Yoshiyasu Itoh

Transfer of latissimus dorsi to replace a paralysed anterior deltoid. A new technique using an inverted pedicled graft

A new method of replacement for the paralysed anterior deltoid is described. The latissimus dorsi with its neurovascular pedicle is freed and rotated, and then placed over the anterior part of the paralysed muscle. The lever arm of the transposed muscle is as long as that of the deltoid, and the muscle volume is enough to restore the natural contour of the shoulder. We report operations on 10 patients with shoulder palsy, eight caused by brachial plexus injury and two by resection of a neurilemmoma of the plexus. In six cases, active flexion to over 90 degrees was achieved. At least one of the rotator cuff muscles or the long head of biceps should have some active function if good results are to be obtained.

Extensor tendon involvement in Smith's and Galeazzi's fractures

Extensor tendon involvement in three Smiths and two Galeazzis fractures are reported. In two cases of previous Smiths fracture, the extensor indicis proprius tendon had been entrapped and ruptured in one case, and in the other the extensor digitorum communis tendon of the index was pierced by the fragment. Both showed a severe tenodesis effect on the index finger and thumb. In a new case of Smiths fracture, long extensor tendons of the fingers and thumb had been trapped beneath a dorsally displaced third fragment making closed reduction impossible. In the two cases of Galeazzis fracture; in one the extensor carpi ulnaris tendon was trapped between the dorsally displaced ulnar head and the avulsed styloid process and in the other, the extensor digiti minimi tendon was caught beneath the radial border of the dorsally dislocated ulnar head.

Classification of Olecranon Stress Fractures in Baseball Players

Background: Although the onset mechanism of an olecranon stress fracture (OSF) due to a throwing disorder is believed to involve valgus extension overload, olecranon posteromedial impingement, or triceps traction force, this issue is still debated in the literature. Purpose: To establish a classification system for the different types of OSFs to improve diagnosis and clarify the onset mechanism. Study Design: Case series; Level of evidence, 4. Methods: A total of 200 baseball players (198 male, 2 female; mean age, 16.1 years; age range, 13-27 years) who were diagnosed with an OSF from January 1987 to July 2012 were studied. Combined disorders as well as the direction and form of the fracture line were analyzed on plain radiographs, computed tomography, and magnetic resonance imaging. Furthermore, the presence or absence of ulnar collateral ligament (UCL) injuries and avulsion fractures of the lower pole of the medial epicondyle was determined by imaging findings to calculate the combined percentage of OSFs. In addition, the prevalence of OSFs was evaluated among patients who were evaluated between April 2008 and March 2011 for throwing elbow disorders. Results: There were 5 types of OSFs identified in the new classification system: physeal, classic, transitional, sclerotic, and distal. The physeal type was further separated into stages 1 to 4 based on severity. The mean age for each type identified was as follows: physeal, 14.1 years; classic, 18.6 years; transitional, 16.9 years; sclerotic, 18.0 years; and distal, 19.6 years. A concomitant UCL injury and/or medial epicondyle avulsion fracture was diagnosed in 71% to 95% of cases, depending on the OSF type. Among baseball-related elbow disorders, the incidence of OSFs was 5.4%. Conclusion: This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane. This new system was strongly influenced by the age at symptom onset. Such information is essential for successful open reduction and internal fixation by ensuring that fixation pressure is perpendicular to the fracture plane, which will avoid the recurrence of stress fractures. In addition, the prevalence of UCL injuries suggests that it is a major risk factor for the development of OSFs.

Circulatory disturbances in the throwing hand of baseball pitchers

Three cases of circulatory disturbance with ulcer for mation in the pitching hand of baseball pitchers are reported. The pathophysiology was of an entirely new entity. In one case, the neurovascular bundles of the middle finger were entrapped by the proximal edges of Clelands ligaments. In the other two cases, the blood vessels to the index and middle fingers were com pressed within the lumbrical canal. Hypertrophy of the lumbrical muscles and/or thickening of the palmar apo neurosis were responsible for the compression of the vessels. Surgical release of Clelands ligaments or pal mar aponeurosis, including superficial transverse fiber and vertical septa, resulted in good recovery of the circulation of the involved fingers. All of the pitchers returned to professional or college league baseball with out recurrence of the ulcer.

Treatment of pseudoarthrosis of the distal phalanx with the palmar midline approach

Six patients with pseudoarthrosis of the waist of the distal phalanx were operated on with the palmar midline approach. Of these, four patients had sustained injuries of the crush type. The period between the initial injury and this surgery ranged from 2 to 10 months, averaging 4.2 months. With a midline straight incision on the pulp, bone grafting was followed by cross-pinning with Kirschner wires. All six cases obtained bony union within 6 to 11 weeks postoperatively. The operative scar was scarcely detectable and caused no problem.

Dorsal dislocation of the D.I.P. joint with fracture of the volar base of the distal phalanx.

Between 1978 and 1985, we treated 12 cases of dorsally displaced fracture-dislocation of the I.P. joint of the thumb or of the D.I.P. joint of the finger, with a volar bony fragment. All were treated surgically, active exercise being started three to five weeks later. At the last follow-up, averaging 6.4 years (range 4.3-10 years) after operation, none of the joints was painful but the range of motion was somewhat limited.

