Hypothenar Research Articles

Palmar Musculature: Does It Affect the Development of Carpal Tunnel Syndrome? A Pilot Study.

Background The etiology of carpal tunnel syndrome (CTS) is multifactorial. Static mechanical characteristics of CTS have been described, but dynamic (muscular) parameters remain obscure. We believe that musculature overlying the transverse carpal ligament may have an effect on carpal tunnel pressure and may explain the prevalence of CTS in manual workers. Questions/Purposes To utilize magnetic resonance imaging (MRI) imaging to estimate the amount of muscle crossing the area of the carpal tunnel and to compare these MRI measurements in patients with and without documented CTS. Methods A case-control study of wrist MRI scans between January 1, 2018, and December 1, 2019, was performed. Patients with a diagnosis of CTS were matched by age and gender with controls without a diagnosis of CTS. Axial MRI cuts at the level of the hook of the hamate were used to measure the thenar and hypothenar muscle depth overlying the carpal tunnel. Muscle depth was quantified in millimeters at three points: midcapitate, capitate-hamate border, capitate-trapezoid border. Average depth was calculated by dividing the cross-sectional area (CSA) by the transverse carpal ligament width. Statistical analysis included Student's t -test, chi-square test, and Pearson's correlation coefficient calculation. Results A total of 21 cases and 21 controls met the inclusion criteria for the study. There were no significant differences in demographics between case and control groups. The location and depth of the musculature crossing the carpal tunnel were highly variable in all areas evaluated. A significantly positive correlation was found between proximal median nerve CSA and muscle depth in the capitate-hamate area (correlation coefficient = 0.375; p = 0.014). CSA was not significantly associated with chart documented CTS. Conclusions We found large variability in our measurements. This likely reflects true anatomical variation. The significance of our findings depends on the location of the muscles and the line of pull and their effect on the mechanics of the transverse carpal ligament. Future research will focus on refining measurement methodology and understanding the mechanical effect of the muscular structure and insertions on carpal tunnel pressure. Level of Evidence This is a Level 3, case-control study.

Association of core body temperature and peripheral blood flow of the hands with pain intensity, pressure pain hypersensitivity, central sensitization, and fibromyalgia symptoms.

Our aim was to analyse body core temperature and peripheral vascular microcirculation at skin hypothenar eminence of the hands and its relationship to symptoms in fibromyalgia syndrome (FMS). A total of 80 FMS women and 80 healthy women, matched on weight, were enrolled in this case–control study. Thermography and infrared thermometer were used for evaluating the hypothenar regions and core body temperature, respectively. The main outcome measures were pain pressure thresholds (PPTs) and clinical questionnaires. Significant associations were observed between overall impact [β = 0.033; 95% confidence interval (95%CI) = 0.003, 0.062; p = 0.030], daytime dysfunction (β = 0.203; 95%CI = 0.011, 0.395; p = 0.039) and reduced activity (β = 0.045; 95%CI = 0.005, 0.085; p = 0.029) and core body temperature in FMS women. PPTs including greater trochanter dominant (β = 0.254; 95%CI = 0.003, 0.504; p = 0.047), greater trochanter non-dominant (β = 0.650; 95%CI = 0.141, 1.159; p = 0.013), as well as sleeping medication (β = −0.242; 95%CI = −0.471, −0.013; p = 0.039) were also associated with hypothenar eminence temperature. Data highlighted that FMS women showed correlations among body core temperature and hand temperature with the clinical symptoms.

Distribution Patterns of the Deep Branch of the Ulnar Nerve into the Hypothenar Muscles

Distribution Patterns of the Deep Branch of the Ulnar Nerve into the Hypothenar Muscles

A Rare Case of Hypothenar Hammer Syndrome Triggering Guyon’s Canal Syndrome

In certain occupations, injuries and microtrauma are commonly encountered by the soft tissues of the hand in the adult population, which may, however, less frequently lead to arterial occlusion. One such example is that of the Hypothenar Hammer Syndrome (HHS). It is a rare traumatic disease of the hand, caused by blunt traumas to the heel of the hand that may damage the ulnar artery at the level of hypothenar eminence. This results in occlusion or aneurysm of the vessel. It is of clinical importance due to the risk of loss of limb function following digital ischemia. The ulnar nerve barely gets compressed in the Guyon’s canal, which may in turn cause Guyon’s canal syndrome. This is a case of a 43-year-old male patient who presented with painful swelling of the right hand, which was diagnosed as a bizarre presentation of a bilobed and partially thrombosed pseudoaneurysm of the ulnar artery producing Guyon’s canal syndrome that had to be surgically excised. The objective of this case is to highlight the clinical presentation of HHS for early diagnosis and treatment.

