Is Tension Band Wire Fixation Superior to Plate Fixation for Simple Displaced Olecranon Fractures? A Randomized Trial With Median Follow-up of 7.5 Years.

BACKGROUND: Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. QUESTIONS/PURPOSES: (1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? METHODS: Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. RESULTS: No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). CONCLUSION: No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. LEVEL OF EVIDENCE: Level I, therapeutic study.

Merkel Cell Carcinoma of the Digit.

Merkel cell carcinoma (MCC) is a biologically aggressive neuroendocrine tumor of the skin. There are roughly 1500 new cases of MCC diagnosed every year in the United States, with an increased incidence over the past 15 years reaching up to 8%. Epidemiological studies show that the highest MCC incidence is seen in men older than 65 years, with a ratio of 0.23 per 10,000 among whites. Merkel cell carcinoma of the skin most commonly presents as a single, rapidly growing, flesh-colored, painless mass. Because MCC is uncommon, histopathological examination is usually delayed. Because of the high mortality rate associated with this aggressive tumor, a multidisciplinary panel is recommended to ensure high-quality coordinated care. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities, and performance status of the patient. We report a case of MCC to alert medical professionals of this potentially fatal tumor, as early diagnosis and treatment may improve morbidity and mortality rates.

First clinical experience with a new injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma for the treatment of lateral epicondylar tendinopathy (tennis elbow).

BACKGROUND: Lateral epicondylitis is a tendinopathy of the common extensor origin at the elbow. When traditional conservative treatment fails, more effective therapies are needed. Vergenix Soft Tissue Repair (STR) Matrix (CollPlant Ltd., Ness-Ziona, Israel) is an injectable gel composed of cross-linked bioengineered recombinant human type I collagen combined with autologous platelet-rich plasma (STR/PRP). The complex forms a collagen-fibrin matrix that promotes cell migration and tissue repair. Based on positive outcomes from preclinical trials, this study is the first clinical trial of STR/PRP on tendinopathy. We hypothesized that STR/PRP would be a safe and effective treatment for lateral epicondylar tendinopathy. METHODS: Patients with chronic lateral epicondylitis underwent treatment with STR/PRP. Outcome assessment included grip strength, functional disability, and changes in sonographic tendon appearance for up to 6 months after treatment. RESULTS: The study enrolled 40 patients. No systemic or local severe adverse events were reported. Clinical evaluation revealed an improvement in the mean Patient-Rated Tennis Elbow Evaluation score from 64.8 before treatment and showed a 59% reduction at 6 months. The 12-Item Short-Form Health Survey questionnaire showed improvement from a mean score of 30.7 to 37.7 at the final follow-up. Grip strength increased from 28.8 kg at baseline to 36.8 kg at 6 months. Improvements in sonographic tendon appearance were evident among 68% of patients. CONCLUSION: STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments.

Trapeziectomy With a Tendon Tie-in Implant for Osteoarthritis of the Trapeziometacarpal Joint.

PURPOSE: To evaluate the early to mid-term clinical and radiological outcomes of trapeziectomy with a tendon tie-in trapezium implant arthroplasty for moderate to severe trapeziometacarpal (TMC) joint osteoarthritis (Eaton stages III to IV). METHODS: We assessed all patients who underwent trapeziectomy and tendon tie-in trapezium implant arthroplasty stabilized with a Weilby flexor carpi radialis tendon sling for osteoarthritis of the TMC joint between 2008 and 2010 at our institution. Twenty-two patients (28 thumbs) who had had an operation at least 12 months earlier were clinically evaluated at an average follow-up of 18 months. Subjective clinical outcomes evaluation included visual analog scale scores and Disabilities of the Arm, Shoulder, and Hand score questionnaires. Objective clinical evaluation included lateral pinch and grip tests and active thumb range of motion. All patients underwent a radiological assessment by 2 independent musculoskeletal radiologists. In cases of unilateral treatment, we compared clinical results obtained from the operated hands with the contralateral hand. RESULTS: The mean preoperative visual analog scale score of the cohort was 7.4. We documented a statistically significant improvement to 1.2 at a mean of 18 months after the operation (range, 12-26 mo). The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 21. Thumb palmar abduction was 85°; thumb metacarpophalangeal joint flexion and TMC joint extension were 30° and 10°, respectively. There were 2 cases of prosthesis removal owing to implant dislocation. No late complications were recorded. CONCLUSIONS: Good short-term to mid-term results and stability of TMC arthroplasty implant can be achieved with tie-in trapezium implant stabilized with a Weilby flexor carpi radialis tendon sling. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Minimally Invasive Corrective Osteotomy (MICO) of the Hand a Novel Technique.

