A novel radiological assessment to identify acute vertebral compression fractures: A pilot observational study

Aim

The diagnosis of acute vertebral compression fractures (AVCFs) is often challenging. An alternative to magnetic resonance imaging, which may not always be available, includes a comparison of supine and sitting/standing position radiographs. However, this cannot be accomplished in patients with acute vertebral compression fractures who require emergency transport and are in severe pain. In this study, aimed to assess the diagnostic accuracy of comparing lateral-view radiographs of the thoracolumbar spine in supine and 30° head-elevated positions, which are less painful.

Methods

We retrospectively examined 30 patients with AVCFs who were transported by ambulance to our emergency department between June 2018 and May 2019. All underwent 30° head-elevated lateral-view thoracolumbar spine radiography and magnetic resonance imaging. We evaluated vertebral fractures by examining changes in vertebral wedging ratio (WR) from supine to 30° head-elevated position (Δ WR) using the following equation: Δ WR = WR (30° head-elevated) - WR (supine). We compared Δ WR to that of unfractured vertebrae as control.

Results

A total of 176 vertebrae were included (fractured, 32 and non-fractured, 144). Δ WR of fractured vertebrae ranged between 5.1% and 24.4%, whereas non-fractured vertebrae ranged between -6.7% and 4.3%. Median Δ WR of fractured vertebrae was significantly higher than non-fractured vertebrae (12.6% versus -0.5%, p < 0.001). No patients reported pain during 30° head-elevated positioning.

Conclusions

Lateral radiographs in supine and 30° head-elevated positions can accurately diagnose of AVCF, without worsening pain. This study showed a Δ WR value of ≥5.1% for AVCFs.

The "sliding door" technique for closure of abdominal wall defects after rectus abdominis musculocutaneous flap transposition

Radical surgery is often necessary in patients with local recurrence of rectal cancer or in those with carcinoma associated with an anal fistula. The surgery may include extended excision of the perineal area and can create a large dead space in the pelvis and a large skin defect, often necessitating reconstruction of the pelvic floor using rectus abdominis musculocutaneous (RAM) flap transposition. Wound dehiscence and incisional hernia are common complications of RAM flap transposition. We report herein our encounter with 3 patients in whom we used a "sliding door" technique for reconstruction of the abdominal wall after the creation of a RAM flap. One patient underwent abdominoperineal resection with sacrectomy and RAM flap transposition; he experienced a postoperative surgical site infection and wound dehiscence, which we urgently repaired by reconstructing the abdominal wall using the sliding door technique. Two other patients underwent posterior pelvic exenteration with sacrectomy and RAM flap transposition. These patients underwent simultaneous abdominal wall reconstruction using the sliding door technique. No patient experienced postoperative pelvic sepsis, wound dehiscence, or incisional hernia. The sliding door technique might be useful for preventing wound dehiscence and incisional hernia in patients undergoing RAM flap transposition.

Ewing sarcoma of the proximal phalanx: case report

We report a case of primary Ewing sarcoma of the proximal phalanx of the right middle finger in an 18-year-old boy. He was treated with neoadjuvant chemotherapy, followed by ray amputation. To restore maximum function, the index ray was transferred to the base of the third metacarpal bone and fixed with a plate. The function of his right hand after the operation was excellent and the cosmetic appearance acceptable. There was no evidence of local recurrence or metastasis after 20 months follow up.

[Arthroscopic synovectomy for rheumatoid arthritis]

Even though the paradigm shift was occurred in treatments for rheumatoid arthritis (RA), some patients are not well controlled with several treatments. Because arthroscopic techniques advanced remarkably, effectiveness of arthroscopic synovectomy is reconsidered, especially for residual synovitis in biologics unresponders. A combined therapy with biologics and arthroscopic synovectomy leads to improvement of composite measures such as DAS28. Arthroscopic synovectomy can be a powerful tool for the tight control in RA treatments. In addition with progressions of ultrasonography, ultrasound-guided regional anesthesia became popular recently. Using this technique, we can expand indication of surgical intervention even in patients with severe lung problems.

