Indications for upper extremity surgery in rheumatoid arthritis patients.

In selected circumstances, especially those associated with pain and mechanical instability, early surgical therapy is indicated for patients with rheumatoid arthritis. Close consultation between the rheumatologist and surgeon enables identification of focused goals attainable by synovectomy, ligament or tendon reconstruction, joint replacement, or arthrodesis. If these goals are met, the result can be a gratifying return of function and independence. This article describes some of the more common deformities of the hand, wrist, and elbow in patients with rheumatoid arthritis. Current surgical therapy, along with outcome and complications, is also discussed. Emphasis is placed on decisions and indications for surgical evaluation.

Intrathoracic ganglioneuroblastoma.

Thirty-one patients treated for isolated intrathoracic ganglioneuroblastoma have been evaluated. The surviving patients (27/31) have been followed for periods up to 25 years. The modes of treatment consisted of complete or partial resection of the tumor, radiation therapy, or chemotherapy. Analysis of the data revealed that four patients treated with radiation alone died within 3 months after the start of treatment. Two patients had complete removal of the tumor without adjuvant therapy. Each is free of recurrent disease at 10 and 11 years postoperatively. The other 25 survivors had complete or incomplete surgical resection followed by radiation and/or chemotherapy. All are free of recurrent disease. Of the 25 patients who received postoperative radiation, 11 developed moderate-to-severe skeletal deformity. There appeared to be a correlation between deformity and the dose of radiation. Our current treatment recommendation consists of immediate operative intervention with an attempt at complete removal of the tumor. Patients with incomplete removal of tumor should be treated with radiation (2,000 r). Chemotherapy consisting of methotrexate or a combination of cyclophosphamide (Cytoxan) and vincristine should be reserved for patients with distant metastasis.

Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries.

Although the internal mammary artery (IMA) is superior to the saphenous vein graft for bypassing certain coronary arterial obstructive lesions, such operations may predispose the patient to sternal infection or dehiscence--presumably as a result of sternal ischemia. This study was designed to measure sternal blood flow before and after median sternotomy and IMA mobilization in order to quantify the hemodynamic effects of these procedures. Rhesus primates were randomized into control, unilateral IMA-harvested, and bilateral IMA-harvested groups. After selective angiography enabled confirmation of IMA patency, 15 micron microscopheres, labeled with specific-spectra radioactive isotopes, were injected at baseline, after sternotomy, and after IMA harvesting. The sternal halves were subjected to gamma counting, and sternal circulation was accurately quantified. Our results showed that blood flow to the sternal halves in which the IMA was harvested decreased precipitously (from 4.5 to 0.8 ml/gm/min; p less than or equal to 0.001), although it remained unchanged in response to median sternotomy. This represented a 90% decrease in the mean rate of flow within the IMA-harvested sterna versus a stable flow rate for the unharvested sides. We conclude that mobilization of the internal mammary artery, as in coronary bypass procedures, significantly devascularizes the sternal half from which it was harvested.

Osseous wound healing with xenogeneic bone implants with a biodegradable carrier.

Human antigen-extracted, autolyzed (AA) bone and a bovine bone morphogenetic protein were prepared as implants within biodegradable carriers and compared with autogenous bone grafts and controls in the healing of critical-size bony defects in nonhuman primates. The treated craniotomy sites were studied 3 and 6 months after surgery; radiodensity and volume of newly deposited trabecular bone were assessed by radiomorphometric and histomorphometric methods, respectively. There was no evidence of adverse immunologic response to the experimental implants. The autografts resulted in the greatest volume of new bone formation (p less than 0.01), but the AA implants elicited a significantly greater response than either the bovine bone morphogenetic protein derivatives or the controls (p less than 0.05). By 6 months, the AA derivatives had healed with actively coalescing islands of new bone, displaying normal-appearing outer and inner tables along with well-developed marrow cavities. It appears that xenogeneic AA implants have the ability to elicit an excellent osseous response in critical-size calvarial wounds. In addition, the carrier polymer for the implants acted as an effective soft-tissue spacer before being absorbed.

Intracellular processing of epidermal growth factor by early wound healing cells.

Epidermal growth factor (EGF) is a potent 53-amino-acid residue polypeptide that has been implicated in normal wound healing. Although past studies have shown that locally applied EGF accelerates wound healing, these studies have not examined intracellular events related to the processing of the growth factor. The objective of this study was to characterize both initial and later postbinding intracellular processing of EGF by a responsive cell line (osteoblasts) that is important in the healing of wounds. Cloned mouse calvarial osteoblasts (MC-3TC-E1) were incubated with radiolabeled EGF, with and without preincubation with nonlabeled EGF, for specific time intervals. Cell-associated radioactivity was characterized by nondenaturing polyacrylamide gel electrophoresis. Results showed that EGF is processed as three distinct species and that the relative proportions of these species are altered at later time periods when compared with initial processing. The patterns, similar to those reported for human fibroblasts, indicate a possible common pathway for the mitogenic signal in cells associated with the early events of wound healing. In addition, these data represent the first direct evidence that preexposure of cells to nonlabeled EGF alters the processing of radiolabeled EGF. This is significant, because cells must be exposed to EGF for 5 to 8 hours to elicit a growth response. Such data may help to explain the "lag phase" of wound healing.

