The anterior cruciate ligament (ACL), anterolateral complex (ALC) and lateral meniscus (LM) maintain the anterolateral rotatory stability of the knee and control the internal rotation of the tibia. Anterolateral rotatory instability (ALRI) of the knee is not uncommon in clinic, and its main injury mechanism is non-contact injury. A pivot shift test or a tibial internal rotation test can indicate ALRI while X-ray, CT, MRI and ultrasound can assist in its diagnosis and differential diagnosis. For acute ALRI, good technique of ACL reconstruction is the basis to avoid postoperative residual ALRI, and anterolateral ligament reconstruction and extra-articular tenodesis are optional as appropriate. For chronic cases, however, both anterolateral ligament reconstruction and extra-articular tenodesis are effective. This article reviews the progress in research on the diagnosis and treatment of ALRI of the knee, hoping to provide references for its clinical diagnosis and treatment.

Objective:To explore rational surgical treatment for childhood nail matrix nevi.Methods:A retrospective analysis was conducted on clinical data from 35 children with pathologically confirmed nail matrix nevi, who received surgical treatment in Children′s Hospital of Chongqing Medical University from September 2015 to March 2019. Different surgical approaches were adopted according to the site and width of lesions. For lesions with a width of ≤ 3 mm, the nail bed and nail matrix lesions were directly excised with 1-to-2-mm margins and sutured in 11 cases. For lesions with a width of > 3 mm, one of the following 3 surgical procedures was selected by the children′s parents: (1) shaving of nail bed and nail matrix lesions under a microscope at ×8 magnification (8 cases) ; (2) excision of lesions followed by full-thickness skin grafting on the periosteum of the phalanx (8 cases) ; (3) excision of lesions of the second to fifth fingers followed by transfer of skin flaps from the thenar muscle area and full-thickness skin grafting (5 cases) , or excision of lesions of the thumb followed by abdominal-wall flap transfer (3 cases) . The patients were followed up for 12 months, and clinical efficacy was evaluated.Results:During the follow-up, no recurrence occurred in the 11 cases receiving direct excision and suture, with good appearances and longitudinal linear scars on the nail. Among the 8 cases receiving shaving therapy under a microscope, 4 experienced relapse during the follow-up of 6 - 12 months, and the nail/toenail plates were rough and poor in lustrousness in the other 4 without recurrence. No recurrence was observed in the 8 cases receiving excision of the lesions and full-thickness skin grafting, of whom 1 experienced skin graft necrosis, and skin grafts survived with obvious pigmentation in the other 7 cases. Among cases receiving excision of the lesions combined with transfer of skin flaps from the thenar muscle area or abdominal-wall flap transfer, no recurrence was observed, and all transferred flaps survived; good appearances, nearly normal color and gloss of nails were obtained in the cases after transfer of skin flaps from the thenar muscle area, while the color and gloss of postoperative nails were markedly different from those of normal nails in the cases receiving abdominal-wall flap transfer.Conclusion:For nail matrix nevi with a width of ≤ 3 mm, direct excision and suture with 1-to-2-mm margins are recommended; for those with a width of > 3 mm, excision of lesions combined with full-thickness skin grafting, transfer of skin flaps from the thenar muscle area or abdominal-wall flap transfer is recommended; the shaving procedure under a microscope should be used with caution.

