Alternative Flap Options for Upper Extremity Reconstruction.

For major upper limb defects, a wide range of established pedicled and free flap options can be used. These include the latissimus dorsi/thoracodorsal artery perforator, lateral arm, posterior interosseous artery, rectus abdominis, gracilis, and anterolateral thigh flaps. Technical proficiency is essential, and favorable success rates in terms of functional and esthetic outcomes can be achieved. Herein, alternative flap options (both pedicled and free) are introduced and discussed through a few illustrative case examples.

Tripolar Dislocation: Elbow Terrible Triad-Essex-Lopresti Injury-Trans-scaphoid Perilunate Dislocation: A Case Report.

CASE: A 23-year-old man presented with a right upper limb injury after a 10-m fall. Initial evaluation demonstrated a terrible triad elbow injury associated with a trans-scaphoid perilunate dislocation. Elbow stabilization with radial head replacement and carpal fixation was performed. Radiographs on postoperative day 7 demonstrated an ipsilateral Essex-Lopresti injury, which had been initially missed, and revision surgery was performed to reconstruct the interosseous membrane. CONCLUSION: Surgeons should maintain a high degree of suspicion for an ipsilateral Essex-Lopresti injury in patients with a terrible triad elbow fracture-dislocation in combination with a trans-scaphoid perilunate dislocation. Both preoperative imaging, including the contralateral side, and intraoperative evaluation are recommended to rule out longitudinal instability of the forearm in the setting of combined wrist and elbow fracture-dislocations.

Non-operative management of humeral periprosthetic fracture after stemless shoulder arthroplasty.

PURPOSE: Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty. METHODS: A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications. RESULTS: Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed. CONCLUSIONS: Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening.

Acute digit ischemia due to a ruptured digital collateral artery aneurysm in a patient of hemophilia: A case report.

Introduction: Digital artery aneurysms are a rare event but cases have been reported in the literature. The hemostasis disorders make these aneurysms particularly dangerous with potentially irreversible hand complications: Compression of adjacent vascular and nervous structures, embolization of associated thrombi, finger ischemia, and necrosis. Case Report: We reported a case of digital ischemia due to a ruptured aneurysm of a digital collateral artery, leading to the diagnosis of congenital hemophilia A. Hematoma evacuation allowed finger revascularization. Complete symptom resolution required ligature excision associated with Factor VIII supplementation. Conclusion: Aneurysms of the digital collateral arteries are a rare event. In the case of a hemophilic patient, surgical management is necessary, and medical treatment alone is not sufficient. The consequences of a ruptured aneurysm in this type of patient can be serious. A close monitoring is required to ensure the absence of early recurrence.

Can you maintain a competitive golf swing after total shoulder arthroplasty?

PURPOSE: Return to sports after joint arthroplasty is mainly evaluated for lower limbs procedures. When a return to a specific sport is mentioned, no technical approach nor level consideration are specified. We suggested that patients who undergo total shoulder arthroplasty will be able to maintain playing golf at same high level. METHODS: We performed a retrospective study on active golf players who have undergone shoulder arthroplasty. Inclusion criteria were: (1) over 50 years old (2) handicap < 54 (3) playing golf before the procedure (4) minimum follow-up of 1 year. Patients were divided into two groups: ASA group and RSA Group. A clinical assessment was performed using the following scores: Constant, ASES and QuickDash. RESULTS: Sixty-one patients were retrospectively included in the cohort. Mean age was 69.1 years old. Mean follow-up was 79 months. Preoperative golf frequency and handicap were similar between the two groups. Surgery resulted in significant pain relief in both groups. No difference was shown between the two groups in clinical assessment. Satisfaction rate was 95%. Return to golf time was done progressively from the twentieth week for putting until the twenty-seventh week for playing on the course. Handicap analysis did not show any difference between the level before surgery and the current level in ASA group (23.7 vs. 22.9,p = 0.33) and RSA group (24.2 vs. 23.3,p = 0.63). CONCLUSION: Our study suggested that both patients with ASA or RSA can maintain an active lifestyle with moderate to high frequencies of participation after surgery, particularly in golf. Surgeons can reassure their patients about their recovery and show confidence with regard to their ability to return to a similar golf practice also after RSA. Prospective study with larger cohort is required to confirm the results. LEVEL OF EVIDENCE: Level IV, cases study.

Daily Life Impact of Brachial Plexus Reconstruction in Adults: 10 Years Follow-Up.

