Central column reconstruction following total resection of a third metacarpal giant cell tumour.

A wide resection of a giant cell tumour involving the entire middle metacarpal is presented. Reconstruction preserving the central column and metacarpophalangeal joint was achieved using autologous iliac crest bone as a spacer and structural support. The fibro-osseous cartilage portion of the iliac graft was used as a "hemi-joint" replacement. By using a bridging bone graft and screw to fuse the adjacent proximal phalanges of the middle and index fingers, a stable "internal syndactyly" was achieved. Although independent index and middle finger motion was sacrificed, the approach allowed wide resection for local tumour control, re-established structural integrity, preserved metacarpophalangeal joint motion and allowed early motion. The aesthetic result was also good.

Report of an unusual case of trigger finger secondary to phalangeal exostosis.

Trigger finger is commonly secondary to stenosing tenosynovitis. Space occupying lesions in the tendon bed, although uncommon, may prevent smooth tendon gliding. These include lipoma, anomalous muscle insertions, tumours of the tendon sheath and haemangiomas. We describe a patient who had triggering of the left middle finger at the proximal interphalangeal joint due to an exostosis blocking the flexor tendons gliding. Removal of the exostosis relieved the problem. The clinician must be aware that there are other causes for triggering. These may be identified with pertinent findings in the history and physical examination.

Malignant giant-cell tumor of the distal end of the radius treated by a free vascularized fibular transplant.

Five patients with a malignant giant-cell tumor involving the distal end of the radius were treated successfully by wide resection and reconstruction of the radius with a vascularized fibular transplant. This technique has the great advantage of early bone union at the host-graft junction and enables the patient to regain limb function early, with preservation of near-normal appearance of the limb.

Cervical disc calcification in children. A long-term review.

Four cases of symptomatic cervical disc calcification in children are presented. Three cases were followed for more than 10 years. In one case, persistent flattening of the adjacent vertebral body remained into adulthood. To quantify the deformity, the height and width of each vertebral body was measured. These permanent changes may be associated with early degenerative changes seen radiologically in young adults.

Infantile fibrosarcoma: report of cases.

Infantile "fibrosarcoma" occurred in a newborn male infant and in a 2-month-old female infant. In both cases, the tumors grew rapidly and showed the histological features of malignancy. However, they were treated successfully with simple resections. Review of the literature shows that infantile fibrosarcoma has a relatively favorable prognosis. Simple local excision is the initial treatment of choice for lesions occurring in infants and children less than 5 years old.

Free vascularised fibular transplant for replacement of the lower radius.

An operation is described in which a microvascular technique was used to transfer a living fibula, with its vascular pedicle intact, to replace the lower end of the radius after massive resection for giant-cell tumour. Angiography carried out six weeks later showed that the grafted bone was viable. Six months after operation the transplanted fibula showed no osteoporosis or bone resorption and bony union at the junction of host and graft.

Stress fractures of the tibia in osteoarthritis of the knee.

Three women with osteoarthritis of the knee presented after sudden worsening of their symptoms. In each case this was found to be due to a stress fracture of the tibia. With treatment by rest and reduced activity, the fracture healed uneventfully in all three patients.

A gastrocnemius-pedicled femoral bone graft in resection arthrodesis at the knee.

We describe a new method of reconstruction after resection of tumours of the proximal tibia by grafting and arthrodesis of the knee. Two separate vascularised bone grafts from the ipsilateral limb were used, one a gastrocnemius-pedicled femoral graft and the other a pedicled fibular graft. An anatomical study of the gastrocnemius-pedicled femoral graft was made. The method was shown to be practical and reproducible. One patient with osteosarcoma has a successful result with no recurrence at two-and-a-half years.

Radial reconstruction in segmental defects of both forearm bones.

Seven patients with segmental defects of both bones of the forearm had reconstruction operations using a vascularised fibular graft to bridge the radius. Reasonable forearm rotation was preserved with full elbow movements and satisfactory hand function.

Donor site morbidity following resection of the fibula.

Ten adults were studied two to seven years after resection of a fibula for use as a free vascularised bone graft. Six had no symptoms in the donor leg, four had some aching, weakness or paraesthesia and three had definite weakness of the long toe flexors and extensors. All knees and ankles were clinically and radiologically stable, but the distal fibular remnant was osteoporotic in nine patients. Gait analysis of the donor leg and the contralateral normal leg showed definite differences, which could be attributed to weakness of the deep muscles caused by loss of their normal origin and to the change in load transmission through the fibula.

Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia.

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time.

Rerouting vessels and nerves from other digits in replanting an avulsed and degloved thumb.

In avulsion and degloving injuries of amputated thumbs, we have rotated nearby neurovascular bundles and dorsal digital vessels to restore circulation and sensation. This has been done in 5 patients, and 3 thumbs survived with preservation of length and good function.

Neurovascular supply of the gracilis muscle: a study in the monkey and human.

A comparison of the gross anatomy, extramuscular nerve branches, and intramuscular blood supply of the gracilis muscle showed similar patterns in both monkey and human. The number and pattern of distribution of the extramuscular terminal branches to the muscle were similar. The intramuscular neural pattern demonstrated with the Sihler's staining technique was also similar in both species. In vivo electrical stimulation studies in the monkey revealed that stimulating each extramuscular terminal nerve branch produced a distinct segmental contraction of the muscle. Independent contraction with force generation was observed when the monkey muscle was split into anterior and posterior segments and stimulated through each of the two subdivisions of the main nerve trunk to the muscle. Angiograms verified that circulation was preserved in these two segments.

