Detection of Local Recurrence in Patients with Head and Neck Squamous Cell Carcinoma Using Voxel-Based Color Maps of Initial and Final Area under the Curve Values Derived from DCE-MRI

BACKGROUND AND PURPOSE

Early detection of local recurrence is important to increase the chance of cure because local recurrence is the main cause of treatment failure in head and neck squamous cell carcinoma. We evaluated the added value of voxel-based color maps of dynamic contrast-enhanced MR imaging compared with conventional MR imaging alone for detecting local recurrence of head and neck squamous cell carcinoma.

MATERIALS AND METHODS

We retrospectively enrolled 63 consecutive patients with head and neck squamous cell carcinoma after definitive treatment and posttreatment surveillance MR imaging studies that demonstrated focal enhancement at the primary site. Three independent readers assessed conventional MR imaging and a pair of color maps of initial and final 90-second time-signal intensity areas under the curve from dynamic contrast-enhanced MR imaging. The sensitivities, specificities, and accuracies of both conventional MR imaging alone and combined interpretation of conventional and dynamic contrast-enhanced MR imaging were assessed using the clinicopathologic diagnosis as the criterion standard. κ statistics were used to evaluate interreader agreement.

RESULTS

There were 28 patients with subsequently documented local recurrence and 35 with posttreatment change. Adding dynamic contrast-enhanced MR imaging to conventional MR imaging significantly increased the diagnostic accuracies for detecting local recurrence (48%-54% versus 87%-91%; P < .05), with excellent interreader agreement (κ = 0.8; 95% CI, 0.67-0.92 to κ = 0.81; 95% CI, 0.69-0.93). By all 3 readers, the specificities were also significantly improved by adding dynamic contrast-enhanced MR imaging to conventional MR imaging (22%-43% versus 87%-91%; P < .001) without sacrificing the sensitivities (68%-82% versus 86%-89%; P > .05).

CONCLUSIONS

Adding voxel-based color maps of initial and final 90-second time-signal intensity areas under the curve from dynamic contrast-enhanced MR imaging to conventional MR imaging increases the diagnostic accuracy to detect local recurrence in head and neck squamous cell carcinoma by improving the specificity without sacrificing the sensitivity.

A Scoring System for Prediction of Cervical Lymph Node Metastasis in Patients with Head and Neck Squamous Cell Carcinoma

BACKGROUND AND PURPOSE

An accurate and comprehensive assessment of lymph node metastasis in patients with head and neck squamous cell cancer is crucial in daily practice. This study constructed a predictive model with a risk scoring system based on CT characteristics of lymph nodes and tumors for patients with head and neck squamous cell carcinoma to stratify the risk of lymph node metastasis.

MATERIALS AND METHODS

Data included 476 cervical lymph nodes from 191 patients with head and neck squamous cell carcinoma from a historical cohort. We analyzed preoperative CT images of lymph nodes, including diameter, ratio of long-to-short axis diameter, necrosis, conglomeration, infiltration to adjacent soft tissue, laterality and T-stage of the primary tumor. The reference standard comprised pathologic results. Multivariable logistic regression analysis was performed to develop the risk scoring system. Internal validation was performed with 1000-iteration bootstrapping.

RESULTS

Shortest axial diameter, ratio of long-to-short axis diameter, necrosis, and T-stage were used to develop a 9-point risk scoring system. The risk of malignancy ranged from 7.3% to 99.8%, which was positively associated with increased scores. Areas under the curve of the risk scoring systems were 0.886 (95% CI, 0.881-0.920) and 0.879 (95% CI, 0.845-0.914) in internal validation. The Hosmer-Lemeshow goodness-of-fit test indicated that the risk scoring system was well-calibrated (P = .160).

CONCLUSIONS

We developed a comprehensive and simple risk scoring system using CT characteristics in patients with head and neck squamous cell carcinoma to stratify the risk of lymph node metastasis. It could facilitate decision-making in daily practice.

Peeled volume models of a whole body to enhance comprehension of anthropological bone landmarks

BACKGROUND

In physical anthropology, bone landmarks are palpated in living humans for the identification of corresponding skin landmarks and exact biometry. The purpose of this study is to help comprehend the locations and depths of representative bone landmarks all over the body.

MATERIALS AND METHODS

The sectioned images of a male cadaver's whole body were used to build a volume model, which was continuously peeled at 1 mm thicknesses to disclose 27 selected landmarks in the anterior, lateral, or posterior views.

RESULTS

The captured views of peeled volume models along with the labels of the bone landmarks were loaded to browsing software that was distributed for free. The browsing software containing the peeled volume models will enhance convenient studying of the bone landmarks.

CONCLUSIONS

With the knowledge of bone landmarks, investigators would be able to attain more accurate measurements between skin landmarks.

MR Imaging-Based Evaluations of Olfactory Bulb Atrophy in Patients with Olfactory Dysfunction

BACKGROUND AND PURPOSE

Although the olfactory bulb volume as assessed with MR imaging is known to reflect olfactory function, it is not always measured during olfactory pathway assessments in clinical settings. We aimed to evaluate the utility of visual olfactory bulb atrophy and neuropathy analyses using MR imaging in patients with olfactory dysfunction.

MATERIALS AND METHODS

Thirty-four patients who presented with subjective olfactory loss between March 2016 and February 2017 were included. Patients underwent a nasal endoscopic examination, olfactory testing with the Korean Version of the Sniffin' Sticks test, and MR imaging. All patients completed the Sino-Nasal Outcome Test and Questionnaire of Olfactory Disorders. Olfactory bulb atrophy and neuropathy were evaluated on MR images by 2 head and neck radiologists.

RESULTS

The etiology of olfactory loss was chronic rhinosinusitis with/without nasal polyps in 15 (44.1%) patients, respiratory viral infection in 7 (20.6%), trauma in 2 (5.9%), and idiopathic in 10 (29.4%) patients. Although 10 (29.4%) of the 34 patients were normosmic according to the Sniffin' Sticks test, their scores on the other tests were like those of patients who were hyposmic/anosmic according to the Sniffin' Sticks test. However, the detection rate of olfactory bulb atrophy was significantly higher in patients with hyposmia/anosmia than it was in patients with normosmia (P = .002). No difference in olfactory bulb neuropathy was identified among patients with normosmia and hyposmia/anosmia (P = .395).

CONCLUSIONS

MR imaging evaluations of olfactory bulb atrophy can be used to objectively diagnose olfactory dysfunction in patients with subjective olfactory loss.

Ethanol Ablation of Ranulas: Short-Term Follow-Up Results and Clinicoradiologic Factors for Successful Outcome

BACKGROUND AND PURPOSE

Surgical excision of an affected sublingual gland for treatment of a ranula can carry a potential of a nerve damage or postoperative complications. However, there have been little studies about effective minimally invasive therapeutic method, yet. Our aim was to evaluate the efficacy and safety of ethanol ablation of ranulas and the clinicoradiologic factors that can predict outcome.

