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To introduce the surgical procedure of orthopaedic robot-assisted vascularised fibular grafting for the treatment of ANFH and report the short-term result. Methods From September, 2016 to November, 2018, 17 patients (21 hips) with ANFH had undergone robot-assisted free fibular grafting. There were 14 males and 3 females, of which, 8 cases were associated with the right side, 5 cases the left side, and 4 cases with both sides. The average age was 35 (ranged from 17 to 55) years. There were 7 patients suffered from idiopathic ischemic necrosis of femoral head, 4 patients who had cannulated screws fixed after a femoral neck fracture, 4 patients who had a history of alcohol consumption, 1 patient who had taken corticosteroids for 6 months to treat nephritis, and 1 patient who had a history of alcohol consumption and had also taken corticosteroids. Seventeen hips were in Ficat stage II, and 4 hips were in Ficat stage III. The orthopaedic surgical robot workstation was used to plan the entry point and target of the guide pin during the operation, to place a cannula in the optimal position. Then a bone window was created and the fibula was placed into the bone tunnel.Using fluoroscopy to monitor each step of the procedure and verify the position of the fibula. Finally, the vessels were anastomosed. The patient remain in bed completely for a week with the use of vasodilator. The follow-up was accomplished with phone call and outpatient clinic, and Harris score was evaluated. Results All 21 surgical procedures were successful. The guide pins and fibula were accurately placed according to the robot’s plan, and the tips of the fibula were placed at the centre of the load-bearing region of the femoral heads, 4 to 6 mm from the articular surface. Conventional anticoagulant, anti-infective therapy was performed after the pro-cedure. Ten patients were followed-up postoperatively more than 1 year, with an average of 15 (from 12 to 24) months. The function of the hip joint recovered smoothly for 9 patients.Frontal and lateral X-ray and CT scans showed that the tips of the fibula were placed at the centre of the load-bearing region, 4 to 6 mm from the articular surface.One patient suffered from bilateral femoral head necrosis and the right side recovered smoothly after operation.However, joint move-ment was restricted for the left hip and the pain was significant.An arthroscopic examination was performed 1 month after the operation and did not identify any problems such as intraarticular incular infection or articular surface of the femoral head was protruded by the tip of the fibula.The symptoms were alleviated after removing the osteophytes at the rim of the acetabulum.The Harris score was 62.4±13.6 before operation, and 84.5±4.5 at the last time of followed-up after opera-tion.The difference in Harris scores was statisticly significant (P＜0.05). Conclusion With the assistance of an or-thopaedic robot system, the guide pin can be accurately positioned, thereby allowing the tip of the fibula to be inserted in-to the optimal anatomical position and maximising its mechanical efficacy.In theory, it is the best choice for performing fibular bone transplantation in ANFH.And the early effect of treatment is good.
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Objective@#To investigate the efficacy and the technical details of utilizing a long segment of vein graft to bridge the vascular defect when a free flap is used to repair extensive injuries in lower extremities.@*Methods@#For the reconstruction of extensive leg defect caused by serious composite injury, a local flap is unavailable or cannot fulfill the requirements. The main vessels of the leg could be damaged. It is challenging work to find an ideal recipient vessels for a free flap. The saphenous vein was harvested from the contralateral lower extremities and utilized to bridge the vascular gap between the recipient vessels and flap pedicle vessels. A latissimus dorsi myocutaneous or anterolateral thigh free flap was used to reconstruct the leg defect. The distal end of the grafted vein was anastomosed to the superficial femoral artery in an end-to-side fashion, and the proximal end to the artery of flap pedicle in an end-to-end fashion. When a vein insufficiency was present, the proximal and distal ends of the additional grafted vein were anastomosed to the recipient vein and vein of flap pedicle in an end-to-end fashion.@*Results@#From July 2010 to April 2019, 27 patients underwent reconstruction of leg using the above-mentioned method. There were 20 males and 7 females. The patients′ age ranged from 16 to 54 years with an average of 30.6 years. There were 19 latissimus dorsi myocutaneous flaps and eight anterolateral thigh flaps. The grafted saphenous vein was used to bridge the arterial gap in 21 cases and to bridge both the arterial and venous gaps in 6 cases. The length of the grafted vein for arterial and venous defects was ranged from 14 cm to 43 cm (mean, 24.8 cm) and 5 cm to 12 cm (mean, 8.6 cm), respectively. 26 flaps completely survived after surgery. Venous congestion occurred in the remaining one flap and the flap eventually lost. The patient eventually opted for amputation. All patients were followed up for 3 to 14 months with an average of 9 months. Functional and aesthetic outcomes were obtained in both the recipient and donor sites. No obvious edema of lower extremities was observed.@*Conclusions@#For patients with a severe and large soft-tissue defect of the leg, fining an ideal recipient vessels for a free flap is crucial for a successful reconstructive surgery. It is a reliable and an additional option to choose the superficial femoral artery and/ or saphenous vein as the recipient vessels by using the grafted vein to bridge the vascular gaps.
