Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a one-year follow-up study.

BACKGROUND: Trapeziectomy and ligament reconstructions are favoured by surgeons concerned that telescoping of the thumb may reduce its function. However, theoretically ligamentoplasties are at risk to develop tendinosis or tendon rupture or trigger a complex regional pain syndrome type 1. HYPOTHESIS: Authors tested the looping of a slip from the abductor pollicis longus (APL) tendon around the first intermetacarpal ligament. They intended to use a surgical treatment which does not require bone tunnelling or looping around a tendon. Their results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis. PATIENTS AND METHODS: Forty-two patients were followed up to one year. Each patient had subjective assessment for: pain; function (DASH score); overall satisfaction. An objective assessment was used for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at three, six and 12 months. X-ray films were taken to monitor thumb height. RESULTS: A substantial improvement in all these parameters was measured in all patients. X-ray films showed the mantainance of a physiological heigth after one year. We recorded one complication of keloid and two of temporary dysesthesia but no case of tendinosis, delayed rupture, or CRPS 1. Mean operative time was 27 minutes. DISCUSSION: Simplification and search for a technique which avoids the looping around a tendon is why the authors undertook this study. Advantages are the small number of required steps, short time of surgery and comfortable postoperative rehab regimen for the patient. The technique provides a distal anchoring point (without bone tunnelling). It is quite respectful of anatomy and physiology, in minimizing the re-routing of functioning tendons. We propose it as an effective procedure both to expand the armamentarium for treating the thumb carpometacarpal joint osteoarthritis and/or to simplify the ligamentoplasties already in use.

Cholinesterase activities and sensitivity to pesticides in different tissues of silver European eel, Anguilla anguilla.

Cholinesterase (ChE) activities were characterized in silver European eel, Anguilla anguilla, grown in the brackish lagoon of Comacchio (Italy). All specimens were harvested at the "lavoriero", a traditional eel trapping weir that captures eels while leaving internal waters at the onset of reproductive migration. To our knowledge, no investigation on ChE was reported in silver eels. Therefore a first characterization of enzyme activity in muscle, brain, liver and plasma of silver eel was carried out, in the presence of different substrates, selective inhibitors, and four pesticides representative of the carbamate and organophosphate classes. Brain and white skeletal muscle showed similar ChE activities, 5- and 10-fold higher than those detected in liver and plasma, respectively. Km values of 0.31 and 0.30 mM, and Vmax values of 40.28 and 35.47 nmol min(-1) mg protein(-1) were obtained in brain and muscle ChE, respectively. Acetycholinesterase was the predominant ChE form in all tissues, as concluded by comparing the effects of BW 284c51, iso-OMPA and eserine. ChE activities in brain and muscle were significantly inhibited by in vitro treatment with pesticides, with the following order of potency: carbofuran>carbaryl>chlorpyrifos≥diazinon.

Morphology and TGF-beta1 Concentration Analysis of Ligamentum Flavum in Patients with Lumbar Canal Stenosis and Lumbar Disc Herniation.

The most common spinal disorder in elderly patients is lumbar spinal canal stenosis, causing low back and leg pain and paresis. The aetiology of degenerative changes occurring in lumbar stenosis remain unclear: some authors hypothesize hyperplasia and others hypertrophy of the LF. The change in LF is known to be related to degenerative changes secondary to the aging process or mechanical instability. This study aimed to analyse the ligamentum flavum (LF) of patients with lumbar canal stenosis and lumbar disc herniation to evaluate the morphology and concentration of the Transforming Growth Factor-beta 1 (TGF-beta 1). The study was undertaken in three phases: A) Measurement of the thickness of the ligamentum flavum in patients with lumbar stenosis and/or herniated lumbar disc through axial T1 weighted lumbo-sacral MR images; B) Removal of ligamentum flavum in patients undergoing intervention for lumbar stenosis and lumbar disc herniation (control group); C) Optical microscopy study of the morphology of degenerated ligamentum and immunohistochemical analysis to assess the concentration of TGF-beta 1 in the LF. Morphological analysis of the LF (i.e. the increase in the number of fibres or distension and relaxation of the same as a result of degenerative processes) and the presence or absence of a high concentration of TGF-beta1 (then more fibroblasts involved in the degenerative process) can be important to establish whether there is hypertrophy or hyperplasia of the LF in lumbar canal stenosis. The current study showed that decreased elasticity of the LF in the elderly is due to a loss of elastic fibres that are degenerated and a concomitant increase in collagenous fibres (hypertrophy). TGF-beta1 concentrations of the LF were higher in lumbar spinal stenosis than in disc herniations. This suggest that LF of lumbar canal stenosis is hypertrophic: LF hypertrophy could be due to thickening of the normal elastic layer and the abnormal collagenous layer and to higher expression of TGF-beta 1 by fibroblasts.

