Outcomes and Early Recurrence Following Enzymatic (Collagenase) Treatment of Moderate and Severe Dupuytren Contractures.

PURPOSE: We offer collagenase Clostridium histolyticum (CCH) injections to all patients with a Dupuytren contracture and a palpable cord. We assessed whether more severe contractures respond less well or recur more frequently. METHODS: From a database of 502 CCH injections, 386 (77%) had a complete dataset with minimum 1-year face-to-face follow-up. Contracture severity was assessed using the Tubiana system: grade 1 (27%), grade 2 (49%), grade 3 (19%), and grade 4 (5%). Patients received a single intralesional injection of 0.58 mg CCH followed by manipulation. Finger position was measured at 6 to 12 weeks, 6 months, and 1 year. Failure to break the cord, skin tears, and any adverse events were noted. Recurrence was defined as a failure to maintain any prior correction to within 20°. RESULTS: There were 17 failures (4%) and 6 allergic reactions (1%). We found 31% corrected completely, with approximately half remaining corrected at 1 year. We achieved 43° (95% confidence interval, 40°-46°) correction of combined deformity, with 11° (95% confidence interval, 9°-13°) correction attrition over 1 year. Sixteen percent of treated digits experienced a recurrence with no difference between Tubiana grades, and one-third chose further treatment. Following treatment, Tubiana grade 1 contractures improved by 78% in comparison with higher grade contractures (55%-67% relative correction). By 1 year, all grades had a similar mean 46% relative correction. A complete correction was seen in 61% of grade 1 contractures, with more severe contractures less likely to correct completely (9%-24%). A 31% skin tear rate had no impact on outcome, recurrence, or long-term morbidity. CONCLUSIONS: CCH may treat any Dupuytren cord regardless of severity. Although contracture may recur, few patients pursue further treatment within 1 year. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study.

PURPOSE: The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy. METHODS: Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up. RESULTS: After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2-8.7), and mean follow-up length was 6.5 years (2.9-9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up. CONCLUSION: Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.

Soft tissue stabilization for palmar midcarpal instability using a palmaris longus tendon graft.

PURPOSE: To report the results of a technique of soft tissue stabilization for palmar midcarpal instability using a palmaris longus graft. METHODS: In patients' symptomatic wrists with palmar midcarpal instability that had failed conservative management, we used a dorsal approach and stabilized the hamate and triquetrum by reconstructing the dorsal triquetrohamate ligament. The palmaris longus tendon graft was fixed with bone anchors. Seven wrists in 6 patients were available for follow-up at a mean of 28 months (range, 17-37 mo). RESULTS: There was an overall meaningful improvement in function (mean preoperative Disabilities of the Arm, Shoulder, and Hand score, 49 preoperatively, 28 postoperatively). There was a significant increase in grip strength from 15 to 21 kg. At final follow-up, 2 patients had moderate pain. The others had mild or no pain. Four patients returned to their previous occupation or activity. Patients retained full pronation and supination. When compared with the normal side, flexion was reduced to 71%, extension to 81%, radial deviation to 90%, and ulnar deviation to 65% of the opposite side. Although the mean results show an improvement, one patient had a poor result with deterioration in Disabilities of the Arm, Shoulder, and Hand score in spite of a clinically stable wrist, and another had clinical evidence of recurrent instability during pregnancy. One patient had residual symptoms from a prominent bone anchor. CONCLUSIONS: Overall, this technique showed good medium-term results in most of our patients. It retained some midcarpal mobility, eliminated clunking in most patients, and provided a noteworthy improvement in grip strength and function. We continue to use this technique for patients with symptomatic midcarpal instability, but it requires further evaluation with larger patient numbers and a longer follow-up to assess its overall value.

Morpho-Physiological and Biochemical Responses of Field Pea Genotypes under Terminal Heat Stress.

