Rejuvenation of the lower third of the face and the neck

One of the marks of the youth of a face is the absence of ptosis of the cheek and the perfect delimitation of the neck with an angle well defined. The objective of this work is to present our surgical technique for the treatment of the lower third of the face and the neck. After a degreasing of the neck and lower part of the cheek, we carry out an extensive cutaneous separation of these areas. The cervical face lift is performed in different layers. A suspension with posterior direction of the platysma is systematic. It is associated or not, according to the importance with the platysma bands, with an anterior approach or with counter side incisions. A reinforcement of the angles is obtained by a fat grafting. One fills the mandibular ligament and one underlines the relief of the chin.     

Transchondral fractures of the dome of the talus

Osteochondritis dissecans of the talus is a well documented entity, defined as a transchondral fracture of the dome of the talus. As a fracture, it should heal with immobilization; however, this lesion often causes severe disability and, more often than not, the fragment will not unite with conservative treatment. There is much debate concerning operative versus nonoperative treatment, and the purpose of this paper is to discuss the salient points of the controversy, review literature on the subject, and present a case with a follow-up of 4.5 years.     

Extra-articular arthrodesis of the carpometacarpal joint of the thumb

There are numerous surgical treatment options for instability and painful trapeziometacarpal arthrosis. The available surgical treatments are arthrodesis and trapeziectomy alone or with synthetic/biologic interpositions, osteotomy, and total joint replacement. However, there is no clear consensus regarding the appropriate surgical procedure, and a unique situation exists in which the surgeon can develop a successful hybrid technique based on his own philosophy and experience. Traditionally, ligament reconstruction and tendon interposition have been used for elderly patients with lower demands whereas arthrodesis has been reserved for the treatment of posttraumatic arthritis in high-demand, younger patients. Regarding the second case, when thumb carpometacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. However, it is important to know the indications and contraindications, as well as benefits and risks of this procedure. Therefore, the surgical technique is straightforward, and fusion may be performed with either a plate-and-screw construct, power staples, tension band wiring with or without Kirschner wires, or alone with multiple Kirschner wires. However, in all the techniques, it is necessary to remove the articular surfaces of the metacarpal and trapezium apart from the need of autogenous bone graft to fill the defect between those bones from either the distal radius or iliac crest. In addition, later in almost all the cases, it is necessary to remove the metal work because of protrusion or skin intolerance. The technique described in this article is a modification of a sliding inlay metacarpal bone graft technique originally described by Müller in 1949 and, 52 years after, perfected by Doyle. However, and as opposed to these, with the extra-articular arthrodesis technique, it is not necessary to remove the articular surfaces, and the graft fixation is performed by 2 Herbert screws which, when buried into the bone, avoid the need to remove the metal work because of the protrusion under the skin. Therefore, this intervention easily permits to convert the arthrodesis to another method of treatment (implant arthroplasty or tendon interposition arthroplasty) by means of the resection of the bone bridge between the metacarpal and trapezium and proceed to the chosen surgical intervention.     

Developments in the treatment of fractures of the coxal end of the femur

The therapeutic concept for proximal femur fractures has changed to varying degrees from 1978 to 1988 in the Department of Traumatology and Reconstructive Surgery at Steglitz Medical Center. In general, conservative therapy has been abandoned. Alloplastic joint replacement is performed in patients with coxarthrosis in the fracture area. A head prosthesis is chosen for those with a life expectancy of less than eight years. Clearly favourable results have been achieved in our department with the Duokopf prosthesis. Patients with a higher life expectancy are submitted to a total hip endoprosthesis, preference being given in cases of collum femoris fractures to the combination of a Spotorno shaft and a Morscher acetabulum. Loading should only be partial for five weeks in patients treated with this cement-free total endoprosthesis. We use the Duokopf prosthesis in the combination of a Spotorno shaft with a Uni-Hip head. We submit these patients to full loading primarily. --We have completely abandoned Ender nailing. We prefer the dynamic hip screw for per- and intertrochanteric femur fractures. For subtrochanteric femur fractures, we use the condyl plate. For lateral collum femoris fractures we have used the four-hole angle plate until 1988. Since 1989 we also use the dynamic hip screw. The one-hole angle plate is used for osteosynthesis in cases of medial collum femoris fractures.     

