How to do an outside-in/outside-in microsuture for nerve repair.

Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.

Modified Capanna's Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm.

Objectives Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna's technique-a reliable single-stage procedure of combining allograft and free vascularized fibular graft-in treating large posttraumatic bone defects in the distal third of the femur. Study Design This is a retrospective analysis. Materials and Methods Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18-49 years) and an average defect of 14.5 cm (range: 9.5-20 cm) in the distal femur were managed by the modified Capanna's technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted. Outcomes and Results Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5-9), with an average knee flexion of 80 degrees (range: 45-110 degrees) and an average LEFS of 63 (range: 46-72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union. Conclusion The modified Capanna's technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur. Level of Evidence Level 4. Level of Clinical Care Level I tertiary trauma center.

Successful reconstruction of a post-traumatic defect of 16 cm of the distal femur by modified Capanna's technique (vascularised free fibula combined with allograft) - A case report and technical note.

Reconstruction of large defects following trauma in the distal femur are a surgical challenge. These cases usually require multiple procedures and are associated with poor functional outcomes. We managed a post-traumatic distal femur defect of 16 cm using the modified Capanna's technique - combination of a vascularised free fibula and an allograft - and achieved a successful union at 6 months and also a good functional outcome with knee flexion of 100°. The patient received a vascularised free fibula which was pegged into an allograft which was sculptured to bridge the defect. The construct was fixed with a locking compression plate on the lateral side. With the allograft providing structural stability and the vascularised free fibula enhancing biology, our technique which involves the expertise of an orthopaedic surgeon and a plastic surgeon is a useful single stage procedure to manage large post-traumatic bone defects.

Reconstruction of segmental defects of Achilles tendon: Is it a must in infected complex defects?

Loss of Achilles tendon combined with overlying soft tissue loss is a challenging problem. Multiple techniques like tendon graft with coverage by soft tissue flap or composite flaps have been used. All these options are technically demanding. Reports do exist whereby muscle flaps bridging the defect used as cover in course of time could transmit the tendon force across the defect. We are presenting a case where a free gracilis muscle flap used to cover the soft tissue defect at the Achilles tendon at 2 years follow up provided stable cover and produced active function of the Achilles tendon allowing the patient to stand tip toe. Mechanism of its action has been analysed by MRI and M-mode ultrasound. While in primary Achilles tendon injury reconstruction is still the recommended option, in complex situations mere filling of the gap with the flap without formal reconstruction of the tendon could give good functional outcome. This technique can be used in demanding situations.

Correlation between clinical findings and CT scan parameters for shoulder deformities in birth brachial plexus palsy.

PURPOSE: The shoulder is the most common site of secondary deformities after birth brachial plexus palsy. The severity and the pattern of deformity vary in patients and have implications for clinical decision making. This study aimed to find the correlation between clinical findings and computed tomography (CT) scan parameters for these deformities. METHODS: This prospective study included 75 patients aged 3 to 23 years. The clinical parameters included age, extent of involvement (nerve roots affected), degree of shoulder abduction, active and passive external rotation, and Mallet score. These were correlated with 3 CT scan parameters: elevation of the scapula above the clavicle, relative glenoid version, and percentage of the humeral head anterior to the scapular line. RESULTS: There was a significant correlation between lack of active and passive external rotation and relative glenoid version and humeral head subluxation. There was a significant correlation between active abduction and elevation of the scapula above the clavicle. There was no significant correlation between age or Mallet score with any of the CT scan parameters. CONCLUSIONS: These results suggest that presence of active and passive external rotation beyond 10° is associated with significantly lesser shoulder deformity irrespective of the degree of shoulder abduction. Hence, a patient with more than 10° external rotation does not need a screening CT scan evaluation regardless of the degree of shoulder abduction present. Conversely, a lack of external rotation beyond 10° strongly suggests relative glenoid retroversion and posterior subluxation of the humeral head and should be considered a clinical indicator of shoulder deformation. TYPE STUDY/LEVEL OF EVIDENCE: Diagnostic II.

An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre.

BACKGROUND: Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre. MATERIALS AND METHODS: Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients. RESULTS: Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.