Vascularized fibular grafts in the reconstruction of bone defects caused by war injuries

The efficiency of the vascularized fibular graft application in the reconstruction of diaphyseal defects of the long bone of extremities caused by war injuries was prospectively investigated in the group of 33 patients in the period 1991-1996, during the war in the former Yugoslavia. The preoperative, intraoperative and postoperative procedures were systematized. Early and late complications in donor and recipient regions were shown. The primary success was 63.6% and the total one was 93.9%. The efficiency of the vascularized fibular graft in the treatment of bone defects caused by war injuries could be compared with bone defects caused by trauma or by resection of malignant tumors.     

Computational simulation of projectile injuries to human parietal bone using finite element analysis

The aim of this study was to evaluate the morphological and biomechanical characteristics of a wound entrance on the parietal bone from the impact of projectiles presenting three different calibres. Three-dimensional finite element models of dry human skull and of three projectiles with calibres .380 Auto, .40 S&W and 9 × 19 mm Luger were obtained. These geometries were used to perform a simulation of projectile impact on the parietal bone by the finite element method. We calculated the morphological aspect of the wounds on the external bone surface, the equivalent von Mises stress and the kinetic energy loss. The wounds from the 9 × 19 mm and .380 calibres presented a circular aspect, while the wound from the .40 calibre presented an oval aspect. The 9 × 19 mm caused a major wound area compared with the other calibres. The maximum von Mises stress in the bone was higher from the .40 calibre penetration, and the .380 had the major kinetic energy loss. In conclusion, the 9 × 19 mm and .380 presented similarity in the shape of the entrance hole. The projectile with 9 × 19 mm calibre seems to have greater penetration power and the .40 S&W projectile greater power of destruction and dissipation of energy.     

The use of three-phase bone imaging in vascularized fibular and iliac bone grafts

Three-phase bone imaging was undertaken to monitor the viability of vascularized bone grafts after surgery. Eleven vascularized fibular grafts and six vascularized iliac grafts were reviewed. The study evaluated patients over multiple time intervals from 1 week to 6-8 weeks postoperatively. Follow-up ranged from 12 to 60 months. In most of the patients who achieved a successful clinical outcome, the study was positive; blood perfusion and blood pool radioactivity at sites of bone grafts were higher than those at recipient sites two weeks postoperatively and became equal to surrounding tissue thereafter. The grafted bone uptake of radiophosphate was constantly positive in these cases. Conversely, the study was negative in three cases of postoperative vascular complications. Serial three-phase bone imaging is a useful tool to monitor the viability and early complications of vascularized bone grafts after surgery.     

Microvascular free flaps and care of war injuries with tissue defects

BACKGROUND: War wounds caused by modern infantry weapons or explosive devices are very often associated with the defects of soft and bone tissue. According to their structure, tissue defects can be simple or complex. In accordance with war surgical doctrine, at the Clinic for Plastic Surgery and Burns of the Military Medical Academy, free flaps were used in the treatment of 108 patients with large tissue defects. With the aim of closing war wounds, covering deep structures, or making the preconditions for reconstruction of deep structures, free flaps were applied in primary, delayed, or secondary term. The main criteria for using free flaps were general condition of the wounded, extent, location, and structure of tissue defects. The aim was also to point out the advantages and disadvantages of the application of free flaps in the treatment of war wounds. METHODS: One hundred and eleven microvascular free flaps were applied, both simple and complex, for closing the war wounds with extensive tissue defects. The main criteria for the application of free flaps were: general condition of the wounded, size, localization, and structure of tissue defects. For the extensive defects of the tissue, as well as for severely contaminated wounds latissimus dorsi free flaps were used. For tissue defects of distal parts of the lower extremities, scapular free flaps were preferred. While using free tissue transfer for recompensation of bone defects, free vascularized fibular grafts were applied, and in skin and bone defects complex free osteoseptocutaneous fibular, free osteoseptocutaneous radial forearm, and free skin-bone scapular flaps were used. RESULTS: After free flap transfer 16 (14.4%) revisions were performed, and after 8 unsuccessful revisions another free flaps were utilized in 3 (37.5%) patients, and cross leg flaps in 5 (62.5%) patients. CONCLUSION: The treatment of war wounds with large tissue defects by the application of free microvascular flaps provided shorter wound-closing period, earlier beginning of physical therapy, as well as the treatment of great number of patients with the extensive tissue defects in the conditions of massive influx of the wounded.     

