Free vascularized tibial periosteal graft with monitoring skin island for limb reconstruction: Anatomical study and case report

Several types of vascularized periosteal flaps have recently been described for the treatment or prevention of complex non‐union in pediatric patients. Among them, a vascularized tibial periosteal graft (VTPG), supplied by the anterior tibial vessels (ATV), has been used successfully as a pedicled flap in a few patients. The purpose of the study is to describe the periosteal branches of the ATV, as well as the cutaneous and muscular branches by means of an anatomical study. In addition, to report on the use of VTPG as a free flap with a monitoring skin island in a clinical case. A mean of 6.5 periosteal branches (range 5–7) were found. In all cases we located a cutaneous perforator branching from one of the periosteal branches located at the midlevel of the leg. We performed a two‐stage reconstruction of a recalcitrant non‐union and residual shortening of the right tibia in a 17‐year‐old boy. After nonunion focus distraction, we used a massive bone allograft fixed with a nail and covered by a VTPG as a biological resource. Allograft consolidation was achieved 5.5 months after surgery. At eighteen months after surgery, no complications were observed and the patient had resumed all his daily activities, despite a residual 2‐cm limb‐length discrepancy. VTPG may be considered as a valuable surgical option for bone reconstruction in complex biological scenarios in the young population. © 2015 Wiley Periodicals, Inc. Microsurgery 37:248–251, 2017.     

Micro-anatomy of collateral perforating branches of the middle cerebral artery

The lenticulostriate arteries are the subject of a microanatomical study on 50 formalin fixed human brains. A single trunk arising from the middle cerebral artery is rarely found. In fact the branches are numerous and they are found to ramify before penetrating the anterior perforated substance. The length of the sphenoidal segment is variable and this aspect is discussed in the light of the literature data. The origin of the perforating branches is spread from the internal carotid artery to the bifurcation branches of the middle cerebral artery (M2 segment). On the other hand lenticulostriate arteries arising from the cortical branches of the middle cerebral artery are often found. These anatomical patterns are of essentially surgical interest. No branches must be damaged during the opening of the Sylvian fissure or during the dissection of an aneurysm in this region.     

以掌背动脉为蒂尺骨远段背侧骨瓣移位术的应用解剖

目的 为以掌背动脉为蒂的尺骨远段背侧骨瓣移位修复第３、４、５掌骨头缺损提供解剖学依据。方法 在３０侧成人上肢标本上解剖,观察腕背动脉网的构成及分支。结果 腕背动脉网由桡动脉及尺动脉腕背支及与骨间后动脉终末支,骨间前动脉腕背支吻合形成,由该网发生第２、３、４掌背支,第２、３、４掌背动脉由掌背支与掌深弓所发深支吻合而成。结论 以第３、４掌背动脉为蒂的尺骨远端背侧半片骨瓣,可修复第３、４、５掌骨头缺损。     

股外侧肌上端肌支股骨骨（膜）瓣的解剖与临床应用

目的报道股外侧肌上端肌支股骨骨(膜)瓣的应用解剖及临床应用。方法在40侧成人下肢标本上解剖观测股外侧肌上端血管肌支的分支分布情况,设计以股外侧肌支为蒂的股骨骨(膜)瓣移位术,并进行了摹拟手术。1989年2月～1999年2月,以股外侧肌支为蒂切取股骨骨(膜)瓣移位修复股骨上段骨不连、骨缺损7例。结果股外侧肌上端肌支来自旋股外侧动脉横支,肌支在大转子尖下(16.8±3.0)cm发出肌骨膜支和骨膜支,肌骨膜支外径1.4～1.7mm,长度2.7～5.6cm,骨膜支外径0.4～0.6mm,长度1.2～1.5cm。骨膜血管向下或水平走行,达骨膜后发出吻合支,参与形成股骨血管网,分布于股骨上段。临床应用的7例,术后经18～42个月的随访,骨折于术后10～18周获得骨性愈合。髋关节活动度在180°者4例,120°者2例,65°者1例。供区愈合良好,无不适。结论以股外侧肌上端肌支为蒂的股骨骨(膜)瓣,可用于修复股骨中上段的骨不连、骨缺损。     

Choledochal cyst as a complex malformation of the intra and extrahepatic bile ducts

The authors present the case of a 64 years woman with a choledochal cyst along with a complex malformation of both intra and extrahepatic bile ducts. The patient was admitted with a diagnosis of acute and underestimated cholecystitis, which was in fact a real acute severe suppurated angiocolitis located at the cystic cavity level along with severe hepato-renal failure. As long as the choledochal cyst evolves as a stand-alone entity, it can frequently be associated with other malformations of the bile ducts--such as choledochal duct stenosis or abnormal connection of the common hepatic duct with pancreatic ducts. The main dilatation was engulfing the whole common bile duct with a fusiform aspect, and the cranial end is opening into a long hepatic duct from which were emerging several biliary segments branches, for both hepatic lobes. This aspect of a multistage convergence with four branches which is opening into a long hepatic bile duct and then in the choledochal cyst, represents an unusual malformation which does not respect the rules described by former published authors.     