Ultrasonographic Features of Hypothenar Region Extra Digital Glomus Tumor

We report a case of a 32-year-old female with a 6-month history of excruciating pain in hypothenar region of the left hand. Pain was aggravated by pressure, touch, and cold temperature. Musculoskeletal ultrasonography revealed a well-defined, hypoechoic lesion in the deep dermis and subcutaneous fat in the left hypothenar eminence with mixed arterial and venous signals within on Doppler study, suggestive of subcutaneous vascular lesion, and a diagnosis of glomus tumor was suggested. The patient underwent excision of the lesion. Pathological examination of the specimen showed a glomus tumor and excluded malignant transformation to glomangiosarcoma. Extra digital glomus tumor can be diagnosed on ultrasound with high confidence in appropriate clinical setting.

Reliability of Peg Restrained Intrinsic Muscle Evaluator for Measurement of Intrinsic Hand Muscle Strength in Adults with Tetraplegia

Background: The manual muscle test (MMT) is the traditional method to assess the intrinsic hand muscle test. However, this test is qualitative and subjective. A device capable of rapidly measuring motor output along a linear scale may be of value in the evaluation of hand recovery from any neurological impairment. Objective: To demonstrate inter-rater reliability of the Peg Restrained Intrinsic Muscle Evaluator (PRIME) device for measuring intrinsic hand muscle strength in adults with impaired hand functions. Methods: 16 subjects (2 female, 14 male, mean age=47±15 years) with cervical spinal cord injury were enrolled. Intrinsic hand muscle strength of adults were performed by two-tester with use of PRIME device and manual muscle testing, within the same session. Inter-tester correlation was tested by Pearson's correlation and Intraclass correlation coefficient (ICC). Results: Intraclass correlation coefficients for hypothenar, first dorsal interosseous, abductor pollicis brevis and opponence pollicis muscles ranged from 0.7 to 0.8 with hypothenar muscle test being lowest ICC=0.7 and thumb opposition highest, ICC=0.81. Conclusion: Results from this study suggest that PRIME device demonstrates good reliability within testers for quantified measuring of intrinsic hand muscle strength. Further use of PRIME in clinic will aid in diagnostics, medical decision making and evaluation of rehabilitation progress in patients with cervical spinal cord injury.

Circumscribed palmoplantar hypokeratosis

Circumscribed palmoplantar hypokeratosis (CPH) is a rare acquired dermatosis first described in 2002. It affects mostly the thenar or hypothenar eminences of the palm of middle-aged or elderly women and manifests clinically with sharply limited, annular erythematous plaques with a depressed surface, rimmed by a slightly raised, keratotic border. Microscopically, circumscribed palmoplantar hypokeratosis shows a sharp decrease of the horny layer thickness, with few, if any, associated changes (parakeratosis, dermal inflammation). Despite a characteristic clinical and microscopic aspect, the disease remains poorly known, as does its pathogenesis, even if several hypotheses have been proposed (clonal epidermal malformation, disorder of epidermal differentiation/keratinization and/or desquamation, human papillomavirus– or trauma-induced disease). Several therapies have been proposed with varying results, the best ones achieved with surgical excision; however, because the disease is benign, intervention is optional. © 2020 Elsevier Inc. All rights reserved.

