Flexion Contracture Research Articles

BONE RECONSTRUCTION IN THE TREATMENT OF TIBIAL HEMIMELIA: AN ALTERNATIVE TO AMPUTATION?

To evaluate the advantages and disadvantages of bone reconstruction and lengthening compared to amputation in the treatment of tibial hemimelia for patients and their families. Systematic review of articles published in English and Portuguese between 1982 and 2022 in the MEDLINE, PubMed, Cochrane and SciELO databases. The variables of interest were: year of publication, sample characteristics, classification of tibial hemimelia according to Jones, treatment outcome and follow-up time. A total of eleven articles were included in the scope of this review. The studies involved 131 patients, 53.4% male and 46.6% female. The age of the patients who underwent a surgical procedure ranged from 1 year and 10 months to 15 years. The most common type was Jones' I (40.9%). The most recurrent complications in the reconstruction treatment were: infection of the external fixator path, flexion contracture (mainly of the knee), reduction in the range of motion of the knee and ankle. We did not find enough relevant studies in the literature to prove the superiority of reconstruction. Amputation remains the gold standard treatment for tibial hemimelia to this day. Level of Evidence III, systematic review of level III studies.

Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: A two-year follow-up prospective bi-center study.

This prospective bi-center study aimed to analyze the outcomes of primary total knee arthroplasty using the Stemmable Tibia Attune system. A total of 100 patients who underwent primary total knee arthroplasty with Stemmable Tibia from January 2019 to December 2021 were enrolled in the study. Radiological outcomes (hip-knee-ankle axis and medial proximal tibial angle) were assessed preoperatively and postoperatively. Clinical outcomes (visual analog scale score, Hospital for Special Surgery score, Knee Society function score, Knee Society knee score, flexion contracture, further flexion, and range of motion) were analyzed preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Complications (periprosthetic joint infection and aseptic loosening) were examined. The hip-knee-ankle axis decreased (preoperative: 9.5° ± 6.3°, postoperative: 1.1° ± 2.7°), whereas the medial proximal tibial angle increased (preoperative: 84.6° ± 4.1°, postoperative: 89.8° ± 1.9°). The visual analog scale score, Hospital for Special Surgery score, Knee Society knee score, and Knee Society function score increased postoperatively. The Knee Society knee score indicated above good outcomes (100.0% and 99.0% at 1 and 2 years postoperatively, respectively). The Knee Society function score also showed above good results (98.0% and 93.0% at 1 and 2 years postoperatively, respectively). The range of motion significantly improved (p < 0.001): flexion contracture decreased from 9.10° ± 7.23° to 2.15° ± 2.87°, whereas further flexion increased from 136.05° ± 14.78° to 139.80° ± 10.02°. One patient developed periprosthetic joint infection; no early loosening was observed. In conclusion, Attune primary total knee arthroplasty with Stemmable Tibia not only is safe and effective but also leads to radiological and clinical improvements.

Subtotal palmar fasciectomy with skin Z-plasty results in Dupuytren’s disease : Minimum one year follow-up

Backround Dupuytren's disease is a condition that leads to progressive contractures in the hand, significantly impacting the quality of life. These rigid deformities impair hand functions and have adverse effects on daily life. Various surgical treatment options are available. In this study, our goal is to report the results of patients for whom we performed subtotal palmar fasciectomy and skin Z-plasty. Method A retrospective analysis was conducted on 16 patients who underwent subtotal palmar fasciotomy. The range of motion before and after the operation, along with patient-reported outcome scores using the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QDASH), were compared. Additionally, the time return to work time and any complications were documented. Results The mean preoperative MCP joint flexion contracture degree was 42.8 (range: 30-70 degrees), while the postoperative mean was 2 (range: 0-30 degrees). Similarly, the mean preoperative PIP joint flexion contracture degree was 41 (range: 20-90 degrees), and the postoperative mean was 8 (range: 0-30 degrees). The mean preoperative QDASH score decreased from 44 (range: 32.5-50) to 9.6 postoperatively (range: 7.5-12.5). The average return-to-work time was 42 days. Conclusion Subtotal palmar fasciotomy stands as a surgical alternative with high patient satisfaction in treating Dupuytren's disease. The application of Z-plasty during closure helps to reduce postoperative wound problems by alleviating tension.

