Use of the anterolateral thigh free flap for the soft tissue coverage of Gustilo grade-ⅢB open bone fractures in lower extremities

Objective To investigate the clinical results of the anterolateral thigh free flaps for the soft tissue coverage of Gustilo grade-Ⅲ B open bone fractures in lower extremities.Methods The anterolateral thigh free flaps were applied to treat 42 Gustilo grade-11Ⅲ B open fractures.Ten flaps were performed through an emergency procedure.Sixteen were performed at early stage and the other 16 were performed at later stage .The results of the therapy were analyzed after long time follow up. Results All limbs were salvaged and all the flaps survived without protracted course to obtain soft tissue coverage.The follow up ranged 11 to 47 months.The healing time of the bones were significant prolonged in the later stage therapy group compared with the emergency therapy group and the early stage therapy group.In the later stage therapy group,the incidences of the bone infection and nonunion were also higher than the other two groups,and the second stage bone transplantation to repair bone defect and nonunion were needed in 76% patients in this group.The lower limb functions of the later stage treated group were worse than those of the other two groups.Compared to the early stage treated group,better lower limb functions could be obtained in the emergency treated group. Conclusion Delayed soft tissue coverage resulted in higher incidence of complications.The immediate soft tissue coverage of severely injured limbs complicated by Gustilo grade-Ⅲ B open fractures and massive soft tissue defects had the advantages over traditional methods.Hard work though it was,one-stage soft tissue coverage using anterolateral thigh free flaps could obtain better lower limb function.     

应用股前外侧皮瓣修复Gustilo Ⅲ B型小腿开放性骨折并软组织缺损

目的 探讨股前外侧皮瓣在Gustilo ⅢB型小腿开放性骨折软组织缺损修复中的应用价值.方法 对GustiloⅢB胫骨骨折合并软组织缺损42例,分别行股前外侧皮瓣急诊修复创面10例,早期修复创面16例和晚期修复创面16例,术后随访,对各组疗效进行分析.结果 移植皮瓣全部成活,无截肢病例,术后随访11～47个月,骨愈合时间6～13个月.和急诊、早期修复组相比,晚期修复组骨折愈合时间延长,骨感染、骨不连发生率明显升高,76%的病例需要行二期骨移植修复骨缺损和骨不连,下肢功能评分低于前两组.结论 对Gustilo Ⅲ B型骨折尽早行创面修复手术,可以缩短治疗周期,改善治疗效果,对严重开放性骨折创伤的治疗有较大临床指导意义.

Abstract：

Objective To investigate the clinical results of the anterolateral thigh free flaps for the soft tissue coverage of Gustilo grade-Ⅲ B open bone fractures in lower extremities.Methods The anterolateral thigh free flaps were applied to treat 42 Gustilo grade-11Ⅲ B open fractures.Ten flaps were performed through an emergency procedure.Sixteen were performed at early stage and the other 16 were performed at later stage .The results of the therapy were analyzed after long time follow up. Results All limbs were salvaged and all the flaps survived without protracted course to obtain soft tissue coverage.The follow up ranged 11 to 47 months.The healing time of the bones were significant prolonged in the later stage therapy group compared with the emergency therapy group and the early stage therapy group.In the later stage therapy group,the incidences of the bone infection and nonunion were also higher than the other two groups,and the second stage bone transplantation to repair bone defect and nonunion were needed in 76% patients in this group.The lower limb functions of the later stage treated group were worse than those of the other two groups.Compared to the early stage treated group,better lower limb functions could be obtained in the emergency treated group. Conclusion Delayed soft tissue coverage resulted in higher incidence of complications.The immediate soft tissue coverage of severely injured limbs complicated by Gustilo grade-Ⅲ B open fractures and massive soft tissue defects had the advantages over traditional methods.Hard work though it was,one-stage soft tissue coverage using anterolateral thigh free flaps could obtain better lower limb function.     

