Francisco Soldado

Femoral head bone viability after free vascularized fibular grafting for osteonecrosis: SPECT/CT study

To evaluate femoral head bone viability following free vascularized fibular grafting (FVFG) for osteonecrosis using SPECT/CT imaging.

Cam deformity and the omega angle, a novel quantitative measurement of femoral head-neck morphology: a 3D CT gender analysis in asymptomatic subjects

ObjectiveOur objectives were to use 3D computed tomography (CT) to define head–neck morphologic gender-specific and normative parameters in asymptomatic individuals and use the omega angle (Ω°) to provide quantification data on the location and radial extension of a cam deformity.MethodsWe prospectively included 350 individuals and evaluated 188 asymptomatic hips that underwent semiautomated CT analysis. Different thresholds of alpha angle (α°) were considered in order to analyze cam morphology and determine Ω°. We calculated overall and gender-specific parameters for imaging signs of cam morphology (Ω° and circumferential α°).ResultsThe 95xa0% reference interval limits were beyond abnormal thresholds found in the literature for cam morphology. Specifically, α° at 3/1 o´clock were 46.9°/60.8° overall, 51.8°/65.4° for men and 45.7°/55.3° for women. Cam prevalence, magnitude, location, and epicenter were significantly gender different. Increasing α° correlated with higher Ω°, meaning that higher angles correspond to larger cam deformities.ConclusionHip morphometry measurements in this cohort of asymptomatic individuals extended beyond current thresholds used for the clinical diagnosis of cam deformity, and α° was found to vary both by gender and measurement location. These results suggest that α° measurement is insufficient for the diagnosis of cam deformity. Enhanced morphometric evaluation, including 3D imaging and Ω°, may enable a more accurate diagnosis.Key Points• 95% reference interval limits of cam morphotype were beyond currently defined thresholds.• Current morphometric definitions for cam-type morphotype should be applied with care.• Cam prevalence, magnitude, location, and epicenter are significantly gender different.• Cam and alpha angle thresholds should be defined according to sex/location.• Quantitative 3D morphometric assessment allows thorough and reproducible FAI diagnosis and monitoring.

Thoracodorsal nerve transfer for triceps reinnervation in partial brachial plexus injuries.

To report the clinical outcomes of thoracodorsal nerve (TDN) transfers to the triceps motor branches for elbow extension restoration in patients with partial brachial plexus injuries (BPI).

Arthroscopic Talocalcaneal Coalition Resection in Children

PURPOSEnTo present the technique and outcomes of arthroscopic talocalcaneal coalition (TCC) resection in pediatric patients.nnnMETHODSnWe performed a prospective study of 16 consecutive feet with persistent symptomatic TCCs in 15 children. The mean age was 11.8 years (range, 8 to 15 years), and the mean follow-up period was 28 months (range, 12 to 44 months). A posterior arthroscopic TCC resection was performed. The plantar footprint, subtalar motion, pain, and the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale score were evaluated preoperatively and postoperatively. Preoperative computed tomography (CT) scans were used to classify the coalition according to the Rozansky classification, to measure the percentage of involvement of the surface area, and to determine the degree of hindfoot valgus. Postoperative CT scans at 1 year (nxa0= 15) and 3 years (nxa0= 5) were used to assess recurrences. Patient satisfaction was also evaluated.nnnRESULTSnThe TCC distribution according to the Rozansky classification was type I in 7 cases, type II in 3, type III in 3, and type IV in 3. In all cases the arthroscopic approach enabled complete coalition resection. All patients increased by at least 1 stage in the footprint classification and showed clinical subtalar mobility after surgery. All patients showed a statistically significant improvement in pain after surgery except for 1 patient in whom complex regional pain syndrome developed (P < .001). The mean American Orthopaedic Foot & Ankle Society score was 56.8 (range, 45 to 62) preoperatively versus 90.9 (range, 36 to 100) postoperatively, showing a statistically significant increase (P < .001). Preoperative CT scans showed that all TCCs involved the medial subtalar joint facet, with mean involvement of 40.8% of the articular surface. All postoperative CT scans showed complete synostosis resections with no recurrences at final follow-up. At final follow-up, all patients were either satisfied (nxa0= 4 [27%]) or extremely satisfied (nxa0= 10 [67%]) with the outcome, except the 1 patient (7%) in whom complex regional pain syndrome developed.nnnCONCLUSIONSnArthroscopic TCC resection provides good outcomes (symptom relief and restoration of subtalar motion), with no recurrence of the coalition.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Vascularized tibial periosteal graft in complex cases of bone nonunion in children

Bone nonunion in the pediatric population usually occurs in the context of highly unfavorable biological conditions. Recently, the vascularized fibular periosteal flap has been reported as a very effective procedure for treating this condition. Even though a vascularized tibial periosteal graft (VTPG) was described long ago and has been successfully employed in one adult case, there has been no other report published on the use of this technique. We report on the use of VTPG, pedicled in the anterior tibial vessels, for the treatment of two complex pediatric bone nonunion case: a recalcitrant supracondylar femoral pseudarthrosis secondary to an infection in an 11‐year‐old girl, and a tibial nonunion secondary to a failed bone defect reconstruction in a 12‐year‐old girl. Rapid healing was obtained in both cases. In the light of the data presented, we consider VTPG as a valuable surgical option for the treatment of complex bone nonunions in children.

