Closed rupture of the flexor tendons caused by carpal bone and joint disorders.

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).

Closed rupture of the flexor tendons of the little finger secondary to non-union of fractures of the hook of the hamate.

We report six patients with closed flexor tendon rupture affecting the little finger, occurring secondarily to non-union of the hook of the hamate bone. The ununited fragments were separated from the basal part of the hook by more than 1mm. The fragments were also rounded and showed marginal sclerosis. Non-union was located in the middle part of the hook in three patients, the tip in two, and the base in one. At operation, the fragments were removed in all patients. Five patients were treated by free tendon grafts using three palmaris and two plantaris grafts and one underwent tendon transfer. Postoperative total range of active motion of the little finger averaged 218 degrees (range 185-265 degrees ). All patients returned to their original employment. This series would suggest that flexor tendon rupture can occur after fracture of the hook of the hamate bone, even when the ununited fragment is small and/or rounded.

A less invasive surgery for rotator cuff tear: mini-open repair.

As a less invasive surgery of the shoulder, the mini-open repair was carried out from March 1997 through December 1998 in 22 patients (mini-open repair group) for all types of rotator cuff tears, except massive tears. A transacromial skin incision about 3 cm long was made. The anterior deltoid was split along its muscle fibers, and an anterior acromioplasty was accomplished by using a specially designed bone rasp. The rotator cuff was repaired with use of the McLaughlin technique. The results were compared with those obtained in 36 patients subjected to conventional open surgery from April 1994 through February 1997 (control group). No significant difference was seen between the UCLA (University of California, Los Angeles) shoulder scores of the two groups 1 year after the repair. However, active forward flexion in the mini-open group was significantly greater than in the control group 3 and 6 months after surgery. With mini-open repair, patients seem to be able to return to sports or social activities earlier than with conventional open surgery.

Scaphoid nonunion and flexor pollicis longus tendon rupture.

Four patients presented with a rupture of the flexor pollicis longus tendon that was associated with a longstanding scaphoid nonunion. A radiocarpal arthrosis was present in 3 of the 4 patients and a dorsiflexed intercalated segment instability deformity was also seen in 3 of the 4 patients. Three patients underwent surgery consisting of an osteosynthesis with an iliac bone graft for the scaphoid nonunion and a palmaris longus tendon graft for the ruptured flexor pollicis longus tendon. An osseous union of the scaphoid and a functional active range of motion of the thumb interphalangeal joint (33 degrees on average) was attained in all 3 of the patients treated surgically. Preoperative radiologic examinations and intraoperative findings suggest that the volarly protruding distal scaphoid segment is the cause of the rupture.

Contact area of the trapeziometacarpal joint.

Eighteen cadaver hands were studied to determine the contact area of the trapeziometacarpal joint by using silicone rubber casts. Casting material was introduced into the trapeziometacarpal joint during several motions of the thumb and the contact location was observed. The ratios of the contact area to the total joint area were calculated. The contact locations in opposition were the radial, volar, and ulnar segments of the trapezium and the dorsal, radial, and volar segments of the metacarpal. On average, 53% of the trapezium was in contact with 53% of the metacarpal in opposition, while 28% of the trapezium was in contact with 28% of the metacarpal in palmar abduction and 25% of the trapezium was in contact with 25% of the metacarpal in radial abduction. The contact area was the largest in opposition. The trapeziometacarpal joint is stable in opposition and facilitates a strong pinch.

Granular cell tumour of the ulnar nerve.

Although granular cell tumours have been demonstrated to have a neural origin, they rarely arise in peripheral nerve trunks. We report a case of granular cell tumour of the ulnar nerve in a 51-year-old man. Though dissectable from the nerve, this intraneural tumour showed microscopic involvement of focal nerve fibres. This tumour tended to infiltrate the nerve in the same manner as a neurofibroma.

Cinearthrography of the Bankart lesion and anterior capsule elongation.

