Use of "Spare" Autografts in Emergency Reconstructive Surgery of the Upper Limb

The dissertation addresses the problem of emergency reconstructive surgery for severe injuries of the upper limb using so-called "spare" autografts — tissue complexes harvested from limb segments not subject to replantation or reconstruction. The work is based on the author's 25-year clinical experience and is aimed at systematizing the concept of "spare" tissues, developing their classification, determining indications and contraindications for their use, and describing the methods and techniques of emergency operations. Particular attention is paid to the possibility of performing reconstruction without intervention on intact donor zones, which reduces additional trauma to the patient. The study analyzes the immediate and long-term results of operations and substantiates the effectiveness of the proposed approach in clinical practice.

Relevance of the Problem. According to many leading specialists engaged in reconstructive hand surgery in our country and abroad, the frequency and severity of upper limb injuries are steadily increasing, accompanied by prolonged loss of working capacity (up to 30%), high disability (up to 23%), and a significant number of diagnostic and treatment errors (from 30 to 80%) [15; 24; 26; 132].

A significant group of hand injuries (up to 18.1%) consists of severe traumas [52]. Such injuries are characterized by an extensive zone of soft tissue crushing, multiple comminuted fractures with disruption of the integrity of blood vessels, nerves, and tendons [36], as well as defects of the covering tissues and skeleton [9; 55, 38].

Restoration of the function of the injured hand is a relevant problem of modern reconstructive surgery. The increase in gunshot and mine-explosive injuries of the upper limb in the structure of traumatism is associated with local military conflicts and terrorist acts. Upon admission of the wounded to the stage of specialized medical care, gunshot injuries of the hand are noted in 12% of patients, and destruction and avulsion of the hand reach 49% [47]. The treatment of patients with open hand injuries is a very difficult and multi-task problem, since it is necessary to restore not only the anatomical integrity of the organ, but also its complex fine function [38].

Restoration of the skin cover is one of the main tasks in the treatment of open injuries of the upper limb. The modern and earlier literature is rich in information about methods of replacing fresh traumatic defects of the skin cover of the hand and fingers, such as free transplantation of split-thickness and full-thickness skin grafts, and various methods of plasty with local tissues. However, the former can be used only for superficial defects, and local tissues are strictly limited in size. For the replacement of deep defects, plasty with a flap on a temporary feeding pedicle or free microsurgical autotransplantation of tissues from a distant donor zone is indicated. The first method is characterized by duration, and the second always involves the infliction of additional trauma to the donor zone.

In the dictionary of D.N. Ushakov, the word "spare" (from Latin utilis — useful) designates things that are unfit for use but suitable as raw material for processing.

Starting from 1881, alloskin has been used for the treatment of burns. Most often, alloskin is taken from the corpses of people who died from accidental causes (car accidents, injuries, etc.). So-called "spare" skin after amputations, etc., is also used. In the legal documents "On Skin Donation," the first source of skin is indicated as "spare" tissues — tissues taken from amputated limbs. "Spare" tissues as a source for the replacement of local burns are used in burn centers. However, these transplants are not vascularized.

The development of the method of microsurgical transplantation and tissue transposition required an assessment of severe limb injuries from a new perspective [37]. Studies in the field of human vascular anatomy led to the discovery of the principle of axial blood circulation in tissues. A unique opportunity emerged to use tissue complexes with autonomous blood circulation for reconstructive operations. Further development of microsurgery made it possible to harvest transplants from limb segments not subject to replantation or reconstruction, that is, "spare" ones.

These tissues can serve as a source of vascular, neural, soft-tissue, and composite autografts. This technique makes it possible to use for plasty full-fledged, homogeneous, adequately blood-supplied, and innervated tissues that are as close as possible in their structure and function to the reconstructed segment, and relieves the patient and the surgeon from intervention on other (intact) donor zones.

Leading microsurgical clinics in Russia reported the use of "spare" flaps for emergency restoration of injured limbs [59].

However, in the modern domestic and foreign literature there are only isolated reports on the use of "spare" autografts for emergency reconstructions of the upper limb. The absence of a unified understanding of the concept of "spare" tissues, the classification of these transplants, indications, contraindications, and surgical techniques, combined with our accumulated 25-year experience, prompted this study.

