Cement Spacer Formed in a 3D-Printed Mold for Endoprosthetic Reconstruction of an Infected Sarcomatous Radius: A Case Report.

CASE: The ulcerated recurrent clear cell sarcoma of the forearm with bony invasion of the radius needed an uncontaminated resection and control of infection. A mold was printed based on CT-reconstructed 3D models of the patient's anatomy to create an antibiotic-loaded cement spacer as endoprosthetic replacement used in combination with soft-tissue reconstruction and systemic antibiotics. CONCLUSION: This then undescribed novel technique allowed for fast local recovery of the patient's hand function and return to work. In selected cases, such an anatomically formed spacer may be preferred for faster functional recovery and longer intervals before definitive reconstruction is possible.

Benefits of Additional Procedures for Metacarpophalangeal Hyperextension on Simple Trapeziectomy in Thumb Basal Osteoarthritis: A Biomechanical Cadaver Study.

Background: Patients with advanced osteoarthritis of the first carpometacarpal joint (CMC-1) may develop hyperextension of the first metacarpophalangeal joint (MCP-1). No clear clinical benefice has been reported consecutively to the surgical treatment of the MCP-hyperextension combined to a trapeziectomy. The reason of the missing benefit may be due to changes in the thumb position impairing the thumb stability secondary to the surgical procedures. We assessed changes in the transmission of forces at the thumb's end phalanx following a trapeziectomy combined with the surgical adjustment of the hyperextension of the MCP-1-joint in a biomechanical investigation using cadavers. Methods: The thumb muscles were loaded with nylon cables connected to a tension meter in 8 forearm cadavers. A 6-axis force sensor assessed the termino-lateral key-pinch orthogonal strength vectors at the level of the thumb distal phalanx prior to any surgery, and following a simple trapeziectomy, a trapeziectomy combined to a MCP-1-capsulodesis and the transfer of the extensor pollicis brevis over the metacarpal-1 head, or to an MCP-1-arthrodesis. Results: Combination of the trapeziectomy with the MCP-1- joint palmar capsulodesis and EPB-transfer or with a MCP-arthrodesis in neutral pronation-supination resulted in a significant shift of the thumb in pronation-abduction with respect to the preoperative assessment. The lowest shift was achieved when performing the arthrodesis in 20° supination or by overloading of the adductor pollicis. Conclusions: Combining the trapeziectomy with surgeries addressing the MCP-1-joint hyperextension induced a shift of the thumb in pronation-abduction that could impair the key-pinch stability. When considering additional procedures for MCP-1-joint hyperextension deformities, it should be recommended to fix the EPB-tendon on the radial aspect of the metacarpal head if a tendon transfer is considered, otherwise the MCP joint arthrodesis should be performed in supinated position, in order to achieve lateral key-pinch stability.

Physeal distraction for joint preservation in malignant metaphyseal bone tumors in children.

BACKGROUND: Physeal distraction facilitates metaphyseal bone tumor resection in children and preserves the adjacent joint. The technique was first described by Cañadell. Tumor resection procedures allowing limb-sparing reconstruction have been used increasingly in recent years without compromising oncologic principles. QUESTIONS/PURPOSES: We report our results with Cañadell's technique by assessing tumor control, functional outcome, and complications. METHODS: Six consecutive children with primary malignant metaphyseal bone tumors underwent physeal distraction as a part of tumor resection. Tumor location was the distal femur in four patients, the proximal humerus in one patient, and the proximal tibia in one patient. The functional outcome was evaluated after a minimum of 18 months (median, 62 months; range, 18-136 months) using the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). RESULTS: At latest followup, five patients were alive and disease-free and one had died from metastatic disease. All tumor resections resulted in local control; there were no local recurrencies. The mean MSTS score was 79% (range, 53%-97%) and corresponding mean TESS was 83% (range, 71%-92%). In one case, postoperative infection required amputation of the proximal lower leg. All physeal distractions were successful except for one patient in whom distraction resulted in rupturing into the tumor. This situation was salvaged by transepiphyseal resection. CONCLUSIONS: We consider Cañadell's technique a useful tool in the armamentarium to treat children with malignant tumors that are in close proximity to an open physis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reconstruction of Large Diaphyseal Defects of the Femur and the Tibia with Autologous Bone.

