Three-Dimensional Visualization for Extended Deep Inferior Epigastric Perforator Flaps.

PURPOSE: The aim of the study was to provide an applied and digital anatomical basis of acquiring extended deep inferior epigastric perforator (DIEP) flaps for clinical use. METHODS: Five formalin-soaked specimens were received red latex injection and dissected by layers. The arteriography using the modified mixture of lead oxide-gelatin was performed on 10 adult cadavers that were serially scanned by a spiral computed tomography. The DIEPs were 3 dimensionally reconstructed by Mimics. RESULTS: The medial row perforators of DIEP arteries are located in the medial 1/third of rectus abdominis muscle, and lateral row perforators in the lateral 1/third of the muscle. The perforators distribute mainly from the upper tendinous intersection of umbilicus to below umbilicus within 8.0 cm, especially 4.0 cm. There are constant diameter 0.8-mm perforators or greater accompanied with nerveswithin this region. The main perforators are shown by fast direct volume rendering (VR) reconstruction method, and 3-dimensional images of DIEPs are acquired by dynamic reconstruction (DR) method. Consecutively, the adjacent perforators can be combined freely and the position and anastomosis of extended branches can be easily observed. The extended DIEP flaps were designed by VR and DR methods. CONCLUSIONS: The DIEPs can obtain large extended perforator flaps accompanied with nerves. The perforator close to the umbilicus should be selected while designing the DIEP flap. The 3-dimensional model of extended DIEP flaps can be established conveniently and intuitively by VR and DR methods of Mimics.

Anatomical feasibility study of flexor hallucis longus transfer in treatment of Achilles tendon and posteromedial portal of ankle arthroscopy.

PURPOSE: The aim of this study was to evaluate the occurrence of anatomical variations of the musculotendinous junction of the flexor hallucis longus (FHL) muscle, the relationship between FHL tendon or muscle and the tibial neurovascular bundle at the level of the posterior ankle joint in human cadavers. METHODS: Seventy embalmed feet from 20 male and 15 female cadavers, the cadavers' mean age was 65.4 (range from 14 to 82) years, were dissected and anatomically classified to observe FHL muscle morphology define the relationship between FHL tendon or muscle and the tibial neurovascular bundle. The distance between the musculotendinous junction and the relationship between FHL tendon or muscle and the tibial neurovascular bundle was determined. RESULTS: Three morphology types of FHL muscle were identified: a long lateral and shorter medial muscle belly, which was observed in 63 specimens (90%); equal length medial and lateral muscle bellies, this variant was only observed in five specimens (7.1%); one lateral and no medial muscle belly, which was observed in two specimens (2.9%). No statistically significant difference was observed according to gender or side (p > 0.05). Two patterns were identified and described between FHL tendon or muscle and the tibial neurovascular bundle. Pattern 1, the distance between the neurovascular bundle and FHL tendon was 3.46 mm (range 2.34-8.84, SD = 2.12) which was observed in 66 specimens (94.3%); Pattern 2, there was no distance which was observed in four specimens (5.7%). CONCLUSION: Knowing FHL muscle morphology, variations provide new important insights into secure planning and execution of a FHL transfer for Achilles tendon defect as well as for the interpretation of ultrasound and magnetic resonance images. With posterior arthroscopic for the treatment of various ankle pathologies, posteromedial portal may be introduced into the posterior aspect of the ankle without gross injury to the tibial neurovascular structures because of the gap between the neurovascular bundle and FHL tendon.

Anatomical Study of the Neurovascular in Flexor Hallucis Longus Tendon Transfers.

The transfer of the flexor hallucis longus tendon or flexor digitorum longus tendon is frequently used for the treatment of posterior tibial tendon insufficiency or chronic Achilles tendinopathy. According to several anatomical studies, harvesting the flexor hallucis longus (FHL) tendon may cause nerve injury. Sixty-eight embalmed feet were dissected and anatomically classified to define the relationship between Henry's knot and the plantar nerves. Two different configurations were identified. In Pattern 1, which was observed in 64 specimens (94.1%), the distance between the medial plantar nerve and Henry's knot was 5.96 mm (range, 3.34 to 7.84, SD = 1.12). In Pattern 2, which was observed in 4 specimens (5.9%), there was no distance between the medial plantar nerve (MPN) and Henry's knot. No statistically significant difference was observed according to gender or side (p > 0.05). A retraction was performed to harvest the FHL through the posteromedial hindfoot incision using a single minimally invasive technique, and the medial and lateral plantar nerve lesions were scrupulously assessed. In conclusion, medial and lateral plantar nerve injuries did not occur more frequently, even after performing a single minimally invasive incision to harvest the FHL tendon, due to the large distance between the FHL tendon and the medial and lateral plantar nerves.