Hypothenar Island flap: a safe and excellent choice for little finger defects

Objective The aim was to evaluate the functional and cosmetic results of hypothenar island flap for the reconstruction of little finger defects and to assess them by follow-up. Background Reconstruction of soft-tissue defects of little finger of the hand needs a single-stage procedure that can provide well-vascularized coverage at the earliest stage to give the best functional result. Patients and methods This follow-up study that included 19 patients (13 men and six women) was carried out in the Plastic and Reconstructive Surgery Departments of Menoufia University and Helmia Military Hospital from October 2017 to October 2019, with assessment by a follow-up period of 12 months and physiotherapy. All the patients studied had the hypothenar island flap for coverage of the defects. The defects were due to postblunt trauma in three cases, post-burn in three cases, and post-sharp trauma in 13 cases. The largest flap was 20 × 15 mm2. The donor site was directly closed in all cases. Results The overall results were satisfactory regarding the function and appearance without major complications according to patient and doctor satisfaction. Regarding flap course and survival, 14 (73.7%) flaps passed uneventfully, five (26.3%) flaps suffered from venous congestion, five congested flaps survived without total loss and only partial loss and thus we had 19 (100%) survived flaps. Conclusion Hypothenar island flap is a reliable and versatile source for coverage of soft-tissue defects of little finger of the hand.

Split hand and motor axonal hyperexcitability in spinal and bulbar muscular atrophy

ObjectiveThe ‘split hand’ sign refers to preferential wasting of the thenar and first dorsal interosseous muscles with relatively sparing of the hypothenar muscles in amyotrophic lateral sclerosis (ALS) and both...

The diagnostic quandary of magnetic resonance imaging-negative Hirayama disease: a case report

BackgroundMagnetic resonance imaging (MRI) features are typical findings in Hirayama disease (HD) and are useful diagnostic entities but may not be present in all patients.Case presentationWe present the case of a 22-year-old Nepalese man who presented with insidious onset of weakness of his right upper limb of more than 5 years duration. His weakness was progressive for the first 3 years, and then remained static. On examination, weakness of the interossei, thenar, hypothenar, flexor, and extensor muscles were present in his right upper limb, power was normal in his left upper and bilateral lower limbs. Minipolymyoclonus was present in both upper limbs, less prominent on the left side. Electrophysiological findings showed motor axonal neuropathy in his right upper limb, neurogenic discharges and fibrillations, and fasciculations in both upper limbs. Contrast magnetic resonance imaging (MRI) of his cervical spine in flexion was normal. Our patient was diagnosed with HD based on clinical and electrophysiological findings. Our patient was advised to use a cervical collar and regular physiotherapy and was found to have subjective benefit.ConclusionA normal cervical MRI does not rule out HD and the diagnosis can also be made based on clinical and electrophysiological studies. Progressive distal upper limb weakness or tremor in young patients should be evaluated for HD, because early diagnosis and intervention might halt the progression.

Corticomotor Excitability in Two Kinds of Motor Neuron Diseases: A Study on the Patients With Amyotrophic Lateral Sclerosis and Poliomyelitis Survivors.

To examine upper motor neuron functions comparatively in patients with amyotrophic lateral sclerosis (ALS) and poliomyelitis survivors using transcranial magnetic stimulation (TMS) methods. Single- and paired-pulse TMS with conventional methods and the triple-stimulation technique were performed by recording from the abductor digiti minimi and abductor pollicis brevis muscles in 31 patients with ALS, 18 patients with poliomyelitis survivors, and 21 controls. Nine patients were diagnosed as having postpoliomyelitis syndrome after a 6-month follow-up. Triple-stimulation technique and some of conventional TMS studies were able to distinguish ALS from both poliomyelitis survivors and controls. A reduced ipsilateral silent period in abductor pollicis brevis muscles was the only parameter to show a significant difference when comparing thenar and hypothenar muscles in ALS. No significant difference was present in any TMS parameters between the postpoliomyelitis syndrome and non-postpoliomyelitis syndrome groups. Conventional TMS and particularly triple-stimulation technique studies are helpful in disclosing upper motor neuron dysfunction in ALS. The results of this study might favor the cortical hypothesis for split hand in ALS, but they revealed no significant indication for upper motor neuron dysfunction in postpoliomyelitis syndrome.

Analysis of Compound Muscle Action Potential of Median and Ulnar Nerves: Possible Anatomical Correlation

