Septic Bone and Joint Surgery Bearbeitet von Reinhard Schnettler 1. Auflage 2010. Buch. 328 S. Hardcover ISBN 978 3 13 149031 5 Format (B x L): 19,5 x 27 cm Weitere Fachgebiete > Medizin > Chirurgie > Orthopädie- und Unfallchirurgie Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, ebooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte.
6 Plastic and Reconstructive Surgery Shoulder Girdle and Upper Arm The maximal available flap size in adults is 32 12 cm. Since the sternocostal and abdominal edges of the muscle are generally left in place, the remaining available flap measures approximately 28 10 cm. In septic bone surgery, the pectoralis major and the latissimus dorsi muscles, as well as scapular and parascapular flaps, are primarily used to cover defects in this area. Pectoralis Major Flap In principle, the whole muscle with adjacent skin and soft tissues can be raised as a flap due to the intramuscular branches. Numerous anatomical norm variants exist. In 30 % there is no pars abdominalis, and a smooth transition to the deltoid muscle (no deltoideopectoral sulcus) often exists. Indications: Defects in the lateral head/neck Defects in the mouth Defects in the thoracic wall/shoulder Vascular and nervous supply: Thoraco-acromial artery and vein: The blood vessels cross the clavipectoral fascia with one to two large branches and the accompanying nerves and proceed on the lower surface of the muscle in a mediocaudal direction. The trunks divide into several lateral branches. The muscle and the skin above it is reached from medial by terminal branches of the anterior intercostal arteries II V from the region fed by the internal thoracic artery. Venous drainage occurs through several veins running parallel to the arteries. The motor innervation of the myocutaneous pectoral flap derives from the medial (C5 C7) and lateral (C8 T1) pectoral nerves. The normal length of a neurovascular pedicle is 4 8 cm. The length of the neurovascular pedicle depends on the distribution of vessels and nerves on the lower surface of the muscle. In 40 % of cases there is only one neurovascular pedicle. In the remaining 60 % there is a further pedicle to the pars clavicularis or abdominalis. The main neurovascular pedicle proceeds in a cranial direction and is prevented from kinking by the clavicle. The vascular course should prevent twisting of the pedicle in flaps rotated in a ventrocranial direction. This portion of the muscle receives very little additional blood supply from segmental skin vessels (Figs. 6.10, 6.11, 6.12, 6.13). 184
Special Section: Covering a Defect Fig. 6.10 Empyema of the left sternoclavicular joint with osteomyelitis after a cortisone injection. Fig. 6.11 Radical debridement with partial resection of the sternum, clavicle, and the first rib resulting in a defect measuring 8 10 cm. The pleura and mediastinum are exposed at the donor site. The course of the thoracoacromial artery and vein has been drawn. Fig. 6.12 The joint and the first rib have been resected en bloc. The fistulous sinus is shown. 185
6 Plastic and Reconstructive Surgery Fig. 6.13 Coverage of the defect with an ipsilateral pectoralis major island flap. The skin island is raised from the fold under the breast. After removal of mammary-gland tissue the muscle is removed from the pectoralis minor muscle beneath it and dissected from caudad to craniad. Following subcutaneous tunneling the pedicled myocutaneous graft is placed in the defect. Tips AND Tricks In this case it is not necessary to remove the attachment of the major pectoral muscle from the humerus because the pedicle only needs to cover a short distance. Complications at the donor site are few; scar tissue in the fold under the breast is generally not visible. If a large defect requires covering, it may be necessary to cover the donor region with a splitskin graft. If it is necessary to mobilize the flap, the muscle attachment on both the humerus and the clavicle can be severed. After dissection of the afferent vessels to their origins, a flap can be harvested to cover defects in the lower face and inside the mouth. Combined flaps can be obtained from the scapular region; a combination of parascapular, scapular, and latissimus flaps enable coverage of very large defects. Parascapular Flap Although flaps from the scapular region have no sensory nerves, this is an ideal donor region because the blood supply is reliable and the skin is thick and resistant to trauma. A parascapular flap and a variation thereof (scapular flap) can be used either as a free flap or a pedicle flap (Fig. 6.14). Indications: A pedicle flap is used to cover defects in the armpit. A free flap is especially suited to cover areas requiring a hearty skin graft (foot, distal portion of the lower leg). Vascular Supply: These flaps contain a main branch of the circumflex scapular artery (see also Fig. 6.39). This originates from the subscapular artery and proceeds between the teres major and teres minor muscles. The subscapular artery divides into two branches. Besides the branch described above, there is the thoracodorsal artery, which supplies the latissimus dorsi muscle (see Latissimus Dorsi Flap, p. 203) on the lateral margin of the scapula. The thoracodorsal artery branches here into the parascapular artery, which runs in a caudad direction, and the scapular artery, which runs in a medial direction. A small branch also runs in a caudad direction. The arteries are accompanied by veins. The flaps can have a separate pedicle for each artery, or both arteries can be in one pedicle. 186
Special Section: Covering a Defect Outline of the scapular flap Position of the pedicle a Circumflex scapular artery and vein Teres major muscle b Teres minor muscle Neurovascular pedicle to the teres major muscle Fig. 6.14a, b Planning a flap a The skin island is elliptical. The possibility of primary closure of the donor site after harvesting the graft can be tested preoperatively by pinching the folds of skin together in an axial direction. Dissection should always begin from medial with visualization of the vascular pedicle, because this is the safer method. Alternatively, the flap can be completely incised and dissected from the periphery to the center until the vascular pedicle is visible. Only choose this method if it is possible to precisely evaluate the relationship between the medial armpit and the top of the scapula. b The flap is principally raised in the epifascial layer. Some fascia should also be raised around the vascular pedicle, because the first branching off of the vessels could lie just below the fascia. Tie off lateral branches of the circumflex scapular artery. Further anterior dissection of the pedicle is easy. Outline of the parascapular flap Thoracodorsalis artery and vein Latissimus dorsi muscle Vascular pedicle to the teres major muscle The parascapular artery is larger and anatomically more consistent than the scapular artery. 187