[The application of external fixator for complex tissue defect in the forearm]

OBJECTIVE

To discuss the curative effect of the external fixator for complex tissue defect in the forearm.

METHODS

From May, 2005 through December, 2008, the external fixators were used in 17 patients to treat the complex tissue defect in the forearm caused by trauma. There were 11 male and 6 female, with a mean age of 25.6. All patients were accompanied with the exposure of tendon, muscle or screw. The skin defect ranged from 7 cm x4 cm to 19 cm x9 cm. All patients underwent pedicle flap repair. The flap ranged from 10 cm x 6 cm to 20 cm x 15 cm. The proximal pedicle of the flap was sutured into a tubular. The position of the pedicle was fixed by the external fixator. The pin was at the ulnar and the iliac (n=5), and the radius and the iliac (n=12). The immobilization lasted 3 to 8 weeks, 5.1 weeks in average.

RESULTS

All patients were followed up for 3 to 20 months, 11.3 in average. All pedicle flaps survived with no pressure ulcer, or no erosion in the axilla. No compartment syndrome or osteomyelitis occurred. Four to six week after surgery, the pedicle was cut. Infection occurred at the cutting end in 1 patient. The wound healed after addressing. The wound in the other 16 patients healed successfully. The fracture of the ulnar and the radius healed 8.5 or 15 weeks after surgery, 13.5 weeks in average. Eleven patients underwent second stage reshape and function restoration. The function of the hands and forearms recovered satisfactorily. Eleven patients returned to their work. Six patients can live with basic function for living.

CONCLUSIONS

The external fixator used for complex tissue defect in the forearm can keep the position of the pedicle, replacing plaster fixation. It can reduce the incidence of flap and vessel spasm, and get good outcomes.

The effect of nitroglycerin as an adjuvant to lidocaine in intravenous regional anesthesia

PURPOSE

The disadvantages of intravenous regional anesthesia (IVRA) include slow onset, poor muscle relaxation, tourniquet pain, and rapid onset of pain after tourniquet deflation. In this randomized, double-blind study, we evaluated the effect of nitroglycerin (NTG) in quality improvement when added to lidocaine in IVRA.

METHODS

Forty-six patients (20-50 yrs), were randomly allocated in two equal groups. Under identical condition, the control group received a total dose of 3 mg/kg of lidocaine 1% diluted with saline, and the study group received an additional 200 microg NTG. Vital signs and tourniquet pain, based on visual analog scale (VAS) score were measured and recorded before and 5, 10, 15, 20, and 30 min after anesthetic solution administration. The onset times of sensory and motor block were measured and recorded in all patients. After the tourniquet deflation, at 30 min and 2, 4, 6, 12 and 24 h, VAS score, time to first analgesic requirement, total analgesic consumption in the first 24 h after operation, and side effects were noted.

RESULTS

The sensory and motor block onset time were shortened in study group (2.61 vs. 5.09 and 4.22 vs. 7.04 min, respectively) (p < 0.05). The recovery time of sensory and motor block and onset of tourniquet pain were also prolonged (7.26 vs. 3.43, 9.70 vs. 3.74 and 25 vs. 16.65 min., respectively) (p < 0.05). Analgesia time after tourniquet deflation was prolonged and tourniquet pain intensity was lowered in study group (p < 0.05). Intraoperative fentanyl and meperedine requirement during first postoperative day and pain intensity at 4, 6, 12 and 24 hr postoperatively were lower in the study group (p < 0.05). There were no significant side effects.

CONCLUSION

The NTG adding to lidocaine in intravenous regional anesthesia shortens onset times of sensory and motor block and decreases the tourniquet and postoperative pain, without any side effect.

Should tourniquets be used in upper limb surgery? A systematic review and meta-analysis

This study compares the intra- and post-operative outcomes of upper limb orthopaedic surgical procedures performed with and without tourniquet assistance. A systematic review was undertaken assessing the electronic databases Medline, CINAHL, AMED and EMBASE. The evidence-base was critically appraised using the Cochrane Bone, Joint and Muscle Trauma Group quality assessment tool. Study heterogeneity was statistically tested using Chi2 and I2 statistics. Where appropriate a random-effects meta-analysis was undertaken to pool results of primary studies assessing mean difference of each outcome. Two studies investigating fifty-five patients undergoing upper limb surgery were identified. The limited findings suggest that the use of tourniquets may reduce the incidence of technical difficulties during upper limb surgery. It remains unclear whether the application of a tourniquet can influence pain perception or operative duration. The evidence-base was considerably limited in both size and methodological quality. Further study is recommended to address the literature's methodological weaknesses.