Epiphyseal Arterial Network and Inferior Retinacular Artery Seem Critical to Femoral Head Perfusion in Adults With Femoral Neck Fractures.

BACKGROUND: A better understanding of the blood supply of the femoral head is essential to guide therapeutic strategies for patients with femoral neck fractures. However, because of the limitations of conventional techniques, the precise distribution and characteristics of intraosseous arteries of the femoral head are not well displayed. QUESTIONS/PURPOSES: To explore the characteristics and interconnections of the intraosseous vessel system between different areas of the femoral head and the possible blood supply compensatory mechanism after femoral neck fracture. METHODS: The three-dimensional (3-D) structures of the intraosseous blood supply in 30 uninjured normal human femoral heads were reconstructed using angiography methods and microCT scans. The data were imported in the AMIRA® and MIMICS® software programs to reconstruct and quantify the extra- and intraosseous arteries (diameter, length). In a separate experiment, we evaluated the residual blood supply of femoral heads in 27 patients with femoral neck fractures before surgery by analyzing digital subtraction angiography data; during the study period, this was performed on all patients in whom hip-preserving surgery was planned, rather than arthroplasty. The number of affected and unaffected subjects included in the three groups (superior, inferior, and anterior retinacular arteries) with different types of fractures (Garden Types I-IV) were recorded and analyzed (Fisher's exact test) to reflect the affected degrees of these three groups of retinacular arteries in patients after femoral neck fractures. RESULTS: The main results of our cadaver study were: (1) the main blood supply sources of the femoral head were connected by three main network structures as a whole, and the epiphyseal arterial network is the most widely distributed and the primary network structure in the femoral head; (2) the main stems of the epiphyseal arteries which were located on the periphery of the intraosseous vascular system have fewer anastomoses than the network located in the central region; (3) compared with the round ligament artery and anterior retinacular artery, the inferior retinacular artery has a relatively large caliber. Digital subtraction angiography of the 27 patients with hip fractures indicated that the inferior retinacular arterial system had a high likelihood of being unaffected after femoral neck fracture (100% [14 of 14] in nondisplaced fractures and 60% [six of 10] in Garden Type III fractures). CONCLUSIONS: The epiphyseal arterial network and inferior retinacular arterial system appear to be two important structures for maintaining the femoral head blood supply after femoral neck fracture. Increased efforts to protect these key structures during surgery, such as drilling and placing internal implants closer to the central region of the femoral head, might be helpful to reduce the effect of iatrogenic injury of the intraosseous vascular system. CLINICAL RELEVANCE: 3-D anatomic evidence of intraosseous arterial distribution of the femoral head and the high frequency with which the inferior retinacular arteries remained patent after femoral neck fracture lead us to consider the necessity of drilling and placing internal implants closer to the central region of the femoral head during surgery. Future controlled studies might evaluate this proposition.

A method to quantify and visualize femoral head intraosseous arteries by micro-CT.

