The Effect of Epiphysiodesis on the Longitudinal Bone Growth of Hands or Feet in Children With Macrodactyly Based on Long-term Quantitative Analysis.

BACKGROUND: Treatment protocols for macrodactyly have not been elucidated due to its rarity and variety of clinical manifestations. This study aims to share our long-term clinical results of epiphysiodesis in children with macrodactyly. METHODS: A retrospective chart review was performed for 17 patients with isolated macrodactyly treated with epiphysiodesis over 20 years. Length and width of each phalanx in both the affected finger and the corresponding unaffected finger in the contralateral hand were measured. Results were presented in ratios of the affected to unaffected side for each phalanx. Measuring of length and width of phalanx was performed preoperatively and postoperatively at 6, 12, and 24 months, and the last follow-up session. Postoperative satisfaction scoring was done with visual analogue scale. RESULTS: The mean follow-up period was 7 years and 2 months. In the proximal phalanx, length ratio significantly decreased compared with preoperative state at after more than 24 months, in the middle phalanx after 6 months, in the distal phalanx after 12 months. When classified by the growth patterns, the progressive type showed significant decrease in length ratio at after 6 months, and the static type after 12 months. Patients were overall satisfied with the results. CONCLUSION: Epiphysiodesis effectively regulated longitudinal growth with different degree of control for different phalanges in the long-term follow-up.

Tumor invasion in the hyponychium is associated with distant metastasis and poor prognosis in subungual melanoma: A histologic landscape of 44 cases.

BACKGROUND: Subungual melanoma (SUM) has a poor prognosis because of delayed diagnosis. Its progression, consensus on surgical treatment, and correlation with clinical outcomes remain unclear. OBJECTIVE: We aimed to identify the pattern of dermal invasion in different locations of the nail apparatus and its relationship with prognosis. METHODS: In this retrospective review of surgically treated SUM patients between January 2011 and April 2019, the nail apparatus was divided into 5 anatomic subunits: the dorsal roof of proximal nail fold, ventral floor of proximal nail fold, germinal matrix, nail bed, and hyponychium. Invasions in the subunits were categorized using 3 criteria: no tumor, in situ tumor, or invasion. RESULTS: Among 44 cases of SUM, dermal invasion occurred mostly in the distal areas, with 11, 30, 18, 7, and 4 in the hyponychium, nail bed, germinal matrix, ventral floor of proximal nail fold, and dorsal roof of proximal nail fold, respectively. The patients with hyponychial invasion showed a significantly greater Breslow depth (P = .009), a higher rate of lymph node metastasis (P = .019), distant metastasis (P = .036), and shorter disease-free survival (P = .001). CONCLUSION: Hyponychial invasion is an important prognostic predictor of SUM, given its strong association with invasion depth, metastatic progression, and disease-free survival. Patients with invasion in the hyponychium should undergo more strict workup, treatment, and surveillance.

Functional Surgery for Subungual Melanoma: Surgical Tips Based on Histological Analysis of 21 Cadavers.

BACKGROUND: Amputation has been the standard treatment for subungual melanoma. Although there is growing attention toward a more conservative functional surgery, specific operative techniques are not yet available. OBJECTIVE: We aimed to provide objective measurements for use in functional surgery by analyzing the anatomy of the nail apparatus obtained from 21 cadavers. MATERIALS AND METHODS: Nailbed thickness was histologically measured in each subunit, and skin surface anatomy was evaluated to determine the proximal resection margin. Immunohistochemical staining was performed to analyze microvessel distribution according to the nail subunit. RESULTS: The nailbed thickness was the thinnest at the most proximal point of the nail matrix (thumbs, 1.10 ± 0.42 mm; big toes, 1.15 ± 0.37 mm) and the thickest at the hyponychium (thumbs, 2.86 ± 0.82 mm; big toes, 2.72 ± 0.84 mm). The distance from the eponychium to the skin surface closest to the bony cortex of extensor tendon insertion was 6.92 ± 5.13 mm in thumbs and 5.14 ± 1.59 mm in big toes. The median microvessel density was the highest at the hyponychium (25.74 vessels/mm2) and lowest at the germinal matrix (16.26 vessels/mm2) (p < .05). CONCLUSION: This histological study offers practical tips, including those to help decide the proximal and deep resection margins, in functional surgery.

