Total Elbow Arthroplasty and Antegrade Posterior Interosseous Flap for Infected Posttraumatic Arthritis with an Active Fistula. A Rationale for Comprehensive Treatment. Case Report.

The indication for total elbow arthroplasty (TEA) for primary and posttraumatic elbow arthritis has increased, however, its indication after infection remains elusive. Wound closure about the elbow increases the challenge of treating a previously infected elbow, often necessitating soft tissue coverage with local or regional flaps. We present a 75-year-old male patient with an elbow infection following a failed complex intraarticular fracture open reduction and internal fixation of the distal humerus. Initially, he presented with severe functional impairment and pain, also with an active fistula with serous exudate, whose culture was positive for Cutinebacterium acnes. Septic hardware loosening, and septic nonunion with intraarticular involvement of the left elbow was diagnosed. The patient underwent hardware removal, fistulectomy, serial irrigation and debridement and a pedicled antegrade posterior interosseous artery (PIA) flap on staged surgical treatment. Finally, after ruling out infection persistence, a TEA was performed. We aim to report the outcome of a patient treated with a TEA in the context of a previously infected elbow with soft tissue coverage with an antegrade PIA flap. Comprehensive treatment must be done in an appropriate manner, to obtain an expedited and desirable outcome.

Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis.

Osteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.

Infrared imaging of lymphatic function in the upper extremity of normal controls and hand transplant recipients via subcutaneous indocyanine green injection.

OBJECTIVES: The goal of this study was to define the parameters of movement of indocyanine green in the upper extremity of normal control and hand transplant recipients. The purpose was to establish a non-invasive method of determining the level of lymphatic function in hand transplant recipients. In hand transplantation (and replantation), the deep lymphatic vessels are rarely repaired, resulting in altered lymphatic connections. In most cases, the relatively rapid inosculation of superficial lymphatic networks and drainage via the venous systems results in sufficient interstitial fluid and lymph drainage of the graft to prevent edema. However, our group and others have determined that some transplant recipients demonstrate chronic edema which is associated with lymphatic stasis. In one case, a patient with chronic edema has developed chronic rejection characterized by thinning of the skin, loss of adnexal structures, and fibrosis and contracture of the hand. METHODS: Lymphatic function was evaluated by intradermal administration of near-infrared fluorescent dye, indocyanine green, and dynamic imaging with an infrared camera system (LUNA). To date, the assessment of lymphatic drainage in the upper extremity by clearance of indocyanine green dye has been studied primarily in oncology patients with abnormal lymphatic function, making assessment of normal drainage problematic. To establish normal parameters, indocyanine green lymphatic clearance functional tests were performed in a series of normal controls, and subsequently compared with indocyanine green clearance in hand transplant recipients. RESULTS: The results demonstrate varied patterns of lymphatic drainage in the hand transplant patients that partially mimic normal hand lymphatic drainage, but also share characteristics of lymphedema patients defined in other studies. The study revealed significant deceleration of the dye drainage in the allograft of a patient with suspected chronic rejection and edema of the graft. Analysis of other hand transplant recipients revealed differing levels of dye deceleration, often localized at the level of surgical anastomosis. CONCLUSION: These studies suggest intradermal injection of indocyanine green and near-infrared imaging may be a useful clinical tool to assess adequacy of lymphatic function in hand transplant recipients.

Metacarpal Aneurysmal Bone Cyst En Bloc Resection Reconstructed With Osteoarticular Allograft.

Aneurysmal bone cysts are large lytic lesions that appear most often around metaphyseal bone. The lesions are locally aggressive with high recurrence rates. Therefore, wide resection is commonly necessary, leading to challenging reconstruction of the defect, especially when the articular surface is involved. We present a case of an aneurysmal bone cyst of the fourth metacarpal, treated with an en bloc resection and reconstruction with a metacarpal osteoarticular allograft. At 8 years after surgery, the patient has shown no signs of recurrence, but radiographic articular reabsorption was noted. However, the patient showed an excellent outcome with a satisfactory active range of motion and grip strength. Despite potential complications, osteoarticular allograft is a feasible alternative when autologous osteoarticular reconstruction is not an option.

Innervation of the interphalangeal joint of the thumb: anatomical study.

We dissected 30 cadaveric thumb interphalangeal joints to delineate the sensory nerve anatomy of its capsule. Four articular branches supplying the interphalangeal joint capsule of the thumb were found in all specimens. Ulnar and radial proper digital nerves provide one palmar capsular nerve branch on their respective sides. Of the two dorsal branches of the radial nerve at the dorsum of the thumb, we observed that each nerve provided one branch to the interphalangeal dorsal capsule. Our findings demonstrate a consistent pattern of innervation and may provide the anatomical basis to the treating surgeon for an effective and safe denervation of the interphalangeal joint of the thumb.

Antegrade Posterior Interosseous Flap for Nonhealing Wounds of the Elbow: Anatomical and Clinical Study.

