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CASE: We report a case of intraneural nodular fasciitis in the forearm initially suspected as a schwannoma, emphasizing the importance of accurate diagnosis. A 40-year-old woman presented with mass on the lateral aspect of her right forearm and radial neuropathy symptoms for 2 months. An excisional biopsy and histopathological examination confirmed nodular fasciitis. Postoperative evaluation at 4.5 years found no pain, paralysis, or recurrence. CONCLUSION: Awareness of nodular fasciitis is crucial to prevent misdiagnosis and unnecessary treatment. Despite its rapid growth, nodular fasciitis generally has an excellent prognosis without long-term consequences.

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We describe a 13-year-old boy with piso-hamate coalition confirmed by X-ray. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed type 1 coalition according to the classification of DeVilliers Minnaar. Piso-hamate coalition is rare, and suspicions should be raised in instances of chronic ulnar-sided wrist pain, particularly in individuals with a history of elevated hand usage, especially amongst athletes engaging in intensive hand grip activities. Surgical resection of the synchondrosis site between the pisiform and the hamate is an efficacious intervention that can mitigate pain. Level of Evidence: Level V (Therapeutic).

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CASES: Two competitive athletes with isolated comminuted trapezium fractures, sustained during American football and rugby, presented with pain and swelling of the first metacarpal base. Computed tomography confirmed isolated comminuted trapezium fractures. Arthroscopic reduction of displacement with screw fixation below the articular surface was performed through a small incision. Both patients returned to their preinjury sports levels within 2 months postoperatively. CONCLUSION: Arthroscopic treatment of isolated comminuted trapezium fractures achieved accurate reduction of articular surface displacement and preserved trapeziometacarpal joint stability with minimal soft-tissue invasion. This facilitated an early return to contact sports for the affected athletes.

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Background: The anterolateral thigh (ALT) flap, which is nourished by perforators from the descending branch of the lateral femoral circumflex artery (P), is one of the most commonly used flaps in soft tissue reconstruction. With the growing use of ALT flaps, attention toward donor-site morbidity has increased in recent years. Damage to the motor nerve branches of the vastus lateralis muscle (N) is one of the causes of donor-site morbidity, particularly muscle weakness. This study investigated the anatomical locations of the P and N in fresh-frozen cadaveric specimens. Methods: This study included 43 cadaver limbs. A silicone rubber compound (30 mL) was injected into the femoral artery to visualize the vessel. The locations of the P and motor points of N were measured to assess the risk of N injury during ALT flap harvesting. Results: There were one to six (mean, 2.7) P and two to seven (mean, 4) N. When the two most proximal perforators were used for flap harvesting, an average of 1.5 motor nerve branches (42%) was damaged because transection of the motor nerve branches was required for flap harvesting. In 33% of the limbs, only one motor nerve branch remained after the flap harvest. However, there were no cases where all motor nerve branches were severed. Conclusion: When an ALT flap with two perforators is harvested, weakness of the vastus lateralis muscle may occur in cases with a small number of motor nerve branches.

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PURPOSE: This study aimed to describe the reposition flap for reconstructing fingertip amputation when replantation is not possible. METHODS: This study retrospectively reviewed the records of patients with reposition flap transfers and investigated postoperative clinical outcomes and patient satisfaction. Sixteen patients with fingertip amputations treated with a reposition flap from 2016 to 2020. The mean age at injury was 46 years (range, 26-70 years). Ten cases were treated with oblique triangular advancement flaps, 3 with retrograde-flow digital artery flaps, and 3 with thumb palmar advancement flaps. Postoperative outcomes, including wound healing period and the IP/PIP extension angle, and the presence of grafted bone absorption and patient satisfaction were evaluated as of 3 years after surgery. RESULTS: The average reduction in passive extension angle of the IP/PIP joint was 19°. The average time for complete wound healing was 28 days (range, 18-41 days). The reduction in passive extension angle of the IP/PIP joint was significantly correlated with the wound healing period (r = 0.66, p = 0.01). The absorption of the grafted bone was observed in 3 cases. In these cases, the distal tip of the flap became thin due to flap retraction and an insufficient flap volume. All patients were highly or fairly satisfied with the results of surgery. CONCLUSION: Our findings show that IP/PIP flexion contracture can occur due to delayed wound healing after reposition flap transfer, but the patient satisfaction level was generally high. Therefore, reconstruction using a reposition flap gives acceptable clinical outcomes and high patient satisfaction as a result of medium to long-term.