We describe a technique for perfusing a barium sulphate suspension into the intraosseous artery. Following the perfusion of abarium sulphate suspension into 14 fresh lower limbs of Chinese cadavers, micro-CT scanning was applied to digitize, quantify and visualize the intraosseous arteries in the human femoral heads. Then, the femoral heads were removed and subjected to micro-CT scanning. The data were imported into the amira and mimics programs to reconstruct and quantify the intraosseous arteries. The femoral head intraosseous artery lengths, areas, volumes, and femoral head bone volumes were quantified. The artery densities and artery ratios were calculated and analysed with independent-samples t-tests. The intraosseous vasculature volume renderings were displayed as screenshots and videos made with amira. Many intraosseous artery study technologies were compared. The barium sulphate suspension was milky white in colour. The perfusion of the barium sulphate suspension followed by micro-CT scanning provided a good representation of the intraosseous artery. The femoral head intraosseous artery lengths, areas and volumes, and the femoral head bone volumes were displayed as the X¯±S . No differences were observed between the left and right femoral head intraosseous arteries in terms of the artery densities or artery ratios. The volume renderings and 3-D orthogonal projections displayed the overall distributions of the intraosseous arteries. The videos clearly demonstrated the entry sites of the nutrition-carrying arteries, their courses and branches, and the intraosseous arterial anastomoses. Our technique is the simplest and least time-consuming method of producing accurate vascular three-dimensional reconstructions. The perfusion of a barium sulphate suspension into intraosseous arteries combined with micro-CT scanning can deliver high-resolution 3-D digitized data and images of intraosseous arteries. This technique does not require bone decalcification or bone dissection and thus significantly shortens the time required to quantify and display intraosseous arteries. This method provides a simple and rapid technique for quantifying and visualizing human intraosseous arteries.

Neglected Achilles Tendon Rupture Treated with Flexor Hallucis Longus transfer with two turndown gastrocnemius fascia flap and reinforced with plantaris tendon.

Neglected Achilles Tendon Ruptures are commonly seen by orthopaedic surgeons. In cases resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The senior -surgeon at our institution has utilized a technique -employing two turndown fascia flaps fashioned from the proximal Achilles tendon augmented by a tenomyodesis of the flexor hallucis longus and plantaris tendon. The purpose of this study was to assess the clinical outcome of all patients who underwent this procedure. The medical records of 10 cases that underwent this procedure were retrospectively reviewed. We completed data collection sets using the American Orthopaedic Foot and Ankle Society ankle-hind foot scores, isokinetic evaluation, and postoperative magnetic resonance imaging (MRI) at 1 year of follow-up. The mean American Orthopaedic Foot and Ankle Society ankle-hind foot scores improved from 64.4±3.54. Isokinetic testing at 30º/sec and 120º/sec revealed an mean deficits of 24.5%, respectively, in the plantar flexion peak torque of the involved ankle than non-involved ankle. The flexor hallucis longus tendon, gastrocnemius fascia flap and plantaris were well -integrated into the Achilles tendon forming a homogenous tendon, which was confirmed in MRI. Our subjective and objective data indicate that the reconstructive technique using flexor hallucis longus transfer with two turndown gastrocnemius fascia flaps and plantaris tendon is a good option for repairing large gap defect of Achilles tendon.

Treatment of the distal fracture in radioulna based on the volar wrist dual channel approach and postoperative X-ray diagnosis.

The fracture of the distal ulna and radius is a kind of fracture that results in high morbidity and occurrence rate and contributes to about one-sixth of the entire body's fracture. In this study, we implemented the improved palmar wrist surgery by a volar wrist dual channel approach. Between 2011 and 2014, we have treated 67 distal radius fracture patients. We divided them into two parts randomly, and treat them by the Carpometacarpal direct approach solution and dual wrist palmar surgical approach solution respectively. After the surgery, the differences in the incidence of median nerve irritation are significant (P < 0.01). With reference to the exposure time of fracture, the operation time and the pronator quadratus muscle repair rate, we find that the exposure time of fracture and the operation time in the dual wrist palmar surgical approach solution are much less than that as compared to the Carpometacarpal direct approach solution (P < 0.01). The improved dual wrist palmar surgical approach can lead to a successful treatment of the distal radius fractures volar distal radial ulnar by reducing the blind exposure problem. As such, the surgeon can complete treatment of fractures of the region under direct vision during operation. Furthermore, reducing the median nerve in the carpal tunnel and the structure of the stretch can decrease the incidence of postoperative complications. Postoperative X-ray diagnosis is then performed to examine the patients' recovery and assist in clinical follow-up. Our study proves that the volar wrist dual channel approach can be successfully achieved by a surface incision surgical implementation of the dual channel, and gives rise to a minimally invasive operation.

[The anatomy and clinical application of reverse saphenous nerve neurocutaneous flaps for reparing skin defects of forefoot].

