Evaluation of free vascularized medial femoral condyle bone grafts in the treatment of avascular scaphoid waist nonunion.

OBJECTIVES: The aim of this study was to evaluate the medial femoral condyle (MFC) bone graft procedure for scaphoid waist nonunion with avascular necrosis on magnetic resonance imaging or prior surgery failure. PATIENTS AND METHODS: Between June 2015 and December 2018, a total of 17 patients (16 males, 1 female; mean age: 29±8.2 years; range, 16 to 40 years) with scaphoid waist nonunion who were treated with vascularized MFC bone grafting were retrospectively analyzed. Pre- and postoperative carpal indices, grip strengths for both hands, range of motion, Visual Analog Scale (VAS) pain score, Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score, and Mayo Wrist Score (MWS) were evaluated. RESULTS: After vascularized MFC bone graft surgery, 15 patients healed and returned to work without any limitations. Ten patients of left scaphoid nonunion and seven cases of right scaphoid nonunion were treated; for eight of these patients, the operation was on the dominant side. Eight of these patients were smokers. The mean follow-up was 22.4±5.8 months. The mean hand grip strength was increased from 74.5 to 84% on the contralateral side (p<0.05). The average revised carpal height ratio improved from 1.57 to 1.59 (p<0.05) and the scapholunate angle changed from 56.9° to 51.6° (p<0.05). CONCLUSION: The MFC bone grafting is one of the best surgical procedures for small defects such as scaphoid waist nonunion with high union rates, good functional outcomes, and minimal donor site morbidity.

Medium-term clinical and radiological results of surgically treated stage 3A Kienböck's disease.

The purpose of this study was to compare the methods of distal radial shortening osteotomy (RSO), lateral closing distal radial wedge osteotomy (RWO), and scaphotrapeziotrapezoid (STT) fusion in the treatment of stage 3A Kienböck's disease (KD). The research was planned as a single-center and retrospective study for the period 2008-2018. Patients were allocated to three groups according to surgical method: group 1, patients with negative ulnar variance, undergoing RSO; group 2, patients with non-negative (neutral or positive) ulnar variance, undergoing RWO; and group 3, patients with non-negative ulnar variance, undergoing STT fusion. Radiological measurements were compared: pre- and postoperative Stahl index, radioscaphoid angle, and carpal height ratio. Clinical comparison used QuickDASH and modified Mayo wrist scores. Fifty-one patients, with a mean age of 34 ± 12 years (range; 16-69 years), were included. Mean follow-up was 4.47 ± 1.8 (range 2-9) years. No statistically significant difference was observed between the groups in terms of change in carpal height ratio or Stahl index (respectively; P = 0.08, P = 0.065). A significant difference was observed in change in radioscaphoid angle between patients undergoing STT fusion versus RWO (P < 0.05). There was no statistically significant difference in postoperative functional scores between groups, and similar postoperative functional scores were achieved with STT fusion and with RWO in the surgical treatment of stage 3A KD with positive or neutral ulnar variance. Good medium-term radiological and clinical results were obtained with RSO in patients with stage 3A KD with negative ulnar variance.

The axillary sheath and single-injection axillary block.

Failure to block the terminal nerves of the brachial plexus, the circumferential type of incomplete axillary brachial plexus block, is the main problem of the single-injection technique. Two studies were carried out to observe the internal anatomy of the axillary sheath and the effect of different volumes of dye injected into the sheath in cadavers. In our first study, the internal arrangement of the axillary sheath and its septae were examined microscopically by slicing the sheath longitudinally and transversely. In the second study, boluses of 10, 20, and 40 cc of methylene-blue were injected into one of the compartments of the axillary sheath. The axillary sheath was dissected out and sliced transversely to observe the spread of the dye in the injected and in the adjacent compartments. The specimens of the axillary sheath were then opened longitudinally and the septae excised and examined at x10 magnification to see the effect of the various volumes of the injection bolus. This study shows that septae from the deep surface of the axillary sheath form compartments for each nerve. The septae function as barriers under physiologic conditions. By increasing the injected volume of solutions, bubble-like defects are produced in the septae in the compartments into which leakage was demonstrated.

The anterior cubital approach for displaced pediatric supracondylar humeral fractures.

The authors report a technique of the anterior cubital approach that is an exposure for displaced pediatric supracondylar fractures. Reduction is very safe and easy with this approach. Anatomical structures that hinder reduction such as the brachialis muscle or joint capsule and neurovascular tissues can be identified easily. This technique has not been a popular form of treatment in many countries, particularly in the United States.

[External rotation osteotomy of the humerus for the treatment of shoulder problems secondary to obstetric brachial plexus palsy]. / Dogumsal brakial pleksus felcine bagli omuz sorunlarinin humerus dis rotasyon osteotomisiyle tedavisi.

