Renal impairment and time to fracture healing following surgical fixation of distal radius fracture.

INTRODUCTION: Despite the prevalence of renal impairments, the existing literature examining fracture healing in the upper limb in patients with renal impairment is sparse. This study hence aims to investigate the effect of renal impairment on time to fracture healing after distal radius fracture fixation surgery. MATERIALS AND METHODS: Patients above 50 years old who underwent distal radius fracture fixation via volar plating were included. Time to fracture healing was defined as duration between day of surgery and presence of radiographic union as evidence by bridging of callus or osseous bone. To assess for renal impairment, estimated glomerular filtration rate (eGFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Pre-existing comorbidities were also collected and analysed. RESULTS: Ninety-nine consecutive patients took mean 65.5 ± 8.0 days to fracture healing post-operatively. Patients with renal impairment had longer time to fracture healing than patients without (67.1 ± 50.4 days versus 50.4 ± 31.8 days, p = 0.044). Patients ≥ 65 years also had a longer duration to fracture healing compared to patients < 65 years (mean 63.7 ± 53.0 days versus 50.2 ± 27.2 days, p = 0.033). Similarly, patients with ASA Class I had a shorter mean time to fracture healing than patients with ASA Class II and above (mean 42.5 ± 22.8 days versus 62.8 ± 47.6 days, p = 0.028). CONCLUSIONS: Time to fracture healing post-distal radius fracture fixation was significantly related to renal impairment, age and ASA classification.

An atypical presentation of a flexor intratendinous ganglion of the hand.

Intratendinous ganglions of the hand are rare. We report an unusual case of a ganglion arising within the flexor tendon in the hand. The intratendinous ganglion arose from the flexor digitorium profundus tendon of the little finger, causing flexion deformity of the finger.

Outcomes of Autologous and Synthetic Bone Grafts in Locking Plate Fixation of Comminuted Distal Radius Fractures.

Background The introduction of locking plate technology has improved the feasibility of distal radius fracture fixation without the need for bone grafting, yet challenges persist in cases of severely comminuted fractures and small, unstable intra-articular fragments. This study aimed to assess the outcomes of bone grafting in severely comminuted distal radius fractures treated with locking plates. Methods We performed a retrospective analysis involving 450 patients who underwent distal radius fracture fixations. We evaluated wrist motion, grip strength, and radiographic parameters, including radial inclination, radial tilt, ulnar variance, articular step, and fracture union at standardized intervals. In addition, at the 12- and 24-month marks, we assessed the disabilities of the arm, shoulder, and hand (DASH) questionnaire score. Results Out of the 450 patients who underwent distal radius fracture fixation using volar locking plate systems, 59 individuals (13%) required either autologous bone graft (n = 24) or synthetic bone substitutes (n = 35). In the final follow-up, all fractures had successfully united, displaying an average volar tilt of 4°, radial inclination of 18.8°, and an articular step or gap of 0.1 mm. Conclusion There was no significant difference between the use of autologous or synthetic bone grafts on clinical or radiological outcomes in the long term. Bone grafts are useful in severe metaphyseal comminution and aid in the reduction of articular fragments and bi-cortical comminution.

Fingertip Replantation: Surgical Technique, Tips, and Tricks.

SUMMARY: Replantation of fingertip amputations restores the original tissue and is the ideal treatment to provide the best aesthetic and functional outcome. However, successful fingertip replantation is considered challenging because it requires supermicrosurgery techniques. This article provides a detailed surgical technique for fingertip replantation and the authors' preferences and recommendations. In the authors' experience, the most important factors for successful fingertip replantation are meticulous vascular dissection, reliable arterial repair, and venous anastomosis to avoid postoperative venous congestion. Proximal arterial dissection until pulsatile bleeding is encountered avoids the zone of vascular injury, and is particularly important in crush or avulsion amputations. Distal arterial dissection is performed until undamaged intima is identified. The authors believe anastomosis to the central artery is reliable even in a Tamai zone II amputation. When an arterial defect is present, the authors recommend using a vein graft to anastomose to the central artery. In addition, the authors highly recommend at least one venous anastomosis to avoid postoperative venous congestion. In Tamai zone I, available veins can be found on the palmar side of the pulp. It is important to search directly below the dermis and remove adipose tissue around the vessels to secure space for anastomosis. The authors consider nerve suture in Tamai zone I and II replantations inessential, because spontaneous sensory recovery can be expected. Postoperative management of venous congestion, spasm in artery, and arterial thrombosis are as important as surgery.

