Surgical Treatment of a Neglected Thumb Volar Plate Injury in an 11-Year-Old Girl: A Case Report.

BACKGROUND Volar plate injuries are rare and difficult to diagnose and treat. Only a few cases have been described on the thumb, especially in children, that resulted in swan-neck type deformity. Conservative treatment has been suggested as first-line management, but surgical reconstruction utilizing flexor digitorum superficialis tenodesis has been described for refractive cases. Only a few attempted surgical repairs of the volar plate have been reported, since it is a technically demanding procedure. CASE REPORT We present the case of a neglected thumb volar plate injury in an 11-year-old girl after a thumb hyperextension injury. The patient presented 2 months after her injury with functional disability of her thumb. Magnetic resonance imaging had been performed, with no signs of volar plate injury, and she was consequently treated with an extension-blocking splint, with no effect. Clinical examination raised the suspicion of a thumb volar plate injury, which was confirmed during surgical exploration. Therefore, fixation with a bone anchor was performed, and the metacarpophalangeal joint was immobilized in 20° flexion with a percutaneously inserted Kirschner wire. After splinting for 3 weeks, the patient had 10 sessions of physical therapy. At 6-week follow-up, she presented with excellent active and passive range of motion and absence of pain. CONCLUSIONS Magnetic resonance imaging did not have high sensitivity. Six weeks after surgery, full range of motion was achieved, with no stiffness or tenderness at the first metacarpophalangeal joint, suggesting that a thumb volar plate injury had been managed surgically with a suture anchor with excellent results.

Surgical Treatment of Monteggia-Like Lesions With a Modified Boyd Approach.

Introduction: Monteggia-like lesions are rare injuries in adults that include a wide spectrum of complex fracture-dislocations of the proximal ulna and radius. In this retrospective study, we performed a modified Boyd approach and a standard surgical protocol for the treatment of these lesions. Our aim was to evaluate the results of the operative treatment for patients with Monteggia-like lesions, using a modified Boyd approach. Materials and Methods: We present a retrospective study of 14 patients who underwent surgical treatment for Monteggia-like lesions. Preoperative clinical and radiological evaluation was performed. In 5 cases radial head prosthesis was placed, and in 3 cases the radial fracture was stabilized with the use of interfragmental screws. Regarding the proximal ulnar fracture, ORIF-anatomical plate and ORIF-straight plate was used in 12 and 2 cases, respectively. Results: Average clinical follow up was 16.9 months. Postoperatively, the mean Mayo Elbow Performance score was 83.4 points (range 70-100) and the mean visual analog scale was 1.7 (range 0-14). Mean flexion and loss of extension were 122.1° (range 80°-140°) and 21.4° (range 5°-40°), respectively. Mean supination of the forearm was 66.8° (range 50°-80°) and the mean pronation was 67.5° (range 60°-75°). Heterotopic ossification was observed in 3 patients (21.4%) and 1 patient developed stiffness (7.1%). The patient who developed stiffness underwent reoperation for plate removal and arthrolysis, with satisfactory results. Conclusions: The surgical treatment of Monteggia-like lesions in adults remains a challenge. In the present study, the use of a standard surgical protocol, with a modified Boyd approach, successfully restores the movement and stability of the elbow, with a low complication rate.

Study protocol: biomechanical testing, finite element analysis and prospective, randomized, clinical study of single screw cephalomedullary nailing versus integrated dual interlocking screw fixation for unstable (31A21-3) intertrochanteric fractures in patients > 70 years old.

BACKGROUND: Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. The vast majority of intertrochanteric fractures require surgical treatment to withstand early mobilization and weight bearing, which prevents complications due to prolonged bed rest and aids in fracture healing. METHODS: This study is compromised by two parts, the experimental study and the clinical part. In the first part, a standard 130° nail will be used with the appropriate lag screw(s) and dynamic distal locking in synthetic osteoporotic femurs and the transmission of forces in the proximal femur, measured by a cortical surface-strain distribution, will be evaluated using digital image correlation. Finite element parametric models of the bone, the nails and their interface will be also developed. Finite element computations of surface strains in implanted femurs, after being validated against biomechanical testing measurements, will be used to assist the comparison of the nails by deriving important data on the developed stress and strain fields, which cannot be measured through biomechanical testing. In the other part, will set up a prospective, randomized, comparative clinical study among the Gamma3 and IT cephalomedullary nailing, in order to investigate if there are any statistical important differences in the main radiological measurements and functional status in closed unstable intertrochanteric fractures (A21-3) in patients aged over 70 years old at the 24-week follow-up evaluation using patient reported disease-specific outcomes. DISCUSSION: This study will be the first to compare clinical, radiological and biomechanical measurements of the two different cephalomedullary nails. Our main hypothesis is that the IT nail would provide better radiological outcome and probably better clinical results than the Gama3 nail. Clinical trial registration International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN15588442 , registered on 19/4/2022.

