Metacarpal rotational osteotomy

Maximum metacarpal rotation and corresponding phalangeal correction were measured in 80 fingers of 40 cadaver hands. Total metacarpal rotation averaged 50 degrees to 52 degrees in the index, long, and ring fingers and 69 degrees in the small finger. Phalangeal correction averaged 36 degrees to 37 degrees in the index, long, and ring fingers and 50 degrees in the small finger (70% of rotation in the metacarpal). The orientation of the metacarpophalangeal joint was not a significant limiting factor. However, the deep transverse metacarpal ligament did limit maximum rotation at the metacarpal and the phalanx. The advantages of basal metacarpal osteotomy make this technique the procedure of choice for correcting malrotation of up to an average of 18 degrees to 19 degrees for the index, long, and ring fingers. For the small finger, 20 degrees to 30 degrees of correction is possible, depending on the direction of rotation. A table has been devised to predict the correction for individual digits.     

Forearm arterial injuries.

The effects of single forearm arterial injuries with and without associated neurological injuries were studied. Fifty subjects were evaluated: seven patients with isolated arterial lacerations, 15 patients with isolated nerve lacerations, 13 patients with combined nerve and arterial injuries, and 15 control subjects. A series of noninvasive peripheral vascular studies were correlated with the symptoms produced by a controlled cold-environment exposure. The hemodynamic alterations associated with symptoms of hand ischemia, and particularly with cold intolerance, were studied. Unrepaired single arterial injuries caused modest, consistent alterations in hand vascularity, but few signs of ischemia or symptoms of cold intolerance. The remaining intact artery demonstrated a consistent increase in flow velocity. Combined nerve and artery injuries caused the most significant alterations in hand vascularity, and median nerve and associated artery injuries caused the most disabling symptoms. Single arterial lacerations had no effect on the rate or completeness of recovery from associated nerve injuries.     

Effect of Albumin and Mannitol on Organ Blood Flow,Oxygen Delivery,Water Content,and Renal Function during Hypothermic Hemodilution Cardiopulmonary Bypass

The present study was designed to determine if the addition of albumin or mannitol to the priming solution of the pump oxygenator would diminish edema in organs, without diminishing some of the beneficial effects of hemodilution on blood flow and renal function. Tissue blood flow (15 μ spheres), water content, and renal clearances were determined in 8 animals during cardiopulmonary bypass. A 2² factorial, completely fixed experimental design was used. All animals were placed on cardiopulmonary bypass with hemodilution (hematocrit 25 ± 2%) and hypothermia (25° ± 1°C).Albumin decreased flow to the midmyocardium of the left ventricle and to the spleen, and increased flow to the inner cortex of the kidney. Albumin caused decreased urine flow and decreased urine sodium, and also diminished renal osmolar, sodium, and free-water clearances. Both mannitol and albumin decreased lung water. Mannitol decreased water content of the outer renal cortex, and decreased flow to the inner cortex and medulla of the kidney and to the spleen. Mannitol had no significant effect on urine flow, renal plasma flow, or renal clearances. Neither albumin nor mannitol had any effect on water content of the intestine, stomach, liver, or myocardium where the greatest accumulation of water occurs with hemodilution. The effect of albumin on renal function is potentially deleterious during cardiopulmonary bypass because it decreases urine flow, and osmolar and free-water clearance.     

Injury to the brachial plexus as a result of diagnostic arteriography

Six cases of brachial plexus injury within the brachial sheath are reported following axillary-brachial arteriography. Direct compression resulted from leakage of arterial blood into the space formed by the fascial sheath. In one, hemorrhage occurred several days after arteriotomy. Early decompression and arteriorrhaphy resulted in restoration of normal function. Permanent nerve damage resulted when surgical decompression was delayed.     

Blood Conservation Techniques

Increasing numbers of operations requiring cardiopulmonary bypass have been accompanied by greater demands for blood resources. Improved techniques of blood conservation have diminished the average blood requirements per operation and have increased the percent of operations that can be done without homologous blood. The conservation of blood can be planned according to each patient's requirements. The techniques include preoperative blood donation, intraoperative withdrawal of blood, reinfusion of oxygenator blood, autotransfusion of blood after heparin neutralization, autotransfusion after wound closure, and hemodilution. The availability of techniques for filtration, centrifugation, and washing of blood have improved the safety of autotransfusion. The techniques that give the best cost/benefit ratio appear to be preoperative withdrawal of blood, reinfusion of centrifuged oxygenator contents, and reinfusion of filtered blood from chest drainage.     

Management of the patient with emphysema,coronary artery disease,and lung cancer

Coronary artery disease, emphysema, and lung cancer often occur together and have cigarette smoking as a common etiologic contributor. The management of the patient with lung cancer, coronary artery disease, and emphysema is complex. The patient with significant coronary artery disease should undergo coronary artery bypass before or concurrently with pulmonary resection. Only proven carcinomas should be resected at the time of coronary artery bypass grafting because immunosuppression secondary to cardiopulmonary bypass can result in the life-threatening spread of fungal or other infections if biopsy is performed at the time of cardiopulmonary bypass. The risk of pulmonary resection is increased in the patient with emphysema because of decreased efficiency of the lungs and chest wall. Likewise, emphysema results in greater risk in the patient with coronary artery disease because of increased demands on the heart.