In recent years, flap surgery has been well-developed, and many theories and techniques of flap surgery have been updating. The purpose of manuscript which is based on the flap-related literature is to summarize recent developments of basic and clinic researches, indicate the future of the flap surgery, and show the consensus and guidelines of flap surgery made by Chinese experts.
Objective To review the latest researches of synthetic biodegradable polymers for bone repair and reconstruction, to predict the progress of bone substitute materials and bone tissue engineering scaffolds in future. Methods The l iterature concerning synthetic biodegradable polymers as bone substitute materials or bone tissue engineering scaffolds was collected and discussed. Results Al i phatic polyester, polyanhydride, polyurethane and poly (amino acids) were the most extensively studied synthetic biodegradable polymers as bone substitutes and the scaffolds. Each polymer was of good biological safety and biocompatibil ity, and the degradation products were nontoxic to human body. The mechanical properties and degradation rate of the polymers could be adjusted by the type or number of the monomers anddifferent synthetic methods. Therefore, the polymers with suitable mechanical strength and degradation rate could be produced according to the different requirements for bone grafting. Prel iminary studies in vivo showed their favorable capacity for bone repair. Conclusion The synthetic biodegradable polymers, especially the copolymers, composite materials and those carrying bone growth factors are expected to be the most promising and ideal biomaterials for bone repair and reconstruction.
Objective To review recent advance in the application and research of three-dimensional digital knee model. Methods The recent original articles about three-dimensional digital knee model were extensively reviewed and analyzed. Results The digital three-dimensional knee model can simulate the knee complex anatomical structure very well. Based on this, there are some developments of new software and techniques, and good clinical results are achieved. Conclusion With the development of computer techniques and software, the knee repair and reconstruction procedure has been improved, the operation will be more simple and its accuracy will be further improved.
ObjectiveTo explore the application of three-dimensional (3-D) printing technique in repair and reconstruction of maxillofacial bone defect. MethodsThe related literature on the recent advance in the application of 3-D printing technique for repair and reconstructing maxillofacial bone defect was reviewed and summarized in the following aspects:3-D models for teaching, preoperative planning, and practicing; surgical templates for accurate positioning during operation; individual implantable prosthetics for repair and reconstructing the maxillofacial bone defect. Results3-D printing technique is profoundly affecting the treatment level in repair and reconstruction of maxillofacial bone defect. Conclusion3-D printing technique will promote the development of the repair and reconstructing maxillofacial bone defect toward more accurate, personalized, and safer surgery.
ObjectiveTo investigate the short-term effectiveness of allogeneic bone transplantation for pelvic reconstruction of large skeletal defects after tumor resection. MethodsBetween January 2008 and November 2009, 9 patients with pelvic tumor were treated, and the clinical data were retrospectively analyzed. There were 1 male and 8 females with an average age of 36.1 years (range, 18-44 years). There were 5 cases of giant cell tumor of bone, 2 cases of chondrosarcoma, 1 case of malignant giant cell tumor of bone, and 1 case of Ewing sarcoma. According to the Enneking system for staging musculoskeletal tumors, the lesion involved ilium (region I) in 4 cases, acetabulum (region II) in 6 cases, pubis and ischium (region III) in 3 cases, and sacrum (region IV) in 1 case. The average disease duration was 6.8 months (range, 1-36 months). After accurate resection of the tumor, allograft ilium with or without acetabulum was used in 6 cases and 2 cases respectively, and allogenous bone plate in 1 case for pelvic reconstruction; total hip arthroplasty was performed in 6 cases; sacrum screw was used in 1 case. ResultsInfection of incision and abdominal distention occurred in 1 case, and was cured after debridement; primary healing of incision was obtained in the other cases, without infection, lower limb deep venous thrombosis, or dislocation. The average follow-up was 11.8 months (range, 8-15 months). The X-ray films showed breakage of plate in 1 case at 8 months after operation and partial bone resorption in 2 cases; good position of the prosthesis, plate, and transplanted bone was observed in the other cases. No local recurrence was found. At last follow-up, the average musculoskeletal tumor score (MSTS) was 23 (range, 18-29). ConclusionAllogeneic bone transplantation for pelvic reconstruction of large skeletal defects after tumor resection can achieve satisfactory short-term surgical and functional effectiveness.