Bilateral Locked Posterior Fracture-Dislocation of the Shoulder After Epileptic Seizures Secondary to Cavernous Hemangioma: A Case Report and Literature Review.

BACKGROUND Posterior shoulder dislocation is an uncommon injury, accounting for less than 5% of all glenohumeral dislocations. Bilateral locked posterior shoulder fracture-dislocation is an extremely rare entity with an incidence of 0.6 cases/100 000 people/year. A few reports have been published in the literature, predominantly associated with epileptic seizures. CASE REPORT We present a rare case of a 55-year-old male patient with a history of epileptic seizures, who presented with bilateral, locked, posterior fracture-dislocation of the shoulder following an epileptic seizure. The patient was diagnosed with a cavernous hemangioma, which caused his epileptic episode. He was treated operatively, with a modified McLaughlin procedure performed on both sides, at 1 stage, by 2 surgical teams. The cavernous hemangioma was also resected 2 months later. After a follow-up period of 18 months, no recurrent episodes of instability or dislocation were identified. Full range of motion was present on both sides, with good clinical and radiological outcomes. We also conducted a literature review to elucidate the causes of this rare incidence, along with diagnostic workup and treatment options. We were able to identify 36 cases, involving 72 shoulders of bilateral posterior fracture-dislocations in 30 case reports and 2 case series. CONCLUSIONS Bilateral posterior fracture-dislocation of the shoulder is uncommon. Treatment strategy depends on the chronicity, involvement of the humeral head, and the patient's age and functional level. The target is to restore shoulder anatomy and maintain a functional range of motion.

A Review of Current Concepts of the Anterolateral Complex of the Knee.

The anterolateral complex (ALC) of the knee has gained increased interest over the last decades due to the high revision rates of anterior cruciate ligament reconstruction (ACLR). Furthermore, in patients with an ACL tear, the injury of at least one of the ALC's anatomic structures has been shown to be significantly higher, thus affecting its secondary stabilizing role at the knee joint. As such, ACLR augmentation techniques, that embrace the ALC, have been proposed recently, and indications for these procedures are still evolving. This review aims to present and discuss the most current anatomical, biomechanical, and imaging data, current reconstruction techniques, and the clinical results of ALC reconstruction.

Avoiding Complications of Locking Plating for Proximal Humerus Fractures.

Proximal humeral fractures are very common, especially among elderly people with osteoporosis. The treatment methods are numerous, according to the characteristics of the patient and the fracture, as well as the surgeon's preference. These fractures can be treated either conservatively or operatively with closed or open reduction and internal fixation, or arthroplasty. During the past decades, with the advances in osteosynthesis and the establishment of locking plates, many surgeons prefer managing humeral fractures with open reduction and internal fixation with locking plates. Even though this is a widespread method of treatment, many studies report high complication rates, including perioperative and hardware complications. This article presents the most common complications a surgeon may face when managing this kind of fractures, as well as intraoperative techniques that can be used to avoid them.

Reverse Shoulder Arthroplasty for Failed Operative Treatment of Proximal Humeral Fractures.

Introduction: Failure after operative treatment of complex proximal humeral fractures (PHF) can prove challenging even for experienced surgeons. Reverse shoulder arthroplasty (RSA) seems to offer a satisfactory revision procedure with good clinical outcomes. Materials and Methods: We present a case series of 14 patients, who were treated during a 3.5 years period (from 01/2016 until 06/2019). They all underwent revision surgery with RSA for failed operative treatment of PHF. Their mean age was 68 years (range, 51-84 years). 2 patients (14.3%) had been primarily treated with open reduction and internal fixation (ORIF), 5 patients (35.7%) with hemiarthroplasty, 3 patients (21.4%) with closed reduction and percutaneous fixation and 4 patients (28.6%) with transosseous suture fixation (TSF). We evaluated their absolute Constant score (CS), Visual Analogue Scale (VAS) score, and Range of Motion at their final follow-up, and we made a full clinical and radiological assessment to detect any postoperative complications. Results: The mean absolute CS, VAS score, active anterior elevation, active abduction significantly improved compared with the preoperative status. Less significant difference was found in external rotation when comparing with the preoperative status (P = .0304). No significant differences were found when comparing RSA for different failed primary techniques (P > .05). No complications were detected following the revision surgeries of all patients. Conclusion: RSA is an appropriate treatment as a revision technique for failed primary surgical treatment of PHFs. Though challenging it can offer good clinical results and pain relief.