Reconstruction of the distal finger with partial second toe transfers by means of an exteriorised pedicle.

This study reports the outcome of a series of ten microsurgical fingertip reconstructions with partial toe transfers in which the vascular pedicle was exteriorised and subsequently excised after the transfer had become established. The aim of this technique was to provide better aesthetic and functional outcomes. The technique was successful and without complication in nine of the ten patients who had excellent functional and aesthetic outcomes. Arterial thrombosis resulted in partial necrosis of the fingertip in the other case.

[Coverage of dorsal distal skin defects of the digits. Techniques and indications]. / Couverture des pertes de substance cutanée distales des doigts. Techniques et indications.

Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area is challenging according to the following points: the proximity of the distal interphalangeal joint, the thinness of the extensor apparatus and the vicinity of the nail. Among the numerous flaps described, the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.

[Dynamic correction of static scapholunate instability using an active tendon transfer of extensor brevi carpi radialis: preliminary report]. / Correction dynamique d'une instabilité statique scapholunaire par transfert tendineux actif du muscle court extenseur du carpe: rapport préliminaire.

We present the case of a twenty year old man who developed static scapholunate instability on the right side following a road traffic accident seven months previously. A dynamic surgical technique was devised to treat this problem using the tendon of extensor brevi carpi radialis as an active transfer. The tendon, divided at its insertion on the base of the third metacarpal, was reinserted into the distal part of the scaphoid using two anchors after shortening it by removing the distal centimetre. The tendon was rerouted via a pulley created 'de novo' at Lister's tubercle in order to centre the tendon on the same axis as the scaphoid. No other material was used for bone fixation. The wrist was immobilized in extension for six weeks. The clinical and radiological result eight months after the intervention showed excellent reduction of the scapholunate joint and a pain-free wrist with satisfactory mobility.

Dominances in finger arteries.

We studied the patterns of dominance in the palmar digital arteries of the fingers in 39 fresh cadaver arms which had been injected with coloured latex solution. We also performed photoplethysmographic studies in 20 hands. The ulnar digital artery in the index finger and the radial digital artery of the little finger were usually dominant, and their counterparts were slim and often hypoplastic. The findings are relevant to digit revascularization and might influence the planning of digital island-flaps or toe transfers.

An anatomical study of the relationship between excursion of the flexor tendons and digital mobility: proposition of an intraoperative test for flexor tendon tenolysis.

The excursion of the flexor tendons of the thumb and fingers was studied in ten fresh cadaveric upper limbs. For each centimetre of tendon movement, obtained by traction of the flexor tendons at the wrist, the angular changes of the digital articulations were measured; movement started at extension and proceeded to maximum flexion. A further five upper limbs were used to evaluate the effect of pressure over the musculotendinous area of the flexor tendons of the fingers and thumb. Pressure on the muscle bellies in the forearm causes movement of the tendons, different for each finger, with the accompanying digital flexion depends on the magnitude of the movement. On the basis of this anatomical study a test is described which may be beneficial in the diagnosis of pathology and trauma of the flexor tendons and, particularly, in the intraoperative evaluation of the quality of motion obtained during tenolysis.

Direct muscle neurotization after end-to-side neurorrhaphy.

