Endoscopic carpal tunnel release using the single proximal incision technique.

The goal of the single incision endoscopic technique is to avoid an incision on the palmar surface of the hand. As compared with open release and the two-portal endoscopic technique for release of the carpal tunnel, this single incision technique permits the patient to return earlier to work and activities of daily living as a result of less tenderness and earlier return of strength. Safe performance of the technique requires that the surgeon have both a thorough knowledge of the anatomy of the hand and a commitment to master the technical details of the surgical approach. Because the technique is of value strictly to view and divide the TCL, patient selection requires careful preoperative evaluation to exclude those carpal tunnels with pathology that requires direct inspection or surgical treatment. In a prospective study with the redesigned point of entry blade assembly that allows a view of the blade's entry into the ligament, no device-related complications occurred. In considering a surgical approach for endoscopic carpal tunnel release, the authors feel that it is important to recognize the value of an "open" proximal surgical incision designed to directly view the plane between the finger flexor synovium and the deep surface of the TCL. Stab wound "portals" that are widely used in arthroscopic surgery are inadequate for endoscopic carpal tunnel releases. The device and the procedure are designed to obtain an unobstructed view of the underside of the TCL and divide it completely. Additional long-term prospective studies are needed to define the comparative recurrence rates of open versus single incision endoscopic carpal tunnel release surgeries.

Wrist injuries: correlation of clinical and arthroscopic findings.

Wrist arthroscopy was done for one hundred nine patients with chronic wrist pain, averaging 22.8 months in duration. History regarding mechanism of injury, painful crepitus, pain with activity or at rest, localization of tenderness, visible swelling, and instability with examination was compared with arthroscopic findings of ligament damage, articular cartilage damage, and synovitis. Both pain at rest and swelling correlated significantly with synovitis. Tenderness did not correlate with specific ligament injury. Wrist ligament injuries and/or cartilage damage were noted in 96.3% of these wrists. Ligament injuries were frequently multiple, averaging 2.6 ligament injuries per wrist. No significant association was found between the presence of chondromalacia, synovitis, or specific ligament tears and the mechanism of injury, duration of symptoms, presence of clicking, or pain with activity.

An anatomic guide for arthroscopic visualization of the wrist capsular ligaments.

Wrist arthroscopy allows examination of the palmar capsular wrist ligaments without extensive exposure. Arthroscopic examination of the wrist requires an accurate knowledge of the ligamentous anatomy as seen from inside the joint. In this study 13 fresh cadaver wrists were examined from the inside out to provide a visual guide for ligament identification during arthroscopy. The major palmar capsular ligaments seen from the inside of the wrist at the radiocarpal joint include the radioscaphoid, radioscaphocapitate, radiolunate, radioscapholunate, ulnolunate, ulnotriquetral ligaments, and the ulnar capsule. At the midcarpal joint, the scaphocapitate, radioscaphocapitate, triquetrocapitate, and triquetrohamate ligaments are identified palmarly. Dorsally, constant capsular structures at the radiocarpal joint are the radiolunate and radioulnotriquetral ligaments along with a prominent synovial fold.

Studies on interactions of dTK-HSV mutants with neurons in vitro.

Thymidine kinase negative (dTK-) mutants of herpes simplex virus type 1 (HSV-1) multiplied well in rat brain glioma cells. A proportion (less than 1%) of glioma cells survived the infection with HSV and were designated "survivor" glioma cells. Survivor cells of dTK- mutant virus infection ceased to produce infectious virus after two passages and were highly resistant to both HSV-1 and HSV-2 but not to vesicular stomatitis virus (VSV). Flow cytometric studies indicated morphological differences between parental and survivor glioma cells, and HSV-1 specific antigens as well as DNA were detected in the survivor glioma cells, but only in early passages. Sensitivity to superinfection with HSV appears to correlate to loss of HSV-specific viral DNA in the survivor glioma cells. Survivor glioma cells after several subcultures lost their ability to resist superinfecting HSV, reverted morphologically to the appearance of parental glioma cells and also lost significant amount of HSV-1 specific DNA. These transient survivor glioma cells became persistently infected-virus producer cells upon HSV infection.

