Resection and reconstruction for radial polydactyly Type IV-D in 206 cases: a retrospective clinical analysis.

BACKGROUND: Radial Polydactyly Type IV-D deformity is difficult to treat because of the most complex bone and soft tissue anomalies. Resection and reconstruction for one of the two thumbs was an option for treatment. OBJECTIVE: The study was to present our method of resection and reconstruction with a new incision for radial polydactyly Type IV-D and evaluate the clinical efficacy comprehensively using Rotterdam assessment system in a large sample. METHODS: 206 cases of type IV-D thumb duplication underwent resection and reconstruction surgical treatment between 2010 and 2019. Two equal triangle flap incisions were designed around the radial thumb. The radial thumb was resected and the ulnar thumb was reconstructed in aspects of bone, tendons, ligaments and abductor pollicis brevis. The clinical results were evaluated using Rotterdam assessment system. RESULTS: The mean follow-up period was 2.2 years (SD 1.5). The mean age of the patients was 9 months (SD 1.8) at the time of operation. The mean ranges of active IP and MP joint flexion and extension were 110° and 26°. The mean angulations for IP and MP joint instabilities were 3° and 11°, relatively. Angulation for palmar abduction was 58°. The mean appearance domain score was 8.9. The average parental satisfaction score was 2.5 and the average patient-reported pain score was 2.1. The mean functional domain score for all patients was 6.6. The average appearance domain score was 8.9. The mean patient-reported domain score was 4.5. The mean Rotterdam outcome score was 20.0, equivalent to 67% of the full score. The postoperative score of patients over two years old was significantly lower than that of patients under two years old. CONCLUSION: Resection and reconstruction method with two equal triangle flap incisions was a recommended treatment for radial polydactyly Type IV-D. LEVEL OF EVIDENCE: IV.

[Clinical practice guidelines for brachydactyly type A1].

Brachydactyly type A1 (BDA1) is the first autosomal dominant genetic disease recorded in the literature. The main characteristics of BDA1 include shortening of the middle phalanx and fusion of the middle and distal phalanges. So far more than 100 pedigrees have been reported around the world. This paper summarizes the clinical manifestation, pathogenesis, diagnostic criteria and treatment plan for BDA1, with an aim to improve its diagnosis and clinical management.

An alternative method to reconstruct grade-3 hypoplastic thumb by hemi-metacarpal transfer.

We designed a new method using hemi-longitudinal second metacarpal bone to reconstruct grade-3 hypoplastic thumbs. Seven patients were treated in two stages. In the first stage, the second metacarpal was split longitudinally and transferred to reconstruct the first metacarpal. In the second stage, opponensplasty was performed by transferring the FDS tendon. Bone union was achieved in all cases. All patients could oppose to their middle finger at least. They managed to do daily activities such as writing, eating, using smartphones and so on. This is a useful procedure to preserve a 5-digit hand with good function in treating grade-3 hypoplastic thumbs, with no harm to the foot and no need for vascular anastomosis. LEVEL OF EVIDENCE: IV.

Classification and treatment of congenital central slip hypoplasia.

OBJECTIVES: The aim of this study is to make a diagnosis and a classification for congenital central slip hypoplasia. The surgical treatment was determined according to the classification. METHODS: A retrospective study of 25 treated digits in 13 patients with congenital central slip hypoplasia was carried out. The central slip was classified into two types. Type I: The distance between the insertion of central slip and the proximal interphalangeal joint was shorter than or equal to 5 mm. Type II: The distance between the insertion of central slip and the proximal interphalangeal joint was longer than 5 mm. Tendon advancement or tendon graft was used for type I or II, respectively. RESULTS: The preoperative mean extension lag was 91° (range, 80°-100°), and the mean follow-up duration was 18 months (range, 9-24 months). The postoperative mean extension lag was 19° (range, 0°-50°). No matter whether in type I or II, the postoperative ranges of proximal interphalangeal joint extension had significant improvement compared with the preoperative ones. There was no statistical difference of proximal interphalangeal joint extension lag changes before and after surgery between the two types. CONCLUSION: Congenital central slip hypoplasia could be classified into two types. Either tendon advancement or tendon graft might be effective, which depended on the classification.

Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach.

The upper brachial plexus injury leads to paralysis of muscles innervated by C5 and C6 nerve roots. In this report, we present our experience on the use of the combined nerve transfers for reconstruction of the upper brachial plexus injury. Nine male patients with the upper brachial plexus injury were treated with combined nerve transfers. The time interval between injury and surgery ranged from 3 to 11 months (average, 7 months). The combined nerve transfers include fascicles of the ulnar nerve and/or the median nerve transfer to the biceps and/or the brachialis motor branch, and the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) and triceps branches to the axillary nerve through a posterior approach. At an average of 33 months of follow-up, all patients recovered the full range of the elbow flexion. Six out of nine patients were able to perform the normal range of shoulder abduction with the strength degraded to M3 or M4. These results showed that the technique of the combined nerve transfers, specifically the SAN to the SSN and triceps branches to the axillary nerve through a posterior approach, may be a valuable alternative in the repair of the upper brachial plexus injury. Further evaluations of this technique are necessary.

Clinical assessment of the results of one-stage circular incision techniques for limb ring constriction due to amniotic band syndrome.

BACKGROUND: Amniotic band syndrome (ABS) is a congenital malformation that results in abnormalities in many parts of the body. Most surgical treatments for ABS used multi-stage Z-plasties. The purpose of this study was to assess the clinical results of one-stage circular incision techniques for limb ring constriction due to amniotic band syndrome. METHODS: We reviewed 27 patients with limb ring constriction in ABS from 2010 to 2020. The mean ages of the patients were 11.7 months (range, 0-72 months). The complete circular incision release the ABS. All patients' operations were used one-stage circular incision surgical techniques, including patients with multiple bands. All the patients were followed up with a period ranges from 2 years to 10 years. Patient-reported visual analog scale (VAS) scar ranking on a scale of 0 (minimum satisfaction) to 10 (maximum satisfaction) were used to evaluate esthetic outcomes. RESULTS: After our surgery, all the limbs, toes, and fingers were rescued, and the lymphedema reduced remarkably. The VAS scores (mean ±â€ŠSD) for patient satisfaction were 7.55 ±â€Š1.89. The surgical treatment of amniotic band syndrome in a one-stage circular incision is safe and effective. CONCLUSION: The one-stage circular incision surgical techniques have many advantages, including reduced surgical invasiveness, scar formation, and the cost of treatment. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone.

The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic thumb amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11-24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for amputation of the thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time.

[Impact of loss of sympathetic innervation on peripheral nerve regeneration: an experimental study with rats].

OBJECTIVE: To investigate the impact of loss of sympathetic innervation on peripheral nerve regeneration. METHODS: Thirty-two SD rats underwent resection of the right middle cervical ganglion and excision and re-anastomosis of bilateral medium nerve, and then were randomly divided into 4 equal groups to undergo the following experiments. One, 2, 3, and 4 weeks later the sensory nerve action potentials (SNAPs) of bilateral medium nerves 5 mm from the anastomotic stoma and the compound muscle action potentials (CMAPs) of bilateral superficial digital flexor muscles were measured with stimulating and recording electrodes. Specimens of the distal part of bilateral medium nerves 5 mm from the anastomotic stoma were collected to calculate the number of modulated fibers by electron microscopy. The tendons of bilateral superior digital flexor muscles were cut ant the wrist, isolated to the terminal points, ligated, and connected to a sensor so as to record the maximum contraction power. The superior digital flexor muscle was completely resected to be weighted. RESULTS: CMAP failed to be recorded 1 week later. The wave amplitude of the nerve at the affected side increased along with time, however, the CMAP wave amplitudes of the affected side were all significantly lower than those of the healthy side (all P < 0.05). The SNAP wave amplitudes of the medium nerve of both sides increased along with the time. The SNAP levels 4 and 8 weeks later of the affected side were both lower than those of the healthy side (both P < 0.05). The number of modulated fibers of the medium nerve increased along with the time, however, the number of the affected side were significantly lower than those of the healthy side (all P < 0.05). Electron microscopy showed degeneration of medulla in bilateral medium nerves 1 week later, and newborn modulated fibers began to be seen since 2 weeks later. However, there were a greater number and more complete structure in the healthy side in comparison with the affected side. The wet weights of bilateral superior digital flexor muscles decreased 2 weeks later and then began to increase gradually. However, the wet weight 4 and 8 weeks later were significantly greater in the healthy side then in the affected side (both P < 0.05). CONCLUSION: Resection of sympathetic nerve is advantageous on nerve regeneration.

