Pollicization of the index finger for radial hypoplasia

Background

Associated with anomalies such as VACTERL and Fanconi anemia, congenital hypoplasia of the thumb has a strong association with radial hypoplasia. The majority of patients have bilateral thumb underdevelopment, and those that have a unilateral deformity tend to have the right hand more commonly affected. In order to gain an opposable thumb, patients with a deficient carpometacarpal (CMC) joint, a floating thumb, or complete absence of the thumb can benefit with a thumb amputation and a translocation of the index finger (pollicization) to the thumb position. This video demonstrates the technical steps involved in performing a pollicization procedure in a patient with radial hypoplasia. The video is available electronically.

Methods

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all individual participants included in the video. The authors declare that they have no conflict of interest.

Results

Pollicization allows for improved functional results in patients with radial hypoplasia.

Conclusions

This video has reviewed the essential steps in performing a pollicization procedure in patients with radial hypoplasia.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-014-9693-z) contains supplementary material, which is available to authorized users.     

Indications for microsurgical reconstruction of congenital hand anomalies by toe-to-hand transfers

Background

The indications for microsurgical toe-to-hand transfers in congenital hand surgery have not been defined as clearly as for posttraumatic reconstruction of thumb and finger amputations. The purpose of this study was to develop simple guidelines for referral of children with congenital absent digits for consideration of microsurgical reconstruction with toe-to-hand transfers, based on the morphological or radiographic anatomy of the hand anomaly, not on embryological classifications.

Methods

From a consecutive series of 204 children referred with congenital absence of the thumb and fingers, 100 toe-to-hand transfers were performed. The indications for microsurgical reconstruction of these children were analyzed retrospectively.

Results

Forty-one thumbs were reconstructed in 38 children—15 children with an absent thumb distal to the metacarpal base but with four relatively normal fingers; 12 children with an absent thumb and only one or two digits remaining on the ulnar side of the hand; and 11 children with complete absence of all five digits. Twenty-nine second toes and 12 great toes were transferred to reconstruct congenital absent thumbs. Fifty-nine fingers in 52 children were reconstructed mostly with single second toe transfers—41 children with a thumb but absence of all four fingers and 11 children with absence of all five digits.

Conclusions

The morphological or radiographic anatomy of a child’s hand with congenital absent digits is a more logical indication for microsurgical reconstruction than any embryological classification. The three most common indications for toe transfers for reconstruction of congenital absent thumbs are (1) absent thumb distal to the carpometacarpal joint with four relatively normal fingers, (2) absent thumb with only one or two fingers remaining on the ulnar border of the hand, and (3) complete absence of the thumb and all four fingers. The two indications for toe transfers for reconstruction of congenital absent fingers are (1) absence of all four fingers but with a normal thumb remaining and (2) complete absence of all five digits.     

Outcome of index finger pollicisation

Background

Pollicisation of the index finger for absence or severe hypoplasia of the thumb has been reported as a good procedure to recreate a new ‘thumb’ with good cosmesis and acceptable function. The purpose of this study is to evaluate the outcome of our series from different viewpoints.

Methods

Seventeen patients with 24 involved hands were willing to come back for evaluation. The mean age at operation was 12 months. In 8 hands there was also a radial club hand. Buck Gramcko’s technique was used with slight modifications. The mean follow-up time was 53 months (ranging from 6 to 142). The outcome was determined in a variety of ways: the functional assessment, cosmesis (objectivated with measurement of thumb length, girth and nail size) and a subjective evaluation of function and aspect done with a patient/parent questionnaire and a visual analogue score.

Results

The mean functional score was: one excellent, eleven good, five fair and five poor results. The mean length was 96% the width was 93%, the nail width was 85%. There was no significant different outcome in the syndrome related thumbs versus the isolated cases, unilateral versus bilateral cases. A significant worse outcome was seen for function and subjective evaluation in the radial club hand associated thumbs and for the functional score for the more severe Blauth group.

Conclusion

The general outcome for non radial club hand associated thumb reconstructions was satisfying. There was good correlation between the different scoring systems.     

Reconstruction of the thumb tip using palmar neurovascular flaps

Objective

Reconstruction of the tip of the thumb using a neurovascular flap.

Indications

Transverse defects of the thumb??s tip or large defects of the palmar pulp (max. 2.0?C2.5?cm) with exposure of bone and/or tendons.

Contraindications

Extensive crush injury, heavy wound contamination, circulatory disorders, acute infection, very large defects (>?2.0?C2.5?cm finger length), circumferential soft tissue defects, and previous defects/operations (relative).