Midterm Outcomes of Surgical Reconstruction and Spontaneous Recovery of Upper-Extremity Paralysis Following Acute Flaccid Myelitis.

Background: Acute flaccid myelitis (AFM) is a disabling, poliomyelitis-like illness that mainly affects children. Although various surgical interventions are performed for intractable paralysis due to AFM, the timing of surgery and its long-term outcomes have yet to be established, especially for shoulder reconstruction. This study aimed to analyze the midterm outcomes of nonsurgically and surgically treated upper-extremity AFM and the factors influencing shoulder functional outcomes after surgical reconstruction. Methods: We retrospectively examined 39 patients with AFM in 50 upper extremities between 2011 and 2019. The degree of spontaneous recovery of completely paralyzed muscles was evaluated at a median of 3, 6, and 37 months after the onset of paralysis. Twenty-seven patients with 29 extremities underwent surgery involving nerve transfer, muscle-tendon transfer, or free muscle transfer for shoulder, elbow, and hand reconstruction. Results: Patients with complete paralysis of shoulder abduction at 6 months did not show later recovery. Twenty-two patients with 24 extremities underwent shoulder surgery, and all but 1 were followed for at least 24 months after surgery. Although postoperative shoulder abduction recovery was similar between transfer of the spinal accessory nerve and of the contralateral C7 nerve root to the suprascapular nerve, the outcomes obtained with spinal accessory nerve transfer had more variability, likely related to latent spinal accessory nerve paralysis, shoulder instability related to pectoralis major paralysis, and the type of paralysis. Shoulder abduction recovery was also greatly affected by scapulothoracic joint movement. In contrast, the outcomes of the elbow flexion and hand reconstructions were more consistent and acceptable. Conclusions: All patients had loss of shoulder abduction, and restoration of shoulder function was less predictable and depended on the quality of the donor nerves and recovery of the synergistic muscles. Strict donor nerve selection and additional nerve transfer for shoulder reconstruction are imperative for satisfactory outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple.

Traumatic foveal tears of the triangular fibrocartilage complex lead to ulnar-sided wrist pain and instability, resulting in painful motion and loss of grip strength with a severe impact on the overall function of the upper limb. Surgical repair is nothing new and has traversed through the realm of open repair to arthroscopic assisted to all arthroscopic repair techniques over the many decades, with arthroscopic repairs showing better visualization, lesser trauma, and equally favorable patient outcomes. Techniques had varied from using trans osseous tunnels to bone anchors, with or without the usage of special jigs. Here, we describe a simple and fast 3 portal arthroscopic technique of repairing the torn foveal insertion of the triangular fibrocartilage complex using a bone anchor inserted under arthroscopic and fluoroscopic guidance into the fovea. Both the dorsal and volar limbs of the triangular fibrocartilage complex are repaired arthroscopically, resulting in a strong anatomic repair resulting in a stable and pain-free wrist.

Symptomatic Radial-Sided Tears of the Triangular Fibrocartilage Complex: An All-Arthroscopic Repair Using Bone Anchors.

Radial-sided tears of the triangular fibrocartilage, though uncommon, can still be a reason for ulnar-sided wrist pain, and, at times, instability of the distal radioulnar joint. Historically, it has been believed that because of the paucity of vascularity along the radial edge of the triangular fibrocartilage complex (TFCC), any form of repair will not lead to healing, thus stating it to be an exercise in futility. Current literature deftly argues against this previously prevailing concept and supports the need of repair in case of symptomatic radial-sided TFCC tears. In our study, we describe an all-arthroscopic technique of repairing radial-sided tears using a bone anchor which can be a fast and simple procedure in the hands of an orthopaedic or hand surgeon trained in arthroscopy. This technique also circumvents the risk of injuring the superficial radial nerve and other radial-sided structures which are stated complications of the current arthroscopic repairs.

Secondary Intention Healing for Fingertip Amputations in a Tropical Climate.

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates. Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient's final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed. Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported. Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing. Level of Evidence: Level IV (Therapeutic).

Determination of gestational age in twin pregnancy: Which fetal crown-rump length should be used?

