Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.

Objective To investigate the clinical effect of wrist arthroscopy in the treatment of scaphoid nonunion advanced collapse (SNAC).Methods A retrospective case series study was performed on the clinical data of 15 SNAC patients admitted from March 2011 to January 2016.There were 12 males and three females,with a mean age of 32 years (range,26-43 years).There were nine cases of right wrist injury and six cases of left wrist injury.The injury duration was 14-72 months,with an average of 18 months.According to the evaluation of the extent of wrist joint inflammation involvement under wrist arthroscopy,there were nine cases at SNAC Ⅰ stage,four at stage Ⅱ,and two at stage Ⅲ.Stage Ⅰ patients underwent wrist arthroscopy assisted radius styloid process resection,scaphoid sclerosis bone removal,and iliac bone grafting and internal fixation.Stage Ⅱ and Ⅲ patients underwent wrist arthroscopy assisted removal of most of the scaphoid and fusion fixation of skull bone and lunate bone.Joint healing time in the first month of fracture and fusion,visual analogue score (VAS) before operation and at the last follow up,joint mobility,and grip strength were recorded.Wrist function was evaluated by modified Mayo wrist function score at the last follow up.Results The patients were followed up for 9-23 months,with an average of 14 months.All cases were seen primary bone healing.The mean time of fracture healing was 11.7 weeks in stage Ⅰ SNAC patients and the mean healing time was 11 weeks in stage Ⅱ and Ⅲ patients in the first month of joint fusion.VAS decreased from (5.9 ± 0.8) points to (1.6 ± 0.9) points.Range of motion of the wrist including the flexion/extension arc and the radial/ulnar deviation arc increased respectively from preoperative (38.7 ± 6.3) °,(28.6 ± 11.2) °,(19.8 ± 1.4) °and (22.7±5.7) ° to postoperative (54.1 ±5.8)°,(43.3±9.3)°,(22.0±1.9) ° and (30.3± 4.3) °.Grip strength was improved from preoperative (10.7 ± 2.4) kg to postoperative (15.0 ± 1.9) kg (all P ＜ 0.05).The modified Mayo wrist score was increased from preoperative (57.9 ± 7.3) points to postoperative (84.5 ± 6.9) points (P ＜ 0.05).According to modified Mayo wrist scores,the result was excellent in one case,good in nine cases and fair in five.Conclusions For patients with SNAC,it is necessary to evaluate the staging under wrist arthroscopy.Arthroscopy assisted scaphoid bone grafting can be applied to stage Ⅰ patients.For stage Ⅱ and Ⅲ patients,wrist arthroscopy-assisted removal of most of the scaphoid and fusion fixation of skull bone and lunate bone is helpful to facilitate bone healing,relieve pain,and improve function.

Objective To compare the efficacy of percutaneous Kirschner wire fixation assisted by wrist arthroscopy and percutaneous hollow screw fixation under fluoroscopy in the treatment of scaphoid fresh fractures.Methods A retrospective case control study was conducted on the clinical data of 34 patients with scaphoid fresh fractures admitted from April 2009 to January 2016,including 23 males and 11 females,aged 21-44 years,with an average of 28.9 years.There were 21 cases on the right side and 13 cases on the left side.According to the classification of Herbert scaphoid fractures,there were 25 cases of type B2 and nine cases of type B3.The duration from injury to operation was 1-13 d,with an average of 3.2 d.According to the different surgical methods,the patients were divided into arthroscopic assisted percutaneous Kirschner wire fixation group (Group A,16 cases) and percutaneous hollow screw fixation under fluoroscopy group (Group B,18 cases).In Group A,four cases were treated with autogenous iliac bone graft,and three cases with scapholunate ligament injury were treated with fixation of scaphoid joint with stage Ⅰ Kirschner wire.The operation time,hospitalization time,bone healing time,visual analogue scale (VAS),disabilities of arm,shoulder and hand score (DASH),modified Mayo wrist function score,and complications were compared between the two groups.Results The patients were followed up for 6-12 months,averaging 7.5 months.The operation time of Group A and Group B was (52.3 ± 11.2) minutes and (42.5 ± 9.7) minutes,respectively (P ＜ 0.01),hospitalization time was (3.9 ± 1.4) d and (4.1 ± 1.5) d respectively (P ＞ 0.05),bone healing time was (11.8 ± 1.4) weeks and (13.2 ± 2.4) weeks respectively (P ＜ 0.05),VAS was (1.1 ± 0.6) points and (1.8 ± 0.7) points respectively (P ＜ 0.05),DASH score was (14.1 ± 5.3) points and (17.2 ± 7.8) points respectively (P ＞ 0.05),and modified Mayo wrist score was (92.1 ± 6.6) points and (85.4 ± 7.5) points respectively (P ＜0.05).One case of early Kirschner wire loosening occurred in Group A,and one case of nonunion and another of residual scapholunate instability were found in Group B.Conclusion For fresh scaphoid fractures with displacement,percutaneous Kirschner wire fixation assisted by wrist arthroscopy can shorten operation time,promote fracture healing,relieve pain,and improve wrist joint function compared with percutaneous hollow screw fixation under fluoroscopy.

