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Purpose: Preiser disease is difficult to diagnose and treat because of its unclear pathophysiology. Although both nonsurgical treatment and surgical treatment for Preiser disease have been reported, there is no consensus on the optimal treatment because of its rarity. The purpose of this study was to investigate the relationship between treatment selection and characteristics of patients with Preiser disease. Methods: This single-institution retrospective chart review included nine patients (two men and seven women) with Preiser disease who were treated at our hospital. We divided patients into two groups consisting of elderly (older than 65 years of age) and nonelderly patients. Herbert-Lanzetta classification, presence of dorsal intercalated segment instability (DISI), Watson classification based on plain radiography, Kalainov classification based on magnetic resonance imaging, and treatment modalities were investigated in both groups. Results: In the elderly group, three of five cases were in advanced stages of Preiser disease according to the Herbert-Lanzetta classification. Three wrists had a DISI deformity. Three patients underwent conservative treatment. The two remaining cases classified as Herbert-Lanzetta stage II underwent closing radial wedge osteotomy. In the nonelderly group, three of four cases were in the early stages of Preiser disease according to the Herbert-Lanzetta classification. One wrist had a DISI deformity. Two patients were treated conservatively. The other two patients were surgically treated using closing radial wedge osteotomy in one case and vascularized bone graft from the second metacarpal base in another case, both classified as Herbert-Lanzetta stage II. Conclusions: Most elderly patients with Preiser disease showed concurrent DISI at the time of initial presentation and advanced stage. Most elderly patients underwent nonsurgical treatment. Even when surgical treatment is implemented, our study suggests that the less invasive and optimal treatment is closing radial wedge osteotomy. Type of study/level of evidence: Therapeutic IV.
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Purpose: The placement of multistrand sutures during flexor tendon repair is complex and challenging. We developed a new, simpler, nine-strand suture, which we term the Tajima nines. The Tajima nines repair method is a new odd-numbered strand tendon technique. Methods: Fourteen porcine flexor tendons were transected and repaired using the Tajima nines repair method, without placement of peripheral sutures. This technique is a modification of the Lim and Tsai repair method; it uses a 4-0 monofilament nylon, 3-strand line, and two needles. The repaired tendons were tested for linear, noncyclic, load-to-failure tensile strength. The initial gap, 2-mm gap-formation force, and ultimate strength were measured. Results: The initial gap-formation force was 27.9 ± 7.5 newtons (N), the 2-mm gap-formation force was 39.2 ± 4.7 N, and the ultimate strength was 76.7 ± 17.2 N. Eight, three, and three of the 14 tendons repaired using the Tajima nines method demonstrated failure because of thread breakage, knot failure, and suture pull-out, respectively. Conclusions: This biomechanical study demonstrated that Tajima nines repair was associated with particularly high initial tension at the repair site; there were minor variations in the initial load and 2-mm gap-formation load. Our results suggest that Tajima nines repair with peripheral suturing allows the repaired flexor tendon to tolerate the stresses encountered during early active mobilization. Clinical relevance: This simple nine-strand technique will be particularly useful for inexperienced surgeons who perform early active mobilization after primary flexor tendon repair because the technique is a modification of the Lim and Tsai repair method using a triple strand instead of a double strand.
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As the thumb is pronated, primary repair of complex injuries may be more difficult than the repair of other digits. We describe a simple technique that facilitates thumb repair. We insert a Kirschner wire perpendicular to the bone axis in the middle of the proximal phalanx, which ensures adequate exposure of the palmar aspect without the need for thumb position adjustment by an assistant. This technique is particularly useful when inexperienced surgeons perform thumb replantation and primary flexor tendon repair using a multistrand suture technique.
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Despite medical advances, degloving injury remains one of the most difficult traumatic injuries to treat. The conventional method for treating degloving injury of the hand is reconstruction with a groin flap. However, few reports have described the mid- or long-term functional and aesthetic outcomes after a hand reconstruction with a groin flap. This case report describes a 68-year-old woman with no specific medical history who presented with a severe degloving injury of the right hand, caused by a roller machine. The area of skin loss was covered with a pedicled groin flap that was separated after 3 weeks. Five years after the reconstruction, she had poor functional and aesthetic outcomes. The Japanese Society for Surgery of the Hand version of the Quick Disabilities of the Arm, Shoulder and Hand score was 57.5; the Hand20 score was 60; and the Michigan Hand Outcomes Questionnaire score was 37.5. The static two-point discrimination of the index and middle fingers was more than 15 mm, and Semmes-Weinstein monofilament examination showed that the sensation thresholds of these fingers were purple and blue. The range of motion was 10-degree angle of extension and 60-degree angle of flexion for the metacarpophalangeal joints of the index and middle fingers. Grip strength was 0.0 kg; pulp pinch strength of the index and middle fingers was 1.1 and 0.8 kg, respectively; and side pinch of the index and middle fingers was 0.1 and 0.7 kg, respectively.
