American Society for Surgery of the Hand

PROCEEDINGS American Society for Surgery of the Hand The Thirty-seventh Annual Meeting of the American Society for Surgery of the Hand was held Jan. 18 through 20 in New Orleans, Louisiana. The following is a condensation of the papers presented at the scientific session. Primary and delayed primary repair of flexor tendon lacerations in zone II in children. JosEPH P. LEDDY, M.D., reported 27 consecutive primary or delayed primary flexor tendon repairs in zone II in children 14 years of age and younger. Both the superficialis and profundus tendons were repaired whenever possible. Eighty-eight percent of the patients achieved excellent or good results. There were only three failures and two of these were salvaged by a tendolysis at a later date. The author concluded that primary or delayed primary repair is the treatment of choice in zone II flexor tendon injuries in children. Delayed primary repair can be carried out as late as 2 months or more after the injury. Children can tolerate an acutely flexed finger to accommodate delayed primary repair without developing fixed contractures. CHARLES R. AsHWORTH, M.D., agreed with the concept of delayed primary repair. He emphasized that repair of the tendon sheath is important. Reconstruction of digital flexor tendons in zone II. TANG-KuE Lru, M.D., presented an experimental study of 40 frozen stored profundus tendon allografts in 20 chickens. The gross and histologic examinations were assessed 1 week to 1 year after transplantation. The allograft was reorganized by host fibroblasts. Results were demonstrated to be acceptable. The second part of this paper reviewed 35 patients with involvement of 42 fingers who were treated by a two-stage flexor tendon allografting procedure. These were mostly salvage operations on severely damaged digits. The overall results indicated that frozen stored allografts could be used clinically in two-stage procedures. SPENCER A. RowLAND, M.D., commended the author for his presentation and asked if any composite grafts had been carried out, emulating the work of Peacock and others. Dr. Liu stated that they had only done composite free allografts in experimental animals, but that they had not performed this procedure on a patient. Flexor tendon healing and restoration of the gliding surface: An ultrastructural study in dogs. RICHARD H. GELBERMAN, M.D., JERRY S. VANDE BERG, PH.D., GORAN N. LUNDBORG, M.D., PH.D., 410

THE JOURNAL OF HAND SURGERY

and WAYNE H. AKESON, M.D., reviewed an experimental study in which healing canine flexor tendons were treated with either total immobilization or early controlled passive mobilization and studied by light, scanning, and transmission electron microscopy at 10, 21, and 42 days. The immobilized tendons healed by connective tissue ingrowth from the digital sheath and cellular proliferation of the endotenon. In contrast, mobilized tendons healed by a proliferation and migration of cells from the epitenon. The epitenon cells exhibited greater cellular activity and collagen production at each interval compared to cells of the immobilized repairs. Early controlled passive motion was shown to stimulate an intrinsic healing response in a clinically relevant tendon-repair model. The gliding surface was restored at an early stage and the tendon healed more rapidly than in the immobilized repairs. These data support the concept that a precise, limited immediate mobilization program improves the quality of the biological repair response following flexor tendon repair within the digital sheath. PAUL R. MANSKE, M.D., criticized the dog as an experimental model. He felt that the flexor tendon vasculature was not comparable to the primate or the human. He did present a tissue culture study that supported the authors. He agreed with the author about the importance of the contribution of the epitenon, particularly during the first 21 days. Intrinsic tendon healing-Documentation by in vitro studies. MARTIN F. GRAHAM, M.D., HILTON BECKER, M.D., KELMAN COHEN, M.D., WYNDELL MERRITT, M.D., and RoBERT F. DIEGELMANN, PH.D., reported their experiment with punch biopsies (2 mm) of chicken tendons that were embedded in 50 t-tl of plasma clot and incubated in culture medium for 5 days. At this time, fibroblasts had migrated out of the plug into an area of 6 to 8 mm 2 • Fibroblast proliferation increased linearly during this time and relative collagen synthesis, as measured by 3 H-proline incorporation into collagenase-sensitive protein, was 6. 7% of the total protein synthesized. The plasma clot stimulated fibroblast proliferation by 44% and was absolutely necessary for migration. Removal of cells from the plasma reduced the area of migration by 50% (6.8 vs 3.5 mm 2 ). Fibroblast proliferation, however, was not affected. Reconstitution of the clot individually with serum, thrombin, and fibrin demonstrated that fibrin

Vol. 7, No.4 July 1982

was the main component necessary for tendon fibroblast migration. EARL Z. BROWNE, JR., M.D., emphasized that the adhesive protein, fibronectin, which is on the fibroblast, may be the critical adherent material necessary to allow these fibroblasts to accumulate and to migrate.

