Purpose Baek’s modified Bilhaut-Cloquet procedure is indicated for patients with symmetric bifid thumbs in Wassel type II or III polydactyly. The radially deviated type of thumb polydactyly with asymmetric bifid thumbs was previously contraindicated for this procedure. The objective of the study was to describe the results of our modified Bilhaut-Cloquet procedure using a neurovascular island flap of the radial duplicate for radially deviated type of thumb polydactyly with hypoplasia. Methods Twelve thumbs of 12 patients with a radially deviated type of thumb polydactyly underwent our modified Bilhaut-Cloquet procedure using a neurovascular island flap of the radial duplicate and were followed up for an average of 38.4 months. Functional and cosmetic assessments were made using the Japanese Society for Surgery of the Hand scoring system. Results All neurovascular island flaps survived, and the thumb size was restored close to that of the unaffected contralateral side in all cases. According to the Japanese Society for Surgery of the Hand scoring system, 8 cases achieved good results, and 4 achieved fair results. In terms of functional and aesthetic results, all cases were considered acceptable by the patient’s parents. Conclusions Our technique using a neurovascular island flap of the radial duplicate in conjunction with the modified Bilhaut-Cloquet procedure was effective for the treatment of radially deviated type of thumb polydactyly with hypoplasia. This technique is an option for the treatment of radially deviated type of thumb polydactyly with hypoplasia. Type of study/level of evidence Therapeutic IV.

Diabetic wounds are hard to heal due to ferroptosis, a specific type of cell death triggered by high blood sugar in human umbilical vein endothelial cells (HUVECs) in the lining of blood vessels. Ferroptosis occurs as a result of excessive iron accumulation and lipid peroxidation. The resulting impairment in endothelial function and tissue scaffolding creates a persistent barrier against effective wound healing. Our study found that artemisitene (ATT), a bioactive compound derived from the herb Artemisia annua, speeded up diabetic wound healing by blocking ferroptosis through the Nrf2 (NFE2 like bZIP transcription factor 2, also known as NRF2: Nuclear factor erythroid 2-related factor 2)/GPX4 (Glutathione peroxidase 4) pathway. In studies with HG (high glucose)-damaged HUVECs, treatment with ATT (20 μM) effectively counteracted harmful iron buildup and lipid peroxidation, while also restoring mitochondrial health and reducing the levels of damaging reactive oxygen species (ROS). Computational modeling confirmed that ATT binds tightly to both Nrf2 and GPX4 molecules. Notably, when Nrf2 was blocked, ATT completely lost its protective effect, indicating that Nrf2 is essential for its action. In diabetic rats, applying ATT directly to wounds (20 mg/kg/day) significantly accelerated the rate of wound closure. This treatment worked by triggering two key regenerative processes: stronger new blood vessel growth and better-organized collagen structure. In practical terms, ATT prevents diabetic wound complications through three connected mechanisms: it uses GPX4 to counteract lipid peroxides, leverages Nrf2 to restore healthy antioxidant balance, and regenerates endothelial cells to drive new blood vessel formation. As the first drug of its kind to target ferroptosis this way, ATT offers a promising multitarget approach for diabetic wounds, tackling the combined problems of oxidative damage, mitochondrial failure, and poor tissue regeneration.

Random-pattern skin flaps play a vital role in repairing and reconstructing soft tissue defects. Clinical utilization of skin flaps is limited due to distal necrosis. Calycosin (CAL) is an effective ingredient present in Astragalus, and is reported to possess diverse pharmacological properties. Our study aims to assess the potential benefits of CAL on random flap survival and reveal the underlying mechanisms. Our study revealed that CAL promoted the survival area of the skin flap and improved flap blood flow. CAL treatment exerted anti-apoptosis and anti-ferroptosis effects in the flap model. In our mechanistic investigation, we demonstrated that CAL could activate the AMPK-mTOR signaling pathway and increase transcription factor EB (TFEB) nucleus translocation, thereby suppressing ferroptosis and apoptosis as a result of decreased reactive oxygen species (ROS) which was triggered by increasing superoxide dismutase 1(SOD1). In summary, our findings revealed CAL may protect against flap necrosis by inhibiting ferroptosis and apoptosis via AMPK-mTOR signaling pathway modulation.

