Microvascular Reconstruction of Extensive Foot Injuries

정윤규,정섬,김주봉,Chung, Yoon-Kyu,Chung, Seum,Kim, Joo-Bong The Korean Society for Microsurgery 1994 Archives of reconstructive microsurgery Vol.3 No.1

The successful treatment of the extensively traumatized foot warrants reconstruction utilizing tissue that will provide adequate coverage, is resistant to infection, thin enough to conform to the contours of the foot as well as durable to constant frictional movement and weight bearing. Currently, free flaps offer the best means in achieving these difficult and sometimes contradictory goals. We treated twenty-one patients suffering from extensive soft tissue loss of the foot due to trauma, electric burn or postburn sequelae with free flaps. A fasciocutaneous, musculocutaneous or muscle flap with skin grafting was used based on the location, volume of tissue required, and the functional anatomical requirement of the injured region. The follow-up duration averaged twenty-nine months. From our group of patients, we believe that the muscle free flap with skin grafting offers the most favorable outcome. 해부학적으로 족부는 주위에 이용할 수 있는 연주 조직이 별로 없을 뿐 아니라 이용할 수 있더라도 크기가 제한되어 있으므로 광범위한 연부조직 결손시 이의 복원이 어렵다. 광범위하고 오염된 족부의 창상을 재건시 이상적인 조직의 조건으로서는 감염에 잘 견디고, 가능한한 원래의 모양 및 크기에 가깝게 복원해야 하며, 적절한 감각이 있어야 하고, 끊임없는 마찰력과 체중 부하에 잘 견뎌야 할 것이다. 미세혈관술을 이용한 유리조직이식은 비교적 위와같은 장점들을 제공할 수 있다. 저자들은 최근 약 4년간 외상과 전기화상 및 화상후 후유증으로 인하여 족배부, 발꿈치, Achilles건, 족저부등에 광범위한 결손 및 변형이 있었던 환자 21예에서 미세혈관술을 이용하여 Fasciocutaneous, musulocutaneous, muscle with skin graft 등으로 족부를 재건하여 추적중에 있으며 현재까지 관찰된 결과 및 장점, 단점과 문제점들을 보고하는 바이다.

수부 굴곡건에 발생한 결핵성건초염

민희준,정윤규,Min, Hee-Joon,Chung, Yoon-Kyu 대한성형외과학회 2010 Archives of Plastic Surgery Vol.37 No.5

Purpose: The sheath of tendon is uncommon site of tuberculous involvement as compared to other parts of the body. Especially, tuberculous tenosynovitis affecting flexor tendon of the hand is a rare condition. In recent years, furthermore, the incidence of tuberculosis is increasing in our country. Tuberculous tenosynovitis is a chronic, slowly destructive disease, which is difficult to diagnosis before operation, but can be definitively diagnosed by the pathologic microscopic examination. Early detection and surgical excision combined with antituberculous medication is important. We report a rare case of tuberculous tenosynovitis of the flexor tendon of the hand. Method: A 12-year-old woman presented with a painless, nontender mass on palmar side between distal interphalangeal joint and proximal area of metacarpophalangeal joint of the left third finger. We had surgical excision of the involved flexor tendon sheath and studied histopathologically. Result: The histopathological findings were chronic granulomatous inflammation with caseating necrosis consistent with tuberculosis. We started antituberculous medication. Conclusion: Tuberculous tenosynovitis is a rare condition, especially involving on the flexor tendon of the hand. But because of increasing tendency of tuberculosis, it is important to differentiate it from other tumors of the hand.

The Protective Effect of Prostaglandin E1 Against Ischemia-reperfusion Injury of Musculocutaneous Flaps

홍준표,정윤규,정순희,Hong, Joon Pio,Chung, Yoon Kyu,Chung, Soon-Hee The Korean Society for Microsurgery 2000 Archives of reconstructive microsurgery Vol.9 No.2

