2022年9月，徐州仁慈医院手外科收治1例39岁男性患者,双手内固定取出术后出现右侧肩关节周围急性疼痛伴右前臂桡掌侧感觉麻木及屈肘无力,2周后出现臂屈肌萎缩。检验发现白细胞和C反应蛋白等异常,接受抗感染治疗后症状未缓解。体格检查、肌电图和神经超声提示肌皮神经病变,经手术探查发现肌皮神经缩窄伴扭转,取同侧腓肠神经进行神经移植修复。术后8个月随访，患者症状明显改善。
Objective:To explore the feasibility in reconstruction of the muscular power with the superficial part of lateral femoral muscle through anatomical study on the superficial region of lateral femoral muscle.Methods:Studies on 4 sides of lower limbs of 2 cadaver specimen were conducted in the Department of Hand and Foot Microsurgery of Xi'an Fengcheng Hospital. Intraoperative observations and measurements were further carried out on 21 sides of 21 patients. Muscular fascia in superficial region, muscular gross morphology, thickness, length and width of muscles, length of muscle fibres and pinnate angles of muscle surface were observed and measured. Both blood vessels and nerves in the muscle were separated to measured.Results:The superficial region of lateral femoral muscle was in a shape of fusiform and started from the greater trochanter and ended at the patella and rectus femoris, with the fascia at proximal end and the muscle of distal end. The inferior muscle fibres of the fascia were arranged in sequence and ended at the deep fascia from proximal to distal. Mean muscle thickness was measured at 1.96 cm±0.48 cm, and mean pinnate angle was of 18.9°±3.3°. The superficial region was found being distributed by the descending branches of lateral circumflex femoral artery(LCFA) and the second branch of femoral nerve, and they accompanied each other. At 5.0 cm from the point of entry to the muscle, the diameter of the vessels was measured at 2.39 mm±0.52 mm, and the diameter of nerves was at 2.64 mm±0.61 mm. Both of arteries and nerves further branched out anteriorly and posteriorly in 1.0-1.5 cm intervals after having entered the muscle. At 0 - 2.5 cm away from the muscle entry point, a larger branch was often running posteriorly into the muscle, and this branch appears on all 4-sided specimens. While the occurrence rate in the 21 sides of patients observed in operations was of 90.5%, with a transverse diameter at 1.23 mm±0.28 mm.Conclusion:The superficial region of lateral femoral muscle is dominated by independent vessels and nerves and there are many branches from superior vessels and nerves, which form an anatomical basis for one or more muscular flaps.
Objective:To investigate the efficacy of digital reconstruction technology in assisted design of lobulated deep inferior epigastric perforator flap (DIEPF) for surgical reconstruction of large defect in lower extremity.Methods:From January 2017 to January 2022, a study was carried out to retrospectively analyse 8 patients who had massive soft tissue defects in lower extremities were admitted in the Department of Orthopaedic Surgery of the 920 Hospital of Joint Logistic Support Force of Chinese PLA. The size of defects varied from 16.0 cm×12.0 cm-28.0 cm×22.0 cm. CTA scans were performed over abdominal aorta and the arteries of lower extremities. Three-dimensional model of DIEPF and vascular pedicles were reconstructed by Mimics software. According to the shape and size of the wound, targeted perforators were determined on the 3D images, and precisely mapped in a digitised rectangular coordinate system. The lobulated flap was then digitally designed in the 3D coordinate system. Flaps were harvested according to preoperative digital designs for the reconstruction of large defects in the lower extremities. The donor site was sutured directly. The flaps and recovery of lower extremities were observed though postoperative follow-ups and were conducted through visits of outpatient clinics and distance interviews via telephone and WeChat. Recoveries of lower extremities were evaluated using Maryland ankle-foot function scoring system.Results:The 3D reconstructed models of the vessels in donor sites were successfully completed for all patients. The harvests of lobulated DIEPF were successfully guided by the digital designs. Fifteen lobes of lobulated DIEPF survived successfully in all 8 patients. All donor sites were closed in the stage-I. Necrosis occurred at the distal tip of a lobulated flap due to a local venous occlusion, and healed after debridement and re-suture. Four patients received further flap debulking surgery. Time of postoperative follow-ups had ranged 15-27 months, with an average of 20 months. At the last follow-up, all the flaps had satisfactory appearance with linear scars at the donor sites. All fractures were healed. Five patients achieved Maryland's ankle-foot function score in excellent, 2 in good, and 1 was acceptable.Conclusion:Digital reconstruction technology can accurately map the perforators and reasonably assist the design of lobulated flaps. A lobulated DIEPF offers a wider area for flap excision and allows a primary closure of the donor sites. Combination of the 2 advantages of a lobulated DIEPF can be effectively applied in reconstruction of a large-sized defect in lower extremity.
