Trapeziometacarpal joint arthrodesis: a functional evaluation.

Over a 10-year period, 39 trapeziometacarpal (TM) joint fusions were performed in 37 patients. Pin fixation was used in 27 fusions and staple fixation in 12; all were bone grafted. There were five delayed unions (greater than 3 months) and three nonunions. Twenty-four fusions were evaluated at an average of 4 years. Subjectively, there were 11 excellent, 7 good, 5 fair, and 1 poor result. Grip and pinch strength were symmetrical, and the nine-hole peg test (a measurement of dexterity) was slightly better on the treated side. X-ray films were taken and compared with 25 normal films to assess metacarpal mobility. There was a 72% reduction in the adduction/abduction arc and a 61% reduction in the flexion/extension arc. Despite the marked decrease in motion, subjective functional complaints were minimal. X-ray films were evaluated independently by a radiologist to assess progression of degenerative changes. Only two patients were noted to have changes at the scaphotrapezial joint.

Reconstruction of the anterior skull base after craniofacial resection.

Significant controversy continues as to how best to reconstruct anterior skull base defects after craniofacial resection with a view to minimizing the postoperative morbidity. Techniques varying from simple skin grafts to local and pedicled flaps, as well as bone harvested from a variety of sources have all been proposed. Careful review of the literature combined with personal experience with 34 anterior skull base defects following tumor surgery are presented in an attempt to develop a decision-making process to determine the ideal reconstructive technique for various situations.

Pilon fractures of the proximal interphalangeal joint.

A pilon fracture is an uncommon intraarticular fracture of the proximal interphalangeal (PIP) joint resulting in comminution, central depression, and splay, sagittally and coronally, of the articular surface of the base of the middle phalanx. This study reviews three treatment methods and results in 20 patients. Injury was produced by an axial load and occurred primarily to the ulnar digits. Clinical and radiographic follow-up averaged 25 months. Treatment was divided into three categories: splint (four patients), skeletal traction through the middle phalanx (seven patients), and open reduction with Kirschner pins (nine patients). Anatomic restoration of PIP articular contour was not achieved, regardless of technique. No patient regained full mobility at either interphalangeal joint. Treatment by immobilization is undesirable. Open reduction should be approached cautiously and may result in significant complications. Skeletal traction is safe and gives results that are radiographically and clinically comparable to those achieved with open reduction.

Microvascular reconstruction of the pharyngoesophagus with free jejunal graft.

Free jejunal graft reconstruction of the pharyngoesophagus has become reliable one-stage technique, but the microsurgeon must be aware of numerous pitfalls. Forty-two patients were retrospectively reviewed. There were four graft failures for a success rate of 90.5%. When harvesting the graft the thick fatty mesentery may make dissection difficult, and injuries to the mesenteric artery and vein can occur. Neck preparation can be tedious because of previous radiation, and size discrepancies with the carotid branches and the mesenteric artery are seen. Intimal dissection of the mesenteric artery can present as an isolated flap or a circumferential "rosette," despite the most careful preparation of the vessels; and great care must be taken in the microvascular anastomosis. The end-to-end arterial anastomosis to a branch of the external carotid and an end-to-side venous anastomosis to the internal jugular were preferred. Vein grafts are occasionally necessary.

Effects of glucose-saccharin preloads on schedule- and deprivation-induced drinking in rats.

The present series of experiments found that high volumes of a glucose-saccharin solution consumed by rats prior to testing (i.e., a preload) produced a small, but significant suppression of established schedule-induced drinking (Experiment 2). This reduction in polydipsic drinking did not appear to be due to the caloric value of the preload (Experiment 1) or to any changes in food motivation, since Experiment 2 showed that there were no changes in lever pressing on a fixed-interval 1-min food schedule. In Experiment 3, the glucose-saccharin preloads produced a complete suppression of water deprivation-induced drinking. While schedule-induced drinking does appear to be a nonhomeostatic form of drinking, under certain testing conditions, it is sensitive to manipulations which affect homeostatic thirst mechanisms.

Complications associated with free jejunal graft reconstruction of the pharyngoesophagus--a multiinstitutional experience with 52 cases.

Fifty-two patients who underwent reconstruction of the pharynx and esophagus using the free jejunal graft were retrospectively reviewed. The complications were categorized into those associated with the resection, those associated with the harvesting of the graft, and those related to the reconstruction per se. In this series, the graft failure rate was 7.6% with an overall success rate of 90.3%. Graft necrosis was found to be the most serious complication occurring in four patients. Methods of detection of graft necrosis and management of these complications are discussed.

Established hand infections: a controlled, prospective study.

A randomized, prospective study of 200 consecutive established hand infections was designed to compare the efficacy of two antibiotics, cefamandole and nafcillin. Bacteriologic data revealed 63.5% of the patients grew multiple organisms (2.3 organisms per culture) and 26% of the patients had anaerobic infections. Complications were noted in 13% of all patients--26% in patients who grew aerobes and anaerobes and 9.8% in patients who grew aerobes alone (p less than 0.05). Despite the fact that 95% of all organisms were sensitive in vitro to cefamandole whereas only 67% of organisms were sensitive to nafcillin (p less than 0.01), complications occurred more frequently in patients treated with cefamandole. We conclude that the empirical selection of a broad-spectrum antibiotic is reasonable based on in vitro sensitivity studies; however, other factors such as treatment delay, initial extent of infection, anatomic location of infection, cause of infection, and extent of surgical debridement are important in the development of complications.

Functional reconstruction of an extremity by free tissue transfer of the latissimus dorsi.

Fifteen lower extremities with large traumatic defects in the soft tissues were resurfaced by free microvascular transfer of the latissimus dorsi muscle and overlying skin. This procedure was particularly useful in four patients in whom a portion of the extremity had been acutely denuded of its soft-tissue sleeve, leaving exposed bone, joint, or tendon. It was also effective in eleven patients with chronic lesions who required additional reconstructive procedures (arthrodesis, internal fixation, bone-grafting, or tendon-grafting), and in the treatment of chronic osteomyelitis when infected bone and soft tissue had to be liberally debrided. In the eleven patients who had chronic osteomyelitis at the time of the transfer (five with infected, unstable tibial fractures), no subsequent drainage was evident at an average of twenty-two months' follow-up.

Intraperitoneal preloads of water, but not isotonic saline, suppress schedule-induced polydipsia in rats.

In Experiment 1, 10 ml intraperitoneal preloads of water completely suppressed the acquisition of schedule-induced polydipsia in four of six rats. Preloads of 10 ml of isotonic saline retarded the acquisition of polydipsia slightly, but there were no significant differences in asymptotic levels of water intake between Saline Preload and Sham Preload groups. Experiments 2 and 3 demonstrated that established polydipsia was suppressed by about 10 ml when 10 ml water preloads were given; whereas, 10 ml saline preloads had no significant effect on established polydipsia. These results demonstrate that schedule-induced polydipsia is sensitive to internal states of water balance.