Correction of Congenital Ring-Little Finger Metacarpal Synostosis Through Simultaneous Interpositional Allograft Bone After Split Osteotomy of the Synostosis Site and Distraction Lengthening of the Fifth Metacarpal.

PURPOSE: We attempted a technique for patients with congenital ring-little finger metacarpal synostosis involving simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal along with correction of the metacarpal joint abduction contracture. The purpose of this study was to describe the surgical technique and its outcomes. METHODS: We reviewed the medical records of children with congenital ring-little finger metacarpal synostosis treated surgically at our institute. Eight hands of six children with an average age of 5.0 (range, 1.7-9.3) years were treated by simultaneous interpositional allograft bone after split osteotomy, distraction lengthening, and tenotomy of abductor digiti minimi. We measured the metacarpal head-to-capitate area ratios from serial radiographs and analyzed them according to age. We also measured the change in the intermetacarpal angle (IMA) and metacarpal length ratio during an average of 8.1 (range, 1.4-16.8) years of follow-up. These changes were compared with changes in seven hands of five children with an average age of 8.1 (range, 1.5-15.6) years treated by the same method, but without a distraction lengthening of the fifth metacarpal and followed up for an of average 12.1 (range, 4.1-19.8) years, as a control group. RESULTS: Abnormal metacarpal head-to-capitate area ratio before surgery was normalized in all patients within the first 2 years after surgery. The IMA change averaged 39.8°, and the metacarpal length ratio changed by 17%. The control group showed an average IMA change of 36.6° and metacarpal length ratio change of 6%. CONCLUSIONS: Simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal with correction of metacarpal joint abduction contracture can restore the radiographic parameters in congenital ring-little finger metacarpal synostosis. The normalized ossification of the fifth metacarpal head indicates that the surgical procedure is probably safe. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Computed Tomography Evaluation of Forearm and Hand Muscles in Patients With Distal Radius Fracture.

INTRODUCTION: Computed tomography (CT) can be used to assess bone status with measurement of Hounsfield unit (HU). The objective of this study was to evaluate whether HU of muscle might be associated with parameters of bone and muscle status. METHODS: We reviewed 71 women aged over 50 yr of age who had distal radius fracture and underwent CT evaluation of affected wrist. We assessed HUs of forearm flexor muscles (flexor digitorum superficialis) and thenar muscles and bone HUs at the capitate and the ulnar head. Other parameters included femur neck and lumbar bone mineral density (BMD), upper extremity lean mass, hand grip strength, and muscle fiber cross-sectional area. We performed correlation analyses to determine associations between variables. RESULTS: Thenar and forearm muscle HUs were significantly correlated with each other, but not with other parameters. HUs of the capitate and ulnar head were positively correlated with femur neck and lumbar BMDs and inversely correlated with age. Ulnar head HU was positively correlated hand grip strength. CONCLUSIONS: HUs of forearm and thenar muscles did not show significant correlations with bone or muscle parameters, although bone HUs correlated well with bone mineral densities. These results support the opportunistic use of CT for evaluating bone fragility. Clinical usefulness of muscle HU measurement needs further studies.

Diagnosis of Neurogenic Thoracic Outlet Syndrome Based on the Clinical Status.

OBJECTIVES: At our institute, we devised a clinical algorithm for diagnosis of neurogenic thoracic outlet syndrome (TOS). Our approach assisted in the accurate diagnosis and in detection of patients likely to benefit from surgical treatment. The purposes of this study were to propose our diagnostic approach to neurogenic TOS, and to describe the outcomes of surgical and conservative treatment. METHODS: Patients (n = 91) who were suspected to have neurogenic TOS, and therefore, underwent a routine clinical protocol from January 2012 to January 2018 were reviewed. Through the clinical protocol, diagnosis of "true neurologic TOS", "symptomatic TOS", and "not likely TOS" was made. The visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder and Hand (DASH) score were used to assess the treatment outcomes. Satisfaction with surgery was assessed according to the Derkash classification as excellent, good, fair, or poor. RESULTS: Among 91 patients with presumed neurogenic TOS, 25 patients were "true neurologic TOS", 61 patients were "symptomatic TOS", and five patients were "not likely TOS". Nineteen patients underwent supraclavicular decompression of the brachial plexus whose mean age at the time of surgery was 36.4 years. The VAS average pain score improved from 3.6 to 0.8, and the DASH score improved from 38.4 to 17.1. According to the Derkash classification, ten patients (53%) rated their recovery as excellent, four (21%) as good, and five (26%) as fair. Sixty-seven patients underwent conservative treatment. At the last follow-up visit, their VAS and DASH score were 2.3 and 11.8, respectively. CONCLUSIONS: By using an algorithm, we diagnosed the patients suspected to have neurogenic TOS into three groups based on clinical status. We surgically treated 19 patients using supraclavicular approach, and achieved favorable outcomes.

