Objective To introduce the clinical application and method of endoscopic harvesting the sural nerve in the carbon dioxide gas cavity. Methods 7 cases with peripheral nerve defect were involved, including 5 men and 2 women. The length of nerve defects ranged from 5 to 8 cm, all the nerve defects were repaired by autogenous sural nerve grafting. The sural nerve were removed from 9 calves in 7 cases. Along the course of the sural nerve in the proximal calf, a transverse 1.0 to 1.5 cm incision was done for endoscope approach, another transverse 0.5 to 1.0 cm incision was done lateral to the sural nerve for operation approach. Using abdominoscope system, the sural nerves were cut and removed smoothly in the cavities which were maintained the gas pressure 10 to 15 mm Hg with carbon dioxide insufflation. All the peripheral nerve defects of 7 cases were repaired as cable graft with harvested sural nerve. Results The length of nerve graft harvested from 30 to 42 cm in 9 calves. It took about 30 minutes to harvest the nerve in each side. There was no abvious injuries found by pathologic inspection. No carbonemia and air embolism occurred on patients during operating time, no complications of hypodermic pneumatosis and hematoma occurred on all cases. All patients followed up from 6 to 10 months, the function recovery of the nerves was good. The muscle power was obtained 2 to 4 grade, the sensation was obtained S3 to S4 grade. The function recovered as fast as the traditional operation of sural nerve transfer. Conclusion The method of endoscopic harvesting the sural nerve in the carbon dioxide gas cavity with minimal incision is easy to perform. Compared with the long longitudinal incision and multiple stair-step incision, the method can get less invasive and traumatic, and good aesthetic results. This technique deserves the doctor application in clinical work.

Objective To study the methods of repairing the sole defects and reconstruction of the sensory function. Methods Twenty- nine cases of sole defect were repaired with flaps and full- thickness grafting according to the weight- bearing area and non- weight- bearing area. Sixteen cases had reconstruction of the sensory nerves. Results Twenty- nine cases were followed up for 1－ 9 years. One case failed. One case required thinning the flap. Twenty- eight cases have gained normal weight bearing ambulation. Ulcer occurred in one case, giving an ulcer rate of 3.4％ . The sensation have recovered to S2－ S3 in 16 cases repaired with reconstruction of cutaneous sensory nerves. Thirteen cases repaired with non- innervated flaps and full- thickness grafting showed deep pain sensation, and over the 1－ 2 cm area coverage around the flaps there was light touch sensation. No significant difference was found in the ulcer rate between reinnervated and non- innervated flaps. Conclusion Defects of the weight- bearing area in sole must be repaired with flaps. The medial foot island flap, medial pedal island flap, toe arterial flap and anterolateral thigh flap are the appropriate options. Defects of the non- weight- bearing area could be repaired with full- thickness grafting. The transplantation of non- sensory skin flaps can re- establish the sensory function, so the reconstruction of sensory nerve is of minor importance.

OBJECTIVETo observe the effects of surgical delay procedure on the survival of perforator flap with three angiosomes in rat, and to explore its possible mechanism.

METHODSThe flap model was a perforator flap with three angiosomes which located on the right dorsal side of a rat based on the right deep circumflex iliac vessel. The two connection areas between the three angiosomes were successively named choke zone (CZ) 1 and CZ 2 beginning from the pedicle to the remote area. A total of 110 SD rats were divided into routine flap group (RF, n = 40), delay only group (DO, n = 30), and delay flap group (DF, n =40) according to the random number table. (1) In group RF, 30 rats were selected according to the random number table, and flap surgery was performed directly. Six rats were sacrificed on post operation day (POD) 0, 1, 2, 3, 7 respectively to collect the full-thickness skin samples at both CZs for HE staining to measure the vascular density and diameter. The rest 10 rats underwent flap surgery immediately after a catheter was successfully implanted into their external jugular vein. A volume of 1.5 mL sodium fluorescein solution (100 g/L) was injected to the 10 rats on POD 0 (5 rats) or POD 1 (5 rats) each time with a 2-day interval to learn the change in flap circulation. Each rat was injected for 4 times. The flap survival rate of the 10 rats was calculated on POD 7, and the configuration and distribution of the vessels in the flap were observed through angiography with the improved perfusion method of lead oxide-gelatin. (2) In group DO, the right thoracodorsal perforators of all the rats were surgically ligated through a small skin incision, and 6 rats were sacrificed on POD 0, 1, 2, 3, 7 respectively. The skin samples of each rat at the same area as in group RF were harvested to measure the vascular density and diameter. (3) In group DF, rats were treated with ligation surgery as in group DO, and then they were assigned and treated as in group RF on POD 7 with corresponding indexes detected later. Data were processed with group t test, analysis of variance with factorial design, and SNK test.

