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Objective:To investigate the clinical effect of "ladder reduction method" in the treatment of iliac fracture combined anterior dislocation of sacroiliac joint.Methods:The retrospective analysis was performed on 10 cases of iliac fracture combined anterior sacroiliac joint dislocation admitted to the Affiliated Hospital of Yunnan University from February 2010 to January 2022, among which 5 cases were males and 5 cases were females, aged ranging from 22 to 52 years, with an average age of 38.8 years. All patients were injured in car accidents including 5 cases of C1.2, 3 cases of C2, and 2 cases of C3 fractures according to Tile classification. All patients were treated with the "ladder reduction method" with plate and screw fixation. In the first step, 1-2 Schanz pins were inserted into the iliac crest to control the ilium, and the Schanz pins were appropriately pulled laterally; in the second step, the periosteal stripper was used to pry the reduction between the sacrum and ilium; in the third step, for the patients who still could not be reduced, a 2.5 mm diameter Kirschner wire was placed on the sacrum close to the iliac crest, and a periosteal stripper was inserted between the sacrum and iliac crest, with its tip against the Kirkner wire, and the iliac crest as the fulcrum for pry pulling to separate the two. In the fourth step, the pry was maintained, and then another 2.5 mm diameter Kirschner wire was placed on the sacrum close to the internal margin of the iliac bone. The periosteal stripper was continued to pry between the sacrum and the iliac bone, and the operation was repeated. At the same time, the anterior dislocation of the sacroiliac joint was reduced with traction of the lower limb. Postoperatively, the quality of reduction was evaluated by the Matta score, and the degree of functional recovery after pelvic fracture was evaluated by the Majeed score.Results:Four patients completed the reduction through the first and second steps, and 6 cases of refractory sacroiliac joint anterior dislocation were successfully reduced through the first to fourth steps. The fracture reduction time of 6 patients with refractory anterior sacroiliac joint dislocation was 39.67±3.09 min (range, 35-44 min), with intraoperative blood loss of 300.00±141.42 ml (range, 150-600 ml); in the other 4 cases, the fracture reduction time was 36.75±4.38 min (range, 30-42 min), and the intraoperative blood loss was 225.00±44.30 ml (range, 200-300 ml). All 10 patients were followed up for 12.9±3.7 months (range, 9-20 months). The anterior and posterior pelvic ring fractures were healed in all patients, and the fracture healing time was 12.77±1.62 weeks (range, 10.71-15.28 weeks). At the last follow-up, Matta evaluation was excellent in 5 cases, good in 1 case, and excellent in the other 4 cases. The Majeed scores of 6 cases were 86.50±6.08 points (range, 74-92 points), of which 5 cases were excellent and 1 case was good. The other 4 cases were 81.5±9.39 scores (range, 71-94), of which 2 were excellent and 2 were good.Conclusion:The "ladder reduction method" is a safe, effective and easy-to-operate method for the treatment of iliac fracture combined anterior dislocation of the sacroiliac joint, especially for refractory anterior dislocation of the sacroiliac joint, which can still obtain satisfactory curative effects.
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Objective:To investigate the effectiveness of postoperative radiotherapy using shrinking field for patients with extremity soft tissue sarcoma (STS), mainly focusing on the local control rate and adverse events.Methods:Clinical data of 49 extremity STS patients who received postoperative intensity-modulated radiotherapy in the First Hospital of Tsinghua University from October 2017 to March 2021 were retrospectively analyzed. Target volumes were contoured on CT and MRI fusion images. The tumor bed was defined as GTV tb, with 3 cm expansion in the longitudinal direction and 1.5 cm expansion in the radial direction to construct CTV (the target volume should be properly repaired according to the anatomical barrier, and the edema area around the tumor should be included). GTV tb and CTV were expanded in all directions by 0.5 cm to construct PTV1 and PTV2 respectively, at a dose of 95%PTV1 63-66 Gy, 95%PTV2 50-56 Gy,1.8-2.0 Gy/f. The dose of surgical volume should be given at 70 Gy for patients who had a microscopic positive margin. Results:The median follow-up time was 32.1 months (7.9-45.6 months). The 3-year local failure-free survival (LFFS), overall survival (OS)and distant metastasis-free survival (DMFS) were 91.7%,77.6% and 71.5%, respectively. Univariate analysis showed that patients with a microscopic positive margin were more likely to develop local recurrence ( P<0.05). The incidence of grade 2 or above wound complications, joint stiffness, fracture, edema and skin fibrosis were 2%, 4.1%, 2%, 8.2% and 26.5%, respectively. Conclusion:Postoperative radiotherapy with shrinking field provides excellent local control rate and low incidence of late adverse events in patients with extremity STS.
