Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study.

PURPOSE: The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint. METHODS: Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up. RESULTS: Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications. CONCLUSIONS: Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pedicled palmar intermetacarpal perforator flap for skin-graftless syndactyly release: Anatomical study and clinical application.

INTRODUCTION: Dorsal hand skin flaps have been described in order to avoid digit skin grafting in syndactyly release. Although these skin-graftless techniques present a lower rate of long term complications, they result in unsightly dorsal scarring and worse patient satisfaction. We describe a novel technique using an intermetacarpal palmar flap by performing an anatomic study and clinical application. MATERIALS AND METHODS: Ten colored-latex-injected fresh upper limbs were used to study the palmar cutaneous perforators to second to fourth intermetacarpal space skin flaps designed elliptical, its width extending from the center of each involved ray and measuring 40%-50% the length of the palm. RESULTS: The anatomical study revealed a mean 2.77 (range 1 to 4) cutaneous perforators originating from either the common or proper digital vessels for every intermetacarpal space and measuring 0.4 mm (range 0.3 to 0.5 mm) in diameter. CLINICAL APPLICATION: This flap, measuring a mean of 21.5 mm (range 20 to 23 mm) in length and 9.5 mm (range 9 to 10 mm) in width, was used to release simple syndactylies in three patients of mean age 24 months (range = 18-30 months). After skin incision, cutaneous septa to the digital canal were released to permit flap advancement to the web space. Cutaneous perforators were not dissected. Intra-operative palmar-flap advancement provided commissure coverage in all children with no skin grafts needed. Over a mean follow-up of 15 months, no complications occurred, mean palm scar VSS was 2.4 (range 2 to 3) while it was 3 (range 3 to 3) for the commissure scars. CONCLUSIONS: Skin-graftless syndactyly release using a palmar intermetacarpal flap seems both reliable and easy-to-perform. LEVEL OF EVIDENCE: Therapeutic IV.

Locking plate versus retrograde intramedullary headless compression screw for unstable extra-articular metacarpal base fractures of the thumb.

The purpose was to compare clinical and radiological outcomes between two fixation techniques used to treat extra-articular fractures involving the base of the thumb metacarpal: retrograde intramedullary cannulated headless screw (RICHS) and locking plate (LP). Fifty-one patients who underwent RICHS (n = 22) or LP fixation (n = 29) from January 2010 through 2020 were included in this retrospective case-control study with mean follow-up 39 months. No inter-group differences were observed comparing mean time to radiological union, grip strength, range of motion, pain severity or QuickDASH scores. Mean surgery time was shorter with RICHS (18.9 min) than with LP fixation (44.4 min). Mean time to return to work or routine activities was less in RICHS than LP (22 vs. 32 days), as was the percentage of patients requiring hardware removal (0% vs. 44.8%). We conclude that RICHS fixation requires less operating time and yields faster post-operative return to full function and fewer secondary procedures.

Triceps to teres minor motor nerve transfer to restore glenohumeral external rotation after neonatal brachial plexus injury.

INTRODUCTION: Attaining active glenohumeral external rotation (aGHER), whether via primary reconstruction or spontaneous recovery, is infrequent in patients with neonatal brachial plexus palsy (NBPI). We evaluated the effectiveness of triceps-to-teres minor motor branch transfers to restore this function, both performed primarily (i.e., in conjunction with microsurgical plexus reconstruction) or secondarily (after primary surgery has failed to restore aGHER). PATIENTS AND METHODS: This was a retrospective study of 12 children with NBPI undergoing triceps-to-teres minor motor branch transfer via an axillary approach, six undergoing primary surgery and six secondary. The primary outcome was post-operative restoration of aGHER in abduction. The primary-surgery group consisted of six children of mean age 8 months (range 5-11) with partial injuries ranging from C5-C6 to C5-C8. The secondary-surgery group included six patients with C5-C6 injuries of mean age 43 months (range 23-120), undergoing re-operation a mean 40 months (range 18-116) after their primary surgery. RESULTS: No complications occurred after surgery. At a mean follow-up of 22 months (range 14-30), aGHER in abduction only was restored in one patient in the primary group while in the secondary group, aGHER in abduction was restored in all patients to a mean 73° (range 70-80) after a mean follow-up of 16 months (range 6-26). CONCLUSIONS: Triceps-to-teres minor motor branch transfer is not indicated as primary surgery for NBPI. However, they can be effective in children in whom primary surgery has failed to restore aGHER, even if the spinal accessory nerve is unavailable for transfer to the infraspinatus motor branch.

Gartland Type-IV Supracondylar Humeral Fractures: Preoperative Radiographic Features and a Hypothesis on Causation.

