Outcomes of conservative treatment for bony mallet fingers.

BACKGROUND: The treatment strategy for bony mallet fingers remains controversial. The outcomes of conservative treatment were investigated in this study. In addition, the time to bone union, and gap between the bone fragment and distal phalanx are discussed. METHODS: The subjects were 26 patients (27 fingers) with bony mallet fingers (20 males and 6 females, mean age: 46.0 years old, the mean limitation of extension of the distal interphalangeal (DIP) joint: - 20.2°). In conservative treatment, splinting was applied for 6 weeks, followed by 2-week taping. The time to bone union, range of motion of the DIP joint, and the Crawford classification on the final follow-up were investigated. In addition, the bone fragment occupation rate was evaluated on plain radiography on the first examination. Furthermore, the gap on the first examination and after splinting. The relationship between the gap and bone union period was also investigated. RESULTS: The mean time from injury to bone union was 170.2 days, the mean range of motion of the DIP joint was - 8.5° in extension and 60.9° in flexion, and the Crawford classification was Excellent for 22 fingers, Good for 2, Fair for 2, and Poor for 1. On the first examination, the mean bone fragment occupation rate was 44.0%. The mean gap on the first examination was 1.1 mm and this was significantly narrowed to 0.8 mm after splinting (p < 0.01). No significant correlation was noted between the time to bone union and gap on the first examination (p = 0.16), however, a significant positive correlation was noted between them after splinting (p < 0.01). CONCLUSIONS: This study suggested that a favorable clinical outcome can be achieved by conservative treatment. Moreover, the bone union period decreased as the gap after splinting decreased, being significantly correlated.

Locked wires fixator for fractures of the distal third of the radius and ulna in children.

BACKGROUND: Prevention of redisplacement is an issue after the treatment of fractures of the distal third of the radius in children. In this study, we used a locked wires fixator for this type of fracture and achieved favorable treatment outcomes. METHODS: The subjects were 8 children with fractures of the distal third of the radius (male: 7, female: 1, mean age: 9.0 years old) who underwent surgery with locked wires fixators and were able to be evaluated 12 months after surgery. Immobilization was not applied after surgery. The locked wires fixator or K-wire was removed when the bridging callus was observed on plain radiography 4-6 (mean 5.5) weeks after surgery in all patients. The presence of bone union, functional outcomes, and complications were investigated postoperatively. RESULTS: All patients achieved bone union without redisplacement excellent function. The pin site infection was observed in two patients. CONCLUSIONS: The locked wires fixator may be a new useful treatment method for fractures likely to cause postoperative redisplacement.

Anatomical-positional relationship between the bone structure of the distal radius and flexor pollicis longus tendon using ultrasonography.

PURPOSE: In this study, using an ultrasonography, we investigated the positional relationship between the volar bone cortex of distal radius and flexor pollicis longus (FPL) tendon in the distal radius of healthy subjects. METHODS: The subjects were 32 healthy volunteers (56 wrists) (Age 32.9 ± 8.5, 16 males and 16 females). Their wrists were imaged by an ultrasonography. The distances between the watershed line (WS) and FPL (A), between the distal margin of pronator quadratus (DMPQ) and FPL (B), between the FPL and volar radial bone cortex at the maximum muscle belly of the PQ muscle right below the sliding region of the FPL tendon (C), and between the WS and DMPQ (D) were measured. RESULTS: All these parameters showed a normal distribution. When the correlation among the parameters was investigated, a correlation with an index of the physique, BMI, was noted in A (P < 0.01), B (P < 0.01), and C (P < 0.01), but no correlation was noted only in D (P = 0.59). CONCLUSIONS: Our results were suggested that when distal radius fracture is treated with a distal plate placement, the appropriate placement can be achieved by applying about 3 mm additional dissection of soft tissue on the volar bone cortex distal to the DMPQ.

Is actual surgical experience reflected in virtual reality simulation surgery for a femoral neck fracture?