PURPOSE: Reconstructive surgery of brachial plexus injury in adults remains a challenge. Short- and midterm follow-up results have been described in terms of impairments, such as muscle strength grading. However, psychologic management has been shown to be a major contributor in long-term results. A new, specific brachial plexus injury scale, including functional and psychologic components, was described. Objectives of this study were: (1) to assess functional long-term brachial plexus reconstruction outcomes; and (2) to validate the Mancuso scale at 10 years of follow-up. METHODS: Twenty patients with at least 10 years of follow-up were included in the study. Four patients had C5-C6 palsy and 16 had a C5-T1 injury. Shoulder abduction and elbow flexion were assessed with Medical Research Council grades. Shoulder function was evaluated with a Constant score. The 36-item short-form survey (SF36) was used to assess quality of life, and the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) was used for patient reports of disability. The Mancuso scale was assessed and correlated to the different scores used. RESULTS: At the last follow-up, the Medical Research Council grade was at least grade 3 in 10 cases (50%) of shoulder abduction and in 12 cases (60%) of elbow flexion. The Constant score was 31.4 (SD, 15.1). The SF36 score was 67.5 (SD, 4.25) and the QuickDASH was 50 (SD, 15.9). We found a correlation between the symptom score (Mancuso score) and the different quality-of-life scores (QuickDASH: coefficient, 0.491; SF36: coefficient, -0.565; limitations score: coefficient, 0.445). CONCLUSIONS: This study reported results from the Mancuso scale at a minimum of 10 years of follow-up of reconstructive surgery for brachial plexus injury in adults. Correlations between this composite scale and the SF36 and QuickDASH scores suggest construct validity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center.

INTRODUCTION: For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals. OBJECTIVES: The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors. METHODS: We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test. RESULTS: A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI. CONCLUSION: En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures. LEVEL OF EVIDENCE: III, case-control study.

Use of an external fixator during one-step surgical management of missed chronic Monteggia injuries.

The incidence of untreated Monteggia fracture-dislocations is not insignificant. But there is no consensus as to the surgical indication and best surgical technique to use. Single-stage reduction of the radial head through an elbow arthrotomy and ulnar osteotomy is a complex surgical procedure that requires stabilization of the ulnar segments during every step of the intervention. Here, we describe the possibility of using an external fixator intraoperatively to facilitate the various steps of the procedure: (1) gradual distraction and angulation of the osteotomy site to allow thorough excision of any interposed capsular tissue, (2) stable hold on the ulnar fragments independent of the surgical assistant, which allows the stability of the radial head reduction to be tested in pronation and supination and (3) facilitation of plate fixation at the ulnar osteotomy site. LEVEL OF EVIDENCE: IV; case series.

Atypical Presentation of Juvenile Hyaline Fibromatosis of Hands.

Juvenile hyaline fibromatosis is a rare disorder characterized by an extracellular accumulation of hyaline deposit. In the extremities, lesions may remain quiescent or gradually increase in size, eventually resulting in skin ulceration. There is no curative treatment. Surgery may allow some recovery of function, but recurrence is possible. We report a case of juvenile hyaline fibromatosis in both hands of a 25-year-old man who required multiple surgical procedures to address problems with function, pain, and appearance.

Contribution of shear wave elastography in evaluation of the deltoid in reverse shoulder arthroplasty: reproducibility study and preliminary results.

AIMS: The current difficulty of reverse shoulder arthroplasty (RSA) is soft tissue management, and adequate deltoid tension and at present there is no consensus and available tools (X-ray, MRI, EMG) remain difficult to apply in clinical follow-up. The objective of this study was (1) to determine reliability and feasibility of deltoid elasticity assessment using ultrasound elastographyand (2) to assess the change of deltoid stiffness after RSA by comparing shear wave speed (SWS) between healthy and RSA shoulders. MATERIAL AND METHODS: Twenty-six healthy (native shoulder, painless and complete range of motion) subjects and twelve patients with RSA were included. Two independent investigators performed 3 measurements on each segment. Measurements were bilateral. Anterior segment was also evaluated at 45° and 60° of passive abduction. Reliability and feasibility have been assessed (ISO5725-standard). RESULTS: Coefficient of measurements variation was less than 6.1% and 0.13 m/s. In the healthy group, SWS was not significantly different between anterior and middle segments; however, the SWS of the posterior segment was significantly lower than others (p<0.0001). In abduction position, compared to the rest position, SWS of the anterior segment decreased at 45° abduction (p=0.0003) and increased at 60° abduction (p<0.0001). Variability of measurement was higher in the RSA group. No significant difference was found between the SWS measurement of the operated and non-operated side. SWS measurements of the operated side of the anterior and middle segment were significantly higher compared to the healthy group. In abduction position, compared to rest position, no difference in SWS of the anterior segment was found at 45° abduction (p=0.71) and nor at 60° abduction (p=0.75). CONCLUSION: This study demonstrated feasibility and reliability of shoulder assessment with shear wave elastography. Reference values for asymptomatic patients can already be used in future studies on shoulder pathology and surgery.

Long-term outcomes of non-invasive expandable endoprostheses for primary malignant tumors around the knee in skeletally-immature patients.