Objective To evaluate the effect of wrist arthroscopy-assisted repair of stable or slightly unstable type Ⅰ B triangular fibrocartilage complex (TFCC) injury of distal radio-ulnar joint (DRUJ).Methods A retrospective case series study was conducted to analyze the clinical data of 42 patients with type Ⅰ B TFCC injuries admitted from May 2015 to August 2017,including 17 males and 25 females,aged 18-64 years,with an average of 38 years.Among the patients,20 were injured on the left side,and 22 on the right side.During the operation,if the injury was diagnosed as type Ⅰ B injury under wrist arthroscopy,outside in method with 3-0 purdis stitch was adopted to repair TFCC after joint cleaning.After the operation,the wrist joint was fixed in a neutral rotation position for 3 weeks with a long arm plaster over the elbow and then replaced with a short arm plaster for 2-3 weeks.Visual analogue scale (VAS),grip strength,joint mobility,modified Mayo wrist function score,and disabilities of arm,shoulder and hand score (DASH) before operation and at the last follow-up were compared.Results All patients were followed up for 6-24 months,with an average of 11 months.No infection or nerve injury occurred after operation.At the last follow up,wrist pain disappeared in 13 cases completely,while 29 cases still had pain during moderate activities.VAS was decreased from preoperative (2.7 ± 0.9) points to (1.2 ± 1.0) points (P ＜ 0.05).The grip strength was increased from preoperative (20.6 ± 8.3) kg to postoperative (22.5 ± 8.5) kg (P ＜ 0.05).The wrist flexion and extension,radial ulnar deviation,and forearm rotation were increased from preoperative (116.4 ± 26.0) °,(36.7 ± 10.7) °,and (137.9 ±29.1) ° to postoperative (119.4 ± 22.8) ° (P ＞ 0.05),(40.0 ± 10.6) ° (P ＜ 0.05),and (148.9 ±21.4) ° (P ＜ 0.05).The modified Mayo wrist function score increased from preoperative (67.3 ±9.6) points to postoperative (84.4 ± 6.7) points.The results were excellent in 13 cases,good in 24,and fair in five,with an excellent and good rate of 88％.The DASH score decreased from (34.6 ± 10.2)points to (10.4 ± 6.5) points after operation (P ＜ 0.05).Conclusion For patients with stable or slightly unstable type ⅠB TFCC injury of DRUJ,synovial membrane cleaning under wrist arthroscopy plus capsule repair combined with active rehabilitation training can effectively reduce wrist pain,and improve wrist radial ulnar deviation,forearm rotation and grip strength as well as improve wrist joint function.

Aseptic necrosis of lunate bone (Kienb(o)ck's disease) is a comnon cause of wrist pain in clinic.After more than a century of research,although progress has been made in the etiology,pathogenesis and clinical treatment of lunar bone aseptic necrosis,its pathogenesis remains unclear.At present,it is generally believed that the blood supply destruction of lunar bone due to trauma is one of the causes for aseptic necrosis of lunar bone.Treatnent varies according to different classifications,yet without unified or clarified therapeutic regimen.Wrist arthroscopy is a new method for Kienb(o)ck's disease.This article reviews the different stages and treatment methods of traumatic simple Kienb(o)ck's disease,providing reference for clinical treatment.

Objective:To compare the clinical efficacy between wrist arthroscopy-assisted ulnar head Wafer resection and ulnar shortening osteotomy in the treatment of ulnar impaction syndrome.Methods:From March 2012 to February 2017, 45 patients with ulnar impaction syndrome were treated at Department of Hand Surgery, No. 6 Hospital of Ningbo. They were 26 males and 19 females, aged from 28 to 48 years (average, 38 years). The right side was affected in 31 cases and the left side in 14. They were divided into 2 groups according to different surgical methods: 22 patients were subjected to arthroscopy-assisted ulnar head Wafer resection (the resection group) and 23 to open ulnar shortening osteotomy and internal fixation (the osteotomy group). Preoperative X-rays were taken to evaluate the height of positive ulnar variances and MRI was used to initially assess the damages to triangular fibrocartilage disc complex (TFCC), the semilunare and the tri-quetrum. Arthroscopy was conducted to evaluate intra-articular conditions, remove hyperplastic synovial membrane and repair the injured TFCC. In the resection group, the patients underwent arthroscopic ulnar head Wafer resection while in the osteotomy group, the patients underwent open ulnar shortening osteotomy and plate fixation. The platelet-rich plasma (PRP) was injected into the wrist joint in all cases after operation. Regular follow-ups and X-rays were performed to observe healing of the ulna. The wrist function was evaluated by the modified Mayo scoring system.Results:There was no significant difference in the general data between the resection group and the osteotomy group, showing comparability beween groups( P>0.05). Twenty patients in the resection group were followed up for an average time of 13.7 months. Their modified Mayo scores were 80.3±6.2; 7 of them were rated as excellent, 11 as good and 2 as fair, yielding a good and excellent rate of 90.0%(18/20). Twenty-two patients in the osteotomy group were followed up for an average time of 14.3 months. Three of them reported slight pain at 6-month follow-up. Their modified Mayo scores were 85.1±5.9; 6 of them were rated as excellent, 13 as good and 3 as fair, yielding a good and excellent rate of 86.4%(19/22). There was a significant difference in the modified Mayo scores between the 2 groups ( P<0.05). Conclusion:In treatment of ulnar impaction syndrome with the height of positive ulnar variances ≤3 mm, wrist arthroscopy-assisted ulnar head Wafer resection can obtain better clinical results than ulnar shortening osteotomy.