Objective:This study aims at exploring the groin area, the ulnar side of the wrist, and the medial plantar side as a more optimal donor area for repairing children’s hand volar skin defects.Methods:From December 2017 to December 2018, clinical data of children with palmar skin defects of hands who underwent full-thickness skin grafting in the Department of Burn and Plastic Surgery, Children’s Hospital Affiliated to Chongqing Medical University, were retrospectively analyzed. All skin grafts survived utterly. According to the donor site of full-thickness skin graft, the children were divided into three groups: the groin, ulnar wrist, and medial plantar skin donor group. The PANTONE skin tone guide measured the color difference between the full-thickness skin graft and the surrounding skin. The postoperative scars of the recipient and donor areas were scored by the Patient and Observer Scar Assessment Scale. Meanwhile, the postoperative effect and parents’ satisfaction with recipient and donor areas were evaluated. Kruskal Wallis rank-sum test and Mann Whitney U test were used for measurement data. Fisher’s exact test was used for counting data. A P-value <0.05 was considered significant. Results:A total of 68 children were enrolled, including 44 males and 24 females. The mean age was (3.19 ± 2.74) years (ranging from 6 months to 14 years). Among them, 37 children’s palmar skin defects were reconstructed by full-thickness skin grafts from the inguinal region, 19 from the ulnar side of the wrist, and 12 from the medial side of the plantar. The final follow-up time was from 7 months to 18 months, with an average of (14.07±2.94) months. There were significant differences among the three groups in the pigmentation of skin grafts and parents’ satisfaction ( P<0.01). The color difference of medial plantar skin donor group and ulnar wrist skin donor group was small, and the groin skin donor group had the most obvious color difference of skin graft. The satisfaction of parents in the medial plantar skin donor group was the best, followed by the ulnar wrist skin donor group, and the groin skin donor group had the worst satisfaction of parents. There was no significant difference in scar evaluation in recipient and donor areas among the three groups( P>0.05). Among the parents’ satisfaction ratings in the receiving area of the three groups, the medial plantar group had the highest proportion of excellent, followed by the ulnar wrist group and the groin group. There were significant differences among the three groups( P<0.01). Conclusions:The full-thickness skin graft harvested from the medial plantar and ulnar side of the wrist are better choices for small or medium-sized palmar skin defects in children than the inguinal area with superior aesthetics. The medial plantar area is recommended as a donor site for the palmer skin defects in hands, choosing the ulnar aspect of the wrist is more appropriate for the defects in the lateral fingers.

Objective:To investigate the safety and effectiveness of modified contiguous gullwing flaps for web space reconstruction of multiple digit symbrachydactyly.Methods:A retrospective analysis was performed on patients of multiple digit symbrachydactyly who underwent surgery in the Children’s Hospital of Chongqing Medical University from January 2018 to January 2021. The modified dorsal contiguous gullwing flaps were designed to reconstruct the web space without leaving a gap between the distal ends of each flap. After separating the fused digits with a zigzag incision, most of the wounds could be closed directly. For a few cases of the skin defect, the skin grafts harvested from the palmer-ulnar site of the ipsilateral wrist was used to cover the wound. In 2 cases, the modified design and the original design were used in combination. Intraoperative findings of the digital proper arteries, skin grafts, operation time and the finger blood supply, and the postoperative data of wound healing grade were recorded. The results were followed up and evaluated by a modified Withey scale.Results:A total of 21 patients were enrolled, including 13 males and 8 females, ranging in age from 6 months to 6 years old with an average age of 20 months. Among them, there were 13 cases of three-fingered syndactyly and 8 cases of four-fingered syndactyly, with a total of 50 webs. Among them, 8 cases were combined with the first web stenosis or partial syndactyly. In 19 cases, the degree of syndactyly was at least the half length of fingers, and the remaining 2 cases had mild symptoms. All operations could be finished within 2 hours. During the operation, one side digital artery in 6 webspaces was ligatured owing to the bifurcation point was too distal, and the vascular perfusion was normal. Small pieces of skin grafts were used in 12 fingers, the wound healed in one stage with no wound infection, and skin graft necrosis occurred. After 3-37 months of follow-up (average of 10 months), the shape of the formed webspace was natural, and the width of the webspace at the level of the metacarpophalangeal crease was not less than one-third of the width of the finger, which was coordinated with the proportion of the palm and fingers. The depth of the webs could reach or exceed the level of the metacarpophalangeal crease. The fingers were still shorter according to the size of the palm. No secondary flexion deformity, lateral deviation deformity, and rotation deformities occurred. The appearance was acceptable to the parents and no hypertrophy scar was noticed. The score evaluated by the modified Withey scale of the follow-up cases was 0.Conclusions:Using the modified contiguous gullwing flap could separate multiple fingers symbrachydactyly in one stage operation safely without skin grafting or small-size skin grafting. The procedure is mainly indicated for those cases with tight skin syndactyly. The combined application of the modified design and the original design of the contiguous gullwing flap could be recommended for patients whose skin tension is different between the three coterminous webspaces.

