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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY NGUYEN DUC TIEN RESEARCH ON RECONSTRUCTION OF SOFT TISSUE DEFECTS IN FINGERS USING LOCAL PEDICLE FLAPS Speciality Orthope[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY NGUYEN DUC TIEN RESEARCH ON RECONSTRUCTION OF SOFT TISSUE DEFECTS IN FINGERS USING LOCAL PEDICLE FLAPS Speciality: Orthopedic and Plastic Surgery Code: 9720104 MEDICAL DOCTORAL THESIS HANOI - 2022 THE WORK HAS BEEN SUCCESSFULLY COMPLETED AT: HANOI MEDICAL UNIVERSITY Scientific supervisor: Assoc Prof Nguyen Bac Hung Assoc Prof Pham Van Duyet Opponent 1: Assoc Prof Nguyen Hong Ha Opponent 2: Prof.Dr Nguyen Duy Bac Opponent 3: Assoc Prof Nguyen Huy Tho The thesis has been defended at University-level Thesis Evaluation Council held in Hanoi Medical University At, (hour), / /2022 (date) This thesis may be found at: - National Library - Library of Hanoi Medical University ABSTRACT Hand flaps are flaps taken from the finger itself or the injured hand6 In 1935, Tranquilli-Leali was the first to report the use of in situ flaps to reconstruct soft finger defects Since then, there have been many types of flaps administrated to shape the soft software defects of the finger Until today, with the rapid development of free flaps, in situ microsurgery is still the first choice for shaping finger soft tissue defects Because in situ flaps have advantages: No further damage to the healthy fingers, the color of the flap structure is similar to the surrounding, and the patient soon recovers both in function and morphology of the palm In Vietnam, there have been studies on the imaging of finger software defects by Tran Thiet Son (2007) 9, Nguyen Anh To (2008) 10 However, these studies only evaluated the results of one type of flap in shaping finger software defects from which to evaluate advantages and disadvantages and propose indications of each flap In clinical practice, each type of flap in situate can be used to shape many different forms of software defects, and conversely, a type of software defect can be imaged with many different types of flaps Currently, there are many ways to classify finger soft tissue defects, but these classifications are quite complicated and the application from the classification of lesions to the choice of flap type is still difficult Therefore, it is necessary to have a simple way of classifying finger software defects to recommend each suitable flap to shape the flaw Consequently, we researched the topic " Research on reconstruction of soft tissue defects in fingers using local pedicle flaps " with two objectives: Evaluation of results of reconstructing soft tissue defects in fingers by local pedicle flap Determination of some factors affecting the results of reconstructing soft tissue defects in fingers by local pedicle flap New contributions of the thesis This is the first study in Vietnam using the required to move as the first factor that determines the selection of flaps: If the flap is required to move below 11 mm we use random flaps, if the flap is required to move from 11-20 mm we use axial flaps that moves down the finger direction If the flap is required to move above 20 mm, it will use axial flaps that move in the opposite direction of the finger when using random flaps required to move down the finger has higher vitality, the ability to restore motor function and the sensation of the finger is better when using the axial flaps that moves in the opposite direction of the finger Thesis layout The thesis has 120 pages, including: abstract (2 pages), overview (32 pages), research subjects and method (20 pages), results (28 pages), discussion (35 pages) ), conclusion (2 pages) The thesis has 42 tables, 32 figures, chart 116 references in Vietnamese and English Chapter OVERVIEW 1.1 Summary of finger anatomy 1.1.1 Anatomical features of the soft tissue in fingers 1.1 Finger blood supply characteristics 1.2 Classification of soft tissue defects in fingers Divide by hand unit, we have right hand, left hand Division of fingers in each hand: Fingers 1,2,3,4,5 1.2.1 Classification of soft tissue defects in fingers by subunits Each anatomical unit based on morphological and functional characteristics will be divided into subunits, with clear boundaries between subunits Each long finger has subunits, the thumb has subunits corresponding to the dorsal and hepatic surfaces of each phalanx At the same time, the author also gives the scale on the size of soft tissue defect: small soft tissue defect is soft tissue defect in