Salvage reconstruction with vascularized fibular strut graft fusion using posterior approach in the treatment of severe spondylolisthesis.

STUDY DESIGN: One case is reported in which a failed anterior fusion for Grade 4 spondylolisthesis was treated with a vascularized fibular strut graft using a posterior approach. OBJECTIVES: To demonstrate the applicability of this technique for salvage cases or patients with systemic conditions that may decrease the success of more standard techniques. SUMMARY OF BACKGROUND DATA: Surgical stabilization of spondylolisthesis through posterior approach with a fibular strut graft has been previously described. A vascularized strut graft can be used in the treatment of spondylolisthesis and may have applicability in those patients with underlying disease that may impair the use of more standard techniques or in salvage reconstruction. METHODS: With the patient under general anesthesia, through a posterior approach S1 and L4 were decompressed. The fibula with its vascularity intact was harvested and anastomosed with the superior gluteal artery and vein. The fibular strut was placed into the space formed by reaming between L5 and S1. Ilial autograft was used to augment the posterior fusion. After the procedure the patient was placed in a hip spica cast. RESULTS: At the 2-year follow-up the patient has incorporation of the graft, with no evidence of fracture and no significant progression of anterior slip. CONCLUSION: A vascularized fibular strut graft is a feasible alternative in the treatment of severe spondylolisthesis. No complications were encountered in the involved patient. Future application may include salvage reconstruction of failed arthrodesis or in individuals with systemic conditions that may impair graft incorporation using more standard techniques.

Salvage procedures after failed surgery about the distal ulna.

This article discusses four types of salvage procedures that may offer a successful means of treating patients after failed distal ulnar surgery. The procedures include distal radio-ulnar joint fusion, the Sauvé-Kapandji procedure, creation of a one-bone forearm, and massive resection of the distal ulna.

Congenital radial head dislocations.

Congenital radial head dislocation is the most common congenital elbow abnormality. Patients generally remain asymptomatic until adolescence and, at that time, may benefit from radial head resection. Open reduction and ligament reconstruction may offer advantages over late radial head resection if performed before the age of 2 years. Further long-term studies are needed to determine if open reduction and ligament reconstruction are helpful.

Congenital clasped thumb.

Congenital clasped thumb is a disorder characterized by flexion posture of the thumb secondary to extensor side underdevelopment, flexor side tightness, or both. Mild cases may be treated by splintage whereas more advanced cases require tendon transfer or a combination of tendon transfer and flexor side releases. Clasped thumb can be seen in conjunction with syndromes such as arthrogryposis and, in these cases, recognition of the abnormal anatomic structures is required to effect satisfactory reconstruction.

Microvascular surgery in the reconstruction of congenital hand anomalies.

Several congenital upper extremity anomalies may be treated using micro-surgical techniques. Long-term studies have shown the usefulness of microvascular toe transfer in the treatment of adactyly with the incorporation of the transferred digit into grasp-and-pinch function. The use of free fibular transfer for long bone deformities of the forearm has been shown to provide bony union as well as growth. Factors that must be considered include patient age, vessel availability, and lack of other possible reconstructive options.

Complications of duplicate thumb reconstruction.

Thumb duplication is a common anomaly treated by most hand surgeons. Successful reconstruction of this disorder requires the surgeon to address abnormalities of collateral ligaments, tendon, and bone. With growth, secondary problems may occur, including bony overgrowth, tendon imbalance, and joint stiffness. Surgeons must be aware of these potential complications when the performance of initial surgery and long-term follow-up of the child are necessary.

Wide excision of the distal ulna: a multicenter case study.

Excision of the distal ulna to treat degenerative disease or instability has fallen into disfavor following reports of radioulnar impingement, carpal instability, and distal ulnar instability. Alternative procedures for reconstruction of the painful distal ulna have been developed to address these problems; the results have been generally favorable. When faced with distal ulnar reconstruction that has failed after multiple surgical procedures, or a distal ulnar neoplasm, the surgeon is left with few treatment options. Creation of a one-bone forearm, free fibular transfer, and allograft replacement have been attempted, with mixed outcomes. We report the results of 5 men and 7 women who underwent wide excision of the distal ulna, defined as surgical excision of 25% to 50% of the ulnar length. The diagnosis was failed distal radioulnar reconstruction or excision in 8 patients, osteomyelitis in 1, congenital pseudoarthrosis of the radius in 1, and neoplasm in 2. No soft tissue reconstruction was performed. Patients were examined at an average of 22 months after surgery for radiocarpal and radioulnar instability, functional outcome, pain relief, grip strength, and range of motion. Nine of the 12 procedures resulted in good or excellent results; 1 patient had a fair result after resection for osteosarcoma, and the procedure in 2 patients failed, requiring conversion to a one-bone forearm. Grip strength was restored to 75% of the normal side and range of motion was restored to 86% of the normal side. Wide excision of the distal ulna without soft tissue reconstruction is a simple and durable treatment of neoplasms of the distal ulna or salvage of the failed reconstruction of the distal radioulnar joint. We do not recommend its use in patients with incompetency or disruption of the interosseous membrane.

