OBJECTIVE: To investigate the effectiveness of free latissimus dorsi myocutaneous flap transplantation combined with external fixation in the treatment of bone and soft tissue defects around the knee joint. METHODS: A retrospective analysis was conducted on the clinical data of 13 patients with high-energy trauma-induced bone and soft tissue defects around the knee joint admitted between January 2016 and July 2023. Among them, 11 were male and 2 were female, the age ranged from 23 to 61 years, with an average of 35.7 years. The causes of injury included 10 cases of traffic accident, 2 cases of machine entanglement injury, and 1 case of heavy object crush injury. According to the Gustilo-Anderson classification, 11 cases were type Ⅲ B and 2 cases were type Ⅲ C. Post-injury, 2 cases had wound infection and 2 cases had popliteal artery injury. The time from injury to flap repair was 40-49 days, with an average of 27.5 days. The wound size was 18 cm×13 cm to 32 cm×20 cm, all accompanied by distal femoral bone defects and quadriceps muscle defects. After primary debridement, vacuum sealing drainage combined with external fixation was used for treatment. In the second stage, free latissimus dorsi myocutaneous flaps were transplanted to repair soft tissue defects, with the flap size ranging from 20 cm×15 cm to 34 cm×22 cm. The donor sites of 9 flaps were directly sutured, and 4 cases with large tension were repaired with a keystone flap based on the posterior intercostal artery perforator. At 6-15 months postoperatively, with an average of 10.5 months, 11 patients underwent knee arthrodesis surgery; 2 patients with large bone defects at the distal femur and proximal tibia underwent multi-segment bone transport reconstruction of the bone defect. At last follow-up, the recovery of the flap and the donor site was recorded, and the function of the shoulder joint was evaluated by the American Shoulder and Elbow Surgeons (ASES) score, and the function of the affected knee joint was evaluated by the Knee Society Score (KSS). RESULTS: All the flaps survived after operation, the wounds and donor site incisions healed by first intention. All 13 patients were followed up 15-55 months, with an average of 21.6 months. Four patients who underwent the restoration of the donor site with the thoracodorsal keystone perforator flap had obvious scar hyperplasia around the wound, but no contracture or symmetrical breasts on both sides. At last follow-up, the appearance and texture of the flaps were good; the bony fusion of the knee joint was good, and the range of motion and function recovered well; the shoulder joint function on the flap-harvested side was not significantly affected, and the range of motion was satisfactory. The ASES shoulder joint score of the latissimus dorsi muscle-harvested side was 85-95, with an average of 89.5. The knee joint function KSS score was 75-90, with an average of 81.2. CONCLUSION Free latissimus dorsi myocutaneous flap transplantation combined with external fixation for the treatment of bone and soft tissue defects around the knee joint caused by high-energy trauma can repair bone and soft tissue defects and reconstruct the stability of the knee joint, effectively preserve the integrity of the limb and soft tissues, and improve the patient's ability of self-care.
