Anaerobic metabolism and wound healing: an hypothesis for the initiation and cessation of collagen synthesis in wounds.

The implanted cylinder model was used to measure LDH activity and lactate and pyruvate concentrations in the extracellular fluid of wounds and wound tissue. Total LDH activity corresponded directly to lactic acid concentration and inversely to oxygen availability. LDH isoenzymes in wound fluid were in an anaerobic pattern soon after injury and evolved toward the aerotic pattern as oxygen supply more nearly matched metabolic capacity. Lactate levels in the wound space are elevated soon after wounding and remain elevated far above those in blood. These data again indicate that wound metabolism is characterized by a relatively poor oxygen supply. Current data from several sources indicate that lactate found in the hypoxic area of the wound may stimulate collagen synthesis in fibroblasts lying in the high lactate environment. We postulate that elevated concentration of lactate in wounds is a major signal for collagen synthesis and repair.

Clinical evaluation of the masman pressure unit in the reduction of limb oedema.

A clinical evaluation of the Masman Pressure Unit (M.P.U.) was undertaken in the Physiotherapy Department of Sydney Hospital to determine whether or not the M.P.U. was effective in reducing limb oedema. The study also investigated the pressures necessary to reduce oedema, the duration of treatment necessary, the duration of oedema relief, and how often treatment was necessary.

Electro-analgesia.

Between May 1975 and March 1976, 19 patients with pain or hypersensitivity, or both, in the distribution of a peripheral nerve were treated with electro-analgesia in the physiotherapy department of Sydney Hospital. The rationale for this treatment is the work of Melzack and Wall (1965). The current selected was that used by Meyer and Field (1972), a unidirectional square wave current with pulse length of 0.1 millisecond at a frequency of 100 Hertz. The machine used was a GRASS S48 stimulator, which is a highly accurate instrument. The electrodes were twin silver plates, 15 mm x 7 mm approximately, covered with lint mounted with a space of 2.5 cm on a piece of perspex (Fig. 1) or silver wire covered with lint for use on fingers.

Silastic implant arthroplasty for post-traumatic stiffness of the finger joints.

In the years 1981 to 1987, 50 patients had 59 replacements of the finger joints. Of these, 41 patients with 49 joint operations were reviewed, with follow-up ranging from two to eight years (average 32 months). About 80% of these patients were satisfied that silastic implant arthroplasty had relieved their pain and stiffness and improved function of the finger and hand. They were satisfied that this procedure was preferable to amputation or fusion. Success or failure was assessed not only on the range of movement of the joint being replaced, but on relief of pain, correction of deformity, stability and overall finger function. The seven patients regarded as failures are analysed in detail.

Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb.

Between the years 1980 to 1987, 17 patients had revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb. 12 followed silastic implant arthroplasty, four trapeziectomy and one arthrodesis. The failed silastic arthroplasties were treated by removal of the implant, and soft tissue arthroplasty in eight, revision with another implant in three and intermetacarpal bone grafting in one. Patients with metacarpo-scaphoid arthritis after trapeziectomy were treated by silastic implant arthroplasty in three and fusion in one. Nine of the 17 revision procedures (53%) had good, three (18%) fair and five (29%) poor results respectively.

Fracture of the proximal phalanx. An unusual complication of pulley reconstruction in a child.

We report a case of a fracture occurring in the proximal phalanx of a child following pulley reconstruction. The operative technique and the difficulties of pulley reconstruction in the immature skeleton are discussed.

Iatrogenic injection injuries of the hand and upper limb.

30 cases of iatrogenic injection injuries to the hand and upper limb are reported. 16 followed therapeutic injections (steroids--11 cases, infusions--five cases) and 14 occurred during anaesthetics procedures (local blocks--ten cases, general anaesthetics--four cases). Guidelines for minimizing the risk of injection injury are outlined.

Closed rupture of both flexor tendons in the same digit.

Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. We describe the case of a patient who sustained a closed rupture of both flexor digitorum profundus and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The patient was treated by a two stage reconstruction of the flexor digitorum profundus. He regained full flexion and extension of the finger.

Post-traumatic triggering of extensor pollicis longus at the dorsal radial tubercle.

A case of post-traumatic triggering of the tendon of extensor pollicis longus around Lister's tubercle is described. This condition was successfully treated by surgical release.

Risk and complications in endoscopic carpal tunnel release.

