Reconstruction of chronic boutonniere deformity with wide awake local anesthesia and no tourniquet in a patient with upper type brachial plexus injury: A case report

@#Reconstruction of chronic boutonniere deformity remains to be a challenging procedure especially when combined with other debilitating injuries in the same extremity. The balance to properly tension the reconstruction with active motion is often prevented by the need to perform the procedure under sedation of block to tolerate the use of tourniquet. We present a case of a young patient who successfully underwent restoration of active proximal interphalangeal (PIP) extension with a Palmaris longus graft while wide awake under local anesthesia and no tourniquet (WALANT) before subsequently having nerve transfers for upper type brachial plexus injury.

The functional outcomes of scaphoid nonunion with deformity treated with anterior wedge bone grafting: A case series

INTRODUCTION@#Scaphoid nonunion is one of the most difficult fractures to treat. Restoration of carpal alignment and fracture stability can provide good outcomes in the management of scaphoid nonunion.@*OBJECTIVE@#The purpose of this study was to determine the functional outcomes of scaphoid nonunion associated with humpback deformity treated with anterior wedge bone grafting and internal fixation.@*METHODS@#A retrospective review of all patients with scaphoid nonunion treated with anterior wedge bone grafting from January 1, 2014 to December 31, 2019 was done. Outcome measurements were time to union, pre- and postoperative FIL-DASH scores, grip, pinch, and scapholunate angle improvement. The other outcome measures were pain and complications.@*RESULTS@#A total of 12 patients were included in the study. All were males with an average age of 27.4 years (SD, 9.6). The average delay to surgery was 9.5 months (SD, 10). All fractures were at the waist, except for three proximal pole fractures, none had established avascular necrosis. Eleven out of 12 scaphoids healed at an average of 11.5 weeks (SD, 3.2). There was a significant improvement in the FIL-DASH score and scapholunate angle after surgical reconstruction. Grip strength averaged 83% of the contralateral side. All returned to previous normal activities. One patient with persistent proximal pole nonunion was managed with a 4-corner arthrodesis.@*CONCLUSION@#Anterior wedge bone grafting for scaphoid nonunion restored the scapholunate angle and was able to establish union in 11 of 12 scaphoid nonunions with good outcomes.

Clinical outcome of the latissimus dorsi muscle flap in orthopedic reconstruction

INTRODUCTION@#The latissimus dorsi muscle has been the “workhorse” of reconstructive surgery because of its predictable neurovascular anatomy and ability to perform both wound coverage and restoration of function. @*OBJECTIVES@#We determined the flap viability, complications, and muscle function (if used as muscle transfer) of our latissimus dorsi flaps for orthopedic reconstruction.@*METHODS@#This is a retrospective review of all cases done in the Microsurgery Unit of the Philippine General Hospital and The Medical City from January 2005 to present using the latissimus dorsi muscle for reconstructive surgery. All patients were followed-up for six months.@*RESULTS@#There were 14 patients who had reconstructive surgeries using the latissimus dorsi muscle. Three patients had traumatic brachial plexus injuries where the latissimus dorsi muscle was used for the reconstruction of elbow flexion. Eleven patients required coverage of a large defect, where seven were secondary to tumor resection and four were secondary to trauma. Of the fourteen patients, nine were pedicled flaps and five were free flaps. We had one failure (free flap group/tumor resection). The rest of the flaps survived completely. The smallest flap was 10 x 8 cm, and the largest flap was 28 x 24 cm.@*CONCLUSION@#The latissimus dorsi muscle remains to be a versatile muscle in the field of orthopedic reconstructive surgery.

Functional outcome of displaced intra-articular fractures of the distal radius: Comparison of closed reduction percutaneous pinning with or without external fixation versus open reduction plate fixation

OBJECTIVES@#The purpose of the study was to determine the outcomes of closed reduction percutaneous pinning (CRPP) with or without external fixation (EF) with open reduction and internal fixation (ORIF) using plate and screws. @*METHODS@#Outcomes of ORIF versus CRPP, with or without external fixation for intra-articular distal radius fractures were compared through a multicenter, non-randomized, ambispective cohort study. A validated Filipino version of the DASH score (FIL-DASH) was used as primary outcome measure.@*RESULTS@#The ORIF group consisted of 13 patients and the CRPP group, eight patients. Pain scores, post-operative complications and radiographic measurements were also evaluated. Mean FIL-DASH score for the ORIF group (M=26.69, SD=4.88) was significantly higher versus the CRPP group (M=14.59, SD=10.64; t(19)=3.58, p=0.002). No significant differences in radiologic parameters, pain scores, and complications were found.@*CONCLUSION@#The study demonstrates that functional outcomes post-CRPP with or without external fixation compares favorably over ORIF for distal radius fractures at one-year post-surgery.

Semi-occlusive dressing as non-operative treatment vs. operative treatment for fingertip amputations: A retrospective cohort study

INTRODUCTION@#Treatment of fingertip amputations have demonstrated good outcomes with both surgical and nonsurgical management.@*OBJECTIVE@#The objective of this study was to compare non-operative treatment with semi-occlusive dressing with any surgical treatment for fingertip amputations in adult fingers, Allen types I-III in a retrospective cohort review.@*METHODS@#A retrospective chart review was done on adult patients with fingertip amputations Allen types I-III from January 1, 2018 to December 31, 2020. Patients included in the studies were distributed into two treatment groups: non-operative and operative groups. Outcomes to be measured were time to full healing, range of motion, nail deformities, Tinel’s sign, and discoloration of the reconstructed fingertip.@*RESULTS@#A total of 38 patients with 40 digits were included (19 patients with 20 digits for each treatment group). The results showed a larger defect for the operative group (3 cm2 vs 2.1 cm2), with shorter time to healing (1.4 months vs 2.2 months). There were more complications in the operative group like the Tinel’s sign, nail deformity and discoloration, as well as joint contractures. Range of motion was better for patients treated non-operatively.@*CONCLUSION@#Treatment with semi-occlusive dressing showed similar results in terms of wound healing but takes a longer time and less complications compared to operative treatment.

