Herpes zoster in the ulnar nerve distribution.

Varicella zoster is a ubiquitous virus which usually affects school-aged children as Chicken Pox. While the initial disease is self-limiting and seldom severe, the virus remains in the body. It lies dormant in the dorsal root ganglia and reactivation may occur years later with variable presentations as Herpes Zoster, or Shingles. While Shingles is common, it rarely presents exclusively in the upper extremity. It is important that hand surgeons recognize the possibility of zoster infection, with or without a rash, when evaluating the onset of neuralgia in a dermatomal distribution in the upper limb. Early diagnosis allows rapid and appropriate treatment, with a lower risk of complications. We report on a case of Herpes Zoster isolated to the ulnar nerve distribution in a young woman.

Steroid secretion by masculinizing and "feminizing" Hilus cell tumors.

The clinical course, histology, and steroid secretion observed in two patients with hilus cell tumors are presented. One patient had signs of virilism and the other had estrogenic signs only. Steroid secretion was examined by measuring peripheral and ovarian venous gradients and pre- and postoperative levels of hormones to explain the profound differences in the biological effects exerted by the neoplasms. In the patient with virilism, the tumor's major secretory product was testosterone (T), and the dominant biosynthetic pathway was pregnenolone (Pe) leads to 17-hydroxypregnenolone leads to 17-hydroxyprogesterone leads to androstenedione (delta) leads to T. In the patient with estrogenic signs, the major secretory product was delta, derived from a similar pathway of pregnenolone leads to 17-hydroxypregnenolone leads to 17-hydroxyprogesterone leads to delta. Circulating estrone and estradiol levels were elevated, but the tumor showed limited aromatase activity, as reflected by 60- to 1500-fold larger peripheral-ovarian venous gradients of delta and T than estrone and estradiol. The high circulating estrogen levels mainly arose from the peripheral aromatization of the increased secretion of delta by the tumor. It was concluded that a similar steroidogenic pathway was employed by both tumors. The predominant secretion by the neoplasm of either T of delta was determined by the presence and the oxidation reduction equilibrium of the 17 beta-dehydrogenase enzyme. The action of this enzyme resulted in profound differences in the biological effects exerted by these tumors.

The effects of different schedules of total-body irradiation in heterotopic vascularized bone transplantation. An experimental study in the Lewis rat.

To evaluate the effects of irradiation on heterotopically placed vascularized knee isografts, a single dose of 10 Gy of total-body irradiation was given to Lewis donor rats. Irradiation was delivered either 2 or 6 days prior to harvesting or subsequent transplantation, and evaluated at 1, 2, and 4 weeks after grafting. Irradiation caused endothelial depopulation of the graft artery, although vascular pedicle patency was maintained throughout the study. Bone graft viability and mineralization were normal. Dramatic changes in the bone marrow were seen that included an increase of its fat content (P less than 0.001), and a concomitant decrease in bone marrow-derived immunocompetent cells. These changes were more prominent in recipients of grafts from day -6 irradiated donor rats. Total-body irradiation did not prejudice the use of vascularized bone grafts, and exhibited an associated immunosuppresant effect over the vascular endothelium and bone marrow. This may be a further rational conditioning procedure to avoid recipient manipulation in vascularized bone allotransplantation.

Rheumatoid arthritis of the wrist and hand.

A complete assessment of the entire patient along with a clear understanding of the progression of rheumatoid deformities is the key to success when contemplating surgical intervention for rheumatoid arthritis of the hand. The decision to perform surgery must be made following careful evaluation of the patient's signs and symptoms weighed against the potential benefits likely to be gained. The surgical plan will vary from patient to patient and should be tailored accordingly. Early in the disease process, conservative measures including pharmacologic intervention, steroid injections, and hand therapy, including splinting and wrist use modification, are indicated. Surgical intervention, however, should not be avoided for so long that the benefit of successful intervention is diminished. Hand surgery has proven to be effective in correcting deformity and maintaining or increasing function in patients with rheumatoid arthritis. The indications for synovectomy, tenosynovectomy, tendon repair or realignment, arthroplasty, and arthrodesis have been well established. Superior results are possible when surgical reconstruction is performed before tendon rupture, severe fixed contractures, subluxation, or dislocation.

