Microsurgical Operation Research Articles

The perforators-chain island flap based on the saphenous artery and posterior tibial artery for covering skin defects in middle and distal lower leg

Objective To evaluate the clinical utility of perforators-chain island flap based on the saphenous artery and posterior tibial artery for covering soft tissue defects in middle and distal lower leg. Methods From April, 2012 to February, 2015, the perforators-chain island flaps based on the saphenous artery and posterior tibial artery were used reversely for covering soft tissue defects in middle and distal lower legs in 11 cases. With the assistance of doppler flowmeter, this perforators-chain island flap in the medial aspect of middle and distal thigh was designed to rotate at the perorating point of the posterior tibial artery perforator in the medial proximal crus, with the flap axis connecting the emerging points of perforators from saphenous artery and posterior tibial artery. The size of the flap ranged from 8.0 cm × 5.0 cm to 16.0 cm × 9.0 cm. The donor site was closed directly. Results All 11 flaps survived completely. No one lost to follow-up and the follow-up time varied from 3 to 18 months (mean, 8 months). All flaps were flat with good contour and texture. Satisfactory function and esthetic appearance were achieved in all patients. The two-point discrimination ranged from 6 to 10 mm. Only leaner scar was observed in the donor site and no disability of the knee joint was recorded during follow-up. Conclusion The perforators-chain island flap based on the saphenous artery and posterior tibial artery provides a practical option for covering soft tissue defects in the middle and distal lower leg. This flap is characteristiced by reliable blood supply without sacrificing main vessels, good contour and texture, satisfactory sensory recovery, conceal donor location, and minimal donor site morbidity with only leaner scar. Key words: Saphenous artery; Posterior tibial artery; Lower leg; Perforator flap; Microsurgical operation

Curative effect of surgical treatment for severe hypertensive intracerebral hemorrhages in basal ganglia and broken into ventricles

Objective To investigate the clinical treatment of severe hypertensive intracerebral hemorrhage in basal ganglia and broken into ventricles. Methods 16 patients with severe hypertensive intracerebral hemorrhage in basal ganglia and broken into ventricles received microsurgical treatment using posterior central gyrus posterior-lateral fissure upper approach.The hematoma cavity and ventricle were opened,and brain surgical department drainage was placed in the hematoma cavity in the operation.The curative effect was analyzed retrospectively 6 months after operation. Results According to Glasgow Outcome Scale(GOS):6 cases had good recovery;4 cases had moderate disability;2 cases had severe disability;1 case was in persistent vegetative state and 3 cases were dead. Conclusion Craniotomy microsurgical operation using posterior central gyrus posterior-lateral fissure upper approach is an effective treatment of severe hypertensive intracerebral hemorrhage in basal ganglia and broken into ventricles.The fatality rate was reduced. Key words: Neurosurgical procedures; Cerebral hemorrhage

Clinical Study of CT classifications of subarachnoid hemorrhage in ruptured anterior communicating aneurysms

Objective To explore the characteristics of CT manifestations and their clinical application in subarachnoid hemorrhage (SAH) induced by ruptured anterior communicating aneurysms (ACoA). Methods A group of patients suffered from SAH with ruptured ACoA were reviewed from 1997 to 2013. A total of 405 ACoAs were clipped. According to the CT manifestations of the hemorrhage, SAH was classified into 5 types. Statistical analysis was performed to assess the relativity between this CT classification and the Hunt-Hess scale, the clinical outcomes as well as delayed cerebral ischemia(DCI). Results Among 279 cases ofⅠ-Ⅲ types, 266 cases (95.3%) were cured, 8 (2.9%) died. Among 126 cases of Ⅳ-Ⅴ types, 93 cases(73.8%) were cured, 19 (15.1%) died. The CT classification (Ⅰ-Ⅴ) was positively correlated with the patients′ prognosis (cure - death)(P<0.01), which became poor with the gradual increase of CT classification. Among 279 cases ofⅠ-Ⅲ types, 267 cases(95.7%) were Hunt - Hess classification levels (Ⅰ-Ⅲ) , 12(4.3%) were Hunt - Hess classification levels (Ⅳ - Ⅴ) . Among 126 cases of Ⅳ -Ⅴ types, 87 cases(69%) were Hunt - Hess classification levels (Ⅰ-Ⅲ), 39(31.0%) were Hunt - Hess classification levels (Ⅳ-Ⅴ) . The CT classification (Ⅰ-Ⅴ and the types with Hunt - Hess classification levels (Ⅰ-Ⅴ) were positively correlated(P<0.01). The morbidity of patients whose CT classifications wereⅠ-Ⅴ was 2.70%, 5.43%, 12.39%, 16.36% and 6.25% respectively. Conclusions The CT classifications of SAH in ruptured ACoA had comparatively higher Clinical value in predicting the patients′ prognosis. It should be noted that early diagnosis and microsurgical operation skills were important for the improvement of the patients′ prognosis. The CT classifications of SAH in ruptured ACoA which had guiding significance in predicting DCI had a good correlation with Hunt - Hess classification and the patients′ prognosis. Key words: Anterior communicating aneurysm; Subarachnoid hemorrhage; CT classifications; Clinical implication

