Refinements in the Treatment of Volkmann Ischemic Contracture of the Forearm: A Thematic Review.

Volkmann contracture of the forearm is a devastating complication of muscle ischemia. It is most commonly associated with trauma and a sequela of compartment syndrome. In the last few decades, much has improved in our ability to treat these patients. Our preferred treatments are presented along with representative case studies that illustrate the functional gains that can be achieved with a focus on moderate and severe contractures. Refinements in care that have evolved over the past 40 years of experience in treating these patients are presented.

First report of Aspergillus welwitschiae causing maize ear rot in Serbia.

In recent years, countries in Southeast Europe are facing climate changes characterized by extreme hot weather, which contribute to the increased frequency of Aspergillus species. Because of these changes, Aspergillus parasiticus was isolated, for the first time, from maize grain in Serbia (Nikolic et al, 2018). The presence of black powdery mycelia on maize ears indicated occurrence of species of the genus Aspergillus section Nigri, which led to the need for detailed identification of these fungi. Disease incidence ranged from 10 and 15% in August 2013. Maize ears with black powdery symptoms were collected from field in Zemun Polje, Serbia. Symptomatic kernels were surface sterilized with 1% sodium hypochlorite solution for 3 min, rinsed three times with sterilized water, then incubated at 25°C in the dark for 7 days on potato dextrose agar (PDA). Twenty isolates were identified as genus Aspergillus section Nigri. Monospore cultures formed black cottony colonies with a yellowish border on PDA. The average colony diameter was 50 mm. In order to reliably identify, isolates were transferred to Malt Extract agar (MEA) and Czapek Yeast Autolysate agar (CYA) (Samson et al, 2014). On CYA fungal colonies consisted of a white mycelium, covered by a layer of black conidiophores. On MEA fungal colonies were dense, black, with yellowish border. The reverse side was colorless to pale yellow, with a yellow ring in the middle. The average size of conidia was 4.3 µm. The conidia were globose to sub-globose, smooth to roughened, which coincides with previous research (Silva et al, 2020). Given that the fungi Aspergillus niger and Aspergillus welwitschiae are morphologically indistinguishable (Susca et al, 2016), species level identification was completed by analysis of a partial sequence of the internal transcribed spacer (ITS) region (ITS1/ITS4 primers) and calmodulin gene (CMD5/CMD6 primers) (Samson et al., 2014). The sequences were compared with the sequences of A. welwitschiae strains registered in the GenBank database based on nucleotide similarity, and results showed 99,64 and 100% similarity with ITS (OL711714) and calmodulin (KX894585), respectively. The sequence was deposited in GenBank with accession numbers OQ456471 (ITS) and OQ426518 (calmodulin). We also confirmed the presence of this species with specific primers (AWEL1/AWEL2) designed by Susca et al. 2020. Pathogenicity test was performed in Zemun Polje on the same maize hybrid from which the fungal species was isolated. Using artificial inoculations by the injecting conidial suspension into the silk channel, three days after 50% of plants reached the silking stage. Twenty ears were inoculated with each isolate, in four replicates (Reid et al, 1996). Inoculum was prepared from 7-day-old colonies on PDA, and 2 ml of a conidial suspension (1×106 spores/ml) was used. Control plants were inoculated with sterile water. All inoculated ears showed symptoms, similar to those from field infections. Control ears were symptomless. The fungus was reisolated and was morphologically identical to the original isolates, thus completing Koch's postulates. Based on molecular, morphological and pathogenic properties, the isolates were identified as A. welwitschiae. This is the first report of A. welwitschiae as the causal agent of black maize ear rot not only in Serbia, but also in the other countries of the Western Balkans. Given that the fungus A. welwitschiae synthesizes both ochratoxin A (OTA) (Battilani et al, 2006) and fumonisin (FB) (Frisvad et al, 2011), further studies should be focused on assessment its aggressiveness and toxicological profile.

Neuroma Treatment With the Acellular Nerve Allograft Reconstruction Technique.