Use of intercostal muscle in primary repair of esophageal atresia with tracheoesophageal fistula.

Forty-one patients with esophageal atresia and distal tracheoesophageal fistula underwent primary repair. Results are compared among patients in whom an intercostal muscle graft was interposed between the trachea and esophagus and those without the graft. Patients with muscle interposition had lower morbidity and mortality and better long-term results.

The healing sternum: a comparison of osseous healing with wire versus rigid fixation.

Although median sternotomy is used for most cardiac procedures, postoperative dehiscence remains a serious and persistent problem. This investigation was designed to assess new bone formation and sternal healing across the linear osteotomy of the sternum and to determine if rigid fixation would enhance bony healing and thus decrease unfavorable sequelae. To test this hypothesis, 14 skeletally mature baboons (Papio anubis) underwent standard median sternotomy; seven sternotomies were closed with interrupted 24-gauge cerclage wires, and seven, with thin Vitallium compression miniplates and transverse lag screws. The sterna from each group were harvested en bloc at 4 and 8 weeks, radiographed, processed, and serially sectioned and stained for histomorphometry to assess the quantity of new bone across the linear osteotomy. Clinical stability was superior with the plated and lag screw group at 4 weeks; however, by 8 weeks, no clinical difference between treatments was apparent. Histomorphometric analysis indicated that the linear osteotomy gap treated with plates and screws was less than the gap associated with the wire group. Rigid fixation of the sternum resulted in earlier union with primary osseous healing, suggesting greater inherent stability. these factors may decrease adverse sequelae for this procedure.

Chest wall implantation of lung cancer after thin-needle aspiration biopsy.

Percutaneous aspirational biopsy of intrathoracic lesions has become a popular technique. One of the rarest complications is that of implantation of malignant cells within the needle tract and subsequent development of a chest wall mass. A case of chest wall implantation of adenocarcinoma of the lung after thin-needle biopsy is reported. The lesion was successfully treated with radical full-thickness excision of the chest wall and immediate reconstruction with a large rectus abdominis musculocutaneous flap.

Use of trapezius muscle for closure of complicated upper spinal defects.

Dehiscence of cervicothoracic incisional wounds is an occasional complication of laminectomy. Subsequent healing can be further compromised by associated immunodeficiency, malignancy, infection, previous radiotherapy, and cerebrospinal fluid fistula. Two such cases that responded dramatically to the use of a lower trapezius muscle flap are described. Pertinent anatomical and surgical considerations are reviewed.

Nasal encephaloceles: definitive one-stage reconstruction.

Nasal encephaloceles can cause complex deformities of the naso-orbital skeleton. As the encephalocele pushes through a defect in the facial skeleton it causes lateral displacement of the medial orbital walls. Correction of this skeletal deformity is necessary to achieve a normal facial contour. Two examples of nasal encephaloceles are presented and the classification, diagnosis, and treatment of this entity are discussed. The correction of these deformities at an early age is recommended. The suggested method of reconstruction is a combined intracranial and extracranial approach with mobilization of the nasal skeleton and medial orbital walls to their normal position. The remaining defects are treated with bone grafts.

Surgical considerations in hyperparathyroidism: reappraisal of the need for multigland biopsy.

Sixty-seven cases of neck exploration for suspected hyperparathyroidism were reviewed. Thirty-nine patients underwent removal of an adenoma with biopsy of one or more other parathyroid glands. In another group, nine patients underwent removal of the adenoma only. Both groups have had no recurrences of hyperparathyroidism in follow-up periods of two months to twelve years. The data presented indicate that removal of a parathyroid adenoma alone, without biopsy of other tissue, represents satisfactory treatment. Experience with hyperplastic glands is also reviewed. Subtotal parathyroidectomy was effective treatment in all patients, but a 30 per cent incidence of hypocalcemia was noted after this operation.

Reconstruction of congenital chest-wall deformities.

Pectus deformities and Poland's syndrome are two relatively common congenital deformities of the chest wall that are amenable to reconstruction. The extent of the structural deformity in pectus deformity and the degree of associated cardiopulmonary dysfunction are critical variables in preoperative assessment. The operative approaches range from more extensive sternal eversion to the more popular subperichondrial cartilage resection with or without internal fixation. In Poland's syndrome, the options for reconstruction include anterior transfer of the ipsilateral latissimus dorsi muscle through a transaxillary tunnel and attachment to the clavicle and sternum. Submuscular insertion of a mammary prosthesis can be added in the female patient.

Preoperative evaluation and general preparation for chest-wall operations.