What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis.

BACKGROUND: The purpose of the present study was to systematically review the current treatment strategies for the treatment of Neer type IIB distal clavicle fractures in terms of functional outcome and complication rates and to examine the most appropriate surgical method by comparing all the available surgical techniques and implants. METHODS: We performed a systematic review of the existing literature (2000-2021) in accordance with the PRISMA statement. We searched PubMed, Scopus, Web of Science, Research Gate and Google Scholar using the general terms 'distal AND clavicle AND fracture' to capture as many reports as possible. The MINORS tool was used to assess the risk of bias of the nonrandomized studies. We categorized the reported surgical techniques into four main types: open or arthroscopic coracoclavicular (CC) stabilization, locking plate fixation with or without CC augmentation, hook plate fixation and acromioclavicular joint (ACJ) transfixation. We reported findings for two main outcomes: clinical results and complication rates categorized into major and minor. RESULTS: Our database search yielded a total of 630 records; 34 studies were appropriate for qualitative analysis. There were 790 patients, with a mean age of 40.1 years, a female percentage of 37% and a mean follow-up period of 29.3 months. In total, 132 patients received a hook plate, 252 received a locking plate, 368 received CC stabilization and 41 received transacromial transfixation. All studies were retrospective and had fair MINORS scores. Locking plate, CC stabilization and ACJ transfixation showed similar clinical results but were much better than hook plate fixation; CC augmentation did not significantly improve the outcome of locking plate fixation. The rate of major complications was similar among groups; hook plate and AC joint transfixation had the worst rates of minor complications. Open CC techniques were slightly better than arthroscopic techniques. CONCLUSIONS: The present systematic review for the optimal fixation method for Neer type IIB fractures of the distal clavicle showed similar major complication rates among techniques; the hook plate technique demonstrated inferior clinical results to other techniques. Open CC stabilization and locking plate fixation without CC augmentation seem to be the best available treatment options.

A Unique Technique for Precise Targeting in Treatment of Rare Bifocal Intraosseous Ganglion Cysts of the Talus: A Case Report and Review of the Literature.

BACKGROUND This article presents a rare case of 2 separate intraosseous ganglion cysts of the talus in a 51-year-old man, treated with a unique technique of precise lesion targeting to avoid extensive bone loss and minimize articular chondral injury of the talus. CASE REPORT Two separate intraosseous ganglion cysts of the talus were diagnosed in a 51-year-old man with chronic ankle pain. A single straight-line incision with an entry point through the talonavicular joint was created to spare the precarious blood supply of the talus network. The 2 distinct subchondral lesions were approached under fluoroscopic control for curettage and autologous bone grafting using the anterior cruciate ligament tibial guide in a pair-of-compasses fashion. In almost 5 years of follow-up the patient has been asymptomatic. Magnetic resonance imaging has revealed no signs of degenerative changes in the ankle or the talonavicular joint, and the intraosseous edema has almost disappeared. CONCLUSIONS To the best of our knowledge, this case is the first report of 2 distinct intraosseous ganglion cysts of the talus. We recommend the precise targeting technique used in our case for treating intraosseous talar lesions with intact articular cartilage.

A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature.

BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

Intraneural ganglion cysts of the peroneal nerve.

