Murat KAYALAR, Emir BAL, Tulgar TOROS, S. Tahir SÜĞÜN, Kemal ÖZAKSAR, Yusuf GÜRBÜZ

Pulpa doku kayıplarında nörovasküler doğrudan akımlı ada doku nakillerinin sonuçları

Amaç: Çalışmamızda pulpa doku kayıplarında nörovasküler doğrudan akımlı ada doku nakillerinin sonuçlarının incelenmesi amaçlandı. Çalışma planı: Pulpa defekti nedeniyle ada doku nakli uygulanan doksanaltı hastanın 115 parmağı çalışmaya alındı. Hastaların 93'ü (%97) acil hastasıydı. Yetmiş hastada (%72.9) yaralanma ezilme tipinde idi. Hastalarda pediküllü ada dokusu nakli ile pulpa rekonstrüksiyonu gerçekleştirildi. Sonuçlar proksimal interfalangeal eklem ekstansiyon kaybı, Semmes Weinstein monoflaman testi, statik iki nokta ayrımı ve soğuk intoleransı ile değerlendirildi. Yaralanma mekanizması ile hasta memnuniyeti, soğuk intoleransı ve tamir dokusu problemleri arasındaki ve çengel tırnak ile cilt grefti kullanımı arasındaki ilişki ki kare testi ile incelendi. Bulgular: Tüm olgularda nakil dokusunun canlı kaldığı görüldü. Ortalama 41 ±20.3 (12-108) ay takip parmakların ll'inde (%9.5) proksimal interfalangeal eklemde ekstansiyon kaybı görüldü. Kısıtlılık 7 olguda 10 derecenin altındaydı. Sekiz parmakta (%7) çengel tırnak deformitesi, 16 hastada (%17) isesoğuk intoleransı saptandı. Semmes Weinstein monoflaman testi ve statik iki nokta ayrımı sonuçları tatminkar idi. İstatistiksel olarak farklı yaralanma mekanizması ile başvuran hastalar arasında soğuk intoleransı, hasta memnuniyeti ve skar sorunu oranları açısından anlamlı fark gözlenmedi (p>0.05). Serimizde hasta memnuniyeti oranı %91.7 olarak bulundu. Çıkarımlar: Pulpa defektlerinde aynı parmak üzerinden kaldırılan direkt akımlı ada doku nakilleri verici alanda az morbidite yaratıp, fonksiyon ve estetik açısından tatminkar sonuçlar veren güvenli bir yöntem olarak görünmektedir.

Anahtar Kelimeler:

Hareket açıklığı, eklem, Ameliyat sonrası komplikasyonlar, Mikrocerrahi, El parmağı eklemi, İskemi, Perioperatif bakım, Tedavi sonucu, Periferik sinir yaralanmaları, Deri nakli, Bölgesel kan akımı, Travma şiddeti indeksleri, Fonksiyon iyileşmesi, El parmağı yaralanmaları, Cerrahi flepler

The outcome of direct-flow neurovascular island flaps in pulp defects

Objective: In this study we aimed to evaluate the results of the direct-flow neurovascular island flap (NIF) transfers in pulp defects. Methods: We reviewed the records of 96 patients with 115 NIF transfers performed for pulp defect reconstruction. The injury mechanism was crush type injury in 70 patients (72.9%). Ninety-three patients (97%) were emergency cases. Pulp reconstruction was performed by means of pedicled island flap transfer. The results were evaluated with proximal interphalangeal joint range of motion, the Semmes Weinstein monofilament test, static two-point discrimination and cold intolerance assessments. The relations between the injury mechanism, patient satisfaction, cold intolerance and scar problems were analyzed. Also, the association between skin grafting and hook nail deformity was investigated. The level of significance was set at p<0.05. Results: All flaps survived. The mean follow-up time was 41±20.3 (range: 12-108) months. We observed proximal interphalangeal joint flexion contracture in 11 (9.5%) cases. In seven of these, the limitation was less than 10 degrees. Hook nail deformity was seen in 8 fingers (7%). Cold intolerance was found in 16 (17%) cases. Semmes Weinstein monofilament and static-two point discrimination tests of flaps revealed satisfactory results. There was no relation between the injury mechanism and cold intolerance, patient satisfaction and scar problems (p>0.05). Among patients, 91.7% were satisfied with their results. Conclusion: The transfer of direct-flow island flaps, from the same finger, causes minimal mor bidity on the donor site and appears to be a safe method, providing satisfactory functional and aesthetic results in the reconstruction of pulp defects.

