A review of the biomechanics of intrinsic replacement in ulnar palsy.

The actions of the interossei and lumbricals are many and their loss causes significant impairment of hand function. Many procedures have been described to restore intrinsic function following ulnar nerve palsy. There are many biomechanical issues involved in tendon transfers, including choice of muscle-tendon unit, route, insertion site, tension and drag. The surgeon, therefore, should have a good understanding of biomechanical principles to ensure optimal results. In this article the principles of biomechanics are reviewed with specific reference to tendon transfers for intrinsic reconstruction in ulnar palsy, along with their practical implications.

Results of arthrodesis in neuropathic feet.

We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy. Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high.

Re-enablement of the neurologically impaired hand--2: surgical correction. report of a surgical workshop held at Green Pastures Hospital and Rehabilitation Centre, November 2004, Pokhara, Nepal.

The last half-century has seen tremendous advances in the surgical treatment of neuropathic conditions of the hand. Many of these procedures give clear benefit to patients and have been established by clinical practice and well-formulated assessment. However, much remains to be discovered, especially with respect to which procedures should be used on which hands, and the impact of various procedures on the ability to carry out activities of daily living. Increased communication between the 'West', where funding is available for well designed trials and where reference textbooks are usually published, and the 'East', where the surgery is most commonly performed, will undoubtedly lead to an even better understanding of the treatment of the neuropathic hand.

Transformation of a leprosy hospital in Nepal into a rehabilitation centre: the Green Pastures Hospital experience.

Green Pastures Hospital for leprosy patients in Pokhara Nepal, was established in 1957 by the International Nepal Fellowship (INF) in a decade which saw the establishment of many similar hospitals in other leprosy endemic countries. In recent years, mainly due to significant improvements in leprosy control services and the wide implementation of multiple drug therapy (MDT) for all patients, many of these specialist hospitals have encountered 1) a decline in prevalence rate, 2) a large decline in the percentage of patients presenting with WHO grade 2 disability, 3) a decline in the previous indications for hospital admission, e.g. immunologically mediated reactions, and 4) a need to develop financial independence making them less dependent on donor agencies. In addition, the decision to change from specialist to general services opened up the possibility of using facilities and expertise for the rehabilitation of non-leprosy affected persons, whilst also moving towards the reduction of stigma and prejudice against patients with leprosy. This paper describes the process of 'transformation' of an established and well known leprosy hospital in Western Nepal from 1997 onwards into a general rehabilitation hospital. Careful preparation, with full involvement of existing staff and co-operation with other agencies in the hospital catchment area were key factors in what has now become a successful venture. Surgical procedures and orthopaedic appliance services for non-leprosy affected persons have increased in recent years and the introduction of a dermatology service has resulted in out-patient attendance rising from about 1000 in 1999 to 4500 in 2003. No evidence of reluctance to attend and use the facilities offered by this hospital because of stigma against leprosy has been encountered. Many of the changes described have been made in order to reduce financial dependence on donor sources of support, but the underlying reason for transformation is still based on the vision of the INF mission to work for and improve the condition of the marginalized in society.

Needle aspiration of breast abscesses.

BACKGROUND: Traditional treatment of breast abscesses involves incision and drainage, with and without ultrasound guidance. These procedures cause considerable discomfort and morbidity for the patient. This study was conducted to determine whether needle aspiration of breast abscesses without ultrasound guidance was an effective treatment modality. METHOD: In our prospective study, 30 patients with 33 breast abscesses were treated by needle aspiration of pus, oral antibiotics, and repeat aspiration, if necessary. All were outpatients, and ultrasonography was not used. Twenty-five of the 30 patients were lactating. RESULTS: Eighteen patients required only a single aspiration, 9 patients required multiple aspirations, and 6 patients required incision and drainage (overall cure rate, 82%). Those patients in whom needle aspiration was successful had a significantly smaller volume of pus on initial aspiration (4.0 mL versus 21.5 mL, P = 0.002) and were more likely to have presented earlier than those not cured by aspiration (5.0 days versus 8.5 days, P = 0.006). CONCLUSION: Needle aspiration without ultrasound guidance is an effective treatment for breast abscesses.

Trans-scrotal intra-abdominal injuries: two case reports.

