吻合血管的游离腓骨移植修复桡骨远端骨缺损重建腕关节8例报告

目的 :评价吻合血管的游离腓骨移植重建骨巨细胞瘤切除后桡骨远端的可行性和疗效。方法 :将带血管的腓骨近端用 2或 3枚螺钉固定于大块切除瘤体后的桡骨远端 ,腓动脉两端与切断的桡动脉远近两端吻合 ,腓静脉与皮静脉吻合。膝关节外侧副韧带和股二头肌腱固定于胫骨的适当位置。结果 :平均骨愈合时间 3 .5个月。 5例术后 1周桡动脉造影 ,证实吻合的腓动脉血流通畅。末发现患侧前臂有残留性疼痛及腕关节不稳。腕关节外形基本正常 ,主动运动良好 ,患侧手的握力均比较满意。结论 :本方法是目前治疗桡骨远端骨缺损、重建腕关节较理想的方法     

带血供腓骨小头骨骺移植的解剖与临床研究

目的 观察腓骨小头骨骺的血供来源及带血供腓骨小头骨骺移植治疗骨骺损伤的效果。方法 5具10侧足月新生儿尸体的下肢标本。对腓骨头的营养血管进行显微解剖观察。本组共6例患者,平均年龄9岁,胫骨近端内侧骨骺骨桥形成1例,胫骨远端骨骺骨桥形成伴踝关节畸形3例。股骨头骨骺陈旧性滑脱1例,股骨头缺血性坏死1例,应用带膝下外血管的腓骨小头骨骺移植进行修复。结果 膝下外动脉、胫前返动脉、旋腓动脉的分支在腓骨小头的表面形成广泛血管吻合,营养腓骨小头骨骺。以膝下外动脉为蒂的腓骨头骨骺移植,血供丰富。经术后平均2年6个月的观察,5例移植骨骺生长良好,1例因术后感染,移植物部分吸收且骺板闭合。结论 以膝下外血管为蒂的腓骨骨骺游离移植,适合于长骨骨骺损伤的修复。     

Differentiated therapy of distal radius fracture

The fracture of the distal radius loco typico is one of the most frequently occurring fractures. This article presents types of fractures, in particular Colles', Smith's, Barton's and multiple-fragment's fractures. Conservative and operative treatment is described, as well as problems related to the different procedures. Besides fracture retention by plaster splint or cast, Besides fracture retention by plaster splint or cast, transcutaneous osteosynthesis by Kirschner wire, lag screws, osteosynthesis by buttress plate and the use of the external fixator are described as examples of operative therapeutics.     

Salvage of contaminated fractures of the distal humerus with thin wire external fixation

Fractures and osteotomies of the distal humerus that are contaminated or infected represent a difficult management problem. Stable anatomic fixation with plates and screws, the acknowledged key to a good result in the treatment of bicondylar fractures, may be unwise. A thin wire circular (Ilizarov) external fixator was used as salvage treatment in such complex situations in five patients. The fixator allowed functional mobilization of the elbow while allowing achievement of the primary goal of eradicating the infection or colonization. Two patients required a second operation for fixation of a fibrous union of the lateral condyle. One patient with a vascularized fibular graft later required triple plate fixation for malalignment at the distal host and graft junction. Four of five patients ultimately achieved complete union. The fracture remained ununited in one patient who has declined additional intervention. All five patients achieved at least 85 degrees ulnohumeral motion, two after a secondary elbow capsulectomy performed after healing was achieved. This experience suggested that the Ilizarov construct, although not a panacea, represents a reliable method of skeletal stabilization that allows functional mobilization while elimination of infection or colonization is ensured. If necessary, stiffness and incomplete healing can be addressed with an increased margin of safety at subsequent operations.     

Congenital pseudarthrosis of both forearm bones: long-term results of two cases managed by free vascularized fibular graft.

We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.     

A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation

PurposeThe present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur.MethodsTwelve patients (aged 15–58 years) with infected bone defects of the femur (between 6.0 and 18.0 cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1–2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site.ResultsMean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7–15 cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9–72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%.ConclusionsFree vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.     