桡骨远端逆行带血管蒂植骨治疗舟状骨骨不连

目的探讨桡骨远端逆行带血管蒂植骨治疗舟状骨骨不连的疗效。方法从2003年3月—2009年5月我科收治舟状骨骨折骨不连病人16例,采用桡骨远端逆行带血管蒂植骨的方法进行治疗。结果平均随访时间12月,采用Herbert和F isher的舟骨骨折分级评价系统,所有病人骨折愈合,平均愈合时间2月,有较高的满意度和好的临床结果。结论桡骨远端逆行带血管蒂植骨治疗舟状骨骨折骨不连疗效好,可以作为治疗舟状骨骨不连的首选方法。     

Imaging of vascularized fibular grafts in large bone reconstruction in skeletally immature patients

 Objective. To describe the imaging findings of vascularized fibular grafts (VFG) in large bone reconstruction in children and teenagers. Design and patients. Fifteen patients aged from 4 to 19 years underwent VFG for bone reconstruction for primary tumors involving bone in 13 cases and for chronic osteomyelitis in 2 cases. Lesions were located in the femur (6 cases), the tibia (6 cases), the humerus, the distal fibula and the ilium. Radiographic follow-up was performed in all patients, radionuclide studies in 12 patients and MRI in 8. Results. Plain films showed a lamellated periosteal reaction on the VFG within 3 weeks following the procedure in all cases. Fusion of VFG and host bone occurred during the first 3 months. Radionuclide uptake of the VFG was seen in all cases but one. MRI showed cortical thickening and conservation of the high signal intensity of fatty marrow on T1-weighted sequences, and periosteal enhancement on dynamic post-contrast studies in all but one of the patients. Conclusion. Radionuclide studies and MRI show the periosteal enhancement and assess the viability of the VFG satisfactorily. However, we feel that plain films may be sufficient to ascertain this viability.     

异体脱脂骨板加自体腓骨移植治疗前臂节段性骨缺损

目的 探讨尺骨或桡骨单根节段性骨缺损的治疗方法。方法 自1997年1月至2003年1月共收治尺骨节段性骨缺损10例，桡骨节段性骨缺损2例。采用自体游离腓骨桥接骨缺损、钢板加对侧骨板双固定治疗。结果 10例切口Ⅰ期愈合，2例Ⅱ期愈合。随访时间12～36个月，平均25个月；骨缺损愈合时间4～8个月，平均6个月20d，无骨不连患者。前臂旋转功能参照Grace评定标准，优3例，良5例，一般2例，差2例。结论 采用自体腓骨桥接尺或桡骨骨缺损，钢板、骨板双固定是一种治疗尺或桡骨节段性骨缺损较理想的方法。     

桡骨远端背侧带血管蒂骨瓣转位治疗陈旧性舟骨骨折

目的 评价桡骨远端背侧带血管蒂骨瓣转位治疗陈旧性舟骨骨折的中远期疗效.方法 回顾性分析1995-2006年行桡骨远端背侧带血管蒂骨瓣转位治疗的13例陈旧性舟骨骨折,其中9例伴近侧极缺血坏死.血管蒂为1,2区间间伸肌支持带上血管.固定方式包括螺钉内固定及外支架固定.评价内容包括Mayo腕关节临床功能评分以及影像学评价.结果 手术距受伤时间平均22.2个月,平均随访76.6个月.骨折愈合13例,平均愈合时间11.2周.功能评价:优3例,良8例,可2例.末次随访时,腕关节功能评分、关节活动度、握力均较术前有显著提高.舟骨角以及舟月角明显改善.结论 桡骨远端背侧带血管蒂骨瓣转位治疗陈旧性舟骨骨折手术过程相对简单,疗效满意.术中予腕关节松解,术后腕关节在外支架的保护下进行早期功能锻炼可促进关节功能的恢复.     

