Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm.

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Regulation of thyroid hormone receptor beta-2 mRNA levels by retinoic acid.

The thyroid hormone receptor, TR beta-2, whose expression is limited to the pituitary and parts of the central nervous system, is strongly negatively regulated at the pre-translational level by thyroid hormone (T3). We have investigated whether retinoic acid (RA), whose receptors (RARs) share a high degree of homology with the thyroid hormone receptors (TRs), can regulate this gene in a manner similar to T3, as has been shown for the growth hormone (GH) gene. GH3 cells were incubated with 10 nM T3, 1 microM RA or both for 48 h and then TR beta-2 mRNA levels determined by RNA blot hybridization analysis. We observed a 73% decrease in TR beta-2 mRNA levels after incubation with T3 and a two-fold increase in TR beta-2 mRNA levels after incubation with RA alone. In the presence of RA, the T3 effect on TR beta-2 mRNA levels was blunted with mRNA levels decreasing by only 20%. We investigated the mechanism by which retinoic acid increases and opposes the effects of T3 on levels of TR beta-2 mRNA. In transient transfection experiments using a reporter plasmid containing the TR beta-2 promoter and in nuclear run on assays, we found no effect of RA on TR beta-2 gene transcription. We then investigated whether the effects of RA were mediated at the post-transcriptional level. Determination of the apparent half-life of TR beta-2 mRNA using the transcriptional inhibitor, actinomycin D, showed that RA had no effect on TR beta-2 mRNA stability.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytomegalovirus infections in Toronto child-care centers: a prospective study of viral excretion in children and seroconversion among day-care providers.

OBJECTIVES: To prospectively determine the rate of cytomegalovirus shedding in children and the rate of seroconversion to cytomegalovirus in providers at 38 infant-toddler day care centers in Toronto, Canada. METHODS: Urine was collected for shell vial assay in 471 children between the ages of 3 and 42 months. Providers (n = 206) were tested for the presence of cytomegalovirus antibody by latex agglutination. Of the 68 providers who were seronegative, 56 were retested approximately 1 year later. RESULTS: Viruria was documented in 79 (17%) children and antibody in 67% of providers. Seropositivity was significantly related to country of birth outside Canada, presence of children at home < 5 years of age and increased household size. Seroconversion was documented in 12.5% (n = 7). Of these providers 71% worked at centers where workers never wore gloves for diaper changing vs. 33% of those who did not seroconvert (P = 0.06), and all were younger than 30 years vs. 59% of those who did not seroconvert (P = 0.04). In centers with viruria the association of seroconversion with lack of glove use was enhanced (P = 0.04). Seroconversion was marginally more likely in providers working with infants only than with infants and toddlers or with toddlers alone. Logistic regression confirmed that seroprevalence was more likely in providers who were born outside Canada, had children younger than age 5 years in the household and with an increased number of people in the household. Seroconversion was more likely if the provider worked at centers not using gloves for diaper changes, worked with infants only rather than with toddlers and infants and was < 30 years old, with each factor contributing independently to the model. CONCLUSIONS: Cytomegalovirus infection is common in children and providers in Toronto day-care centers.

Villonodular synovitis of the shoulder in the elderly.

Villonodular synovitis of the shoulder developed in two elderly patients. Huge soft tissue mass, marked joint effusion, and radiographs demonstrating severe osteoarthritic changes characterized these patients. Localized shoulder muscle atrophy accounts for residual painfree limitation of active shoulder motion following synovectomy of the shoulder joint.

Postburn peroneal nerve palsy--a report of two consecutive cases.

We report two patients suffering from mixed deep partial and full skin thickness flame burns covering 45 and 95 per cent of the total body surface area respectively. These patients, following sepsis and multisystem failure, developed unilateral peroneal nerve palsy. The possible aetiology of isolated injury to the peroneal nerve in burned and critically ill trauma patients is discussed.

The effect of a simple preservation method on immediate and late patency rates of autogenous microvenous grafts.