Objective:This study aims at exploring the groin area, the ulnar side of the wrist, and the medial plantar side as a more optimal donor area for repairing children’s hand volar skin defects.Methods:From December 2017 to December 2018, clinical data of children with palmar skin defects of hands who underwent full-thickness skin grafting in the Department of Burn and Plastic Surgery, Children’s Hospital Affiliated to Chongqing Medical University, were retrospectively analyzed. All skin grafts survived utterly. According to the donor site of full-thickness skin graft, the children were divided into three groups: the groin, ulnar wrist, and medial plantar skin donor group. The PANTONE skin tone guide measured the color difference between the full-thickness skin graft and the surrounding skin. The postoperative scars of the recipient and donor areas were scored by the Patient and Observer Scar Assessment Scale. Meanwhile, the postoperative effect and parents’ satisfaction with recipient and donor areas were evaluated. Kruskal Wallis rank-sum test and Mann Whitney U test were used for measurement data. Fisher’s exact test was used for counting data. A P-value <0.05 was considered significant. Results:A total of 68 children were enrolled, including 44 males and 24 females. The mean age was (3.19 ± 2.74) years (ranging from 6 months to 14 years). Among them, 37 children’s palmar skin defects were reconstructed by full-thickness skin grafts from the inguinal region, 19 from the ulnar side of the wrist, and 12 from the medial side of the plantar. The final follow-up time was from 7 months to 18 months, with an average of (14.07±2.94) months. There were significant differences among the three groups in the pigmentation of skin grafts and parents’ satisfaction ( P<0.01). The color difference of medial plantar skin donor group and ulnar wrist skin donor group was small, and the groin skin donor group had the most obvious color difference of skin graft. The satisfaction of parents in the medial plantar skin donor group was the best, followed by the ulnar wrist skin donor group, and the groin skin donor group had the worst satisfaction of parents. There was no significant difference in scar evaluation in recipient and donor areas among the three groups( P>0.05). Among the parents’ satisfaction ratings in the receiving area of the three groups, the medial plantar group had the highest proportion of excellent, followed by the ulnar wrist group and the groin group. There were significant differences among the three groups( P<0.01). Conclusions:The full-thickness skin graft harvested from the medial plantar and ulnar side of the wrist are better choices for small or medium-sized palmar skin defects in children than the inguinal area with superior aesthetics. The medial plantar area is recommended as a donor site for the palmer skin defects in hands, choosing the ulnar aspect of the wrist is more appropriate for the defects in the lateral fingers.

Objective:To investigate the safety and effectiveness of modified contiguous gullwing flaps for web space reconstruction of multiple digit symbrachydactyly.Methods:A retrospective analysis was performed on patients of multiple digit symbrachydactyly who underwent surgery in the Children’s Hospital of Chongqing Medical University from January 2018 to January 2021. The modified dorsal contiguous gullwing flaps were designed to reconstruct the web space without leaving a gap between the distal ends of each flap. After separating the fused digits with a zigzag incision, most of the wounds could be closed directly. For a few cases of the skin defect, the skin grafts harvested from the palmer-ulnar site of the ipsilateral wrist was used to cover the wound. In 2 cases, the modified design and the original design were used in combination. Intraoperative findings of the digital proper arteries, skin grafts, operation time and the finger blood supply, and the postoperative data of wound healing grade were recorded. The results were followed up and evaluated by a modified Withey scale.Results:A total of 21 patients were enrolled, including 13 males and 8 females, ranging in age from 6 months to 6 years old with an average age of 20 months. Among them, there were 13 cases of three-fingered syndactyly and 8 cases of four-fingered syndactyly, with a total of 50 webs. Among them, 8 cases were combined with the first web stenosis or partial syndactyly. In 19 cases, the degree of syndactyly was at least the half length of fingers, and the remaining 2 cases had mild symptoms. All operations could be finished within 2 hours. During the operation, one side digital artery in 6 webspaces was ligatured owing to the bifurcation point was too distal, and the vascular perfusion was normal. Small pieces of skin grafts were used in 12 fingers, the wound healed in one stage with no wound infection, and skin graft necrosis occurred. After 3-37 months of follow-up (average of 10 months), the shape of the formed webspace was natural, and the width of the webspace at the level of the metacarpophalangeal crease was not less than one-third of the width of the finger, which was coordinated with the proportion of the palm and fingers. The depth of the webs could reach or exceed the level of the metacarpophalangeal crease. The fingers were still shorter according to the size of the palm. No secondary flexion deformity, lateral deviation deformity, and rotation deformities occurred. The appearance was acceptable to the parents and no hypertrophy scar was noticed. The score evaluated by the modified Withey scale of the follow-up cases was 0.Conclusions:Using the modified contiguous gullwing flap could separate multiple fingers symbrachydactyly in one stage operation safely without skin grafting or small-size skin grafting. The procedure is mainly indicated for those cases with tight skin syndactyly. The combined application of the modified design and the original design of the contiguous gullwing flap could be recommended for patients whose skin tension is different between the three coterminous webspaces.

