Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study.

PURPOSE: The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint. METHODS: Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up. RESULTS: Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications. CONCLUSIONS: Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Intratendinous Ganglion Cyst of the Extensor Indicis: A Case Report.

An intratendinous ganglion cyst is a very rare benign lesion with an unknown etiology. The clinical diagnosis can be difficult as patients may have mild symptoms or impaired hand functionality. Ultrasound and magnetic resonance imaging can differentiate a ganglion cyst from other soft-tissue tumors and tumor-like lesions and provide excellent information on the location of an intratendinous lesion to schedule surgical treatment. We present a case report of a 50-year-old female diagnosed with an intratendinous ganglion cyst of the extensor indicis. She complained of right-hand swelling for three months, which was associated with pain. The US revealed an oval hypoechoic mass with cystic formation at the extensor indicis, measuring 9 x 4 mm, compatible with an intratendinous ganglion cyst. The cyst was excised by enucleation. After surgery, the patient was referred to the Department of Physical and Rehabilitation Medicine for evaluation. She started a rehabilitation programme. The patient presented a favourable clinical evolution with a return to her previous professional activity. However, six months after surgery, the cyst recurred, but with a smaller size and no associated pain.

Trochanteric fractures: Tip-Apex distance, Calcar Tip-Apex distance, and Chang criteria-a multiple variable analysis.

Failure of osteosynthesis is a common complication of the nailing of trochanteric fractures which typically occurs through form of cut-out. Tip-Apex distance (TAD), Calcar Tip-Apex distance (CalTAD), and Chang criteria are validated variables to predict failure of cephalomedullary nailing. This is a retrospective study which analyzes treatment of trochanteric fractures from 2018 to 2020 (n = 296) evaluating postoperative radiographs and factors of mechanical failure. Our objective was to assess correlation among these variables and their influence on mechanical failure, either individually or creating a new score. Our results support the CalTAD and Chang's criteria as valid predictors of mechanical failure. Furthermore, they empathize the importance of fracture reduction and proper placement of cervical screw. To our knowledge, this is the first study performing multivariate analysis including these 3 variables.

Locking plate versus retrograde intramedullary headless compression screw for unstable extra-articular metacarpal base fractures of the thumb.

The purpose was to compare clinical and radiological outcomes between two fixation techniques used to treat extra-articular fractures involving the base of the thumb metacarpal: retrograde intramedullary cannulated headless screw (RICHS) and locking plate (LP). Fifty-one patients who underwent RICHS (n = 22) or LP fixation (n = 29) from January 2010 through 2020 were included in this retrospective case-control study with mean follow-up 39 months. No inter-group differences were observed comparing mean time to radiological union, grip strength, range of motion, pain severity or QuickDASH scores. Mean surgery time was shorter with RICHS (18.9 min) than with LP fixation (44.4 min). Mean time to return to work or routine activities was less in RICHS than LP (22 vs. 32 days), as was the percentage of patients requiring hardware removal (0% vs. 44.8%). We conclude that RICHS fixation requires less operating time and yields faster post-operative return to full function and fewer secondary procedures.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients.

PURPOSE: We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options. METHODS: We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported. RESULTS: Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up. CONCLUSIONS: A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children.

We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity.Level of evidence: IV.

Recurrent traumatic hip dislocation in an 8-year-old boy.

Pediatric traumatic hip dislocations (PTHD) are rare and represent around 5% of all pediatric dislocations. Associated bony or soft tissue injury can occur as often as 17%-25% of the time. We report a case of an 8-year-old boy presenting a posterior hip dislocation after a low-energy trauma, which was initially managed with closed reduction and bed rest for 1 week. Two days after hospital discharge, he suffered a recurrent posterior hip dislocation. He was now managed with 4 weeks of bed rest and lower limb skin traction followed by 1 week of no weight-bearing on crutches. With 6 months of follow-up, he is asymptomatic, walking autonomously, with complete and painless range of motion of the affected hip and no major radiographic changes. Pediatric traumatic hip dislocation is a rare and challenging injury that should be managed promptly. Currently, there is no protocol concerning treatment in the literature and its largely dependent of patient and parents' cooperation.

Surgical anatomy of the radial nerve in the arm: a cadaver study.

PURPOSE: The purpose of this study was to analyse the anatomic course of the radial nerve (RN) in the arm, in order to minimize the potential risk of surgical injury. METHODS: The study was performed in 19 embalmed upper extremities of 11 adult human cadavers. We measured: distance from deltoid insertion (DI) into the humerus to lateral epicondyle (LE); distance from RN piercing point into the lateral intermuscular septum (LIS) to three other points-DI, LE and RN division into superficial and deep terminal branches; distance between the LE and the RN division. To assess variability, we correlated the distances between the landmarks to the overall length of the arm. RESULTS: The RN was found to pierce the LIS within 31.6 mm of the most distal DI into the humerus. The mean distance between the entry point of RN in the LIS and the LE was 107.2 mm. The mean distance between RN perforating point in the LIS and RN division in its terminal branches was 86.4 mm. The DI-LE and the LIS-LE showed a moderate positive correlation with the length of the arm. CONCLUSION: We describe the DI relationship to the RN course and also report its proportion within overall arm length which has not been previously described. Using the arm length as reference, our results show that RN can be found to perforate on the LIS at a point distal to the DI by 11% and proximal to the LE by 38%.

Tibialis Posterior Tendon Dislocation: A Case Report.

CASE: A 37-year-old man presented after a sudden snap followed by pain in the medial side of the ankle while playing football. Physical examination showed edema and pain posteriorly to the medial malleolus, and a longitudinal structure was palpable anteriorly. Ultrasound confirmed a dislocated tibialis posterior tendon (TPT). The patient underwent surgery, and the flexor retinaculum was repaired. Six months after the surgery, he was asymptomatic and had resumed his usual physical activity, with an AOFAS score of 100. CONCLUSION: TPT dislocation is rare and orthopaedic surgeons should be aware of this condition in patients with a sudden traumatic medial ankle pain.

Hereditary Neuropathy with Liability to Pressure Palsies: A Rare Condition That Presents with Common Symptoms: A Case Report.

CASE: A 13-year-old girl presented with paresthesia of the fourth and fifth fingers and the dorsal ulnar surface of the left hand that had started 3 months prior. Physical examination showed loss of sensation at the ulnar side of the fourth and fifth fingers and a positive Froment sign. Electromyography showed a severe motor conduction block in the ulnar nerve at the elbow. Eighteen months later, the patient had similar symptoms in the right hand. The diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) was considered and confirmed with genetic testing. CONCLUSION: HNPP is a rare disease that should be considered not only in patients with multiple compressive neuropathies, but also in patients with any unexpected or unexplained neuropathy, even if it is isolated.