Keywords:

Range of Motion, Articular, Postoperative Complications, Microsurgery, Finger Joint, Ischemia, Perioperative Care, Treatment Outcome, Peripheral Nerve Injuries, Skin Transplantation, Regional Blood Flow, Trauma Severity Indices, Recovery of Function, Finger Injuries, Surgical Flaps,

___

1. Varitidimis SE, Dailiana ZH, Zibis AH, Hantes M, Bargiotas K, Malizos KN. Restoration of function and sen sitivity utilising a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br 2005;30:338-42.
2. Elliot D, Moiemen NS, Jigjinni VS. The neurovascular Tranquilli-Leali flap. J Hand Surg Br 1995;20:815-23.
3. Adani R, Busa R, Castagnetti C, Bathia A, Caroli A. Homodigital neurovascular island flaps with direct flow vascularization. Ann Plast Surg 1997;38:36-40
4. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputations of the fingertip and thumb. Plast Reconstr Surg 1980;66:296- 300.
5. Snow JW. The use of a volar flap for repair of fingertip amputations: a preliminary report. Plast Reconstr Surg 1967;40:163-8.
6. Lanzetta M, Mastropasqua B, Chollet A, Brisebois N. Versatility of the homodigital triangular neurovascular island flap in fingertip reconstruction. J Hand Surg Br 1995;20:824-9.
7. Evans DM, Martin DL. Step-advancement island flap for fingertip reconstruction. Br J Plast Surg 1988;41:105-11.
8. Braga Silva J, Jaeger M. Repositioning and flap placement in fingertip injuries. Ann Plast Surg 2001;47:60-3.
9. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg Am 1956;38:917.
10. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg 1946;12:303-19
11. Bertelli JA, Pagliei A. Direct and reversed flow proximal phalangeal island flaps. J Hand Surg Am 1994;19:671-80.
12. Shibu MM, Tarabe MA, Graham K, Dickson MG, Mahaffey PJ. Fingertip reconstruction with a dorsal island homodigital flap. Br J Plast Surg 1997;50:121-4
13. Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001; 47:263-8.
14. Koshima I, Urushibara K, Fukuda N, Ohkochi M, Nagase T, Gonda K, et al. Digital artery perforator flaps for finger tip reconstructions. Plast Reconstr Surg 2006;118:1579-84
15. Netscher DT, Meade RA. Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps. Plast Reconstr Surg 1999;104:1705-12.
16. Kojima T, Kinoshita Y, Hirase Y, Endo T, Hayashi H. Extended palmar advancement flap with V-Y closure for finger injuries. Br J Plast Surg 1994;47:275-9.
17. Lim GJ, Yam AK, Lee JY, Lam- Chuan T. The spiral flap for fingertip resurfacing: short- term and long-term results. J Hand Surg Am 2008;33:340-7.
18. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg 2008;122:105e- 17e.
19. Joshi BB. A local dorsolateral island flap for restoration of sensation after avulsion injury of fingertip pulp. Plast Reconstr Surg 1974;54:175-82.
20. Pho RW. Local composite neurovascular island flap for skin cover in pulp loss of the thumb. J Hand Surg Am 1979;4:11-5.
21. Borman H, Maral T, Tancer M. Fingertip reconstruction using two variations of direct- flow homodigital neurovas cular island flaps. Ann Plast Surg 2000;45:24-30.
22. Chen CT, Wei FC. Lateral-dorsal neurovascular island flaps for pulp reconstruction. Ann Plast Surg 2000;45:616- 22.
23. Tsai TM, Yuen JC. A neurovascular island flap for volar oblique fingertip amputations. Analysis of long-term results. J Hand Surg Br 1996;21:94-8.
24. Foucher G, Smith D, Pempinello C, Braun FM, Citron N. Homodigital neurovascular island flaps for digital pulp loss. J Hand Surg Br 1989;14:204-8.
25. Schuind F, Van Genechten F, Denuit P, Merle M, Foucher G. Homodigital neurovascular island flaps in hand surgery. A study of sixty cases. Ann Chir Main 1985;4:306-15.