Prevalence and Characteristics by Age and Sex in Pediatric Trigger Digits: Nationwide Analysis Using Korea Health Insurance Dataset.

Pediatric trigger digit (TD) does not appear at birth but is diagnosed after birth by finding a flexion contracture of the thumb or other fingers. The reported incidence of pediatric TDs varies from 0.5 to 5 cases per 1,000 live births without sex-specific predominance. We performed a nationwide large-scale study to determine the prevalence and incidence of pediatric TDs and analyzed operative treatment for pediatric TDs using the National Health Insurance data of South Korea. Patients with pediatric TDs, aged 0-10 years between 2011 and 2020, were included in this study. Children born between 2011 and 2015 were set as the reference population and followed up until 2020. We calculated the prevalence and incidence rates of pediatric TDs according to age and sex and analyzed the operation rate, age at surgery, time interval from initial diagnosis to surgery, and follow-up period. Patient selection and treatment were based on International Classification of Diseases, 10th Revision (ICD-10). The prevalence rates of pediatric TDs ranged from 0.063% to 0.084%. Girls had a higher prevalence rate (0.066%-0.094%) than boys (0.060%-0.075%). The total incidence rate was 77.6/100,000 person-years, and the incidence rate was higher in girls (84.8) than in boys (70.7). Among 2,181,814 children born between 2011 and 2015, 12,729 were diagnosed with pediatric TDs, of which 1,128 (8.9%) underwent operative management. The means of age at initial diagnosis, age at surgery, and the time interval between diagnosis and operation were 2.76 ± 1.91 years, 3.79 ± 2.19 years, and 1.15 ± 1.71 years, respectively. High prevalence and incidence rates of pediatric TDs were found in 2- to 3-year-old patients. Among pediatric patients, 8.9% underwent operative management that was most frequently conducted between 2 and 3 years of age (within 1 year of initial diagnosis).

Neurovascular Heterodigital Island Flap for Digital Pulp Defect Reconstruction: 58 Case Series

Aim: Our study aims to report the neurovascular heterodigital island flap reconstruction for finger pulp defects. Patients and Methods: This study included 58 patients presenting to our clinic with pulp defects between 2014 and 2022. The average age of the patients was 26 years (20 - 56 years). Injuries were Allen type 2 for 18 patients, type 3 for 33 patients, and type 4 for 7 patients. Pulp defects were caused by crush injury (n:42) and sharps injury (n:16). Results: None of the flaps administered to the participating patients developed any total loss. Three patients developed partial loss in the distal flap. Six patients were found to have superficial tissue infection. Two patients were found to have hyperpigmentation and hyperesthesia. While one patient with Allen type 3 pulp defect was detected to have 10 degrees of flexion contracture in the distal interphalangeal (DIP) joint and 5 degrees of flexion contracture in the proximal interphalangeal joint, three patients were found to have 5 degrees of flexion contracture only in the DIP joint. The mean static two-point discrimination of the pulp-administered flap was 5.2 mm (3-8 mm) and on the contralateral side was 3 mm. The mean Semmes-Weinstein monofilament test was 3.18 g (2.96 – 4.7 g) in the pulp administered flap and 2.92 g in the contralateral side. Conclusions: Reconstruction of pulp defects with neurovascular heterodigital island flap is a reliable treatment option with satisfactory functional and sensory outcomes.

Phenotypic variability in children with Bruck syndrome type 2: Clinical cases

BACKGROUND: Bruck syndrome is a rare disorder that features osteogenesis imperfecta, combined with severe congenital joint contractures often with pterygia, short stature, severe limb deformities, and progressive scoliosis. Its two forms, Bruck syndrome types 1 and 2, have similar clinical manifestations without osomal recessive inheritance and are caused by pathogenic variants of the nucleotide sequences in the FKBP10 and PLOD2 genes, respectively.&#x0D; CLINICAL CASES: The article demonstrates phenotypic and radiographic features as well as laboratory values of siblings with Bruck syndrome type 2 (a 10-year-old boy and a 13-year-old girl) born to healthy parents in a consanguineous marriage. The boy had congenital flexion contractures of the knee and elbow joints, few fractures, and severe kyphoscoliosis. The girl had no congenital joint contractures but had kyphoscoliosis, more severe osteoporosis, and a history of having more fractures than her younger brother.&#x0D; DISCUSSION: The cases demonstrated the significant phenotypic intrafamilial variability of Bruck syndrome type 2, caused by a newly identified homozygous variant c.1885AG (p.Thr629Ala) in PLOD2, which consists of varying degrees of osteoporosis, and the presence and severity of contractures.&#x0D; CONCLUSIONS: The description of the given clinical observation was made to draw attention to a rare pathology and expand doctors’ knowledge about the variability of clinical manifestations of Bruck syndrome. Genetic diagnostics is necessary for the timely diagnosis of Bruck syndrome, determining the prognosis and developing patient management techniques.