Osteogenesis of cryopreserved osteogenic matrix cell sheets

Cryopreservation of tissue engineered bone (TEB), whilst maintaining its osteogenic ability, is imperative for large-scale clinical application. We previously reported a novel cell transplantation method, in which bone-marrow-derived mesenchymal stem cells (BMSCs) were cultured to confluence and differentiated down the osteogenic lineage to form osteogenic matrix cell sheets (OMCS). OMCS have high alkaline phosphatase (ALP) activity and osteocalcin (OC) contents and can be easily used for producing TEB. The aim of the present study was to investigate whether TEB produced by cryopreserved OMCS maintains sufficient osteogenic potential in vivo. OMCS were prepared and divided into three groups according to storage period of cryopreservation (fresh (no cryopreservation), 4 week and 12 week cryopreservation groups). OMCS were cryopreserved by storage in freezing medium (Cell Banker 1®) at -80 °C. Cryopreserved OMCSs were rapidly thawed at room temperature and wrapped around Hydroxyapatite (HA) scaffolds prior to implantation into subcutaneous sites in rats, to determine their in vivo bone-forming capability. The constructs were harvested 4 weeks after transplantation and examined histologically and biochemically. Histological analysis of the constructs showed extensive bone formation in the HA pores with high ALP activity and OC content detected in the cryopreservation groups. The present study clearly indicates that cryopreserved/thawed OMCS are still capable of producing mineralized matrix on scaffolds, resulting in bone formation. This cryopreservation technique could be applied for hard tissue reconstruction to ease the cell preparation method prior to time of use.

Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

This study investigates long-term clinical results (> 10 years) of periarterial sympathectomy in chronic ischaemic digits compared with intermediate-term results (3 years). Periarterial sympathectomy via the palm and volar wrist was carried out on 11 hands of seven patients with digital ischaemia but no gangrene or severe ulceration. The aetiology of ischaemia was Buerger's disease in four hands, collagen disease in three hands, and repetitive digital trauma in four hands. Subjective symptoms were evaluated at a mean follow-up period of 12 years. The efficacy of surgery was assessed objectively using thermography and plethysmography. Although five of seven patients continued on oral vasodilators and antiplatelet agents until the final follow-up, improvement of symptoms was maintained in all patients between intermediate- and long-term evaluations. Our results suggest that periarterial sympathectomy via the palm and wrist could prevent long-term aggravation of symptoms of chronic digital ischaemia when combined with adequate postoperative drug therapy.

RADIOCARPAL ARTHRODESIS FOR OSTEOARTHRITIS FOLLOWING FRACTURES OF THE DISTAL RADIUS

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50° pre-operatively to 35° post-operatively. In the RL group, it was increased from 72° to 76° after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.

Wrist arthrodesis with vascularized fibular grafting

Six patients underwent wrist arthrodesis using vascularized fibular grafting for treatment of a segmental bone defect across the wrist. Five patients had defects resulting from excision of a giant cell tumor at the distal radius, and one patient had a defect after debridement of a chronic infection. In all cases, bone union was achieved within 3 to 6 months after vascularized fibular grafting without additional procedures. Measurement of postoperative roentgenograms revealed that the average of fixed wrist angle was 13 degrees extension. Postoperatively, average grip strength on the affected side was 59% of that on the unaffected side, and the average range of forearm rotation was 123 degrees. The mean Enneking functional score was 84% at a mean follow-up period of 64 months. There was no recurrence of a tumor or infection. Wrist arthrodesis using vascularized fibular grafting is a useful procedure for the treatment of a segmental bone defect across the wrist.

Advanced Kienböck's disease treated with implantation of a tendon roll and temporary partial fixation of the wrist

Twenty-one patients with advanced Kienböck's disease were treated by implantation of a tendon roll and temporary partial fixation of the wrist. There were 13 women and eight men. Their ages at the time of operation ranged from 24 to 72 years. According to Alexander and Lichtman's classification, 12 patients were stage IIIb and nine stage IV. After implantation of the tendon roll, the scaphotrapezio-trapezoidal joint was fixed with Kirschner wires in 19 patients, and the scaphocapitate joint with absorbable pins in two. Postoperative wrist pain disappeared in nine patients and was reduced in 12. The mean postoperative total arc of flexion and extension of the wrist increased from 91 degrees to 103 degrees, and mean grip strength improved from 11.5 to 17.2 kg. Loosening of Kirschner wires during partial fixation of the wrist was seen in six cases, and required early removal of the loose wires.

