Open release of stiff wrist: a medium to long term case series and literature review.

BACKGROUND AND AIM OF THE WORK: The authors reported a personal case series of open release of stiff wrists performed after previous internal osteosynthesis of distal radius fractures. METHODS: From a series of 16 patients operated by a single surgeon, 12 were evaluated at a mean 7.1 years follow-up (range 2.25 to 19 years), while 4 were lost at follow-up. The ROM in flexion-extension achieved at the final control was measured with a goniometer and compared to that recorded before surgery. The PRWHE questionnaire was administred at the last follow-up. RESULTS: The mean flexion improved from 25.5° to 42.3° and the extension from 15.75° to 43°. The mean PRWHE value was 32.9. CONCLUSIONS: Although arthroscopic release is increasingly used in clinical practice for its minimal invasinevess and warranty of fast recovery, open arthrolysis in post-traumatic stiff wrists appears to be an effective procedure, adaptable to all types of stiffness, that lets get good long lasting functional results.

Retrospective Review of Long-term Outcomes of Patients Undergoing CMC Arthroplasty With Interposition Scaffold.

Background: The treatment of rhizarthritis involves several surgical techniques; among them, bioabsorbable scaffolds have begun to be proposed to avoid the use of other biological tissues or artificial permanent devices. Methods: In this study, we evaluated the long-term outcomes of poly-ld-lactic acid scaffold in interposition arthroplasty in a series of patients treated in our department. Results: Strength, range of motion, and pain improved after the intervention and lasted over the years; nonetheless, most of the radiographs showed a progressive collapse of the first metacarpal. Conclusions: Despite radiological findings, we believe that poly-ld-lactic acid scaffold can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results.

Chest radiography findings of COVID-19 pneumonia: a specific pattern for a confident differential diagnosis.

BACKGROUND: Chest radiography (CR) patterns for the diagnosis of COVID-19 have been established. However, they were not ideated comparing CR features with those of other pulmonary diseases. PURPOSE: To create the most accurate COVID-19 pneumonia pattern comparing CR findings of COVID-19 and non-COVID-19 pulmonary diseases and to test the model against the British Society of Thoracic Imaging (BSTI) criteria. MATERIAL AND METHODS: CR of COVID-19 and non-COVID-19 pulmonary diseases, admitted to the emergency department, were evaluated. Assessed features were interstitial opacities, ground glass opacities, and/or consolidations and the predominant lung alteration. We also assessed uni-/bilaterality, location (upper/middle/lower), and distribution (peripheral/perihilar), as well as pleural effusion and perihilar vessels blurring. A binary logistic regression was adopted to obtain the most accurate CR COVID-19 pattern, and sensitivity and specificity were computed. The newly defined pattern was compared to BSTI criteria. RESULTS: CR of 274 patients were evaluated (146 COVID-19, 128 non-COVID-19). The most accurate COVID-19 pneumonia pattern consisted of four features: bilateral alterations (Expß=2.8, P=0.002), peripheral distribution of the predominant (Expß=2.3, P=0.013), no pleural effusion (Expß=0.4, P=0.009), and perihilar vessels' contour not blurred (Expß=0.3, P=0.002). The pattern showed 49% sensitivity, 81% specificity, and 64% accuracy, while BSTI criteria showed 51%, 77%, and 63%, respectively. CONCLUSION: Bilaterality, peripheral distribution of the predominant lung alteration, no pleural effusion, and perihilar vessels contour not blurred determine the most accurate COVID-19 pneumonia pattern. Lower field involvement, proposed by BSTI criteria, was not a distinctive finding. The BSTI criteria has lower specificity.

Digital Replantations: Comparison Veins Anastomoses first versus Arteries Anastomoses first.

