Presurgical imaging of the subscapular artery with three-dimensional-computed tomography angiography: Application to harvesting subscapular system free-flaps.

A subscapular system free-flap is extremely useful for maxillofacial reconstruction since it facilitates the simultaneous harvesting of multiple flaps using one subscapular artery (SSA) alone. However, cases of aberrations in the SSAs have been reported. Therefore, the morphology of SSA needs to be confirmed preoperatively before harvesting the flaps. Recent developments in imaging, such as three-dimensional (3D) computed tomography angiography (3D CTA), facilitate obtain high-quality images of blood vessel images. Therefore, we examined the utility of 3D CTA in navigating the course of the SSA before harvesting subscapular system free-flaps. We examined the morphology and aberrations of the SSA using 39 sides of the 3D CTA data and 22 sides of Japanese cadavers. SSAs can be classified into types S, I, P, and A. Type S SSAs are significantly long (mean length = 44.8 mm). Types I and P SSAs have short mean lengths, measuring ≤2 cm in approximately 50% of cases. In type A, the SSA is absent. The frequency of types S, I, P, and A SSAs were 28.2%, 7.7%, 51.3%, and 12.8%, respectively. Type S can be advantageous for harvesting the SSA in subscapular system free-flaps, because it is significantly longer. In contrast, types I and P might be dangerous because their mean lengths are shorter. In type A, caution is needed not to injure the axillary artery because the SSA is absent. When surgeons need to harvest the SSA, presurgical 3D CTA is recommended.

Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery.

PURPOSE: We investigated chronological changes in active range of motion (ROM) of the metacarpophalangeal (MCP) joint after zone VII extensor tendon reconstruction with wide-awake local anesthesia no tourniquet (WALANT) surgery. METHODS: Reconstruction of the extensor tendons ruptured in zone VII of 82 fingers in 40 patients was performed using WALANT techniques. The mean patient age was 71.3 years. During surgery, we evaluated passive stretch distance and active contraction distance of the ruptured musculocutaneous unit. The sum of passive stretch distance and active contraction distance was defined as total excursion. In cases with total excursion ≥30 mm, we selected bridge tendon grafting for tendon reconstruction. In cases with total excursion <30 mm, end-to-side tendon transfer was performed. Active ROM of the MCP joint was measured before surgery; during surgery; 1, 3, and 5 months after surgery, and at the final follow-up. RESULTS: Extension lag of the MCP joint was 49.2° before surgery, improving to 2.9° during surgery, deteriorating to 18.7° at 1-month, and improving again to 15.6° at 3-months, 13.6° at 5-months, and 10.5° at the final follow-up. Meanwhile, the active flexion angle of the MCP was 87.9° before surgery, 87.3° during surgery, 67.6° at 1-month, 76.0° at 3-months, 79.7° at 5-months, and 81.0° at the final follow-up. Extension and flexion angles at each time point remained nearly constant regardless of whether tendon grafting or tendon transfer was used. CONCLUSIONS: Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. The changes in ROM of the MCP joint during follow-up are an approximate indication of the progression of postoperative recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic Ⅳ.

Therapeutic strategy for atypical ulnar fracture in long use of bisphosphonate: A systematic review.

BACKGROUND: Atypical fractures are caused by the combined effects of severe suppression of bone metabolism (SSBT) due to long-term bisphosphonate therapy and chronic repetitive bone microdamage. Atypical ulnar fractures (AUFs) due to SSBT are rare, and there is no standard treatment strategy for such fractures. The relevant literature was reviewed, and the treatment strategy for AUF is discussed. METHODS: A systematic review was conducted. All studies on ulnar fractures in individuals with a history of bisphosphonate use were included, and the data were extracted and analyzed from the perspective of the therapeutic strategy. RESULTS: Forty limbs of 35 patients were included. As for the treatment of AUF, 31 limbs were treated surgically, and conservative treatment with casting was performed for 9 limbs. The bone fusion rate was 22/40 (55.0%), and non-union was seen in all patients treated conservatively. There was a significant difference in the bone fusion rate between patients with surgical treatment and those with conservative treatment. The bone fusion rate of patients with parathyroid hormone (PTH) and surgery was 82.3% (14/17 limbs); the bone fusion rate with PTH and bone graft was 69.2% (9/13 limbs). However, there were no significant differences in the fusion rate in the groups with or without PTH, with or without bone grafting, or the combination of the two treatments. There was also no significant difference in the bone fusion rate in the groups with or without low-intensity pulsed ultrasound (LIPUS) treatment. CONCLUSIONS: Based on the literature review, surgery is necessary to achieve bone union, but surgery alone is not adequate to achieve bony union. Bone grafting and the administration of PTH and LIPUS may promote early bone fusion, but the present study did not show significant advantages of these additional treatments for bone union.

