Styloid Ulna Window Approach for Repair of Avulsed Foveal Attachment of Triangular Fibrocartilage Complex.

PURPOSE: To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results. METHODS: We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems. RESULTS: Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve. CONCLUSIONS: Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Single-strand repair of EWAS 1 lesion of triangular fibrocartilage complex.

PURPOSE: To report the results of our modified technique for repair of the EWAS 1 lesion of triangular fibrocartilage complex (TFCC). METHODS: This retrospective case series reviewed 22 consecutive patients with EWAS 1 TFCC tear. Arthroscopic repair was done using our modified double-loop arthroscopic outside-in technique which is originally described by Mathoulin and Del Piñal. The repair was performed using single-strand suture and 18-gauge cannula, having three passes through the tear. Follow-ups ranged from 24 to 33 months with an average of 29.3 months. The results were evaluated by the Modified Mayo Wrist Score (MMWS), Visual Analog Score (VAS). In addition, range of motion (ROM) and power grip were compared with the contralateral side. RESULTS: The mean age was 23 years. The dominant side was affected in 16 wrists. There was postoperative improvement of the all functional outcome measures (MMWS, VAS, ROM, and power grip). All the patients returned to their previous activities with no reported intra- or postoperative complications. CONCLUSIONS: The described outside-in technique is safe and effective technique for repair of EWAS 1 TFCC tear. LEVEL OF EVIDENCE: Therapeutic, case series, level IV.

Reliability of propeller flaps in post-traumatic reconstruction of wrist and hand defects.

PURPOSE: This is a purely observational study with a literature comparison to assess the effectiveness of radial and ulnar arteries propeller perforator-based flaps in post-traumatic soft tissue reconstruction and identify the risk factors for complications. METHODS: Sixteen patients were involved with post-traumatic wrist and hand soft tissue defects not exceeding 5 × 20 cm. Defects were covered with propeller radial and ulnar arteries perforator-based flaps. Patient demographics, soft tissue defects, complications and clinical outcomes were recorded. Assessment of patients' satisfaction for donor site morbidity and aesthetic outcome of the flap were performed. RESULTS: Radial artery propeller perforator flap was performed in seven cases, and ulnar artery propeller perforator flap was done in nine cases. The size of the skin paddle ranged from 2.5 × 5 cm to 4.5 × 10.5 cm. Primary closure of the donor site was performed in all cases. One flap was lost, while superficial epidermolysis occurred in seven cases (45%). Edge necrosis ranging between 3 and 7 mm occurred in nine cases (60%). Patients' factors, mode of injury, associated injuries and interval between trauma and coverage were all correlated with complication incidence. The patients' satisfaction for donor site morbidity was very good and good in 80% of patients, while satisfaction for aesthetic outcome of the flap was very good and good in only 40%. CONCLUSION: Radial and ulnar arteries have reliable perforators for flap elevation, which produce reliable outcome for small- and medium-sized soft tissue reconstruction. Effectiveness decreases in post-traumatic reconstructions. Complications are more frequent in crushing injuries especially if associated with bony fractures. Most complications in trauma cases were attributed to venous congestion, for which supercharging with a vein if accessible to the surgeon is recommended.

Comparison Between Supercharged Ulnar Nerve Repair by Anterior Interosseous Nerve Transfer and Isolated Ulnar Nerve Repair in Proximal Ulnar Nerve Injuries.

PURPOSE: To compare combined ulnar nerve repair with supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer (UR+SETS) with conventional isolated ulnar repair techniques in proximal ulnar nerve transection, with respect to intrinsic muscle power recovery and claw hand deformity correction. METHODS: We conducted a comparative matched-paired series prospectively on 21 patients with proximal ulnar nerve transection injury. Eleven patients were managed by UR+SETS and 10 by isolated ulnar repair. The outcome was reported at 3, 6, 12, and 18 months using the score of Birch and Raji and Brand's criteria. RESULTS: A total of 21 patients with acute proximal ulnar nerve transection injury had completed 18 months' follow-up. We observed better results in the UR+SETS group regarding the return of intrinsic function and reduction of deformity with earlier improvement in the score of Birch and Raji and Brand's criteria. CONCLUSIONS: In the short term, UR+SETS transfer appears to result in better intrinsic muscle reinnervation and clawing deformity correction after proximal ulnar nerve transection injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Foot and ankle function after tibial overlengthening.

Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.

Lower limb coronal malalignment correction by percutaneous osteotomy and schanz screws fixation.

Pediatric knee deformities are common, and the classic treatment is corrective osteotomy. The aim of this study to assess the safety and efficacy of percutaneous low-energy osteotomy and casting with shanz screws fixation in treatment of Genu varum in children equal or younger than 7 years. This is a prospective nonrandomized case series study was conducted. A total of 38 patients (total of 60 limbs: 36 varus and 24 valgus) were treated by percutaneous low-energy osteotomy and casting with shanz screws fixation and observed over 2-5 years. Clinical and radiological outcomes were evaluated at the end of follow-up period by standing scanogram which enabled tibiofemoral angles and the mechanical axis to be measured and the rate of complications. There was a statistically significant improvement of the radiographic parameters in the form of tibiofemoral angle and MAD. Clinically, all the cases were completely corrected just one patient (two limbs) complicated by over-correction but statically non-significant and. pin tract infection in shanz screws fixation was noticed in one Patient. Percutaneous low-energy osteotomy and casting with shanz screws fixation is a simple, safe, and effective method in dealing with 7 years and younger children with pathological knee deformities. Level of evidence: Therapeutic level IV.

Mid-term results of sub-trochanteric valgus osteotomy for symptomatic late stages Legg-Calvé-Perthes disease.

BACKGROUND: The treatment of late stages of Legg-Calvé-Perthes disease (LCPD) is controversial. Although the concept of femoral head containment is a well-established technique of treatment, its use remains debatable in the late stages of the disease, as it does not improve symptoms in terms of limb length discrepancy and gait. AIM: To assess the results of subtrochanteric valgus osteotomy in symptomatic patients with late-stage Perthes disease. METHODS: From 2000 to 2007, 36 symptomatic patients with late stage of Perthes disease were surgically treated with subtrochanteric valgus osteotomy and followed-up for 8 to 11 years using the IOWA score and range of motion (ROM) variables. The Mose classification was also assessed at the last follow-up to reflect possible remodeling. The patients were 8 years old or older at the time of surgery, in the post-fragmentation stage, and complaining of pain, limited ROM, Trendelenburg gait, and/or abductor weakness. RESULTS: The preoperative IOWA score (average: 53.3) markedly improved at the 1-year post follow-up period (average: 85.41) and then slightly improved at the last follow-up (average: 89.4) (P value < 0.05). ROM improved, with internal rotation increased on average by 22° (from 10° preoperatively to 32° postoperatively) and abduction increased on average by 15.9° (from 25° preoperatively to 41° postoperatively). The mean Mose deviation of femoral heads was 4.1 mm at the end of the follow-up period. The tests used were the paired t-test and Pearson correlation test, where the level of significance was a P value less than 0.05. CONCLUSION: Subtrochanteric valgus osteotomy can be a good option for symptomatic relief in patients with late-stage of LCPD.

Virtual orthopedic assessment: Main principles and specific regions.

Telemedicine was originally created as a way to treat patients who were located in remote places far away from local health facilities or in areas with shortages of medical professionals. Telemedicine is still used today to address those problems, and is increasingly becoming a tool for convenient medical care. With the emergence of pandemics, telemedicine became almost a mandatory and valuable option for continuing to provide medical care in various specialties. As the threat of pandemic progress has continued for months and may continue for years, it is essential to validate existing tools to maintain clinical assessment and patient treatment to avoid negative consequences of the lack of medical follow-up. Therefore, the establishment of a virtual assessment technique that can be conducted effectively is of outmost importance as a way of adapting to the current situation. This study evaluated the role of telemedicine in the assessment of various orthopedic pathologies by means of a systematic virtual evaluation.

