Ligament reconstruction of the painful, unstable, nonarthritic thumb carpometacarpal joint.

Thirty-seven cases of ligament reconstruction of the nonarthritic thumb carpometacarpal joint were performed in 35 patients, 29 female and 6 male, between 1980 and 1996. Follow-up ranged from 1 to 17 years with an average of 5.2 years. The procedure described by Eaton and Littler in which a slip of the flexor carpi radialis (FCR) weaved through the first metacarpal and around the abductor pollicis longus and FCR was used. All patients had marked pain before surgery, and 65% were unable to work. No patient had radiographic evidence of arthritis before surgery. Sixty-seven percent had excellent results, and 30% had good results. All but 1 had complete or nearly complete pain relief. One hundred percent had good stability and improved pinch strength. All patients were able to return to work, 94% to their prior level of performance. There was no clinical or x-ray evidence of osteoarthritis in any patient at final follow-up.

Treatment of de Quervain's disease:role of conservative management.

This retrospective study compares two methods used to treat de Quervain's disease: splintage with oral non-steroidal anti-inflammatory drugs (NSAIDs) and steroid injection. Patients were separated into three groups based on symptom severity: group I-minimal, group II-mild, and group III-moderate or severe. Three hundred and nineteen wrists in 300 patients were followed from one to six years. Fifteen of 17 patients with minimal symptoms were relieved with splintage and NSAIDs. However, only seven of 20 in Group II and two of eight in Group III treated similarly were relieved. Of the 249 patients in Group III treated with injections, 76% were completely relieved, 7% were improved, and 4% were not improved. We conclude that classification of patients' with de Quervain's disease based on their pre-treatment symptoms may assist surgeons in selecting the most efficacious treatment and in providing prognostic information to their patients.

Palmar fracture dislocation of the proximal interphalangeal joint.

Palmar fracture dislocation of the proximal interphalangeal joint is uncommon. Thirteen patients treated for this injury were retrospectively reviewed. There were 9 acute injuries. Seven were treated by closed reduction and percutaneous pin fixation and 2 were treated by open reduction and internal fixation. The 4 chronic injuries (more than 1 month after injury) were treated with open reduction and soft tissue reconstruction. The length of follow-up averaged 55 months. Eight patients were free from pain. Postoperative proximal interphalangeal motion averaged 91 for the acute injuries and 70 degrees for the chronic injuries. Follow-up radiographic findings were notable for an increased height of the middle phalangeal base in 6 patients, articular irregularity in 4, and residual subluxation in 2; however, these changes did not correlate with the clinical results. Complications included loss of reduction in 1 patient, progressive swan neck deformity in 1, and development of an average 25 degrees extension lag of the distal interphalangeal joint in 5.

Treatment of trigger finger in patients with diabetes mellitus.

We present a retrospective study of 54 diabetic patients with 121 trigger digits treated over a 3-year period by one to three injections of corticosteroid mixed with local anesthetic. As a group, diabetic patients responded less favorably to treatment by steroid injection (50% symptom resolution) when compared to reported outcomes of steroid injection treatment for stenosing tenosynovitis in the general population. Insulin-dependent diabetic patients have a higher incidence of multiple digit involvement (59% of patients) and of requiring surgical release for relief of symptoms (56% of digits) when compared to non-insulin-dependent diabetic patients (28% of patients with multiple digit involvement; 28% of digits requiring surgery).

Phase I study of amonafide dosing based on acetylator phenotype.

Amonafide is extensively metabolized, including N-acetylation to an active metabolite. Prior studies have demonstrated that patients who are fast acetylators of amonafide (and other drugs) have increased toxicity at standard doses of amonafide. The primary objective of this study was to define the recommended phase II dose of amonafide separately for slow and fast acetylators. Twenty-six patients with advanced cancer underwent acetylator phenotyping with caffeine and were assigned to a dose level. Slow acetylators were treated at 375 mg/m2 (daily for 5 days) and had a median WBC nadir of 1600/microliters. Fast acetylators were treated at both 200 and 250 mg/m2, resulting in median WBC nadirs of 5300 and 2000/microliter, respectively. Two patients were not typeable, and two patients appear to have been misphenotyped, one in each phenotype category. Pharmacodynamic analysis yielded a model for nadir WBC including acetylator phenotype, 24-h N-acetyl-amonafide plasma concentration, gender, and pretreatment WBC. We recommend doses of 250 and 375 mg/m2 (for 5 days) for further phase II testing of amonafide in fast and slow acetylators, respectively.

The scaphoid shift test.

The scaphoid test described by Watson has generally been accepted as the definitive test for scaphoid instability and uses pressure against the scaphoid tubercle as the wrist moves from ulnar to radial deviation for the evaluation. This article describes a stress test done with the wrist in neutral position, which actively provokes scaphoid instability. Variations in stability can be used to grade scaphoid laxity.

Acute Grade III ulnar collateral ligament ruptures. A new surgical and rehabilitation protocol.

