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BACKGROUND: Flexor tendon injuries pose many challenges for the treating surgeon, the principal of which is creating a strong enough repair to allow early active motion, preserving a low-profile of the repair to prevent buckling and subsequent pulley venting. A main concern is that a low-profile repair is prone to gap formation and repair failure. The Dynamic Tendon Grip (DTG™) all suture staple device claims to allow a strong and low-profile repair of the flexor tendon. The purpose of this study is to test the effects of the DTG™ device in early active motion simulation on range of motion, load to failure and gap formation and to compare it to traditional suturing technique. METHODS: Twelve fresh-frozen cadaveric fingers were assigned to two groups: DTG™ device (n = 9) and traditional suturing (double Kessler 4-core suture and a peripheral suture, n = 3). The deep flexor was incised and repaired in zone 2, and active motion simulation was carried out with a cyclic flexion-extension machine. Finger range of motion and gap formation were measured, as well as load to failure and method of repair failure. RESULTS: Following motion simulation, ROM decreased from 244.0 ± 9.9° to 234.5 ± 5.8° for the DTG™ device compared to 234.67 ± 6.51° to 211.67 ± 10.50° for traditional suturing. The DTG™ repair demonstrated gap formation of 0.93 ± 0.18 mm in 3 of 8 specimens after applying 1 kg load, which negated after load removal. Load to failure averaged 76.51 ± 23.15 N for DTG™ and 66.31 ± 40.22 N for the traditional repair. Repair failure occurred as the suture material broke for the DTG™ array and at the knot level for the traditional repair. CONCLUSIONS: The DTG™ all-suture stapling concept achieved a strong low-profile repair in zone 2 flexor tendon injury after active motion simulation. Further clinical studies will be needed to determine the effectiveness of this device compared to traditional techniques.

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BACKGROUND: Foot ulcers have been implicated as a causative factor in diabetic foot amputations. The purpose of this study was to evaluate treating foot ulcers in patients with diabetes by percutaneous tenotomy. METHODS: We retrospectively reviewed the computerized medical files of 83 patients treated for foot ulcers by percutaneous tenotomies. Results were analyzed on the basis of indication and per patient. RESULTS: The 83 patients had 160 tenotomies for 4 indications: 103 tip-of-toe ulcers (treated by flexor digitorum longus tenotomy), 26 cock-up/dorsal ulcers (extensor digitorum longus tenotomy), 21 kissing ulcers (extensor digitorum longus and/or flexor digitorum longus tenotomies), and 10 plantar metatarsal ulcers (extensor digitorum longus with or without flexor digitorum longus tenotomy). Healing at 4 weeks was 98%, 96%, 81%, and 0%, respectively. The complication rate was very low, with the exception of "transfer lesions," where an adjacent toe became involved and needed subsequent tenotomy in 8% of tip-of-toe ulcers. CONCLUSIONS: Percutaneous tenotomy was an effective and safe method for treating toe ulcers in neuropathic patients. It was not effective in treating plantar metatarsal ulcers. LEVEL OF EVIDENCE: Level IV, case series.

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The lumbrical muscles are unique in having their origin and insertion on tendons. The lumbricals assist in metacarpophalangeal joint flexion; they contribute to interphalangeal joint extension by acting as deflexors of the proximal interphalangeal joint. Anatomically, they are highly specialized in terms of their architectural properties, with a small physiologic cross-sectional area but long fiber length. Their unique properties indicate that they are probably important in fast, alternating movements and fine-tuning digit motion.

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BACKGROUND: The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose, a metal-on-metal prosthesis with improved tribology was developed. Our early results using this implant are presented. MATERIALS AND METHODS: A prospective analysis was performed for 56 Metasul hip arthroplasties between 1997 and 2001. There were 39 patients (43 hips) available for both clinical and radiographic evaluation at an average follow-up period of 42 months. Outcomes were measured using the Harris hip score. DISCUSSION: The average Harris hip score increased from 40.7 to 81.1. Subjectively, 87% of the primary cases were satisfied. The majority of patients had pain-free range of motion and had returned to improved daily functions. One technical intraoperative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring, due to a femoral crack. There were two cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intraoperative culture was successfully treated with intravenous antibiotics. Two patients required revision to a cemented acetabular prosthesis, one due to cup loosening and the other due to a painful hip with a suspected infection. Radiolucent lines were seen in the acetabulum in one case, which underwent revision. No femoral or pelvic radiolucent lines were found. CONCLUSIONS: We have had relatively satisfactory results in the early follow-up period. It remains premature to draw conclusions as to the superiority of this system over a conventional metal-on-polyethylene bearing prosthesis. Long-term follow-up studies are needed.