Bilateral comminuted radial shaft fractures from a single gunshot: fixation with alternative techniques

Acute bilateral radial shaft fractures are an unusual entity that has not been previously reported in the literature. Given its bilaterality, this rare clinical entity is best treated with stable internal fixation. Here we report the case of an 18-year- old right-hand-dominant man who sustained a low-caliber gunshot injury. He had been driving with both hands on the steering wheel when he was struck by a single bullet. The bullet caused displaced fractures of the left proximal radial shaft and the right distal radial shaft. Each fracture had extension outside the mid-diaphysis. The patient underwent operative fixation with plating of the right upper extremity and intramedullary nailing on the left side. Both fractures healed, and range of motion was functional.

Paediatric diaphyseal forearm refractures after greenstick fractures: operative management with ESIN

BACKGROUND

One of the complications of forearm shaft fracture is refracture. Elastic stable intramedullary nailing represents an alternative method for refracture treatment to cast immobilisation for another five to seven weeks. Operative treatment often necessitates an open reduction in most cases due to blocked or narrowed medullary canals. The purpose of this study was to examine the expense of the operative procedure, technique (closed or open intramedullary nailing) and postoperative complications in diaphyseal forearm refractures.

METHODS

We retrospectively examined the expense of operative procedure in 21 children with diaphyseal forearm refractures treated with ESIN.

RESULTS

In 18 cases, closed reduction with nailing was possible; three required an open reduction. In nine patients a closed medullary cavity was present; only two of them needed an open reduction. None of the patients had complications (wound healing, osteomyelitis, rupture of the extensor pollicus longus). Swelling appeared in four patients, paraesthesia of the thumb in one. Free functional movement was achieved in all children. Long term results: No re-refracture occurred. One patient suffered from meteorosensitivity. Twelve are able to do the same sporting activities as before injury.

CONCLUSION

ESIN seems to be one choice for treatment in refracture of the forearm, as in most cases the operative reduction can be performed in a closed way by means of "tricks and hints".

One-bone forearm reconstruction procedure as salvage operation after severe upper extremity trauma: a case report

An industrial worker in his early 20s sustained a severe injury to the right dominant upper extremity: fracture, inversion, and complete devascularization of the ulna; transection of the median nerve, the radial artery, and almost all flexor tendons of the hand and fingers; loss of all extensor muscles; and transection of the biceps and brachialis muscles at the elbow. Treatment consisted of conversion to one-bone forearm, immediate reconstruction of the biceps and brachialis muscles and of all flexor tendons of the hand, repair of the radial artery and median nerve and late tendon transfer for extension of the wrist and fingers. Two and a half years after injury, the patient had full flexion and extension of the elbow, full extension but limited flexion of the wrist, and full flexion and extension of the fingers.

[Using compressive internal osteosynthesis in condition of free vascularizational reconstruction of defects of the forearm bones]

It was developed and analyzed a method of fixation by blocked compression base of free vascularizational transplant in condition of reconstructing of forearm bones. This method was approved in clinical practice in treatment of 13 patients. In comparison with traditional method of fixation by apparatus of Ilizarov, the proposed method reduces the time of operation using reduction of anoxi period of transplant on 32.9% (p < 0.0001) and permits to improve the live characteristics on 12.5% (p = 0.0065) and functional results on 21.2% (p = 0.0048) during first 6 months after operation.

Sensory recovery after forearm median and ulnar nerve grafting

BACKGROUND

Median and ulnar nerve injuries are common, whether isolated or combined injury of both nerve. A nerve graft, if performed in a tensionless manner, has been shown to generally have better results than an end-to-end approximation performed under tension.

