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.

Cleft hand in Kabuki make-up syndrome: case report.

Kabuki make-up syndrome (KMS) is a multiple malformation/mental retardation syndrome that was first described in Japan but is now reported in many other ethnic groups. Kabuki make-up syndrome is characterized by multiple congenital abnormalities: craniofacial, skeletal, and dermatoglyphic abnormalities; mental retardation; and short stature. Common hand anomalies associated with KMS include persistent fingertip pad, brachydactyly, clinodactyly, and lax joints. We report a patient with KMS who presented with cleft hand, a feature that has not yet been described in KMS, and describe the potential genetic cause.

Age- and site-related bone mineral densities in Korean women with a distal radius fracture compared with the reference Korean female population.

PURPOSE: To assess age- and site-related bone mineral density (BMD) values in Korean female patients with a distal radius fracture, and to compare them with those of the community-based general Korean female population. METHODS: For this study, we recruited 54 consecutive Korean women, 50 to 79 years of age, with a distal radius fracture caused by minor trauma. We performed dual-energy x-ray absorptiometry scans at central sites: the lumbar spine, femoral neck, trochanter, and Ward's triangle, which is a triangular area within the femoral neck. Age- and site-related BMDs were assessed and compared with those of population-based reference data for Korean women. RESULTS: The overall prevalence (defined as meeting the osteoporosis criteria in at least one of the earlier-described measurement areas) of osteoporosis in patients with a distal radius fracture was 57%. The site-related prevalence was 54% at Ward's triangle, 43% at the lumbar spine, 32% at the femoral neck, and 26% at the trochanter, and these values were individually statistically significantly higher than those of the general Korean female population except for the lumbar spine. In patients 50 to 59 and 70 to 79 years of age, patients' mean BMD values at the hip were statistically significantly lower than those of the reference female population of corresponding age groups, but the hip BMD differences were not statistically significant in patients 60 to 69 years of age. There were no statistically significant BMD differences measured at the lumbar spine in any age group. CONCLUSIONS: Korean female patients with a distal radius fracture, 50 to 59 and 70 to 79 years of age, had lower BMDs at the hip than the reference Korean female population. However, no statistically significant BMD differences were found in those 60 to 69 years of age. Low BMD may have a greater impact on distal radius fracture in women younger than 60 years of age or over 70 years of age. Considering the young onset of bone loss, patients younger than 60 years of age with a distal radius fracture are a good target group for secondary prevention of osteoporosis.

Incidence of clinically diagnosed and surgically treated carpal tunnel syndrome in Korea.

PURPOSE: Most epidemiologic studies on carpal tunnel syndrome (CTS) have been performed on specific regional or occupational groups, or on general populations in the West. The authors undertook to determine the incidence of clinically diagnosed and surgically treated CTS in the Korean general population. METHODS: A retrospective, nationwide cohort study was performed using data collected from 2005 to 2007 (inclusive) by the Korean Health Insurance Review Agency, which covers 97% of the population. We analyzed the incidence of clinically diagnosed, electrophysiologically diagnosed, and surgically treated CTS in patients aged over 20 years, and the influences of gender and age on incidence. RESULTS: The incidence of total clinically diagnosed CTS and electrophysiologically diagnosed CTS in patients over 20 years of age was 4.96 and 0.98 per 1,000 person-years, respectively. The incidence of surgically treated CTS was 0.29 per 1,000 person-years. The age-adjusted female to male incidence ratio of diagnosed CTS was 2.58 (95% confidence interval, 2.56-2.59) and that of surgically treated CTS was 5.82 (95% CI, 5.64-6.00). Women aged 50 to 59 years had the highest incidence of CTS (18.11 per 1,000 person-years), whereas men showed a slow increase in incidence with age, highest at 60 to 69 years. CONCLUSIONS: Compared with Western studies, our study of the Korean population shows a similar incidence of CTS but a lower incidence of surgery. Korean women with CTS are more likely to be treated surgically than men. Further studies may be warranted to identify ethnic, gender, and socioeconomic factors that influence surgical treatment rates.

