Objectives To approach the method and clinical effect on tendo calcaneus and complex tissue defect with microsurgery repair.Methods Retrospective summary the methods of 356 cases with tendo calcaneus and complex tissueserious defect,which repaired by different microsurgery from June 1994 to March 201 1.Two type were divided on account of different degree of serious tendo calcaneus and complex tissue defect.Type A:the length of tendo calcaneus defect was less than 3 cm,and cutaneous deficiency is less than 3 cm × 20 cm.Direct suture (166 cases) or Abraham retrograde "V-Y" method (72 cases)was used to repair endo calcaneus defec,anfregional flap metastasis was used to repair cutaneous deficiency.Two hundred and thirtyeight cases were used by those methods,including of lateral heel flap repair(23 cases),medial plantar island flap(58 cases),instep island flap(40 cases),above medial malleolus flap(48 cases),above ateral malleolus flap (24 cases),sural nerve nutrient vessel flap (29 cases) gastrocnemius muscle flap (16 cases).Type B:the length of tendo calcaneus defect was more than 3 cm,and cutaneous deficiency was more than 3 cm × 20 cm.Direct suture could not repair tendo calcaneus,the complex tissue flap free grafting was used to primary repair tendo calcaneus and complex tissue defect.One hundred and erghteen cases were used by those methods,including of tensor fasciae latae flap free grafting (52 cases),lateral above knee complex tissue flap free grafting (26 cases),latissimus dorsi muscle fascia flap free grafting (24 cases),rectus abdominis muscle front sheath flap free grafting (16 cases).Three hundred and fifty-six cases were repaired by these methods,including 238 cases of regional flap transfer 118 cases of tissue flap free grafting.Results In 238 cases of regional flap transfer,two hundred and twenty-six cases were successful,and 12 cases were partly success,which were wound healing by change dressings.In 118 cases of tissue flap free grafting,one hundred and nine cases were successful,and blood vesse articulo were happened to 8 casess,which were success by operations research,and 1 case was failure which had to use another tissue flap.Follow-up visit was dane from 1.0 year to 4.5 years after operation (average 3.2 years).Functional assessment according to the Thermann ralted the results as excellent in 240 csaes,good in 86 cases,common in 22 cases and worse in 8 cases.The fineness rate was 91.6％.Conclusion Microsurgical repair is a good method to tendo calcaneus and complex tissue defect,different method and strategy selected actively by tissue defect degree of tendo calcaneus and complex tissue can achieve satisfactory functional rehabilitation purpose.

Objective To introduce the surgical procedure of reconstructing the distal segment of the thumb using combined bilateral big toe wrap-around flap.Methods A partial fibular side wrap-around flap was harvested from both big toes.The flaps were tailored and designed based on measurements taken from the thumb of the intact side.These two flaps were combined like "mirror image" to reconstruct the distal segment of the thumb.Results This technique was used in 6 thumbs of 6 cases.All the transplants survived.The patients were follow-up for 3 to 9 months.All reconstructed thumbs had full pulp.Two-point discrimination was 5.0 to 8.0 mm.The appearance of the thumb looked real with normal growing nail.There was no impairment of joint movement and thumb function.Donor sites could be directly closed and healed uneventfully.No walking problems were encountered.Conclusion Reconstruction of the distal segment of the thumb using combined bilateral partial big toe wrap-around flap causes less trauma to the donor sites by preserving the shape and nail of the big toes.The appearance of the reconstructed thumb looks near normal.This surgical procedure is an ideal method for finger reconstruction.

2003年6月-2010年12月笔者应用足背皮瓣修复创面,皮瓣内动静脉桥接再植断指,Ⅰ期完成大面积皮肤软组织缺损及长段血管神经缺损的修复9例(12指),全部成活,再植后的手指外形及功能满意.现报告如下.1临床资料1.1一般资料本组男7例,女2例;年龄19 ～41岁,平均27岁.致伤原因:机器压榨伤6例,绞压伤3例,均为掌指关节及附近部位离断,伴手背皮肤软组织缺损.缺血时间1～8h,皮肤缺损面积6.0 cm×4.5 cm～11 cm×7 cm。

