[Repair of the soft tissue defects at legs with free tissue flap anastomosed with descendant branch of lateral femoral circumflex artery].

OBJECTIVE: To investigate the therapeutic effect of free tissue flap anastomosed with reverse descendant branch of lateral femoral circumflex artery for severe soft tissue defect at leg. METHODS: The severe soft tissue defect at leg, without any vessels for anastomosis of free tissue flap, was reconstructed with free tissue flap, which was anastomosed with proximal end of descendant branch of lateral femoral circumflex artery and great saphenous vein. From Oct. 2004 to Dec. 2009, 36 cases were treated with 15 cases of latissimus dorsi musculocutaneous flaps, 12 cases of anterolateral femoral flaps, and 9 cases of thoracoumbilicus flaps. RESULTS: All the 36 free flaps survived completely. The patients were followed up for 6 months to 2.5 years with good cosmetic results. CONCLUSIONS: It is effective and practical to repair the severe soft tissue defects at legs with the reverse descendant branch of lateral femoral circumflex artery to carry the free flaps.

[Clinical analysis of acute carpal tunnel syndrome after reduction of Colles' fracture in twenty-two patients].

OBJECTIVE: To investigate the etiology, diagnosis, and treatment of acute carpal tunnel syndrome (ACTS) after reduction of Colles' fracture. METHODS: Between December 2006 and June 2010, 22 patients with ACTS after reduction of Colles' fracture were treated with expectant treatment and surgical treatment. There were 9 males and 13 females with an average age of 46.2 years (range, 23-60 years). Fractures were caused by traffic accident in 9 cases, falling in 8 cases, falling from height in 2 cases, hitting in 2 cases, and crushing in 1 case. The mechanism of fracture was direct violence in 3 cases and indirect violence in 19 cases. According to Gartland & Werley classification, there were 2 cases of type I, 5 cases of type II, 14 cases of type III, and 1 case of type IV. Closed reduction was performed in 19 cases and open reduction and internal fixation (ORIF) in 3 cases. The average symptom time of ACTS after reduction of Colles' fracture was 11.6 hours (range, 1 hour 30 minutes to 48 hours) in patients undergoing closed reduction and was 24 hours in 1 patient and 2 weeks in 2 patients undergoing ORIF. Expectant treatment was performed first, the forearms were put in neutral position in closed reduction cases; if there was no relief of ACTS symptom 1 week later, the mixture of 1 mL glucocorticosteroid and 1 mL 2% lidocaine was injected into carpal tunnel once a week for 2 weeks. The mixture was injected into carpal tunnel directly once a week for 2 weeks in ORIF cases. In the patients who failed to expectant treatments, ORIF was performed. RESULTS: In 7 cases of type III that failed expectant treatment, ACTS symptoms were relief completely after ORIF. All the 22 patients were followed up 12 months on average (range, 8-18 months). The average time of complete disappearance of median nerve compression symptom was 11 days (range, 2-25 days). All the patients had normal finger motion, sensation, and opposition of thumb with no sensation of anaesthesia and pinprick. The results of Tinel test, Phalen test, and Reverse Phalen test were all negative. The X-ray film showed good fracture reduction and healing with an average healing time of 6 weeks (range, 3-14 weeks). According to GU Yudong's criteria for functional assessment, the results were excellent in 18 cases and good in 4 cases; the excellent and good rate was 100%. CONCLUSION: Malposition, displacement of fracture fragments, and ulnar deviation of the wrist after plaster immobilization are the most important risk factors for ACTS. Expectant treatments are recommended in patients with Colles' fracture of types I, II, and IV, but surgical treatment is the first choice for Colles' fracture of type III.

Treatment of a combination of volar soft tissue and proper digital nerve defects using the dorsal digital nerve island flap.