Introduction: Patients facing post-traumatic malunion or congenital hand differences often contend with functional and cosmetic issues. Traditional correction methods involve open osteotomy, marked by drawbacks like scarring, non-union risks, prolonged rehabilitation, and adhesions. We therefore introduce a novel minimally invasive technique called Minimally Invasive Corrective Osteotomy of the Hand (MICO), which can be performed under local anesthesia. MICO employs a low-speed, high-torque burr to address finger malunions and congenital anomalies. Case Report: A 49-year-old male patient, generally healthy and right hand dominant, presented with a post-traumatic left middle finger, middle phalanx malunion who underwent the MICO procedure, with a 1-year post-operative follow-up. Conclusion: Our findings suggest that MICO offers a straightforward, reproducible, and delicate solution for correcting hand malunions and congenital finger deformities, potentially mitigating the well-established disadvantages and complications associated with the traditional open approach. Although early results of MICO are promising, a larger case series is needed to evaluate the superiority of this technique compared with current open corrective osteotomy methods.Level of Evidence: IV.

Predictors of back pain in adolescent idiopathic scoliosis surgical candidates.

BACKGROUND: There are contradictory reports on the overall prevalence of back pain in the adolescent population compared with adolescent idiopathic scoliosis (AIS) patients. Most reports do not investigate pain in patients with AIS but try to identify in which subgroup of patients with AIS an underlying pathology should be excluded. The objective of this study was to find whether AIS in operative candidate patients is a painful condition and to try and find clinical and radiologic predisposing factors, which will help us to predict patients who are going to have pain. METHODS: Candidates who had to undergo an operative treatment for AIS between October 2004 and October 2009 in our institution, were enrolled to the study. Pain was graded with the use of visual analogue scale (VAS) on a scale from 0 to 10. We recorded the age at presentation, sex, menarchal status, family history of scoliosis, brace treatment history, and neurological findings. Radiologic parameters recorded were: the type of curve according to the Lenke classification, Cobb angle, thoracic kyphosis angle, apex vertebra rotation, Risser grade, coronal balance, and curves flexibility. RESULTS: Seventy patients with AIS were included in this study. Fifty patients (71%) reported of some kind of back pain with 34 patients (48%) grading their pain as ≥5 on the VAS.Patients in whom scoliosis was diagnosed in older age and patients with a more rigid lumbar curve had statistically significant higher VAS scores (P=0.014, P=0.036). Patients who were treated with a brace had a statistically significant lower VAS scores (P=0.019). CONCLUSIONS: Back pain is common in patients with AIS who are candidates for operative treatment. The following parameters correlate with worse back pain: older age at diagnosis, no use of brace, and rigid lumbar curve. LEVEL OF EVIDENCE: Type III.

Efficacy of Intra-articular Versus Extra-articular Bupivacaine Injection in Arthroscopic Partial Meniscectomy: A Prospective, Randomized, Double-Blind Clinical Trial.

