108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCE NGUYEN QUANG VINH ANATOMICAL AND CLINICAL INVESTIGATION OF THE FREE SENSORY FASCIOCUTANEOUS DELTOID FLAP FOR SOFT TISSUE D
Trang 1108 INSTITUTE OF CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCE
NGUYEN QUANG VINH
ANATOMICAL AND CLINICAL INVESTIGATION OF THE FREE SENSORY FASCIOCUTANEOUS DELTOID FLAP FOR SOFT TISSUE DEFECTS RECONSTRUCTION
OF THE FOOT WEIGHT-BEARING AREA
Specialty: Orthopaedic Trauma and Reconstructive Surgery
Code: 62720129
MEDICAL DOCTORAL THESIS SUMMARY
HANOI 2019
Trang 2THE WORK HAS BEEN COMPLETED
AT 108 MILITARI CENTRAL HOSPITAL
Scientific instructors: Prof., Dr of Science Nguyen The Hoang
Reviewer 1: Prof., PhD Le Gia Vinh
Reviewer 2: Assoc Prof., PhD Pham Dang Ninh
Reviewer 3: Assoc Prof., PhD Lam Khanh
The dissertation defense will take place in front of 2nd dissertation committee in 108 Institute Of Clinical Medical And Pharmaceutical Science at hour: DD/MM/YYYY
This Study available at:
1 National Library of Viet Nam
2 Library of 108 Institute Of Clinical Medical And Pharmaceutical Science
Trang 3BACKGROUND
The weight-bearing area of the foot has unique physiological and anatomy features (characteristics) to adapt to the role of bearing gravity Until now, the reconstruction of the weigth bearing area of the foot has always been a challenge due to the lack of comparable replacement materials The skin grafts are a simple method, however skin graft has no bearing gravity The local random flaps are only suitable for small defects The local neurovascular island flaps have treated a lot of defects
in the weight-bearing area of the foot, but the applicability of local neurovascular island flaps was limited by the size and sometimes these flaps were not available If using crossflaps, cylinder flaps, the patient has to undergo many surgeries, suffering from long-term restrictive posture
The reconstruction by free flaps has been successful since the 70s
of last century and has flourished for more than last four decades Overcoming the initial challenges of covering defects only for the purpose of wound healing, the present challenge is the increasing functional and aesthetic requirements For defects in the weight-bearing area of the foot, covering is required a thin flap, good perfusion ability, sensation to protect the flap, size of the flap is large, hairless and possibly minor donor-site comorbidities The fasciocutaneous deltoid free flap is one of the few flaps that can meet most of the above criteria
The fasciocutaneous deltoid free flap was discovered by Franklin J.D in 1984 Later, many authors applied this flap to cover the defects of the hands, feet and face Overall, the fasciocutaneous deltoid free flap was found to be suitable for covering defects in the weight-bearing area
of the foot by the authors However, the anatomical studies on flap has been less informed These studies also did not mention much about the anatomical characteristics of the Posterior circumflex humeral vascular bundles and the sensory nerve branches of the flap About the thickness
of this flap and especially the size of blood vessels of this flap on the body has not been mentioned by any author
Trang 4In Vietnam, the sensory deltoid free flap has been used in Military Central Hospital 108 since 2005 The initial results of using flap to treat defects in the weight-bearing area of the foot are encouraging However, there is currently no systematic study linking the anatomy study of the flap with clinical applications For all above reasons, we studied
"Anatomical and clinical investigation of the free sensory fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the foot weight-bearing area " Our goals were:
1 Research on anatomical characteristics of fasciocutaneous deltoid free flap in Vietnamese adults
2 Assess the results of clinical application to treat soft-tissue defects in the weight-bearing area of the foot
Our contribution
1 Using ultrasound to measure the thickness of the fasciocutaneous deltoid flap: In Vietnam, this is the first time this method has been performed The results show that this method is reliable, practical and scientific
2 Determine the length, diameter and three-dimensional image of arterial system blood- supplying for deltoid flap on the living organism through CTA-320 For deltoid flap, this is the first time this method has been used
3 Detecting anatomical abnormalities related to the original types, course of the posterior circumflex humeral artery and cutanous branch artery This finding gives surgeons more confidence in using deltoid free flap on clinically