BACKGROUND: Intraneural ganglion cysts of the peroneal nerve are rare, and there is lack of evidence for the surgical management of this entity. We performed this study to evaluate the imaging, diagnosis, treatment and outcome of seven patients with intraneural ganglion cysts of the peroneal nerve. MATERIALS AND METHODS: We retrospectively studied the files of seven patients with intraneural ganglion cysts of the peroneal nerve, diagnosed and treated from 2016 to 2019. Diagnostic approach included clinical examination of the leg and foot, magnetic resonance imaging, nerve conduction studies, surgical excision of the cyst and histological examination. The mean follow-up was 2 years (range 1-3.5 years). We evaluated the time and methods for surgical treatment, and the clinical outcomes of the patients. RESULTS: All patients presented symptoms of peripheral compression neuropathy; three patients presented with foot drop. The intraneural ganglion cysts were excised in all cases in addition to knee articular nerve branch transection to avoid cysts recurrence. Postoperatively, all patients experienced complete neurological recovery without clinical evidence of intraneural ganglion cysts recurrences. CONCLUSION: The treating physicians should be aware of intraneural ganglion cysts of the peroneal nerve in patients presenting with limb weakness, sensory deficits at the lateral and anterior side of the leg and foot, paresis or paralysis of the foot and ankle. MR imaging is the imaging modality of choice for a clear and accurate preoperative diagnosis to avoid misdiagnosis and wrong treatment. In case of doubt, these patients should be managed in an orthopedic oncology setting with microsurgery facilities available for complete excision of the intraneural ganglion cyst.

Injury to the Medial Superior Genicular Artery After Isolated Posterior Cruciate Ligament Reconstruction: A Case Report.

CASE: A 19-year-old male patient with isolated posterior cruciate ligament (PCL) rupture underwent arthroscopic reconstruction using reinforced synthetic ligament (LARS system). Three weeks postoperatively, he presented with active bleeding from the medial side of his knee, near the proximal interference screw. An angiogram revealed extravasation from the medial superior genicular artery which was successfully embolized. One week later, he returned with active bleeding from the same area, located just under the initial coiling; a second embolization during superselective angiography was successful. CONCLUSION: Although rare, minor vascular injuries are a risk inherent to PCL surgery.

Arthroscopic reduction and fixation of greater tuberosity fractures of the humerus.

BACKGROUND: The optimal technique for the displaced greater tuberosity (GT) fractures remains unclear; those in favor of arthroscopic techniques emphasize on the feasibility of arthroscopic reduction and fixation, while others report that anatomic reduction and osteosynthesis of the fracture are optimal through open surgery. Therefore, we performed this study to evaluate the clinical results of arthroscopic fixation for displaced and/or comminuted GT fractures using a bridging arthroscopic technique. MATERIALS AND METHODS: We studied the files of 11 patients (4 men, 7 women; mean age, 55 years; range, 28-74 years), with an isolated, displaced GT fracture treated with arthroscopic reduction and double-row suture anchor fixation technique from December 2016 to October 2018. All patients were operated at a mean time from their injury of 23 days (range, 1-85 days) using an arthroscopic technique. Any concomitant pathology that was arthroscopically identified was identified and repaired after arthroscopic fixation of the GT fracture. The mean follow-up was 12 months (range, 6-18 months). We evaluated pain using a 0-10 point visual analog scale (VAS), shoulder range of motion, fracture healing, Constant-Murley Shoulder Outcome Score, and patients' satisfaction from the operation. RESULTS: Postoperative radiographs showed anatomic reduction without any displacement of the GT fracture in eight patients and residual displacement of < 3 mm in three patients. All patients significantly improved in VAS score from 8.4 points (range, 7-10 points) preoperatively to 0.9 points (range, 0-3 points) postoperatively. Range of motion was 153 degrees forward flexion (range, 130-170 degrees), 149 degrees abduction (range, 120-170 degrees), 42 degrees external rotation (range, 20-70), and internal rotation between T10 and L3 spinal level. The final mean Constant-Murley Shoulder Outcome Score was 85.8 points (range, 76-94 points); correlation analysis showed that the patients with the higher greater tuberosity fracture displacement had the worst postoperative score (Pearson correlation coefficient -0,85; p = 0.0009), and the patients with nonanatomic reduction had close to average score. All patients were very satisfied with the end result of the operation, even the 3 patients with residual fracture displacement. No patient experienced any postoperative complications. CONCLUSIONS: Arthroscopic reduction and fixation of displaced GT fractures is a feasible minimally invasive procedure for optimal fracture healing and patients satisfaction.

A Novel Treatment of a 65-Year-Old Woman with a Neglected Type IIIB Open Fracture of the Tibia with Inadequate Soft Tissue Coverage and Periosteal Stripping Requiring an Ilizarov Approach to Bone and Soft Tissue Lengthening and Reconstruction: A Case Report and Review of the Literature.

BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Arthroscopic Treatment of Luxatio Erecta Humeri Associated with Greater Tuberosity Fracture, Bankart Lesion, and Partial Rotator Cuff Tear: A Case Report.