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Background: Functional outcomes of patients who underwent arthroscopy-assisted surgery for trapeziometacarpal osteoarthritis were reported. Methods: We included 24 consecutive patients (6 males and 18 females) who underwent surgery and postoperative hand therapy at our hospital between April 2012 and March 2018. For functional evaluation, we used the Purdue Pegboard Test (PPT), grip and pinch strength, range of motion of the thumb, visual analogue scale (VAS) for thumb pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Japanese version of the Patient-Rated Wrist Evaluation (PRWE-J) preoperatively and 3 months postoperatively. Results: The mean PPT rating improved from 12.3 to 13.3, the VAS score from 51 to 16, the QuickDASH score from 48 to 30 and the PRWE-J score from 55 to 29. All the improvements were statistically significant. There was a moderate positive correlation between the magnitude of improvement in PPT and QuickDASH scores. Conclusions: Arthroscopic intervention and associated hand therapy were effective in achieving early postoperative relief of thumb pain and in improving hand dexterity and activities of daily living. Level of Evidence: Level IV (Therapeutic).

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PURPOSE: The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery. METHODS: Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured. RESULTS: The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively. CONCLUSIONS: The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery.

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PURPOSE: Triangular fibrocartilage complex injuries can cause distal radioulnar joint (DRUJ) instability, which can be evaluated clinically with the DRUJ ballottement test. However, the reliability and validity of the test are unclear. This study aimed to analyze the reliability and validity of the test using a tracking device on healthy participants and patients with triangular fibrocartilage complex injuries. METHODS: In this cross-sectional study, three orthopedic hand surgeons performed the DRUJ ballottement test using a technique of holding the carpal bones to the radius on 25 healthy participants (50 hands; 10 men and 15 women; mean age, 33 years; range, 20-51 years) and eight patients with triangular fibrocartilage complex injuries (16 hands; six men and two women; mean age, 43 years; range, 27-59 years). We used a three-dimensional electromagnetic tracking device to quantify the movement of the DRUJ and verify the reliability and validity of the test. RESULTS: The intrarater and interrater intraclass correlation coefficients for DRUJ movement were 0.77 and 0.61, respectively, and the kappa coefficient for grading of DRUJ instability was 0.79. The correlation coefficient between DRUJ movement measured using the tracking device and instability judged clinically was 0.77. A comparison of healthy participants and the patients showed significantly greater DRUJ movement in the patients. CONCLUSIONS: The test showed substantial intrarater and interrater reliability for assessing DRUJ movement and instability. The significant positive correlation between DRUJ movement and instability indicates the concurrent validity of the test. Moreover, the test showed discriminative validity in identifying mild or moderate DRUJ instability. CLINICAL RELEVANCE: The DRUJ ballottement test using the holding technique has a relatively high diagnostic accuracy and can be used to assess DRUJ instability.

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CASE: A 46-year-old man with vascular Ehlers-Danlos syndrome (EDS) had an open ankle fracture with a 10 × 5-cm skin defect on the medial side of the ankle. The patient underwent open reduction and internal fixation, as well as coverage of the skin defect with a posterior tibial artery perforator flap, which led to successful outcomes. CONCLUSION: We present the successful implementation of a posterior tibial artery perforator flap for the reconstruction of skin defects in a patient with vascular EDS. Despite the fragility of soft tissues, favorable surgical outcomes were observed.

