Yue-Liang Zhu

Distal foot coverage with reverse dorsal pedal neurocutaneous flaps

Various types of neurocutaneous flaps have been used for extremity reconstructions. However, the application of this technique to the dorsum of the foot has not been reported previously. The aim of this article is to evaluate the attempts and clinical results from dorsal pedal neurocutaneous flap procedures. Harvesting of these flaps included the medial, intermediate and lateral dorsal cutaneous nerves, the deep peroneal nerve and the nutrient arteries of these nerves. The vascular anatomy of these flaps was studied before the clinical usage of the procedure. From 2003 to 2008, 30 patients with skin defects and bone exposure of the dorsum of the distal foot were treated with 39 dorsal pedal neurocutaneous flaps in our centre. The flaps in this series ranged from 3.5 to 7.0 cm in width and 4.0 to 10.0 cm in length. Totally, 35 flaps healed uneventfully. One showed partial loss at the distal edge, and three survived entirely following continuous massage. The postoperative contour of the flaps was acceptable. The reverse dorsal pedal neurocutaneous flap has proved effective and convenient for coverage of minor- to medium-sized defects in the distal foot.

Motorcycle spoke injuries of the heel

INTRODUCTION The spoke injuries of the lower extremity seems never stop haunting the surgeons since its first report 62 years ago. A prospective study of motorcycle spoke injuries in the heel was undertaken to study the injury mechanism, the treatment protocols, and the outcomes. PATIENTS AND METHODS From 2001 to 2010, 89 cases of motorcycle spoke injuries of the heel were examined. The various injury mechanisms were analysed. Flaps and other reconstruction surgeries were used to manage the involved extremity. RESULTS The mechanisms of the motorcycle spoke injuries of the heel had some unique features. A grading system was developed for the injuries according to the tissues involved. The surgery protocols primarily consisted of flap transfers, Achilles tendon reconstruction, and calcaneus management. CONCLUSIONS The eradication of the motorcycle spoke injuries is a difficult task, but the treatment outcomes have been greatly improved due to the advancement of surgical techniques.

One-stage reconstruction of Achilles tendon and skin defects by the sliding gastrocnemius musculocutaneous flap without anastomosis.

BACKGROUND Simultaneous defects of Achilles tendon and skin remain a big challenge for clinical surgeons. This article reviews the experience of a one-stage reconstruction of the defects. The sliding gastrocnemius musculocutaneous flap without anastomosis was used and the associated anatomy was studied. METHODS Fourteen cases of Achilles tendon and skin defects have been treated by the V-Y advancement of the gastrocnemius musculocutaneous flap in our orthopedic center from 1993 to 2006. Results of the pedicle anatomy and the sliding distances of the flap are analyzed with different degrees of knees on 30 cadaver specimens. RESULTS Twelve cases healed uneventfully. Two cases had partial necrosis on the distal portion of the flap. The follow-up of all the 14 cases ranged from 4 months to 12 years. There was no ankle stiffness, tendon rerupture, or walking inconvenience observed in their daily lives. During the surgery process, the sliding distance of the flap reached (9.2 +/- 0.9 cm) when the knee was flexed by 90 degrees. CONCLUSIONS For one-stage reconstruction of Achilles tendon and skin defects, the sliding gastrocnemius musculocutaneous flap is advantageous in vascularity, function, and sensation without anastomosis. The harvest of the flap demands familiarity with the anatomy.

An anatomic study of vascularized fibular grafts.

OBJECTIVE To study the applied anatomy of the vascular and muscular innervations related to vascularized fibular grafts. METHODS Thirty-four cadaveric lower extremities were dissected for this study. The observations included fibular length, fibular nutrient artery, arcuate arteries, and innervation of fibular muscles. The fibulas were averagely divided into four segments and the locations of relevant vessels and nerves were ascertained. RESULTS All specimens had 1 fibular nutrient artery and 4-9 arcuate arteries except 1 specimen which had only 1 arcuate artery. The fibular nutrient artery and the first three arcuate arteries were constantly located between the distal half of the 1/4 segment and 2/4 segment of the fibula. The muscular branch of the superficial peroneal nerve passed through the surface of the periosteum in the 2/4 segment of the fibula. CONCLUSIONS The most proximal osteotomy point locates at the midpoint of the 1/4 segment by which it ensure the maximal potential for preserving the nutrient vessels. The muscular branch of the superficial peroneal nerve is fragile to injury at the 2/4 segment of the fibula.

The Role of the Distal Runoff Vessel of the Descending Branch of the Lateral Circumflex Femoral System in Anterolateral Thigh Flap Surgery: A Case Series and Literature Review.

