Tarsal Tunnel Syndrome Due To Three Different Types of Ganglion During a 12-Year Period: A Case Report.

A 52-year-old male complained of numbness and radiating pain affecting the plantar region of his left foot. He was found to have recurrent tarsal tunnel syndrome due to posterior tibial nerve compression by 3 different types of ganglion during a 12-year period. To the best of our knowledge, a similar case has not been documented. At the first operation, flexor retinaculum release and simple excision of an epineural ganglion were performed without injuring the nerve fascicles; however, an intrafascicular ganglion developed approximately 2 years later. At the second operation, the ganglion cyst was resected completely to prevent recurrence, despite the risk of nerve fiber injury. The cyst originated from the subtalar joint; thus, the joint was closed, and a free fat graft was placed to prevent adhesion formation. However, an extraneural ganglion occurred about 3 years later. At the third operation, the cyst was resected completely, and a free periosteal graft was used to close the joint more effectively. No recurrence had developed at 6 years after the third operation. The findings of the present case show the need for long-term monitoring of patients with tarsal tunnel syndrome caused by a ganglion owing to the possibility of recurrence related to different ganglion types.

Three-dimensional ultrasonography for visualization of muscular anomalies in type VI and VII radial polydactyly.

OBJECTIVE: To describe a technique and its clinical applications of three-dimensional ultrasonography to type VI and VII radial polydactyly for identification of potential muscular anomalies. MATERIALS AND METHODS: Ultrasonographic examinations were performed at an out-patient department without sedation or an operative room prior to surgery. The palm was scanned in the transverse direction using a 18-MHz linear transducer under speed regulation at 3 mm/s. Sequential images acquired at 0.2 mm intervals were converted into volume data. After validation of the technique, patients with a radial polydactyly in association with triphalangism (type VII) or with polydactylies of metacarpal duplication (type VI) were included for the examination. RESULTS: Five hands of five patients, one with type VI and four with type VII, were included the study. All the patients were male and the ages at examination ranged from 7 months to 2 years. Of the five patients, four examinations were performed at an out-patient department without sedation and one was under anesthesia just prior to surgery. The muscular abnormalities identified were mal-positions of the thenar muscles in a type VI case and a deficiency of the abductor pollicis brevis muscle in a type VII case with a delta phalanx in the ulnar part. CONCLUSION: Three-dimensional ultrasound technique could be an aid to plan strategies in radial polydactyly if intrinsic muscular anomalies are suspected to be involved.

Loss of Smad3 gives rise to poor soft callus formation and accelerates early fracture healing.

Smad3 is an intracellular signaling molecule in the transforming growth factor ß (TGF-ß) pathway that serves as a regulator of chondrogenesis and osteogenesis. To investigate the role of the TGF-ß/Smad3 signaling in the process of fracture healing, an open fracture was introduced in mouse tibiae, and the histology of the healing process was compared between wild-type (WT) and Smad3-null (KO) mice. In KO mice, the bone union formed more rapidly with less formation of cartilage in the callus and eventually the fracture was repaired more rapidly than in WT mice. Alkaline phosphatase staining showed that osteoblastic differentiation in the fracture callus was promoted in KO mice. Additionally, TRAP staining and the TUNEL assay revealed that the induction of osteoclasts and apoptotic cells was significantly promoted in the healing callus of KO mice. Sox9 expression clearly decreased at both mRNA and protein levels in the early stage of fracture in KO mice. In contrast, the expression of genes for osteogenesis and osteoclast formation increased from day 5 until day 14 post-fracture in KO mice compared to WT mice. From these results, we concluded that the loss of TGF-ß/Smad3 signaling promoted callus formation by promoting osteogenesis and suppressing chondrogenesis, which resulted in faster fracture healing.

Distraction arthrolysis using an external fixator and flexor tenolysis for proximal interphalangeal joint extension contracture after severe crush injury.