BACKGROUND Luxatio erecta humeri (LEH) is a rare injury present in only 0.5% of shoulder dislocations. Much of the relevant literature is focused on the initial management and proper reduction techniques, although the prevalence of associated injuries can reach 80%. A case of LEH associated with greater tuberosity (GT) fracture and rotator cuff (RC) tear in a young laborer managed with closed reduction and arthroscopic repair of the labrum and rotator cuff is presented. CASE REPORT A 28-year-old man presented to our hospital with severe pain in his right shoulder after a high-impact motor vehicle accident. Standard anteroposterior radiographs revealed an inferior dislocation (LEH) of the right shoulder and a fracture of the GT. The patient was initially managed with closed reduction under mild intravenous sedation, using a 2-step maneuver followed by arthroscopic evaluation of the joint the next day. During arthroscopic evaluation, an anterior-inferior Bankart lesion, impaction of the humeral head with a minimal displaced GT fracture, and a partial RC tear were identified and successfully treated arthroscopically. The patient had immobilization in a simple sling for 6 weeks and he followed a standard 3-month physiotherapy protocol for rotator cuff, finally regaining almost normal range of shoulder motion at 1 year. CONCLUSIONS Although very good results of non-operative treatment of LEH have been reported in the literature, the co-existence of intra-articular lesions such as labral and rotator cuff tears makes arthroscopic repair an attractive alternative in individual cases.

Neurovascular Bundle Entrapment and Through Knee Amputation After Cerclage Cabling of Distal Femoral Peri-implant Fracture: A Case Report.

CASE: We report the case of an 82-year-old woman with diabetes, arteriosclerosis, chronic heart failure, and hypertension treated with an anatomical locking plate and multiple cables for a spiral-wedged periprosthetic fracture of the distal femur which was complicated by direct occlusion of the femoral artery and crush of the sciatic nerve, resulting in leg necrosis and, ultimately, through-knee disarticulation despite early recognition and arterial repair. CONCLUSIONS: Neurovascular injury is a potential complication of cerclage cables placement around the femoral shaft during complex fracture fixation. Devastating complications cannot always be corrected despite early vascular intervention.

Benign peripheral nerve tumors.

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach.

Reconstruction of elbow flexion with a modified Oberlin procedure: A comparative study.

INTRODUCTION: In upper brachial plexus injuries (C5-C6-C7), selective nerve transfers appear as a favourable technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. In this paper we present our modified Oberlin technique, as well as a comparison of this method with the classic Oberlin procedure. MATERIALS AND METHODS: We present two groups of patients that where operated by two different surgeons. The first group, consisting of 16 patients was treated with the classic Oberlin procedure. The second group included 5 patients treated with a modified Oberlin procedure, where two fascicles from the ulnar nerve were transferred to both the motor branch of the biceps and the motor branch of the brachialis muscles. RESULTS: In the last follow-up of the 16 patients from the first group with the classic Oberlin procedure, 15 patients (93.75%) had Medical Research Council (MRC) grade of biceps strength 4 and 1 patient (6.25%) had MRC grade 3, whereas in the group where the modified Oberlin procedure was used the muscle strength was very durable with 4 out of 5 the patients reached MRC grade of 4+ and one MRC grade of 4, and with a mean elbow strength at 5.4 kg (3-8 kg). No sensitivity or motor problems were encountered on the ulnar territories for both groups. CONCLUSION: With the modified Oberlin technique, the median nerve is reserved and both elbow flexors are innervated. The results of this technique compare favourably with those of other methods. Thus, we propose using the double fascicle transfer from the ulnar nerve to both elbow flexors in order to restore a strong elbow flexion in patients with upper brachial plexus injuries.

Lateral arm flap: indications and techniques.

The lateral arm flap (LAF) is a popular flap transfer, which can be applied in many procedures. It was first described in 1982, and till then, even more clinical applications are suggested. It can be used as a free fasciocutaneous or fascial flap to cover small- to medium-sized soft tissue defects in head and neck but also in upper and lower extremity reconstruction, or as an osteocutaneous flap when vascularized bone graft is needed. We present the indications and contraindications, the advantages and disadvantages, as well as the step-by-step technique of harvesting a fasciocutaneous and an osteocutaneous flap and its complications. We conclude that the LAF is a reliable and versatile tool for reconstructive surgery, due to its anatomical characteristics and the low complication rate.