4 Determine the participation of deltoid flap in walking through footprint: In Vietnam, this is the first time this method has been applied
5 Currently, the deltoid flap is rarely used and reported in the literature This study contributes to affirming that deltoid flap is a suitable and reliable material when choosing flaps that cover expose tendons, bone, joint defects in weight-bearing area of the foot
Trang 5STRUCTURE OF THE THESIS
Total page: 127
- Introduction: 2 pages
- Chapter 1 Overview: 31 pages
- Chapter 2 Method: 29 pages
- Chapter 3 Result: 28 pages
- Chapter 4 Discussion: 34 pages
- Conclusion: 2 pages
- Include: 13 tables, 2 figures, 67 photos
- References: 144 (Vietnamese: 29, Foreign languages: 115)
- 3 reports related to our study has been announced
Chapter 1: OVERVIEW 1.1 Anatomy and physiological characteristics of weight- bearing area of the foot
1.2 Treatment of defects in weight-bearing area of the foot
1.2.1 Skin grafts method
1.2.2 The local random flaps
1.2.3 The local neurovascular island flaps
1.2.4 The flaps moves from afar
1.2.4.1 The flaps moves from afar without vascular anastomosis
1.2.4.2 The free flaps
a The muscle flaps recontruction of soft-tissua defects in the weight- bearing area of the foot
b The fasciocutaneous flap and role of sensation when recontruction
of defects in the weight- bearing area of the foot
In 1990, Meland studied free flaps reconstruction in the bearing area of the foot and synthesized literature, showing the following trends in the choice of fasciocutaneous flaps Initial, the largest number used were the tensor fascia lata flaps They were reported early in the literature and had a high minor and major complication rate of 20-47%, respectively Eleven of these flaps were also innervated with a 36% ulceration rate despite adequate return of two-point discrimination in the
Trang 6weight-25-30mm Because of the thickness of this flap and its inability to withstand the stress forces of ambulation, most authors have now abandoned it Of particular interest is the noted success of the relatively more recently described, thin fasciocutaneous flaps that may provide sensory innervation (i.e., the radial forearm, dorsalis pedis, and the deltoid flap) This review included 24 of these flaps, all with very minor complications that responded well to local, conservative therapy The only major complication was an infection that required debridement in one radial forearm flap All of the innervated flaps eventually developed two-point discrimination in the 20-30 mm range and the flaps seemed to hold up very well to the stresses of ambulation They most certainly showed improved results when compared to the early, thicker fasciocutaneous flaps studied including the tensor fascia lata, scapular/parascapular, and groin flaps
Summary: There are many options for recontruction of soft-tisue
defects in the weight-bearing area of the foot Skin grafting is usually only considered a temporary solution The Cross-flap is only applied to save limbs in special cases Most commonly used in reconstruction in the weight-bearing area of the foot is local neurovascular flaps and free flaps With limit size defects is local neurovascular flaps is often chosen Nowadays, with the advancement of microsurgical techniques, along with the increasing demands on functional and aesthetic reconstruction, free flaps are increasingly more widely assigned The free flaps are often used to cover in the weight-bearing area of the foot is the free sensory fasciocutaneous flap and muscle flaps Because of the thickness of the flap, skin grafts must be grafted onto the surface and there is no sensation
so muscle flaps only really fit deep cavities, osteoarthritis The free sensory fasciocutaneous flap, especially thin flaps such as the anterior thigh flap, radial forearm flap, lateral arm flap and deltoid flap are the preferred ones, even with large imperfections, with shallow bone damage, superficial osteitis
Trang 71.3 The fasciocutaneous deltoid flap
1.3.1 Anatomy research situation of fasciocutaneous deltoid flap
1.3.1.1 In the world
The fasciocutaneous deltoid free flap was discovered by Franklin J.D in 1984 The flap is the skin covering the deltoid muscle and posterolateral arm The axis of the flap is the path connecting acromion and medial epicondyle The flap is dominated sensation by the lateral brachial cutaneous nerve separated from axilary nerve The pedicle consists of cutaneous vascular bundles separated from Posterior circumflex humeral vascular bundles According to Franklin, the pedicle has a length of about 6 - 8cm, posterior circumflex humeral artery has a diameter of about 2 - 4mm, cutaneous branch artery has a diameter of about 1mm and usually has two dependent