Entrapment of the long head of the biceps tendon: the hourglass biceps--a cause of pain and locking of the shoulder

We describe an unrecognized mechanical condition affecting the long head of the biceps (LHB) tendon with entrapment of the tendon within the joint and subsequent pain and locking of the shoulder on elevation of the arm. We identified 21 patients with a hypertrophic intraarticular portion of the LHB tendon during open surgery (14 patients) or arthroscopic surgery (7 patients). All cases but one were associated with a rotator cuff rupture. Patients were treated by biceps tenotomy (2 patients) or tenodesis (19 patients) after removal of the hypertrophic intraarticular portion of the tendon and appropriate treatment of concomitant lesions. Minimum follow-up was 1 year. All patients presented with anterior shoulder pain and loss of active and passive elevation averaging 10 degrees to 20 degrees. A dynamic intraoperative test, involving forward elevation with the elbow extended, demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic buckling of the tendon and squeezing of it between the humeral head and the glenoid (hourglass test). The mean Constant score improved from 38 to 76 points at the final follow-up (P <.05). Complete and symmetric elevation was restored in all cases after resection of the intraarticular portion of the LHB tendon. The hourglass biceps is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm; it can be compared with the condition of trigger finger in the hand. A loss of 10 degrees to 20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in the diagnosis. A definitive diagnosis is made at surgery with the hourglass test: incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. The hourglass biceps is responsible for a mechanical block, which is similar to a locked knee with a bucket-handle meniscal tear. Simple tenotomy cannot resolve this mechanical block. Excision of the intraarticular portion of the LHB tendon, during bipolar biceps tenotomy or tenodesis, must be performed. The hourglass biceps is an addition to the familiar pathologies of the LHB (tenosynovitis, prerupture, rupture, and instability) and should be considered in cases of shoulder pain associated with a loss of elevation.     

Free transfer of the radial forearm flap with preservation of the radial artery

One of the main disadvantages of the radial forearm flap is the sacrifice of a major artery. To overcome this drawback the authors describe a technique of free transfer of the flap with preservation of the radial artery. The flap is elevated as a distal row perforator-based fasciocutaneous flap with a very short segment of the radial artery included in the inverted-T-shaped arterial pedicle. The venous outflow of the flap is provided by the cephalic vein, with accompanying veins of the radial artery left behind. Although the donor radial artery is repaired primarily, the flap is transferred to reconstruct a soft-tissue defect resulting from the release of a neck contracture after radiotherapy in a 42-year-old patient who had previous excision of a mandibular osteosarcoma. The arterial anastomosis was performed end to end between the superior thyroid artery and one limb of the arterial pedicle, with the other limb ligated. The venous anastomosis was performed end to end between the cephalic vein and the external jugular vein. The flap survived completely and a satisfactory result was obtained. The radial artery is demonstrated to be patent long after surgery, both with Allen's test and with a Doppler examination. Considering the possible sequelae of the sacrifice of the radial artery, this technique is obviously advantageous to such patients, even with a nonsatisfactory preoperative Allen's test. This perforator-based radial forearm flap is very easy to raise and to transfer, with anastomoses of large-diameter vessels.     

Assessment of the suspected fracture of the scaphoid

A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid. The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture. The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.     

