METHODS: According to different bone and soft tissue defects, single、 demifacet、folded and a pair of fibulas(two single bones are took from a fibula that have the same pedicled artery) were combined with the fibula artery flap or use fow-though to restore the blood supply to the distal end of the extremities.Twenty-seven partients with extremities defects treated in our hospital from Jan 2010 to May 2018,include 2 cases of phalanges, 3 cases of first metacarpal, 1 case of metatarpal, 9 case of tibula,4 case of radius, 2 case of ulna,3 case of femur, 3 case of calcane, and 1 case of medial malleolus with different degrees of soft tissue defects. 3 cases of no blood supply to the distal limb, flow-through vascular anastomosis. All partients include 24 cases of traumatic, and 3 cases of osteomyelitis.The methods include 16 cases of single fibula graft, 6 cases of folded fibula(2 cases of repair of lower femur defect, 1 case of middle femur, 3 cases of calcaneus defect) ,3 cases of demifacet fibula,1 case of both ulnar and radius bone defects was treated with a pair of fibulas(two single bones are took from a fibula that have the same pedicled artery).All cases were combined with flap transplantation, 3 cases of emergency, 4 cases repaired within 2 weeks to 4 weeks , 20 cases of second-stage.Results:Among the 27cases with these methods,the result was 1 case failed, 1 case of bone resorption, 2 cases of re-fracture.At last one case was amputated and 24 cases were successful.

Introduction
In 1914, avascular necrosis of the second metatarsal head was described. Since then several conservative and surgical procedures have been developed. However, no procedure to date has received unanimous support. In recent years, periosteal flaps have been showing promising revascularization properties in cases of osteonecrosis.

Aim
By using a periosteal flap of a vascularized metatarsal bone, we sought to effectively induce bone revascularization, preventing metatarsal head collapse and promoting local regeneration.

Methodology
Revascularization by pedicle graft of the dorsum of the first metatarsal bone was performed to treat 2 patients with avascular necrosis (Smilie 3 and 4) of the second metatarsal head after failure of conservative treatment.

Results
The 2 patients were able to resume their previous physical activity without pain. No loss of range of motion was detected. By means of imaging tests, joint regeneration could be verified. The favorable results were maintained at 24 months.

Conclusion
By using this novel technique that counteracts vascular insufficiency, the very cause of the disease, we believe that periosteal flaps may be an alternative to other conventional joint preservation and reconstruction procedures to treat Freiberg's disease, given the excellent clinical, radiological, and low morbidity.

Osteomyelitis remains a challenging surgical problem. Temporary external fixators are a treatment option when soft tissue conditions are not adequate; however, pin-track infections occur in 0.5-42% of cases. Sometimes the treatment of chronic osteomyelitis requires radical debridement and an orthoplastic approach to cover the bone. We report the case of a distal tibial infection treated using an anterolateral thigh (ALT) free flap. A healthy 26-year-old male was brought to the emergency department after a 6-meter fall – suicide attempt. Initial assessment and imaging revealed radial head, left calcaneus and right tibial pilon fractures. This report will focus on the complex pilon fracture. The fracture was immobilized for surgery the following day, however, cutaneous conditions were not favourable and a transarticular external fixator was performed. After 10 days cutaneous conditions were deemed acceptable for plate osteosynthesis. 3 months later the patient stopped attending consultations and reappeared after 2 years in the emergency department. He had undergone removal of the plate and screws in another country and now complained of a wound that would not close. Upon inspection the distal tibia was exposed and imagining techniques suggested chronic osteomyelitis. Plastic surgery was consulted and the patient underwent radical debridement of soft tissues and bone, and the defect was covered with an ALT free-flap with anastomosis to the posterior tibial artery. 6 weeks of antibiotics were given. After a year the patient is stable with clean scintigraphy. An orthoplastic approach allows radical debridement for the treatment of chronic osteomyelitis.

Background: Managing large wounds in the lower extremities remain a challenge for reconstructive surgeons. Herein, we describe the surgical technique and clinical algorithm of using combined transfer of a latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap for the treatment of extensive soft-tissue defects.Methods: From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, with large soft-tissue defects underwent lower extremity reconstruction using combined transfer of the latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap. All patients had sustained injuries in road traffic accidents.Results: Twelve patients were treated with combined transfer of the latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap. The size of the flow-through anterolateral thigh perforator flaps ranged from 13.5 × 6.5 cm2 to 31 × 8.5 cm2. The size of the latissimus dorsi musculocutaneous skin paddle ranged from 25 × 6 cm2 to 34 × 7 cm2, and that of the muscle paddle ranged from 13 × 3.5 cm2 to 30 × 11 cm2. The mean harvest times were 93.3 and 56.7 minutes for the anterolateral thigh perforator and latissimus dorsi musculocutaneous flaps, respectively. The mean follow-up period was 26.8 months. All patients regained functional ability and could resume their activities of daily living 1 month after surgery. Conclusions: The combined transfer ensured adequate surface coverage and limited donor site morbidities, making it a reliable procedure for large soft-tissue defects to prevent lower extremity amputation.