Radial forearm flaps for reconstruction in hand surgery

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.

Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint

An 11-year-old girl with Kienböck disease (stage IIIA) was treated by temporary scaphotrapeziotrapezoidal fixation. It was fixed in a cast for four weeks and wires removed after eight weeks. Follow up examinations showed that movement of the wrist and grip strength were improved, and she had no pain while revascularisation of the lunate could be seen on magnetic resonance imaging.

A pilot feasibility study for ultrasound evaluation of living human wrist cartilage: site-specific differences in acoustic properties

PURPOSE

The field of cartilage repair has changed dramatically in the past decade but has not answered the question of how to treat an articular cartilage lesion in the wrist. Indeed, the characteristics of wrist articular cartilage, such as cartilage thickness, hardness, and smoothness, have not been clarified. The purpose of this study was to evaluate and quantify the acoustic properties of wrist articular cartilage quantitatively using a new acoustic probe under arthroscopic observation.

METHODS

We evaluated 10 consecutive patients (9 men, 1 woman) who were examined or treated arthroscopically. The mean age at evaluation was 27 years. In total, 468 points of wrist articular cartilage were investigated using the ultrasonic probe, and the data were transformed into a wavelet map by wavelet transformation. Two parameters, maximum magnitude and echo duration, which are indices of articular cartilage stiffness and macroscopic surface roughness, respectively, were used to evaluate the acoustic properties of wrist cartilage.

RESULTS

The distribution pattern of the acoustic properties was similar to that of previous results for the ankle joint. The mean maximum magnitude and echo duration were 3.41 +/- 1.50 (range, 0.89-7.53) and 1.33 mus +/- 0.30 (range, 0.51-2.17 mus), respectively. For the scaphoid fossa, the maximum magnitude of the radial side was significantly lower than that of the ulnar side, and the echo duration of the radial side was significantly longer than that of the ulnar side.

CONCLUSIONS

A new measurement system using an acoustic probe made it possible to perform a quantitative analysis of wrist articular cartilage, similar to the case for knee and ankle articular cartilage. In addition, site-specific differences in the acoustic properties of the distal radial cartilage were detected in living human wrist cartilage.

Vascularized proximal fibular autograft for treatment of post-traumatic segmental bony defects in the distal radius

Vascularized proximal fibular autograft is reported as one of the reconstructive procedures for the wrists following tumor resection in the distal end of the radius. However, it is rarely performed for the treatment of segmental bony defects in the distal radius after trauma. A 19-year-old man who had traumatic bony defects in the distal radius involving the articular surface underwent vascularized proximal fibular grafting for reconstruction of the wrist. After surgery, he regained wrist functions, with 40 degrees of flexion, 45 degrees of extension, 90 degrees of pronation, and 45 degrees of supination. No evidence of instability or degenerative changes was noted in the reconstructed wrist at 3 years after surgery. Vascularized proximal fibular autograft appears a useful procedure both for reconstruction of the wrist in cases with segmental bony defects in the distal radius after trauma, as well as for after tumor resection.

Epiphyseal preservation and an intercalary vascularized fibular graft with hydroxyapatite composites. Reconstruction in metaphyseal osteosarcoma of the proximal tibia: a case report

BACKGROUND DATA AND OBJECTIVES: We present here a case report of a patient with metaphyseal osteosarcoma with a preserved epiphysis and reconstructed by a vascularized fibular graft and hydroxyapatite composites.

METHODS

The case was a 14-year-old boy, who had osteosarcoma in the proximal tibia. After the diagnosis was confirmed by biopsy, the patient immediately received preoperative chemotherapy including high-dose Methotrexate, Cisplatin and Doxrubicin. Imagings after preoperative chemotherapy including MRI and contrasted enhanced CT confirmed no tumor penetration into the physis. Subsequently, we performed transepiphyseal resection of the proximal tibia to reserve the joint surface. The intercalary twin-barreled vascularized fibular graft was placed with hydroxyapatite composites. The patella tendon was reattached to the grafted fibular to biologically reconstruct the knee extensor mechanism. Postoperative chemotherapy was completed with the same regime as preoperative chemotherapy.