This study aims to establish reference values for the normal bone axis in children to assess the effectiveness of corrective osteotomy procedures and guide the treatment of congenital hand malformations and post-operative axis deviations. A retrospective study was carried out between January 1, 2022, and October 9, 2024. A total of 192 individuals were included. In both abnormal and normal individuals, we measured the angles within the zone of provisional calcification and the bone axis. The metacarpal, proximal, and distal phalanx of the thumb were measured in both males and females. We calculated the average and standard deviations for both groups. These normal reference values were then compared with the abnormal reference values of patients who had types II and IV polydactyly. Our work effectively established thorough reference values for the thumb's normal axis. Considering the success of corrective osteotomies in children with congenital deformities depends mostly on these values. In polydactyly type IV, we observed a change in the angle on the side with the axis deviation. Our results highlight the need for an exact preoperative design for thumb reconstruction. It also implies the possibility of choosing the side with little or no axis deviation during operation. This strategic selection can help prevent the need for additional osteotomies or subsequent surgeries. Evaluating and preparing corrective osteotomy treatments benefits significantly from the reference values for the proper alignment of the thumb's bones. These results enable surgeons to predict the degree of corrective osteotomy needed, thereby improving postoperative surgical results and patient satisfaction.

Background: Introduced in clinical practice in 1989, perforator flaps are vital for tissue defect repair, but they are challenged by distal necrosis. Tetrahydropalmatine (THP) from celandine is renowned for its anti-inflammatory and analgesic effects. This study investigates THP's use in perforator flaps. Methods: Thirty rats were divided into a control group and four THP concentration groups, while seventy-eight rats were categorized as control, THP, THP combined with rapamycin (RAP), and RAP alone. We created 11 cm by 2.5 cm multi-regional perforator flaps on rat backs, assessing survival blood flow and extracting skin flap tissue for autophagy, oxidative stress, apoptosis, and angiogenesis markers. Results: The THP group exhibited significantly reduced distal necrosis, increased blood flow density, and survival area on the seventh day compared to controls. Immunohistochemistry and Western blot results demonstrated improved anti-oxidative stress and angiogenesis markers, along with decreased autophagy and apoptosis indicators. Combining THP with RAP diminished flap survival compared to THP alone. This was supported by protein expression changes in the PI3K-AKT-mTOR pathway. Conclusion: THP enhances flap survival by modulating autophagy, reducing tissue edema, promoting angiogenesis, and mitigating apoptosis and oxidative stress. THP offers a potential strategy for enhancing multi-regional perforator flap survival through the PI3K/AKT/mTOR pathway. These findings highlight THP's promise in combatting perforator flap necrosis, uncovering a novel mechanism for its impact on flap survival.

BACKGROUND:Multi-territory perforator flaps have become the preferred option for the repair and reconstruction of large soft tissue defects. Although methods (e.g., pharmacological agents, mechanical stimulation, and thermal stimulation) were developed to open choke vessels to improve flap survival, the flap necrosis rate is still as high as 28.8%. The authors hypothesized that high-pressure infusion might enhance flap viability by dilating choke arteries intraoperatively in a rat model of multi-territory perforator flap. METHODS:Two-month-old male Sprague-Dawley rats were randomized into two groups (n = 32 each). During the multi-territory perforator flap elevation based on the right superficial epigastric angiosome, one group received continuous high-pressure infusion (mean pressure, 250 mmHg; duration, 1 min) of an isotonic heparin sodium solution (12,500 U/L) via the artery in the pedicle, whereas the other group received no infusion. At 7 days postoperatively, arteriography was performed; endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor (VEGF) expression and microvascular density were evaluated by western blot and histology, respectively; and flap survival was compared. Moreover, intraluminal diameters were examined at 1 day and 7 days postoperatively using hematoxylin and eosin staining, and coagulation function was assessed immediately postoperatively. RESULTS:High-pressure infusion significantly promoted the dilation of choke arteries at 1 day and 7 days postoperatively. It also increased eNOS and VEGF expression, flap survival, and microvascular density. The coagulation function remained unaffected. CONCLUSIONS:High-pressure infusion allowed intraoperative and postoperative dilation of the choke arteries that enhanced the viability of multi-territory perforator flaps in rats.

