Robert W. Beasley

The thenar flap—An analysis of its use in 150 cases

A skillfully applied thenar flap is an excellent method of restoring major distal soft tissue losses of fingers. It not only provides full-thickness skin of near perfect tissue match but also is the only local flap with sufficient subcutaneous tissues to restore adequately the lost finger pulp. Its recovery of sensibility yields good function, it does not hyperpigment, and the donor site is on the less exposed palmar surface of the hand. Age is not a contraindication for its use. The thenar flap must not be confused with the palmar flap, whose bad reputation is well deserved and whose use if probably never indicated. The cardinal technical principles that must be observed for the thenar flap are (1) design the flap out on the thumb near the MP joint crease, (2) fully flex the MP joint and, when possible, the distal IP joint of the recipient finger to minimize proximal IP joint flexion, and (3) sever the pedicle of the flap after 10 to 14 days and immediately start active exercises. Experience bears out that the thenar flap applied with observance of the stated principles usually offers the best solution for treatment of major distal phalangeal soft tissue losses for all age groups.

Treatment of dysesthesia of the sensory branch of the radial nerve by distal posterior interosseous neurectomy

Complete injuries to the sensory branch of the radial nerve may lead to the development of an area of dysesthesia in the dorsoradial aspect of the hand. However, lesions of the radial nerve proximal to the elbow level, affecting both the sensory branch and the posterior interosseous nerve, will never develop an area of distal dysesthesia. Therefore, it seems likely that the dysesthesia observed in isolated injuries of the sensory branch of the radial nerve is transmitted to the cortical receptors through the intact posterior interosseous nerve. On the basis of the above clinical observations, we have successfully treated 43 patients with radial dysesthesia by division of the distal posterior interosseous nerve. There have been no complications or functional deficits related to this procedure.

Thumb metacarpophalangeal joint ulnar collateral ligament repair with condylar shaving

Introduction Injuries to the ulnar collateral ligament (UCL) are relatively common and are best treated in the acute setting. The acute version of this injury can often be repaired primarily but in the chronic setting the ligamentous remnants are often retracted making this method of repair difficult. We present a novel alternative approach for UCL repair after chronic injuries or difficult acute injuries. Methods We describe the procedure and postoperative results. A standard S-shaped incision over the dorsal ulnar aspect of the thumb is used. The adductor aponeurosis is identified and separated from the joint capsule. A proximally based and distally based rectangular flap containing the UCL remnants is elevated exposing the metacarpophalangeal joint. A burr is used to shave the condyles on the ulnar aspect of the metacarpal and proximal phalanx. The joint is stabilized with a Kirschner wire. A suture anchor is used to secure the proximally based flap. The distal flap is secured on top of this using the same sutures from the anchor. The repaired ligament is secured to the volar plate on the palmar aspect using a 4-0 Ethibond. Results This surgical technique has been used extensively by the senior authors; we present a representative case. At 3 months the patient had a grip strength of 85 lbs, tripod pinch of 12 lbs, lateral pinch of 5 lbs, 2-point pinch of 6 lbs, active range of motion at metacarpophalangeal joint of 0 to 70 and passive range of motion at the metacarpophalangeal joint MP of 0 to 85. Conclusion Despite a number of options for ligament reconstruction many of the described methods of repair are relatively complex and involve derangement of local tissues. We offer a novel adjunct to current methods of UCL reconstruction in which condylar shaving makes repair much more simple and avoids the use of a tendon graft. This approach provides a shorter course for the retracted UCL remnants allowing primary repair in the chronic setting and in the difficult acute repair.

Cosmetic Considerations in Surgery of the Hand

As the hand is superseded only by the face in portraying one’s personality, cosmetic aspects are prominent factors in treating disorders of the hand. Manner of usage is as important as form and color in determining the inconspicuousness of a deformity.

Rebalancing of forces as an adjunct to resection suspension arthroplasty for trapezial osteoarthritis.

Abstract:The carpometacarpal (CM) joint of the thumb is commonly affected by osteoarthritis. The strength required for a first CM ligament reconstruction depends on the forces across the joint. If these forces are rebalanced to reduce the requirements necessary to prevent subluxation, reconstructive requirements are lowered and surgical dissections reduced. A method to achieve this goal based on Landsmeers zig-zag compression concept is presented. Fifteen consecutive patients (11 women; mean age, 63 years) with pantrapezial osteoarthritis were selected over a 2-year period to undergo this novel procedure. After standard trapezial resection, trapezoidal hemiresection was performed, allowing for medial movement of the first metacarpal base. Following the zig-zag concept, the first metacarpophalangeal joint reciprocally fell into flexion, decreasing forces causing subluxation of the first metacarpal base. A saddle-like suspension under the metacarpal base was created using the trapezial capsule. All 15 patients had excellent outcomes with elimination of pain, early recovery of mobility and power, and no recurrent subluxations. The durability of the procedure was confirmed clinically and radiologically. The medial relocation of the first metacarpal base rebalances and attenuates the normal deforming forces thereby eliminating the need for a strong CM ligament reconstruction.

Passive hand prostheses

For many mangled hands, appropriately designed passive prostheses now available, alone or in conjunction with surgical reconstruction, can offer the best available improvement, provided they are of high quality and backed by prompt and reliable after-delivery services. Invariably, there is improvement in physical capability along with restoration of good social presentation.

A Comparative Electrophysiological Study on Neurotisation in Rats

A comparative experimental study has been carried out in rats with denervated gastrocnemius muscles. Three groups of five rats were treated by three different types of implantation of nerve directly into muscle (neurotisation). In the fourth group, the common peroneal nerve was sutured to the transected tibial nerve. The fifth group was left denervated as a control. The muscles were studied by serial electrodiagnostic studies and later histologically. The results showed little difference between nerve suture and implantation of nerve directly into muscle. Extension of the common peroneal nerve with a pair of sural nerve grafts did not produce a detrimental effect.