OBJECTIVE

The aim of this study is to analyze the long-term results of sensory recovery after secondary reconstruction median and ulnar nerve by autograft in patients who were treated on Clinic for Plastic and Reconstructive Surgery in the period from January 1st 1993 to December 31st 2005. We analyzed the influence of the patients age, level of injury, the size of the graft and the period between the injury and operation on the late results.

PATIENTS AND METHODS

Evaluation was performed in 55 patients with adequate follow-up. The mean follow-up period was 3.9 years. Reconstructions were applied on the median nerve in 31 patients and ulnar nerve in 24 patients. Criteria for inclusion in the study was median and ulnar nerve grafting in the forearm region. Patients were divided by age in two groups, below 25 and over 25 years, by injury level in the distal and proximal forearm injuries, by the length of autograft up to 5 cm and other group with graft length over 5 cm, by the period between injury and operation in group with denervation time up to 6 months and the group with denervation time over 6 months. Rating of sensibility was presented on the Highet Scale as modified by Dellon and more precise rating of sensibility was presented by Moberg's rating scale of sensibility. Calculation of frequencies and percentual values was performed for all included variables. For establishment of differences between the frequencies the /2-test was used (Chi square test) at the level of statistical importance (p < 0.05) with contingency tables.

RESULTS

We analyzed the results of reconstruction of median and ulnar nerves with respect to factors affecting functionally the result of operation, which are age, injury level, graft length and denervation time. We had 31 patients with median nerve grafting and we achieved sensory recovery S4 in 3 (10%) patients, S3+ in 9 (29%) patients, S3 in 8 (25.5%) patients, 52 in 9 (29%) patients and S2 in 2 (6.5%) patients. We had 24 patients with ulnar nerve grafting and we achieved S4 sensory recovery in 2 (8.5%) patients, S3+ in 6 (25%) patients, 53 in 5 (21%) patients, S2 in 10 (41%) patients and S2 in 1 (4%) patient. There was not significant difference in sensory recovery of median and ulnar nerve (chi-square = 1.00; df = 4; p = 0.909). There was not statistically significant difference by age and level of injury. The results were significantly better in patients with short grafts than in long ones (chi-square = 12.6; df = 4; p = 0.014) and in patients who had undergone surgical repair within 6 months (chi-square = 10; 2 df = 4; p = 0.038).

CONCLUSION

There was not significant difference in sensory recovery of median and ulnar nerves. The graft length and denervation time significantly influenced the functional outcome in sensory recovery. Mechanism of injury impacted on the results. Two point discrimination testing using a paperclip is a cheap, easily and quickly performed reproducible test of tactile gnosis, and should be included in nerve assessment protocols. We recommended using Moberg's rating scale for further research.

[Surgical therapeutic strategy in vital risk polytrauma with multiple organ injuries, case report]

The medical interest for trauma pathology is incresing, due to the gravity of the given injuries. The surgical therapeutic strategy used is directly related to the localization and to the type of the trauma. The supplementary lesions and their vital risk also matter. The multidisciplinary team approach is the key to resolve this type of lesions with a good outcome. We recently observed an increasing tendency toward the rise of number and variety of patients with trauma, due to the great diversity of the etiopathogenic agents. The most important factor, during the assessment of a politraumatised patient is to diagnose correctly the functional deficits of vital organs and establish the vital prognosis. It is necessary to adopt the best and fast therapeutic strategy in order to obtain rapid life-saving decisions.

Distal forearm fractures: the analytical approach for treatment

Although distal radius fractures are in the centre of orthopedic surgeons' attention, the rate of unsatisfactory treatment results remains very high. This study evaluates the analytical approach to distal radius fracture treatment. We observed 59 patients divided into 4 groups according to a modified Fernandez classification, regarding the patomechanism of injury: 1. bending extraarticular fractures; 2. shearing fractures; 3. comminuted fractures, and 4. malunions. We also took account of patients' compliance and demands. 1st and 2nd group patients underwent ORIF, the 3rd group was subjected to external fixation, and the 4th group underwent radial corrective osteotomy with plating. We obtained 53% good, 40% satisfactory and 7% poor results according to the Mattis score. We consider such analytical approach to distal forearm fracture treatment very promising and well-founded.

