Treatment of painful neuromas of sensory nerves in the hand: a comparison of traditional and newer methods.

The results of treatment of 348 painful neuromas of sensory nerves of the hand in 172 patients were evaluated. Three hundred and sixteen were treated by simple excisional neurectomy and these results may be used for comparison with other methods. Sixty-five percent had an excellent or satisfactory result from a single such procedure. A repeated neurectomy improved the results to 78 percent. The use of silicone rubber caps as a secondary procedure over the nerve stump in 32 cases did not improve the results. A technique of funicular resection with epineurial ligation in 45 patients with neuromas achieved about the same percentage of good results as did simple excisional neurectomy. The ideal treatment is not at hand yet, but at the present time it is recommended that treatment should consist of excisional neurectomy, repeated at least one if necessary.     

A further look at the gastric tube as an esophageal replacement in infants and children

Gastric tubes were constructed for infants with pure esophageal atresia as well as for “impossible” or “failed” repairs of esophageal atresia, and for children with esophageal stricture as well. More than two-thirds of the patients had the gastric tube operation before 2 yr of age (esophageal atresia). The children with esophageal strictures had the operation usually between 2 and 10 yr. The two-stage retrosternal reversed gastric tube was used most frequently. The isoperistaltic tube is an excellent alternate method should a reversed gastric tube be impossible to construct. If the gastric tube is short and used as an esophageal interposition in a patient with peptic esophagitis, there is a good possibility of developing esophagitis above the esophagogastric tube anastomosis. The most common complications that arise are related to the esophagogastric tube anastomosis (leak and stricture). We have found no correlation between the operative technique, the postoperative management as it concerns esophageal suction, and the eventual early or late anastomotic leak. Nor were these factors related to the time of eventual closure of the leak, the presence and severity of any subsequent stricture, and the results of its dilatation. The longest follow-up is $\text{7}\text{1}\text{2}$ yr. Once the esophagogastric tube anastomosis has been healed and asymptomatic for 1 yr, the child is well on the way to a life of normal swallowing.     

Primary chemotherapy in the treatment of children with bladder--prostate tumors in the Intergroup Rhabdomyosarcoma Study (IRS-II)

Twenty-nine children (24, male; 5, female) with non-disseminated rhabdomyosarcomas of the bladder or prostate were treated (1978-1980) by a primary chemotherapy regimen consisting of vincristine, actinomycin D, and cyclophosphamide ("Pulse" VAC), with or without local radiotherapy. During the initial 20 wk of chemotherapy, nine children achieved a Clinical Complete Response (CCR). Three of these are without evidence of disease (NED) and have functional bladders, two following partial cystectomy. Four who achieved a CCR subsequently relapsed or remained biopsy positive, but are at present NED following radiotherapy and anterior exenteration. Two patients who achieved CCR status relapsed and have died of disease. Twelve patients had a Clinical Partial Response (CPR) in less than 20 wk and two others in less than 40 wk. Seven of these are NED with intact bladders following chemotherapy-radiotherapy; and an additional patient is NED following partial cystectomy. Four patients in the CPR group have been treated by exenteration following failure to achieve complete response, and are NED. One patient has died, and one has progressive disease. Six patients had an inadequate response to chemotherapy (NR). Anterior exenteration was carried out in three, and two of these have survived. The overall results in these 29 patients are: (A) alive and disease-free with functional bladders, 11; (B) alive and disease-free following anterior exenteration, 10; and (C) dead or death from tumor anticipated, 8. The function of retained bladders (11) has been satisfactory.     

Malignant fibrous histiocytoma of the forearm: report of a case and review of the literature.

The tissue histiocyte can give rise to a variety of lesions, either benign or malignant, and the latter often is confused with other sarcomas. The multipotential nature of the histiocyte results in the presence of at least five different cell types in these tumors, and all may be derived from a common precursor cell. The anaplasia of elements which differentiate as fibroblasts appears to correlate with survival. The tumors may be highly malignant, and the 10 year survival rate approximates 40%. Aggressive surgical management of these tumors is mandatory, with either wide en bloc resection or primary amputation of the involved extremity. Should the tumor recur locally after a wide resection and there be no detectable metastases, prompt amputation is indicated.     