PURPOSE: A combination of volar soft tissue and proper digital nerve (PDN) defects in the middle and proximal phalanges can cause sensory loss of the finger pulp, which results in functional disability. This study reports treatment of these complex soft tissue defects using the dorsal digital nerve island flap (DDNIF) from the adjacent finger. METHODS: From May 2005 to October 2008, we used the DDNIF in 12 digits in 12 patients who had a combination of volar soft tissue and PDN defects in the middle phalanx, the distal third of the proximal phalanx, or both. The flaps ranged in size from 2.0 × 1.7 to 3.3 × 2.4 cm (mean, 2.8 × 1.9 cm). We reconstructed the PDN defect using the dorsal branch of the PDN graft harvested from the adjacent finger. The average length of the nerve grafts was 2.7 cm (range, 2.0-3.6 cm). Patient follow-up was 10 to 22 months, with a mean of 15 months. We evaluated sensibility of the pulp of the injured finger by moving and static 2-point discrimination. We measured the range of motion of the donor finger and compared the data with those of the opposite side. Hand appearance was assessed using the Michigan Hand Outcomes Questionnaire. We measured cold intolerance of the injured finger using the self-administered Cold Intolerance Severity Score questionnaire. RESULTS: All flaps survived completely. At the final follow-up, the mean values of moving and static 2-point discrimination were 5.4 and 7.2 mm in the pulps of the respective injured fingers. The range of motion of the donor finger was similar to that of the opposite side. The mean appearance score of the hands based on the Michigan Hand Outcomes Questionnaire was 18.5 (range, 17-20). All patients experienced mild finger cold intolerance. CONCLUSIONS: The DDNIF can be used to cover the combination of volar soft tissue and PDN defects, restoring sensation in the pulp of the adjacent finger. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of thumb tip degloving injury using the modified first dorsal metacarpal artery flap.

PURPOSE: This study reports repair of a thumb tip degloving injury using the modified first dorsal metacarpal artery (FDMA) flap, including both dorsal branches of the proper digital nerve (DBPDNs). METHODS: From May 2006 to February 2008, the modified FDMA flap was used in 11 thumbs in 11 patients. All patients suffered a degloving injury to the thumb tip, and 4 had associated bone loss ranging from 1 to 3 mm (mean, 2 mm) in length. The size of the soft tissue defects was 2.6 to 4.6 cm (mean, 3.5 cm) in length and 1.8 to 2.2 cm (mean, 2.0 cm) in width. The flaps ranged in size from 2.7 × 2.2 cm to 4.8 × 2.1 cm (mean, 3.6 × 2.1 cm). The mean pedicle length was 7.2 cm (range, 6.8-7.5 cm). Neurorrhaphy between the DBPDN and the proper digital nerve was performed in both sides in all cases. Patient follow-ups ranged from 26 to 47 months (mean, 32 mo). Sensibility of the reconstructed thumb was evaluated by static 2-point discrimination. The range of motion of the donor fingers was measured. The data were compared to those of the opposite sides. RESULTS: All flaps survived completely. At the final follow-up, the mean values of static 2-point discrimination were 5 mm (range, 4-8 mm) and 6 mm (range, 4-8 mm) on the radial and ulnar sides of the distal portion of the flap, respectively. The mean values of the radial and ulnar distal portions of the flaps reached 75% and 72% of those of the opposite sides. The mean range of motion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the donor fingers were 73°, 101°, and 70°, respectively. CONCLUSIONS: The modified FDMA flap, including both DBPDNs, is useful for restoration of sensation on the thumb tip and maintenance of adequate length of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Anatomical studies on low end-to-side anastomosis of median nerve and ulnar nerve in repair of Dejerine Klumpke type paralysis or high ulnar nerve injury].

