Vastus medialis muscle flap and hemi V-Y skin flap for knee extensor and soft tissue reconstruction.

Simultaneous reconstruction of extensor mechanism and skin defect of the knee joint is a difficult problem. We present a case of a 55-year-old man with loss of patella and 9 x 6 cm skin defect after total patellectomy for infected open patellar fracture. Vastus medialis muscle flap and hemi V-Y skin flap were elevated. Vastus medialis muscle flap was advanced and sutured to the remaining patellar tendon. Hemi V-Y skin flap covered the skin defect. The wound healed uneventfully. After a follow-up period of 30 months, active range of motion of the knee joint is 0-120 degrees, and extension strength of the knee joint is [4] in a manual muscle test. He can stand on his right leg without any assistance. The combination of vastus medialis flap and hemi V-Y skin flap is a valuable option in knee reconstruction after total patellectomy.

Scaphoid fractures in children: problems and treatment.

From 1984 to 1999, the authors treated 64 cases of fracture of the scaphoid in children. Causes of injury were sports (n = 27), punching game machines or fighting (n = 22), and traffic accident or other trauma (n = 15). Most (46 cases) were nonunion cases. Eighteen cases were acute. Cast immobilization was performed in 10 acute cases and two nonunion cases. Screw fixation was performed in 52 cases, including 35 cases of bone graft. In 10 of these operated cases, freehand screw insertion was used. Ultimately, good bony fusion was achieved in all cases, but in two nonunion cases a secondary bone graft was necessary. Functional results in all cases were acceptable. A major problem is that children are not brought to clinics immediately after injury, so the percentage of nonunion is high.

Osteosynthesis for nonunion of the lateral humeral condyle.

The treatment of established nonunion of the lateral humeral condyle is controversial. Twenty patients who had osteosynthesis of the nonunion were evaluated to clarify the changes in range of motion and the factors influencing those changes. The average age of the patients at surgery was 13.6 years (range, 6-25 years). The average duration of followup was 8.8 years. Outcome was rated as excellent in seven patients and good in 13 patients according to the score of Broberg and Morrey. In five of the 20 patients, the preoperative range of motion was limited and their motion improved an average of 35 degrees as a result of surgery. In the remaining 15 patients, the range of motion did not change or was reduced an average of 19 degrees postoperatively. Of the 15 patients, 11 had Milch Type II injuries and four had Milch Type I injuries. In the 11 patients with Milch Type II injuries, the loss of range of motion postoperatively averaged 13 degrees. However, in the four patients with Milch Type I injuries, loss of range of motion postoperatively averaged 21 degrees. Complications such as delayed union, nonunion, or infection occurred in five patients. The main factors influencing the results of osteosynthesis are the age of the patient, the preoperative symptoms, and the postoperative complications.

Complications of vascularized fibula graft for reconstruction of long bones.

The clinical results and complications of the vascularized fibular graft for the reconstruction of various long bone defects were reviewed in 60 cases. Bony reconstruction was achieved in 57 of the 60 cases; however, various postoperative complications occurred in 54 percent of the cases. One case of arterial thrombosis of an anastomosed vessel and nine cases of venous congestion of the monitoring flap occurred in the early postoperative periods. The authors managed the nine cases of venous congestion of the flap conservatively, and all flaps survived. Partial necrosis of the flap was noted in eight of these nine cases, but additional surgical intervention was required in only four cases. Treatment included a gastrocnemius musculocutaneous flap in one case and a full-thickness skin graft in three cases. The vascularized fibula survived and bony fusion was achieved in all of these cases. The one case of arterial thrombosis resulted in graft failure due to a delay in the decision to perform a thrombectomy. Graft fracture occurred in 13 cases as the mechanical stress to the graft increased. In two cases of femoral reconstruction, graft fracture occurred during dynamization of the graft, despite the use of an Ilizarov external fixator. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibular grafting offers the patient a great deal of benefit; however, this graft has a concomitant high risk of complications. Great attention to detail must be paid to prevent postoperative complications.

Long-standing nonunion of fractures of the lateral humeral condyle.

BACKGROUND: Patients with nonunion of a fracture of the lateral humeral condyle often have pain, instability, or progressive cubitus valgus deformity with tardy ulnar nerve palsy. However, some patients have minimal or no symptoms or disabilities. We evaluated patients with long-standing established nonunion of the lateral humeral condyle to correlate the clinical long-term outcome of this condition with the original fracture type. METHODS: Nineteen elbows in eighteen patients who were at least twenty years of age were evaluated. Fourteen patients were male, and four were female. The average age at presentation was 42.5 years. The average interval from the injury to the presentation of the symptoms of the nonunion was thirty-seven years. Patients were divided into two groups on the basis of the size of the fragment and the location of the fracture line. Group 1 included nine elbows with nonunion resulting from a Milch Type-I injury, and Group 2 included ten elbows with a nonunion resulting from a Milch Type-II injury. Evaluations were performed with use of radiographic examination, clinical assessment, and calculation of the Broberg and Morrey score. RESULTS: Symptoms were seen more frequently in Group 1 than in Group 2. The range of flexion in Group 1 (range, 60 degrees to 145 degrees; average, 99 degrees) was more restricted than that in Group 2 (range, 100 degrees to 150 degrees; average, 129 degrees) (p = 0.0078). The functional score in Group 2 was significantly higher than that in Group 1 (p = 0.03). CONCLUSION: Disabling symptoms only rarely developed in Group-2 patients. Occasionally, however, these patients do present with clinically detectable dysfunction of the ulnar nerve. In contrast, pain, instability, and loss of range of motion as well as ulnar nerve dysfunction developed in Group 1. For this reason we think that a nonunion of a Milch Type-I fracture should be treated as soon as possible after injury, preferably before the patient reaches skeletal maturity.