Open-wedge osteotomy for thumb radial angulation in Apert syndrome using a bone-graft substitute

A short thumb with radial angulation causes loss of hand function in patients with Apert syndrome. Although past reports have described various procedures for the correction of the thumb, there has been no consensus on the best procedure. This study aimed to assess the clinical and radiographic results of a surgical technique for the correction of a thumb radial angulation deformity: open-wedge osteotomy using a bone-graft substitute. Ten patients (18 thumbs) who underwent open-wedge osteotomy on the proximal phalange using a bone-graft substitute were evaluated retrospectively. The open-wedge osteotomies had been performed at the center of the proximal phalanx. Thumb radial angles and thumb lengths were measured on radiographs, and the clinical results were investigated, including bone union and complications. The median patient age at the time of surgery was 5.8 years, and the average follow-up period was 6.7 years. The average thumb radial angle was 57.3° preoperatively, 6.5° immediately postoperatively, and 19.8° at the most recent follow-up. The average thumb length was 12.1 mm preoperatively, 18.1 mm immediately postoperatively, and 22.3 mm at the most recent follow-up, indicating an extension effect of more than 50% immediately postoperatively. In all cases, the artificial bone had been absorbed and developed into autologous bone, and there were no complications such as infection and skin necrosis. These findings suggest that open-wedge osteotomy with an artificial bone substitute is simple and effective for treating radial-angulation deformities in patients with Apert syndrome. Level of evidence: Level IV - retrospective case series.

Thoracic Outlet Syndrome with Subclavian Artery Thrombosis Caused by Synostosis of the First and Second Ribs: A Case Report

CASE

A 43-year-old woman presented with pain, paresthesia, and coldness of the right upper extremity suggestive of the diagnosis of thoracic outlet syndrome. Three-dimensional computed tomography angiography revealed that the right subclavian artery was constricted because it traveled over an abnormal first rib. After anticoagulation and antithrombotic therapy, the patient underwent resection of the abnormal first rib. Postoperative angiography documented improvement over time of the poststenotic dilatation and recanalization of the subclavian artery capable of delivering almost normal distal flow.

CONCLUSION

Arterial reconstruction is not always necessary for the treatment of arterial thoracic outlet syndrome associated with poststenotic dilatation of the subclavian artery.

Divergent Dislocation of the Elbow in an Adult with Ehlers-Danlos Syndrome: A Case Report

CASE

A 32-year-old man with Ehlers-Danlos syndrome (EDS) fell while snowboarding and injured his right elbow. Radiography revealed a posterior dislocation of the elbow and a proximal radioulnar joint dislocation. A diagnosis of transverse divergent dislocation of the elbow was established. Open reduction and repair of the annular ligament, anterior oblique ligament, and capsule was performed with good clinical results.

CONCLUSION

This is the first report of divergent dislocation of the elbow in an adult with EDS. Dislocation occurred without a fracture that required open reduction and internal fixation. The presence of soft-tissue fragility, hyperextension, and joint laxity peculiar to EDS are likely contributing factors to this phenomenon.

Computer-Assisted Three-Dimensional Corrective Osteotomy for Malunited Fractures of the Distal Radius Using Prefabricated Bone Graft Substitute

BACKGROUND

Three-dimensional computed tomography (3D-CT) imaging has enabled more accurate preoperative planning. The purpose of this study was to investigate the results of a novel, computer-assisted, 3D corrective osteotomy using prefabricated bone graft substitute to treat malunited fractures of the distal radius.

METHODS

We investigated 19 patients who underwent the computer-assisted 3D corrective osteotomy for a malunited fracture of the distal radius after the operation was stimulated with CT data. A prefabricated bone graft substitute corresponding to the patient's bone defect was implanted and internal fixation was performed using a plate and screws. We compared postoperative radiographic parameters of the patient's operated side with their sound side and analyzed clinical outcomes using Mayo wrist score.

RESULTS

All patients achieved bone union on X-ray imaging at final follow-up. The mean differences of palmar tilt, radial inclination and ulnar variance between the operation side and the sound side were 4.3°, 2.3° and 1.2 mm, respectively. The Mayo wrist score was fair in 4 patients and poor in 15 patients before surgery. At the final follow-up after surgery, the scores improved to excellent in 3 patients, good in 11 patients and fair in 5 patients. There were two patients with correction loss at the final follow-up, but no patient complained of hand joint pain.

CONCLUSIONS

We believe that computer-assisted 3D corrective osteotomy using prefabricated bone graft substitute achieved good results because it worked as a guide to the accurate angle.

Limited Wrist Arthrodesis for Scapholunate Advanced Collapse Wrist: Triangle Fixation for Four-Corner Fusion

BACKGROUND

Limited wrist arthrodesis with scaphoid excision is a useful treatment for scapholunate advanced collapse (SLAC) of the wrist. Multiple Kirschner wires were originally used for internal fixation of the four carpal bones, however long-term cast immobilization, pin tract infection, and hardware removal are still problematic. We introduce and evaluate the clinical outcomes of an internal fixation technique; triangle fixation for four-corner fusion, using three headless screws, as an alternative to conventional multiple Kirschner wires for the treatment of SLAC wrist.