Background: Immediate postoperative pain relief following arthroscopic partial meniscectomy remains a critical contributor to improved patient experience, early recovery of range of motion, and enhanced rehabilitation. Purpose: To evaluate the effect of intra-articular versus extra-articular bupivacaine on pain intensity and analgesic intake after arthroscopic partial meniscectomy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective double-blind, randomized clinical trial. All patients included underwent arthroscopic partial meniscectomy under general anesthesia. Patients were randomized into 2 groups, with 20 patients in each group. At the conclusion of the arthroscopic procedure, the intra-articular group received 10 mL 0.5% bupivacaine introduced intra-articularly and 10 mL isotonic saline 0.9% infiltrated subcutaneously around the portals. The extra-articular group received the isotonic saline intra-articularly and the bupivacaine around the portals. The primary outcome was the visual analog scale (VAS) for pain. Assessments were performed 0 to 0.5, 1 to 2, 2 to 4, and at 24 and 48 hours postoperatively. In addition, analgesic and narcotic consumption was monitored. Results: There were no differences between the groups in terms of patient demographics. VAS scores for the intra-articular group were 6, 8, 3.25, 4.3, and 4.5 at 0 to 0.5, 1 to 2, 2 to 4, 24, and 48 hours postoperatively, respectively. VAS scores for the extra-articular group were 3.8, 5, 2.9, 5.2, and 5.25, respectively. No statistically significant differences were observed between the 2 groups regarding pain intensity at all time points. There was also no statistically significant difference in analgesic consumption. Dipyrone was the preferred drug by patients from the intra-articular group, while the extra-articular group preferred to use opioids and nonsteroidal anti-inflammatory drugs. Conclusion: There were no differences in pain severity and analgesic intake between intra- or extra-articular bupivacaine administration after arthroscopic partial meniscectomy.

Frostbite of The Extremities - Recognition, Evaluation and Treatment.

OBJECTIVES: Frostbite refers to the freezing of body tissue which is caused by prolonged exposure to cold temperatures and results in tissue destruction. Tissue damage is due to both immediate cold-induced cell death and the more gradual development of localized inflammatory processes and tissue ischemia. A detailed treatment plan based on the current UpToDate literature is needed to decrease morbidity and mortality rates. METHODS: The United States National Library of Medicine (PubMed/Medline), EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews were systematically searched to identify publications relevant to this review. CONCLUSION: In this review, we present the current knowledge on the diagnosis and treatment of frostbite injuries. We then provide an extended and detailed treatment plan, from first aid in the field to treatment of short and long-term complications .

[The thumb in agony--osteoarthritis of the thumb].

Osteoarthritis of the basal joint of the thumb is common, particuLarLy in postmenopausal females. The male to female ratio is 1:10 respectively. Basal joint arthritis can cause considerable pain and disability. Incompetence of the volar beak ligament is thought to be the pivotal injury that will eventually lead to joint degeneration. Patient history and physical examination can reliably lead to the diagnosis. Radiographs are used for the evaluation of the severity of the arthritis and for treatment strategy. Conservative treatment can be effective in the early stages of the disease. Operative treatment has been shown to be successful in relieving pain and restoring thumb function. The majority of reconstructive procedures include partial or complete trapezectomy with beak ligament reconstruction and tendon interposition.

[Treatment for Pott's disease with neurological complication].

Tuberculosis of the spine (Pott's disease) is the most common skeletal involvement in tuberculosis, and is often accompanied with neurological deficiency. Surgical treatment was previously the mainstay of therapy in cases of Pott's disease with neurological deficiency, but since clinical recovery was found in patients awaiting surgery, conservative management with antibiotic treatment as a first Line treatment has been advocated. This conservative approach may improve the patients' neurological status while avoiding the morbidity and mortality of surgical treatment.

Epithelioid sarcoma of the hand: a wolf in sheep's clothing.

Epithelioid sarcoma (ES) of the hand is a rare, aggressive cutaneous malignancy with high rates of recurrence, metastases and mortality. With an incidence rate of 0.4 cases/y per one million population, which compromise for approximately 1-1.4% of all soft tissue sarcoma, ES accounts for 10% of soft tissues sarcomas of the hand and foot. Its aggressiveness and propensity to spread and metastases without being noticed, makes it unique and potentially lethal. Missed or delayed diagnosis are often encountered as this tumor can mimic variety of different entities and due to the infrequent nature of this lesion, treatment options are still controversial. The authors provide systemic review of the current literature on epidemiology, etiology, pathogenesis, management and outcomes of this disease as well as a case presentation and a proposed treatment algorithm. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities and performance status of the patient. Emphasis on a multidisciplinary coordinated care is crucial as early diagnosis and treatment can decrease morbidity and mortality rates.