Preservation of the pylorus and resection of the head of the pancreas

The historical evolution of the pylorus-preservation resection of the head of the pancreas is traced from the first resections early in this century to relative standardization of the operation, to a lowering of the operative mortality, and to an interest in improving nutritional status after resection. There are many theoretical advantages for the function of the upper gastrointestinal tract after pylorus and gastric preservation, such as maintenance of gastric capacitance and equilibration of osmotic pressure in gastric digestants, foodstuff digestion and absorption, and bowel motility. After the pylorus-preserving resection, gastric emptying is normal, pyloric function to prevent duodenal reflux is often normal, and gastric acids and serum levels of duodenal hormones are at normal levels, whereas after standard pancreatoduodenectomy, all of these are often abnormal. No prospective blinded studies have been published comparing nutritional values after the two operative procedures, but evidence is presented of a satisfactory result with regard to gastric capacitance, body weight gain, and lack of postgastrectomy symptoms. An undoubted advantage of the pylorus-preserving feature is a simplification of the operation. These gains are achieved without increase in operative mortality, without increase in the incidence of jejunal ulcer, and without theoretical or actual decrease in value of the procedure as a cancer operation, except in patients with duodenal carcinoma proximal to the ampulla of Vater.     

Management of the traumatized joint of the finger

Selection of the reconstructive technique for the traumatized joint requires a careful consideration of the condition of the injured and adjacent joints, the needs and desires of the patient, and an understanding of the advantages and disadvantages of the available options. The MP joint is the key to a useful arc of motion, providing 77 per cent of the total arc of flexion. Every effort should be made to preserve its maximum pain-free movement. PIP joint motion, although important in maintaining grip strength, can more readily be sacrificed to provide stability when MP joint motion is normal. Arthrodesis provides a pain-free stable joint with a sacrifice of motion. It may be indicated in young patients in whom heavy loading is likely; in joints with a fixed, painful deformity, instability, or loss of motor; and in the salvage of failed implant arthroplasty. Arthrodesis is generally contraindicated where physes are open. PIP joint arthrodesis is well tolerated in the index finger with minimal morbidity. Motion of MP joints and PIP joints of the long, ring, and small fingers, however, should be preserved using other techniques when possible. Resection arthroplasty may be useful in selected cases of post-traumatic arthroplasty where other treatment techniques are not available. Soft tissue interposition techniques are useful in specific cases. Eaton volar plate arthroplasty provides good results where 50 per cent of the articular surface is preserved. The technique, however, requires precision to avoid rotational malalignment. Perichondrial resurfacing provides a reasonable alternative in patients younger than 40 years of age who have a relatively well maintained joint contour, preferably involving a single joint surface. Prior infection is a relative contraindication. MP joints generally produce better results than PIP joints. Swanson interposition arthroplasty remains the most widely accepted implant technique, providing improved stability and earlier motion than simple resection arthroplasty. Reported arcs of motion range from a minimum of 29 degrees to a maximum of 85 degrees, with results generally better for MP than for PIP joints. Complications are common and include implant fracture, lateral instability of the PIP joint, and, occasionally, synovitis. Patient satisfaction, however, has been consistently reported as high. The use of Swanson arthroplasty in acute cases remains controversial, although several authors report favorable results. Silicone arthroplasty is contraindicated in joints with open physes. Allograft small joint reconstruction provides replacement bone and articular surface without donor site morbidity. Experience with the technique, however, has been limited. Increasing concern over the transmission of infectious diseases may make this option less desirable.(ABSTRACT TRUNCATED AT 400 WORDS)     