OBJECTIVES: We evaluated the results of external rotation osteotomy of the humerus for the treatment of shoulder problems secondary to obstetric brachial plexus palsy. METHODS: Forty children (24 boys, 16 girls; mean age 7.5 years; range 23 months to 14.8 years) underwent external rotation osteotomy of the humerus. Involvement was at the C5-6 roots in 11 patients, C5-6-7 roots in 19 patients, and at all the roots in 10 patients. Twenty-six patients had humeral head deformity and eight patients had posterior subluxation. The shoulder was ankylosed in one patient. Zancolli and Putti signs were positive in six and eight patients, respectively. The mean active shoulder abduction was 80 degrees (range 0 to 170 degrees ) and the mean internal rotation contracture was 27 degrees (range 10 degrees to 50 degrees ). Fourteen patients, all of whom were beyond five years of age, had an abduction contracture. Preoperative and postoperative functional evaluations were made with the use of the Mallet scale. Preoperatively, 35 shoulders had a score of II, five had a score of III. Osteotomies were performed in the proximal humerus in patients older than five years and in the mid-humerus in those without a contracture or younger than five years. RESULTS: The mean postoperative shoulder abduction was 95.7 degrees (range 30 degrees to 170 degrees ). Internal rotation contractures improved in all the patients. Abduction contractures did not resolve in two patients in whom a mid-humeral osteotomy was performed. Postoperative Mallet scores ranged from II to V in five, six, 15, and 14 shoulders, respectively. Rotation provided by the osteotomy was lost in one patient because of a humerus fracture that occurred in a traffic accident. Passive total shoulder rotation remained unchanged following surgery. Patients having better preoperative range of motion and who were at younger ages benefited the most from surgical treatment. CONCLUSION: External rotation osteotomy of the humerus must be performed at early ages before the shoulder gets stiffer.

Anatomic pattern of the terminal branches of posterior interosseous nerve.

To understand the lesion of the terminal branches of posterior interosseous nerve (PIN), an anatomic study was carried out. Thirty adult cadaver arms were dissected and the anatomic pattern of the nerve was documented. The distance between the point at which the nerve divides into branches and the distal edge of the supinator were measured, as well as the length of each nerve branch to its muscle-entering sites. The number of branches innervating each muscle was recorded. It was found that the PIN was branching to multiple short branches and a single deep long branch after leaving the supinator muscle with great morphometric and schematic variances.

Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach.

The authors performed a retrospective review of the anterior cubital approach, an alternative exposure for displaced pediatric supracondylar fractures. Anatomic structures that hinder reduction, such as the brachialis muscle or joint capsule, and neurovascular tissues can be identified easily with this approach. Sixty-one children with displaced supracondylar humeral fractures were treated surgically with Kirschner wires using the anterior cubital approach between January 1996 and August 2002. The cohort comprised 35 boys and 26 girls with a mean age of 8.7 years (range 3-13 years). Mean follow-up was 3.5 years (range 1-6 years). Preoperatively 13 children (21.3%) had a neurovascular insufficiency that required an exploration during the operation. All patients were reduced completely with full anatomic position. On follow-up, no patient had any scar formation or deformity or experienced any restricted motion. The authors conclude that the anterior cubital approach is very effective and is an option for the treatment of pediatric supracondylar humerus fractures without serious complications.

Surgical treatment of macrodactyly in older children and adults.

PURPOSE: To introduce a surgical technique for the treatment of macrodactyly in older children and adults, to represent the degree of correction obtained by the procedure, and to give the functional results. METHODS: Two thumbs and 5 fingers of 5 patients aged 12 to 32 years (mean, 17.5 years) with macrodactyly had surgery. The amount of tissue sufficient to reconstruct a normal-sized digit was left attached with the neurovascular bundle on the concave side of the macrodactylic digit and complete excision of whatever remained was performed. This requires usually arthrodesis of the distal interphalangeal joint with bone shortening. The large skin fold created during bone shortening and remaining angulations at the proximal phalanx were corrected during a second procedure. The patients were evaluated for 3 to 9 years (mean, 5.4 years) after the surgery. The length and circumferences of the involved digits and their opposites were measured before surgery and during the last follow-up examination to calculate the differences between the involved and the healthy digits, which were documented. The degree of reduction was quantified and noted. Two-point discrimination tests and active range of motion of the joints were recorded as well. RESULTS: For the thumbs an average 37% of circumference and 15% of length were reduced and for the fingers an average 44% of circumference and 35% of length were reduced. Ranges of motion of the joints of the involved digits were the same or nearly the same as before surgery in all of the cases. Two-point discriminations at the pulp of the involved digits were found to be the same as presurgical values in all digits. CONCLUSIONS: The technique is precise and simplifies the planning of the surgery. Although the macrodactylic digits with angulation deformities required a subsequent surgery for corrections patients with marked macrodactyly of the digit without a very wide proximal phalanx and metacarpal gained most from this technique.

The Brooks and Graner procedure for treatment of chronic tendinous mallet finger deformity.

Most of the mallet finger deformity results from tendinous origin. Many surgical techniques defined for chronic mallet deformity are aggressive, which often result in disappointment. The Brooks and Graner procedure is a developed surgical technique and useful procedure for chronic mallet finger deformity with tendinous origin. The method is simple and very effective for treatment of chronic mallet deformity.

Primary transposition of digital nerves into muscle in second ray amputation: a possible answer for neuroma formation.

After second ray amputation, neuroma formation is a common cause of postoperative pain localized at the web space due to sectioning and leaving the digital nerve ends. Most of the time the complaints lead to two or more operations, using several described techniques, with some limited success. However, transposition of the digital nerve ends into interosseous muscles should be added to the second ray amputation as a part of procedure, neuroma problems can be solved. The technique is described by detail in this article which is advised for other ray amputations and during revisions.