Frequency, etiology, localization and surgical treatment of war injuries with tissue defects

The retrospective analysis of 1,514 cases treated at the Clinic for Plastic Surgery and Burns of the Military Medical Academy in the period between 1991 and 1995, established that the percentage of the injuries caused by gunshots and those caused by explosives during the conflict in former Yugoslavia, was more or less the same. The injuries caused by gunshot more often occurred on the head, neck, arms and trunk. The injuries of the legs caused by the explosives were more frequent, and they occurred in 83% of the cases. All the plastic surgeons who took part in the treatment of patients and in preparing the surgeons of other specialties for the treatment applied the original classification of the war injuries according to the structure of the defects that had occurred, to standardize the approach to the planning of treatment and the treatment itself of the wounded. In the delayed primary or secondary treatment of the injuries with the tissue defects all known plastic and reconstructive methods were applied. In the cases requiring the covering of the the tissue defect with the full thickness skin, local skin, fasciocutaneous, fascioadipose or muscle flap was chosen. Distant pedicled direct flaps were used in cases when it was not possible to use a more suitable reconstructive method. Free skin, myocutaneous or complex microvascular flaps were applied in cases of more extensive defects or if a more suitable solution could not be found. Our experience in surgical treatment of war injuries with skin defects during the civil war in former Yugoslavia has shown that over 50% of all the injured patients required the treatment of a plastic surgeon in a definite surgical treatment of a war injury. A multidisciplinary approach is necessary in the majority of the injured, and the surgical team is composed according to the affected area and the extent of the injury.     

Pre- and postoperative imaging of vascularized fibular grafts

Free vascularized fibular grafting, in which the peroneal artery is harvested with the fibula, is a popular procedure for filling osseous defects and for treatment of femoral head avascular necrosis. Preoperative vascular imaging is required in all patients to detect the origin of the peroneal artery, to measure the length available for the vascular pedicle, and to evaluate for the normal continuation of the three major vessels of the lower leg. Magnetic resonance imaging of the lower leg with use of gradient-recalled acquisition in a steady, state was performed in 35 patients to evaluate vascular anatomy. Surgical correlation was available in 91% of cases, and in these 100% accuracy was demonstrated. Postoperative radiographs showed that grafts placed for osseous defects in the upper extremity were incorporated and hypertrophied extremely quickly, while those placed in the major weight-bearing bones of the lower extremity were much more prone to complications including delayed union, fracture, and infection. Vascularized grafts placed in the femoral head and neck for avascular necrosis incorporate only in the cephalic portion and should be watched carefully for signs of early and progressive femoral head collapse.     

Reconstruction of the infected war defects of the tibia: a fragment elongation according to the Ilizarov technique

INTRODUCTION/AIM: The treatment of tibia defects complicated with chronic osteomyelitis is difficult, often requiring one or more surgical interventions with prolonged periods of functional incapacity. METHODS: We treated 20 patients with tibia defects, who had been wounded during the war operations in the former Yugoslavia, complicated with chronic osteomyelitis by applying the Ilizarov apparatus. In 10 patients with the average defect of 4.7 cm, interfragmentary diastasis of 1.5 cm, and 3.1 cm of shortening we applied the bilocal synchronous compressive - distractive method (BSCD). In the remaining 10 patients with average defect of 6.4 cm, interfragmentary diastasis of 5.5 cm, and 1.6 cm of shortening we applied bilocal alternating distractive - compressive osteosynthesis (BADC). RESULTS: The average followup was 93 months. In the group A, the average distraction index was 10.6, maturation index 39.8, and external fixation index 52.5. In the group B, the average distraction index was 11.7, maturation index 47.1, and external fixation index 60.1. The average time from the application to the apparatus removing was in the group A 6.5 months, and in the group B 11.9 months. There were 27 complications: 11 problems, 8 disturbs, and 8 true complications. Pin-track inflammation of the soft tissue was noted most frequently (6 patients). CONCLUSIONS: One stage of repairing inflamation and the restitution of defect in lower leg tissue was the advantage of this type of treatment. All of the patients recovered. There was not any bad result, either in osteal or in functional outcome.     

