Surgical Results of Ulnar Component Excision and Radial Component Reconstruction in Patients With Preaxial Polydactyly of the Hand.

PURPOSE: Resection of the underdeveloped digit and reconstruction of the robust digit is the standard treatment option for preaxial polydactyly of the hand. As an underdeveloped digit, the radial component is usually excised, whereas the ulnar component excision is rarely needed. This study aimed to evaluate the surgical results of ulnar component excision and radial component reconstruction in patients with preaxial polydactyly of the hand. METHODS: We retrospectively reviewed the medical records and radiographs of 809 patients (861 thumbs) who underwent surgery for preaxial polydactyly of the hand from November 2006 to June 2018. Among these, 22 (2.6%) thumbs in which the ulnar component was more hypoplastic or had more severe deformities than the radial component were treated with ulnar component excision and radial component reconstruction. The mean follow-up duration was 49 months (range, 12-142 months). We evaluated the Japanese Society for Surgery of the Hand scores and whether the patients were satisfied with the thumb function and appearance at the final follow-up. We also recorded any complications, such as reoperation. RESULTS: The mean Japanese Society for Surgery of the Hand score was 12.8 (range, 5-17). Six patients had poor results, 7 had fair results, and 2 had good results; however, none of the patients had an excellent result. Satisfaction with thumb function and appearance was reported in 11 (50%) and 6 (27%) cases, respectively. Thirteen of 22 (59.1%) cases involved reoperations, and the most common reason for reoperation was interphalangeal joint deviation of the remaining thumb. CONCLUSIONS: Ulnar component excision and radial component reconstruction are rare operative choices in preaxial polydactyly of the hand. Surgeons and patients should be aware that a considerable number of patients treated with this method required reoperations and had low clinical outcome scores. TYPE OF STUDY/ LEVEL OF EVIDENCE: Prognostic IV.

Modified Wassel-Flatt Type III Radial Polydactyly: Subtypes and Their Outcomes.

PURPOSE: We aimed to subdivide modified type III radial polydactyly and evaluate the applied surgical procedures and outcomes according to the subtypes. METHODS: This study included 32 thumbs of 32 patients treated for modified Wassel-Flatt type III radial polydactyly from March 2008 to December 2018. Each patient was subclassified into parallel, divergent, and convergent types according to the alignment of the duplicated digit. The parallel type was further divided according to the treatment method applied. The parallel A group comprised patients treated with reconstructing the radial collateral ligament of the interphalangeal (IP) joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit, and the parallel B group comprised patients treated with excision of the extra digit at the bifurcation site of the proximal phalanx. We evaluated the Japanese Society for Surgery of the Hand scores and radiographic angulation of the IP and metacarpophalangeal joints at a mean follow-up of 38 months. RESULTS: Fourteen cases were parallel type (6 and 8 in the parallel A and B groups, respectively), 14 were divergent type, and 4 were convergent type. Patients in the parallel A group had significantly better IP and metacarpophalangeal joint angulation and Japanese Society for Surgery of the Hand scores than those in the parallel B group. Patients in the parallel A group had significantly better Japanese Society for Surgery of the Hand scores than those in the divergent and convergent groups. CONCLUSIONS: Reconstructing the radial collateral ligament of the IP joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit was associated with better outcomes than the excision of the extra digit at the bifurcation site in the parallel type cases. The parallel type treated with proximal phalanx preservation and ligament reconstruction had better clinical outcomes than other types of modified Wassel-Flatt type III radial polydactyly. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Reoperation after primary operation for pre-axial polydactyly of the hand: A 12-year experience at a single institute.

