Microsurgical Foot Reconstruction Using Endoscopically Harvested Muscle Flaps

우경제,임소영,변재경,방사익,오갑성,문구현,Woo, Kyong-Je,Lim, So-Young,Pyon, Jai-Kyong,Bang, Sa-Ik,Oh, Kap-Sung,Mun, Goo-Hyun Korean Society of Plastic and Reconstructive Surge 2010 Archives of Plastic Surgery Vol.37 No.5

Purpose: Reconstruction of soft tissue defects of the foot often requires free-flap transfer. Free muscle flap transfer and skin grafts on the muscle has been an option for these defects. Here we present our experiences of foot reconstruction using an endoscopy-assisted free muscle flap harvest. Methods: Using endoscopy-assisted free muscle flap harvests, four patients with soft tissue defects of the foot were treated with a free muscle flap and skin graft. The gracilis muscle was used for two patients and the rectus abdominis muscle for two. A single small transverse skin incision was placed on the lower abdomen for the rectus abdominis muscle. A small transverse skin incision on the proximal thigh was the only incision for harvesting the gracilis muscle flap. The small incisions were enough for the muscle flap to be pulled through. Results: The flaps survived successfully in all cases. Contours were good from both functional and aesthetic aspects. No breakdowns or ulcerations of the flap developed during long-term follow-up. Resultant scars were short and relatively hidden. Functional morbidities such as abdominal bulging were not noted. Conclusion: Endoscopy-assisted harvest of muscle flap and transfer with skin graft is a good option for soft tissue defects of the foot. Morbidities of the donor site can be minimized with endoscopic flap harvest. This method is preferable for young patients who want a small donor site scar.

이개기시부 유리피판을 이용한 단계적 양측 콧방울의 재건례

우경제,임소영,변재경,문구현,방사익,오갑성 대한성형외과학회 2009 Archives of Plastic Surgery Vol.36 No.6

Purpose: Reconstruction of full - thickness defects of the nasal ala has always been a challenge. Local flaps can be used easily, and good result can be achieved when it is indicated. But local flaps often result in facial scars and bulky ala that require secondary revisions. Composite auricular chondrocutaneous graft may matches nasal alae well in terms of contour, color and texture, however, the size of composite graft is limited. We performed free vascularized helical root flaps for reconstruction of nasal ala. Methods: Bilateral ala were excised and the defects were reconstructed with a chondrocutaneous free helical root flap. Each side of ala was reconstructed in 3 months interval. Superficial temporal vessels of vascularized helical root flap were anastomosed to facial vessels. Great saphenous vein was used for interpositional vascular graft. Results: Flaps were survived successfully. The contour, texture and color match were satisfactory. Functional problem of nasal obstruction caused by scar stenosis of nostrils was also resolved. Conclusion: The free vascularized helical root flap is a reliable method in reconstruction of nasal alar defects. The donor deformity was minimal.

Persistent retrograde venous-lymphatic reflux in side-to-end lymphaticovenous anastomosis in a lower extremity with lymphedema: a case report

우경제,Mi Kyung Lee,Jin-Woo Park 대한수부외과학회 2022 대한수부외과학회지 Vol.27 No.3

End-to-end (ETE) and side-to-end (STE) anastomosis are two common configurations of lymphaticovenous anastomosis (LVA); however, it remains inconclusive which method is better. A 62-year-old man with lower extremity lymphedema underwent LVA with the STE method on the ankle. When the lymphatic vessel was cut for additional LVA at the proximal lower leg, blood drained out from the cut end of a lymphatic vessel, which suggested venous-lymphatic reflux at the STE anastomosis at the ankle. Because the reflux continued until 1 hour after the previous LVA at the ankle, the STE anastomosis at the ankle was re-explored and converted to ETE by ligation of the proximal lymphatic vessel. Reverse venous-lymphatic reflux was corrected, and a lymphovenous shunt was created immediately after the ligation. The current case suggests that STE anastomosis can be inferior to ETE anastomosis for creating a lymphovenous shunt when venous backflow exists.

Incidental finding of subclavian artery occlusion and subsequent hypoplastic internal mammary artery as a candidate recipient vessel in DIEP flap breast reconstruction

Ik Hyun Seong,우경제 대한성형외과학회 2019 Archives of Plastic Surgery Vol.46 No.6

We report a case of autologous breast reconstruction in which a thoracodorsal vessel wasused as a recipient vessel after a hypoplastic internal mammary vessel was found on preoperativecomputed tomography (CT) angiography. A 46-year-old woman with no underlying diseasewas scheduled to undergo skin-sparing mastectomy and breast reconstruction using adeep inferior epigastric artery perforator flap. Preoperative CT angiography showed segmentalocclusion of the right subclavian artery with severe atherosclerosis and calcification nearthe origin of the internal mammary artery, with distal flow maintained by collateral branches. The thoracodorsal artery was selected to be the recipient vessel because CT showed that itwas of adequate size and was not affected by atherosclerosis. The patient experienced nopostoperative complications, and the flap survived with no vascular complications. Thebreasts were symmetrical at a 6-month follow-up. This case highlights that preoperative vascularimaging modalities may help surgeons avoid using diseased vessels as recipient vesselsin free flap breast reconstructions.