Usefulness of Wide-Awake Local Anesthesia No Tourniquet Surgery to Decide on Tendon Transfer Versus Grafting in Chronic Flexor Tendon Rupture.

Purpose: We investigated the clinical outcomes of flexor tendon reconstruction for chronic rupture of the flexor tendon based on an evaluation of the voluntary active contraction distance (ACD) of the ruptured musculotendinous unit and changes in intraoperative total active motion (TAM) that could only be observed during wide-awake local anesthesia no tourniquet (WALANT) surgery. Methods: Reconstructions of 19 tendons of the flexor pollicis longus (FPL) and 18 tendons of the flexor digitorum profundus (FDP) were performed during WALANT surgery to evaluate the ACD of the ruptured musculotendinous unit and TAM observed during the surgery. Tendon grafting or tendon transfer was selected during the surgery based on ACD. TAM, pinch strength, and grip power were evaluated before the surgery, during the surgery, and at final follow-up, and they were surveyed based on Quick Disabilities of the Arm, Shoulder, and Hand (q-DASH) scores. The final outcomes of tendon grafting and tendon transfer were compared. Results: In FPL tendon reconstruction, tendon grafting was performed in 10 patients with a total PDD and ACD value greater than 30 mm, and tendon transfer was performed in 9 patients with the value less than 30 mm. In FDP tendon reconstruction, tendon grafting was performed in 8 patients and tendon repair in 2 patients with a total PDD and ACD value greater than 40 mm, and tendon transfer was performed in 8 patients with the value less than 40 mm. The TAM value, q-DASH score, pinch power, and grip strength were improved in all patients. In both the tendon reconstructions, intraoperative TAM was significantly increased compared with preoperative TAM but significantly decreased at final follow-up. No significant differences were identified in final follow-up TAM and the q-DASH scores between tendon transfer and tendon grafting. Conclusions: The great advantage of WALANT surgery is that surgeons can evaluate the ruptured musculotendinous unit and measure TAM during the surgery. Type of study/level of evidence: Therapeutic I.

Effect of hyperdry amniotic membrane in preventing tendon adhesion in a rabbit model.

BACKGROUND: No anti-adhesive materials are currently in clinical use for orthopaedic surgery. We developed a hyperdry amniotic membrane (HD-AM) for easy storage and transplantation as amniotic membrane. The purpose of this study was to examine the application of HD-AM to reduce peritendinous adhesions without impairing tendon healing. METHODS: We randomly divided 3 digits (2nd, 3rd, and 4th digits) from each rabbit into three groups: a tendon repair group; a tendon repair with HD-AM group (HD-AM group); and a control group (cast only). The effects of HD-AM on peritendinous adhesions and tendon healing were examined using microscopic, histological, and mechanical analyses in a rabbit flexor digitorum profundus tendon model. RESULTS: Adhesions on macroscopic evaluation of the tendon repair site were significantly smaller in the HD-AM group than in the tendon repair group. Little adhesion formation or foreign body reactions were seen by on histologic evaluation in the HD-AM group. Range of motion following tendon repair was significantly better in the HD-AM group than in the tendon repair group. Maximal tensile strength required to pull the tendon from the site of adhesion was significantly smaller in the HD-AM group than in the tendon repair group. As for tendon repair site, no significant difference was seen between the tendon repair and HD-AM groups. CONCLUSIONS: HD-AM prevented peritendinous adhesion macroscopically, pathologically, and mechanically without impairing the sutured tendon. HD-AM has already been clinically applied in neurosurgery, ophthalmology, and otolaryngology, and clinical application as an anti-adhesive materials may be achieved in the future.

Wide-awake Surgery for Congenital Thumb Flexion Anomaly in a Child.

We report a rare case of absent thumb IP joint flexion in bilateral thumbs due to anomalous tendon slips of the flexor pollicis longus. Cutting the anomalous insertions failed to improve active flexion of the IP joints. Successful treatment was achieved by evaluating the musculotendinous units of the original flexor pollicis longus and the anomalous flexor pollicis longus tendon during a wide-awake surgery.

