Retrospective study of radial dome osteotomy with volar plate fixation versus K-wires in Madelung's deformity: long-term follow-up.

PURPOSE: The emerging role of the locking plate improved the technique also in corrective osteotomies in Madelung's deformity, but there is a lack of analyses between the fixation techniques, as well as little information in functional outcomes and long-term follow-up. The current study compared the outcomes, pitfalls, and advantages of volar plate and screws fixation versus K-wires fixation in a long-term follow-up. METHODS: Twenty-eight children presenting the "distal radius" variant of Madelung's deformity underwent Vickers ligament release and distal radial dome osteotomy between 2009 and 2015. Twenty-three children (20 females and 3 males, mean age 15 years and 7 months at surgery and 24 years and 8 moths at follow-up), with 26 operatively treated wrists, were available for follow-up. A retrospective two-cohort study, evaluating clinically and radiologically results, has been conducted with a mean eight years and seven months follow-up. RESULTS: Bone union and pain relief were obtained in all cases, as well as improvements in wrist motion and radiographic indices. A statistically significant correlation was identified between the volar plate fixation and an improved lunate subsidence on X-ray, and a trend towards an improved DASH score in the cohort with plate and screws, as well as significant improvement in wrist extension and supination always in the plate fixation cohort. CONCLUSIONS: The long-term follow-up enabled the patients to report on more definitive outcomes in terms of functional and cosmetic improvements. Volar plate fixation is an effective technique allowing for simple post-operative management and earlier rehabilitation program with improved clinical and radiographic outcomes.

VACTERL (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, cardiac defects, renal and limb anomalies) association: disease spectrum in 25 patients ascertained for their upper limb involvement.

OBJECTIVE: To review the clinical characteristics in a series of 25 patients with VACTERL (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, cardiac defects, renal and limb anomalies) association who were ascertained for upper limb involvement. STUDY DESIGN: The study involved a review of clinical and radiologic data from patients with VACTERL association collected by a hand surgery clinic between 2004 and 2013. RESULTS: Radial axis involvement was found in all 25 patients (100%), with severe thumb function impairment in 79% and complete absence of the radius in roughly 33%. Costovertebral anomalies were the most frequent feature, found in 23 patients (92%). All 3 core features (anal atresia, tracheoesophageal fistula with esophageal atresia, and costovertebral anomalies) were present in only 12% of the patients. Twelve patients (48%) had abnormalities not part of the VACTERL spectrum, showing a specific pattern of non-VACTERL-type malformations, including genitourinary abnormalities (12%), single umbilical artery (8%), and tethered cord (8%). Previously unreported clinical findings were concurrent hypoplasia of both the odontoid process and the coccyx in 2 patients and an isolated sacral dimple in 2 patients. CONCLUSION: Upper limb involvement in VACTERL association is a specific feature of the radial axis that occurs in monolateral form in approximately 75% of cases and, when bilateral, always occurs in a nonsymmetrical fashion. Odontoid and coccygeal hypoplasia and sacral dimple are newly reported malformations of the VACTERL phenotype.

Genetic basis of congenital upper limb anomalies: analysis of 487 cases of a specialized clinic.

BACKGROUND: Specific data regarding the frequencies of the congenital upper limb anomalies (CULA) according to their etiology are hardly available due to the heterogeneity across classification systems. In this study, we aim at defining the CULA etiology of patients that have been evaluated at the Modena University Hospital's Congenital Hand Malformations multidisciplinary clinic in the years 2004 to 2012. METHODS: Medical records of 487 patients were retrospectively reviewed. On the basis of clinical, anamnestic, and genetic data, the CULA were distributed into two main groups: (1) non-Mendelian etiology, including prenatal exposure, somatic mutations and amniotic bands; and (2) Mendelian etiology, including single gene and genomic/chromosomal diseases. CULA were further grouped according to the embryological damage (formation, separation and growth defects) and to the involved axis (radial, ulnar, central). RESULTS: A Mendelian etiology was diagnosed in 199 patients (40.9%), whereas the remaining 288 cases (59.1%) were described as non-Mendelian. The involvement of the lower limbs, the presence of malformations in other organs and facial dysmorphisms were significantly more represented in the Mendelian cases. The formation defects were significantly more frequent in the non-Mendelian group (p < 0.001), whereas the frequency of separation defects was higher in the Mendelian cases (p = 0.0025). Patients with non-Mendelian etiologies showed a significantly higher frequency of central defects (p = 0.0031). CONCLUSION: The two etiologies differ in terms of patient's clinical features, morphology defect and axis involvement. This data may be helpful to the clinician during the patient's diagnostic workup by indicating the necessity for genetic testing and for determining the anomaly's recurrence risk.