报道1例2021年3月中国人民解放军陆军第八十集团军医院骨科收治的左手挤压脱套伤并软组织缺损患者，经急诊清创血管修复、二期双层人工真皮修复及后期游离植皮手术治疗，全手除拇指远节及小指远节外全部保留，术后配合规律的康复锻炼。术后30个月随访，左手功能恢复良好，能完成基本日常生活，功能评定按照中华医学会手外科学会上肢部分功能评定试用标准为良，外观较满意。
Objective:To investigate the surgical approaches and clinical outcomes of endoscopic endonasal approaches (EEA) for trigeminal schwannomas(TSs).Methods:Clinical data, surgical videos and outpatient follow-up notes of 41 patients with TSs and underwent EEA between January 2013 to October 2022 in the Department of Neurosurgery of the First Affiliated Hospital of Nanchang University were retrospectively studied. The patients were 19 males and 22 females, with an average age of 45.3 (22-63) years old. Twenty-four patients had TSs on the left and 17 on the right. According to Jeong's classification, for 6 TSs with type MP, 2 tumours were resected by trans-Meckel's cave approach (TMCA) alone, and the remaining 4 TSs were resected by combined transclival approach (TCA). For the 4 tumours that involved infratemporal fossa(2 of type E3, 1 of type mE3 and 1 of type Mpe3), the surgery were performed via a trans-prelacrimal recess approach(TPRA), of which the operation for type Mpe3 was combined with a TMCA. The trans-laminal papyracea approach (TLPA) was applied to remove 2 tumours of type E1. The rest of 29 patients received the surgery by TMCA alone to remove tumours including 15 of types M, 10 of type Mp, 1 of type ME2, 2 of type E2 and 1 of type MpE2. Gross total tumour resection was achieved in 40 patients(97.6%), with only 1 patient (2.4%) had a subtotal tumour resection.Results:A total of 40 patients had completed the long-term follow-up, with 1 patient lost in follow-up. The average follow-up period was 34(3-101) months; No tumour recurrence or progression was observed over follow-up. After the surgery, preoperative symptoms were improved in 34 patients(89.5%). The main improved symptoms were: facial numbness(78.9%), facial pain(70.0%), headache(88.2%), mastication weakness (50.0%), poor vision (60.0%), diplopia (83.3%), and abducens nerve palsy (100%). Transient and permanent neurological deficits occurred in 8 (19.5%) and 9 (22.0%) patients, respectively. Cerebrospinal fluid leakage and internal carotid artery injury occurred in 1 patient each.Conclusion:According to the location of a tumour, an appropriate EEA should be selected and satisfactory results can be achieved for all types of tumours, except the TSs that has the main body of the tumour located in the posterior cranial fossa.
Objective:To compare the clinical effecacy of artificial dermal regeneration matrix (as "artificial dermis" hereafter) and flap transfer in the treatment of soft tissue defects around interphalangeal joint.Methods:Through postoperative follow-up at outpatient clinic, a retrospective study was conducted on the clinical data of 60 patients who had soft tissue defects around the interphalangeal joints and received treatment in the Department of Hand Surgery, the Sixth Hospital of Ningbo from January 2018 to January 2022. According to applied surgical procedures, patients were divided into a flap transfer group (group A, n=30) and an artificial dermis group (group B, n=30). Group A included 19 males and 11 females aged 44.83 years ± 11.56 years including 5 patients with simple soft tissue defects, and 6 with soft tissue defects and fractures, 10 with soft tissue defects with tendon and (or) ligament injuries, 3 with soft tissue defects and vessel and (or) nerve injuries, and 6 with soft tissue defects and over 2 other types of compound injuries. The defect areas ranged from 2.5 cm×1.2 cm to 5.0 cm×1.6 cm. After emergency debridement and treatment for bone and tendon injuries, the patients in group A received transfers of free flap or transfers with adjacent digit flaps or island flaps. Postoperative functional exercise started from 1-6 weeks after surgery. Patients in group B included 17 males and 13 females, aged 44.70 years ± 11.20 years and there were 6 patients with simple soft tissue defects, 6 with soft tissue defects and fractures, 9 with soft tissue defects and tendon and (or) ligament injuries, 5 with soft tissue defects and vessel and (or) nerve injuries, and 4 with soft tissue defects and over 2 other types of compound injuries. The defect area ranged from 3.1 cm ×1.3 cm to 4.5 cm × 1.8 cm. Debridement and treatment of the bone and tendon injury in group B were the same as what in group A, but the patients in group B received artificial dermis coverage other than transfer of flap. After an artificial dermis had completely vascularised, a split-thickness skin graft was performed over the neo-dermis in the second phase surgery. Postoperative functional exercise started from 1-2 weeks after artificial dermis grafting surgery. The interval time of flap transfer or split-thickness skin grafting, survival rate of flap transfer or split-thickness skin grafting, Vancouver Scar Scale(VSS), TPD and total active movement(TAM) were compared between the 2 groups. The count data were analysed by Chi-square test. All measured data were analysed by independent sample t test or Mann-Whitney