Rames Mattar

Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study

OBJECTIVE: To compare the functional results of carpectomy and four‐corner fusion surgical procedures for treating osteoarthrosis following carpal trauma. METHODS: In this prospective randomized study, 20 patients underwent proximal row carpectomy or four‐corner fusion to treat wrist arthritis and their functional results were compared. The midcarpal joint was free of lesions in all patients. RESULTS: Both proximal row carpectomy and four‐corner fusion reduced the pain. All patients had a decreased range of motion after surgery. The differences between groups were not statistically significant. CONCLUSIONS: Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non‐union advanced collapse (SLAC/SNAC) wrist without degenerative changes in the midcarpal joint.

Vascularized Bone Grafts for Upper Limb Reconstruction: Defects at the Distal Radius, Wrist, and Hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius

We conducted a prospective randomised study comparing the clinical, functional and radiographic results of 46 patients treated for scaphoid nonunion using a vascularised bone graft from the dorsal and distal aspect of the radius (group I), relative to 40 patients treated by means of a conventional non-vascularised bone graft from the distal radius (group II). Surgical findings included 30 sclerotic, poorly-vascularised scaphoids in group I versus 20 in group II. Bone fusion was achieved in 89.1% of group I and 72.5% of group II patients (p = 0.024). Functional results were good to excellent in 72.0% of the patients in group I and 57.5% in group II. Considering only patients with sclerotic, poorly-vascularised scaphoids, the mean final outcome scores obtained were 7.5 and 6.0 for groups I and group II, respectively. We conclude that vascularised bone grafting yields superior results and is more efficient when there is a sclerotic, poorly-vascularised proximal pole in patients in scaphoid nonunion.

Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial.

BACKGROUND Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing. The objective of this study was to compare these methods in terms of clinical and radiographic results. METHODS In this prospective, randomized controlled trial, fifty-nine patients with displaced midshaft clavicular fractures were randomly assigned to receive fixation with either a reconstruction plate (thirty-three patients), known as the plate group, or elastic stable intramedullary nailing (twenty-six patients), known as the nail group. The primary outcome was the six-month Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes included the Constant-Murley score, time to fracture union, residual shortening, level of postoperative pain, percentage of satisfied patients, and complication rates. RESULTS The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). Similarly, there were no differences in the twelve-month DASH and Constant-Murley scores. Time to union was equivalent (p = 0.352) between the groups at 16.8 weeks for the plate group and 15.9 weeks for the nail group, whereas the residual shortening was 0.4 cm greater in the plate group (p = 0.032). The visual analog scale pain score and the satisfaction rate were similar between the groups. Implant-related pain was more frequent in the nail group (p = 0.035). There were no differences in terms of major complications. CONCLUSIONS Reconstruction plates and elastic stable intramedullary nailing yielded similar functional results, time to union, level of postoperative pain, and patient satisfaction rates. Both methods were safe in terms of major complications.

Anterograde removal of broken femoral nails without opening the nonunion site: a new technique

OBJECTIVE: We describe a new technique for removing the distal fragments of broken intramedullary femoral nails without disturbing the nonunion site. METHODS: This technique involves the application of an AO distractor prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material. RESULTS: Nails were removed from five patients using the technique described above without any complications. After a mean follow-up period of 61.8 months, none of these patients showed worsened knee osteoarthritis. CONCLUSION: The original technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments.

MMP‐1 promoter polymorphism is associated with primary tendinopathy of the posterior tibial tendon

Posterior tibial tendon (PTT) dysfunction is recognized as an etiology leading to acquired flatfoot in adults, causing significant functional loss. Many risk factors and systemic conditions have been proposed in literature. However, many patients present PTT dysfunction without any of these characteristics. This suggests that there could be a genetic influence associated with posterior tibial tendinopathy. The purpose of the present study is to investigate the association of the −1607 polymorphism in the promoter gene of MMP‐1 and posterior tibial tendinopathy. The test group included 50 women, who presented PTT dysfunction grade 2 or 3, and who were submitted to surgical treatment, with histopathological examination of the tendon and magnetic resonance image (MRI) confirming tendinopathy, while the control group was 100 asymptomatic women who presented intact PTT at MRI. The results were analyzed using the chi‐square test. The data showed a 75% incidence of the allele 1G and 62% of the genotype 1G/1G at the control group while, at the test group, they showed a 78% incidence of the allele 2G and 72% of the genotype 2G/2G (p < 0.001). The −1607 polymorphism of promoter gene of MMP‐1 is associated with the posterior tibial tendinopathy in the studied population.

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.

Estudo comparativo entre a técnica endoscópica pelo portal proximal e a técnica de mini-incisão palmar no tratamento cirúrgico da síndrome do túnel do carpo

Os autores apresentam estudo prospectivo onde comparam duas tecnicas cirurgicas empregadas no tratamento de pacientes acometidos pela sindrome do tunel do carpo. A tecnica de descompressao por via aberta, atraves de mini-incisao palmar(3), e analisada em relacao a tecnica por via endoscopica, descrita por Agee et al.(2), que utiliza apenas um unico portal proximal. Foram operados, de forma randomizada, 28 punhos em 28 pacientes com o diagnostico clinico e eletromiografico de sindrome do tunel do carpo idiopatico, e que nao obtiveram melhora com o tratamento conservador previo. Os seguintes parâmetros, foram analisados no pre-operatorio e na primeira, segunda, quarta, sexta e decima segunda semanas de pos-operatorio: forca de preensao com dinamometro, sensibilidade com monofilamentos de Semmes-Weinstein, presenca de dor e parestesia, tempo necessario para retorno as atividades da vida diaria e complicacoes. Apos acompanhamento medio de 12 meses, constatamos que a tecnica endoscopica demonstrou-se segura, apresentando vantagens significativas em relacao ao metodo aberto quanto a precocidade da recuperacao da forca de preensao, ao retorno as atividades da vida diaria e a menor incidencia de dor na palma da mao. Nao houve diferenca em relacao a resolucao da parestesia, melhora da sensibilidade ou incidencia de complicacoes.

Measurement of the flexing force of the fingers by a dynamic splint with a dynamometer

PURPOSE AND METHODS In order to determine forces acting upon an articular joint during hand rehabilitation, a dynamic splint was built and connected to a dynamometer (capable of measuring forces in the range 0 - 600 gf). Through trigonometric calculation, the authors measured the flexing force in the proximal interphalangeal joint of the middle finger at 30 degrees, 45 degrees, 60 degrees, and 90 degrees of flexion. Measurements were obtained in a population of 40 voluntary adults, 20 females and 20 males, This flexing force was correlated with age, sex, and anthropometric measures. RESULTS Force in the flexing tendon is maximal at the start of flexion, and decreases as the angle of joint flexion increases. A relationship was observed between finger length and the magnitude of the force exerted on the tendon: the longer the finger, the greater the force exherted upon the tendon. Force is greater at all the measured angles, (except 30 degrees) in males and in individuals of higher stature, and bigger arm span. CONCLUSIONS The flexing force can be effectively measured at all flexing angles, that it correlates with a number of different anthropometric parameters, and that such data are likely to open the way for future studies.