INTRODUCTION: A virtual reality simulator developed for orthopaedic and trauma surgical training has been introduced. However, it is unclear whether the experiences of actual surgery are reflected in virtual reality simulation surgery (VRSS) using a simulator. The aim of this study is to investigate whether the results in VRSS differ between a trauma expert and a trauma novice. METHODS: In Group A (expert), there are ten orthopaedic trauma surgeons and in Group B (novice) ten residents within 2 years after medical school graduation. VRSS for a femoral neck fracture using Hansson hook-pins (Test 1) and Hansson twin hook plate (Test 2) was performed. The parameters evaluated were total procedure time (s), fluoroscopy time (s), number of times X-ray was used (defined by the number of times the foot pedal was used), number of retries in guide placement, and final implant position. RESULTS: In Test 1, the averages of four parameters (distance to posterior cortex (p = 0.009), distal pin distance above lesser trochanter (p = 0.015), distal pin hook angular error (p = 0.004), and distal pin tip distance to centre (lateral) (p = 0.015)) were significantly different between Groups A and B. In Test 2, no parameters in a mean were significantly different between groups, but seven parameters in a variance (guide wire distance to joint surface (p = 0.0191), twin hook length outside barrel (p = 0.011), twin hook tip distance to centre (lateral) (p = 0.042), twin hook distance to centre of lateral cortex (lateral) (p = 0.016), plate end alignment error (lateral) (p = 0.027), guide wire angle with lateral cortex (front) (p = 0.024), and 3.2-mm drill outside cortex (p = 0.000)) were significantly different between groups. In Test 1, Group B showed significantly longer fluoroscopy time than Group A (p = 0.044). In Test 2, Group B showed significantly fewer instances of X-ray use than Group A (p = 0.046). CONCLUSIONS: Our study showed that the experiences of actual surgery are reflected in the result of VRSS using the simulator.

Evaluation of the pulley function of the hamulus of the hamate for the flexor tendons.

PURPOSE: The aim of this study was to measure the curvature radii of the finger flexor tendons on CT acquired using tendon conditions to examine whether the hamulus of the hamate functions as a pulley of the flexor tendon. METHODS: The subjects were 20 healthy volunteers (40 hands) (14 males and 6 females, mean age: 27.5 years old). Their hands were imaged in extension and flexion of the fingers on CT. The curvature radii of the little and middle finger flexor tendons at the hamulus of the hamate were calculated. RESULTS: The curvature radii of the little and middle finger flexor tendons were 24.8 ± 7.3 and 327.1 ± 343.9 mm in finger extension, respectively, and 21.3 ± 5.3 and 265.1 ± 202.9 mm in finger flexion, respectively. The curvature radius of the little finger flexor tendon was significantly smaller than that of the middle finger flexor tendon in both finger extension and flexion (P < 0.01). CONCLUSIONS: Our study suggested that the hamulus of the hamate functions as a pulley for the little finger flexor tendon.

Assessment of dorsal instability of the ulnar head in the distal radioulnar joint: comparison between normal wrist joints and cases of ruptured extensor tendons.

In the present study, the adaptability of the distal radioulnar joint (DRUJ) was evaluated using conventional computed tomography (CT) evaluation methods. In addition, we investigated/compared a new method to evaluate dorsal displacement of the ulnar head. Our subjects consisted of 32 healthy volunteers (64 wrists) and 11 patients (13 wrists) with extensor tendon injuries related to dorsal displacement of the ulnar head. To diagnose instability in the DRUJ based on CT scans, the radioulnar line method and the modified radioulnar line method were measured. Instability was evaluated by the new method that the ulnar head was located on the dorsal side from a line involving the peak of Lister's tubercle in parallel to this baseline was regarded as showing abnormal dorsal displacement of the ulnar head. The diagnostic accuracy of each method was calculated. The sensitivities, specificities, false-positive rates, positive predictive values and the negative predictive value of new methods were better than other two methods. The new method that we recommend is simple. Based on the results of this study, an evaluation of normal/abnormal dorsal displacement of the ulnar head in the DRUJ using the new method may be useful for determining the timing of surgery.

Treatment strategy for distal radius fractures with ipsilateral arteriovenous shunts.