Does Radial Head Resection Impair Hand and Wrist Function? A Long-Term Follow-Up.

OBJECTIVE: To evaluate the long-term outcome in patients after radial head resection surgery for isolated Mason type III radial head fractures. DESIGN: An observational retrospective case series. SETTING: A Hand and Upper-Extremity Surgery Unit in a tertiary care center. PATIENTS: Data were collected from files of patients who were operated between the years 1980 and 2020. Of 352 patients who underwent surgery for radial head fractures, 25 patients were eligible and were enrolled in the study. INTERVENTION: All participants underwent radial head resection surgery and a follow-up clinical and radiographic evaluation by 2 senior orthopaedic surgeons. OUTCOME MEASUREMENTS: Objective evaluation included active range of motion of the elbow and wrist joints, ulnohumeral angle, key pinch and grip measurements, and radiographic imaging of elbow and wrist joints. Subjective evaluation included visual analog scale measurements, disability of arm shoulder and hand questionnaire, Mayo wrist score, Michigan hand outcome, and Oxford elbow score. RESULTS: The mean follow-up was 18 years. Mean elbow range of motion and mean grip strength were lower in the operated hand, as compared to the contralateral hand. Mean proximal radial migration was 1.6 mm. Mean results of visual analog scale, disability of arm shoulder and hand, Mayo wrist score, Michigan hand outcome, and Oxford elbow score indicated good functional outcome and high patient satisfaction. CONCLUSIONS: In our study population, long-term functional outcomes after radial head resection were encouraging. Thus, this procedure may be considered as a surgical alternative when radial head reconstruction or replacement fails. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Piezo2 expressed in proprioceptive neurons is essential for skeletal integrity.

In humans, mutations in the PIEZO2 gene, which encodes for a mechanosensitive ion channel, were found to result in skeletal abnormalities including scoliosis and hip dysplasia. Here, we show in mice that loss of Piezo2 expression in the proprioceptive system recapitulates several human skeletal abnormalities. While loss of Piezo2 in chondrogenic or osteogenic lineages does not lead to human-like skeletal abnormalities, its loss in proprioceptive neurons leads to spine malalignment and hip dysplasia. To validate the non-autonomous role of proprioception in hip joint morphogenesis, we studied this process in mice mutant for proprioceptive system regulators Runx3 or Egr3. Loss of Runx3 in the peripheral nervous system, but not in skeletal lineages, leads to similar joint abnormalities, as does Egr3 loss of function. These findings expand the range of known regulatory roles of the proprioception system on the skeleton and provide a central component of the underlying molecular mechanism, namely Piezo2.

Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers.

BACKGROUND: Patients with peripheral neuropathy and pressure under a relatively plantar deviated metatarsal head frequently develop plantar foot ulcers. When conservative management with orthotics and shoes does not cure the ulcer, surgical metatarsal osteotomy may be indicated to relieve the pressure and enable the ulcer to heal. The purpose of this study is to evaluate the use of a mini-invasive floating metatarsal osteotomy in treating recalcitrant ulcers or recurrent ulcers plantar to the metatarsal heads in patients with diabetes mellitus (DM) related neuropathy. METHODS: Computerized medical files of patients with diabetic neuropathy treated with an osteotomy during 2013 and 2014 were retrospectively reviewed. There were 20 osteotomies performed on 17 patients (mean age 58 years). The patients had a diagnosis of DM for a mean of 17 years. All ulcers were University of Texas grade 1A; mean ulcer age was 19 months. RESULTS: After 17/20 operations, the ulcer completely resolved after 6 weeks and did not recur after a mean follow-up of 11.5 months. One patient developed an early post-operative infection with osteomyelitis at the osteotomy site (proximal shaft of the fifth metatarsal) that needed debridement and IV antibiotics. In the other 19 cases, the surgical wound healed within 1 week. Asymptomatic radiological non-union developed in six cases (30 %). CONCLUSIONS: Mini-invasive floating metatarsal osteotomy can cure resistant and recurrent University of Texas grade 1A ulcerations plantar to the metatarsal heads in neuropathic patients.

