Treatment of proximal humeral fractures accompanied by medial calcar fractures using fibular autografts:A retrospective,comparative cohort study

BACKGROUND Severe proximal humerus comminuted fractures are often accompanied by medial calcar comminuted fractures and loss of medial support,which are important factors that lead to internal fixation failure.The appropriate treatment for proximal humerus comminuted fractures has not been established.Therefore,this study assessed the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.AIM To investigate the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.METHODS This retrospective,comparative cohort study included two groups of patients.Group 1 comprised 22 patients and group 2 comprised 25 patients with complete follow-up data.Group 1 was treated with a fibular autograft with open reduction and locking plates to enable internal fixation.Group 2 was treated with open reduction and locking plates to enable internal fixation.The intraoperative blood loss volume from the shoulder wound,operative time,shoulder wound pain,bone fracture healing time,Constant-Murley score of the shoulder joint,preoperative Holden walking function score,Mallet score of the shoulder joint,and humeral neck-shaft angle during surgery of the two groups were compared,and the differences were analysed using an independent sample t-test.RESULTS Group 1 had a shorter mean operative time than group 2(2.25±0.30 h vs 2.76±0.44 h;P=0.000).Group 1 had a lower shoulder wound pain score on the first day after surgery than group 2(7.91±1.15 points vs 8.56±1.00 points;P=0.044).Group 1 had a shorter fracture healing time than group 2(2.68±0.48 mo vs 3.64±0.64 mo;P=0.000).Group 1 had higher Constant-Murley scores of the shoulder joint at 3,6,and 12 mo after surgery than group 2(76.64±4.02 points vs 72.72±3.02 points,86.36±3.53 points vs 82.96±3.40 points,and 87.95±2.77 points vs 84.68±2.63 points,respectively;P=0.000,0.002,and 0.000,respectively).Group 1 had higher Mallet scores of the shoulder joint at 3,6,and 12 mo after surgery than group 2(10.32±0.57 points vs 9.96±0.54 points,13.36±1.00 points vs 12.60±0.87 points,and 13.91±0.75 points vs 13.36±0.70 points,respectively;P=0.032,0.007,and 0.013,respectively).CONCLUSION Using locking plates with a fibular autograft can recreate medial support,facilitate fracture healing,and improve shoulder function;therefore,this may be an effective treatment option for severe proximal humerus comminuted fractures.

Proximal fibular osteotomy:Systematic review on its outcomes

BACKGROUND The morbidity and burden of knee osteoarthritis affecting millions of lives worldwide has created a constant pursuit in finding the ideal treatment for knee osteoarthritis.There has been a paradigm shift in the surgical treatment of osteoarthritis ever since the initial description of Volkmann’s tibial osteotomy.This review focuses on one such recent procedure,the proximal fibular osteotomy(PFO)for medial compartment knee osteoarthritis.This review encompasses the history,evidence,risk factors,outcomes and technical considerations of PFO.AIM To understand the evidence and its techniques,and whether this could be an alternative solution to the problem of knee osteoarthritis in the developing world.METHODS The phrases“proximal fibular osteotomy”and“knee osteoarthritis”were searched(date of search December 20,2019)on PubMed to identify articles evaluating the biomechanical and clinical outcomes of PFO in patients with knee osteoarthritis.A total of 258 were retrieved.After reviewing the summary of the texts,22 articles written in English were marked for abstract review.Articles that were case studies or cadaver experiments were excluded.The abstracts of the remaining articles were read,and only those that focused on the history,outcomes of case studies and technical considerations of PFO were included in the review.A total of 12 articles were included in this review.RESULTS At least six studies reported improvement in the visual analogue scale(VAS)from the average preoperative VAS score[6.32,95%confidence interval(CI)=(4.05,8.59)]to average postoperative VAS score[1.23,95%CI:(-1.20,3.71)],which was statistically significant.Similarly,the American Knee Society Score(KSS)functional score improved from an average preoperative KSS functional score[43.11,95%CI:(37.83,48.38)]to postoperative KSS functional score[66.145,95%CI:(61.94,70.35)],which was statistically significant.The femorotibial angle improved by around 7º,and the hip knee ankle angle improved by around 6º.CONCLUSION With the existing data,it seems that PFO is a viable option for treating medial joint osteoarthritis in selected patients.Long term outcome studies and progression of disease pathology are some of the important parameters that need to be addressed by use of multicenter randomized controlled trials.

