Staged Reconstruction of Chronic Constriction of Thumb Caused by a Stuck Ring - A Case Report.

We report the management of a 45-year-old man with a ring stuck in his dominant thumb for 3 weeks causing vascular and neural compromise and deep-seated infection. Previous reports have described rings embedded in the digits, though we were not able to find any reports of such rings causing ischaemia. We performed staged reconstruction to salvage the thumb. The thumb viability was confirmed after ring removal and the infection was treated as per culture sensitivity report. Both digital nerves were reconstructed with sural nerve graft and the circumferential soft tissue defect was covered with bilobed first dorsal metacarpal artery flap from index and middle finger. At the 6-month follow-up, the patient had useful function of the thumb with well-settled donor site on index and middle finger. Level of Evidence: Level V (Therapeutic).

Tendinopathies of the Hand and Wrist.

Tendinopathies involving the hand and wrist are common. Many are diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the tendons of the hand and wrist include trigger finger, tenosynovitis of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as tendon release.

Percutaneous release of the A1 pulley: a cadaver study.

PURPOSE: Percutaneous release of the A1 pulley has been used for treatment of trigger fingers with success. However, lack of direct visualization raises concerns about the completeness of the release and about potential injury to the tendons or neurovascular structures. The purpose of this study was to assess the efficacy and safety of percutaneous release of the A1 pulley in a cadaveric model using a commonly available instrument, a #15 scalpel blade. METHODS: Fourteen fresh frozen cadaveric hands (54 fingers, thumbs excluded) were used. Landmarks were established for the A1 pulley based upon cutaneous features. Percutaneous release was performed using a #15 blade. The specimens were then dissected and examined for any tendon or neurovascular injury, and completeness of A1 pulley release was evaluated. RESULTS: There were 39 (72%) complete releases of the A1 pulley with 14 partial and 1 missed (failed) release. There was a 22% incidence of release of the proximal edge of the A2 pulley. However, there was no case of release of more than 25% of the A2 pulley length, nor was bowstringing of flexor tendons seen in these specimens. Eleven digits showed longitudinal scoring of the flexor tendons and 3 had partial tendon lacerations. No neurovascular injuries were noted. CONCLUSIONS: Percutaneous release of the A1 pulley using a #15 blade was associated with good efficacy and an acceptable margin of safety in this series. CLINICAL RELEVANCE: Percutaneous release of trigger digits may assume a greater role in the treatment of patients with trigger finger because of cost containment pressures. The data from this study suggest that the technique used in this study is both safe and effective. With use of proper anatomical guidelines, risk to neurovascular structures is low, although longitudinal scoring of the tendon can occur.

Effect of pregnancy and obesity on arch of foot.

OBJECTIVE: Endocrine changes occurring during pregnancy result in increased laxity of the ligaments of the foot. This may lead to gradual collapse of the foot arches. The aim of the study was to determine whether pregnancy and body mass index (BMI) had a role in affecting the foot arches at long term. METHODS: A collapsed arch results in widening of the feet, thus altering the foot size. The control group included nulliparous women, while the study group included women who had been pregnant at least once. The groups were stratified secondarily by obesity according to BMI. We reviewed over 1000 charts at the outpatient offices in a large Mid-Western city. The age, BMI, and shoe size in an athletic shoe were recorded. RESULTS: There were 40 subjects in the control group and 70 in the study group. 19/40 women in control and 46/70 in study group experienced a change in shoe size (P = 0.06). Of those affected, the non-obese control group experienced a 9.7% change in shoe size while the obese study group experienced a 15.5% change (P < 0.05). CONCLUSION: There was neither a change in size between women who had been pregnant and the nulliparous, nor was there a difference between the obese and non-obese. However, there was a statically significant difference between those affected who were both non-obese and nulliparous and those who had been pregnant and who are obese. Individually, the effect of pregnancy and BMI are highly suggestive and clinically relevant.

Operative correction of arch collapse with forefoot deformity: a retrospective analysis of outcomes.