본 연구는 백서 복직근피판에 있어 허혈-재혈류 손상에 미치는 prostaglandin E1(PGE-1)의 예방효과를 분석 실험하였으며, 그 기전으로 내피세포의 intercellular adhesion molecule-1(ICAM-1)이 down regulation 됨을 확인하였다. 기존의 PGE-1은 혈관 확장 및 혈소판 응고 저하 등의 기전으로 피판 이식술 후 주로 사용하였으나, 허혈-재혈류 손상 시에 PGE-1 역할에 대한 연구는 잘 알려진바 없다. 허혈-재혈류 손상에 대한 기전은 현재 여러 가설로 설명되고 있으나, 최근 내피 세포와 백혈구의 역할이 주목을 받고 있다. 장시간 허혈 상태의 피판은 재혈류시 백혈구가 내피세포에 접착함으로써 직간접적인 경로로 독소를 생성하며, 결국 내피세포 및 주변조직의 괴사로 이어진다. 본 연구는 면역조직학 염색을 통한 내피세포의 ICAM-1 발현 억제와 그로 인한 백혈구의 내피세포 접착 억제를 그 기전으로 볼 수 있었으며, PGE-1을 술 중 투여함으로써 피판의 생존율을 향상시킬 수 있었다.

말초신경 손상 후 측측문합을 이용한 신경이식시 신경이식의 수에 따른 신경재생 및 근육 기능 회복에 관한 비교 연구

김석원,정윤규,강상윤,조필동,Kim, Sug-Won,Chung, Yoon-Kyu,Kang, Sang-Yoon,Cho, Pil-Dong 대한미세수술학회 2001 Archives of reconstructive microsurgery Vol.10 No.1

Recovery of nerve injury is conditioned by various factors including physical state, injured site, cause of injury, and neurorrhaphy Many researchers have reported on regeneration of nerve using end to side neurorrhaphy. The purpose of this study was to examine regeneration of nerve in various conditioned side to side neurorrhaphy. Total of 25 male Sprague-Dawley rats weighing 220 to 250 gm were divided into five groups of five rats each. The group 1, sham group, composed of dissection only without nerve transaction. The group 2, control group, composed of nerve division only without neurorrhaphy or sural nerve graft. The group 3 composed of one segmental sural nerve graft between the tibial and peroneal nerve after division. Group 4 had two segment graft, and the group 5 with three segment graft, each segment being 6mm long and 5 mm apart. The side to side neurorrhaphy was performed between peroneal nerve and tibial nerve using segmental sural nerve graft in rats. We exposed the sciatic nerve, tibial nerve, peroneal nerve, and sural nerve on left side with prone position. The peroneal nerve was cut on the bifurcation site from tibial nerve and the side to side epineurial neurorrhaphy was performed between peroneal nerve and tibial nerve through 6 mm sural nerve segment graft with 11-0 nylon under operating microscope. The electromyography and the weight from ipsilateral tibialis anterior muscle was performed at one month after neurorrhaphy Peroneal and tibial nerve was examined at distal and proximal to the neurorrhaphy site by methylene blue stain under light microscope for histologic appearance. The number of nerve fibers were counted using the image analyzer. Statistically, both in electromyography and number of nerve fibers, the differences in values between the groups were significant.

측두두정근막 자유피판술을 이용한 수부재건의 장기추적조사

윤도원,김지예,양은정,정윤규,Yoon, Do-Won,Kim, Jiye,Yang, Eun Jung,Chung, Yoon-Kyu 대한미세수술학회 2013 Archives of reconstructive microsurgery Vol.22 No.1

Purpose: Soft tissue defect of the hand, which cannot be covered with skin graft or local flap, is usually reconstructed using a free flap. Temporoparietal fascial free flap is one of the best alternatives for functional reconstruction of the hand with exposed tendons, bones, and joints. Materials and Methods: We have experienced four cases of reconstruction using a temporoparietal fascial flap with a skin graft and followed up for 20 years. We conducted a retrospective review of the patients' clinical charts and photos. Results: At the time of initial injury, the average age of patients was 50.3 (39~62) years. The radial artery was used for reconstruction of the dorsal side of the hand, whereas the ulnar artery was used for that of the volar side of the wrist. Short term complication such as skin graft loss and donor site alopecia occurred. However, during the long term follow-up period, no change of flap volume was noted, and full range of motion in the adjacent joint was maintained. In addition, hyperpigmentation of the grafted skin on the flap disappeared gradually. Conclusion: Selection of the optimal flap is important for reconstruction of the hand without functional limitation. We obtained satisfactory soft tissue coverage and functional outcomes using a temporoparietal fascial free flap and followed up for 20 years.

