Closed rupture of the flexor tendons of the little finger secondary to non-union of fractures of the hook of the hamate.

We report six patients with closed flexor tendon rupture affecting the little finger, occurring secondarily to non-union of the hook of the hamate bone. The ununited fragments were separated from the basal part of the hook by more than 1mm. The fragments were also rounded and showed marginal sclerosis. Non-union was located in the middle part of the hook in three patients, the tip in two, and the base in one. At operation, the fragments were removed in all patients. Five patients were treated by free tendon grafts using three palmaris and two plantaris grafts and one underwent tendon transfer. Postoperative total range of active motion of the little finger averaged 218 degrees (range 185-265 degrees ). All patients returned to their original employment. This series would suggest that flexor tendon rupture can occur after fracture of the hook of the hamate bone, even when the ununited fragment is small and/or rounded.

Clinicopathological characterization of cardiac free wall rupture in patients with acute myocardial infarction: difference between early and late phase rupture.

Differences in morphological characteristics have been described in early phase and late phase post-infarction cardiac rupture. In this study, the clinicopathological characteristics of early and late phase rupture have been clarified by reviewing the clinical records of 1450 consecutive patients with acute myocardial infarction (AMI). Rupture of the left ventricular free wall (blow-out type) developed in 27 of the 1450 patients, and these patients were divided into two groups on the basis of the rupture time: early phase (< 72 h) and late phase (> 4 days). Only one patient had a history of prior infarction. Early phase rupture was characterized by an abrupt slit-like tear in the infarcted myocardium, a preference for anterior infarction sites, no prior myocardial infarction, and no difference in incidence in conventional and reperfusion therapy, while late phase rupture was characterized by the presence of infarct expansion, no preferential infarct site and a very low incidence in patients with successful reperfusion. Hence, early and late phase cardiac rupture differ in their pathogenesis, and thus the approach to the prevention and prediction of early and late phase cardiac rupture should be different.

Telescoping and glue technique in vein grafts for arterial defects.

Fibrin glue was applied at the anastomotic site of the vein graft that was placed in rat femoral artery defects by the telescoping anastomotic technique at both proximal and distal anastomoses. All 35 vein grafts thus placed were patent, yielding a statistically higher patency rate than those placed in the same femoral artery by the same telescoping anastomotic technique but without fibrin glue. The telescoping anastomotic technique assisted by fibrin glue appears to give as reliable a patency rate as the conventional method even if it is used twice, both at the proximal and distal anastomoses, in autogenous vein grafting for arterial defects. Deformities of the inserted vessel should be minimized for patency by some means such as an application of fibrin glue so that the inserted vessel does not bulge under high arterial pressure.

Assessment of fracture healing in the tibia using the impulse response method.

The resonant frequency of a long bone as measured using the impulse response method (IRM) can reflect the bending rigidity of the bone. A study was performed using IRM to quantitatively assess fracture healing in 67 tibial fractures. A temporary decrease in resonant frequency early in the treatment course was found in 55.6% of tibias, most frequently in the cases treated by external fixation (83.3%) and the AO plate (80%). The resonant frequency also decreased temporarily following the removal of the fixation devices in 76% of the tibias where they were removed. The resonant frequency of the fractured tibia at the final follow-up exceeded that of the contralateral side in 18% of tibias, approached within 20 Hz in 11.5%, and did not reach within 20 Hz in 70.5%. A questionnaire on the effectiveness of the IRM examination in the treatment of the tibia fractures was completed by the treating orthopaedic surgeons. The IRM examinations were found to be very useful in 58.2% of cases, useful in 31.3%, and useless in 10.4%. Thus, IRM examinations are most helpful when they are able to detect the change in bending rigidity early in the treatment of tibia fractures.

The vibrational mode of the tibia and assessment of bone union in experimental fracture healing using the impulse response method.

This study attempts to clarify the use of the impulse response method in the assessment of fracture healing. The vibrational mode as well as the effect of simulated callus consolidation on the vibrational parameters of excised human tibia were studied. Two separate vibrations were found, one vibrating strongly in the lateral direction and the other vibrating weakly in the antero-posterior direction. The ability to identify the primary vibrational mode in the lateral direction would make the impulse response method suitable for use in clinical practice. The callus consolidation process was simulated by the sequential consolidation of an adhesive material in an experimentally produced fracture gap. The change in hardness of the epoxy was found to correlate well with the change of resonant frequency of the bone. The resonant frequency demonstrated a steady increase during the initial phase of consolidation of the adhesive, up to about 40% of its final hardness. With the addition of various constructs for fracture fixation to the in vitro model such as a plate, Ender's pins, a Russell-Taylor intramedullary nail, or an Orthofix external fixator, the relationship between the consolidation of the 'callus' and the change in resonant frequency of the bone was not disturbed.

