Peroneus brevis rotation flap: anatomic considerations and clinical experience.

BACKGROUND: Large soft tissue defects of the distal third of the leg are common occurrences at trauma centers. Massive defects often require vascularized free tissue transfer for coverage; however, smaller defects may frequently be closed by rotation of local tissue. The peroneus brevis muscle is ideally located to provide coverage of the exposed distal fibula. METHODS: An anatomic dissection of the peroneus brevis muscle and its vascular pedicles was performed in 10 fresh cadaveric leg specimens. Patients who underwent this procedure at our institution were retrospectively reviewed. RESULTS: Each dissected muscle had an average of 3.5 vascular pedicles (range, 2-6), which arose from the peroneal artery in all but two cases. The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5-12.0 cm). The muscle belly ended an average of 6.0 mm proximal to the tip of the lateral malleolus. Half of the specimens had muscle bellies that extended to or past the tip of the lateral malleolus. This rotation flap has been successful in covering four wounds with exposed distal fibula in four patients. CONCLUSION: The anatomic characteristics of the peroneus brevis muscle are ideal for soft tissue coverage of the distal fibula. Ease of elevation and reliability have made this rotational flap the procedure of choice for small soft tissue defects over the distal fibula at our institution.

Results of acute zone III extensor tendon injuries treated with dynamic extension splinting.

Motivated by the favorable results of dynamic splinting in the treatment of more proximal extensor tendon injuries, we explored the use of dynamic splinting in the treatment of zone III extensor tendon lacerations. Twenty-two tendon repairs in 19 patients were available for review. On the basis of degree of extension lag and pulp-to-palm distance, 14 repairs were rated as excellent, 6 as good, and 2 as fair. Using total active motion at 10 weeks, the proximal interphalangeal and distal interphalangeal joints averaged 170 degrees. There was one mild boutonniere deformity. The results of this prospective study show that carefully monitored dynamic splinting is safe in the treatment of zone III lacerations. When results were compared with the results of our method of static splinting used prior to this prospective study, patients returned to full activities with good-to-excellent results 8 weeks earlier instead of at 16 to 18 weeks.

Intraosseous ganglia of the carpal bones.

Intraosseous ganglia are benign, cystic lesions of bone that are most commonly found in the subchondral region of long bones of the lower extremity. Reports of isolated carpal involvement are rare; however, it has been well documented that these lesions may produce chronic wrist pain. Various theories of pathogenesis have been advanced, including synovial herniation, mucoid degeneration, primary cellular metaplasia, and chronic repetitive trauma. In our study, 11 patients (seven female, four male) with 12 lesions were treated for chronic wrist pain associated with intraosseous carpal ganglia. All patients had similar complaints preoperatively and were unable to obtain relief with rest, immobilization, or nonsteroidal medication. Aside from local tenderness over the involved bone, the physical examination was unremarkable. Acute trauma was not found to be a factor in any of these patients' histories. Eleven lesions in 10 patients were grafted with bone from the distal radius. A complete resolution of symptoms was seen at a 20-month follow-up examination.

Complications experienced in the rehabilitation of zone I flexor tendon injuries with dynamic traction splinting.

A retrospective review of all flexor tendon repairs done between January 1985 to June 1987 determined the complication rate with our method of rehabilitation. One hundred sixty-three flexor tendon lacerations in 83 patients were reviewed. Follow-up ranged from 6 to 42 months. All patients participated in the same 12-week rehabilitation protocol. All patients had passive motion exercises of the interphalangeal joints in the first 2 weeks. We believe that passive stretching of zone I injuries during the first 2 weeks contributed to the zone I complication rate. Of the 20 patients with zone I tendon-to-tendon repairs, 7 patients had significant complications. The 35% complication rate found with zone I injuries has prompted us to modify our postoperative rehabilitation protocol in zone I injuries.

Further experience in rehabilitation of zone II flexor tendon repair with dynamic traction splinting.

A review of all flexor tendon repairs in the "no man's land" performed from January of 1985 to June of 1987 was done to evaluate the efficacy of our method of rehabilitation. There were 60 fingers (57 patients) with complete laceration of the flexor digitorum profundus and flexor digitorum superficialis tendons in zone II. Fingers with phalangeal fractures, joint injuries, or significant skin loss were excluded. Follow-up ranged from 12 to 48 months. Rehabilitation consisted of a 12-week protocol using the U.S. military combined regimen of controlled motion. Features from the technique of controlled active extension against rubber band passive flexion as well as those of controlled passive extension and passive flexion were incorporated. The palmar pulley modification of Kleinert's dynamic traction splint was utilized. Strickland's total active motion formula was employed to determine results. The results were classified into the four categories of excellent, good, fair, and poor. Fifty-two fingers (86 percent) were rated excellent, 4 fingers (7 percent) were rated good, 1 finger (2 percent) was rated fair, and 3 fingers (5 percent) were rated poor.

Resection arthroplasty at the basilar joint of the thumb.

Resection arthroplasty at the base of the thumb has a long history in the surgical literature. It is a less complex procedure than other operative approaches; pain relief along with useful hand function is reliably achieved. Sixty-six trapezial resection arthroplasties using either a tendon or Gelfoam spacer (The Upjohn Co, Kalamazoo, MI) were reviewed with improvement noted in 62 patients.

A modified extensile exposure for the treatment of complex or malunited acetabular fractures.

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.