Free Flap Coverage of Pyoderma Gangrenosum Leg Ulcers

Background:

Pyoderma gangrenosum is a necrotizing skin disorder of unknown cause. Treatment of pyoderma gangrenosum usually entails medical treatments. Surgical treatment is generally not successful.

Objective:

Two patients with pyoderma gangrenosum of their lower extremities are presented. The application and utility of microvascular free flap coverage of their ulcers is discussed.

Results:

Both patients achieved successful healing with microvascular free flaps.

Conclusion:

Microvascular free flap coverage may be a surgical treatment option for selected patients with pyoderma gangrenosum.

The indications and reliability of vein graft use in free flap transfer

BACKGROUND

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.

Complications in a Consecutive Series of 250 Free Flap Operations

The purpose of this study was to determine the rate of major and minor flap, donor site, and systemic complications in a consecutive series of 250 free flap operations. The following factors were analyzed to determine their significance on complication rates: age of patient, gender, wound etiology, smoking history, type of flap, operative time, vein graft use, surgeon experience, and the presence of comorbid disease. The major flap, donor-site, and systemic complication rates were 17.2%, 2%, and 6.4%, respectively. The minor flap, donor-site, and systemic complication rates were 7.2%, 12.8%, and 7.2%, respectively. The presence of comorbid medical condition was the only factor which had a statistically significant impact on the rate of major flap complications (P = 0.02). Age and comorbid disease impacted on major systemic complications (P = 0.04).

Hand trauma in shop class

The environment and equipment used in shop class are potential sources of serious injury. There has been little published to date on injuries sustained in shop class, with no reports examining injuries to the hand. The authors report a case series collected from a health records database at a pediatric and hand surgery referral center. Fifteen patients who sustained injuries to their wrist or hand in shop class were identified. Sixty percent of the injuries were caused by table saws. Eighty percent required treatment from a hand surgeon. Sixty-seven percent of patients sustained a serious injury in the form of amputation or tendon or neurovascular injury. Most of the patients had functional deficits at final follow-up. Shop class is a setting where serious hand trauma can occur. School administrators and educators should direct efforts at preventing these injuries. Parents and students must recognize the risks associated with shop class. Physicians should be prepared for severe injuries and the frequent need for hand surgical consultation.

Alternative techniques for pedicle transfer of an island flap and a free flap

Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Exteriorization of the vascular pedicle of a reverse radial forearm flap allows a greater arc of movement of the flap for more distal coverage, and avoids the potential vascular compromise of tunnelling under a tight skin bridge. Two-stage transfer of a latissimus dorsi myocutaneous free flap on a wrist carrier pedicle may be useful in circumstances when local recipient vessels are inadequate for free flap transfer. Although both of these vascular pedicle modifications have drawbacks, they may be of value in limited circumstances. Their advantages and limitations are discussed.

Free Muscle Flap Transfer as a Lymphatic Bridge for Upper Extremity Lymphedema

There are limited reports in the literature describing the use of muscle or skin pedicle flaps as a lymphatic bridge to treat obstructive lymphedema. This report demonstrates the successful use of a free muscle flap for a circumferential scar of a forearm as treatment for obstructive lymphedema. Lymphatic drainage is demonstrated across the free flap by lymphoscintigraphy postoperatively. This is the first case report using a free muscle flap to reestablish lymphatic flow across an area of obstructive limb lymphedema.

Zygomycotic infection of the neonatal upper extremity

Zygomycosis is a rare fungal infection that may present as a necrotizing soft tissue infection in the neonate. This report illustrates the typical presentation of a premature, infant with a rapidly progressive soft tissue necrotizing infection of his upper extremity at an intravenous site. Early diagnosis with tissue biopsy confirmed the diagnosis of Zygomycosis. Successful treatment required systemic amphotercin B and aggressive debridement requiring through-the-elbow amputation for survival.

Free flap coverage of pyoderma gangrenosum leg ulcers

BACKGROUND

Pyoderma gangrenosum is a necrotizing skin disorder of unknown cause. Treatment of pyoderma gangrenosum usually entails medical treatments. Surgical treatment is generally not successful.