Treatment of a painful neuroma is a challenging problem for both the patient and the providers. Current surgical treatment options typically include excision of the neuroma and stump relation. However, with both treatment options, patients have high rates of persistent pain and rates of neuroma recurrence. We describe two patients with neuromas treated with our acellular nerve allograft reconstruction technique. This technique involves the excision of the neuroma and bridging the proximal nerve end to the surrounding tissue with an acellular nerve allograft. Both patients had immediate resolution of their neuropathic pain that was maintained at their final follow-up. Acellular nerve allograft reconstruction is a promising treatment option for the treatment of painful neuromas.

Shoulder Surgery Google Search Trends during the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has strained many healthcare systems. Google Trends is a tool that provides information on online interest in selected keywords and topics over time. The purpose of this study is to describe the effect of the COVID-19 pandemic on online interest in elective shoulder pathology. Online search pattern data were obtained via Google Trends from November 2019 to November 2020 using the search terms 'orthopedic surgery' and 'shoulder pathology' search terms. Relative search volume index (SVI) graphs were generated from this data and the 7-day average of new COVID-19 cases in the United States. Orthopaedic surgery and shoulder pathology search trends decreased during March 2020 with a sudden rise in the 7-day average of new COVID-19 cases. After March 2020, orthopaedic surgery and shoulder pathology search terms approached pre-COVID-19 pandemic values despite continued increases in the 7-day average of new COVID-19 cases. (Journal of Surgical Orthopaedic Advances 32(1):014-016, 2023).

Free Vascularized Fibula Graft for Staged Reconstruction of Infected Humerus Nonunions.

OBJECTIVE: To evaluate the union rate and rate of postoperative complications in patients with septic nonunions of the humerus after a two-stage reconstruction using a free vascularized fibula graft. DESIGN: Retrospective case series. SETTING: Academic, tertiary referral center. PATIENTS/PARTICIPANTS: Adult patients with staged reconstruction for infected nonunion of the humerus with at least 2 years follow-up after vascularized fibula graft transfer. INTERVENTION: First, infected nonunion debridement with antibiotic spacer and external fixator placement. After antimicrobial treatment, free vascularized fibula transfer with internal fixation. MAIN OUTCOME MEASUREMENTS: Time to union, pain, affected extremity range of motion, and function. RESULTS: 10 patients with septic humerus nonunion treated with staged reconstruction using a free vascularized fibula graft, with a mean follow-up of 32.3 months were included. After the two-stage reconstruction using a free fibula, radiographic union was achieved in 6/10 patients, with a mean time to union of 19.9 weeks. The remaining 4 patients required an additional procedure with graft augmentation and/or implant revision. After the revision procedure, union was noted in 3/4 patients, 21 weeks postoperatively. Mean patient visual analog scale pain scores improved from 5.8 preoperatively to 0.9 at final follow-up ( P = 0.02). Postoperatively, mean elbow flexion was 110 ± 20 degrees and extension 15 ± 7.5 degrees. CONCLUSION: A two-stage reconstruction using a free fibula graft can be used in patients with septic nonunions of the humerus in the setting of multiple failed prior surgeries and compromised local biology. Additional procedures may be needed in some to achieve final union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Necrotizing Soft Tissue Infection of the Upper Extremity as a Manifestation of Hansen's Disease.

Hansen's disease is a well-described, largely historic infection that is caused by Mycobacterium leprae. Lucio's phenomenon is an aggressive, rare form of untreated lepromatous leprosy characterized by diffuse cutaneous lesions and systemic symptoms. To date, cases of necrotizing soft tissue infection in the setting of leprosy have rarely been reported in the literature. We present the case of a 51-year-old man with no known past medical history who presented for the evaluation of acute-on-chronic left upper extremity ulceration, soft tissue swelling, and pain. The patient was diagnosed with necrotizing soft tissue infection of the left upper extremity and underlying multibacillary lepromatous leprosy with Lucio's phenomenon. He underwent dermatofasciectomy of the affected extremity, followed by staged soft tissue coverage, including dermal allograft placement. Proper antibiotic management was also undertaken. In this article, we describe a case of previously undiagnosed leprosy with Lucio's phenomenon manifesting as necrotizing fasciitis of the upper extremity.