Long-term results of vein grafts interposed in arterial defects using the telescoping anastomotic technique and fibrin glue.

Fibrin glue has been applied in the anastomosis of vein grafts placed in rat femoral arteries using the telescoping technique at both ends of the graft. 34 out of 35 grafts which were patent 1 to 3 weeks post-operatively were kept for 3 months to assess the long-term patency, and the effect of the glue on the diameters of the graft and femoral artery. All 34 grafts were patent 3 months post-operatively. Excessive enlargement of the graft diameter was alleviated by the fibrin glue without affecting the diameter of the femoral artery. The diameter at the proximal anastomosis was 66% and that at the distal anastomosis was 87% of the diameter of the femoral artery.

Anatomical and radiological evaluation of the triangular fibrocartilage complex of the wrist.

109 wrists from 69 cadavers (mean age 74 years) have been studied to clarify the pathology and morphology of the triangular fibrocartilage complex (TFCC) and to correlate pathological and radiological findings. Perforation of the TFCC was observed in 65% of the specimens and was considered to be secondary to a degenerative process, because it was often accompanied by degenerative changes in the ulnar carpal bones and perforation of the lunotriquetral ligament. To detect TFCC perforations on plain postero-anterior radiographs, it is important to evaluate ulnar plus variance and degenerative changes in the ulnar carpus. Existence of ulnar plus variance alone is more sensitive but less specific in detection of TFCC perforation than the existence of degenerative changes in the ulnar carpus.

Arterial grafting with the telescoping anastomotic technique for arterial defects.

An arterial graft was taken from the left femoral artery of the rat and grafted into the right femoral artery using the telescoping anastomotic technique at both the proximal and distal anastomoses to compare the patency rate with that of the vein grafts interposed into the arterial defect with the same telescoping technique. The time required for each anastomosis was about 10 minutes and all of the 31 grafts remained patent without application of xylocaine, yielding a higher patency rate than the vein grafts interposed in an arterial defect. The telescoping technique proved to be so dependable that it could be used at least twice in an artery. Inserting one vessel stump into another using the telescoping technique may not itself be responsible for the failure of vein grafts interposed in an arterial defect, but distortion of the slack venous wall of the graft by high arterial blood pressure is.

Vein grafting with the telescoping anastomotic technique for venous defects.

The telescoping anastomotic technique was used at both ends of autogenous vein grafts bridging a defect in slow-running, vulnerable veins. This was done on left epigastric veins of the rat, the central part of which was used as a graft. In the right epigastric veins, both the proximal and distal anastomoses were repaired using the conventional anastomotic technique. The overall patency rate of the grafts repaired with the telescoping anastomotic technique was 27/29 (93.3%) compared to 17/28 (60.7%) in the conventional group. The telescoping technique was also easier to perform than the conventional method.

Osteoid osteoma of the terminal phalanx.

The occurrence of osteoid osteoma in the hand is rare, and the rarest of all locations is the terminal phalanx. An osteoid osteoma of the terminal phalanx of the middle finger in a twenty-four-year old woman is described. This case illustrated the very typical clinical and x-ray features of an osteoid osteoma, which made diagnosis and treatment of this rare clinical entity straightforward. On pathological examination, a bundle of nerve fibres was found in the lesion, an explanation that the pain of this tumour may have been mediated by the nervous system via the nerve fibre.

Granular cell tumour of the ulnar nerve.

Although granular cell tumours have been demonstrated to have a neural origin, they rarely arise in peripheral nerve trunks. We report a case of granular cell tumour of the ulnar nerve in a 51-year-old man. Though dissectable from the nerve, this intraneural tumour showed microscopic involvement of focal nerve fibres. This tumour tended to infiltrate the nerve in the same manner as a neurofibroma.

Conservative treatment of thoracic outlet syndrome using an orthosis.

We describe a strapping device for elevation of the shoulder in patients with thoracic outlet syndrome (TOS). The device was used by 86 patients with TOS whose symptoms had been alleviated by passively raising the shoulder. Symptoms of TOS were classified as proximal, including pain in the shoulder girdle, and distal, in which there were neurological deficits related to the brachial plexus. The device was more effective in patients with distal symptoms: pain disappeared or improved in 67% of patients; numbness in 85%; sensory disturbance in 84%; and motor disturbance in 80%. However, proximal symptoms were relieved in only 65% of the patients. The ability to perform activities of daily living was rated as excellent in 33% of patients, good in 44%, fair in 12%, and poor in 9%. The shoulder orthosis described in this report can counterbalance downward traction on the brachial plexus and reduce the tension on it, thereby relieving symptoms of TOS.