광범위 회전근 개 파열의 관절경하 부분 봉합술의 임상적 결과

유재철(Jae-Chul Yoo),고경환(Kyung-Hwan Ko),우경제(Kyung-Jea Woo) 대한견주관절의학회 2009 대한견주관절학회지 Vol.12 No.2

목적: 거대 및 광범위 회전근 개 파열은 치료하기 어려운 질환이나 회전근개에 대한 이해가 높아짐에 따라 완전봉합은 불가능하여도 부분 봉합 또는“force couple repair”를 통해서도 통증 및 기능호전을 가져올 수 있다고 여겨진다. 그러나 이를 뒷받침하는 연구는 부족한 실정이다. 본 연구의 목적은 회전근개의 부분봉합술만을 시행한 환자들에서의 임상결과와 방사선학적 변화를 평가하는 것이다. 대상 및 방법: 2005년 6월에서 2008년 2월까지 거대 범위에서 광범위 회전근 개 파열에 대해 부분 봉합을 시행 받고 1년 이상 추시가 가능하였던 16예를 대상으로 하였다. 평균 추시 기간은 27.3개월 (15~46)이었고 수술 시 평균 연령은 66.6세 (57~76)였으며 성별은 남자가 7명, 여자가 9명 이었다.동통과 기능에 대한 Visual Analogue Scale (VAS)을 수술 전 후에 비교하였으며 견관절 기능 평가는 American Shoulder and Elbow Surgeons (ASES) score와 Korean Shoulder Scoring system (KSS)을 통해 시행하였다. 술 전 및 술 후에 견관절의 방사선검사를 통해 견봉-상완골 간격 및 퇴행성 변화의 진행 여부를 평가하였다. 결과: 동통에 대한 VAS 점수는 술 전 평균 4.4 (±2.50)에서 2.1 (±2.26)로 감소하였고 (p=0.0029) 기능에 대한 VAS 점수는 술 전 46.9 (±16.64)에서 70.0 (±22.80)로 호전된 양상 관찰되었다 (p=0.0023). 견관절 기능 평가인 ASES 점수는 술 전 평균 39.0 (±10.80)에서 80.3 (±16.78)로 증가하였고 (p<0.0001), KSS 점수는 술 후 평균 81.9 (±16.74)로 관찰되었다. 술 전 6.6 cm (±1.74)의 견봉-상완골 간격은 술 후 6.2 cm (±1.69)로 의미 있는 변화가 없었다 (p=0.3874). Hamada classification을 이용한 견관절의 퇴행성 변화 역시 술 전에 비해 술 후에 통계학적으로 진행하지 않았다 (p=0.2663). 만족도에 있어 3명의 환자에서 매우 좋음, 9명의 환자에서 좋음, 3명의 환자가 보통, 그리고 1명의 환자에서 불량을 표시하였다. 또한 추시 기간 동안 추가적인 수술을 시행한 환자는 없었다. 결론: 완전 봉합이 불가능한 광범위 회전근개 파열 환자에 대해서 부분 봉합술 (force couple repair)를 통해서 술 후 평균 2.3년 (15~46개월)에 좋은 임상결과를 가져올 수 있었으며, 견봉-상완골 간격도 의미 있는 변화가 없었으며 관절와 상완관절의 퇴행성 변화 역시 통계학적으로 진행하지 않았다. Purpose: With the better understanding of cuff function, partial repair or “force couple repair” for treating massive irreparable rotator cuff tear has gained some popularity. However, there were few reports on the results of partial repair. The purpose of this study was to report the clinical outcome of massive irreparable rotator cuff tears who received arthroscopic force-couple repair or partial repair. Materials and Methods: From June 2005 to Feb 2008, arthroscopic partial repairs were performed for 16 irreparable rotator cuff tears among the 101 large to massive rotator cuff tears that were operated on. Clinical and radiographic evaluation were done at the final follow-up Results: There were 7 men and 9 women with a mean age of 66.6 years. The mean follow-up period was 27.3 month (range: 15-46). The pain VAS improved from 4.4 (±2.50) to 2.1 (±2.26) and the functional VAS improved from 46.9 (±16.64) to 70.0 (±22.80). The ASES score improved from 39.0 (±10.80) to 80.3 (±16.78) and the KSS score was 81.9 (±16.74) at the final follow-up. The acromio-humeral distance was 6.6 cm (±1.74) preoperatively and 6.2 cm (±1.69) postoperatively without significant change (p=0.3874). The degenerative changes had no statistically progressed (p=0.2663). Conclusion: Partial repair for massive rotator cuff injury patients showed improvement in the clinical score without progression of arthritic change at a mean of 2.3 years follow-up.