BACKGROUND: There are many forefoot deformities, including hallux valgus, forefoot overload, and hammertoe that are treated as unrelated problems with multiple different techniques. Currently, there has been renewed interest in the role of a gastrocnemius contracture on foot deformities. Our objective was to review a specific surgical treatment plan for forefoot deformities classified by us as Type 2 arch collapse and evaluate the outcomes. MATERIALS AND METHODS: We retrospectively reviewed the charts of 374 patients who underwent foot procedures to treat deformity classified as a Type 2 arch collapse. Data was collected regarding complications and need for secondary surgery. A phone survey was performed to assess patient satisfaction, pain level, and Foot Function Index (FFI) scores. RESULTS: Of the 374 patients (412 feet), there was a 96% (357 of 371 feet) union rate at the first tarsometatarsal joint and 98% (227 of 232 feet) union rate at metatarsal shortening osteotomy sites. Recurrence of hallux valgus was 2.7% (7 of 256 feet), while hallux varus occurred in 1.6% (4 of 256 feet). There were 292 patients (78%) available for phone interview. Of those patients, 88% were satisfied with the results of the procedure. The subset of procedures relating to the highest mean FFI was hammertoe correction (22.2) and the highest mean pain score was related to metatarsal shortening osteotomy (2.6). CONCLUSION: Utilizing the arch collapse model, operative treatment of forefoot deformities with a combination of procedures including gastrocnemius recession, first TMT fusion, modified McBride, hammertoe correction, and metatarsal shortening osteotomy can produce good satisfaction rates with low complication rates.

Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture.

BACKGROUND: Nonunion following a proximal fifth metatarsal metaphyseal-diaphyseal or Jones fracture can cause considerable pain with high morbidity and loss of work. Treatment should aim for early union, thus allowing early return to activity. The present study evaluated the outcomes and the time required for union following closed intramedullary screw fixation for this condition. MATERIALS AND METHODS: Between January 2005 to August 2009, 14 patients were diagnosed with nonunion following a Jones fracture. Mean age at surgery was 49 years. Mean duration from injury to surgery was 28 weeks. All nonunions were fixed with a single intramedullary screw inserted from the base of the fifth metatarsal without opening the nonunion site. Serial postoperative radiographs were evaluated to determine union. Time required for return to activity was determined. Outcome was assessed with help of pain scores. Mean followup was 27 months. RESULTS: Union was achieved in all 14 patients with one delayed union. Mean time to union was 13.3 (range, 8 to 20) weeks. All patients were able to start unassisted full weightbearing without pain at mean 10.2 weeks. Overall pain score improved from a preoperative mean of 5.4 to postoperative mean of 1.0. Complications included one deep infection, one delayed wound healing and one sural neuroma. CONCLUSION: Closed intramedullary screw fixation achieved an excellent union rate when used in the treatment of nonunion of a Jones fractures.

Outcomes following midfoot arthrodesis for primary arthritis.

BACKGROUND: Primary midfoot arthritis is a disabling painful condition of the foot. The aim of the study was to assess the functional outcomes following midfoot arthrodesis for primary midfoot arthritis. MATERIALS AND METHODS: Between 2000 and 2006, 95 patients (104 feet) underwent midfoot arthrodesis for primary midfoot arthritis. Midfoot collapse, if present, was corrected at the time of arthrodesis. Mean age at surgery was 62 years. Gastrocnemius contracture was seen in 81 (78%) feet and was treated with a recession. Radiographs were reviewed for correction of deformity. Complications and reoperations were noted. Outcome evaluation included pain, American Orthopaedic Foot Ankle Society (AOFAS) midfoot score and patient satisfaction. Outcomes were available in 68 patients (74 feet) with mean followup of 56 (range, 24 to 102) months. RESULTS: We achieved union in 96 out of 104 feet (92 %). There was one delayed union and eight nonunions. Major complications (4/104, 4%) included three deep infections and one chronic regional pain syndrome. Reoperations were required in 11 feet in addition to 26 symptomatic hardware removals. Radiographs showed a significant improvement in the talo-first metatarsal angle and medial cuneiform height. Pain improved from preoperative mean of 7 ± 2 to postoperative mean of 2 ± 2. AOFAS score improved from preoperative mean of 32 (range, 25 to 43) to postoperative mean of 79 (range, 65 to 90). Ninety percent of patients were satisfied with the final result. CONCLUSION: Primary or degenerative arthritis of the midfoot with refractory symptoms was treated with midfoot arthrodesis with good results and a low incidence of nonunion.