The effects of proximal load on the excursion of autogenous flexor tendon grafts.

To determine the relationship between the intrinsic properties of tendon and tendon excursion in 2 types of autogenous tendon grafts, hindpaw intrasynovial and extrasynovial tendons were transferred to the lateral and medial forepaws of adult mongrel dogs (16 experimental and 16 control tendons). After each digit was marked with radiopaque markers, it was placed in a specialized jig, and weights of 25 g, 100 g, or 200 g were applied to the flexor tendons. Specialized radiographs were obtained with the digit in flexion and extension. Tendon excursion and joint rotation were calculated. There were no statistically significant differences between experimental groups for tendon excursion or for joint angular rotation (p > .05). For intrasynovial tendon grafts, the angular rotation per millimeter tendon excursion was 10.9 degrees +/- 2.4 degrees/mm, 9.4 degrees +/- 1.2 degrees/mm, and 9.0 degrees +/- 1.4 degrees/mm with 25-g, 100-g, and 200-g loads, respectively. Comparisons between experimental groups revealed that a statistically significant difference could not be determined (p > .05). With varying proximal loads, both intrasynovial and extrasynovial grafts showed similar amounts of tendon excursion. Variations in proximal load did not significantly influence the amount of excursion within the range of loads tested. Based on these data, it appears that the difference in repair potential for these 2 types of tendon grafts is not related to a differential in the amount of tendon graft excursion following transfer to the synovial space.

Aneurysmal bone cyst involving the lunate.

Aneurysmal bone cysts are rare lesions which even more rarely involve the bones of the hand. We report a case of a cyst involving the lunate which was initially mistaken for interosseous ganglion. Due to delay in diagnosis, marked destruction of the lunate occurred, necessitating excision and scapho-capitate arthrodesis. Although rare, aneurysmal bone cysts should be included in the differential diagnosis and ruled out prior to embarking on a course of treatment.

Predictors of neurovascular displacement in hands with Dupuytren's contracture.

A prospective study of hands with Dupuytren's contracture was designed to test the association of three variables, the presence of an interdigital soft tissue mass, the presence of flexion contractures at each digital joint, and the duration of contracture, with the formation of spiral nerves. 66 digits in 37 hands affected by Dupuytren's disease were examined intra-operatively. Of the 34 digits (52%) with spiral nerves, 28 had soft tissue masses (42%). The sensitivity of a soft tissue mass alone as a predictor of a spiral nerve was 59% and the specificity 75%. The presence of a flexion contracture at the PIP joint had a sensitivity of 88% and a specificity of 62% for the presence of a spiral nerve. The combination of a soft tissue mass and a PIP joint contracture was a very specific (94%) but not a particularly sensitive (50%) test for spiral nerve formation. The formation of a spiral nerve is progressive, occurring most often in hands with significant PIP joint contractures with or without soft tissue interdigital masses.

Dropping out of marriage and family therapy: a critical review of research.

The lack of attention given to research on the premature termination by clients in marriage and family therapy is evident in research reviews of the dropout phenomenon in psychotherapy. This article is an attempt to fill that void. The research literature on dropping out of family therapy is reviewed and organized. Studies in this area tend to focus on four kinds of variables: client characteristics, therapist characteristics, therapy process variables, and interventions. Stable findings in each of these areas are pointed out. Both limitations and recommendations for future research are discussed.

A comparison of computed tomography-myelography, magnetic resonance imaging, and myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis.

The sensitivity, specificity, and accuracy of computed tomography (CT)-myelography, magnetic resonance imaging (MRI), and myelography in making the diagnosis of herniated nucleus pulposus (HNP) and spinal stenosis were compared in a retrospective study involving 59 surgical procedures in 57 patients who had all three tests performed preoperatively. One hundred nineteen levels were surgically explored for evidence of HNP and spinal stenosis. The results of each test were correlated with what was found at each surgical level explored. Overall, myelo-CT was the most accurate test for diagnosing HNP (76.4%) as well as the most sensitive (77.8%), whereas myelography was the most specific (89.2%). In making the diagnosis of spinal stenosis, myelo-CT and MRI were equally accurate (85.3%) and sensitive (87.2%), whereas myelography was the most specific (88.9%). In a special subset of patients who had revision surgery, the accuracy rate in diagnosing spinal stenosis or HNP was highest with MRI (84.9%), as was the sensitivity (69.2%) and specificity (95%). According to the results obtained from this series of patients, myelo-CT seems to be the most sensitive and accurate test in diagnosing HNP and spinal stenosis, whereas myelography is the most specific, although no statistical significance was noted in this study. However, because MRI did compare favorably with myelo-CT in most instances, particularly in revision surgery; it may be the procedure of choice due to its noninvasiveness and relative lack of side effects.

Impact of anesthetic agents on patients with sickle cell disease.

Fifty-two surgical procedures were performed on 45 patients with sickle cell anemia. All patients were managed perioperatively with hydration and were kept warm and well oxygenated. Patients were anesthetized with either halothane (n = 16), enflurane (n = 22), isoflurane (n = 6), or intravenous narcotics (n = 4). Four patients had epidural anesthesia. Perioperative morbidity was assessed using the criteria of atelectasis, urinary tract infection, wound infection, thrombophlebitis, drug reaction, hypotension, and vaso-occlusive crisis. The overall perioperative complication rate in this study was 45 per cent. Patients anesthetized with isoflurane and enflurane had postoperative morbidity rates of 83 and 59 per cent, respectively, while the patients anesthetized with halothane had a complication rate of 25 per cent. In all three groups, atelectasis was the main cause. No complications occurred in the epidural group. In the intravenous anesthesia group, one patient developed sickle cell crisis. It appears that the types of anesthetic agents used do not impact on postoperative morbidity in patients with sickle cell anemia more than any other type of patient.

Assessment of the use of transfusion therapy perioperatively in patients with sickle cell hemoglobinopathies.

During the period of 1978 to 1986, 66 patients (31 men, 35 women) with a mean age of 28.4 years and various sickle cell hemoglobinopathies underwent 82 surgical procedures; 28 were emergencies. Fifty of the 66 patients had HbSS, 13/66 had HbSC, and 3/66 had HbS-thalassemia. All 66 patients received transfusions, although not for all procedures. In 48 patients, transfusion therapy was only administered preoperatively. Simple transfusions (1 to 10 units) were administered in 31 of 48 procedures. Exchange transfusions (1 to 6 units) were performed in nine of 48 procedures. Preoperative hematocrit ranged from 7.0% to 54.2%; of those receiving transfusions the hematocrit ranged from 22.6% to 53.7%. Intraoperative transfusions (1 to 10 units) were performed in 14 of 82 procedures; postoperative transfusions (1 to 6 units) were performed in 13 of 82 procedures. No advantage was noted in preoperative exchange transfusion as measured by a decrease in postoperative complications; a slight increase was seen in atelectasis in this group of patients with preoperative transfusions. An increase was reported in the complication rate of patients with an hematocrit of less than 30%. The type of transfusion (preoperative, intraoperative, or postoperative) administered did not appear to be related to postoperative morbidity rates. The complication rate for simple transfusions was 51.6% and for multiple transfusions, 55.6%. HbSS hemoglobinopathy had the higher complication rate. The hepatitis B surface antigen was demonstrated in four of 66 (6.1%) patients; ten of 66 (15.2%) developed alloantibodies. The benefits of transfusion therapy should be judged according to clinical needs; not all sickle cell patients need exchange or preoperative transfusion.