A neglected problem in the utilization of free anterolateral thigh flap toward reconstructing complicated wounds of extremities: the obliteration of deep dead space.

BACKGROUND: Deep dead space may be thought as an independent risk factor of the poor infection control after flap reconstruction in complex limb wounds. But it can be easily neglected. The conventional skin flap and musculocutaneous flap are difficult to obliterate the deep dead space in irregular shape effectively. It was investigated that the clinical application of chimeric anterolateral thigh perforator flap in the treatment of complex wounds complicated with deep dead space of the extremities in the paper. METHODS: Fifty-six cases complicated with deep dead space wounds were registered in group. Following thorough debridement and treatment with VSD, the granulation tissues grew with well-controlled infection. And then the chimeric anterolateral thigh perforator flap was used to obliterate the deep dead space and repair the wounds. The postoperative flap survival and infection conditions were evaluated. RESULTS: Overall, the infection was effectively controlled, without persistent exudation or sinus tract formation after wound healing. While 5 cases lost to follow-up, the remaining 51 cases were followed up until 15 months on average. Generally, the affected extremities recovered satisfactorily with normal appearances and texture of the flaps, along with normal functions. Importantly, no recurrence of infection was observed. CONCLUSION: During the grafting of chimeric perforator flap pedicled with lateral thigh muscle flap, the muscle flap is recommended to obliterate the deep dead space while the skin flap is being used to cover the wound. The combination of these two technologies performed well in the repair and reconstruction of the complex wounds of the extremities, possessing potential for broader clinical application.

Reconstruction of shoulder abduction by multiple nerve fascicle transfer through posterior approach.

PURPOSE: To evaluate the feasibility and clinical efficacy of multiple nerve fascicle transfer through posterior approach for reconstruction of shoulder abduction in patients with C5 or upper brachial plexus injury. METHODS: 11 patients (aged between 17 and 56 years) with dysfunction of shoulder abduction post C5 or upper brachial plexus injury were recruited in this study. Among them, four out of 11 patients also had dysfunction of elbow flexion simultaneously. The duration from injury to the surgery ranged from 4 to 12 months, with an average of 6.7 months. The affected shoulder joints showed abduction, extension and elevation dysfunction, but the muscle strength of shoulder shrugging and elbow extension was graded to M4 or higher. Accessory nerve was transferred to the suprascapular nerve and triceps muscle was branched to the axillary nerve through posterior approach. Ulnar fascicle was transferred to the motor branches of biceps for the 4 patients involved with elbow flexion dysfunction. RESULTS: Ten out of 11 cases were followed-up for 15-36 months. Neo-potential of deltoid and supraspinatus/infraspinatus was documented at 4-5 months post surgery. Shoulder abduction (and elbow flexion) was reanimated at 4-8 months post surgery. Significant improvement was observed at 15-36 months post surgery, shoulder abduction regained to 40-160° (mean: 92.5°), muscle strength of supraspinatus/infraspinatus and deltoid were graded to M3-M5 (mean: 4.0 and 4.1); 3 cases muscle strength of elbow flexion was graded from M4 to M5- (mean: 4.4) with 1 case loss. Shoulder shrugging of trapezius was graded to M5 in 5 cases, M5- in 2 cases, M4 in 2 cases and M3 in 1 case (mean: 4.5). All cases showed normal elbow extension and muscle strength of triceps (M5). CONCLUSION: It is feasible to carry out multiple nerve fascicle transfers for early reconstruction of shoulder abduction by posterior approach. Patients who received this procedure achieved good functional recovery and their donor site morbidity/injury was minimal.

[Establishment of a goat model of tibial bone hole defect suitable for repair using injectable bone materials].

OBJECTIVE: To prepare a goat model of tibial bone hole defect suitable for studies of bone defect repair using tissue-engineered injectable bone materials. METHODS: A circular hole bone defect 1.2 cm in diameter was induced below the tibial medial plateau of the goat. X-ray, histological inspection, and image analysis were carried out to evaluate the validity of the model in simulating limb bone defect for the study of tissue-engineered injectable bone materials. RESULTS: At 4 and 8 weeks after the operation, neither X-ray nor histological examination showed obvious bone tissues in the bone defect. Image analysis showed a area of new bone tissue formation of (8.79 - or + 3.63)% in the total defect area at 4 weeks, which increased to (15.41 - or + 4.21)% at 8 weeks. CONCLUSION: The goat model of tibial bone hole defect established in this study is suitable for studying the ability of injectable bone materials for repairing limb bone defect, and offers a simple and reliable means to simulate the local condition of bone regeneration and mechanical environment of bone defect in the limbs.

[Design and preliminary clinical application of a new digitalized navigation template for fixation of the inferior tibiofibular joint].

OBJECTIVE: To design and prepare a new digitalized navigation template for fixation of inferior tibiofibular joint using three-dimensional reconstruction and reverse engineering techniques. METHODS: Five patients with inferior tibiofibular joint rupture without fibula fracture underwent three-dimensional CT scanning of the lower limbs. The image data were transferred into Mimics software, and after reconstruction of the three-dimensional models of inferior tibiofibular joint rupture and saving in .stl format, the three-dimensional models were imported into Imageware10.0 software to determine the three-dimensional plane of reference. The location of the optimal pedicle channel was defined using reverse engineering and AO internal fixation principle. The template was designed according to the anatomic features of the fibular surface, and the optimal pedicle channel and the template were overlapped as the navigational template, which was manufactured by rapid prototyping. The inferior tibiofibular joint was reduced and the template was placed distally on the external fibula, and the location for screw insertion was defined by the navigation template. RESULTS AND CONCLUSION: The digitalized model of the inferior tibiofibular joint was established. The navigation template manufactured offered good compatibility and was applied successfully for fixation of the inferior tibiofibular joint. This approach provides a new means for fixation of ruptured inferior tibiofibular joint using the reverse engineering and digitized 3-dimensional reconstruction techniques.

Monitoring of T lymphocyte subset during ATG induction therapy in hand allograft with report of 3 cases.

OBJECTIVE: To investigate the significance of T lymphocyte subset determination during antithymocyte globulin (ATG) induction therapy in reducing the total drug dose, incidence of complications and cost of treatment in hand allograft. METHODS: The changes in peripheral blood T lymphocyte subsets (CD3+, CD4+, CD8+, and CD28) were determined by flow cytometry in 3 cases of hand allograft who received ATG treatment. RESULTS: Flow cytometry showed that the percentages of CD3+, CD4+, and CD8+ T lymphocytes, along with the ratio of CD4/CD8, decreased significantly during ATG induction therapy, and the results were consistent in the 3 cases. Long-term continuous changes of peripheral blood lymphocytes were observed after antithymocyte globulin induction therapy. CONCLUSION: The understanding of the immunological state of the patient with hand allograft after ATG induction therapy by monitoring T lymphocyte subsets may allow adjustment of the total dose of the drugs administered and help prevent the occurrence of complications.