Accepted Manuscript Emergency repair of upper extremity large soft tissue and vascular injuries with flowthrough anterolateral thigh free flaps Yi Zhan, Guo Fu, Xiang Zhou, Bo He, Li-Wei Yan, Qing-Tang Zhu, Li-Qiang Gu, XiaoLin Liu, Jian Qi PII:
S1743-9191(17)31335-3
DOI:
10.1016/j.ijsu.2017.09.078
Reference:
IJSU 4211
To appear in:
International Journal of Surgery
Received Date: 24 August 2017 Accepted Date: 29 September 2017
Please cite this article as: Zhan Y, Fu G, Zhou X, He B, Yan L-W, Zhu Q-T, Gu L-Q, Liu X-L, Qi J, Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2017.09.078. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps Running title: Extremity repairment with Flow-through flaps
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Yi Zhan, PhD 1#, Guo Fu, PhD 2#, Xiang Zhou, PhD 1, Bo He, PhD 1, Li-Wei Yan, PhD , Qing-Tang Zhu, PhD 1, Li-Qiang Gu, PhD 1, Xiao-Lin Liu, PhD 1*#, Jian Qi, PhD1*#
1. Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of
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Sun Yat-sen University, Guangzhou, Guangdong, China 510080
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2. Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China 510630 #
These authors contributed equally to this work.
Corresponding author:
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Jian Qi, Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, China 510080
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Email: qijian17[email protected]; Tel: +86 20 87332200 ext 8242; Fax: +86 20 8733 2150.
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Xiao-Lin Liu, Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, China 510080
Email: [email protected]; Tel: +86 20 87332200 ext 8242; Fax: +86 20 8733 2150.
Conflict of interest: None
ACCEPTED MANUSCRIPT Funding: This study was supported by the National Health and Family Planning
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Commission and Public welfare research projects (# 201402016) in China
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Emergency repair of upper extremity large soft tissue and vascular injuries with flow-
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through anterolateral thigh free flaps
Abstract
Background/Objectives: Complex extremity trauma commonly involves both soft tissue and
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vascular injuries. Traditional two-stage surgical repair may delay rehabilitation and functional recovery, as well as increase the risk of infections. We report a single-stage reconstructive
to improve functional outcomes.
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surgical method that repairs soft tissue defects and vascular injuries with flow-through free flaps
Methods: Between March 2010 and December 2016 in our hospital, 5 patients with severe upper extremity trauma received single-stage reconstructive surgery, in which a flow-through
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anterolateral thigh free flap was applied to repair soft tissue defects and vascular injuries simultaneously. Cases of injured artery were reconstructed with the distal trunk of the descending branch of the lateral circumflex femoral artery. A segment of adjacent vein was used if there was
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a second artery injury. Patients were followed to evaluate their functional recoveries, and received computed tomography angiography examinations to assess peripheral circulation.
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Results: Two patients had post-operative thumb necrosis; one required amputation, and the other was healed after debridement and abdominal pedicle flap repair. The other 3 patients had no major complications (infection, necrosis) to the recipient or donor sites after surgery. All the patients had achieved satisfactory functional recovery by the end of the follow-up period. Computed tomography angiography showed adequate circulation in the peripheral vessels.
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Conclusions: The success of these cases shows that one-step reconstructive surgery with flowthrough anterolateral thigh free flaps can be a safe and effective treatment option for patients with
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complex upper extremity trauma with soft tissue defects and vascular injuries.
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Keywords: extremity injury; flow-through flaps; emergency repair, microsurgery
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1 Introduction Complex extremity trauma that causes skin and soft tissue defects and also vascular injuries can lead to permanent disabilities. Treatment of these cases is always challenging for surgeons[1-
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4]. Traditional surgical treatment is performed in two stages; the first to repair the vascular injury, and the second to reconstruct the soft tissue defects with free or pedicled flaps[5-9]. These twostage surgical procedures commonly require significant time to complete, which delays patients’
such as infections, including osteomyelitis.
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subsequent rehabilitation and functional recovery, and also increases the risk of complications
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A flow-through technique has been reported to repair soft tissue and vascular injury simultaneously in a single-stage surgery[10-12]. Flow-through flaps allow repair of the injured soft tissues, as well as revascularization through anastomosis to the body parts distal to the injured site. Patients with complex injury to the extremities reportedly achieve satisfactory
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recoveries after one-stage flow-through free flap reconstructive surgery. A limited study reported the repair of upper extremity large soft tissue defects and major vascular injuries with a free flow-through anterolateral thigh flap. This has the advantage of
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providing large flow-through free flaps, with a minimal conspicuous scar at the donor site[13]. Herein, we report 5 patients treated with flow-through anterolateral thigh free flaps during
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reconstructive surgery to repair large soft tissue and vascular injuries of the upper extremity.
2 Material and methods
2.1 Study design and participants This was a prospective observational study performed at an urban academic teaching hospital between March 2010 and December 2016. The hospital ethics committee approved the
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study protocol. All of the study participants signed informed consent. We would like to state that the current research work has been reported in line with the PROCESS criteria. All the included 5 patients had severe upper extremity injury with a large skin defect and
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major vascular injury, and agreed to receive one-stage reconstruction surgery with flow-through anterolateral thigh free flaps on the recommendation of the primary treating surgeon. Excluded from the study was any patient unable or unwilling to sign the informed consent, or had
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concomitant major injury such as chest or abdominal injury that precluded emergency surgery for
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the extremity[14].