Blood supply of the flexor pollicis longus tendon. CARLOS A. AZAR, M.D., JAMES E. CULVER, M.D., and EARL J. FLEEGLER, M.D., have studied the blood supply of the flexor pollicis longus (FPL) tendon in 10 fresh cadaver hands. They identified two vinculae distally, designated V 1 and V 2 , which arose from either the digital arteries or the princeps pollicis artery and entered the tendon at the digital level from the dorsal side. They identified two vinculae, designated pseudovincula 1 and pseudovincula 2, arising from the artery of the median nerve at the wrist level. Pseudovinculae are more variable than those lying distally. They could identify no other arterial blood supply. They noted the sparseness of vascularity of the FPL tendon between the vinculae in the digit and the pseudovinculae at the wrist. JAMES W. SMITH, M.D., complimented the authors and, in general, agreed with their conclusions.

Flexor superficialis tendon transfers to the thumb-An alternative to the free tendon graft.

MARTIN A. PosNER, M.D., reported his results in 23 patients upon whom this procedure was performed. The superficialis tendon was taken from the ring finger and transferred to the thumb to substitute for the flexor pollicis longus (FPL) tendon. A sufficient length of superficialis tendon was left distally in the finger to prevent the development of swan-neck deformity. The author noted that this tendon is of ideal length and ideal excursion with suitable direction, amplitude, and work capacity to substitute for the FPL tendon. In addition, no tendon graft is required. EUGENE S. KILGORE, M.D., noted that the same effect of solid pinch can be achieved by fusion of the interphalangeal joint and he questioned whether or not the loss of the superficialis tendon from the ring finger might be a significant detriment in some patients.

An evaluation of digital performance following two-stage flexor tendon reconstruction. WILLIAM B.

LASALLE, M.D., and JAMES W. STRICKLAND, M.D., evaluated the performance of 43 two-stage flexor tendon reconstructions in 39 patients. Results were graded according to the percentage of the preoperative passive motion at the proximal and distal interphalangeal joints, which was actively achieved following the second stage. The initial results were 16% excellent, 23% good, 26% fair, and 35% poor. There were three graft

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ruptures. Twenty grafts (45%) required tenolysis. After tenolysis the results of the entire group were improved as follows: 27% excellent, 28% good, 30% fair, and 16% poor. Staged reconstruction, including tenolysis, was felt to be the best available method for restoration of digital function following flexor tendon loss in the badly scarred digit. JAMES F. MURRAY, M.D., discussed the paper and complimented the authors on their honesty.

Muscle contractile forces in tendon transfer. EDWARD R. NoRTH, M.D., and PAUL C. McCLEOD, M.S., transferred the extensor carpi radialis longus (ECRL) to the flexor carpi radialis in 25 adult rabbits. With a modified cable tensiometer, force readings of the ECRL muscle were obtained prior to transfer, immediately following transfer and at 2 months. A ten percent drop in maximum contractile force followed the transfer due to increased frictional forces from the route of the transfer around the radius. There was a 46% drop in maximum contractile force at 2 months. This appeared to result from a stretching out of the transfer juncture. Neither postoperative muscle atrophy nor adhesion formation were responsible for a significant drop in maximum muscle contractile force. The resting tension selected must take into account both the force and excursion needs of the transfer. WILLIAM K. LINDSAY, M.D., noted that there is a need to make tendon transfers precise and predictable. He recommended cooperation between the surgeon and the department of Biomedical Engineering.

