bluuebunny/crossref_metadata_2025 huggingface dataset:
Osteotomy of Malunited Metacarpals and Phalanges in Pediatric Patients
Authors: Kebrle Radek , Schmoranzova Alena
Published: September 2016

Objectives: Malunion of the phalanges and metacarpals in the hand cause malposition, pain, and functional impairment that can be treated by osteotomy of malunited bone. Posttraumatic malunion in pediatric hand is a rare condition. Growing bone and its small size need “special” approach to the problem. Procedure must preserve growing ability, osteosynthetic material must be fine, and postoperative care has to be aimed not only on deformity correction but also on preserving range of motion. Authors present group of 12 pediatric patients treated by osteotomy of the phalanx or metacarpal. They describe specifics of the technique used, present results, and discuss complications. Patient and Methods: Thirteen osteotomies in 12 patients with “virgin“—nonoperated posttraumatic malunion of phalanges and metacarpals were performed by senior author between 2001 and 2014. Four intraarticular corrections and 7 extraarticular corrections were used for various malunions. Authors used different approaches to reflect bone from dorsal, dorsolateral or lateral side, according to type of deformity and type of osteotomy. Eight cases were corrections of proximal phalanx in proximal interphalangeal joint region, 2 at the base of proximal falanx, 1 at the base of middle phalanx, 1 at the head of middle phalanx and 1 at the base of first metacarpal. One patient was treated by sequential osteotomy repeated after 3 years due to growth disturbance at the base of middle phalanx. In 3 patients bone graft from distal radius was used to fill the gap in open wedge osteotomy. Removal of osteosynthetic material was performed in 4 cases. In 3 patients and 4 osteotomies no osteosynthetic material was used. All patients had a cast for 1 to 2 weeks after surgery followed by protected mobilization until x-ray healing of the bone. Results: All patients healed uneventfully. Deformity was fully reconstructed in 9 patients and 3 had some residual deformity with functionally and aesthetically much better result. Range of motion was preserved or reconstructed in all. Functional impairments like triggering or scissoring of the fingers were relieved. Pain subsided to zero in all. Discussion: Symptomatic malunion in fingers and metacarpals causing functional impairment is indicated to surgical treatment and osteotomy of malunited bone. Soft tissue coverage and small size of the bone put great requirements to the operating surgeon due to risk of breakage of the bone, necrosis of small bony fragments, loosening or interference of osteosynthetic material, malposition of the bone, and functionally risk of loosing range of motion after correction. Malunion in children enhances these requirements by risk of growth disturbance and smaller size of the operated bone. Anyway if functional impairment is present, osteotomy is indicated. With individualized approach to osteotomy, osteosynthesis, and postoperative care, it leads to a good functional result.
Early Nerve and Muscle Transfers in Upper Limb Arthrogryposis
Authors: Bahm Jörg , Wagemann Christian
Published: September 2016

Introduction: Arthrogryposis congenita multiplex (AMC) is a multifactor-determined limb affection characterized by joint stiffness and motor impairment. Upper and/or lower limbs may be involved with variable severity; upper limb treatment strategy concentrates on joint stiffness first and is limited by the availability of active muscles. In specific cases, early nerve and/or muscle transfers show to be very helpful. Materials and Methods: Since 2013, 6 AMC children have been operated to improve upper limb function, using early nerve transfers to reanimate elbow flexion and/or shoulder abduction. When there was no target muscle present, early muscle transfers were performed. All cases are analyzed retrospectively with the assessment of active and passive range of motion and video motion analysis. Results: Nerve transfers allowed to achieve otherwise unexpectable elbow flexion and shoulder abduction/external rotation. In this 2-year follow-up, the involved and operated upper limb achieved better functional integration. Discussion: This early microsurgical strategy does apply to specific cases with limited joint contracture and seen before 1 year. The treatment allows good muscle targeting and improved function, if muscle tissue is found to be neurotized or moved as a pedicled functional flap. Although etiology of AMC remains unclear and multifactorial, our strategy applied to selected cases highly improved upper limb function and thus should be considered in an (early) treatment algorithm.
The Pathophysiology of the Osteoarthritis of the Thumb
Authors: Lamas Claudia , Llusà Manuel , Mustafa Amer , Proubasta Ignacio , Morro Rosa , Carrera Anna
Published: September 2016