AIM: For twin pregnancy, discrepancies in the crown-rump length (CRL) between two fetuses often exist. Evidence is lacking regarding which fetal CRL should be used for estimation of gestational age (GA). Our aim was to determine whether the larger, smaller or the mean CRL is more accurate in determining the GA in the first trimester of pregnancy. METHODS: This is a retrospective study of twin pregnancies conceived by assisted reproduction. The oocyte retrieval date was used for determination of the true gestational age. CRL dating charts by Robinson, Hadlock and Chitty were used for reference. The values of the larger, smaller and mean CRL were compared with the reference CRL for the corresponding GA, which was obtained from each of the three reference charts. The differences between the reference CRL and measured CRL were calculated. The percentages of which CRL, the larger, smaller or the mean, was closest to the expected reference values were calculated. RESULTS: A total of 52 pairs of twins were included in the study. According to Robinson's chart, the proportion of larger, smaller and mean CRL values that were closest to the reference value was found in 11.5%, 75.0% and 5.8% of cases respectively. The larger, smaller and the mean CRLs were closest to the reference CRL in the Hadlock chart for 28.9%, 44.2% and 19.2% of cases, respectively, and closest to the reference CRL in the Chitty chart for 17.3%, 59.6% and 15.4% of cases, respectively. CONCLUSION: The smaller CRL is more accurate in the estimation of the GA for twin pregnancy compared to the larger or mean CRL values.

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients.

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.

Fetal congenital heart diseases: Diagnosis by anatomical scans, echocardiography and genetic tests.

Objective: To determine the distribution of major fetal congenital heart diseases (CHDs) diagnosed antenatally during routine second-trimester obstetric anatomical scans in an unselected population at a single tertiary centre and to characterise and stratify risk factors, genetic diagnosis and long-term health at 4 years old. Method: A single-centre cohort study of all major fetal CHDs detected on routine obstetric fetal anatomical ultrasound scans between January 2014 and December 2017 was performed in an unselected population. Demographic details, fetal echocardiogram reports, genetic test results, delivery outcomes and postnatal progress were stratified by CHD subtype. Results: Of 20,031 screened pregnancies, 109 pregnancies (0.53%) had major fetal CHDs. The most common subtypes were coarctation of aorta (17.4%), transposition of great arteries (16.5%), and tetralogy of Fallot and univentricular hearts (13.8% each). Of the 60.5% that underwent confirmatory genetic testing-mostly conventional karyotyping and testing for 22q11 microdeletion-about a quarter had abnormalities, of which 22q microdeletion was the most common. We had complete obstetric data in 85 pregnancies (78%), of which 76.5% progressed to live birth. Among these, 92.1% of postnatal echocardiograms concurred with antenatal ones. At 4 years old, 43.2% of offspring had no medical or developmental issues, 20.0% had mild medical or developmental issues, 21.5% had major medical or developmental issues, and 12.3% had deceased. Conclusion: Fetal echocardiograms accurately diagnose CHDs. Future studies should evaluate the roles of chromosomal microarray and next-generation sequencing in diagnosing CHD.

The right turn around: Penrose tourniquet application in paediatrics.

INTRODUCTION: Commercially available tourniquets are ill-suited for paediatric patients with limb circumferences smaller than the required mechanism, forcing surgeons to improvise. This study aimed to quantify pressures exerted by the Penrose tourniquet when applied on a phantom model and evaluate the intra-/inter-rater reproducibility of the technique previously proposed. METHODS: Eight calibrated pressure sensors were distributed evenly along the inner and outer circumference of a silicon-based model. A 30cm-by-3.2 cm ARGYLE Penrose drain, 4-by-4 gauze, marker and ruler were used. The optimal interval for arterial occlusion was determined to be 70% of limb circumference. The tourniquet was secured using two half-knots formed by gauze. RESULTS: Two-turns of the tourniquet about the model generated mean pressures (SD) of 209.43 (SD:35.98 mmHg) (95%CI: 195.85-224.00 mmHg) (outer-sensor) and 246.32 (SD:61.92 mmHg) (95%CI: 221.02-273.49 mmHg) (inner-sensor). Three-turns generated mean pressures of 302.07 (SD:23.98 mmHg) (95%CI: 292.29-312.53 mmHg) (outer-sensor) and 314.44 (SD:56.70 mmHg) (95%CI: 291.25-338.25 mmHg) (inner-sensor). CONCLUSION: The Penrose tourniquet has clinical utility, particularly for patients where commercially available tourniquets are not suitable. Current application techniques generate inconsistent pressures. Using the existing model, further refinement can be done to improve the consistency and safety of the application. We recommend using intervals of slightly more than 70% of limb circumference and only two turns of the Penrose tourniquet during application. LEVEL OF EVIDENCE: V.

Virtual Rehabilitation of Elbow Flexion Following Nerve Transfer Reconstruction for Brachial Plexus Injuries Using the Single-Joint Hybrid Assisted Limb.