OBJECTIVE: To investigate the anatomical evidence of low end-to-side anastomosis of median nerve and ulnar nerve in repair of Dejerine Klumpke type paralysis or high ulnar nerve injury. METHODS: Twelve formaldehyde anticorrosion specimens (24 sides) and 3 fresh specimens (6 sides) were observed. There were 9 males (18 sides) and 6 females (12 sides). The specimen dissected under the microscope. S-shape incision was made at palmar thenar approaching ulnar side, the profundus nervi ulnaris and superficial branch of ulnar nerve were separated through near end of incision, and the recurrent branch of median nerve and common digital nerve of the ring finger were separated through far end of incision. The distances from pisiform bone to the start point of the recurrent branch of median nerve, and to the start point of common digital nerve of the ring finger were measured. The width and thickness of the profundus nervi ulnaris and superficial branch of ulnar nerve, and the recurrent branch of median nerve and common digital nerve of the ring finger were measured, and the cross-sectional area was calculated. The number of nerve fiber was determined with HE staining and argentaffin staining. RESULTS: The cross-sectional area and the number of nerve fiber were (2.46 +/- 1.03) mm2 and 1305 +/- 239 for the profundus nervi ulnaris, (2.62 +/- 1.75) mm2 and 1634 +/- 343 for the recurrent branch of median nerve, (1.60 +/- 1.39) mm2 and 1201 +/- 235 for the superficial branch of ulnar nerve, and (2.19 +/- 0.89) mm2 and 1362 +/- 162 for the common digital nerve of the ring finger. There were no significant differences (P > 0.05) in the cross-sectional area and the number of nerve fiber between the profundus nervi ulnaris and the recurrent branch of median nerve, between the superficial branch of ulnar nerve and the common digital nerve of the ring finger; and two factors had a linear correlation (P < 0.05) with correlation coefficients of 0.68, 0.66 and 0.56, 0.36. The distances were (36.98 +/- 4.93) mm from pisiform bone to the start point of the recurrent branch of median nerve, and (28.35 +/- 6.63) mm to the start point of common digital nerve of the ring finger. CONCLUSION: Low end-to-side anastomosis of median nerve and ulnar nerve has perfect match in the cross-sectional area and the number of nerve fiber.

[Anatomic study on injury of simple deep branch of ulnar nerve].

OBJECTIVE: To provide anatomy evidence of the simple injury of the deep branch of the ulnar nerve for clinical diagnosis and treatments. METHODS: Fifteen fresh samples of voluntary intact amputated forearms with no deformity were observed anatomically, which were mutilated from the distal end of forearm. The midpoint of the forth palm fingerweb was defined as dot A, the midpoint of the hook of the hamate bone as dot B, the ulnar margin of the flexor digitorum superficialis of the little finger as OD, and the superficial branch of the ulnar nerve and the forth common finger digital nerve as OE, dot O was the vertex of the triangle, dot C was intersection point of a vertical line passing dot B toward OE; dot F was the intersection point of CB's extension line and OD. OCF formed a triangle. OCF and the deep branch of the ulnar nerve were observed. From May 2000 to June 2007, 3 cases were treated which were all simple injury of the deep branch of the ulnar nerve by glass, diagnosed through anatomical observations. The wounds were all located in the hypothenar muscles, and passed through the distal end of the hamate bone. Muscle power controlled by the ulnar nerve got lower. The double ends was sewed up in 2 cases directly intra operation, and the superficial branch of radial nerve grafted freely in the other 1 case. RESULTS: The distance between dot B and dot O was (19.20 +/- 1.30) mm. The length of BC was (7.80 +/- 1.35) mm. The morphia of OCF was various, and the route of profundus nervi ulnaris was various in OCF. OCF contains opponens canales mainly. The muscle branch of the hypothenar muscles all send out in front of the opponens canales. The wounds of these 3 cases were all located at the distal end of the hook of the hamate bone, intrinsic muscles controlled by the ulnar nerve except hypothenar muscles were restricted without sensory disorder or any other injuries. Three cases were followed up for 2 months to 4 years. Postoperation, the symptoms disappeared, holding power got well, patients' fingers were nimble. According to the trial standard of the function of the upper limb peripheral nerve established by Chinese Medical Surgery of the Hand Association, the synthetical evaluations were excellent. CONCLUSION: Simple injuries of the deep branch of the ulnar nerve are all located in OCF; it is not easy to be diagnosed at the early time because of the little wounds, the function of the hypothenar muscles in existence and the normal sense.

[Anatomic study on hook of hamate bone].