2.2 Surgical technique
The 5 patients received basic blood tests that included complete cell counts, basic metabolic panel, coagulation study, and type and screen; and extremity imaging studies such as X-ray and
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computed tomography angiography (CTA). The surgeries were performed with patients under general anesthesia. Skin flaps were prepared based on the severity of the individual patient’s extremity injury, with perforator flaps for less contaminated wounds, and musculocutaneous flaps
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for contaminated wounds or deep wounds with large muscular defects. A long segment of the distal trunk of the descending branch of the lateral femoral
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circumflex artery was preserved, to reconstruct the major vessel in the injured upper extremity. After thorough wound debridement of the injured upper extremity, emergency one-stage repair of the large soft tissue defects and vessel injury of the upper extremity was performed with flowthrough anterolateral thigh free flaps (Figure 1). The upper extremity soft tissue defects were covered by the thigh free flaps. The injured artery was reconstructed and anastomosed to the femoral circumflex artery to regain blood flow. A segment of vein close to the descending branch of the lateral femoral circumflex artery (either the lateral femoral circumflex vein or the great 4
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saphenous vein) was also used for reconstruction if there was a second artery injury. The thigh area for the donor flap was sutured primarily. External fixation was applied if there was concomitant bone fracture or a requirement for postoperative nursing care.
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After the reconstructive surgery, the repaired upper extremity was elevated and kept warm. Routine antibiotics, analgesics, anti-spasmodic, and anti-thrombotic treatments were applied. Upper extremity blood supply and discharges from the flaps and the thigh donor sites were
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closely monitored. Patients were encouraged to participate in rehabilitation as early as possible and were followed for up to 60 months after the surgery. At the end of the follow-up period, CTA
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was repeated to assess peripheral blood circulations.
3 Results
We enrolled 5 patients in this analysis, 2 females and 3 males, with ages ranging from 2 to
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55 years (Table 1). All of them had upper extremity (upper arm, forearm, or wrist) large soft tissue defects and vascular damages from either traffic accidents or crush injuries. The mangled extremity severity scores (MESS) were between 7 and 9. The times from injury to emergency
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surgical operations were between 5 and 12 hours. The sizes of the soft tissue defects ranged from 13 × 7 to 30 × 10 cm2.
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One patient had only one artery injury (radial artery), and the other 4 patients had two artery injuries (the ulnar artery with either the brachial or radial artery). None of the 5 patients had palpable distal limb arterial pulses. Four patients had sluggish capillary refills and one patient had a pale hand with no detectable capillary refill. During the operations, the sizes of the anterolateral thigh free flaps were between 14 × 8 and 32 × 12 cm2. The length of the major reconstructed artery ranged from 4 to 10 cm. During the follow-up after the surgeries, all the donor flaps survived. There was no complication involving the thigh donor sites. Patients began rehabilitation 5
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for functional recovery as early as possible when tolerated, or underwent subsequent bone fracture treatments, if necessary.
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3.1 Case 1
A 45-year-old woman experienced injury resulting from a traffic accident (Figure 2). She had a right upper arm-to-forearm injury with a soft tissue defect size 30 × 10 cm2. Both the brachial
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artery and the ulnar artery were injured (8- and 10-cm ruptures, respectively) with a thrombosis observed in the brachial artery. Her MESS was 7. A 32 × 12-cm flow-through left anterolateral
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thigh flap was prepared and transplanted to the right arm to cover the defected soft tissue. The injured brachial artery was reconstructed and anastomosed to the descending branch of the femoral circumflex artery to regain vascularization. A segment of the great saphenous vein was used to reconstruct the injured ulnar artery. External fixation was used after the surgery. The
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postoperative recovery was uneventful. This patient was followed for 60 months. Her right elbow and wrist flexion and extension and hand grip function were almost fully recovered. CTA showed
3.2 Case 2
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satisfactory circulations to the right arm at the end of the follow-up.
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A 20-year-old man presented with trauma to the right forearm and wrist due to a crushing injury from operating a machine (Figure 3). His MESS was 9 and the size of skin defect was 22 × 10 cm2, with accompanied distal radial and ulnar fractures. The preoperative CTA showed ruptures of both the ulnar artery and radial artery. During the surgery, a 25 × 8 cm2 anterolateral thigh free flap was transplanted to repair the arm soft tissue injury. Similar to case 1, the injured radial artery was reconstructed and anastomosed to the descending branch of the femoral circumflex artery to regain vascularization. A segment of the great saphenous vein was used to reconstruct 6
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the injured ulnar artery. Unfortunately, the thumb became necrotic during the postoperative recovery period. After debridement, an abdominal pedicle flap was used for repairment. At the 6-
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month follow-up visit, CTA showed satisfactory blood circulation.
4 Discussion
In the current study, we describe 5 patients who had severe upper extremity trauma, with
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both large soft tissue defects and major vascular injuries. Emergency reconstructive surgeries were performed with flow-through anterolateral thigh free flaps. All the 5 patients had
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satisfactory functional recovery at the end of the follow-up period.
Previous studies reported that early emergency surgery to repair extremity injuries was safe and effective, and could potentially yield better functional outcomes[15-17]. However, complex extremity trauma commonly involves both soft tissue and vascular structures. Emergency
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surgical repair should reconstruct both damaged soft tissue and vessels. Traditional 2-stage operations may delay recovery and increase the risk of infections[8, 9]. The flow-through flap can repair large soft tissue and vascular defects in a single one-stage operation and provides
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blood supply through anastomosis to the free flaps without disrupting distal circulation to the extremities[18, 19]. This potentially makes the flow-through flap a better option to repair both
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soft tissue and vascular injuries in the extremities. The one-stage simultaneous repair of both soft tissue defects and vascular injuries may save recovery time, improve rehabilitation, and decrease the risk of infections.