METHODS

Five male patients with SLAC wrist secondary to three scaphoid nonunions and two scapholunate dissociations were treated with four-corner fusion using triangle fixation with three Double-threaded Japan screws. The mean age was 59.5 years (35-79 years) and the mean follow-up period was 40 months. After surgery, short arm splints were applied for 3-4 weeks, and then range of motion exercises were initiated.

RESULTS

Wrist range of motion and grip strength both improved postoperatively. At the final follow-up evaluation, bone union was completely achieved and satisfactory pain relief was observed in all patients.

CONCLUSIONS

Compared with the conventional Kirschner wire technique, the present technique shortens the period of splint immobilization due to a strong compression force in a skewed position, does not require pin removal or cause pin tract infections, and provides satisfactory results.

Low second to fourth digit ratio in Dupuytren disease

The ratio of the lengths of the second and fourth digits (2D:4D) has been described as reflecting endogenous prenatal androgen exposure. In general, 2D:4D is lower in men than in women and has potential as a biomarker or predictor for various diseases, athletic ability, and academic performance. Dupuytren disease has digital flexion contractures and is known to predominate in men, but the pathogenesis of the disease remains unclear. To clarify the relationships between Dupuytren disease and endogenous androgens, we performed a retrospective analysis of hand radiographs to investigate 2D:4D in Dupuytren disease. The study included male patients with Dupuytren disease (n = 22) and a control group (n = 18) of male patients with carpal tunnel syndrome. Only unaffected hands, without contractures or osteoarthritis, were evaluated for the purpose of radiographic assessment. The lengths of the phalanx and metacarpal bones in the second and fourth digits were measured by 2 independent observers who each performed 2 sets of measurements separated by a minimum 1-week interval. The 2D:4D was calculated separately for the phalanges and metacarpals, and a combined (phalanx + metacarpal) 2D:4D was also calculated. The reliability of the observer measurements was established using the intraclass correlation coefficient, and both the intra- and interobserver reliability showed excellent agreement. We found that compared with control group, the Dupuytren disease group had significantly lower phalanx and combined 2D:4D. These findings suggest that endogenous prenatal androgens could contribute to the development of Dupuytren disease, leading to its characteristic clinical presentation predominantly in men and affecting the ulnar rays.

Correlation between luminescence intensity and cytotoxicity in cell-based cytotoxicity assay using luciferase

The luciferase reporter assay has become one of the conventional methods for cytotoxicity evaluation. Typically, the decrease of luminescence expressed by a constitutive promoter is used as an index of cytotoxicity. However, to our knowledge, there have been no reports of the correlation between cytotoxicity and luminescence intensity. In this study, to accurately verify the correlation between them, beetle luciferase was stably expressed in human hepatoma HepG2 cells harboring the multi-integrase mouse artificial chromosome vector. We showed that the cytotoxicity assay using luciferase does not depend on the stability of luciferase protein and the kind of constitutive promoter. Next, HepG2 cells in which green-emitting beetle luciferase was expressed under the control of CAG promoter were exposed to 58 compounds. The luminescence intensity and cytotoxicity curves of cells exposed to 48 compounds showed similar tendencies, whereas those of cells exposed to 10 compounds did not do so, although the curves gradually approached each other with increasing exposure time. Finally, we demonstrated that luciferase expressed under the control of a constitutive promoter can be utilized both as an internal control reporter for normalizing a test reporter and for monitoring cytotoxicity when two kinds of luciferases are simultaneously used in the cytotoxicity assay.

Case of Trigger Finger Related to an Intertendinous Connection between the Flexor Tendons

We report a rare cause of trigger finger related to an anatomical variation of an intertendinous connection between the flexor digitorum superficialis and flexor digitorum profundus tendons in the palmar region.

Effects of duration of electric pulse on in vitro development of cloned cat embryos with human artificial chromosome vector

The current applications for cat cloning include production of models for the study of human and animal diseases. This study was conducted to investigate the optimal fusion protocol on in vitro development of transgenic cloned cat embryos by comparing duration of electric pulse. Cat fibroblast cells containing a human artificial chromosome (HAC) vector were used as genetically modified nuclear donor cells. Couplets were fused and activated simultaneously with a single DC pulse of 3.0 kV/cm for either 30 or 60 μs. Low rates of fusion and embryo development to the blastocyst stage were observed in the reconstructed HAC-transchromosomic embryos, when the duration of fusion was prolonged to 60 μs. In contrast, the prolongation of electric pulse duration improved the embryo development and quality in the reconstructed control embryos without HAC vector. Our results suggested that the optimal parameters of electric pulses for fusion in cat somatic cell nuclear transfer vary among the types used for donor cells.

