BIO-RSA vs. metal-augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

BACKGROUND: Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that (1) metal-augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to bony increased-offset (BIO)-RSA and (2) bone graft viability and healing in BIO-RSA patients become compromised over time. MATERIALS AND METHODS: Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal-augmented baseplate (metallic increased-offset [MIO]-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (ß angle) and retroversion were also measured. RESULTS: Delta scores of active anterior elevation were higher in the MIO-RSA group (P = .027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, and glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (P = .022), whereas the values of ß angle and postoperative retroversion were similar in the 2 groups. BIO-RSA group showed radiolucent lines <2 mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rates of humerus condensation lines in MIO-RSA patients (P = .01) and higher rates of cortical thinning and tuberosity resorption in the BIO-RSA group (P = .027 and P = .004, respectively). CONCLUSION: Metal-augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patients raise concern about the risk of baseplate loosening and requires further long-term studies.

Navigation in reverse shoulder arthroplasty: how the lateralization of glenosphere can affect the clinical outcome.

INTRODUCTION: One of the main causes of RSA failure is attributable to the malpositioning of the glenoid component. Initial experiences with computer-assisted surgery have shown promising results in increasing the accuracy and repeatability of placement of the glenoid component and screws. The aim of this study was to evaluate the functional clinical results, in terms of joint mobility and pain, by correlating them with intraoperative data regarding the positioning of the glenoid component. The hypothesis was that the lateralization more than 25 mm of the glenosphere can led to better stability of the prosthesis but should pay in term of a reduced range of movement and increased pain. MATERIALS AND METHODS: 50 patients were enrolled between October 2018 and May 2022; they underwent RSA implantation assisted by GPS navigation system. Active ROM, ASES score and VAS pain scale were recorded before surgery. Preoperative data about glenoid inclination and version were collected by pre-op X-Rays an CT. Intraoperative data-inclination, version, medialization and lateralization of the glenoid component-were recorded using computer-assisted surgery. 46 patients had been further clinically and radiographically re-evaluated at 3-months, 6-months, 1-year, and 2-years follow-up. RESULTS: We found a statistically significant correlation between anteposition and glenosphere lateralization value (DM - 6.057 mm; p = 0.043). Furthermore a statistically significant correlation has been shown between abduction movement and the lateralization value (DM - 7.723 mm; p = 0.015). No other statistically significant associations were found when comparing the values of glenoid inclination and version with the range of motion achieved by the patients after reverse shoulder arthroplasty. CONCLUSION: We observed that the patients with the best anteposition and abduction results had a glenosphere lateralization between 18 and 22 mm. When increasing the lateralization above 22 mm or reducing it below 18 mm, on the other hand, both movements considered decreased their range. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis.

BACKGROUND: Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity. This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years. MATERIALS AND METHODS: OBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study. RESULTS: Four Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:- 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+- 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting. CONCLUSIONS: RSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements. LEVEL OF EVIDENCE: Level IV, Case series.

Study of a constrained finite element elbow prosthesis: the influence of the implant placement.

BACKGROUND: The functional results of total elbow arthroplasty (TEA) are controversial and the medium- to long-term revision rates are relatively high. The aim of the present study was to analyze the stresses of TEA in its classic configuration, identify the areas of greatest stress in the prosthesis-bone-cement interface, and evaluate the most wearing working conditions. MATERIALS AND METHODS: By means of a reverse engineering process and using a 3D laser scanner, CAD (computer-aided drafting) models of a constrained elbow prosthesis were acquired. These CAD models were developed and their elastic properties, resistance, and stresses were studied through finite element analysis (finite element method-FEM). The obtained 3D elbow-prosthesis model was then evaluated in cyclic flexion-extension movements (> 10 million cycles). We highlighted the configuration of the angle at which the highest stresses and the areas most at risk of implant mobilization develop. Finally, we performed a quantitative study of the stress state after varying the positioning of the stem of the ulnar component in the sagittal plane by ± 3°. RESULTS: The greatest von Mises stress state in the bone component for the 90° working configuration was 3.1635 MPa, which occurred in the most proximal portion of the humeral blade and in the proximal middle third of the shaft. At the ulnar level, peaks of 4.1763 MPa were recorded at the proximal coronoid/metaepiphysis level. The minimum elastic resistance and therefore the greatest stress states were recorded in the bone region at the apex of the ulnar stem (0.001967 MPa). The results of the analysis for the working configurations at 0° and 145° showed significant reductions in the stress states for both prosthetic components; similarly, varying the positioning of the ulnar component at 90° (- 3° in the sagittal plane, 0° in the frontal plane) resulted in better working conditions with a greater resulting developed force and a lower stress peak in the ulnar cement. CONCLUSION: The areas of greatest stress occur in specific regions of the ulnar and humeral components at the bone-cement-prosthesis interface. The heaviest configuration in terms of stresses was when the elbow was flexed at 90°. Variations in the positioning in the sagittal plane can mechanically affect the movement, possibly resulting in longer survival of the implant.