Post-traumatic segmental bone defects of the femur and the tibia above the critical size require special attention because conventional bone grafts result in high rates of nonunion. The biological and biomechanical aspects of this challenging surgery, as well as ongoing refinements to achieve mechanically stable bone healing with correct bone alignment are reviewed. Choosing the best appropriate method is mainly dependent on both the location and etiology of the bone defect. Three patients with successful bone reconstruction using two-stage reconstruction with cancellous bone graft, double-barrel free vascularized fibula transfer and distraction osteogenesis are described. Advantages and disadvantages of these methods are discussed in accordance with recent literature.

Rotationplasty (Borggreve/Van Nes and modifications) as an alternative to amputation in failed reconstructions after resection of tumours around the knee joint.

Failure of reconstructions as a result of infective or aseptic loosening and massive bone loss may make amputation necessary. If neurovascular structures can be preserved to keep a functional foot, rotationplasty may be considered an option. Four patients treated for malignant bone tumours (two osteosarcomas, one Ewing sarcoma, and one malignant fibrous histiocytoma) of the proximal tibia and distal femur (n=2 each) at the ages of 13 to 21 years had reconstructions that failed 3, 4, 5, and 15 years later. In three patients the cause was intractable infection, and in one loosening with shortening and deficiency of the extensor mechanism. The patients had the option to contact patients who had had rotationplasty as the primary procedure for tumours or severe femoral deficiencies. In two patients an AI-type rotationplasty was done, in one a type AII rotationplasty, and in the fourth a modification with shortening of the lower leg but retention of the knee joint. There were no postoperative complications such as persisting infections, fractures, or pseudarthrosis. All patients are active and are able to go alpine skiing or snowboarding. The main advantage of procedures in which a sensory-motor functional foot is retained is to avoid neuroma pain or phantom sensations. The foot allows for active knee movement of the orthoprosthesis and full weight bearing. It is of great psychological help for the patients to have contact during the decision-making with patients who have had similar procedures. It should be considered as an alternative to amputation.

Extra-articular en bloc resection of the talocrural and the talocalcaneonavicular joints for primary malignant synovial tumour (myxoinflammatory fibroblastic sarcoma).

A 13-year-old boy presented with a diagnosis of intra-articular myxoinflammatory fibroblastic sarcoma of the ankle. There had been no previous description of a sarcoma arising directly from the synovium of the ankle and limb salvage for malignant tumours of the ankle has rarely been reported. We treated him by peritalar extra-articular resection, and draw attention to this rare tumour and to a technique of limb-sparing resection of the ankle joint.

Results of treatment of malignant soft tissue tumours in the groin.

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or - if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.

Correction of forearm malunion guided by the preoperative complaint.

UNLABELLED: Diaphyseal malunion of the forearm may cause loss of pronation and supination, a painful distal radioulnar joint, and aesthetic problems. Seventeen patients (10 males, seven females; mean age, 20.6 +/- 9.3 years) were operated on because of symptomatic malunion after a pediatric forearm fracture. Six patients had predominant loss of pronation (Group 1), four had predominant loss of supination (Group 2), and seven had a painful distal radioulnar joint (Group 3). An osteotomy of the radius was performed in seven patients and of both forearm bones in 10. All patients were available for clinical and radiologic assessments at a minimum followup of 6 months (mean +/- standard deviation, 3.7 +/- 2.3 years; range, 0.5-9.9 years). Release of the contracted interosseous membrane frequently was necessary for patients in Groups 1 and 2 to allow for correction and did not result in weakness, instability of the distal radioulnar joint, or synostosis. The overall improvement in range of motion after osteotomies for patients with a supination deficit was much better than in those with a pronation deficit. All patients in Group 3 gained a pain-free and stable distal radioulnar joint and their range of motion was unchanged. Therefore, ability to improve overall range of motion through forearm osteotomies is dependent on the patients' preoperative complaint. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Multiple subungual soft tissue metastases from a chondrosarcoma.

