Metatarsal Bones/surgery* ; Thumb/abnormalities* ; Metacarpal Bones/surgery* ; Plastic Surgery Procedures

Objective:To evaluate the short-term outcomes of modified reverse Sauvé-Kapandji technique in treating the congenital radioulnar synostosis.Methods:A retrospective analysis was performed on the data of 46 congenital radioulnar synostosis patients were treated with modified reverse Sauvé-Kapandji technique in Beijing Jishuitan Hospital from December 2018 to January 2020, including 38 males (45 sides), 8 females (9 sides), average age 6.6 (3.2, 8.1) years old. All the patients were classified as type III according to Cleary-Omer classification and were followed up for at least 1 year. All the patients were treated with same operation, in which 1.5 cm shaft was resected at the proximal radius, allogeneic graft tendon was used as interposition, and rotational osteotomy was performed in the middle of the ulnar shaft, with intramedullary needle or Kirschner wire fixation, depending on the intramedullary width of ulnar shaft. The radiological features were collected and recorded preoperatively and at the latest follow-up, together with the following evaluation indexes: modified Morrey tasks score, subjective function score, active forearm rotation range without compensation, active forearm rotation range with wrist joint compensation, and active forearm rotation range with wrist and shoulder joint compensation.Results:All patients were followed up for 14.6±3.4 months (range, 11.2-19.5 months). The uncompensated forearm rotation Angle was 0.0°±0.0° before surgery and 62.3°±23.7° after surgery. The forearm rotation angles before and after surgery with wrist compensatory surgery were 86.9°±29.4° and 133.2°±27.9°, respectively. The forearm rotation angles before and after surgery with wrist and shoulder joint compensatory surgery were 205.2°±42.7° and 245.2°±35.8°, respectively. There were statistically significant differences in the above indexes before and after surgery ( t=8.71, P<0.001; t=2.54, P=0.030; t=5.05, P<0.001). Ulnar union was observed in 31 patients (37 sides) after the operation, and the union duration was 6.1±2.3 months. There were 15 patients (17 sides) ulnar shafts faced with postoperative delayed union, the union duration was 8.4±1.6 months and were recovered after prolonging brace fixation and orthopedic shock wave treatment. The scores of subjective function and improved Morrey tasks of the 43 sides with good pseudo-joint were 12.1 (0.0, 20.8) and 0.7 (0.0, 1.0) points, respectively, which were improved compared with 33.9 (25.0, 41.6) and 3.2 (2.0, 4.0) points before surgery. The differences were statistically significant ( Z=-2.44, P=0.015; Z=-2.83, P=0.005). There were 11 forearms with postoperative pseudo-joint re-ankylosis, the average forearm rotation ranges without compensation was 11.4°±10.5°(range, 0°-30°), the average forearm rotation ranges with wrist compensation was 98.6°±15.9° (range, 80°-120°), the average forearm rotation ranges with wrist and shoulder compensation was 231.7°±16.9° (range, 210°-255°). The average subjective function scores was 26.7 (8.3, 39.6). The average modified Morrey tasks scores was 1.2 (0, 2), and there were no other postoperative complications. Conclusion:The reverse Sauvé-Kapandji technique showed a satisfying short-term outcome, and can be a new choice of treatment for type III congenital radioulnar synostosis.

