Adolfo Vigasio

Microvascular fibular grafts in skeleton reconstruction

Extensive bone defects from any cause require large bone grafts. Such large defects usually cannot be repaired by conventional, nonvascularized cancellous grafts. Before the advent of microsurgery, many of these lesions could not be cured, and amputation was often the only solution. The bone may be transferred alone or in combination with skin or muscle or both. Idiopathic femoral head necrosis is 1 of the main indications for free microvascular (fibular) transfer. The authors propose a new classification for idiopathic femoral head necrosis. A technique that has been used for the past 14 years, on providing mechanical support and improved blood supply to the femoral head, is described. The fibula is favored for its mechanical properties and its vascular pedicle, and because it is easier to harvest.

Homolateral Hourglass-Like Constrictions of the Axillary and Suprascapular Nerves: Case Report

In contrast with previous research, it was recently demonstrated that hourglass-like constriction is not exclusive to the elbow region. We present a report of a patient who had an axillary nerve and a suprascapular nerve hourglass-like constriction, found 7 years apart.

Correction of Drop-Foot in Common Peroneal Nerve Palsy: The Anterior Tibialis Tendon Rerouting Technique

Drop-foot is a consequence of a common peroneal nerve palsy, which is a disabling condition characterized by a steppage gait. For the cases in which the primary nerve repair does not produce muscle reinnervation or the nerve reconstruction is not indicated, a dynamic tendon transposition may be a plausible surgical option for the restoration of functional dorsiflexion. In an effort to find a solution to the major disadvantage of the numerous techniques, which were developed from the original procedure presented by Codivilla and Putti, we use the anterior tibialis tendon (ATT) rerouting technique. We reroute the ATT on the dorsum of the tarsus by drilling a transosseous tunnel from the first to the third cuneiform. With this approach, we create a new tendon origin at the level of the third cuneiform. The ATT is then passed under the extensor retinaculum, reaching the distal third of the leg. The posterior tibialis tendon (PTT) and the flexor digitorum longus (FDL) tendon are transferred through the anterior aspect of the interosseous membrane. A tendon-to-tendon suture is performed between the ATT and PTT using the Pulvertaft technique, and similarly, the FDL tendon is sutured end-to-side to the extensor digitorum longus and extensor hallucis longus tendons. Originating a new tendon at the tarsus and the positioning of the recipient ATT in closer proximity to the donor PTT are novel aspects of this technique. These modifications produce a sufficient tendon length, which would permit an easy tendon-to-tendon suture at the distal third of the leg. This, in turn, eliminates the PTT length-related problems associated with other techniques. The transfer of the FDL tendon, which is associated with a straight line of pull, improves the power of foot dorsiflexion not only avoiding the drop of toes but also allowing the voluntary dorsiflexion of digits.

Repair of collateral ligament ruptures in the metacarpophalangeal joints of the long fingers.

Isolated collateral ligament ruptures in the metacarpophalangeal joints of the fingers seem to be more frequent than described. For ligament repair, dorsal access is generally described, but the proper method by which to proceed inside the joint is unclear and left to the surgeons discretion and experience. With the technique we propose, it is possible to explore the interior of the joint from the top, allowing an easy and complete examination of the entire length of the ligament. This proposed method allows for a better identification of the lesion and the area of ligament reinsertion, facilitating technical decision-making, and reducing the operating time.

Arthrodesis of the wrist in cases of hand paralysis (personal technique)

Arthrodesis of the wrist in cases of paralysis of the upper limb, although rejected by certain authors, is a valid operation provided it is confined to certain indications such as paralyses requiring minimal muscle transfers. Arthrodesis of the wrist is particularly useful in the sequelae of brachial plexus lesions with dissociated paralysis and in total paralysis of the radial nerve with hand drop and preservation of the wrist flexors. Numerous techniques of arthrodesis have been proposed. Over the last 27 years, the authors use a technique with a direct dorsal incision. The first row of carpal bones and the radius are roughened with chisel. A cortico-cancellus graft is then raised from the dorsal surface of the radius, leaving a distal cortical bridge. The graft is slid under this bridge, placed onto the roughened surface of the carpus and pushed under the operculum raised at the base of the 2nd and 3rd metacarpals. The arthrodesis is fixed with two Kirschner pins and a plaster for 3 months. We have used this technique in 31 patients with nerve paralyses since 1971 and have obtained complete consolidation with total patient satisfaction in all but one case.

