Intramedullary versus plate fixation of both bone forearm fractures in skeletally immature patients: a systematic review and meta-analysis.

BACKGROUND: Both bone forearm fractures (BBFFs) are a common injury amongst the pediatric population. The main indications of surgical fixation are open, irreducible, or unstable fractures. The two most commonly used surgical techniques are closed or open reduction with intramedullary fixation (IMF) and open reduction with plate fixation (PF). The aim of this systematic review and meta-analysis was to determine which fixation method is superior for BBFFs. METHODS: PubMed, Scopus, Web of Science, and CENTRAL were searched to identify studies comparing IMF and PF. We extracted data on union rates, complications, early hardware removal rates, reoperation rates, and radiographic, clinical, and perioperative outcomes. RESULTS: Sixteen studies were included in the analysis, with a total of 922 patients (539 IMF and 383 PF). Similar union rates were achieved by both fixation technique. IMF was associated with a higher incidence of symptomatic hardware, and early hardware removal. Better restoration of the radial bow was observed with the PF group, especially in older children and adolescents. The rate of excellent function was comparable between groups, whereas better cosmesis was reported with the IMF group. Despite shorter fluoroscopy time and immobilization time, PF demonstrated longer tourniquet time, operating time, and hospital stay compared to IMF. CONCLUSIONS: We found no significant difference between IMF and PF in terms of union rates and functional outcomes taking in consideration the merits and demerits of each technique. High-quality randomized controlled trials are, therefore, necessary to determine the superiority of one fixation technique over the other. LEVEL OF EVIDENCE: III.

Comparison of the clinical and radiological outcomes of Puddu and TomoFix plates for medial opening-wedge high tibial osteotomy: A two-year follow-up of a randomized controlled trial.

PURPOSE: Opening-wedge high tibial osteotomy (OWHTO) requires fixation devices for stabilization of the osteotomy gap. The two most commonly used fixation devices are the Puddu and the TomoFix plates. Based on its design, each implant generates a characteristic stability profile. The aim of this randomized controlled trial (RCT) was to investigate the short-term clinical and radiological outcomes of OWHTO using the Puddu and TomoFix plating systems. We hypothesized that the TomoFix plate would achieve superior clinical and radiographic results compared to the Puddu plate. METHODS: A total of 60 patients were randomly allocated to undergo OWHTO either using the Puddu plate or the TomoFix plate if conservative treatment failed with symptomatic medial compartment knee osteoarthritis (OA) stage I or II according to Ahlbäck classification, and varus malalignment. All patients underwent clinical and radiological assessment preoperatively, and at 3, 6, 12, and 24months postoperatively. Radiological measurement of the hip-knee-ankle (HKA) angle, and posterior tibial slope (PTS) was performed. Functional assessment was carried out using the Hospital for Special Surgery Knee-Rating Scale (HSS) and the Western Ontario McMaster Universities (WOMAC) Osteoarthritis Index. Patients were also evaluated for intraoperative and postoperative complications throughout the follow-up period. RESULTS: The mean angular correction was 9.6±4°, and 10.5±4.8° in the Puddu and TomoFix groups, respectively (p=0.488). The mean PTS change was significantly higher in the Puddu group (3.4±1.1°) compared to the TomoFix group (0.8±0.7°) (p<0.001). There was a statistically significant improvement in the mean HSS and WOMAC in both groups until one year postoperatively. Neither HSS nor WOMAC showed a statistically significant difference between the Puddu and TomoFix groups at any time during the first two postoperative years. The overall complication rate was not significantly different between the Puddu and TomoFix groups. However, the TomoFix group demonstrated higher incidence of symptomatic hardware (23% vs. 3.3%) and removal of metalwork (17% vs. 0%) than the Puddu group (p=0.023 and 0.020, respectively). CONCLUSION: This RCT suggests that the implant choice for OWHTO has no significant impact on functional outcomes during the first 2years postoperatively. While the Puddu plate was associated with an unintentional increase in the PTS during the surgery, both implants allowed coronal and sagittal plane corrections to be preserved postoperatively. The overall complication rates were similar, but the TomoFix required more material to be removed because it is more cumbersome. However, these results need to be confirmed on a larger scale. LEVEL OF EVIDENCE: II; randomized controlled trial.

