Management of scaphoid nonunion with iliac crest bone graft and K-wire fixation.

PURPOSE: Scaphoid nonunion can occur in both non-operative and operatively treated scaphoid fractures. Without treatment, this can lead to a predictable pattern of carpal collapse and degenerative arthritic change and patients can experience both pain and functional loss in the early and late phases of progression. An operative technique with a high success rate for union is important. This paper describes a technique for treatment of scaphoid nonunion with K-wire fixation and iliac crest cancellous bone graft. METHODS: A retrospective review from 1996 to 2010 was performed on a single senior surgeon's private university-based practice. Patient demographic information and fracture characteristics were obtained to evaluate for influence on success and time to union. RESULTS: There were 32 patients identified for inclusion in this study. Union was achieved in 100% of the patients, including 44% that had proximal pole fractures. The median time from injury to surgery was 41.86 weeks. The median time from surgery to healing was 17.93 weeks. Time to union was not affected by patient age, fracture location, smoking, alcohol use, or time to treatment. CONCLUSION: K-wire fixation and ICBG for treatment of scaphoid nonunion using our technique have equal or superior union rates compared to other techniques in the literature. This paper highlights the keys to success using this method. LEVEL OF EVIDENCE: Therapeutic Level IV.

A combined microdialysis and FDG-PET study of glucose metabolism in head injury.

BACKGROUND: Microdialysis continuously monitors the chemistry of a small focal volume of the cerebral extracellular space. Positron emission tomography (PET) establishes metabolism of the whole brain but only for the scan's duration. This study's objective was to apply these techniques together, in patients with traumatic brain injury, to assess the relationship between microdialysis (extracellular glucose, lactate, pyruvate, and the lactate/pyruvate (L/P) ratio as a marker of anaerobic metabolism) and PET parameters of glucose metabolism using the glucose analogue [(18)F]-fluorodeoxyglucose (FDG). In particular, we aimed to determine the fate of glucose in terms of differential metabolism to pyruvate and lactate. MATERIALS AND METHODS: Microdialysis catheters (CMA70 or CMA71) were inserted into the cerebral cortex of 17 patients with major head injury. Microdialysis was performed during FDG-PET scans with regions of interest for PET analysis defined by the location of the gold-tipped microdialysis catheter. Microdialysate analysis was performed on a CMA600 analyser. FINDINGS: There was significant linear relationship between the PET-derived parameter of glucose metabolism (regional cerebral metabolic rate of glucose; CMRglc) and levels of lactate (r = 0.778, p < 0.0001) and pyruvate (r = 0.799, p < 0.0001), but not with the L/P ratio. CONCLUSION: The results suggest that in this population of patients, glucose was metabolised to both lactate and pyruvate, but was not associated with an increase in the L/P ratio. This suggests an increase in glucose metabolism to both lactate and pyruvate, as opposed to a shift towards anaerobic metabolism.

Reliability of the "Ten Test" for assessment of discriminative sensation in hand trauma.

"Ten Test" (TT) is a bedside measure of discriminative sensation, whereby the magnitude of abnormal sensation to moving light touch is normalized to an area of normal sensation on an 11-point Likert scale (0-10). The purposes of this study were to determine reliability parameters of the TT in a cohort of patients presenting to a hand trauma clinic with subjectively altered sensation post-injury and to compare the reliability of TT to that of the Weinstein Enhanced Sensory Test (WEST). Study participants (n = 29, mean age = 37 ± 12) comprised patients presenting to an outpatient hand trauma clinic with recent hand trauma and self reported abnormal sensation. Participants underwent TT and WEST by two separate raters on the same day. Interrater reliability, response stability and responsiveness of each test were determined by the intraclass correlation coefficient (ICC: 2, 1), standard error of measurement (SEM) with 95% confidence intervals (CI) and minimal detectable difference score, with 95% CI (MDD95), respectively. The TT displayed excellent interrater reliability (ICC = 0.95, 95% CI 0.89-0.97) compared to good reliability for WEST (ICC = 0.78, 95% CI 0.58-0.89). The range of true scores expected with 95% confidence based on the SEM (i.e. response stability), was ±1.1 for TT and ±1.1 for WEST. MDD95 scores reflecting test responsiveness were 1.5 and 1.6 for TT and WEST, respectively. The TT displayed excellent reliability parameters in this patient population. Reliability parameters were stronger for TT compared to WEST. These results provide support for the use of TT as a component of the sensory exam in hand trauma.

Sentinel node biopsy as an adjunct to limb salvage surgery for epithelioid sarcoma of the hand.

BACKGROUND: Epithelioid sarcomas of the hand are rare, high-grade tumors with a propensity for regional lymphatic spread approaching 40%. CASE PRESENTATION: A 54-year-old male with an epithelioid sarcoma of the palm was treated with neoadjuvant radiation, wide excision, and two-stage reconstruction. Sentinel lymph node biopsy was used to stage the patient's axilla. Sentinel node biopsy results were negative. The patient has remained free of local, regional and distant disease for the follow-up time of 16 months. CONCLUSION: The rarity of this tumor makes definitive conclusions difficult but SLN biopsy appears to be a useful adjunct in the treatment of these sarcomas.

Free vascularized fibula graft to treat chondroblastoma of the hip.

Chondroblastomas are rare tumors that present in the epiphysis of the long bones. Bone grafting following aggressive surgical curettage has yielded the best results. When present in the femoral head, they pose a higher risk of recurrence due to the difficulty of achieving an adequate resection without destroying the structural integrity of the weight-bearing surface. This article describes a case of surgical treatment of a chondroblastoma of the femoral head with the use of a free vascularized fibula graft. A 26-year-old woman had several months of increasing left hip pain and decreased range of motion. Imaging studies confirmed a large bubbly lesion with sclerotic borders in the left femoral head consistent with chondroblastoma. After performing an aggressive and complete excisional biopsy, a large cavitary defect remained in the femoral head. Reconstruction of the defect and structural support was achieved using a free vascularized fibula. Nine years postoperatively, the patient had full hip motion, no pain, and no radiographic evidence of collapse. A free vascularized fibula graft is an excellent option for the reconstruction of a large femoral head defect after chondroblastoma resection.

Desmoplastic squamous cell carcinoma: case presentation and literature review.

BACKGROUND: Desmoplastic squamous cell carcinoma (DSCC) is a variant of squamous cell carcinoma (SCC) with aggressive histologic and clinical features. DSCC has a 6 to 10 times higher rate of both local recurrence and metastatic spread compared with well-differentiated SCC. Clinical estimation of tumor margins can grossly underestimate both the depth and the peripheral extent of the tumor. Surgery with intraoperative margin control has been recommended. In many cases, postoperative radiotherapy or prophylactic lymph node dissection may be required. CASE PRESENTATION: A 71-year-old man with a biopsy positive for DSCC involving the left postauricular area was treated with nine-stage Mohs micrographic surgery before the tumor margins were negative. CONCLUSION: There are minimal reports in the literature pertaining to the presentation and treatment of DSCC; therefore, definitive conclusions are difficult. The depth of tumor penetration and peripheral spread of the DSCC presented in this case, however, supports the need for aggressive surgical excision, preferably with intraoperative margin control. To maximize the chance of cure, physicians must be aware of the distinct clinical and histologic features of DSCC and the aggressive treatment required.