Correction of syndactyly: advantages with a non-grafting technique and the use of absorbable skin sutures.

Correction of syndactyly without skin grafts is simple and reliable. Combined with an absorbable suture technique the non-grafting method is further advantageous minimising risks and saving time and costs. Three methods are compared: skin grafts plus monofilament polyamide (Ethilon, Ethicon) (n = 32), no skin grafts plus Ethilon (n = 19), and no skin grafts plus polyglactin 910 (Vicryl rapide, Ethicon) (n = 9). The two groups in which grafting was not used had significantly shorter operations (mean 86 minutes compared with 118 minutes) and fewer complications. They also required fewer operations and spent less time in hospital.

Mycobacterium marinum wrist arthritis: local and systematic dissemination caused by concomitant immunosuppressive therapy.

The diagnostic difficulties and the potential serious course of Mycobacterium marinum synovitis are illustrated in a patient in whom treatment with local steroid injections and immunosuppressive therapy resulted in local destruction of the wrist and systemic reactions. Healing was achieved after correct medical and surgical treatment was initiated.

A case of digital glomus tumour: misdiagnosis and verification by magnetic resonance imaging. Case report.

A patient with a digital glomus tumour had for years been misdiagnosed as having ulnar nerve entrapment. The correct clinical diagnosis was verified by magnetic resonance imaging (MRI) and excisional biopsy.

Multifocal neurilemomas in the same upper extremity. Case report.

Multifocal neurilemomas in different nerves of the same upper extremity are rare. A 36-year-old woman presented with five neurilemomas involving the main trunks of the median and radial nerve and digital nerves of her left upper extremity. These were excised and she recovered without complications. Fifteen years later she presented with several recurrences which were removed, and two years after that she required a further operation to excise tumours. At the time of writing she has at least five tumours on different nerves of her left arm but these are causing her no problems.

Syndactyly correction without skin-grafting.

Syndactyly correction results in skin deficiency. Skin grafting is avoided by the use of an extended dorsal interdigital flap for the web and approximation of the side flaps to cover the length of the digits. The technique has been used in 17 cases with all varieties of syndactyly. There were no early complications. The follow-up averaged 2 years. There were two cases of web creep but no contractures. The method combines the advantage of direct suture with an acceptable frequency of web creep.

Palmar dislocation of the trans-scaphoid-lunate unit.

A rare case of total palmar trans-scaphoid-lunate dislocation is reported. Open reduction, bone grafting and internal fixation were followed by uneventful healing. At follow-up 70 months after injury there is no osteonecrosis and the wrist function is almost normal.

The distally-based dorsal hand flap for resurfacing skin defects in Dupuytren's contracture.

Surgery for recurrence of Dupuytren's disease often results in a volar skin defect. The use of the distally-based dorsal hand flap for resurfacing is reported. 17 flaps were used to cover 16 fingers after radical digital fasciectomy. All flaps survived with minor areas of partial necrosis in four of them. The raising of the flap was a simple procedure and good quality skin cover was achieved. There were no complaints about the donor site or the flap pedicle passing between the digits. The short post-operative immobilization time might result in less stiffness and a better functional result. It is concluded that the flap is a useful technique in treating skin defects in this condition resulting from surgical excision of the disease and involved skin.

Post-traumatic neuralgia in the upper extremity treated with extraneural scar excision and flap cover.

19 patients with neuralgia in the upper limb after surgical or non-surgical trauma to peripheral nerves were treated by excision of the extraneural scar and surrounding hypersensitive skin and application of free or pedicle flaps. The subcutaneous fat of the flaps was wrapped around the affected nerves. After a mean follow-up time of 5.8 years the patients were sent a questionnaire. Only one patient considered herself cured, six were almost cured and seven improved. Two patients were unchanged and three worse. The results after three to four months appeared stable.

The free scapular flap. An alternative to conventional flaps on the upper extremity.

