Use of Three-Column Reconstruction and Free Vascularized Fibular Grafts for the Repair of Large Tibial Defects after Tumor Resection.

Background: This study aimed to evaluate the clinical outcomes of three-column reconstruction of the lower leg using a single-barrel contralateral vascularized fibular graft (VFG), medial locking plate, and the ipsilateral fibula for the repair of large tibial defects after tumor resection. Methods: In this retrospective study, we reviewed 12 patients who underwent three-column reconstruction using a single-barrel contralateral VFG, medial locking plate, and the ipsilateral fibula between June 1996 and May 2020. These patients had large tibial bone defects following tumor resection. The mean age of the patients was 26.3 years (range, 11-63 years), and 7 of them were women. The mean follow-up period was 104.8 months (range, 26-284 months). The mean size of the tibial bone defect after tumor resection was 17.8 cm (range, 11-26.8 cm). The clinical and radiological outcomes were evaluated at the final follow-up. Results: All patients survived beyond the final follow-up without recurrence of the primary bone tumor. The mean time from reconstruction to bony union at both host-graft junctions was 12.9 months (range, 4-36 months). The mean Musculoskeletal Tumor Society score was 82.3% (range, 60%-97%). All tibial defects were reconstructed with adequate bone healing. There were 4 cases of stress fracture and graft failure; these were resolved by using longer plates and more screws. All patients were ambulatory without assistance and showed no permanent complications. Conclusions: Large tibial defects that occur after tumoral resection can be effectively reconstructed by three-column reconstruction using a medial locking plate, an inlay single-barrel VFG harvested from the contralateral side, and the intact ipsilateral fibula. This technique permits early weight-bearing before fibular hypertrophy and bony union.

Resident Education on the Surgical Treatment of Distal Radius Fractures Using a Point-of-View Camera.

Background: In the coronavirus disease 2019 (COVID-19) era, surgical resident education depends largely on virtual materials. With the help of point-of-view (POV) cameras, educational videos have become widely used for surgical training. A video recorded from the surgeon's POV helps demonstrate the procedure. We made training movies of the surgical approach to distal radius fractures for residents using a head-mounted video recording system with a laser point targeting device (LPTD). Methods: A 15-minnute movie of the trans-flexor carpi radialis approach for distal radius fractures was made. A POV camera was assembled with an LPTD and strapped on the surgeon's head. This enabled maintenance of the surgical field while recording the procedure. A shorter version of the clip was also made to investigate trainee preference. We asked 24 trainees to watch the two versions of the video and complete a short questionnaire. Results: All trainees felt that the movie made with a POV camera was more efficient than existing materials. Only 1 (4.2%) felt that the laser pointer hindered the view. Four of the 23 trainees (16.7%) felt dizzy while watching the video. Of the two versions, 16 trainees (66.7%) preferred the shorter, edited version. The average score for the video was 8.42 out of 10. Conclusions: A video recording system in the operating room that uses an LPTD-POV camera is an efficient way to produce educational material, particularly for surgical residents during the COVID-19 era.

Reconstruction of Small-Sized Complex Defect on the Foot Dorsum Without Microsurgery: Intrinsic Adipofascial Flap.

Dorsal foot defects are difficult to cover and often require major flap surgery by microsurgeons, even for defects of limited sizes. Intrinsic adipofascial flaps for small-sized complex defects are simple and do not require microsurgery; thus, a flap specialist is unnecessary. This study aimed to assess our institutional experience with this technique and define its role in dorsal foot reconstruction. Nine patients aged 48 to 86 years with soft tissue defects of the dorsal foot were treated with the intrinsic adipofascial flap by rotating the adjacent adipofascial tissues from May 2019 and January 2021 in our institution. Demographic, clinical, and followup data were evaluated. Primary outcomes include flap viability, flap bulkiness, ability to wear shoes, and donor site morbidity. The mean followup period was 24.5 months (range, 10-30 months) and the mean defect size was 6.4 cm2 (range, 3.0-9.0 cm2). Eight flaps survived providing an adequate contour and durable coverage with a thin flap. Among 8 cases of healed flaps, 6 required secondary skin grafts while the other 2 healed spontaneously without additional operation. One patient (defect size: 3.0 cm × 3.0 cm) with underlying diabetes mellitus and peripheral arterial occlusive disease encountered flap total necrosis. Revisional flap surgery was performed to cover the flap total necrosis. In conclusion, the intrinsic adipofascial flap is a relatively simple and suitable method for complex dorsal foot defect reconstruction because it provides minimal donor site morbidity. However, relatively large defect size and comorbidities, such as underlying diabetes mellitus and vascular occlusive disease could accompany a risk of flap necrosis.

