Our institution has conducted an annual perforator flap-based microsurgical training course for clinicians from different institutions. This study aims to characterize the post-training practice patterns and outcomes of the course. From 2016 to 2022, a two-week course was conducted annually, including three modules: theoretical lectures, cadaver-based surgical simulation, and live surgical demonstrations. A cross-sectional study was carried out among course participants in November 2024. Participant demographics, training backgrounds, course evaluations, and their clinical practice over the two years following the training were collected and analysed. A total of 279 two-year follow-up questionnaires were distributed, with a 74.6

The purpose of this study is to reveal the expression profile of microRNA (miRNA) in the plasma exosomes of patients with alcohol-induced osteonecrosis of the femoral head (AIONFH), and to further explore the potential effect of alcohol-stimulated hepatocyte exosomes on vascular endothelial cells (VECs). The total RNA of plasma exosomes of normal people (NC-Exos) and patients with AIONFH (AI-Exos) were extracted, followed by Illumina high-throughput sequencing. GO and KEGG analyses were performed. MiR-155-5p in alcohol-stimulated hepatocyte exosomes (AML-Exos) was detected by RT-PCR. The effects of AI-Exos/AML-Exos on the migration, proliferation, and apoptosis of VECs were detected by wound healing assay, CCK-8 assay, and flow cytometry, respectively. The expression of HIF-1α in VECs, a target gene of miR-155-5p, was detected by Western Blot and qRT-PCR. High-throughput sequencing showed that 82 miRNAs were differentially expressed in AI-Exos. RT-PCR results indicated that miR-155-5p, which targets to regulate HIF-1α as confirm via dual-luciferase assay, was the most significantly up-regulated in AI-Exos. Further studies demonstrated that miR-155-5p was specifically up-regulated in AML-Exos. Both AI-Exos and AML-Exos inhibited the proliferation and migration of VECs, promoted their apoptosis, and down-regulated the expression of HIF-1α and VEGFA. This study is the first to reveal the miRNAs expression profile in plasma exosomes of AIONFH patients and suggest a potential mechanism by which exosomes released from alcohol-stimulated hepatocytes may regulate VECs in AIONFH.

ABSTRACTIntroductionReconstruction for various regions of the foot and ankle in pediatric patients remains a challenging topic. This study presents the circumflex scapular artery perforator (CSAP) flap and its surgical refinements for addressing soft tissue defects in various regions of the foot and ankle in pediatrics.Patients and MethodsForty‐seven patients underwent CSAP flap and its surgical refinements for the reconstruction of foot and ankle defects from 2010 to 2022. Mean age was 6.9 (range 2–14). Defects were observed in the ankle, dorsal foot, heel, and sole. The classic CSAP flap was used in 23 patients, and the CSAP flap with refined techniques was utilized in 24 patients, including double skin paddle, debulking, flow‐through, and chimeric CSAP flaps.ResultsThe size of the CSAP flaps ranged between 4.5 × 4 and 18 × 6.5 cm2. All flaps survived except for one case. The patient suffered total flap necrosis and was treated with a secondary reconstructive surgery. Primary closure of the donor site was achieved in all cases. The average follow‐up period was 15.6 months. At the final follow‐up, the mean AOFAS score was 93.6 (range 77–100). Mean VAS flap appearance score was 8.1 (range 6–10). Most patients showed satisfactory results.ConclusionThe CSAP flap and its surgical refinements are alternative options for repairing pediatric foot and ankle defects, especially in cases involving large defects around the ankle joint, dorsal foot, and non‐weight‐bearing regions of the heel and sole.

