Alvaro Baik Cho

Alternative to the Distal Interphalangeal Joint Arthrodesis: Lateral Approach and Plate Fixation

PURPOSE Several fixation techniques for distal interphalangeal (DIP) joint arthrodesis have been described, with good clinical results and complication rates between 10% and 20%. We propose an alternative technique and fixation method using a lateral approach and 1.3-mm plate and screws fixation. METHODS Between March and September 2005, 11 patients, totaling 15 fingers, had DIP joint arthrodesis by the described technique. The indications were posttraumatic arthritis in 8 fingers, degenerative or rheumatoid arthritis in 5 fingers, and isolated flexor digitorum profundus tendon lesions in 2 fingers. Patients were analyzed for osseus union, pain relief, and functional mobility of the finger. RESULTS Arthrodesis relieved pain and restored stability at the 12th week, on average, with osseous union in all patients. All patients maintained full proximal interphalangeal joint motion with pulp-to-palm distance of zero at 6 months of follow-up evaluation. There were no rotational or angular deformities, nail bed lesions, or skin complications. CONCLUSIONS The lateral approach with plate and screws fixation is an option for DIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Anatomic study of the dorsal arterial system of the hand

UNLABELLED Historically, the dorsal arterial system of the hand received less attention than the palmar system. The studies concerning dorsal arterial anatomy present some controversies regarding the origin and presence of the dorsal metacarpal artery branches. Knowledge of the anatomy of dorsal metacarpal arteries is especially applied in the surgical planning for flaps taken from the dorsum of the hand. The purpose of this study is to analyze the arterial anatomy of the dorsum of the hand, compare our observations with those of previous studies from the literature, and therefore to define parameters for surgical planning for flaps supplied by the dorsal metacarpal arteries. METHOD Twenty-six dissections were performed at the dorsum of the right hand of 26 cadavers by making a distal-based U-shaped incision. After catheterization of the radial artery at the wrist level, a plastic dye solution with low viscosity and quick solidification was injected to allow adequate exposure of even small vessels. The radial artery and its branches, the dorsal arterial arch, the dorsal metacarpal arteries, the distal and proximal communicating branches of the palmar system, and the distal cutaneous branches were carefully dissected and identified. RESULTS The distal cutaneous branches originating from the dorsal metacarpal arteries were observed in all cases; these were located an average of 1.2 cm proximal from the metacarpophalangeal joint. The first dorsal metacarpal artery presented in 3 different patterns regarding its course: fascial, subfascial, and mixed. The branching pattern of the radial artery at the first intermetacarpal space was its division into 3 branches. We observed the presence of the dorsal arterial arch arising from the radial artery in 100% of the cases. The distance between the dorsal arterial arch and the branching point of the radial artery was an average of 2 cm. The first and second dorsal metacarpal arteries were visualized in all cases. The third and fourth dorsal metacarpal arteries were visualized in 96.2% and 92.3% of cases, respectively. There was proximal and distal communication between the dorsal arterial arch and the palmar system through the communicating branches contributing to the dorsal metacarpal artery formation. CONCLUSION At the dorsum of the hand there is a rich arterial net that anastomoses with the palmar arterial system. This anatomical characteristic allows the utilization of the dorsal aspect of the hand as potential donor site for cutaneous flaps.

Four corner arthrodesis limited to the centre using a scaphoid one piece graft and a dorsal circular plate

We present 20 patients, who had a four corner arthrodesis, from July 2006 to March 2008, using a dorsal circular plate, to treat scaphoid nonunion and scapholunate dissociation with advanced collapse (SNAC, SLAC). The surgical technique was a fusion restricted to the central area filled with one piece of cancellous bone graft taken from the excised scaphoid. Wrist motion, grip strength, and Disabilities of Arm Shoulder and Hand (DASH) score improved after surgery at a mean follow-up of 20.2 months. Fusion occurred in 19/20 patients. Two patients (10%) had persistent pain. The rest had a good clinical result. We found that four-corner fusion using a dorsal circular plate using the specific technical modifications was successful.

Effect of fibrin adhesive application in microvascular anastomosis: a comparative experimental study.