Endovascular stenting of mid-aortic syndrome due to Takayasu arteritis

Introduction–patients: Takayasu arteritis may involve various parts of the aorta and its major branches. It leads to occlusive or aneurysmal disease of the vessel. It can be treated either with surgery or percutaneous intervention. We report a successful endovascular treatment of stenosis of the descending thoracic and abdominal aorta in a 19-year-old female.

Methods–results–conclusions: Self-expandable nitinol stent was deployed and adequate opening of the aorta was obtained in this patient. Long-term durability of endovascular approach is a matter of debate. We also reviewed the sufficiency of endovascular treatment versus surgery.     

Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

BACKGROUND: Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. CASE DESCRIPTION: This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. CONCLUSION: Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.     

Anterior clinoidectomy and opening of the internal auditory canal using an ultrasonic bone curette

OBJECTIVE: During cranial base surgery, use of a high-speed drill for osteotomy has become common. We performed anterior clinoidectomy and opening of the internal auditory canal using an ultrasonic bone curette, and we report the advantages and clinical applications of this method. DESCRIPTION OF INSTRUMENTATION: The ultrasonic surgical equipment comprises a power supply unit, footswitch, and handpiece (weight, 110 g; diameter, 20 mm; length, 140 mm from tip to angled section). The handpiece tip is 2 mm wide, and the amplitude of longitudinal vibration can be varied from 120 to 365 microm at an ultrasonic frequency of 25 kHz. Cool-controlled irrigation fluid emerges near the tip, through the sheath. EXPERIENCE AND RESULTS: We performed anterior clinoidectomy in eight cases of paraclinoid aneurysm and opening of the internal auditory canal in six cases of acoustic neuroma without damage to the dura mater or nearby structures such as brain tissue, blood vessels, and cranial nerves. In addition, no damage to the facial nerve or labyrinthine organ resulted from heat or vibration caused by the ultrasonic bone curette. CONCLUSION: Ultrasonic bone curettage represents safe instrumentation for performance of anterior clinoidectomy and opening of the internal auditory canal without damage to surrounding structures. This technique allows surgeons to perform procedures on deep areas without incurring psychomotor stress.     

A bipedicled neurovascular step-advancement flap for soft tissue lengthening in clinodactyly.

Recommendations for the surgical treatment of clinodactyly have centered on techniques of osteotomy with or without bone grafting. However, the limiting factor to the correction may be tension in the soft tissues. A new technique to correct clinodactyly is described utilising an opening wedge osteotomy and bone grafting plus a bipedicled neurovascular step-advancement flap to correct the soft tissue deficiency. The procedure has been performed in five cases.     

Strategy for direct anastomosis in moyamoya disease

Direct and/or indirect revascularization is usually performed in the surgical management of moyamoya disease. The surgical technique for direct anastomosis is thought to be difficult in some patients with moyamoya disease. In the present report, a more reliable technique for direct anastomosis is reported and demonstrated. Strategy for hemostatic procedure on the dura mater, preservation of fine branches originating from a recipient artery, opening of the recipient artery, and the technique for an anastomosis between a superficial temporal artery and a branch of the middle cerebral artery are discussed.     

Surgical procedures for management of right portal venous branching in right lobe living donor liver transplantation

OBJECTIVE: This study sought to describe the surgical management of right portal venous (PV) branches encountered among 104 cases of right lobe living donor liver transplantation (LDLT). METHODS: From January 2002 to September 2007, we performed 104 cases of right-lobe LDLT including 11-donors who had anomalous right portal venous branches (APVB). One recipient had PV sponginess hemangioma. The donor right PV branches were type I in 93 cases, type II (trifurcation) in nine cases, and type III in two cases. Except one narrow bridge of tissue excision, the PV branches were transected on the principal of donor priority: PV branches were excised approximately 2 to 3 mm from the confluence while leaving the donor's main portal vein and confluence intact. In type II APVB, donor PV branches were obtained with two separate openings in six cases; with two separate openings joined as a common orifice at the back table in two cases, with one common opening with a narrow bridge of tissue in one case. In type III APVB, the donor right anterior and posterior PV branches were obtained with separate openings. The donor right PV branches with one common opening in 92 cases of type I PV branches and a joined common orifice in three cases of type II APVB were anastomosed to the recipient's main portal vein or to right branching. As the unavailable recipient PV for sponginess hemangioma, one case of type I right PV branches was end-to-end anastomosed to one of the variceal lateral veins of about 1 cm diameter in a pediatric patient. The PV were reconstructed as double anastomoses in six type II APVB and in one type III APVB obtained with two separate PV openings. In the another type III APVB reconstruction, we successfully utilized a novel U-shaped vein graft interposition. RESULTS: The type II APVB donor receiving a narrow bridge of portal vein tissue excision developed portal vein thrombosis on the third postoperative day and underwent reexploration for thrombectomy. There were no vascular complications, such as portal vein thrombosis or stricture among other donors or all recipients. The velocity of blood flow in the U-graft was normal. The anastomosis between the type I donor right portal vein and recipient variceal lateral vein was unobstructed. CONCLUSION: Right PV branches should be excised on the principal of donor priority while leaving the donor's main portal vein and confluence intact. Single anastomoses was the fundamental procedure of right branch reconstruction. Double anastomoses could be used as the main management for type II and type III APVB reconstruction. U-graft interposition may be a potential procedure for type III APVB reconstruction. Single anastomoses between the donor right portal vein and the recipient variceal lateral vein may be performed when recipient portal vein is unavailable. These innovations for excision and reconstruction of right PV branches were feasible, safe, and had good outcomes.     