Irreducible dorsal dislocations of the proximal interphalangeal joint

Dorsal dislocations of the proximal interphalangeal joint are common injuries, and reduction is usually obtained by manipulation. We describe four cases of dorsal dislocation in which attempts at reduction by manipulation were not successful. Three of these injuries were open and one was closed. At surgery, the main block to reduction in all cases was the palmar plate that had ruptured from its proximal attachment and was interposed between the joint surfaces.     

Bilateral extraosseous chondromas of the hand in a patient with chronic renal failure

Extraosseous cartilage tumors of the hand are rare. Histologically they can be distinguished from chondrosarcomas. We report a patient with bilateral extraosseous chondromas of the hand with rapid appearance and growth of this unusual tumor during chronic renal failure. The clinical and histological characteristics of these benign tumors are reviewed, and the possible role of the patient's depressed cellular immunity in the appearance of these chondromas is discussed.     

An evaluation of the results of primary internal fixation in the treatment of open fractures

An analytical study of 91 open fractures treated during the period 1967–1973 has been presented. Fifty-three were treated conservatively, whereas 38 were managed by primary internal fixation.There were 12 cases of deep infection in the conservatively treated group (22.6 per cent), of which 4 had persistent infection in spite of adequate treatment. In contrast to this, the group treated by primary internal fixation showed 5 cases of deep infection (13.1 per cent). All of these healed after the implants were removed, following union of the fractures. Minor sequestrectomy was performed simultaneously in 3 of them.Analysis of the results showed poor results after 22.6 per cent of fractures with conservative treatment in contrast to 5.2 per cent in the group managed by primary internal fixation.It is felt that judicious application of primary internal fixation in injuries associated with severe soft-tissue damage or multiple fractures is of definite advantage to the patient.     

Von Frey's method of measuring pressure sensibility in the hand: an engineering analysis of the Weinstein-Semmes pressure aesthesiometer

The development of microsurgical techniques has generated a resurgence of interest in estimating local pressure sensibility as a measure of sensory improvement. Because our experience with Weinstein's modification of Von Frey's probes yielded variable and poorly understood results, we measured two sets of probes and examined them in the light of the engineering principles on which their behavior is based. The mechanical behavior of the nylon monofilaments can be described as buckling with one end built in and the other end pinned. The probes are relatively uniform and consistent. However, no loss in sensitivity would accompany division of the set into two or three equivalent sets. Variations in the buckling stress as high as a factor of eight are difficult to avoid. Gross errors arise from careless application, variations in the elastic modulus due to changes in temperature and humidity, and variations in the attachment of fibers to handles and differences in the ends of the filaments. Interpreting results for this instrument requires an understanding of the factors which can influence those results. The rpobes are simple to use but easy to misinterpret.     

Improved intravenous regional anesthesia for surgery of the hand, wrist, and forearm. The second wrap technique

In 330 consecutive anesthetics administered over a period of 24 months, an improved method of upper extremity intravenous regional anesthesia, entitled "the second wrap technique," included wrapping the extremity a second time with a Martin rubber bandage after the extremity was prepared and draped. In addition, a Penrose drain tourniquet often was applied during injection of the 0.5% lidocaine. No complications occurred. The technique provides a nearly bloodless operative field, improves the anesthesia, diminishes tourniquet pain, lessens the contraindications, and requires no premedication. The only contraindications are allergy to lidocaine, infection, operating time over 2 hours, and severe hypertension.     

Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders

Traumatic subluxation and dislocation of the extensor digitorum tendons are uncommon in patients without rheumatoid disorders. Management of the acute injury is not well defined in the orthopedic literature. Two cases of traumatic dislocations of the extensor digitorum tendon were seen acutely in young persons without rheumatoid disease. These patients were successfully managed by early closed reduction and immobilization. This treatment had yielded good hand function to date, without recurrence of the dislocation. One of these cases was particularly unusual in that the direction of the tendon dislocation was radial. This particular injury has not been previously described.     