[Ulnar-side wrist pain unduced by the compression of the dorsal branch of the ulnar nerve: anatomical and clinical study].

OBJECTIVES: To investigate anatomical mechanism of the ulnar wrist pain caused by the compression of the dorsal branch of the ulnar nerve, and discuss the diagnosis and treatment of the compression. METHODS: 40 sides of the upper extremities of adult cadavers were studied anatomically. The dorsal branch of the ulnar nerve and its relationship to the surroundings was dissected and observed grossly and microscopically. 13 cases of the compression of the dorsal branch of the ulnar nerve were treated and followed up. RESULTS: The dorsal branch of the ulnar nerve was penetrated from the deep of the flexor carpi ulnaris muscle 5.6 approximately 6.8 cm proximally from the styloid process of the ulna, then ran along the ulna and divided into 2 approximately 3 big branches at the medial side of the head of the ulna. The transverse branch was apt to injury during wrist movement as it crossed or rounded the head of the ulna where it was close to the peristeam. Seven of 13 cases of the compression of the dorsal branch of the ulnar nerve were treated by local block, and 6 by surgical neurolysis. Nine cases of this group got showed good effect without recurrence after 4 months to 1 year follow-up. CONCLUSION: The anatomical basis of the compression of the dorsal branch of the ulnar nerve is repetitive traction to this nerve during wrist movement, and the compression of the transverse branch is the main cause of ulnar wrist pain. The compression of the dorsal branch of the ulnar nerve should be considered to the patients with ulnar wrist pain and abnormal sensation along the dorsal ulnar side of hand.

[Surgical treatment of suprascapular nerve compression syndrome through posterior approach].

OBJECTIVE: To discuss the optimal approach to treat suprascapular nerve compression syndrome. METHODS: From January 2000 to June 2003, 8 cases of suprascapular nerve compression syndrome were treated by surgical intervention to cut the transverse scapular ligament through posterior approach. Of the 8 patients, there were 2 males and 6 females (age ranged from 21 to 53) with duration of 6 months to 3 years. The change of symptom, muscle power, and muscle atrophy after operation were observed. RESULTS: One week after operation, pain around the scapular disappeared, muscle power of supraspinatus and infraspinatus muscles recovered to normal. One, 6, 12 and 16 months after the operation, the patients were followed up. No recurrence was observed. Muscle atrophy didn't recover. CONCLUSION: To treat suprascapular nerve compression syndrome with operation through posterior approach is easy to operate. When the suprascapular nerve is entrapped in scapular notch, this approach is a good choice.

[Early microsurgical treatment of upper obstetrical brachial plexus injury].

OBJECTIVE: To search for the operation timing and methods for obstetrical brachial plexus injury (OBPI). METHODS: Thirty-two children with upper OBPI were treated by microsurgical procedure from October 1997 to April 2001. The average age of patients was 10 months, ranged from 3 months to 24 months; of them, 19 were below 6 months while 13 were over 6 months. Surgical procedure included neurolysis(n = 12), coaptation after resection of the neuroma without function (n = 7), phrenic nerve transfer to anterior cord of upper trunk or musculocutaneous nerve (n = 7) and intercostal nerves transfer to musculocutaneous nerve(n = 6). The children underwent operation with microsurgical technique and 7/0 or 9/0 nylon was used for nerve suture. RESULTS: Thirty cases were followed up for 21 months postoperatively; the excellent and good rate was 76.7% (23/30). The results of the children under 6 months were better than those over 6 months. CONCLUSION: The microsurgical operation might be considered at the age of 3-6 month infants who had shown little or no improvement in elbow flexion. Neurolysis and nerve coaptation are superior to neurotization. The appropriate procedure should be selected according to the findings of exploration.