The Putti Sign Following Residual Brachial Plexus Birth Injury: Prevalence and Significance.

BACKGROUND: The Putti sign, a common deformity and complaint in children with brachial plexus birth injury (BPBI), stems from a glenohumeral (GH) abduction contracture. Despite recent clinical studies offering insights into this deformity, none have explored the prevalence of the Putti sign or its correlation with GH abduction contractures. METHODS: We conducted a prospective analysis of 238 patients (median age 7.5 years; range, 4.1-16.2) with residual BPBI seen in the clinic from December 2019 to December 2022. Epidemiological data, including demographics, palsy levels, modified Mallet scale sum, surgical history, and presence/absence of the Putti sign and glenohumeral adduction angle (GHADD), were collected. Patients were categorized into 4 age groups: 0 to 5 years (n=67), 6 to 10 years (n=102), 11 to 15 years (n=53), and 16 years and older (n=16). Results were expressed as medians (minimum-maximum), with frequency comparisons done using Pearson's chi-square analysis. Mann-Whitney U and Kruskal-Wallis tests were used for quantitative variable comparison, and receiver operating characteristic (ROC) analysis determined the threshold GHADD angle for Putti sign appearance. RESULTS: Main findings included: (1) 27% of patients with residual BPBI exhibited the Putti sign, (2) confirmed correlation between the Putti sign and GH adduction contractures, (3) Putti sign manifestation with GHADD angle measuring less than -5° because to abduction contracture, and (4) association between this deformity and reduced activities requiring external rotation. No significant differences in Putti sign prevalence were found across age groups. CONCLUSIONS: Our study underscores the common occurrence of the Putti sign in children with residual BPBI. It is important to note that we highlight its functional significance beyond cosmetic concerns. Contrary to prior literature, our analysis reveals functional impairment associated with the Putti sign. Although no age-based differences in Putti sign prevalence were observed, patients aged 0 to 5 years and 11 to 15 years showed more severe glenohumeral abduction contractures, possibly due to growth spurts. LEVEL OF EVIDENCE: Diagnosis IV.

Plantar intermetatarsal perforator flap for first web skin-graftless syndactyly release: Anatomical study and clinical application.

INTRODUCTION: Foot-syndactyly has long been managed through conventional surgical procedures, each having its own distinct advantages and drawbacks. While these methods, which do not require skin grafts, exhibit a lower incidence of long-term complications, they lead to undesirable scarring on the dorsal side of the foot and reduced patient satisfaction. In this study, we introduce an innovative technique involving an intermetatarsal plantar flap, supported by an anatomical investigation and clinical application. METHODS: Eight freshly preserved lower limbs were injected with colored latex to examine the cutaneous vessels on the plantar surface, a skin-flap was designed in an elliptical shape to address first web conjoined toes. The flap was extended from the center of each affected ray measuring ~30% of the sole's length. Using the mentioned novel approach, a flap was created and dorsally extended with a straight incision to release bilateral simple foot-syndactyly in an 8-year-old child presented with Apert's Syndrome. RESULTS: We identified cutaneous branches originating either from the medial plantar vessels or the lateral proper artery of the hallux. On average, the mean number of cutaneous branches found over the first intermetatarsal web spaces was 5.8 (ranging from 5 to 8) most of them originating from medial plantar vessels with a mean of 5.1 branches (range 4-6) while proper lateral great-toe digital artery provided a mean of 0.6 branches (range 0-2). Intra-operatively, in our patient, advancing the plantar flap ensured complete coverage of the commissure, obviating the necessity for skin grafts. Incisions healed uneventfully and a wide first web was obtained. Over a 15 months follow-up, no complications were observed. CONCLUSIONS: Our findings suggest that the skin-graftless first web release of syndactyly using a plantar intermetatarsal flap is a reliable and straightforward procedure with good cosmetic results, offering a promising alternative to conventional techniques. LEVEL OF EVIDENCE: Therapeutic IV.

