We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE). Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology. None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores. The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE. Level IV.

Periosteal or osteoperiosteal medial femoral condyle (MFC) flaps may be good options for atrophic nonunion. The aim of this study was to evaluate the effectiveness and safety of pedicled MFC flap in the treatment of recalcitrant femur nonunion without bone defect. Thirteen patients (11 male and 2 female), who suffered recalcitrant femur nonunion and were treated with pedicled osteoperiosteal MFC flap between January 2014 and April 2018, were included in this study. Patient files were reviewed retrospectively. Atrophic or recalcitrant 2/3 distal femoral nonunion were the indications for this clinical procedure. Demographics and operative data, flap size, visual analog scale (VAS) score, time to union, and complications were evaluated. A total of 13 patients underwent femur nonunion treatment with MFC flap after an average of 3.4 previous surgical procedures. The median age was 34 (Q1: 32.5, Q3:43) years old. The mean flap size was 4.3 × 6.4 cm, all nonunions healed in a median 5 months (Q1: 4.5, Q3: 6). There were an intraoperative knee medial collateral ligament injury in a patient, hematoma in a patient, and seroma in two patients. The median length of the follow-up was 40 months (Q1: 30, Q3: 47). There wasn’t any additional complication in long-term follow-up. Functional outcomes were satisfactory. The median preoperative VAS score was 7 (Q1: 6, Q3: 9.5), decreasing to 1 (Q1: 0, Q3: 1) at the 6-month follow-up, and further reducing to 0 (Q1: 0, Q3: 1) at the 24-month follow-up. The nonunion period ranged from 6 to 18 months. The pedicled MFC flap is a good option for recalcitrant femur nonunion where larger vascularized flaps are not warranted. It is easy to harvest, does not require microvascular anastomosis, is effective, and offers minimal donor site morbidity.

BACKGROUND: Recalcitrant fracture non-union is a condition that is difficult to treat and may require multiple surgeries, some-times requiring treatment with periosteal flaps. The use of periosteal flaps can be preferred for the treatment of non-unions that do not yet have extensive bone defects. This study aims to share our experience with medial femoral condyle periosteal flap for the treatment of recalcitrant non-union in long bones of the upper limb.METHODS: Seven patients who underwent treatment for upper limb non-union with a free medial femoral condyle periosteal flap be-tween 2015 and 2019 were retrospectively evaluated. Patients who had previously underwent implant revision and non-vascular grafting procedures and with failed atrophic non-union were included in the study. Non-union was in the humerus in two patients, ulna in three, radius in one, and clavicula in one patient. Demographic data, non-union features, complications, and radiographic findings of the patients were evaluated. Functional results were evaluated according to Quick Disabilities of Arm, Shoulder, and Hand (Q-DASH) scores. RESULTS: Mean patient age was 41 (23-60) years and the mean follow-up time was 33 months (16-56). Non-union time ranged from 9 to 24 months. Additional surgical procedures were not required. One patient developed a hematoma in the donor site and required surgical drainage. Medial collateral ligament injury of the knee occurred in one patient. Union was observed in all patients in an average of 3 (2-7) months. Mean pre-operative Quick Disabilities of Arm, Shoulder, and Hand (Q-DASH) score was 56 (33-95), while mean post-operative control Q-DASH score was 5 (0-33); the improvement was statistically significant (p=0.017). The functional outcomes of all patients improved, as confirmed by Q-DASH score.CONCLUSION: The medial femoral condyle periosteal flap offers a viable treatment option for recalcitrant non-unions. This flap has low comorbidity compared to other flaps and is a feasible option for revascularization and bone formation in atrophic non-unions.