Vascularized pedicled graft from distal radius for scaphoid nonunion with double stabilization: A long term follow up study.

PURPOSE: The aim of the present study is to present the long-term efficacy of the graft of the distal radius based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for the treatment of scaphoid nonunion with a proposed treatment of double stabilization with Kirschner wires and external fixator. METHODS: Between 2007 and 2013 we retrospectively reviewed 11 patients who were operated for established scaphoid nonunion with pedicled vascularized distal radius graft based on the 1,2 ICSRA in our department. Stabilization of the graft was achieved with Kirschner wires and the wrist was immobilized with a transarticular external fixator. All patients were evaluated pre- and post-operatively both clinically and radiologically. The DASH score was also completed by the patients before and after the operation. The minimum follow-up of the patients was 5 years. RESULTS: The mean age of the patients was 28.64 years (range, 18-49 years). Ten patients were males (90.91%) and one female (9.09%). In all patients, union was achieved. The mean time of union was 11.2 weeks (range, 8-18 weeks). The mean follow-up was 61.32 months (range, 60-72 months). Compared to the contralateral hand there was noticed 14° lack in flexion and 18° in extension. The mean DASH score showed also significant improvement from 23.1 (range, 9.4-50.6) preoperatively to 4.72 (range, 0-22.8) during the last follow-up. CONCLUSION: The 1,2 ICSRA distal radius graft consists a trustworthy pedicled vascularized graft for the treatment of nonunion presenting very promising long-term outcomes.

Trends in pediatric cervical spine injuries in the United States in a 10-year period.

BACKGROUND: Cervical spine fractures (CSFs) are potentially devastating injuries in pediatric population. Fortunately, these injuries are uncommon in pediatric patients. The purpose of this study was to determine the epidemiology, the risk factors, mechanisms of injury and to identify possible strategies for prevention. In addition, the aim of the current study was to compare CSF sustained in 2003 to CSF sustained in 2008 and 2013 so as to recognize the trend of pediatric CSFs in the United States. METHODS: The National Electronic Injury Surveillance System was queried for CSF sustained in pediatric population up to 16 years of age for years 2003, 2008, and 2013. Outcomes of interest were patient characteristics (age and sex), causes of CSF, and mechanism of injury. RESULTS: Eighty pediatric patients with CSF were identified. The average age was 10.5 years. Boys sustained significantly more CSF than girls. Statistically significant more CSF were occurred in children of 10-16 years than in children up to 9 years. Sports or recreational activities and home-related accidents were the predominant causes of CSF. Mechanisms of injury were age-related, with younger children sustaining CSF as a result of home-related accidents while adolescents commonly injured during sporting or recreational activities. In contrast to current data in literature, motor vehicle accidents were not a major cause of CSF. Comparing the years 2003, 2008, and 2013, statistically significant differences in the incidence of CSF were not found. CONCLUSIONS: Our study confirms previous findings that adolescents who sustain CSF have higher incidence of sport or recreation-related accidents than younger patients who sustain commonly home-related accidents as a consequence of insufficient parental supervision. The perception that motor vehicle accidents comprise major cause of CSF appears not to be true.

Predicting Risk of Recurrent Patellar Dislocation.

PURPOSE OF REVIEW: Lateral patellar dislocation (LPD) is one of the most common injuries of the knee, especially in a young patient. It is multifactorial with several underlying risk factors. The purpose of this review is to present the most recent data concerning risk factors and their predictive value to estimate recurrent LPD risk. RECENT FINDINGS: Several demographic risk factors (age, skeletal immaturity, sex, bilaterality), mechanism of injury, and anatomic risk factors (trochlear dysplasia, patella alta, excessive tibial tubercle lateralization, increased patellar tilt) have been recognized. The combination of different risk factors, their relative contribution to instability, weightage of each factor, and multivariate analysis have led to the development of a prediction model and instability scoring system. If recurrent instability and poor outcomes could be predicted based on these prediction tools, then alternative treatment or early surgical intervention after first-time LPD could be considered. This information can also be used to predict contralateral LPD and failure of surgical treatment. Current prediction tools are mainly based on retrospective studies. In the future, prospective validation of these prognostic factors would be beneficial.

Minimally invasive spine surgery for degenerative spine disease and deformity correction: a literature review.

