Improving Metacarpophalangeal Joint Instability by Joint Implantation in Parallel From a Supernumerary Thumb in Severely Hypoplastic Duplicated Thumbs.

ABSTRACT: Here, we present 2 cases of a severely hypoplastic duplicated thumb classified as Wassel types 5 and 6 and discuss whole-joint implantation from a supernumerary thumb as an alternative to stabilize the hypoplastic metacarpophalangeal (MCP) joint. The aim of the surgical treatment of thumb polydactyly is to reconstruct a functional and aesthetically pleasing thumb. Hypoplasia of joint components and abnormal tendon alignment lead to unpleasing results with angular deformity of the reconstructed thumb. In 2 cases, the MCP joint of the dominant digit was hypoplastic and unstable in all directions. The main problem was underdevelopment of the affected MCP joint, and it was reasonable to attempt to stabilize the unstable joint by adding another redundant joint in parallel. Whole-joint implantation with a flap on a vascular pedicle is useful to repair both joint instability and soft tissue hypoplasia, as in case 1. The vascularized joint can maintain balanced growth potential. However, nonvascularized interphalangeal (IP) joint implantation is a simple solution for repairing MCP joint instability, as in case 2. These joints have no tendon insertions, so we believe they are acting as a splint supporting the hypoplastic joint for a long period. The transfer of composite tissues from the foot has been reported for reconstruction of finger and thumb hypoplasia. Duplicated thumb operation is usually recommended at 1 year old. Similarly, nonvascularized joint implantation in parallel may be a promising choice to overcome MCP joint instability and to maintain range of motion in hypoplastic cases with a duplicated thumb.In conclusion, joint implantation in parallel from a supernumerary thumb could prevent angular deformity and is an alternative to overcome MCP joint instability in cases of a severely hypoplastic duplicated thumb without any donor morbidity.

Subtotal Nasal Reconstruction in a 91-year-old Patient: Expanded Double Forehead Flaps and Costal Cartilage.

Nasal reconstruction in very elderly patients is challenging. We attempted subtotal nasal reconstruction with an expanded double forehead flap and autologous costal cartilage support in a 91-year-old woman presenting with subtotal nasal defects after sebaceous carcinoma resection. Only small parts of the bilateral alae and the columella base remained after resection, and the frontal area of the septum was also resected. We planned to use an expanded double forehead flap to reconstruct the whole external skin cover and lining of the nose. We chose a 200-mL tissue expander and injected 152 mL of saline over 15 weeks. The expansion course in this patient was slower than that in younger patients because of the limited expansibility of her forehead skin. However, the skin tolerated the repeated expansions well, and the double forehead flap was expanded to the planned size preoperatively. The nasal support grafts were composed of the L-strut and alar battens from the eighth and ninth costal cartilages, and were fixed using nonabsorbable sutures. Histological examination revealed cartilage matrix degeneration and a reduced number of living chondrocytes, yet no calcification or fragility. After 18 months of follow-up, the framework maintained its shape, and the dorsum was straight without warping. The autologous costal cartilage provided a natural nasal shape and nostrils. Thus, an expanded double forehead flap with careful tissue expansion and a rib cartilage graft can allow natural nose reconstruction without a microvascular technique in very elderly patients.

Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method: A Combination of Pulp Tissue Reduction, Bone Fixation Without Gaps, and Pinprick Testing Twice a Day.

BACKGROUND: In fingertip replantation with arterial anastomosis alone, many external bleeding techniques have been described to satisfy venous outflow, and some patients require blood transfusions. We used a pulp tissue reduction method to avoid the need for external bleeding techniques and blood transfusions. METHODS: We examined 18 fingers in cases of Ishikawa's subzone II, III, and IV amputation that were replanted with artery-only anastomosis and pulp tissue reduction from April 2003 to March 2018. The method consisted of pulp tissue reduction to the level of the fingerprint core, bone fixation without gaps to promote venous drainage through bone marrow, and pinprick testing twice a day. Prostaglandin E1 and/or urokinase were administered intravenously, but no other anticoagulants were used systemically or locally. Postoperatively, only the pinprick test was performed twice a day for 5 days. RESULTS: The patients ranged in age from 26 to 74 years (mean, 47 years). There were 13 men and 5 women. The total success rate was 89% (16/18). Of the 2 salvage failures, one was due to venous congestion and the other was due to arterial insufficiency. The survival rates of Ishikawa's subzone II, III, and IV amputation were 100% (4/4), 71% (5/7), and 100% (7/7), respectively. No blood transfusions were required in any of the cases. The Semmes-Weinstein test was performed for 14 of 18 fingers: the result was blue in 11 fingers and purple in 3 fingers. CONCLUSIONS: The pulp tissue reduction method resulted in a high success rate without the need for external bleeding or blood transfusions. Fingertip replantation with artery-only anastomosis, a pulp tissue reduction method, is effective for replant survival when subcutaneous venous repair is impossible because a reduced pulp volume may facilitate replant survival under conditions of irregular venous drainage, such as bone marrow drainage.

