Objective To investigate short-term clinical outcomes of double-modified Limberg flap transplantation in treatment of sacrococcygeal pilonidal sinus. Methods One hundred patients with sacrococcygeal pilonidal sinus from October 2010 to May 2015 in this hospital were included, and subsequently were divided into double-modified Limberg flap transplantation group (double-modified flap group,n=30), classical Limberg flap transplantation (classical flap group,n=30), and interrupted suture after resection group (interrupted suture group,n=40). The duration of operation, intraoperative bleeding, hospital stay, duration of return to work, recurrence rate, and incision complications rate were compared among these three groups. Results ① The age, gender, body mass index, and preoperative complications had no significant differences among these three groups (P>0.05). ② The intraoperative bleeding and the hospital stay had no significant differences among these three groups (P>0.05). Compared with the interrupted suture group, the durations of operation were significantly longer (P<0.05), the durations of return to work were significantly shorter (P<0.05), the recurrence rates were significantly lower (P<0.05) in the double-modified flap group and the classical flap group. The above indicators had no significant differences between the double-modified flap group and the classical flap group (P>0.05). ③ The incision hematoma and the part disruption of incision had no significant differences among these three groups (P>0.05). Compared with the interrupted suture group, the rates of incision infection and incision complete disruption were significantly lower (P<0.05) in the double-modified flap group and in the classical flap group. The incision maceration of the classical flap group was significantly higher than that of the interrupted suture group (P<0.05) or the double-modified flap group (P<0.05). No skin flap necrosis occurred in the double-modified flap group and the classical flap group. Conclusions Double-modified Limberg flap transplantation and classical Limberg flap transplantation have less complications and lower recurrence rate than interrupted suture after resection. Compare with classical Limberg flap transplantation, double-modified Limberg flap transplantation has a lower incision maceration rate. Because of limitation of sample size in this study, long-term clinical efficacy of double-modified Limberg flap transplantation needs to be confirmed by multicenter randomized controlled trials.
Objective To present and summarize the data concerning the treatment and prognosis of acute limb arterial embolism in West China Hospital. Methods Forty three patients with 52 limbs of acute arterial embolism were treated in West China Hospital from January 2003 to March 2006. There were 15 males and 28 females, aging from 26 years to 77 years 〔(58.88±13.90) years〕. The diagnosis was based on clinical manifestations and results of color Doppler sonography or DSA. The follow-up ranged from 1 month to 39 months. The following factors, which might influence the prognosis, were analysed through multiple linear regression of SPSS 10.0: age, sex, uper limb or lower limb, location of embolus, ischemic time, clinical categories of acute limb ischemia, history of smoking, atherosclerosis and other combined diseases, pervious history of acute limb arterial embolism, operative or nonoperative treatment, and postoperative complications. Results Clinical categories of acute limb ischemia include: Ⅰ (n=0),Ⅱa (n=16), Ⅱb (n=29), Ⅲ (n=7). The ischemic time varied from 3 h to 2 weeks. The sources of embolus: heart (n=39), vessle (n=7), iatrogenic origin (n=1), unidentidied origin (n=5). The therapies included embolectomy (n=38), catheter-directed thrombolysis (n=2) and medical treatment (n=12). The following postoperative complications occured: compartment syndrome (n=12), respiratory failure (n=3), alkalolsis (n=3), acute renal failure (n=2), wound infection (n=2) and pulmonary infection (n=1). Two patients died of cerebral infarction in hospital and one patient died of heart failure 3 months after discharge. Thirty-eight patients with 45 diseased limbs were followed up. The results were excellent in 13 limbs, good in 15 ones, fair in 8 ones and poor in 9 ones. The statistically significant influencing factors of prognosis include ischemic time, clinical categories of acute limb ischemia and history of smoking (P＜0.05). Conclusion The operation of embolectomy is the main treatment of acute limb arterial embolism. In selected patients, catheter-directed thrombolysis and medical treatment could be used to alleviate the limb ischemia. The treatment against the etiological factors should not be ignored. The prognosis of this disease could be influenced by ischemic time, clinical categories of acute limb ischemia and history of smoking.