대퇴골두 중심간 거리를 이용한 골수강외 슬관절 전치환술

서재곤(Jai-Gon Seo),임지순(Ji-Soon Lim),이현일(Hyun-Il Lee),우경제(Kyung-Jea Woo) 대한정형외과학회 2010 대한정형외과학회지 Vol.45 No.5

목적: 기존의 골수강외 정렬기법을 이용한 슬관절 전치환술은 대퇴골두의 중심을 수술 중 확인하는데 한계가 있어 대퇴삽입물의 관상면 정렬이 정확하지 않다는 문제점이 있었다. 본 연구에서는 새롭게 고안된 marker를 이용하여 슬관절 중심과 대퇴골두의 중심을 기계적 축에 일치시키는 방법을 사용하였고 이를 통하여 원위 대퇴골 절제 및 삽입물 정렬의 정확성이 향상되는지 평가하고자 하였다. 대상 및 방법: 2008년 10월부터 2009년 1월까지 156명 255예의 슬관절을 대상으로 하였다. 술 전 PACS system에서 양측 대퇴골두 중심간 거리를 측정하였으며, 이를 새롭게 고안된 Mechanical Axis Marker에 적용하여 환자에게 장착함으로써, 수술 시 기계적 축 상에서 슬관절의 중심과 대퇴골두의 중심, marker가 일직선상에 위치하도록 하였다. Marker가 실제 대퇴골두의 중심에 위치하는 지 20명의 환자에서 C-arm으로 직접 확인하였다. 술 후에는 대퇴삽입물의 관상면에서의 정열을 보기 위해 PACS system으로 기계적 축에 대한 대퇴삽입물의 내외반각(frontal femoral component angle)을 측정하여 결과를 분석하였다. 이상적인 각에서 3° 이내의 오차를 우수, 3-5°를 양호, 5° 이상을 불량으로 정의하였다. 결과: 수술직전 C-arm으로 marker의 위치를 확인하였을 때 대퇴골두 중심과 marker의 금속 peg 간의 간격이 95%에서 5㎜ 이내로 측정되어 높은 정확성을 보였다. 평균 기계적 축에 대한 대퇴삽입물의 내외반각은 89.0°±1.1(range 86°-96.6°)였으며, 90.6%에서 우수(231예), 8.6%에서 양호(22예), 0.8%에서 불량(2예)을 보였다. 대퇴삽입물의 내외반각에 대한 두 측정자 간 intraclass correlation coefficient는 0.972로 높은 일치도를 보였다. 결론: 골수강외 정렬기법을 이용한 슬관절 전치환술시 Mechanical Axis Marker를 이용하여 대퇴골두의 중심을 용이하게 파악할 수 있으며 이를 이용하여 기계적 축을 추적함으로써 관상면상 대퇴삽입물 정렬의 정확성을 높일 수 있었다. Purpose: Total knee arthroplasty using the extramedullary technique for alignment has some difficulty for detecting the center of the femoral head intra-operatively. In this study we tried to evaluate the usefulness and accuracy of a newly developed Mechanical Axis Marker that synchronizes the center of the knee joint and femoral head with the mechanical axis for the distal femoral cutting and femoral prosthesis alignment. Materials and Methods: Between October 2008 and January 2009, 255 knees in 156 patients underwent total knee arthroplasty. We measured the distance between each centers of the femoral head using the PACS system and we applied the distance to the newly developed Mechanical Axis Marker. Subsequently, we applied the new marker to patients to align the centers of knee, the femoral head and the marker in line with the mechanical axis intra-operatively. The accuracy of the marker was validated with C-arm fluoroscopy pre-operatively in 20 patients. Post-operatively we measured and analyzed the frontal femoral component angle to evaluate the coronal alignment of the femoral implant. The accuracy was rated as excellent when the alignment was <3°, as good when the alignment was 3-5°, and as poor when the alignment was >5°. Results: The pre-operative validation study with the C-arm fluoroscopy showed that the distance between the femoral head center and the metal peg of the marker was within 5 mm in 95% of the patients, which implied acceptable accuracy. The average frontal femoral component angle against the mechanical axis was 89.00± 1.1 (range 86°-966°) The proportion of excellent, good, and poor alignments was 90.6% (231 cases), 8.6% (22 cases), and 0.8% (2 cases), respectively. The intraclass correlation coefficient between the two observers for the frontal femoral component angle was 0.972 which showed high concordance. Conclusion: Our results indicate that the extramedullary technique assisted by our new Mechanical Axis Marker can easily identify the center of femoral head and improve the accuracy of frontal femoral component alignment with the proper mechanical axis.