Three-Dimensional Computed Tomography Assessment and Planning for Severe Lower Limb Deformities: A Case Report of Bilateral Fibular Hemimelia

To correct a lower limb deformity, orthopedic surgeons must have an exact understanding of the deformity. In general, preoperative planning is carried out using anterior-posterior (AP) and lateral radiographs. However, for severe cases with a combination of angular and rotational deformities of the lower limb, obtaining true AP and lateral radiographs is difficult and accurate calculation of the rotational deformity from radiographs is impossible. In this report, we propose to focus on preoperative assessment using three-dimensional (3D) reconstruction images of computed tomography (CT) scans for severe lower limb deformity in a patient with bilateral fibular hemimelia type II according to the Achterman- Kalamchi classification. She underwent bifocal deformity corrections of the bilateral tibiae using Taylor spatial frames in combination with the Ilizarov external fixator. Complete bony union was achieved, without angular deformity or limb length discrepancy.

Evaluation of mandibular reconstruction with free vascularized fibular flap

Objective： To evaluates mandible reconstruction by free vascularized fibular flap with special emphasis on the immediate complications. Methods：The clinical data of 63 patients were reviewed, 35 male and 28 female（age range 16 to 73 years）. Aesthetic and functional outcomes were evaluated by follow-up and/or telephone conversation. Results：Among the 63 fibular flaps, 29 were osteocutaneous flaps with one or two skin islands. All the flaps were surviving well and the success rate was 100%. Long term donor site disability was not recorded for any patient. Thirty-one patients responded for aesthetic and functional evaluation, 20 cases（64.5%） reported their facial appearance as excellent or good, 11 （35.48%） felt fair; 14 cases （45%） could eat unrestricted diet, 17（55%） could eat soft diet; 21 cases were（67.67%） speech normal, 10（22.33%） speech intelligible. Conclusion：Free fibular flap reflects good functional and esthetic results with a high degree of consistency, and acceptable level of complications, and we strongly believe the vascularized fibular flap is the first choice for mandibular reconstruction.

Recurrent Giant Cell Tumor of the Distal End Radius: A Case Report and Surgical Treatment with Wide Resection and Reconstruction with Non-Vascularised Autologous Proximal Fibular Graft

Giant cell tumour of the distal radius is the 3rd most common site after proximal tibia and distal femur. It is locally aggressive and is associated with a high rate of recurrence. Although it is usually treated with various modalities of treatment, wide resection and reconstruction with proximal fibular autograft is most commonly accepted in recurrent cases. The following is a case report of such a case with surgical management.

Endosteal Fibular Strut Graft with Proximal Humeral Locking Plate in Delayed and Neglected Fractures of the Proximal Humerus

Purpose: The purpose of this study was to define a treatment protocol in which a non-vascularized endosteal fibular strut graft, a corticocancellous grafts and a locking plate construct are used for stabilization of the delayed and neglected proximal humerus fractures and to report its outcome. Patients & Methods: Eleven patients (6 females and 5 males) with delayed, neglected proximal humerus fractures were included in this study, conducted between March 2015 and December 2019. Average age of the patients was 57 years (range: 41 to 67 yrs). All patients were treated with the debridement, decortication and shingling of the bone at the site of the fracture followed by using an endosteal fibular strut graft, corticocancellous bone grafts and stabilization with locking plate. The patients were followed up for a mean time of 16.3 months (range: 13 to 40 months). The patient outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, and the modified scoring system of Constant and Murley. Results: Union at the fracture site was achieved in all patients at a mean of 8.5 months (range: 6 to 11 months). The DASH score improved from an average pre-operative score of 71.1 (range: 64 to 78) to an average post-operative score of 25.2 (range: 21 to 35) at the final follow-up. Albeit with a small sample size of n = 11, this difference was found to be statistically significant (p < 0.05). The CM score improved from an average pre-operative score of 33.2 (range: 20 to 48) to an average post-operative score of 66.8 (range: 59 to 72) at the final follow-up. This difference was also found to be statistically significant in this patient cohort (p < 0.05). The results were excellent in 3 patients, good in 6 and moderate in 2. Conclusions: An endosteal fibular strut, subperiosteally placed cortico-cancellous grafts with a locking plate fixation helps in biological healing of neglected fractures of proximal humerus.