Association of Knee Osteoarthritis and Flexion Contracture With Localized Tibial Articular Cartilage Loss: Data From the Osteoarthritis Initiative.

To evaluate whether a knee flexion contracture (FC) was associated with localized tibial articular cartilage loss over a 1-year period using Osteoarthritis Initiative quantitative data. Five hundred seventy-eight participants from a previously established nested case-control study of people with radiographic knee OA with or without progression, based on radiographs and symptoms, had their knee range of extension measured at baseline and received magnetic resonance imaging (MRI) at baseline and 1 year. The tibial articular cartilage of the medial and lateral condyles was segmented into anterior, center, and posterior regions. We tested for associations between knee FC (defined as lack of extension to 0°), and localized changes in tibial articular cartilage thickness or percent of denuded bone (0 mm thickness) after 1 year relative to baseline using ANOVA, controlling for baseline MRI outcomes and clinical factors. Knee FC was associated with denuded bone in the medial condyle center (β 0.44, 95% CI 0.02-0.86) and preserved cartilage thickness in the medial condyle posterior (β 0.01, 95% CI 0.002-0.03) regions. Knee FC unloading the tibial center region and loading the posterior region was associated with localized articular cartilage loss centrally and preserved articular cartilage posteriorly. These findings are consistent with knee FC negatively affecting unloaded tibial articular cartilage.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies.

To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level III, Systematic review of level III studies.

Surgical Treatment for Patients with Post-traumatic Flexion Contracture of Proximal Interphalangeal Joint: Analysis of Various Affecting Factors.

Background: A flexion contracture (FC) of the proximal interphalangeal (PIP) joint can have a profound negative influence on daily activity. The outcomes of surgical release of the PIP joint in literature are based on small sample size studies done several decades ago. The aim of this study is to report the outcomes of surgical treatment for post-traumatic FC of the PIP joint and to identify factors that affect these outcomes. Methods: This single institute retrospective study included patients from 2000 to 2020. We only included patients with post-traumatic FC of the PIP joint. We evaluated the demographic characteristics, cause of FC, surgical approaches and the various procedures conducted. We surveyed postoperative complications. During the study period, we asked about their current symptoms and evaluated their operative outcomes as excellent, good, fair or poor through the phone. Results: The average FC recovery angle was 37.3°. The small finger was the most affected, and the most common cause of FC was a tendon laceration. The volar plate complex release was the most frequently conducted procedure. The FC improvement was positively correlated to the degree of preoperative FC. The more severe preoperative flexion-extension arc was presented, the more FC recovery was achieved after operation. Patients who underwent multiple procedures had a higher degree of preoperative FC, and better correction was achieved with multiple procedures than with a single procedure. The most critical complication was recurrence. Conclusions: We were able to obtain average 37.3° of extension by surgical treatment. The more severe the FC presented before surgery, the greater the need for multiple procedures, however, this resulted in a significant increase in joint extension. Nevertheless, caution should be exercised regarding recurrence and could occur even with an experienced surgeon. Level of Evidence: Level IV (Therapeutic).

Knee Flexion While Walking Exceeds Knee Flexion Contracture in Children with Spastic Cerebral Palsy.

Flexed knee gait is commonly related to contractures in children with cerebral palsy (CP). Therefore, knee position while walking was compared with passive knee extension and explored with respect to functional mobility. Gait was assessed with 3D motion analysis in 30 children with bilateral spastic CP, Gross Motor Function Classification System (GMFCS) levels I-III, and in 22 typically developing (TD) children. Knee angle at initial contact (KneeAngleIC) was greater than knee flexion in stance (MinKneeFlexSt) in all groups. MinKneeFlexSt exceeded knee contractures at GMFCS levels II and III. Both KneeAngleIC and MinKneeFlexSt were greater at GMFCS II and III than at GMFCS I and the TD group. The excessive knee flexion while walking at GMFCS II and III could not be explained by knee joint contractures. Functional mobility measured with the timed-up-and-go test took longer in children at GMFCS level III compared to the other groups, assumed to be explained by the energy-requiring flexed knee gait and spatial insecurity. Discriminating between passive knee extension at the physical assessment and maximum knee extension while weight bearing may contribute to further understanding of flexed knee gait and its causes in ambulating children with spastic bilateral CP.