Radial shortening, bone grafting and vascular pedicle implantation versus radial shortening alone in Kienböck's disease.

We prospectively compared outcomes of two surgical procedures for Stage II and IIIa Kienböck's disease with negative ulnar variance. Group I (13 wrists) was treated with radial shortening alone, and Group II (14 wrists) with combined radial shortening, bone grafting and implantation of a vascular pedicle. At follow-up 3 to 7 years (mean 4.5) after operation, scores by the Quick version of the Disability of Arm, Shoulder and Hand questionnaire and scores for pain and grip strength were significantly better in Group II, but the differences were rather small. On MRI all patients in Group II had revascularization, but 11 patients in Group I had not. We conclude that combining radial shortening with the revascularization procedure improved revascularization. Clinically, both treatments were efficient, and the additional bone grafting and vascular pedicle insertion did not greatly improve function, although statistically there were differences in several follow-up variables. This study also could not identify the independent role of the three procedures (drilling, grafting and artery insertion) in Group II, because decompression or bone grafting alone may be effective.Level of evidence: II.

Reconstruction of complex hand defects using trapezoidal osteocutaneous free fibular flap.

BACKGROUND: Traumatic defects of multiple metacarpal bones can be addressed using conventional or vascularized bone grafts. When associated with extensive skin and tendon loss, the treatment becomes more challenging. The aim of the study was to describe the results of using free osteocutaneous fibular flap placed in a new fashion for the reconstruction of complex hand defects. PATIENTS AND METHODS: Six patients with complex hand defects underwent reconstruction using free osteocutaneous fibular flap placed in trapezoidal fashion with two-stage tendon reconstruction using fascia lata graft. The mean age at the time of injury was 34.7 years (range: 14-54 years). The injury was caused by motor vehicle accident in four patients, machine injury in one patient, and falling from height in one patient. All patients had extensive three or four metacarpal bones defects, segmental loss of tendons, and large skin defect ranging from 6 × 10 cm to 10 × 15 cm. The fibular graft was divided into three segments and positioned in a trapezoidal fashion with the middle bone segment placed transversely to support the bases of the proximal phalanges while the first and third bone segments were placed obliquely along the metacarpal axis converging toward the remaining metacarpal bases and/or carpal bones. At final follow-up visit, the finger range of motion was assessed using the total active motion (TAM) scoring system. Functional outcome was evaluated by the disabilities of the arm, shoulder and hand (DASH) score. Active range of motion (AROM) of the pseudo-metacarpophalangeal (MP) joint was measured. The handgrip strength was measured using Jamar hydraulic dynamometer. RESULTS: The mean length of the harvested fibular graft was 18 cm (range: 17-19). The mean size of the skin paddle was 7.5 × 13.1 cm (range: 6 × 10 cm to 10 × 15 cm). Fibular flaps survived in all patients. The mean follow-up period was 30.8 months (range: 24-40 months). The mean time to achieve bone healing was 3.8 months (range: 3-5 months). The mean TAM was 185° (range: 165-204°) and TAM percentage was described as excellent in two patients and good in four patients. The mean AROM at the pseudo-MP joint was 53.8° (range: 42-70°). The mean injured handgrip strength was 27.3 kg (range: 23-31 kg) and the mean grip strength ratio was 74.8% (range: 69-80%). The mean DASH score was 19.6 (range: 11.67-26.67). Pin tract infection, partial skin paddle necrosis, and wound infection were reported. CONCLUSION: The fibular osteocutaneous flap arranged in trapezoidal fashion is a viable choice for the reconstruction of complex hand defects, particularly when the metacarpophalangeal joints are not preserved.

Anterior Cervical Corpectomy with free vascularized fibular graft versus multilevel discectomy and grafting for Cervical Spondylotic Myelopathy.

