This article reviews the currently most widely used methods and their features of the non operative and operative treatment for the fractures of long tubular bones. It is widely accepted that each of the two methods is useful in its injury degree and in kind. It is wise to choose the non operative treatment for child fractures, adult fractures easily reduced, and the complementary therapy after surgery. External bone fixation is preferentially selected as for the open long tubular bone fracture with severe injuries to the soft tissues, early freatments of long tubular bone fracture with multiple injuries all over the body and fire arm injury. While it is widely accept that an active operative treatment should be take for the open fractures, multiple fractures, multi plane fractures, intraarticular fractures, and the fractures with vessel or nerve injury, and the biological fixation should be chosen in order not to impair circulartory supply of soft tissues. Arriving at the conclusions that future studies of the treatments for the fractures of long tubular bones will be conducted in meticulously design for therapy, minimally invasive osteosynthesis, satisfactory reduction, stably biological fixation, immediately active motion and results in a good runctional recovery for the limbs.

Recent years have witnessed an extre mely rapid development in minimally invasive surgery(MIS).It is widely accepted that treatmen t of bone fractures should be shifted from biomechanical fixation to biological fixation in order to gain a minimal invasion and good function al recovery.Minimally invasive tec hniques have been widely applied in clinics,such as procedures assisted by arthr oscope in orthopedics and endoscope in spine surgery,percutaneous treatm ent of the fractures and diseases of l imbs and spines.They have also been enhanced by the computer-assisted s urgical navigation system,surgical simulation system,telepresence c onsul-tation system and robotic remote-co ntrol surgery.Application of MIS in microsurgery has been documented to be able to decrease the notorious donor site morbidity while maintaining th e quality and costs of outcomes.Adva nces in image technique and intervention al radiology have greatly improved minimally invasive methods to be used in orthopedics.MIS has also found new p ossible and potential therapeutic means in such technologies as laser,microwave,cryoablation,ultrason ofocusing,nanotechnology,gene th erapy and tissue engineering.In short,since the scope of MIS will keep on exp anding during the 21st century,it is certain that MIS will see an in-creasingly bright future and become a mainstay in orthopedics.

Virtual reality that is based on the high and new technology has witnessed great progress since the end of 20th century. It will result in promising methods to be used widely in clinic and to promote the development of minimally invasive surgery (MIS). As far as MIS is concerned, it will reshape the principles, expand the scope and improve the result of diagnose and treatment. Furthermore, it will also accelerate innovation of the instrument for MIS. The development of virtual reality, however, is still at its beginning. Not only high-level specialists but also expensive and special equipment is needed to explore virtual reality before it can be applied in MIS. As a result, virtual technology should be applied step by step, first in the most suitable indications. Meanwhile basic and applied research on virtual reality should be forcefully carried on to render it into effective and practical methods for the minimally invasive or non-invasive surgical treatment.

Microsurgery has been in a plateau period after a development of 4 decades. Now it has been faced with a difficult situation in China: shrinking scope and increasingly slow development. This may be an inevitable outcome of the spiral rising pattern of development of anything in the world, as well as a combined result of fierce impact of market economy, hysteresis of medical system, ideological deviation and investment deficiency. Recently, however, application of new and high technology, new devices and materials in microsurgery, such as nanometer techniques and materials, gene and tissue engineering, and computerization, has broadened a new development space. Microsurgery in the 21st century should make more efforts in expanding its application dimension, perfecting its therapeutic methods, enhancing basic research, raising technical proficiency of its personnel and improving the welfare of its workers. It should also be nourished with new ideas, interdisciplinary cooperation before it can realize its rejuvenation in the new century.

[Objective]To evaluate several abdominal skin flaps used for treatment of whole-finger degloving injury of multiple fingers.[Method]Since 2000, 45 patients with whole-finger degloving injury of multiple fingers except the thumb were treated with transfer of abdominal skin flaps. Among these patients,10 were treated with random abdominal tubed pattern flaps,15 with pedicle skin flaps with thoraco-umbilical perforator artery,12 with pedicle skin flaps with superficial iliaccircumflex artery,and 8 with embedding with abdominal flaps.At the second-stage operation,fingers were dissected with pedicels or with abdominal flaps before fingerweb plasty and flap plasty were carried out for many times.[Result]All the skin flaps survived. Three fingers of 3 cases had distal cutaneous necrosis after finger web plasty.Follow-up from 5 to 36 months showed the active motion of metacarpophalangeal joints averaged 60?, and interphalangeal articulations averaged 30?.Sensation recovery reached S3 in fingers with remanent palmar digital nerve, but poor in other fingers. All fingers could perform grasping. The contour of fingers was fine except for the 3 cases of necrosis.[Conclusion]Treatment of whole-finger degloving injury of multiple fingers except the thumb with suitable abdominal flaps can restore the shape and function of hand to the greatest extent and is still a practical, safe and convenient operative method.