MATERIALS AND METHODS

This retrospective study evaluated 23 patients with ranulas treated by percutaneous ethanol ablation. Treatment outcome was assessed in 20 patients followed for at least 6 months. The duration of symptoms before ethanol ablation, pretreatment volume, and parapharyngeal extension on sonography and/or CT were correlated with the outcome. The Mann-Whitney U test and Fisher exact test were used for comparison of the factors according to the outcome.

RESULTS

The study evaluated 14 males and 9 females with a median age of 26 years (range, 3-41 years). Among 20 patients who were followed for at least 6 months (median, 20 months; range, 6-73 months), 9 patients (45%) demonstrated complete disappearance of the ranulas and 11 (55%) showed an incomplete response. When the patients were divided according to the duration of symptoms before ethanol ablation, the complete response rate was significantly higher in patients with ≤12 months of symptoms (73%, 8/11) than that in others (11%, 1/9) (P = .010). Pretreatment volume and parapharyngeal extension were not significantly different between the 2 groups.

CONCLUSIONS

Ethanol ablation is a safe and noninvasive treatment technique for ranulas with a significantly better outcome in patients with ≤12 months of symptoms. Therefore, it could be considered an alternative nonsurgical approach for ranulas with recent onset of symptoms.

Improved Diagnostic Accuracy Using Arterial Phase CT for Lateral Cervical Lymph Node Metastasis from Papillary Thyroid Cancer

BACKGROUND AND PURPOSE

Contrast-enhanced CT protocols for papillary thyroid cancer are yet to be optimized. Our aim was to compare the diagnostic accuracy of arterial phase CT and delayed-phase CT protocols for lateral cervical lymph node metastasis from papillary thyroid carcinoma by using the lymph node tissue attenuation.

MATERIALS AND METHODS

This retrospective study included 327 lateral cervical lymph nodes (177 metastatic and 150 benign) from 131 patients with papillary thyroid carcinoma (107 initially diagnosed and 24 recurrences). Patients underwent CT by using 1 of 3 protocols: a 70-second (A) or a 35-second (B) delay with 100 mL of iodinated IV contrast or a 25-second delay with 75 mL of IV contrast (C). Two readers independently measured and compared lymph node tissue attenuation between metastatic and benign lymph nodes. An area under the receiver operating characteristic curve analysis was performed to differentiate metastatic and benign lymph nodes after multiple comparison correction for clustered data and was compared across the protocols.

RESULTS

The difference in mean lymph node tissue attenuation between metastatic and benign lymph nodes was maximum in protocol C (P < .001 for both readers). Protocol C showed the highest diagnostic performance (area under the receiver operating characteristic curve, 0.88-0.92) compared with protocol A (area under the receiver operating characteristic curve, 0.73-0.74, P < .001 for both readers) and B (area under the receiver operating characteristic curve, .63-0.65, P < .01 for both readers). The sensitivity, specificity, positive predictive value, and negative predictive value of lymph node tissue attenuation by using a 99-HU cutoff value were 83%-87%, 93.7%-97.9%, 95.1%-97.3%, and 81.2%-87%.

CONCLUSIONS

A combination of 25-second delay CT and 75 mL of iodinated IV contrast can improve the diagnostic accuracy for lateral lymph node metastasis from papillary thyroid carcinoma compared with a combination of a 35- or 70-second delay with 100-mL of iodinated IV contrast.

Comparison of High-Resolution MR Imaging and Digital Subtraction Angiography for the Characterization and Diagnosis of Intracranial Artery Disease

BACKGROUND AND PURPOSE

High-resolution MR imaging has recently been introduced as a promising diagnostic modality in intracranial artery disease. Our aim was to compare high-resolution MR imaging with digital subtraction angiography for the characterization and diagnosis of various intracranial artery diseases.

MATERIALS AND METHODS

Thirty-seven patients who had undergone both high-resolution MR imaging and DSA for intracranial artery disease were enrolled in our study (August 2011 to April 2014). The time interval between the high-resolution MR imaging and DSA was within 1 month. The degree of stenosis and the minimal luminal diameter were independently measured by 2 observers in both DSA and high-resolution MR imaging, and the results were compared. Two observers independently diagnosed intracranial artery diseases on DSA and high-resolution MR imaging. The time interval between the diagnoses on DSA and high-resolution MR imaging was 2 weeks. Interobserver diagnostic agreement for each technique and intermodality diagnostic agreement for each observer were acquired.

RESULTS

High-resolution MR imaging showed moderate-to-excellent agreement (interclass correlation coefficient = 0.892-0.949; κ = 0.548-0.614) and significant correlations (R = 0.766-892) with DSA on the degree of stenosis and minimal luminal diameter. The interobserver diagnostic agreement was good for DSA (κ = 0.643) and excellent for high-resolution MR imaging (κ = 0.818). The intermodality diagnostic agreement was good (κ = 0.704) for observer 1 and moderate (κ = 0.579) for observer 2, respectively.

CONCLUSIONS

High-resolution MR imaging may be an imaging method comparable with DSA for the characterization and diagnosis of various intracranial artery diseases.

Isolated Ischemic Contracture of the Mobile Wad: A Report of Two Cases

Two children with isolated ischaemic contractures of the mobile wad (extensor carpi radialis longus, extensor carpi radialis brevis and brachioradialis), which developed after treatment of a supracondylar fracture, are presented. Z-lengthening of the extensor carpi radialis longus and brevis tendons improved wrist flexion.

Segmentation and surface reconstruction of a cadaver heart on Mimics software

The Visible Korean research team used Mimics software (Materialise, Leuven, Belgium) for the segmentation and subsequent surface reconstruction of heart structures using information obtained from sectioned images of a cadaver. Twenty-six heart components were outlined in advance on Photoshop (Adobe Systems, San Jose, CA, USA). By use of the Mimics, the outlined images were then browsed along with the vertical planes as well as the 3-dimensional surface models, which were immediately built by piling the images. Erroneous delineation was readily detected and revised until satisfactory heart models were acquired. The surface models and the selected sectioned images in horizontal, coronal, and sagittal planes were inputted into a PDF file, where any combinations of reconstructed constituents could be displayed and rotated by the user. Mimics software accelerated the segmentation and surface reconstruction of heart anatomical structures. Similar benefits hopefully result from various serial images of other organs. The PDF file, and plane and stereoscopic image data are being distributed to others, and should prove valuable for medical students and clinicians.

Abstract P2-10-39: Does E-cadherin or N-cadherin or epithelial-mesenchymal transition have a probability of clinical implication of the prognostic marker in invasive ductal carcinoma?

Purpose: Epithelial to mesenchymal transition (EMT) is widely accepted hypothesis of progression and metastasis in carcinoma. EMT can be explained as a loss of epithelial features and gain of mesenchymal properties, and in the same manner, it can be characterized by down-regulation of epithelial cellular markers, such as E-cadherin (EC) and up-regulation of mesenchymal cellular markers, such as N-cadherin (NC). Breast cancer has a diverse clinical spectrum, treatments and prognosis according to clinicopathologic characteristics and immunohistochemical features. Identifying the presence of EMT also would be able to predict the prognosis and design better and customized therapy. Our objective was to evaluate expression of the EC/NC and EMT and correlation between EMT and clinicopathologic, immunohistochemical features and to investigate clinical implication of the EC/NC and EMT as prognostic marker in breast cancer.

