Acral angioosteoma cutis: A rare case.

Acral angioosteoma cutis is a rare and benign cutaneous lesion clinically characterized by an exophytic growth resembling pyogenic granuloma on the acral skin; first described in 2006. Its pathogenesis is still unclear while well-formed capillaries, pale stroma, bland fibroblast-like cells, and multiple tiny spicules of woven bone constitute the histological hallmarks. Here, we present a case of acral angioosteoma cutis in a 34-year-old man to increase awareness regarding this rare condition.

Split flexor pollicis longus tendon transfer to A1 pulley for correction of paralytic Z deformity of the thumb.

PURPOSE: To test the hypothesis that split flexor pollicis longus (FPL) transfer to the A1 pulley will correct a thumb paralytic Z deformity and that the transfer can be subjected to early postoperative active mobilization protocol. METHODS: In a prospective trial, 19 consecutive thumbs with ulnar or combined ulnar and median nerve paralysis received split FPL transfer to the thumb A1 pulley and active mobilization of transfer after 48 hours. Outcomes were assessed by correction of Z deformity during pinch, tendon transfer insertion pullout during early active mobilization, range of motion at the thumb metacarpophalangeal and interphalangeal joints, and postoperative treatment time. Data from historical records of 20 thumbs with split FPL to extensor pollicis longus (EPL) and 3 weeks' immobilization, treated before the prospective trial in the same institution, were used for comparison. RESULTS: All 19 thumbs with split FPL to A1 pulley achieved Z deformity correction at discharge from rehabilitation. There was no incidence of transfer insertion pullout during active mobilization, and patients were discharged 22 days earlier than the controls who received transfer of FPL to EPL insertion. Seventeen thumbs were available for follow-up more than 1 year after the index procedure. Fifteen thumbs retained deformity correction, and 2 had recurrence of Z deformity. The interphalangeal joint had considerably greater active motion following split FPL to A1 pulley compared with transfer of split FPL to EPL insertion. CONCLUSIONS: This study supports the hypothesis. Split FPL tendon transfer to thumb A1 pulley can correct paralytic thumb Z deformities and be mobilized early for transfer re-education. Improved interphalangeal joint active motion and reduced treatment time are added advantages over FPL transfer to the EPL insertion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Re-enablement of the neurologically impaired hand--2: surgical correction. report of a surgical workshop held at Green Pastures Hospital and Rehabilitation Centre, November 2004, Pokhara, Nepal.

The last half-century has seen tremendous advances in the surgical treatment of neuropathic conditions of the hand. Many of these procedures give clear benefit to patients and have been established by clinical practice and well-formulated assessment. However, much remains to be discovered, especially with respect to which procedures should be used on which hands, and the impact of various procedures on the ability to carry out activities of daily living. Increased communication between the 'West', where funding is available for well designed trials and where reference textbooks are usually published, and the 'East', where the surgery is most commonly performed, will undoubtedly lead to an even better understanding of the treatment of the neuropathic hand.

Abductor pollicis longus deviation graft operation: modified for stabilizing CMC and MCP joints of 'intrinsic minus' thumb.

The original procedure abductor pollicis longus deviation graft operation by Beine (1996) was introduced to correct retroposition of the thumb and to balance the instability at the carpometacarpal (CMC) joint in cases of ulnar-cum-low median palsy in leprosy, so that bone-using procedures can be avoided to some extent. It provides an antagonistic force to the action of the abductor pollicis longus (abd. pol. long.) by giving this muscle a second insertion, with the result that the action of the abd. pol. long. now stabilises to a considerable extent the CMC joint in its mid-rotational position by a partial replacement of the action of the opponens pollicis (opp. pol.) and abductor pollicis brevis (abd. pol. brev.). Experience over five years with the original procedure showed us that it can make an ulnar deviation more visible at the MCP joint of the thumb. The modification of the procedure corrects this as well, as the results in 12 hands of 11 patients have shown. Interestingly, of the 11 patients who underwent operation, one was not a leprosy patient, but referred to us for partial triple palsy of the left hand and arm without sensory loss. It is shown that the indication of this procedure is wider than mentioned earlier.

Assessment of results of opponensplasty.

One hundred and fifty-six opponensplasties carried out on 115 patients at Anandaban Hospital between 1987 and 1997 were reviewed. In most cases a flexor digitalis superficialis opponensplasty was performed. The outcome was assessed by measuring the finger to which the thumb could obtain a pinch grip, the gap between the thumb and little metacarpophalangeal joints, and the satisfaction of the patient. The objective assessments demonstrated excellent or good results in 89%. Good or fair patient satisfaction was obtained in 93%. Early complications were seen in seven cases (4%). Objective measurements of outcome and patient satisfaction were not always in agreement, indicating that objective measures do not adequately assess the success of surgery from the patient's perspective. We thus conclude that subjective measurements of results are an important measure of success and should be included in the evaluation of surgical results.

Results of thumb correction in leprosy using different techniques.

