Mismatch of the short straight cephalomedullary nail (PFNA-II) with the anterior bow of the Femur in an Asian population.

OBJECTIVES: The aims of this study were to evaluate the morphologic discrepancies between the short straight proximal femoral nail antirotation-Asian version (PFNA-II) and the anterior bow of the femur in Chinese patients and to propose a further design modification. DESIGN: Retrospective study. SETTING: Level I academic trauma center. PATIENTS/PARTICIPANTS: A consecutive 158 cases (35 men and 123 women with mean age of 77.2 years) with unstable per/intertrochanteric fractures (AO/OTA 31 A2 and A3) treated by PFNA-II from August 2008 to December 2010 participated in this study. INTERVENTION: Nailing of PFNA-II. MAIN OUTCOME MEASUREMENTS: The nail tip position was classified to a 5-grade scale on postoperative lateral radiographs of the femur. The distance between the nail axis and the canal axis at the tip level was measured. The degree of the theoretical bent curvature and its corresponding radius were calculated, assuming that the anterior protrusive nail tip was placed back to the central canal axis. RESULTS: The distal tip of PFNA-II was located anterior to the femur canal central axis in 118 cases (74.7%), of which 55 cases abutted against the anterior cortex (contact between nail and internal cortex) (34.8%). With longer nails, the abutment occurred more often and was more prominent. For nail lengths of 170, 200, and 240 mm, the theoretical distance to replace the nail tip to the central canal axis was 1.42 ± 0.18, 1.77 ± 0.39, and 2.46 ± 0.20 mm, respectively; the corresponding bent curvature angle was 2.51 ± 2.40, 2.13 ± 1.65, and 2.09 ± 0.98 degrees, respectively; and the bent curvature radius was 1483 ± 818, 2329 ± 1293, and 3710 ± 1957 mm, respectively. CONCLUSIONS: There is a mismatch between the current short straight PFNA-II and the anterior bow of the femur in the Chinese population. In light of the documented complications and technical problems related to this mismatch, further modifications with an anterior bow are proposed.

Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique.

BACKGROUND: Distally based perforator propeller sural flaps that pedicled on an isolated perforator from the peroneal artery or posterior tibial artery are a versatile local reconstructive option for defects of the foot and ankle region. However, flap venous congestion is yet a difficult problem after operation. We hypothesize that containing some adipofascial tissues around the axial perforator can preserve some tiny venous return routes, improve venous drainage, and ultimately enhance flap safety in distally based sural flaps. METHODS: A prospective case series of 12 patients undergoing distally based perforator sural flaps for foot and ankle coverage were included in this study from January 2008 to December 2010. There were 7 posterior tibial artery perforator flaps from the posteromedial sural region and 5 peroneal artery perforator flaps from the posterolateral sural region. After identifying the proper viable perforator during operation as the pivot point, the whole flap was designed in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous flap, whereas the distal smaller blade was a subdermal vascular plexus flap, preserving at least a quarter area of adipofascial tissue intact around the perforator. Postoperatively, flap swelling was classified into a 5-grade assessment scale. Flap survival, complications, and patient functional recovery were evaluated. RESULTS: The proximal fasciocutaneous flap measured 4 × 8 to 6 × 18 cm (mean, 57.8 cm), and the distal subdermal cutaneous flap measured 2 × 2 to 4 × 4 cm (mean, 9.2 cm). The flaps were rotated 160 to 180 degrees. Postoperatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2, and grade 4 in 1 with some distal superficial skin necrosis, which occurred in the largest flap in our series. All flaps survived uneventfully. After a mean of 13 months of follow-up, the wounds were cured successfully. All patients recovered walking and shoe wearing function. CONCLUSION: Keeping a quadrant adipofascial tissue around the distal pivot perforator to form a perforator-adipofascial-pedicle can preserve more venous return routes and relieve flap swelling. This technique should be recommended in distally perforator-pedicled propeller flaps because it enhances flap safety yet does not increase the difficulty of 180-degree rotation.