Humans ; Male ; Female ; Adult ; Middle Aged ; Retrospective Studies ; Soft Tissue Injuries/surgery* ; Plastic Surgery Procedures/methods* ; Superficial Back Muscles/transplantation* ; External Fixators ; Myocutaneous Flap/transplantation* ; Knee Joint/surgery* ; Young Adult ; Treatment Outcome ; Knee Injuries/surgery* ; Free Tissue Flaps/transplantation*

Objective:To investigate the clinical effect on sural neurovascular flap of small saphenous vein super drainage in reconstruction of soft tissue defects in foot and ankle.Methods:A retrospective case study was conducted to analyse the data of 22 patients who had transfer of sural neurovascular flaps of small saphenous vein with super drainage for reconstruction of soft tissue defects in foot and ankle in the Department of Microrepair and Reconstruction, the First Affiliated Hospital of Xinjiang Medical University from June 2018 to September 2023. The patients were 19 males and 3 females aged from 16 to 70 years, with an average age of 39.0 years. Seven patients had the injury caused by compression cut, 2 of car accident, 4 of falling from height, 8 of infective wound and 1 of burning scar. The flaps were 7.0 cm × 5.0 cm - 15.0 cm × 9.0 cm in size. High frequency CDU was employed before surgery to detect the velocity of blood flow of the super drainage small saphenous vein. The patients who received transfer of sural neurovascular flap of small saphenous vein super drainage were entered in scheduled follow-up at outpatient clinic or via telephone interviews after surgery to observe the flap appearance, healing of donor and recipient sites, and the function of the affected limb. High frequency CDU was used to detect the velocity of blood flow of the small saphenous vein super drainage in follow-up.Results:All patients were included in the postoperative follow-up for 8-36 months, with an average of 20.15 months. Twenty-one flaps survived completely. One flap had partial necrosis at the edge. High frequency CDU detected an average velocity of blood flow at 2.80 cm/s in the small saphenous vein super drainage. The flaps had good colour and texture without swelling, and the wound in the recipient site healed well. The function of the affected limb was evaluated according to the functional assessment criteria of American Orthopaedic Foot and Ankle Society (AOFAS), with 21 patients in excellent and 1 in good. All patients had gained normal ankle function.Conclusion:The sural neurovascular flap with a super perfused small saphenous vein can establish effective venous reflux, reduce the risk of distal necrosis of the flap, and is an effective method for reconstruction of soft tissue defects around foot and the ankle.

Objective:To preliminarily explore and compare the efficacy of free fibular flap transfer with vascular anastomosis and Ilizarov bone transport in treatment of infected bone defects after internal fixation of humeral fractures.Methods:A retrospective analysis was conducted on 29 patients who were treated by transfer of free fibular flap and Ilizarov bone transport for infected nonunion of humeral fractures after internal fixation in the Department of Trauma and Microreconstructive Surgery, the First Affiliated Hospital of Xinjiang Medical University between January 2017 and January 2023. Twelve patients with humeral defects at 4.0 - 6.0 cm in length (5.1 cm in average) were treated with free fibular flap transfer (flap transfer group) and 17 patients with humeral defect at 6.0-10.0 cm in length (7.3 cm in average) were treated by Ilizarov bone transport (bone transport group). All patients were included in the scheduled postoperative follow-up through a combination of outpatient visits and WeChat and telephone interviews. Follow-up included observation of humeral X-ray and shoulder-elbow function. Data were analysed using SPSS 27.0. Homogeneity tests were conducted on the basic data of the 2 groups, such as age, gender, length of bone defect, bone healing time and follow-up period. P<0.05 was considered statistically significant for the difference. Results:All 29 patients had completed the postoperative follow-up that lasted 8-89 months with 41.3 months in average. The lengths of bone defects were 5.2 cm±0.5 cm and 7.0 cm±1.2 cm, the bone healing time was 6.4 months±1.8 months and 14.2 months±4.6 months, and the follow-up time was 17.6 months±6.8 months and 34.4 months ±18.2 months in flap transfer group and bone transport group, respectively. Constant-Murley shoulder score was recorded of 86.0 ± 8.6 and 82.4±10.0 respectively for flap transfer group and bone transport group. Enneking Lower Extremity Functional Score in the flap transfer group was 25.0 ± 3.4, while that for bone transport group was not evaluated due to the absence of lower extremity surgery. There were statistically significant differences in bone defects, bone healing time, and follow-up time between the 2 groups ( P<0.01). There was no statistically significant differences in Constant-Murley shoulder score between the 2 groups ( P>0.05). However, in the flap transfer group, 1 patient developed a haematoma at fibular donor site after surgery, and the haematoma was removed in a secondary surgery, after which the surgical site healed smoothly. The external fixator had gone loose in 1 patient and resulted in a fracture of the transferred fibula. After the external fixator was re-fixed, the fracture healed at 8 months after surgery, and the external fixator was removed at 10 months after surgery. In the bone transport group, 3 patients had poor bone healing at fracture ends. Two patients had axial shifting of bones, the external fixator was adjusted during the bone transport process to correct the bone shifting. One patient suffered an incomplete radial nerve injury, and the radial nerve exploration and release surgery was performed. For that patient, an improvement of muscle strength was seen at 3 months and the wrist and digital extensions regained at 7 months after the radial nerve release surgery. The rest of humeri healed smoothly. Conclusion:In treatment of an infected humeral defect, it was found that a bone transport might be a better option for a larger humeral defect, while the free fibular flap transfer would be more suitable for a smaller humeral defect.

