Bone lengthening technique is one of the core surgical technique for skeletal lengthening and reconstruction. It is widely used in the treatment of nonunion, segmental bone defect, bone infection, congenital or post-traumatic limb length differences, and hand-foot deformity correction. Until today, the surgical techniques and devices of bone lengthening are improving over time, and it is to improve the quality of treatment and reduce complications. However, the bone lengthening technique is different from the treatment for other orthopedic diseases, and it has the following feature, including requiring multiple steps, longer treatment course, and application of external fixator. This article will summarize the hot research in the field of bone lengthening treatment in recent years and provide reference for future clinical treatment.
ObjectiveTo study the effectiveness of anterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle in the treatment of severe cubital tunnel syndrome. MethodsBetween March 2006 and May 2015, 22 cases (23 hands) of severe cubital tunnel syndrome were treated by use of anterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle. There were 15 males and 7 females, aged 45-60 years (mean, 55 years). The causes were valgus deformity of elbow joint in 12 cases, ulnar nerve subluxation in 4 cases, and osteoarthritis in 6 cases. The disease duration was 10 months to 3 years (mean, 17 months). According to Akahori classification, 14 cases were rated as type 4 and 9 cases as type 5. The ring/little finger's numbness, hand intrinsic muscle atrophy, recovery of thumb adduction function, and improvement of claw hand deformity were observed after operation. Thumb and index finger's pinch strength was measured by use of pinch device; postoperative hand function was evaluated by the standards of Chinese Medical Society of Hand Surgery of upper limb assessment protocol. ResultsAll incisions healed well and all cases were successfully followed up 8 to 24 months (mean, 14 months). Numbness of ring/little finger was significantly reduced at 1 day after operation in 10 hands; numbness disappeared completely at 1 month after operation in 12 hands; mild numbness remained at 14 months after operation in 11 hands. At last follow-up, hand intrinsic muscle atrophy partially improved (+++) in 1 hand, no improvement in 22 hands; improvement of claw hand deformity was achieved in 17 hands, no improvement in 6 hands; pinch strength of thumb and index finger was significantly improved to (5.07±1.11) kg from preoperative (2.91±0.63) kg (t=-12.340, P=0.032). At last follow-up, the results were excellent in 11 hands, good in 8 hands, fair in 3 hands, and poor in 1 hand, and the excellent and good rate was 82.6%. ConclusionAnterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle is a simple, effective, and reliable surgical treatment for severe cubital tunnel syndrome.
ObjectiveTo determine the feasibility of fabricating molds using a three-dimensional (3D) printer for producing customized bone cement for repairing bone defect. MethodsBetween February 2015 and March 2016, 13 patients with bone defects were treated. There were 9 males and 4 females with an average age of 38.4 years (range, 20-58 years), including 7 cases of chronic osteomyelitis, 3 cases of bone tuberculosis, 2 cases of bone tumor, and 1 case of ischemic necrosis. The defect located at the humerus in 3 cases, at the femur in 4 cases, and at the tibia in 6 cases. The defect ranged from 4.5 to 8.9 cm in length (mean, 6.7 cm). Before operation, Mimics10.01 software was used to design cement prosthesis, 3-matic software to design shaping module which was printed by 3D technology. After removal of the lesion bone during operation, bone cement was filled into the shaping module to prepare bone cement prosthesis for repairing defect. ResultsThe measurement result from Image J software showed that the match index of interface between the mirror restored digital and bone interface was 95.1%-97.4% (mean, 96.3%); the match index of interface between bone cement prosthesis and bone interface was 91.2%-94.7% (mean, 93.2%). It was one time success during separation between formed bone cement and shaping module without any shatter or fall off. All incisions healed by first intention. The cases were followed up 5-17 months (mean, 9.4 months). X-ray films and CT scans showed good position of bone cement prosthesis without any fracture; no peripheral fracture occurred. Conclusion3D printing customized bone cement shaping module can shorten the operation time, and customized bone cement prothesis has good match with bone interface, so it can avoid further adjustment and accord with the biomechanical rules of surgical site.