Bone invasion by squamous cell carcinoma in situ (Bowen's disease) of the finger during treatment with imiquimod 5% cream: case report.

Imiquimod 5% cream is known as an alternative treatment option for squamous cell carcinoma in situ (SCCIS), frequently termed Bowen's disease. Although imiquimod cream has been reported by many authors to treat SCCIS successfully, its efficacy and safety have not been fully established. The authors experienced a case in which ray amputation was necessary because of bone invasion by SCCIS in a finger being treated with imiquimod cream.

Failure of the interosseous membrane to heal with immobilization, pinning of the distal radioulnar joint, and bipolar radial head replacement in a case of Essex-Lopresti injury: case report.

The authors report a case of a patient with complex radial head and ulnar shaft fractures with an associated tear of the interosseous membrane, which failed to heal despite open reduction internal fixation of the ulna, a bipolar radial head replacement, and cross pinning of the distal radioulnar joint. This case demonstrates that failure of the interosseous membrane can occur even in a properly replaced bipolar radial head with adequate immobilization of the forearm and pinning of the distal radioulnar joint.

Evaluation of early postoperative pain and the effectiveness of perifracture site injections following volar plating for distal radius fractures.

PURPOSE: Few studies have investigated the effectiveness of early postoperative pain control regimens after volar plating for distal radius fractures. This study evaluated postoperative levels of pain after volar plating of distal radius fractures under axillary nerve block in patients with and without injections of local anesthetics, narcotics, and epinephrine around the fracture site. METHODS: Perioperative pain levels were prospectively assessed in 44 consecutive patients who had had volar plating for a distal radius fracture under axillary nerve block at a mean time of 2.8 days after trauma. Intravenous, patient-controlled analgesia and prescheduled analgesic medications were administered to all patients. In addition, patients were randomly allocated to 2 groups: perifracture site injection (PI; n = 22) and no perifracture site injection (no-PI; n = 22). At the end of surgery, PI group patients were administered perifracture site injections and blocks of the superficial radial and interosseous nerves with a local anesthetic mixture consisting of ropivacaine, morphine, and epinephrine. During the first 48 hours after surgery, pain visual analog scale (VAS) scores (0 to 100), total amount of narcotic consumption, incidences of additional narcotic requirement, and opioid-related side effects were assessed. RESULTS: The overall mean pain VAS scores among all 44 study subjects were 29 before surgery, and 58, 47, 40, and 27 at 4, 8, 24, and 48 hours after surgery, respectively. Thirteen patients needed additional pain rescue despite the multimodal analgesic approach used. No intergroup differences were observed between the PI and no-PI groups in terms of VAS pain scores, total narcotic consumption, adjuvant pain rescue incidence, and opioid-related side effects. CONCLUSIONS: Postoperative mean pain VAS scores after volar plating of distal radius fractures were found to be 58 at 4 hours and 47 at 8 hours. Perifracture site injections were not found to provide any additional pain control benefit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Delayed-onset ulnar neuropathy at the wrist associated with distal radioulnar joint arthritis after radius malunion: report of two cases.

Although ulnar neuropathy can occur at the wrist in association with distal radius fractures, few late-onset cases have been reported. The authors describe 2 cases of delayed-onset ulnar neuropathy at the wrist, which developed 12 and 30 years after sustaining a conservatively treated distal radius fracture. During late neurolysis, both patients were found to have a perforation in the volar wrist capsule and synovitis and arthritis in the distal radioulnar joint.

Functional outcomes after upper extremity surgery for cerebral palsy: comparison of high and low manual ability classification system levels.