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Replantation is widely regarded as the first choice of treatment for finger amputations. However, if the fingertip of a traumatic finger amputation is missing after an injury, the following procedures are often performed to reconstruct this portion: flap surgery, stump surgery, or conservative treatment, including occlusive dressings. To our knowledge, no existing English literature reports using negative-pressure wound therapy (NPWT) to treat traumatic finger amputations. We postulated that NPWT may be applied as a conservative treatment for traumatic finger amputations, promoting the growth of granulation tissue and achieving early epithelialization of the fingertips. Among the case series of five patients, we included six injured fingers comprising two index, two middle, and two ring fingers. The fingertip of each traumatic finger amputation was either missing or highly crushed, making replantation impossible. To preserve finger length with conservative treatment, we adapted an NPWT device for finger amputations. It took an average of 22.7 days for the fingertips to epithelialize. Immediately after epithelialization, there was a slight decrease in sensory perception; however, all patients showed good recovery of sensory perception after 3 months. Range of motion remained unrestricted, with no reduction in grip strength. Patients were highly satisfied with their fingertip appearance. The regenerated nail exhibited slight deformation and shortening. No complications were observed. Our novel study regarding this new conservative treatment and its outcomes revealed that healing was achieved in a relatively short period; therefore, NPWT may serve as a new conservative treatment option in the future.

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BACKGROUND: Information regarding the therapeutic effect and outcome of transcatheter arterial embolization (TAE) for hepatic masses is limited in veterinary medicine. HYPOTHESIS/OBJECTIVES: To analyze the therapeutic response, outcome (overall survival), and their predictors in dogs that underwent TAE for primary hepatocellular masses. We hypothesized that larger pre-TAE tumors would be associated with worse outcomes. ANIMALS: Fourteen client-owned dogs. METHODS: Retrospective study. Medical records between 1 September 2016 and 30 April 2022 were reviewed to identify dogs treated with TAE for hepatic masses diagnosed as hepatocellular origin by cytological or histopathological examination. Computed tomography images were compared before and after TAE. The univariate Cox proportional hazards test was performed to assess the associations between variables and survival. Univariate linear regression analysis was performed to assess the associations between variables and the tumor reduction percentage: ([post-TAE volume - pre-TAE volume]/pre-TAE volume) × 100. RESULTS: The median survival time was 419 days (95% confidence interval, 82-474). History of intra-abdominal hemorrhage (P = .03) and pre-TAE tumor volume/body weight (P = .009) were significantly associated with overall survival. The mean reduction percentage was -51% ± 40%. Pre-TAE tumor volume/body weight ratio (cm3 /kg; P = .02, correlation coefficient = 0.704) was significantly correlated with the volume reduction percentage. CONCLUSIONS: History of intra-abdominal hemorrhage and large pre-TAE tumor volume/body weight ratio could be predictive factors for adverse outcomes after TAE. Pre-TAE tumor volume/body weight ratio could be a predictive factor for therapeutic effect.

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A 16-year-old intact female Miniature Dachshund (dog 1) and a 13-year-old intact female American Cocker Spaniel (dog 2) presented with a chief complaint of bleeding from a mammary gland tumour ulceration. Dog 1 was transferred to hospital from a local hospital in a haemorrhagic shock state with uncontrolled continuous bleeding. Thoracic radiographs revealed multiple nodular shadows suspected to be pulmonary metastasis. Dog 2 presented with intermittent bleeding from a mass lesion in the right fifth mammary gland. Due to high anaesthetic risk secondary to severe mitral valve insufficiency (ASA status III), the owner declined surgical excision of the tumour. Therefore, microwave ablation (MWA) under local anaesthesia was chosen in order to achieve adequate haemostasis. Both dogs received local anaesthesia around the bleeding mass lesion, and the disintegrated site was microwave-ablated; dog 1 underwent MWA after blood transfusion to improve the haemorrhagic shock. The ablation site was protected using a non-adhesive dressing. Scarring of the ulcerated site led to complete haemostasis in both cases. Dog 1 underwent tumorectomy on the 31st hospital day to prevent rebleeding; histopathology results were consistent with mammary adenocarcinoma with the ablation site covered by a capsule structure. To the authors' knowledge, this is the first case report describing the use of MWA to stop bleeding from mammary tumours in veterinary medicine. MWA is a feasible and potentially effective palliative treatment modality to stop bleeding from disintegrated mammary tumours in dogs under local anaesthesia.

