Massimo Ceruso

Vascularized Proximal Fibular Epiphyseal Transfer for Distal Radial Reconstruction

BACKGROUND Treatment of the loss of the distal part of the radius, including the physis and epiphysis, in a skeletally immature patient requires both replacement of the osseous defect and restoration of longitudinal growth. Autologous vascularized epiphyseal transfer is the only possible procedure that can meet both requirements. METHODS Between 1993 and 2002, six patients with a mean age of 8.4 years (range, six to eleven years) who had a malignant bone tumor in the distal part of the radius underwent microsurgical reconstruction of the distal part of the radius with a vascularized proximal fibular transfer, including the physis and a variable length of the diaphysis. All of the grafts were supplied by the anterior tibial vascular network. The rate of survival and bone union of the graft, the growth rate per year, the ratio between the lengths of the ulna and the reconstructed radius, and the range of motion of the wrist were evaluated for five of the six patients who had been followed for three years or more. RESULTS The mean duration of follow-up of the six patients was 4.4 years (range, eight months to nine years). All six transfers survived and united with the host bone within two months postoperatively. The five patients who were followed for three years or more had consistent and predictable longitudinal growth. Serial radiographs revealed remodeling of the articular surface. The functional result was rated as excellent for all but one patient, in whom the distal part of the ulna had also been resected because of neoplastic involvement. No major complication occurred at the recipient site, whereas a peroneal nerve palsy occurred at the donor site in three patients. The palsy was transient in two patients, but it persisted in one. No instability of the knee joint was observed. CONCLUSIONS After radical resection of the distal part of the radius because of a neoplasm in children, vascularized proximal fibular transfer, based on the anterior tibial artery, permits a one-stage skeletal and joint reconstruction, provides excellent function, and minimizes the discrepancy between the distal radial and ulnar lengths.

A new technique for regional anesthesia for arthroscopic shoulder surgery based on a suprascapular nerve block and an axillary nerve block: an evaluation of the first results.

PURPOSE We propose a new technique of regional anesthesia that combines suprascapular nerve block (SSNB) and axillary nerve block (ANB) in arthroscopic shoulder surgery. METHODS Twenty consecutive patients undergoing arthroscopic procedures for shoulder cuff diseases were included in the trial. SSNB was performed by introducing the stimulating needle approximately 2 cm medial to the medial border of the acromion and about 2 cm cranial to the superior margin of the scapular spine until supraspinatus or infraspinatus muscle contractions were elicited. Following negative aspiration, 15 mL of a mixture of 2% lidocaine (5 mL) and 0.5% levobupivacaine (10 mL) was injected. ANB was performed; a line was drawn between the lateral-posterior angle of the acromion and the olecranon tip of the elbow. The location was about 2 cm cranial to the convergence of this line with the perpendicular line from the axillary fold. The needle was introduced approximately 2 cm cranial to this crossing point to elicit deltoid muscle contractions, and another 15 mL of the same anesthetic mixture was injected. Five mL of the same mixture was injected into each portal of the arthroscopic area. During surgery, patients were sedated with the use of midazolam. General anesthesia was not performed. Acceptance of the technique was assessed through a postsurgical survey of those treated. RESULTS No serious complications occurred. None of the patients required opiates, analgesics, or general anesthesia during the surgical procedure. Postoperative pain control, which was assessed using a visual analog scale, was effective during the observation time. The total demand for nonopiate analgesics during the first 24 postoperative hours was negligible. Patient satisfaction and comfort were satisfactory. CONCLUSIONS Combining SSNB and ANB is an effective and safe technique for intraoperative anesthesia and postoperative analgesia for certain procedures of shoulder arthroscopic surgery.

Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993–2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16–65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6–13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow‐up period ranged from 10–93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5–8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.

Original biological reconstruction of the hip in a 4-year-old girl

We resected the proximal femur in a 4-year-old child who had Ewings sarcoma. We reconstructed her hip by an autotransplant of the ipsilateral proximal fibula with its vascular supply, inserted inside a massive bone allograft, and fixed to the residual femur by a plate. Serial postoperative imaging showed the progressive hypertrophy of the transplanted fibula, whose head displayed impressive tridimensional growth inside the acetabulum. 4 years after surgery, hip motility is 100 degrees in flexion, 10 degrees in extension, and 30 degrees in abduction, and the patients limb is weight bearing.

Vascularised fibula graft inlaid in a massive bone allograft: Considerations on the bio-mechanical behaviour of the combined graft in segmental bone reconstructions after sarcoma resection☆

SUMMARY Vascularised fibula transfer (VFT) is a trustworthy procedure in the reconstruction of skeletal defects secondary to several pathological conditions. Over the last 20 years, progress in diagnosis in skeletal oncology and in adjuvant therapy has increased the possibility of applying limb-saving procedures in the treatment of bone sarcoma. In this context, VFT appeared to be a valuable reconstructive tool following the wide segmental resection of the long bones of the limbs. The vascularized fibula allows for fast bone fusion. It also demonstrates a tendency of progressive hypertrophy and, in those instances in which it is associated with an avascular massive bone allograft (MBA), it induces a process of osteo-integration which enhances the biomechanical properties of a combined graft. In order to assess the progression of the morphologic and structural changes of combined bone grafts we reviewed a group of 31 bone sarcoma patients who had had tibia reconstruction with a VFT inlaid in a massive allograft. Patients had been operated on between 1994 and 2006. Ages ranged from 4 to 31 years (mean 14 years). Thirty patients had received neo-adjuvant chemotherapy. Morphological variations were investigated by means of serial X-ray and CT scan examinations. All patients were regularly reviewed over an average time of 75 months (range 14-154 months). Computer assisted analysis was repeated at every control and performed at the same levels within the reconstruction, so that subsequent CT exams could be compared. We measured the sagittal and transverse diameters, total and medullary area, cortical thickness and cortical density of the VFT. Cortical thickness and cortical density of the massive bone allograft were measured as well. Two different remodelling patterns of the combined graft could be noted over time, that depended on the load trend on the vascularised fibula and that varied according to the persisting integrity of the allograft shell.

