Synthetic Ligament-Assisted Functional Soft-Tissue Reconstruction in Tumor-Related Proximal Femoral Replacements

BACKGROUND

Soft-tissue functional reconstruction is important for restoring hip function in proximal femoral replacement for tumor resection. This study evaluated the functional outcome and postoperative complications of a specific synthetic ligament for soft-tissue functional reconstruction in proximal femoral replacement for tumor resection.

METHODS

This cohort included 80 patients (40 men and 40 women, mean age, 40 years (range, 10 to 79)) who had benign invasive tumors (n = 13), primary malignant bone tumors (n = 40), or bone metastases (n = 27). Patients' medical records, imaging files, surgical details, and postoperative pathological diagnoses were collected. Tumor staging was performed with the Enneking staging criteria. Lower limb and hip functions were assessed using the Musculoskeletal Tumor Society scoring system and Harris Hip score, respectively.

RESULTS

Mean postoperative Musculoskeletal Tumor Society and Harris Hip scores were 27 (range, 24 to 30) and 90 (range, 76 to 97), respectively, indicating satisfactory range of motion and stability. Trendelenburg gait was observed in 3 osteosarcoma patients (3.8%), and 6 patients showed unequal lower-limb lengths. Reoperations occurred in 5 cases, including 3 cases of deep vein thromboses and 1 case each of giant cell granuloma and periprosthetic infection. There were 27 patients who had bone metastases who did not require reoperation.

CONCLUSIONS

The synthetic ligament reconstruction of the hip with proximal femoral replacement for tumor resection was associated with improved outcomes. Its implementation exhibits the potential to reduce postoperative incidences of hip dislocation and periprostheses infection, thereby warranting its prospective clinical application.

Pedicled Rectus Femoris Flap for Restoration of Suprapatellar Quadriceps Tendon and Defect Coverage after Multiple Reconstruction Attempts-A Case Report and Literature Review

There is no unified approach for restoring the suprapatellar quadriceps tendon and covering tissue defects simultaneously. In this case report, we present the pedicled myocutaneous rectus femoris flap as one effective approach in two cases with extensive loss or impairment of the suprapatellar muscle-tendon structures after trauma-related suprapatellar quadriceps tendon rupture and multiple reconstruction attempts. Additionally, we provide a literature review of the reconstructive use of the functional pedicled myocutaneous rectus femoris flap.

METHODS

Two male patients, 48 and 74 years old, with extensive loss or impairment of the suprapatellar muscle-tendon structures due to multiple reconstruction attempts, underwent restoration of the knee extension with a pedicled myocutaneous rectus femoris flap.

RESULTS

Three months after reconstruction, both patients were able to walk freely, unaided. After a six-month follow-up, the free passive mobility of the knee joint was restored, and the active extension of the knee joint was possible in both patients.

CONCLUSION

The authors conclude that the pedicled rectus femoris flap is a reliable method for the restoration of knee extension, with excellent functional results in cases of suprapatellar tendon lesions. Further to the functional restoration, this technique has the additional advantage of simultaneously achieving coverage of soft-tissue defects, while a direct closure of the donor site is possible. Elderly patients and patients with relevant comorbidities or multiple revisions may especially benefit from this technique.

Nerve function restoration following targeted muscle reinnervation after varying delayed periods

Targeted muscle reinnervation has been proposed for reconstruction of neuromuscular function in amputees. However, it is unknown whether performing delayed targeted muscle reinnervation after nerve injury will affect restoration of function. In this rat nerve injury study, the median and musculocutaneous nerves of the forelimb were transected. The proximal median nerve stump was sutured to the distal musculocutaneous nerve stump immediately and 2 and 4 weeks after surgery to reinnervate the biceps brachii. After targeted muscle reinnervation, intramuscular myoelectric signals from the biceps brachii were recorded. Signal amplitude gradually increased with time. Biceps brachii myoelectric signals and muscle fiber morphology and grooming behavior did not significantly differ among rats subjected to delayed target muscle innervation for different periods. Targeted muscle reinnervation delayed for 4 weeks can acquire the same nerve function restoration effect as that of immediate reinnervation.

Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review

Background

Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic.

Methods

We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail.

Results

Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months.

Conclusion

Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.

837例创伤后遗下肢畸形患者特点分析（秦泗河矫形外科数据库1978年5月25日—2020年12月31日）

OBJECTIVE

To summarize and analyze the characteristics and treatment strategies of post-traumatic lower limb deformity based on QIN Sihe Orthopaedic Surgery Database.

METHODS

A clinical data of 837 patients with post-traumatic lower limb deformities treated by orthopaedic surgery between May 25, 1978 and December 31, 2020 in QIN Sihe Orthopaedic Surgery Database were analyzed retrospectively. The information of the patient's gender, age at the time of surgery, region of origin, cause of trauma, deformity side, orthopedic surgery related information (operation time, location, type, and fixation method after operation) were summarized and analyzed.

RESULTS

All patients came from 32 provinces, municipalities, autonomous regions, and Taiwan in China. Among them, 551 cases (65.83%) were male and 286 cases (34.17%) were female. The age of the patients at the time of surgery was 3-84 years old, with an average of 27.6 years old, and the most patients were 16-45 years old (559 cases, 66.78%). The main cause of trauma was traffic accident injury (639 cases, 76.34%). The deformity mainly involved unilateral limbs, including 394 cases (47.07%) on the left side and 376 cases (44.92%) on the right side. The most patients were admitted between 2008 and 2017, accounting for 53.05% (444/837). All patients were operated on one or more sites (1 048 sites), among which ankle and toe surgery were the most, accounting for 48.38% (507/1 048). The patients received 1204 surgeries including tendon lengthening and soft tissue contracture release, et al. Orthopedic surgery combined with bone external fixation was used in 624 cases (467 cases of Ilizarov external fixation and 157 cases of combined external fixation), and plaster or brace external fixation was used in 213 cases.

CONCLUSION

Post-traumatic lower extremity deformity patients have a large proportion of males, with a wide geographical distribution, involving various parts of the lower extremities, and most commonly in the foot and ankle. Orthopedic surgery combined with bone external fixation (Ilizarov technique) is the main methods for correction and functional reconstruction of post-traumatic lower limb deformity.

A novel injectable fibromodulin-releasing granular hydrogel for tendon healing and functional recovery

A crucial component of the musculoskeletal system, the tendon is one of the most commonly injured tissues in the body. In severe cases, the ruptured tendon leads to permanent dysfunction. Although many efforts have been devoted to seeking a safe and efficient treatment for enhancing tendon healing, currently existing treatments have not yet achieved a major clinical improvement. Here, an injectable granular hyaluronic acid (gHA)-hydrogel is engineered to deliver fibromodulin (FMOD)-a bioactive extracellular matrix (ECM) that enhances tenocyte mobility and optimizes the surrounding ECM assembly for tendon healing. The FMOD-releasing granular HA (FMOD/gHA)-hydrogel exhibits unique characteristics that are desired for both patients and health providers, such as permitting a microinvasive application and displaying a burst-to-sustained two-phase release of FMOD, which leads to a prompt FMOD delivery followed by a constant dose-maintaining period. Importantly, the generated FMOD-releasing granular HA hydrogel significantly augmented tendon-healing in a fully-ruptured rat's Achilles tendon model histologically, mechanically, and functionally. Particularly, the breaking strength of the wounded tendon and the gait performance of treated rats returns to the same normal level as the healthy controls. In summary, a novel effective FMOD/gHA-hydrogel is developed in response to the urgent demand for promoting tendon healing.

[Pelvic limb-salvage surgery for malignant tumors: 30 years of progress in China]

This article reviews the development and progress in the field of limb salvage treatment, surgical techniques, and function reconstruction of pelvic malignant tumors in China in the past 30 years. Based on the surgical classification of pelvic tumor resection in different parts, the development of surgical techniques and bone defect repair and reconstruction methods were described in detail. In recent years, in view of the worldwide problem of biological reconstruction after pelvic tumor resection, Chinese researchers have systematically proposed the repair and reconstruction methods and prosthesis design for bone defects after resection of different parts for the first time in the world. In addition, a systematic surgical classification (Beijing classification) was first proposed for the difficult situation of pelvic tumors involving the sacrum, as well as the corresponding surgical plan and repair and reconstruction methods. Through unremitting efforts, the limb salvage rate of pelvic malignant tumors in China has reached more than 80%, which has preserved limbs and restored walking function for the majority of patients, greatly reduced surgical complications, and achieved internationally remarkable results.