Penetrating injury to the scrotum is uncommon. Usually not serious in itself it may be associated with other more serious conditions. A 15-year-old boy was involved in a tobogganing accident, and a shard of wood penetrated the left scrotum, the anterior abdominal wall and the rectus sheath one-third of the way from umbilicus to xiphisternum. There was also a liver laceration. Removal of the piece of wood and closure of the wounds with drainage resulted in successful recovery. A 45-year-old man, sustained a penetrating straddle-type injury from a broom handle. The handle penetrated Dartos fascia but there was no testicular injury. It also perforated the rectus sheath 6 cm inferior to the costal margin, and both anterior and posterior gastric walls. The tract of the handle extended along the base of the transverse mesocolon and posterior to the pancreas. The perforations were debrided and repaired. The patient received a 5-day course of broad-spectrum antibiotics and recovered fully. As a result of their experience with these two patients the authors recommend that when there is penetration of Dartos fascia, the testicle and cord should be inspected, lavage and débridement should be carried out, and any foreign bodies should be removed and the injuries repaired. Antibiotics should be given perioperatively. In all cases the entire tract should be explored to its terminus to search for other injuries. Even upper abdominal injuries can occur with penetrating scrotal injuries.

Diagnosis and management of stage IE and stage IIE gastric lymphomas.

We performed a retrospective study involving 56 patients with stage IE or stage IIE gastric lymphomas treated between January 1980 and January 1990. Endoscopy had a sensitivity of 98% compared with 83% for radiographic contrast studies. The data were analyzed with respect to 10 prognostic factors. Age greater than 65 years and an elevated lactate dehydrogenase level were associated with a significantly lower 5-year survival rate (each p = 0.001). Those patients having had gastric resection with grossly negative margins demonstrated improved survival compared with those patients who did not have complete resection (67% versus 29%). The use or omission of radiotherapy had no effect on survivorship (51% versus 55%). Neither tumor size, stage, sex, site of extragastric involvement, time from onset of symptoms to diagnosis, nor microscopic resection margins influenced survival. We conclude that endoscopy with biopsy is the diagnostic procedure of choice for gastric lymphoma. Gastric resection still plays an important role in the management of stage IE and stage IIE gastric lymphomas, whereas chemotherapy remains the mainstay of therapy. The role of radiotherapy remains undefined.

Failure of right-sided coloanal anastomosis for treatment of left-sided ulcerative colitis. Report of a case.

A patient with ulcerative colitis limited to the rectum and distal colon underwent a left hemicolectomy, a mucosal proctectomy, and a coloanal sleeve anastomosis using the normal proximal colon. She experienced macroscopic recurrence of her disease within 2 months of the operation and eventually required excision of the remaining colon and an end ileostomy. Our experience and that of others would indicate that a right-sided coloanal operation is unsuitable for the treatment of left-sided ulcerative colitis.

Efficient management of adrenal tumors.

A retrospective analysis was carried out on 121 patients with primary adrenal tumors operated on at 2 Vancouver hospitals between the years 1970 and 1990. The purpose of the study was to identify discriminating factors between the various diagnoses in order to minimize both the time and the cost of the investigative process. There were 57 cortical adenomas, 35 pheochromocytomas, 15 carcinomas, 8 cases of cortical hyperplasia, and 6 miscellaneous tumors. The mean time from the onset of symptoms to diagnosis of those patients presenting with an identifiable syndrome was 48.3 months. Those with a hypertensive syndrome presented significantly later than those with Cushing's syndrome (57.7 months versus 22.8 months, p less than 0.01). There was a significant delay in diagnosis in those patients with hypertension on the basis of an aldosteronoma as compared with those with hypertension secondary to a pheochromocytoma (75.4 months versus 36.1 months, p = 0.02). Cortical carcinomas were significantly larger than benign cortical tumors (12.7 cm versus 5.5 cm). No malignant neoplasm measured less than 5 cm in diameter. Diagnostic sensitivity for intravenous pyelogram (IVP) was 59%, for ultrasound 71%, for venography 50%, for meta-iodobenzylguanidine (MIGB) (pheochromocytoma only) 80%, and for angiography 70%. However, for those patients with adrenal carcinomas, angiography was positive in 100% of cases. Computed tomography (CT) was the most sensitive localizing investigation with a sensitivity of 98%. While other localizing techniques were less sensitive than CT, they may still play a useful role in selected situations. Factors causing delay in diagnosis and the role of the various imaging modalities are discussed.

Condensation of chromatin into chromosomes preserves an open configuration but alters the DNase I hypersensitive cleavage sites of the transcribed gene.

DNase I was used to probe the molecular organization of the chicken ovalbumin (OV) gene and glyceraldehyde 3-phosphate dehydrogenase (GPD) gene in interphase nuclei and in metaphase chromosomes of cultured chicken lymphoblastoid cells (MSB-1 line). The OV gene was not transcribed in this cell line, whereas the GPD gene was constitutively expressed. The GPD gene was more sensitive to DNase I digestion than the OV gene in both interphase nuclei and metaphase chromosomes, as determined by Southern blotting and liquid hybridization techniques. In addition, we observed DNase I hypersensitive sites around the 5' region of the GPD gene. These hypersensitive sites were not always at the same locations between the interphase nuclei and metaphase chromosomes. Our results suggest that chromatin condensation and decondensation during cell cycle alters nuclease hypersensitive cleavage sites.