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PubMed2004

Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus.

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.

Adolescent↗

PubMed2006

Static progressive splinting for posttraumatic elbow stiffness.

OBJECTIVES: To determine the value of static progressive splinting in helping patients with posttraumatic elbow stiffness regain functional motion and avoid operative treatment for stiffness. DESIGN: Retrospective case series. SETTING: Level I Trauma Center. PATIENTS AND INTERVENTION: Over a 3-year period, 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. Three patients were treated after the injury alone; 14 were treated after operative treatment of the initial injury, and 12 after a secondary operative contracture release for posttraumatic stiffness. Splinting was initiated on an average of 55 days (range, 15 to 200 d) after injury or operative treatment. MAIN OUTCOME MEASUREMENTS: Ulnohumeral range of motion before and after splint treatment. RESULTS: The flexion arc improved from 71 degrees (range, 0 to 100 degrees) before splinting to 112 degrees (range, 20 to 150 degrees) after splinting. After splinting, 3 patients had a flexion contracture greater than 30 degrees and 10 patients (34%) had fewer than 130 degrees of flexion. Only 3 patients-2 with heterotopic bone and 1 with an associated ulnar neuropathy-requested an operation to address elbow stiffness. Patients who were splinted after the initial injury (n=17, average improvement (fl-ext)=51+/-37 degrees) regained greater motion during splint wear than patients treated after elbow capsulectomy (n=12, average improvement (fl-ext)=22+/-24 degrees). CONCLUSIONS: Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients.

Adolescent↗

PubMed2006

Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases.

Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing.

Adult↗

PubMed1982

The effect of hypothermia and tissue perfusion on extended myocutaneous flap viability.

The salutary effect of hypothermia and tissue perfusion on extending the ischemic tolerance of the canine latissimus dorsi myocutaneous flap was demonstrated in this experimental study. A total of 175 flaps from 89 adult mongrel dogs were elevated with one-half the flaps perfused with iced Collins renal preservation solution. With the exception of control flaps kept at ambient temperature, the remaining flaps were stored at 4 degrees C for periods ranging from 24 to 192 hours followed by transplantation into the groins of recipient dogs, with anastomosis of the thoracodorsal artery and vein in an end-to-side manner to the femoral artery and vein, respectively. The study was divided into two distinct sections. The acute phase involved the transplantation of 77 flaps into random recipient dogs, and following a 3-hour period of systemic perfusion, the flaps were removed, weighed, and sectioned for later histologic study. Progressive increase in flap weight was observed up to 96 hours of hypothermia with a sharp decline in weight at 120 hours of hypothermia. The increase in flap weight in the nonperfused flaps was significantly greater than the previously perfused flaps. Histologically, at 120 hours of hypothermia, loss of vascular integrity was noted, suggestive of a no-reflow phenomenon. In the second, or extended-flap, study, 98 flaps were transplanted into the groins of the original donor animal and allowed to remain in situ for a 2-week period. The flaps were then carefully observed for viability, removed, and sectioned for histologic study. Hypothermic support of up to 96 hours extended viability in both perfused and nonperfused flaps, although beyond this hypothermic period viability was seen only in previously perfused flaps. The clinical implications of this study include hypothermic perfusion of a major-extremity amputation prior to replantation or the temporary storage of a free myocutaneous flap.

Animals↗

PubMed1984

Free latissimus dorsi muscle flap with skin graft for treatment of traumatic chronic bony wounds.

Based on this review of 35 cases of chronic bony wounds, it would appear that the free-muscle flap method of wound closure and nourishment after thorough dead bone debridement is an attractive and successful alternative to local skin flaps, staged skin flaps, or extend skin-muscle flaps in areas where reliable muscle flaps are not available. It would also seem that the latissimus dorsi muscle flap with skin graft is an ideal donor-muscle transfer with features allowing a favorable and contoured surface in the recipient site and minimal aesthetic and functional deformity in the donor site.

Adolescent↗

PubMed1987

Free flaps to preserve below-knee amputation stumps: long-term evaluation.

Five patients with insufficient soft-tissue coverage on below-knee amputation stumps have been treated with free-tissue transfer surgery to preserve a functional below-knee prosthetic level. The flaps employed include one latissimus dorsi myocutaneous flap, two latissimus dorsi muscle-skin graft flaps, one groin flap, and one foot-fillet flap. All five flaps survived; one patient required early venous anastomosis reexploration and revision. The patients have been followed for a mean duration of 5.5 years (range 3 to 8 years). The mean duration to first ambulation with a prosthesis was 3.6 months (range 2 to 7 months). Four of the five patients developed ulcerations on or adjacent to their flaps which required surgical revision. The patients required a mean of 1.28 prosthesis changes annually since surgery. The functional motion (mean active knee motion is 100 degrees) and ligamentous stability of the knee joints were well preserved in all patients. Five patients wear patella tendon-bearing prostheses, with one requiring an additional thigh corset. In two of the patients, nerve anastomoses to their flaps were performed. Both patients developed true cutaneous sensibility, but nevertheless experienced flap ulceration. All the patients are fully ambulatory on their free flaps. Free-tissue transfer can assist in preserving traumatic below-knee amputations so that patients can benefit from the functional advantage of a below-knee prosthetic device.

