TREATMENT OF SCAPHOID NONUNION USING VOLAR BICONCAVE CANCELLOUS BONE GRAFTING

We report the results of 28 patients with scaphoid nonunion treated with curettage and biconcave cancellous bone grafting from the distal radius using a volar approach and pin fixation. This study consisted of 28 patients (24 males and 4 females). The mean age at surgery was 28 years. The mean interval from injury to surgery was 22 months. The mean follow-up period was 20 months. By Russe classification, there were 6 distal third nonunions, 19 middle third nonunions and 3 proximal third nonunions. We reviewed final function and radiographic appearance. Bony union was achieved in all cases. Pins were removed at a mean of 7 weeks after surgery. Post-activity pain resolved in all cases. Mean wrist extension was 79° and mean flexion 77°. Mean grip strength was 35.8 kgf. The mean postoperative radio-lunate angle was 4.9° (-21–28.8) compared to -5.9° (-37.5–17.5) preoperatively. No complications were encountered. Our procedure is straightforward and not technically demanding. An STT arthrotomy is not necessary and the technique allows for concurrent correction of carpal instability. Bony union was achieved in all cases with no complications.

[How to protect the surgeons' faces against spurting blood from the ascending aorta]

The blood spurting from the ascending aorta is uncomfortable for cardiac surgeons. To protect the surgeons' faces from this spurting blood, we use a longitudinal half of a plastic bottle, which is semi see-through. While the assistant is holding this device above the ascending aorta, the surgeons can proceed the operation with good surgical view.

A comparative study of the modified Sauvé-Kapandji procedure for rheumatoid wrist with and without stabilization of the proximal ulnar stump

We compared the clinical and radiological results of the modified Sauvé-Kapandji procedure for 41 of 86 operated rheumatoid wrists with (n=22) and without (n=19) stabilization of the proximal ulnar stump with a slip of half the extensor carpi ulnaris tendon. Gender, age, and follow-up period were similar in the two groups. We found no difference clinically or on radiographs between the two groups other than better early postoperative pain relief in those stabilized. Stabilization of the proximal ulnar stump may not be necessary in the modified Sauvé-Kapandji procedure for rheumatoid wrists.

Role of ET(B) receptors and nitric oxide in adrenal catecholamine secretion in anesthetized dogs

We examined the effects of sarafotoxin 6c (S6c), an endothelin-B (ET(B)) receptor agonist, on adrenal catecholamine secretion in response to cholinergic stimuli in pentobarbital sodium-anesthetized dogs. Drugs were administered intra-arterially into the adrenal gland through the phrenicoabdominal artery. Infusion of S6c attenuated increases in adrenal catecholamine output induced by splanchnic nerve stimulation. The inhibitory effect of S6c on the catecholamine secretion response was suppressed with a selective ET(B) receptor antagonist N-cis 2, 6-dimethylpiperidinocarbonyl-L-gamma-methylleucyl-D-1-methoxycarbonyl tryptophanyl-D-norleucine (BQ-788), a nitric oxide synthase (NOS) inhibitor N(omega)-nitro-L-arginine methyl ester, and a neuronal NOS inhibitor 7-nitroindazole monosodium salt (7-NINA). Similar results were obtained with the catecholamine secretion response induced by injection of ACh. 7-NINA alone did not affect these catecholamine secretion responses. These results suggest that ET(B) receptors play an inhibitory role in adrenal catecholamine secretion by activating neuronal NOS, whereas neuronal NOS is unlikely to be involved in regulation of adrenal catecholamine secretion in the absence of simultaneous ET(B) receptor stimulation.