Split flexor carpi radialis muscle.

A detailed anatomic and intramuscular neural staining study in 22 human and 5 monkey upper limbs revealed that the flexor carpi radialis can be raised on its proximal neurovascular pedicle and that the muscle can be split along its tendon into two independently functioning neuromuscular compartments, each with its own nerve and blood supply. A study of the muscle architecture in the human specimens found the radial compartment to have significantly longer fiber length and a larger physiologic cross-sectional area than the ulnar compartment. Independence of function of each compartment was demonstrated in electrical stimulation studies in six monkeys (Macaca fascicularis), but no significant difference was noted in the peak isometric load between the two compartments (p = 0.68) in the monkey. The extra functioning muscle units become important in local transfers for restoring function in multiple nerve palsies as in Hansen's disease, severe traumatic loss of muscle in crush injuries and compartment syndromes, and after wide resection in infective and neoplastic conditions in the forearm and hand.

The neuromuscular compartments of the flexor carpi ulnaris.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Report on the vascular supply and innervation pattern of the flexor carpi ulnaris. 2. Describe the muscle architecture of the flexor carpi ulnaris, including the physiological cross-sectional area and fiber length. 3. State the uses of the flexor carpi ulnaris both for resurfacing defects in the vicinity of the elbow and in local functional tendon transfers. 4. Understand the principles of splitting skeletal muscles based on neurovascular supply to enhance its utilization in reconstructive procedures. The aim of this study was to describe the intramuscular innervation and vascular supply of the human flexor carpi ulnaris, with confirmation of findings by a similar study in the primate. Two distinct intramuscular nerve branches running parallel to each other, on either side of a central tendon, from the proximal quarter of the muscle belly to its insertion were found. The muscle could then be split into a humeral and an ulnar compartment, each with its own primary nerve branch. Perfusion studies confirmed the adequacy of circulation to the two compartments. In the primate flexor carpi ulnaris, electrical stimulation of the respective branches revealed independent contraction of each compartment. This study provides useful information for enabling the local transfer of the muscle as a whole, both for resurfacing in the vicinity of the elbow and for functional tendon transfers. It will also enable the transfer of the muscle as one or two separate compartments (for resurfacing, in tendon transfers for muscle paralysis, congenital defects, and muscle defects resulting from trauma, and after resections for neoplasm and infection).

Optimal circumference reduction of finger models for good prosthetic fit of a thimble-type prosthesis for distal finger amputations.

The prosthetic fit of a thimble-type esthetic silicone prosthesis was retrospectively reviewed in 29 patients who were fitted following distal finger amputations. The aim was to correlate prosthetic fit with the magnitudes of circumference reduction in the finger models used to produce the prostheses and to identify the optimum reduction for the best outcome. A good fit is achieved primarily by making the prosthesis circumferentially smaller than the segment of the residual finger (residuum) over which it "cups". The percentage reduction in circumference of the finger model against the residuum model was calculated by dividing the difference in circumference between the residuum model and the finger model by the residuum model circumference and multiplying the result by 100. The computed percentage circumference reduction in the finger models ranged from small (1-3), moderate (5-7), to large (8-9). Twelve of 15 patients whose finger models had between one to three circumference reductions had a loose prosthetic fit. Only two of 14 patients who had a larger model circumference reduction of between five to nine had loose-fitting prostheses. Two of five patients who had eight to nine model circumference reduction had an uncomfortably tight prosthetic fit. A 5-7% circumference reduction in the finger model was shown in this study to best translate into good fit of a thimble-type prosthesis for distal finger amputations.

Anatomical basis of dorsal forearm flap. Based on posterior interosseous vessels.

Injection studies on 35 upper limbs with neoprene latex were carried out and the limbs carefully dissected to observe the vascular contribution of the posterior interosseous branches of the dorsal forearm, the transverse anastomosis between anterior and posterior interosseous vessels and the calibre of the vessel. The findings indicated that a fascio-cutaneous flap based on septocutaneous branches of the posterior interosseous artery can be raised as a reversed forearm flap for resurfacing after skin loss in the hand.

Median nerve compression, with tendon ruptures, after Colles' fracture.

A rare case of rupture of the flexor pollicis longus tendon following a Colles' fracture is described. The patient also had a ruptured flexor digitorum profundus to the index finger and compression of the median nerve of the same hand. The ruptures were noted after four weeks of plaster immobilisation. Decompression of the median nerve and corrective osteotomy was performed but no tendon repair was attempted. The patient regained good function of the hand.

The reverse radial forearm flap in the severely injured hand: an anatomical and clinical study.

An anatomical study in 25 cadaveric upper limbs quantified the communications between the radial and ulnar arteries immediately proximal to the carpus. These studies suggest that the reverse radial forearm flap can safely be used in severe hand trauma where reliable pre-operative assessment of the palmar collateral circulation is not possible. It is recommended that the pedicle is pivoted 4 cm from the styloid process at which point there is a 96% probability of leaving the superficial palmar branch and one other communication intact and a 77% probability of leaving two other communications intact. Two clinical cases are outlined for illustration.

Tikhoff procedure in recurrent chondrosarcoma following free vascularised fibular graft.

A forty year old housewife presented with a recurrent chondrosarcoma in a vascularised fibular transplant for a tumour in the proximal humerus. The Tikhoff-Linberg procedure was carried out with satisfactory results. The case report serves to emphasize the need to be aggressive in the initial management of malignant bone tumours. Careful planning and execution of a further aggressive procedure in the presence of a recurrence, ensures adequate clearance of tumour while still preserving a functional and useful limb.