Localization of osteomyelitis lesions for operative eradication of chronic osteomyelitis of the lower extremities by bone SPECT/CT: a feasibility study.

PURPOSE: This study was performed to investigate the feasibility of bone single-photon emission tomography/computed tomography (SPECT/CT) for pre-operative planning of chronic osteomyelitis (COM) of the lower extremities by localization of osteomyelitis lesions. METHODS: From January 2016 to January 2020, we surgically treated ten adult patients with Cierny-Mader type III COM in the tibia or femur for a mean duration of 24.4 months (range 7.0-70.0 months). We conducted pre-operative planning by bone SPECT/CT and localization of osteomyelitis lesions. The treatment consisted of intra-operative eradication of the infective focus and antibiotic administration. The clinical and radiological outcomes were retrospectively analyzed after a minimum of one year of follow-up. RESULTS: The patients were surgically treated by thorough debridement, dead space management, and appropriate antibiotics without bone transport or an external fixator. The location of the hot uptake region on bone SPECT/CT coincided with that of the osteomyelitis lesion, which was confirmed intra-operatively in all patients. At an average of 16.5 ± 4.3 months (range, 13.0-25.0 months), clinical eradication of osteomyelitis was achieved in nine of the ten patients. One patient required amputation due to recurrence of osteomyelitis. A successful clinical outcome was achieved in eight patients; one suffered persistent ankle pain due to a destructive change in the ankle joint despite eradication of the infection. CONCLUSION: Bone SPECT/CT is a feasible method for the localization and eradication of osteomyelitis lesions in COM of the lower extremities and has favourable clinical outcomes. It can also be applied in cases of distorted bony structures caused by previous trauma or surgery, or in the presence of implants.

Radiographic and Clinical Outcomes of Non-Operative Treatment for Patients with Non-Union of Fractures of the Mid-Shaft of the Clavicle in Adults.

Background: Non-unions of clavicle fracture after conservative treatment have been treated surgically, but carry a risk of complications. The aim of this study is to report the outcomes of non-operative treatment for patients with non-union of fractures of the mid-shaft of the clavicle following initial conservative treatment. Methods: This is a retrospective study done at a single centre. Subjects with non-union after conservative treatment of clavicle mid-shaft fractures between March 2004 and February 2019 were included in this study. The exclusion criteria included follow-up period <1 year after the diagnosis of non-union and concomitant upper extremity injury. Final radiographs were assessed for fracture healing, vertical displacement, and shortening. Visual analog scale (VAS) pain scores, shoulder range of motion (ROM) and self-rated outcomes were obtained. Results: Fourteen patients (five females) with an average age of 58 (range, 29-76) years and a mean follow-up duration of 4.0 (range, 1.5-10.2) years were included in the study. The average vertical fracture displacement was 188.7 (range, 95.4-301.4) percent and the average shortening was 13.2 (range, 2.7-16.9) percent. The average VAS pain score was 0.21 (range, 0-2) points. There was no significant difference in the ROM between the injured and uninjured shoulder (p = 0.715 for forward flexion, 0.070 for abduction and 0.714 for external rotation) and the Constant shoulder score (p = 0.190). Thirteen of the 14 patients were satisfied with the treatment, and 12 returned to their pre-injury level of sports participation. Conclusions: Non-operative treatment resulted in a favourable outcome for patients with non-union of clavicle fracture after conservative treatment. Self-rated outcome score was excellent, regardless of the presence of radiographic abnormalities. Level of Evidence: Level IV (Therapeutic).

Biomechanical comparison between double-plate fixation and posterior plate fixation for comminuted olecranon fracture using two triceps screws in synthetic bone model.

