The Dorsoulnar Artery Perforator Adipofascial Flap in the Treatment of Distal Radioulnar Synostosis.

Posttraumatic radioulnar synostosis (RUS) is a rare event following forearm fractures. Consequences are disabling for patients who suffer from functional limitation in forearm pronosupination. Distal RUS are even more rare and more difficult to treat because of high recurrence rates. The patient we describe in this paper came to our attention with a double distal RUS recurrence and a Darrach procedure already performed. We performed a radical excision of RUS and interposition with a vascularized dorsoulnar artery (DUA) adipofascial perforator flap. Four years after surgery, the patient shows the same complete range of motion in pronosupination, and MRI confirms that the flap is still in place with signs of vascularization. Simple synostosis excision has been proven ineffective in many cases. Interposition is recommended after excision, and biological material interposition seems to be more effective than foreign material. Surgeons are increasingly performing vascularized interposition, and the results are very encouraging.

Single forearm radius and ulna asymmetric lengthening in multiple cartilaginous exostoses: a case report and a long-term follow-up.

We describe one case of forearm deformity in a patient affected by multiple cartilaginous exostoses - also known as the forearm 'candy stick deformity'. Surgical treatment usually focuses on the correction of the wrist deformity without correcting the forearm shortening, the latter not being given the same consideration as lower limb shortening. In the presented case, radius and ulna corticotomies were performed and distal forearm deformity and shortening were corrected by two independent monoaxial external fixators, with full pronosupination. It is our belief that simultaneous treatment of forearm shortening and deformity not only results in an improved clinical and functional result but also provides significant psychological benefit. We recommend a long-term follow-up.

Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature.

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Perthes-like disease in Alagille syndrome.

We describe a unique case of a bilateral osteochondrosis of the femoral heads, similar to Perthes disease, in a boy affected by Alagille syndrome. This is a rare genetic syndrome, caused by vascular anomalies, and characterized by five main features: hepatic, cardiovascular, ophthalmological, skeletal malformations, and characteristic facial appearance. The most frequent skeletal finding is the 'butterfly vertebra'. We have followed the patient from the age of 5 years to the age of 20 years. We performed two bilateral valgus osteotomies when he was 10 years old to limit the progression of the deformity. We believe that the association of a bilateral osteochondrosis of the femoral heads with Alagille syndrome, a disease characterized by a vascular etiology, supports the hypothesis of angiogenic pathogenesis of Perthes disease.

Recurrence of axial malalignment after surgical correction in congenital femoral deficiency and fibular hemimelia.

PURPOSE: Recurrent genu valgum deformity complicates treatment of congenital femoral deficiencies (CFD) and fibular hemimelia (FH). We analysed factors influencing recurrence. METHODS: Patients who underwent limb lengthening or deformity correction for CFD and/or FH were reviewed. Radiographs after surgery and after a minimum of a further six months were analysed. Change in parameters of mechanical axis deviation per month (∆ MAD/month) and of angle per month were calculated. These parameters were tested against cofactors patient age, baseline MAD, type of CFD and FH, severity of ball-and-socket joints, ankle-joint stiffness, absence of cruciate ligaments and resection of the fibular anlage. RESULTS: Recurrent valgus deformity was found in 23 of the 42 limbs included with a mean change of MAD of 23.4 mm (5-60 mm). There was no significant difference between patients with ∆ MAD/month <0.5 mm versus >1 mm regarding MAD in the first radiograph and patient age. CFD cases Pappas types VII and VIII showed a ∆ MAD/month of 1.6 mm, whereas milder cases of Pappas IX showed a ∆ MAD/month of 0.8. Mild FH (type Ia) showed a mean ∆ MAD/month of 0.39 mm, whereas mean ∆ MAD/month for FH type Ib/II was 0.72 mm. In FH type II cases, mean ∆ MAD/month was 0.79 mm after resection of the fibular anlage compared with 1.98 mm in those without resection. CONCLUSIONS: Recurrence in FH and CFD was not dependent on patient age but partly on FH and CFD type. Limbs with more severe ball-and-socket knee joints showed more recurrence. Overcorrection depending deformity type should be performed.