PURPOSE: The heterogeneity of cerebral palsy makes interpretation and prediction of outcome after upper extremity surgery difficult. We hypothesized that the outcome of upper extremity surgery for cerebral palsy is related to the Manual Ability Classification System (MACS) level. METHODS: We reviewed 27 patients with a mean age of 22 years, who underwent upper extremity surgery for spastic cerebral palsy at a mean follow-up of 29 months. Patients were classified into 5 MACS levels using a standardized questionnaire completed by their primary caregivers. Preoperatively and at most recent follow-up visits, patients were assessed using the House scale and patient-reported functional outcomes on a 5-point scale. We compared the outcomes of patients with high (I-II, independence in daily activities) and low (III-V, dependence in daily activities) MACS levels. RESULTS: The overall mean House scale improved from 2.9 to 4.6 postoperatively (p<.001), dressing ability from 3.7 to 4.2 (p=.005), hygiene from 4.2 to 4.9 (p=.005), and appearance from 2.4 to 4.2 (p<.001). A total of 13 patients had a high MACS level (7 had I and 6 had II) and 14 had a low MACS level (8 had III, 6 had IV, and none had V). The high-MACS group had a greater improvement according to the House scale (p=.009) and the low-MACS group had a larger improvement in hygiene status (p=.043). There were no differences in the amount of improvement in dressing ability (p=.169) and appearance (p=.765). Overall satisfaction with surgery was higher for the high-MACS group (p=.038). CONCLUSIONS: The high-MACS group had a greater improvement in rating according to the House scale and higher satisfaction than the low-MACS group after upper extremity surgery for cerebral palsy in our small number of patients. This study suggests that the MACS level can be used to predict upper extremity surgery outcomes for cerebral palsy. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Ulnar subluxation of a ruptured EPL tendon at the metacarpophalangeal joint: case report.

We report a case of ulnar subluxation of a ruptured extensor pollicis longus tendon at the metacarpophalangeal joint due to tethering of the distal tendon and an abnormal vector of pull. In this case, thumb flexion with the tethered EPL tendon resulted in attenuation of the radial sagittal band of the extensor hood. After plication of the radial sagittal band and relocation of the EPL tendon, adequate thumb extension was restored.

Comparison of loop-tendon versus end-weave methods for tendon transfer or grafting in rabbits.

PURPOSE: The loop-tendon method for the stabilization of tendon transfers or grafts has been demonstrated previously to have greater initial tensile strength than that of the end-weave method. To our knowledge, a comparison of the mechanical strengths of these methods over the early postoperative period has not been made. The purpose of this study was to compare the mechanical strengths of loop-tendon and end-weave methods of repair during the early postoperative period in rabbit hind limb tendons. METHODS: In bilateral hind limbs of 30 New Zealand white rabbits of an average weight of 3.5 kg, a distally cut gastrocnemius Achilles' tendon and a proximally cut flexor digitorum superficialis tendon were connected to each other by using the loop-tendon method with 5 stitches in one limb and a 1-pass end-weave method in the contralateral limb. Postoperatively, all rabbits were immobilized by a short-leg cylinder cast. Six rabbits were killed at each of the following time points: immediately after surgery (baseline) and at 1, 2, 3, and 4 weeks postoperatively. Repaired tendons were harvested and were loaded to failure in a tensile load-testing machine to record the ultimate strength and to calculate the absorbed energy. RESULTS: Ultimate tensile loads were significantly higher in the loop-tendon method group than in the end-weave group from baseline to 3 weeks postoperatively, but there was no difference at 4 weeks postoperatively. During the postoperative period, the ultimate tensile load and absorbed energy decreased over the first 2 weeks postoperatively and then increased to reach baseline strengths at 3 weeks postoperatively in both groups. CONCLUSIONS: The loop-tendon method provided greater strength than that of the end-weave method during the early postoperative period in rabbit tendons. The loop-tendon method may provide greater surgical repair strength during the early postoperative rehabilitation period than the end-weave method.

Clinical features influencing the patient-based outcome after carpal tunnel release.

