Comparison of pullout button versus suture anchor for zone I flexor tendon repair

PURPOSE: To evaluate the clinical outcome after repair of zone I flexor tendon injuries using either the pullout button technique or suture anchors placed in the distal phalanx. METHODS: Between 1998 and 2002 we treated 26 consecutive zone I flexor tendon injuries. Thirteen patients had repairs from 1998 to 2000 using a modified pullout button technique (group A) and 13 patients had repair using suture anchors placed in the distal phalanx (group B). Patient characteristics were similar for both groups. The same postoperative flexor tendon rehabilitation protocol and follow-up schedule were used for both groups. Evaluation included range of motion, sensibility and grip strength, failure, complications, and return to work. The Student t test was used to determine significant differences. RESULTS: All patients completed 1 year of follow-up evaluation. There were 2 infections in group A that resolved with oral antibiotics and no infections in group B. There were no tendon repair failures and no repeat surgeries in either group. At final follow-up evaluation there were no statistically significant differences for the following end points: sensibility (Semmes-Weinstein monofilament testing and 2-point discrimination), active range of motion (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined motion), flexion contracture (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined contracture), and grip strength (injured tendon as a percent of the contralateral uninjured tendon). The suture anchor group had a statistically significant improvement for time to return to work. CONCLUSIONS: There was no significant difference in the clinical outcome after flexor tendon repair using either suture anchors or the pullout button technique. A significant improvement was found for time to return to work for repairs using the suture anchor technique. Flexor tendon repair can be achieved using suture anchors placed in the distal phalanx, thereby avoiding the potential morbidity associated with the pullout button technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Treatment of plastic deformation of the forearm in young adults with double-level osteotomies: case reports

Plastic deformation of the forearm is a rare injury in young adults that occurs when a slow bending or rotational force is applied to the arm, most commonly in the setting of an industrial workplace accident. There are currently no guidelines for treatment of the residual forearm deformity that often results in limitations of forearm supination and pronation. We present 2 cases demonstrating that deformity correction with single cortex, double-level osteotomies combined with rigid plate fixation and early range of motion exercise that results in good functional outcomes.     

The effect of thumb metacarpophalangeal ulnar collateral ligament attachment site on joint range of motion: an in vitro study

Although reconstruction of the torn thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) has been shown to reduce symptoms, final joint motion may be different from that of the uninjured state. It was hypothesized that nonanatomic repositioning of the UCL might affect joint motion; therefore, the effect of UCL attachment site on MCP range of motion was investigated. The UCL and MCP joint capsule were visualized in each of 8 fresh cadaveric hands without otherwise disrupting the joint. The centers of the ligament attachments were marked with pins and each specimen was mounted on a testing frame capable of applying loads through the flexor and extensor tendons. After measuring the flexion, extension, and radial and ulnar deviation ranges of motion of the intact specimen, the origin of the ligament (on the metacarpal) and an attached bone block were elevated and repositioned 2 mm proximal and 2 mm palmar and range of motion was tested. The origin was reattached in its anatomic location and the insertion of the ligament was similarly elevated and displaced 2 mm in distal, dorsal, and palmar directions. Compared with the intact joint, palmar placement of the UCL origin on the metacarpal increased radial deviation (from a mean of 18 degrees to a mean of 27 degrees); proximal placement of the origin decreased it (from 18 degrees to 10 degrees). Similarly, dorsal placement of the UCL insertion on the phalanx increased radial deviation (from 18 degrees to 25 degrees) and distal positioning of the insertion decreased it (from 18 degrees to 11 degrees). Relative to intact joint flexion range of motion (mean, 57 degrees), distal placement of the UCL phalangeal insertion restricted motion (mean, 47 degrees), as did palmar placement (mean, 48 degrees). Extension and ulnar deviation motions were unaffected by ligament attachment position. This study demonstrates that nonanatomic reconstruction of the UCL alters normal MCP joint range of motion.     

A simplified method of determining synovial fluid chondroitin sulfate chain length

OBJECTIVE: To determine whether dimethylmethylene blue (DMMB) analysis, when combined with agarose gel filtration chromatography (Superose 6), can be performed instead of fluorophore-assisted carbohydrate electrophoresis (FACE) to determine chondroitin sulfate (CS) chain length in synovial fluid (SF). METHODS: SF was obtained from (1) normal horses after 8 weeks of rest, (2) the same horses after 9 months of treadmill training, and (3) horses with osteochondral (OC) injury from racing. SF CS concentrations and chain lengths were determined by gel chromatography and DMMB analysis and compared with previous results determined by FACE analysis on the same samples. RESULTS: DMMB analysis showed that SF CS peak chain length in the OC injury group increased significantly (18.7 kDa) when compared to rested and exercised normal horses (15.6 kDa). The assay had a positive predictive value of 71% and a negative predictive value of 75% for discriminating between normal and injured joints. CONCLUSIONS: We report a simple and inexpensive DMMB analysis of SF CS chain length, which, when coupled with Superose 6 chromatography, discriminates between normal and post-injury joints. Similar to our previous FACE analysis results [Brown MP, Trumble TN, Plaas AHK, Sandy JD, Romano M, Hernandez J, et-al. Exercise and injury increase chondroitin sulfate chain length and decrease hyaluronan chain length in synovial fluid. Osteoarthritis Cartilage 2007;15], our DMMB results show an increase in the chain length of the CS in the SF of injured joints.     

Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire

PURPOSE: To determine the clinical outcome of patients with perilunate and lunate dislocations treated with a combined dorsal and volar approach and intraosseous cerclage wire. METHODS: A combined dorsal and volar approach with an intraosseous wiring technique was used to treat 22 isolated perilunate and lunate dislocations. The mean interval between injury and surgery was 3 days. Outcome was assessed after an average of 49 months. Patients were assessed subjectively with a Disabilities of the Arm, Shoulder, and Hand questionnaire and were asked to rate their overall satisfaction, pain relief, problems with activities of daily living, and return to work and previous activity status. Results were assessed objectively by range of motion and grip-strength measurements and initial postsurgical radiographs were compared with final radiographs with regard to scapholunate angle and gap. RESULTS: Patient satisfaction was high in 15 of 22 patients. Seven patients stated they had problems with activities of daily living after their injury. Only 10 patients returned to the same job they had before their injury; however, all 22 patients were able to return to some type of work. Sixteen of the patients stated they were able to return to their previous level of activity. The wrist flexion-extension arc and grip strength averaged 80% and 77%, respectively, compared with the opposite side. Follow-up radiographs showed no significant change in scapholunate angle or gap with time. As expected the scapholunate cerclage wire broke frequently. The cerclage wire was removed in 16 patients, 12 because of broken hardware and 4 because of pain. CONCLUSIONS: Our results show that a combined dorsal and volar approach with an intraosseous wiring technique can restore effectively normal intercarpal relationships, providing acceptable pain relief, functional motion, and grip strength.