Early Surgical Treatment of Both Tumor and Fracture in Patients With Enchondroma of the Hand Combined With Pathologic Fracture.

PURPOSE: The aims of this study were to evaluate the degree of cortical thinning and the tumor area in simple radiographs in patients with enchondroma of the hand combined with pathologic fracture and to determine the surgical outcome of simultaneous tumor curettage and internal fixation of fracture. METHODS: We enrolled 23 bone lesions of 21 patients diagnosed with enchondroma of the hand. Of them, 9 bone lesions of 8 patients had pathologic fracture. We evaluated the degree of cortical thinning and tumor area in simple radiographs and compared them between patients with and without pathologic fracture. For patients with pathologic fracture, we performed curettage of the tumor through the fracture site and fixed the fracture using K-wires. We then evaluated the clinical outcome of these patients using the visual analog scale to measure pain intensity and Takigawa's criteria 1 year after surgery. RESULTS: There was a significant difference in the degree of cortical thinning between the 2 groups (P < 0.001); however, there was no significant difference in the percentage of tumor area (P = 0.259). The average time from surgery to bony union was 8.5 weeks in patients with pathologic fracture. The patients reported that they could return to their previous activities of daily living within 12 weeks of surgery. The average visual analog scale score was 0.6 at 1 year after surgery, and 6 patients were graded as excellent and 2 as good according to Takigawa's criteria. CONCLUSIONS: Cortical thinning seems to be related to pathologic fracture. Our scoring system for cortical thinning may be helpful in evaluating the risk for pathologic fracture. Early 1-stage surgical treatment for pathologic hand fracture with enchondroma is a very useful method with satisfactory outcomes that could shorten the treatment period.

Prevalence and distribution of MRI abnormalities in the articular cartilage and supporting ligaments in patients with early clinical stage first carpometacarpal joint osteoarthritis.

OBJECTIVE: We used magnetic resonance imaging (MRI) to evaluate where articular degeneration begins and which ligaments are most often involved in the early clinical stage first carpometacarpal joint (CMCJ-1) osteoarthritis. MATERIALS AND METHODS: We retrospectively analyzed the MRI findings of 26 patients with early clinical stage CMCJ-1 osteoarthritis and no radiologic abnormalities and 19 control patients without CMCJ-1 pain or osteoarthritis who underwent MRI for dorsal or ulnar wrist pain. Two observers blinded to group and clinical findings independently assessed the presence of chondral defects in four quadrants of the CMCJ-1: volar-ulnar (VU), volar-radial (VR), dorso-ulnar (DU), and dorso-radial (DR). The integrity of the four major ligaments of the CMCJ-1, i.e., the anterior oblique ligament (AOL), the intermetacarpal ligament (IML), the posterior oblique ligament (POL), and the dorsal radial ligament (DRL), was assessed. The observer reliability was analyzed using Cohen's kappa coefficient. The prevalence of cartilage lesions and ligament abnormalities in the osteoarthritic and control patients was compared using Fisher's exact test. RESULTS: Cartilage lesions were significantly more common in the VU quadrant of the trapezium in the osteoarthritic patients than in the control patients (17/26 vs. 2/19; P = 0.002). AOL abnormalities were more common in the osteoarthritic patients than in the control patients (14/26 vs. 3/19; P = 0.009). CONCLUSION: The MRI findings of early clinical stage CMCJ-1 osteoarthritis commonly demonstrated cartilage lesions in the VU quadrant of the trapezium and ligament abnormalities in the AOL.

Is Thumb Proprioception Decreased in Patients With Trapeziometacarpal Joint Osteoarthritis?