Diagnostic cinearthrography was performed on 3368 patients with shoulder pain during the period of 1982 through 1992. Cinearthrography identified a Bankart lesion in 128 shoulders on which surgical stabilization was performed for recurrent anterior dislocation. The operative pathologic condition for each of these patients was correlated and analyzed with the measurements of the Bankart lesion identified on the cinearthrogram. A small Bankart lesion was seen in patients with anterior capsular elongation. A larger Bankart lesion was observed in patients who did not have anterior capsular elongation. Preoperative measurement of anterior capsular elongation has been difficult. An 80% probability existed that the presence and extent of a Bankart lesion identified on a cinearthrogram could be an indicator for the presence of anterior capsular elongation. Preoperative determination of anterior capsular elongation could be useful in selection of the optimum surgical procedure to correct recurrent anterior shoulder dislocations.

Long-term results of vein grafts interposed in arterial defects using the telescoping anastomotic technique and fibrin glue.

Fibrin glue has been applied in the anastomosis of vein grafts placed in rat femoral arteries using the telescoping technique at both ends of the graft. 34 out of 35 grafts which were patent 1 to 3 weeks post-operatively were kept for 3 months to assess the long-term patency, and the effect of the glue on the diameters of the graft and femoral artery. All 34 grafts were patent 3 months post-operatively. Excessive enlargement of the graft diameter was alleviated by the fibrin glue without affecting the diameter of the femoral artery. The diameter at the proximal anastomosis was 66% and that at the distal anastomosis was 87% of the diameter of the femoral artery.

Telescoping and glue technique in vein grafts for arterial defects.

Fibrin glue was applied at the anastomotic site of the vein graft that was placed in rat femoral artery defects by the telescoping anastomotic technique at both proximal and distal anastomoses. All 35 vein grafts thus placed were patent, yielding a statistically higher patency rate than those placed in the same femoral artery by the same telescoping anastomotic technique but without fibrin glue. The telescoping anastomotic technique assisted by fibrin glue appears to give as reliable a patency rate as the conventional method even if it is used twice, both at the proximal and distal anastomoses, in autogenous vein grafting for arterial defects. Deformities of the inserted vessel should be minimized for patency by some means such as an application of fibrin glue so that the inserted vessel does not bulge under high arterial pressure.

Conservative treatment of thoracic outlet syndrome using an orthosis.

We describe a strapping device for elevation of the shoulder in patients with thoracic outlet syndrome (TOS). The device was used by 86 patients with TOS whose symptoms had been alleviated by passively raising the shoulder. Symptoms of TOS were classified as proximal, including pain in the shoulder girdle, and distal, in which there were neurological deficits related to the brachial plexus. The device was more effective in patients with distal symptoms: pain disappeared or improved in 67% of patients; numbness in 85%; sensory disturbance in 84%; and motor disturbance in 80%. However, proximal symptoms were relieved in only 65% of the patients. The ability to perform activities of daily living was rated as excellent in 33% of patients, good in 44%, fair in 12%, and poor in 9%. The shoulder orthosis described in this report can counterbalance downward traction on the brachial plexus and reduce the tension on it, thereby relieving symptoms of TOS.

Arterial grafting with the telescoping anastomotic technique for arterial defects.

An arterial graft was taken from the left femoral artery of the rat and grafted into the right femoral artery using the telescoping anastomotic technique at both the proximal and distal anastomoses to compare the patency rate with that of the vein grafts interposed into the arterial defect with the same telescoping technique. The time required for each anastomosis was about 10 minutes and all of the 31 grafts remained patent without application of xylocaine, yielding a higher patency rate than the vein grafts interposed in an arterial defect. The telescoping technique proved to be so dependable that it could be used at least twice in an artery. Inserting one vessel stump into another using the telescoping technique may not itself be responsible for the failure of vein grafts interposed in an arterial defect, but distortion of the slack venous wall of the graft by high arterial blood pressure is.

Anatomical and radiological evaluation of the triangular fibrocartilage complex of the wrist.