INTRODUCTION: Expandable endoprostheses are used to restore limb function and compensate for the sacrifice physis involved in carcinologic resection. Long-term outcomes of the last generation of knee "non-invasive" expandable endoprostheses are required. Objectives were to report on oncologic results of bone sarcoma resection around the knee with expandable endoprosthesis reconstruction and to compare the surgical outcomes of the "non-invasive" expandable endoprostheses used in our department. MATERIALS AND METHODS: Retrospective study that included all children with bone sarcoma around the knee that underwent tumor resection reconstructed with non-invasive expandable prosthesis. Phenix-Repiphysis was used from 1994 to 2008 followed by Stanmore JTS non-invasive from 2008 to 2016. Survival and complications were recorded. Functional outcomes included Musculoskeletal Tumor Society (MSTS) score, knee range of motion, lower limb discrepancy (LLD). RESULTS: Forty children (Sex Ratio = 1) aged a mean 8.8 years (range, 5.6-13.8) at surgery were included in the study. There were 36 osteosarcoma and 4 Ewing sarcoma that involved 33 distal femur and 7 proximal tibia. Cohort (n = 40) consisted of 28 Phenix-Repiphysis and 12 Stanmore with a mean follow-up of 9.8 ± 5.8 years and 6.1 ± 3.1 years, respectively. Postoperative infection rate was 7.5% in the cohort (3 Repiphysis). Functional results were significantly better in the Stanmore group with a mean MSTS of 87.6 ± 5.4% and knee flexion of 112 ± 38°. At last follow-up, implant survival was 100% in Stanmore group, whereas all living Phenix-Repiphysis were explanted. Mechanical failure was the primary cause for revision of Phenix-Repiphysis. Limb length equality was noted in 79% patients with Phenix-Repiphysis and 84% with Stanmore at last follow-up. CONCLUSION: Chemotherapy and limb-salvage surgery yield good oncologic outcomes. Expandable endoprostheses are effective in maintaining satisfactory function and lower limb equality. With improvements made in the last generation of "non-invasive" prostheses, implants' survival has been substantially lengthened.

Rare Case of Dynamic Thoracic Outlet Syndrome Resolved by an Isolated Subclavius Posticus Muscle Resection: A Case Report.

CASE: We reported a dynamic neurogenic left thoracic outlet syndrome (TOS) with a permanent abduction of the fifth left finger. Preoperative magnetic resonance imaging (MRI) assessed the presence of subclavius posticus muscle (SPM). Because of a nonoperative treatment failure, we performed a brachial plexus neurolysis and SPM resection. Immediate postoperative assessment showed an immediate disappearance of the Wartenberg sign. CONCLUSION: SPM constitutes an underestimated cause of TOS. A careful MRI reading is necessary to make correct diagnosis. Nonoperative treatment includes physiotherapy and can be proposed in first instance. When nonoperative treatment fails, brachial plexus exploration with release of the SPM may result in resolution of symptoms.

Displaced three and four part proximal humeral fractures: prospective controlled randomized open-label two-arm study comparing intramedullary nailing and locking plate.

PURPOSE: The aim of this study was (1) to compare clinical and radiological outcomes of 3- and 4-part proximal humeral fractures using either IMN or LP (2) and to report complications related to each technique. METHODS: A prospective controlled randomized open-label two-arm study was performed. Ninety-nine consecutive adult patients with a 3- and 4-part displaced acute proximal humeral fractures were randomized to be treated with IMN (n = 49) or LP (n = 50). Constant, ASES and SST scores were recorded by the surgeon. Range of motion was evaluated. A visual analog scale (VAS) was used to assess shoulder pain. Complications and revision surgeries were reported. RESULTS: Eighty-five patients were analyzed, nine were lost, and five died during the follow-up period. The mean age was 73.7 years (± 13.3,, and the mean follow-up was 66 months (± 13.5). At last follow-up, VAS was lower in the IMN group (0.9 (± 1.1) vs. 1.9 (± 1.7), p = 0.001). The median Constant score was significantly higher in the IMN group (81.6 (± 10.9) points) vs. in the LP group (75.6 (± 19.5) points) (p = 0.043), and ASES score was also significantly higher in the IMN group (86.3 (± 9.5) vs. 75.2 (± 19.6), p = 0.001). There was no difference in the range of motion or SST scores between the two groups. Complications were seen higher in the LP group (9 (21%) vs. 22 (52%), p = 0.003). Revision surgery was higher in the LP group (37% vs. 21%). CONCLUSION: Satisfactory results were accomplished in both groups according to the reported clinical outcomes. Complication and revision rates were higher in LP group.

'In-Out-In' K-wires sliding in severe tibial deformities of osteogenesis imperfecta: a technical note.

