Guoxian Pei Editor Microsurgical Orthopedics 123 Microsurgical Orthopedics Guoxian Pei Editor Microsurgical Orthopedics Editor Guoxian Pei Orthopedic Hospital Xijing Hospital Fourth Military Medical University Xi’an China ISBN 978-94-024-1623-7 ISBN 978-94-024-1625-1 (eBook) https://doi.org/10.1007/978-94-024-1625-1 © Springer Nature B.V. 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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The registered company address is: Van Godewijckstraat 30, 3311 GX Dordrecht, The Netherlands Preface Microsurgery, an emerging subdiscipline in the field of contemporary surgery, has reached a new technical height after over half a century of development and effectively improved the technology of surgical interventions. China has been in the leading tier in microsurgery world- wide. Chinese microsurgery has been admired by international peers because of its large num- ber of clinical patients; complex, unique, and innovative operations; excellent surgical outcomes; and ingenious and exquisite microscopic skills displayed by Chinese surgeons. In fact, microsurgery is one of the proud disciplines of China which can catch the eye of the world. In 2013, upon the invitation of the Springer Press, l took the responsibility to compose a globally distributed English version monograph on the application of microsurgical techniques in orthopedics along with Chinese orthopedists. Considering that Chinese clinicians, many of whom may have limitation in English language, will account for a substantial proportion of the readers and that a Chinese version of this monograph will benefit much more Chinese readers as well, we made a request to Springer Press to publish a Chinese version along with this English one. Springer Press kindly agreed on publishing the Chinese version, which will be issued by People’s Medical Publishing House under the authorization of Springer. The Chinese version is basically consistent with the English one in arrangement of contents except for nec- essary supplements in wording. The first time for Chinese microsurgery to be noticed by the world is the successful replan- tation of a severed limb which was conducted by an expert orthopedist, Zhong-wei Chen, in China in 1963. Among all the areas of surgery, microsurgical techniques are applied the most widely in orthopedics, resulting in the largest number of approaches and types and the best professional talents as well. However, there have been few monographs on applications of microsurgical techniques in the field of orthopedics. Unfortunately, Microsurgical Technique in Orthopaedics, with Robert W. H. Pho as the leading author, published by Butterworth- Heinemann Press in 1988, is the only relative monograph in English. This book, entitled Microsurgical Orthopedics, focuses on the clinical application of micro- surgical techniques in orthopedic practices from the perspective of microsurgery, highlighting the repair, reconstruction, healing, and regeneration of severe traumatic injuries and complex cases in microsurgical orthopedics. From the point of view of orthopedics, this book outlines the history of microscopic orthopedics, the basic techniques, perioperative management, oper- ation principles, indications, surgical techniques, and postoperative treatment in replantation of severed limbs (fingers), reconstruction of hands (thumbs), and transplantation of various types of tissue flap (skin flap, myocutaneous flap, muscle, fascia, composite tissue flap, small joint, bone flap, periosteal flap, and peripheral nerve). In the above chapters, new theories, new ideas, consensus views, new techniques, new diagnostic methods, new testing equipment, and new research achievements are elaborated in particular. Special chapters are dedicated to newly developed techniques in orthopedics such as limb allograft transplantation, regenerative medicine, and tissue engineering technology. This book is the first monograph which systemically introduces application of microsurgi- cal techniques in the field of orthopedics. It reflects the latest progress and development trends in this field in recent years, representing the latest clinical techniques. This systematic, v vi Preface innovative, and practical book is a clinical reference of high value. At this time when the manu- scripts have been completed and submitted for printing, special thanks are conveyed to all the authors for