Primary Replacement of Soft Tissue Defects of the Upper Extremities with Vascularized Autotransplants

The dissertation is dedicated to the development and implementation of methods for primary replacement of soft tissue defects of the upper extremities using vascularized autotransplants. The study investigates indications, techniques, and outcomes of microsurgical autotransplantation of tissue complexes for traumatic defects, after oncological resection, and for vascular malformations of the upper extremities. The work contains a clinical analysis of operations, proposes methods for one-stage reconstruction, and substantiates the advantages of microsurgical approaches over traditional plastic surgery techniques.

Relevance of the Problem

One of the principal unresolved problems in surgery of extremity injuries and diseases is the primary replacement of extensive soft tissue defects of the upper extremities resulting from trauma, neoplasms, or vascular pathology. The application of microsurgical technology has made it fundamentally possible to provide primary one-stage treatment of patients with large tissue defects of the extremities, since restoration of extremity function is the principal criterion of success in reconstructive operations, which is not always achievable in delayed reconstructions. The technique of free autotransplantation of vascularized flaps has been sufficiently well studied and mastered, and near-term positive results in some clinics reach 100% [22, 58].

Among the causes of high disability, errors or insufficient volume in the provision of qualified assistance occupy the first place [63, 1, 3, 51]. In non-specialized hospitals (which lack magnification equipment, microsurgical instruments, and do not possess microsurgical technique), in cases of traumatic vascular and nerve injuries of the upper extremities, vessels are most often ligated, and nerves are left for subsequent (often repeated) planned operations [7, 162]. Delayed operations on vessels and nerves aimed at restoring extremity function are not always feasible due to degenerative changes in tissues and often require autoplastic material, which is not always available and increases the overall quantitative trauma to the patient's organism.

In recent years, there has been a substantial increase in severe extremity injuries, among which injuries of the upper extremities (88%) prevail over injuries of the lower extremities (12%) and occupy the leading place among injuries of the musculoskeletal system (up to 70%), which are often accompanied by traumatic amputation of extremity segments with the formation of functionally significant tissue defects requiring primary plastic surgery. Traumatic defects of soft tissue of the upper extremities constitute up to 25% among defects of other etiologies. It is known that flap plastic surgery on a vascular pedicle or split skin graft cannot compete in cosmetic and functional effectiveness with transplantation of microsurgical flaps. This is especially true for the upper extremities, where the possibilities of local plastic surgery are limited due to a deficit of surface tissue area.

Alongside extremity injuries, there exists the problem of one-stage replacement of tissue defects formed after resection of malignant neoplasms in oncological patients.

Primary plastic surgery of soft tissue defects after oncological surgical interventions remains an urgent problem, as it allows improving the outcomes of surgical treatment and makes it possible to reduce the number of days a patient stays in the hospital, thereby enabling assistance to a greater number of patients.

Another group of patients in need of primary plastic surgery of tissue defects consists of patients with various pathologies of the upper extremity, such as hemangiomas, arteriovenous fistulas, aneurysms of the palmar arch, and other vascular malformations. This group of patients is characterized by a prolonged and severe course. These diseases, being congenital, do not respond to conservative therapy, and all attempts at surgical treatment have so far led to failure and, as a rule, ended in necrosis and amputation within healthy tissues. Here, for the treatment of this pathology, and perhaps the only radical operation, is autotransplantation of vascularized flaps.

Goal of the Research:

Improvement of the results of primary surgical treatment of patients with soft tissue defects of the upper extremities using autotransplantation and transposition of vascularized flaps.

Tasks of the Research:

1. To refine approaches to the treatment of patients with tissue defects of the upper extremities.

2. To improve the methodology and technique of one-stage autotransplantation/transposition of soft tissue flaps during replantation of extremity segments.

3. To develop and implement autotransplantation of combined flaps during radical oncological operations.

4. To develop and implement in clinical practice one-stage plastic surgery with autologous flaps for various vascular malformations.

5. To study the results of reconstructive operations using the method of microsurgical autotransplantation of tissue complexes.

Scientific Novelty

• Indications and contraindications for various reconstructive operations using microsurgical techniques have been refined, and near-term and late treatment outcomes of patients with soft tissue defects of the upper extremities have been summarized, on the basis of which the advantage of these techniques over traditional plastic surgery methods has been proven.

• For the first time, a method of autotransplantation and transposition of vascularized flaps has been applied for the treatment of patients with involvement of the distal vascular trunk.

• For the first time in this work, the possibility of using non-replantable tissues for restoration of function of the traumatized extremity segment has been utilized.

• The data obtained in the research, implemented in clinical practice, make it possible to speak of a fundamentally new approach in the pursuit of obtaining the most optimal functional results based on the full use of microsurgical technique.

Practical Significance

The application of the method of autotransplantation of vascularized tissues for the primary replacement of tissue defects of the extremities has made it possible to improve the results of emergency restorative operations in severe upper extremity injuries, reduce patient hospitalization periods, overall disability, and the duration of full rehabilitation.

When using this method for closure of soft tissue defects (STDs) of the extremities after resection of malignant tumors in oncological patients, such operations can be regarded as organ-preserving, as they improve the quality of life of oncological patients and serve as an alternative to limb amputation.

The use of the microsurgical autotransplantation and transposition flap technique has made it fundamentally possible to treat patients with various pathologies of the vessels of the upper extremity, such as hemangiomas, arteriovenous fistulas, aneurysms of the palmar arch, and other vascular malformations.

Principal Propositions for Defense:

- The advantages of microsurgical techniques over traditional methods of plastic surgery of traumatized extremity tissues have been proven.

- The application of these techniques significantly reduces the duration of general rehabilitation, including hospital bed days.

- The application of the method of microsurgical autotransplantation and transposition of flaps in oncological patients after resection of malignant tumors improves their quality of life and also allows their rehabilitation in short terms.

- The use of the method of autotransplantation and transposition of vascularized flaps in patients with involvement of the distal vascular trunk has made their surgical treatment fundamentally possible, in contrast to the amputation previously proposed until recently.

Implementation of the Research Results

Eleven printed works have been published on the topic of the dissertation, including foreign ones, of which 3 are in the central press and 8 are in abstracts.

The dissertation materials were reported at:

- The IV International Conference on Plastic and Reconstructive Surgery (Yaroslavl, 2003);

- The Second Anniversary International Scientific and Practical Conference "Modern Technologies of Diagnosis, Treatment, and Rehabilitation of Injuries and Diseases of the Hand," dedicated to the 35th anniversary of the Hand Surgery Clinic of the Department of Traumatology and Orthopedics of RGMU, 2005.

- The Congress of Cardiovascular Surgeons at the Bakulev Scientific Center of Cardiovascular Surgery, 2006.

Volume and Structure of the Work. The dissertation is presented in 160 pages of typed text, consists of an introduction, 5 chapters, a bibliography list comprising 369 sources, including 119 domestic and 250 foreign sources. The work is illustrated with 56 figures, 13 tables, and 6 diagrams. It contains a conclusion, findings, practical recommendations, a list of abbreviations, and an appendix.