Анестезіологічне забезпечення ендоскопічних мікрохірургічних втручань з приводу паралітичного стенозу гортані

Surgical repair of bilateral vocal cord paralysis is widely considered as one of the most complicated procedures in laryngeal microsurgery. Unobstructed view of laryngeal structures and adequate amount of working space are essential prerequisites for successful microsurgical operation. In order to provide necessary surgical condition several ventilatory techniques can be employed. Available options include preventive tracheostomy, conventional ventilation via small endotracheal tubes and jet ventilation. At the same time, improvement of surgeons’ working conditions is never considered as an ultimate goal if it does not lead to better results or decrease of expenses.Materials and methods: We report a retrospective study of 104 patients who had undergone microlaryngeal surgery for bilateral vocal cord paralysis. Duration of hospital stay, duration of surgery and time spent in the operating room were compared between the three groups of patients with different ventilation strategies.Results: The highest duration of hospital stay was in the group of preventive tracheostomy (18,68±7,48 days), whereas in the groups of tracheal intubation and subglottic jet ventilation it was considerably lower (12,9±7,11 and 12,15±5,69 respectively).Conclusions: Obtained data suggest that preventive tracheostomy performed prior to endoscopic microlaryngeal surgery is the major independent risk factor of prolonged hospital stay for patients with bilateral vocal cord paralysis

腹腔镜与显微镜下治疗青年精索静脉曲张疗效分析

目的：探讨腹腔镜与显微镜下治疗青年原发性精索静脉曲张的疗效、安全性。方法：回顾性分析71名青年原发性精索静脉曲张患者治疗后随访资料，其中有5例慢性前列腺炎患者。39例接受腹腔镜精索静脉高位结扎术(腹腔镜组)，2例慢性前列腺炎患者；32例接受显微镜下精索静脉结扎组(显微镜组)，3例慢性前列腺炎患者。比较两组患者术前、术后3月精液质量、激素水平、睾丸体积变化情况及手术时间、住院天数、费用。结果：两组患者手术均顺利完成，腹腔镜组与显微镜组相比手术时间明显缩短(85.94 ± 20.44 vs 39.00 ± 9.69, P 0.05)。两组患者术后精液质量较术前无差异(P > 0.05)，精子密度、精子存活率、A + B级精子明显改善，差异有统计学意义(P 0.05)。腹腔镜组术后2例(5.1%)复发，1例(2.6%)附睾炎，2例(5.1%)症状持续存在，2例(5.1%)阴囊水肿；显微镜组术后无复发、附睾炎、阴囊水肿，但是有1例(3.1%)患者症状持续存在。结论：青年精索静脉曲张患者精液质量大多已受影响，早期手术可以恢复精液质量或减轻精液质量的下降。腹腔镜与显微镜下治疗精索静脉曲张均为微创手术，创伤小、疗效好，但是显微镜下治疗精索静脉曲张费用低、术后复发率低、并发症更少。 Objective: To compare curative effect between microscopic and laparoscopic approach for treatment of varicocele. Method: We retrospectively analyzed 71 adolescence varicocele patients after treatment follow-up data. 39 cases underwent laparoscopic high ligation of spermatic vein (laparoscopic group). 32 patients received ligation of varicocele group under the microscope (microscopy group). The semen quality, hormone levels and testicular volumes of these two groups of patients before and after the operation, operation time, hospitalization days and cost were compared. Results: All patients were successfully completed the operation. Laparoscopic group compared with microscope group operation time is obviously shortened (85.94 + 20.44VS39.00 + 9.69, P 0.05), but the cost was significantly increased (4866 + 541.45VS7820 + 906.21, P < 0.05). Compared with preoperative semen quality, postoperative semen quality of these two groups of patients showed no statistical significance. Sperm density, sperm survival rate, A + B grade sperm significantly improved (P < 0.05). In the laparoscopic group after operation, 2 cases (5.1%) of recurrence, 1 case (2.6%) of patients with epididymitis; 2 cases (5.1%) clinical symptoms persisted and 2 cases (5.1%) occurred scrotal edema. However, no recurrence, epididymitis, scrotal edema in the microscope group after operation, but 1 case (3.1%) of patients with persistent symptoms. Conclusion: Most of the youth semen quality of patients with varicocele has affected; early operation can restore the semen quality or decrease the damage level of semen quality. Laparoscopic and microscope to treat varicocele were minimally invasive operation. They have the characteristics of small trauma, good curative effect, but the microsurgical operation has the advantages of low cost, lower postoperative recurrence rate and fewer complications characteristics.

