Replantation and revascularization of the digits in a community microsurgical practice.

One-hundred and twenty-seven digits in Verdan zones I and II, and 24 thumbs in 106 patients were reviewed from 1979 to 1995. Patients were all followed for a minimum of 5 months to assess early results and complications, and to determine if a short course (minimum 3 days) of dextran 40 anticoagulation adversely affected digit survival. The total survival rate was 88 percent. Digits with only a single artery and vein repaired had a significantly higher rate of failure (p > .05). Index and small fingers also showed a trend toward lower survival. Vein grafts were used in 22 percent of cases. No vascular problems were noted after 5 days. Variables not affecting survival were: presence of a joint fusion, type of fixation, level of injury, number of digits, mechanism of injury, and use of vein grafts. The average hospital stay for the group was 6.5 days (+/-SD 3.3). No complications were seen with dextran use. A total of 51 complications were seen overall and the non-union rate was 10 percent. Community-based replantation and revascularization can be performed with early results equivalent to prior published studies. Complications are to be expected and demand expeditious treatment. Functional recovery of severed digits remains the benchmark for success in these injuries, however, lost digits never work.

Ulnar nerve compression at the arch of origin of the adductor pollicis muscle.

The motor branch of the ulnar nerve can be compressed by the arch of origin of the adductor pollicis muscle. There can be a well-defined band of tissue either at the point where the nerve crosses the third metacarpal or where it penetrates the adductor muscle. In over half of the cadaver hands studied no arch was demonstrated. Clinically these patients present with obvious atrophy of the first dorsal interosseous and adductor muscle. Usually pain is not a prominent symptom. This type of ulnar nerve compression neuropathy is present in less than 1% of those ulnar neuropathies that occur at the wrist and hand.

Computer-generated bone models in the planning of osteotomy of multidirectional distal radius malunions.

Computer-assisted design and manufacturing technology has been used to create solid models of five unusually complex, multidirectional malunions of distal radius fractures. Preoperative planning was dramatically enhanced by the ability to perform the surgical procedure on these models, with a model of the uninjured limb used for comparison. All five patients had significant malunions, with malrotation in the horizontal plane in five and an impacted articular fragment in two. A satisfactory outcome was achieved in each case.

Treatment of mediastinitis after heart transplantation.

Mediastinal infection carries a high mortality in any heart surgery patient. The risks are even greater after heart transplantation. We present two cases of mediastinitis in heart transplant patients. The first patient was successfully treated with closed mediastinal irrigation. The second patient was initially treated with closed mediastinal irrigation, developed recurrent infection, and subsequently responded to a muscle flap operation. A review of the literature and our own experience suggest that muscle flaps should be applied earlier in heart transplant recipients with severe or recurrent mediastinal infections.