Hidehiko Kawabata

Early microsurgical reconstruction in birth palsy.

Most patients with birth palsy can be expected to recover spontaneously. But in some patients the recovery is unsatisfactory and the functional results are disappointing. One possible way to improve the prognosis for such patients is early surgical nerve reconstruction. In six infants, exploration of the brachial plexus was carried out at about six months after delivery, when there were no signs of recovery in shoulder and elbow joint movements. Preoperative metrizamide myelography, computerized tomography with intrathecal metrizamide (CT myelography), and axon reflex test (histamine test) were followed by intraoperative electrophysiologic examinations of root sensory evoked potential (SEP), nerve action potential (NAP), and evoked muscle response (M-response). Microsurgical nerve repair was performed on the basis of intraoperative diagnosis. Metrizamide myelography showed 13% false-positive root avulsion. Reliability of the histamine test was 80%. The intraoperative electro-diagnosis is essential for understanding the actual condition of the brachial plexus lesion and obtaining better results from microsurgical reconstruction in birth palsy. The surgical results, with an average follow-up evaluation of two years and four months, have been encouraging enough to continue this diagnostic and therapeutic program, though its superiority to natural recovery has not yet been clarified.

Operations for forearm deformity caused by multiple osteochondromas

We reviewed 36 cases of forearm deformity caused by multiple osteochondromas in 30 patients and classified them into three types: Type I showed a combination of ulnar shortening and bowing of the radius secondary to osteochondromas of the distal ulna (22 forearms). Type II showed dislocation of the radial head, either with osteochondromas of the proximal radius (Type IIa, two forearms) or secondary to more distal involvement (Type IIb, five forearms). Type III had relative radial shortening due to osteochrondromas at the distal radius (seven forearms). Operations were performed on 16 forearms in 13 patients, with 92% of satisfactory results. For Type I deformity, excision of osteochondromas, immediate ulnar lengthening and corrective osteotomy of the radius are recommended. For Type IIa, excision of the radial head is necessary, and for Type IIb, we advise gradual lengthening of the ulna using an external fixator. Excision of osteochondromas alone gave good results in Type III deformity. Our classification gives a reliable indication of the prognosis and is a guide to the choice of surgical treatment.

Nerve repairs for traumatic brachial plexus palsy with root avulsion

Thirty-six patients with traumatic brachial plexus lesions and root avulsions were treated surgically between 1972 and 1986 and were followed for more than 24 months (average, 42.6 months). Neurotization of the musculocutaneous nerve with intercostal nerves or the spinal accessory nerve resulted in satisfactory elbow flexion in 21 of the 33 cases (64%). Combined nerve repairs (i.e., intercostal and spinal accessory neurotization of the terminal branch of the brachial plexus in combination with nerve grafts from the upper spinal nerves of the brachial plexus) created a useful function in at least one functional level of the upper limb for 11 of the 15 cases so treated. Nerve repairs resulted in stability of the shoulder and elbow function controllable with a sensible hand for patients with root avulsion injury of the brachial plexus.

Revision of residual deformities after operations for duplication of the thumb.

We treated thirty-six patients (thirty-eight thumbs) who had residual deformity after ablation of a duplicated thumb. The deformities were classified into three groups: interphalangeal (eight thumbs), metacarpophalangeal (sixteen thumbs), and zigzag (fourteen thumbs). The indication for operation was primarily cosmetic; only eight patients had a functional disability, and that was mild. At the most recent follow-up, the results were rated good except for three fair results in the group that had an interphalangeal deformity, two fair results in the group that had a metacarpophalangeal deformity, and two poor and seven fair results in the group that had a zigzag deformity.

Lengthening of the lower limbs in patients with achondroplasia and hypochondroplasia.

Ten years of experience in lower limb lengthening achieved in 35 patients with achondroplasia and seven patients with hypochondroplasia is reported. A uniform method of callus distraction (callotasis) was used in all cases, although the order of lengthening of each bone differed among the cases. The mean age of the patients at the time of first operation was 14.5 years; at followup, the mean age was 18.8 years. The mean lengthening achieved in the femur was 7.2 cm (range, 4.5–12 cm) and in the tibia 7.1 cm (range, 4.5–13 cm). More lengthening was achieved in the more recent cases. The function of lengthened limbs, evaluated by physical strength tests, was better at followup than before lengthening in the growing children, although the mechanical axes of the lengthened bones were not necessarily in correct alignment.