精索静脈瘤に対する術中インドシアニングリーン蛍光血管造影下顕微鏡下低位結紮術の有用性：予備的検討

Microsurgical subinguinal varicocelectomy is one of the best treatment modalities for varicoceles. However, the difficulty in identifying testicular arteries that should be spared is a limitation of this technique. We assessed the efficacy of intraoperative indocyanine green angiography (ICGA) during microsurgical subinguinal varicocelectomy in three pilot cases. We performed microsurgical subinguinal varicocelectomy using a surgical microscope for observing infrared fluorescence in patients with infertility or chronic pain associated with varicoceles. After the exposure of the spermatic cord blood vessels, ICG was injected intravenously to identify and isolate the testicular artery. Thereafter, the varicose veins were repeatedly ligated, while preserving a few lymphatic vessels and the spermatic duct. The testicular artery could be clearly identified by ICGA and were able to separate under ICGA. The preserved arteries were confirmed by ICGA at the end of microsurgical operation. Though, all the internal spermatic veins could be safely ligated, while sparing the testicular arteries and lymphatic vessels. Microsurgical subinguinal varicocelectomy using intraoperative ICGA facilitated safe and quick surgery by enabling the visualization of the spermatic cord blood vessels. This is the first report to indicate the usefulness of vessel visualization by ICGA during microsurgical subinguinal varicocelectomy.

Clinical analysis of reconstruction of thumb or finger by free second-toe transfer and one stage appearance remodeling

Objective To explore the effects of reconstruction and shaping of thumb or finger defects by free second-toe transfer and one stage appearance remodeling.Methods From October,2007 to August,2013,128 thumb or finger Ⅴ degree defect of 109 cases were reconstruct with free second-toe transfer,and one stage shape remodeling at the same time.Among them,20 fingers by nail bed expand one stage; 23 fingers were nail bed expand added on toe pulp splayed resection on both sides; 29 fingers were added on embedded the philp island flap of great toe to the section of plantar side narrow part in the second digit,19 fingers were added on embedded the abdominal phil chamfered-edge-shape flap to that narrow part in the second digit,and 37 fingers added on toe pulp resection and embedded the philp island flap of great toe to that narrow part.Results All reconstructed thumb or fingers survived and appearance were good.The nail shape of reconstructed thumb or fingers were improved obviously,the shape of narrow part in middle segment was recovered satisfactorily.Seventy-nine cases (72.5％) were followed-up from 3 months to 5 years,and the other 30 cases (27.5％) were lost.The function of the reconstructed thumb or finger and hand feeling was ideal recovered.There were no claudication,no pain and no other sequelaes for donor foot.According to the Standard on Approval of Reconstructed Thumb and Finger Functional Assessment of Chinese Medical Association,43 cases excellent,26 cases good,10 cases approve.The rate of excellent and good was 87％.Conclusion Second-toe transfer and shape remodeling is a good method of thumb or finger reconstructing.The appearance of the thumb reconstruction can be improved obviously.Preoperative carefully design and the combination of the above several kinds of operation,for draw up an personalized surgical program is necessary. Key words: Second-toe ; Thumb ; Finger; Reconstruction ; Microsurgical operation

Application of anti skin grafting and two pedicled abdominal flap to repair the whole hand degloving injury