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BACKGROUND: Ulnar shortening osteotomy using various osteotomy sites, osteotomy methods, and surgical techniques with a variety of implants has been reported, but nonunion rates and the duration of bone healing are not uniform by the authors. The purpose of this study was to investigate the duration of bone healing and nonunion ratio in patients who underwent ulnar shortening osteotomy by a 5-hole nonlocking plate with a simple transverse osteotomy for ulnar impaction syndrome and to determine the correlation between the gap length of the osteotomy site and the duration of bone healing. METHODS: We assessed patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome using a 5-hole nonlocking plate fixation followed by a simple transverse osteotomy between July 2012 and October 2021. This study was a case series study, and the level of evidence was IV. RESULTS: A total of 80 patients were included. The mean age of the patients was 46.7 years, and 46 patients were men. The average bone union period was 41.8 ± 18.7 weeks. The correlation between the gap length of the osteotomy site and the duration of bone union of the osteotomy site was not significant. The nonunion ratio of our method was 2.5%. CONCLUSION: The nonunion rate of our ulnar shortening osteotomy with a simple transverse osteotomy and a 5-hole nonlocking plate was comparable to that in previous reports, but our method required slightly longer periods for bone union. There was no correlation between the gap length of the osteotomy and the duration of bone union. LEVEL OF EVIDENCE: Level IV (Case series).
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CASE: A 71-year-old otherwise healthy man presented with an 8-week history of elbow pain and weakness in both elbow flexion and forearm supination. Magnetic resonance imaging revealed complete rupture of the distal biceps tendon insertion associated with 65 mm of proximal retraction. At 10 weeks after initial injury, the patient underwent a novel reconstruction technique using a periosteal flap from the iliac crest; subsequently, all symptoms resolved. CONCLUSION: Chronic distal biceps tendon injuries can be reconstructed safely and effectively using a periosteal flap from the iliac crest that allows not only rigid but also biological graft attachment.
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Articulação do Cotovelo , Traumatismos dos Tendões , Masculino , Humanos , Idoso , Cotovelo/cirurgia , Traumatismos dos Tendões/diagnóstico por imagem , Traumatismos dos Tendões/cirurgia , Tendões/cirurgia , Músculo Esquelético , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/cirurgiaRESUMO
We assessed the influence of different directions of suture strands using the double Tsuge repair on the resistance to gap formation and mode of failure. In total, 25 porcine flexor digitorum profundus tendons were split into two groups. One group was repaired using a conventional double Tsuge suture created by two bands of looped suture placed longitudinally parallel (parallel method), and the other group was repaired using a new technique comprising two bands of looped suture placed in a crossed fashion in the anterior and posterior half of the tendon (cruciate method). The repaired tendons were subjected to linear, non-cyclic load-to-failure tensile testing. The cruciate method had a significantly higher mean load at a 2-mm gap tensile load (29.7 N [SD, 8.3]) than the parallel method (21.6 N [SD, 4.9]) and failed significantly more often due to suture pull-out. The direction of a core suture and its location within the tendon affect both gap resistance and the mode of failure of repair when using the double Tsuge suture technique, with a cruciate configuration achieving a greater gap resistance than a parallel one.
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Traumatismos dos Tendões , Animais , Suínos , Traumatismos dos Tendões/cirurgia , Resistência à Tração , Fenômenos Biomecânicos , Tendões/cirurgia , Suturas , Técnicas de SuturaRESUMO
Background The placement of multistrand sutures during flexor tendon repair requires complicated surgical skills; such suturing is difficult. We developed a new, simpler eight-strand suture, which we term the Yoshizu cross-lock. This reduces the numbers of suture passages through the tendons, as well as the numbers of knots. Methods Fourteen porcine flexor tendons were transected and repaired using the Yoshizu cross-lock system; no peripheral sutures were placed. Our system is a modification of the published, exposed cross-lock repair method that employs a 4-0 monofilament nylon two-strand line and two needles. The repaired tendons were subjected to linear, noncyclic load-to-failure tensile testing. The initial gap, the 2-mm gap force, and the ultimate strength were measured. Results The initial gap force was 12.6 ± 5.6 Newtons (N), the 2-mm gap force was 33.9 ± 10.9 N, and the ultimate strength was 70.1 ± 17.0 N. All tendons subjected to Yoshizu cross-lock repair failed due to suture rupture rather than pullout. Conclusions Our biomechanical study revealed that Yoshizu cross-lock repair had sufficient tensile strength but was associated with wide variation in the 2-mm gap load (standard deviation = 10.9 N). This study is clinically relevant, showing that the Yoshizu cross-lock repair combined with peripheral suturing may allow a repaired flexor tendon to withstand the stresses encountered during early active mobilization. This simple eight-strand technique will be particularly useful to surgeons who commonly employ the cross-lock stitch for primary flexor tendon repair following early mobilization.
