Charles E. Dumont

An evaluation of the infraclavicular block via a modified approach of the Raj technique.

UNLABELLED Infraclavicular plexus block has recently become a technique of increasing interest. However, no approach has provided easily identifiable landmarks, good conditions for catheter placement, and lack of complications (mainly pneumothorax). We describe a modified approach of the Raj technique based on the identification of the anterior acromial process, jugular notch, and emergence of the axillary artery within the axillary fossa, with the arm abducted to 90 degrees and elevated by approximately 30 degrees. We evaluated the clinical characteristics of this approach by injecting 40 to 50 mL of ropivacaine 0.6% in 150 patients scheduled for elective surgery of the forearm, wrist, or hand. Success was defined as a sensory block of the 5 nerves with territories distal to the elbow within 30 min after performing the block. The success rate was 97% when a distal response (flexion or extension of the wrist or fingers) was elicited and 44% when a proximal (contraction of the triceps, biceps) was obtained using a nerve stimulator. Complications were rare: aspiration of blood was seen in 2% of patients and hematoma was seen at the puncture site in 0.6%; no pneumothorax occurred. Eleven patients (7%) complained of some pain during the procedure. We conclude that the modified approach of the Raj technique for infraclavicular block is very effective when a distal nerve stimulator response is obtained with a small complication rate and a high degree of patient satisfaction. IMPLICATIONS We describe a modified approach of the Raj technique for the infraclavicular brachial plexus. The elicitation of a distal nerve stimulator response is associated with a high success rate, a low incidence of complications and a high degree of patient satisfaction.

Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years

Background Vascularized soft tissue transfer may give better results of treatment of infected nonunions of the tibia. Methods 6 patients with infected nonunion of the tibia and combined soft tissue (70–170 cm2) and bony (5–8 cm) defects underwent staged reconstruction. Initial surgery consisted of soft tissue and bone debridement, external fixation, filling of the bony defect with a gentamicin-impregnated cement spacer, and reconstruction of the soft tissue with a free microsurgical muscle flap and skin graft. Second-stage surgery consisted of removal of the cement spacer and osseous reconstruction with nonvascularized bone graft. Results All patients except 1 achieved full weight-bearing and radiographic consolidation after 7–10 months. This patient required repeated bone grafting and internal plate fixation to heal. There were no cases of recurrence of infection at the latest follow-up, after a mean of 3 (1.5–5) years. Interpretation Staged reconstruction with free vascularized soft tissue transfer and conventional bone grafting within a cement-induced membrane is a low-risk surgical strategy resulting in a high rate of bone healing.   ▪

Corrective osteotomies in malunions of the distal radius: do we get what we planned?

Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5° angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10° with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness.Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Assessment of Radial and Ulnar Torsion Profiles with Cross-sectional Magnetic Resonance Imaging: A Study of Volunteers

BACKGROUND We determined whether the torsion profiles of the radius and ulna could be reliably assessed with cross-sectional magnetic resonance imaging and whether these torsion profiles were comparable on the two sides of volunteers. METHODS We assessed magnetic resonance imaging cross sections of the left and right forearms of twenty-four asymptomatic volunteers. The torsion profile of the ulna was defined as the angle formed between a line tangential to the volar cortical surface of the distal part of the humerus and a line connecting the center of the ulnar head and the center of the ulnar styloid. Use of paired proximal and distal landmarks resulted in five different methods of assessment of the radial torsion profile. Intrarater and interrater reliabilities and side-to-side variability were assessed. RESULTS This method of assessment of the ulnar torsion profile had intraclass and interclass coefficients of 0.95 and 0.91, respectively. A method previously described by Bindra et al. had the best combined intrarater and interrater reliabilities for assessment of the radius. The mean differences between the right and left sides of the volunteers were the lowest with the use of these two methods; nevertheless, the maximum side-to-side difference was > 30 degrees with techniques. CONCLUSIONS Torsion-profile assessment with cross-sectional magnetic resonance imaging had high intrarater and interrater reliabilities. However, individual side-to-side variations in the radial and ulnar profiles are important considerations. CLINICAL RELEVANCE Cross-sectional magnetic resonance imaging is currently the only available method to quantify rotational malunion of the radius and ulna. Its low side-to-side reliability warrants comparison between the imaging results and the clinical findings. A side-to-side difference in the rotation profile may serve as a reason to perform an axial osteotomy when the results of the clinical and magnetic resonance imaging assessments are consistent with each other.

Pedicled vascularized rib transfer for reconstruction of clavicle nonunions with bony defects: anatomical and biomechanical considerations.