BACKGROUND: This study aimed to evaluate and describe the rate, reasons, and detailed procedures of reoperations for pre-axial polydactyly of the hand at our institute conducted within 12 years. METHODS: We retrospectively reviewed the medical records and radiographs of 268 patients (292 digits) with pre-axial polydactyly of the hand, who were treated surgically at our institute from November 2006 to May 2018 and followed up for >12 months. RESULTS: Fifty-two thumbs of 47 patients underwent reoperations, yielding a 17.8% reoperation rate. According to the initial deformity type, the highest reoperation rate was observed in the cases classified under modified Wassel type VIIA (60.9%, 14/23 thumbs), followed by those under type VIIB (44.4%, 8/18 thumbs). Scheduled reoperations were performed in seven type VIIA and four type VIIB cases with a triphalangeal thumb and eight with triangular epiphysis of the distal phalanx. Unexpected reoperations were conducted in 33 cases, 31 (93.9%) of which had deviated thumbs. Various surgical treatments, including corrective osteotomy, collateral ligament plication, and flexor pollicis longus tendon relocation, were performed to correct deviations. A total of 23 cases (74.2% of 31 thumbs) received a corrective osteotomy at the second or third operation. CONCLUSIONS: The reoperation rate after primary operation for pre-axial polydactyly of the hand was 17.8%. It was higher in the cases initially classified under modified Wassel type VII; however, a considerable number of cases received scheduled reoperations. A deviated thumb was the most common cause of unexpected reoperation, and corrective osteotomy was the most commonly performed procedure. The rate and details of reoperation should be routinely mentioned for preoperative planning and patient education in pre-axial polydactyly. LEVEL OF EVIDENCE: Therapeutic level IV.

Excision of Rudimentary Preaxial Polydactyly of the Hand with Use of Electrocautery.

BACKGROUND: Suture ligation has been used widely for the treatment of rudimentary type extra digits, but several complications related to this treatment have been reported. The purpose of this study was to describe a new technique for excision of rudimentary preaxial polydactyly of the hand using electrocautery and assess its clinical outcomes. METHODS: The authors performed a retrospective study of 34 thumbs (32 patients) that had undergone excision of rudimentary preaxial polydactyly using electrocautery under local anesthesia. The mean follow-up period was 16.5 months. RESULTS: All children had full range of thumb motion without angular deformity at the most recent follow-up. There were no postoperative complications such as bleeding or infection. In 33 thumbs (97.1% of 34 thumbs), there were no signs of residual digit prominence. One thumb had a residual digit prominence at the extra digit removal site. In two thumbs, scar hypertrophy was evident at the operation site. All parents of the patients except two were very satisfied with this technique and the mean visual analog scale score for satisfaction was 9.5 ± 2.0 (range, 0-10). CONCLUSIONS: Excision of rudimentary preaxial polydactyly of the hand with the use of electrocautery could remove an extra digit completely in 97.1% of the cases. This technique would be a useful alternative to suture ligation, surgical clip application, or surgical excision for the treatment of rudimentary preaxial polydactyly of the hand.

Pronator quadratus pedicled bone graft in the treatment of Kienböck disease: follow-up 2 to 12 years.

We inserted a pronator quadratus pedicled bone graft into the avascular lunate with preservation of its corticocartilaginous portion for the treatment of Kienböck disease. Twenty-seven patients (14 men, 13 women; mean age, 42 years (range 17-66 years)) were treated between September 2005 and July 2014 and followed up from 2 to 12 years. Three patients had Lichtman stage II disease, 13 had stage IIIA, and 11 had stage IIIB. Among them, 18 patients showed radiological improvement in lunate morphology. The Lichtman stage was unchanged in 23 patients and aggravated in four patients. The Stahl index was significantly decreased, but grip strength was significantly improved and 18 patients did not have any wrist pain during daily activities. Although our technique did not restore the already changed carpal malalignment, it improved lunate morphology. Clinically, it provided satisfactory pain levels in two-thirds of the patients and grip strength was improved. Level of evidence: IV.

Comparison of Long-Term Outcomes of Radial Osteotomy and Nonoperative Treatment for Kienböck Disease: A Systematic Review.

