Department of Vascular and Endovascular Surgery, Singapore General Hospital, Academia Level 5, Outram Road, 169608, Singapore.
Podiatry Department, Singapore General Hospital, Academia Level 5, Outram Road, 169608, Singapore.
Foot (Edinb). 2021 Jun;47:101803. doi: 10.1016/j.foot.2021.101803. Epub 2021 Apr 20.
Exposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap - a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing.
A retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization.
9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function.
The TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.
在使用局部负压伤口治疗（TNPWT）治疗射线截肢伤口时，通常会暴露相邻的跖趾关节（MTPJ）。这是由于机械性软组织侵蚀或直接压迫作用导致相邻的趾动脉创伤。这会导致脚趾坏疽，需要进行射线截肢，最终导致更大的创面床。我们描述了使用翻下的围绕关节囊组织的半切断截肢脚趾瓣（TOPHAT）瓣——一种鱼片状的脚趾瓣，以保护相邻的 MTPJ 囊，同时结合一种新的负压伤口治疗与灌输和驻留时间（NPWTi-d）敷料技术。该瓣保护相邻的关节囊，减轻创面负担，同时允许创面受益于 TNPWT，从而加速创面愈合。
对 2019 年至 2020 年在我院接受 TOPHAT 瓣治疗的脚趾坏疽需要射线截肢的患者进行回顾性研究。记录了伤口裂开、血肿、瓣坏死和继发感染等并发症。记录的其他结果包括最终皮肤移植所需的时间和完全上皮化所需的时间。
9 例患者接受 TOPHAT 瓣治疗。2 例患者出现瓣坏死。7 例患者进展为确定性皮肤覆盖，行皮片移植。1 例患者尽管皮片移植成功，但随后出现进行性动脉疾病，需要行膝上截肢。最终皮肤移植和完全上皮化的平均时间分别为 49.5 天和 107.5 天。所有患者对结果均满意，并能够恢复到术前的功能状态。
TOPHAT 瓣具有稳定的血管供应，提供持久的软组织覆盖。即使在患有周围血管疾病的患者中，它也是一种可靠且易于复制的技术，可以加速射线截肢后的伤口愈合。