Toe-Sparing Surgery for Neuropathic Toe Ulcers With Exposed Bone or Joint in an Outpatient Setting: A Retrospective Study.

The purpose of this study was to review the results of aggressive surgical debridement of neuropathic toe ulcers with exposed bone or joint. We identified patients with a single toe ulcer with exposed bone or joint that had been operated on in an outpatient setting. The surgery had included aggressive debridement and was performed using a small curette and rongeur, followed by oral antibiotic treatment at home. Success was defined as complete healing with no recurrence 6 months after full wound closure and epitheliazation was achieved. Twenty-five patients with neuropathic toe ulcers (72% male) had a total of 26 primary operations. Their mean age was 60 ± 12 years. In 22 patients, the neuropathy resulted from diabetes mellitus of 17 ± 9 years' duration. The mean ulcer duration was 6 weeks (range 1-24). The mean number of visits per patient was 6.5 (range 3-20). The ulcers closed in a median of 5 weeks (8 ± 6 weeks, range 3-24 weeks, Q1-Q3 4-10 weeks). At 6 months, 3 (11.5%) patients had needed a toe amputation for infection or necrosis that could not be controlled. None needed a major amputation or hospitalization related to the ulcer. Toe-sparing surgery is feasible and in a select population can have a high success rate (88%), even though it does dictate more dedicated patient care.

Defining occult injuries of the distal forearm and wrist in children.

PURPOSE: The nonspecific terms "wrist sprain" and "suspected occult bony injury" are frequently documented as diagnoses in occult paediatric wrist injuries. To date, however, no one has accurately defined their true underlying pathology. The primary objective of this study was to identify the true pathoanatomy of occult acute paediatric wrist injuries. Our secondary objective was to compare our findings with existing adult data in order to determine any population differences that might be clinically relevant. METHODS: We performed a single-centre retrospective case series evaluating MRI findings in acute paediatric wrist injuries presenting to the hand injury unit between 2011 and 2014. All patients underwent standardised radiographs of the wrist and, where clinically indicated, of the scaphoid. Where no bony anomaly was identified, MRI scanning was offered. Cohen's kappa coefficient was used to calculate the agreement between clinical and MRI diagnosis. RESULTS: 57 patients met the final inclusion criteria. Occult fractures and bony contusions comprised the majority of the pathologies, at 36.5 and 35.0 %, respectively. There were no cases of isolated soft-tissue injury. MRI effected management change in 35.1 % of cases. Paediatric wrists demonstrated differences in injury pattern and distribution when compared to an adult population. CONCLUSION: This study defines for the first time the true pathology of occult paediatric wrist injuries. The current definition of a wrist sprain was not applicable to a single case and therefore appears to be inappropriate for use in the paediatric population. A precise knowledge of the likely pathology facilitates accurate information delivery whilst reducing parental uncertainty and treatment variation.

Severe vascular complications and intervention following elective total hip and knee replacement: A 16-year retrospective analysis.