sub-unit, medium soft tissue defect is soft tissue defect in sub-units, big soft tissue defect is soft tissue defect in more than sub-units of fingers 1.2.2 Classification of soft tissue defects according to wound direction: According to the position of the front and back of the finger : Including the soft tissue defects: finger horizontal, palm cross, and dorsal cross Dividing the two sides of the radius cuff, the ulnar of the finger : There is a radius cuff defect in the finger and a soft part that is diagonally across the ulnar margin of the finger 1.2.4 Background condition of soft tissue defects - Clean, new lesion base (wounds come early in the first day) - The background of the defect has an infection (the wound is late, there is necrotic tissue on the surface of the defect, dirty foreign body) - The defect foundation has exposed tendons, bones, joints 1.3 Methods of covering soft tissue defects in finger 1.3.1 Direct closure stitch With small soft defects, the wound is clean and the patient can come early to be able to cut and suture directly 1.3.2 Natural healing This is the simplest treatment method, it is a treatment method applied exclusively to small defects from to mm, defect area less than cm wounds without bone exposure and minimal nail damage 1.3.3 Autologous skin graft Autologous skin grafting is a technique to transfer a piece of skin taken from one place on the patient's body and transferred to another place on the same body and the life of this piece of skin relies on permeation from the tissue layer of the place of contact 1.3.4 Replanting a broken finger 1.3.4.1 Replant the severed bud as a composite graft Indication for soft tissue defect in finger in region 1,2 according to the Allen classification 1.3.4.2 Replanting the severed finger by microdissection technique Indicated for soft tissue defect from zone and up 1.4 Reconstructing soft tissue defects of the finger by the local pedicle flaps 1.4.1 Reconstructing finger soft tissue defects using dorsal pedicle flaps Pedicle flaps in the back of the hand are the largest flaps in width x length about 10 cm x 12 cm and are loosest of the hand Along with that, there is a very rich blood supply by the dorsal branches of the radial and ulnar arteries and the perforating branches from the palmar side, the loop of dorsal metacarpal arteries and dorsal digital arteries of hand, so we can consider the entire skin of the back of the hand as a reserve for the local pedicle flap 1.4.2 Reconstructing the soft part of the finger by pedicle flaps in the dorsal region Double-peduncle sliding flap: Performed by making an additional horizontal incision in the skin, limited to the midlateral lines, and then pulling the flap up or down to cover the lack of space The place where the skin is taken will be a loose skin graft The mobility of this flap is very poor Flaps using the perforating branch of the dorsal digital arteries of hand 1.4.3 Reconstructing the soft tissue defects of the finger with a pedicle flap in the palmar region Thenar flap The flap was used as a retrograde elliptical inversion of the skin where the thumb tissue was moved with the perforating branches and dorsal digital arteries of hand artery at the ulnar border of the thumb The flap is supplied with blood from the percutaneous branches of the thenar tissue Radial thenar flap: The flap is supplied with blood by the direct percutaneous branch of the radial artery that supplies the radial skin to the thenar tissue The flap was determined on the basis of doppler ultrasound based on the axial path of the short fascia of the thumb Hypothenar percutaneous flap: The flap is supplied with blood by the percutaneous branches of the ulnar artery that supplies the fifth finger 1.4.4 Reconstructing the soft tissue defects of the finger with vascular pedicle flaps from the palmar region Reconstructing the finger soft tissue defect with random palmar flaps : Atasoy flap, Kutler flap, Venkataswami R flap and Subramanian N flap Reconstructing the soft part of the finger with vascular flaps in the palmar region : Depending on the characteristics of the defect, we can take the skin island from the back area, the front or the side of the finger, at the 1st, 2nd or 3rd phalanges 1.4.4.2 Reconstructing the soft tissue defects of the thumb with vascular flaps in the palmar region Smuler swing flap The ability to move in a VY-type finger slide is often limited, to increase the flexibility of the flap, we can move the flap in a push-pull style combined with rotation Moberg skin flap The flap was designed by cutting two