Styloid Ulna Window Approach for Repair of Avulsed Foveal Attachment of Triangular Fibrocartilage Complex.

PURPOSE: To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results. METHODS: We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems. RESULTS: Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve. CONCLUSIONS: Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Blocking Plate for Volar Proximal Interphalangeal Joint Fracture Dislocation.

PURPOSE: To assess the use of a 2-mm miniplate as a dorsal blocking plate to stabilize the central avulsion fragment in a proximal interphalangeal joint (PIP) volar fracture dislocation. METHODS: This was a case series comprising 8 patients with volar fracture dislocation of the PIP joint. The average age of the patients was 36 years. The patients were managed by this technique within an average of 11 days following the injury. The clinical outcome measurements included the assessment of pain and range of motion of the PIP and distal interphalangeal joints. RESULTS: The average follow-up duration was 20 months. The mean visual analog scale pain score was 1.9. The average range of motion of the PIP joint was 82°, whereas the average range of motion of the distal interphalangeal joint was 43°. Reduction of the subluxation was achieved in all cases, with no articular step remaining. CONCLUSIONS: A dorsal blocking plate is a simple technique, associated with a satisfactory outcome, for volar fracture dislocation injuries of the PIP joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Single-strand repair of EWAS 1 lesion of triangular fibrocartilage complex.

PURPOSE: To report the results of our modified technique for repair of the EWAS 1 lesion of triangular fibrocartilage complex (TFCC). METHODS: This retrospective case series reviewed 22 consecutive patients with EWAS 1 TFCC tear. Arthroscopic repair was done using our modified double-loop arthroscopic outside-in technique which is originally described by Mathoulin and Del Piñal. The repair was performed using single-strand suture and 18-gauge cannula, having three passes through the tear. Follow-ups ranged from 24 to 33 months with an average of 29.3 months. The results were evaluated by the Modified Mayo Wrist Score (MMWS), Visual Analog Score (VAS). In addition, range of motion (ROM) and power grip were compared with the contralateral side. RESULTS: The mean age was 23 years. The dominant side was affected in 16 wrists. There was postoperative improvement of the all functional outcome measures (MMWS, VAS, ROM, and power grip). All the patients returned to their previous activities with no reported intra- or postoperative complications. CONCLUSIONS: The described outside-in technique is safe and effective technique for repair of EWAS 1 TFCC tear. LEVEL OF EVIDENCE: Therapeutic, case series, level IV.

Partial Capitate with/without Hamate Osteotomy in the Treatment of Kienböck's Disease: Influence of the Stage of the Disease on the Midterm Outcome.

Objective Moritomo et al introduced partial capitate osteotomy as a treatment modality for early stages of Kienböck's disease. This technique maintains articular contact between the capitate and the scaphoid. We added hamate-shortening osteotomy in addition to partial capitate shortening in cases of lunate type II. The purpose of this study was to evaluate intermediate-term results of partial capitate shortening, investigate the influence of the stage of the disease on the outcome, and assess the clinical and radiological outcomes of adding hamate osteotomy in cases of type II lunate. Patients and Methods A total of 17 consecutive patients (3 women, 14 men) with early stages of Kienböck's disease were prospectively reviewed using the aforementioned technique. Eight patients were in stage II and nine patients were in stage IIIA according to the Lichtman classification system. Clinical outcome measures included pain visual analog score, grip strength and range of motion as a percentage of the unaffected side, and assessment using the Patient-Rated Hand and Wrist Evaluation (PRHWE) and the modified Wrightington Hospital Wrist Score (MWHWS). Radiological outcome measures included healing of the osteotomy site, Stahl index, radioscaphoid angle, and progression of the disease. Results Follow-up period averaged 72 months. All cases of isolated capitate osteotomy and combined capitate and hamate osteotomies united fully. Clinical results revealed significant improvement in pain, grip strength and extension, and PRHWE and MWHWS values. Wrist flexion did not change postoperatively. Patients with stage II showed better overall results and significant MWHWS improvement. Conclusion At the intermediate term, partial capitate with/without hamate shortening is an effective modality for the treatment of patients with early stage Kienböck's disease. Stage II patients showed better results than stage IIIA patients in terms of pain, flexion, grip, PRHWE, and MWHWS. Adding hamate osteotomy may improve the functional results for type II lunate; however, a larger sample is needed to elicit statistical significance. Level of Evidence This is a Level IV, therapeutic study.

Current paediatric orthopaedic practice in hereditary multiple osteochondromas of the forearm: a systematic review.