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Objective@#To present the clinical result of a procedure using pedicle posterior interosseous perforator adipofascial flaps for the treatment of congenital proximal radioulnar synostosis (CPRUS).@*Methods@#Eight forearms (from eight patients) with CPRUS were treated by the operation during December 2013 to January 2018 at Beijing Jishuitan Hospital. The average age of the children are seven years old (range: five years old to twelve years old). There were six boys and two girls. Seven forearms were classified as the Cleary type Ⅲ, and one forearm was classified as the Cleary type Ⅱ. Five children were suffered with bilateral CPRUS, and three children were unilateral. The average fixed forearm pronation angle was 43° (range: 0° to 80°). The operating procedure: a dorsal incision from olecranon to the distal 1/3 part of the middle axial of forearm was designed. Then the pedicle posterior interosseous perforator adipofascial flap was harvested. Elevated the anconeus muscle retrogradely, and the location of the osseous synostosis was exposed. Then the radial volar Henry incision just below the elbow joint crease was designed, the insertion part of the biceps brachii was exposed and elevated. The osseous synostosis was exposed and removed with the help of burr at the dorsal side. The cartilage part of the radial head was remolded. A trapeziform osteotomy was made at the site of radial tubercle due to the deformity angle of the radial shaft to reduce the dislocated radial head, then the distal and proximal part of radius was reduced and fixed with plate and screw. The pronator quadratus and the adipofascial flap were pulled to the volar side, and sutured to the deep fascia. The tendon of the biceps brachii was pulled dorsally and reattached to the radial tubercle. Postoperatively, an above-the-elbow splint was applied to keep the elbow in 90° of flexion and the forearm in 80° of supination. Three days later, the other splint was used to keep the forearm in 80° of pronation. Two splints were worn every other day alternatively. At four weeks after the operation, the ROM exercises were initiated both actively and passively, with the splints worn every other night alternatively. The splint was worn for six months.@*Results@#All patients received follow-up, the average duration of follow-up was 27 months (average: 6-48 months). The space of the proximal radioulnar joint could be seen clearly in seven patients, without the sign of recurrence of the synostosis. The synostosis was occurred in one child. Removed the synostosis part and the implant six months after operation, and placed an allograft tendon ball as the interposition tissue simultaneously. The problem was resolved successfully after that. Fingers extension weakness was happened in two patients, and recovered spontaneously and completely in three months. Limitation of elbow extension was occurred in two patients (range: 15° and 20°). The average pronation was 32.5° (range: 10°-65°), and the average supination was 31.9° (range: 10°-70°).@*Conclusions@#Using the perforator adipofascial flap pedicled with posterior interosseous vessels to treat the CPRUS is an easier method compared with classical Kanaya method . It could prevent the recurrence of synostosis effectively, and the treatment result is satisfied. The possibility of injury of the deep branch of radial nerve may be the potential problem.
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Objective: To evaluate the role of the deep radioulnar ligament in the stability of the distal radioulnar joint (DRUJ).Methods: In the study, 14 fresh cadaver upper extremities were randomly divided into two groups.After exposuring the palmar and dorsal deep distal radioulnar ligament, one group was marked as palmar deep radioulnar ligament, and the other group was marked as dorsal deep radioulnar ligament.The pronator teres and the supinator were exposed.A Kirschner wire perpendicular to the bone on Lister tubercle of radius was inserted, then another Kirschner wire on the same level of ulnar inserted when the forearm was in neural position, which was kept parallel to the first Kirschner wire.These specimens were mounted on a specially designed jig which held the limb rigidly, keeping the elbow fle-xion and the ulnar fixation.The radius could freely rotate around the ulnar.Then 50 N force on the pronator teres was applied to simulate the active pronation, and 60 N force on the supinator to simulate the active supination.The active pronation was stimulated, and the displacement of the distal radius was measured with respect to the ulna.The active supination was atimulated, and the displacement of the distal radius was measured with respect to the ulna.The palmar deep radioulnar ligament in one group was cut, then the displacement of the distal radius measured with respect to the ulna when the forearm was in pronation and supination.The dorsal deep radioulnar ligament in the other group was cut, and the displacement of the distal radius measured with respect to the ulna when the forearm was in pronation and supination.Results: After resection of the palmar deep radioulnar ligament, the displacement of the distal radius with respect to the ulna was statistically significantly different when the forearm was in pronation (t=5.591, P=0.001), but there was no difference when the forearm was in supination (t=0.433, P=0.680).After resection of the dorsal deep radioulnar ligament, the displacement of the distal radius with respect to the ulna was not different when the forearm was in pronation (t=1.000, P=0.356), but there was statistically significant difference when the forearm was in supination (t=6.225, P=0.001).Conclusion: DRUJ is unstable when the forearm is in pronation after resection of the palmar deep ra-dioulnar ligament, and DRUJ is unstable when the forearm is in supination after resection of the dorsal deep radioulnar ligament.
