Trapeziometacarpal Arthrodesis Using a Combination of Chevron Osteotomy, Longitudinal K-wire, and K-wire Compression Staples.

Among surgical methods for advanced trapeziometacarpal arthrosis, arthrodesis may benefit high-demand patients such as laborers because it preserves the osseous foundation of the thumb. The authors achieved successful trapeziometacarpal arthrodesis in 3 patients by a combination of chevron osteotomy, longitudinal K-wire, and K-wire compression staples without using bone graft. There were no complications specifically associated with the surgery other than asymptomatic slight pull-out of a staple. This combination is a good option for trapeziometacarpal arthrodesis, having the advantages of using a small incision and common devices and being low cost. [Orthopedics. 2018; 41(6):e894-e896.].

Cubital Tunnel Syndrome Caused by Anconeus Epitrochlearis Muscle.

OBJECTIVE: We evaluated the clinical manifestation and surgical results following operative treatment of cubital tunnel syndrome (CuTS) caused by anconeus epitrochlearis (AE) muscle. METHODS: Among 142 patients who underwent surgery for CuTS from November 2007 to October 2015, 12 were assigned to the AE group based on discovery of AE muscle; 130 patients were assigned to the other group. We analyzed retrospectively; age, sex, dominant hand, symptom duration, and weakness in hand. Severity of the disease was evaluated using the Dellon classification and postoperative symptom were evaluated using disability of arm shoulder and hand (DASH) and visual analogue scale (VAS) scores. Surgery consisted of subfascial anterior transposition following excision of AE muscle. RESULTS: AE muscle was present in 8.5% of all patients, and was more common in patients who were younger and with involvement of their dominant hand; the duration of symptom was shorter in patients with AE muscle. All patients showed postoperative improvement in symptoms according to DASH and VAS scores. CONCLUSION: The possibility of CuTS caused by AE muscle should be considered when younger patients have rapidly aggravated and activity-related cubital tunnel symptoms with a palpable mass in the cubital tunnel area. Excision of AE muscle and anterior ulnar nerve transposition may be considered effective surgical treatment.

Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft.

BACKGROUND: Vascularized bone grafts for the treatment of Kienböck's disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results obtained when a fourth extensor compartmental artery (ECA) bone graft was used to treat Kienböck's disease. METHODS: Between May 2009 and June 2012, 13 patients (6 men, 7 women) with Kienböck's disease were treated with placement of fourth ECA vascularized bone grafts. The mean patient age was 39.2 (20-58) years, and the mean follow-up period was 32.5 (12-72) months. At the time of surgery, One patient had Lichtman's stage II Kienböck's disease, 11 stage IIIA disease, and one stage IIIB disease. We measured the pre- and post-operative ranges of motion, pain, grip strength, and radiological parameters, including the carpal height ratio and the radioscaphoid angle. RESULTS: At the last follow-up, pain was significantly reduced, and grip strength had improved from 60.5% to 87.8% relative to that of the contralateral side. The mean range of motion for flexion had improved from 39° to 53° while that of wrist joint extension improved from 41° to 56°. There were little or no changes in either the carpal height ratio or the radioscaphoid angle (both p values > 0.05). CONCLUSIONS: Placing of a fourth ECA vascularized bone graft is a reliable alternative to other revascularization procedures for treatment of Kienböck's disease. Such grafting is effective, minimally invasive, and associated with a low risk of pedicle kinking. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

Multiple etiologies of trigger wrist.

BACKGROUND: Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. The clinical manifestations and surgical results of trigger wrist with multiple etiologies were evaluated. METHODS: From October 2008 to December 2012, this study retrospectively reviewed 15 patients diagnosed with trigger wrist. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29-86 years). The mean follow-up period was 16.2 months (range, 11-30 months). RESULTS: The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n = 5), severe tenosynovitis of the flexor tendon (n = 4), fibroma around the flexor tendon sheath (n = 2), a rheumatoid nodule (n = 1), both anomalous muscle belly and tenosynovitis (n = 1), a ganglion (n = 1), and pigmented villonodular synovitis (n = 1). Mild-to-moderate symptoms of median neuropathy without thenar muscle atrophy were present in all patients. Postoperatively, all patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent. CONCLUSIONS: Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

An intraosseous epidermal cyst developing in a metacarpal bone after K-wire fixation: a case report.

Intraosseous epidermal cysts (IECs) are rare benign lesions caused by the proliferation of epidermal cells within the bone. The pathogenesis of IEC remains unclear; however, trauma-triggered infiltration of the bone by epidermal elements has been suggested. Here, we present a case of an IEC in the metacarpal bone of the little finger associated with K-wire fixation for treatment of a fifth metacarpal fracture.

Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery.