Objective To explore different techniques for treat me nt of complicated distal femoral fractures in order to obtain the best curative effects. Methods A retrospective study was done on the cli nical data of 62 patients (64 sides) with complicated distal femoral fractures a dmitted to our hospital from January 1999 to June 2002. According to AO classifi cation: 20 cases (21 sides) belonged to type A and 42 (43 sides) to type C. The supporting steel of AO femoral condyles were applied in 18 cases (19 sides), loc ked double-plating (steel plate and polyethylene plate) in 20 (21 sides) and th e retrograde intramedullary nail in 24. All cases received scientific and ration al rehabilitative treatment post-operatively. Results The 4-38 months follow up showed that 62 cases go t fracture healing with average healing period of 4.2 months (from 10 weeks to 1 6 months). According to criteria of Kolmert and Wulff, 31 sides were excellent, 28 good but 5 poor with an excellence rate of 75%. Conclusions A majority of treatment results of complicate d distal femoral fractures are satisfactory through rational and reliable intern al fixation. The supporting steel plate is suitable for all distal femoral fract ures; and the retrograde intramedullary nail is the treatment of choice for type A and type C1 fractures. As for types C2 and C3 fractures, the locked double-p lating combined with polyethylene is more effective than the supporting steel pl ate or the retrograde intramedullary nail for it has advantages of reasonable de sign, convenient operation and firm fixation.

Objective To discuss the technique and clinical effect of infective long bone defect treated by external fixator combination of iliac bone graft with deep iliac circumflex vessels.Methods All 28 patients with posttraumatic infective long bone defect were treated by external fixator and iliac bone graft with deep iliac circumflex vessels from July, 2008 to June, 2014.The length of the bone defect was from 3 to 7 cm (averaged 5.1 cm), including tibia defect in 13 patients, femoral defect in 7, humeral defect in 4, and ulna and radius defect respectively in 2, and 17 patients also with soft tissue defect.After thorough debridement, the bone defect was fixed by the external fixator, and then VSD was applied for irrigation drainage.As fresh granulation tissue growth, iliac bone vascularized by deep iliac circumflex vessels, size from size 5.0 cm× 3.0 cm to 8.0 cm× 3.5 cm, was transplanted.As for composite defect of infective bone and soft tissue in 17 patients, 6 cases of them was repaired with the iliac flap combined free flap, three with the iliac flap combined local skin flap, 4 cases with the iliac flap doubled with both the deep and the shallow iliac circumflex vessels, 3 cases with the circumflex iliac artery chimeric perforators flap and 1 with random iliac osteocutaneous flap.Affected limb function was graded with Enneking's system.Results All transplanted vascularized iliac bone survived, postoperative infection controlled well, but there were 2 patients of iliac flap partial necrosis.After dressing exchange and reoperation, the wound all repaired again.Twenty-six patients followed from 8 to 50 months, with an average of 18 months while 2 patients lost postoperative.The osseous healing time of the iliac bone graft was an average of 6.5 months, 25 patients healed well but 1 case encouraged tibia fracture again.Appearance of the limb also recovered satisfactorily.Twenty-six patients had the average limb function restored in 89.7％.There was no obvious complication in the donor.Conclusion It is an effective technical method to treat infective long bone defect by external fixator combination of iliac bone graft with deep iliac circumflex vessels, which can not only fix and bridge bone defects and enhance bone healing, but also obliterate dead space and resist local infection by ensuring blood supply.But the method is suitable for the receipt site infection under control and the length of the long bone defect less than 10 cm.

ObjectiveTo discuss the clinic application and surgical technique of the free flap by inverted-Y-shape microvascular anastomosis in tissue defect repair and functional reconstruction of the limb.Methods Twenty-two flaps in 18 patients were involved in the study between June 2006 and September 2010( 12 cases for soft tissue defect repair with exposure of the tendons, bones or joints, and 6 cases for functional reconstruction;five cases were around the elbows and 13 cases were around the extremity of the lower limb). Before free flap graft, twelve cases with infective tissue defect were debrided extensively and covered with vacuum sealing drainage from 1 to 2 times and each time last 5 to 7 days until the granulation tissue growing well.Designed the free anterolateral thigh flaps with the transverse and descending branches of the lateral femoral circumflex vessels or free latissimus dorsi flaps with the subscapular and circumflex scapular vessels forming a inverted-Y-shape pedicle to repair the tissue defect or to reconstruct the limb function.The recipient artery was sectioned and the arterial tree of the flap was anastomosed to the recipient vessel by two end-to-end anastomoses.This inverted-Y-shape microvascular anastomosis could supply blood for both the free flap and the extremity of the limb.Not all of the veins of the recipient limb need to be cut off.Observed the circulation of the limb extremity, and evaluated the quality of flaps'survival.ResultsComplete flap survival was achieved in 21 flaps and without vaso-occlusive crisis;while partial flap loss in 1 case, which healed after changing dressings.The mean follow-up was 16.2 (6-36) months postoperatively,appearance of the flaps and the functions of limbs were satisfactory,and no obvious complication was found in the donor site.ConclusionThe free flap by inverted-Y-shape microvascular anastomosis is a new choice for the tissue defect repair and functional reconstruction of the limb,especially for the wound around elbow or extremity of the lower limb with one major artery destroyed.