Forty-four hands of 42 leprosy patients with paralysis of intrinsic muscles of the hand were treated by opponensplasty using ring finger superficialis (FDS4) or extensor indicis proprius (EIP). Superficialis tendon of middle finger was also used in these hands for lumbrical replacement by "direct lasso" operation. Low ulnar paralysis with Froment's sign was corrected by transfer of radial half of flexor pollicis longus (FPL) to extensor pollicis longus (EPL). Results of thumb correction were assessed and analysed in 37 hands of 35 patients. The mean follow-up period was 19 months. Best results were found with transfer of half FPL to EPL. Results of FDS transfer was good in 12 out of 16 manual workers. EIP transfer worked well, but the power of the thumb and patients' satisfaction was less.

The distally based posterior interosseous fasciocutaneous island flap in reconstruction of the hand in leprosy.

In leprosy a functionally useless hand can be the sequelae of resorption of the sensation-impaired thumb and fingers resulting from repeated trauma and infection. When this process shortens the thumb to the level of the proximal phalanx or metacarpal, the effect is to produce a relatively shallow first web space which together with the shortening, can prevent the most basic hand manoeuvre of a pincer or pinch grip. The reconstructive procedure commonly used in this situation is to widen and deepen the web space with a z-plasty combined with excision of the second metacarpal but the result can be inadequate. We have used the posterior interosseous fasciocutaneous island flap, both as a simple and a compound flap, to solve this challenging problem and we report here our experience with four patients.

Extensor indicis opposition transfer in the ulnar and median palsied thumb in leprosy.

Twenty seven opponensplasties for ulnar and median paralysis in 25 leprosy patients were performed using extensor indicis proprius. An additional transfer of the radial half of flexor pollicis longus to extensor pollicis longus was done to stabilize the metacarpophalangeal joint of the thumb. The biomechanical aspects of extensor indicis proprius tendon transfer were studied and results evaluated using various anatomical and functional parameters. Extensor indicis proprius provides adequate strength to position the thumb. However, sometimes it does not reach its new insertion. There is no significant deficit at the donor site but in a few cases the index finger may lose its capability for independent extension and sometimes a proximal interphalangeal joint contracture may develop.

Evaluation of the results of opponensplasty.

A comprehensive evaluation system for opponensplasties has been described taking into consideration several variables. Each variable has been assigned a score depending upon its significance in the normal hand. The total score of the hand is used for grading the results as good, fair and poor.

Abductor pollicis longus deviation grant operation: a new procedure on the thumb in ulnar cum low median palsy for correction of subluxation of carpometacarpal (CMC) joint.

For correction of instability of the carpometacarpal joint (CMC joint) of the thumb in combined paralysis of ulnar and median nerves in leprosy bone fusing procedures have been used, but they are not desirable and can often be avoided. A procedure analogous to the "Extensor pollicis brevis deviation graft operation" for the correction of instability of the metacarpophalangeal joint of the thumb is described here. The new procedure appears to be useful to correct and stabilize the subluxated carpometacarpal joint of the thumb actively during the use of the hand. When thumb web contracture has occurred and the passive range of movement needed for successful opponents replacement of thumb is not available, this new procedure helps to prepare such a severe deformed thumb for correction at earlier time.

A cirurgia de Smith na perda do movimento de aduçäo do polegar / Smith's surgery in the loss of the thumb adduction movement

Os autores analisam os resultados obtidos pela técnica cirúrgica descrita por Smith, que consiste na transferência do tendäo extensor radial curto do carpo para o tendäo do músculo adutor do polegar em sete pacientes com incapacidade da realizaçäo do movimento de aduçäo do polegar, devido à lesäo traumática do nervo ulnal (qatro casos) e neuropatia ulnal (três casos) causada pelo mal de Hansen.

Paralysie lépreuse de l'opposition: réanimation par transfert de l'extenseur propre de l'index. A propos de 27 cas opérés a Hô Chi Minh Ville (viet Nam) / Leprosy paralysis of the opposition: resuscitation by transfer of the proper extensor of the index. About 27 cases operated in Ho Chi Minh City (Viet Nam)

Pour réanimer l'opposition du pouce, les chirurgiens du Centre de Dermato-Vénérologie d'Hô Chi Minh Ville ont choisi le transfert de l'extenseur propre de l'index dérouté par voie circumcubitale. Décrite par Chouhy-Aguirre en 1956, cette technique a été modifiée par Burkhalter en 1973 puis par Bourrel en 1978. Depuis 1990, 46 pouces paralytiques lépreux ont bénéficié de cette intervention à Hô Chi Minh Ville. Nous avons pu évaluer les résultats de 27 d'entre eux, en privilégiant les tests moteurs standardisés. Ces tests de dextérité nous ont permis d'exprimer de manière quantitative la fonction du pouce. Nous avons ensuite associé ces résultats à ceux obtenus par des tests anatomiques classiques de certaines déformations

Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer.

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.

A modification of the surgical correction of the thumb--a long term follow up.

A modification of the commonest surgical procedure to restore Abduction-Rotation using the flexor superficialis transfer with Y-insertion is described. The modification consists of doing a triple insertion at the thumb instead of Y-insertion. After introducing the triple insertion the procedure shows 80-90% or more good results, whereas 50% or more failures are reported in the existing literature, when a Y-insertion only is used which cannot safely prevent 'Z' deformity. 60 cases were followed up.