Clinical outcome and ultrasonographic evaluation of treatment using polyglycolic acid-collagen tube for chronic neuropathic pain after peripheral nerve injury.

BACKGROUND: A novel polyglycolic acid (PGA)-collagen tube has been available in Japan since March 2013, and the development of high-resolution ultrasonography has recently allowed detailed evaluation of nerves. The purpose of this study was to report the clinical outcomes and evaluations of in-vivo changes under high-resolution ultrasonography for treatment using PGA-collagen tube for painful chronic nerve injury. METHODS: Four patients underwent surgical management of peripheral nerve neuroma, with nerve defects after neuroma resection reconstructed using PGA-collagen tube. Mean duration of follow-up was 30 months. Patients were surveyed to determine visual analog scale scores for pain before surgery and at final follow-up. At final follow-up, sensory function was evaluated using the Semmes-Weinstein test, static 2-point discrimination (2PD), and moving 2PD. Furthermore, we performed ultrasonography for all patients every 1 month after surgery. RESULTS: In all cases, resting pain, radicular pain, and dysesthesia were improved immediately after the operation and remained improved until the last follow-up. At the time of final follow-up, the Semmes-Weinstein test was red in 2 cases and blue in 2 cases. Mean static 2PD was 15.5 ± 5.3 mm and mean moving 2PD was 11.5 ± 5.3 mm. Ultrasonography revealed that the PGA outer wall had disappeared by 3 months postoperatively, and a hypoechoic linear shadow bridged the proximal and distal stumps. Swelling of the junction between nerve and nerve conduits was revealed at 4 months after surgery and remained until last follow-up. CONCLUSIONS: All patients were very satisfied with pain relief, but recovery of sensory function was insufficient. Ultrasonographic evaluation after using PGA-collagen tube for painful chronic peripheral nerve injury was useful for observing in-vivo changes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radial Dislocation of Extensor Tendon Over the Metacarpophalangeal Joint of the Thumb due to Cerebral Hemorrhage: A Case Report.

We report a rare case of radial dislocation of the extensor tendon over the metacarpophalangeal (MCP) joint of the thumb. Ulnar dislocation has been reported, but previous reports have not mentioned radial dislocation of the extensor tendon in the thumb. Radial dislocation of the extensor tendon of the thumb gradually progressed after cerebral hemorrhage and the patient could not extend MCP joint of the thumb. To resolve difficulty in extending the MCP joint, surgical centralization of the extensor tendon and partial resection of the flexor pollicis brevis (FPB) and abductor pollicis brevis (APB) insertions was performed. The patient recovered function of thumb extensors.

Wide-Awake Flexor Pollicis Longus Tendon Reconstruction with Evaluation of the Active Voluntary Contraction of the Ruptured Muscle-Tendon.

The purpose of this study was to investigate the clinical outcome of the wide-awake tendon reconstruction for chronic rupture of the flexor pollicis longus tendon with evaluation of the voluntary active contraction distance of the ruptured musculotendinous unit. Eleven consecutive patients underwent tendon reconstruction under wide-awake surgery. If the total of the passive distraction distance and the active contraction distance of the ruptured flexor pollicis longus musculotendinous unit was greater than 30 mm, tendon grafting was performed. If not, tendon transfer was performed using the fourth flexor digitorum superficialis. Patients were evaluated with total active motion before surgery, during surgery, and in final follow-up and subjectively surveyed with quick Disabilities of the Arm, Shoulder and Hand scores. The final outcomes of tendon grafting and of tendon transfer were compared. Tendon grafting was performed in four patients, and tendon transfer was performed in seven patients. The final follow-up total active motion was 84.3 ± 12.7 percent in the tendon transfer group and 80.7 ± 10.2 percent in the tendon grafting group. There were no significant differences between the two groups in the final follow-up total active motion percentage and quick Disabilities of the Arm, Shoulder and Hand scores. The functional outcomes of both tendon grafting and tendon transfer were acceptable based on evaluating the active contraction distance and passive distraction distance of the ruptured musculotendinous unit during wide-awake surgery. Evaluating these distances may be a useful index to assess the ruptured musculotendinous unit. The greatest advantage of the wide-awake tendon reconstruction is that surgeons can evaluate the ruptured musculotendinous unit and measure total active motion during surgery while adjusting suture tension. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Active Voluntary Contraction of the Ruptured Muscle Tendon during the Wide-awake Tendon Reconstruction.