Introduction: Jersey finger is defined as a flexor digitorum profundus tendon (FDP) avulsion injury in flexor zone I, however it can be a purely tendinous injury. The FDP of the ring finger is the most commonly involved. Objectives: The aim of this work is to report a surgical technique for the repair of a chronic jersey finger injury using a one stage flexor tendon grafting. Methods: The authors report a case of a 26 years old male with a ring finger injury of the right hand that happened 6 months before. The MRI confirmed a FDP rupture with tendon retraction to the palm, corresponding to a chronic jersey finger injury, Leddy and Packer type I. It was performed a suture anchor repair using a palmaris longus autologous tendon graft of the right forearm. He recovered 20º of flexion at 2 months and 55º at 6 months. The patient didn’t report any limitations of daily living activities at 6 months. The functional range of motion reported in the literature of the DIFJ is 10°–64°. Using a one stage surgical procedure the authors aim to avoid adhesion formation and contractures, besides succumbing the patients to a second surgery. Conclusion: The authors concluded that a one stage flexor tendon grafting surgery seems a viable surgical procedure to treat type I chronic jersey finger injuries, with good functional results. However, more studies should be done to establish the best indications to this technique.

Introduction: Leprous neuropathy is treatable but still a source of disability worldwide. Nerve decompression may be required in selected cases by an epineurotomy (internal neurolysis). The preferred surface of ulnar nerve for performing this procedure to minimize iatrogenic vascular compromise is a matter of debate. We describe the epineural vessel arrangement on the medial and lateral surface of ulnar nerve around the medial epicondyle while performing epineurotomy. Methods: We enrolled patients of symptomatic leprous ulnar neuropathy of less than one-year duration on MDT, that did not respond to steroids, for surgical decompression. Ten patients underwent epineurotomy of ulnar nerves (N=11) around medial epicondyle. The epineural vessels were classified as per Sunderland’s classification of arteriae nervorum. The number of epineural vessels was assessed on the medial and lateral surface of the ulnar nerve adjoining the medial epicondyle. The epineurotomy incision was placed over the surface of ulnar nerve having relatively less vessels. Results: The mean number of epineural vessels on the medial surface was 9.72 (range; 7-14) and on the lateral surface were 4.72 (range; 3-6). The average number of vessels per cm 2 of the medial and lateral surface of the nerve were 0.94 and 0.48 respectively. The most common type of epineural vessel was type 3 on both medial and lateral surface of the nerve. Lateral epineurotomy was performed in all 11 cases. Conclusion: Lateral surface (facing the medial epicondyle) of ulnar nerve has a lesser density of epineural vessels in comparison to its medial (subcutaneous) surface.

Purpose: To perform a morphological analysis of the carpal tunnel, determine its mean dimensions and compare them with the data in the literature.
Methods: The carpal tunnel of twenty fresh cadaveric hands was emptied and a silicone cast was created. Carpal tunnel was determined as the area underneath the transverse carpal ligament plus its aponeurotic extension between the thenar and hypothenar muscles. The casts were measured by industrial computer tomography.
Results: The mean length, width, depth, proximal, middle and distal cross-sectional areas and volume of seventeen male casts were respectively 26.97 mm, 21.84 mm, 21.45 mm, 23.13 mm, 10.69 mm, 10.82 mm, 11.48 mm, 173.91 mm2 , 172.87 mm2 , 191.93 mm2, and, 4 879.39 mm3, and of three female casts 24.16 mm, 19.36 mm, 20.44 mm, 20.97 mm, 9.02 mm, 9.85 mm, 9.34 mm, 127.82 mm2 , 141.61 mm2, 141.57 mm2, and 3 576.75 mm3.
Conclusions: The morphology of nineteen casts was found to be of a truncated cylinder of relatively regular shape, with little variation of its measures along its length. The narrowest section of the carpal tunnel varied between casts. Length of the roof of the carpal tunnel and its volume are underreported.
As new mini-invasive surgical techniques emerge, thorough knowledge of carpal tunnel morphology is paramount. Due to the unpredictability of the narrowest section of the carpal tunnel, it seems advisable to continue to release the flexor retinaculum along its entire length during carpal tunnel release.