Histological and biochemical evidence related to the collagen quality in torn rotator cuff tendons.

This study investigates the histological background of torn rotator cuff tendons, evaluates the stability of newly synthesized collagen by measuring the hydro-xyproline content and attempts to correlate these findings with the clinical outcome after reconstruction of the rotator cuff. Sixty-one patients underwent reconstruction for a -rotator cuff tear. They were evaluated preoperatively with the Constant-Murley score, MRI and ultrasound. Biopsy samples were taken from chronic rotator cuff tears and histological analysis was performed. Hydroxyprolin presence was evaluated in various -tissues. Mean follow-up was 46 months. Histological analysis revealed collagen fragmentation and thinning (90.2% of patients), myxoid degeneration (88%), hyaline degeneration (50.8%), chondroid metaplasia (44.3%), calcification (24.7%), fatty infiltration (20.4%) and vascular proliferation (62.3%). Hydroxyproline was under-represented in newly synthesized collagen in 57% of patients. In the majority of the patients with a low hydroxyproline/collagen ratio the histological findings were abnormal. None of the findings was related to the clinical outcome with a statistical significance. Histological and biochemical findings reflected the poor quality of the tendon. The good clinical outcome did not depend on the histological or biochemical findings but rather on the meticulous surgical reconstruction and physical therapy.

Early results of a novel technique using multiple small tantalum pegs for the treatment of osteonecrosis of the femoral head: a case series involving 26 hips.

The introduction of a trabecular tantalum rod has been proposed for the management of early-stage osteonecrosis of the femoral head but serves as a single-point of support of the necrotic lesion. We describe a technique using two or three 4.2 mm (or later 4.7 mm) tantalum pegs for the prevention of collapse of the necrotic lesion. We prospectively studied 21 patients (26 hips) with non-traumatic osteonecrosis of the femoral head treated in this manner. Of these, 21 patients (24 hips) were available for radiological and clinical evaluation at a mean follow-up of 46 months (18 to 67). Radiological assessment showed that only eight hips deteriorated according to the Association Research Circulation Osseous classification, and four hips according to the Classification of the Japanese Investigation Committee of Health and Welfare. Functional improvement was obtained with an improvement in the mean Harris hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean Merle D'Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18), a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6 (0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1) to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum of 18 months, three were considered as failures at the final follow-up, having required total hip replacement. One of the hips without full follow-up was also considered to be a failure. In more than two-thirds of the surviving hips a satisfactory clinical outcome was achieved with promising radiological findings. The estimated mean implant survival was 60 months (95% confidence interval 53.7 to 66.3).

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone.

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Skeletal muscle hydatid cysts presenting as soft tissue masses.

Muscle hydatidosis is rare, accounting only for 3-5% of all cases. We present a case series of 9 patients (8 male, one female, mean age 59.3 years, range 48-75 years) with primary echinococcosis of skeletal muscles. The cysts presented as soft tissue masses in 8 patients, whereas in one, the cyst was an incidental finding on a CT scan performed for investigation of a lung problem. All hydatid cysts were confined into muscles, without affecting the bone. The location was the thigh region in 6 patients (quadriceps in 4, biceps in 2), the popliteal fossa (gastrocnemius) in one, the humerus (triceps branchii) in one and the shoulder (infraspinatus) in one patient. MRI showed multi-vesicular cysts in all patients. Indirect hemagglutination serological test was positive in 6 out of 9 cases. En block surgical excision of the cysts was undertaken in all patients. Two patients received antihelminthic chemotherapy preoperatively. Histopathologic findings confirmed the diagnosis. No recurrence occurred during the follow-up period (1-8 years). Skeletal muscle echinococcosis should be considered in the differential diagnosis of limb masses, especially in endemic countries. A meticulous history taking and MRI imaging are essential, while pericystectomy is an effective method of treatment.

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.

Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip.

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.

Partial rupture of the distal biceps tendon.

We report on 7 cases of partial rupture of the distal biceps tendon. The mean patient age was 52 years (range, 38-58 years). There were 5 men and 2 women. The dominant arm was affected in all 7 patients. Pain was the chief complaint in all patients. Immobilization and physiotherapy were attempted in all patients, and 4 had at least 1 local steroid injection. No patient improved from the conservative treatment. All patients eventually underwent surgical debridement and reattachment of the biceps tendon with use of a 1-incision technique with suture anchors. After a mean follow-up of 31 months (range, 25-44 months), all patients reported a significant decrease in their pain. No complications were noted.