PURPOSE: To introduce a technique for distraction arthrolysis with an external fixator followed by flexor tendon tenolysis for extension contracture of the proximal interphalangeal (PIP) joint after severe crush injury. We also assessed the results of this method in all patients treated. METHODS: Five fingers of 4 men with extension contracture of the PIP joint after severe injury underwent distraction arthrolysis using an external fixator, followed by flexor tenolysis. On the day of attaching the external fixator, moderate distraction was applied to the joint and the gap was widened to approximately 2 mm. From the following day onward, the PIP joint was gradually widened for 10 days until a gap of about 5 mm was attained. After sustaining this amount of distraction for 3 or 4 days, the fixator was removed. Passive range of motion was performed for about one week until swelling of the affected digit subsided. Then, flexor tenolysis was performed. Patients were follow-up for an average of 31 months after surgery. RESULTS: After tenolysis, the average improvement of active range of motion was 20 degrees, average gain of active flexion was 41 degrees, and average loss of active extension was 21 degrees. The average range of active motion was from 6 degrees to 38 degrees preoperatively, and from 27 degrees to 79 degrees postoperatively. The average median of active motion was 22 degrees preoperatively, and 52 degrees postoperatively. In all fingers, there was no significant difference in the total arc of active motion preoperatively and postoperatively, but there was a significant difference between preoperative and postoperative maximum active flexion. In all patients, painless motion was maintained and arthritic changes of the PIP joint did not worsen during the follow-up period. CONCLUSIONS: Distraction arthrolysis with an external fixator followed by flexor tenolysis was a useful treatment for our patients with extension contracture of the PIP joint and tendon adhesions after severe crush injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Trps1 plays a pivotal role downstream of Gdf5 signaling in promoting chondrogenesis and apoptosis of ATDC5 cells.

Tricho-rhino-phalangeal syndrome (TRPS) is an autosomal dominant skeletal disorder caused by mutations of TRPS1. Based on the similar expression patterns of Trps1 and Gdf5, we hypothesized a possible functional interaction between these two molecules. Using a chondrogenic cell line (ATDC5), we investigated the association of Gdf5-mediated signaling pathways with Trps1 and the phenotypic changes of ATDC5 cells due to over-expression or suppression of Trps1. Treatment of cells with Gdf5 enhanced Trps1 protein levels and phosphorylation of p38 mitogen-activated protein kinase (MAPK) in a dose-dependent manner. Nuclear translocation of Trps1 was also induced by Gdf5. These effects were blocked by a dominant negative form of activin-linked kinase 6 (dn-Alk6) and by SB203580, an inhibitor of the p38 MAPK pathway. Conversely, Gdf5 expression was suppressed by the over-expression of Trps1. Trps1-overexpressing ATDC5 (O/E) cells differentiated into chondrocytes more quickly than mock-infected control cells, whereas cells transfected with dn-Alk6 showed slower differentiation. On the other hand, O/E cells showed an increase of apoptosis along with the up-regulation of cleaved caspase 3 and down-regulation of Bcl-2, whereas dn-Alk6 cells showed suppression of apoptosis. In conclusion, Trps1 acts downstream of the Gdf5 signaling pathway and promotes the differentiation and apoptosis of ATDC5 cells.

A case of venous varix of the volar digit and review of the literature.

Venous varix of the volar digit (VVVD) is a rare condition that is usually described as a firm, blue, and painful mass. However, the clinical features of VVVD are still unclear. We treated a patient who had a firm, normal-skin-colored, and painless mass on the volar aspect of a digit. The mass was removed and was diagnosed as VVVD by histological examination. Magnetic resonance imaging was useful for assisting with the pre-operative diagnosis. We also review 11 previously reported cases.

Free medialis pedis venous flap transfer for reconstruction of volar finger defects: Clinical application and esthetic evaluation.

BACKGROUND: There have been many reports about venous flaps, which are often used for the reconstruction of soft tissue defects after finger injury because such flaps are simple to elevate. Recently, high viability rates and nearly normal histological findings were reported for venous flaps, although the mechanism of flap survival remains unclear. This study investigated the esthetic outcomes after the reconstruction of volar finger defects with free medialis pedis venous flaps, which are venous flaps that elevated between the submalleolar and medial plantar regions. MATERIALS AND METHODS: Reconstruction of volar finger defects was performed in 6 patients. All flaps were arterialized flow-through flaps with the venous anastomosis as the outflow. All 6 patients were men, with a mean age of 32.0 years. The defect involved the finger shaft in 4 patients and the finger pulp in 2 patients, and the mean size of the venous flap was 16.7 mm (width) × 34.2 mm (length). Five plastic surgeons specializing in maxillofacial surgery evaluated the color match of the flaps at 6 months postoperatively by assigning a score (maximum: 5 points). RESULTS: The flap showed complete viability with little postoperative atrophy in all 6 patients. The mean color match score for the flaps was 3.7, and it decreased as the flaps were raised further from the medial plantar region. CONCLUSION: Free medialis pedis venous flaps can be used for the reconstruction of volar soft tissue defects of the finger. Acceptable esthetic results can be obtained if flaps are harvested from an appropriate location in the medialis pedis region by a suitable method.