During the last two decades, minimally invasive techniques and instruments in spine surgery have undergone serious development in all fields. Specific advantages of these minimally invasive methods have put them forward in spine surgery in recent times. Preservation of important anatomical structures of the spine is a major factor for the evolution of these procedures. The lower prevalence of complications and faster rehabilitation of patients are some of the advantages of minimally invasive spine surgery (MISS). Due to the increasing use of minimally invasive methods in the clinical practice worldwide, there is a strong need for clarification of basic principles, tips and tricks, complications, and clinical outcomes. This review is an effort to provide a better understanding of some of these procedures.

Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report.

Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.

Use of recombinant human bone morphogenetic protein-2 in spine surgery.

Bone morphogenetic proteins are osteoinductive factors which have gained popularity in orthopaedic surgery and especially in spine surgery. The use of recombinant human bone morphogenetic protein-2 has been officially approved by the United States Food and Drug Administration only for single level anterior lumbar interbody fusion, nevertheless it is widely used by many surgeons with off-label indications. Despite advantages in bone formation, its use still remains a controversial issue and several complications have been described by authors who oppose their wide use.

Intraoperative measurement of limb lengthening during total hip arthroplasty.

BACKGROUND: Limb length discrepancy (LLD) after total hip arthroplasty (THA) is a common problem which cannot be completely resolved. Many techniques have been described in order to minimize postoperative LLD, but most of these techniques are difficult to apply. Ideal technique must be simple and accurate. The most simple technique using a suture tied on the skin has well-known limitations, but its accuracy has not been evaluated before. MATERIALS AND METHODS: Sixty THAs in sixty patients (mean age 71 years, 1:1 male to female ratio) with hip osteoarthritis (37 cases in the right, and 23 cases in the left side) were studied in this prospective study. In all surgeries, the intraoperataive measurement of limb lengthening was performed using a suture tied on the skin of the lateral pelvis. The accuracy of this technique and correlation between intraoperative and postoperative radiological measurements of lengthening were evaluated. RESULTS: The mean preoperative LLD was -7.5 mm while the mean postoperative LLD was 1.58 mm. The accuracy of this technique, defined as the mean difference between the intraoperative and postoperative measurements was 1.8 mm. A strong correlation between these two measurements was noticed (r = 0.86). CONCLUSION: The accuracy and correlation index of this simple technique were similar to those of other techniques. The studied technique is quite accurate when attention is given to certain details, such as the amount of tension applied on the suture, the position of the tied point on the skin, and the position of the leg during measurements.

Classification of Lateral Patellar Instability in Children and Adolescents.

There is significant heterogeneity in the literature related to the causes and treatment of patellar instability. To address the multifactorial issue of patellar instability, the first task is to classify the instability pattern. Once a classification system is developed, future studies can differentiate between treatment recommendations and outcomes for each instability pattern. Existing classification systems do not include the entire spectrum of patellar instability patterns. The aim of this article is to review the nomenclature and existing patellar instability classification systems and analyze the different patterns into a comprehensive system.

Percutaneous repair of acute Achilles tendon rupture: a functional evaluation study with a minimum 10-year follow-up.

OBJECTIVE: The purpose of this study was to present the functional outcomes of percutaneous tenorrhaphy of the Achilles tendon with a minimum follow-up of 10 years. METHODS: The medical records of patients who underwent percutaneous surgery for acute unilateral Achilles tendon rupture between 2000 and 2004 were retrospectively reviewed. RESULTS: A total of 11 male patients met the inclusion criteria and were followed for a mean of 12.6 years (range: 10-13 years). The average age at the time of surgery was 39.3 years (range: 29-53 years). Patients returned to work at an average of 2.7 months (range: 1-4 months) after surgery and to normal daily activities (NDA) at an average of 4.1 months (range: 3-6 months) postoperatively. The mean strength ratio between the injured and normal sides was 90%. Compared with the contralateral normal side, the thickness of the operated tendon increased by a mean of 0.7 cm, while the circumference of the affected calf diminished by a mean of 1.1 cm. No difference in active and passive range of motion (ROM) was recorded between the affected and the contralateral normal ankle joints. Isometric plantar flexion was 87% of normal. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after surgery. The sensory defect had completely resolved by 6 months postoperatively. CONCLUSION: Long-term outcomes of our series support the effectiveness of percutaneous tenorrhaphy in Achilles function rehabilitation of patients with acute ruptures.

Pin tract infection of operatively treated supracondylar fractures in children: long-term functional outcomes and anatomical study.

