Early recognition and treatment of volar plate injuries within two weeks is reported to give a good outcome, but there is no published information about the consequences of delayed presentation. We present a series of 14 patients with 16 injuries, who presented more than two weeks after the initial injury. All patients were referred to a specialist hand trauma clinic over a 10 months period and were evaluated prospectively and treated with immediate mobilisation by a specialist hand therapist. Mean time to presentation was 27 days (range 14-79) and mean improvement in range of movement was 25 degrees (range 2-52) with mean residual extension lag 10 degrees (range -4-56). All patients returned to their previous levels of function by the time of discharge. We conclude that it is possible to achieve good outcome without surgical intervention even when the presentation time is four weeks if experienced hand therapists manage the rehabilitation.

We set out this study to verify a hypothesis that orbital floor fractures tend to affect wider areas in patients with unilateral complete cleft palate. Using a striking machine, the inferior orbital rims of eight normal skulls (intact skull group) and eight skulls with parts of the maxillas removed to simulate alveolar and palatal clefts (cleft skull group) were impacted. The fractured areas were compared. Models designed using a computer were produced to simulate the skulls of 12 normal people and 12 patients with left unilateral complete cleft palate, and were classified as the intact model group and the cleft model group, respectively. Computer simulation of applying external forces to the inferior orbital rim of each model was performed. Areas where stresses exceeded the bone-yielding threshold were compared. Actual fractured areas were significantly larger in the cleft skull group than in the intact skull group. Theoretical fracture areas were also significantly greater in the cleft model group than in the intact model group. We conclude that orbital floor fractures develop in wider areas in patients with unilateral complete cleft palates, because of the instability of the maxilla on the cleft side.

Our aim was to evaluate the functional outcome of reconstruction of elbow extension in tetraplegia using a new technique for improving the attachment sites of posterior deltoid-to-triceps transfer in conjunction with an active rehabilitation programme. Ten tetraplegic patients (15 arms) had modified deltoid-to-triceps transfer using a tibialis anterior tendon graft. The operation included large overlaps between the tendon attachments, and additional security by anchoring the distal stump of the tendon graft to the olecranon. During the first 3 weeks of immobilisation, isometric contractions were made and during the following 4 weeks the flexion angle of the elbow was increased by 15 degrees a week; weights were also used to reinforce muscle strength. The mean follow up was 10 months (range 5-19). The elbow extension strength after posterior deltoid-to-triceps transfer was measured in horizontal and vertical planes. After rehabilitation the active range of motion and strength of elbow extension had improved substantially. The mean active elbow extension range of motion was 132 degrees (range 120 degrees -145 degrees ) and the elbow could be extended actively in all planes. Elbow extension strength was restored to well above the counteraction of the weight of the arm. Mean (SEM) elbow extension was significantly greater in the horizontal shoulder plane compared with the vertical plane (10.4 (1.0) compared with 6.5 (1.2) Nm, p < 0.001) and strength increased roughly linearly as the degree of flexion of the elbow increased. The most dramatic increase was in the range between 120 degrees and 135 degrees of flexion, regardless of the plane of action of the shoulder. We have shown good functional results and a shorter rehabilitation period using a rigorous suturing technique that allows for active strength and mobility training without additional adverse effects.

Nowadays direct repair is the treatment of choice for a lacerated flexor pollicis longus (FPL) tendon in any anatomical zone. Up to now repair with the motion-stable Mantero technique has not been published. Over a five years period (2004-2008) 21 complete divisions of FPL tendons in zones 1 and 2 were treated surgically with the Mantero technique. Seventeen patients were evaluated at a mean of 33 (range 14-59) months postoperatively by measuring the range of movement of interphalangeal (IP) and metacarpophalangeal (MP) joints and assessing the results with the Buck-Gramcko score. Fourteen of the patients reported excellent or good results. The mechanical rupture rate was zero. Mantero repair therefore provides a means other than more complex methods to repair FPL tendons and rehabilitation, adding strength while simplifying suture of the FPL.

Total joint prosthesis in carpometacarpal joint arthritis of the thumb often fails. Loosening of the implant is often treated by resection arthroplasty, and we reviewed 10 patients, mean age 54 years (range 47-63) who were treated by resection arthroplasty after a failed total joint prosthesis. The male:female ratio was 1:4 and the mean duration of observation 32 months (range 6-52). In three patients the revised implant was a MOJE uncemented carpometacarpal joint prosthesis and in seven patients an Elektra uncemented one. At follow-up grip strength was reduced to less than 90% of the other hand in eight of 10 patients, but the mean Disabilities of the arm, shoulder, and hand (DASH) scores, self-reported pinch-grip-related function, and pain were comparable with our earlier published results with the Elektra carpometacarpal total joint prosthesis.