A New Family of Axial Reduction Clamps - Design and Surgical Technique

Objectives: With a tendency to less invasive approaches in trauma surgery, today's reduction clamps are often insufficient due to their scissors-like opening and closing mechanism. Therefore we designed a new family of axial reduction clamps, which is presented in this paper. Technical Development and Possible Applications: The new type of reduction clamp consists mainly of an axial opening and closing mechanism. Several kind of clamps using this mechanism are designed specifically for different indications such as pelvic, long bone or foot surgery. Surgical Technique: The clamp can be manipulated with one hand and is closed with a pistol-like handle. To avoid dislocation on oblique bone surfaces, a central K-wire can be pushed through the cannulated straight arm and drilled through the bone until penetrating a hole in the opposite curved arm. Using the percutaneous reduction forceps, different drill and holding sleeves allow insertion of screws whilst the forceps maintains reduction. Discussion. The new family of reduction clamps differs from conventional reduction forceps in an axial closing mechanism which allows reduction and retention of fractures through limited approaches.     

Trapezoid rotational bone graft osteotomy for metacarpal and phalangeal fracture malunion

Metacarpal and phalangeal fracture malunions with significant angulation deformity are associated with bone shortening, prominence of the metacarpal head in the palm or pseudoclaw deformity and may be symptomatic. If so, they may need corrective osteotomy procedures. Conventional methods of closing, or opening, wedge osteotomy do not restore the length of the bone exactly. Simultaneous correction of the angular deformity and restoration of bone length can be addressed by a trapezoid rotational bone graft osteotomy. A double osteotomy is done and the segment of bone is rotated and re-inserted as a bone graft. This was done successfully in four metacarpal and two phalangeal fracture malunions with angulation deformities.     

Simple reconstruction of frontal sinus opened during craniotomy using small autogenous bone piece: technical note

BACKGROUND: Accidental opening of the frontal sinuses during craniotomy can lead to various postoperative complications. We report a simple and reliable reconstruction method using no exogenous or autogenous material obtained from another site. METHODS: This method involves packing a small wedge-shaped piece of bone obtained from the bone flap of the craniotomy into the nasal recess of the exposed sinus. The large opened frontal sinus is reconstructed as a new minimized frontal sinus with mucous membrane and bony roof in the nasal recess. RESULTS: Eleven patients with large frontal sinus opening during craniotomy (7 cases of bifrontal craniotomy for the basal interhemispheric approach) underwent frontal sinus reconstruction by packing of a small bone piece into the nasal recess. No patients suffered postoperative complications related to the opened frontal sinus such as pneumocephalus or cerebrospinal fluid rhinorrhea. CONCLUSIONS: Packing of a small bone piece from the bone flap is a quick and reliable method to reconstruct the frontal sinus opened during craniotomy.     

以隐血管为蒂的逆行股骨内侧髁骨瓣骨皮瓣的解剖学研究及临床应用

目的　为治疗胫骨骨不连和骨缺损提供一种新方法。方法　通过解剖学观察膝降动脉关节支及隐支的关系,并摹拟手术证实以隐血管为蒂的逆行股骨内侧髁骨瓣的切取可能。结果　尸体摹拟手术4例,切取后关节支均有墨汁显示。临床应用2例,切取骨瓣分别为5.0cm×2.0cm×1.5cm及4.5cm×1.5cm×1.5cm均有活跃渗血。随访8～12周,骨折愈合良好。结论　应用以隐血管为蒂的逆行股骨内侧髁骨瓣骨皮瓣治疗胫骨骨不连和骨缺损具有手术方法简便,疗效可靠,易于推广等优点。     

Cholesteatoma of the clivus.