Trps1 deficiency enlarges the proliferative zone of growth plate cartilage by upregulation of Pthrp.

We have reported that elongation of the columnar proliferative zone of long bone growth plates in Trps1-/- mice during the late fetal stage in the previous study [1]. Since expression of Trps1 protein was found to overlap with that of mRNAs for Indian hedgehog (Ihh), PTH/PTHrP receptor (PPR), and PTHrP, we hypothesized that Trps1 may inhibit the hypertrophic differentiation of chondrocytes by interacting with the Ihh/PTHrP feedback loop. To investigate whether Trps1 has a role in this Ihh/PTHrP feedback loop, we compared the growth plates of Trps1-/- mice and wild-type (Trps1+/+) mice. Immunohistochemistry showed that Trps1 protein was strongly expressed in the periarticular and prehypertrophic zones of the fetal growth plate in wild-type mice on embryonic day 18.5 (E18.5). On the other hand, Ihh, PPR, and PTHrP mRNAs were predominantly expressed in the prehypertrophic zone at this stage of development. While expression of Ihh and PPR by prehypertrophic chondrocytes was unaffected in the growth plates of Trps1-/- mice, the range of PTHrP expression was expanded toward the proliferating zone in these mice. Quantitative real-time PCR analysis demonstrated upregulation of PTHrP in the epiphyseal growth plates of Trps1-/- mice. Furthermore, promoter analysis combined with the chromatin immunoprecipitation (ChIP) assay demonstrated that direct binding of Trps1 to the PTHrP promoter suppressed the transcription of PTHrP. Finally, organ culture of E14.5 tibiae in the absence or the presence of Pthrp revealed that the proliferative zone of the tibial growth plate was elongated by culture with Pthrp compared to that of control tibiae. Taken together, these data provide the first genetic evidence that lack of Trps1 leads to overexpression of PTHrP, and that Trps1 is required to maintain the normal organization of chondrocytes in the growth plate.

TNF-alpha deficiency accelerates renal tubular interstitial fibrosis in the late stage of ureteral obstruction.

TNF-alpha and TGF-beta1 have a complementary relationship in fibrogenesis. This study was performed to investigate the role of TNF-alpha in renal tubular interstitial fibrosis. We compared the extent of renal tubular interstitial fibrosis after unilateral ureteral obstruction (UUO) between wild-type and TNF-alpha-deficient mice by using immunohistochemistry, enzyme-linked immunoassay, and the real-time polymerase chain reaction (PCR). In comparison with wild-type mice, there was no significant difference in the extent of renal fibrosis in the TNF-alpha-deficient mice at 2 weeks after UUO. By 4 weeks after UUO, however, fibrosis marked an increase in the TNF-alpha-deficient mice to exceed that in the wild-type mice. Immunohistochemistry, enzyme-linked immunoassay, and real-time PCR demonstrated an increase of extracellular matrix in the kidneys of TNF-alpha-deficient mice that was caused by upregulation of the expression of TGF-beta1 and Snail, which in turn resulted from an increase of infiltrating macrophages. Real-time PCR revealed an increase in expression of the TNF-alpha type 2 receptor at 4 weeks after UUO, which explained the difference in the extent of renal fibrosis between TNF-alpha-deficient and wild-type mice. In the chronic stage of renal fibrosis, TNF-alpha suppresses the infiltration of macrophages by inducing TNF-alpha type 2 receptor expression, resulting in the amelioration of fibrosis.

Simultaneous Regional Fasciectomy, Skin Grafting, and Distraction Arthrolysis of the Proximal Interphalangeal Joint for Dupuytren's Contracture of the Little Finger.