Extensor carpi radialis brevis motor branch transfer to the deep branch of the ulnar nerve to repair intrinsic hand palsy in neonatal lower brachial plexus and spinal cord injury: A case report.

Concomitant lower neonatal brachial plexus palsy (Klumpke) and spinal cord injury is extremely rare but with a clearly established mechanism of injury pattern. No successful surgical techniques have been reported to date to restore intrinsic hand function. We report a case of successful transfer of the extensor carpi radialis brevis motor branch to the deep branch of the ulnar nerve to repair intrinsic hand palsy. Three-month-old boy with the diagnosis of left Klumpke paralysis and thoracic spinal cord injury associating left Horner's sign, intrinsic minus deformity of all the digits, and thenar muscle paralysis in the upper limb. Both lower limbs were fully paralyzed. Cervical magnetic resonance imaging (MRI) revealed spinal cord narrowing from T1 to T5 and pseudo-meningoceles involving the left C8 through T3 roots. Since no spontaneous recovery was apparent by 6.5 months and surgical exploration showed pronator quadratus denervation, the ECRB motor branch deep branch was transferred to the ulnar nerve (DBUN) with interposed a 7.5 cm-long sural nerve graft. By 18 months post-operatively, all the digits showed complete active IP extension. Thirty-six months after surgery, no signs of first dorsal interosseous nerve or thenar muscle reinnervation were present, thus an extensor carpi ulnaris opponensplasty was performed. ECRB motor branch might be a valuable tool to restore finger intrinsic function in these uncommon cases.

Triceps to teres minor motor nerve transfer to restore glenohumeral external rotation after neonatal brachial plexus injury.

INTRODUCTION: Attaining active glenohumeral external rotation (aGHER), whether via primary reconstruction or spontaneous recovery, is infrequent in patients with neonatal brachial plexus palsy (NBPI). We evaluated the effectiveness of triceps-to-teres minor motor branch transfers to restore this function, both performed primarily (i.e., in conjunction with microsurgical plexus reconstruction) or secondarily (after primary surgery has failed to restore aGHER). PATIENTS AND METHODS: This was a retrospective study of 12 children with NBPI undergoing triceps-to-teres minor motor branch transfer via an axillary approach, six undergoing primary surgery and six secondary. The primary outcome was post-operative restoration of aGHER in abduction. The primary-surgery group consisted of six children of mean age 8 months (range 5-11) with partial injuries ranging from C5-C6 to C5-C8. The secondary-surgery group included six patients with C5-C6 injuries of mean age 43 months (range 23-120), undergoing re-operation a mean 40 months (range 18-116) after their primary surgery. RESULTS: No complications occurred after surgery. At a mean follow-up of 22 months (range 14-30), aGHER in abduction only was restored in one patient in the primary group while in the secondary group, aGHER in abduction was restored in all patients to a mean 73° (range 70-80) after a mean follow-up of 16 months (range 6-26). CONCLUSIONS: Triceps-to-teres minor motor branch transfer is not indicated as primary surgery for NBPI. However, they can be effective in children in whom primary surgery has failed to restore aGHER, even if the spinal accessory nerve is unavailable for transfer to the infraspinatus motor branch.

Unsuccessful mid-term results for distal humeral hemiepiphysiodesis to treat cubitus varus deformity in young children.

Cubitus varus is the most common complication following a pediatric humeral supracondylar fracture. No reports are available on the result of hemiepiphysiodesis to correct this deformity. We report the use of a transphyseal crossed cannulated screw (Metaizeau technique) in five very young children (mean 3 years and 7 months). No correction was observed after a mean of 3 years and 10 months of follow-up. The low growing capacity of the distal humeral physis makes corrective osteotomy the procedure of choice for cubitus varus deformity correction in children.

Congenital pseudarthrosis of the tibia: Rate of and time to bone union following contralateral vascularized periosteal tibial graft transplantation.