Hourglass-like constriction of the suprascapular nerve: a contraindication for minimally invasive surgery

BACKGROUND Suprascapular nerve (SSN) entrapment is usually ascribed to static or dynamic compression. When no cause of compression is found, SSN entrapment is defined as idiopathic. Focal hourglass-like constriction (H-LC) of the SSN that results in muscle paralysis represents an unusual condition that may be misinterpreted and erroneously diagnosed as SSN entrapment or as neuralgic amyotrophy. METHODS With the aim of finding clinical and surgical clues that could differentiate the traditional form of idiopathic SSN entrapment from the rare H-LC, a series of 6 cases of SSN palsy caused by H-LC is presented. RESULTS All but 1 supraspinatus muscle recovered M5 muscle strength. The Constant shoulder score was excellent in 3 patients, good in 1, fair in 1, and poor in 1. DISCUSSION If a diagnosis is not made in time, H-LC may evolve from mild to severe nerve torsion that may require a shift in surgical procedure from epineurotomy and external neurolysis to focal resection and suture. If an incorrect therapy is chosen, the chance of recovery might be definitively compromised with the persistence of muscle palsy. Conversely, when SSN palsy persists despite notch decompression, especially when it is performed with a limited open approach or arthroscopically, concerns about the real etiology and location of nerve compression responsible for the nerve palsy may arise. CONCLUSION When approaching SSN pathology, H-LC should be considered as a potential cause of nerve palsy, as it may represent a contraindication for a limited open approach or arthroscopic decompression.

Recalcitrant cubital tunnel syndrome

Ulnar nerve neuropathy at the elbow represents the second most frequent compression neuropathy of the upper extremity. Of the five different anatomical areas responsible for ulnar nerve compression at the elbow region, the epitrochlear-olecranon channel and Osbornes arcade are the most common. An additional cause of nerve damage is a dynamic process in which the ulnar nerve dislocates anteriorly at the epitrochlear-olecranon level during elbow flexion, partially or completely, causing nerve friction and constriction leading to chronic neuropathic pain. Failure after primary surgery is generally secondary to procedural errors or technical omissions, frequently represented by incomplete nerve decompression, failure to recognize nerve instability after nerve decompression, loosening of the nerve anchor after superficial nerve transposition with consequent spontaneous nerve relocation in the epitrochlear-olecranon channel, perineural fibrosis and neurodesis, which creates new nerve compression. In association with the clinical evaluation, electromyography studies, magnetic resonance imaging and ultrasound are useful tools that may aid in the decision-making process when considering revision surgery. Superficial anterior transposition is the most commonly employed technique but also has a high failure rate, as opposed to anterior deep transposition that is the method of choice for many surgeons despite being more technically demanding. The results of revision surgery following recalcitrant ulnar nerve compression at the elbow are inferior to those obtained after primary surgery. Nonetheless, the clinical advantages remain relevant provided that the revision surgery is performed by an expert surgeon. To avoid misinterpretation, the patient is completely informed of the quality of results.

Reply to Letter to the Editor: New Tendon Transfer for Correction of Drop-foot in Common Peroneal Nerve Palsy

Titolo and colleagues proposed a modified version of Vigasio tendon transfer [7, 8] in which surgeons reroute only half of the anterior tibialis tendon. The remaining half of the anterior tibialis tendon is used as a rein to “improve in dorsiflexion the correct balance of pronation/supination of the foot especially when the exit hole of the transosseous tunnel at the third cuneiform is not perfectly centered on the axis of the ankle,” according to Titolo and colleagues’ letter to the editor. The basis for their proposal is not new. Numerous papers [2–6, 9] play on the “reins” concept in order to obtain a balanced foot dorsiflexion. Several bone attachments have also been tested (first, second, third cuneiform, cuboid, and the base of the fifth metacarpal bone). Goh and colleagues [1] demonstrated that the ideal tendon insertion to achieve a balanced foot dorsiflexion is on the third cuneiform. Generally, a “reins” procedure, like the one proposed by Titolo, has not been widely adopted among surgeons because the approach is technically demanding. Additionally, the procedure does not respect the “straight line of pull principle” on tendon transfer [1]. According to this principle, if two or more tendons are sutured with an oblique angle of incidence, the donor tendon further dissipates the residual contraction power, risking the creation of a tenodesis effect rather than a voluntary, dynamic dorsiflexion of the ankle and digits. The anterior tibialis tendon rerouting technique as described by Vigasio [7, 8] use an anterior tibialis tendon as a single rein. When correctly extracted from the third cuneiform, the tendon gives a working balanced foot dorsiflextion. We understand that surgical techniques continually need updates and revisions, and we thank Titolo and coauthors for their proposal.