Objective To investigate the methods and effects of the pedicle modification in free flap which use medial-lower-leg-flap with a healthy limb cross-leg bridging thoracic umbilical flap.Methods From June 2006 to June 2010,twenty-eight cases with a large area of soft tissue defects caused by severe trauma were included in this study.We used The flap was used to repair the wound,the pedicle of the flap was improved which was designed by medial lower leg flap with a healthy limb cross-leg bridging thoracic umbilical flap:thoracic umbilical flap carrying the cross midline side flap.Medial lower leg flap in tongue cutting out and carrying on the medial malleolus perforator.In the processing of bridge-pedicled,we rolled the proximal porting of cross-leg flap,used medial malleolus perforator flap as a posterior wall and used thoracic umbilical flap carrying the cross midline lateral flap as anterior wall.Two portions formed a combined percutaneous tube.The two tile formmed a combined percutaneous tube.Fixing method for operation adopted external fixator which two legs were paralleling.Observation of postoperative flap survival situation,shape,color,elastic,scar contracture,and dysfunction.Results Twenty-eight cases of postoperative all flaps survived.Vascular crisis was appeared in 2 cases after 8 hours.Upon examination that was low blood pressure,low hematocrit.In treatment of transfusion and infusion,crisis mitigated.In 1 case after 12 hours with pain occurred arterial crisis,which was reliefed with analgesia.There were no vascular crisis in other 26 cases.Followed up for 2-20 months,flap had good blood supply,color and good elasticity.The appearance was not bloated and sensory recoverred partly.There was no apparent stiffness in double knee,ankle joint.Conclusion Medial lower leg flap with a healthy limb cross-leg bridging thoracic free flap transplantation for repairing serious soft tissue defects of the leg is clinically proven good means.Based on the improvement of pedicle,it can reduce the risk and complications.At the same time,it can improve the postoperative nursing care effects.It is worthy of popularization and application. Key words: Medial lower leg flap ; Thoracic umbilical flap ; Transplantation ; Vascular crisis ; Microsurgical operation

<正>胫骨平台骨折临床常见,占所有骨折的1%[1]。若初期处理不当,术后常常出现平台高度丢失,导致关节面不平,力线改变,膝关节不稳,引起创伤性关节炎、膝内外翻,临床表现为关节疼痛、活动障碍等症。2004-01～2010-06笔者对所在科收治的34例胫骨平台骨折术后高度丢失的患者进行统计,分析高度丢失的原因,并进行手术翻修,现报告如下。

OBJECTIVE:To investigate the therapeutic effect of fibular head composite flap for bone and skin defect at medial malleolus in children.METHODS:From Aug. 2005 to Apr. 2009, 4 children cases (2 male, 2 female, from 3 to 11 year) with bone and skin defect at medial malleolus were reconstructed with fibular head composite flaps pedicled with lateral inferior genicular vascular bundle. The skin defect was 3- 6 cm x 8-10 cm in size.RESULTS:All the 4 composite flaps survived completely. The patients were followed up for 4 months to 4 years with good bony healing. Both esthetic and functional results were satisfactory in ankle joint.CONCLUSIONS:The fibular head composite tissue flap has a good therapeutic effect for bone and skin defect at medial malleolus in children.

Objective To explore the surgical method of applying free lateral arm flap in the replantation of complex thumb severance and report the clinical outcomes.Methods From June 2007 to December 2009,9 cases of complex thumb severance with large size skin defect were treated.The lateral arm flap was harvested and applied to bridge the tissue in replantation of complex thumb severance.The radial collateral vessel of the lateral arm flap was used to establish blood supply to the flap and the replanted thumb.The posterior brachial cutaneous nerves were included in the flap and repaired to restore sensation of the flap and the replanted thumb.The sizes of the harvested flaps ranged from 6.5 cmx 4.5 cm to 11.0 cmx 6.5 cm.Blood vessels and nerves were anastomosed in an end-to-end fashion.Results All 9 replanted thumbs and the transplanted lateral arm flaps survived completely.Postoperative follow-up ranged from 5 to 12 months.The overall appearance and texture of the transferred flaps were good.Sensory recovery reached S3 to S4.The length of the replanted thumbs was similar to the healthy side with good appearance.According to the upper limb functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association,the results were rated as excellent in 5 cases,good in 3 cases,and poor in 1 case.Conclusion The hteral arm flap based on the radial collateral artery has constant vascular anatomy and the calibre of the vascular pedicle is big enough for anastomosis.When the cutaneous nerve is repaired,sensory recovery is satisfactory.It is an effective procedure in bridge replantation of complex thumb severance with large size skin defect.

Objective To study the anatomy of the soleus muscle perforator flap and its clinical application.Methods In 6 cadavers specimen with 12 lower limbs,the cutaneous branches and soleus muscle perforator artery were dissected and their measurements were recorded.Fourteen patients with skin and soft tissue defects from July 2002 to October 2010 were repaired by the soleus muscle perforator flap.Of the 14 patients,eight for dorsal and anterior defects of foot,two for anterior defects of malleolus,two for hand defects,two for elbow defects.The size of the flaps was 5 cm × 6 cm - 12 cm × 20 cm.Flap success rates and postoperative course were evaluated. Results The soleus musclocutaneous perforators mostly appeared within 5 - 24 cm length below the head of fibula.The diameter of the artery cutaneous perforator was( 1.08 ±0.22)mm,vena concomitants was (1.20 ± 0.32)mm.All flaps were survived completely and the wounds got primary closure in 14 cases.The flaps were not overstaffed,and their shape,texture and color were similar to normal.All of the 14 cases were evaluated as satisfactory after 6 months to 12 months follow-up. Conclusion The free soleus muscle perforator flap is an ideal flap for repairing skin and soft tissue defects with the merit of simple procedure,minimal trauma and more physiological circulation established.