INTRODUCTION: Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging orthopedic disorders. The use of a vascularized tibial periosteal grafts has been recently reported as a powerful tool to obtain bone union. We report its use in CPT. PATIENTS AND METHODS: Retrospective short-term study of 29 children (18 male/11 female, 15 right-sided/14 left-sided) of mean age 45 months (range 11-144 months), operated upon after October 2014. Nonunion site was debrided, and the periosteum of the involved limb was excised. A vascularized tibial periosteal graft (mean length 10.7 cm (range 9-15 cm) with a monitoring skin island (mean length 4.1 cm (range 3-5 cm) and based on the anterior tibial vessels, was obtained from the contralateral tibia. Anterior tibial vessels were always the recipient vessels. Most cases were stabilized with an LCP plate. The rate of and time to bone union were analyzed. Charts only were evaluated through the first 3 months after bone union was achieved. RESULTS: The flap survived and bone union was obtained in all cases, through a periosteal callus, in a mean time of 5.1 weeks (range 3-6 weeks). Mean follow-up was 8.3 months (range 7-19 months). No union failures occurred 3 months after resuming unprotected weight bearing. CONCLUSIONS: Our novel technique produced a consistent, rapid capacity for CPT union, superior to previously-reported techniques. However, it cannot be recommended as a standard method of treatment until consistent, long-term, refracture-free follow-up is documented.

Gartland Type-IV Supracondylar Humeral Fractures: Preoperative Radiographic Features and a Hypothesis on Causation.

BACKGROUND: The diagnose of Gartland Type-IV (G-IV) supracondylar humeral fractures (SCHF) has been reported to only be possible via fluoroscopy intra-operatively. HYPOTHESIS: A preoperative radiographic fracture pattern can indicate a G-IV SCHF. PATIENTS AND METHODS: Retrospective qualitative analysis of radiographs and reduction techniques used in twenty-seven GIV SCHF. RESULTS: Anterior-posterior radiographs demonstrated lateral translation or angulation in 21 cases (valgus type) and medial translation or angulation in 6 cases (varus type). In spite of a complete cortical disruption, lateral radiographs showed that the distal fragment was vertically aligned with the proximal fragment. Reduction was achieved in semi-extension, via supination in valgus type fracture and pronation for varus type fractures. DISCUSSION: Our conjecture is that a trauma vector in the coronal plane would result in a near-circumferential periosteal disruption, with which either a medial or lateral periosteal hinge remains. The distal fragment would be vertically aligned in lateral radiographs. LEVEL OF EVIDENCE: IV; Diagnostic.

Arthroscopic Calcaneonavicular Coalition and Too-long Anterior Process of the Calcaneus Resection in Children.

Persistent symptomatic calcaneonavicular coalition (CNC) and too-long anterior process of the calcaneus (TLAP) are congenital disorders that can benefit from surgical treatment. The arthroscopic technique for CNC and TLAP resection has previously been described. The aim of this prospective study was to describe outcomes following arthroscopic resection of 12 (38.71%) CNC and 19 (61.29%) TLAP cases in 30 consecutive pediatric patients treated between July 2009 and March 2013. There mean age was 12.4 (range 10 to 15) years, and the mean follow-up was 55.2 (range 24 to 79) months. Radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, AOFAS pain scores, and patient satisfaction were assessed. All final postoperative imaging scans revealed complete synostosis resection without recurrence. The mean overall AOFAS Ankle-Hindfoot Score increased from 78.87 (95% confidence interval [CI] 76.74 to 81.01) to 93.06 (95% CI 91.10 to 95.03) (p < .001). All patients showed pain reduction after surgery; even 1 patient (3.23%) who initially developed complex regional pain syndrome eventually had a successful outcome. The mean AOFAS pain score increased from 23.87 (95% CI 22.05 to 25.69) to 34.84 (95% CI 32.97 to 36.70) (p < .001). All patients were either satisfied (n = 9 [30%]) or very satisfied (n = 21 [70%]) with the intervention at the final follow-up. Although both arthroscopic CNC and TLAP resection are demanding techniques, they allow for precise coalition resection through a less invasive approach, which may ultimately lead to faster recovery and improved outcomes.

