One vs. two-stage arteriovenous loops in lower extremity reconstruction with free flaps: Systematic review and metanalysis.

BACKGROUND: Arteriovenous loops are one of the main therapeutic alternatives to address the absence of recipient vessels in lower extremity microsurgical reconstruction. However, there is no consensus on whether to perform them in one or two surgical stages. The objective of this work is to determine whether the outcome of lower limb free flaps anastomosed to vascular loops depends on the number of surgical stages. MATERIALS AND METHODS: A literature review was conducted, following PRISMA guidelines, on vascular loops and free flaps in lower limb. Survival rate, as well as major and minor complications were studied. A forest plot and Pearson's chi-square were used for statistical analysis. Study quality was assessed in duplicate using Methodological Index for Non-Randomized Studies (MINORS) and Joanna Briggs Institute (JBI) tool. This study was registered on PROSPERO. RESULTS: Thirty-two articles using free flaps anastomosed to vascular loops in lower limb, either one or two-stage, were selected. A total of 296 flaps were included, 52% (n = 154) in one and 48% (n = 142) in two surgical times. No statistically significant differences were found in the survival rate (OR = 1.85, 95% CI 0.62; 5.47, p = .09 and p = .344) or major complications (OR = 0.70, 95% CI 0.31; 1.57, p = .56 and p = .92) of flaps between both groups. CONCLUSIONS: According to the available evidence, the outcome of free flaps anastomosed to vascular loops in the lower limb does not depend on the number of surgical stages they undergo. Although there is some heterogeneity in the groups studied, the decision on the number of procedures to be performed should be determined by the surgeon, concerning the clinical situation of the patient, as well as to the vascular, bone and soft tissue status of the extremity.

Plantar intermetatarsal perforator flap for first web skin-graftless syndactyly release: Anatomical study and clinical application.

INTRODUCTION: Foot-syndactyly has long been managed through conventional surgical procedures, each having its own distinct advantages and drawbacks. While these methods, which do not require skin grafts, exhibit a lower incidence of long-term complications, they lead to undesirable scarring on the dorsal side of the foot and reduced patient satisfaction. In this study, we introduce an innovative technique involving an intermetatarsal plantar flap, supported by an anatomical investigation and clinical application. METHODS: Eight freshly preserved lower limbs were injected with colored latex to examine the cutaneous vessels on the plantar surface, a skin-flap was designed in an elliptical shape to address first web conjoined toes. The flap was extended from the center of each affected ray measuring ~30% of the sole's length. Using the mentioned novel approach, a flap was created and dorsally extended with a straight incision to release bilateral simple foot-syndactyly in an 8-year-old child presented with Apert's Syndrome. RESULTS: We identified cutaneous branches originating either from the medial plantar vessels or the lateral proper artery of the hallux. On average, the mean number of cutaneous branches found over the first intermetatarsal web spaces was 5.8 (ranging from 5 to 8) most of them originating from medial plantar vessels with a mean of 5.1 branches (range 4-6) while proper lateral great-toe digital artery provided a mean of 0.6 branches (range 0-2). Intra-operatively, in our patient, advancing the plantar flap ensured complete coverage of the commissure, obviating the necessity for skin grafts. Incisions healed uneventfully and a wide first web was obtained. Over a 15 months follow-up, no complications were observed. CONCLUSIONS: Our findings suggest that the skin-graftless first web release of syndactyly using a plantar intermetatarsal flap is a reliable and straightforward procedure with good cosmetic results, offering a promising alternative to conventional techniques. LEVEL OF EVIDENCE: Therapeutic IV.

Distal nerve transfers for peripheral nerve injuries: indications and outcomes.

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Anatomical study of first palmar intermetacarpal flap in cadavers and application for congenital first web contracture in a child with Apert's syndrome.

INTRODUCTION: Reconstructing severe first web contractures often involves using either pedicled forearm flaps, which can cause extensive scarring, or free flaps, which can be highly complex. In this study, we present a local palmar hand flap that overcomes both of these challenges. METHODS: Ten fresh upper limbs were examined after arterial injection with colored latex. The study focused on identifying the most distal palmar vascular cutaneous branches suitable for designing an elliptical cutaneous flap over the volar intermetacarpal area. This flap's width was approximately 50% of the width of the thenar eminence. Additionally, we present the case of an 8-year-old child with a type 1 Upton's Apert's hand, which exhibited a severe first web contracture. RESULTS: In seven cadaver hands, one distal cutaneous perforator was found, while in three hands, two perforators were identified. These perforators originated from the thumb radial collateral artery six times, pollex princeps three times, index radial collateral vessels twice, and thumb ulnar collateral vessels twice. The mean perforator diameter was 0.5 mm (ranging from 0.4 to 0.6 mm), and the mean perforator length was 10 mm (ranging from 0.8 to 12 mm). Using this flap bilaterally in our patient resulted in a straightforward procedure that created a broad and functional first web. A total-thickness skin graft was necessary to cover the proximal thenar area, and fortunately, no complications arose. A wide first web with an intermetacarpal angle of 40° ultimately was obtained scoring 8 on the kapandji. CONCLUSIONS: The first palmar intermetacarpal flap presents itself as a reasonable and uncomplicated option for addressing significant moderate-to-severe first web contractures.