Epiphyseal distraction and hybrid reconstruction using polymethyl methacrylate construct combined with free non-vascularized fibular graft in pediatric patients with osteosarcoma around knee: A case report

BACKGROUND In children with osteosarcoma around the knee joint without epiphysis involvement,joint-sparing surgery seems to be an ideal way to retain knee joint function.However,there are two points of debate with regard to the technique:How to accurately achieve a safe surgical margin,and how to achieve intercalary reconstruction of the massive bone defect following resection of the tumor.CASE SUMMARY We present the case of an 8-year-old girl with osteosarcoma of the distal femur without involvement of the epiphysis.Epiphyseal distraction was applied to separate the epiphysis and metaphysis,and this provided a safe surgical margin.The massive bone defect was reconstructed with a custom-made antibioticloaded polymethyl methacrylate(PMMA)construct combined with a free nonvascularized fibular graft.Six months after surgery,bone union between the autograft and host bone was confirmed in both the proximal and distal femur by computer tomography(CT)examination.Moreover,considerable callus formation was found around the PMMA construct.After 28 mo of follow-up,there was no sign of recurrence or metastasis.The patient could walk without any aid and carry out her daily life activities satisfactorily.CONCLUSION In cases of osteosarcoma without epiphysis involvement,epiphyseal distraction can be easily applied to obtain a safe margin.Hybrid reconstruction with an antibiotic-loaded PMMA construct combined with a free non-vascularized fibular graft has the advantages of being easy to manufacture,less time-consuming to place,and less likely to get infected,while also ensuring bone union.Our case provides an alternative technique for biological reconstruction after joint-sparing surgery in patients with osteosarcoma around the knee without epiphyseal involvement.

Live Fibular Graft for the Treatment of Long Bone Tumors in Children

Purposes: We would like to inform the characteristics of recurred osteo-fibrous dysplasia (OFD), and also the possible use of vascularized composite autograft and allografts (VCA) combined with live fibular graft (LFG) for the treatment of aggressive benign bone tumor and osteogenic sarcomas in children. Materials and Methods: We reviewed one boy with recurred OFD after LFG, and other four children with osteogenic sarcoma in long bone which was treated with LFG and VCA, and followed them for average 9 years (3 - 14 years). Survival of the LFG and VCA was estimated by the ISOLS Functional Radiologic Scoring System, but not with Kaplans-Meier’s scoring system because of a small series of case reports. Results: All succeed after surgeries initially, but the cause of recurrence of OFD was still unclear, and one girl with osteogenic sarcoma on distal femur died with skip and lung metastasis, 4 years after surgeries. Conclusions: The causes of recurred OFD are not found thru pathologic studies of our patient, but we believe the multifocal origin of tumor cells even on the adjacent soft tissues in OFD is one of the causes. The excised long bone tumor is recycled by pasteurization or autoclaving, or allograft, then LFG, and neo-adjuvant chemotherapy would be one of elective surgery for the treatment of malignant long bone tumors in children. The LFG into recycled autograft or allograft bone is difficult to perform simultaneously, but very effective to increase more earlier regenerative vascularities and also the stabilities of the dead bones in children.

TREATMENT OF ISCHEMIC NECROSIS OF FEMORAL HEAD BY THE FREE TRANSFERRING FIBULAR BONE GRAFT WITH VASCULAR PEDICLE IN ADULTS：A

cases (97 hips) with avascular necrosis of femoral head caused by variors factors treated by the free transferring fibular graft with vascular pedicle in the Second Teaching Hospital of Xi'an Medical University are reported. All patients have ben followed up for 2 to 11 years. Excellent and good rate of operative results was 86. 6%. A long observation indicated that this procedure was superior to the other operations for the osteonecrosis of femoral head. Successful interim and final operative results can warrant its continued use in management of this kind of patients.

