Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Introduction:. 20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation. Material and Methods:. 9 cases of long bone defect (humerus and forearm) and 11 cases of bone defect at the hand have been included in this multicentre prospective study (3 centers). The aetiology in 11 cases was trauma, 7 cases were septic nonunions and 2 cases followed tumors. In the hand the bone loss was at least one phalanx, and for long bones the mean defect was 5 cm (3–11). All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary and in filling the void created by the bone defect by a cement spacer (PMMA). This technique needs a second stage procedure at the 2. nd. month where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which appeared around the cement spacer and which creates a biologic chamber for the second procedure. Bone union was evaluated prospectively in each case by a surgeon not involved in the treatment, by X-ray and CT scan. Failure was defined as a nonunion at 1 year, or an uncontrolled sepsis at 1 month. Results:. 3 cases failed to achieve bone union, 2 in the hand and 1 in a long bone. No septic complications occurred and all septic cases healed. In 14 cases bone union was achieved with a delay of 5 months (1, 5–12). 2 biopsies allowed us to prove that osteoid tissue was created by the technique. At hand level all fingers have included. At shoulder and elbow level, function reached 75% of motion of the contralateral side. Discussion:. Masquelet first reported 35 cases of large bone defect of tibia nonunion treated by the induced membrane technique which allow filling a bone defect with cancellous bone alone. The cement spacer induces a foreign body membrane (neo periosteum) which constitute a biological chamber. Animal models showed the properties of the membrane: secretion of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. Conclusion:. This technique is useful in emergency or in septic condition where a bone defect cannot be solved by shortening. The technique avoids the use of microsurgery and the limit is the quantity of available cancellous bone

The treatment of critical-sized bone defects still remains today a challenge, especially when the surrounding soft, vascularized and innervated tissues have been damaged - a lack of revascularization within the injured site leading to physiological disorders, from delayed healing to osteonecrosis. The axial insertion of a vascular bundle (e.g. arterio-venous loop, AVL) within a synthetic bone filler to initiate and promote its revascularization has been foreseen as a promising alternative to the current strategies (e.g., vascularized free flaps) for the regeneration of large bone defects. In a previous work, we showed that the insertion of a vein in a 3D-printed monetite scaffold induced its higher revascularization than AVL, thus a possible simplification of the surgical procedures (no microsurgery required). Going further, we investigate in this study whether or not the presence of a vein could stimulate the formation of mineralized tissue insides a synthetic scaffold filled with bone marrow and implanted in ectopic site. Monetite scaffolds were produced by additive manufacturing according to a reactive 3D-printing technique co-developed by the authors then thoroughly characterized. Animal study was performed on 14 male Wistar rats. After anesthesia and analgesia, a skin medial incision in rat thigh allowed the site on implantation to be exposed. Bone marrow was collected on the opposite femur through a minimally invasive procedure and the implant was soaked with it. For the control group (N=7), the implant was inserted in the incision and the wound was closed whereas the femoral bundle was dissected and the vein inserted in the implant for the experimental group (N=7). After 8 weeks animals were sacrificed, the implant collected and fixed in a 4% paraformaldehyde solution. Explants were characterized by µCT then embedded in poly-methyl methacrylate prior SEM, histology and immunohistochemistry. Images were analyzed with CT-Analyzer (Bruker) and ImageJ (NIH) and statistical analyses were carried out using SPSS (IBM). Implants were successfully 3D-printed with a +150 µm deviation from the initial CAD. As expected, implants were composed of 63%wt monetite and 37%wt unreacted TCP, with a total porosity of 44%. Data suggested that scaffold biodegradation was significantly higher when perfused by a vein. Moreover, the latter allowed for the development of a dense vascular network within the implant, which is far more advanced than for the control group. Finally, although mineralized tissues were observed both inside and outside the implant for both groups, bone formation appeared to be much more important in the experimental one. The ectopic formation of a new mineralized tissue within a monetite implant soaked with bone marrow seems to be highly stimulated by the simple presence of a vein alone. Although AVL have been studied extensively, little is known about the couple angiogenesis/osteogenesis which appears to be a key factor for the regeneration of critical-sized bone defects. Even less is known about the mechanisms that lead to the formation of a new bone tissue, induced by the presence of a vein only. With this in mind, this study could be considered as a proof of concept for further investigations

Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery. Microsurgery surely is a good weapon when facing extensive tissue losses and infections. From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb. These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps). In the last few years, the approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery. Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis Flap in the coverage of an amputation stump and that of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated. In 78.5% of the cases of osteomyelitis recovery was obtained after a single operation, and in only 12.3% of the cases the flaps had to be partially revised. In 2 cases, after the bony resection and coverage by means of a Gracilis Muscle Flap, a homolateral fibular transfer with the Ilizarov technique was performed. The length of bone resections treated by fibular flaps was 8–12 cm (mean 9)

Aims

To evaluate inducing osteoarthritis (OA) by surgical destabilization of the medial meniscus (DMM) in mice with and without a stereomicroscope.

The Authors report a case about a scaphoid remowing’s wrong operation performed in anohter hospital on a woman who was affected by rizoarthrosis. The authors visited the woman in the clinical outpatients six months after the wrong operation. In the Centre of Hand Surgery and Microsurgery of Modena the Authors performed an operation of an arthrodesis of TM associated with a arthrodesis capitate-lunate-hamate on that woman. The Authors report the good clinical outcome and X-ray’s results

Modern microsurgery has allowed severed digits to be salvaged by replantation. A retrospective case review was undertaken of all patients undergoing digital replantation at Middlemore Hospital between February 2004 and February 2009. 48 digits from 28 patients underwent digital replantation during this period. The aim of the analysis was to determine what factors were predictive for survival of the replants. Secondary outcomes of interest included subjective functional recovery, pain and further procedures. Digital replantation over the review period was subject to a 75% survival rate. Smoking and male gender were identified as significant negative prognostic factors (p=0.02). 69% of patients reported post operative stiffness, chronic pain or cold intolerance. The majority of replanted digits underwent secondary procedures. Patients should be counseled prior to digital replantation that while the procedure is subject to a high rate of digit survival, they should expect stiffness and discomfort and are likely to undergo secondary procedures

In amputation or amputation-like injuries of lower limbs, only in a few cases reconstructive treatment with microsurgery is encouraged, according to evaluation of lesion by Mangled Extremity Severity Score (MESS). Replantation cases may require substantial bone shortening, as consequence to seriousness of the trauma or a deliberate choice to enable primary vessel and nerve repair. Callus distraction technique by external fixation, circular or axial, is a common method for recover lengthening in these cases of replanted or revascularized extremities. We report six cases of lower limb replantation or revascularisation, with primary bone shortening from 3 to 7 cm and secondary lengthening by callus distraction. It was always obtained equalization of lower extremities, with successful rehabilitation of the patients and low onset of complications during treatment

Aim: Lumbar spinal stenosis is a common disease in spine surgery, especially for older patients. Internal laminoplasty technique is minimal invasive and can offer relieve from symptoms and early recovery to the patient. This method is our choice for surgical treatment in lateral spinal stenosis. Material and Method: From 1996–2002, 48 patients (28 male-28 female) operated for lumbar spinal stenosis (central or lateral).Eighteen(18) of them in level L3-L4, twenty two(22) in level L4-L5 and eight(8) in level L5-S1 with mane age of 62 years. Their clinical condition was neurogenic claudication, radiculopathies and/or bladder dysfunction. Preoperative examination included X-rays, 3-D X-rays, CT-scan (in combination with myelography in many cases) and MRI. Results: We used internal laminoplasty without fusion for all cases. We had no infection or neurological complication. 44patients (91%) mentioned sufficient clinical improvement and pain relief. Conclusions: Internal laminoplasty technique is a progress in microsurgery, which reduces iatrogenic damage and rehabilitation time, giving excellent results when it is indicated

Aims

Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years.