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Objective To investigate the clinical effect of thin-layer free anterolateral thigh flap with iliotibial tract for reconstruction of heel soft tissue and Achilles tendon defect.Methods From January,2017 to December,2017,11 cases of heel soft tissue and Achilles tendon defect were repaired by thin-layer free anterolateral thigh flap with iliotibial tract.There were 5 cases with tibia/fibula fracture,3 cases with ankle fracture and 1 case with calcaneal fracture.The area of soft tissue defect was 6.5 cm×10.0 cm-8.0 cm×13.0 cm,and the length of Achilles tendon defect was 5.5-11.5 cm.All wounds were treated with debridement and negative pressure sealing drainage technique at first stage.After 6 days,the soft tissue defect around posterior calcaneal region combined with Achilles tendon defect were repaired by the thin-layer free anterolateral thigh flap with iliotibial tract.Reasonable rehabilitation training was established after operation.Results The flaps survived in 11 cases and the donor region healed in one stage.The patients were followed-up for 8 to 20 (mean,15.74) months by outpatient review,calling or WeChat.Slightly bloated in appearance in 2 cases,and were thinned by orthopedic operation 1 year later.The other flaps were well shaped and moderately thick.At the last follow-up,the flaps were soft in texture and elastic.The sensory recovery of the flap was good,and the two-point discriminant perception in the posterior region of the heel was 3.0-5.0(mean,4.11) mm.Thompson's sign was negative,double or one-foot heel lift test was negative,and there was no recurrence of Achilles tendon rupture or skin ulceration in the heel region.The range of motion (ROM) of affected side was (23.1 1±1.17)°of extension and (43.67±1.06)°of flexion,and the ROM of normal side was (23.79±1.03)°of extension and (44.03±0.94)°of flexion.There was no statistical difference between them (P＞0.05).Postoperative follow-up was conducted according to the Thermann's function evaluation system,the evaluated result was excellent in 8 cases,good in 2 cases,and receivability in 1 case.Conclusion It is a reliable and effective method to repair heel soft tissue and Achilles tendon defect by thin-layer free anterolateral thigh flap with iliotibial tract.And this method can better restore foot ankle shape and function.
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Objective: To investigate the clinical application and effectiveness of the composite tissue flaps pedicled with perforating branch of posterior tibial artery for repairing distal leg defects. Methods: Between September 2014 and August 2017, 12 patients with skin and bone defects of distal leg were repaired with the composite tissue flaps pedicled with perforating branch of posterior tibial artery. There were 8 males and 4 females with an average age of 41.3 years (range, 25-66 years). The causes of injury included traffic accident injury in 7 cases, heavy crushing injury in 2 cases, tibial osteomyelitis with soft tissue ulcer and necrosis in 2 cases, and bone and soft tissue defect after resection of bone tumor in 1 case. Eight patients underwent primary repair, and 4 patients underwent second-stage repair. The size ranged from 6 cm×4 cm to 10 cm×7 cm in skin flap, from 4.0 cm×2.5 cm to 8.0 cm×6.0 cm in muscle flap, and from 4 cm×2 cm×2 cm to 5 cm×4 cm×4 cm in tibial bone flap. Tibial defects of the donor region were repaired by autologous iliac bone grafting, and the wounds were sutured directly in 7 cases and repaired by autologous skin grafting in 5 cases. Results: All composite tissue flaps survived and both the recipient and the donor wounds healed primarily. All patients were followed up 6-12 months, with an average of 10.8 months. The appearance, color, texture of the composite tissue flaps and ankle function were satisfactory. X-ray films showed that the bone flap at the tibia defect and the ilium graft at the donor site both healed well at 6 months after operation. Conclusion: The composite tissue flaps pedicled with perforating branch of posterior tibial artery has abundant blood, and it is a good donor region for repairing the distal leg defects combined with circumscribed bone defect.