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Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects. Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle. All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction. Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.

Purpose The aim of the present study is to present the long-term efficacy of the graft of the distal radius based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for the treatment of scaphoid nonunion with a proposed treatment of double stabilization with Kirschner wires and external fixator. Methods Between 2007 and 2013 we retrospectively reviewed 11 patients who were operated for established scaphoid nonunion with pedicled vascularized distal radius graft based on the 1,2 ICSRA in our department. Stabilization of the graft was achieved with Kirschner wires and the wrist was immobilized with a transarticular external fixator. All patients were evaluated pre- and post-operatively both clinically and radiologically. The DASH score was also completed by the patients before and after the operation. The minimum follow-up of the patients was 5 years. Results The mean age of the patients was 28.64 years (range, 18–49 years). Ten patients were males (90.91%) and one female (9.09%). In all patients, union was achieved. The mean time of union was 11.2 weeks (range, 8–18 weeks). The mean follow-up was 61.32 months (range, 60–72 months). Compared to the contralateral hand there was noticed 14° lack in flexion and 18° in extension. The mean DASH score showed also significant improvement from 23.1 (range, 9.4–50.6) preoperatively to 4.72 (range, 0–22.8) during the last follow-up. Conclusion The 1,2 ICSRA distal radius graft consists a trustworthy pedicled vascularized graft for the treatment of nonunion presenting very promising long-term outcomes.

Summary Background A growing body of evidence associates malnutrition with several adverse outcomes. Aim To investigate the link between malnutrition with surgical site and periprosthetic joint infections (SSIs and PJIs) following total knee and hip arthroplasty (TKA and THA) through a comprehensive meta-analysis of observational studies. Methods A systematic search was conducted on PubMed and Scopus databases through December 2018, and recent proceedings of major orthopaedic meetings. Data from eligible studies were extracted and synthesized; pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. Findings Seven publications were included, reporting eight independent cohort studies with >250,000 subjects. SSIs and PJIs were more likely to develop in malnourished patients (OR: 2.49; 95% CI: 2.13–2.90; and 3.62; 2.33–5.64, respectively). The association of SSI with malnutrition was evident both after TKA (2.42; 1.94–3.02) and after THA (2.66; 1.64–4.30). Similarly, PJI was associated with malnutrition after TKA (2.55; 1.10–5.91) and after THA (3.10; 1.84–5.25). Finally, PJI correlated with malnutrition both after primary arthroplasty (3.58; 1.82–7.03) and revision arthroplasty (3.96; 2.47–6.33). The subgroup analysis by study setting confirmed the relationship between PJI and malnutrition in hospital (6.02; 3.07–11.81) and population-based (2.80; 1.76–4.44) studies. Conclusion Malnutrition is associated with PJIs and SSIs after total joint arthroplasty. Further high-quality research is warranted to confirm or refute these findings.

Objective There are several factors which affect bone growth. One of them is the peripheralnervous system whose effect on the biomechanics has not been extensively studied. The purpose of this study is to assess the effect of peripheral nervous system in bone biomechanics in an experimental rat model. Materials & methods 27 male Wistar rats were used. In all animals, the roots of the right brachial plexus were dissected and after that the animals were divided into three groups A, B and C. The animals were sacrificed six, nine, and twelve months respectively after the denervation. Both humerus were resected and biomechanical analysis was performed. Results According to the findings of the present study the denervated bones sustain less loading before fracture and they become also more elastic. Additionally, in greater time after denervation plastic deformity is noticed. Conclusion Apart from structural changes, the peripheral nerves are responsible for biomechanic changes in the bones such the greater elasticity of the bone and the reduced strength