Introduction. 20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation. Material and Methods. 9 cases of long bone defect (humerus and 2 bones arm) and 11 cases of bone defct at the hand have been included in this multicentric prospective study (3 centers). 11 cases were traumatic, 7 cases were septic non union and 2 cases were tumor. At hand level's bone reached at least one phalanx, and for long bone the mean defect was 5cm (3–11). All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary and in filling the void created by the bone defect by a cement spacer (PMMA). This technique needs a second stage procedure at the 2. nd. month where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membane which appeared around the cement spacer and which create a biologic chamber after the second time. Bone union was evaluated prospectively in each case by an surgeon not involved in the treatment by Xray and CT scan. Failure was defined as a non union at 1 year, or an uncontrolled sepsis at 1 month. Results. 3 cases failed to achieve bone union, 2 at hand level and 1 for long bone. No septic complications occured and all septic cases werre stopped. In 14 cases bone union was achieved with a delay of 5 months (1, 5–12). 2 biopsies allowed to proove us that osteoid tissue was created by the technic. At hand level all fingers have included. At shoulder and elbow level, function reached 75% of motion than controlateral side. Discussion. Masquelet first reported 35 cases of large bone defect of tibia non union treated by the induced membrane technic which allow to fill bone defect with cancellous bone alone. The cement spacer allows to induce a foreign body membrane which constitute a biological chamber. Works on animal model reported by Pellissier and Viatteau showed the properties of the membrane: secretion of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. The induced membrane seem to play the role of a neo periosteum. Using this technic is possible in emergency or in septic condition where bone defect can not been solved by shortening. This technic avoids to use microsurgical technic and the limit is the quantity of avalaible cancellous bone

Initially, all surgeons in Australia were generalists and those with an interest in the anatomy of the hand performed hand surgery. Early hand surgeons, such as Benjamin Rank, excelled and Rank and Wakefield's Textbook of Hand Surgery was widely used throughout the world. Eventually, groups of like-minded surgeons formed the Australian Hand Club in 1972, which subsequently became formalised as The Australian Hand Surgery Society (AHSS), in 2001. A very high standard of hand surgery has been achieved in Australia, with most hand surgeons having trained in either plastic surgery or orthopaedic surgery, and then further trained in Fellowships in Europe or North America. Bernard O'Brien and John Hueston achieved international recognition in the field of microsurgery and Dupuytren's surgery. Wayne Morrison has been responsible for pioneering work in toe–to–hand transfer and basic research. Tim Herbert changed the way fractures of the scaphoid are managed throughout the world. In 2007 the AHSS commenced a Travelling Fellowship Programme to facilitate an increased involvement in Australia in academic hand surgery and to foster contacts between hand surgeons of the future. At the present time, the AHSS is concentrating on education and training in order to raise the overall standard of management of hand surgery, particularly in relation to after hours' trauma. This is particularly necessary in rural and regional areas where hand surgery has traditionally been treated by occasional practitioners. There is a risk that hand surgery falls between the two stools of plastic surgery and orthopaedic surgery and the AHSS wishes to further formalise training and education within the Royal Australasian College of Surgeons (RACS) as a single training stream in the future. There are potential threats both within and without, with safe working hours a particular threat in relation to reducing both the quantity and quality of training. The future will almost certainly involve greater emphasis on biomaterials and prosthetic compounds, but trying to ensure a uniformly high standard of hand surgery management throughout the country will remain as a primary focus

Author’s experience in surgical treatment of aplasia of the thumb according to the Buck-Gramcko procedure introduced by this author in 1971 is reported. Inidcation of the pollicization of the index finger according to Buck-Gramcko is aplasia of the thumb in the 3rd, 4th and 5th stages (Blauth’s classification). The surgical technique is particulary complex because of knowledge of microsurgery and soft-tissue reconstruction necessary. The different surgical phases may be schematically divided into a cutaneous stage which calls for the reconstruction of the web space, a vacular stage, a skeletal stage in which the reduction of the trapezium radial I metacarpal is reduced and a miotendinous stage. Surgery is carried out on patients of at least one year of age as it is necessary their cardial-pulmonary system be adequately mature, development of the endostal circle, thicker vascular walls and a suitably developed bimanual grasp, as well. The revision of these cases treated is especially significant because an average follow-up of the 17 years puts in good light the functionality of the hand, both from the points of view of strength and movement (Percival’s classification). After a revision of the case studies with a long term f.-u. we may affirm that the pollicization of the index finger according Buck-Gramcko, to achieve the development of the first finger in opposition, is the best-choice surgery in the reconstruction of the aplasial thumb and owes its effectiveness to the association of microsurgical techniques for preparing an island pedicle composite-tissue flap to the cardinal principles of articular reconstruction and of tendon transfers