Objective To explore the value and limitation of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma. Methods Between January 2013 and December 2019, 18 male patients with hypopharyngeal carcinoma were admitted. The patients’ age ranged from 48 to 77 years, with a median age of 65 years. The disease duration ranged from 3 to 8 months (mean, 5 months). All patients were diagnosed as squamous cell carcinoma by biopsy before operation. According to the American Joint Committee on Cancer (AJCC) guidelines (2017, 8th ed), TNM staging was T2N0M0 in 9 cases, T2N1M0 in 2 cases, and T3N0M0 in 7 cases, and cTNM staging was stage Ⅱ in 9 cases and stage Ⅲ in 9 cases. The lesions of 15 cases were located in the piriform fossa of hypopharynx on one side, among which the esophageal entrance was involved in 4 cases. The lesions of 3 cases were located in the posterior wall of the hypopharynx with esophageal entrance involvement. After partial pharyngo- laryngectomy and bilateral neck lymph node dissection, the hypopharyngeal and laryngeal defects were repaired with transverse cervical artery flaps, the size of the flap ranged from 4 cm×3 cm to 6 cm×4 cm. The accompanying vein of transverse cervical artery (7 cases), external jugular vein (6 cases), and combination of both (5 cases) served as venous reflux. Retrograde external jugular venous reflux exercise was performed in 2 flaps with venous reflux obstruction during operation. The incisions at donor sites were directly sutured or via relaxed incision sutured. Radiotherapy and chemotherapy were supplemented within 3 months after operation. Tracheal cannula with air bag was used to prevent patients from aspiration in the early postoperative stage. Results The operation time was 4-6 hours, with an average of 4.5 hours. All patients were followed up 1-5 years (mean, 2 years and 6 months). Postoperative pathological examination showed that 7 cases had cervical lymph node metastases on the affected side, and there was no lymph node metastasis in cervical region Ⅴ; the remaining 11 cases had no lymph node metastasis. After operation, 16 flaps survived successfully, and 2 flaps with external jugular vein reflux were covered with white pseudomembrane, no flap necrosis was found after the pseudomembrane fell off. Four cases had no obvious accidental aspiration after operation; 14 cases had obvious accidental aspiration, of which 13 cases were significantly reduced at 3 months after operation, and 1 case still had obvious accidental aspiration at 6 months after operation, and the accidental aspiration decreased significantly after pulling out the gastric tube. All patients had no aspiration pneumonia. One case developed upper mediastinal lymph node metastasis at 1 year and 2 months after operation, and died of recurrence and pulmonary infection at 1 year and 3 months after operation. No recurrence or metastasis was found in the remaining 17 cases during follow-up. Tracheal cannula was successfully removed in 7 cases at 2-5 months after operation. Different degrees of accidental aspiration in 11 patients were confirmed by esophagography, so the tracheal cannula was retained. All patients had pronunciation function after operation. All incisions at the donor sites healed by first intention, and the shoulder joint function was normal. Conclusion Using transverse cervical artery flap to repair the hypopharyngeal and laryngeal defects during hypopharyngeal carcinoma surgery in patients without lymph node metastasis in cervical region Ⅴ, can achieve good results of laryngeal function preservation. In cases with suspected lymph node metastasis in cervical region Ⅴ or venous dysplasia of accompanying vein of transverse cervical artery, there is a risk of tumor recurrence or flap necrosis, and the repair method needs to be cautiously employed.
Objective To investigate the effectiveness of posterior lateral perforator flap in lower limb combined with free fibula for maxillary tissue defect repair. Methods Between December 2018 and December 2023, 16 patients with the maxillary malignant tumors were admitted. There were 10 males and 6 females, with an average age of 64.3 years (range, 54-75 years). There were 7 cases of maxillary gingival cancer, 5 cases of hard palate cancer, and 4 cases of maxillary sinus cancer. According to the 2017 American Joint Committee on Cancer (AJCC) TNM stage, there were 8 cases of stage Ⅲ, 6 cases of stage Ⅳa, and 2 cases of stage Ⅳb. After resection of the lesion, the remaining maxillary defects were classified into class Ⅱa in 3 cases, class Ⅱb in 5 cases, and class Ⅲb in 8 cases according to Brown’s classification. The size of soft tissue defects ranged from 4 cm×3 cm to 8 cm×6 cm. The posterior lateral perforator flap in lower limb in size of 5 cm×4 cm-9 cm×7 cm were harvested to repair soft tissue defects, and free fibula in length of 6-11 cm were used to repair bone defects. The donor sites of the lower limb were sutured directly (6 cases) or repaired with free skin grafting (10 cases). Six patients with positive lymph node pathology were treated with radiotherapy after operation. At 6 and 12 months after operation, the self-assessment was performed by the University of Washington Quality of Survival Questionnaire Form (QUW-4) in five dimensions (facial appearance, swallowing function, chewing function, speech function, and mouth opening), and swallowing function was evaluated by using the Kubota water swallowing test. Results Postoperative pathological examination showed that all patients were squamous cell carcinoma. One patient who was treated with radiotherapy developed osteomyelitis and 1 patient developed venous crisis of skin flap. The rest of the flaps and all skin grafts survived, and the wounds healed by first intention. All patients were followed up 1-5 years (mean, 2.8 years). Two patients died of local recurrence of the tumor at the 4th and 5th years after operation, respectively. Except for the chewing function score and total score at 6 months after operation, which showed significant differences compared to preoperative scores (P<0.05), there was no significant difference in other QUW-4 scale scores between different time points (P>0.05). The patients’ swallowing function evaluated by Kubota water swallowing test reached normal in 4 cases, suspicious in 9 cases, and abnormal in 3 cases at 6 months after operation, and 10, 6, and 0 cases at 12 months after operation, respectively. The swallowing function at 12 months was significantly better than that at 6 months (Z=–2.382, P=0.017). Conclusion The posterior lateral perforator flap in the lower limb combined with free fibula to repair maxillary tissue defects can repair soft and hard tissue defects at the same time, so that the patient’s facial appearance, swallowing function, chewing function, speech function, and mouth opening are satisfactorily restored and the mid-term effectiveness is good.