The subject of this study was assessing in vivo a simple short-term preservation method of autogenous microvenous grafts. Forty-five autogenous vein grafts in rats were divided into groups of five and preserved in lactated Ringer's solution at 4 degrees C for 0, 1, 2, 3, 5, 8, 10, 12, and 14 days. After a designated preservation period, the veins were implanted as autografts into defects created in the animal's femoral arteries, while a small portion of each vein was processed for histologic examination. The patency was assessed immediately, at 1 week, and at 5 to 6 weeks following grafting, at which time the patent grafts were biopsied. Preserving the grafts for up to 2 days had no effect on their patency rate, which remained 100 percent, and no histologic changes were noted in the veins preserved for this period. However, longer preservation resulted in gradual necrotic changes in the veins, which were reflected in lower patencies of the grafts. The histology of the preserved veins and of the patent vein grafts 5 to 6 weeks following grafting is discussed. The model developed in this study can be used as a benchmark for further preservation studies using more sophisticated methods.

An epidemiologic assessment of exposure of children to polychlorinated biphenyls (PCBs) in a Toronto community.

In 1985, the human exposure from a site of PCB (Aroclor 1260) contamination in a Toronto community was assessed. The primary source of potential exposure was soil. Extensive surface soil sampling revealed levels greater than expected (geometric mean level = 0.19 ppm). Children under age 6 were considered to be at greatest risk of exposure as they may absorb PCBs from ingested soil or skin contact. A sample of children aged 1-5 was recruited from the community (n = 30) and from a socio-demographically similar control area (n = 23) that had significantly lower but detectable soil PCB levels (geometric mean level = 0.12 ppm). Exposure to PCBs from breastfeeding, food consumption, contact with soil, and parental occupation was comparable in the two groups. Geometric mean blood PCB levels did not differ significantly between the study (1.5 ppb) and control (1.9 ppb) group. Levels ranged up to 5 ppb in both groups and are comparable to those described in children elsewhere in North America.

Survey of infection control procedures at manicure and pedicure establishments in North York.

OBJECTIVE: To describe infection control practices used by technicians doing manicures and pedicures in an urban setting in Ontario. METHODS: A random sample of 120 establishments was selected from a sampling frame. A survey was designed and administered to technicians through face-to-face interviews. RESULTS: Technicians in 72 establishments were interviewed, representing a 60% response rate. Twenty-nine (40%) of these technicians indicated that they had been immunized against hepatitis B. Technicians re-used almost all instruments even if this was not the intent of the manufacturer. Isopropyl alcohol was the most commonly used disinfectant. Many technicians did not wear gloves while performing procedures. Most did not follow universal precautions when asked how they would react to incidental cuts on either the client or themselves. CONCLUSION: There is a need for the development of infection control protocols for manicure and pedicure establishments since the potential for transmission of infectious diseases does exist.

Factitious lymphedema of the hand: a diagnostic challenge.

A case of factitious lymphedema of the hand is presented. Attention is drawn to this entity and its differential diagnosis. Delayed detection in our case resulted in prolonged and costly hospitalization with some loss of hand function. Treatment should be left to those skilled in psychotherapy.

The role of three dimension computerized imaging in hand surgery.

Three-dimensional computerized imaging is a new modality of radiological imaging. This new technique transforms the two-dimensional slices of bi-plane CT into a three-dimensional picture by a computer's monitor adjusted to the system. This system enables the physician to rotate the angle of viewing of the desired region to any desired angle. Moreover, this system can delete certain features of different densities from the picture, such as silicone implants, thus improving visualization. Our preliminary results using this technique are presented. The advantages, pitfalls, and suggested future applications of this new technique in hand surgery are discussed.

Traumatic arm amputation, an uncommon parachuting injury.

Parachuting is a unique method of deploying troops. Accidents in parachuting are common, but usually carry minimal risk for severe injury. Most accidents occur during landing and injuries often affect the lower limbs and spine. Traumatic amputation of a limb is an extremely rare event in parachuting. We present a case of a parachutist who suffered a traumatic amputation of the left hand during jumping off the plane.

[Incomplete penile amputation: diagnostic and therapeutic challenge].

Traumatic penile amputation is a severe injury associated with a potential for multidisciplinary dysfunction. Since such injuries are rare, diagnostic and therapeutic experience is minimal. While complete penile amputation is a straight-forward diagnosis, incomplete amputations are not as evident and diagnosis may be delayed. The therapeutic endpoint includes restoration of an acceptable appearance of the phallus and a urethral meatus that allows normal voiding. Other objectives include re-establishment of sexual potency and fertility. As in other amputations, the treatment of choice is meticulous microsurgical replantation, including re-anastomosis of dorsal and cavernosal arteries, the deep dorsal vein, the urethra and nerves, as well as suturing the tunica albuginea. While appropriate cosmetic results and normal voiding can be achieved in most cases, potency is less frequently achieved due to neurological deficit leading to impaired erection and loss of sensation. Penile amputation is thus a complex therapeutic challenge, as meticulous anatomic reconstruction of blood vessels and nerves is essential for restoration of function. Since incomplete penile amputation may be overlooked when other more obvious injuries draw attention, this injury should be suspected in all cases of penetrating injury of the male genitalia. We present a 17-year-old man who sustained an incomplete penile amputation in a traffic accident.