Introduction: More than 16 ligaments around the joint have been described by Bettinger et al. (1999); four ligaments and the joint capsule are the main stabilizers of the trapeziometacarpal (TM) joint. These ligaments are the dorsoradial (DRL), intermetacarpal (IML), anterior oblique (AOL), and posterior oblique ligaments (POL). The importance of each of these ligaments in the stability of the TM joint is debatable. The purpose of the study was (1) to describe the anatomy and dimension of the thumb carpometacarpal (CMC) joint ligaments, (2) to assess the ligament lesions and the degree of subluxation of the CMC joint, and (3) to measure cartilage thickness in the trapezium and metacarpal and pattern of chondromalacia and osteoarthritis (OA). We investigated the role that these ligament ruptures play in the pathophysiology of the OA. Methods: Twenty-five fresh-frozen cadaver hands were dissected of all soft tissue to expose the joint capsule and ligaments of the TM joint. There were 14 male and 11 female with mean age of 67 years (range, 51-94 years). The dissection was performed under ×4.5 loupe magnification. We showed the main ligaments and also the ligament ruptures in IML, AOL or beak ligament, dorsal oblique ligament (DOL), and DRL. We described the location of the ligament tears and whether these ruptures were partial or total. The ligament ruptures and the metacarpal translation associated with these ruptures were measured (mm). Cartilage thickness in the trapezium and metacarpal of specimens was assessed. We described the degree of degenerative changes using the stanging protocol to describe visual degeneration by Koff et al. (2003). We investigated the relationship between the ligament ruptures and the area of chondromalacia and OA. Statistical analysis of data was performed with the chi-square test, and the level of significance was P < .05. Results: Seven principal ligaments of the thumb CMC joint were identified using Berger’s principles (200s1). Ligament lesions were found in all 25 specimens. Isolated rupture of the AOL was found in 7 (28%), isolated rupture of the DRL was found in 10 (40%), isolated rupture of the IML was found in 2 (8%). Combined rupture of the AOL and IML was found in 2 (8%) and combined rupture of the DRL and IML in 4 (16%) joints. The mean metacarpal displacement due to isolated rupture of the ligaments was DRL 17 mm ( P = .006), AOL 11 mm, POL 0.5 mm, and IML 0.4 mm. We found 2 cases OA stage I, 7 cases OA stage II (1 IIa, 3 lib, and 3 IIc), 9 OA stage III, and 7 OA stage IV. There was a relationship between the presence of a tear in the DRL and the presence of OA in the radial quadrants ( P = .032). Conclusion: These observations suggest a translation of metacarpal on trapezium in the production of arthritic lesions and support a hypothesis that pathologic joint instability could be a cause of CMC OA. This study suggests that repairing the DRL during ligament reconstruction of the CMC joint should be considered.
Heterotopic Digital Replantation in Mutilating Hand Injuries
Authors: Lin Cheng-Hung , Chang Nai-Jen , Hsu Chung-Chen , Lin Yu-Te , Lin Chih-Hung
Published: September 2016

Objective: Reconstruction of the mutilated hand is one of the most difficult challenges for hand surgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction. Patients and Methods: Between 1997 and 2008, 29 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes. Results: In total, 100 digits were amputated from 29 patients’ hands. Thirty-nine digits underwent heterotopic digital replantation, 20 digits had orthotopic digital replantation, and 41 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 87.2% (34/39) and 95% (19/20), respectively. Tripod pinch was achieved in 82.8% (24/29) of patients following replantation and any secondary reconstructive surgery that was required. Conclusions: Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. It is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result. The principles are to restore a functional thumb in the first instance, followed by at least 2 adjacent fingers against which the thumb can oppose.
Comparison Between Different Techniques of Central Slip Reconstruction for Correcting Extensor Lag in Vascularized Toe Proximal Interphalangeal Joint Transfers
Authors: Lee Che-Hsiung , Hsu Chung-Chen , Lin Cheng-Hung , Chen Shih-Heng , Lin Yu-Te
Published: September 2016

Objective: From our previous study, deficiency of the central slip was identified in more than 86% of the lesser toes. This was correlated with the extension lag of proximal interphalangeal joint (PIPJ) after vascularized joint transfers (VJT). Subsequently, we demonstrated our clinical experiences that extension lag associated with poor central slip formation in the toe can be corrected using central slip reconstruction with the Stack method. The Stack procedure involves the dorsal passing of a distally based flexor digitorum superficialis (FDS) slip through the middle phalangeal base. To drill an extra hole along with extensive manipulation of periosteum can increase the risk of damage to the perfusion of the transferred joint. As such, we present a novel, simple, and effective technique to correct extensor lag during VJT and compared it with our prior VJT with the Stack method. Methods: In our new technique, the lack of a central slip in type I toes can be corrected by anchoring the lateral bands to the middle phalanx of the transferred PIPJ. When transferring a PIPJ of the second toe for the reconstruction of PIPJ defect in a finger, osteosynthesis is first performed passing cerclage wire through 2 holes drilled through the distal and proximal ends of the joint complex. Re-creation of the extensor insertion to the middle phalanx is performed by anchoring the lateral bands down to bone with sutures. Tenorrhaphy of extensor digitorum longus (EDL) to central extensor of the finger at zone IV is performed utilizing Pulvertaft weaving. After the surgery, this group of patients followed the same rehabilitation protocol as those with the Stack method. The arc of motion of the PIPJ was measured in the latest clinics. Results: The use of this novel technique in our institution has seen equivalent results in range of motion when compared with the use of Stack’s technique (61.0 ± 19.6° vs. 54.4 ± 11.8°) in the reconstruction of PIPJs using VJTs. This technique is also safe and quick to perform when compared with our prior adopted method in central slip reconstruction, and no injury to neurovascular structures have been seen in our institution. The anchored lateral bands sufficiently enhances the axial pull of the extensor mechanism and corrects the inherent extensor lag of the type I toe joints. Only by correcting this inherent extensor lag can we maximize the full potential range of motion of the toe PIPJ. Conclusions: Our method achieves similar outcomes to the Stack procedure, but has the advantage of minimizing addition bone drilling and soft tissue manipulation, hence making the procedure markedly easier to perform.
Free Vascularized Fibular Bone Graft for Treatment of Difficult Cases of Infected Nonunion of Both Forearm Bones
Authors: Noaman Hassan Hamdy
Published: September 2016

