Free Vascularized Proximal Fibular Epiphyseal Transfer For Hip Reconstruction Following Septic Necrosis In Children.

BACKGROUND: Septic necrosis of the femoral head and neck in children represents a challenging problem. Several reconstructive techniques have been described but with disappointing long-term results. Vascularized epiphyseal transfer utilizing the proximal fibula have been successfully used for reconstruction of the proximal humerus and distal radius and only scarcely used for hip reconstruction. This cohort represents the largest reported series of epiphyseal transfer for hip reconstruction following septic necrosis in children. METHODS: A total of 18 patients with an average age at surgery of 5.4 years were included. The average follow-up was 3.6 years (range 2.3 to 6.8 y). RESULTS: Transient postoperative foot drop was observed in 4 patients. Radiographic resorption of the transferred fibula occurred in 2 cases. Longitudinal growth averaged 7.3 mm/year, and the physis width increased by an average of 2.7 mm/year. The rate of longitudinal growth was fastest after the age of 10 years (18.5 mm/y), which coincides with the pubertal growth spurt. All successful transfers had an open growth plate on final follow-up radiographs. Ten patients had limb length discrepancy of an average 2.8 cm (range 1 to 8 cm). Thirteen patients had satisfactory functional according to the criteria of Hunka et al. Three patients had unsatisfactory results; one had painful nonunion at the fibula-femur junction, and the other two had limited flexion range of 45 degrees. The average postoperative neck-shaft angle was 96.4 degrees which decreased by an average of 8 degrees at the final follow-up. Three patients underwent a valgus subtrochanteric osteotomy to correct a severe varus deformity. The final neck-shaft angle correlated significantly with the functional results where it averaged 96 degrees in the satisfactory group and 57 degrees in the unsatisfactory group. CONCLUSION: Vascularized epiphyseal transfer presents a promising treatment for children with septic necrosis of the femoral head and neck in whom other methods have failed to provide satisfactory long-term results. We recommend the procedure be done before the age of 5 years for optimum results. LEVEL OF EVIDENCE: Level-IV.

Outcome of Flexor Tendon Repair Using Eight-Strand Core Stitch Without Postoperative Finger Splinting.

BACKGROUND: There are no reports that detail clinical outcomes using the 8-strand suture techniques and early active mobilization. We aim to report the outcome of using an 8-strand double-cruciate core suture followed by early active motion without finger splinting. MATERIALS AND METHODS: Thirty-five patients with 41 affected digits were operated and followed up for at least 6 months. A double cruciate repair with 4 single cross-grasping stitches on either side was employed. Active full-range finger flexion/extension exercises were allowed from the third postoperative day with the wrist held in the neutral position. RESULTS: The total active motion (TAM) calculated for the proximal interphalangeal and distal interphalangeal joints averaged 151° ± 22°, and the TAM% averaged 86% ± 13%. Based on the original Strickland-Glocovac criteria, excellent and good outcomes were achieved in 25 of 29 fingers (86.2%). An average extension lag of 21° ± 11° (range 10°-40°) was observed in 11 (38%) fingers. The Buck-Gramcko scale showed excellent and good results in 10 (83.4%) thumbs. Active interphalangeal range of motion averaged 68° ± 23°. An average extension lag of 12° ± 4° (range 10°-20°) was observed in 7 (58%) thumbs. Complications occurred in 4 thumbs, including bowstringing (2), rupture (1), and flexion contracture of 60° (1). CONCLUSIONS: Using the 8-strand repair technique and active mobilization performed by the patient is both practical and cost-saving. Intensive supervision of a hand therapist is generally not required. Notably improved outcomes have been achieved while preventing adhesions at the repair site. Further clinical outcome studies devoted specifically to the flexor pollicis longus are recommended to validate early-phase active mobilization following the 8-strand repair.

Treatment of Concomitant Congenital Pseudarthrosis of the Fibula With Propeller Periosteal Flap.

INTRODUCTION: Congenital pseudarthrosis of the fibula is not an uncommon condition to accompany congenital pseudarthrosis of the tibia. Persistence of the fibular pseudarthrosis has been linked to inferior outcomes including tibial union and alignment, refractures, and ankle alignment. In this report, we present the results of a pedicled periosteal propeller flap technique for the treatment of fibular pseudarthrosis. METHODS: Ten children with an average age at surgery of 5.3 years who had congenital pseudarthrosis of both tibia and fibula were studied. The tibia was treated with free vascularized fibular grafting, and the ipsilateral fibula was treated with a technique after resection of the pseudarthrosis. A periosteal flap from the proximal healthy part of the fibula is harvested off the bone, rotated 180° based on a branch from the peroneal vessels to cover the fibular defect and fashioned in the form of a tube filled with bone fragments. RESULTS: The periosteal flap size ranged from 5 to 7 cm. Follow-up averaged 37.2 months. The tibia was united in all cases; in 2 of them, refractures occurred and healed with conservative management. The fibula was united in 8 cases. At final follow-up, 5 cases showed residual tibial deformity, and 5 showed residual ankle deformity. Average leg-length discrepancy was 1.4 cm (0-3 cm). CONCLUSION: The pedicled periosteal propeller flap presents a useful new technique for managing concomitant congenital fibular pseudarthrosis.

Outcomes of Surgical Treatment of Peripheral Neuromas of the Hand and Forearm.