Objective:To investigate the role of magnetic resonance imaging (MRI) in the preoperative differentiation of Wassel type Ⅳ congenital thumb polydactyly in infants.Methods:A total of 286 fingers of 266 patients with congenital thumb polydactyly who were admitted to our hospital from January 2016 to December 2020 and completed preoperative X-ray and MRI examinations were statistically analyzed, and the results were compared with the intraoperative classification according to the two auxiliary examinations.Results:A total of 123 Wassel type Ⅳ fingers were classified by preoperative X-ray film reading. Compared with intraoperative classification, about 18.7% of the patients had classification errors, and Wassel type Ⅲ had the most classification errors. A total of 99 Wassel typeⅣ patients were classified by MRI film reading, and none of them had classification errors.Conclusion:In Wassel classification of congenital thumb polydactyly, type Ⅳ is the most common, and there is a high error rate in classification only by preoperative X-ray films. MRI can effectively reduce the error rate of preoperative classification, and also obtain comprehensive preoperative information to guide treatment more accurately.

Flaps are mainly used for wound repair. However, postoperative ischemic necrosis of the distal flap is a major problem, which needs to be addressed urgently. We evaluated whether tetrandrine, a compound found in traditional Chinese medicine, can prolong the survival rate of random skin flaps. Thirty‐six rats were randomly divided into control, low‐dose tetrandrine (25 mg/kg/day), and high‐dose tetrandrine (60 mg/kg/day) groups. On postoperative Day 7, the flap survival and average survival area were determined. After the rats were sacrificed, the levels of angiogenesis, apoptosis, and inflammation in the flap tissue were detected with immunology and molecular biology analyses. Tetrandrine increased vascular endothelial growth factor and Bcl‐2 expression, in turn promoting angiogenesis and anti‐apoptotic processes, respectively. Additionally, tetrandrine decreased the expression of Bax, which is associated with the induction of apoptosis, and also decreased inflammation in the flap tissue. Tetrandrine improved the survival rate of random flaps by promoting angiogenesis, inhibiting apoptosis, and reducing inflammation in the flap tissue through the modulation of the PI3K/AKT signaling pathway.

Background To explore the clinical efficacy of using tongue-shaped flaps and advancement flaps to reconstruct the fingertips in congenital syndactyly patients with osseous fusion of the distal phalanges. Methods From January 2016 to January 2019, 12 patients with congenital syndactyly, involving 30 digits in total, presented to our hospital and were surgically treated with tongue-shaped flaps, as well as with advancement flaps to reconstruct the fingertips. The flap infection rate, necrosis rate and any other early complications were recorded. Fingertip aesthetics were reported according to the modified Bulic scale. A questionnaire was used to assess the satisfaction of the patients' family members. Results All cases were thoroughly reviewed. The postoperative period for inclusion in this study ranged from 36 to 60 months, with an average follow-up time of 45 months. During this period, no complications such as infection and/or necrosis of any flap were observed. Significant improvements in finger aesthetics and functioning compared to preoperative values were observed in most cases. Based on the modified Bulic scale, of 30 fingertips, an excellent result was obtained for 3, a very good result for 13, a good result for 13 and a poor result for just 1. Family members were satisfied with the treatment outcome. Conclusions This technique employing tongue-shaped flaps and advancement flaps to reconstruct fingertips is effective, which enables the attainment of favourable aesthetic and functional outcomes in congenital syndactyly patients with osseous fusion of the distal phalanges.