A review is presented here of 36 cases, seen since 1980, of acute Grade III (unstable) sports-related sprains of the thumb metacarpophalangeal joint. In all cases, the injury involved the ulnar collateral ligament. A Stener lesion was present in 97% of cases. Followup was from 2.0 to 8.5 years, the average being 3.9 years. All of the patients underwent repeat examination and radiography at followup. The first seven patients were treated by "traditional" pull-out suture and K-wire fixation, put into a cast for 4 weeks, and then gradually mobilized over 4 additional weeks. Thereafter, a "new method" was used. Avulsed ulnar collateral ligament stumps were sutured to the tendinous insertion of the adductor pollicis or to a soft tissue remnant using strong suture material. Large bony avulsions were pinned; small fragments were excised and the ligament was repaired. This latter method of repair was quite strong and allowed rapid mobilization: only 2 weeks in a cast, then a hand-mounted thumb spica orthosis was used while therapy progressed. Of the patients treated with the new method, 84% had excellent results and, overall, were able to return to sports sooner than patients treated with the traditional method. Pain, stability, and strength were corrected equally between groups; however, strength was restored more rapidly in the new method group. Range of motion was reduced equally in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia.

A long-term retrospective study of patients with chronic paronychia treated by eponychial marsupialization with or without nail removal is presented. Twenty-eight consecutive fingers with chronic paronychia in twenty-five patients were surgically treated. Symptoms had been present for 28 +/- 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first seven fingers were treated with marsupialization alone. Recurrences developed in two of these. The next sixteen patients with nail irregularities were treated with marsupialization plus nail removal, and there were no recurrences (p less than 0.05). Furthermore, when the two recurrent paronychia were treated with both procedures, one healed completely and the other was markedly improved. All fingers without nail irregularities healed with marsupialization alone. These results confirm that eponychial marsupialization is an effective means of treating chronic paronychia and suggest that nail removal should be done when concurrent nail irregularities are seen.

Treatment of trigger finger by steroid injection.

A retrospective study of 235 patients with 338 primary trigger fingers determined the efficacy and safety of steroid injection. Initial treatment consisted of one to three injections of corticosteroid mixed with local anesthetic. Those fingers that failed injection therapy had conventional release of the first annular pulley. Seventy-seven percent of all fingers showed resolution or improvement; 49% after a single injection, 23% after two injections, and 5% after three injections.

Unilateral osteonecrosis in a patient with bilateral os centrale carpi.

Accessory carpal bones, although uncommon, are usually of no clinical significance. This report describes a patient who had bilateral presence of the accessory bone called the os centrale carpi. The patient was seen with disabling pain in the dominant right wrist and both radiologic and pathologic findings showed osteonecrosis and secondary degenerative arthritis. His left wrist was asymptomatic and the accessory ossicle was normal in appearance. We have not been able to discover any cases in the literature describing the development of unilateral osteonecrosis in a patient with bilateral os centrale capri.

Ligament reconstruction for the painful "prearthritic" thumb carpometacarpal joint.

An extraarticular ligament reconstruction to stabilize the painful, hypermobile trapeziometacarpal (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the thumb metacarpal has been performed in 25 "prearthritic" (Stage I) and 17 minimally involved (Stage II) basal joints. At an average follow-up examination of 5.2 years, 100% of the Stage I patients had achieved good or excellent results, having little or no pain with return of strength and stability. Eighty-two percent of Stage II patients had similar results. Intractable pain was the primary surgical indication. Pain was dramatically relieved in all Stage I cases and in 70% of the Stage II cases. The presence and degree of crepitus correlated closely to the result and was a good prognostic indicator. Direct inspection of both the basal and scaphotrapezial joints is essential to determine whether ligament reconstruction or another surgical procedure is the procedure of choice. The procedure was particularly useful in patients with untreated Bennett's fractures. Follow-up roentgenograms showed no further degeneration, suggesting that the procedure was reliable, reproducible, and durable, and that it might even retard future joint degeneration.

Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment.

An extra-articular ligament reconstruction to stabilize the thumb carpometacarpal (CMC) (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal has been performed on more than 100 patients since 1967. This study reviews the first 50 consecutive reconstructions with an average follow-up of 7 years. Intractable pain was the primary indication for surgery. Each joint was examined both pre and postoperatively and rated as a stage I through stage IV according to the radiographic appearance. Of the patients with zero or minimal articular changes (stages I and II), 95% achieved good or excellent results because of having little or no postoperative pain. Of the patients with moderate to advanced degenerative changes (stages III and IV), 74% achieved good or excellent results. All stage I cases and 82% of stage II cases were free of recognizable degeneration on follow-up radiographs up to 13 years postoperatively. These findings suggest that ligament reconstruction that is now recommended only for stage I or stage II disease will restore stability, reduce pain, and possibly even retard joint degeneration in a large proportion of patients with painful instability of the thumb CMC joint.