Anatomical Origins of Radial Artery Perforators Evaluated Using Color Doppler Ultrasonography

Background The radial artery perforator (RAP) flap has been widely used for covering hand and forearm defects, and real-time accurate perforator mapping is important in planning and elevating the perforator flap. The origins of perforators, especially the superficial and ulnar perforators, arising from the radial artery are very important in the elevation of the RAP flap. Recently, color Doppler ultrasonography (US) using a higher frequency transducer has been developed for high-quality detection of lower flow in smaller vessels. This study aimed to identify the anatomical locations and origins of perforators arising from the radial artery using color Doppler US in healthy volunteers. Methods Twenty forearms of 10 volunteers were examined. Results In total, 120 perforators arising from the radial artery were identified 15 cm proximal to the distal wrist crease, with an average of six perforators per forearm. More than half the perforators (n = 72, 60%) were located within 50 mm proximal to the distal wrist crease. Regarding the perforator origins in the axial view, 40 perforators (33%) were located in the radial aspect of the radial artery, 47 (39%) in the ulnar aspect, 15 (13%) in the superficial aspect, and 18 (15%) in the deep aspect. In total, 62 (52%) perforators were located in the superficial and ulnar areas, which are important in nourishing and elevating the RAP flap. Conclusion We are the first to evaluate RAP using color Doppler US. This noninvasive, convenient, and real-time technique could be useful for preoperative planning and reliably elevating the RAP flaps.

The Classification of Swanson for Congenital Anomalies of Upper Limb Modified by the Japanese Society for Surgery of the Hand (JSSH)

The aim of this study is to introduce the classification of Swanson for congenital anomalies of upper limb modified by the Japanese Society for Surgery of the Hand (the JSSH modification) in English. The Swanson classification has been widely accepted by most hand surgeons. However, several authors have suggested that complex cases, particularly those involving the complex spectrum of cleft hand and symbrachydactyly, are difficult to classify into the classification schemes. In the JSSH modification, brachysyndactyly, so-called atypical cleft hand and transverse deficiency are included under the same concept of transverse deficiency. Cleft hand, central polydactyly, and syndactyly are included in the same category of abnormal induction of digital rays. We believe that the JSSH modification system is effective in providing hand surgeons with the clinical features and conditions for congenital anomalies.

Osteomyelitis and arthritis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient: a case report and literature review

Mycobacterium intracellulare causes infection in humans. Involvement of joint and bone, however, is extremely rare. We present the case of an immunocompetent 67-year-old female with chronic swelling of the wrist joint diagnosed as rheumatoid arthritis by her previous physician. Examination revealed an unclosed fistula associated with a puncture, and bone and joint destruction on radiographs. She was diagnosed with osteomyelitis and arthritis due to M. intracellulare on histological and microbiological examinations. She was successfully treated with radical surgical debridement and anti-tuberculous drugs for 1 year and there was no recurrence at 3 years postoperatively.

Bisphosphonate-related atypical femoral fracture with bone metastasis of breast cancer: case report and review

BACKGROUND

Intravenous bisphosphonates (BPs) have been used to reduce the frequency of skeletal-related events due to bone metastases of several kinds of cancers. Although many studies on BP-related atypical fractures (BRAFs) due to the use of BP for osteoporosis treatment have been reported, few reports on BRAFs arising as a complication of long-term BP use for bone metastasis of cancer are available.

CASE REPORT

A 62-year-old woman with a history of breast cancer presented with right thigh pain after she had a fall. Radiographs indicated a transverse fracture in the shaft of the right femur. She had been on zoledronate treatment for six years. Based on radiographic and histopathological findings, we concluded that the fracture was not a pathological fracture associated with metastasis but was a complication of long-term BP treatment.

CONCLUSION

Clinical oncologists should consider the possibility of BRAFs in patients on long-term zoledronate treatment for bone metastases.

Successful treatment of nonunion with teriparatide after failed ankle arthrodesis for Charcot arthropathy

We describe a case of successful treatment to nonunion after multiple arthrodesis operations for Charcot arthropathy with teriparatide. We describe the case of a 25-year-old woman with severe Type I diabetes mellitus that resulted in nonunion after multiple arthrodesis operations for Charcot arthropathy. The woman sustained a femoral shaft fracture for which she underwent surgery with intramedullary nail fixation. Immediately after surgery, an empiric course of teriparatide was initiated. Femoral shaft fracture healing was observed after 2 weeks, and the woman was able to walk 12 weeks after the surgery, at which point plain film and computed tomography images revealed complete union of the ankle.