Ligneous cellulitis associated with an IUD.

Many reports have documented serious pelvic infection associated with an IUD. A case of ligneous pelvic cellulitis with cutaneous sinus tract formation, hydronephrosis, and ureteral obstruction in a patient with an IUD is presented. This is an uncommon manifestation of chronic pelvic infection and responded to antibiotics and steroid administration. The origin and treatment of ligneous cellulitis are discussed.

Valgus stability of the elbow.

The valgus stabilizers of the elbow have been identified anatomically, but their relative importance has not been quantified. The purpose of this study was to analyze the acute changes of the torque-displacement curve to valgus stress following (a) section of the posterior portion of the medial collateral ligament; (b) excision of the radial head; (c) prosthetic replacement of the radial head; and (d) excision of the anterior portion of the medical collateral ligament. Thirty cadaver specimens underwent load-displacement testing in three positions: 0 degrees, 45 degrees, and 90 degrees of flexion. The anterior portion of the medial collateral ligament was the primary stabilizer of the elbow to valgus stress. The relative contribution of the posterior ligament was minimal. After excision of the radial head alone, the slope of the load-displacement curve decreased an average of 30%. Silicone rubber radial head replacement did not significantly improve the stability to valgus stress after radial head excision.

Allogenic transplants of bone revascularized by microvascular anastomoses: a preliminary study.

An area of experimental bone grafting that needs further study is the use of free vascularized allografts of bone. In 35 outbred mongrel dogs, the viability of vascularized bone allografts with and without azathioprine immunosuppression was compared to vascularized autogenous bone grafts. Viability was assessed by histologic techniques, fluorochrome bone labeling, and electron microscopy. Autogenous vascularized bone grafts remained viable, and it was concluded that microvascular technique was not the limiting factor in attaining survival of the grafts. The behavior of autogenous vascularized bone grafts with and without the influence of azathioprine was similar. Allogenic vascularized bone transplants uniformly failed at a period between 2 and 3 weeks. Immunosuppression with azathioprine did not appreciably affect survival of the osteocytes. However, the host response to the foreign tissue was slightly modified. The clinical ramifications of bone transplantations in humans are not analogous to the clinical situation of transplantation of other organs. If vascularized bone transplants are performed in humans, a relatively safe form of immunosuppression is necessary. This study suggests that azathioprine alone does not offer sufficient immunosuppression to insure viability of the vascularized transplant.

Microvascular anastomoses for bone grafts in the treatment of massive defects in bone.

Six patients with large defects in bone are described in whom we performed microvascular anastomoses of grafted fibular vessels (arteries and veins) to vessels in the recipient site. Two other patients, with massive loss of bone and skin, were treated by grafting of osteocutaneous composites also using microvascular anastomoses. All but one defect healed successfully. There is a wide potential for applications of these two techniques in the treatment of large segmental bone defects secondary to trauma or following tumor resection.

Free microvascular epiphyseal-plate transplantation. An experimental study in dogs.

To evaluate the feasibility of transplanting vascularized epiphyseal plates while maintaining normal growth in the recipient site, twenty-two puppies from known, large breeds were divided into one control and three experimental groups of four animals each and one long-term group of six animals. The control group underwent insertion of a radiopaque marker in the fibular metaphysis bilaterally, and, in addition, a fibular osteotomy was performed on one side. In the experimental groups, a fibular switch was carried out, selecting one fibula as a vascularized graft and the other as a non-vascularized graft. Both the controls and the experimental groups were evaluated using serial roentgenograms, histological examination, fluorescent bone-labeling, and microangiography. One week, six weeks, three months, and seven months postoperatively, animals from each group were killed. Continuous growth was observed in the vascularized epiphyseal transplants and in the controls, with no statistical difference noted, whereas the non-vascularized transplants exhibited considerably less or no growth. Vascularized transplants demonstrated an average 21.2-millimeter increase in length while non-vascularized transplants showed a 6.6-millimeter increase. Histological examination, fluorochrome bone-labeling, and microangiography confirmed the continued viability of the vascularized epiphyseal transplants in contrast to the non-vascularized transplants.

Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve.

An anatomical study was performed to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. In ten cadaveric specimens, the radial nerve was found to cross the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. As it crossed the posterior aspect of the humerus in each specimen, the nerve had several branches to the lateral head of the triceps; however, no branches were found innervating the medial head of the triceps in the posterior aspect of any of the specimens. At the lateral aspect of the humerus, the nerve trifurcated into a branch to the medial head of the triceps, the lower lateral brachial cutaneous nerve, and the continuation of the radial nerve into the distal part of the upper arm and the forearm. Three operative approaches were performed in each specimen. The posterior triceps-splitting approach exposed an average of 15.4 +/- 0.8 centimeters of the humerus from the lateral epicondyle to the point at which the radial nerve crossed the posterior aspect of the humerus. For the second approach, the radial nerve was mobilized proximally to allow an additional six centimeters of the humeral diaphysis to be visualized. The third approach (the modified posterior approach) involved the identification of the radial nerve distally as it crossed the lateral aspect of the humerus, followed by reflection of both the lateral and the medial heads of the triceps medially. This exposure permitted visualization of 26.2 +/- 0.4 centimeters of the humeral diaphysis from the lateral epicondyle proximally. The results after use of the modified posterior approach in seven patients were also reviewed.

The treatment of infected non-union of fractures of long bones. Study of sixty-four cases with a five to twenty-one-year follow-up.

The result of treatment of sixty-four patients with infected ununited fractures of long bone by debridement of soft tissue and bone and open suction-irrigation drainage, followed by rigid stabilization of the non-union and cancellous bone-grafting when indicated, was bone union in sixty cases, even in the presence of infection. The late results five to twenty-one years later showed good function despite the fact that prolonged periods of hospitalization were often required. The importance of local treatment of the infection prior to stabilizing the fracture fragments, and the use of cancellous bone grafts when necessary, are emphasized.

Bone scintigraphy in evaluating the viability of composite bone grafts revascularized by microvascular anastomoses, conventional autogenous bone grafts, and free non-revascularized periosteal grafts.

We studied the value of bone scintigraphy in the assessment of anastomotic patency and bone-cell viability in free bone grafts revascularized by microvascular anastomoses in twenty-seven dogs. The dogs were divided into three different groups, and scintigraphy was carried out using technetium-labeled methylene diphosphonate in composite bone grafts revascularized by microvascular anastomoses, conventional autogenous bone grafts, and periosteal grafts placed in different recipient beds. The viability of the grafts was evaluated by histological examination and fluorescence microscopy after triple labeling with oxytetracycline on the first postoperative day, alizarin complexone on the fourth postoperative day, and DCAF on the eleventh postoperative day. A positive scintiscan within the first week following surgery indicated patent microvascular anastomoses, and histological study and fluorescence microscopy confirmed that bone throughout the graft was viable. A positive scintiscan one week after surgery or later does not necessarily indicate microvascular patency or bone-cell survival, because new bone formed by creeping substitution on the surface of a dead bone graft can result in this finding.

Histological characteristics of acute rejection in vascularized allografts of bone.

Using a genetically defined rat model for the heterotopic transplantation of a vascularized knee in the rat, histological and histochemical studies of acute rejection in vascularized allografts of bone were carried out. The graft consisted of the knee joint with the distal end of the femur, the proximal part of the tibia, the cartilaginous growth plates, the articular cartilage, and a minimum cuff of muscle, which was transferred to a location under the abdominal skin. A total of 160 transplants, including vascularized and non-vascularized isografts, vascularized and non-vascularized allografts that were transplanted across a strong histocompatibility barrier, and vascularized allografts of bone that were transplanted across a weak histocompatibility barrier, were studied by light microscopy at intervals for as long as twelve weeks after transplantation. Vascularized allografts of bone that were transplanted across a strong histocompatibility barrier showed evidence of rapid rejection, similar to that after transplantation of allografts of visceral organs. This was manifested at one week by necrosis of osteocytes, cessation of microcirculatory flow, massive extravasation of red cells, and deposition of fibrin in the marrow. The large vessels demonstrated changes that were characteristic of vascular rejection. Allografts that were transplanted across a weak histocompatibility barrier showed a more gradual, less intense process of rejection that allowed observation of the evolution of the process. In these grafts, the osteoblasts and marrow in the primary spongiosa of the metaphysis were early targets of rejection, as indicated by necrosis of osteoblasts, extravasation of red blood cells, and deposition of fibrin in the marrow spaces. Loss of osteoblasts from the surfaces of osteoid as well as from bone on spicules of calcified cartilage resulted in the cessation of new-bone formation. Calcification of the longitudinal septa between the lowermost hypertrophic chondrocytes was decreased. However, the proliferation and maturation of chondrocytes in the zone of proliferating chondrocytes and in the upper hypertrophic zone continued and resulted in the formation of a thickened growth plate. The loss of osteocytes in other areas of the graft occurred later and only in the areas where the microcirculation had been lost. These data suggest that ischemic damage, which is probably secondary to an immune-related vascular compromise, is a significant factor in the failure of grafts. In the grafts that were transplanted across a weak histocompatibility barrier, the growth of new bone and revascularization by the host occurred by twelve weeks.