Posterior circumflex humeral artery (PCHA) and cutaneous branch artery’course and branch distribution: According to Franklin, from original in axillary artery, PCHA runs back through Velpeau quadrangle space and then go around the surgical neck of the humerus The PCHA is divided into several branches, including: the branch connected to the deltoid branch of the deep arm artery, the branch connected to the anterior humeral circumflex artery, the branches supply blood to the deltoid muscle and the cutaneous branch artery supply blood to the deltoid flap Cutaneous branch artery travels within the deltoid-triceps muscles wall to enter the flap Russell (1985) and Strauch (1993) described a bifurcation of cutaneous branch artery in the muscular septum, and the case of a branch going through the deltoid muscle However, both authors did not give statistial ratios
Pedicle position enters the flap: According to Franklin, the pedicle position enters the flap at the back of point A (the intersection of the axis
of the deltoid flap and the back edge of the deltoid muscle) and the average distance from point A is 2cm This distance according to Wang
is 1.86cm and according to Meltem is 1.5cm
Trang 8In 2003, Wang was dissection the vascular network of deltoid flap
at 21 cadavers The skin vascular network of deltoid flap consists of five layers and the vascular network of deep fascia is the most dense with 96.5 ± 14 artery branch / mm2 Through the continuity of the vascular network from the cutaneous branch artery to the vascular network from multiple musculocutaneous perforators, from the brachial artery, the transverse cervical artery, the thoracoacromial artery helps the flap to be well perfected and the flap blood supply area is expanded Wang is also the only author who mentioned the anatomical features of PCHA, and described this artery only penetrates the quadrangular space in 90 percent
of cases, the remaining case it arose from the arch of the brachialis and profunda brachii and did not penetrate the quadrangular space
1.3.1.2 In Vietnam
In 2013, dissection in 43 deltoid regions on formalin storage corpses, Nguyen Duc Nghia described the cutaneous branch artery always present and always derived from PCHA The cutaneous branch artery split 2 branches at 74.42% (32/43 templates), in 5/43 templates (11.63%), after the split there was a branch that went through the deltoid muscle to enter the flap The author did not describe the posterior circumflex humeral bundle
In general, the anatomy researchs on deltoid flap of authors in the country as well as in the world has focused mainly on the description of cutaneous branch bundle The research results show that deltoid flap has dense vascular network with lots of rich connections The anatomical characteristics of posterior circumflex humeral bundle have not been described According to the documents we found, the authors did not dissect deeply into the Velpeau quadrangle space to describe the anatomical characteristics of Posterior circumflex humeral bundle, as well as the sensory nerve branch of the flap The size of the pedicled deltoid flap has also been described by some authors, but the data are still very different The determination of the length and diameter of the pedicled deltoid flap on living organism has not been mentioned
Trang 9Regarding the thickness of deltoid flap, the authors all considered deltoid flap to be a thin flap, but no author had ever measured the thickness
1.3.2 Situation of deltoid flap clinical application
1.3.2.1 In the world
2.3.2.2 In Vietnam
Through international and national literature, the deltoid flap is applied to cover hand defects and especially in the weight-bearing area of the foot With the advantage of color, some authors also applied deltoid flap to recontruction of oral and maxillofacial In general, the authors stated that fasciocutaneous deltoid flap is a thin flap, hairless, the constant vascular pedicle with a convenient length and diameter, safe for free flap transfer The deltoid flap has a rich vascular network, good perfusion, helps to minimize the phenomenon of pressure ulcer caused by the lack of support and anti-bacterial infection Statistics of 125 deltoid flaps covering soft-tissue defects have been reported by 13 authors, including complex soft-tissue defects and bacterial infections All deltoid flap are alive (100%), which helps heal injuries and facilitate patients both functionally and aesthetically The deltoid flap has a sensory nerve branch, can be harvested with a large size, allowing the donor site to be directly closed, scars are easy to hide and do not affect the function of the deltoid muscle as well as the shoulder joint after surgery Disadvantage factors of the flap are also shown, which is the difficult flap dissection process due to the multiple branching of the neurovascular pedicle in Velpeau quadrangle space In addition, Krishnan and Musharafieh have recommended that scar donor sites be at risk for hypertrophic, especially