Medial Plantar Fasciocutaneous Flap Reconstruction for Load-Bearing Foot Defects in Patients With Acral Melanoma.

BACKGROUND: Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma that usually involves the weight-bearing plantar area. Plantar defect reconstruction has traditionally been performed with skin grafts or free flaps. This study examined the efficacy and safety of a medial plantar artery perforator flap (MPAPF) for plantar defect reconstruction after wide excision of an ALM. METHOD: Twenty-five patients who underwent reconstruction with a MPAPF between 2011 and 2021 were enrolled in this study. The defects were classified into 6 plantar zones. Demographic and clinical data were retrospectively analyzed. RESULTS: Reconstruction with medial plantar fasciocutaneous island flaps was performed in all cases, except for 4 patients who had lesions in forefoot, which required free medial plantar flaps. Defects in lateral and posterior heel were more likely to present with venous congestion and require longer healing times and revision surgery (P < 0.05). The average follow-up period was 49 months. Four and 5 patients developed local recurrence and distant metastasis, respectively. Four cases of hyperkeratosis and paresthesia were documented, but there were no cases of ulceration or wound dehiscence. None of the cases required secondary debulking procedures. CONCLUSIONS: The MPAPF is safe and effective for plantar defect reconstruction among patients with ALM. Meticulous dissection and adequate tunneling are needed, particularly for defects in the lateral and posterior heel, to minimize flap congestion and revision operations.

Potential of autologous adipose-derived stem cells to regenerate atrophied muscle in a rat model.

Muscle atrophy results in severe functional impairment and is a significant clinical problem. We examined and characterized the therapeutic effects of autologous adipose-derived stem cells (ADSCs) using an in vivo muscle atrophy rat model. To identify the effect of injected ADSCs into muscle, we developed the following two models of muscle atrophy in rats: induction of denervation by sciatic nerve defects; and nerve repair after severing the sciatic nerve. The inguinal fat pads were harvested from each rat and autologous ADSCs were cultured and ADSCs were injected in the right hind limbs as the experimental group, while normal saline was injected in the left hind limbs, which served as the control group. After 2 weeks, gross examination and histologic analyses were performed. Additionally, to investigate the survival of ADSCs in muscle tissues, we traced the injected ADSCs. The fate of injected ADSCs into muscle was investigated using a green fluorescent protein (GFP) tagging method with lentivirus transfection. The muscle weight and cross-sectional area of muscle were greater and proliferation of connective tissue was less prominent in the ADSC-injected group. Alpha-bungarotoxin binding in the neuromuscular junction was significantly increased, and neoangiogenesis was higher in the ADSCs-injected group. green fluorescent protein-labeled ADSCs survived in the gastrocnemius muscle after 2 weeks. These findings could give a support in finding the role of autologous ADSCs as new therapeutic modality for regeneration of atrophied muscle.

Nerve Regeneration and Functional Recovery With Neurorrhaphy Performed at the Early Distraction Osteogenesis: An Experimental Study.

Distraction osteogenesis is widely used in many clinical situations, but distraction in cases accompanying nerve injury has been avoided due to concern of unfavorable effect on nerve regeneration by traction. This study evaluated the feasibility of early distraction lengthening after neurorrhaphy. Thirty-six rats were evenly distributed into 3 groups (12 rats in each group); neurorrhaphy and distraction (group I), neurorrhaphy and osteotomy without distraction (group II), and only distraction without neurorrhaphy (group III), respectively. After osteotomy on the right tibia, distraction started after 1 week and was continued for 40 days with 0.25 mm per day. Histological evaluation was carried out to identify nerve regeneration at 4, 8, and 12 weeks after surgery. Walking tract analysis was performed to assess the functional recovery preoperatively and 1, 4, 8, and 12 weeks postoperatively. Histologically, axon number ratio was significantly impaired in group I (0.48 ± 0.14) and group II (0.53 ± 0.13) compared with group III (0.88 ± 0.04) at 4 weeks (P = 0.020). There was no significant difference at both 8 and 12 weeks. Walking tract analysis showed significant differences between groups I and III (-40.5 ± 4.3), and groups II and III (-35.5 ± 5.0) at 1 week (P = 0.001), but no difference was observed at 8 and 12 weeks. Distraction osteogenesis in early stage after nerve repair is safe and effective, when performed at a rate of 0.25 mm per day in rats.

