Application of extended ulnar parametacarpal perforator free flap for the reconstruction of total pulp defect of the thumb: A case report.

Many procedures are available for the coverage of thumb pulp defects; however, to gain thumb function and esthetics, a similar tissue is desirable. If the length of the longitudinal defect is <2 cm, a volar advancement flap is appropriate; however, if the flap is >2 cm long or wider, retrograde or free flaps are required. Here, we present a case of thumb pulp reconstruction using an extended ulnar parametacarpal perforator (UPM) flap, which achieved excellent functional and esthetic outcomes. A 46-year-old man underwent reconstruction surgery of his thumb, which was a degloved total pulp. A sensate 5.2 × 3.2 cm UPM flap was designed on the ulnar side of the right palm and transferred to his thumb. The flap donor site was covered with a V-Y advancement flap on the dorsal side of the right hand. At 12 months postoperatively, the patient achieved a functional and natural thumb appearance with high satisfaction. The UPM flap can offer soft tissue similar to the pulp region in the digit without a palm scar at the donor site. This extended application is suitable for the reconstruction of a total pulp defect of the digit and is an alternative option for a hemi-pulp flap from the toe area.

Efficacy of Minimally Invasive Ulnar Superficialis Slip Resection for Unfavourable Results after Trigger Finger Release.

Background: This study aimed to evaluate the efficacy of ulnar superficial slip resection (USSR) for improving hand function after unfavourable results after triggering finger release using a minimally invasive approach. Methods: We evaluated 17 consecutive fingers of 16 patients who complained of unfavourable outcomes after primary trigger finger release. The chief complaints of the two index and 15 middle fingers were proximal interphalangeal (PIP) joint pain during movement, flexion contracture of the PIP joint and snapping at the A2 pulley in eight, seven and two fingers, respectively. The joint arc of the active range of motion and extension loss of the PIP joint, grip strength, visual analogue score (VAS) of PIP joint pain and Quick Disability of the Arm, Shoulder and Hand were evaluated before and after surgery. Results: Thirteen fingers could release joint contracture and snapping by the USSR procedure. However, four fingers of three patients required total flexor digitorum superficialis resection to resolve the unsatisfactory conditions of the intraoperative decision. The joint arc of active range of motion and extension loss of the PIP joint, grip strength and VAS score significantly improved (mean of 16.1 months follow-up). Finally, 15 patients (88.2%) were satisfied with the symptom relief outcomes. Conclusions: USSR is an effective and satisfactory procedure for unfavourable conditions after trigger finger release, including PIP joint pain, joint contracture and snapping at the A2 pulley. Level of Evidence: Level IV (Therapeutic).

"Idiopathic" Shoulder Pain and Dysfunction from Carpal Tunnel Syndrome and Cubital Tunnel Syndrome.

As a referral center for chronic pain, we see many patients with "idiopathic" shoulder pain and limited range of motion. The combination of mild or subclinical carpal tunnel syndrome and cubital tunnel syndrome may be an underrecognized etiology of symptoms in such patients. Here, we report our treatment algorithm and results for such patients. METHODS: Of patients with a chief complaint of shoulder pain, we identified 56 consecutive patients who had pain or tingling with median nerve compression at the proximal wrist crease and positive Tinel's around the cubital tunnel. They were first provided a night-time wrist orthosis. If still symptomatic, nerve blocks were given to median and ulnar nerves under ultrasound guidance. If symptoms recurred after nerve blocks, nerve conduction studies and surgical release of affected nerves were performed. RESULTS: Six patients had 60% or more pain relief with orthosis (mean 4.7 ± 0.8 (SD) to 2.2 ± 0.8). Twenty-three patients had nerve blocks and had persistent pain relief (6.0 ± 1.7 to 2.1 ± 1.9) and significant shoulder motion improvement. Twenty-seven patients only had temporal relief and required surgery but postoperatively had persistent pain relief (6.2 ± 2.0 to 1.2 ± 1.0) and improved shoulder motion. qDASH improved from 33.4 ± 20.1 preoperatively to 12.2 ± 7.4 postoperatively. CONCLUSIONS: All patients had substantial improvement in shoulder pain and motion with compressive neuropathy treatments. Targeted physical examination can identify these patients, who can have significant improvement with appropriate diagnosis and treatment. The study sheds light on an underrecognized cause of shoulder dysfunction.