The flow-through flap technique was first proposed for reconstruction of intra-oral injuries by Soutar et al. in 1983[20]. One year later, in 1984, Foucher et al[21]. described a radial artery forearm flow-through flap to repair an extremity injury. Since then, various types of flow-through flaps have been reported[10-12]. 7
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The donor sites for flaps are commonly from the extremities. The free flow-through anterolateral thigh flap can provide a large area of skin flap, up to 650 cm2, with a long pedicle 37.1 cm[12, 22]. The mean diameter of the descending branch of the circumflex femoral artery is
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up to 3.0 mm[22]. Depending on the requirement of the injured site, the anterolateral thigh flap can be harvested as a skin-alone, adipofascial, myocutaneous, or musculocutaneous flap[23-25]. All these characteristics have made the thigh an ideal location to harvest the flow-through free
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flap to repair soft tissue defects and re-vascularize the ischemic extremity[26, 27].
Major complications after extremity reconstructive surgery include infections and vascular
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thrombosis, with subsequent distal limb necrosis. Delay in reconstructive surgery increases the chance for infection. All our patients received emergency repair within 12 hours after their injury. There was no infection in any of our patients. One patient (case 5) had thumb necrosis after the emergency repair surgery. The necrotic part was debrided, and healed after an abdominal pedicle
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flap repairment. This patient had a high MESS 9 from the crush injury, a large soft tissue defect 22 × 10 cm2, both radial and ulnar artery injuries, long segment artery injury (8 and 10 cm), and a long period of ischemia before the surgery (10 h). Any of these might have contributed to the
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thumb necrosis after the operation.
Considering our experience and previous publications, we recommend that several issues be
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considered during this type of reconstructive surgery. Firstly, there are 8 types of anatomic variations of anterolateral thigh flaps. The flow-through flap should have clearly identified proximal and distal vascular pedicles. Type seven, which misses the blood vessels used for bridging vascular pedicles, is not recommended for the flow-through flap[28]. Secondly, emergency surgery is recommended to repair the extremity trauma. However, a preoperative CTA or Doppler should still be considered to assess the vascular injury, to aid operative planning and consultation with the patient regarding prognosis[22, 29]. 8
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We used the distal trunk of the descending branch of the lateral circumflex femoral artery to reconstruct the injured upper extremity artery. The lateral branch of the lateral circumflex femoral artery should still be retained as a backup for vascular reconstruction. In addition, a
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segment of vein adjacent to the lateral circumflex femoral artery, such as the lateral circumflex femoral vein or great saphenous vein, can be used for vascular reconstruction if there is more than one artery injury.
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Finally, the prognosis after surgery may be associated with the mechanism of injury. For example, both our patients with post-operative thumb necrosis had suffered crush injuries. Pre-
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operative consideration of reconstructive surgery should consider this possibility.
5 Conclusions
In conclusion, emergency surgery with flow-through anterolateral thigh free flap to repair
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upper extremity soft tissue and vascular injuries is safe and effective. This is a one-stage operation and potentially provides faster and better functional recovery with low risk of infections. To achieve the best post-operative recovery, the injury mechanism, pre-operative
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imaging studies, flap site, and flap type should be carefully considered.
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Conflicts of interest: none
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cases, Microsurgery. 34(2014) 425-433.
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26(2016) 25-31.
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soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap, Int J Surg.
[4] Y.C. Hsiao, J.Y. Yang, C.J. Chang, C.H. Lin, S.Y. Chang, S.S. Chuang, Flow-through anterolateral thigh flap for reconstruction in electrical burns of the severely damaged upper
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extremity, Burns. 39(2013) 515-521.
[5] A. Spyropoulou, S.F. Jeng, Microsurgical coverage reconstruction in upper and lower extremities, Semin Plast Surg. 24(2010) 34-42.
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[6] J. Bullocks, B. Naik, E. Lee, L. Hollier, Jr., Flow-through flaps: a review of current knowledge and a novel classification system, Microsurgery. 26(2006) 439-449.
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[7] D.W. Zheng, Z.C. Li, R.J. Shi, F. Sun, L. Xu, K.S. Shou, Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury, Injury. 47(2016) 364-371. [8] C.A. Derderian, W.A. Olivier, G. Baux, J. Levine, G.C. Gurtner, Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience, J Reconstr Microsurg. 19(2003) 455-462.
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[9] A.R. Kumar, N.S. Grewal, T.L. Chung, J.P. Bradley, Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period, J Trauma. 67(2009) 752757.
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[10] S. Nasir, M.A. Aydin, E. Sonmez, B. Baykal, Flow-through free latissimus dorsi flap for reconstruction of injured limbs: Evaluation of hemodynamic effects on extremity circulation, Ann Plast Surg. 65(2010) 164-169.
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[11] K. Yokota, T. Sunagawa, O. Suzuki, M. Nakanishi, M. Ochi, Short interposed pedicle of
Reconstr Microsurg. 27(2011) 109-114.
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flow-through anterolateral thigh flap for reliable reconstruction of damaged upper extremity, J
[12] L. Qing, P. Wu, J. Liang, F. Yu, C. Wang, J. Tang, Use of Flow-Through Anterolateral Thigh Perforator Flaps in Reconstruction of Complex Extremity Defects, J Reconstr Microsurg. 31(2015) 571-578.
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[13] N. Spindler, S. Al-Benna, A. Ring, H. Homann, L. Steinstrasser, H.U. Steinau, et al., Free anterolateral thigh flaps for upper extremity soft tissue reconstruction, GMS Interdiscip Plast Reconstr Surg DGPW. 4(2015) Doc05.
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[14] R.A. Agha, A.J. Fowler, S. Rajmohan, I. Barai, D.P. Orgill, Preferred reporting of case series in surgery; the PROCESS guidelines, Int J Surg. 36(2016) 319-323.
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[15] L.C. Fox, M.P. Kreishman, High-energy trauma and damage control in the lower limb, Semin Plast Surg. 24(2010) 5-10. [16] C.C. Hsu, Y.T. Lin, C.H. Lin, C.H. Lin, F.C. Wei, Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity, Plast Reconstr Surg. 123(2009) 1739-1747. [17] M. Ninkovic, H. Deetjen, K. Ohler, H. Anderl, Emergency free tissue transfer for severe upper extremity injuries, J Hand Surg Br. 20(1995) 53-58.