Classification of osteonecrosis of the femoral head. Reliability, reproducibility, and prognostic value.

The purpose of the current investigation was to determine interobserver and intraobserver reliability of the classification system of Steinberg et al for osteonecrosis of the femoral head. Sixty-five anteroposterior and lateral radiographs of hips were selected randomly from a pool of patients with confirmed osteonecrosis of the femoral head. Six fellowship-trained observers viewed the radiographs (Reading 1). The observers used six main stages of the classification excluding A, B, and C subgroups. The same observers viewed the radiographs 4 months later in reverse order (Reading 2). Reading 1 was used to calculate interobserver kappa values. Reading 2 was used to calculate intraobserver kappa values. Stage-specific kappa values for interobserver variation between all viewers were as follows: Stage I, k = 0.64; Stage II, k = 0.51; Stage III, k = 0.21; Stage IV, k = 0.49; Stage V, k = 0.36; and Stage VI, k = 0.80. Stage-specific kappa values for intraobserver variation between all viewers were as follows: Stage I, k = 0.74; Stage II, k = 0.60; Stage III, k = 0.46; Stage IV, k = 0.59; Stage V, k = 0.27; and Stage VI, k = 0.78. An average of 10 of 21 (48%) of these errors involved Stage III. An average of 6.3 of 21 (30%) intraobserver errors involved Stage V. The presence of the crescent sign in Stage III and joint space narrowing in Stage V markedly diminished the overall reliability of any four- to six-stage classification system. Based on the authors' experience and analysis of the current classifications of osteonecrosis of the femoral head, an easy and reproducible Pittsburgh classification system is proposed.

Vascularized orthotopic osteochondral transplantation of the canine proximal femur.

Osteochondral vascularized proximal femoral allografts were orthotopically transplanted in five adult beagles (four experimental and one control). The experimental animals were placed on 0.1 mg/kg of FK506 intravenously for 7 days, and then converted to 1.0 mg/kg orally. Biopsies of the femoral heads were taken at 3 weeks postoperatively and at 1-month intervals thereafter. The specimens were studied histologically with a hemotoxylin and eosin staining technique. Bone biopsies showed no microscopic evidence of rejection, and only minimal evidence of necrosis. Patency of the microvascular anastomosis was confirmed with bone scanning, using technitium 99m phosphate, arteriograms, and by Doppler flowmeter. All animals had an uneventful postoperative course, with achievement of full weight-bearing status by postoperative day 10, and normal activity by 1 month postoperatively. There were no infections or hip dislocations. One animal sustained a femoral neck fracture and was sacrificed at 4 months. At 6 months, the remaining animals were sacrificed. At necropsy, the experimental animals and the normal dog showed viable chondrocytes and osteocytes, with minimal bone necrosis. No dislocations or allograft rejections were observed. Based on this small series, a successful technique has been developed for orthotopic transplantation of a vascularized hip joint in a canine model.

Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator.

The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not uncommon and its management is both challenging and difficult. Nineteen patients with recurrent carpal tunnel and cubital tunnel syndrome were treated with the vein wrapping technique using the autogenous saphenous vein. The average number of surgeries before vein wrapping was 3.3. The mean patient age was 53 years (range, 28-75 years) and the mean follow-up period was 43 months (range, 24-78 months). All patients reported reduction in pain and the sensory disturbances secondary to the compression of the median or ulnar nerve. Two-point discrimination and electrodiagnostic findings also improved.

Findings of exploration of a vein-wrapped ulnar nerve: report of a case.

A 54-year-old woman underwent a revision procedure after failure of 3 previous procedures for recalcitrant cubital tunnel syndrome. She underwent neurolysis and vein wrapping of the ulnar nerve during the fourth procedure. Two years later she developed a neuroma of the medial antebrachial cutaneous nerve necessitating a fifth procedure. At the time of neuroma relocation we noted that the vein was intact around the ulnar nerve and that there was no scarring between the vein and nerve.