BACKGROUND:The reconstruction of complex wounds of the hand still has challenges in achieving aesthetic, functional and sensory recovery. We presented our experience of using the polyfoliate and chimeric radial collateral artery perforator flaps (RCAPF) to repair complex hand defects, aiming to explore the feasibility of special-form RCAPFs in hand coverage and enhance the comprehension of their respective indications. METHODS:From June 2014 to March 2021, 26 cases (19 males and 7 females, mean 44.4 years) underwent defect and sensation reconstruction of their hands with special-form RCAPFs, which manifested as multiple adjacent or irregular single wounds and composite tissue defects complicated with a degree of nerve injury. The clinical effects of the free RCAPFs were evaluated by integrating the postoperative and long-term follow-up outcomes of all cases. RESULTS:Altogether 8 polyfoliate flaps, 17 chimeric flaps and 1 polyfoliate-chimeric flap were harvested. Of them, 23 flaps survived uneventfully in one stage. Venous congestion occurred in 3 cases, two of which survived through vascular exploration and another one was finally repaired by the contralateral RCAPF. The follow-up results showed that the appearance of both the recipient and donor sites mostly recovered satisfactory. All the bone flaps properly healed. The BMRC sensory evaluation results of all skin flaps were S4 in 8 flaps, S3 in 18 flaps, and S2 in 9 flaps. CONCLUSIONS:The free RCAPFs can be designed in various forms with a reliable blood supply, contributing to reconstructing simple and multiple wounds of the hand with or without bone defects and dead space.

Background Polydactyly is a prevalent congenital anomaly with an incidence of 2.14 per 1000 live births in China. GLI family zinc finger 3 (GLI3) is a classical causative gene of polydactyly, and serves as a pivotal transcription factor in the hedgehog signaling pathway, regulating the development of the anterior-posterior axis in limbs. Methods Three pedigrees of polydactyly patients were enrolled from Hunan Province, China. Pathogenic variants were identified by whole-exome sequencing (WES) and Sanger sequencing. Results Three variants in GLI3 were identified in three unrelated families, including a novel deletion variant (c.1372del, p.Thr458GlnfsTer44), a novel insertion-deletion (indel) variant (c.1967_1968delinsAA, p.Ser656Ter), and a nonsense variant (c.2374 C > T, p.Arg792Ter). These variants were present exclusively in patients but not in healthy individuals. Conclusions We identified three pathogenic GLI3 variants in polydactyly patients, broadening the genetic spectrum of GLI3 and contributing significantly to genetic counseling and diagnosis for polydactyly.

Objective:Management of large irregular wounds in children had been confusing plastic and reconstructive surgeons. Herein, this study was aimed to propose a new treatment method based on the principle of adapting different recipient zones to overcome the intractable wounds, simplifying and programing the design process of targeted flaps for covering large irregular soft-tissue defects. Patients and methods:From January 2009 to December 2020, 31 children (9 girls and 22 boys) aged 3-16 years (mean 9.8 years) underwent multiple modular flaps with edge to edge splicing reconstruction of the lower extremities. All the wounds were large with non-adjacent defects and with or without a dead space. Several variants of flaps were harvested according to the needs and reconstruction requirements of patients. Results:A total of 71 flaps were harvested from 31 patients and all flaps donor sites received primary closure. Nine patients underwent split-thickness skin grafting, and three cases of flaps survived from vascular crisis by rebuilding the vessels and the rest accepting LD flap transplants. And five partial necrosis of the distal epidermis flaps recovered using skin grafting and dressing change. No major complication was encountered in other patients and donor sites, except one heel ulcer. During the follow-up (ranging from 16 to 38 months, mean 27.7 months), aesthetic and functional results of reconstructed limbs were satisfactory in all patients. Conclusions:The Individualized design program of multiple flaps for adapting different recipient zones is an alternative for repairing large irregular soft-tissue defects in children, beneficial for plastic and reconstructive surgeons to simplify and program the process of designing and perform multiple flaps to achieve this goal. Level of evidence:III, Retrospective.