Methods: Using the clinicopathologic data of 480 patients who underwent operation for invasive ductal carcinoma (IDC) during February 2001 to December 2008. 282 patients with good quality of paraffin embedded tissue block were selected. The ER and PR immunohistochemistry was scored using the Allred Score. EC and NC expression were classified on the basis of intensity of immunohistochemistry staining. The gain of a mesenchymal marker or loss of an epithelial marker was interpreted as EMT-positive. In this study, breast cancer was classified into four types according to the immunohistochemical expression of ER, PR and HER2 expression on immunohistochemical analysis and/or with HER2 gene by FISH analysis: luminal A, luminal B, HER2-enriched, and triple negative type.

Results: Median follow-up period was 52.6 months (range 1–113) and median age was 49 years (range 27–79). Of total 282 cases, 152 (53.9%) cases were classified as luminal A, 32 (11.3%) classified as luminal B, 43 (15.2%) cases were HER2-enriched and 55 (19.5%) cases were triple negative type. Expression of a mesenchymal marker, NC was observed in 22 (7.8%) patients and loss of an epithelial marker, EC was observed in 57 (20.2%) cases. A total of 75 (26.6%) were interpreted as EMT-positive. NC score was associated with HER2-enriched, and triple negative molecular subtype (P = 0.0234). NC status was associated with HER2 positive status (P = 0.0456) and HER2-enriched, triple negative molecular subtype (P = 0.0029). EMT correlated with ER negative status (P = 0.0199). T stage (P &lt; 0.001), N stage (P &lt; 0.001) and TNM stage (P &lt; 0.001) and ER (P = 0.0403) and PR (P = 0.0041) status significantly influenced disease-free survival (DFS). Age (P = 0.0185) and T stage (P = 0.0017), N stage (P &lt; 0.001) and ER (P = 0.0048), and PR status (P = 0.0072), molecular subtype (P = 0.0372), significantly influenced overall survival (OS). The status of the EC/NC and EMT did not significantly affect DFS or OS.

Conclusion: NC status was associated with HER2 positive status and HER2-enriched, triple negative molecular subtype. And EMT correlated with ER negative status. EC/NC and EMT status have relevance to a specific molecular subtype or a probability of clinical implication of the poor prognostic marker in breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-39.

Vitamin D levels in post-menopausal Korean women with a distal radius fracture

INTRODUCTION

The purpose of this study was to investigate serum levels of vitamin D in post-menopausal Korean women with a distal radius fracture (DRF) and to determine if there is any association between vitamin D levels and bone-related variables such as bone mineral densities (BMDs), serum parathyroid hormone (PTH) levels and several bone turnover markers.

MATERIALS AND METHODS

The data of 104 postmenopausal women surgically treated for a distal radius fracture (DRF group) and 107 age-matched control patients without a fracture (control group) were compared. Serum vitamin D levels (25-hydroxycholecalciferol, 25(OH)D(3)) were compared between the groups with consideration of age and seasonal variations. BMDs, serum PTH and several bone turnover markers, including serum osteocalcin, C-telopeptide and urine N-telopeptide, were measured and analysed to find any association with vitamin D levels.

RESULTS

The mean 25(OH)D(3) level was significantly lower in the DRF group compared to the control group (p < 0.001). In particular, patients in their sixth and seventh deciles in the DRF group had significantly lower 25(OH)D(3) levels than patients in the control group (p = 0.001 and 0.013, respectively). When seasonal variation was considered, significant differences of 25(OH)D(3) levels were found between the groups in autumn and winter. Hip BMDs were significantly lower in the DRF group than in the control group, and there was a positive correlation between serum 25(OH)D(3) levels and hip BMDs. Bone turnover markers were not significantly different between the two groups, although serum PTH levels were marginally higher in the DRF group (p = 0.08).

CONCLUSIONS

Post-menopausal Korean women with a DRF were found to have significantly lower serum vitamin D levels than the control group, and vitamin D levels were particularly lower in women in their sixth and seventh deciles who may be a good target group for prevention of future fractures. Future investigation should focus on determining whether vitamin D supplementation can be helpful in preventing future fractures in patients with a DRF.

Comparative rapid onset of efficacy between doxazosin gastrointestinal therapeutic system and tamsulosin in patients with lower urinary tract symptoms from benign prostatic hyperplasia: a multicentre, prospective, randomised study

AIMS

To compare the rapidity of improvement in lower urinary tract symptoms (LUTS) for the doxazosin gastrointestinal therapeutic system (GITS) and tamsulosin in benign prostatic hyperplasia (BPH) patients.

METHODS

A total of 207 patients were randomised to one of two groups for a 12-week daily treatment with doxazosin-GITS 4 mg or tamsulosin 0.2 mg. The primary end-point was to compare the early onsets of efficacy between the two drugs. This was assessed by analysing the changes from baseline in the total International Prostate Symptom Score (IPSS) in the early period of treatment. Secondary aims were to compare improvements in obstructive/irritative subscore and quality of life (QoL) score between the two groups, and to evaluate the adverse events (AEs) with the drugs.

RESULTS

After 12 weeks of treatment, both groups showed significant improvements in IPSS scores (total, obstructive and irritative subscores, QoL score) from baseline (p < 0.0001). However, the doxazosin-GITS group showed significantly greater improvements in total IPSS and obstructive subscore than the tamsulosin group in the early period (p < 0.05). Improvements in irritative subscore (within 4 weeks) and QoL score (during 12 weeks) were not significantly different between the groups. The incidences of AEs were similar between the groups.

CONCLUSION

In this study, doxazosin-GITS showed significantly more rapid onset of efficacy and similar AEs compared with tamsulosin in BPH patients with LUTS. We believe this will probably improve patient compliance. Future studies with a larger number of patients and a longer follow-up period will be required to confirm this.

Congenital differences of the upper extremity: classification and treatment principles

For hand surgeons, the treatment of children with congenital differences of the upper extremity is challenging because of the diverse spectrum of conditions encountered, but the task is also rewarding because it provides surgeons with the opportunity to impact a child's growth and development. An ideal classification of congenital differences of the upper extremity would reflect the full spectrum of morphologic abnormalities and encompass etiology, a guide to treatment, and provide prognoses. In this report, I review current classification systems and discuss their contradictions and limitations. In addition, I present a modified classification system and provide treatment principles. As our understanding of the etiology of congenital differences of the upper extremity increases and as experience of treating difficult cases accumulates, even an ideal classification system and optimal treatment strategies will undoubtedly continue to evolve.