OUTCOMES

The bony union was completed at 10 months after the operation. The Enneking's functional evaluation score was 28 out of 30 points (93%). There was no evidence of local recurrence and no metastatic disease during the 42 months follow-up after initial diagnosis.

CONCLUSION

An accurate evaluation of MRI and CT can give a reliable assessment of intraphyseal penetration of metaphyseal osteosarcoma. In case of no involvement of the tumor in the physis, transepiphyseal osteotomy is the optimal procedure to preserve the joint surface and superior function of the joint, especially in the proximal tibia.

Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head

Background

The present study aimed to determine the indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head.

Methods

Seventy-one hips (60 patients) were clinically followed for a minimum of 3 years. Average follow-up period was 7 years. Etiologies were alcohol abuse in 31 hips, steroid use in 27, idiopathic in 7 and trauma in 6. Preoperative staging of the necrotic lesion was done using the Steinberg's classification system. The outcomes of free vascularized fibular grafting were determined clinically using the Harris hip-scoring system, radiographically by determining progression, and survivorship by lack of conversion to total hip replacement.

Results

The average preoperative Harris hip score was 56 points and the average score at the latest follow-up examination was 78 points. Forty-seven hips (67%) were clinically rated good to excellent, 4 hips (6%) were rated fair, and 20 hips (28%) were rated poor. Thirty-six hips (51%) did not show radiographic progression while 35 hips (49%) did, and with an overall survivorship of 83% at 7 years. Steroid-induced osteonecrosis was significantly associated with poor scores and survival rate (68%). Preoperative collapse was significantly associated with poor scores, radiographic progression and poor survival rate (72%). A large extent of osteonecrosis greater than 300 degrees was significantly associated with poor scores, radiographic progression and poor survival rate (67%). There was no relationship between the distance from the tip of the grafted fibula to the subchondral bone of the femoral head and postoperative radiographic progression.

Conclusion

In conclusion, small osteonecrosis (less than 300 degrees of the femoral head) without preoperative collapse (Steinberg's stages I and II) is the major indication for free vascularized fibular grafting. Steroid-induced osteonecrosis is a relative contraindication. Large osteonecrosis (greater than 300 degrees) with severe preoperative collapse (greater than 3 mm) is a major contraindication. Hips with 2 negative factors such as severe preoperative collapse and a large extent of osteonecrosis, require hip replacements.

Long-Term Outcomes of Flap Transfer for Treatment of Intractable Venous Stasis Ulcers in the Lower Extremity

There is little information about long-term outcomes of flap transfer for treatment of venous stasis ulcers in the lower extremity. Eleven patients who underwent free and pedicled flap transfer for treatment of intractable venous stasis ulcers were evaluated retrospectively. The operative procedures consisted of removal of the ulcer and surrounding lipodermatosclerotic tissue, venous stripping, and flap transfer. No ulcer recurrences in the territory of the transferred flap were identified for a mean of 11 years during the follow-up period. However, four patients developed new ulcers in the same leg after the flap transfer at 18, 24, 52, and 81 months. This was probably the result of incomplete excision of surrounding lipodermatosclerotic tissue. Three of four recurrent ulcers were healed with additional procedures. The results of this study indicated that flap transfer combined with venous stripping could lead to long-term healing of venous stasis ulcers. However, incomplete excision of surrounding lipodermatosclerotic tissue caused new ulceration around the transferred flap.