BackgroundLegg–Calvé–Perthes disease (LCPD) is a juvenile form of ischemic femoral head osteonecrosis affecting children. The lack of effective and timely treatment results in severe sequelae in children (especially older ones). Although LCPD has been widely studied, little is known about its etiology. As a result, its clinical management is still challenging. This study will investigate the clinical and radiological results of patients older than 6 years and treated with pedicled iliac bone flap grafting for LCPD.Materials and methodsA total of 13 patients (13 hips) with late presentation of LCPD were treated with pedicled iliac bone flap grafting. Of the 13 patients, 11 were male and 2 were female. The average age of the patients was 8.4 years (range 6–13). Preoperational radiographs and pain scores were analyzed for lateral pillar classification and the Oucher scale. The final follow-up radiograph was classified using a modified Stulberg classification. Limping, extremity length inequality, and range of motion were clinically assessed.ResultsThe average follow-up of the patients was 70 months (range 46–120). During the surgery, seven hips were found to be lateral pillar grade B, two were grade B/C, and four were grade C. In the final examination, 12 hips were evaluated as good (Stulberg class I or II) and one as medium (Stulberg class III). There was limb shortening in one patient who was Stulberg class III. There was a significant difference between the preoperational and postoperational radiographic values and the Ocher scale, regardless of the surgical staging (P < 0.05).ConclusionsPedicled iliac bone flap graft can treat LCPD accompanied by pain and lateral pillar stage B, B/C, and C in children over 6 years.Level of EvidenceLevel IV—case series.

Background: The recent increase in the number of patients with lower extremities lymphedema and the development of microsurgery techniques have led to a rise in lymphedema treatment. Vascularized omental lymph node transfer (VOLT), an emerging treatment modality for extremity lymphedema, has shown its unique advantages in reconstructing lymphatic circulation and absorbing exudated lymphatic fluid. Patients who underwent radical tumor resection with/without radiation therapy treatment often present with impairment or degeneration of the inguinal lymph nodes. For such cases, VOLT could provide adequate lymph nodes and tissue to absorb edema fluid in these areas. Therefore, we analyzed the operative outcomes of VOLT under the guidance of magnetic resonance lymphangiography (MRL) in this study, as this individualized and precise surgical procedure could benefit patients and improve their quality of life. Methods: From November 2021 to September 2022, a total of 14 patients' 19 legs with extremity lymphedema underwent a VOLT with or without lymphaticovenous anastomosis (LVA). Outcomes, including circumference reduction rates, preoperative and postoperative MRL results, and other complications, were analyzed. Results: The mean follow-up period was 8.86 & PLUSMN;1.41 months (range, 7-11). The mean circumference reduction rates {circumference reduction rate (%) = [1 - (postoperative affected limb - healthy limb)/ (preoperative affected limb - healthy limb)] x 100%} of different planes (i.e., ankle, 10 cm above the knee, 10 cm below the knee, 10 cm above the ankle, and 20 cm above the knee) were 15.64%& PLUSMN;40.08%, 11.79%& PLUSMN;30.69%, 20.25%& PLUSMN;24.94%, 7.73%& PLUSMN;30.05%, -1.517%& PLUSMN;16.75%. Notably, one patient had multi-drug-resistant gram-negative infections, which resulted in the loss of three flaps. The postoperative MRL showed improved lymphatic drainage and lower extremity volume in the remaining 13 cases. Conclusions: The precision evaluation of inguinal lymph nodes and lower extremities lymphatic system through MRL using VOLT can provide surgeons with a comprehensive understanding and reliable evidence for the treatment of cancer-related lower extremity lymphedema.

Abstract Background Application of the thoracodorsal artery perforator (TDAP) flap is known to be a popular and reliable method for extremity reconstruction. This manuscript presents our clinical outcomes in reconstructing soft tissue defects using simple and advanced TDAP flaps. Methods From 2013 to 2022, 53 patients with a mean age of 23 years (ranging from 2 to 72 years) underwent reconstructive surgery with different patterns of free TDAP flaps, including chimeric TDAP flaps, double skin paddle TDAP flaps, flow-through TDAP flaps, conjoined TDAP flaps, and microdissected debulking TDAP flaps. Results All TDAP flaps survived. The size of the TDAP skin paddle ranged between 5 × 3 and 25 × 10 cm2. Primary closure of the donor site was achieved in all patients in the simple application group, and one patient in the advanced application group underwent partial skin grafting. Partial flap loss occurred in one case in the simple TDAP flap group and four cases in the advanced application group. There was one case of flap bulkiness and two cases of scar hyperplasia in the simple TDAP flap group. The mean follow-up duration was 11 months (4–46 months). Conclusions The free TDAP flap, with five types of advanced applications, makes it versatile for reconstructing different kinds of soft tissue defects of the extremities that can be used to achieve individualized defect reconstruction, minimize donor site morbidities, and an aesthetic appearance.