Objective:To analyze the efficacy of distal tibial osteotomy and bone transport in the treatment of infected bone defects at the proximal tibia.Methods:A retrospective study was conducted to analyze the clinical data of 25 patients with infected bone defects at the proximal tibia who had been treated by distal osteotomy and bone transport at Department of Microprosthetic Surgery, The First Hospital Affiliated to Xinjiang Medical University from May 2015 to June 2023. There were 20 males and 5 females with an age of (45.9±7.1) years. The length of bone defects was (7.5±3.9) cm, the number of operations 3 (2, 4) times, the distance from bone defects to the tibial plateau (4.1±1.9) cm, and the length of bone defects (7.5±3.9) cm. Six patients finished debridement and osteotomy in one operation. Staged surgery was conducted in 19 patients. At first, the original fixator was removed, followed by debridement and injection of the antibiotic bone cement. Next, the bone cement was removed to clean the lesion completely, and then the medullary cavity was penetrated by an electric drill to install an external fixator after flushing. Bone transport started 7 to 10 days later, at a speed of 1 mm/d, and was carried out in 4 times. The healing index, external fixation time, and external fixation index were recorded. The visual analog scale (VAS) for pain, knee range of motion (ROM), and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were compared between preoperation, 1-month postoperation, and the last follow-up. Fracture healing was evaluated using the Paley criteria, and complications were documented.Results:In this cohort, the healing index was (68.9±35.6) points, the external fixation time 13.0 (8.5, 21.8) months, and the external fixation index (2.43±1.24) points. All patients were followed up for 13.0 (8.5, 21.7) months. The VAS score, knee ROM, and AOFAS ankle-hindfoot score at the last follow-up were significantly improved compared with preoperation and 1-month postoperation ( P<0.05). According to the Paley criteria, fracture healing was excellent in 14, good in 9 and poor in 2 cases, giving an excellent and good rate of 92.0%. The incidences of ankle and knee movement limitations were 92.0% (23/25) and 76.0% (19/25), respectively, being the highest. The incidences of foot drop, clubfoot and claw toe were 68.0% (17/25), 24.0% (6/25) and 20.0% (5/25), respectively. The incidences of pin tract infection and nonunion at the junction were 56.0% (14/25) and 60.0% (15/25), respectively. All these complications were improved by dressing change or surgery. Conclusions:Distal tibial osteotomy and bone transport can effectively treat infected bone defects at the proximal tibia, and the complications during the treatment need to be treated accordingly.

Objective:To investigate the clinical effect on sural neurovascular flap of small saphenous vein super drainage in reconstruction of soft tissue defects in foot and ankle.Methods:A retrospective case study was conducted to analyse the data of 22 patients who had transfer of sural neurovascular flaps of small saphenous vein with super drainage for reconstruction of soft tissue defects in foot and ankle in the Department of Microrepair and Reconstruction, the First Affiliated Hospital of Xinjiang Medical University from June 2018 to September 2023. The patients were 19 males and 3 females aged from 16 to 70 years, with an average age of 39.0 years. Seven patients had the injury caused by compression cut, 2 of car accident, 4 of falling from height, 8 of infective wound and 1 of burning scar. The flaps were 7.0 cm × 5.0 cm - 15.0 cm × 9.0 cm in size. High frequency CDU was employed before surgery to detect the velocity of blood flow of the super drainage small saphenous vein. The patients who received transfer of sural neurovascular flap of small saphenous vein super drainage were entered in scheduled follow-up at outpatient clinic or via telephone interviews after surgery to observe the flap appearance, healing of donor and recipient sites, and the function of the affected limb. High frequency CDU was used to detect the velocity of blood flow of the small saphenous vein super drainage in follow-up.Results:All patients were included in the postoperative follow-up for 8-36 months, with an average of 20.15 months. Twenty-one flaps survived completely. One flap had partial necrosis at the edge. High frequency CDU detected an average velocity of blood flow at 2.80 cm/s in the small saphenous vein super drainage. The flaps had good colour and texture without swelling, and the wound in the recipient site healed well. The function of the affected limb was evaluated according to the functional assessment criteria of American Orthopaedic Foot and Ankle Society (AOFAS), with 21 patients in excellent and 1 in good. All patients had gained normal ankle function.Conclusion:The sural neurovascular flap with a super perfused small saphenous vein can establish effective venous reflux, reduce the risk of distal necrosis of the flap, and is an effective method for reconstruction of soft tissue defects around foot and the ankle.

