1. Introduction
In the reconstructive management of severe upper extremity trauma involving arterial injury, efforts are made to shorten the revascularization time in various phases, including the evaluation of the injured vessels, wound exploration, graft vein harvest, and anastomosis. During this period, the incorporation of temporary intravascular shunts (TIVS) have been widely applied in efforts to shorten revascularization time.[ 1 , 2 ] However, if a flow-through type vastus lateralis muscle (VLm) flap can be harvested rapidly as a bypass graft, the role of TIVS placement could be significantly reduced because the distal blood flow can be reestablished early.
2. Patients and methods, results
2.1. Case 1
An 84-year-old woman suffered multiple amputation trauma to her hand when her left upper extremity was caught in a farm tractor. The left thumb was completely amputated at the CM joint level; the index, middle, ring, and little fingers were amputated at the distal interphalangeal (DIP) joint level; the distal ends of the radius and ulna and carpal bones were crushed; and the ulnar side of the hand was degloved to the distal 1/3 of the forearm (Fig. 1A ). Because blood flow in the hand was unstable, we used a flow-through-type VLm flap that had been harvested within 20 minutes (tentative name: Rapid Harvested-Vastus Lateralis muscle bypass flap [RH-VLbf]) to bypass not only the radial artery to the amputated thumb, but also to the palmar arterial arch. After blood flow to the ulnar side of the hand and the amputated thumb was reestablished, the deficient skin of the hand was covered with the skin of this flap (Fig. 1B ). Because the distal ends of the radius and ulna and the carpal bones were crushed, a titanium plate was used to fix the wrist joint. In Case 1, the time from injury to the start of surgery was 2 hours 50 minutes, the time for harvesting the flow-through-type VLm flap was 25 minutes, and the time from the start of surgery to the reestablishment of blood flow with the flow-through-type VLm flap was 1 hour 10 minutes. The total operation time was 6 hours 28 minutes (Table 1 ). At 1 year after surgery, the active range of motion of the index, middle, ring, and little fingers was as follows: Index total active motion (T.A.M.); 170, Middle T.A.M.;175, Ring T.A.M.; 70 (DIP defect), Little T.A.M.; 70 (DIP defect), and the patient has achieved pinch movements and can operate buttons (Fig. 1C ).
Table 1 -
Data on our cases.
Time of surgery from the onset (h)
Flap harvest time (h)
Revascularization time from flap harvest (h)
Total operation time (h)
Case1
2.8
0.4
1.2
6.5
Case2
3
0.3
1.3
8.4
Case3
3
0.3
1.5
4.4
Figure 1.: (A) An 84-yr-old woman suffered multiple amputation trauma to her hand when her left upper extremity was caught in a farm tractor. (B) We used RH-VLbf to bypass not only the radial artery to the amputated thumb, but also to the palmar arterial arch. (C) The patient has achieved pinch movements and can operate buttons.
2.2. Case 2
A 77-year-old man suffered a left upper extremity avulsion injury involving a large shaker. It was a complete avulsion amputation at the middle level of the left forearm, and the radial artery, ulnar artery, flexor muscle, extensor muscle, radial nerve, ulnar nerve, and median nerve were all severely crushed and contused at the elbow joint level. The peripheral amputated limb was also avulsed and the muscular and neurovascular tissue was contused to the level of the wrist (Fig. 2A ). After bypassing the brachial artery to the radial artery and the ulnar artery using a flow-through-type VLm flap that was harvested within 20 minutes (RH-VLbf) to reestablish blood flow, the deficient forearm skin was reconstructed using a combination of skin grafts and the skin paddle of the flap (Fig. 2B ). The venous system was reconstructed not only bypassing the descending branch of the lateral femoral circumflex vein, but also by long bypass using the great saphenous vein from the snuff box level to the deltoid portion of the upper arm. The proximal radial and ulnar segments were shortened by 3 cm and the bone was fixed using a titanium plate. The flexor and extensor muscles of the forearm were sutured as much as possible, with the VLm of the flap partially interposed (Fig. 2C ). No nerve reconstruction was performed because the defect length of all nerves was >5 cm. In Case 2, the time from injury to the start of surgery was 3 hours 5 minutes, the time for harvesting the flow-through-type VLm flap was 20 minutes, and the time from the start of surgery to the reestablishment of blood flow with the flow-through-type VLm flap was 1 hour 20 minutes. The total operation time was 8 hours 22 minutes (Table 1 ). Since it currently only 1 month after surgery, a postoperative assessment of the hand function remains to be performed (Fig. 2D ).
Figure 2.: (A) The peripheral amputated limb was also avulsed and the muscular and neurovascular tissue was contused to the level of the wrist. (B) After bypassing the brachial artery to the radial artery and the ulnar artery using RH-VLbf to reestablish blood flow. (C) The venous system was reconstructed not only bypassing the descending branch of the lateral femoral circumflex vein, but also by long bypass using the great saphenous vein. (D) Since it currently only 1 mo after surgery, a postoperative assessment of the hand function remains to be performed.