OBJECTIVE: To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects of forefoot. METHODS: In the anatomic study, 50 cadaveric feet were injected with red latex and the anastomosis, distribution and external diameters of medialtarsal artery, medial anterior malleolus artery, medial plantar artery, the superficial branch of the medial basal hallucal artery and saphenousnerve nutritional vessels were observed. Based on anatomic research results, we designed the reverse saphenous nerve neurocutaneous flaps for repairing skin defects of forefoot. RESULTS: The blood supply of reverse saphenous nerve neurocutaneous flaps were based on the vasoganglion, which consist of arterial arch at the superior border of abductor hallucis and arterial network on the surface of abductor hallucis around the saphenous nerve and medial pedis flap. From Oct. 2006 to Oct. 2011, the reverse saphenous nerve neurocutaneous flaps were used to repair skin defects of forefoot in 11 cases. The flap size ranged from 2.5 cm x 3.5 cm to 7.5 cm x 8.5 cm. The wounds at donor site were covered with full-thickness skin graft. All flaps survived completely with no ulcer at the donor site. 11 cases were followed up for 6 to 18 months( mean, 10 months). The skin color and texture were satisfactory. The patients could walk very well. CONCLUSIONS: It is reliable to repair the skin defects of forefoot with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity. This flap should be considered as a preferential way to reconstruct skin defects of forefoot.

Minimally invasive technique for medial subtalar dislocation associated with navicular and entire posterior talar process fracture: a case report.

This is a case report of 31-year-old woman who sustained medial subtalar dislocation with navicular and entire posterior talar process fracture. After closed reduction of the subtalar dislocation, compute tomography (CT) demonstrated that the talus fracture involved the entire posterior process and navicular. The fracture of the talus was fixed with a cannulated screw and the navicular was held with two K-wires to the main body using with a minimally invasive approach. Follow-up revealed that the functional and radiographic results were graded as good.

[The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction to treat severe hallux valgus].

OBJECTIVE: To explore the method of the treatment for hallux valgus with the proximal crescentic osteotomy of the first metatarsal bone, combining with distal lateral soft tissue release. METHODS: From January 2008 to December 2012, 21 cases 21 hallux valgus feet were treated by operative procedure, included 1 male (1 foot) and 20 females (20 feet), with the mean age of 52 years (range, 36-68 years). Among all patients were followed up for 12 to 26 months, with the mean 16 months. The preoperative, post-operative and final follow-up X-ray films of all patients were collected. The hallux valgus angle, intermetatarsal angle and distal metatarsal articular angle were measured and analyzed. The surgical outcome was evaluated combined with the AOFAS score. RESULTS: The average hallux valgus angle decreased from 42.3° ± 1.8° preoperatively to 14.5° ± 1.8 postoperatively, the average intermetatarsal angle did from 21.9° ± 1.7 to 9.1° ± 1.8°, and the average distal metatarsal articular angle did from 14.9° ± 1.8 to 7.2° ± 1.5, respectively. There were significant differences between the preoperative and postoperative roentgenographic index. AOFAS score was improved from 44.0 ± 1.8 preoperatively to 83.9 ± 2.2 at the final follow-up. CONCLUSIONS: The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction obtained satisfactory results in severe hallux valgus patients with big intermetatarsal angle.

Anatomical study for flexor hallucis longus tendon transfer in treatment of Achilles tendinopathy.

PURPOSE: The purpose of the study was to describe the anatomical variations of the connection between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons in the knot of Henry in Asians, and quantify the length of FHL tendon graft with different incisions. METHODS: Sixty-four embalmed feet of 32 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. Single incision technique graft length was measured from the musculotendinous junction of FHL and the point at sustentaculum tali. Double incision technique was measured from musculotendinous junction of FHL and the level of the master knot of Henry. Additionally, minimally invasive incision technique was measured from musculotendinous junction of FHL to the first interphalangeal joint. These three techniques were then combined to determine the total potential tendon graft length obtainable using different approach. RESULTS: Only two different configurations were found. Type 1, a tendinous slip branched from the FHL to the FDL (62 of 64 feet). Type 2, a slip branched from the FHL to the FDL and another slip from the FDL to FHL (2 of 64). The average length of the FHL graft available from a single incision measured 5.08 cm (range 3.32-10.35, SD = 1.09), double incision technique measured 6.72 cm (range 4.69-12.09, SD = 1.03), and minimally invasive incision measured 17.49 cm (range 13.51-20.52, SD = 1.80). The difference between the lengths obtained from these three techniques was statistically significant (p < 0.001). CONCLUSION: The absence of no attachment and FDL tendon to the FHL between the two tendons in the foot may be more frequent than previously reported. Only two configurations of the anatomical relationship were found in this study. In over 96 % of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.