BACKGROUND: The diagnose of Gartland Type-IV (G-IV) supracondylar humeral fractures (SCHF) has been reported to only be possible via fluoroscopy intra-operatively. HYPOTHESIS: A preoperative radiographic fracture pattern can indicate a G-IV SCHF. PATIENTS AND METHODS: Retrospective qualitative analysis of radiographs and reduction techniques used in twenty-seven GIV SCHF. RESULTS: Anterior-posterior radiographs demonstrated lateral translation or angulation in 21 cases (valgus type) and medial translation or angulation in 6 cases (varus type). In spite of a complete cortical disruption, lateral radiographs showed that the distal fragment was vertically aligned with the proximal fragment. Reduction was achieved in semi-extension, via supination in valgus type fracture and pronation for varus type fractures. DISCUSSION: Our conjecture is that a trauma vector in the coronal plane would result in a near-circumferential periosteal disruption, with which either a medial or lateral periosteal hinge remains. The distal fragment would be vertically aligned in lateral radiographs. LEVEL OF EVIDENCE: IV; Diagnostic.

The One-Bone Forearm in Children: Surgical Technique and a Retrospective Review of Outcomes.

PURPOSE: The purpose of this study was to describe a technique of end-to-end rigid fixation of the distal radius to the proximal ulna. The shortening and radioulnar overlap in this technique yield a high union rate, large corrections, and few complications. METHODS: This retrospective chart review from 2 centers was undertaken in 39 patients (40 forearms) who underwent one-bone forearm operations between 2005 and 2019. There were 25 male and 14 female patients, with a mean age at surgery of 9.7 years (range 3 to 19 years; SD, 4.5 years). The diagnoses included brachial plexus birth injury, spinal cord injury, arthrogryposis multiplex congenita, cerebral palsy, ulnar deficiency with focal indentation, multiple hereditary exostosis, acute flaccid myelitis, and tumor. RESULTS: The average follow-up was 33.5 months (1.2-110.1 months; SD, 27.1 months). The 36 forearms in supination had an average supination contracture of 93° (range, 15° to 120°; SD, 15.4°). The 4 pronated arms had an average pronation contracture of 80° (range, 50° to 120°; SD, 29.2°). The average postoperative position was 22.8° of pronation (range, -15° to 45°; SD, 12.9°). The average correction obtained with our technique was 113° (range, 20° to 145°; SD, 22.9°). Radiographic union was demonstrated in 32 (80%) of the one-bone forearms by 10 weeks, 39 (97.5%) by 16 weeks, and 40 (100%) by 24 weeks. One patient had peri-implant fractures prior to union. No forearms required reoperation for nonunion. CONCLUSIONS: One-bone forearm performed with this technique allows reliable healing and a large degree of correction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children.

We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity.Level of evidence: IV.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients.

PURPOSE: We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options. METHODS: We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported. RESULTS: Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up. CONCLUSIONS: A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Basal joint arthroplasty and carpal tunnel release comparing a single versus double incision: a prospective randomized study.

PURPOSE: Basal thumb joint osteoarthritis frequently coexists with carpal tunnel syndrome. The two conditions have traditionally been treated surgically through separate incisions. We sought to determine whether carpal tunnel release using a single incision during basal joint arthroplasty is as effective as a two-incision approach in patients with concomitant carpal tunnel syndrome and basal thumb joint osteoarthritis. METHODS: For this purpose, 40 patients were randomly allocated to either a single-incision or double-incision approach, all of whom completed the full follow-up period. The Boston Carpal Tunnel Questionnaire, QuickDASH, and a 10-point visual analog scale pain-severity rating were obtained from patients 3, 6 and 12 months post-operatively. RESULTS: The two treatment groups experienced comparable, progressive improvement in all symptom-, function-, and pain-related outcomes, with mean surgery time significantly shorter with the single-incision approach, and four versus zero patients in the double-incision group developing pillar pain (p = 0.035). CONCLUSIONS: Concomitant basal thumb joint osteoarthritis and carpal tunnel syndrome might be effectively performed through a single-incision approach, potentially avoiding any morbidity classically associated with a second incision. LEVEL OF EVIDENCE: Level II/Therapeutic Study. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04391751, 04/29/2020, retrospectively registered.

Free vascularized iliac periosteal graft for bilateral forearm nonunion reconstruction in a child with bilateral transfemoral amputation.

