Sergi Barrera-Ochoa

Pyrocarbon Interposition (PyroDisk) Implant for Trapeziometacarpal Osteoarthritis: Minimum 5-Year Follow-Up

PURPOSE To report outcomes after a minimum of 5 years following pyrocarbon interposition (PyroDisk) trapeziometacarpal joint implant for osteoarthritis at a single center. METHODS We retrospectively reviewed the midterm clinical and radiological outcomes of 19 patients who had a pyrocarbon interposition implant (PyroDisk; Integra Life Sciences, Plainsboro, NJ) arthroplasty. The rate and causes of repeat surgeries, revisions, and complications were examined. RESULTS The mean follow-up period was 68 months. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable with that of the contralateral thumb. Grip strength improved by 26%. Overall function, according to the Quick Disabilities of the Arm, Shoulder, and Hand score, showed an average improvement of 71 to 20. Pain decreased by 78% according to the numerical rating scale. Radiological evaluation using a modification of the system described by Herren revealed progression of the periprosthetic lucency (grade I-II) of the implant after 5 years in 5 of 19 (26%) patients. Progression of lucency did not predict implant loosening or failure at 5 years. Two patients had symptomatic instability that required revision. No dislocations occurred. The 5-year survival of the prosthesis was 90%. CONCLUSIONS The PyroDisk implant for treating advanced trapeziometacarpal arthritis did not demonstrate superiority over published outcome data of trapeziectomy with or without ligament reconstruction and tendon interposition. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Multidisciplinary Management of a Giant Plexiform Neurofibroma by Double Sequential Preoperative Embolization and Surgical Resection

Plexiform neurofibromas are benign tumors originating from subcutaneous or visceral peripheral nerves, which are usually associated with neurofibromatosis type 1. Giant neurofibromas are very difficult to manage surgically as they are extensively infiltrative and highly vascularized. These types of lesions require complex preoperative and postoperative management strategies. This case report describes a 22-year-old female with a giant plexiform neurofibroma of the lower back and buttock who underwent pre-operative embolization and intraoperative use of a linear cutting stapler system to assist with haemostasis during the surgical resection. Minimal blood transfusion was required and the patient made a good recovery. This case describes how a multidisciplinary management of these large and challenging lesions is technically feasible and appears to be beneficial in reducing perioperative blood loss and morbidity. Giant neurofibroma is a poorly defined term used to describe a neurofibroma that has grown to a significant but undefined size. Through a literature review, we propose that the term “giant neurofibroma” be used for referring to those neurofibromas weighing 20% or more of the patients total corporal weight.

Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) of the Hand: A Report of Two Atypical Cases

Bizarre parosteal osteochondromatous proliferation (BPOP), also called Noras lesion, is an unusual, benign, bony lesion frequently found in the hand. Originally, two of the key radiological features used to describe such lesions were: (1) a lack of corticomedullar continuity and (2) an origin from the periosteal aspect of an intact cortex. The authors present 2 unique cases of histologically proven BPOP in which the integrity of the cortex was affected. In the first case there was medullary continuity, and in the second case there was saucerization of the underlying cortical bone. The authors support that simple X-ray evaluation is insufficient to diagnose BPOP in atypical cases. Careful axial CT scanning or MRI may prove helpful. Taking into account these new notions, histopathology gains greater importance as a diagnostic tool for this particular group of entities.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis.

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

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.

Simultaneou Triple Dislocation of the Small Finger

To the Editor: Simultaneous dislocation of all phalangeal joints of a triphalangeal digit is extraordinary. The literature documents just one such a case in an index finger in 1989. We present a patient with a triple dislocation of the small finger. A 34-year-old, right-handed man experienced a direct impact to the tip of his right little finger and forced hyperextension while practicing karate. He presented to our emergency department with a grossly deformed and painful finger. There were no neurovascular or skin lesions. Radiology showed simultaneous dorsal dislocation of both interphalangeal joints and a dorsal dislocation of the metacarpophalangeal joint without any avulsion fractures (Fig. 1). Under regional anesthesia, closed reduction of the triple dislocation was achieved by longitudinal traction. The reduction was performed progressing

Osteoid Osteoma of the Distal Humerus Mimicking Sequela of Pediatric Supracondylar Fracture: Arthroscopic Resection—Case Report and A Literature Review

Osteoid osteoma (OO) is a small and painful benign osteoblastic tumour located preferentially in the shaft of long bones near the metaphyseal junctions, with a predilection for the lower limbs. Juxta- and intra-articular OOs are rare and even though hip, elbow, and talus are the most commonly reported locations, they may be found in any joint accounting for approximately 13% of all osteoid osteomas. There is usually a significant time delay between symptom initiation and diagnosis when the lesion is present in an uncommon location due to the diagnostic challenge it presents due to the lack of classical clinical signs and/or radiographic features found in the extra-articular lesions. A case of a distal humerus OO of a 15-year-old girl is presented to point out that a confounding factor, such as a previous paediatric supracondylar fracture, may further delay the already difficult diagnosis of a juxta- or intra-articular osteoid osteoma and also to emphasize the possibility of arthroscopic treatment of such lesions.

Brucellosis as a Primary Cause of Flexor Tenosynovitis on the Hand: Case Report and Literature Review.

Brucellosis is primarily a disease of animals but is often transmitted to man either by drinking raw milk; by direct contact through the broken skin or the conjunctiva; or by the inhalation of infected dust [1]. Currently Brucella melitensis remains the principal cause of human brucellosis worldwide [2, 3]. Brucellosis is a zoonosis that usually affects the musculoskeletal system. Vertebral bodies, particularly in the lumbar region, are the bones more frequently involved [4]. Osteoarticular involvement in the hand and wrist is not common, and development of secondary tenosynovitis in the course of a brucellar infection is even more unusual [5, 6]. There are no previous references to flexor tenosynovitis without osteoarticular involvement caused by Brucella. As far as we know, this is the first reported case of a primary brucellar tenosynovitis.

Periprosthetic Proximal Fracture in Total Wrist Arthroplasty

To the Editor: A periprosthetic fracture in total wrist arthroplasty (TWA) is rare. The literature documents 1 case in 1996 after revision of the distal component of a TWA for bone loosening. A 54-year-old, right-handed man fell on the right wrist, causing forced hyperextension. He had undergone right TWA (Universal Total Wrist; KMI, San Diego, CA) 9 years previously for rheumatoid arthritis. Radiographs showed periprosthetic fracture at the tip of the radial component. Computed tomography showed no signs of subsidence or loosening of radial component (Fig. 1). Fracture reduction and internal fixation were achieved with the assistance of fluoroscopic guidance. A locking compression plate using 4 distal unicortical screws and 5 proximal bicortical screws secured fixation. The fracture site was grafted by autologous cancellous bone from the patient’s olecranon. At the 12-month follow-up, the patient had recovered painless range of motion. X-rays showed bone healing and good alignment without signs of loosening. Total wrist arthroplasty is associated with complications such as joint imbalance, dislocations, and loosening of the components. Although fixation of the proximal component usually has not been a problem because the implant rests against cortical

Vascularized ulnar periosteal pedicled flap for forearm reconstruction: Anatomical study and a case report

Through an anatomical review, the aim of this study is to define the ulnar periosteal branches of the posterior interosseous vessels (PIV). In addition, we report the clinical utility of a vascularized ulnar periosteal pedicled flap (VUPPF), supplied by the investigated PIV, in a complex case of radial nonunion.