Field pea is one of the important short-duration cool season pulse crops which contributes significantly towards food and nutritional security. Two heat-susceptible (HS) and two heat-tolerant (HT) genotypes were selected from the previous study for further characterization. A significant variation was observed for morpho-physiological traits studied. Principal component analysis explained that first two principal components, i.e., PC1 and PC2 showed 76.5% of the total variance in optimal condition, whereas 91.2% of the total variance was covered by the first two PCs in heat stress environment. The seed yield per plant determined significant and positive association with superoxide dismutase and number of seeds per pod under optimal conditions, whereas under heat stress condition, it was positively associated with number of effective pods per plant, biological yield per plant, proline, pod length, number of seeds per pod, superoxide dismutase, and peroxidase. The significant reduction was noticed in the susceptible genotypes, whereas tolerant genotypes showed stable and non-significant reduction in chlorophyll content. Further, minimum cell damage and higher hydrogen peroxide production was noticed in the susceptible genotypes. In addition, the biochemical characterization of HS and HT genotypes revealed that the higher expression of peroxidase, superoxide dismutase, and catalase modulates the tolerant responses in HT genotypes. These genotypes were further used in developing heat-tolerant field pea genotypes.

A Systematic Review of the Outcomes of Flexor Tenolysis in Zones 2-5.

Background: Although numerous surgical techniques have been described and deployed, flexor tenolysis remains one of the most challenging procedures in hand surgery and there is no standardised way of recording the outcomes. The aim of this study is to systematically review the evidence supporting current concepts and outcomes in flexor tenolysis. Methods: The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline and EMBASE databases were searched for articles published in English using the keyword search terms 'flexor' or 'tendon' and 'tenolysis' or 'tenoarthrolysis'. A total of 555 articles were listed and further screening provided fourteen studies remaining for final inclusion. The parameters for data extraction included number of digits operated on, age of the patients, initial injury mechanism requiring flexor tenolysis, outcome assessment method, follow-up period, results and complications. The primary outcome was postoperative active range of motion. Results: 556 digits were included across all studies and the age of patients ranged between 1 and 75 years. Eleven out of fourteen of the articles used the Strickland criteria to report their outcomes. Other outcome measures used were total active motion (TAM), Buck-Gramcko and pulp-to-palm distance. In the studies which used the Strickland criteria, the average percentage of outcomes reported as 'good' or 'excellent' was 68% with a range between 45% and 91%. Three other studies used Buck-Gramcko, TAM and pulp-to-palm distance outcome reporting and achieved 72% 'good' or 'excellent', 84% improvement and 30% able to touch distal palm crease respectively. Conclusions: Although the literature contains a limited number of observational studies, the current evidence shows that 68% of well-selected patients who undergo flexor tenolysis achieve a good or excellent outcome as measured by the Strickland criteria. Level of Evidence: Level III (Therapeutic).

Genome-Wide Analysis of Late Embryogenesis Abundant Protein Gene Family in Vigna Species and Expression of VrLEA Encoding Genes in Vigna glabrescens Reveal Its Role in Heat Tolerance.

Late embryogenesis abundant (LEA) proteins are identified in many crops for their response and role in adaptation to various abiotic stresses, such as drought, salinity, and temperature. The LEA genes have been studied systematically in several crops but not in Vigna crops. In this study, we reported the first comprehensive analysis of the LEA gene family in three legume species, namely, mung bean (Vigna radiata), adzuki bean (Vigna angularis), and cowpea (Vigna unguiculata), and the cross-species expression of VrLEA genes in a wild tetraploid species, Vigna glabrescens. A total of 201 LEA genes from three Vigna crops were identified harboring the LEA conserved motif. Among these 55, 64, and 82 LEA genes were identified in mung bean, adzuki bean, and cowpea genomes, respectively. These LEA genes were grouped into eight different classes. Our analysis revealed that the cowpea genome comprised all eight classes of LEA genes, whereas the LEA-6 class was absent in the mung bean genome. Similarly, LEA-5 and LEA-6 were absent in the adzuki bean genome. The analysis of LEA genes provides an insight into their structural and functional diversity in the Vigna genome. The genes, such as VrLEA-2, VrLEA-40, VrLEA-47, and VrLEA-55, were significantly upregulated in the heat-tolerant genotype under stress conditions indicating the basis of heat tolerance. The successful amplification and expression of VrLEA genes in V. glabrescens indicated the utility of the developed markers in mung bean improvement. The results of this study increase our understanding of LEA genes and provide robust candidate genes for future functional investigations and a basis for improving heat stress tolerance in Vigna crops.