During the last decade direct oral anticoagulants (DOAC) have been established in various fields of medicine.Their use in microsurgery has not been evaluated yet though. This study aims to evaluate their efficacy in microsurgery and additionally compare them with a well established antithrombotic agent.The right femoral artery of 101 rats divided into 4 groups, was crushed and anastomosed. Group A (20 rats) received placebo therapy (1 ml NaCl 0.9%, orally), while Group B (27 rats), Group C (27 rats) and Group D (27 rats) received rivaroxaban (3 mg/kg, orally), dabigatran (30 mg/kg, orally) and enoxaparin (30 mg/kg, subcutaneously) respectively. All drugs were administered 3 h preoperatively and once daily for the following postoperative days until the sacrifice of the animals. Patency was evaluated at 1st, 7th and 20th postoperative day. Following patency evaluation the rats were sacrificed and the vessels were harvested for histological examination.None of the rats died postoperatively. Patency rates of rivaroxaban group (78%), dabigatran group (70%) and enoxaparin group (63%) were statistically similar, but significantly higher than the placebo-treated control group (p 0.05). Cells with morphologic features of endothelial cells were evident 7 days after the injury.The results of this study demonstrate the following: (1) rivaroxaban and dabigatran through inhibition of thrombus formation significantly enhanced the patency rate compared to placebo treatment (2) the antithrombotic efficacy of rivaroxaban and dabigatran in compromised microvessels was similar to that of enoxaparin, the most widely used antithrombotic agent.

Background Hip fracture is common and morbid in elderly patients. Postoperative cognitive dysfunction (POCD) is also very common in these subjects undergoing surgery with an incidence which exceeds 40% in some reports. To date, the evidence is ambiguous as to whether anesthetic technique may affect the patients’ outcome as far as postoperative cognitive function is concerned. Objective The aim of this study was to compare the effect of general and subarachnoid (spinal) anesthesia on the development of POCD up to 30 days after surgery in elderly patients undergoing hip fracture surgery. Methods Subjects over 65 years with hip fracture undergoing surgery were recruited for this study. They were enrolled and randomized to receive either general anesthesia (GA group) or subarachnoid (spinal) anesthesia (S group). Cognitive function was assessed using a battery of neuropsychological tests undertaken preoperatively and at 30 days postoperatively. The incidence of delirium was examined during the same period and their functional status, in terms of activities of daily living was also recorded. Results A total of seventy patients, 33 men and 37 females, mean age of 76 years were analyzed. Thirty-three patients received general anesthesia (GA group) and 37 subarachnoid (spinal) anesthesia (S group). The two groups of patients were similar with respect to baseline characteristics, comorbidities and perioperative data. The results of neuropsychological testing showed that there were no significant differences between the groups in eight out of ten neurocognitive tests at baseline and 30 days after surgery. There was a statistically significant decline of the Instrumental Activities of Daily Living Scale score in S group compared with group GA on the 30th postoperative day (p = 0.043). A significant decline was also present in Color-Word Task test in S group compared with group GA at baseline (p = 0.014) and 30 days postoperatively (p = 0.003). Postoperative delirium was present in four patients (12%) for the GA group, and in 10 patients (27%) for the group receiving subarachnoid anesthesia. Conclusion We concluded that the choice of anesthesia modality does not appear to influence the emergence of postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery.

Purpose To present our experience with vascularized bone grafting based on the 1,2-intercompartmental supraretinacular artery for the management of established scaphoid nonunion and to investigate the efficacy of graft immobilization with a combination of Kirschner wires and transarticular external fixation. Methods A retrospective chart and radiographic review was conducted for patients with the diagnosis of scaphoid nonunion of the proximal pole or the waist treated with the 1,2-intercompartmental supraretinacular artery–based vascularized graft and fixed with a combination of Kirschner wires and transarticular external fixation between 2007 and 2011. Results We observed 23 consecutive patients for a mean of 34 ± 4 months. All patients were males with mean age of 25 ± 5 years. All patients had scaphoid nonunion and associated humpback deformity. The mean duration of nonunion was 7 ± 1 months. All scaphoid nonunions united after the index procedure at a mean of 10 ± 1 weeks. Two patients had avascular necrosis of the proximal pole based on the preoperative magnetic resonance imaging findings. After surgery, deformity correction was achieved in all patients, as recorded by the decrease in the lateral intrascaphoid angle and the increase in the dorsal scaphoid angle. At the last follow-up, no patients reported wrist pain. The mean Disabilities of the Arm, Shoulder, and Hand score improved significantly from 32 ± 12 before the operation to 5 ± 3 at the last postoperative visit. All patients showed statistically significant improvement in the range of motion and the grip strength of the involved wrist. Conclusions The results of this study support the combined use of Kirschner wires and transarticular external fixation for fixation of a 1,2-intercompartmental supraretinacular artery–based vascular bone graft in the treatment of scaphoid nonunions. Type of study/level of evidence Therapeutic IV.