Clinical and operative risk factors for complications after Apert hand syndactyly reconstruction.

III.

C-X-C domain ligand 14-mediated stromal cell–macrophage interaction as a therapeutic target for hand dermal fibrosis

Dupuytren’s contracture, a superficial dermal fibrosis, causes flexion contracture of the affected finger, impairing hand function. Specific single-nucleotide polymorphisms within genes in the Wnt signalling pathway are associated with the disease. However, the precise role of Wnt signalling dysregulation in the onset and progression of Dupuytren’s contracture remains unclear. Here, using a fibrosis mouse model and clinical samples of human Dupuytren’s contractures, we demonstrate that the activation of Wnt/β-catenin signalling in Tppp3-positive cells in the dermis of the paw is associated with the development of fibrosis. Fibrosis development and progression via Wnt/β-catenin signalling are closely related to stromal cell–macrophage interactions, and Wnt/β-catenin signalling activation in Tppp3-positive stromal cells causes M2 macrophage infiltration via chemokine Cxcl14, resulting in the formation of a TGF-β-expressing fibrotic niche. Inhibition of Cxcl14 mitigates fibrosis by decreasing macrophage infiltration. These findings suggest that Cxcl14-mediated stromal cell–macrophage interaction is a promising therapeutic target for Wnt/β-catenin-induced fibrosis.

A Femoral Neck Osteotomy for the Patients with Ankylosing Spondylitis and Thoracolumbar Kyphosis Combined with Hip Flexion Contracture.

The surgical treatment of patients with ankylosing spondylitis and severe thoracolumbar kyphosis combined with hip flexion contracture is very difficult for all the surgeons. The femoral neck osteotomy (FNO) is the first step to break the ice. The evaluation of a new modified FNO method is very important to improve the curative effect. Five male patients with nine bone-fused hips who underwent the new femoral neck osteotomy were included from October 2021 to March 2022. The FNO was designed that the saw blade was manipulated from the lateral femoral neck base to the inferior part of the femoral head, keeping Pauwels' angle less than 30° on the coronal plane. On the transverse plane, the angle between the saw blade and the coronal plane was more than 15°. On the sagittal plane, the saw blade cut through the femoral neck. They accepted pedicle subtraction osteotomy (PSO) after FNO according to the patient' recovery. Then, 2 weeks later, the patients underwent total hip arthroplasty (THA). The visual analogue scale (VAS), Harris hip score (HHS) and passive hip flexion-extension range of motion (ROM) were used to evaluate hip function. The data were analyzed by paired t-test. The average operation time and blood loss of FNO, the average interval between FNO and THA were collected. The average angle of the trunk and lower limb (ATL) was 36.33° ± 16.36° pre-FNO, 82.89° ± 13.51° post-FNO and 175.22° ± 3.42° post-THA. The average VAS scores were 0 pre-FNO, 5 ± 1.58 post-FNO and 2.6 ± 0.55 post-THA. The average HHS was 43.56 ± 1.59 preoperatively and 83.89 ± 2.21 postoperatively. The average hip extension ROM was 23.89° ± 12.69° pre-FNO, -22.67° ± 14.18° post-FNO and - 3.33° ± 2.50 post-THA°. The average hip flexion ROM was 23.89° ± 12.69° pre-FNO, 35.56° ± 12.11° post-FNO and 104.44° ± 5.27° post-THA. The differences among them were significant (p < 0.05). Only one hip (11.11%) displaced completely after FNO. A new modified FNO was developed, which can provide osteotomy with a certain degree of stability and greater ease for performing PSO and THA.