Effects of poly(vinyl alcohol) blending with Ag/alginate solutions to form nanocomposite fibres for potential use as antibacterial wound dressings.

In this work, nanocomposite fibres and microfibres based on alginate and poly(vinyl alcohol) (PVA) with silver nanoparticles (AgNPs) were produced and characterized for potential application as antibacterial wound dressings. PVA/Ag/Na-alginate colloid solution was used for the preparation of the fibres by a simple extrusion technique followed by freezing-thawing cycles. UV-Visible spectroscopy confirmed successful preservation of AgNPs in fibres while Fourier transform infrared spectroscopy has shown a balanced combined effect on the Ca-alginate spatial arrangement with the addition of both AgNPs and PVA. The presence of PVA in fibres induced an increase in the swelling degree as compared with that of Ag/Ca-alginate fibres (approx. 28 versus approx. 14). Still, the initially produced PVA/Ca-alginate fibres were mechanically weaker than Ca-alginate fibres, but after drying and rehydration exhibited better mechanical properties. Also, the obtained fibres released AgNPs and/or silver ions at the concentration of approximately 2.6 µg cm-3 leading to bacteriostatic effects against Staphylococcus aureus and Escherichia coli. These results are relevant for practical utilization of the fibres, which could be stored and applied in the dry form with preserved mechanical stability, sorption capacity and antibacterial activity.

Forearm and Arm Tourniquet Tolerance.

BACKGROUND: In distal upper extremity surgeries, there can be a choice to use an upper arm or forearm tourniquet. This study examines discomfort and tolerance in healthy volunteers to determine whether one is more comfortable. METHODS: Forty healthy, study participants were randomized to an upper extremity laterality and site. Tourniquets were inflated to 100 mm Hg over systolic blood pressure. Participants experienced an upper arm and a forearm tourniquet sequentially. Visual analog scores (VAS) were recorded at 2-minute intervals. Time until request and VAS at tourniquet deflation were recorded. Time until the complete resolution of paresthesias was also recorded. Participants subjectively stated which tourniquet felt more comfortable. RESULTS: Tourniquets were inflated longer on the forearm than the upper arm (mean 16.1 minutes versus 12.2 minutes; P < 0.0001). VAS at tourniquet removal was not different between the sites (means 7.3 and 7.3) (P = 0.839). Time until paresthesia resolution after the tourniquet was deflated was not different (means 8.1 and 7.7 minutes) (P = 0.675). Time until paresthesia resolution was proportional to tourniquet inflation time for both sites (regression coefficient 0.41; P < 0.00001). Participants found the forearm more comfortable (95% confidence interval, 0.63 to 0.92). CONCLUSION: Forearm placement allows the tourniquet to be inflated for an average of 4 minutes longer. Forearm tourniquet is subjectively more comfortable.

A Diagnostic Algorithm to Guide Operative Intervention of Zone 5 Flexor Injuries.

Background: Given the importance of the neurovascular structures in the volar forearm, accurate diagnosis of zone 5 flexor injuries is critical. Purpose: We sought to test the hypothesis that tendinous injury would be more likely in the distal 50% of the forearm and muscle belly injury would be more likely in the proximal 50% of the forearm. Methods: From December 2015 to December 2016, we conducted a prospective clinical study of patients 18 years and older with zone 5 flexor lacerations. We excluded those with concomitant ipsilateral injuries in flexor zones 1 to 4, multiple lacerations in flexor zone 5, prior neurovascular injuries, crush injuries, patients who underwent operative exploration prior to transfer to our facility, and patients who were unable or unwilling to provide consent. Neurovascular and musculotendinous injuries on physical examination were recorded. All patients underwent operative exploration. Physical examination accuracy and the incidence of musculotendinous and neurovascular injury in the distal 50% of the forearm were compared with the proximal 50% of the forearm. Results: The distal 50% of the forearm (group 1, n = 14) had higher probability of tendon injury (64%), whereas lacerations of the proximal 50% of the forearm (group 2, n = 5) did not result in any tendinous injuries. Rather, all patients in group 2 had muscle belly injuries. There was no difference in the rate of neurovascular injury between groups. Physical examination alone was highly accurate in diagnosing nerve injuries (93%-100%) but less accurate in diagnosing arterial injuries (79%-80%) regardless of the location of injury. Conclusions: Due to the lack of tendinous injuries in proximal zone 5 lacerations, along with the accuracy of physical examination in determining the presence of neurovascular injuries, patients with lacerations in the proximal half of the forearm, without evidence of nerve or arterial injury, can likely be observed in lieu of immediate operative exploration.

