Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients.

PURPOSE: We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options. METHODS: We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported. RESULTS: Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up. CONCLUSIONS: A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients.

PURPOSE: To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). MATERIALS AND METHODS: Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more. RESULTS: In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength. CONCLUSIONS: In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical measurements for inferior, posterior, and superior glenohumeral joint contracture evaluation in children with brachial plexus birth palsy: intraobserver and interobserver reliability.

BACKGROUND: Glenohumeral (GH) contractures appear in most patients with incomplete motor recovery as a result of progressive development of periarticular muscle contractures. The objectives of this study were to describe a method to measure the passive range of motion of the glenohumeral joint (GHJ) in patients with brachial plexus birth palsy (BPBP) and to evaluate its intraobserver and interobserver reproducibility. METHODS: Three orthopedic surgeons measured the passive GHJ mobility of 25 patients older than 4 years with unilateral BPBP. Measurements were performed twice on both shoulders. They comprised the spinohumeral abduction angle (SHABD), spinohumeral adduction angle (SHADD), GH cross-body adduction (CBADD), and GH internal rotation in abduction (IRABD). Anterior GH contracture was not evaluated. RESULTS: Passive shoulder measurements obtained from the uninvolved and involved shoulders were as follows: SHABD, 42° and 18°, respectively; SHADD, 14° and -1°, respectively; CBADD, 71° and 41°, respectively; and IRABD, 54° and 37°, respectively. Contracture of the lower portion of the involved GHJ was observed in 18 of 25 patients (72%); the upper portion, in 16 of 25 (64%); and the posterior portion, in 22 of 25 (88%). Interobserver variation (intraclass correlation coefficient) was 0.91 (excellent) for SHABD, 0.63 (good) for SHADD, 0.86 (excellent) for CBADD, and 0.67 (good) for IRABD. Intraobserver variation (intraclass correlation coefficient) was 0.94 (excellent) for SHABD, 0.87 (excellent) for SHADD, 0.92 (excellent) for CBADD, and 0.89 (excellent) for IRABD. CONCLUSIONS: Clinical measurements of passive GHJ range-of-motion analyzed in this study showed excellent or good intraobserver and interobserver variability. Our study showed that BPBP resulted in a multidirectional GH contracture in most patients. We have described a simple and reliable way to evaluate passive GH motion, providing reliable anatomic landmarks.

Locking plate versus retrograde intramedullary headless compression screw for unstable extra-articular metacarpal base fractures of the thumb.

The purpose was to compare clinical and radiological outcomes between two fixation techniques used to treat extra-articular fractures involving the base of the thumb metacarpal: retrograde intramedullary cannulated headless screw (RICHS) and locking plate (LP). Fifty-one patients who underwent RICHS (n = 22) or LP fixation (n = 29) from January 2010 through 2020 were included in this retrospective case-control study with mean follow-up 39 months. No inter-group differences were observed comparing mean time to radiological union, grip strength, range of motion, pain severity or QuickDASH scores. Mean surgery time was shorter with RICHS (18.9 min) than with LP fixation (44.4 min). Mean time to return to work or routine activities was less in RICHS than LP (22 vs. 32 days), as was the percentage of patients requiring hardware removal (0% vs. 44.8%). We conclude that RICHS fixation requires less operating time and yields faster post-operative return to full function and fewer secondary procedures.

Glenohumeral abduction contractures after residual neonatal brachial plexus injury.

Glenohumeral abduction contractures are common in patients with neonatal brachial plexus injury, but little has been previously published about them. We conducted a retrospective analysis of data prospectively collected from 205 consecutive children (108 female) of mean age 9.6 years with neonatal brachial plexus injury (C5-C6, 58%; C5-C7, 29%; C5-T1, 14%). Most children (69%) showed a glenohumeral abduction contracture, it being more common in those with upper neonatal brachial plexus injury.Level of evidence: III.

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children.

We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity.Level of evidence: IV.