Congenital thumb hypoplasia is a rare congenital limb deformity, which has major impact on hand and upper limb functions. Since Buck-Gramcko published the classic literature on index finger pollicization, it has become the standard technique for the treatment of severe thumb dysplasia. This technique is also recognized as one of the milestones in the history of hand surgery. Blauth classification and later modified classification are proposed to find a designated point that separates "thumb preservation with functional reconstruction" and "index finger pollicization" . It has been repeatedly established that "index finger pollicization should be the first option" . But in reality, regardless of race, culture or country, most parents would still prefer surgeons to preserve the thumb, even if the functions are somewhat compromised. For them, "five is better than four under any circumstances" . Over the past ten years, our team has treated more than nearly 300 cases of Manske type 3-4 thumb dysplasia. For everyone of them, we had a detailed preoperative consultation and demonstrated the photos of the post-pollicization thumb that presented unparalleled functions. Nevertheless, after reviewing the postoperative photos of the cases of thumb preservation, 90% of the parents still insisted on keeping the thumb. "4" or "5" is not just a matter of numbers, but more of a complicated conundrum of philosophy, psychology and ethics, like many other clinical dilemmas. Anytime when physicians’ own preferences are inconsistent with the patients’, it is up to the physicians’ to listen and make compromises accordingly. The major principles of thumb hypoplasia treatment and surgical details were summarized in this manuscript. It is our intention that such comprehensive guidelines could be helpful to our colleagues in the same field.

Objective:To investigate the clinical effect of free fibular head epiphysis transplantation pedicled with the recurrent branch of the anterior tibial artery in the treatment of children with Bayne-Klug Ⅱ-Ⅲ congenital radial dysplasia.Methods:From February 2013 to September 2018, we retrospectively reviewed and analyzed our prospective database of four patients with Bayne-Klug type Ⅱ-Ⅲ congenital radius dysplasia referred to Beijing Jishuitan Hospital for consideration of free fibular head epiphysis transplantation. All children underwent surgical treatment by stages: (1) Before surgery, the radial soft tissue and wrist joint were gradually stretched by massage and traction braced to maximize the radial space. (2) A free fibular head pedicled with the recurrent branch of the anterior tibial artery was harvested from the ipsilateral lower limb and transferred as a vascularized fibular head composite flap for reconstructing the stable structure of the distal radius and wrist joint. (3) At least six months after the procedure, pollicization was performed on Blauth type Ⅳ and Ⅴ. The treatment effect was evaluated by measuring the radial deviation angle, the growth length of the fibula, and the ratio of the radius/ulna length.Results:A total of 4 boys with right side deformity were enrolled. The ages of the patients ranged from 16 to 62 months, with an average of 30.5 months. The post-operative follow-up period was 19 to 78 months, with an average of 40.5 months. Three children with Blauth type Ⅳ or Ⅴ thumb dysplasia were performed with pollicization about one year after free fibular head epiphysis transplantation. All the grafted bones healed; the radial deviation angle was corrected by an average of 24°; the reconstructed distal radius grew longer, with an average increase of 13.2% when the plate was removed compared with six weeks post-operatively; the ratio of the radius/ulna was an average increase of 13.3% compared with preoperative.Conclusions:The use of fibular head epiphyseal flap pedicled with the recurrent branch of the anterior tibial artery is a good method for the treatment of Bayne-Klug type Ⅱ-Ⅲ radius dysplasia. The reconstructed distal radius has the ability to grow longitudinally, which can effectively correct the radial deviation and avoid the further development of the deformity.

Objectives:To observe the possibility of enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus,and performing the nerve graft for surgical repairing the sacral plexus ruptured injuries or sacral plexus nerve tumor resection.Methods:The clinical data of 10 patients with sacral plexus injury or sacral plexus nerve tumor underwent the surgical operation via the expanded greater sciatic notch at Department of Hand Surgery,Beijing Jishuitan Hospital from July 2016 to November 2020 were retrospectively analyzed.There were 4 male and 6 female patients,with an age of (38.0±9.3)years (range:26 to 56 years).There were 8 cases with sacral plexus injury at the intrapelvic or covergence level (deep to the piriformis). Out of this 8 cases,4 cases with intrapelvic pan-sacral plexus injury,1 case with upper sacral plexus injury and 3 cases with convergence level pan sacral plexus injury.Another 2 cases were sacral plexus neoplasm.The average time from injury or onset to operation was 10.4 months (range:1.5 to 60.0 months). All cases were performed surgery for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus with enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach.Intraoperation the sacral plexus ruptured injurie was repaired and the sacral plexus nerve tumor was resected.Intraoperative findings,postoperative complications and healing of incision and osteotomy of patients were recorded.Results:All the 10 patients underwent the sacral plexus surgical exploration and cutaneous nerve graft for sacral plexus nerve repairing or neurolysis or neoplasm resection through the posterior gluteal approach successfully.The length and width of illium osteotomy mass were (2.9±0.4)cm (range:2.5 to 3.8 cm) and (2.5±0.5)cm (range:1.5 to 3.4 cm) respectively.The median intraoperative bleeding volume was ( M( Q R))800(800)ml (range:400 to 2 000 ml).There were no complication with major vascular injury and hematoma formation,and all incisions healed.The postoperative follow-up was 29.8 months (range:1.5 to 54.0 months).Nine cases of iliac osteotomy were healed,and 1 case was not healed because the follow-up was only 1.5 months. Conclusions:The intrapelvic upper sacral plexus and the convergence level of sacral plexus deep to the piriformis can be exposed clearly through this posterior gluteal approach via illium osteotomy for enlarging the greater sciatic notch,and there was enough operative space that surgical exploration and nerve graft or nerve transfer or neoplasm resection can be performed.