109 wrists from 69 cadavers (mean age 74 years) have been studied to clarify the pathology and morphology of the triangular fibrocartilage complex (TFCC) and to correlate pathological and radiological findings. Perforation of the TFCC was observed in 65% of the specimens and was considered to be secondary to a degenerative process, because it was often accompanied by degenerative changes in the ulnar carpal bones and perforation of the lunotriquetral ligament. To detect TFCC perforations on plain postero-anterior radiographs, it is important to evaluate ulnar plus variance and degenerative changes in the ulnar carpus. Existence of ulnar plus variance alone is more sensitive but less specific in detection of TFCC perforation than the existence of degenerative changes in the ulnar carpus.

Long thoracic nerve paralysis associated with thoracic outlet syndrome.

Two cases of long thoracic nerve palsy associated with thoracic outlet syndrome are reported. Both patients had abnormal posture, with low-set shoulders and winged scapulae. Clinically there was weakness of the serratus anterior muscle with partial denervotion on electromyography. The diagnosis of thoracic outlet syndrome was based on positive vascular tests and brachial plexus nerve compression symptoms induced by the vascular testing positions. An orthosis that held the shoulder in an elevated position was used in both cases. Complete recovery of shoulder function and relief of the symptoms was achieved in both cases at 8 and 13 months, respectively, after application of the orthosis.

Distribution of bone mineral density and bone strength of the proximal humerus.

Clinical experience led us to the hypothesis that in the proximal humerus cancellous bone beneath the top part of the head is the strongest and the bone of the humeral neck is the weakest. This hypothesis was examined on dissected proximal humeri with bone mineral densitometry and an indention test. Both dual photon absorptiometry and bone mineral analyses confirmed that the top part of the humeral head was the region with the greatest amount of bone mineral. The humeral neck had approximately one half the bone mineral density of the humeral head. The cancellous bone of the neck had only one third the mechanical strength of the humeral head on the indention test. The high degree of osteoporosis of the neck region increases the difficulty of surgical treatment for displaced humeral neck fractures.

Vein grafting with the telescoping anastomotic technique for venous defects.

The telescoping anastomotic technique was used at both ends of autogenous vein grafts bridging a defect in slow-running, vulnerable veins. This was done on left epigastric veins of the rat, the central part of which was used as a graft. In the right epigastric veins, both the proximal and distal anastomoses were repaired using the conventional anastomotic technique. The overall patency rate of the grafts repaired with the telescoping anastomotic technique was 27/29 (93.3%) compared to 17/28 (60.7%) in the conventional group. The telescoping technique was also easier to perform than the conventional method.

Introduction of loop sutures in microsurgical telescoping anastomosis.

We have designed a loop suture technique for use in microsurgical telescoping (sleeve) anastomosis to prevent problems from the free floating inserted vessel stump. The patency rate of rat femoral arteries repaired with this technique was 95% and that of interpositional vein grafts, in which both the proximal and distal anastomoses were completed with the same sleeve technique, was 81.0%.

Osteoporosis of the proximal humerus: Comparison of bone-mineral density and mechanical strength with the proximal femur.

The hypothesis that the proximal humerus is more osteoporotic than the proximal femur has been examined by the indention test and bone-mineral density measurement on dissected proximal humeri and femora. The bone section at the base of the humeral head had about 65% of the bone-mineral density of the base of the femoral head. The energy required for 50% strain in the indention test on the humeral bone section was about 50% of that on the femoral head. The fact that the cancellous bone in the humeral head is more osteoporotic than in the femur may complicate surgical treatment of displaced humeral neck fractures.

Anatomic study of the glenoid labrum.

Thirty-one shoulder joints from the cadavers of 13 men and four women and from two cadavers of unspecified sex were dissected to investigate the anatomic characteristics of the glenoid labrum. The ages at death ranged from 63 to 90 years with a mean age of 78.5 years. The glenoids were divided with a bone saw along both their long and short axes. The size of the glenoid and the labrum of each specimen was then measured with calipers. No significant correlation existed between the size of the labrum and that of the glenoid. This indicated that even if the glenoid was large, the labrum was not always correspondingly large. If one aspect of the labrum was large, other portions of the labrum tended to be large also. The anterior and inferior portions of the labrum were the largest, and this may have contributed to stability in the anterior and inferior directions.