Outcomes following endoscopic-assisted Woodward procedure for Sprengel deformity.

PURPOSE: An endoscopic-assisted approach for Sprengel deformity has been previously reported. Our objective was to assess outcomes of the endoscopic Woodward procedure in a series of patients. METHODS: Retrospective analysis was performed of children with a Sprengel deformity treated between November 2014 and February 2018. Recorded data were demographic, pre- and postoperative active shoulder elevation and deformity severity according to Cavendish. RESULTS: A total of 12 children (four girls and eight boys, ten right-sided/two left-sided) with a mean age of nine years two months (3 years 5 months to 16 years 1 month) and mean follow-up 19.8 months (10 to 48) were assessed. Nine children were classified as Cavendish Grade III and three as grade IV, respectively. Mean preoperative active shoulder forward elevation was 100.8° (70° to 120°), while postoperatively it increased to 149.2° (100° to 170°). Mean preoperative scapular high difference was 4.5 cm (2.8 to 5.2), while postoperatively it was 1.33 cm (0 to 2.8). CONCLUSION: The endoscopic assisted Woodward procedure is an effective technique. Further comparative studies will ascertain advantages in functional and cosmetic results compared to the standard Woodward procedure. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Passive range of glenohumeral motion in children with a Sprengel's deformity.

BACKGROUND: In Sprengel's deformity, loss of shoulder motion has been attributed exclusively to scapulothoracic stiffness. The purposes of this study were to evaluate passive glenohumeral (GH) joint motion in these children. METHODS: A prospective evaluation of 23 children was performed. Obtained data were demographics, Cavendish grade, bilateral active global shoulder elevation, and multidirectional passive GH range of motion, including: (a) GH internal rotation in abduction and GH cross-body adduction to assess for posterior GH contracture; (b) spinohumeral abduction angle (SHABD) to assess for inferior GH contracture; (c) spinohumeral adduction angle to assess for superior GH contracture; and (d) passive external rotation in shoulder adduction and abduction to assess for anterior GH contracture. Paired t tests and both Pearson's and Spearman's correlation analyses were performed. RESULTS: The mean patient age was 8.1 years (range, 1.4-16.7 years), with 13.4% of deformities Cavendish grade 1, 52.2% grade 2, 13.4% grade 3, and 21.7% grade 4. The involved shoulder showed a statistically significant decrease in mean active global shoulder elevation (117.4° vs. 176.1°), SHABD (14.6° vs. 41.5°), cross-body adduction (43° vs. 71.3°), and internal rotation in abduction (17.8° vs. 49.4°), all at P < .001. Strong inverse correlations were noted between Cavendish grade and both global shoulder elevation (r, -0.784) and SHABD (r, -0.669). Cavendish grade IV patients showed a mean decrease of 45° (range, 40°-60°) of SHABD. CONCLUSION: Shoulder elevation is also impaired by GH joint contractures.

Transverse Anterior Approach to the Elbow for Pediatric Displaced Lateral Humeral Condyle Fractures.