INTRODUCTION: This systematic review aims to answer three research questions concerning the management of hereditary multiple osteochondromas of forearm in children: What is the best available evidence for the currently employed surgical procedures? What patient characteristics are associated with better prognosis? What disease characteristics are associated with better prognosis? METHODS: We searched the literature using three major databases with no publication date restrictions. To enhance search sensitivity and maintain precision we used keywords/subject terms correlating with patient population, problem and interventions. We used strict inclusion/exclusion criteria to improve validity evidence. RESULTS: The search process yielded 34 eligible studies with a total of 282 patients (315 forearms). We comprehensively analysed study and patient demographics and interventions and outcomes. Eleven studies (32%) had a long-term follow-up and 31 studies (91%) were retrospective. Of the total number of forearms, ulnar lengthening +/- associated procedures was used in 210 forearms (66.7%), isolated osteochondroma excision in 65 forearms (20.6%) and isolated distal radius hemiepiphysiodesis in 15 forearms (4.7%) among others. DISCUSSION: Ulnar lengthening can restore radiologic anatomy, improve appearance and to a lesser extent objective clinical parameters like joint range of motion on the short/intermediate term. Isolated osteochondroma excision can relief pain and satisfy cosmetic concerns occasionally. There is poor evidence to suggest that surgery improves quality of life or function. Predictors of surgical success in regard to patient and disease characteristics remain elusive. Natural history and prospective randomized control studies where the control group receives no treatment should be rethought. They have the potential for bias control and identification of the ideal surgical candidate. The complex interplay between the confounding variables has undermined the capability of most studies to provide well-grounded evidence to support and generalize their conclusions. Valid quality of life scales should supplement objective outcome measures.

Functional topography of the primary motor cortex during motor execution and motor imagery as revealed by functional MRI.

Controversy exists regarding the involvement of the primary motor cortex (M1) during motor imagery (MI) and also regarding the differential somatotopic representation of motor execution (ME) and mental simulation of movement, that is, MI within M1. Although some research reported clear M1 involvement during MI without overt motor output, others did not. However, possible somatotopic representation between execution and imagery has not been clearly investigated to date. The aim of the present study was to aid in the resolution of this controversy by investigating the possible involvement of M1 during MI, and the differential, within M1, somatotopic representation between execution and imagery by quantitatively assessing different location markers such as activation peak and center of mass as well as intensity differences between the two tasks in case of with and without the overlap between the two representations. Forty-one healthy volunteers participated in two functional MRI runs of mouth-stretching ME and MI tasks. Our findings suggest the clear involvement of M1 (BA 4) during MI with lower signal intensity compared with ME, and further showed distinct centers for each representation along the y-axis (anteroposterior plane), with MI showing more involvement of the anterior sector of M1 (BA 4a), whereas ME recruited more of the posterior sector (BA 4p). These results parallel the pioneering findings of a functional distinction between BA 4a and BA 4p, where BA 4a is more involved in the cognitive aspects of MI, whereas BA 4p is more related to executive function, promoting the idea of distinctive somatotopic mapping between execution and imagery within M1 sectors.

Brain correlates to facial motor imagery and its somatotopy in the primary motor cortex.

Motor imagery (MI) has attracted increased interest for motor rehabilitation as many studies have shown that MI shares the same neural networks as motor execution (ME). Nevertheless, MI in terms of facial movement has not been studied extensively; thus, in the present study, we investigated shared neural networks between facial motor imagery (FMI) and facial motor execution (FME). In addition, FMI somatotopy within-face was investigated between the forehead and the mouth. Functional MRI was used to examine 34 healthy individuals with ME and MI paradigms for the forehead and the mouth. The general linear model and a paired t-test were performed to define the facial area in the primary motor cortex (M1) and this area has been used to investigate somatotopy between the forehead and mouth FMI. FMI recruited similar brain motor areas as FME, but showed less neural activity in all activated regions. The facial areas in M1 were distinguishable from other body movements such as finger movement. Further investigation of this area showed that forehead and mouth imagery tended to lack a somatotopic representation for position on M1, and yet had distinct characteristics in terms of neural activity level. FMI showed different characteristics from general MI as the former exclusively activated facial processing areas. In addition, FME and FMI showed different characteristics in terms of BOLD signal level, while sharing the same neural areas. The results imply a potential usefulness of MI training for rehabilitation of facial motor disease considering that forehead and mouth somatotopy showed no clear position difference, and yet showed a significant BOLD signal intensity variation.

Simultaneous open and Closed Dislocation of four Metacarpophalangeal Joints: A Case Report and Review of Literature.

INTRODUCTION: Multiple simultaneous dislocations of the metacarpophalangeal joints are exceedingly rare. Five cases only were described in the English literature. Only one case necessitated open reduction. A case of simultaneous open and closed dislocation of ipsilateral four metacarpophalangeal joints is presented. The case had a delayed presentation (8 days following the trauma) and needed open reduction. CASE PRESENTATION: A 33-year-old manual worker sustained dislocation of the ulnar four metacarpophalangeal joints of his non dominant hand. The hand injury was missed for eight days. The injury was successfully managed by open reduction. The patient regained near normal functional outcome. CONCLUSION: Open reduction may be needed for these injuries. Prompt intervention and early rehabilitation are needed for satisfactory outcome.