Treatment of Gustilo grade Ⅲ leg fractures by external fixation associated with limited internal fixation

Objective： To explore the clinical effects of external fixation associated with limited internal fixation on treatment of Gustilo grade Ⅲ leg fractures. Methods： From July 2006 to December 2008, 40 cases of Gustilo grade Ⅲ leg fractures were emergently treated in our unit with external fixation frames. Soft tissue injuries were grouped according to the Gustilo classification as ⅢA in 17 cases, ⅢB in 13 cases, and ⅢC in 10 cases. All the patients were debrided within 8 hours, and then fracture reposition was preformed to reestablish the leg alignment. Limited internal fixation with plates and screws were performed on all the Gustilo IliA cases and 10 Gustilo ⅢB cases at the first operation. But all the Gustilo ⅢC cases and 3 Gustilo ⅢB cases who had severe soft tissue injuries and bone loss only received Vacuum-sealing drainage （VSD）. Broad-spectrum antibiotics were regularly used and VSD must be especially maintained easy and smooth for one week or more after operation. Limited internal fixation and transplanted free skin flaps or adjacent musculocutaneous flaps were not used to close wounds until the conditions of the wounds had been improved. Results： The first operations were completed within 90-210 minutes （170 minutes on average）. The blood trans- fusions were from 400 ml to 1500 ml （those used for antishock preoperatively not included）. All the 40 patients in this study were followed up for 6-28 months, 20.5 months on average. The lower limb function was evaluated according to the comprehensive evaluation standards of leg function one year after operation and the results of 28 cases were excellent, 9 were good and 3 were poor. Conclusion： External fixation associated with limited internal fixation to treat Gustilo grade Ⅲ leg fractures can get satisfactory early clinical therapeutic effects.     

An anterolateral thigh perforator chimeric flap combined with calcium sulfate impregnated with vancomycin for treatment of chronic fracture-related infection complicated with extensive soft-tissue defects北大核心CSCD

Objective To investigate the efficacy of an anterolateral femoral chimeric perforator flap combined with vancomycin-loaded calcium sulfate in the treatment of chronic infection after internal fixation of calf fracture with soft tissue defects. Methods Retrospectively analyzed were the data of 16 patients with chronic infection combined with extensive soft tissue defects after internal fixation of calf fracture who had been admitted to Department of Orthopedics, Shenzhen Hospital Affiliated to Peking University from September 2008 to November 2020. There were 11 males and 5 females, aged from 16 to 62 years (average, 37 years). Infection sites: the upper tibia in 4 cases, the middle and lower tibia in 10 cases, and the middle fibula in 2 cases. According to the Cierny-Mader classification, all patients were anatomical type III and by the host classification, there were 14 cases of type B and 2 cases of type C type. The areas of soft tissue defects ranged from 6 cm × 4 cm to 23 cm × 14 cm. All patients were treated by transplantation of an anterolateral thigh chimeric perforator flap combined with vancomycin-loaded calcium sulfate therapy. At the last follow-up, the curative efficacy was evaluated according to the Paley fracture union scoring. Results All patients were followed up for 8 to 24 months (mean, 16 months). Complete flap survival was achieved in 15 flaps and partial survival in one. According to the Paley fracture union scoring at the last follow-up, the curative efficacy was evaluated as excellent in 15 cases and as good in one. Both the grafted artificial bone and the tibia and fibula achieved bone union after 6 to 12 months (mean, 8.9 months). Infection with chronic sinus tract pus recurred in one case at post-operative one year. After re-debridement, the infection was controlled and the wound healed. The plate internal fixation was replaced by the unilateral or annular external fixator in 14 patients and retained in 2 patients. The lengths of the bone defects averaged 2.4 cm and the time for the external fixation 10.5 months (from 8 to 14 months). Conclusion In the treatment of chronic infection after internal fixation of calf fracture with extensive soft tissue defects, the efficacy of an anterolateral femoral chimeric perforator flap combined with vancomycin-loaded calcium sulfate is satisfactory, because the flap can fully cover the bone and soft tissue defects while the vancomycin-loaded calcium sulfate can effectively control the infection. © 2023 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