BACKGROUND: Radial osteotomy has shown favorable clinical results for early to advanced stages of Kienböck disease. However, it is not clear whether this technique could change the natural course of the disease, or whether its clinical results are actually superior to those of nonoperative treatment. The purpose of this study was to compare radial osteotomy with nonoperative treatment in terms of long-term radiographic and clinical outcomes in patients with Kienböck disease. METHODS: We systematically reviewed retrospective studies of radial osteotomy and nonoperative treatment for Kienböck disease with long-term follow-up (mean of ≥10 years). A systematic search was conducted across 3 databases (CENTRAL, PubMed, and Embase) and relevant articles were selected. Data regarding patient demographics, treatment details, and radiographic and clinical outcomes were abstracted from the selected studies. RESULTS: Seventeen studies (5 of nonoperative treatment and 12 of radial osteotomy) were included. Before treatment, the mean age of patients and mean proportion of wrists with Lichtman stage III or higher were not significantly different between the 2 groups. Neither the mean proportion of wrists that showed worsening of the Lichtman stage after treatment nor the proportion that showed no change in the stage were significantly different between the 2 groups. However, the mean proportion of wrists that had more than moderate pain at the time of final follow-up was significantly lower in the radial osteotomy group (5.7%; range, 0% to 18.2%) than in the nonoperative treatment group (23.2%; range, 17.4% to 35.3%). In addition, the total arc of wrist motion at the time of final follow-up was significantly greater in the radial osteotomy group (107.4° ± 10.0°; range, 93.0° to 126.0°) than in the nonoperative treatment group (88.8° ± 13.2°; range, 68.5° to 103.5°). CONCLUSIONS: Systematic review of long-term follow-up studies showed that radial osteotomy was not superior to nonoperative treatment in terms of disease progression according to the Lichtman stage. Nevertheless, radial osteotomy was reported to have better outcomes with respect to the extent of pain and range of wrist motion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Psychological Status Is Associated With Symptom Severity in Patients With Carpal Tunnel Syndrome.

PURPOSE: The purpose of this study was to investigate whether psychological status is associated with symptom severity or functional disability of carpal tunnel syndrome (CTS) patients. PATIENTS AND METHODS: Sixty patients diagnosed with CTS and treated with carpal tunnel release (CTR) were asked to complete a self-administered questionnaire consisting of 3 validated measures obtained before and 3 months after surgery. The Boston Carpal Tunnel Questionnaire (BCTQ) was administered to assess symptoms (BCTQ-S) and functional disabilities (BCTQ-F), and the Center for Epidemiologic Studies Depression Scale (CES-D) and Pain Anxiety Symptoms Scale (PASS) were administered to assess depression and pain anxiety. The preoperative scores and those obtained 3 months after CTR were compared. Bivariate and multivariable regression analyses were performed to determine whether the variance of CES-D and PASS scores are associated with the variance of symptom severity or functional disability of CTS patients. RESULTS: The CES-D and PASS scores significantly improved after surgery. In a multivariable linear regression model, the CES-D and PASS scores were significantly associated with the BCTQ-S scores both before and 3 months after surgery. In addition, the changes in CES-D and PASS scores were significantly associated with the change in BCTQ-S scores. CONCLUSIONS: The depression level and pain anxiety of CTS patients were significantly improved at 3 months after CTR. The depression level and pain anxiety were significantly associated with the CTS symptoms in both the preoperative and the postoperative period. In addition, the improvement of depression and pain anxiety were associated with the improvement of CTS symptoms. Thus, our findings indicate that the depression and pain anxiety of CTS patients are associated with the symptom severity of CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Comparison of outcomes between partially healed and acute metaphyseally malaligned distal radial fracture treated by palmar locking plate fixation.