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[18] Y. Wang, S.Y. Chen, W.Y. Gao, J. Ding, W. Shi, X.L. Feng, et al., Experimental study of survival of pedicled perforator flap with flow-through and flow-end blood supply, Br J Surg. 102(2015) 375-381.
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[19] S. Miyamoto, M. Okazaki, N. Ohura, T. Shiraishi, A. Takushima, K. Harii, Comparative study of different combinations of microvascular anastomoses in a rat model: end-to-end, end-toside, and flow-through anastomosis, Plast Reconstr Surg. 122(2008) 449-455.
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[20] D.S. Soutar, L.R. Scheker, N.S. Tanner, I.A. McGregor, The radial forearm flap: a versatile method for intra-oral reconstruction, Br J Plast Surg. 36(1983) 1-8.
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[21] G. Foucher, F. van Genechten, N. Merle, J. Michon, A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap, Br J Plast Surg. 37(1984) 139-148.
[22] K. Sananpanich, Y.K. Tu, J. Kraisarin, P. Chalidapong, Flow-through anterolateral thigh
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flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: anatomical study and case report, Injury. 39 Suppl 4(2008) 47-54. [23] C.H. Wong, F.C. Wei, B. Fu, Y.A. Chen, J.Y. Lin, Alternative vascular pedicle of the
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anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery, Plast Reconstr Surg. 123(2009) 571-577.
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[24] M.M. Hanasono, R.J. Skoracki, A.K. Silva, P. Yu, Adipofascial perforator flaps for "aesthetic" head and neck reconstruction, Head Neck. 33(2011) 1513-1519. [25] S. Devansh, Lateral thigh free flap with flow-through vascular pedicle, Ann Plast Surg. 67(2011) 44-48.
[26] Y.G. Song, G.Z. Chen, Y.L. Song, The free thigh flap: a new free flap concept based on the septocutaneous artery, Br J Plast Surg. 37(1984) 149-159.
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[27] I. Koshima, S. Kawada, H. Etoh, S. Kawamura, T. Moriguchi, H. Sonoh, Flow-through anterior thigh flaps for one-stage reconstruction of soft-tissue defects and revascularization of ischemic extremities, Plast Reconstr Surg. 95(1995) 252-260.
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[28] Y. Kimata, K. Uchiyama, S. Ebihara, T. Nakatsuka, K. Harii, Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases, Plast Reconstr Surg. 102(1998) 1517-1523.
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[29] R.A. Agha, B. Gundogan, A.J. Fowler, T.W. Bragg, D.P. Orgill, The efficacy of the Cook-
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protocol, BMJ Open. 4(2014) e004253.
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Swartz implantable Doppler in the detection of free-flap compromise: a systematic review
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Figure legends Figure 1. Operation methods: (A) Complex to the upper arm forearm soft tissue defect of brachial artery defect. (B) low-through anteriolateral thigh free flap repair. (C) Complex to the
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palm of the soft tissue defect of forearm, ulnar artery defect. (D) Flow-through anteriolateral thigh free flap repair, rotation the lateral femoral artery to repair radial artery, great saphenous
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vein graft of ulnar artery.
Figure 2. Female patient, 45 years old,Traffic accident, after debridement, the right arm and right
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forearm extensive soft tissue defect after anastomosis of brachial artery thrombosis was observed, cut off serious contusion and thrombosis of blood vessels, blood vessels visible defects was 8 cm (Fig 2a, 2b); the left anterolateral thigh flap size is 32 cm × 12 cm (Fig 2C), flap transplantation combined with external fixation (Fig 2D, 2e), the appearance, function and CTA after operation
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60 months(Fig 2f~2i).
Figure 3. Male patient, 20 years old, the right forearm and wrist injury caused by machine, the
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appearance after debridement and external fixation (Fig 3a~3c), preoperative x-ray (Fig 3d), preoperative CTA showed ulnar artery and radial artery rupture (3e), design anterolateral thigh
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flap 25 cm×8 cm (Fig 3f), anterolateral thigh flap transplantation during the operation (Fig 3g,3h), Thumb ischemic necrosis,the look after debridement,abdominal pedicle flap to repair (3i~3k),the appearance and CTA after operation 6 months (3l~3m).
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Table 1. Patient characteristics Case 2
Case 3
Case 4
Case 5
Age/gender
45/F
3/M
2/F
55/M
20/M
Cause of injury
Traffic accident
Traffic accident
Crush injury
Crush injury
Affected site
Right upper arm
Left forearm to
Right upper arm
Left forearm
to forearm
wrist
to forearm
Damage characteristics
Segmental injury
Extensive rolling
Segmental injury
Segmental injury
Extensive rolling
Tissue ischemia time, h
8
9
5
12
10
Defect size, cm2
30 × 10
19 × 8
13 × 7
Flap size, cm2
32 × 12
21 × 9
14 × 8
Vessels reconstructed
BA/UA
RA
RA/UA
Length every vessel, cm2
8/10
8
5/8
MESS score
7
8
9
Recipient site complications
No
No
Thumb
6
12
Right forearm to
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60
Crush injury
wrist
15 × 6
22 × 10
18 × 8
25 × 8
RA/UA
RA/UA
5/5
10/4
8
9
No
Abdominal pedicle
amputation Follow-up, mo
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Case 1
flap repair 16
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* No donor site complications occurred in any patient; all flaps survived.
Abbreviations: BA, brachial artery; MESS, Mangled Extremity Severity Score; RA, radial artery; UA, ulnar artery.
