Rapid Functional Enhancement of Ankylosing Spondylitis with Severe Hip Joint Arthritis and Muscle Strain

Arthritis of hip joints deteriorates the quality of life in ankylosing spondylitis (AS) patients. Secondary to the articular inflammatory process, the shortened hip-girdle muscles contribute to the decreased joint mobility which may lead to the functional impairment. As the limitation of range of motion (ROM) usually progress slowly, clinicians regard it as a chronic condition and prescribe long-term therapy. However, by short-term intensive multimodal treatment, a 20-year-old man diagnosed as AS with severely limited hip joint ROM who relied on crutches doubled the joint angle and could walk independently only within 2 weeks. The combination included intra-articular steroid injection, electrical twitch obtaining intramuscular stimulation, extracorporeal shock wave therapy, heat, manual therapy, and stretching exercises. The management focused on the relaxation of hip-girdle muscles as well as the direct control of intra-articular inflammation. Hereby, we emphasize the effectiveness of intensive multimodal treatment in improving the function even within a short period.

Aneurismas da artéria e da veia braquial induzidos por uso contínuo de muleta: relato de caso / Aneurysms of brachial artery and vein induced by continuos use of crutch: case report

O aneurisma arterial induzido por uso de muleta é um evento raro, e a associação com aneurismas venosos não está descrita na literatura. Relatamos o caso de uma paciente que, após o uso prolongado dessa órtese, apresentou quadro de isquemia aguda de membro superior secundária à trombose de um aneurisma da artéria braquial, associado ao achado incidental de aneurismas da veia braquial. Embora a principal causa de oclusão arterial aguda de membro superior seja a embolização de fonte cardíaca, deve-se considerar a possibilidade de embolização arterioarterial por aneurismas provocados pelo uso prolongado de muletas. Os aneurismas venosos também devem ser suspeitados, uma vez que podem ser sede de trombos e fonte de êmbolos pulmonares

Crutch-induced arterial aneurysm is a rare event and there are no descriptions in the literature of cases with concomitant venous aneurysms. We report the case of a patient who, after prolonged crutch use, presented with acute ischemia of the upper limb secondary to brachial artery aneurysm thrombosis, associated with the incidental finding of brachial vein aneurysms. Although the main cause of acute upper limb occlusion is embolization of cardiac origin, consideration should be given to the possibility of arterio-arterial embolization due to an aneurysm induced by prolonged use of crutches. Venous aneurysms should also be suspected since they can be sites of thrombosis, and a source of pulmonary embolism

Novel Measurement Technique for the Sagittal Vertical Axis and Its Clinical Application in Adult Spinal Deformity

STUDY DESIGN: Prospective physical measurement of the sagittal vertical axis (SVA). PURPOSE: To evaluate a simple method for measuring SVA by analyzing its relationship with radiographic measurements and clinical appearance. OVERVIEW OF LITERATURE: No studies have examined physical measurements using the cranial center of gravity (CCG) in a relaxed standing position. METHODS: The physical measurement of the horizontal distance between CCG and spina iliaca posterior superior (CCG-SIPS) was measured using a straight ruler in 252 healthy volunteers and 56 patients with adult spinal deformity. Health-related quality of life (HRQOL) was evaluated using the Oswestry disability index (ODI), and clinical symptoms were assessed according to standing status and the presence of gastroesophageal reflux disease (GERD). RESULTS: CCG-SIPS increased with age in the volunteer group and strongly correlated with radiographic SVA in the patient group (r=0.984). Differences increased between CCG-SIPS in patients in the relaxed position and radiographic SVA with an increase in sagittal malalignment (r=0.692, p120 mm) was significantly larger in the patient group than in the group with low sagittal malalignment (59.9±18.8 vs. 45.1±17.0; p=0.004); these patients (CCG-SIPS>120 mm) needed crutches or walkers for standing. The patient group with GERD had significantly larger sagittal malalignment than the group without GERD (160.3 mm vs. 81.0 mm). CONCLUSIONS: The CCG-SIPS correlated with age and strongly reflected radiographic SVA and HRQOL in the patients. Moreover, it reflects a relaxed posture without a backward shift in the radiographic position even in patients with severe sagittal malalignment. The critical limit of CCG-SIPS can be relevant to clinical appearance, including standing assistance (>120 mm) and the existence of GERD (>150 mm). Thus, it will be a useful predictor of true SVA in clinical practice before radiographic evaluation.

