Ilizarov technology in China: a historic review of thirty-one years.

PURPOSE: To summarize the evolution of Ilizarov technology in China, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of this technology, and share Chinese modification and experience in this field. METHOD: A thorough interview with senior ASAMI members of China and literature search and physical books in libraries was undertaken to summarize the history of Ilizarov technology in China. RESULTS: The formal development of Ilizarov technology began when professor Ilizarov himself came to Beijing (1991) and gave a speech. In the following 31 years, his technology was rapidly developed through China, with many symposiums held and associations established including ASAMI China (2003) and ILLRS China (2015). Today, Ilizarov technology has become the main treatment of complex fractures, defects, nonunion, infections, deformities, and chronic ischemic ulcers of the limbs. In those years, Chinese scholars also developed some special treatment methods and made many modifications to Ilizarov external fixators. CONCLUSION: Ilizarov technology has developed in China for 31 years. It revolutionized the treatment of complex limb traumas, deformities, and diseases. In the treatment of millions of patients, Chinese scholars had many unique experiences and made modifications to this technology which is worthy to share with the world.

Reconstruction of Moderate-Sized Hand Defects Using a Superficial Lateral Sural Artery Perforator Flap.

BACKGROUND: The skin on the lower leg has abundant perforators and, thus, is an excellent donor site for transplant tissue flaps. However, due to vascular variations and body positions, tissue flaps at the posterolateral proximal portion of the lower leg are rarely used for transplantation. This study reports our experience with the use of superficial lateral sural artery perforator (SLSAP) flaps in the repair of moderate-sized hand wounds. METHODS: From March 2012 to April 2015, the hand wounds of 15 patients were planned for repair using a superficial sural artery perforator flap. In total, 6 patients had a defect in the palm of the hand, 5 in the dorsum of the hand, and 3 in the finger; 1 patient sustained a contracture of the first web space. RESULTS: In 12 of the 15 cases, an SLSAP flap was successfully harvested. In the remaining 3 cases, the planned harvest of an SLSAP flap was converted to the harvest of a superficial medial sural artery perforator flap during the operation. The flaps ranged in area from 1.8 × 3.8 cm to 5.5 × 6.5 cm. Primary suture of the donor site was performed in all cases. Dissection of the muscular tissue was avoided. After the operation, venous crisis occurred in 1 case, and a partial area of necrosis developed at the distal end in 1 case. The flap survived in all other cases. CONCLUSIONS: Our experience showed that the SLSAP flap is suitable for reconstruction of moderate-sized hand defects.

Post Traumatic Reconstruction of the Pediatric Heel and Achilles Tendon: A Review of Pedicle Flap Options in 31 Motorcycle Spoke Trauma Patients.

Severe motorcycle spoke injuries of the heel lead to Achilles tendon defects, calcaneal tubercle exposure or loss, and overlying soft tissue defects, which are challenging to treat. Given the special physiological and developmental characteristics of children, severe spoke injuries of the heel in children are especially troublesome.We report details of 31 cases of severe motorcycle spoke injuries of the heel in children. The reconstruction timing depended on the time since injury, systematic conditions, and concurrent injuries. Eighteen cases were reconstructed at the time of emergency surgery, and 13 cases underwent delayed reconstruction. Appropriate flap transfer and Achilles tendon repair were conducted based on the defect size of the Achilles tendon, the main location of the soft tissue defect, and the distal residues of the Achilles tendon.Of the 31 cases, 16 cases were reconstructed with sliding gastrocnemius musculocutaneous flaps, 7 cases had saphenous neurocutaneous flaps, 4 cases had posterior tibial perforator flaps, 3 cases had sural neurocutaneous flaps, and 1 case was repaired with a peroneal artery perforator flap. All flaps healed uneventfully except for 3 cases of flap partial necrosis and 1 case of local infection of the Achilles tendon. During 6 months to 4 years of follow-up, dorsiflexion of the ankle was obviously limited at first but gradually recovered and enabled normal walking. However, due to the possibilities of calcaneal defects, epiphyseal injuries, and Achilles tendon problems, long-term follow-up is indicated.

The Role of the Distal Runoff Vessel of the Descending Branch of the Lateral Circumflex Femoral System in Anterolateral Thigh Flap Surgery: A Case Series and Literature Review.

