Evaluation of dural closure techniques. Suture methods, fibrin adhesive sealant, and cyanoacrylate polymer.

A study was undertaken to investigate the relative strengths of dural repair using standard suture techniques, suture supplemented with tissue adhesive, and tissue adhesive alone. The efficacy of two tissues adhesives, fibrin adhesive sealant and cyanoacrylate polymer, as adjunctive or the sole means of effecting dural closure, was studied. In vitro analysis of repair techniques was accomplished using fresh human cadaveric dura. Uniform 4 mm defects were created, repaired using various techniques, and then subjected to pressurization testing. Defects repaired with suture alone leaked at pressurization levels within the physiologic range, while those supplemented with tissue adhesives failed at higher pressurization levels. In vitro testing, accomplished in white New Zealand rabbits, supported this conclusion. Histologic sections obtained from dura treated with fibrin adhesive sealant demonstrated minimal inflammatory response, while those sections obtained at the site of dural repair augmented with cyanoacrylate polymer featured significant inflammatory responses, including dural thinning, gliosis, and cortical necrosis. Results indicate that a new substance, fibrin adhesive sealant, appears to have application as an adjunctive means of effecting dural closure.

Traumatic atlantal anterior arch fracture with associated avulsion fracture of the transverse ligament attachment: a previously undescribed combined entity.

A case of an atlantal anterior arch burst fracture combined with an avulsion fracture of the transverse ligament attachment is presented. Similar cases have dealt with either isolated transverse ligament ruptures and avulsions or with Jefferson fractures associated with transverse ligament ruptures and avulsions. This case probably represents an entity in the spectrum of injury patterns to the atlanto-axial articulation.

Proximal interphalangeal joint arthroplasty.

Prosthetic implant arthroplasty of the proximal interphalangeal (PIP) joint has a limited role in the reconstruction of the rheumatoid hand. Ninety-three PIP joint arthroplasties, including 56 Flatt, 30 Swanson, and seven Niebauer implants, were reviewed with postoperative follow-up periods averaging 6.2 years. The average maximum extension/flexion for the prostheses were Flatt, 28 degrees/45 degrees; Swanson, 1 degree/40 degrees; and Niebauer, 3 degrees/26 degrees. The average active ranges of motion for the prosthetic groups were Flatt, 15 degrees; Swanson, 37 degrees; and Niebauer, 19.5 degrees. Analysis of active motion at intervals of up to ten years indicated gradually decreasing active motion for each prosthesis. Comparison of preoperative motion with motion three years after operation indicated a decrease in the Flatt prosthesis group, from 35 degrees to 20 degrees. Radiographically, cortical perforation by the prosthesis was common with the Flatt prosthesis (80%), and recurrent swan-neck deformity was frequent with the Swanson spacer (27%). Despite suboptimal clinical results, patient satisfaction was high, and the ability of patients to perform activities of daily living was acceptable.

The absent fifth metacarpal.

Although many patterns of metacarpal abnormalities have been described, the congenital anomaly of complete or partial absence of the fifth metacarpal has not been well defined. This article reports on seven patients with longitudinal partial or complete absence of the fifth metacarpal with the ulna and the three phalanges of the little finger present.

Hinged total elbow replacement.

Total elbow arthroplasty using a hinged prosthesis was performed on 17 elbows in 12 patients. Clinical follow up ranged from 18 to 85 months, and averaged 56 months. Indications for surgery included disabling pain, restricted motion of the elbow, and roentgenographic evidence of joint destruction. We did not use this prosthesis in patients with restricted shoulder motion or in those with demanding occupational or recreational activities. Fifteen elbows showed good results; one elbow was complicated by ectopic ossification, and one prosthesis was removed for a deep wound infection. No other instances of symptomatic loosening were found, although radiographs demonstrated a lucent line around the cement in four elbows and a cement fracture in one elbow. All patients were relieved of their pain. The low incidence of loosening may be explained by the selective use of the hinged prosthesis. Index Terms: elbow, arthroplasty, hinged prosthesis.

Treatment of chronic elbow instability.

Four patients developed chronic elbow instability following closed traumatic dislocations. All patients had disruption of the anterior capsule of the elbow joint with avulsion of the brachialis from its insertion on the coronoid process. Repair of the anterior soft tissues restored elbow stability with minimal difficulty and no significant complications.

Lyme arthritis in Wisconsin.

Rash, severe constitutional symptoms, and arthritis developed in three persons who were bitten by ticks in Wisconsin. On comparison with other reports of arthritis related to tick bites, we found that the illness of our patients had clinical features consistent with Lyme arthritis. Lyme arthritis appears not to be restricted to New England as has been previously reported.

Pentasomy X with multiple dislocations.

We describe a pentasomy X (49,XXXXX) patient whose multiple dislocations led to a consideration of the Larsen syndrome. Review of the 11 reported cases of pentasomy X showed that elbow dislocations are known to occur in this syndrome. Our patient is the first to present hypoplasia of the glenoid process with consequent should dislocation. Clinical and radiologic findings of previously reported cases of pentasomy X are reviewed.