PURPOSE: This retrospective study analyses the effect performing veins anastomoses before arteries anastomoses in digital replantation. PATIENTS AND METHODS: 38 adult patients with replantation of 12 thumbs and 39 fingers, in whom the veins anastomoses were performed prior to the arteries anastomoses, were compared with 29 patients with replantation of 9 thumbs and 30 fingers, in whom the arteries anastomoses were done first, with respect to the survival rate, total active motion, grip strength, and duration of the replantation. RESULTS: There was no significant difference between the two groups with respect to the survival rates, total active motion, and grip strength, while the duration of the replantation was significantly shorter in patients, in whom the veins anastomoses were performed prior to the arteries anastomoses (2 hours and 50 minutes versus 3 hours and 42 minutes; p < 0.001). CONCLUSION: Performing veins anastomoses before arteries anastomoses in digital replantations reduces the replantation time significantly without influencing the survival rate and the clinical outcome.

The Challenges in restoration of extensor tendons function at the hand.

INTRODUCTION: The authors discuss challenges in extensor function restoration at the finger level following distal posterior interosseous or tendon complex injuries, according to the typologies of lesions or the specific patient requirements. MATERIALS: The authors report on two cases describing challenging resolutions. One patient with EDC lag from zone 6B to 8 requiring FCU prolonged with cadaveric grafts.  One young patient with distal posterior interosseous lesion requiring selective tendon transfers to EPL and EIP to restore selective and autonomous index extension. RESULTS: In both cases the main goals were obtained, achieving high index of patient satisfaction and excellent outcomes with the restoration of the extension of the fingers.  Conclusions: In distal posterior interosseous nerve lesion, high demanding patients may require selective function to restore fine motor skills, such as autonomous index extension. In extensor tendons loss of substance from zone 6 to 8, involving musculotendinous junction proximally and short remnants distally, by-pass tendon transfer prolonged with cadaveric grafts is required. The authors highlight the techniques available as escape plan according to the necessary solutions.

Soft tissue coverage of the upper limb: A flap reconstruction overview.

Different opinions about the reconstructive choice for upper limb are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common reconstructive options. Local and regional flaps can be used to cover small defects while large wounds require the use of free flaps or distant pedicled flaps. The coverage of large wounds opens a discussion about when to use free flaps and when distant pedicled flaps. This review will describe the different methods used for the coverage of soft tissues injuries affecting hand and/or forearm (excluding fingers). The aim is to show all flap reconstructive options in order to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

Sarcopenia in distal radius fractures: systematic review of the literature and current findings.

INTRODUCTION: Sarcopenia is a clinical syndrome characterized by the reduction in muscle mass, strength and physical ability. Although proximal femur fractures are one of the major burdens affecting the ageing population, distal radius fractures are equally important for frequency, clinical and social consequences. The aim of this study is to evaluate the incidence of sarcopenia in distal radius fractures and clinical implications in functional recovery. MATERIALS AND METHODS: Scopus and PubMed search was performed to find relationship between sarcopenia and distal radius fractures. Literature search was performed between 2009 and 2019 including clinical trials and clinical studies related to "sarcopenia and distal radius fracture" and "sarcopenia and wrist fracture". After identification, studies were screened and analysed through the Oxford Level of Evidence. RESULTS: According to the inclusion and exclusion criteria, five articles were included. Four articles analysed the incidence of sarcopenia and its role as a risk factor in patients with distal radial fractures, while one article focused on sarcopenia and clinical results of surgical treatment of distal radius fractures. Incidence of sarcopenia in patients older than 50 years with distal radius fracture varied between 29.7% and 31.7%. Patients with distal radial fractures did not show a significant inferior muscle mass than control group in examined population. Functional results of surgery were significantly inferior in sarcopenic patients than control group (no sarcopenia). CONCLUSIONS: About 30% of patients older than 50 years with distal radius fracture suffered by sarcopenia; sarcopenic patients surgically treated had worse clinical results than no sarcopenic patients. Further studies with larger samples are needed to confirm these preliminary results.

Principles of Cortical Plasticity in Peripheral Nerve Surgery.

Cortical plasticity is a finely regulated process that allows the central nervous system (CNS) to change in response to internal and external stimuli. While these modifications occur throughout normal brain development, interestingly, they are also elicited after peripheral nerve injury and surgery. This article provides an overview of the principle mechanisms of synaptic, neuronal, cortical and subcortical neuroplasticity, with special attention to cortical and subcortical modifications-as suggested by modern neuroimaging techniques-after peripheral nerve surgery. The main nerve transfer techniques for the superior extremities and their effect on cortical plasticity are also described.