Patients' preferred and retrospectively perceived levels of involvement during decision-making regarding carpal tunnel release

BACKGROUND

Patient-centered care requires physicians to respond to patients' preferences, including their preferences regarding treatment decision-making. The authors surveyed patients to determine their preoperative preferences and their retrospectively perceived levels of involvement in decision-making for carpal tunnel release, and they attempted to identify factors that affect patient preferences and experiences.

METHODS

Seventy-eight patients who underwent carpal tunnel release for carpal tunnel syndrome were requested to indicate their preferred level of involvement preoperatively and to assess their actual levels of involvement postoperatively, using a Control Preferences Scale containing five levels that range from fully active to fully passive. Clinical and demographic factors that potentially affected patients' preoperative preferences and postoperative assessments of levels of involvement were analyzed.

RESULTS

Fifty-nine patients (76%) indicated preoperatively that they preferred shared decision-making, and sixty-six (85%) thought postoperatively that they had experienced this type of decision-making. The correlation between preoperative and postoperative Control Preferences Scale assessments was significant (r = 0.525, p &lt; 0.001). A history of a surgical procedure was independently associated with a preoperative preference for a more active role (odds ratio = 4.2), and patients with a caregiver (odds ratio = 4.0) or private insurance (odds ratio = 2.6) were more likely to experience an active role. Patients who preferred a collaborative role had lower scores on the Disabilities of the Arm, Shoulder and Hand questionnaire than those who preferred a fully active role (p = 0.002) or a fully passive role (p = 0.009).

CONCLUSIONS

The majority of patients with carpal tunnel syndrome preferred to share surgical decision-making with the surgeon, and those who preferred a collaborative role had less severe symptoms than those who preferred a fully active or a fully passive role. A history of a surgical procedure, having a caregiver, and having private insurance were associated with a more active role. This information may assist the establishment of patient-centered consultation in patients with carpal tunnel syndrome.

Responsiveness of the Korean version of the disabilities of the arm, shoulder and hand questionnaire (K-DASH) after carpal tunnel release

BACKGROUND

The Korean version of the Disability of the Arm, Shoulder and Hand Questionnaire (K-DASH) was recently validated, but its responsiveness, which is the degree to which an instrument is sensitive to change, has not been thoroughly evaluated in a specific condition in Koreans. We evaluated the responsiveness of the K-DASH in a homogenous cohort of patients with carpal tunnel syndrome (CTS) and we compared it with that of the disease-specific Carpal Tunnel Questionnaire (CTQ).

METHODS

Fifty-six patients with CTS prospectively completed the K-DASH and CTQ before and 6 months after surgery. The responsiveness statistics were assessed for both the K-DASH and CTQ by using the standardized response mean (SRM) and the effect size (ES). Pearson correlation coefficients were calculated between the K-DASH and CTQ.

RESULTS

The SRM and ES of the K-DASH were all 0.8. The SRM of the symptom and function part of the CTQ was 1.5 and 1.1, and the ES was 1.5 and 1.1, respectively. The K-DASH had moderate correlations with the symptom and function parts of the CTQs, but the postoperative K-DASH had a weak correlation with the symptom part of the postoperative CTQ.

CONCLUSIONS

The K-DASH was found to have a large degree of responsiveness (SRM, ES ≥ 0.8) after carpal tunnel release in Korean patients with CTS, which is comparable to the other language versions of the DASH. Although it was less responsive than the CTQ, which is disease-specific, the region-specific K-DASH can be used as an effective outcome measurement tool for CTS, and especially for research that compares CTS with other upper limb conditions.

Cleft hand in Kabuki make-up syndrome: case report

Kabuki make-up syndrome (KMS) is a multiple malformation/mental retardation syndrome that was first described in Japan but is now reported in many other ethnic groups. Kabuki make-up syndrome is characterized by multiple congenital abnormalities: craniofacial, skeletal, and dermatoglyphic abnormalities; mental retardation; and short stature. Common hand anomalies associated with KMS include persistent fingertip pad, brachydactyly, clinodactyly, and lax joints. We report a patient with KMS who presented with cleft hand, a feature that has not yet been described in KMS, and describe the potential genetic cause.

The effect of muscle excursion on muscle recovery after tendon repair in a neglected tendon injury: a study in rabbit soleus muscles

We attempted to determine whether muscle excursion observed during operation can be a prognostic indicator of muscle recovery after delayed tendon repair in a rabbit soleus model. Eighteen rabbits underwent tenotomy of the soleus muscles bilaterally and were divided into three groups according to the period from tenotomy to repair. The tendons of each group were repaired 2, 4, and 6 weeks after tenotomy. The excursion of each soleus muscle was measured at the time of tenotomy (baseline), at 2, 4, 6 weeks after tenotomy, and 8 weeks after tendon repair. The amount of muscle recovery after tendon repair in terms of muscle excursion independently depended on the timing of repair and on the muscle excursion observed during repair. The regression model predicted that the muscle excursion recovered on average by 0.6% as the muscle excursion at the time of repair increased by 1% after adjusting for the timing of repair. This study suggests that measuring the muscle excursion during tendon repair may help physicians estimate the potential of muscle recovery in cases of delayed tendon repair.

Incidence of clinically diagnosed and surgically treated carpal tunnel syndrome in Korea

PURPOSE

Most epidemiologic studies on carpal tunnel syndrome (CTS) have been performed on specific regional or occupational groups, or on general populations in the West. The authors undertook to determine the incidence of clinically diagnosed and surgically treated CTS in the Korean general population.

METHODS

A retrospective, nationwide cohort study was performed using data collected from 2005 to 2007 (inclusive) by the Korean Health Insurance Review Agency, which covers 97% of the population. We analyzed the incidence of clinically diagnosed, electrophysiologically diagnosed, and surgically treated CTS in patients aged over 20 years, and the influences of gender and age on incidence.

RESULTS

The incidence of total clinically diagnosed CTS and electrophysiologically diagnosed CTS in patients over 20 years of age was 4.96 and 0.98 per 1,000 person-years, respectively. The incidence of surgically treated CTS was 0.29 per 1,000 person-years. The age-adjusted female to male incidence ratio of diagnosed CTS was 2.58 (95% confidence interval, 2.56-2.59) and that of surgically treated CTS was 5.82 (95% CI, 5.64-6.00). Women aged 50 to 59 years had the highest incidence of CTS (18.11 per 1,000 person-years), whereas men showed a slow increase in incidence with age, highest at 60 to 69 years.

CONCLUSIONS

Compared with Western studies, our study of the Korean population shows a similar incidence of CTS but a lower incidence of surgery. Korean women with CTS are more likely to be treated surgically than men. Further studies may be warranted to identify ethnic, gender, and socioeconomic factors that influence surgical treatment rates.

Failure of the interosseous membrane to heal with immobilization, pinning of the distal radioulnar joint, and bipolar radial head replacement in a case of Essex-Lopresti injury: case report

The authors report a case of a patient with complex radial head and ulnar shaft fractures with an associated tear of the interosseous membrane, which failed to heal despite open reduction internal fixation of the ulna, a bipolar radial head replacement, and cross pinning of the distal radioulnar joint. This case demonstrates that failure of the interosseous membrane can occur even in a properly replaced bipolar radial head with adequate immobilization of the forearm and pinning of the distal radioulnar joint.