The free scapular flap was used as an alternative to a conventional pedicle flap in resurfacing scarred areas and padding major nerve trunks on the upper extremities in a series of 8 patients. The free flap proved to be rather reliable (one failure), convenient to the patients and cheaper for the Health Service than a conventional flap.

Wrist denervation and compression of the lunate in Kienböck's disease.

Thirteen wrists with Kienböck's disease, stage III or IV, were denervated. Three wrists were examined repeatedly over a period of 2 1/2 years prior to operation, showing the natural course of lunate compression. The remaining 10 wrists were operated on sooner after diagnosis and the lunate compression was compared with the natural compression course. The hypothesis that wrist denervation was detrimental to the lunate was not supported by the present material.

Flap coverage for post-traumatic nerve pain in the arm.

14 patients with painful neuroma, skin hyperesthesia or neuralgic rest pain were followed up (mean 20 months) after excision of skin and scar, neurolysis and coverage with pedicled or free flaps. Painful neuroma had improved in 3 of 7 patients. Skin hyperesthesia had been eliminated in 8 of 11 patients, and had improved in 3. Neuralgic rest pain had been eliminated in 5 of 6 patients, and was partially relieved in one. It is concluded that painful neuroma in continuity is not relieved by flap coverage, whereas skin hyperesthesia and neuralgic rest pain are appropriate for this type of treatment.

Thumb replantation or not?

Over a three-year period 14 consecutive cases of amputated thumbs, 10 complete and 4 incomplete, were replanted/revascularized. Eight thumbs (57%) survived. These cases were compared with a control group, in which replantation had failed or had not been attempted. The control group was chosen to be as similar as possible with respect to thumb amputation level, type of trauma, age, occupation and sex. Costs for hospital care, duration of sick leave and disability rate were calculated. Hand function was estimated as the ROM of the thumb, power of pinch and grip, two-point discrimination and ability to perform a standardized hand function test (Sollerman). It was concluded that replantation yields better functional and social results than alternative treatment of thumb amputation at similar costs.

Elimination of protease-inhibitor complexes from the arthritic joint.

In the rheumatic joint, destructive proteolytic enzymes are released and counteracted by complexation to the predominant inhibitors alpha 2-macroglobulin and alpha 1-antitrypsin. The articular elimination of these complexes is thought to be of decisive importance in the protease-inhibitor interplay influencing the inhibitory capacity of the synovial fluid. Protease-alpha 2-macroglobulin complexes showed an intraarticular half-life shorter than 2 hours in arthritis and were eliminated by various routes including phagocytosis in cells of the synovial membrane and in regional lymph nodes, in addition to haematogenous resorption and uptake in the liver. The phagocytosed complexes were degraded to low-molecular-weight metabolites excretable in the urine. The articular elimination of elastase-alpha 1-antitrypsin complexes seemed to be an equivalent process, but an additional intrasynovial dissociation of the complexes was also indicated. Thus the intraarticularly released elastase seemed to be bound and eliminated in complex with alpha 2-macroglobulin.

Silicone carpal implants: risk or benefit?

The present report is based on assessment of 48 patients who underwent carpal Silastic H.P. implant arthroplasty (trapezium, condylar, scaphoid, lunate and scapholunate implants). Mean follow-up period was 29 months (range 6-82). Recurrent pain and/or evidence of wrist synovitis and lytic lesions made early subsequent surgery necessary in 10 patients. In the remaining 38 patients the post-operative course was followed for an average period of 33 months (range 8-82). Severe giant-cell silicone synovitis combined with isolated or disseminated osteolytic lesions were found in 17/30 (56%) patients with scaphoid or lunate implants and in 2/18 (11%) with other types of Silastic carpal implants. Well-defined cysts were observed within 8 months of insertion of the implant. Morphologically, an erosive giant-cell synovitis was regularly seen, with large quantities of intra- and extracellular silicone debris. Abraded material was also observed in central parts of normal bone and in lymph node tissue distant from the implant. The ultimate tissue response to this propagation of silicone particles is unknown. The situation is of great concern and the continued use of proximal carpal Silastic H.P. implants should at present be seriously questioned.