Outcomes of Rotator Cuff Repair in Patients with Comorbid Disability in the Extremities

BACKGROUND: Rehabilitation and overuse of the shoulder after rotator cuff repair are a concern in patients with comorbid disability in other extremities. Improvement of outcomes can be hampered in this situation. This study was to describe the clinical outcomes of rotator cuff repair in patients with comorbid disability in other extremities. METHODS: In two tertiary institutions, 16 patients with comorbid disability (9 men and 7 women; mean age of 57.1 years [range, 45 to 71 years]; 14 dominant arms; mean follow-up of 18 months [range, 12 to 38 months]) underwent rotator cuff repair. There were 5 massive tears, 1 large tear, 9 medium tears, and 1 small tear. Open repair was performed in 3 patients and arthroscopic repair in 13. The most common comorbid condition was paralysis (n = 7). Eight patients walked with crutches preoperatively. Anatomical outcome was investigated in 12 patients using either magnetic resonance imaging or ultrasonography at least 6 months postoperatively. RESULTS: Range of motion, visual analogue scale for pain and satisfaction, and all functional scores improved significantly. Healing failure occurred in 4 patients (2 large-to-massive and 2 medium size tears), but none required revision surgery. All 4 retears involved the dominant side, and 3 patients were crutch users. CONCLUSIONS: The current data suggested favorable outcome of rotator cuff repair in patients with comorbid disability. Careful surgical planning and rehabilitation is particularly important for crutch users and in the case of dominant arm involvement in disabled patients.

Modified Iliac Crest Reconstruction with Bone Cement for Reduction of Donor Site Pain and Morbidity after Open Wedge High Tibial Osteotomy: A Prospective Study

PURPOSE: This study was to determine the efficacy of iliac crest reconstruction using bone cement in reducing pain and morbidity at the donor site in patients undergoing open wedge high tibial osteotomy (OWHTO) with tricortical iliac crest autologous graft. MATERIALS AND METHODS: Thirty-three patients who underwent iliac crest reconstruction using polymethyl methacrylate (PMMA) bone cement (group A) and thirty patients who had no iliac crest reconstruction (group B) were enrolled in this study. All patients were evaluated for pain and functional disability related to graft harvesting using the pain and functional visual analogue scale (VAS) score during hospital stay and at 6 weeks, 3 months, and 6 months postoperatively. RESULTS: There was significant difference between the two groups in terms of pain and function. The pain VAS score was significantly lower in group A than group B during the first 2 weeks postoperatively (p=0.04) and the functional VAS score was also significantly lower in group A during the first 2 weeks postoperatively (p<0.001) in terms of breathing, sitting up from the supine position, and standing up with crutches from the sitting position. CONCLUSIONS: Iliac crest donor site reconstruction using PMMA bone cement in patients undergoing OWHTO significantly decreased pain and improved function during the first 2 weeks postoperatively when compared to patients who underwent OWHTO without iliac crest reconstruction.

The Effect of Weightbearing after Distal Reverse Oblique Osteotomy for Bunionette Deformity / 대한족부족관절학회지

PURPOSE: To evaluate the radiological and clinical effects of early eightbearing after distal reverse oblique osteotomy of bunionette. MATERIALS AND METHODS: Between 2009 and 2015, 52 patients who underwent surgical treatment at our hospital for bunionette deformity with a minimum follow up of one year were included in the study. Postoperatively, foot cast was applied and full weightbearing was permitted in 28 patients. And short leg splint was applied with only partial weightbearing using crutches allowed in 24 patients. Clinical scores were evaluated. Radiologically, the 4th~5th intermetatarsal angle (IMA), and 5th metatarsophalangeal angle (MPA) were analyzed preoperatively and at the final follow up visit. RESULTS: The visual analogue scale and American Orthopaedic Foot and Ankle Society scores improved in the partial weightbearing group and full weightbearing group, but without significant differences. The average 4th~5th IMA and average 5th MPA correction also did not showed significant differences between the partial weightbearing group and full weightbearing group. Moreover, the full weightbearing group did not encourage non-union rate compared with the partial weightbearing group. CONCLUSION: Effective bone union may be achieved through early weightbearing, resulting in better clinical outcomes. It is considered that early weightbearing did not have any effect on the changes of IMA and bone union.