Objective: The treatment of infected non-union both bone forearm is considered as challenge orthopaedic procedure. Infection should be eradicated, non-union should be treated meticulously with debridement, removal of necrotic bridging tissue. Vascularized fibula bone graft is considered as the best solution to bridge the defect and eradicate the infection. Methods: Twenty-four patients (16 men and 8 women), who formed the basis of the study, underwent surgery in the Hand and Microsurgery Unit, Sohag University, from January 2008 to January 2015. The right side was involved in 11 cases and the left side in 13 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 10 cases, infected nonunion of the middle part of radius in 7 cases, post-traumatic bone loss of distal radius in 4 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients). The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin. The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 10 cases and the left fibula in 14 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. Results: The average follow-up was 84 months. Bone union was ultimately obtained in 22 patients except 2 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor. Conclusion: We recommend free vascularized fibula bone graft for treatment of difficult cases of infected non-union both bone forearm not only to restore the anatomy but also to obtain nearly normal hand function.
Microsurgical MTP
Authors: Vilkki Simo
Published: September 2016

Introduction: In the treatment of radial dysplasia or radial club hand the surgical methods are changing from centralization to microsurgical bone and joint transfer to stabilize the hand with a growing autogenous bone. Materials: Thirty-four radial club hand extremities have been treated with a microsurgical metatarsal bone and joint transfer. Patients’ age has been optimally between 2 and 5 years at the time of operation. Methods: The operation is done in 2 stages. (1) Preoperative distraction and alignment of the hand using the speed of 0.5 mm/day. (2) After about 6 to 7 weeks, a microvascular transfer of second metatarsophalangeal (MTP) joint and metatarsal bone has been done. Results and Conclusions: In a group of 19 patients with long-term follow-up, the growth of the forearm has occurred well without additional growth disturbance. Also, the wrist alignment has been adequate in long term or only 29 degrees of radial deviation has returned. These patients gain best with the new mobile wrist. The wrist motion will be typically from 20° extension to 80° flexion. With the growing experience, the results have got even better and the technique has become refined.
Costs of Hand Injuries for the Economy
Authors: Leixnering Martin , Pezzei Christoph , Jurkowitsch Josef , Szolarz Christian , Quadlbauer Stefan
Published: September 2016

Introduction: Hand injuries are a frequent occurrence and account in occupational accidents up to 41%. The main reasons for hand injuries are stress, inattention, tiredness, and the use of maintained machinery. For that reason, in the last 10 years, much affords had been carried out in Europe to reduce the numbers of hand injuries. In Austria, the Austrian Workers’ Compensation Board (AUVA) has started in 2014 a prevention campaign to reduce the numbers of hand injuries during work. As well, the “Circle for Leisure Time Hand Injury Prevention” was instituted with the aim to take measures to avoid especially hand injuries during leisure activities. Material and Methods: Hand injuries at work had been analyzed in the years 2010-2011 in respect of nature of the injury, time of the injury, sick leave duration, and cause of injury. Furthermore, the costs for each type of hand injury for the companies and economy had been calculated. Results: Overall, 632.693 injuries had been treated in hospitals of the AUVA. Of these, 174.855 involved hand injuries. Each year, 4.826 new pensions had been because of injuries during work, and 1.224 of these because of an injury of the hand. Total sick leave of all hand injuries amount in total 474.859 days per year, which means 12.3 days per hand accident. In 26% of the cases not powered handheld tools, in 25% (building-) materials, and in 10% machines had been the reason for a hand injury. Hand injuries entail annual costs of €309 million per year. Average costs per hand accident had been €7.778 per patient. Conclusions: Hand injuries are very common and account for up to 41% of all injuries, and they cause annual costs in Austria by €309 million. Therefore, in the last decade, much affords have been done to reduce hand injuries.
Seton Drainage for Therapy of Cat Bites
Authors: Henne Thomas
Published: September 2016

