We devised a peroneal vascularized composite tissue transfer procedure that utilizes the peroneal artery and vein and their branches as a pedicle, and the skin on the outer side of the leg as a flap. It can be used not only for pedicled and free flap transfer, but also as a flap together with the muscle or fibula.
This procedure has a wide range of applications such as monitoring buoy flaps in free vascularized fibular grafts, and for vascularized fibular grafts with an island flap, peroneal island flaps, cross leg island flaps, peroneal free flaps, double peroneal free flaps, peroneal myocutaneous flaps, vascularized fatty tissue grafts, or vascularized sural nerve grafts. It can be utilized as a pedicle for the cutaneous artery or for both the peroneal artery and its cutaneous artery.
The vascular pedicle is long, enabling a wide range of transplants from the knee to the foot and to the opposite side.
As interpositional anastomosis is carried out using the recipient artery and vein, noncirculatory disturbance develops, which can be applied to the reconstruction of ruptured arteries.

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We describe the clinical picture and indications for three fix and flap strategies（fix and flap, fix followed by flap, and flap followed by fix）that we have selectively used to treat severe open extremity fractures. Gopal’s fix and flap, which is completed within 72 hours of injury, remains the best reconstruction strategy to avoid deep wound infection and post-traumatic vessel disease. The indications for fix followed by flap are as follows: In the upper extremities, the eventual length of the bone after osteosynthesis determines our approach to the nerve and musculotendinous reconstruction. In the lower extremities, we decide the area of soft tissue reconstruction after osteosynthesis depending on whether we are treating a joint and metaphysis fracture or multiple fractures of a long bone. The indications for flap followed by fix are cases with previous infection, in which the priority is soft tissue reconstruction rather than bone reconstruction. It is important for the operator to use different treatment strategies for bone and soft tissue reconstruction, and it is necessary to select the best method.

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Currently, carpal tunnel release（CTR）is a common surgical procedure performed in clinical practice. Although this surgery has been demonstrated to be reliable and safe, iatrogenic median nerve injury may infrequently occur. Patients with iatrogenic nerve injury require treatment by experts at specialized centers. This study investigated patients exhibiting iatrogenic injuries of the median nerve following surgical release for carpal tunnel syndrome at our hospital. This study included 7 patients presenting with iatrogenic median nerve injuries after CTR between 2006 and 2017（6 women, 1 man, mean age 64.3 years）. This condition developed in 3 patients following open CTR and in 4 patients following endoscopic CTR before visiting our facility. The mean timing of surgery was 9.7 months after the injury. We performed nerve grafting on all patients, and opponensplasty using the palmaris longus tendon（Camitz transfer）was performed simultaneously for 2 patients. Intraoperatively, complete median nerve injury was observed in 5 and partial injury was observed in 2 patients. In those with complete injury, the mean gap length was 17 mm between the proximal and distal stumps. Thus, it is important that surgeons be aware that CTR is associated with iatrogenic nerve injury.

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A 27-year-old male presented with incomplete left foot amputation caused by a machine accident. The foot was salvaged after two rounds of surgery, but was insensate due to tibial nerve injury. This unusual sensation bothered the patient after surgery, but he was able to be barefoot at 5 months postoperatively. Eleven months later, he was able to jog using an ankle-foot orthosis, the reformation of inversion and equinus strap, with slight pain and no medication. Treatment of severe lower extremity trauma is complex and challenging. Early amputation may result in better long-term outcomes than limb salvage for some patients; however, no established guidelines are available to make informed treatment decisions. Although all injury characteristics are significant indicators of limb status, soft tissue injury and absence of plantar sensation are the most important. Previous studies reported that initial plantar sensation is not a prognostic factor for long-term plantar sensory status or functional outcome, and should not be a component of limb-salvage decision algorithms. Our case demonstrates the importance of limb salvage even for a patient with tibial nerve injury secondary to incomplete foot amputation.

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We report the use of a free flap with proximal arterial reconstruction to cover Gustilo III B skin defect wounds of the lower extremity. A 22-year-old man was injured in a motorcycle accident, sustaining a right femoral fracture and right leg joint open fracture. CT images revealed obstruction of the superficial femoral artery（SFA）, and ultrasonic examination demonstrated reduced distal blood flow. To cover the bone soft tissue defect of the right foot joint, free latissimus dorsi musculocutaneous flap transplantation was performed on the 70th day after injury with SFA reconstruction by a large saphenous vein graft. Right leg joint fixation was performed five months after surgery. He was able to walk one year after surgery. Evaluating the hemodynamics requires ultrasound examination or angiography, and ultrasound examination is useful, minimally invasive and highly accurate for assessing hemodynamics. We assessed the hemodynamics of the recipient vessel before and after reconstruction of the SFA by ultrasound, and confirmed hemodynamic improvement. Peripheral limbs may be preserved even in cases with decreased blood flow due to arterial injury. In cases with poor circulation, we should reconstruct the vessels whenever possible.

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Four patients who underwent thumb reconstruction surgery using reverse radial midpalmar island flaps between May 2017 and July 2018 were retrospectively investigated. Elevated flap sizes ranged from 2.6×1.0 cm to 3.0×1.5 cm, and the mean age of the patients was 52.5 years old（range 18 to 76）. Although two flaps required bloodletting for a few days for postoperative congestion, all flaps survived. After a mean 7.8 months of follow-up, the mean static and moving two-point discriminations were 9.8 mm and 7.5 mm, respectively. For one patient, additional surgery for release of first web scar contracture was required. This flap, which uses similar tissue to the fingertip region, results in a preferable appearance with good fingertip function, and is a useful procedure for thumb finger-pulp reconstruction.

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It is important to establish blood flow as soon as possible in patients with major limb amputation. Temporary intravascular shunt（TIVS）is useful to restart blood flow to the amputated limb prior to permanent vascular reconstruction and to reduce the ischemic time. We report the use of pancreatic duct tube as a TIVS.
We treated a 37-year-old man with incomplete left forearm amputation（Gustilo type III C）who was rescued using a pancreatic duct tube as a TIVS. The radial artery and ulnar artery had deficiencies of 7.5 and 5.0 cm, respectively. The pancreatic duct tube was inserted at both ends of the radial artery and blood flow was reconstructed temporarily. Surgery was performed three times in total due to thrombosis. The saphenous vein was ultimately transplanted into the radial artery. The postoperative course was good after the third surgery, and the patient is currently undergoing rehabilitation.
Pancreatic duct tube is made of flexible polyvinyl chloride, has moderate hardness, and does not twist or bend without special fixation when placed in a blood vessel. Moreover, it can be obtained easily in several sizes, making it useful as a TIVS.

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While downhill skiing, a 19-year-old man collided with a steel tower, sustaining traumatic dissection of the aorta, bilateral pulmonary contusions, and fractures of the right femoral neck and left humeral neck. He was treated conservatively in the intensive care unit under continuous sedation for 9 days. After osteosynthesis of the fractures, his left hand was completely paralyzed. He was referred to our institution, where we diagnosed severe Volkmann’s contracture. Five months after his accident, we performed neurolysis of the median and ulnar nerves, flexor tenotomy, and flexor-muscle sliding operation. One year after these procedures, we restored flexion of his four fingers by free functional gracilis muscle transfer and that of the thumb by brachioradialis muscle tendon transfer. Two years and 10 months after surgery, finger flexion was sufficient to assist in performing activities of daily living. For severe Volkmann’s contracture involving the total loss of finger flexion and partial loss of finger extension, free functional gracilis muscle transfer can effectively restore the range of motion, although the procedure is technically demanding, given the requirements of a reliable donor nerve and limited ischemic time.

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