Suppression of cellular immunity by anesthesia and operation

The effect on in vivo cellular immunity of anesthesia and operation was evaluated in 250 cancer patients who received sensitizing doses of dinitrochlorobenzene (DNCB). The primary immune response to DNCB of 218 patients who completed the 2-week sensitization period prior to operation was compared with that of 32 patients who had interruption of the sensitization period by general anesthesia or operation. The extent and histologic types of malignances were similar in the two groups; however, 53% of patients who had interruption of sensitization by anesthesia or operation were anergic to DNCB, while only 9% of patients with an uninterrupted sensitization period were anergic (P < 0.001). Similarly, in patients who responded to DNCB, there was an increased incidence of impaired responses in the group who had interruption of the sensitization period. These findings extend previous demonstrations of an immunosuppressive effect of anesthesia and operation as assayed by in vitro correlates of cellular immunity and in vivo response to recall antigens.The results indicate that correlations between primary immune responses to DNCB of tumor-bearing patients and prognosis after treatment may be invalid if the sensitization period is interrupted by anesthesia or operation. Because of the possible facilitation of the dissemination, implantation, and propagation of tumor cells during a period of suppressed cellular immunity related to anesthesia and operation, these results suggest the need for investigating the desirability and means of maintaining and even augmenting cellular immune competence in cancer patients during anesthesia and operation.     

Management of post-traumatic instability of the wrist secondary to ligament rupture

A retrospective review of 55 patients with post-traumatic radioscapholunate ligament disruption suggests that rupture of this ligament can be treated successfully if certain guidelines are followed. If the rupture is seen within 4 weeks, an anatomic reduction maintained in plaster for 8 weeks leads to good results. Ligament ruptures that cannot be held in reduction or that are diagnosed after 4 weeks do poorly with immobilization only. Results after ligament reconstruction have ranged from good to fair but appear to have been sufficiently successful to warrant continued trial rather than resort to arthrodesis, proximal row carpectomy, or similar reconstructive procedures. Patients with degenerative joint disease associated with radioscapholunate rupture are not candidates for ligament reconstruction. Radial styloidectomy or some variety of wrist arthrodesis or wrist arthoplasty should be considered in these instances.     

Studies in the pathogenesis, diagnosis, and treatment of Candida sepsis in children

The pathogenesis of Candida sepsis was investigated by animal studies in the laboratory and by correlation of experimental data obtained with a 10-yr clinical experience in the management of 29 children with yeast septicemia.The intestinal tract of the primate was found to be much more susceptible to fungal invasion than was a bacteria-free granulating wound in the dog. Prophylaxis against Candida sepsis by oral nystatin in 100 randomized burned children gave results that agreed with these findings.Difficulties in confirming the clinical diagnosis of Candida septicemia are probably due to tissue filtration of yeast from the circulation, thereby making venous blood samples of little value until late in the patient's course. Arterial or right atrial blood has now been demonstrated to provide a more reliable specimen.For treatment to be successful, the source of Candida invasion must be eliminated as soon as possible. Mere parenteral antifungal drugs alone are of little benefit, while continuation of systemic antibiotics almost assures a fatal outcome.     

"Tie-in" trapezium prosthesis: Long-term results.

Seventeen of 20 thumbs treated with a silicone-Dacron trapezium replacement arthroplasty for disabling rheumatoid and osteoarthritis at the base of the thumb were reviewed. Patients were uniformly satisfied with the results. Relief of pain was achieved in all but three patients. The latter required excision for tissue reaction to the implant. (Histological findings are reported in these cases.) Motion and stability were satisfactory but not normal. Postoperative subluxation occurred in six cases. Wear and bone erosion were present in two cases after operation.     

Sacrifice of the unsatisfactory hand.

