Richard D. Goldner

The results of replantation after amputation of a single finger.

We reviewed fifty-nine consecutive cases of patients who had replantation of a single finger (excluding the thumb) after traumatic amputation, with an average follow-up of fifty-three months. Fifty-one (86 per cent) of the replanted fingers survived. Survival was found to be affected by the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeons. The survival rate was not affected by the gender of the patient, the mechanism of injury, or which finger was amputated. As compared with survival only, the functional results were most dependent on the level of amputation. The proximal interphalangeal joint in amputated fingers that were replanted distal to the insertion of the flexor superficialis tendon had an average range of motion of 82 degrees after replantation, while those amputated proximal to the insertion had an average range of motion of only 35 degrees after replantation. The average operating time was six hours and ten minutes, and the average time until the patient returned to work was 2.3 months. Based on this experience, it is our opinion that replantation of a single finger that was amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is seldom indicated.

Snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve : anatomical and dynamic factors

&NA; We describe seventeen patients (twenty-two limbs) who had snapping (dislocation) of both the ulnar nerve and the medial head of the triceps over the medial epicondyle. Two patients (two limbs) were seen because of painless snapping, four patients (five limbs) had snapping and pain in the medial aspect of the elbow, three patients (three limbs) had symptoms related to the ulnar nerve only, and six patients (seven limbs) had snapping and symptoms related to the ulnar nerve. In addition, snapping was identified incidentally on routine screening in five asymptomatic limbs in four patients, one of whom was seen because of snapping and symptoms related to the ulnar nerve on the contralateral side. The diagnosis was confirmed with magnetic resonance imaging or computerized tomography, or both, in all but the first three patients, in whom the operative findings were confirmatory. Only six patients (seven limbs) were sufficiently symptomatic to be managed operatively.Of these six patients, five (six limbs) who had symptoms related to the ulnar nerve had lateral transposition or excision of the dislocating medial head of the triceps in addition to decompression and transposition of the ulnar nerve. Two of these patients had had persistent symptoms immediately after a previous transfer of the ulnar nerve performed at another institution for symptoms related to, and well documented dislocation of, the ulnar nerve; we performed the index procedure to correct the postoperative snapping, which was the result of an unrecognized dislocation of the medial head of the triceps in one patient and the result of an accessory triceps tendon in the other. One patient who had pain in the medial part of the elbow, snapping (without symptoms related to the ulnar nerve), and cubitus varus had a valgus osteotomy of the distal aspect of the humerus that corrected the line of pull of the triceps and relieved the snapping. All of the patients who were managed operatively had an excellent result (no snapping, no symptoms related to the ulnar nerve, and a full range of motion), at an average of 4.5 years postoperatively. Non-operative treatment provided control of symptoms related to the ulnar nerve in four limbs and control of pain from the snapping in four limbs. Snapping on the medial side of the elbow, even if it is associated with symptoms related to the ulnar nerve, is not necessarily caused by dislocation of the ulnar nerve alone.Patients who have a transposition of the ulnar nerve, especially those who have dislocation of the ulnar nerve, should be examined intraoperatively with the elbow in flexion and extension so that the surgeon can be certain that the medial head of the triceps does not snap over the medial epicondyle. Failure to recognize concurrent dislocation of the ulnar nerve and the medial head of the triceps can result in persistent, symptomatic snapping after an otherwise successful transposition of the ulnar nerve.

Luxatio Erecta: The Inferior Glenohumeral Dislocation

Luxatio erecta, or inferior glenohumeral dislocation, is a rare shoulder dislocation usually caused by a hyperabduction injury to the arm. We have reviewed the literature consisting of 80 cases of luxatio erecta and also discuss six additional cases that we have treated. The literature shows that either a fracture of the greater tuberosity or a rotator cuff tear was associated with this injury in 80% of patients; 60% of the patients reviewed sustained some degree of neurologic compromise, most commonly to the axillary nerve. These injuries usually resolved; the time for recovery varied from 2 weeks to 1 year. Only 3.3% of the cases demonstrated significant vascular compromise, but this is the highest incidence for any shoulder dislocation. Doppler studies of the affected arm or observation of the patient overnight are recommended because of the potentially disastrous complications of vascular insufficiency. If there is any indication of a vascular problem, immediate arteriogram is indicated. Although usually fairly easily reduced by overhead traction, the lesion is so rare that few physicians are familiar with the technique of reduction. Fluoroscopy was used in our most recent cases and was helpful in obtaining a complete and safe reduction.

Digital replantation at the level of the distal interphalangeal joint and the distal phalanx

Forty-two complete, single digit amputations at the level of the distal interphalangeal joint or distal phalanx are reviewed. Viability was 81%. Operative time averaged 4.6 hours. Average age of patients was 28 years and 90% were male. Forty-eight percent of the amputations involved the thumb; 79% were at the distal interphalangeal joint and 21% were more distal. One artery was repaired in 64% of replantations, two or three veins were repaired in 61%, and veins grafts were used in 19% of cases. Sixty-nine percent of the crush-avulsion injuries succeeded compared with 89% of lacerations. Two-point discrimination averaged 10 mm and proximal interphalangeal motion averaged 91 degrees. Patients returned to work an average of 2.5 months after replantation and none required additional procedures. The average total cost of treatment was

The vascularized cutaneous scapular flap.

