVg Y^\^iVa VgiZgn d[ i]Z a^iiaZ Ñc\Zg#-'Ã-* Id XdkZg h`^c VcY hd[i i^hhjZ YZ[ZXih d[ i]Z a^iiaZ Ñc\Zg! i]Z ÒVe XVc WZ YZh^\cZY VcY igVch" [ZggZY ^c V gZigd\gVYZ [Vh]^dc#-' >c i]ZhZ XVhZh! i]Z e^kdi ed^ci ^h adXViZY Vi i]Z egdm^bVa e]VaVc" \ZVa aZkZa# HZchdgn ^ccZgkVi^dc d[ i]Z VgZV ^h bV^can egdk^YZY Wn i]Z YdghVa WgVcX] d[ i]Z jacVg cZgkZ# >c i]Z hZchViZ ÒVe! i]Z ^ccZgkVi^c\ cZgkZ ^h hjijgZY id i]Z eVabVg Y^\^iVa cZgkZ Vi i]Z Y^hiVa e]VaVc\ZVa _d^ci ;^\jgZ ("&& # I]Z VgiZg^Va WaddY hjeean d[ i]^h gZkZghZ ÒVe ^h ZchjgZY Wn Xdbbjc^XVi^dc WZilZZc i]Z gVY^Va
Advanced Concepts in Vascularized Tissue Transfer in the Hand
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YZh^\c! VcY ]ZcXZ i]Z kZghVi^a^in! d[ i]ZhZ adXVa ÒVeh ;^\jgZ ("&' #.%Ã.( >c &..,! ild bV_dg YZkZa" debZcih ^c i]Z ÒVe lZgZ gZedgiZY/.% VcÅZmiZcYZY! gZkZghZ! YdghVa bZiVXVgeVa VgiZgn ÒVe!Æ YZh^\cZY Wn @VgVXVaVg Zi Va#.'0 VcY V ÅgZkZghZ YdghVa bZiVXVgeVa VgiZgn Xdbedh^iZ ÒVeÆ XdciV^c^c\ V kVhXjaVg hZ\bZci d[ WdcZ# KVg^djh Vji]dgh gZedgiZY Xdbedh^iZ ÒVeh ^cXajY^c\ iZcYdc hZ\bZcih#-,!--
Extended Dorsal Metacarpal Artery Flaps I]Z ZmiZcYZY YdghVa bZiVXVgeVa VgiZgn ÒVe ^h V gZXZcian YZhXg^WZY kVg^Vi^dc d[ i]Z YdghVa bZiV" XVgeVa VgiZgn 9B86 ÒVe#.) I]Z VgX d[ gdiVi^dc XVc WZ bVg`ZYan ZcaVg\ZY Wn jh^c\ i]Z Ñghi eZg" [dgVidg kZhhZa ^c i]Z egdm^bVa e]VaVcm Vi i]Z bdhi Y^hiVa WVhZ d[ i]Z ÒVe# I]^h kZhhZa Vahd [dgbh i]Z WVhZ d[ i]Z b^Ye]VaVc\ZVa ^haVcY ÒVe VcY [ZZYh i]Z hjWXjiVcZdjh VgiZg^Va cZildg`# I]Z Figure 3-10. Arterial anatomy of the little finger. (Schmidt HM, Lanz U. Chirurgische Anatomie der Hand. New York: Georg Thieme Verlag, 2003.)
VcY jacVg eVabVg Y^\^iVa VgiZg^Zh d[ i]Z a^iiaZ Ñc\Zg! i]gdj\] i]Z YdghVa dg eVabVg VgiZg^Va VgXVYZ# I]ZgZ[dgZ! egZdeZgVi^kZ Y^\^iVa 6aaZc iZhih VcY 9deeaZg ZmVb^cVi^dc d[ i]Z eVabVg Y^\^iVa VgiZg^Zh VgZ ^cY^heZchVWaZ [dg VhhZhh^c\ i]Z kVh" XjaVijgZ d[ i]Z a^iiaZ Ñc\Zg# >c XdcigVhi id di]Zg XdckZci^dcVa ÒVeh ! hjX] Vh i]Z Xgdhh"Ñc\Zg ÒVe VcY i]Z i]ZcVg ÒVe! i]^h ÒVe ^ckdakZh V h^c\aZ"hiV\Z egdXZYjgZ l^i]dji egdadc\ZY ^bbdW^a^oVi^dc# >i ^h V kZghVi^aZ ÒVe lZaa hj^iZY [dg Xdbea^XViZY Ñc\Zg ^c_jg^Zh l^i] hjWhiVci^Va eVabVg i^hhjZ YZ[ZXih! VcY ^i Vaadlh eg^bVgn Ydcdg"h^iZ XadhjgZ l^i]dji [jaa" dg hea^i" i]^X`cZhh h`^c \gV[ih#
Flaps Based on the Dorsal Metacarpal Network I]Z Ydghjb d[ i]Z ]VcY ^h ^cXgZVh^c\an jhZY Vh V hdjgXZ d[ kVg^djh ^cig^ch^X ÒVeh! l^i] V l^YZ gVc\Z d[ YZh^\ch VcY i^hhjZ XdbedcZcih#-+Ã-I]ZhZ ÒVeh VgZ Z^i]Zg egdm^bVaan VciZ\gVYZ YdghVa bZiVXVgeVa VgiZgn dg Y^hiVaan gZkZghZ YdghVa bZiVXVgeVa VgiZgn WVhZY# I]Z Y^hiVaan WVhZY ÒVeh ^c i]Z ]VcY VgZ XVaaZY ÅgZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVehÆ VcY ÅZmiZcYZY gZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVeh#Æ ;^ghi YZiV^aZY ^c &..%! i]ZhZ ÒVeh VgZ jhZY ^cXgZVh^c\an#-,!-. BdgZ [dXjh dc i]Z kVhXjaVg VcVidbn ^c i]Z aVhi YZXVYZ ]Vh XaVg^ÑZY i]Z
Figure 3-11. Diagram of the reverse ulnar hypothenar flap. The flap is designed over the distal half of the ulnar aspect of the hypothenar eminence. UPDA ulnar palmar digital artery; PP pivot point of the reverse flap; SPA superficial palmar arch; DUN dorsal branch of the ulnar nerve. (Omokawa S, Yajima H, Inada Y, et al. A reverse ulnar hypothenar flap for finger reconstruction. Plast Reconstr Surg. 2000;106(4):828–833.)
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Figure 3-12. Vascular network supplying dorsum of the hand: (1) rete carpi dorsale, (2) dorsal carpal arch, (3) dorsal metacarpal artery (DMCA), (4) junctura tendineae, (5) cutaneous perforator from DMCA, (6) continuation of DMCA to join the confluence of common digital artery and digital arteries, (7) lateral terminal branches of DMCA anastomosing (C) with dorsal branches of digital artery, (8) deep palmar arch, (9) proximal communication perforator between DMCA and palmar metacarpal artery (PMCA), (10) superficial palmar arch, (11) PMCA,
(12) distal communicating perforator between DMCA and PMCA, (13) common digital artery, (14) digital artery to the neighboring finger, (15) digital artery to the same finger,(a-d) dorsal branches of the digital artery.(Vuppalapati G,Oberlin C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
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WZilZZc i]Z ZmiZchdg iZcYdch! dg i]gdj\] dcZ d[ i]ZhZ iZcYdch l]Zc V hZ\bZci ^h ^cXajYZY ^c i]Z ÒVe! l^i]dji Y^hijgW^c\ i]Z i]^c WgVcX]Zh d[ i]Z YdghVa bZiVXVgeVa VgiZgn id i]Z WdcZ hZ\" bZci! i]Z iZcYdc hZ\bZci! VcY i]Z h`^c eVYYaZ ;^\jgZ ("&) # KjeeVaVeVi^ Zi Va#.+ jhZY V Xdbedh^iZ gZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVe id Wg^Y\Z V hZ\bZci d[ hZkZgZ Xdbb^cji^dc d[ i]Z egdm^" bVa e]VaVcm l^i] i]Z adhh d[ i]Z hZ\bZciVa ZmiZchdg iZcYdc ^c i]Z ^cYZm Ñc\Zg# I]^h ÒVe ^cXajYZY V kVhXjaVg^oZY hZ\bZci d[ ZmiZchdg iZcYdc [gdb i]Z ZmiZchdg ^cY^X^h VcY Xdgi^XVa WdcZ [gdb i]Z hZXdcY bZiVXVgeVa WdcZ# HVciV" 8dbWV Zi Va# gZXdchigjXiZY i]Z egdm^bVa e]VaVcm d[ i]Z Ñ[i] Ñc\Zg l^i] V XdbedjcY dhiZd"[VhX^d"XjiVcZdjh YdghVa bZiVXVgeVa ÒVe#-@V`^cd`^ Zi Va#.- igZViZY X]gdc^X dhiZdbnZa^i^h ^c i]Z egdm^bVa e]VaVcm d[ i]Z b^YYaZ Ñc\Zg Wn ^chZgi^c\ V hbVaa e^ZXZ d[ i]Z ^ciZgdhhZdjh bjhXaZ hjeea^ZY Wn V gZkZghZ Òdl d[ i]Z hZXdcY YdghVa bZiVXVgeVa VgiZgn ^cid i]Z WdcZ bVggdl heVXZ! V[iZg gVY^XVa YWg^YZbZci#
Composite Dorsal Metacarpal Artery Flaps I]Z Xdbedh^iZ! gZkZghZ! YdghVa bZiVXVgeVa VgiZgn ÒVe ^h iZX]c^XVaan bdgZ YZbVcY^c\ i]Vc i]Z XdckZci^dcVa YdghVa bZiVXVgeVa VgiZgn ÒVe# I]Z hZ\bZciVa WaddY hjeean id i]Z bZiVXVgeVah VcY ZmiZchdg iZcYdch.*Ã., jcYZga^cZh i]Z ^bedgiVcXZ d[ ^cXajY^c\ i]Z YdghVa bZiVXVgeVa VgiZgn ^c i]ZhZ ÒVeh# =ZcXZ! i]Z Y^hhZXi^dc bjhi egdXZZY
Figure 3-13. Extended reverse dorsal metacarpal artery flap. (Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps:clinical experience,cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
Advanced Concepts in Vascularized Tissue Transfer in the Hand
33
Figure 3-14. Composite reverse dorsal metacarpal artery flap. (Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
Free “Kite” Flap I]Z Ñghi [gZZ b^Xgdhjg\^XVa `^iZ ÒVe lVh gZedgiZY Wn
Venous Flaps I]Z hd"XVaaZY kZcdjh ÒVeh Xdch^hi d[ V kVg^Zin d[ ÒVeh WVhZY dc cjig^Zci eZg[jh^dc [gdb i]Z kZcdjh hnhiZb# I]ZhZ ÒVeh VgZ jhZY Vh b^Xgd" kVhXjaVg ÒVeh id ZhiVWa^h] VgiZg^Va eZg[jh^dc VcY XVccdi WZ Xdch^YZgZY Å^cig^ch^X ÒVeh#Æ HZkZgVa
ineZh I]VkZ WZZc YZhXg^WZY! Z^i]Zg l^i] Vc VciZ" \gVYZ VgiZg^Va Òdl i]gdj\] i]Z kZcdjh hnhiZb dg Vh gZkZghZ VgiZg^Va^oZY kZcdjh Òdl"i]gdj\] ÒVeh# I]Zn ]VkZ cdi nZi WZZc l^YZan VXXZeiZY! Wji i]Zn VgZ [VkdgZY Wn V hadlan \gdl^c\ cjbWZg d[ eaVhi^X hjg\Zdch#(!(,!&%(Ã&%.
Vascularized Bone Grafts I]Z igZVibZci d[ XVgeVa [gVXijgZ cdcjc^dch dg VkVhXjaVg cZXgdh^h! hjX] Vh @^ZcWX`Èh Y^hZVhZ dg EgZ^hZgÈh Y^hZVhZ! ^h X]VaaZc\^c\ [dg i]Z ]VcY hjg\Zdc# I]Z \dVa d[ hjg\Zgn ^h id hiVW^a^oZ VcY gZkVhXjaVg^oZ i]Z V[[ZXiZY WdcZ! i]ZgZWn egZ" kZci^c\ XVgeVa XdaaVehZ# I]ZhZ \dVah XVc WZ VX]^ZkZY l^i] kVhXjaVg^oZY WdcZ \gV[ih VcY kVh" XjaVg WjcYaZ ^beaVciVi^dch# CjbZgdjh Vji]dgh YZhXg^WZY Y^[[ZgZci VeegdVX]Zh VcY edhh^W^a^i^Zh [dg i]^h ^hhjZ ;^\jgZ ("&+ #)+!&&%Ã&(, I]Z iZgb i]ZgVeZji^X Vc\^d\ZcZh^h YZhXg^WZh i]Z ^cYjXi^dc dg hi^bjaVi^dc d[ cZdkVhXjaVg^oV" i^dc [dg i]Z igZVibZci dg egZkZci^dc d[ eVi]da" d\n X]VgVXiZg^oZY Wn adXVa ]nedkVhXjaVg^in#&(-!&(. AjcViZ gZkVhXjaVg^oVi^dc ^h Vc ZmVbeaZ d[ dcZ [dgb d[ i]ZgVeZji^X ^ciZgkZci^dc! iZgbZY hjg\^" XVa Vc\^d\ZcZh^h! l]^X] ^h i]Z hjg\^XVa igVch[Zg d[ kZhhZah dg lZaa kVhXjaVg^oZY Vjid\Zcdjh i^hhjZ! VadcZ dg Vj\bZciZY l^i] i]Z h^bjaiVcZdjh Veea^" XVi^dc d[ kVhXjad\Zc^X Xnid`^cZh#&)% >c ]VcY hjg\Zgn! Wdi] ^beaVciZY 6K WjcYaZh VcY kVhXj" aVg^oZY eZY^XaZ dg [gZZ WdcZ ÒVeh dg \gV[ih ]VkZ WZZc jhZY ^c i]Z heZX^ÑX XVhZ d[ dhiZdcZXgd" h^h#&'%!&(,!&)%Ã&)- KVhXjaVg WjcYaZ ^beaVciVi^dc lVh ZhiVWa^h]ZY Wn =dg^ VcY IVbV^ ^c V XVc^cZ bdYZa#&(, Di]Zg Vji]dgh jhZY aje^cZ VcY XVc^cZ Vjid\gV[ih!&'%!&)%!&). XVc^cZ cdckVhXjaVg^oZY Vaad" \gV[ih!&)& VcY Yd\"id"gVWW^i cdckVhXjaVg^oZY
34
Tissue Surgery
a
b
c
d
Figure 3-15. Free kite flap. a. Defect on the palmar aspect of the index finger. Both flexor tendons and the neurovascular bundles are exposed.9 b. Results intraoperative and c) postoperative.9 d. Follow-up 40 months with a good aesthetic result.9
mZcdigVcheaVcih#&)) 8a^c^XVaan! i]^h bZi]dY ]Vh WZZc jhZY id igZVi @^ZcWX`Èh Y^hZVhZ!&), iVaVg VkVhXjaVg cZXgdh^h!&(, hXVe]d^Y cdcjc^dc l^i] VkVhXjaVg cZXgdh^h!&)'!&)* VcY ^c egZ[VWg^XViZY" WdcZ [gZZ ÒVeh#&)(!&)-!&*%!&*& KVhXjaVg^oZY WdcZ \gV[ih ]VkZ WZZc YZhXg^WZY Wn bVcn ^ckZhi^\Vidgh VcY ]VkZ WZZc igVchedhZY [gdb kVg^djh Ydcdg h^iZh! hjX] Vh i]Z e^h^[dgbZ WdcZ VcY i]Z h]V[i d[ i]Z gVY^jh dg jacVg! Vh lZaa Vh [gdb i]Z hZXdcY bZiVXVgeVa ]ZVY# ;gZZ b^Xgd" kVhXjaVg igVch[Zg d[ WdcZ [gdb i]Z ^a^VX XgZhi VcY bZY^Va [ZbdgVa XdcYnaZ ]Vh Vahd WZZc YZhXg^WZY#&'&!&')!&*'Ã&*)
OV^YZbWZg\ Zi Va# lVh dcZ d[ i]Z Ñghi id jhZ gZkZghZ eZY^XaZY kVhXjaVg^oZY WdcZ \gV[ih hjXXZhh[jaan id igZVi hXVe]d^Y cdcjc^dc#&(' BVi]dja^c VcY =VZgaZ&'* gZedgiZY V &%% hjXXZhh gViZ [dg Vc VciZ\gVYZ eZY^XaZY kVhXjaVg^oZY igVcheaVci [gdb i]Z eVabVg XVgeVa VgiZgn# IZX]" c^XVaan! i]Z eVabVg VeegdVX] ^h bjX] bdgZ X]Va" aZc\^c\ i]Vc i]Z YdghVa WZXVjhZ d[ i]Z egdm^b^in d[ XdbeaZm VcVidb^XVa higjXijgZh# BVi]dja^c VcY 7gjcZaa^&'+ YZhXg^WZY V iZX]c^fjZ jh^c\ eZY^" XaZY igVcheaVciVi^dc d[ i]Z hZXdcY bZiVXVgeVa ]ZVY i]Vi ]VY VXXZeiVWaZ gZhjaih# <j^bWZgiZVj VcY EVcXdc^&(( ZbeadnZY V WdcZ \gV[i WVhZY dc
Advanced Concepts in Vascularized Tissue Transfer in the Hand
dICa dRCa 1,2 IC SRA 2nd EC br of 1,2 IC SRA 2,3 IC SRA 2nd EC br of 2,3 IC SRA RA
dSRa 4th EC br of 5th ECA 5th ECA 4th ECA ODA distal ulna UA
pAnt Int A Post Int A
aAnt Int A
Ant Int A
Figure 3-16. Dorsal distal radius and ulna showing extraosseous vessels. aAnt Int A anterior division of the anterior interosseous artery; Ant Int A anterior interosseous artery; dlCa dorsal intercarpal arch; dRCa dorsal radiocarpal arch; dSRa dorsal supraretinacular arch; 2nd EC br of 1,2 IC SRA second extensor compartment branch of 1,2 intercompartmental supraretinacular artery; 2nd EC br of 2,3 IC SRA second extensor compartment of 2,3 intercompartmental artery; 4th EC br of 5thECA fourth extensor compartment branch of fifth extensor compartment artery; 4th ECA fourth extensor compartment artery; 5th ECA fifth extensor compartment artery; 1,2 IC SRA 1,2 intercompartmental supraretinacular artery; 2,3 IC SRA 2,3 intercompartmental supraretinacular artery; ODA, distal ulna oblique dorsal artery of the distal ulna; pAnt Int A posterior division of the anterior interosseous artery; Post Int A posterior interosseous artery; RA radial artery; UA ulnar artery.1
i]Z jacVg VgiZgn l^i] \ddY gZhjaih# 6 Y^hVYkVc" iV\Z d[ i]Z^g iZX]c^fjZ ^h i]Z hVXg^ÑXZ d[ i]Z jacVg VgiZgn#
Modifications of Vascularized Bone Grafts KVhXjaVg^oZY eZY^XaZ WdcZ \gV[ih [gdb i]Z Ydghjb d[ i]Z Y^hiVa gVY^jh ]VkZ WZZc YZh^\cZY dc i]Z VcVidb^X hijY^Zh d[ H]ZZio! 7^h]de! VcY 7Zg\Zg#)+!&&+ I]Z^g VcVidb^X hijY^Zh)+!&&+ Xdch^hi"
35
Zcian ^YZci^ÑZY hZkZgVa adc\^ijY^cVaan dg^ZciZY kZhhZah i]Vi hjeean cjig^Zci kZhhZah id i]Z Ydghjb d[ Y^hiVa gVY^jh#)+ I]ZhZ kZhhZah ]VkZ Xdch^hiZci heVi^Va gZaVi^dch]^eh id hjggdjcY^c\ VcVidb^XVa aVcYbVg`h i]Vi Vaadl hV[Z Y^hhZXi^dc VcY gZa^VWaZ ]VgkZhi d[ V hZ\bZci d[ kVhXjaVg^oZY gVY^Va bZi" Ve]nh^h! l]^X] XVc WZ igVch[ZggZY Vh V eZY^XaZ \gV[i id i]Z XVgejh# I]Z gVY^Va VgiZgn VcY i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn VgZ i]Z eg^bVgn hdjgXZh d[ dgi]d\gVYZ WaddY Òdl id i]Z Ydghjb d[ i]Z Y^hiVa gVY^jh ;^\jgZ ("&+ # ;djg kZhhZah i]Vi Vg^hZ [gdb i]ZhZ VgiZg^Zh hjeean i]Z YdghVa gVY^jh l^i] cjig^Zci WgVcX]Zh# Ild VgZ hjeZgÑX^Va id i]Z ZmiZchdg gZi^cVXjajb! egdk^Y^c\ cjig^Zci WgVcX]Zh id i]Z WdcZ jcYZg" cZVi] i]Z ZmiZchdg iZcYdc XdbeVgibZcih# I]Zn VgZ cVbZY i]Z &!' VcY '!( ^ciZgXdbeVgibZciVa hjegVgZi^cVXjaVg VgiZg^Zh &!' VcY '!( >8 HG6h # I]Z di]Zg ild VgZ YZZe kZhhZah! adXViZY dc i]Z Òddg d[ ZmiZchdg XdbeVgibZcih! cVbZY i]Z [djgi] VcY Ñ[i] ZmiZchdg XdbeVgibZciVa VgiZg^Zh )i] VcY *i] :86h [dg i]Z^g heZX^ÑX VcVidb^X adXVi^dc ^c i]Z gVY^Va VheZXi d[ ZVX] XdbeVgi" bZci# I]Z &!' >8 HG6 XdjghZh [gdb i]Z gVY^Va VgiZgn * Xb egdm^bVa id i]Z gVY^dXVgeVa _d^ci! WZcZVi] i]Z WgVX]^dgVY^Va^h bjhXaZ! id ZbZg\Z dc i]Z YdghVa hjg[VXZ d[ i]Z ZmiZchdg gZi^cVXj" ajb# >c i]Z VcVidb^X hcj[[Wdm! i]Z &!' >8 HG6 VcVhidbdhZh l^i] i]Z gVY^Va VgiZgn dg i]Z gVY^d" XVgeVa VgX] ;^\jgZ ("&, # I]^h kZhhZa! WVhZY dc ^ih Y^hiVa VcVhidbdi^X XdccZXi^dc id i]Z gVY^Va VgiZgn! ^h i]Z ÅVhXZcY^c\ ^gg^\Vi^c\ WgVcX]Æ YZhXg^WZY Wn OV^YZbWZg\ Zi Va#&(' I]^h kZhhZa ^h VXijVaan hjeZgÑX^Va id i]Z ZmiZchdg gZi^cVXjajb! gVi]Zg i]Vc dc i]Z eZg^dhiZjb! Vh dg^\^cVaan YZhXg^WZY# I]Z '!( >8 HG6 dg^\^cViZh [gdb i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn dg i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn# >i ^h hjeZgÑX^Va id i]Z ZmiZchdg gZi^cVXjajb! Y^gZXian dkZg A^hiZgÈh ijWZgXaZ! VcY VcVhidbdhZh l^i] i]Z YdghVa ^ciZg" XVgeVa VgX]! i]Z YdghVa gVY^dXVgeVa VgX]! dg i]Z )i] :86# >ih cjig^Zci VgiZgn WgVcX]Zh eZcZigViZ YZZean ^cid XVcXZaadjh WdcZ# A^`Z i]Z &!' >8 HG6! i]Z '!( >8 HG6 XVc WZ ZVh^an ]VgkZhiZY VcY jhZY Vh V kVhXjaVg^oZY eZY^XaZ WdcZ \gV[i# I]Z VgX d[ gdiVi^dc ^h \gZViZg VcY XVc gZVX] i]Z Zci^gZ egdm^bVa gdl! bV`^c\ ^i jhZ[ja [dg Z^i]Zg @^Zc" WX`Èh Y^hZVhZ dg hXVe]d^Y cdcjc^dch ;^\jgZ ("&, # I]Z )i] :86 dg^\^cViZh [gdb i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn dg ^ih Ñ[i] ZmiZchdg XdbeVgibZci WgVcX] VcY