Acceleration of peripheral nerve regeneration using nerve conduits in combination with induced pluripotent stem cell technology and a basic fibroblast growth factor drug delivery system

Various modifications including addition of Schwann cells or incorporation of growth factors with bioabsorbable nerve conduits have been explored as options for peripheral nerve repair. However, no reports of nerve conduits containing both supportive cells and growth factors have been published as a regenerative therapy for peripheral nerves. In the present study, sciatic nerve gaps in mice were reconstructed in the following groups: nerve conduit alone (control group), nerve conduit coated with induced pluripotent stem cell (iPSc)-derived neurospheres (iPSc group), nerve conduit coated with iPSc-derived neurospheres and basic fibroblast growth factor (bFGF)-incorporated gelatin microspheres (iPSc + bFGF group), and autograft. The fastest functional recovery and the greatest axon regeneration occurred in the autograft group, followed in order by the iPSc + bFGF group, iPSc group, and control group until 12 weeks after reconstruction. Thus, peripheral nerve regeneration using nerve conduits and functional recovery in mice was accelerated by a combination of iPSc-derived neurospheres and a bFGF drug delivery system. The combination of all three fundamental methodologies, iPSc technology for supportive cells, bioabsorbable nerve conduits for scaffolds, and a bFGF drug delivery system for growth factors, was essential for peripheral nerve regenerative therapy.

Clinical characteristics of intraspinal facet cysts following microsurgical bilateral decompression via a unilateral approach for treatment of degenerative lumbar disease

PURPOSE

Primary intraspinal facet cysts in the lumbar spine are uncommon, but it is unclear whether cyst incidence increases following decompression surgery and if these cysts negatively impact clinical outcome. We examined the prevalence, clinical characteristics, and the risk factors associated with intraspinal facet cysts after microsurgical bilateral decompression via a unilateral approach (MBDU).

METHODS

We studied 230 patients treated using MBDU for lumbar degenerative disease (133 men and 97 women; mean age 70.3 years). Clinical status, as assessed by the Japanese Orthopedic Association (JOA) score and findings on X-ray and magnetic resonance images, was evaluated prior to surgery and at both 3 months and 1 year after surgery. The prevalence of intraspinal facet cysts was determined and preoperative risk factors were defined by comparing presurgical findings with clinical outcomes.

RESULTS

Thirty-eight patients (16.5%) developed intraspinal facet cysts within 1 year postoperatively, and 24 exhibited cysts within 3 months. In 10 patients, the cysts resolved spontaneously 1 year postoperatively. In total, 28 patients (12.2%) had facet cysts 1 year postoperatively. The mean JOA score of patients with cysts 1 year postoperatively was significantly lower than that of patients without cysts. This poor clinical outcome resulted from low back pain that was not improved by conservative treatment. Most cases with spontaneous cyst disappearance were symptom-free 1 year later. The preoperative risk factors for postoperative intraspinal facet cyst formation were instability (OR 2.47, P = 0.26), scoliotic disc wedging (OR 2.23, P = 0.048), and sagittal imbalance (OR 2.22, P = 0.045).

CONCLUSIONS

Postoperative intraspinal facet cyst formation is a common cause of poor clinical outcome in patients treated using MBDU.

A tissue-engineered bioabsorbable nerve conduit created by three-dimensional culture of induced pluripotent stem cell-derived neurospheres

We previously reported a bioabsorbable nerve conduit coated with Schwann cells for the treatment of peripheral nerve defects. Since there have been dramatic developments in induced pluripotent stem (iPS) cells in recent years, the purpose of the present study was to create a tissue-engineered nerve conduit coated with iPS cell-derived neurospheres. Such a conduit was constructed by three-dimensional (3D)-culture of these cells using a bioabsorbable polymer conduit as a scaffold. The nerve conduit was composed of a mesh of poly L-lactide, and a porous sponge of 50% poly L-lactide and 50% poly ε-caprolactone. The primary and secondary neurospheres (PNS and SNS, respectively) induced from iPS cells were suspended in individual conduits. The conduits were incubated for 7 or 14 days in vitro and then evaluated using immunohistochemistry. All of the 7- and 14-day differentiated PNS and SNS were observed to have adhered to the inner surface of the conduits and to have migrated into the inner porous sponge. The engrafted cells were positive for anti-Tuj1, -S-100 and -GFAP antibodies, indicating that their pluripotent ability to form neural or glial cells was maintained. These findings indicate the feasibility of creating nerve conduits coated with a 3D-culture of iPS cell-derived neurospheres for the treatment of peripheral nerve defects.

PAEDIATRIC GALEAZZI-EQUIVALENT FRACTURE: TWO CASE REPORTS

The authors present two rare cases of a paediatric Galeazzi-equivalent fracture. In contrast to Galeazzi's fracture-dislocation in adults, an epiphyseal separation of the distal ulna occurred instead of dislocation of the distal radioulnar joint (DRUJ) or both. A precise radiographic analysis of the epiphyseal separation of the distal ulna and its anatomical reduction were keys to obtaining a good result in the treatment of paediatric Galeazzi-equivalent fracture.