U test. P<0.05 indicates a statistically significant difference. Results:The interval time of flap transfer in group A and artificial dermis grafting in group B were 2.93 days ± 2.48 days and 19.87 days ± 3.35 days, respectively. There was a statistically significant difference between the 2 groups( P<0.05). All patients were entered in postoperative outpatient follow-up for 11-14 months(12.00 months ± 0.93 months). The appearance of flaps of some patients in group A was bloated with slightly limited digit movement. In group B, the digit movement was normal, without obvious scar hyperplasia in both of the recipient and donor sites. The survival rate of flap transfer or artificial dermis graft, TPD, VSS score and TAM score for group A and group B were 96.00% ± 9.32% and 98.17% ± 3.07%, respectively, 8.67 mm ± 2.01 mm and 9.50 mm ± 1.81 mm, 3.40 ± 1.07 and 3.17 ± 0.91 and 18.30 ± 1.97 and 18.93 ± 1.64, respectively. There were no significant differences between the 2 groups( P>0.05). Conclusion:In comparison with the transfer of flap, an artificial dermis is also effective and satisfactory in the treatment of soft tissue defects around the interphalangeal joint. Further large scale and multi-centre investigations are required.
In 1959, Douglas reported successful survival of in-situ suturing composite graft of completely amputated fingertips. In the early 1960s, Jacobson and Buncke respectively performed experimental microvascular anastomosis in vessel diameters of 1.4 mm and 0.8 mm, and achieved replantation of amputated finger in monkey. In 1962, Kleinert successfully replanted incompletely amputated thumbs through microvascular anastomoses. In 1965, Tamai achieved replantation of completely amputated thumbs using microsurgery techniques. In 1967, Chen Zhongwei published the first report in English on successful replantation of severed digits in 20 cases. In October 1972, O'Brien reported Chinese limb (digit) replantation techniques and experiences after his visit to China. In November 1972, an exchange meeting on replantation of amputated limb was held in Guangzhou, China, where a total of 398 complete severed digits of 260 patients, with 179 successful replantation(44.9%) were reported. In May 1973, a delegation of North American limb replantation surgeons visited China and later published a report about the visit. Since then the techniques and principles of limb (digit) replantation applied by the Chinese surgeons were recognised by international peers. In January 1974, a Chinese delegation of representatives in microsurgery led by Chen Zhongwei visited the United States and delivered a presentation as the pioneer of limb (digit) replantation. It further expanded the influence of Chinese limb (digit) replantation on the international community.
Objective:To investigate the clinical efficacy in one stage reconstruction of composite defects of Achilles tendon and surrounding soft tissues with a flap transfer combined with allogeneic tendon transplantation.Methods:From July 2018 to August 2022, a total of 12 patients, including 9 males and 3 females, with a mean age of 31.5(ranged 8 to 56) years old, had surgery with flap transfer combined with transplantation of allogeneic tendon in one stage reconstruction for compound defects of Achilles tendon and soft tissue at the Department of Orthopaedics of First Affiliated Hospital of Nanchang University. The defects of Achilles tendons ranged from 4.0 to 9.0 cm, and the soft tissue defects sized from 3.0 cm × 4.0 cm to 14.0 cm × 6.0 cm. Of the 12 patients, 6 received transfers of sural neurovascular flaps, 3 with peroneal perforator flaps and 3 with free anterolateral thigh flaps(ALTF). The flaps sized from 4.0 cm × 4.5 cm to 15.0 cm×7.0 cm, and in addition, allogeneic tendon grafts were used to reconstruct the defects of Achilles tendons in all patients. All the flap donor sites were either directly sutured or covered with skin grafts. Follow-up was carried out by visits of outpatient clinic or telephone or WeChat distant interviews. The flap survival and recovery of ankle function and Achilles tendon were observed.Results:During the 3 months to 2 years of follow-up, none of the patient showed obvious immunological rejection against the transplanted allogeneic tendon. All 12 flaps survived well with the colour and texture close to the surrounding skin. No ulceration occurred in both of the donor and recipient sites. There was no re-rupture of the transplanted allogeneic tendon. At the final follow-up, ankle movement was measured at 13.4°±2.6° in dorsal extension and 33.6°±3.2° in plantar flexion. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hind foot function score, a score of 88.7±5.6 was achieved with 7 patients in excellent, 4 in good and 1 was acceptable.Conclusion:In patients with a composite defect of Achilles tendon and surrrounding soft tissue, the application of a flap transfer combined with a homogeneous allograft tendon transplantation in an one stage surgery is a feasible surgical procedure. It can achieve a satisfactory outcome with less trauma and fewer complications.