RESULTS(1) Significant differences of vascular density at both CZ 1 and CZ 2 were found on POD 7 among the three groups ( with F values respectively 2. 69 and 2. 76, P values below 0.05). The vascular density values of CZ 1 and CZ 2 of rats in group DF were (29 ± 7) and (31 ± 8) per mm on POD 7, which were significantly higher than those of group RF [(23 ± 5) and (23 ± 3) per mm2, with q values respectively 5.67 and 6.01, P values below 0.05] and those within group DF on POD 0 (with q values respectively 6.42 and 7. 14, P values below 0. 05). On POD 3 and 7, the vascular diameter values of CZ 1 of rats in groups RF and DF were significantly higher than those of group DO (with q values from 8. 15 to 11.13, P values below 0.05). The vascular diameter values of CZ 2 of rats in group DF onPOD 0, 1, 2, 3,7 [(65 ± 8), (63 ± 13), (69 ± 9), (67 ± 8), (64 ± 13) 230m] and in group DO on POD 3 and 7 were significantly higher than those in group RF [respectively (46 ± 10) , (40 ± 9), (43 ± 13), (46 ± 12), (47 ± 11) µm on POD 0, 1,2, 3, 7 ] at corresponding time point (withqval- ues from 7.29 to 10.79, P values below 0.05). The difference in vascular diameter between CZ 1 and CZ 2 was statistically significant in groups RF and DO on POD 3 and 7, and in group DF on POD 0, 1 , and 2 (with q values from 5.32 to 9.56, P values below 0.05). Compared with that on POD 0 within each group, the vascular diameter of CZ 1 in groups RF and DF and that of CZ 2 in group DO increased significantly on POD 3 or 7 (with q values from 6.12 to 8.13, P values below 0.05). (2) In groups DF and RF, blood from the pedicle ran through CZ 1 and covered the dynamic territory successfully within POD 7. On POD 0, the blood within all flaps was blocked for about 3 min after going through CZ 1 at 1 cm distal from CZ 2 in group DF and around CZ 2 in group RF. (3) Flap survival rate of rats in group DF was (95 ± 12) % , which was statistically higher than that of group RF [(80 241 9) % , t = 2.91, P <0.01]. All the partial flap necrosis occurred in potential territory. (4) Compared with the vessels in the left dorsal side without surgery, the vessels of CZ 1 in group RF were dilated obviously, and the boundary between vascular trees became indistinct, but the vessels in CZ 2 changed slightly; the vessels in both CZs in group DF were dilated dramatically.

CONCLUSIONSThe delay method could enhance the survival of potential territory in perforator flap with three angiosomes, and it acted mainly by dilating the choke vessels in CZ 2 before flap surgery.

Angiography ; Animals ; Graft Survival ; physiology ; Male ; Necrosis ; Perforator Flap ; blood supply ; physiology ; Rats ; Skin ; blood supply ; Surgical Flaps ; blood supply ; physiology ; Time Factors

Objective To explore the strategy of damage control in clinic treatment of severe limb (finger) with multiple injuries.Methods Severe multiple injuries patients with ISS evaluation more than 16 points were chosen for this study.Simple replatations of severed limb(finger) were perfored in 40 patients while their multiple injuries were actively treated.Results Among the 40 cases, all cases survived.1-3 years follow-up showed that the results were excellet in 8, good in 21, middle in 7, and poor in 4, with an excellent or good rate of 72.5 percent.Conclusion Multiple specialties cooperation, early treatment of multiple injuries and experienced microsurgery operation are the keys to improve success rate of replantation of severed limb(linger) with multiple injuries.

