E.F. Shaw Wilgis

Aneurysms of the upper extremity.

Thirty aneurysms in the upper extremity in 28 patients over the last 10 years are reviewed. Analysis showed that false aneurysms develop from penetrating trauma, while true aneurysms tend to arise in parts of the arterial tree exposed to blunt trauma. Penetrating injury to vessels should be thoroughly explored and repaired. Arterial aneurysm should be included in the differential diagnosis of masses in the upper extremity, especially after trauma. Three-phase radionuclide scanning is a useful tool for evaluating lesions of the distal arterial tree. When an aneurysm is suspected, early treatment is advised. Treatment options of resection and ligation versus reconstitution of vessel flow should be based on preoperative and intraoperative evaluation of circulatory status.

One hundred tendon grafts for isolated flexor digitorum profundus injuries

One hundred cases of isolated flexor profundus tendon laceration or rupture were repaired by tendon graft over a 30-year period. Thirteen patients were over 40 years of age with the age range in the study from 1 1/2 to 60 years. Unless the flexor profundus tendon remained in the decussation of the superficialis, all grafts were placed around the superficialis tendon decussation. Measurements of passive tendon excursion were considered critical in the selection of a motor for the tendon graft. All but two profundus graft motors could be passively extended to 30 mm. Average active distal interphalangeal (IP) joint flexion was 48 degrees following surgery. In thirteen patients the results were considered unsuccessful, with loss of greater than 20 degrees from preoperative proximal IP joint flexion or distal IP joint flexion less than 20 degrees. We suggest that, in properly motivated patients, tendon graft replacement of isolated profundus tendon injuries can give satisfactory results even in the older age group.

Radial artery use in bypass grafting does not change digital blood flow or hand function.

BACKGROUND Patient selection criteria have not been clearly established for use of the radial artery as a bypass conduit. To help establish such criteria, we measured changes in digital blood flow and hand function after radial artery removal. METHODS Ninety-eight patients of the first 122 consecutive patients considered for radial artery harvest met predetermined criteria by vascular noninvasive studies to undergo removal of the radial artery. In 42 of these 98 patients, the radial artery was actually used as a bypass conduit; 28 of these 42 patients returned for noninvasive vascular studies, a critical review of hand function, and a hand symptom questionnaire. RESULTS There were no significant differences between the operated and nonoperated hands for digital-brachial indices, cold response, grip or pinch strength, digital two-point discrimination, or nine-hole peg tests. The patients had an increased incidence of a small amount of forearm numbness and tingling, but no increase of pain or cold intolerance. CONCLUSIONS For properly selected patients, there are minimal changes in hand function after radial artery removal.

Distal digital nerve grafts: Clinical and anatomical studies

An anatomical study of the terminal branches of the digital nerves of thumb and finger indicated a constant trifurcation at the level of the distal interphalangeal joint. Twelve microscopic interfascicular nerve grafts were done in 11 patients who had nerve division at this level with insensitive fingertips. All patients exhibited improved sensibility. Eight of 12 or 67% achieved 6 mm of two-point discrimination. Although there were no children in this study, the subjects under 30 years of age enjoyed better final results.

Validity and responsiveness of the Michigan hand questionnaire in patients with rheumatoid arthritis: A multicenter, international study†

Millions of patients experience the disabling hand manifestations of rheumatoid arthritis (RA), yet few hand‐specific instruments are validated in this population. Our objective was to assess the reliability, validity, and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with RA.

Multiple digital glomus tumors

In 28 patients with glomus tumors of the digits, 21 were relieved of symptoms by excision of a solitary tumor. Seven other patients had multiple tumors, four of which were the cause of recurrent symptoms. Three patients had multiple tumors--five in one patient, four in another, and two in a third, which had been found at the time of the first operation. A 25% incidence of multiple tumors and a 15% incidence of recurrent symptoms indicates that a careful search should be made for additional tumors.