Transverse snuffbox perforator flap for a first-web contracture: an anatomical study and case report.

This cadaveric study describes a dorsal wrist transverse elliptical cutaneous flap, based on radial artery cutaneous perforators in the region of the snuffbox. The flap was then successfully used in a child with thumb hypoplasia and severe first-web contracture.

Shoulder extension impairment with residual neonatal brachial plexus injury.

BACKGROUND: Impairment of both shoulder extension and behind-the-back function are common in patients with residual neonatal brachial plexus injury (NBPI), but have scarcely been studied or reported in the literature. Behind-the-back function is classically evaluated using the hand-to-spine task used for the Mallet score. Angular measurements of shoulder extension with residual NBPI have generally been studied utilizing kinematic motion laboratories. To date, no validated clinical examination method for this has been described. METHODS: Intraobserver and interobserver reliability analyses of 2 shoulder extension angles-passive glenohumeral extension (PGE) and active shoulder extension (ASE)-were performed. Afterwards, a retrospective clinical study was conducted on prospectively collected data on 245 children with residual BPI treated from January 2019 through August 2022. Demographic characteristics, level of palsy, previous surgical procedures, modified Mallet score, and bilateral PGE and ASE data were analyzed. RESULTS: All inter- and intraobserver agreements were excellent, ranging from 0.82 to 0.86. The median patient age was 8.1 years (3.5-21). Among the 245 children, 57.6% had Erb's palsy, 28.6% extended Erb's palsy, and 13.9% global palsy. One hundred sixty-eight (66%) of the children could not touch their lumbar spine, among whom 26.2% (n = 44) had to swing the arm to reach it. Both the degrees of ASE and PGE achieved correlation significantly with the hand-to-spine score, the ASE strongly (r = 0.705) and the PGE weakly (r = 0.372) (both P < .0001). Significant correlations also were found between lesion level and the hand-to-spine Mallet score (r = -0.339; P < .0001) and ASE (r = -0.299; P < .0001), and between patient age and the PGE (P = .0416, r = -0.130). A statistically significant decrease in PGE and incapacity to reach the spine were found in patients who underwent glenohumeral reduction, shoulder tendon transfer, or humeral osteotomy, relative to those who had microsurgery or no surgery. Receiver operating curves showed that, for both PGE and ASE, the minimum extension angle required to successfully perform the hand-to-spine task was 10°, with sensitivity levels of 69.9 and 82.2, and specificity levels of 69.5 and 87.8 (both P < .0001), respectively. CONCLUSIONS: Glenohumeral flexion contracture and lost ASE are extremely common in children with residual NBPI. Both the PGE and ASE angles can be measured reliably with a clinical exam, with at least 10° of PGE and ASE necessary to perform the hand-to-spine Mallet task.

Extensor carpi radialis brevis motor branch transfer to the deep branch of the ulnar nerve to repair intrinsic hand palsy in neonatal lower brachial plexus and spinal cord injury: A case report.

Concomitant lower neonatal brachial plexus palsy (Klumpke) and spinal cord injury is extremely rare but with a clearly established mechanism of injury pattern. No successful surgical techniques have been reported to date to restore intrinsic hand function. We report a case of successful transfer of the extensor carpi radialis brevis motor branch to the deep branch of the ulnar nerve to repair intrinsic hand palsy. Three-month-old boy with the diagnosis of left Klumpke paralysis and thoracic spinal cord injury associating left Horner's sign, intrinsic minus deformity of all the digits, and thenar muscle paralysis in the upper limb. Both lower limbs were fully paralyzed. Cervical magnetic resonance imaging (MRI) revealed spinal cord narrowing from T1 to T5 and pseudo-meningoceles involving the left C8 through T3 roots. Since no spontaneous recovery was apparent by 6.5 months and surgical exploration showed pronator quadratus denervation, the ECRB motor branch deep branch was transferred to the ulnar nerve (DBUN) with interposed a 7.5 cm-long sural nerve graft. By 18 months post-operatively, all the digits showed complete active IP extension. Thirty-six months after surgery, no signs of first dorsal interosseous nerve or thenar muscle reinnervation were present, thus an extensor carpi ulnaris opponensplasty was performed. ECRB motor branch might be a valuable tool to restore finger intrinsic function in these uncommon cases.

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.

Shelf Osteotomy for Madelung's Deformity in Adults: A Novel Technique.

Background Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods We describe the technique in details and report the treatment of a 25-year-old female patient. Results Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

Microsurgery in pediatric upper limb reconstructions: An overview.

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.

