Simon Tan

Scaphoid Nonunion With Poor Prognostic Factors The Role of the Free Medial Femoral Condyle Vascularized Bone Graft

Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.

A systematic review of medial epicondylectomy as a surgical treatment for cubital tunnel syndrome

The aim of this study was to review the literature of decompression of the cubital tunnel with medial epicondylectomy and to assess outcomes and complications. Twenty-one case series reported on 886 medial epicondylectomies. The mean percentage of patients obtaining improvement of one or more McGowan grade was 79%. The mean percentage obtaining a good/excellent Wilson Krout grade of outcome was 83%. Of six comparative studies, two showed no significant differences in outcomes between medial epicondylectomy and transposition procedures, and three reported better outcomes with medial epicondylectomy. One reported similar outcomes with medial epicondylectomy and simple decompression. The existing literature on medial epicondylectomy is of limited methodological quality and does not allow for firm conclusions to be drawn regarding its efficacy compared with other surgical techniques. Further studies should aim for high methodological quality, randomized comparison with simple decompression or anterior transposition and should utilize standardized outcome measures. Level of evidence: II

Nerve Transfer for Restoring Upper Limb Function in Traumatic Cervical Spinal Cord Injury An Evidence-based Surgical Algorithm

Introduction: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that leads to disabling loss of upper limb function. Restoration of any upper limb function can improve quality of life, reduce long-term care needs, and is highly rated by affected individuals. Historically, the International Classification of Surgery of the Hand in Tetraplegia (ICHST) has guided the use of tendon transfers in CSCI but there is now renewed interest in the role of nerve transfer. Selective nerve fascicle transfer offers opportunities for greater functional gain with restoration of prehensile grip and maintenance of donor muscle function. We present an evidence-based surgical strategy for restoration of upper limb function using nerve transfer in CSCI. Objectives: Derivation of evidence-based surgical algorithm for restoration of upper limb function in CSCI. Methods: A nonsystematic review of all studies reporting nerve transfer in CSCI available through PubMed was performed. For each level of spinal cord injury, a reconstructive algorithm was constructed considering available donors. The following hierarchy of movement was prioritized: elbow extension, wrist extension, finger flexion, finger extension, and intrinsic function. Results: The reconstructive algorithm derived is summarized below. >C5—Limited donors available. Suggest lateral branch of accessory nerve transfer to long thoracic nerve or phrenic nerve (in cases of phrenic nerve palsy). Achievable outcomes: respiratory independence for ventilator or cough assist. C5*†—Suggest: (1) Axillary nerve fascicle to teres minor transfer to medial or long head of triceps fascicles. (2) Proximal supinator nerve transfer to nerve to extensor carpi radialis brevis (ECRB) fascicles. (3) Finger extensor tenodesis. (4) Nerve to brachialis transfer to fascicles to anterior interosseous nerve (AIN) and pronator teres. Achievable outcomes: active elbow and wrist extension, passive finger extension, active pronation, and finger flexion. C6*†—Suggest: (1) Axillary nerve fascicle to teres minor transfer to medial or long head of triceps fascicles. (2) Nerve branches to supinator transfer to ECRB. (3) Finger extensor tenodesis. (4) Nerve to brachialis transfer to fascicles to AIN and pronator teres. Achievable outcomes: active elbow extension, stronger active wrist and passive finger extension, active pronation, and finger flexion. C7*†—Suggest: (1) Nerve to brachialis transfer to fascicles to AIN and pronator teres. (2) posterior interosseous nerve (PIN) branches to abductor pollicis longus (APL), extensor pollicis brevis (EPB) and extensor indicis proprius (EIP) transfer to deep branch ulnar nerve fascicles. Achievable outcomes: active pronation, finger flexion, and intrinsics. C8*—Suggest: (1) AIN branch to pronator quadratus transfer to deep branch ulnar nerve fascicles. (2) PIN branches to APL, EPB and EIP transfer to deep branch median nerve fascicles. Achievable outcomes: active intrinsics. Conclusion: Nerve transfer for CSCI is an emerging area of upper limb surgery that demonstrates very significant promise. A bespoke surgical strategy tailored to each patient’s level of CSCI and individual needs that is undertaken early during the rehabilitative course will revolutionize functional outcomes for this deserving patient group. *Brachioradialis to flexor pollicis longus (FPL) tendon transfer as necessary. †House intrinsic tenodesis and/or carpometacarpal joint (CMCJ) arthrodesis as necessary.

Microsurgery training courses in Singapore

Microsurgical training is essential for those embarking on a career in plastic surgery, maxillofacial surgery or hand surgery. Training courses in the UK are generally oversubscribed with long waiting lists and course fees are now in excess of £1,000 for a five-day basic microsurgery training course. With our meagre study-leave budgets already stretched beyond breaking point, we decided to look for cheaper alternatives. A Singaporean colleague recommended the department of hand and reconstructive microsurgery at the National University Hospital (NUH), Singapore.