OBJECTIVE

Two patients with pyoderma gangrenosum of their lower extremities are presented. The application and utility of microvascular free flap coverage of their ulcers is discussed.

RESULTS

Both patients achieved successful healing with microvascular free flaps.

CONCLUSION

Microvascular free flap coverage may be a surgical treatment option for selected patients with pyoderma gangrenosum.

Free flap coverage of bilateral frostbite of the feet

The indications, principles of management, and outcomes of free flap transfer for limb salvage in four patients with bilateral frostbite of their feet are presented. A fasciocutaneous flap was used for coverage when the wound involved a single surface of the foot. When multiple surfaces of the foot required free flap coverage, a muscle flap was used because it could more easily improve the shape and contour of the defect. Successful coverage was achieved in all four patients.

A Review of 100 Consecutive Free Flaps

This study is an analysis of the first 100 consecutive free flaps performed by the author. During a 61 month period, 100 free flaps were performed in 90 patients. The overall flap success rate was 93%. A review of the indications, donor sites, recipient sites, outcomes and complications is presented. A comparison is made between the first 50 free flaps and the second 50 free flaps to examine evolving practice patterns. Techniques that were of value are discussed.

Aplasia cutis congenita associated with fetus papyraceous

This report describes a healthy infant born with an isolated, truncal cutis aplasia defect in association with a fetus papyraceous. Effective healing of the cutaneous defect occurred over the course of a month. A 2-year follow-up demonstrate stable wound coverage. This rare association of aplasia cutis congenita, with a fetus papyraceous points most likely to the vascular causation of the cutaneous defect.

Anterior interosseous nerve syndrome presenting with pronator teres weakness: a case report

Anterior interosseous nerve syndrome (AINS) has been well described. A key muscle to examine clinically and on electromyography is the pronator teres, as this can differentiate between forearm and more proximal entrapment sites. We present a case of AINS with marked weakness and denervation of pronator teres. At operation the anterior interosseous nerve gave rise to the nerve to pronator teres and was entrapped by a fibrous band from the deep head of pronator teres.

Antibiotic Bead Pouch Dressing

The antibiotic bead pouch is a dressing consisting of antibiotic laden polymethylmethacrylate (PMMA) beads placed in a wound, which is covered by a porous membrane (Opsite). This paper outlines the method, rationale and results of the use of this dressing technique for extensive wounds before definitive wound closure. A case series review of 15 consecutive patients with a variety of soft tissue wounds that were managed with an antibiotic bead pouch dressing is presented. The method of dressing has been a useful and successful adjunct to the management of extensive infected and contaminated wounds.

Plantar fibromatosis and bilateral flexion contractures: a review of the literature

Plantar fibromatosis is a benign multinodular lesion occurring in the plantar fascia. It is generally an asymptomatic lesion or may occasionally cause discomfort or pain in the foot. We present a man who has bilateral flexion contractures of his great toes as a result of his plantar fibromatosis. A review of the literature indicates that this is a very rare presentation of plantar fibromatosis.

The anatomy and treatment of camptodactyly of the small finger

Having observed an anomalous insertion of the lumbrical muscle in 74 consecutive operations for correction of camptodactyly of the small finger, we have concluded that the loss of normal lumbrical action is the principal cause of the intrinsic minus deformity seen in this condition. Other anatomic abnormalities observed in this series of patients are those of the superficial tendon in 47%, the x-ray appearance of the proximal interphalangeal (PIP) joint in 15%, and a fixed flexion contracture of the PIP joint in 66%. Fifty-seven percent of our patients had PIP flexion contracture of more than 45 degrees. To determine the contribution of these anomalies to this deformity, we analyzed a series of 53 patients who had been followed up for at least 1 year. The study revealed that these conditions are interdependent and that each had an adverse effect on the final operative results. Treatment included a transfer of the superficial tendon of the ring or little finger to the extensor mechanism of the little finger in all cases and other procedures as dictated by the individual situation. Overall, the joint contracture was reduced from 49 degrees to 25 degrees, but only 33% of the patients regained full flexion of the small finger.