Does anterior plus posterior interosseus neurectomy lead to better outcomes than isolated posterior interosseus denervation in the treatment of chronic wrist pain? A systematic review of the literature and meta-analysis.

Purpose: Partial wrist denervation can be performed by isolated posterior interosseous nerve (PIN) or combined PIN plus (+) anterior interosseous nerve (AIN) neurectomy procedures. The purpose of the current systematic review is to investigate any differences in clinical outcomes and failures in patients undergoing AIN + PIN vs isolated PIN neurectomy. Methods: A review of the English Literature was performed on Medline, WOS and Scopus according to PRISMA protocol combining 'wrist denervation', 'PIN neurectomy', 'AIN neurectomy', anterior interosseous nerve neurectomy' and 'posterior interosseous nerve neurectomy'. Studies were assessed with a modified Coleman Methodology Score (CMS). The primary outcome for meta-analysis was 'Failures', including all patients who have required a second surgery or those who are left with pain (defined as 'bad'). Results: Overall, 10 studies totalling 347 wrists were included in this systematic review, with a 'moderate' CMS. The isolated PIN neurectomy technique showed a 15.1% pooled failure rate at a median follow-up of 22 months, while the combined AIN+PIN denervation had a pooled failure rate of 23.6% at a follow-up with a median of 29 months. The combined analysis of both procedures did not show significantly better results in favour of either technique, with a general failure rate of 21.6% (P = 0.0501). Conclusion: Partial denervation for chronic wrist pain is a salvage procedure that leads to an overall success of 78.4% for pain relief, with no substantial complications. Apparently, performing the neurectomy also of the AIN does not offer greater advantages compared to the isolated PIN neurectomy.

Long-term donor site morbidity after free nonvascularized toe phalangeal transfer.

PURPOSE: Free nonvascularized toe phalangeal transfer is an established surgical option for the reconstruction of hypoplastic digits. This study assessed long-term morbidity in the feet using this technique. METHODS: We reviewed 40 children treated between 1991 and 2007 by free nonvascularized toe phalangeal transfer. The diagnosis was digital hypoplasia resulting from symbrachydactyly in 33 cases, constriction ring syndrome in 3 cases, thumb hypoplasia in 3 cases, and perinatal subclavian venous thrombosis in 1 case. The patients were followed up after surgery for a mean of 10 years (range, 3-19 y). The Oxford Ankle Foot Questionnaire was administered to patients and families to assess patient symptoms and patient and parental satisfaction. We assessed toe length ratio, the presence of visible deformity, and distal hypoplasia of the donor toes clinically and radiographically. RESULTS: Emotional problems related to foot appearance were common. We also found functional problems with footwear in some patients. All patients had floppy unstable toes with visible deformity. Increasing foot deformity was seen with growth, which led to deterioration in foot aesthetics, particularly where multiple donor toes had been harvested. We identified distal and middle phalangeal and metatarsal hypoplasia in the donor toes. CONCLUSIONS: Donor site morbidity for free toe phalangeal transfer is greater than previously documented. This should be considered during surgical decision making for reconstruction of hypoplastic digits. Preoperative counseling should include discussion regarding possible consequences of phalangeal harvest on donor toes and options for donor site reconstruction. Long-term follow-up of the donor site is essential to accurately assess results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

[A year of fellowship abroad: comparative analysis of specialized training and role of the surgical specialist in Italy and the United Kingdom]. / Un anno di fellowship all'estero: analisi comparativa del programma di formazione specialistica e del ruolo di specialista chirurgo in Italia e nel Regno Unito.

