胫后动脉穿支皮瓣修复足部软组织缺损

目的总结内踝上胫后动脉穿支带蒂皮瓣修复足部软组织缺损的临床应用结果。方法 2006年10月至2012年10月,应用内踝上胫后动脉穿支带蒂皮瓣修复9例足部软组织缺损,年龄16~52岁,平均35岁。软组织缺损的面积5.5 cm×3.5 cm~13.0 cm×6.0 cm。供区创面行一期全厚网状游离植皮。3例皮瓣携带的隐神经在足部与腓肠神经吻合。结果所有的皮瓣完全成活,取得了满意的临床效果。随访1.5~4年,平均随访2.5年,皮瓣恢复了感觉,两点分辨觉为6~9 mm,受区未发生溃疡。结论胫后动脉穿支带蒂皮瓣具有血管解剖恒定、血运丰富以及操作简单等优点,适宜修复足部软组织缺损。     

Replantation of the digits amputated by motorcycle chain injury

Summary Over the past 5 years, 134 digits were replanted in 85 patients. In 9 patients — 10 digits (11%) — the causation of injury was a motorcycle chain. The significant incidence of this type of injury has prompted us to report the replantation results. Hopefully, this might be used to caution the public against cleaning the chain while it is in motion. The sites of amputation were 5 in Tamai's Zone I and 5 in Tamai's Zone II. All amputated parts were distal to the DIP joint. The digits were replanted with anastomosis of both the artery and the vein. Eight out of the 10 replanted digits survived to give a success rate of 80%. There was no statistical difference between this rate and that for all other replanted digits resulting from various causes in Zones I and II, i.e. 86%. The high success rate suggests that replantation of the chain-amputated digits should be recommended, and the apparently poor conditions of the crush injury are no contraindications for surgery.     

踝足部组织缺损的显微外科修复

目的研究踝足部组织缺损显微外科修复的效果。方法回顾性分析应用带血管蒂(肌)皮瓣、骨瓣等组织瓣移植修复踝足部组织缺损的临床资料。结果本组共78例,其中吻合血管(肌)皮瓣移植术21例,带血管蒂(肌)皮瓣移位术53例,吻合血管骨瓣移植术4例。组织瓣全部成活,随访3月～1年,骨愈合时间8～10周,踝足部大部分恢复保护性感觉,行走正常。结论踝足部组织缺损应用带血管蒂(肌)皮瓣、骨瓣移植、移位术修复效果好。     

A Microsurgical Technique for Posterior Lumbar Interbody Fusion: Technical Note

Summary  Objective. To describe a microsurgical modification of the Ray Threaded Fusion Cage (TFC) instrumentation technique for achieving lumbar interbody fusion.  Technique. The lumbar fusion is established by application of two titanium cages through two different short skin incisions, first on one and then on the other side. The spinous processes and the whole interspinous ligament are preserved. Under microscopic control, the lower nerve root and foramen are identified and foraminotomy performed. The dural sac is carefully exposed so that a free and gentle retraction of the nerve root to the midline can be obtained. After removal of the disc material, the retractor is inserted. Special attention should be paid to visualization of the superior nerve root in order to avoid neural injuries. The end plate and disc material are then drilled and tapped for insertion of the appropriate cage.  Conclusion. The Ray TFC lumbar fusion can be practically and safely performed under microscopic control.     

腕前区游离静脉皮瓣修复断指血管与皮肤缺损

目的总结游离静脉皮瓣在伴有血管及皮肤缺损的断指再植中的应用效果。方法临床应用18指,其中伴掌侧皮肤缺损15指,背侧皮肤缺损3指,从腕前区切取适宜大小的、带有皮下静脉和掌长肌腱的游离皮瓣植于手指组织缺损处,掌侧部位皮瓣倒置,背侧则同方向放置。结果除1例中指中节离断伴背侧血管和皮肤缺损于术后第3 d坏死外;17例术后手指均成活,外观及功能良好,功能评价:优11指,良4指,可2指。结论应用腕前区游离静脉皮瓣修复断指血管与皮肤缺损,效果良好,且简单易行。     

逆行法再植足趾

目的　探讨逆行法足趾再植的特点及其效果。方法　从 1991年～ 1999年 ,对 19例 (2 5趾 )离断足趾进行再植 ,再植时保持患足背伸 90°～ 12 0° ,逆行法再植的顺序 :趾底皮肤→趾底皮下静脉→趾固有神经→趾固有动脉→屈趾肌腱→单根克氏针固定趾骨→趾伸肌腱→趾背动脉→趾背皮下静脉→两侧及背侧皮肤。结果　 2 5趾中 2 3趾成活 ,成活率 92 % ,患趾总屈曲度 ,趾为 2 5°～ 70° ,第 2、 3趾为 35°～ 90° ,断趾外形恢复良好 ,趾尖两点辨别觉 10mm～ 16mm ,患者行走步态正常 15例 ,基本正常 4例。结论　离断足趾再植极大减轻了病人伤残率 ,功能及外观恢复满意 ,逆行法再植足趾显示了独特的不需变换体位的优点     