Objective: About 35 000 people are victims of animal bites in Germany every year. Eighty percent of them never see or need a doctor. Nevertheless, especially cat bites are a therapeutic problem, because they are like inoculation injuries and are in up to 50% infected. However, the clinical course without intervention cannot be predicted due to multiple variables (microbiological settlement of cats oral cavity, immunobiological state of the patient). The therapeutic range starts with watchful waiting and raise up to operative revision in every case. We present a seton drainage as a new tool for treatment of cat bites. Method: A monofile nonresorbable seton is led through the cat bite in the subcutaneous tissue, stitched out 1” proximally and fixed by a false knot, though the cat bite wound cannot close. After a wound dressing soaked with an alcoholic disinfection fluid, the related upper extremity is immobilized with a splint. Moxifloxacin is given as an antibiotic. The wounds were controlled day by day by the same surgeon (if possible). After clinical recovery of inflammation, the setons were removed, antibiotic ran 2 days longer. Return to work is possible 2 days later. Results: Up to now, 17 patients with hand and forearm bite injuries (cat, 15; dog, 1; Degu [South American hamster], 1) were treated according to the procedure described above. One patient is treated currently. The patients came to hospital between 6 and 48 hours after injury. Clinical findings were pain (n = 17), local swelling (n = 17), local inflammation (n = 17), lymphangitis (n = 3), and fever (n = 1). In 15 patients, the wounds healed without complications. One patient presenting himself 48 hours after cat bite required surgery 24 hours later, and 1 patient developed an abscess 6 weeks later. Conclusion: The successful start with this small number of patients encourages us to continue with this treatment.
Surgeon Volume Influences Treatment Outcome in the Dupuytren Disease Surgery
Authors: Zhou Chao , Ceyisakar Iris , Lingsma Hester , Feitz Reinier , Slijper Harm , Hovius Steven , Selles Ruud
Published: September 2016

Objective: High surgeon procedural volume has been linked to better outcomes for a variety of surgical procedures, but the impact of surgeon volume on outcomes of Dupuytren surgery remains uncertain. Materials and Methods: We used data from a quality-of-care registry from 6 hand surgery practice sites between 2011 and 2014. We included 561 patients with the Dupuytren disease who underwent fasciectomy (71%) or percutaneous needle fasciotomy (29%) by 16 hand surgeons. Outcomes were the degree of residual contracture and adverse events assessed at 6 to 12 weeks after treatment. Relations between volume and outcomes were examined using linear and logistic regression models, with adjustment for patient characteristics and the type of procedure. Nonlinearity was assessed with restricted cubic splines. Results: Overall, mean residual contracture (total active extension deficit) at follow-up was 24°, which corresponded to a postprocedure improvement of 65%. Forty-seven percent of patients experienced at least 1 adverse event, with neuropraxia (12%), scar sequelae (12%), and wound healing problems (8%) being the three most common events. Surgeon volume was inversely related to the degree of residual contracture: Every 58 additional procedures performed annually were associated with 5° less residual contracture at follow-up ( P, .03). Moreover, surgeon volume had an inverse effect on overall events (odds ratio per 50 additional procedures, 0.86, P, .01). Conclusions: Even among experienced hand surgeons, patients treated by surgeons performing high volumes of Dupuytren surgery had better outcomes in terms of residual contracture and adverse events. The findings of this study suggest that surgeons may improve outcomes by increasing their annual procedural volume for these specific interventions.
MRI Analysis of Carpal Tunnel Syndrome Hemodialysis Patients, Compared With Nonhemodialysis Patients
Authors: Fujita Koji , Kimori Kenji , Kadonishi Yutaka , Okawa Atushi , Ikuta Yoshikazu
Published: September 2016

Objective: Carpal tunnel syndrome (CTS) is common among patients receiving hemodialysis and deeply influences the daily life. Amyloid deposits are considered as the main reason for median nerve compression but the prevalence is unclear. In this study, to determine the main region of amyloid deposit inside carpal tunnel, we measured cross-sectional area (CSA) of each composition of carpal tunnel in preoperative MRI. Materials and Methods: In all, 41 hemodialysis patients (HD) and age, sex-matched 41 nonhemodialysis patients (NHD), who underwent the first surgery for CTS in Tsuchiya General Hospital (Hiroshima, Japan) from 2005 to 2015, were retrospectively collected. CTS was diagnosed from clinical and electromyographic (EMG) findings. CSA of carpal tunnel, each flexor tendon and median nerve at the level of hook of hamate, were measured in T1-weighted axial image in preoperative MRI, by using Synapse OP-A software. Statistical analysis was performed by student’s t test and Pearson’s chi-square test. This study was approved by institutional review board. Results: HD was 64.3 years and the dialysis duration was 21.9 (11-35) years, and NHD was 65.5 years. CSA of carpal tunnel (HD: 204.2 mm2, NHD: 191.3 mm2, P = .01), flexor tendon (HD: 101.2 mm2, NHD: 92.7 mm2, P = .03), and flexor digitorum profundus tendon (FDP; HD: 57.3 mm2, NHD: 49.8 mm2, P = .04) were bigger in HD group, but median nerve, flexor digitorum superficialis tendon, and flexor pollicis longus tendon were not significantly different from NHD group. Dialysis duration or age to each CSA did not show any strong correlation. In one dialysis patient, accessory tendon of FDP was dissected during the surgery to reduce the pressure of carpal tunnel, and then it was histologically analyzed. Amyloid deposition was confirmed not only around but inside the tendon itself by Dylon stain. Conclusions: We identified hemodialysis caused CSA expansion of carpal tunnel due to amyloid deposition as previously described. Also CSA expansion of flexor tendon, especially FDP, was happened, possibly because amyloid deposited not only around but inside the tendon. We could not identify why it happened to FDP mostly from this study. Great progress had been made on the technique of Beta 2-microglobulin removal in these years, and it is a possible reason why we could not find any correlation between duration of hemodialysis or age to any CSA.
Incidence of Surgically Treated Carpal Tunnel Syndrome
Authors: Vergara Jorge , Pino Paula , Lira María Jesús , Mery Pamela
Published: September 2016