Predictive Reliability of the Phoenix Sign for the Outcome of Common Fibular (Peroneal) Nerve Decompression Surgery

A positive Phoenix sign occurs when a patient, with a suspected focal nerve entrapment of the Common Fibular (Peroneal) Nerve (CFN) at the level of the fibular neck, demonstrates an improvement in dorsifexion after an ultrasound guided infiltration of a sub-anesthetic dose of lidocaine. Less than 5 cc’s of 1% or 2% lidocaine is utilized and the effect is seen within minutes after the infiltration, but usually lasts only 10 minutes. This effect may be due to the vasodilatory action of lidocaine on the microcirculation in the area of infiltration. This nerve block has significant diagnostic utility as it is highly specific in the confirmation of true focal entrapment of the CFN, has high predictive value for a patient who may undergo surgical nerve decompression if they have demonstrated a positive Phoenix Sign, and may help in the surgical decision-making process in patients who have had a drop foot for many years but still may regain some motor function after decompression. In this retrospective review, 26 patients were tested, and 25 of this cohort demonstrated a Positive Phoenix Sign (an increase in dorsiflexion strength of the Extensor Hallucis Longus muscle (EHL)). One patient had no response to the peripheral nerve block. Of the 25 patients who demonstrated a positive “Phoenix Sign” and underwent nerve decompression of the CFN, and 25 (100%) showed an increase in dorsiflexion strength of the EHL after nerve decompression surgery of the CFN. The one patient in this cohort who did not demonstrate any improvement in dorsiflexion of the EHL after the nerve block did not have any improvement after surgery.

Reconstruction Using a Free Vascularized Fibular Graft after Frozen Autograft Reconstruction for Osteosarcoma of the Distal Tibia: A Case Report

Recently we have been performing biological reconstruction for malignant bone tumors of the extremities using frozen autografts. Here we present a case treated with free vascularized fibular graft (FVFG) after this method. A 23-year-old man developed osteosarcoma in his left distal tibia. There was nonunion after frozen autograft reconstruction, which we treated with FVFG. Twenty-four months later, bridging between the host bone and the frozen autograft was achieved. Our department has achieved bone union in almost all cases, but we sometimes encounter cases of nonunion after this method because of delayed blood supply. In these instances, reconstruction using FVFG may represent an attractive choice for salvage treatment.

Three-Dimensional Finite Elemental Analysis of Bone Stress near an Implant Placed at the Border between Mandible and Fibular Graft in Mandibular Reconstruction

Purpose: The aim of the present study was to use finite elemental analysis (FEA) to evaluate bone stress near an implant placed at the border between the mandible and fibular graft in mandibular reconstruction. Materials and Methods: A fibular model (FM) and transplantation model (TM) were constructed for FEA. In TM, mandible was on the mesial side and the fibular graft was on the distal side. The implant was positioned at the center of both bone models. In TM, it was placed on the border between the mandible and fibular graft. A 10-mm implant was used in the monocortical model and a 15-mm implant was used in the bicortical model. The loading force was set at 100 N, the angle was set at 90°, and the loading position was set as center, mesial, or distal on the upper surface of the prosthesis. Von Mises equivalent stress values of the bone near the implant collar and apex at the middle line between buccal and lingual side were measured. Results: In all models, stress values were significantly lower with center loading than with distal loading and mesial loading. In center loading, the stress values were significantly lower in the bicortical model than in the monocortical model. There were no significant differences in stress values between FM and TM in all conditions. Conclusions: Bone stress was least with the center loading position, which was further decreased by bicortical fixation. There was no increase in mechanical stress associated with placing an implant at the border between the mandible and the fibular graft.