Objective: To analyze of shape, amplitude of CMAP of both median and ulnar in normal population and to analyze the anatomical innervations of small muscles of hand in normal cadavers. Design: Cross sectional study. Settings: outpatient settings and department of anatomy at Alexandria University. Participants: 300 normal adults (82 males and 218 females) and 30 normal adult cadavers. Main outcome measures: Motor conduction study of both median and ulnar nerves for the included normal subjects. Surface recording of CMAP from thenar and hypothenar muscles respectively with analysis of the shape of the waveform and amplitude. The nerve supply of both thenar and hypothenar muscles were dissected for the included normal cadavers. The main nerve trunk (median or ulnar), the number of branches, their sizes and their sites of entering into the muscles were recorded. Results: The mean age of the studied population was 37.86 ± 8.83 (age range 19-69). The mean amplitude of the median nerve was significantly higher than that of the ulnar nerve (11.785 ± 5.0, 10.45 ± 2.96 respectively, p=0.0001). The mean distal latency of median nerve was significantly higher than that of ulnar nerve (3.38 ± 0.41 and 2.698 ± 0.40 respectively, p=0.0001). The median nerve had mostly dome shaped CMAP rather than double peaked CMAP with significant difference (p=0.0001), while the shape of CMAP of the ulnar nerve was more frequently double peaked rather than dome shaped with significant difference (p=0.0001). The mean distal latency of the median nerve was significantly longer in those with dome shaped CMAP rather than those with double peak CMAP (p=0.002). Similarly, the mean distal latency of the ulnar nerve was significantly longer in those with dome shaped CMAP compared with those with double peak CMAP (p=0.0001). There were no statistical significant differences between the amplitude of dome shaped CMAP and the double peaked CMAP in either the median or the ulnar nerve. The anatomical results showed that abductor pollicis brevis supplied by the median nerve in 90% of specimens, and by both nerves in 10%. The abductor digiti minimi brevis supplied by the deep branch of the ulnar nerve in 90% and by superficial branch of the ulnar nerve in 10%. There was a connection between the median and ulnar nerves in 50% of specimens. Conclusion: The configuration of the CMAP of the median nerve is mostly dome, whereas that of the ulnar is mostly double peaked. Variability in the pattern of innervations of the small muscle of the hand could be a possible etiological factor.

Guyon’s Canal Syndrome with Ganglion Cyst Compression from Baby-Holding Overuse

A 45-year-old man was frequently bothered by a weakness of the right hand, and it was difficult for him to do adduction of the thumb for half a year. According to his presentation, the patient held his child by the right upper limb with wrist flexion habitually for a year. Besides, there was an obvious atrophy of the hypothenar eminence. In MRI image, there were two lobulated cyst lesions in the Guyon’s canal between the right hook of the hamate bone and the abductor digiti minimi muscle. During the surgery, the two lobulated cysts were in the Guyon’s canal, and the ulnar nerve was compressed. Three weeks after the tumor excision, the weakness of the right hand improved dramatically, and the patient could perform adduction of the right thumb to pinch paper easily without flexion of the interphalangeal joint.

101 Amyotrophic Lateral Sclerosis (ALS) - Not Just a Motor Disease? Isolated Bitter and Sweet Taste Loss in ALS

Specific taste quality deficits in ALS has not heretofore been described. Case Study: A 71 year old right handed female presented with a two year course of progressive reduction in strength in her hands, arms and legs with difficulty tying shoe laces, opening jars, writing and walking. She described nocturnal muscle spasms involving all extremities. Gradually, over eight months prior to presentation, all food began to taste bad and horribly bitter. Associated with no appetite and a seven pounds weight loss. Abnormalities in Neurological examination: Cranial Nerve (CN) examination: CN IX and X: Gag absent bilaterally. Motor examination: Bulk: atrophy in thenar and hypothenar eminences and intrinsics in both upper extremities. Percussion induced fasciculation and myotonia in both shoulders and arms. Fasciculation of tongue with percussion myotonia of tongue. Strength: Intrinsic 4/5 in both upper extremities, 3/5 in abductor policis brevis bilaterally, 3/5 right gastrocnemius soleus, 4/5 bilateral anterior tibialis. Drift testing: left abductor digiti minimi sign. Gait: Heel and toe walking unstable with circumduction of left leg. Tandem gait unstable. Cerebellar: Holmes rebound phenomena positive in the left upper extremity. Deep tendon reflexes: 1+ left brachioradialis. 1+ left triceps. 3+ right ankle jerks. 0 left ankle jerk. Positive jaw jerk. Chemosensory Testing: Normosmia to: Alcohol Sniff Test (46), Pocket Smell Test (3/3) and Retronasal Smell Index (9). Taste Quadrant Testing: ageusia in the palate to sodium chloride and citric acid. Ageusia throughout the palate, tongue and whole mouth to sucrose and quinine hydrochloride. Fungiform papillae count: left 18, right 20 (normal). Lip biopsy (normal). MRI: T2 flair in bilateral corticospinal tracts, left greater than right in the spinal cord and the brain. EMG: fibrillation, positive waves with fasciculation in all four extremities. Voluntary contraction with polyphasic unstable motor unit action potentials. While Lang found no taste loss in ALS (Lang, 2011), Pelletier found reduction in intensity of taste to all modalities in different sectors of the tongue, but paradoxically demonstrated normogeusia in whole mouth taste perception (Pelletier, 2013). Pathological specimens of those with ALS revealed degeneration in the nucleus parabrachialis medialis and tractus trigeminothalamicus dorsalis (Oyanagi, 2015), suggesting that taste deficit may be due to central white matter abnormalities. Sweet taste is localized in the most posterior and rostral aspect of the right insular cortex, immediately adjacent to bitter (Prinster, 2017), suggesting a neighborhood effect phenomena. Weight loss in ALS may be due to sensory distortion and secondary impairment of appetite. It would be worthwhile to investigate those with ALS for evidence of otherwise overlooked gustatory deficits, correction of which may improve appetite and nutritional state.

