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.

Brachial plexus injuries in adults: evaluation and diagnostic approach.

The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries.

Osteosarcoma of navicular bone. En bloc excision and salvage of the foot.

AIM: To present foot salvage for osteosarcoma of the navicular bone with en bloc resection and reconstruction using bone allograft and talus-cuneiform arthrodesis. PATIENT AND SURGICAL TECHNIQUE: A 20 year-old male with a history of osteosarcoma of the distal femur presented to our department 5 years later with a metastatic lesion of the navicular bone of the contralateral foot. The patient received 4 cycles of neo-adjuvant chemotherapy with satisfactory response. Tumor shrinkage allowed en bloc excision of the navicular bone with clear margins. Reconstruction was done using a tricortical allograft and talus-allograft-cuneiform arthrodesis, secured with a mini-fracture plate (Synthes). Weight bearing protection was advised for 2 months and partial weight bearing for another 4 months. Patient received 4 cycles of adjuvant chemotherapy. RESULTS: Three years postoperatively, the patient was free of local recurrence or distant metastasis. There were no signs of allograft resorption, fracture or non union. The patient was asymptomatic and full weight bearing. Ankle and subtalar joint motion was within normal limits. CONCLUSION: Foot salvage after excision of osteosarcoma of the navicular bone could be possible if en bloc resection of the lesion could be performed. Talus-cuneiform fusion with allograft interposition is a viable reconstructive option.

Results of extra-articular subtalar arthrodesis in children with cerebral palsy.

BACKGROUND: Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the long-term results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. METHODS: Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. RESULTS: Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. CONCLUSION: Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity.

Avascular necrosis of the hamate treated with capitohamate and lunatohamate intercarpal fusion.

This article describes a case of a 58-year-old man with no significant underlying disease who had chronic pain due to osteonecrosis of the hamate. Following physical examination, imaging, and laboratory findings, he underwent surgical exploration via a limited dorsal approach. The hamate bone did not have a normal anatomical appearance or structure. It was marble-like in appearance, soft, friable, and lacking physiologic contour and bone strength. We removed the dorsal aspect of the hamate piecemeal. The articular surfaces of the adjacent carpal bones (capitate and lunate) were excised, and the lesion was packed with iliac autograft. Three months postoperatively, fusion of the remaining hamate and the adjacent capitate and lunate carpal bones was evident, and the patient reported mild wrist pain, moderate grip strength improvement, and mild improvement of wrist range of motion and stiffness. Currently, no standard treatment algorithm exists for patients with avascular necrosis of the hamate. However, delayed diagnosis of this clinical entity can be debilitating. A high index of clinical suspicion and an early course of treatment offers considerable benefits to patients with osteonecrosis of the hamate.

Recurrent fluctuant mass of the wrist and forearm associated with chronic tenosynovitis by Mycobacterium kansasii.

This article presents a case of a painless fluctuant mass on the volar aspect of the wrist and forearm of an immunocompetent 45-year-old man with no history of significant underlying disease. This mass proved to be a chronic tenosynovitis associated with Mycobacterium kansasii infection. The patient, who had a history of multiple minor cuts and abrasions plus exposure to an aquatic environment, had a wide resection of the lesion and elective tenosynovectomy. Operative findings revealed a marked tenosynovitis of flexor tendons. Several rice bodies lesions were also observed along the course of the involved flexor tendons.Biopsy showed a granulomatous inflammatory reaction. Specimens of affected tissue were sent to a laboratory for solid (at 30°C and at 37°C) and liquid (at 37°C) mycobacterial culture. The initial Ziehl-Neelsen stain for acid-fast bacilli was positive. After 8 days of incubation, acid-fast bacilli were recovered. In accordance with the diagnosis of M kansasii tenosynovitis and the results of antibiotic susceptibility testing, triple therapy with rifampicin, isoniazid and clarithromycin was initiated. After 3 months of therapy, the patient experienced improvement in the swelling and is due to receive 12 months of antibiotic therapy. Despite awareness of atypical mycobacterial infections, diagnosis is frequently delayed, leading to increased morbidity. Patients with exposure to these atypical pathogens require a broadened differential to include appropriate testing and culture of specimens to obtain an accurate diagnosis.