The role of neurectomy in the management of spasticity of the upper limb.

Neurectomy is one of the treatments available to the surgeon treating patients with spasticity of the upper limb.Its popularity has increased in recent years.Accurate knowledge of the anatomical variations of the terminal branches to the muscles is required in order to achieve a successful outcome.Although the anatomy has been thoroughly studied, there are still controversies regarding the percentage of the nerve to be resected for a successful result, and also regarding the terminology that has been used in the literature to describe the procedure.The literature for neurectomies for the upper limb is reviewed and an agreement regarding terminology is proposed. Cite this article: EFORT Open Rev 2017;2:469-473. DOI: 10.1302/2058-5241.2.160074.

The Versatile Hook Plate in Avulsion Fractures of the Hand.

Avulsion fractures can pose technical difficulties for surgical fixation. The fragments are often small and around finger joints with access being difficult due to attachment of ligaments or tendons. Traditionally, these have been treated using K wires, lag screws, or pullout sutures.Hook plates were originally described for operative management of mallet fractures. We have been using hook plates in our unit for over 10 years. However, over the years, we have extended their use to other avulsion fractures in the hand such as proximal interphalangeal joint fracture dislocations, central slip avulsions, flexor digitorum profundus avulsions and collateral ligament avulsions.The aim of this article is to describe the technique of fabricating a hook plate and using it for avulsion fractures in the hand. A few illustrative cases are discussed along with a review of the current literature. METHODS: In a retrospective review of our use of hook plates in hand fractures from 2008 to 2014, a total of 63 cases were identified from the hospital data base. There were 35 cases of Mallet fractures, 16 cases of proximal interphalangeal joint fracture dislocations, 5 cases of flexor digitorum profundus avulsion fractures, 5 cases of Central slip avulsions, and 2 collateral ligament avulsions. RESULTS: All fractures healed well with this technique with no biomechanical failures and good functional outcome. Plates needed removal in a total of 25 cases, of which 14 were in mallet fractures. Thirteen (21%) cases suffered complications, of which the majority were again related to mallet fractures. CONCLUSIONS: The hook plate is a simple device that can be created quite easily with readily available materials. We have extended the use of these plates to avulsion fracture fixation in the hand and found this to be a versatile technique. The risk of fragmenting the small fracture fragment is reduced because the hooks secure it and the plate is fixed in the bone. If done meticulously, joint congruence can be achieved. It has a biomechanical advantage over current methods of fracture fixation of small but important bone fragments in the hand.

Management of distal clavicle fractures.

Management of type II distal clavicle fractures has always been a challenge. Non-operative treatment has a high risk of complications and should be considered only for elderly and frail patients. For younger and active patients there is a wide variety of operative options, each with advantages and disadvantages. According to our unit's experience the first choice could be hook plate fixation, with very good and reproducible results. Another option could be Kirschner-wire fixation with or without tension band wiring; however, because of potential wire complications or difficulties in rehabilitation, the method should be reserved for reliable patients and used with a meticulous technique.

Meniscal tears in the ACL-deficient knee: correlation between meniscal tears and the timing of ACL reconstruction.

Despite the fact that anterior cruciate ligament reconstruction (ACLR) is a common procedure, no clear guideline regarding the timing of reconstruction has been established. We hypothesized that there is a point in post injury period, after which significant increase in meniscal tears occurs. The purpose of this study was to derive a guideline in order to reduce the rate of secondary meniscal tears in the ACL-deficient knee. A total of 451 patients were retrospectively studied and divided into six groups according to the time from injury to ACLR: (a) 105 patients had undergone ACLR within 1.5 months post injury, (b) 93 patients within 1.5-3 months, (c) 72 patients within fourth to sixth month, (d) 56 patients within seventh to twelfth month, (e) 45 patients within the second year and (f) 80 patients within the third to fifth year. The presence of meniscal tears was noted at the time of ACL reconstruction and then recorded and statistically analysed. Fifty-three (50.5%) patients from group a, 46 (49.5%) from group b, 39 (54.2%) from group c, 31 (68.9%) from group d, 28 (62.2%) from group e and 54 (67.5%) from group f had meniscal tear requiring treatment. The statistical analysis demonstrated that the earliest point of significantly higher incidence of meniscal tears was in patients undergoing ACLR more than 3 months post injury. Therefore, ACLR should be carried out within the first 3 months post injury in order to minimise the risk of secondary meniscal tears.

Injuries to the infrapatellar branch(es) of the saphenous nerve in anterior cruciate ligament reconstruction with four-strand hamstring tendon autograft: vertical versus horizontal incision for harvest.

The goal of this study is to evaluate the incidence rate of iatrogenic injuries to the infrapatellar branch(es) of saphenous nerve during ACL reconstruction with four-strand hamstring tendon autograft. Retrospective review of 226 patients that underwent 230 arthroscopically assisted primary ACL reconstructions with four-strand hamstring tendon autograft, between March 2002 and December 2004. The patients were separated into two groups. In group 1 (116 knees) the tendon was harvested and tibia prepared through a 3-cm vertical surgical incision (between March 2002 and September 2003) and in group 2 (114 knees) through a 3-cm horizontal surgical incision (between October 2003 and December 2004). In group 1, we found 39.7% of the patients with disturbed sensitivity in the area of the infrapatellar branch(es) of the saphenous nerve distribution. In patients of group 2 the incidence of nerve injury was 14.9% (P<0.001). The horizontal surgical incision in harvesting hamstrings tendon autograft for ACL reconstruction was found to have less associated chance of iatrogenic injury to the infrapatellar branch(es) of the saphenous nerve. No technical ties were found in both incisions for graft harvest.