Thoracic Vertebral Fracture due to Spinal Tuberculosis which was Misdiagnosed as Matastatic Cancer: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report the case of a patient whose preoperative imaging results seemed to show metastatic spine tumor but who actually had a vertebral pathologic fracture caused by spine tuberculosis. SUMMARY OF LITERATURE REVIEW: Tuberculosis spondylitis is classified into peridiscal, central, anterior, and posterior spondylitis according to the portion involved, and central spondylitis can be mistaken as a tumor. MATERIALS AND METHODS: Imaging studies were performed in a 79-year-old female with progressive lower extremity weakness. We found a T12 pathologic vertebral fracture, which was suspected to be metastatic cancer. RESULTS: We performed surgery and found spine tuberculosis in the pathological and immunological examinations. Two weeks postoperatively, the patient could walk with crutches and underwent anti-tuberculosis therapy. CONCLUSIONS: Even when the results of imaging studies predict spinal metastasis, we should keep in mind the possibility of spinal tuberculosis.

Surgical Treatment of Undisplaced Femur Neck Fractures in Dementia Patients Using Proximal Femoral Nail Antirotation / 대한고관절학회지

PURPOSE: People with dementia have poor mobility and discharge outcomes following hip fractures. The purpose of this study was to evaluate the clinical and radiological results of internal fixation of undisplaced femur neck fractures (Garden types 1 and 2) by proximal femoral nail antirotation (PFNA) in dementia patients. MATERIALS AND METHODS: We studied retrospectively 19 patients with undisplaced femur neck fracture. All patients were over 70 years of age, walked independently with a cane or crutches and suffered moderate-to-severe dementia. Patients were treated with PFNA and followed-up for more than 2 years. Revision, loss of fixation, complications, and walking ability outcomes were measured. RESULTS: In walking-ability evaluation, patients showed an average decrease of just 0.2 points at the final follow-up. Walking ability was evaluated from before injury to 4 weeks after surgery and decreased by less than 0.5 points. Radiological bone union was achieved in 17 cases; the average time to bone union was 4.14 months (range, 2.5-7 months). Complications included non-union in two cases and femoral head avascular necrosis in one case of non-union. CONCLUSION: We found that for patients with osteoporotic bone tissues in their femoral heads or patients (e.g., those suffering dementia) for whom cooperating with medical workers for postoperative walking control or rehabilitation exercises is difficult, implanting a mechanically stable spiral blade for fixation of femoral neck fractures could facilitate walking after surgery.

Crutch-related acute arterial thrombosis in upper limb: case report / Oclusão arterial aguda de membro superior associada à utilização de muleta: relato de caso

Case report of an acute arterial obstruction in the upper limb secondary to thrombosis of the axillary artery caused by chronic use of crutches. The authors make a brief review of the literature and discuss it in relation to the present case.

Relato de caso de obstrução arterial aguda do membro superior por trombose da artéria axilar secundária ao uso crônico de muleta. Os autores fazem uma breve revisão da literatura, discutindo o presente caso.

Tradução e validação do Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2. 0) para o idioma português do Brasil / Translation and validation of the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2. 0) into Portuguese

Objetivo: Traduzir e validar o Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) para o idioma Português do Brasil. Métodos: Tradutores juramentados traduziram e retrotraduziram o Quest. A validade do conteúdo (IVC) foi determinada por cinco especialistas e, após a versão final do B-Quest, foi aplicado um pré-teste a usuários de cadeiras de rodas manuais, andadores e muletas. As propriedades psicométricas foram testadas como garantia da validade dos itens, confiabilidade e estabilidade da escala. Resultados: Foram obtidos dados de 121 usuários dos dispositivos mencionados. Nosso estudo demonstrou um IVC de 91,66% e uma análise de fatores satisfatória com referência à estrutura bidimensional do instrumento, o que assegurou a representatividade dos itens. Os coeficientes alfa de Cronbach dos itens "dispositivo", "serviços" e "escore total" do B-Quest foram 0,862, 0,717 e 0,826, respectivamente. A estabilidade de teste-reteste, realizada após terem transcorrido dois meses, foi analisada com o uso do teste de correlação de Spearman, tendo sido demonstrada elevada correlação (ρ>0,6) para a maioria dos itens. Conclusão: O estudo sugere que o B-Quest é um instrumento confiável, representativo e válido para a medição da satisfação de usuários de tecnologia assistiva no Brasil. .