Objective To provide an anatomical basis for repairing the medial malleolus with bone-severed vascularized fibular head epiphysis, and to explore the effect of clinical application with this method. Methods Figures of fibular head and medial malleolus were measured on 20 fresh lower limbs specimens of child age from 2 to 12 years old, then bone-severed formula was deduced. The bone-severed composite fibular head epiphysis to repair the defect of medial malleolus were carried for 6 child patients of emergency or post-poned cases on one stage. Obersved the clinical effect by following-up. Results The angle between fibular head and stem (M) was(170±8)°, angle of fibular head sadacc(N) was (145 ±6)°, length(1.5±0.2)cm and width (1.4±0.2)cm; angle between medial malleolus and stem(1) was(152±8)°, length of the articular surface of medial malholus was(1.25 ± 0.2)cm and width (1.25 ± 0.2)cm. Angle between defect surface and tibia was(Q). Formula: angle of bone-severing X = L-N-Q, and apex at the upper 1/6 of the reversed articular surface of fibular. 6 cases with this method was completed, all healed at stage one, following-up 1 to 3 years, medial malleolos developed well and no epiphysis ossification anticipation, and the ankle joint has no inversion with its loadind and walking function good. Conclusion The fibular head epiphysis and the medial malleolus differ in shape to some extent, but good donor can be got by bone-severing, can repair the epiphysis and soft tissue defect of the medial malleolus at one stage with additional flap, developing with the child at the same time, it is a perfect method to reconstruct the traumatic defect of child medial malleohs.

Objective To explore and solve the problem of insufficiency and malformation due to cripple hand and defect of digital bone resulted of innate and injured. Evaluation to the methods of bone autografting combinated with flaps to reconstruct the deficient hand and digits. Methods Vascularized iliac bone or metatarsophalangeal joints (MPJ) or toes transplantation incorporated with flaps were used to reconstruct the defected bone in palm or fingers. Combined with tendon absence in such cases should be repaired or restituted by tendon autografting in one stage or by stages. Results Total 16 cases were treated by the methods metioned above. Except 1 of 16 was failure resulted in severe infection, the others were reconstructed successfully. 13 of 16 were followed up 8 months to 2 years, the evalution of the group from motion,sensation and appearance shew that the fine rate of motion was 53.8 percent, the rate of appearance and sensation were both 69 percent. Conclusion Vascularized iliac bone or metatarsophalangeal joints (MPJ) or toes transplantation incorporated with flaps are available to reconstruct the defected bone in palm or fingers, and can reduce disability effectively while obtain a satisfactory outlook and proper functions by those methods.

Objective To introduce a new procedure for 2nd toe plasty by transferring local flap from the 3rd toe in 2nd toe-to-thumb/finger reconstruction. Methods In 26 cases of 2nd toe transfer to reconstruct the thumb or fingers,a flap from the 3rd toe based on an anastomosing branch from the 2nd dorsal metatarsal artery or the 2nd plantar metarsal artery was harvested and insetted to the fibular side of the middle phalanx of the 2nd toe to increase the circumference of the transplant. A pulp flap was also designed based on the anastomosis between the dorsal digital arteries,between the dorsal and plantar arteries.or between the plantar arteries.It was transfefred and insetted in the plantar aspect of the 2nd toe to eliminate middle stenosis.The pre-fabricated 2nd toe was transferred to reconstruct the thumb and fingers. ResultsAll 76 flaps of 38 toe transfers in the 26 cases survived.There was no compromise of the blood circulation to the 3rd toe.The appearance of the reconstructed finger was satisfying. Conclusion Transfer of local flap from the 3rd toe in 2nd toe-to-thumb/finger reconstruction can improve the appearance of the 2nd toe transplant and is thus a good procedure.

Objective To investigate a more perfect method for a nice outward appearance of the reconstructed thumb (finger) Methods An artery pedicle composite flap from fibular side of the great toes inlaid in the tibial (ventral) side of the free second toe before transplantation Results The reconstructed thumb (finger) gots a nice looking and normal function while no blight to the great toe was occurred Conclusion It is an effective new procedure in ameliorating outward appearance of the reconstructed thumb (finger) by transferring the free second toe inlaid with the composite pedicle flap form fibular side of the great toe

Objective To explore the available methods in repairing and restoring the composite tissue defects after trauma of the lower extremities Methods One hundred and sixty four cases were studied in this article,each has a large area of skin defect and soft tissue defect,or combined with other tissue defects such as bone,muscle tendon,blood vessel,while blood supply to the foot of the injuried in all the cases was deficiency of bloodless which we calledsever trauma of the lower limb According to the varied tissue defects and its injuried degree,five operating procedures were designed and introduced Result None of the limbs was severed,a 5～10 year follow up found a good result in 96 3% in all the cases Conclusion The five surgical means mentioned above were satisfied in repairing and restoring varied tissue defects following severe trauma of the lower limbs,and the injuried limbs may be saved