Upper blepharoplasty approach to frontozygomatic dermoid cysts.

OBJECTIVES: Dermoid cysts are common periorbital lesions in children. Traditional surgical approaches have included incisions over the mass; above, below, or through the brow; and parallel to the superior orbital rim and the Lynch incision, as well as lateral canthotomy. We aimed to present experience of Alder Hey Children's Hospital on frontozygomatic dermoid removal through a blepharoplasty incision. In this article, we also aimed to review the current literature, describe the operative technique clearly, and offer reasonable explanations for the operative choices made based on our experience of the clinical anatomy and pathology. METHODS: Thirty-four children were operated on (19 girls and 15 boys), aged 1 to 11 years, between 2005 and 2008. The lesions were left sided in 14 patients and right sided in 20 patients. Preoperative computed tomographic/magnetic resonance imaging scan was generally not used, except in cases where the cyst was more than 1 cm away from the brow margin. RESULTS: All cysts were completely excised. At surgery, all cysts were adherent to the periosteum, and 3 were subperiosteal. None extended through the bone into the orbit. The average operating time was 30 minutes. The average follow-up duration was 1 year. The only complications were early mechanical ptosis in 3 children, which completely resolved; the majority had an uneventful postoperative course. There were no recurrences, and in all patients, scar camouflage was described as excellent. CONCLUSIONS: This interesting and extremely effective technique provides excellent scar camouflage with no lid or ocular dysfunction.

A 15-year mystery resolved: a large bone-boring glomus tumor mistaken as dermatitis.

Glomus tumor (GT) is a rare, benign neoplasm of the glomus apparatus. Being most common in the subungual region, it often misdiagnosed with dermatological conditions. Severe tenderness, paroxysmal pain and cold intolerance symptomatically denote GT. Clinical tests such as Love's pin test and Hildreth's test assist in diagnosing the disease. X-ray, ultrasonography and magnetic resonance imaging can confirm the severity of the lesion. Complete surgical excision is the only treatment available for these subcutaneous nodules. A middle-aged male with a hand pain, who misdiagnosed for dermatitis over 15-year period, has identified as having a large bone-boring GT. Awareness of GT among healthcare professionals is a must to increase the quality of life of patients.

FDP Avulsion Injury Due to Enchondroma: A Unique Surgical Approach.

Flexor Digitorum Profundus avulsion injury associated with an enchondroma at the level of the distal phalanx is extremely rare. There have been few cases reported to date and most have been surgically managed using a screw and/or Bunnell pull-out wire technique with or without bone grafting. We describe the first case using a simple interosseus fixation technique for the reattachment of FDP tendon without bone grafting. The patient made an excellent post-operative recovery. This technique is a simple, effective, patient-friendly and internalised solution which, in addition, may prevent the need for bone grafting.

The management of acute fracture dislocations of proximal interphalangeal joints: a systematic review.

LEVEL OF EVIDENCE: III.

Brachial plexus impingement secondary to implantable cardioverter defibrillator: A case report.

Overall complication rates of 9.1% have been reported following implantable cardioverter defibrillator (ICD) placement. Brachial plexus injury is infrequently reported in the literature. We describe a 26-year-old female experiencing left arm nerve pain, a positive Tinel's sign, numbness in the median nerve distribution of the hand and biceps muscle weakness following revision ICD via subclavian vein approach. Nerve conduction studies identified severe partial left brachial plexopathy, which remained incompletely resolved with conservative management. Surgical exploration revealed lateral cord impingement by the ICD generator and a loop of the ICD lead, along with fibrosis, necessitating surgical neurolysis and ICD generator repositioning. As increasing numbers of patients undergo cardiac device implantation, it is incumbent on practitioners to be aware of potential increases in the prevalence of this complication.

Component separation of the index finger to reconstruct the thumb: case report with review of literature.