Protease inhibitors in rheumatoid synovial fluid: a quantitative analysis.

The concentrations of the main endogenous inhibitors of granulocyte proteases (anti-leukoprotease, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and alpha 2-macroglobulin) were estimated in paired samples of synovial fluid and serum/plasma from seropositive rheumatoid arthritics and controls. Rheumatoid synovial fluid contained significantly higher levels of all inhibitors except antileukoprotease. The influence of the synovial membrane on these concentrations was taken into account by comparing the ratio between the observed concentration and that predicted from a certain regression curve fitted to a set of non-inhibitory reference proteins of extra-articular origin (orosomucoid, albumin, and ceruloplasmin). Divergences were interpreted as the net result of intra-articular production or consumption of the inhibitor in question. The results suggested a consumption of antileukoprotease and alpha 1-antitrypsin in the rheumatoid joint, while the increased levels of alpha 1-antichymotrypsin and alpha 2-macroglobulin probably reflected the altered trans-synovial membrane protein flux with some reservation for alpha 2-macroglobulin.

The looping procedure. An alternative method of thumb restoration.

An alternative method of thumb restoration is described, using a damaged finger of inferior functional value as a composite pedicle. After removing the proximal and distal phalangeal bones as well as the nail region, the finger, now carrying the midphalangeal bone only, is reversed and attached to the remnant of the thumb. The method is most useful after severe mutilations.

Median nerve compression complicating arthrodesis of the rheumatoid wrist.

The frequency and pathogenesis of median nerve compression complicating the Rush pin method of fusing the rheumatoid wrist was evaluated retrospectively. This complication was encountered in 14/50 wrists (28%). In 7 hands the carpal tunnel was explored, mostly within 2 weeks after fusion. In addition to signs of acute entrapment of the median nerve the most constant finding was that the volar edge of the resected distal end of the radius was prominent and projected into the bottom of the carpal tunnel caused by too vigorous correction of the subluxed carpus. Obviously the median nerve was squeezed or angulated at the volar edge of the radius. After median nerve release and resection of the bony prominence all patients regained full sensibility within the period of observation (in average 2.5 years). It is concluded that this mechanism of nerve entrapment should be realized when fusion of a severely destructed rheumatoid wrist is considered.

Denervation of the wrist.

In a series of 48 painfully restricted wrists denervation was used during a 6-year period on wide indications as a surgical alternative. The observation time averaged 2.4 years. Pain relief occurred in 56% of the patients. Considering the simplicity of the method and the lack of serious complications, it is concluded that denervation of the wrist is worth trying as a palliative measure prior to more extensive surgery.

Immunoreactive granulocyte elastase in rheumatoid synovial fluid and membrane.

A specific radioimmunoassay (RIA) was utilized to determine granulocyte elastase in the synovial fluid of a series of 45 rheumatoid joints in 39 patients. The average concentration was approximately 340 micrograms/l, exceeding that of the paired serum sample in all but 6 cases. No correlation was noted in synovial fluid between its content of granulocyte elastase and the total number of white blood cells. The concentrations in sera from rheumatoid patients with non-steroidal anti-inflammatory agents and controls were equivalent. Non-inflammatory exudates contained low concentrations of elastase. The immunoreactive granulocyte elastase in rheumatoid synovial fluid was bound to alpha 1-antitrypsin suggesting release of the enzyme in its active form. An uptake of elastase-containing complexes by macrophage-like cells in the synovial membrane was demonstrated by immunohistochemical staining of tissue using antiserum against granulocyte elastase. The concentrations of immunoreactive granulocyte elastase in the free synovial fluid of rheumatoid arthritic joints presumably only faintly reflect the situation concerning the target substrates.