543 Acute Carpal Tunnel Syndrome from a Solar Panel Electrical Injury: A Case Report and Literature Review

Abstract Introduction The utilization of solar panels for residential and industrial purposes is increasing. Electrical injury from solar panels has not been well defined. Most of the literature on electrical burns is predominately from alternating current (AC) injuries instead of direct current (DC) as seen in solar panels. The implication of solar panel electrical injury in the pathogenesis of acute carpal tunnel syndrome has yet to be reported. Methods A retrospective chart review of a patient presenting to our burn unit following a solar panel electrical injury was performed. Results The patient was a 46 year old otherwise healthy male who presented after 5–10 seconds of high voltage (~7500V) direct current injury to his right forearm. The patient had deep partial thickness burns to his right hypothenar eminence and a full thickness defect with exposed muscle on his right volar forearm. On admission he had complete function, but within hours developed an inability to move his hand. He was taken for exploration on hospital day 2 because of mildly elevated compartment pressures, pain, and paresthesia. The hypothenar injury was noted to have converted to full thickness injury and a distal right volar forearm fasciotomy and carpal tunnel release was performed. On hospital day 3, the patient’s pain and neurologic examination improved. At 3 month follow-up, the patient had some restored function of his hand, but reduced grip strength, and mild persistent pain and paresthesia in the volar wrist and hand. Conclusions Solar panel injuries are expected to rise. The use of high voltage direct current energy has the potential to cause serious harm and appropriate awareness can lead to thorough management and better outcomes of burn victims. With electrical injuries to the hand, providers should have a low threshold for carpal tunnel syndrome, whose symptoms may be complicated by concomitant compartment syndrome of the hand and/or forearm. Lastly, as with most burn injuries a multidisciplinary approach should be established with focus on long term care. Applicability of Research to Practice We suspect that this new etiology of electrical burn is on the rise as we see more solar panels being utilized. Physician should be familiar with potential complications in this complex patient population.

Compression Neuropathy of the Ulnar Nerve due to the Accessory Abductor Digiti Minimi at Guyon’s Canal: A Case Report

Guyon’s canal syndrome is a compression neuropathy of the ulnar nerve that occurs at the wrist. Compression can be caused by many conditions, such as benign tumors, repeated occupational trauma, vascular lesions, fractures of the carpal bones, rheumatoid arthritis and anomalous hypothenar muscle at Guyon's canal. Here, the authors report a case of compression neuropathy of the ulnar nerve by the accessory abductor digiti minimi muscle (AADM), one of the anomalous hypothenar muscles, at Guyon's canal. The case report is accompanied by a literature review.

