Single-stage posterior vertebral column resection and internal fixation for old fracture-dislocations of thoracolumbar spine: a case series and systematic review.

PURPOSE: To evaluate the efficacy of single-stage posterior vertebral column resection for old thoracolumbar fracture-dislocations with spinal cord injury. METHODS: From January 2007 to June 2013, twelve male patients (average age, 32.6 years; range 19-57 years) with old fracture-dislocations of the thoracolumbar spine and spinal cord injury underwent single-stage posterior vertebral column resection and internal fixation. All patients were assessed for relief of the pain and restoration of neurologic function. Postoperative Cobb angle was measured and bone graft fusion was evaluated by X-ray. A systematic review of 25 studies evaluating surgical management of thoracolumbar fractures with spinal cord injuries was also performed. RESULTS: From our case series, six of the nine patients with Frankel grade A had significant improvement in urination and defecation after surgery. The three patients with Frankel grades B and C had progression of 1-2 grades after surgery. Bony fusion was achieved and local back pain was relieved in all patients after surgery. From our systematic review of 25 studies, the majority of patients had improved back pain, the postoperative kyphotic angle was significantly reduced compared with pre-operative kyphotic angle. CONCLUSION: Single-stage posterior vertebral column resection and internal fixation for old thoracolumbar fracture-dislocations is an ideal treatment allowing for thorough decompression, relief of pain, correction of deformities, and restoration of spinal stability. LEVEL OF EVIDENCE: IV.

Anatomic study of selective neurectomy of gastrocnemius muscle for calf reduction in Chinese.

BACKGROUND: Selective neurectomy of the innervating nerves of the gastrocnemius muscle is a popular method employed for calf reduction. However, accidental injury to the untargeted adjacent nerves could happen. This study aims to provide detailed morphometry of the motor branches from the tibial nerve innervating the gastrocnemius muscle, the soleus and the medial sural cutaneous nerve in the popliteal fossa. METHODS: 23 lower legs from female cadavers were dissected to explore the origin, length of and the spatial relationship between the four branches given off from the tibial nerve in the popliteal fossa. RESULTS: Our study showed there were seven origin patterns existing among the four nerve branches; the origin of the branches to the medial and lateral heads of the gastrocnemius muscle was located ranging from -16 mm to 22 mm away from the midpoint of the line between the lateral and medial condyles of the femur; In 95% of the specimens, the location of the origin of the nerve branch to the medial head was proximal to its lateral counterpart. The nerve to the medial head was often given off from the medial aspect or the posteromedial aspect of the tibial nerve, while the other three often from the lateral aspect. CONCLUSIONS: A variety of origin patterns among the nerves to the lateral and medial gastrocnemius muscle, the nerve to the soleus muscle and the sural cutaneous nerve exist, necessitating the formulation of diversifying surgical strategies preoperatively and the meticulous and sequential dissection intra-operatively to ensure the lowest level of accidental injury.

Vasculature at the medial aspect of the foot and clinical application of flaps based on it for forefoot reconstruction.

BACKGROUND: Detailed knowledge of the vasculature of the medial aspect of the foot has rarely been reported, but it is of tremendous importance for harvesting the flap in this area to cover defects of the foot and hand. Repair of soft-tissue defects at the dorsal forefoot remains a challenge in reconstructive surgery. The authors describe the use of the distally based saphenous neurovenofasciocutaneous flap at the medial aspect of the foot to cover this region. METHODS: This study was divided into two parts: an anatomical study and clinical application. In the anatomical study, 35 cadaveric feet were injected with red gelatin, five others were made as corrosive vascular casts, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, six cases of soft-tissue defects at the dorsal forefoot were reconstructed with distally based saphenous neurovenofasciocutaneous flaps. RESULTS: The anatomical study showed that (1) the vasculature pattern could roughly be classified into three types and (2) there were constant anastomoses between the above-mentioned arteries around the midpoint of the first metatarsal bone. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSIONS: The blood supply to the medial aspect of the foot has multiple origins, on the basis of which of several flaps can be harvested, either a pedicled or free. Of particular clinical significance is the distally based saphenous neurovenofasciocutaneous flap, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap should be considered as a preferential way to reconstruct soft-tissue defects of the dorsal forefoot.

[Case-control study on cannulated screw fixation and percutaneous autogenous bone marrow grafting for the treatment of femoral neck fractures].