Congenital thumb hypoplasia is a rare congenital limb deformity, which has major impact on hand and upper limb functions. Since Buck-Gramcko published the classic literature on index finger pollicization, it has become the standard technique for the treatment of severe thumb dysplasia. This technique is also recognized as one of the milestones in the history of hand surgery. Blauth classification and later modified classification are proposed to find a designated point that separates "thumb preservation with functional reconstruction" and "index finger pollicization" . It has been repeatedly established that "index finger pollicization should be the first option" . But in reality, regardless of race, culture or country, most parents would still prefer surgeons to preserve the thumb, even if the functions are somewhat compromised. For them, "five is better than four under any circumstances" . Over the past ten years, our team has treated more than nearly 300 cases of Manske type 3-4 thumb dysplasia. For everyone of them, we had a detailed preoperative consultation and demonstrated the photos of the post-pollicization thumb that presented unparalleled functions. Nevertheless, after reviewing the postoperative photos of the cases of thumb preservation, 90% of the parents still insisted on keeping the thumb. "4" or "5" is not just a matter of numbers, but more of a complicated conundrum of philosophy, psychology and ethics, like many other clinical dilemmas. Anytime when physicians’ own preferences are inconsistent with the patients’, it is up to the physicians’ to listen and make compromises accordingly. The major principles of thumb hypoplasia treatment and surgical details were summarized in this manuscript. It is our intention that such comprehensive guidelines could be helpful to our colleagues in the same field.

Objective:To investigate the clinical effect of free fibular head epiphysis transplantation pedicled with the recurrent branch of the anterior tibial artery in the treatment of children with Bayne-Klug Ⅱ-Ⅲ congenital radial dysplasia.Methods:From February 2013 to September 2018, we retrospectively reviewed and analyzed our prospective database of four patients with Bayne-Klug type Ⅱ-Ⅲ congenital radius dysplasia referred to Beijing Jishuitan Hospital for consideration of free fibular head epiphysis transplantation. All children underwent surgical treatment by stages: (1) Before surgery, the radial soft tissue and wrist joint were gradually stretched by massage and traction braced to maximize the radial space. (2) A free fibular head pedicled with the recurrent branch of the anterior tibial artery was harvested from the ipsilateral lower limb and transferred as a vascularized fibular head composite flap for reconstructing the stable structure of the distal radius and wrist joint. (3) At least six months after the procedure, pollicization was performed on Blauth type Ⅳ and Ⅴ. The treatment effect was evaluated by measuring the radial deviation angle, the growth length of the fibula, and the ratio of the radius/ulna length.Results:A total of 4 boys with right side deformity were enrolled. The ages of the patients ranged from 16 to 62 months, with an average of 30.5 months. The post-operative follow-up period was 19 to 78 months, with an average of 40.5 months. Three children with Blauth type Ⅳ or Ⅴ thumb dysplasia were performed with pollicization about one year after free fibular head epiphysis transplantation. All the grafted bones healed; the radial deviation angle was corrected by an average of 24°; the reconstructed distal radius grew longer, with an average increase of 13.2% when the plate was removed compared with six weeks post-operatively; the ratio of the radius/ulna was an average increase of 13.3% compared with preoperative.Conclusions:The use of fibular head epiphyseal flap pedicled with the recurrent branch of the anterior tibial artery is a good method for the treatment of Bayne-Klug type Ⅱ-Ⅲ radius dysplasia. The reconstructed distal radius has the ability to grow longitudinally, which can effectively correct the radial deviation and avoid the further development of the deformity.