A Two-Phase Rupture of the Superficial and Profundus Flexor Tendons of the Second Finger of a Hand in a Patient with an Undiagnosed Kienböck Disease.

The authors present an unusual case of a two-phase rupture of the superficial and profundus flexor tendons of the second finger of a hand in a patient with an undiagnosed Kienböck disease. This kind of lesions may be progressive and extend to adjacent tendons in a relatively rapid succession; therefore, they should be treated urgently. The intervention must provide for the removal of the cause of mechanical unbalance or friction before acting on the tendon, thus a radiographic study of the wrist is essential to plan the treatment of any closed rupture of a flexor tendon.

Management of Locked Volar Radio-ulnar Joint Dislocation.

Isolated volar dislocation of the distal radio-ulnar joint is an extremely rare lesion. Diagnosis is commonly missed. The authors report their experience about a case of an acute locked volar distal radio-ulnar joint dislocation. A correct clinical and radiological diagnosis was done in the Emergency Department, and a closed reduction was achieved only after an axillary block, after a first failed attempt under slight sedation. A K-wire blocking the prono-supination and a short removable forearm cast protected the reduction for 25 days. Two weeks after the removal of the immobilization, the patient presented a complete functional recovery, with full range of motion. The authors highlight the importance of the clinical and radiological findings: a dorsal dimple at the ulnar side leads to a high index of suspicion, and represent the most relevant aid in diagnosis, associated to a proper imaging assessment. Prompt management allows a minimally invasive approach and a rapid functional recovery.

Median Nerve Injury Caused by Screw Malpositioning in Percutaneous Scaphoid Fracture Fixation.

An unusual complication of percutaneous fixation of a schapoid fracture in a 36-year-old man is described. After this surgery, the patient complained of numbness and tingling within the median nerve distribution and thenar weakness. An Electromyography showing moderate CTS had led to carpal tunnel decompression, which resulted unsuccessful. When the patient presented to us, both sensory and motor median nerve impairment were present, interfering with his professional activity. A computed tomography scan performed to assess the scaphoid screw position, showed that the screw had been placed volar to the scaphoid, adjacent to the median nerve. Surgery confirmed median nerve compression by the screw, especially during complete wrist extension. The surgical removal of the screw led to immediate improvement of both the motor and sensory functions of the nerve, with complete clinical restoration of nerve function and resolution of the symptoms 2 months postoperatively.

Chronic Essex-Lopresti injury: a systematic review of current treatment options.

INTRODUCTION: Essex-Lopresti lesion (ELL) is a severe injury. Most of ELL is recognized in chronic phase representing a therapeutic challenge for orthopaedic surgeons. The aim of this systematic review is to highlight and criticize current concepts in the surgical treatment. MATERIALS AND METHODS: The search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. A comprehensive research of Pubmed database was made using the following Mesh term: ((Essex-Lopresti injury) OR (Essex Lopresti) OR (distal radio ulnar dissociation) OR (distal radio ulnar dislocation) OR (longitudinal forearm instability)). Quality assessment of each article was performed according to Coleman score by two authors. RESULTS: Eight full articles were included to the systematic review. Surgical treatment was differentiated in five categories according to the most common procedure reported in clinical series. The mean Coleman Score was 51.13 ± 9.76. DISCUSSION: Case series reported in the literature include a limited number of patients with chronic ELL. Currently, salvage procedure devoted to treat a wrong diagnosis and an incorrect treatment is used. Radial head replacement together with ulnar shortening osteotomy and interosseous membrane reconstruction are the most common treatments of choice, but at present, there is not yet a shared scheme of management for patients with chronic ELL. CONCLUSIONS: According to current literature, a case-by-case treatment must always be considered. Further investigations, with higher level of evidence, quality of study design, and number of patients, are needed to better assess clinical results and complication of each technique. LEVEL OF EVIDENCE: IV.

Metallosis in Sequelae of Prosthetic Revision for Ceramic Components Fracture: A Case Report with Clinical Presentation Mimicking Periprosthetic Hip Infection.