대퇴 전자하 골절 불유합에 대한 칼날 금속판을 이용한 수술적 치료

박윤수(Youn-Soo Park),김진홍(Jin-Hong Kim),우경제(Kyung-Jea Woo),임승재(Seung-Jae Lim) 대한정형외과학회 2011 대한정형외과학회지 Vol.46 No.1

목적: 대퇴 전자하 골절의 치료 시에는 비교적 높은 빈도의 불유합이 발생하는 것으로 보고되고 있으나 불유합의 치료에 대한 연구는 드물다. 이에 저자들은 대퇴 전자하 골절의 불유합에 대하여 칼날 금속판을 이용한 수술적 치료의 임상적 및 방사선학적 결과를 보고하고자 한다. 대상 및 방법: 1997년 4월부터 2008년 10월까지 대퇴 전자하 골절의 불유합에 대하여 칼날 금속판을 이용한 수술적 치료를 시행 받은 환자 중에서 최소 1년 이상 추시가 가능하였던 16예의 환자를 후향적으로 분석하였다. 남지가 8명, 여자가 8명이었으며, 수술 시 평균 연령은 58세(42-77세)였다. 결과의 평가는 골유합 시기, 술 후 합병증, Harris 고관절 점수 및 Sanders 기능적 평가 척도를 이용하여 시행하였으며, 평균 추시 기간은 26개월(12-63개월)이었다. 결과: 최종 추시 시에 16예의 환자 중 15예(94%)에서 골유합을 얻을 수 있었으며, 평균 유합 기간은 7개월(4-11개월)이었다. 골유합을 얻지 못한 1예의 환자는 한차례 더 칼날 금속판을 이용한 내고정술과 골이식술을 시행하였으나 다시 금속판의 파단 및 불유합 소견 발생하여 결국 인공 고관절 전치환술을 시행 받았다. 합병증은 총 2예에서 발생하였는데, 대전자부 점액낭염 1예와 대퇴골 두 무혈성 괴사 1예가 있었다. 이 중 대퇴골 두 무혈성 괴사 환자는 지속적인 동통으로 술 후 2년에 인공 고관절 전치환술을 시행 받았는데, 재수술 시에 대퇴 전자하 불유합 부위의 안정된 골유합 소견을 관찰할 수 있었다. 최종 추시 시에 Harris 고관절 점수는 평균 88점(36-100점)이었으며, Sanders의 기능적 평가 지수에서는 88%에서 양호 이상의 결과를 보였다. 결론: 대퇴 전자하골절의 불유합에 대하여 칼날 금속판을 이용한 내고정술을 시행하여 매우 높은 비율의 골유합 소견 및 우수한 임상적 평가 결과를 얻을 수 있었다. Purpose: Although nonunion is a relatively common complication in the management of subtrochanteric fractures, there are few studies regarding the treatment of nonunion. The purpose of this study was to evaluate clinical and radiological results for the treatment of subtrochanteric nonunions with a blade plate. Materials and Methods: We retrospectively analyzed 16 cases of subtrochanteric nonunions that were treated with a blade plate between April 1997 and June 2008 and were followed for at least one year after the index operation. There were 8 males and 8 females with an average age of 58 years (range, 42-77 years). Outcome variables included the time to union, postoperative complications, Harris hip score, and the functional rating scale of Sanders. The average follow-up period was 26 months (range, 12-63 months). Results: Union was achieved in 15 (94%) of 16 subtrochanteric nonunions after an average of 7 months (range, 4-11 months). One patient who did not reach union after the index operation underwent repeated surgery with a longer blade plate and bone graft, but this patient was eventually treated with total hip arthroplasty because of persistent nonunion and breakage of the blade plate Two patients developed complications. One patient had bursitis around the greater trochanter and the other developed avascular necrosis of the femoral head. Of these, the patient with avascular necrosis of the femoral head was treated with total hip arthroplasty because of persistent hip pain 2 years after the index operation. At latest follow-up, the mean Harris hip score was 88 points (range, 36-100 points) and the functional rating scale of Sanders was good or excellent in 14 (88%) of 16 patients. Conclusion: The treatment of subtrochanteric nonunions with a blade plate is associated with a very high union rate and good clinical results.