Interrelation between Sarcopenia and the Number of Motor Neurons in Patients with Parkinsonian Syndromes

Introduction: Pathogenesis in a subgroup of sarcopenic patients seems to be based on a reduced number of motor neurons. This study aimed at investigating the overlap between sarcopenia and neurodegeneration, as reflected by a low number of motor neurons in patients with Parkinsonian syndromes (PS). Methods: The motor unit number index (MUNIX) of the hypothenar muscle was used to assess the number and size (MUSIX) of motor units (MUs) in patients with idiopathic Parkinson disease (iPD, n = 53), patients with atypical Parkinsonian syndrome (aPS, n = 21), and a control group (n = 30). Mean age of participants was 70.3 years and 54.1% were female. Skeletal muscle mass by bioelectrical impedance analysis, hand-grip strength and gait speed were measured. Based on these assessments, sarcopenia was diagnosed according to the criteria of the European Working Group on Sarcopenia in Older People. Results: Sarcopenia criteria were met by 10 patients with PS (13.5%). The study group had significantly lower MUNIX values than the control group (109 [SD ±39.1] vs. 129 [SD ±45.1]; p = 0.020) even after adjustment for age and sex. Three of the 5 sarcopenic iPD patients (75%) had pathological low MUNIX values (<80). Discussion/Conclusion: Sarcopenia is a frequent comorbidity in PS. The pathologically low MUNIX values found in 75% of our sarcopenic iPD patients provides further support for the existence of a neurodegenerative overlap syndrome with a reduced number of MUs potentially leading to sarcopenia. This finding warrants further evaluation.

The Cutaneous Branch of the Deep Palmar Artery and Blood Supply to the Proximal Hypothenar Skin: An Anatomic Research Oriented to Flap Design.

Background: The distal half of the hypothenar eminence (HE) skin vascularization has been extensively investigated. Different flaps have been described based on these arteries. Similarly, the vascularization of the proximal half of HE has also been investigated, although to a lesser extent. The aim of this paper is to determine, in a cadaver sample, the anatomy of the hypothenar cutaneous branches in their proximal half. Methods: In all, 20 adult, red-colored-latex-injected hands were studied. Dissections were performed with a 4X to 10X magnification. Cutaneous branches in the proximal half of the HE were found. Their variants were studied, and they were classified into different types according to their relationships. Results: A cutaneous branch of the deep palmar artery (CBDPA) was identified. It was located in the subcutaneous cellular tissue thickness in the proximal half of the HE. Moreover, it presented 3 anatomical variants, classified according to its relationships with the superficial ulnar nerve branch (SUN). Type 1 variant: the CBDPA and the PDA ran in front of the SUN (60% of cases). Type 2: the CBDPA and the DPA ran behind the SUN (30% of cases). Type 3: the CBDPA ran in front of the SUN while the DPA ran behind it (10% of cases). Conclusion: There is a CBDPA which is the HE proximal half main cutaneous branch. Although it presented several variants, its existence is constant, making it possible to use it as pedicle for proximal hypothenar flaps.

Hypothenar muscles—A popular object of anatomy and surgery and some misdescriptions

Hypothenar muscles—A popular object of anatomy and surgery and some misdescriptions

Distal nerve transfer for thenar palsy: A cadaveric study.

Severe proximal median nerve palsies often result in irreversible thenar atrophy and thumb abduction function loss. Tendon transfer involves substantial limitations and challenges; but, distal nerve transfer may provide an alternative treatment. Our goal was to validate the anatomical suitability of two distal ulnar nerve branches for thenar muscle reanimation. We assessed nerve transfer to the recurrent branch of median nerve (RMN) in 16 embalmed cadaveric hands. The ulnar motor branch to the flexor digiti minimi brevis (FDMBn) and the ulnar motor branch to the third lumbrical (3rdLn) were assessed for transfer. Coaptation success was measured by the overlap of the nerve donor with the RMN and correspondence of nerve diameters. The mean transferable length and width of the RMN were 20.7 ± 4.5 and 1.0 ± 0.3 mm, respectively. We identified an average of three branches in the branching anatomy from the ulnar nerve to the hypothenar muscles. The maximal transferable lengths and widths of the FDMBn and the 3rdLn were 13.8 ± 4.4 and 0.5 ± 0.1 mm and 24.1 ± 6.4 and 0.4 ± 0.1 mm, respectively. The overlap with the RMN of the FDMBn and 3rdLn was 9.0 ± 3.6 (2.0-15.3) and 17.8 ± 6.0 (4.7-27.5) mm, respectively. This anatomical study demonstrates the feasibility of distal nerve transfers between the ulnar and median nerves in the hand for reanimation of thenar muscles. Ulnar motor donors of the BrFDMBn and 3rdLn likely represent the least morbid donors with short distances for regeneration and a single coaptation repair.