2.3. Case 3[ 3 ]
A 48-year-old man sustained a severe punching hole injury of 8 cm in diameter on the palm of his left hand using a punching instrument (for making the bottom of drink cans), and his middle and ring fingers were almost amputated. The neurovascular bundle was continuous on the radial side of the middle finger, but 35 mm was missing on the ulnar side of the middle finger, 30 mm was missing on the radial side of the ring finger, and there was contusion damage on the ulnar side of the ring finger. This was accompanied by paresthesia of the left middle finger and ring finger, and blood flow disturbance in the ring finger (Fig. 3A ). Using a flow-through-type VLm flap that was harvested within 20 minutes (RH-VLbf), the finger blood flow was improved with bypass from the base of the finger artery bifurcation in the superficial palmer arterial arch to the radial side digital artery of the ring finger (Fig. 3B ). Reconstruction of the palmar raw surface was performed using plantar glabrous skin graft with a full plantar layer. For rigid reconstruction, a mandibular reconstruction titanium plate (thickness: 2.5 mm) was used to bridge the phalanx bones and metacarpal bones to maintain the finger length, without tendon reconstruction. The digital nerve was sutured only on the ulnar side of the ring finger, and the other injured digital nerves were not reconstructed due to the long length of the defect (Fig. 3C ). In Case 3, the time from injury to the start of surgery was 3 hours 0 minutes, the time for harvesting the flow-through-type VLm flap was 20 minutes, and the time from the start of surgery to the reestablishment of blood flow with the flow-through-type VLm flap was 1 hour 30 minutes. The total operation time was 4 hours 23 minutes (Table 1 ). At 1 year and 4 months after the injury, the patient achieved a HAND20 score[ 4 ] of 54, a Quick DASH score[ 5 ] of 29.5, and has returned to his previous position at work (Fig. 3D ).
Figure 3.: (A) A 48-yr-old man sustained a severe punching hole injury of 8 cm in diameter on the palm of his left hand using a punching instrument. (B) Using RH-VLbf, the finger blood flow was improved with bypass from superficial palmer arterial arch to the digital artery of the ring finger. (C) Reconstruction of the palmar raw surface was performed using plantar glabrous skin graft, and a mandibular reconstruction titanium plate was used to bridge the phalanx bones and metacarpal bones. (D) The patient achieved a HAND20 score of 54, a Quick DASH score of 29.5, and has returned to his previous position at work.
None of the cases showed ischemia-reperfusion injury or severe muscle contracture.
3. Discussion
Reconstruction of severe extremity trauma at >6 hours after the onset of ischemia are associated with an increased rate of final amputation, and the course of treatment may even involve a worsening of the general condition.[ 6 , 7 ] The benefits of temporary reperfusion using a TIVS to improve ischemia as quickly as possible and avoid amputation has been reported in a number of cases.[ 1 , 2 , 8 , 9 ] Since the placement of an indwelling TIVS is a temporary procedure, subsequent bypass with the great saphenous vein is necessary. With regard to the time required to harvest the great saphenous vein, which is frequently used in such bypass procedures, the average harvest time was reported to be 23 minutes (23.680 ± 56.57 minutes).[ 10 ] The greatest advantage of using an indwelling TIVS is the shortening of the time to reperfusion of the ischemic site. However, if a flow-through-type VLm flap can be harvested in 20 minutes and bypassed at the obstructed ischemic zone within 30 minutes, blood flow can be reestablished as quickly or more quickly than when using a TIVS, eliminating the need for a TIVS. In our cases, the average time for harvesting the flow-through-type VLm flap was 23 minutes (25, 20, and 20 minutes, respectively) (Table 1 ). A review of cases of severe extremity trauma reported that in 101 limbs, the average time of reperfusion with TIVS was 3.8 hours after injury.[ 6 ] However, in our cases using the flow-through-type VLm flap, the average time to complete revascularization with reconstruction of both arteries and veins was 4.3 hours after injury; thus, similar results were achieved, even though—unlike TIVS placement—this was not a temporary procedure (Table 2 ). Our method is of course based on an insufficient number of cases and weak statistical power. However, if only arterial reconstruction is performed to rapidly improve the complete ischemic condition of the amputated broken limb, it can actually be completed in less than 2 hours on average. In other words, this method does not cause unnecessary damage to the amputated limb. Although we might temporarily irrigate an amputated transected limb with heparinized saline solution, we consider TIVS unnecessary if blood flow can be restored within 2 hours.
Table 2 -
Surgery time by reconstruction type.
Flap transfer time (h) = Ischemic time
Total operation time (h)
Number of cases
Reference
ALTbf
7.8
8.6
12
Plast. Reconstr.Surg. 123: 1739–1747, 2009.
TIVS followed by vein graft
3.8
Not mentioned
30
JPRAS 62, 571–579, 2009.