Anatomically reduced fixation should always be considered when treating B and C proximal epiphyseal humeral fractures.

BACKGROUND: Proximal humeral fractures are commonly observed in elderly patients. Management of these injuries is controversial. Literature comparing locking plate fixation, arthroplasty, and conservative treatments show no clear advantages for any of these management strategies. Thus far, no study has considered anatomically reduced fractures obtained after locking plate treatment. To clarify the best surgical procedure in middle-aged patients, we considered outcomes and major complications leading to surgical revision following an anatomically reduced fracture fixed with locking plate and reverse shoulder arthroplasty (RSA) in the treatment of type B/C fractures in patients between 50 and 75 years of age. METHODS: This is a retrospective study including 59 patients between 50 and 75 years of age with type B/C proximal humeral fracture treated with RSA or with locking plate fixation (resulting in an anatomical reduction) between January 2010 and December 2018. Preoperative radiographs and computed tomography (CT) were evaluated in all patients. Clinical and radiologic follow-up was performed using range of motion (ROM), the Constant-Murley Score (CMS), the Oxford Shoulder Score (OSS), the Simple Shoulder Test (SST), the Subjective Shoulder Value (SSV), and visual analog scale (VAS). Major complications were considered. RESULTS: In the plate fixation group, ROM, CMS, SST, and VAS were higher than in the RSA group. Lower complication rates compared with the literature were observed in both groups. Anatomically reduced fracture fixed with plate and screw could outperform RSA in terms of outcome. In second-level centers where traumatology is performed by surgeons with great expertise in upper limb trauma, the choice between plate fixation and reverse arthroplasty should be made during surgery. CONCLUSION: Anatomically reduced fractures showed better outcomes compared with RSA in type B/C fractures. Surgeons should always try to perform a reduction of the fracture in order to understand if a plate fixation could be feasible. If it is impossible to perform an anatomical reduction, we suggest to consider RSA. This is a retrospective observational study.

Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury.

PURPOSE: The aim of this current study was to assess elbow ligament tears after dislocation using magnetic resonance imaging (MRI) and to correlate any pre-operative imaging with intra-operative findings of elbow ligament tears. METHODS: We prospectively included 32 patients with acute elbow dislocation investigated by MRI at a means of five days from dislocation. A simple elbow dislocation was diagnosed in 14 patients (44%); associated bone injuries were identified in 18 elbows (56%). Surgical repair of elbow ligaments was carried out in 23 patients, and nine cases were treated non-operatively. A blinded MRI evaluation of all 32 elbows was performed by an orthopaedic surgeon (rater 1) and a musculoskeletal radiologist (rater 2). RESULTS: Inter-rater agreement for MRI evaluation of 32 was poor for lateral ulnar collateral ligament (LUCL) tears, fair for radial collateral ligament (RCL), moderate for annular ligament (AL), and fair for ulnar collateral ligament (UCL). All tears were reported as complete by rater 1; 13/32 partial tears were identified by rater 2 (LUCL = 2, RCL = 2, UCL = 9). Correlation between surgical and MRI findings showed good inter-rater agreement for LUCL and AL tears in both raters. Agreement for RCL tear was poor for rater 1 and fair for rater 2; agreement for UCL tear was fair for rater 1 and poor for rater 2. Intra-operative findings showed ten radial head fractures (RHFs) and ten coronoid fractures (CFs). LUCL tears were found in the four cases of type II RHFs and in 3/4 cases of CFs. Bone injuries and ligament tears were not significantly associated. CONCLUSION: MRI scan supported surgeons to identify soft tissue injuries and to address the most suitable surgical approach after acute elbow dislocation. Inter-observer agreement for intra-operative findings was high for LCL complex injuries and poor for UCL.

Surgical tips and tricks for coronal shear fractures of the elbow.

INTRODUCTION: Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns. MATERIALS AND METHODS: From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score. RESULTS: Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients. CONCLUSION: Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up. LEVEL OF EVIDENCE: Therapeutic III.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up.