Purpose: Vascular injuries occur in approximately 3% of all patients with major civilian trauma and peripheral vascular injuries account for 80% of all cases of vascular trauma. Upper extremity arterial injuries represents about 30% of all cases arterial trauma. The present study was designed to document and analyze the respective role of arterial damage and associated injuries on functional outcomes after upper extremity arterial trauma. Material and Methods: Excluding the arterial injuries resulting in immediate amputation there were 57 patients who sustained arterial trauma of the upper extremity. Their mean age was 33 years (range 4–68 years), and 40 were males and 19 were females. The most frequently injured vessel was the ulnar artery (42%) followed by the brachial artery (29.8%), radial artery (26.3%) and axillary artery (1.7%). Concomitant fractures or nerve injuries were present in 54% and 45% respectively. Results: An average of 5.6 hours elapsed between the time of injury and the time of vessel reconstruction. The most common method of surgical management was end to end anastomosis. Twenty one autogenous vein grafts were employed. Primary nerve repair was carried out in 29 patients and in another 18 secondary repair was performed. None of patients had any residual compromise from the arterial injury. Discussion: Vascular injuries are potentially limb threatening. Improvements in the technical ability to revascularize injured extremities and advances in microsurgery, resulting in the low present day limb loss rate associated with attempted vascular repairs. Associated injuries, rather than vascular injuries, cause long-term disability in the trauma of the upper extremity. Persistent nerve deficits, joint contractures and pain are principal reasons for functional impairment

Purpose of the study: The different conflicts in ex-You-goslavia left a health care desert. A few medicosurgical units attempted to reconstruct, but their capacities were limited and focused on emergencies. Many patients had to be abandoned. One was a 13-year-old Kosovar boy with active torpid osteomyelitis of the humerus whose family brought him to the French military field hospital in Mitrovica. Case report: The patient’s general status was mediocre with a hanging left arm which was painful upon mobilization. The skin had a normal aspect. Plain x-rays showed a purulent disintegration of the proximal third of the humerus with 11 cm shortening and loss of bone continuity. The forearm and hand were free of vascular or nervous deficits. Joint testing of the elbow and should was not contributive. The infectious agent was identified (multiple susceptible staphylococcus) and treated. A sequential strategy was undertaken for bone healing. The focus was exposed and stabilized by external fixation with insertion of a spacer and cement. At day 45, an autologous graft was inserted into the induced membrane. The fixator was removed at bone healing (20 days). Results: The gain was 8 cm. Postoperatively, the patient responded well to double antibiotic therapy. Recovery of joint motion was spectacular for the shoulder but difficult for the elbow. The autologous graft inserted on day 45 was composed of a non-vascularized fibular component completed with grafts harvested from the two anterior iliac crests. At one year follow-up, the infectious focus remains quiescent. The patient can use his arm with no problem. The shoulder motion is subnormal and there is a certain degree of persistent stiffness of the elbow but with no functional complaint. Discussion: This is a unusual clinical case where the induced membrane technique proposed by Masquelet for osteomyelitis of the humerus was used in an adolescent. The surgical strategy was chosen in part because of the context where microsurgery was not available. Conclusion: Therapeutic success was achieved with simple reliable techniques. The motivation of the young patient and the efforts of four medicosurgical teams overcame the technical limitations encountered in this field situation. The potential usefulness of the induced membrane technique proposed by Masquelet was demonstrated