Objective To explore the application of anti skin grafting and two pedicled abdominal flap to repair the whole hand degloving injury.Methods From June,2007 to December,2013,20 cases of hand degloving injury of skin and skin graft,waste application and combined application of VSD vacuum suction and two fingers abdominal pedicled skin flap repair,postoperative fingers activity,strength,degree of sensory recovery and function of four standards,respectively.After doing comprehensive evaluation.Evaluation standard:excellent for 13-16,good for 9-12 minutes,could be 5-8,difference of 4 points.Results Excellent functional recovery in 19 cases,accounting for 95％.In 1 patient the pain was not combined with exercise induced proximal interphalangeal joint part stiffness function can,accounted for 5％.Metacarpophalangeal joint activity of about 80 °-90 °,proximal interphalangeal joint activity of about 85 °-90 °.The 6 cases of sensory recovery grade S5,14 cases of abdominal two-way two subdermal vascular network flap for repair of sensory recovery S3.The patients were followed up for 2-6 years,results of 19 cases of activity were 4 points,1 case of active degree was 3,16 cases of power:4 points,3 points in 3 cases,1 case of 2 points.Feel:18 cases was 3,2 cases of 2 points.Function:18 cases was 4,2 cases of 3 points.Conclusion The operation method of small trauma,no multiple finger operation,avoids the contracture of the first web space and joint stiffness,for basic level hospital. Key words: Hand; Degloving injury ; Vacuum sealing pressure drainage technique ; Skin graft ; Microsurgical operation

Anatomy on chimeric flaps of lateral circumflex femoral vessel and application for the reconstruction of complex oral and maxillofacial defects

Objective To discuss the anatomic basis for design of chimeric flaps pedicled with lateral circumflex femoral vessel and to evaluate the feasibility of the chimeric flaps for the reconstruction of complex oral and maxillofacial defects.Methods Sixty-six patients who underwent oral and maxillofacial malignant tumor resection and reconstruction with the flaps pedicled with lateral circumflex femoral vessel from October,2008 to April,2009 in the Second Xiangya Hospital were selected as the subjects.The distribution,number,type and origin of cutaneous perforators arising from lateral circumflex femoral vessel in the anterior thigh region were explored by anatomic observation.A retrospective review was performed of 29 patients who underwent reconstruction of through-and-through oral and maxillofacial defects with chimeric flaps pedicled with lateral circumflex femoral vessel from October 2008 to October2011.The chimeric flaps were harvested to reconstruct through-and-through cheek defects in 26 cases,through-and-through defects from floor of the mouth to mental region in 2 cases,through-and-through defects of basis nasi in 1 case.Results In the 66 cases,333 cutaneous perforators originating from the lateral circumflex femoral vessel were present in the anterior thigh region (5.0 perforators per case on average; range,1 to 9).And 282 cutaneous perforators were present in the anterolateral thigh region (4.3 perforators per case on average; range,1 to 8).78.7％ of cutaneous perforators in the anterolateral thigh region derived from the descending branch of the lateral circumflex femoral artery (LCFA),19.9％ derived from the transverse branch of the LCFA,1.4％ derived from the ascending branch of the LCFA.Further,most perforators (85.5％) in the anterolateral thigh region were musculocutaneous perforators; the rest (14.5％) were septocutaneous perforators.In addition,38 cases of patients had cutaneous perforators deriving from the lateral circumflex femoral vessel in the anteromedial thigh region.Postoperatively,28 of 29 cases of chimeric flaps survived completely,providing a success rate of 96.6 percent.All patients were followed for approximately 6 to 36 months,and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction.Conclusion With the convenient design of the flaps,chimeric flaps pedicled with lateral circumflex femoral vessel are suitable for the reconstruction of complex oral and maxillofacial defects. Key words: Oral and maxillofacial region; Lateral circumflex femoral vessel; Chimeric flap; Microsurgical operation

Transplantation of the free anterolateral thigh flap combined with iliotibial band for reconstruction of children's soft tissue defects at foot and ankle

Objective To investigate the clinical effect of transplantation of the free anterolateral thigh flap and iliotibial band for the repair of soft tissue defects at foot and ankle and functional reconstruction.Methods From January,2008 to January,2013,25 pediatric patients with soft tissue defects at foot and ankle were transplantation of the free anterolateral thigh flap and iliotibial band.Of the 25 cases,there were 12 cases at heel,8 cases at dorsum of foot,3 cases at medial malleolus and 2 cases at external malleolus.All the cases were accompanied with different degree of fracture or dislocation,and with soft tissue defect such as achilles tendon,extensor tendon of dorsal,collateral ligament of ankle.The length of soft tissue defect which were reconstructed with iliotibial band were 3 cm to 16 cm.The causes of injury:19 cases were crushed by motorcycle or bicycle,4 cases were crushed machines,2 cases were injuryed in traffic accidents.The areas of free anterolateral thigh flaps were 8 cm × 5 cm to 18 cm × 12 cm.All the patients begined to early rehabilitative exercise under the protection of orthosis after 2 weeks of the operation.Results All cases were followed up from 6 to 24 months,averaged of 14 months.All the flaps survived,and only 2 cases with necrosis of small area in distal,and which were healed by dressing.The healing time were 12 to 24 days,and the average of 15.1 days; The surgery function were assessed according to Thermann's scale,and the results was 14 cases for excellent,9 cases was good,the general was 2 cases,and the excellent and good rate was 92％.Conclusion The transplantation of the free anterolateral thigh flap and iliotibial band for the repair of soft tissue defect at foot and ankle and functional reconstruction is a safe and effective strategy,and it has the advantages such as covering the wound at foot and ankle approvingly,reconstruction of power device once,the flap and iliotibial band were in the same wound,the trauma of doner site is small invasive,early recovery functional exercise,shorten the treatment cycle,and relieve the suffering of children. Key words: Foot; Ankle; Iliotibial band; Anterolateral thigh flap; Children; Microsurgical operation