Vascularized periosteal flaps have been reported as very effective for treating biologically complex bone nonunion in pediatric patients, owing to their high angiogenic and osteogenic potentials. The purpose of this article is to report a case of a 6-year-old patient with nonunion involving both forearms and a very limited bone flap donor site in the context of prior bilateral transfemoral amputation due to meningococcal sepsis. Two free vascularized iliac periosteal flaps (VIPF), supplied by the deep circumflex iliac vessels, were used in two stages to reconstruct the forearms. In the first stage, the left forearm, which had a diaphyseal bone defect of 5 cm diameter in the ulna and 4 cm in the radius, was combined with an iliac-crest bone allograft, fixed with two longitudinal 1.8 mm Kirschner wires and surrounded with a free VIPF of 24 cm2 . Consolidation was achieved 3 months after left forearm surgery, while complete allograft revascularization and remodeling was observed at 12 months. In the second stage, the right forearm, which had a diaphyseal bone defect of 3 cm diameter in the ulna and 1 cm in the radius, was fixed the radius with a 2.7 mm plate and surrounded with a free VIPF of 24 cm2 . The radius nonunion healed 6 weeks after surgery. There were no postoperative complications. Two years postoperatively, the patient had again resumed his arm gait painlessly and without a splint. VIPF may be considered a valuable and reliable surgical option for nonunion reconstruction in complex clinical scenarios in children.

Accidents and injuries in elite MotoGP motorcycle riders.

OBJECTIVE: Evaluating incidence, characteristics and risk factors of accidents and injuries in each elite motorcycle racing class (MotoGP, Moto2 and Moto3), 2013-2017. DESIGN: Descriptive epidemiological study. SETTING: MotoGP Medical Team, Dorna Sports SL. PARTICIPANTS: Competing riders in elite motorcycling racing classes, 2013-2017. INTERVENTIONS: Benchmarking incidence, characteristics and risk factors of accidents and injuries in each elite motorcycle racing class, 2013-2017. MAIN OUTCOME MEASURES: Association between accident type (by class and year) and fracture, withdrawal from race, need for surgery, injuries (fractures or contusions/wounds) and time riders kept inactive. Circuit and curve, weather conditions, presence and type of fracture, clinical outcome, and time until return to competition. Event outcomes were defined as rider fit/rider unfit after each accident. Racing class, track curves and circuits with the most and fewest accidents, circuit characteristics, speed and deceleration, G-forces, and time race differences between classes. RESULTS: 9092 accidents (mean 1818,4 per year). Most during race and under wet-weather conditions. Class and circuit with most accidents 2013-2017 were Moto3 (3374; 37.11%) and MWC - Marco Simoncelli -with 430.119/9092 accidents resulted in a fracture (1.31%), 83, surgical fractures (70%). Most frequent surgical fractures were upper extremity (clavicular; 29/119; 21%). On average, riders returned to competition after two circuits (1-5 weeks). CONCLUSIONS: Accidents are not uncommon among elite motorcycle riders; incidences of fractures and surgical fractures are low. Factors such as weather conditions and circuit's characteristics influence the risk of accidents. Further research is necessary to clarify the magnitude of the role each of these factors play.

Trigger Digit Incidence After Carpal Tunnel Release: Reconstruction in Elongated Position Versus Traditional Carpal Tunnel Release.

Background: The development of trigger digit after carpal tunnel syndrome release surgery has been widely reported. Lluch described reconstruction of the flexor retinaculum in elongated position to prevent such complication. Methods: We conducted a retrospective review to determine whether patients who undergo reconstruction in elongated position of the flexor retinaculum have a lower incidence of trigger digit postoperatively. In total, 1050 patients were included, 865 of whom had undergone traditional carpal tunnel release and 185 flexor retinaculum reconstruction. Results: No differences were found in the incidence of trigger digit after surgery (8.7% of the patients who underwent traditional release vs 11.9% in the reconstruction group). Neither difference was found when comparing mean time with the development of trigger digit. Conclusions: In the absence of randomized long-term studies comparing traditional release and reconstruction in elongated position after carpal tunnel release, given our results, we see no reason to favor reconstruction over standard carpal tunnel release as a means to prevent postoperative triggering of digits.

Analysis of 3 Different Operative Techniques for Extra-articular Fractures of the Phalanges and Metacarpals.