Osteosynthesis for old, established non-union of the lateral condyle of the humerus.

In thirty elbows that had an established non-union of a fracture of the lateral humeral condyle that had occurred more than five years before, treatment consisted of one of three operations: anterior transposition of the ulnar nerve (nine patients), corrective osteotomy of the humerus and anterior transposition of the ulnar nerve (four patients), or osteosynthesis of the non-union combined with neurolysis and anterior transposition of the ulnar nerve, with or without corrective osteotomy of the humerus (seventeen patients). Of the thirty patients, fifteen had been apprehensive when using the elbow, due to lateral instability, or had had pain in the elbow. In thirteen of these fifteen patients, the non-union was treated by osteosynthesis. Afterward, the pain and apprehension disappeared, but the range of motion of the elbow decreased in all but three patients. Three patients had clicking between the humerus and radius, and the bone failed to unite in three others. Osteosynthesis is indicated for the treatment of non-union of the lateral humeral condyle only if the patient has serious pain in the elbow or apprehension when using the elbow, due to lateral instability.

Genotype phenotype correlation in achondroplasia and hypochondroplasia

Recent studies of the fibroblast growth factor receptor 3 (FGFR3) gene have established that achondroplasia and hypochondroplasia are allelic disorders of different mutations. To determine whether the genotype could be distinguished on the basis of the phenotype, we analysed height, arm span, and skeletal radiographs from 23 patients with achondroplasia and the G380R mutation of FGFR3 and eight with hypochondroplasia and the N540K mutation. Both conditions share the classical pathological features of micromelic short stature, reduced or unchanged interpedicular distances in the lumbar spine, disproportionately long fibulae, and squared and shortened pelvic ilia. These were significantly more severe in the G380R patients than in the N540K patients. Our findings have shown a firm statistical correlation between the genotype and the phenotype, although there were a few exceptional cases in which there was phenotypic overlap between the two conditions.

Congenital clasped thumb: A review of forty-three cases

Over a 10-year period, 43 patients (75 hands) with congenital clasped thumb were seen in our institution. Three groups were identified: group I, 14 patients (24 hands) without contracture; group II, 14 patients (21 hands) with contractures of the palmar side; and group III, 15 patients (30 hands) with arthrogryposis multiplex congenita. Forty-two hands were treated with splinting alone and 16 hands with surgery. The remaining 17 hands were followed conservatively without splinting or surgery. The mean follow-up was 32 months. The results were evaluated by active abduction of the carpometacarpal joint and extension of metacarpophalangeal joint. All patients in group I showed good response to splinting, and the cause of the deformity appeared to be the predominance of the flexor muscles. In groups II and III, 10 patients (16 hands) who had severe deformity or no response to splinting were treated by release of the palmar soft tissues, skin grafts, and reconstruction of the extensors. Satisfactory results were obtained in 12 of 16 hands.

Brachial plexus palsy

Part 1 Brachial plexus injury in adults: anatomy of the brachial plexus historical review of the brachial plexus surgery closed traction injury of the brachial plexus clinical assessment of the brachial plexus lesion nerve surgery of the brachial plexus intercostal nerve transfer pain management of the brachial plexus lesion reconstructive musculoskeletal surgery of the paralyzed limb. Part 2 Brachial plexus birth palsy: perinatal factors natural history treatment - rehabilitation neurosurgery musculoskeletal surgery.

Treatment of preaxial polydactyly of the foot

Fourteen patients with preaxial polydactyly are classified into four types according to their morphologic configuration: type 1--ray duplication; type 2--completely duplicated phalanges; type 3--incompletely duplicated metatarsals; and type 4--incompletely duplicated phalanges. The surgical treatment and timing thereof appropriate for each group are discussed. Three cases of congenital hallux varus deformity are analyzed, focusing on the pathomechanism of this disorder. Based on our experience, two main factors are noticed in the etiology of congenital hallux varus deformity: inadequacy of the adductor hallucis and tightening of the fibrous band pulling the big toe into the varus.