[Lateral arm free flap transfer to cover traumatic hand injuries].

The advantages of free flaps over distant pedicled flaps in hand reconstruction are well documented. They often require only a single operation, do not depend on local conditions of the wound and permit early physiotherapy. The lateral arm free flap is essentially suitable for reconstruction of the hand. It is thin, potentially sensate, and gives nearly perfect skin color and texture match. An additional technical advantage is the possibility of elevating the lateral arm free flap with tourniquet control at the same surgical field as the recipient site. We describe 3 cases of traumatic damage to skin and soft tissue of the hand, in which reconstruction was by both elective and emergency lateral arm, free flap transfer. They demonstrate the merits of this method of reconstruction.

[Early microsurgical reconstruction of extremities with free microvascular flaps].

The key to successful reconstruction of the extremities after complex trauma is often adequate soft tissue cover of the injured area. In the past, when surgical debridement of wounds was too extensive, or it exposed vital structures such as blood vessels, nerves, tendons or bones, the limb either had to be amputated or reconstructed in multiple surgical procedures. The use of free microvascular flaps in the immediate postinjury period allows single stage reconstruction of wounds including exposed vital tissues. It promotes limb salvage and shortens recovery time after severe trauma. 4 patients with severe complex trauma of the extremities underwent reconstruction with immediate free microvascular flaps, which included latissimus dorsi and rectus abdominis muscle and free scapular flaps. The surgical protocol included debridement of wounds on arrival with primary fixation of fractures and additional debridement procedures in the first week until the wound was stable. Then final fixation of fractures was performed and the wound was covered by a free microvascular flap. With this technique, single stage reconstruction is possible in most cases, with improvement in function and cosmetic outcome, multiple operations are avoided and the recovery period is shortened.

Major upper extremity replantations.

The usual mechanism of a major amputation creates a mutilating injury. Although survival rate is high, the functional results are guarded [1, 2]. The aim of this study is to review our experience with major upper extremity replantations performed between the years 1987-2007 with respect to the type of amputation as proposed by Chuang et al. [3]. 23 upper extremities were replanted in 22 patients (7 arms and 16 proximal forearms and elbows). All but one replanted parts survived. Out of 6 patients with arm replants 4 gained useful extremities and two had poor result after more than 2 years of rehabilitation and 17 additional surgical procedures. Out of 16 replanted forearms, after more than 2 years of rehabilitation period and 50 operations, useful extremity was achieved in 11 and poor result in 5. The main factor influencing functional result was the type of amputation according to Chuang et al. [3].

Ankle instability of the donor site following removal of vascularized fibula bone graft.

We have assessed the donor site of fibula bone graft to detect signs and symptoms of ankle instability in 8 patients. In 1 patient with generalized joint hyperlaxity pain, clinical instability and pathological motion of the proximal end of the distal remaining fibula were encountered. Seven other patients were asymptomatic and had no instability both clinically and on stress radiographs.

Complication with the elastic tubed net bandage.

A case is presented in which inappropriate application of extensible tubed net bandage to a finger caused local skin necrosis. Only one comparable complication of this dressing material has been reported previously.

Successful replantation of a totally avulsed scalp.

A case of successful replantation of a totally avulsed scalp in a 19-year-old woman is presented. Although severely traumatized, about 90 percent of the surface of the replanted scalp survived. Only one artery (left superficial temporal) and four veins were anastomosed, sufficient enough to revascularize the entire scalp.

Sulfasalazine pneumonitis.

A man with alleged Crohn's disease of the terminal ileum was started on sulfasalazine. Five weeks later he developed progressive cough, shortness of breath, and fever associated with peripheral eosinophilia and bilateral pulmonary infiltrates. After withdrawal of sulfasalazine all abnormalities returned to normal. This case supports the conviction that there is an entity of sulfasalazine-induced lung disease.