骨形成蛋白与磷酸钙复合材料对椎体骨缺损的修复作用

 目的 探讨骨形成蛋白(BMP)与磷酸钙骨水泥(CPC) 复合材料在椎体骨缺损的修复能力及其作为椎体成形术的生物活性灌注剂可能性.方法 将CPC作为BMP的载体复合成为CPC/BMP生物活性人工骨材料.在16只羊腰1～ 3椎体侧前方制成约1 cm×1 cm×1 cm的骨缺损,分别植入CPC/MBP生物活性人工骨材料和CPC.术后3、6个月行X线、组织学检查和电镜扫描.观察新骨形成和材料降解情况.[ HTH〗结果 术后所有的动物成活.CPC/BMP植入3个月时植入材料与受区骨间出现软骨细胞向成骨分化,新骨组织长入材料并与材料紧密结合.6个月时新骨多为板层骨,植入材料范围缩小,材料大量溶解,出现较大的空隙.BMP与CPC复合有效地促进了新骨的形成和新骨的钙化,同时也加速CPC材料的降解.而CPC材料降解速度缓慢,新骨形成量少,仅在材料的表面.结论 CPC是BMP理想的载体,CPC/BMP生物活性人工骨材料椎体骨缺损有较强的修复能力,可作为椎体成形术的生物活性灌注剂.     

Fasciocutaneous flaps in the treatment of soft tissue defects of the lower leg caused by explosive war injuries

The use of fasciocutaneous flaps for the reconstruction of lower leg soft-tissue defects inflicted during the bombing of our country is presented in this case report. The experience with 9 patients with soft-tissue defects of the lower leg is presented with the aim of examining the possibilities of war-wound reconstruction. The results of the earlier use of fasciocutaneous flaps in the lower leg reconstruction as well as the those obtained during the reconstruction of the lower leg soft-tissue defects in war wounds was proven to be safe and reliable method of the reconstructions of severe lower leg injuries, particularly of its distal segment and the malleolus region.     

血管内皮祖细胞促血管化组织工程骨修复兔大段骨缺损的效果评价

目的 评价血管内皮祖细胞(endothelial progenitor cells,EPCs)促血管化组织工程骨修复兔桡骨大段骨缺损的效果.方法 选用68只新西兰大耳白兔,以数字随机法分为3组.实验组:EPCs+经成骨诱导的骨髓间充质干细胞(bone marrow mesenchymal stem cells,BMSCs)+脱钙骨基质(decalcified bone matrix,DBM);自身对照组:BMSCs+DBM;阴性对照组:单纯DBM.将上述材料置入桡骨中段15 mm骨缺损区,术后12,16周摄X线片行骨密度、组织学光镜、骨钙素免疫组化染色及生物力学测试.结果 实验组的骨痂生长、塑形、髓腔再通、骨愈合速度及力学强度等方面均明显优于对照组.结论 EPCs促血管化组织工程骨成骨能力强,能有效促进骨愈合,是修复大段骨缺损的有效方法.     

Prevention of serious injuries due to bicycle riding

In 1984 there were 32,860 persons who suffered from bicycle-related injuries in Switzerland. They accounted for 27% of the persons injured on the road. Cranio-cerebral trauma had to be treated in 26% of the injured bicyclists. Two thirds of hospital admissions after bicycle accidents were due to head injuries. Craniocerebral trauma accounted for about 65% of the residual lesions and for 69% of the lethal injuries related to bicycle accidents. A relatively simple and effective protection for these injuries would consist of the use of a helmet. To estimate the expected reduction of head injuries if everybody had a helmet, the regression analysis of a previous study from Seattle was applied. By wearing hard-shell helmets, there would be a reduction in number and severity of 7500 head injuries and a decrease of 2000 hospital admissions each year in Switzerland. In addition to the decrease in suffering and quality of life of the use of helmets would lower health costs by at least 22 million swiss francs per year.     

