Bone compression technique for arthrodesis and nonunion in the hand.

We present a simple compression technique for treatment of difficult nonunions and joint fusions in the hand. This technique utilizes only K-wires and small vessel loops. The results of 44 consecutive cases were studied retrospectively. Union was achieved in 37/44 cases. The average time to union was 7 weeks and our results were comparable to those of other studies. We found this technique useful, especially in complicated cases.

Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant.

Currently, there is no reliable reconstructive modality allowing anatomic resurfacing of traumatic digital osteochondral articular defects. The purpose of the present study is to demonstrate the utility of Medpor, a high-density porous polyethylene (HDPP) scaffold biomaterial that can (1) be readily contoured to fit any joint defect, (2) permit stable internal fixation, and (3) permit osteocyte and chondrocyte ingrowth and subsequent articular cartilage resurfacing necessary to restore joint congruity. HDPP has gained wide acceptance for use in craniofacial and skeletal reconstruction and augmentation. An avian non-weight-bearing joint model was designed to study the role of the HDPP implant in small joint reconstruction. An osteochondral defect was created with a 5-mm circular punch in the humeral articular surface of both glenohumeral joints of 32 adult White Leghorn chickens. In each animal, one defect was press-fitted with a correspondingly sized HDPP implant (HDPP implant group); the contralateral defect was filled with the original osteochondral plug (isograft group) or left unrepaired (control group). At 2 weeks, and 1, 3, and 6 months,joints from each group were harvested and evaluated. Over the 6-month study period, joints in the control group demonstrated healing with dense collagenous scar tissue leaving residual defects at the articular surfaces and significant degenerative disease of the glenohumeral joints radiographically. Joints in the isograft group demonstrated near-complete resorption with some preservation of the cartilaginous cap but overall depression of the articular surface and significant degenerative joint disease. Joints in the HDPP implant group demonstrated stable fixation by highly mineralized bony trabecular ingrowth, preservation of the articular contour of the humeral head, and no evidence of significant degenerative joint disease. These findings indicate a potential role for this high-density porous polyethylene implant in the reconstruction of small joint articular and osseous defects.

Lip reconstruction following Mohs' surgery: the role for composite resection and primary closure.

Surgical outcomes and patient satisfaction with composite resection and primary closure for the management of upper-lip defects following Mohs' surgery were evaluated. Twenty-seven patients underwent upper-lip reconstruction following Mohs' surgery from 1993 to 1997. Twelve of these patients were selected for this report based on adequate follow-up examinations and photographs. There were nine women and three men with a mean age of 46 years (range, 33 to 70 years). Eleven patients underwent Mohs' surgery for basal cell carcinoma and one patient for squamous cell carcinoma of the upper lip. The defects varied in size and location, often extending beyond a single aesthetic subunit. The reconstruction was performed an average of 7 days after Mohs' surgery (range, 1 to 23 days). In 50 percent of the cases, a full-thickness excision was performed, which included orbicularis oris and inner-lip mucosa. The functional results were graded as near normal to normal in all cases. There were no observed changes in oral continence, eating or speech. Two patients experienced numbness medial to the operative site, but this had no adverse affect on lip function. The aesthetic results were graded as very good to excellent in all cases. Eleven of the 12 patients were satisfied with their lip appearance and function. Conventional wisdom dictates that during reconstruction of upper-lip defects, one should attempt to maintain a majority of the uninvolved tissue for the best result. Although these techniques result in wound closure, they fail to consider lip aesthetics. By using a vertically oriented composite resection of the tipper lip with the additional resection of uninvolved tissue, normal lip architecture is maintained. In our experience, this results in a superior aesthetic and functional result.

Recurrent myxoma of the hand.

Myxoma is a rare benign tumor composed of stellate or spindle-shaped cells in a loose myxoid stroma. Few cases involving the hand have previously been described. We present a rare case of recurrent myxoma in the intermetacarpal space and detail the clinical behavior of this indolent tumor.

Comparison of cleft palate induction by Nicotiana glauca in goats and sheep.