The efficacy of free tissue transfer in the treatment of osteomyelitis.

We evaluated the efficacy of free tissue transfer in the treatment of osteomyelitis in thirty-three patients who were followed for an average of 41.4 months (range, twenty-four to fifty-nine months). The bone lesions were classified in two ways: first, according to whether there had been drainage for less or more than six months and second, according to whether the lesion was Type I, II, or III. The thirty-three patients underwent a total of thirty-seven free tissue transfers, and thirty (79 per cent) of the transfers survived. Major complications were encountered after 41 per cent of the surgical procedures, consisting of failure of the free tissue transfer in seven patients (21 per cent) and recurrent sepsis in six (20 per cent) at follow-up. Four of the seven patients in whom the free tissue transfer failed underwent an amputation. Six of the patients with a failed transfer and nine of the ten with recurrent sepsis had a Type-III lesion. Previously published reports have suggested that free tissue transfer is an extremely successful and reliable procedure for the treatment of osteomyelitis. In our series limited success was achieved in patients with a Type-I or II lesion, but six of the patients with a Type-III lesion had recurrence of infection despite a successful transfer.

Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis.

Forty-six patients with rheumatoid arthritis underwent metacarpophalangeal-joint arthroplasty of the index through little fingers on 210 joints in fifty-five hands using the Swanson-design silicone-rubber spacer. The patients were followed for two to eight years (average, five and one-quarter years). They were evaluated both preoperatively and postoperatively for range of motion, deformity, subjective sense, grip strength, and prehension. In the initial postoperative evaluation, the majority of patients expressed a strong subjective impression of improvement. Ulnar drift improved from the preoperative average of 25 degrees to less than 5 degrees. The preoperative average extension deficit decreased from 56 to 10 degrees, while the average range of motion increased from 17 to 51 degrees. In the long-term postoperative evaluation, the average ulnar drift had increased to 12 degrees, the average extension deficit had increased to 22 degrees, and the average range of motion had decreased to 39 degrees. Grip strength and prehension did not significantly improve at either evaluation. There were no fractures of the prosthesis and no patient had synovitis. We have found the procedure to be useful for the correction of deformity, increasing range of motion of the fingers, and improving the patient's sense of well-being.

Microvascular free bone transfer with revascularization of the medullary and periosteal circulation or the periosteal circulation alone. A comparative experimental study.

UNLABELLED: Two different types of vascularized rib grafts presently are used in clinical practice and as experimental models for investigations on free microvascular bone transfer: the posterior rib graft, including both medullary and periosteal blood supply to the bone; and the posterolateral segmental rib graft, supplied by periosteal vessels alone, Complete survival of bone after successful revascularization of the posterior type of graft is well established, but this graft has the disadvantage of a complicated dorsal dissection which has limited its clinical use. Instead, many microsurgeons have utilized the posterolateral rib segment, which is easy and safe to excise although its viability and adequate microcirculation have not yet been confirmed. In nine large dogs, we compared the viability and vascularity of bone after transfer of the two types of bone grafts by histological methods, fluorochrome bone-labeling, microangiography, and technetium scintigraphy. The grafts were transferred to the subcutaneous fat tissue in the groin, where blood supply was reconstituted by microvascular anastomoses to local donor vessels. The results suggest that a bone transplant with revascularization of periosteal only established a collateral circulation to medullary vessels, and that there is no difference in viability of the two kinds of grafts. CLINICAL RELEVANCE: The technique of transferring whole bone segments by microvascular anastomoses of their vascular pedicles has been employed clinically either by preserving the periosteal blood supply alone or by preserving the medullary and the periosteal blood supply. This study demonstrates that the preservation of the periosteal blood supply alone can result in complete bone-graft survival even when the graft is placed in a poorly vascularized tissue bed.

Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years.

Long-term review of fifty-two displaced supracondylar humeral fractures in children treated by open reduction and crossed Kirschner-wire fixation demonstrated functional results similar to those obtained by closed methods, but fewer and milder cases of cubitus varus deformity (only 25 per cent of patients). The deformity appeared to result from faulty reduction with medial angulation of the distal fragment. Surgical treatment of these fractures may offer, as its principal advantages: reduced hospitalization time, fewer sequelae, more stable fixation, and slightly better anatomical results. No infections or other specific complications (such as myositis ossificans or Volkmann's contracture) were encountered.

Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia.

Free vascularized fibular bone grafts were used in nineteen children, seen consecutively, who had congenital pseudarthrosis of the tibia. The average age was 5.1 years (range, 1.4 to 11.4 years). Sixteen of the patients had been treated with electrical stimulation for at least one year, and the tibia had not united. All but four patients had had at least one previous operative procedure. At an average follow-up of 6.3 years (range, 2.0 to 11.0 years), eighteen (95 per cent) of the nineteen pseudarthroses had healed. The leg-length discrepancy averaged 1.6 centimeters (range, 0 to 4.0 centimeters), but ten tibiae had residual or progressive valgus or anteroposterior malalignment despite bracing. There was minimum morbidity at the donor site.

Radial shortening for Kienböck disease.

The cases of twenty-nine consecutive patients (thirty wrists) who had radial shortening for the treatment of stages I through IIIB Kienböck disease were reviewed to assess the results of this procedure. Thirteen patients (45 per cent) had a history of trauma, and all thirty wrists had a negative ulnar variance (average, 2.8 millimeters) on radiographs. All wrists were re-examined after an average follow-up of 3.8 years (minimum, two years). At that time, the pain had decreased in 87 per cent of the wrists. Extension of the wrist had improved an average of 32 per cent; flexion, 27 per cent; radial deviation, 30 per cent; ulnar deviation, 41 per cent; and grip strength on the affected side, 49 per cent. Analysis of the radiographs by computer digitization showed no significant changes in the amount of collapse of the lunate at the latest follow-up. In two wrists, there were complications at follow-up (excessive shortening of the radius and non-union of the radial osteotomy). Radial shortening is an effective treatment for Kienböck disease in wrists that do not have degenerative changes in adjacent carpal joints. Pain, range of motion, and strength can be expected to improve, but the radiographic appearance of the lunate changes little, if any.

Capitellocondylar total elbow replacement. A long-term follow-up study.

The results of forty total elbow replacements in which a capitellocondylar prosthesis was implanted in thirty-five patients (five of whom had a bilateral procedure) were reviewed retrospectively. The average length of follow-up was 7.2 years (range, four to twelve years). Pronation, supination, and flexion of the elbow improved considerably, but extension did not change a great deal. The average rating of the elbow, according to the scoring system of Ewald et al., improved from 30 to 88 points, but the functional score, as defined by the American Rheumatism Association, improved in only four patients. Malarticulation or dislocation of the prosthesis occurred in ten patients (29 per cent). In two other patients, a deep infection developed, necessitating removal of the prosthesis. Ten prostheses (ten patients) had radiolucent lines on follow-up radiographs, but these lines were not associated with pain or loosening. Seven patients (seven elbows) had a transient ulnar-nerve palsy. The incidence of this complication was reduced from 30 per cent (five of seventeen patients) to 15 per cent (four of twenty-eight patients) when the lateral Kocher approach to the elbow was adopted.