From 2000 to 2010 we treated 24 cases of the Gustilo typeIIIB/C open fracture of the tibia. There were 18 men and 6 women with an average age of 41.2 years ( 20 to 75 ). We divided these patients into four groups by the injury degree of bone and soft tissue. Group 1 comprised 17 patients who had a small bone defect and a large soft tissue defect. The soft tissue defects were treated with flap surgery ( 14 free and three regional ) and the bone defects with conventional bone grafts. Fourteen patients healed without any trouble, but three patients experienced deep infections and these were treated by bone transfer of tibio fibular synostosis. Group 2 comprised one patient who had the same size of bone and soft tissue defect and these defects were treated by distractive histiogenesis. The patient healed without any trouble. Group 3 comprised five patients who had a segmental bone defect ( 6cm> ) and a large soft tissue defect. The soft tissue defects were treated with free flap and the bone defects by Masquelet or vascularized bone grafts. They healed without any trouble. Group 4 was one patient who had a segmental bone defect ( 6cm< ) and a large soft tissue defect and was treated with vascularized fibula graft and peroneal flap. The patient healed without any trouble. If the soft tissue defects are treated appropriately during the acute phase, the VBG or Ilizarov methods are rarely indicated.

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Locking Compression Plates ( LCPs ) are ideal devices for the internal fixation of fractures; they have been gradually modified to anatomically conform to every bone in the body, increasing their applicability in clinical practice. Previous reports have demonstrated the efficacy of LCPs in free vascularized bone graft procedures for patients with postoperative malignant tumors or pseudoarthrosis. When stabilizing pedicled vascularized bone grafts, we have utilized LCPs as the internal fixation material. In this study, we report our clinical experiences associated with LCPs.

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Objective: We have experienced the replantation of 730 digits ( 558 cases ) at our hospital over the past thirty years. Of these cases, 29 amputations ( 23 cases ) were caused by ropes. The aim of this study was to assess the mechanism of digital amputation by ropes.
Methods and Results: This study design was a retrospective analysis. All cases had undergone replantation by microvascular anastomoses. The success rate was 65.5% ( 19/29 ) , which was much lower than that of the other digital amputation cases ( 83.0% ) during the same period. Cases of amputation caused by a cattle-leading rope presented particularly poor results, even though 5 of 7 digits were replanted with vein grafts.
Conclusion: Both crushing and avulsion forces can be involved in rope injury. We speculate that severe digital vascular damage may occur even though the skin remains intact. Therefore, we have to differentiate damaged vessels from normal tissue, and vascular repair with a vein graft is clearly essential for successful engraftment.

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In thumb reconstruction, the wrap around free flap ensures excellent functionality and a superb aesthetic outcome. However, delayed wound healing, pain, ulceration, and erosion at the donor site can be problems.
In ten patients, microdissected thin perforator flaps comprising four anterolateral thigh flaps, two tensor fasciae latae perforator flaps and four microdissected groin flaps were used for coverage of the donor defect of the big toe resulting from wrap around flap transfers. Major complications were not observed except for intraoperative arterial thrombosis in one microdissected groin flap. No patient required revisions. Covering the big toe after a wrap around flap transfer with microdissected thin perforator flaps caused no significant morbidity.

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We retrospectively evaluated patients who received reverse digital artery island flaps for fingertip injuries. The study included 13 patients ( 12 males and 1 female ) and 14 fingers. We reviewed postoperative evaluations of the range of motion of the proximal interphalangeal ( PIP ) joint. Mean active flexion and extension of the PIP joint were 97.9° and −5.0° degrees, respectively; this was considered a relatively satisfactory outcome. However, six fingers ( 43% ) had flexion contracture ( extension < 0°). Conversely, the flexion of the PIP joint seen in the flexion contracture group tended to be better than that of the non-flexion contracture group. Dermatogenic contracture was not observed, and there were no statistically significant differences between the two groups with respect to age, flap size, incidence of each finger, and preoperative waiting period. This study focused on surgical technique and postoperative therapy, which currently affects outcomes significantly. Patients must also be educated regarding the importance of postsurgical extension exercises. In addition, we must be alert for early extensive restriction, and intervention with rehabilitation and splinting must be performed.