Numerous static and dynamic techniques have been described for the management of acute acromioclavicular (AC) joint dislocation. To date, no standard technique has been established and several complications have been described for each of these techniques. The purpose of the present study was to evaluate the functional and radiographic outcomes of acute AC joint reconstruction after a mini-open technique using the double-button fixation system.Twelve patients with acute AC joint dislocation treated with the double-button fixation system by one surgeon were retrospectively reviewed. Functional assessment was performed by an independent reviewer using the DASH, Constant and the VAS scores. The coracoclavicular (CC) distance of the affected shoulder was assessed on a standard radiograph and compared with the contralateral normal one.Eight patients were operated on for grade III AC joint dislocation and 4 for grade IV. The mean age of the patients at the time of surgery was 27.5 years. The mean follow-up was 18.25 months (range: 12-30 months). At the most recent follow-up, the mean Constant score was 94.8 (range: 84-100) showing a significant increase compared with the mean pre-operative value of 34.4 (range: 25-52) (p0.001). The mean DASH score was significantly decreased from 19.6 (range: 14-28) preoperatively to 0.25 (range: 0-3) at the last follow-up (p0.001). The mean VAS score showed a significant decrease from 5.75 (range: 4-7) to 0.2 (range: 0-2) (p0.001). The mean CC distance on the operated shoulder was found to have no significant difference from the CC distance on the contralateral normal side (10.5 vs. 10mm) (p0.05). There was no evidence of AC joint osteoarthrosis, CC calcification or osteolysis of the distal clavicle or the coracoid process.The proposed mini-open technique provides adequate exposure of the base of the coracoid with minimal damage to the soft tissues surrounding the CC ligaments while ensures an excellent cosmetic result. We recommend this fast and relatively simple technique for all type IV injuries and for type III injuries in heavy manual workers and high-demand upper extremities athletes.

Only 18 cases of congenital radial pseudarthrosis have been reported in the English literature; of these, 4 have been treated with free vascularized fibular graft. We present a case of a 9-year-old female patient with neurofibromatosis type 1 who underwent gradual distraction through the pseudarthrosis site and subsequent vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius and concomitant longitudinal and angular deformity of the wrist joint. At the last follow-up, 10 years postoperatively, the patient has maintained bony union, with full wrist flexion-extension and forearm pronation-supination.

Summary An entire generation of orthopaedic and plastic surgeons has been indelibly and perhaps overwhelmingly influenced by the introduction of microvascular technology to the fields of limb salvage and musculoskeletal reconstruction. Free-tissue transfer using microsurgical techniques has become a valuable method for the salvage of lower extremities after trauma. The goals of free flaps are both soft-tissue coverage and improvement of the functional outcome. The flap selection criteria for lower extremity reconstruction are based on the wound surface area, the type of tissue deficiency, length of the pedicle, volume of deficient tissue components and donor site morbidity. Composite flaps represent the state-of-the-art for reconstructive microsurgery, providing more than one function. Although many different treatment protocols have been proposed, they all highlight the importance of early tissue coverage with bone management performed in a later stage.