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ACCEPTED MANUSCRIPT Highlights 1. ALT flap is one of the best choice for reconstruction of large soft tissue defects. 2. Flow-through flap can repair vascular defects without disrupting donor sites.
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3. Emergency repair is feasible in the selection of appropriate cases.
S1743-9191(17)31335-3
DOI:
10.1016/j.ijsu.2017.09.078
Reference:
IJSU 4211
To appear in:
International Journal of Surgery
Received Date: 24 August 2017 Accepted Date: 29 September 2017
Please cite this article as: Zhan Y, Fu G, Zhou X, He B, Yan L-W, Zhu Q-T, Gu L-Q, Liu X-L, Qi J, Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2017.09.078. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps Running title: Extremity repairment with Flow-through flaps
1
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Yi Zhan, PhD 1#, Guo Fu, PhD 2#, Xiang Zhou, PhD 1, Bo He, PhD 1, Li-Wei Yan, PhD , Qing-Tang Zhu, PhD 1, Li-Qiang Gu, PhD 1, Xiao-Lin Liu, PhD 1*#, Jian Qi, PhD1*#
1. Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of
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Sun Yat-sen University, Guangzhou, Guangdong, China 510080
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2. Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China 510630 #
These authors contributed equally to this work.
Corresponding author:
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Jian Qi, Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, China 510080
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Email: qijian17[email protected]; Tel: +86 20 87332200 ext 8242; Fax: +86 20 8733 2150.
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Xiao-Lin Liu, Department of Microsurgery and Orthopedic Trauma, First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, China 510080
Email: [email protected]; Tel: +86 20 87332200 ext 8242; Fax: +86 20 8733 2150.
Conflict of interest: None
ACCEPTED MANUSCRIPT Funding: This study was supported by the National Health and Family Planning
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Commission and Public welfare research projects (# 201402016) in China
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Emergency repair of upper extremity large soft tissue and vascular injuries with flow-
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through anterolateral thigh free flaps
Abstract
Background/Objectives: Complex extremity trauma commonly involves both soft tissue and
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vascular injuries. Traditional two-stage surgical repair may delay rehabilitation and functional recovery, as well as increase the risk of infections. We report a single-stage reconstructive
to improve functional outcomes.
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surgical method that repairs soft tissue defects and vascular injuries with flow-through free flaps
Methods: Between March 2010 and December 2016 in our hospital, 5 patients with severe upper extremity trauma received single-stage reconstructive surgery, in which a flow-through
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anterolateral thigh free flap was applied to repair soft tissue defects and vascular injuries simultaneously. Cases of injured artery were reconstructed with the distal trunk of the descending branch of the lateral circumflex femoral artery. A segment of adjacent vein was used if there was
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a second artery injury. Patients were followed to evaluate their functional recoveries, and received computed tomography angiography examinations to assess peripheral circulation.
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Results: Two patients had post-operative thumb necrosis; one required amputation, and the other was healed after debridement and abdominal pedicle flap repair. The other 3 patients had no major complications (infection, necrosis) to the recipient or donor sites after surgery. All the patients had achieved satisfactory functional recovery by the end of the follow-up period. Computed tomography angiography showed adequate circulation in the peripheral vessels.
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Conclusions: The success of these cases shows that one-step reconstructive surgery with flowthrough anterolateral thigh free flaps can be a safe and effective treatment option for patients with
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complex upper extremity trauma with soft tissue defects and vascular injuries.
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Keywords: extremity injury; flow-through flaps; emergency repair, microsurgery
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1 Introduction Complex extremity trauma that causes skin and soft tissue defects and also vascular injuries can lead to permanent disabilities. Treatment of these cases is always challenging for surgeons[1-
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4]. Traditional surgical treatment is performed in two stages; the first to repair the vascular injury, and the second to reconstruct the soft tissue defects with free or pedicled flaps[5-9]. These twostage surgical procedures commonly require significant time to complete, which delays patients’
such as infections, including osteomyelitis.
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subsequent rehabilitation and functional recovery, and also increases the risk of complications
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A flow-through technique has been reported to repair soft tissue and vascular injury simultaneously in a single-stage surgery[10-12]. Flow-through flaps allow repair of the injured soft tissues, as well as revascularization through anastomosis to the body parts distal to the injured site. Patients with complex injury to the extremities reportedly achieve satisfactory
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recoveries after one-stage flow-through free flap reconstructive surgery. A limited study reported the repair of upper extremity large soft tissue defects and major vascular injuries with a free flow-through anterolateral thigh flap. This has the advantage of
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providing large flow-through free flaps, with a minimal conspicuous scar at the donor site[13]. Herein, we report 5 patients treated with flow-through anterolateral thigh free flaps during
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reconstructive surgery to repair large soft tissue and vascular injuries of the upper extremity.
2 Material and methods
2.1 Study design and participants This was a prospective observational study performed at an urban academic teaching hospital between March 2010 and December 2016. The hospital ethics committee approved the
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study protocol. All of the study participants signed informed consent. We would like to state that the current research work has been reported in line with the PROCESS criteria. All the included 5 patients had severe upper extremity injury with a large skin defect and
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major vascular injury, and agreed to receive one-stage reconstruction surgery with flow-through anterolateral thigh free flaps on the recommendation of the primary treating surgeon. Excluded from the study was any patient unable or unwilling to sign the informed consent, or had
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concomitant major injury such as chest or abdominal injury that precluded emergency surgery for
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the extremity[14].