Objectives:To observe the possibility of enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus,and performing the nerve graft for surgical repairing the sacral plexus ruptured injuries or sacral plexus nerve tumor resection.Methods:The clinical data of 10 patients with sacral plexus injury or sacral plexus nerve tumor underwent the surgical operation via the expanded greater sciatic notch at Department of Hand Surgery,Beijing Jishuitan Hospital from July 2016 to November 2020 were retrospectively analyzed.There were 4 male and 6 female patients,with an age of (38.0±9.3)years (range:26 to 56 years).There were 8 cases with sacral plexus injury at the intrapelvic or covergence level (deep to the piriformis). Out of this 8 cases,4 cases with intrapelvic pan-sacral plexus injury,1 case with upper sacral plexus injury and 3 cases with convergence level pan sacral plexus injury.Another 2 cases were sacral plexus neoplasm.The average time from injury or onset to operation was 10.4 months (range:1.5 to 60.0 months). All cases were performed surgery for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus with enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach.Intraoperation the sacral plexus ruptured injurie was repaired and the sacral plexus nerve tumor was resected.Intraoperative findings,postoperative complications and healing of incision and osteotomy of patients were recorded.Results:All the 10 patients underwent the sacral plexus surgical exploration and cutaneous nerve graft for sacral plexus nerve repairing or neurolysis or neoplasm resection through the posterior gluteal approach successfully.The length and width of illium osteotomy mass were (2.9±0.4)cm (range:2.5 to 3.8 cm) and (2.5±0.5)cm (range:1.5 to 3.4 cm) respectively.The median intraoperative bleeding volume was ( M( Q R))800(800)ml (range:400 to 2 000 ml).There were no complication with major vascular injury and hematoma formation,and all incisions healed.The postoperative follow-up was 29.8 months (range:1.5 to 54.0 months).Nine cases of iliac osteotomy were healed,and 1 case was not healed because the follow-up was only 1.5 months. Conclusions:The intrapelvic upper sacral plexus and the convergence level of sacral plexus deep to the piriformis can be exposed clearly through this posterior gluteal approach via illium osteotomy for enlarging the greater sciatic notch,and there was enough operative space that surgical exploration and nerve graft or nerve transfer or neoplasm resection can be performed.