Chest-wall reconstruction is a major procedure with a risk of life-threatening complications. Accurate preoperative assessment is therefore critical, as it allows detection and treatment of correctable problems and permits the surgeon to individualize postoperative management. Risk factors may be cardiovascular, pulmonary, or nutritional. The guiding principle of planning for the reconstruction is that there must be absolutely no tension at the site of the full-thickness defect in the chest wall.

Breast cancer invasion into the chest wall with resection and reconstruction.

Despite the advent of limited resections and radiation therapy in the treatment of breast cancer, a substantial number of women experience recurrence or persistent disease that invades the skin, soft tissues, and musculoskeletal layers of the chest wall. This problem, which can compromise local control of the tumor, can also involve pleura, lung tissue, and mediastinal structures. This article will cover some of the pertinent clinical decisions related to these lesions, their prognosis, and management by chest wall resection and reconstruction.

Endometriosis causing acute small bowel obstruction: report of a case and review of the literature.

Endometriosis causing acute small bowel obstruction is a clinical complex which should be considered in the differential diagnosis of intestinal obstruction. Theories as to etiology and pathogenesis are discussed. The best clue to preoperative diagnosis of the lesion is a careful history with regard to previous episodes of ileus having menstrual periodicity. The lesion itself usually causes obstruction by kinking or volvulus secondary to serosal adhesion formation, and more rarely by stenosis or intussusception. The treatment of total small bowel obstruction secondary to endometriosis is surgical, with resection of the involved bowel and end-to-end anastomosis.

Bioactive factors and biosynthetic materials in bone grafting.

The ability to initiate bone repair with bioactive factors and delivery systems is contingent upon understanding and mimicking biochemical and cellular events that occur in response to autograft and allograft repair. This review develops the concept that osseous repair must be linked to a time-dependent sequence of structured events, the chronobiologic continuum of wound repair. Selected factors that have shown promise for promoting bone formation are discussed. The deployment of select factors by a biodegradable delivery system that fulfills physiologic requirements for osseous repair is explored.

Late results of free-muscle flaps and delayed bone grafting in the secondary treatment of open distal tibial fractures.

Since no current studies reflect the long-term function of patients accurately categorized and uniformly managed for the same degree and location of tibial injury, seven individuals with type IIIB open distal tibial fractures were studied prospectively for 2 to 4 years after debridement, free-muscle transfer, and delayed autologous bone grafting. Lymphedema, transient drainage, poor ankle motion, limb shortening, nonunion, and delayed union were all significant problems. On average, the patients endured over six operations, 2 months of hospitalization, and a year's course of physical rehabilitation. The study indicates that, although popular, such a regimen is not without important shortcomings. This experience has influenced our selection of and counseling for patients in whom we are contemplating such management.

Effects of unrestricted motion on healing: a study of posttraumatic adhesions in primate tendons.

The effects of unrestricted motion on the surfaces of injured, healing tissue are largely speculative. To study this phenomenon, a new model employing 54 primate tendons and stereomorphometric image analysis was used to quantitate adhesion volume after a standardized surface injury. Three randomized groups (n = 18 per group) were studied: group I, incision/resection; group II, incision/resection plus ischemia; and group III, ischemia alone. The moving surfaces were observed at intervals from 1 week to 2 1/2 years using dissecting, light, and scanning electron microscopy. Fibroblasts were found to invade the traumatized segment from sources both intrinsic and extrinsic to the tendon, generating adhesive bands whose volume correlated with the degree of initial injury. The defect was ultimately effaced by scar, yet the continuous motion appeared to modify the healing by lengthening adhesive elements and by establishing a smooth, functional "neosheath" that coalesced from the overlying soft tissues. This proliferative response occurred in all specimens, peaked during the third week, and limited normal motion in only 12 percent. This model, the first to successfully study such surfaces in primates, also indicates that closure of the tendon sheath is unnecessary.

Long-term results following the repair of palatal clefts: a comparison of three different techniques.

A series of 109 patients was divided according to type of palatal defect, technique of repair (pushback, von Langenbeck, or pushback with island flap), results of standardized multifactorial speech analyses, and effectiveness of primary and secondary operations. Sixty-five patients (60 percent) showed improved speech after the initial repair, with 49 of these rated as "good." Forty-five percent improved after the von Langenbeck operation, 57 percent improved after the pushback procedure, and 53 percent improved after the pushback/island flap repair. Persistent hypernasal speech was treated with superiorly based pharyngeal flaps in 18 patients with uniform success (p less than or equal to 0.001). The worst results (after all three techniques) followed the repair of bilateral complete clefts. This experience has tempered our expectations in dealing with cleft palate patients, especially those having bilateral defects.

Use of the latissimus dorsi muscle to restore elbow flexion in arthrogryposis.

The successful use of ipsilateral pedicle latissimus dorsi muscle to restore elbow flexion in a child with arthrogryposis multiplex congenita is described. In appropriately selected patients, use of the latissimus dorsi muscle for elbow flexor reconstruction is a strong, reliable flexorplasty without significant donor-site morbidity.