BACKGROUND: As a distal portion of the descending branch of the lateral circumflex femoral system (LCFS), the role of the distal runoff vessel in anterolateral thigh (ALT) flap surgery has long been overlooked. Recently, however, the distal runoff vessel has been increasingly used in many aspects of ALT flap surgery, and it has exhibited superior properties in solving some difficult problems. METHODS: Fourteen ALT flaps using the distal runoff vessel of the descending branch of the LCFS for extremity defects were retrospectively reviewed, and recent reports on using the distal runoff vessel were reviewed to determine the role of this vessel in ALT flap surgery. RESULTS: In our series, the distal runoff vessel was used as a flow-through pattern in 10 cases, as a recombined chimeric flap in 2 cases, and as a backup vessel for flap salvage in 2 cases. All of the ALT flaps completely survived. None of the donor sites presented with additional morbidity as a result of harvesting the distal runoff vessel. In the literature review, the following are 5 other options for using the distal runoff vessel: in interposition artery and vein grafts, as the pedicle of the reverse-flow ALT flap, as the recipient vessel, to avoid twisting, and as a monitoring method. CONCLUSIONS: The distal runoff vessel of the descending branch of the LCFS could be used for many aspects of the ALT flap surgery, and this vessel plays an irreplaceable role in some difficult reconstruction surgeries.

Traumatic Forefoot Reconstructions With Free Perforator Flaps.

The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.

Implant-related infection in the tibia: surgical revision strategy with vancomycin cement.

The development of a deep wound infection in the presence of internal hardware presents a clinical dilemma. The purpose of the present study was to evaluate the treatment outcomes of vancomycin cement with other advances of surgical techniques for implant-related infection (IRI) in the tibia. This study included 217 consecutive patients who had sustained IRI of the tibia. Of them, 152 patients had soft tissue defects and the internal hardware was exposed. Repeated debridement and negative pressure assisted closure were used. All the infected internal hardware was removed. External fixations and flaps were used. Custom-made vancomycin cement was inserted into the dead space of the wounds and left in site for a month. The follow-up was from 12 months to 108 months, averaging 37.5 months. For all the 217 patients, the general osteomyelitis healing rate and bone union rate were 86.6% and 97.2%, respectively. This study shows high rates of healing of IRI in the tibia if the new advances of surgery could be effectively combined into the treatment strategy with vancomycin cement as an important treatment.

Open achilles tendon defects: a 12-year study on the injury mechanisms, reconstructions, and late complications.

BACKGROUND: Open injuries of the Achilles tendon, which can be complicated by skin and bone injuries, continue to be a great challenge for surgeons. This study aims to report our experience with treatment of open Achilles tendon defects, focusing on the injury mechanisms, soft tissue coverage and late complications. METHODS: A retrospective review was performed on 31 patients with open Achilles tendon defects between 1999 and 2011. The analyzed factors were injury mechanisms, surgeries, and long follow-up complications. The defect lengths of the Achilles tendons in the study ranged from 1 to 11 cm and the soft tissue defects ranged from 3 × 3 to 12 × 10 cm. Nine types of flaps were used for the coverage of concomitant skin defects. RESULTS: Motorcycle spoke injuries were the most common cause of injury. There was no complete flap loss or rerupture of the reconstructed Achilles tendon. At the latest follow-up, all limbs were preserved and all the patients had regained full walking abilities. The algorithm of one-stage reconstruction was established, according to the defect length of the Achilles tendon and the defect size of skin. Late complications included maximum dorsiflexion loss and failure of heel raising ability on the single reconstructed foot. CONCLUSION: Open Achilles tendon defects are characteristic of concurrent skin and bone injuries and the reconstruction protocols of the different tissues should not be separated.

Foot and ankle reconstruction: an experience on the use of 14 different flaps in 226 cases.

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety-four cases were combined with open fractures. One hundred and sixty-two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice.

Staphylococcal protein A, Panton-Valentine leukocidin and coagulase aggravate the bone loss and bone destruction in osteomyelitis.

