Ulnar dimelia - a review of 24 cases.

Ulnar dimelia is a very rare unilateral congenital upper limb anomaly (CULA) affecting the whole extremity. Treatment remains difficult because of the complexity and multi-level involvement. Twenty-four cases with duplicated ulna, absent radius and polydactyly from seven European centres were reviewed according to a structured list of parameters. At first consultation, median age 8 months (1-178), the shoulder movement was good in 17 patients or poor in six, and the median passive elbow range of motion was 20° (0°-90°). The resting wrist position was flexed in 22/24 patients. Following stretching and splinting, elbow surgery included resection of the lateral proximal ulna in 11 patients and muscle transfers in six to improve passive movement and increase active elbow motion, respectively. Tendon transfers were performed in eight wrists and a pollicization or pseudo-pollicization in 23 patients. Overall, patients demonstrate acceptable function postoperatively. Guidelines for treatment of this severe CULA are presented.Level of evidence: IV.

Protective distal side-to-side neurorrhaphy in proximal nerve injury-an experimental study with rats.

BACKGROUND: Side-to-side neurorrhaphy may protect the denervated end organ and preserve the initial connection with proximal stump. We examined the effect of protective side-to-side anastomosis on nerve and end organ regeneration in proximal nerve injury model. METHODS: The left common peroneal nerve of 24 Sprague Dawley rats was proximally transected. In groups B and C, side-to-side neurorrhaphy was performed distally between the peroneal and tibial nerves without (group B) and with (group C) partial donor nerve axotomy inside the epineural window. Group A served as an unprotected control. After 26 weeks, the proximal transection was repaired with end-to-end neurorrhaphy on all animals. Regeneration was followed during 12 weeks with the walk track analysis. Morphometric studies and wet muscle mass calculations were conducted at the end of the follow-up period. RESULTS: The results of the walk track analysis were significantly better in groups B and C compared to group A. Groups B and C showed significantly higher wet mass ratios of the tibialis anterior and extensor digitorum longus muscle compared to group A. Group C showed significantly higher morphometric values compared to group A. Group B reached higher values of the fibre count, fibre density, and percentage of the fibre area compared to group A. CONCLUSIONS: Protective distal side-to-side neurorrhaphy reduced muscle atrophy and had an improving effect on the morphometric studies and walk track analysis. Distal side-to-side neurorrhaphy does not prevent the regenerating axons to grow from the proximal stump to achieve distal nerve stump.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update.

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

Keyhole Revascularization for Treatment of Coronal Plane Fracture of the Lunate in Kienböck Disease.

Coronal plane fracture of lunate in Kienböck disease is a challenging problem with no proven treatment. We present a technique for the treatment. A vascularized bone graft from the distal radius employing the fourth and fifth extracompartmental artery pedicles is used as a mechanical support in order to enable fracture union. The technical pearls and pitfalls are described and a clinical case is presented.

Effect of Axonal Trauma on Nerve Regeneration in Side-to-side Neurorrhaphy: An Experimental Study.

BACKGROUND: Side-to-side (STS) neurorrhaphy can be performed distally to ensure timely end-organ innervation. It leaves the distal end of the injured nerve intact for further reconstruction. Despite encouraging clinical results, only few experimental studies have been published to enhance the regeneration results of the procedure. We examined the influence of different size epineural windows and degree of axonal injury of STS repair on nerve regeneration and donor nerve morbidity. METHODS: Three clinically relevant repair techniques of the transected common peroneal nerve (CPN) were compared. Group A: 10-mm long epineural STS windows; group B: 2-mm long windows and partial axotomy to the donor tibial nerve; and group C: 2-mm long windows with axotomies to both nerves. Regeneration was followed by the walk track analysis, nerve morphometry, histology, and wet muscle mass calculations. RESULTS: The results of the walk track analysis were significantly better in groups B and C compared with group A. The nerve fiber count, total fiber area, fiber density, and percentage of the fiber area values of CPN of the group C were significantly higher when compared with group A. The wet mass ratio of the CPN-innervated anterior tibial muscle was significantly higher in group C compared with group A. The wet mass ratio of the tibial nerve-innervated gastrocnemial muscle was higher in group A compared with the other groups. CONCLUSIONS: All three variations of the STS repair technique showed nerve regeneration. Deliberate donor nerve axotomy enhanced nerve regeneration. A larger epineural window did not compensate the effect of axonal trauma on nerve regeneration.

Comparison of Peripheral Nerve Regeneration with Side-to-side, End-to-side, and End-to-end Repairs: An Experimental Study.

BACKGROUND: The present study was conducted to find out a tool to enable improved functional recovery with proximal nerve injury. In this experimental study, nerve regeneration was compared between side-to-side (STS), end-to-side (ETS), and end-to-end repairs. METHODS: The walk track analysis was used as an outcome of functional recovery. Nerve regeneration was studied with morphometry and histology 6 or 26 weeks postoperatively. RESULTS: All 3 repair techniques showed regeneration of the nerve. From 12 weeks onward, the functional results of the 3 intervention groups were significantly better compared with the unrepaired control group. End-to-end repair was significantly better when compared with the STS and ETS groups. At 26 weeks, the functional and morphometric results and histologic findings did not differ between the STS and ETS groups. The functional results correlated with the morphometric findings in all groups. CONCLUSIONS: STS neurorrhaphy showed nerve regeneration, and the end results did not differ from clinically widely used ETS repair. Further studies are warranted to optimize the neurorrhaphy technique and examine possible applications of STS repair in peripheral nerve surgery.