Toxigenic Species Aspergillus parasiticus Originating from Maize Kernels Grown in Serbia.

In Serbia, aspergillus ear rot caused by the disease pathogen Aspergillus parasiticus (A. parasiticus) was first detected in 2012 under both field and storage conditions. Global climate shifts, primarily warming, favour the contamination of maize with aflatoxins in temperate climates, including Serbia. A five-year study (2012-2016) comprising of 46 A. parasiticus strains isolated from maize kernels was performed to observe the morphological, molecular, pathogenic, and toxigenic traits of this pathogen. The HPLC method was applied to evaluate mycotoxin concentrations in this causal agent. The A. parasiticus isolates synthesised mainly aflatoxin AFB1 (84.78%). The percentage of isolates synthesising aflatoxin AFG1 (15.22%) was considerably lower. Furthermore, the concentration of AFG1 was higher than that of AFB1 in eight isolates. The polyphase approach, used to characterise isolates, showed that they were A. parasiticus species. This identification was verified by the multiplex RLFP-PCR detection method with the use of restriction enzymes. These results form an excellent baseline for further studies with the aim of application in the production, processing, and storage of cereal grains and seeds, and in technological processes to ensure the safe production of food and feed.

Differentiating Upper Extremity Necrotizing Soft Tissue Infection From Serious Cellulitis and Abscess.

Introduction Necrotizing soft tissue infection (NSTI) of the upper extremity (UE) is a rapidly progressing infection that requires early diagnosis and emergent treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to serious cellulitis or abscess. The purpose of this study was to identify factors that are associated with NSTI rather than serious cellulitis and abscess to differentiate patients with similar clinical presentations. Methods This study uses a retrospective cohort design that compares patients ultimately diagnosed with UE NSTI versus those diagnosed with UE serious cellulitis or abscess. Cohorts were matched using the Laboratory Risk Indicators for Necrotizing Fasciitis (LRINEC) score in the setting of UE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse and domiciled status were recorded. Continuous variables were compared using the Mann-Whitney U test, whereas categorical variables were compared using the chi-squared test or the Fisher exact test (for expected values less than 5). A binary logistic regression for continuous and categorical variables was also performed. Significance was set at p<0.05. Univariate and multivariate analyses were performed. Results Multivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than serious cellulitis or abscess: elevated lactate on hospital presentation, a patient-reported history of fever, male gender, and homelessness.  Conclusions In patients with upper extremity infections, the clinical presentation of NSTI and serious cellulitis or abscess may appear similar. In this retrospective cohort of patients matched with LRINEC scores, elevated lactate, subjective fever, male gender, and homelessness were significantly associated with NSTI rather than serious cellulitis or abscess.

Google trends as a tool for evaluating public interest in total knee arthroplasty and total hip arthroplasty.