PALMAR PLATING FOR AO/ASIF C3.2 FRACTURES OF THE DISTAL RADIUS WITH ARTHROSCOPICALLY ASSISTED REDUCTION

We performed a retrospective study of 15 patients with AO/ASIF C3.2 fracture of the distal radius. All patients were treated with arthroscopically assisted reduction of the radiocarpal joint followed by palmar plating with autologous bone graft, with a follow-up evaluation of 24 months. According to the demerit point system of Gartland and Werley, five patients had excellent results and 10 had good results. Grade 1 arthritic changes were found in 10 patients even though with no step-off on radiographs. In the current study, this combined treatment was challenging and useful for AO/ASIF C3.2 fractures.

Transplantation of induced pluripotent stem cell-derived neurospheres for peripheral nerve repair

In spite of the extensive research using induced pluripotent stem (iPS) cells, the therapeutic potential of iPS cells in the treatment of peripheral nerve injury is largely unknown. In this study, we repaired peripheral nerve gaps in mice using tissue-engineered bioabsorbable nerve conduits coated with iPS cell-derived neurospheres. The secondary neurospheres derived from mouse iPS cells were suspended in each conduit (4000,000 cells per conduit) and cultured in the conduit in three-dimensional (3D) culture for 14 days. We then implanted them in the mouse sciatic nerve gaps (5 mm) (iPS group; n=10). The nerve conduit alone was implanted in the control group (n=10). After 4, 8 and 12 weeks, motor and sensory functional recovery in mice were significantly better in the iPS group. At 12 weeks, all the nerve conduits remained structurally stable without any collapse and histological analysis indicated axonal regeneration in the nerve conduits of both groups. However, the iPS group showed significantly more vigorous axonal regeneration. The bioabsorbable nerve conduits created by 3D-culture of iPS cell-derived neurospheres promoted regeneration of peripheral nerves and functional recovery in vivo. The combination of iPS cell technology and bioabsorbable nerve conduits shows potential as a future tool for the treatment of peripheral nerve defects.

Clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture: use of one-stage skin closure

Y-V or Z-plasties are a useful one-stage technique for skin closure after aponeurotomy. However, we know no details about postoperative improvement, particularly at each joint. The purpose of this study was to evaluate the clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture. We retrospectively reviewed the postoperative results of 23 patients (25 hands, 29 fingers). The preoperative severity of the contracture evaluated by the Meyerding classification was grade I in 11 fingers, II in two fingers, and III in 16 fingers. In total, 26 metacarpophalangeal (MP) joints and 27 proximal interphalangeal (PIP) joints were treated. In each finger we assessed clinical outcomes according to the percentage improvement in extension and a modified version of Tubiana's classification. Primary wound closure was possible in all cases. The mean contracture values were improved from 46.5° preoperatively to 4.2° postoperatively for the MP joint and from 43.9° to 22.4° for the PIP joint. The mean percentage improvement in extension for the MP joint was 92% and for the PIP joint 56%. The rate for the PIP joint of the little finger was 40% and for the other fingers 78%. In total, 83% of the fingers had satisfactory results. For Dupuytren's contracture, primary skin closure with Y-V and Z-plasties gives satisfactory results, more so with involvement of the MP than the PIP joint and less so with involvement of the little finger.

Intraneural nodular fasciitis of the median nerve: case report and literature review

Nodular fasciitis, a benign soft tissue tumor, occurs most frequently in the forearm and is generally divided into subcutaneous, intramuscular, and fascial types. Intraneural nodular fasciitis has been reported in only 5 patients previously. We present the case of a 79-year-old woman with nodular fasciitis within the median nerve at the proximal forearm. Carpal tunnel syndrome was suspected at the initial visit, but high median nerve palsy and a mass at the proximal forearm were found a few months later. Subtotal resection of the tumor within the median nerve was performed and histological diagnosis indicated nodular fasciitis. There was no evidence of recurrence at follow-up 1 year and 3 months after surgery. Motor weakness had resolved but sensation was compromised.

Refined human artificial chromosome vectors for gene therapy and animal transgenesis

Human artificial chromosomes (HACs) have several advantages as gene therapy vectors, including stable episomal maintenance, and the ability to carry large gene inserts. We previously developed HAC vectors from the normal human chromosomes using a chromosome engineering technique. However, endogenous genes were remained in these HACs, limiting their therapeutic applications. In this study, we refined a HAC vector without endogenous genes from human chromosome 21 in homologous recombination-proficient chicken DT40 cells. The HAC was physically characterized using a transformation-associated recombination (TAR) cloning strategy followed by sequencing of TAR-bacterial artificial chromosome clones. No endogenous genes were remained in the HAC. We demonstrated that any desired gene can be cloned into the HAC using the Cre-loxP system in Chinese hamster ovary cells, or a homologous recombination system in DT40 cells. The HAC can be efficiently transferred to other type of cells including mouse ES cells via microcell-mediated chromosome transfer. The transferred HAC was stably maintained in vitro and in vivo. Furthermore, tumor cells containing a HAC carrying the suicide gene, herpes simplex virus thymidine kinase (HSV-TK), were selectively killed by ganciclovir in vitro and in vivo. Thus, this novel HAC vector may be useful not only for gene and cell therapy, but also for animal transgenesis.

