Bony mallet toe of the hallux treated with screws: a case report.

Traumatic avulsion fracture of the distal phalanx of the hallux, known as the bony mallet toe of the hallux, is rare, and there is no consensus regarding its treatment. Few reports of treatment methods exist, such as nonsurgical treatment using a splint, Kirschner wires, and suture anchors, but there are no reports of screw fixation. We describe the case of a 54-year-old man with a bony mallet toe of the hallux treated with screws and augmented with strong sutures. The interphalangeal joint of the hallux was fixed with a Kirschner wire for 4 weeks after surgery, and weight bearing was allowed on the hallux 5 weeks postoperatively. A total of 20 months after the surgery, the patient had no symptoms or complications. Because of screw fixation and augmentation with strong sutures, fixation strength increased. We showed the feasibility of this new technique for treating an uncommon bony mallet toe of the hallux.

Endoscopic Surgery under Fluoroscopic Guidance Is Useful for Diagnosing and Treating Epiphyseal Osteomyelitis Caused by Mycobacterium Species.

Osteomyelitis caused by Mycobacterium species may be difficult to diagnose and treat. We report a case of treatment for osteomyelitis caused by Mycobacterium species in the epiphysis of the right proximal tibia. A 28-month-old boy presented to a hospital with symptoms of fever and right knee pain. He had been vaccinated with Mycobacterium bovis Bacille Calmette-Guérin (BCG) at five months of age. The epiphyseal radiolucent lesion had increased in size and extended to the metaphysis through the physis on a plain radiograph of the right proximal tibia. Surgical drainage and curettage of the lesion were performed with an endoscope under C-arm fluoroscopy. The intraoperative histopathological examination revealed granulation tissue composed of caseous necrosis and Langerhans giant cells, revealing Mycobacterium species to be the causative pathogen. Because of suspected osteomyelitis caused by BCG, the antituberculosis drugs were administered orally from an early postoperative stage. A plain radiograph taken eight months postoperatively showed bone regeneration in the area of curettage and a slight physeal bridge, in addition to normalization of the inflammatory response on blood sampling. It was possible to perform accurate diagnosis and rapid treatment for epiphyseal osteomyelitis caused by Mycobacterium species using endoscopic surgery under fluoroscopic guidance.

Extensor retinaculum graft for chronic boxer's knuckle.

PURPOSE: Boxer's knuckle is a tear of the metacarpophalangeal (MCP) joint capsule that occurs while punching. Because of the nature of boxing, boxer's knuckle tends to be a chronic condition and often is associated with sagittal band rupture. Chronic cases often feature excessive scarring in the damaged area where the sagittal band and the MCP joint capsule become indistinguishable. The purpose of this study was to ascertain whether extensor retinaculum grafting to the defect is useful in treating chronic boxer's knuckle when direct repair of a capsular tear is not possible. METHODS: In 5 professional boxers with chronic boxer's knuckle in whom capsular repair could have impaired MCP joint flexion, scar tissue of the damaged capsule and the sagittal band-if ruptured-were removed and an oval extensor retinaculum graft was sutured in the capsule/sagittal band defect. The mean age of the patients was 22 years. In all patients, surgery was performed on the middle finger. The capsule was damaged on the ulnar side in 3 patients and on the radial side in 2 patients. RESULTS: All boxers reported alleviation of pain when punching. The range of motion for the MCP joint was not restricted after surgery in any patient. Tendon dislocation did not occur after surgery in any patient. All 5 patients were able to return to professional competition. CONCLUSIONS: Extensor retinaculum grafting is useful in treating chronic boxer's knuckle if the damaged capsule cannot be repaired directly. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Trapeziometacarpal joint instability after Bennett's fracture-dislocation.

BACKGROUND: Investigation of trapeziometacarpal joint instability was undertaken following Bennett's fracture-dislocation. METHODS: We treated six patients who were experiencing trapeziometacarpal joint instability following Bennett's fracture-dislocation. The average age of the patients at the initial visit was 22.2 years. There were four men and two women. All six patients complained of trapeziometacarpal joint pain and instability preoperatively. Fluoroscopy confirmed that the beak fragment moved with the shaft fragment. The length of time from injury to surgery ranged from 1 to 29 months (average 10.7 months). Ligament reconstruction based on Eaton's method was performed on five patients, and in one patient the fracture site was osteotomized and reduced and the dorsoradial ligament repaired. RESULTS: Over an average follow-up observation period of 20 months, none of the patients complained of severe joint pain or instability. CONCLUSIONS: When treating Bennett's fracture-dislocation, it is necessary to pay careful attention not only to accurate anatomic reduction of the joint surface but also to joint instability.

Three-dimensional description of ligamentous attachments around the lunate.

PURPOSE: To detail the location and area of specific ligament attachments on the 3-dimensional (3-D) surface morphology of the individual carpal bones. METHODS: We describe the attachment regions of both extrinsic and intrinsic intercarpal ligaments by using a combination of detailed dissection, computed tomography imaging, and a 3-D digitization technique and provide detailed information about ligament attachments around the lunate. RESULTS: The length, width, and thickness of each ligament are described in millimeters and its area of attachment is given in square millimeters and as a percentage of the bone surface and/or total ligament attachment area. The attachment sites of the ligaments also are shown visually on 3-D images of the bones. CONCLUSIONS: This study improves the knowledge and understanding of carpal ligament anatomy, which can result in better intraoperative assessment of ligament integrity/disruption and allow more accurate and anatomic repair, reattachment, and/or reconstruction of carpal ligaments for the treatment of carpal instability.