Introduction: Most studies about surgical treatment of carpal tunnel syndrome (CTS) focus on specific population subgroups, worker’s compensation patients, or specific types of surgical treatment. There are no general population studies about epidemiological characterization of surgically treated patients with CTS. Factors such as gender, age, and health insurance status may influence the rate of surgical treatment of CTS. Purpose: Evaluate the influence of epidemiological factors such as gender, age, and health insurance status in the rate of CTS surgery in a mixed health care system. Materials and Methods: Nationwide transversal study of total surgically treated patients with CTS in Chile during 2012. The rate of CTS surgeries was estimated using data collected from Chile’s National Hospital Discharge Records, Public and Private Health Care Systems’ yearly reports on population coverage. Chile’s mixed health care system has a distribution of its population of 81% public, 12.9% private, and 6.1% other insurance. Inclusion criteria: Surgical treatment of CTS (ICD-10 International Statistical Classification of Diseases and Related Health Problems diagnosis G560), age older than 20 years. We analyzed the influence of epidemiological factors such as age, gender, and health insurance status on the rate of CTS surgery. The rate of CTS surgeries was estimated per 1000 habitants in each groups, with their confidence intervals (CI) of 95%. Results: National rate of surgical CTS in patients over 20 years during 2012 was of 0.191 (95% CI, 0.184-0.199). Gender distribution showed higher rate of surgeries in female patients, 0.302 (95% CI, 0.289-0.316), compared with males, 0.077 (95% CI, 0.070-0.084). The age distribution of female patients shows a higher rate of surgeries in the 50- to 59-year group, 0.671 (95% CI, 0.622-0.721). Male patients have a later surgical peak in the 60- to 69-year group, 0.126 (95% CI, 0.098-0.154). The rate of surgical CTS is lower in the public health care system, 0.123 (95% CI, 0.116-0.130), than private insurance, 0.406 (95% CI, 0.379-0.433). The gender distribution was similar in both groups. Conclusions: Health insurance status is the most important factor in the rate of surgical CTS. The access to surgical treatment is 3.3 times higher in private insurance than public system. Gender and age show a higher rate of surgery in female patients in the 50- to 59-year group. This distribution is not influenced by insurance status. National rates of surgical CTS are comparable with reports from the literature. These new data can help understand the population’s behavior and plan resources distribution. It also shows the breach that still has to be covered by the public health care system in terms of surgical treatment of CTS.
The Super Supinator! Reliably Restoring Active Hand Opening in C5/6 Tetraplegia Using the Supinator Nerve to Posterior Interosseous Nerve Transfer
Authors: van Zyl Natasha , Weymouth Michael , Flood Stephen , Hahn Jodie , Cooper Cathy
Published: September 2016

Objective/Hypothesis: Achieving satisfactory hand opening as a part of surgical reanimation for the upper limb post cervical spinal cord injury (SCI) has been an elusive goal. This study presents outcomes in 11 consecutive patients (17 limbs) who underwent supinator nerve to posterior interosseous nerve (PIN) transfers for the restoration of finger and thumb extension. Materials and Methods: Eleven patients (17 limbs) with a mean age of 25.6 years and a C5 to C7 motor complete SCI underwent supinator nerve to PIN transfers between 5 and 52 months post injury at a single center. Prior to surgery, all patients had preserved biceps and supinator function, but absent digital extension. All patients received follow-up hand therapy and underwent a final evaluation at a mean age of 19.3 months (range, 14-26) post surgery. Clinical outcome measures included manual muscle testing and measurement of first web space opening. Canadian Occupation Performance Measure (COPM) and patient satisfaction scores were recorded. Results: All 17 transfers resulted in active, voluntary finger and thumb extension. The mean Medical Research Council Grade for power in extensor digitorum communis was 3.9 and for extensor pollicis longus was 3.7. The mean first web space opening was 99.7 mm. As a consequence, patients were able to open their hand to place it around or release an object and to extend their hand in greeting. Further benefits included counteracting spasticity in the finger flexors and reducing the radial deviation of the wrist through the reanimation of extensor carpi ulnaris. At final review, all patients had functional supination even with the elbow extended. Conclusions: The supinator to PIN transfer provides a promising option for restoring finger extension in people with C5/6/7 cervical SCI and has high rates of technical success along with high patient satisfaction rate. It can be performed in combination with other tendon or nerve transfers to maximize functional reconstruction of the upper limb in tetraplegia.
Should Single-Stage Opponensplasty Be Added at the Time of Release for Severe Carpal Tunnel Syndrome?
Authors: Garg Bhavuk , Kotwal Prakash , Srivastav Deep , Das Chandan , Vibha Deepti , Manhas Vikrant , Vardhan Anand , Malhotra Rajesh
Published: September 2016