CUBITAL TUNNEL RECONSTRUCTION FOR ULNAR NEUROPATHY IN OSTEOARTHRITIC ELBOWS

We operated on 16 patients for ulnar neuropathy associated with osteoarthritis of the elbow. They were all male manual workers, with an average age of 51 years at the time of surgery. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in nine and grade 3 in two. The mean follow-up was 36 months. The operation consists of resecting the osteophytes around the postcondylar groove. The shallow and narrow cubital tunnel is made deep and wide and the ulnar nerve is replaced with its surrounding soft tissues in the enlarged groove. All patients were relieved of discomfort and all showed some improvement or full recovery of motor and sensory function. The ulnar nerve showed no evidence of irritation or adhesion. This procedure also allows early movement of the elbow after operation, because the subcutaneous tissues and muscles have not been detached.

Operation des dislozierten knöchernen Strecksehnenausrisses an den Langfingern

ZusammenfassungOperationszielGeschlossene Reposition des dislozierten knöchernen Strecksehnenabrisses aus dem Fingerendglied und Fixation mit zwei Kirschner-Drähten ohne Perforation des abgerissenen Fragmentes. Wiederherstellung der Form und Funktion des Fingers.IndikationenKnöcherner, dislozierter Strecksehnenabriß aus einem Langfingerendglied mit großem Knochenfragment und Streckdefizit.Knöcherner Strecksehnenabriß mit palmarer Subluxation des Endgliedes.KontraindikationenBegleitende Sehnenruptur oder multiple kleine Fragmente.Relative Kontraindikation: Fraktur älter als fünf Wochen.Absolute Kontraindikation: Fraktur älter als acht Wochen.OperationstechnikFinger- oder Mittelhand-Leitungsanästhesie. Forcierte Flexion des distalen Interphalan-gealgelenkes zur Reposition des dorsalen Fragmentes. Blockieren des Fragmentes in reponierter Position mit einem Kirschner-Draht. Extension des distalen Fragmentes zur endgültigen Reposition und Retention mit einem zweiten Kirschner-Draht zur temporären Arthrodese. Der zweite Draht wird in leichter Beugung des Endgelenkes schräg transartikulär eingebracht. Bei älteren Frakturen wird die Frakturfläche durch Kratzen mit einer transkutan eingebrachten Injektionsnadel angefrischt.Ergebnisse90 Finger wurden in der beschriebenen Technik operiert (Patientenalter zwischen zwölf und 84 Jahren). Bei 24 Patienten wurde eine palmare Subluxation beobachtet. 87 Finger wurden bis fünf Wochen nach Verletzung, drei Finger sechs bis acht Wochen nach Verletzung operiert. Das Nachuntersuchungsintervall betrug zwischen sechs Wochen und 36 Monaten. Alle Frakturen heilten innerhalb vier bis sechs Wochen knöchern aus. Erneute Dislokationen traten nicht auf. Zum Zeitpunkt der Nachuntersuchung betrug das Bewegungsausmaß im distalen Interphalangealgelenk 65°. Sieben Finger zeigten ein Extensionsdefizit von 10°. Sekundäre Arthrose wurde bisher an drei Fingern beobachtet.

Surgical Management of Eosinophilic Fasciitis of the Upper Extremity

Eosinophilic fasciitis is a rare inflammatory disease associated with peripheral eosinophilia, hyper-gammaglobulinaemia and contractures of any joint in the upper extremity. Although conservative treatments are generally advocated, this study reports the results of surgical intervention. Four patients aged from 20 to 48 years underwent fasciectomy followed by oral administration of prednisolone. All presented with contractures of digits, wrist, or elbow due to eosinophilic fasciitis in the upper extremities. Despite one case that required a second operation for recurrence, all patients regained the range of motion of the affected joints a few weeks after surgery. The recovery was much sooner than in previously reported cases treated conservatively, suggesting that surgical management of eosinophilic fasciitis is effective in alleviating symptoms quickly and allows patients to resume activities of daily living sooner.

Advancement of the insertion of the biceps brachii muscle: A technique for increasing elbow flexion force

A new technique for increasing weak flexion force of the elbow in patients with brachial plexus injuries is reported. The concept of this procedure is to increase the moment arm of the biceps brachii muscle by moving the point of action distally. Advancement of the insertion of the biceps brachii muscle was performed with an anterior approach to the radius. The biceps tendon was stripped off the radius at its insertion. A hole was dug into the radius 2 cm distal to the original insertion. The biceps tendon was then reattached to the drill holes made in the distal edge of the initial hole with the elbow in 30 degrees of flexion. After immobilization in 70 degrees of flexion for 5 weeks, range-of-motion exercises were initiated. This procedure was applied in six cases of brachial plexus injury. Flexion force at the elbow was increased, and the initial motion of elbow flexion has become very smooth in all patients. Consequently the activities of daily living are easier to perform. This procedure is simple and involves no functional or tissue sacrifice.