Closed tendon rupture is a well-known complication of Kienböck disease, but only 11 cases have been reported. We reviewed six cases of Kienböck disease with subcutaneous rupture of a tendon. There were five cases of 4th extensor tendons and one case of the flexor digitorum profundus tendons of the ring finger and little finger. Radiographs showed protrusion of the segmented lunate or the deformed lunate in all cases. Intraoperative findings confirmed rupture of the wrist joint capsule by these lunate lesions. We then reviewed 11 reported cases in English and 48 cases in Japanese and confirmed that all cases had similar clinical characteristics and radiological features to our own, except the involved digits of flexor tendon rupture. Our case was unique in that the ulnar side tendons were ruptured, while in the reported cases the radial flexor tendons were more susceptible to rupture than the ulnar ones. Closed rupture of tendons should be recognised as a complication in patients over middle age with stage IIIb or IV asymptomatic or less symptomatic Kienböck disease.
We report three cases of malunion after fractures of the proximal phalangeal neck in children. A 12-year-old boy and a 7-year-old girl had malunited fractures with dorsal and ulnar deviation of their fingers. Several years later remodeling had been achieved well for dorsal deviation but little for the ulnar deviation in each case. A 10-year-old boy had a similar malunited fracture with dorsal and ulnar deviation of his finger. The proximal bony spike, which protruded to the volar side, collided with the middle phalanx during flexion of the proximal interphalangeal (PIP) joint, so we shaved it. One year after operation, flexion of the PIP joint had improved. In cases of these malunited fractures in children, remodeling is considered possible for dorsal deviation but difficult for ulnar deviation. Surgical shaving of the protruding bone should be considered.
We report our method of restoration of the radial artery in the use of the anterolateral thigh.(ALT) flap to overcome the important drawback of sacrificing the radial artery in cases of free radial forearm flap (FRFF), which is indicated for reconstruction of the tongue and other intraoral defects. There were 12 patients in our series, but only seven completed their postoperative evaluations. We harvested FRFF and ALT flaps simultaneously. The former was used for palatal or lip reconstruction and the latter was anastomosed as a flow-through flap to salvage the radial artery. All major donor site problems of the FRFF were solved by coverage by the ALT flap, except for abnormal sensation on the radial side of the donor hand. The FRFF is a proper choice for small tongue or lip defects. When it is chosen for its unique merits, the ALT flap can also serve as an alternative in reconstructing the donor site with least morbidity, including the restoration of patency to the radial artery.
Since 2005 we have treated many older patients with upper blepharochalasis but no obvious aponeurotic ptosis by infraeyebrow excision of skin and orbicular muscle with tucking of the orbital septum. Thirty-five patients (70 lids) were studied, age range 61-80 years (mean 68). There were 6 men and 29 women, who were followed up for 3 months to 2 years (mean 7 months). All patients reported improvement in the upper visual fields and lessening of headaches and neck stiffness. The lateral drooping of the lid also improved, and the crease was more clearly defined than before the operation. There were no serious complications. We conclude that infraeyebrow blepharoplasty with tucking of the orbital septum is a simple and effective treatment for blepharochalasis in older East Asian patients.
Several previous reports have documented arteriovenous malformations associated with anomalies of the arterial tree. We report two cases in which a malformation on the foot coexisted with arterial variants of the popliteal artery. Careful therapeutic planning was required to avoid jeopardising perfusion to the distal area.
We retrospectively studied the epidemiology of adult patients admitted for possible replantation or revascularisation of an injured upper extremity during the period June 2003 to May 2008. A total of 121 patients were admitted (71 graded severe), mean 24 (14 graded severe), being admitted each year. The annual rate of amputation injuries in the referral area of 1.5 million was 1.5/100 000 and for severe amputation injuries 0.9/100 000. Most injuries occurred in patients aged 41-50. Fifty-eight patients had the accident during working hours (36 severe), and 62 during leisure time (34 severe). The survival rate for subtotal amputations was 77% and for total amputations 55%. Of 15 further vascularisation procedures, two succeeded at the metacarpal level. Most of the accidents occurred during wood-processing with circular saws or powered wood splitters. More efforts should focus on preventing such injuries.
Untreated ununited scaphoid fractures are a hazard to the wrist because of increasing degenerative changes with time. We have treated 81 consecutive ununited scaphoid fractures by open reposition, autologous bone transplantation, and Kirschner wire fixation, 2.7 years after the primary injury. Sixty-nine were men and the mean age at operation was 29 (range 15-71) years. Anatomy of the wrist was restored and radiological healing confirmed in 72/81 patients. There were two deep infections, and the fractures did not heal. Patients with moderate preoperative arthritic wrist changes (scaphoid non-union advanced collapse (SNAC) stage 2) or ununited fractures of the proximal 1/6 of the scaphoid had worse healing than the remainder. Two of nine scaphoids that did not heal were reoperated on with autologous bone grafting and fixation with screws or pins, both of which healed successfully. Three salvage procedures (two wrist arthrodeses and one four corner fusion) were done and the remaining four declined further treatment. Our overall results are comparable to results published where alternative fixation methods have been used. We find that our standard method using Kirschner (K) wires and bone grafting is reliable and inexpensive for most scaphoid pseudarthroses and our results are comparable to published results when alternative fixation methods have been used.