Assessing knee joint biomechanics and trunk posture according to medial osteoarthritis severity

During progression of knee osteoarthritis (OA), gait biomechanics changes three-dimensionally; however, its characteristics and trunk posture according to OA severity remain unknown. The present study investigated three-dimensional knee joint biomechanics and trunk posture according to knee OA severity. Overall, 75 patients (93 knees) with medial knee OA [Kellgren-Lawrence grade ≥ 2, grade 2: 20 patients with 24 knees (mean 60.0 years old); grade 3: 25 with 28 knees (mean 62.0 years old); grade 4: 30 with 41 knees (mean 67.9 years old)] and 14 healthy controls (23 knees, mean 63.6 years old) underwent gait analysis using an optical motion capture system and point cluster technique. In grade 2 knee OA, the relative contribution of the knee adduction moment (KAM) increased significantly (P < 0.05), and that of the knee flexion moment decreased (P < 0.05) prior to significant progression of varus knee deformity. Grade 3 knee OA showed significant exacerbation of varus knee deformity (P < 0.01) and KAM increase (P < 0.001). The maximum knee extension angle decreased (P < 0.05) and trunk flexion increased during gait in grade 4 knee OA (P < 0.001). Our study clarified the kinematics and kinetics of medial knee OA with trunk flexion according to severity. Kinetic conversion occurred in grade 2 knees prior to progression of varus deformities, knee flexion contractures, and sagittal imbalance during gait in patients with severe knee OA.

Digital skin defect management: Hand and wrist volar flap solutions

BackgroundSelecting the optimal flap for managing digit skin defects is challenging, particularly for inexperienced surgeons, given the numerous reconstructive options and insufficient evidence supporting one flap type's superiority over another. This retrospective study introduces four efficacious hand flaps to address volar skin defects and transverse and oblique cuts, examines the optimal flap advancement distance, and discusses effective management. MethodsPatients with digit skin defects who underwent flap surgery between 2009 and 2022 were included. Fifty-four patients treated with oblique triangular, volar VY advancement (unilateral and bilateral pedicled volar VY advancement flaps for fingers and thumbs, respectively), reverse homodigital island, and radial artery superficial palmar branch flaps were included. We evaluated the flap advancement distance, flap length, range of motion, complications, and Semmes–Weinstein monofilament test and Disabilities of the Arm, Shoulder, and Hand questionnaire results. ResultsThe median flap advancement distances for triangular oblique (19 patients), unilateral (11 patients), and bilateral pedicled (5 patients) volar VY advancement flaps were 1.3, 1.8, and 2.0 cm, respectively. The flap lengths for the reverse digital island (8 patients) and radial artery superficial palmar branch (11 patients) flaps were 2.4 and 5.0 cm, respectively. Five, three, and one cases of proximal interphalangeal flexion contractures of ≥ -20° were observed in the VY advancement, reverse digital island, and radial artery superficial palmar branch flaps, respectively. One unilateral VY advancement flap case caused severe numbness and neuroma. All complication cases featured >15 and > 20 mm defect lengths on the fingers and thumb, respectively. ConclusionsTo minimize sensory disruption and contractures, we recommend oblique triangular and unilateral pedicle volar VY advancement flaps for finger skin defects up to 12 mm and defects sized 12–15 mm, respectively. Advancement flaps are unsuitable for >15 and > 20–25 mm defects on the fingers and thumb, respectively.

Achieving Correct Balance in Total Knee Arthroplasty with Fixed Varus Deformity.

Varus knee deformity is one of the most common deformities presenting for total knee arthroplasty (TKA). When present, a varus knee deformity contributes to overload of the medial joint compartment during gait, leading to increased medial compartment forces as well as lateral soft tissue lengthening. Additionally, a fixed varus deformity is associated with medial soft tissue contractures of the deep and superficial medial collateral ligament (MCL) and posteromedial capsule. With a fixed varus deformity, soft tissue releases may be necessary to create equivalent and rectangular flexion and extension gaps. There may also be anteromedial tibial bone defects, medial femoral condyle defects, and occasionally flexion contractures, especially in more severe cases. In cases of severe varus deformity with medial tibial bone loss, bone defects must be addressed to ensure adequate implant support. In many cases, a primary knee implant can be utilized in cases of varus knee deformity, but occasionally prostheses with higher levels of constraint may be required to balance and stabilize the knee. TKA has had a successful track record, with high levels of long-term implant survivorship even in cases of severe varus. Iatrogenic MCL instability and tibial aseptic loosening are complications associated with TKA in cases of severe varus, and multiple methods to avoid complications are presented here.