AIM: To compare the Italian and UK specialist training programmes and the role of the specialist in a surgical discipline. BACKGROUNDS: Italian postgraduate medical and surgical trainees have the opportunity to spend up to 12 months in accredited foreign health facilities as part of their training programme. MATERIALS AND METHODS: A comparison between the Italian and the UK specialist training programmes structure, training methods, trainees assessments, board examinations and clinical duties and research opportunities of the specialist trainees is performed. Also the role of the specialist surgeon working within the Italian and the UK National Health Service is discussed. RESULTS: Several differences between the Italian and the UK training programmes and specialist surgeon role have been identified. Training programmes mainly differ in general structure and organization, duration, trainees' assessments and examinations. The Specialist surgeon in Italy is effectively a member of a team of specialists, led by a Director who has managerial and organizational duties and responsibilities, which include among the others the supervision and organization of the clinical activities of the other specialists. The specialist surgeon who works as a Consultant in the UK manages autonomously his own activities and duties, this resulting in a more independent approach to the profession. Each national system presents with unique and interesting characteristics. CONCLUSION: A mutual exchange of experience, information and methods between different countries with different specialist training programmes and career paths would be auspicable in order to aid the further growth and development of a more integrated and homogeneous European health system.

Modified dome osteotomy and anterior locking plate fixation for distal radius variant of Madelung deformity: a retrospective study.

PURPOSE: Dome osteotomy of the distal radius with Vickers ligament release is an established method of treatment for Madelung deformity. Many different surgical procedures have been proposed in literature but techniques, patient inclusion and efficacy evaluations are heterogeneous. MATERIALS AND METHODS: A retrospective review of children affected by 'distal radius' Madelung deformity and treated with a standardized surgical procedure (modified reverse dome osteotomy of the distal radius and volar fixation with a small locking plate) between 2010 and 2018 at a single center was performed. The technique used in this study, reversing the shape of the classical dome osteotomy, allowed for an improved three-planar correction of the distal radial epiphysis and volar plate fixation allowed for an increased stability and reduced soft tissue morbidity. A structured follow-up including a prompt post-operative rehabilitation program (without wrist immobilization) was established. Pain relief, functional outcome and cosmetic appearance were assessed with a structured clinical assessment, DASH Score and radiographic assessment, accordingly. RESULTS: A total of 15 wrists in 13 children (12 females, mean age of 15.6 years, range 11-19) were included. The mean follow-up time was 3.8 years. Bone union and pain relief were obtained in all cases. Improvement in the range of motion was detected in extension, supination and flexion of the wrist. Radial inclination was increased by 15.3° and lunate subsidence by 4.1 mm. CONCLUSIONS: The use of volar fixation with a small locking plate and immediate post-operative rehabilitation for reverse dome osteotomy of the distal radius in pediatric patients affected by 'distal radius' Madelung's deformity is stable and effective.

Salvage of the Failed Total Wrist Arthroplasty: A Systematic Review.

Background Although the performance of total wrist arthroplasty systems has improved, failure is encountered and is a major challenge to manage. Questions Does physical function improve with surgical management of the failed wrist arthroplasty? Is there an improvement in secondary outcome measures including pain, grip strength, and range of motion? What are the reasons for failure in primary total wrist arthroplasty? What are the complications associated with revision of the failed total wrist arthroplasty? What are the survival profiles of the different revision strategies? Methods A systematic review of available literature was performed. Studies were systematically assessed, and data extracted from suitable studies for review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were adhered to. The study protocol was modified from a previous protocol published on the PROSPERO database. Results Fourteen studies were identified considering 218 patients/214 index operations with a follow-up duration following revision surgery of 2 months to 21 years (silicone wrist arthroplasty-42 cases; nonsilicone wrist arthroplasty-172 cases). The functional outcome of revision surgery was infrequently recorded and documented with only short-term assessments undertaken. Complications were seen in 1:2 revision procedures, with re-revision surgeries required in 21.6% of revised primary nonsilicone arthroplasties. Re-revision rate following a revision arthrodesis was 21.4% (15/70 cases) compared with revision arthroplasty of 34.8% (32/92 cases). Revision arthrodesis nonunion rate was 17.5% (22 cases). Conclusion This review has confirmed the high level of surgical complexity and the likelihood of a complicated postoperative outcome when salvaging a failed wrist replacement. Level of Evidence This is a Level 3, systematic review study.

Anterolateral soft tissue sparing approach to the hip. Surgical technique.

The long-term successful outcomes of total hip replacement led to an extension of the surgical indications to young and active patients. To achieve a prompt functional recovery, varying surgical techniques have been proposed. In this study we present our anterolateral soft tissue sparing approach characterised by a lesser dissection of the muscles, a capsular repair and an accurate soft tissue tensioning and reconstruction. The target of this procedure is a full and quick restoration of hip function, reducing the rate of early complications such as hip dislocation.