Objective To determine the protection effects and mechanisms for immature myocardium with limbs ischemic preconditioning (LIP). Methods Using the Langendorff perfusion apparatus to perfuse isolated hearts, we randomly divided 30 Japanese longeared white rabbits into 5 groups, each having 6 rabbits. For the I/R group，after the perfusion model was established, the isolated hearts underwent 15 min of perfusion with KH solution before working for another 15 min . Then perfusion was stopped to cause ischemia for 45 min before reperfusion for 15 min and working for another 30 min . For E1 group, the model was established by 3×LIP (double limbs obstructed for 5 min followed by 5 min reperfusion for 3 times) and then procedures of the I/R group were carried out. For E2 group, before procedures of the E1group were done, superoxide dismutase (SOD) was injected till LIP was completed. For E3 group, intravenous protein kinase C (PKC) polymyxin (PMB) was injected for 10 minutes before E1 procedures were repeated. For E4 group, intravenous mitochondrial ATPsensitive K+ channels (mitoKATP) blocker 5-hydroxydecanoate was injected for 10 min before E1 procedures were carried out. The left ventricular function recovery, myocardial water content (MWC), creatine kinase (CK) and lactate dehydrogenase (LDH) leakage, malondialdehyde (MDA) and ATP content, SOD activity and superoxygen negative ion (O2 ·-) content were tested. Results Left ventricular recovery in E1 group was better than other groups (Plt;0.05). ATP content and SOD activity in E1 group were also better than all other groups (Plt;0.05). MWC in E1 group was lower than other groups (Plt;0.05). MDA content, CK and LDH leakage in E1 group were also lower than other groups (Plt;0.05). There was no significant difference of the above indications among I/R,E2,E3 and E4 groups, while the difference of O2·- content in E1,E3 and E4 groups before and after preconditioning was significant. Conclusion LIP has obvious protective effects for immature myocardium and the mechanisms are probably through PKC stimulation and opening of mitoKATP.
Objective To investigate the clinical application and early results of combined epiphyseal preservation and autograft bone transfer for limb salvage in children with osteosarcoma. Methods Between March 2010 and March 2011, 3 children with osteosarcoma were treated with epiphyseal preservation and autograft bone transfer. There were 1 boy and 2 girls with the age of 10-14 years. The disease duration was 2 weeks to 3 months. The tumors were rated as type II according to San-Julian radiological classification and as type IIB according to Enneking surgical classification. The locations were the distal femur in 1 case and the proximal tibia in 2 cases. The surgical technique included preoperative neoadjuvant chemotherapy, excision of part of the epiphysis, preservation of subarticular epiphysis, external fixation with Ilizarov apparatus and transport osteogenesis treatment. Safe excision border was confirmed by histological examination. Postoperative observation included the wound healing, local recurrence or distant metastasis, length, speed, alignment, and regeneration of transplanted bone, the length and function of the affected limb. Results The postoperative histological examination proved the safe surgical margin in all 3 patients. The incision healing by first intention was obtained at distal femur in 1 case and by second intention at proximal tibia in 2 cases at 4 weeks after changes of dressing. Three patients were followed up 12, 18, and 24 months, respectively. There was no local recurrence or distant metastasis during follow-up. Two cases had pin-tract infection at 10 months after external fixation and were cured after changes of dressing and antibiotics administration. The length of transplanted osteogenisis was 18.0, 9.5, and 16.0 cm, respectively. The speed of lengthening was 2.57, 2.07, and 1.20 cm/month, respectively. One patient had alignment deviation during lengthening, which was adjusted under anaesthesia. Bony healing was achieved at 8 months after lengthening end in 2 cases and external fixation was removed; 1 patient had poor bone growth and was given retraction for promoting bone growth. At last follow-up, the length of the affected limbs was 1.0-1.5 cm shorter than that of normal limbs, but no abnormalities was observed at donor sites. The affected knee flexion reached 90° and 120° in 2 patients and poor knee function was observed in 1 patient for external fixation. Conclusion The combined epiphyseal preservation and transport osteogenesis technique can be used for bone defect repair by lengthening the residual bone. It is a promising limb salvage treatment for children with osteosarcoma.