The induction of cleft palate by Nicotiana glauca (wild tree tobacco) during the first trimester of pregnancy was compared between Spanish-type goats and crossbred western-type sheep. Cleft palate was induced in 100% of the embryonic/fetal goats when their pregnant mothers were gavaged with N. glauca plant material or with anabasine-rich extracts from the latter, during gestation days 32-41. Seventy-five percent of newborn goats had cleft palate after maternal dosing with N. glauca during gestation days 35-41, while no cleft palates were induced when dosing periods included days 36-40, 37-39, or day 38 only. The induced cleft palates were bilateral, involving the entire secondary palates with complete detachment of the vomer. Eleven percent of the newborn goats from does gavaged during gestation days 32-41 had extracranial abnormalities, most often contractures of the metacarpal joints. Most of these contractures resolved spontaneously by 4-6 weeks postpartum. One newborn kid also had an asymmetric skull due to apparent fetal positioning. No cleft palates were induced in lambs whose mothers were gavaged with N. glauca plant or anabasine-rich extracts during gestation days 34-41, 35-40, 35-41, 36-41, 35-51, or 37-50. Only one of five lambs born to three ewes gavaged with N. glauca plant material during gestation days 34-55 had a cleft palate, but all five of these lambs had moderate to severe contractures in the metacarpal joints. The slight to moderate contracture defects resolved spontaneously by 4-6 weeks postpartum, but the severe contractures resolved only partially. Embryonic/fetal death and resorption (determined by ultrasound) occurred in 25% of pregnant goats fed N. glauca compared to only 4% of pregnant sheep. Nicotiana glauca plant material contained the teratogenic alkaloid anabasine at 0.175% to 0.23%, dry weight, demonstrating that Spanish-type goats are susceptible to cleft palate induction by the natural toxin anabasine, while crossbred western-type sheep are resistant. However, clinical signs of toxicity were equally severe in goats and sheep, even though maternal alkaloid tolerance was generally lower in sheep. We postulate that an alkaloid-induced reduction in fetal movement during the period of normal palate closure is the cause of the cleft palate and multiple flexion contractures. Teratology 61:203-210, 2000. Published 2000 Wiley-Liss, Inc.

The fetal cleft palate: II. Scarless healing after in utero repair of a congenital model.

The role of fetal surgery in the treatment of non-life-threatening congenital anomalies remains a source of much debate. Before such undertakings can be justified, models must be established that closely resemble the respective human anomalies, and the feasibility and safety of these in utero procedures must be demonstrated. The authors recently described and characterized a congenital model of cleft palate in the goat. The present work demonstrates the methodology they developed to successfully repair these congenital cleft palates in utero, and it shows palatal healing and development after repair. A surgically created cleft model was developed for comparative purposes. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Six pregnant goats were gavaged twice daily during gestational days 32 to 41 (term, 145 days) with a plant slurry of Nicotiana glauca containing the piperidine alkaloid anabasine; the 12 fetuses had complete congenital clefts of the secondary palate. Repair of the congenital clefts was performed at 85 days of gestation using a modified von Langenbeck technique employing lateral relaxing incisions with elevation and midline approximation of full-thickness, bilateral, mucoperiosteal palatal flaps followed by single-layer closure. Six congenitally clefted fetuses underwent in utero repair, six remained as unrepaired controls. Twelve normal fetuses underwent surgical cleft creation by excision of a 20 x 3 mm full-thickness midline section of the secondary palate extending from the alveolus to the uvula, at 85 days of gestation. Six surgically clefted fetuses underwent concurrent repair of the cleft at that time; six clefted fetuses remained as unrepaired controls. At 2 weeks of age, no congenitally or surgically created clefts repaired in utero demonstrated gross or histologic evidence of scar formation. A slight indentation at the site of repair was the only remaining evidence of a cleft. At 6 months of age, normal palatal architecture, including that of mucosal, muscular, and glandular elements, was seen grossly and histologically. Cross-section through the mid-portion of the repaired congenitally clefted palates demonstrated reconstitution of a bilaminar palate, with distinct oral and nasal mucosal layers, after single-layer repair. In utero cleft palate repair is technically feasible and results in scarless healing of the mucoperiosteum and velum. The present work represents the first in utero repair of a congenital cleft palate model in any species. The use of a congenital cleft palate model that can be consistently reproduced with high predictability and little variation represents the ideal experimental situation. It provides an opportunity to manipulate specific variables, assess the influence of each change on the outcome and, subsequently, extrapolate such findings to the clinical arena with a greater degree of relevance.

