Myles J. Cohen

Vitiligo: Treatment by dermabrasion and epithelial sheet grafting

BACKGROUND Several years ago, a surgical technique for treating depigmentation resulting from burn injuries was developed. The treatment of this problem in the patient with burns was consistently successful. OBJECTIVE The purpose of this study was to investigate the usefulness of the surgical technique developed for patients with burn injuries to determine whether the same technique would be useful in treating patients with vitiligo whose skin did not repigment with conventional medical treatments. METHODS Five patients with stable vitiligo were treated. The epithelium of the vitiliginous areas was removed by dermabrasion. The dermabraded area was then reepithelialized with epithelial sheet grafts sufficient to cover the entirety of the vitiliginous dermabraded region. RESULTS Each operation was successful. Scarring did not develop in the repigmented or donor site regions. The final color match has been good to excellent in all patients. CONCLUSION Good to excellent repigmentation was observed in each patient. We believe our results, to date, are more successful than the results of other procedures reported previously in the medical literature.

Histology and ultrastructure of the human flexor tendon sheath

Twenty human flexor tendons and their sheaths were studied to determine the gross, microscopic, and ultrastructural morphology of their surfaces. Specimens were obtained at the time of autopsy or at the time of reconstructive and reparative surgery. The flexor tendon sheath consists of a noninterrupted layer of parietal synovium reinforced externally at intervals by dense bands of collagen, the annular and cruciform pulleys, and the palmar plates of the respective finger joints. The sheath contents are independently covered by a second similar layer of visceral synovium. These two layers are continuous at the proximal cul-de-sac, the vincula origins, and the tendon insertions. While the synovial cells lining the pulleys and tendons differ quantitatively from those of the membranous portion of the sheath, they are morphologically identical. The presence of a visceral synovial layer covering each tendon may indicate a key role of the synovial cell in tendon healing.

The Use of Acellular Dermal Matrix in Release of Burn Contracture Scars in the Hand

Background: Contracture deformities of the upper extremity are encountered frequently in burn victims. Surgical repair of this problem is challenged by a paucity of soft tissue, poor functional outcome, and a high rate of recurrence. Acellular dermal matrix has become increasingly popular in reconstructive surgery—at times—as an alternative to local and free tissue transfer in different parts of the body. However, its applicability in contracture release, particularly in hand surgery, has not been widely explored. Methods: Nine patients with burn contracture scars involving different locations in the hand and the wrist underwent two-stage reconstruction consisting of contracture release and use of acellular dermal matrix followed by definitive coverage with skin graft at the second stage. Patients were followed up for a period of at least 10 months (range, 10 to 25 months), during which time the passive range of motion of the hand was used as a quantitative measure of surgical outcome. Results: All nine patients retained at least 83 percent of the corrected range of motion involving the affected joints by 1 year and at least 89 percent of correction at each webspace. No patient required a revision procedure. Conclusion: Acellular dermal matrix can be an effective tool in surgical treatment of difficult burn contracture deformity in the hand, with lasting results.

Lateral antebrachial cutaneous nerve injury as a complication of phlebotomy.

The lateral antebrachial cutaneous nerve may be injured by attempts at cephalic vein venipuncture because of its anatomic location under the cephalic vein. Multiple attempts at venipuncture using plunging-type action should be avoided. Electric dysesthesias during venipuncture should alert the phlebotomist to possible nerve damage. Primary repair of the injured nerve or its fascicles may be hindered by tension across the antecubital fossa when the elbow is in extension or by the presence of the biceps tendon. As an alternative surgical solution, the neuroma may be resected and the proximal end buried within the substance of the brachialis muscle.

Candida albicans tenosynovitis of the hand.

Invasive fungal infections of the hand are extremely rare and usually require an immunocompromised host. We report the first known case of Candida albicans tenosynovitis of the hand presenting as a mass in a boy with Buckleys immunodeficiency. Treatment was successful after radical synovectomy of both the flexor and extensor aspects of the hand after he failed to respond to combined amphotericin B and 5-fluorouracil therapy. Fungal tenosynovitis should be considered when swelling and decreased range of motion occur in the hands or digits of an immunocompromised host, especially if pain is not a prominent symptom.

Heritability patterns in hand osteoarthritis: the role of osteophytes.