Objective To analyze the effectiveness and application value of epiphysis preserving by the method of physeal distraction for treatment of femur osteosarcoma in children’s limb saving surgery. Methods Between January 2007 and January 2011, 6 patients with femur osteosarcoma underwent epiphysis preserving operation by physeal distraction. There were 4 males and 2 females with a mean age of 11.4 years (range, 9-14 years). The mean disease duration was 4.8 months (range, 1-9 months). The pathology confirmed osteosarcoma in all patients by core needle or open biopsy, including 1 case of osteogenic sarcoma, 1 case of chondroblastic osteogenic sarcoma, 1 case of osteoblastic osteogenic sarcoma, and 3 cases of no classified osteosarcoma. The clinical stage was IIA in 1 case and IIB in 5 cases according to the Enneking staging system. All patients received 2 cycles of neoadjuvant chemotherapy before operation. Then physeal distraction was performed for 4-7 days (mean, 5.7 days) based on Cantilde;adell technique. After 1-2 days of physeal distraction, massive allograft bones and interlocking intramedullary nails were used to reconstruct bone defect after tumor resection. All patients received another 4-6 cycles of chemotherapy and were followed up. Bone healing, limb discrepancy, and complications were recorded. Functional outcomes were assessed by the system of the Musculoskeletal Tumor Society (MSTS) and the range of motion (ROM) of both knee joints. Results Superficial infection occurred in 1 case and was cured after dressing change, and primary healing was obtained in the other patients. All 6 patients were followed up 2.5 years on average (range, 1-5 years). Symptoms of pain and swelling disappeared. No complication of allograft rejection, loosening or breaking of fixation occurred. No relapse or metastasis happened during follow-up. Bone healing was observed at the metaphysis junction in 5 cases at 6-9 months after operation and in 1 case at 14 months. Delayed union happened at the diaphysis junction in all patients. Different amount of callus formation was seen at the surface of diaphysis junction, but the fracture line remained clear at 12-48 months after operation. At last follow-up, limb discrepancy was 1-3 cm in 4 patients and 3-5 cm in 2 patients; 3 patients had compensatory scoliosis, and 2 patients had claudication. The MSTS score was 27.20 ± 1.92, showing significant difference (t= — 4.12, P=0.00) when compared with preoperative score (19.60 ± 2.74). The ROM of affected knee was (127.00 ± 17.89)°, showing no significant differences when compared with preoperative ROM (109.00 ± 12.45)° (t= — 1.84, P=0.10) and with ROM of normal knee (126.00 ± 9.62)° (t= — 0.11, P=0.92). Conclusion Limb saving surgery by physeal distraction can be used in young patients with open epiphyseal plate, which has the advantages of simple operation, good effectiveness, and less complications.
【Abstract】 Objective To evaluate the outcome of two-stage revision for prostheses infection in patients with bone tumor after knee prosthetic replacement. Methods Between August 2003 and August 2010, 22 patients with prostheses infection, who underwent knee prosthetic replacement in limb salvage treatment because of bone tumor, received two-stage revision. There were 11 males and 11 females with an average age of 29.6 years (range, 15-55 years). Prosthetic infection occurred after primary replacement in 20 patients and after revision surgery in 2 patients from 15 days to 89 months after operation. According to Coventry and Fitzgerald classification, type I was found in 3 cases, type II in 15 cases, and type III in 4 cases. The time from infection to admission was 5-47 months (mean, 10.2 months). The results of bacterial culture were positive in 9 cases and negative in 13 cases. Two patients had fever and leukocytosis. In one-stage, the implants and infected tissue were removed, and an antibiotic cement spacer with an intramedullary nail was implanted. In two-stage, a new endoprosthesis was inserted after infection was controlled. Results The C-reactive protein and erythrocyte sedimentation rate before one-stage debridement were significantly higher than those before two-stage revision (P lt; 0.05). All patients were followed up 5-63 months (mean, 23.6 months). Infection was controlled after one-stage debridement in 18 cases (81.8%); two-stage revision was performed in 17 cases, and 1 case refused to receive two-stage revision. Of 17 patients, 1 patient was amputated because of infection at 5 months after revision. Four patients (18.2%) underwent amputation because of failure to control infection after one-stage debridement. The limb salvage rate was 77.3% (17/22). One case of renal cell carcinoma with bone metastasis died of original disease after 1 year and 6 months of operation. The Musculoskeletal Tumor Society (MSTS 93) score was 69.4 ± 12.7 at last follow-up. Conclusion Two-stage revision should be performed in time and it has good results in the treatment of prostheses infection in patients with bone sarcomas after knee prosthetic replacement.
【Abstract】 Objective To report cl inical experience in the use of temporary intravascular shunts (TIVS) for quickrestoration of perfusion to the extremity with major vascular injury. Methods Between August 2009 and March 2011, TIVSwas applied temporarily to restore blood perfusion to the extremity in 6 patients with major extremity vascular structure injury secondary to trauma (4 patients) or tumor resection (2 patients), who would received vascular transplantation and underwent long ischemia. The patterns of vascular shunts included external carotid artery-subclavian artery, axillary artery-axillary artery, axillary vein-subclavian vein, brachial artery-brachial artery, brachial vein-brachial vein, brachial artery-radial artery, femoral artery-popliteal artery, and popliteal artery-posterior tibial artery. After TIVS, extensive debridement, fracture fixation, or tumor excision was performed. Then the shunted tubes were removed, and the vessels were repaired definitly. Six vessels were repaired by transplanting the great saphenous veins; one vessel was anastomosed directly without tension; and one vessel was repaired by artificial vascular graft. Results All shunted tubes were successfully established within 5 to 10 minutes (mean, 8.2 minutes). The duration of bypass ranged from 67 to 210 minutes. After establishment of TIVS, blood perfusion to the affected limb was improved. When shunted tubes were removed, thrombosis and partial obstruction occurred in one who accepted amputation, and the others kept patency. No loosening of tubes and haemorrhage occurred. At 2-15 months of follow-up, affected limbs had good blood supply. Conclusion TIVS is rapid and simple, which can quickly restore blood perfusion to the extremity with major vascular injury and shorten the ischemic time of the affected extremity.