Plate osteosynthesis of simple forearm fractures: LCP versus DC plates

The aim of this study was to compare the time to radiological bony union of simple A-type fractures of the forearm, treated with either a locking compression plate (LCP) or a dynamic compression plate (DCP). For each fracture, the relation between the use of compression and radiological healing time was studied. Nine fractures were treated with LCP and 10 fractures with DC plates. The mean time to definite radiological bony union in the LCP group was 33 weeks and in the DCP group 22 weeks. Compression was used in 7 fractures in the DCP group and in 3 fractures in the LCP group. The compressed fractures, irrespective of the type of plate, healed 10 weeks faster than the non-compressed fractures. Time to definite radiological bony union of simple A-type fractures does not depend on the type of plate used, but on the application of axial or interfragmentary compression.

Segmental radius and ulna fractures with scaphocapitate fractures and bilateral multiple epiphyseal fractures

Segmental forearm fractures are rare in children, and management is controversial. Epiphyseal injuries further complicate matters. We report the case of a 15-year-old boy who had segmental radius and ulna fractures with a coronal split of a metaphyseal fragment, along with bilateral epiphyseal fractures of the distal radius and ulna as well as ipsilateral scaphocapitate fractures with perilunate dislocation. There was also a contralateral fracture through the radial neck. The patient underwent immediate internal fixation of the forearm fractures and delayed fixation of the scaphocapitate fractures. Results at 12 months showed excellent functional outcome.

[Crossover extremity transfers. Limb salvage in amputations with segmental defects]

Clinical conditions in which crossover extremity transfer should be considered are rare. In the case of bilateral amputation associated with extensive proximal segmental injury, ectopic implantation could be an additional concept for two-stage limb salvage. If replantation is impossible due to segmental damage of the amputated part, at least uninvolved tissue should be harvested for stump lengthening or improving soft-tissue at the ends. The case of a 34-year-old man with segmental amputation of the left forearm and left lower leg and mutilated amputation of the right hand caused by a train accident is presented. Limb salvage was performed by cross-hand replantation and modified rotationplasty of the left foot as a stump lengthening procedure.

Surgical management of forearm and distal radius fractures in children and adolescents

Closed reduction with cast immobilization is the preferred method of treatment for most fractures of the forearm and distal radius in children and adolescents. Nonunion of these fractures is exceptionally rare, and remodeling restores alignment for minor incomplete reductions. Most closed reductions can be performed in the emergency department with the patient sedated or with regional anesthesia. However, reduction in an operating room with the patient under general anesthesia lowers the threshold for surgical stabilization to avoid the need for repeat reductions under general anesthesia. Surgical management with fixation is often indicated for unstable fractures, open fractures, refractures, and in circumstances involving multiple trauma and other complex injuries.

The results of locked intramedullary nailing for non-union of forearm bones

BACKGROUND

We report our experience with the use of a full-thickness corticocancellous iliac-crest graft, 1 to 5 centimeters in length - to treat established nonunion of the radius and/or ulna.

MATERIAL AND METHODS

The technique was used in 14 patients (11 men and 3 women, age 19 to 59). The graft application was combined by rigid fixation with intramedullary locking nail, permitting early active mobilisation. We treated also one patient with infection complication of nonunion radius and ulna. In this case evacuation of metal plate, sequestrectomy, fixation external then antibiotics have been applied in first stage. After curing bone infection the grafting and fixation with the use of intramedullary locking nail have been made in second stage. RESULTS. The bone union has been achieved between 26-th and 33-rd week after operation in seven patients, in four patients with nonunion of radius and ulna bone union has been achieved after 33 weeks. In another two patients with graft 5 cm in length - bone union has been achieved after 28 weeks. In one patient with bone infection the grafts were good incorporated after 40 weeks. The motion of elbow and wrist in all cases has been satisfactory.

CONCLUSIONS

Intramedullary nailing in treatment for forearm bones nonunion with use corticocancellous graft is technically easy, didn't require immobilization in the cast and enable early postoperative rehabilitation.

Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases

This study was undertaken in an attempt to improve the versatility of the posterior interosseous artery flap (PIA flap) and to decrease flap complication rate. The PIA flap was used for resurfacing 25 cases of the hand and distal forearm over a 2-year period. Observations were made on the anatomy of the PIA flap and its distal reach. Doppler analysis was made a mandatory part of the preoperative planning. Flaps were also raised from the zone of injury if Doppler confirmed the presence of good perforators. No attempt was made to identify the anastomosis between the anterior interosseous artery (AIA) and the PIA prior to flap raising since its presence was ascertained preoperatively with a Doppler and flap raising could begin straightway, saving precious tourniquet time. The surgical technique was further modified to include a large amount of fascia and subcutaneous tissue with the flap. This could perhaps be the reason for survival of larger flaps, absence of venous congestion and the low complication rate seen in our series. These flaps were used to resurface defects involving the dorsum of the hand, palm, distal forearm, wrist and fingers (both dorsal and volar surfaces). The distal reach of the flap was improved by exteriorising the pedicle and bowstringing it across the wrist which was kept in extension. The flap could thus easily reach the distal interphalangeal joint. This exteriorised pedicle was covered with a split thickness skin graft and was divided 3 weeks later under local anaesthesia making it a two-stage procedure. Adipofascial and osteocutaneous PIA flaps were also used depending on the requirement. Out of 25 flaps, 23 were of the adipofascial variety and one each of the fascial and osteocutaneous type. The majority of the patients were between 21 and 30 years old. Trauma was the leading cause of tissue deficit in our series (19/25). Within the trauma group occupational mishap (entrapment of hand in roller machine, presser machine, etc.) was the leading cause, road traffic accident being the next most common. The most common site of defect was the dorsum of the hand (14/25). The largest flap measured 12x8cm and the smallest flap measured 3x2cm. Only three minor complications were noted, two cases of partial flap loss (one of them needing a secondary procedure of debridement and grafting) and one partial graft loss in the case of fascial flap which needed regrafting. Importantly no evidence of venous congestion was noted in any of the flaps.

[Clinical comparative studies on multiphase lipectomy and one-phase lipectomy with skin graft transplantation in skin flap contouring]

OBJECTIVE

To discuss the advantages of two flap contouring methods and to explore the best choice for the flap contouring.

METHODS

From March 2002 to March 2006, 59 patients were admitted for a flap-contouring operation. Of the 59 patients, 40 (32 males, 8 females; average age, 34 years) underwent the multiphase lipectomy (the multiphase lipectomy group). The original flaps included the abdominal flap in 19 patients, the groin flap in 10, the thoracic flap in 4, the free anteriolateral thigh flap in 6, and the cross leg flap in 1. The flaps ranged in size from 6 cmX 4 cm to 32 cm x 17 cm. However, the remaining 19 patients (16 males, 3 females; average age, 28 years) underwent the one-phase lipectomy with skin graft transplantation(the one-phase lipectomy group). The original flaps included the abdominal flap in 4 patients, the groin flap in 6, the thoracic flap in 3, and the free anteriolateral thigh flap in 6. The flaps ranged in size from 4 cm x 3 cm to 17 cm x 8 cm. The results were analyzed and compared.

RESULTS

In the multiphase lipectomy group, partial flap necrosis developed in 4 patients but the other flaps survived. The followed-up of 27 patients for 3 months to 2 years revealed that the flaps had a good appearance and texture, having no adhesion with the deep tissues. However, the flaps became fattened in 22 patients with their body weight gaining. The patients who had a flap >5 cm x 5 cm in area had their sensation functions recovering more slowly; only part of the sensations to pain and heat recovered. The two point discrimination did not recover. In the one-phase lipectomy group, total graft necrosis developed in 1 patient but the healing was achieved with additional skin graft transplantation; partial graft necrosis developed in 2 patients but the wounds were healed after the dressing changes; the remaining flaps survived completely. The follow-up of the 16 patients for 3 months to 3 years revealed that all the 16 patients had a good sensation recovery, 12 patients had the two point discrimination <15 mm, with no recurrence of the fattening of the flaps; however, the grafted skin had a more severe pigmentation, and no sliding movement developed between the skin and the tissue basement.

CONCLUSION

The multiphase lipectomy and the one-phase lipectomy with skin graft transplantation are two skin flap contouring methods, which have their own advantages and disadvantages. Which method is taken should be based on the repair location of the skin flap and the condition of the skin flap.