第12届世界重建显微外科学会会议（12th Congress of the World Society of Reconstructive Microsurgery, WSRM2023）于2023年8月17日至19日在新加坡召开。该学会由国际显微外科学会(IMS)和国际重建显微外科学会(ISRM)在1999年合并后成立，此后每2年举办1次学术会议。本次会议的主题是"显微外科的艺术性（Artistry in Microsurgery）"。全球共1 335名显微外科学者注册参会，其中581人次分别以教学课程、全体会议、专家小组讨论或自由论文汇报等形式作了精彩的学术演讲。大会围绕肢体、躯干、头颈、颌面和乳房的显微重建，以及淋巴水肿的外科治疗等内容进行了深入浅出的讨论。
Objective:To explore the technique and clinical effects of free medial plantar flap on reconstruction of the severe defect of thumb caused by electric burn.Methods:Surgical techniques and clinical effects were explored in reconstruction with free medial plantar flap for treatment of severe electric burns of thumbs. From July 2016 to July 2021, 18 patients suffered from severe electric burns of thumbs were admitted in the Department of Burn, Zhengzhou First People's Hospital. All the wounds were the entrance of electric burns. After thorough debridement, the arteries, nerves, tendons, phalanges and interphalangeal joints were exposed to various degrees. Damaged digital proper palmar arteries were ligated and defected proper palmar digital nerves were marked and further anastomosed with the nerves carried by the flap. Palmaris longus tendon grafts were employed to reconstruct the defects of flexor pollicis longus tendon. Wounds were closed by transfer of free medial plantar flaps, and the flap donor sites were closed by inguinal skin grafts. Survival of the flap was observed 1 week after surgery, and the survival of the skin graft in the foot donor site 12 days after surgery. Outpatient follow-up including observation of the appearance and texture of the flap, evaluation of sensory function, thumb alignment and finger flexion according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association. Evaluate the scar hyperplasia in the foot donor site and the standing and walking functions of the donor foot.Results:All flaps survived,at 1 week after surgery. On the 12th day after surgery, all 16 foot flap survived, and 2 patients had local necrosis, and the necrosis healed completely after dressing change for 10 days, the wound healed completely. Among them, 3 patients without tendon transfer experienced a rupture of the flexor pollicis longus tendon at 2 months after surgery, and underwent another palmaris longus tendon transfer. After the surgery, functional exercise was performed with the palm and flexor fingers. After 6-12 months of follow-up, the blood supply, appearance, and texture of the flap were good and similar to that of the palmar skin of the thumb, with varying degrees of recovery in sensation. The TPD was 6-11 mm, and the thumb was restored to varying degrees. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 13 cases in excellent and 5 cases in good. Mild scar hyperplasia remains in the flap site of donor feet, which does not affect the standing and walking functions of the donor foot.Conclusion:The texture of medial plantar skin is similar to that of palmar skin, with good wear resistance and good sensation. Furthermore, it causes a little damage to the donor site and without obvious complication. The medial plantar flap is ideal for reconstruction of a severe wound caused by electric burn in thumb.
Objective:To explore the effect of hallux nail flap design assisted with 3D printing in reconstruction of thumb defect in degloving injury.Methods:From January 2020 to March 2022, 16 patients with thumb defect caused by degloving injury with intact digit flexor and extensor tendons were treated. The patients were 11 males and 5 females, aged 20 to 52 years old, with an average age of 31 years old. The injured patient's hands were firstly scanned by CT and the 3D models were created to map the profile of the tissues required for reconstruction. Photopolymer templates for the defects in thumb were then 3D printed. The printed templates were put on the great toes and accordingly the hallux nail flaps were designed and harvested. The degloving wound of thumb was repaired by the hallux nail flap. Donor sites were repaired with artificial dermis in 6 patients and with ilioinguinal flaps in 10 patients. The effect of surgery was observed at outpatient clinic during postoperative follow-up. The survival of the hallux nail flap and the recovery of the donor site were observed. Function recovery were evaluated according to the Evaluation Standard of Finger Replantation and Reconstruction of Hand Surgery Society of Chinese Medical Association.Results:All the harvested hallux nail flaps matched with the profiles of recipient sites. All the hallux nail flaps survived over 4 to 30 months of follow-up, in an average of 16 months. Appearance of all hallux nail flaps was similar to normal thumbs, with good fingerprint and nails. Sensation recovery were S 3-S 4, with TPD at 4-7 mm. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 15 thumbs were excellent and 1 was good. Conclusion:Application of 3D printing assisted hallux nail flap transfer in reconstruction of defect of thumb in degloving injury can precisely design and harvest the required tissue and minimise a damage to the donor great toe. It improves the appearance of thumb as well as patient satisfaction. It is practical in reconstruction of the defect of thumb in degloving injury.
