Strategies in Trauma and Limb Reconstruction

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2009 | April | Volume 4 | Issue 1

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Review

G. Lovisetti, M. A. Agus, F. Pace, D. Capitani, F. Sala

Management of distal tibial intra-articular fractures with circular external fixation

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:6] [Pages No:1 - 6]

Keywords: Distal tibial fractures, External fixation, Ilizarov, Minimally invasive

   DOI: 10.1007/s11751-009-0050-7  |  Open Access |  How to cite  | 

Abstract

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.

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Original Article

Annette W-Dahl, Sören Toksvig-Larsen

Undisturbed theatre dressing during the first postoperative week. A benefit in the treatment by external fixation: a cohort study

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:6] [Pages No:7 - 12]

Keywords: Pin-site infection, Theater dressing, External fixation, Chlorhexidine, Pin-site care

   DOI: 10.1007/s11751-009-0053-4  |  Open Access |  How to cite  | 

Abstract

In the literature, there are several different suggestions as to when the first postoperative pin-site care should be carried out to best prevent pin-site infections during the treatment by external fixation. In a cohort study, we compared the use of antibiotics and complications in patients where the theatre dressing was changed during the first postoperative week with patients where the theatre dressings were left undisturbed for the first postoperative week. Sterile compresses moistened with chlorhexidine 5 mg/ml in alcohol (70%), draped around each pin site and fixed by a bandage, were used as theatre dressing. In all patients, cultures were taken 1 week postoperatively from each pin site; use of antibiotics and complications during the treatment was documented. In 101 consecutive patients (118 knees) (73% men, mean age 50, mean BMI 27.5 kg/m2) operated on by high tibial osteotomy for knee deformity using the hemicallotasis technique, during 2005–2006, the theatre dressings were left undisturbed during the first postoperative week in 90 patients (104 knees) of group 1, and in 11 patients (14 knees) of group 2, the theatre dressings were changed during the first postoperative week. Eight of 11 patients in group 2 were treated with antibiotics compared to 32 of 90 patients in group 1 (RR 2.0, 95% CI 1.6–2.7, p = 0.02) during the treatment period by external fixation. Patients with a disturbed theatre dressing during the first postoperative week had an increased use of antibiotics by 18.6 days (95% CI 10.6–26.5, p < 0.0001, adjusted analysis). Four of 11 patients in group 2 had complications and 11 of 90 in group 1, adjusted analysis (RR 2.7, 95% CI 0.4–16.2, p = 0.3). Bilateral surgery simultaneously showed increased use of antibiotics by 10.4 days (4.4, 16.4, p = 0.0009) and increased risk of complications (RR 5.8, 95% CI 1.2–27.5, p = 0.03). In conclusion, the increased use of antibiotics indicates that leaving the theatre dressing undisturbed during the first postoperative week is beneficial to the treatment by external fixation and is probably of importance in the prophylactic pin-site care.

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Original Article

A. H. Tiemann, H. G. K. Schmidt, R. Braunschweig, G. O. Hofmann

Strategies for the analysis of osteitic bone defects at the diaphysis of long bones

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:6] [Pages No:13 - 18]

Keywords: Osteitis, Segment resection, Preservation of bone continuity

   DOI: 10.1007/s11751-009-0054-3  |  Open Access |  How to cite  | 

Abstract

Septic diseases of the bone and the immediate surrounding soft tissue, i.e., osteitis, belong to the most alarming findings in recent traumatology and orthopedic surgery. The paramount goal of this therapy is to preserve the stable weight-bearing bones while maintaining a correct axis and proper working muscles and joints, in order to avoid permanent disability in the patient. “State-of-the-art” therapy of osteitis/osteomyelitis therapy has two priorities: eradication of the infection and reconstruction of bone and soft tissue. Surgical treatment of the affected bone segments and soft tissue, followed by reconstructive methods, continues to be the main basic therapy. It is often extremely difficult to decide whether the affected bone segment has to be resected, or whether bone continuity can be preserved. The following paper provides strategies and guidance to help guide decisions in this complex and challenging area.

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Original Article

Shahram Nazerani, Mohammad Hosein Kalantar Motamedi

Soft tissue distraction in hand surgery: the “pentagonal frame” technique

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:7] [Pages No:19 - 25]

Keywords: Soft tissue distraction, Hand surgery

   DOI: 10.1007/s11751-009-0055-2  |  Open Access |  How to cite  | 

Abstract

Soft tissue distraction (STD) is an increasingly accepted operation in all fields of hand surgery from elbow contracture release to PIP joint release. Current techniques reported lack the ability to distract the joints of the fingers or the hand, maintain the length of released contractures, and hold them in a position while active and passive physiotherapy is possible. We describe a technique by which STD of the hand and fingers is done with no joint or tendon involvement overcoming the aforementioned drawbacks. Thirty-three patients with hand contractures were treated. In this method, a thin 1–1.5-mm Kirschner wire was passed horizontally at the proximal head of the distal phalanx and bent like a frame around the finger, forming a pentagonal shape for anchorage. The distal distraction was exerted at the distal phalanx. Various forms of external fixation were then used to distract a finger, several fingers, or the hand by placing tension on this frame; the distraction was either static (with a wire exerting pressure) or dynamic (using a rubber band to adjust the tension). After obtaining the desired result, the wire or rubber band was temporarily freed to commence active and passive physiotherapy. We maintained the frame for 3–6 weeks. All 33 patients were successfully treated. No major complications were encountered during the follow-up period (3–5 years). The pentagonal frame allows for effective distraction of soft tissues and joint ligaments and maintains the space needed for healing of fractures of the metacarpals and phalanges.