Purpose of the study: Benign tumors of peripheral nerves are exceptional. Schwannomas predominate. Most tumors are revealed by tumefaction or pain over a nerve trajectory. The risk of degeneration is very low. Magnetic resonance imaging is the exploration of choice. The risk of sequelae or recurrence must nevertheless be determined with precision. We reviewed our experience with 93 benign tumors of peripheral nerves to search for factors predictive of prognosis. Material and methods: This retrospective analysis included patients seen between 1979 and 2004. We collected a series of 89 patients, 41 women and 48 men, mean age 48 years, age range 18–80, with 93 benign tumors. Mean time from symptom onset (pain) to diagnosis was 20 months. The patients consulted for pain (n=78), presence of a mass (n=79) or both (n=66). Percussion produced paresthesia in 54 patients. Pre-operative magnetic resonance imaging was available for 45 patients. The same surgeon performed nerve microsurgery in all patients. A prior procedure had been performed in another institution for 23 patients. The tumors were: schwannoma (n=74), neurofibroma (n=14), plexiform neurofibroma (n=3), angiolipoma (n=1) and intranervous lipoma (n=1). Mean tumor size was 31 mm (range 7–120 mm). Tumors were located in the brachial plexus (n=13), the upper limb (n=29), the trunk (n=1) and the lower limb (n=50). Complete resection was achieved in 83 cases, with removal of a non-stimulatable fascicle in 50 cases and a motor fascicle in. 4. Nerve repair was required for 11 cases: 5 by direct suture and 6 with grafts. Resection was impossible for 4 tumors treated by neurolysis, decompressive epineu-rotomy, biopsy and interfascicular dissection. Results: Mean follow-up was 96 months (range 3–300). Outcome was very good for 42, good for 25, fair for 8 and poor for 5 (all seen secondarily). Nine patients were lost to follow-up. There were no cases of recurrence. Discussion: Microsurgical procedures are necessary for resection of nerve tumors in order to preserve the fascicles and thus function. Unresectable tumors and secondary grafts yield les satisfactory results, in our series and in the literature. Similarly, the duration of the symptoms and the size of the tumor increase the risk of operative difficulty and sequelae. Despite high-performance imaging techniques, surgery is the only sure way to establish certain diagnosis

Purpose: We report a retrospective consecutive series of 57 hemiplegic patients (32 men and 25 women) who underwent surgery between 1995 and 2000 for spastic talipes equinovarus associating fascicular neurotomy of the tibial nerve and tendon release in order to recover sole to floor walking capacity. Material and methods: Mean patient age was 47 years (16–75). The hemiplegia resulted from stroke (n=41), trauma (n=8), and other causes (n=8). All patients had spastic talipes equinovarus and 46 required a walking aid. Triceps force and spasticity were scored 2.1 (MRC) and 3.66 (Ashworth) respectively. Pedial hypoaesthesia was present in 23 patients. The mean functional ambulation classification (FAC) score was 3.3, with severe disability (FAC 1 or 2) in 13 patients. Surgery was performed three years (average) after the causal event. After identification by electrical stimulation, we performed microsurgical section of 4/5 nerve fibres of the terminal branches of the tibial nerve in 55 patients. After physical exploration of musculotendon retraction (triceps and toes flexors) and dorsiflesion palsy, we released tendons as needed. The Achilles tendon was lengthened percutaneously in 13 patients, Bardot tenodesis or transfer of the anterior hemi-tibial anterior tendon was performed in 29, and tenotomy of the toe flexors in 12. Results: Mean follow-up was three years (1–6). Triceps force and foot sensitivity were not modified by the surgery. Spasticity was scored 1.08 and 1.19 (Ashworth) postoperatively and at last follow-up respectively. The FAC walking score was 4.13 and 4.15 postoperatively and at last follow-up respectively. The walking aid was no longer necessary or was improved in 52 patients. Tibiotalal arthrodesis was necessary for recurrent spasticity in three patients. Discussion: The preoperative assessment of foot deformity and gait is an essential element. Correct preoperative assessment enables microsurgery for fascicular neurotomy of the posterior tibial nerve and tendon lengthening or tenodesis during the same operation. These procedures are indicated for severe deformity and should be used as the first intention treatment before arthrodesis which involves greater morbidity

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle. We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed. In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary. In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs. Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination)

