Plate augmentation and bone grafting in treatment of femoral shaft nonunion initially fixed by intramedullary nail.

INTRODUCTION: This study aims to evaluate the results of plate augmentation and bone grafting without removing the nail in the treatment of nonunited, nailed femoral shaft fractures. METHODS: Twenty patients with atrophic nonunion femoral shaft fractures initially fixed by intramedullary nail were treated by augmentation plating and iliac bone graft with retention of the nail. Patients were evaluated at regular intervals using an X-ray and Wu scoring system, which assesses clinical and radiological signs of healing. RESULTS: All 20 patients achieved bony union at a mean time of 4.9 months (3-8 months). According to Wu's score, 12 cases showed excellent results, and 8 cases obtained good results with no complications recorded. CONCLUSION: augmentation plating and iliac bone graft provide a good and safe method of treatment of previously nailed and non-united femoral shaft fractures. LEVEL OF EVIDENCE: Level 4; Case Series.

Different surgical procedures for reconstruction of soft-tissue defects around the ankle.

INTRODUCTION: Management of soft tissue defects around the ankle is a difficult and challenging situation for all reconstructive surgeons. A microsurgical free flaps coverage can solve this problematic situation especially with large defects that is not available in all trauma centers. Moreover, long operating time and suitable operative demands are considered obstacles. MATERIALS AND METHOD: Eighty five patients having soft tissue defects around ankle were included in this study. They underwent various reconstructions in our specialized hand and reconstructive microsurgery unit from 2015 to 2019. Fifty two were males and thirty three patients were females. Road traffic accident was the main cause of injury in 66 patients followed by implant exposure in 15 patients and chronic osteomyelitis in 4 patients. Distally based superficial sural artery flap was used to reconstruct the defects in 21 cases, free flap was used in 32 cases, Rotational local flap was used in 8 cases, contralateral distally based superficial sural artery flap was used in 2 cases, full or partial skin flaps were used in 10 cases and Propeller flap was used in 12cases. RESULTS: All flaps survived except for one modified sural flap with 98% success rate and average follow up of 48 months. All patients were satisfied with the functional capacity of operated limbs. Average time of bone healing postoperative was 3 months with gradual return to original work with acceptable degrees for cosmotic appearance of the limbs. CONCLUSION: Many treatment options are available to cover defects around the ankle. Propeller and rotational flaps are fast and easy but cover small defects, distally-based modified sural artery flap is an excellent reliable flap. Microsurgical free flaps provide good contour, color, texture and cover large defects but require microsurgery facilities to execute.

Modified Stoppa Approach for the Treatment of Complex Acetabular Fractures.

Complex acetabular fractures are due to high-energy trauma in most cases. The operative management of these types of fractures is often difficult and technically challenging. Almost all of these types of fractures are treated through extensile approaches, and a variety of them have been described. Some of these approaches are associated with complications such as infection, heterotopic ossification, and increased blood loss in addition to increased operative time. This retrospective study was performed at an academic Level I trauma center. From January 2013 to March 2019, 21 patients with complex acetabular fractures were treated with open reduction and internal fixation through a single anterior modified Stoppa approach. The average operative time was 98.80 minutes (range, 60-180 minutes), the average follow-up time was 40 months (range, 24-72 months), and the average Harris Hip Score (HHS) was 87.85 (range, 75-100). At the latest follow-up, 12 (57.1%) patients had an excellent HHS, 8 (38.1%) patients had a good HHS, and 1 (4.8%) patient had a fair HHS. Complex acetabular fractures can be effectively managed by a modified Stoppa approach without the need for extensile or combined approaches. [Orthopedics. 2021;44(3):e353-e358.].

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects.

OBJECTIVE: Management of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. PATIENTS AND METHODS: Thirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6-33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. RESULTS: All the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. CONCLUSION: Skin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft.

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.

Anterior shoulder release and tendon transfer as 1-stage procedure for treatment of internal rotation contracture deformity in obstetric brachial plexus injuries.

PURPOSE: Children who had internal rotation contracture deformities of the shoulder secondary to obstetric brachial plexus palsy were studied. The outcomes of anterior shoulder release and tendon transfer in 1-stage procedure were analyzed. METHODS: Anterior shoulder release and tendon transfer in 2 separate incisions as 1 procedure were performed in 76 patients for improvement of shoulder function. Anterior shoulder release was performed through the deltopectoral incision, starting with the coracoid process that extended 5 cm caudally. Osteotomy of the coracoid process subperiosteally with retaining the pectoralis minor attached to the periosteum. Z-plasty of the subscapularis and resuturing of the pectoralis minor short head of biceps and coracobrachialis to their original position were performed in all cases. A separate second incision in the posterior axillary fold was carried out to perform rerouting of the latissimus dorsi and teres major tendons with a mean follow-up of 5.6 years (range, 1-7 years). RESULTS: The average active external rotation with the arm at the side increased from -26 + 15 degrees preoperatively to 67 + 17 degrees postoperatively (average gain, 85 degrees). The average shoulder abduction increased from 46 + 22 degrees preoperatively to 130 + 32 degrees postoperatively (average gain, 75 degrees). Mallet score improved from 12.3 to 22.6. CONCLUSIONS: Anterior shoulder release combined with latissimus dorsi and teres major rerouting significantly improved global shoulder function.