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Original Article

Thomas Muyldermans, Robert Hierner

First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:7] [Pages No:27 - 33]

Keywords: Hand, Trauma, Thumb, Flap, First dorsal metacarpal artery, Reconstruction

   DOI: 10.1007/s11751-009-0056-1  |  Open Access |  How to cite  | 

Abstract

Extensive pulp (zone 4) defects of the thumb, with the exposure of tendon or bone, are challenging reconstructive problems. Surgical treatment includes the use of local, regional, and free flaps. The first dorsal metacarpal artery flap has been used successfully for defects of the thumb. The innerved first dorsal metacarpal artery flap from the dorsum of the index finger was first described by Hilgenfeldt and refined by Holevich. An island flap carried on a neurovascular pedicle consisting of the first dorsal metacarpal artery was first demonstrated by Foucher and Braun. Seven innervated FDMCA island flaps were performed from May 2005 until July 2007 for thumb reconstruction. There were three women and four men with an average age of 54.9 years (range 28–89 years). The mean follow-up period was 15.4 months (range 4–29 months). The dominant hand was involved in six (85.7%) patients. In a retrospective clinical study, the following criteria were evaluated: (1) etiology of the defect, (2) time of reconstruction (primary vs. delayed), (3) survival rate of flap, (4) sensory function (Semmes–Weinstein monofilaments, static 2-PD, pain, cortical reorientation), (5) TAM measured with the Kapandji index, and (6) subjective patient satisfaction (SF 36). Four patients presented with trauma, two patients with defects after tumor resection and one with infection of the thumb. The flap was used for immediate reconstruction in three (42.9%) patients and for delayed reconstruction in four (57.1%) patients. Delayed reconstruction was performed 4.75 (1–12) months after initial trauma or first surgery. The donor area was grafted with full-thickness skin grafts in all cases. All flaps survived. The mean SWMF was 3.31 g and average statis 2-PD over the flap was 10.57 mm. Pain at the flap scored 3.71 over 10 and at the donor site 2.17 over 10. Paresthesia at the flap scored 0.57 over 4 and at the donor site 0.33 over 4. Complete cortical reorientation was only seen in one patient. The mean Kapandji score of the reconstructed thumb was 7.43 over 10. Using the SF-36, mean physical health of the patients scored 66.88% and mean mental health scored 70.55%. Disturbing pain and paresthesia of the flap are exceptional. The static 2-PD is more than 10 mm, and is clinically over the limit. Cortical reorientation was incomplete in all but one patient. Touch on thumb is felt on the dorsum of the index finger; however, sensation is not disturbing or interfering with the patient's activities. Foucher described the technique débranchement–rébranchement in order to improve this problem. The postoperative total amount of motion of the reconstructed thumb was very good. The results demonstrated that the FDMCA flap has a constant anatomy and easy dissection. It has a low donor site morbidity if FTSG is used. It also shows good functional and aesthetic results. Therefore, the FDMCA flap is a first treatment of choice for defects of the proximal phalanx and proximal part of the distal phalanx of the thumb.

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TECHNICAL REPORT

Bulent Daglar, Onder M. Delialioglu, Erman Ceyhan, Okyar Altas, Kenan Bayrakci, Ugur Gunel

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:5] [Pages No:35 - 39]

Keywords: Triceps tendon, Rupture, Elbow, Collateral ligament

   DOI: 10.1007/s11751-009-0057-0  |  Open Access |  How to cite  | 

Abstract

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.

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CASE REPORT

Ronald Boer, Bart A. Swierstra, Cees C. P. M. Verheyen

Neglected Achilles tendon rupture with central insertional plantaris tendon hypertrophy: two cases

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:3] [Pages No:41 - 43]

Keywords: Achilles tendinopathy, Achilles tendinosis, Plantaris tendon hypertrophy, Neglected Achilles tendon rupture

   DOI: 10.1007/s11751-009-0051-6  |  Open Access |  How to cite  | 

Abstract

A neglected Achilles tendon rupture is often characterized by muscle weakness and an overlengthened repair by scar tissue. Reconstructive surgery is usually performed taking into account the patient's required level of function. Two surgical cases of neglected Achilles tendon rupture are presented in this article. In both instances it was expected that central fibrosis, possibly after neglected tendon rupture, would be found. However, after longitudinal opening of the tendons, a thickened plantaris tendon was evident at the insertion on the calcaneus in both cases. This hypertrophic tendon occupied most of the diameter of the Achilles tendon. Due to partial or complete rupture of the Achilles tendon, there was notable weakening and tendon transfer-augmentation was performed. A thickened plantaris tendon as a reaction to a neglected rupture of the Achilles tendon is a rare presentation. It can be detected preoperatively by MRI and subsequently preoperative planning can be optimized.

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CASE REPORT

Roop Singh, Sarita Magu, Virender Kumar Kadian, Ramchander Siwach, Rajesh Kumar Rohilla, Vishal Dhir

Unusual cause of haemorrhage from surgical wound in a child

[Year:2009] [Month:April] [Volume:4] [Number:1] [Pages:4] [Pages No:45 - 48]

Keywords: Pseudoaneurysm, Profunda femoris artery, Haemorrhage

   DOI: 10.1007/s11751-009-0052-5  |  Open Access |  How to cite  | 

Abstract

Haemorrhage from a surgical wound can be from many potential sources such as injury to vessel, muscle and bone; bleeding disorders; incomplete haemostasis; pseudoaneurysm; and neovascularisation. We report an unusual cause of haemorrhage from the surgical incision in a 9-year-old child. We emphasize that a high index of suspicion is required for early diagnosis, and pseudoaneurysm and neoangiogenesis should be considered in the differential diagnosis of soft tissue masses resulting from direct, blunt trauma even in children.

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