Repairing defects of foot and ankle by sural neurovascular adipofascial flap

Objective To investigate the clinical effect of repairing soft tissue defects of foot and ankle by sural neurovascular adipofascial flap.Methods Application of sural neurovascular adipofascial flap to repaire soft tissue defects of foot and ankle in 19 patients,inclouding 3 csaes with the soft tissue defects of medial malleolus and 16 cases of dorsum pedis from May,2006 to May,2013.The size of soft tissue defects was 3 cm ×3 cm-7 cm ×9 cm.The skin of the donor site was sutured directly.The recipient area was reshaped granulation and underwent free skin graft after the adipofascial flap survived.Results After followed up of 3-18 months,the adipofascial flaps were all survived,the recipient area was almost flat with the surrounding tissue,the donor area only leaving linear scar,the appearance and function of donor area and adopt area were satisfactory.The sensation of lateral dorsal region of foot decreased to S3,and the sensation of recipient site recovered to S2.There were some changes in pigmentation with the skin graft region.Conclusion Sural neurovascular adipofascial flap can be effectively repaired soft tissue defects of foot and ankle,and it can avoid irregularity of donor area and enlargement of adopt area,the appearance and function were satisfactory. Key words: Sural nerve ; Adipofascial flap ; Foot ; Ankle ; Microsurgical operation

Classification and reconstruction of the defects after combined cranio-maxillo-facial resection

Objective To review our patients who underwent reconstruction of the defect after combined cranio-maxillo-facial resection in recent years.Methods From January,2005 to January,2011,88 patients underwent reconstruction of the defect after combined cranio-maxillo-facial resection.Different reconstructive techniques were used according to the defect classifications in dura,skull base bone,and facial tissues.For dural defects,no repair (37 cases),primary closure (25 cases),and dural repair (26 cases) were performed,respectively.Dural repair materials included thigh fascia lata (2 cases),temporalis fascia (2 cases),pericranium (1 case) and artificial dural patch (21 cases).Bone reconstruction of the skull base were performed in 61 patients with titanium mesh (57 cases),free iliac bone graft (1 case),free cranial bone graft (2 cases) and Medpor (1 case),respectively.Limited facial soft and hard tissue defects in 44 patients were reconstructed with temporalis system of flaps (36 cases),sternocleidomastoid myocutaneous flap (6 cases),and pterygoid muscle flap (2 cases),respectively.Extensive facial soft and hard tissue defects in 44 patients were reconstructed with free latissimus dorsi myocutaneous flap (26 cases),free pectoralis major myocutaneous flap (12 cases),free anterolateral thigh perforator flap (5 cases cases) and free anteromedial thigh perforator flap (1 case),respectively.Results The overall success rate of 88 flaps was 100％.Cerebrospinal fluid leak was found in 4 patients,wound infection was found in 2 patients,intracranial infection was found in 2 patients,respectively.Six patients with cerebrospinal fluid leak or wound infection were cured by conservative treatment.Two patients with intracranial infection were dead although they underwent salvage surgery.Overall rate of complications was 9.1％,dead rate was 2.3％.Conclusion Successful reconstruction of the defect after combined cranio-maxillo-facial resection can be achieved by watertight dural repair,bone reconstruction of the skull base and well-vascularized tissue covered.Regional flap and free tissue transfer are both preferred reconstructive technique depending on the anatomic site and the extent of the defect. Key words: Combined cranio-maxillo-facial resection; Tumor; Head and neck; Free flap; Microsurgical operation

Percutaneous screw fixation of scaphoid fractures aided by computerized imaging processing: preliminary report