PURPOSE: A retrospective study to compare the radiologic and clinical outcomes of 2 different anterior approaches, multilevel anterior cervical discectomy with fusion (ACDF) using autologus ticortical bone graft versus anterior cervical corpectomy with fusion (ACCF) using free vascularized fibular graft (FVFG) for the management of cervical spondylotic myelopathy(CSM). METHODS: A total of 15 patients who underwent ACDF or ACCF using FVFG for multilevel CSM were divided into two groups. Group A (n = 7) underwent ACDF and group B (n = 8) ACCF. Clinical outcomes using Japanese Orthopaedic Association (JOA) score, perioperative parameters including operation time and hospital stay, radiological parameters including fusion rate and cervical lordosis, and complications were compared. RESULTS: Both group A and group B demonstrated significant increases in JOA scores. Patients who underwent ACDF experienced significantly shorter operation times and hospital stay. Both groups showed significant increases in postoperative cervical lordosis and achieved the same fusion rate (100 %). No major complications were encountered in both groups. CONCLUSION: Both ACDF and ACCF using FVFG provide satisfactory clinical outcomes and fusion rates for multilevel CSM. However, multilevel ACDF is associated with better radiologic parameters, shorter hospital stay and shorter operative times.

Role of wrist arthrodesis in patients receiving double free muscle transfers for reconstruction following complete brachial plexus paralysis.

PURPOSE: We reviewed 18 patients who had received double free muscle transfers and wrist arthrodesis to determine the effect of the stiff wrist on digital motion and function. METHODS: The patients were 15 men and 3 women with a mean age of 24 years. We determined the total active motion of the metacarpophalangeal and interphalangeal joints just before performing the arthrodesis and at final follow-up. We recorded the Disabilities of the Arm, Shoulder, and Hand functional score at the same times. RESULTS: All of our patients showed evidence of fusion at a mean of 12 ± 2 weeks (range, 10-15 wk). The digital mean total active motion was 39° ± 21° before arthrodesis and 49° ± 25° after arthrodesis. Preoperative Disabilities of the Arm, Shoulder, and Hand scores significantly decreased after fusion. Three cases were complicated postoperatively by wound hematoma. Five patients required wrist arthrodesis hardware removal because of skin irritation. CONCLUSIONS: Wrist fusion in patients receiving double free muscle transfers resulted in improved finger range of motion and overall hand function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study.

There are several options for the treatment of traumatic tibial defects. Among these options, free vascularized fibula and Ilizarov bone transport are well-known and effective techniques. The differences between both techniques and the indications for each of them are not well studied in the literature. Between September 1995 and December 2004, Ilizarov bone transport and free vascularized fibula were used to treat 25 traumatic bone. Patients were divided into two groups, Ilizarov group (12) and free fibula group (13). Preoperative data, operative data, duration of treatment, functional outcome, range of motion loss, number of secondary procedures, and type and rate of complications were compared in both groups. All the cases were ultimately united in both groups. Operative time and blood loss were significantly higher in the free fibula group. Although external fixation time was longer in the Ilizarov group, the overall duration of treatment was similar. Range of motion loss was less in the Ilizarov group, but the overall functional outcome was similar. There was no difference in complication rate, or number secondary procedures. Defect size was found to have the most significant effect on the results. Results were much better in the free fibula group when the defect length was 12 cm or more while the results were better in Ilizarov group when the defect length was less than 12 cm. We recommend using free vascularized fibula for traumatic tibial defects of 12 cm or more, whenever experience is available.

Importance of early passive mobilization following double free gracilis muscle transfer.

BACKGROUND: The tendinous portion of the transferred muscle following double free gracilis muscle transfer for reconstruction of prehensile function in complete paralysis of the brachial plexus has a tendency to adhere to the surrounding bed and thus impede active finger motion despite powerful contraction of the muscle per se. The purpose of this study was to evaluate the effectiveness of early postoperative passive mobilization of the tendon to prevent its adhesion and the need for tenolysis. METHODS: Of 34 patients who underwent double free gracilis muscle transfer technique, the initial 19 patients (group 1) underwent the conventional postoperative management consisting of 6 weeks of immobilization, and the following 15 patients (group 2) had early passive mobilization. Postoperative active range of motion of elbow and finger joints and the incidence of tenolysis were reviewed. RESULTS: Early passive mobilization technique in group 2 negated the need for tenolysis of the transferred muscle, whereas 10 of 38 transferred muscles in group 1 required tenolysis to improve finger motion. Before tenolysis, there was a significant difference of total active finger motion between group 1 and group 2, although there was no significant difference in the total active finger motion between group 1 and group 2 after tenolysis. CONCLUSION: Early passive mobilization in the postoperative period, consisting of tendon compression at the elbow and assisted resistance exercises of finger and wrist joints, can prevent postoperative adhesion and improve tendon excursion and motion of the free transferred muscle.

