The effects of streptokinase on ischemic flaps

Prolonged ischemic periods may inhibit success in microsurgical procedures. Impairment of fibrinolytic activity could be a factor contributing to this problem. Ischemic epigastric flaps in the rat were used as a model to measure the potential of streptokinase to improve blood flow and tissue survival. A moderate but statistically significant improvement in flap survival was observed and is felt to be due to the enhancement of fibrinolytic activity previously impaired by ischemia. Saline irrigation alone in control animals was found to be detrimental to flap survival. Streptokinase might prove beneficial when dealing with an ischemic replant or free flap.     

Correction of rheumatoid swan-neck deformity by lateral band mobilization

Fifty-seven digits in 18 hands of 14 patients with rheumatoid disease were retrospectively evaluated after surgical correction of swan-neck deformity. Release of each hyperextension deformity was done via a previously described lateral band mobilization technique with temporary pin fixation of the proximal interphalangeal (PIP) joint and primary skin closure. Extension block splinting was used for 1 month after pin removal. Follow-up averaged 24 months. Twenty-two percent of the patients were enthusiastic about their results, 56% were satisfied, 22% were equivocal, and none were dissatisfied. Maximum active flexion at the PIP joint averaged 55 degrees, and maximum extension averaged--10 degrees. The average distance from fingertip to distal palmar crease was 32 mm. Average grip strength was 10 kg of force in men and 4 kg in women. Step-cut lengthening of the central slip was associated with the development of a boutonniere deformity and an unsatisfactory result in three digits. Even with narrowing of the PIP joint or articular erosions, which were found on 91% of roentgenograms, lateral band mobilization to correct swan-neck deformity can predictably improve the function and cosmesis of rheumatoid hands.     

Simultaneous dislocation of the hamate and pisiform: a case report

A 27-year-old man fell on his flexed wrist and simultaneously sustained a posteriorly dislocated hamate and a laterally dislocated pisiform. The hamate was openly reduced and fixed, and the pisiform was excised. The result was excellent.     

Clinical Experience with Permanent Atrioventricular Sequential Pacing

In a 23-month period, we implanted 26 permanent atrioventricular (AV) sequential pacing units in 11 women and 15 men ranging from 37 to 85 years old (mean, 68 years). Indications for pacing were complete heart block in 12 patients and sick sinus syndrome in 14 patients.Cardiac index, using standard thermodilution techniques, was determined in 9 patients during ventricular pacing and AV sequential pacing at constant heart rate. Atrioventricular sequential pacing was superior in all patients, with a mean increase in cardiac index of 22% (p < 0.01). Complications of AV sequential pacing included the need to revise two pulse generator pockets due to the large size of the pulse generator. One transvenous atrial lead displacement occurred in a patient who had previously undergone right atrial appendage ligation at open-heart operation. No failures of pacing or sensing occurred during 279 patient-paced months.The theoretical hemodynamic advantage of AV sequential pacing has been confirmed in this clinical trial. Experience with electrode placement and improvements in pulse generator design should aid in eliminating complications with this pacing modality.     

A comprehensive report on the experience of patients on continuous ambulatory peritoneal dialysis for the treatment of end-stage renal disease

This article summarizes highlights of data from the National Institutes of Health Continuous Ambulatory Peritoneal Dialysis Registry Report released in early 1984. Follow-up data for 6,656 patients were collected from January 1981 through June 1983 and were analyzed for this report.     

Primary carcinoma of the gallbladder

The clinical records of thirty-three patients treated at the University of Missouri Medical Center for carcinoma of the gallbladder have been studied retrospectively. Eighty-five per cent of these patients were over sixty years of age and all but three were female. The most common symptom was abdominal pain. Gallstones were present in 75.8 per cent. The most common histologic type of tumor encountered was adenocarcinoma, but 12.1 per cent of the tumors were adenoacanthoma. The mean survival time after operation was 2.95 months.On the basis of current information and knowledge, early cholecystectomy in all patients with calculous disease appears to offer the best hope for decreasing the distressingly high mortality associated with carcinoma of the gallbladder.     

Control of vasospasm following trauma and microvascular surgery.

Vasospasm may result in marked reduction of blood flow through injured or revascularized tissues. Neurogenic vasoconstriction is mediated through sympathetic pathways which may be blocked by long-acting local anesthetics resulting in optimal intravascular pressures and elevated flow. An experimental study performed on normal human volunteers has shown that distal sympathetic blockade using Bupivacaine protects the digital circulation against vasospasm elicited by a strong stimulus for a minimum of 7 to 8 hours. A catheter, placed adjacent to the median or ulnar nerve at the wrist level after digital microvascular reconstruction, facilitates continuous Bupivacaine sympathetic blockade. This technique has been used clinically and appears to improve the circulation of replanted or revascularized tissues and protects against vasospasm caused by a variety of stimuli.     