OBJECTIVE: To compare clinical results of two methods for the treatment of femoral neck fracture, which are cannulated screw fixation combined with percutaneous autogenous bone marrow grafting, and simple cannulated screw fixation. To investigate the curative effects of cannulated screw fixation combined with percutaneous autogenous bone marrow garfting to promote fracture healing and reducing femoral neck necrosis. METHODS: The clinical data of 60 cases, which were enrolled from December 2000 to December 2008 consecutively in our hospital, were analyzed retrospectively. Thirty patients with femoral neck fractures were treated with cannulated screw fixation and percutaneous autogenous bone marrow grafting. There were 20 males and 10 females, ranging in ages from 18 to 89 years,with an average of (52.3 +/- 0.2) years. There were 13 patients with traffic accident, 3 patients with falling injuries and 14 patients with tumble. Based on the Garden classification for femoral neck fractures, 1 patient was type I, 6 patients were type II, 12 patients were type III and 11 patients were type IV. Among 30 patients in the control group, 16 patients were male and 14 patients were female, ranging in age from 18 to 91 years, with an average of (51.9 +/- 0.1) years. Twelve patients injured with traffic accident, 1 patient with falling injuries and 17 patients with tumble. Based on the Garden classification for femoral neck fractures, 5 patients were type I, 2 patients were type II,15 patients were type III, and 8 patients were type IV. Patients in the control group were treated with cannulated screw fixation only. All the patients were followed up for 2 years after operation. The fracture healing and complications were evaluated and compared between the two groups. RESULTS: The average healing time was (7.1 +/- 1.2) months in the observing group and (8.0 +/- 1.4) months in the control group. The healing of femoral neck fracture occurred in 29 cases in observing group while in 24 cases in the control group contrast to femoral head necrosis occurred in 1 case in the observing group while in 6 cases in the control group. According to Harris scoring system, the good and excellent rate of the two groups had statistical difference (P < 0.05). CONCLUSION: Cannulated screw fixation and percutaneous autogenous bone marrow grafting is a more efficient method for accelerating healing of femoral neck fractures and reducing femoral head necrosis.

[A controlled clinical trial on the therapy of injured shoulder arthrochalasis by shoulder-elbow elastic band immobilization with functional exercise].

OBJECTIVE: To observe the therapeutic effects of shoulder-elbow elastic immobilization and functional exercise for injured shoulder arthrochalasis, and compare it with forearm-suspending immobilization and functional exercise therapy. METHODS: The patients with injured shoulder arthrochalasis were randomly divided into treatment group (38 cases) and control group (37 cases). Treatment group underwent the therapy of shoulder-elbow elastic band immobilization and functional exercise; control group was managed by forearm-suspending band immobilization and functional exercise therapy. RESULTS: In treatment group, 29 (76.3%) cases recovered, 7 (18.4%) improved and 2 (5.3%) failed; in control group, 15 (40.5%) cases recovered, 15 (40.5%) cases improved and 7 (19.0%) failed. The differences between two groups were statistically significant (P<0.01). The AHI (acromio-humeral interval) ranged from 8 to 19 mm (11.9+/-5.1) in treatment group and 8 to 27 mm (14.2+/-5.4) in control group, and the difference was also statistically distinct (t=2.7525, P<0.01). CONCLUSION: The treatment with shoulder-elbow elastic band immobilization and exercise therapy for injured shoulder arthrochalasis is a safe and effective method. Immobilization with shoulder-elbow elastic band is better than forearm-suspending band for injured shoulder arthrochalasis.

Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications.

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.

[Microsurgery treatment of old Achilles tendon rupture merging with skin defect].

OBJECTIVE: To explore the methods of treatment for old achilles tendon rupture merging with skin defect. METHODS: By following up retrospectively 10 patients from February 1995 to December 2001, we analyzed the operative methods, the points for attention and the results. Gastrocnemius musculocutaneous flaps were used in 3 cases, foot lateral skin flaps in 4 cases, superior medial malleolus skin flaps in 2 cases, and sural neural skin flap in 1 case. The Achilles tendon was sutured directly in 8 patients, with Lindholm's technique in 2 patients. RESULTS: All flaps survived and the wound healed well in 8 cases and reruptured in 2 cases. According to Yin Qing-shui's criteria to test the efficacy, the results were excellent in 5 patients, good in 4 and poor in 1. CONCLUSION: Repairing the old Achilles tendon rupture merging with skin defect by use of microsurgery has good results and plays an important role in reducing joint contracture and stiffness, and in saving the ability to push forward and flex.