BACKGROUND AND AIMS: There are approximately 1 million total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures performed annually in the United States. With this number projected to increase, it is vital for orthopedic surgeons and health-care systems to properly anticipate healthcare utilization related to TKA and THA. Google Trends (GT) is a free, open source tool that provides customizable analysis of search terms entered into the Google search engine. We aim to explore the relationship between public interest in TKA and THA as determined by GT data and volume of TKA and THA procedures. METHODS: GT data were compiled for ten search terms related to TKA and ten search terms related to THA from January 2009 to December 2017. Annual case volumes for TKA/THA procedures were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample from 2009 to 2017. Trend analysis was performed using univariate linear regression of GT data and TKA/THA case volumes. RESULTS: There was a statistically significant positive correlation between GT data and procedure volume for 14 of the 20 search terms studied. Seven TKA-related search terms with a positive correlation to procedure volumes include "total knee replacement," "knee replacement," "knee osteoarthritis," "knee ache," "knee swelling," "knee stiffness," and "chronic knee pain." Seven THA-related search terms with a positive correlation to procedure volumes include "hip arthroplasty," "total hip replacement," "hip replacement," "hip osteoarthritis," "hip ache," "hip swelling," and "chronic hip pain." CONCLUSION: GT may provide a high utility as a convenient and informative data set for orthopedic surgeons to analyze public interest in TKA and THA procedures. The data provided by GT have the potential to provide real-time, actionable information that may help surgeons and health systems to characterize public interest in TKA and THA and to best identify and address patient needs. RELEVANCE FOR PATIENTS: The GT tool can be used to measure public interest in TKA/THA, which can inform physician expectations for the patient encounter and lead to the creation of decision aids that better inform the public about the risks and benefits of TKA/THA.

Utilizing Google Trends to Track Online Interest in Elective Hand Surgery During the COVID-19 Pandemic.

Introduction Elective hand surgery encompasses a large volume of orthopaedic cases annually. Carpal tunnel syndrome, ganglion cysts, and trigger digits are some of the most common pathologies treated by hand surgeons. In the midst of the COVID-19 pandemic, patient's interest in elective hand surgery for these conditions is uncertain. The objective of this study is to use Google Trends to track online interest in elective hand surgery in the United States during the COVID-19 pandemic. Methods Online search trends regarding elective orthopaedic hand surgery were obtained via Google Trends from November 2019 to November 2020. Three common hand pathologies in lay terms ("carpal tunnel," "'ganglion cyst' + 'wrist cyst,'" and "trigger finger") and three hand surgery-specific keywords ("hand surgery," "carpal tunnel surgery," and "trigger finger surgery") were used as search terms. The search volume index (SVI) graphs for the United States for both sets of search terms were then generated from the Google Trends data and compared to the seven-day average of new COVID-19 cases per day as reported by the CDC. A separate SVI graph was then created for the search term "coronavirus" and was compared against both sets of search terms as above. Results Search trends for all elective hand pathologies and surgery-specific keywords remained constant from November 2019 to the beginning of March 2020 and then decreased significantly within a one-month period following the peak in COVID-19 cases the week of March 15, 2020. Search trends for these keywords increased to baseline levels over the next few months. The search trend for "coronavirus" demonstrated a small search volume index peak of 13 during January 2020 followed by the maximum peak of 100 during the week of March 15, 2020, corresponding to the decrease in search trends of elective hand surgery at that time. Conclusions Online interest in elective hand surgery remained constant prior to the COVID-19 pandemic; however, there was a marked decrease in search trends of elective hand surgery with the rise in daily reported COVID-19 cases, suggesting that patient's interest in elective hand surgery decreased with the onset of the pandemic.

First report of Head blight of wheat caused by Fusarium vorosii in Serbia.