BACKGROUND/AIMS: Osteomyelitis is a debilitating infectious disease of the bone which is predominantly caused by Staphylococcus aureus (S. aureus). The purpose of this study was to investigate the role of the S. aureus virulence factors, i.e. protein A (SpA), Panton-Valentine leukocidin (PVL) and coagulase (Coa) on osteomyelitis. METHODS: The effect of SpA, PVL and Coa on osteoblasts was studied through the following aspects including osteoblast proliferation, apoptosis, bone formation, bone mineralization and RANK-L expression. S. aureus overexpressing PVL, SpA or Coa was constructed and used to study the role of PVL, SpA and Coa, respectively. S. aureus silencing PVL, SpA or Coa was also constructed and used for reversing verification. Osteoblast proliferation was detected by MTT tetrazolium dye reduction assay. Apoptosis was determined by Annexin V-FITC staining. The levels of pro-caspase 3, cleaved-caspase 3, pro-caspase 9 and cleaved-caspase 9 were detected by western blot. Bone formation markers including collagen I, osteopontin and osteocalcin were detected by real time RT-PCR. Alkaline phosphatase activity was measured by adding p-nitrophenyl phosphate as a phosphatase substrate. Von kossa stain and alizarin red stain were applied for determining phosphate and calcium deposition, respectively. The RANK-L expression was tested by ELISA. RESULTS: PVL, SpA and Coa inhibited osteoblast proliferation, induced osteoblast apotosis, prohibited bone formation and mineralization and upregulated RANK-L expression. CONCLUSIONS: PVL, SpA and Coa play a critical role on bone loss and bone destruction of osteomyelitis.

The memory plate for four-corner fusion of scaphoid non-union advanced collapse.

The aim of this study was to evaluate the clinical outcomes of the memory plates for four-corner fusion (FCF) of scaphoid non-union advanced collapse (SNAC). From 2005-2010, 11 cases of SNAC received FCF with the memory plate designed by the authors. At an average follow-up of 21 months, there were no non-unions and postoperative infections. One patient complained of dorsal impingement. The pain relief rate was 100% and the average grip strength increased from 11.3% preoperatively to 56.3% postoperatively of the contralateral side. The primary results of FCF with memory plates are promising. By its compressive property, the memory plate facilitates the arthrodesis with a lower complication rate.

Traumatic spondyloptosis of L4.

STUDY DESIGN: Case report of 2 patients with traumatic L4-L5 spondyloptosis. OBJECTIVE: To report the diagnosis and treatment of the traumatic L4-L5 spondyloptosis. SUMMARY OF BACKGROUND DATA: Traumatic L4-L5 spondylolisthesis is even rarer than traumatic L5-S1 spondylolisthesis. No case of traumatic L4-L5 spondyloptosis (anterolisthesis of Grade V) has been reported. The injury mechanism and surgery management merit more studies. METHODS: Through the posterior approach, both of the 2 patients underwent the decompression and reduction with pedicle screws. One had the posterolateral fusion and the interbody fusion from L4-L5 whereas the other had the posterolateral fusion from L4-S1. RESULTS: Complete reduction and fusion were achieved. The neurologic symptoms improved after the surgery. At follow-ups of 1 year and 6.5 years, there was no further slippage of the vertebrae. They were satisfied with the treatment outcomes. CONCLUSION: Posterior decompression, reduction, internal fixation, and fusion is effective and dependable for traumatic L4-L5 spondyloptosis.

Medial approach for popliteal artery injuries.

OBJECTIVE: To evaluate the clinical application of the medial approach for repairing popliteal artery injuries. METHODS: From 2002 to 2008, 11 cases of popliteal artery injuries had been repaired via the medial approach. Of these cases, 8 had limb fractures, 1 had knee dislocation, and 2 had visceral injuries. Ten popliteal arteries were anastomosed directly while one was repaired with a great saphenous vein graft. RESULTS: The operation time ranged from 3 to 4 hours (averaging 3.6 hours). All the injured limbs survived. At the follow up, 8 legs recovered the full function, 2 had minor contracture, and 1 serious Volkmann's contracture without amputation. CONCLUSION: The medial approach for repair of the popliteal artery is effective, applicable, and more advantageous to the management of multi-injures.

Four-corner arthrodesis concentrator of Ni-Ti memory alloy for carpal collapse.

