ObjectiveTo investigate the effectiveness of free second toe dorsal flap combined with middle or ring finger island flap for repairing degloved thumbs. MethodsBetween August 2009 and June 2013, 6 patients with degloving injury of the thumb were treated using free second toe dorsal flap combined with middle or ring finger island flap. There were 4 males and 2 females, aged 19-44 years (mean, 32 years). The left thumb was involved in 2 cases and the right thumb in 4 cases, including 5 cases of type II and 1 case of type III degloving injury. The size of wound was 5.5 cm×2.5 cm to 6.5 cm×5.0 cm. After emergency debridemented, 5 patients underwent vacuum sealing drainage and surgical repair after 3-5 days; 1 patient underwent abdominal embedding and repair after 14 days. The size of second toe dorsal flap ranged from 2.5 cm×2.2 cm to 4.2 cm×3.0 cm, and the size of middle or ring finger island flap ranged from 2.0 cm×1.5 cm to 3.5 cm×2.8 cm. Neurorrhaphy was performed between the plantar digital nerve of the second toe and the proper digital nerve at the recipient site in 5 cases, and no nerve anastomose in 1 case. All the distal phalanxes were partially excised. The donor sites were covered with free skin grafts. ResultsAll of the flaps survived completely and incision healed by first intention. Three patients had alloesthesia of the middle or ring finger island flaps. All of the 6 patients were followed up from 6 months to 3 years (mean, 23 months). The flaps had good color and soft texture, and the finger had satisfactory appearance, but the fingernails were smaller than that of normal side. The sensation of the dorsum of the second toe reached S3, and the mean two-point discrimination of the pulp was 6 mm (range, 4-7 mm). According to total active movement (TAM) system, the function of the thumbs was excellent in 5 cases and good in 1 case. ConclusionA combination of free second toe dorsal flap and middle or ring finger island flap is a useful and reliable technique for reconstruction of a degloved thumb.
Objective To investigate the effectiveness of wrist tube inside and outside releasing for treating median nerve double entrapment at wrist. Methods Thirty-one patients of median nerve double entrapment at wrist were treated between April 2011 and May 2014. There were 8 males and 23 females with an age of 33-69 years (mean, 56.4 years). In palm lateral three and a half finger, the two-point discrimination was 7-14 mm (mean, 9.5 mm), in which 24 cases were 4-10 mm and 7 cases were more than 10 mm. Carpal tunnel median nerve Tinel sign was positive; there was weak and acid swollen felling when press big thenar muscle on median nerve return branch palm surface projection points. Electromyography examination showed that median nerve endings movement incubation period was 4.5-10 ms in 22 cases, more than 10 ms in 9 cases; fibrillation potentials and positive phase voltage happened in 6 cases; the median nerve sensory conduction velocity of all patients was slow, and the motor conduction velocity also slowed down; the motor amplitude was 5-10 mV in 19 cases, less than 5 mV in 12 cases. The disease duration was 3-8 months (mean, 5.5 months). Surgical exploration of wrist median nerve in carpal tunnel and median nerve return branch outside carpal tunnel were performed in patients, especially completely released the variety entrapment factors such as thickening bow at starting point of short hallux flexor tendon, fiber bundles at ulnar side of short hallux flexor tendon, deep layer fiber of the palmar aponeurosis, and variant shallow head of short hallux flexor. Results All the wounds healed by first intention without wound scar pain. The patients were followed up 24-59 months (mean, 33 months). Night numbness and pain disappeared, and weak and acid swollen feeling in big thenar muscle on median nerve return branch points also disappeared. The sensation recovered to S4 in 28 patients in palm lateral three and a half finger, the index and middle fingertip sensation recovered to \begin{document}$ \small{{\rm{S}}_{{{ 3}^ + }}} $\end{document} in 3 cases. In the median nerve innervation area, the two points discrimination was 4-6 mm (mean, 4.8 mm). The thumb opposition function returned to normal in 29 cases and mild confinement in 2 cases. The grip strength of all the 31 cases recovered, and 1 of them increased significantly. In preoperative big thenar muscle atrophy cases, muscle strength recovered to S5 in 4 cases, S4 in 2 cases. At 2 years after operation, according to the functional assessment of carpal tunnel syndrome recommend by GU Yudong, the results were excellent in 29 cases and good in 2 cases, with an excellent and good rate of 100%. Conclusion When treating the nerve double entrapment in wrist using wrist tube inside and outside releasing method, the variety entrapment factors of return branch of median nerve should be completely released, so the effectiveness can be improved.
