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1/16. Surgical management of hands in children with recessive dystrophic epidermolysis bullosa: use of allogeneic composite cultured skin grafts.

    Recessive dystrophic epidermolysis bullosa (RDEB) is characterised by progressive childhood hand syndactyly and flexion contractures, which can be managed surgically but require split thickness autografts to facilitate satisfactory postoperative healing. We report on the partial substitution, for autografts, of improved composite cultured skin (CCS) allografts. The structure and preparation of these CCSs is outlined and their application in the course of 16 operations performed on 7 RDEB children with syndactyly and flexor contractures of fingers is described. Hand contractures were released and web spaces were covered with local flaps and split thickness autografts, while adjacent sides of the digits and other areas, as well as donor sites were generally grafted with CCS. Morphologic and functional results with CCS were judged to be good to excellent, the average time to recurrence was increased approximately 2-fold and smaller autografts needed to be used. In addition, healed CCS-treated donor sites could provide superior donor sites for further surgery.
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keywords = operative
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2/16. Operative treatment of mallet finger due to intra-articular fracture of the distal phalanx.

    Treatment of a mallet finger due to an intra-articular fracture of the distal phalanx involving one-third or more of the articular surface is controversial. Thirty-three digits with such fractures were treated by open reduction and internal fixation with Kirschner wires. Of these 33 fractures, 13 were associated with subluxation of the distal phalanx. After an average follow-up period of 29 months, the average loss of extension of the distal phalanx was 4 degrees, and the average flexion of the distal interphalangeal joint was 67 degrees. Radiographs of the distal joint in 27 digits appeared normal, while in the remaining 6 digits, slight degenerative changes were noted. In one there was a minor surgical complication. By using the operative technique described, a congruous reduction of the inta-articular fracture and satisfactory function were achieved.
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keywords = operative
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3/16. Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers.

    Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.
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keywords = operative
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4/16. Postoperative management of functionally restrictive muscular adherence, a corollary to surgical tenolysis: a case report.

    After a surgical release of adhered nongliding tendons, early active mobilization is encouraged to prevent the reformation of unfavorable adhesions that would limit functional tendon excursion. These restricting adhesions can also occur in non-synovial regions, such as within the flexor mass in the forearm. A "myolysis," or release of muscle fibers from tethering adhesions, can be performed surgically to restore the muscle's gliding and lengthening properties. Postoperative management consists of treatment techniques that include low-load prolonged stress, differential tendon gliding, and active-resistive exercises, all of which are effective in restoring and maximizing a patient's active and passive range of motion to allow optimal mobility and performance. This case study demonstrates the successful management of a patient following a surgical myolysis, utilizing treatment techniques conceptually derived from postoperative tenolysis rehabilitation.
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ranking = 6
keywords = operative
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5/16. Proximal interphalangeal joint surface replacement arthroplasty.

    A consecutive series of 20 joints in 13 patients underwent arthroplasty with the RMS PIP joint surface replacement implant. Twelve joints were treated for painful osteoarthritis (all females). Two joints were implanted for rheumatoid arthritis, two for post-traumatic pain and stiffness, two for post-traumatic stiffness and one each for post-traumatic pain and pain-free post-traumatic instability. Excellent, often total long-term pain relief was obtained in 18 joints. The other two patients with (compensible work-related) post-traumatic pain and stiffness reported "50-70% pain reduction". No patients lost movement and 14 out of 20 joints were pain-free with a 73.1 degrees average arc of motion. Six joints from the first half of the series had poor motion (average arc of 19.6 degrees ), even after open extensor tenolysis or manipulation under anaesthesia. As experience was gained, reliably better results were achieved with a more intensive regimen of hand therapy, particularly within the first post-operative week.
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6/16. Treatment of hand deformities in a long-term survivor with dermolytic bullous dermatosis-recessive (DBD-R).

    Treatment of hand deformities in a long-term survivor with dermolytic bullous dermatosis-recessive is described. An "open method" is sufficient for dealing with volar skin defects. There is still no effective treatment for perfect control of blister formation. But appropriate surgery, followed by careful post-operative rehabilitation can give reasonable hand function.
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keywords = operative
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7/16. Microvascular reconstruction of congenital anomalies and post-traumatic lesions in children.