Systematic Review of Total Wrist Arthroplasty and Arthrodesis in Wrist Arthritis.

Background End-stage wrist arthritis has traditionally been treated with a total wrist fusion. There is a recent trend toward motion preserving surgery in the form of total wrist replacement. Questions Is there a functional benefit to performing a total wrist replacement instead of a total wrist fusion in patients with end-stage wrist arthritis? Is there any difference in secondary outcome measures including pain, grip strength, and range of motion? Does the risk of adverse events and treatment failure differ between the two techniques? Methods A systematic literature search was performed to identify studies reporting either total wrist arthrodesis or arthroplasty for end-stage wrist arthritis. Studies were systematically screened and assessed for risk of bias and quality. Data were extracted and reviewed. Results A total of 43 studies were included in the review: 17 on arthrodesis, 24 on arthroplasty, and 2 matched cohort studies. This represented 669 index arthrodesis operations in 603 patients, and 1,371 index arthroplasty operations in 1,295 patients. A significant improvement in functional outcome was seen with both interventions. Similar improvements were seen in pain scores, and modest improvements were seen in grip strength. Range of motion following arthroplasty improved to a functional level in two studies. Complication rates were higher after arthroplasty (range: 0.2-9.5%) than those after arthrodesis (range: 0.1-6.1%; p = 0.06). Fourth-generation implants (range 0.1-2.9%) performed better than earlier designs (range: 0.2-8.1%; p = 0.002). Implant revision rates ranged from 3.5 to 52.6%. Fourth-generation prostheses survival rates were 78% at 15 years (Universal 2), 86% at 10 years (Motec), 90% at 9 years (Re-Motion), and 95% at 8 years (Maestro). Conclusion The newer fourth-generation wrist implants appear to be performing better than earlier designs. Both wrist arthrodesis and wrist arthroplasty improve function, pain, and grip strength. The risk of complication following wrist replacements is higher than that after total wrist arthrodesis.

Lipomatous tumours of the hand and wrist A series of 25 cases and review of the literature.

UNLABELLED: consequently reports in the international literature are mainly of individual cases and small series. MATERIAL OF STUDY: This is a retrospective review of a series of 25 patients with lipomatous tumours of the hand and wrist treated between 2001 and 2009. All patients underwent clinical and radiological assessment and a marginal excisional biopsy. 23 lipomas, 1 fibrolipomatous hamartoma (FLH) and 1 well differentiated lipoma-like liposarcoma/atypical lipomatous tumour (WDLLL/ALT) were identified. CONCLUSION: Choosing the most appropriate investigations is mandatory for a correct diagnosis and planning. Ultrasound should always be considered as the first line investigation. MRI helps delineating the anatomy of the lesions and their relationships with the surrounding structures in the hand and wrist, enabling more accurate surgical planning. Histological examination of the excised specimen remains the gold standard for the formulation of the definitive diagnosis and should be performed in every case. KEY WORDS: Digits tumours, Fibrolipomatous hamartoma, Hand tumours, Lipoma, Lipoma-like liposarcoma, Wrist tumours.

A palmar approach for insertion of a free, nonvascularized phalangeal transfer.

Free nonvascularized phalangeal transfer from a toe to congenitally hypoplastic digits, is an established procedure in the repertoire of digit reconstruction. The hypoplastic digit is frequently flexed, due to shortage of palmar soft tissues. The phalanx must be transferred intact, with a complete periosteal covering. A new technique of incision and dissection is described utilizing a palmar V approach, closed after skin advancement, as a Y. This permits ample visualization of the digital envelope to receive the phalanx, protection under direct vision of the digital bundles, and simultaneous correction of the deficient palmar skin, without tension.

Primary hydatid cyst of the root of the thigh: a case report and review of the literature.

Hydatid disease of bone is a rare event, and it is characterized by a high diagnostic and therapeutic complexity. We report a case of primary hydatidosis of the proximal thigh involving both the soft tissues and the proximal femur in a 59-year-old man. It has been possible to establish the diagnosis only 8 years after the appearance of the first symptoms (painful swelling over the root of the left thigh), when the patient came to our institution after several investigations.