ObjectiveTo explore the effectiveness of bone transportation by ring type extenal fixator combined with locked intramedullary nail for tibial non-infectious defect. MethodsBetween June 2008 and October 2012, 22 cases of tibial large segment defect were treated. There were 15 males and 7 females, aged 24-58 years (mean, 36.8 years), including 17 cases of postoperative nonunion or malunion healing, and 5 cases of large defect. After debridement, bone defect size was 5.0-12.5 cm (mean, 8.05 cm). Bone transportation was performed by ring type external fixator combined with locked intramedullary nail, the mean indwelling duration of external fixation was 10.2 months (range, 2-26 months); the external fixation index was 1.57 months/cm (range, 0.3-3.2 months/cm); and the mean length increase was 8.05 cm (range, 5.0-12.5 cm). ResultsAll patients were followed up 19-58 months (mean, 32 months). No infection occurred after operation and all patients obtained bony union, and the union time was 4.7-19.4 months (mean, 11.9 months). Complications included refracture (1 case), skin crease (1 case), lengthening failure (1 case), foot drop (2 cases), retractions of the transport segment (1 case), delay of mineralization (1 case), which were cured after corresponding treatment. According to Hohl knee evaluation system to assess knee joint function after removal of external fixator and intramedullary nail, the results were excellent in 15 cases, good in 5 cases, and fair in 2 cases, with an excellent and good rate of 90.9%; according to Baird-Jackson ankle evaluation system to evaluate ankle joint function, the results were excellent in 10 cases, good in 3 cases, fair in 7 cases, and poor in 2 cases, with an excellent and good rate of 59.1%. ConclusionBone transportation by ring type external fixator combined with locked intramedullary nail could increase stability of extremities, allow early removal of external fixator and avoid axis shift of extremities, so it has good effect in treating tibial noninfectious defect.
ObjectiveTo provide the anatomical basis for the selection of osteotomy site in leg lengthening or tibial slip. MethodsBetween August 2010 and July 2014, 10 adult fresh amputated leg specimens were collected. The pressure perfusion of red latex was performed by the popliteal artery. The anterior tibial artery and its main branches were separated and exposed, and the periosteal branch of anterior tibial artery was adequately exposed;the posterior tibial artery and its main branches were exposed;the peroneal artery was separated and exposed. The tibial and peroneal artery and its branches were observed and measured. When measuring the proximal end, the medial tibial plateau bone margin, the most prominent part of the tibial tuberosity, and the fibular head edge were used as a reference;when measuring the distal end, distal medial condyle of tibia malleolus tip, tibial lateral malleolus lateral tip, and distal tibial articular surface were used as a reference;the vertical distance between tibia proximal and distal main arteries and bone end reference was measured to determine the optimal osteotomy position of upper and lower tibia. The osteotomy index was calculated which was used to represent the relative position of osteotomy site in the whole tibia. ResultsThe proximal tibial osteotomy site located at (78.2±19.5) mm from medial tibial plateau margin, (41.8±16.0) mm from the tibial tuberosity pole, and (66.7±16.4) mm from the fibular head edge. The distal tibial osteotomy site located at (70.8±12.1) mm above the inferior margin of tibial medial malleolus, (83.3±13.0) mm above the inferior margin of lateral malleolus tip, and (59.1±11.7) mm from distal tibial articular surface. The proximal tibial osteotomy index was 18.45-23.35 (mean, 20.46);the distal tibial osteotomy index was 14.36-23.05 (mean, 18.81). ConclusionThe metaphyseal-diaphyseal connection shold be selected in the proximal and distal tibia osteotomy, the lower one third of the tibia is not suitable for ostetomy.