Tissue Coverage and Functional Reconstruction Outcomes With Use of Serratus Osteomusculocutaneous Free Flap in Lateral Malleolar Reconstruction: A Case Report

Currently, there is no ideal method defined in the repair of complex lateral malleolar defects, and the existing methods (i.e., bone repair, soft tissue or free flap closure) are far from producing functional results in terms of the ultimate recovery of ankle movements. Herein, an operative technique for soft tissue, ligamentous, and osseous reconstruction of fibular defect, using a free vascularized serratus anterior osteomusculocutaneous flap for reconstruction of a fibular deficit and the sixth costa for soft tissue coverage, was described in relation to tissue coverage and functional reconstruction outcome in a 31-year-old male patient with soft tissue and distal fibula defects in the lateral malleolus region caused by a traffic accident. Ankle movement was regained to almost full extent. No complications requiring further intervention was encountered in the donor site or ankle. In conclusion, the described operative technique enabled the repair of functional ligaments of the ankle joint in addition to repair of the soft tissue, lateral malleolus bone and skin defects in one session without the need for further additional operative intervention. Hence, the use of serratus osteomusculocutaneous free flap as a lateral malleolar reconstruction method seems to enable not only the tissue coverage but also to assist with functional reconstruction.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel

Objective

To summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.

Methods

A total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.

Results

After surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3-44 months) and the two-point discrimination of 5-14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.

Conclusion

The repair method should be selected according to the"5-zone method": The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6-10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

[Effectiveness of combined tissue transplantation to repair serially damaged injuries on radial side of hand]

OBJECTIVE

To investigate the effectiveness of combined tissue transplantation for repair of serially damaged injuries on radial side of hand and function reconstruction.

METHODS

Between May 2013 and May 2017, 34 cases of serially damaged injuries on radial side of hand were treated. There were 29 males and 5 females; aged 17-54 years, with an average of 32.1 years. There were 23 cases of crushing injuries, 5 cases of bruising injuries, 4 cases of machine strangulation injuries, and 2 cases of explosion injuries. The time from injury to admission was 40 minutes to 3 days, with an average of 10 hours. According to the self-determined serially damaged injuries classification standard, there were 1 case of typeⅠa, 2 cases of typeⅠb, 10 cases of typeⅡa, 5 cases of type Ⅱb, 3 cases of type Ⅱc, 1 case of type Ⅱd, 7 cases of type Ⅲa, 3 cases of type Ⅲb, 1 case of type Ⅲc, and 1 case of type Ⅲd. According to the classification results, the discarded finger, nail flap, the second toe, anterolateral thigh flap, ilium flap, fibula flap, and other tissue flaps were selected to repair hand wounds and reconstruct thumb, metacarpal bones, and fingers.

RESULTS

After operation, 2 cases of flaps developed vascular crisis and survived after symptomatic treatment; the other transplanted tissue survived smoothly. All cases were followed up 1 to 7 years, with an average of 2.4 years. The average fracture healing time was 7.4 weeks (range, 5.3-9.0 weeks). At last follow-up, the reconstructed fingers and the grafted flaps recovered good sensory function, with a two-point discrimination of 5 to 11 mm (mean, 9 mm). According to the evaluation standard of the upper limb function evaluation of the Chinese Medical Association Hand Surgery Society, the reconstructed thumb was rated as excellent in 24 thumbs, good in 8 thumbs, and fair in 2 thumbs; the reconstructed finger was rated as excellent in 18 fingers, good in 2 fingers, and fair in 1 finger.