RH-VLbf
4.3
6.4
3
Our cases
ALTbf = a flow-through type anterolateral thigh flap, RH-VLbf = = a flow-through type Vastus Lateralis muscle flap that had been harvested within 20 min, TIVS = temporary intravascular shunt.
Anatomically, the descending branch of the lateral femoral circumflex artery, which is the bypass component, can be harvested at a length of approximately 20 cm, and the average diameter reported to be 3.0 mm (2.2–4.0) on the proximal side of the vessel, and 1.3 mm (0.9–1.8) on the distal side.[ 11 ] Therefore, the descending branch of the lateral femoral circumflex artery is suitable for use as a bypass graft in cases involving large (diameter: 10–20 cm) defects distal to the elbow. Previous reports have also highly evaluated the versatility of flow-through type anterolateral thigh (ALT) flaps in cases of extremity vascular injury[ 12–14 ] ; however, the availability of a VLm-attached versions like the flap used in this study will also remain unchanged.
The main disadvantage of harvesting a skin flap for bypass as a flow-through type ALT flap instead of a myocutaneous flap is that it requires at least 1 hour of harvest time because of the complicated dissection of the thin perforating branch. The average total flap transfer time was reported to be 7.8 hours (4.0–13.0, n = 12) after injury in reconstructions using a flow-through type ALT-flap[ 15 ] (Table 2 ). When harvested as a flow-through-type VLm flap with the VL attached, the flap harvest time is significantly reduced because it eliminates the need for complicated dissection of the thin perforating branch altogether, and debridement, bone stabilization, and nerve reconstruction can be performed steadily in a 1-stage procedure without rushing after early revascularization. In addition, harvesting the flap attached to blood-rich muscle not only controls infection of contaminated wounds through the filling of dead space, but it also has the potential to replace damaged muscle or tendon tissue. Furthermore, in addition to the main descending branch of the lateral circumflex femoral artery, branches such as muscle branches running within the VL muscle can be harvested for the peripheral segment of the bypass component. In case 1 and 2 of the present study, multiple branches of the descending branch of the lateral circumflex femoral artery were also successfully applied.
The drawback of this technique includes, highly technical with steep learning curve, it limited the reconstruction associated with the muscle flap and donor site morbidity. We operate under the direction of the attending plastic surgeon harvesting the flap, with another resident performing the debridement simultaneously. Our 3 cases were relatively easy-to-manage debridement cases. If they had been more complex with extensive degloving injuries, 2 teams would have been needed.
In Japan, hospitals like level 1 trauma centers in the U.S. that handle severe extremity trauma in civilian patients have not been integrated. Even in our cases, it took an average of 2.9 hours from the time of injury to the start of surgery (Table 1 ), but an increased time from injury to operating room arrival has been reported to be associated with an increased risk of amputation,[ 16 ] A trauma care system in Japan may be required to shorten the time from injury to the start of surgery and there is a strong need for the establishment of such a system. In the first place, TIVS placement is associated with various serious disadvantages, including increased bleeding and the risk of thrombosis.[ 9 ] TIVS is only performed temporarily in actual clinical situations, and ultimately, another true bypass graft of some sort will be required in the subsequent stage. In other words, it is a 2-step process and time-consuming. Therefore, if a flow-through-type VLm flap is used from the onset, a procedure almost identical to TIVS in terms of time required, final reconstruction can be achieved in a single step, saving a great deal of time and effort.
Although it will continue to have a role in war zones and other unusual environments where operating rooms are not available, a flow-through-type VLm flap that can be harvested within 20 minutes (tentative name: Rapid Harvested-Vastus Lateralis bypass flap [RH-VLbf]) will reduce the role of TIVS in the treatment of severe extremity trauma in civilian patients.
3.1. Limitations
The study is limited by the small sample size, and all results came from a single plastic surgeon. We showed only 3 clinical cases, and the follow-up period was not sufficiently long in the present study, which have contributed to lack of statistical power. The accumulation of more cases and further studies is needed to confirm the statistical significance.
4. Conclusion
A flow-through-type VLm flap that can be harvested within 20 minutes (RH-VLbf) achieves immediate revascularization in the reconstructive management of severe upper extremity trauma, may therefore have the potential to reduce the role of vein grafts or TIVS using the great saphenous vein. There have been no similar reports in the past and this procedure is educational.
Author contributions
Conceptualization: Masakatsu Hihara, Toshihito Mitsui, Natsuko Kakudo.
Data curation: Masakatsu Hihara, Natsuko Kakudo.
Formal analysis: Masakatsu Hihara, Natsuko Kakudo.
Investigation: Toshihito Mitsui.
Methodology: Masakatsu Hihara, Atsuyuki Kuro.
Project administration: Atsuyuki Kuro.
Supervision: Masakatsu Hihara, Natsuko Kakudo.
Validation: Masakatsu Hihara, Atsuyuki Kuro.
Visualization: Masakatsu Hihara, Toshihito Mitsui.
Writing – original draft: Masakatsu Hihara.
Writing – review & editing: Masakatsu Hihara, Natsuko Kakudo.
References
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