AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

Free Flap Reconstruction Extends the Indications for Forequarter Amputation
Institution where the work was prepared: Helsinki University Hospital, Helsinki, Finland
Erkki Tukiainen; Helsinki University Hospital; Outi Kaarela, MD, PhD; Oulu University
Conventionally forequarter amputation (FQA) has been performed for aggressive tumors at the shoulder girdle and the proximal humerus. Distant disease and
chest wall involvement have been considered as contraindications to this ablative procedure. Moreover, the wound closure has been was gained with the local
posterior tissues. When the invading tumour is located on scapula or the local option for coverage already have been used, also microvascular cover should be
considered. In addition, the chest wall resection can also be performed. This extends the conventional FQA.
FQAs performed in two university hospital were retrospectively reviewed (1990 - 2004). The indication was large, primary or recurrent soft tissue sarcomas . In
most cases the operation was performed in palliative intention due to unbearable pain, paralysis, oedema, persistent infection and/or ulceration. There were
19 patients, 10 males and 9 females, aged 18 - 78 years. Conventional FQA was performed to eight patients, and in eleven cases the defect was closed with
free flap. Two of these patients had and extended FQA including all layers of the chest wall (2-3 ribs). If a free flap was indicated, the remnant forearm was
the first choice (7 cases). The bone of the fore arm can be included in the flap to add the skeletal stability of the chest wall reconstruction. If the forearm was
not usable due to tumor contamination or severe chronic infection, a tensor fasciae latae free flap was used ( 4 cases). The TFL-flap can be harvested in the
lateral position, and the harvest does not affect the respiratory function, which is important especially if also chest wall is resected.
All patients recovered the operation, and the wounds healed primarily. There were no flap losses. Two local recurrences were detected. The survival varied from
? to 5 years, usually the patient died of disseminated disease with pulmonary metastases.
FQA is a mutilating procedure, but in some cases it is the only option to relieve the serious local complications caused by shoulder girdle tumors. Usually the
procedure is performed with palliative indications.
Radical Reduction of Upper Extremity Lymphedema with Preservation of Perforators (RRPP)
Institution where the work was prepared: E-Da Hospital / I-Shou University, Kaohsiung, Taiwan
Paolo Sassu; E-da Hospital / I-Shou University Hospital
Background:
Excisional procedures have been successfully utilized by different authors in multi-stage treatment of upper extremity lymphedema. In the last five years we
have combined microsurgical principles of perforator flap surgery in order to develop a one-stage procedure that enables a radical reduction of the lymphedematous
tissue with preservation of the vascular supply to the overlying skin.
Methods:
Between March 2000 and November 2005 seven patients were treated by Radical Reduction of the subcutaneous tissue with Preservation of Perforators (RRPP).
Perforator vessels from the radial and posterior interosseous arteries were identified with a doppler probe and marked. Through medial and lateral forearm incisions,
skin flaps as thin as 5 mm were raised off the underlying lymphedematous tissue and the affected tissue was removed off the deep fascia. During the
dissection, 3 cm of soft tissue was preserved around the perforators in order to avoid their injury and guarantee adequate perfusion of the skin flaps. Medial
and lateral antebrachial cutaneous nerves were preserved during the dissection.
Results:
At a mean follow-up of 9.1 months all patients showed a significant reduction of the entire extremity and satisfaction from our evaluation. Measurements
were evaluated from above and below the elbow joint, at the wrist and the hand. At each of these regions the average percentage reduction was 11.7%, 21.5%,
3.4%, and 5.4% respectively. There were no cases of wound breakdown, skin necrosis or cellulitis in the postoperative period.
Conclusions:
Even though further evaluations will be necessary, the application of the angiosome concept to the radical excision of the subcutaneous tissue seems to offer
a new promising one-stage surgical procedure in patients affected by upper extremity lymphedema.
Restoration of Dynamic External Rotation by Muscle Transfers in OBPP
Institution where the work was prepared: Mircosurgical Research Center, EVMS, Norfolk, VA, USA
Julia K. Terzis, MD, PhD; Epaminondas Kostopoulos, M.D.; Eastern Virginia Medical School
Objectives:
Restoration of shoulder external rotation is very important to upper extremity function following obstetrical brachial plexus paralysis. The purpose of this study
is to present our experience with the secondary restoration of external rotation by the rerouting of latissimus dorsi and teres major muscles in patients with
obstetrical brachial plexus palsy.
Methods:
From 1978 to 2002, 46 children underwent secondary surgery for the restoration of external rotation (ER). Outcomes were analyzed in relation to various factors
including the type of procedure (muscle transfer only, MT, versus nerve exploration and muscle transfer, N+MT), denervation time, type of injury (Erb's
versus Global), and severity score. Additionally, the effect of ER restoration on shoulder abduction will be studied.
Results:
There was a significant improvement in every case (p0.05). The resulting gain in degrees of external rotation was
990 versus 93.80. Patients with Erb's palsy had a better, but not significant result (p>0.05; p=.94) compared to those with global palsy in both Mallet score
(3.77 vs. 3.76) and final active external rotation (81.70 vs. 77.60). In both populations a very significant improvement (p