We set out this study to verify a hypothesis that orbital floor fractures tend to affect wider areas in patients with unilateral complete cleft palate. Using a striking machine, the inferior orbital rims of eight normal skulls (intact skull group) and eight skulls with parts of the maxillas removed to simulate alveolar and palatal clefts (cleft skull group) were impacted. The fractured areas were compared. Models designed using a computer were produced to simulate the skulls of 12 normal people and 12 patients with left unilateral complete cleft palate, and were classified as the intact model group and the cleft model group, respectively. Computer simulation of applying external forces to the inferior orbital rim of each model was performed. Areas where stresses exceeded the bone-yielding threshold were compared. Actual fractured areas were significantly larger in the cleft skull group than in the intact skull group. Theoretical fracture areas were also significantly greater in the cleft model group than in the intact model group. We conclude that orbital floor fractures develop in wider areas in patients with unilateral complete cleft palates, because of the instability of the maxilla on the cleft side.
Malignant blue naevus is a rare but highly aggressive form of cutaneous malignant melanoma, which spreads often and early to the regional lymph nodes, liver, lungs, and other organs. We report three cases, review published reports, and recommend treatment.
Syndromes with focal overgrowth are sporadic diseases and comprise Proteus syndrome and congenital lipomatous overgrowth, vascular malformations, and epidermal naevi (CLOVE) syndrome, and isolated hemihyperplasia. We describe 3 children classified according to standard criteria with dysregulated growth of various tissues that was excised, together with excess toes, and tumours. Correct classification facilitates diagnosis and operations. Interdisciplinary treatment and follow-up are recommended to prevent disfiguration.
Our aim was to identify factors associated with the incidence of pharyngoplasty in patients with clefts of the secondary palate (CP). We studied 351 children born between 1968 and 1999 with CP alone, who had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. During the study period 1968-2007, 68 children (19%) had a pharyngoplasty to improve their speech. Mean follow up time from the primary operation was 16 years (range 2-37). The estimated incidence of pharyngoplasty at 5, 7, 10, and 15 years after the primary operation was 9%, 12%, 14%, and 15%, respectively. Thirty-one (46%) of the pharyngoplasties were done more than seven years after the primary palatal repair. Children with total clefts of the secondary palate had a pharyngoplasty more often than children with clefts of the soft palate alone (7 years incidence: 11 (42%) compared with 22 (10%), p<0.001). Sex, age at time of primary operation, and surgeon's experience were not significantly associated with the necessity for pharyngoplasty. Our study suggested that the necessity for pharyngoplasty is related to the severity of clefts, and duration of observation.
A major drawback with myoelectric prostheses is that they do not provide the user with sensory feedback. Using a new principle for sensory feedback, we did a series of experiments involving 11 healthy subjects. The skin on the volar aspect of the forearm was used as the target area for sensory input. Experiments included discrimination of site of stimuli and pressure levels at a single stimulation point. A tactile display based on digital servomotors with one actuating element for each of the five fingers was used as a stimulator on the forearm. The results show that the participants were able to discriminate between three fingers with an accuracy of 97%, between five fingers with an accuracy of 82%, and between five levels with an accuracy of 79%. The tactile display may prove a helpful tool in providing amputees with sensory feedback from a prosthetic hand by transferring tactile stimuli from the prosthetic hand to the skin at forearm level.
The distally-based superficial sural flap has proved to be an easy and reliable method of reconstruction in soft tissue cover of the distal third part of the leg. There are two ways to prepare this flap: as a fasciocutaneous flap, which includes the fascia with the subcutaneous tissue including the skin; or as an adipofascial flap, which is made up of both the fascia and the subcutaneous adipose tissue. In the latter case, the flap is covered with a partial thickness skin graft either immediately after or at a later stage. The aim of this study was to assess the advantages and disadvantages of the two flaps. The adipofascial flap seems to be better, as it is associated with less donor site morbidity, improved quality of reconstruction, and fewer complications.