One thousand intercarpal arthrodeses.

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienbock's disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

Triquetral impingement ligament tear (tilt).

Ulnar-wrist pain is a complex problem whose cause often remains elusive. A diagnostic triad of localized triquetral pain, history of a wrist hyperflexion injury, and normal radiographs, accompanied by ulnar wrist swelling and limited wrist motion, is often attributable to a syndrome we have termed triquetral impingement ligament tear (TILT). The mechanism of injury causes a cuff of fibrous tissue to be displaced distally from the ulnar sling mechanism, resulting in chronic impingement on the triquetrum that causes hyperaemia, loss of articular cartilage, and softening of the bone. Surgical repair consists of simply excising the impinging fibrous cuff. The outcome of 44 patients treated for TILT over a 6-year period is reviewed. In all cases, TILT repair resulted in improved wrist motion and strength. Ninety-five percent of patients reported a significant improvement in pain both at rest and with activity.

Topical and systemic calcium channel blockers in the prevention and treatment of microvascular spasm in a rat epigastric island skin flap model.

Vasospasm is a frustrating problem commonly encountered in microvascular surgery. Extreme arterial vasoconstriction usually occurs intraoperatively, shortly after release of the vascular clamps, but can be a problem for 48 to 72 hours postoperatively. Failure to alleviate vasospasm can have disastrous consequences in replanted and revascularized tissues, ultimately resulting in microsurgical failure. The authors investigated the efficacy of topical and systemic administration of two commonly prescribed calcium channel blockers-nifedipine and verapamil-in both the prevention and treatment of vasospasm in a rat epigastric island skin flap model. Superficial epigastric island skin flaps were elevated in 60 Sprague-Dawley rats. Femoral vessels were isolated from the inguinal ligament to a point 1 cm distal to the origin of the epigastric vessels, and the feeding vessels were ligated. The flap was returned to its natural anatomic bed and was sutured into place, leaving the femoral vessels exposed. The femoral artery and vein were transected, and anastomoses were performed under the operating microscope. A block of ice was then applied directly to the anastomotic site for 1 minute to induce additional vasospasm. Groups I through III received topical application of solutions of 0.5 ml of either 0.9% normal saline (control), verapamil (2.5 mg per milliliter), or nifedipine (5 mg per milliliter) directly to the anastomotic site immediately prior to release of the vascular clamps. Groups IV through VI received intraperitoneal injections of 1.0-ml solutions of either 0.9% normal saline (control), verapamil (2.5 mg per milliliter), or nifedipine (5 mg per milliliter) at 30 minutes prior to performing the anastomoses. Thermocouple temperature probes reflecting blood flow were placed at the center of the skin flap in a subcutaneous position, at the proximal femoral artery, and at the takeoff of the epigastric artery. Accurate, direct temperature measurements of the isolated skin flap and femoral vessels were recorded at 10, 20, and 30 minutes after release of the vascular clamps. Topical and systemic administration of verapamil and nifedipine moderated significantly the temperature declines observed at 10 minutes at the level of the femoral artery proximally and distally compared with controls. Following this decline, groups I through III (topical) demonstrated significant recovery of temperature toward baseline, with verapamil and nifedipine showing significantly better recovery of temperature than controls. Groups IV through VI (systemic) demonstrated a stabilization of temperature without any significant additional recovery of temperature toward baseline. Verapamil was more effective than nifedipine in its actions when administered topically or systemically. The authors' results suggest a potential role for topical and systemic administration of verapamil and nifedipine in preventing, or at least minimizing, the deleterious effects of vasospasm on flap survival, as demonstrated by its temporizing effect on temperature change across the anastomosis in their model.

The fetal cleft palate: I. Characterization of a congenital model.