36
Tissue Surgery
R S
1,2 IC SRA
RA
Figure 3-17. Vascularized pedicle bone graft based on the 1,2 intercompartmental supraretinacular artery.The incision is curvilinear, allowing wide exposure for scaphoid vascular bone graft elevation and osteonecrosis visualization.1
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Summary
Figure 3-18. Intraoperative view: the 4th extensor compartment artery (ECA) is ligated distal to the bone graft and centered proximal to the radiocarpal joint margin. It is elevated, including the overlying 4th ECA, based on an orthograde 4th ECA pedicle with retrograde flow from the 5th ECA.1
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4 Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery Jean Claude Guimberteau and Joseph Bakhach
Introduction
Microanatomical Observations In Vivo
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41
42
Tissue Surgery
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“Microvacuola” and the Microvacuolar Collagenic-Absorbing System LZ hijY^ZY ]jbVc VcY Vc^bVa i^hhjZ hVbeaZh! hjX] Vh i]Z ÒZmdg XVge^ gVY^Va^h ^c XViiaZ! ^c l]^X] i]Z dg\Vc^oVi^dc d[ i]Z XdaaV\Zcdjh hnhiZb ^h h^b^aVg id i]Vi d[ i]Z ]jbVc ÒZmdg egd[jcYjh bjhXaZ# I]Z hVbeaZ lVh egZeVgZY Wn igZVi^c\ ^i l^i] ediVhh^jb W^X]gdbViZ! i]Zc [dgbVa^c! VcY ÑcVaan XVjhi^X hdYV! i]jh Vaadl^c\ [dg hd[iZg VcY bdgZ XdbeaZiZ ]nYgdanh^h# I]Z hVbeaZ lVh i]Zc [gdoZc VcY [gZZoZ"Yg^ZY jcYZg hiVcYVgY XdcY^i^dch [dg YZ]nYgVi^dc# 6[iZglVgY! ^i lVh Y^hhZXiZY jcYZg W^cdXjaVg bV\c^ÑXVi^dc# HVbeaZh lZgZ iV`Zc! \^kZc V \daY"bZiVaa^X Ñc^h]! VcY dWhZgkZY jcYZg Vc ZaZXigdc b^XgdhXdeZ# I]^h XdaaV\Zcdjh hnhiZb! igVY^i^dcVaan XVaaZY i]Z ÅeVgViZcYdc!Æ hjggdjcYh i]Z iZcYdc# >i ^h
Figure 4-1. a) Traction on the paratendon during surgery. b) Searching for an epitendinous plane. c) Network between the tendon and the peripheral system: the MVCAS. (A.D.F. Video-Productions with special permission)
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Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
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Figure 4-2. MVCAS under the electron microscope. a) Histological and collagenous continuity between the epitendon and MVCAS. b) Sketch of this organization, in vacuoles. c) 3D tissue supports. d) 3D vacuola. (A.D.F. Video-Productions with special permission)
43
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Figure 4-3. Notion as “combined transmitted and absorbed stress.” Tension is applied to the link, the adjacent element undergoes tension and decreases in size little by little until deformation occurs. All of the component parts then turn so as to be oriented as far as possible in the direction of the applied force. (A.D.F. Video-Productions with special permission)
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Tissue Surgery
Figure 4-4. MVCAS and physiopathologies. (A.D.F. Video-Productions with special permission)
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a
Figure 4-5. a) The MVCAS disappears in its basic network under mechanical constraint and adapts to the new situation with a megavacuola response. b) Different MVCAS distributions in the common carpal sheath. c) The digital canal is an efficient adaptation of the MVCAS as a megavacuola with vincula: type III. d) A proposed new layout of the sliding sheaths in the finger flexor system. (A.D.F. VideoProductions with special permission)
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Tissue Surgery
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Figure 4-6. Vascularization is continuous and permanent. a) Tendons are not hypovascular. Like every organ, vascularization is adapted to its function. b) Bleeding of the flexor profundus at A3 pulley level. (A.D.F. Video-Productions with special permission)
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Figure 4-7. The transfer of a sliding flexion unit composed of a flexor tendon and its surrounding sheaths in a reverse island pedicled manner. 1st stage: Mesotendon identification. 2nd stage: Section of FSIVth flexor sublimis of the ring finger and ulnar pedicle. Island ulnar tendon transfer isolated. 3rd stage: Insertion of the island transfer into digital zone. 4th stage: Tendon sutures outside of the No Man’s Land and pulley reconstruction. (A.D.F. VideoProductions with special permission)
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4th stage
Figure 4-8. 1st stage: The mesotendon and ulnar artery branches. Flexor superficialis section at the tendinomuscular junction and at the level of decussation. 2nd stage: The flexion sliding unit after revascularization. 3rd stage: Forward translation of the sliding unit transfer. 4th stage: Before inserting and pulley reconstruction. (A.D.F. Video-Productions with special permission)
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Figure 4-9. a) Diagram of the different vascular branches emerging from the ulnar artery before Guyon’s canal entrance. Bone, skin, flexor tendons. b) Ulnar artery dissection before Guyon’s canal entrance. c) A bayonet-shaped incision including an outline of the skin flap is traced on the medial side of the forearm. d) Raising of the composite flexor tendon and skin flap island transfer for tendon repair and digital palmar resurfacing. Before and after tourniquet release. e) Other multiple combinations: combined island flexor superficialis tendon and palmaris longus transfer for flexor and pulley reconstruction. f) The double flexor tendons and double skin flaps transfer. g) The composite skin, flexor tendon, and bone transfer. (A.D.F. Video-Productions with special permission)
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Tissue Surgery
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Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
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Transplantation Technique I]Z dg^\^cVa igVcheaVciVi^dc egdXZYjgZ! WVhZY dc djg `cdlaZY\Z d[ i]Z jacVg WaddY hjeean d[ i]Z ÒZmdg hjeZgÑX^Va^h! ZheZX^Vaan d[ i]Z g^c\ Ñc\Zg! ]Vh WZZc eZg[dgbZY [gdb V a^k^c\ Ydcdg# HdbZ gZÑcZbZcih VcY bdY^ÑXVi^dch lZgZ
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Conclusion I]Z egZhZciZY iZX]c^fjZ ^h V hiZe idlVgY V cZl ineZ d[ gZXdchigjXi^dc ^c ]VcY hjg\Zgn# >i XVc WZ jhZY cdi dcan [dg i]Z ÒZmdg hnhiZb! Wji Vahd [dg WdcZ VcY _d^cih# ;dg i]Z bdbZci! bZY^XdaZ\Va XdchigV^cih VgZ hZkZgZ! VcY ZmVXi^c\ Xg^iZg^V bjhi WZ bZi WZ[dgZ Vcn igVcheaVci XVc WZ eZg[dgbZY# HjX] XdchigV^cih bVn Y^b^c^h] dkZg i^bZ! VcY iZX]c^fjZh d[ gZeV^g VcY gZXdchigjXi^dc! hjX] Vh i]dhZ YZhXg^WZY ]ZgZ! l^aa YZkZade [gZZan [dg jhZ ^c hZaZXiZY eVi^Zcih# 9Zhe^iZ i]Z hjXXZhh d[ i]^h iZX]c^fjZ! ^i h]djaY WZ gZhZgkZY [dg XdbeaZm XVhZh ^c l]^X] XdckZci^dcVa iZX]c^fjZh VgZ cdi edhh^WaZ#
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Tissue Surgery
a
b
c Figure 4-10. Flexor tendon unit allotransplantation program. a) A monoflexor superficialis allotransplant after tourniquet release. b) A bi flexor superficialis and profundus allotransplant after milking and washing, to be placed in a sterile refrigerated container. c) Layout of the allotransplant before inserting. d) Insertion and anastomoses. (A.D.F. Video-Productions with special permission)
d
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5 Innovations in Peripheral Nerve Surgery Christopher T. Maloney, Jr. and A. Lee Dellon
Introduction 6cn iVa` d[ ^ccdkVi^dc ^c eZg^e]ZgVa cZgkZ hjg\Zgn egZhjeedhZh i]Z Zm^hiZcXZ d[ V heZX^Va" ^oZY VgZV d[ hjg\Zgn gZaViZY id i]Z eZg^e]ZgVa cZgkZh# L^i] i]Z [djcY^c\ d[ i]Z 6bZg^XVc HdX^Zin [dg EZg^e]ZgVa CZgkZ ^c &..%! VcY ^ih VccjVa bZZi^c\h WZ^c\ ]ZaY ^c Xdc_jcXi^dc l^i] i]Z 6bZg^XVc 6hhdX^Vi^dc d[ =VcY Hjg\Zgn VcY i]Z 6bZg^XVc HdX^Zin d[ GZXdchigjXi^kZ B^Xgd" hjg\Zgn! i]Z ÑZaY d[ eZg^e]ZgVa cZgkZ hjg\Zgn ^h XaZVgan cdl VXXZeiZY Vh V heZX^Va^oZY ÑZaY d[ hjg\Zgn! l^i] ^ih dlc WdYn d[ `cdlaZY\Z# >i ]Vh WZZc hj\\ZhiZY i]Vi ?VbZh AZVgbdci]! B9! V cZjgdhjg\Zdc [gdb HXdiaVcY! h]djaY WZ Xdch^YZgZY Vh i]Z e^dcZZg! ^[ cdi i]Z Ñghi! eZg^e]" ZgVa cZgkZ hjg\Zdc#& >[ i]Vi hj\\Zhi^dc ^h VXXZeiZY! i]Zc Å^ccdkVi^dcÆ ^c eZg^e]ZgVa cZgkZ hjg\Zgn ldjaY WZ gZaViZY id i]Z XdcXZeih AZVgbdci] ^cigdYjXZY# 6bdc\ i]ZhZ ldjaY WZ i]Z YZhXg^e" i^dc d[ hjg\^XVa iZX]c^fjZh! hjX] Vh YZXdbegZhh" ^c\ i]Z eZg^e]ZgVa cZgkZh! i]Z bZY^Vc cZgkZ XdbegZhh^dc Vi i]Z lg^hi!' VcY i]Z hjWbjhXjaVg igVchedh^i^dc d[ i]Z jacVg cZgkZ [dg XdbegZhh^dc d[ i]Z jacVg cZgkZ ^c i]Z XjW^iVa ijccZa#( AZVg" bdci] Vahd YZhXg^WZY kVg^Vi^dch ^c eZg^e]ZgVa cZgkZh!) i]Z [jcXi^dc d[ eZg^e]ZgVa cZgkZh! a^`Z i]Z hnbeVi]Zi^X cZgkZh!* VcY i]Z ^YZV i]Vi V eZg^e]ZgVa cZgkZ XdjaY WZ gZhZXiZY id igZVi eV^c#+ >c a^cZ l^i] i]ZhZ XdcXZeih! i]Zc! Å^ccdkVi^dcÆ l^aa WZ Xdch^YZgZY Vh ^YZVh i]Vi aZVY id cZl hjg" \^XVa egdXZYjgZh gZaViZY id i]Z eZg^e]ZgVa cZgkZ! l]Zi]Zg i]ZhZ cZl egdXZYjgZh Wj^aY dc ZVga^Zg YZhXg^ei^dch d[ cZjgdVcVidbn dg dc ZVga^Zg egd" XZYjgZh i]Vi ]VkZ WZZc eaVXZY cdl dc V Ñgb Zk^YZcXZ WVhZ# Å>ccdkVi^dcÆ Vahd ^bea^Zh ÅcZl!Æ VcY [dg i]Z ejgedhZh d[ i]^h X]VeiZg! i]Z i^bZ"a^cZ l^aa WZ l^i]^c i]Z aVhi * nZVgh# I]Z XdcXZeih i]Vi Ñi ^cid i]^h YZÑc^i^dc VgZ & igZVi^c\ i]Z hnbeidbh d[
cZjgdeVi]n Wn YZXdbegZhh^c\ eZg^e]ZgVa cZgkZh! ' igZVi^c\ adc\ cZgkZ \gV[ih l^i] Vc Vaad\gV[i! ( igZVi^c\ h]dgi cZgkZ \Veh l^i] V XdcYj^i! VcY ) eVgi^Va _d^ci YZcZgkVi^dc [dg gZa^Zk^c\ eV^c! Zbe]Vh^o^c\ i]Z `cZZ! Vc`aZ! VcY h]djaYZg#
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55
56
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Table 5-1. Results of Studies Treating Diabetic Neuropathy with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 1992, Dellon12 31 32 85 72 1995, Wieman13 33 26 92 72 2000, Caffee14 58 36 86 50 2000, Aszmann15 16 12 NA 69 16 2001, Tambwekr 10 10 80 70 2003, Wood17 33 33 90 70 2004, Biddinger18 15 22 86 80 2004, Valdivia19 60 60 85 85 29 2004, Lee 46 46 92 92 2005, Steck32 25 25 84 72 49 49 90 72 2005, Rader89 Total 376 351 88 78 NA not available
Tissue Surgery
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Innovations in Peripheral Nerve Surgery
Figure 5-1. Decompression of the four medial ankle tunnels. a) The medial ankle region contains the tibial nerve, which passes through four discreet anatomical tunnels, each of which must be decompressed. The tarsal tunnel itself is opened by dividing the flexor retinaculum to expose the tibial vessels and the tibial nerve. In this region, high origins of the calcaneal nerve are identified, and a high division of the tibial nerve is identified, if present. In this region, the tibial nerve is neurolyzed internally, if needed, and sympathetic innervation of the tibial artery can be disrupted. b) The abductor hallucis brevis muscle is retracted (not divided) after incising its superficial fascia. In 50% of patients, a
57
small branch from the medial plantar nerve innervating the skin of the heel-arch region is present and is preserved. When the muscle is retracted, the thick fascia providing the roof of the medial and lateral plantar tunnels is identified. c) The roof of the medial plantar tunnel has been incised, and the roof of the lateral plantar tunnel is being incised. d) The septum between the two tunnels has been cauterized and is being incised to permit the removal of this “T” shaped structure, releasing the medial and lateral plantar nerves into the plantar aspect (porta pedis) of the foot. e) The incised calcaneal tunnel is shown, and the “T” structure is being removed.
