An operative procedure for advanced Kienböck's disease. Excision of the lunate and subsequent replacement with a tendon-ball implant.

Excision of the lunate and subsequent replacement with a tendon implant was performed in 22 patients with Kienböck's disease between 1971 and 1985. This procedure was indicated mainly for those with advanced Kienböck's disease, i.e., stage III or IV according to the Lichtman classification. After the collapsed lunate is removed, a tendon-ball implant, made of the palmaris longus and plantaris tendons is placed in the resultant space in the carpus. A forearm distractor is applied during the operation, and distraction is continued for 4 weeks postoperatively. We report the long-term results in 15 patients, whose average follow-up period was 16 years and 3 months. One patient with infection was excluded from the study because the implanted tendon was removed 2 weeks after the operation, and 6 patients were lost to follow-up. All patients were free of pain after the surgery. The flexion-extension range of the wrist increased by 14.2 degrees, on average, after the surgery. The average grip power of the operated hand was 90.2% of that in the non-operated hand. Calcification and ossification were frequent in the implanted tendons a few months postoperatively. The average carpal height ratio (defined as carpal height/length of the third metacarpal) was 0.53 before the operation and 0.49 at the time of follow-up. According to Dornan's classification of clinical results, 9 of the 15 patients were classified as having excellent results and 6 as good.

Nerve regeneration over a 20-mm gap through a nerve conduit containing blood vessels in rats: the influence of interstump distance on nerve regeneration.

BACKGROUND: The present study was conducted in rats to investigate whether a tube with additional intrachamber vascularization could permit axons to extend over a distance greater than 10 mm, which appears to be the maximum axon regeneration distance for rat sciatic nerve axons through a normal empty tube. METHODS: A sural vessel-containing tube (VCT) was designed and interposed between transected sciatic nerve stumps in the thigh, leaving a 20-mm interneural gap. RESULTS: Twelve weeks after tubulation, six out of nine rats showed successful nerve regeneration and re-innervation of the soleus muscle using the VCT. At 24 weeks, intrachamber nerve regeneration and re-innervation of the soleus and pedal adductor muscles were electrophysiologically and histologically confirmed in all rats. However, no neural tissue was observed within any ligated sural vessel-containing tube (LVCT) or empty unmodified tube (ET) with a 20-mm interneural gap. When nerves regenerated in the VCT with a 20-mm gap were compared with those regenerated in a VCT with a 10-mm gap 12 and 24 weeks after surgery, the results produced by the VCT with a 20-mm gap were inferior to those after use of the VCT with a 10-mm gap, except for motor nerve conduction velocity at 24 weeks. CONCLUSIONS: The value recovered to almost identical levels (about 50-60% normal) in both groups.

Nerve regeneration over a 25 mm gap in rat sciatic nerves using tubes containing blood vessels: the possibility of clinical application.

This study was undertaken to investigate the effect of including vessels in a tube used to promote nerve regeneration across a gap. A tube containing sural vessels was designed in a rat model and interposed between the proximal and distal stumps of a divided sciatic nerve, leaving a 25 mm gap. At 12 weeks, a few myelinated axons were seen at the most distal parts of regenerated nerves in 6 out of 10 rats, none of which evoked action potentials in the tibialis anterior muscle, but by 24 weeks all the rats had developed neural tissue in the tubes, which evoked action potentials in the muscle. The vessels within the tube enhanced nerve regeneration and its distance up 25 mm. This type of vessel-containing tube would be useful for the repair of divided human peripheral nerves with long gaps, almost equivalent to or slightly longer than the maximum length over which nerve fibres can regenerate through a unvascularised unmodified tube.

Congenital metacarpal synostosis treated by longitudinal osteotomy and placement of a silicone wedge.

Three cases of congenital metacarpal synostosis are reported. Two had congenital synostosis between the fourth and fifth metacarpal, and one between the third and fourth metacarpal. Both hands were involved in the former cases, while only one unilateral hand was involved in the latter case. An abnormal abduction position of the finger was noted in early infancy, and this gradually progressed as the patients grew. Operations were performed between the ages of three to eleven years. Fused metacarpal bases were longitudinally osteotomized with a chisel, and a silicone wedge was inserted between the metacarpal bases. After the operation, the hand was immobilized with a plaster cast for four weeks. The follow-up periods range from two to sixteen years. The postoperative function and appearance of the hand were remarkably improved.

Relationship between axonal regeneration and vascularity in tubulation--an experimental study in rats.

This study investigated the effect of vascularity in a nerve conduit on peripheral nerve regeneration. The effect of three different types of tube (empty, blood vessel-containing and ligated vessel-containing) was compared using a rat sciatic nerve preparation with a 10-mm gap. Nerve regeneration through the vessel-containing tube was more efficient than in the other tubes 6 and 12 weeks after tubulation surgery, but there were no statistically significant differences among the three types of tube after 24 weeks. Electrophysiological, histological and microangiographic studies showed that vessels which were preinserted in the nerve conduit accelerated axonal regeneration through rapid capillary formation in the tube.

Flexor tendon growth in chickens.

We investigated the longitudinal growth of the flexor tendon in detail by marking tendons along their lengths in young chickens, using a microsurgical technique, and observing the separation of the marks at various times during tendon growth to establish normative standardized data on the longitudinal growth of flexor tendons. The interstitium throughout the entire tendon was found to increase in length, although the growth at the insertion zone was less marked than that in other areas. To determine the relationship between the growth of the tendon and the growth of the underlying bone, the lengths of the phalanges and metatarsus were measured. The distance from the insertion to the bifurcation of the tendon and the distance from the bifurcation to the most distal point of the musculotendinous junction also were measured. The findings suggest that the growth of tendon is proportionate to the growth of underlying bone. Tendon growth at the musculotendinous junction was studied in further detail, and no significant difference was found between growth at the most proximal zone of the tendon and growth at the zone within the musculotendinous junction.