There are various techniques for palatoplasty, but no studies of postoperative osteogenesis at the palatal fissure. In the cranial and maxillofacial region it is thought to develop from the periosteum, so palatoplasty with mucoperiosteal flaps may encourage new bone to form at the fissure. We evaluated the status of osteogenesis in the hard palate after palatoplasty on computed tomograms (CT). We studied 29 patients (22 boys and 7 girls) with unilateral cleft lip and palate who had pushback palatoplasty with the use of CT obtained between May 2003 and March 2007. Age at the time of operation was recorded. The width of the palatal fissure at the first premolar, the first molar, and the maxillary posterior region were measured on coronal CT. The mean (SD) age at the time of palatoplasty was 16 (2) months. The mean (SD) width of the fissure at the first molar was 3.96 (3.1) mm, and bony union was seen in four patients. The width of the fissure was significantly less at the first molar than at the other sites (p = 0.006). The shape of the margin of the fissure was irregular in nearly all patients. The width of the fissure at the first molar became significantly less, suggesting that osteogenesis had occurred. In some patients the height of the fissure differed. Given the results of previous studies, bony regeneration from the periosteum most likely happens together with regeneration from the margins of the fissure.
A 72-year-old woman had her bladder injured accidentally during repair of a severe hernia of the abdominal wall. Primary closure was impossible because of previous heavy irradiation. We therefore did an ileocystoplasty to cover the defect. Her postoperative course was uneventful, and she could void spontaneously at seven months postoperatively.
High tension and tissue dislocation caused by wide maxillary clefts could prevent an optimal aesthetic and functional outcome in primary cheilognathoplasty. Many surgical techniques or conservative (orthodontic and orthopaedic) devices have been proposed for the initial management of infants with complete cleft lip and palate to achieve a tension-free repair of the lip. Adhesion converts a wide unilateral complete cleft into a lesser deformity anatomically similar to an incomplete cleft lip. This study aimed to measure the effect of lip adhesion on the width of maxillary clefts. Between 2000 and 2007 lip adhesion was used on 49 consecutive infants affected by complete unilateral (n = 35) and bilateral (n = 14) cleft lip and palate. The indication for lip adhesion was the presence of a wide alveolar cleft (gap > 7 mm) with severely malpositioned maxillary segments. Lip adhesion was done at about 48 days, followed by definitive cheilognathoplasty at 98 days. Photographs and impressions were obtained before any operation. The width of the maxillary clefts was reduced by 60% in unilateral clefts and 61% in bilateral clefts. By converting a complete wide cleft lip to an incomplete cleft in both unilateral and bilateral clefts, adhesion of the lip achieved a better position and stabilised the arch in a symmetrical platform that eased both definitive closure of the defect in the lip and the restoration of the maxillary gap by periosteoplasty during definitive cheilognathoplasty.
The operative treatment of mallet fractures of more than one third of the articular surface is controversial. The purpose of this study was to evaluate the complications and functional outcome of extension block pinning technique. Thirty-six consecutive patients with mallet fractures that involved more than one third of the joint surface were treated by extension block pinning a median of 3 days after injury (range 0-35, mean 7). Clinical outcome was graded according to Crawford's criteria. At a median follow-up of 16.5 months (range 2.5-52, mean 20) 23 patients had an excellent or good result, 11 patients had a fair, and 2 patients a poor, clinical outcome according to Crawford's criteria. None of the patients complained of pain. The median extension loss was 0 degrees (range 0-20, mean 4) and the median flexion was 70 degrees (range 30-95, mean 68). Eight patients had operative or direct postoperative complications including superficial infection (n = 6), loss of Kirschner wire (K-wire) fixation (n = 1), and K-wire mal position (n = 1). The extension block pinning technique is a minimally invasive method of treating mallet fractures with low morbidity and a good functional outcome.
Replantation of an avulsed ear was completely successful with only arterial repair (to the superficial temporal artery) and the use of medicinal leeches.
Early recognition and treatment of volar plate injuries within two weeks is reported to give a good outcome, but there is no published information about the consequences of delayed presentation. We present a series of 14 patients with 16 injuries, who presented more than two weeks after the initial injury. All patients were referred to a specialist hand trauma clinic over a 10 months period and were evaluated prospectively and treated with immediate mobilisation by a specialist hand therapist. Mean time to presentation was 27 days (range 14-79) and mean improvement in range of movement was 25 degrees (range 2-52) with mean residual extension lag 10 degrees (range -4-56). All patients returned to their previous levels of function by the time of discharge. We conclude that it is possible to achieve good outcome without surgical intervention even when the presentation time is four weeks if experienced hand therapists manage the rehabilitation.
Nowadays direct repair is the treatment of choice for a lacerated flexor pollicis longus (FPL) tendon in any anatomical zone. Up to now repair with the motion-stable Mantero technique has not been published. Over a five years period (2004-2008) 21 complete divisions of FPL tendons in zones 1 and 2 were treated surgically with the Mantero technique. Seventeen patients were evaluated at a mean of 33 (range 14-59) months postoperatively by measuring the range of movement of interphalangeal (IP) and metacarpophalangeal (MP) joints and assessing the results with the Buck-Gramcko score. Fourteen of the patients reported excellent or good results. The mechanical rupture rate was zero. Mantero repair therefore provides a means other than more complex methods to repair FPL tendons and rehabilitation, adding strength while simplifying suture of the FPL.