Objective To explore the clinical significance of micro-metastasis ( mM ) in the nipple-areola complex (NAC) and the regional skin of breast cancer. Methods Samples from the skin projection of the lump and the midline-transection of the nipple-areola complex were collected from 60 breast cancer patients for both routine pathological examination ( RP) and cytokeratin-19 (CK-19) monoclonal antibody immuneohistochemical examination (IHC). Results NAC invasion was identified by RP in 3 cases (5. 0% ) , and by IHC in 7 cases (11.7%) ( x2 = 2. 25, P

OBJECTIVETo develop a new experimental animal model of different a single perforating vessel as its pedicle, and to investigate this vessel can captures how many adjacent angiosomes in different directions.

METHODSThirty-six Sprague-Dawly rats of both sexes were used. The rats were divided into group A, group B and group C. Group A: the unilateral deep circumflex iliac perforator artery- based flap. Group B: the unilateral posterior intercostal perforator artery-based flap. Group C: the unilateral lateral thoracic perforator artery-based flap. An extended dorsal perforator flap measuring up to 13 cm x 6 cm was designed in 36 rats to assess the viability of the flap. The upper margin was located at the level of the tip of the scapula and the lower margin at a level 1 cm below the iliac crest. All flaps were observed for 7 days postoperatively, 72 hours after flap elevation, observe flap dyeing conditions through the vivo fluorescein injection, the surviving flap area was calculated as a percentage of total flap dimensions and the angiosome's structure of the flap was displayed by radiopaque microangiography.

RESULTSNo fluorescence was visible in the distal flap of groups A and C, the whole flap show bright fluorescence in group B. Survival rate of C, A, B were improved in order. Statistic difference is significant (P < 0.01) between group and group. In group A, lead oxide-gelatin angiography shows the cephalic flap necrosis occurred in the bilateral lateral thoracic territories, and the vascular architecture partly disappeared in the necrotic area. In group B, the vascular architecture of flap is unbroken. In group C, the caudal flap necrosis occurred in the bilateral deep circumflex iliac perforator artery territories, and the vascular architecture partly disappeared and disordered in the necrotic area.

CONCLUSIONSThe perforator flap is based centrally on a single perforator, this vessel can capture multiple the second vascular territory. In a direction, the longest distance that the blood supply can reach is the point of the third perforator vessel puncture into skin, which can provide certain theoretical guidance for designing of perforator flap.

Angiography ; Animals ; Female ; Graft Survival ; Male ; Models, Animal ; Perforator Flap ; blood supply ; Rats ; Rats, Sprague-Dawley

OBJECTIVETo study the classification and individualized treatment of the terminal phalanx of thumb duplication.

METHODSFrom Apr. 2003 to Dec. 2012, 76 patients with 77 involved thumbs duplication at the level which is distal to the interphalangeal joint were retrospectively studied. Based on the morphology (the nail width and the thumb circumference) and the deviation of the thumb, we classified the terminal phalanx of thumb duplication into 5 types as Type A (no bony connection called floating thumb), Type B(asymmetry and no deviation), Type C(asymmetry and deviation), Type D (symmetry and no deviation) and Type E(symmetry and deviation). Different surgical procedures were selected according to different types. Simple excision of the smaller thumb was adopted for Type A case. Removement of the smaller thumb (usually the radial) and of the collateral ligament of the interphalangeal joint were selected for Type B. Removement of the smaller thumb (usually the radial) and reconstruction of the collateral ligament of the interphalangeal joint, as well as corrective osteotomies at the neck of the proximal phalanx were performed for Type C. The modified Bilhaut-Cloquet procedure with reconstruction of the collateral ligament of the interphalangeal joint were adopted in Type D. The classical Bilhaut-Cloquet procedure, or the modified Bilhaut-Cloquet procedure with reconstruction of the collateral ligament of the interphalangeal joint and corrective osteotomies at the neck of the proximal phalanx were performed in Type E. The results were assessed by an evaluation form for thumb duplication by the Japanese Society for Surgery of the Hand.

RESULTSAccording to our new classification standard, there were 3 cases with Type A duplicated thumbs, 36 with Type B, 13 with Type C, 15 with Type D, 10 with Type E. All the 76 patients underwent the individualized surgical treatment. The patients were followed up for 6-60 months. According to the evaluation form, excellent results were achieved in 66 thumbs, good in 9 thumbs and fair in 2 thumbs.

CONCLUSIONSThe new classification could comprehensively describe the clinical features of the terminal phalanx of congenital thumb duplication. Individualized therapy, including basic and repeated surgical procedure could be adopted for each type with satisfactory results.