Objective To evaluate the preliminary clinical outcome of the screw fixation of minimally displaced scaphoid fracture assisted by computerized imaging reconstruction and preoperative planning system.Methods From March 2013 to Feburary 2014,Five screws on five patients were treated.We calculated and designed the position of scaphoid screw guide wire and ensured the guide wire centrally placed in the scaphoid by using the computerized imaging reconstruction and preoperative planning system software.The appropriate length of the screw was measured too in the software.We also identified the entry and exit points of the guide wire on the custom orthoses splinting the wrist joint.Five patients with scaphoid fractures were treated with percutaneous screw fixation under the guidance of a C-arm fluoroscopy and a guide wire were inserted based on the entry and exit points calculated preoperatively.All of the scaphoid fracture was nondisplaced or less than 1 mm.The modified MAYO wrist scoring system was used to evaluate the pain,function and range of motion for the wrist joint during follow up.Results Total surgical time was 28.8 min (25-39 min)and Fluoroscopy time was 18.4 s (11-23 s).The fracture healing was observed at routine 8 weeks follow up.No complication such as infection or fixation failure was reported.Modified MAYO wrist score was 83.8 (81-88)at average followup at 15 months (6-12 months).Conclusion Computer assisted percutaneous screw fixation is an effective method for the treatment of nondisplaced scaphoid fractures.It leads to significantly reduced guidewire placement time and radiological exposure time while provides accurate placement of the screw. Key words: Scaphoid ; Fracture fixation; Microsurgical operation Computer-asisted

Repair of fingertip defect with improved transverse palmar island flap

Objective To introduce the technique and treatment outcome of the fingertip soft tissue defect with improved transverse palmar island flap.Methods From January 2011 to February 2013,15 cases(17 fingers) fingertip defect were repaired by improved transverse palmar island flap,the vascular pedicled of flap was a side of the neurovascular bundle,the flap revolved 90° to coversoft tissue defect.Defect area:1.2 cm × 0.8 cm to 1.7 cm × 1.6 cm.The time between the injury and admission was 40 minutes to 27 hours.Five cases were repaired defection with flap immediately,10 cases were repaired defection in stage Ⅱ.Results The wounds of injury in 15 cases get primary healing,and all the flaps were successfully survived.The 13 cases were followed up for 6 months to 14 months.The blood circulation of flap was fine,and the fingertip shape as well.The two point discrimination of the skin pulp was 6 mm to 11 mm.Conclusion The improved transverse palmar island flap for repairing transverse finger pulp defect and a small area of skin defect in patients.The procedure has a simple surgery,donor area don't skin graft,postoperative appearance and hand finger satisfactory functional recovery,etc. Key words: Fingertip defect; Finger pulp; Island flap; Microsurgical operation

Clinical application of the multimodality treatment of brain arteriovenous malformation with Onyx embolization and microsurgery

Objective To evaluate the clinical application of multimodality treatment of brain arteriovenous malformation (BAVM) with Onyx embolization and microsurgery.Methods There were 48 patients with BAVM treated by combination of Onyx embolization and microsurgery.The clinical features,therapeutic process,complications and discharge status (by MRI,DSA and Glasgow outcome scale,GOS) were recorded in detail.The prognosis was estimated by modified Rankin scale (mRS) with 6-42 months' follow-up.Results The total resection rate was 97.9％.The therapy-related complications happened in 8 patients (16.7％).Among them,4 cases had dysfunction of central nervous system (8.3％),2 cases with intra-cerebral hemorrhage (4.2％),and 2 suffered from severe cerebral edema (4.2％).Good recovery was seen in 38 cases (79.2％) evaluated by GOS when discharged from hospital.The follow-up result mRS ＜ 3 was 97.9％.Conclusion Multimodality treatment of BAVM with Onyx embolization and microsurgery should be a good therapeutic strategy. Key words: Brain arteriovenous malformation (BAVM) ; Onyx ; Embolization; Microsurgical operation

Outcome of free flap vascularized by the dorsal artery of big toe in treating finger skin defect