2.2 Surgical technique
The 5 patients received basic blood tests that included complete cell counts, basic metabolic panel, coagulation study, and type and screen; and extremity imaging studies such as X-ray and
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computed tomography angiography (CTA). The surgeries were performed with patients under general anesthesia. Skin flaps were prepared based on the severity of the individual patient’s extremity injury, with perforator flaps for less contaminated wounds, and musculocutaneous flaps
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for contaminated wounds or deep wounds with large muscular defects. A long segment of the distal trunk of the descending branch of the lateral femoral
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circumflex artery was preserved, to reconstruct the major vessel in the injured upper extremity. After thorough wound debridement of the injured upper extremity, emergency one-stage repair of the large soft tissue defects and vessel injury of the upper extremity was performed with flowthrough anterolateral thigh free flaps (Figure 1). The upper extremity soft tissue defects were covered by the thigh free flaps. The injured artery was reconstructed and anastomosed to the femoral circumflex artery to regain blood flow. A segment of vein close to the descending branch of the lateral femoral circumflex artery (either the lateral femoral circumflex vein or the great 4
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saphenous vein) was also used for reconstruction if there was a second artery injury. The thigh area for the donor flap was sutured primarily. External fixation was applied if there was concomitant bone fracture or a requirement for postoperative nursing care.
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After the reconstructive surgery, the repaired upper extremity was elevated and kept warm. Routine antibiotics, analgesics, anti-spasmodic, and anti-thrombotic treatments were applied. Upper extremity blood supply and discharges from the flaps and the thigh donor sites were
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closely monitored. Patients were encouraged to participate in rehabilitation as early as possible and were followed for up to 60 months after the surgery. At the end of the follow-up period, CTA
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was repeated to assess peripheral blood circulations.
3 Results
We enrolled 5 patients in this analysis, 2 females and 3 males, with ages ranging from 2 to
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55 years (Table 1). All of them had upper extremity (upper arm, forearm, or wrist) large soft tissue defects and vascular damages from either traffic accidents or crush injuries. The mangled extremity severity scores (MESS) were between 7 and 9. The times from injury to emergency
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surgical operations were between 5 and 12 hours. The sizes of the soft tissue defects ranged from 13 × 7 to 30 × 10 cm2.
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One patient had only one artery injury (radial artery), and the other 4 patients had two artery injuries (the ulnar artery with either the brachial or radial artery). None of the 5 patients had palpable distal limb arterial pulses. Four patients had sluggish capillary refills and one patient had a pale hand with no detectable capillary refill. During the operations, the sizes of the anterolateral thigh free flaps were between 14 × 8 and 32 × 12 cm2. The length of the major reconstructed artery ranged from 4 to 10 cm. During the follow-up after the surgeries, all the donor flaps survived. There was no complication involving the thigh donor sites. Patients began rehabilitation 5
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for functional recovery as early as possible when tolerated, or underwent subsequent bone fracture treatments, if necessary.
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3.1 Case 1
A 45-year-old woman experienced injury resulting from a traffic accident (Figure 2). She had a right upper arm-to-forearm injury with a soft tissue defect size 30 × 10 cm2. Both the brachial
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artery and the ulnar artery were injured (8- and 10-cm ruptures, respectively) with a thrombosis observed in the brachial artery. Her MESS was 7. A 32 × 12-cm flow-through left anterolateral
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thigh flap was prepared and transplanted to the right arm to cover the defected soft tissue. The injured brachial artery was reconstructed and anastomosed to the descending branch of the femoral circumflex artery to regain vascularization. A segment of the great saphenous vein was used to reconstruct the injured ulnar artery. External fixation was used after the surgery. The
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postoperative recovery was uneventful. This patient was followed for 60 months. Her right elbow and wrist flexion and extension and hand grip function were almost fully recovered. CTA showed
3.2 Case 2
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satisfactory circulations to the right arm at the end of the follow-up.
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A 20-year-old man presented with trauma to the right forearm and wrist due to a crushing injury from operating a machine (Figure 3). His MESS was 9 and the size of skin defect was 22 × 10 cm2, with accompanied distal radial and ulnar fractures. The preoperative CTA showed ruptures of both the ulnar artery and radial artery. During the surgery, a 25 × 8 cm2 anterolateral thigh free flap was transplanted to repair the arm soft tissue injury. Similar to case 1, the injured radial artery was reconstructed and anastomosed to the descending branch of the femoral circumflex artery to regain vascularization. A segment of the great saphenous vein was used to reconstruct 6
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the injured ulnar artery. Unfortunately, the thumb became necrotic during the postoperative recovery period. After debridement, an abdominal pedicle flap was used for repairment. At the 6-
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month follow-up visit, CTA showed satisfactory blood circulation.
4 Discussion
In the current study, we describe 5 patients who had severe upper extremity trauma, with
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both large soft tissue defects and major vascular injuries. Emergency reconstructive surgeries were performed with flow-through anterolateral thigh free flaps. All the 5 patients had
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satisfactory functional recovery at the end of the follow-up period.
Previous studies reported that early emergency surgery to repair extremity injuries was safe and effective, and could potentially yield better functional outcomes[15-17]. However, complex extremity trauma commonly involves both soft tissue and vascular structures. Emergency
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surgical repair should reconstruct both damaged soft tissue and vessels. Traditional 2-stage operations may delay recovery and increase the risk of infections[8, 9]. The flow-through flap can repair large soft tissue and vascular defects in a single one-stage operation and provides
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blood supply through anastomosis to the free flaps without disrupting distal circulation to the extremities[18, 19]. This potentially makes the flow-through flap a better option to repair both
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soft tissue and vascular injuries in the extremities. The one-stage simultaneous repair of both soft tissue defects and vascular injuries may save recovery time, improve rehabilitation, and decrease the risk of infections.