Over the recent years, end-to-side neurorrhaphy has reemerged in the literature for reconstructive nerve surgery. Another technique, in which interest has remained continuous during the last century, is direct nerve implantation into muscle belly, so-called direct muscle neurotization (DMN). In this work, the authors present a new technique to recover muscle innervation through direct nerve implantation into muscle belly, by means of a nerve graft, and sutured with end-to-side neurorrhaphy. They carried out experiments on 20 Wistar rats divided into two groups. In Group 1 (10 rats), on the right side, the peroneal nerve was sutured to the tibial nerve with end-to-side neurorrhaphy. Subsequently, the terminal branches of the same nerve were implanted in the anterior tibial muscle (ATM). On the left side, the peroneal nerve was severed, and the ATM completely denervated. In Group 2 (10 rats), on the right side, the same technique was used as in first group. On the left side, the normal innervation of the ATM was maintained. After 4 months, all muscles and nerves were harvested and evaluations carried out on the morphologic aspect, weight, and histology of the ATM, as well as the histology of the nerves. The authors analyzed the results, which demonstrated good reinnervation of the muscles deprived of any nerve connection.

Vascularization of the thumb. Anatomy and surgical applications.

Microsurgical procedures require rapid and atraumatic dissection of vessels. The authors have tried to schematize the most common variations of the palmar arteries, dividing the thumb into three segments, delimited from the MCP and interphalangeal flexion crease. If a vascular anastomosis has to be carried out in the first segment, the arteries that intersect the palmar surface of such a region do not generally hold much interest for the surgeon as far as size and constancy are concerned. One therefore can avoid frustration while searching in vain for such an artery by starting dissection in the dorsal compartment, where there is a much better chance of finding an artery suitable in every aspect. In replanting a thumb in the second segment, the ulnar collateral artery should be the artery that is looked for first, because it is usually the biggest, the most superficial, and nearly always is composed of a single trunk (Fig. [figure: see text] 18). Let us not forget, however, that the contralateral artery can frequently have all the necessary requirements for an adequate anastomosis. In the third segment, the layout of the vessels is rather difficult to schematize; if it is true that the inverted Y or H shape can make a microanastomosis easier in cases of distal reimplantation (Fig. 19), it is also true that such a pattern is impossible to foresee, and, therefore, the interest of such classification is more academic than practical. Skin loss coverage at the thumb level greatly differs from the that of fingers. In the past few years, a multitude of useful new flaps has been presented by different authors. Their accomplishment (especially those of the last generation, who base their survival on extremely fine vascular axes) presupposes an adequate knowledge of surgical and microsurgical anatomy. Surgeons dealing with this type of pathology should be capable of performing all of the possible flaps because each may be indicated in specific situations.

The posterior interosseous reverse flap: experience with 113 flaps.

The authors have used a posterior interosseous flap for resurfacing in 113 cases of hand injury during the past 13 years. Its main indications were complex hand trauma or burn injuries with large skin loss, either acute or postprimary. Flaps survived completely in 98 patients. Twelve patients had superficial necrosis of the distal part of the flap, which did not require additional surgical procedures. Three flaps were lost and alternative coverage was used. Six patients demonstrated paralysis of the motor branch to the extensor muscles of the wrist or fingers (generally to the extensor carpi ulnaris, the extensor digiti quinti, or the extensor pollicis longus). All recovered completely within 6 months. The donor area was closed directly in 3 to 4-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. Donor site morbidity was minimal. Major anatomic variations precluding the use of the flap were encountered twice in this series.

Reverse posterior interosseous flap based on an exteriorized pedicle to cover digital skin defects.

The posterior interosseous arterial flap is limited by its short vascular pedicle and proximal axis of rotation to the coverage of defects on the dorsal aspect of the hand and the first web space. The authors present the results of three cases in which these limits were surpassed by extending the wrist and exteriorizing the vascular pedicle, thus causing it to bowstring across the angle created by the extended wrist. When flap inset is complete the vascular pedicle is excised under local anaesthesia. This technique is an amalgamation of an island flap and a traditional pedicle flap and, as such, it is a two-stage procedure.

Arterial anatomy and clinical application of the dorsoulnar flap of the thumb.