Sweat gland carcinoma of the hand: Two cases of malignant eccrine spiradenoma

Two cases of malignant eccrine spiradenoma of the hand are reported. This malignancy is potentially fatal and is believed to arise from preexisting, long-standing benign spiradenomas. These rare tumors should be considered in the hand surgeons evaluation and management of any long-standing undiagnosed tumor of the hand. Benign spiradenomas should be excised completely and the patient followed carefully. Location and grade of established malignant tumors should dictate therapy.

Efficacy of magnetic resonance angiography in the evaluation of vascular malformations of the hand

&NA; Conventional arteriography has been the accepted standard technique for demonstrating the anatomic details in vascular malformations of the hand. The technique of magnetic resonance angiography provides detailed anatomy for vascular anomalies of the hand without the use of an invasive technique or contrast enhancement. When magnetic resonance angiography is combined with magnetic resonance imaging, the extent of the lesion with respect to the surrounding tissues and the flow characteristics of the lesion can be determined noninvasively. In our institution, magnetic resonance angiography has replaced conventional arteriography as the technique of choice for the evaluation of these lesions. This report evaluates the efficacy of magnetic resonance imaging/magnetic resonance angiography in the management of vascular malformations of the hand. Ten consecutive patients over 30 months (median age 37 years) underwent magnetic resonance imaging/magnetic resonance angiography evaluation after the clinical diagnosis of a vascular malformation of the hand was made. Four patients in the group had conventional arteriography performed before referral. Magnetic resonance imaging/magnetic resonance angiography clearly defined the anatomic extent of the lesion, its relationship to surrounding tissues, and the flow characteristics in each patient. In the four patients in whom conventional arteriography had been performed, the magnetic resonance angiography findings matched the arteriographic findings. On the basis of the magnetic resonance imaging/magnetic resonance angiography findings, six patients were treated nonoperatively with compressive garments and four patients had operative treatment (resection of lesion n = 2, digital ray resection n = 2). In this series, magnetic resonance imaging/magnetic resonance angiography was efficacious in the management of vascular malformations of the hand. This technique provides detailed images of both the arterial and venous components of the lesions without the requirements of contrast enhancement, ionizing radiation, or an invasive procedure. Furthermore, the resectability can be determined based on the extent of involvement and the flow characteristics.

Long-term followup for rheumatoid arthritis patients in a multicenter outcomes study of silicone metacarpophalangeal joint arthroplasty.

Rheumatoid arthritis (RA) often results in deformities at the metacarpophalangeal (MCP) joints. Patients with severe deformities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). The objective of the study is to prospectively compare long‐term outcomes for an SMPA surgical and a nonsurgical cohort of RA patients.

Prevention of anastomotic thrombosis by botulinum toxin a in an animal model

Background: Free tissue transfer is used widely for reconstruction of complex defects throughout the body. The most common cause for free flap failure remains vascular thrombosis. Currently, there exists no animal model for anastomotic vasospasm. Botulinum toxin type A has been successfully used to treat vasospasm in Raynaud’s phenomenon. A blinded, vasospasm animal model was designed to determine its ability to prevent anastomotic thrombosis. Methods: Ten Sprague-Dawley–derived rats were pretreated with botulinum toxin type A subcutaneously to a randomly determined femoral vessel. Animals acted as their own controls, receiving saline to the contralateral limb. Five days postoperatively, femoral vessels were measured to determine the effect of neuromuscular blockade on diameter. Vessels were then divided and reanastomosed. Animals were subjected to a systemic treatment with a peripheral vasoconstrictor, phenylephrine, and a lower extremity thermic challenge in an ice bath. Vessel patency was recorded before cold challenge and 1 hour after. Results: Vessel diameter was consistently larger in all neuromuscularly blocked vessels. The botulinum toxin type A–treated arterial average was significantly larger than the matched control average, and the venous average was significantly larger than the matched control average. Difficulty of anastomosis and time of suturing were significantly less in the pretreated botulinum toxin type A group. Patency was maintained in 100 percent of vessels treated with botulinum toxin type A and in 44 percent of saline-treated vessels at 1 hour after vasospastic challenge. Conclusions: Botulinum toxin type A was successful in preventing thrombosis within this model. Its ability to decrease vasospasm and thrombosis may have applications for improving free flap survival in select patients.