We have developed a classification system for osteoarthritis (OA) of the scaphotrapeziotrapezoidal (STT) joint that can be used on posteroanterior, lateral, and oblique wrist radiographs. It can be used to communicate the degree of severity of arthritis, and to study arthritis in the wrist further. Currently we know of no classification system for OA of the STT. We devised a classification system and made an initial study to assess the reproducibility of the system. It was compared with a classification system similar to the Eaton classification of carpometacarpal OA of the thumb. Cohen's kappa test and the sign test were used for comparison. Thirty-seven of the 46 wrists evaluated (80%) showed radiographic evidence of osteoarthritis of the scaphotrapeziotrapezoidal joint. Most kappa values for intrarater and inter-rater reliability lay between 0.87 and 0.95. There was absolute agreement between both systems about the existence of osteoarthritis. When we compared the two classification systems, ours tended to underestimate the arthritic stage. This classification may be helpful for communication, comparison, and evaluation of osteoarthritis of the STT joint among surgeons. Further study is needed to define the clinical and mechanical relevance of osteoarthritis in this joint.

The most common complication of the minimally-invasive technique for the repair of pectus excavatum is displacement of the bar, and it may cause retraction of the chest. We aimed to find out if there was any factor that could predict displacement of the bar after operation. The records of 12 patients who were operated on for repair of pectus excavatum at the Osaka Medical College between December 1999 and August 2006 were analysed. Their mean age was 9 years (range 4-21). The mean Haller computed tomographic (CT) index was 4.9 (range 3.8-6.9). To predict the risk of postoperative rotation of the bar we considered patients' age, Haller CT index, intercostal distance where the pectus bar passed through, and the depression index. The bar was displaced in four patients, and there was a significant difference in depression index between those in whom the bar was displaced (n=4) and those in whom it was not (n=8). In the displacement group, it ranged from 25% to 38% (mean 32%), and in the undisplaced group from 15% to 27% (mean 18%). There was a significant difference between the groups (p< 0.01). Rotation of the bar is thought to be closely related to its stability at the deepest point of the depressed sternum. The depression index is useful in predicting the risk of rotation of the bar.

The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle-sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle-sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.

Excision of intramuscular venous malformations may damage intact functional muscles, and sclerotherapy is an alternative way of relieving symptoms. Several sclerosants are available, but selection of the optimal one is controversial. We report our clinical experiences of sclerotherapy, and experimental studies in rats that investigated muscular damage after injection of various sclerosants. For the clinical study, 10 patients with intramuscular venous malformations were reviewed who had been treated by sclerotherapy using ethanolamine oleate. The rate by which the volume reduced was assessed quantitatively using findings from magnetic resonance imaging (MRI). Pain was cured or improved in all cases, and volume reduced on imaging analysis. There were no severe complications such as renal failure or thromboembolism. For the experimental study, 62 Wistar rats were used to investigate the toxicity of sclerosants on the intact-muscle by injecting three types of sclerosants (100% ethanol, 5% ethanolamine oleate, and 1% polidocanol). After the injection of each sclerosant into the anterior tibial muscle, the daily measurement of the circumference of the legs, histological and morphological alterations in the muscles, and maximal isometric tetanic tension, were investigated. Swelling was most prominent with ethanolamine oleate, while destruction and atrophy of the muscle were most prominent after injection of ethanol. In the clinical study, the efficacy of 5% ethanolamine oleate was at least equivalent or possibly superior to that of 100% ethanol. In the experimental study, ethanol had a more detrimental effect on muscles than the other agents. We consider that ethanolamine oleate is the most suitable sclerosant for the treatment of intramuscular venous malformations.

An anonymous questionnaire was sent to 118 women who had their breasts reconstructed at the Department of Plastic Surgery, Ullevaal University Hospital, Oslo, from 1992-2001. The questionnaire included 36 questions scored on 6-point scales. Seventy-nine women returned a filled-in questionnaire. Five reconstruction methods had been used, but only implants (n = 32), lateral thoracodorsal flaps (n = 18), and transverse rectus abdominis musculocutaneous (TRAM) flaps (n = 12) had an acceptable number of cases for analysis. A total of 62 patients were included. Most of the cosmetic results differed significantly between the groups. Three-quarters of the patients in the TRAM group were very satisfied with the overall cosmetic results, compared with 11/18 in the lateral thoracodorsal flap group and 11/32 in the implant group. There were general good effects in all groups from the physical, social, and psychological points of view with no significant differences between them. However, achieving symmetry between breasts and the satisfaction about information given to patients about the procedures were two areas that fell short. Fifty (81%) of the 62 women would have recommended the operation to a friend under similar conditions.