괴저성 농피증의 수술적 치험례

설철환,김범진,이성준,김석원,정윤규,Seul, Chul Hwan,Kim, Bom Jin,Lee, Sung Joon,Kim, Sug Won,Chung, Yoon Kyu 대한성형외과학회 2005 Archives of Plastic Surgery Vol.32 No.1

Pyoderma gangrenosum(PG) is an uncommon cutaneous vascular disease that typically presents as a painful and destructive ulceration on the anterior surface of the legs. The etiology of PG is currently unknown. But, the association with many immunologic disorders and its clinical response to immunomodulating agents suggest an immune etiology. A common feature of patients with PG is the presence of pathergy(the induction of lesion following injury of the skin). The trauma of surgery can be sufficient to induce pathergy, thus paradoxically limiting the usefulness of surgical treatment of PG. For that reason, medical treatments have been commonly used, while surgical treatments have been regarded not suitable. However, the use of the classic systemic agents is limited by their side effects and contraindications. Moreover, the large, problematic ulcers take too long to heal with medical management only. We present our experience in closing large wounds with the goal of decreasing morbidity, drug side effects and hospital stay by combination of medical and surgical therapy(split thickness skin graft). And authors advocate that surgical management is not a contraindication and may be considered as a selective modality in treatment of PG.

확장된 박근 유리 피판을 이용한 족관절 및 족배부 연부조직 결손의 치유

김석원,김광섭,서동완,이훈범,정윤규,Kim, Sug Won,Kim, Kwang Seop,Seo, Dong Wan,Lee, Hoon Bum,Chung, Yoon Kyu 대한미세수술학회 2000 Archives of reconstructive microsurgery Vol.9 No.2

Soft tissue defects of the dorsum of foot and ankle can be covered from skin graft to free tissue transfer. The extent of injury which may be complex including the exposure of paratenons or bones requires free flap reconstruction. Some of the precautions for reconstruction are providing minimal bulkiness and well conforming to irregular contour thus making normal footwear possible. Though the muscle flap having its advantages and versatility, the fascial flap such as temporoparietal fascial flap has been considered the choice for reconstruction of the dorsum of foot and ankle. The purpose of our study is to utilize the advantages and versatility of the muscle flap as a first choice for reconstruction for the defects involving the dorsum of foot and ankle. The gracilis muscle with its anatomic and donor characteristics, it can be utilized to maximal effect by expanding its slim muscle width removing the epimysium and reducing its bulk by muscle atrophy through denervation. We present our experience with ten cases of reconstruction for the dorsum of foot and ankle using the gracilis muscle free flap. Results were satisfactory without flap loss, skin loss and infection. The contour and aesthetic aspect of the foot was satisfactory. Gait analysis showed near normal gait without limitations from everyday activities. Normal footwear was tolerable in all the cases. The keys to consider in the reconstruction of the dorsum of foot and ankle are appropriate bulkiness, conforming to its contour and able to apply normal footwear. With minimal donor morbidity and satisfying results, the extended gracilis muscle should be considered as the first line for reconstruction of the ankle and dorsum of foot.

복합 내측 족저부 및 내측 족부 피판을 이용한 광범위 족저부 결손의 재건

김석원,민완기,홍준표,정윤규,Kim, Sug Won,Min, Wan Kee,Hong, Joon Pio,Chung, Yoon Kyu 대한미세수술학회 2000 Archives of reconstructive microsurgery Vol.9 No.2

The reconstruction of soft tissue defects of the sole requires to stand the force of weight bearing, provide sensation and adequacy for normal foot-wear. Although certain local flaps have been described and used for resurfacing the foot, extensive injury requires distant or free flaps for coverage. There is no doubt that the ideal tissue for resurfacing the sole is the plantar tissue itself. The specialized dermal-epidermal histology and fibrous septa of the subcutaneous layer gives its unique property to stand the pressure and to absorb the shock upon gait. This paper presents a case of reconstructing the sole that involves about 70% of the weight bearing portion. The combined medial plantar and dorsalis pedis chimeric free flap based on the medial plantar artery and medial plantar nerve adds another dimension in resurfacing the weight bearing sole of moderate to large sized defects.