Objective:To preliminarily explore and compare the efficacy of free fibular flap transfer with vascular anastomosis and Ilizarov bone transport in treatment of infected bone defects after internal fixation of humeral fractures.Methods:A retrospective analysis was conducted on 29 patients who were treated by transfer of free fibular flap and Ilizarov bone transport for infected nonunion of humeral fractures after internal fixation in the Department of Trauma and Microreconstructive Surgery, the First Affiliated Hospital of Xinjiang Medical University between January 2017 and January 2023. Twelve patients with humeral defects at 4.0 - 6.0 cm in length (5.1 cm in average) were treated with free fibular flap transfer (flap transfer group) and 17 patients with humeral defect at 6.0-10.0 cm in length (7.3 cm in average) were treated by Ilizarov bone transport (bone transport group). All patients were included in the scheduled postoperative follow-up through a combination of outpatient visits and WeChat and telephone interviews. Follow-up included observation of humeral X-ray and shoulder-elbow function. Data were analysed using SPSS 27.0. Homogeneity tests were conducted on the basic data of the 2 groups, such as age, gender, length of bone defect, bone healing time and follow-up period. P<0.05 was considered statistically significant for the difference. Results:All 29 patients had completed the postoperative follow-up that lasted 8-89 months with 41.3 months in average. The lengths of bone defects were 5.2 cm±0.5 cm and 7.0 cm±1.2 cm, the bone healing time was 6.4 months±1.8 months and 14.2 months±4.6 months, and the follow-up time was 17.6 months±6.8 months and 34.4 months ±18.2 months in flap transfer group and bone transport group, respectively. Constant-Murley shoulder score was recorded of 86.0 ± 8.6 and 82.4±10.0 respectively for flap transfer group and bone transport group. Enneking Lower Extremity Functional Score in the flap transfer group was 25.0 ± 3.4, while that for bone transport group was not evaluated due to the absence of lower extremity surgery. There were statistically significant differences in bone defects, bone healing time, and follow-up time between the 2 groups ( P<0.01). There was no statistically significant differences in Constant-Murley shoulder score between the 2 groups ( P>0.05). However, in the flap transfer group, 1 patient developed a haematoma at fibular donor site after surgery, and the haematoma was removed in a secondary surgery, after which the surgical site healed smoothly. The external fixator had gone loose in 1 patient and resulted in a fracture of the transferred fibula. After the external fixator was re-fixed, the fracture healed at 8 months after surgery, and the external fixator was removed at 10 months after surgery. In the bone transport group, 3 patients had poor bone healing at fracture ends. Two patients had axial shifting of bones, the external fixator was adjusted during the bone transport process to correct the bone shifting. One patient suffered an incomplete radial nerve injury, and the radial nerve exploration and release surgery was performed. For that patient, an improvement of muscle strength was seen at 3 months and the wrist and digital extensions regained at 7 months after the radial nerve release surgery. The rest of humeri healed smoothly. Conclusion:In treatment of an infected humeral defect, it was found that a bone transport might be a better option for a larger humeral defect, while the free fibular flap transfer would be more suitable for a smaller humeral defect.