Objective To investigate the operative techniques and clinical significance in the treatment of large area soft tissue defect in children limbs by sequential vacuum-assisted closure and free flaps. Methods Twenty-two cases of children patients, with a range between 3 and 10 years, were treated by sequential vacum-assisted closure (VSD) and free flaps. All the patients suffered from large area soft tissue defect after severe trauma of limbs, with bone, tendon and other deep tissues exposed or partial defected. The wound area varied from 12 cm × 8 cm to 34 cm × 25 cm, and among the wound 9 cases were fresh and the other 13 were necrotizing infection. After strictly cleaned, the wound was covered with VSD according to the condition of the soft tissue defect and its underlying tissue damage. For the patients complicated with unsteady fracture, the fracture was fixed with outside-fixed frame or inside-Kirschner nails. The VSD negative pressure membrane was removed after 5 to 9 days, then the wound was repaired by free flaps grafting in 8 cases and by free flap combined with skin grafting in the other 14 cases. The survival and recovery conditions were followed up after the operation. Results After treatment by VSD, no obvious infection was seen in 22 cases of children patient with large area soft tissue defect complicated by underlying tissue exposure, and granulation tissue surrounding tendons and bone exposure area grew well. The survival rate of the free flaps was 100% whithout vascular crisis.The infection was well controlled, and no fistula tract was seen. The patients were followed up for 6-24 months and the flaps had soft texture and good appearance with satisfactory functional recovery of the affected limbs.Conclusion For pediatric patients with large area soft tissue defect complicated by underlying tissue exposure, after strict debridement, the treatment circle will be obviously shortened by the application of sequential vacuan seding dranage and microsurgical technique, and the success rate of the operation is improved. Therefore, function of the affected limbs in children will be recovered as far as possible.

Objective To explore the surgical method and curative effect of free vascularized fibular graft bridged vascu?lar pedicle by vein transplantation for infective long bone defect with or without soft tissue defect reconstruction. Methods From June 2008 to January 2014, 17 patients with infective long bone defect were treated, 11 male and 6 female, 1.5 to 55 years old and averaged 31.3 years. 8 cases in femur, 5 cases in tibia, 3 cases in humerus and 1 case in radius. Bone defect were 4 to 19 cm in length with an average of 9.4 cm. 8 cases with soft tissue defect, from 5.0 cm×3.0 cm to 17.0 cm×5.5 cm. Required adequate surgi?cal debridement, and vacuum sealing drainage (VSD) was used. Free vascularized fibular (skin) flap was designed and harvested . Artery and veins close to the health site were dissected, and bridged vascular pedicle of free vascularized fibular flap by autolo?gous vein transplantation with end to end anastomosis. The length free vascularized fibular graft was from 5 to 18 cm, with an aver?age of 9.6 cm. The free fibula flap ranged from 6.5 cm×4.0 cm to 18.0 cm×6.0 cm. Results All the 17 cases of fibular flap sur?vived, no vascular crisis happened. Post?operative wound primary healed in 11 cases, delayed 1 to 2 weeks to heal in 6 cases. Cal?lus was seen in the 6 to 8 weeks later. 15 cases were followed from 9 months to 6 years (averaged 30 months) while 2 cases were lost to follow?up. Bone defect primary healed in 13 cases, and the fibula graft unhealed in 2 cases, but healed again after a second operation. Fibula stress fracture occurred in one case at 7 months after grafting procedures and bone union was achieved 4 months after reapplying an external fixator. Infected bone defect healing time ranged from 4.2 to 9.8 months, averaged 5.9 months. Accord?ing to the Enneking score, 11 cases were excellent, good in 3 cases, one in fair. Excellent and Good rate was 93.3%. Conclusion Free vascularized fibular (skin) graft with vein bridged vascular pedicle can not only effectively repair infected bone and soft tissue defect, but also improve local blood supply and control infection, shorten the course of treatment, which is an effective treatment of infective long bone defects with or without soft tissue defects.