The influence of joints and soft tissue on the natural frequency of the human tibia using the impulse response method.

The influences of the joints adjacent to the human tibia, the surrounding soft tissue and the fibula on the vibrational parameters of the tibia (that is natural frequency, mode shape and damping ratio) are in need of clarification. Using five cadaveric human legs, the resonant frequency and damping ratio were measured with an accelerometer placed on the medial tibial condyle while the medial malleolus was impacted by an impulse hammer. The legs were subsequently dissected and the measurements were made in six conditions. The mode shape was obtained by use of modal analysis. Hammer impacts were given at 15 points along the three surfaces of the tibia, while an accelerometer was attached to the surface of the medial malleolus. Resonant frequencies ranged from 275 to 405 Hz in the intact specimens and successively increased with removal of the skin, muscles and foot, and then decreased with the removal of the femur and the fibula. Damping ratios successively decreased. The transitional pattern of natural frequencies was similar to that of the resonant frequencies. The mode shape represented the first bending mode and it corresponded to the condition of the tibia in which the proximal and distal ends of the bone were free.

[Estimation of myocardial viability in left ventricular regions with akinetic wall motion by postextrasystolic potentiation using list-mode radionuclide ventriculography in an interesting case with silent ischemia and with premature ventricular complexes (quadrigeminy)].

For determining an indication of percutaneous transluminal angioplasty (PTCA), a 73-year-old-man with silent ischemia and with ventricular premature complexes (quadrigeminy) were performed cardiac nuclear studies. This case had 99% stenosis in LCX (#11) and 90% stenosis in RCA (#1), and demonstrated akinetic wall motion in left ventricular (LV) inferior and posterior regions. Exercise-redistribution Tl-201 studies indicated myocardial viability in a portion of the inferior wall but not in the posterior wall. To estimate the potential contractile function in the regions with akinesis, from the list-mode data of radionuclide ventriculography, those of postsinus beats and postextrasystolic beats were separately selected and were analyzed for investigating LV wall motion and LV ejection fraction (EF). With the post-extrasystolic potentiation, LVEF increased from 36% to 45% and the systolic wall motion was augmented in the inferior wall but not in the posterior wall. From these findings we recognized the existence of myocardial viability in a portion of the inferior wall. After PTCA for the RCA lesion, improvements of the myocardial Tl-201 distribution and LV wall motion in the inferior wall were definitely observed and hence LVEF increased by 16% to contribute to an increase in exercise performance. Thus, this case indicates that the postextrasystolic potentiation is useful for determining an indication of PTCA in patients with LV asynergy, demonstrating the myocardial viability and the potential LV function.

Closed rupture of the flexor tendons caused by carpal bone and joint disorders.

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).

Introduction of loop sutures in microsurgical telescoping anastomosis.

We have designed a loop suture technique for use in microsurgical telescoping (sleeve) anastomosis to prevent problems from the free floating inserted vessel stump. The patency rate of rat femoral arteries repaired with this technique was 95% and that of interpositional vein grafts, in which both the proximal and distal anastomoses were completed with the same sleeve technique, was 81.0%.

Osteoporosis of the proximal humerus: Comparison of bone-mineral density and mechanical strength with the proximal femur.

The hypothesis that the proximal humerus is more osteoporotic than the proximal femur has been examined by the indention test and bone-mineral density measurement on dissected proximal humeri and femora. The bone section at the base of the humeral head had about 65% of the bone-mineral density of the base of the femoral head. The energy required for 50% strain in the indention test on the humeral bone section was about 50% of that on the femoral head. The fact that the cancellous bone in the humeral head is more osteoporotic than in the femur may complicate surgical treatment of displaced humeral neck fractures.

Total scapulectomy for metastatic pheochromocytoma of the scapula. Case report.

A case of metastatic pheochromocytoma of the reconstruction of the shoulder joint is reported. During the operation elevation of the blood pressure was controlled by venous injection of alpha-blocker and ligation of the three main feeder arteries and veins.

Contact area of the trapeziometacarpal joint.

Eighteen cadaver hands were studied to determine the contact area of the trapeziometacarpal joint by using silicone rubber casts. Casting material was introduced into the trapeziometacarpal joint during several motions of the thumb and the contact location was observed. The ratios of the contact area to the total joint area were calculated. The contact locations in opposition were the radial, volar, and ulnar segments of the trapezium and the dorsal, radial, and volar segments of the metacarpal. On average, 53% of the trapezium was in contact with 53% of the metacarpal in opposition, while 28% of the trapezium was in contact with 28% of the metacarpal in palmar abduction and 25% of the trapezium was in contact with 25% of the metacarpal in radial abduction. The contact area was the largest in opposition. The trapeziometacarpal joint is stable in opposition and facilitates a strong pinch.