Purpose We aimed to evaluate the use of magnetic resonance imaging (MRI) to visualize unossified bone sites that are often not visible with radiography in pediatric radial polydactyly patients with bifurcation at the metacarpophalangeal (MP) joint level. The MRI validation could help in planning for surgical procedures. Patients and Methods A total of 141 thumbs in 139 pediatric patients with bifurcation at the MP joint on radiography were included in this study. All the patients had undergone MRI with proton density-weighted fat-suppressed fast spin-echo (FS PDWI) sequence and fast fat-suppressed 3D spoiled gradient-recalled echo (FS 3D SPGR) sequence. The MR images of the cartilaginous structure and joint characteristics at the MP joint were evaluated and categorized by two experienced radiologists. Results Our analysis demonstrated that MR imaging, especially the FS 3D SPGR sequence, yields better visibility of the cartilaginous structure and shows clearer joint characteristics that could not be detected by radiography. The abnormalities included a cartilaginous connection on the base of duplicated proximal phalanx, cartilaginous joint connection and the shape of articular cartilage on the head of metacarpal and soft tissue band. Radiologically encountered duplications at the MP joint level were successfully classified into six types based on the MRI-detected structural changes. The distribution of the six types was 17.7% (25/141) in type 1, 53.9% (76/141) in type 2, 2.8% (4/141) in type 3, 9.9% (14/141) in type 4, and 13.5% (19/141) in type 5. Conclusion This data showed that MR imaging provides practical information on the anatomic characteristics in radial polydactyly with bifurcation at the MP joint level that could aid surgical decision-making processes. Thus, the FS 3D SPGR sequence could be used as a MR imaging technique in radial polydactyly.

Diabetes mellitus is associated with refractory wound healing, yet current therapies are insufficient to accelerate the process of healing. Recent studies have indicated chemically modified mRNA (modRNA) as a promising therapeutic intervention. The present study aimed to explore the efficacy of small skin engineered to express modified mRNAs encoding the stromal cell-derived factor-1α (SDF-1α) facilitating wound healing in a full-thickness skin defect rat model. This study, devised therapeutic strategies for diabetic wounds by pre-treating small skin with SDF-1α modRNA.The in vitro transfection efficiency was evaluated using fluorescence microscopy and the content of SDF-1α in the medium was determined using ELISA after the transfection of SDF-1α into the small skin. To evaluate the effect of SDF-1α modRNA and transplantation of the small skin cells on wound healing, an in vivo full-thickness skin defect rat model was assessed.The results revealed that a modRNA carrying SDF-1α provided potent wound healing in the small skin lesions reducing reduced scar thickness and greater angiogenesis (CD31) in the subcutaneous layer. The SDF-1α cytokines were significantly secreted by the small skin after transfection in vitro.This study demonstrated the benefits of employing small skin combined with SDF-1α modRNA in enhancing wound healing in diabetic rats having full-thickness skin defects.

Random skin flaps are frequently applied in plastic and reconstructive surgery for patients suffering from soft tissue defects caused by congenital deformities, trauma and tumor resection. However, ischemia and necrosis in distal parts of random skin flaps remains a common challenge that limits the clinical application of this procedure. Recently, chemically modified mRNA (modRNA) was found to have great therapeutic potential. Here, we explored the potential of fibroblasts engineered to express modified mRNAs encoding the stromal cell-derived factor-1α (SDF-1α) to improve vascularization and survival of therapeutic random skin flaps. Our study showed that fibroblasts pre-treated with SDF-1α modRNA have the potential to salvage ischemic skin flaps. Through a detailed analysis, we revealed that a fibroblast SDF-1α modRNA combinatorial treatment dramatically reduced tissue necrosis and significantly promoted neovascularization in random skin flaps compared to that in the control and vehicle groups. Moreover, SDF-1α modRNA transcription in fibroblasts promoted activation of the SDF-1α/CXCR4 pathway, with concomitant inactivation of the MEK/ERK, PI3K/AKT, and JAK2/STAT3 signaling pathways, indicating a possible correlation with cell proliferation and migration. Therefore, fibroblast-mediated SDF-1α modRNA expression represents a promising strategy for random skin flap regeneration.