Analysis of 3 Different Operative Techniques for Extra-articular Fractures of the Phalanges and Metacarpals.

Background: Several techniques have been described for treating metacarpal and phalangeal fractures. We sought to compare the 3 techniques most frequently used for extra-articular metacarpal and phalangeal fractures: plate screw (PS), Kirschner wire (KW), and retrograde intramedullary screw (RIS) fixation. We aimed to determine whether using an RIS provides better clinical outcomes than using either a PS or a KW fixation. Methods: We conducted a retrospective review of patients who underwent surgical treatment of metacarpal and phalangeal fractures from January 2011 to December 2017 in our department. Only patients with an acutely displaced short oblique or transverse extra-articular metacarpal or phalangeal fracture were included. Patients were classified into 3 groups depending on the treatment they received: PS, KW, or RIS fixation. The duration of each procedure was recorded. Clinical assessments included measuring total active motion (TAM), grip strength, and an evaluation of plain radiographs through to ultimate healing. A Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was collected on all patients. Data were analyzed by analysis of variance or Kruskal-Wallis rank test, as indicated. Results: A total of 253 fractures (202 metacarpal and 51 phalangeal) in 230 patients were included in analysis. In all, 135 fractures (53.3%) underwent PS fixation; 53 (20.9%), KW fixation; and 65 (25.6%), RIS fixation. In the KW fixation group, Bouquet pinning was performed for metacarpal fractures and cross pinning for phalangeal fractures. When more than 1 fracture coexisted in the same patient, they were considered separate instances. No differences among the 3 groups were observed when evaluating mean time to radiological union, grip strength, TAM, or QuickDASH score. Mean surgery time was significantly shorter with KW (20 minutes) and RIS (25 minutes), than with PS (32 minutes). Mean return to work or routine activities time was significantly less in the RIS (7.8 weeks) group than in the PS and KW groups (8.3 and 9.2 weeks, respectively). Conclusions: Surgical treatment is recommended in patients with unstable metacarpal and phalangeal fractures. The use of RIS was associated with shorter mean surgery duration and return to work times than PS and KW, respectively.

Suprascapular Neuropathy around the Shoulder: A Current Concept Review.

Suprascapular neuropathy is an uncommon but increasingly recognized cause of shoulder pain and dysfunction due to nerve entrapment. The aim of this review is to summarize some important aspects of this shoulder pathology. An extensive research was performed on PubMed and Clinical Key. The goal was to collect all the anatomical, biomechanical and clinical studies to conduct an extensive overview of the issue. Attention was focused on researching the state of art of the diagnosis and treatment. A total of 59 studies were found suitable and included. This condition is more frequently diagnosed in over-head athletes or patients with massive rotator cuff tears. Diagnosis may be complex, whereas its treatment is safe, and it has a great success rate. Prompt diagnosis is crucial as chronic conditions have worse outcomes compared to acute lesions. Proper instrumental evaluation and imaging are essential. Dynamic compression must initially be treated non-operatively. If there is no improvement, surgical release should be considered. On the other hand, soft tissue lesions may first be treated non-operatively. However, surgical treatment by arthroscopic means is advisable when possible as it represents the gold standard therapy. Other concomitant shoulder lesions must be recognized and treated accordingly.

Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures.

The purpose of the study was to evaluate clinical and radiological outcomes of extra-articular fractures involving the base of the thumb metacarpal treated with fixation using a retrograde intramedullary cannulated headless screw. A review of prospectively collected data was conducted on a consecutive series of 13 patients, treated with headless screw fixation for acute displaced fractures. All workers resumed full duties, while non-workers returned to unlimited leisure activities within a mean of 42 days. At 3 months follow-up, all range of motion measurements in the treated and untreated thumb were similar. Mean visual analogue pain score was 0.8 at rest and 1.4 during exercise and mean Quick Disabilities of the Arm, Shoulder, and Hand score was 5. All patients achieved radiographic union by 8 weeks. We conclude that the intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. Level of evidence: IV.