58 Table 5-2. Results of Studies Treating Neuropathy of Unknown Cause with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 2004, Valdivia19 40 40 90 80 2004, Lee21 40 40 80 80 2005, Steck32 26 26 88 68 Total 106 106 85 72
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Tissue Surgery
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Nerve Reconstruction Ild ^ccdkVi^dch ^c i]Z igZVibZci d[ i]Z cZgkZ \Ve ]VkZ cdl WZZc ^cigdYjXZY ^cid Xa^c^XVa egVX" i^XZ# DcZ ^h gZaViZY id igZVi^c\ eVi^Zcih [dg l]db V aVg\Z cZgkZ \gV[i ^h cZZYZY VcY [dg l]db i]^h aZc\i] d[ \gV[i b^\]i cdi WZ gZVY^an VkV^aVWaZ# I]^h egdWaZb ]Vh WZZc gZhdakZY Wn cZgkZ Vaad" \gV[i^c\# I]Z hZXdcY ^ccdkVi^dc ^h i]Z jhZ d[ V cZgkZ XdcYj^i id XdccZXi cZgkZ \Veh gVc\^c\ [gdb i]dhZ hj^iVWaZ [dg igVY^i^dcVa cZgkZ gZeV^g id \Veh d[ je id ( Xb#
Nerve Allografts JcYZg i]Z aZVYZgh]^e d[ HjhVc :# BVX`^ccdc! B9! ild YZXVYZh d[ WVh^X hX^ZcXZ gZhZVgX] ]VkZ ZhiVWa^h]ZY i]Vi & i]Z HX]lVcc XZaah d[ Vc Vaad\gV[i VgZ gZ_ZXiZY! ' i]Z ]dhi Vmdch gZ\Zc" ZgViZ VXgdhh i]Z WVhZbZci d[ i]Z Vaad\gV[i! ( i]Z ]dhi HX]lVcc XZaah gZedejaViZ i]Z gZXdchigjXiZY hZ\bZci V[iZg gZ_ZXi^dc d[ i]Z Ydcdg HX]lVcc XZaah! ) ^bbjcdhjeegZhh^dc XVc WZ Y^hXdci^c" jZY VcY cZgkZ [jcXi^dc egZhZgkZY V[iZg [jcXi^dc ]Vh WZZc gZhidgZY! VcY * ^bbjcdhjeegZhh^dc XVc WZ VX]^ZkZY l^i] V gZ\^bZc aZhh hjeegZhh^kZ id i]Z ]dhi i]Vc i]Vi gZfj^gZY [dg `^YcZn dg ]ZVgi"ajc\ dg ]VcY igVcheaVciVi^dc# 8jggZci gZ\^bZch VgZ d[iZc WVhZY dc iVXgda^bjh ;@*%+ VcY WVh^a^m^bVW! VcY V hZXi^dc d[ cZgkZ ^h eaVXZY hjWXjiVcZdjhan id YZiZXi gZ_ZXi^dc# I]Z Ñghi Xa^c^XVa cZgkZ Vaad\gV[i lVh gZedgiZY Wn BVX`^ccdc VcY =jYhdc ^c &..'! [dg V X]^aY l^i] V hX^Vi^X cZgkZ ^c_jgn#(* I]Vi Ñghi eVi^Zci! Vc -"nZVg"daY Wdn! lVh ^c_jgZY ^c &.-- VcY gZfj^gZY V Å&%"XVWaZ! '( XbÆ gZXdchigjXi^dc# I]Z Ñghi hZg^Zh d[ cZgkZ Vaad\gV[ih! Xdch^hi^c\ d[ , eVi^Zcih! lVh gZedgiZY ^c '%%&#(+ I]^h hZg^Zh ^cXajYZY eVi^Zcih l^i] Vaad\gV[ih id i]Z Vgbh VcY aZ\h# >c Vaa eVi^Zcih! i]Z cZgkZ \Veh VcY i]Z ^ciZgedhZY \gV[ih gZfj^gZY Xdchi^ijiZY V idiVa aZc\i] d[ cZgkZ i]Vi XdjaY cdi WZ gZXdchigjXiZY [gdb VkV^aVWaZ ]dhi hdjgXZh# 8VYVkZg^X Vaad\gV[ih lZgZ ]VgkZhiZY VcY egZhZgkZY [dg , YVnh ^c Jc^kZgh^in d[ L^hXdch^c 8daY HidgV\Z Hdaji^dc Vi *8# >c i]Z ^ciZg^b! eVi^Zcih lZgZ hiVgiZY dc Vc ^bbjcd" hjeegZhh^kZ gZ\^bZc d[ Z^i]Zg XnXadhedg^c 6 dg ;@*%+! VoVi]^deg^cZ! VcY egZYc^hdcZ# DcXZ
Innovations in Peripheral Nerve Surgery
hZchdgn dg bdidg [jcXi^dc lVh VX]^ZkZY [dg + bdci]h! ^bbjcdhjeegZhh^dc lVh hideeZY# L^i] i]^h VeegdVX]! + d[ i]Z , eVi^Zcih gZXdkZgZY hdbZ YZ\gZZ d[ [jcXi^dc! VcY i]Z dcZ [V^ajgZ lVh Viig^WjiZY id V ÅhjW"i]ZgVeZji^XÆ ^bbjcdhje" egZhh^kZ gZ\^bZc# I]^h WVh^X hX^ZcXZ VcY Xa^c^XVa gZhZVgX] ]Vh WZZc YdcZ eg^bVg^an ^c jc^kZgh^in ]dhe^iVah#=dl" ZkZg! i]Z gZXZci ZmeZg^ZcXZ d[ B^X]VZa GdhZ! B9! VcY 6cYn :a`lddY! B9! eaVhi^X hjg\Zdch ^c eg^kViZ egVXi^XZ ^c hdji]Zgc CZl ?ZghZn! ^h gZaZ" kVci# 6h d[ ?VcjVgn '%%*! i]Zn ]VY XdbeaZiZY ÑkZ hjXXZhh[ja cZgkZ Vaad\gV[ih ;^\jgZ *"' #(, I]gZZ d[ i]Z^g * eVi^Zcih gZXZ^kZY cZgkZ igVch" eaVcih [gdb a^k^c\"gZaViZY Ydcdgh# I]Zn gZXZ^kZY i]Z hVbZ gZ\^bZc Vh i]Z jcgZaViZY Ydcdgh# BVX`^ccdcÈh \gdje Xdci^cjZh id hZVgX] [dg lVnh id b^c^b^oZ i]Z Vbdjci d[ ^bbjcdhje" egZhh^dc cZXZhhVgn ^c cZgkZ Vaad\gV[i^c\# I]Zn ]VkZ YZhXg^WZY jh^c\ Vci^WdY^Zh id VY]Zh^dc bdaZXjaZh! bdY^ÑXVi^dch d[ i]Z^g XdaY egZhZg" kVi^dc iZX]c^fjZ! VcY gVY^Vi^dc#(-Ã)% >c i^bZ! ^bbjcdhjeegZhh^kZ gZ\^bZch i]Vi VgZ ZkZc aZhh Y^[ÑXjai [dg i]Z eVi^Zci l^aa WZ ^cigdYjXZY! VcY eVi^Zcih gZfj^g^c\ ZmiZch^kZ Vbdjcih d[ eZg^e]" ZgVa cZgkZ l^aa ]VkZ i]Z^g YZ[ZXih gZXdchigjXiZY l^i] cZgkZ Vaad\gV[ih# 6ai]dj\] eZg]Veh [ZlZg i]Vc V YdoZc Xa^c^XVa cZgkZ Vaad\gV[ih ]VkZ WZZc eZg[dgbZY ^c i]Z eVhi &+ nZVgh! i]^h cjbWZg l^aa ^cXgZVhZ Vh di]Zg eZg^e]ZgVa cZgkZ XZciZgh VgZ VeegdkZY id jhZ i]^h VeegdVX] id cZgkZ gZXdchigjXi^dc#
Figure 5-2. Use of nerve allograft to reconstruct a peripheral nerve defect. The pale segment of nerve in the center is the allograft, sutured to the recipient’s common peroneal nerve to the right, with connection to the sciatic nerve’s common peroneal nerve component to the left. The patient recovered foot dorsiflexion and sensation to the dorsum of the foot. (Courtesy of Michael Rose, MD, and Andrew Elkwood, MD, Short Hills, New Jersey)
59
Nerve Conduits BdgZ i]Vc ild YZXVYZh ]VkZ eVhhZY h^cXZ ZmeZg" ^bZciVa bdYZah d[ cZjgVa gZ\ZcZgVi^dc! jh^c\ kVg^djh bViZg^Vah [dg cZgkZ XdcYj^ih! lZgZ Ñghi jhZY id bZVhjgZ cZjgdigde]^X hjWhiVcXZh VcY id ^cigdYjXZ hjWhiVcXZh gZaViZY id i]Z cZgkZ gZ\Zc" ZgVi^dc egdXZhh#)& 6ai]dj\] h^a^XdcZ X]VbWZgh lZgZ Vbdc\ i]Z ZVga^Zhi XdcYj^ih jhZY ZmeZg^" bZciVaan! cZgkZh Yd cdi gZ\ZcZgViZ bdgZ i]Vc &% bb ^c i]Zb! eg^bVg^an WZXVjhZ i]Zn VgZ cdc" edgdjh# ;jgi]ZgbdgZ! h^a^XdcZ VgdjcY V cZgkZ ^h dcZ bdYZa d[ X]gdc^X cZgkZ XdbegZhh^dc#)' CZgkZ gZ\ZcZgVi^dc i]gdj\] V gZ\^dc d[ Xdb" egZhh^dc ^c Vc Vc^bVa bdYZa YdZh dXXjg! Wji i]Zc i]Z cZgkZ [V^ah! V\V^c WZXVjhZ d[ X]gdc^X XdbegZhh^dc#)( H^a^XdcZ ]Vh WZZc jhZY [dg bVcn nZVgh id Xdc" cZXi cZgkZh i]Vi ldjaY di]Zgl^hZ ]VkZ jcYZg" \dcZ eg^bVgn gZeV^g! Wji ZkZc i]Z bdhi gZXZci gZedgi d[ i]^h VeegdVX]! ^c '%%)! YZhXg^WZh i]Z cZXZhh^in d[ gZbdk^c\ i]Z h^a^XdcZ [gdb eVi^Zcih Vh V gZhjai d[ adc\"iZgb egdWaZbh l^i] hnbe" idbh d[ XdbegZhh^dc dg eV^c#)) I]Z Ñghi ZkZg gVcYdb^oZY bjai^XZciZg! Wa^cYZY hijYn d[ V cZgkZ XdcYj^i [dg gZXdchigjXi^c\ V hZchdgn cZgkZ YZ[ZXi ^c i]Z ]VcY lVh gZedgiZY ^c '%%% Wn LZWZg Zi Va#)* I]Z XdcYj^i lVh V edgdjh! edan\anXda^X VX^Y E<6 W^dVWhdgWVWaZ XdcYj^i i]Vi ^h gZbdkZY Wn ]nYgdanh^h! XVaaZY i]Z CZjgdijWZ [dgbZgan Y^hig^WjiZY Wn CZjgdZ\Zc! VcY! Vh d[ 9ZXZbWZg d[ '%%)! Wn Hncdk^h B^XgdhnhiZbh # 9Zaadc VcY BVX`^ccdc Ñghi gZedgiZY i]Z gZhjaih d[ cZjgVa gZ\ZcZgVi^dc i]gdj\] i]^h ijWZ# I]Z gZhjaih lZgZ Zfj^kVaZci id i]dhZ dWiV^cZY l^i] hiVcYVgY ^ciZgedh^i^dc ^ciZg[VhX^XjaVg hjgVa cZgkZ \gV[ih ^c V cdc]jbVc eg^bViZ id gZeV^g V ("Xb jacVg cZgkZ YZ[ZXi Vi i]Z ZaWdl l^i] gZXdkZgn d[ ^cig^ch^X bdidg [jcXi^dc Vi dcZ nZVg #)+ I]^h &.-- gZedgi lVh [daadlZY Wn i]Z Ñghi Xa^c^XVa gZedgi d[ XdcYj^i ^c i]Z hZchdgn cZgkZh ^c i]Z ]jbVc ]VcY#), I]Z bVm^bjb \Ve [dg Xa^c^XVa jhZ lVh ZhiVWa^h]ZY Vi ( Xb Wn YZbdc" higVi^c\ ^c cdc]jbVc eg^bViZh i]Vi cZjgVa gZ\ZcZgVi^dc Vi V \gZViZg Y^hiVcXZ lVh cdi hjXXZhh[ja#)I]Z CZjgdijWZ ]Vh WZZc hjXXZhh[ja ^c igZVi^c\ hZchdgn dg b^mZY cZgkZh ^c i]Z Vgbh VcY aZ\h! Vh lZaa Vh ^c XgVc^Va cZgkZh K!K>>! VcY M> ^c ]jbVch IVWaZ *"( # I]Z gZhjaih d[ V gVcYdb^oZY hijYn! Wn LZWZg Zi Va! lZgZ i]Vi i]Z CZjgdijWZ gZhjaiZY ^c hiVi^hi^XVaan h^\c^ÑXVci WZiiZg gZXdkZgn d[ hZc" hVi^dc [dg cZgkZ \Veh aZhh i]Vc ) bb VcY \gZViZg
60
Tissue Surgery
Table 5-3. Reports of Clinical Applications of the Neurotube Peripheral Nerve Reconstructed Report Sensory Nerve: Arm Digital and Median at the Wrist47 Digital45 Digital49 Sensory Nerve: Foot50 Cranial Nerves: Sensory V (inferior alveoloar)51 Cranail Nerve: Motor VII (facial)52 XI (spinal accessory)53
Date of 1990 2000 2003 2001 1992 2005 2005
i]Vc - bb! ^cY^XVi^c\ i]Vi i]Z CZjgdijWZ h]djaY WZ i]Z XdcYj^i d[ X]d^XZ [dg Z^i]Zg V eg^bVgn gZeV^g dg V cZgkZ \Ve gZXdchigjXi^dc d[ aZhh i]Vc (% bb#)* I]Z CZjgdijWZ ]Vh WZZc jhZY l^i]
Figure 5-3. Reconstruction of the neuroma-in-continuity of the median nerve in the forearm of a 37-year-old man. Previous primary repair was unsuccessful. a) Resection of the neuroma showing the 3-cm gap in the median nerve. The tourniquet is inflated. b) Interfascicular reconstruction of the defect with four, 2.3-mm-diameter Neurotubes, each 4 cm long.
Figure 5-4. Reconstruction of the median and ulnar nerve at the level of the brachium 18 months ago in a 51-year-old man. Note the recovered bulk of the forearm muscles. Electromyographic evidence of reinnervation of the flexor carpi radialis, flexor profundus, flexor superficialis, pronator, and flexor carpi ulnaris was obtained. Sensation was recovered in the fingertips with two-point discrimination and good localization 24 months after the Neurotube reconstruction. Two tubes were placed for the ulnar nerve and three for the median nerve. (Courtesy of A. L. Dellon, MD.)
