Complex dislocation of the index metacarpophalangeal joint with entrapment of a sesamoid.

Entrapment of a sesamoid in a complex dislocation of the index metacarpophalangeal joint is a rare finding that may make even open reduction difficult. A case of unusual anatomic derangement of the volar plate is reported that highlights the underlying pathophysiology of complex dislocations.

Comparison of the operating microscope and loupes for free microvascular tissue transfer.

A retrospective study of 200 consecutive free microvascular tissue transfers over a 3-year period was done to compare the performance of free-tissue transfers with loupes and with the operating microscope. One-hundred and nineteen flaps (59.5 percent) were performed under 3.5 x loupe magnification and 81 under the operating microscope (40.5 percent). The magnification selection process was based on cumulative past experience, with all early anastomoses performed with the microscope and the vast majority of the more recent operations performed with loupe magnification. Loupes were used preferentially for head and neck reconstruction and breast reconstruction. The microscope was required for performing vascular anastomoses on children and on vessels less than or equal to 1.5 mm in diameter. Results were compared with respect to etiology of defect, type of flap, age of patient, free-flap success, complications, and overall success of the reconstruction. There was no difference in outcome between the two groups, with free-flap success rates of 99 percent for both the loupe and the microscope groups. We believe that our success with loupe-only free-tissue transfers is attributable to our prior considerable experience with the microscope. We would caution that comfort and experience with microanastomoses under the operating microscope should be obtained prior to beginning a loupe-only experience.

Asymmetrical hypersensitivity to bovine collagen.

We report a unique patient with true asymmetrical hypersensitivity to bovine collagen. Hypersensitivity is the development of an inflammatory response at a treatment site after a negative skin test. She developed an inflammatory response in only one of two simultaneously injected sites. About 1.5% of patients with a negative skin test have a hypersensitivity reaction consisting of firmness, erythema, and swelling. The signs and symptoms generally resolve spontaneously in a few months.

Long-term patient satisfaction following reduction mammoplasty.

This study documents that reduction mammoplasty is a procedure with excellent long-term patient satisfaction. This has not been previously well documented. One hundred nine patients after reduction mammoplasty were surveyed by questionnaire. Results of the questionnaire indicated that the majority of patients were pleased with their breast size and breast shape. The majority had equal-sized breasts. Most were comfortable after surgery and had an easier time buying clothes. Ninety-four percent of patients would have the procedure again. Multiple techniques for reduction mammoplasty were used and there were no significant differences with the exception of a change in nipple sensation. Nipple sensation was best preserved by using the inferior pedicle technique.

Simultaneous dorsal trapezium-scaphoid and trapezoid-carpal subluxations.

Trapezium-scaphoid-trapezoid subluxations and trapezoid-capitate-scaphoid-trapezium subluxations or dislocations are rare. A single case combining these two injuries is presented. The mechanism may have been axial loading in extension or flexion. Two modes of treatment, closed and open, were needed for the two injuries.

A biomechanical study of the collateral ligaments of the proximal interphalangeal joint.

Collateral ligament injuries of the proximal interphalangeal joint are common. A significant number of these injuries result in complete rupture of the ligament. The forces that damage the ligaments are abduction and adduction stresses. Previous studies have investigated laxity, angulation, and patterns of failure, but detailed biomechanical rupture studies are scant. Sixty-eight proximal interphalangeal joints from fresh human cadaver fingers (average age, 67 years) were stressed at velocities of 1 mm/sec, 4 mm/sec, and 10 mm/sec. Sectioning studies were also done. Four distinct rupture patterns were noted: midsubstance tear, proximal detachment, distal detachment, and distal avulsion fracture. The prevalence of these patterns differed with the rate at which the ligaments were stressed. Lower speeds tended to produce midsubstance tears, while higher speeds yielded distal damage. The study confirmed that the lateral collateral ligament is the primary restraint against medial-lateral stress and that other supporting structures (the extensor hood and the palmar plate) did not contribute significantly to side-to-side stability.

A comparison of conventional and low-bleed implants in augmentation mammaplasty.

We conducted a double-blind, retrospective comparison between low-bleed and non-low-bleed (conventional) mammary implants because no controlled study has shown a difference in the degree of capsular contracture between the two types of implants. Twenty-five patients had conventional implants and form group A; twenty-eight patients had low-bleed implants and form group B. All patients had submuscular augmentation. The mean Baker score was 1.51 for group A and 1.04 for group B for the entire patient population and 1.65 for group A and 1.07 for group B for patients with more than 1 year of follow-up. For the entire population, 34 percent of group A and 3.6 percent of group B had a Baker score of 2 or greater. For the population with more than 1 year of follow-up, 42 percent of group A and 7 percent of group B had a Baker score of 2 or greater. There was significantly (p less than 0.007) less contracture with the low-bleed implants for the entire population as well as for those patients with greater than 1 year of follow-up (p less than 0.015).

Spontaneous flexor tendon rupture in the palm.

A 54-year-old, right-handed man developed spontaneous rupture of his flexor digitorium profundus at the level of the lumbrical. There was no history to suggest rheumatoid arthritis, abnormality of the carpal bones, fractures, or gout. No evidence of any of these disorders was found at the time of surgery. He was treated with a "mini" interposition flexor tendon graft and regained normal motion. Although the cause of his tendon rupture is unclear, we postulate that the blood supply to the tendon at the level of the lumbrical was compromised by an undefined mechanism.

Treatment of delayed union, nonunion, and malunion of the phalanges of the hand.

Nonunion occurs in less than 1% of phalangeal fractures. Despite this rarity we have accumulated a series of 14 proximal and middle phalangeal delayed unions, nonunions, and malunions. All patients but 1 were initially treated by a physician other than the senior author. All patients developed loss of active motion following their primary treatment. Secondary treatment was by open reduction and internal fixation with Kirschner wires. The mean and median total active motion before secondary treatment were 130 and 90 degrees, respectively. Following secondary treatment, the total active motion increased significantly (p less than 0.05) to a mean of 215 degrees and a median of 255 degrees. We recommend secondary treatment of delayed union, nonunion, and malunion of phalanges of the hand. Open reduction and internal fixation followed by early (two to three weeks) active motion leads to a significant improvement in finger function.

Repair of sensory nerves distal to the wrist.

Treatment of patients with severed distal sensory nerves is an exercise in simultaneous gratification and frustration. The gratification comes from realizing that the results of distal sensory nerve repair exceed those obtained after repair of other nerves. The frustration follows from the knowledge that truly normal sensation virtually never follows the most successful repair.

Use of the rectus abdominis muscle flap to reconstruct an elbow defect.

A superiorly based rectus abdominis muscle flap was successfully used to reconstruct an infected elbow wound with exposed bone and metal screws. We could find no previous report describing the use of this muscle to cover elbow defects.