Summary Reconstruction of elbow function in severe or late brachial plexus injuries represents a challenge to the reconstructive microsurgeons. The current sophisticated techniques of nerve reconstruction in combination with secondary local or free functional muscle transfers, may offer satisfactory outcome. Latissimus dorsi can be transferred as a pedicled or free muscle to restore elbow function. We present our experience with elbow reanimation in late cases of brachial plexus paralysis utilising latissimus dorsi muscle transfer. From 1998 to 2006 we operated 103 patients with brachial plexus paralysis. Amongst these patients, 21 were late cases and underwent latissimus dorsi muscle transfer for elbow reanimation. Ten patients had free latissimus dorsi transfer for elbow flexion. Free latissimus dorsi muscle was neurotised either directly via three intercostals in three patients or with a nerve transfer procedure using the contralateral seventh cervical nerve root in seven patients. Care was taken to maintain the proper tension to the muscle, which must hold the elbow in static flexion of about 120° at the end of the procedure. Powerful elbow flexion (M4–M4+) or extension (M4) was obtained after the first 3 months in all patients who had an ipsilateral pedicled latissimus dorsi transfer. In the group of free muscle transfers, elbow flexion was seen after 6–8 months. After the initiation of muscle contraction, eight of the patients regained elbow flexion of M3–M4+. Latissimus dorsi muscle transfer is a reliable method for elbow reanimation. Appropriate postoperative management is also an important factor to obtain better outcome.

Femoral neck fractures, frequently complicated by non-union and femoral head osteonecrosis,present a difficult clinical situation, especially when young patients are concerned. Existing treatment options are valgus osteotomy to address the biomechanical factors or bone grafting to address the biologic factor. The authors describe the operative technique and results of combined subtrochanteric valgus osteotomy and free vascularized fibular grafting in management of five young patients with both non-union and avascular necrosis.

The relatively high frequency of coagulation abnormalities in patients with hip osteonecrosis might represent increased risk factors for the development of bone necrosis by predisposing these patients to thromboembolic phenomena. The recognition of this association may increase as more patients with osteonecrotic lesions are tested for haemostatic abnormalities. Early diagnosis of hypercoagulability in the group of patients at risk may allow pharmacologic intervention that may prevent this devastating process from developing.

This study evaluated the influence of the dose and administration methods of enoxaparin, a low-molecular-weight heparin, on the patency rate of crushed rat femoral arteries following anastomosis. An impact crush with a 25-kg magnitude was applied to a 2-mm segment of 100 rat femoral arteries, followed by anastomosis. The arteries were divided into five groups: group 1 received systemic enoxaparin alone with a relatively high dose (45 IU) twice a day for 3 days; groups 2 and 3 received topical irrigation with a lower (15 IU/mL) concentration and a higher (45 IU/mL) concentration, respectively; group 4 received systemic and topical application at a lower (15 IU) dose and concentration (15 IU/mL); and group 5 received systemic and topical application at a higher (45 IU) dose and concentration (45 IU/mL). The results of this study demonstrate the following: (1) topical irrigation with enoxaparin at a concentration of 45 IU/mL-three times higher than that recommended for clinical use adjusted by body weight (15 IU/mL)-is effective for antithrombotic action; (2) a combination of systemic and local application does not offer additional benefit in the patency rate when compared to local irrigation alone; (3) systemic administration alone does not prevent thrombus formation; and (4) enoxaparin is potentially useful to enhance the patency rate in compromised microvessels.

We report 3 cases of periprosthetic fractures after total knee replacement treated with Ilizarov external fixator (Smith and Nephew plc, Memphis, Tenn) and a follow-up of at least 3 years. We used 2 rings in the supracondylar area distal to the fracture and 3 half pins proximally in all our cases leaving the knee free to move. In one patient apart from the 2-ring frame placed distal to the fracture site the fixator included another ring frame placed proximally just below the 3 half pins. Uncomplicated fracture healing with lower extremity excellent alignment was achieved in 12 weeks after surgery. In periprosthetic femoral fractures, especially in elderly patients, Ilizarov external fixator is a treatment option which provides stable fixation, prompt postoperative mobilization, and has no major complications.