Temporary scaphotrapezoidal joint fixation for adolescent Kienböck's disease

PURPOSE

There are few therapeutic guidelines for adolescent Kienböck's disease. The purpose of our study was to investigate the clinical and radiographic outcomes of temporary scaphotrapezoidal (ST) joint fixation for adolescent Kienböck's disease.

METHODS

This was a retrospective review of 6 adolescent patients with Kienböck's disease treated by temporary ST joint fixation. All patients had pain with rest and activity before surgery. The mean patient age at the time of surgery was 14 years, and final follow-up examination was at a mean of 23 months. Under general anesthesia, 2 or 3 K-wires were inserted from the dorsal trapezoid to the scaphoid. The wires were removed at 3 to 6 months.

RESULTS

Mean postoperative wrist extension and flexion were increased from 46 degrees and 48 degrees to 68 degrees and 77 degrees , respectively. These improvements were statistically significant compared with preoperative wrist extension and flexion. Grip strength significantly increased from 52% to 86% of the unaffected side. None of the 6 patients had postoperative pain either at rest or with activity. On final follow-up wrist x-ray films, none of the patients had sclerotic change or fragmentation of the lunate, although decreased lunate height remained in all patients. Magnetic resonance imaging revealed improvement to nearly normal intensity of the lunate on T1- and T2-weighted images in all patients.

CONCLUSIONS

Both clinical and radiographic outcomes of temporary ST joint fixation for adolescent Kienböck's disease were excellent. We therefore recommend this procedure for the surgical treatment of adolescent Kienböck's disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical outcome of extrasynovial steroid injection for trigger finger

A prospective clinical study was performed to investigate the clinical results of extrasynovial (subcutaneous) steroid injection for trigger finger. One hundred and twenty-nine trigger fingers were investigated in 100 adult patients; 76 were women and 24 were men. Their mean age was 60 years (range: 17 to 88 years). We classified trigger fingers into three different grades according to clinical severity at a medical examination. All patients were injected with betamethasone mixed with lidocaine. Surgical release of the A1 pulley was performed at the patients' request if steroid injection therapy was not effective. Pain and snapping were relieved in 98% and 74% of cases, respectively. Recurrence occurred in about half our patients, but the same clinical benefit was obtained after re-injection. Surgery was performed for seven fingers. No complications of steroid injections were observed. This study suggests that extrasynovial steroid injection is a valuable conservative treatment for trigger finger and it is not necessary to try and inject into the tendon sheath to get a good result and markedly reduce the risk of causing damage to tendons and other structures.

Volar dislocation of the extensor carpi ulnaris tendon on magnetic resonance imaging is associated with extensor digitorum communis tendon rupture in rheumatoid wrists

PURPOSE

Extensor tendon rupture in rheumatoid wrists is a common problem and causes immediate dysfunction of the digits. The best treatment for tendon rupture may be prophylactic management, although the factors associated with tendon rupture must first be identified. The purpose of this study was to evaluate structures around rheumatoid wrists using magnetic resonance imaging with forearm rotation and to identify factors associated with extensor tendon rupture as indications for prophylactic surgery.

METHODS

The subjects were 34 patients (40 wrists) with active rheumatoid arthritis. The extensor digitorum communis (EDC) tendons were ruptured in 15 wrists. Magnetic resonance imaging of the wrists was performed in maximally pronated and supinated positions of the forearm. Axial images of the distal radioulnar joints (DRUJs) were selected to evaluate DRUJ synovitis, dorsal tenosynovitis, volar dislocation of the extensor carpi ulnaris (ECU) tendon, sigmoid notch angle, and the radioulnar ratio (RUR) (ie, the degree of DRUJ subluxation).

RESULTS

No significant correlations were found between EDC tendon rupture and DRUJ synovitis, dorsal tenosynovitis, or RUR in pronation. Extensor digitorum communis tendon rupture correlated significantly with volar ECU tendon dislocation, sigmoid notch angle, and RUR in supination. Radioulnar ratio correlated significantly with volar ECU tendon dislocation only in supination and not in pronation. Thus, DRUJ subluxation was advanced even in the supinated wrist with volar ECU tendon dislocation. As a factor associated with EDC tendon rupture, volar ECU tendon dislocation had 87% sensitivity and 76% specificity.

CONCLUSIONS

Volar ECU tendon dislocation is associated with increased RUR in supination and EDC tendon rupture. Volar ECU tendon dislocation can thus be considered a factor associated with EDC tendon rupture, and its presence may indicate the need for prophylactic surgical intervention in a subset of rheumatoid arthritis patients.