Purpose: The upper limb single-joint hybrid assistive limb (HAL), a wearable robot that can support elbow flexion and extension motions, was originally used to rehabilitate patients with stroke. We report the preliminary outcomes of serial HAL use for rehabilitation following nerve transfer (NT) for elbow flexion reconstruction in brachial plexus injuries. Methods: Hybrid assistive limb training consisted of virtual and power training courses. Virtual training was started before HAL picked up motor unit potentials (MUPs) from the target muscle through electrodes attached to the skin overlying the original donor muscles. Power training was started after the maturation of MUPs, the stage where the MUPs were strong to be recognized to arise from the target muscles. Hybrid assistive limb assist at this stage was carried out by decreasing the settings in an inversely proportionate manner to the increase in target muscle strength. Fourteen patients underwent HAL training following NT. Eight patients had the intercostal nerve to musculocutaneous nerve (ICN-MCN) transfer, and their postoperative functional outcomes and rehabilitation performance were compared to 50 patients with ICN-MCN transfer who underwent conventional postoperative rehabilitation with electromyographic biofeedback (EMG-BF) techniques. Results: Comparison of the long-term results following ICN-MCN transfer between EMG-BF and HAL groups showed similar follow-up times, elbow flexion range of motion, or power of elbow flexion assessed using the British Medical Council grade, and quantitative measurement using Kin-Com dynamometer. However, the number of rehabilitation sessions was significantly fewer in the HAL than EMG-BF group. Conclusion: HAL training accelerated patients' learning to convert the original muscle function into elbow flexion following NT by replicating elbow flexion during the pre-MUP detection stage and shortening the rehabilitation time. Type of study/level of evidence: Therapeutic IV.

Arthrodesis for Primary Osteoarthritis of Trapeziometacarpal Joint Using Multiple Kirschner Wires and Tension Band Wire in Female Patients Older than 40.

Background: The purpose of this study was to evaluate the results of arthrodesis with multiple Kirschner (K)-wires and tension band wire for primary osteoarthritis of trapeziometacarpal (TM) joint in female patients aged 40 years or older. Methods: We retrospectively obtained data regarding all female patients 40 years or older who underwent TM joint arthrodesis for TM joint osteoarthritis with K-wires and tension band wire over a 10-year period from 2009 till 2019. Thumb length, active range of motion (ROM) at the metacarpophalangeal (MCP) joint, active ROM of radial and volar adduction and abduction and key pinch strength was measured. Patient-reported outcomes were assessed using a pain and satisfaction questionnaire and the DASH score. We also recorded postoperative complications. Results: The study included 60 thumbs in 49 patients with an average age 60 years and a mean follow-up of 40 ± 21 months. All but one thumb had radiographic evidence of fusion within 6 months and the union rate was 98%. Key pinch strength increased from 2.3 to 4.9 kg after surgery. Total arc of motion in radial adduction-abduction decreased from 16° to 10°. Total arc of motion in volar adduction-abduction decreased from 25° to 9°. One patient experienced attritional rupture of the flexor pollicis longus tendon attributed to a K-wire penetration into the carpal tunnel. Although 46 thumbs (77%) had no or mild hardware-related symptoms, they underwent hardware removal after solid bone union. In 23 thumbs with follow-up period longer than 48 months, two thumbs developed scaphotrapeziotrapezoid joint arthritis and two thumbs developed metacarpophalangeal joint arthritis. Conclusions: We found that arthrodesis with multiple K-wires and tension band wire is a valuable option in the management of trapeziometacarpal joint osteoarthritis in female patients aged 40 years or older. Level of Evidence: Level IV (Therapeutic).

The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures.

Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing. Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing. Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038). Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing. Level of Evidence: Level IV (Therapeutic).

Tension Reducing Muscle Stretch Protocol to Obtain Full Distal Tendon Excursion: A New Rehabilitation Protocol after Flexor Tendon Repair.

Background: Flexor tendon rehabilitation protocols minimize repair tension by limiting range of movement to prevent tendon rupture. The resultant muscle contracture inhibits finger extension, increases resistance in tendon gliding distally, and progress to proximal interphalangeal (PIP) joint flexion contracture. This study describes our new rehabilitation protocol, the Tension Reducing Muscle Stretch (TRMS), designed to prevent flexor muscle contracture and obtain full distal tendon excursion. Methods: We reviewed retrospectively 14 fingers in 13 consecutive patients with primary repair of complete zone I or II flexor digitorum profundus (FDP) tendon rupture were treated with our protocol between 2007 and 2019. Our rehabilitation following FDP 4-strand repairs consisted of three steps. The first step comprised of exercises from traditional protocols such as Duran, Kleinert, Synergistic-wrist-motion, and Place-and-hold. The second step comprised the TRMS exercise to prevent the onset of muscle contracture. Anatomically, FDP tendons arise from the same FDP muscle belly. TRMS involved placing the affected finger in full passive flexion while unaffected fingers were passively extended to full extension. This made the affected FDP muscle stretched. The final step incorporated the early active flexion motion exercise, in which simple fisting was performed, from a fully extended position. Results: The mean total active motion at the final follow up was 235° (range 170-265). Using the Strickland criteria, eight achieved excellent, four had good, two had fair results. The mean angle of passive extension deficit at the PIP joint at four weeks after surgery was -7° (-30-0), and at the final follow up was -3° (-20-0). No tendon repair was ruptured. Conclusions: This protocol reduced tension in the affected tendon muscle and encouraged tendon excursion distal to the repair site without complications. It allows full tendon excursion and prevents PIP joint contractures.