PURPOSE: The purpose of this study was to measure the active voluntary contraction distances of ruptured musculotendinous units during wide-awake tendon reconstruction surgery and to investigate the relationships between active contraction distance and the passive distraction distance and the time elapsed before reconstruction. METHODS: The passive distraction distance and active contraction distance of 36 tendons of 22 patients who underwent forearm tendon transfer or tendon graft during wide-awake surgery were measured. RESULTS: The passive distraction distance was significantly related to the active contraction distance of the ruptured musculotendinous unit (r = 0.60, P < 0.05). The passive distraction distance accounted for approximately half of the total excursion of the musculotendinous unit. There was no significant correlation between each distance and the time elapsed before reconstruction. CONCLUSIONS: The passive distraction distance was significantly related to the active contraction distance of the ruptured musculotendinous unit in vivo during wide-awake surgery. Active musculotendinous unit contraction distance may be a useful index to evaluate ruptured musculotendinous unit degeneration and donor muscle function in standard tendon reconstruction. This study suggested that the advantages of the wide-awake approach were not just as a clinical tool but also as an in vivo research tool.

Continuous peripheral nerve block in forearm for severe hand trauma.

We studied the use of a continuous peripheral nerve block (CPNB) in the distal forearm and wrist immediately after emergent surgery for severe hand trauma in 22 hands. After emergent surgery, a 2-3 cm longitudinal incision was made at the distal forearm and an 18-gauge catheter was inserted along the peripheral nerves. All patients received postoperative analgesia by continuous infusion of 0.2% ropivacaine at 2 ml/h for seven to 21 days. Pain score remained low during postoperative period and only a small number of analgesic rescues were needed. There were no major complications related to the CPNB and one patient showed mild superficial infection at the insertion site that immediately recovered after catheter removal. This method provides good postoperative analgesia without loss of motor function in extrinsic hand muscles and should be considered as a postoperative pain management for severe hand trauma.

Usefulness of blood supply visualization by indocyanine green fluorescence for reconstruction during esophagectomy.

BACKGROUND: Adequate blood supply for the reconstructed organ is important for safe esophagogastric anastomosis during esophagectomy. Recently, indocyanine green (ICG) has been used for visualization of the blood supply when anastomosis is performed in vascular surgery. To visualize the blood supply for reconstruction, we employed ICG fluorescence during esophagectomy. METHODS: From August 2008, 40 patients received cervical or thoracic esophagectomy. They consisted of 33 patients having esophagectomy for thoracic esophageal cancer, 3 being treated for cervical esophageal cancer, and 4 with double cancer of the thoracic and cervical regions. Before and after pulling up the reconstructed organ, 2.5 mg of ICG was injected as a bolus. Then ICG fluorescence was detected by a camera and recorded. RESULTS: ICG fluorescence was easily detected in all patients at 1 min after injection. The vascular network was well visualized in the gastric wall, colonic grafts, and free jejunal grafts. In five patients, we also performed anastomosis between the short gastric vein and the external cervical vein or superficial cervical vein. The intraoperative and postoperative course of all patients was uneventful apart from three anastomotic leakages. CONCLUSIONS: ICG fluorescence can be employed to evaluate the blood supply to reconstructed organs and can be useful in selecting the patients who do not need additional vessel anastomosis. However, anastomotic leakage was not reduced, so the microcirculation detected by ICG fluorescence did not necessarily provide appropriate blood supply for a viable anastomosis.

Multicentric diffuse-type giant cell tumor of the hand.

Diffuse-type giant cell tumor (D-TGCT) is relatively rare. We report a case of multicentric D-TGCT located in the finger and wrist. A 79-year-old man presented with a more than two-year history of tumors. Marginal resection was performed. Histological study of the specimens disclosed D-TGCT. Recurrence occurred two years and five months postoperatively and was again excised. Clinical presentation, radiological features and histopathological findings are discussed with reference to the literature.

Periodontoid pannus migration into the spinal canal with reduction of rheumatoid atlantoaxial subluxation: a case report.

We report a patient with rheumatoid arthritis in whom periodontoid pannus migrated into the spinal canal with reduction of atlantoaxial subluxation. In this case, magnetic resonance imaging in the extension position was valuable for determining the therapeutic strategy.