Trauma or lesion resection often causes complex wounds with deep soft tissue defects in extremities. Simply covering with a skin flap will leave a deep dead space resulting in infection, non‐healing wounds, and poor long‐term outcomes. Thus, effectively reconstructing complex wounds with dead space leaves a clinical challenge. This manuscript presents our experience using chimeric medial sural artery perforator (cMSAP) flap, to reconstruct complex soft tissue defects of the extremities, thereby exploring broader analysis and indications for future reference. Between March 2016 and May 11, 2022, patients (8 males and 3 females) with a mean age of 41 years (range from 26 to 55 years) underwent reconstructive surgery with the cMSAP flap. The cMSAP flap consists of an MSAP skin paddle and a medial sural muscle paddle. The size of the MSAP skin paddle ranged between 9 × 5 cm and 20 × 6 cm, and the size of the medial sural muscle paddle ranged between 2 × 2 cm and 14 × 4 cm. Primary closure of the donor site was achieved in all cases. Of the 11 patients, the cMSAP flap survived in 10 cases. The vascular compromise occurred in one special case and was treated with surgical procedures. The mean follow‐up duration was 16.5 months (range of 5–25 months). Most patients present satisfactory cosmetic and functional results. The free cMSAP flap is a good option for reconstructing complex soft tissue defects with deep dead space in extremities. The skin flap can cover the skin defect, and the muscle flap can fill the dead space against infection. In addition, three types of cMSAP flaps can be used in a broader range of complex wounds. This procedure can achieve an individualised and three‐dimensional reconstruction of the defects and minimise the donor site morbidities.

Objective: Vascularized composite allografts (VCAs) refer to the transplantation of multiple types of tissues during plastic and reconstructive surgery. Several publications have emerged in the field of VCA. However, there are no bibliometric studies on this topic. The aim was to multidimensionally analyze the knowledge base and hotspots in this subject. Methods: We retrieved all publications related to VCA from the Web of Science Core Collection (WoSCC), published from 2002 to 2021. Next, scientometric analysis of different items was performed using various bibliometrics software to explore knowledge base, research hotspots, and advancement trends in this field. Results: We included a total of 3,190 English articles from 2002 to 2021. The number of publications increased steadily annually. The United States produced the highest number of publications, followed by China. Most publications were from Harvard University, followed by Johns Hopkins University. The most authoritative academic journal was Plastic and Reconstructive Surgery. Transplantation occupied the first rank of co-cited journal list. Maria Z Siemionow may have the highest influence in the VCA field with the highest number of citations (n = 88) and co-cited references (n = 1252). Clinical studies on different allografts, immunosuppression, and tissue engineering were both the knowledge base and recent topics in VCA research. Conclusions: The first bibliometric study comprehensively summarized the trends and development of VCA research with steady growth over the past two decades. Currently, the most active topics are the clinical application of multiple allografts, immunosuppression strategies/therapies, and translation of tissue engineering to clinical practice.

BACKGROUND:Vascular malformations are common but complicated types of disease in infants, with unclear causes and lack of effective prevention. The symptoms usually do not disappear and tend to progress without medical intervention. It is extremely necessary to choose correct treatment options for different types of vascular malformations. A large number of studies have confirmed that sclerotherapy has a tendency to become the first-line treatment in near future, but it is also associated with mild or severe complications. Furthermore, to our knowledge, the serious adverse event of progressive limb necrosis has not been systematically analyzed and reported in the literature.CASE PRESENTATION:Three cases (two females and one male) were presented who were all diagnosed as vascular malformations and were treated by several sessions of interventional sclerotherapy. Their previous medical records showed the use of several sclerosants in different sessions including Polidocanol and Bleomycin. The sign of limb necrosis did not occur during the first sclerotherapy, but after the second and third sessions. Furthermore, the short-term symptomatic treatment could improve the necrosis syndrome, but could not change the outcome of amputation.CONCLUSION:Sclerotherapy undoubtedly tends to be the first-line treatment in near future, but the adverse reactions still remain major challenges. Awareness of progressive limb necrosis after sclerotherapy and timely management by experts in centers of experience of this complication can avoid amputation.