BACKGROUND: Although preventing triceps fragment displacement is essential for treating an olecranon fracture, we frequently encounter situations in which only a few screws can be fixed to the triceps fragment. The aim of this study was to compare the stability of double-plate fixation and posterior plate fixation for olecranon fractures when the triceps fragment was small and only 2 screws could be inserted. METHODS: A composite ulna model was used to simulate olecranon fracture. Four groups were formed consisting of double-plate and posterior plates with cortical and locking screws. The cyclic loading test was conducted for 500 cyclic loads of 5 to 50 N on a specimen to measure micromotion and displacement of the gap caused by light exercise. The load-to-failure test was performed by applying a load until fixation loss, defined as when the fracture gap increased by 2 mm or more or catastrophic failure occurred, to measure the maximum load. RESULTS: Eight samples per group were tested through the pilot study. All groups were stable with a micromotion of <0.5 mm. However, the mean micromotion showed significant differences between the 4 groups (P < .001, Table 1). In the mean micromotion during exercise, posterior plating with cortical screws was the most stable (0.09 ±â€Š0.02 mm) while double-plating with cortical screws was the most unstable (0.42 ±â€Š0.11 mm). At the maximum load, posterior plating with locking screws was the strongest (205.3 ±â€Š2.8 N) while double-plating with cortical screws was the weakest (143.3 ±â€Š27.1 N). There was no significant difference in displacement after light exercise between the groups. CONCLUSIONS: This study showed that when 2 triceps screws were used, both groups were stable during light exercise, but posterior-plating was stronger than double-plating.

Arc center distance as a novel quantitative radiographic parameter for volar Barton fractures.

PURPOSE: The aims of this study were to investigate conventional radiographic parameters and introduce a novel parameter (arc center distance, ACD) for volar Barton fractures. METHODS: Twenty-four cases of volar Barton fracture were retrospectively analyzed. We measured volar tilt angle (VTA), anteroposterior distance (APD), teardrop angle (TDA), and capitate-to-axis-of-radius distance (CARD) on lateral plain radiographs. The ACD was measured on the sagittal images of computed tomography scans. VTAs, APDs, TDAs, and CARDs were compared between the fractured and normal contralateral wrist. The area under the receiver operating characteristic curve was calculated for each parameter. RESULTS: TDAs did not differ significantly between the fractured wrists and the controls. On the other hand, VTAs, APDs, and CARDs were all significantly greater in the fractured wrists (mean values were 17.25°, 20.70 mm, and - 3.40 mm, respectively). The area under the curve value was highest (0.943) for the ACD. When a cutoff value of 1.02 mm was used as a threshold, a sensitivity of 100% and specificity of 80.95% were achieved. CONCLUSIONS: The mean values of conventional parameters (VTA, APD, TDA and CARD) in volar Barton fractures were presented. The ACD can be useful parameter for quantitatively evaluating volar Barton fractures.

Reduction of olecranon fractures with no or minimal dorsal cortex comminution based on the contour of the posterior ulnar cortex: does it restore the greater sigmoid notch?

INTRODUCTION: When treating olecranon fractures surgically, surgeons rely on the contour of the posterior cortex of the proximal ulna. However, it is unclear whether the greater sigmoid notch (GSN) is restored anatomically by this method. We analyzed whether reduction of fractures based on the posterior ulnar cortex contour is reliable for restoration of the GSN contour in displaced olecranon fractures with no or minimal dorsal cortex comminution. MATERIALS AND METHODS: We performed a retrospective review of 23 patients with Mayo type 2 olecranon fractures with no or minimal dorsal cortex comminution who were treated surgically. We analyzed pre- and postoperative elbow CT images and measured the interfragmentary distance (IFD), articular step-off, articular gap, contour defect and GSN angle to evaluate the restoration of the GSN contour. RESULTS: The mean preoperative IFD and contour defect were 16.5 mm (range 4.3-35.6 mm) and 4.3 mm (range 0.7-13.3 mm), respectively. Postoperatively, there was no residual IFD, and the mean contour defect decreased significantly to 1.4 mm (range 0-3.7 mm). The residual articular step-off and gap were 0.2 mm (range 0-3.8 mm) and 1.0 mm (range 0-5.9 mm), respectively. Acceptable GSN restoration was achieved in 14 of 23 patients (60.9%). Sixteen patients had > 2 mm of preoperative contour defect, and 7 (43.8%) achieved acceptable GSN restoration; the remaining 7 patients (100%) who had < 2 mm of the contour defect achieved acceptable GSN restoration. Patients whose preoperative contour defect was > 2 mm had a higher risk of unacceptable GSN restoration, with an odds ratio of 2.29 (p = 0.019). CONCLUSIONS: In displaced olecranon fractures without significant dorsal cortex comminution, reduction based on the posterior ulnar cortex could be reliable for fractures with under 2 mm of preoperative contour defect, but not for those with > 2 mm of contour defect. LEVEL OF EVIDENCE: IV.