Objective:To analyze the efficacy of distal tibial osteotomy and bone transport in the treatment of infected bone defects at the proximal tibia.Methods:A retrospective study was conducted to analyze the clinical data of 25 patients with infected bone defects at the proximal tibia who had been treated by distal osteotomy and bone transport at Department of Microprosthetic Surgery, The First Hospital Affiliated to Xinjiang Medical University from May 2015 to June 2023. There were 20 males and 5 females with an age of (45.9±7.1) years. The length of bone defects was (7.5±3.9) cm, the number of operations 3 (2, 4) times, the distance from bone defects to the tibial plateau (4.1±1.9) cm, and the length of bone defects (7.5±3.9) cm. Six patients finished debridement and osteotomy in one operation. Staged surgery was conducted in 19 patients. At first, the original fixator was removed, followed by debridement and injection of the antibiotic bone cement. Next, the bone cement was removed to clean the lesion completely, and then the medullary cavity was penetrated by an electric drill to install an external fixator after flushing. Bone transport started 7 to 10 days later, at a speed of 1 mm/d, and was carried out in 4 times. The healing index, external fixation time, and external fixation index were recorded. The visual analog scale (VAS) for pain, knee range of motion (ROM), and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were compared between preoperation, 1-month postoperation, and the last follow-up. Fracture healing was evaluated using the Paley criteria, and complications were documented.Results:In this cohort, the healing index was (68.9±35.6) points, the external fixation time 13.0 (8.5, 21.8) months, and the external fixation index (2.43±1.24) points. All patients were followed up for 13.0 (8.5, 21.7) months. The VAS score, knee ROM, and AOFAS ankle-hindfoot score at the last follow-up were significantly improved compared with preoperation and 1-month postoperation ( P<0.05). According to the Paley criteria, fracture healing was excellent in 14, good in 9 and poor in 2 cases, giving an excellent and good rate of 92.0%. The incidences of ankle and knee movement limitations were 92.0% (23/25) and 76.0% (19/25), respectively, being the highest. The incidences of foot drop, clubfoot and claw toe were 68.0% (17/25), 24.0% (6/25) and 20.0% (5/25), respectively. The incidences of pin tract infection and nonunion at the junction were 56.0% (14/25) and 60.0% (15/25), respectively. All these complications were improved by dressing change or surgery. Conclusions:Distal tibial osteotomy and bone transport can effectively treat infected bone defects at the proximal tibia, and the complications during the treatment need to be treated accordingly.

Objective:To investigate the clinical effect of two types of free gracilis musculocutaneous flap in transverse or vertical for reconstruction of the complex wound in calf.Methods:A retrospective series case study was conducted to analyse the clinical data of 22 patients who were treated in the Department of Microrepair and Reconstruction, the First Affiliated Hospital of Xinjiang Medical University for complex single wounds in calf from August 2019 to January 2023. The patients were 12 males and 10 females and aged 26-58 years old, with 46.7 years old in average. There were 12 wounds on the left calf and 10 on the right. Nine of the wounds were of car accident, 8 of iatrogenic complications, 3 of bone infection and 2 of tumour resection. The wounds sized at 10.0 cm× 5.0 cm - 15.0 cm×7.0 cm. Sixteen transverse gracilis myocutaneous flaps and 6 vertical gracilis myocutaneous flaps were designed and harvested to reconstruct complex wounds in calf. The flaps were 12.0 cm×6.0 cm - 22.0 cm×9.0 cm in size. Time for the gracilis myocutaneous flap harvesting and the time for whole surgery were recorded. The time for flap harvest was 40-60 minutes and the time for the whole surgery was 3- 5 hours. Flap donor sites were directly sutured. All patients were included in the regular postoperative follow-up at outpatient clinic or through telephone and WeChat interviews and the flap survival, long-term flap appearance, healing of donor and recipient sites and limb functions were observed.Results:All 22 flaps survived after surgery. One flap had a blue edge with blood oozing. Urgent surgical exploration revealed that embolization occurred at the anastomotic site between the great saphenous vein at the proximal end of the flap and the great saphenous vein at the recipient site. After removal of the thrombus, the veins were re-anastomosed and flap survived. All the donor sites healed in stage one and functioned well. All patients entered postoperative follow-up for 5-25 months, 14.42 months in average. The flaps were in satisfactory appearance with good texture. All recipient sites healed without complication. The infected wounds were controlled. Function of the limbs was evaluated according to the Punor functional assessment criteria with excellent for 15 patients, good for 5 and fair for 2.Conclusion:Application of free transverse and vertical layout of gracilis musculocutaneous flap is an effective method to reconstruct a complex wound in calf. The anastomosis of the great saphenous vein at the proximal end of the gracilis muscle flap with great saphenous vein or small saphenous vein at the recipient site can reduce the occurrence of venous occlusion.

