The effect of suture coated with mesenchymal stem cells and bioactive substrate on tendon repair strength in a rat model.

PURPOSE: Exogenously administered mesenchymal stem cells and bioactive molecules are known to enhance tendon healing. Biomolecules have been successfully delivered using sutures that elute growth factors over time. We sought to evaluate the histologic and biomechanical effect of delivering both cells and bioactive substrates on a suture delivery vehicle in comparison with sutures coated with bioactive substrates alone. METHODS: Bone marrow-derived stem cells were harvested from Sprague-Dawley rat femurs. Experimental cell and substrate-coated, coated suture (CS) group sutures were precoated with intercellular cell adhesion molecule 1 and poly-L-lysine and seeded with labeled bone marrow-derived stem cells. Control (substrate-only [SO] coated) group sutures were coated with intercellular cell adhesion molecule 1 and poly-L-lysine only. Using a matched-paired design, bilateral Sprague-Dawley rat Achilles tendons (n = 105 rats) were transected and randomized to CS or SO repairs. Tendons were harvested at 4, 7, 10, 14, and 28 days and subjected to histologic and mechanical assessment. RESULTS: Labeled cells were present at repair sites at all time points. The CS suture repairs displayed statistically greater strength compared to SO repairs at 7 days (12.6 ± 5.0 N vs 8.6 ± 3.7 N, respectively) and 10 days (21.2 ± 4.9 N vs 16.4 ± 4.8 N, respectively). There was no significant difference between the strength of CS suture repairs compared with SO repairs at 4 days (8.1 ± 5.1 N vs 6.6 ± 2.3 N, respectively), 14 days (22.8 ± 7.3 N vs 25.1 ± 9.7 N, respectively), and 28 days (40.9 ± 12.4 N vs 34.6 ± 15.0 N, respectively). CONCLUSIONS: Bioactive CS sutures enhanced repair strength at 7 to 10 days. There was no significant effect at later stages. CLINICAL RELEVANCE: The strength nadir of a tendon repair occurs in the first 2 weeks after surgery. Bioactive suture repair might provide a clinical advantage by jump-starting the repair process during this strength nadir. Improved early strength might, in turn allow earlier unprotected mobilization.

Subtalar arthroscopy and flurosocopy in percutaneous fixation of intra-articular calcaneal fractures: the best of both worlds.

BACKGROUND: Fixation of intra-articular calcaneal fractures has traditionally been guided by intraoperative fluoroscopy. Recent reports indicate that there is a role for subtalar arthroscopy in surgical fixation of these fractures. The earliest reports described the use of subtalar arthroscopy for joint assessment during late hardware removal. It then served as an adjunct for joint inspection in open reduction and internal fixation. In its final permutation, percutaneous arthroscopy was performed with minimally invasive reduction and fixation, minimizing soft tissue complications commonly associated with the open approach. In practiced hands, this technique yields good results with minimal morbidity. METHODS: We performed a prospective analysis of 22 consecutive patients with Sanders II, AO-OTA 83-C2 intra-articular calcaneal fractures who underwent dual-modality imaging (subtalar arthroscopic- and intraoperative fluoroscopic-) guided percutaneous fracture fixation with a minimum follow-up of 2 years. Maximum accepted postreduction step-off was 1 mm. Fractures were fixed definitively with four to eight percutaneous cancellous screws. RESULTS: There was significant correction of Böhler's tuberosity-joint angle from 4.2 degrees±11.1 degrees preoperatively to 21.3 degrees±8.8 degrees on immediate postoperative radiographs, with minimal subsidence to 20.1 degrees±8.2 degrees at 2 years. Böhler's angle correction and joint surface restoration could not be achieved percutaneously in one patient with an impacted, depressed joint fragment. Compared with preoperative values, there was significant improvement in mean Visual Analog Scale, American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score, and Short Form-36 (Physical Function) scores at 3 months, with further improvement up to 2-years. CONCLUSIONS: Subtalar arthroscopy augments intraoperative fluoroscopy in anatomic reduction of the posterior calcaneal facet of the subtalar joint and is most useful for Sanders type II, AO-OTA 83-C2 fractures. The percutaneous approach further avoids soft tissue complications associated with open reduction. However, this procedure has a steep learning curve, and conversion to open reduction must be considered when percutaneous reduction fails.

Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist.

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. Operative findings of "rice bodies, millet seeds, or melon seeds" are highly suggestive of tuberculous tenosynovitis. Six patients with TB of the hand and wrist at various stages of disease with characteristic operative findings are reviewed. Four patients had underlying immunosuppression. One patient had previous pulmonary TB, whereas 3 patients had radiographic evidence of previously undiagnosed pulmonary TB. The interval to presentation ranged from 1 week to 2 years. Two patients had median nerve irritation, 3 patients had osteomyelitis, and 1 patient had flexor tendon rupture. Mycobacterial cultures were positive in 4 patients; acid-fast bacilli stain, and polymerase chain reaction were positive in remaining 1 patient; and both stain and culture were negative in the last patient who had history of pulmonary TB. All 6 patients were managed with combination therapy comprising antituberculous chemotherapy and at least 1 debulking tenosynovectomy. Two patients had 2 debridements. Of these 2 patients, 1 underwent wrist arthrodesis during the second procedure. Mean follow-up was 4 years. There were no recurrences after the most recent debridement. The diagnosis of TB of the hand and wrist is often missed. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. Combination therapy comprising thorough excisional debridement and antituberculous chemotherapy will minimize recurrence of this difficult-to-treat disease.