ObjectiveTo investigate the clinical application of the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap in repair of foot and ankle defects.MethodsBetween October 2014 and October 2018, 18 cases with foot and ankle defects were treated. There were 12 males and 6 females with an average age of 32.8 years (range, 8-56 years). There were 11 cases of traffic accident injuries, 3 cases of falling from height injuries, and 4 cases of heavy objects injuries. The wound was at the dorsum of the foot in 9 cases, the heel in 4 cases, the lateral malleolus in 5 cases. The time from injury to flap repair was 7-34 days (mean, 19 days). The size of wound ranged from 6.0 cm×2.5 cm to 11.0 cm×6.0 cm. The foot and ankle defects were repaired with the peroneal artery terminal perforator propeller flap in size of 6 cm×3 cm-18 cm×7 cm, which donor site was repaired with the anterior tibial artery perforator propeller flap in size of 8 cm×3 cm-16 cm×6 cm.ResultsOne patient had a hemorrhagic swelling in the peroneal artery terminal perforator propeller flap, and survived after symptomatic treatment. All recipient and donor sites healed by first intention. Eighteen patients were followed up 6-15 months (mean, 12.5 months). At last follow-up, the shape, color, texture, and thickness of the flaps in the donor sites were similar with those in the recipient sites. There were only linear scars on the donor sites. The two-point discrimination of the peroneal artery terminal perforator propeller flap ranged from 10 to 12 mm (mean, 11 mm). According to American Orthopaedic Foot and Ankle Society (AOFAS) score criteria, the results were excellent in 15 cases and good in 3 cases, with an excellent and good rate of 100%.ConclusionThe foot and ankle defects can be repaired with the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap. The procedure is not sacrificing the main vessel and can avoid the skin grafting and obtain the good ankle function.
ObjectiveTo investigate the clinical application and effectiveness of V-Y plasty combined with gastrocnemius aponeurosis turndown in the repair of Myerson type Ⅲ chronic Achilles tendon rupture combined with large tendon defect. MethodsBetween February 2008 and July 2019, 25 patients underwent the V-Y plasty combined with gastrocnemius aponeurosis turndown to treat the Myerson type Ⅲ chronic Achilles tendon rupture. There were 21 males and 4 females. The age ranged from 17 to 56 years, with an average of 34.3 years. Achilles tendon rupture was caused by sports injury in all patients, and the duration from Achilles tendon rupture to operation was 31-70 days, with an average of 53.9 days. After resection of fibrous scar tissue, the distance of Achilles tendon defect was 7-12 cm, with an average of 9.04 cm. The clinical results were evaluated by the Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) score, dorsiflexion and heel raise height before and after operation. Results The donor and recipient wounds of all 25 cases healed by first intention after operation. All patients were followed up 24 months. During the follow-up, 3 patients developed mild wound infection, which was cured after anti-infection treatment. One patient had Achilles tendon exposure, which was cured after local flap transfer and repair. Ultrasound and MRI reexamination at 3-12 months after operation showed no Achilles tendon elongation, adhesion, or re-rupture. At 24 months after operation, the ATRS score, AOFAS score, dorsiflexion and heel raise height of affected side significantly improved when compared with those before operation (P<0.05). However, the dorsiflexion and heel raise height of affected side were still significantly worse than those of the healthy side (P<0.05). ConclusionV-Y plasty combined with gastrocnemius aponeurosis turndown to repair the chronic Achilles tendon rupture can achieve good effectiveness, and the Achilles tendon function significantly improved after repair. However, the procedure is more invasive and has a long duration of intraoperative wound exposure, causing an increased risk of infection, and the aesthetic is not good.
Objective To investigate the effectiveness of anatomical locking plate in the treatment of Rockwood type Ⅰ-Ⅲ patella fractures. Methods The clinical data of 16 patients with patella fractures who were admitted between November 2021 and January 2023 and met the selection criteria was retrospectively analyzed. There were 14 males and 2 females, with an average age of 44.5 years (range, 19-72 years). Causes of injuries included tumble in 12 cases and traffic accident in 4 cases. The fractures were rated as type Ⅰ in 2 cases, type Ⅱ in 9 cases, and type Ⅲ in 5 cases according to Rockwood classification criteria. The time from injury to operation ranged from 6 to 15 days, with an average of 9 days. After fracture reduction, an appropriate anatomical locking plate was selected for internal fixation. The operation time, intraoperative blood loss, and incision healing were recorded; the Lysholm score, Böstman patella fracture efficacy score, knee joint mobility, and visual analogue scale (VAS) score were used to evaluate the knee joint function and pain degree; X-ray films were used to review the fracture reduction and healing. Results The operation time was 65-100 minutes (mean, 75.3 minutes); the intraoperative blood loss was 10-35 mL (mean, 25.6 mL). All incisions healed by first intention after operation. All patients were followed up 11-26 months (mean, 19.7 months). X-ray films showed that the fractures were reduced satisfactorily, and all achieved bony healing with healing time of 3-5 months. At last follow-up, the Lysholm score was 90-95 (mean, 93.0); the Böstman patella fracture efficacy score was 27-30 (mean, 28.8), of which 12 cases were excellent and 4 were good; the VAS score was 0-1 (mean, 0.3). There was no significant difference in the range of motion of the knee joint between the healthy and affected sides [145° (140°, 150°) vs 145° (140°, 145°); Z=1.890, P=0.059]. Conclusion Choosing anatomical locking plates for Rockwood typeⅠ-Ⅲ patella fractures can achieve strong fixation with minimal surgical trauma, rapid recovery of knee joint function, and mild pain after operation.