Availability of the lateral calcaneal region as a donor site of free flaps.

INTRODUCTION: Various methods have been used for the coverage of soft-tissue defects, such as local and free flaps, as well as perforator flaps performed using even supermicrosurgery. However, the techniques have some limitations regarding flap size and location when used to reconstruct small defects. We introduced the lateral calcaneal region as a donor site for free flaps in order to overcome these disadvantages and presented the results from a series of cases. PATIENTS AND METHODS: A retrospective chart review was performed on 10 patients with small soft-tissue defects who underwent reconstruction with a lateral calcaneal free flap between January 2011 and May 2014. The reconstruction was performed on the defects at medial and lateral plantar area, dorsum of the foot, great toes and preauricular area. RESULTS: The size of the flaps ranged from 2.5 × 2.5 cm to 4.5 × 4.5 cm. The flaps exhibited complete survival in five cases. Partial necrosis occurred in three cases, two cases healed with secondary intention, and one case required a skin graft. The donor sites were treated with skin grafts and healed completely, with no complications. CONCLUSION: Lateral calcaneal free flaps have several advantages, such as anatomically constant pedicles, a pliable and thin texture, and the ability to be used as sensory flaps. They therefore represent an alternative option when conventional local or free flaps are not suitable, especially in cases of small defects. © 2016 Wiley Periodicals, Inc. Microsurgery 37:494-501, 2017.

Venous free flaps for the treatment of skin cancers of the digits.

Microvascular reconstruction using distant free flaps is often required after excision of skin cancers of the digits. The delivered flaps should be chosen with many factors taken into consideration, especially in the digits, in which a very thin, pliable, and durable flap is required to maintain both function and cosmetic appearance. Free flaps, such as perforator flaps, however, for distal or small defects of the hand after excision of skin cancer, require the sacrifices of the main arterial pedicle with deep dissection and exhibit potential limitations regarding flap size and location of the defect. Instead, arterialized venous free flap could be used as an alternative reconstructive method for skin cancers of the digits. Twelve soft tissue defects of the digits after excision of skin cancers (5 cases of malignant melanoma and 7 cases of squamous cell carcinoma) were reconstructed using arterialized venous free flaps from January 2009 to May 2011. The flaps ranged in size from 1 × 1.5 cm to 5 × 7 cm. The flaps completely survived in 9 cases. Partial necrosis developed in 3 cases; however, skin graft was necessary only for 1 case. There were no recurrences or metastases for at least 20 months after the last case. Recently in cases of noninvasive or low-grade skin cancer of the hand, the concept of "preservative surgery" has been a higher priority compared with functional and esthetic aspects. Particularly in cases of reconstruction of a small-sized fingertip defect as 1 functional unit, arterialized venous free flaps offer several advantages, such as thinness and color similar to the hand, technical ease with a short operative time, long vascular pedicle, less donor site morbidity with no sacrifice of a major vessel, applicable to any site, and modifiable to the appropriate size and shape. Arterialized venous free flap could serve as a useful and reliable method for soft tissue reconstruction after excision of skin cancers in the digits.

Roles of Polycaprolactone Membrane on Guided Bone Formation in High-Speed Distraction of Experimental Design Cranium.