A new strategy for treatment of suprascapular entrapment neuropathy in athletes: Shaving of the base of the scapular spine.

A study of three volleyball teams comprising 40 players demonstrated the frequent occurrence of infraspinatus muscle atrophy. Anatomic studies of the suprascapular nerve in 20 cadavers revealed the possibility of entrapment of the nerve at the spinoglenoid notch. Four athletes with suprascapular neuropathy were followed up after surgical treatment. Shaving of the lateral edge of the base of the scapular spine proved effective. However, it is suggested that preventive measures such as strengthening of the infraspinatus muscle are important because suprascapular neuropathy in athletes is combined to at least some degree with damage to the muscle itself.

Ventilatory and cardiometabolic responses to unilateral sanding in elderly women with ischemic heart disease: a pilot study.

This study was undertaken to investigate how 8 elderly women with ischemic heart disease would respond to a unilateral sanding activity. Three ventilatory measures-expiratory tidal volume, respiratory rate, and expiratory volume--and four cardiometabolic measures--metabolic equivalent, systolic blood pressure, heart rate, and pressure rate product--were continuously recorded during the sanding activity. The two independent variables were angle of the sanding board and sanding velocity. The activity was graded to yield five conditions: (a) sitting at rest; (b) 0 degrees at 15 cycles per min (cpm); (c) 0 degrees at 30 cpm; (d) 15 degrees at 15 cpm; and (e) 15 degrees at 30 cpm. The findings indicated that increasing the angle of the board while holding the velocity constant did not always increase the mean values of the ventilatory and cardiometabolic measures. However, increasing the velocity while holding the angle constant always increased the mean values of the dependent variables. The data also indicated that the metabolic equivalent reached during the sanding activity was no greater than 2, which corresponds to a light activity, such as playing a musical instrument. Replication of the study with a larger sample size may further elucidate the behavior of these two functions during a graded sanding activity. In the present study, a unilateral sanding activity by elderly patients with cardiac impairment was shown to provide valuable data on ventilatory and cardiometabolic functions. The study also demonstrated that a unilateral sanding activity can be safely used as a graded activity in occupational therapy for the cardiac rehabilitation of elderly women.

A pedigree of cervical stenosis, brachydactyly, syndactyly, and hyperopia.

Cervical myelopathy due to developmental cervical canal stenosis occurred in a 13-year-old boy. The patient's father and aunt also had an abnormally small cervical canal, although both were asymptomatic. The patient and his family had many congenital anomalies including hereditary brachydactyly, syndactyly, and hyperopia. The association of these anomalies seems not to have been previously reported in the literature.

Growth of autografted tendons: an experimental study in vivo.

The growth of transplanted tendons was investigated in 54 young chickens. The transplantations were done within the first week of life. The flexor digitorum profundus tendon in the digital sheath of the right third digit was replaced by a graft taken from the same tendon of the left third digit. The growth of the grafted tendons was measured and compared with control tendons at the first, fifth, tenth, fifteenth, and twentieth week after the operation. Five weeks after operation the grafted tendons showed the same growth rate as the control tendons. Although tendon growth was retarded compared with the control tendons 15 weeks after operation, it was not statistically different at 20 weeks.

Interaction of polymorphonuclear leukocytes with calcium pyrophosphate dihydrate crystals deposited in chondrocalcinosis cartilage.

Electron microscopy was used to investigate the characteristics of calcium pyrophosphate dihydrate (CPPD) crystals in chondrocalcinosis (pseudogout syndrome). Crystals in midzone cartilage were frequently seen adjacent to chondrocytes. Great variation in crystal size and shape was observed. Most of the pyrophosphate crystals that had been phagocytosed by polymorphonuclear leukocytes of synovial fluid from patients with acute pseudogout were small (less than or equal to 1 micron), indicating that small crystals can cause intense inflammation. Large numbers of polymorphonuclear leukocytes became attached to the eroded articular surface and phagocytosed microcrystals. Interaction of polymorphonuclear leukocytes with CPPD crystals in the superficial region of articular cartilage may stimulate the release of inflammatory mediators.

Congenital aplasia of the extensor muscles of the fingers and thumb associated with generalized polyneuropathy: an autosomal recessive trait.

Three sibs born to normal but consanguinous parents had flexion deformities of the thumb and fingers on one hand and sensory deficit in the other hand. Extensor muscles were absent or vestigial in all of them. Polyneuropathic electrophysiological findings were detected in 4 limbs. This is an apparently autosomal recessive trait previously unreported.

Diplopodia with reversed foot. Normal gait after operation at 8 years of age.

Diplopodia with the duplicated foot tucked up posteriorly, was reconstructed successfully in an 8-year-old boy. The knee joint, fibula and tibia were uninvolved; he had been walking on the dorsum of the foot wearing an ordinary shoe with the heel forward. The foot had ten toes, nine metatarsals and nine tarsal bones including one talus and one large calcaneus on which two Achilles tendons were inserted into two tuberosities. The lateral supernumerary foot was excised and the medial foot was dorsiflexed by almost 180 degrees by massive release and elongation of tendons. He could walk on his bare reconstructed foot without a brace 10 months after the operation.

Tendon excursion and moment arm of index finger muscles.

Tendon excursions during rotation of individual index finger were recorded continuously throughout the joints' ranges of motion. Both intrinsic and extrinsic muscles were studied during flexion--extension and abduction--adduction functions. Excursions and joint-displacement relationships were observed to not always be linear. Moment arms of tendons with respect to joint centers were further derived from excursion data. The significance of this information to tendon transfer techniques is discussed. These data are also important for theoretical modeling in muscle force determination.