IntroductionThe objective of the present study was to assess heritability of clinical and radiographic features of hand osteoarthritis (OA) in affected patients and their siblings.MethodsA convenience sample of patients with clinical and radiographic hand OA and their siblings were evaluated by examination and radiography. Radiographs were scored for hand OA features by radiographic atlas. The heritability of hand OA phenotypes was assessed for clinical and radiographic measures based on anatomic locations and radiographic characteristics. Phenotypic data were transformed to reduce non-normality, if necessary. A variance components approach was used to calculate heritability.ResultsOne hundred and thirty-six probands with hand OA and their sibling(s) were enrolled. By anatomic location, the highest heritability was seen with involvement of the first interphalangeal joint (h2 = 0.63, P = 0.00004), the first carpometacarpal joint (h2 = 0.38, P = 0.01), the distal interphalangeal joints (h2 = 0.36, P = 0.02), and the proximal interphalangeal joints (h2 = 0.30, P = 0.03) with osteophytes. The number and severity of joints with osteophyte involvement was heritable overall (h2 = 0.38, P = 0.008 for number and h2 = 0.35, P = 0.01 for severity) and for all interphalangeal joints (h2 = 0.42, P = 0.004 and h2 = 0.33, P = 0.02). The severity of carpometacarpal joint involvement was also heritable (h2 = 0.53, P = 0.0006). Similar results were obtained when the analysis was limited to the Caucasian sample.ConclusionsIn a population with clinical and radiographic hand OA and their siblings, the presence of osteophytes was the most sensitive biomarker for hand OA heritability. Significant heritability was detected for anatomic phenotypes by joint location, severity of joint involvement with osteophytes as well as for overall number and degree of hand OA involvement. These findings are in agreement with the strong genetic predisposition for hand OA reported by others. The results support phenotyping based on severity of osteophytes and a joint-specific approach. More specific phenotypes may hold greater promise in the study of genetics in hand OA.

Preserving the posttrapeziectomy space with a human acellular dermal matrix spacer: a pilot case series of patients with thumb carpometacarpal joint arthritis.

Background: Advanced thumb carpometacarpal arthritis is widely treated with trapeziectomy and tendon interposition despite donor-site morbidities. Trapeziectomy alone leaves a postresection space, leading to proximal metacarpal migration and scaphoid/trapezoid impingement. Prosthetic implants have been unsuccessful due to particulate debris, silicone synovitis, osteolysis, and migration. Recent studies have shown successful use of allograft for interposition material in the posttrapeziectomy space both in animal and human models. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using a spacer constructed from human acellular dermal matrix (HADM). Methods: Sixteen patients with Eaton stage III–IV thumb carpometacarpal osteoarthritis received the above procedure from the 2 senior authors. HADM was imbricated to fill the posttrapeziectomy space and secured to the volar capsule and metacarpal base. Pre- and postoperative trapezial space on radiograph, pain scores, and grip strength were recorded. Results: Six months postoperatively, radiographs showed an average joint space loss of 11%. Heights postoperatively were not significantly different from immediate postoperative heights (P ≥ 0.01). At 6 months, patients had improved pain and grip strength (P ⩽ 0.01). No infections, foreign body reactions, or other complications occurred. Conclusions: HADM has been used extensively in other forms of reconstruction and has been shown to incorporate into surrounding tissues through neovascularization. Our early results illustrate that HADM can safely fill the dead space left by trapeziectomy.

Reconstruction of Ollier disease in a severely involved hand.

Ollier disease is a nonhereditary disorder characterized by multiple enchondromata, with a random asymmetrical distribution. We report an unusual case of massive ulcerating multiple enchondromata of the left hand of an 11-year-old male patient. A methodical approach to treating such a massive tumor burden and steps in reconstructing the hand are described. This case report demonstrates a radical expression of this disease; however, no malignancy was identified despite the aggressive and chronic nature of the disease. Unlike previously reported cases with less severe involvement, this patient did not undergo amputation, and this approach demonstrates a strategy for limb salvage not previously described. In particular, despite bony defects of 6 cm, no autograph was necessary for the reconstruction of the hand.

Successful Arthroplasty Using Cadaveric Meniscus for Osteochondral Defects in the Wrist and Hand Joints

Background: Osteochondral defects of the radiocarpal, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints often necessitate joint arthrodesis or mechanical arthroplasty, which has a limited lifespan. In severely arthritic wrist and finger joints, we propose a novel adjunct for joint salvage using cadaveric meniscus for joint resurfacing as an off-the-shelf alternative to address osteochondral defects and restore normal intraarticular contact stress. Methods: A total of 14 patients with osteochondral defects in 5 radiocapitate, 5 MCP, 3 PIP, and 1 carpometacarpal joints received cadaveric meniscus to facilitate arthroplasty. Patient demographic, perioperative pain, range of motion, and complications were examined. Results: Patients aged 17 to 73 years old (average, 54.6 years old) underwent joint reconstruction for scaphoid nonunion (n = 1), scaphoid-lunate advanced collapse (n = 4), or osteoarthritis of MCP/carpometacarpal (n = 6) or PIP (n = 3) joints. Successful arthroplasty with joint space preservation occurred in all joints. Patients had a significant reduction in average pain scale score (P < 0.01) and improved average range of active motion degrees of flexion (P < 0.01) and degrees of extension (P < 0.05). No complications resulted; only a revision tenolysis and capsulotomy were required for PIP and MCP arthroplasties. Postoperative films reveal preservation of arthroplasty joint space after an average 19.7-month follow-up (range, 8–54). Conclusions: We believe that meniscus is a viable joint salvage option or adjunct to preserve pain-free motion and avoid total joint arthrodesis. In this series of 14 patients, we demonstrate the successful use of cadaver meniscus in hand joint arthroplasty, such that it advantageously maintains a low metabolic demand, is biointegratable, and is surgically malleable.