Objective To evaluate the effectiveness of soft tissue reconstruction after resection of musculoskeletal tumor and to discuss the strategy of soft tissue reconstruction. Methods Between June 2003 and December 2010, 90 patients with musculoskeletal tumor underwent tumor resection and soft tissue reconstruction. There were 59 males and 31 females with a median age of 37.2 years (range, 9-85 years), including 52 bone tumors and 38 soft tissue tumors. One stage reconstruction of soft tissue was performed after tumor resection in 75 cases; reconstruction of soft tissue was performed after debridement in 7 cases of wound dehiscence; and two stage reconstruction of soft tissue was performed after debridement and vacuum sealing drainage placement in 8 cases of infected wounds. The gastrocnemiums flap was used in 40 cases, the latissimus dorsi myocutaneous flap in 6 cases, rectus abdominis myocutaneous flap in 4 cases, gluteus maximus musculocutaneous flap in 1 case, pectoralis major muscle flap in 1 case, cross-abdominal flap in 1 case, local transfer flap in 27 cases, pedicled flaps in 5 cases, and skin grafts in 5 cases. The size of the flap ranged from 6.5 cm × 4.5 cm to 21.0 cm × 9.0 cm. Results Eighty-seven flaps survived, and incisions healed by first intention in 81 cases. In 6 cases of healing by second intention, 2 had partial flap necrosis, which was cured by dressing change; 3 had delayed healing; 1 had mild infection, which was cured after conservative treatment. Wound of donor site healed primarily, and the grafted skin survived. Seventy-three patients were followed up 10-102 months (mean, 36.1 months). Local tumor recurrence was observed in 6 patients, who received second resection at 2-27 months (mean, 8.2 months) after operation. Thirteen patients dead of primary disease at 6-34 months (mean, 19.2 months) after operation. Conclusion The defects caused by resection of musculoskeletal tumor require soft tissue reconstructions. Optimal reconstruction can enhance wound closure, decrease incidence of wound complication, preserve limb function.
Objective To explore an improved method of surgical operation for redintegration of the articular surface and alignment with type III Pilon fractures. Methods Between August 2005 and August 2010, 31 patiens with closed type III Pilon fracture (Rüedi-Allgouml;wer type III) were treated. There were 25 males and 6 females, aged 36.8 years on average (range, 16-60 years). The injury was caused by falling from height in 18 patients, by traffic accident in 10 patients, and by other reasons in 3 patients. The average time between injury and operation was 10 days (range, 6-14 days). Temporary external fixation was used for adjustment and maintenance of limb length and power lines; application of fibular flip combined with anteromedial approach was used for the repair of articular surface; and bone grafting and fixation were performed. Results No extensive necrosis or deep infection were observed. Superficial skin infection of incision and wound edge necrosis occurred in 2 cases respectively, and were cured after dressing change. All patients were followed up 26 months on average (range, 9-79 months). According to the Burwell et al. judging standards of radiology evaluating, the anatomical reduction was found in 25 cases (80.6%), satisfactory reduction in 4 cases (12.9%), and unsatisfactory reduction in 2 cases (6.5%). The X-ray films showed bony healing was achieved in all cases with an average fracture healing time of 16 weeks (range, 12-25 weeks). According to the Mazur et al. criterion for ankle joint function, excellent result was obtained in 11 cases, good in 13, fair in 5, and poor in 2; the excellent and good rate was 77.4%. Conclusion Good exposure and fixation of articular surface or accurate adjustments and maintenance of the limb alignment are key factors of successful operation to treat type III Pilon fractures.
Objective To review the methods of metacarpal and phalange lengthening and to point out the problems at present as well as to predict the trend of development in the field. Methods Domestic and abroad l iterature concerning the methods of metacarpal and phalange lengthening in recent years was reviewed extensively and thoroughly analyzed. Results At present, there are many methods to treat the short finger disabil ity, but the methods of metacarpal and phalange lengthening have an advantage, which include closed osteotomy lengthening, callus-lengthening, and modified Il izarovmethod. Each surgical method has its advantages and l imitations. However, the part of osteotomy, the length and speed, and the postoperative compl ications etc. have been disputed. Conclusion The modified Il izarov method has the advantages of simple operation, minimal invasion, and less compl ications, but the long-term results of each treatment method are unknown and need more further studies.