Skin Tension in the Aetiology of Dupuytren’s Disease; a Prospective Trial

Tension in the palmar fascia has been proposed as a factor causing Dupuytren’s disease. If tension does stimulate the growth of new Dupuytren’s tissue, relieving longitudinal tension should reduce the recurrence rate following surgery. Thirty patients with palmar Dupuytren’s contracture of a single ray that affected only the metacarpophalangeal joint were divided into two groups. Both groups had a fasciotomy: one group through a transverse incision that was closed directly and the other through a longitudinal incision with Z-plasty closure. Half the patients (seven of 14) who had direct closure had recurrence at 2 years as compared to two of the 13 in the Z-plasty group. The trial was stopped at the interim analysis stage due to the high recurrence rate in the first group. These results are consistent with the tension hypothesis for the aetiology of Dupuytren’s disease.

Medium-term outcomes of pyrocarbon arthroplasty of the proximal interphalangeal joint

We evaluated the outcome of pyrocarbon arthroplasty for proximal interphalangeal joint osteoarthritis in 18 arthroplasties carried out by a single surgeon using the Ascension prosthesis (Ascension Orthopedics Inc., Austin, Texas) in 15 patients after a mean of 6.2 years. Significant and maintained improvements in pain scores at rest and on active movements were achieved for surviving implants, and the range of motion was comparable with preoperative measurements. The radiographs, which were evaluated for evidence of ongoing migration and potential failure, were of concern in 10 out of 18 joints. Two patients required implant removal.

Fascial flap for recurrent ganglion

INTRODUCTION

Recurrence of a dorsal wrist ganglion following surgery is not uncommon and we propose a technique to deal with the problem.

METHOD

A flap of extensor retinaculum is used to fill the defect left in the wrist capsule following repeat radical excision of the recurrent ganglion. The flap is based on a distal arterial pedicle, usually the intercompartmental 2:3 supraretinacular artery or one of its branches.

RESULTS

Eight patients have been operated with a mean follow-up of 28 months. So far there have been no recurrences.

CONCLUSION

Full recovery of wrist function ocurred in all cases except one who had slight restriction of flexion. We believe this to be a useful technique but a larger series with longer follow up would be needed to show its true value.

Carpal tunnel release by the Agee endoscopic technique. Results at 4 year follow-up

Ninety-five hands (86 patients) were treated by endoscopic carpal tunnel release using the technique of Agee. They were the first ones operated on by the senior author (GF) using this technique. The patients were interviewed at a mean follow-up of 4.5 years: 72% of hands were free of symptoms and 94% were described by the patients as functionally normal. Seventeen hands (out of 27) with residual or recurrent symptoms were examined. Nine hands (nine patients) were only partially improved (mean 6.7 on a 10 point scale) and in eight hands (seven patients), some symptoms had recurred after a mean delay of 3.8 years. It was possible to find a second pathology in most of these cases. It is necessary to inform the patient before operation that incomplete relief or recurrence of symptoms can occur after endoscopic carpal tunnel release, as with conventional release.

Patterns of healing of scaphoid fractures. The importance of vascularity

We studied 45 patients with 46 fractures of the scaphoid who presented sequentially over a period of 21 months. MRI enabled us to relate the pattern of the fracture to the blood supply of the scaphoid. Serial MRI studies of the four main patterns showed that each followed a constant sequence during healing and failure to progress normally predicted nonunion.

Patterns of healing of scaphoid fractures

We studied 45 patients with 46 fractures of the scaphoid who presented sequentially over a period of 21 months. MRI enabled us to relate the pattern of the fracture to the blood supply of the scaphoid. Serial MRI studies of the four main patterns showed that each followed a constant sequence during healing and failure to progress normally predicted nonunion.

Long-term outcome of neurovascular palmar advancement flaps for distal thumb injuries

Thirteen neurovascular palmar flaps for thumb tip coverage were reviewed: six O'Brien and seven Moberg flaps with a mean follow-up of 81 months. Both techniques were found to be safe and effective in preserving pulp sensibility, with a mean 2PD of 5 mm and a Semmes-Weinstein identical to the contralateral side in nine cases. The interphalangeal joint regained a normal range of motion, and did not seem to be affected by the perioperative flexion. The main residual complaints were persistent cold intolerance (present in all cases and severe in three), pulp instability (present in six and severe in two), and nail deformity. This last problem was more related to the injury. Despite these drawbacks, O'Brien and Moberg flaps remain the first choice for coverage of 1-2 cm pulp defects of the thumb.

The use of skeletal traction in the treatment of severe primary Dupuytren’s disease

In 13 patients (18 fingers) we used two types of external fixator as progressive static splints for the preoperative correction of the deformities of severe Dupuytren’s disease before conventional fasciectomy. The duration of treatment was from one to four weeks.