Paralysis of the intrinsic muscles of the hand

Intrinsic muscles of the fingers are the interosseous, lumbricals and hypothenar muscles. Their main action is metacarpophalangeal (MP) flexion and interphalangeal (IP) extension. If extrinsic muscles remain active, intrinsic paralysis results in a claw deformity: MP hyperextension and IP flexion. Bouvier's test is positive if IP extension is actively possible when MP hyperextension is passively prevented. Surgical operations to correct claw deformity are divided into passive and active palliative procedures. Passive palliative procedures are tenodeses and capsuloplasties. Active palliative procedures have either a proximal action (MP flexion only): lasso and direct interosseous activation, or a distal action (MP flexion and IP extension). When Bouvier's maneuver is positive, a simple claw deformity may be treated by a passive procedure and/or an active palliative with proximal action procedure. This last procedure should be preferably indicated on index and middle finger if a few muscular motors are available. When claw deformity is complicated by MP stiffness in extension, a capsulectomy-capsuloplasty is indicated. When Bouvier's test is negative, and passive IP extension is possible, an active palliative with distal action procedure is indicated. Even when there is no claw deformity, intrinsic paralysis may be treated by an active palliative with proximal action procedure, in order to stabilize pinch and grasp. Capsuloplasties, lassos and interosseous activation procedures were all invented by Eduardo Zancolli.     

Staging of Charcot neuroarthropathy along the medial column of the foot in the diabetic patient.

Diabetes mellitus is the leading cause of Charcot neuroarthropathy. The most common location is along the medial column of the foot. Over a 2-year period, the process can result in a severely deformed foot, which is highly prone to ulcers, infection, and subsequent amputation. To help identify the early stages of the disease process, the histories, physical examinations, and radiographs of 40 patients with 51 neuropathic feet were evaluated. We were able to identify five stages of Charcot deformities. Stage 0 is a clinical stage in which the patient presents with a locally swollen, warm, and often painful foot. Radiographs are negative and technetium 99 bone scan is markedly positive. Indium and gallium scans are normal. Stage 1, in addition to the clinical findings, demonstrates periarticular cysts, erosions, localized osteopenia, and sometimes diastases. Stage 2 is marked by joint subluxations, usually starting between the second cuneiform and the base of the second metatarsal and spreading laterally. Stage 3 is identified by joint dislocation and arch collapse. Stage 4 is the healed and stable end result of the process. Clinically, there is no temperature gradient between the two feet. Radiographically, there is bony trabeculation across joint spaces indicative of mature fusion. Treatment of stage 0 consists of limited weightbearing and close observation while the diagnosis becomes clear. Stage 1 is treated with casting followed by a University of California Biomechanics Lab orthosis (UCBL), to maintain the arch while allowing limited weightbearing. In stage 2, a partial weightbearing total contact cast followed by a Charcot restraint orthotic walker (CROW) is used. Surgery may be needed at this stage, while the joints are still reducible. Arthrodesis with rigid fixation is recommended. Stage 3 is treated with casting for the acute phase, then with a patellar-tendon-bearing ankle-foot orthosis, CROW, or caliper orthosis. If ulcers are present, they are treated with weekly local debridement, antibiotics, and total contact casting. Occasionally decompressive ostectomy is required. Stage 4 may need surgical removal of the bony prominences causing the nonhealing ulcers. Extra-depth shoes and pressure-relieving orthoses are also used. Twenty-five percent of our patients diagnosed and treated in the early stages (stages 0, 1 and 2) did not develop deformity. Surgery to prevent deformity is recommended early, before the destructive stage (stage 3). Close follow-up, especially in a noncompliant population is necessary.     

Traumatic pseudo-boutonniere of the metacarpophalangeal joint of the little finger. Case report and review of the literature

Dislocation of the extensor tendon over the metacarpophalangeal joint is common among patients with rheumatoid arthritis. Patients without arthritis are exceptionally involved. The authors describe a new case of traumatic boutonniere-like of the metacarpophalangeal joint of the little finger. This lesion is a rarely, only eleven cases are described in literature. Patients are usually young adults and dislocation is related to a direct axial trauma on their fifth metacarpophalangeal joint. Diagnosis is clinical and relies on an incomplete active extension of the metacarpophalangeal joint, secondary to the dislocation of the extensor apparatus. Diagnosis is often delayed the lesion remaining unnoticed with the occurrence of others hand lesions. Proper treatment is surgery, based on suturing side to side both extensor digiti minimi and common extensor tendon over the fifth metacarpophalangeal joint. Results are excellent, with a complete range of motion and the absence of recurrence.     

