MRI in acute simple elbow dislocations: correlation of preoperative imaging and intraoperative findings of collateral ligaments and associated soft tissue injuries.

PURPOSE: The aim of our study was the evaluation of correspondence among collateral ligaments and other soft tissue injuries detected by MRI and by intraoperative findings in a consecutive series of patients treated for simple elbow dislocation. METHODS: After clinical and MRI examination, 16 out of 59 consecutive patients with moderate or severe instability after simple elbow dislocation were addressed to surgical treatment. There were 14 men and 2 women. The mean age was 39.6 years (range 16-69 years). RESULTS: MRI showed full-thickness lesion of MCL in 9/16 patients (53.3%) and partial lesion in 6/16 patients (40%), and in 1 case, the MCL was considered intact. On the lateral side, MRI showed complete injury of LCL in 7/16 patients (46.6%) and partial injury in 7/16 patients (40%). No lesions of LCL were observed in 2 patients (13.4%). MCL was surgically explored in all the patients. We observed 10/16 full-thickness lesions (62.5%) and 6/16 partial lesions (37.5%). LCL was surgically explored in 11/16 patients. We observed 6/11 full-thickness lesions (54.6%) and 5/11 partial lesions (45.4%). In 3 cases, associated soft tissue injuries were detected. The rate of concordance between MRI and surgical findings was 87.5% (14/16 cases) on the medial side and 90.9% (10/11 cases) on the lateral side. CONCLUSION: Our study demonstrated that MRI is a reliable and useful tool to investigate collateral ligaments and soft tissue injuries around the elbow and to plan the most adequate surgical treatment.

Impact of COVID-19 on hand surgery in Italy: A comparison between the Northern and the Southern regions.

The aims of this study were to evaluate the impact of the COVID-19 pandemic on emergency and elective hand surgery in four Italian regions that had either a high (Lombardy and Piemonte) or a low (Sicilia and Puglia) COVID-19 case load to discuss problems and to elaborate strategies to improve treatment pathways. A panel of hand surgeons from these different regions compared and discussed data from the centers they work in. The COVID-19 pandemic had an enormous impact on both elective and emergency surgery in Italy, not only in highly affected regions but also - and paradoxically even at a higher extent - in regions with a low COVID-19 case load. A durable and flexible redesign of hand surgery activities should be promoted, while changing and hopefully increasing human resources and enhancing administrative support. Telematics must also be implemented, especially for delivering rehabilitation therapy.

One bone forearm with vascularized fibular graft. Clinical experience and literature review.

One-Bone-Forearm (OBF) is a procedure in which the proximal stump of the ulna is fixed to the distal stump of the radius. Historically, the indications for OBF have been represented by forearm instability due to trauma, infection, tumor resection, and congenital deformities with severe radius and ulna bone loss. When major bone loss prevents direct fixation between ulna and radius a Vascularized Fibular Bone Graft (VFBG) may allow forearm bone reconstruction and fixation. In this study we report our clinical experience in 4 cases of OBF with VFBG performed in 3 patients. Compared to standard OBF technique with direct osteodesis, OBF with VFBG showed similar clinical results and high rate of healing even in case of bone infection. Moreover, composite osteocutaneous VFBG might concurrently allow to treat local soft tissue defects.

Treatment of acute bone defects in severe lower limb Trauma.

PURPOSE: To present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames. PATIENTS AND METHODS: During a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) RESULTS: The mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues. DISCUSSION: based on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.

Free composite groin flap to solve a complex loss of tissue in a traumatic injury of the foot: A case report.

Severe traumatic losses of soft tissues and bone at foot and ankle level are often treated by means of amputation, but this may involve important psychological and anatomic consequences for the patient. If there are good vascular conditions, reconstruction by means of composite free flaps is often the only alternative to this demolitive treatment. The transfer of composite free flaps that include vascularized bone from various donor sites may provide anatomical reconstruction and recovery of function of the foot and ankle. If plantar skin and its sensation are present, these techniques may represent a good choice in the treatment of complex injuries of the foot, and by means of skeletal morphological reconstruction, they may give good functional results. With these premises, we report a case in which was used a groin flap to fill and solve a complex defect of bone and soft tissues of midfoot in a gunshot injury.

Treatment of flexor tendon reconstruction failures: multicentric experience with Brunelli active tendon implant.