Surgical Outcomes of Coronal Shear Fracture of the Distal Humerus in Elderly Adults.

BACKGROUND: This study evaluated clinical outcomes of elderly adults with coronal shear fractures (CSFs) of the distal humerus treated by open reduction and internal fixation (ORIF). METHODS: Between April 2002 and March 2019, data from eight elderly patients (76.3 ± 5.1 years) with CSFs of the distal humerus were analyzed retrospectively. Postoperative complications, range of motion of the elbow joint, and functional elbow scoring (Mayo Elbow Performance Score; MEPS) were assessed. RESULTS: The mean follow-up duration was 23.6 ± 13.9 months. CSFs were treated by a buried implantable headless screw or Kirshner wires or bioresorbable screw with/without lateral locking plates. There were no superficial or deep infections or elbow joint instability. Seven patients obtained fracture healing, but one patient exhibited nonunion. Osteochondritis dissecans was present in one patient. Three patients had a step-off deformity (>2 mm) of the articular surface. Two patients exhibited collapse of the fractured articular surface. A patient with severe comminution of both the capitellum and trochlea exhibited collapse of the entire articular surface, with osteonecrosis of the capitellum and trochlea. Mean range of motion of the elbow was 116.3±12.7° of flexion and -28.8±14.1° of extension. The mean MEPS was 78.8±10.2 points, representing patients scored as excellent (n=1), good (n=3), and fair (n=4). CONCLUSIONS: ORIF yielded satisfactory outcomes for elderly adults with noncomminuted CSFs of the distal humerus. However, treatment of comminuted articular fracture fragment and complex posterior fracture remains challenging.

An Isolated Iliac Wing Stress Fracture in a Male Marathon Runner: A Case Report.

CASE: A 49-year-old man, who had started jogging 3 months before his first participation in a marathon race, presented with acute pain and difficulty walking that began during the marathon race. Tumors and bone metabolism factors were ruled out by blood examination and various imaging findings. Isolated iliac wing fatigue fracture was diagnosed and treated with conservative therapy. CONCLUSION: This is the first English-literature report we know of an isolated iliac wing stress fracture in a male marathon runner without underlying disease. Our study highlights the importance of considering this rare fracture when diagnosing patients presenting with iliac pain.

Minimally Invasive Corrective Osteotomy with the Ilizarov Mini-Fixator for Malunited Fractures of the Phalanges: Technical Note.

Posttraumatic malunion of the phalanx with rotational deformity may cause crossing of the finger and impair hand function. Cosmetic disfigurement and severe dysfunction of the fingers require surgical correction, most often via open corrective osteotomies and rigid fixation with plates. However, such an approach requires a longer incision, inevitably results in a scar, and has a higher potential for extensor tendon adhesions, which result in extension lags. In addition, abruption of the periosteum and plating of the phalanges require longer bone healing. This report describes the straightforward, minimally invasive correction of phalangeal malunions with a mini-external fixator. In this procedure, a digital block of the affected finger can be performed. The fully flexed position of all fingers provides accurate correction of phalangeal malunions. Although treatment of phalangeal malunions remains challenging, the present procedure is an alternative solution for phalangeal malunions.

Tarsal Navicular Stress Fracture in a Young Athlete: A Case Report.

Approximately 30% of tarsal navicular stress fractures are missed by physicians because plain radiographs often show no diagnostic clues. If early diagnosis and treatment are not obtained, such fractures will become refractory and the patient will no longer be able to actively participate as an athlete. We herein describe our experience treating a 14-year-old female track sprinter with persistent foot pain. Magnetic resonance imaging 6 months after the onset of pain showed a stress fracture of the tarsal navicular bone. Computed tomography showed the tarsal navicular stress fracture as well as sclerosis at the fracture edges. We diagnosed a refractory tarsal navicular stress fracture. Conservative management in the form of non-weight-bearing cast immobilization is the standard treatment for both partial and complete stress fractures of the tarsal navicular bone. However, surgical treatment is required in refractory cases. We treated the herein-described refractory case with 6 weeks of non-weight-bearing cast immobilization. We instructed the patient to perform quad muscle training at the same time as casting. Six weeks later, follow-up computed tomography showed callus formation and disappearance of the fracture line. The patient thus began full weight bearing with daily use of arch support equipment, and we allowed her to gradually return to sports. We gradually increased her activity intensity from jogging to running. She completely and successfully returned to sports after 3 months of treatment.