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Complete anaesthesia in the cutaneous distribution of the ulnar nerve following submuscular anterior transposition of the ulnar nerve has not been previously reported. We postulate vascular insult as the etiology of this condition and suggest there may be clinical importance to preserving the ulnar nerve blood supply during submuscular anterior transposition.

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PURPOSE: Zone II flexor tendon repairs may create a bulging effect with resistance to tendon gliding. A biomechanical study was performed comparing the 4-strand cross-locked cruciate (CLC) to a 4-strand Strickland repair, both with and without an interlocking horizontal mattress (IHM) suture, in terms of strength characteristics and work of flexion. METHODS: Sixteen fresh-frozen human fingers were placed in a custom jig. Flexor digitorum profundus tendons were sectioned at the A3 pulley level. Fingers were separated into 2 repair groups: 4-strand CLC and 4-strand Strickland core suture. Work of flexion was determined for each group, with and without an IHM circumferential suture. Final repair including IHM was tested for 2-mm gap failure and ultimate load to failure. RESULTS: The CLC-IHM had a significantly smaller increase in work of flexion than the Strickland-IHM. For both suture types, the circumferential suture resulted in a statistically significant increase in work of flexion; however, peak entry force produced upon entry of the repair into the A2 pulley was reduced, although the decrease was not statistically significant for each group. The CLC-IHM had a significantly higher ultimate load to failure. CONCLUSIONS: (1) The CLC-IHM suture method is stronger with less work of flexion than the Strickland-IHM method. (2) This new, combination repair method of CLC core suture with IHM circumferential suture is biomechanically superior to the commonly performed Strickland-IHM technique.

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We present a case of inoculation of the first dorsal web space by a nurse practitioner who accidentally stuck herself while preparing Bacilli Calmette-Guérin vaccine for treatment of bladder tumor. We report the evolution and management of this resistant chronic Mycobacterium infection that ultimately required use of a vacuum wound management system followed by a microvascular free tissue transfer.

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Neurilemomas are the most frequently arising benign nerve tumors of the upper extremity and are also called Schwannomas. Generally, they present as solitary tumors, although multiple tumors are common. Regardless of number, they are usually found on the lexor surface of the forearm and hand, and multiple tumors are almost always located within a single major nerve, its branches, or both. We present three patients who had multiple neurilemomas; two patients had tumors within a single major nerve and its branches, and the third patient had an unusual occurrence of one tumor in the ulnar nerve and a second tumor in a branch of the median nerve.

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Although carpal fractures other than of the scaphoid are uncommon, vigilance in diagnosing these potentially serious fractures is paramount to early and effective treatment. Physical examination and standard plain radiographs may reveal only subtle findings. Use of special radiographic views and computed tomography may help elucidate the diagnosis. Treatment is particular to each fracture. Nondisplaced fractures should be treated nonoperatively. For intra-articular carpal bone fractures, virtually any amount of displacement is unacceptable and requires reduction and fixation. This article organizes current knowledge of these potentially difficult fractures, with a table of diagnosis and treatment guidelines.

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Seven children were treated surgically as a result of a pathologic fracture through a simple bone cyst in the subtrochanteric region of the proximal femur. Average age at surgery was 10.6 years. Six children were treated primarily. One child was operated for a refracture through a persistent cyst and malunion of a previous fracture that had been treated nonoperatively. Surgery included curettage of cysts in all patients. The cysts were filled with autologous bone graft in five patients and Osteoset bone substitute in two patients. The fracture was stabilized using a blade plate in three patients, a screw and side plate in three patients and an external fixator in one. At average follow-up of 4.7 years, all fractures had healed uneventfully. The cyst was fully obliterated in five patients and partially obliterated in two patients. One patient had a relative lengthening of 2 cm on the affected side. All patients were asymptomatic, fully active and had full range of motion.

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