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Gustilo type IIIC open fractures of the tibia are high-energy injuries necessitating long treatment periods and usually multiple surgical procedures and eventually resulting in high morbidity rates and even amputations. We present here a case involving a type IIIC open tibial fracture with massive loss of the entire tibial diaphysis, which we treated by performing acute tibialization of the fibula after revascularization of the posterior tibial artery in a single-stage emergency operation.

Background Lateral malleolar fractures (Weber type B or OTA 44-B) account for 60% of all ankle fractures. To achieve anatomic restoration, surgical stabilization provides better results than conservative treatment. Various fixation methods are available to treat these fractures; however, the best method is still unknown. Our objectives were to present a new, useful, and efficient surgical technique for stabilizing lateral malleolar fractures and to analyze the outcomes of patients treated with the compression cerclage system. Methods The surgical technique consists of a Kirschner wire that is passed percutaneously and perpendicular to the fracture line, and a cerclage wire that is passed in a semi-circular fashion over the ends of the Kirschner wire on the lateral side of the bone, leaving loops on each side to allow bilateral compression while twisting both wires. We retrospectively evaluated patients treated with this technique, with or without additional fractures. Follow-up of Results At the final follow-up, 15 out of 21 patients (9 women and 6 men; mean age, 48.2 years [range, 19–78 years]) were evaluated. The mean follow-up was 5.16 years (28–129 months). Five patients had an isolated lateral malleolar fracture; eight had lateral and medial malleolar fractures; and two had trimalleolar fractures. At the final follow-up, 11 patients were rated good functionally and four were fair, and all patients were rated good radiographically according to the criteria by McLennon and Ungersma. Mean Olerud and Molander ankle score was 93.3 (range, 80–100). Conclusions The compression cerclage system provides good functional and radiological outcomes in patients with lateral malleolus fractures. This method is useful, safe, and efficient with minimum hardware. It can be applied through limited soft-tissue stripping, which is especially important in patients with a high risk for wound complications.

We report a successful thumb replantation by resecting the remnants of the crushed proximal phalanx and uniting the distal phalanx with the thumb metacarpal. The procedure resulted in extreme shortening, which we managed by distraction lengthening and deepening of the first webspace.

Although trigger finger occurs mostly due to a problem at the A1 pulley various other causes have also been reported. We present three patients with different tumors at the carpal tunnel as a cause of triggering. All patients were treated with local excision., Tetik parmak genellikle A1 pulley seviyesindeki sorun nedeni ile ortaya çıksa da, literatürde farklı nedenler de bildirilmiştir. Çalışmamızda, tetiklenme nedeni olarak karpal tünel seviyesinde tümör saptanan ve bu tümörlerin lokal eksizyonu ile tedavi edilen üç hastayı sunuyoruz.

Two total and one subtotal above-elbow amputations had replantation or revascularization for their severely damaged upper extremities followed by functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion. The mean follow-up was 68 months (range: 14 to 121 months). At final follow-up examinations, the patients had sufficient range-of-motion of their elbows with good strength. Restoring elbow function eliminates one of the most important limiting factors for above-elbow replantations. Functional latissimus dorsi island pedicle musculocutaneous flap is very reliable, has minimal donor-site morbidity and offers a wider choice when deciding about arm replantation in the upper arm region by providing a chance of restoring functions.