BACKGROUND: The purpose of this study was to determine whether a partially healed (surgical delay of 2-6 weeks) metaphyseally malaligned distal radius fracture (DRF) treated using the extended palmar approach with palmar locking plate fixation has poorer clinical or radiological outcomes than those of acute (surgical delay of ≤2 weeks) metaphyseally unstable DRF treated by palmar locking plate fixation. METHODS: We identified 24 patients (Group A) who were treated with palmar locking plate for a partially healed (surgical delay of 2-6 weeks) metaphyseally malaligned DRF. We selected 48 patients (Group B) who were treated with palmar locking plate among the acute (surgical delay of ≤2 weeks) metaphyseally unstable DRF to be individually matched in a 1:2 ratio for sex, age, and fracture type. The two study groups were compared with respect to clinical and radiological parameters. The clinical parameters examined were; wrist range of motion (flexion, extension, supination, and pronation), grip strength, and Disabilities of Arm, Shoulder and Hand (DASH) scores. Radiological measurements included radial inclination, palmar angulation, and ulnar variance. RESULTS: The wrist flexion and grip strength were significantly greater in group B than group A at 3 months postoperatively. However, wrist ranges of motion, grip strengths, and DASH scores were not significantly different at 1 year postoperatively. Radiographic evaluation demonstrated no intergroup difference in terms of radial inclination, palmar angulation, or ulnar variance at 1 year postoperatively. CONCLUSIONS: Partially healed metaphyseally malaligned healed DRFs had inferior clinical outcomes to acute metaphyseally unstable DRFs in an early postoperative period, however, achieved similar clinical outcomes at 1 year postoperatively when treated using palmar locking plate fixation.

The Outcomes of Extension Block Pinning and Nonsurgical Management for Mallet Fracture.

PURPOSE: We aimed to compare the clinical and radiographic results of patients with a mallet fracture involving more than one-third of the articular surface, but without a high degree of distal interphalangeal (DIP) joint subluxation, treated with extension block pinning or nonsurgical management. METHODS: Forty-nine patients with a mallet fracture involving more than one-third of the articular surface were reviewed. Twenty-six cases were treated using extension block pinning (surgery group) and 23 were treated nonsurgically (nonsurgical group). At the final follow-up, extension lag and flexion of the DIP joint of the affected digit were measured. Distal interphalangeal joint pain was rated using a visual analog scale and the overall clinical outcomes were graded using Crawford's criteria. Complications, including nail deformity and dorsal prominence, were also assessed. The rate of DIP joint subluxation and fracture fragment size were radiographically evaluated. RESULTS: Mean extension lag and flexion of the DIP joint and mean visual analog pain scores were not significantly different in the 2 groups. Outcomes, as assessed using Crawford's criteria, were excellent in 5, good in 12, fair in 6, and poor in 3 in the surgery group, and excellent in 2, good in 11, fair in 8, and poor in 2 in the nonsurgical group. Moreover, the frequency of nail deformity or dorsal prominence was similar in the 2 groups. The rate of DIP subluxation and mean fracture fragment size were similar between the 2 groups. All the fractures had united by 3 months after injury in both groups. CONCLUSIONS: The clinical outcomes do not significantly differ between extension block pinning and nonsurgical management for mallet fractures involving more than one-third of the articular surface, but without high degree subluxation of the DIP joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bone Mineral Density and Prevalence of Osteoporosis in Postmenopausal Korean Women with Low-Energy Distal Radius Fractures.

The aim of this study was to evaluate the bone mineral density and the prevalence of osteoporosis in postmenopausal Korean women with low-energy distal radius fractures and compared with those of aged-matched normal Korean women. Two hundred and six patients with distal radius fractures between March 2006 and March 2010 were included in this study. Patients were divided into three groups by age; group 1 (50-59 years), group 2 (60-69 years), and group 3 (70-79 years). Controls were age-matched normal Korean women. The bone mineral density values at all measured sites, except for the spine, were significantly lower in group 1 than those of control. While the bone mineral density values in group 2 and 3 were lower than those of controls, these differences were not statistically significant. All groups had significantly higher prevalence of osteoporosis at the Ward's triangle; however, at the spine, femoral neck and trochanteric area it was not significantly different from those of age-matched controls. Although the prevalence of osteoporosis of the postmenopausal women with low-energy distal radius fractures may not be higher than that of the control, osteoporosis should be evaluated especially in younger postmenopausal patients to prevent other osteoporotic hip and/or spine fractures.

Reliability of semi-pronated ulnar deviation PA view (billiard view) of the wrist in evaluating the scaphoid.