The Compass Elbow Hinge: indications and initial results.

The Compass Elbow Hinge uses Illizarov's methods of fixation to externally hold the elbow reduced and allow both passive and active motion. Eleven patients with degenerative disease, contracture or instability were treated with the Compass Elbow Hinge and were retrospectively evaluated at an average follow-up of 29 months (range: 18-62 months). One was lost to follow-up. Patients with degenerative changes underwent fascia lata interposition while those treated for contractures underwent anterior and posterior capsular release with or without fascia lata interposition. Those with elbow instability underwent ligament reconstruction. The device was removed after 6 weeks and seven of the 11 patients were satisfied with the outcome of the operation. Stability could not be achieved in two patients with coronoid fractures that were not reconstructed. One patient did not tolerate the device and requested its removal with subsequent subluxation. We conclude that patient selection and compliance are key elements in achieving a satisfactory outcome with the device.

Treatment of chronic injuries of the ulnar collateral ligament of the thumb using a free tendon graft and bone suture anchors.

We report the results of a simple technique, using bone suture anchors and free tendon graft, for the reconstruction of chronic injuries of the ulnar collateral ligament complex at the thumb metacarpophalangeal (MP) joint. Our series includes 20 patients, with a mean age of 29 years. The mean follow-up period was 42 months. Using the Glickel grading system, 14 patients had excellent results and six had good results. Seventeen patients had no pain and three complained of mild pain with weather changes. Fourteen patients regained full stability of the MP joint and six had mild laxity. The mean loss of pinch strength was 18% compared with the contralateral thumb. The mean loss of motion at the metacarpophalangeal joint was 21%.

Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition.

We studied the elongation and excursion of cadaveric ulnar nerves during elbow flexion in control conditions and after in situ decompression and anterior subcutaneous transposition. We found that the normal nerve had the greatest elongation (23%) and excursion (14 mm) in the epicondylar groove. Decompression did not alter the excursion, but significantly reduced the elongation in the groove (6%) and increased it proximally (19%). After anterior subcutaneous transposition, the nerve segment which was originally in the groove elongated with elbow extension to the same extent as occurred with the normal nerve during flexion.

Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping.

Recurrence of symptoms occurs in a significant number of patients after surgical decompression for carpal tunnel syndrome, and its management is both challenging and difficult. Fifteen patients with recurrent carpal tunnel syndrome were treated with a vein wrapping technique using the autologous saphenous vein. A total of 48 operations had been performed on these patients before wrapping the median nerve with a saphenous vein graft. At a mean follow-up of 43 months all patients reported significant pain relief and improvement in their sensory disturbances. Two-point discrimination and the findings of nerve conduction studies also improved.

A simplified method for repair of distal biceps tendon ruptures.

Repair of distal biceps brachii tendon ruptures is recommended for active individuals desiring maximum return of elbow supination and flexion strength. A 2-incision method of repair has been most popular but carries a risk of radioulnar synostosis. In the past, repair through a single anterior incision required more dissection and risked injury to the posterior interosseous nerve. The authors present a simplified method for the repair of distal biceps tendon ruptures through a single anterior incision. The use of suture anchors provides secure fixation to the radius with minimal volar dissection. This method was used successfully in 16 patients, 8 acutely (<6 weeks) and 8 chronically, with excellent functional results. Patients who received acute repairs regained elbow strength and power; patients who received chronic repairs showed slight deficits of supination strength (16%) and flexion power (14%). Of 10 chronic ruptures treated, only 2 tendons could not be mobilized back to the radial tuberosity and had to be transferred to the brachialis. There were no failures and no complications of radioulnar synostosis or posterior interosseous nerve palsy. The single anterior incision approach in which suture anchors are used is recommended as an alternative to the traditional 2-incision method.

Recalcitrant post-surgical neuropathy of the ulnar nerve at the elbow: treatment with autogenous saphenous vein wrapping.

