A Comparative Outcome Study of Hamstring Versus Tibialis Anterior and Synthetic Grafts for Deltoid to Triceps Transfers.

PURPOSE: To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts. METHODS: A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014. RESULTS: Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms. CONCLUSIONS: Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Iliosacral resection for primary bone tumors: is pelvic reconstruction necessary?

UNLABELLED: Iliosacral resection for primary bone tumors creates a large unstable pelvic ring defect, the treatment of which remains controversial. We did this study to determine if skeletal reconstruction of such defects is necessary. Sixteen patients whose data were collected prospectively had iliosacral resection with a minimum followup of 12 months. The surgical and functional results of patients who had skeletal reconstruction (n = 4) were compared with the results of patients who did not have iliosacral repair (n = 12) using a case-control design. Function was evaluated by assessing impairment using the Musculoskeletal Tumor Society 1987 and 1993 rating scales, and disability was measured using the Toronto Extremity Salvage Score. Although all four iliosacral arthrodeses initially healed, one allograft used for reconstruction fractured and another was removed because of progressive lumbosacral spinal instability. Patients treated without pelvic reconstruction had fewer operative complications. Although the Toronto Extremity Salvage Score and the Musculoskeletal Tumor Society 1987 and 1993 scores were similar for both patient groups, those patients who were treated without reconstruction were less likely to require the use of an ambulatory assistive device, less likely to require narcotics or have chronic pain, and more likely to return to work. These results suggest that reconstruction of the skeletal defect to restore pelvic stability after iliosacral resection is not mandatory. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Outcome after pelvic sarcoma resection reconstructed with saddle prosthesis.

UNLABELLED: We retrospectively reviewed 27 patients who had saddle prosthetic reconstruction for pelvic sarcoma from 1991 to 2001 with a mean followup of 45 months. Functional outcome was assessed with Musculoskeletal Tumor Society Scores of 1987 and 1993 and the Toronto Extremity Salvage score. Survival, recurrences, and complications were recorded. Seven (26%) patients had Type II (periacetabular) pelvic resection and 20 had Types II and III (periacetabular and pubis) pelvic resection. Eleven patients had chemotherapy treatment. None received radiation therapy. At final followup 14 patients were free of disease, 11 patients died, and two patients were alive with disease. The survival rate was 60%. Twenty-two percent had local recurrence, and 22% had metastasis. The mean Musculoskeletal Tumor Society Score 93 score in 17 patients was 50.8% +/- 21.7%, the mean Musculoskeletal Tumor Society Score 87 score was 15.3 +/- 6.1, and the mean Toronto Extremity Salvage score was 64.4% +/- 17.2%. Infection occurred in 10 patients; six were deep infections. There were five nerve palsies. Heterotopic ossification occurred in 10 patients, fracture occurred in six patients, and dislocation occurred in six patients. Limb shortening was progressive until it stabilized at 12 months, and ultimately ranged between 1 and 6 cm. Five patients were retired, five had full-time employment, and six were disabled. Reconstruction with the saddle prosthesis after resection for pelvic sarcoma is associated with substantial morbidity. However, the functional results seem to confer an advantage when compared with the considerable disability incurred after hemipelvectomy. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series without control group). See the Guidelines for Authors for a complete description of levels of evidence.

Outcome in two groups of patients with allograft-prosthetic reconstruction of pelvic tumor defects.

UNLABELLED: To predict the outcomes obtained with allograft-implant composite reconstruction of pelvic defects after bone tumor resection better, a retrospective review of a prospectively collected database was done and two groups of patients were identified. These groups were compared with respect to oncologic and functional outcomes in this investigation. Group 1 included 21 patients with allograft total hip replacement reconstruction for pelvic bone tumors that required Type I and II or Type I, II, and III pelvic resections. Group 2 included five patients who required an acetabular allograft in combination with proximal femoral replacement for reconstruction of Type II pelvic resections done to treat proximal femoral bone sarcomas that invaded or surrounded the hip joint. Functional assessment was measured with three instruments (Toronto Extremity Salvage Score, Musculoskeletal Tumor Society 1987, and the Musculoskeletal Tumor Society 1993 scores). In Group 1, nine of 19 evaluable patients (two patients died in the immediate postoperative period) either retained the allograft until their death or were still alive at last followup with their allograft in place. An additional patient had revision surgery to an allograft-saddle composite that remains intact. The functional results in Group 1 were influenced heavily by the occurrence of deep infection. Nine of 19 evaluable patients developed infection, with seven patients requiring either removal of the graft (three patients) or hindquarter amputation (four patients). Two patients retained their infected allografts with long-term antibiotic suppression. In 10 Group 1 patients who did not develop infection, reasonable functional results were obtained. Group 2 patients had no infections and better functional results. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Interfragmentary compression across a simulated scaphoid fracture--analysis of 3 screws.

PURPOSE: To measure the interfragmentary compression generated across a simulated fracture in cadaveric scaphoids by 3 different headless compression screws. METHODS: A transverse osteotomy was made through the waist of each scaphoid and a load cell to measure compression was interposed between the fragments, which were then fixed internally retrograde with either an Acutrak Standard (n = 10), Acutrak Mini (n = 12), or Bold (n = 10) screw. The surgeon was blinded to the measured compression, which was recorded during screw insertion and for the following 5 minutes. As a measure of scaphoid bone quality the modulus of elasticity of the trabecular bone of each specimen was then calculated from uniaxial compression tests. RESULTS: The mean interfragmentary compression generated by the Acutrak Standard screw was significantly greater and more consistent than the Bold screw or the Acutrak Mini screw. The compression achieved by the Acutrak Standard screw was also more consistent than that obtained by either the Bold or the Acutrak Mini screws as reflected by the lower standard deviation. The mean modulus of elasticity of the scaphoid trabecular bone was similar for each screw group. CONCLUSIONS: The interfragmentary compression generated by the Acutrak Standard screw was significantly greater and more consistent than that generated by either the Bold or Acutrak Mini screws. The compression generated by the Acutrak Standard and Mini screws was significantly better sustained over time than that generated by the Bold screw; however, these differences were small and may not be clinically important. The optimal compression required to promote scaphoid fracture union remains unknown and clinical trials are needed to further evaluate the outcome from using these devices.