Objective To evaluate the efficiency of free myocutaneous flap transfer for the treatment of refractory post-traumatic osteomyelitis of the lower leg and foot. Methods Eleven patients with refractory post-traumatic osteomyelitis of the lower legs and feet were treated between February 2004 and December 2007. There were 9 males and 2 females. The average age was 3.5 years. All patients had at least four to five unsuccessful surgical procedures and prolonged antibiotic treatment prior to presentation. The mean duration of osteomyelitis was 26 months (12-47 months). According to the Ciemy-Mader classification, there were 3 cases for ⅢA, 2 for ⅢBL, 4 for ⅥA and 2 for ⅥBL. After radical debridement, free myocutaneous flaps were immediately performed. Nine latissimus dorsi and 2 rectus abdominis myocutaneous flaps were used.External fixation was applied in 6 patients with skeletal instability due to tibial defects. Results An average follow-up was 3.5 years. Two cases suffered partial necrosis and were managed successfully with split-thickness skin grafts later. In 4 patients of presenting segmental bone defect, autogenous bone grafting was applied in one patient and achieved consolidation after 5 months; bone transplantation in 2 patients and achieved consolidation after 8 and 10 months; and vascularized fibula graft in one patient in whom the gap of the tibia was about 10 cm and achieved consolidation after 4 months. The other 7 patients of this group achieved bone consolidation without bone graft. Conclusion The cornerstone of the treatment of chronic osteomyelitis was to be the radical debridement of all involved necrotic and infected soft tissue and bone.The free myocutaneous flaps transfer which has the advantage of obliteration of dead space and stable coverage of the defect was a safe and viable treatment option in chronic osteomyelitis of the lower leg and foot.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

Objective To evaluate the efficiency of free myocutaneous flap transfer for the treatment of refractory post-traumatic osteomyelitis of the lower leg and foot. Methods Eleven patients with refractory post-traumatic osteomyelitis of the lower legs and feet were treated between February 2004 and December 2007. There were 9 males and 2 females. The average age was 3.5 years. All patients had at least four to five unsuccessful surgical procedures and prolonged antibiotic treatment prior to presentation. The mean duration of osteomyelitis was 26 months (12-47 months). According to the Ciemy-Mader classification, there were 3 cases for ⅢA, 2 for ⅢBL, 4 for ⅥA and 2 for ⅥBL. After radical debridement, free myocutaneous flaps were immediately performed. Nine latissimus dorsi and 2 rectus abdominis myocutaneous flaps were used.External fixation was applied in 6 patients with skeletal instability due to tibial defects. Results An average follow-up was 3.5 years. Two cases suffered partial necrosis and were managed successfully with split-thickness skin grafts later. In 4 patients of presenting segmental bone defect, autogenous bone grafting was applied in one patient and achieved consolidation after 5 months; bone transplantation in 2 patients and achieved consolidation after 8 and 10 months; and vascularized fibula graft in one patient in whom the gap of the tibia was about 10 cm and achieved consolidation after 4 months. The other 7 patients of this group achieved bone consolidation without bone graft. Conclusion The cornerstone of the treatment of chronic osteomyelitis was to be the radical debridement of all involved necrotic and infected soft tissue and bone.The free myocutaneous flaps transfer which has the advantage of obliteration of dead space and stable coverage of the defect was a safe and viable treatment option in chronic osteomyelitis of the lower leg and foot.     

Clinical study of reconstructing the medial malleolus with free grafting of fibular head composite tendon bone flap

Objective： To explore new surgical procedure for repairing and reconstructing medial malleolus and soft tissue defect.
Methods： According to the size of medial malleolus and composite soft tissue defect, vascular fibular bead composite tendon bone flap free wafting using anterior tibial recurrent vessel as the perforating branch was designed to reconstruct the medial malleolar saddle and triangular ligament, and composite back broadest muscle flap free grafting was designed to repair the medical malleolar wound surface. From January 2000 to December 2006, the technique was used in 5 male patients who were injured by machine or in traffic accidents, causing bone and soft tissue defect. The size of wound surface ranged from 19 cm×12 cm to 24 cm×12 cm.
Results： The wound surface was healed at the first stage in 4 cases, and the other case had infection and was cured in 6 months with anti infection therapy. Postoperative foUow-ups from 6 months to 6 years showed that grafted bones and free cutaneous flaps were healed well, malleolar joints were stable, joint movement was normal, and the appearance was satisfactory. The overall outcome was good.
Conclusion ： Fibular head composite tendon bone flap free grafting is effective for repairing medical malleolar defect.     

Microsurgical repair at early stage for soft tissue defect of limbs wounded by modem firearm

Objective: To explore an early stage repair method for soft tissue defect of limbs of modern firearm wound,and to hnprove treating result. Methods: Defects of the hind limbs of dogs were relmired with skin, muscle and myocutaneous flaps. Results: Wounds healed within 2 weeks in the experimental group except one that healed in 3 weeks because of infection. Limb function was close to normal.The treatment result was better in the experimental group than the control. Conclusions: Skin, muscle and myocutaneous flaps can cover soft tissue defect at an early stage, prevent and reduce infection, promote the healing and recovery of combined injury, reduce the time of treatment and disability rate.     

