Possible common pathogenetic mechanisms for Poland sequence and Adams-Oliver syndrome.

We report on 2 families having members affected with the Poland sequence and Adams-Oliver syndrome. In the first family, a 5-month-old boy presented with Adams-Oliver syndrome; his mother had Poland sequence. In the second family, a 12-year-old boy and his mother presented with findings suggestive of Adams-Oliver syndrome and Poland sequence. This suggests that the same genetic predisposition may result in either or both conditions.

Norman Bethune and Edward Archibald: sung and unsung heroes.

Edward Archibald was a pioneer, master thoracic surgeon. He laid the foundation for surgical research in Canada and made fundamental contributions to the training and certification of surgeons. He did it all without raising his voice and within the confines of organized medicine. He became an unsung hero. Norman Bethune, with a flair for publicity, used extraordinary measures and delivered them heroically with talent and total dedication, ignoring conventional approaches. He became a truly sung hero.

Syndactyly of upper limb. Morphogenesis, classification, and management.

The distinction between primary and secondary syndactyly is made on the basis of their relation to the morphogenesis. The latter is associated with antecedent malformation which results in subsequent refusion of parts. Based on these considerations, a practical classification is suggested. The management of the various types of malformations is considered in relation to the complexity of the structures involved. Certain deformities require very early treatment in order to permit prehensile function to the developing infant, or to release the impaired part. It is desirable to complete all surgery before the child enters school. The severe complex syndactyly could rarely be solved by one operation. Normal appearance and function are rarely attained and, with growth, newer problems of imbalance and contracture appear. While rehabilitation of the hand is seldom needed for the children with cutaneous syndactyly, the severe deformities associated with complex syndactyly often require supervision in order to regain the potential function and simple dynamic splints are very helpful.

Practical microsurgery.

The reconstructive surgeon who wishes to learn microsurgery must realize that its acquisition demands extensive practice in the research laboratory with clinical application occurring after perfection of the fundamental techniques. Their initial usage should be in traumatic extremity injuries followed by replantation of complete and incomplete amputations. Elective reconstructive microsurgery demands consummate clinical skills and should not be attempted except by those who have convincingly demonstrated their microsurgical skills either in replantation surgery or in the research laboratory.

Management of mutilating injuries of the hand.

In the devastating destruction of parts associated with mutilating injuries of the hand, it is often not possible to salvage the elements essential to normal function of the hand. The objective of primary treatment is re-establishment of circulation to the devitalized part, realignment of the remaining skeletal structures, and skin cover of the denuded portions. Definitive reconstruction has to be delayed until survival of the salvaged parts is assured. Occasionally, complex procedures have to be carried out to convert a marginal remnant of the hand into a useful functional unit. These may comprise rearrangement of bony elements to provide a radial digit with intervening space to permit pinch and grasp. Lack of sensibility can be corrected by shifting neurovascular pedicle or by immediate transfer of free neurovascular flap from a distance. Challenge met by skill, tempered by knowledge and sound judgment, comprise the elements of reconstructive hand surgery in the face of mutilating trauma. It is a field in which the surgeon is continually reminded of humility and yet it is filled with rewards for both patient and plastic surgeon.

Congenital syndactyly: a reappraisal.

Digital syndactyly is a common congenital anomaly and is associated with other anomalies affecting the digits, the hand, the arm or even the entire body. In the past it has been considered a single entity. However, recent information provided by experimental embryology, studies of morphogenesis and other sources, suggests that there are at least two distinct entities: primary syndactyly due to interference with the sequence of events that normally culminate in the division of digits into discrete parts and secondary syndactyly due to readhesion of adjacent digits as a result of close contact between raw surfaces. Primary syndactylyl may arise de novo, or it may occur as a manifestation of a mutation phenomenon or as a genetically controlled syndrome. Secondary syndactyly is the result of mechanical adhesion of adjacent parts involved in a general reparative or healing process. The initial insult leading to amputation of a portion of the digits may or may not be genetically controlled; adhesion is fortuitous. Management of syndactyly is determined by the complexity of the malformation. For simple cutaneous syndactyly the surgeon should make a zigzag incision and provide a rectangular, proximally based flap for the floor of the web, usually before the child is 2 years of age. A full- or split-thickness skin graft should be applied to the defects. For complex deformities involving several digits and associated with postural or osseous malformation, several operative procedures may be required. The surgeon must be vigilant to note and correct the sequelae resulting from recurrent contractures and imbalances associated with growth.

Successful orthotopic free autogenous joint grafts in the dog.

Thirty free autogenous metacarpal and 26 phalangeal articular cartilages were transplanted in the forefoot of dogs. The graft in each case included the articular surface and a minimal amount of supporting subchondral bone. The majority of the metacarpal grafts retained a normal gross, microscopic, and radioautographic appearance, some for up to 1 year after transplantation. In contradistinction, all of the phalangeal grafts failed, probably because their flatt surface made it impossible to maintain adequate fixation to the host bed. As a result the majority of these grafts became displaced. Analysis of the incorporation of the metacarpal grafts into the host bed showed that this occurred when there was no significant period during which the articular cartilage was without subchondral support. The situation is different in the case of joint grafts with a larger amount of subchondral bone. In these, during the time that this necrotic bone is being resorbed and replaced by normal viable bone, the articular cartilage has extremely limited subchondral support.