Objective: Thumb amputation is a major cause of hand dysfunction, and the treatment for distal thumb amputations remains controversial. Although finger reconstruction methods using distraction lengthening are known to restore finger length and function, we found no reports in the literature regarding phalangeal lengthening in thumb amputations. We aimed to evaluate proximal phalangeal lengthening in thumb amputations at or near the interphalangeal (IP) joint.Methods: We retrospectively evaluated patients who had undergone distraction lengthening of the proximal phalanx of the thumb. All patients underwent osteotomy, either during the initial procedure or as a second-stage procedure. Distraction began 10 days after osteotomy with the use of an external fixator that remained in place until ossification of the gap occurred without bone grafting. Patients were evaluated using the QuickDASH score.Results: Fourteen patients with a mean age of 27 years and a mean follow-up period of 7 years were enrolled. The mean phalangeal lengthening achieved was 20 mm. Ossification occurred at all distraction sites, and the fixators were maintained for a mean of 85 days. The mean healing index was 42.5 days/cm. All 14 patients achieved the desired amount of phalangeal lengthening without major complications such as nonunion, premature union, or gross infection.Conclusion: For reconstruction in cases of distal thumb amputations, distraction lengthening of the proximal phalanx can be used to improve absolute length, web space, and grip distance. The technique is safe and effective, improves functionality/cosmesis, and offers a low complication risk., Amaç: Başparmağın amputasyonu el fonksiyonlarında kısıtlanma yaratan önemli bir etkendir. Başparmağın distal amputasyonlarının tedavisi tartışmalıdır. Her ne kadar parmakların distraksiyon yöntemi ile uzatılması parmakların uzunluğunu ve fonksiyonunu tekrar sağlamak için uygulanan yöntemlerden biri olsa da, literatür araştırmamızda başparmak amputasyonlarının tedavisi için falanks uzatmasına yönelik bir yayın bulamadık. Başparmağın interfalangial (İF) eklem seviyesi veya civarındaki amputasyonlarında proksimal falanksın uzatılması ile tedavi edilen hastaların sonuçlarını değerlendiren bir çalışma düzenledik.Çalışma planı: Distraksiyon yöntemi ile proksimal falanksları uzatılan hastalar geriye dönük olarak değerlendirildi. Osteotomi, ya ilk ameliyat esnasında ya da ikinci aşamada yapıldı. Osteotomiden 10 gün sonra bir eksternal fiksatör üzerinden distraksiyona başlandı. Bu fiksatör oluşan boşluğun kemikleşmesine kadar yerinde bırakıldı. Kemik grefti kullanılmadı. Hastalar QuickDASH skorlaması ile değerlendirildi.Bulgular: 14 hastanın ortalama yaşı 27, ortalama takip süresi 7 yıl idi. Falankslar ortalama olarak 20 mm. uzatıldı. Tüm uzatma bölgeleri kemikleşti. Fiksatörlerin çıkarılma zamanları ortalama 85 gün, iyileşme indeksi ortalaması 42.5 gün/cm idi. 14 hastanın tümünde amaçlanan falanks uzatmasına, kaynamama, erken kaynama veya belirgin infeksiyon gibi major komplikasyonlar gelişmeden, ulaşıldı.Çıkarımlar: Başparmağın distal amputasyonlarının rekonstrüksiyonu için proksimal falanksın distraksiyon yöntemi ile uzatılması, başparmağın mutlak uzunluğunun ve web aralığının arttırılması ve daha iyi bir kavrama mesafesi yaratmak için kullanılabilir. Güvenli ve etkili olan bu yöntem, fonksiyonu ve görünüşü iyileştirirken, düşük komplikasyon riskine sahiptir.

This study presents the surgical and functional outcomes of below-knee total leg amputation and Gustilo type III C open fracture cases that were considered appropriate for salvage treatment according to a more proactive approach, despite being candidates for amputation according to the current scoring systems. Nineteen patients (21 legs) underwent replantation-revascularization surgery. At least Chen Grade II functional level was the aim. A limb salvage operation was performed in 21 legs in 19 patients (18 male, 1 female). The mean age was 28.5 years (range: 11 to 42 years). Six legs in four patients presented with total amputation, and 15 legs in 15 patients had Gustilo Type III C open fractures. A successful replantation/revascularization was performed in 20 legs, with a Chen Grade I and Grade II functional outcome in 3 and 17 legs, respectively. None of these patients were eligible for salvage operation according to currently used scoring systems. Limb-preserving surgery performed upon the assessment of local and general conditions of the patients with traumatic below-knee amputations or Gustilo Type III C open fractures seems to be a viable therapeutic option that can serve to achieve Chen Grade II functional level in most patients.