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Objective:To investigate the validity and the outcome of a new surgery method that utilizes lateral great toe flap to decoratively reconstruct the thumb pulp loss.Methods:From Jan.2009 to Jan. 2014 , 22 cases with unilateral thumb pulp defect were included, for whom, lateral great toe flap was de-ployed to reconstruct the thumb.Blood circulation was re-established by the anastomosis of the digital vessels of toes and fingers in 18 cases, the other 4 cases were conducted by a dorsal metatarsal artery and vein anastomosed to the deep branch of the radial artery and the dorsal metacarpal vein respectively; as for the nerve repair, toe-to-finger digital nerve anastomosis was performed.The donor sites were covered by full-thickness inguinal skin grafts.Results:All the 22 flaps survived without complications.With 6 to 12 months follow-up, the surviving fingers all presented aesthetically pleasant appearance with vivid loops and whorls.Normal functions like sweating were restored as well, and the two-point-discrimination ranged 3.0 to 6.0 mm (4.2 mm in average).The skin grafts to the donor sites healed uneventfully, the appearance and functions of the feet were unaffected.Conclusion: Lateral toe flap should be the first-line choice for reconstructing thumb defect, as it conveniently restores both functions and outlook.
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Objective To evaluate the feasibility,technique and preliminary clinical results of the intraoperative three-dimensional (3-D) computer navigation system assisted free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head.Methods From October 2010 to April 2013,14 patients (18 hips) with osteonecrosis of the femoral head were treated by free vascularized fibular graft transfer,assisted by intraoperative3-D computer navigation system.Of 18 hips,8 were classified as stage Ⅱ ;6 as stage Ⅲ,4 as stage Ⅳ according to Steinberg system.The entire procedures were visualized and guided by the 3-D navigation system,including location of optimal entry point,exploration of the field,excision of the necrotic bone tissues,and the fibular grafting transfer with vessel anastomosis.The follow-up records included the results of X-ray,the Harris score of the hip,and the complications.Results Operations of all 14 patients (18 hips) were smooth and successful with patent vessel and umcompromised grafts evidenced by ECT scan at day 7 postoperatively.Postoperative X-ray confirmed the complete eradication of necrotic focuses with surrounding calcified bone and the accurate positioning of fibular grafts.The mean follow-up period was 23.6 months (8-29 months).Harris scores significantly improved from 57.5 ± 14.5 before operations to 87.5 ±2.5 after,with 6 hips' scores classified as Excellent,and 11 as Good.X-ray obtained more than 1 year after operation suggested improvement was achieved in 15 hips.Conclusion Intraoperative 3-D computer navigation system has multiple merits in assisting free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head,including clear anatomic structure,better accuracy,less damage,and reliable functional recovery,which imply it is a highly applicable approach.
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ObjectiveTo introduce the indications and operative procedure of anatomic reconstruction of the distal radioulnar ligaments in patients with chronic instability of the distal radioulnar joint(DRUJ),and report its preliminary clinical results.Methods From October 2008 to June 2009,6 patients with instability of the DRUJ underwent anatomical reconstruction using a free palmaris longus tendon graft,including 4 males and 2 females with an average age of 22 years.A 5 cm dorsal incision was made between the fifth and sixth extensor compartments.An L-shaped flap was created in the DRUJ capsule.This flap is then elevated proximally to expose the articular surface of the DRUJ and the proximal triangular fibular cartilage complex(TFCC).A tunnel was made through the radius.The other tunnel was made between the ulnar neck and the fovea of the ulnar head.A whole-length palmaris longus tendon graft was taken.The volar opening of the radius tunnel was exposed through a longitudinal incision radial to the flexor carpi ulnaris tendon.One end of the graft was pulled to the palmar side easily through the tunnel.A hemostat was penetrated through the volar capsule to the volar side proximal to the remaining TFCC.The end of the graft was grasped with the hemostat and pulled back along this tract.Both graft limbs were passed through the ulnar tunnel to exit at the ulnar neck.One limb of the tendon was passed around the ulnar neck and deep to the ECU sheath.With the forearm in neutral rotation,the limbs were pulled taut,tied together,and secured with sutures.Immobilize the extremity in a long-arm plaster splint with the forearm in neutral position for 4 weeks,and changed to a short arm cast for an additional four weeks.ResultsThe average follow-up period for all 6 patients was 14 months(range,9-24).No infection and sensory nerve branch disturbance occurred.The pain symptom was reduced and the grip force was improved significantly.A functional evaluation was performed using the modified Mayo wrist scoring system.All patients had better wrist scores postoperatively in the short (mean,95) term compared to preoperatively(mean,69).Five patients satisfied with the final result.Conclusion Anatomic reconstruction of the distal radioulnar ligaments is indicated for chronic DRUJ instability without osteoarthritis,it is a reliable method with a very good short term follow up result.Restoration of the radioulnar ligaments offers the best possibility to restore the normal DRUJ primary constraints and kinematics.