Complications following metatarsal lengthening by callus distraction for brachymetatarsia

We performed six metatarsal lengthenings in four patients for brachymetatarsia of the fourth toe by callus distraction from 1991 to 1995. Healing was achieved in all cases. The average amount of lengthening was 30% (range, 15-41%) of the original length. The average healing index was 82 days/cm (range, 66-113 days/cm). After the operation, range of movement of the metatarsophalangeal joint decreased in all cases (120 degrees before and 57 degrees after surgery). In two cases in which the lengthening exceeded 40% of the original length, stiffness of the joint (20 degrees and 0 degrees each) and joint deformity occurred. These two cases also had angulation of the metatarsal. Corrective osteotomy and release surgery was performed in one case. Angulation of the metatarsal was corrected, but the range of movement of the joint did not much recover after surgery. Another case was left untreated because the patient had no complaints. In metatarsal lengthening by callus distraction, the amount of lengthening should not exceed 40% of the original length.

Effects of adrenomedullin and PAMP on adrenal catecholamine release in dogs

We examined the effects of proadrenomedullin-derived peptides on the release of adrenal catecholamines in response to cholinergic stimuli in pentobarbital sodium-anesthetized dogs. Drugs were administered into the adrenal gland through the phrenicoabdominal artery. Splanchnic nerve stimulation (1, 2, and 3 Hz) and ACh injection (0.75, 1.5, and 3 microgram) produced frequency- or dose-dependent increases in adrenal catecholamine output. These responses were unaffected by infusion of adrenomedullin (1, 3, and 10 ng. kg-1. min-1) or its selective antagonist adrenomedullin-(22-52) (5, 15, and 50 ng. kg-1. min-1). Proadrenomedullin NH2-terminal 20 peptide (PAMP; 5, 15, and 50 ng. kg-1. min-1) suppressed both the splanchnic nerve stimulation- and ACh-induced increases in catecholamine output in a dose-dependent manner. PAMP also suppressed the catecholamine release responses to the nicotinic agonist 1, 1-dimethyl-4-phenylpiperazinium (0.5, 1, and 2 microgram) and to muscarine (0.5, 1, and 2 microgram), although the muscarine-induced response was relatively resistant to PAMP. These results suggest that PAMP, but not adrenomedullin, can act as an inhibitory regulator of adrenal catecholamine release in vivo.

Role of K+ channels in adrenal catecholamine secretion in anesthetized dogs

We examined the role of K+ channels in the secretion of adrenal catecholamine (CA) in response to splanchnic nerve stimulation (SNS), acetylcholine (ACh), 1,1-dimethyl-4-phenyl-piperazinium (DMPP), and muscarine in anesthetized dogs. K+ channel blockers and the cholinergic agonists were infused and injected, respectively, into the adrenal gland. The voltage-dependent K+ channel (KA type) blocker mast cell degranulating (MCD) peptide infusion (10-100 ng/min) enhanced increases in CA output induced by SNS (1-3 Hz), but it did not affect increases in CA output induced by ACh (0.75-3 micrograms), DMPP (0.1-0.4 microgram), or muscarine (0.5-2 micrograms). The small-conductance Ca(2+)-activated K+ (SKCa) channel blocker scyllatoxin infusion (10-100 ng/min) enhanced the ACh-, DMPP-, and muscarine-induced increases in CA output, but it did not affect the SNS-induced increases in CA output. These results suggest that KA channels may play an inhibitory role in the regulation of adrenal CA secretion in response to SNS and that SKCa channels may play the same role in the secretion in response to exogenously applied cholinergic agonists.

Flexor tendon ruptures caused by an intraosseous ganglion of the hook of the hamate

A rare case of pathological rupture of the flexor tendons of the small finger caused by an intraosseous ganglion of the hook of the hamate is described.

Osteosynthesis for the treatment of non-union of the lateral humeral condyle in children

We reviewed the results of osteosynthesis for the treatment of an established non-union of the lateral humeral condyle in sixteen children whose average age was nine years (range, four to thirteen years) at the time of the operation. The average interval between the injury and the operation was five years (range, five months to ten years). The presenting symptoms were pain in the elbow in seven patients, apprehension in nine, a cubitus valgus deformity in six, limitation of motion in three, and dysfunction of the ulnar nerve in four. The average duration of follow-up was eleven years (range, four to thirty-two years). Osseous union was achieved after the initial operation in thirteen patients. Of the three patients who had a persistent non-union, two had a second operation and the third, who was asymptomatic, refused additional operative intervention. The result was rated excellent in eight patients, good in seven, and poor in one, with use of a modification of the functional rating index of Broberg and Morrey. The patient who had a poor result had evidence of avascular necrosis of the fragment.