Objectives: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of upper limb. In advanced stage of CTS, nerve conduction studies demonstrate undetectable compound muscle action potentials of the abductor pollicis brevis (APB-CMAP) following stimulation of the median nerve at the wrist. Opponensplasty is a surgical option for patients with severe CTS. Should single-stage opponensplasty be added at the time of release for severe carpal tunnel syndrome? Methods: We prospectively evaluated patients following carpal tunnel release to observe correlation between clinical and electrophysiological recovery and to determine the necessity for single-stage opponensplasty. Subjects were prospectively collected 22 hands from 22 carpal tunnel syndrome patients, with APB-CMAP of 2 mV or less and evaluated preoperatively and postoperatively for clinical and electrophysiological recovery. Results: All 3 components of pulp pinch strength (PPS)—that is, tip-tip, lateral, 3 point; grip strength; and thumb opposition—showed statistical significant improvement after 6 months. There was statistical significant improvement in APB-CMAP postoperatively after 6 months. Functional outcome was assessed with Mayo wrist score and showed statistical significant improvement postoperatively. Conclusion: We conclude that all patients had good clinical and electrophysiological recovery at 6 months; therefore, single-stage opponensplasty may not be necessary for such patients.
Peripheral Nerve Rewiring in the Treatment of Hemiplegic Upper Extremity Following Central Neurologic Injury
Authors: Yin Huawei , Xu Wen-Dong
Published: September 2016

Object: To analyze the recovery of peripheral nerve rewiring (PNR) surgery in the treatment of hemiplegic upper extremity and evaluate its relevant clinical features, efficiency, and optimal indications. Methods: Prospective follow-up were carried out in patients with hemiplegic upper extremity following stroke, traumatic brain injury, and cerebral palsy. Patients underwent PNR surgery and were followed-up every 3 months after surgery. Measurements included Fugl-Meyer scale, sensorimotor functions, range of motion, and muscle strength. Primary outcomes were assessed and influencing factors such as etiology, disease course, age at surgery, and injured side were also evaluated. Results: A total of 67 patients underwent PNR surgery between April 2007 and December 2015. Fifty-one patients had been followed-up for more than 1 year and the Fugl-Meyer score were 47.52 ± 6.94 at 12 months, compared with 28.31 ± 3.15 before surgery. Patients showed improvements in wrist stability, motor control of the paralyzed hand, and the grasping function. The items that reflect fine motor functions of wrist and fingers increased from 8.65 ± 1.61 to 18.91 ± 4.16. The range of motion increased from 98.35 ± 29.67 to 123.12 ± 19.46 in the elbow and from 34.81 ± 29.20 to 79.55 ± 23.68 in the wrist at 12 months after surgery. And the strength improved from 3.4 ± 1.0 to 4.4 ± 0.5 in elbow extension and from 1.3 ± 1.3 to 3.7 ± 0.6 in wrist extension according to British Medical Council grading system. The patients of cerebral palsy obtained more satisfactory outcomes than those of other causes such as stroke, traumatic brain injury, and encephalitis, that was from 27.6 ± 1.18 preoperation to 47.5 ± 5.54 at 12 months postoperation. Patients who were under 25 years old presented best improvements in the Fugl-Meyer score, from 28.16 ± 1.24 to 47.3 ± 4.56. Patients between 25 and 45 years took the second place while those more than 45 years obtained the third favorable results. However, patients who were older than 45 years still significantly recovered, with Fugl-Meyer score improving from 31.5 ± 2.97 to 43.6 ± 1.97. No significant differences were found when either side was involved or between different sexes. Conclusion: PNR surgery is an effective procedure in treating hemiplegic upper extremity following central neurologic injury. The range of motion and extension strength of paralyzed, wrist and elbow significantly improved. The patients especially reported obvious improvements in wrist stability and hand grasping function. The surgery was effective for all the etiologies including cerebral palsy, traumatic brain injury, stroke, and encephalitis, and cerebral palsy patients obtained most favorable recovery. Patients at lower ages showed better results than other age groups. However, it is still effective in older patients over 45 years. Side of injury and sex do not influence the results.
Is Trigger Finger an Associated Condition of Carpal Tunnel Syndrome or a Consequence of Its Release?
Authors: Vergara Jorge , Pino Paula , Lira María Jesús , Figueroa María Jesús , Mery Pamela
Published: September 2016