Objective: To translate and validate the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) into Brazilian Portuguese. Methods: Certified translators translated and back-translated Quest. Content validity (CVI) was determined by 5 experts and, after the final version of B-Quest, a pre-test was applied to users of manual wheelchairs, walkers and crutches. The psychometric properties were tested to assure the validity of items and the reliability and stability of the scale. Results: Data were obtained from 121 users of the above-mentioned devices. Our study showed a CVI of 91.66% and a satisfactory factor analysis referent to the two-dimensional structure of the instrument that ensured the representativeness of the items. The Cronbach's alpha of the items device, service and total score of B-Quest were 0.862, 0.717 and 0.826, respectively. Test-retest stability conducted after a time interval of 2 months was analyzed using Spearman's correlation test, which showed high correlation (ρ >0.6) for most items. Conclusion: The study suggests that the B-Quest is a reliable, representative, and valid instrument to measure the satisfaction of users of assistive technology in Brazil. .

Bilateral wrist drop complicating axillary crutches mobilization in a young adult / Mano péndula bilateral que complica la movilización con muletas axilares en un adulto joven

OBJECTIVE: Axillary crutches are simple rehabilitative devices that are globally used temporarily or permanently to assist in ambulation of patients and rarely present with complication. This report is about bilateral wrist drop incidentally noticed in a young adult patient mobilized on axillary crutches after internal fixation of a simple right tibia fracture. METHODS: The fracture was fixed by intramedullary nailing and the patient was mobilized on axillary crutches. At six weeks, patient fearfully refused to be commenced on partial weight bearing and at 12 weeks after surgery he was noticed to be totally weightbearing on the bars of the appropriately long axillary crutches and had developed bilateral wrist drop. There was radiological evidence of healing at the fracture sites. Treatment included mobilization on one elbow crutch on the left, physical therapy and nerve stimulation. RESULTS: At six weeks of physiotherapy, the power of the dorsiflexors of the wrists had recovered completely. CONCLUSION: Bilateral posterior cord palsy of brachial plexus could occur even in young healthy patients but total recovery could occur if the diagnosis and treatment are prompt. Patients should be told in unequivocal terms not to weight bear directly on axillary bars.

OBJETIVO: Las muletas axilares son simples dispositivos de rehabilitación que se utilizan en todo el mundo de manera temporal o permanentemente para ayudar a caminar a los pacientes, y raramente presentan complicación. Este trabajo trata de la mano péndula o mano caída, observada incidentalmente en un paciente adulto joven movilizado en muletas axilares, después de la fijación interna de una fractura simple de la tibia derecha. MÉTODOS: La fractura fue fijada mediante clavo intramedular, y el paciente fue movilizado con muletas axilares. A las seis semanas, el paciente se negó temeroso a la iniciación para sostener parcialmente todo su peso con ayuda de muletas, y a las 12 semanas después de la cirugía, se le vio sostener todo su peso sobre las barras de las muletas axilares de longitud adecuada, y había desarrollado mano péndula bilateral. Había evidencia radiológica de curación en los sitios de fractura. El tratamiento incluyó la movilización con una muleta de codo a la izquierda, terapia física, y estimulación nerviosa. RESULTADOS: A las seis semanas de fisioterapia, la capacidad de los dorsiflexores de las muñecas se había recuperado completamente. CONCLUSIÓN: La parálisis del fascículo posterior bilateral del plexo braquial podría ocurrir incluso en pacientes jóvenes sanos, pero la recuperación total podría ocurrir si el diagnóstico y el tratamiento se hacen a tiempo. A los pacientes se les debe decir en términos inequívocos que no deben soportar todo su peso directamente en las barras axilares.

Searching for Hidden, Painful Osteochondral Lesions of the Ankle in Patients with Chronic Lower Limb Pain: Two Case Reports

It is easy to overlook osteochondral lesions (OCLs) of the ankle in patients with chronic lower limb pain, such as complex regional pain syndrome (CRPS) or thromboangiitis obliterans (TAO, Buerger's disease). A 57-year-old woman diagnosed with type 1 CRPS, and a 58-year-old man, diagnosed with TAO, complained of tactile and cold allodynia in their lower legs. After neurolytic lumbar sympathethic ganglion block and titration of medications for neuropathic pain, each subject could walk without the aid of crutches. However, they both complained of constant pain on the left ankle during walking. Focal tenderness was noted; subsequent imaging studies revealed OCLs of her talus and his distal tibia, respectively. Immediately after percutaneous osteoplasties, the patients could walk without ankle pain. It is important to consider the presence of a hidden OCL in chronic pain patients that develop weight-bearing pain and complain of localized tenderness on the ankle.