Objective:To explore the application and clinical efficacy of an innervated arterialised venous flap of the first dorsal metacarpal in reconstruction of thumb and finger pulp defects.Methods:From December 2021 to August 2022, 17 patients received surgery for reconstruction of thumb and finger pulp defects in the Department of Hand Surgery of Sichuan Modern Hospital. All were carried out in emergency surgery. The affected digits included: 3 thumbs, 4 index fingers, 6 middle fingers, 1 ring finger and 3 little fingers. After emergency debridement, a flap of the first dorsal metacarpal carrying superficial radial nerve and arterialised vein was taken for reconstruction of the defect. Donor site of the flap was directly closed with sutures. The survival and functional recovery of the digits and flaps were evaluated through postoperative follow-ups via outpatient visit and telephone and WeChat interviews.Results:Seven flaps developed blisters after surgery, which gradually subsided and healed after dressing change. The rest of 10 flaps survived smoothly, without any vascular compromise. All of the 17 patients(17 digits) had postoperative follow-up for 3-15 months, with 8 months in average. Appearance of thumb and finger pulps were good, with sensation restored to S 1-S 3+, according to the sensory function evaluation criteria of the British Medical Research Council(BMRC). According to Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, all 17 patientswere in excellent of total active movement(TAM). Conclusion:Innervated arterialised venous flap of the first dorsal metacarpal is reliable in reconstruction of the defects of digit pulps with good function and appearance. The flap is easy to take and with a satisfactory recovery of sensation.
目的:探讨60岁以上合并糖尿病的老年人断指再植的治疗方法及体会。方法:2016年1月-2022年1月，陆军第80集团军医院全军创伤骨科研究所对收治的老年糖尿病断指患者，通过围手术期多学科联合诊治，实行断指再植术，共13例24指，男9例18指，女4例6指，年龄60~73岁，平均67岁，均合并1年以上糖尿病病史，急诊随机血糖8.4~17.3 mmol/L，其中8.4~11.1 mmol/L 7例，>11.1 mmol/L 6例。所有患者均为单侧肢体受伤，离断指体：拇指8例10指，示指6例7指，中指4例4指，环指2例2指，小指1例1指。致伤原因：电锯伤6例，三角带挤伤2例，机器伤5例。离断平面：近节9指，近侧指骨间关节处4指，中节7指，中节以远2指。结果:本组13例共24指，最终成活10例21指，断指成活率87.5%，有2手指发生静脉危象、1拇指发生动脉危象，指体坏死后行残端修整术。所有患者术后生命体征平稳，血糖逐步控制至正常水平，未出现感染及其他严重并发症，骨折断端均在6~8周顺利愈合。随访6~24个月，平均11个月，门诊随访9例，微信随访4例。门诊随访中，成活指体外观接近正常，有轻度至中度萎缩，长度略缩短。依据断指再植功能评定标准评定，优11指，良7指，差3指。结论:对合并糖尿病的老年断指患者，把握好手术适应证，通过多学科联合会诊，在围手术期积极对症处理，行断指再植术可取得良好效果。
Objective:To explore the feasibility and clinical effect of modified tibial transverse transport (TTT) technique in treatment of severe diabetic foot.Methods:The research was carried out from November 2015 to November 2017 at the Department of Hand Microsurgery, Xiangya Hospital of Central South University. Red latex was used to perfuse 10 adult lower limb specimens through femoral artery. The study observed the occurrence rate of osteofascial cutaneous branches from the inner and posterior edge of tibia within 6.0 to 10.0 cm distal from the tibial tubercle, as well as the number, distribution, outer diameter and other indicators of the perforating cutaneous branches and periosteal branches. Combined with findings in the anatomical observation, a chimeric flap with a vessel of posterior medial tibial osteofascial cutaneous branch was designed to improve TTT in the treatment of diabetic foot. From February 2016 to November 2018, 12 patients with Wagner’s Grades Ⅲ and Ⅳ diabetic feet were treated. All the patients were treated with a modified TTT, with a piece of designed tibial bone flap at 10.0 cm × 2.5 cm in size. After surgery, 5 patients with gangrenous toes received various toe stump reconstruction surgery for removal of the external fixator for bone transport. Two patients had arch stone flap reconstructions for the wounds of heel and sole, 3 patients had the wounds self-healed, and 2 patients with Wagner’s Grade IV diabetic feet had proximal calf amputations. Postoperative follow-ups were run through visits of outpatient clinic, and meanwhile the preliminary effects of the surgical procedure were observed and summarised.Results:Among the 10 specimens, it was found that a total of 11 osteofascial cutaneous branches(2 branches in 1 case and 1 branch in 9 cases) branched out from the posterior edge of tibia within 6-10 cm distal to the tibial tubercle. The distance to the tibial tubercle was 9.23 cm± 0.62 cm, with an outer diameter at 1.10 mm ± 0.10 mm. After penetrating the deep fascia, the osteofascial cutaneous branch further branched out a skin branch with an outer diameter of 0.59 mm± 0.09 mm, and delivered blood supply to the