In the present report, we describe the clinical results of using a vascularized bone graft ( VBG ) combined with a locking compression plate ( LCP ) for the treatment of large bone defects in the extremities.
Between 2006 and 2014, 19 patients ( 8 males, 11 females ; mean age, 35.1 years ) with upper and lower extremity bone defects were treated with VBG and LCP. The bone defects were located in the upper and lower extremities in 10 and 9 patients, respectively. In total, 1 graft was obtained from the iliac bone and 19 grafts were obtained from the fibula.
Graft union occurred in all patients, expect in 1 because of death ; the mean healing duration was 4.6 months. In 3 children ( mean follow-up, 50.3 months ), the sling procedure was performed for the proximal humerus ; the mean total growth was 16.7 mm. In 6 patients, the sling procedure was performed for proximal humeral defects, and no fibular head collapse or absorption was observed in any of these cases. In the lower limbs, graft hypertrophy was observed at an average of 59.4%.
Thus, the method involving a VBG combined with a LCP is useful for the reconstruction of large bone defects in the extremities.

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It is difficult to reconstruct the extensor mechanism of the knee joint following extensive resection for malignant soft tissue sarcoma generated in the anterior surface of the knee joint. We introduced a surgical technique for this condition using recycled tissue including bone and tendon, and free myocutaneous flap of latissimus dorsi. Three patients surgically underwent wide resection for malignant soft tissue sarcoma in the anterior knee. Then, the resected tissue was devitalized for tumor cells using irradiation or pasteurization. This recycled tissue included the inferior patella, patellar ligament, and anterior proximal tibia with tuberosity. The recycled tissues were fixed on both sides and covered by the free latissimus dorsi myocutaneous flap. All patients had good function with neither recurrence of sarcoma nor complications at an average of 3.5 years after the surgery. Moreover, histological findings demonstrated remodeling of recycled tendon with longitudinal arrangement of tendon cells, which was resected in the debulking surgery. In contrast to easier techniques, there is concern over reconstructive surgery using recycled tissue in terms of various problems including infection and mechanical weakness. The present report suggests that the transferred tissue with rich circulation could promote remodeling of recycled tissue as well as decreased complications such as infection.

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Compared with other regions, open wounds around the ankle are difficult to treat, especially in patients with exposed bone, as there is less soft tissue, which delays healing. In addition, the choice of flap around the ankle is limited, which means that a free flap is often needed. A retrospective review of 11 patients who underwent reconstruction around the ankle at our institution after 1996 was performed. In these patients, causes and sites of defects, types of flap, survival rate, and complications were evaluated. Three pedicle flaps and eight free flaps were performed. The pedicle flaps included two distally based superficial sural artery flaps and one peroneal perforator flap. The free flaps included two anterolateral thigh flaps, two tensor fascia lata flaps, one latissimus dorsi muscle flap, two peroneal perforator flaps, and one saphenous flap. There were 3 cases of complications : one partial flap necrosis and two with bulkiness of the flap. Because it was difficult to accommodate the pedicle flap to a wide range of defects around the ankle, many free flaps were selected. After evaluating the lost tissue that needs to be reconstructed, the appropriate flap should be selected.

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Bone fixation at digital replantation often has a critical impact on the entire rehabilitation program, months or even years after the initial repair. The incidence of bony union problems following replantation can reach as high as 30 - 40 %. We examined the factors affecting delayed union and nonunion after digital replantation in 34 patients with 42 replanted digits in Tamai zones I to V. The radiographic information was reviewed retrospectively. Five females and 29 males averaging 48.6 years of age were followed for an average of 35 weeks. Thirty-two digits went on to bone union at an average of 15 weeks after replantation. Delayed union or nonunion occurred in ten digits ( 24 % ). Of the variables examined (age, gender, zone and type of amputation, fixation technique, and gap at the fixation site), univariate risk factors for delayed union and nonunion were female gender and amputations distal to the distal interphalangeal joint. However, no risk factors were significant on multivariate analysis. Our data suggest that a large series of females with replanted digits is needed to determine the role of gender in delayed union and nonunion following replantation because of the different outcomes in the univariate and multivariate analyses.

