Mycotic aneurysm in a free flap.

A 41-year-old man developed a 3 x 4 cm wound after corrective osteotomies of his distal tibia and fibula. The wound was debrided and covered with a free gracilis muscle flap. Seven days after flap transfer, the arterial pedicle ruptured adjacent to the anastomosis. Attempted repair of the aneurysm failed and the graft was subsequently debrided. Intraoperative wound cultures grew Pseudomonas and Enterobacter cloacae, which were attributed to formation of the aneurysm.

Ligament reconstruction basal joint arthroplasty without tendon interposition.

The necessity of tendon interposition for the maintenance of joint space after basal joint resection arthroplasty with ligament reconstruction has not been established. A prospective, randomized study was performed. In Group I (nine patients), ligament reconstruction was performed to suspend the first metacarpal in addition to placement of a rolled tendon interposition to fill the void created by resection of the trapezium. In Group II (11 patients), ligament reconstruction alone was performed, with use of a Mitek suture anchor. No tendon interposition was performed. This allowed use of a more limited incision and shorter length of tendon graft. Average followup was 23 months. There was no difference between the two groups in range of motion of the thumb, grip strength, lateral pinch strength, the ability to perform activities of daily living, or subjective satisfaction with the procedure. Two- and three-point pinch strength was statistically significantly greater in Group II. Lateral radiographs of the basal joint at followup, at rest and with pinch, showed maintenance of the joint space, and no difference between the two groups. Tendon interposition is not necessary for maintenance of joint space after basal joint resection arthroplasty if ligament reconstruction is performed.

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor.

Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.

Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve.

An anatomical study was performed to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. In ten cadaveric specimens, the radial nerve was found to cross the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. As it crossed the posterior aspect of the humerus in each specimen, the nerve had several branches to the lateral head of the triceps; however, no branches were found innervating the medial head of the triceps in the posterior aspect of any of the specimens. At the lateral aspect of the humerus, the nerve trifurcated into a branch to the medial head of the triceps, the lower lateral brachial cutaneous nerve, and the continuation of the radial nerve into the distal part of the upper arm and the forearm. Three operative approaches were performed in each specimen. The posterior triceps-splitting approach exposed an average of 15.4 +/- 0.8 centimeters of the humerus from the lateral epicondyle to the point at which the radial nerve crossed the posterior aspect of the humerus. For the second approach, the radial nerve was mobilized proximally to allow an additional six centimeters of the humeral diaphysis to be visualized. The third approach (the modified posterior approach) involved the identification of the radial nerve distally as it crossed the lateral aspect of the humerus, followed by reflection of both the lateral and the medial heads of the triceps medially. This exposure permitted visualization of 26.2 +/- 0.4 centimeters of the humeral diaphysis from the lateral epicondyle proximally. The results after use of the modified posterior approach in seven patients were also reviewed.

Revision total elbow replacement.

Revision total elbow surgery is technically demanding with high complication rates. It requires precise preoperative planning and a surgeon prepared to use any of several surgical options during surgery. Satisfactory results can be achieved in complex cases.

The history of Kienböck's disease.

The history of Kienböck's disease is outlined from its description in 1910 in Europe, to its acceptance as a disease entity in the United States, to the advent of therapeutic surgical treatment in 1950. The concepts developed during this period, such as the association of ulnar variance and Kienböck's disease, are the basis for many of the present day surgical interventions performed.

Gastrocnemius muscle flap coverage of exposed or infected knee prostheses.

A retrospective analysis was performed of 12 patients who required soft-tissue coverage of an exposed or infected total knee prosthesis between 1982 and 1989. All knees had skin closure with medial gastrocnemius muscle flaps. At a mean follow-up period of 41 months, all patients who were treated for infected prostheses with removal of the implant, intravenous antibiotics, and muscle flap closure had an excellent clinical result with complete skin coverage and no infection. Five of the six patients went on to successful reimplantation. Of the patients with an exposed prosthesis, five of six had an excellent outcome with retention of the prosthesis. Thus, 11 of 12 patients (92%) who had medial gastrocnemius flap coverage of an exposed or infected knee prosthesis had an excellent outcome, with ten of 12 patients (82%) retaining their prostheses or having a successful reimplantation. No medial gastrocnemius flap failed after standard primary or revision total knee arthroplasty. Gastrocnemius muscle flaps provide excellent soft-tissue coverage of exposed or infected knee prostheses and facilitate surgical care of this difficult problem.

Vascularized bone grafts to the upper extremity. Indications and technique.

Massive autogenous bone grafts with an intact vascular pedicle decrease the time to bony union and immobilization required for treatment of segmental bony defects. These techniques have been shown to be effective in treatment of segmental defects of more than 6 cm after trauma or tumor resection in relatively avascular beds. Additionally, in the upper extremity, the free vascularized bone graft is in the developmental phase for employment in the reconstruction of epiphyseal arrest and congenital radial club hand. There are disadvantages to free vascularized bone transfers compared with conventional techniques. For example, a free vascularized fibular transfer requires a team skilled in microvascular technique, a long operative time (6 to 10 hours), and the sacrifice of a major vessel to the lower extremity. If the anastomosis fails, however, the free vascularized fibula will act as a conventional bone graft, thereby minimizing adverse effects. We think that by proper patient selection, appropriate evaluation and preparation of the bony defect, meticulous microvascular anastomosis, and correct fixation and immobilization of the graft a good outcome can be achieved in those patients with large bony defects that defy the use of conventional methods.