OBJECTIVES: This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. DESIGN: Retrospective study. SETTING: University trauma center. PATIENTS AND INTERVENTION: We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. MAIN OUTCOME MEASUREMENTS: Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. RESULTS: Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. CONCLUSIONS: Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Spontaneous anterior interosseous nerve syndrome: clinical analysis of eleven surgical cases.

The aetiology of anterior interosseous nerve (AIN) syndrome and an optimal treatment strategy remain controversial. Eleven patients with spontaneous AIN syndrome, who were treated by surgical exploration, were reviewed at a mean of 32.5 months after the operation. Eight men and three women were included in the study. None of the patients had a history of trauma and there was no evidence of a neuropathy other than AIN syndrome. Six patients showed complete paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus of the index finger (FDS1). Five patients had incomplete paralysis, with isolated lesions of the FPL in two and the FDP1 in three. Surgery was performed 7.8 months after the onset of paralysis. The most common structure of nerve compression was a fibrous band of the flexor digitorum sublimis muscle. However, no definitive compression site or anatomic abnormality could be found in four patients. Ten of the 11 patients had recovered muscle strength above grade 4 within 12 months of the operation. Good results were obtained in 10 patients and fair in only one at final assessment. Four patients (one man and three women) raised cosmetic concerns due to excessive scar formation on the upper forearm. Surgical exploration is recommended only in cases where AIN syndrome is apparent, no other neuronal lesions are apparent, and where there was no recovery after 6 months of conservative treatment. Careful preoperative examination is essential to avoid misdiagnosis and inappropriate operation, particularly in cases of incomplete AIN syndrome.

Giant cell tumor with secondary aneurysmal bone cyst: a unique presentation with an ossified extraosseous soft tissue mass.

The authors describe a case of giant cell tumor (GCT) with secondary aneurysmal bone cyst (ABC) in a 44-year-old man with chronic, intermittent knee pain. A unique feature is the presentation of GCT with an ossified extraosseous soft tissue mass. Radiograph demonstrates a multiloculated lytic lesion in the distal meta-epiphyseal region of the femur with an adjacent extraosseous soft tissue mass. The soft tissue mass was partially ossified along its margin and internal septa. MRI demonstrates a multiloculated lesion in the distal femur with multiple fluid-fluid levels and cortical penetration of the lesion. Both the intraosseous lesion and extraosseous soft tissue mass have similar MR signal characteristics. At surgery, the intraosseous component was found to be contiguous with the extraosseous soft tissue mass through a cortical perforation. To the best of our knowledge, this is the first case report of GCT with aneurysmal bone cyst initially presenting with an extraosseous soft tissue mass.

Bilateral carpometacarpal joint dislocations of the thumb.

A traumatic carpometacarpal joint dislocation of the thumb accounts for less than 1% of all hand injuries. Optimal treatment strategies for this injury are still a subject of debate. In this article, we report a case of bilateral thumb carpometacarpal joint dislocations: a unique combination of injuries. We believe our case is the second report of bilateral carpometacarpal joint dislocation regarding the thumb in English literature. It was successfully treated with closed reduction and percutaneous K-wires fixation on one side, and an open reduction and reconstruction of the ligament on the other side.

Isolated fractures of the greater trochanter with occult intertrochanteric extension.

INTRODUCTION: Isolated fractures of the greater trochanter (GT) are relatively rare. The diagnosis can be done on routine radiographs, but it is difficult to fully define the geographic extent of these injuries. This study examined the pattern and extent of an injury shown by magnetic resonance imaging (MRI) and radionuclide bone scan (RBS) in patients whose plain radiographs revealed fractures limited to the GT. MATERIALS AND METHODS: Between July 2004 and October 2008, 25 patients who displayed an isolated GT fracture on plain radiograph examination were examined by both MRI and RBS due to a suspicion of an extension into the intertrochanteric (ITC) region. The patients were then divided into two groups. Group A patients had an isolated fracture of GT, and group B patients had an occult fracture of ITC. RESULTS: All 25 cases were caused by a low-energy injury and plain radiographs showed non-displaced or minimally displaced isolated GT fractures. For 22 of the 25 patients, the result agreed with MRI and RBS. However, three patients had focal increased uptake at the GT region only according to RBS and an extension of signal intensity into the ITC region according to MRI. Group A and B comprised 5 and 20 patients, respectively. Of the group B patients, 8 had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. Eleven of the 12 incomplete types showed an extension more than half way to the medial cortex. Fifteen group B patients underwent an internal fixation using a two-hole dynamic hip screw. CONCLUSION: Patients with an isolated fracture of GT can have a broader fracture extending into the ITC region than that diagnosed by standard radiographs. We recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.

Opponensplasty using palmaris longus tendon and flexor retinaculum pulley in patients with severe carpal tunnel syndrome.