The flow-through flap technique was first proposed for reconstruction of intra-oral injuries by Soutar et al. in 1983[20]. One year later, in 1984, Foucher et al[21]. described a radial artery forearm flow-through flap to repair an extremity injury. Since then, various types of flow-through flaps have been reported[10-12]. 7
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The donor sites for flaps are commonly from the extremities. The free flow-through anterolateral thigh flap can provide a large area of skin flap, up to 650 cm2, with a long pedicle 37.1 cm[12, 22]. The mean diameter of the descending branch of the circumflex femoral artery is
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up to 3.0 mm[22]. Depending on the requirement of the injured site, the anterolateral thigh flap can be harvested as a skin-alone, adipofascial, myocutaneous, or musculocutaneous flap[23-25]. All these characteristics have made the thigh an ideal location to harvest the flow-through free
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flap to repair soft tissue defects and re-vascularize the ischemic extremity[26, 27].
Major complications after extremity reconstructive surgery include infections and vascular
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thrombosis, with subsequent distal limb necrosis. Delay in reconstructive surgery increases the chance for infection. All our patients received emergency repair within 12 hours after their injury. There was no infection in any of our patients. One patient (case 5) had thumb necrosis after the emergency repair surgery. The necrotic part was debrided, and healed after an abdominal pedicle
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flap repairment. This patient had a high MESS 9 from the crush injury, a large soft tissue defect 22 × 10 cm2, both radial and ulnar artery injuries, long segment artery injury (8 and 10 cm), and a long period of ischemia before the surgery (10 h). Any of these might have contributed to the
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thumb necrosis after the operation.
Considering our experience and previous publications, we recommend that several issues be
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considered during this type of reconstructive surgery. Firstly, there are 8 types of anatomic variations of anterolateral thigh flaps. The flow-through flap should have clearly identified proximal and distal vascular pedicles. Type seven, which misses the blood vessels used for bridging vascular pedicles, is not recommended for the flow-through flap[28]. Secondly, emergency surgery is recommended to repair the extremity trauma. However, a preoperative CTA or Doppler should still be considered to assess the vascular injury, to aid operative planning and consultation with the patient regarding prognosis[22, 29]. 8
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We used the distal trunk of the descending branch of the lateral circumflex femoral artery to reconstruct the injured upper extremity artery. The lateral branch of the lateral circumflex femoral artery should still be retained as a backup for vascular reconstruction. In addition, a
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segment of vein adjacent to the lateral circumflex femoral artery, such as the lateral circumflex femoral vein or great saphenous vein, can be used for vascular reconstruction if there is more than one artery injury.
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Finally, the prognosis after surgery may be associated with the mechanism of injury. For example, both our patients with post-operative thumb necrosis had suffered crush injuries. Pre-
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operative consideration of reconstructive surgery should consider this possibility.
5 Conclusions
In conclusion, emergency surgery with flow-through anterolateral thigh free flap to repair
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upper extremity soft tissue and vascular injuries is safe and effective. This is a one-stage operation and potentially provides faster and better functional recovery with low risk of infections. To achieve the best post-operative recovery, the injury mechanism, pre-operative
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imaging studies, flap site, and flap type should be carefully considered.
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Conflicts of interest: none
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cases, Microsurgery. 34(2014) 425-433.
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26(2016) 25-31.
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soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap, Int J Surg.
[4] Y.C. Hsiao, J.Y. Yang, C.J. Chang, C.H. Lin, S.Y. Chang, S.S. Chuang, Flow-through anterolateral thigh flap for reconstruction in electrical burns of the severely damaged upper
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extremity, Burns. 39(2013) 515-521.
[5] A. Spyropoulou, S.F. Jeng, Microsurgical coverage reconstruction in upper and lower extremities, Semin Plast Surg. 24(2010) 34-42.
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[6] J. Bullocks, B. Naik, E. Lee, L. Hollier, Jr., Flow-through flaps: a review of current knowledge and a novel classification system, Microsurgery. 26(2006) 439-449.
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[7] D.W. Zheng, Z.C. Li, R.J. Shi, F. Sun, L. Xu, K.S. Shou, Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury, Injury. 47(2016) 364-371. [8] C.A. Derderian, W.A. Olivier, G. Baux, J. Levine, G.C. Gurtner, Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience, J Reconstr Microsurg. 19(2003) 455-462.
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[9] A.R. Kumar, N.S. Grewal, T.L. Chung, J.P. Bradley, Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period, J Trauma. 67(2009) 752757.
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[10] S. Nasir, M.A. Aydin, E. Sonmez, B. Baykal, Flow-through free latissimus dorsi flap for reconstruction of injured limbs: Evaluation of hemodynamic effects on extremity circulation, Ann Plast Surg. 65(2010) 164-169.
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[11] K. Yokota, T. Sunagawa, O. Suzuki, M. Nakanishi, M. Ochi, Short interposed pedicle of
Reconstr Microsurg. 27(2011) 109-114.
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flow-through anterolateral thigh flap for reliable reconstruction of damaged upper extremity, J
[12] L. Qing, P. Wu, J. Liang, F. Yu, C. Wang, J. Tang, Use of Flow-Through Anterolateral Thigh Perforator Flaps in Reconstruction of Complex Extremity Defects, J Reconstr Microsurg. 31(2015) 571-578.
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[13] N. Spindler, S. Al-Benna, A. Ring, H. Homann, L. Steinstrasser, H.U. Steinau, et al., Free anterolateral thigh flaps for upper extremity soft tissue reconstruction, GMS Interdiscip Plast Reconstr Surg DGPW. 4(2015) Doc05.
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[14] R.A. Agha, A.J. Fowler, S. Rajmohan, I. Barai, D.P. Orgill, Preferred reporting of case series in surgery; the PROCESS guidelines, Int J Surg. 36(2016) 319-323.
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[15] L.C. Fox, M.P. Kreishman, High-energy trauma and damage control in the lower limb, Semin Plast Surg. 24(2010) 5-10. [16] C.C. Hsu, Y.T. Lin, C.H. Lin, C.H. Lin, F.C. Wei, Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity, Plast Reconstr Surg. 123(2009) 1739-1747. [17] M. Ninkovic, H. Deetjen, K. Ohler, H. Anderl, Emergency free tissue transfer for severe upper extremity injuries, J Hand Surg Br. 20(1995) 53-58.