CONCLUSION

For the serially damaged injuries on radial side of hand, according to its classification, different tissues are selected for combined transplantation repair and functional reconstruction, which can restore hand function to the greatest extent and improve the quality of life of patients.

[Retrograde muscle release method in treatment of mild to moderate ischemic muscle contracture of forearm]

Objective

To investigate the effectiveness of retrograde muscle release in treatment of mild to moderate type ischemic muscle contracture of forearm classified by Tsuge.

Methods

Between March 2010 and September 2018, 11 patients with mild to moderate ischemic muscle contracture of forearm were treated with retrograde muscle release. There were 6 males and 5 females with an average age of 24 years (range, 16-29 years). According to Tsuge classification, 6 cases were mild type and 5 cases were moderate type. The interval between injury and operation was 9 months to 25 years, with a median of 17 years. The scar cords in the muscle of the middle one-third of the forearm was released firstly. If the standard of sufficient release was not reached, further releasing the scar cords in the muscle and the tense tendon structure in the proximal one-third of the forearm and the origins of the flexor muscles was necessary. If the standard was still not reached, the origins of the flexor muscles can be released and slid. The effectiveness was evaluated from six aspects of the range of motion of the hand and wrist, dexterity, grip strength, sensation, subjective function scores [quick-disability of the arm, shoulder, and hand questionnaire (Quick-DASH) and the patient-related wrist/hand evaluation (PRWHE)] and satisfaction.

Results

All the incisions healed by first intention. Eight patients were followed up 1-106 months (median, 13 months). The range of motion of the hand and wrist was significantly improved, the results were excellent in 3 cases, good in 3 cases, and fair in 2 cases, with an excellent and good rate of 75%. The patient's dexterity evaluation scored a perfect score of 12, which was close to the normal hand dexterity. At last follow-up, the grip strength on the affected side was 37.6%-95.5% of the contralateral side, with an average of 77.6%. Seven patients had normal sensation before and after operation, and the two-point discrimination of median nerve and ulnar nerve was 4-5 mm at last follow-up; 1 patient with forearm mechanical crush injury still felt numb after operation, and the two-point discrimination of median nerve and ulnar nerve was 8 mm and 7 mm, respectively. The Quick-DASH score was 0-15.9, with an average of 4.5, and the PRWHE score was 0-23.0, with an average of 6.6. All the patients were satisfied with the surgery and the effectiveness.

Conclusion

A targeted retrograde muscle release method for mild to moderate type ischemic contracture of forearm can achieve satisfactory effectiveness.

[Long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade giant cell tumor]

OBJECTIVE

To evaluate the long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade Ⅲ giant cell tumor (GCT) of distal radius.

METHODS

Between December 2010 and December 2014, 10 patients with Campanacci grade Ⅲ GCT of distal radius were treated with en bloc excision and inradiocarpal joint reconstruction using vascularized fibula flap. They were 6 males and 4 females, with an average age of 39.9 years (range, 22-65 years). The disease duration was 1.5-6.0 months (mean, 2.6 months). The length of distal radius defect was 6.0-12.5 cm (mean, 8.4 cm) after en bloc excision of GCT. Vascularized fibula flap with inferior lateral genicular vessels were performed in 6 patients and with inferior lateral genicular vessels and peroneal vessels in 4 cases.

RESULTS

All incisions healed by first intention. All patients were followed up 4.4-8.3 years (mean, 6.0 years). There was no tumor recurrence during follow-up. At last follow-up, the mean ranges of motion of wrist joint were 55.0° (range, 25-85°) in extension, 26.5° (range, 15-40°) in flexion, 12.0° (range, 5-25°) in radial deviation, 19.6° (range, 10-30°) in ulnar deviation, 50.5° (range, 5-90°) in pronation, and 66.5° (range, 20-90°) in supination. The mean grip strength of effected wrist was 75% (range, 60%-85%) of the healthy wrist. The mean Musculoskeletal Tumor Society (MSTS) score was 82.7% (range, 75%-90%). X-ray films showed that the fibula flap healed at 12-16 weeks after operation (mean, 14.1 weeks) and there were 9 cases of radiological complications.