Severe infant osteogenesis imperfecta requires osteosynthesis. Intramedullary tibia's osteosynthesis is a technical challenge given the deformity and the medullar canal's narrowness. We describe an extramedullary technique: 'In-Out-In' K-wires sliding. We performed an anteromedial diaphysis approach. The periosteum was released while preserving its posterior vascular attachments. To obtain a straight leg, we did numerous osteotomies as many times as necessary. K-wires ('In') were introduced into the proximal epiphysis, and the medial malleolus ('Out') bordered the cortical and ('In') reach their opposite metaphysis. K-wires were cut, curved and impacted at their respective epiphysis ends to allow a telescopic effect. All tibial fragments are strapped on K-wires, and the periosteum was sutured over it. Our inclusion criteria were children with osteogenesis imperfecta operated before 6 years old whose verticalization was impossible. Seven patients (11 tibias) are included (2006-2016) with a mean surgery's age of 3.3 ± 1.1 years old. All patients received intravenous bisphosphonates preoperatively. The follow-up was 6.1 ± 2.7 years. All patients could stand up with supports, and the flexion deformity correction was 46.7 ± 14.2°. Osteosynthesis was changed in nine tibias for the arrest of telescoping with flexion deformity recurrence and meantime first session-revision was 3.8 ± 1.7 years. At revision, K-wires overlap had decreased by 55 ± 23%. Including all surgeries, three distal K-wires migrations were observed, and the number of surgical procedures was 2.5/tibia. No growth arrest and other complications reported. 'In-Out-In' K-wires sliding can be considered in select cases where the absence of a medullary canal prevents the insertion of intramedullary rod or as a salvage or alternative procedure mode of fixation. It can perform in severe infant osteogenesis imperfecta under 6 years old with few complications and good survival time.

High-resolution sonographic study of the communicating branch of Berrettini: an anatomical feasibility study.

Sensory changes are common manifestations of nerve complications of carpal tunnel surgery. Division or contusion of a superficial communicating branch between the median nerve and the ulnar nerve, the communicating branch of Berrettini, can explain these symptoms. The aim of this study was to describe the potential value of high-resolution sonography to examine this branch. We conducted a study on eight fresh cadaver hands. An ultrasound assessment of the communicating branch of Berrettini, accompanied by an injection of methylene blue, was performed by a senior radiologist. Subsequent dissections confirmed that the eight guided ultrasound injections allowed the methylene blue to be placed around the origin and termination of the communicating branch of Berrettini. This study extends the limits of ultrasound both in the postoperative diagnosis of potential nerve complications and its possible use in ultrasound-guided carpal tunnel release.

Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

INTRODUCTION: Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. MATERIALS AND METHODS: This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. RESULTS: Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DISCUSSION: Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. CONCLUSION: Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. LEVEL OF EVIDENCE: IV; retrospective study.

Safety of shoulder arthroplasty in lung transplant recipients.

PURPOSE: Although shoulder arthroplasty is relatively safe in general population, it remains unclear in transplant recipient. Aim of this study was to determine outcomes and morbidity after shoulder arthroplasty in lung transplant recipients. METHODS: A retrospective analysis was performed at our university hospital center from 2001 to 2015. Main inclusion criterion was all lung transplant recipient who underwent shoulder arthroplasty. Clinical outcomes including Constant score, visual analogue scale (VAS), American Shoulder and Elbow Surgeons score (ASES) were determined in pre-operative period and a minimum follow-up of 36 months. Special attention was taken about complications. RESULTS: Among 700 lung transplant recipients, we identified 12 patients who underwent 14 shoulder arthroplasties. Arthroplasties were performed after proximal humeral avascular necrosis (n = 10), degenerative osteoarthritis (n = 1) and non-union of proximal humeral fracture (n = 1). 8 anatomical total shoulder arthroplasties and 6 reversed shoulder arthroplasties were performed. Mean follow-up was 61.4 months (± 22.1). Mean age was 47.1 (± 9.3) years. All patients had immunosuppression therapy at the time of surgery. Mean Constant score was improved at last follow-up [43(± 9.7) vs 94(± 4), p < 0.001]. VAS decreased from 6.4 (± 1.2) to 0.4 (± 0.8), p < 0.001. Mean ASES was improved from 33 (± 6) to 91 (± 5) at last follow-up (p < 0.001). Range of motion were improved between early post-operative evaluation and last follow-up: forward flexion: 85° (± 8°) vs 119°(± 13°); abduction: 83° (± 14°) vs 106°(± 23°); external rotation (RE1): 26° (± 7°) vs 36°(± 10°). At last follow-up, one revision was required for humeral prothesis loosening at 2 years post-surgery. One patient died due to acute pulmonary decompensation on chronic rejection 66 months after shoulder arthroplasty. CONCLUSION: Shoulder arthroplasty is a safe procedure in this vulnerable population of lung transplant recipients. Such results encourage us to continue arthroplasty surgery when required. LEVEL OF EVIDENCE: IV.