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A limitation of finger extension resulting from scarring of the juncturae tendinum (JT) is a rare condition. We report a patient with limitation in active extension of the metacarpophalangeal joint (MCPJ) of the ring finger due to a scarred JT in a 37-year-old man. Surgical exploration showed a hard, fixed and scarred JT in the third intermetacarpal space. After resection of the scarred JT, the patient achieved full range of active extension of the ring finger MCPJ. Scarring of the JT may decrease excursion of the extensor digitorum communis and must be considered as one of the differentials in patients with limitation in MCPJ extension. Level of Evidence: Level V (Therapeutic).
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Cicatriz , Tendões , Adulto , Dedos/cirurgia , Humanos , Masculino , Articulação Metacarpofalângica/cirurgia , Doenças RarasRESUMO
This study compared hand function and the cost-effectiveness of treatment between collagenase Clostridium histolyticum (CCH) injection and limited fasciectomy for patients with Dupuytren's contracture (DC). The CeCORD-J study is a prospective, multicenter, non-randomized controlled, observational study of two parallel groups. Participants were DC patients with multiple affected fingers, including flexion contracture of the proximal interphalangeal (PIP) joint. The primary outcome was the Hand10 score, as a patient-reported outcome measure (PROM). We set secondary outcomes of EQ-5D-5L (QOL) score, degree of extension deficit, and direct cost. Propensity score adjustment was used to balance differences in patient characteristics between groups. Participants comprised 52 patients in the Collagenase group and 26 patients in the Surgery group. There were no significant differences in the Hand10 and QOL scores between the two groups at 26 weeks. Mean direct cost was 248,000 yen higher in the Surgery group than in the Collagenase group. Extension deficit angle of the PIP joint was significantly larger in the Collagenase group at 26 weeks. Although the Collagenase group showed dominance in cost-effectiveness, there was no significant difference between the two groups in hand function at 26 weeks.
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Contratura de Dupuytren , Colagenases , Análise Custo-Benefício , Contratura de Dupuytren/tratamento farmacológico , Contratura de Dupuytren/cirurgia , Humanos , Colagenase Microbiana/uso terapêutico , Estudos Prospectivos , Qualidade de Vida , Resultado do TratamentoRESUMO
The purpose of this study was to compare the outcomes of bridge tendon grafts and end-to-side tendon transfers for treating closed ruptures of the flexor tendons in Zones 3 to 5 of the little finger. We selected the surgical procedure based on the passive distraction amplitude of the proximal part of the ruptured flexor tendon. Eleven patients comprised the bridge tendon graft group and ten patients comprised the end-to-side tendon transfer group. We found no significant between-group differences in the total active motion, percentage of total active motion, functional assessment by the Strickland and Glogovac criteria and grip strength compared with the unaffected hand. We believe that choosing the surgical procedure after determining the passive distraction amplitude of the ruptured tendon can be useful in clinical practice.Level of evidence: III.
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Traumatismos dos Dedos , Traumatismos dos Tendões , Traumatismos dos Dedos/cirurgia , Humanos , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Transferência Tendinosa/métodos , Tendões/cirurgiaRESUMO
BACKGROUND: Tendon rupture has been recognized as a complication of distal radius fracture (DRF); however, the clinical outcome of reconstructive surgery for this injury remains unclear. We examined prognostic factors for the outcomes of reconstructive surgery in patients with a tendon rupture after DRF. METHODS: This study was a retrospective review of a case series. Seventy-five consecutive patients were treated at our institution for tendon rupture after DRF. The cohort included 14 males and 61 females with a mean age of 67.7 years at the time of tendon reconstruction. Sixty-four and eighteen tendon ruptures occurred after non-operative management for DRF and palmar locking plate fixation, respectively. Seven ruptured tendons received a free tendon graft from the palmaris longus tendon, and the others underwent tendon transfers. All patients were managed postoperatively by our hand therapy unit according to a controlled active mobilization regime. RESULTS: The mean follow-up period was 28 weeks (range: 12-80 weeks). Patients with extensor tendon ruptures were significantly younger than those with flexor tendon ruptures regardless of the initial DRF treatment. The mean percentage active range of motion of the injured digits relative to normal active motion (%AROM) at the final follow-up was 70% (range: 30-101%) in all patients. The %AROM after flexor tendon reconstruction for patients after non-operative management was significantly inferior to that of other patients. Multiple regression analysis revealed that aging and non-operative management of DRF are independent risk factors for poor %AROM. CONCLUSIONS: This study confirmed that advanced age and non-operative management of DRF were prognostic factors for digital joint motion following surgical reconstruction for tendon rupture. Our results suggest that it may be difficult to achieve good clinical outcomes in elderly patients with tendon ruptures (particularly flexor tendon ruptures) following non-operative management of DRF.