Any animal model of a human congenital anomaly established by iatrogenic methods involving intrauterine fetal manipulation has limited clinical applicability. A congenital model that more closely simulates the etiopathogenesis of a human anomaly may provide data that can more readily be extrapolated to that anomaly and, therefore, be used in diagnostic and management strategies. The present work provides a description and characterization of a congenital model of cleft palate in the goat. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Sixteen pregnant goats were gavaged twice daily during gestational days 32 through 41 [term, 145 days] with a plant slurry of Nicotiana glauca containing the piperidine alkaloid teratogen anabasine. Gross analysis and measurement of fetal clefts were performed at 60, 70, and 85 days gestation (four fetuses were studied at each time point). Seventeen clefted kids were sacrificed at specific intervals after birth (2 weeks, and 1, 3, and 6 months); after skull debridement and preparation, they were compared with 12 unclefted control kids. Complete clefting of the secondary palate occurred in 97 percent of the fetuses. In all cases, the cleft extended from the posterior aspect of the alveolar ridge to the uvula; the majority of these clefts were bilateral, with complete detachment of the vomer. Morphologically, these clefts were similar to human clefts. Eighteen percent of clefted newborn kids demonstrated gross maxillary hypoplasia and midfacial retrusion at birth with a relative Class III malocclusion. Direct measurement of the congenital caprine skulls confirmed these findings. The incidence of midfacial growth abnormalities in these clefted animals raises questions regarding the etiopathogenesis of facial dysmorphology that is unrelated to scarring of the maxilla. This congenital cleft palate model is currently being used to explore these questions and others related to craniofacial growth and palatal function after in utero repair.

Brain abscess as a complication of orthognathic surgery: diagnosis, management, and pathophysiology.

We present what we believe is the first case of a brain abscess resulting from orthognathic surgery reported in the literature. Although recent advances have significantly improved the treatment of brain abscesses, delays in diagnosis lead to persistent high rates of mortality. Often, the initial symptoms are vague and nonspecific. Commonly, the neurologic status of the patient deteriorates significantly before suspicion is raised and a CT scan is obtained. This case report is intended to benefit all practitioners who participate in the perioperative care of orthognathic surgery patients. Although the occurrence of a brain abscess is rare, it is hoped that this case will heighten the awareness of clinicians to this potential complication.

Snowblower injuries to the hand.

A retrospective review of 22 patients who sustained snowblower injuries to the hand was performed. There were 17 men and 5 women, ranging in age from 20 to 68 years (average age, 39.7 years). Fifty percent were manual laborers, 25% were unemployed, 15% were office workers, and 10% were not categorized. The dominant hand was involved in 86% of patients. In all patients, injuries occurred during an attempt to unclog manually the snowblower of wet snow. Patients were evaluated initially in the emergency room, where their wounds were irrigated and debrided, subungual hematomas drained, and nail bed lacerations repaired. Patients with more extensive injuries were taken to the operating room for definitive treatment including open or closed reduction of fractures, fingertip replacement as composite grafts or skin grafts, revision amputations, tenorrhaphies, and digital nerve repairs. All injuries occurred distal to the metacarpophalangeal joints. Only 1 patient sustained an injury to the proximal phalanx. Ten patients injured only 1 finger, 6 patients injured 2 fingers, and 6 patients injured 3 fingers. The middle and ring fingers were most commonly injured (39.6% and 33.3% respectively), followed by the index and little fingers (16.7% and 8.3% respectively), and the thumb (2.1%). Phalangeal fractures were the most common type of injury, occurring in 29.2% of patients, and usually involved the distal phalanx. This was followed in frequency by nail bed injuries (22.9%), amputations (22.9%), tendon lacerations (14.6%), soft-tissue avulsions (6.3%), and digital nerve injuries (4.2%). Snowblower injuries can involve bone, soft tissue, nail bed structures, nerves, and tendons, and may even result in amputation of one or several fingers. These injuries are localized to the distal portions of the fingers. The middle and ring fingers are most commonly involved, with relative sparing of the thumb. Fractures are the most frequent injury, followed by nail bed injuries and amputations. Snowblower injuries are often managed as open fractures with intravenous antibiotics; irrigation and debridement; and repair of bone, soft tissue, and nail bed structures.