Prefabricated Anterolateral Thigh Flaps for Phalloplasty in Female-to-Male Transsexuals

Background Phalloplasty is still a challenging operation because of the high urethral complication rate.Several options regarding different flaps can be chosen,but there is still no perfect solution for phalloplasty in female-to-male(FTM)transgender patients.Our group tried to use prefabricated anterolateral thigh(ALT)flaps for phalloplasty to overcome the urethral complications.Methods A total of 21 transgender patients were included from 2010 to 2019.A twostage operation was performed to reconstruct the phallus.The vaginal mucosa was prefabricated as neourethra at the first stage,and the shaft of the phallus was reconstructed at the second stage.Results All reconstructed phallus survived completely in our study,and the satisfaction rate was 76.2%.The total complication rate was 57.1%.The occurrence of fistula and strictures after the operation was 52.4%and 5.8%,respectively Conclusion Prefabricated ALT flaps with vaginal mucosa have a lower stricture rate.This technique provides a simple,effective surgical option in FTM transsexuals.     

胫后动脉穿支骨(膜)皮瓣移植修复手部复合组织缺损

Objective To study the methods and effects of repairing composite tissue defects of the hand by transfering posterior tibial artery perforator bone(periosteum) flap.Methods Nine cases of traumatic bone and soft tissue defects in the hand underwent digital subtraction angiography (DSA) of the lower leg preoperatively.According to angiography results and the anatomical characteristics, the tibial nutrient artery or osteoseptocutaneous perforator vessel of the posterior tibial artery was selected as vascular pedicle to harvest tibial artery perforator bone (periosteum) flap.The osteocutaneous flap was transferrede to repair the bone and soft tissue defect in the hand.The volume of the harvested bone ranged from 1.5 cm× 0.6 cm× 0.4 cm to 3.5 cm×0.7 cm×0.5 cm.The area of the skin flap ranged from 4.0cm×3.5cm to 7.0cm×4.0cm.Results All the composite tissue flaps survived completely.Postoperative follow-up for 3 to 18 months revealed that the fracture line disappeared in 3 to 4 months and all fractures healed.According to the TAM system of joint function assessment/provisional upper limb function evaluation standard isled by the Chinese Hand Surgery Society,88.9% of the cases achieved satisfactory results.Conclusion Transfer of posterior tibial artery perforator bone (periosteum) flap is an ideal procedure to repair composite tissue defects of the hand.No major vessel of the donor site is sacrificed.The good size match between the vessels of the donor site and recipient site makes vascular anastomosis easy.Donor site morbidity is minor.Bone healing time is short.     

胫后动脉穿支骨(膜)皮瓣移植修复手部复合组织缺损

Objective To study the methods and effects of repairing composite tissue defects of the hand by transfering posterior tibial artery perforator bone(periosteum) flap.Methods Nine cases of traumatic bone and soft tissue defects in the hand underwent digital subtraction angiography (DSA) of the lower leg preoperatively.According to angiography results and the anatomical characteristics, the tibial nutrient artery or osteoseptocutaneous perforator vessel of the posterior tibial artery was selected as vascular pedicle to harvest tibial artery perforator bone (periosteum) flap.The osteocutaneous flap was transferrede to repair the bone and soft tissue defect in the hand.The volume of the harvested bone ranged from 1.5 cm× 0.6 cm× 0.4 cm to 3.5 cm×0.7 cm×0.5 cm.The area of the skin flap ranged from 4.0cm×3.5cm to 7.0cm×4.0cm.Results All the composite tissue flaps survived completely.Postoperative follow-up for 3 to 18 months revealed that the fracture line disappeared in 3 to 4 months and all fractures healed.According to the TAM system of joint function assessment/provisional upper limb function evaluation standard isled by the Chinese Hand Surgery Society,88.9% of the cases achieved satisfactory results.Conclusion Transfer of posterior tibial artery perforator bone (periosteum) flap is an ideal procedure to repair composite tissue defects of the hand.No major vessel of the donor site is sacrificed.The good size match between the vessels of the donor site and recipient site makes vascular anastomosis easy.Donor site morbidity is minor.Bone healing time is short.     