CONCLUSION

For Campanacci grade Ⅲ GCT of distal radius, application of the vascularized fibula flap in radiocarpal joint reconstruction after en bloc excision of GCT can obtain good wrist function.

FUNCTIONAL RECONSTRUCTION OF SOFT TISSUE OROFACIAL DEFECTS WITH MICROVASCULAR GRACILIS MUSCLE FLAP

INTRODUCTION

Free flap reconstructive surgery of middle size and large oral and facial defects enables aesthetic and functional rehabilitation. Microvascular flap reconstructive surgery, with flap survival success rate more than 90-98%, is a gold standard in head and neck extensive reconstructions. Currently, head and neck reconstructive surgery is focused not only on defect occlusion and adequate aesthetical result, but the same emphasize is aimed at functional result. Functional result post tongue and lip resection means defect occlusion with the possibility of movement restoration. Free gracilis muscle flap appears to be a choice for functional tongue and lip reconstruction.

MATERIAL AND METHODS

We present 1-year experience with 5 microvascular flap functional reconstructions of middle size and large defects of tongue and lip with free gracilis muscle flap. Four patients post tongue resection and one post subtotal lower lip and cheek resection underwent immediate functional microvascular gracilis muscle flap reconstruction.

RESULTS

All five patients were successfully reconstructed with functional free gracilis muscle flap, with no flap loss. We found gracilis muscle flap harvest is not technically demanding, provides adequate tissue volume for middle size orofacial defects reconstruction, with possibility for skin island harvest, and simple primary closure of donor site with very low morbidity. Patients after tongue reconstruction with free gracilis flap were swallowing spoon ood 1 week post operation. Patient after total lip resection and immediate reconstruction with free gracilis flap presented with oral competence before the discharge. The functional result in the group of patients with free gracilis flap reconstruction for orofacial defect will have to be further evaluated again after 2 years post operation considering the ability to swallow and articulate during the speech for the tongue reconstructions and the oral competence and facial mimic for the lip reconstruction.

CONCLUSION

Microvascular gracilis muscle flap reconstruction compared to radial forearm flap reconstruction enables functional reconstruction of soft tissue defect. Functional reconstruction of soft tissue defects of tongue or lip with microvascular gracilis muscle flap appears to have advantage of adequate volume, very low donor side morbidity and expectancy of movement renewal compared to other microvascular flap reconstructive options such as anterolateral thigh flap, superficial circumflex iliac artery perforator flap, lateral arm free flap or deep inferior epigastric perforator free flap.

Plate-prosthesis composite reconstruction after large segmental resection of proximal humeral tumors: A retrospective comparative study

Since the standard reconstructive option after large segmental resection of proximal humeral tumors remained controversial, we designed and applied plate-prosthesis composite (PPC) for this circumstance. The purposes of the study were to: compare the functional outcome, implant survival (IS), surgical risk of PPC with those of conventional proximal humeral prosthesis (PHP); and describe the design and reconstructive procedure of PPC.Twenty patients (11 males, 9 females), who received intraarticular proximal humeral resection without preservation of abductor mechanism, were included in this study, with a mean resection length accounting for 72.5% (range, 61.9-81.8%) of whole humeral length. According to the reconstructive options, we categorized patients into PPC group (9 patients) and PHP group (11 patients). PPC was a semi-custom-made endoprosthesis, with modular proximal part same as PHP and custom-made distal part including dumpy stem and composite lateral anatomic plate for distal humerus. The mechanical prosthetic complication was defined as the imaging evidence regardless of reoperation. The IS was defined as the time from surgery to the occurrence of mechanical prosthetic complication.The mean follow-up time was 40.1 months (range, 14-129). The Musculoskeletal Tumor Society 93 scores of PPC and PHP group showed no significant difference (73.3% vs 70.0%, P = .46). Compared to PHP group, PPC group showed significantly lower mechanical prosthetic complication rates (0 vs 45.4%, P = .03) and better IS (86.0 vs 59.3 ± 21.7 months, P = .028). Moreover, the comparison of surgical time (3.2 vs 3.3 hours, P = .60), blood loss (288.9 vs 376.4 mL, P = .15) and perioperative complication rates (11.1% vs 18.2%, P = .58) between 2 groups showed no differences.For reconstruction after large segmental resection of proximal humeral tumors, PPC achieved better IS while maintained similar functional outcome compared to conventional PHP without influencing the complexity and safety of surgery.