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Postoperative management of digital replantation often involves anticoagulation with heparin. To clarify when bolus injection of heparin should be performed for maximum anticoagulation at the time of restarting blood flow, we measured the activated coagulation time ( ACT ) immediately before and after bolus heparin injection in 10 patients who underwent replantation and received bolus heparin during the procedure. The patients ranged in age from 26 to 70 years ( mean : 46 years ). They received 3,000 units of heparin and we evaluated the difference of ACT between before and after bolus injection. Measurements were obtained at 2, 10, 20, and 25 minutes after bolus injection in more than 3 patients. The average ACT was 130.5 seconds before bolus injection. At 2, 10, 20, and 25 minutes after bolus injection, the average ACT was extended by 124.8, 56.8, 17.3, and 46.3 seconds, respectively. Because extension of the ACT was maximal at 2 minutes and was reduced by 10 minutes, the peak extension was presumably between 2 and 10 minutes after bolus injection.

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Purpose : To attempt microvascular surgery, a necessary technique for hand surgeons and plastic surgeons, we have conducted microvascular suture training since 2010. Herein, we report the training results.
Materials and Methods : From September 2012 through July 2014, 128 university students in 29 groups participated in microvascular suture training. First, the teacher performed a demonstration with a careful explanation of the microvascular suture method. Next, the students performed the procedures one at a time. We assessed the use of both eyes, comprehension, and the time necessary for the suture.
Results : The results show that 101 students used both eyes ; 27 students used only one eye. Their respective suture times were 90 - 671 s ( avg. 264 s ) and 134 - 840 s ( avg. 380 s ). Students with excellent understanding numbered 64, those with good understanding 37, and fair 27. Their times required for suturing were, respectively, 90 - 397 s ( avg. 225 s ), 114 - 591 s ( avg. 319 s ), and 170 - 840 s ( avg. 395 s ).
Discussion：We explained the microvascular suture method carefully and sequentially, but the students performing the task early understood it only slowly. The distribution of materials explaining microvascular suture on the first day of orthopedics training is expected to be beneficial.

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A 19-year-old male suffered from severe open fracture behind the knee via an accident. Since the popliteal artery was severely injured, revascularization with vein graft was performed on the same day. Grossly, the sciatic nerve was minimally injured.
Severe soft-tissue defect of the popliteus including biceps femoris, gastrocnemius, and soleus was reconstructed using a functioning latissimus dorsi free flap. Functional recovery of the transplanted muscle was obtained one year after reconstruction.

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Background : Deep inferior epigastric artery perforator ( DIEP ) free flap has become one of the good options for breast reconstruction due to its advantage of less donor site morbidity. We experienced a rare complication of intraoperative perforator avulsion and spasm and attempted to salvage this situation using the intravascular stenting ( IVaS ) method.
Case reports : A 64-year-old woman who underwent breast reconstruction using a DIEP free flap accidentally suffered perforator avulsion, and a 40-year-old woman had persistent perforator spasm due to a previously formed abdominal scar during flap harvesting procedures. In these two cases, the IVaS method was performed to salvage these situations.
Result : Although the salvage procedures using the IVaS method in these two cases were performed successfully, there was extensive flap loss in the former case and partial flap loss in the latter case. In the former case, progressive venous thrombosis occurred three days postoperatively, and in the latter case, repeated temporary flap ischemia occurred due to unstable blood flow of the salvaged perforators.
Discussion : The IVaS method is supposed to be a technically reliable technique to overcome perforator difficulties, but careful postoperative care is necessary for such patients due to the fragility and instability of the salvaged perforators.

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Neurovascular variations in the hand are common and have been well documented. Muscle anomalies and median artery may cause median nerve compression. We report median nerve compression due to an aberrant course of the radial artery within the carpal tunnel. A 23-year-old right-handed woman had felt palpable string and pain in the right palm. She had also experienced weakness of her right hand upon working. Tinel’s sign and Phalen’s test were negative and electrophysiological examinations revealed no abnormality of median nerve conduction. Magnetic resonance imaging and CT angiography revealed an aberrant course of the radial artery in the palm.
Surgical exploration was performed under brachial plexus block. The superficial palmar arch of the radial artery ran over the flexor retinaculum and passed deep between the two recurrent motor branches of the median nerve. Traction applied to a proximal branch was thought to have caused her symptoms. Microsurgical reconstruction was performed by transposition of the course of the radial artery. The patient’s symptoms resolved completely and she returned to her job two months after surgery.

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