bjai^eaZ XdcYj^ih! ^chiZVY d[ bjai^eaZ hjgVa cZgkZ \gV[ih! id gZXdchigjXi i]Z bZY^Vc cZgkZ Vi i]Z lg^hi ;^\jgZ *"( ! VcY id gZXdchigjXi i]Z bZY^Vc VcY jacVg cZgkZ ^c i]Z WgVX]^jb d[ i]Z [dgZVgb ^c V *&"nZVg"daY bVc ;^\jgZ *") # I]Z ;ddY VcY 9gj\ 6Yb^c^higVi^dc VeegdkZY i]Z CZjgdijWZ [dg Xa^c^XVa jhZ ^c &..,# 6[iZg i]Vi VeegdkVa! di]Zg XdcYj^ih XdjaY WZ jhZY l^i]dji i]Z cZZY [dg gVcYdb^oZY XdcigdaaZY hijY^Zh ^c ]jbVch# 6c ZmVbeaZ d[ dcZ hjX] ijWZ ^h i]Z CZjgVciZ\gV A^[ZHX^ZcXZh VcY cdi id WZ Xdc[jhZY l^i] i]Z CZjgdijWZ! l]^X] ^h bVYZ d[ E<6! Vb^cd VX^Y! VcY hj\Vg bdaZXjaZh! VcY cdi V [dgZ^\c egdiZ^c # Cd Xa^c^XVa ig^Vah d[ i]^h XdaaV\Zc ijWZ ]VkZ nZi WZZc ejWa^h]ZY# 6 hZg^Zh d[ . eVi^Zcih lVh YZhXg^WZY Vi i]Z '%%* bZZi^c\ d[ i]Z 6bZg^XVc HdX^Zin [dg EZg^e]ZgVa CZgkZ Hjg\Zgn#*) I]Z Xda" aV\Zc ^h Wdk^cZ! VcY Vh hjX] XVgg^Zh i]Z g^h` d[ Vc ^c VbbVidgn dg ^bbjcdad\^XVa gZVXi^dc! ^c XdcigVhi id i]Z E<6 ijWZ! l]^X] ^h ]nYgdanoZY# >c i]^h hZg^Zh d[ eVi^Zcih l]d gZXZ^kZY i]Z Xda" aV\Zc ijWZ i]Z h^oZ d[ i]Z cZgkZ \Ve ^h cdi \^kZc ! i]Z gZXdkZgn d[ hZchVi^dc lVh YZhXg^WZY Vh ÅVi aZVhi egdiZXi^kZ! l^i] i]Z bZVc hiVi^X '"ed^ci Y^hXg^b^cVi^dc WZ^c\ . bb#Æ I]^h VkZgV\Z gZhjai ^h bjX] ^c[Zg^dg id i]Vi dWiV^cZY l^i] i]Z CZjgdijWZ! l]ZgZ i]Z bZVc hiVi^X '"ed^ci Y^hXg^b^cVi^dc lVh (#, bb [dg YZ[ZXih aZhh i]Vc ) bb VcY +#- bb [dg YZ[ZXih \gZViZg i]Vc - bb#)* 6cdi]Zg ijWZ VkV^aVWaZ cdl ^c i]Z JH ^h bVYZ d[ edan 9A"aVXi^YZ"Z"XVegdaVXidcZ 9jgdaVX0
Innovations in Peripheral Nerve Surgery
61
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Partial Joint Denervation EVgi^Va _d^ci YZcZgkVi^dc ^h i]Z XdcXZei d[ egZ" hZgk^c\ _d^ci [jcXi^dc VcY gZa^Zk^c\ _d^ci eV^c Wn ^ciZggjei^c\ i]Z cZjgVa eVi]lVn i]Vi igVchb^ih i]Z eV^c bZhhV\Z [gdb i]Z _d^ci id i]Z WgV^c# IgVY^i^dcVa VeegdVX]Zh id igZVi^c\ _d^ci eV^c gZan dc bjhXjadh`ZaZiVa VeegdVX]Zh id i]Z _d^ci ^ihZa[ VcY d[iZc gZfj^gZ _d^ci [jh^dc dg idiVa gZeaVXZ"
bZci Vgi]gdeaVhin# I]Z XdcXZei d[ eVgi^Va _d^ci YZcZgkVi^dc d[[Zgh i]Z eVi^Zci Vc djieVi^Zci! VbWjaVidgn deZgVi^kZ VeegdVX] i]Vi ^h _d^c Ä heVg^c\ VcY gZ]VW^a^iVi^dc"[gZZ# :hiVWa^h]^c\ i]Z kVa^Y^in d[ eVgi^Va _d^ci YZcZgkVi^dc gZfj^gZh & ^YZci^[n^c\ i]Z ^ccZgkVi^dc d[ i]Z heZX^ÑX _d^ci i]gdj\] Y^hhZXi^dc WZXVjhZ i]^h ^c[dgbVi^dc ^h cdi XdciV^cZY ^c VcVidbn iZmih! ' YZÑc^c\ V gdjiZ id VYb^c^hiZg adXVa VcZhi]Zi^X WVhZY dc i]^h cZl VcVidb^X `cdlaZY\Z! ( YZbdchigVi^c\ i]Vi adXVa VcZhi]Zi^Xh l^aa gZa^ZkZ eV^c ^c eVi^Zcih ^c l]db i]Z bjhXjadh`ZaZiVa VeegdVX] ]Vh [V^aZY! ) eaVcc^c\ V hjg\^XVa VeegdVX] id gZhZXi i]Z cZgkZ VcY ^ciZggjei^c\ i]Z eV^c eVi]lVn! VcY * YdXjbZci^c\ i]Z hjXXZhh d[ i]^h VeegdVX] l^i] Vc Veegdeg^ViZ eVi^Zci edejaVi^dc# I]^h egdXZhh bjhi WZ gZeZViZY [dg ZVX] Y^[[ZgZci _d^ci# EVgi^Va _d^ci YZcZgkVi^dc lVh ^cigdYjXZY Wn 9Zaadc ^c V &.,- YZhXg^ei^dc d[ i]Z ^ccZgkVi^dc d[ i]Z YdghVa lg^hi XVehjaZ Wn i]Z edhiZg^dg ^ciZg" dhhZdjh cZgkZ*+ VcY ^c ]^h YZhXg^ei^dc d[ i]Z igZVibZci d[ eV^c gZaViZY id ^c_jgn id i]Vi cZgkZ ^c &.-*#*, I]Z ^ccZgkVi^dc d[ i]Z VciZg^dg lg^hi _d^ci lVh YZhXg^WZY ^c &.-)! VcY eVgi^Va kdaVg lg^hi YZcZgkVi^dc lVh i]Zc edhh^WaZ#*7Z[dgZ i]^h VeegdVX]! idiVa lg^hi YZcZgkVi^dc ]VY WZZc YZhXg^WZY VcY egVXi^XZY ^c :jgdeZ Wji gZfj^gZY ) ^cX^h^dch VcY gZbdkVa d[ &% Y^[[ZgZci cZgkZ WgVcX]Zh#*.!+% I]Z ZmiZch^dc d[ i]Z XdcXZei d[ eVgi^Va _d^ci YZcZgkVi^dc lVh i]Zc ZmiZcYZY Wn 9Zaadc id i]Z `cZZ _d^ci#+&Ã+( I]gdj\] '%%%! i]Z gZedgiZY gZhjaih [dg ()) eVi^Zcih igZViZY l^i] eVgi^Va `cZZ YZcZgkVi^dc IVWaZ *") VgZ i]Vi .% gZhedcYZY id V adXVa VcZhi]Zi^X WadX` l^i] ^cXgZVhZY VbWjaVi^dc! hiV^g Xa^bW^c\! `cZZa^c\! VcY gZYjXZY eV^c ^begdkZbZci d[ Vi aZVhi * bb dc V k^hjVa VcVad\ hXVaZ [dg eV^c #+. 8VjhZh [dg aZhh"i]Vc"\ddY gZhjaih lZgZ gZaViZY id
Table 5-4. Partial Joint Denervation: Relationship of Joint to its Innervation Painful Anatomic Site Wrist, Dorsal Wrist, Volar Knee Sinus Tarsi Shoulder, Anterior Elbow, Lateral Epicondyle Elbow, Medial Epicondyle Temporomandibular Joint
Nerve Innervating Site Posterior interosseous, 197856 anterior interosseous, 198458 medial & lateral retinacular, 199461 deep peroneal nerve, 200164 lateral thoracic, 199566 Posterior brachial cutaneous nerve, 196283 br. to medial epicondyle, 200485 auriculotemporal & br. of masseteric, 200368
Denervation Described Dellon, 198557 Dellon, 198458 Dellon, 199562 Dellon, 200265 Dellon, 200367 DeJesus, 200484 Dellon, 200486 Dellon, 200580
62
Tissue Surgery
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b
a
c Figure 5-5. The anterolateral ankle has a space described as the sinus tarsi that is illustrated in a) and b). In a), the deep peroneal nerve is shown innervating the extensor brevis muscle, and in b), the sinus tarsi is identified by the black arrow. In c), the deep peroneal nerve is shown innervating the sinus tarsi proximal to its
d innervating the brevis. Its terminal branch to the dorsal first webspace is also shown. In d), the deep peroneal nerve is resected through an approach in the lateral leg, to denervate the sinus tarsi.
Innovations in Peripheral Nerve Surgery
dg Y^hadXVi^dc! Wji ^i ^h ValVnh VhhdX^ViZY l^i] V iZVg d[ i]Z a^\VbZcih id i]Z _d^cih ^c i]^h heVXZ# L]Zc igVY^i^dcVa cdc"deZgVi^kZ igZVibZci [dg h^cjh iVgh^ hncYgdbZ [V^ah! VcY eV^c WZXdbZh gZXVaX^igVci! hjg\^XVa dei^dch jhjVaan ^ckdakZY ZkVXjVi^c\ i]Z XdciZcih d[ i]Z h^cjh iVgh^ hdbZi^bZh gZ[ZggZY id Vh V ÅXaZVc djiÆ ! V hjWiVaVg _d^ci Vgi]gdYZh^h! dg V hjWiVaVg _d^ci Vgi]gdhXden#,&Ã,( I]Z ^ccZgkVi^dc d[ i]Z h^cjh iVgh^ lVh YZhXg^WZY ^c '%%& Vh WZ^c\ [gdb i]Z YZZe eZgd" cZVa cZgkZ! l^i] i]Z WgVcX] Zh Vg^h^c\ _jhi egdm" ^bVa id i]Z Vc`aZ ^c &%% d[ eZdeaZ ;^\jgZ *"*X ! VcY l^i] VYY^i^dcVa ^ccZgkVi^dc Xdb^c\ [gdb i]Z hjgVa cZgkZ ^c VWdji '% d[ eZdeaZ#+) I]Z ZkVajVi^dc d[ i]ZhZ eVi^Zcih gZfj^gZh egZk^djh [ddi VcY Vc`aZ XdchjaiVi^dc id WZ hjgZ i]Vi Vaa bjhXjadh`ZaZiVa hdjgXZh d[ eV^c ]VkZ WZZc igZViZY VcY i]Vi i]Z Vc`aZ ^h higdc\# I]^h ZkVaj" Vi^dc ^cXajYZh WZ^c\ hjgZ i]Vi i]ZgZ VgZ cd WdcZ [gV\bZcih ^c i]Z hjWiVaVg _d^ci# ;^ghi! cZgkZ WadX`h l^i] adXVa VcZhi]Zi^X bjhi WZ YdcZ [dg i]Z YZZe eZgdcZVa cZgkZ egdm^bVa id i]Z Vc`aZ! VcY i]Zc! ^[ i]ZgZ ^h hi^aa eV^c l^i] VbWjaVi^dc! i]Z hjgVa cZgkZ h]djaY WZ WadX`ZY# 6ai]dj\] i]Z Ñghi eVi^Zci gZedgiZY ZmXZaaZci eV^c gZa^Z[ V[iZg eVgi^Va gZhZXi^dc d[ i]Z YZZe eZgdcZVa cZgkZ _jhi VWdkZ i]Z Vc`aZ! l]^X] egZhZgkZY [jcXi^dc ^c i]Z ZmiZchdg WgZk^h bjhXaZ VcY i]Z Y^hiVa YdghVa [ddi h`^c!+* ^c V aVg\Zg hZg^Zh! hdbZ eVi^Zcih Y^Y cdi ZmeZg^ZcXZ gZa^Z[# I]Z XjggZci gZXdbbZcYV" i^dc ^h id gZhZXi i]Z Zci^gZ YZZe eZgdcZVa cZgkZ i]gdj\] i]Z VciZgdaViZgVa adlZg aZ\ ;^\jgZ
Figure 5-6. Characteristics of recovery from different surgeries for sinus tarsi syndrome.
63
Figure 5-7. Innervation of the anterior shoulder capsule from a branch of the lateral pectoral nerve (arrow). Because this nerve crosses the coracoid, it is the site for a nerve block.
*"*Y !,) Vh YZhXg^WZY [dg i]Z igZVibZci d[ YdghVa [ddi cZjgdbVh#,* GZhjaih dWiV^cZY l^i] eVgi^Va gZhZXi^dc d[ i]Z YZZe eZgdcZVa cZgkZ lZgZ ZmXZa" aZci ^c ) eVi^Zcih! \ddY ^c '! VcY eddg ^c &! ^c XdcigVhi id i]Z gZhjaih d[ igVY^i^dcVa i]ZgVen! l]^X] lZgZ ZmXZaaZci ^c + VcY eddg ^c & ;^\jgZ *"+ #,) I]Z dcZ [V^ajgZ ^c i]^h aVhi \gdje d[ eVi^Zcih ^ckdakZY V XdbeaZm gZ\^dcVa eV^c hncYgdbZ# 6ciZg^dg h]djaYZg eV^c ^h i]Z bdhi Xdbbdc hnbeidb d[ [V^aZY dgi]deZY^X VeegdVX]Zh id igZVi^c\ ^be^c\ZbZci hncYgdbZ VcY gdiVidg Xj[[ iZVgh# H]djaYZg eV^c a^b^ih bdkZbZci d[ i]Z h]djaYZg! i]Z VW^a^in id eZg[dgb VXi^k^i^Zh d[ YV^an a^k^c\! VcY bVcn ldg` VXi^k^i^Zh! ^c eVgi^XjaVg ldg` gZfj^g^c\ i]Z dkZg]ZVY jhZ d[ i]Z ]VcY# DkZg i]Z eVhi '* nZVgh! deZc dg Vgi]gdhXde^X VeegdVX]Zh id XdggZXi h]djaYZg eV^c ]Vh aZ[i VWdji '% d[ eVi^Zcih l^i] VciZg^dg h]djaYZg eV^c#,+Ã,. >c &.+,! V YZhXg^ei^dc d[ i]Z ^ccZgkVi^dc d[ i]Z VciZg^dg h]djaYZg XVehjaZ [gdb V WgVcX] d[ i]Z aViZgVa i]dgVX^X cZgkZ ;^\jgZ *", +, hj\\ZhiZY i]Vi i]^h cZgkZ XdjaY WZ WadX`ZY Wn adXVa VcZhi]Zi^X ^c_ZXi^dc dc i]Z hjg[VXZ d[ i]Z XdgVXd^Y ;^\jgZh *"-V VcY *"-W # 7Z[dgZ i]Z WadX`! i]Z eVi^ZciÈh eV^c ^h bZVhjgZY l^i] V k^hjVa VcVad\ hXVaZ! VcY i]Z gVc\Z d[ eV^caZhh h]djaYZg bdi^dc ^h ^YZci^ÑZY# I]Z cZgkZ ^h i]Zc WadX`ZY! iV`^c\ XVgZ cdi id ^c_ZXi idd YZZean id i]Z XdgV" Xd^Y! id egZkZci WadX`^c\ i]Z WgVX]^Va eaZmjh VcY ^c_jg^c\ i]Z ajc\#>[ i]Z WadX` ^h hjXXZhh[ja!l^i]^c &% b^cjiZh i]Z eVi^ZciÈh eV^c l^aa Y^b^c^h] VcY gVc\Z d[ bdi^dc d[ i]Z h]djaYZg l^aa ^begdkZ ;^\jgZh *"-X VcY *"-Y #
64
Tissue Surgery
a
b
c
d
Figure 5-8. Technique for nerve block of the anterior shoulder capsule. a) Identifying the coracoid as a site of pain and b) doing the nerve block. c) The site before surgery and d) after a successful block, establishing that this nerve was the source of shoulder pain.
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Innovations in Peripheral Nerve Surgery
Figure 5-9. Intra-operative view of a nerve to the anterior shoulder capsule. a) The incision on the right shoulder of a patient who had a previous open-shoulder surgery. b) A nerve to the anterior shoulder capsule adjacent to vessels.
VgZ ^cheZXiZY! VcY Vcn cZgkZ l^i]^c i]^h i^hhjZ ^h ZmX^hZY! d[iZc gZfj^g^c\ ZmX^h^dc d[ dcZ d[ i]Z kZ^ch Vh lZaa ;^\jgZ *".W # I]Zc! i]Z XdgVXd^Y ^h VeegdVX]ZY! VcY i]Z dg^\^c d[ i]Z W^XZeh VcY XdgVXdWgVX]^Va^h ^cheZXiZY# 6 hZXdcY WgVcX] d[ i]Z cZgkZ bVn WZ egZhZci Vi i]^h aZkZa! bZVhjg^c\ aZhh i]Vc &#% bb# 6 '"Xb hZ\bZci ^h gZhZXiZY# BVgXV^cZ ^h eaVXZY ^cid i]^h VgZV# >[ i]ZgZ ^h Vcn fjZhi^dc VWdji i]Z cZgkZ WZ^c\ V bdidg WgVcX] id i]Z eZXidgVa^h! ^cigV"deZgVi^kZ hi^bjaVi^dc ^h jhZY# I]Z cZgkZ ine^XVaan XVc WZ igVXZY Y^gZXian id i]Z h]djaYZg XVehjaZ! Wji ^i ^h gZhZXiZY dkZg i]Z XdgVXd^Y# I]Z gZhjaih ^c i]Z Ñghi \gdje d[ &' eVi^Zcih igZViZY l^i] i]^h iZX]c^fjZ lZgZ gZedgiZY ^c
65
'%%(! id i]Z 6g\Zci^c^Vc =VcY Hjg\Zgn HdX^Zin bZZi^c\ ;^\jgZ *"&% #+, I]Z bZVc V\Z d[ i]Z - bZc VcY ) ldbZc lVh (,#* nZVgh gVc\Z '. id *) nZVgh # I]Z bZX]Vc^hb d[ ^c_jgn lVh ldg`" gZaViZY ^c ,# I]Z bZVc i^bZ [gdb ^c_jgn id h]djaYZg YZcZgkVi^dc lVh '#* nZVgh gVc\Z/ %#* id ,#% nZVgh # Id WZ Za^\^WaZ [dg i]Z egdXZYjgZ! ZVX] eVi^Zci ]VY id ]VkZ Vi aZVhi * ed^cih dc i]Z eV^c hXVaZ VcY gZfj^gZY Vc ^cXgZVhZ ^c gVc\Z d[ bdi^dc# 6i V bZVc d[ &#' nZVgh V[iZg VciZg^dg h]djaYZg YZcZgkVi^dc! - eVi^Zcih ]VY ZmXZaaZci gZhjaih VcY ) ]VY \ddY gZhjaih# BZVc K6H eV^c hXdgZh YgdeeZY [gdb -#* id &#-! VcY bZVc gVc\Z d[ bdi^dc! eV^c"[gZZ! ^cXgZVhZY [gdb % id +% id & id &%%# :aWdl _d^ci eV^c bjhi WZ Y^hi^c\j^h]ZY [gdb bZY^Va VcY aViZgVa ]jbZgVa Ze^XdcYnaVg eV^c# 6ai]dj\] i]Z ^ccZgkVi^dc d[ i]Z ZaWdl _d^ci lVh YZhXg^WZY bdgZ i]Vc ]Va[ V XZcijgn V\d!-% VcY idiVa ZaWdl YZcZgkVi^dc lVh YZhXg^WZY bdgZ i]Vc )% nZVgh V\d!-&!-' eVgi^Va ZaWdl _d^ci YZc" ZgkVi^dc ]Vh cdi WZZc YZhXg^WZY! cdg ]Vh ^hd" aViZY YZcZgkVi^dc d[ Z^i]Zg i]Z bZY^Va dg aViZgVa ]jbZgVa Ze^XdcYnaZ# @VeaVc VcY L^a]Zab Y^Y YZhXg^WZ YZcZgkVi^dc d[ i]Z aViZgVa ]jbZgVa Ze^XdcYna^i^h! Wji @VeaVc-& XaZVgan YZcZgkViZY dcan WgVcX]Zh d[ i]Z gVY^Va cZgkZ Vi i]Z gVY^Va"]jbZgVa _d^ci! l]ZgZVh L^a]Zab-' Y^Y i]^h Vh lZaa! eajh YZcZgkVi^c\ bjhXaZh ^ccZg" kViZY Vi i]Z Ze^XdcYnaZ# =Z Vahd ^cXajYZY i]Z edhiZg^dg WgVX]^Va XjiVcZdjh cZgkZ cZgkjh XjiVcZdjh VciZWgVX]^^ YdghVa^h ^c eZg]Veh ]^h Ñghi YZhXg^ei^dc d[ i]^h egdXZYjgZ ^c c '%%)! ^hdaViZY YZcZgkVi^dc d[ i]Z aViZgVa ]jbZgVa Ze^XdcYnaZ Wn gZhZXi^c\ i]Z WgVcX]Zh d[ i]Z edhiZg^dg XjiVcZdjh cZgkZ d[ i]Z Vgb VcY [dgZVgb lVh YZhXg^WZY Vi i]Z 6bZg^XVc 6hhdX^V" i^dc d[ =VcY Hjg\Zgn bZZi^c\#-) I]Z ^ccZgkVi^dc d[ i]Z bZY^Va ]jbZgVa Ze^XdcYnaZ lVh YZhXg^WZY ^c '%%* Vi i]Z 6bZg^XVc HdX^Zin [dg EZg^e]ZgVa CZgkZ# I]^h cZgkZ lVh cdiZY Yjg^c\ gZhZXi^dc d[ i]Z bZY^Va ^ciZgbjhXjaVg hZeijb Yjg^c\ hjWbjh" XjaVg igVchedh^i^dc d[ i]Z jacVg cZgkZ# 8VYVkZg Y^hhZXi^dch gZkZVaZY i]Vi ^i dg^\^cViZh [gdb i]Z gVY^Va cZgkZ ^c i]Z Vm^aaV ^c Vaa XVhZh! l^i] dcZ XVhZ ]Vk^c\ V Xdcig^Wji^dc [gdb i]Z jacVg cZgkZ ^c i]Z Vm^aaV Vh lZaa# I]^h cZgkZ XVc WZ gZhZXiZY Vi i]Z ^chZgi^dc d[ i]Z bZY^Va ^ciZgbjhXjaVg hZeijb ^cid i]Z bZY^Va Ze^XdcYnaZ [dg i]Z igZVibZci d[ bZY^Va Ze^XdcYna^i^h Å\da[ZgÈh ZaWdlÆ #-*!-+ IZbedgdbVcY^WjaVg _d^ci IB? eV^c ^h Vcdi]Zg ZmVbeaZ d[ YZW^a^iVi^c\ _d^ci eV^c#
66
Tissue Surgery
Figure 5-10. Results of anterior shoulder denervation. A typical patient preoperatively and 6 months after surgery, showing increased range of motion.