吻合血管腓骨瓣治疗股骨头缺血性坏死的疗效观察

目的分析吻合血管腓骨瓣治疗股骨头缺血性坏死(ONFH)的临床疗效。方法2016年3月至2022年9月中南大学湘雅二医院骨科收治股骨头缺血性坏死患者23例(26髋),按照国际骨循环协会(ARCO)分期:Ⅱ期6例、ⅢA期15例、ⅢB期5例。术前髋关节Harris评分为(60.9±9.0)分。所有患者均采用吻合血管的腓骨瓣进行治疗,腓骨瓣近端距离腓骨头约10 cm,腓骨瓣长度约7 cm。除少数早期病例外,其余病例术中均未使用植骨材料或内固定装置。术后定期随访,进行影像学检查评估腓骨瓣愈合及股骨头坏死区域变化情况,评价髋关节功能。结果术后无伤口感染、下肢深静脉血栓形成等并发症。患者均获得随访,随访时间13~93个月。末次随访患髋Harris评分为(90.9±4.5)分,与术前相比差异有统计学意义(P=0.000)。影像学未见腓骨瓣移位,均愈合良好,无坏死区域进展。结论吻合血管的腓骨瓣治疗股骨头缺血性坏死能够有效改善患者髋关节功能。改良的手术方法和技术,使得腓骨瓣的切取、植入、固定等更加精准、有效。

坏死及支撑区三维空间分布对腓骨支撑保髋结局的影响

背景:坏死区分布在保髋治疗中有重要影响,目前探讨股骨头坏死在三维空间分布上的差异对腓骨支撑术的临床结局是否存在影响的研究较少。目的:利用CT三维重建探究股骨头坏死区和腓骨支撑区的空间分布与临床结局的关系,为优化腓骨支撑术的适用条件、提高腓骨支撑术的保髋疗效提供一定依据。方法:以2010年1月至2021年1月收治并符合纳入标准的80例使用腓骨支撑术保髋的股骨头坏死患者为研究对象,至少随访2年。根据临床结局分为2组,保髋成功组55例,保髋失败组25例。根据患者术前和术后CT影像进行三维重建,参照三柱理论,将股骨头划分为外九区、中九区、内九区共27个区域(L1-9,C1-9,M1-9),探究患者股骨头坏死区、腓骨支撑区的空间分布情况及其与临床结局的关系。结果与结论:①术前股骨头坏死区分布主要集中在股骨头前外侧的L1、L2、L4、L5、C1、C2、C4、C5(外九区和中九区的前中部上中段)区域,术后腓骨支撑区分布主要集中于L5、L6、C5、C6(外九区和中九区的中部中下段)区域;②保髋成功组与保髋失败组在L8(外九区的后部中段)、C3(中九区的前部下段)、C6(中九区的中部下段)、M2(内九区的前部中段)区域的股骨头坏死分布差异有显著性意义(P<0.05),在L5、L6区域(外九区的中部中下段)的腓骨支撑分布差异有显著性意义(P<0.05);其中L8区域可作为腓骨支撑术保髋失败的独立预测因素,L8单一因素预测模型曲线下面积为0.698[95%CI(0.575,0.822)],敏感度为76%,特异性为63.6%;③结果提示,当坏死区涉及L8、C3、C6、M2区域,尤其是L8区域时,腓骨支撑术保髋治疗的失败率可能升高;当腓骨支撑区涉及L5、L6区域时,保髋疗效常不理想。