Background: Clavicular nonunions with large bony defects, although rare, are difficult to treat and often result from multiple failed attempts at surgical management. Reconstruction using vascularized bone graft is the accepted standard in cases of large osseous defects. Methods: An anatomical vascular corrosion study with cadaveric dissections and finite element analyses was designed to assess the feasibility of clavicular reconstruction with a musculo-osteous graft interposition based on a pedicled serratus anterior flap. Results: Rib vascularization through the serratus anterior was demonstrated, so that the thoracic branch of the thoracodorsal artery can been considered a secondary blood supply for the seventh and eighth ribs. Single and double pedicled rib transfers allowed for reconstruction with as much as 8 cm of bone loss. The maximal stress found in the single-rib reconstruction interfaces was located at the medial contact of the plate with the clavicle. It was 2.7-fold higher than the maximal stress of the medial bow of the intact clavicle. Conversely, the double-rib reconstruction had improved mechanical resistance. A case report using a single-rib transfer supported the biomechanical study by showing that the maximal risk of material loosening was located at the medial bone interface. Conclusions: Double vascularized rib transfer as part of a serratus anterior flap should be used instead of single-rib transfer to reconstruct large clavicle defects. This technique is reproducible and does not require microvascular anastomoses. Therefore, it has potential advantages over free fibula transfer.

Rotationplasty (Borggreve/Van Nes and modifications) as an alternative to amputation in failed reconstructions after resection of tumours around the knee joint

Failure of reconstructions as a result of infective or aseptic loosening and massive bone loss may make amputation necessary. If neurovascular structures can be preserved to keep a functional foot, rotationplasty may be considered an option. Four patients treated for malignant bone tumours (two osteosarcomas, one Ewing sarcoma, and one malignant fibrous histiocytoma) of the proximal tibia and distal femur (n=2 each) at the ages of 13 to 21 years had reconstructions that failed 3, 4, 5, and 15 years later. In three patients the cause was intractable infection, and in one loosening with shortening and deficiency of the extensor mechanism. The patients had the option to contact patients who had had rotationplasty as the primary procedure for tumours or severe femoral deficiencies. In two patients an AI-type rotationplasty was done, in one a type AII rotationplasty, and in the fourth a modification with shortening of the lower leg but retention of the knee joint. There were no postoperative complications such as persisting infections, fractures, or pseudarthrosis. All patients are active and are able to go alpine skiing or snowboarding. The main advantage of procedures in which a sensory-motor functional foot is retained is to avoid neuroma pain or phantom sensations. The foot allows for active knee movement of the orthoprosthesis and full weight bearing. It is of great psychological help for the patients to have contact during the decision-making with patients who have had similar procedures. It should be considered as an alternative to amputation.

Extra-articular en bloc resection of the talocrural and the talocalcaneonavicular joints for primary malignant synovial tumour (myxoinflammatory fibroblastic sarcoma).

A 13-year-old boy presented with a diagnosis of intra-articular myxoinflammatory fibroblastic sarcoma of the ankle. There had been no previous description of a sarcoma arising directly from the synovium of the ankle and limb salvage for malignant tumours of the ankle has rarely been reported. We treated him by peritalar extra-articular resection, and draw attention to this rare tumour and to a technique of limb-sparing resection of the ankle joint.

IDIOPATHIC TUMORAL CALCINOSIS OF THE INDEX FINGER

Tumoral calcinosis of the hand is rare, and we present a case report of idiopathic tumoral calcinosis of the index finger, which posed a diagnostic problem as it looked like an infection. We successfully removed the calcific deposit and there had been no recurrence one year after the operation.Tumoral calcinosis of the hand is rare, and we present a case report of idiopathic tumoral calcinosis of the index finger, which posed a diagnostic problem as it looked like an infection. We successfully removed the calcific deposit and there had been no recurrence one year after the operation.

Borggreve-Van Nes rotationplasty for infected knee arthroplasty - a case report.