Role of immunohistochemical cyclo-oxygenase-2 (COX-2) and osteocalcin in differentiating between osteoblastomas and osteosarcomas.

BACKGROUND/AIMS: Differential diagnosis between aggressive osteoblastoma and low grade osteosarcoma may be very difficult or even impossible on a small biopsy. This study was designed to assess the usefulness of immunoexpression of COX-2 and osteocalcin in the differential diagnosis of the two tumour types. METHODS: Immunostaining of COX 2 and osteocalcin were studied in 9 osteoblastomas and 30 osteosarcomas. RESULTS: All osteoblastomas and 11/20 (55%) high-grade osteosarcomas showed COX-2 immunoreactivity. All low grade osteosarcomas were COX-2 negative. COX-2 was significantly higher (p<0.002) in osteoblastomas 9/9 (100%) than in osteosarcomas 13/30 (43%) and in aggressive osteoblastomas versus low grade osteosarcomas (p<0.01). Osteocalcin was found in tumour cells of all osteosarcomas and osteoblastomas and in the osteoid matrix of 84% of osteosarcomas and 78% of osteoblastomas. Strong osteocalcin was significantly higher (p<0.02) in osteoblastomas (78%) than in osteosarcomas (27%). CONCLUSION: COX-2 is a valuable marker in distinction between osteosarcoma and osteoblastoma. Negative COX-2 could confirm the diagnosis of low grade osteosarcoma versus aggressive osteoblastoma. Intensity and distribution of osteocalcin may indicate the degree of osteoblastic differentiation.

Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique.

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

Functional outcomes of nonunion scaphoid fracture treated by pronator quadratus pedicled bone graft.

Between 1998 and 2007, a pronator quadratus pedicled bone graft was performed for 45 patients of ununited scaphoid fracture. One of them had bilateral ununited scaphoid fracture. There were 29 men and 16 women with a median age at operation of 24 (16-32) years. The affected side was the right side (dominant hand) in 32 patients whereas 13 patients had fracture of the nondominant left side. There had been 32 proximal pseudoarthrosis (through or proximal to the junction of the proximal and middle thirds of the bone) and 14 of the middle third of the scaphoid. The original fractures were caused by motor cycle accidents in 23 patients, falling on outstretched hand in 15 patients, and sport injuries in the remaining 7 patients. Surgery was indicated from 5 months to 6 years after injury (average 43 months) because of complaints of pain on heavy work. The fracture has been missed at the initial examination in 23 patients whereas cast immobilization was done for 6 weeks and 3 months in 15 and 7 cases, respectively, that had failed to result in union. There were no preoperative osteoarthritic changes, but in 25 cases, there were avascular necrosis of the proximal fragment of the scaphoid. Forty-three patients showed radiographic union after an average of 14 weeks (12-16 weeks). One patient had dislodgement of the graft and refused to do it again. The average range of movement of wrist improved after operation. Taken as a percentage of the normal range, dorsiflexion increased from 69% to 80%, palmar flexion from 66% to 76%, radial deviation from 45% to 70%, and ulnar deviation from 67% to 84%. Grip strength improved from 82% to 92% of normal. All the patients have been able to return to their former activities with no pain.

Early surgical exploration of radial nerve injury associated with fracture shaft humerus.

The series included 36 patients, predominantly male, mean age 30.3 years. The most common cause of injury was motor car accident in 20 patients. Postreduction radial nerve injury occurred in nine cases. Open fracture humerus with radial nerve injury in seven cases. The fractures were situated in the middle or distal third of the humeral shaft. Most were transverse fractures. Twelve patients had surgery on the day of injury and the other 24 at a mean of 8 days later (3-14). Narrow dynamic compression plate was generally used for fixation. Exploration of the radial nerve demonstrated compression at the lateral intermuscular septum in 19 cases, entrapment in the fracture site in nine cases, and loss of its continuity in eight cases. Neurolysis was required in 20 cases, epineurorrhaphy in nine cases, interfascicular nerve grafts in five, and first-intention tendon transfer in two. Results of nerve surgery were assessed with the MRC (Medical Research Council) at a mean follow-up of 8.2 years. Outcome was rated good to excellent in 28 patients, fair in 1, and poor (failure) in 3. First-intention tendon transfers were performed in 2 patients and 2 patients were lost to follow-up. Mean delay to recovery was 7 months after neurolysis and nerve repair and 15 months after nerve grafts. The fracture was united in all cases. The mean time of union was 5 months.