their hard work and precious time devoted beyond their busy clinical work. I am very grateful to my editor assistants, Dr. Xing Lei and Dr. Hui-jie Jiang, for their effective work in arranging contents, coordinating, and text processing for this book. Meanwhile, I would also like to thank Dr. Chuan-lei Ji for his beautiful drawings in part of this book and Bin Hu, editor of Springer Publishing Group, for his guidance, support, and hard work in the plan- ning, editing, and revision of the book. As the authors are clinical surgeons from different medical institutions who are very busy in their daily practices, it is highly demanding to present all the chapters in uniform writing style and skills. Since errors and shortcomings are inevitable, feedbacks and opinions are sin- cerely expected from our peers for the improvement of this book. Xi’an, China Guoxian Pei August 2018 Contents 1 Overview of Microscopic Orthopaedics ................................ 1 Guoxian Pei and Huijie Jiang 2 Basic Techniques of Micro-Orthopedics ................................ 5 Chunguang Duan and Dawei Zhang 3 Perioperative Management in Microsurgical Orthopaedics ................ 15 Yong-Qing Xu and Yue-Liang Zhu 4 Major Limb Replantation ........................................... 21 Jianli Wang and Zhaohui Pan 5 Replantation of Amputated Palm ..................................... 43 Yong Liu 6 Replantation of Amputated Finger .................................... 53 Xiaoheng Ding 7 Replantation of Finger .............................................. 75 Zengtao Wang 8 Skin Flap and Myocutaneous Flap .................................... 129 Shi-Min Chang, Ying-Qi Zhang, and Xiao-Hua Li 9 Compound Tissue Transfer .......................................... 167 Yimin Chai 10 Small Joint Transplantation .......................................... 175 Jianli Wang 11 Bone and Periosteal Flap Transplantation .............................. 185 Aixi Yu 12 Microsurgical Repair of Soft-Tissue Defects of the Upper Extremity ........ 211 Yongjun Rui 13 Microsurgical Reconstruction of Lower Extremity Soft-Tissue Defects ...... 245 Changqing Zhang, Xianyou Zheng, and Shengdi Lu 14 Functional Reconstruction of the Upper Extremity ...................... 273 Liqiang Gu and Jiantao Yang 15 Functional Anatomy of Brachial Plexus ................................ 289 Jie Lao and Kaiming Gao 16 Microsurgical Repair of Peripheral Nerve Injury ........................ 317 Rui Cong and Liu Yang 17 Treatment of Peripheral Nerve Entrapment ............................ 337 Can-Bin Zheng and Qing-Tang Zhu vii viii Contents 18 Microsurgical Repair of Peripheral Vascular Injury. . . . . . . . . . . . . . . . . . . . . . 347 Guangyue Zhao and Long Bi 19 Microsurgical Repair of Bone Defects and Bone Nonunion ................ 363 Chun Zhang 20 Microsurgical Repair of Ischemic Necrosis of Bone ...................... 387 Benjie Wang, Yupeng Liu, Yao Zhang, Xiaobing Yu, Weimin Fu, Daping Cui, Fengde Tian, Xiuzhi Zhang, and Dewei Zhao 21 Microsurgery of Bone Disease and Bone Tumor ......................... 435 Jing Li, Lei Shi, Chun Zhang, Jianli Wang, and Guangjun Liu 22 Spine Microscopic Surgery .......................................... 485 Huiren Tao, Donglin Li, Haodong Lin, Chunlin Hou, Shaocheng Zhang, and Wenbin Ding 23 Limb Allografts .................................................... 505 Dayong Xiang, Guoxian Pei, and Jimeng Wang 24 Tissue Engineering and Orthopedic Microsurgery ....................... 521 Dan Jin, Su Fu, Tao Wu, Lei Wang, Yongtao Zhang, Song Liu, and Kuanhai Wei Overview of Microscopic Orthopaedics 1 Guoxian Pei and Huijie Jiang 1.1 A Brief History of Microscopic through in surgical replantation. In 1966, Dong-yue Yang Orthopedics successfully conducted the world’s first case of thumb recon- struction with the second toe graft using microsurgical tech- Microsurgery refers to the surgical techniques for operations niques. The successful replantation of free inguinal flap was with fine surgical instruments and materials under optical respectively reported by Daniel and Dong-yue Yang in 1973, amplification equipment (surgical magnifying glass or surgi- leading to successive success in tissue replantation (free flap, cal microscope). Exposure to the amplified surgical field has muscle, bone, periosteum and nerve) with anastomosed made a breakthrough which surmounts the natural limit of blood vessels. These