Objective:To analyze and report the anatomical characteristics, surgical management and clinical outcome for preaxial polysyndactyly with varus deformity.Methods:We retrospectively reviewed our database of cases with preaxial polysyndactyly in the Department of Burn and Plastic Surgery of Children’s Hospital of Chongqing Medical University from January 2010 to January 2020. The clinical manifestations are duplicated hallux, with complete fusion of the main and auxiliary hallux, tibial hallux dysplasia, and fibular hallux with obvious varus deformity. The anatomical characteristics of this special polysyndactyly, surgical incision design, osteoarticular correction methods were analyzed, and the axial line of the big toe after the operation and its influence on the walking function were followed up.Results:A total of 10 children with preaxial polysyndactyly (12 toes) were enrolled, including 6 male and 4 female patients. Age ranged from 5 to 45 months, with an average of 19.3 months. Eight cases were unilateral, and 2 cases were bilateral. All the cases had duplicated hallux, with tibial hallux dysplasia and proximal displacement. The fibular hallux was dominant but with varus deformity to varying degrees (varus angle 25°-90°, mean 55°). During the operation, the abductor hallucis (AbdH) was found to be attached to the tibial hallux, and the metatarsophalangeal (MTP) joint of the dominant hallux was dislocated to the tibial side, with an inclination of the joint surface. Incision design: zigzag incision around extra toes were used in 3 toes with varus angle from 25° -40°, proximal pedicle flap of the extra toe was taking in 3 toes with varus angle from 45°-90°, and double Z-plasty incision was designed in 6 toes which varus angle is from 75°-90°. Correction of bone and joint: after extra toe resected, the axis of two cases with mild hallux varus was corrected by releasing the soft tissue contracture in the tibial side of the main toe and reducing the joint. The other 10 cases were obtained completely axially corrected after opening osteotomy performed at the tibial side of the metatarsal bone or phalanx, and nine of them were treated with bone graft for filling the bone defect. Wound closure: all wounds were successfully closed. Among these, 2 of the 3 toes that taking transferred proximal pedicle flap of extra toe were supplemented with skin grafts due to skin deficiency. Although the varus angle was large, the wounds of 6 toes with double Z-plasty incision were completely closed after lengthened the longitudinal skin of the tibial side of the big toe. Two cases were lost to follow-up, and the other 8 cases (10 toes) were followed up for 5-38 months (mean 13 months). Except for 1 toe with insufficient correction (hallux varus 15°) and 2 toes with overcorrection (hallux valgus 15°, 20°), the axial lines of the other big toes were normal. All cases wore shoes and walked normally.Conclusions:The anatomical characteristics of this type of preaxial polysyndactyly are the AbdH terminating in the deformed tibial toe and the medial dislocation of the associated main hallux MTP joint resulting in varus and the oblique planar of the metatarsal articulations. The deformity of hallux varus and the deficiency of tibial skin were the characteristics and the difficulties of this special type of preaxial polysyndactyly. Good axial correction can be obtained by means of opening osteotomy and intraoperative release of abductor insertion. Then the wound can be closed at one stage without skin grafting by using a double Z-plasty incision which could fully elongate the tibial side skin.