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BACKGROUND: Cubital tunnel syndrome can be caused by overtraction and dynamic compression in elbow deformities. The extent to which elbow deformities contribute to ulnar nerve strain is unknown. Here, we investigated ulnar nerve strain caused by cubitus valgus/varus deformity using fresh-frozen cadavers. METHODS: We used six fresh-frozen cadaver upper extremities. A strain gauge was placed on the ulnar nerve 2 cm proximal to the medial epicondyle of the humerus. For the elbow deformity model, osteotomy was performed at the distal humerus, and plate fixation was performed to create cubitus valgus/varus deformities (10°, 20°, and 30°). Ulnar nerve strain caused by elbow flexion (0-125°) was measured in both the normal and deformity models. The strains at different elbow flexion angles within each model were compared, and the strains at elbow extension and at maximum elbow flexion were compared between the normal model and each elbow deformity model. However, in the cubitus varus model, the ulnar nerve deflected more than the measurable range of the strain gauge; elbow flexion of 60° or more were considered effective values. Statistical analysis of the strain values was performed with Friedman test, followed by the Williams' test (the Shirley‒Williams' test for non-parametric analysis). RESULTS: In all models, ulnar nerve strain increased significantly from elbow extension to maximal flexion (control: 13.2%; cubitus valgus 10°: 13.6%; cubitus valgus 20°: 13.5%; cubitus valgus 30°: 12.2%; cubitus varus 10°: 8.3%; cubitus varus 20°: 8.2%; cubitus varus 30°: 6.3%, P < 0.001). The control and cubitus valgus models had similar values, but the cubitus varus models revealed that this deformity caused ulnar nerve relaxation. CONCLUSIONS: Ulnar nerve strain significantly increased during elbow flexion. No significant increase in strain 2 cm proximal to the medial epicondyle was observed in the cubitus valgus model. Major changes may have been observed in the measurement behind the medial epicondyle. In the cubitus varus model, the ulnar nerve was relaxed during elbow extension, but this effect was reduced by elbow flexion.

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BACKGROUND: The causes of ulnar neuropathy at the elbow are unclear. The authors hypothesized that the humeral trochlea protrudes into the cubital tunnel during elbow flexion and causes a dynamic morphologic change of the ulnar nerve in the cubital tunnel. METHODS: An ultrasonic probe was fixed to the ulnar shafts of 10 fresh cadavers with an external fixator, and dynamic morphology of the cubital tunnel and ulnar nerve was observed. The distance from the Osborne band to the trochlea (OTD), distance from ulnar nerve center to the trochlea (UTD), and the short- and long-axis diameters of the nerve at 30°, 60°, 90°, and 120° of elbow flexion were recorded. We compared the OTD, UTD, and the flattening of the ulnar nerve at the different angles of flexion using single-factor analysis of variance. Correlation between the ulnar nerve flattering, OTD, and UTD was examined using Spearman correlation coefficient. A P value less than .05 was used to denote statistical significance. RESULTS: Flattening of the ulnar nerve progressed with increasing elbow flexion and was significantly different between 0° and 60°, 90°, and 120° (P = .03 at 60°, P < .01 at 90° and 120°). OTD decreased with elbow flexion, and there was a significant difference at all elbow flexion angles (all P < .01). UTD decreased significantly from 0° flexion to 90° flexion (P = .03). Flattening of the nerve was significantly correlated with the OTD (r = 0.66, P < .01). CONCLUSIONS: A positive correlation was found between the protrusion of the humeral trochlea into the cubital tunnel during elbow flexion and ulnar nerve flattening using cadaveric elbow and ultrasonography.

