Reverse Anterolateral Thigh Flap to Reconstruct a Below-Knee Amputation Stump: Two Case Reports

During below knee amputation, the amputation stump must be covered with well-vascularized and sensate soft tissue. Many flaps can be used for this purpose, but available reconstructive options are limited. We performed reverse flow ALT flap elevation on two patients with below knee amputations to reconstruct defects in the stumps. The sizes of the defects in the stumps were 4x16 cm and 5x5 cm, respectively. The most distal portion of the defects were located 20 cm and 16 cm lateral to the knee joint in a curve, respectively. The size of the elevated flap was 5x18 cm for case 1 and 18x10 cm for case 2. The respective pivot points of the pedicles were 7 cm and 6 cm above the patella and the respective lengths of the pedicles were 17 cm and 16 cm. In both cases, venous congestion occurred on the second postoperative day and the flap distal to 10 cm or more from below the knee joint was necrotized at the second postoperative week. Surgeons should be cautious when using a reverse ALT flap to reconstruct a soft tissue defect located 10 cm or more distal from below the knee joint. Since a pedicle longer than 15 cm may develop partial necrosis of the flap, simultaneous application of antegrade venous drainage is recommended.

Hip Resurfacing Arthroplasty in Patients with Rheumatoid Arthritis

OBJECTIVE: This study analyzed the midterm results of hip resurfacing arthroplasty in patients with rheumatoid arthritis. METHODS: Between October of 2003 and September of 2008, 13 consecutive hips that were treated with hip resurfacing arthroplasty due to rheumatoid arthritis were analyzed. The average follow up period was 48.6 months and the mean age at the time of operation was 35.9 years old. The mean BMI at the operation was 23.2 kg/m2. The implanted prostheses were the Conserve Plus system in five hips, the Birmingham hip resurfacing system in four hips and the Durom system in four hips. The results were clinically evaluated with the Harris hip score, the UCLA activity score, hip or thigh pain, the limb length discrepancy and the range of motion. As radiological evaluation, we observed the patterns of bone remodeling and complications such as femoral neck fracture, loosening and osteolysis. RESULTS: The average Harris hip score improved from 62.2 to 98.9 at the final visit. The range of motion improved to 0degrees in flexion contracture, 118.1degrees in further flexion, 22.7degrees in internal rotation, 40.4degrees in external rotation, 28.8degrees in adduction and 38.1degrees in abduction, respectively. No patient complained of a limb length discrepancy and hip or thigh pain. Radiographically, impingement between the acetabular component and the femoral neck was observed in one case. However, radiographic findings such as osteolysis, radiolucency, wear and loosening were not observed. CONCLUSION: The midterm results of hip resurfacing arthroplasty in patients with rheumatoid arthritis were excellent. But long-term studies are needed to determine the survivorship and to evaluate the osteoporotic change, the metal ion level and their influence after hip resurfacing arthroplasty.

Comparative Study of the Clinical Outcomes of Unilateral Transforaminal Lumbar Interbody Fusion(TLIF) with Bilateral TLIF using Wiltse Approach and Conventional Approach

STUDY DESIGN: Comparative study. OBJECTIVES: To compare the outcomes of unilateral TLIF, bilateral TLIF using Wiltse approach and bilateral TLIF using conventional midline approach. SUMMARY OF LITERATURE REVIEW: There are many studies about outcomes of Unilateral TLIF, but few have compared the 3 different fusion procedures. MATERIALS AND METHODS: 60 patients were divided into 3 groups. Each group has enrolled 20 patients (Study group: unilateral TLIF, Control group 1: bilateral TLIF using Wiltse approach, Control group 2: bilateral TLIF using conventional midline approach). For clinical outcomes, we compared operative time, blood loss, time for ambulation and discharge, VAS for back pain and leg pain and ODI among three groups. For radiologic evaluation, disc height and segmental lordosis were examined. RESULTS: The mean operative time was 147 minutes in study group(SG), 172 minutes in control group 1(CG1), 167 minutes in control group 2(CG2). The mean total blood loss was 466ml in SG, 569ml in CG1, 1140ml in CG2 respectively. VAS for back pain at the third postoperative day significantly decreased in SG and CG1 compared with CG2. There was no significant difference in ODI, disc height and segmental lordosis among the groups. CONCLUSION: Using Wiltse approach, there were several advantages in decreasing blood loss, immediate postoperative back pain, hospital stay and early ambulation. Clinical and radiological results of unilateral TLIF were comparable with bilateral TLIF.