Surgical technique

Supine position, hand supinated, tourniquet, loupe magnification. Mid-lateral incisions along both sides of the finger running from the defect to the interphalangeal joint (small defect) or proceeding further proximally. Careful elevation of the flap including both neurovascular bundles leaving dorsal branches of the bundles (long fingers only) and the flexor tendon sheath intact. Suture of the flap in either flexion position (i.e., advancement flap) (Moberg) or by creating an island-flap through an additional transverse skin incision along the flap??s base (O??Brien). Finally, closure of the defect at the flap??s base using a full thickness skin graft, Z plasty, or V-Y plasty.

Postoperative management

Plaster cast (finger slightly flexed) for 2 weeks.

Results

Reliable method. Good functional results with good sensibility and only minor reduction in range of motion.     

Pollicization of the most radial finger in five-fingered hand: report of three cases

The treatment objective in the five-finger hand is to create an opposable thumb with two phalanges and a first web space having a normal appearance. We report three cases of pollicization of the most radial finger in two patients evaluated by the Percival Score. Currently, the treatment of reference of five-finger hand is the pollicization of the most radial finger. We present a particular technical enhancement, which is the adaptation to a shorter osseous skeleton and the utilization of extrinsic or intrinsic motors present in the radial side of the hand.     

Musculoskeletal congenital malformations: do paternal occupational exposures play a role?

Background

Paternal occupational exposures to potential health hazards are likely to affect congenital malformations through the spermatogenesis cycle.

Purpose

The aim of this case–control study was to assess the relationship between the risk of musculoskeletal congenital malformations in offspring and paternal workplace exposure to potential health hazards during the preconception period.

Method

The study comprised 105 patients (cases) with a musculoskeletal congenital malformation(s) and 135 controls matched for age and demographic characteristics. Both parents of each case and control were interviewed in the hospital by a trained physician. They also completed a questionnaire focusing on the preconception period and on the 3-month period immediately before and after the pregnancy conception date, respectively, of the child under study.

Results

The odds of having a child with a congenital malformation was higher (P < 0.05) if the father was occupationally exposed to pesticides, solvents, or welding fumes during the preconception period.

Conclusion

Control of workplace exposures and adherence to threshold limit values of these potential health hazards should be adopted to minimize the risk of fathers having offspring with a congenital malformation.     

Modeling manual perineal protection during vaginal delivery

Introduction and hypothesis

We compared hands-on manual perineal protection (MPP) and hands-off delivery techniques using the basic principles of mechanics and assessed the tension of perineal structures using a novel biomechanical model of the perineum. We also measured the effect of the thumb and index finger of the accoucheur’s dominant-posterior hand on perineal tissue tension when a modified Viennese method of MPP is performed.

Methods

Hands-off and two variations of hands-on manual perineal protection during vaginal delivery were simulated using a biomechanical model, with the main outcome measure being strain/tension throughout the perineal body during vaginal delivery.

Results

Stress distribution with the hands-on model shows that when using MPP, the value of highest stress was decreased by 39 % (model B) and by 30 % (model C) compared with the hands-off model A. On the cross section there is a significant decrease in areas of equal tension throughout the perineal body in both hands-on models. Simulation of the modified Viennese MPP significantly reduces the maximum tension on the inner surface of the perineum measured at intervals of 2 mm from the posterior fourchette.

Conclusions

In a biomechanical assessment with a finite element model of vaginal delivery, appropriate application of the thumb and index finger of the accoucheur’s dominant-posterior hand to the surface of the perineum during the second stage of delivery significantly reduces tissue tension throughout the entire thickness of the perineum; thus, this intervention might help reduce obstetric perineal trauma.     

The role of thumb and index finger placement in manual perineal protection

Introduction and hypothesis

Comparison of the modifications of the Viennese method of manual perineal protection (VMPP) and hands-off delivery techniques by applying basic principles of mechanics with assessments of tensions within perineal structures using a novel biomechanical model of the perineum. Evaluation of the role of the precise placements of the accoucheur’s posterior (dominant) thumb and index finger in perineal tissue tension when performing a modified Viennese method of MPP.

Methods

We carried out an experimental study on a biomechanical model of the perineum at NTIS (New Technologies for Information Society, Pilsen, Czech Republic). Hands-off and 38 variations of VMPP were simulated during vaginal delivery with the finite element model imitating a clinical lithotomy position.