Background: Several techniques have been described for treating metacarpal and phalangeal fractures. We sought to compare the 3 techniques most frequently used for extra-articular metacarpal and phalangeal fractures: plate screw (PS), Kirschner wire (KW), and retrograde intramedullary screw (RIS) fixation. We aimed to determine whether using an RIS provides better clinical outcomes than using either a PS or a KW fixation. Methods: We conducted a retrospective review of patients who underwent surgical treatment of metacarpal and phalangeal fractures from January 2011 to December 2017 in our department. Only patients with an acutely displaced short oblique or transverse extra-articular metacarpal or phalangeal fracture were included. Patients were classified into 3 groups depending on the treatment they received: PS, KW, or RIS fixation. The duration of each procedure was recorded. Clinical assessments included measuring total active motion (TAM), grip strength, and an evaluation of plain radiographs through to ultimate healing. A Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was collected on all patients. Data were analyzed by analysis of variance or Kruskal-Wallis rank test, as indicated. Results: A total of 253 fractures (202 metacarpal and 51 phalangeal) in 230 patients were included in analysis. In all, 135 fractures (53.3%) underwent PS fixation; 53 (20.9%), KW fixation; and 65 (25.6%), RIS fixation. In the KW fixation group, Bouquet pinning was performed for metacarpal fractures and cross pinning for phalangeal fractures. When more than 1 fracture coexisted in the same patient, they were considered separate instances. No differences among the 3 groups were observed when evaluating mean time to radiological union, grip strength, TAM, or QuickDASH score. Mean surgery time was significantly shorter with KW (20 minutes) and RIS (25 minutes), than with PS (32 minutes). Mean return to work or routine activities time was significantly less in the RIS (7.8 weeks) group than in the PS and KW groups (8.3 and 9.2 weeks, respectively). Conclusions: Surgical treatment is recommended in patients with unstable metacarpal and phalangeal fractures. The use of RIS was associated with shorter mean surgery duration and return to work times than PS and KW, respectively.

Effect of vascularized periosteum on revitalization of massive bone isografts: An experimental study in a rabbit model.

INTRODUCTION: In the last years, limb salvage has become the gold standard treatment over amputation. Today, 90% of extremity osteogenic sarcomas can be treated with limb salvage surgery. However, these reconstructions are not exempt from complications. Massive allografts have been associated to high risk of nonunion (12-57%), fracture (7-30%) and infection (5-21%). Association of vascularized periosteum flap to a massive bone allograft (MBA) has shown to halve the average time of allograft union in clinical series, even compared to vascularized fibular flap. Creeping substitution process has been reported in massive allograft when periosteum flap was associated. However, we have little data about whether it results into allograft revitalization. We hypothesize that the association of a periosteum flap to a bone isograft promotes isograft revitalization, defined as the colonization of the devitalized bone by new-form vessels and viable osteocytes, turning it vital. MATERIALS AND METHODS: Forty-four New Zealand white male rabbits underwent a 10 mm segmental radial bone defect. In 24 rabbits the bone excision included the periosteum (controls); in 20 rabbits (periosteum group) bone excision was performed carefully detaching periosteum in order to preserve it. Cryopreserved bone isograft from another rabbit was trimmed and placed to the defect gap and was fixed with a retrograde intramedullar 0.6 mm Kirschner wire. Rabbits were randomized and distributed in 3 subgroups depending on the follow-up (control group: 5 rabbits in 5-week follow up group, 8 rabbits in 10-week follow-up group, 7 rabbits in 20-week follow-up group; periosteum group: 5 rabbits in 5-week follow up group, 7 rabbits in 10-week follow-up group, 7 rabbits in 20-week follow-up group). Fluoroscopic images of rabbit forelimb were taken after sacrifice to address union. Each specimen was blindly evaluated in optical microscope (magnification, ×4) after hematoxylin and eosin staining to qualitative record: presence of new vessels and osteocytes in bone graft lacunae (yes/no) to address revitalization, presence of callus (yes/no) and woven bone and cartilage tissue area (mm2 ) to address remodeling (osteoclast resorption of old bone and substitution by osteoblastic new bone formation). RESULTS: No isograft revitalization occurred in any group, but it was observed bone graft resorption and substitution by new-formed bone in periosteum group. This phenomenon was accelerated in 5-week periosteum group (control group: 49.5 ± 9.6 mm2 vs. periosteum group: 34.9 ± 10.4 mm2 ; p = .07). Remodeled lamellar bone was observed in both 20-week groups (control group: 6.1 ± 6.3 mm2 vs. periosteum group: 5.8 ± 3.0 mm2 , p = .67). Periosteum group showed complete integration and graft substitution, whereas devitalized osteons were still observed in 20-week controls. All periosteum group samples showed radiographic union through a bone callus, whereas controls showed nonunion in eight specimens (Union rate: control group 60% vs. periosteum group 100%, p = .003). CONCLUSIONS: Association of vascularized periosteum to a massive bone isograft has shown to accelerate bone graft substitution into a newly formed bone, thus, no bone graft revitalization occurs.

Bone nonunion management in children with a vascularized tibial periosteal graft.