Bilobed Flap in Hand Clinodactyly Reconstruction: Technique Description and Result Appraisal / Retalho bilobado na reconstrução das clinodactilias da mão: Descrição da técnica e avaliação do resultado

Abstract Objective Clinodactyly is a congenital hand deformity that is characterized by coronal angular deviation and may occur in thumbs or fingers. Surgical treatment is indicated for severe angulations. Among the described techniques, one of the options consists of bone alignment by wedge-shaped addition osteotomy of the anomalous phalanx. Such alignment maneuver creates a problem in skin cover, along with soft-tissue tension at the concave aspect of the deformity. Hence, some sort of skin flap is required for the adequate operative wound closure. We aim to demonstrate the aforementioned technique and to assess the results of bilobed flap in the treatment of hand clinodactyly. Methods Retrospective study conducted between January 2008 and January 2015. Five patients were included in the study, including nine operated digits. Surgical indication consisted of angular deviations ˃ 30o. Neither patients with thumb deformities nor those with deformities associated to syndromes were excluded from the study. We assessed the functional and cosmetic outcomes of the technique, as well as complications and the satisfaction rates of the family. Results All patients had satisfactory functional and cosmetic results, with a mean skin healing of 18.6 days. Among nine operated digits, only one of the patients presented vascular compromise at the distal portion of the first flap lobe, albeit without necrosis or the need for any additional procedure. Patients were followed up on a minimum of 12-month interval. No deformity recurred during the observation period. Conclusion Bilobed flap for the treatment of hand clinodactyly is a good option for skin cover after the osteotomy.

Resumo Objetivo A clinodactilia é uma deformidade congênita da mão, caracterizada por desvio angular coronal, podendo ocorrer em polegares ou dedos. O tratamento cirúrgico é indicado para angulações severas. Dentre as técnicas descritas, uma das opções consiste no alinhamento ósseo, através de osteotomia em cunha de adição da falange anômala. Essa manobra de alinhamento gera uma dificuldade de cobertura cutânea, juntamente com a tensão das partes moles no lado côncavo da deformidade. Sendo assim, algum tipo de retalho cutâneo é necessário para o fechamento adequado da ferida cirúrgica. Objetivamos demonstrar a técnica citada e avaliar os resultados do retalho bilobado no tratamento das clinodactilias da mão. Métodos Estudo retrospectivo entre janeiro de 2008 e janeiro de 2015. Foram incluídos cinco pacientes no estudo, nove dedos foram submetidos à cirurgia. Tiveram indicação cirúrgica os pacientes com desvios angulares nos dedos acima de 30 graus. Não foram excluídos do estudo os pacientes com deformidades no polegar, nem aqueles com deformidades associadas a síndromes. Foram avaliados os resultados funcionais e estéticos com o uso desta técnica, assim como as complicações e o grau de satisfação dos familiares. Resultados Todos os pacientes apresentaram resultados funcionais e estéticos satisfatórios, com cicatrização cutânea média de 18,6 dias. Entre os nove dedos submetidos à cirurgia, apenas um dos pacientes apresentou comprometimento vascular na porção distal do primeiro lobo do retalho, porém sem necrose ou necessidade de qualquer procedimento adicional. Os pacientes foram acompanhados durante um intervalo mínimo de 12 meses. Nenhuma deformidade ocorreu durante o período de observação. Conclusão O uso do retalho bilobado no tratamento das clinodactilias da mão é uma boa opção para cobertura cutânea após a realização de osteotomia.

Quadrant Flap for Fingertip Reconstruction in Macrodactyly: Technique and Case Report.

Macrodactyly is a serious and rare disease and considered one of the most difficult pathologies to treat. There is no rule and the treatment for each patient must be tailor-made, depending on the location and degree of macrodactyly. Although amputation is a valid option for adult patients, nail preservation and reconstruction are important and has a direct impact on the treatment outcome, both aesthetically and on the patient's self-esteem. We have used a wide, z-shaped fingertip flap associated with the preservation of a nail quadrant, bone shortening and distal interphalangeal arthrodesis. We have obtained good functional and aesthetic outcomes with this 'quadrant flap' technique. The technique allows decreasing digit size and volume and reconstruction of the nail complex and finger pulp. Level of Evidence: Level V (Therapeutic).

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.

Glenohumeral abduction contractures after residual neonatal brachial plexus injury.

Glenohumeral abduction contractures are common in patients with neonatal brachial plexus injury, but little has been previously published about them. We conducted a retrospective analysis of data prospectively collected from 205 consecutive children (108 female) of mean age 9.6 years with neonatal brachial plexus injury (C5-C6, 58%; C5-C7, 29%; C5-T1, 14%). Most children (69%) showed a glenohumeral abduction contracture, it being more common in those with upper neonatal brachial plexus injury.Level of evidence: III.

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.

Treatment of hallux valgus in children and adolescents.

Juvenile hallux valgus is one of the most common pathologies of the forefoot in children and adolescents. Nevertheless, its treatment is still controversial. This deformity has some distinct anatomical features, particularly a lateral tilt of the articular facet of the head of the first metatarsal and congenital metatarsus adductus, which often occur in combination. Some mediocre surgical treatment results can be explained by the lack of correction of all these factors when we approach the problem as we would in adults. A double osteotomy to correct the DMAA and varus of the first metatarsal is a good solution in most cases with satisfactory functional outcomes. A percutaneous approach seems efficient in the pediatric population, given that the periosteum and growth plates, which are very active in younger children, help the osteotomies to heal and remodel. Guided growth surgery - using this approach is a viable alternative in this age bracket. Finally, minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on.

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.