Biomechanics and biology of plate fixation of distal radius fractures

The fracture management principles of anatomic or near anatomic reduction, fracture stabilization, minimal operative trauma, and early joint motion are paramount in man-aging unstable distal radial fractures. The operative approach and plate selection should correlate with the fracture configuration. Plates have the advantages of providing secure fixation throughout the entire healing process without protruding wires or pins and allowing early and intensive forearm, wrist, and digital exercises. Disadvantages include additional operative trauma, including fragment devascularization; some additional risk of wrist stiffness; occasional tendon rupture; and at times, the need for plate removal. New developments in plate and screw design and operative strategies, fragment specific fixation, and plate strength have improved results with plate fixation. Fixed angle blades and locking screws and pegs enhance overall plate stability, support the articular surface of the distal radius, and are effective in fractures occurring in osteopenic bone.     

Vascularized fibular graft as a surgical option for osteosarcoma of distal humerus: A case report

IntroductionDistal humerus is a very rare predilection site of osteosarcoma. Limb salvage surgery has widely replaced amputation for surgical treatment of most types of malignant bone sarcomas.Presentation of caseWe presented a 42 years old male with rapidly growing osteosarcoma on his right distal humerus. After induction chemotherapy, wide excision and reconstruction using free vascularized fibular graft followed with interpositional elbow arthroplasty technique was done.DiscussionOne of the option for surgical treatment for distal humerus osteosarcoma is limb salvage sugery with free vascularized fibular graft technique. Good functional outcome and no signs of local recurrence were found during 2,5 years follow up.ConclusionFree vascularized fibular graft with interpositional elbow arthroplasty is a good option for management of bone sarcoma of distal humerus.     

Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.     

Management of radioulnar synostosis with mobilization, anconeus interposition, and a forearm rotation assist splint

Three cases of post-traumatic proximal radioulnar synostosis are presented. Each was treated with surgery with excision of the heterotrophic new bone and mobilization of the proximal radius. The anconeus muscle was mobilized as a vascularized pedicle graft and then interposed between the proximal radius and ulna. Two patients had postoperative radiotherapy. A forearm rotation assist splint was used to augment rehabilitation after surgery. This device consists of an inner sleeve that attaches to the hand and then rotates within a standard turnbuckle flexion/extension assist splint. The overall improvement in forearm rotation in each case was 100 degrees, 140 degrees, and 150 degrees, respectively.     

吻合血管的游离腓骨移植修复长段骨缺损

目的探讨吻合血管的游离腓骨移植(VFG)在骨科疾病中的应用。方法本组1例胫骨多发骨样骨瘤并病理骨折,行病灶边缘切除+对侧VFG+外固定架固定;1例桡骨远端骨巨细胞瘤并病理骨折,行瘤段广泛切除+同侧VFC+腕关节重建术;3例创伤性胫骨缺损,采用对侧VFG+外固定架固定。2例股骨近端骨肿瘤合并病理性骨折,采用病灶囊内刮除+对侧带血管折叠腓骨移植+95°角钢板桥接固定。术后随诊1～3年,依据Enneking肢体评分系统进行疗效评价。结果7例病人均获骨性愈合,全部病例供区功能正常,X线显示无踝关节外翻及关节炎改变。结论利用VFG治疗各种原因所致大段骨缺损,疗效良好,是临床治疗大段骨缺损的理想手术方法。     

Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones

Eighteen infected nonunions and segmental defects of both the radius and ulna which had failed to resolve with conventional treatment were treated with a free vascularized fibular graft to restore radial, but not ulnar, continuity. In three patients there was destruction of the wrist joint and in two destruction of the elbow. The time from injury to referral ranged from 4 weeks to 3 months. The ipsilateral fibula was used as an osseous or osseocutaneous free flap to reconstruct the radius. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation.     

