Change in the collateral and accessory collateral ligament lengths of the proximal interphalangeal joint using cadaveric model three-dimensional laser scanning.

UNLABELLED: The purpose of this study was to assess the lengths of the index and middle finger proximal interphalangeal joint ligaments and determine the relative changes in the collateral and accessory collateral ligament lengths at 0°, 45° and 90° flexion. We generated three-dimensional scans of 16 finger (eight index and eight middle) proximal interphalangeal joints to assess relative changes in ligament length. Significant changes were found between 45°-90° and 0°-90° for the ulnar collateral ligament of the index finger and both collateral ligaments of the middle finger between 45°-90° and 0°-90°. No significant changes in length were found for the radial collateral ligament of the index finger or the accessory collateral ligaments of the index and middle fingers. Overall, it was found that the collateral ligament length changed significantly, but there was no significant change in the accessory collateral ligaments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Cost-effectiveness in the management of Dupuytren's contracture. A Canadian cost-utility analysis of current and future management strategies.

In Canada, Dupuytren's contracture is managed with partial fasciectomy or percutaneous needle aponeurotomy (PNA). Injectable collagenase will soon be available. The optimal management of Dupuytren's contracture is controversial and trade-offs exist between the different methods. Using a cost-utility analysis approach, our aim was to identify the most cost-effective form of treatment for managing Dupuytren's contracture it and the threshold at which collagenase is cost-effective. We developed an expected-value decision analysis model for Dupuytren's contracture affecting a single finger, comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase from a societal perspective. Cost-effectiveness, one-way sensitivity and variability analyses were performed using standard thresholds for cost effective treatment ($50 000 to $100 000/QALY gained). Percutaneous needle aponeurotomy was the preferred strategy for managing contractures affecting a single finger. The cost-effectiveness of primary aponeurotomy improved when repeated to treat recurrence. Fasciectomy was not cost-effective. Collagenase was cost-effective relative to and preferred over aponeurotomy at $875 and $470 per course of treatment, respectively. In summary, our model supports the trend towards non-surgical interventions for managing Dupuytren's contracture affecting a single finger. Injectable collagenase will only be feasible in our publicly funded healthcare system if it costs significantly less than current United States pricing.

The vascularized pig fibula bone flap model: effect of segmental osteotomies and internal fixation on blood flow.

The free fibular flap is the flap of choice for reconstruction of complex mandibular defects, although two or more osteotomies may be required to recreate the normal mandibular contour. The effect of these surgical manipulations on the fibula has not been adequately investigated. This study was designed to study the effect of multiple segmental osteotomies and internal fixation techniques on blood flow in the vascularized pig fibula bone flap model. The hindlimbs of 15 Yorkshire pigs were randomized into 1 of 5 groups (n = 6 fibulae per group) consisting of: (1) a nonoperated, in situ fibula; (2) an elevated fibula flap; (3) an elevated fibula flap with two segmental osteotomies; (4) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm miniplates; (5) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm lag screws. Total and gradient blood flow was measured in the bone and soft-tissue components of these flaps using the 15-microm radioactive microsphere technique. The creation of two segmental osteotomies in the vascularized pig fibula bone flap model resulted in a significant decrease (p<0.05) in the gradient blood flow in the segment of bone distal to the second osteotomy. Application of miniplates or lag screws across closing osteotomies resulted in a significant decrease (p<0.05) in total and gradient blood flow to the bone component of the fibulae, as compared with the elevated and osteotomized fibulae groups. An increase in blood flow suggesting a hyperemic response was noted in the bone and soft tissue in the elevated and osteotomized flap groups as compared with the in situ, nonoperated controls. This study established the validity of the pig fibula as a suitable model for investigating the pathophysiology of blood flow changes in the face of standard surgical maneuvers necessary for the restoration of mandibular form and function. The results demonstrated that the creation of multiple segmental osteotomies and the application of internal fixation significantly decreases (p<0.05) blood flow to the distal portion of the flap. The effects of segmental osteotomies and internal fixation on healing and growth of the pig fibula bone flap model are investigated in a separate study.