Isquemia arterial aguda del miembro superior por uso de muletas / Isquemia arterial aguda do membro superior por uso de muletas / Crutches induced acute arterial ischemia of the upeer limb

La compresión axilar por el uso de muletas es una causa infrecuente y subdiagnosticada de isquemia arterial aguda del miembro superior. Se presenta el caso de un paciente con isquemia aguda debido a trauma en la confluencia de las arterias axilar y humeral inducido por el uso de muletas. Dicha lesión fue el foco de microembolias que ocluyeron el arco palmar y la arteria humeral. Se diagnosticó con una arteriografía selectiva de la arteria axilar, y se tratómediante un bypass axilo-humeral con prótesis de PTFE anillado de 6 mm, con resultado satisfactorio en el seguimiento clínico a cinco años del postoperatorio.

A compressão axilar devido ao uso de muletas é uma causa pouco frequente e subdiagnosticada de isquemia arterial aguda do membro superior. Apresenta-se o caso de um paciente com isquemia aguda por trauma da confluência das artérias axilar e femoral induzido pormuletas. Esta lesão foi o foco de microembolias que provocaram a oclusão do arco palmar e da artéria femoral. Foi diagnosticado com uma arteriografia seletiva da artéria axilar, e tratado com um bypass axilo-femoral com prótese de capas de PTFE de 6 mm, com resultado satisfatório no seguimento clínico, cinco anos depois do pós operatório.

Crutch induced axillary trauma represents an infrequent but underdiagnosed cause of acuteischemia to the upper limb. We present a case of acute arterial ischemia caused by trauma of the confluence of the axillary and brachial arteries induced by the use of crutches. This lesion was the origin of microembolisms that occluded both the palmar arch and the brachialartery. The diagnosis was made by a selective arteriography of the axillary artery. An axillobrachial bypass with a 6 mm ringed PTFE prosthesis was performed showing satisfactory resultson his 5 year postoperative clinical follow up.

Operative Treatment of Periprosthetic Unstable Femoral Fractures of Vancouver Type B1 and C with Variable Plates / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the outcome after operative treatment with plate fixation in Vancouver B1 and C periprosthetic unstable femoral fractures. MATERIALS AND METHODS: We conducted a retrospective assessment of 15 patients who had under gone treatment for a periprosthetic unstable femoral fracture around primary hip arthroplasty between April 1997 and July 2010. The mean age of patients was 69 years(53 to 82 years) at the time of surgery and the mean duration of follow-up was 29.2 months (six to 110 months). According to Vancouver classification, 10 patients were type B1 and five were type C. According to the time of operation, open reduction and internal fixation was performed using four different plates. Bone graft was applied in all patients, regardless of the type of plate. The present review describes the clinical and radiographic results. RESULTS: All patients were able to ambulate without assistance of crutches or walkers. Of the 15 patients, the fracture site was united in all patients. Postoperative dislocation of the ipsilateral hip was observed in one patient; however, there was no occurrence of further complications, such as infections, nerve injuries, or loosening of the femoral stems. CONCLUSION: In Vancouver type B1 and C fractures, without any loosening of the femoral stems, open reduction with plate fixation using our operative methods provided a satisfactory result.

Percepção de hemiplégicos crônicos sobre o uso de dispositivos auxiliares na marcha / Perception of patients with chronic hemiplegia regarding the use of assistive walking devices

