ObjectiveTo study the effectiveness of Keystone flap in the repair of soft tissue defect of lower extremity.MethodsThe clinical data of 27 cases with soft tissue defects of lower extremity treated by Keystone flap between January 2018 and June 2020 were retrospectively analyzed. There were 18 males and 9 females, with an average age of 43.9 years (range, 8-63 years). The cause of soft tissue defects included skin tumor in 3 cases, ulcer in 2 cases, soft-tissue infection in 8 cases, trauma in 7 cases, and donor site defect after free or pedicled flap transplantation in 7 cases. Defect size ranged from 2.0 cm×1.5 cm to 15.0 cm×9.5 cm. The types of Keystone flaps included type Ⅰ in 2 cases, type Ⅱa in 16 cases, type Ⅱb in 1 case, type Ⅲ in 6 cases, and Moncrieff modified type in 2 cases. The area of flap ranged from 3.0 cm×1.5 cm to 20.0 cm×10.0 cm. The donor site was directly sutured (26 cases) or repaired with skin grafting (1 case).ResultsThe operation time was 45-100 minutes, with an average of 67.5 minutes; the hospitalization stay was 3-12 days, with an average of 8.5 days. Postoperative incision dehiscence occurred in 1 case, and flap marginal necrosis occurred in 2 cases, all of which were completely healed after dressing change; 1 case of incision was swollen and congested with tension blisters, which resolved spontaneously at 7 days after operation. The other flaps and the skin grafting survived and healed successfully, the wounds of recipient and donor sites healed by first intention. The healing time was 2-3 weeks (mean, 2.2 weeks). No pain occurred in all patients. All 27 cases were followed up 3-26 months (mean, 11.5 months). No obvious scar contracture and bloated skin flap were found. The texture and color of the skin in the recipient area were similar to those of the surrounding tissues and feel existed.ConclusionThe Keystone flap is a feasible and efficient way to repair soft tissue defect of lower extremity. Furthermore, the skin color and texture is similar to the surrounding tissue after healing.
ObjectiveTo explore the technique of hepatic artery reconstruction in complicated hilar cholangiocarcinoma surgery. MethodThe clinicopathologic data of 3 patients with complicated hilar cholangiocarcinoma with arterial invasion underwent hepatic artery reconstruction in the Department of Hepatopancreatobiliary Center of Beijing Tsinghua Changgung Hospital from March to July 2022 were retrospectively analyzed. ResultsAll 3 patients (case 1–3) were the males, aged 53, 68, and 56 years, respectively, and with hypertension or diabetes; the longitudinal diameters of the tumor were 3.5 cm, 3.0 cm, and 3.2 cm, respectively. All patients had the right hepatic artery invasion. Case 2 and 3 had the arterial stratification. The arterial defects after radical resection were 4.5 cm, 3 cm, and 3 cm, respectively. The right or right posterior hepatic artery was reconstructed by the autotransplantation of right gastroomental artery, the left hepatic artery, and the anterior superior pancreaticoduodenal artery, respectively. After operation, the reconstructed hepatic arteries were unobstructed and free of stenosis, and there were no complications such as bleeding, infection, and thrombosis by Doppler ultrasound and CT angiography. The results of postoperative pathological diagnosis were the hilar cholangiocarcinoma with arterial invasion, and all the incisal edges were negative. ConclusionFrom the preliminary results of 3 cases, it is safe, feasible, and effective to select proper autologous artery (matched in length and caliber) for reconstruction the defective invaded hepatic artery which resected together with hilar cholangiocarcinoma, but the technical difficulty is still relatively high.
Objective To investigate the management strategies of external fixation combined with microsurgery for the treatment of complex foot and ankle wounds in children. MethodsThe clinical data of 9 children with complex foot and ankle wounds who met the selection criteria between June 2017 and December 2021 were retrospectively analyzed. There were 6 males and 3 females, aged 3-13 years, with an average of 7.4 years. The causes of injury included crush injury in 5 cases and traffic accident injury in 4 cases. The wound size ranged from 6 cm×5 cm to 25 cm×18 cm. The time from injury to surgery ranged from 3 to 8 hours, with an average of 5 hours. All cases underwent staged surgical treatment. Among the 3 cases requiring deformity correction, 2 cases initially underwent free anterolateral thigh flap transplantation for wound coverage and limb salvage, followed by circular external fixation combined with osteotomy to address postoperative limb deformity, while 1 case received osteotomy for tibial fracture realignment prior to local pedicled flap reconstruction. All the 6 cases with non-deformity correction underwent initial external fixation followed by secondary flap reconstruction for wound management. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate the foot and ankle function of children. Results All patients successfully achieved limb salvage postoperatively. Among the 6 non-deformity correction cases, all flaps survived with satisfactory wound healing and no infections observed; fractures healed within 2.5-4.5 months, after which external fixators were removed for functional rehabilitation with favorable recovery. One patient treated with circular external fixation combined with osteotomy achieved bone union 4 months postoperatively, followed by fixator removal. One patient undergoing osteotomy for tibial fracture realignment showed bone healing at 2.5 months post-correction, with subsequent fixator removal. One patient receiving bone lengthening developed infection 1 week postoperatively, which was managed with multiple debridements, ultimately achieving bone union at 16 months postoperatively and followed by fixator removal. At last follow-up, all patients demonstrated satisfactory ankle-hindfoot functional recovery, with AOFAS ankle-hindfoot scores ranging from 80 to 90 (mean, 84.2). Conclusion The combination of external fixation and microsurgical techniques demonstrates significant advantages in reconstructing complex foot and ankle wounds in children. The synergistic interaction provides both mechanical stability and biological repair, enabling early functional rehabilitation while reducing infection risks.