吻合血管游离腓骨移植治疗股骨头坏死

背景:吻合血管游离腓骨移植是治疗股骨头坏死常用的有效保髋治疗手段,但其影响因素仍存在争议。目的:探究吻合血管游离腓骨移植治疗股骨头坏死的临床疗效,及股骨头坏死的病因分类和病变严重程度对其疗效的影响。方法:采集吻合血管游离腓骨移植治疗股骨头坏死患者63例(共73髋)的临床资料及术前、术后髋关节的临床疗效评分。按股骨头坏死的病因分类标准分为激素性、酒精性和特发性3组,参照Ficat分期标准分为FicatⅡ期、FicatⅢ期和FicatⅣ期3组,分析病因分类和病变程度对吻合血管游离腓骨移植治疗股骨头坏死临床疗效的影响。结果与结论:①吻合血管游离腓骨移植治疗股骨头坏死术后各阶段的目测类比评分均较术前明显降低(P<0.001),术后各阶段的Harris评分均较术前明显升高(P<0.001);②在激素性、酒精性和特发性3组中,除激素性组术后2,3年,其余各组术后各时点Harris评分均较术前明显升高(P<0.05);③在FicatⅡ期、FicatⅢ期和FicatⅣ期3组中,FicatⅡ期和FicatⅢ期各组术后Harris评分均较术前明显升高(P<0.05),FicatⅣ期术后Harris评分与术前比较差异无显著性意义(P>0.05);④结果提示,吻合血管游离腓骨移植治疗股骨头坏死临床疗效显著,可以减轻患者髋部疼痛和改善髋关节功能;其疗效可能不受病因的影响,而受病变严重程度的影响。

Proximal tibiofibular stabilization by anatomical ligamentoplasty and diaphyseal osteotomy of the fibula

Proximal tibiofibular instability is a rare condition for which treatment is poorly codified.A 21-year-old patient,a leisure sportswoman,presented a post-traumatic anterolateral instability of the proximal tibiofibular articulation without cartilage lesion.We propose an original surgical technique based on a review of the literature that combines an anatomical ligamentoplasty of the proximal tibiofibular joint and a proximal fibular diaphyseal osteotomy to reduce the distal tibiofibular mechanical stresses.This original technique allows a favorable evolution with recovery of professional and sports activities at 6 months.

腓骨近端骨折对伸直状态下膝关节应力影响的有限元分析

背景:传统观点认为绝大多数的腓骨近端骨折是不需要固定的,他人和此次研究提示,近端腓骨结构对于膝关节后外侧结构的稳定性具有重要影响,其作用机制值得研究。目的:探讨腓骨近端骨折对于伸直状态膝关节各结构生物力学的影响。方法:运用有限元方法进行仿真生物力学试验。选用1名健康青年男性志愿者膝关节MRI和CT影像数据资料建立伸直状态下的膝关节有限元模型,并模拟4种近端腓骨形态:模型A为完整模型,模型B为腓骨头下以远1 cm骨折模型,模型C为腓骨近端最顶端向远端1 cm的尖端缺损骨折模型,模型D为腓骨近端最顶端向远端2 cm的骨缺损模型。在股骨干上施加纵向集中载荷1500 N,对比分析膝关节伸直状态下,4种工况下膝关节各个结构最大等效应力、最大第一主应力的分布以及改变趋势。结果与结论:①模型A胫骨软骨、半月板外侧室最大等效应力大于内侧;胫骨平台、半月板内侧室最大第一主应力大于外侧;股骨软骨内侧髁最大等效应力大于外侧髁,股骨软骨内侧髁最大第一主应力大于内侧髁;②相较于模型A,模型C的软骨、半月板的最大等效应力和最大第一主应力大小以及分布情况无明显差异;③相较于模型A,模型B的最大等效应力上升幅度依次为内侧胫骨软骨(14.9%),股骨软骨内侧髁(13.6%),内侧半月板(6.6%);最大第一主应力上升幅度依次为内侧半月板(11.06%),内侧胫骨软骨(8.65%),股骨软骨内侧髁(7.46%);韧带的最大等效应力上升幅度依次为:腘弓状韧带(33.2%)>前交叉韧带(21.3%)>腓侧副韧带(17%)>后交叉韧带(14.3%)>前外侧副韧带(13.2%)>内侧副韧带(10.1%);④相较于模型A,模型D的最大等效应力上升趋势依次为内侧胫骨软骨(19.5%),股骨软骨内侧髁(17.9%),内侧半月板(9.9%);最大第一主应力依次为内侧半月板(14.04%),内侧胫骨软骨(13.03%),股骨软骨内侧髁(11.37%);韧带最大等效应力上升趋势依次为:前交叉韧带(25.2%)>后交叉韧带(18.9%)>内侧副韧带(18.5%)>前外侧副韧带(12.7%);⑤提示在膝关节伸直情况下,腓骨头下1 cm骨折和2 cm腓骨尖端骨缺损对内侧室软骨、前交叉韧带以及后外侧韧带复合体结构的影响较大。