7500.00. Compared with conventional procedures, disadvantages of replantation at or distal to the distal interphalangeal joint are that it does require microsurgical training, initial operating time is longer, and it is more expensive. Advantages are that it is a one-stage procedure that gives good distal soft tissue coverage, adequate sensibility without painful neuroma, good metacarpophalangeal and proximal interphalangeal joint motion; it preserves the nail, maintains digit length, is cosmetically pleasing, and the patient is satisfied.

Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosis

Five cases of cutaneous free tissue transfer using the cutaneous and circumflex scapular vessels are presented. The free scapular flap is an excellent choice when intermediate-sized (6 to 10 by 10 to 16 cm) uninnervated flap coverage is necessary and cannot be achieved by conventional methods. The flap is exposed easily and has a constant artery and venous system, 2- to 3-mm-diameter vessels, and a 4- to 6-cm vascular pedicle. The shoulder donor site can be closed primarily. Like all shoulder wounds, it has a tendency to spread, but not functional deficit exists at the shoulder or on the posterior chest wall.

Results after replantation and revascularization in the upper extremity in children.

Although uncommon, infection of prostheses with Mycobacterium tuberculosis can be managed successfully if it is diagnosed early and treated correctly. A case of M. tuberculosis infection of a prosthetic knee first diagnosed 4.5 years after initial arthroplasty is described. This case and a review of the literature led to the conclusion that there are two distinct patterns of M. tuberculosis infection following joint implant surgery in patients without a history of tuberculosis. (1) Mycobacterium tuberculosis infection may be an unexpected finding at the time of arthroplasty. These patients generally have favorable outcomes using standard antituberculous chemotherapy, without implant removal. (2) Late-onset M. tuberculosis joint infection may be identified in patients with painful, clinically infected, or malfunctioning prostheses. In these cases, medical treatment alone is usually unsuccessful; prosthesis removal is often required. With recent increases in the incidence of tuberculosis in the United States and the emergence of multidrug-resistant strains of M. tuberculosis, periprosthetic tuberculous infection is likely to become more common.

Macrodystrophia lipomatosa with associated fibrolipomatous hamartoma of the median nerve

The rates of survival of the amputated part and the functional outcomes were studied retrospectively after seventy-three replantations and eighty-nine revascularizations in the upper extremity in 120 children. All operations were performed between January 1974 and December 1988 after partial and complete amputations at various levels. The ages of the patients ranged from three days to sixteen years. The average duration of follow-up was thirty-six months (range, fourteen months to seven years) for the patients who had had a replantation and thirty months (range, fourteen months to eight years) for the patients who had had a revascularization. The rate of survival of the amputated part was significantly higher (p < 0.0002) after revascularization (seventy-eight parts [88 per cent]) than after replantation (forty-six parts [63 per cent]). There was no association, for either group, between survival and the preoperative duration of ischemia, the level of the injury, the digit that had been injured, the number of arteries that had been repaired, or the use of venous grafts. The rate of survival after replantation of completely amputated parts was 72 per cent (twenty-eight of thirty-nine parts) when the amputation had resulted from a laceration injury and 53 per cent (eighteen of thirty-four parts) when the amputation had resulted from a crush or an avulsion injury. The rate of survival after revascularization of incompletely amputated parts was 100 per cent (all forty-five parts) when the injury had been the result of a laceration and 75 per cent (thirty-three of forty-four parts) when it had been the result of a crush or an avulsion. We did not find any relationship between the age of the patient and the rate of survival of the amputated part after revascularization; however, there was a significantly higher rate of survival (p , 0.02) after replantation in children who were less than nine years old (77 per cent [twenty-four of thirty-one parts]) compared with the rate in those who were nine to sixteen years old (52 per cent [twenty-two of forty-two parts]). The viability of the digit was in jeopardy after twenty-nine (40 per cent) of the seventy-three replantations and nineteen (21 per cent) of the eighty-nine revascularizations. Immediate reoperation resulted in the salvage of only two of the twenty-one replanted parts and six of the twelve revascularized parts that had a reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)

Achilles Tendon Injuries: A Comparison of Surgical Repair Versus No Repair in a Rat Model∗

Abstract Macrodystrophia lipomatosa (MDL) is a rare disease typically causing localized gigantism and is often associated with a fibrolipomatous hamartoma (FH) of the median or plantar nerve. A previously unreported case of MDL with associated FH of the median nerve is presented.

Longitudinal epiphyseal growth after replantation and transplantation in children

Controversy exists regarding the treatment of Achilles tendon ruptures. The aim of this study was to determine whether surgical repair of the rat Achilles tendon offered any biomechanical, functional, or morphological advantage over no repair. Thirty-two male Sprague-Dawley rats were randomly allocated into four groups: (1) sham operated (skin incision only), (2) no repair (complete division of the Achilles tendon and plantaris tendon without repair), (3) internal splint (plantaris left intact), and (4) Achilles repair (with a modified Kessler-type suture). Functional performance was determined from the measurements of hindpaw prints utilizing the Achilles Functional Index. On day 15, the animals were killed, and biomechanical and histological evaluations were performed on both the injured and uninjured Achilles tendon constructs. All groups subjected to Achilles tendon division had a significant initial functional impairment that gradually improved so that by day 15 there were no functional or failure load impairments in any group. The injured tendons in all three groups subjected to Achilles tendon division had a 13-fold increase in the cross-sectional area and were less stiff and more deformable than uninjured and sham-operated tendons on day 15 (P < .001). The magnitude of the biomechanical and morphological changes at postoperative day 15 and the initial impairment and rate of functional recovery were similar for no repair, internal splint, and Achilles repair groups. In summary, this study demonstrates that surgical repair of the Achilles tendon in the rat does not offer any advantage over nonoperative management.