Andrew J. Weiland

Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods.

To define the role of two-portal endoscopic carpal-tunnel release as a method for the treatment of compression of the median nerve at the wrist, a prospective, randomized, multicenter study was performed on 169 hands in 145 patients. Either open or endoscopic carpal-tunnel release was performed in all of the patients who had clinical signs and symptoms consistent with carpal tunnel syndrome, had not responded to or had refused non-operative management, and had had electrodiagnostic studies consistent with carpal tunnel syndrome. Follow-up evaluations were performed at twenty-one, forty-two, and eighty-four days. At the end of the follow-up period, both the open and endoscopic methods had resulted in high levels of achievement of the primary outcomes (relief of pain and paresthesias). The numbness and paresthesias were relieved in eighty (98 per cent) of eighty-two hands in the open-release group compared with seventy-seven (99 per cent) of seventy-eight hands in the endoscopic-release group. This parameter was not recorded for three hands in the open-release group or six hands in the endoscopic-release group. The satisfaction of the patients with the procedure, graded on a scale of 0 to 100 per cent, averaged 84 per cent in the open-release group compared with 89 per cent in the group that had had endoscopic release. We found no significant differences between the two groups with regard to the secondary quantitative-outcome measurements, including two-point discrimination, postoperative interstitial-pressure data for the carpal canal, Semmes-Weinstein monofilament testing, and motor strength. The open technique resulted in more tenderness of the scar than did the endoscopic method. Thirty-two (39 per cent) of eighty-two hands in the open-release group and fifty (64 per cent) of seventy-eight hands in the endoscopic-release group were not tender at eighty-four days. This parameter was not recorded for three hands in the open-release group and six hands in the endoscopic-release group. The open method also resulted in a longer interval until the patient could return to work (median, twenty-eight days, compared with fourteen days for the open-release and endoscopic-release groups). Four complications occurred in the endoscopic carpal-tunnel release group: one partial transection of the superficial palmar arch, one digital-nerve contusion, one ulnar-nerve neuropraxia, and one wound hematoma.(ABSTRACT TRUNCATED AT 400 WORDS)

The Elbow and its Disorders. 3rd ed.

Bernard F. Morrey and Joaquin Sanchez-Sotelo, editors. Philadelphia: Saunders Elsevier; 2009. 1211 pages.

Experimental Orthotopic Transplantation of Vascularized Skeletal Allografts: Functional Assessment and Long-Term Survival

299.00. ISBN: 978-1-4160-2902-1. nnIn the fourth edition of The Elbow and Its Disorders, Dr. Morrey has again succeeded in accomplishing something quite difficult. Through skillful editing, he and Dr. Sanchez-Sotelo have produced a text that is both comprehensive and concise. The number of contributors is now eighty, nearly double that of the first edition. This …

The healing of facial bone fractures by the process of secondary union.

Vascularized skeletal tissue allografts would greatly expand the domain of reconstructive surgery. Few studies to date have examined the functional aspects of these allografts or their long-term fate. An orthotopic transplant model of rat distal femur and surrounding muscular cuff was developed to assess graft function in fracture healing and weight bearing. Isografts (RT1l to RT1l, n = 40), weak-barrier allografts (RT1l to RT1lv, n = 40), and strong-barrier allografts (RT1l to RT1n, n = 40) were transplanted. As the histocompatibility barrier increased between the donor and recipient animals, the graft viability and performance deteriorated according to radiographic, histologic, and immunologic analyses. Administration of cyclosporine led to survival of strong-barrier allografts similar to that of isografts. A long-term study of these allografts (RT1l to RT1n) was then performed on various immunosuppressive regimens. After an initial 10-week course of cyclosporine to achieve bony union and remodeling, subsequent cessation (n = 20) or intermittent pulsing (n = 20) of the immunosuppressant was insufficient in maintaining graft survival. However, graft viability and function were preserved through 1 year on continuous daily cyclosporine (n = 32). There was no evidence of host renal or hepatic toxicity by serum chemistry or histologic sections. Thus long-term survival of functional skeletal allografts was achieved in this orthotopic model without significant host toxicity from immunosuppression.

Prolonged Survival of Vascularized Limb Tissue Allografts by Donor Irradiation

The mechanism of healing of facial bone fractures was investigated in a rabbit model. Twelve New Zealand white rabbits underwent surgically induced fractures of the right infraorbital rim and fracture ostectomies (4 to 5 mm) of the left infraorbital rim. Animals were sacrificed 2, 4, and 8 weeks postfracture. Bone, including periosteum, obtained from each fracture or fracture ostectomy site was divided longitudinally for hematoxylin and eosin staining, fluorescent microscopy, microangiography, and microradiography. Sequential fluorochrome labels of oxytetracycline (30 mg/kg), alizarin complexone (30 mg/kg), DCAF (20 mg/kg), and xylenol orange (90 mg/kg) were administered 24 hours preoperatively and at 1, 2, 4, and 8 weeks postfracture. All fracture and fracture ostectomy sites demonstrated vascular ingrowth, mineralization, and woven bone formation by 2 to 4 weeks postoperatively, beginning with a cartilage precursor. Subsequently, the woven bone was replaced with remodeled lamellar bone, resulting in complete bony healing by 8 weeks postoperatively. These steps were substantiated by microscopic, microradiographic, and radiologic examination of the specimens. This study demonstrates that fractures of the facial bones in a rabbit model heal by a process of new bone formation that resembles secondary union in endochondral bones.