Objective To explore the feasibility of transferring of the obturator nerve onto the vesical branch of pelvic nerve with direct anastomosis,in order to restore the automatic micturition function of patients with bilateral lower sacral plexus injury (S2-S4).Methods Data of five patients (4 males and 1 female) with bilateral lower sacral plexus injury who had surgery from May to July 2018 were retrospectively analyzed.The average age was 26 years old (range,23-30 years old) and the average delay from injury to operation was 10.2 months (range,7-14 months).Three patients suffered with fell off injury and two patients had car accident injury.All patients presented with continence and the urodynamics revealed flaccid neuropathic bladder with neurogenic adynamia of detrusor muscle.The vesical branch of pelvic nerve was dissected between the bladder and the ureter where it entered the bladder neck from backward to forward almost vertically.The obturator nerve was dissected along the pelvic sidewall,and the comparable bundle branch of obturator nerve was transferred onto the vesical branch of pelvic nerve with direct anastomosis.The diameter and freed length of pelvic nerve and the fascicles of the obturator nerve were measured intraoperatively,and the cutaneous sensation of medial thigh and the muscle strength of hip adduction were evaluated postoperatively.Results The surgery was performed through the traditional abdominal paramedian approach in 3 patients and through the pararectus approach in 2 patients.The vesical branch of pelvic nerve in all five patients could be revealed clearly and there was enough operative space for nerve transferring.The surgery was successful in all five patients without any complication.The donor nerves were anterior branch of obturator nerve in 2 patients,posterior branch of obturator nerve in 1 patient,2/3 fascicles of anterior branch of obturator nerve in 1 patient and 2/3 fascicles of posterior branch of obturator nerve in 1 patient.The average length and diameter of freed fascicles of obturator nerve were 2.28 cm (range,1.9-2.6 cm) and 1.36 mm (range,1.2-1.5 mm).The average length and diameter of pelvic nerve were 2.46 cm (range,2.2-2.7 cm) and 1.2 mm (range,1.1-1.3 mm).The vesical branch of pelvic nerve and the bundle branch of the obturator never were comparable and anastomosed free of tension.The sensation of medial aspect of thigh was almost normal and the muscle strength of hip adduction was M4 postoperatively.Conclusion The vesical branch of pelvic nerve can be well exposed via pararectus approach.Transferring of the fascicles of obturator nerve onto the vesical branch of pelvic nerve is feasible and safe.

To introduce the surgical procedure of orthopaedic robot-assisted vascularised fibular grafting for the treatment of ANFH and report the short-term result. Methods From September, 2016 to November, 2018, 17 patients (21 hips) with ANFH had undergone robot-assisted free fibular grafting. There were 14 males and 3 females, of which, 8 cases were associated with the right side, 5 cases the left side, and 4 cases with both sides. The average age was 35 (ranged from 17 to 55) years. There were 7 patients suffered from idiopathic ischemic necrosis of femoral head, 4 patients who had cannulated screws fixed after a femoral neck fracture, 4 patients who had a history of alcohol consumption, 1 patient who had taken corticosteroids for 6 months to treat nephritis, and 1 patient who had a history of alcohol consumption and had also taken corticosteroids. Seventeen hips were in Ficat stage II, and 4 hips were in Ficat stage III. The orthopaedic surgical robot workstation was used to plan the entry point and target of the guide pin during the operation, to place a cannula in the optimal position. Then a bone window was created and the fibula was placed into the bone tunnel.Using fluoroscopy to monitor each step of the procedure and verify the position of the fibula. Finally, the vessels were anastomosed. The patient remain in bed completely for a week with the use of vasodilator. The follow-up was accomplished with phone call and outpatient clinic, and Harris score was evaluated. Results All 21 surgical procedures were successful. The guide pins and fibula were accurately placed according to the robot’s plan, and the tips of the fibula were placed at the centre of the load-bearing region of the femoral heads, 4 to 6 mm from the articular surface. Conventional anticoagulant, anti-infective therapy was performed after the pro-cedure. Ten patients were followed-up postoperatively more than 1 year, with an average of 15 (from 12 to 24) months. The function of the hip joint recovered smoothly for 9 patients.Frontal and lateral X-ray and CT scans showed that the tips of the fibula were placed at the centre of the load-bearing region, 4 to 6 mm from the articular surface.One patient suffered from bilateral femoral head necrosis and the right side recovered smoothly after operation.However, joint move-ment was restricted for the left hip and the pain was significant.An arthroscopic examination was performed 1 month after the operation and did not identify any problems such as intraarticular incular infection or articular surface of the femoral head was protruded by the tip of the fibula.The symptoms were alleviated after removing the osteophytes at the rim of the acetabulum.The Harris score was 62.4±13.6 before operation, and 84.5±4.5 at the last time of followed-up after opera-tion.The difference in Harris scores was statisticly significant (P＜0.05). Conclusion With the assistance of an or-thopaedic robot system, the guide pin can be accurately positioned, thereby allowing the tip of the fibula to be inserted in-to the optimal anatomical position and maximising its mechanical efficacy.In theory, it is the best choice for performing fibular bone transplantation in ANFH.And the early effect of treatment is good.