Time course of magnetic resonance images in an adolescent patient with Kienböck's disease treated by temporary scaphotrapezoidal joint fixation: a case report

Kienböck's disease in a 15-year-old girl was treated successfully by temporary scaphotrapezoidal joint fixation using longitudinal K-wires. Repeated magnetic resonance imaging begun 3 months after surgery showed progressive increases in signal intensity on T1-weighted sequences of the lunate and was almost normal 6 months after surgery. The K-wires used for the temporary joint fixation were removed 6 months after surgery. The signal intensity of the lunate on magnetic resonance images remained normal 2 years after surgery. At that time plain x-ray showed no sign of lunate sclerosis and there was no cystic shadow or sign of advanced collapse. At 2 years after surgery the patient does not complain of wrist pain, can lead a normal daily life, and plays sports without difficulty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

A case of toe macrodactyly treated by application of a vascularised nail graft

Macrodactyly is a relatively rare congenital abnormality of the fingers and toes and is difficult to treat. We report a new method for treating toe macrodactyly in which a nail with a vascularised pedicle is raised, the toe is shortened to an appropriate length, and the nail transferred to an aesthetically appropriate proximal site. Although this technique is of a higher level of difficulty than conventional procedures involving pedicled nail flaps, allows aesthetically more favourable nail reconstruction by single-stage operation.

Palmar plating system for Colles' fractures--a preliminary report

PURPOSE

To present our results of the palmar plating system that we developed for the treatment of Colles' fractures.

METHODS

By using the palmar plating system that we developed a consecutive series of 40 acute Colles' fractures were treated surgically. There were 12 men and 28 women with a mean age of 57 years at the time of the injury (range, 25-90 y). All patients had internal fixation using the trans-flexor carpi radialis tendon approach. The system has 3 main features. First, the plate is small in size, being 1.1 mm in thickness and 47 mm in length. Only a 3- to 4-cm skin incision is required for application of the plate. Second, the screw is cannulated and cancellous in type, with a low-profile head. Subchondral screw fixation is achieved both easily and safely by using a guidewire. Third, the plate has a window through which injectable bone cement can be placed.

RESULTS

Union was achieved in all patients. The palmar tilt, radial inclination, radial length, and ulnar variance were maintained after surgery. According to the Gartland and Werley rating scale that was modified by Sarmiento there were 12 excellent and 28 good results. There were no extensor tendon injuries that could occur when the dorsal approach was used.

CONCLUSIONS

This palmar plating system can make fixation of the distal radius easy, safe, and effective in the treatment of unstable Colles' fractures.

Ulnar focal cortical indentation: a previously unrecognised form of ulnar dysplasia

Deformity of the forearm due to growth disturbance of the ulna occurs in a number of conditions such as ulnar deficiency, multiple exostoses, and neurofibromatosis. We report a previously unrecognised form, caused by focal cortical indentation. We have treated five children with this condition, three girls and two boys; the mean age at presentation was 5 years (2 to 8). The deformity was first recognised about the age of two years, and progressed gradually. The radiological findings were the same in all cases. The focal cortical indentation was seen at the distal end of the ulna with anteromedial bowing and dysplasia. The radial head was dislocated posterolaterally. In one patient the histological findings at the site of indentation were of a fold of tissue resembling periosteum, which interfered with enchondral ossification. Treatment by ulnar lengthening using an external fixator and osteotomy which corrected both the ulnar deformity and reduced the dislocated radial head in two cases gave the best results.

Anatomic variation--a bony canal for the median nerve at the distal humerus: a case report

We report a rare anatomic variation in which the median nerve travels in a bony canal of the distal humerus, separating from the brachial artery. We encountered this during neurolysis for posttraumatic median nerve palsy in a 10-year-old boy. We suggest that this anatomic variation was related strongly to this patient's median nerve palsy.

Glomangioma arising from the superficial palmar arch in the hand: case report

A patient presented with a glomangioma that presented as an aneurysm of the superficial palmar arch. Throbbing pain, tenderness over the tumor, and cold intolerance were clinical features. Cold intolerance was the major problem. The pathologic diagnosis was glomangioma. Excision of the tumor provided a good result and there has been no recurrence.

Palmar plating with calcium phosphate bone cement for unstable Colles' fractures

A prospective study was done in 20 patients with unstable Colles' fractures with metaphyseal bone defects and who were treated with palmar plating combined with injectable calcium phosphate bone cement. The patients were three men and 17 women with a mean age of 69 years (range, 65-86 years) at the time of the injury. The followup after the operation ranged from 6 to 24 months (mean, 12 months). Union was gained in all the patients. The records of radiographic parameters, including the palmar tilting angle, radial inclination, radial length, and ulnar variance had been maintained since the surgery. According to the rating scale of Gartland and Werley, 16 patients had excellent results and four had good results. There were no neurovascular and tendon injuries as complications.