BACKGROUND: The aim of this research was to investigate whether covering of the distracted cranial bone segment with a polycaprolactone (PCL) membrane (guided bone formation) would accelerate the process of osteogenesis in high-speed distraction of adult rabbit. METHODS: Eighteen 24-weeks old, 3.0 to 3.5  kg, male New Zealand rabbits underwent routine gradual cranium distraction (group 1), distraction at high speed without the membrane (group 2), and distraction at high speed with a PCL membrane covering the cranium at the distraction gap (group 3). Five days after the cranial osteotomy, the distraction process was initiated at 3  mm per day (1.5  mm twice a day) in group 2 and group 3, and 1  mm per day (0.5  mm twice a day) in group 1 until 10  mm of length gain was achieved. At the consolidation 4 and 6 weeks, the bone mineral density was analyzed by a computerized tomography imaging protocol. The bone formation ratio of each group was compared with Hematoxylin and Eosin stain. The collagen formation of each group was analyzed by Massons' trichrome staining. RESULTS: Radiographic imaging and quantitative data indicated a significant increase in bone mineral density in group 1 and group 3 compared with group 2. Bone formation ratio in histologic analysis showed an increase in group 1 and group 3. Collagen synthesis in group 2 was significantly increased in distraction gap. In group 3, collagen fibers were significantly decreased underneath the PCL membrane. CONCLUSIONS: Polycaprolactone membrane covering the bone distraction gap provides an environment for faster bone formation in high-speed distraction.

Case-control study of the treatment of postaxial polysyndactyly of the foot: Comparison of surgical results after removal of the fifth or sixth toe.

BACKGROUND: In postaxial polysyndactyly of the foot, the choice of which toe to excise is controversial. It is often treated by resection of the fifth toe to save the lateral neurovascular bundles of the sixth toe. However, the sixth toe is often short and laterally deviated, which may require wedge osteotomy, potentially shortening the phalanx and compromising circulation. This study outlines an individualized method to spare the length and axis of the fifth toe in polysyndactyly with a short and deviated sixth toe. METHODS: We retrospectively analyzed 38 patients who underwent surgery between 2006 and 2019. The fifth toe was spared in 18 cases, and the sixth toe in 20 cases. The ratios of the forefoot width, angle difference, and toe length were compared between the affected and unaffected sides postoperatively. Complications and subjective judgments on cosmetic results were recorded and compared. RESULTS: No significant between-group differences were observed for sex, age at surgery, or the follow-up period. The forefoot width ratio did not significantly differ between the groups. However, the angle difference and toe length ratios showed significantly better results in the fifth toe-spared group than in the sixth toe-spared group (P<0.05 and P<0.01, respectively). There were no cases of impaired circulation, and subjective evaluations revealed satisfactory results in the fifth toe-spared group. CONCLUSIONS: In cases with short and deviated sixth toes, sparing the fifth toe is an effective method of cosmetic treatment. The surgical results were satisfactory, with an improved appearance and no residual deformities.

Effects of Administration Route of Adipose-Derived Stem Cells on the Survival of Allogeneic Skin Grafts in Mice.

BACKGROUND: Composite tissue allotransplantation presents considerable potential for defective tissue reconstruction. However, the high immunogenicity of the allogeneic skin grafts can cause acute rejection. Adipose-derived stem cells (ADSCs) reportedly have an immunomodulation potential, which may improve the survival of allogeneic skin grafts. However, there is currently no consensus on administration route of ADSCs. This study compared the effectiveness of local injection vs intravenous (IV) administration of ADSCs in improving the survival of allogenic skin grafts in mice. METHODS: BALB/c and C57BL/6 mice were used as skin graft donors and recipients, respectively. Mice were divided into 3 groups for IV injection of ADSCs (IV group) or phosphate-buffered saline (PBS; control), or for local injection in the fascial layer of the recipient bed (FL group). After allogeneic skin transplantation, 0.1 mL of PBS alone or with 1.5 × 105 ADSCs was immediately injected. The grafts were histologically evaluated on days 7 and 14 postoperation. RESULTS: The graft necrotic area was significantly smaller in the IV and FL groups than in the control group. Additionally, the grafts in these 2 groups exhibited decreased interleukin 17/6, tumor necrosis factor-α, and interferon-γ messenger mRNA levels; inflammatory changes; and cluster of differentiation 4 expression, and increased expression of vascular endothelial growth factor expression (P < .05). However, these 2 groups did not significantly differ (P > .05). CONCLUSIONS: ADSCs increased the survival of allogeneic skin grafts in mice regardless of IV or FL route of administration, and this effect is likely through anti-inflammatory and angiogenic effects of ADSCs.