Plastic deformation of the forearm in an adult: treatment with multiple osteotomies

Plastic deformation of the forearm is a rare and frequently missed injury in adults that can result in significant loss of forearm rotation. We report on a skeletally mature 19-year-old man with traumatic plastic deformation of the radius and ulna resulting in complete loss of forearm pronation. The patient was treated with multiple-level osteotomies of the radius and ulna 7 months postinjury. The patient had full forearm pronation at 4 months followup.

Paediatric forearm refractures with retained plates managed with flexible intramedullary nails

During the past 18 months we have managed four paediatric patients who have sustained forearm refractures associated with retained plates that were used to treat their original fracture. Although this complication is not new, most literature regarding paediatric forearm refracture relates to refractures that occur after closed treatment or after removal of metalwork. We treated the patients in this small series with plate removal and intramedullary stabilisation using elastic stable intramedullary nails (Nancy, Depuy, UK) as opposed to revision plating. Treatment of this complication by this method has not previously been described.

[Elastic stable intramedullary nailing (ESIN) in pediatric forearm shaft fractures: intraoperative image intensifier times]

AIM

Elastic stable intramedullary nailing (ESIN)is the therapy of choice in pediatric forearm shaft fractures. It requires increased intraoperative image intensifier times and radiation load.

METHOD

We performed a retrospective analysis of 78 operative procedures from a five-year period. In 16 cases the image intensifier times of the distinct steps of the operation were investigated prospectively.

RESULTS

Average duration of the surgical procedure was 36.9 (18-144) minutes. Average radiation time was 59.5 (8-222) seconds. In educational operations, the duration of surgery was significantly longer than in procedures performed by experienced surgeons, but radiation times only were increased tendentially. In those procedures investigated prospectively, 53.1% of the image intensifier time was used for fracture passage.

CONCLUSION

In ESIN of forearm shaft fractures,intraoperative image intensifier times of less than 2 minutes can be expected. Low intraoperative radiation times are a mark of quality. They serve for radiation protection of the patients, surgeons and OT staff.

[Repair of soft-tissue defect of amputation stumps of the forearm with free flap from the traumatic amputated extremity]

OBJECTIVE

To report the clinical results of the repair of soft-tissue defect of amputation stumps of the forearm with free flap from the traumatic amputated extremity.

METHODS

Five patients, 4 males and 1 female, aged 32 (22 - 43), with soft-tissue defect of the remaining stump of the traumatic amputation of the forearm, 3 cases in the right forearm and 2 cases in the left forearm, underwent repair of the defect by free flap from the traumatic amputated extremity with the size of the flaps ranging from 8 cm x 9 cm to 9 cm x 12 cm. The patients were followed up for 2.6 years (1.5 - 3.5 years).

RESULTS

Superficial infection occurred in one patient postoperatively and the wound was gradually healed by daily wound dressings. All the flaps survived completely with satisfactory clinical results. The cosmetic appearance on the recipient area was good and the function of the elbow recovered satisfactorily.

CONCLUSION

The flap from the traumatic amputated extremity has a constant vascular anatomy and a long vascular pedicle, so that dissection of the flap can be accomplished easily. The surgery allows to preserve the functional length or the elbow function of the remaining stump of the traumatic amputation.

[Cross-bridge vascular anastomosis free tissue transplantation in repairing tissue defects of extremities]

OBJECTIVE

To investigate the application and effect of the cross-bridge vascular anastomosis free flap transplantation for tissue defects of extremities.

METHODS

From May 1982 to November 2005, 110 cases of tissue defects of extremities were treated with cross-bridge vascular anastomosis free tissue transplantation. Of 110 patitents, 80 were male and 30 were female with a median age of 30 years(5 to 54 years). Tissue defects were caused by traffic accidents (59 cases), machine injuries (32 cases) and mangled injuries (19 cases). The locations were the forearms in 2 cases and the legs in 108 cases. And 69 cases had simple soft tissue defects, 6 cases had simple bone defects, and 35 cases had complicated defects. The length of bone defect ranged from 5 cm to 19 cm and the area of soft tissue defect ranged from 6 cm x 10 cm to 15 cm x 35 cm. The graft tissue included latissimus dorsi musculocutaneous flap, vastus anterolateral flap,cutaneous fibula flap, osseous fibula flap, and cutaneous iliac flap. The cross-bridge of the two lower extremities was performed in 106 cases, the cross-bridge of the two upper extremities in 2 cases, and the cross-bridge of the upper-lower extremities in 2 cases. The composite tissue transplantation was used if the graft tissues were two or more. The wounds of donor site was directly sutured in 67 cases, and partly sutured with skingrafting in 43 cases.