BACKGROUND:The free 1st toe hemi-pulp transfer for finger pulp reconstruction was acknowledged as the optimal one. However, the treatment of the 1st toe donor defect, owning to the impossibility of primary closure, was frequently oversimplified. This study presented a "hitchhiking" approach to resurface finger pulp and the subsequent 1st toe donor site defect in a one-stage procedure. METHODS:From 2014 to 2019, finger pulp amputations (13 digits in 12 patients) were reconstructed with free 1st toe pulp flaps, and the donor site was resurfaced by the 2nd toe pedicled flap with the 2nd toe's primary closure. Therapeutic evaluation of repaired fingers and toes was based on cold intolerance, two-point discrimination (2PD), and gait disturbance. RESULTS:All finger and toe pulp flaps survived uneventfully. The average size of free 1st toe and pedicled 2nd toe flap was 3.1 cm × 2.0 cm (3.5 cm × 1.4 cm to 4.2 cm × 2.5 cm) and 3.0 cm × 1.1 cm (2.0 cm × 0.9 cm to 3.8 cm × 1.5 cm), respectively. The regained average static 2PD on the finger and 1st toe pulps was 6 mm (ranged 5-10 mm) and 4 mm (ranged 2-6 mm), respectively. All reconstructed 1st toe pulps were qualified for normal gait. One patient complained the mild cold intolerance, and hammer-toe deformities were involved in two cases. CONCLUSION:To fulfill donor site care and cost-effective rule, the toe-to-finger pulp reconstruction can't underestimate the morbidity on 1st toe donor site due to inappropriate intervention. Equally importantly, the hitchhiking pedicled 2nd toe flap should be recruited in the reconstructive scheme.

We present the MRI findings for 39 Wassel Type IV duplicated thumbs in 38 patients. We found that MRI revealed the morphology of the cartilaginous connection between the thumb anlages and the location of the deviation corresponding to the classification of Horii, which allowed precise preoperative planning of corrective osteotomies. All 39 thumbs were available for follow-up after surgical reconstruction at a mean of 29 months (range 25 to 39). Four out of nine Horii Type A cases and all 12 Type B, as well as the six Type C and the six Type D cases, achieved good results according to the Tada scoring system. Five Type A cases achieved fair results with residual stiffness of the interphalangeal joint. No secondary operations were needed. We conclude that MRI proved useful in subclassifying Wassel Type IV duplicated thumbs and may aid in planning the osteotomies needed for their reconstruction. Level of evidence: IV

目的 探讨分叶指背五边形皮瓣应用于并指分指术的近期疗效.方法 对2018年1月至2019年10月温州医科大学附属第二医院育英儿童医院手外整形科应用分叶指背五边形皮瓣手术治疗的单侧单纯皮肤并指患儿15例临床资料进行回顾性分析.记录术后皮瓣坏死和创口感染等早期并发症发生情况;采用指蹼爬移Withey评分和瘢痕温哥华评分对患指术后外观进行评价;记录因手术并发症而需行再次手术情况;测量指蹼深度并与健侧进行比较;利用调查问卷评估患儿家长对术后效果满意度.结果 15例患儿均获随访,平均随访时间14(12～20)个月.全部皮瓣均一期成活,术后未见皮瓣坏死和感染等并发症.无患儿因指蹼爬移或屈指挛缩需行再次手术.术后指蹼外形宽大,患侧指蹼深度与健侧差异无统计学意义.患儿家长对手术效果满意.结论 应用分叶指背五边形皮瓣手术治疗并指畸形,可避免指蹼和指体掌侧线性瘢痕的形成,减少指蹼爬移和屈指挛缩的发生,近期疗效令人满意.

Objective In this study,a new surgical technique was developed to reconstruct the lateral nail fold in the duplicated thumbs with a common nail and postoperative outcomes were evaluated.Methods From December 2012 to October 2015,sixteen duplicated thumbs with a common nail were treated in our hospital using a flap from resected finger pulp which did not include the nail and phalanx.Unilateral inverting suture was performed between the flap and nail bed to reconstruct the lateral nail fold and nail groove.Postoperative outcomes were evaluated by Wang-Gao scoring system (total 12).Results The follow-up period ranged from 10 to 45 months.The reconstructed nails were smooth and had a natural lunula,and the nail width was about 80％-100％ of their normal sides.There was a right angle between the nail epithelium and lateral nail fold in four cases,and an acute angle in two cases.The reconstructed nails were asymmetrical in these thumbs.One patient showed a hypertrophy in the lateral nail fold.The reconstructed nails were evaluated by Wang-Gao scoring system:10 in 2 cases,11 in 4 and 12 in 10.All the cases had excellent results.Conclusions The nail width usually is more than 80％ of the normal sides in the radial polydactyly with a common nail.The surgical technique can reconstruct a natural lateral nail fold and nail groove,and avoid the nail deformity caused by the Bilhaut-Cloquet procedure.