in young patients (two authors did not give specific statistics)
From this fact, we found that the results of deltoid flap application
in the treatment of soft-tissue defects in the weight-bearing area of the foot were positive However, thickness and sensory nerve branches of the flap have not been described The posterior circumflex humeral bundle characteristics are just mentioned very briefly The determination of the length and diameter of the pedicled deltoid flap on living organims has
Trang 10not been mentioned In addition, the number of patients of each author is small (< 20 patients) Some characteristics of reinnervation, the function
of using the flap and the aesthetic problem of the whole tie-receiving place and donor site have not been specifically described by the authors From the above reasons, we believe that the implementation of the subject: "Anatomical and clinical investigation of the free sensory fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the foot weight-bearing area" to have more general conclusions about the anatomy and results after shaping the flap is needed
Chapter 2: SUBJECT AND METHODS 2.1 Research on anatomical characteristics of fasciocutaneous deltoid flap
2.1.1 Measure the thickness of deltoid flap through ultrasound
- Subjects: 72 deltoid areas/36 patients, from 4/2015-12/2017 at department C7, of Military Central Hospital 108
- Methods: Using soft tissue ultrasound program with frequency probe 7-16 MHz on Logiq S8 machine manufactured by GE The probe
is gently applied to the surface of the skin without subsidence, measuring the thickness of the deltoid flap in 8 positions: 1 (located on the axis and below 5cm A point), 2 (point A- intersection of the axis of the flap and posterior deltoid muscle), 3 (acromion), 4 (located on the axis and on the acromion 5cm), 5 and 6 (two symmetrical positions via acromion and 5cm from the acromion, position 5 in front and position 6 in the back), 7 and 8 (two symmetrical positions over point A and 5cm from point A, position 7 in front and position 8 on the back)
- Evaluation criteria: Average thickness at 8 locations on the flap (mm) and average thickness of flap
2.1.2 Determination of blood artery system for deltoid flap through CTA-320
- Subjects: 54 shoulder and arm areas of 27 Vietnames adult patients, pre-surgical angiography with CT-320 at Diagnostic Imaging Department of Military Central Hospital 108 from 5/2015 - 5/2017
Trang 11- Methods: Using CT-320 Aquilion One machine manufactured by Toshiba, Xenetic® (France) Contrast does not ionize vials of 350mg / 100ml, at a dose of 1.5ml / kg, injected with an automatic syringe into saphenous vein in leg at 5ml / sec The time taken after the injection of contrast material is about 120 - 180 seconds The following image was taken in 3-D by Vitrea FX software, Version 6.3 (Toshiba)
- Evaluation criteria: Statistics about origins, paths, branches and measuring the length and diameter of posterior circumflex humeral artery
as well as cutaneous branch artery
2.1.3 The characteristics of neurovascular pedicled deltoid flap through autopsy
2.1.3.1 Subjects: The dissection 54 deltoid regions in 27 Vietnames adult
cadavers (13 males, 14 females) at the Anatomical Department of Ho Chi Minh Medical University in March 2014 and September 2016 Among them, there are 16 cadavers preserved by 10% Formol (preserve cadavers), 11 preserved at -300C (fresh cadavers)
2.1.3.2 Methods
a Research design: Cross-sectional descriptive research
b The technique of dissection on cadaver:
+ Put the cadaver lying prone on the operating table, shoulder height padded, spread arms 300 Draw the axis of the flap and determine point A Draw a center circle A with a radius of 3cm Draw a line through A and perpendicular to the axis of the flap to divide the circle into 4 equal areas The goal is to locate the pedicle into the flap
+ Incise skin and deep fascial from between spine of scapula going
up to front to midpoint of clavicle, going outward to deltoid-thoracic groove, straight down to lateral condyle of humerus, going backwards to medial condyle of humerus pulling up to the posterior edge of armpit Dissect by Franklin's method from the front of the shoulder, along the flap, to the trunk of the flap at the base of the deltoid-triceps wall
+ Dissection neurovascular pedicled deltoid flap in the triceps wall and Velpeau quadrangle space