BACKGROUND: Vascularized periosteal graft have demonstrated a tremendous bone healing capacity in children. The objective is to report outcomes on the use of vascularized tibial periosteal graft (VTPG) during bone reconstruction in a series of children with complex bone healing problems. PATIENTS AND METHODS: Cases were collected retrospectively since May 2013 to May 2019, excluding cases of congenital pseudarthrosis of the tibia. Mean age at surgery was 12.8 (range 11-18) years. Indications included treatment of recalcitrant bone nonunion and the prevention of bone allograft-host junction nonunion in seven and three patients, respectively. The periosteal flap, based on the anterior tibial vessels, was harvested as a free flap in six instances and as a pedicled flap in four. RESULTS: Mean follow-up was 25.2 months (range 8-36). The flap showed a 13.6 cm (range 9-16) and mean width 3.4 cm (range 2.7-3.9). Early bone union was achieved, initially through periosteal callus, followed by cortical union at mean times of 2 and 4 months, respectively, in nine cases. The flap was not successful in a patient with severe comorbidities. No donor site complications were registered. CONCLUSIONS: VTPG was fast and high effective for the treatment complex bone nonunion or the prevention of allograft nonunion in children.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients.

PURPOSE: To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). MATERIALS AND METHODS: Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more. RESULTS: In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength. CONCLUSIONS: In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Transverse Anterior Approach to the Elbow for Pediatric Displaced Lateral Humeral Condyle Fractures.

BACKGROUND: The anterior approach to the elbow for pediatric lateral condyle fractures (LCF) would provide a better visualization of the articular fracture resulting in better functional results, less complications and a more cosmetically-appealing scar than usually seen with the lateral approach. METHODS: Retrospective study of children undergoing an open reduction and internal fixation of a displaced LCF via an anterior approach with a transverse incision. Bilateral elbow range of motion (ROM), upper limb alignment and complications were registered. A 4-point ordinal Likert-type scale was employed for parents to rate their level of satisfaction with the cosmetic appearance of the scar. RESULTS: Eighteen children of mean age 76 months (range 27 to 101 months) were included. Fractures were classified as Jackob's Type II in 14 cases and Milch's type II in all cases. Mean follow-up was 12 (range 4 to19) months.Successful condral fracture visualization and reduction was achieved in every case. No intra-operative or post-operative complications occurred. In all cases bone union was obtained 4 to 5 weeks after surgery and at final follow-up, active elbow ROM of at least 90%, was obtained. All parents claimed to be "very satisfied" with their child's scar. A lateral spur was identified in 66.7% o patients. CONCLUSION: The anterior approach to the elbow was both a feasible and safe allowing full anatomical cartilage reduction. Complications after this technique might decrease compared to the lateral approach but need future comparative studies. The rate of lateral spur did not decreased. Cosmetic scar results seem to be a clear advantage of this approach compared to the classical lateral approach.

Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures.

The purpose of the study was to evaluate clinical and radiological outcomes of extra-articular fractures involving the base of the thumb metacarpal treated with fixation using a retrograde intramedullary cannulated headless screw. A review of prospectively collected data was conducted on a consecutive series of 13 patients, treated with headless screw fixation for acute displaced fractures. All workers resumed full duties, while non-workers returned to unlimited leisure activities within a mean of 42 days. At 3 months follow-up, all range of motion measurements in the treated and untreated thumb were similar. Mean visual analogue pain score was 0.8 at rest and 1.4 during exercise and mean Quick Disabilities of the Arm, Shoulder, and Hand score was 5. All patients achieved radiographic union by 8 weeks. We conclude that the intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. Level of evidence: IV.

Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal osteoarthritis: minimum 8-year follow-up.

We undertook a retrospective study to evaluate minimal 8-year outcomes of 46 trapeziometacarpal joints (46 patients) treated with pyrocarbon implant arthroplasty after partial trapeziectomy for trapeziometacarpal joint osteoarthritis in two different hand surgery units. The mean follow-up interval was 9.5 years (average 113 months with a range 97-144 months). The study showed that pyrocarbon interpositional arthroplasty provided pain relief and high patient satisfaction. All patients experienced a reduction in the DASH score, with an average change of 30 points. The visual analogue scale score, the Kapandji score, and key pinch also showed remarkable improvement. The PyroDisk implant exhibited good longevity, with good implant survival. A review of the literature revealed that the functional outcomes after implant surgery are not superior to more common techniques, such as trapeziectomy with or without ligamentoplasty. Therefore, this is a reliable surgery but may not have added benefits over simpler surgical treatments. This implant could have a role, perhaps in a select group of young patients, as a time-procuring procedure. Level of evidence: IV.