Isolated bilateral triphalangeal thumb with delta phalanx: a case report.

Triphalangeal thumb is characterized by the interposition of an extra-phalanx between two normal ones. In this article the authors present the case of a 24-year-old man with bilateral triphalangeal thumb of opposable type, without any other associated anomaly or genetic syndrome. The patient had triangular delta extra-phalanxes that caused ulnar deviation of both thumbs. Surgical procedure for the correction of the congenital anomaly consisted of a closing wedge osteotomy and distal interphlangeal joint arthrodesis in the left thumb, and a wedge osteotomy in the deformed distal phalanx of the right thumb. Appearance and precision function of hands considerably improved 6 months after the operation, and there was no major stiffness in proximal interphalangeal joints of thumbs.

Modified simple decompression of ulnar nerve in treatment of cubital tunnel syndrome.

BACKGROUND: There are two main surgical approaches, simple ulnar nerve decompression at the elbow, and anterior transposition of the nerve in treatment of cubital tunnel syndrome. Both techniques were reported in literature in details with similar reported success rates. Here, we present a modified simple decompression surgical technique in treatment of cubital tunnel syndrome. METHODS: Fifty eight patients diagnosed with cubital tunnel syndrome undergoing the presented technique were enrolled. This procedure consisted of ulnar nerve decompression at the elbow and a supplementary procedure of inter-muscular septum transverse cut between triceps and brachialis muscle above the elbow. RESULTS: Complete sensory recovery was observed in 35 (60.3%) patients, however, mild and occasional sensory symptoms remained in 15 (25.9%), and moderate symptoms persisted in 6 (10.3%) patients. In two patients (3.4%), no sensory improvement was recorded. Post-operatively, muscular hypotrophy improved completely in 5 out of 12 patients (41.7%). However, in the remaining 7 patients (58.3%) with muscular atrophy, motor recovery never took place. CONCLUSION: The presented modified simple decompression technique was shown to be an effective and safe procedure for the treatment of cubital tunnel syndrome without any complications.

Treatment of facial paralysis: dynamic reanimation of spontaneous facial expression-apropos of 655 patients.

BACKGROUND: Six hundred fifty-five cases of unilateral facial paralysis were treated by different surgical methods to achieve dynamic reanimation of facial muscle movement. In a retrospective study, the recovery of both truly spontaneous smile and facial muscle movement was evaluated independently. METHODS: The authors performed 505 two-stage gracilis, one rectus abdominis, and 14 single-stage latissimus dorsi microneurovascular muscle transfers, in addition to 28 cross-facial facial nerve neurotization procedures. These procedures were based on neurotization of the paralyzed region by the contralateral healthy facial nerve. Procedures involving motor nerves or muscle beyond the territory of the facial nerve included 73 temporalis muscle transpositions, four lengthening temporalis myoplasty procedures, 26 neurotizations by the hypoglossal nerve, and four neurotizations by the spinal accessory nerve. RESULTS: Patients treated by techniques based on the motor function of nerves other than the facial nerve did not recover spontaneous smile. Neurotization by the facial nerve, however, did result in the recovery of spontaneous smile in all satisfactory or better outcomes. Recovery of lip commissure movement based on neurotization by the contralateral healthy facial nerve was better than that of the remaining groups (p < 0.0001). CONCLUSIONS: Temporalis muscle transposition and lengthening myoplasty are acceptable options for patients who are not good candidates for neurotization by the facial nerve. For the restoration of both truly spontaneous smile and facial muscle movement, free microneurovascular muscle transfer neurotized by the contralateral healthy facial nerve has become the authors' first-choice surgical technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Division of the first dorsal compartment of the hand into two separated canals: rule or exception?

BACKGROUND: Tendon entrapment of the first dorsal compartment of the wrist, the de Quervain disease, is a common cause of wrist and hand pain and disability. A group of 50 consecutive patients operated for the treatment of de Quervain disease from 2003 through 2006 were prospectively studied to determine the variation in the pattern of the first extensor compartment. METHODS: Eighty-six percent of the patients were females, and 14% were males. In 80% of the cases the nondominant and in 20% the dominant hand was involved. These interesting findings may rule out the occupation's relation to de Quervain disease. RESULTS: Our study revealed that the compartment is completely separated into two canals in 86% of the patients which was significantly higher than that reported in similar studies. CONCLUSION: The existence of two separated compartments for abductor pollicis longus and extensor pollicis brevis tendons should be considered as a common finding during operation to prevent incomplete treatment and recurrence of the symptoms.

Therapeutic results of sciatic nerve repair in Iran-Iraq war casualties.