ObjectiveTo evaluate the methods and effectiveness of contralateral C7 nerve root and multiple nerves transfer for the treatment of brachial plexus root avulsion. MethodsBetween June 2006 and June 2010, 23 patients with brachial plexus root avulsion were treated. There were 20 males and 3 females, aged 17 to 42 years (mean, 27.4 years). The time from injury to operation was 4 to 12 months (mean, 5.9 months). In 16 patients having no associated injury, the first stage procedure of contralateral C7 nerve root transfer and accessory nerve transfer to suprascapular nerve or phrenic nerve transfer to anterior upper trunk was performed, and the second stage procedure of the contralateral C7 nerve root transfer to median nerve and intercostal nerve transfer to axillary nerve was performed. In 4 patients having phrenic nerve and accessory nerve injuries, the first stage procedure of the contralateral C7 nerve root transfer and second stage procedure of the contralateral C7 nerve root transfer to median nerve and musculocutaneous nerve were performed. In 3 patients having hemothorax, pneumothorax, and rib fractures, the first stage procedure of the contralateral C7 nerve root transfer and accessory nerve transfer to suprascapular nerve, and the second stage procedure of the contralateral C7 nerve root transfer to median nerve and musculocutaneous nerve were performed. The British Medical Research Council (MRC) sensory grading (S0-S4) and modified muscle strength grading standard (M0-M5) were used for comprehensive assessment of limb and shoulder abduction, elbow/biceps muscle strength, flexor wrist and finger muscle strength and median nerve sensory recovery. ResultsTwenty-three patients were followed up 3-4.5 years (mean, 3.4 years). At 3 years after operation, the shoulder abduction reached 0-82°(mean, 44°). In 16 patients having no associated injuries, the shoulder abduction was more than 30°in 13 cases, and was more than 60°in 3 cases; in 3 patients having hemothorax, pneumothorax, and rib fractures, the shoulder abduction was more than 30°; and in 4 patients having phrenic nerve and accessory nerve injuries, the shoulder abduction was 0°. The muscle strength of elbow/biceps was M3 or more than M3 in 9 cases, was M1-M2 in 8 cases, and was M0 in 6 cases; the muscle strength of flexor wrist or finger was M3 or more than M3 in 7 cases, was M1-M2 in 11 cases, and was M0 in 5 cases. Median nerve sensory recovery was S3 or more than S3 in 11 cases, was S1-S2 in 7 cases, and was S0 in 5 cases. After 3 years, affected limb had locomotor activity in 11 patients, affected limb had activities driven by the contralateral latissimus dorsi muscle contraction in 12 patients. ConclusionContralateral C7 nerve root and multiple nerves transfer is a good method to treat brachial plexus root avulsion.
ObjectiveTo study the digital anatomy and application value of the thoracic dorsal artery based on CT angiography (CTA). MethodsBetween September 2012 and June 2014, aorta CTA images were chosen from 10 cases (20 sides) undergoing aorta CTA. By using Mimics 17.0 software for three dimensional (3D) reconstruction of image post-processing, the digital vascular anatomical information were obtained after observing and measuring the origin of the thoracic dorsal artery, the number of perforators, type, inner diameter, and pedicle length; and the body surface location of perforator vessel was determined, and then the thoracic dorsal artery perforators tissue flap harvesting was simulated. Results3D reconstruction images showed that the thoracic dorsal artery originated from subscapular artery, 76 perforator vessels were found, including 32 perforators (42.1%) from the medial branch of the thoracic dorsal artery and 44 perforators (57.9%) from the lateral branch of the thoracic dorsal artery, of which 69 were intramuscular perforators (90.8%) and 7 were direct skin artery (9.2%). The inner diameter of the thoracic dorsal artery was (1.69±0.23) mm, and its pedicle length was (2.12±0.64) cm. The first lateral perforator of the thoracic dorsal artery located at (1.65±0.42) cm above the horizontal line of the inferior angle of scapula and at (1.68±0.31) cm lateral to vertical line of the inferior angle of scapula. The first medial perforator located at (1.43 ±0.28) cm above the horizontal line of the inferior angle of scapula and at (1.41±0.28) cm lateral to vertical line of the inferior angle of scapula. The thoracic dorsal artery perforators flap harvesting was successfully simulated. ConclusionCTA is a more intuitive method to study the thoracic dorsal artery in vivo, it can clearly display 3D information of the main blood supply artery course and distribution after flap reconstruction, so it can effectively and accurately guide the design of the flap.