Aim of the Work.

To improve the results of surgical treatment of patients with severe injuries of the upper limb without intervention in distant donor zones.

To achieve this aim, the following tasks must be solved:

1. To define "spare" tissue complexes.

2. To develop a working classification of "spare" flaps.

3. To determine indications and contraindications for autotransplantation operations of "spare" tissue complexes in the clinic.

4. To introduce into broad clinical practice the methods and technique of emergency operations for autotransplantation of "spare" tissue complexes in patients with severe injury of the upper limbs.

5. To establish the effectiveness of emergency reconstructive operations using this technique in patients with severe injury of the upper limbs.

Scientific Novelty.

The role of "spare tissues" in emergency reconstructive operations in patients with severe injury of the upper limbs has been determined. A classification of "spare" autografts used for the replacement of traumatic defects of the upper limb has been developed. Indications and contraindications for the use of this method have been substantiated.

Practical Significance of the Work. The use of "spare" tissue complexes in emergency reconstruction of severe injuries of the upper limb makes it possible to perform plasty of traumatic limb defects with full-fledged, homogeneous, blood-supplied, innervated tissues that are as close as possible in their structure and function to the tissues of the reconstructed segment. The proposed method of restoring an injured limb allows the use of tissue complexes taken from segments not subject to restoration for reconstruction. The use of the "spare" flap method relieves both the patient and the surgeon from intervention in intact donor zones. In injuries of the hand when there is a defect of the soft tissues of the palmar surface combined with finger ischemia, the use of "spare" flaps allows replacement of the tissue defect and simultaneous revascularization of the reconstructed segment with the flap artery. The use of "spare" transplants makes it possible to preserve the functional length of the limb stump and provides the opportunity for subsequent adequate prosthetics.

Statements for Defense.

1. In severe injuries, there is the possibility of using tissue complexes taken from limb segments not subject to replantation or reconstruction for reconstructive operations. Such tissue complexes have axial blood supply and can be transplanted as free grafts, or they can be transposed on a vascular pedicle. Such tissue complexes are called "spare." The use of "spare" autografts is an effective technique for emergency reconstruction of the upper limbs in patients with severe injury.

2. According to their composition, "spare" flaps are divided into two groups: simple (skin-fat) and composite (including fragments of bone, tendon, nerve, or joint), which in turn are subdivided into island (on a vascular pedicle) and free (revascularized).

3. Indications for the use of "spare" autografts are the presence of a traumatic defect and the possibility of harvesting a flap from "spare" tissues. General and local contraindications do not differ from those for traditional techniques.

Approbation of the Dissertation. The main provisions of the dissertation were reported and discussed at a joint conference of the Department of Plastic and Reconstructive Microsurgery and X-ray Surgery and the Department of Traumatology and Orthopedics of the State Educational Institution of Additional Professional Education "RMAPO of Roszdrav" dated April 13, 2006.

The materials of the study were reported at the Conference of Young Scientists, July 8–9, 1999, NTsKh RAMS, Moscow; the Fourth International Congress on Plastic, Reconstructive, and Aesthetic Surgery, June 9–11, 2003, Yaroslavl; the Second Anniversary Scientific and Practical Conference "Modern Technologies for the Diagnosis, Treatment, and Rehabilitation of Injuries and Diseases of the Hand," November 9–10, 2005, Moscow.

Implementation of the Results. The results of the dissertation research have been implemented in the practice of the Department of Microsurgery of City Clinical Hospital No. 71, Moscow, and the Department of Orthopedics and Microsurgery of the Central Clinical Hospital of the Russian Academy of Sciences. The data of the work are used in the educational process at the Department of Plastic and Reconstructive Microsurgery and X-ray Surgery and the Department of Traumatology and Orthopedics of the State Educational Institution of Additional Professional Education "RMAPO of Roszdrav."

Scope and Structure of the Work. The dissertation is written in Russian, contains 127 pages, and consists of an introduction, a literature review, a description of the material and methods of the study, three chapters of research, a conclusion, findings and practical recommendations, and a list of references. The work includes 47 figures and 11 tables. The bibliography includes 265 sources, of which 62 are domestic and 203 are foreign authors.