Coronal fracture of the body of the trapezium: a case report.

An unusual fracture of the trapezium was found on computed tomography examination after plain radiographs failed to demonstrate any bony pathology. This coronal fracture has not been previously mentioned in the literature. Management included open reduction and internal fixation with 2 lag screws.

Effect of electrosurgical technique on wound healing and early complication rate following abdominal dermolipectomy.

Thirty-eight patients with significant weight loss after vertical banded gastroplasty were studied prospectively while undergoing abdominal dermolipectomy to determine if the current intensity used during electrosurgical dissection influenced wound complication rates after this surgery. Patients were assigned randomly to one of two groups: (1) a HI group, in which the electrosurgical current intensity was set at a level that easily allowed coagulation of all vessels smaller than 0.5 mm in diameter or (2) a LO group, in which the current intensity was set at a much lower level that allowed dissection, but required that nearly all visible vessels be ligated separately. A standardized procedure was employed for all patients. The patients in the LO (N = 14) and HI (N = 24) groups were well matched for age, weight history, nutritional parameters, operative times, surgical blood loss, and postoperative hospital stay. The overall complication rates of 36% and 21%, and wound complication rates of 36% and 13% for the LO and HI groups, respectively, were not significantly different. These data indicate that using a relatively high electrosurgical current intensity for dissection during abdominal lipectomy does not result in a higher wound complication rate.

Plea to save the great toe in total thumb reconstruction.

Thumb reconstruction remains a controversial field. In young, well-motivated patients, in the absence of avulsion injuries, toe to hand transfer is an accepted procedure. With refinement, it is possible to avoid sacrifice of the great toe and in many cases avoid resorting to a second toe which is functionally and cosmetically insufficient. Custom-made reconstruction allows us both to save the donor great toe and to improve function and cosmesis of the donor site. Three basic techniques are reviewed: the modified wrap-around, bipolar lengthening, and twisted two-toes techniques.

[Results of orthopedic and surgical treatment of mallet finger by subcutaneous rupture of the extensor tendon. Apropos of a series of 216 cases]. / Les résultats du traitement orthopédique et chirurgical du doigt en maillet par rupture sous-cutanée du tendon extenseur. A propos d'une série de 216 cas.

PURPOSE OF THE STUDY: To assess the late results of orthopaedic and surgical treatment for mallet finger, two groups of patients were reviewed in a retrospective study. MATERIAL AND METHODS: 156 fingers (Group I) had conservative treatment and 60 fingers (Group II) some form of surgical treatment. RESULTS: In Group I, a dorsal custom-made perforated splint maintained the distal interphalangeal joint (DIP) in extension for an average of 54 days (st13). The mean delay of presentation was 22 days (st36). Initial lack of extension was 35 degrees (st13). After an average follow-up of 154 days (st240), the lack of extension was only 7 degrees with an active range of flexion of 61 degrees (st11). 68 of these patients were reviewed for a long-term assessment (61 months). At this time, lack of extension and range of flexion were not different (respectively 5 degrees- st10 and 61 degrees- st16). In Group II, 45 per cent of patients had initially some form of orthopaedic treatment. Delay between injury and consultation was 118 days (st250). Review with a mean follow-up of 5.6 years demonstrated a lack of extension and a DIP joint flexion of 12 degrees and 53 degrees for tenodermodesis (14 cases), 2 degrees and 59 degrees for the Thompson and Littler procedures (14 cases), 1 degree and 55 degrees for the Fowler tenotomy (10 cases). DISCUSSION AND CONCLUSION: Orthopaedic treatment gave good functional results even in cases with delay of presentation. Surgery is only indicated in failure of conservative treatment. In absence of swan-neck deformity, tenodermodesis is a simple and effective technique. When a swan-neck is present, if the DIP deformity is corrected by PIP stabilization, the Fowler tenotomy is used. Otherwise, the Thompson and Littler operation allows to fully correct the deformity.