Simple Osteotomy Site Repair Method for the Trans-Olecranon Approach: Tension Band Wiring with Ring Pins.

Background: The trans-olecranon approach is commonly used to treat intra-articular distal humeral fractures (DHFs). We describe an osteotomy site repair technique that is both simple and safe. Methods: We retrospectively reviewed 30 patients with intra-articular DHFs who were treated via olecranon osteotomies repaired by tension band wiring (TBW) with ring pins. Medical records and radiographs were retrospectively assessed in terms of injuries, operative characteristics, clinical outcomes, and complications, as well as any need for hardware removal. Clinical outcomes were evaluated by deriving the range-of-motion and the Mayo elbow performance score. Results: Thirty patients (nine men, 21 women; mean age, 49.7 years) with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 13-B and 13-C DHFs were included; the mean follow-up time was 49.9 months (range, 12-145 months). Anatomical reduction and bony union were achieved at all osteotomy sites. The mean elbow flexion was 121.7° (range, 100-135°) and the mean elbow extension was 11.3° (range, 0-30°). The mean Mayo elbow performance score was 90 points (range, 55-100 points); outcomes were excellent in 15 patients, good in 12 patients, fair in two patients, and poor in one patient. Olecranon implant removal was performed for 10 patients (33.3%; total removal in nine and isolated olecranon implant removal in one). Four of these patients (13.3%) complained of olecranon implant discomfort. Implants were removed during other surgical procedures from the remaining six patients (20%). No implant migration/breakage or wound complications were encountered. Conclusions: TBW with ring pins is a simple and safe method for olecranon osteotomy site repair.

Sensory Reconstruction of a Posterior Heel Defect Using a Proximally Based Sensate Medial Plantar Flap with Retrograde Nerve Cleavage Technique.

Reconstruction of posterior heel defects is important because it requires thick and durable skin that can withstand pressure and shear from shoe and bed contact. Therefore, the sensate flap could be a better option for the defect. This paper reports on the safety of a medial plantar sensory flap for these defects as well as an objective measurement of the sensation of the medial plantar flap and the plantar surface distal to the donor site. Twelve patients had soft-tissue defects in the posterior heel and underwent reconstructive surgery using a proximally based sensate medial plantar sensory flap. Cases of plantar defects involving not posterior heel were excluded. For wider flap coverage, special neurovascular dissection was required. We evaluated levels of sensation quantitatively using Semmes-Weinstein (SW) monofilaments and a two-point discriminator at the final follow-up. All flaps survived without major complications. Postoperative follow-up was 12 to 64 months (mean 26 months). All 12 flaps healed without postoperative complications. There was no significant difference in minimal two-point discrimination and SW evaluator size between the transferred medial plantar flap area and the contralateral heel area or between the plantar area distal to the donor site and the contralateral side. Patients could walk normally and sleep without protective shoes or brace. A proximally based sensate medial plantar flap is a good option for the reconstruction of posterior heel defects. It can restore the characteristics of the posterior heel for shoe wearing and sleeping.

Mini-Screws-Only Fixation Method for Small Fragments of Medial Malleolus Fractures.