Objective To review the research progress and clinical prospect of three-dimensional spheroid culture of mesenchymal stem cells (MSCs). Methods Recent literature about three-dimensional spheroid culture of MSCs was summarized, mainly on the formation of MSCs spheroids collected by three-dimensional culture, differences between MSCs spheroids and MSCs collected by traditional two-dimensional culture, and the mechanism underlying these differences. Last, its clinical prospect was discussed. Results Compared with MSCs collected by traditional two-dimensional culture, MSCs spheroids collected by three-dimensional culture get a salient up-regulation in anti-apoptosis, multiple differentiation potential, paracrine, and anti-inflammatory effect, which may be related to the morphology and cytoskeleton organization, cell-to-cell contact and gap junctions, and the hypoxia microenvironment. The animal experiments show obvious effects in repair of refractory wounds, repair of ischemic injury, and tissue remodeling, so MSCs spheroid has broad clinical prospect. Conclusion MSCs spheroids collected by three-dimensional culture have stronger biological potential and treatment effect than MSCs collected by traditional two-dimensional culture, MSCs spheroids can be used to optimize stem cell therapy and improve its treatment effect.
Objective To investigate the effectiveness of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction combined with l imited open repair of medial collateral ligament (MCL) in recovering the stabil ity and the function of the knee. Methods Between April 2003 and October 2010, 14 patients (14 knees) with multi ple injuries of ACL, PCL, and MCL were treated. There were 10 males and 4 females with an average age of 41 years (range, 21- 71 years). Injury was caused by traffic accident in 11 cases and fall ing in 3 cases. The average time from injury to admissionwas 2 days (range, 1-4 days). Lysholm score was 17.00 ± 8.29, and the International Knee Documentation Committee (IKDC) score was 20.93 ± 8.28. The complicated injuries included dislocation of the knee joint in 9 cases and meniscus injury in 5 cases. Allogeneic tendons (2 cases) and autologous harmstring tendon (12 cases) were used to reconstruct ACL and PCL under arthroscopy, and all cases underwent limited open repair of MCL. Results All incisions healed by first intention. Numbness of the lower limb occurred in 3 cases and alleviated spontaneously. All patients were followed up 14 months on average (range, 12-18 months). The knee flexion was 120° and extension was 0° at 3 months of follow-up. After 1 year of follow-up, IKDC score and Lysholm score were 89.93 ± 6.26 and 88.93 ± 4.82, respectively, showing significant differences when compared with preoperative scores (P lt; 0.01). Conclusion For multi ple injuries of the knee ligaments, an arthroscope with limited open repair and reconstruction of the knee ligament can avoid open joint chamber, reduce postoperative articular adhesion, and encourage the joint function recovery.
ObjectiveTo investigate the effectiveness of autogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture.MethodsBetween June 2015 and June 2018, 16 patients with chronic Achilles tendon ruptures were treated by autogenous tendon reconstruction under total arthroscopy. Of the 16 patients, 11 were males and 5 were females. Their mean age was 40.7 years (range, 21-55 years). The disease duration was 14-20 months (mean, 16.4 months). Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 41.2±2.2 and the pain visual analogue scale (VAS) score was 7.9±1.2. MRI and B-ultrasonography examinations showed that the Achilles tendon was not continuous. The length of Achilles tendon defect was 5.0-10.3 cm, with an average of 5.8 cm. The rupture of the Achilles tendon happened on top of the insertion of the tendon in 4 cases and at the tendon-muscle belly connection in 12 cases. The operation time, intraoperative blood loss, hospital stay, and related complications were recorded. The AOFAS score and VAS score were used to evaluate the improvement of ankle joint function and pain.ResultsThe average operation time was 77.2 minutes (range, 60-90 minutes). The average intraoperative blood loss was 20.5 mL (range, 15-30 mL). The average hospital stay was 7.2 days (range, 5-10 days). All incisions healed by first intention. There was no skin necrosis, infection, or deep vein thrombosis. All the patients were followed up 8-18 months, with an average of 12 months; and 10 cases were followed up more than 12 months. During the follow-up, there was no Achilles tendon re-rupture, and the symptoms of pain and heel lifting failure significantly improved. MRI reexamination showed that the continuity of Achilles tendon recovered. At 1, 3, 6, and 12 months postoperatively, AOFAS scores significantly improved and VAS scores significantly reduced, except for 1 month postoperatively, the scores at other time points were superior to that before operation, the differences were significant (P<0.05).ConclusionAutogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture has the advantages of small trauma, rapid functional recovery, and satisfactory surgical efficacy.