Background: Reconstruction of the large soft-tissue defects in the lower extremity still constitutes a challenge for plastic surgeons. This retrospective study was conducted to compare the surgical and clinical outcomes of the chain-linked bilateral anterolateral thigh perforator flaps and extended latissimus dorsi musculocutaneous flap in the reconstruction of the large soft tissue defects of the lower extremity. Methods: From January 2012 to December 2021, 34 patients aged between 20 and 66 years received chain-linked bilateral anterolateral thigh perforator flaps (15 cases) or extended latissimus dorsi musculocutaneous flaps (19 cases) for the reconstruction of extensive soft-tissue defects in the lower extremity. The two groups were homogeneous in terms of age, etiology, comorbidities, and flap area. In addition, the intraoperative data, outcomes, complications, and long-term follow-up results were collected and analyzed. Results: The extended latissimus dorsi musculocutaneous flap group had a shorter operation time (271.8 ± 59.5 min vs. 429.6 ± 51.9 min), harvest time (58.9 ± 24.8 min vs. 152.7 ± 41.4 min), and anastomosis time (27.2 ± 10.4 min vs. 53.7 ± 8.1 min) than the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Based on patient self-assessment, the donor site temporary muscle weakness in the extended latissimus dorsi musculocutaneous flap group was significantly more than that in the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Conclusion: Both methods can repair large defects and restore the function of the injured limbs at a single stage. However, considering the operation time and flap-harvesting time, the authors recommend the extended latissimus dorsi musculocutaneous flap, especially for those who cannot tolerate a prolonged surgery.

BackgroundTransverse and oblique deep inferior epigastric artery perforator (DIEP) flaps are widely used in breast, lower extremity, urogenital, head and neck reconstruction. In this report, we present our experience with selecting perforator vessels for transverse and oblique DIEP flaps based on an anatomical study and clinical cases.Materials and methodsA detailed anatomical study of the DIEP flap was carried out using a standardized injection of lead oxide in 10 fresh cadavers. Additionally, 35 male pediatric patients (age 5–12 years) underwent lower extremity reconstruction with a DIEP flap. A transverse DIEP flap was used when the defect template did not exceed zone IV, while an oblique DIEP flap was used when the defect template exceeded zone IV.ResultsPerforators located below the umbilicus in zones I and II were rich in transverse anastomoses across the midline of the abdominal wall, which is the basis for the transverse DIEP flap. Perforators lateral to the umbilicus in zone I had true anastomoses with the musculophrenic artery, the morphological basis for the oblique DIEP flap. The DIEP flap design was transverse in 20 patients and oblique in 15. Flap sizes ranged from 8 × 4.5 cm2 to 24 × 9 cm2. One oblique DIEP flap was necrosed totally, and it was repaired by a latissimus dorsi musculocutaneous flap.ConclusionThe transverse DIEP flap design based on the perforator located below the umbilicus in zone I is recommended for small skin and soft tissue defects. We recommend the use of the oblique DIEP flap design based on the perforator lateral to the umbilicus in zone I as an extended flap to reconstruct large tissue defects.