Objective:To investigate the clinical effect of vascularised free fibula transfer in the treatment of infectious bone defects after the surgery of proximal and distal femoral fractures.Methods:The clinical data of 27 patients with femoral bone defects treated by vascularised free fibulae grafting with fibular artery and vein as pedicle from December 2010 to December 2022 were retrospectively analysed in the Department of Trauma and Microreconstructive Surgery, the First Affiliated Hospital of Xinjiang Medical University. There were 21 males and 6 females, at 17-72 years old, with a mean age of 41.7 years old. Twenty-one patients had bone defect of right femurs and 6 of left femurs. The length of bone defect ranged from 5.0 cm to 9.0 cm, with an average of 6.6 cm. The length of transferred fibulae ranged from 5.0 cm to 14.0 cm, with an average of 6.8 cm. Donor sites were carefully sutured layer by layer, and standardised antibiotic therapy was given before and after surgery. X-ray reviews of the affected limbs were taken at 1, 3, 6, 12, 18 and 24 months after surgery to observe the healing of the transferred fibulae and femurs to evaluate the time for full weight-bearing and removal of external frames. Before discharge, the patients were instructed to carry out pin tract care for prevention of infection. The psychological status of the patients was monitored at outpatient clinic or telephone interviews, and the functional recovery of the affected limbs was assessed using the Enneking lower limb function scoring system.Results:All of 27 patients were included in the postoperative follow-up from 19 months to 34 months, with a mean time of 26.1 months. The transferred fibulae survived with bone union. The bone healing time was from 5.1 months to 8.8 months, with an average of 7.1 months. Twenty-five patients had primary healing of the recipient site wound, and 2 patients had a sinus formed at the orifice of drainage with secretion, and the results of bacterial culture were negative. The sinuses healed after cleaning and dressing change at outpatient clinic. No stress fracture was observed from the transferred fibulae in all patients, as well as no recurrence of infection at recipient sites. The Enneking lower limb function score at the final follow-up ranged from 22 points to 27 points, with an average of 23.7 points.Conclusion:Anastomosis of vascularised free fibula in bone transfer is a feasible method to reconstruct the infected bone defects after proximal and distal femoral fractures. It provides reliable fixation and satisfactory bone healing for bone defects and facilitates the healing of transferred fibula and the recovery of lower limb function.

In January 2021, a 48-year old patient with an extensive open fracture and an infection in left calf was treated in the Microsurgical Orthopaedic Centre, the First Affiliated Hospital of Xinjiang Medical University. After the thorough debridement and successful infection control, a large soft tissue defect (32.0 cm×25.0 cm) in the left calf was reconstructed using a 35.0 cm×8.0 cm free latissimus dorsi myocutaneous flap which also facilitated the replacement of damaged Achilles tendon. The large area of wound in anterior tibia was covered with a medium-thickness skin graft. The 13.0 cm defect of left tibial bone was reconstructed by an in situ bone lengthening from the fractured left tibia in the stage Ⅱ surgery. At the 23-month postoperative follow-up, the flap survived well, with the Achilles tendon had regained a muscle strength at grade Ⅲ. Sensation was improved to S 4 in the weight-bearing areas of left foot, with TPD of 15 mm. The fracture of the extended tibial segment healed well. Overall function of the left ankle was rated as good using the American Orthopedic Foot and Ankle Society (AOFAS) standards.