Proprioception is thought to be essential for normal joint homeostasis, and its decreased function has been associated with an increased risk of joint diseases. However, only a few studies have been performed on the association between proprioceptive function in the trapeziometacarpal joint (TMCJ) and osteoarthritis. The purpose of this study was to compare TMCJ proprioceptive function in elderly women with radiographic TMCJ osteoarthritis relative to age-matched control women without osteoarthritis. We enrolled 19 women (mean age, 66 years) with symptomatic, radiographic Eaton and Littler grade 2, 3, and 4 TMCJ osteoarthritis and 19 age-matched control women without osteoarthritis. We evaluated thumb proprioception by using a joint-position reproduction test and compared the reposition error (RE) between the groups. We carried out a multivariate analysis for factors potentially associated with increased RE, such as age, body mass index, hand dominance, the presence of diabetes, pain level, and the presence of osteoarthritis. Also, a logistic regression analysis was performed for factors associated with the occurrence of TMCJ osteoarthritis. Patients with TMCJ osteoarthritis had greater RE than did the control patients in the joint-position reproduction test at 20°, 30°, and 40° of thumb palmar abduction. The multivariate analysis indicated that increased RE was associated with the presence of osteoarthritis, but not with the other factors assessed. The occurrence of TMCJ osteoarthritis was associated with increased RE at 20°, 30°, and 40° of thumb palmar abduction. This study showed that decreased proprioceptive function was associated with the presence of osteoarthritis in the TMCJ, although the causality remains unknown. Further studies on the role of proprioception in the pathogenesis of TMCJ osteoarthritis and the potential role of its training for disease prevention or treatment are required.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly.

PURPOSE: The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities. METHODS: Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment. RESULTS: Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges. CONCLUSIONS: Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Is There a Relation Between Lateral Epicondylitis and Total Cholesterol Levels?

PURPOSE: To investigate whether high total cholesterol (TC) levels are associated with lateral epicondylitis (LE). METHODS: We retrospectively reviewed all patients with LE who presented to our institution between 2011 and 2015. The inclusion criteria were a diagnosis of LE based on clinical history and physical examination findings and age between 40 and 55 years. For healthy controls, we obtained data from a national cohort (sixth Korean National Health and Nutrition Examination Survey) aged between 40 and 55 years. We compared TC levels between the groups, determined the incidence of hypercholesterolemia (TC level ≥ 240 mg/dL) according to the occurrence of LE, and calculated odds ratios for the occurrence of LE. We also evaluated whether cholesterol levels were associated with clinical findings of LE, such as pain level, onset age, symptom duration, and number of corticosteroid injections. RESULTS: The study comprised 289 patients with LE (mean age, 47.9 years) and 1,077 healthy individuals (mean age, 47.7 years). TC levels were significantly higher in patients with LE than in healthy individuals (205.0 mg/dL vs 194.6 mg/dL, P < .001). The mean difference of 10.4 mg/dL was clinically meaningful because a change of 10 mg/dL with medical intervention is considered significant. The incidence of hypercholesterolemia was higher in LE patients than in healthy controls (16.6% vs 9.0%, P < .001). After adjustment for age, sex, body mass index, and glucose level, patients with hypercholesterolemia (TC level ≥ 240 mg/dL) were 2.47 (95% confidence interval, 1.65-3.70) times more likely to experience LE than those with normal cholesterol levels (<200 mg/dL). TC levels correlated with pain level, onset age, and number of corticosteroid injections. CONCLUSIONS: A clinically meaningful difference in TC levels was found between LE patients and healthy controls. In addition, the incidence of hypercholesterolemia was higher in LE patients than in controls. The present findings suggest a potential association between high TC levels and LE. LEVEL OF EVIDENCE: Level III, case-control study.

The Effect of Vitamin D Deficiency Correction on the Outcomes in Women After Carpal Tunnel Release.