Bone invasion by squamous cell carcinoma in situ (Bowen's disease) of the finger during treatment with imiquimod 5% cream: case report

Imiquimod 5% cream is known as an alternative treatment option for squamous cell carcinoma in situ (SCCIS), frequently termed Bowen's disease. Although imiquimod cream has been reported by many authors to treat SCCIS successfully, its efficacy and safety have not been fully established. The authors experienced a case in which ray amputation was necessary because of bone invasion by SCCIS in a finger being treated with imiquimod cream.

Solitary intra-articular osteochondroma of the finger

BACKGROUND

A solitary osteochondroma of the finger occasionally occurs intra-articularly and may cause clinical symptoms, including limited motion and deformity. The present report describes the clinical features and the results of operative treatment for a series of patients who had a solitary intra-articular osteochondroma of the finger.

METHODS

Ten patients with a solitary intra-articular osteochondroma of a phalanx of a finger were managed surgically. Eight patients were male, and two were female. The average age at the time of surgery was fourteen years. Treatment consisted of mass excision for three patients and mass excision with corrective osteotomy for six. One additional patient had a boutonniere deformity and underwent extensor tendon reconstruction combined with mass excision. The average duration of follow-up was forty-four months.

RESULTS

The proximal phalanx was affected in six patients, and the middle phalanx was affected in four. All tumors involved the distal epiphysis. All patients had postoperative improvement in terms of deformity and/or limitation of motion. Six patients had a preoperative mean coronal plane deformity of 29 degrees, which improved to 4 degrees after surgery. The preoperative mean arc of flexion-extension improved from 54 degrees to 78 degrees in four patients who had a motion deficit at the proximal interphalangeal joint and from 60 degrees to 80 degrees in one patient who had a motion deficit at the distal interphalangeal joint. Two patients had a residual flexion contracture, one with preexisting osteoarthritis and one with a longstanding progressive boutonniere deformity. There were no other complications or recurrences.

CONCLUSIONS

Isolated intra-articular osteochondroma of the finger can cause deformity and/or motion limitation. Early mass excision and corrective osteotomy when indicated are recommended to restore full range of motion and to prevent osteoarthritis and secondary deformity.

Simulations of infrared and optical rectification by geometrically asymmetric metal-vacuum-metal junctions for applications in energy conversion devices

We use a transfer-matrix methodology to simulate the rectification of infrared and optical radiation by geometrically asymmetric metal-vacuum-metal junctions in which one of the metals is flat while the other is extended by a tip. We determine in particular the power this junction could provide to an external load and the efficiency with which the energy of incident radiations is converted. We consider first situations in which the external radiation is monochromatic, with typical frequencies in the infrared and optical domains. We then consider situations in which the external radiation consists of a full range of frequencies, with amplitudes that are representative of a focused beam of solar radiation. We investigate in particular how the efficiency of the rectification is affected by the aspect ratio of the tip, the work function of the metallic elements and the occurrence of polarization resonances. Our results demonstrate that the rectification of infrared and optical radiation is possible using devices of the type considered in this work. They finally provide a quantitative analysis of the efficiency of this rectification.

Delayed-onset ulnar neuropathy at the wrist associated with distal radioulnar joint arthritis after radius malunion: report of two cases

Although ulnar neuropathy can occur at the wrist in association with distal radius fractures, few late-onset cases have been reported. The authors describe 2 cases of delayed-onset ulnar neuropathy at the wrist, which developed 12 and 30 years after sustaining a conservatively treated distal radius fracture. During late neurolysis, both patients were found to have a perforation in the volar wrist capsule and synovitis and arthritis in the distal radioulnar joint.

Functional outcomes after upper extremity surgery for cerebral palsy: comparison of high and low manual ability classification system levels

PURPOSE

The heterogeneity of cerebral palsy makes interpretation and prediction of outcome after upper extremity surgery difficult. We hypothesized that the outcome of upper extremity surgery for cerebral palsy is related to the Manual Ability Classification System (MACS) level.

METHODS

We reviewed 27 patients with a mean age of 22 years, who underwent upper extremity surgery for spastic cerebral palsy at a mean follow-up of 29 months. Patients were classified into 5 MACS levels using a standardized questionnaire completed by their primary caregivers. Preoperatively and at most recent follow-up visits, patients were assessed using the House scale and patient-reported functional outcomes on a 5-point scale. We compared the outcomes of patients with high (I-II, independence in daily activities) and low (III-V, dependence in daily activities) MACS levels.

RESULTS

The overall mean House scale improved from 2.9 to 4.6 postoperatively (p<.001), dressing ability from 3.7 to 4.2 (p=.005), hygiene from 4.2 to 4.9 (p=.005), and appearance from 2.4 to 4.2 (p<.001). A total of 13 patients had a high MACS level (7 had I and 6 had II) and 14 had a low MACS level (8 had III, 6 had IV, and none had V). The high-MACS group had a greater improvement according to the House scale (p=.009) and the low-MACS group had a larger improvement in hygiene status (p=.043). There were no differences in the amount of improvement in dressing ability (p=.169) and appearance (p=.765). Overall satisfaction with surgery was higher for the high-MACS group (p=.038).

CONCLUSIONS

The high-MACS group had a greater improvement in rating according to the House scale and higher satisfaction than the low-MACS group after upper extremity surgery for cerebral palsy in our small number of patients. This study suggests that the MACS level can be used to predict upper extremity surgery outcomes for cerebral palsy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Patients with wrist fractures are less likely to be evaluated and managed for osteoporosis

BACKGROUND

Although osteoporosis is being evaluated and treated increasingly in elderly patients with fragility fractures, some studies have suggested that physicians may be missing important opportunities, especially in patients with nonvertebral fractures. The purpose of the present study was to determine whether specialists responsible for treating fractures at various locations have different propensities for evaluating and treating osteoporosis after a fracture in female patients over the age of fifty years.

METHODS

A retrospective nationwide cohort study was performed with use of data collected during 2007 by the Korean Health Insurance Review Agency, which covers 97% of the population. The incidences of fractures around the hip, spine, and wrist in female patients more than fifty years of age and the frequencies of bone density scans for osteoporosis and the use of medications for its treatment were analyzed and compared.

RESULTS

The database identified 31,540 hip fractures, 58,291 spine fractures, and 61,234 wrist fractures in female patients who were more than fifty years of age in Korea during 2007. Of these patients, 7095 (22.5%) with a hip fracture, 16,779 (28.8%) with a spine fracture, and 5348 (8.7%) with a wrist fracture underwent diagnostic bone density scans. Furthermore, 7060 patients (22.4%) with a hip fracture, 17,551 (30.1%) with a spine fracture, and 4594 (7.5%) with a wrist fracture were managed with at least one medication approved for the treatment of osteoporosis.