Closed reduction and internal fixation of proximal phalangeal fractures.

Displaced fractures of the shaft of the proximal phalanx can lead to marked deformity and disability when poor results are obtained. Despite the attention popular concepts of open reduction and internal fixation have received, a less invasive technique has been our standard approach. A prospective study of closed reduction and percutaneous Kirschner wire fixation in 100 consecutive fractures yielded good or excellent results in 90% of cases when treated within 5 days of injury.

Abnormal cardiovascular regulation in the mitral valve prolapse syndrome.

Studies of patients with mitral valve prolapse syndrome have suggested autonomic nervous system dysfunction, but a precise definition of mechanisms is lacking. We measured supine and standing heart rate, blood pressure, cardiac output, oxygen consumption, plasma catecholamines, and blood volume in 23 symptomatic women with both echocardiographic and phonographic signs of MVP and in 17 normal control subjects. An analysis of the results revealed 2 distinct subgroups of patients: those with normal heart rates but increased vasoconstriction (Group I, n = 10) and those with orthostatic tachycardia (Group II, n = 13). Group II patients had heart rates at rest supine of 97 +/- 3 compared with 79 +/- 2 in Group I patients and 78 +/- 8 in control subjects. Estimated total blood volumes were lowest in Group I patients, intermediate in Group II patients, and highest in control subjects (p less than 0.05). Other measurements at rest supine were similar in patients and controls. After standing for 5 minutes, patients had a higher mean plasma epinephrine value, diastolic blood pressure (81 +/- 2 versus 74 +/- 3 mm Hg, p less than 0.05), and peripheral resistance (1,878 +/- 114 versus 1,414 +/- 92, dynes s cm-5, p less than 0.01), wider arteriovenous oxygen difference (6.7 +/- 0.4 versus 5.3 +/- 0.5 vol%), and lower stroke volume index (26 +/- 2 versus 33 +/- 2 ml/m2, p less than 0.01) than did the control subjects. Cardiac output was normal in Group II patients but reduced in Group I patients, who demonstrated marked vasoconstriction. No patient had evidence of a "hyperkinetic" circulatory state. A cycle of decreased forward stroke volume, vasoconstriction, and blood volume contraction appears to be present in at least some symptomatic patients with MVP.

Effects of long-term clonidine administration on the hemodynamic and neuroendocrine postural responses of patients with dysautonomia.

Patients with mitral valve prolapse syndrome (MVPS), vasoregulatory asthenia, and poor postural adjustment often have orthostatic intolerance characterized by tachycardia and a narrow pulse pressure on standing. Autonomic dysfunction is thought to play an important role. Increased alpha-adrenergic activity has been shown in MVPS patients with orthostatic intolerance. We measured hemodynamic and neuroendocrine responses to long-term oral clonidine therapy in eight women, aged 36 +/- 1.8 years (27 to 44 years). None had responded favorably to beta-blockers. Heart rate, blood pressure, oxygen consumption, cardiac output, and plasma norepinephrine levels were measured in both supine and standing positions, before and after one to four weeks of clonidine (0.3 to 0.4 mg daily). Clonidine reduced standing plasma norepinephrine levels, total peripheral resistance, and diastolic blood pressure; a smaller decrease in cardiac output on standing was noted. Plasma volumes increased 12 percent. Mild reductions in plasma catecholamines and total peripheral resistance are associated with fewer, not more, orthostatic symptoms in this group of patients. "Placebo" or mild sedative effects may explain part of the response to clonidine, but the hemodynamic and neuroendocrine data suggest that decreased alpha-adrenergic hyperactivity may also be important.

Age-related changes in the thickness of the calcified zone and the number of tidemarks in adult human articular cartilage.

The thickness of the calcified zone of the articular cartilage and the number of tidemarks at the junction between articular cartilage and bone has been determined in specimens from 41 femoral heads and 42 humeral heads from cadavers aged between 25 and 93. The thickness of the calcified zone decreased with age but the number of tidemarks increased, particularly over the age of 60. These observations suggest that remodelling of the bone ends occurs and that this process is accelerated with increasing age.

The vascularity and remodelling of subchondrial bone and calcified cartilage in adult human femoral and humeral heads. An age- and stress-related phenomenon.

A quantitative study of the vascularity and a qualitative study of the remodelling of the calcified cartilage and subchondral bone end-plate of adult human femoral and humeral heads were performed with respect to age. In the femoral head the number of vessels per unit area was found to fall 20% from adolescence until the seventh decade and in the humeral head 15% until the sixth decade. Thereafter an increase was noted in the femur but none in the humerus. More vessels were present at all ages in the more loaded areas of the articular surfaces: 25% more for the femur and 15% more for the humerus. The degree of active remodelling by endochondral ossification declined 50% from adolescence until the seventh decade in the femoral head, and 30% until the sixth decade in the humeral head, rising thereafter to levels comparable to those found at young ages. More remodeling was noted in the more loaded areas at all ages.