BACKGROUND: Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up. MATERIALS AND METHODS: In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated. RESULTS: In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected. CONCLUSIONS: Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries. LEVEL OF EVIDENCE: Level IV-case series.

Isolate and irreducible radial head dislocation in children: a rare case of capsular interposition.

BACKGROUND: Radial head dislocation with no associated lesions, is a relatively uncommon injury in children. In this case report, it is reported a case of anteromedial locked radial head dislocation in children, and we discuss its clinical presentation and pathogenetic mechanism of injury. CASE PRESENTATION: An 8-year-old girl fell off on her right forearm with her right elbow extended in hyperpronation. An isolated radio-capitellar dislocation was identified with no other fractures or neurovascular injuries associated. Elbow presented an extension-flexion arc limited (0°- 90°), and the prono-supination during general anesthesia shows "a sling effect" from maximal pronation (+ 55°) and supination (+ 90°) to neutral position of forearm. The radial head dislocation was impossible to reduce and an open reduction was performed using lateral Kocher approach. The radial head was found "button-holed" through the anterior capsule. The lateral soft tissues were severely disrupted and the annular ligament was not identifiable. Only by cutting the lateral bundle of the capsule was possible to reduce the joint. At 50 moths follow-up, patient presented a complete Range of motion (ROM), complete functionality and no discomfort or instability even during sport activities. DISCUSSION AND CONCLUSION: It is important to understand the pathogenic mechanisms of locked radial head dislocation in children. Some mechanism described are the distal biceps tendon or the brachialis tendon interposition. However even the anterior capsule can hinder reduction. A characteristic "sling-effect" of the forearm could be pathognomonic for capsular button-holing. Surgical release of the capsular bundle sometimes is the only way to reduce the dislocation and obtain a good outcome.

Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear.

BACKGROUND: The aim of this study was to determine the lateral ulnar collateral ligament (LUCL) injury associated with isolated radial head fracture (RHF) and the relationship of the ligament injury with the displacement of the fragment-loss of contact-in unstable displaced partial articular RHF in individuals without any history of ulnohumeral dislocation. METHODS: We retrospectively identified 131 consecutive patients who underwent open reduction and internal fixation of isolated closed Mason type II RHF performed at our institution. We identified 3 subsets by the pattern of RHF and the position of the unstable fragment (anterior or posterior) relative to the capitulum humeri: displaced stable (group I), displaced anterior unstable (group II), and displaced posterior unstable (group III). Standard radiographs were obtained preoperatively and postoperatively. The pattern of lateral collateral ligament avulsion and its distribution were inferred from intraoperative records. RESULTS: Preoperative radiographs of the 131 patients showed 101 nonseparated fractures (77%, group I) and 30 unstable fractures (23%). Anterior displacement of the fragment was found in 18 elbows (14%, group II) and posterior displacement in 12 (9%, group III). LUCL avulsion was found in 18 of 30 unstable RHFs (60%) and in 1 of 60 stable RHFs (1.6%). CONCLUSION: RHF is a complex fracture often associated with soft tissue lesions. It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability. The RHF pattern and classification as stable or unstable can help the surgeon in the identification and treatment of LUCL lesions.

Volar PEEK plate for distal radius fracture: analysis of adverse events.

BACKGROUND: The aim of the present retrospective study was to evaluate complications following carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) volar plating in distal radius fracture in a large cohort of patients. As an alternative to conventional metallic devices, CFR-PEEK plates have been introduced over the last few years. METHODS: We performed a retrospective study including all patients who were treated for distal radius fracture using a volar fixed-angle plate DiPHOS-RM (Lima Corporate, Udine, Italy). All CFR-PEEK plates implanted were reviewed between May 2012 and December 2017. Plate removal, second surgery and adverse events were collected by reviewing medical records. A total of 110 patients were included with a mean follow-up of 4 years. RESULTS: Adverse side effects were observed in 9 cases (8%), developed during or after treatment. The most frequent complication was represented by intraoperative plate rupture (4%). Infection was reported in one case. DISCUSSION: The rate of complications of PEEK volar plates seems to be similar to those occurring with plates of different materials. Advantages of PEEK plates are the absence of the cold-welding phenomenon and the absence of exuberant bone callus on the plate, ensuring an easy hardware removal. Intraoperative rupture remains the main complication correlated with PEEK material. These complications can be reduced with an accurate surgical technique, especially at the beginning of the learning curve. LEVEL OF EVIDENCE: Therapeutic IV.