At a mean follow-up of 18 months the mean total fixed flexion deficit had been reduced from 138° to 39° and the mean proximal interphalangeal joint contracture from 80° to 29°. The mean total active range of movement had increased from 123° to 175°. These preliminary results are promising, but continued follow-up is needed since recurrence is common.

The use of skeletal traction in the treatment of severe primary Dupuytren's disease

In 13 patients (18 fingers) we used two types of external fixator as progressive static splints for the preoperative correction of the deformities of severe Dupuytren's disease before conventional fasciectomy. The duration of treatment was from one to four weeks. At a mean follow-up of 18 months the mean total fixed flexion deficit had been reduced from 138 degrees to 39 degrees and the mean proximal interphalangeal joint contracture from 80 degrees to 29 degrees. The mean total active range of movement had increased from 123 degrees to 175 degrees. These preliminary results are promising, but continued follow-up is needed since recurrence is common.

Isolated subluxation of the extensor pollicis longus tendon. A cause of 'boutonnière' deformity of the thumb

Isolated ulnar subluxation of the extensor pollicis longus (EPL) tendon occurs when there is damage to the radial side of the extensor hood on the dorsum of the metacarpophalangeal joint of the thumb. The thumb collapses into a pseudoboutonnière deformity because the EPL tendon subluxes and comes to lie palmar to the centre of rotation of the metacarpophalangeal joint to act as a flexor instead of an extensor. The extensor pollicis brevis tendon which lies in a deeper plane to the EPL is unaffected. We describe four cases and propose conservative treatment as being effective in recent injuries.

A modified open palm technique for Dupuytren's disease. Short and long term results in 54 patients

Fifty-four patients with Dupuytren's disease were operated on using transverse and Bruner incisions, leaving the transverse palmar and digital wounds open. The mean follow up was 6.6 years (minimum 5 years). The mean percentage correction of the overall fixed flexion deformity was 71%. The incidence of recurrence and extension of the disease were similar to other series of limited aponeurectomy. However, the postoperative complications were very much lower and the method is particularly suitable for patients over 50 years of age.

Free vascularized toe-joint transfer in hand reconstruction: a series of 25 patients

Twenty-eight vascularized toe-joint transfers performed on 25 patients were reviewed. A number of different techniques were used: proximal interphalangeal joint or metacarpophalangeal joint reconstruction, one-stage double joint transfer, and interphalangeal thumb or trapezometacarpal joint replacement. Using these types of vascularized joint transfer allows one-stage composite transfer (including skin, bone, and extensor tendon) and provides rapid bone healing, potential growth in the young, good long-term cartilage preservation, normal lateral stability in pinch, and limited but useful range of motion (mainly at the proximal interphalangeal level).

Homodigital neurovascular island flaps for digital pulp loss

Terminal amputations with loss of the distal pulp are common injuries. This report analyses 64 consecutive cases of advanced or exchanged homodigital neurovascular island flaps operated on by one surgeon between 1981-1986. The surgical technique, indications, contra-indications and five year results are evaluated. Overall, these flaps provide reliable vascularity as well as normal sensibility at the distal end of the finger where high quality perception is required.

Homodigital neurovascular island flaps for digital pulp loss

Terminal amputations with loss of the distal pulp are common injuries. This report analyses 64 consecutive cases of advanced or exchanged homodigital neurovascular island flaps operated on by one surgeon between 1981-1986. The surgical technique, indications, contra-indications and five year results are evaluated. Overall, these flaps provide reliable vascularity as well as normal sensibility at the distal end of the finger where high quality perception is required.

Some aspects of lumbrical function

An electromyographic investigation was performed on the hands of six volunteers. The functioning of the lumbrical and flexor digitorum profundus muscles during resisted and unresisted extension was studied. No subject showed much simultaneous contraction of the two muscles in unresisted extension of the interphalangeal joints, but some showed marked simultaneous contraction during resisted extension. We suggest that, in these individuals, the profundus is acting to steady the origin of the lumbrical so that it can act more efficiently.

Some Aspects of Lumbrical Function

An electromyographic investigation was performed on the hands of six volunteers. The functioning of the lumbrical and flexor digitorum profundus muscles during resisted and unresisted extension was studied. No subject showed much simultaneous contraction of the two muscles in unresisted extension of the interphalangeal joints, but some showed marked simultaneous contraction during resisted extension. We suggest that, in these individuals, the profundus is acting to steady the origin of the lumbrical so that it can act more efficiently.