Chondrosarcoma metastasises to the lungs and from there to other organs. A patient with several metastases in the soft tissues of the fingers and toes had previously been treated for a chondrosarcoma of the foot. Subungual metastases of chondrosarcoma are unusual and there is no evidence based treatment. We therefore treated the lesion of the finger by total resection of the nail (RO).

Bioengineering of a composite nerve graft for peripheral nerve reconstruction.

Engineering of nerve graft substitutes is challenging because of the complex cell and tissue interactions leading to successful nerve regeneration. Moreover cells in contrast to the extracellular nerve matrix are rejected by the immune system. We have developed ofa non-immunogenic nerve scaffold that can be seeded with autogenous Schwann cells prior to implantation in patients suffering extensive peripheral nerve lesions.

Pedicled vascularized rib transfer for reconstruction of clavicle nonunions with bony defects: anatomical and biomechanical considerations.

BACKGROUND: Clavicular nonunions with large bony defects, although rare, are difficult to treat and often result from multiple failed attempts at surgical management. Reconstruction using vascularized bone graft is the accepted standard in cases of large osseous defects. METHODS: An anatomical vascular corrosion study with cadaveric dissections and finite element analyses was designed to assess the feasibility of clavicular reconstruction with a musculo-osteous graft interposition based on a pedicled serratus anterior flap. RESULTS: Rib vascularization through the serratus anterior was demonstrated, so that the thoracic branch of the thoracodorsal artery can been considered a secondary blood supply for the seventh and eighth ribs. Single and double pedicled rib transfers allowed for reconstruction with as much as 8 cm of bone loss. The maximal stress found in the single-rib reconstruction interfaces was located at the medial contact of the plate with the clavicle. It was 2.7-fold higher than the maximal stress of the medial bow of the intact clavicle. Conversely, the double-rib reconstruction had improved mechanical resistance. A case report using a single-rib transfer supported the biomechanical study by showing that the maximal risk of material loosening was located at the medial bone interface. CONCLUSIONS: Double vascularized rib transfer as part of a serratus anterior flap should be used instead of single-rib transfer to reconstruct large clavicle defects. This technique is reproducible and does not require microvascular anastomoses. Therefore, it has potential advantages over free fibula transfer.

Fluoroscopic and magnetic resonance cross-sectional imaging assessments of radial and ulnar torsion profiles in volunteers.

PURPOSE: Planning an osteotomy to correct rotational malunions of the forearm is difficult because the uninvolved side is the only available reference to assess radial and ulnar torsions. This study was designed to compare the reliability of 2 methods for the determination of the torsion profile of both forearm bones and to assess side differences further in volunteers. METHODS: Fluoroscopy in combination with goniometry and magnetic resonance (MR) cross-sectional imaging were used to determine torsion profiles of the radius and the ulna in 24 asymptomatic volunteers. Interrater and interside reliabilities were assessed. RESULTS: For the radius, interclass correlation coefficients were less than 0.65 with fluoroscopy and greater than 0.80 with magnetic resonance imaging (MRI). For the ulna, both methods had an interclass correlation coefficient of greater than 0.90. Maximum side-to-side differences assessed with fluoroscopy and MRI were 25 degrees and 34.5 degrees for the radius and 20 degrees and 32 degrees for the ulna, respectively. There were no statistical differences between sides using both methods for both forearm bones. CONCLUSIONS: Fluoroscopy coupled with goniometry is a valuable method for assessing the torsion profile of the ulna. MR cross-sectional imaging is better to assess the torsion profile of the radius; however, a side difference in torsion profile of up to 35 degrees for the radius and of up to 20 degrees for the ulna should be considered physiologic. Hence, only side differences greater than these limits may serve as an indication for an axial osteotomy in the clinical setting.

Free functional gracilis muscle transfer for reconstruction of massive ectopic calcification following a lower extremity fracture: a case report and overview of the literature.