Vascularized Proximal Fibular Epiphyseal Transfer for Distal Radial Reconstruction: Surgical Technique

BACKGROUND Treatment of the loss of the distal part of the radius, including the physis and epiphysis, in a skeletally immature patient requires both replacement of the osseous defect and restoration of longitudinal growth. Autologous vascularized epiphyseal transfer is the only possible procedure that can meet both requirements. METHODS Between 1993 and 2002, six patients with a mean age of 8.4 years (range, six to eleven years) who had a malignant bone tumor in the distal part of the radius underwent microsurgical reconstruction of the distal part of the radius with a vascularized proximal fibular transfer, including the physis and a variable length of the diaphysis. All of the grafts were supplied by the anterior tibial vascular network. The rate of survival and bone union of the graft, the growth rate per year, the ratio between the lengths of the ulna and the reconstructed radius, and the range of motion of the wrist were evaluated for five of the six patients who had been followed for three years or more. RESULTS The mean duration of follow-up of the six patients was 4.4 years (range, eight months to nine years). All six transfers survived and united with the host bone within two months postoperatively. The five patients who were followed for three years or more had consistent and predictable longitudinal growth. Serial radiographs revealed remodeling of the articular surface. The functional result was rated as excellent for all but one patient, in whom the distal part of the ulna had also been resected because of neoplastic involvement. No major complication occurred at the recipient site, whereas a peroneal nerve palsy occurred at the donor site in three patients. The palsy was transient in two patients, but it persisted in one. No instability of the knee joint was observed. CONCLUSIONS After radical resection of the distal part of the radius because of a neoplasm in children, vascularized proximal fibular transfer, based on the anterior tibial artery, permits a one-stage skeletal and joint reconstruction, provides excellent function, and minimizes the discrepancy between the distal radial and ulnar lengths.

Fibular autograft and silicone implant arthroplasty after resection of giant cell tumor of the metacarpal—a case report with 9-year follow-up

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Reverse flow first dorsal metacarpal artery flap for covering the defect of distal thumb.

Reconstruction of distal thumb injuries still remains a challenge for hand surgeons. Surgical treatment includes the use of local, regional, and free flaps. The purpose of this report is to present the results of the use of a sensitive reverse flow first dorsal metacarpal artery (FDMA) flap. The skin flap was designed on the radial side of the proximal phalanx of the index finger based on the ulnar and radial branch of the FDMA and a sensory branch of the superficial radial nerve. This neurovascular flap was used in five patients to cover distal soft‐tissue thumb defects. All flaps achieved primary healing except for one patient in whom superficial partial necrosis of the flap occurred, and the defect healed by second intention. All patients maintained the thumb original length and were able to return to their previous daily activities. The reverse flow FDMA flap is a reliable option to cover immediate and delayed defects of distal thumb, offering acceptable functional and cosmetic outcomes in respect to sensibility, durability, and skin‐match.

A 4-year-old with a rash

A 4-year-old boy came to our attention in May, 1998, with a history of eczema and swelling of his arms and legs. His mother had a history of giant urticaria. The boy was born by caesarean section in his mother’s 37th week of gestation because of pre-eclampsia. There were no neonatal complications. He was breastfed until he was 10 months old, and then given cow’s milk. This milk was stopped after 1 week because of dermatitis. Soy milk was then given. His skin rash resembled eczema, but was not itchy and was on extensor surfaces of his limbs. From the age of 2 years he was again given cow’s milk, which did not worsen his skin complaints, which were diagnosed by a dermatologist as atopic dermatitis and treated with topical corticosteroids. Skinprick testing was not done. At the age of 4 years, his right foot became swollen, without pain or restricted movement. After 2 weeks the backs of both hands swelled. Laboratory investigations showed no evidence of inflammation. A magnetic resonance image showed fluid along the tendon sheaths.

Proximal interphalangeal (PIP) joint replacements with pyrolytic carbon implants in the hand

Until the late 1980s, proximal interphalangeal (PIP) joint reconstruction had been almost exclusively performed by the use of monobloc silicone spacers and associated with acceptable to good clinical outcomes. More recently, new materials such as metal-on-polyethylene and pyrocarbon implants were proposed, associated with good short-term and mid-term results. Pyrocarbon is a biologically inert and biocompatible material with a low tendency to wear. PIP pyrolytic implants are characterised by a graphite core, visible on radiographs and covered by a radiolucent outer layer of pyrocarbon. New surgical techniques and better patient selection with tailored rehabilitative protocols, associated with the knowledge arising from the long-term experience with pyrocarbon implants, has demonstrated noteworthy clinical outcomes over the years, as demonstrated by recent studies. Cite this article: EFORT Open Rev 2017;2:21–27. DOI: 10.1302/2058-5241.2.160041