PURPOSE: The purpose of our study was to determine the long-term functional outcomes of pin tract infection after percutaneous pinning of displaced supracondylar humeral fractures in children, and to evaluate the potential for intracapsular pin placement based on pin configuration in cadaveric elbows. METHODS: We conducted a retrospective review of all patients requiring percutaneous pinning in a single institution over a 19-year period. The functional outcome assessment consisted of a telephone interview using the Disabilities of the Arm, Shoulder and Hand (DASH)] Outcome Measure and the Patient-Rated Elbow Evaluation (PREE) questionnaires. The risk of intracapsular pin placement was studied in cadaveric elbows for the three most common pin configurations: divergent lateral, parallel lateral, and medial and lateral crossed pins. RESULTS: Of 490 children, 21 (4.3 %) developed pin tract infection. There were 15 (3.1 %) superficial and six (1.2 %) deep infections (osteomyelitis and septic arthritis). Both DASH and PREE scores were excellent at a mean of 18 years post-surgery. The risk of intracapsular pin placement using parallel lateral pins was found to be greater (p < 0.05) than either crossed or divergent lateral pinning configurations. CONCLUSIONS: Most infections after pinning of supracondylar humerus fractures are superficial and can be managed with pin removal, oral antibiotics, and local wound care. Septic arthritis and osteomyelitis are rare complications; when they do occur, they seem to be associated with parallel lateral pin configuration, though a causal relationship could not be established from the current study. Satisfactory long-term outcomes of these deep infections can be expected when treated aggressively with surgical debridement and intravenous antibiotics.

Atraumatic Sacral Fracture in Late Pregnancy: A Case Report.

Study Design Case report. Objective Sacral fractures, traumatic or atraumatic, are a rather rare cause of low back pain. The majority of the cases of pregnancy-related sacral fractures are reported as a postpartum complication, and only few cases of sacral atraumatic fractures have been reported in the last trimester of the pregnancy. The aim of this study is to report a rare case of atraumatic sacral fracture in the third trimester of pregnancy. Methods We report the case of a 30-year-old Caucasian European woman during her 37th week (36 weeks and 4 days) of gestation, who complained during her scheduled obstetric examination of continuous low back pain with no associated history of trauma. The patient performed activities of daily living with a normal level of fatigue and reported no running or walking long distances. She was examined in our department, and a magnetic resonance imaging scan was performed that showed a vertical nondisplaced fracture in her left sacrum. Results The patient was treated conservatively, and analgesics were administrated according to the consensus of the orthopedic and the anesthesiology departments. No further complications were recognized in the remaining period of her pregnancy, and a healthy child was born by caesarean section. Conclusions Atraumatic fractures of the sacrum should be included in the differentiated diagnosis of pregnant patients with low back pain.

Fatal Isolated Cervical Spine Injury in a Patient with Ankylosing Spondylitis: A Case Report.

Study Design Case report. Objective The purpose of the present case report was to present a patient with a history of ankylosing spondylitis who sustained a dislocation of C6 on C7 and died soon after his presentation in the emergency room (ER). Methods An 88-year-old man was brought to the ER due to a neck injury secondary to a fall. Imaging of the cervical spine revealed anterior dislocation of C6 on C7 and the characteristic "bamboo" spine of ankylosing spondylitis. Results The patient died within 30 minutes due to respiratory insufficiency. Conclusion Isolated cervical spine injuries in patients with ankylosing spondylitis can be fatal. A high degree of clinical suspicion, thorough imaging with computed tomography, and meticulous handling are required in this patient population.

Subtalar dislocation without associated fractures: Case report and review of literature.

Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed.

Lateral versus medial approach for intra-articular knee injections.

OBJECTIVE: The aim of this study was to determine whether the medial or the lateral mid-patellar approach is the most reliable for intra-articular knee injections. METHODS: The study included 76 knees of 76 patients divided into 2 groups. The first group consisted of 38 patients with a knee injury and resultant knee effusion. The second group included 38 patients without any known knee pathology. Patients were matched according to age and gender. The medial joint opening (medial patellofemoral angle) was calculated on a T1-weighted transverse image by measuring the anatomic angle between the femur and the patella. The lateral joint opening (lateral patellofemoral angle) was calculated in a similar way. RESULTS: The medial patellofemoral angle was significantly higher than the lateral patellofemoral angle in both groups (p<0.001). CONCLUSION: The medial patellofemoral angle is significantly higher than the lateral patellofemoral angle in both healthy knees and knees with effusion. Therefore, the medial approach appears to be more accurate for intra-articular knee injection due to the medial joint's larger opening.