Adolescent↗

PubMed1987

Streptokinase salvage of a free-tissue transfer: case report and review of the literature.

Postoperative thrombosis is a devastating complication after a microvascular free-tissue transfer. We are reporting the case of a clinical free osteomyocutaneous flap (fibula, peroneal, and soleus muscle, and skin) which suffered recalcitrant postoperative venous thrombosis and was salvaged only after isolated selective infusion of streptokinase. The use of a fibrinolytic agent or plasminogen activator for this purpose in humans has not previously been reported.

Adult↗

PubMed1988

The "double barrel" free vascularized fibular bone graft.

A further modification of the free vascularized fibular bone graft is described in which a transverse osteotomy is made from the anterolateral aspect of the fibular shaft just distal to the entry of the nutrient artery. This produces two vascularized bone struts that may be folded parallel to each other but that remain connected by the periosteum and muscle cuff surrounding the peroneal artery and vein. The proximal strut is vascularized by both a periosteal and an endosteal blood supply, whereas the distal strut is vascularized by a periosteal blood supply alone. This so-called "double barrel" free vascularized fibular graft has been employed in three patients with segmental bone defects of the distal femur and in one patient with adjacent bony defects of the radius and ulna.

Adult↗

PubMed1989

The parascapular flap for treatment of lower extremity disorders.

The parascapular flap was used as a free microvascular transfer for soft-tissue resurfacing of 11 lower extremities. The diagnoses included four cases of osteomyelitis, three cases of vascular ulceration, one case of combined osteomyelitis and vascular ulceration, two cases of posttraumatic heel defects, and one case of extensive soft-tissue contracture overlying a posttraumatic defect of the femur. All cases were successful clinically. Anatomically, the parascapular flap is supplied by the cutaneous parascapular artery, a branch of the circumflex scapular artery, which itself derives from the subscapular artery. Flap territory may reach 15 x 30 cm, and the vascular pedicle can extend 14 cm if the subscapular artery is taken. Advantages of this flap include the constancy, length, and caliber of the vascular pedicle; the length and width attributes, which allow both coverage of large wounds and primary closure of the donor defect; and an absence of disruption of musculoskeletal function.

Adolescent↗

PubMed1991

Limb reconstruction by free-tissue transfer combined with the Ilizarov method.

In four complex cases of extremity reconstruction, we have been able to overcome the problems of combined bone and soft-tissue loss and length discrepancy by a combination of free-tissue transfer and the Ilizarov method of slow distraction. It is our observation that gradual distraction of a free tissue is a safe and viable procedure; the free tissue tolerates the pins of the circular external fixator well, and there is an equal degree of distraction and regeneration of the transferred free tissue and the native recipient tissue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Manipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for later microsurgical procedures or endanger the axial flow pattern of the transferred free tissue.

Adolescent↗

PubMed1999

Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer.

Ten male patients with previously infected bony defects involving both sides of an articulation underwent arthrodesis using a vascularized fibular transfer. The average age of these patients was 38 years (range, 20 to 60 years). The size of the bony defect averaged 9 cm (range, 3 to 21 cm). The ankle was involved in five patients, the knee in two patients, the wrist in two patients, and the elbow in one patient. Nine cases represented septic pseudarthroses (eight after trauma and one after attempted ankle arthrodesis). One patient had a defect across the wrist after debridement of a chronic infection. The patients were followed for an average of 71 months (range, 26 to 144 months). Nine patients healed after the index vascularized fibular transfer, and one patient (ankle arthrodesis) required a second cancellous bone-grafting procedure for delayed union at the junction of the fibula with the talus. Four of seven patients with lower limb involvement had residual leg length discrepancies averaging 5 cm (range, 3 to 8 cm), and one had a persistent 20-degree internal rotation deformity. Two of the patients with upper limb involvement had stiff digits. Five of the nine previously employed patients returned to their former occupation (including heavy labor in four cases). Complications included two wound separations, one case of instability of the donor ankle after removal of a large fibular graft (related in part to a prior injury), and one fracture at the junction of the fibular graft with the local bone 10 months after the index procedure, which united after plate fixation and application of autogenous cancellous bone graft. Arthrodesis using a transfer of vascularized fibular bone represents a viable option for limb salvage in the face of an infected transarticular bony defect.

Adult↗

PubMedDate not supplied

The management of patients with back pain and idiopathic vertebral sclerosis.

Twenty-two patients with severe back pain associated with radiologic evidence of vertebral sclerosis are reported. There were 19 women and 3 men; the average age was 42 years. Duration of pain averaged 4.3 years. The characteristic radiologic findings were diffuse sclerosis of the anterior inferior portion of the vertebral body and narrowing of the adjacent disc space. There was no extension of the sclerosis beyond the vertebral body, no paravertebral mass, and no loss of vertebral height. These radiologic characteristics, in conjunction with other clinical findings, should permit a diagnosis without the need for biopsy.

Adult↗

PubMed1997