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CASE: A 24-year-old professional judo competitor suffered injuries to both the wrists when he fell on his back while lifting a 90-kg barbell in the bilateral dorsiflexed wrist position. Simultaneous bilateral volar lunate dislocation had been missed for a year. The degenerated lunates were simultaneously removed using a palmar approach. At 12 months postoperatively, the patient returned to judo competitions without pain. Radiography showed no progression of the intercarpal alignment abnormality. CONCLUSION: Simultaneous bilateral chronic volar lunate dislocation is extremely rare. Long-term follow-up is necessary to check for carpal alignment.

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BACKGROUND: The acromioclavicular (AC) and coracoclavicular (CC) ligaments are important stabilizers of the AC joint. We hypothesized that AC and trapezoid ligament injuries induce AC joint instability and that the clavicle can override the acromion on cross-body adduction view even in the absence of conoid ligament injury. Accordingly, we investigated how sectioning the AC and CC ligaments contribute to AC joint instability in the cross-body adduction position. METHODS: Six fresh-frozen cadaveric shoulders were used in this study, comprising five male and one female specimen, with a mean age of 68.7 (range, 51-87) years. The left side of the trunk and upper limb, and the cervical and thoracic vertebrae and sternum were firmly fixed with an external fixator. The displacement of the distal end of the clavicle relative to the acromion was measured using an electromagnetic tracking device. We simulated AC joint dislocation by the sequential resection of the AC ligament, AC joint capsule, and CC ligaments in the following order of stages. Stage 0: Intact AC and CC ligaments and acromioclavicular joint capsule; stage 1: Completely sectioned AC ligament, capsule and joint disc; stage 2: Sectioned trapezoid ligament; and stage 3: Sectioned conoid ligament. The superior clavicle displacement related to the acromion was measured in the horizontal adduction position, and clavicle overriding on the acromion was assessed radiologically at each stage. Data were analyzed using a one-way analysis of variance and post-hoc tests. RESULTS: Superior displacement was 0.3 mm at stage 1, 6.5 mm at stage 2, and 10.7 mm at stage 3. On the cross-body adduction view, there was no distal clavicle overriding at stages 0 and 1, and distal clavicle overriding was observed in five cases (5/6: 83%) at stage 2 and in six cases (6/6: 100%) at stage 3. CONCLUSION: We found that AC and trapezoid ligament sectioning induced AC joint instability and that the clavicle could override the acromion on cross-body adduction view regardless of conoid ligament sectioning. The traumatic sections of the AC and trapezoid ligament may lead to high grade AC joint instability, and the distal clavicle may subsequently override the acromion.

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[Purpose] Knee osteoarthritis can alter gait variability; however, few studies have investigated the associating factors with gait cycle time variability. The first objective was to compare gait cycle variability between female patients with knee osteoarthritis and healthy elderly females and to determine gait characteristics in patients with knee osteoarthritis. The second objective was to identify the associating factors with gait cycle time variability. [Participants and Methods] The participants included 24 female patients diagnosed with knee osteoarthritis and 12 healthy elderly females. Gait cycle variability (coefficient of variation of gait cycle time), knee extension range of motion, knee extension strength, 5-m walk test, Timed Up & Go Test, and Western Ontario and McMaster Universities Osteoarthritis Index were measured. All assessment results were compared between the knee osteoarthritis and healthy groups. [Results] Gait cycle time variability was significantly higher in the knee osteoarthritis group than in the healthy group. Further, it showed a significant positive correlation with the 5-m walk test and the Western Ontario and McMaster Universities Osteoarthritis Index. [Conclusion] Patients with knee osteoarthritis presented greater gait cycle variability than that of healthy individuals. Therefore, rehabilitation to improve gait variability might enhance the quality of life of patients with knee osteoarthritis.

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BACKGROUND: Reduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs. METHODS: We analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment. RESULTS: Fifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44). CONCLUSION: Impacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.

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