Ceramic on ceramic total hip arthroplasties have been developed and widely used during last decades because of their long-term survival and biomechanical properties. One of the most dangerous complication of these implants is the fracture of the ceramic components. The management of this condition should be carefully planned and the choice of the new implant is crucial. We describe a rare case of severe hip synovitis due to massive metallosis in sequelae of mismanaged prosthetic revision for fracture of the ceramic acetabular liner with an unusual clinical presentation that simulate a periprosthetic infection.

Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review.

The extensor apparatus is a complex muscle-tendon system that requires integrity or optimal reconstruction to preserve hand function. Anatomical knowledge and the understanding of physiopathology of extensor tendons are essential for an accurate diagnosis of extensor tendon injuries (ETIs) of the hand and wrist, because these lesions are complex and commonly observed in clinical practice. A careful clinical history and assessment still remain the first step for the diagnosis, followed by US and MR to confirm the suspect of ETI or to investigate some doubtful conditions and rule out associate lesions. During last decades the evolution of surgical techniques and rehabilitative treatment protocol led to gradual improvement in clinical results of ETI treatment and surgical repair. Injury classification into anatomical zones and the evaluation of the characteristics of the lesions are considered key points to select the appropriate treatment for ETI. Both conservative and surgical management can be indicated in ETI, depending on the anatomical zone and on the characteristics of the injuries. As a general rule, an attempt of conservative treatment should be performed when the lesion is expected to have favorable result with nonoperative procedure. Many surgical techniques have been proposed over the time and with favorable results if the tendon injury is not underestimated and adequately treated. Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of ETI. Further clinical and biomechanical investigations would be advisable to clarify this complex issue.

Megaprostheses in the Revision of Infected Total Hip Arthroplasty. Clinical Series and Literature Review.

PURPOSE: The management of severe femoral bone loss associated with hip infection is a major problem in joint replacement surgery. Femoral megaprostheses have been rarely reported in reconstructive procedure for this complex condition. The aim of the study was to evaluate clinical results observed after such uncommon reconstruction in our case series and in a similar group of patients extracted by literature review. METHODS: We evaluated clinical outcomes and eradication of sepsis in five patients who underwent femoral revision with modular femoral resection stems at our institution, and we reviewed the literature about this topic. In our case series, the femoral bone loss was grade III-B in three cases and grade IV in two cases according to the Paprosky classification. One patient was operated with one-stage revision, and four patients were operated with two-stage revision. The mean age was 72 years (range: 60 to 81 years), and the mean time of follow-up was 62 months (range: 36 to 82 months). RESULTS: We observed sepsis eradication in four out of five patients in our series, and clinical results were satisfactory with a mean Harris Hip Score of 74 points (range: 46 to 95 points). Cumulative results obtained considering our series and data obtained by literature review showed a mean Harris Hip Score of 75 points (range: 42 to 95 points) in patients able to walk and an overall incidence of recurrent infection in 33% of patients. Complications were observed in 8 out of 20 patients (dislocation, 6 cases; greater trochanter displacement 2 cases; and transient sciatic palsy, 1 case). CONCLUSIONS: Revision with megaprostheses in case of infected total hip arthroplasty with severe femoral bone loss have a high risk of complication and should be carefully evaluated and used in selected patients when other surgical procedures are not feasible.

Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review.

The reconstruction of loss of substance due to trauma or oncological excision may have relevant functional and aesthetic implications. We report our experience in twenty-one cases of propeller flaps for the treatment of loss of substance of the upper and lower limbs. The etiology of defect was tumor excision in nine cases, trauma in seven cases, surgical wound complications in four cases, and chronic osteomyelitis in one case. Clinical results were favorable in most cases and eighteen flaps survived. We observed an overall complication rate of 33% with four cases of superficial epidermolysis that spontaneously healed and three cases of partial flap loss ranging from 10 to 50% that required surgical revision by means of skin graft (two cases) or ALT free flap (one case). Propeller flap harvesting requires great care and experience, and potential complications may occur even in expert hands. When indicated by the characteristic of the defect, these flaps can be a useful surgical option for the treatment of loss of substance of upper and lower limbs.