lines parallel to the finger axis on the lateral side, dissecting both the neural vascular pedicles on both sides Push the flap up to cover the skin of the fingertips O'Brien flap The design is similar to the Moberg flap but is used in the form of an island flap to increase the mobility of the flap, limiting complications of finger contraction after surgery Hueston flap This is a rotated, quadrangle-lift flap with an L-shaped incision The flap is moved by both rotation and elevation, so the flap has better coverage than V-Y flaps Joshi-Pho flap This is an island-shaped fascia flap taken from the lateral and dorsal surfaces of the thumb, the flap is supplied with blood by the common palmar digital arteries 1.5 The situation of local flap research in the world and in Vietnam 1.5.1 Research situation in the world The history of hand surgery has evolved in tandem with the history of plastic surgery and is an integral part of the world of orthopedic surgery 1.5.2 Research situation in Vietnam In Vietnam, the specialty of plastic surgery was established very early, but the number of published research works on the reconstruction of soft tissue defects in finger by using vascular pedicle local flaps is still quite modest The book "Hand surgery" by the authors Dang Kim Chau, Nguyen Trung Sinh, Nguyen Duc Phuc in 1982 is the first document to describe in a fairly detailed and systematic way the types of vascular stem flaps in reconstructing the soft tissue defects of the finger However, the author has not discussed the factors affecting the outcome of surgery Following the use of vascular pedicle flaps, some authors applied to reconstructing finger soft tissue defects such as: Tran Thiet Son and Nguyen Vu Hoang (2007) “ The situation of hand wound reconstructive surgery at the plastic surgery department of Saint Paul hospital ” In this study, the author described 78 peritoneal lesions that were imaged by different methods: Pulp grafting, local flap however, the author only gave initial comments on the surgical results that had not yet been established the protocol which is indicated for each specific type of injury, as well as the assessment of factors affecting the surgical results such as: the vitality of the finger, the ability to recover movement and sensation after surgery Nguyen Anh To (2008) "Initial results of treatment of soft tissue defects of the finger with a vascular dorsal fascia flap" Do Quang Hung 2020 "Evaluate the results of treatment of finger pulp defects with Atasoy flap" However, these studies only refer to the application of one type of flap in the reconstructing of finger soft tissue defects, so there is no general overview of the flexibility in reconstructing finger soft tissue defects with the local pedicle flap so as to fully analyze the advantages and disadvantages of each type of local flap in the reconstruction of infected soft tissue finger defects, as well as have not discussed the main factors affecting the surgical results, so that develop indications for each type of lesion Chapter SUBJECTS AND METHODS 2.1 Subject, location, duration of research 2.1.1 Research subjects The study was conducted on 115 patients with 130 wounds of soft tissue defect in finger with indication for surgery to cover the soft tissue defect with local pedicle flap In which, 52 patients with soft tissue defect were treated at the Department of Plastic and Reconstructive Surgery - Saint Paul General Hospital and 63 patients with soft tissue defect were treated at the Department of Plastic and Reconstructive Surgery - Viet Tiep Friendship Hospital from 10/2016 to 12/2020 * Criteria for selection: - Includes all patients with finger soft tissue defect lesions after trauma due to different causes, or post-resection defects after treatment of finger infections lead to loss of subcutaneous fat, causing exposed tendons and bones that require covering with tissue flaps - These patients were clinically examined, performed paraclinical tests, operated, treated and monitored after surgery Data were collected according to the case study sample *Exclusion criteria - Patients with life-threatening surgical emergencies need to prioritize intervention first , patients with coagulopathy - The patient has a morphological defect of the entire finger, in the form of peeling gloves, the soft part around the finger is completely crushed soft tissue defect with intact subcutaneous fat can be covered by skin grafts - Patients with latent soft tissue defects in finger are in the advanced stage of infection - Patients did not agree to participate