INTRODUCTION: Secondary repair of flexor tendon injuries remain a challenging procedure for hand surgeons. Usually, secondary reconstruction should be performed by staged approach. When the tendon and pulley integrity are intact, tenolysis may be the first surgical option. One-/two-stage tendon grafts are suggested when the integrity of flexor tendon is compromised. Active tendon implants (Brunelli prostheses) may represent an efficient option in patients with a poor prognosis, as well as whenever classical techniques fail. Due to lack of literature about this second-line treatment, the authors present the experience of two different orthopedic departments with the permanent active tendon implant. MATERIALS AND METHOD: Nineteen consecutive patients with failed previous flexor tendons repairs were treated with active tendon implants between 2000 and 2011. The functional outcome of the patients was examined with a mean follow-up of 5.6 years, using Strickland assessment and QuickDASH. RESULTS: In 16 cases, the tendon implants were well tolerated and patients resulted satisfied with a QuickDASH score less than 33. Strickland score was fair to excellent in 10 patients. We registered adhesion complications in 3 cases. CONCLUSION: We can conclude that these prostheses represent an alternative to biological reconstructions and a potentially permanent procedure in complicated flexor tendon injuries. LEVEL OF EVIDENCE: Multicentric case series, Level IV.

The posterior bundle of the elbow medial collateral ligament: biomechanical study and proposal for a new reconstruction surgical technique.

BACKGROUND: The medial collateral ligament (MCL) is one of the primary elbows stabilizers. It is composed of an anterior bundle (AB), a posterior bundle (PB) and a transverse bundle. In elbow dislocations, until today MCL reconstruction has addressed the AB only. The purpose of this paper is to understand the biomechanical role of the PB of the MCL and to propose a new surgical technique for the simultaneous reconstruction of the anterior and posterior bundles, preventing the risk of recurrent posterior dislocation or posteromedial rotational instability (PMRI). MATERIALS AND METHODS: Sixteen cadaveric elbows were subjected to a force in compression, supination valgus and pronation varus. The residual stability was evaluated in three conditions: intact MCL, sectioned AB and sectioned AB + PB. The tests were performed in collaboration with the Department of Mechanical and Aerospace Engineering of the Politecnico di Torino. In six elbows, the MCL was then reconstructed with the new technique. RESULTS: Complete posterior elbow dislocation does not occur until the PB is sectioned. The section of the AB alone causes elbow instability in valgus stress, but not a dislocation. The reconstruction of the AB and the PB using the described technique allows a good recovery of range of motion and joint stability. CONCLUSIONS: The PB of the MCL has a primary role in elbow stability against valgus stress, and it prevents elbow posterior dislocation at all flexion angles. The described reconstruction technique should reduce the risk of residual PMRI.

Step-by-step surgical technique for mandibular reconstruction with fibular free flap: application of digital technology in virtual surgical planning.

At present, mandibular reconstruction with a fibular free flap is the gold standard for functional and esthetic rehabilitation after oncological surgery. The purpose of this study was to describe the computer-assisted mandibular reconstruction procedure adopting the customized solution Synthes ProPlan CMF. The study reports five consecutive patients with benign or malignant disease requiring mandibular reconstruction using a microvascular fibular free flap, pre-operative virtual planning, construction of cutting guides and customized laser pre-bent titanium plates. The surgical technique is discussed in a step-by-step fashion. The average post-operative hospital stay was 18 ± 3 days. Ischemia time was recorded in all five cases, with an average of 75 ± 8 min. No problems were encountered in any surgical step and there were no major complications. Excellent precision of cutting guides and a good fit of pre-bent plates were found on both the mandible and fibula. There was excellent precision in bone to bone contact and position between mandible and fibula graft. Measurement data from the pre-operative and post-operative CT scans were compared. The average difference (Δ) between programed segment lengths and CT control segment lengths was 0.098 ± 0.077 cm. Microsurgical mandibular reconstruction using a virtual surgical planning yields significantly shorter ischemia times and allows more precise osteotomies. The technology is becoming increasingly recognized for its ability to optimize surgical outcomes and minimize operating time. Considering that the extent of resection can be wider than predicted, this results in safer modeling of the fibula only after frozen sections have demonstrated the radicality of resection.

Reconstruction of traumatic losses of substance at the elbow.

Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.

The role of the FESSH Hand Trauma Committee in Europe.