Objective: The objective of this study is to analyze the factors that may impact on the development of trigger digit (TD) in patients with carpal tunnel release (CTR). Materials and Methods: We conducted a retrospective cohort study of patients who underwent surgery for carpal tunnel syndrome (CTS) and/or TD between January 2004 and May 2014, at our institution. Inclusion criteria were treatment of at least one TD or CTS and age older than 18 years. We performed a manual chart review of the participants and analyzed the following factors: age, gender, previous surgery for CTS or TD, and comorbidities (hypothyroidism and diabetes). In addition, we searched for previous CTS surgery on the same hand of TD symptoms. We performed a follow-up of patients through phone calls, with our primary outcome measure being presence of TD symptoms or need for TD surgery on any hand. The mean follow-up period for this study was 63 months (range, 19-137 months). Statistical Analysis: Patients with CTS were divided into 2 groups: group 1—history of TD surgery or symptoms, and group 2—no TD history. Analysis of associated factors was performed through chi-square and Mann-Whitney tests for an alpha level of significance of .05. An additional analysis was performed of patients with the diagnosis of TD who had a previous CTR surgery on the same hand. Results: In total, 716 charts were reviewed, with 391 patients interviewed and included in the analysis. Of these, 307 patients had history of CTR. There were 106 (27.9%) patients with the diagnosis of TD. Analysis of associated factors showed a significant difference ( P = .01) between the median age of patients with TD, 54 years (range, 32-81), compared with the group of no TD, 51 years (range, 25-86). We found no association between the development of TD and other factors (gender, hypothyroidism, and diabetes). From the total of charts reviewed, 190 patients had TD history or surgery. Only 38 (20%) of them had a previous CTR on the same hand. We found that there was a significantly higher proportion of female patients in the group of TD with prior CTR ( P = .028). The other variables did not show significant differences. Conclusions: This study shows that there is a high number of patients, 27.9%, with CTS surgery that also have history of TD. We found that older patients with CTS had a significantly higher rate of TD. Only 20% of patients who had TD surgery or symptoms during follow-up had a previous CTS surgery on that hand. CTS and TD are conditions which occur in a group of patients with similar characteristics. We did not find a higher rate of TD development in patients with previous CTS surgery.
Multistrand Tendon Repairs With Early Active Motion Versus 2-Strand Repairs With Passive Motion
Authors: Pan Zhang Jun , Xu Yun Fei , Pan Lei , Chen Jing , Tang Jin Bo
Published: September 2016

Objective: To report the results of an audit of repair of zone 2 flexor tendons in 68 digits using two different repair methods and rehabilitation protocols. Materials and Methods: From January 2014 to January 2015, we treated 35 digits in 21 consecutive patients who had complete divisions of flexor tendons in zone 2. All tendon repairs followed an established surgical and rehabilitation protocols. The flexor digitorum profundus (FDP) tendons in 31 fingers and flexor pollicis longus tendons in 4 thumbs were repaired using either 6-strand M-Tang or 4-strand U-Tang methods. In 13 fingers, we vented part of the A2 pulley, and the entire A4 pulley was vented in 5 fingers. Active digital motion started from 4 days post-surgery. In 2013, the same surgical team repaired zone 2 flexor tendons in 25 consecutive patients (33 digits) with a conventional 2-strand modified Kessler repair with a passive motion protocol. Their outcomes were collected as the historical controls. Results: In evaluations of 35 digits with multistrand repair with early active motion 10 to 16 months postsurgery, the outcomes were excellent in 27 (80%), good in 3 (8.5%), fair in 3 (8.5%), and poor in 1 (2.2%) digits according to Strickland and Glogovac criteria. There were no repair ruptures. Four thumbs were all rated as excellent. No bowstringing was found in the 18 fingers, where either a part of the A2 pulley or entire A4 pulley was vented. The outcomes of 33 digits with a modified Kessler repair with passive motion were excellent in 13 (39.3%), good in 9 (27.2%), fair in 4 (12.1%), and poor in 7 (21.1%) digits. Repair ruptures were noted in 6 (18.2%) digits. Conclusions: Multi-strand core repairs with early active motion significantly improve outcomes over a conventional 2-strand repair with early passive motion in zone 2 flexor tendon repair.
Double-Loop 10-Strand Flexor Tendon Repair
Authors: Lee Gi Jun , Lee Hyun , Lee Jae Sung , Ha Sung Han , Park Min Jong
Published: September 2016

Purpose: To compare mechanical properties of a multistrand suture technique for flexor tendon repair with those of conventional suture methods through biomechanical and clinical studies. Methods: We describe a multistrand suture technique that is readily expandable from 6 to 10 strands of core suture. For biomechanical evaluation, 60 porcine flexor tendons were repaired using one of the following 6 suture techniques: Kessler (2-strand), locking cruciate (4-strand), Lim/Tsai’s 6-strand, and our modified techniques (6-, 8-, or 10-strand). Structural properties of each tenorrhaphy were determined through tensile testing (ultimate failure load and force at 2-mm gap formation). Clinically, we repaired 25 flexor tendons using the described 10-strand technique in zones 1 and 2. Final follow-up results were evaluated according to the criteria of Strickland and Glogovac. Results: In the biomechanical study, tensile properties were strongly affected by repair technique; tendons in the 10-strand group had approximately 106%, 66%, and 39% increased ultimate load to failure (average, 87 N) compared with those in the 4-, 6-, and 8-strand groups, respectively. Tendons in the 10-strand group withstood higher 2-mm gap formation forces (average, 41 N) than those with other suture methods (4-strand, 26 N; 6-strand, 27 N; and 8-strand, 33 N). Clinically, we obtained 21 excellent, 2 good, and 2 fair outcomes after a mean of 16 months (range, 6.53 months) of follow-up. No patients experienced poor results or rupture. Conclusions: The 10-strand suture repair technique not only increased ultimate strength and force at the 2-mm gap formation compared with conventional suture methods, but it also showed good clinical outcomes. This multistrand suture technique can greatly increase the gap resistance of surgical repair, facilitating early mobilization of the affected digit.
Epithelioid Sarcoma of the Upper Extremity
Authors: Irimura Sanae C. , Morioka Hideo , Horiuchi Koichi , Sato Kazuki
Published: September 2016