In the last ten years, the percutaneous laser disc decompression and nucleotomy has been done worldwide in more than 60000 cases of herniated disc disease. Because water is the major component of the intervertebral disc, and in herniated disc disease pain is caused by the disc protrusion pressing against the nerve root, a small reduction of volume in a closed hydraulic space, such as an intact disc, results in a considerable fall of intradiscal pressure. 980 nm Diode laser is the optimal wavelength for laser disc decompression and nucleotomy, because 980nm is 5 times more absorbent in water than 810nm, and 2 times more absorbent than 1064nm. A MULTIDIODE PL3D (INTERmedic) 980nm laser energy introduced through a 400 micron silica-silica fiber into a 21G needle under X-ray guidance and local anesthesia, vaporizes a small amount of nucleus polposus with a disc shrinkage and a relief of pressure on nerve root. The gas formed due to the vaporization of the nucleus is removed by a specific handpiece (Menchetti’s handpiece) connected to a smoke evacuation system, to minimize the postop muscle spasm. Most patients get off the table pain free and are back to work in 5 to 7 days. Material and method: to date, 480 patients (600cases) suffering for relevant symptoms therapy-resistant 6 months on average before consulting our department, have been treated. Three hundred-twenty (67%) males and 160 (33%) females had a percutaneous laser disc decompression and nucleotomy. The average age of patients operated was 46 years (16 to 76). The level of disc removal was L2/L3 in 26 cases, L3/L4 in 58 cases, L4/L5 in 294 cases and L5/S1 in 222 cases. Two different levels were treated at the same time in 80 patients, and three different levels in 20 patients. In 44 cases the PL3D has been performed after an unsuccessful microsurgical approach with a relapse of the disc herniation. Results: The sucess rate at a mean follow-up of 22 months was 91% with a complication rate of 0.5%. Because of the best absorption of the water content of the disc by the 980nm wavelength laser, compared to others lasers (810nm, 940nm, 1064nm), 980nm Diode laser requiring less laser energy with a less heat diffusion in surrounding tissue, reduces postoperative complication, and appears to be safe and effective, specifically designed for discectomy, and results in no peridural scarring or spinal microsurgical instability. Microsurgery if needed is not precluded

Introduction and Aims: An important prognostic factor in neonatal brachial plexus injury is the timing of biceps recovery. Although the natural history is not clear, biceps recovery after three months has been used to predict universally poor long-term shoulder function. The absence of biceps function at three months has been adopted as an indication for early microsurgery, in an attempt to improve upper limb function. e. Method: Between 1980 and 1992, 170 patients with neonatal brachial plexus injury were entered into a prospective study, which recorded details of the birth and serial examinations. Patients were grouped according to the level of injury and timing of biceps return. Twenty-nine patients were observed to have absent biceps at three months. Twenty-eight of 29 patients were available for long-term review at an average of 11 years and one month (range 5yrs 7mths–16 years). At follow-up, patients answered a questionnaire, underwent muscle strength testing, sensory evaluation, and had their shoulder function graded according to Gilbert’s modification of the Mallet score. The level of injury and time of biceps return were compared to the final outcomes. Results: The level of injury was C5/6 in 13/28 (46%), C5/6/7 in 5/28 (18%) and pan-plexus in 10/28 (36%), with a Horner’s syndrome in four patients. Of the 28 patients with absent biceps function at three months, biceps contraction was observed in 20 patients (71%) by six months. 13/13 C-5,6 patients, 3/5 C-5,6,7 patients, and 4/9 pan-plexus patients (0/4 of those with a Horner’s syndrome) regained biceps by six months. Twenty-two patients did not have plexus surgery, nine of these had subsequent shoulder surgery. At follow-up, 27 of 28 patients had at least anti-gravity biceps function. Patients who regained biceps function between three and six month had better scores for abduction (p=0.04), hand to neck (p=0.05) and hand to back (p< 0.001) than patients who regained biceps after six months. Patients with C-5, 6 lesions had better scores for external rotation (p=0.04), hand to neck (p=0.05), hand to mouth (p< 0.01) and hand to back (p< 0.001) than patients with pan-plexus lesions. Twelve of the 22 (55%) patients who did not have plexus surgery had Mallet class IV shoulders (good function). Of the C-5, 6 patients who did not have plexus surgery, 8/12 had class IV shoulders. Conclusion: This study supports the associations between prolonged neurological recovery, more extensive level of injury and worse long-term shoulder function. In patients with C-5, 6 injuries and absent biceps function at three months, good shoulder function is common in the long-term without plexus surgery. This finding is important in considering the indications for and the results of early microsurgical intervention