Objective To evaluate the outcome of the procedure of using the free flap vascularized by the dorsal artery of big toe to treat finger skin defect. Methods From August 2010 to April 2013, 21 cases of finger shin defect were treated with the free flap vascularized by the dorsal artery of big toe in which emergency surgeries were conducted in 9 cases and sub emergency surgeries were conducted in 12 cases. The age of the 21 patients was 21 to 48 years old and 15 of them were males and 6 were females. Thumb was involved in 6 patients and index finger was involved in 15 patients. The skin defect occurred at dorsal in 7 patients and palm in 14 patients. The area of the flaps ranged from 2. 2 cm x 1.6 cm to 4. 0 cm ~ 3.2 cm. Observed the restoration of the affected fingers＇ appearance and function, investigated the clinical results and concluded the indication and advantages and disadvantages of this procedure by following up. Results All of the 21 flaps survived at the last office visit. The follow-up period ranged from 3 to 18 months. The shapes and the fingerprints of the flaps were satisfied. The color and texture of the flaps were similar to those of the finger skin. The 2 points discriminations of the flaps was 6-8 mm. No function deficits were found in the donor feet. Conclusion This free flap is satisfied in the shape, easy to harvested and the blood supply was constant in its location, and recommend it in treating the small of middle area skin defect in the finger. Key words: Dorsal flap of big toe; Finger; Transplantation; Microsurgical operation

Dupuytren’s contracture of hand and its medical and social review

IntroductionDupuytren's contracture is a disease of connective tissue with the affection of palmar aponeurosis, frequently with chronic recurrent course, the flexion deformities of fingers and dysfunction of the hand. It composed 11,8 % among of all types of the hand pathology. The mostly it develops in men of middle-aged and elderly. At young age it occurs more rarely, but with fast progressing current, which in 67 % of cases leads to impaired ability to perform professional hand-work and in 3 % patients to physical inability. Predisposing factors for this fibromatosis are numerous, but one of the popular opinion among of authors is a hereditary character of disease. In clinical practice, the most frequently used fourth degree’s classification of Dupuytren's contracture includes severity of deformation and function disorders of the hand. It is correspond to the normative standards of medical and social expertiseThe aim of research: to specify the most optimal methods of surgical treatment, the criteria of medical and social examination and rehabilitation, clinical and labor prognosis, indications to establishment of disability after operations concerning of Dupuytren’s contracture.In our clinic was performed three methods of operation: aponeurotomia “open hand”, partial aponeuroectomia, total aponeuroectomia. Errors in the treatment of palmar fibromatosis we shared on: preoperated, intraoperated and associated with violations of the mode of rehabilitation. The next clinical observation of 68 patients (up to 3 years after surgery) with Dupuytren’s contracture of hand showed the recurrence rate amounted to 31,7%, and physical inability level is 5,9% of cases. In our opinion the most optimal operative methodic is total aponeuroectomia with rational surgical approaches.Clinical and labour prognosis depends on the manifestations of disease which can develop regardless of the stage, methods of treatment and patient's age. Disadvantageous prognostic factors include: the formation of keloid scars, persistent development of contractures and arthritis of the joints of fingers. For the expert diagnosis, the most important are functional disorders such as the capture and retention of items. Other types of disorders are less important. The restriction of mobility little joints with vicious position of fingers of the hand limit the ability to work and ability to self-service. The case of the bilateral affected leads to disability group III. At carrying out of medical and social examination and its conclusion, it is necessary to take into account the age, concomitant pathology, compensatory abilities of the patient, as well as the dynamics of recovery function of the hand after correction.Conclusions:Dupuytren’s contracture is the complex orthopedic pathology that can be interpreted as dysplasia of connective tissue. It makes 11,8% of all diseases of hand and affects mainly men of the middle age.In clinical practice is most often applied four-degree’s classification considering severity of deformation and function disorders of hand, which needs clarification of criteria for medical and social examination.The optimal method of Dupuytren’s contracture treatment is operative – the total aponeuroectomia, however the quantity of unsatisfactory outcomes reaches 13 % of cases, and cases on physical inability up to 3 %. According to our clinical observation of the 68 patients (up to 3 years after surgery) the recurrence rate amounted to 31,7%, and physical inability level is 5,9% of cases.In our opinion, aponeuroectomia should be regarded as complex microsurgical operation, by using rational approaches and obligatory plastic substitution of the defects of the skin.The basic criteria of the clinical and labor prognosis and medical and social examination are characters of morphological changes and a degree of the basic functions disorders of hand. They reduce work capacity, quality of life, and at bilateral affection results to ІІІ group of physical inability and to 1-st degree of disability. At conclusions of medical and social examination it is necessary to consider compensatory possibilities of the person and concomitant pathology, as well as its profession and age.