足及小腿软组织缺损的显微外科修复

目的：报道应用皮瓣修复胫前区，足背，足跟创面的经验，方法：应用带蒂皮瓣或游离皮瓣转移覆盖外露，贴骨疤痕，溃疡共35处，皮瓣切取面积3cm*3cm-20cm*12cm，结果：35例中32例成功，恢复外形及行走功能；3例失败，结论：根据 同情况及患者条件，就近避远，就简避繁合理设计皮瓣，其中腓汤浅动脉逆行岛状皮瓣切取简单安全，覆盖范围广，可有效修复胫前区，足背，足跟创面。     

Replantation of the upper extremity in children

Since Malt and McKhann performed the first successful replantation of a traumatically amputated extremity in 1962, there has been a flurry of case reports and articles debating the pros and cons of the various technical aspects of replantation. There have been three case reports of children, under the age of 15, who have successfully undergone replantation of the upper extremity transected through the humerus. The first case report in this article is the fourth. The factors involved in selecting replantation or amputation, and the technical aspects of the operation which are felt to be important, are briefly reviewed. Because the mechanics of limb replantation are rather straightforward, we feel that the pediatric surgeon should be familiar with the preoperative and intraoperative factors to be weighed, and that this alternative to stump closure be carefully considered when one is presented with an upper extremity transection.     

逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复足踝部软组织缺损

目的报道逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复足踝关节周围软组织缺损的手术方法和临床效果。方法对48例足踝关节周围皮肤软组织缺损的患者采用逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复,单纯逆行胫后动脉穿支蒂隐神经营养血管皮瓣39例,肌皮瓣9例;其中胫后动脉穿支筋膜蒂神经营养血管皮瓣29例,胫后动脉穿支血管蒂营养血管皮瓣19例,软组织缺损大小12 cm×9 cm~4 cm×3 cm,皮瓣面积13 cm×9.5cm~6 cm×5 cm。结果 43例皮瓣完全存活,5例皮瓣远端部分坏死,经积极换药、清创植皮修复。皮瓣术后轻度肿胀,无感染及淤血,皮瓣蒂部无臃肿。术后随访6~18个月,皮瓣质地优良,肢体外形与功能恢复满意,供区植皮术后恢复保护性感觉。结论胫后动脉穿支蒂隐神经营养血管皮瓣血供可靠,质地优良,是修复足踝关节周围软组织缺损的良好选择。     

Aplastic Posterior Tibial Artery in the Presence of Trimalleolar Ankle Fracture Dislocation Resulting in Below-the-Knee Amputation

We present an interesting, but unfortunate, case of an 86-year-old female who sustained a trimalleolar ankle fracture dislocation that resulted in below-the-knee amputation after open reduction and internal fixation of the fracture. To the best of our knowledge, this is the first case report describing popliteal variants that ultimately resulted in critical limb ischemia and below-the-knee amputation after foot and ankle trauma. The anatomic variation altered the expected outcome from a relatively straightforward surgical case. We introduce the previously described lower extremity Allen test and describe how it can be a useful adjunct in the initial physical examination of lower extremity trauma. The ability to identify abnormal distal perfusion to the foot could provide enough insight to warrant evaluating the patient with angiography or computed tomography angiography.     

Replantation at the level of the wrist joint: A case report

Upper extremities amputations are devastating injuries that have a major impact on patients’ quality of life. Replantation after traumatic amputation is often performed to obtain limb recovery. Following the high survival rate of replantation of post-traumatic hand amputation, recent emphasis has now shifted to functional recovery rather than survival only. Wrist replantation remains a challenging procedure for orthopaedic and hand surgeon. We reported a case of a 25-year-old male with traumatic amputation of the right hand.     

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection,Outcomes, and Cost

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid’s Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.     

皮瓣修复足跟部皮肤软组织缺损的研究进展

用于修复足跟部皮肤软组织缺损的皮瓣,主要分为知名血管皮瓣和非知名血管皮瓣,前者主要包含小腿外侧、内侧皮瓣和足背皮瓣等;后者主要包括足底内侧皮瓣、足外侧皮瓣、外踝上逆行岛状皮瓣,以及皮神经营养血管皮瓣（腓肠神经营养血管筋膜蒂皮瓣和隐神经营养血管皮瓣）等。本文对用于足跟部皮肤软组织缺损的各种皮瓣的解剖学基础和治疗优缺点进行综述。     

A Unique Case of Replantation of Previously Replanted Fingers

Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of “repeat amputation of the replanted finger.” Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be attempted especially in the event of multiple digit amputations.