After injection of stained latex at the brachial artery, the arterial supply of the dorsal aspect of the thumb was studied by light microscopy in 25 cadavers. An artery, located on the dorsoulnar side and connecting the head of the first metacarpal with the dorsal arcade of the proximal nail fold, was found in all dissections. We report the results of the anatomic study and the clinical applications of a dorsoulnar skin flap that can be raised on its artery with a distal pedicle. Clinical experience is based on 32 flaps. In 25 cases this flap was used for distal skin loss coverage (palmar or dorsal) of the thumb as an island flap. In 7 cases it was used for reconstruction of the finger pulp (5 index and 2 middle fingers) in the form of a cross-finger flap.

Effect of omeprazole on interdigestive gastroduodenal motility of patients with ulcer-like dyspepsia.

BACKGROUND/AIMS: As omeprazole, an antisecretory drug, is largely used in the treatment of acid-related diseases, we investigated its effects on the interdigestive gastroduodenal motility of ulcer-like dyspepsia. METHODOLOGY: Gastroduodenal motility was recorded manometrically in 9 patients complaining of ulcer-like dyspepsia with normal gastric emptying at scintigraphy, without ulcerative lesions and H. pylori infection at endoscopy, and without diseases known to affect gut motility (group ULD), and in a group of 9 healthy subjects as control (group C). After a period sufficient to record two consecutive phases III of the migrating motor complex (MMC) in patients of group ULD, omeprazole 20 mg was infused intravenously 30 min after the end of the last duodenal phase III and the recording was continued to the next one. RESULTS: With respect to the control group, the group ULD showed a significantly longer MMC cycle duration, a frequent absence of gastric phases III and a shorter duration of duodenal phases III. Omeprazole administration in group ULD was followed after 18.9 +/- 8.5 min by a typical gastroduodenal phase III and, consequently, the duration of the omeprazole-related cycle was significantly shortened. These omeprazole-related phases III started from the stomach in nearly all cases and showed a significantly longer duration at the duodenal level with respect to the spontaneous ones. CONCLUSIONS: Patients with ulcer-like dyspepsia showed a decrease in frequency and duration of gastroduodenal phases III. The omeprazole intravenous administration induced the anticipated appearance of an apparently normal gastroduodenal phase III, probably by suppressing the inhibitory action of acid secretion.

Effect of intravenous clarithromycin on interdigestive gastroduodenal motility of patients with functional dyspepsia and Helicobacter pylori gastritis.

Gastroduodenal motility of 16 patients complaining of functional dyspepsia and Helicobacter pylori gastritis was recorded by means of a low-compliance manometric system with four recording ports in the stomach and four in the duodenum. Clarithromycin (CLA) 250 mg (group A: 8 patients) or normal saline solution (group B: 8 patients) was infused intravenously randomly and in double-blind manner 30 min after the end of the first recorded activity front (AF) of the migrating motor complex or, in the absence of AFs, after 200 min of recording, continuing the recording until an AF was observed during the subsequent 200 min. CLA administration was followed by a typical gastroduodenal AF in a significantly higher number of patients than saline administration. In addition, the time-lag between the drug administration and the appearance of AFs was 22 min +/-7.4 (mean +/- SD), significantly shorter than after saline (109+/-56 min) and the CLA-related duodenal AFs showed a duration of 7.4 min +/-1.6 in group A, significantly longer than that of the spontaneous AFs (3.5 min +/-1), while in group B AF duration after saline was not significantly different from that of the spontaneous ones. In conclusion, clarithromycin is able to stimulate cyclic interdigestive gastroduodenal motility. This prokinetic property of clarithromycin is not unexpected because it is a macrolide like erythromycin, the prokinetic activity of which is well known, and could be utilized for therapeutic uses.

Effects of oral clarithromycin and amoxycillin on interdigestive gastrointestinal motility of patients with functional dyspepsia and Helicobacter pylori gastritis.

