Scaphoid, lunate and capitate kinematics in the normal and ligament deficient wrist: A bi-plane X-ray fluoroscopy study.

The ligamentous structures of the wrist stabilise and constrain the interactions of the carpal bones during active wrist motion; however, the three-dimensional translations and rotations of the scaphoid, lunate and capitate in the normal and ligament deficient wrist during planar and oblique wrist motions remain poorly understood. This study employed a computer-controlled simulator to replicate physiological wrist motion by dynamic muscle force application, while carpal kinematics were simultaneously measured using bi-plane x-ray fluoroscopy. The aim was to quantify carpal kinematics in the native wrist and after sequential sectioning of the scapholunate interosseous ligament (SLIL) and secondary scapholunate ligament structures. Seven fresh-frozen cadaveric wrist specimens were harvested, and cycles of flexion-extension, radial-ulnar deviation and dart-thrower's motion were simulated. The results showed significant rotational and translational changes to these carpal bones in all stages of disruptions to the supporting ligaments (p < 0.05). Specifically, following the disruption of the dorsal SLIL (Stage II), the scaphoid became significantly more flexed, ulnarly deviated, and pronated relative to the radius, whereas the lunate became more extended, supinated and volarly translated (p < 0.05). Sectioning of the dorsal intercarpal (DIC), dorsal radiocarpal (DRC), and scaphotrapeziotrapezoid (STT) ligaments (Stage IV) caused the scaphoid to collapse further into flexion, ulnar deviation, and pronation. These findings highlight the importance of all the ligamentous attachments that relate to the stability of the scapholunate joint, but more importantly, the dorsal SLIL in maintaining scapholunate stability, and the preservation of the attachments of the DIC and DRC ligaments during dorsal surgical approaches. The findings will be useful in diagnosing wrist pathology and in surgical planning.

Satisfaction with hand appearance in children with index pollicization for thumb hypoplasia.

Although the primary aim of pollicization is to augment function, aesthetic improvement is an important secondary aim. Satisfaction with hand appearance in children with index pollicization for thumb hypoplasia was evaluated in 18 patients at an average of 7.5 years after surgery. Patients and their parents rated the appearance of their operated hand using a 10-point visual analogue scale (VAS). Four independent surgeons and 16 non-surgeon observers also rated the hands after reviewing standardized photographs of each child. The median patient-reported and parent-reported scores were 9 for both groups (IQR: 7-10) with a trend for children 12 years and older, to report lower satisfaction with appearance. The non-surgeon group assessments varied more for a given hand than the surgeons' assessments, though when scores were averaged within these groups for each hand, there was a high degree of correlation between the two groups. Surprisingly, the patient's own assessment showed a trend towards negative correlation when compared with the average rating of the non-surgeon assessors, suggesting that patients' own assessment of their hand's appearance is more affected by subjective factors than the objective physical outcome.

Scaphocapitate fusion for the treatment of Lichtman stage III Kienböck's disease. Results of a single center study with literature review.

The purpose of this study was to report the outcomes of scaphocapitate fusion without lunate excision for the treatment of stage III Kienböck's disease and to compare these results with historical results of limited wrist arthrodesis and proximal row carpectomy. Clinical and radiographic evaluations were performed preoperatively and at a mean of 5.8-years' follow-up (range 1.5 to 10.5years) on 17 patients with advanced Kienböck's disease (Lichtman stages: IIIA n=4 and IIIB n=13) treated by scaphocapitate fusion without lunate excision between January 2000 and July 2015. The average DASH score was 19 points (range 2 to 61) and the PRWE score was 23 points (range 0 to 77). The average preoperative VAS for pain of 8 was significantly reduced to an average of 4 with activity (P=0.002) and 1 at rest (P=0.001). The flexion/extension arc was 91° and grip strength was 76% of the contralateral side. The preoperative mean modified carpal height ratio decreased significantly to an average of 1.14 at the latest follow-up (P=0.02). The average carpal-ulnar distance ratio was not altered (P=0.89). The radioscaphoid and scapholunate angles were restored to their normal range. Four scaphocapitate joints failed to fuse. No re-operations were performed. Scaphocapitate fusion for advanced Kienböck's disease maintains wrist motion and significantly relieves pain. Lunate excision is not necessary. Based on a literature review, our results were comparable to those of scaphotrapeziotrapezoid fusion. Proximal row carpectomy is still an option when the radius and capitate articular surfaces are free of significant chondral lesions.