Association Between Compensatory Overaction of the Non-Injured Eye, Measured by HESS Chart and Postoperative Diplopia in Blow-Out Fracture.

In orbital floor fracture, diplopia often persists post-operatively. This study evaluated the association between pre-operative parameters concerning the extent of the injury and post-operative diplopia, using multivariate analysis. A retrospective computed tomography analysis and chart review was performed for patients with punched out orbital floor fracture, who underwent operations during the period from April 2011 to March 2018. Five parameters were evaluated: the number of upward arrows on the Hess chart (representing compensatory overaction of the non-injured eye), time interval to surgery, muscular subscores, fracture area, and swelling rate of the inferior rectus muscle. Of the 32 patients, 9 (28%) had post-operative diplopia; pre-operative diplopia was completely restored in 23 (72%) patients by 6 months after surgery. Univariate analysis found statistically significant differences in the number of upward arrows on the Hess chart, time interval to surgery, muscular subscores, and fracture area. Logistic regression analysis demonstrated that only the number of upward arrows displayed a significantly increased risk for post-operative diplopia (odds ratio, 15.3; 95% confidence interval, 2.0-117.0; P = 0.008). Excessive overaction of the non-injured eye predicted persistent diplopia by 6 months post-operatively. Surgical intervention may be insufficient to achieve full recovery from diplopia and disturbances of ocular motility in some patients.

Gliding Tissue Reconstruction Using a Dorsal Digital Adipofascial Flap in Complex Extensor Injury.

BACKGROUND: Postoperative scar adhesions between tendons and phalanx bones cause persistent disability in complex injuries involving tendons and bones of the hand. Although gliding tissue reconstruction is effective in preventing peritendinous adhesion formation and a dorsal digital adipofascial flap is a reliable method to prevent scar adhesion between tendon and bone after extensor tendon repair, no comparative clinical reports exist. This study aimed to determine the usefulness of a gliding tissue reconstruction method by comparing postoperative range of motion between patients who underwent gliding tissue reconstruction and those who did not. METHODS: Medical records of patients with complex extensor tendon injury who underwent extensor repair between April 2005 and March 2018 were retrospectively analyzed. Ten patients underwent extensor repair with gliding tissue reconstruction using a dorsal digital adipofascial flap and 13 underwent only extensor repair. A triangular flap was separated after zig-zag incision to expose the injured extensor tendon into dermal and adipofascial flaps. The adipofascial flap, based on a dorsal branch of the digital artery, was placed on the injured bone as the tendon gliding surface. The same extensor tendon suture method and rehabilitation protocol were used in both groups. All patients were followed up for 6 to 12 months. RESULTS: The mean ± SD % total active movements were 84.1% ± 12.4% and 57.6% ± 13.0% in the groups with and without gliding tissue reconstruction, respectively. Significant differences were found between the 2 groups (P < 0.05). CONCLUSIONS: Patients with gliding tissue reconstruction had better functional recovery. This reconstruction is recommended to restore the extensor function in cases of complex extensor injury involving finger tendons and bones.

Prevention of Mandible Reconstruction Plate Exposure by Costal Cartilage Wrapping.

After mandibulectomy in cancer surgery, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap in patients in poor condition. However, the rate of complications for mandibular reconstruction is higher with a reconstruction plate than with vascularized bone grafts. We have developed a costal cartilage wrapping method to prevent exposure of the mandible reconstruction plate. The eighth costal cartilage was removed and split into 2 pieces to wrap around the reconstruction plate. In our case, the artificial plate wrapped with costal cartilage graft was not exposed and the skin over the plate did not become atrophic over 27 months follow-up even after irradiation. Wrapping around an artificial reconstruction plate with autologous costal cartilage grafts may be more effective than using only a flap covering to prevent exposure of the plate after tumor ablation and radiation therapy.