Objective:To analyze and report the anatomical characteristics, surgical management and clinical outcome for preaxial polysyndactyly with varus deformity.Methods:We retrospectively reviewed our database of cases with preaxial polysyndactyly in the Department of Burn and Plastic Surgery of Children’s Hospital of Chongqing Medical University from January 2010 to January 2020. The clinical manifestations are duplicated hallux, with complete fusion of the main and auxiliary hallux, tibial hallux dysplasia, and fibular hallux with obvious varus deformity. The anatomical characteristics of this special polysyndactyly, surgical incision design, osteoarticular correction methods were analyzed, and the axial line of the big toe after the operation and its influence on the walking function were followed up.Results:A total of 10 children with preaxial polysyndactyly (12 toes) were enrolled, including 6 male and 4 female patients. Age ranged from 5 to 45 months, with an average of 19.3 months. Eight cases were unilateral, and 2 cases were bilateral. All the cases had duplicated hallux, with tibial hallux dysplasia and proximal displacement. The fibular hallux was dominant but with varus deformity to varying degrees (varus angle 25°-90°, mean 55°). During the operation, the abductor hallucis (AbdH) was found to be attached to the tibial hallux, and the metatarsophalangeal (MTP) joint of the dominant hallux was dislocated to the tibial side, with an inclination of the joint surface. Incision design: zigzag incision around extra toes were used in 3 toes with varus angle from 25° -40°, proximal pedicle flap of the extra toe was taking in 3 toes with varus angle from 45°-90°, and double Z-plasty incision was designed in 6 toes which varus angle is from 75°-90°. Correction of bone and joint: after extra toe resected, the axis of two cases with mild hallux varus was corrected by releasing the soft tissue contracture in the tibial side of the main toe and reducing the joint. The other 10 cases were obtained completely axially corrected after opening osteotomy performed at the tibial side of the metatarsal bone or phalanx, and nine of them were treated with bone graft for filling the bone defect. Wound closure: all wounds were successfully closed. Among these, 2 of the 3 toes that taking transferred proximal pedicle flap of extra toe were supplemented with skin grafts due to skin deficiency. Although the varus angle was large, the wounds of 6 toes with double Z-plasty incision were completely closed after lengthened the longitudinal skin of the tibial side of the big toe. Two cases were lost to follow-up, and the other 8 cases (10 toes) were followed up for 5-38 months (mean 13 months). Except for 1 toe with insufficient correction (hallux varus 15°) and 2 toes with overcorrection (hallux valgus 15°, 20°), the axial lines of the other big toes were normal. All cases wore shoes and walked normally.Conclusions:The anatomical characteristics of this type of preaxial polysyndactyly are the AbdH terminating in the deformed tibial toe and the medial dislocation of the associated main hallux MTP joint resulting in varus and the oblique planar of the metatarsal articulations. The deformity of hallux varus and the deficiency of tibial skin were the characteristics and the difficulties of this special type of preaxial polysyndactyly. Good axial correction can be obtained by means of opening osteotomy and intraoperative release of abductor insertion. Then the wound can be closed at one stage without skin grafting by using a double Z-plasty incision which could fully elongate the tibial side skin.