PURPOSE: Studies suggest that vitamin D supplementation improves myelination and recovery after nerve injuries. The purpose of this study was to evaluate whether correction of vitamin D level leads to better surgical outcomes in women with both carpal tunnel syndrome (CTS) and vitamin D deficiency. METHODS: We retrospectively reviewed 84 vitamin D-deficient women with CTS who underwent carpal tunnel release and then received daily vitamin D supplementation of 1,000 IU vitamin D for 6 months. We also reviewed 35 control patients who were vitamin D-nondeficient at baseline and thus did not receive the supplementation. At baseline and 6 months after surgery, we measured serum vitamin D levels, the Disabilities of the Arm, Shoulder, and Hand (DASH) score, motor conduction velocity, and grip and pinch strengths. We compared the outcomes of CTS related to vitamin D levels. We also correlated baseline and follow-up vitamin D levels with the assessed parameters. RESULTS: At 6 months, 59 patients became vitamin D-nondeficient (≥ 20 ng/mL) and 25 were still vitamin D-deficient (< 20 ng/mL). Patients who became vitamin D-nondeficient had subtle but better DASH scores than patients who were still vitamin D-deficient or the control patients. Vitamin D levels at 6 months were found to have significant correlation with the DASH score at 6 months. Vitamin D levels at 6 months did not have significant correlation with motor conduction velocity or grip and pinch strengths. CONCLUSIONS: Women with CTS and vitamin D deficiency showed subtle but better DASH scores after surgery when vitamin D deficiency was corrected by supplementation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Quantitative Measurements of the Cross-sectional Configuration of the Flexor Pollicis Longus Tendon Using Ultrasonography in Patients With Pediatric Trigger Thumb.

PURPOSE: Pediatric trigger thumb is regarded as an acquired condition characterized by flexion deformity of the interphalangeal joint of the thumb. However, the exact etiology and pathoanatomy of this condition remain unknown. The purpose of this study was to evaluate cross-sectional configurations of the flexor pollicis longus (FPL) tendon and the area under the A1 pulley quantitatively using ultrasonography. METHODS: In this study we enrolled 43 patients, 23 boys and 20 girls, with unilateral pediatric trigger thumb. We measured the anteroposterior (AP) diameter, radioulnar diameter, and cross-sectional area of the FPL tendon at the level of the greatest AP diameter of the FPL tendon proximal to the A1 pulley and those of the inner dimensions of the A1 pulley using ultrasonography. The measurements were repeated on the contralateral side. Average age at the time of the measurements was 32 months. RESULTS: Average AP and radioulnar measurements of the FPL tendon were 13% and 55% larger than those of the inner dimensions of the A1 pulley in the trigger thumb. The average AP measurement in the area under the A1 pulley was notably larger in the trigger thumb than on the normal side. CONCLUSIONS: Using ultrasonographic measurements, we were able to identify enlargement of the FPL tendon proximal to the A1 pulley in the symptomatic thumb, compared with the area under the A1 pulley in the symptomatic thumb or FPL tendon on the contralateral side. Developmental mismatch between the FPL tendon and the area under the A1 pulley is a possible cause of pediatric trigger thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Radial polydactyly: proposal for a new classification system based on the 159 duplicated thumbs.

BACKGROUND: Polydactyly is one of the most common congenital differences that affect the hand. It has various anatomic and morphologic features. Although the Wassel classification has been used widely for radial polydactyly, it is based on the anatomic level of duplication and has some limitations in describing the concrete morphology of the duplication. The authors devised a new classification system based on the anatomic pattern of duplication to facilitate surgical correction of the deformity and evaluated surgical outcomes. METHODS: A total of 159 duplicated thumbs in 142 patients who were treated surgically from 1990 to 2007 and followed for > 12 months were included in this series. The authors categorized all cases of radial polydactyly into the following: type I (joint type), where the extra digit has its own joint at its origin; type II (single epiphyseal type), where the origin of the extra digit is derived directly from the common epiphysis; type III (osteochondroma-like type), where the origin of the extra digit resembles an osteochondroma; and type IV (hypoplastic type), where the extra digit is connected to the main digit by soft tissue alone. All patients underwent surgical treatment based on this classification. The surgical outcomes were assessed using the Tada score. RESULTS: Of the 159 radial polydactyly cases, 84 (50%) were classified as the joint type-37 (22%) as the osteochondroma-like type, 33 (19%) as the single epiphyseal type, and 15 (9%) as the hypoplastic type. All the cases were classified with the proposed classification system. In the evaluation of the surgical outcomes, 134 (84%), 17 (11%), and 8 (5%) were rated as good, fair, and poor, respectively. CONCLUSIONS: This new classification system for radial polydactyly is practical and closely related to the surgical strategies. LEVEL OF EVIDENCE: Diagnostic IV.