Isometric thumb forces: An electromyographic study. WILLIAM P. CooNEY, M.D., and KAI-NAN AN, PH.D., utilized integrated electromyography to study the force of isometric contraction in eight thumb muscles. This was performed by invasive wire electrodes. They studied isolated muscle strength to electromyogram ratios, abduction-adduction and flexion-extension strength and isometric tip, key, pulp pinch, and prehensile grasp. Their results indicated that in flexion the flexor pollicis longus (FPL) was the primary muscle. In prehensile pinch and grasp the adductor pollicis, opponens pollicis, and FPL were the primary muscles. In isometric abduction the abductor pollicis brevis was the primary muscle. In isometric adduction the adductor pollicis was the primary muscle. When considering tendon transfers for absent intrinsic or extrinsic thumb muscles, the relative strength contribution of these muscles must be considered for optimum pinch and grasp strength. PAUL W. BRAND, M.D., stated that this concept of integrated muscle strength as it applies to pinch and grasp is indeed useful.

Preliminary studies of the upper limb with ultra-

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sound transmission imaging. VINCENT R. HENTZ, M.D., KENNETH W. MARICH, PH.D., and PARVATI DEv, PH.D., presented a study utilizing the ultrasound transmission imaging (UTI) camera developed by the Stanford Research Institute. This device uses an array of transmitting and receiving transducers to form a three-dimensional video image of an object as it is moved in and out of the camera's focal plane. Neurovascular bundles, tendons, ligaments, bones, and joints can be visualized. The advantages of this technique are that it is noninvasive and requires no ionizing radiation. The signals can also be stored in a computer for later analysis. The resolution and depth of focus need to be improved. This will improve the usefulness of this device in clinical situations. GRAHAM D. LISTER, M.D., stated that the depth of focus of 1 mm is not sufficient for clear visibility. He further stated that there has never been any demonstrable disability from exposure to sound waves. Upper extremity radionuclide imaging. L. ANDREW KOMAN, M.D., JAMES A. NUNLEY, M.D., JAMES R. URBANIAK, M.D., and ROBERT H. WILKINSON(, JR., M.D., evaluated vascular competence in the upper extremities of 44 patients by three-phase bone scans consisting of rapid sequence dynamic radionuclide imaging (DRI), an immediate postinjection "blood pool" image (BPI), and a 3- to 4-hour delayed image. Findings were correlated with definitive anatomy determined by arteriography, operative findings, or both, in 50 extremities. DRI and BPI provided the correct diagnosis in all but four extremities (92%). The limited resolution when adequate collateral circulation was present precluded precise anatomic definition of aneurysm in three extremities and digital artery occlusion in one extremity. Quantitative information about relative blood flow and preferential perfusion was provided in all instances. E. F. SHAW WILGIS, M.D., commenting upon his experience with this technique, indicated that it correlated very well with clinical diagnosis. He stated that this three-phase study would confirm the presence of disease, but might not determine exactly the nature of the disease. Painful calcific syndromes of the hand and wrist. A. LEE OSTERMAN, M.D., F. WILLIAM BORA, JR., M.D., and MURRAY DALINKA, M.D., presented an analysis of 64 patients with painful calcific syndromes of the hand and wrist associated with crystal deposits. Twenty-two percent of these were secondary to gout, 25% were secondary to pseudogout or calcium pyrophosphate disease, and 46% were secondary to hydroxyapatite deposition disease. The diagnosis depended upon crystal analysis, hematologic studies, and