INTRODUCTION: Thenar muscle atrophy is a common finding in long-standing severe carpal tunnel syndrome (CTS). Combination of carpal tunnel release and Camitz opponensplasty has been used to treat severe CTS with thenar muscle atrophy. Camitz opponensplasty is beneficial for abduction, but provides little benefit to thumb flexion and pronation. This problem could be overcome by the use of a pulley. MATERIALS AND METHODS: Twelve cases of long-standing CTS with severe thenar muscle atrophy in 11 patients were investigated. They were treated with the modified Camitz opponensplasty using a pulley at the ulnar side remnant of the flexor retinaculum at the time of carpal tunnel release. Outcome was assessed by clinical grade of thenar muscle atrophy, degree of thumb opposition and the patient's satisfaction. RESULTS: The average grade of thenar muscle atrophy improved from grade 3 pre-operatively to grade 0.83 at the last follow-up. Mean maximal palmar abduction improved from 3.6 to 6.8 cm, and spatial rotation improved from 54 degrees to 83 degrees . Kapandji tip opposition changed from 65 to 85% symmetry at the last follow-up. All 11 patients were 'very satisfied' or 'satisfied' with the outcome. CONCLUSION: Modified Camitz opponensplasty is a simple procedure that provides immediate improvement of thenar function. Palmar flexion and pronation can be further improved by addition of a pulley.

Coexisting avascular necrosis of the scaphoid and lunate.

Reports of coexisting avascular necrosis of more than one carpal bone are rare. We report coexisting avascular necrosis of the scaphoid and lunate in a 56-year-old woman with no history of using steroids or injury. We treated her with a radioscapholunate fusion with two angled 2.4 mm distal radius plates to stabilise the locking plate. At her 12-month follow up there was no evidence of non-union.

Treatment of popliteal pterygium using an Ilizarov external fixator.

Popliteal pterygium syndrome is a rare congenital disorder that consists of popliteal webs and craniofacial, genitourinary and extremity anomalies. Only moderate successful surgical excision of the fibrotic band within the popliteal web has been reported because the nerves and vessels in the affected site are short and displaced into the web and they are attached to adjacent tissues. We performed hamstring tenotomy on the ischial tuberosity, tenotomy of the flexor hallucis longus and Z-lengthening of the Achilles tendon on the ankle in our patient, and this was followed by gradual correction using an Ilizarov external fixator. Full extension of the knee joint was achieved at the ninth postoperative week. However, some recurrence of flexion contracture was noted at two years follow-up. Gradual soft tissue lengthening with an Ilizarov external fixator can be one of the optimal procedures when excision of a fibrous band and Z-plasty are not possible due to severe adhesion of the nerves and vessels into a fibrotic band. However, a cautious approach is recommended when considering the high risk of recurrence.

Simultaneous double dislocation of the interphalangeal joint in a finger.

Isolated traumatic dislocation of the distal and proximal interphalangeal joints of the fingers is a common occurrence. However, simultaneous dislocation of both interphalangeal joints in a single finger appears to be a rare event. We report five cases of simultaneous dislocation of both interphalangeal joints in a single finger with a review of the literature.

Extension limitation and deviation of fingers by the scarred junctura tendinum: a case report.

The juncturae tendinum (inter-extensor connections) are structures connecting each of the extensor digitorum communis (EDC) tendons. Nine months before the presentation to us, this 21-year-old man had painful swelling on the dorsum of the right hand after punching. At present, the patient showed an ulnar deviation of the long finger and a limited extension of the ring finger. The scarred junctura tendinum between long and ring fingers inhibited proximal sliding of the EDC tendon of ring finger, and affect the functions of adjacent metacarpophalangeal joint. The scarred junctura tendinum was resected, while the sagittal band was preserved to prevent subluxation of the EDC tendon of long finger. One year after operation, the range of motion of fingers was full.

Subtrochanteric fracture after free vascularised fibular grafting for osteonecrosis of the femoral head.

The aim of this study was to determine the incidence and factors associated with subtrochanteric fracture after free vascularised fibular grafting for osteonecrosis of the femoral head, and to analyse clinical and radiological outcomes of open reduction and internal fixation. From April 1991 to May 2004, eight such fractures were managed by Rowe plate fixation. Factors examined included age, gender, side of operation, cause and preoperative and postoperative stage of osteonecrosis, and preoperative and postoperative functional assessment. The osteonecrosis was caused by alcohol consumption in six, steroid use in one and was idiopathic in one case. The overall incidence of fracture was 4.1% (13.9% in bilateral operations) and all occurred in men of mean age 36.3 years, were induced by low-energy injury and were attributed to defects created in the lateral femoral cortex for graft placement. Seven of the eight fractures (87.5%) developed within 12 weeks and all fractures healed at a mean of 16.6 weeks after internal fixation. No major complications occurred and no significant differences were found in clinical or radiological results between the fracture and non-fracture groups. Our findings indicate that strict education and mandatory protection from full weight bearing are required for 12 weeks after free vascularised fibular grafting for osteonecrosis of the femoral head.