Using Imageless Optical Navigation to Identify the New Hip Center in Crowe IV Dysplasia.

In total hip arthroplasty for patients with acetabular dysplasia, cup placement in the native acetabulum is preferred to placement in the pseudoacetabulum. Identifying the true acetabulum may prove challenging. In a patient with Crowe IV dysplasia, 3-dimensional mini-optical navigation was used to match the new hip center to the preoperative radiographic plan, which was identified to be 34 mm inferior to the pseudoacetabulum. This allowed titration of femoral shortening to 20 mm, to arrive at final limb lengthening of 14 mm. Although the use of other enabling technologies in hip dysplasia has been reported, to the authors' knowledge, this is the first reported case demonstrating the use of imageless optical navigation in this setting. It is a navigational tool with a small spatial footprint, does not mandate preoperative axial studies, and does not require multipoint bone surface registration. Imageless navigation may be a useful option for cup positioning and subsequent titration of femoral shortening in the reconstruction of Crowe IV dysplastic hips with degenerative joint disease. [Orthopedics. 2020; 43(2):e119-e122.].

Resurfacing hemipulp losses of the thumb: the cross finger flap revisited: indications, technical refinements, outcomes, and long-term neurosensory recovery.

Volar-oblique injuries of the thumb pulp are particularly disabling. Many methods have been described to treat these injuries and provide return of sensibility. The conventional cross finger flap is an established technique and is well suited for intermediate-sized partial pulp losses. We review our experience with this flap and describe technical refinements that have contributed to improved early outcome and long-term neurosensory recovery. Thirty patients underwent 31 cross finger flaps to the thumb for volar-oblique pulp defects. Defect sizes ranged from 1.5 to 5 cm in length and 1.5 to 3 cm in width. Dorsal skin of the index finger proximal phalanx was used in 26 patients, index finger middle phalanx in 2 patients, and long finger middle phalanx in 3 patients. Nine patients were available for long-term follow-up and were subjected to functional assessment (DASH questionnaire), sensitivity testing (2-point discrimination, Semmes-Weinstein monofilament testing), and range of motion evaluation. Thirty of 31 flaps survived. In 1 patient, trauma to the attached flap from the long finger middle phalanx resulted in flap ischemia. This was revised with a fresh cross finger flap from the index finger proximal phalanx. Employed patients were able to return to their original jobs. Recalled patients (n = 9) were assessed at a mean of 29 months after surgery (range, 12-70 months). All recalled patients regained normal sensibility on 2-point discrimination testing. Functional outcome was satisfactory in 8 patients (DASH score, 0-20). The last patient (DASH score, 61.67) complained of hypersensitivity and cold intolerance that affected his work. The conventional cross finger flap provides reliable coverage for volar-oblique hemipulp losses of the thumb, with patients regaining at least protective sensibility in the long term. The proximal and middle phalanges of both the index and long fingers may serve as donor sites, allowing the surgeon to best select skin cover based on defect size and options in finger positioning.

A Stepwise Approach to Management of Open Radiocarpal Fracture-Dislocations: A Case Report.

Radiocarpal dislocations are uncommon and occur after significant trauma. We describe a unique case of open radiocarpal fracture-dislocation presenting with progressive neurovascular compromise. Staged management was necessary. As a first stage, emergent provisional bedside reduction in the emergency room with manual pressure through the open wounds was performed. The second stage then involved formal open reduction and internal fixation as soon as operating room staff and resources became available.

That Tendon is the Median Nerve: Perils of a Palmaris Longus Deficient Wrist.

BACKGROUND: To document the course of the median nerve in the distal forearm in palmaris longus (PL) deficient forearms and elucidate features that help distinguish it from the PL. METHODS: In the cadaveric study, 56 cadaveric forearms were dissected and the location and course of the median nerve were documented. In the clinical study, 20 healthy subjects with absent PL were examined with provocative tests to elucidate the PL (Schaeffer's test and Thompson's test), and modified Durkan's and Phalen's tests. In the imaging study, one subject with a clearly visible and palpable median nerve was further evaluated with MRI with a superficial fiducial marker. RESULTS: Cadaveric dissection revealed that the median nerve was deep to the antebrachial fascia and superficial to the FDS tendons in the distal forearm. In 9 specimens without a PL, the median nerve was the most superficial structure deep and lay draped over the FDS tendons. In the clinical study, PL absence was bilateral in 4 subjects and unilateral in 16. The nerve was visible and palpable in 4 forearms and palpable but not visible in 20 forearms. In all 24 forearms, the nerve was palpable as a lax, mobile, cord-like structure that could be rolled over the taut FDS tendons. Tinel's and Durkan's signs were positive in 11 subjects. In the imaging study, MRI confirmed that the palpable structure was the median nerve. CONCLUSIONS: Unlike the PL, the nerve is non-contractile and remains flaccid on provocative testing. It is usually palpable and may also be visible in thin forearms. Careful scrutiny may reveal it to be distinct from, and draped over underlying FDS tendons. These findings may help avoid inadvertent median nerve harvest in place of a PL tendon graft.

