Shi-Min Chang

Treatment of isolated posterior coronal fracture of the lateral tibial plateau through posterolateral approach for direct exposure and buttress plate fixation

PurposeTo present a case series of patients with isolated posterior coronal fractures of lateral tibial plateau treated by direct exposure and buttress plate fixation through posterolateral approach.MethodsBetween May 2007 and April of 2008, eight middle aged patients were identified that had isolated posterior coronal fractures of the lateral tibial plateau. All eight patients underwent direct fracture exposure, reduction under visualization, and buttress plate fixation through posterolateral approach.ResultsThere were 1 case of split, two cases of pure depression and five cases of split-depression fractures. Four were associated fibular head split fractures without common peroneal nerve injuries. Five patients were injured from a simple fall on riding electrical bicycle while the knee was relaxed in 90° position The articular displacement (8 cases) measured in CT scan was 10.5xa0mm in average (range 8–15xa0mm). The cortical split length (from the articular rim to the distal tip, 6 cases) was 2.8xa0cm in average (range 2.4–3.5xa0cm). The articular reduction was perfect in seven (absolutely no step-off) and imperfect in 1(<2xa0mm step-off) as measured by X-ray. With a mean follow-up of 10xa0months (6 casesxa0>xa012xa0months), the average range of motion arc was 119°, four patients have flexion lag 10°–20°. The average SMFA dysfunction score was 15.8, and average HSS score was 98. All eight patients stated they were highly satisfied.ConclusionsDirect posterolateral approach by dividing lateral border of soleus muscle, provides excellent fracture reduction under visualization and internal buttress plate fixation for posterior coronal fracture of the lateral tibial plateau. Good functional results and recovery can be expected.

Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage.

Background: Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator–based neurocutaneous flap with a lower pivot point. Methods: This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator–based sural neurofasciocutaneous flap. Results: The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 × 6 cm to 5 × 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications. Conclusions: The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel.

The reconstruction of the distal third leg and weight‐bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo‐fasciocutaneous perforators with diameter 0.2–0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm2, and the muscle component 17.7 cm2. All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel.

The posterolateral approach for plating tibial plateau fractures: problems in secondary hardware removal

Posterolateral tibial plateau fractures are recognized recently in orthopedic trauma. It can occur in isolation (only the posterolateral quadrant) or in combination (more than two quadrants) [1]. Although several papers have been published on this topic in the recent years, yet optimal and rational surgical approaches to various patterns has not been reached [2–7]. For isolated posterolateral tibial plateau fractures, we described a modified posterolateral approach without fibula neck osteotomy and reported 8 cases with excellent outcomes in 2009 [4]. With the patient lying in prone position, the fracture can be easily exposed through a lateral border dissection and medial retraction of the gastrocnemius and soleus muscles. After direct reduction under visualization, a small 3.5-mm T-plate placed in vertical direction over the posterolateral cortice buttresses the fracture very well. After fracture union, most Chinese patients ask their doctors to remove out the implants, even no stimulating symptoms are present. From November 2009 to October 2011, we have operated secondarily in 5 patients to take out the plate, through the primary posterolateral approach. However, problems and difficulties are encountered. Heavy scar formation over the plate and the surrounding tissues makes the surgical dissection very tedious and time consuming. Usually, 1.5 h is the minimal time cost with this implant removal operation. Furthermore, 4 out of 5 patients had iatrogenic venous rupture during blunt dissection to expose the distal screw. Subsequently, wound hematoma and delayed healing occurred in those 4 patients. The anterior tibial vascular bundle consisted of one artery and two venae comitantes. They pass through the opening of the interosseous membrane to the anterior compartment, usually 5 cm below the joint line. During their forward perforating, the three vessels are arranged in fashion with one upper vein, one middle artery, and one lower vein. As the small 3.5-mm T-plate with 3-hole is approximately 5.0 cm in length, the upper concomitant vein is more vulnerable for its closeness to or even overriding the distal tip of the plate (Fig. 1). Now, we do not use this posterolateral approach any more in practice for isolated posterolateral quadrant tibial plateau fractures, as there are too much problems and difficulties in the secondary plate removal after fracture

Letter to the Editor: Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?

To the Editor n nWe read the article entitled “Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?” by Macheras et al. [3] with great interest. We commend the authors for confirming that the Proximal Femoral Nail Antirotation (PFNA)-II could avoid lateral cortex impingement; they concluded a flattened lateral surface and smaller mediolateral angle could decrease the pressure on the lateral trochanteric wall. n nBeginning in August 2009, we have used PFNA-II to treat more than 300 cases of pertrochanteric and intertrochanteric fractures (AO/OTA: 31A) [4]. In our opinion, the operative technical evolution in nail insertion may be more important than instrument modification. n nIn cephalomedullary nailing, it is important to ensure the instrument insertion line (guide wire, reamer, and the nail) and the femoral canal line are coaxial. However, there are several reasons that make this unachievable in some patients [1, 2]. In addition to morphologic features of the fracture (some can be reduced only with the hip in abduction) and a stiff spine in geriatric patients, the soft tissue mass about the hip, operative drapes, or a laterally oriented operating trajectory of the side-standing surgeon can result in a shift of the ideal trochanteric tip entry point and gradual enlargement in a lateral direction. A laterally enlarged oval hole combined with the existing trochanteric fracture line will lead to more lateral placement of the intramedullary nail than intended. n nTo avoid lateralization, we move the entry point slightly medial (approximately 5xa0mm) from the trochanteric tip, near the medial wall of the greater trochanter (Fig.xa01). There are several advantages to medial reaming. First, it avoids the hard-crest bone of the head-neck fragment, preventing medial abutment and thus reduces the risk of varus reduction of the proximal head-neck fragment or a high helical blade position in the femoral head, both of which are undesirable. Second, it provides adequate space for nail insertion, preventing a wedge-opening effect between the head-neck fragment and the shaft fragment. Third, it provides a well-aligned tube after reaming (even with lateralization) for nail insertion, avoiding pressure on the trochanteric lateral cortex, and nail-cortex impingement or even lateral wall rupture. n n n nFig.xa01 n nMedial migration of the entry point (red point) from the exact tip of the greater trochanter produces an optimal aligned tube (blue area) after reaming. n n n nWe thank the authors for sharing their experience. We agree with their conclusion that regardless of the implant choice and its specific technical characteristics, the technique of inserting is the key to ensuring a stable fixation and preventing major complications.

