Missed Monteggia fractures in children treated by open reduction of the radial head and corrective osteotomy of the ulna.

Missed Monteggia fractures in children may cause pain, deformity, decreased range of motion, neurological symptoms, and late arthritis of the elbow. Numerous surgical techniques have been advocated to reconstruct missed Monteggia lesions. The purpose of the present study were first to evaluate the clinical and radiographic outcomes after open reduction of the radial head and corrective osteotomy of the ulna, second to identify the factors associated with the preoperative radial notch/head appearance and the postoperative radiographic results. This study investigated the preoperative MRI presentation and the treatment of 29 patients who were diagnosed missed Monteggia fracture. Radiologic and clinical results of these patients were evaluated retrospectively, and the patient's and surgical factors related to preoperative radial notch/head appearance and the postoperative radiographic results were analyzed. Of the 29 patients, the average Kim elbow performance score at the last follow-up was 93.6, with 25 excellent, three good, one fair, and no poor results. 19 children had reduced radial heads, 8 had a subluxated radial head and 2 had dislocated radial heads at the last follow-up. The patient's gender and age had no significant influence on the appearance of radial notch/head and final radiographic results. However, the appearance of radial notch/head can significantly affect the final radiographic result (P < 0.001). The interval time was an important factor which related with the appearance of radial notch/head and final radiographic results (P < 0.001). Treating a missed Monteggia fracture by open reduction of the radial head and corrective osteotomy of the ulna is generally successful and preoperative MRI is meaningful for evaluation of the condition of the radial head and the radial notch which is related with the final radiographic result. The interval time from injury to operation exceeds 6 months, the risk of radial notch/head abnormality and radial head subluxation/re-dislocation after operation significantly increase.

Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Considerations and a Retrospective Study of a Clinical Series of 378 Flaps.

BACKGROUND: This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points. METHODS: Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups. RESULTS: The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively. CONCLUSION: True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.

Distally based perforator-plus sural fasciocutaneous flap for soft-tissue reconstruction of the distal lower leg, ankle, and foot: comparison between pediatric and adult patients.

There are no large series comparing the distally based perforator-plus sural fasciocutaneous flap used in pediatric and adult populations. The flaps were divided into two groups: the children (patient's age<14 years) group (n=53) and the adults (patient's age ≥ 18 years) group (n=148). We compared flap-viability-related complications and their potential risk factors. In the patients with at least 12-month postoperative follow-up, the reconstruction outcomes, donor-site morbidities, and transitory and permanent swelling of the affected lower limb were compared. Partial necrosis, marginal necrosis, and overall complication rates were 13.2, 3.8, and 17.0% in the pediatric group, and 12.2, 1.4, and 13.6% in the adult group, respectively; the differences were not statistically significant (p>0.05). Incidences of hypertrophic scar and pruritus at the donor site were significantly higher, while incidence of transitory swelling of the affected lower limb was significantly lower in the pediatric group. This flap in children is similar to that in adults in the reliability.

Anterograde-retrograde method for harvest of distally based sural fasciocutaneous flap: report of results from 154 patients.

Distally based sural fasciocutaneous flap is traditionally raised by the retrograde method. This article introduces the anterograde-retrograde method for harvest of the flap and describes our experience on altering the flap plan. A total of 159 flaps in 154 patients were elevated by the anterograde-retrograde approach that harvest of the flap began with exploring the peroneal artery perforators nearby the pivot point before the upper and bilateral edges of the flap were incised. Partial necrosis occurred in 16 (10.1%) flaps, and marginal necrosis developed in 10 flaps. Nine flaps were redesigned with adjusted pivot point and skin island. The anterograde-retrograde approach for harvest of the flap can accurately locate the perforator, readily adjust both the pivot point and skin island if necessary, and thus improve reliability of the flap. This approach is particularly applicable for elevation of the flap without preoperative localization of the perforators by means of the Doppler.

Influence of flap factors on partial necrosis of reverse sural artery flap: a study of 179 consecutive flaps.

BACKGROUND: Partial necrosis is a main complication of reverse sural artery flap. The purpose of this article is to evaluate effect of flap factors on partial necrosis in the flap. PATIENTS AND METHODS: We retrospectively reviewed data of 175 patients with 179 flaps used to reconstruct soft tissue defects in the distal lower leg, heel, and foot between April 2001 and April 2010. Posterior aspect of the lower leg was equally divided into nine zones. The flap factors were compared between the survival flaps and the partial-necrosis flaps. RESULTS: There were 141 flaps surviving completely; distal de-epithelialization and wound dehiscence developed in 12 flaps and 6 flaps, respectively; partial necrosis occurred in 20 (11.2%) flaps. Partial-necrosis rate was significantly higher in the flaps with top-edge locating in the upper 1/9 of the calf (32.3%, 10 of 31), in the flaps with length-width ratio (LWR) ≥5:1 (17.8%, 13 of 73), or in the flaps with width of skin island (width) ≥8 cm (15.2%, 16 of 105); it was significantly lower in the flaps with top-edge locating in the lower 7/9 of the calf (3.8%, 3 of 80). Seventeen (80.9%) of 21 flaps with LWR ≥6:1 survived, and the maximal LWR of completely survival flap was 7.00:1. CONCLUSION: Probability of partial necrosis occurring in reverse sural artery flap significantly increase when top-edge of the flap locates in the upper 1/9 of the calf, when LWR of the flap is 5:1 or more, or when width is 8 cm or more. The flap with top-edge locating lower 7/9 of the calf is safe and reliable.