BACKGROUD: Open reduction and internal fixation is the standard treatment for a displaced medial malleolus fracture (MMFx), achieving ankle stability and bony union to prevent post-traumatic arthritis. Previous fixation techniques including tension band wiring and unicortical screw fixation are not optimal for fixation of small fragments in MMFx due to their small size and poor manipulability. Here, we describe a novel surgical method using mini-screws only for fixation of small fragments in MMFx. METHODS: We conducted a retrospective consecutive study of patients who underwent surgery using mini-screws for small fragment MMFx between April 2013 and March 2018. We reviewed the patients' clinical characteristics and assessed the fracture features radiographically. Clinical outcomes were assessed by measuring the range of motion of both ankle joints and investigating symptomatic implants. We reviewed the radiographic outcomes of the medial malleolus and the functional outcomes using the Foot and Ankle Outcome Score (FAOS) at the last follow-up. RESULTS: Nine patients were included in the study. The minimal follow-up period was 27 months. There was no incidental bone breakage during the procedure. All MMFx healed without reduction loss, nonunion, or implant failure at the last follow-up. Two patients had mild osteoarthritic changes of the ankle joint. The mean FAOS score of the patients was 80.99 (range, 65.44-98.42). No patients required removal of the hardware. CONCLUSIONS: Fixation of comminuted fractures of the medial malleolus using mini-screws for young adult patients is a straightforward and simple technique. Safe fixation of the anterior and posterior colliculi reduces the risk of implant irritation symptoms that necessitate implant removal.

Quantitative evaluation of posterior talar subluxation in posterior malleolar fractures: A preliminary study.

BACKGROUNDS: Although ankle posterior subluxation is one of the major mechanisms by which posterior malleolar fractures (PMF) contribute to a worse prognosis, there is no parameter to address it quantitatively. So, we suggest a method that can evaluate posterior talar subluxation quantitatively in PMF. METHODS: We retrospectively analyzed 37 patients with posterior malleolar fractures. The patients were divided into two groups: PMF without posterior talar subluxation (n = 18) and with posterior talar subluxation (n = 19). We measured the distance between the arc center of the talus and the anterior tibia (TAD), the percentage of articular involvement of the fracture fragment, the inter-fragment distance (IFD) and articular step-off. We analyzed significant differences and the correlations between the two groups for each index. The estimated area of the receiver operating characteristic (ROC) curve was calculated, and cutoff values were suggested to discriminate posterior talar subluxation. RESULTS: TAD, IFD, and articular step-off were significantly greater in patients with posterior talar subluxation. (TAD: 14.3 vs. 2.8 mm, p < 0.001, IFD: 7.8 vs. 4.0 mm, p < 0.001, articular step-off: 3.6 vs. 2.0 mm, p = 0.004). The ROC curve showed that TAD was most useful to determine cutoff values for posterior talar subluxation. The area under the curve for TAD was 1.000, and the appropriate cutoff value was 5 mm. When a TAD of > 5 mm was used as a threshold, a sensitivity of 100% and a specificity of 100% were achieved in determining the presence of posterior talar subluxation. Also, higher TAD was correlated with IFD and articular step-off. CONCLUSIONS: TAD can be a useful parameter for evaluating the posterior talar subluxation in PMF. It can reflect not only the degree of fracture displacement but also posterior talar subluxation quantitatively.

Biomechanical comparison of three tension band wiring techniques for transverse fracture of patella: Kirschner wires, cannulated screws, and ring pins.

PURPOSE: The purpose of this study is to compare biomechanical characteristics of tension band wiring using Kirschner wires (TBWKW), cannulated screws (TBWCS), and ring pins (TBWRP) for transverse fracture of the patella. METHODS: A total of 48 polyurethane synthetic patellae were biomechanically tested. All patellae were osteotomized to create a transverse fracture. Each TBWKW, TBWCS, and TBWRP fixed 16 broken patellae. A specially designed fixation board simulated a knee with 90° flexion. Ten static tests and six dynamic tests were performed on each method. The static test is measuring maximum strength (N) during traction until breakage of the fixation. The dynamic test consisted of measuring the fracture gap (mm) after 10,000 repetitive loading cycles between 100 N and 300 N that simulated actual daily activity. A gap of 2 mm or more was defined as a failure in both tests. RESULT: The failure load was 438.6 ± 138.6 N, 422.2 ± 72.7 N, and 1106.8 ± 230.3 N for TBWKW, TBWRP, and TBWCS, respectively. TBWCS showed a statistically significant difference compared to TBWKW and TBWRP in the static test (p < 0.001). All the groups had no failure in the dynamic test. The mean fracture gap after completion of the dynamic test was 0.3267 ± 0.3395 mm, 0.2938 ± 0.2165 mm, and 0.0360 ± 0.0570 mm for TBWKW, TBWRP, and TBWCS, respectively (p = 0.044). The mean values in the dynamic test showed no statistical difference. There was a significant difference between TBWRP and TBWCS (p = 0.009), but others showed no difference with statistical significance. CONCLUSION: All three methods have sufficient stability at a daily activity. TBWCS showed a better failure load compared with TBWKW and TBWRP. TBWRP showed compatible mechanical characteristics with traditional tension band wiring. TBWRP could be an alternative method for TBWKW.