laid a cornerstone for microsurgery human’s vision, transforming a macroscopic view into a which was progressing into an age of reconstruction surgery. microcosmic world. This makes surgeries more accurate and With the progress in the microsurgical anatomy, more donor exquisite, reduces tissue injuries, and facilitates tissue heal- areas for various tissue transplantations have been found, ing, greatly improving the quality and outcomes of surgeries. resulting in more extensive clinical application of microsur- The scope of surgical treatment has also been expanded gical techniques. Over the past decade in China, new innova- because the surgeries which would be impossible in the past tions and progress have been made to combine microsurgical under naked eyes can be conducted when tiny structures can techniques with new technology and new materials, making be easily identified and manipulations can be precisely ful- China constantly hold a leading position in the world’s filled with the aid of amplifier equipment. microsurgical circles. Microsurgery is a new modern surgical technology which The development of microsurgery has experienced four brings revolutionary changes to surgery. It can be employed periods over the past half century. (1) The starting period in any of the surgical specialties, but not uniquely associated (1960s): During this period, only a few types of microsur- with a specific clinical department. Nevertheless, it has been gery were developed in limited regions, such as replantation applied the most extensively and in the largest quantity in of finger or limb, inguinal flap and thumb or finger recon- orthopaedics due to the particularity of orthopaedics and the struction by toegrafting in medical centers with very good fact that the first successful application of microsurgical conditions. (2) Developing period (1970s): This period wit- techniques occurred in orthopedics. In 1921, Nylen initia- nessed increasing types and expanding scopes of microsurgi- tively performed inner ear surgery for patients with ear scle- cal application, involving multiple disciplines. Replantation rosis using a microscope. Perritt employed a surgical of severed limbs (fingers), flap transplantation, muscle or microscope for corneal suture in 1940, which was a break- myocutaneous flap transplantation, thumb or finger recon- through from microscopic manipulation to microscopic struction by toegrafting, neural transplantation, bone or peri- suture. In 1960, vascular anastomosis was successfully per- osteum transplantation, and small joint transplantation as formed by Jscobson for small blood vessels of 1.6–3.2 mm well, were all applied in clinical practices to a more or less in diameter under a surgical microscope, resulting in a rela- extent. (3) Maturity period (1980s): This stage witnessed a tively high patency rate. Zhong-wei Chen reported the first climax in the development of microsurgery. Microsurgical successful replantation of a severed limb in the world in techniques were widely applied in hospitals not only in large 1963 and another successful case in 1965, marking a break- cities but also in small townships where various microsur- gical operations were carried out. Almost all the surgical disciplines were involved. Microsurgery was highly recom- G. Pei (*) · H. Jiang mended by the surgeons for its advanced surgical approaches Department of Orthopaedics, Xijing Hospital, Air Force Military and excellent curative effects. Many immature theories, Medical University, Xi’an, Shaanxi, China © Springer Nature B.V. 2019 1 G. Pei (ed.), Microsurgical Orthopedics, https://doi.org/10.1007/978-94-024-1625-1_1 2 G. Pei and H. Jiang techniques and methods in the early days grew into mature grafting with vascular anastomosis. In this surgery, an autolo- ones. Consensus was reached in many methods, approaches gous toe is transplanted at one stage to the defect at the hand, and techniques which had been previously misused or ill- thumb or finger and the blood vessels and nerves are anasto- formed. In this period, Chinese surgeons made multiple mosed using microsurgical techniques, to recover the basic innovative achievements, leading the world’s microsurgi- appearance and function of the original hand, thumb or finger. cal practice and exerting a great influence in the world. For This surgery has been widely performed in clinic, benefiting example, the forearm