Results

The main outcome measures were quantity and extent of strain/tension throughout the perineal body during vaginal delivery. Stress distribution between modifications of VMPP showed a wide variation in peak perineal tension from 72 to 102 % compared with 100 % for the “hands-off” technique. Extent of reduction depended on the extent of finger movement across a horizontal, transverse x-axis, and on final finger position on a vertical, antero-posterior y-axis. The most effective modification of VMPP was initial position of fingers 12 cm apart (x?=?±6) on the x-axis, 2 cm anteriorly from the posterior fourchette (y?=?+2) on the y-axis with 1cm movement of both finger and thumb toward the midline on the x-axis (Δx?=?1) with no movement on the y-axis (Δy?=?0).

Conclusions

In a biomechanical assessment with simulation of vaginal delivery, exact placement of fingertips on the perineal skin, together with their co-ordinated movement, plays an important role in the extent of reduction of perineal tension.     

Treatment of osteoarthritis of the first carpometacarpal joint by resection–suspension–interposition arthoplasty using the split abductor pollicis longus tendon

Objective

Reduction of pain and gain of functionality in symptomatic osteoarthritis of the first carpometacarpal joint.

Indications

Idiopathic, rheumatic, or posttraumatic osteoarthritis of the first carpometacarpal joint.

Relative contraindications

Poor general condition, poor condition of the hand’s soft tissue/skin, chronic regional pain syndrome, current or recent infections of the hand, heavy manual labor (decision on a by-case basis).

Surgical technique

Supine position, hand pronated or slightly tilted. Upper arm tourniquet (Esmarch’s method). Loupe magnification. Incision over the first extensor compartment. Exposure and incision of the thumb’s basal joint. Resection of the trapezium. Exposure of the abductor pollicis longus (APL) tendon. Longitudinal split of the tendon harvesting the distally based ulnar part of the tendon. The split APL tendon is wrapped around the flexor carpi radialis (FCR) muscle tendon, suturing it to the tendon and back to itself. The rest of the split APL tendon is placed into the gap between the scaphoid and the first metacarpal bone, which is followed by wound closure.

Postoperative management

Plaster cast (thumb abduction splint) for 4 weeks. Stable commercially available wrist brace for at least 2 more weeks.

Results

There were no significant differences between the FCR arthroplasty (Epping’s method) and the APL arthroplasty (Wulle’s technique) regarding pain (visual analog scale), disability/usability (DASH score), or range of motion. Patients who had undergone APL arthroplasty showed significantly better grip and pinch strength. Furthermore, the operating time was significantly shorter and scars were significantly smaller in APL arthroplasty.     

Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application

Purpose

Reconstruction of the thumb with exposure of bone and tendon is challenging. We designed a bipedicle island flap from the dorsum of the index finger to repair thumb defects. One pedicle includes the radial proper palmar digital artery (PDA) of the index finger, another pedicle includes the first dorsal metacarpal artery (FDMA). The aim of the study was to investigate the anatomical basis and clinical application of this flap.

Methods

Eleven fresh cadaver hands were dissected, the FDMA and the radial proper PDA were exposed. Their origin, distribution and diameter in different locations, especially in the dorsum of the proximal phalanx of the index finger, were examined. Ten patients (11 hands) underwent thumb reconstruction using this flap. During follow-up, the flap survival and hand function were evaluated.

Results

The origin of the FDMA in three cadaver hands was abnormal. The FDMA was mainly distributed in the proximal area of the dorsum of the proximal phalanx. The radial proper PDA of the index finger formed one constant dorsal branch, mainly distributing in the middle and distal area of the dorsum of the proximal phalanx. All flaps survived. At follow-up, the span of the first web and the range of motion of the thumbs and index fingers reached more than 94 % of the contralateral finger. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire (MHQ).

Conclusions

The bipedicle island flap has two arterial systems to provide sufficient blood supply. This technique provides another option for thumb reconstruction when a large supercharged FDMA island flap needs to be designed, or when there is an additional injury to the radial side of the dorsum of the hand or if there are anatomical variations of the FDMA, or if damage to the FDMA occurs during surgery.     

Transposition der oberflächlichen Beugesehnen von Mittel- und Ringfinger zur Wiederherstellung der Daumen- und Fingerstreckung (Boyes-Transfer)

Objectives

Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV).

Indications

The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots.

Contraindications

The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue.

Surgical technique

The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper’s chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons.

Postoperative management

Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free.

Results

From March 1999 to January 2010 a Boyes’ transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47?±?17 (13–73) years. The interval between radial palsy and tendon transfer was an average of 79?±?144 (4–543) months. The final follow-up was performed at an average of 82?±?35 (32–165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36?±?24 (11–85) points. Although disability of varying degrees persisted in all patients, Boyes’ transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.     

