Treatment of congenital clasped thumb in arthrogryposis.

We report the result of treatment of 69 complex clasped thumbs in 39 patients with distal arthrogryposis. The mean age at surgery was 30 months. Surgical reconstruction included skin augmentation of the first web using modified dorsal rotation advancement flap (Abdel-Ghani flap), a la Carte release of tight structures of the first web, and chondrodesis of the thumb metacarpophalangeal joint. The mean follow-up was 4 years. We prefer chondrodesis because of the presence of global instability, abnormal joint structure, abnormal articular surfaces, and inefficient muscles for transfer. Also, chondrodesis shortens the thumb and may alleviate the need for release of deficient palmar skin and lengthening of a short flexor pollicis longus. The Abdel-Ghani flap provides ample skin that gives a wide rounded web. It is a simple procedure with minimal donor site morbidity. Surgical reconstruction significantly improved the cosmetic appearance and function of the thumb. LEVEL OF EVIDENCE: IV.

The anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis by modified Dunn subcapital osteotomy using the Ganz approach: functional and radiological outcomes.

AIMS: This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz. PATIENTS AND METHODS: We prospectively studied 31 patients (32 hips; 16 females and five males; mean age 14.3 years) with SCFE. On the Southwick classification, ten were of moderate severity (head-shaft angle > 30° to 60°) and 22 were severe (head-shaft angle > 60°). Each underwent open reduction and internal fixation using an intracapsular osteotomy through the physeal growth plate after safe surgical hip dislocation. Unlike the conventional procedure, 25 hips did not need an osteotomy of the apophysis of the great trochanter and were managed using an extended retinacular posterior flap. RESULTS: Clinical outcome was assessed using the range of movement and the Harris Hip (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC), and Merle d'Aubigné scores, while radiological measurements included slip and alpha angles. The mean duration of follow-up was 24.1 months (12 to 40). There was a significant improvement in all clinical and radiological measurements after treatment (p < 0.001). Post-operative major complications were one deep infection and one case of femoral head collapse. CONCLUSION: These findings suggest that a modified Dunn osteotomy carried out through Ganz approach is a safe and effective method of treating the stable SCFE with a high degree of slip. Cite this article: Bone Joint J 2016;98-B:1283-8.

Tendon transfer for treatment of internal rotation contracture of the shoulder in brachial plexus birth palsy.

We retrospectively analyzed 63 patients with internal rotation contracture of the shoulder secondary to brachial plexus birth palsy treated with subscapularis sliding combined with either latissimus dorsi transfer (group A: n = 18) or latissimus dorsi and teres major transfer (group B: n = 45) to the rotator cuff. The mean age at time of surgery was 43 months (SD 21 months; range 8 months to 9 years). We used a modification of the Gilbert shoulder grading system for assessment. All patients showed statistically significant improvement of active shoulder abduction and external rotation without significant differences between the two groups. Significant external rotation contracture of the shoulder (inability to touch the abdomen with the wrist extended) occurred in 42 of 63 patients, and there was a greater incidence of external rotation contracture in group B. We conclude that surgery should be restricted to latissimus dorsi transfer without teres major transfer to avoid external rotation contractures. Our modification of the Gilbert grading system appears to be valid and applicable.

Management of combined nonunion and limb-length discrepancy after vascularised fibular grafting.

We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma. Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems.

Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation.

We treated 30 tibial plateau fractures (Schatzker Type VI) in 29 patients, with a mean age of 41.4 (20-76) years, with the Ilizarov fixator. In 18 fractures, we combined the treatment with minimal internal fixation. All fractures were the result of high-energy trauma, and 20 patients had associated injuries. Twenty-eight fractures were available for follow-up after 27 (16-36) months. Using The Knee Society clinical rating system, 18 knees were rated as excellent, seven as good, one as fair, and two as poor. There was a direct correlation between the presence of associated injuries and the final outcome. The most significant concomitant injuries were distal femoral fractures and extensive soft-tissue injury. This study emphasizes the clinical success and low morbidity associated with the use of external fixation and minimal internal fixation.

Correction of relapsed or neglected clubfoot using a simple Ilizarov frame.

We present the results of using a simple Ilizarov fixator frame in treatment of 66 feet in 52 patients (mean age 8.5 years) of 58 relapsed and eight neglected clubfeet with grade III or IV severity with a mean follow-up of 40 (26-58) months. Our frame, in spite of being simple and easy for surgeons and patients to handle, achieved satisfactory correction comparable to the literature.