Comparison between absorbable pins and mini-screw fixations for the treatment of radial head fractures Mason type II-III.

BACKGROUND: The treatment of comminuted radial head fractures can include prosthetic replacement or open reduction and internal fixation. The purpose of this study is to evaluate the results of two different internal fixation systems for Mason type II-III radial head fractures. METHODS: Between 2005 and 2015, 82 patients were treated using pins and 65 patients by mini-screws. The follow-up protocol included: a clinical evaluation 15 days after surgery, and clinical and radiographic evaluations performed at 30 and 60 day intervals, unless any complications were reported by the patient. Over a period of at least 12-months of follow-up, patients were checked and interviewed. Clinical examinations included elbow range of motion (ROM), arm, shoulder and hand Disabilities, (DASH), and the Mayo Elbow Performance Score (MEPS). RESULTS: Sixty-one subjects who had been treated with mini-screws were clinically reviewed at a mean 47.3 ± 35.8 month of follow-up; all patients who had been treated using absorbable pins were evaluated at a mean 82.5 ± 20.6 month of follow-up. No significant statistically differences were observed between the two groups in the mean ROM, DASH, and MEPS scores. Residual pain was reported in 15.8%of the patients treated by pins and 9.2% patients treated by mini-screws. Secondary displacement of fracture fragments was observed in 8.5% patients treated by pins and 1.6% using mini-screws. CONCLUSIONS: Both absorbable pins and mini-screws provided adequate strength and rigidity, allowing good clinical and functional scores at a mid-term follow-up. However, a higher rate of secondary displacement of the fracture fragments was reported among subjects who had been treated using absorbable pins.

Clinical outcome is not affected by total knee arthroplasty alignment.

PURPOSE: This study aims to analyse the influence on total knee arthroplasty (TKA) clinical outcomes of biomechanical intra-operative computer-assisted surgery-measured parameters, together with radiographic and demographical data. METHODS: Between 2007 and 2009, 227 computer-assisted surgery (CAS) primary TKAs were performed in 219 consecutive patients. Information about gender, age and body mass index (BMI) was collected for each patient. Before knee replacement, all patients underwent a complete radiographic examination and passive flexion-extension range of motion was recorded. All TKAs were implanted using an image-free knee navigation system. Patients included in the study were evaluated at 3, 6 and 12 months of follow-up and then yearly. At each follow-up, subjects were asked to answer the validated Italian version of the Knee Injury and Osteoarthritis Outcome Score. RESULTS: One hundred and eighty patients (187 knees) had data available for analysis. Complications were reported in 13 patients (7.0 %). Intra-operative CAS-measured parameters, together with age, BMI, gender, pre- and post-operative radiographic alignment, did not influence TKA clinical results at a mean 2 years of follow-up. On the other hand, higher post-operative flexion arc of movement was suggestive of better clinical outcomes. CONCLUSION: TKA clinical outcome is influenced by post-operative knee flexion, other than neutral mechanical limb alignment. Therefore, it is recommended to prefer TKA designs that allow high flexion and to encourage early physical rehabilitation. LEVEL OF EVIDENCE: IV.

Pediatric medial epicondyle fractures with intra-articular elbow incarceration.

BACKGROUND: Intra-articular incarceration of the epicondylar fragment occurs in 5-18 % of all cases of medial epicondyle fracture. It requires stable fixation to allow early motion, since elbow stiffness is the most common complication following medial epicondyle fracture. In this retrospective study, we report the clinical and functional outcomes and the complications that occurred following open reduction and screw fixation of medial epicondyle fractures with intra-articular fragment incarceration. METHODS: Thirteen children who had a fracture of the medial epicondyle with incarceration of the fragment in the elbow joint (type III) were surgically treated in our university hospital between 1998 and 2012. There were eight male and five female patients. The mean age at the time of injury was 13 years (range 9-16). Operative treatment consisted of open reduction and internal fixation with one or two 4.0-mm cannulated screws under fluoroscopic control. RESULTS: All of the patients were clinically reviewed at an average follow-up of 29 months. The overall range of motion limitation was about 5° for flexion-extension and 2° for pronation-supination. The score was excellent in all patients (mean 96.3). Complications occurred in four (31 %) children: two cases of symptomatic screw head prominence, irritation with partial lesion of the distal triceps myotendinous junction in one patient, and median nerve entrapment syndrome in one patient. CONCLUSIONS: In conclusion, open reduction and screw fixation yielded excellent clinical and functional outcomes for the treatment of medial epicondyle fractures with intra-articular fragment incarceration. However, particular attention is should be paid when treating these potentially serious injuries in order to minimize the risk of possible complications. LEVEL OF EVIDENCE: Therapeutic IV.