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Procedimentos de Cirurgia Plástica , Fraturas do Rádio , Traumatismos dos Tendões , Idoso , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Fraturas do Rádio/complicações , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/cirurgia , Ruptura , Traumatismos dos Tendões/etiologia , Traumatismos dos Tendões/cirurgia , Transferência Tendinosa/efeitos adversos , TendõesRESUMO
Background The standard clinical practice to treat closed ruptures of the flexor digitorum profundus (FDP) tendons includes free tendon grafting; however, it is not suitable when the muscle amplitude of the ruptured FDP is not sufficient. We report outcomes of six patients who underwent flexor digitorum superficialis (FDS) tendon transfer of the ring finger using the wide-awake approach to repair the closed rupture of the FDP tendon of the little finger in zone 3 or 4. Methods The patients were identified by reviewing our institutional billing records from January 2012 to October 2019 for the International Classification of Disease 10 code M66.3 that describes the diagnosis as "spontaneous rupture of flexor tendons." Results The patients comprised two men and four women with an average age of 72.2 years (standard deviation [SD], 8.4 years). All patients were hospitalized after surgery to undergo early active mobilization. The average total active motion at the final evaluation was 201.8° (range: 85-248°). According to Strickland's criteria, outcomes were excellent for two, good for three, and poor for one patient. No patients complained about the ring finger. Conclusion These results suggest that FDS tendon transfer is recommended when the muscle amplitude of the ruptured FDP is insufficient. We believe that the wide-awake approach and early active mobilization may contribute to satisfactory outcomes.
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Snapping elbow is a rare syndrome caused by dislocation of the medial head of the triceps. Simultaneous dislocation of the ulnar nerve occurs even less frequently. We report a case of ulnar nerve dislocation accompanied by dislocation of the triceps over the medial humeral epicondyle. The ulnar nerve was located in front of the medial epicondyle and did not change position with the elbow flexed or extended. At the point of insertion, the proximal end of the triceps muscle was displaced anteriorly. In this case, diagnosis by physical examination was challenging, but ultrasonography proved useful for diagnosis. During surgical treatment, partial resection of the triceps medial head was achieved, and the patient demonstrated a full recovery.
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Articulação do Cotovelo , Luxações Articulares , Braço , Cotovelo , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/cirurgia , Humanos , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Nervo Ulnar/diagnóstico por imagem , Nervo Ulnar/cirurgiaRESUMO
BACKGROUND: Even in patients with an open capitellar physis, nonsurgical treatment for advanced-stage osteochondritis dissecans (OCD) of the capitellum often yields poor outcomes. However, surgical methods for such patients are controversial. At our institution, we have consistently performed closed-wedge osteotomy of the distal humerus to treat advanced-stage OCD of the capitellum, regardless of the OCD grade or condition of the capitellar physis. PURPOSE: To clarify the clinical and radiological results and determine the influence of the capitellar physis on closed-wedge osteotomy for advanced-stage OCD of the capitellum in young patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 32 patients with OCD of the humeral capitellum were treated surgically with closed-wedge osteotomy. Of these, 17 patients with more than 2-year follow-up were available for an evaluation. The mean patient age was 11.8 years (range, 11-12 years), and the mean follow-up period was 70.1 months (range, 25-184 months). The clinical assessment included range of motion, elbow pain, and the Japanese Orthopaedic Association (JOA) and Timmerman-Andrews scores. The radiological assessment at the final examination included cross-bridging of the physis, size and fishtail deformity of the distal part of the humerus, size of the radial head, healing of the OCD lesion, and osteoarthritis. RESULTS: The mean range of motion and JOA and Timmerman-Andrews scores improved significantly after surgery; 13 patients were completely pain free. In 11 patients with an open capitellar physis, metaphyseal-epiphyseal, cross-bridging was observed in 1 patient. A fishtail deformity of the distal part of the humerus was not observed. Healing of the OCD lesion was defined as excellent in 9 patients, good in 3, fair in 3, and poor in 2. In 3 of the 5 patients in whom healing was described as fair or poor, there was a lesion of the lateral widespread type with osteoarthritis before surgery. Moderate osteoarthritic changes were evident in 2 patients. CONCLUSION: Closed-wedge osteotomy for the treatment of advanced-stage OCD of the capitellum in young patients can provide satisfactory clinical and radiological results. However, fair and poor outcomes were found in lateral widespread-type cases with osteoarthritis before surgery. We believe that patients in whom osteoarthritic changes have not yet appeared are eligible for closed-wedge osteotomy.