Treatment of adenoid cystic carcinoma of the mobile tongue with anterolateral thigh flap reconstruction: A case report

RATIONALE

Adenoid cystic carcinoma (ACC) is an infrequent malignant neoplasm of the salivary glands. The clinical and pathological characteristics include slow growth, perineural invasion, and local recurrence. ACC of the mobile tongue is rarely reported in the literature.

PATIENT CONCERNS

We describe a case of a 43-year-old man patient with numbness and growth in the tongue for 1 month duration. The patient reported a long-term smoking and drinking habit.

DIAGNOSES

A biopsy was carried out and histopathological analysis confirmed as diagnosis of adenoid cystic carcinoma. Computed tomography (CT) of the head and neck enhanced scanning revealed an ill-defined high density mass with altered enhanced signal entities involving the anterior 2/3rd of the tongue.

INTERVENTIONS

The patient was treated with surgery and adjuvant radiotherapy. Incision was placed over the anteriorly till 2/3rd of tongue and then the femoral anterolateral free flap was used to repair and reconstruct the defect of tongue.

OUTCOME

The patient is currently under a postsurgical 29-month regular follow-up, showing good swallowing and speaking function without any recurrence and metastasis.

LESSONS

This case report suggests that surgery and adjuvant radiotherapy are suitable procedures for patients with resectable ACC of the mobile tongue.

[Progress of reconstruction in bone tumor surgery]

Bone tumor surgery involves tumor resection and subsequent reconstruction. With the development of surgical technique and new material, there is a great step toward bone and joint reconstruction in bone tumor surgery. Generally speaking, there are two major reconstructive methods including bio-reconstruction and mechanical reconstruction. In addition, three-dimensional printed prosthesis has been widely applied in the field of bone tumor surgery. The short-term result is encouraged; however, long-term results and related complications are seldom reported.

Functional Reconstruction with Latissimus Dorsi Flap following Resection of an Extensive Basal Cell Carcinoma in the Shoulder Region: A Case Report

Large and ulcerating skin tumors have become a rarity in the modern Western world. However, these conditions can cause serious life-threatening complications. The case of a 60-year-old male Caucasian patient is reported, who had suffered from an extensive basal cell carcinoma in the right shoulder region for several years. The patient kept the lesion secret from his friends and family and delayed presentation to health care services. After an episode of tumor-related heavy bleeding, the patient was referred to our clinic and received a radical surgical tumor resection—followed by defect coverage with a latissimus dorsi myocutaneous flap. An alternative treatment option that could be offered to the patient would have been a mutilating surgical procedure with an arm amputation. By using this plastic reconstructive surgical technique, the main function of the shoulder joint was conserved. The presented case demonstrates options for defect coverage of problematic wounds in anatomically complex body regions—like the shoulder—by using a functional reconstruction using myocutaneous flaps.

[Effectiveness of Ilizarov technique in treatment of clubfoot after burns]

Objective

To investigate the effectiveness of Ilizarov technique in treatment of the clubfoot after burns.

Methods

Between March 2012 and February 2017, 12 patients (17 feet) with clubfoot after burns were treated with Ilizarov technique. There were 10 males (14 feet) and 2 females (3 feets) with an average age of 38 years (range, 18-52 years). There were 3 cases of left foot, 4 cases of right foot, and 5 cases of both feet. According to the Qin's classification of clubfoot deformity, there were 5 feet of degreeⅠ, 9 feet of degreeⅡ, and 3 feet of degree Ⅲ.

Results

All clubfeet were completely corrected without local skin necrosis, needle tract infection, or acroanesthesia. All patients could walk with a heavy load. Pationts were followed up from 4 months to 3 years (mean, 10 months). At last follow-up, according to the International Clubfoot Study Group (ICFSG) score, the effectiveness was rated as excellent in 7 feet, good in 7 feet, and fair in 3 feet, with the excellent and good rate of 82.4%.