Impact of Injection Frequency of Adipose-Derived Stem Cells on Allogeneic Skin Graft Survival Outcomes in Mice.

Previous studies indicated that mesenchymal stem cells (MSCs) exhibit immunomodulatory properties in composite tissue allotransplantation. However, due to the high immunogenicity of skin, although the single administration of MSCs improves survival of the skin allotransplant, immune rejection is still inevitable. The aim of our study was to evaluate whether multiple administrations of MSCs would improve immune tolerance in the allogeneic skin graft, compared to that with a single administration in a mouse model. After full-thickness skin allotransplantation on the backs of the mice, the recipient mice were infused with phosphate-buffered saline and isogenic 1.5 × 105/mL adipose-derived stem cells (ADSCs). ADSCs were transplanted into different mice according to the different injection frequencies such as single, once a week, and twice a week. Skin sections were taken on days 7 and 21 post-transplantation in all groups for gene expression and histological studies. ADSCs increased skin allograft survival compared to that in control mice (P < 0.05). Interleukin-6 and tumor necrosis factor-alpha messenger RNA levels were decreased, and the abundance of lymphocytes, based on immunohistochemistry, was also decreased in ADSC-infused mice (P < 0.05). However, among the different ADSC injection frequency groups, multiple ADSC infusion did not improve the survival rate and decreased proinflammatory cytokines and lymphocytes, compared to those with the single administration of ADSCs (P > 0.05). Conversely, the results with single administration were slightly better than those with multiple administrations. Our study demonstrated that ADSCs have the potential for immunomodulation in vivo. However, the results with multiple ADSC administration were not as good as those with single administration, which indicates the complexity of ADSCs in vivo and implying the need for adequate preclinical experimentation.

Validation of digital tourniquet pressures: An experimental comparison of T-RingTM and conventional surgical glove in human volunteers.

Digital tourniquets are widely used for the management of digital injuries in emergency departments or outpatient clinics. This study is focused on the pressure analysis of digital tourniquets on some points not covered in the existing literature.A total of thirty volunteers were enrolled in this study. Instantaneous surface pressure was measured at the thumbs, index fingers, and little fingers. We investigated the pressure according to the circumference of digits, tourniquet types, and measurement sites (dorsal and mid lateral volar sides) above the digital vessels. Continuous pressure was measured in artificial silicone models to determine the change of pressure over 2 hours.The average pressure measured on the mid lateral volar side of volunteers fingers were 154.3 ± 54.9 mm Hg by T-Ring and 162.6 ±â€Š61.0 mm Hg by surgical glove. The pressure on the dorsal side were 224.7 ±â€Š57.7 mm Hg by T-Ring and 228.8 ±â€Š66.0 mm Hg by surgical glove, each significantly higher than the mid lateral volar side. The circumference of digits did not significantly affect the surface pressure. The pressure pattern did not change significantly over 2 hours in both tourniquet types.The surface pressure of the mid lateral volar side was significantly lower than that of the dorsal side. However, there was no significant pressure difference according to the circumference of digits. Time dependent pressure change were not significantly different between 2 tourniquets.

Clinical analysis and review of literature on pilomatrixoma in pediatric patients.