Zymosan-induced inflammation stimulates neo-adipogenesis.

OBJECTIVE: To investigate the potential of inflammation to induce new adipose tissue formation in the in vivo environment. METHODS AND RESULTS: Using an established model of in vivo adipogenesis, a silicone chamber containing a Matrigel and fibroblast growth factor 2 (1 microg/ml) matrix was implanted into each groin of an adult male C57Bl6 mouse and vascularized with the inferior epigastric vessels. Sterile inflammation was induced in one of the two chambers by suspending Zymosan-A (ZA) (200-0.02 microg/ml) in the matrix at implantation. Adipose tissue formation was assessed at 6, 8, 12 and 24 weeks. ZA induced significant adipogenesis in an inverse dose-dependent manner (P<0.001). At 6 weeks adipose tissue formation was greatest with the lowest concentrations of ZA and least with the highest. Adipogenesis occurred both locally in the chamber containing ZA and in the ZA-free chamber in the contralateral groin of the same animal. ZA induced a systemic inflammatory response characterized by elevated serum tumour necrosis factor-alpha levels at early time points. Aminoguanidine (40 microg/ml) inhibited the adipogenic response to ZA-induced inflammation. Adipose tissue formed in response to ZA remained stable for 24 weeks, even when exposed to the normal tissue environment. CONCLUSIONS: These results demonstrate that inflammation can drive neo-adipogenesis in vivo. This suggests the existence of a positive feedback mechanism in obesity, whereby the state of chronic, low-grade inflammation, characteristic of the condition, may promote further adipogenesis. The mobilization and recruitment of a circulating population of adipose precursor cells is likely to be implicated in this mechanism.

Actinomycosis infection of the finger.

Actinomycosis is a rare cause of infection in the hand. We report a case of actinomycosis infection involving proximal phalanx, with the clinical presentation mimicking that of a bony neoplasm.

The histochemical structure of the deep fascia and its structural response to surgery.

The histochemical structure of the deep fascia and its interface with the underlying muscle was examined in ten pigs. This structure was also evaluated after it had been raised as a fascial flap and in another site after the underlying muscle surface had been disrupted. The deep fascial is a simple structure of densely-packed collagen bundles and elastin fibres, and has hyaluronic acid concentrated on its inner surface, which is in contact with the underlying muscle. There is no specialised lining of this surface of the fascia to account for its gliding properties. The post-surgical specimens demonstrated preservation of the structure of the interface between fascia and muscle, including the retention of the hyaluronic acid lining, if the epimysium was intact. However, if the epimysium was disrupted, the structure of the interface was obliterated.

Resurfacing the nasomaxillary cavity for management of epistaxis in Osler-Rendu-Weber disease.

Recurrent massive epistaxes due to heriditary haemorrhagic telangectasia were managed in two patients by ablation of the mucosa of the nasal and maxillary cavities and resurfacing with radial forearm fasciocutaneous free flaps. Both patients had undergone multiple procedures attempting to control the epistaxes prior to the definitive procedures described. Both patients remained epistaxis free postoperatively and retained their nasal airways. Olfactory function was preserved in the second patient due to preservation of the superior turbinate and cribriform olfactory mucosa.

A collagen prolyl 4-hydroxylase inhibitor reduces adhesions after tendon injury.