[Botulinum toxin treatment in children]. / Mitä annettavaa botuliinilla on lapsille?

Botulinum toxin type A treatments in children were started nearly 20 years ago. The first and still most common indication is spastic equinus gait in cerebral palsy, but other indications have emerged, such as idiopathic toe-walking, peri- and post-operative pain, drooling and idiopathic congenital torticollis. The official indication for botulinum toxin treatment is spastic equinus gait in children over 2 years of age. Botulinum toxin is known as the most potent toxin. However, it has proved to be safe and well tolerated among paediatric patients. Adverse events are infrequent, mostly bruising and limited, temporary muscle weakness. With higher doses the risk for generalized adverse events increases.

Dermal pocketing following distal finger replantation.

Replantation is an ideal technique for reconstruction following fingertip amputation as it provides 'like for like' total reconstruction of the nail complex, bone pulp tissue and skin with no donor-site morbidity. However, fingertips are often not replanted because veins cannot be found or are thought to be too small to repair. Attempts at 'cap-plasty' or pocketing of replanted tips with and without microvascular anastomosis have been done in the past with varying degrees of success. We prospectively followed up a group of patients who underwent digital replantation and dermal pocketing in the palm to evaluate the outcome of this procedure. There were 10 patients with 14 amputated digits (two thumbs, five index, four middle, two ring and one little) who underwent dermal pocketing of the amputated digit following replantation. Among the 14 digits that were treated with dermal pocketing, 11 survived completely, one had partial atrophy and two were completely lost. Complications encountered included finger stiffness (two patients) and infection of the replanted fingertip with osteomyelitis of the distal phalanx (one patient). We believe that this technique can help increase the chance of survival for distal replantation with an acceptable salvage rate of 85% in our series.

Long-term results of transmetacarpal replantation.

UNLABELLED: The aim of this study was to evaluate subjective, functional and occupational outcome after transmetacarpal amputations. PATIENTS AND METHODS: Forty-three patients (mean age 34, range 1-71) with a transmetacarpal injury devitalizing three or more finger rays were treated with revascularization (22 patients) or replantation (21 patients). Most of the injuries (60%) were caused by a circular saw. Altogether 174 rays were injured of which 14 were doomed unsalvageable. An attempt was made to save the rest (n=160). Metacarpals were shortened on average 8 (range 0-22)mm. The number of arteries repaired varied from 2 to 5 and a vein graft was used in 16 patients. Thirty-eight patients (88%) attended a clinical follow-up examination performed by an independent observer at mean 9 years (range 2-24 years) after the injury. Subjective result was documented. Sensation was tested by two-point discrimination and Semmes-Weinsten filaments. Total active motion of MP- and IP-joints was measured. Grip and pinch strength was recorded. Functional results were assessed by Tamai's and Chens scoring systems. Cold intolerance and occupational history was registered. RESULTS: Primary survival of the replanted or revascularized digital rays was 86% (137/160). Subjective result was excellent in 11, good in 11, fair in 10 and poor in 6 patients. Out of 110 revascularized/replanted digits 86 (78%) achieved 2PD, among those the mean 2PD was 14.7 mm (range 6-25 mm). Total active motion (TAM) was on average 154 degrees (range 20-270 degrees ) per injured digit. The mean grip strength measured 56% (range 3-100%, n=33) and pinch strength 58% (10-100%, n=30) of the uninjured side. Using Tamai's scoring system the outcome was excellent in eight, good in 11, fair in 12 and poor in seven patients. According to Chen's criteria the result was excellent in seven, good in eight, fair in 18 and poor in five patients, respectively. The majority experienced cold intolerance. Sixteen of the 30 manual workers resumed to their previous or related occupation, ten were re-educated and four retired. CONCLUSIONS: The majority of transmetal carpal injuries with devascularized rays can be revascularized/replanted with a good subjective and satisfactory functional end result. Most patients can resume their old occupations or be employed after re-education.

Poor correlation of clinical signs with patellar cartilaginous changes.

PURPOSE: There is controversy between the symptoms and signs of chondromalacia. Patellar chondromalacia has several clinical tests, whose reliability as a parameter of chondral damage is unclear. The purpose of this prospective study was to correlate the sensitivity, specificity, predictive values and accuracy of clinical patellar tests with the findings at arthroscopy. Type of Study: In this prospective study, 100 consecutive knees that were subjected to arthroscopy were examined. METHODS: Because of missing data, 85 of the 100 knees were included in the final analysis. There were 41 male and 44 female patients with an average age of 39 and 44 years, respectively. The clinical tests were the tracking test, the apprehension test, the patellar inhibition test, and the flexion test. These tests were compared with the arthroscopic findings of the patellar cartilage. The classification of Outerbridge was used for evaluation of the condition of the patellar cartilage. RESULTS: At arthroscopy, there were no patellar cartilage changes in 33 knees. Patellar chondromalacia was seen in 52 knees. Grade I changes were found in 9 knees, grade II in 21 knees, grade III in 17 knees, and grade IV in 5 knees. Among the 4 clinical tests, the sensitivity was best for the tracking test (56%). The flexion test had the greatest specificity (85%), but a low sensitivity (35%). None of the tests showed acceptable results in terms of both sensitivity and specificity. The predictive values and the accuracy of a test were low, too. CONCLUSIONS: The sensitivity and specificity, predictive values, and accuracy of a test were generally low, except perhaps the specificity of the flexion test. The current clinical tests seem to have little value as indicators of patellar chondral pathology.