Trang 12deltoid-+ Determination of blood supply area: 500ml of 1% Methylene blue solution is suspended 1.5m above the flap and infused at maximum speed into the cutaneous branch artery on fresh cadavers for 30 minutes, then measure the size of infusion area
+ Measurement of the distribution of the sensory nerve branch: Dissection in the soft-tissue of deltoid flap on the preserved 10% Formol cadavers (under 5X magnifier) to show the path and branching of the sensory nerve Measure the distribution of this nerve branch from the position it enters the flap up and down
+ Statistics about origins, paths, branches and measuring the length and diameter of posterior circumflex humeral artery as well as cutaneous branch artery and accompany veins
2.2 CLINICAL RESEARCH
2.2.1 Patients: 60 patients with expose tendons, bone, joint defects in
weight-bearing area of the foot, reconstruction using fasciocutaneous sensory deltoid free flap at Institute of Orthopaedics and Traumatology
of Military Central Hospital 108, from 7/2005 - 12/2017
2.2.2 Methods
Retrospective and prospective, cross-sectional description, longitudinal monitoring and no control group
Retrospective group: 18 patients from 7/2005 - 8/2012
Prospective group: 36 patients from 9/2012 - 12/2017
2.2.2.2 Follow up after surgery
2.2.2.3 Treatment after surgery
2.2.2.4 To guider patients how to care and exercise against for flap:
After 3 weeks of surgery, the flap is pressed and the patient is trained to
Trang 13stand on a foam sheet with pressure and time increasing to the flap After
2 weeks, give the patient a walker with crutches with increased support to the flap patients are instructed to check the flap daily and encourage the use of shoes and sandals with comfortable sole throughout the life
2.2.2.5 Evaluation criteria
The examination and evaluation process is conducted every 3 months in the first year and once every 1 year in subsequent years
* Evaluation of early results after surgery (≤ 3 months)
+ Ratio of surviving flap: Good (whole flap survives), Fair (partial necrotic flap) and Bad (failure - total necrotic flap)
+ Results of cover soft-tissue defect: Good: first heal, Moderate: may require intervention to clear the infection or a skin graft to heal the wound, with a second heal Bad: fistula with prolonged inflammation
* Evaluate long-term results at recipient site and donor site (≥ 9 months)
- Results at recipient site (foot area):
+ Investigation patient satisfaction with flap (Appendix 5): The results are classified according to Graf P into 4 levels including: (1): Very satisfied, (2): Satisfied, (3): Accepted and (4): Not satisfied
+ Level of sensate recovery was assessed by BMRC (British Medical Research Council), and was compared with the corresponding area on the opposite leg on the Kalbermatten Results are classified into 4 levels: Very Good, Good, Fair and Poor
+ Restoration of walking ability: assessed according to Rautio: Very Good, Good, Fair and Poor
+ The durability of the flap (assessed by Rautio): Very Good, Good, Fair and Poor
+ The aesthetic of the flap (assessed by Graf P.): Very Good, Good, Fair and Poor
+ General classification of results at the recipient site: Based on the 5 criteria above, the overall results are classified into 4 corresponding levels: Very Good, Good, Average and Poor when that level is achieved
at 4/5 criteria
Trang 14- Comorbity at the donor site: 4 criteria: (1) Patient ’s satisfaction with scar at the donor site, (2) Deltoid muscle and shoulder joint function, (3) Scars formed after harvest flap and ( 4) Ability to hide scars
+ Investigation patient satisfaction with scar at the donor site: Includes 4 levels: (1): Very satisfied, (2): Satisfied, (3): Accepted and (4): Not satisfied
+ Deltoid muscle and shoulder joint function: Very Good, Good, Fair and Poor
+ Cosmetic problem of scar after harvest flap: 4 levels: good scar, spread scar, hypertrophic scar and keloid scar
+ Ability to hide scars: Very Good, Good, Fair and Poor
+ General classification of comorbity at the donor site:
Based on the 4 criteria above, the overall results are classified into
4 corresponding levels: Very Good, Good, Average and Poor when that level is achieved at 3/4 criteria
Chapter 3: RESULTS 3.1 Anatomical research results fasciocutaneous deltoid flap
3.1.1 Result of thickness of fasciocutaneous deltoid flap
Table 3.1 The thickness of fasciocutaneous deltoid flap
Position 5: in front of the acromion 5cm 3,2 6,5 3,99 ± 0,75
The average thickness of the flap through ultrasound is: 5.14 ± 0.81mm The thickest flap at the vascular position enters the flap (position 2) and thins towards the shoulder (Table 3.1)