Collagen synthesis inhibition potentially can reduce adhesion formation after tendon injury but also may affect cutaneous wound healing. We hypothesized that a novel orally administered collagen synthesis inhibitor (CPHI-I) would substantially reduce flexor tendon adhesions after injury, without any clinically important effect on cutaneous wound healing. The experiments were performed in a rat model with an in-continuity crush injury model in the rat hindfoot flexor tendon to provoke adhesion formation. Assays of dermal collagen production and the rate of healing of an excised wound were performed to assess cutaneous wound healing. Animals in the treatment groups received CPHI-I for 1, 2, or 6 weeks and were assessed at either 2 or 6 weeks. The work of flexion in the injured digit was reduced in the CPHI-I-treated animals compared with control animals, (0.188 J versus 0.0307 J at 2 weeks, and 0.0231 J versus 0.0331 J at 6 weeks) The cutaneous wound healing rate was similar in all animals, but dermal collagen synthesis was reduced in the treated animals. The CPHI-I seems to reduce tendon adhesion, and although collagen synthesis was reduced in cutaneous wounds, CPHI-I did not retard wound healing.

Speech and swallowing following radial forearm flap reconstruction of major soft palate defects.

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge. Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech. The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.

Distal scaphoid excision after radioscaphoid arthrodesis.

Radioscaphoid and radioscapholunate arthrodeses are effective surgical procedures for the treatment of nonsalvageable and isolated radiocarpal arthritis. These procedures, however, limit wrist motion significantly as the immobile scaphoid bridges the remaining midcarpal joint. A cadaver study of radioscaphoid arthrodesis followed by distal scaphoid excision was undertaken. Range of motion after radioscaphoid K-wire fixation alone demonstrated a 58% decrease in the preoperative flexion-extension arc to 60 degrees. After distal scaphoid excision (with the radioscaphoid pins still in place) the flexion-extension arc increased to 122 degrees or 86% of the preoperative range of motion; most of the increase in motion occurred at the midcarpal joint. Distal scaphoid excision releases the midcarpal joint following radioscaphoid fixation and results in a significantly greater wrist motion. If the results of this cadaver study are extrapolated to clinical practice the addition of this step to the previously described procedures of radioscaphoid or radioscapholunate arthrodesis addresses their major limitation, restricted motion.

Squamous cell carcinoma of the lip: a retrospective review of the Peter MacCallum Cancer Institute experience 1979-88.

BACKGROUND: Squamous cell carcinoma (SCC) of the lower lip is a common malignancy in Australia. Surgical excision and/or radiotherapy are used in treatment, and are regarded as equally effective. METHODS: A retrospective review of 323 patients treated at the Peter MacCallum Cancer Institute with either surgical excision and/or radiotherapy, evaluated disease recurrence, cause-specific mortality, and the incidence of metachronous lesions. RESULTS: Recurrence-free survival at 10 years was estimated to be 92.5%, and cause-specific survival at 10 years was estimated to be 98.0%. Equivalent rates of local control were obtained with surgery and radiotherapy. Recurrence was related to tumour stage and differentiation. A high incidence of metachronous lesions was noted, 25 patients had a lesion prior to presentation and 33 patients developed second lip lesions during the study period. CONCLUSIONS: Squamous cell carcinoma of the lower lip is well treated with surgery or radiotherapy. The preferred treatment for most patients with SCC of the lower lip in the Australian population is surgical excision. This study has shown a significant incidence of metachronous lip neoplasia, except in those patients whose whole lip had been resurfaced.

Free flaps in the treatment of locally advanced malignancy of the scalp and forehead.

Locally advanced cutaneous malignancy of the scalp and forehead is a disease that requires an aggressive approach to resection and reconstruction. Free flap reconstruction in these sites has been advocated because of the advantages of importing large amounts of well-vascularized tissue into a recipient site, which has often been compromised by previous surgery or radiotherapy. A consecutive series of 32 free flap reconstructions in 29 patients with cutaneous malignancy of the scalp and forehead was reviewed. The flap failure rate was 6% (two flaps) and the major complication rate was 10%. Of the surviving flaps, 97% (N = 29) were successful in reconstructing a challenging group of defects. Three patients developed local recurrence of the primary malignancy (mean follow-up, 21 months). The use of a broad repertoire of free tissue transfers in reconstruction of the scalp and forehead defects has allowed effective treatment of locally advanced malignancy of this region. Critical analysis of the results, however, indicates that microsurgical reconstruction is not without morbidity and that there are refinements in the diagnostic and operative steps of management that can maximize the functional and aesthetic results.