The Innervated Distally Based First Dorsal Metatarsal Artery Flap with a Wide Pedicle for Reconstruction of a Great Toe Defect.

BACKGROUND: It is difficult for surgeons to reconstruct soft tissue defects of the great toe. This report aims to evaluate the utility and efficacy of innervated distally based first dorsal metatarsal artery (FDMA) flap with a wide pedicle for reconstruction of soft tissue defects of the great toe. METHODS: This is a retrospective report. Between January 2015 and December 2017, six cases of skin defect of the great toe were reconstructed with an innervated distally based FDMA flap with a wide pedicle. One case was excluded in this report because of chronic pain on the metatarsophalangeal joint due to osteoarthritis before the injury. A total of five cases were evaluated for flap survival and sensory recovery. The sensory recovery was investigated by two-point discrimination and Semmes-Weinstein monofilament tests. The average age of the selected patients was 40 years (range, 36 to 56 years), and the average size of the defect in the toe was 8.3 cm2 (range, 4 to 13.8 cm2). The average follow-up period was 29.4 months (range, 18 to 38 months). RESULTS: All patients survived without any complications. The average two-point discrimination test value was 8.0 ± 0.89 mm (range, 7 to 9 mm), and the average value obtained from the Semmes-Weinstein monofilament test was 4.53 ± 0.33 (range, 4.17 to 4.93). The average residual pain score evaluated with a visual analog scale was 1 (range, 0 to 2). Two patients complained of stiffness in the great toe below 30° of total range of motion during the early stages after surgery, but this stiffness gradually improved after rehabilitation. The average range of motion of three patients with a remaining metatarsophalangeal joint after surgery was 80° (range, 70° to 90°). All five cases could walk regularly without any unique footwear at the final follow-up. CONCLUSIONS: The innervated distally based FDMA flap with a wide pedicle could be a good alternative method for repair of soft tissue defects of the great toe.

Supplemental Method for Reduction of Irreducible Mallet Finger Fractures by the 2-Extension Block Technique: The Dorsal Counterforce Technique.

PURPOSE: We suggest a method to achieve anatomical reduction in mallet finger fractures that are insufficiently treated by the 2-extension block wire technique. METHODS: We performed a retrospective review of 18 patients who were found to have an irreducible dorsal fragment and distal interphalangeal joint incongruence owing to rotation of the dorsal fragment in the sagittal plane. In these cases, we additionally employed a dorsal counterforce technique to supplement the 2-extension block technique. An additional K-wire was used to apply counterforce against the distal part of the dorsal fragment and control rotation in the sagittal plane. RESULTS: All 18 fractures united. Congruent joint surfaces and anatomical reduction were seen in all cases. The mean active flexion of the distal interphalangeal joints was 83.8° (range, 79°-88°) and the mean extension loss was 0.4° (range, 0°-4°). CONCLUSIONS: We believe that the dorsal counterforce technique effectively supplements the 2-extension block K-wire technique and aids control of dorsal fragment rotation in the sagittal plane. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist.

BACKGROUND: A skin defect of the hand and wrist is a common manifestation in industrial crushing injuries, traffic accidents or after excision of tumors. We reconstructed a skin defect in the ulnar aspect of the hand and wrist with a perforator-based propeller flap from the ulnar artery. The aims of our study are to evaluate the utility and effectiveness of this flap and to discuss the advantages and disadvantages of the flap in hand and wrist reconstruction with a review of the literature. METHODS: Between April 2011 and November 2016, five cases of skin defect were reconstructed with a perforator-based propeller flap from the ulnar artery. There were four males and one female. The age of patients ranged from 36 to 73 years. Skin defect sites were on the dorso-ulnar side of the hand in three cases and palmar-ulnar side of the wrist in two cases. The size of the skin defect ranged from 4 × 3 cm to 8 × 5 cm. We evaluated the viability of the flap, postoperative complication and patient's satisfaction. RESULTS: There was no failure of flap in all cases. The size of the flap ranged from 4 × 4 cm to 12 × 4 cm. One patient, who had a burn scar contracture, presented with limited active and passive motion of the wrist after the operation. The other patients had no complications postoperatively. Cosmetic results of the surgery were excellent in one patient, good in three patients, and fair in one patient. CONCLUSIONS: The fasciocutaneous propeller flap based on a perforating branch of the ulnar artery is a reliable treatment option for the ulnar side skin defect of the hand and wrist.