6ai]dj\] IB? eV^c ^h iVj\]i igVY^i^dcVaan id WZ gZaViZY id YZciVa bVadXXajh^dc! ^i ^[ d[iZc Xdch^YZgZY id WZ eVgi d[ i]Z hnbeidb XdbeaZm ^c WgVX]^Va eaZmjh XdbegZhh^dc! ^c i]Z i]dgVX^X ^caZi i]dgVX^X djiaZi hncYgdbZ VcY XZgk^XVa hegV^c# I]Z IB? XVc WZ i]Z XZciZg d[ gZ[ZggZY eV^c [gdb i]Z XZgk^XVa eaZmjh! Vh ^c i]Z ild Xa^c^XVa ZmVbeaZh \^kZc VWdkZ! [gdb i]Z bVm^a" aVgn h^cjh^i^h ^c[gVdgW^iVa cZgkZ ! dg [gdb i]^gY bdaVg egdWaZbh hjeZg^dg VcY ^c[Zg^dg VakZdaVg cZgkZh # I]^h gZ[ZggVa eViiZgc ^h WZhi jcYZghiddY Wn gZaVi^c\ ^i id i]Z gZXZci ^iZgVi^dc d[ i]Z bVcn ZVga^Zg eVeZgh i]Vi YZhXg^WZ i]Z ^ccZgkV" i^dc d[ i]Z IB?! [gdb WgVcX]Zh d[ i]Z ig^\Zb^cVa cZgkZ Y^k^h^dc K'! i]Z bVcY^WjaVg cZgkZ# I]Z aViZgVa VheZXi d[ i]Z IB? ^h ^ccZgkViZY Wn i]Z Vjg^XjadiZbedgVa cZgkZ WZ[dgZ ^i e^ZgXZh i]Z iZbedgVa [VhX^V id ^ccZgkViZ i]Z egZVjg^XjaVg VcY iZbedgVa gZ\^dc# I]Z bZY^Va VheZXi d[ i]Z IB? ^h ^ccZgkViZY Wn V WgVcX] [gdb i]Z cZgkZ i]Vi ^ccZgkViZh i]Z bVhhZiZg bjhXaZ _jhi WZ[dgZ i]Vi cZgkZh XgdhhZh WZilZZc i]Z Xdgdcd^Y VcY XdcYnaVg egdXZhhZh! Vi i]Z bVcY^WjaVg cdiX]#+- 6YY^i^dcVa bZY^Va ^ccZgkVi^dc bVn XdbZ [gdb i]Z cZgkZ id i]Z aViZgVa eiZgn\d^Y bjhXaZ#+9Zhe^iZ ZmiZch^kZ egdidXdah [dg bVcV\^c\ IB? eV^c! ^[ i]Zn [V^a! ZcYdhXde^X dg deZc egdXZYjgZh ViiZbei id i^\]iZc i]Z a^\VbZcih d[ i]Z IB? dg
id gZh]VeZ dg gZXdchigjXi i]Z _d^ci ^ihZa[# I]ZhZ egdXZYjgZh XaVhh^XVaan \^kZ ^bbZY^ViZ gZa^Z[! Wji eV^c gZXjgh ^c ( id + bdci]h# BjX] d[ i]^h hjXXZhh ^h a^`Zan gZaViZY id XdbeaZiZan YZcZgkVi^c\ i]Z IB?! VcY i]Z gZXjgg^c\ eV^c ^h XVjhZY Wn gZ^ccZgkVi^dc d[ i]Z _d^ci dg igjZ cZjgdbV [dgbVi^dc# Dc ?VcjVgn '-! '%%*! i]Z Ñghi ViiZbei id YZcZg" kViZ i]Z IB? lVh eZg[dgbZY ;^\jgZ *"&&V ^c V eVi^Zci l]d ]VY i]gZZ egZk^djh egdXZYjgZh! ild ZcYdhXde^X VcY dcZ deZc#-,6 egZVjg^XjaVg ^cX^h^dc lVh bVYZ! VcY i]Z jeeZg edgi^dc d[ i]Z bVcY^WjaVg gVbjh lVh VeegdVX]ZY! jh^c\ V Y^ajiZ Ze^cZe]g^cZ hdaji^dc id Xdcigda WaZZY^c\ VcY ^cigVdeZgVi^kZ ZaZXig^XVa hi^bjaVi^dc id ^YZc" i^[n i]Z [VX^Va cZgkZ WgVcX]Zh ;^\jgZ *"&&W # I]Z Vjg^XjadiZbedgVa cZgkZ bdkZh [gdb edhiZg^dg id VciZg^dg VXgdhh i]^h edgi^dc d[ i]Z bVcY^WaZ VcY bVn WZ ^YZci^ÑZY Vi i]^h ed^ci ;^\jgZ *" &&W VcY [daadlZY id i]Z aViZgVa IB? XVehjaZ! VcY gZhZXiZY ;^\jgZ *"&&X # 6 WgVcX] id i]Z ZjhiV" X]^Vc ijWZ XVc WZ ^YZci^ÑZY VcY h]djaY Vahd WZ gZhZXiZY WZXVjhZ i]^h WgVcX] bVn XgZViZ gZ[ZggZY dg cZjgdbVidjh eV^c ^c i]Z ZmiZgcVa VjY^idgn bZVijh l]^X] ^i Y^Y ^c i]^h eVi^Zci! egZkZci^c\ ]Zg [gdb lZVg^c\ ]Zg ]ZVg^c\ V^Y # I]Z WgVcX] [gdb i]Z cZgkZ id i]Z bVhhZiZg ^h Y^[ÑXjai id ^YZci^[n! Wji ^i lVh VeegdVX]ZY ^c i]^h eVi^Zci Wn ZmiZcY^c\ i]Z ^cX^h^dc idlVgY i]Z bVcY^WjaVg
Innovations in Peripheral Nerve Surgery
67
a
b
c
d
Figure 5-11. Denervation of the temporomandibular joint (TMJ). a) Preoperative view of the TMJ outlined with innervation, from the auriculotemporal nerve to the lateral and the masseteric nerve to the medial side of the joint capsule. b) Intra-operative view, with the blue vessel loop on a facial nerve branch (note nerve stimulator in use) and white vessel loop on branch of auriculotemporal
nerve. c) After resection of the auriculotemporal nerve, its proximal end is placed deep to the mandibular ramus (dark hole and arrow). The specimen is lying on the cheek skin. d) The branch of the masseteric nerve to the joint capsule is approached by elevating the masseter from the mandibular ramus (white area) and then grasping the nerve with a right-angle clamp, reaching behind the condyle.
Vc\aZ! ZaZkVi^c\ i]Z bVhhZiZg [gdb i]Z bVcY^WaZ! VcY Y^hhZXi^c\ hjeZg^dgan idlVgYh i]Z cdiX]# >c i]^h adXVi^dc! V g^\]i Vc\aZ XaVbe XVc WZ eaVXZY edhiZg^dgan! VcY i]Z ^ccZgkVi^dc d[ i]Z bZY^Va IB? XVc WZ Y^hgjeiZY ;^\jgZ *"&&X # >i bVn WZ i]Vi dcan V eVgi^Va! aViZgVa IB? YZcZgkVi^dc ^h cZZYZY [dg bdhi eVi^Zcih l^i] ^cigVXiVWaZ IB? eV^c# ;dg eaVhi^X hjg\Zgn! i]Z XdcXZei d[ eVgi^Va _d^ci YZcZgkVi^dc deZch V cZl VgZV [dg eVi^Zci XVgZ! eZgb^ii^c\ gZa^Z[ d[ eV^c VcY gZhidgVi^dc d[
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6 Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm Reimer Hoffmann
Introduction B^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X iZX]c^fjZh VgZ cdi cZl ^c hjg\Zgn0 ^c [VXi! i]Zn VgZ lZaa ZhiVWa^h]ZY ^c bVcn ÑZaYh! hjX] Vh \ZcZgVa VcY \ncZXdad\^XVa hjg\Zgn# >c ]VcY hjg\Zgn! dcan i]Z ZcYdhXde^X deZgVi^dc d[ i]Z XVgeVa ijccZa hncYgdbZ ]Vh WZXdbZ Vc ZhiVWa^h]ZY iZX]c^fjZ#&!' >c he^iZ d[ Vc ^c^i^Va Zci]jh^Vhi^X gZXZei^dc Wn bVcn ]VcY hjg\Zdch! i]^h deZgVi^dc ]Vh cdi bVg`ZY i]Z WZ\^cc^c\ d[ V cZl ÅZcYd" hXde^XÆ ZgV ^c ]VcY hjg\Zgn# 6 ]^\] Xdbea^XVi^dc gViZ VcY i]Z [VXi i]Vi ^i ^h iZX]c^XVaan YZbVcY^c\ VcY gZaVi^kZan ZmeZch^kZ VgZ hdbZ d[ i]Z gZVhdch Zci]jh^Vhb lVcZY# 6c VaiZgcVi^kZ [dg bVcn ]VcY hjg\Zdch WZXVbZ b^c^b^o^c\ i]Z ^cX^h^dc [dg i]Z deZc deZgVi^dc! id V ed^ci l]ZgZ i]Z h^oZ d[ i]Z ^cX^h^dc lVh cdi aVg\Zg i]Vc i]Z dcZ cZZYZY [dg i]Z ^cigdYjXi^dc d[ Vc ZcYdhXdeZ#(!) I]^h b^c^bVaan ^ckVh^kZ iZX]c^fjZ! ]dlZkZg! ]Vh WZXdbZ edejaVg dcan [dg XVgeVa ijccZa gZaZVhZ# =VcY hjg\Zdch Xdci^cjZ id add` [dg WgdVYZg Veea^XVi^dch [dg Wdi] b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X hjg\Zgn# >i gZbV^ch V X]VaaZc\Z! i]ZgZ" [dgZ! id ^cigdYjXZ b^c^bVaan ^ckVh^kZ VcY ZcYd" hXde^X iZX]c^fjZh id ]VcY hjg\Zgn ^c V lVn i]Vi Vaadlh i]Zb id WZXdbZ V gdji^cZ VcY jhZ[ja VheZXi d[ i]^h heZX^Vain# >c i]^h X]VeiZg lZ YZhXg^WZ hdbZ d[ i]Z iZX]c^fjZh lZ ]VkZ jhZY id igZVi XVgeVa ijccZa hncYgdbZ! egdcVidg hnc" YgdbZ! VciZg^dg ^ciZgdhhZjh hncYgdbZ! XjW^iVa ijccZa hncYgdbZ! iZcc^h ZaWdl ^cXajY^c\ i]Z edhiZg^dg ^ciZgdhhZjh cZgkZ ! VcY i]Z gVY^Va hZchdgn cZgkZ#
Endoscopic and Minimally Invasive Hand Surgery :cYdhXde^X hjg\Zgn VcY b^c^bVaan ^ckVh^kZ hjg\Zgn VgZ cdi hjg\^XVa iZX]c^fjZh0 gVi]Zg! i]Zn VgZ V XdbeaZiZan cZl VeegdVX] id hjg\Zgn i]Vi ZcVWaZh jh id hZZ VcY id Yd bdgZ i]gdj\] bjX] hbVaaZg ^cX^h^dch# I]Z h`^c ^cX^h^dc h]djaY [daadl i]Z cVijgVa h`^c XgZVhZh VcY! ^c bdhi XVhZh! l^aa WZ igVchkZghZ dg dWa^fjZ# I]Z gZhjai^c\ hXVgh VgZ ldcYZg[jaan ^cXdche^Xjdjh# >[ edhh^WaZ! i]Z ^cX^" h^dc h]djaY WZ Vi V Y^hiVcXZ [gdb i]Z VgZV id WZ Y^hhZXiZY id `ZZe i]Z ^ciZgcVa VcY ZmiZgcVa hXVgh hZeVgViZ# 6h l^i] di]Zg [dgbh d[ ZcYdhXde^X hjg\Zgn! i]Z hjg\Zdc cZZYh id XgZViZ V heVXZ id ldg` ^c# 7ZXVjhZ lZ XVccdi ^cÒViZ i]Z hd[i i^hhjZ d[ Vc ZmigZb^in l^i] \Vh! Vh ^h YdcZ ^c VWYdb^cVa hjg\Zgn! lZ bjhi XgZViZ V heVXZ jh^c\ V ijccZa" ^c\ [dgXZeh d[ i]Z Veegdeg^ViZ h^oZ ;^\jgZ +"& # L^i] i]Z WaVYZh d[ i]^h [dgXZeh! i]Z i^hhjZ aVnZgh lZ lVci id Y^hhZXi XVc WZ \Zcian hZeVgViZY# ;dg \ddY k^hjVa^oVi^dc! lZ jhZ heZXjaV VcY ZcYdhXdeZh ViiVX]ZY id V a^\]i hdjgXZ# I]Z heZXjaV VgZ h^b^aVg id i]dhZ jhZY ^c :CI hjg\Zgn ;^\jgZ +"& ! VcY i]Z ZcYdhXdeZhÄdg^\^cVaan YZh^\cZY [dg ZcYdhXde^X [VXZ a^[i^c\Ä]VkZ Y^h" hZXidgh d[ kVgn^c\ h^oZ VcY h]VeZ Vi i]Z^g i^e ;^\jgZ +"& # L^i] i]Z heZXjaV! i]Z ijccZa XVc WZ deZcZY ^c i]gZZ Y^gZXi^dch! VcY l^i] i]Z ZcYd" hXdeZ! i]Z hd[i i^hhjZ ZckZadeZ XVc WZ ]ZaY je! ZcVWa^c\ i]Z hjg\Zdc id ^cigdYjXZ ^chigjbZcih VcY id Y^hhZXi l^i]^c i]^h heVXZ# L]Zc jh^c\ ^aajb^cViZY heZXjaV! Y^hhZXi^dc ^h YdcZ jcYZg Y^gZXi k^h^dc ^c i]Z ijccZa0
71
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Figure 6-1. Instruments for endoscopic nerve decompression: tunneling forces (top middle), speculum (bottom right), endoscope with dissector on tip (bottom left).
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Tissue Surgery
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Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
Figure 6-2. Incision for the “author’s preferred method,” as described in Green’s hand surgery textbook.5
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73
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Figure 6-3. Small incision for minimally invasive, open carpal tunnel surgery. The motor branch of the median nerve has been dissected.
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Tissue Surgery
Figure 6-4. a) Tunneling with the needle holder (see text). b) Speculum inserted for viewing the undivided part of the flexor retinaculum and forearm fascia.
