Twenty-minute harvesting of flow-through type vastus lateralis muscle flap significantly reduces the need for a temporary intravascular shunt in the treatment of severe upper extremity trauma in civilian patients

Abstract

For the reconstruction of severe upper extremity trauma involving arterial injury in civilian patients, it is generally recommended that the revascularization time be shortened using a temporary intravascular shunt (TIVS). However, if a flow-through type vastus lateralis muscle (VLm) flap can be harvested in 20 minutes and bypassed at the obstructed ischemic zone within 30 minutes, blood flow can be restored as quickly or more quickly than when using a TIVS, eliminating the need for a TIVS. This procedure was applied in the reconstruction of 3 cases of severe extremity trauma with vascular injury. The mean age was 69.7 years. Surgery was started an average of 2.93 hours from the onset. The average flap harvest time was 0.33 hours. The average time to revascularization from flap harvest was 1.33 hours, the average total operation time was 6.43 hours, and all upper extremities were salvaged. No cases showed ischemia-reperfusion injury or severe muscle contracture. The flow-through-type VLm flap can be applicable as a bypass graft for a 20 cm defect at any region distal to the elbow. In addition, harvesting the flap attached to blood-rich muscle not only controls the infection of contaminated wounds through the filling of dead space, but also has the potential to replace damaged muscle or tendon tissue. Even though TIVS placement is currently used extensively in this field of treatment, its role could be significantly reduced if a flow-through-type VLm flap can be harvested within 20 minutes.

Figure 1.

(A) An 84-yr-old woman suffered multiple amputation trauma to her hand when her left upper extremity was caught in a farm tractor. (B) We used RH-VLbf to bypass not only the radial artery to the amputated thumb, but also to the palmar arterial arch. (C) The patient has achieved pinch movements and can operate buttons.

Figure 2.

(A) The peripheral amputated limb was also avulsed and the muscular and neurovascular tissue was contused to the level of the wrist. (B) After bypassing the brachial artery to the radial artery and the ulnar artery using RH-VLbf to reestablish blood flow. (C) The venous system was reconstructed not only bypassing the descending branch of the lateral femoral circumflex vein, but also by long bypass using the great saphenous vein. (D) Since it currently only 1 mo after surgery, a postoperative assessment of the hand function remains to be performed.

Figure 3.

(A) A 48-yr-old man sustained a severe punching hole injury of 8 cm in diameter on the palm of his left hand using a punching instrument. (B) Using RH-VLbf, the finger blood flow was improved with bypass from superficial palmer arterial arch to the digital artery of the ring finger. (C) Reconstruction of the palmar raw surface was performed using plantar glabrous skin graft, and a mandibular reconstruction titanium plate was used to bridge the phalanx bones and metacarpal bones. (D) The patient achieved a HAND20 score of 54, a Quick DASH score of 29.5, and has returned to his previous position at work.