New Simple Technique for Syndactyly Release.

Can good functional and cosmetic result be achieved in syndactyly separation using a straight midline incision with a hexagonal dorsal skin flap? METHODS: We performed 39 web reconstructions at a median of 20 months of age (11-43 months) to 26 consecutive children (21 male) with 30 simple, 4 complex, and 5 complicated syndactylies. Eighteen of the simple syndactylies were incomplete, ending at the proximal interphalangeal joint in 15 and at the distal interphalangeal joint in 3. Inguinal skin grafts were used in 2 children with either complex or complicated syndactyly. Operation time was recorded. Complications were registered. Height of the new web spaces was calculated. Parents' satisfaction on both functional and cosmetic outcome was assessed using a Visual Analog Scale from 0 to 100. RESULTS: Duration of one web reconstruction ranged from 50 to 95 minutes in simple incomplete, 56 to 135 in simple complete, 116 to 151 in complex, and 72 to 123 in complicated syndactylies. One child had a self-induced bilateral postoperative infection that lead to web creep. Two patients developed hypertrophic scars, which responded well to silicone treatment. Mean cosmetic and functional Visual Analog Scale scores were 87 (45-100) and 92 (63-100), respectively, at a mean follow-up of 1.3 years (range, 0.5-3.7). CONCLUSION: Web reconstruction using a hexagonal dorsal skin flap and straight midline incisions with closure at mid-lateral lines is safe, with good cosmetic and functional outcome in our short-term follow-up.

Selective Neurotization of the Infraspinatus Muscle in Brachial Plexus Birth Injury Patients Using the Accessory Nerve.

The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus birth injury. Eight brachial plexus birth injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction (<10 degrees) with congruent glenohumeral joints and no significant internal rotation contracture (passive external rotation >45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents' satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient's parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus birth injury by direct neurotization of the infraspinatus muscle.

MRI of rotator cuff muscle atrophy in relation to glenohumeral joint incongruence in brachial plexus birth injury.

PURPOSE: To evaluate rotator cuff muscles and the glenohumeral (GH) joint in brachial plexus birth injury (BPBI) using MRI and to determine whether any correlation exists between muscular abnormality and the development of glenoid dysplasia and GH joint incongruity. MATERIALS AND METHODS: Thirty-nine consecutive BPBI patients with internal rotation contracture or absent active external rotation of the shoulder joint were examined clinically and imaged with MRI. In the physical examination, passive external rotation was measured to evaluate internal rotation contracture. Both shoulders were imaged and the glenoscapular angle, percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the greatest thickness of the subscapular, infraspinous and supraspinous muscles were measured. The muscle ratio between the affected side and the normal side was calculated to exclude age variation in the assessment of muscle atrophy. RESULTS: All muscles of the rotator cuff were atrophic, with the subscapular and infraspinous muscles being most severely affected. A correlation was found between the percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the extent of subscapular muscle atrophy (r(s)=0.45, P=0.01), as well as between its ratio (r(s)=0.5, P P=0.01). Severity of rotator cuff muscle atrophy correlated with increased glenoid retroversion and the degree of internal rotation contracture. CONCLUSIONS: Glenoid retroversion and subluxation of the humeral head are common in patients with BPBI. All rotator cuff muscles are atrophic, especially the subscapular muscle. Muscle atrophy due to neurogenic damage apparently results in an imbalance of the shoulder muscles and progressive retroversion and subluxation of the GH joint, which in turn lead to internal rotation contracture and deformation of the joint.