Dorsal wedge osteotomy of the proximal phalanx for hallux rigidus. Long-term results

Eight women had 10 toes treated for hallux rigidus by dorsal wedge osteotomy of the proximal phalanx and were reviewed after an average follow-up of 22 years. Five toes were symptom-free, four others did not restrict walking, and only one had required metatarsophalangeal fusion. We conclude that dorsal wedge osteotomy affords long-lasting benefits for hallux rigidus in the adolescent female.

Osteoid osteoma of the distal phalanx: a report of four cases and review of the literature

Four cases of osteoid osteoma of the distal phalanx are described. The difficulty of diagnosis is stressed. Complete removal of the nidus is essential for surgical cure. Other modes of treatment are discussed and our series compared to other similar cases described in the literature.

Free compound transfer of the distal interphalangeal joint. A case report

The first case of free vascularized transfer of a distal interphalangeal (DIP) joint, used to replace a severely damaged proximal one, is presented. The case is interesting not only for the procedure used, but it also illustrates the principle by which useful components of nonsalvageable digits are used to reconstruct other damaged, but still salvageable, parts of the hand.

Osteoid Osteoma of the Distal Phalanx: A Report of Four Cases and Review of the Literature

Four cases of osteoid osteoma of the distal phalanx are described. The difficulty of diagnosis is stressed. Complete removal of the nidus is essential for surgical cure. Other modes of treatment are discussed and our series compared to other similar cases described in the literature.

Tendon Transfer in Partially Anaesthetic Hands

Stereognosis and sensory localisation were studied in hands of patients with partial anaesthesia due to peripheral nerve injury both before and after tendon transfer to impart movement to the anaesthetic part. One patient showed a marked improvement in stereognosis and localisation, but in general little was gained in terms of improved sensation. Function was improved more in the dominant than in the non-dominant hand. Earlier tendon transfer in cases of peripheral nerve injury might decrease cortical exclusion.

Tendon transfer in partially anaesthetic hands

Stereognosis and sensory localisation were studied in hands of patients with partial anaesthesia due to peripheral nerve injury both before and after tendon transfer to impart movement to the anaesthetic part. One patient showed a marked improvement in stereognosis and localisation, but in general little was gained in terms of improved sensation. Function was improved more in the dominant than in the non-dominant hand. Earlier tendon transfer in cases of peripheral nerve injury might decrease cortical exclusion.

Joint reconstruction following trauma: comparison of microsurgical transfer and conventional methods: a report of 61 cases

Joint reconstruction at the metacarpophalangeal or proximal interphalangeal levels remains a difficult problem in hand surgery. The authors reviewed sixty-one joints reconstructed acutely or electively allowing to compare Swanson spacer (30 joints), interpositional arthroplasty (4), non vascularized joint transfer (5) and vascularized joint transfer (21). Among these, two different techniques have been used: island compound transfer from a finger bank (10) and free vascularized transfer from the second toe (10) or from a non replantable finger (1). It is not worth while comparing different techniques applied to different indications. The only point which can be stressed is the better average range of movement of metacarpophalangeal reconstruction compared to that obtained at the proximal interphalangeal level.

[Revascularization of digital avulsion injuries caused by rings]

The authors describe an original technique of ring fingers revascularization, avoiding two chief dangers met in the double vein grafts: the one of the joint and tendinous devascularization with its risks of stiffness, and the other one of the devascularization of the skin sheath with secondary necrosis or trophic trouble. The worse artery is resected and the defect is bridged by a long venous graft, the skin of the distal fingers being provided by the backflow.

Injury of the tibialis posterior tendon: a cause of acquired valgus foot in childhood

Accidental division of the tibialis posterior tendon near the medial malleolus is easily overlooked and can, if left untreated, cause a painful planovalgus deformity of the foot. Two such patients are described, who had small wounds near the medial malleolus and in whom the tendon's damage was not initially diagnosed. Both patients came later with a painful valgus flat foot. Diagnosis of the lesion may be difficult because the inversion and supination action of the tibialis posterior tendon can be mimicked by the long flexor tendons of the toes. A patient with an intact tibialis posterior tendon can invert and supinate the foot and then plantarflex and dorsiflex the toes with the foot held in that position. Damage to the tendon should be suspected in all penetrating wounds near the medical malleolus.

Intramedullary spinal cord tumours presenting as scoliosis

Intramedullary spinal cord tumours may present as scoliosis without neurological signs. Those treating spinal deformities should be alert to this possible aetiology. The clinical features of 12 such cases are discussed with reference to early diagnosis and treatment. Patients with a painful scoliosis should be investigated with myelography as well as bone scintigraphy. Many intrinsic spinal cord tumours are now amenable to surgical removal. The prognosis for neurological recovery is poor once a severe deficit becomes established. The importance of early diagnosis and joint orthopaedic and neurosurgical management is emphasised.