BACKGROUND: The anterior approach to the elbow for pediatric lateral condyle fractures (LCF) would provide a better visualization of the articular fracture resulting in better functional results, less complications and a more cosmetically-appealing scar than usually seen with the lateral approach. METHODS: Retrospective study of children undergoing an open reduction and internal fixation of a displaced LCF via an anterior approach with a transverse incision. Bilateral elbow range of motion (ROM), upper limb alignment and complications were registered. A 4-point ordinal Likert-type scale was employed for parents to rate their level of satisfaction with the cosmetic appearance of the scar. RESULTS: Eighteen children of mean age 76 months (range 27 to 101 months) were included. Fractures were classified as Jackob's Type II in 14 cases and Milch's type II in all cases. Mean follow-up was 12 (range 4 to19) months.Successful condral fracture visualization and reduction was achieved in every case. No intra-operative or post-operative complications occurred. In all cases bone union was obtained 4 to 5 weeks after surgery and at final follow-up, active elbow ROM of at least 90%, was obtained. All parents claimed to be "very satisfied" with their child's scar. A lateral spur was identified in 66.7% o patients. CONCLUSION: The anterior approach to the elbow was both a feasible and safe allowing full anatomical cartilage reduction. Complications after this technique might decrease compared to the lateral approach but need future comparative studies. The rate of lateral spur did not decreased. Cosmetic scar results seem to be a clear advantage of this approach compared to the classical lateral approach.

Vascularized humeral periosteal flap to treat lateral humeral condyle nonunion: An anatomical study and report of two successfully-treated pediatric cases.

PURPOSE: Nonunion is a common complication of lateral condyle humeral (LCH) fractures in children. In situ fixation with a screw and bone grafting is the classically-recommended method of treatment. The purpose of this study is to analyze the feasibility of obtaining a vascularized periosteal flap obtained from the lateral humerus and based on the posterior collateral radial vessels (PCRV). Second, to report the results after the application in two pediatric cases. METHODS: Periosteal branches of PCRV were studied in ten upper limbs from fresh human cadavers. Then, two children with LCH nonunion were treated with this flap. RESULTS: The PCRV provided mean of 5.3 anterior periosteal branches (range 4-7) with a mean distance between them of 19.1 mm (range 5-29 mm) and 5.7 posterior periosteal branches (range 3-7) with a mean distance between them of 15.9 mm (range 6-33 mm. PCRV distally anastomosed to the interosseous recurrent artery and the radial recurrent artery, creating a vascular net over the lateral condyle and allowing for the design of a reverse vascularized humeral periosteal flap (VHPF). Abundant periosteal callus and rapid consolidation were achieved in both children. No bone fixation or grafting was necessary. CONCLUSIONS: VHPF might be considered a viable biological surgical option to promote bone healing in LCH nonunions in children, while avoiding the need for bone fixation and the donor morbidity associated with bone grafting.

Bone Allograft Segment Covered with a Vascularized Fibular Periosteal Flap: A New Technique for Pediatric Mandibular Reconstruction.

The free vascularized fibular graft is nowadays the preferred technique for pediatric mandibular reconstruction. Despite the versatility and proven efficacy for restoring the facial appearance and maxillomandibular function, those mandibular reconstructions with free vascularized fibula associate difficulties for a simultaneous restoration of the alveolar height and facial contour, which are derived from the height discrepancy between the fibula and the native mandible. In addition, the donor-site growth and morbidity are of special concern in the pediatric patient. We report a novel technique for pediatric mandibular reconstruction, in an 11-year-old girl, using a combination of a bone allograft segment with a vascularized fibular periosteal flap (VFPF), after resection of an Ewing sarcoma located at the right body of the mandible. The patient has showed optimal cosmetic, functional, and radiological outcomes, which have been maintained for 2.5 years, without detecting donor-site complications. Through this original technique, and based on the powerful osteogenic and vasculogenic properties of the pediatric VFPFs, we could effectively reconstruct a large mandibular defect providing a functional and aesthetic reconstruction, while avoiding the potential morbidity associated with the fibula resection.

Endoscopic Woodward procedure for Sprengel deformity: case report.

Sprengel deformity (SD) results in a limitation of movement of the shoulder girdle and produces an esthetic defect. Our aim is to assess the feasibility and advantages of a minimally invasive endoscopic approach for SD correction. A 4-year-old boy with a Cavendish grade III right SD. The patient underwent an endoscopic Woodward procedure with access through two small incisions at the level of the upper and lower angles of the scapula. Near-symmetrical shoulder elevation was achieved, with an excellent cosmetic result. The endoscopic Woodward procedure is a feasible, effective, and minimally invasive technique in the treatment of SD. LEVEL OF EVIDENCE: V.