Factors affecting bone growth.

Bone growth and development are products of the complex interactions of genetic and environmental factors. Longitudinal bone growth depends on the growth plate. The growth plate has 5 different zones-each with a different functional role-and is the final target organ for longitudinal growth. Bone length is affected by several systemic, local, and mechanical factors. All these regulation systems control the final length of bones in a complicated way. Despite its significance to bone stability, bone growth in width has not been studied as extensively as longitudinal bone growth. Bone growth in width is also controlled by genetic factors, but mechanical loading regulates periosteal apposition. In this article, we review the most recent data regarding bone growth from the embryonic age and analyze the factors that control bone growth. An understanding of this complex system is important in identifying metabolic and developmental bone diseases and fracture risk.

Digital ray reconstruction through distraction osteogenesis: a retrospective study of 82 rays with long-term follow-up.

PURPOSE: The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. METHODS: The medical records and radiographs of 65 consecutive patients (27 metacarpals and 55 phalanges) with either traumatic or congenital digital length discrepancies were retrospectively reviewed. The mean follow-up was 8.2 years. The mean distraction period was 21 days with a distraction rate of 4×0.25mm/day. Callus consolidation was obtained in all patients. RESULTS: The bones were lengthened by a mean amount of 17.5mm, with a mean increase in bone length of 68±17.3%. The mean healing index was 28.57 days/cm. Ray reconstruction with callus distraction can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers. CONCLUSION: A distraction rate of 1mm/day proved to be a safe rate of lengthening in both metacarpals and phalanges.

Modeling of blood flow through sutured micro-vascular anastomoses.

Microanastomosis is a surgical procedure used to reconnect two blood vessels using sutures. The optimal microanastomosis may be predicted by assessing the factors that influence this invasive procedure. Blood flow and hemodynamics following microanastomosis are important factors for the successful longevity of this operation. How is the blood flow affected by the presence of sutures? Computational Fluid Dynamics (CFD) is a powerful tool that permits the estimation of specific quantities, such as fluid stresses, that are hardly measurable in vivo. In this study, we propose a methodology which evaluates the alterations in the hemodynamic status due to microanastomosis. A CFD model of a reconstructed artery has been developed, based on anatomical information provided by intravascular ultrasound and angiography, and was used to simulate blood flow after microanastomosis. The 3D reconstructed arterial segments are modeled as non-compliant 1.24 - 1.47 mm diameter ducts, with approximately 0.1 mm arterial thickness. The blood flow is considered laminar and the no-slip condition is imposed on the boundary wall, which is assumed to be rigid. In analyzing the results, the distribution of the wall shear stress (WSS) is presented in the region of interest, near the sutures. The results indicate that high values of WSS appear in the vicinity of sutures. Such regions may promote thrombus formation and subsequently anastomotic failure, therefore their meticulous study is of high importance.

Popliteal artery damage during total knee arthroplasty.

Injury of popliteal artery during total knee arthroplasty is a relatively rare complication. We report on one case of transverse semi-dissection of the popliteal artery during the tibial cut and one case of popliteal pseudoaneurysm formation caused by Hohmann retractors. Diagnosis was made early in the first case but it was delayed in the second due to misdiagnosis of deep vein thrombosis. Both injuries were managed eventually by open surgery. Postoperative clinical examination and ultrasound imaging confirmed the successful restoration of the blood flow. This case report also describes the classification system of the type of vascular damage and describes the mechanism, the clinical presentation, diagnostic modalities and treatment options for these rare complications of total knee arthroplasty surgery.

Spinal subdural hematoma following lumbar decompressive surgery: a report of two cases.

Spinal subdural hematoma (SSDH) following spine surgery is an extremely rare condition, with only three cases being reported in the literature. Unintended durotomy has been associated with SSDH due to alterations of pressures in the dural compartments. The objective of the present report was to report two rare cases of acute SSDH developed after lumbar decompressive surgery. In one of the patients, the diagnosis of SSDH was followed by urgent hematoma evacuation via durotomy due to the patient's worsening neurological symptoms. In the second patient, the SSDH was treated conservatively due to the absence of severe or progressive motor or sensory deficits. In conclusion, emergency evacuation via durotomy is the treatment of choice for patients with SSDH and neurologic impairment. Conservative management may be indicated in selected cases with absent motor and sensory deficits.