To explore the clinical and radiological effects of the free vascularized iliac bone flap (FVIBF) based on deep iliac circumflex vessels for Association Research Circulation Osseous (ARCO) stage 3 traumatic osteonecrosis of the femoral head (TONFH) in young adults. From February 2017 to August 2020, a total of 29 (29 hips) TONFH patients with ARCO stage 3 were enrolled in this study. Following the FVIBF standard procedure, the necrotic area of the femoral head was removed and a free vascularized iliac bone flap was harvested and grafted. X-rays were performed at 1, 3, 6, 9, and 12 months and every 6 months thereafter postoperatively for evaluation of the degree of femoral head collapse. The Beijing University of Chinese Medicine X-ray Evaluation Method (BUCMXE) was used to evaluate the hip preservation effects based on anteroposterior hip radiographs. Hip functions were evaluated using the Harris hip score (HHS) every 6 months and annually after 24 months, and the quality of life was assessed using the SF-36 questionnaire at 18 months postoperatively. The mean follow-up time was 30 months (range 12–54 months). None of the patients was lost to follow-up, and the wounds healed primarily without infection and deep venous thrombosis of lower limbs. The HHS at 12 months postoperatively was significantly improved than that before surgery (83.4 ± 7.4 vs. 64.8 ± 14.1; p < 0.05). The BUCMXE radiographic score at 12 months postoperatively did not reveal any significant differences in femoral head morphology and osteonecrotic lesion, when compared to preoperation. The SF-36 questionnaire showed significant improvements in social functioning, role physical, bodily pain, and general health (p < 0.05). However, eight patients had varying degrees of femoral head collapse after surgery, and only one of them underwent THA due to pain and collapse aggravation. BUCMXE-Osteoarthritis scores showed that 23 hips were stable and six hips were advanced, among which five hips staged ARCO 3B and one staged ARCO 3A preoperatively, with statistically significant differences (p < 0.05). Although some patients showed no improvement of radiological outcomes, most patients with severe TONFH could still benefit from the FVIBF procedure. Further studies should attempt to improve this surgical procedure and explore its long-term efficacy.

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.

Background Complex heel defects constitute a significant challenge for plastic surgeons. Objectives In this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored. Methods From January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases. Results Flap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm2 to 22 × 10 cm2, and the size of a muscle segment ranged from 6 × 3 × 1 cm3 to 10 × 3 × 2 cm3. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm). Conclusion Double skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.

Objective:To explore the clinical efficacy of modified osteotomy with vascularized capitate bone transfer for the treatment of Kienbock′s disease.Methods:From March 2014 to December 2019, 19 patients with Kienbock′s disease were treated in our department, including 15 cases of Lichtman stage ⅢA and 4 cases of ⅢB. After the necrotic lunate bone was removed, the capitate bone was obliquely osteotomized, the iliac bone graft was used to repair the secondary bone defect of the capitate bone, and the vascularized capitate bone was transferred to reconstruct the lunate bone defect. The grip strength, wrist pain VAS, Quick-DASH score, PRWE score, wrist height index and wrist range of motion were recorded.Results:The patients were follow-up for 16 to 86 months, with an average of 47 months. All the incisions achieved primary healing, and there were no complications of infection and neurovascular injury. The VAS of wrist joint was (5.53±1.46) points before operation and (2.12±1.41) points after operation. The postoperative pain was significantly relieved compared with that before operation. The average grip strength of the affected wrist was (10.05±2.83) kg before operation and (28.45±4.58) kg after operation. The Quick-DASH score was 25.45±4.56 before operation and 8.12±1.81 after operation. The PRWE score was 26.97±7.52 before operation and 4.41±1.73 after operation, with significant difference ( P<0.05). X-ray film showed that the wrist height index was 0.49±0.03 before operation and 0.48±0.04 after operation, and the difference was not statistically significant ( P>0.05). Conclusion:The modified osteotomy with vascularized capitate bone transfer is an effective method for the treatment of Kienbock′s disease.

BACKGROUND:Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects. PATIENTS AND METHODS:From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap. RESULTS:All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm2 to 26 × 11 cm2, and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm2 to 21 × 7 cm2. The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula. CONCLUSION:We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

Objective The aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities. Methods From January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty‐one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty‐eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single‐ and double‐wing extended LD flaps were designed and harvested according to the shape of the wounds. Results The flaps received consisted of 64 single‐wing and eight double‐wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re‐exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow‐up was 15.7 months (range, 10–56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow‐up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh. Conclusion Single‐ and double‐wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.