WOS: 000289788800001, PubMed ID: 21328193, Reconstruction of foot soft tissue is challenging particularly in the presence of a large defect involving both dorsal and plantar surfaces. In large defects, use of a latissimus dorsi muscle (LDM) flap is the preferred coverage method, yet LDM flaps are bulky. Despite undergoing multiple debulking procedures, patients whose feet are repaired with LDM flaps must wear oversized custom-made shoes. We developed an approach to allow patients to wear regular shoes. In six patients, we used a debulking procedure that was based on tangential trimming of the flap to the level of thickness required for normal foot contour. All patients underwent debulking 3 months after initial LDM flap coverage. The mean duration of follow-up care was 21 months (range, 8 to 32 months). All flaps survived a secondary debulking procedure. One patient developed an ulcer at the weight-bearing area of a sole. All six patients were able to wear regular shoes without difficulty.

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.

Background: Advancement of pressurized air through subcutaneous tissue after barotraumas involving skin laceration has been documented in the literature. The type and anatomic location of injury, amount of pressure, and time elapsed all play a role in determining the destination of the air advancing through tissues. Objectives: To report a case demonstrating the vascular system as the anatomic pathway for subcutaneous pressurized air resulting from an industrial accident. Case Report: We present the case of a 28-year-old laborer wounded by an air valve blast. An enormous accumulation of air was released through a subtotal fingertip amputation. The clinical appearance of massive subcutaneous emphysema around the upper extremity, neck, and chest suggested chest trauma to the clinicians, despite the absence of signs of respiratory distress. X-ray studies revealed pneumomediastinum. After confirmation that the respiratory system was undamaged, microsurgical repair of the injured finger was performed. Resolution of subcutaneous emphysema and pneumomediastinum was complete at the end of follow-up. Conclusion: Compressed air injuries constitute a well-known form of industrial accident. Although most result in localized subcutaneous emphysema, the risk of pneumomediastinum should not be overlooked due to the anatomic structure of the vascular system. The clinician should consider the pressure of compressed air, and must be alert for potential complications.

High-pressure injection injuries to the hand are uncommon soft tissue traumas of the hand which are frequently underestimated. They are, however, not uncommon among workers in industry using paint, automotive grease, solvents and diesel oil. The prognostic factors are the type, amount and temperature of the material and the pressure of injection. The results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up are reported. Ten cases required soft tissue debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation, which followed major and devastating soft tissue problems. In the present study, we describe the mechanism of the soft tissue damage and the principles of treatment. This study confirms the fact that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation. © 2007 The British Society for Surgery of the Hand.

The role of side branches, when the parent arterial trunk is stretched, with emphasis on preventing the effects of avulsion injury, was investigated in an experimental model. In ten New Zealand rabbits, the femoral arteries were isolated with and without side branches in the left and right legs, respectively, and controlled longitudinal traction was applied. The elongation of the arteries just before avulsion rupture at each side, with and without side branches, was compared, by measuring the initial and final length from the inguinal ligament to the mid-point of the distance between the inguinal ligament and the saphenous bifurcation. Side branches were observed to be tethered in a way that resisted elongation of the trunk artery. Arteries without side branches in the right legs elongated more, as they lacked the fixating and protective support provided by the side branches. Comparison of the two legs, with and without side branches, showed an average of 50 percent more arterial elongation, resulting in severe injury to the arteries without side branches. In the light of these results, the authors suggest performing microsurgical arterial anastomosis after resection past a minimum of two unruptured branch points of the avulsed part, in order to obtain a safer arterial segment for a better patency rate.