OBJECTIVE: To study the hook of hamate bone by anatomy and iconography methods in order to provide information for the clinical treatment of injuries to the hook of hamate bone and the deep branch of ulnar nerve. METHODS: Fifty-two upper limb specimens of adult corpses contributed voluntarily were collected, including 40 antisepticized old specimens and 12 fresh ones. The hook of hamate bone and its adjacent structure were observed. Twenty-four upper limbs selected randomly from specimens of corpses and 24 upper limbs from 12 healthy adults were investigated by computed tomography (CT) three-dimensional reconstruction, and then related data were measured. The measurement results of 24 specimens were analyzed statistically. RESULTS: The hook of hamate bone is an important component of ulnar carpal canal and carpal canal, and the deep branch of ulnar nerve is located closely in the inner front of the hook of hamate bone. The flexor tendons of the forth and the little fingers are in the innermost side, closely lie next to the outside of the hook of hamate bone. The hamate bone located between the capitate bone and the three-cornered bone with wedge-shaped. The medial-, lateral-, and front-sides are all facies articularis. The hook of hamate bone has an approximate shape of a flat plate. The position migrated from the body of the hamate bone, the middle of the hook and the enlargement of the top of the hook were given the names of "the basis of the hook", "the waist of the hook", and "the coronal of the hook", respectively. The short path of the basement are all longer than the short path of the waist. The long path of the top of the hook is the maximum length diameter of the hook of hamate bone, and is longer than the long path of the basement and the long path of the waist. The iconography shape and trait of the hook of hamate bone is similar to the anatomy result. There were no statistically significant differences (P > 0.05) between two methods in the seven parameters as follows: the long path of the basement of the hook, the short path of the basement of the hook, the long path of the waist of the hook, the short path of the waist of the hook, the long path of the top of the hook, the height of the hook, of hamate bone, and the distance between the top and the waist of the hook. CONCLUSION: The hook of hamate bone can be divided into three parts: the coronal part, the waist part, and the basal part; fracture of the hamate bone can be divided into fracture of the body, fracture of the hook, and fracture of the body and the hook. Fracture of the hook of hamate bone or fracture union can easily result in injure of the deep branch of ulnar nerve and the flexor tendons of the forth and the little fingers. The measurement results of CT three-dimensional reconstruction can be used as reference value directly in clinical treatments.

[Microsurgical treatment of arterial occlusion in lower extremity].

OBJECTIVE: To investigate the procedure and clinical effect of revascularization for arterial occlusion in lower extremity. METHODS: From July 1998 to March 2005, 29 cases of arterial occlusion were treated by microsurgery. Of 29 cases, there 22 males and 7 females, aging 22-86 years, including 9 cases of thromboangiitis obliterans (TAO), 17 cases of arterial sclerosis obstruction (ASO) and 3 cases of diabetic foot (DF). The location was the left in 17 cases, the right in 11 cases and both sides in 1 case. All cases were inspected by color-Doppler ultrasonic scanning before operation. The cases of ASO and DF were checked with MRA. The results of examinations showed that the locations of arteriostenosis and obstruction were: in 9 cases of TAO, the distal superficial femoral artery in 3 cases, popliteal artery in 5 cases, bilateral dorsal metatarsal artery in 1 case; in 17 cases of ASO, common iliac artery in 2 cases, external iliac artery in 4 cases, femoral artery in 10 cases and popliteal artery in 1 case; and were all superficial femoral artery in 3 cases of DF. DSA examination confirmed that there was appropriate outflow in 15 cases. Basing on the location and extent of the arterial occlusion, 11 cases were treated by the primary deep vein arterializing, 16 cases by arterial bypass distribution and 2 cases of extensive common iliac arterial occlusion were amputated in the level of 1/3 distal thigh. RESULTS: The postoperative duration of follow-up for all cases was 3 months to 7 years. In 9 cases of TAO, 2 healed by first intention after deterioration, 4 healed after changing dressing and 3 had fresh soft tissue growth after debrided superficial secondary necrosis. In 17 cases of ASO, 13 healed by first intention, 2 healed after changing dressing and 2 were amputated. In 3 cases of DF, 2 healed after changed dressing and debrided, 1 was aggravated with the second toe necrosis. CONCLUSION: Performing primary deep vein-arterialization and arterial bypass distribution is effective for treatment of arterial occlusion of lower extremity. The arterial reconstructive patency rate can be improved by microsurgical treatment.