Dynamic External Fixator as Treatment for Congenital Little Finger Contracture.

The surgical soft tissue release of extension contracture at metacarpophalangeal (MP) joint is technically easy; however, the preventive hand therapy after surgery is really difficult in clinical practice. Congenital MP joint contracture, especially little finger, is also difficult to spread its limited range of motion (ROM). Here, we present a patient with a congenital MP joint contracture of the little finger managed with dynamic external fixator (DEF). A 21-year-old male irritated from limited ROM associated with pain of the right little finger of more than 1 year. The symptom started after trauma on his hand while playing lacrosse. Further examination revealed that his MP joint was congenitally contracted. To address this pathology, DEF followed by orthotic therapy was done. Two years after the procedure and therapy, the MP joint ROM of the finger surpassed that of the contralateral unaffected digit without pain and recurrence. The patient was able to return to his sports of lacrosse.

Inoculation of sonicate fluid into blood culture bottles improves microbial detection in patients with orthopedic bone and soft tissue infections of the upper and lower extremities.

BACKGROUND: The usefulness of sonicate fluid culture for biological tissues in orthopedic bone and soft tissue infections have not been reported. We assessed whether inoculating the sonicate fluid of bone and soft tissue into a blood culture bottle could increase the diagnostic accuracy for biofilm-related orthopedic infections. METHODS: Twenty consecutive patients with infections (9 purulent arthritis, 4 osteomyelitis, 4 purulent tenosynovitis, 2 purulent bursitis, and 1 cellulitis) and 10 non-infected cases (6 carpal tunnel syndrome, 3 Dupuytren contracture, and 1 soft tissue tumor) between October 2018 and December 2020 were evaluated prospectively. We analyzed a total of 107 culture submissions (87 bone and tissue specimens and 20 controls); 42 intraoperative tissue specimens (32 infected samples and 10 non-infected samples) using the conventional method, 45 sonication samples (35 infected samples and 10 non-infected samples), and 20 control samples. Intraoperative infectious tissues were cultured using sonicate fluid culture in a blood culture bottle (SFC-CB). The applications of SFC-CB and the conventional culture method and the detection rate, sensitivity, and relationship between the sensitivity of the diagnostic methods and duration of administered preoperative antibiotics were assessed. RESULTS: The causative microorganism was detected only by SFC-CB in five patients (25%). The sensitivity (85% vs. 60%; P = 0.077) and detection rate (80% vs. 60%; P = 0.065) were higher for SFC-CB than for the conventional culture method. The sensitivity of SFC-CB was significantly higher than that of the conventional culture method in cases in which preoperative antibiotics were administered for more than 1 week (77% vs. 39%; P = 0.047). CONCLUSIONS: Using SFC-CB, the diagnostic accuracy for bone and soft tissue infection was significantly improved. As biofilms are readily formed in biological tissues, sonication may also be useful for diagnosis. SFC-CB was particularly useful for cases in which preoperative antibiotics were administered.

Conversion to Extension Contracture as a Means of Correction of Severe Flexion Contracture of the PIP Joint Using a Modified Dynamic External Fixator.

Background: This is a retrospective case series investigating the outcomes using a dynamic external fixator (DEF) for treatment on severe flexion contractures at the proximal interphalangeal (PIP) joint. Severe flexion contractures of the PIP joint occurring after multiple operations and neglected over a long period of time are difficult to treat. The recurrence of contracture, even after successful treatment, is inevitable in patients with severe cases. In this study, we defined the severity of PIP joint contracture based on the active range of motion (ROM), soft tissue condition, and duration of the contracture. We also illustrated the strategy, results, and complications of using a DEF with rubber bands in these severe cases. Methods: We studied 11 fingers of 10 patients with PIP joint contracture treated by DEF. These were fixed at a small arc and neglected for an average 4.1 years (range, 1-9 years). The temporal Kirshner wire (K-wire) fixation after achieving an extension via DEF was maintained for 9.1 weeks on average. We retrospectively reviewed the results of these patients with an average 2-year follow-up. Results: Our method yielded favorable results upon retrospective evaluation. The average active ROM of the affected PIP joint improved from 90/96° to 34/83° with a functional arc and good patient satisfaction. The elastic force induced by strong rubber bands was safe and effective. The first step of joint space widening was the key to obtaining a successful joint extension afterwards. Serious progression of osteoarthritis at the PIP joint and pin-site fracture were a complication in each one case. Conclusions: In this study, we evaluate the surgical strategy of using DEFs powered by elastic torque from rubber bands to treat severe cases of flexion contractures of fingers. We first created extension contracture intentionally, followed by promoting flexion movement during follow-up in this group of patients.