Three amputated thumbs were reconstructed with a composite osteocutaneous groin flap and a neurovascular island flap. The average age at the time of surgery was 28 (range 25–35) years. The level of the amputation was distal to metacarpophalangeal joint in two cases and proximal in one case. The injury mechanism was avulsion in all cases. The postoperative follow-up periods ranged from 27 to 30 months. There were no cases of skin necrosis, bone resorption or infection. Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. This surgical procedure is reliable and simple and the functional results are satisfying. We reserve this technique for the treatment of thumb amputations which cannot be replanted, particularly as it does not result in bone resorption.

Some replantation cases require substantial bone shortening for primary closure. Leg-length discrepancy can be restored by lengthening of the replanted or revascularized extremities. Between 1991 and 2000, four patients with four total and two subtotal below-knee amputations had replantation or revascularization for their severely damaged extremities. All of them had extensive debridement, vascular repair, bone shortening and nerve repair for sensibility of their soles. One of the replanted extremities failed and had to undergo below-knee amputation because of sepsis. No other infection or vascular complications were encountered following the replantations or revascularizations. After bony consolidation, four legs were lengthened; for elimination of length discrepancy in three cases, and for obtaining balanced body proportion in one case in which the other leg was also amputated. In all procedures, a unilateral dynamic axial external fixator was used. The lengthening was performed from the proximal tibial metaphysis, with a subperiosteal osteotomy. Evaluation of injury according to the Mangled Extremity Severity Score (MESS) would encourage the surgeon to avoid salvage surgery with a shortened extremity, because of the required debridement of soft tissue and bone. These authors think the amount of limb shortening is not a major criterion in evaluating a traumatic total or subtotal below-knee amputation for salvage replantation or revascularization. A knee that has stable joint motion and the possibility of preservation of sensibility of the sole broadens the scope of indications for limb salvage, even with deliberate shortening that can be restored by lengthening; length discrepancy is not a contraindication for limb salvage.

A modified technique of vein grafting for vascular reconstruction that facilitates surgical procedures by preventing size, diameter, and length discrepancies as well as twisting, is presented. The distal end of the harvested vein graft is ligated, and the graft is inflated with heparinzed saline. The determination of the small side branches makes ligation easier. Gentle hydrostatic dilation relieves spasm, straightens the vein, and ligation of the proximal end is then performed under tension. As the vein inflated with heparinzed saline achieves maximum size, diameter, and length without torsion, the sausage-like graft can easily be interposed in tunnels, passages, or soft tissues between recipient vessel gaps. As the graft is under adequate tension, it is easy to determine its appropriate length, size, and diameter. Suturing is carried out using double approximating clamps. The graft will not twist or kink, as it is anastomosed under tension. The clamps are left in place until completion of the distal and proximal anastomoses. The distal clamp is released first. With this simple modification, most of the technical difficulties, such as length, size, and diameter discrepancies, and twisting and torsion of the graft, can be eliminated. The risk of failure due to vascular thrombosis at the anastomotic sites is lowered, as the vein graft is filled with heparinzed saline, and no blood flow is permitted during the reconstruction. The surgeon also saves time with this easy, simple, and feasible method.

Haemangioma localised in the wrist originating from the sheath of the fifth deep flexor tendon and obstructing the movement of the tendon through the carpal tunnel as an unusual cause of trigger wrist is presented. Tumoural masses around the wrist can cause triggering by obstructing the movement of tendons through the carpal tunnel and the clinician should consider other causes of triggering for surgical treatment.

The use of microvascular techniques in the Plastic and Reconstructive Surgery Department began in 1980. The Hospital de .%o Jolo, located at Oporto, is the only hospital in the northern region of Portugal which has in the Emergency Service, specialists of Plastic and Reconstructive Surgery available 24 hours per day, 7 days per week. The majority of the patients following amputation with a possible indication for replantation are therefore sent there. This work presents replantations of the upper limb during the decade 1992-2001, and is illustrated by clinical cases.