RESULTS

Vascular crisis occurred in 9 cases. Vascular crisis was relieved in 5 cases and grafting tissues was survival after exploring the vessel; 4 cases failed. The graft tissue was survival in 101 cases, and the survival rate was 96.4%. The follow-up time was 4 months to 22 years with an average of 6.3 years. Graft bone healed and mean healing time was 4 months. The flap appearance was satisfactory and extremity function was restored to normal. One case became necrosis in the edge of the flap and cured by debridement, dressing and skingrafting, the other got primary healing at 2-3 weeks after operation.

CONCLUSION

The application of the cross-bridge vascular anastomosis free tissue transplantation for tissue defects of extremities is an effective method, when extremities have no vessel anastomosed.

Treatment of non-union of the forearm using distraction-compression osteogenesis

BACKGROUND

The goal of the study is presentation broad abilities like gives Ilizarov method in the treatment of posttraumatic nonunion the of forearm with concomitant shortening and axis deformity, in minimally invasive technique, with contemporary axis correction and lengthening .

MATERIAL AND METHODS

. Authors present 6 patient operated on with the use of Ilizarov method, in years 2001-2005 , suffer from vital nonunion of the forearm - 6 cases radius; 1 case ulna and radius. In all cases with nonunion concomitant shortening of the radius from 2 to 3 cm and valgosity of radius with deformity in sagittal plane in 4 patients (2antecurvation, 2 retrocurvation). All patients had restricted rotation ROM of forearm and restriction of wrist motion . Author's modification of Ilizarov apparatus (with mini-Schanz's half-pins, which permitted rotation of forearm) was used in most of patients. In 3 cases monofocal slow correction with lengthening within nonunion was performed. In 2 cases bifocal, one-step slow correction of deformity and compression within nonunion with lengthening was performed. In 1 remaining case compression of ulna nonunion and compression with deformity correction of radius nonunion were performed. Distraction and correction start in 7 postoperative day in rate from 0,25 to 1 mm/day and correspondingly from1 to 2o/day.

RESULTS

Time of correction and distraction was average 63,3 days (40 - 90 days) . Total time of stabilization was average 25,4 weeks (20 - 35 weeks). Bone union was obtained in all patients. In all cases considerable recovery of limb function was achieved. All patients had superficial pin-tract infection . One patient had staphylococcal pin-tract infection of soft tissues, which retreat after 3-weeks guided antibiotic therapy.

CONCLUSION

The Ilizarov method permit for contemporary axis correction and/or distraction or compression. There is the method of choice in the treatment of nonunion of forearm with concomitant shortening and axis deformity.

Actualities in big segments replantation surgery

Replantation of an amputation is no longer a difficult technical problem. Indeed, the experience gathered over the last few decades, right from the first concepts posed by the pioneers up to the present era and the improved technical aids, all go to suggest that the majority of amputated segments may now be reconstructed. However, what we really want from a replant is not just survival but function. Indications for replantations must follow careful and objective patient selection together with the evaluation of type and site of lesion and possible complications. Furthermore, the important role of emergency organization in this type of surgery is to be emphasized. Nowadays, clean cut injuries are rarer and are being substituted by high energy trauma which may produce extensive tissue lesions that increase complications and lead to poor functional results. Consequently, some authors were induced to describe evaluation systems for decision making which still present problems which are in part due to the large number of parameters to be taken into consideration as well as to the complex functionality of the upper limb. This led us to evaluate our case series of 52 major replantations of the upper limb over the last 10 years and to compare it with other published series. The best form of reconstruction following total amputation of a major limb segment is still its replantation. The highly significant increase in the quality of life is able to justify the higher social costs and the number of operations required.