BACKGROUND: Pilomatrixoma is a benign tumor that originates from the hair follicle matrix. It usually presents as a hard, slow growing, solitary mass that can be easily misdiagnosed as other skin masses. The aim of this study was to clinically analyze a case series of pilomatrixoma in pediatric patients from Korea. METHODS: A total of 165 pediatric patients from 2011 to 2018 with a histological diagnosis of pilomatrixoma were included. A retrospective review was performed using the electronic medical records, including patient demographics, number and location of the mass, clinical and imaging presentation, and postoperative outcomes. RESULTS: There were 61 male and 104 female patients with 152 solitary and 13 multiple pilomatrixomas. Among solitary pilomatrixomas, the lesion commonly occurred in the head and neck (84.2%), followed by upper limbs (11.2%), lower limbs (3.3%), and trunk (1.3%). The pilomatrixoma lesion presented as the following types based on our clinical classification: mass (56.02%), pigmentation (25.31%), mixed (12.65%), ulceration (4.82%), and keloid-like (1.2%). Ultrasonography showed a high positive predictive value (95.56%). There were no specific complications observed except for two cases of recurrence. CONCLUSION: Pilomatrixoma has various clinical feature presentations and commonly occurs in the head and neck. Ultrasonography is a helpful diagnostic tool. Surgical removal of the lesion is the main treatment method with a low recurrence rate.

An intermaxillary fixation screw traction wire: an aid for facial bone fracture repair.

We have devised a new technique to improve stabilization of fractured facial bone fractures (frontal sinus fractures, zygomatic fractures, mandibular condyle fractures) by intermaxillary fixation screw traction wires (stainless steel wires through intermaxillary fixation screws). A retrospective study evaluating intermaxillary fixation screw traction wires was performed. We have used this technique for 3 cases of frontal sinus fractures, 9 cases of zygomatic fractures, and 7 cases of mandibular condyle fractures. After dissection of a fractured site, a hole is drilled on the fractured bone where it does not interfere with positioning the plate across the fracture line. After an intermaxillary fixation screw is inserted, a stainless steel wire is tied through a hole in the screw head. By the aid of wire for traction, the displaced fractured bone is easily aligned to the proper position. Plates and screws are applied readily on the predetermined area. A retrospective study on 19 patients using intermaxillary fixation screw traction wires was performed. The diagnoses and associated complications of the cases were recorded. No associated complication as a result of using this technique was identified. The use of intermaxillary fixation screw traction wire enhances stabilization and visualization without possible risk for surrounding soft tissue injury using, a sharp traction device like a bone hook. An intermaxillary fixation screw traction wire is an useful aid for visualization and stabilization during facial bone fracture reduction, particularly where exposure is difficult such as in the condylar region of the mandible. And unlike a classic traction wire, the intermaxillary fixation screw traction wire has almost no risk of having it loosened from the screw.

Hand Transplantation: Current Status and Immunologic Obstacles.

Hand transplantation is the most common form of modern composite tissue allotransplantation, with 89 cases reported worldwide since 1998. The procedure is a treatment option for complex injuries that leave patients with structural, functional, and aesthetic deficits that cannot be addressed by other means. Successful application of this technology requires a multidisciplinary approach, incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and so on. Its long-term results depend on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection. Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation. Despite the enormous antigen load associated with composite tissue allografts, hand transplant has become a clinical reality, with immunosuppression comparable to that of solid-organ transplants. Our understanding of hand transplantation is still evolving, and ongoing research is needed to improve functional outcomes and to decrease the morbidity associated with long-term immunosuppression. This review discusses the current protocols for upper extremity donation, transplant receipt, surgical techniques, postoperative rehabilitation and immunosuppression, nerve regeneration, functional outcomes, ethical issues, and financial considerations.

Impact of lifetime subthreshold depression and major depression before internship on psychopathology and quality of life in Korean interns: 6 month follow-up study.

OBJECTIVE: The aim of the present study was to investigate the influences of lifetime subthreshold depression and major depression before internship on the changes in psychopathology and subjective quality of life during internship. METHOD: A total of 151 interns at Seoul National University Hospital completed questionnaires including World Health Organization Quality of Life Assessment Instrument, Brief Version (WHOQOL-BREF), Symptom Checklist-90-Revised (SCL-90-R), and Beck Depression Inventory (BDI) twice at an interval of 6 months. Their lifetime diagnosis of depression before internship was made using the Korean version of Mini International Neuropsychiatric Interview (MINI), Modified Form for Self-Administration. RESULTS: Significant changes over time were detected including total score in the BDI and the Somatization, Depression, Anxiety, and Phobic Anxiety dimension scores in the SCL-90-R as well as all four domain scores in WHOQOL-BREF. In addition, in all scores except Somatization dimension score, group difference existed. Post-hoc comparisons showed that interns without lifetime depression were significantly different from those with lifetime subthreshold depression and those with lifetime major depression. CONCLUSIONS: Even a subthreshold-level, lifetime depression before internship has an adverse effect on the psychopathology and the subjective quality of life during internship. Therefore, earlier detection, monitoring, and management of this population would be needed throughout the intern year and beyond.