Surgical treatment of extension contractures caused by war injuries to the knee

Immobilization with external fixation bridging the knee joint in extension is frequently used after sustaining a war injury to the region of the knee joint with femoral and tibial bone fractures. Immobilization of the knee with plaster splints is performed in the same position. This usually prolonged treatment results in extension contractures of the knee joint. From June 1991 until March 1994, 54 patients with extension contractures of the knee caused by war wounds were treated at the Department of Orthopedics, Zagreb University Hospital Center, in Zagreb, Croatia. Results of surgical treatment of 44 patients are presented. The operative procedure consisted of extensive intra- and extra-articular adhesiolysis of the knee. The control group included 30 patients with knee contractures caused by injuries sustained in car crashes or secondary to previous operative procedures. The mean duration of immobilization was 5 months and 6 days. The mean preoperative knee motion amplitude ranged from 5 degrees in extension to 38 degrees in flexion. The mean postoperative knee motion was 98 degrees (range, 2 to 110 degrees). Treatment results did not depend on either duration of preoperative immobilization of the knee or previous infection in the region of injury. Previous knee joint bridging with an external fixator had no impact on the results of extension contracture treatment. Adequate intra- and extra-articular adhesiolysis with appropriate long-term postoperative rehabilitation is essential for the success of the operative treatment for knee joint contracture.     

论战创伤心脏呼吸骤停的精准心肺复苏模式

直接针对战创伤心脏呼吸骤停进行心肺复苏(CPR)是提高战创伤心脏呼吸骤停复苏成功率的重要保证.本文结合不同战创伤心脏呼吸骤停特点,探索战创伤心脏呼吸骤停的规律模式,认识“因人而异、因地制宜”的精准个体化心肺复苏程序、方法及终止时限,以达到降低战创伤心脏呼吸骤停死亡率的目的.     

外固定架联合带蒂游离腓骨移植修复股骨感染性骨缺损

目的 探讨单边外固定架与带蒂游离腓骨移植治疗股骨感染性骨缺损的疗效.方法 回顾性分析2013年12月—2019年1月新疆医科大学第一附属医院骨科中心显微修复外科收治的12例采用单边外固定架与带蒂游离腓骨移植治疗股骨感染性骨缺损的患者,男性9例,女性3例;年龄31-53岁,平均41.5岁;道路交通伤8例,高处坠落伤3例,重物砸伤1例;术前窦道及术中病灶处分泌物经细菌培养均证实感染:金黄色葡萄球菌感染9例,金黄色葡萄球菌和表皮葡萄球菌混合感染2例,大肠杆菌感染1例.一期手术8例,清创待感染控制后二期行游离腓骨移植4例.清创后行外固定架联合带蒂游离腓骨移植修复,术后对骨结合部愈合及移植腓骨的成活情况进行影像学评估,应用Enneking下肢功能评分评估术后下肢功能.结果 12例患者术后获(19.5±4.7)个月门诊随访,经清创后骨缺损长度(8.2±0.7)cm,移植腓骨均成活并达到骨性连接.移植腓骨长度(9.0±0.7)cm,愈合时间(9.1±1.5)个月,末次随访Enneking下肢功能评分(23.9±2.1)分.移植腓骨无应力骨折,供区肢体无功能障碍,供区及移植区均无感染复发.结论 单边外固定架与带蒂游离腓骨移植是重建股骨感染性骨缺损的可行选择,该术式术后护理简易,可尽早展开康复训练,有利于患肢功能恢复.     

汽车安全气囊致眼外伤临床分析

目的 探讨汽车安全气囊致眼外伤的临床特点及诊治方法.方法 对2004～2006年于我院眼科住院的15例30眼汽车安全气囊致眼外伤病例进行回顾性分析.结果 闭合性眼球钝挫伤15例30眼,均伴有角膜挫伤(占100%),其中合并有前房积血12例20眼(占66.67%),瞳孔括约肌撕裂6例9眼(占30%),视神经挫伤5例6眼(占20%),玻璃体积血3例3眼(占10%).经治疗12例24眼角膜恢复透明,合并前房积血全部吸收,其中18眼视力恢复至1.0;1例1眼在临时角膜下行玻璃体切割、穿透性角膜移植术,术后视力0.1;4例5眼形成角膜瘢翳,因为同时合并有视神经挫伤,视力0.2～0.3.结论 汽车安全气囊可导致多种类型眼损伤,其中尤以角膜挫伤发病率高,且多为双眼性,角膜恢复透明时间长,治疗棘手,可延误合并有眼后段损伤的诊断及治疗,因此对合并有眼后段损伤的病例临床上容易漏诊,早期诊治有利于患者视力恢复.