Treatment of limb arterial in juries caused by traffic accidents

Objective:To analyze the features,diagonosis and treatment of limb arterial injuries caused by traffic accidents.Methods:A total of 43 patients with limb arterial injury admitted in our department over the past 30years(about50%of them happened during the last10 years)were analyzed retrospectively in this article.The popliteal,femoral and brachial arteries were mainly involved,accounting for 432%,20.5%and20.5%respectively of all the involvements.There were 35cases of open injury and9of close injury,The involved vessels were transected in 43.2%of the cases and contused in 40.9%,All the patients had various complications,such as fractures,dislocations and severe soft tissue injuries.The injured vessels were repaired by means of end-to-end anastomosis in 10cases,autogenous vein graft in 23cases and intraluminal hydraulic dilatation in 4cases.Results:Successful limb salvage was achieved in 34cases initially,whereas10amputations were carried out due to injuries to popliteal arteries in7,femoral arteries in2and humeral artery in 1and severe soft tissue damages in9 cases.Twenty-nine patients were followed up for 1-156months,with the averageof48.8months.There was good circulation in 22 cases and certain ischemia in 5cases.Two amputations were carried out in the late stage because of popliteal artery thrombosis after repair in 2cases.There was no death in this series.Conclusions:The limb arterial injuries caused by traffic accidents are severe and complicated.It is proposed that particulatr attentions should be paid to the features in diagnosis and treatment for this type of injury and special efforts should be made for both life saving and limb salvage.     

Oral and maxillofacial-head and neck reconstruction with soft tissue free flaps of 41 cases:A single team's experience

Objective To retrospectively review the single team’s experience of oral and maxillofacialhead and neck reconstruction involving 41 soft tissue free flap procedures.Methods From 1994 to 2012,41 patients who underwent oral and maxillofacial-head and neck soft tissue free flap reconstruction at the Department of Oral and Maxillofacial-Head and Neck Surgical Oncology,Hospital and College of Stomatology,Xi’an Jiaotong University,were reviewed with clinicopathologic data.Results The 41 patients included 24 men and 17 women with a mean age of 54 years.A total of 41 soft tissue free flaps were performed to reconstruct different anatomical structures in the head and neck region including oral mucosa,facial bone,head and neck skin.Two types of soft tissue free flaps were used to reconstruct surgical defects,including radial forearm flap and latissimus dorsi myocutaneous flap.Radial forearm flaps were used for 37cases and latissimus dorsi-myocutaneous flaps were 4 cases.Of 41 cases,39 were successful,with an overall success rate of 95.1%.There were 2 free flap failures,including one radial forearm flap and one latissimus dorsi-myocutaneous flap(partial flap necrosis);hence,the flap success rates for radial forearm flap and latissimus dorsimyocutaneous were,respectively,97.3% and 87.5%.Conclusions Radial forearm flap and latissimus dorsi-myocutaneous flap are reliable soft tissue free flaps to repair oral and maxillofacial-head and neck area with high success rate,which resulted in good functionally and cosmetically with fewer complications both donor and recipient sites.     

Should we change our approach to resuscitating victims of femoral fracture?A clinical experience in a busy trauma hospital in Shiraz,Iran

Purpose Traumatic hemorrhagic shock is a life-threatening event worldwide.Severe brain trauma accompanying femoral fractures can trigger inflammatory responses in the body and increase pre-inflammatory cytokines such as TNF-α,IL-1.The primary treatment in these cases is hydration with crystalloids,which has both benefits and complications.The purpose of this study was to investigate the effects of fluid therapy on the hemodynamics,coagulation profiles,and blood gases in such patients.Methods In this cross-sectional study,patients were divided into two groups:femoral fracture group and non-femoral group.The hemodynamic status,coagulation profile,and blood gases of patients in both groups were evaluated upon arrival at the hospital and again 2 h later.Data were analyzed by t-test and ANOVA with repeated data and paired samples t-test.Results A total of 681 trauma patients(605 men and 76 women)participated in this study,including 69(86.3%)men and 11(13.8%)women in femoral fracture group and 536 men(89.2%)and 65 women(10.8%)in non-femoral group.The laboratory parameters were evaluated in response to the equal amount of crystalloid fluid given upon arrival and 2 h later.Blood gases decreased in the fracture group despite fluid therapy(p<0.003),and the coagulation profile worsened although the change was not statistically significant.Conclusion The treatment of multiple-trauma patients with femoral bone fractures should be more concerned with the need for the infusion of vasopressors such as norepinephrine.If there is evidence of clinical shock,excessive crystalloid infusion(limited to 1 L)should be avoided,and blood and blood products should be started as soon as possible.     