In Europe the need for clear definitions of hand surgery facilities regarding trauma is becoming really important to guarantee a correct and up-dated treatment of lesions more and more frequent and complex. The goal for European patients should be to have similar treatment based on appropriate referral and assistance in centres officially accredited for hand surgery. The target for the European countries, giving the correct support to the centres and surgeons treating these problems, should also be to save the costs of residual invalidities. These are some of the reasons for the European Federation of Societies for Surgery of the Hand (FESSH) decided to form a committee (Hand Trauma Committee) devoted to study this problem, trying to give common guidelines and forming an European net of accredited centres. The first step was to collect data through a network of national representatives. Covering a 487 millions population, 309 centres were recorded, including 1 797 surgeons and 20 363 patients treated during January 2006, then having a clear situation of hand trauma treatment through Europe. Next, the HTC worked on 3 definitions: hand trauma, hand trauma surgeons and hand trauma centres and started to accredit centres applying to these well defined criteria. The HTC is now working on scientific consensus on some traumatic lesions but also on the important topic of prevention of hand traumas. This work is expected to improve an homogenous situation throughout Europe focusing on the better use of the given resources for the prevention and the treatment of these traumatic lesions.

Secondary repair of flexor tendon injuries.

Tendon adhesions or even secondary ruptures causing severe hand functional impairment still represent a frequent complication after repair of flexor tendon injuries. Secondary treatment of these problems includes tenolysis, one or two stages flexor tendons reconstruction by grafts or even the use of tendon prosthesis. The mechanism and severity of injury, the status of the surrounding tissues and injured finger, the presence of associated lesions, the age of the patient, post-operative management, patient motivation and the surgeon's skill, may all have implications in the final outcome of the tendon reconstruction. A correct evaluation of the problem by means of classifications such as the one described by Boyes, may help the surgeon in choosing the appropriate technique.

Perineural fat grafting in the treatment of painful end-neuromas of the upper limb: a pilot study.

The purpose of this study was to evaluate the effectiveness and middle-term durability of the results achieved with perineural fat grafting of painful neuromas of the upper limb. We retrospectively analysed eight patients, affected by eight neuromas, treated by neuroma excision and fat grafting around the proximal nerve stump. Clinical parameters, the disabilities of the arm shoulder and hand score, and the visual analogue scale were recorded at 2, 6 and 12 months after surgery. A reduction of 23.2% was observed in the mean disabilities of the arm shoulder and hand scores at 12 months. The spontaneous baseline visual analogue scale score showed a mean improvement of 22% at 12 months, although not this was not statistically significant. Perineural fat grafting is a quick and useful procedure and could represent a useful primary operation in the treatment of pain syndromes of neuropatic origin.

Experimental and clinical employment of end-to-side coaptation: our experience.

The last 15 years have seen a growing interest regarding a technique for nerve repair named end-to-side coaptation. Since 2000, we have carried out experimental studies on end-to-side nerve repair as well as employed this technique to a series of selected clinical cases. Here we report on the results of this experience.For experimental studies, we have used the model represented by median nerve repair by end-to-side coaptation either on the ulnar (agonistic) or the radial (antagonistic) nerve. For time course assessment of median nerve functional recovery we used the grasping test, a test which permits to assess voluntary control of muscle function. Repaired nerves were processed for resin embedding to allow nerve fibre stereology and electron microscopy. Results showed that, in either experimental group, end-to-side-repaired median nerves were repopulated by axons regenerating from ulnar and radial donor nerves, respectively. Moreover, contrary to previously published data, our results showed that voluntary motor control of the muscles innervated by the median nerve was progressively recovered also when the antagonistic radial nerve was the donor nerve.As regards our clinical experience, results were not so positive. We have treated by end-to-side coaptation patients with both sensory (n = 7, collateral digital nerves) and mixed (n = 8, plexus level) nerve lesions. Results were good, as in other series, in sensory nerves whilst they were very difficult to investigate in mixed nerves at the plexus level.Take together, these results suggest that clinical employment of end-to-side coaptation should still be considered at the moment as the ultima ratio in cases in which no other repair technique can be attempted. Yet, it is clear that more basic research is needed to explain the reasons for the different results between laboratory animal and humans and, especially, to find out how to ameliorate the outcome of end-to-side nerve repair by adequate treatment and rehabilitation.

Efficiency of Hyaloglide in the prevention of the recurrence of adhesions after tenolysis of flexor tendons in zone II: a randomized, controlled, multicentre clinical trial.