Schwannomas of the upper extremity: analysis of 34 cases.

BACKGROUND: Schwannomas are the most common benign tumours developing in peripheral nerves. They usually present as a slow-growing mass, sometimes associated with pain and paraesthesia. The aim of this study is to define the correct preoperative diagnosis, to review the surgical treatment employed and to evaluate short- and long-term neurological deficits. METHODS: Thirty-four patients affected by schwannoma in the upper limbs were treated in the period 1995-2011. In 15 patients the tumour was located on the ulnar nerve, in 8 on the median nerve, in 2 on the radial nerve, in 1 on the anterior interosseous nerve, in 1 on the muscle-cutaneous nerve, and in the remaining 7 on the digital nerves. All patients were surgically treated using a microsurgical approach. RESULTS: The enucleation of the mass was possible without fascicle lesion in 12 cases. In 22 cases resection of the indissociable fascicles was performed. Postoperative paraesthesia was present in 28 out of 34 treated patients; this clinical sign regressed in a mean period of 12 months in 27 patients. CONCLUSIONS: When approaching a palpable mass in the upper limbs, the possibility of a peripheral nerve tumour should always be considered. It is important to look for typical signs of schwannomas, such as a positive Tinel sign and peripheral paraesthesia. Imaging assessment with magnetic resonance imaging (MRI) and ultrasonography enables the determination of where the tumour takes its origin and from which nerve. Microsurgical techniques and know-how are recommended in approaching the resection in order to respect as many nerve fibres as possible.

Use of integra artificial dermis to reduce donor site morbidity after pedicle flaps in hand surgery.

PURPOSE: To assess the results obtained with Integra artificial dermis to cover donor site following the harvesting of pedicle flaps for hand reconstruction. METHODS: Between April 2010 and August 2013, 11 patients (8 men and 3 women; mean age, 37 y) were treated with Integra Dermal Regeneration Template (Integra LifeSciences, Inc., Plainsboro, NY) to cover donor defects after raising pedicle flaps for hand and finger reconstruction: radial forearm flap (4 cases), ulnar artery perforator flap (2 cases), and heterodigital island flap (5 cases). After neodermis formation the silicone layer of the artificial dermis was removed (on average after 22 days) and a split- or full-thickness epidermal autograft placed. RESULTS: No infections, hematoma, or bleeding were recorded during the entire phase in which the artificial skin was applied. Two patients experienced a partial skin graft loss. Median follow-up was 20 months, and results included an average Vancouver Scar Scale rating of 2.7 and an average DASH score of 39. There were no cases of graft adherence to the underlying tendons or muscles. CONCLUSIONS: Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of painful median nerve neuromas with radial and ulnar artery perforator adipofascial flaps.

PURPOSE: To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps. METHODS: Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel's sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18-84 mo). Preoperative and postoperative pain was measured with a visual analog scale. RESULTS: Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site. CONCLUSIONS: Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Simple and comminuted displaced olecranon fractures: a clinical comparison between tension band wiring and plate fixation techniques.

INTRODUCTION: The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon fractures. MATERIALS AND METHODS: Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications. RESULTS: Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures. CONCLUSIONS: The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Malunited extra-articular distal radius fractures: corrective osteotomies using volar locking plate.

BACKGROUND: Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Volar fixed-angle plates have added a new concept to the treatment of distal radius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function. MATERIALS AND METHODS: Between 2005 and 2012, 20 patients with symptomatic dorsally malunited extra-articular fractures of the distal radius underwent corrective osteotomy using a volar locking plate without additional bone graft. At a mean follow-up of 50 months, all the patients were clinically and functionally evaluated. RESULTS: All measurements of pain, final range of motion and grip strength significantly improved compared with preoperative measurements. The mean preoperative DASH score reduced from 54 points preoperatively to 25 postoperatively. Based on the modified Mayo wrist score, we obtained 14 excellent and six good results. Palmar tilt improved from an average of 23° to 11°. Radial inclination improved from an average of 29° to 22°, and ulnar variance decreased from an average of 3.6 mm to 0.9 mm. There were two cases of transient median neuroapraxia that resolved before the 6-week follow-up appointment. No other major complications, including non-union and infection, were observed. CONCLUSION: The volar approach and locking plate, without necessarily the use of bone grafting, proved to be an effective approach for addressing symptomatic and even severe deformities of the distal radius. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.