Limited wrist fusion.

Limited wrist fusion can provide patients a measure of pain relief with retention of a functional range of motion. Recent biomechanic investigations have shed light on the potential benefits of such procedures. Clinical studies have demonstrated the usefulness of limited wrist fusion for the treatment of numerous conditions involving the wrist. Significant complications are associated with many of these fusions and should be considered before performing these procedures.

Pedicle flaps for coverage of the wrist and hand.

The coverage of wounds about the hand and wrist may be accomplished by numerous pedicled flaps. Attention must be given to preservation of the perforating arteries that supply these fasciocutaneous flaps. Difficulties with wound healing over the area of flap harvest may occur and care must be given to preservation of the peritenon in the distal forearm. The use of fascial flaps may allow coverage that is quite pliable and the radial forearm fascial flap may be performed with preservation of the radial artery. In some cases, the use of a groin flap may be required for coverage of large wounds that do not have arteries available for sacrifice.

Occult dorsal carpal ganglion: comparison of US and MR imaging.

PURPOSE: To evaluate the usefulness of ultrasound (US) and magnetic resonance (MR) imaging in patients suspected of having an occult dorsal carpal ganglion. MATERIALS AND METHODS: The authors prospectively studied US and MR images of 14 wrists in 13 consecutive patients suspected of having an occult dorsal carpal ganglion. RESULTS: Eleven dorsal carpal ganglia were identified with US and nine with MR imaging. One patient refused the MR imaging study. Of two equivocal cases at MR imaging, one was a ganglion and another was a compressible capsular recess, as determined at US. One ganglion was missed with both techniques. The average diameter of the ganglion cysts was 4.9 mm. CONCLUSION: MR imaging and US are equally effective in the detection of occult dorsal carpal ganglia. Because of its dynamic capabilities and lower cost, US should be the initial imaging procedure for suspected occult dorsal carpal ganglia.

Surgical release of elbow-capsular contracture in pediatric patients.

Nine pediatric patients with elbow-capsular contractures were treated by surgical release. Six patients had sustained prior trauma and three patients had medical conditions leading to capsular contracture. A lateral approach was used to release the anterior and posterior capsules, as well as to remove sites of bony impingement. All patients were treated with postoperative range of motion and splinting, with six patients receiving a continuous brachial plexus block to facilitate therapy. Average loss of extension improved from 47 to 15 degrees, mean angle of flexion from 102 to 124 degrees, and total arc of motion increased from 55 to 108 degrees at an average of 17 months after surgery. Complications included wound infection and catheter-site erythema.

Long-term follow-up of forearm bone diaphyseal plating.

A retrospective review of 175 patients treated with forearm bone plating for acute diaphyseal fractures, nonunions, and malunions was undertaken to identify problems related to plate removal as opposed to plate retention. One hundred thirteen patients retained their forearm plates, of which five patients experienced complications related to the plate, including infection, bone failure, plate failure, and loosening. Patients retaining forearm bone plates reported minimal discomfort or functional limitation. Sixty-two patients had plate removal at an average of 19 months after insertion. Ten patients suffered major complication, including seven refractures through screw holes, osteotomy, or original fracture sites. Fractures occurred at an average of six months after plate removal. The difference in complication rates between patients treated with plate removal and patients retaining plates was statistically significant.

Soft tissue coverage of the hand with a free digital fillet flap.

A free digital fillet flap was used to achieve soft tissue coverage of the ulnar border of the hand in a 38 year old man with an industrial fan blade injury to the dominant hand. The use of a digital fillet flap from an unsalvageable ring finger allowed for a one-stage procedure avoiding donor site morbidity or need for additional reconstructive surgery.

Synovial cysts of the spine.

A series of 13 patients with synovial or ganglion cysts of the spinal facet joints causing nerve root compression is reported. These cysts were found in both the cervical and the lumbar spine, and the anatomical location of each cyst corresponded to the patient's signs and symptoms. In no case was there evidence of intervertebral disc abnormality found at operation. The patients ranged from 49 to 77 years of age and included 4 men and 9 women. Radiographic evidence of facet degenerative change and degenerative spondylolisthesis was frequently but not invariably noted. The extradural defects defined with positive contrast myelography or postmyelography computed tomographic scanning were usually posterior or posterolateral to the common dural sac and were misinterpreted as extruded discs in the majority of cases. Treatment consisted of laminectomy and surgical excision of cysts. All patients reported improvement or resolution of their presenting symptoms.