A quantitative measurement of trapeziometacarpal joint pressure using a cadaveric model of lateral pinch.

Trapeziectomy is performed for trapeziometacarpal (TMC) arthritis but decreased lateral pinch strength is a major source of discomfort after the surgery. The magnitude of the decrease is unclear, however, and how the pressure changes in the TMC joint is unknown. To investigate this relationship, we designed a cadaveric study to measure TMC joint pressure using a lateral pinch model, and quantitatively evaluated the effect of trapeziectomy on the pressure measurements. For 10 cadaveric forearms, physiologic forces were applied across the thumb TMC joint by loading five tendons, thereby simulating lateral pinch. Using pressure sensors, we measured the lateral pinch pressure and TMC joint pressure, which averaged 10.1 (range, 4.2-16.2) kg/cm2 and 2.0 (range, 0.8-4.4) kg/cm2 , respectively. A significant correlation between the measurements was found, with an average ratio of 19% (range, 10%-27%). After trapeziectomy and interposition of the tendon ball using flexor carpi radialis, the pressure measurements were repeated under the same conditions. Significant changes were found, which averaged 5.1 (range, 1.7-10.7) kg/cm2 for lateral pinch pressure and 15.0 (range, 5.6-25.6) kg/cm2 for TMC joint pressure. In conclusion, TMC joint pressure could be measured as the ratio relative to lateral pinch pressure using a cadaveric model. After trapeziectomy, the lateral pinch strength decreased, whereas the TMC joint pressure increased.

Rotational osteo-onychocutaneous flap for central polydactyly of the foot: A novel technique for correction of the deformity.

Eccentric location of two nails like eyes of a bird are frequently observed in central polydactyly of the foot. A novel technique of rotational osteo-onychocutaneous (OOC) flap procedure is introduced to correct this deformity. Six children with central polydactyly of the foot who showed eccentric locations of nails were operated by this technique. Four patients were distal phalangeal type, and two middle phalangeal type. Preoperatively the angulation deformity of distal phalangeal type was average 16.8 (range, 2.3-48.0) degrees, and middle phalangeal type 10.3 (range, 2.9-17.7) degrees. The rotational OOC flap procedure was performed at average 24 (range, 12-51) months of age. Cosmetic and radiographic assessments were done after an average of 42 (range, 6-79) months of follow-up. All patients and their parents were satisfied with the cosmetic results. The angulation deformity was improved to average 4.2 (range, 0.5-11.2) degrees in distal phalangeal type, and 5.9 (range, 2.0-9.8) degrees in middle phalangeal type, respectively. Postoperative residual angulation deformity measured by simple radiographs were less than 5° in all patients. Complications such as partial necrosis of the flap were not found. In conclusion, our novel technique of rotational OOC flap procedure resulted in satisfactory outcome for patients with 'eyes of a bird' type toe nail deformity of central polydactyly of the foot. It corrected the angulation and rotational deformity of the toe nail of the main digit without causing any complications.

The Natural History of Kienböck's Disease Diagnosed at More than 50 Years of Age.

Background: Previous literatures suggest that the prognosis of Kienböck's disease might be favorable despite no surgery if it is diagnosed in late age, but the evidence is not clear. The aim of this study was to determine the radiographic and clinical progression of Kienböck's disease diagnosed at more than 50 years of age. Methods: Data of 27 patients diagnosed with Kienböck's disease at more than 50 years of age between 2000 and 2016 were investigated. During the study period, no treatment, either surgical or nonsurgical, was applied. We explained to the patients that the affected lunate was not expected to collapse further if found late in age. Annual visits were recommended, through which radiographic and clinical observation was made. We assessed changes in Stahl index and radioscaphoid angle between the initial assessment and the final follow-up, and clinical assessment was made using pain in visual analog scale (VAS) and Dornan's criteria. Results: Initially, 2 patients were in Lichtman stage 1, 6 in stage 2, 5 in stage 3A, 11 in stage 3B, and 3 in stage 4. Radiographic follow-up of at least 5 years (mean, 7.8 years) was made in 14 patients, whose Stahl index and radioscaphoid angle did not differ significantly from their initial measurements. Arthritic appearance was not found, and progression in the Lichtman stage was detected in 1 lunate, from 3A to 3B. Despite no surgical treatment for an average of 7.5 years (range, 5.0-15.7 years) of observation period in the 27 patients, average pain in VAS improved from 3.5 (range, 1-7) to 0.8 (range, 0-2), with excellent or good clinical status by Dornan's criteria. Conclusions: Our study suggests that Kienböck's disease diagnosed at more than 50 years of age can follow a benign natural course in radiographic and clinical aspects. Therefore, surgical interventions should be considered carefully in this age group.