We present a 58-year-old right-handed man, who consulted us with an 11-year history of Dupuytren's disease. To correct contracture of the little finger, we performed regional fasciectomy, skin grafting, and distraction arthrolysis of the proximal interphalangeal (PIP) joint using an external fixator. Preoperative or postoperative skeletal traction has been advocated to treat potential or residual stiffness of the PIP joint in Dupuytren's contracture, but its intraoperative use has not been reported before. Our method has the advantage of treating each problem caused by Dupuytren's disease. A good range of painless PIP joint motion is achieved by our intraoperative distraction technique without interfering with the skin graft and without reducing extensor tone, while the healing period is shortened by performing all procedures simultaneously.

Modified posterior interosseous flap in hand reconstruction.

Hand reconstruction methods using posterior interosseous flaps have the merits of being thin and pliable, they do not require sacrifice of any major hand arteries, and closure of the donor site is readily performed. Drawbacks include unreliability of blood flow due to the presence of posterior interosseous artery anatomic variants or damage to the venous circulation. We present some modifications to methods for the preparation of posterior interosseous flaps with which we have achieved some favorable results.

Venous varix on the dorsal aspect of the thumb: report of two cases.

Venous varix on the volar aspect of the digits or the hand is a rare subcutaneous lesion that is usually described as a firm, blue, and painful single nodule that contains thrombus. However, there have been no reports about venous varix on the dorsal aspect of the digits or the hand, so its features are unknown. We treated two patients who each had a soft blue painless mass on the dorsal aspect of the thumb that became enlarged with the tourniquet test. Ultrasonography and/or magnetic resonance imaging were used for assisting with the preoperative diagnosis, and showed each lesion was composed of two or more varicosities. Each mass was removed and was diagnosed as a venous varix without thrombus by histological examination.

Free arterialised flow-through venous flap with venous anastomosis as the outflow (A-A-V flap) for reconstruction after severe finger injuries.

Abstract For reconstruction of volar defects, an arterialised flow-through venous flap (A-A flap) can be used to restore the soft tissues and the digital artery at the same time. However, there have been reports that the circulation of this flap is inadequate. This study used a venous flap with only one venous anastomosis for the outflow of an A-A flap (A-A-V flap) to solve this problem. Six patients with defects of the finger soft tissues and digital artery after severe finger injuries were performed. The venous flap with a Y-shaped vein was harvested. The digital artery was reconstructed, after which the other proximal vein of this flap was anastomosed to the dorsal subcutaneous vein. The flap survived in all patients and histological examination of flap tissue showed a nearly normal architecture. This study describes the good results obtained with an A-A-V flap, and discusses the utility of our flap in comparison with previously reported venous flaps.

Importance of the reconstruction of the extensor retinaculum after injury.

We reconstructed an extensive soft tissue defect of the dorsum of the left wrist after an injury using a free anterolateral thigh flap and a tendon graft, and intending to substitute the extensor retinaculum for the fascia in this flap. As a result, maximum function of the extension mechanism was restored to the reconstructed hand.

Dorsal digital perforator flap for reconstruction of distal dorsal finger defects.

Three patients are presented in whom defects of the distal part of the dorsum of the finger were covered with a rotation flap or V-Y advancement flap based on a single perforating branch of the digital artery running from the volar to the dorsal side. This method is useful for the reconstruction of the distal dorsal region of the fingers, because the flap is more mobile, has a smaller skin island and is less invasive compared to the previous flaps. This type of flap conforms to the concept of a perforator flap arising from the main artery.

Free latissimus dorsi musclocutaneous flap transfer for chronic osteomyelitis of the tibia: 16-year follow-up.

Free latissimus dorsi musculocutaneous flap transfer is one of the surgical methods for treating the difficult problem of chronic osteomyelitis of the tibia. We evaluated the viability of the flap and the influence on the bone in a patient at 16 years after surgery by using X-ray films, computed tomography and magnetic resonance imaging.

Two-stage arthroplasty with joint distraction and costal osteochondral grafting for ankylosis of a metacarpophalangeal joint: nine years' follow-up.

After ankylosis of a finger has occurred, it is often difficult to restore joint mobility. We report a two-stage arthroplasty procedure for correcting ankylosis of the metacarpophalangeal joint, which involved joint distraction to extend the soft tissues, followed by costal osteochondral autografting. After 9 years of follow-up, the results are acceptable.