BACKGROUND: Clarithromycin and amoxycillin are antibiotics commonly used in association for Helicobacter pylori eradication. Because this treatment, which lasts 1-2 weeks, is frequently associated with gastrointestinal symptoms, we investigated the effects of these antibiotics on gastrointestinal motility. PATIENTS AND METHODS: Gastroduodenal motility was recorded in 14 patients with functional dyspepsia and H. pylori gastritis by means of a low-compliance manometric system with four recording ports in the stomach and four in the duodenum. Two tablets of clarithromycin 250 mg (seven patients, clarithromycin group) or one of amoxycillin 1 g (seven patients, amoxycillin group), ground and dissolved in 20 mL of water, were given randomly and in double-blind manner 30 min after the end of the first activity front (AF) of the migrating motor complex (MMC) or, in the absence of AFs, after at least 200 min of recording. Recording continued until an AF was observed during the subsequent 200 min. RESULTS: Clarithromycin administration was followed by a typical gastroduodenal AF in a significantly higher number of patients than for amoxycillin administration. In addition, the time lag between clarithromycin administration and the appearance of AFs was 48 min +/- 8.5 (mean +/- s.d.), significantly shorter than after amoxycillin (121 min +/- 29). The clarithromycin-related duodenal AFs showed a duration of 6.6 min +/- 1.5, significantly longer than that of the spontaneous AFs (3.6 min +/- 1.2, P < 0.01), while the amoxycillin-related AFs were not significantly different from the spontaneous ones. CONCLUSION: Clarithromycin stimulated cyclic gastroduodenal motility, while amoxycillin was ineffective. It is likely that symptoms during the eradication treatment are due to this effect of clarithromycin.

Further experience with the index metacarpal vascularized bone graft.

We report our experience in the use of a vascularized bone graft harvested from the head of the index metacarpal to treat scaphoid nonunion after failure of other techniques. Only 15 patients were treated between 1988 and 1994, showing the scarcity of indications for the operation. Union was obtained in 14 cases but the functional results were acceptable in ten cases only. This was due to previously unnoticed degenerative lesions.

Clinical and manometric effects of L-arginine in patients with chest pain and oesophageal motor disorders.

BACKGROUND/AIMS: Nitroderivatives are therapeutically effective in spastic disorders of the oesophagus through the generation of nitric oxide, a non-adrenergic non-cholinergic inhibitory neurotransmitter, but their use is limited by undesirable side effects and rapid appearance of drug tolerance. As nitric oxide "in vivo" is generated from L-arginine, an amino acid normally present in the diet and completely devoid of toxic effects, we administered the latter substance in patients with chest pain and oesophageal motor disorders of the spastic type to investigate if it is able to produce clinical and manometric effects similar to those manifested by nitroderivatives. METHODS: In eight patients affected by non cardiac chest pain and oesophageal motor disorders of a hypertonic-hyperkinetic type without pathologic gastro-oesophageal reflux, a solution containing L-arginine and a placebo solution were infused in random order and double blind manner during a manometric examination of the oesophagus, taking into account the spontaneous variations of oesophageal motility connected with the phases of the Migrating Motor Complex. Afterwards, in the same patients a solution containing L-arginine and a placebo solution were administered orally, in random order and double blind manner, each for a period of six weeks. The effect of each treatment on frequency and intensity of chest pain attacks and on nitroderivatives intake was recorded on a diary by the patients. RESULTS AND CONCLUSIONS: The intravenous administration of L-arginine did not show the typical inhibitory effect of nitroderivatives on lower oesophageal sphincter tone and on amplitude and duration of pressure waves, but the chronic oral intake of L-arginine significantly decreased the frequency and intensity of chest pain attacks, as well as the number of nitroderivative tablets taken for analgesic purposes, thus suggesting a possible therapeutic role of this substance in this kind of patient.

Arterial switch operation: myocardial ischemia reversed by internal mammary artery graft.

We report a case in which an internal mammary artery graft to the left anterior descending coronary artery was successfully used in a newborn boy to reverse life-threatening myocardial ischemia 24 hours after arterial switch operation. One year later, angiography showed patency of both the graft and the transposed coronary ostium with normal left ventricular function. A brief review of the literature shows encouraging results of internal mammary artery grafts in pediatric patients.