The cosmopolitan species Fusarium graminearum Schwabe directly reduces yield, as well as grain quality of cereals, due to its ability to synthesize mycotoxins. Previously it was considered to be one species occurring on all continents. However, phylogenetic analysis employing the GCPSR method (Genealogical Concordance Phylogenetic Species Recognition) revealed the existence of 15 phylogenetic species within what is now recognised as the Fusarium graminearum Species Complex (FGSC) (Sarver et al. 2011). During 1996-2008, a MRIZP collection of FGSC isolates was established and isolates originating from wheat (5), maize (3) and barely (2) were selected for further study. Morphological features including the appearance of colonies and macroconidia (average size 38.5-53.1 × 4.6-5.4 µm, No 50) of all 10 isolates on PDA were consistent with descriptions of F. graminearum (O'Donnell et al. 2004, Leslie and Summerell 2006). Total DNA was isolated from mycelium removed from 7-day old colonies of single-spore isolates grown on PDA using the DNeasy Plant Mini Kit (Qiagen, Hilden). Further identification was based on amplification and sequencing of elongation factor TEF-1α, histone H3 and ß-tubulin in both directions, with primers ef1/ef2, H3-1a/H3-1b and T1/T22, respectively (Jacobs et al. 2010). The sequences were deposited in NCBI under accession numbers MF974399 - MF974408 (TEF-1α), MG063783 - MG063792 (ß-tubulin) and MF999139 - MF999148 (histone H3). Sequence analysis was performed using BLAST while genetic similarity was calculated using MEGA 6.0 software. Isolate 1339 originating from wheat (collected at the locality of Kikinda in 2006), shared 100% nucleotide identity with TEF-1α (DQ459745), histone H3 (DQ459728) and ß-tubulin (DQ459643) of F. vorosii isolate NRRL37605 (Starkey et al. 2007). The remaining nine isolates were identified as F. graminearum as they shared 99% to 100% nucleotide similarity with F. graminearum NRRL 28439 (O'Donnell et al. 2004). Pathogenicity was tested using artificial inoculations of spikes during wheat flowering (Mesterhazy et al. 1999). Thirty classes were inoculated with each isolate, in three replicates. Inoculum was prepared from 7-day colonies on PDA, and 30 ml of a conidia suspension (1x105 conidia/ml) was used. Control plants were inoculated with sterile water. Three weeks after inoculation, typical Fusarium head blight symptoms were visible on inoculated plants, from which all 10 isolates were successfully reisolated. Control spikes remained symptomless. Disease severity was estimated on the 1-7 scale (Blandino et al. 2012). Average pathogenicity of the F. vorosii isolate 1339 was 1.9, and 2.4 -5.1 of F. graminearum isolates. Toxin production was determined using gas chromatography-tandem mass spectrometry. Kernels inoculated with the 10 isolates were ground and tested for the presence of deoxynivalenol (DON) and its acetyl derivatives 3ADON, 15ADON and NIV. F. vorosii isolate 1339 possessed the 15ADON chemotype, as well as eight F. graminearum isolates, while only one F. graminearum isolate was 3ADON chemotype. To date, F. vorosii has only been detected in Hungary on wheat (Toth et al. 2005) and Korea on barley, corn and rice (Lee et al. 2016). This is the first report of F. vorosii in Serbia, which is of great importance, because it indicates the spread of this toxigenic species. Further studies should be focused on determining the distribution, aggressiveness and toxicological profile of F. vorosii.

Treatment of Iatrogenic Saphenous Neuroma after Knee Arthroscopy with Excision and Allograft Reconstruction.

The treatment of postoperative, painful sensory neuromas is an ongoing challenge for surgeons. Here, we describe a technique for treatment with excision and allograft reconstruction and report on early results of its use in treating painful saphenous neuromas after knee arthroscopy. METHODS: A retrospective review of a single surgeon's peripheral nerve clinic from January 1, 2013, to December 31, 2019, was conducted to identify post-knee arthroscopy saphenous neuroma cases in which reconstruction with processed human nerve allograft distally implanted into healthy muscle belly was performed. We examined the outcomes for each patient, including subjective pain self-assessment and need for further surgical treatment. RESULTS: In total, 9 cases were identified, with patient ages ranging from 21 to 74 years. The average time to referral to peripheral nerve clinic was 31 months (range: 4-143 months). Upon exploration, all nerves were found to have a neuroma in continuity. Six of the 9 patients reported subjective improvement through final follow-up. Three of the 9 patients reported initial improvement, with recurrence of pain at/near the site of the neuroma. The average follow-up time was 9 months (range: 1-21 months). CONCLUSIONS: Here, we report on a novel technique of using a processed human nerve allograft after neuroma resection to provide an organized environment for bridging regenerated axons into muscle tissue. We also describe our early results using this technique to treat iatrogenic saphenous neuromas after knee arthroscopy. Results are encouraging, with 6 of the 9 patients experiencing subjective reduction in pain at final follow-up.