CONCLUSIONS

Despite a recent increase in the recognition of osteoporosis in patients with fragility fractures, our review of this national cohort indicates that patients with a wrist fracture are less likely to be evaluated and managed for osteoporosis than those with a hip or spine fracture by physicians who are responsible for treating symptomatic fractures. Additional studies and intervention programs are necessary to improve this care gap, beginning with physicians who are responsible for fracture treatment.

Factors affecting willingness to undergo carpal tunnel release

BACKGROUND

Factors regarding patient willingness to undergo or avoid joint replacement have been studied; however, these factors have not been studied in patients with carpal tunnel syndrome. To further understand the aspects that are important for a patient with carpal tunnel syndrome in deciding whether to have surgery, we identified factors that affect this decision in women and that are not related to Workers' Compensation status.

METHODS

We retrospectively reviewed 282 female patients with electrophysiologically confirmed carpal tunnel syndrome without a known cause who were recommended for carpal tunnel release by a single hand surgeon in a tertiary medical setting. Of those, thirty-six female patients who were not entitled to Workers' Compensation canceled the operation during the waiting period, which averaged four weeks. Thirty-three of them were surveyed with a questionnaire sent by mail, and eighteen completed surveys were reviewed at a mean follow-up of thirty-two months. Furthermore, seventy female patients who underwent carpal tunnel release were randomly sampled, and thirty-eight patients completed the survey. The operation and cancellation groups were compared with regard to the reasons for choosing or canceling surgery.

RESULTS

The groups were similar with regard to age, sociodemographic variables, follow-up length, initial electrophysiological findings, and functional status. The highest-ranked reason for choosing surgery was symptom severity rather than fear of progression or a positive electrodiagnostic result. Those who canceled the operation rated symptom improvement during the waiting period as the leading reason for doing so, but they were also concerned about transient weakness, the financial burden, and a scar or pillar pain. Disease persistence or recurrence was the issue of most concern in both groups. At the time of the final review, the functional status was significantly improved in both groups and no significant difference between the groups was detected.

CONCLUSIONS

Women with carpal tunnel syndrome report that subjective symptom severity is the most important reason for undergoing surgery. Understanding this and other patient concerns may help physicians during patient-oriented consultation and decision-making. In particular, recommendations for carpal tunnel release on the basis of symptoms are reasonable from the perspective of the patient who has carpal tunnel syndrome without a known cause.

Comparison of loop-tendon versus end-weave methods for tendon transfer or grafting in rabbits

PURPOSE

The loop-tendon method for the stabilization of tendon transfers or grafts has been demonstrated previously to have greater initial tensile strength than that of the end-weave method. To our knowledge, a comparison of the mechanical strengths of these methods over the early postoperative period has not been made. The purpose of this study was to compare the mechanical strengths of loop-tendon and end-weave methods of repair during the early postoperative period in rabbit hind limb tendons.

METHODS

In bilateral hind limbs of 30 New Zealand white rabbits of an average weight of 3.5 kg, a distally cut gastrocnemius Achilles' tendon and a proximally cut flexor digitorum superficialis tendon were connected to each other by using the loop-tendon method with 5 stitches in one limb and a 1-pass end-weave method in the contralateral limb. Postoperatively, all rabbits were immobilized by a short-leg cylinder cast. Six rabbits were killed at each of the following time points: immediately after surgery (baseline) and at 1, 2, 3, and 4 weeks postoperatively. Repaired tendons were harvested and were loaded to failure in a tensile load-testing machine to record the ultimate strength and to calculate the absorbed energy.

RESULTS

Ultimate tensile loads were significantly higher in the loop-tendon method group than in the end-weave group from baseline to 3 weeks postoperatively, but there was no difference at 4 weeks postoperatively. During the postoperative period, the ultimate tensile load and absorbed energy decreased over the first 2 weeks postoperatively and then increased to reach baseline strengths at 3 weeks postoperatively in both groups.

CONCLUSIONS

The loop-tendon method provided greater strength than that of the end-weave method during the early postoperative period in rabbit tendons. The loop-tendon method may provide greater surgical repair strength during the early postoperative rehabilitation period than the end-weave method.

Computed tomographic assessment of reduction of the distal radioulnar joint by gradual lengthening of the radius

Congruency of the distal radioulnar joint was assessed by computed tomography after gradual lengthening of the radius in patients with considerable ulnar positive variance of mean 12 (range 10-17) mm and chronic dislocation of the distal radioulnar joint. Six patients of mean age 25 years were treated by radial osteotomy and subsequent gradual lengthening using either a single-rod or a half-ring external fixator, which was applied for a mean of 81 days. The causes of deformity were distal radial epiphyseal injury in four, malunion of a radius shaft fracture in one and Madelung deformity in one. Computed tomography scans taken at 1 year postoperatively demonstrated that all patients had a congruent distal radioulnar joint. All patients achieved symptom and radiographic parameter improvements at a mean follow-up of 40 months. A disadvantage was unattractive scars on a cosmetically important surface of the forearm. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction of the distal radioulnar joint can be obtained by gradual lengthening of the radius.

Contribution of the proximal nerve stump in end-to-side nerve repair: in a rat model

Background

The aim of this study was to evaluate the contribution of the proximal nerve stump, in end-to-side nerve repair, to functional recovery, by modifying the classic end-to-side neurorrhaphy and suturing the proximal nerve stump to a donor nerve in a rat model of a severed median nerve.

Methods

Three experimental groups were studied: a modified end-to-side neurorrhaphy with suturing of the proximal nerve stump (double end-to-side neurorrhaphy, Group I), a classic end-to-side neurorrhaphy (Group II) and a control group without neurorrhaphy (Group III). Twenty weeks after surgery, grasping testing, muscle contractility testing, and histological studies were performed.

Results

The grasping strength, muscle contraction force and nerve fiber count were significantly higher in group I than in group II, and there was no evidence of nerve recovery in group III.

Conclusions

The contribution from the proximal nerve stump in double end-to-side nerve repair might improve axonal sprouting from the donor nerve and help achieve a better functional recovery in an end-to-side coaptation model.

Ulnar subluxation of a ruptured EPL tendon at the metacarpophalangeal joint: case report

We report a case of ulnar subluxation of a ruptured extensor pollicis longus tendon at the metacarpophalangeal joint due to tethering of the distal tendon and an abnormal vector of pull. In this case, thumb flexion with the tethered EPL tendon resulted in attenuation of the radial sagittal band of the extensor hood. After plication of the radial sagittal band and relocation of the EPL tendon, adequate thumb extension was restored.

Lateral calcaneal artery adipofascial flap for reconstruction of the posterior heel of the foot

BACKGROUND

Soft tissue defects of the posterior heel of the foot present difficult reconstructive problems. This paper reports the authors' early experience of five patients treated with a lateral calcaneal artery adipofascial flap.

METHODS

Between 2003 and 2007, five patients (3 males and 2 females) with soft-tissue defects over the posterior heel underwent a reconstruction using a lateral calcaneal artery adipofascial flap and a full-thickness skin graft. The flap sizes ranged from 3.5 x 2.5 cm to 5.5 x 4.0 cm.