Treatment of traumatic radioulnar synostosis by excision, with interposition of a posterior interosseous island forearm flap

A 21-year-old man had proximal radioulnar synostosis 10 months after fracture of the proximal radius and the ulna. The bony bridge was excised and a direct posterior interosseous island flap was interposed as a biological barrier. One year after surgery, the range of forearm rotation was 65 degrees. There was no radiographic evidence of recurrence.

Developmental dislocation of the radial head

An unusual case of developmental dislocation of the radial head is reported. A 6-year-old boy was referred for evaluation of his elbow and was diagnosed as having an anterior dislocation of the right radial head. No dislocation was present on the left. Subsequently, the left radial head dislocated anteriorly without associated trauma 1 year after the initial examination. Intraoperative findings on the right revealed the dislocation occurred during pronation of the forearm when the radius abutted the interosseous border of the ulna. Ulnar osteomy and reinstruction of the annular fragment were performed but were, not effective in preventing redislocation.

Isolated fracture-dislocation of the sacrum: case report

An unusual case of isolated fracture-dislocation of the sacrum is reported. A 19-year-old woman had a fracture-dislocation of S-1-2 combined with two longitudinal fractures of the sacrum, but no other pelvic fractures were identified. The possible mechanisms of fracture-dislocation of the sacrum are discussed. The fracture site was identified accurately on a CT scan. Pain relief was obtained by application of an external fixator. A mild neurologic deficit in the S-1 root distribution disappeared uneventfully.

Perceptions of psychological researchers and clinicians: a questionnaire based on empirical data and theory

Clinical and research psychologists continue to be regarded stereotypically even by 187 students currently anticipating careers in psychology and closely related fields. This article gives data for 10 issues on which clinicians and researchers are perceived to differ. Specifically, a 10-item questionnaire is described which allows such stereotypes to be further explored or explained.

Lymphangioma of the upper extremity

Lymphangioma of the upper extremity is rare; its treatment is unstandardized. We reviewed five female and one male patient with cavernous lymphangioma of the hand and forearm. Each of them underwent at least one surgical procedure. Five patients had satisfactory results with cosmesis and hand function. Satisfactory results are expected in those treated initially in early childhood, as most lymphangiomas tend to increase gradually in size and infiltrate previously uninvolved normal tissues.

Effect of early synovectomy on the course of rheumatoid arthritis

Ninety-one patients with rheumatoid arthritis were retrospectively assigned to 3 subsets according to the number of joints with erosion (NJE). The subsets were least erosive (LES); more erosive (MES); most erosive involving multilating disease (MUD). In the early stages of disease the subsets were distinct (p less than 0.001) regarding mean values of annual reduction of carpal height (delta CHR) and serum Clq levels. Patient assessment (radiographic and clinical) continued to deteriorate in the MES and MUD subsets over the 1-5 year interval after synovectomy. Apparent stabilization of knee disease in the LES subset may be a feature of this subset rather than a result of synovectomy. Although synovectomy may offer short term symptomatic relief, we found no evidence that it retards the bony destruction or the disease process.

Constrained total elbow arthroplasty

In 1972, the senior author designed a condylar-sparing constrained hinge elbow prosthesis with a high-density polyethylene bushing. The condylar-sparing design allows both intercondylar and intramedullary fixation of the humeral component with methylmethacrylate cement. Reattachment of the muscles and collateral ligaments to the preserved condyles provides further stability. The clinical experience spans more than 16 years in 42 elbows with a relatively low loosening rate of 7%. The implant was removed and not replaced in three elbows: one for late infection, one for posttraumatic comminuted fracture of the distal humerus, and one for loosening of a humeral component. A series of 27 patients (31 elbows) with 24-204 months of follow-up study (average, 77 months) had excellent pain relief and an average range of motion of 129 degrees flexion, -44 degrees extension, 69 degrees pronation, and 61 degrees supination.