PURPOSE: We analyzed several clinical features of carpal tunnel syndrome to identify potential prognostic factors influencing a patient-based outcome assessment after carpal tunnel release. METHODS: We evaluated 102 hands of 64 patients with carpal tunnel syndrome using the Boston self-assessment questionnaire preoperatively and 3, 6, 9, and 12 months postoperatively. The clinical findings evaluated as prognostic indicators were paresthesia, cold intolerance, subjective weakness, nocturnal pain, thenar atrophy, Tinel sign, Phalen test, and electrophysiologic grades. All assessments of outcome were subjective based on the reports of patients, and no objective measurements were obtained to establish improvement after surgery. RESULTS: The overall symptom and functional scales of the self-assessment questionnaire demonstrated a significant improvement at 3 months after surgery, but no significant further improvement was observed thereafter. Patients with nocturnal pain, patients without subjective weakness, and patients without cold intolerance demonstrated more improvement of the scores in the bivariate analysis. CONCLUSIONS: This information may be used in preoperative consultation regarding the outcome of surgery from the patient's perspective. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports.

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.

Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb.

BACKGROUND: The Bilhaut-Cloquet operation is a combined surgical procedure for the treatment of a symmetric bifid thumb. Although this procedure can obtain a normal-sized thumb with a stable interphalangeal joint, it has limitations, such as the technical difficulty of combining all segments of a duplicated thumb, possible later physeal growth arrest, joint stiffness, and nail-plate deformity. We reviewed the results of our modification of this procedure for the treatment of Wassel type-II and III polydactyly of the thumb. METHODS: Seven patients, two with type-II and five with type-III polydactyly of the thumb, underwent the modified Bilhaut-Cloquet procedure and were followed for an average of fifty-two months. Cosmetic and functional assessments were made. RESULTS: All patients and their parents were satisfied with the cosmetic and functional results. Compared with the preoperative motion, the postoperative range of motion of the interphalangeal joint was preserved in thumbs with type-III deformity and was increased in those with type-II deformity. No nail deformity or growth arrest occurred, and remodeling and hypertrophy of the distal phalanx occurred with time. CONCLUSIONS: Our modification of the Bilhaut-Cloquet procedure for the treatment of type-II and III thumb polydactyly is effective in preserving interphalangeal joint motion, minimizing nail deformity, and preventing growth arrest.

Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation.

BACKGROUND: The purpose of this study was to evaluate the outcome of intra-articular dorsal wedge osteotomy and absorbable pin fixation for the treatment of Freiberg disease. METHODS: From January of 1997, to July of 2003, 12 patients with symptomatic Freiberg disease had intra-articular dorsal wedge osteotomy through the affected metatarsal head fixed with absorbable polyglycolide pins. All 12 patients were women with an average age of 36 (range 16 to 59) years. The Smillie stage of necrosis ranged from II to V. Active range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed after radiographic union was achieved. The mean followup was 45 (range 22 to 84) months. RESULTS: Radiographically, solid healing of all osteotomies was observed at an average of 10 (range 8 to 16) weeks. There was no evidence of displacement, osteolysis, sinus formation, or progression of osteonecrosis at final followup. Pain measurement on a visual analog scale had improved significantly from an average of 8.0 to 2.3 (p<0.05). The range of motion of the metatarsophalangeal joint increased by a mean of 26 (range 5 to 60) degrees. All patients were satisfied with the results and would have the surgery again. CONCLUSIONS: In patients with Freiberg disease, intra-articular dorsal wedge osteotomy restores congruity of the metatarsophalangeal joint, and fixation with absorbable pins provides adequate fixation and avoids a second procedure for implant removal.

Modified end-to-side neurorrhaphy enhances axonal sprouting: a motor functional and morphological study.

This study evaluated the effect of modified end-to-side neurorrhaphy on functional recovery by modulating the epineurial window and contact areas, with a donor nerve, using a rat median nerve and finger flexors. Grasping testing, muscle contractility testing, and a histological study were performed 20 weeks after surgery. The modified end-to-side repair can enhance axonal sprouting from an intact nerve, and improve the functional recovery. Either the epineurial window surface area, or the contact configuration with the donor nerve is an important factors in an end-to-side coaptation model.

Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome.