    A series of toe-to-hand transfers in children with congenital or post-traumatic deficits is reported to emphasize the role of microvascular reconstruction as an important alternative. morbidity to the donor site is almost negligible, and the functional improvement to the hand is reasonably good considering the young age of the patients. Functional results are limited by the lack of full motion, soft-tissue contractures, sensory recovery, and the delay in cortical reeducation. We were surprised to find a relatively high number of vascular anomalies in the foot (both traumatic as well as congenital). Abnormalities in the transferred toe can limit the function of the hand, and the best (not worse) tissues available should be transferred. The importance of digit positioning to provide prehensile pinch and grasp as the ultimate goal needs to be emphasized so that opposing fingers rather than cosmetic fingers result in effective hand use. We recommend this operative procedure in selected patients along with other reconstructive alternatives, taking care in the selection process to consider factors related to both asthetic improvement of the hand as well as long-term functional return.
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ranking = 1
keywords = operative
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8/16. Correction and lengthening for deformities of the forearm in multiple cartilaginous exostoses.

    BACKGROUND: Multiple cartilaginous exostoses cause various deformities of the epiphysis. In exostoses of the ulna, the ulna is shortened and the radius acquires varus deformity, which may lead to dislocation of the radial head. In this study, we present the results of exostoses resection, with correction and lengthening with external fixators for functional and cosmetic improvement, and prevention of radial head dislocation. methods: We retrospectively reviewed seven forearms of seven patients who had deformities of the forearm associated with multiple cartilaginous exostoses. One patient had dislocation of the radial head. Operative technique was excision of osteochondromas from the distal ulna, correction of the radius, and ulnar lengthening with external fixation up to 5 mm plus variance. We evaluated radiographs and the range of pronation and supination. Furthermore, we conducted a follow-up of ulnar length after the operation. RESULTS: Dislocation of the radial head of one patient was naturally reduced without any operative intervention. At the most recent follow-up, six of the seven patients showed full improvement in pronation-supination. Ulnar shortening recurred with skeletal growth of four skeletally immature patients; however, it did not recur in one skeletally mature patient. Overlength of 5 mm was negated by the recurrence of ulnar shortening about 1.5 years after the operation. CONCLUSIONS: We treated seven forearms of seven patients by excision of osteochondromas, correction of radii, and gradual lengthening of ulnas with external fixators. The results of the procedure were satisfactory, especially for function of the elbow and wrist. However, we must consider the possible recurrence of ulnar shortening within about 1.5 years during skeletal growth periods in immature patients.
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ranking = 1
keywords = operative
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9/16. Sequential multiple free flap transfers for reconstruction of devastating hand injuries.

    Restoring function to a severely damaged hand can require complex reconstructions using multiple tissue transfers to replace skeletal, soft tissue, and nerve components. We present 2 patients with severe hand trauma treated with serial multiple flap transfers, an operative sequence not previously reported in detail. One patient underwent five flap transfers in three operations, whereas the second patient underwent four flap transfers in two operations. All the flaps survived. Total anesthesia time for these patients was 43.5 and 34.5 hours, respectively. Both patients obtained measurable functional restoration, and suffered no significant perioperative morbidity. These patients illustrate the clinical feasibility of serial multiple microvascular transplantations for complicated reconstructions.
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ranking = 2
keywords = operative
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10/16. Tendon transfers in muscle and tendon loss.

    Tendon transfers in muscle and tendon loss offer some of the most gratifying results to both patient and surgeon. Poor results do occur at times in tendon transfer. When patients whose results were found to be less than expected were studied, the following problems were identified: 1. Acceptance of less than full passive range of motion before transfer. In some instances, this will be unavoidable. The use of pretransfer hand therapy techniques may improve the situation; or, if possible, pretransfer capsulotomies may better prepare the patient for the tendon transfer. 2. Adhesions along the course of the transfer. At times the transfer route can be better prepared by the use of skin grafts adding subcutaneous tissue to the transfer bed. The use of a staged technique in which a silicone rubber tendon implant is installed along the transfer route, to prepare for a later transfer, is occasionally indicated. 3. Technical failures: a. juncture breakdown, b. transfer put in under too little tension. 4. Patient noncompliance. A recent experience in which a patient removed his postoperative cast and came in 2 weeks later with his transfer disrupted is an extreme example. Many other patients are not prepared to undertake what may be a rigorous and time-consuming postoperative transfer program. Adequate preoperative evaluation, including patient selection as well as careful attention to the details of the procedure during surgery, along with attentive postoperative care, should eliminate most of these problems.
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ranking = 4
keywords = operative
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