Objective:To evaluate the clinical performance of postoperative deformity after the release of simple syndactyly, and to discuss the corresponding method for repair.Methods:Clinical data of 25 children with postoperative deformities after simple syndactyly releasing were reviewed retrospectively in the past 5 years, including 13 males and 12 females, with an average age of 3 years and 2 months. The possible causes leaded to postoperative deformity were analyzed by investigating the data of the first operation, including the age of the first operation, whether there was skin graft and whether there was postoperative infection. The common types of postoperative deformities were summarized through morphological observation, and the main methods of reoperation repair were reviewed. During follow-up, the improvement of postoperative deformities after repair was evaluated from the four aspects of webbed shape, finger shape, fingernail shape and skin color difference, so as to propose an effective repair plan for such postoperative deformities.Results:The average age of the first operation was 1 year and 5 months, 15 cases had no skin graft with tense skin, and 4 cases had a history of wound infection. The postoperative deformities of simple syndactyly can be summarized in four main categories: web deformity in 27 webs, finger deformity in 53 fingers, nail deformity in 46 nails and skin color difference in 15 fingers. During the revision surgery, for web deformity, Z-plasty technique were used to widen narrow webs, the flaps were used to reconstruct the recurred webs and the double wing flap were used in 13 webs. For finger deformity, in all cases, most of scar skin was reserved and released by multiple Z-plasty incisions to extend and straighten the fingers, while full-thickness skin grafting was employed if lacking of enough skin to close wound. For nail deformity, using the adjacent flap pushed forward to wrap the nail margin in 14 crooked nail cuticles and others remained untreated. For skin color difference, using z-plasty incision to break the large piece of dark skin into small one and remove the overly dark skin as much as possible. The average follow-up time after reoperation was 33 months, and all webs reached the normal depth and width. Except for the incomplete correction of the lateral deviation in 1 finger, the deformity of the other fingers hand was corrected completely. There was no improvement in other nail deformity except for 10 skew nail cuticle being improved. The skin color difference were improved in all cases.Conclusions:The occurrence of postoperative deformity of simple syndactyly may be related to the tight stitching (should have skin grafting) and the wound infection during primary surgery. The reconstructive operation should be performed about one year after the initial operation when the scar is softened. The flaps for construction of web space, especially double wing flap, can be used widely in all kinds of web deformities, which could result in excellent web shape. The area of skin grafting can be reduced dramatically by reserving softened scar skin. Multiple Z-plasty technique can make use of the transverse excess skin to extend the longitudinal skin and corrected enlarged finger bodies. When should be used to reduce the color difference. But the repair of most of nail deformity were too difficult to improve.

Objective:To evaluate the clinical performance of postoperative deformity after the release of simple syndactyly, and to discuss the corresponding method for repair.Methods:Clinical data of 25 children with postoperative deformities after simple syndactyly releasing were reviewed retrospectively in the past 5 years, including 13 males and 12 females, with an average age of 3 years and 2 months. The possible causes leaded to postoperative deformity were analyzed by investigating the data of the first operation, including the age of the first operation, whether there was skin graft and whether there was postoperative infection. The common types of postoperative deformities were summarized through morphological observation, and the main methods of reoperation repair were reviewed. During follow-up, the improvement of postoperative deformities after repair was evaluated from the four aspects of webbed shape, finger shape, fingernail shape and skin color difference, so as to propose an effective repair plan for such postoperative deformities.Results:The average age of the first operation was 1 year and 5 months, 15 cases had no skin graft with tense skin, and 4 cases had a history of wound infection. The postoperative deformities of simple syndactyly can be summarized in four main categories: web deformity in 27 webs, finger deformity in 53 fingers, nail deformity in 46 nails and skin color difference in 15 fingers. During the revision surgery, for web deformity, Z-plasty technique were used to widen narrow webs, the flaps were used to reconstruct the recurred webs and the double wing flap were used in 13 webs. For finger deformity, in all cases, most of scar skin was reserved and released by multiple Z-plasty incisions to extend and straighten the fingers, while full-thickness skin grafting was employed if lacking of enough skin to close wound. For nail deformity, using the adjacent flap pushed forward to wrap the nail margin in 14 crooked nail cuticles and others remained untreated. For skin color difference, using z-plasty incision to break the large piece of dark skin into small one and remove the overly dark skin as much as possible. The average follow-up time after reoperation was 33 months, and all webs reached the normal depth and width. Except for the incomplete correction of the lateral deviation in 1 finger, the deformity of the other fingers hand was corrected completely. There was no improvement in other nail deformity except for 10 skew nail cuticle being improved. The skin color difference were improved in all cases.Conclusions:The occurrence of postoperative deformity of simple syndactyly may be related to the tight stitching (should have skin grafting) and the wound infection during primary surgery. The reconstructive operation should be performed about one year after the initial operation when the scar is softened. The flaps for construction of web space, especially double wing flap, can be used widely in all kinds of web deformities, which could result in excellent web shape. The area of skin grafting can be reduced dramatically by reserving softened scar skin. Multiple Z-plasty technique can make use of the transverse excess skin to extend the longitudinal skin and corrected enlarged finger bodies. When should be used to reduce the color difference. But the repair of most of nail deformity were too difficult to improve.