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Figure 6-5. “Endoscopic” view with speculum. a) The undivided part of the flexor retinaculum and forearm fascia are clearly visible, as are the blades of the speculum. b) The flexor and adjacent forearm fascia completely divided.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
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Pronator Syndrome Egdm^bVa bZY^Vc cZgkZ XdbegZhh^dc ^h bjX] aZhh Xdbbdc i]Vc XVgeVa ijccZa hncYgdbZ! VcY ^i bVn WZ dkZgadd`ZY WZXVjhZ i]Z Vhhd" X^ViZY hnbeidbh VcY e]nh^XVa h^\ch bVn WZ kV\jZ# EgdcVidg hncYgdbZ gZhZbWaZh XVgeVa ijccZa hncYgdbZ ^c i]Vi cjbWcZhh dXXjgh ^c i]Z hVbZ Y^\^ih! lZV`cZhh bVn YZkZade ^c i]Z i]ZcVg bjhXaZh! VcY eV^c ^h gZedgiZY ^c i]Z lg^hi VcY [dgZVgb# EVgZhi]Zh^V d[ i]Z bZY^Vc" ^ccZgkViZY Ñc\Zgh l^i]dji e]nh^XVa h^\ch d[ XVgeVa ijccZa dg X]gdc^X eV^c ^c i]Z egdm^bVa eVabVg gZ\^dc d[ i]Z [dgZVgb gZh^hiVci id XdchZg" kVi^kZ igZVibZci h]djaY WZ Xdch^YZgZY id WZ i]Z gZhjai d[ XdbegZhh^dc d[ i]Z bZY^Vc cZgkZ ^c i]Z egdcVidg ijccZa# I]Z ediZci^Va h^iZh d[ XdbegZh" h^dc! ]dlZkZg! VgZ cdi dcan ^c i]Z egdcVidg bjhXaZ0 i]ZgZ[dgZ! ^i ldjaY WZ bdgZ VYZfjViZ id iZgb i]^h XdcY^i^dc Åegdm^bVa bZY^Vc cZgkZ XdbegZhh^dc#Æ I]Z bdhi egdm^bVa ediZci^Va higjXijgZ i]Vi XVc XdbegZhh i]Z bZY^Vc cZgkZ i]Z a^\VbZci d[ Higji]Zgh# I]^h ÑWgdjh WVcY gjch [gdb V hjegV" XdcYnad^Y egdXZhh id i]Z bZY^Va Ze^XdcYnaZ! VcY i]Z bZY^Vc cZgkZ eVhhZh WZcZVi] ^i# 6ai]dj\] i]Z hjegVXdcYnad^Y egdXZhh ^h [djcY ^c dcan ( d[ eVi^Zcih! i]Z a^\VbZci d[ Higji]Zgh ^h ediZc" i^Vaan egZhZci ^c ZkZgndcZ0 i]jh! i]Z egdm^bVa bZY^Vc cZgkZ h]djaY WZ ZmeadgZY egdm^bVa id i]Z ZaWdl id WZ hjgZ i]Z cZgkZ ^h cdi XdbegZhhZY Vi i]^h aZkZa# I]Z cZmi higjXijgZ i]Vi XVc XdbegZhh i]Z bZY^Vc cZgkZ ^h i]Z aVXZgijh ÑWgdhjh#I]Z bZY^Vc cZgkZ i]Zc eVhhZh i]gdj\] i]Z egdcVidg ijccZa! l]^X] ^h [dgbZY Wn i]Z ild ]ZVYh d[ i]Z egdcVidg iZgZh! l^i] i]Z^g iZcY^cdjh dg^\^ch VcY ÑWgdjh ZY\Zh# >c VYY^i^dc! di]Zg ÑWgdjh WVcYh bVn Xdchig^Xi i]Z cZgkZ Vh ^i eVhhZh i]gdj\] i]^h bjhXaZ# 9^hiVa id i]Z egdcVidg!i]Z cZgkZ eVhhZh i]gdj\] V iZcY^cdjh VgX [dgbZY Wn i]Z dg^\^c d[ i]Z ÒZmdg Y^\^idgjb hjeZgÑX^Va^h ;9H #, L]Zc YZXdbegZhh^c\ i]Z cZgkZ! ^i ^h l^hZ id [daadl i]Z V[dgZbZci^dcZY XdjghZ VcY cdi id aZVkZ Vcn d[ i]Z XdbegZhh^dc h^iZh jcgZaZVhZY# I]ZgZ[dgZ! ^c i]Z eVhi, VcY hi^aa idYVn! adc\ ^cX^h^dch! [gdb &' Xb id '% Xb! ]VkZ WZZc hj\\ZhiZY#* 6h ^c XVgeVa ijccZa hncYgdbZ! i]Z V^b d[ hjg\Zgn ^c egdcVidg hncYgdbZ ^h i]Z XdbeaZiZ YZXdbegZhh^dc d[ i]Z bZY^Vc cZgkZ# 6aa d[[ZcY" ^c\ iZcY^cdjh VcY ÑWgdjh higjXijgZh Xgdhh^c\
Figure 6-6. Skin incision for a minimally invasive approach to pronator tunnel release.
i]Z bZY^Vc cZgkZ bjhi WZ gZaZVhZY# I]Z ÒZh]n eVgih d[ i]Z bjhXaZh ^ckdakZY VgZ cZkZg Åd[[ZcY" ^c\Æ higjXijgZh VcY XVc WZ aZ[i ^ciVXi# I]^h X^g" XjbhiVcXZ bV`Zh i]Z hjg\Zgn aZhh Åd[[Zch^kZÆ VcY deZch i]Z Yddg [dg V b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X VeegdVX]# ;daadl^c\ \j^YZa^cZh [dg hV[Z ZcYdhXde^X hjg\Zgn! lZ ZmedhZ i]Z bZY^Vc cZgkZ i]gdj\] V ("id")"Xb igVchkZghZ ^cX^h^dc ' Xb id ( Xb Y^hiVa [gdb i]Z XjW^iVa XgZVhZ! dc i]Z jacVg"eVabVg VheZXi d[ i]Z [dgZVgb ;^\jgZ +"+ # I]Z [VhX^V ^h ZmedhZY WZilZZc i]Z ÒZmdg XVge^ gVY^Va^h VcY egdcVidg iZgZh# I]Z bZY^Vc cZgkZ XVc WZ ZVh^an adXViZY ]ZgZ Wn eVaeVi^dc ;^\jgZ +",V # I]Z [VhX^V ^h deZcZY! VcY i]Z bjhXaZ WZaa^Zh VgZ gZigVXiZY gVY^Vaan VcY jacVgan l^i] Veegdeg^ViZan h^oZY AVc\ZcWZX` gZigVXidgh WaVYZ ( Xb l^YZ VcY * Xb id + Xb adc\ # 6 hZa["gZiV^c^c\ gZigVXidg bVn WZ ]Zae[ja Y^higVXi^c\ i]Z ldjcY bVg\^ch ^c i]Z Y^hiVa"egdm^bVa Y^gZXi^dc# I]Z cZgkZ ^h Y^h" hZXiZY l^i] ZVhZ jcYZg Y^gZXi k^h^dc Vh [Vg Vh edhh^WaZ ;^\jgZ +",W # 6 hjWXjiVcZdjh ijccZa ^h XgZViZY Y^hiVaan VcY egdm^bVaan# 6 ."id"&&"Xb heZXjajb ^h ^cigd" YjXZY! VcY [dgZVgb [VhX^V VcY bjhXaZ gVe]Z VgZ igVchZXiZY Ñghi ^c V egdm^bVa Y^gZXi^dc# I]Z ZcYdhXdeZ ^h ^cigdYjXZY! VcY Y^hhZXi^dc XVgg^ZY dji Vh YZhXg^WZY [dg i]Z hjg\Zgn d[ XjW^iVa ijccZa hncYgdbZ# I]Z ÑWgdjh VgXVYZh VcY di]Zg Xdc" hig^Xi^c\ WVcYh l^i]^c i]Z egdcVidg VcY egdm^" bVa id ^i VgZ Y^k^YZY! VcY i]Z cZgkZ ^h XdbeaZiZan YZXdbegZhhZY je id - Xb egdm^bVa id i]Z XjW^iVa XgZVhZ ;^\jgZ +"- # I]Z bjhXaZh i]ZbhZakZh VgZ aZ[i ^ciVXi# I]Z hVbZ egdXZYjgZ ^h YdcZ ^c V Y^hiVa
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Tissue Surgery
Figure 6-7. a) Exposure of the forearm fascia in a direct approach to dissecting the median nerve. b) Further direct dissection of the median nerve (left distal).The muscular nerve branches, and first fibrous arcade are distal to the nerve.
Y^gZXi^dc# 6aa WgVcX]Zh d[ i]Z cZgkZ XVc WZ k^hj" Va^oZY! ^YZci^ÑZY! VcY egdiZXiZY# ;^Wgdjh VgXVYZh ^c i]Z egdcVidg ijccZa VgZ Y^k^YZY ;^\jgZh +".V VcY +".W # I]Z VciZg^dg ^ciZgdhhZjh cZgkZ XVc WZ [daadlZY VcY ^h Xdb" eaZiZan YZXdbegZhhZY ;^\jgZ +"&% # 6i i]Z ZcY d[ i]Z ZcYdhXde^X gdjiZ! i]Z ;9H VgX ^h adXViZY VcY Y^k^YZY ;^\jgZ +"&& # 6 hjXi^dc YgV^c ^h ^chZgiZY VcY i]Z ldjcY XadhZY# 6 Wja`n YgZhh^c\ ^h Veea^ZY! VcY i]Z jeeZg Vgb ^h XVhi ^c eaVhiZg d[ EVg^h [dg ' YVnh# EdhideZgVi^kZan! eVi^Zcih VgZ ZcXdjgV\ZY id bdkZ i]Z Vgb! l]^X] ^h egdiZXiZY dcan Wn Vc ZaVhi^X WVcYV\Z#
Figure 6-8. Endoscopic view of the fibrous arcade in the proximal pronator tunnel.
Figure 6-9. Fibrous arcade in the distal part of pronator tunnel a) before and b) after endoscopic release.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
Figure 6-10. Endoscopic view of the anterior interosseus nerve branching off median nerve and crossing under the tendinous edge (right).
Figure 6-11. Endoscopic view of the flexor digitorum superficialis arc before division.
LZ XVc dcan gZedgi egZa^b^cVgn gZhjaih ^c * eVi^Zcih! Wji i]Zn VgZ kZgn ZcXdjgV\^c\# 6aa eVi^Zcih lZgZ hjXXZhh[jaan gZa^ZkZY d[ i]Z^g hnbe" idbh VcY ]VY [jaa gVc\Z d[ ZaWdl bdi^dc l^i]^c * id + YVnh# I]Z aZVhi lZ XVc hVn Vi i]^h ZVgan hiV\Z ^h i]Vi i]Z gZhjaih d[ ZcYdhXde^X bVcV\ZbZci d[ i]^h cZgkZ ZcigVebZci VgZ ZfjVa id i]Z deZc bZi]dY Wji i]Vi bdgW^Y^in ^h bjX] aZhh VcY ZVgan gZ]VW^a^iVi^dc bjX] [VhiZg#
Anterior Interosseus Syndrome 8a^c^XVaan! i]Z VciZg^dg ^ciZgdhhZjh hncYgdbZ ^h bjX] bdgZ dWk^djh VcY ZVh^Zg id Y^V\cdhZ i]Vc i]Z egdcVidg hncYgdbZ#, EVi^Zcih egZhZci l^i]
77
lZV`cZhh dg eVahn d[ i]Z bjhXaZh ^ccZgkViZY Wn i]Z VciZg^dg ^ciZgdhhZjh cZgkZ! i]Z ÒZmdg edaa^X^h adc\jh! i]Z ÒZmdg Y^\^idgjb egd[jcYjh id i]Z ^cYZm Ñc\Zg! VcY i]Z egdcVidg fjVYgVijh# >c Xdc" igVhi id egdcVidg hncYgdbZ! ZaZXigdbnd\gVe]n d[ i]Z ;EA ^h jhjVaan ]Zae[ja id XdcÑgb i]Z Y^V\" cdh^h# 6ciZg^dg ^ciZgdhhZjh eVahn bVn WZ XVjhZY Wn V cZjg^i^h EVghdcV\Z"IjgcZg hncYgdbZ ! l]^X] bjhi WZ gjaZY dji Wn V cZjgdad\^hi WZ[dgZ hjg\Zgn# 6ai]dj\] Xa^c^XVa ÑcY^c\h jhjVaan ^YZci^[n i]Z h^iZ d[ XdbegZhh^dc! [VhX^XjaVg XdbegZhh^dc l^i]^c i]Z bZY^Vc cZgkZ bVn Xdc[djcY i]Z adXVi^dc#- 6ai]dj\] lZ Yd cdi eZg[dgb Vc ^ciZg" cVa cZjgdanh^h ^c Vaa XVhZh d[ VciZg^dg ^ciZgdhhZjh hncYgdbZ!lZ XdbeaZiZan YZXdbegZhh i]Z bZY^Vc cZgkZ Vh YZhXg^WZY [dg egdcVidg hncYgdbZ! ^c VYY^i^dc id V bZi^Xjadjh YZXdbegZhh^dc d[ i]Z VciZg^dg ^ciZgdhhZjh cZgkZ VcY Vaa ^ih WgVcX]Zh# I]Z b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X VeegdVX]! cVijgVaan! ^h h^b^aVg id i]Vi ^c i]Z egd" cVidg hncYgdbZ# LZ gdji^cZan ^YZci^[n i]Z aZkZa l]ZgZ i]Z VciZg^dg ^ciZgdhhZjh WgVcX]Zh d[[ i]Z bZY^Vc cZgkZ hiZb Wn cZjgdjaigVhdjcY egZ" deZgVi^kZan hd i]Vi i]Z h`^c ^cX^h^dc XVc WZ eaVXZY bdgZ egZX^hZan# I]Z VciZg^dg ^ciZgdhhZjh WgVcX] ^h ^YZci^ÑZY VcY [daadlZY id ^ih bjhXjaVg WgVcX]Zh! ZheZX^Vaan i]Z dcZ ^ccZgkVi^c\ i]Z ÒZmdg edaa^X^h! id bV`Z hjgZ ZkZgn ediZci^Va XdbegZhh^dc ^h VYYgZhhZY# 6i i]^h hiV\Z d[ djg ZcYdhXde^X ZmeZg^ZcXZ! lZ WZa^ZkZ i]^h Y^hhZX" i^dc h]djaY WZ YdcZ jcYZg Y^gZXi k^h^dc# DcXZ Vaa Xdchig^Xi^c\ ZaZbZcih ]VkZ WZZc gZaZVhZY! i]Z bZY^Vc cZgkZ ^h ZcYdhXde^XVaan YZXdbegZhhZY Vh YZhXg^WZY VWdkZ#
Cubital Tunnel Syndrome I]Z dkZgVaa hjXXZhh gViZ d[ i]Z Y^[[ZgZci hjg\^XVa egdXZYjgZh [dg XjW^iVa ijccZa hncYgdbZ! l]^X] ^h i]Z hZXdcY bdhi [gZfjZci cZgkZ ZcigVebZci d[ i]Z Vgb! ^h WZilZZc -% VcY .%#* Hi^aa! i]Z YZWViZ dc ^c h^ij Åh^beaZÆ cZgkZ YZXdbegZhh^dc kZghjh VciZg^dg igVchedh^i^dc Xdci^cjZh#.!&%!&& >[ ^c h^ij YZXdbegZhh^dc \^kZh i]Z hVbZ \ddY hjXXZhh gViZ!&'!&( dcZ ldjaY i]^c` i]Vi V XdbeaZm egdXZYjgZ! hjX] Vh i]Z VciZg^dg igVch" edh^i^dc d[ i]Z jacVg cZgkZ! ZheZX^Vaan ^ih bdhi V\\gZhh^kZ hjWbjhXjaVg kZgh^dc! ldjaY ]VkZ cd eaVXZ# L]n ldjaY V hjg\Zdc jccZXZhhVg^an g^h` ediZci^Va Xdbea^XVi^dch! hjX] Vh YZkVhXj" aVg^oVi^dc d[ i]Z cZgkZ! eV^c[ja ZmiZch^dc d[
78
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Tissue Surgery
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Figure 6-12. Retrocondylar dissection of the ulnar nerve through a small incision. The nerve is always identifiable by the vasa nervorum.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
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WZilZZc &,Xb VcY '( Xb adc\# JcYZg bdc^idg k^h^dc! i]Z [dgZVgb [VhX^V ^h Y^k^YZY id V ed^ci &%Xb id &)Xb Y^hiVaan [gdb i]Z Ze^XdcYnaZ ;^\jgZ +"&+ # 8VgZ bjhi WZ iV`Zc cdi id ^c_jgZ i]Z XjiVcZdjh cZgkZ WgVcX]Zh dg i]Z kZ^ch i]Vi bVn Xgdhh i]Z [VhX^V# DcXZ i]Z [VhX^V ]Vh WZZc Y^k^YZY! i]Z ZcYdhXdeZ ^h XVgZ[jaan ejaaZY WVX`! VcY [jgi]Zg Y^hhZXi^dc ^h XVgg^ZY dji XadhZ id i]Z cZgkZ# I]Z cZmi hiZe ^h id Y^k^YZ i]Z ild bjhXjaVg ]ZVYh d[ i]Z ÒZmdg XVge^ jacVg^h VcY id gZaZVhZ d[ Vaa ÑWgdjh WVcYh Xgdhh^c\ i]Z cZgkZ# 9^hiVaan [gdb DhWdgcZÈh a^\VbZci! i]Z [VhX^V WZilZZc i]Z ild ]ZVYh d[ i]Z ÒZmdg XVge^ jacVg^h ;8J ^h Figure 6-13. Distal tunneling of the cubital tunnel (see text).
a
c
b
d
Figure 6-14. a) Speculum inserted for initial viewing of the distal cubital tunnel. b) Ulnar nerve entering the cubital tunnel under Osborne’s ligament (cubital retinaculum). c) Speculum view of scissors about to cut Osborne’s ligament and
the first part of the flexor carpi ulnaris (FCU) fascia. d) Osborne’s ligament and the first part of the FCU fascia released. The scissors blades are under the first fibrous arcade between the two heads of the FCU.
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Figure 6-15. Endoscopic dissection 10 cm to 12 cm from the ulnar epicondyle.
Figure 6-16. Dissecting scissors “en route,” dividing the superficial forearm fascia 8 cm to 10 cm from the retro-condylar groove. A tiny nerve, identifiable by the vasa nervorum, crosses fascia distal from the scissors.
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Figure 6-17. Magnified endoscopic view of nerve branches in the cubital tunnel.
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Figure 6-18. The 3rd fibrous arcade at the distal end of the cubital tunnel about 9 cm from the retro-condylar groove.The two layers of dissection are shown: the superficial fascia already split, and the arcade close to the nerve before release.
Figure 6-19. a) Cadaver dissection of the ulnar nerve in the cubital tunnel showing fibrous thickening around the nerve. b) “Anterior transposition” of the ulnar nerve demonstrating the possibility of a new nerve compression and kinking against the cut edge of the fascia and fibrous arcade.
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Tissue Surgery
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Figure 6-20. Incision, following the skin crease, for a minimally invasive approach to the peri-epicondylar area and radial tunnel of the posterior interosseus nerve.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
Figure 6-21. Insertion of the speculum (blade length, 11 cm) for viewing the peri-epicondylar area.
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83
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Figure 6-22. a) Endoscopic view of the peri-epicondylar area. The lateral epicondyle and extensor tendon origins are visible. b) The peri-epicondylar area after release of the extensor tendon origins.
84
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Figure 6-23. Dissection of RSN through a small incision on the forearm.
Figure 6-24. Endoscopic view of a partially divided fascia between the tendons of brachioradialis (right) and the extensor carpi radialis longus muscles (left).
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7 Soft Tissue Reconstruction with Perforator Flaps Phillip N. Blondeel
Introduction
The Evolution of Perforator Flaps
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Tissue Surgery
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Figure 7-1. a,b) Preoperative pictures of a middle-aged woman with invasive ductular breast carcinoma of the left breast, immediately after open biopsy through a supra-areolar scar. c) Intraoperative picture (right cranial; left caudal) of the dissection of a lateral perforator of the left rectus abdominis muscle between the umbilicus and the pubis. The fat of the flap, seen in the top of the picture, is folded medially; the deep (rectus) fascia (bottom of the picture) and muscle are split; and the deep inferior epigastric vessels are dissected from in between. The perforator has been isolated (white arrow), as well as the medial and lateral branches of the motor nerves (black arrows). Wide exposure and a bloodless field are the keys to success. d,e) Postoperative images after skin-sparing mastectomy, immediate autologous breast reconstruction with a DIEAP flap, nipple reconstruction, and areolar tattooing.