The Journal of HAND SURGERY

radiographic appearance. Seventy-six percent of their patients were treated successfully with conservative measures. Of the unimproved, 14% were treated surgically with calcium removal. In addition to routine histologic studies, electron microscopy revealed the presence of hydroxyapatite crystals in six of eight specimens. All but one patient improved significantly after surgery. Painful calcific syndromes in the hand and wrist are common and can be related to the specific crystal-deposition diseases. Diagnosis should include joint aspiration, where possible, and blood studies to rule out secondary causes. The majority of cases will respond to conservative care. In those patients who do not respond to conservative measures, surgery yields a reliable result. WILLIAM B. KLEINMAN, M.D., suggested that multiple additional radiographic views might be helpful in the diagnosis of these conditions. He indicated that the actual cause of the acute pain, particularly about the insertion of the flexor carpi ulnaris, was still not well explained. The force/time relationship of clinically used sensory testing instruments. Juony A. BELL, O.T.R., F.A.O.T.A., and WILLIAM L. BuFORD, JR., C.C.E., reported a system devised to observe and measure the dynamic properties of instruments currently used in sensory testing. Measurements included (1) force amplitudes and (2) force-frequency spectral content. The stimuli tested in the study exhibited variations in force that cannot be compensated for by care in application or external controls commonly utilized in testing. It was suggested that the lack of stimulus control described in the measurements may explain the lack of agreement and wide variations in clinical assessment and results. The authors believe such knowledge should be helpful in the improvement of the current testing instruments and in the development of more effective clinical assessment methods. JEROME E. ADAMSON, M.D., stated that all components of sensory testing were not addressed by the authors (for example, the moving two-point sensory test). He acknowledged that the present sensory testing methods need to be improved considerably. The moment arms of the carpometacarpal joint of the thumb: Their laboratory determination and clinical application. JOHN M. AGEE, M.D., PAUL W. BRAND, F.R.C.S., and D. E. THOMPSON, PH.D., stated that this study's definition of normal thumb carpometacarpal (CMC) joint moment arms forms a basis for our continuing objective assessment of the pathomechanics of thumb collapse deformities by intraoperative determination of moment arms during reconstructive surgical procedures. In part one, the pertinent data from the laboratory phase of this effort is presented

Vol. 7, No. 4 July 1982

from the experimental determination of moment arms at the CMC joint. Four fresh human cadaver specimens were instrumented and mounted to permit moment arm determination. The changing position of the thumb in space occurring as a function of CMC joint motion was defined geometrically as that of a cone with its apex concentric with the effective center of the CMC joint and its base, marked out by the thumb nail. By monitoring the tendon excursion incurred by each known angular positional change of the CMC joint, moment arms were determined with the radian concept. In part two, an example of the intraoperative determination of moment arms illustrated the role of the demise of moment arms in collapse deformities of the thumb. WILLIAM P. CooNEY, M.D., discussed the concept of the use of the radian to determine thumb moment arm and he also questioned the exact terminology used by Dr. Agee with reference to the geometric pattern of a cone.

Variations in digital sensory patterns: A clarification of the ulnar nerve-median nerve palmar communicating branch. RoY A. MEALS, M.D., and MARTIN A. SHANER, found that 80% of 50 dissected cadaver hands revealed the presence of a communicating ramus in the palm between the superficial ulnar nerve and the median nerve branch to the third web space. Although the ramus was ordinarily adjacent to the superficial palmar arterial arch, more proximal and more distal crossings were observed. The ramus most commonly passed from the ulnar nerve entirely into the ring finger radial digital nerve and accounted for as much as 80% of its diameter. Less frequently the branch contributed fibers to the long finger ulnar digital nerve. In one case fibers were found crossing from the median nerve into the ulnar digital nerve of the ring finger. Caution should be taken during carpal tunnel release or other surgery along the axis of the fourth ray to avoid injury to this common structure. MICHAEL E. JABALEY, M.D., questioned the actual clinical significance of injury to the structure described by the authors. He did feel, however, that knowledge of this anatomic pattern was essential whenever one is operating upon this particular part of the hand. Pattern of venous drainage of the digits. GEORGE L. LucAs, M.D., reported that failure following revascularization or replantation of digits is more commonly due to venous congestion than to lack of arterial perfusion. Thus, it is important to understand the pattern of venous anatomy in the fingers. Thirty fingers were dissected after the venous system was injected with colored latex. The venous system is delineated as a ladder system or a series of arcades on the dorsal and palmar surface of the digit with interconnecting oblique or