A Transpatellar Approach to Treat Distal Femoral Type C3 Fractures Combined with Patellar Fractures.

We report our surgical method used to treat type C distal femur fractures accompanied by patella fractures whereby we approach the articular surface of the femur through the already-fractured patella. We treated 10 patients with type C3 distal femur and patella fractures between May 2013 and April 2015. Because the patella was fractured in all cases, we could approach the articular surface of the distal femur through the transverse gap between the retracted patellar fracture fragments, "transpatellar approach." Any surgical complications were recorded. Knee function was evaluated using the Böstman system. The average age of the 10 patients (8 males) was 42.9 years (range, 22.0-58.0 years). All distal femur fractures were type C3, combined with patella fractures. Bony union of the distal femur and patella was achieved in all but one patient, who required an additional bone graft (without any change in the implant). Overall, three patients (30%) reported excellent results and seven (70%) reported good results, based on the Böstman system. A midline anterior approach through a patella fracture adequately exposes the entire joint surface of the distal femur, except the posterior surface. This approach is useful when treating a type C distal femur fracture accompanied by a patella fracture. The level of evidence is IV.

One-Barrel Microsurgical Fibula Flap for Reconstruction of Large Defects of the Femur.

Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a 1-barrel free vascularized fibular graft (FVFG) protected by a lateral locking plate for large femoral defects not involving the knee joint.Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12-36 years), and 3 were women. All defects were free of infection before the procedure. Femoral bone defects were reconstructed using a 1-barrel FVFG protected by a lateral locking plate. The mean bone defect size was 10.5 cm (range, 6-16 cm). We reviewed clinical outcomes at the last follow-up.All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26-100 months). Two patients sustained stress fractures of the FVFG, but the lateral locking plate protected the fractured graft until in situ bone healing obtained. Mean time to bone union of both host-graft junctions was 24 months (range, 18-31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80-95%).A 1-barrel FVFG protected by a lateral locking plate maintained a stable graft-host bone construct, successfully leading to bone healing, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects.

A modified deltoid splitting approach with axillary nerve bundle mobilization for proximal humeral fracture fixation.

INTRODUCTION: The deltopectoral and the deltoid splitting approach are commonly used for the treatment of proximal humeral fractures. While the deltopectoral approach requires massive soft tissue devascularization, the deltoid splitting approach needs an additional skipped incision to avoid axillary nerve injury. The purpose of this study was to describe a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures and to assess its radiologic and clinical outcomes. PATIENTS AND METHODS: Twenty-two consecutive patients with proximal humeral fractures were treated with minimally invasive plate osteosynthesis by using a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization. The patients were divided into two groups: 10 patients of Neer type 2 or 3 fractures vs. 12 patients of Neer type 4 fractures. The mean age of the study population was 63.5 years (range: 30-80 years). Six patients had valgus impacted fractures, and nine had fractures with medial comminution. RESULTS: Fracture union was achieved in all cases. The mean time to union was 8.6 weeks (range: 6-12 weeks). Major complications, such as avascular necrosis of the humeral head and varus collapse at the fracture site, were not observed. No patients had clinically detectable sensory deficits in the axillary nerve distribution or paralysis of the anterior deltoid muscle. The mean neck-shaft angle at the final follow-up was 136.9° (range, 115°-159°). The mean visual analog score for patient satisfaction was 9.1 (range, 6-10), and the mean Neer scores were 93.5 (range, 84-100). There were no significant differences between the two groups with respect to radiologic and clinical outcomes except Neer scores: 95.8 (range: 86-100) in Neer type 2 or 3 fractures and 91.7 (range: 84-99) in Neer type 4 fractures. CONCLUSION: The use of a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures yielded excellent outcomes. This approach is a useful alternative to the deltopectoral or the deltoid splitting approaches in the treatment of proximal humeral fractures.