BACKGROUND: The posterior interosseous artery (PIA) flap has been widely reported to cover defects at the dorsal aspect of the hand. However, the use of this flap to cover elbow defects has been rarely reported. The purpose of this study was to analyze the anatomical feasibility of the PIA flap to cover elbow soft-tissue defects and, additionally, to review the clinical outcomes of patients treated with this flap. METHODS: An anatomical study was performed on 14 cadaveric specimens to assess the number of PIA perforators at the distal third of the forearm, along with the distance of the perforators from the ulnar styloid. Additionally, the pedicle distance from the pivot point to the lateral epicondyle was recorded. A clinical study in 4 patients with elbow soft-tissue defects treated with the antegrade PIA was also performed to assess viability and clinical outcomes. RESULTS: A mean of 3 perforators (range, 2-4) of the PIA were found in the distal third of the forearm. The pedicle distance from the pivot point to the lateral epicondyle was 10 cm (range, 8-11.5 cm). In the clinical study, all cases treated with the antegrade PIA flap showed satisfactory outcomes without loss of the flap or significant partial necrosis. CONCLUSION: In this limited series, the antegrade PIA flap has shown to be a reliable and effective alternative for treatment of soft-tissue defects at the elbow. The PIA perforators in the distal forearm and the pedicle length allow the flap to easily reach the elbow.

Extended Posterior Interosseous Artery Flap: Anatomical and Clinical Study.

PURPOSE: A reverse-flow pedicled flap from the posterior interosseous artery (PIA) has been used to cover defects on the dorsal and volar aspects of the hand. However, the original description of this flap does not reach further than the metacarpophalangeal joints of the 4 ulnar digits. In the present study, we describe a distal variant (type 2) of the PIA flap, which changes the pivot point of the classic variant (type 1) and which can provide full coverage of single or multiple digits in the entire dorsum and palmar surface of the fingers. METHODS: An anatomical study was performed on 26 cadaveric specimens to assess the presence of the anastomosis between the PIA and the dorsal intercarpal arch (DIA). In addition, the gain in pedicle length using the DIA anastomosis as a pivot point was compared with the classic pivot point at the anterior interosseous artery. A clinical study in 19 patients with soft tissue defects distal to the proximal interphalangeal joint of the fingers was also performed to assess the viability and clinical outcomes of the new variant of the PIA flap. RESULTS: The PIA was identified reaching the dorsal carpal arch in all anatomical specimens. The mean pedicle length of the fifth extensor compartment artery was 4.8 cm (range, 4.1-5.3 cm). The mean arterial diameter was 0.8 mm (range, 0.6-1.2 mm). In the clinical study, 17 flap reconstructions were done for posttraumatic lesions and 2 postburn contractures. All extended PIA flap procedures were performed successfully without loss of the flap or significant partial necrosis. We had only 1 superficial infection. There was no need for revision of the flap in any case. CONCLUSIONS: By extending the pivot point of the PIA flap through the DIA, instead of the anastomosis with the anterior interosseous artery, the flap distance can be increased by about 8.5 cm, allowing complete coverage of the fingers. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Functional result in distal radius fractures. Comparison between the severity of the fracture, the treatment of choice and the baseline X-ray parameters]. / Resultado funcional en fracturas del radio distal. Comparación entre gravedad de la fractura, tratamiento de elección y parámetros radiológicos iniciales.

BACKGROUND: The AO classification has a prognostic value and assists physicians in the planning of fracture management. The X-ray data and the DASH questionnaire are used to assess the outcome of radial fractures. A trend towards open treatment, opposite to closed or percutaneous approaches, has been observed in the past ten years. METHODS: Descriptive study evaluating the functional outcome, with a follow-up from 6-months to one year, using the DASH questionnaire and correlating the outcomes with the treatment used, the type of fracture, the AO and Frykman classifications, and the baseline X-ray parameters. The fracture stability and the treatment of choice were recorded. Patients were grouped according to the treatment used. RESULTS: A DASH score < or = 20 was considered as good, and > 20 as poor. The questionnaires were applied at the 6- and 12-month follow-up visits, the mean score was 14.46. No statistical difference was found between the good or bad outcomes and the type of treatment. A correlation was found between both the type of fracture and the X-ray parameters and the functional outcome. CONCLUSIONS: Regardless of the treatment of choice of distal radius fractures, the major goal is to restore the normal X-ray parameters to improve the functional outcome and decrease the complications. No difference was found in the functional outcome among the treatment options used to treat the distal radius fractures. The AO classification is valid as a prognostic indicator and useful to make therapeutic decisions.

[Minimally invasive treatment of mild and moderate hallux valgus]. / Tratamiento mínimo invasivo de hallux valgus leve y moderado.

INTRODUCTION: Our institution implemented a minimally-invasive surgery program that included a thorough preoperative assessment and planning to provide the patient with an appropriate correction of the radiographic parameters as well as esthetic satisfaction, together with a shorter hospital stay and less analgesic use. MATERIAL AND METHODS: Retrospective, comparative, longitudinal and observational clinical trial. The study period was from January 2002 to December 2007; 40 patients with hallux valgus underwent minimally invasive surgery, 12 of them underwent bilateral surgery, for a total of 52 feet with hallux valgus; 100% of them were females. Patients with mild hallux valgus were 59.6% (31 patients) and those with moderate hallux valgus represented 40.4% (21 patients). Radiographic measurements were assessed in the pre- and postoperative periods; the AOFAS test was performed in the pre- and postoperative periods and 6 months later. Central trend and scatter measurements and Student's t-Test were performed. RESULTS: A significant difference was found in both the pre- and postoperative measurements. In both groups the postoperative results were within the normal ranges and there was no significant difference between them in the 6-month postoperative assessment. DISCUSSION: Any failed correction of some of the intrinsic and extrinsic components may cause a recurrent deformity. Certain parameters cannot be corrected with this method and therefore the orthopedic surgeon should be familiar with more than one corrective surgical method to decipher the deformative biomechanics of each patient.