Percutaneous release of trigger finger.

PURPOSE: To evaluate the condition of the tendons and neurovascular bundles after percutaneous release for trigger finger of the middle, ring, and little fingers. METHODS: 30 women and 13 men aged 20 to 55 (mean, 40) years underwent percutaneous release of the A1 pulley using a 18-gauge needle for 43 trigger fingers of the middle, ring, or little finger unresponsive to conservative treatment. 19 trigger fingers were grade II and 24 were grade III. Open exploration was performed to evaluate the condition of the tendons and neurovascular bundles after percutaneous release. RESULTS: Incomplete release of the A1 pulley was noted in 3 fingers, which occurred during the early study period. Superficial flexor tendon laceration was noted in 6 fingers but this did not interfere with tendon function. No injury to the A2 pulley, nerve, or artery of any finger was noted. CONCLUSION: Percutaneous release of trigger fingers is quick, safe, and effective.

Recent biological trends in management of fracture non-union.

Bone regeneration is a complex, well-orchestrated physiological process of bone formation, which can be seen during normal fracture healing, and is involved in continuous remodelling throughout adult life. Currently, there is a plethora of different strategies to augment the impaired or "insufficient" bone-regeneration process, including the "gold standard" autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. Improved "local" strategies in terms of tissue engineering and gene therapy, or even "systemic" enhancement of bone repair, are under intense investigation, in an effort to overcome the limitations of the current methods, to produce bone-graft substitutes with biomechanical properties that are as identical to normal bone as possible, to accelerate the overall regeneration process, or even to address systemic conditions, such as skeletal disorders and osteoporosis. An improved understanding of the molecular and cellular events that occur during bone repair and remodeling has led to the development of biologic agents that can augment the biological microenvironment and enhance bone repair. Orthobiologics, including stem cells, osteoinductive growth factors, osteoconductive matrices, and anabolic agents, are available clinically for accelerating fracture repair and treatment of compromised bone repair situations like delayed unions and nonunions. A lack of standardized outcome measures for comparison of biologic agents in clinical fracture repair trials, frequent off-label use, and a limited understanding of the biological activity of these agents at the bone repair site have limited their efficacy in clinical applications.

Cost of external fixation vs external fixation then nailing in bone infection.

AIM: To study the cost benefit of external fixation vs external fixation then nailing in treatment of bone infection by segment transfer. METHODS: Out of 71 patients with infected nonunion tibia treated between 2003 and 2006, 50 patients fitted the inclusion criteria (26 patients were treated by external fixation only, and 24 patients were treated by external fixation early removal after segment transfer and replacement by internal fixation). Cost of inpatient treatment, total cost of inpatient and outpatient treatment till full healing, and the weeks of absence from school or work were calculated and compared between both groups. RESULTS: The cost of hospital stay and surgery in the group of external fixation only was 22.6 ± 3.3 while the cost of hospital stay and surgery in the group of early external fixation removal and replacement by intramedullary nail was 26.0 ± 3.2. The difference was statistically significant regarding the cost of hospital stay and surgery in favor of the group of external fixation only. The total cost of medical care (surgery, hospital stay, treatment outside the hospital including medications, dressing, physical therapy, outpatient laboratory work, etc.) in group of external fixation only was 63.3 ± 15.1, and total absence from work was 38.6 ± 6.6 wk. While the group of early removal of external fixation and replacement by IM nail, total cost of medical care was 38.3 ± 6.4 and total absence from work or school was 22.7 ± 4.1. The difference was statistically significant regarding the total cost and absence from work in favor of the group of early removal and replacement by IM nail. CONCLUSION: Early removal of external fixation and replacement by intramedullary nail in treatment of infected nonunion showed more cost effectiveness. Orthopaedic society needs to show the cost effectiveness of different procedures to the community, insurance, and health authorities.