Objective: Epithelioid sarcoma (ES) is a relatively rare soft tissue tumor that occurs in the extremities. Slow-growing, the seemingly benign appearance often results in misdiagnosis. Inadequate surgeries, as well as mistaken treatment as chronic ulcer or wound infection may lead to delayed recognition. ES is usually resistant to chemotherapy; thus, once metastasized, few options remain for its treatment. We reviewed upper limb ES cases that underwent treatment at our institution, all of which had experienced misdiagnosis. Patients: Ten patients (7 male, 3 female) were treated for ES in the upper limb between 1992 and 2015. The age at presentation was 6 to 88 years (mean, 36.7 ± 2.4 years). The initial tumor site was the digits in 4, palm in 2, forearm in 3, and upper arm in 1 case. All 10 had been treated previously at other institutions before diagnosis as a malignancy and subsequent referral to the orthopedic oncology division at our hospital. Results: The time between onset of symptoms and histological diagnosis was 3 months to 14 years (mean, 66.7 ± 6.2 months). The initial symptoms were a nodule in 5 cases (3 asymptomatic), persistent swelling after trauma in 2 cases, and a chronic ulcer in 1. Two cases were presented as neuropathies; a tumor at the wrist was diagnosed as Guyon canal syndrome and another in the forearm had caused anterior interosseous nerve palsy. Before recognition as a malignancy, 4 had been operated on as a benign tumor, and the others had been treated surgically as osteomyelitis, hematoma, wound infection, neuropathy, or chronic ulcer. None had evidence of metastasis on positron emission tomography (PET) scans at the time of referral to our services. Once correctly diagnosed, all cases received additional surgery. As adjuvant therapy, 3 received chemotherapy. Three were given radiotherapy; one at the primary site and 2 at sites of metastasis. At last follow-up, 5 cases were continuous disease free (CDF) and 2 were alive with disease (AWD); their follow-up was 19 months to 13 years and 9 months (mean, 95.9 ± 7.6 months). Five had experienced metastasis. Of the metastasis cases, 3 had died of disease. All 3 had been given radiotherapy and 2 were given chemotherapy. The duration of disease before death in these cases was 185, 197, and 30 months. There seemed to be no apparent correlation between the duration of symptoms and disease progression. A case treated 6 months after onset experienced multiple metastases and died 22 months after diagnosis, while cases of more than 10 years of duration are currently CDF or AWD. As surgery still seems to be the only curative option, early diagnosis and immediate treatment before metastasis are advisable. Conclusions: ES is not only rare, but does not always present as a typical sarcoma. Misdiagnosis is common, and in some instances, the mistake may be fatal. This tumor should be kept in mind when observing and treating a seemingly benign skin lesion that is taking time to heal.
Long-term Follow-up of Radial Shortening and STT Arthrodesis in Kienböck Disease
Authors: Bravo Arturo Patiño
Published: September 2016

Purpose: The purpose of the study is to assess the long-term results of radial shortening and scaphoid-trapezium-trapezoid (STT) arthrodesis performed in the same surgical procedure to treat Kienböck disease stage IIIB and negative ulnar variance. Methods: Twenty patients with Kienböck disease in stage IIIB and negative ulnar variance were studied between August 1999 and December 2012. Patients were classified according to Lichtman’s classification. Stage distribution was 20 patients in stage IIIB. All patientes had negative ulnar variance. The average follow-up was 8 years and 4 months. The review includes assessment of pain, swelling, mobility of the wrist, grip strength, carpal height, and patient satisfaction. Results: Twenty patients with an average age of 28 years (range, 14-35) were studied. The pain improved markedly (2.25 visual analogue scale, range, 0-10). The flexion, extension, radial deviation, and ulnar deviation also improved. No wrist movement declined compared with preoperative values. Grip strength increases over the preoperative average of 26.6 kg to 34.6 kg. Carpal height ratio remained constant, indicating no increase in carpal collapse. The degree of patient satisfaction was high according Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Conclusions: According to the results obtained in our study, the STT arthrodesis with radial shortening osteotomy performed in the same surgical is a good option for the treatment of Kienböck disease stage IIIB and negative ulnar variance.