Repair and reconstruction of severe leg injuries： retrospective review of eighty-five patients

Objective:To explore a good way of the reconstruction of severe tibial shaft fractures by using different flaps and external fixators. Methods: Eighty-five patients of TypeⅢC tibial shaft fractures with average age of 42.5 years were treated in our hospital from 1990 to 2005. Injuries were caused by motorcycle accidents in 66 patients, by machine accidents in 16 patients, and by stone bruise in 3 patients. The management procedures consisted of administration of antibiotics, serial debridment, bone grafting if needed, application of different flaps, such as free thoracoumbilical flaps, fasciocutaneous flaps, saphenous neurocutaneous vascular flaps, sural neurocutaneous vascular flaps and gastrocnemius muscular flaps, and different external fixations, for instance, half-ring fixators, unilateral axial dynamic fixators, AO fixators, Weifang fixators, and Hybrid fixators. The average follow up was 6.3 years. Results: All flaps survived. Eighty-three cases had bone healed. The average bone healing time of different external fixations was 5.5 months in 47 cases with half-ring fixators, 9.2 months in 4 cases treated with unilateral axial dynamic fixators, 8.5 months in 6 cases with AO fixators, 10.7 months in 16 cases with Weifang fixators, and 7.8 months in 10 cases with assembly fixators. Except half-ring fixation, other fixations all needed necessary bone graft. Two cases treated with unilateral axial dynamic fixators had nonunion of bone and developed osteomyelitis. The wounds healed after the removal of the fixators and immobilization by plaster. The last follow up examination showed ankle and knee motion was normal and no pain was noted. Conclusions: The combination of half-ring external fixators with various flaps provides good results for TypeⅢC tibial shaft fractures.     

Immunological study on the transplantation of an improved deproteinized heterogeneous bone scaffold material in tissue engineering

Objective： To observe the immune response after the transplantation of a deproteinized heterogeneous bone scaffold and provides the theoretic reference for clinical practice.
Methods： The fresh pig bone and deproteinized bone were transplanted respectively to establish BABL/C thigh muscle pouches model of male mice and take the samples for detection at 1, 2, 4, 6 weeks after operation. Lymphocyte stimulation index, subset analysis, serum specific antibody IgG, cytokine detection and topographic histologic reaction after implantation were investigated.
Results： After the transplantation of deproteinized bone, lymphocyte stimulation index, CD4^＋ and CD8^＋ T-lymphocyte subsets, serum specific antibody IgG and cytokines in deproteinized bone group were significantly lower than those in fresh pig bone group at each time point （P〈0.05）. The histological examination found that in fresh bone group at each time point, a large quantity of inflammatory cells infiltrated in the surrounding of bone graft, and they were mainly lymphocytes, including macrophages and monocytes. In deproteinized bone group, there were few inflammatory cells infiltration around bone graft one week after operation. The lymphocytes were decreased as time went by. At 6 weeks, fibroblasts and fibrous tissue grew into the graft, and osteoclasts and osteoprogenitor cells appeared on the verge.
Conclusions： The established heterogeneous deproteinized bone has low immunogenicity and is a potentially ideal scaffold material for bone tissue engineering.     

Treatment of femoral neck fracture with muscle-bone flap of both tensor fasciae latae and sartorius

Objective： To evaluate the effect of muscular pedicle bone grafts with sartorius or tensor fasciae latae and sartorius in fresh transcervical or subcapital fractures of the femoral neck. Methods: Thirty cases of fresh transcervical and subcapital fractures of the femoral neck were treated by the tail breakable screws and sartorius pedicle bone grafts(single muscular pedicle, SMP group). The other 23 cases were treated by cannulated pressure screws and bone grafts with the muscular pedicles of both sartorius and tensor fasciae latae (double muscular pedicles, DMP group). Results: Fifty-two cases were followed up for 3 to 5 years (mean, 4 years). In SMP group, ten cases showed poor therapeutic results. Excellent therapeutic effects were achieved in all cases of DMP group. Conclusions : The transcervical or subcapital fractures of the femoral neck can be treated by double muscular pedicles bone graft. The bone graft with double muscular pedicles is more effective than single sartorius muscular pedicles for fresh transcervical and subcapitul fractures of the femoral neck during short and medium terms.     