Application of free perforator flaps transfer in senile patients with limb skin defects

Objective To explore the clinical effect of applications of free perforator flaps in repairing limb skin defect in senile patients.Methods From January 2008 to November 2012,forty-three senile patients with limb skin defects were treated by free perforator flaps transfer after the underlying diseases were controlled,in which 15 patients with hypertension,thirteen patients with diabetes or glucose tolerance abnormalities.Location of skin defect:thirty three cases were located in anterior ankle and tibia,ten cases were located in the dorsum of hand,wrist or forearm,and the size of skin defects were ranged from 2 cm ×3 cm to 10 cm × 16 cm.Twenty-eight cases were treated with free anterolateral thigh flaps transfer,seven cases were treated with free medial sural artery perforator flaps transfer,four cases were treated with free peroneal artery perforator flaps transfer,four cases were treated with free interosseous artery perforator flaps transfer.The blood vessels were anastomosed either end-to-end or end-to-side.Results There was no obvious vascular crisis in 36 cases.Partial necrosis occurred in 3 cases and all healed after dressing changes.Venous crisis occurred in 2 cases,and healed after treated by removing stitches,raising the limb,spasmolysis drugs local injecting; Flap partial infections occurred in 2 cases,and healed after debridement and dressing changes.All the cases were followed up for 3 to 20 months (7.2 months on average).Seven cases were performed flap trimming after 6 months,and the appearance and quality of the other flaps were satisfied.The scars of the donor site was not obvious.Conclusion With active treatment of the underlying diseases,strict surgical indications control,adequate preoperative preparation,close observation of the changes in the postoperative condition and timely processing,application of free perforator flaps transfer in repairing limb skin defects in senile patients also achieved good results. Key words: Senile patients ; Extremity ; Perforator flap ; Microsurgical operation

Repairing donor site after harvested of wrap-around flap of toe by peroneal artery perforator flap

Objective To investigate the prothetic effect of free grafting of microvascular anastomotic peroneal artery perforator flap when used to repair the donor tissue defects of wrap-around flap of toe.Methods From January 2008 to March 2013,twenty-six cases thumb avulsion at proximal and distal phalanx level with skin and nail bed defect caused by trauma were admitted to our hospital.After incising wrap-around flap of toe to repair the thumb defects,microvascular anastomotic peroneal artery perforator flap was transplanted freely to repair the donor site of it.Results The skin flaps of 26 cases all successfully survived.After a followed-up of 3 months to 4 years,the length of donor toes were the same as before.The appearance of skin flaps were no fat and clumsy and the abradability of their skin were well.Algesia,thalposis and thigmesthesia were partially recovery.Two point discrimination reached to 5-10 mm.There were no obvious uncomfortableness in donor feet when standing and walking except wearing flip-flops.Conclusion Free grafting of peroneal artery perforator flap is a good method to repair the donor defect caused by incising wrap-around flap of toe. Key words: Wrap-around flap of toe; Donor sites; Peroneal artery perforator flap; Microsurgical operation

Vascularized iliac grafting combined with tantalum rod implantation for osteonecrosis of the femoral head

Objective To explore the clinical outcome of vascularized iliac bone flap combined with tantalum rod implantation for the treatment of osteonecrosis of the femoral head (ONFH).Methods Totally 28 cases (36 hips) of non traumatic avascular necrosis of the femoral head patients from January 2010 to January 2011,which were 15 males and 13 females; a mean age of 40 years (ranged,18-53years),according to ARCO stages:eight hips of stage Ⅱ a,ten hips of stage Ⅱ b,nine hips of stage Ⅲ a,nine hips of stage Ⅲ b,adopt to vascularized iliac grafting combined with tantalum rod Implantation for osteonecrosis of the femoral head.The Harris hip score and VAS score of pre-and post-operation was recorded to evaluate the clinical outcome,and to compare observe and analyze the change of postoperative of patients by used three-dimensional gait.Results All 28 cases (36 hips) were followed up 6 ～20 months,averaged 12 months.The results of Harris hip score and VAS score of the 6 months postoperatively and last follow-up were significantly higher than preoperative ones (P ＜0.05).And the Harris hip score of the last follow-up was also significantly higher than the one of 6 months postoperatively (P ＜ 0.05).However,there was no significant different in that of VAS score (P ＞0.05).There were 13 cases in excellent,fourteen in good and 4 in fair with an excellent and good rate of 89.8％,which shows that the extension of time and changes in patients gait tends to normal by three-dimensional gait analysis.Conclusion Vascularized iliac bone flap transplantation combined with tantalum screw was an effective method with high clinical success rate for treatment of younger patients with early-mid stage ONFH.It provided good blood supply and enough mechanical support to reduce the progress of femoral head collapse. Key words: Osteonecrosis of the femoral head ; Vascularized iliac ; Tantalum ; Microsurgical operation