medial skin of calf. Meanwhile, it also branched out a periosteal branch with an outer diameter of 0.85 mm ± 0.10 mm, and supplied blood to the medial periosteum of tibia. All surgery went smoothly. A significant increase of temperature in foot skin and a significant decrease in postoperative Visual Analogue Scale(VAS) score were found in comparison with what before the surgery( P<0.05). The follow-up time of 12 patients was 24-36(29.33 months ± 4.36 months). After surgery, the symptoms of pain and numbness in the affected limbs were significantly improved or even disappeared and the wounds in foot were completely healed in 10 patients. The wounds of TTT in the calf were all healed in stage-I. The segments of tibial bone transport were all completely healed with healing time of 6.17 months ± 0.83 months. The wounds of the 2 amputees healed well. Conclusion:Modified TTT bone graft can effectively promote wound healing and reduce complications by covering the wound with a posterior tibial medial fascia flap in the treatment of severe diabetic foot. Further studies are required to confirm the benefits to the patients from this modified surgical procedure.
Objective:To explore the therapeutic effect on transposition of peroneal longus tendon in reconstruction of long segment defects of chronic Achilles tendon.Methods:From November 2013 to November 2018, 17 patients with long segment defects of chronic Achilles tendon(greater than 5.0 cm of defect) were admitted in the Department of Trauma and Micro-orthopaedics of Zhongnan Hospital of Wuhan University. The patients were 14 males and 3 females, aged 19-55 years old, with an average of 34.7 years old. Eleven patients had defects on left Achilles tendon and 6 on the right. The chronic defects lasted over 1-12 months with an average of 3.8 months. The broken ends of the Achilles tendon located at 0-5.0 cm from the insertion point. The defects were at 5.0-9.0 cm in length, after debridement of the broken ends. After thoroughly debridement of the scar tissue over the broken end of an Achilles tendon, an autologous peroneal tendon transposition was performed for reconstruction of an Achilles tendon. Postoperative follow-ups were conducted to observe wound healing and complications. Arner Lindholm score was employed to evaluate the therapeutic efficacy before surgery and at the final follow-up. Ankle-hindfoot score of American Orthopedic Foot and Ankle Society(AOFAS) and Achilles Tendon Total Rupture Score(ATRS) were used to evaluate functional recovery. At the final follow-up, heel raise of single affected foot and the maximum circumference of both calves were observed, gait analyses for plantar stress assessment as well as review of ankle CT and MRI scans were conducted for assessment of therapeutic efficacy. Using t test in SPSS 22.0 software to compare preoperative and postoperative AOFAS and ATRS scores, P<0.05 indicates a statistically significant difference. Results:Wounds healed in one stage, except 1 diabetic patient who had haematoma in the wound after surgery and healed after debridement combined with VSD treatment. All the 17 patients had completed the postoperative follow-up that lasted for 24-48 months, with an average of 33 months. According to Arner Lindholm score for efficacy evaluation, 11 patients were in excellent and 6 in good. The postoperative AOFAS scores increased from 62.94 ± 6.51 before surgery to 93.71 ± 6.15 after the surgery. ATRS increased from 29.00 ± 3.54 before surgery to 92.29 ± 3.02 after the surgery, and the score difference between before and after surgery was staistically significant ( P<0.05). No patient experienced a complication such as Achilles tendon rupture, wound infection or nerve injury. During follow-up, ankle functions recovered well, valgus was found powerful as well as heel raise on single foot. The circumference of the affected calf was smaller than that of the healthy side by no more than 1.5 cm. Gait analysis showed balanced distribution of plantar stress. No corpus callosum formation was found in both of the affected and the healthy feet. No obvious sign of osteoarthritis of ankle showed review in CT scans. Ankle MRI scans showed good continuity of the reconstructed Achilles tendons, which become significantly thicker after the surgery. Conclusion:The transposition of the long peroneal tendon is a relatively simple and effective surgical technique for reconstruction of a chronic Achilles tendon rupture or defect in a longer length or a rupture at the insertion point.