Finger Rescue Using the Induced Membrane Technique for Osteomyelitis of the Hand.

Background: The induced membrane technique is now commonly used for large diaphyseal bone defects. Recently, several papers reported using the induced membrane technique for hand surgery. We applied this technique with some modifications to treat osteomyelitis of the phalanges. Methods: This study included six men and one woman with a mean age of 56 years. The causes of osteomyelitis included animal bite (n = 3), trauma (n = 3), and an indwelling needle (n = 1). Two-staged surgeries were performed, including an initial stage with radical debridement of the infected tissue and placement of a cement spacer into the bone defect. Four weeks after the first stage, a bone graft was performed. A bone block with cortex was harvested from the iliac crest or radius, and costal cartilage was used for proximal interphalangeal (PIP) joint arthroplasty in two cases. Grafted bones were fixed with a mini screw or an external fixator. Results: In all cases, the infection subsided, and bone union was obtained within two to three months. No absorption of the grafted bone was observed. In the two cases with PIP joint defect, joint motion without pain was preserved at 56° and 26°. Conclusions: A short interval between the two surgical stages of the induced membrane technique could be advantageous for patients in terms of time and financial burden and early rehabilitation of movement. Cortico-cancellous bone grafts were able to maintain bone length and stability with screw fixation. In the cases with PIP joint defects, instead of arthrodesis, we performed PIP arthroplasty using costal cartilage, eventually obtained some motion without pain. The induced membrane technique was useful and technically feasible for treating osteomyelitis in the hand, and secondary joint reconstruction was possible to obtain some motion.

Mallet Fractures with Long Fragment Had Poor Outcomes on Extension Block Pinning.

Background: Although extension block pinning for mallet fracture is popular, it occasionally results in poor outcome. We reviewed previous cases to elucidate the factors associated with poor outcome. Methods: From 2012 to 2017, 50 mallet fingers in 50 patients were consecutively repaired by extension block pinning using modified Ishiguro method. Inserted Kirschner-wires (K-wires) were removed at 6 weeks, followed by night splinting in extension. For outcome evaluation, distal interphalangeal (DIP) joint motion was measured and classified as either good or poor. Poor outcome was defined as either > 10° of extension lag or < 40° of active flexion or the presence of DIP joint pain. Associations between outcome and age, affected finger, interval to operation, fragment size (in terms of joint surface and dorsal cortex ratios), and fixation angle were evaluated. Results: 33 fingers (66%) had good outcome and 17 (34%) had poor outcome. Mean age was significantly greater in the poor (50.6 years) than in the good (40.1 years) outcome group (p < 0.05). The dorsal cortex ratio was also significantly larger in the poor than in the good outcome group (p = 0.006), but there was no significant difference between two groups in joint surface ratio. Affected finger, interval to surgery, and fixation angle also did not significantly differ between groups. Conclusions: Fracture fragments with a long dorsal cortex and older age associated with poor outcome following extension block pinning for mallet finger. The dorsal cortex ratio should be evaluated pre-operatively to determine the appropriate treatment method.

Immunohistochemical analyses to determine pathogenesis of tenosynovitis with psammomatous calcification in the wrist: A case report.

Tenosynovitis with psammomatous calcification is an extremely rare clinicopathological condition, which is characterized histopathologically by the presence of numerous psammomatous calcifications surrounded by a granulomatous reaction comprising a mixture of histiocytes and fibroblasts. The pathogenesis of this disease remains unclear, although an association with repetitive tendinous injury has been proposed. The present study describes the details of a case in an elderly Japanese female, and, to the best of our knowledge, the first known immunohistochemical analysis of the mechanism underlying psammomatous calcification formation. A 66-year-old Japanese woman presented with pain in the right wrist. The lesion was surgically resected. Histopathological examination revealed a well-circumscribed lesion composed of psammomatous calcification. The calcification was surrounded by histiocytes, and a few multinucleated giant cells and fibroblastic spindle cells. Immunohistochemical study revealed that these histiocytes were positive for cluster of differentiation 163, and the histiocytes and spindle cells surrounding the psammomatous calcification expressed bone morphogenetic protein-1 (BMP-1). Tenosynovitis with psammomatous calcification is hypothesized to be a distinctive subtype of idiopathic calcifying tenosynovitis involving an unusual reactive or degenerative process. BMP-1 has been demonstrated to be involved in the regulation of hard tissue mineralization, and its expression has been suggested to be associated with psammoma formation in papillary thyroid cancer. To the best of our knowledge, the case report within the present study suggested for the first time that BMP-1 expression was associated with development of psammomatous calcification in this condition.