Restoration of venous outflow by simultaneous creation of an arteriovenous shunt and pedicle flap using a rat model of foot replantation.

Replantation of amputated rat feet utilizing an efferent arteriovenous shunt constructed between the distal posterior tibial artery and the proximal posterior tibial vein, in the absence of all other venous drainage, provides an alternative pathway to the normal venous drainage in a replanted rat foot. However, this substitute venous drainage was insufficient to prevent progressive ischemia and necrosis of some or all of a replanted rat foot. When a cutaneous pedicle flap supplemented the arteriovenous shunt, venous drainage was much improved, tissue hypoxia and edema began to subside on the third day, severe tissue necrosis was prevented, and seven of eight feet replanted by this technique survived. These observations may be useful in replantation in humans when veins in the amputated part are too small to be used or so damaged that they cannot be repaired or reconstructed by a vein graft, but arteries can still provide a means of returning blood from the amputated part. Constructing an alternative pathway to the normal venous drainage pattern may allow severely damaged parts to survive after replantation.

Tendon arthroplasty of the fifth carpometacarpal joint for treatment of posttraumatic arthritis.

Resectional arthroplasty with interposition of a rolled tendon spacer was used to treat posttraumatic arthritis of the fifth metacarpal-hamate joint in eight patients. The average follow-up was 5 years. All of the patients subjectively rated the functional capability and the cosmetic appearance of their hands as good or excellent. After operation, there was a net increase of 30% in the average grip strength of the study group. The motion preserved at the small finger carpometacarpal joint facilitated power function of the hand.

Fracture of the hook of the hamate.

We removed the fracture fragment from fifty-nine patients who had an isolated fracture of the hook of the hamate. Preoperatively, all had complained of pain and tenderness on the ulnar side of the palm or on the dorsal ulnar aspect of the wrist. Most fractures were thought to have occurred while the patient was swinging a racquet, golf club, or baseball bat. Some fractures were caused by striking the palm on a solid object, by falling on the palm, or by a crush injury to the hand. Most of the fractures were diagnosed conclusively on a carpal tunnel roentgenogram or on a special oblique roentgenogram of the wrist supinated. We now believe that computed axial tomography is the best imaging technique for demonstrating this fracture. Except for two patients who had a crush injury, all of the patients returned to their regular occupational and athletic pursuits. There were no surgical complications.

Bridge flexor tendon grafts.

In adults, when flexor tendons cannot be repaired until weeks or months after injury or when tendons have ruptured and part of the tendon is nonviable, it is often inadvisable to suture the tendon ends together. When a primary repair has failed, when there has been a delay in tendon reconstruction to allow skin coverage or joint mobilization, or when repair has been delayed because of infection, continuity of a profundus tendon or flexor pollicis longus tendon can often be restored by using a free graft to bridge the defect. Many patients treated by this procedure will have a satisfactory result providing that the flexor tendon is undamaged within its digital sheath and the muscle is intact and has adequate amplitude. In the study reported here, satisfactory function was restored to 28 of 37 fingers and to eight of ten thumbs treated by this method.

Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire fixation.

Of 151 ununited fractures of the scaphoid that were treated with iliac bone grafts and Kirschner-wire fixation through a volar approach, all but four (97 per cent) healed in an average of seventeen weeks, Three of the four failures resulted from obvious technical errors. Neither the preoperative existence of necrosis of the proximal fragment nor the location of the fracture affected the results. When there was mild radiocarpal arthritis preoperatively, it did not progress postoperatively; if there was moderate radiocarpal arthritis preoperatively, progression seldom was seen if a radial styloidectomy was done. Displaced and unstable ununited fractures healed even if the deformity was not corrected completely. The principal benefit of the procedure was relief of pain rather than an increase either in motion of the wrist or in strength of grip.

Dupuytren's disease in women: evaluation of long-term results after operation.

A study of the long-term results after operation on 66 women (83 hands) with Dupuytren's disease showed that women are twice as likely as men to have a postoperative flare reaction. Why a flare reaction develops is uncertain. In this study, patients who had a carpal tunnel release at the time of operation for treatment of Dupuytren's disease or those who had an extensive fasciectomy, as opposed to removal of only the contracted tissue, were more apt to have a flare reaction. In addition, after operation, moderate or severe loss of finger flexion occurred in 35% of hands without a flare reaction and in 76% of those who had a flare reaction. This suggests that women having an operation for treatment of Dupuytren's disease are apt to have a worse result than men.

Operative treatment of intra-articular fractures of the dorsal aspect of the distal phalanx of digits.

Thirty-six digits with an intra-articular fracture of the dorsal aspect of the distal phalanx that involved one-third or more of the articular surface were treated by open reduction and internal fixation with Kirschner wires. After an average length of follow-up of forty-six months, roentgenograms of the distal joint in twenty-six digits appeared essentially normal. Ten digits had minor roentgenographic changes but, with the exception of one digit, the joint space was congruous and free of significant abnormalities. The average loss of extension of the distal joint was 2 degrees, and the average arc of flexion of the distal joint was 69 degrees. The average strength of pinch in all digits that were operated on was essentially equal to the strength of pinch in the contralateral digit. Exact reduction and internal fixation using the technique described resulted in excellent motion and function.

Isolated compression neuropathy of the palmar cutaneous branch of the median nerve.

A case of isolated thenar numbness, with an associated painful palmar wrist mass is presented. At operation, a palmar wrist ganglion compressing the palmar cutaneous branch of the median nerve was encountered. After ganglion excision the numbness in the palm was relieved, and there was no recurrence at 6 years follow-up.

Treatment of selected patients with an ununited fracture of the proximal part of the scaphoid by excision of the fragment and insertion of a carved silicone-rubber spacer.

An ununited scaphoid fracture whose proximal fragment is small, sclerotic, fragmented, or badly deformed is usually not suitable for bone-grafting. We treated twenty-one such patients by excision of the small proximal fragment through a volar incision and the insertion of a hand-carved silicone-rubber spacer. After surgery, twenty patients (95 per cent) were able to return to work and engage in strenuous activities, including sports. Pain was significantly relieved, although wrist motions and grip were only minimally improved. Preoperative and postoperative comparative measurements of carpal collapse and translation showed only insignificant changes after this procedure.