in the study, the medical records did not have complete research information 2.1.2 Research location - Department of Plastic and Reconstructive Surgery - Saint Paul General Hospital, Hanoi - Department of Plastic and Reconstructive Surgery, Viet Tiep Friendship Hospital, Hai Phong 2.1.3 Research time From October 2016 to December 2020 2.2 Research method Non-controlled clinical intervention study 2.3 Result evaluation Evaluation of results immediately after surgery : Evaluation is based on a scale of research indicators in the results immediately after surgery, divided into levels: - Excellent : The flap is completely alive, the first stage of scar healing - Good: The flap is completely alive but there is peeling of the epidermis of the flap, inflammation of the exudate is less than weeks, without any further intervention, the wound still heals - Moderate: Partial necrosis flap, fistula lasts for more than weeks, additional surgical intervention is required, the flaw heals - Failure: Dead flap must be removed, or the exposed skin area is less than 1/3 of the design area at the time of flap removal, does not meet the coverage requirements, must replace other flaps or other methods for treatment Assess the ability to restore motor function: - Excellent : Restore normal motor function - Good: Restores more than 75% of the joint's range of motion - Moderate: recover from 50 to 75% of the range of motion of the joint - Poor: recovery of less than 50% of the normal range of motion of the joint - Failure: joint does not move - Assessment of sensory function after rehabilitation : Assess the results of sensory rehabilitation according to the criteria for sensory rehabilitation : S0 There is no sensation in the nerve distribution region Restoration of deep pain sensation in the skin in the nerve S1 distribution region S2 Presence of feeling of collision with dysesthesia Restoration of sensations of touch and pain, with S2+ dysesthesia Restoration of the sense of touch and pain, the loss of anesthesia, the function of distinguishing two points when S3 in the static state: > 15 mm, when in the dynamic state > mm As S3 and incomplete recovery function recognize two S3+ distinguishing points when in static state: 7-15 mm, when in dynamic state 4-7 mm Full sensory recovery recognizes two distinguishing S4 points when in the stationary state: 2-6 mm, in the dynamic 2-3 mm 2.4 Statistics processing methods The data recorded in the research medical records were recorded and processed using SPSS 16.0 software Qualitative variables were calculated frequency, injury rate, recovery according to surgical methods Compare the ratios and test the difference between the ratios according to the relevant factors using the χ2 test; Fisher's exact test combined calculates the odds ratio OR Statistical significance threshold when p < 0.05 2.5 Ethics of research The research protocol was approved by the Biomedical Research Ethics Council, the Board of Directors, the Graduate Training Department of Hanoi Medical University The study was approved by the Board of Directors of Saint Paul Hospital, the Board of Directors of Viet Tiep 11 months after surgery We followed up after surgery after months to evaluate the results to 94/130 finger software defects Table 3.4: Restoration of motor function of fingers after surgery Location Donor site Recipient site Ratio Ratio n n Level (%) (%) Excellent 91 96.8 90 95.7 Good 3.2 4.3 Total 94 100 94 100 Restoration of motor function of the fingers after surgery : The results of recovery of motor function of the wound after surgery after months are 100 % at the level of good or better Table 3.5: The ability to restore sensory function to recognize distinguishing points in the static state of the flap after surgery after months Location Ability to recognize points (mm) Static state 7-15 >15 Total Donor site Ratio n (%) 80 85.1 14 14.9 0 94 100 Recipient site Ratio n (%) 58 61.7 36 38.3 0 94 100 Review: In both the donor and recipient sites, the ability to recognize two points in the static state at ≤ mm at the donor and recipient sites was 85.1 % and 61.7% , respectively Table : Compare the ability to recognize two distinguishing points when in the static state of the donor site at the first months after surgery and after surgery months The ability to recognize two distinguishing points when in a stationary state, the donor site The ability to recognize two distinguishing points when in the dynamic state of the donor site Early results after surgery Distant results after surgery Devian t p* 7.54±3.45 5.46±2.1 -2.08