RESULTS

All five flaps survived completely with no subsequent breakdown of the grafted skin, even after regularly wearing normal shoes. The adipofascial flap donor sites were closed primarily in all patients.

CONCLUSIONS

Lateral calcaneal artery adipofascial flaps should be included in the surgical armamentarium to cover difficult wounds of the posterior heel of the foot. These flaps do not require the sacrifice of a major artery to the leg or foot, they are relatively thin with minimal morbidity at the donor site, and leave a simple linear scar over the lateral aspect of the foot.

Clinical features influencing the patient-based outcome after carpal tunnel release

PURPOSE

We analyzed several clinical features of carpal tunnel syndrome to identify potential prognostic factors influencing a patient-based outcome assessment after carpal tunnel release.

METHODS

We evaluated 102 hands of 64 patients with carpal tunnel syndrome using the Boston self-assessment questionnaire preoperatively and 3, 6, 9, and 12 months postoperatively. The clinical findings evaluated as prognostic indicators were paresthesia, cold intolerance, subjective weakness, nocturnal pain, thenar atrophy, Tinel sign, Phalen test, and electrophysiologic grades. All assessments of outcome were subjective based on the reports of patients, and no objective measurements were obtained to establish improvement after surgery.

RESULTS

The overall symptom and functional scales of the self-assessment questionnaire demonstrated a significant improvement at 3 months after surgery, but no significant further improvement was observed thereafter. Patients with nocturnal pain, patients without subjective weakness, and patients without cold intolerance demonstrated more improvement of the scores in the bivariate analysis.

CONCLUSIONS

This information may be used in preoperative consultation regarding the outcome of surgery from the patient's perspective.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.

Complications of distraction lengthening in the hand

This study examined the features of 16 complications from 51 distraction lengthenings in the hands of 43 patients. From 1996 to 2006, 24 metacarpals and 27 phalanges were lengthened at a rate of 0.5 and 0.25 mm/day, respectively, using a callus distraction technique. The indications were congenital (33 cases in 27 patients) and traumatic (18 cases in 16 patients) deformities. The average percentage lengthening in the phalanges and metacarpals was 62% (16 mm) and 63% (34 mm), respectively. The distraction rates in the phalanges and metacarpals were 69 and 52 days/cm, respectively. The overall complication rate was 31%. Major complications requiring secondary procedures were non-union (one case), fracture (one case), premature union (one case), angulations (two cases) and dislodgment of pins (two cases). The minor complications encountered were delayed callus formation (four cases), joint stiffness (four cases) and soft tissue thinning (one case). Traumatic deformities had more complications than the congenital ones (nine of 18 cases and seven of 33 cases, respectively). The phalanges had a higher rate of complication than the metacarpals (11 of 27 cases and four of 24 cases, respectively). Most patients with complications except for two children with dislodgment were as satisfied with the final results as those without complications. Although callus distraction in the hand requires a long treatment period and has a relatively high rate of complication, it appears to be effective in achieving adequate bone length. A high level of patient compliance and prompt management of complications by an experienced surgeon are essential for achieving good results.

Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults

BACKGROUND

Plate osteosynthesis is the most commonly used technique for the treatment of diaphyseal forearm fractures in adults. However, application of a plate can disrupt the periosteal blood supply and necessitates skin incisions that may be unsightly, and there is a risk of refracture if the implant is removed. The purpose of this study was to assess the early results of the use of a contoured interlocking intramedullary nail to stabilize displaced diaphyseal fractures of the forearm.

METHODS

Between January 2004 and July 2006, a total of thirty-eight interlocking intramedullary nails were inserted into the forearms of twenty-seven adults. Eighteen nails were used in the radius and twenty were used in the ulna to stabilize a diaphyseal fracture. The mean follow-up period was seventeen months. Functional outcomes were assessed with use of the Grace and Eversmann rating system, and patient-rated outcomes were assessed by completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The average time to fracture union was fourteen weeks. There was one nonunion of an open comminuted fracture of the middle third of the ulna. There were no deep infections or radioulnar synostoses. According to the Grace and Eversmann rating system, twenty-two patients (81%) had an excellent result; three (11%), a good result; and two (7%), an acceptable result. The DASH scores averaged 15 points (range, 5 to 61 points).

CONCLUSIONS

Our experience indicates that the advantages of an interlocking intramedullary nail system for the radius and ulna are that it is technically straightforward, it allows a high rate of osseous consolidation, and it requires less surgical exposure and operative time than does plate osteosynthesis. We suggest that the interlocking intramedullary nail system be considered as an alternative to plate osteosynthesis for selected diaphyseal fractures of the forearm in adults.

The natural history of pediatric trigger thumb

BACKGROUND

Pediatric trigger thumb is a condition of flexion deformity of the interphalangeal joint in children. Although the surgical outcome is satisfactory, the indications for nonoperative treatment for this condition are not clear. The aim of the present study was to determine the rate of resolution of untreated pediatric trigger thumb.

METHODS

Data on seventy-one thumbs in fifty-three children were collected prospectively. The dates of the first visits ranged from April 1994 to March 2004. Patients were diagnosed with pediatric trigger thumb during initial outpatient department visits. During the present study, no treatment such as passive stretching or splinting was applied. The amount of flexion deformity at the thumb interphalangeal joint was measured at every six-month follow-up visit, and the duration of follow-up was at least two years after diagnosis. The end point of follow-up was when the deformity caused pain or secondary deformity or prevented normal use of the hand. The median duration of follow-up was forty-eight months.

RESULTS

Of the seventy-one trigger thumbs, forty-five (63%) resolved spontaneously. The median time from the initial visit to resolution was forty-eight months. There was no significant difference in the pattern of resolution between patients with unilateral and bilateral trigger thumb. Although resolution was not observed in the remaining twenty-six thumbs, flexion deformities improved in twenty-two thumbs. For the first two years after the initial visit, the mean flexion deformity significantly decreased over the one-year intervals (p < 0.05).

CONCLUSIONS

Pediatric trigger thumb can be expected to resolve without treatment in >60% of patients. Moreover, the flexion deformity can be expected to show an improving pattern in patients who do not have resolution. This information may help both parents and surgeons to make decisions regarding the treatment of pediatric trigger thumb.

Extensor indicis proprius transfer for the abducted small finger

PURPOSE

Persistent abduction of the small finger has usually been treated by transfer of the extensor digiti minimi muscle. However, anatomic variations of the extensor system may limit the potential for a successful extensor digiti minimi transfer. Therefore, we evaluated the outcomes of an alternative reconstruction method for the abducted small finger using an extensor indicis proprius (EIP) transfer.

METHODS

We performed 8 EIP transfers in 8 patients with persistent, flexible abduction posturing of the small finger. The primary etiology of the deformity was incomplete motor reinnervation after surgeries for ulnar neuropathy in 6 patients, rupture of the third palmar interosseous musculotendinous unit in 1 patient, and intrinsic muscle fibrosis in 1 patient. The EIP was elongated by splitting the tendinous portion and was transferred to the distal and radial part of the extensor hood. Surgical outcomes were assessed by comparing preoperative and postoperative active adduction and abduction motion of the 2 ulnar digits.