LCP external fixation--external application of an internal fixator: two cases and a review of the literature.

The locking compression plate (LCP) is an angle-stable fixator intended for intracorporeal application. In selected cases, it can be applied externally in an extracorporeal location to function as a monolateral external fixator. We describe one patient with Schatzker V tibial plateau fracture and one patient with Gustillo IIIB open tibia shaft fracture treated initially with traditional external fixation for whom exchange fixation with externally applied LCPs was performed. The first case went on to bony union while the second case required bone grafting for delayed union. Both patients found that the LCP external fixators facilitated mobilization and were more manageable and aesthetically acceptable than traditional bar-Schanz pin fixators.

CASE REPORT Journey of a Noma Face.

OBJECTIVE: Noma, or cancrum oris, is rare in developed countries. Surgeons are likely to encounter this disease only in the context of a medical mission. While it is tempting to approach noma sequelae as an oncologic resection, an understanding of the disease process will reveal that the challenge is quite different. In addition, unlike the oncologic patient who desires rapid return to an aesthetically normal facies, the adult noma patient with chronic history of noma sequelae may be more accepting of a functional but less aesthetic outcome. METHODS: We describe a noma patient with soft-tissue losses involving right cheek, nasal ala, upper lip and oral commissure, and severe trismus who underwent staged reconstructive surgery. RESULTS: The objectives of temporomandibular joint release, facial defect coverage, correction of occlusal cant, and restoration of lower facial symmetry were met. The final planned stage of reconstruction was declined as the patient had regained sufficient self-confidence to participate in social activities. CONCLUSIONS: Surgeons from developed countries rarely encounter adult patients with noma sequelae. While reconstructive principles remain the same, noma reconstruction must be approached differently from oncologic resection and a staged approach is often necessary. Although complete correction may be planned to restore function and aesthetics, the noma patient may eventually be satisfied with a functional but less aesthetic outcome.

Hazards of steroid injection: Suppurative extensor tendon rupture.

Local steroid injections are often administered in the office setting for treatment of trigger finger, carpal tunnel syndrome, de Quervain's tenosynovitis, and basal joint arthritis. If attention is paid to sterile technique, infectious complications are rare. We present a case of suppurative extensor tenosynovitis arising after local steroid injection for vague symptoms of dorsal hand and wrist pain. The progression of signs and symptoms following injection suggests a natural history involving bacterial superinfection leading to tendon rupture. We discuss the pitfalls of local steroid injection and the appropriate management of infectious extensor tenosynovitis arising in such situations.

Spontaneous spinal epidural haematomas and the prognostic implications of interval to surgical decompression: a report of two cases.

Spontaneous spinal epidural haematomas (SSEHs) are rare causes of spinal cord compression. We present 2 cases of thoracic SSEHs with similar magnetic resonance imaging (MRI) features. Patient 1 was on long-term oral anticoagulants and patient 2 had uncontrolled hypertension. Patient 1 presented with a dense motor deficit, whereas patient 2 developed progressive lower limb weakness. Decompression laminectomy and haematoma evacuation was performed 51 hours later for patient 1 and 14 hours later for patient 2. Both had recovered their lower limb power, but neurological recovery was greater for patient 2. In patients with bleeding diatheses or uncontrolled hypertension, acute SSEHs must be suspected when they present with atraumatic back pain and signs of spinal cord compression. The interval to surgical decompression greatly influences the prognosis for neurological recovery.

Delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by computed tomography: a case report.

INTRODUCTION: Gastric volvulus is a rare condition. Presenting acutely, mesenteroaxial gastric volvulus has characteristic symptoms and may be easily detected with upper gastrointestinal contrast studies. In contrast, subacute, intermittent cases present with intermittent vague symptoms from episodic twisting and untwisting. Imaging in these cases is only useful if performed in the symptomatic interval. CASE PRESENTATION: We describe a patient with a long history of intermittent chest and epigastric pain. An earlier barium meal was not diagnostic. Diagnosis was finally secured during the current admission by a combination of (1) serum investigations, (2) endoscopy, and finally (3) computed tomography. CONCLUSION: Non-specific and misleading symptoms and signs may delay the diagnosis of intermittent, subacute volvulus. Imaging studies performed in the well interval may be non-diagnostic. Elevated creatine kinase and aldolase of a non-cardiac cause and endoscopic findings of ischaemic ulceration and difficulty in negotiating the pylorus may raise the suspicion of gastric volvulus. In this case, abdominal computed tomography with spatial reconstruction was crucial in securing the final diagnosis.