T cells promote the regeneration of neural precursor cells in the hippocampus of Alzheimer's disease mice.

Alzheimer's disease is closely associated with disorders of neurogenesis in the brain, and growing evidence supports the involvement of immunological mechanisms in the development of the disease. However, at present, the role of T cells in neuronal regeneration in the brain is unknown. We injected amyloid-beta 1-42 peptide into the hippocampus of six BALB/c wild-type mice and six BALB/c-nude mice with T-cell immunodeficiency to establish an animal model of Alzheimer's disease. A further six mice of each genotype were injected with same volume of normal saline. Immunohistochemistry revealed that the number of regenerated neural progenitor cells in the hippocampus of BALB/c wild-type mice was significantly higher than that in BALB/c-nude mice. Quantitative fluorescence PCR assay showed that the expression levels of peripheral T cell-associated cytokines (interleukin-2, interferon-γ) and hippocampal microglia-related cytokines (interleukin-1ß, tumor necrosis factor-α) correlated with the number of regenerated neural progenitor cells in the hippocampus. These results indicate that T cells promote hippocampal neurogenesis in Alzheimer's disease and T-cell immunodeficiency restricts neuronal regeneration in the hippocampus. The mechanism underlying the promotion of neuronal regeneration by T cells is mediated by an increased expression of peripheral T cells and central microglial cytokines in Alzheimer's disease mice. Our findings provide an experimental basis for understanding the role of T cells in Alzheimer's disease.

Reconstruction of the distal ulnar epiphysis with vascularized proximal fibula including epiphysis in children after osteochondroma resection: report of two cases.

BACKGROUND: Osteochondromas, especially multiple hereditary osteochondromas, usually cause various deformities of the joints. The authors sometimes find ulnar shortening and acquired wrist varus deformity in distal ulnar osteochondromas and even radial head dislocation resulting in ulnar shortening. In this study, the authors present the clinical outcomes of distal ulnar epiphysis reconstruction in two children using vascularized proximal fibula including the epiphysis after osteochondroma resection. METHODS: The authors used vascularized proximal fibula including the epiphysis as a substitute to reconstruct the distal ulnar epiphysis after osteochondroma resection and investigated the clinical outcome in two patients (aged 4 and 9 years). RESULTS: The wrist deformity was corrected successfully for both cases. Bone union between fibular grafts and hosts was found 2 months postoperatively. The reconstructed distal ulna and contralateral limbs were growing almost simultaneously. The morphology and function were also satisfactory at 1- and 8-year follow-up, respectively. CONCLUSIONS: It is possible to reconstruct the distal ulna after osteochondroma resection and simultaneously keep the ulna in longitudinal growth by using vascularized proximal fibula including the epiphysis in children. However, the growth plate in the reconstructed distal ulnar epiphysis might be prematurely closed approximately 8 years after reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Modified classification and single-stage microsurgical repair of posttraumatic infected massive bone defects in lower extremities.

Posttraumatic infected massive bone defects in lower extremities are difficult to repair because they frequently exhibit massive bone and/or soft tissue defects, serious bone infection, and excessive scar proliferation. This study aimed to determine whether these defects could be classified and repaired at a single stage. A total of 51 cases of posttraumatic infected massive bone defect in lower extremity were included in this study. They were classified into four types on the basis of the conditions of the bone defects, soft tissue defects, and injured limb length, including Type A (without soft tissue defects), Type B (with soft tissue defects of 10 × 20 cm or less), Type C (with soft tissue defects of 10 × 20 cm or more), and Type D (with the limb shortening of 3 cm or more). Four types of single-stage microsurgical repair protocols were planned accordingly and implemented respectively. These protocols included the following: Protocol A, where vascularized fibular graft was implemented for Type A; Protocol B, where vascularized fibular osteoseptocutaneous graft was implemented for Type B; Protocol C, where vascularized fibular graft and anterior lateral thigh flap were used for Type C; and Protocol D, where limb lengthening and Protocols A, B, or C were used for Type D. There were 12, 33, 4, and 2 cases of Types A, B, C, and D, respectively, according to this classification. During the surgery, three cases of planned Protocol B had to be shifted into Protocol C; however, all microsurgical repairs were completed. With reference to Johner-Wruhs evaluation method, the total percentage of excellent and good results was 82.35% after 6 to 41 months of follow-up. It was concluded that posttraumatic massive bone defects could be accurately classified into four types on the basis of the conditions of bone defects, soft tissue coverage, and injured limb length, and successfully repaired with the single-stage repair protocols after thorough debridement.