Reappraisal of Clinical Deficits Following High Median Nerve Injuries

PURPOSEnTo describe clinically apparent motor and sensory deficits in a cohort of 11 patients with isolated injury of the median nerve above the elbow and compare them against similar cases reported in the literature.nnnMETHODnEleven patients of mean age 30 years (SD ± 14 years; 6 males, 5 females) were examined a mean of 21 weeks (SD ± 16 weeks) after an isolated high median nerve injury. Pronation, wrist flexion, and finger flexion range of motion and strength (British Medical Research Council scale) were evaluated. Grasp and lateral pinch strength were assessed bilaterally using a dynamometer. Thumb opposition was evaluated using the Kapandji score. Sensoryxa0impairment was considered significant when there was no perception of a 2.0-g Semmes-Weinstein filament.nnnRESULTSnPronation was largely preserved in all patients to a mean range of motion of 52° (SD ± 13°), and pronation strength was M4 in 10 of 11 patients. Wrist flexion scored M5 in all patients. Thumb and index distal interphalangeal joint flexion were absent in all patients. In all patients, middle, ring, and little finger flexion was complete and scored M5. Thumb function scored above 5 in all patients, averaging 7.5 (SD ± 1.2) on the Kapandji scale. Grasp and pinch strength were 43% (SD ± 12%) and 36% (SD ± 11%) of the contralateral (normal) limb, respectively. Impaired sensation of a 2.0-g monofilament was found only in the palmar region over the middle and distal phalanges of the index and middle fingers and the distal phalanx of the thumb.nnnCONCLUSIONSnNoteworthy discrepancies were identified between the clinical motor and sensory deficits described in the literature and those observed in our patients.nnnCLINICAL RELEVANCEnIn most patients with a high median nerve injury, only thumb and index flexion and palmar sensation warrant surgical reconstruction. Decreased grasp and pinch strength wasxa0a major finding that should also be addressed by surgery.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnPrognostic IV.

Non-invasive expandable prosthesis in musculoskeletal oncology paediatric patients for the distal and proximal femur. First results

PurposeThe non-invasive expandable prosthesis for skeletally immature patients is used after limb salvage surgery following tumor resection. The aim of the study was to assess the effectiveness of this treatment.MethodsSeven paediatric patients with femoral tumors had resection and limb salvage with an uncemented non-invasive growing prosthesis. Mean age at the time of surgery was 9.8 (range 8–12) years. There were six distal femur osteosarcomas and one proximal femur Ewing sarcoma. Six total knee prosthesis were implanted at the time of primary tumor resection and one bipolar hip prosthesis was a revision from a failed osteoarticular hip allograft. Functional outcomes and emotional acceptance were assessed using the MSTS score.ResultsThe mean follow-up was 65.3xa0months (range 29–91) months. Two patients died of pulmonary metastasis and there was no local recurrence. The mean femoral resection was 18 cm (range 17–19) on the knee, and 24xa0cm on the hip. Mean total expansion was 36.4xa0mm (range 12.3–63.5). The mean MSTS score after rehabilitation was 26.3 (range 21–29). There was one lengthening device failure, one late infection and one patient who required iliofemoral bypass grafting surgery for a pelvic metastasis. No local recurrence occurred.ConclusionsThe non-invasive expandable prosthesis reduces the final limb-length discrepancy in growing patients with an acceptable function and appears to have an advantage as compared to invasive expandable prostheses which require multiple surgical procedures, but the complications rate is still high.

High Median Nerve Injury: Motor and Sensory Nerve Transfers to Restore Function

This article describes the clinically significant motor and sensory deficits that follow high median nerve injuries and addresses the indications, limitations, and outcomes of nerve transfers, when striving to overcome the deficits these patients experiences. Preferred surgical reconstructive strategy using motor and sensory nerve transfers, and surgical techniques used to perform these transfers, are described.

Free vascularized tibial periosteal graft with monitoring skin island for limb reconstruction: Anatomical study and case report

Several types of vascularized periosteal flaps have recently been described for the treatment or prevention of complex non‐union in pediatric patients. Among them, a vascularized tibial periosteal graft (VTPG), supplied by the anterior tibial vessels (ATV), has been used successfully as a pedicled flap in a few patients. The purpose of the study is to describe the periosteal branches of the ATV, as well as the cutaneous and muscular branches by means of an anatomical study. In addition, to report on the use of VTPG as a free flap with a monitoring skin island in a clinical case. A mean of 6.5 periosteal branches (range 5–7) were found. In all cases we located a cutaneous perforator branching from one of the periosteal branches located at the midlevel of the leg. We performed a two‐stage reconstruction of a recalcitrant non‐union and residual shortening of the right tibia in a 17‐year‐old boy. After nonunion focus distraction, we used a massive bone allograft fixed with a nail and covered by a VTPG as a biological resource. Allograft consolidation was achieved 5.5 months after surgery. At eighteen months after surgery, no complications were observed and the patient had resumed all his daily activities, despite a residual 2‐cm limb‐length discrepancy. VTPG may be considered as a valuable surgical option for bone reconstruction in complex biological scenarios in the young population.

Injury mechanisms in supraclavicular stretch injuries of the brachial plexus

The aim of this study was to describe the mechanisms involved in stretch injuries of the brachial plexus. One hundred and fifty consecutive patients with supraclavicular brachial plexus injuries (BPI) were asked about the mechanism of injury during the actual injury event, particularly about the type of trauma to their shoulder, shoulder girdle and head. Fifty-seven of the patients provided enough information about their accident to allow for analysis of the shoulder trauma. The injury mechanism for all patients having upper root or total palsy (n=46) was described as a direct vertical impact to the shoulder. In 44 of these patients, the trauma followed a motorcycle accident and, in most of them, the patient hit a fixed vertical structure before falling to the ground. The injury mechanism for the lower root palsy cases (n=11) was variable. The most frequent mechanism was forceful anterior shoulder compression by a car seat belt. We found that injury mechanisms differed significantly from the ones commonly discussed in published studies.