Management and functional outcomes of combined injuries of flexor tendons, nerves, and vessels at the wrist.

A retrospective review of 42 patients with spaghetti wrist lacerations operated on by the author between June 1997 and May 2005 was completed. A total of 31 males and 11 females, average age of 17.1 years (range, 2-40 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (55%), knife wounds (24%), and electrical saw injuries (11%). An average of 9.16 structures was injured, including 6.95 tendons, 1.4 nerves, and 0.8 arteries. The most frequently injured structures were median nerve (83%), flexor digitorum superficialis 2-4 tendons (81%), flexor digitorum profundus 2-4 tendons (66%), ulnar nerve and ulnar artery (57%), and flexor pollicis longus (40%). Combined flexor carpi ulnaris, ulnar nerve, and ulnar artery (ulnar triad) injuries occurred in 31%, while combined median nerve, palmaris longus, and flexor carpi radialis injuries (radial triad) occurred in 43%. Simultaneous injuries of both median and ulnar nerves occurred in 40.5%. Simultaneous injuries of both ulnar and radial arteries occurred in 14%. Neither artery was injured in 30.9%. Follow-up has ranged from 1 to 8 years, with an average of 46 months. Only four patients have been completely lost to follow-up. Range of motion of all involved digits (tendon function) was excellent in 34 patients, good in 3 patients, and poor in only 1 patient. Opposition was excellent in 31 patients, good in 5 patients, and poor in 2 patients. Intrinsic muscle recovery was subjectively reported to be excellent in 29 patients, good in 7, and fair to poor in 2 patients. Minor deformity (partial clawing) was reported in 4 patients and 1 patient has major deformity (total clawing). Sensory recovery was reported, excellent in 32 patients, good in 5 patients, and fair in only 1 patient.

Microsurgical technique in obstetric brachial plexus repair: a personal experience in 200 cases over 10 years.

We present our personal operative technique in exposing and repairing obstetric brachial plexus (obp) lesions. This technical description of the operative procedure and the strategic choice for the neurotisations are analysed with special regards on the follow-up of these patients (always performed by the surgeon), the histological quality of the proximal root stumps used for cable grafting, and the general reconstruction principles established in international workshops. We would like to encourage debate on these detailed considerations wherever they could affect the functional outcome.

Microsurgical reconstruction of brachial artery injuries in displaced supracondylar fracture humerus in children.

Between March 2000 and March 2005, 840 children with grade III supracondylar humeral fractures presented for treatment, consecutively at our hospital. One hundred twenty had absent or diminished (detected by Doppler but not palpable) radial pulse on initial examination. Eighty-nine of these 120 children recovered pulse (palpable) after closed reduction and percutaneous pinning of the fracture. The remaining 31 children had persistent absent radial pulse. Twenty-two of the 31 children had median nerve signs. Each of these 31 children was explored. The intraoperative findings were intact median nerve in all cases (neuropraxia), traumatic aneurysm with thrombus formation in 17 cases, complete injury of the brachial artery in 8 cases (loss of continuity), thrombosis in 3 cases, partial tear in 2 cases, and brachial artery entrapment in the fracture site in 1 case. Microsurgical reconstruction of the 31 brachial arteries was done as the following: reversed vein graft for 8 cases, excision and repair in 17 cases, partial repair in 2 cases, thrombectomy in 3 cases, and release of the brachial artery from the fracture site in 1 case. The average follow up was 26 months range (6-60) months. All children had excellent to good functional and cosmetic outcome except one who had Volkman's ischemic contracture, treated later by free functioning gracilis muscle transfer.

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results.

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle

Repeated upper limb salvage in a case of severe traumatic soft-tissue and brachial artery defect.

We present the case of a 9-year-old male patient who suffered a gunshot injury to the right arm. The patient arrived in shock, his right arm severely traumatized, with soft-tissue loss involving the anterior surface and both sides of the right arm. The humerus was exposed. There was brachial artery defect and damage to the lateral fibers of the median nerve. The mangled extremity severity score (MESS) was 8 points. The patient was treated with general resuscitation, blood transfusion, and debridement. A venous graft, 12 cm in length, to bridge the brachial artery defect, and tendon transfer, triceps to the biceps, was performed in one step. Postoperatively, there was a normal radial pulse, normal skin color, normal temperature, and normal movement of the fingers without pain. Unfortunately, the patient then sustained a second trauma to the right arm 3 weeks later, rupturing the graft. This time he lost 1,500 cc of blood. After another blood transfusion, we performed a second reverse saphenous vein graft. The patient stayed at the hospital for 3 weeks. At follow-up 12 months later, the limb has good function and, except for the presence of a scar and skin graft, is equal in appearance to the left side.