Correction of contracted nail deformity by distraction lengthening.

Ten callus distraction-lengthening procedures were performed in 10 distal phalanges to correct contracted nail deformities. The average age of the patients was 28.8 (14 approximately 41) years. A 1-week resting period was allowed, followed by gradual lengthening at a rate of 0.125 mm/day. The average lengthening achieved was 9.8 mm (86.3%; 43% approximately 218%). The healing indices were 68.6 days/cm. Additional minor procedures for the paronychium, nail bed, and hyponichium were performed in 6 cases. All patients were satisfied with the reformed nail, which overcame the disfigurements resulting from a deficiency of the bone and soft tissue. Distraction lengthening along with the microvascular free toenail transfer is recommended for nail reconstructions due to its simultaneous gain of bone and soft tissue.

Changes in skin during distraction osteogenesis of the tibia in Sprague-Dawley rats: verification of epidermal proliferation by immunohistochemical methods.

To investigate the effect of bone lengthening by distraction osteogenesis, a pair of external fixators was placed in the right tibias of 40 Sprague-Dawley rats. Two weeks (n=10) and 12 months (n=10) after 25% lengthening, skin flaps were removed and prepared for the immunohistochemical measurement of bromodeoxyuridine (BrdU) and staining with haematoxylin and eosin. The same procedures were done for the rest of 20 unlengthened tibias. At 2 weeks the number of cells labelled with BrdU, which indicate the extent of DNA synthesis, was 4.35 times (p<0.001) greater in the lengthened than the unlengthened skin. However, at 12 months, there was no difference. Haematoxylin and eosin staining showed no additional findings. Although the physical properties of the skin can accommodate a lengthened bone, our results suggest that distraction osteogenesis stimulates epidermal proliferation, which might lead to an increase in the amount of skin.

Oblique Osteotomy for the Correction of the Zigzag Deformity of Wassel Type IV Polydactyly.

BACKGROUND: Surgical treatment of Wassel type IV thumb polydactyly is technically challenging, especially when it has a zigzag deformity. However, the authors obtained good operative results by performing oblique osteotomy with autologous fat graft in 30 patients. METHODS: After removal of the extra digit, the radially deviated distal phalanx was corrected by performing oblique osteotomy at the proximal phalanx. Free fat tissue was grafted to the areas with soft-tissue deficiency. Surgical outcomes were evaluated in terms of the thumb length ratio compared to the normal counterpart, the angulation between the proximal phalanx and the distal phalanx, and the Tada score. As a negative control, the data of 46 type IV polydactyly patients without a significant axis deviation were evaluated. RESULTS: The thumb length ratio was maintained from 0.96 ± 0.06 preoperatively to 1.01 ± 0.07 4-year postoperatively. The angulation improved from 30.84 ± 14.78 degrees to 11.03 ± 7.67 degrees. In comparison, the length ratio and angulation of the control group changed from 0.97 ± 0.04 to 0.98 ± 0.02, and from 19.46 ± 8.27 degrees to 14.10 ± 6.61 degrees, respectively. The Tada scores were 5.3 ± 0.88 in the oblique osteotomy group and 6.59 ± 0.62 in the control group, both of which were graded as good. CONCLUSIONS: Oblique osteotomy with autologous fat graft is a good surgical option for treating the Wassel type IV polydactyly with zigzag deformity. This technique allows sufficient axis correction without bone shortening, and it provides adequate soft-tissue contouring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.