The role of the Verebelyi-Ogston procedure in the management of the arthrogrypotic foot

The Verebelyi-Ogston procedure, initially described in the nineteenth century, was recently reported by Stephen Kopits for the treatment of the myelodysplastic foot. The author has used this procedure for the rigid myelodysplastic or arthrogrypotic foot. The operation, consisting of subchondral decancellization of the cuboid and talus, is effective in converting a rigid varus foot into a supple, braceable, plantigrade foot. Based on the author's experience with four arthrogrypotic feet with a minimum follow-up period of 57 months, the procedure is recommended as an alternative to talectomy. Prolonged postoperative orthotic support is necessary to prevent recurrence.     

Solving the problem of the uninsured

Reform of the United States health care system is less complicated than at first might appear. The building blocks of an ideal system are already in place. The federal government already generously subsidizes private health insurance and safety net care. What is wrong with the current system is that there are too many perverse incentives. One could reasonably argue that government is doing more harm than good, and that a laissez faire policy is better than what is now in place. Nonetheless, if government is going to be involved in a major way in the health care system, perverse incentives should be replaced with neutral ones. At a minimum, government policy should be neutral between private insurance and the social safety net, never spending more on free care for the uninsured than it spends to encourage the purchase of private insurance. Careful application of this principle would go a long way toward creating an ideal health care system.     

Mathematical explanation of the buckling of the vessels after twisting of the microanastomosis

BACKGROUND: To obtain free flap success, microvascular anastomosis must be perfectly constructed. External compression, twisting (torsion) of the anastomosis site, tension on the anastomosis site, and kinking of the pedicle must be avoided. Few experimental studies report the patency rates of rat vessels after twisting (torsion) of the microanastomosis: these results recently opened a discussion for the maximal angle of torsion, which can be impressed to a vessel in order to have the best patency rates. MATERIALS AND METHODS: To describe specifically the changing of shape of the vessels after the twisting of the microanastomosis, we extrapolate, to our experimental model (constituted by the femoral vessels of Wistar rats), the mathematical formula that engineers use to calculate the torsion of a beam when a torsion force is applied. The mathematical model used is the shell theory. Then, with a computer program using MATLAB, we could obtain the representation of these shapes at any degree of torsion. RESULTS: If a small load is applied to the vessels, it maintains its straight geometry. However, as soon as the load exceeds a critical value, which is a function of the vessel geometry and its mechanical characteristics, it snaps suddenly to a different equilibrium configuration. This phenomenon is called "buckling." When buckling occurs, wave-like deformations appear on the wall of the vessels. We calculate, in our experimental rat model, the critical twisting angle that induces buckling: maintaining a constant length of dissection of 25 mm, a minimum twisting angle of 360 degrees + 161 degrees, or 105 degrees, is required, respectively, for the femoral artery or vein, to have the buckling phenomenon and the appearance of two waves and decreased section area. CONCLUSIONS: In surgical practice, with the parameters of our experimental Wistar rats model (vessel diameter, length of dissection), it is fundamental to be below 105 degrees of torsion angle for the vein microanastomosis, in order to decrease its risk of failure.     

缺血后处理对保护皮瓣的作用机制研究

目的：缺血后处理已经在心、肾等器官上广泛应用,进行相关研究进一步探究缺血后处理对皮瓣有否保护作用。方法：健康成年新西兰大白兔,分为3组。A组为给予缺血后处理;B组为再灌注前5min给予A2A阻滞剂SCH58261＋缺血后处理。C组,直接应用微血管夹阻断腹壁浅血管持续缺血6h后,恢复正常血供。分别进行中性粒细胞浸润,MPO含量和皮瓣存活率检测。结果：新西兰大白兔完全存活。B、C组相比较,中性粒细胞计数以及MPO含量也未见统计学差别（P〉0.005）。实验组皮瓣存活面积比较,B与C相比较,无统计学意义（P〉0.005）,但是A与B、C相比较,上述指标两两之间都有统计学意义差别（P〈0.005）。结论：缺血后处理对皮瓣再灌注损伤有保护作用,该作用可能和A2A受体性质有关。     