Free vascularized tibial periosteal graft with monitoring skin island for limb reconstruction: Anatomical study and case report.

Several types of vascularized periosteal flaps have recently been described for the treatment or prevention of complex non-union in pediatric patients. Among them, a vascularized tibial periosteal graft (VTPG), supplied by the anterior tibial vessels (ATV), has been used successfully as a pedicled flap in a few patients. The purpose of the study is to describe the periosteal branches of the ATV, as well as the cutaneous and muscular branches by means of an anatomical study. In addition, to report on the use of VTPG as a free flap with a monitoring skin island in a clinical case. A mean of 6.5 periosteal branches (range 5-7) were found. In all cases we located a cutaneous perforator branching from one of the periosteal branches located at the midlevel of the leg. We performed a two-stage reconstruction of a recalcitrant non-union and residual shortening of the right tibia in a 17-year-old boy. After nonunion focus distraction, we used a massive bone allograft fixed with a nail and covered by a VTPG as a biological resource. Allograft consolidation was achieved 5.5 months after surgery. At eighteen months after surgery, no complications were observed and the patient had resumed all his daily activities, despite a residual 2-cm limb-length discrepancy. VTPG may be considered as a valuable surgical option for bone reconstruction in complex biological scenarios in the young population. © 2015 Wiley Periodicals, Inc. Microsurgery 37:248-251, 2017.

Vascularized fibular grafts extended with vascularized periosteum in children.

PURPOSE: The purpose of this report is to evaluate the results of extending vascularized fibular grafts (VFG) with vascularized periosteum (VPG) in bone defect reconstruction in children. METHODS: Retrospective study of 10 children, mean age at surgery was 9.8 years (range, 4-16 years). Origin of one defect was oncological (n = 5), septical (n = 2), traumatic (n = 2), or congenital (n = 1). In five cases the flap consisted of a VFG and a vascularized epiphyseal transfer (VFET) in five. Mean bone defect was 8.5 cm .Mean length of the vascularized periosteal extension was 5.5 cm (range 3.5-8) for VFET, 4.8 cm for VFG (range 3-8). Bone union was assessed with monthly radiographs. RESULTS: Radiographs showed a periosteal callus at 4 weeks in all cases. Bone union was achieved at a mean of 8.4 weeks (range 4-12). Donor site complications included two cases of flexor hallucis longus contracture, and one case of surgical wound marginal necrosis following FVG. One transient tibialis anterior weakness and one tibialis anterior contracture occurred following VFET harvest. None required surgical treatment. Mean follow-up was 28.7 months (range 7-72). CONCLUSIONS: The association of a vascularized periosteal extension with fibular flaps seems to accelerate flap to recipient bone union. © 2016 Wiley Periodicals, Inc. Microsurgery 37:410-415, 2017.

Ultrasound-guided Percutaneous Medial Pinning of Pediatric Supracondylar Humeral Fractures to avoid Ulnar Nerve Injury.

BACKGROUND: Medial pinning is one of the most controversial aspects of the surgical treatment of supracondylar fractures (SHF) owing to the risk of ulnar nerve injury. AIM: To evaluate the safety and usefulness of medial pinning for SHF using ultrasound imaging for ulnar nerve visualization. METHODS: Fifteen children, with a mean age of 60 months, with displaced SHF were treated with a crossed-pinning configuration after fracture reduction. Intraoperative ultrasound was used to guide medial pin insertion to avoid ulnar nerve injury. RESULTS: Cubital tunnel anatomy was easily identified in all children. All children showed a subluxating ulnar nerve that required elbow extension to about 90º before medial pin insertion. None suffered ulnar nerve dysfunction after using the referred technique. CONCLUSIONS: Although technically demanding, ultrasound may be a valuable adjuvant to avoid ulnar nerve injury while performing a medial pinning in pediatric SHF.