Anatomic study of selective neurectomy of gastrocnemius muscle for calf reduction in Chinese.

BACKGROUND: Selective neurectomy of the innervating nerves of the gastrocnemius muscle is a popular method employed for calf reduction. However, accidental injury to the untargeted adjacent nerves could happen. This study aims to provide detailed morphometry of the motor branches from the tibial nerve innervating the gastrocnemius muscle, the soleus and the medial sural cutaneous nerve in the popliteal fossa. METHODS: 23 lower legs from female cadavers were dissected to explore the origin, length of and the spatial relationship between the four branches given off from the tibial nerve in the popliteal fossa. RESULTS: Our study showed there were seven origin patterns existing among the four nerve branches; the origin of the branches to the medial and lateral heads of the gastrocnemius muscle was located ranging from -16 mm to 22 mm away from the midpoint of the line between the lateral and medial condyles of the femur; In 95% of the specimens, the location of the origin of the nerve branch to the medial head was proximal to its lateral counterpart. The nerve to the medial head was often given off from the medial aspect or the posteromedial aspect of the tibial nerve, while the other three often from the lateral aspect. CONCLUSIONS: A variety of origin patterns among the nerves to the lateral and medial gastrocnemius muscle, the nerve to the soleus muscle and the sural cutaneous nerve exist, necessitating the formulation of diversifying surgical strategies preoperatively and the meticulous and sequential dissection intra-operatively to ensure the lowest level of accidental injury.

Tension band wire fixation for anterior cruciate ligament avulsion fracture: biomechanical comparison of four fixation techniques.

PURPOSE: The purpose of this study is to design a new fixation method to treat tibial eminence fractures and assess its stability compared with conventional fixation methods. METHODS: Eighty fresh porcine knees were stripped of all soft tissue, leaving intact only the femur-anterior cruciate ligament (ACL)-tibia complex. A standardized type III fracture was simulated at the anterior cruciate ligament attachment region using an osteotome. Then, the 80 specimens were randomly divided into 4 groups consisting of 20 knees each. The bony fragments were, respectively, fixed with sutures, steel wire, screws, and the newly designed tension band wire. All specimens were subsequently tested on a Material Testing Machine at a load rate of 60 mm/min. The statistically significant difference between the methods in terms of ultimate failure load, yield load, and displacement of the fragment under single-cycle loading and cyclic loading were analysed. RESULTS: Steel wire encircling K-wire fixation showed significantly higher maximum loads, yield loads, and less displacement than all the other fixation methods tested. Specimens fixed with steel wire had the second highest maximal load followed by fixation with the cannulated screw. The lowest maximal load was observed in the group using PDS II suture. CONCLUSIONS: The ultimate strength of tension band wire fixation of tibial eminence fractures in these specimens was significantly greater than those of the other three fixation methods. Tension band wire fixation of eminence fractures appears to provide biomechanical advantages over the other three fixation methods; hence, it is a practical alternative to conventional fixation techniques.

Structure of the brachial plexus root and adjacent regions displayed by ultrasound imaging.