Collateral ligament reconstruction of the metacarpophalangeal and proximal interphalangeal joints using porous dacron tendon

We are encouraged by the favorable preliminary results of ligamentous reconstruction using the porous Dacron tendon. It provides a stable construct in cases where there is insufficient local autogenous tissue, and obviates the need for a tendon graft. Early active range of motion is permitted. Current investigation for additional applications for the use of the porous Dacron tendon include volar plate reconstruction following disruption, capsuloligamentous reconstruction of the trapezial metacarpal joint (with trapezium implant arthroplasty as well as for isolated disruption of the volar oblique ligament), intercarpal ligament repair or augmentation, and distal radioulnar joint stabilization.

Rupture of the flexor pollicis longus in von Recklinghausen's disease

An unusual cause of inability to flex the interphalangeal joint of the thumb in a patient with von Recklinghausen's disease is reported. A tumor in the cubital fossa and the basic characteristics of this disease led to a preoperative misdiagnosis of anterior interosseous nerve paralysis. However, surgical exploration and histological examination showed that the correct diagnosis was rupture of the flexor pollicis longus tendon caused by intratendinous proliferation of a neurofibroma. This is the first report in the English-language literature of a flexor tendon rupture caused by intratendinous tumor proliferation.

Topical use of Xylocaine for relieving vasospasm: effect of concentration

The spasmolytic and antispasmodic effects of Xylocaine in different concentrations were studied. Twenty-five Wistar rats were divided into five groups according to the concentrations of Xylocaine used (2 percent, 4 percent, 10 percent, 20 percent, and 40 percent). The diameters of rat femoral arteries were measured with vernier calipers under the microscope. Effects were evaluated by the percentage of the test arterial diameter compared with that of the control contralateral artery. Vasospasm of both femoral arteries was produced by administration of the fresh blood of other rats. After immersion in the blood for 10 min. Xylocaine was administered into the right femoral artery for 10 min to examine its spasmolytic effect. The effects of the concentrations shown by the percent diameter were 106 percent, 108 percent, 107 percent, 111 percent, and 106 percent, respectively. There was no significant statistical difference between each agent and its control. Thirty minutes after removal of the agent, 2 percent Xylocaine failed to maintain its spasmolytic effect, while 4 percent, 10 percent, 20 percent, and 40 percent Xylocaine did maintain it. Next, blood was again administered after vessel immersion in the agent to examine its antispasmodic effect. The effects of the concentrations were 100 percent, 114 percent, 124 percent, 152 percent, and 146 percent. There were statistically significant differences, except in the case of 2 percent Xylocaine. Twenty-percent Xylocaine demonstrated a superior antispasmodic effect. The duration of the spasmolytic effect and the antispasmodic effect were concentration-dependent, up to approximately 20 percent.

Revision of residual deformities after operations for duplication of the thumb

We treated thirty-six patients (thirty-eight thumbs) who had residual deformity after ablation of a duplicated thumb. The deformities were classified into three groups: interphalangeal (eight thumbs), metacarpophalangeal (sixteen thumbs), and zigzag (fourteen thumbs). The indication for operation was primarily cosmetic; only eight patients had a functional disability, and that was mild. At the most recent follow-up, the results were rated good except for three fair results in the group that had an interphalangeal deformity, two fair results in the group that had a metacarpophalangeal deformity, and two poor and seven fair results in the group that had a zigzag deformity.

Stretching of the brachial plexus in rabbits

The brachial plexus of rabbits was stretched until mechanical failure. The level and site of rupture varied according to the direction of the stretching force. Upward and lateral traction of the forelimbs caused spinal nerve-root avulsions combined with nerve-trunk ruptures distal to the dorsal root ganglions. In such tractions the C5 nerves consistently exhibited postganglionic nerve-trunk rupture. The C6, C7, and C8 nerves had root avulsions. The T1 nerve was avulsed from the spinal cord in 7 cases out of 10; the other 3 cases had postganglionic nerve-trunk rupture. Downward traction of the forelimbs caused nerve avulsions from the scapulohumeral muscles innervated by the terminal branches of the brachial plexus and peripheral nerve ruptures in the course of the arm. The force producing trunk rupture of the C6 nerve was twice as great as that for root avulsion. The required stain was similar for nerve trunk rupture and root avulsion.

