Midcervical tetraplegia with strong wrist extension: a two-stage synergistic reconstruction of the hand.

Reconstructive surgery can restore appreciable function of the upper limb in tetraplegic patients. The magnitude of the function regained depends on several factors: (1) the level of the spinal cord lesion, (2) careful patient selection, (3) thoughtful application of the basic principles of tendon transfer, (4) absence of severe spasticity, (5) the remaining sensory function of the hand, and (6) the surgical program and the surgeon's expertise with this type of patient. Reconstructive surgery offers patients not only greater physical independence but also psychological benefits. This article refers to cases with midcervical spinal cord lesion where wrist extension is complete and strong (MRC grading 5). It describes the author's strategy and technical choices in these patients, based on an ever evolving experience of more than 30 years.

The trapeziometacarpal joint. Tenotomy of the accessory tendons in early osteoarthritis.

The TMC joint is an articulation with special articular surfaces adapted to produce simple (nonrotatory) and complex (rotatory) metacarpal movements. Its articular anatomy and biomechanics are closely related to the pathogenesis of osteoarthritis. The joint works under high transarticular compressive-shearing forces. In osteoarthritic thumbs, the articular forces are increased because of the constant presence of accessory APL tendons, almost exclusively of the digastric type. Other factors should be considered in the pathogenesis of TMC joint osteoarthritis, such as repetitive use of the thumb under unfavorable patterns of function) strong side-to-side pinch grips, thumb with the tendency to maintain in reposition), cartilage aging, hormonal disturbances in women, and general osteoarthritic disease. Osteoarthritic thumbs in stages I and II that have failed to respond to conservative treatment are candidates to unload the joint by tenotomy of the transarticular accessory tendons. Long-term results have been very satisfactory (97%), eliminating or substantially reducing pain and returning patients to their activity. The procedure is contraindicated in severe (stage III) TMC joint osteoarthritis and in primary articular instability.

Posterior interosseous reverse forearm flap: experience with 80 consecutive cases.

The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)

Palliative surgical procedures in sequelae of obstetric palsy.

The authors present 28 years of combined experience with reconstructive surgery for the different sequelae of obstetric palsy. The sequelae have been classified to indicate in each case the most adequate surgical procedure.

Posterior interosseous island forearm flap.

The skin of the dorsal aspect of the forearm is supplied by several cutaneous branches of the posterior interosseous artery. This vascular anatomy permits the surgeon to obtain an island flap of the dorsal forearm based on the distal anastomosis between the two interosseous arteries at the distal part of the interosseous space. This flap can reliably be transferred to different skin defects of the hand such as those created by correction of an adduction contracture of the first web space, or on the back or front of the wrist level. Its principal advantages are that it is a thin flap with excellent circulation and that it is possible to close the donor area primarily provided the island flap is not wider than 3 to 4 cm. The procedure has been employed in 25 patients with satisfactory results.

Biomechanics of the trapeziometacarpal joint.

The trapeziometacarpal joint is structured to allow simple angular and simultaneous angular or rotational movements of the first metacarpal. The geometry of the joint is partitioned as follows: a saddle-shaped area (the central area of the trapezium and metacarpal ridge), where simple angular movements occur, and a spherical region (the palmar area of the trapezial articular surface and metacarpal slopes), where simultaneous angular movements take place. Rotation of the first metacarpal during opposition (pronation) and retroposition (supination) depends on three factors: muscular activity, ligament tension, and congruence of the spherical portion of the trapeziometacarpal joint.

Congenital ulnar drift and camptodactyly produced by malformation of the retaining ligaments of the skin.

Two digital congenital deformities produced by failure of differentiation of parts of the retaining ligaments of the skin or the retinaculum cutis are named "congenital cutaneous ulnar drift" and "congenital cutaneous multiple camptodactyly," respectively, based on their pathogenesis and clinical characteristics. A classification of the deformities based on the tissues involved is presented which can be useful in determining when and what operative procedures to use for treatment. Types I and II can usually be corrected easily; they differ from Type III deformities, such as camptodactyly of the fifth finger and multiple congenital arthrogryposis, which do not lend themselves well to surgical correction. Surgical correction is indicated early in Type I and Type II cases, particularly when the deformity begins to increase; secondary tendinous, capsule, and bony alterations should be avoided.

The infantile spastic hand. Surgical indications and management.

The infantile spastic hand represents a complex problem that can be improved by surgery when surgery is properly indicated and performed candidates for surgical reconstruction must be carefully selected according to general and local characteristics.