Brachial plexuses of 110 healthy volunteers were examined using high resolution color Doppler ultrasound. Ultrasonic characteristics and anatomic variation in the intervertebral foramen, interscalene, supraclavicular and infraclavicular, as well as the axillary brachial plexus were investigated. Results confirmed that the normal brachial plexus on cross section exhibited round or elliptic hypoechoic texture. Longitudinal section imaging showed many parallel linear hypo-moderate echoes, with hypo-echo. The transverse processes of the seventh cervical vertebra, the scalene space, the subclavian artery and the deep cervical artery are important markers in an examination. The display rates for the interscalene, and supraclavicular and axillary brachial plexuses were 100% each, while that for the infraclavicular brachial plexus was 97%. The region where the normal brachial plexus root traversed the intervertebral foramen exhibited a regular hypo-echo. The display rate for the C5-7 nerve roots was 100%, while those for C8 and T1 were 83% and 68%, respectively. A total of 20 of the 110 subjects underwent cervical CT scan. High-frequency ultrasound can clearly display the outline of the transverse processes of the vertebrae, which were consistent with CT results. These results indicate that high-frequency ultrasound provides a new method for observing the morphology of the brachial plexus. The C7 vertebra is a marker for identifying the position of brachial plexus nerve roots.

[Development and current status of perforator flaps].

OBJECTIVE: To provide a comprehensive review for development and existing problems of the perforator flaps. METHODS: The related home and abroad literature concerning perforator flaps was extensively reviewed. RESULTS: The perforator flaps are defined as the axial flaps nourished solely by small cutaneous perforating vessels (perforating arteries and veins), which are exclusively composed of skin and subcutaneous fat. The perforator flaps have the advantages as follows: less injury at donor site, less damage to the contour of the donor site, good reconstruction and appearance of the recipient site flexible design, and short time of postoperative recovery, which have been widely used in reconstructive surgery. CONCLUSION: The perforator flaps are the new development of the microsurgery, which usher an era of small axial flaps; However, the controversies of the definition, vascular classification, the nomenclature, and the clinical application of the perforator flaps still exist, which are therefore the hot spot for future study.

Novel patient-specific navigational template for total knee arthroplasty.

Current techniques for total knee arthroplasty have certain drawbacks, including violation of the intramedullary canals and limited accuracy. The aim of this research was to develop and validate the accuracy of a new computer-assisted preoperative planning concept for the creation of patient-specific navigational templates to replace conventional instruments. Volumetric computerized tomography (CT) scanning was performed on 30 cadaveric knees, and a three-dimensional reconstruction model of each knee was generated from the scan data. Using a reverse-engineering technique, optimal lower-limb alignment and rotational alignment were determined. A navigational template was also designed with a surface that matched the distal femur and proximal tibia. This template, with its corresponding femur and tibia, was manufactured using a rapid-prototyping technique and tested for violations. The navigational template was then used intraoperatively to assist with an arthroplasty in each of the 30 cadaveric knees. Following surgery, the positions of the prostheses were evaluated with X-rays and CT scans. The method showed a high degree of accuracy and reproducibility. In all cases, placing the template manually on the lamina of the femur and tibia was relatively easy. Twenty-eight prostheses were considered to be positioned entirely accurately, whereas two prostheses were considered to have a 1-2° malpositioning. This study thus introduces a novel navigational template for total knee arthroplasty. Preliminary cadaveric trials have demonstrated that this design can improve the accuracy of osteotomy in the surgical procedure.

Vasculature at the medial aspect of the foot and clinical application of flaps based on it for forefoot reconstruction.

BACKGROUND: Detailed knowledge of the vasculature of the medial aspect of the foot has rarely been reported, but it is of tremendous importance for harvesting the flap in this area to cover defects of the foot and hand. Repair of soft-tissue defects at the dorsal forefoot remains a challenge in reconstructive surgery. The authors describe the use of the distally based saphenous neurovenofasciocutaneous flap at the medial aspect of the foot to cover this region. METHODS: This study was divided into two parts: an anatomical study and clinical application. In the anatomical study, 35 cadaveric feet were injected with red gelatin, five others were made as corrosive vascular casts, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, six cases of soft-tissue defects at the dorsal forefoot were reconstructed with distally based saphenous neurovenofasciocutaneous flaps. RESULTS: The anatomical study showed that (1) the vasculature pattern could roughly be classified into three types and (2) there were constant anastomoses between the above-mentioned arteries around the midpoint of the first metatarsal bone. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSIONS: The blood supply to the medial aspect of the foot has multiple origins, on the basis of which of several flaps can be harvested, either a pedicled or free. Of particular clinical significance is the distally based saphenous neurovenofasciocutaneous flap, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap should be considered as a preferential way to reconstruct soft-tissue defects of the dorsal forefoot.