Verletzungen des Sattelgelenks und posttraumatische Rhizarthrose

Background

Precise function of the hand is crucially characterized by opposition movement of the thumb, only possible because of the functional anatomy of the first carpometacarpal joint. High functional demands to this joint consequently lead to the highest rate of osteoarthritis of the hand joints and loss of function. Carpometacarpal (CMC) osteoarthritis of the thumb is rarely seen in posttraumatic cases. It can be caused by fractures involving the joint surfaces of both, the trapezium or the first metacarpal, whereas dislocations of the carpometacarpal joint itself only occasionly lead to osteoarthritis.

Objectives

Identification and compilation of current concepts in diagnosis and therapy of posttraumatic carpometacarpal osteoarthritis of the thumb.

Methods

Selective PubMed and Cochrane review, data obtained from own patient investigations and author’s experiences were used.

Results

Adequate treatment of the injury will minimize the risk for future malfunction. In early stages, arthroscopy is a valuable method for the diagnosis and treatment of posttraumatic rhizarthrosis. For all stages, a multitude of operative procedures are described and being used but yet not finally assessed for effectiveness. Advanced osteoarthritis of the first CMC joint is widely treated by trapeziectomy, which is suitable for most patients, and considered as gold standard. Additional procedures like suspension, interposition or k-wire transfixation do not provide any significant advantage and lead to comparable results. It is advisable to treat hyperextension of the metacarpophalangeal joint of the thumb at any stage of CMC osteoarthritis.     

示指拇化治疗重度拇指发育不全

目的 介绍示指拇化治疗先天性重度拇指发育不全(ⅢB～V型)的手术方法.方法 对Ⅳ型(漂浮拇)2例、ⅢB型(腕掌关节缺如)2例采用示指拇化,将示指自掌骨部位转位重建拇指.结果 4例移位指全部存活.术后随访2～3年,虎口开大70°～90°,接近健侧.拇指掌指关节屈曲后可与所有手指对指,近指间关节活动度从0°至100～120°,远指间关节活动度从0°至90°.指端两点分辨觉同健侧,外观和功能满意.结论 采用示指转位治疗重度发育不全的拇指,外形和功能满意,克服了以往采用皮瓣和骨瓣移植的缺点,是一种实用而可取的方法,值得推广.     

Daumenreplantation nach traumatischer Amputation

Introduction

Replantation using microsurgical techniques is a fairly new procedure in Vietnam. We reviewed and evaluated our 7-year results of thumb replantation in Vietnamese patients following traumatic thumb amputation.

Material and methods

Traumatic thumb amputations between September 1999 and July 2006 were reexamined and evaluated. Postoperative functional results were evaluated based on four main criteria: 1) the patient’s subjective attitude regarding the replanted thumb, 2) the degree of mobility of the replanted thumb compared with its counterpart, 3) the level of sensitivity of the replanted thumb, and 4) the objective ability to perform daily tasks.

Results

A total of 26 patients were documented. The duration of follow-up averaged 22 months (range 6–72 months). The success rate of replantation was 81%. A rating of either “good” or “very good” was obtained for 81% of the replanted thumbs.

Discussion

Vascular thrombosis was the cause of all failures. Proper debridement, standardized microvascular techniques, timely detection of thrombosis formation, and reoperation using vein grafts play a decisive role in the final success.     

Restoration of sexual activity in patients with chronic hydrocephalus after shunt placement

Background

Chronic (normotensive or low pressure) hydrocephalus is characterized clinically by gait disturbance, cognitive and urinary impairment, known as Hakim’s triad. Nothing has been reported about impairment in sexual function, which could involve both the patient and the patient’s partner.

Methods

Out of 97 patients undergoing shunt placement for chronic hydrocephalus, 28 male patients (28.8%) referenced sexual dysfunction before operation. In these cases, we performed a preoperative and postoperative survey of sexual activity.

Results

In the preoperative period, all 28 patients reported having no sexual activity or arousal, from 2 to 4 years before the operation. Following shunt placement, 22/28 (78.5%) of patients regained variable sexual desire within a period ranging from 3 to 8 weeks, affording normal sexual activity with their partner.

Conclusions

Sexual dysfunction can be part of the very early clinical background in patients with Hakim’s triad and neuroradiological imaging compatible with chronic hydrocephalus. Restoration of sexual ability and arousal should be considered among the postoperative goals in these cases, together with improvements in cognition, gait, and urinary continence.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Bifid thumb type IV in children: transferring an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon

Objective

To evaluate the clinical and functional results of the surgical treatment of bifid thumb type IV in children.