Single portal endoscopic carpal tunnel release was carried out in 107 hands of 88 patients. There were 11 complications. These included incomplete release (2), post operative scarring around the median and ulnar nerves (2), laceration of the superficial palmar arterial arch (1), reflex sympathetic dystrophy (2), palmar fasciitis (1), and wound inflammation (3). In two cases there was no relief of symptoms. In one there was incorrect diagnosis and in another, incorrect indication for endoscopic carpal tunnel release. The follow-up was from 3 to 18 months with an average of 6.8 months. The overall results of the patients in this series are being presented in another paper. Of the 107 procedures, 73 were rated as having an excellent, 25 good, three fair, and six poor results. The case of laceration of the superficial palmar arterial arch is discussed in detail in the paper. The two cases of reflex sympathetic dystrophy and the one case of palmar fasciitis had mild clinical features and resolved within 3 months. The inflammation in three of the wounds at the wrist resolved within 2 days of removal of the percutaneous sutures. These three patients had returned to heavy hand activities within a few days of surgery.

Silicone synovitis. A perspective.

Silicone implant arthroplasty is, arguably, the most effective treatment for the majority of patients with symptomatic arthritis in the hand and wrist. In 1985 the problem of silicone synovitis was first brought to our attention. Since that time there have been numerous reports on this condition leading to a worldwide trend against the use of silicone implants. However, the true incidence and effects of silicone synovitis have not been clearly defined. For this reason, we have undertaken a survey of all patients who have undergone silicone implant arthroplasty in the wrist and hand in our Unit between 1975 and 1990. Patients with rheumatoid arthritis and those undergoing MP or IP joint arthroplasty were excluded. Of the 289 implant arthroplasties remaining, we have been able to review personally 229 implants with a mean follow-up of 3.8 years (range 1-15). Although 40% of cases showed significant radiological changes, only 11 patients (4.8%) developed symptoms requiring treatment. Of these, two were managed conservatively whilst the rest underwent revision surgery, all with entirely satisfactory results. We conclude that silicone implant arthroplasty remains the treatment of choice for patients with painful joint disease in the hand and wrist.

The symptomatic carpal boss. Is simple excision enough?

We reviewed 48 patients with symptomatic carpal boss seen during the 10 year period 1985-1994. Thirty-one patients had undergone either local excision of the boss or arthrodesis of the affected carpometacarpal joint. The mean follow-up was 3 years and nine cases have been revised. Twenty-four patients remained symptomatic and considered that surgery had failed to relieve their symptoms. These findings are in sharp contrast to previous reports that suggest simple excision of the carpal boss gives uniformly good results.

Chondrosarcoma of thumb metacarpal--a case report with literature review.

Function preserving management of a dominant thumb metacarpal chondrosarcoma is reported, with a literature review for this uncommon neoplasm. Wide local excision of the metacarpal followed by temporary silicone block interposition and definitive iliac crest bone grafting was performed. A persistent wound defect was managed by a radial artery forearm flap. The functional result was acceptable. In the literature, there were seven cases of thumb metacarpal chondrosarcoma reported; two were treated by ray amputation, and the other five were treated by excision of the metacarpal. Three of those five had bone graft and the other two had simple resection. Of these seven cases, three had local recurrence and one a distant metastasis.

Pitfalls in carpal tunnel decompression.

In the period 1972 to 1977, 35 patients with persistent pain and other disabilities after carpal tunnel decompression were referred for treatment. The pitfalls included: (i) wrong diagnosis--5 patients; (ii) inadequate decompression--9 patients; (iii) recurrent compression--4 patients; (iv) iatrogenic nerve injury--7 patients; and (v) postoperative complications--10 patients. The patients in Groups 1 and 5 were treated by non-operative measures. Most of the patients in Groups 2, 3, and 4 were treated by reoperation. This paper outlines the causes and prevention of pitfalls in carpal tunnel decompression.

Surgical management of arthritis of the carpo-metacarpal joint of the thumb.

In the years 1970-90, 118 procedures were performed on 100 patients with arthritis (osteoarthritis in all but 13) of the carpo-metacarpal joint of the thumb. The patients were aged 17 to 83 years (mean 54.5 years); 75 were females and 25 males; there were 73 right and 45 left hands; 18 patients had bilateral procedures. The average follow up period was 4.3 years, with a range of 1 to 20 years. Sixteen of the 118 procedures were arthrodeses; all these patients had isolated trapezio-metacarpal joint arthritis. Fifteen procedures were trapeziectomies and soft tissue arthroplasties; they were performed for pan-trapezial arthritis in the older age group, or as a secondary procedure for failed previous operations. Eighty-seven of the 118 procedures were silicone partial or total arthroplasties either for pan-trapezial arthritis or isolated trapezio-metacarpal joint arthritis (53 trapezium, 32 metatarso-phalangeal and 2 condyle implants). The overall results were: arthrodesis (68.7% good, 18.8% fair, 12.5% poor); soft tissue arthroplasty (80% good, 6.7% fair, 13.3% poor); silicone total arthroplasty (73.5% good, 15.1% fair, 11.3% poor); silicone hemiarthroplasty (68.8% good, 15.6% fair, 15.6% poor). No silicone synovitis was found in any of the 87 cases of silicone arthroplasties.