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8 Remote Ischemic Preconditioning of Flaps: Current Concepts Markus V. Küntscher, Bernd Hartmann and Günter Germann
Introduction
Historical Preface
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Remote Ischemic Preconditioning >c &..(! Egon`aZc` Zi Va# Ñghi dWhZgkZY i]Vi gZ\^dcVa >E d[ i]Z ]ZVgi cdi dcan egdiZXih i]dhZ bndXniZh hjW_ZXiZY id Wg^Z[ XdgdcVgn dXXajh^dc [gdb ^hX]Zb^V"gZeZg[jh^dc ^c_jgn Wji Vahd a^b^ih ^c[VgXi h^oZ ^c gZbdiZ Åk^g\^cÆ bndXVgY^jb ^c V XVc^cZ bdYZa#)' KZgYdjl Zi Va# lZgZ i]Z Ñghi id gZedgi V gZVa gZbdiZ >E d[ i]Z ]ZVgi Wn bZhZc" iZg^X VgiZgn dXXajh^dc ^c V gVi bdYZa#)( I]Z egd" iZXi^kZ ^cÒjZcXZ d[ a^bW ^hX]Zb^V dc bndXVgY^Va ^c[VgXi^dc ]Vh Vahd WZZc gZedgiZY Wn 7^gcWVjb Zi Va# VcY DmbVc Zi Va#))!)*
Figure 8-1. A noninvasive tourniquet (Martin, Tuttlingen, Germany) applied to the hind limb of a rat to induce ischemia.
96
Tissue Surgery
100 90 80 70 60 50 40 30 20 10 0
CG
PG*
FG*
TG* *p<0.001 vs. CG
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Figure 8-2. Clamping the femoral artery is as effective at preconditioning the flap as a noninvasive tourniquet applied to the rat hind limb followed by 30 minutes limb reperfusion.27 Average flap necrosis was 68.2% (q18.1%) in the control group (CG), 11 q 8.38% in the preclamping group (PG), 12.5 q 5.83% in the femoral ischemic group (FG), and 24 q 11.75% in the tourniquet group (TG). All preconditioned animals had a significantly smaller area of flap necrosis than did the control animals (*p < 0.001 vs. CG). The differences between PG, FG and TG groups were not significant.
\gdje# L]Zi]Zg gZbdiZ ^hX]Zb^X egZXdcY^i^dc" ^c\ XdjaY WZ ^cYjXZY Wn V aViZ bZX]Vc^hb lVh Vahd YZiZgb^cZY#*% 6 gVi ]^cY a^bW lVh hjW_ZXiZY id &% b^cjiZh d[ ^hX]Zb^V VcY (% b^cjiZh d[ gZeZg[jh^dc l^i] V idjgc^fjZi ') ]djgh WZ[dgZ ÒVe ^hX]Zb^V# I]^h egdidXda ^cXgZVhZY gZY WaddY XZaa kZadX^in ^c i]Z XVe^aaVg^Zh VcY Ñghi"dgYZg VgiZg^daZh VcY kZcjaZh VcY ^cXgZVhZY XVe^aaVgn Òdl! Vh lZaa Vh YZXgZVhZY aZj`dXniZ hi^X`^c\ ^c V XgZbVhiZg bdYZa VcY i]jh! ViiZcjViZY ZVgan ^hX]Zb^V"gZeZg[jh^dc ^c_jgn ^c bjhXaZ ÒVeh# Dc i]Z di]Zg ]VcY! ^i Y^Y cdi ^begdkZ ÒVe hjgk^kVa ^c VY^edXjiVcZdjh ÒVeh# I]ZhZ ÑcY^c\h ^cY^XViZ
8 7 6
mm/s*cap
5 4 3 2 1 0
CG
cIP
rIP *p<0.02 vs. CG
Figure 8-3. Both classic and remote acute ischemic preconditioning improve microcirculation of muscle flaps after ischemia in a rat model.47 Capillary flow results; capillary flow was significantly higher in the groups with classic ischemic preconditioning (cIP) and remote ischemic preconditioning (rIP) than in the control group (p < 0.02). The difference within the groups cIP and rIP was not significant.
Remote Ischemic Preconditioning of Flaps: Current Concepts
97
90 80
sticker / mm venule
70 60 50 40 30 20 10
Figure 8-4. Leukocyte count. A significantly lower number of permanent adhering leucocytes (stickers) was observed in both the preconditioned groups cIP and rIP, compared to the control group (p < 0.01).
0
CG
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9 Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems James E. Zins and Andrea Moreira-Gonzalez
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Figure 9-1. a) Preoperative view of 43-year-old woman with eyebrow ptosis treated by endoscopic subperiosteal browlift using the cortical tunnel technique for fixation, a cheeklift, and submental liposuction. b) The patient 1 year later.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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103
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104
Tissue Surgery
a
b
Figure 9-2. a) Preoperative view of a 52-year-old woman who underwent an endoscopically assisted cheeklift, with a combined intraoral incision and spanning sutures from the intraoral soft tissues to the temporalis fascia proper. b) The patient 1 year later.
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Figure 9-3. The gull-wing excision at the base of the nose to shorten the upper lip and lip-lift procedure by direct excision of skin above the vermilion-cutaneous junction. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
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Figure 9-4. a) Corner of the lip lift performed by marking the commissure. b) Drawing a line from the commissure 11 mm long medially along the vermilioncutaneous junction and drawing a second line from “A” laterally toward the top of the ear. These lines create a triangle with the apex of the triangle at “A” and the base at “B-C.” The vertical distance from “A” is 5 mm for minimal lip elevation, 7 mm for moderate elevation (most common), and 9 mm for high elevation. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
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Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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b
Figure 9-6. a) Preoperative view of a 68-year-old woman who underwent a facelift and perioral phenol-croton oil peel using 50% phenol and 1.1% croton oil. b) The patient 1 year later. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
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Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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Figure 9-8. Preoperative a) frontal and b) lateral view of a 63-year old woman with moderate skin laxity. c) Frontal and d) lateral view of the patient 6 months after anterior lipectomy and platysmaplasty.
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Figure 9-9. Preoperative a) frontal and b) lateral view of a 50-year old woman with substantial submental and submandibular fat and mild skin laxity. c) Frontal and d) lateral view of the patient 6 months after anterior lipectomy and platysmaplasty.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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112
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Figure 9-10. Preoperative a) frontal and b) lateral view of a 76-year-old man who underwent direct skin excision of the neck with Z-plasty and platysmaplasty. c) Frontal and d) lateral view of the patient 6 months after anterior lipectomy and platysmaplasty.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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Figure 9-11. a) Preoperative view of a 58-year-old woman who recently lost 110 pounds. b) The patient 1 year after a facelift, secondary direct excision of the nasolabial folds, and CO2 laser resurfacing of the scars. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
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Tissue Surgery
Figure 9-12. Preoperative a) frontal and b) lateral view of a 35-year-old [[man/woman]] with HIV-associated lipodystrophy characterized by submental and submandibular fat excess and peripheral wasting after highly aggressive antiretroviral therapy (HAART). c) Frontal and d) lateral view of the patient 6 months later.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
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10 Perspectives for Facial Allograft Transplantation in Humans Maria Z. Siemionow and Galip Agaoglu
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Facial Allograft Transplantation
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Tissue Surgery
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Figure 10-1. The full-facial allograft transplantation model across a major histocompatibility barrier. Preoperative views of the donor rat showing markings of the facial skin flap, the dorsal surface a and the ventral surface b. Preoperative views of the recipient rat showing markings of the skin to be excised before the donor facial skin transplant inset, the dorsal surface c and the ventral surface d. (Reprinted from Siemionow MZ, Agaoglu G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
Figure 10-2. The full-facial allograft transplantation model. Late post-transplant views of face allograft recipient on low-dose of cyclosporine A monotherapy at day 200 showing no signs of rejection. a) The frontal view. b) The lateral view. (Reprinted from Siemionow MZ, Agaoglus G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
Perspectives for Facial Allograft Transplantation in Humans
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Figure 10-3. The hemi-facial allograft transplantation model. Preoperative view of the donor Lewis-Brown Norway rat showing markings of the facial skin flap a). Preoperative view of the recipient Lewis rat showing marking of the skin to be excised before the skin flap inset from the donor b). Immedi-
ate post-transplant view of the hemiface allograft recipient c). The recipient of hemifacial allograft 200 days after transplant shows no signs of rejection on a low maintenance dose of cyclosporine A monotherapy d).
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c Figure 10-4. Dissection of the facial-scalp flap. a) After marking the vascular structure of the flap. b) Through a midline incision, the flap was elevated in the subplatysmal plane, including external jugular vein in the flap. (Siemionow MZ, Unal S, Agaoglu G, et al. What are alternative sources for total facial defect coverage? A cadaver study in preparation for facial allograft transplantation in humans. Plastic and Reconstructive Surgery (PRS-D-04-00324, in press) 2005.)
a
c) Elevation of the flap showing arterial network of the flap. 1) The common carotid artery. 2) The external carotid artery. 3) The superficial temporal artery. 4) The facial artery. 5) The lower border of mandible. (Reprinted from Siemionow MZ, Agaoglu G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
b
Figure 10-5. a) Harvested total facial-scalp flap. b) Harvested facial flap without scalp. (Siemionow MZ, Unal S, Agaoglu G, et al. What are alternative sources for total facial defect coverage? A cadaver study in preparation for facial allograft transplantation in humans. Plastic and Reconstructive Surgery (PRS-D-04-00324, in press) 2005.)
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Figure 10-6. Outline of the percentage of the conventional flaps that covers the surface area of a) a total facial scalp defect and b) a facial defect without scalp.
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Perspectives for Facial Allograft Transplantation in Humans Table 10-1. Advantages and Disadvantages of Facial Allograft Transplantation Advantages Disadvantages • No donor site morbidity • Adequate matching between the • Complete facial reconstruction in donor and recipient is difficult single surgical procedure (age, sex, race) • Option for total external ear • Lifelong immunosuppression replacement or reconstruction • Increased risks of comorbidities • Better skin texture, pliability, and (diabetes, infections, color match lymphoproliferative disorder, avascular necrosis of bones) • Social, ethical, and psychological issues
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11 Tissue Engineering: Current Approaches and Future Directions Amir H. Ajar and Gregory R.D. Evans
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References &# NVccVh >K# I]Z b^hh^c\ dg\Vc VcY ]dl id gZeaVXZ ^i# >c/ I^hhjZ VcY Dg\Vc GZ\ZcZgVi^dc ^c 6Yjaih# NVccVh! >K! Vji]dg# CZl Ndg`/ Heg^c\Zg"KZgaV\! '%%&# '# LVa\ZcWVX] @?! Kd^\i B! G^VW^`]^c 6L! Zi Va# I^hhjZ Zc\^cZZg^c\ ^c eaVhi^X gZXdchigjXi^kZ hjg\Zgn# 6cVidb^X GZX# '%%&0'+(/(,'Ã(,-# (# KVih H! IdaaZn CH! EdaV` ?#! Zi Va# HiZb XZaah/ hdjgXZh VcY Veea^XVi^dch# 8a^c DidaVgnc\da# '%%'0',/'',Ã'('# )# I]dbehdc ?6! >ih`dk^io":aYdg ?! H]Ve^gd HH# :bWgndc^X hiZb XZaah YZg^kZY [gdb ]jbVc WaVhidXnhih# HX^ZcXZ# &..-0'-'/&&)'Ã&&)*# *# BVihj^ N! OhZWd @! =d\Vc 7A# 9Zg^kVi^dc d[ eajg^ediZci ZbWgndc^X hiZb XZaah [gdb bjg^cZ eg^bdgY^Va \Zgb XZaah ^c XjaijgZ# 8Zaa# &%%'0,%/-)&Ã-),# +# =Zcc^c\hdc 8I! HiVc^haVjh B6! bbjcda# '%%(0&&&/H,)*Ã,*(# ,# @dgWa^c\ B! :higdk O! 8]Vbea^c G# 6Yjai hiZb XZaah VcY i^hhjZ gZeV^g# 7dcZ BVggdl IgVcheaVci# '%%(0('/H'(Ã')# -# EZiZghZc 7:! IZgVYV C# HiZb XZaah/ V _djgcZn ^cid V cZl [gdci^Zg# ? 6b HdX CZe]gda# '%%&0&'/&,,(Ã&,-%# .# G^c\Z ?! @Veh 8! 7jgbZhiZg ! 7gjYZg HE# BZhZcX]nbVa hiZb XZaah/ Wj^aY^c\ WadX`h [dg bdaZXjaVg bZY^X^cZ ^c i]Z '&i] XZcijgn# IgZcYh BdaZX BZY# '%%&0,/'*.Ã'+*# &&# EVhh^Zg G! BjbbZgn 8# Dg^\^c VcY jhZ d[ ZbWgndc^X VcY VYjai hiZb XZaah ^c Y^[[ZgZci^Vi^dc VcY i^hhjZ gZeV^g# 8VgY^dkVhX GZh# '%%(0*-/(')Ã((*# &'# 9gj``Zg B! @Vio ci ? 6gi^[ Dg\Vc# '%%'0'*/)()Ã))%#
Tissue Engineering: Current Approaches and Future Directions &,# 7ZcnV E9! HXV[[Zg ?9# 9ZY^[[ZgZci^ViZY X]dcYgdXniZh gZ" ZmegZhh i]Z Y^[[ZgZci^ViZY XdaaV\Zc e]ZcdineZ l]Zc XjaijgZY ^c V\VgdhZ \Zah# 8Zaa# &.-'0(%/'&*Ã'')# &-# =daa^hiZg H?! BVYYdm G9 IVWdVh ?B# Dei^bVa YZh^\c VcY [VWg^XVi^dc d[ hXV[[daYh id b^b^X i^hhjZ egdeZgi^Zh VcY hVi^h[n W^dad\^XVa XdchigV^cih# 7^dbViZg^Vah# '%%'0 '(/)%.*Ã)&%(# &.# Aj A! O]j M! KVaZcojZaV Gci ? E]VgbV# '%%(0'*+/&-(Ã&-.# ')# > XdaaV\Zc bVig^XZh/ egZeVgVi^dc! X]VgVXiZg^oVi^dc VcY ediZci^Va [dg XVgi^aV\Z Zc\^cZZg^c\# 7^dbViZg^Vah# '%%'0'(/(&-(Ã(&.'# '+# HVX]adh :! GZ^h C! 6^chaZn 8! 9ZgWn 7! 8oZgcjho`V ?I# CdkZa XdaaV\Zc hXV[[daYh l^i] egZYZÑcZY ^ciZgcVa bdg" e]dad\n bVYZ Wn hda^Y [gZZ[dgb [VWg^XVi^dc# 7^dbViZg^" Vah# '%%(0')/&)-,Ã&).,# ',# 7! >id 6! DcjbV @! @VcoV`^ C! GZ^h GA# >c k^igd W^dVXi^k^in d[ hiVgX] i]ZgbdeaVhi^X$]nYgdmnVeVi^iZ Xdbedh^iZ W^dbViZg^Vah/ Vc ^c h^ij hijYn jh^c\ Vidb^X [dgXZ b^XgdhXden# 7^dbViZg^Vah# '%%(0')/*,.Ã*-*# (%# <jidlh`V 6! ?Zdc\ 7! ?Vh^dcdlh`^ B# >c_ZXiVWaZ \Zah [dg i^hhjZ Zc\^cZZg^c\# 6cVidb GZX# '%%&0'+(/()'Ã().# (&# C\jnZc @I! LZhi ?A# E]didedanbZg^oVWaZ ]nYgd\Zah [dg i^hhjZ Zc\^cZZg^c\ Veea^XVi^dch# 7^dbViZg^Vah# '%%'0 '(/)(%,Ã&)#
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12 The Role of Stem Cells in Plastic Surgery Maria Z. Siemionow and Selahattin Özmen
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Figure 12-1. Plasticity of stem cells. Adult stem cells have the ability to differentiate into multiple cell types. (ESC: Embryonic stem cells from the inner surface of the blastocyst).
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Figure 12-2. a) Intraosseous transplantation of the cellular bone-marrow-derived CD90 stem and progenitor cells as a therapeutic approach to composite limb allograft transplantation. b) Limb allograft recipients at 7 days posttransplantation after treatment with CD90 stem and progenitor cells without immunosuppression.
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160
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:bWgndc^X hiZb XZaah :H8h ! ]ZbVided^Zi^X hiZb XZaah [gdb! &),Ã&):cYdhXde^X Wgdla^[i! &%&Ã&%( :cYdhXde^X ]VcY VcY cZgkZ hjg\Zgn! ,&Ã,' :H8# HZZ :bWgndc^X hiZb XZaah :miZchdg XdbeVgibZciVa VgiZg^Zh! (* ; ;VXZ! YZ[dgb^in d[! XdckZci^dcVa gZXdchigjXi^kZ bZi]dYh [dg! &&.Ã&'% ;VXZ! gZ_jckZcVi^dc d[! &%&Ã&%, Wgdla^[i! &%&Ã&%( X]ZZ`a^[i! &%) a^ea^[i! &%* b^Y[VXZ XdggZXi^dc! &%(Ã&%) eZg^dgVa! &%)Ã&%, ;VX^Va Vaad\gV[i igVcheaVciVi^dc! &'%Ã&'Veea^XVW^a^in d[! &'& Zi]^XVa Xdch^YZgVi^dch ^c! &(% [ZVh^W^a^in d[! &'& Ñghi ^chi^iji^dcVa gZk^Zl WdVgY VeegdkVa [dg! &(% [jaa"[VX^Va"hXVae! &''Ã&'(! &')! &'* ]Zb^[VX^Va! &''! &'(! &'*! &'+ ]jbVc! &'*Ã&'^bbjcdhjeegZhh^kZ higViZ\^Zh ^c! &'*Ã&(% ZmeZg^bZciVa! &'-Ã&'.