ObjectiveTo evaluate the effectiveness of free anterolateral thigh flap in repairing hand twist trauma combined with forearm main vascular injury.MethodsBetween February 2016 and March 2020, 14 patients with hand twist trauma combined with forearm main vascular injury were admitted. There were 10 males and 4 females. The mean age was 36.3 years (range, 22-53 years). There were 5 cases with left hand and 9 cases with right hand. The degloving injury of hand was rated as type ⅢA in 2 cases, type ⅢB in 9 cases, and type Ⅳ in 3 cases. The size of soft tissue defects range from 8.0 cm×4.5 cm to 13.5 cm×8.0 cm. Of all patients, 11 cases were ulnar artery injury and 3 cases were radial artery injury. Time from injury to operation was 2-16 hours (mean, 7.1 hours). The free anterolateral thigh flaps with the size of 10.0 cm×5.5 cm to 15.0 cm×9.5 cm were used to repair the soft tissue defects with the “T” shape anastomosis of blood vessel in 8 cases or direct anastomosis of blood vessel in 6 cases. The donor sites were directly sutured in 9 cases and repaired with free skin graft in 5 cases.ResultsAll patients were followed up 6-12 months (mean, 10.5 months). The vascular crisis occurred in 1 case and the flap survived with symptomatic treatment after operation. Other flaps survived and the wounds healed by first intention. All donor sites healed by first intention and the skin grafts survived. Three cases underwent the fat-free trimming at 4-5 months after operation. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the hand function was evaluated as excellent in 4 cases, good in 7 cases, and fair in 3 cases, with an excellent and good rate of 78.6% at last follow-up.ConclusionBecause the diameter of the descending branch of the lateral femoral circumflex artery is similar to that of the ulnar artery and radial artery, the use of free anterolateral thigh flap can not only repair the wound and obtain a good hand shape, but also repair blood vessels and promote recovery of hand function.
ObjectiveTo study the effectiveness of Keystone flap in the repair of soft tissue defect of lower extremity.MethodsThe clinical data of 27 cases with soft tissue defects of lower extremity treated by Keystone flap between January 2018 and June 2020 were retrospectively analyzed. There were 18 males and 9 females, with an average age of 43.9 years (range, 8-63 years). The cause of soft tissue defects included skin tumor in 3 cases, ulcer in 2 cases, soft-tissue infection in 8 cases, trauma in 7 cases, and donor site defect after free or pedicled flap transplantation in 7 cases. Defect size ranged from 2.0 cm×1.5 cm to 15.0 cm×9.5 cm. The types of Keystone flaps included type Ⅰ in 2 cases, type Ⅱa in 16 cases, type Ⅱb in 1 case, type Ⅲ in 6 cases, and Moncrieff modified type in 2 cases. The area of flap ranged from 3.0 cm×1.5 cm to 20.0 cm×10.0 cm. The donor site was directly sutured (26 cases) or repaired with skin grafting (1 case).ResultsThe operation time was 45-100 minutes, with an average of 67.5 minutes; the hospitalization stay was 3-12 days, with an average of 8.5 days. Postoperative incision dehiscence occurred in 1 case, and flap marginal necrosis occurred in 2 cases, all of which were completely healed after dressing change; 1 case of incision was swollen and congested with tension blisters, which resolved spontaneously at 7 days after operation. The other flaps and the skin grafting survived and healed successfully, the wounds of recipient and donor sites healed by first intention. The healing time was 2-3 weeks (mean, 2.2 weeks). No pain occurred in all patients. All 27 cases were followed up 3-26 months (mean, 11.5 months). No obvious scar contracture and bloated skin flap were found. The texture and color of the skin in the recipient area were similar to those of the surrounding tissues and feel existed.ConclusionThe Keystone flap is a feasible and efficient way to repair soft tissue defect of lower extremity. Furthermore, the skin color and texture is similar to the surrounding tissue after healing.