A hand which compares unfavorably with a prosthesis in function, comfort, and appearance may be better amputated. This decision must be made conjointly by the surgeon and the patient. Contributory factors are severe tissue loss, pain, appearance, infection, functional requirements, sexual reasons, psychological makeup of the patient, economics, safety, the time elapsed since injury, the patient's body image and his desires, and the surgeon's opinion. Fifteen patients elected hand amputation for various combinations of these factors. Eleven were fitted with a prosthesis at the time of operation and three within 3 weeks. All patients expressed satisfaction with their decision and 12 were successful users of the prosthesis.     

The use of three-phase radionuclide bone scanning in the diagnosis of reflex sympathetic dystrophy

One hundred forty-five consecutive three-phase radionuclide bone scans were reviewed. One hundred two of these were performed to evaluate pain in the hand. Of these, 23 patients clinically had reflex sympathetic dystrophy (RSD). The hand scans were performed by the three-phase technique. Phase I is a radionuclide angiogram. Phase II is the blood pool or tissue phase. Phase III consists of delayed images obtained 3 to 4 hours after radionuclide injection. Detailed analysis of the 145 three-phase radionuclide bone scans of the hand demonstrated that the diffuse increased tracer uptake in the delayed image (phase III) is diagnostic for RSD, with a sensitivity of 96% and a specificity of 98%. The two early phases (radionuclide angiogram and blood pool) were positive in only 45% and 52% of the RSD patients, respectively. The strictly interpreted delayed radionuclide image is extremely sensitive in the diagnosis of RSD and will facilitate the early diagnosis and subsequent treatment of this syndrome.     

Evaluation of functional sensation in the hand

The ability to predict hand function based upon the degree of sensory impairment is required in determining disability rating, evaluating patients for reconstructive surgery, measuring end results of nerve repairs, and following peripheral neuropathies. The present study evaluated the ability of four tests of sensibility to predict hand function. It was found that the moving two-point discrimination test best correlated with the patient's ability to identify objects with the fingertips, p less than 0.001. The time required for object recognition correlated best with the static two-point discrimination test, p less than 0.001. This study also suggests that the most precise prediction of functional sensation in the hand requires the combined use of both these tests.     

Scanning Electron Microscopic Observations on the Epithelium of the Human Prostatic Urethra

The human prostatic urethra has been investigated by means of scanning electron microscopy. On the posterior wall of the urethra, the seminal colliculus with the orifices of the ejaculatory ducts is clearly detectable. The upper portion of the prostatic urethra shows a typical transitional epithelium with large superficial cells of a ruffled appearance. In the lower portion of the organ (underneath the openings of the ejaculatory ducts), the apical pattern of the cells varies considerably. Four main aspects are recognizable: apices provided with microvilli, dome-shaped apices with an almost smooth surface, large apices with labyrinthic microplicae and ciliated apices. Also, apices showing intermediate characteristics can be noted. The functional significance of the morphological patterns as well as the possibility of a transition among the various types of surface structures are discussed.     

An evaluation of the two-stage flexor tendon reconstruction technique

The performance of 43 two-stage flexor tendon reconstructions in 39 patients was reviewed. Results were graded by comparing the preoperative passive motion of the proximal and distal interphalangeal joints after stage one to the active motion of these same joints after stage two. The procedures returned 16% excellent, 23% good, 26% fair, and 35% poor results with three graft ruptures. Following the tenolysis of 20 grafts (47%) the results for the entire group were improved to 27% excellent, 28% good, 30% fair, and 16% poor. Stage reconstruction, including tenolysis, was felt to be the best available method for restoration of digital function following flexor tendon loss in the badly scarred digit.     

Fracture-dislocations of the elbow.

This paper presents a series of 105 cases of fracture-dislocation of the elbow joint. All these fractures differ in mechanism, age of patient and method of treatment, so problems arise in classification. Causes can be grouped together more easily than in principles of treatment. The cases are classified into 2 major groups and 10 subgroups. Single fracture types are analysed and the optimal type of treatment is studied. As with all joint fractures, adequate reconstruction is obilgatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, where excision is indicated. The different fracture types and their relevant operations are illustrated with examples.