다양한 형태의 생 비골 이식술을 이용한 경골의 재건

남상현,김범진,고성훈,정윤규,Nam, Sang-Hyun,Kim, Bom-Jin,Koh, Sung-Hoon,Chung, Yoon-Kyu 대한미세수술학회 2006 Archives of reconstructive microsurgery Vol.15 No.1

Twelve cases in eleven patients with segmental bone defects were treated with contralateral fibula free flap and ipsilateral island fibula flap in an antegrade, retrograde or bidirectional flow fashion. Five cases were managed with free flaps and seven were with ipsilateral fibula island transfer. Among seven cases, antegrade fashion was three, retrograde was three, and bidirectional was one. All patients were related with open tibial fractures and its sequelae except one who had open foot bone fracture. According to Gustilo's classification, ten patients were type IIIb and one was type IIIc. Basically, antegrade-flow flaps based on the peroneal vessels as in the conventional free flap were used for the proximal or middle one-third tibial defects. On the contrary, retrograde-flow flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. Bidirection-flow flap based on intact peroneal vessels were used for the middle portion of the tibia. The patients who have undergone ipsilateral fibula island flap had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibial fracture, refusal to use the contralateral sound leg, or poor general condition to stand a lengthy operation. Six of the patients who have got ipsilateral fibula island flap also had an associated fibula fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 1 to 10 years. Two cases of free flap were failed: one patient had below-knee amputation and the other patient had ipsilateral fibula transfer. Other cases were successful and excellent hypertophy of the transferred fibula was achieved. Time to bone union ranged from 4 to 11 months. Time to full weight bearing was from 5 to 13 months after surgery. All of the transferred fibulas showed hypertrophy after weight bearing. In one case, stress fracture was developed during ambulation, which was healed conservatively. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. Length discrepancy of the legs was noted. The limb was shorter by an average 0.5 cm in three cases, longer by 1.1 cm in one case. In the case of island fibula transfer, limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these diverse modalities using a vascularized fibula will make us more comfortable to handle major bone defects.

족배부 복합 피부-건 유리피판을 이용한 Achilles건의 일단계 재건술

김석원,이원재,서동완,정윤규,탁관철,Kim, Sug Won,Lee, Won Jai,Seo, Dong Wan,Chung, Yoon Kyu,Tark, Kwan Chul 대한미세수술학회 2000 Archives of reconstructive microsurgery Vol.9 No.2

The soft tissue defects including the Achilles tendon are complex and very difficult to reconstruct. Recently, several free composite flaps including the tendon have been used to reconstruct large defects in this area in an one-stage effort. Our case presents a patient reconstructed with free composite dorsalis pedis flap along with the extensor digitorum longus and superficial peroneal nerve for extensive defects of the Achilles tendon and surrounding soft tissue. A 36-year-old-man sustained an open injury to the Achilles tendon. He was referred to our department with gross infection of the wound and complete rupture of the tendon associated with loss of skin following reduction of distal tibial bone fracture. After extensive debridement, $6{\times}8cm$ of skin loss and 8cm of tendon defect was noted. Corresponding to the size of the defect, the composite dorsalis pedis flap was raised as a neurosensory unit including the extensor digitorum longus to provide tendon repair and sensate skin for an one-stage reconstruction. One tendon slip was sutured to the soleus musculotendinous portion, the other two were sutured to the gastrocnemius musculotendinous portion with 2-0 Prolene. The superficial peroneal nerve was then coaptated to the medial sural cutaneous nerve. The anterior tibial artery and vein were anastomosed to the posterior tibial artery and accompanying vein in an end to end fashion. After 12 months of follow-up, 5 degrees of dorsiflexion due to the checkrein deformity and 58 degrees of plantar flexion was achieved. The patient was able to walk without crutches. Twopoint discrimination and moving two-point discrimination were more than 1mm at the transferred flap site. The donor site healed uneventfully. Of the various free composite flaps for the Achilles tendon reconstruction when skin coverage is also needed, we recommand the composite dorsalis pedis flap. The advantages such as to control infection, adequate restoration of ankle contour for normal foot wear, transfer of the long tendinous portion, and protective sensation makes this flap our first choice for reconstruction of soft tissue defect including the Achilles tendon.