Surgical decompression or transposition is generally efficacious for cubital tunnel syndrome. However, recurrence is not rare and its management is both challenging and difficult. Four patients with refractory cubital tunnel syndrome were operated on with the vein-wrapping technique, using the autologous saphenous vein. A total of 16 operative procedures were performed on these patients prior to wrapping the ulnar nerve with a saphenous vein graft. The mean patient age was 43 years (range: 30 to 54 years) and the mean follow-up was 34 months (range: 24 to 44 months). All patients reported significant pain relief and improvement in sensation. Two-point discrimination and EMG findings also improved. This is the first study reporting long-term results of the vein-wrapping technique for the treatment of recalcitrant cubital tunnel syndrome.

Partial nerve injuries in the upper extremity.

The level of injury of a peripheral nerve is a critical factor that has a great impact on the result of the repair. At the level of the wrist, the median and ulnar nerves have pure motor and sensory fascicular groups. Proximal to the wrist, the motor fascicular groups combine with sensory fascicles and become mixed nerves. Mapping the fascicular orientation with electrical stimulation is indicated for injuries located from the wrist to the distal third of the forearm. Successful application of this technique depends on the level of injury, anesthetic technique, and careful patient selection. Children and patients with other serious coexisting injuries are not candidates for this technique. The depth of anesthesia must provide adequate analgesia while allowing the patient to communicate and cooperate with the surgeon during the procedure. There are few reports in the literature about repair of partially injured nerves in the upper extremities and the comparison of functional outcomes with or without the use of nerve grafts is not easy. Even under ideal operative conditions and with ideal indications, the outcomes are not always satisfactory. Hurst et al reported very good results using end-to-end repair of fascicular groups in their series. Using the rating system of the British Medical Research Council, they reported motor values of 4.0 (normal 5.0), and sensory values of 3.8 (normal 4.0). Kato et al reported very good results in their series of 51 cases with group fascicular end-to-end suture using orientation with electrical stimulation. In this series, there were five patients with partial nerve laceration and end-to-end coaptation of the fascicular groups provided very satisfactory outcome. End-to-end repair of the fascicular groups seems to provide better results than repair of the nerve using nerve grafts. It is desired, however, that the nerve gap be less than 2 cm for the application of end-to-end repair of the nerve.

Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon.

Fifty-eight patients (62 joints) with arthritis of the thumb carpometacarpal joint were treated with resection arthroplasty, ligament reconstruction, and tendon interposition with the entire flexor carpi radialis tendon. The mean age of the patients at the time of surgery was 58.4 years (range, 28-80 years), and the average followup was 42.5 months (range, 21-86 months). The entire flexor carpi radialis tendon was used for reconstruction and interposition. In 32 of the 62 joints, a partial trapezoidectomy was performed for scaphotrapezoidal arthritis. Finger-tip pinch improved by 88%, key pinch improved by 86%, and grip strength improved by 69%. Palmar and radial abduction also improved by 8% and 10%, respectively. Fifty-five (95%) patients reported excellent pain relief, whereas three patients reported only mild pain. No patients experienced an increase in pain. All thumbs were stable radiographically. This study indicated ligament reconstruction with tendon interposition, accompanied by partial trapezoidectomy when indicated, provides excellent pain relief and restoration of function. No morbidity was observed with use of the entire flexor carpi radialis tendon.

The effect of wrapping scarred nerves with autogenous vein graft to treat recurrent chronic nerve compression.

The purpose of this study was to determine the efficacy of vein wrapping of scarred nerves in a chronic nerve compression model in rats. The ultimate goal was to provide experimental evidence for application of the technique of vein wrapping of nerves for the treatment of recurrent compressive neuropathy. The chronic nerve compression model was created in 100 rats. After 8 months the nerves were decompressed. In 50 rats the nerves were wrapped with an opened femoral vein graft; the remaining 50 animals served as controls. The sciatic nerves of both groups were evaluated at 4, 8, 12, 24, and 48 weeks after surgery. Functionally, the sciatic nerves in the vein-wrapped group showed greater improvement than those in the non-vein-wrapped group. For electrophysiologic testing the latency was significantly shorter in the vein-wrapped group. Histologic evaluation showed marked nerve degeneration and scar tissue formation around the nerves in the non-vein-wrapped group but not in the vein-wrapped group. The results indicate that the vein graft could improve the recovery of nerve function by protecting the nerve from surrounding scar and is an effective and feasible technique for the surgical treatment of recurrent compressive neuropathy. (J Hand Surg 2000; 25A:93-103.