OBJETIVO: Avaliar a percepção de hemiplégicos crônicos sobre o uso de dispositivos auxiliares (DA) na marcha. MÉTODOS: A partir de um banco de dados de 360 hemiplégicos, foram recrutados 23 indivíduos que utilizavam DA e preenchiam os critérios de inclusão. A média de idade foi de 58,4 anos, tempo pós-acidente vascular encefálico de 80,8 meses e tempo de uso do DA de 67,6 meses. Para avaliar a percepção dos participantes, utilizou-se um questionário padronizado, composto por cinco questões: impacto do DA na habilidade para descarregar peso no membro parético; impacto na habilidade para movimentar o membro parético; impacto na confiança; impacto na segurança; e impacto no jeito de caminhar. As respostas possíveis eram "melhorou", "não alterou" ou "piorou". RESULTADOS: Quatorze indivíduos utilizavam bengalas e nove utilizavam muletas canadenses; 21 (91,3 por cento) utilizavam DA somente em vias públicas e dois (8,7 por cento) utilizavam DA também em ambiente domiciliar. A percepção em relação ao uso do DA foi positiva nas quatro primeiras questões (6,87 < χ2< 29,83; 0,0001 < P < 0,03), com relatos de melhora na descarga de peso (82,6 por cento), na habilidade de movimentar o membro parético (39,1 por cento), na confiança para caminhar (82,6 por cento) e na segurança (86,9 por cento). Não foram observadas diferenças significativas para o item jeito de caminhar (χ2= 1,09; P = 0,30). CONCLUSÕES: A percepção dos indivíduos hemiplégicos crônicos foi positiva em relação ao uso de DA para deambulação, sugerindo que esses dispositivos podem melhorar a mobilidade e a independência durante as atividades de vida diária.

OBJECTIVE: To assess the perception of patients with chronic hemiplegia regarding the use of assistive walking devices (AWD). METHODS: Twenty-three individuals who met the inclusion criteria and used AWD were recruited from a database of 360 stroke survivors. Their mean age was 58.4 years, mean time since stroke was 80.8 months, and mean time using AWD was 67.6 months. To assess the participants' perception, was used a standardized questionnaire covering the impact of AWDs on five aspects: weight-bearing on the paretic limb; ability to move the paretic limb; confidence; safety; and walking style. Possible answers were "improved," "unchanged," or "decreased." RESULTS: Fourteen individuals used canes and nine used elbow crutches; 21 (91.3 percent) used AWDs on public roads and only two (8.7 percent) used AWDs at home. The perception regarding the use of AWDs were positive in the first four questions (6.87 < χ2 < 29.83; 0.0001 < P < 0.03), with reports of improvement in weight-bearing (82.6 percent), ability to move the paretic limb (39.1 percent), confidence (82.6 percent), and safety (86.9 percent). No significant differences were found in terms of walking style (χ2 = 1.09; P = 0.30). CONCLUSIONS: The perception of chronic hemiplegic subjects regarding the use of AWD were positive, suggesting that these devices can improve mobility and independence in activities of daily living.

Prosthesis for a patient with proximal femoral focal deficiency

Proximal femoral focal deficiency is a rare birth defect that affects the hip bone and the proximal femur. The incidence is one case per 50,000 to 200,000 population. The disorder may be unilateral or bilateral, with the hip being deformed and the leg shortened. The goal of treatment is to provide optimal function during standing and ambulation. A 15-year-old male diagnosed with left proximal femoral focal deficiency was admitted for prosthetic rehabilitation. He presented with a very short left lower extremity, 38 cm leg length discrepancy, flail left hip and knee joints, and normal range of motion at the left ankle, and with muscles graded at 4/5. The patient was independent in transfer activities and ambulated with bilateral axillary crutches. A combination of orthosis and prosthesis (henceforth "prosthosis") was designed for the patient with a mechanical hinge joint to equalize the leg length and to improve lower extremity function during standing and ambulation. Upon discharge, the patient was independent in donning and doffing the prosthesis, was ambulatory using the prosthesis without gait aid but with minimal listing during the stance phase on the prosthesis side. During the patient's two-year follow-up, adjustment of the prosthesis was done to accomodate growth; checking of the prosthesis for mechanical breakdown and anticipatory management of potential musculoskeletal complications and psychosocial concerns on the use of the prosthesis were also done.