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We report seven patients requiring tenolysis after primary or delayed primary flexor tendon repair and early active mobilization out of 148 fingers of 132 consecutive patients with Zone 1 or 2 injuries from 1993 to 2017. Three fingers had Zone 2A, two Zone 2B, and two Zone 2C injuries. Two fingers underwent tenolysis at Week 4 or 6 after repair because of suspected repair rupture. The other five fingers had tenolysis 12 weeks after repair. Adhesions were moderately dense between the flexor digitorum superficialis and profundus tendons or with the pulleys. According to the Strickland and Tang criteria, the outcomes were excellent in one finger, good in four, fair in one, and poor in one. Fingers requiring tenolysis after early active motion were 5% of the 148 fingers so treated. Indications for tenolysis were to achieve a full range of active motion in the patients rated good or improvement of range of active motion of the patients rated poor or fair. Not all of our patients with poor or fair outcomes wanted to have tenolysis. Level of evidence: IV.
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Traumatismos dos Dedos/cirurgia , Traumatismos dos Tendões/cirurgia , Tendões/cirurgia , Aderências Teciduais/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Cuidados Pós-Operatórios , Estudos Retrospectivos , Adulto JovemRESUMO
Opioid-related postoperative nausea and vomiting should not occur following remifentanil administration because of its relatively short time to elimination. However, studies have indicated that the incidence of postoperative nausea and vomiting associated with remifentanil is similar to that with other opioids. Hence, we aimed to determine whether intraoperative remifentanil itself is associated with postoperative nausea and vomiting when postoperative pain is managed without opioid use. In this prospective pilot study, 150 patients who underwent unilateral upper limb surgery under general anesthesia with brachial plexus block were included. Patients in the remifentanil and control groups received 0.5 µg/kg/min remifentanil and saline, respectively. Postoperative pain was managed using a brachial plexus block, non-steroidal anti-inflammatory drugs, and acetaminophen. The presence of postoperative nausea and vomiting within the first 24 h after anesthesia was assessed by an evaluator blinded to patient allocation. Eight patients were excluded from the final analysis, resulting in 72 and 70 patients in the remifentanil and control groups, respectively. Postoperative nausea and vomiting within 24 h after surgery occurred in 11 and 9 patients in the remifentanil and control groups, respectively. These data suggest that remifentanil use only minimally affects the incidence of postoperative nausea and vomiting under sevoflurane anesthesia. UMIN Clinical Trials Registry identification number: UMIN000016110.
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Analgésicos Opioides/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/epidemiologia , Remifentanil/administração & dosagem , Adulto , Idoso , Anestesia Geral/métodos , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos ProspectivosRESUMO
BACKGROUND: Postoperative pain management after upper limb surgery is important for preventing adverse events that can prolong hospital stay and cause readmission. This study aimed to identify the risk factors associated with rescue analgesic use on the first postoperative day after upper limb surgery performed under single-injection brachial plexus block (BPB). FINDINGS: We retrospectively analyzed records from 930 patients who underwent upper limb surgery under a single-injection BPB. Postoperatively, patients were administered oral loxoprofen regularly and rescue analgesics when analgesia was insufficient. We assessed the association between patient, surgical information, and rescue analgesic use on the first day after surgery (from 7:00 PM on the day of surgery to 7:00 AM on the first postoperative day), using a logistic regression model. Multivariate analysis revealed a significant association between rescue analgesic use and bone surgery, in particular, osteotomy, ligament repair and reconstruction, osteosynthesis, treatment for an amputated digit, and surgical duration. CONCLUSION: Bone surgery (osteotomy, ligament repair and reconstruction, osteosynthesis, treatment for an amputated digit) and a longer operative time were risk factors for rescue analgesic use for treating postoperative pain after upper limb surgery performed under single-injection BPB.