The trapezium-thumb metacarpal joint: the relationship of joint shape and degenerative joint disease.

An investigation of sixty-seven embalmed cadaver hands was performed to determine if the topography of articular surfaces was related to thumb basal joint arthritis. The trapezial articular surface tended to be flatter in women and joints with early degenerative changes. The trapezial surface was transformed from a saddle type to a semi-cylindrical type with advancing arthritis.

Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study.

The accuracy of radiographic evaluation of the pantrapezial joints and the anatomic incidence of pantrapezial arthrosis, were studied by comparing radiographs with anatomic dissections of 68 cadaver hands. When the trapezium-thumb metacarpal joint demonstrated degenerative changes, multitrapezial joint changes were noted in 73% radiographically, but in only 46% anatomically. The major reason for this discrepancy was a radiographic misinterpretation of the nature of osteophytes near the trapezium-index metacarpal joint. Anatomic changes of degenerative joint disease were noted in 60% of the trapezium-thumb metacarpal joints and 34% of the trapezium-scaphoid joints. Degenerative joint changes were rare in the trapezium-index metacarpal and trapezium-trapezoid joints. Routine anteroposterior, lateral, and oblique radiographs of the hand cannot be depended upon to provide adequate visualization of all the trapezial joints.

Transferring the flexor superficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability.

Transfer of the flexor digitorum superficialis tendon to restore functional loss may result in a flexion contracture or hyperextension deformity of the proximal interphalangeal joint of the donor finger. Removal of the flexor tendon through the membranous interval in the fibro-osseous sheath between the annular pulley (A2) and the proximal collar (A1) avoids scarring of the structures volar to the proximal interphalangeal joint. Sixteen flexor superficialis tendons were removed at this membranous interval for transfer. No functional impairment from flexion contracture or hyperextension deformity developed after operation in the donor fingers, although an average 8 degrees of loss of extension was noted at the proximal interphalangeal joint in 50% of the donor fingers.

Current status of total knee replacement.

Correction of deformity and relief of pain in advanced arthritis of the knee joint can be obtained by implantation of a total knee prosthesis. For the painful, mildly damaged knee, the Charnley prosthesis may be used, while in the more moderately damaged knee, the geometric prosthesis may be indicated. For the unstable, severely damaged knee, a constrained prosthesis may be implanted. These knee prostheses can be used to treat knees which previously were not amenable to surgical correction, except by arthrodesis.

Sodium nitroprusside-induced hypotension for supine total hip replacement.

Deliberate hypotension was produced during general anesthesia by the infusion of sodium nitroprusside in 13 patients undergoing total hip replacement. Hemodynamic data from these patients were compared with those obtained from 5 patients under normotensive anesthesia for the same procedure. During the hypotensive period, which averaged 1.5 hours, the cardiac index rose 20 percent compared with controls. No acidotic tendency was seen. Blood loss in the study group averaged 475 ml, compared with 1475 ml in controls. From these data, a dose-response curve was derived which may allow the accurate prediction of the minute dosage of sodium nitroprusside required to safely induce hypotension during anesthesia.

Clinical diagnosis of Down's syndrome.

A physical examination checklist of 25 signs of Down's syndrome was used to predict the presence of absence of 21-trisomy in 291 individuals examined for suspected Downs syndrome. Using only total numbers of signs present, 21-trisomy was unambiguously predicted in about half those examined. Discriminant analysis using the most informative 10 signs misclassified only 11 of 169 infants aged 2 years or less, and allowed non-overlapping classification into Down's and non-Down's of almost three-fourths of suspected individuals. The risk for Down's syndrome in the overlap area was 58%.