Vascularized fibula transfer for lower limb reconstruction.

Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.

Intramuscular hemangioma of the foot: A case report and review of the literature.

Intramuscular hemangiomas (IHs) are rare benign neoplasms usually seen in children, adolescents and young adults. Although lower extremities are the commonest localization, the localization at the foot is extremely rare since only a few cases have been reported. We report a case of mixed type IH of the flexor digitorum brevis muscle in a 12-year-old boy who was treated with surgical excision, with wide surgical margins.

Digit and hand replantation.

For the past 45 years, the advent of microsurgery has led to replantation of almost every amputated part such as distal phalanx, finger tip, etc. Replantation of digits and hand can restore not only circulation, but also function and cosmetic of the amputated part. The goals of replantation are to restore circulation and regain sufficient function and sensation of the amputated part. Strict selection criteria are necessary to optimize the functional result. The management of this type of injuries includes meticulous preoperative management, microsurgical experience and continuous postoperative care. Among various factors influencing the outcome, the most important are the type and the level of injury, ischemia time, history of diabetes, age, sex, and smoking history. During the replantation procedure, bone stabilization, tendon repair, arterial anastomoses, venous anastomoses, nerve coaptation, and skin coverage should be performed. All structures should be repaired primarily, unless a large nerve gap or a flexor tendon avulsion injury is present. Adequate postoperative evaluation is mandatory to avoid early or late complications. To improve functional results, many replantation patients may need further reconstructive surgery.

Pyomyositis in children: early diagnosis and treatment.

PURPOSE: This study was conducted to evaluate early diagnosis, clinical course, and treatment outcome in children with pyomyositis. METHODS: Between 2001 and 2006, 6 children with a mean age of 7.2 years were diagnosed and treated for pyomyositis in our clinic. The most common site of involvement was the hip and thigh region. All patients underwent early magnetic resonance imaging (MRI) examination that played a significant role in the early diagnosis and management of the disease. RESULTS: Staphylococcus aureus was the most common pathogen and was identified in 3 cases. Intravenous antibiotics were administered and were followed by oral agents for an additional period. The duration of therapy ranged from 3 to 6 weeks. No surgical intervention was needed. Magnetic resonance imaging was used to evaluate response to the therapy. CONCLUSIONS: Although pyomyositis is a rare disease, it should be considered in the differential diagnosis of immediate onset of musculoskeletal pain in children. Early diagnosis and antibiotic treatment are important as major complications such as abscess formation and sepsis can be avoided. Having a high sensitivity to reactive inflammatory changes, MRI is a valuable tool in the armamentarium of the clinician in early diagnosis of pyomyositis.

Can end-to-side neurorrhaphy bridge large defects? An experimental study in rats.

This study was undertaken to evaluate collateral sprouting capability in an end-to-side repair model with long regenerative distance. Forty-five rats were used and divided into four groups, according to the reparative procedure following peroneal nerve division: (A) "double" end-to-side neurorrhaphy with a regenerative distance of 0.6 cm; (B) "double" end-to-side neurorrhaphy with a regenerative distance of 1.2 cm; (C) end-to-end neurorrhaphy; and (D) nerve stumps buried into neighboring muscles. In all animals the contralateral healthy side served as a control. Functional assessment of nerve regeneration was performed at intervals up to 5 months using the Peroneal Function Index (PFI). Evaluation 150 days after surgery included peroneal and tibial nerve histologic and morphometric examination and wet weights of the tibialis anterior muscle. Functional evaluation and axonal counting data demonstrated that there was no statistically significant difference between groups A and B, or between groups A and C. There was no functional or histologic evidence of donor nerve deterioration. In conclusion, the present study confirms that "double" end-to-side neurorrhaphy may be useful for the repair of divided human nerves with long gaps.

Axonal regeneration stimulated by erythropoietin: an experimental study in rats.

The aim of the present study is to evaluate the effects of erythropoietin to the collateral sprouting by using systemically delivered erythropoietin in an end-to-side nerve repair model. Forty-five rats were evaluated in four groups: (A) end-to-side neurorrhaphy only, (B) end-to-side neurorrhaphy and erythropoietin administration, (C) end-to-end neurorrhaphy and (D) nerve stumps buried into neighboring muscles. In all animals, the contralateral healthy side served as control. Functional assessment of nerve regeneration was performed at intervals up to 5 months using the Peroneal Function Index. Evaluation 150 days after surgery included peroneal and tibial nerve morphometric examination, and wet weights of the tibialis anterior muscle. During the first three weeks after surgery, when erythropoietin was regularly administered, functional evaluation showed that erythropoietin may facilitate peripheral nerve regeneration. However, there was rapid deterioration in the functional recovery when erythropoietin's administration was discontinued. As a consequence, at the end of this study, erythropoietin failed to maintain its initial stimulating effect in axonal regeneration. The results of wet muscle weights revealed statistically significant differences between Groups A and C, and Group B. Furthermore, data on axonal counting showed significant difference between Groups A and C, and Group B. Erythropoietin appears to facilitate peripheral nerve regeneration at the initial phase of its administration. Further investigation will be necessary to optimise the conditions (dose, mode of administration) in order to maintain its effects.

Two-stage flexor tendon reconstruction in zone 2 of the hand in children.

Two-stage flexor tendon reconstruction (Hunter) is indicated in children with extensive adhesions in zone 2 of the hand, with some reservations concerning the patient's age and cooperation. Nine children (mean age 6.9 years) were treated with the modified Paneva-Holevich technique, which has advantages over the classic Hunter reconstructions. It involves an intrasynovial graft (FDS of the injured finger) that is anatomically stable and morphologically more appropriate compared with free grafts. The size of the silicone rod is precisely assessed in the first stage, the proximal tenorrhaphy has healed by the time the second stage is performed, and donor site morbidity is minimized. After a mean follow-up of 40.1 months, the mean total active motion was 196 degrees, and eight patients achieved a good or excellent result according to the Buck-Gramcko and the revised Strickland scale. Staged flexor tendon reconstruction is technically feasible even in very young children. Results in children are comparable to those achieved in adults.

Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.

PURPOSE: To evaluate the results of a modified Paneva-Holevich technique for flexor tendon reconstruction in zone II. METHODS: Twenty patients (22 digits) with poor prognosis injuries (Boyes grade 2-5) were reconstructed. The technique included placing a silicone rod and creating a loop between the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) in the first stage and reflecting the latter as a pedicled graft through the pseudosheath created around the silicone rod in the second stage. RESULTS: After a follow-up period of at least 1 year (mean, 50 mo) the rate of good and excellent results was 82% according to the Buck-Gramco scale and 73% using the modified Strickland scale. CONCLUSIONS: These results compare favorably with those using the classic (Hunter) 2-stage reconstructions with a silicone rod and a free tendon graft. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity, and a low rate of postreconstruction tendon ruptures and tenolysis.