Venous drainage in retrograde island flap: An experimental study using fluorescence tracing technique

The pathway of venous drainage in retrograde island flaps was investigated by fluorescence tracing technique using the saphenous fasciocutaneous flap in New Zealand White rabbits. Forty animals were allocated into four groups according to the different times at 30 minutes (I), 24 hours (II), 72 hours (III), and 7 days (IV) after the operation. According to the different routes to give tracer, each group was further allocated into two subgroups of the artery injection and vein injection. For each animal, one hindlimb was assigned as the experimental side, the contralateral side as control without giving tracer. The erythrocytes were separated, labeled with fluorescein isothiocyanate (FITC), detected, and injected into the artery or vein. Subsequently, the flaps were harvested 5 seconds after injection and immediately frozen, sectioned, and observed under microscope. In group I and II, the fluorescence was observed mainly around the vessel adventitia of the vein and artery and tunica intima of the artery. In group III, there was weak fluorescence observed in the lumen of vein. In group IV, fluorescence was distributed principally in the lumen of the vein. In addition, fluorescence was not observed in the saphenous nerve in group I and there was mild fluorescence in the saphenous nerve in groups II, III, and IV. These findings suggest that the venous return is through “bypass route” in earlier period. In later period, the venous retrograde return is through “bypass route” and “incompetent valves route;” however, “incompetent valves route” becomes the main route.

An overview of skin flap surgery in the mainland China: 20 years' achievements (1981 to 2000).

Microsurgical anatomy and clinical applications have been widely and extensively practiced throughout the mainland of China since late 1970s. During the 1980s to 1990s, Chinese surgeons and anatomists developed many new flap donor sites and modifications, most of which were published in Chinese literature. These achievements were not fully realized by the Western surgeons. In this overview, we attempt to give a brief introduction of these contributions made by the Chinese authors in the mainland. Of the new flaps first or independently described by the Chinese, most were in the limbs. These flaps can be classified into three categories. First are free flaps with a main artery trunk, such as the radial forearm flap with radial artery, the medial leg flap with posterior tibial artery, and lateral leg flap with peroneal artery. Second are reverse-flow island flaps based on distal main vascular bundles (e.g., the radial artery and venae comitantes, the ulnar, the posterior tibial, and the peroneal arteries). Third are septocutaneous perforator flaps that avoid sacrifice of the main artery trunk, which include the anterolateral thigh flap, lateral lower-leg flap, dorsoulnar flap, distally adipofascial pedicled radial forearm flap, and so on.

The influence of anaesthetics on the reverse-flow fasciocutaneous flaps.

Dear Editor: We are interested in the article by Uygur et al. entitled ‘‘The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flaps: An experimental study in rabbits’’ (Burns, 2010, 36:270–276). Throughout the experiment, a significant difference was noted between the groups including the microcirculatory flow in the flap surfaces, intravenous pressure (IVBP) and intra-arterial blood pressure (IABP). In the end, they concluded that epidural anaesthesia (EA) can improve blood flow to reverse-flow fasciocutaneous flaps (RFFFs) and prevent the progression of venous congestion, which can offer a reliable way to prevent the venous congestion of RFFF in the early postoperative period [1].

Letter to the Editor: Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation

To the Editor: n nWe read with great interest the paper by Miller et al. [3]. The authors concluded syndesmotic fixation through the posterior malleolus results in outcomes similar to those with syndesmotic screw fixation. This study describes what may be an alternative method for syndesmotic stabilization and avoid the disadvantage of the traditional transsyndesmostic fixation. However, there are some concerns regarding this study. n nFirst, the patients chosen reflected a selective population. Most fractures (25 of 31) included in the study were attributable to supination-external rotation (SER) injuries. Although fractures from SER injuries at the level of the joint (Weber B fractures) occasionally have syndesmotic diastasis on stress testing, syndesmotic stabilization is used more frequently for fractures from pronation-external rotation (PER) (Weber C) injuries [4, 5]. The fractures occurring within 5xa0cm of the joint line, most of which usually are considered unable to produce syndesmotic instability, may not benefit from syndesmotic fixation [1]. n nSecond, could posterior malleolar fixation provide sufficient syndesmotic stabilization for injuries with a different level of fibular fractures? For injuries with greater instability, we believe more fixation is necessary. For example, with a SER injury that shows just slight syndesmosis diastasis, one three-cortex 3.5-mm screw is sufficient. For a Maisonneuve’s fracture, in contrast, a heavier screw and probably two screws engaging four cortices are preferable [2]. n nThird, is combined posterior malleolar and transsyndesmotic fixation necessary for patients with fracture-dislocations (Group C)? When the posterior malleolar fragments are less than 25% of the joint surface, the only purpose of posterior malleolar fixation is to stabilize the syndesmosis through the posterior inferior tibiofibular ligament, which is the same as with transsyndesmotic fixation. Considering no other structures of the ankle were stabilized further, why did the authors perform combined fixation? Was it because the syndesmotic instability was still present after either of the procedures?