Child ; Collateral Ligaments ; surgery ; Finger Phalanges ; surgery ; Humans ; Orthopedic Procedures ; methods ; Osteotomy ; methods ; Polydactyly ; classification ; surgery ; Reconstructive Surgical Procedures ; methods ; Retrospective Studies ; Thumb ; abnormalities

Surgery is still the main treatment for congenital polydactyly, and the aim of surgical reconstruction is to obtain a thumb with excellent function and appearance. A systematic assessment of polydactyly is required prior to surgery, including bone stress lines, joint deviation, joint activity and joint instability, size and development of finger and nail. Bone shape, joint incongruency, and abnormal tendon insertions must be corrected completely, in order to obtain good function and to avoide secondary surgery. Bilhault-Cloquet procedure can reconstruct the size of the finger and nails. Fine manipulation can improve the postoperative nail deformity, so that the reconstructed nail reaches a satisfactory aesthetic score.

Objective To investigate the outcome between endoscopically assisted and routine anterior transposition of the ulnar nerve for treatment of cubital tunnel syndrome.Methods From Februray 2008 to June 2010, forty-four patients with cubital tunnel syndrome were treated with routine anterior subcutaneous transposition (routine group,28 cases) and endoscopically assisted anterior subcutaneous transposition (endoscope group,16 cases).The operate time,drug administration,scar and postoperative hospital stay were compared.The patients were followed 1-12 month postoperatively,postoperative time back to work and function of ulner nerve were recorded.Results The results of endoscope group were as follows: operative time was (67.20 ± 19.69)min; postoperative scar length was (1.5％ ± 0.58) cm; rate of administration of anodyne was 6.3％; postoperative hospital stay was (2.4％ ± 1.42) days; postoperative time back to work,(14.6 ± 4.69)days; the results of open surgery group were as follows:operative time (62.8％ ± 11.06) min; postoperative scar length was (8.7％ ± 1.42) cm; rate of administration of anodyne was 42.8％; postoperative hospital stay was (5.7％ ± 2.53) days; postoperative time back to work was (29.40 ± 8.75) days; all differences of the results were significant between two groups (P ＜ 0.05).According to function of ulner nerve scoring system,one year postoperatively, excellent or good results were 82.14％ in routine group and 81.25％ in endoscope group,no significant difference between two groups (P ＞ 0.05). Conclusion Compared with routine anterior transposition of the ulnar nerve,endoscopically assisted anterior transposition has the following advantages: smaller incision and less tissue damage,less postoperative pain and sooner returning to work.And similar outcome was achieved from the two group.

To analyze the molecular basis of the variation of the pathogenicity of the influenza B virus, we rescued a recombinant virus with a deletion in the carboxyl terminal of the NS1 protein using reverse genetics based on the parental virus B-S9 of B/Yamagata/16/88. A mutant strain with a deletion of 171 amino acids in the carboxyl terminal of the NS1 protein was named "B-L5". BALB/c mice were inoculated with 3 X 105 EID50 of B-L5 and the parental virus B-S9, respectively. Then, weight changes, survival, and viral titers were documented. During 3 days post-inoculation (dpi) to 7 dpi, the weight of mice infected with B-S9 decreased. However, the weight of mice infected with B-L5 showed weight decreases only at 2 dpi, and quickly recovered at 3 dpi. B-S9 and B-L5 could replicate in the lungs of BALB/c mice. However, viral titers in the lungs of mice infected with B-L5 were 7900-times lower than those of mice infected with B-S9 at 3 dpi. Viral titers in the lungs of mice infected with B-L5 were not detected at 6 dpi. These results showed that, compared with the parent virus B-S9, the mutant virus B-L5 showed lower pathogenicity in BALB/c mice. Our study suggests that deletion of the carboxyl terminal of the NS1 protein decreases the pathogenicity of the influenza B virus. Establishment of a reverse-genetics system for the B influenza virus will provide a platform for studying its pathogenesis, and mechanism of transmission, and for developing live-attenuated influenza B virus vaccines.
Animals ; Body Weight ; Dogs ; Female ; HEK293 Cells ; Humans ; Influenza B virus ; genetics ; pathogenicity ; physiology ; Madin Darby Canine Kidney Cells ; Mice ; Mice, Inbred BALB C ; Sequence Deletion ; Survival Analysis ; Viral Load ; genetics ; Viral Nonstructural Proteins ; chemistry ; genetics ; Virulence