Giovanni R. Brunelli

Stabilisation of the Trapezio-Metacarpal Joint

A new technique of trapezio-metacarpal stabilisation is described which uses the abductor pollicis longus tendon passed through the bases of the first and second metacarpals to fasten the base of the thumb. A biomechanical rationale is presented, as well as the surgical technique and 12 results at follow-up one to six years later.

Modified steindler procedure for elbow flexion restoration

The results of modified Steindler procedures for elbow flexion performed during the past 20 years were reviewed retrospectively. The modifications were designed to avoid the phenomenon of the patient having to make a fist in order to obtain elbow flexion (Steindlers effect). The flexor carpi ulnaris, the flexor carpi radialis, and the palmaris longus, along with a bone fragment, are transferred to the anterior aspect of the humerus. The muscles are carefully separated from the flexor digitorum superficialis, which is left in place. This avoids both flexion of the fingers and pronation. Indications are discussed, especially in brachial plexus reconstructive surgery. Steindlers procedure is indicated in upper plexus lesions (C5-C6); other transfers are more appropriate for lower plexus palsies. Results were assessed according to elbow flexion against resistance. Flexion over 120 degrees when lifting 3 kg was rated very good. Of 32 modified Steindler procedures reviewed, 18 were rated very good, 8 good, 4 fair, and 2 poor.

Preoperative assessment of the adult plexus patient

Methods of assessing brachial plexus lesions are presented in relation to the type of lesion, the severity, the prognosis, and the timing of nerve repair and reconstructive surgery. A careful physical examination of both muscles and sensory function, the sweating concordance, and the Tinel sign are considered the most important aspects of assessment which is completed by electromyography (evoked potentials), radiographs, magnetic resonance imaging, and contrast computerised axial tomography (CT scanning). Contrast‐CT is considered the most reliable investigation to reveal root avulsion from the cord. An assessment chart able to show the extent and location of the lesion at a glance is included.

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.

Traumatic Aneurysms of Two Proper Digital Arteries in the Same Patient: A Case Report

Aneurysms in the hand are infrequent and aneurysms of the proper digital arteries are particularly rare, only 11 cases having been reported in the literature. The authors describe the case of a patient operated on for two traumatic false aneurysms of the ulnar digital arteries of the middle and ring fingers. Arterial aneurysms should be carefully evaluated to exclude other lesions such as cysts, abscesses, neuromas. The choice between ligation and resection or reconstruction of the vessel should be based on pre-operative and intra-operative evaluation of circulation.

Research on the Biology of Microvascular Bone Grafts

More and more often the orthopedic surgeon must treat large bone defects due to bone tumors, resections, osteomyelitis, congenital pseudarthrosis, and post-traumatic bone defects that require large bone grafts. In these cases, conventional autogenous corticocancellous bone grafts can hardly solve the problem. Using vascularized bone grafts, which do not undergo creeping substitution, which heal swiftly, and which are not parasitic of surrounding tissues, yields better, safer and quicker results [2, 4]. To better understand the recovery of vascularized grafts as compared to conventional ones, research on rabbits has been done comparing the biological features of repair by means of scintigraphic, radiographic, and histologic methods [1, 3].

Iatrogenic nerve lesions

tion. We used this neurotization in traumatic cases but it is possibly applicable to complete palsies caused by ulnar entrapment at the elbow that cannot be improved by a simple neurolysis. We describe the assessment protocol, physiotherapy and operative regime and standardized functional review which we have instituted to maximize the hand and upper limb function of children with mucopolysaccharidoses and mucolipidoses.

Zed Osteotomy with Trapezoidal Resection in Internal Rotations of the Tibia and Secondary Static Arthrosis of the Knee

Internal rotation of the tibia is a frequent malformation. A little degree of internal rotation in newborns is considered normal but disappears in the first years of life to be replaced by a very moderate external rotation. Internal rotation at birth is often more severe than originally thought, or derotation does not take place, and in adults internal rotation can persist to varying extents (Fig. 1). Until some years ago this deformity was disregarded, notwithstanding several publications about it [1-9] and its importance in causing static and dynamic alterations of the knee [1-3]. Tibial internal rotation has to be considered as being equivalent to club foot and is often associated with varum of the tibia, especially in congenital but less often in rachitic deformities [10-16].