Computer-aided analysis of Z-plasties

Various Z-plasties were evaluated with a mathematical analytical method called the finite-element method. The lengthening and shortening effects on the skin proved to depend on the tip angle. Serial Z-plasties diminished the stress concentration after pairs of flaps had been transposed. Subdivided Z-plasties proved to be the most effective for lengthening. The finite-element method provided a good simulation of Z-plasties on a skin with complex properties. The lengthening and shortening effects on anisotropic skin were influenced not by the degree but by the direction of the anisotropy, whereas the total force required for transposing the two flaps was vice versa. The finite-element method was found to be useful for finding analytical solutions for biomechanical skin problems.

Operations for forearm deformity caused by multiple osteochondromas

We reviewed 36 cases of forearm deformity caused by multiple osteochondromas in 30 patients and classified them into three types: Type I showed a combination of ulnar shortening and bowing of the radius secondary to osteochondromas of the distal ulna (22 forearms). Type II showed dislocation of the radial head, either with osteochondromas of the proximal radius (Type IIa, two forearms) or secondary to more distal involvement (Type IIb, five forearms). Type III had relative radial shortening due to osteochrondromas at the distal radius (seven forearms). Operations were performed on 16 forearms in 13 patients, with 92% of satisfactory results. For Type I deformity, excision of osteochondromas, immediate ulnar lengthening and corrective osteotomy of the radius are recommended. For Type IIa, excision of the radial head is necessary, and for Type IIb, we advise gradual lengthening of the ulna using an external fixator. Excision of osteochondromas alone gave good results in Type III deformity. Our classification gives a reliable indication of the prognosis and is a guide to the choice of surgical treatment.

Nerve repairs for traumatic brachial plexus palsy with root avulsion

Thirty-six patients with traumatic brachial plexus lesions and root avulsions were treated surgically between 1972 and 1986 and were followed for more than 24 months (average, 42.6 months). Neurotization of the musculocutaneous nerve with intercostal nerves or the spinal accessory nerve resulted in satisfactory elbow flexion in 21 of the 33 cases (64%). Combined nerve repairs (i.e., intercostal and spinal accessory neurotization of the terminal branch of the brachial plexus in combination with nerve grafts from the upper spinal nerves of the brachial plexus) created a useful function in at least one functional level of the upper limb for 11 of the 15 cases so treated. Nerve repairs resulted in stability of the shoulder and elbow function controllable with a sensible hand for patients with root avulsion injury of the brachial plexus.

Treatment of preaxial polydactyly of the foot

Fourteen patients with preaxial polydactyly are classified into four types according to their morphologic configuration: type 1--ray duplication; type 2--completely duplicated phalanges; type 3--incompletely duplicated metatarsals; and type 4--incompletely duplicated phalanges. The surgical treatment and timing thereof appropriate for each group are discussed. Three cases of congenital hallux varus deformity are analyzed, focusing on the pathomechanism of this disorder. Based on our experience, two main factors are noticed in the etiology of congenital hallux varus deformity: inadequacy of the adductor hallucis and tightening of the fibrous band pulling the big toe into the varus.

Early microsurgical reconstruction in birth palsy

Most patients with birth palsy can be expected to recover spontaneously. But in some patients the recovery is unsatisfactory and the functional results are disappointing. One possible way to improve the prognosis for such patients is early surgical nerve reconstruction. In six infants, exploration of the brachial plexus was carried out at about six months after delivery, when there were no signs of recovery in shoulder and elbow joint movements. Preoperative metrizamide myelography, computerized tomography with intrathecal metrizamide (CT myelography), and axon reflex test (histamine test) were followed by intraoperative electrophysiologic examinations of root sensory evoked potential (SEP), nerve action potential (NAP), and evoked muscle response (M-response). Microsurgical nerve repair was performed on the basis of intraoperative diagnosis. Metrizamide myelography showed 13% false-positive root avulsion. Reliability of the histamine test was 80%. The intraoperative electro-diagnosis is essential for understanding the actual condition of the brachial plexus lesion and obtaining better results from microsurgical reconstruction in birth palsy. The surgical results, with an average follow-up evaluation of two years and four months, have been encouraging enough to continue this diagnostic and therapeutic program, though its superiority to natural recovery has not yet been clarified.