Tissue expansion in reconstructive hand surgery: case report

A 22-year-old musician requested the correction of his digital syndactyly deformity without the use of skin grafts. Failure of the original correction to heal primarily resulted in the formation of dense scar tissue. A small, custom-designed tissue expander was inserted within the web space and was slowly expanded. The additional expanded tissue permitted reconstruction of the web space and the sides of the fingers without the use of skin grafts.     

Traumatic dislocation of the hip with ipsilateral femoral shaft fracture: a method of treatment

Two cases of posterior fracture-dislocation of the hip associated with an ipsilateral femoral shaft fracture are presented with a technique of reduction and stabilization which allows for closed treatment of both injuries. This approach is advantageous in the severely injured patient.     

A cause of painful clicking wrist: a case report

In a patient with symptomatic unilateral clicking of the wrist, a partial tear of the scapholunate ligament with subsequent scarring of the proximal third of the dorsal portion of the ligament had occurred. At operation the dorsomedial edge of the proximal pole of the scaphoid had snapped over the dorsal edge of the lunate as the palmar-flexed wrist was being returned to a neutral position. Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion and no radiographic evidence of widening of the scapholunate space, ligamentous instability, or rotatory subluxation of the scaphoid.     

Spectrum of Pulmonary Sequestration

Bronchopulmonary sequestration was diagnosed in 17 patients ranging in age from newborn to 64 years. The sequestration was intralobar in 14 patients and extralobar in 3. The spectrum of symptoms could be divided into three patterns: no symptoms (6 patients), respiratory problems (8 patients), and cardiovascular problems (3 patients). Cardiovascular problems usually manifest themselves in the first few weeks or months of life and often have a respiratory component. In older patients the sequestration is first manifested by recurrent pulmonary infections or, if it remains uninfected, an asymptomatic density on chest roentgenogram.The definitive diagnostic study is arteriography. Operative treatment for the intralobar variety consists of segmental resection or, if the inflammatory process is more extensive, lobectomy. An extralobar sequestration may simply be excised.     

Effects of tourniquet ischemia and postischemic edema on muscle metabolism.

In vivo interstitial muscle pressures measured by wick catheter, tissue gas tensions measured by mass spectrometer, and glucose and high-energy phosphate metabolism measured fluorometrically were studied in the anterior tibial (AT) and vastus lateralis (VL) muscles of primate limbs during and following tourniquet ischemia (2.5 hours; 400 mm Hg) to elucidate postischemic edema and its metabolic consequences. During ischemia, interstitial pressure in the VL rose, while in the AT it decreased, but 24 hours later pressures in both experimental muscles were significantly greater than those in the controls. In both experimental muscles PO2 decreased significantly within 15 minutes of ischemia. PCO2 increased significantly in the AT at 30 minutes and at 75 minutes in the VL muscle. Twenty-four hours later only PO2 in the experimental AT was significantly different than its matched control. During ischemia glucose and phosphocreatine (CrP) decreased significantly, and G-6-P and lactate increased significantly in both muscles, but at 24 hours glucose levels were 25% lower and G-6-P 16.2% higher in the experimental AT and CrP 34% lower in the experimental VL. This study shows that there are significant acute and delayed alterations in primate muscle metabolism following tourniquet ischemia and suggests that these changes may be related to the anatomic location of the muscle studied and the type of trauma it has sustained.     

Three-dimensional imaging of the wrist

The objective of this study was to determine the diagnostic quality of three-dimensional images of the carpal bones that could be constructed from raw data obtained from a computerized tomography scan. The quality of raw data collected was determined by collimation, slice interval, the number of projections, and x-ray tube operating specifications. The quality of two-dimensional images that were constructed from the raw data was determined by user-specified parameters including zoom or magnification factor, convolution kernels, and centering. The two-dimensional images were modified by erasure, the level of reconstruction, and animation, which permitted isolation of individual carpal bones, the construction of three-dimensional images viewing the external and internal surfaces of the bones, and the rotation of the images to provide multiple views. Representative images are presented.     

Comparison of histologic and functional recovery after peripheral nerve repair.

After repair, nerve stains of skin and subcutaneous tissue biopsies of 23 fingertips contained identifiable axons in all patients. The level of recovery was more advanced in some patients than in others, as manifested by identifiable nerve in various plexuses and receptors. Meissner's corpuscles were observed to be reinnervated in 12 of 17 patients and in 16 of 23 fingertips. The degree and level of reinnervation did not correlate with clinical testing or subjective impression of the result. The authors conclude that sensibility is the result of several factors active in the peripheral and central nervous system. Axonal regrowth is but one of these.