Complications after hand surgery in patients with a raised International Normalized Ratio.

A multicentre database was used to compare complications in 231 patients with an elevated International Normalized Ratio with 1626 control patients with a normal International Normalized Ratio. Patients with International Normalized Ratios measured within 48 hours of hand surgery were identified. Logistic regression models were used to assess the association between anticoagulation and reoperation rates, emergency department visits and hospital readmissions for the first 30 days after operation. The group with a raised International Normalized Ratio had a significantly higher Charlson Comorbidity Score. An elevated International Normalized Ratio was associated with an odds ratio for a post-operative emergency department visit of 3.3 and an odds ratio of 4.7 for readmission. There was no statistically significant difference in early reoperations between the two groups. LEVEL OF EVIDENCE: III.

Wrist arthrography versus arthroscopy: a comparative study of 150 cases.

One hundred fifty patients with suspected wrist ligamentous injuries were studied with both triple injection wrist arthrography and arthroscopy. The diagnoses obtained by these two techniques were compared to determine the differences between these two modalities. All the patients in this study had both the clinical diagnosis of ligamentous injuries of the wrist and normal findings on x-ray films. Intercarpal abnormalities were found in 106 patients (71%) at wrist arthrography and in 136 patients (91%) at arthroscopy. There was only 42% agreement (63 patients) between the arthrographic and arthroscopic diagnoses. Eighty-seven patients (58%) had alterations of their arthrographic diagnoses following arthroscopy. For patients with normal arthrographic findings (44 patients), 88% underwent arthroscopy because there was insufficient correlation between the physical examination findings and the arthroscopic findings. Out of the 44 patients with normal arthrographic findings, 35 patients (80% of the subgroup) had injuries found at arthroscopy. Over half of the patients had alterations in their arthrographic diagnoses following arthroscopy. In a patient with suspected ligamentous injury of the wrist, wrist arthroscopy may be the most efficient method in arriving at a definitive diagnosis.

Neurologic and ischemic complications of upper extremity vascular access for dialysis.

This study reviews the clinical course of 22 patients with chronic renal failure on hemodialysis with ischemic or neurologic problems in the upper extremity distal to an arteriovenous fistula. Two distinct presentations were observed. Twelve patients developed significant motor and/or sensory impairment immediately following surgical construction of the fistula. Ten patients presented with upper extremity ischemia, established or impending tissue loss, or nonhealing wounds distal to a dialysis fistula. Seventeen of the 22 patients were diabetic. Nerve conduction studies, noninvasive vascular studies, and arteriography were used to confirm the diagnosis. Sixteen of the 22 patients had ligation or revision of the fistula. Five patients underwent amputations at the metacarpal or phalangeal level, and one patient underwent below-elbow amputation.

Long-term recovery following surgical treatment for ulnar artery occlusion.

Fourteen patients were surgically treated for ulnar artery occlusion. Digital blood pressure measurements obtained pre- and intraoperatively helped guide the choice between ligation or reconstruction of the ulnar artery following resection of the occluded segment. The digital brachial index (DBI) was derived by calculating the ratio of digital blood pressure to the simultaneous brachial artery pressure. A DBI value of less than or equal to 0.7 was an indication for arterial reconstruction. If the DBI was greater than 0.7, resection of the occluded arterial segment without reconstruction was considered appropriate. Eight patients were treated by arterial reconstruction and six patients were treated with arterial resection. Seven of the eight reconstructed ulnar arteries were patent at follow-up evaluation by Doppler evaluation. DBI measurements obtained at follow-up were compared to preoperative values. In the reconstruction group, DBI change in the small, ring, and index fingers was positive, whereas it was negative in the resection group. Eleven patients indicated improvement from their presurgical status, although over half continued to experience pain on a regular basis. Reports of environmental and contact cold intolerance also showed improvement following surgery. Complaints of pain and cold intolerance were not significantly different between the resection and reconstruction groups at follow-up evaluation.

Occlusive vascular disorders of the upper extremity.

Arterial occlusive disease of the upper extremity is most often due to posttraumatic occlusion of the ulnar artery. An embolic source of the ischemia should be considered most strongly when sudden ischemia or vasospasm is associated with atrial fibrillation or follows a myocardial infarction. Connective tissue disorders and several arteridities are infrequent causes of upper-extremity occlusive disease and can usually be detected by a thorough peripheral vascular examination and blood studies. Atherosclerosis of the upper extremity is usually localized to the region of the subclavian artery and can present as a subclavian steal syndrome or arm ischemia. Finally, upper-extremity venous occlusive disease occurs in association with the hypercoagulable state, venous endothelial injury, or arises in otherwise healthy patients because of venous impingement in the thoracic outlet.

Neuropathy in the workplace.

Cumulative trauma disorders are frequently responsible for the development of occupational neuropathy. Predisposing factors in the workplace are identified, and ergonomic principles to minimize these risks are presented.