26. Cook FW, Jakab E, Pollock MA. Local neurovascular island flap. J Hand Surg Am 1990;15:798-802.
27. Tan ST. Homodigital onycho-osseo-cutaneous island flap: a novel technique for a tricky fingertip injury. Plast Reconstr Surg 2002;110:709-10.
28. Henry M, Stutz C. Homodigital antegrade-flow neurovas cular pedicle flaps for sensate reconstruction of fingertip amputation injuries. J Hand Surg Am 2006;31:1220-5.
29. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast Surg 1997;24:1-32.
30. Lanzetta M, St-Laurent JY. Pulp neurovascular island flap for finger amputation. J Hand Surg Am1996;21:918-21.
31. Karamürsel S, Kayıkçıoğlu A, Aksoy HM, Dayıcan A, Şafak T, Keçik A. Dorsal visor flap in fingertip recon struction Plast Reconstr Surg 2001;108:1014-8.
32. Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001; 47:263-8.
33. Chen SL, Chou TD, Chen SG, Cheng TY, Chen TM, Wang HJ. The boomerang flap in managing injuries of the dorsum of the distal phalanx. Plast Reconstr Surg 2000;106: 834-9.
34. Chen SL, Chiou TF. Innervated boomerang flap for finger pulp reconstruction. Injury 2007;38:1273-8.
35. Niranjan NS, Armstrong JR. A homodigital reverse pedi cle island flap in soft tissue reconstruction of the finger and the thumb. J Hand Surg Br 1994;19:135-41.
36. Lai CS, Lin SD, Chou CK, Tsai CW. A versatile method for reconstruction of finger defects: reverse digital artery flap. Br J Plast Surg 1992;45:443-53.
37. Hoşnuter M, Kargı E, Işıkdemir A. An improvement in dorsal reverse adipofascial flap for fingertip reconstruc tion. Ann Plast Surg 2005;55:155-9.
38. Laoulakos DH, Tsetsonis CH, Michail AA, Kaxira OS, Papatheodorakis PH. The dorsal reverse adipofascial flap for fingertip reconstruction. Plast Reconstr Surg 2003;112: 121-5; Discussion 126-8.
39. Hirase Y, Kojima T, Matsuura S. A versatile one-stage neurovascular flap for fingertip reconstruction: the dorsal middle phalangeal finger flap. Plast Reconstr Surg 1992; 90:1009-15.
40. Datiashvili RO, Shibaev EY, Tsagikyan AA. Autotrans plantation of heterodigital neurovascular free flaps for plas ty of finger defects. J Reconstr Microsurg 1992;8:101-6.
41. Lee YH, Baek GH, Gong HS, Lee SM, Chung MS. Innervated lateral middle phalangeal finger flap for a large pulp defect by bilateral neurorrhaphy. Plast Reconstr Surg 2006;118:1185-93; Discussion 1194.
42. Tay SC, Teoh LC, Tan SH, Yong FC. Extending the reach of the heterodigital arterialized flap by vein division and repair. Plast Reconstr Surg 2004;114:1450-6.
43. Leoh JY, Teoh LC, Seah VW. Extending the reach of the heterodigital arterialized flap by cross-finger transfer. Plast Reconstr Surg 2006;117:2320-8.
44. Ünlü RE, Mengi AS, Koçer U, Şensöz Ö. Dorsal adipofas cial turn over flap for fingertip amputations. J Hand Surg Br 1999;24:525-30.
45. Braga-Silva J, Kuyven CR, Albertoni W, Faloppa F. The adipofascial turn-over flap for coverage of the dorsum of the finger: a modified surgical technique. J Hand Surg Am 2004;29:1038-43.
46. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse dorsal digital island flap for fingertip reconstruc tion. J Hand Surg Am 2006;31:1094-9.
47. Alagöz MS, Uysal CA, Kerem M, Şensöz Ö. Reverse homodigital artery flap coverage for bone and nailbed grafts in fingertip amputations. Ann Plast Surg 2006;56: 279-83.
48. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290-5.
49. Yıldırım S, Avcı G, Akan M, Aköz T. Complications of the reverse homodigital island flap in fingertip reconstruc tion. Ann Plast Surg 2002;48:586-92.