Conclusion

Using Ilizarov technique can gradually correct the clubfoot deformity with the advantages of minimal invasion, safeness, and simpleness.

[Repair of composite tissue defects and functional reconstruction of upper arm with latissimus dorsi Kiss flap]

Objective

To investigate the effectiveness of latissimus dorsi Kiss flap for repairing composite tissue defects and functional reconstruction of upper arm.

Methods

Between March 2010 and November 2016, 12 cases of composite tissue defects of upper arm were repaired by latissimus dorsi Kiss flap with blood vessel and nerve bunch. There were 8 males and 4 females with a median age of 34 years (range, 21-50 years). The reason of injury included plowing mechanical injury in 4 cases, traffic accident injury in 5 cases, electrical injury in 2 cases, and resecting upper arm soft tissue sarcoma in 1 case. There were deltoid defect in 5 cases, triceps brachii and brachialis defect in 4 cases, and deltoid, triceps brachii, and brachialis damaged in varying degrees in 3 cases. The defect area ranged from 13 cm×7 cm to 20 cm×8 cm. Among them, there were 6 cases of fracture combined with partial bone exposure, one of them with bone defect. The disease duration was 3 hours to 6 months. The flap size ranged from 10 cm×6 cm to 15 cm×7 cm, and the donor sites were directly sutured.

Results

Twelve flaps survived with primary healing of wounds. Ten patients were followed up 6-26 months (mean, 14 months). At last follow-up, the flaps were soft and the skin color was similar to the surrounding skin. No obvious scar was found at donor sites. The abduction range of motion of shoulder was 30-90°. The muscle strength of brachialis were all at grade 4 or above. The superficial sensation and tactile sensation recovered partialy (S ₁ in 2 cases, S ₂ in 6 cases, S ₃ in 2 cases). According to Society of Hand Surgery standard for the evaluation of upper part of the function, the shoulder joint function was excellent in 2 cases, good in 4 cases, and fair in 4 cases.

Conclusion

The design of the latissimus dorsi Kiss flaps are flexible, and the donor site can be directly sutured, with the nerves of the latissimus dorsi muscle can partialy reconstruct abduction function of upper arm. In general, the Kiss flap repairing upper arm defect can obtain satisfactory effectiveness.

Lip reconstruction using a functioning serratus anterior free flap: preliminary study

Reconstructive surgery to the lips requires the replacement of defective tissues with similarly functioning tissues. While non-dynamic free tissue transfers provide adequate lower lip reconstruction, improved benefits may be obtained with innervated free muscle flaps. This study reports the use of innervated serratus anterior muscle free flaps for lip reconstruction in five patients. All patients had squamous cell carcinoma of either the upper or lower lip. After resection of the tumours, the resultant defects comprised two-thirds of the lips. The innervated serratus anterior muscle free flap was transferred to the lip and an end-to-end vascular anastomosis on the facial artery was performed. The marginal mandibular branch of the facial nerve was preferred for nerve coaptation. The inner and outer surfaces of the flaps were grafted with a split-thickness skin graft. Concentric needle electromyography of the orbicularis oris and frontal muscles was performed for all patients in the preoperative, postoperative, and follow-up periods. All patients survived the surgical operation. Three patients achieved perfect oral sphincter function without drooling. Electromyography at 1 year postoperative demonstrated the successful reinnervation of the serratus anterior muscle. This study demonstrates that lip reconstruction using an innervated serratus anterior muscle free flap is a reliable method, providing a functional lower lip.

[Treatment of traumatic ulnar styloid impaction syndrome by Sauvé-Kapandji procedure]

Objective

To evaluate the effectiveness of Sauvé-Kapandji procedure in the treatment of traumatic ulnar styloid impaction syndrome.