Hyaloglide is a hyaluronan-based gel based on a novel auto-crosslinked technology designed to reduce postsurgical adhesions. Its efficacy was assessed in a multicentred randomized controlled trial comparing the results of flexor tenolysis in zone 2 following failed flexor tendon repairs. In the control group a standard release was performed. In the treated group, Hyaloglide was applied into the flexor sheath and around the site of tenolysis. Forty-five patients, 19 controls and 26 treated with Hyaloglide, were enrolled in 13 centres. All the patients were evaluated at 30, 60, 90 and 180 days after surgery by testing Total Active Motion, Quick-DASH questionnaire and number of working days lost after surgery. Patients in the Hyaloglide group had a statistically better recovery of finger motion at all time intervals and returned earlier to work and daily activities. The use of Hyaloglide did not appear to increase the complication rate.

Termino-lateral nerve suture in lesions of the digital nerves: clinical experience and literature review.

Documented experience of treatment of digital nerve lesions with the termino-lateral (end-to-side) nerve suture is limited. Our clinical experience of this technique is detailed here alongside a systematic review of the previous literature. We performed, from 2002 to 2008, seven termino-lateral sutures with epineural window opening for digital nerve lesions. Functional outcome was analysed using the two-point discrimination test and the Semmes-Weinstein monofilament test. The results showed a sensory recovery of S3+ in six cases and S3 in one case. The mean distance found in the two-point discrimination test was 12.7 mm (range 8-18 mm). After a review of the literature, we were able to obtain homogeneous data from 17 additional patients operated by termino-lateral coaptation. The overall number of cases included in our review was 24. A sensory recovery was observed in 23 out of 24 patients. The functional results were S0 in one case, S3 in one case, S3+ in twenty cases and S4 in two cases. Excluding the one unfavourable case, the mean distance in the two-point discrimination test was 9.7 mm (range 3-18 mm). It can thus be concluded that the treatment of digital nerve lesions with termino-lateral suture showed encouraging results. Based on the results obtained in this current study we believe that in case of loss of substance, end-to-side nerve coaptation may be an alternative to biological and synthetic tubulisation when a digital nerve reconstruction by means of nerve autograft is declined by the patient.

Piezosurgery in head and neck oncological and reconstructive surgery: personal experience on 127 cases.

Piezoelectric bone surgery, known simply as piezosurgery, is a new technique of osteotomy and osteoplasty, which requires the use of microvibrations of ultrasonic frequency scalpels. The principle of piezosurgery is ultrasonic transduction, obtained by piezoelectric ceramic contraction and expansion. The vibrations thus obtained are amplified and transferred onto the insert of a drill which, when rapidly applied, with slight pressure, upon the bony tissue, results, in the presence of irrigation with physiological solution, in the cavitation phenomenon, with a mechanical cutting effect, exclusively on mineralized tissues. Personal experience with the use of piezosurgery in head and neck oncological and reconstructive surgery is relatively recent, having been developed in 2002-2006, and, so far, involves 127 cases; preliminary results are interesting and improving in the, hopefully, developmental phases of inserts with specific geometrics on account of the characteristics of the various aspects of surgical ENT operations. Furthermore, with piezoelectric surgery it has been possible to perform precise osteotomy lines, micrometric and curvilinear with absolute confidence, particularly in close proximity to the vessels and nerves and other important facial structures (dura mater). There can be no doubt, since this is a new cutting method, that piezosurgery involves a different learning curve compared to other techniques, requiring obstacles of a psychological nature to be overcome as well as that concerning surgical expertise. Given the numbers of cases treated and the relative power of this instrument, analysis of complications, intra-operative time (which would appear, on average, to be 20% longer) and, therefore, morbility, shows interesting potentiality of the technique. This new ultrasound cutting method will, no doubt, in the future, be increasingly used in ENT surgery, particularly with improvements in power and geometry of the inserts, with possible applications also in neurosurgery, paediatric surgery and orthopedics, branches in which a selective action upon the mineralized tissues is of fundamental importance.

End-to-side nerve suture in traumatic injuries of brachial plexus: review of the literature and personal case series.

We used end-to-side nerve coaptation combined with standard end-to-end neurotisations to treat 11 patients who presented with complete (six cases) or incomplete (five cases) traumatic brachial plexus injuries. All patients were available for functional evaluation at a minimum of 2 years postoperatively. In three patients with shoulder abduction recovery, electromyographical studies (EMG) showed a contribution from the end-to-side neurotisation. In the remaining cases end-to-side neurotisations were unsuccessful. Our study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery. We believe that at present end-to-side suture must not be a substitute for standard reconstructive techniques in brachial plexus surgery. Occasionally termino-lateral nerve sutures may represent a support to standard reconstructive procedures especially in case of severe injuries when few undamaged donor nerves are available.