Improving Understanding and Outcomes in Congenital Hand Differences.

SUMMARY: It is very important for us, the surgeons, to understand the difficulties of parents who have a baby with a congenital hand difference, not only because the parents are the decision makers for the operation but also because they need consolation and care to overcome their distress. The psychological and physical developmental milestones of the child with a congenital hand difference should be considered to achieve a satisfactory surgical outcome from the viewpoint of both the surgeon and the child. Even experts in congenital hand differences may have difficulties in decision-making with regard to certain entities because of the clinical diversity and rarity. Communication among surgeons who are interested in congenital hand differences, through social networking services or other communication tools, is very helpful and effective for the exchange of knowledge and experiences. Although the final decision should be made by the surgeon, many questions and answers from friends and colleagues will lead to better decisions.

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition - A Case Series.

BACKGROUND: Various surgical techniques have been attempted to treat patients with failed anterior subcutaneous transposition performed for cubital tunnel syndrome. OBJECTIVE: To analyze intraoperative findings of failed anterior subcutaneous transposition and to report the outcome of in Situ neurolysis of ulnar nerve. METHODS: Patients who, under diagnosis of failed anterior subcutaneous transposition of ulnar nerve, underwent in Situ neurolysis between 2001 and 2018 were included in this study. We excluded patients with follow-up of less than one year, records of traumatic ulnar nerve injury, and concomitant double crush syndrome such as cervical spondylosis causing radicular pain, ulnar tunnel syndrome, or thoracic outlet syndrome. Surgical outcomes were evaluated using visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder, and Hand (DASH) score, which were assessed before and after surgery. A total of 28 elbows in 27 patients whose average age was 58.5 (range, 31-76) yr were enrolled, and the duration of follow-up was 5.8 (range, 1.0-14.9) yr. RESULTS: The most common pathologic finding identified during operation was severe adhesion of the transposed nerve in all elbows, followed by incomplete decompression of deep flexor-pronator aponeurosis in 26 elbows (93%). The average VAS pain score improved from 4.9 (range, 2-7) to 1.3 (range, 0-5), and the average DASH score from 31.7 (range, 18.1-66.7) to 14.1 (range, 5.0-46.6). Of the 28 elbows, 27 (96.4%) showed improvement of preoperative symptoms. CONCLUSION: In Situ neurolysis of ulnar nerve for patients with failed anterior subcutaneous transposition resulted in satisfactory outcome.

Measurement of compensatory wrist joint rotation using three-dimensional motion analysis in patients with unilateral proximal congenital radioulnar synostosis.

OBJECTIVE: This study aims to investigate compensatory rotational movements of the wrist joint in patients with proximal congenital radioulnar synostosis (CRUS), using a valid and reliable three-dimensional (3D) motion analysis technique. METHODS: A total of 26 patients (6 females, 14 males; mean age=15.3 years; and age range=6-32 years) who were diagnosed with unilateral proximal CRUS but were not operated were enrolled in this study. Patients were then categorized into 2 groups: Group I included 5 patients younger than 10 years, and Group II included 15 patients older than 10 years. Eighteen light-reflective skin markers were placed on the bony landmarks of both upper limbs, and both distal forearms were fixed using a U-shaped device to minimize forearm rotation. Each patient grasped the handle of an instrument that used a goniometer to measure wrist rotation; maximal passive pronation and supination angles of the wrist were measured in this manner and also using 3D motion analysis. RESULTS: There was a significant correlation between measurements by the goniometer and 3D motion analysis (r=0.985, p<0.001). The test-retest reliability of the 3D motion analysis was acceptable for both the affected side (ICC=0.992) and the contralateral normal side (ICC=0.997) with low standard measurement errors (1.3° and 0.8°, respectively). Although no significant difference was observed in the range of the wrist rotation between the affected and contralateral sides in Group I (p=0.686), there was a significant difference in the wrist rotation between the affected and contralateral sides in Group II (p=0.001). Further, the pronation angle of the wrist joint was significantly larger in the affected side than that in the contralateral normal side in Group II (p=0.001). CONCLUSION: The 3D motion analysis technique seems to be a valid and reliable method to measure the rotation of the wrist joint. Unilateral proximal CRUS patients older than 10 years of age may develop rotational hypermobility of the wrist joint compared to the contralateral normal side as a compensatory phenomenon. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