Silicon analysis of breast and capsular tissue from patients with saline or silicone gel breast implants: II. Correlation with connective-tissue disease.

The silicone breast implant controversy rages on. Recent work has demonstrated that normal or baseline breast tissue silicon levels in women who had had no prior exposure to any type of breast implant may be as high as 446 microg/gm of tissue. These data ranged from 4 to 446 microg/gm of tissue, with a median of 27.0 microg/gm of tissue. In addition, numerous other epidemiologic and rheumatologic studies have demonstrated no association between silicone breast implants and any connective-tissue diseases. Despite these reports, the use of silicone implants remains restricted. The present study measured breast and capsular tissue silicon levels from 23 breasts in 14 patients with saline implants, and from 42 breasts in 29 patients with silicone implants. No patient in the saline implant group presented with signs or symptoms of connective-tissue disease. Patients with silicone implants, however, were divided into three groups based on the presence or absence of signs or symptoms of connective-tissue disease: group I, no symptoms or signs; group II, + symptoms, no signs; and group III, + symptoms, + signs. Six patients in group III were diagnosed with a specific connective-tissue disease, including systemic lupus erythematosus, rheumatoid arthritis, or scleroderma. The most common indications for implant removal or exchange were capsular contracture and implant rupture, although 41 percent of patients with silicone implants expressed media-related concern over the implant issue. The most common symptoms described by patients in groups II and III were joint pain and stiffness, arm pain and numbness, and fatigue. In all groups, capsular tissue silicon levels were significantly greater than breast tissue levels. This finding may indicate that the capsule serves as a barrier to the distribution of silicone from the implant into adjacent breast tissue. Although breast tissue silicon levels in patients with silicone implants were not significantly greater than those in patients with saline implants (p = 0.48), capsular tissue levels in patients with silicone implants were, indeed, significantly greater than those in patients with saline implants (p < 0.001). However, no statistically significant differences in tissue silicon levels were observed with relation to the presence or absence of connective-tissue disease signs or symptoms in patients with silicone implants (groups I to III). Therefore, these data strengthen the conclusion that there is no association between tissue silicon levels and connective-tissue disease.

The "Tic-Tac-Toe" classification system for mutilating injuries of the hand.

Several classifications of mutilating hand injuries exist in the literature. Unfortunately, each of these provides a categorization that is arbitrarily grouped according to the part of the hand predominantly involved. It is imperative that a comprehensive classification system incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity in addition to the predominantly involved part of the hand. We therefore devised a new classification system for mutilating injuries of the hand which categorizes them into seven types: (I) dorsal mutilation, (II) palmer mutilation, (III) ulnar mutilation, (IV) radial mutilation, (V) transverse amputations, (VI) degloving injuries, and (VII) combination injuries. These types are subcategorized into three subtypes: (A) soft-tissue loss, (B) bony loss, and (C) combined tissue loss. Vascular integrity is recorded with subscript notation: (0) vascularization intact or (1) devascularization. The hand is then systematically divided into nine numerical zones in "tic-tac-toe" fashion with radial, central, and ulnar columns and proximal, central, and distal rows. The "Tic-Tac-Toe" classification system allows the examining surgeon to describe precisely any mutilating injury of the hand. This system permits accurate assessment of each hand injury by assignment of the appropriate classification type, subtype, vascular status, and zone involvement. Clinical examples illustrate the user-friendliness and practicality of this new classification system.

Sagittal band reconstruction.

Extensor tendon subluxation at the metacarpophalangeal joint occurs only rarely in patients without rheumatoid arthritis. Almost all reported cases involve disruption of the radial sagittal band with ulnar subluxation of the extensor tendon. A technique of sagittal band reconstruction is described that entails weaving a retrograde segment of extensor tendon upon itself after passing it through the deep transverse metacarpal ligament. Twenty-one sagittal band reconstructions were performed in 16 patients. This series included 18 cases of ulnar subluxation secondary to radial sagittal band disruption and 3 cases of radial subluxation secondary to ulnar sagittal band disruption. Using this technique, pain was eliminated in every case and there has been no recurrence of extensor tendon subluxation.