RESULTS

At the mean follow-up of 23 months, the average adduction angle improved from 19 degrees to 1 degrees postoperatively. In terms of active finger motion, 6 patients showed excellent results, 1 good, and 1 fair, without loss of flexion and extension. No patient had an extension lag or complained of functional deficits of the donor index finger. There was not adverse change to digital function or range of motion for the middle and ring fingers that are crossed by the EIP.

CONCLUSIONS

Extensor indicis proprius transfer can be a reliable option for correction of abduction deformity of the small finger, maintaining active abduction and full flexion and extension.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb. Surgical technique

BACKGROUND

The Bilhaut-Cloquet operation is a combined surgical procedure for the treatment of a symmetric bifid thumb. Although this procedure can obtain a normal-sized thumb with a stable interphalangeal joint, it has limitations, such as the technical difficulty of combining all segments of a duplicated thumb, possible later physeal growth arrest, joint stiffness, and nail plate deformity. We reviewed the results of our modification of this procedure for the treatment of Wassel type-II and III polydactyly of the thumb.

METHODS

Seven patients, two with type-II and five with type-III polydactyly of the thumb, underwent this modified Bilhaut-Cloquet procedure and were followed for an average of fifty-two months. Cosmetic and functional assessments were made.

RESULTS

All patients and parents were satisfied with the cosmetic and functional results. Compared with the preoperative motion, the postoperative range of motion of the interphalangeal joint was preserved in thumbs with type-III deformity and was increased in those with type-II deformity. No nail deformity or growth arrest occurred, and remodeling and hypertrophy of the distal phalanx occurred with time.

CONCLUSIONS

Our modification of the Bilhaut-Cloquet procedure for the treatment of type-II and III thumb polydactyly is effective in preserving interphalangeal joint motion, minimizing nail deformity, and preventing growth arrest.

Modified end-to-side neurorrhaphy enhances axonal sprouting: a motor functional and morphological study

This study evaluated the effect of modified end-to-side neurorrhaphy on functional recovery by modulating the epineurial window and contact areas, with a donor nerve, using a rat median nerve and finger flexors. Grasping testing, muscle contractility testing, and a histological study were performed 20 weeks after surgery. The modified end-to-side repair can enhance axonal sprouting from an intact nerve, and improve the functional recovery. Either the epineurial window surface area, or the contact configuration with the donor nerve is an important factors in an end-to-side coaptation model.

The effect of muscle length and excursion on muscle contracture after tendon injury: a study in rabbit soleus muscles

If tendon repair after injury is delayed, intramuscular fibrosis occurs and finally results in irreversible muscle contracture. The purpose of this study was to determine the effect of preserving muscle length and excursion on the progression of muscle contracture after tendon injury in a rabbit soleus tenotomy model. Forty rabbits underwent tenotomy of the soleus muscles bilaterally and the tendons were managed according to the five experimental groups (N=40). In group A, the tendon was lengthened maintaining half the excursion. In group B, maximal muscle length was preserved and in group C, resting muscle length was maintained. In group D, the tendon was allowed to retract and undergo fibrosis. In group E, the tendon was partially transected and repaired. Four and 8 weeks postoperatively, soleus muscles were harvested from each hind limb and histomorphometric evaluations were performed to measure the connective tissue areas. Electrophysiological studies were carried out to measure the compound muscle action potential to assess the number of functioning muscle fibres. The results showed that maximal muscle length preservation (group B) was the most protective in preventing muscle contracture within 4 weeks of tenotomy, but this effect was gradually offset by prolonged fixation of the muscle, and 8 weeks after tenotomy, maintenance of excursion (group A) was the most protective. These observations may be helpful in the intra-operative evaluation of muscle contracture in neglected tendon ruptures, and could be applied to the management of acute tendon injuries to prevent muscle contracture when immediate anatomical reconstruction is not possible.

A loop-tendon suture for tendon transfer or graft surgery

PURPOSE

We present a loop-tendon suture technique that was designed for easy tension adjustment and early postoperative rehabilitation in tendon transfer or graft surgeries. This study tested the biomechanical strength of the loop-tendon suture by using chicken flexor tendons and we report the preliminary clinical results.

METHODS

We tested the ultimate strength of the loop-tendon suture against the end-weave suture technique in chicken flexor tendons. Forty flexor digitorum longus tendons of chickens were divided into 2 groups according to the suture technique, loop-tendon suture and end-weave suture groups, and then were subjected to linear loading in a tensile load testing machine. From 2000 to 2002 we performed 27 tendon transfer surgeries clinically, including 4 interpositional tendon grafts in 15 patients, using this technique followed by immediate passive motion exercise after surgery. The mean follow-up time was 20 months.

RESULTS

The ultimate tensile load of chicken flexor tendons was 31 +/- 6 N for the loop-tendon suture group and 23 +/- 8 N for the end-weave suture group, and the difference was statistically significant. Clinically, 6 patients with an extensor indicis proprius to an extensor pollicis longus transfer showed more than good results in the Geldmacher scheme. Three patients with an extensor indicis proprius to a central tendon transfer achieved proximal interphalangeal extension of less than 15 degrees of extension lag. One patient with a flexor digitorum profundus reconstruction obtained total active motion of 210 degrees. The 5 patients with triple transfers for radial nerve palsy showed more than neutral extension of the wrist and metacarpal joint. There were no tendon ruptures.

CONCLUSIONS

The loop-tendon suture method has greater strength than the conventional end-weave technique, and can be used for secondary tendon reconstruction surgery with favorable clinical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb

BACKGROUND

The Bilhaut-Cloquet operation is a combined surgical procedure for the treatment of a symmetric bifid thumb. Although this procedure can obtain a normal-sized thumb with a stable interphalangeal joint, it has limitations, such as the technical difficulty of combining all segments of a duplicated thumb, possible later physeal growth arrest, joint stiffness, and nail-plate deformity. We reviewed the results of our modification of this procedure for the treatment of Wassel type-II and III polydactyly of the thumb.

METHODS

Seven patients, two with type-II and five with type-III polydactyly of the thumb, underwent the modified Bilhaut-Cloquet procedure and were followed for an average of fifty-two months. Cosmetic and functional assessments were made.

RESULTS

All patients and their parents were satisfied with the cosmetic and functional results. Compared with the preoperative motion, the postoperative range of motion of the interphalangeal joint was preserved in thumbs with type-III deformity and was increased in those with type-II deformity. No nail deformity or growth arrest occurred, and remodeling and hypertrophy of the distal phalanx occurred with time.

CONCLUSIONS

Our modification of the Bilhaut-Cloquet procedure for the treatment of type-II and III thumb polydactyly is effective in preserving interphalangeal joint motion, minimizing nail deformity, and preventing growth arrest.