Effect of Translatoric Joint Mobilization on Knee Joint Range of Motion in Spastic Diplegic Children– A Clinical Trial

Background Cerebral palsy ( CP) is a non progressive but often changing, motor impairements due lesions of the Central Nervous System (CNS). Knee flexion contractures are a common secondary complication experienced by spastic children. The purpose of this study was to examine the effects of Translatoric Joint Mobilization (TJM) program to address bilateral knee flexion contractures in diplegic Cerebral Palsy (CP) children. The use of translatoric joint mobilization along with other common Physical Therapy (PT) interventions in this population remains controversial. Objectives 1. To establish the effectiveness of Kaltenborn’s Translatoric Joint Mobilization in improving knee joint range of motion in spastic diplegia and 2. To see improvement in functional mobility as measured by GMFM (88) scoring. Methodology Examination of function and impairment of 30 children with spastic diplegia included Popliteal Angle, Gross Motor Function Measure (GMFM)1 total score and dimension D and E of GMFM. Physiotherapy intervention consisted of Kaltenborn’s Translatoric knee joint mobilization and NDT for group A (experimental), and for group B (control) only NDT. The treatment was given for 6 days a week for 3 weeks. Results After 3 weeks of mobilization, there was significant improvement in popliteal angle and GMFM scoring seen in group A as compared to group B. Conclusion Translatoric joint mobilization proved to be a safe and effective addition to standard PT interventions for knee flexion contractures for the children in this study. The functional impact of improved knee extension was seen as an improvement in GMFM scores.

Full-thickness Skin Grafts for Hand Contractures in an Adult Patient with Junctional Epidermolysis Bullosa: A Case Report

Epidermolysis bullosa is a group of inherited skin fragility disorders with blister formation in the basement membrane zone. Chronic scarring after repeated blistering of the hands causes narrowing of the first web, flexion contractures of the digits, and pseudosyndactyly. Junctional epidermolysis bullosa is a type of epidermolysis bullosa that is characterized by blister formation in the lamina lucida. This condition is associated with survival into adulthood. In adult survivors, hand function might be required in order to participate in normal social activities. However, there is a lack of literature on the management of hand surgery for adult patients with junctional epidermolysis bullosa. We herein describe an adult patient with junctional epidermolysis bullosa who had pseudosyndactyly and flexion contractures in both hands. Five surgeries were performed. Contractures were released and reconstructed using split- or full-thickness skin grafts. Delayed wound healing was always observed due to epidermal necrosis in the graft. After epithelialization, a satisfactory functional outcome was obtained.

Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up

BackgroundSevere idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA. MethodsA retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes. ResultsMedian flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications. ConclusionsPatients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.

Outcomes of antegrade homodigital neurovascular island flap in fingertip amputations

BackgroundAntegrade homodigital neurovascular island flap (AHIF) is one of the methods used in fingertip amputations to cover the defect area, preserve finger length and obtain a painless and sensitive fingertip. The aim of this study was to evaluate the functional and sensory outcomes in patients who underwent AHIF for fingertip amputation and to analyze the relationship between patient satisfaction and outcome measures. MethodsTwenty patients with a mean age of 37 (18–63) years were analyzed retrospectively. The patients were evaluated in terms of hook nail development, active interphalangeal joint movements, cold intolerance, and sensory function of the flap covered area. Static two-point discrimination test and Semmes Weinstein monofilament test were performed for sensory evaluation. ResultsAll flaps survived completely at the end of follow-up (mean, 36 months; range 11–64 months). Five patients had cold intolerance and two had hook nails. In total, proximal interphalangeal or distal interphalangeal joint flexion contracture developed in 25 % of the patients. The mean static two-point discrimination score was 4.6 ± 1.6 (2–8) and Semmes–Weinstein monofilament test score was 3.48 ± 0.6 (2.44–4.17). Subjective satisfaction levels of the patients were found to be high and did not show a statistical relationship with the measured clinical outcome parameters (p > 0.05). ConclusionsSince AHIF contains a solid and continuous neurovascular pedicle, the probability of necrosis and loss of sensation is low in AHIF. In addition, the graft need of the donor area is not high. Its disadvantage is the rate of restriction of joint movements. Level of evidenceIV.