BACKGROUND: The sciatic nerve is composed of two independent divisions: tibial and peroneal. The results of the repair of these two nerves are not identical. This retrospective study was carried out with the aim of evaluating the results of different therapeutic procedures for sciatic nerve injuries and conducting a comparative evaluation of peroneal and tibial nerve recovery. METHODS: A total of 648 Iranian casualties of the 1980 to 1988 Iran-Iraq war with sciatic nerve injury were treated with nerve grafting, direct end-to-end coaptation, and neurolysis. Patients were subdivided according to nerve injury site into three groups of upper, middle, and lower thirds of the thigh, and followed from 5 to 12 years. RESULTS: In 77.8 percent of patients, the tibial nerve was injured, and in 88.9 percent, the common peroneal nerve was injured. Protective sensation recovery of the sole was evaluated as good in 69.1 percent of those with upper third injuries, 74.4 percent of those with middle third injuries, and 89.3 percent of those with lower third repairs (p < 0.0001), with an overall success rate of 73.4 percent. The overall motor recovery success rate for the three techniques was 86.3 percent for the tibial nerve and 38.9 percent for the common peroneal nerve. CONCLUSIONS: Results of sciatic nerve injury treatment in this group of war casualties were generally satisfactory. Tibial nerve injury repair in the upper thigh has a higher priority than the peroneal nerve. Motor deficits of the common peroneal nerve can be overcome by tendon transfer or orthopedic devices.

Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation.

PURPOSE: To determine the clinical characteristics of 12 patients with Mycobacterium tuberculosis-induced carpal tunnel syndrome. This article also presents our intraoperative findings and surgical treatment results. METHODS: Twelve patients with tuberculosis-induced carpal tunnel syndrome who had surgery during a 10-year period that began in March 1991 were reviewed. The entrance criterion was a positive histologic report of tuberculosis for surgical specimens. The preoperative evaluation leading to diagnosis was reviewed for all patients. Transection of the transverse carpal ligament and complete synovectomy were performed for all patients. After surgery the patients were given an antituberculosis regimen for 1 year and were followed up for an average of 6 years. RESULTS: Twelve cases from a total of 1,180 patients with carpal tunnel syndrome were traced to M tuberculosis involvement of synovial tissue of the flexor tendons. Ten patients had large rice bodies in thick synovial membranes, and in the other 2 patients thick synovial tissue with yellow exudates were observed during surgery. In contrast to tendon involvement with rupture, no direct median nerve involvement was noted. Histopathologic study results of surgical specimens were positive for tuberculosis in all patients. Eight of 10 initial smears showed acid-fast bacillus and all 10 cultures of the specimens were positive for tubercle bacilli. Surgery and antituberculosis therapy were associated with a desirable outcome and sensory disturbance in the median nerve distribution resolved in all patients. Anterior wrist swelling disappeared and there has been no clinical or laboratory evidence of recurrence in all treated patients. CONCLUSIONS: Early diagnosis and surgical treatment combined with antituberculosis medical treatment are important in treating this condition. All patients treated were relieved of symptoms of synovial proliferation at the wrist, with no recurrence of the condition during the follow-up period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Association between carpel tunnel syndrome and arteriovenous fistula in hemodialysis patients.

BACKGROUND: Carpal tunnel syndrome is more common in hemodialysis patients than in the general population. In addition to uremic neuropathy, arteriovenous fistula has been identified as one of the possible causes for the development of carpal tunnel syndrome. METHODS: Wrists of 279 hemodialysis patients who had arteriovenous fistula for at least 6 months served as the case group and the other intact wrists of the same patients served as the control group. Carpal tunnel syndrome was diagnosed clinically; however, 116 random patients underwent electrodiagnostic studies the day after hemodialysis. RESULTS: Clinically, carpal tunnel syndrome was diagnosed less frequently in the contralateral wrist than in the wrist with arteriovenous fistula (12.2 percent versus 30.5 percent, p < 0.0001). Meanwhile, the authors found a positive correlation between the duration of fistula and the development of carpal tunnel syndrome (p < 0.028). The site of fistula (snuffbox, radiocephalic) used, however, had no effect on the rate of development of carpal tunnel syndrome (p > 0.2). Contrary to the clinical assessment, electrodiagnostic studies did not indicate any significant association between the frequency of carpal tunnel syndrome and arteriovenous fistula or its duration. With the nerve conduction velocity abnormalities observed in patients with uremic polyneuropathy, the authors believe that clinical diagnosis of carpal tunnel syndrome is more indicative of the development of the condition than the electrodiagnostic results. CONCLUSIONS: The authors' clinical results have revealed that hemodialysis patients are at considerable risk of developing carpal tunnel syndrome in the wrist with an arteriovenous fistula. These patients should be under close observation and receive routine checkup.

A new surgical technique for the treatment of high common peroneal nerve palsy.

In this article, the authors introduce a new procedure for the treatment of high common peroneal nerve palsy. The principle of this technique consists of the neurotization of the anterior tibial nerve (deep peroneal nerve) with the bundle composed of the nerves to the soleus and lateral head of gastrocnemius muscles. The authors used this procedure for eight children who had permanent common peroneal nerve palsy caused by the injection of diclofenac in the gluteal region and for a 25-year-old male patient whose common peroneal nerve was transected near the gluteal region by a stab wound. For the cases in which paralysis was less than 8 months in duration, the results are satisfactory.