The effects of intra-arterially injected adriamycin on microvascular anastomosis

Although free tissue transfer following limb-saving wide resection has become increasingly necessary in the treatment of sarcomas of the extremities, the side effects of adjuvant chemotherapy on the microvascular structure are not yet known. There may be significant effects, especially with intra-arterial administration. In order to study the time-dependent manifestations of possible effects, experimental microvascular anastomoses in the rat femoral artery were performed at various intervals, after intra-arterial injection of Adriamycin. This drug was used because of its popularity as an adjuvant chemotherapeutic agent. Vessels were examined at varying intervals for macroscopic changes affecting patency and for histologic changes. Anastomoses done at three weeks after Adriamycin injection resulted in the worst patency rate. Histologically, thrombotic occlusion was associated with widespread and profound disruption of the internal elastic lamina, thought to be thrombogenic trauma: the vessel was presumed to have been made fragile by preoperative Adriamycin treatment. Five weeks or longer after injection, this effect was reduced, according to patency rates and histologic findings. Endothelial damage was minimal and appeared insignificant.

Pathologic rupture of flexor tendons due to longstanding Kienböck's disease

A 62-year-old man was seen for rupture of the flexor digitorum superficialis and profundus to the index finger. X-ray films showed longstanding Kienböck's disease with a completely fragmented lunate bone with fragments lying in front of the anterior lip of the radius. Tendon transfer restored active flexion to the index finger.

Infantile digital fibromatosis after web construction in syndactyly

A case of infantile digital fibromatosis with an unusual onset is reported. A Japanese girl, with a simple syndactyly of the right ring and little fingers, had an operation at the age of 2 1/2 years. Three months after the operation, multiple nodules appeared at the skin graft edge. The nodules were excised but soon recurred. When the patient was 8 years old, a large-scale excision of the tumors was performed. Intracytoplasmic inclusion bodies were shown by phosphotungstic acid-hematoxylin stain, and the case was diagnosed as infantile digital fibromatosis.

Terminal limb congenital malformations: analysis of 523 cases

A total of 523 Japanese patients with terminal limb congenital malformations were reviewed for the characteristic features, and especially for type correlation between hand and foot anomalies. There were 281 cases of hand involvement alone, 149 cases of foot involvement alone, and 93 cases of combined hand and foot involvement. Polydactyly was commonly preaxial in the hand and postaxial in the foot, in contrast to the well-known postaxial dominance in the hand among whites. Hand anomalies were likely to show the same Swanson type of anomaly as the foot, with the affected digital ray likely to be identical in both hand and foot.

Congenital clasped thumb: a review of forty-three cases

Over a 10-year period, 43 patients (75 hands) with congenital clasped thumb were seen in our institution. Three groups were identified: group I, 14 patients (24 hands) without contracture; group II, 14 patients (21 hands) with contractures of the palmar side; and group III, 15 patients (30 hands) with arthrogryposis multiplex congenita. Forty-two hands were treated with splinting alone and 16 hands with surgery. The remaining 17 hands were followed conservatively without splinting or surgery. The mean follow-up was 32 months. The results were evaluated by active abduction of the carpometacarpal joint and extension of metacarpophalangeal joint. All patients in group I showed good response to splinting, and the cause of the deformity appeared to be the predominance of the flexor muscles. In groups II and III, 10 patients (16 hands) who had severe deformity or no response to splinting were treated by release of the palmar soft tissues, skin grafts, and reconstruction of the extensors. Satisfactory results were obtained in 12 of 16 hands.