PURPOSE: To describe our management of 3 patients with chronic renal failure who sustained distal radius fractures in limbs containing dialysis shunts. METHODS: The 3 patients were 48-61 years old, and 2 of them were men. Because the injured limbs contained arteriovenous shunts, tourniquets were not used. Volar locking plate fixation was applied via the Henry approach. The patients' grip strength; visual analog scale scores; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores; modified Mayo scores; and their range of wrist joint motion were assessed during the final follow-up examination. In addition, complications and the presence/absence of dysfunction of the forearm shunt were also investigated. RESULTS: The mean duration of the postoperative follow-up period was 9 months (range, 7-10 mo), and the subjects' mean wrist motion values were 75°, 79°, 78°, and 87° during flexion, extension, pronation, and supination, respectively. Grip strength on the affected side as a percentage of that seen on the healthy side ranged from 71% to 90%. The patients' visual analog scale; QuickDASH; and modified Mayo scores were all excellent, and bone union was achieved in all 3 cases. No shunt dysfunction or skin soft tissue complications were noted. CONCLUSIONS: Volar locking plate fixation via the Henry approach might be useful for treating distal radius fractures in cases in which an arteriovenous shunt is present in the same limb. Shunt dysfunction and hemorrhaging are of concern during open surgery, but these were not issues in our patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Irreducible dislocation of the thumb interphalangeal joint due to displaced flexor pollicis longus tendon: case report and new reduction technique.

Dislocation of the thumb interphalangeal (IP) joint is uncommon because of the inherent stability of the joint. Cases in which reduction was blocked by the volar plate, the flexor pollicis longus (FPL) tendon, the sesamoid bone, and an osteochondral fragment have been described in the literature. This article reports a case of closed thumb IP joint dislocation caused by the displacement of the FPL tendon. A new percutaneous reduction technique for this injury will also be presented. A 63-year-old woman presented to the emergency room with an obvious thumb deformity. Radiographs confirmed dorsal dislocation of the thumb IP joint without associated fracture. Closed reduction was not successful. Percutaneous reduction was performed under locoregional anesthesia, because the dislocation was due to an FPL tendon that had displaced dorsally and radially to the proximal phalanx. After reduction, Kirschner wire fixation was not needed, but IP joint immobilization with a splint was required for 3 weeks. Postoperatively, there were no complications in soft tissues and the operative scar was almost unrecognizable. This technique enables a mini-invasive reduction by operating percutaneously on the FPL. In addition, unlike with a volar zigzag approach, it is possible to suppress the occurrence of postoperative adhesion of the flexor tendon. This new minimally invasive reduction technique is useful for irreducible dislocation of the thumb IP joint due to a displaced FPL tendon.

Comparison of Conventional Incision and 10 mm Approach for Volar Locking Plates in Dorsal Displaced Distal Radius Fractures.

Introduction: The aim of this study was to investigate whether surgery with a 10 mm approach for volar locking plate fixation provides equivalent early post-operative outcomes to conventional incision surgery for distal radius fractures. Materials and Methods: The subjects were divided into a conventional incision group (mean age: 59.1 years, 8 males and 23 females) and a 10 mm approach group (mean age: 59.9 years of age, 6 males and 20 females). The wrist range of motion; grip strength; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Q-DASH) score; and modified Mayo score were assessed at 3 months after surgery. In addition, radial inclination, ulnar variance, and volar tilt were evaluated on post-operative radiography. Results: There was no significant difference between the groups in the wrist range of motion, grip strength, VAS, Q-DASH score, modified Mayo wrist score, and three parameters of post-operative radiography. All patients in both groups had no complications during the perioperative period. Conclusion: We found that a 10 mm approach obtained early post-operative outcomes and alignment comparable to conventional incision surgery for patients with dorsal displaced distal radius fractures.

Transseptal dorsal approaches to the wrist.

