Intrinsic muscle flaps: the treatment of painful neuromas in continuity.

Treatment of the pain that is caused by neuroma in continuity in a digital nerve on the palmar surface of the hand is a challenging problem. Eight digital nerves were covered with intrinsic muscle flaps after neurolysis to obtain relief of symptoms in eight patients. Four of the cases involved intrinsic muscles for digital nerves in the thumb. Four patients had digital nerves in the palm covered by lumbrical muscle flaps, two of which were distally based. All patients had significant relief of their symptoms. This report describes the techniques used and their application.

Extensor tendon ruptures in rheumatoid arthritis.

The best treatment for extensor tendon rupture is prevention, either by medical management or surgical tenosynovectomy before tendon ruptures occur. Once a rupture has occurred, tendon transfer or free tendon grafting can provide acceptable restoration of extensor function. Communication with the rheumatologist is necessary to provide timely treatment for chronic dorsal tenosynovitis (and impending tendon rupture) or for single finger extension loss before the disease progresses to multiple finger extension loss. Consideration always must be given to associated joint involvement when planning surgical treatment.

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome.

Partial resection of the distal ulna (wafer resection) has been used to treat patients with symptomatic tears of the triangular fibrocartilage complex or mild ulna impaction syndrome. In this procedure, the distal 2 to 4 mm of the distal ulnar head is resected while preserving the ulnar styloid process and the ligaments attached to it. The triangular fibrocartilage is debrided, repaired, or partially excised as necessary. The procedure is contraindicated if there is more than 4 mm of positive ulnar variance. Thirteen wafer resections of the distal ulna were performed in 12 patients. All had good to excellent results after a minimum follow-up of 1 year. Wafer resection has specific advantages and avoids many of the potential complications of distal ulna recession and ulnar head resection for patients with the conditions described. The procedure is not indicated if instability or degenerative arthritis of the distal radioulnar joint is present or if there is carpal instability.

The "wafer" procedure. Partial distal ulnar resection.

A technique of partial resection of the distal ulna ("wafer" procedure) for the treatment of patients with symptomatic tears of the triangular fibrocartilage complex or mild ulnar impaction syndrome or both is described. The distal 2-4 mm of the distal ulna is resected while preserving the distal radioulnar joint and the styloid process of the ulna and the ligaments attached to it. The triangular fibrocartilage can be debrided, repaired, or partially excised. The wafer procedure has several advantages and avoids some of the potential complications of other treatment methods.

Treatment considerations in the complicated rheumatoid hand.

The rheumatoid patient with complex involvement or multiple deformities of the hand and wrist can be a challenge to the hand surgeon. A systematic and orderly approach is used to formulate and execute a treatment plan that is realistic and that can result in modest, but significant improvement in overall hand function. The evaluation and treatment philosophy which is described can help turn a complicated and seemingly overwhelming situation into smaller components which can be treated in one or more surgical stages.

Degenerative diseases of the metacarpophalangeal joints.

Degenerative arthritis of the finger metacarpophalangeal joints is uncommon and, when seen, a specific etiology should be sought. MP joint arthritis in the absence of a history of trauma may signal an underlying systemic disease. The clinical and radiographic findings may be subtle. Once degenerative changes occur, the usual treatment is arthroplasty using a flexible silicone rubber (Swanson) finger joint implant that should provide a relatively stable and painless joint with a functional range of motion. Degenerative arthritis of the thumb MP joint is more common following injuries that damage the ligaments on the ulnar or radial side of the MP joint and which result in lateral instability of the joint. Arthritis of the MP joint also may occur following infection or direct joint injury. Secondary MP arthritis may result from thumb CMC joint disease and must be attended to at the time CMC joint reconstruction is performed. Degenerative disease of the thumb sesamoid bones must be considered in patients with persistent MP joint pain after either trauma or MP joint fusion.

Hand involvement in psoriatic arthritis.

From a population of 105 patients with confirmed psoriatic arthritis, 25 patients required hand surgery. These 25 surgical patients were evaluated retrospectively both clinically and radiographically. The patterns of hand and wrist involvement as well as the results of surgery differed from those typically seen in rheumatoid disease. Spontaneous fusion of the wrist in a functional position, severe proximal interphalangeal involvement often with marked flexion contractures, severe erosion of the distal interphalangeal joint with spontaneous fusions, and generalized stiffness characterize these hands. Minimal improvement in motion and a significantly increased incidence of infection following arthroplasty were noted.

Airborne bacterial contamination of operative wounds.

Both the numbers and species of airborne bacteria were studied during 263 surgical procedures. The numbers of bacteria isolated were reduced by 95 percent in a horizontal laminar flow room compared with a conventional room and a further 4 percent reduction occurred when a suction-mask system was used. The species of bacteria isolated differed notably at the operative site where a slit sampler was used, as compared with the instrument table and the periphery of the room where settling plates were used. Studies done during simulated surgical operation suggested that light fixtures, pass-through doors, floor contamination and the draped patient were not important sources of airborne contamination in this horizontal laminar flow system. The exact role of airborne bacterial contamination of operative wounds in the development of clinical wound infections is still unknown. Therefore, installation of laminar flow systems must be considered unnecessary at this time.