BackgroundAs a distal portion of the descending branch of the lateral circumflex femoral system (LCFS), the role of the distal runoff vessel in anterolateral thigh (ALT) flap surgery has long been overlooked. Recently, however, the distal runoff vessel has been increasingly used in many aspects of ALT flap surgery, and it has exhibited superior properties in solving some difficult problems. MethodsFourteen ALT flaps using the distal runoff vessel of the descending branch of the LCFS for extremity defects were retrospectively reviewed, and recent reports on using the distal runoff vessel were reviewed to determine the role of this vessel in ALT flap surgery. ResultsIn our series, the distal runoff vessel was used as a flow-through pattern in 10 cases, as a recombined chimeric flap in 2 cases, and as a backup vessel for flap salvage in 2 cases. All of the ALT flaps completely survived. None of the donor sites presented with additional morbidity as a result of harvesting the distal runoff vessel. In the literature review, the following are 5 other options for using the distal runoff vessel: in interposition artery and vein grafts, as the pedicle of the reverse-flow ALT flap, as the recipient vessel, to avoid twisting, and as a monitoring method. ConclusionsThe distal runoff vessel of the descending branch of the LCFS could be used for many aspects of the ALT flap surgery, and this vessel plays an irreplaceable role in some difficult reconstruction surgeries.

Traumatic Forefoot Reconstructions With Free Perforator Flaps

The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.

Implant-related infection in the tibia: surgical revision strategy with vancomycin cement.

The development of a deep wound infection in the presence of internal hardware presents a clinical dilemma. The purpose of the present study was to evaluate the treatment outcomes of vancomycin cement with other advances of surgical techniques for implant-related infection (IRI) in the tibia. This study included 217 consecutive patients who had sustained IRI of the tibia. Of them, 152 patients had soft tissue defects and the internal hardware was exposed. Repeated debridement and negative pressure assisted closure were used. All the infected internal hardware was removed. External fixations and flaps were used. Custom-made vancomycin cement was inserted into the dead space of the wounds and left in site for a month. The follow-up was from 12 months to 108 months, averaging 37.5 months. For all the 217 patients, the general osteomyelitis healing rate and bone union rate were 86.6% and 97.2%, respectively. This study shows high rates of healing of IRI in the tibia if the new advances of surgery could be effectively combined into the treatment strategy with vancomycin cement as an important treatment.

Reconstruction of Moderate-Sized Hand Defects Using a Superficial Lateral Sural Artery Perforator Flap

Background The skin on the lower leg has abundant perforators and, thus, is an excellent donor site for transplant tissue flaps. However, due to vascular variations and body positions, tissue flaps at the posterolateral proximal portion of the lower leg are rarely used for transplantation. This study reports our experience with the use of superficial lateral sural artery perforator (SLSAP) flaps in the repair of moderate-sized hand wounds. Methods From March 2012 to April 2015, the hand wounds of 15 patients were planned for repair using a superficial sural artery perforator flap. In total, 6 patients had a defect in the palm of the hand, 5 in the dorsum of the hand, and 3 in the finger; 1 patient sustained a contracture of the first web space. Results In 12 of the 15 cases, an SLSAP flap was successfully harvested. In the remaining 3 cases, the planned harvest of an SLSAP flap was converted to the harvest of a superficial medial sural artery perforator flap during the operation. The flaps ranged in area from 1.8 × 3.8 cm to 5.5 × 6.5 cm. Primary suture of the donor site was performed in all cases. Dissection of the muscular tissue was avoided. After the operation, venous crisis occurred in 1 case, and a partial area of necrosis developed at the distal end in 1 case. The flap survived in all other cases. Conclusions Our experience showed that the SLSAP flap is suitable for reconstruction of moderate-sized hand defects.

Four-corner arthrodesis concentrator of Ni-Ti memory alloy for carpal collapse

Objective:  To evaluate the treatment outcomes of a four‐corner arthrodesis concentrator of Ni‐Ti memory alloy for carpal collapse.

Absorbable scaphoid screw development: a comparative study on biomechanics

Background The scaphoid is critical for maintaining the stability and movement of the wrist joints. This study aimed to develop a new internal fixator absorbable scaphoid screw (ASS) for fixation of the scaphoid waist after fracture and to test the biomechanical characteristics of ASS. Materials and methods An ASS was prepared using polylactic acids and designed based on scaphoid measurements and anatomic features. Twenty fractured scaphoid waist specimens were randomly divided into experimental and control groups (n=10/group). Reduction and internal fixation of the scaphoid were achieved with either Kirschner wires (K-wires) or ASS. A moving target simulator was used to test palmar flexion and dorsal extension, with the range of testing (waist movement) set from 5° of palmar flexion to 25° of dorsal extension. Flexion and extension were repeated 2,000 times for each specimen. Fracture gap displacements were measured with a computerized tomography scanning. Scaphoid tensile and bending strengths were measured by using a hydraulic pressure biomechanical system. Results Prior to biomechanical fatigue testing, fracture gap displacements were 0.16±0.02 mm and 0.22±0.02 mm in the ASS and K-wire groups, respectively. After fatigue testing, fracture gap displacements in the ASS and the K-wire groups were 0.21±0.03 mm and 1.52±0.07 mm, respectively. The tensile strengths for the ASS and K-wire groups were 0.95±0.02 MPa and 0.63±0.02 MPa, respectively. Conclusion Fixation using an ASS provided sufficient mechanical support for the scaphoid after fracture.