When Is Primary Metacarpal Corrective Osteotomy Recommended in Patients with Flatt Type IV Radial Polydactyly?

BACKGROUND: The aim of this study was to determine when primary metacarpal corrective osteotomy is recommended in patients with Flatt type IV radial polydactyly. METHODS: A total of 78 patients with Flatt type IV radial polydactyly were included. The authors performed metacarpal osteotomy if the angulation of the metacarpophalangeal joint was not correctable by the intraoperative radial stress test. The authors measured the metacarpal deviation angle of the thumb in simple posteroanterior radiographs. The clinical outcomes were assessed using Japanese Society for Surgery of the Hand evaluation total score and the metacarpal deviation angle correction angle. These outcomes were compared between the patients who underwent metacarpal osteotomy and those who did not. Of the patients who did not undergo metacarpal osteotomy, the relationships between preoperative metacarpal deviation angle and the metacarpal deviation angle correction angle were formulated using segmented linear regression analysis. RESULTS: There were no significant differences in the demographic features and the value of preoperative metacarpal deviation angle between the two groups. However, the metacarpal deviation angle correction angle and Japanese Society for Surgery of the Hand evaluation total score were significantly higher in the patients who underwent metacarpal osteotomy. The segmented linear regression analysis demonstrated a breakpoint, indicating that the soft-tissue procedure alone does not sufficiently correct the metacarpal deviation angle. For the postoperative metacarpal deviation angle to be 5 degrees, the preoperative metacarpal deviation angle was calculated as 10.8 degrees. CONCLUSION: If the preoperative metacarpal deviation angle is greater than 10.8 degrees, metacarpal osteotomy can be considered even in patients with correctable metacarpophalangeal joint by intraoperative radial stress test. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture.

OBJECTIVE: We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. METHODS: We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively. RESULTS: Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94. CONCLUSION: Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.

Nerve Repair and Orthodromic and Antidromic Nerve Grafts: An Experimental Comparative Study in Rabbit.

PURPOSE: Although many surgeons have anecdotally described reversing the polarity of the autograft with the intent of improving regeneration, the optimal orientation of the autogenous nerve graft remains controversial. The aim of this study was to compare (1) the outcomes of orthodromic and antidromic nerve grafts to clarify the effect of nerve graft polarity and (2) the outcome of either form of nerve grafts with that of nerve repair. METHODS: In 14 of the 26 rabbits used in this study, a 1 cm defect was made in the tibial nerve. An orthodromic nerve graft on one side and an antidromic nerve graft on the other were performed using a 1.2 cm long segment of the peroneal nerve. In the remaining 12 rabbits, the tibial nerve was transected completely and then repaired microscopically on one side but left untreated on the other. Electrophysiologic studies were performed in all animals at 8 weeks after surgery, and the sciatic nerves were harvested. RESULTS: Compound motor action potential was visible in all rabbits treated by nerve repair but in only half of the rabbits treated by nerve graft. There was no significant difference in the compound motor action potential, nerve conduction velocity, or total number of axons between the orthodromic and antidromic nerve graft groups. However, in both groups, the outcome was significantly poorer than that of the nerve repair group. CONCLUSION: There was no significant difference by electromyographic or histologic evaluation between orthodromic and antidromic nerve grafts. Direct nerve repair with moderate tension may be a more effective treatment than nerve grafting.