Tissue-engineered Approach for the Treatment of Steroid-induced Osteonecrosis of the Femoral Head: Transplantation of Autologous Mesenchymal Stem Cells Cultured With Beta-Tricalcium Phosphate Ceramics and Free Vascularized Fibula

Autologous mesenchymal stem cells (MSCs) cultured with beta-tricalcium phosphate (beta-TCP) ceramics and with a free vascularized fibula were transplanted into three patients with steroid-induced osteonecrosis of the femoral head. The average follow-up period was 34 months and the average patient age at the time of surgery was 28 years old. Fifteen milliliters of bone marrow was obtained from the patients 4 weeks before surgery, and was used for in vitro proliferation of MSCs. beta-TCP granules were immersed in the MSC suspension and the cells were further cultured for 2 weeks. Cultured MSCs/beta-TCP composite granules were implanted into the cavity that remained after curettage of necrotic bone; and finally, a free vascularized fibula was grafted. All hips showed preoperative collapse and radiographic progression was observed in two hips postoperatively. Osteonecrosis did not progress any further and early bone regeneration was observed. This tissue-engineered approach has potentials for the treatment of osteonecrosis. However, our results suggested that the present procedure could not be used for cases with severe preoperative collapse.

Free and Island Flap Transfers for the Treatment of Motor Vehicle Injuries

Thirteen patients (10 males and 3 females; age range at surgery: 2 to 41 years, average: 13.5 years) with motor vehicle injuries of the foot (n = 10) and leg (n = 3) were treated using free and island flaps. Donor flaps consisted of a scapular flap in six cases, a peroneal flap in four, a latissimus dorsi musculocutaneous flap in one, gracillis muscle flap in one, and gastrocnemius muscle flap in one case. Free grafts were transferred in 10 patients and pedicle grafts in three. All flaps survived completely. Moderate scarring was noted in two patients who underwent scapular flap transfer, and growth disturbances occurred in two patients with metatarsal fracture accompanying epiphyseal plate injury. Functionally, no patients experienced any disturbance, and all reconstructed sites were cosmetically satisfactory. Early flap coverage of soft-tissue defects due to motor vehicle injury was shown to be useful from the point of view of both cosmetic and functional results.

Oberlin partial ulnar nerve transfer for restoration in obstetric brachial plexus palsy of a newborn: case report

An 8 month old male infant with Erb's birth palsy was treated with two peripheral nerve transfers. Except for rapid motor reinnervations, elbow flexion was obtained by an Oberlin's partial ulnar nerve transfer, while shoulder abduction was restored by an accessory-to-suprascapular nerve transfer. The initial contraction of the biceps muscle occurred two months after surgery. Forty months after surgery, elbow flexion reached M5 without functional loss of the ulnar nerve. This case demonstrates an excellent result of an Oberlin's nerve transfer for restoration of flexion of the elbow joint in Erb's birth palsy. However, at this time partial ulnar nerve transfer for Erb's birth palsy is an optional procedure; a larger number of cases will need to be studied for it to be widely accepted as a standard procedure for Erb's palsy at birth.

Giant-cell tumors of the carpus

Giant cell tumor (GCT) of bone is a rare, benign tumor with some aggressive characteristics such as a high recurrence rate. The tumor usually occurs in the distal radius although it has been reported in the carpus. We reviewed 63 manuscripts published from 1935 to 2005 and report on the treatment of GCT of carpal bone in 29 cases. Intralesional procedures, such as curettage, were associated with a high incidence of recurrence (24%), whereas cases treated with an excisional procedure did not recur.

Post-Traumatic Big Toe Reconstruction Using Free Flaps

The big toe is of great importance for good stability and gait, but few reports have documented reconstruction of big toe defects. In this study, seven male patients, aged 17 to 59 years at surgery (average: 35 years), were treated for big toe defects. The metatarsophalangeal (MTP) joints of the big toe were intact in all patients. Five patients were treated with free peroneal flaps (including one perforator flap), and two with free scapular flaps; flap sizes ranged from 9 x 4 to 24 x 6 cm. Follow-up periods ranged from 10 to 29 months, (average: 16.6 months). The iliac was used as the grafted bone in four patients and the scapula in one. Six flaps survived completely, and bone unions were achieved within 3 months. One flap became partially necrotic due to arterial thrombosis. All patients returned to their original jobs, and the cosmetic appearances of all toes were acceptable.