Objective:To investigate the efficacy of free superficial circumflex iliac artery perforator flap (SCIAPF) in reconstruction of the donor site of hallux nail flap.Methods:From December 2015 to December 2022, Section Ⅲ of Department of Hand Surgery of Hangzhou Plastic Surgery Hospital conducted thumb reconstruction surgery with free hallax nail flaps for 12 patients with traumatic defects of thumbs. Six patients had degloving injuries of thumb with intact bone scaffold and extensor-flexor tendon. Among the other 6 patients with thumb defects, 3 had grade I defect, 2 had grade II defect and 1 had grade Ⅲ defect, according to Gu Yudong's classification. Free SCIAPFs were used to reconstruct the donor sites of hallux nail flaps. Sizes of the flaps were 3.0 cm× 6.5 cm-9.0 cm ×7.0 cm. All donor sites in the abdomen were directly sutured. After surgery, functional evaluations of the reconstructed thumb were conducted through follow-ups at outpatient clinics and(or) by WeChat interviews, according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, and the functional evaluation of donor feet was conducted according to the Maryland foot function evaluation standard.Results:Successful survival of the 9 cases of flap in the donor site of hallux nail flap. One patient had venous occlusion of flap and survived after timely surgical exploration. One flap had partial necrosis at the tip of flap, and the wound was eliminated with local transfer of a flap. One patient had necrosis over most of the flap with the base of the flap survived, and the wound was repaired by a stage-II skin grafting. The donor sites at groin healed in stage-I in all of 11 patients with a linear scar. One patient who had haematoma at the donor site was cured by removal of the haematoma and a re-suture. All the patients received a 3 to 24 months of postoperative follow-up. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 10 patients were in excellent and 2 in good. All of the great toes remained with original length and recovered normal flexion and extension. No patient suffered pain while walking and running. According to the Maryland foot function evaluation standard, 10 patients were in excellent and 2 in good. All SCIAPFs were satisfactory in colour and texture. Five patients had bloated flaps and underwent Hacks in the stage-Ⅱ.Conclusion:Application of a free SCIAPF in reconstruction of the donor site for hallux nail flap can effectively preserve the appearance and function of the donor site. Meanwhile, the scar in the donor site of groin is concealed with little damage, therefore the groin meets the requirements as a donor site of a flap.
目的:探讨应用分叶股前外侧穿支皮瓣（ALTPF）游离移植修复四肢软组织缺损创面的手术方法。方法:2010年1月-2021年5月，根据四肢软组织缺损、形态不规则、不连续的特点，海南中德骨科医院手足外科设计切取分叶ALTPF游离移植修复四肢软组织缺损创面26例，其中10例大面积缺损面积为13 cm×12 cm~22 cm×19 cm，13例为邻近不相连的创面，3例为贯通型创面。供区创面均直接缝合。出院后主要通过门诊、电话、微信等方式进行定期复查随访，观察皮瓣的血运、肤色、外观、出汗、质地、温度、痛觉、触觉、TPD、有无破溃及供区恢复情况。结果:术后26例患者移植皮瓣均成活。其中2例皮瓣边缘小面积坏死，反复换药后愈合；1例术后48 h内发生静脉危象，积极探查处理，重新吻合血管后皮瓣成活；1例24 h内发生血肿压迫出现血管危象，给予拆除部分缝线充分引流后皮瓣成活。24例患者获得随访，随访时间6~18个月，平均14个月，皮瓣外形良好、无臃肿，质地柔软，色泽正常，感觉功能恢复良好。供区仅留线形瘢痕，外观、功能无明显影响。参照《手外科手术学》的皮瓣综合评定标准，结果优18例、良6例。结论:分叶ALTPF疗效满意，是修复四肢创面的一种较好的手术方法。
目的:探讨干预图在显微神经外科手术患者术中获得性压力性损伤（IAPI）管理中的应用效果。方法:回顾性分析某三甲医院神经外科行显微镜下手术的成人患者216例，其中2022年3-4月在显微镜下行神经外科手术的108例患者作为对照组，采用常规方法进行压力性损伤管理；2023年3-4月在显微镜下行神经外科手术的108例患者作为试验组，采用干预图进行压力性损伤管理。比较两组患者填写压力性损伤风险评估表的例数、压力性损伤风险评估表用时、压力性损伤预防措施执行得分及两组患者压力性损伤发生率，并采用SPSS 25.0统计学软件进行统计学分析。结果:对照组和试验组压力性损伤风险评估表填写例数分别为79例和108例，两组填写评估表用时分别为（118.210±10.271) s和（19.310±3.685) s，差异有统计学意义（ P<0.01)；压力性损伤预防措施执行得分分别为(82.320±3.464）分和（95.610±2.055）分，差异有统计学意义（ P<0.01);压力性损伤发生率分别为12.0%(13/95）和1.9%(2/106)，差异有统计学意义（ P=0.003)。 结论:对于显微神经外科手术患者，干预图有利于促进手术室护士对显微神经外科手术进行IAPI风险评估，降低手术室护士IAPI风险评估用时，并提高IAPI预防措施执行率，干预图可降低显微神经外科手术患者IAPI发生率。