Intra-articular corrective osteotomy for the malunited intercondylar humeral fracture: a case report

A 35-year-old patient sustained comminuted intercondylar fracture of the distal humerus. At six months post-open reduction and internal fixation, the malunion was corrected with an intra-articular osteotomy. The patient obtained a painless, functional elbow joint with increased grip strength after corrective osteotomy, although she had complained of severe elbow pain, limited range of motion, and loss of grip strength before osteotomy. A 15 degrees cubitus varus deformity was also corrected . Radiographs of the elbow joint did not show accelerated degenerative changes at over three years follow-up post-corrective osteotomy. Intra-articular corrective osteotomy should be considered as a salvage procedure for the treatment of a malunited intercondylar humeral fracture, especially in patients who are thought to be too young for elbow arthroplasty.

Palmar plating for dorsally displaced fractures of the distal radius

Extensor tendon rupture and irritation caused by implants or surgical intervention are serious complications in the treatment of fracture of the distal radius when a dorsal approach is used. To prevent complications, the dorsally displaced fracture of the distal radius was treated using a palmar approach. The subjects were 18 men and 15 women with a mean age of 54 years at the time of the injury (range, 23-75 years). All the patients had internal fixation with a plate and screws using the palmar approach. Union was achieved in all patients. Radiographic parameters, including the palmar tilt, radial inclination, radial length, and ulnar variance have been maintained since the operation. According to the rating scale of Gartland and Werley, there were 12 excellent, 20 good, and one fair result. There were no extensor tendon injuries that occurred during use of the palmar approach in this small series of patients. Palmar plating can be safe and effective for treatment of a dorsally displaced fracture of the distal radius.

Cerebral fat embolism after a nondisplaced tibial fracture: case report

Fat embolism syndrome has been observed after traumatic or nontraumatic events. In traumatic cases, fat embolism syndrome is known to occur in patients with a fracture of a long bone. The case of a patient with a cerebral fat embolism associated with a nondisplaced fracture of the tibial shaft is reported.

Palmar lunate transscaphoid fracture-dislocation caused by palmar flexion injury

The authors report a rare case of palmar lunate transscaphoid fracture-dislocation resulting from a palmar flexion injury. After performing an open reduction of the lunate, they used a dorsal approach to fix the fractured scaphoid with a Herbert screw. A Kirschner wire fixation was also performed to stabilize the lunotriquetral joint.

Chondroma within the flexor tendon sheath of the index finger: case report

Chondroma of soft tissue is rare. We report a patient in whom a chondroma occurred within the flexor tendon sheath of the index finger. Magnetic resonance imaging showed the extent of the tumor, which wrapped around flexor tendons within the sheath, but did not invade either tendons or sheath. Total excision was done with preservation of the flexors and flexor tendon sheath. After the operation, the index finger had a full range of motion, and movement was painless.

Correction of dorsi-flexed intercalated segment instability after restoration of scaphoid height in a cadaver model of scaphoid non-union

Models of scaphoid non-union with static dorsi-flexed intercalated segment instability were produced in five frozen arms from cadavers or subjects following accidents by repetitive mechanical loading of the wrist joints longitudinally after a bone defect has been made at the mid-portion of the scaphoid. We designed four models of reduction: anatomical reduction; reduction with a shortened scaphoid; anatomical reduction but with the radio-lunate ligament sectioned, and a shortened scaphoid with the radio-lunate ligament sectioned. Results suggested that anatomical reduction with rigid fixation with a Herbert screw was most effective for correction of malalignment with DISI. Preservation of the radio-lunate ligament during the palmar approach to the scaphoid seemed to be important to prevent ligamentous carpal instability.

Cineradiographic study of wrist motion after fracture of the distal radius

Residual dorsal tilt is one of the main deformative factors in the malunion of fractures of the distal radius. We investigated the effect of such tilt on the range of wrist motion and on carpal alignment in a cineradiographic study of wrist motion in 30 patients with extra-articular Colles' fracture. With increased dorsal tilt, the range of wrist motion became more restricted and abnormalities of carpal alignment during wrist motion became apparent. When the dorsal tilt was less than 10 degrees, the effects on the range of motion and on the dynamic carpal alignment were small.

Pressure distribution in the radiocarpal joint measured with a densitometer designed for pressure-sensitive film

To measure the pressure distribution in the radiocarpal joint, a biomechanical study was done with fresh cadavers and pressure-sensitive film. With a load of 100 newtons, the contact locations were identified for 27 different wrist positions and the peak articular pressures and contact area were measured. Normal wrists were studied first, then modified to show different ulnar variances, and then to be models of malunited Colles' fractures of increasing severity. The contact locations of the scaphoid and the lunate were separate, and the mean peak articular pressures were 2.8 and 2.7 megapascals, respectively, for the normal wrists. In the radiolunate articulation, this mean increased by 27% with 2.5 mm ulnar minus variance and decreased by 22% with 2.5 mm ulnar plus variance. In the models of malunited Colles' fracture, the contact locations shifted from volar to dorsal, and the contact area decreased as the deformity became worse.