Trans-scaphoid Perilunate Fracture-dislocation with Concomitant Lunotriquetral Ligament Disruption: A Case Report.

We report a case of trans-scaphoid perilunate fracture-dislocation with concomitant lunotriquetral ligament disruption of the right wrist in a 44-year-old man, sustained from a 10-m fall landing on his outstretched right hand. Open reduction was performed 1 day after injury; at first the palmar dislocation of the lunate was reduced with the palmar approach. Under direct view with the dorsal approach, the scaphoid was comminuted and then treated with open reduction and internal fixation with a double threshold screw using a dorsal approach and a bone graft from the distal radius. Although the scapholunate ligament was intact, the lunotriquetral ligament was disrupted and required repair with metal suture anchors. At the 28-month follow-up evaluation, the patient had no residual pain in his wrist and returned to work. Trans-scaphoid perilunate fracture-dislocations often accompany a comminuted fracture of the scaphoid and disruptions of the intercarpal ligaments, and bone union and ligament healing time is delayed. Prolonged immobilization of the wrist may restrict its range of motion and limit daily activities. Therefore, open reduction and internal fixation with a bone graft for the scaphoid and simultaneous repair of interosseous intercarpal ligaments are essential for satisfactory recovery from perilunate fracture-dislocations.

Arthroscopic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocation.

BACKGROUND: The purpose of this study was to evaluate mid- and long-term clinical and radiologic outcomes of arthroscopic coracoclavicular ligament reconstruction (ACCLR) with an artificial ligament for acute dislocation of the acromioclavicular joint (ACJ). METHODS: Twelve male patients (average age at the time of surgery: 40.8 years, range: 21-64 years) underwent ACCLR with an artificial ligament for acute dislocation of the ACJ type III or type V according to the Rockwood classification. Arthroscopic surgery was performed with the patient under general anesthesia and interscalene brachial plexus block in the beach-chair position. Reduction of the ACJ was performed manually or using an elevator under control of an imaging intensifier. The ACJ was fixed temporarily with a Kirschner wire. Bone tunnels of the coracoid process and clavicle were made with a cannulated drill. An artificial ligament was pulled out through the bone tunnels and fixed on the upper surface of the clavicle with a staple and interference screw, and on the undersurface of the coracoid process with an Endobutton. The shoulder was immobilized with a shoulder brace for 4 weeks postoperatively, and rehabilitation was started in the first postoperative week. The Japan Shoulder Society Acromioclavicular Joint Function Assessment (JSS-ACJ) score was used for evaluation of clinical outcomes, and plain radiographs were performed after a minimum follow-up period of 5 years postoperatively. RESULTS: The average follow-up period after surgery was 106.3 months (range: 62-128 months). The average postoperative JSS-ACJ score was 97.2 points (range: 92-100). The seven patients who had been playing sports before injury all returned to their pre-injury level. No patients complained of pain or shoulder dysfunction in daily activities, work, or sports. There were no complications such as neurovascular injuries during surgery, infection, or foreign body reaction from the artificial ligament. Radiographs at the final follow-up showed subluxation of the ACJ and non-symptomatic osteoarthritic changes of the ACJ in two patients, respectively. CONCLUSION: ACCLR for acute dislocation of the ACJ is a useful surgical procedure that gives satisfactory clinical and radiologic outcomes on mid- and long-term follow-up. ACCLR can stabilize vertical instability of the ACJ. If instability in the horizontal direction remains, repair or reconstruction of the acromioclavicular ligament should be added to prevent osteoarthritic changes of the ACJ.

Clinical outcomes and structural integrity of arthroscopic double-row versus suture-bridge repair for rotator cuff tears.

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.