Treatment options for severely damaged finger joints include amputation, arthroplasty, arthrodesis, and reconstruction using nonvascularized or vascularized joint transfers. The thumb contributes significantly to global hand function, and functioning metacarpophalangeal and interphalangeal joints are crucial. When 2 adjacent joints are damaged by trauma, vascularized joint transfer from an injured index finger to the thumb is an option to maximize remaining thumb function. Complex composite injuries involving joints, soft tissues, and tendons require customized reconstructive solutions to retain and optimize hand function. We present a case of component separation of an injured index finger as the donor area for 2 flaps to reconstruct a complex bone, joint, and soft tissue thumb defect, which resulted in a high level of patient satisfaction and a return to heavy manual work.

The management of chronic non-arthritic scapholunate dissociation: a systematic review.

A systematic review was conducted to identify the best management for chronic scapholunate dissociation. EMBASE, MEDLINE, and CENTRAL were searched from 1965-2016. A narrative synthesis was performed. One thousand, one hundred and ninety-one citations were identified, of which 17 had final analysis. In all interventions, the pain score at 2 years reduced from 6.0 to 2.8 with similar effect from capsulodesis and tenodesis techniques. Overall there was an 18% loss of flexion arc. Radial to ulnar arc improved in capsulodesis (+19%; n = 45) and worsened in tenodesis (-6%; n = 45). Grip strength was better in capsulodesis (+31%; n = 64 versus + 11%; n = 56). There was insufficient evidence to link radiological outcome with clinical outcome. Rates of complications (20%) and CRPS (3.8%) were high, with implications for patient consent. Due to heterogeneity in data collection, the lack of comparative studies and short-term follow-up, no conclusion regarding the superiority of a single technique was possible. Longer term comparative studies are required, as are natural history studies. A minimum data set has been advised. LEVEL OF EVIDENCE: II.

Imaging of peripheral arteries by 16-row multidetector computed tomography angiography: a feasible tool?

OBJECTIVE: To evaluate the efficacy of multidetector (16-row) computed tomography (MDCT) in imaging the upper and lower limb arterial tree in trauma and peripheral arterial occlusive disease (PAOD). METHODS: Thirty-three patients underwent MDCT angiography (MDCTA) of the upper or the lower limb on 16-row MDCT scanner between November, 2004 and July, 2005. The findings were compared with the surgical outcome in cases with trauma and suspected arterial injuries or color Doppler correlation was obtained for patients of PAOD. RESULTS: MDCTA allowed a comprehensive diagnostic work-up in all trauma cases with suspected arterial injuries. In the 23 cases of PAOD, MDCT adequately demonstrated the presence of stenosis or occlusion, its degree and extent, the presence of collaterals and plaques. CONCLUSION: Our experience of CT angiography (CTA) with 16-row MDCT scanner has clearly demonstrated its efficacy as a promising, new, fast, accurate, safe and non-invasive imaging modality of choice in cases of trauma with suspected arterial injuries and as a useful screening modality in cases of PAOD for diagnosis and for grading.

Imaging of peripheral arteries by 16-slice computed tomography angiography. A valuable tool?

OBJECTIVE: To evaluate the efficacy of multidetector (16-row) computed tomography (MDCT) in imaging the upper and lower limb arterial tree in trauma and peripheral vascular disease. METHODS: Thirty three patients underwent multislice computed tomography angiography (MSCTA) of the upper or the lower limb on multislice (16-slice) CT scanner between November 2004 and July 2005 in the Department of Radiology, National Organ Transplant Center, Tripoli, Libya. The findings were retrospectively compared with the surgical outcome in cases of trauma with suspected arterial injuries; or color Doppler correlation was obtained, for patients of peripheral vascular disease. RESULTS: Multislice computed tomography angiography allows a comprehensive diagnostic work-up in all trauma cases with suspected arterial injuries. In 23 cases of peripheral vascular diseases, MSCTA adequately demonstrated the presence of any stenosis or occlusion, its degree and extent, the presence of collaterals and distal reformation if any; the presence of plaques. CONCLUSION: Our experience of computed tomography angiography with 16-row MDCT scanner has clearly demonstrated its efficacy as a promising, new, fast, accurate, safe and non-invasive imaging modality of choice in cases of trauma with suspected arterial injuries; and as a useful screening modality in cases of peripheral vascular diseases for diagnosis and for grading.