Background: Microvascular anastomosis is the most critical step during free flap transfers or replantations. Although the conventional suture is still considered the standard technique, it is technically difficult, time consuming, and traumatic to the vessel wall. The aim of this study was to evaluate the effectiveness of fibrin adhesive to overcome these problems when applied in microvascular anastomosis. Methods: Sixty-eight Wistar rats were used in this study. Eight animals were used in a pilot study to determine the minimum amount of suture stitches required per anastomosis when the fibrin adhesive was applied. In the definitive study, we performed 30 anastomoses in the femoral artery and 30 anastomoses in the carotid artery. In each artery, half of the anastomoses were performed using interrupted sutures without fibrin adhesive (control groups), and the other half were performed using fibrin adhesive and fewer sutures (experimental groups). Results: The application of fibrin adhesive significantly reduced the number of sutures and the time taken to perform the anastomosis. The anastomotic bleeding was also significantly reduced in both experimental groups. The immediate and late patency rates were not compromised by fibrin glue application. No significant differences were observed in the histologic analysis of the anastomosed vessels between the two techniques. Conclusions: The application of fibrin adhesive did not result in any harmful effects in the microvascular anastomosis. The authors encourage the clinical application of fibrin adhesive in more complex cases, when more than one microvascular anastomosis is required.

Anomalous presentation of flexor carpi radialis brevis: a report of six cases

An anomalous presentation of flexor carpi radialis brevis (FCRB) is reported in six patients. These findings occurred in a consecutive series of 172 distal radius fracture fixations using a volar approach between 2002 and 2007. This is the first report of this anomalous muscle from a clinical series.

Median nerve fascicle transfer versus ULNAR nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: Nonrandomized prospective study of 23 consecutive patients

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty‐five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow‐up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow‐up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5‐C6 or C5‐C7) did not affect anti‐gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5‐C7 injuries.

Intercostal nerve transfer to the biceps motor branch in complete traumatic brachial plexus injuries

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow‐up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow‐up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

Treatment of Hardware Exposure After Severe infections in Spine Surgery with Pedicled Muscular Flaps

The use of internal fixation for spine surgery has become a standard approach for virtually all types of procedures that require bone stabilization. The potential advantages include rigid fixation with early mobilization and more comfort in the post-operative period. However, complications like wound infections can jeopardize the final outcome of these procedures. These infections range from small areas of dehiscence to large wounds with hardware exposure. The conventional approach of serial wound debridement and antibiotic administration can last for a very long period and is only successful in cases of mild infections. Paraspinous muscle flaps have been reported to be a simple and very ef-fective method of treating difficult wounds.

The Proximally Designed Sural Flap Based on the Accompanying Artery of the Lesser Saphenous Vein

Most of the literature about the sural flap deals with soft tissue defects at the lower leg and foot based on the classical description of Masquelet et al. Nevertheless, some authors have shown that the lesser saphenous vein and its accompanying artery play an important role in the vascularization of the posterior skin of the leg. This finding allowed a more proximal design of the flap, increasing its arc of rotation. Thirteen cases of distally based sural flaps were performed and divided in two groups according to the level where the flaps were harvested. In group A, the entire flap was outlined distal to the midpoint of the leg, and in group B, the flap was outlined proximal to the midpoint of the leg. In group A, all the soft tissue defects were located at the lower leg and the foot, and in group B, they involved the anterior the tibia. In group A, the complication rate was 33.33% and the flap survival rate was 83.33%. In group B, the complication rate was 42.85% and survival rate was 100%. The proximally designed sural flap can safely reach the anterior aspect of the tibia in its middle and distal thirds.

A reinforcement of the sutured microvascular anastomosis with fibrin glue application: A retrospective comparative study with the standard conventional technique

Although a reasonable number of studies report satisfactory results with fibrin glue application in microvascular anastomosis since 1977, its utilization in the clinical setting has being scant in the literature. The aim of this study was to report the cumulated experience with the fibrin glue in free flaps over a period of 10 years, comparing the survival rate with the standard sutured anastomosis.