ObjectiveTo investigate the effectiveness of Ilizarov technique in reconstruction of thumb function in patients with thumb degloving injury after amputation.MethodsBetween June 2011 and September 2016, 9 cases of thumb degloving injury were treated with amputation and Ilizarov technology. There were 8 males and 1 female with an age of 18-52 years (mean, 34.7 years). The amputation plane was the level of the metacarpophalangeal joint in 5 cases, the level of the proximal metacarpophalangeal joint in 2 cases, and the level of the base of the proximal phalanx in 2 cases (the length of proximal phalanx was less than 1 cm). After amputation, the affected finger was shorter than the healthy finger by 4.0-7.5 cm, with an average of 5.7 cm. On the fifth day after operation, the semi-loop external fixation extender was applied for extension, which was extended by 0.5 mm per day, and was extended once every 6 hours.ResultsAfter bone lengthening surgery, the first web space elevation and contracture occurred in 8 cases. Six of them were treated with the amputation of the inner muscle of the thumb and the "Z" forming technique, postoperative thumb function recovered well; the remaining 2 cases rejected plasty. All 9 patients were followed up 14-47 months, with an average of 33 months. Bone lengthening time was 64-122 days, with an average of 86 days. The lengthening length of bone was 3.0-5.9 cm, with an average of 4.1 cm, and the average lengthening length was 71.9% of the average shortened length. The fixation time of external fixator was 169-342 days, with an average of 231 days. The healing index was 43.2-59.1 days/cm, with an average of 53.4 days/cm. One case showed prolonged mineralization delay and recovered after "accordion" treatment. Bone healing was finally achieved in all patients, with the healing time ranging from 169 to 342 days, with an average of 231 days. No replantation internal fixation and flexion contracture occurred. The two-point discrimination of extended fingertip was similar to that of normal fingertip. The grip strength reached 53%-89% of the healthy side; the kneading force reached 59%-91% of the healthy side.ConclusionThe application of Ilizarov technology to extend the thumb metacarpal lengthening is a good method to reconstruction the thumb function after degloving injury.
ObjectiveTo investigate the effectiveness of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique in treatment of thumb defect. MethodsBetween February 2017 and June 2019, 6 patients with traumatic thumb defects were treated with double osteotomy and lengthening of proximal phalanx and metacarpal by Ilizarov technique. There were 5 males and 1 female. The age ranged from 28 to 57 years, with an average of 41.5 years. There were 3 cases on the left side and 3 cases on the right side. All patients were admitted to the hospital in emergency department after injury, and the stump of the thumb was trimmed and sutured. The osteotomy plane was the distal part of the proximal phalanx in 4 cases and the interphalangeal joint in 2 cases. The interval between injury and osteotomy was 20-245 days (median, 34.5 days). After minimally invasive osteotomy and placement of a semi-circular external fixator, the lengthening began on the 5th day. The proximal phalanx and metacarpal were lengthened by 0.5 mm every day, once every 12 hours. The thumb of the affected side was distracted to the middle of the distal phalanx of the healthy thumb, and the fixator was removed after the bone healed. ResultsThe distraction time was 14-23 days, with an average of 18.8 days. The osteotomies were healed with healing time of 91-147 days (mean, 120.2 days). The total distraction length of the proximal phalanx and metacarpal was 1.40-2.25 cm, with an average of 1.86 cm; healing index was 51.0-72.2 days/cm, with an average of 64.9 days/cm. All patients were followed up 5-12 months (mean, 8.2 months). At last follow-up, the two-point discrimination was 5.3-8.5 mm with an average of 6.98 mm. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the score was 10-14, with an average of 12.5. Among them, 4 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. All patients were satisfied with the function and appearance of thumb after operation. The Quick Disabilities of Arm, Shoulder, and Hand (Quick-DASH) score was 2.3-9.1, with an average of 6.1. ConclusionThe double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique is an effective method for the treatment of thumb defects.