Distal interphalangeal joint silicone interpositional arthroplasty: surgical technique and functional outcome.

Distal interphalangeal joint arthroplasty is effective in alleviating the pain of degenerative arthritis while preserving motion and stability. This procedure was undertaken as an alternative to arthrodesis for 17 women with osteoarthritis and 1 woman with rheumatoid arthritis. Silicone interpositional arthroplasty was performed in 31 digits of patients whose mean age was 58.3 years. The patients were evaluated at an average of 72.2 months (range, 12.6 to 123.1 months) after surgery. All patients reported that their primary preoperative symptom of pain was effectively eliminated by the procedure. At reevaluation, the active range of motion of the distal interphalangeal joint averaged 32.2 degrees and extension lag averaged 12.7 degrees . Lateral stability of the distal joint was present in all but one middle finger implant. Two implants were removed at 3 months postoperatively for wound problems and one at 31 months because of prothesis fracture.

Scapholunate dissociation in the skeletally immature carpus.

A case of scapholunate dissociation with a dorsal carpal instability pattern is described in a skeletally immature 13-year-old male. The malrotation of the scaphoid was treated by soft tissue reconstruction, with use of a dorsal capsulodesis to provide a dorsal restraint to excessive palmar flexion of the scaphoid. In the skeletally immature carpus, isolated ligamentous injuries are less frequently recognized than epiphyseal injuries. To avoid interference with the successful conclusion of carpal growth, soft tissue reconstruction of deranged carpal relationships is preferable to intercarpal arthrodesis in the skeletally immature patient.

Silicone interpositional arthroplasty of the distal interphalangeal joint.

Twenty-three female patients had silicone interpositional arthroplasty of the distal interphalangeal joint in 38 digits. The operative indications were pain and deformity of the distal interphalangeal joint. The underlying diagnosis was osteoarthritis in all but one patient who had rheumatoid arthritis. The average age at the time of operation was 58.3 years. The implants have been in place for a mean period of 72.2 months (range, 12.6 to 123.1 months). At follow-up, extension lag averaged 12.7 degrees and the range of motion of the distal interphalangeal joint had a mean value of 33.2 degrees. Compared with arthrodesis, silicone interpositional arthroplasty offers the advantage of retained motion while preserving stability.

Ninety-ninety intraosseous wiring for internal fixation of the digital skeleton.

Ninety-ninety intraosseous wiring has been used in more than 150 cases over the last 4 years to obtain skeletal stability. This technique has been effective for the internal fixation of replanted parts, arthrodeses, transverse fractures, and elective free-tissue transfers. All osteotomies and fractures healed promptly, usually within 6 weeks. There have been no instances of nonunion, malunion, or implant failure. Only one wire had to be removed due to its prominence. Ninety-ninety intraosseous wiring is an expeditious, straightforward, and very stable method to secure rigid internal fixation and allow early active motion of the digital skeleton.

Mechanical disruption of human patellar cartilage by repetitive loading in vitro.

Plugs of cartilage and subchondral bone from patellae were subjected to cyclic compression consisting of rapid ramp loading for 0.3 seconds followed by a 2.7 second pause. At 1000 psi cyclic load, surface abrasion of the cartilage was noted at 250 cycles of compression. Primary fissures, which penetrated to the calcified cartilage, developed at 500 cycles. Secondary fissures, emanating from the primary fissures at 30 degrees-90 degrees angles, and penetrating to varying depths, were observed at 1000 cycles. Coalescence of fissures and undermining of cartilage fragments were noted at 8000 cycles. With greater loads, the same sequence of events occurred with fewer cycles except that primary fissures appeared before the surface was abraided. Fissure formation did not occur in specimens subjected to loads of 250 psi to 500 psi even if the superficial 100 micron of cartilage was removed and specimens were loaded for 120,860 cycles. The deeper layers of cartilage appear to be of prime importance in resisting fissure formation.

The malignant potential of enchondromatosis.

In a tri-institutional, retrospective study with long-term follow-up, forty-four patients who had multiple enchondromas were identified. Thirty-seven patients did not have hemangiomas (Ollier disease) and seven did (Maffucci syndrome). Of the thirty-seven patients who had Ollier disease, a low-grade chondrosarcoma developed in four; an astrocytoma, in one; and a granulosa-cell ovarian tumor, in one. In four of the seven patients who had Maffucci syndrome, there were six low-grade chondrosarcomas, one high-grade osteosarcoma, one pancreatic adenocarcinoma, one biliary adenocarcinoma, and one astrocytoma. None of the patients in either group died of the skeletal sarcoma, but four of five patients who had a non-skeletal malignant lesion died. From life-table analyses of these patients, we estimated that the incidence of secondary chondrosarcoma in patients who have Ollier disease is about 25 per cent at the age of forty years, and that malignant degeneration is almost a certainty in patients who have Maffucci syndrome. We concluded that periodic surveillance of the brain and abdomen for occult malignant lesions is indicated in patients who have enchondromatosis.