Sergi Barrera-Ochoa

Resumen: Objetivo El objetivo de este análisis retrospectivo fue cotejar los resultados posoperatorios de la reconstrucción ligamentosa no biológica (RLNB) para lesiones crónicas que involucran la articulación metacarpofalángica (AMCF) y el ligamento colateral cubital (LCC) del primer dedo. Materiales y Métodos En total, 18 pacientes con lesión de la AMCF fueron sometidos a una reconstrucción ligamentosa estática no biológica y se incluyeron en este análisis retrospectivo de casos y controles. Se compararon las mediciones preoperatorias, posoperatorias y del pulgar contralateral (evaluación clínica, radiografías y cuestionarios de resultados subjetivos) durante una media de 38 meses de seguimiento. Resultados Para la RLNB, la media de rangos de movimiento posoperatorios de las AMCF y de las articulaciones interfalángicas del pulgar fueron de 0 a 57,5° y de 0 a 71°, respectivamente. Las fuerzas promedio de agarre y pinza, en relación con la mano no afectada, fueron de 103,3% y 88,7%, respectivamente. Todos los pacientes demostraron estabilidad con un punto final firme en relación con el pulgar no afectado. La puntuación media en la versión corta del cuestionario de Discapacidades de Brazo, Hombro y Mano (Quick Disabilities of the Arm, Shoulder and Hand, QuickDASH, en inglés) entre todos los pacientes fue de 11,9 para el módulo de discapacidad/síntoma, 0 para el módulo de deportes, y 16,5 para el módulo de trabajo. Se informó rigidez en cuatro pacientes, y ningún paciente sufrió problemas relacionados con la herida u otras complicaciones. Conclusión La RLNB del LCC del pulgar genera buenos resultados a corto plazo, lo que puede permitir una recuperación y rehabilitación aceleradas.

Peri-implant fractures occur in association with an implant that was used to treat a previous injury. Peri-implant fractures are considered relatively ‘new’ fractures for which there is no accepted classification system in practice. Treatment is difficult due to altered anatomy, the presence of orthopedic implants and phenomena such as stress shielding, osteopenia when not in use, and fracture remodeling. We present the case of a young man who presented to the emergency room after a sports accident with a successful previous osteosynthesis and a new deformity of the forearm.

Introduction: Dorsal hand skin flaps have been described in order to avoid digit skin grafting in syndactyly release. Although these skin‐graftless techniques present a lower rate of long term complications, they result in unsightly dorsal scarring and worse patient satisfaction. We describe a novel technique using an intermetacarpal palmar flap by performing an anatomic study and clinical application.Materials and Methods: Ten colored‐latex‐injected fresh upper limbs were used to study the palmar cutaneous perforators to second to fourth intermetacarpal space skin flaps designed elliptical, its width extending from the center of each involved ray and measuring 40%–50% the length of the palm.Results: The anatomical study revealed a mean 2.77 (range 1 to 4) cutaneous perforators originating from either the common or proper digital vessels for every intermetacarpal space and measuring 0.4 mm (range 0.3 to 0.5 mm) in diameter.Clinical Application: This flap, measuring a mean of 21.5 mm (range 20 to 23 mm) in length and 9.5 mm (range 9 to 10 mm) in width, was used to release simple syndactylies in three patients of mean age 24 months (range = 18–30 months). After skin incision, cutaneous septa to the digital canal were released to permit flap advancement to the web space. Cutaneous perforators were not dissected. Intra‐operative palmar‐flap advancement provided commissure coverage in all children with no skin grafts needed. Over a mean follow‐up of 15 months, no complications occurred, mean palm scar VSS was 2.4 (range 2 to 3) while it was 3 (range 3 to 3) for the commissure scars.Conclusions: Skin‐graftless syndactyly release using a palmar intermetacarpal flap seems both reliable and easy‐to‐perform.Level of Evidence: Therapeutic IV.

Multiple epiphyseal dysplasia is a condition that courses with a retarded epiphyseal development and may cause joint dysmorphia. We report a case of posterior interosseous nerve palsy in a child with dysplasia. After a physical examination and complementary diagnostic tests that revealed posterior interosseous nerve compression neuropathy, surgical neurolysis og the posterior interosseous nerve was performed at level of the the arcade of Frohse. The satisfactory evolution of the patient confirmed our diagnosis. Attention must be paid to the onset of signs or symptoms of nerve compression in these patients.

