Lower limb replantation: 27 years follow up.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

Forearm reconstruction after loss of radius: case report.

INTRODUCTION: Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. CASE OUTLINE: This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. CONCLUSION: Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential.

[Medial subtalar dislocation--case report].

INTRODUCTION: Subtalar dislocation (SI) is a term that refers to an injury in which there is dislocation of the talonavicular and talocalcanear joint, although the tibiotalar joint is intact. CASE OUTLINE: A case of medial subtalar dislocation as a result of basketball injury, so-called "basketball foot", is presented. Closed reposition in i.v. anaesthesia was performed with the patient in supine position and a knee flexed at 90 degrees. Longitudinal manual traction in line of deformity was carried out in plantar flexion. The reposition continued with abduction and eversion simultaneously increasing dorsiflexion. It was made in the first attempt and completed instantly. Rehabilitation was initiated after 5 weeks of immobilization. One year after the injury, the functional outcome was excellent with full range of motion and the patient was symptom-free. For better interpretation of roentgenogram, bone model of subtalar dislocation was made using the cadaver bone. CONCLUSION: Although the treatment of such injury is usually successful, diagnosis can be difficult because it is a rare injury, and moreover, X-ray of the injury can be confusing due to superposition of bones. Radiograms revealed superposition of the calcaneus, tarsal and metatarsal bones which was radiographically visualized in the anterior-posterior projection as one osseous block inward from the talus, and on the lateral view as in an osteal block below the tibial bone. Prompt recognition of these injuries followed by proper, delicately closed reduction under anaesthesia is crucial for achieving a good functional result in case of medial subtalar dislocation.

[Possible factors for ankle fractures].

BACKGROUND/AIM: Classification of ankle fractures is commonly used for selecting an appropriate treatment and prognosing an outcome of definite management. One of the most used classifications is the Danis-Weber classification. To the best of our knowledge, in the available literature, there are no parameters affecting specific types of ankle fractures according to the Danis-Weber classification. The aim of this study was to analyze the correlation of the following parameters: age, body weight, body mass index (BMI), height, osteoporosis, osteopenia and physical exercises with specific types of ankle fractures using the Danis-Weber classification. METHODS: A total of 85 patients grouped by the Danis-Weber classification fracture types were analyzed and the significance of certain parameters for specific types of ankle fractures was established. RESULTS: The proportion of females was significantly higher (p < 0.001) with a significantly higher age (59.9 years, SD +/- 14.2) in relation to males (45.1 years, SD +/- 12.8) (p < 0.0001). Type A fracture was most frequent in the younger patients (34.2 years, SD +/- 8.6), and those with increased physical exercises (p = 0.020). In type B fracture, the risk factor was osteoporosis (p = 0.0180), while in type C fracture, body weight (p = 0.017) and osteoporosis (p = 0.004) were significant parameters. CONCLUSION: Statistical analysis using the Danis-Weber classification reveals that there are certain parameters suggesting significant risk factors for specific types of ankle fractures.

[Angiosome of the fibular artery as anatomic basis for free composite fibular flap].

INTRODUCTION: The free osteoseptocutaneus fibular flap is, anatomically, an angiosome of the fibular artery. Knowledge of detailed topography anatomy of the fibular artery and its branches is necessary for successful creation and elevation of the flap. OBJECTIVE: The aim of the study was to determine topography of the tissue of the leg supplied only by the fibular artery, to describe topography relations of the branches of the fibular artery, their number, anastomoses, vascular plexus and the way of vascularization of the skin, muscle and bone tissue. METHOD: The popliteal artery was cannulated in 15 cadaveric legs, flushed with ink and then with 10% ink-gelatin. Fixation of tissue was performed with formalin and then micropreparation of the side branches of the fibular artery was performed. Also, two corrosive models were made. Localization of foramen nutrition was determined by measuring 50 fibulas. RESULTS: The skin supplied by the fibular artery forms distal two thirds of the lateral-posterior aspect of the leg. Vascularization of the skin arises from the side branches of the fibular artery forming a rich fascia plexus at the deep fascia level. From 3 up to 7 side branches of the fibular artery are incorporated in the fascia arterial plexus and can be separated as septocutaneus and myocutaneus, according to topography relations. The nutritive artery enters the fibula cortex at a spot that, measured from the top of the fibula, lies in the area between 32% and 65% of the whole length of the fibula. Periosteal circulation of the fibula originates from the short side branches of the fibular artery that anastomoses at the periosteum level. CONCLUSION: The axial line of flap has to be marked 2 cm posterior to the line from caput fibulae to malleolus lateralis. Numerous anastomoses between the side branches of the fibular artery in the fascia plexus enable good circulation of the skin even when some of the branches are not included in the flap. The middle third of fibula has to be used as bone graft because of localization of the foramen nutrition.

Free fibula and corticocancellous bone grafting for salvage of a war-injured forearm.

The treatment of a complex forearm injury inflicted by a wartime mine explosion is presented in this study. Apart from the soft tissue damage, a 4-part fracture of the radius and loss of 19 cm of the ulnar diaphysis were present along with lesions of the median and ulnar nerves. The radial pulse was intact. The first formal treatment of the wounding consisted of extensive soft tissue and bone debridement and external fixation of radius with an additional intramedullary K-wire. After wound closure was obtained, a free vascular fibula grafting of the ulna and corticocancellous bone grafting of the radius were performed. Bone union of both the radius and ulna was subsequently achieved and 9 years after the injury, the patient has full flexion and extension of the elbow, full pronation and 70% of supination. Motion of the wrist is limited because of an ulnar plus variant of the distal radioulnar joint. Hand function is still limited by chronic low-moderate median nerve palsy, but the ulnar nerve has recovered completely. The patient is able to pinch, has full finger extension and can make a fist. He is satisfied that he made the correct decision in not having an initial amputation for his injury.