Place of the free flow curve in the urodynamic investigation of children

In a group of 210 children, predictions based on the form of the free flow rate curve, obtained without invasive instrumentation, have been compared with the results of a full urodynamic study. If the free flow curve is normal and there is no residual urine, then significant voiding abnormality, whether of functional or anatomical origin, is unlikely. If the free flow curve is abnormal or there is residual urine, then a full urodynamic investigation is indicated in order to determine the cause. A child with a normal free flow curve is more likely to show detrusor instability than a child with an abnormal free flow.     

Complete duodenum-preserving resection of the head of the pancreas with preservation of the biliary tract

A complete resection of the head of the pancreas, with preservation of the duodenum and biliary tract was performed for 14 patients: 8 with chronic pancreatitis, 3 with mucin-producing cancer of the head of the pancreas, 2 with pancreas divisum, and 1 with cystadenoma of the head of the pancreas. With our technique, duodenal blood flow is maintained, and no pancreatic parenchyma is left on the duodenal side. For these patients, a pancreaticoduodenostomy without resection of the digestive tract was provided; however, for those in whom an anastomosis between the caudal side of the pancreas and the duodenum was too difficult, due to distance, a pancreaticojejunostomy, using a Roux-en-Y jejunal loop, was performed as an alternative method. The digestive tract was reconstructed by a pancreaticoduodenostomy in 8 patients and by a pancreaticojejunostomy in the remaining 6. The operation time for the former procedure was 5h, and for the latter, 5h and 40 min; the mean blood loss in both groups was similar, being 926 and 940 ml, respectively. The successful results in all cases indicate that maintenance of the duodenal blood flow is significantly related to complete resection of the head of the pancreas. Thus, it appears that the use of Kocher's maneuver should be avoided and that the preservation of the posterior superior pancreaticoduodenal artery is important.     

Surgical repair of the bilateral cleft of the primary palate

A technique to repair clefts of the primary palate is described. This technique is a combination of several surgical methods previously reported to which some modifications have been added. The advantages of this technique are compared with those associated with other surgical methods. A more natural result is obtained with this technique: The undesirable vestibular fistula is avoided and a deeper buccal sulcus is achieved. The criteria in the management of the nose and orbicular muscle is analyzed.     

Indications and results of the multi-hole GECO plate in the treatment of talar fractures of the calcaneus

Summary Since 1979, we have fixed certain fractures of the calcaneus with a GECO plate. This is a thin 0.5 mm multi-hole plate. Its value is to provide a support for the screw heads, when the lateral cortex of the calcaneus is fragmented. This is frequently the case, due to sinking of the talus which pushes out the lateral cortex which is broken in several places like an egg shell. The medial cortex on the contrary, more solid, is intact or crossed by a single fracture line. Therefore, while the transverse screws have a good hold in the medial cortex, they do not hold anything laterally, without a wide support, or a plate placed either horizontally, or perpendicular to the talus in the same direction as the trabeculae.The GECO plate fixes the plate's three trabecular beams with screws at the top of a triangle that will keep its shape, avoiding any secondary deformation of the calcaneus.193 talar fractures have been fixed with the GECO plate from May 1979 to December 1994. Out of 102 cases reviewed, after 8 months, we found 18 with normal talar movement, 17 partially diminished, 36 greatly diminished, and 31 completely stiff. Our global functional result is within the average of that of the SOFCOT symposium in 1988. Over half our cases are satisfactory: complaining at the most from pain when walking on uneven ground and of difficulties on tiptoe. 4/10 are fair, with pain after one hour walking and an inability to get on tiptoe, as well as a diminution of physical activity, 6.6% are poor.Communication presented at the S.O.T.EST-Meeting in Paris, June 9,1995