Cholesteatomas (central nervous system epidermoids) can be found intradurally or extradurally in the central nervous system. Extradural intraosseous lesions are most commonly found in the petrous bone. The authors describe a unique case of a clival cholesteatoma in a 64-year-old woman who presented with headaches. No other neurological complaints or physical examination findings were noted. Magnetic resonance imaging showed an expansile lesion centered in the middle portion of the clivus. A large portion of the clivus was eroded. The lesion was explored via a transnasal trans-sphenoidal approach and granular debris was evacuated. The cystic lining was stripped from the surrounding bone, and the bone opening was widely fenestrated. Pathological examination showed keratinous debris with macrophages and an outer lining of benign epithelial tissue consistent with a cholesteatoma (epidermoid cyst). When surgically accessible, these lesions should be excised to prevent a recurrence. If inaccessible, marsupialization may be considered.     

Total graft replacement of the thoracoabdominal aorta with reconstruction of visceral branches, intercostal and lumbar arteries in expanding chronic dissecting aneurysms of the thoracoabdominal aorta

Four patients with expanding chronic dissecting thoracoabdominal aneurysm underwent total replacement of the thoracoabdominal aorta with reconstruction of all visceral branches, intercostal and lumbar arteries with the aid of femoro-femoral bypass. During aortic cross-clamping, selective celiac and both renal arteries perfusion was performed to prevent the organ ischemia. Somatosensory evoked potentials monitoring or spinal cord evoked potentials monitoring was also performed to detect the spinal cord ischemia. Surgical technique employed in this series was direct anastomosis of onlay patch graft to the normal true lumen from which visceral branches and intercostal and lumbar arteries arise. The celiac artery and left renal artery arise from the false lumen in some cases were reconstructed with graft interposition or direct anastomosis to an opening made in the onlay patch graft. All patients survived the operation, and are leading normal life late in the postoperative period except one who developed partial paraplegia. Total graft replacement of the thoracoabdominal aorta may be a valid technique for the treatment of expanding aneurysms of the dissecting thoracoabdominal aorta.     

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Quadriceps tendon–patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon–patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 329–332     

Radiographic and pedobarographic comparison of femoral head allograft versus block plate with dorsal opening wedge medial cuneiform osteotomy: a biomechanical study

BACKGROUND: The effect of the Cotton osteotomy has not been studied in isolation, and no alternative to bone graft has been investigated for this osteotomy. We hypothesized that there would be no difference in radiographic and pressure findings using the Cotton osteotomy with bone graft or an opening wedge block plate. MATERIALS AND METHODS: Each specimen of eight matched pairs of lower extremities was loaded in simulated double-leg stance via pneumatic cylinders as described previously. Weightbearing lateral and anteroposterior radiographs and medial and lateral pressure measurements were obtained for all intact specimens. Specimens were randomly assigned to receive a Cotton osteotomy with a dorsal opening wedge allograft or an opening wedge plate. Each specimen was cycled at 3 Hz to 720 N for 5000 cycles and measurements were repeated. RESULTS: Calcaneal pitch was lower after the block plate procedure (mean +/- standard error of the mean) (intact, 23.4 +/- 1.2 degrees versus post-procedure, 21.8 +/- 1.1 degrees; p = 0.05). There was a significant difference (p < 0.05) in percentage of total plantar pressure medially and laterally between the intact specimen and the specimen after osteotomy with both methods. Pressure increased medially and decreased laterally. CONCLUSION: With the numbers available, these methods for performing a Cotton osteotomy did not differ in addressing lateral column overload. CLINICAL RELEVANCE: Dorsal opening wedge medial cuneiform osteotomy performed with femoral head allograft or a block plate may be effective both in reducing lateral column pressures and increasing medial column pressures when they are deficient preoperatively.     

指侧方皮支血管链皮瓣修复手指软组织缺损

目的报道采用手指侧方皮支血管链皮瓣一期修复手指皮肤软组织缺损伴骨或肌腱外露的方法,并观察其临床疗效。方法对17例17指手指皮肤软组织缺损伴骨或肌腱外露者,应用指侧方皮支血管链皮瓣一期修复。皮瓣面积：1．5cm×1．5cm-3．1cm×3．6cm。结果17例皮瓣全部成活,术后随访6个月～1年,伤指外形与正常指相近,皮瓣弹性、色泽良好。指腹饱满而不臃肿．质地柔软,有排汗功能,两点辨别觉达5-9mm。结论指侧方皮支血管链皮瓣一期修复手指皮肤软组织缺损伴骨或肌腱外露．疗程短,效果好,是可靠、有效的治疗方法。此皮瓣具有手术操作简便、不损伤指固有动脉及神经等优点．是修复手指皮肤缺损较理想的方法。