INTRODUCTION: Iatrogenic vascular injuries associated with elective orthopaedic joint procedures are relatively rare, however when they do occur they carry a risk of significant morbidity and mortality. The aim of this study was to investigate the incidence of vascular complications and resultant need for specialist intervention following elective total hip replacement (THR) and total knee replacement(TKR). METHODS: This was a retrospective analysis of prospectively collected data. The primary outcome measure was vascular complication requiring an interventional radiology procedures or vascular surgery. As a secondary outcome measure postoperative Modified Knee Society Scores and Harris Hip Scores were analysed to assess long term clinical outcome. RESULTS: Six cases of vascular injury requiring specialist intervention were identified. From 2073 total TKRs there were one cases of popliteal artery injury, one case of venous injury and two case of lateral geniculate artery injury (0.19%). From 1601 THRs there were two cases (0.12%) of arterial injury. All patients were treated successfully by a vascular surgeon or an interventional radiologist. Patient outcome varied considerably with the poorest results seen in the THR group. CONCLUSIONS: Iatrogenic vascular complications following elective THR and TKR carry a risk of significant morbidity and mortality. It is important that surgeons and trainees performing these procedures are conscious of these risks and able to identify vascular injuries promptly when they occur. Detailed preoperative assessment, an awareness of anatomical variants and close liaison with a vascular surgeon may all help to reduce the number and severity of adverse outcomes.

Neonatal course and outcome of twins from reduced multifetal pregnancy versus non-reduced twins.

BACKGROUND: Multifetal pregnancy reduction has been implemented for improving the outcome of multifetal pregnancies. Recent studies reported no difference in pregnancy outcome between reduced twins and non-reduced twins, but the neonatal course and subsequent outcome in reduced twin pregnancies were not well documented. OBJECTIVE: To compare the neonatal course and outcome, as well as the gestational and labor characteristics in twins from reduced multifetal pregnancies and in non-reduced twins. METHODS: This is a retrospective case-control study of the neonatal course of twins from reduced multifetal pregnancies. We found 64 mothers with multifetal pregnancy reduction who delivered twins during 1989-1997; 64 gestational age-matched non-reduced twin pregnancies served as controls. The following neonatal variables were examined: major malformations; small birth weight for gestational age; and neonatal morbidities including respiratory distress syndrome, apnea, pneumothorax, bronchopulmonary dysplasia, hyperbilirubinemia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, seizures, intraventricular hemorrhage, periventricular leukomalacia, ventriculomegaly, and hydrocephalus. In addition, we evaluated several neonatal interventions (surfactant replacement, mechanical ventilation, phototherapy, total parenteral nutrition), and some laboratory abnormalities (thrombocytopenia, leukopenia, anemia, and hypoglycemia), duration of hospitalization, and neonatal mortality. RESULTS: Gestational and labor variables were not significantly different between multifetal pregnancies reduced to twins and non-reduced twin pregnancies. The neonatal morbidity and mortality were not significantly different between twin neonates from multifetal pregnancy reduction and non-reduced control twins. CONCLUSIONS: Multifetal pregnancy reduction to twins appears to bear no adverse effect on the intrauterine course of the remaining fetuses or their neonatal course and outcome when born after 28 weeks of gestation.

Percutaneous tenotomy for the treatment of diabetic toe ulcers.

BACKGROUND: Foot ulcers have been implicated as a causative factor in diabetic foot amputations. The purpose of this study was to evaluate treating foot ulcers in patients with diabetes by percutaneous tenotomy. METHODS: We retrospectively reviewed the computerized medical files of 83 patients treated for foot ulcers by percutaneous tenotomies. Results were analyzed on the basis of indication and per patient. RESULTS: The 83 patients had 160 tenotomies for 4 indications: 103 tip-of-toe ulcers (treated by flexor digitorum longus tenotomy), 26 cock-up/dorsal ulcers (extensor digitorum longus tenotomy), 21 kissing ulcers (extensor digitorum longus and/or flexor digitorum longus tenotomies), and 10 plantar metatarsal ulcers (extensor digitorum longus with or without flexor digitorum longus tenotomy). Healing at 4 weeks was 98%, 96%, 81%, and 0%, respectively. The complication rate was very low, with the exception of "transfer lesions," where an adjacent toe became involved and needed subsequent tenotomy in 8% of tip-of-toe ulcers. CONCLUSIONS: Percutaneous tenotomy was an effective and safe method for treating toe ulcers in neuropathic patients. It was not effective in treating plantar metatarsal ulcers. LEVEL OF EVIDENCE: Level IV, case series.