Surgical technique of pedicled bipolar pectoralis major transfer for reconstruction of elbow flexion in brachial plexus palsy.

In Erb (C5-C6) type of palsy due to traumatic brachial plexus injury, function is dependent upon the ability of the arm to maneuver and stabilize the hand for action. Complete loss of power of elbow flexion after brachial plexus injuries is a severe disability. If there is control of the shoulder, elbow flexion is of major importance. Various types of procedures have been described to recover or reanimate elbow flexion for chronic or failed upper type paralysis, including free muscle transfer, unipolar and bipolar pedicled muscle transfer, and various tendon transfers. In this article, we describe the surgical technique of bipolar pectoralis major transfer and our experience with this type of transfer, wherein we prefer to transfer all components of the pectoralis major muscle including the sternocostal and clavicular origins and humeral insertion without a fascial graft by the inclusion of a strip of the rectus abdominis fascia along with the flap.

Volar plating for intra-articular fracture of the base of the proximal phalanx.

Comminuted fractures involving the articular surface of the base of the proximal phalanx are relatively rare and pose a challenging problem for hand surgeons because of the difficulty in achieving an accurate reduction and secure fixation of the articular surface. These fractures usually comprise a volar base fracture associated with a central depression of the articular surface. We describe a technique for open reduction and plate fixation of intra-articular fractures of the base of the proximal phalanx through a volar A1 pulley approach. Compared with the dorsal approach, this technique offers the advantages of direct visualization of the volar base fragment and the depressed central fragment, allowing for a more accurate reduction and rigid internal fixation using a volar buttress plate. In addition, there is no interference with extensor apparatus. Although our experience is limited to 4 patients, we have had a positive experience with this technique. The technique is useful for internal fixation of intra-articular fractures of the base of the proximal phalanx.

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries.

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.

Wrist arthrodesis after double free-muscle transfer in traumatic total brachial plexus palsy.

Double free-muscle transfer is a technique used to treat patients with total brachial plexus palsy to restore hand prehension. It involves the reconstruction of shoulder stability, the transfer of 2 functioning gracilis muscles, and other complementary procedures to optimize the function of the transferred muscles. Wrist arthrodesis is one of these complementary procedures. Our technique of wrist arthrodesis in these patients is different from the standard technique. In this article, we describe our technique and experience of wrist arthrodesis in patients with complete brachial plexus palsy treated with double free-muscle transfer technique. In our procedure, the plate is fixed from the second metacarpal--and not the third as is the usual practice--to the radius to avoid friction with the extensor digitorum communis tendons. A very small bone graft, prepared from the removed Lister tubercle, is needed because of the very thin articular cartilage in these patients. A short arm splint is used for only 1 week postoperatively to avoid finger stiffness. There were no major complications such as pseudoarthrosis or metal failure in our patients because the affected limb is subjected only to mild stresses.

Fingertip replantation.

Fingertip replantation is now an established technique. Although successful replantation is an ideal method for treatment of fingertip amputation, various other methods still are widely used and may be functionally acceptable. The indications for replantation to treat fingertip amputation is still controversial. This article presents a global view of the current status of replantation for the treatment of fingertip amputation. The surgical technique, strategies to overcome postoperative congestion, and overall results are discussed.

Technique of harvesting the gracilis for free functioning muscle transplantation.

In this article, we describe our technique and experience in harvesting the gracilis muscle for free functioning muscle transplantation (FFMT). The gracilis is the most commonly used muscle for FFMT. The main indication for gracilis FFMT is traumatic brachial plexus injury. Gracilis muscle has a class 2 vascular pedicle, with a dominant vascular pedicle originating from the profunda femoris vessels and a single motor nerve originating from the obturator nerve. During gracilis harvest, it is important to include the entire fascia around the muscle to ensure vascularity of the skin paddle and enhance muscle gliding in its new bed. Mobilization of the adductor longus allows tracing of the pedicle to its origin from the profunda femoris vessels, hence, achieving the maximum available length of the pedicle. Lengthening of gracilis tendon with a periosteal strip provides a free gracilis long enough to span the distance from the clavicle to the distal forearm. The main complications are related to the wound, and these include delayed healing, infection, and scar-related problems. The functional deficit after gracilis harvest is negligible.