单侧腓骨皮瓣重建鼻咽癌患者放疗术后双侧下颌骨放射性颌骨坏死

目的:探讨单侧腓骨皮瓣修复双侧下颌骨放射性颌骨坏死(osteoradionecrosisofthejaw,ORNJ)的应用价值。方法:回顾性分析2010年1月至2020年11月,中南大学湘雅二医院口腔颌面外科采用单侧腓骨修复鼻咽癌放疗后双侧下颌骨ORNJ的7例患者的病例资料,其中男性6例,女性1例,年龄42~56岁,所有病例原发肿瘤均为鼻咽癌,排除鼻咽癌复发。记录腓骨截骨、组织瓣存活、供区和受区的并发症及术后开口度情况。结果:随访10~30个月,7例患者皮瓣完全成活,伤口愈合良好,无严重并发症发生。受区动脉选择面动脉5例、甲状腺上动脉2例,受区静脉均行颈内静脉端侧吻合,1例患者术后6 h出现静脉危象,急诊手术探查,发现端侧吻合时静脉扭转,重新吻合静脉后恢复良好。切取腓骨长度为17.5~21.0 cm,平均18.2 cm,供区创口全部直接拉拢缝合,患者均未出现感染和跛行。术后双侧颜面部基本对称,患者对外形满意,开口度为2.5~3.3 cm。结论:采用游离腓骨肌皮瓣移植修复双侧下颌骨ORNJ扩大切除术后软、硬组织缺损的方法安全可靠,值得临床推广应用。

A finite element analysis of the pelvic reconstruction using fibular transplantation fixed with four different rod-screw systems after type I resection

Background The pelvis often needs to be reconstructed after bone tumor resection. A major challenge here for the orthopedic surgeons is to choose a method that gives the best performance which depends upon its biomechanical properties. In this study, a 3-dimensional finite element analysis （FEA） was used to analyze the biomechanical properties of reconstructed pelvis using fibula transplant fixed by four commonly used rod-screw systems. Methods A total pelvic finite-element model including the lumbar-sacral spine and proximal femur was constructed based on the geometry of CT image from a healthy volunteer. Three-dimensional finite element models of different implants including fibula, rod and screw were simulated using ways of solid modeling. Then various reconstructed finite element models were assembled with different finite element implant model and type Ⅰ resected pelvic finite element model. The load of 500 N was imposed vertically onto the superior surface of L3 vertebral body, and the pelvis was fixed in bilateral leg standing positions. FEA was performed to account for the stress distribution on the bones and implants. The pelvis displacement of the different rod-screw fixation methods and the maximum equivalent stress （max EQV） on all nodes and element were figured out to evaluate the advantages and disadvantages of different reconstructive methods.Results Stress concentration in the fibula transplant was extremely high in the reconstructed pelvis, but could be substantially decreased by internal fixation, which partially transferred the stress from the fibula to the rod-screw systems. High stress concentration was also found in the implants, especially in the connection sites between screw arid rod. Among the four methods of fixation, a double rod system with L5-S1 pedicle and ilium screws （L5-S1 HR） produced the best performance： least stress concentrations and least total displacement.Conclusion According to the stability and stress concentration, the method of L5-S1 HR fixation combined with fibula transplantation is better than other fixation methods in pelvic reconstruction after type Ⅰ resection.

Free vascularized fibular grafting for treatment of old femoral neck fractures

The internal fixation failure for treatment of femoral neck fracture is mainly due to improper fixation, loss of fixation stability and premature ambulation. Bone nonunion and avascular osteonecrosis of the femoral head caused by the internal fixation failure for femoral neck fracture are always the complex topics in orthopedics. With regard to patients who sustain these complications, total hip arthroplasty is a proper choice for elderly patients, but is not acceptable by young patients. We report nine patients with the failure of internal fixation for femoral neck fracture who were treated with free vascularized fibular grafting and internal fixation with cannulated screw from November 2001 to October 2003. All of them achieved good results.