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[18] Y. Wang, S.Y. Chen, W.Y. Gao, J. Ding, W. Shi, X.L. Feng, et al., Experimental study of survival of pedicled perforator flap with flow-through and flow-end blood supply, Br J Surg. 102(2015) 375-381.
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[19] S. Miyamoto, M. Okazaki, N. Ohura, T. Shiraishi, A. Takushima, K. Harii, Comparative study of different combinations of microvascular anastomoses in a rat model: end-to-end, end-toside, and flow-through anastomosis, Plast Reconstr Surg. 122(2008) 449-455.
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[20] D.S. Soutar, L.R. Scheker, N.S. Tanner, I.A. McGregor, The radial forearm flap: a versatile method for intra-oral reconstruction, Br J Plast Surg. 36(1983) 1-8.
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[21] G. Foucher, F. van Genechten, N. Merle, J. Michon, A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap, Br J Plast Surg. 37(1984) 139-148.
[22] K. Sananpanich, Y.K. Tu, J. Kraisarin, P. Chalidapong, Flow-through anterolateral thigh
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flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: anatomical study and case report, Injury. 39 Suppl 4(2008) 47-54. [23] C.H. Wong, F.C. Wei, B. Fu, Y.A. Chen, J.Y. Lin, Alternative vascular pedicle of the
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anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery, Plast Reconstr Surg. 123(2009) 571-577.
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[24] M.M. Hanasono, R.J. Skoracki, A.K. Silva, P. Yu, Adipofascial perforator flaps for "aesthetic" head and neck reconstruction, Head Neck. 33(2011) 1513-1519. [25] S. Devansh, Lateral thigh free flap with flow-through vascular pedicle, Ann Plast Surg. 67(2011) 44-48.
[26] Y.G. Song, G.Z. Chen, Y.L. Song, The free thigh flap: a new free flap concept based on the septocutaneous artery, Br J Plast Surg. 37(1984) 149-159.
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[27] I. Koshima, S. Kawada, H. Etoh, S. Kawamura, T. Moriguchi, H. Sonoh, Flow-through anterior thigh flaps for one-stage reconstruction of soft-tissue defects and revascularization of ischemic extremities, Plast Reconstr Surg. 95(1995) 252-260.
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[28] Y. Kimata, K. Uchiyama, S. Ebihara, T. Nakatsuka, K. Harii, Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases, Plast Reconstr Surg. 102(1998) 1517-1523.
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[29] R.A. Agha, B. Gundogan, A.J. Fowler, T.W. Bragg, D.P. Orgill, The efficacy of the Cook-
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protocol, BMJ Open. 4(2014) e004253.
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Swartz implantable Doppler in the detection of free-flap compromise: a systematic review
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Figure legends Figure 1. Operation methods: (A) Complex to the upper arm forearm soft tissue defect of brachial artery defect. (B) low-through anteriolateral thigh free flap repair. (C) Complex to the
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palm of the soft tissue defect of forearm, ulnar artery defect. (D) Flow-through anteriolateral thigh free flap repair, rotation the lateral femoral artery to repair radial artery, great saphenous
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vein graft of ulnar artery.
Figure 2. Female patient, 45 years old,Traffic accident, after debridement, the right arm and right
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forearm extensive soft tissue defect after anastomosis of brachial artery thrombosis was observed, cut off serious contusion and thrombosis of blood vessels, blood vessels visible defects was 8 cm (Fig 2a, 2b); the left anterolateral thigh flap size is 32 cm × 12 cm (Fig 2C), flap transplantation combined with external fixation (Fig 2D, 2e), the appearance, function and CTA after operation
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60 months(Fig 2f~2i).
Figure 3. Male patient, 20 years old, the right forearm and wrist injury caused by machine, the
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appearance after debridement and external fixation (Fig 3a~3c), preoperative x-ray (Fig 3d), preoperative CTA showed ulnar artery and radial artery rupture (3e), design anterolateral thigh
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flap 25 cm×8 cm (Fig 3f), anterolateral thigh flap transplantation during the operation (Fig 3g,3h), Thumb ischemic necrosis,the look after debridement,abdominal pedicle flap to repair (3i~3k),the appearance and CTA after operation 6 months (3l~3m).
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Table 1. Patient characteristics Case 2
Case 3
Case 4
Case 5
Age/gender
45/F
3/M
2/F
55/M
20/M
Cause of injury
Traffic accident
Traffic accident
Crush injury
Crush injury
Affected site
Right upper arm
Left forearm to
Right upper arm
Left forearm
to forearm
wrist
to forearm
Damage characteristics
Segmental injury
Extensive rolling
Segmental injury
Segmental injury
Extensive rolling
Tissue ischemia time, h
8
9
5
12
10
Defect size, cm2
30 × 10
19 × 8
13 × 7
Flap size, cm2
32 × 12
21 × 9
14 × 8
Vessels reconstructed
BA/UA
RA
RA/UA
Length every vessel, cm2
8/10
8
5/8
MESS score
7
8
9
Recipient site complications
No
No
Thumb
6
12
Right forearm to
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60
Crush injury
wrist
15 × 6
22 × 10
18 × 8
25 × 8
RA/UA
RA/UA
5/5
10/4
8
9
No
Abdominal pedicle
amputation Follow-up, mo
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Case 1
flap repair 16
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* No donor site complications occurred in any patient; all flaps survived.
Abbreviations: BA, brachial artery; MESS, Mangled Extremity Severity Score; RA, radial artery; UA, ulnar artery.
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3. Emergency repair is feasible in the selection of appropriate cases.