Objective To introduce the design of modified Reading man flap, and observe the clinical effect of modified flap for repairing digit and toe wounds. Methods From July 2014 to September 2017,dorsal skin defects on 37 digits and 18 toes were repaired with our modified Reading man flaps. The revised design was characterized with enlargement the major flap and extending the minor flap proximally, and all donor site defect were sutured primarily through the major flap recover the defect and the minor flap repair the subsequent donor defect. Results All the detects in 55 patients were repaired by the modified Reading man flaps with direct donor sites closure. With average of 11. 5 months ( 9. 5-25. 7 months ) follow-up, all flaps survived with satisfactory texture and appearance, the bulky deformity and scar contracture did not occur. Partial necrosis of tip in the minor flaps occurred in 2 toes and healed by wound dressing. The function of the toe joints was good and the walking gait was normal. Partially impaired PIP joint function with limited flexion occurred in 2 cases. Based on the TAM evaluation criteria, the results were excellent in 28 digits, good in 7 digits, and the overall satisfactory rate was 94. 6％. Conclusions The modified Reading man flap can get good clinical effects for treatment of the digit and toe dorsal skin defect with the advantages of simple procedure, easy transfer and direct closure of donor sites. Flaps appearance and joints function can get good result postoperatively.

Objective To summarize retrospectively the manifestation types of nail deformities after Bilhaut-Cloquet (BC) procedure for polydactyly deformity and its influence on aesthetic evaluation.Methods From January 2005 to December 2015,84 patients (88 thumbs) were treated with BC.According to the Wassel classification,3 case was type Ⅰ,20 were type Ⅱ,12 were type Ⅲ,33 were type Ⅳ,6 were type Ⅵ,10 were type Ⅶ.The shape,width,flamess,semilunar and fold shape of reconstructed nails were observed and classified after the operation.The aesthetic effect of the reconstructed nails was evaluated by the modified Wang-Gao score.Results The follow-up period ranged from 6 to 128 months,with an average of 34.4 months.Among them,abnormal flatness of the reconstructed nails occurred in 51 thumbs (57.95％),nail semilunar deformity in 27 fingers (30.68％),nail fold deformity in 22 fingers (25.00％),abnormal nail width in 16 fingers (18.18％) and abnormal nail shape in 7 fingers (7.95％).Acoording to the modified Wang-Gao score,the score was 2 to 12 points with an average of 9.18 points.Among them,the results were rated as excellent in 58 fingers,good in 23 fingers,fair 5 fingers and poor in 2 fingers,with the excellent and good rate being 92.05％.Conclusion The application of BC procedure for correction of polydactyly deformity has a definite effect on the improvement of finger volume and nail width.The deformities may occur in all the nail stmctuwal units requiring reconstruction,and manifestations are diverse,mainly mild deformities.More than three structural unit deformities are the main cause of dissatisfaction of patients or their families,but the incidence is not high.Therefore,BC procedure is still an option for dysplastic polydactyly deformity.

Purpose: To evaluate nail appearance after nail fusion plasty to treat thumb duplication. Methods: A modified form of nail fusion plasty was performed on 17 reconstructed thumbs of 16 children with thumb duplications, commencing in January 2010. We assessed nail width and nail, lunular, and nail fold deformities using the Wang-Gao scoring system. All 17 thumbs were evaluated over an average of 32 months (range, 12-48 months) of follow-up. Results: One patient with bilateral thumb deformities was excluded. The width ratios of 15 reconstructed nails (compared with those of the contralateral thumbs) were 82-118% (average, 97%). Nine thumbs exhibited nail ridges or gaps; the average ridge/gap score was 1.23 (maximum, 2). Six thumbs exhibited lunular deformities; the average score was 1.58 (maximum, 2). Another six thumbs evidenced nail fold deformities; the average score was 1.64 (maximum, 2). Only one thumb exhibited nail dehiscence. Two thumbs had no nail deformity. The final assessments were excellent in 14 cases, good in 2 cases, and fair in 1 case. Conclusions: We could not significantly reduce the deformity rate of the nail plate, nail fold, or lunula using our new technique, but the deformities were much less marked than previously. Nail fusion plasty usefully enlarges the nail and pulp in patients with hypoplastically duplicated thumbs. (C) 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.