A pilot study on the functional outcome using markerless motion analysis tool and surface emg of nerve transfers for upper trunk brachial plexus injuries

INTRODUCTION@#Brachial plexus injuries (BPI) have devastating functional effects. Clinical outcomes of BPI reconstruction have been documented in literature; however, these do not use EMG and quantitative kinematic studies.@*OBJECTIVE@#This study aims to use a markerless motion analysis tool (KINECT) and surface EMG to assess the functional outcomes of adult patients with traumatic upper trunk BPI who have undergone nerve transfers for the shoulder and elbow in comparison to the normal contralateral limb.@*METHODS@#This is an exploratory study which evaluated three participants with BPI after nerve reconstruction. KINECT was used to evaluate the kinematics (range of motion, velocity, and acceleration) and the surface EMG for muscle electrical signals (root mean square, peak EMG signal, and peak activation time) of the extremities. The means of each parameter were computed and compared using t-test or Mann-Whitney U test.@*RESULTS@#Participant C, with the best clinical recovery, showed mostly higher KINECT and EMG values for the BPI extremity. There was a significant difference between the KINECT data of Participants A and B, with lower mean values for the BPI extremity. Most of the EMG results showed lower signals for the BPI extremity, with statistical significance.@*CONCLUSION@#The KINECT and surface EMG provide simple, cost-effective, quick, and objective assessment tools. These can be used for monitoring and as basis for formulating individualized interventions. A specific algorithm should be developed for the KINECT sensors to address errors in data collection. A fine needle EMG may be more useful in evaluating the muscles involved in shoulder external rotation.

Validity and reliability of image intensifier articular step-off and gap measurements for distal radius fractures using a cadaveric model

OBJECTIVES@#The purpose of this study was to determine the accuracy and reproducibility of image intensifier (fluoroscopic) measurements of gap and step-off displacements on the articular surface of the distal radius using a standard cadaver osteotomy fracture model.@*METHODS@#Fourteen orthopedic residents were randomly assigned using the fish bowl method to measure the gap and step-off displacements in cadaveric fluoroscopic images using a digital caliper. Each physician was randomly assigned the images where they examined the images twice and the average taken using a standard technique. The interobserver and intra-observer reliability were calculated using the intraclass correlation coefficient (ICC). Rank Sum test was used to evaluate the validity of measurements.@*RESULTS@#The results of the study showed that there was no significant difference between the cadaveric and measured step-off and gap displacements. Intraclass correlation coefficient scores showed moderate (0.41) to perfect (1.0) agreement.@*CONCLUSION@#The study showed that fluoroscopy can aid in the interpretation of gap and step-off displacements in acute distal radius fractures.

The management of diabetic foot ulcers in patients with SARS-CoV-2 during the COVID-19 pandemic

@#<p style="text-align: justify;"><strong>Objective.</strong> The COVID-19 pandemic continues to wreak havoc in all sectors of society one year after it was declared by the World Health Organization. This retrospective study aims to describe the clinical picture, management, and initial outcomes of patients with infected diabetic neuro-ischemic foot ulcerations (NIFU) afflicted with SARS-CoV-2 managed at a government tertiary hospital during the pandemic; and to compare those who survived from those who did not from this combination of diseases.</p><p style="text-align: justify;"><strong>Methods.</strong> Chart review of patients with combined infected diabetic NIFU and COVID-19, admitted at the Philippine General Hospital serving as a COVID-19 referral center, from April 1 to December 31, 2020 was performed. Data collected included patient demographics, clinical presentation including NIFU grade and stage, and severity of COVID-19, coagulation and inflammatory laboratory results, management, and initial outcomes.</p><p style="text-align: justify;"><strong>Results.</strong> A total of 59 patients with diabetic foot ulcer were co-managed by the Department of Orthopedics during this period of the pandemic. Nine of these patients were COVID-19 positive of which six patients did not survive their illness. The non-survivors were slightly older (58.33 vs. 52.67 y/o), had more co-morbidities, and presented with more severe COVID-19 (3 patients had critical COVID-19) than the survivors. All nine patients had deranged coagulation parameters including elevated D-dimer levels, and elevated inflammatory markers (CRP, Ferritin, LDH). Procalcitonin levels were increased in four of the non-survivors, and normal in all three survivors. Seven of the patients had severe (Grade II or III) and infected/ischemic (Stage B or D) NIFUs that required surgery; however, two patients succumbed to their illness prior to any surgery. Four of the six non-survivors died due to acute myocardial infarction.</p><p style="text-align: justify;"><strong>Conclusion.</strong> The presence of NIFU and COVID-19 in a patient generally results in progression to a turbulent hospital course. This is due to the hypercoagulable and hyperinflammatory states that each disease entity produces, which when combined, are exacerbated. Levels of D-dimer and inflammatory markers, especially procalcitonin, may be used as a predictor of poor outcome, even mortality, in this group of patients.</p>

Restoration of Elbow Flexion for Upper Trunk Brachial Plexus Injuries: Evaluation of Nerve Transfers and Modified Steindler Flexorplasty

@#INTRODUCTION: In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months. OBJECTIVE: The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI). METHODS: A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables. RESULTS: The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in <6 months. CONCLUSION: Nerve transfers and the modified Steindler procedure are still excellent options for successful elbow flexion reanimation in patients with brachial plexus injuries. Our results also showed that those with surgical delays of less than six months had the highest rate of achieving ≥M3 elbow flexion strength in the nerve transfer group.