Open segmental fracture of both bone forearm and dislocation of ipsilateral elbow with extruded middle segment radius

Extruded middle segment of radius with open segmental fracture both bone forearm and dislocation of ipsilateral elbow is a rare injury. A 12-year-old child presented to us within 4 hours following fall from tree. The child''s mother was carrying a 12-cm-long extruded soiled segment of radius. The extruded bone was thoroughly washed. The medullary cavity was properly syringed with antiseptic solution. The bone was autoclaved and put in the muscle plane of the distal forearm after debridement of the wound. After 5 days, a 2.5-mm K-wire was introduced by retrograde method into the proximal radius by passing through the extruded segment. Another 2.5-mm K-wire was passed in ulna. The limb was evaluated clinicoradiologically every 2 weeks. The wound was healed by primary intention. At 4 months, the reposed bone appeared less dense radiologically and K-wire seemed to be out of the bone. In the subsequent months, the roentgenograms show remodeling of the extruded fragment. After 20 weeks, the K-wires were removed (first ulnar and then radial). Complete union was achieved with full range of movement except loss of few degrees of extension of elbow and thumb. This case is reported to show a good outcome following successful incorporation of an extruded segment of radius in an open fracture.     

The Essex-Lopresti forearm fracture (case report)

The radial head fracture associated with dislocation in the distal end of the ulna and tear of interosseous membrane of the forearm with a subsequent proximal migration of the radial shaft is a relatively rare injury. For the first time it was described by Essex-Lopresti in 1951. Our report presents one case together with an analysis of available literature relating to the diagnosis and treatment. A man, 69 years old, hurt his right elbow and forearm in a fall on the outstretched arm. There was a 2 x 1 cm excoriation on the lateral portion of the elbow and a dominating pain and limitation of the range of motion of the right elbow and wrist. The radiograph of the elbow, forearm and wrist showed a dislocated comminuted fracture of the radial head, dorsal subluxation of the ulnar and proximal displacement of radius. The condition was assessed as Essex-Lopresti fracture of the forearm indicated for surgery. The four-fragment fracture of the radial head did not allow reconstruction and therefore the head was resected. Subsequently the distal radio-ulnar joint was revised from dorsal approach with a K-wire inserted transversally. In order to prevent proximal displacement of the radius a K-wire was inserted in the medullary cavity of the radius close to the distal end of the humerus with the elbow in 90 degrees flexion and slight supination. The wounds were sutured and plaster of Paris applied extending across the elbow up to the metacarpal heads. After 6 weeks the plaster fixation and K-wires were removed. Full weight bearing was permitted 4 months after the surgery. Ten months after the surgery the patient was without complaints. Flexion in the elbow ranged between 0-5-130 degrees, pronation-supination was limited by 10 degrees in both extreme positions. The ulnar head became prominent on the dorsal side, dorsiflextion and ulnar duction in the wrist were limited to 10 degrees. The radiograph of the wrist showed and evident proximal displacement of the radius, the dorsally subluxated ulnar head overhung by 7 mm. Our case has confirmed that a mere extirpation of the head with a subsequent stabilization and transfixation of the proximal end of the radius and transfixation of the distal radio-ulnar joint cannot prevent after the extraction of wires a proximal displacement of the radius and development of the "plus variant" resulting in the limitation of both the range of motion of the wrist and the pronation-supination movement of the forearm.     

Limb reconstruction with vascularized fibular grafts after bone tumor resection

Limb-salvage operations are being used with increasing frequency for patients with malignant bone tumors. For children, when a biologic reconstruction is desired, the choice is often between conventional and vascularized fibular grafts. An experimental study was performed in dogs to compare the two types of fibular grafts for bridging segmental defects in the radius and ulna. Twenty-six adult dogs were divided into two groups and studied at intervals of two, three, four, six, and 12 months after transplantation. The conventional grafts healed by creeping substitution i.e., they were first partially resorbed before new bone was laid down. In contrast, the vascularized fibulae maintained their normal structure and hypertrophied by subperiosteal new bone formation. The conventional fibulae eventually hypertrophied but much later than the vascularized grafts. The vascularized grafts were stronger at four and six months. Between six and 12 months, both grafts remodeled to resemble the size and shape of the forearm bones they were replacing. These experimental results have influenced the treatment of patients. Vascularized fibular grafts are ideal for diaphyseal defects greater than 10 cm long, especially in very young children, a poorly vascularized bed, or when bone healing is delayed by chemotherapeutic agents. To maximize hypertrophy, an external fixator is used to immobilize the graft rather than a plate, which acts as a stress shield.     

