Vascularized fibular flap and custom-made synthesis in post-traumatic ulnar diaphyseal pseudarthrosis: a case report.

BACKGROUND: Although isolated fractures of the ulnar shaft are considered common and relatively benign injuries, numerous complications can arise especially in the context of suboptimal care pathways. For pediatric patients, however, there is no single indication of the surgical approach. In the context of the management of these complications, it is known that the vascularized fibular graft has numerous advantages and indications in the treatment of recurrent pseudarthrosis. However, in revision surgery the frequent occurrence of anatomical subversions requires the use of fixation means adapted to the individual patient. We present a clinical case of an adult patient suffering from post-traumatic ulnar pseudarthrosis treated with autologous vascularized fibula grafts and 3D-planned custom-made plate. CASE PRESENTATION: A 38-year-old Ivorian woman came to our attention with a painful nonunion of the ulnar shaft and significant dysmorphism of the left forearm, with shortening and flexion of the limb as an outcome of unspecified road trauma in childhood. No alterations of the nerve compartment were reported. As far as detectable, she had undergone autologous bone grafting and implantation of questionable synthetic means, without acute treatment. Since we evaluated the patient (2012), we have performed two debridement surgeries, associated with autologous avascular bone graft from the iliac crest and plate fixation (2012 and 2014). In both cases, rupture of the fixation media was observed. In 2021, the pseudarthrosis was treated with a vascularized fibular bone graft. The subverted radius and ulna anatomy and poor bone quality required patient-specific reconstruction of the pseudarthrosic ulna from a 3D scan and the production of custom-made plate and screws, supported by the creation of special guides for drilling and by optimizing the positioning of screws with preoperative digital models. In the postoperative period, regular follow-up visits with X-rays evaluations were performed at 1, 3 and 6 months after surgery. No inflammatory reactions or local rejection were found. The fibula graft healed at the proximal ulnar junction six months after the operation while it took eight months to heal at the distal junction. Functionally, we observed a pain reduction and a range-of-motion preservation. CONCLUSIONS: The multiple failures of diaphyseal reconstruction with avascular bone grafts have forced the indication to the vascularized fibular flap. This case is a unique experience but we believe that the association between vascularized bone graft and the potential for customization through 3D planning represents a valid surgical potentiality in complex cases of post-traumatic reconstruction.

Four-Corner Arthrodesis Using a Dedicated Dorsal Circular Plate.

BACKGROUND: Scaphoid excision and 4-corner fusion is a standard procedure for advanced carpal collapse. The purpose of this study was to evaluate its effectiveness using a specific designed locking plate of the latest generation. METHODS: Between October 2012 and December 2015, 12 patients underwent this procedure using the Flower (KLS Martin Group, Tuttlingen, Germany) circular locking plate. The surgical technique is standardized. Three patients were affected by a scapholunate advanced collapse and 9 patients by a scaphoid nonunion advanced collapse. All patients underwent a computed tomographic scan to study the real achievement of the fusion. RESULTS: Only 2 patients did not show complete fusion. All the patients with successful fusion returned to previous work and manual activities. CONCLUSIONS: Four-corner arthrodesis with circular locking plate is an alternative surgical treatment for carpal arthritic collapse.

Proposal for Treatment of Severe Dupuytren Disease in 2 Steps: Progressive Distraction With External Fixator and Collagenase - A Preliminary Case Series.

Background: We want to describe a treatment for advanced Dupuytren disease using a spanning external fixator (EF) applied dorsally to produce progressive extension, followed by collagenase injection. Methods: Between October 2014 and September 2016, a total of 22 fingers from 18 patients were treated with an EF. The devices were implanted under local anesthesia, and the patients were instructed to gradually extend the hinge to gain a progressive extension. The EF was removed in an outpatient clinic setting after obtaining a complete extension of the treated joint in a mean of 19 days (range 15-22 days), and a collagenase injection was performed in the residual cord after a mean of 20 days (18-24 days), followed by splinting. Results: All patients were evaluated at an average follow-up of 14 months (range 3-23 months): the total average residual flexion deformity was 9.7° (range 0°-19°) with a correction of 107.2° (range 94°-138°), the average flexion deformity of the proximal interphalangeal joint was 7.4° (range 0°-15°) with a correction of 64.4° (range 46°-92°), and the average flexion deformity of the metatarsophalangeal joint was 2.4° (range 0°-9°) with a correction of 42.8° (range 15°-59°). No complications were reported in relation to EF treatment. Two cases of cutaneous laceration after collagenase injection were observed, neither of which required any additional treatment. Conclusions: All patients obtained a regression from 2 to 3 stages in disease severity only with EF. We had no report of complications due to the device. After collagenase injection and splinting, we obtained further finger extension with a mean total residual flexion deformity of 9.7° at 14-month follow-up.

Peer-support: a coping strategy for nurses working at the Emergency Ambulance Service.

BACKGROUND AND AIM OF THE STUDY: Working in the emergency medical service often exposes nurses to highly stressful situations and can impact their quality of life. Among the strategies aimed at mitigating the effects of this phenomenon, peer-supporting represents an emerging model used in the emergency medical service setting. The aim of the study is to explore the experiences, the opinions and feelings of emergency medical service nursing staff in relation to the use of the peer supporting model. METHODS: A semi-structured interview was carried out. Participants were recruited on a voluntary basis from an emergency medical service in the north of Italy. Interviews were audio-recorded and the data extracted were anonymised. RESULTS: 14 nurses participated in the study. The totality of the participants recognized that their daily clinical practice, especially when involving paediatric patients, can have a profound emotional impact on their life in general. Furthermore, interviewees admitted that their personal copying mechanisms did not seem to be entirely effective when processing their painful experiences.  The majority of the participants were in favour of introducing a peer-supporter in the ambulance service. CONCLUSIONS: This study emphasises the need to implement emotional support tools for non-hospital emergency nurses in daily clinical practice, in order to facilitate emotional decompression secondary to particularly stressful interventions as soon as possible. The peer-supporting strategy could represent, in this direction, a valid and shared model.