Takayasu arteritis diagnosed by 16-row multidetector CT angiography.

Takayasu`s arteritis is a well-known systemic disease that involves the aorta, major aortic branches, and pulmonary arteries. Conventional catheter angiography remains the gold standard for disease diagnosis, in correlation with clinical data and laboratory findings. Multislice computed tomography angiography (MSCTA) has the advantage of non-invasively providing the angiographic data and combining morphological mural assessment with luminal evaluation. We present 2 such cases diagnosed by 16-slice MSCTA.

Apert syndrome: A consensus on the management of Apert hands.

INTRODUCTION: Apert Syndrome is a congenital condition characterised by primary craniosynostosis, midfacial malformations and complex symmetrical malformations of the hands and feet. The hands demonstrate one of the most complex collections of congenital upper limb deformities, posing a significant challenge for the paediatric hand surgeon. This study examines the extant literature and current practice of the four UK specialist craniofacial units regarding the management of Apert hands in order to provide a basis for guideline development. METHODS: The current literature was reviewed. Survey-type questionnaires were distributed to the four UK specialist craniofacial units and responses analysed. RESULTS: Management of the Apert hand is largely dictated by the degree of malformation present. Although all units aim to achieve a five digit hand, variation in the timing of surgery, operative protocols and mobilisation policies exist. CONCLUSION: The results of this study provide an interesting snapshot of the current management of Apert hands across four UK craniofacial surgery units. The four UK units remain congruent on most areas surrounding the management of Apert hands although some minor inter-unit variation exists. A multidisciplinary approach to management remains fundamental in optimising the regain of function and aesthetically acceptable hands.

Crossing renal vessel causing ureteropelvic junction obstruction.

Ureteropelvic junction UPJ obstruction is caused by the presence of an aperistaltic dysplastic segment at the UPJ. Besides this intrinsic etiology, extrinsic factors, mainly crossing vessels, maybe the causative factor. The controversy regarding the functional significance of vessels crossing at the UPJ is not a new one, though this debate has been resurrected in recent years because of improved detection due to the advent of advanced imaging techniques such as multidetector row computed tomography MDCT and fast magnetic resonance imaging. We present a similar case where MDCT proved the crossing renal vessel to be the cause for UPJ obstruction.

The pattern of renal vessels in live related potential donors pool. A multislice computed tomography angiography review.

OBJECTIVE: To assess the renal vessel anatomy, compare the findings with the perioperative findings, to determine the sensitivity of multislice computed tomography (CT) angiography in the work-up of live potential donors and to discuss and compare the results of the present study with the reported results using single slice CT, magnetic resonance (MRI) and conventional angiography (CA). METHODS: Retrospective analysis of the angiographic data of 118 of prospective live related kidney donors was carried out from October 2004 to August 2005 at the National Organ Transplant Centre, Tripoli Central Hospital, Libya. All donors underwent renal angiography on multislice (16-slice) CT scan using 80 cc intravenous contrast with 1.25 mm slice thickness followed by maximum intensity projection (MIP) and volume rendering techniques (VRT) post-processing algorithms. The number of vessels, vessel bifurcation, vessel morphology and venous anatomy were analyzed and the findings were compared with the surgical findings. RESULTS: Multislice spiral CT angiography (MSCTA) showed clear delineation of the main renal arteries in all donors with detailed vessel morphology. The study revealed 100% sensitivity in detection of accessory renal vessels, with an overall incidence of 26.7%, which is the most common distribution in the parahilar region. CONCLUSION: The present study showed 100% sensitivity in the visualization and detection of main and accessory renal vessels. These results were comparable with conventional angiography which has so far been considered as the gold standard and were found superior in specificity and accuracy to the use of single slice CT (SSCT) and MR in the angiographic work-up of live renal donors. Due to improved detection of accessory vessels less than 2 mm in diameter, a higher incidence of aberrant vessels was seen on the right side as has been suggested so far.

Trichobezoar.

Trichobezoar is an uncommon condition often presenting, among other signs, with a history of trichotillomania and trichophagia. We report an unusual case of gastric trichobezoar with extension into jejunum in a patient with an unusual habit of ingesting hair plucked from other people's scalp.