Experimental Study of Vascularized Tissue-Engineered Bone Grafts

BACKGROUND

Vascularized bone grafting has become a useful method for treatment of large bone defects and infected nonunions that lack adequate blood supply. This method has disadvantages, however, such as donor-site complications. To overcome these disadvantages, the authors developed a new method for creating vascularized tissue-engineered bone grafts in an experimental model.

METHODS

Fisher rat bone marrow mesenchymal stem cells were cultured for 2 weeks in fully opened, interconnected, porous hydroxyapatite ceramic. The composites of mesenchymal stem cells and hydroxyapatite were implanted in the medial calf region together with the saphenous vascular bundle in syngeneic rats. Two weeks after implantation, the vascular pedicle with the implants was exposed and covered with silicone rubber to prevent vascular invasion through surrounding tissues (vascularized mesenchymal stem cell/hydroxyapatite implants). In addition, nonvascularized mesenchymal stem cell/hydroxyapatite implants were created with a ligated vascular pedicle. Implants of vascularized hydroxyapatite alone were prepared as a control. All implants were retrieved 4 weeks after surgery.

RESULTS

Histologically, de novo bone formations were observed in the vascularized implants. This was in contrast with only necrotic tissue observed in the nonvascularized implants. Bone formation was not observed entirely in the vascularized hydroxyapatite-alone implants. For biochemical analysis, alkaline phosphatase activity and osteocalcin content of the vascularized mesenchymal stem cell/hydroxyapatite implants were significantly higher than those of the nonvascularized mesenchymal stem cell/hydroxyapatite and vascularized hydroxyapatite-alone implants.

CONCLUSION

The results of this study indicated that the vascularized tissue-engineered bone grafts could be transferred as free vascularized grafts to lesions that lack adequate blood supply.

Treatment of Kienböck's disease with cultured stem cell-seeded hybrid tendon roll interposition arthroplasty: experimental study

BACKGROUND

Several procedures that consist of excision arthroplasty, intercarpal arthrodesis with or without excision of the lunate, proximal row carpectomy, and joint leveling procedures are used to treat advanced Kienböck's disease. However, no reconstructive surgery for a collapsed lunate has been established. The aim of this study was to develop a method of tendon roll interposition arthroplasty using a tissue-engineering technique to improve the clinical results of the tendon roll interposition arthroplasty for treating advanced Kienböck's disease.

METHODS

Twenty-four Japanese white rabbits were used for this study as three treatment models of Kienböck's disease. The lunate of the right paw was excised, and then one of three kinds of tendon roll was interposed into the excision space as follows: group A (controls), a conventional tendon roll made of autologous Achilles tendon; group B (cored tendon roll) a tendon roll with a core of the collagen-ceramic composite; and group C (hybrid tendon roll), a scaffold seeded with cultured cells was rolled in the Achilles tendon. In all groups the right wrist was immobilized with cast 6 weeks after surgery. Wrist radiography was evaluated 0, 4, 6, and 12 weeks after surgery; specimens were sectioned and evaluated histologically 12 weeks after surgery.

RESULTS

In group C the small shadow of the hydroxyapatite granule gradually increased until 12 weeks after surgery, whereas in group B the shadow of the core gradually decreased. The deficit spaces of the lunate remained radiographically lucent for 12 weeks after surgery in group A. Histological findings revealed new bone formation at the center and stained cartilage matrix at the peripheral of the hybrid tendon roll group (group C) but not in group A or B.

CONCLUSIONS

Radiological and histological examinations proved that it is possible to make new hybrid tendon rolls using this method, as osteogenesis in the center and cartilage matrix in the peripheral of the tendon roll were revealed.

Anatomy of Y-Shaped Configurations in the Subscapular Arterial System and Clinical Application to Harvesting Flow-Through Flaps

BACKGROUND

A flow-through flap is useful in cases where the recipient artery must not be sacrificed. The aim of this study was to investigate Y-shaped configurations in the subscapular arterial system that can safely be used in harvesting a flow-through flap from the scapular region.

METHODS

Sixteen dissections of the subscapular arterial system were carried out in eight embalmed cadavers. The origins and external diameters of branches in the subscapular arterial system were recorded. The distances between the origins of each branch were measured.