重度开放性Pilon骨折的治疗

Objective To discuss the operative methods, timing and outcomes of severe open Pilon fractures. Methods From April 2003 to July 2008, 21 patients with open Pilon fractures were admitted. All the patients were type C fracture according to AO/OTA classification, including 17 cases of type C2 and 4 cases of type C3. According to Gustilo classification, there were 18 cases of type Ⅱ, 2 cases of type ⅢA, 1 case of type ⅢB. The patients were treated in two different ways: one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with transarticular external fixation of the ankle (19 cases),which included 16 cases of Gustilo Ⅱ AO/OTA C2, 2 cases of type Gustilo Ⅱ AO/OTA C3 and 1 case of type Gustilo ⅢA AO/OTA C2. Formal open reconstruction of the articular surface by plating and external fixation was performed when the condition of soft tissue had improved (2 cases), which included 1 cases of type Gustilo ⅢA AO/OTA C3 and 1 cases of type Gustilo Ⅲ B AO/OTA C3. Results All the patients were followed up from 6 to 48 months, with the mean of 24 months. The outcome of reduction was evaluated by the Burwell-Charnley score. Anatomical reduction was found in 6 cases, function reduction was in 14 cases and poor reduction was 1 case. The heal-time ranged from 2.5 to 11 months, with the mean of 4.7 months. The delayed union occurred in 2 cases. The rate of delayed union was 9.5%. Two patients experienced skin superficial necrosis. There were superficial infection in 2 cases and deep infection in 1 case. The infection rate was 14.3%. Eight cases experienced early traumatic arthritis. The incidence of this complication was 38.1%.According to American Orthopedic Foot Ankle Society (AOFAS) scale for ankle joint, the result of the treatment was 66-94, with an average of 85.2. Conclusion It is important to have the optimal timing of surgery and reliable fixation according to fracture classification, the condition of soft tissue and time after injury. It is the key to evaluate the condition of soft tissue and protect the blood supply.     

Compartment syndrome of thigh and lower leg with disruption of the popliteal vascular bundle after being run over by a 25-ton truck

Compartment syndrome of the thigh is a rare condition, potentially resulting in devastating functional outcome. Increasing intracompartmental pressure which suppresses microcirculation and capillary perfusion may lead to cellular anoxia and muscle ischemia. The muscle com- partments in the thigh have a more compliant fascia and blend anatomically into the open compartments of the pelvis, thus compensating higher volumes than the compartments in the lower leg. We present a previously unreported case in which the limb of a 36-year-old man was run over by a 25- ton truck. He presented with a sensomotor deficit in his left lower leg with full paralysis of the shank muscles and ab- sence of all foot pulses. CT scan showed a huge haematoma in the thigh with active bleeding out of the popliteal artery into the haematoma which has already expanded into the muscle compartments of the lower leg. The limb had a disas- trous compartment syndrome of the thigh and lower leg with disruption of the popliteal neurovascular bundle; however, no bones in the limb were fractured. A complete fasciotomy of all the lower limb muscle compartments was immediately performed. The artery was reconstructed with interposition of the smaller saphenous vein, which was al- ready interrupted through the initial trauma.     

Treatment of tibiofibular fractures of Gustilo type Ⅲ by vacuum, sealing drainage and external fixation

Objective To report clinical efficacy of vacuum sealing drainage(VSD)and external fixation in the treatment of tibiofibular fractures of Gustilo type Ⅲ. Methods From October 2006 to November 2009,19 cases of Gustilo type Ⅲ tibiofibular fracture were treated in our department.They were 14men and 5 women,with an average age of 30.1 years(from 17 to 62 years).There were 9 cases of type ⅢA,8 cases of Type ⅢB 2 cases of typeⅢC.After emergency debridement,all the fractures were fixed with an extemal fixator following indirect reduction.The wounds were sealed with VSD.When the wounds were clean and granulation appeared,they were repaired by direct suture(5 cases),split-thickness skin graft(9 cases)and flap transposition(5 cases). Results The 19 cases were followed up for 12 to 24 months,with an average of 16.3 months.A11 the wounds were closed'after VSD for 5 to 17 days.Wound infection occurred in 2 cases and was finally repaired by flap transposition following repeated debridement and VSD.The fractures healed after 4 to 10 months(average,5.6 months). Conclusion External fixation combined with VSD is a simple and effective treatment for tibiofibular fractures of Gustilo type Ⅲ.because it can provide not only rapid fixation but also early wound sealing to facilitate fracture healing and reduce incidence of complications.