Materials and methods

A retrospective study was undertaken from January 1995 to December 2006. Clinical and radiographic evaluations were made according to Wassel’s classification. The patients were performed by transferring an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon into the radial side of the epiphyseal proximal phalanx of the ulnar thumb. All patients were operated using one of five surgical procedures for bicephalous metacarpus, cartilaginous connection between the radial and ulnar proximal phalanges, the angular deformity of the metacarpophalangeal joint (MPJ) is >20°, and zigzag deformities. The postoperative results of the patients were evaluated for both function and cosmesis according to Tien’s modified Tada scoring system.

Results

One hundred and sixty-four patients (102 females, 62 males) were included in this study. The MPJ was stable in 170 thumbs, 15 thumbs had 10° of radial instability, and new collateral ligaments were augmented in 27 thumbs. The alignment was normal in 75 thumbs, with alignment of the interphalangeal joint (IPJ) in 101 thumbs and alignment of the MPJ in 75 thumbs. Postoperatively, there were zigzag deformities in four thumbs (developed zigzag in two thumbs, recurrent zigzag in two thumbs); there was no first web space in those hands. There were four of 185 thumbs with thumb stiffness. The abductor function of 185 thumbs was as follows: >70° in 158 thumbs (85.4%), 50°–70° in 21 thumbs (11.4%), and <50° in six thumbs (3.2%). At the latest follow-up evaluation, no evidence of physeal growth injury or growth arrest was observed in any patient. Overall, we attained good results in 140 thumbs (75.7%), fair results in 36 thumbs (19.4%), and poor results in nine thumbs (4.9%).

Conclusion

We recommend the use of an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon into the radial side of the epiphyseal proximal phalanx of the ulnar thumb and to restore anatomical insertion of the abductor pollicis brevis muscle. The technique is simple, safe, and effective for thumb abductor function in the treatment of bifid thumb type IV in children.     

The innervated first dorsal metacarpal artery island flap for reconstruction of post-traumatic thumb defect

Background

Various surgical techniques contribute to repair distal defects of the fingers, especially the thumb as traumatic loss diminishes or eliminates the thumb prehensile abilities and may affect overall hand function.

Methods

Ten innervated first dorsal metacarpal artery (FDMCA) island flaps were performed and evaluated postoperatively. The function of the thumb and the cosmetic appearance were documented for all patients.

Results

The flap survived with good cosmetic results in all cases. Grasping and pinching activity as well as cortical orientation was achieved for all flaps.

Conclusion

It appears that the FDMCA flap is one of the best solutions for cover of simple or complex skin loss of the thumb. Its technical performance is easy, and it gives durable, sensate, and stable skin cover. Level of Evidence: Level 4, therapeutic study.     

Surgical repair of Kommerell’s diverticulum and an aberrant subclavian artery

Purpose

The coexistence of Kommerell’s diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies.

Methods

Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell’s diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required.

Results

One patient died of mediastinitis, subsequent to a ruptured Kommerell’s diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6–58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications.

Conclusions

Aortic disease with an ASCA and Kommerell’s diverticulum can be repaired safely under elective conditions.     

Reconstruction of the radial collateral ligament of the metacarpophalangeal joints of the fingers

Background

Injury to the collateral ligament of the metacarpophalangeal (MP) joint is less common in the finger than the thumb and can have a significant impact on function. When it affects the middle finger, we have observed a more extensive mechanical disturbance than that affecting just the MP joint, and for the central two fingers with less accessible ligaments, we have developed a strong method of reconstruction using a tendon graft which also corrects the mechanical disturbance caused by loss of suspension of the assemblage nucleus which holds the flexor tendons and adjacent structures into the convexity of the transverse palmar arch.

Methods

Ten patients with painful chronic radial collateral ligament injuries of the MP joint of the finger were treated surgically. Eight of these patients received reconstruction using a tendon graft, whilst in one case, the ligament was reattached directly using a suture and in one by a tendon transfer.

Results

All patients achieved a good outcome following their surgery. Of the six patients treated with the described tendon graft technique, the average post-operative QuickDASH score was 0; the average post-operative grip strength, as a percentage of the unaffected good side, was 100 %, and the average active flexion, active extension, and passive extension were 83°, ?8° and ?24°, respectively.

Conclusions

For the middle and ring fingers, we recommend reconstruction using a tendon graft in order to restore the support to the whole flexor mechanism in the palm and to overcome the difficulty presented by inaccessibility of the ligament. Our cases treated in this way have shown full recovery of the function and correction of incipient deformity even when subluxation had started to occur. Level of Evidence: Level V, therapeutic study.