Longitudinal slit procedure in addition to negative pressure wound therapy for a refractory wound with exposed achilles tendon.

OBJECTIVE: This case report reviews features of negative pressure wound therapy, particularly for the exposed Achilles tendon, and describes an additional effective procedure. METHODS: An 87-year-old man presented with a soft-tissue defect measuring 3×5 cm with the exposed Achilles tendon as a sequela of deep burn. The condition of his affected leg was ischemic because of arteriosclerosis. We used negative pressure wound therapy and made 2 longitudinal slits penetrating the tendon to induce blood flow from the ventral side to the dorsal surface. RESULTS: By this combination therapy, the surface of the exposed Achilles tendon was completely epithelialized and the tendon was spared without disuse syndrome. CONCLUSIONS: The authors conclude that this combination therapy is useful for covering the widely exposed tendon in aged patients.

The Supraorbital Margin of Japanese Who Have No Visible Superior Palpebral Crease and Persistently Lift the Eyebrow in Primary Gaze is Higher and More Obtuse Than Those Who Do Not.

OBJECTIVE: Anthropological studies divided the Japanese into the Yayoi migrants, who had narrow eye, no visible superior palpebral crease, and high-positioned round supraorbital margins for cold tolerance, and the Jomon natives, who had wide eye, visible superior palpebral crease, and low-positioned straight supraorbital margins, thus suggesting an anatomical discrepancy between the vertical palpebral fissure and the height of the supraorbital margin. Because Japanese subjects without visible superior palpebral crease open their eyelids by lifting the eyebrows with the anterior lamella owing to increased tonic contraction of the frontalis muscle, we hypothesized that persistently lifting the eyebrows in primary gaze mechanically remodels the supraorbital margin to be high positioned and round. METHOD: We evaluated whether subjects without visible superior palpebral crease persistently lifted their eyelids more than subjects with visible superior palpebral crease, whether the presence of persistently lifted eyebrow in primary gaze affected the relative height of the supraorbital margin in coronal view 3-dimensional computed tomography imaging, and whether the shape of the supraorbital margin in the coronal view affected that in the sagittal view 3-dimensional computed tomography imaging. RESULTS: Eyebrow height in subjects without visible superior palpebral crease was significantly larger than that in subjects with visible superior palpebral crease. The supraorbital margin of subjects without visible superior palpebral crease who persistently lifted the eyebrows in primary gaze was higher (rounder) and more obtuse than that of Japanese subjects with visible superior palpebral crease who did not. CONCLUSIONS: The mechanical pressure applied to the supraorbital margin by persistently lifting the eyebrows appears to functionally, rather than genetically, create the high (round) and obtuse supraorbital margin.

Surgical removal of amyloid-laden lymph nodes: a possible therapeutic approach in a primary systemic AL amyloidosis patient with focal lymphadenopathy.

We report a patient with primary systemic AL amyloidosis who suffered from remarkable bilateral cervical lymphadenopathy. Intensive chemotherapies, including two cycles of high-dose melphalan with autologous peripheral blood stem cell transplantation, were insufficiently effective for both the lymphadenopathy and amyloidogenic IgGλ-type M-protein in serum, but the patient showed complete haematological remission after extensive surgical removal of enlarged lymph nodes that had massive depositions of λ-type immunoglobulin light chain-derived amyloid. Lymphadenectomy may be a possible therapeutic approach with regard to both cosmetic and haematological aspects in primary systemic AL amyloidosis patients with focal lymphadenopathy.

The practical procedure of tumescent technique in burn surgery for excision of burn eschar.

The tumescent technique, which involves injection of large volumes of dilute epinephrine solution into subcutaneous fat, has been shown to markedly increase the safety of liposuction surgery, which is associated with risks of blood loss. The authors use this technique during burn surgery and developed a practical method of determining the amount of solution injected. The authors have applied the tumescent technique consisting of subeschar infiltration of dilute epinephrine (1 mg/L) in thermoneutral (37 degrees C) saline. Preoperatively, a 5 x 5 cm square grid pattern is drawn on the burn wound, which facilitates estimation of the amount of infiltrated solution. The authors injected 20 ml of solution per square in the grid. Ten consecutive patients underwent 15 surgical procedures for tangential excision and split-thickness skin grafting. There were no complications during the intraoperative or postoperative period. Their method using a grid pattern drawn on the tissue being treated by the tumescent technique in burn surgery facilitates the excision of burn eschar.