Objective:To evaluated the options in selection of surgical procedures for treatment of the patients suffering from diabetic feet with chronic refractory wounds.Methods:From January 2020 to June 2021, 23 patients with diabetic feet complicated with refractory wounds were treated in Department of Hand Surgery, Shunde Heping Surgical Hospital. The patients were 15 males and 8 females, aged 51-86 years old and with an average age of 65 years old. All the patients had Type-II diabetes for over 5 - 22 years. Average blood glucose of the patients was found at 15.6 mmol/L on admission. Free anterolateral thigh perforator flaps (ALTPF) were used for reconstruction of the wound of diabetic feet in 19 patients, 2 patients received vascular bypass surgery and 2 had amputations. Regular outpatient follow-up were conduct on all patients after surgery.Results:Follow-up time lasted for 8 to 30 months, 12 months in average. At the last follow-up, the donor and recipient sites healed well in the 19 patients who received flap reconstruction, without an infection, necrosis and wound recurrence. Pains were significantly relieved after the surgery in the 2 patients who received vascular bypass surgery, and wounds all healed well after symptomatic treatment and dressing change without recurrence of wounds at the last follow-up. Average Maryland score of foot function was 84 for the patients who had limb salvage, and 2 patients were in excellent and 19 in good at the last follow-up. The 2 patients who had amputation successfully survived through the perioperative period, and the wounds healed well at the last follow-up.Conclusion:The treatment is complicated in the patient suffering from diabetic foot with chronic refractory wounds due to factors such as advanced age, co-existing and complicated underlying diseases together with the complex wounds. Most patients can achieve good prognosis in wound treatment of free flap transfer or vascular bypass surgery. However, a limb salvage is recommended with caution for the patients who have severe infections and dry gangrene.
Objective:To explore the clinical effect of a self-designed wound measurement grid on the design of lobulated perforator flap.Methods:From January 2019 to December 2022, soft tissue defects in limbs of 9 patients were reconstructed by lobulated perforator flaps in the Department of Orthopaedics and Traumatology of Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine. The patients were 7 males and 2 females aged 21-55 years old with 40.3 years old in average. There were 6 upper limb defects and 3 lower limb defects. Self-designed wound measuring grids were applied to guide the design and excision of lobulated perforator flaps during surgery. Five patients were treated by lobulated perforator flap pedicled with the descending branch of lateral circumflex femoral artery and 4 by perforator flaps pedicled with dorsal interosseous artery. The areas of soft tissue defect were 4.0 cm×1.5 cm-26.0 cm×8.0 cm, and the sizes of the flaps were 4.5 cm×1.8 cm-22.0 cm×10.0 cm. After surgery, the blood supply of flaps, flap survival and wound healing were monitored. Flap survival, donor site recovery and limb function were observed at outpatient clinic over the postoperative follow-up, and the limb function was evaluated by the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association and Lower Extremity Measure(LEM).Results:In this study, a total of 17 of 18 lobes of the lobulated perforator flaps survived after surgery. One flap had venous occlusion and after exploration and further treatment, a necrosis occurred in 1 lobe of the lobulated flap and then a free flap transfer was performed again. All the wounds achieved stage-I healing. Postoperative follow-up lasted for 3-18 months with 8.6 months in average. All flaps had good colour and texture, satisfactory appearance and only linear scars remained in the donor sites, without pain and scar contracture. The reconstructed upper extremity defect were evaluated according to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, with 4 patients were in excellent and 2 in good. The reconstructed lower extremity defects were evaluated according to the LEM, and 2 patients were in excellent and 1 in good.Conclusion:The self-designed wound measurement grid was successfully applied in the design of lobed perforator flaps. It can accurately measure a wound surface and quickly extract a wound profile, and it is more convenient and intuitive to guide the design of flaps. It has a good effect in clinical application and further clinical trials are required.
