Clinical Application of Instep Flap / 대한정형외과학회잡지

Soft-tissue defects over the plantar forefoot, plantar heel, Achilles tendon and distal parts of lower leg are often troublesome to cover with a simple graft or local flap due to limited mobility of surrounding skin and poor circulation in these area. Soft-tissue reconstruction in these regions should provide tissue components similar to the original lost tissue, supply durability and minimal protective pressure sensation and result in a donor site that is well tolerated. We analysed 14 cases that were treated with the instep flap due to soft-tissue defects over these regions from JuL 1990 to Oct. 1995. All flaps were viable and successful at follow-up. 1. The age ranged from 5 years to 70 years, and 13 cases were male and 1 case was female. 2. The sites of soft-tissue loss were the plantar forefoot (l case), plantar heel (9 cases), Achilles tendon (3 cases), and distal part of lower leg (1 case). 3. The causes of soft-tissue loss were simple soft-tissue injury (l case), crushing injury of the 1st toe (1 case), post-traumatic infection and necrosis (11 cases) and traction sore (1 case). 4. The associated injury were open distal tibio-fibular fractures (2 cases), medial malleolar fracture of the ankle (1 case), Achilles tendon ruptures (4 cases) and 1st metatarsophalangeal disarticulation (1 case), open calcaneus fracture (1 case) and femur shaft fracture (1 case). 5. The size of flap was from 3 1 cm to 5 10 cm (average 4 5 cm). 6. We could not find post-operative necrosis and infection, non-viability and gait disturbance caused by the instep flap surgery except limitation of the ankle joint in 1 case. In conclusion, this study demonstrates that the instep flap should be considered as another valuable technique in the reconstruction of these regions.

Experimental Study of the Effectiveness of Hyaluronic Acid on Adhesion Formation in Digital Flexor Tendon Injuries / 대한정형외과학회잡지

Postoperative adhesions that restrict tendon gliding are a major cause of failure after tendon repair and grafting in Zone II. Several experimental reports have claimed that exogenously administered sodium hyaluronic acid (HA) helps to prevent the adhesion formation after digital flexor tendon repair. However, some investigators reported that HA had no effect on prevention of adhesion. Effectiveness of HA was determined by using an experimental chicken model. HA and physiologic saline solution was injected into the tendon sheath after partial cut of flexor digitorum profundus tendon. On light microscopy, cut ends revealed infiltration of neutrophils with scattered monocytes, 1ymphocytes and eosinophils at the second postoperative day in both control and HA treated goup. At the sixth and eighth postoperative day, the wounds were healed with granulation tissues and adhered to the tendon sheath in control group. Two weeks after operation both control and HA treated group were adhered to the tendon sheaths, but milder in HA treated group than that of control. After three weeks, adhesion to the tendon sheath was marked in both groups. Scanning electron microscopic findings were consistent with light microscopy. As results of above experiments, HA had a significant effect on prevention of adhesion until post-operative S days, and after 2 weeks no difference between HA and control group. No histological difference in process of tendon healing was observed between HA treated and control groups.

Comparative Study of Bone Necrosis between Phenol Cautery and Cryosurgery to the Defects in the Porcine Femur and Tibia / 대한정형외과학회잡지

A corticocancellous core was removed from both femurs and tibias in 5 skeletally immature pigs. The cavity was treated with 5%, 25% phenol cautery, cryosurgery, and normal saline irrigation (control). The animals were sacrified after 7days. The extent of the bone necrosis was assessed by gross examination, simple radiography, MRI evaluation and histological examination with tissue mapping. After cryosurgery, the extent of necrosis was most profound in the depth of 2.0-9.0mm beyond the cavity wall. The effect of 25%-phenol was next to cryosurgery, with a depth of 1.0-3.0mm of necrosis. 5%-phenol made necrosis with the depth of 1.0-2.5mm. Very mild degree of necrosis with the width of 0.5-1.0mm was found along the cavity wall even in control group. On MRI, signal change was well visualized on T2 weighted coronal section and it was quite coincided with the extent of bone necrosis proved by histological tissue mapping to all cases. When the epiphyseal plate was open or very close to the cavity, curettage itself, 5%- and 25%-phenol cautery and cryosurgery all produced mild ischemic necrosis along the provisional calcification zone of physeal plate. These findings suggest that cryosurgery made more profound necrosis beyond cavity than phenol cautery and MRI is very sensitive and specific to find osteonecrosis along the cavity wall after phenol cautery or cryosurgery. When epiphyseal plate is open or very close to the cavity, phenol cautery, or cryosurgery, or even curettage itself could produce an ischemic necrosis to the physeal plate itself.