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Introduction: Distal radius fracture is very common, but few studies have shown its association with radial artery injury. We present two cases of distal radius fracture with radial artery injury.
Patient 1 : A 28-year-old woman sustained a distal radius fracture in a traffic accident. During surgery, the radial artery was found to be entrapped and thrombosed at the fracture site. The thrombosed segment was resected, and end-to-end anastomosis was performed under microscopy.
Patient 2 : A 69-year-old woman fell from standing height and sustained a distal radius fracture to her left wrist. During surgery, the radial artery was found to be completely lacerated at the fracture site. After stable fixation of the radius, the lacerated artery was repaired under a microscope.
Discussion : In both of these cases, the fracture line extended from the distal volar to the proximal dorsal end of the distal radius, which is an uncommon observation. The sharp edge of the proximal fracture segment caused laceration of the radial artery because of the high degree of fracture displacement. Thus, in similar fractures, injury of the radial artery must be suspected.

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Two consecutive patients aged 50 and 65 years underwnt en bloc resection of sarcoma of the upper arm including the brachial artery and vein and median nerve. The pathohistological diagnoses were myxoid liposarcoma and epithelioid hemangioendothelioma. The lengths of the defects were 13 and 12 cm. Resected vessels and median nerve defects were reconstructed using great saphenous vein grafts and vascularized sural nerve grafts, respectively. The nerves were harvested at twice the length of the defects along with the small saphenous vein and surrounding adipose tissue, including the venous network. A “flow-through” venous free sural nerve graft ( VnNG ) was then applied and folded at the midpoint to obtain the nerve graft thickness. Finally, the sural vein was anastomosed to the cutaneous vein to make a “flow-through” venous flap. The postoperative periods were 122 months and 105 months. Although anterior interosseous nerve palsy was still present in the first case, forearm muscle strength in pronation was graded as 4 on the manual muscle testing scale. This paradoxical recovery seemed to be the result of late occlusion of the arterial graft. Tinel’s sign was present in both patients, and nerves were regenerating at rates of 2.06 and 2.3 cm/month. Moving two-point discrimination was found to vary between 0 and 6 mm. Recovery was graded as blue ( good ) to purple ( fair ) on the Semmes-Weinstein test. These results suggest that the sural nerve is the preferred conduit for VnNG of long peripheral nerve defects in the extremities.

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In gastric tube reconstruction for esophagectomy, the blood flow to the gastric tube is mainly supplied by the gastroduodenal artery ( GDA ) via the right gastroepiploic artery ( RGEA ) . Ablation of RGEA in pylorus-preserving pancreaticoduodenectomy ( PPPD ) for pancreatic head cancer may cause ischemia of the gastric tube. The middle colic artery ( MCA ), splenic artery and jejunal artery are potential choices of donor vessel to reconstruct RGEA. We report a case of microsurgical reconstruction of RGEA with MCA, which was ligated during the operation for preservation of the gastric tube. The postoperative course was uneventful and the flow of RGEA was confirmed by CT angiography on the eighth postoperative day. It seemed reasonable to use MCA for the reconstruction of RGEA in that the positions of donor and recipient vessels are close and the sacrifice of blood flow to other organs is limited.

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Free flap transfer is a useful technique for treating severely injured upper extremities with soft tissue defects. In patients who suffer from soft tissue defects due to high energy trauma, there is a large gap between the defect and the anastomosis site. Vein grafts can be used to solve this problem, but it is also reported that this technique increases the complication rate. We had two patients who underwent reconstruction with free flap using the AV loop technique. Both cases had large soft tissue defects and had previously undergone revascularization with vein graft at the time of injury, making the reconstruction procedure more complicated. The free flap with a 20 - 30 cm AV loop in both cases survived and there were no major complications. The AV loop technique is a reliable method for free flap reconstruction in complex injuries with extensive soft tissue defects.

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