Hand Surgery in Singapore.

Singapore as an island nation is one of three countries in the world that has hand and reconstructive microsurgery (HRM) as an independent specialty. The 52 accredited hand surgeons serving a population of 5.7 million facilitate hassle free access to patients. Hand surgery historically is rooted very much in orthopaedic surgery as in most Asian countries with more than five decades of rapid evolution. Singapore pioneered a structured and systematic training program for HRM and the local surgeons have contributed significantly to the body of knowledge in hand surgery with targeted research and publications with three surgeons being awarded international recognition for their contributions. Singapore continues to contribute significantly to surgical volunteerism regionally through active involvement in the training of regional surgeons through their sustainable volunteer activities and through international fellowships in Singapore hospitals. The future of hand surgery in Singapore will be more competency and multidiscipline based on community-centered approach.

Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy.

We report a case of posterior wall intramural pregnancy in a 36-year-old primigravida at 6 weeks gestation. Sonographic examination showed a viable intramural pregnancy distorting the contour of the uterus. The pregnancy was terminated by intrafetal injection of potassium chloride followed by intra-amniotic methotrexate injection.

Elbow flexion strength and contractile activity after partial ulnar nerve or intercostal nerve transfers for brachial plexus injuries.

We compared the outcomes of 23 partial ulnar nerve and 15 intercostal nerve transfers for elbow flexion reconstruction in patients with C56 or C567 brachial plexus injuries using manual muscle power, dynamometric measurements of elbow flexion strength and electromyography. The range of elbow flexion and muscle strength recovery to Grade 3 or 4 were comparable between the two groups. The patients with C567 injuries had significantly stronger eccentric contraction after the partial ulnar nerve transfer than after the intercostal nerve transfer (p < 0.05). Electromyography of individual muscles demonstrated that the patients with partial ulnar nerve transfers were unable to voluntarily isolate biceps contraction and recruited forearm flexors and extensors. The patients after partial ulnar nerve transfer had significantly more activity of the forearm muscles during concentric elbow flexion than after intercostal nerve transfers (p < 0.05). We conclude that partial ulnar nerve transfers were superior to intercostal nerve transfers when assessed quantitatively with the dynamometer to evaluate elbow flexion, although simultaneous recruitment of forearm muscles may have contributed to the increased elbow flexion strength in the patients with the partial ulnar nerve transfer.Level of evidence: III.

The double muscle gastrocnemius-soleus flap in resurfacing large lower limb defects: Modifications and outcomes.

INTRODUCTION: Larger soft tissue defects over critical areas of the lower limb involving the knee and proximal two thirds of the tibia present a challenge to the reconstructive surgeon. Options include a large free flap or pedicled local flaps. The gastrocnemius or soleus flap alone is not sufficient. Combined gastrocnemius-soleus flaps can be used adequately without the need to resort to free flaps. We review the use and outcomes of the combined pedicled gastrocnemius and hemi-soleus double muscle flap to cover large defects of the leg and discuss our technique. MATERIAL AND METHODS: A retrospective review of the patients who underwent the pedicled double muscle (gastrocnemius and soleus) flap for wound resurfacing in our institution between 2008 and 2013 was performed. The patients' case notes were analyzed and data collected included their age, comorbidities, wound characteristics, surgical procedures and post-operative outcomes and complications. RESULTS: There was a total of ten double flaps in ten patients; eight due to trauma and two due to infection. Mean follow up period was 12 months. All flaps achieved primary healing without major complications. There were two cases of minor complications: flap tip necrosis and superficial infection. Nine patients were able to achieve ambulation without aid at final follow up. CONCLUSION: The combined pedicled gastrocnemius and hemisoleus double muscle flap is a useful alternative for reconstruction of large critical soft tissue defects around the knee and leg.