We present a patient with massive posttraumatic ectopic calcification in the lower extremity. The patient complained of an increasing tender soft tissue mass with signs of acute inflammation and foot dorsiflexion weakness following a tibial fracture for 34 years. A large radiopaque mass was resected and reconstructed using a free functional gracilis muscle transfer, resulting in recovery of stable soft tissue and foot dorsiflexion. The resected material showed highly fibrosed soft tissue with extensive dystrophic calcifications. There were no sign of recurrence at 18-month follow-up.

Assessment of radial and ulnar torsion profiles with cross-sectional magnetic resonance imaging. A study of volunteers.

BACKGROUND: We determined whether the torsion profiles of the radius and ulna could be reliably assessed with cross-sectional magnetic resonance imaging and whether these torsion profiles were comparable on the two sides of volunteers. METHODS: We assessed magnetic resonance imaging cross sections of the left and right forearms of twenty-four asymptomatic volunteers. The torsion profile of the ulna was defined as the angle formed between a line tangential to the volar cortical surface of the distal part of the humerus and a line connecting the center of the ulnar head and the center of the ulnar styloid. Use of paired proximal and distal landmarks resulted in five different methods of assessment of the radial torsion profile. Intrarater and interrater reliabilities and side-to-side variability were assessed. RESULTS: This method of assessment of the ulnar torsion profile had intraclass and interclass coefficients of 0.95 and 0.91, respectively. A method previously described by Bindra et al. had the best combined intrarater and interrater reliabilities for assessment of the radius. The mean differences between the right and left sides of the volunteers were the lowest with the use of these two methods; nevertheless, the maximum side-to-side difference was > 30 degrees with techniques. CONCLUSIONS: Torsion-profile assessment with cross-sectional magnetic resonance imaging had high intrarater and interrater reliabilities. However, individual side-to-side variations in the radial and ulnar profiles are important considerations. CLINICAL RELEVANCE: Cross-sectional magnetic resonance imaging is currently the only available method to quantify rotational malunion of the radius and ulna. Its low side-to-side reliability warrants comparison between the imaging results and the clinical findings. A side-to-side difference in the rotation profile may serve as a reason to perform an axial osteotomy when the results of the clinical and magnetic resonance imaging assessments are consistent with each other.

Corrective osteotomies in malunions of the distal radius: do we get what we planned?

UNLABELLED: Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5 degrees angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10 degrees with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Stimulation of neurite outgrowth in a human nerve scaffold designed for peripheral nerve reconstruction.

The clinical outcome of microsurgical reconstruction of large peripheral nerve lesions depends on the availability of suitable graft material. Allogenic nerve grafts are rejected by the immune system. Extracellular-matrix proteins, in contrast to the resident cells, are of low immunogenicity in allografts. Here, human tibial nerve segments were extracted with lysophosphatidyl choline. The obtained cell-free and myelin-free scaffold consisted of empty endoneural tubes with maintained extracellular matrix architecture. The nerve scaffold had mechanical properties comparable to intact nerve, making it suitable for microsurgical reconstruction. Sections of the nerve scaffold were tested as a substrate for the adhesion and neuronal differentiation of human neuroblastoma-derived LAN-5 cells. Nerve extraction removed laminin-2, an isoform of laminin important for peripheral nerve regeneration. Laminin-2 reloading of the nerve scaffold did not improve cell adhesion and axon growth. Chemical crosslinking of heparan sulfate, on the other hand, increased the percentage of adherent cells with outgrowing neurites from 48 to 85%. Combined laminin-2 reloading and heparan sulfate crosslinking reduced the percentage of neurite-forming cells to 22% of the number of adherent cells. Implantation of the nerve scaffold into the peritoneal cavity of mice was not cytotoxic, and neovascularization of the graft material was observed within weeks. In conclusion, extraction of human nerve with detergents revealed a biocompatible nerve scaffold supporting neuronal cell adhesion. Heparan sulfate crosslinking to the scaffold surface improved neurite outgrowth, presumably mediated by midkine, a member of the neurokine family of growth factors, which is secreted by neuroblastoma-derived cells and binds to heparan sulfate.

Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years.

BACKGROUND: Vascularized soft tissue transfer may give better results of treatment of infected nonunions of the tibia. METHODS: 6 patients with infected nonunion of the tibia and combined soft tissue (70-170 cm(2)) and bony (5-8 cm) defects underwent staged reconstruction. Initial surgery consisted of soft tissue and bone debridement, external fixation, filling of the bony defect with a gentamicin-impregnated cement spacer, and reconstruction of the soft tissue with a free microsurgical muscle flap and skin graft. Second-stage surgery consisted of removal of the cement spacer and osseous reconstruction with nonvascularized bone graft. RESULTS: All patients except 1 achieved full weight-bearing and radiographic consolidation after 7-10 months. This patient required repeated bone grafting and internal plate fixation to heal. There were no cases of recurrence of infection at the latest follow-up, after a mean of 3 (1.5-5) years. INTERPRETATION: Staged reconstruction with free vascularized soft tissue transfer and conventional bone grafting within a cement-induced membrane is a low-risk surgical strategy resulting in a high rate of bone healing.

Pedicled flaps for lower extremity reconstruction in the elderly: a retrospective study of 16 cases.

We reviewed a consecutive series of 16 patients above 60 years of age (mean age 71 years) who underwent reconstruction with pedicled flaps in the lower extremity. The soft tissue defects ranged from 9 to 50 cm and were caused in 11 patients (70%) by surgical complications from previous surgeries. Of these, 5 patients underwent a total joint replacement of the knee (4 cases) and of the ankle (1 case). Surgery consisted of 19 muscular flaps, and 3 fasciocutaneous flaps. Six patients were treated with a combination of 2 flaps. The overall surgical complication rate after reconstruction was 44%. There was no perioperative mortality and there were no medical complications. One patient required an above-the-knee amputation because of uncontrollable postoperative bleeding. A thrombectomy was performed in another patient to treat a postoperative popliteal artery occlusion with critical ischemia of the leg. Other complications included recurrent total joint replacement infections (2 cases), marginal flap necrosis (4 cases), and skin necrosis at the donor site (1 case). The mean hospitalization stay was 46 days. All patients but 1 completely healed, although secondary surgery was performed in 7 patients. The occurrence of complications was not correlated with the preoperative morbidity or an age above 75 years. The local complication rate was higher than reported for free flap in the same age category, but the lack of perioperative mortality and medical complications make it a low-risk option for reconstruction of small- to middle-sized defects in the elderly.

Donor site morbidity after serratus anterior free muscular flap: a prospective clinical study.

This study was designed to assess donor site morbidity after using the serratus anterior muscle as a free vascularized flap. The 3 distal slips of the serratus anterior were harvested from 3 dominant and 4 nondominant shoulders of 7 consecutive patients (age range, 36-61 years) to treat chronic osteitis or infected nonunions of the lower limb. Both donor and recipient sites healed primarily in all patients. Six of the 7 patients were enrolled in a postoperative shoulder-strengthening program. Preoperative and 3-month follow-up Constant scores and peak torque values of the operated shoulders were compared using the Wilcoxon matched pairs signed rank test. The pre- and postoperative Constant score were 95% and 93% respectively. Peak shoulder torque for abduction, adduction, flexion, and extension was assessed at both 60 degrees /second and 120 degrees /second. No statistical differences were found between the pre- and postoperative values. At the final follow-up (mean, 17 months), clinical examination revealed no scapular winging in all patients. Six patients answered a self-administered questionnaire to assess function of the shoulder. The average score in the pain domain was 36.3 points (with 40 points meaning free of pain). The average score in the activities of daily living domain was 18.5 of 20 points. The overall satisfaction rate with the donor site was very good in 2 patients and good in 4 patients. In conclusion, removal of the 3 distal slips of the serratus anterior for use as a free vascularized transfer did not impair shoulder function in this group of patients.