Various methods assessing the scaphoid have been reported because of its unique position. In our hospital, pre- and postoperative evaluation of the scaphoid alignment has been carried out in the billiard view, a combination of 45° pronated oblique with ulnar deviation posteroanterior (PA) view, in addition to 3DCT scan and PA and lateral view. This study compared the intra- and inter-observer reliabilities of the lateral intrascaphoid angle and scaphoid length (SL) and scaphoid height (SH) on the billiard view. A total of 60 patients who underwent surgery for scaphoid nonunion were identified and the preoperative and the final follow-up postoperative plain radiographs were used for measurement. Three observers assessed each image. Intra- and inter-observer reliability was determined using intra-class correlation (ICC) coefficients. Intra-observer reliability was all excellent ranging between 0.855 and 0.992. Inter-observer reliability ranged between 0.292 and 0.983. SL and SH demonstrated excellent agreement, while ISA demonstrated poor to moderate agreement. The best method for assessing the scaphoid in simple radiograph remains debatable, but our current data suggest that measuring SL and SH on the billiard view is reproducible and can be used for evaluating restoration of scaphoid alignment.

Double tension band wiring for treatment of olecranon fractures.

PURPOSE: Although tension band wiring (TBW) is generally accepted as standard treatment for olecranon fractures, it has several shortcomings such as loss of reduction, skin irritation, and migration of the K-wires. To overcome these problems and increase fixation stability, we used a rigid fixation technique with double tension band wiring (DTBW). Here, we describe the technique and outcomes of the treatment. METHODS: We retrospectively reviewed 21patients with olecranon fractures who were treated by DTBW. We evaluated clinical and radiological outcomes by checking the range of motion, loss of reduction, functional scoring, skin complications, and pin migration. There were 15 cases of Mayo type IIA fractures (71%) and 6 of type IIB fractures (29%). The mean follow-up period was 37 months (range, 12-58 mo). We also compared the mechanical stability of DTBW and TBW in a sawbone model using a single cycle load to failure protocol. RESULTS: All fractures united without displacement, and no migration of the K-wires was observed during the period of follow-up. Mean loss of elbow extension was 2° (range, 0°-15°) and mean elbow flexion was 134° (range, 125°-140°). The mean Mayo Elbow Performance Score was 94 (range, 70-100). Biomechanical testing revealed greater mechanical strength in the DTBW technique than in the TBW when measured by mean maximum failure load and mean bending moment at failure. CONCLUSIONS: DTBW produced good clinical and radiological outcomes and could be an effective option for the treatment of olecranon fractures by providing additional stability through a second TBW. Biomechanical comparison with a control group (TBW) supported the mechanical benefits of DTBW. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Musicians' medicine: musculoskeletal problems in string players.

There is increasing attention to medical problems of musicians. Many studies find a high prevalence of work-related musculoskeletal disorders in musicians, ranging from 73.4% to 87.7%, and string players have the highest prevalence of musculoskeletal problems. This paper examines the various positions and movements of the upper extremities in string players: 1) basic postures for holding instruments, 2) movements of left upper extremity: fingering, forearm posture, high position and vibrato, 3) movements of right upper extremity: bowing, bow angles, pizzicato and other bowing techniques. These isotonic and isometric movements can lead to musculoskeletal problems in musicians. We reviewed orthopedic disorders that are specific to string players: overuse syndrome, muscle-tendon syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Symptoms, interrelationships with musical performances, diagnosis and treatment of these problems were then discussed.

Reconstruction of the shoulder region using a pedicled latissimus dorsi flap after resection of soft tissue due to sarcoma.

Six patients underwent reconstruction of soft tissue using a pedicled latissimus dorsi flap after tumour resection of the shoulder region. Successful flap healing was observed in all patients. One flap exhibited partial skin necrosis, which healed after conservative treatment. The pedicled latissimus dorsi flap is a safe, easy, and reliable technique for reconstruction of the shoulder region.

Classification of postaxial polydactyly of the foot.

BACKGROUND: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. METHODS: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. RESULTS: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred. CONCLUSIONS: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.