The purpose of this study was to review the results of 2 surgical methods for treating cubital tunnel syndrome. From 1994 to 2001, minimal medial epicondylectomy was performed on 22 elbows, and anterior subcutaneous transposition of the ulnar nerve was done on 34 elbows. In the group treated by medial epicondylectomy, 9 of the results (41%) were excellent, 10 (45%) were good, 2 (9%) were fair, and 1 result (5%) was poor. In the group treated by anterior subcutaneous transposition of ulnar nerve, 14 of the results (41%) were excellent, 13 (38%) were good, 6 (18%) were fair, and 1 result (3%) was poor. No significant difference was found between the 2 groups (P < .05). Both methods can be used for the treatment of cubital tunnel syndrome with a high rate of satisfaction.

Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome.

BACKGROUND: Idiopathic ulnar impaction syndrome can be defined as a degenerative condition of the ulnar aspect of the wrist in patients with congenital or dynamic positive ulnar variance without a history of fracture or premature physeal arrest. The purpose of this study was to evaluate the clinical features of idiopathic ulnar impaction syndrome and the outcomes of ulnar shortening osteotomy for this group of patients. METHODS: Thirty-one wrists in twenty-nine patients with idiopathic ulnar impaction syndrome were treated with an ulnar shortening osteotomy. Ulnar variance was measured on an anteroposterior radiograph of the wrist, and radioulnar distance was measured on a lateral radiograph, with the forearm in neutral rotation, to evaluate any displacement of the ulnar head from the distal aspect of the radius. All patients were followed clinically and radiographically for a mean of thirty-two months. RESULTS: An average preoperative ulnar variance of +4.6 mm (range, 2 to 7.5 mm) was reduced to an average of -0.7 mm (range, -4 to +1 mm) postoperatively. Preoperatively, the modified Gartland and Werley score was an average (and standard deviation) of 69.5 +/- 7.6, with twenty-four wrists rated poor and seven rated fair. Postoperatively, the score improved to an average of 92.5 +/- 8.0, with twenty-four wrists rated excellent; five, good; one, fair; and one, poor. Dorsal subluxation of the distal aspect of the ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening osteotomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not evident one to two years after the operation. CONCLUSIONS: Ulnar shortening osteotomy improved wrist function in patients with idiopathic ulnar impaction syndrome and reduced the subluxation of the distal radioulnar joint, which is commonly found in these patients. Degenerative cystic changes of the ulnar carpal bones appear to resolve following the shortening osteotomy.

Evaluation of pedicle screw position on computerized tomography scans. Technical note.

The quality of a computerized tomography (CT) scan is significantly reduced by metal artifact caused by a pedicle screw system. The purpose of this study was to develop a method of facilitating the evaluation of pedicle screw position on CT scans obtained after screw insertion. The authors developed an algorithm to process spiral CT scans in a personal computer. This uses a digital image enhancement technique, the curve change-based intensity transformation algorithm. This method can generate a clear image of the screw outlines while reducing metal artifact. The resulting images are displayed in arbitrary planes as well as in axial, coronal, and sagittal planes, to support better the evaluation of pedicle screw position. The algorithm was tested using CT scans obtained in 37 patients in whom 186 pedicle screws had been placed. There were five types of screw systems, all of which were made of titanium alloys. In all cases algorithm-based determination of screw position became more convenient and more accurate than when using the conventional bone window setting. In addition, it provided better soft-tissue visualization than the bone window. The software, by displaying clear outlines of screws and decreasing metal artifact, as well as by reconstructing the images in arbitrary planes, was more helpful in identifying the position of pedicle screws than the conventional bone window setting.

Methicillin-resistant Staphylococcus aureus osteomyelitis of the scaphoid from a catheter in the radial artery.

We describe the development of methicillin-resistant Staphylococcus aureus osteomyelitis of the scaphoid in a 49-year-old man from an infection occurring around a catheter in the radial artery. Total scaphoidectomy and appropriate antibiotic therapy eradicated the infection.