The Cross-Leg Gastrocnemius Muscle Flap for Leg Reconstruction of the Difficult and Unfavorable Conditions

PURPOSE: In the cases of a vascular compromised condition in an injured lower extremity, soft tissue coverage with free tissue transfer presents a challenging problem to the reconstructive surgeon. For this reason, cross-leg flaps are still used in unusual circumstances. Advances in surgical technique has made the cross-leg free flap possible although it may require long operation time along with significant donor site morbidity. Therefore, a pedicled cross-leg muscle flap may be an alternative treatment modality when local flap or free flap is not possible. METHODS: Twelve patients(9 males and 3 females) underwent the operation from October 2001 to December 2008. The patients' age ranged from 6 to 82 years. The unusual defects included the regions such as the knee, popliteal fossa, distal third of the tibia, dorsal foot, and the heel. Indications for the cross-leg gastrocnemius flap are inadequate recipient vessels for free flap(in eight cases), extensive soft tissue injuries(in three cases) and free flap failure(in one case). The muscle flap was elevated from contralateral leg and transferred to the soft tissue defect on the lower leg while both legs were immobilized with two connected external fixator systems. Delay procedure was performed in 2 weeks postoperatively, and detachment was done after the establishment of the adequate circulation. The average period from the initial flap surgery to detachment was 32 days(3 to 6 weeks). Mean follow-up period was 4 years. RESULTS: Stable coverage was achieved in all twelve patients without any flap complications. Donor site had minimal scarring without any functional or cosmetic problems. No severe complications such as deep vein thrombosis or flap necrosis were noted although mild to moderate contracture of the knee and ankle joint developed due to external fixation requiring 3 to 4 weeks of physical treatment. All patients were able to walk without crutches in 3 months postoperatively. CONCLUSION: Although pedicled cross-leg flaps may not substitute free flap surgery, it may be an alternative method of treatment when free flap is not feasible. Using this modification of the gastrocnemius flap we managed to close successfully soft tissue defects in twelve patients without using free tissue transfers.

[ evaluation of proximal tibia osteotomy by lateral closing wedge [Coventry] method in association with displacement of distal part to proximal and rigid fixation by T-plate and rapid range of motion]

The objective of this study was the evaluation of genovarum adjustment and the effect of distal part of osteotomy displacement and comparing it with other methods and determination of its complications. A total of 25 knees from 22 patients in 1381-1383 in Baghiatallah Hospital were undergone proximal tibia osteotomy by lateral closing wedge [Coventry] method with rigid fixation by T-plate and rapid range of motion [ROM]. In all patients the distal of osteotomy part was displaced about 1 cm to proximal and was fixed rigidly with a T-plate. ROM and 50% weight bearing with 2 crutches were begun at second day after surgery. After 6 weeks both crutches were put away. Patients were visited again at the end of weeks 4, 6, 8, and 16 and tibio-femoral angle and ROM were measured and registered. Every probable complication and union at any time and patient's satisfaction and the time of getting back to work were registered at the fourth month. The mean of genovarum was 12 degrees varus before surgery which was adjusted to 6.1 degrees valgus after surgery. The majority of patients were able to walk without crutches at the end of the second month. There was union in all patients at the end of the third month. At the end of the fourth month all patients got back to previous activities. There was pain in only one patient [2 knees], but it was milder than before and the patient was satisfied. It seems this kind of operation is more advantages than other methods especially non-rigid fixation and casting in patients older than 40 with osteoarthritis and no tolerance to being immobilized in cast and also with high complication risks such as vascular thrombosis

The Usability of Perforator-based Fasciocutaneous Flap for Trochanteric Pressure Sore

PURPOSE: Myocutaneous flap was widely used for trochanteric pressure sore but it had many drawbacks such as donor site morbidity, dog-ear deformity and functional muscle sacrifice. We have performed fasciocutaneous flap based on perforating vessels and succeeded in overcoming its drawbacks. METHODS: We experienced 11 cases of perforator-based fasciocutaneous flap for the coverage of trochanteric pressure sore in 9 patients, 2 cases of which were bilateral. The ambulatory status of patient group is as follows: 6 of them used a wheelchair, 2 of them are free walking, 1 of them use a wheelchair or crutches. Flap was supplied by cutaneous perforating vessel of descending branch of the lateral circumflex femoral artery and the third perforating artery of the deep femoral artery. The size of wounds were from 4x6.5cm to 10x13cm. RESULTS: We did not find any flap loss or congestion except 2 partial wound dehiscences and 1 wound infection. Donor site morbidity was not found. We observed no recurrence of the pressure sore during the 2.5 year follow-up period. CONCLUSION: We considered that perforator-based fasciocutaneous flap could overcome the traditional drawbacks of the conventional myocutaneous flap and its modified flap for trochanteric pressure sore. And this flap has many advantages for covering trochanteric pressure sore without any donor site deformity and morbidity, which would greatly improve the aesthetic result.