RESULTS

The branches that showed a consistent presence and had a reliable diameter of more than 1.0 mm were the circumflex scapular artery, the bony branch of the circumflex scapular artery, the thoracodorsal artery, the angular branch, and branches to the serratus anterior and latissimus dorsi muscles. It was demonstrated that using the Y-shaped configuration between these branches enables the harvesting of a flow-through flap in various length versions of the Y-shaped vascular pedicles. A significant anatomical variation (i.e., both the thoracodorsal and circumflex scapular artery arose directly from the axillary artery) was found in three of 16 dissections. In this vascular variation, sacrificing the axillary artery must be avoided, so Y-shaped pedicles using the origin of the thoracodorsal or circumflex scapular artery cannot be created. On the basis of these results, flow-through flaps using this arterial system were applied in 10 patients for reconstruction of lower extremities, and satisfactory results were obtained.

CONCLUSIONS

The results of our study are available for determining preoperatively and intraoperatively which Y-shaped configuration to use in harvesting a flow-through flap from the scapular region.

Coverage of Big Toe Defects After Wrap-Around Flap Transfer with a Free Soleus Perforator Flap

In thumb reconstruction, a wrap-around flap transfer from the big toe gives excellent results aesthetically and functionally; however, there may be some problems at the donor site, such as delayed wound healing and skin ulceration. In 10 patients, a free soleus perforator flap was used for immediate coverage of defects of the big toe with wrap-around flap procedures. Eight flaps survived completely, and the time required for wound healing was less than 1 month. Two flaps developed partial necrosis and required additional skin grafts. The average follow-up period was 46 months. There were no patients requiring defatting of the flaps. There were no patient complaints, such as postoperative skin erosion or ulceration. All patients were satisfied with the outcome. A free soleus perforator flap is an available method for covering defects of the big toe after wrap-around flap transfer.

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.

Dysvascular Lower Extremity Reconstruction Using Free Flaps with a “Y” Configuration of the Arterial Pedicle

For patients with a dysvascular lower extremity, free flaps have been transferred by end-to-side anastomosis, in order to maintain peripheral circulation. For such patients, the authors have applied free flap transfers with a "Y" configuration of the arterial pedicle. Eight free flaps with a Y configuration of the arterial pedicle were used in seven patients: latissimus dorsi musculocutaneous flaps in six, and scapular flaps in two. For the former, flaps were harvested with the subscapular and circumflex scapular arteries forming a Y pedicle in three cases, and with the thoracodorsal artery and the branch of the serratus anterior muscle in three. For the scapular flap transfers, the flap was harvested with the subscapular and thoracodorsal arteries forming a Y pedicle in one case, and with the circumflex scapular artery and the descending branch in the other. This procedure was performed for single-artery extremities in two cases. One developed arterial thrombosis of the branch to the foot, but removal of the thrombus and reanastomosis resulted in peripheral blood circulation being maintained. Eventually, all flaps survived. This procedure is indicated in patients with lower-leg reconstruction, especially with vascular disease.

Vascularized Fibular Grafting in the Treatment of Methicillin-Resistant Staphylococcus Aureus Osteomyelitis and Infected Nonunion

Twenty patients with methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis and bone infection were treated with vascularized fibular grafts. There were 16 males and four females, and the patient ages at operation ranged from 17 to 73 years. Nine of the lesions affected the femur, eight the tibia, and there were three others. All of the patients were treated with extensive debridement of the lesions and local antibiotic therapy. Continuous local irrigation was applied in two patients, antibiotic-formulated bone cement in five, and both in 10 patients. Recurrence of local infection occurred in six patients, including one failed graft. Eventually, 18 of the 20 cases attained successful subsidence of the inflammation. The mean period required to obtain radiographic bone union was 7 months in the femoral reconstruction group, 6.1 months in the tibial reconstruction group, and 6 months in the remaining patients. The authors believe that vascularized fibular grafting is the most reliable procedure for the treatment of MRSA osteomyelitis and infected nonunion.