The management of clenched fist injuries with local anaesthesia and field sterility.

Clenched fist injury is associated with a high risk of infectious complications and is commonly managed with formal irrigation and debridement in the operating theatre. The purpose of this study was to determine outcomes associated with irrigation and debridement of clenched fist injuries under local anaesthesia using field sterility outside the operative theatre. In this single centre study, 232 patients were identified with clenched fist injury and 210 were treated with a standard protocol beginning with administration of intravenous antibiotics and then irrigation and debridement at the bedside. Primary outcome measures were the need for repeat debridement and complications. Secondary outcome measures included factors associated with the need for repeat debridement. Fifteen of the 210 patients (7%) required repeat debridement. Patients with cultures positive for gram-negative organisms had a significantly increased risk of repeat debridement. Irrigation and debridement under local anaesthesia using field sterility results in an acceptably low risk of complications or need for repeat debridement.Level of evidence: IV.

Restoration of Elbow Flexion With a Free Functional Gracilis Muscle Transfer in an Arthrogrypotic Patient Using a Motor Nerve to Pectoralis Major.

Background: Patients with arthrogryposis may exhibit inability to flex the elbow. A free functional gracilis muscle transfer (FFGMT) can be used to restore elbow flexion. In our search of the available literature, we have not seen any descriptions of using a motor branch to the pectoralis major as a donor nerve to establish elbow flexion. Methods: We performed an FFGMT for restoration of elbow flexion in an arthrogrypotic patient with no active elbow flexion, who had a Medical Research Council (MRC) muscle grade of 0. Results: We report our 4.5-year outcomes. After undergoing an FFGMT for elbow flexion, our patient was able to gain an MRC grade 4 and achieve an arc of motion of 25° to 140°. Conclusion: An FFGMT for elbow flexion may be performed successfully using a motor branch to the pectoralis major.

Characteristics of Iatrogenic Nerve Injury from Orthopedic Surgery Correlate with Time to Subspecialty Presentation.

There is no current literature examining iatrogenic nerve injury resulting from orthopedic procedures across subspecialties and anatomic areas. This study uses a single peripheral nerve surgeon's experience to investigate the variable time to presentation of adult patients with iatrogenic nerve injury after orthopedic surgery. METHODS: A retrospective review of patients examined in Peripheral Nerve Clinic (PNC) from January 1, 2012, to April 1, 2018, at a single, private, university hospital was performed. Fifty-eight adult patients met inclusion criteria. Charts were reviewed to determine the index orthopedic procedure, peripheral nerve affected, clinical deficits, patient demographics, and time from injury to PNC presentation. RESULTS: The average patient age was 51.2 years, and the average time to PNC referral was 10.9 months after the procedure that resulted in nerve injury. The orthopedic procedures included fracture fixation (13), joint arthroplasty (10) knee arthroscopy and ligament reconstruction (9), mass excision (9), shoulder arthroscopy (7), irrigation and debridement (2), removal of deep hardware (2), tendon procedures (2), trigger digit release (2), nerve decompression (1), and release of exertional compartment syndrome (1). Time from injury to PNC presentation was substantially shorter for patients with upper extremity versus lower extremity deficits (5.9 months vs 19.8 months; P = 0.0173) and for patients with motor nerve involvement versus those with isolated sensory nerve injury (4.5 months vs 24.3 months; P = 0.0164). CONCLUSIONS: Iatrogenic nerve injury is a risk across orthopedic subspecialties. Nerve injuries in the lower extremity and those with isolated sensory deficits have significantly delayed time to subspecialty presentation.

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature.

BACKGROUND: In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. METHODS: Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. RESULTS: A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1-17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60-100%). Mean follow-up was 5.17 years (2-12 years). CONCLUSION: This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique.

AIMS: To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). METHODS: All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. RESULTS: All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). CONCLUSION: Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246-253.