BACKGROUND: The dorsal approach to the wrist is the exposure of choice for most of the surgical procedures on the radiocarpal and intercarpal joints. Contrary to the volar approach, it encounters neither the main arteries nor the motor nerve branch. However, the dorsal approach goes necessarily through the extensor retinaculum. We describe two transseptal dorsal approaches that pass through the extensor retinaculum in the thickness of a septum between two compartments. A virtual space was developed beneath the infratendinous retinaculum (which is a deep layer covering the floor of the extensor compartments) to expose the periosteum, the ligaments and the joint capsule without opening the extensor compartments. METHODS: Twenty cadaveric wrists have been dissected to study the feasibility of the two transseptal approaches. Ten wrists were exposed through a 3-4 transseptal approach, passing through the extensor retinaculum in the thickness of the septum between the third and fourth compartments. Ten wrists were exposed through a 4-5 transseptal approach, passing through the extensor retinaculum in the thickness of the septum between the fourth and fifth compartments. The extent of violations of extensor compartments and joint capsule, and the exposed anatomical structures were noted. At the end of each dissection, the whole extensor system was outrightly removed for histological study. RESULTS: The feasibility of the transseptal approaches was demonstrated for all the dissected wrists. The dissection plane beneath the infratendinous retinaculum was macroscopically and microscopically highlighted. CONCLUSIONS: The transseptal approaches provide a good exposure to the dorsal side of the wrist joint, without opening the extensor tendon compartments.

Triceps tendon avulsion: a case report and discussion about the olecranon ossification nucleus.

Rupture of the triceps tendon is a rare condition. We report a case of triceps tendon rupture with avulsion fracture of the olecranon with discussion about pathogenesis from the viewpoint of healing of the olecranon ossification nucleus. An 18-year-old man presented with avulsion fracture of the olecranon and triceps tendon rupture. Operative treatment was conducted with good results. Rupture of the triceps tendon is a rare injury comprising approximately 2% of all tendon injuries, and avulsion at insertion into the olecranon is the most common site of rupture. This injury is most likely to happen in young people as sports-related trauma. Among young people who have insufficient healing of the olecranon ossification nucleus, avulsion fracture of the olecranon may occur due to strong contraction force of the triceps tendon. Our clinical evidence may suggest that avulsion fracture of the olecranon is related in olecranon ossification center healing. Most triceps tendon ruptures are accompanied by avulsion fracture of the olecranon, and it is important to suspect this injury when radiographs show a small fleck of bone avulsed from the olecranon.

Locked Wire Fixator for a Distal Radius Fracture With Malunion: A Case Report.

Surgical treatment for a distal radius fracture using a volar locking plate is difficult if the distal radius malunion remains. Therefore, a different surgical method from volar locking plate fixation should be required. We report the case of an 83-year-old woman with a left dorsal displaced distal radius fracture. However, the deformity of the volar cortex of the radius was recognized because of a previous distal radius fracture. Therefore, osteosynthesis with a locked wire fixator was performed. At 12 months after surgery, the patient has returned to daily activities without difficulty. A locked wire fixator can be useful for treating a distal radius fracture with malunion of the volar cortex of the distal radius.

Mini-invasive robot-assisted surgery of the brachial plexus: a case of intraneural perineurioma.

Brachial plexus surgery requires extensive incisions. They are esthetically unsightly and compromise the quality of recovery after nerve repair surgery. We present a new approach to brachial plexus surgery using mini-invasive robot-assisted surgery to perform a biopsy of an intraneural perineurioma of the right brachial plexus in a 12-year-old girl.

Robot-assisted free toe pulp transfer: feasibility study.

The current tendency of microsurgery is heading toward supermicrosurgery and microsurgery assisted by robotics. The aim of this work was to study the feasibility of a free hallux hemipulp transfer with a surgical robot in a cadaveric model. We used a human body. The intervention was realized by a Da Vinci SI® robot (Intuitive Surgical™, Sunnyvale, CA) in two stages: first taking off the medial hallux hemipulp, then transferring the hallux hemipulp to the radial thumb hemipulp. The intervention lasted 1 hour 59 minutes, exclusively with the Da Vinci SI® robot, without any interruption or outside intervention. Despite the absence of sensory feedback and an intervention 25% longer than in conventional microsurgery, we have demonstrated the feasibility of free hallux hemipulp transfer with a surgical robot. In the future, it is likely that the added benefits of the robot (physiological tremor suppression, user-friendly ergonomics, ultraprecise control of the instruments) will make the robot an indispensable tool for the surgeon.