Autologous grafts of double-strut fibular cortical bone plate to treat the fractures and defects of distal femur: a case report and review of literature

We reported a 23-year-old man who was involved in a high-speed motorcycle accident. He sustained a closed fracture at the right distal femur. The primary fracture happened on February 2008. He underwent open reduction and internal fixation with cloverleaf plate. And one hundred days after the surgery, the proximal screws were pulled-out, but the bone union was not achieved. Treat ment consisted of exchanging the cloverleaf plate with a locking compression plate and using an auto-iliac bone graft to fill the nonunion gap. In July 2009, the patient had a sharp pain in the right lower limb. The X-ray revealed that the plate implanted last year was broken, causing a nonunion at the fracture site. Immediately the plate and screws were removed and an intramedullary nail was inserted reversely from the distal femur as well as a 7 cm long bone from the right fibula was extracted and longitudinally split into two pieces to construct cortical bone plates. Then we placed them laterally and medially to fracture site, drilled two holes respectively, and fastened them with suture. We carried on auto-iliac bone grafting with the nonunion bone grafts. The follow-up at 15 months after operation showed that the treatment was successful, X-ray confirmed that there was no rotation and no angular or short deformity. We briefly reviewed the literature regarding such an unusual presentation and discussed in details the possible etiology and the advantages of autologous double-strut fibular grafts to cope with such an intractable situation.     

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.     

吻合血管的腓骨近端移植修复桡骨远端骨肿瘤切除术后骨缺损

目的 评价吻合血管的腓骨近端移植修复桡骨远端骨肿瘤切除术后骨缺损的方法及治疗效果.方法 对12例桡骨远端骨肿瘤患者行桡骨远端切除,应用吻合血管的腓骨近端移植修复骨缺损并重建桡腕关节.术后对肢体功能及影像学进行评价.结果 12例患者均获随访,时间1～9年.腕关节平均活动度:掌屈30.3°±6.5°,背伸 52.1°±8.7°,尺偏 19.2°±3.6°,桡偏 12.3°±2.1°,旋前 32.1°±4.2°,旋后 21.2°±3.9°.按Enneking标准评价肢体功能:优4例,良6例,一般2例.移植腓骨均在3～6个月达到骨性愈合.5例出现不同程度的下尺桡关节分离,3例出现桡腕关节半脱位.肿瘤无复发.结论 吻合血管的腓骨近端移植是治疗桡骨远端骨肿瘤切除术后骨缺损的有效方法.     

Free fibula flap elbow-joint hemiarthroplasty reconstruction for chronic osteomyelitis of the distal humerus

The vascularized fibula flap has become a major tool in upper limb reconstruction. Free fibula flap reconstructions of the humeral part of the shoulder and the radial part of the wrist joints are well-documented, but reports of elbow joint reconstruction are rare. The authors report a 53-year-old patient with chronic osteomyelitis of the distal humerus that was unsuccessfully treated by many local surgical debridements and long-term systemic antibiotics. The patient underwent a wide debridement of the distal two-thirds of the humerus, and a spacer was inserted to fill the bony humeral gap. At a second stage, the distal humerus was reconstructed with a free fibula flap that included the proximal fibular head. The fibular shaft was used to bridge the bony gap and the fibular head created an elbow joint with the olecranon process. At an 18-month follow-up after surgery, the patient has stable and sufficient function of his elbow joint with no signs of infection. The free fibula flap has an important role for distal humerus reconstruction, both for bridging the bony gap with a vascularized bone, and for restoring elbow joint function.     

Pseudarthrose congénitale de l’avant-bras. À propos de deux cas et revue de la littérature

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.