A 62-year-old patient presented with a recurrence of infection of the left knee following a two-stage TKA reimplantation for the treatment of a late infection of a TKA implanted in 1995. He had had a right knee arthroplasty in 2004, with good function. The new infection was treated by a debridement, the revision prosthesis was removed, and a cement spacer was placed in the 10-cm bone defect (Figure 1). The tibia tubercle and part of the cement spacer were exposed by an anterior 15-cm2 soft tissue defect. Cultures from the wound taken during the procedure showed a monomicrobial infection with methicillin-resistant coagulase-negative staphylococcus. The patient was treated with intravenous vancomycin. A second look 1 week later showed further deep soft tissue necrosis, probably due to cement heat during the polymerization phase of the spacer, as well as further bone necrosis in the distal femur, the proximal tibia, and the osteotomized tibia tubercle. Therapeutic options, which were discussed with the patient, included arthrodesis, resection arthroplasty (joint resection without joint replacement), amputation, or a rotationplasty (Christie et al. 2003). The patient elected to have a rotationplasty after having seen pictures of a patient who had had a rotationplasty and after having been informed about the expected functional outcome (Fuchs et al. 2003). Figure 1. The cement spacer after revision for an infection recurrence following a 2-stage reimplantation for a late infection of the left TKA. The pelvic obliquity is due to the 10-cm leg length discrepancy. There is no loosening of the right TKA. A rotationplasty was performed according to the technique described by Fuchs and Sim (2004), with the knee “joint” and the distal femur and proximal tibia being resected en bloc (Figure 2). Drainage of a postoperative hematoma was performed on the second postoperative day. The rest of the healing and recovery were uneventful. Time to soft tissue healing was 4 weeks and time to bone consolidation was 4 months. The patient began with full weight bearing with a prosthesis at 6 months. The hardware was removed 1 year after surgery because of pain at the distal edge of the plate.At the last follow-up, 26 months after the rotationplasty, the patient was satisfied with the function of the limb and said that he and his family had no more trouble with the cosmetic appearance of the limb (Figure 3). Radiographs showed healing of the femoro-tibial fusions (Figure 4). The operated limb was pain-free but the contralateral knee was painful after 10 min of walking. He could walk 800 meters without crutches or aid, and could ascend and descend stairs using the handrail. He could drive his car and had no difficulty in getting into and out the car. The active range of the prosthetic knee was 10° to 80°. Dorsiflexion and plantarflexion strength were M5. The free walking speed was 0.75 m/s (averaged on 13 gait cycles). Gait analysis showed a gait pattern that was similar on both sides to an above-the-knee amputation, with both knees extended at heel-strike and no loading response on the side of the rotationplasty because of the stiffness of the prosthesis, and on the contalateral side because of the limited dorsal flexion of the foot. Figure 2. Intraoperative view of the en bloc resection of the knee joint, distal tibia, and proximal femur. Osteotomies of both the femur and the tibia were performed with 2 cm margins above and below the cement spacer endomedullar stumps. The dissected saphenous ... Figure 3. Patient standing with the definitive prosthesis. Figure 4. Femoro-tibial fusion at last follow-up. Discussion The Borggreve-Van Nes rotationplasty was initially used to treat shortened limbs and ankylosis of the knee due to tuberculosis, and for congenital defects of the femur (Borggreve 1930, Van Nes 1950). It consists of en bloc resection of the knee, bone shortening, and rotation of 180° to allow the ankle to function as a knee joint. Today, rotationplasty is mainly used for local disease control in young children with bone sarcoma around the knee (Merkel et al. 1991, Winkelmann 1996). Gait analysis has shown preserved ankle proprioception, resulting in a functional outcome of rotationplasty that is better than following TKA (Fuchs et al. 2003). More recently, its usefulness as a salvage procedure for the treatment of posttraumatic osteomyelitis of the distal femur (Krettek et al. 1997) or in infection of massive endoprosthesis in tumor patients (Wicart et al. 2002) has been reported. Salvage procedures for reinfection of revision TKA focus primarily in curing the infection by means of arthrodesis, resection arthroplasty, or above-the-knee amputation. The functional outcome in patients treated with above-the-knee amputation and resection arthroplasty is poor (for review, see Christie et al. 2003). The range of success after arthrodesis differs widely—from 50% to almost 100%, depending on the type of osteosynthesis material used and the extent of bone defect (Hanssen et al. 1995, McQueen et al. 2006). The function after rotationplasty in our patient was similar to an above-the-knee amputation (Harris et al. 1990), as assessed with gait analysis. The lack of phantom pain because of preservation of the sciatic nerve may indeed argue for inclusion of rotationplasty in the salvage options proposed to non-oncological patients with a history of recurrence of infection and extended bone loss following TKA.

MECHANICAL WEARING DOWN OF FLEXOR TENDONS IN RHEUMATOID ARTHRITIS AS A RESULT OF EXTREME VOLAR-FLEXED INTERCALATED SEGMENT INSTABILITY

We report the case of a 72-year-old patient with rheumatoid arthritis complicated by spontaneous ruptures of the flexor digitorum superficialis and profundus tendons of the left index finger. Extreme volar-flexed intercalated segment instability resulted in protrusion of the head of the capitate bone into the carpal tunnel and rupture of both tendons caused by wear. Reconstruction of the flexor digitorum profundus tendon, interposition of a tendon graft, and radiolunate arthrodesis restored function.