flap, arterialized small saphenous vein numerous patients with their hand, thumb or finger missed. and sural nerve transplantation, hand reconstruction, and Toegrafting techniques can be used to reconstruct the replantation of ten severed fingers. (4) Improvement period thumb and fingers with various degrees of defect, and to (1990s): Further stable and sustainable developments were reconstruct part of a finger, one entire finger, or even multi- achieved in microsurgery in this period. Hand reconstruc- ple fingers. For patients with multiple finger defects, the uni- tion, composite tissue transplantation, combined tissue lateral great, second and third toes can be harvested to rebuild transplantation, contralateral c-7 nerve root translocation a thumb and two fingers. For patient with five finger defects, in the treatment of brachial plexus root avulsion injury, and one-stage combination transplantation can be done using the allotransplantation of hand all exerted a huge impact in the great, second and third toes on one side and the second and world. At the same time, interweaving microsurgery with third toes on the contralateral side as well to reconstruct all multi-disciplines and multi-fields expanded the definition of the five fingers. At present, thumb and finger reconstruction microsurgery, such as microscopic surgery under endoscope, with toegrafting in China is much advanced worldwide in biological materials, tissue engineering and genetic technol- terms of operative variety, quantity and popularity. ogy, pushing microsurgery to leap forward onto a new stage. 1.2.3 Nerve Repair 1.2 Application Range of Microscopic Orthopedic Repair of peripheral nerve injury used to be performed by simple epineurium suture under naked eyes for a long time, As a new surgical technology, microsurgery is applied in all without accurate anastomosis of nerve bundles, resulting in surgical fields. In orthopaedics, microsurgical techniques are axon escaping, glioma or nerve tumor which remarkably mainly used in the following aspects. compromised the outcomes of nerve regeneration. Accurate anastomosis of perineurium and epineurium under a micro- scope can significantly improve the outcomes of nerve repair. 1.2.1 Replantation Surgery Today, microsurgical repair techniques have become conven- tional in the treatment of peripheral nerve injury. Limb (finger) replantation is a classic and iconic microsur- gery and an important part of its clinical applications. Limb (finger) replantation techniques have been highly 1.2.4 Tissue Transplants mature in China. As they are already popularized, hospitals at all levels are able to perform this surgery skillfully, giving Tissue transplantation includes pedicled tissue grafting and a success rate up to 98%. In addition to regular replantation revascularized free tissue grafting. In microsurgery, it is the of severed limbs (fingers) in good conditions, successful most widely applied, involving brain and maxillofacial sur- replantation can be achieved for severed limbs (fingers) in gery, oral surgery, urology, gynecology and obstetrics, gen- poor or complex conditions, like those with rotational avul- eral surgery, plastic surgery and orthopaedics where tissue sion, multi-segments, longitudinal crack, skin defect, and transplantation is the most extensively applied. According to soaking wounds. Limb (finger) replantation has succeeded in the types of tissue transplants, it can be categorized into skin children and the elderly, from the proximal to the distal, from flap transplantation, muscle flap graft, myocutaneous flap one single digit to ten digits, and from one limb to four limbs. transplantation, nerve transplantation, bone graft, perios- These innovative achievements indicate replantation surgery teum graft, and small joint transplantation. technology has reached a very high level. In recent years, with constant improvement of microsur- gical techniques, a large number of composite tissue trans- plantations and combined tissue transplantations have been 1.2.2 Reconstructive Surgery carried out in clinic. The former refers to the transplantation of a vascular pedicle combined with at least two kinds of tis- The representative operation for reconstructive surgery is sue such as bone flap and musculoskeletal flap; in the latter reconstruction of hand, thumb or finger using the second toe procedure, after tissue flaps with two different vascular ped-