Methods

Between June 2010 and January 2013, 12 patients with traumatic ulnar styloid impaction syndrome were treated by Sauvé-Kapandji procedure. There were 4 men and 8 women, with an average age of 58.9 years (range, 50-69 years). The disease was caused by traffic accident in 1 case, and by falling from height in 11 cases. All patients had dislocation of the distal radioulnar joint, and 7 patients also had old fractures of the distal radius. The main clinical symptoms were pain and limited activity of the wrist joint, and the disease duration was 2-4 months (mean, 3.5 months). The visual analogue scale (VAS) was 6.2±1.4. The clinical outcomes were assessed by VAS, range of motion (ROM) of the wrist, grip strength, Evans score, and X-ray film of wrist joint during follow-up.

Results

All patients obtained healing of incision by first intention and were followed up 37-73 months (mean, 58.4 months); no complication of infection, blood vessel injury, or nerves injury occurred. VAS was 1.2±1.0 at the final follow-up, showing significant difference when compared with preoperative one ( t=9.950, P=0.000). The ROM of the affected wrist joint in flexion, extension, ulnar deviation, forearm pronation and supination were improved, but the ROM of the affected side were significantly less than those of normal side ( P<0.05). No significant difference was found in the grip strength and Evans score between the affected side and normal side ( t=-0.885, P=0.386; t=-1.969, P=0.062). According to Evans scores, the results were excellent in 8 cases, good in 3 cases, and fair in 1 case, with an excellent and good rate of 91.7%. Postoperative radiographs showed bony healing in all patients, with the average healing time of 3.5 months (range, 3-6 months). The instability of proximal ulna occurred in 3 cases.

Conclusion

Sauvé-Kapandji procedure is a reliable remedy method for traumatic ulnar styloid impaction syndrome, with favorable improvement in wrist pain and forearm rotation. However, the surgical indications for Sauvé-Kapandji procedure should be strictly controlled.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Functional reconstruction of the knee extension mechanism following wide resection for a prepatellar soft-tissue sarcoma: A case report

Functional reconstruction following a wide resection for a malignant musculoskeletal tumor is often challenging, particularly for juxta-articular tumors. The current study describes a novel surgical procedure for the functional reconstruction of the knee extensor mechanism with a pedicle frozen auto-bone and -tendon graft, in a case of prepatellar clear cell sarcoma. The active range of motion of the knee was from 0-135°, and the extension muscular strength of the knee was evaluated as 5/5 by a manual muscle test at 14 months post-surgery (International Society of Limb Salvage score, 73%); this was improved compared with a similar procedure previously described by Muramatsu et al. This procedure must be considered following the wide resection of juxta-articular malignant musculoskeletal tumors.

Reconstruction of lateral knee joint stability following resection of proximal fibula tumors

Managing tumors of the proximal fibula may require en bloc resection of the fibular head with the attachment site of the lateral collateral ligament (LCL) and biceps femoris tendon. The aim of the present study was to evaluate knee stability and the Musculoskeletal Tumor Society (MSTS) functional score of patients with proximal fibula tumors. Twenty-nine patients with proximal fibula tumors were retrospectively reviewed (18 patients in the reconstruction group and 11 patients in the non-reconstruction group). A comparative analysis was conducted of knee stability (measuring the degree of lateral joint space opening using varus stress radiographs with a 30º knee flexion) and MSTS functional score between the two groups. The mean follow-up period was 42.8±20.9 months (range 24–117) and 40.8±26.0 months (range 24–117) for the reconstruction and the non-reconstruction groups, respectively. Fifteen patients (83.3%) in the reconstruction group had a stable knee, one (5.6%) had grade 1 instability and two (11.1%) had grade 2 instability. Four patients (36.4%) in the non-reconstruction group had a stable knee, three (27.3%) had grade 1 instability, one (9.1%) had grade 2 instability and three (27.3%) had grade 3 instability. Patients who underwent reconstructive surgery exhibited a higher rate of knee stability compared with those in the non-reconstruction group (P<0.05). The MSTS function scores were 93% (range, 93–100%) for the reconstruction group and 87% (range, 60–100%) for the non-reconstruction group (P<0.05). Reconstruction of the LCL and biceps femoris tendon to the lateral tibial metaphysis with a suture anchor was a safe, reliable and simple technique following resection of proximal fibula tumors.