Ankle and pantalar arthrodeses using vascularized fibular grafts

From 1989 to 1998 ankle and pantalar arthrodeses using vascularized fibular grafts were performed for seven patients. The indications for surgery were chronic nonunion following fracture of the distal tibia in four patients, rheumatoid arthritis in two, and talus necrosis in one. The ankle joint was fused in the two patients with a pilon fracture, and in the other five patients, both the ankle and subtalar joints were fused. In one patient, additional bone grafting was required for delayed union. In the other six patients, the mean period required to obtain radiographic bone union was 6 months (range, 4-9 months). The time until the patients could walk without braces ranged from 6 to 20 months (mean, 12.3 months). Local infection was not encountered in any patients. This procedure represents a viable option for patients in whom a standard, less complicated arthrodesis cannot be performed.

Vascularized composite tissue transfers or open fractures with massive soft-tissue defects in the lower extremities

From 1982 to 1998, we treated 39 patients with type IIIB and IIIC fractures in the lower extremities by vascularized composite tissue transfers. Thirty-four of the lesions affected the lower leg, and 5 the foot and ankle. The peroneal flap was used in 25 cases, the latissimus dorsi musculocutaneous flap in 12, the scapula flap in 1, and the gracilis muscle flap in 1. In cases with a peroneal flap transfer, 18 cases used osteocutaneous flap with a fibula. Postoperative circulatory disturbances resulted in revision surgery in 9 patients. Eventually, grafting was successful in 37 patients. In patients with a lower leg reconstruction, additional bone grafting was performed in 7 of 16 patients with cutaneous or musculocutaneous flap transfers. No patient with osteocutaneous flap transfers required an additional bone grafting. The mean periods between injury and time to bone union were 11.7 months in patients with cutaneous flap transfers, and 7.5 months in patients with osteocutaneous flap transfers.

Neurohistochemical analysis of regeneration in rat peripheral nerve after end-to-side neurorrhaphy

We investigated the regenerative capacity of motor nerves repaired by end-to-side or end-to-end neurorrhaphy, using choline-acetyltransferase (ChAT) activity measurement or histological analysis. The right medial gastrocnemius nerves (MGNs) of 62 male Fisher strain rats were transected and divided into three groups. In group 1, the distal ends of the MGN were coapted to the side of the lateral gastrocnemius nerve, using a Y-shaped silicone tube in end-to-side neurorrhaphy. In group 2, the nerve ends were reconnected by the traditional end-to-end technique. In group 3, the nerve ends were separated and remained unrepaired. The MGNs were sampled 1, 2, and 3 months postoperatively for histological examinations and ChAT activity measurement. The medial gastrocnemius muscle (MGM) was also sampled for histological evaluations. Axonal regeneration of MGN and the recovery of MGM to nearly normal histology and weight were observed in groups 1 and 2 3 months postoperatively. Although there were no significant differences in ChAT values between groups 1 and 2, the values were significantly larger than that of group 3 3 months postoperatively. These findings suggested that end-to-side neurorrhaphy would be an alternative treatment for peripheral nerve injury in certain clinical situations.

Sensory reconstruction in sensate radial forearm flap transfer

The authors treated 14 patients (13 men and one woman), using a sensate radial forearm flap. Their ages at operation ranged from 27 to 67 years (mean: 52 years). Preoperative conditions were amputations in 10 cases, degloving injury in three, and crush injury in one. Reconstructive sites involved the thumb in nine cases, the mitten-like hand in two, the index finger in one, the ring and small finger in one, and the palm in one. In all cases, the radial forearm flap, including the lateral antebrachial cutaneous nerve, was harvested. Sensory evaluation was performed using the moving two-point discrimination test (m-2PD). Sensation in the mid-palmar area of 50 forearms was examined in 25 healthy adult volunteers as a control group. Follow-up periods ranged from 12 to 87 months (mean: 39.6 months). The mean m-2PD of the 14 sensory flaps was 13.2 mm, and the mean of 50 forearms in the control group was 18.08 mm. A statistically significant difference was demonstrated between the sensory flaps and the 50 forearms of the control group. The mean m-2PD was much more sensitive in the innervated radial forearm flaps than in the donor forearm. The results suggested that sensory return in the innervated flaps is influenced not by the donor nerve in the flaps, but by the recipient digital nerve.