Introduction: Attaining active glenohumeral external rotation (aGHER), whether via primary reconstruction or spontaneous recovery, is infrequent in patients with neonatal brachial plexus palsy (NBPI). We evaluated the effectiveness of triceps‐to‐teres minor motor branch transfers to restore this function, both performed primarily (i.e., in conjunction with microsurgical plexus reconstruction) or secondarily (after primary surgery has failed to restore aGHER).Patients and Methods: This was a retrospective study of 12 children with NBPI undergoing triceps‐to‐teres minor motor branch transfer via an axillary approach, six undergoing primary surgery and six secondary. The primary outcome was post‐operative restoration of aGHER in abduction. The primary‐surgery group consisted of six children of mean age 8 months (range 5–11) with partial injuries ranging from C5–C6 to C5–C8. The secondary‐surgery group included six patients with C5–C6 injuries of mean age 43 months (range 23–120), undergoing re‐operation a mean 40 months (range 18–116) after their primary surgery.Results: No complications occurred after surgery. At a mean follow‐up of 22 months (range 14–30), aGHER in abduction only was restored in one patient in the primary group while in the secondary group, aGHER in abduction was restored in all patients to a mean 73° (range 70–80) after a mean follow‐up of 16 months (range 6–26).Conclusions: Triceps‐to‐teres minor motor branch transfer is not indicated as primary surgery for NBPI. However, they can be effective in children in whom primary surgery has failed to restore aGHER, even if the spinal accessory nerve is unavailable for transfer to the infraspinatus motor branch.

Introduction: Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging orthopedic disorders. The use of a vascularized tibial periosteal grafts has been recently reported as a powerful tool to obtain bone union. We report its use in CPT.Patients and Methods: Retrospective short‐term study of 29 children (18 male/11 female, 15 right‐sided/14 left‐sided) of mean age 45 months (range 11–144 months), operated upon after October 2014.Nonunion site was debrided, and the periosteum of the involved limb was excised. A vascularized tibial periosteal graft (mean length 10.7 cm (range 9–15 cm) with a monitoring skin island (mean length 4.1 cm (range 3–5 cm) and based on the anterior tibial vessels, was obtained from the contralateral tibia. Anterior tibial vessels were always the recipient vessels. Most cases were stabilized with an LCP plate.The rate of and time to bone union were analyzed. Charts only were evaluated through the first 3 months after bone union was achieved.Results: The flap survived and bone union was obtained in all cases, through a periosteal callus, in a mean time of 5.1 weeks (range 3–6 weeks). Mean follow‐up was 8.3 months (range 7–19 months). No union failures occurred 3 months after resuming unprotected weight bearing.Conclusions: Our novel technique produced a consistent, rapid capacity for CPT union, superior to previously‐reported techniques. However, it cannot be recommended as a standard method of treatment until consistent, long‐term, refracture‐free follow‐up is documented.

Vascularized periosteal flaps have been reported as very effective for treating biologically complex bone nonunion in pediatric patients, owing to their high angiogenic and osteogenic potentials. The purpose of this article is to report a case of a 6‐year‐old patient with nonunion involving both forearms and a very limited bone flap donor site in the context of prior bilateral transfemoral amputation due to meningococcal sepsis. Two free vascularized iliac periosteal flaps (VIPF), supplied by the deep circumflex iliac vessels, were used in two stages to reconstruct the forearms. In the first stage, the left forearm, which had a diaphyseal bone defect of 5 cm diameter in the ulna and 4 cm in the radius, was combined with an iliac‐crest bone allograft, fixed with two longitudinal 1.8 mm Kirschner wires and surrounded with a free VIPF of 24 cm². Consolidation was achieved 3 months after left forearm surgery, while complete allograft revascularization and remodeling was observed at 12 months. In the second stage, the right forearm, which had a diaphyseal bone defect of 3 cm diameter in the ulna and 1 cm in the radius, was fixed the radius with a 2.7 mm plate and surrounded with a free VIPF of 24 cm². The radius nonunion healed 6 weeks after surgery. There were no postoperative complications. Two years postoperatively, the patient had again resumed his arm gait painlessly and without a splint. VIPF may be considered a valuable and reliable surgical option for nonunion reconstruction in complex clinical scenarios in children.