Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: a report of thirteen cases.

Chronic nonunions of the humerus remain a challenging problem. We reviewed 13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional treatment. Patient averages were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site. No significant correlations were found between time to heal and other covariates.

Effect of elbow position on grip strength in the evaluation of lateral epicondylitis.

PURPOSE: This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected lateral epicondylitis (LE). METHODS: From our database we identified 81 patients with grip strength measurements and the diagnosis of LE. From these patient records we collected grip strength measurements with the elbow in full extension and with the elbow in 90 degrees of flexion for the affected and the healthy extremity. We then compared 2 values: the pretreatment grip strength in flexion and extension for the affected extremity and the pretreatment grip strengths of the nonaffected extremity compared with the affected extremity. Grip strengths were compared with paired and unpaired 2-tailed t tests. RESULTS: Grip strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities. CONCLUSIONS: The measurement of extension grip strength is a useful objective tool to aid in the diagnosis of LE. In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension.

Free fibula transfer in the treatment of difficult distal tibia fractures.

Management of the high-grade open distal tibia fracture remains problematic. The authors reviewed the charts of 14 cases of distal tibia and tibial plafond fractures reconstructed with a free fibula transfer. Six cases involved a plafond defect, and the fibula was used to arthrodese the tibio-talar joint. Seven cases included a skin paddle. Three of the four patients with osteomyelitis cleared their infection. Twelve patients went on to osseous union, and two were ultimately treated with amputation. Patients who went on to union had an average of 1.1 subsequent procedures, began full weightbearing in an average of 5.8 months, and were weightbearing without any assistive devices by an average of 8.5 months. There was no significant correlation between the time to full weightbearing and either the presence of infection or the length of the original defect. In this series, 86 percent success was obtained when a free fibula transfer was used either to bridge a tibial non-union or to promote arthrodesis of the tibio-talar joint.

Magnetic resonance imaging of the elbow: update on current techniques and indications.

The utility of magnetic resonance imaging of the elbow has noticeably improved over the past decade. Advances in equipment and refinement of pulse sequences has allowed for superior visualization of many pathologic processes involving the elbow joint and its surrounding structures. At this time, magnetic resonance imaging is most valuable in detecting occult fractures, osteochondritis dissecans, collateral ligament tears, nonossified intra-articular loose bodies, and soft tissue masses. It may also aid in the diagnosis of tendinous injuries, compression neuropathies, and synovial disorders. This article serves as an educational update for hand surgeons and illustrates the features of normal anatomy and specific disorders of the elbow.

A new method of selecting Schwann cells from adult mouse sciatic nerve.

We describe a method of using laminin for the selection and purification of Schwann cells in vitro. We also studied the viability of the selected cells suspended in alginate beads both in vitro and in vivo. We observed that the homogeneity of the Schwann cell culture increased with each round of laminin selection and reached 85-90% after five passages. The viability of cells after incubation within an alginate bead in vivo was between 73 and 76% compared with greater than 90% viability for cells that were maintained in monolayer culture. This new method of serial selection using laminin-coated surfaces has optimized the purification of a Schwann cell culture expanded from cells harvested from the adult sciatic nerve of a mouse. This method has the advantage of being technically easier than other methods described and results in a Schwann cell culture that is 80-90% homogenous.

Interposition arthroplasty with bone-tendon allograft: a technique for treatment of the unstable sternoclavicular joint.

Sternoclavicular joint instability is an uncommon but challenging clinical problem for the orthopaedic surgeon. Although most cases can be treated nonoperatively with minimal long-term pain or functional limitation, a small percentage may require surgical intervention. This includes chronic anterior instability associated with persistent pain or functional limitation as well as irreducible or recurrent posterior instability. Although numerous procedures have been described for treatment of the unstable sternoclavicular joint, the optimal method for stabilization has not been determined. Here we describe a technique using Achilles tendon allograft to create an interpositional arthroplasty and briefly present 3 illustrative cases in which we performed the procedure. We believe this method effectively stabilizes the joint, restores function, relieves pain, and has applications for traumatic sternoclavicular instability as well as instability related to other etiologies.

Use of ultrasound in determining treatment for avulsion of the flexor digitorum profundus (rugger jersey finger): a case report.

Avulsion of the flexor digitorum profundus (rugger jersey finger) commonly occurs in athletes as a result of forced extension of a flexed distal interphalangeal joint. Ultrasound can be a useful tool in defining the anatomy of a tendon avulsion when no fracture is present. In subacute situations, the degree of tendon retraction has important implications for the treatment of these common injuries. Use of ultrasound for closed flexor tendon injuries has not been covered enough in the hand surgery literature. We report on the use of ultrasound as a diagnostic tool in evaluating and treating subacute avulsion injuries to the flexor digitorum profundus.