OBJECTIVE: To evaluate the treatment outcomes of a four-corner arthrodesis concentrator of Ni-Ti memory alloy for carpal collapse. METHODS: From August 2006 to November 2009, 13 patients with carpal collapse underwent scaphoid excision and four-corner (capitate, lunate, triquetrum and hamate) arthrodesis using a four-corner arthrodesis concentrator of Ni-Ti memory alloy. The mean follow-up time was 26.5 months (range, 7-38 months). Various wrist parameters, including the grip strength, range of wrist movements and degree of pain (visual analogue scales) were recorded and compared before and after surgery. RESULTS: The average fusion time was 2.3 months (range, 2-4 months). Neither non-union nor wound infection was found in any of the patients. By the sixth month postoperatively, the grip strength had reached an average of 32.49 ± 6.21 kg with a range of 22.3-39.7 kg, this being 80.8% of that found on the healthy side. The range of motion reached over 53.0% of that of the healthy side. Preoperatively and at 6 months postoperatively, the mean pain scores were (4.46 ± 1.27) and 1.31 ± 0.95, respectively, when resting (P < 0.05), and 7.00 ± 1.41 and 2.62 ± 1.26, respectively, when weight-bearing (P < 0.05). The mean value of the Krimmer wrist score was 79.2 (range, 64-84). The rate of excellent and fine results was 84.6% (11/13), being excellent in three cases, good in eight and fair in two. CONCLUSION: Four-corner arthrodesis using a four-corner arthrodesis concentrator of Ni-Ti memory alloy is an effective method for treating carpal collapse and preserving most wrist function.

Distal foot coverage with reverse dorsal pedal neurocutaneous flaps.

Various types of neurocutaneous flaps have been used for extremity reconstructions. However, the application of this technique to the dorsum of the foot has not been reported previously. The aim of this article is to evaluate the attempts and clinical results from dorsal pedal neurocutaneous flap procedures. Harvesting of these flaps included the medial, intermediate and lateral dorsal cutaneous nerves, the deep peroneal nerve and the nutrient arteries of these nerves. The vascular anatomy of these flaps was studied before the clinical usage of the procedure. From 2003 to 2008, 30 patients with skin defects and bone exposure of the dorsum of the distal foot were treated with 39 dorsal pedal neurocutaneous flaps in our centre. The flaps in this series ranged from 3.5 to 7.0 cm in width and 4.0 to 10.0 cm in length. Totally, 35 flaps healed uneventfully. One showed partial loss at the distal edge, and three survived entirely following continuous massage. The postoperative contour of the flaps was acceptable. The reverse dorsal pedal neurocutaneous flap has proved effective and convenient for coverage of minor- to medium-sized defects in the distal foot.

One-stage reconstruction of Achilles tendon and skin defects by the sliding gastrocnemius musculocutaneous flap without anastomosis.

BACKGROUND: Simultaneous defects of Achilles tendon and skin remain a big challenge for clinical surgeons. This article reviews the experience of a one-stage reconstruction of the defects. The sliding gastrocnemius musculocutaneous flap without anastomosis was used and the associated anatomy was studied. METHODS: Fourteen cases of Achilles tendon and skin defects have been treated by the V-Y advancement of the gastrocnemius musculocutaneous flap in our orthopedic center from 1993 to 2006. Results of the pedicle anatomy and the sliding distances of the flap are analyzed with different degrees of knees on 30 cadaver specimens. RESULTS: Twelve cases healed uneventfully. Two cases had partial necrosis on the distal portion of the flap. The follow-up of all the 14 cases ranged from 4 months to 12 years. There was no ankle stiffness, tendon rerupture, or walking inconvenience observed in their daily lives. During the surgery process, the sliding distance of the flap reached (9.2 +/- 0.9 cm) when the knee was flexed by 90 degrees. CONCLUSIONS: For one-stage reconstruction of Achilles tendon and skin defects, the sliding gastrocnemius musculocutaneous flap is advantageous in vascularity, function, and sensation without anastomosis. The harvest of the flap demands familiarity with the anatomy.

An anatomic study of vascularized fibular grafts.

OBJECTIVE: To study the applied anatomy of the vascular and muscular innervations related to vascularized fibular grafts. METHODS: Thirty-four cadaveric lower extremities were dissected for this study. The observations included fibular length, fibular nutrient artery, arcuate arteries, and innervation of fibular muscles. The fibulas were averagely divided into four segments and the locations of relevant vessels and nerves were ascertained. RESULTS: All specimens had 1 fibular nutrient artery and 4-9 arcuate arteries except 1 specimen which had only 1 arcuate artery. The fibular nutrient artery and the first three arcuate arteries were constantly located between the distal half of the 1/4 segment and 2/4 segment of the fibula. The muscular branch of the superficial peroneal nerve passed through the surface of the periosteum in the 2/4 segment of the fibula. CONCLUSIONS: The most proximal osteotomy point locates at the midpoint of the 1/4 segment by which it ensure the maximal potential for preserving the nutrient vessels. The muscular branch of the superficial peroneal nerve is fragile to injury at the 2/4 segment of the fibula.

Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect: the anatomic basis and clinical application.

OBJECTIVE: To study the anatomic basis of the bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing the composite Achilles tendon defect. METHODS: The pedicle anatomy of the bi-pedicled V-Y gastrocnemius myocutaneous flap was examined on 30 cadaver specimens. The sliding distances of the flap were measured at different knee flexion degrees. The bi-pedicled V-Y gastrocnemius myocutaneous flap was applied in 12 cases of Achilles tendon defect with simultaneous skin and soft tissue defect. RESULTS: The sural arteries could be classified into four types. After cutting off the gastrocnemius origin with a "Z-shaped" incision, the sliding distance of the flap reached (3.7+/-0.5) cm when the knee flexed 0 degree, (4.9+/-0.7)cm when the knee flexed 30 degree,(6.7+/-0.7) cm when the knee flexed 60 degree and (9.2+/-0.9) cm when the knee flexed 90 degree. All the defects healed. The patients recovered ambulation with satisfactory knee and ankle function. The follow-up was 4 months-12 years. CONCLUSIONS: Different sural artery types should be noticed during the harvest of the bi-pedicled-V-Y gastrocnemius myocutaneous flap. With 90 degree knee flexion, this flap is suitable for one-stage repair of composite Achilles tendon defect within 9.2 cm+/-0.9 cm.

Repair and reconstruction of severe leg injuries: retrospective review of eighty-five patients.

OBJECTIVE: To explore a good way of the reconstruction of severe tibial shaft fractures by using different flaps and external fixators. METHODS: Eighty-five patients of Type IIIC tibial shaft fractures with average age of 42.5 years were treated in our hospital from 1990 to 2005. Injuries were caused by motorcycle accidents in 66 patients, by machine accidents in 16 patients, and by stone bruise in 3 patients. The management procedures consisted of administration of antibiotics, serial debridment, bone grafting if needed, application of different flaps, such as free thoracoumbilical flaps, fasciocutaneous flaps, saphenous neurocutaneous vascular flaps, sural neurocutaneous vascular flaps and gastrocnemius muscular flaps, and different external fixations, for instance, half-ring fixators, unilateral axial dynamic fixators, AO fixators, Weifang fixators, and Hybrid fixators. The average follow up was 6.3 years. RESULTS: All flaps survived. Eighty-three cases had bone healed. The average bone healing time of different external fixations was 5.5 months in 47 cases with half-ring fixators, 9.2 months in 4 cases treated with unilateral axial dynamic fixators, 8.5 months in 6 cases with AO fixators, 10.7 months in 16 cases with Weifang fixators, and 7.8 months in 10 cases with assembly fixators. Except half-ring fixation, other fixations all needed necessary bone graft. Two cases treated with unilateral axial dynamic fixators had nonunion of bone and developed osteomyelitis. The wounds healed after the removal of the fixators and immobilization by plaster. The last follow up examination showed ankle and knee motion was normal and no pain was noted. CONCLUSIONS: The combination of half-ring external fixators with various flaps provides good results for Type IIIC tibial shaft fractures.

The first metatarsal web space: its applied anatomy and usage in tracing the first dorsal metatarsal artery in thumb reconstruction.

OBJECTIVE: To clarify the anatomical relationship of the structures in the first toe webbing space for better dissection of toes in thumb reconstruction. METHODS: The first dorsal metatarsal artery, the first deep transverse metatarsal ligament and the extensor expansion were observed on 42 adult cadaveric lower extremities. Clinically the method of tracing the first dorsal metatarsal artery around the space of the extensor expansion was used in 36 cases of thumb reconstruction. RESULTS: The distal segments of the first dorsal metatarsal artery of Gilbert types I and II were located superficially to the extensor expansion. The harvesting time of a toe was shortened from 90 minutes to 50 minutes with 100% survival of reconstructed fingers. CONCLUSIONS: The distal segment of the first dorsal metatarsal artery lies constantly at the superficial layer of the extensor expansion. Most of the first metatarsal arteries of Gilbert types I and II can be easily located via the combined sequential and reverse dissection around the space of the extensor expansion.