The choice of a specific technique for surgical treatment of neuromas remains a problem. The purpose of this study is to determine the overall effectiveness of surgery as well as to find out whether certain surgical procedures are more effective than others. Twenty-nine patients operated between 1998 and 2018 and followed for at least 12 months were reviewed. Clinical assessment included the identification of a pre- and postoperative Tinel sign, pain visual analog score, two-point discrimination (2PD), and grip strength. Mechanisms of injury included clean lacerations (11), crush injuries (11), and other trauma or surgery (7). Mean time from presentation to surgery was 9 months. Seven surgical procedures involving excision in 10 patients and excision and nerve repair in 19 patients were performed. Pain score improved from an average of 7.1 ± 2.3 to 1.8 ± 1.7 with 27 patients (93%) reporting mild or no postoperative pain. Nine patients complained of residual scar hypersensitivity and six patients had residual positive Tinel. No patient required an additional surgical procedure. 2PD improved from an average of 9.6 ± 4.0 to 6.8 ± 1.0. The improvement of pain score and 2PD was statistically significant. Nerve repair resulted in marginally better outcomes, in terms of 2PD and grip strength recovery, than excision alone. The mechanism of injury, zone of involvement, time to intervention, or length of follow-up did not have an impact on the outcomes. Although patient numbers in this study are large in comparison to previous studies, larger patient numbers will allow for a multivariate analysis, which can be possible with a prospective multicenter trial.

Congenital Pseudarthrosis of the Tibia: Long-term Outcome of Treatment With Intramedullary Vascularized Fibular Graft Combined With Ilizarov Distraction.

BACKGROUND: Late presenting cases of congenital pseudarthrosis of the tibia, are further complicated with severe shortening. Limb length discrepancy (LLD) cannot be corrected by vascularized fibular grafting and the use of Ilizarov distraction is associated with a high rate of complications. The aim of this study was to report the long-term follow-up of a combined technique previously published under the name "telescoping vascularized fibular graft". MATERIALS AND METHODS: Eleven patients operated at an average age of 10.2±3.2 years were reviewed. All cases were Crawford type IV affected by neurofibromatosis 1. Nine patients had an average of 4.3 previous operations. Preoperative LLD averaged 7.9±2.5 cm. RESULTS: Follow-up averaged 10±5.4 years. Seven cases (63.6%) reached skeletal maturity before final follow-up. Primary union was achieved in all cases after an average of 7.2±1.3 months. Full weightbearing was possible after an average of 10.6±2.2 months. Recurrent stress fractures occurred in 9 cases (81.8%) and healed with casting in 6 cases and required internal fixation in 3 cases. Eight cases (72.8%) developed tibial shaft deformities, mainly procurvatum that required corrective osteotomy in 2 cases. Final LLD averaged 2.7±1.3 cm. Complete tibialization of the graft was achieved after an average of 17.0 ± 3.6 months. Valgus deformity of the ipsilateral ankle averaged 12.4 degrees±7.5. CONCLUSION: The presented technique avoids osteotomy of the diseased bone and allows simultaneous treatment of the pseudarthrosis and correction of shortening. Compared with conventional bone transport, it requires shorter time of frame application and therefore better patient tolerability because there is no waiting for consolidation of the regenerate. The dis-impaction of the doweled fibula occurs proximally, allowing the less active site located at the distal aspect of the pseudarthrosis to heal without displacement. A shortcoming of the presented technique is the more propensity for axial deviation and refractures that seldom require surgery. LEVEL OF EVIDENCE: Level-IV.

Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries.

INTRODUCTION: In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. PATIENTS AND METHODS: Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. RESULTS: Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. CONCLUSIONS: The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.

Long-term Evaluation of Teres Major to Infraspinatus Transfer for Treatment of Shoulder Sequelae in Obstetrical Brachial Plexus Palsy.

BACKGROUND: The long-term results of soft tissue rebalancing procedures of the shoulder in obstetric brachial plexus palsy have been scarcely reported. The effect of this procedure on the evolution of secondary bone changes has been a subject of controversy. METHODS: Twenty-six children are included in this study. All initially had postganglionic C5-6 or C5-7 (Narakas types I and II) obstetric brachial plexus palsy, which spontaneously recovered. Children included are those who had persistent external rotation weakness with or without internal rotation contracture, nondysplastic glenohumeral joint, and functioning teres major. All had anterior shoulder release and teres major to infraspinatus transfer to correct internal rotation deformity and/or increase active shoulder external rotation. Patients were 18 males and 8 females. The right upper limb was affected in 16 patients, and the left in 10. Surgery was performed at an average age of 3.01 years (range, 1-10 years). Follow-up averaged 8.2 years (range, 5-16 years). Eight cases (30%) were followed up for 10 years or greater. Age at final follow-up averaged 10.5 years (range, 6-17.8 years). RESULTS: The results showed to be significant: 67 degrees (63%), 71.3 degrees (412%), and -32 degrees (-35%), respectively. There was no single recurrence of internal rotation deformity. Global Mallet score averaged 20 ± 2.7. Global abduction and external rotation averaged 3.5 ± 0.8 and 4 ± 0.3, respectively. Shoulder abduction range included an average of 45 degrees glenohumeral and 65 degrees scapulothoracic motion. Postoperative internal rotation in adduction was limited to 55.96 ± 25.65 degrees and was significantly lower that the preoperative value. Radiological measurements showed no significant differences between the operated and normal sides. CONCLUSIONS: We conclude that the long-term results after soft tissue rebalancing, combined with open reduction when required, demonstrated significant improvement of abduction and external rotation and significant loss of internal rotation. The difference in glenoid version and humeral head subluxation continued to be insignificant compared with the normal side.