Usefulness of Bridging External Fixation for Prevention a Collapse in the Case of Osteoid Osteoma in the Lunate.

Introduction: We report a patient with osteoid osteoma that developed in the lunate. Case Report: The patient was a healthy 28-year-old male who had the right wrist joint pain and osteosclerosis of the lunate was noted on plain radiography. Kienböck's disease was considered at the first examination, but a nidus was observed on computed tomography, suggesting osteoid osteoma in the lunate. The resection of the bone lesion and bridging external fixation to prevent post-operative collapse of the lunate was performed. Histopathological diagnosis was also osteoid osteoma in the lunate. At 3 years after surgery, no recurrence of the lesion or progression of collapse of the lunate has occurred. Conclusion: As the development of osteoid osteoma in the lunate is a markedly rare pathology and there are many differential diseases, the time to diagnosis may be prolonged. Moreover, it may be useful to attach bridging external fixation to prevent a collapse of the lunate.

Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures.

Introduction There are various studies that reviewed the effect of cigarette smoking in fracture healing process. Nonunion, delayed union, and residual pain are the significant risk factors associated with smoking and fracture healing. Little has been known about the impact of smoking in distal radius fracture healing. We intend to explore in brief the effect of smoking in distal radius fracture healing and comparing it with nonsmokers having the same fracture fixation and analyze the outcomes with respect to fracture healing and return of function. Materials and Methods Of the total 186 patients, 92 were included in the study with ( n = male: 31, female: 61) mean age of 60.2 years. They were divided into two groups: smoking ( n = 43) and nonsmoking ( n = 49). All had surgical fixation of the distal radius with volar locking plate and started on early mobilization. The range of motion of the wrist, grip, visual analog scale, quick disabilities of the arm and shoulder and hand score, Mayo wrist score, and bone healing period were noted between these two groups and compared with statistical analysis. Results The mean follow-up period was 8.7 months. There was a significant association of young age and male patients having distal radius fractures in the smoking group ( p < 0.05). All fractures healed well in both groups without complications. There was no significant difference between these two groups in terms of range of motion, grasp, bone healing period, and functional outcomes. Conclusion Despite the well-known fact that, smoking has negative implications in the fracture healing process, we found group of patients (smoking and nonsmoking) with distal radius fractures treated by volar locking plates healed well with good radiological union and excellent functional outcome There is no significant influence of smoking in distal radius fracture fixation.

Age­related differences for expression of the nerve­specific proteins after peripheral nerve injury.

The effects of aging on axon regeneration currently remain unclear. In addition, the up-regulated expression of neurotrophic factors that occurs within one week of peripheral nerve injury has been shown to play an important role in the axon regeneration. To investigate the effects of aging on axon regeneration, the expression of nerve-specific proteins immediately after peripheral nerve injury were compared between young and aged mice. A mouse peripheral nerve injury model was prepared using the sciatic nerve compression method. In each group, Luxol fast blue staining and immunofluorescence staining were performed to assess the degree of Wallerian degeneration in the sciatic nerve, and to evaluate the expression of repressor element 1-silencing transcription factor (REST)/neuron-restrictive silencer factor (NRSF), brain-derived neurotrophic factor (BDNF), neurotrophin 3 (NT3), nerve growth factor (NGF), and semaphorin 3A (Sema3A) in the dorsal root ganglion, respectively. Wallerian degeneration was observed in both young and aged mice after peripheral nerve injury. Significant increases were observed in the expression of REST/NRSF (P<0.0001), NT3 (P=0.0279), and Sema3A (P=0.0175) following peripheral nerve injury in young mice, while that of BDNF (P=0.5583) and NGF (P=0.9769) remained unchanged. On the other hand, no significant differences were noted in the expression of these nerve-specific proteins in aged mice. Based on the results of the present study, compensatory changes induced by peripheral nerve injury were initiated by the up-regulated expression of REST/NRSF in young mice, but not in aged mice.