Composite vascularized fibular epiphyseo-osteo-periosteal transfer for hip reconstruction after proximal femoral tumoral resection in a 4-year-old child.

Literature on the reconstruction of the proximal femur in skeletally immature patients with the use of an epiphyseal transplant is scarce and with variable results depending on the indication. We report successful outcomes using a modified vascularized fibular epiphyseal transplant in a 4-year-old boy with an oncologic lesion. We discuss the advantages of supplementing the standard graft with a vascularized fibular periosteal tissue. The vascularized fibular epiphyseal transplant (VFET) is an effective option in the reconstruction of the epiphysis in skeletally immature patients, owing to the advantage of restoring both the joint function and the growth potential in a single surgical operation. Multiple reported cases demonstrate the effectiveness of this complex technique in upper extremity reconstruction. However, literature is scarce regarding its use for the reconstruction of the proximal femur and hip joint. Through this article, we report the use of a VFET in the reconstruction of a proximal femur in a 4-year-old boy after an intra-articular wide excision of an epithelioid hemangioendotelioma. We also discuss the advantages of designing the flap as a composite vascularized epiphyseo-osteo-periosteal flap.

Vascularized fibular periosteal graft: a new technique to enhance bone union in children.

BACKGROUND: The periosteum in children has strong osteogenic power and is quite thick, facilitating procurement. However, it has been rarely used as a vascularized flap to enhance bone union in this age range. The purpose of this study is to assess the effectiveness of a new vascularized periosteal flap harvested from the fibula for the enhancement of bone union in the pediatric age. METHODS: Thirteen vascularized fibular periosteal grafts were used in 12 children, mean age 12.6 years. Indications included the prevention of bone allograft-host junction nonunion and treatment of recalcitrant bone nonunion. In 9 instances, the periosteal flap was harvested as a free flap and in 4 as a pedicled flap. Serial radiographs and computed tomography scans were used to evaluate the progression of callus formation and bone healing. RESULTS: All flaps were successful in promoting bone healing and achieving bone union in a mean time of 2.8 months for metaphyseal junctions and 7.1 months for diaphyseal ones, except for 1 case, which initially failed due to a pedicle torsion. It was then resolved with a second vascularized fibular periosteal grafts, with complete union after 5 months. CONCLUSIONS: Transfer of a vascularized fibular periosteal flap, either pedicled or as a free flap, is an effective treatment to enhance bone union in children in biologically unfavorable scenarios. The properties of periosteal tissue in the pediatric age are unique and its use in bone union enhancement permits new reconstructive strategies in children different from those described in adults. LEVEL OF EVIDENCE: IV.

Terrible triad of the elbow.

PURPOSE: To review epidemiological characteristics and treatment outcomes of the terrible triad of the elbow. METHODS: Records of 18 cases of the terrible triad of the elbow occurring in 8 women and 8 men aged 17 to 77 (mean, 45) years were reviewed. The epidemiology and various treatment approaches and functional outcomes were recorded. The mean follow-up period was 13.6 (range, 4-38) months. The injury mechanisms included simple falls (n=12), falls from a low height (n=2), traffic accidents (n=2), and sports accidents (n=2). Radial head fractures and the coronoid apophysis fractures were classified. RESULTS: There were 10 type-III and 8 type-II radial head fractures, 9 type-I and 9 type-II coronoid apophysis fractures, and all humeroulnar dislocations were posterior. The mean duration of immobilisation was 25.5 (range, 17-38) days. After rehabilitation, the mean range of motion of the elbow improved to 130 degrees flexion (24% recovery), 18 degrees extension (35% recovery), 73 degrees supination (142% recovery), and 85 degrees pronation (25% recovery). The greatest gain in range of motion occurred within 3 to 4 months. Complications included heterotopic ossification (n=4), blocked pronation and supination (n=4), transient ulnar nerve injury (n=2), Essex-Lopresti lesion (n=2), unnoticed dislocation (n=3), and rapidly progressive arthrosis (n=1). CONCLUSION: Although our patients had better recovery of range of motion than those reported in other studies, the terrible triad of the elbow can lead to joint instability, osteoarthritis, arthrosis, and joint stiffness, and may resort to total elbow arthroplasty in some cases.

An inconstant ligament in the popliteal region associated to the superior genicular arteries: surgical importance.

MATERIALS AND METHODS: In the dissection of 60 knees of 30 cadavers (13 women and 17 men), a ligament was located in the posterior femur face above the lateral or medial condyle. RESULTS: This ligamentous structure was found in 12 (20%) out of 60 knees studied (38% of the women and 35% of the men). It had a vertical arrangement and a constant direct relation to the superior (lateral or medial) genicular artery, and in no case it appeared as a posterior reinforcement of the capsule. The superior vessels were fixed by this ligament. DISCUSSION: This fixation may provide stability to the vascular tree but it could be a cause of post-surgical hemarthrosis in arthroscopy of the posterior knee area or in posterior or lateral knee approaches or it could be even implicated in vascular injury of the popliteal artery during knee dislocation. CONCLUSION: The objective was to describe this inconstant ligament and to study its clinical relevance for surgical procedures, and particularly for those using the posterior approach to the knee joint.

Biomechanical evaluation of fixation of clavicular fractures.

Reproducible fractures of the midshaft of the clavicle were created in 14 fresh frozen human cadaveric clavicles. Under the three-point bending loading by a materials testing machine, the load to failure of fixation of the clavicular fractures treated with steel reconstruction plates (five specimens) and Herbert cannulated bone screw (nine specimens), was compared with a group control formed by five specimens of clavicles without osteosynthesis material. No statistically significant differences were observed between the three groups. In consequence and in terms of biomechanics, in clavicular acute fractures, both plating and intramedullary Herbert cannulated bone screw may be utilized in the treatment of these lesions.