Index
egdidXdah! &'.Ã&(% ehnX]dad\^XVa Xdch^YZgVi^dch ^c! &(% hdX^Va Xdch^YZgVi^dch ^c! &(% ;6@# HZZ ;dXVa VY]Zh^dc `^cVhZ ;VhX^dXjiVcZdjh ÒVeh! + ;<;# HZZ ;^WgdWaVhi \gdli] [VXidg ;^WgdWaVhi \gdli] [VXidg ;<; ! &(. ;^WjaV! kVhXjaVg^oZY WdcZ VcY! )Ã+ ;^aaZi ÒVeh! '! ( ;^c\Zgh VgiZg^Va VcVidbn d[! '(! ') kZcdjh VcVidbn d[! '(! ') ;@"*%+# HZZ 8VaX^cZjg^c ^c]^W^idgh ;aVeh Vm^Va"eViiZgc eZg[jh^dc! ', 8"g^c\! '*Ã'+ Xgdhh"Ñc\Zg! '*Ã'+ YZZe ^c[Zg^dg Ze^\Vhig^X VgiZgn! .%! .& YdghVa bZiVXVgeVa! (&Ã('! (( [VhX^dXjiVcZdjh! + ÑaaZi! '! ( [gZZ! '! ) ijbdg VcY! +Ã, [gZZ Å`^iZ!Æ ((! () ]ZiZgdY^\^iVa ^haVcY! '-! '. ]ZiZgdY^\^iVa gZkZghZY cZjgdkVhXjaVg ^haVcY! '=^a\Zc[ZaYi! '* ]dbdY^\^iVa VY^ed[VhX^Va eVabVg! ', ]dbdY^\^iVa ^haVcY! ']nedi]ZcVg! (%Ã(& ^cig^ch^X XaVhh^ÑXVi^dc d[! '*Ã(+ YZh^\c eg^cX^eaZh d[! ')Ã'* ^hX]Zb^X egZXdcY^i^dc^c\ d[! ]^hidgn d[! .(Ã.) eZg[dgVidg ÒVeh! .%Ã.& ^haVcY eZY^XaZ! ' A^iiaZg! '* egdcVidg! -,Ã-gVcYdb"eViiZgc! ', i]ZcVg! '.Ã(% igVY^i^dcVa! '* kZcdjh! (( ;aZmdg iZcYdc VcY h`^c ^haVcY [dgZVgb igVch[Zg! XdbW^cZY! *&Ã*' ;aZmdg iZcYdc VeeVgVijh igVcheaVcih! &)! *(Ã*) ;dXVa VY]Zh^dc `^cVhZ ;6@ ! &(.
;gZZ ÒVeh! '! ) ;gZZ Å`^iZÆ ÒVe! ((! () ;jaa"[VX^Va"hXVae igVcheaVci! &'( bdYZa d[! &''Ã&'( < <^VbeVeÈh iZX]c^fjZ! &%
Index
=>K# HZZ =jbVc ^bbjcdYZÑX^ZcXn k^gjh$ Vjid^bbjcZ YZÑX^ZcXn hncYgdbZ =dbdY^\^iVa VY^ed[VhX^Va eVabVg ÒVe! ', =dbdY^\^iVa ^haVcY ÒVe! '=jbVc [VX^Va Vaad\gV[i igVcheaVci! &'*Ã&'+ =jbVc ^bbjcdYZÑX^ZcXn k^gjh$ Vjid^bbjcZ YZÑX^ZcXn hncYgdbZ =>K$6>9H ! a^edYnhigde]n XdggZXi^dc VcY! &&(Ã&&* =nVajgdc^X VX^Y ^c_ZXi^dch! &%+Ã &%, =neZgWVg^X dmn\Zc! dhiZdbnZa^i^h VcY! , =nedi]ZcVg ÒVe! (%Ã(& > ><;# HZZ >chja^c \gdli] [VXidg >A"'# HZZ >ciZgaZj`^c"' gZXZeidg VciV\dc^hih >a^oVgdk iZX]c^fjZ! )Ã*! +Ã, >bbjcdhjeegZhh^kZ Ygj\h! [dg Xdbedh^iZ i^hhjZ Vaad\gV[ih! &+Ã'%! &'Vci^egda^[ZgVi^kZ V\Zcih! &. XVaX^cZjg^c ^c]^W^idgh! &Xdgi^XdhiZgd^Yh! &. ^cYjXi^dc egdidXdah! &+ ^ciZgaZj`^c"' gZXZeidg VciV\dc^hih! &. anbe]dXniZ YZeaZi^c\ V\Zcih! &.Ã'% bV^ciZcVcXZ egdidXdah! &gZ_ZXi^dc! &h^gda^bjh gVeVbnX^c ! &-Ã&. >chja^c \gdli] [VXidg ><; ! &(. >ciZgXdbeVgibZciVa hjegVgZi^cVXjaVg VgiZg^Zh! (* >ciZgaZj`^c"' >A"' gZXZeidg VciV\dc^hih! &. >ciZgaZj`^ch! &(. >cig^ch^X ÒVeh XaVhh^ÑXVi^dc d[! '*Ã(+ Vm^Va"eViiZgc eZg[jh^dc! ', Xgdhh"Ñc\Zg! '*Ã'+ YdghVa bZiVXVgeVa! (&Ã('! (( [gZZ Å`^iZ!Æ ((! () ]ZiZgdY^\^iVa ^haVcY! '-! '.
161
]ZiZgdY^\^iVa gZkZghZY cZjgdkVhXjaVg ^haVcY! ']dbdY^\^iVa ^haVcY! ']nedi]ZcVg! (%Ã(& gVcYdb"eViiZgc! ', i]ZcVg! '.Ã(% igVY^i^dcVa! '* kZcdjh! (( YZh^\c eg^cX^eaZh d[! ')Ã'* >E# HZZ >hX]Zb^X egZXdcY^i^dc^c\ >hX]Zb^V gZeZg[jh^dc ^c_jgn! .)Ã.YZaVn egdXZYjgZ! .) c^igdjh dm^YZ! gdaZ d[! .,Ã.egZXaVbe^c\! .* gZbdiZ ^hX]Zb^X egZXdcY^i^dc^c\! .*Ã., >hX]Zb^X egZXdcY^i^dc^c\ >E ! d[ ÒVeh! ]^hidgn d[! .(Ã.) >haVcY eZY^XaZ ÒVeh! ' ? ?d^ci YZcZgkVi^dc! +&Ã+* ZaWdl VcY `cZZ! +& h]djaYZg! +(Ã+* h^cjh iVgh^! +&Ã+( iZbedgdbVcY^WjaVg _d^ci! +*Ã+, lg^hi! +& @ @^ZcWX`Èh Y^hZVhZ! kVhXjaVg^oZY WdcZ \gV[ih VcY! ((Ã(+ @^iZ ÒVe# HZZ =^a\Zc[ZaYi ÒVe @cZZ igVcheaVcih! &(Ã&) A AVgncm igVcheaVcih! &* A^bW hVakV\Z! 'Ã, Y^VWZiZh VcY! A^ea^[i! &%* <jaa"l^c\ ZmX^h^dc! &%* A^eZXidbn! VciZg^dg! &%-Ã&&&! &&' A^edYnhigde]n! XdggZXi^dc d[! &&(Ã&&* A^iiaZg ÒVe! '* A^kZg XZaah! [ZiVa! ]ZbVided^Zi^X hiZb XZaah [gdb! &)) Anbe]dXniZ"YZeaZi^c\ V\Zcih! &.Ã'% B B68H"a^[i# HZZ B^c^bVa VXXZhh XgVc^Va hjheZch^dc
B6E@# HZZ B^id\Zc"VXi^kViZY egdiZ^c `^cVhZ BXAZVc! 9dcVaY! .) BZhZcX]nbVa hiZb XZaah BH8h ! VYkVcXZh ^c! &*& BZi]naegZYc^hdadcZ! &(! &* B^XgdkVXjaV! )(Ã)) B^Y[VXZ! XdggZXi^dc d[! &%(Ã&%) B^c^bVa VXXZhh XgVc^Va hjheZch^dc B68H"a^[i ! &%) B^id\Zc"VXi^kViZY egdiZ^c `^cVhZ B6E@ ! &(. BB;# HZZ BnXde]ZcdaViZ bd[Zi^a Bdji]! Ydlcijgc XdgcZgh d[! &%*Ã &%, BH8h# HZZ BZhZcX]nbVa hiZb XZaah Bjai^b^XgdkVXjaVg XdaaV\Zcdjh VWhdgW^c\ hnhiZb BK86H ! ))! )* V[iZg igVjbV! )* VcVidb^XVa XdcXajh^dch d[! )+Ã ),! )\adWVa^in! ))Ã)+ eVi]dad\n! )* e]nh^dad\^XVa XdcXajh^dch d[! ). hjg\^XVa XdcXajh^dch d[! ).Ã*' ^c k^kd dWhZgkVi^dch! )&Ã)' BjgdbdcVW"89(! &* BjhXaZ igVcheaVcih! &* BK86H# HZZ Bjai^b^XgdkVXjaVg XdaaV\Zcdjh VWhdgW^c\ hnhiZb BnXde]ZcdaViZ bd[Zi^a BB; ! &'! &(! &*! &+! &.! &'BndZaZXig^X egdhi]Zh^h! '! ( C CZX`! XZgk^Xd[VX^Va g]ni^YZXidbn! &%,Ã&&& Va^eZXidbn VcY eaVinhbVeaVhin! &%CZgkZh Vaad\gV[ih! *-Ã*. XdcYj^ih! *.Ã+& YZXdbegZhh^dc! **Ã*^c Y^VWZiZh! *+Ã*ZcYdhXde^X hjg\Zgn! ,&Ã,'! ,+Ã -( \gV[ih! *gZXdchigjXi^dc d[! *ineZh d[ XVaXVcZVa! *, aViZgVa eaVciVg! *,
162
CZgkZh Xdc # bZY^Va eaVciVg! +, bZY^Vc! ,'Ã,, edhiZg^dg ^ciZgdhhZjh! -'Ã-) edhiZg^dg i^W^Va! *, gVY^XVa! -) jacVg! ,,Ã-' CZgkZ igVcheaVcih! &)Ã&* CZjgdijWZ! *.Ã+& D D@I(# HZZ 6ci^"89( Vci^WdYn DcZ"hiV\Z gZXdchigjXi^dc! )! + Dgi]deaVhi^X hjg\Zgn! Xdhi Z[[ZXi^kZcZhh d[! ' DhiZdbnZa^i^h VcVidb^X ineZh d[! , e]nh^dad\^X XaVhhZh d[! , igZVibZci d[! ,ÃE EVgViZcYdc! ). EVgVjbW^a^XVa eZg[dgVidg EJE ÒVe# HZZ 9ZZe ^c[Zg^dg Ze^\Vhig^X VgiZgn ÒVe EVghdcV\Z"IjgcZg hncYgdbZ! ,, EVgi^Va _d^ci YZcZgkVi^dc! +&Ã++! +, E7H8# HZZ EZg^e]ZgVa WaddY hiZb"XZaa E9<;# HZZ EaViZaZi YZg^kZY \gdli] [VXidg E:D"EED"E:D# HZZ EdanZi]naZcZ dm^YZ"W"egdenaZcZ dm^YZ" W"Zi]naZcZ dm^YZ EZg[dgVidg ÒVeh! ]^hidgn d[! -,Ã-hjg\^XVa Xdch^YZgVi^dch d[! --Ã.% ineZh d[! .%Ã.& 6AI! -9>:6E! .% A8;6E"ja! -EJE! .% H"<6E! .% IG6B! .% EZg^dgVa gZ_jkZcVi^dc! &%)Ã&%, EZg^e]ZgVa WaddY hiZb"XZaa E7H8 ! &))Ã&), Vaad\Zc^X igVcheaVciVi^dc d[! &), WZcZÑih d[! &), XdaaZXi^dc iZX]c^fjZh! &)*Ã&)+ YgVlWVX`h d[! &),
Index
Zc\gV[ibZci d[! &)+ [VXidgh V[[ZXi^c\ n^ZaY! &)* `^cZi^Xh d[! &)+ bdW^a^oVi^dc egdidXdah! &))Ã&)*! &)+ EZg^e]ZgVa cZgkZ hjg\Zgn ZcYdhXde^X b^c^bVaan ^ckVh^kZ VeegdVX]! ,&Ã,'! ,+Ã-( hnbeidbVi^X cZjgdeVi]n VcY! **Ã*E<6# HZZ Edan\anXda^X VX^Y E]dhe]da^eVhZ"8 \VbbV EA8" \VbbV ! &(. EaViZaZi YZg^kZY \gdli] [VXidg E9<; ! &(. EaVinhbVaeaVhin! &%-Ã&&&! &&' EA8"\VbbV# HZZ E]dhe]da^eVhZ"8 \VbbV EdanZi]naZcZ dm^YZ"W"egdenaZcZ dm^YZ"W"Zi]naZcZ dm^YZ E:D"EED"E:D ! &(Edan\anXda^X VX^Y E<6 ! *. EdhiWVg^Vig^X hjg\Zgn! &&&! &&( EgZYc^hdcZ! &&! &'! &) EgZ^hZgÈh Y^hZVhZ! kVhXjaVg^oZY WdcZ \gV[ih VcY! ((Ã(+ EgdcVidg hncYgdbZ! ,*Ã,, Egdhi]Zh^h bndZaZXig^X! '! ( JiV] Vgb! '! ( EgdiZd\anXVch! )( EJE# HZZ EVgVjbW^a^XVa eZg[dgVidg ÒVe G GVY^Va cZXgZXidbn! ) dhiZdbnZa^i^h VcY! , GVY^Va hZchdgn cZgkZ GHC XdbegZhh^dc! -) GVY^Va ijccZa hncYgdbZ# HZZ IZcc^h ZaWdl GVcYdb"eViiZgc ÒVeh! ', GHC# HZZ GVY^Va hZchdgn cZgkZ XdbegZhh^dc H HXVe]d^Y cdcjc^dc VYkVcXZY XVgeVa XdaaVehZ HC68 ! (+ H:K6"8 hiVgX] WaZcYZY l^i] Zi]naZcZ k^cna VaXd]da ! &(H"<6E# HZZ HjeZg^dg \ajiZVa VgiZgn ÒVe H]djaYZg YZcZgkVi^dc! +(Ã+*
H^bjaZXi# HZZ 7Vh^a^m^bVW HC68# HZZ HXVe]d^Y cdcjc^dc VYkVcXZY XVgeVa XdaaVehZ Hea^i"i]^X`cZhh h`^c \gV[i HIH< ! '+ HiZb XZaah! &(*Ã&(+ VYkVcXZh ^c VYjai! &*%Ã&*& bZhZcX]nbVa! &*& Veea^XVi^dc d[! [dg i^hhjZ gZeV^g! &(+Ã&(, ^c WdcZ Zc\^cZZg^c\! &*( ^c XVgi^aV\Z Zc\^cZZg^c\! &*( ]ZbVided^Zi^X! hdjgXZh d[ [gdb WdcZ bVggdl! &)(Ã&)) [gdb ZbWgndc^X hiZb XZaah! &),Ã&)[gdb [ZiVa a^kZg XZaah! &)) ^c"k^igd ZmeVch^dc d[! &).Ã&*% [gdb eZg^e]ZgVa WaddY! &))Ã&), [gdb jbW^a^XVa XdgY WaddY! &)-Ã&). eaVhi^X hjg\Zgn VcY! &)( ^c iZcYdc Zc\^cZZg^c\! &*) ^c ldjcY ]ZVa^c\! &*) HiZgcjb! ^chiVW^a^in d[! Xjhidb eaViZh VcY! HiZgd^Yh! &&! &' HigZeidbnXZh ]n\gdhXde^Xjh! &HigZeidbnXZh ihj`jWVZch^h! &HIH<# HZZ Hea^i"i]^X`cZhh h`^c \gV[i HjeZg^dg \ajiZVa VgiZgn H"<6E ÒVe! .%Ã.& Hjg\^XVa Vc\^d\ZcZh^h! (( HnbeidbVi^X cZjgdeVi]n! cZgkZ YZXdbegZhh^dc [dg! **Ã*I IVXgda^bjh! &&! &'! &(! &) IV\a^VXdoo^!
Index
IZcYdc!kVhXjaVg^oZYÒZmdg iZcYdcigVch[Zg!).Ã*' IZcc^hZaWdl!-'Ã-) I<;"WZiV&#HZZIgVch[dgb^c\ \gdli][VXidgWZiV"& I]ZcVgÒVe!'.Ã(% I]ZgVeZji^XVc\^d\ZcZh^h!(( I]^c"l^gZÑmVi^dc!)Ã*!+Ã, I^cZaÈhh^\c!cZgkZigVcheaVcih VcY!&)!&* I^hhjZZc\^cZZg^c\ W^dbViZg^Vah!&(,Ã&(. \gdli][VXidgh!&(.Ã&)% egd\Zc^idgXZaah^c!&*(Ã&*) hiZbXZaah^c!&(*Ã&(,! &*(Ã&*) I^hhjZ!ZmeVch^dcd[!VZhi]Zi^X Xdch^YZgVi^dcjh^c\!)! * IB?#HZZIZbedgdbVcY^WjaVg _d^ci IC;#HZZIjbdgcZXgdh^h[VXidg Idc\jZigVcheaVcih!&* IDG iVg\Zid[gVeVbnX^c ^c]^W^idg!&-Ã&.
163
IgVX]ZVigVcheaVcih!&+ IgVY^i^dcVaÒVeh!'* IG6B#HZZIgVchkZghZgZXijh VWYdb^c^hbndXjiVcZdjh ÒVe IgVch[dgb^c\\gdli][VXidg WZiV"& I<;"WZiV& !&)% IgVcheaVcih!&&Ã&+ VWYdb^cValVaa!&( ÒZmdgiZcYdcVeeVgVijh! &) ]VcY!&&Ã&( `cZZ!&(Ã&) aVgncm!&* bjhXaZ!&* cZgkZ!&)Ã&* idc\jZ!&* igVX]ZV!&+ IgVchkZghZgZXijhVWYdb^c^h bndXjiVcZdjh IG6B ÒVe!.%!.& Ig^X]dYZgbVedanhedgjb!&Ijbdgh [gZZÒVehVcY!+Ã, gZXdchigjXi^dcV[iZg!)
IjbdgcZXgdh^h[VXidg IC; ! &(J J87#HZZJbW^a^XVaXdgYWaddY JbW^a^XVaXdgYWaddY J87 ! ]ZbVided^Zi^XhiZbXZaah [gdb!&)-Ã&). JiV]Vgb!'!( K KVhXjaVg^oZYWdcZ\gV[ih!((Ã(* bdY^ÑXVi^dcd[!(*Ã(+ KVhXjaVg^oZYÒZmdgiZcYdc^haVcY [dgZVgbigVch[Zg!).Ã*& KZcdjhÒVe!(( L LZ^\]iadhh!bVhh^kZ#HZZ EdhiWVg^Vig^Xhjg\Zgn LdjcY]ZVa^c\!^chiZbXZaah! &*) O OZcVeVm#HZZ9VXa^ojbVW