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transverse anastomotic vessels or connections through a commissural system of veins. The dorsal ladder, which originates as a small terminal vein at the nail matrix, carries most of the blood from the digit. Longitudinal vessels are connected by transverse channels, the rungs of the ladder, and receive communications from feeding veins and also receive communications from the palmar ladder via transverse or oblique anastomotic vessels. Just distal to the confluence of adjacent radial and ulnar dorsal veins at the metacarpophalangeal joint level, a sizable commissural vein is given off which collects blood from the palmar aspect of the digit and distal palm. The vessels of the palmar ladder are of smaller caliber than those of the dorsal ladder. They parallel the neurovascular bundle, but do not lie strictly within the neurovascular canal. The oblique anastomotic vessels and the commissural vessels are particularly important to preserving venous drainage in case of transsection of the dorsal system. These dissections also demonstrate definite venous channels in the vinculae. BERISH STRAUCH, M.D., stressed the importance of the information set forth in this paper to the surgeon involved in replantation or revascularization of digits. Care of the hand in epidermolysis bullosa. JACK L. GREIDER, JR., M.D., and ADRIAN E. FLATT, M.D., reported the operative treatment of hand deformities in five children, from three to eleven years old, with the recessive dystrophic type of epidermolysis bullosa. Special patient management problems included skin care, the need for dietary supplements, and a preference for ketamine anesthesia. Epidermal degloving, full thickness release of contractures, the use of splitthickness skin grafts, and immobilization and suspension of the hand (with special splints of the newer synthetic materials to maintain the digital separation) are the important points in the management of these patients. Long-term use of a splint to maintain gentle digital separation helped prevent early recurrence of webbing. This is a total patient care problem with limited results. The progression of the disease is not affected by the surgical care of the hands. ROBERT L. HoRNER, M.D., in discussion, stated that surgery can give more immediate improvement than any other available treatment, but that lasting gains can only come from a better understanding of the basic skin defect.

The cause and correction of camptodactyly. RoBERT M. McFARLANE, M.D., G. IAN CuRRY, M.D., and H. BRIAN EVANS, M.D., reported observations that support the view of Millesi that camptodactyly is due to an imbalance between the flexor and

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extensor forces acting upon the proximal interphalangeal joint. In 17 consecutive operations the insertion of the lumbrical muscle was abnormal. The muscle inserted either into the superficialis tendon (two patients), the capsule of the metacarpophalangeal joint (13), or the extensor expansion of the adjacent finger (three). Therefore, it is suggested that the deformity of camptodactyly is due to the absence of normal lumbrical action. It follows that treatment should consist of soft tissue release, as necessary, to correct the flexion deformity, followed by a tendon transfer to restore lumbrical action. The ring finger superficialis tendon is preferred for the tendon transfer. VrRCHEL E. WooD, M.D., disagreed with the concept that all cases of camptodactyly are due to an abnormality of the lumbrical. He commented that this is more theory than fact. He felt that the author had too many operations with very little marked improvement. Only four of 17 patients improved and it appeared that the conditions of some of the patients may have worsened after treatment. Congenital radioulnar synostosis. BARRY P. SIMMONS, M.D., WILLIAM S. SouTHMAYD, M.D., and EDWARD J. RrsEBOROUGH, M.D., presented their experience with 33 patients (19 men and 14 women) over a 30-year period. This condition is often associated with other defects. Seventeen patients were operated upon. Ten of these had bilateral involvement. The majority had a derotational osteotomy through the synostosis. The corrected position was maintained with an intramedullary wire and a secondary transfixing device. There were eight complications, four involving neurovascular compromise. The best position of correction appeared to be 10° to !5° of pronation in the dominant extremity. The neutral position is preferred in the nondominant extremity if the condition is bilateral. Eighty-two percent of the patients who were operated upon had good or excellent results. Lour G. BAYNE, M.D., agreed with the concept of an osteotomy in preference to intrapositional membranes or tendon transfers, which have proven inefficient in the past. Classification and treatment of hand deformities in Apert's syndrome. JosEPH UPTON, M.D., and JosEPH E. MoRRAY, M.D., stated that acrocephalosyndactyly is a rare syndrome that occurs only once in 200,000 live births. This syndrome consists of skull deformities, midface hypoplasia, and severe symmetrical anomalies of all extremities. Hand deformities include (1) a short radially deviated thumb with an abnormal proximal phalanx, (2) a complex osseous acrosyndactyly of the index, long, and ring fingers, and (3) a simple syndactyly of the fifth ray and a brachydactyly with synphalangism. Additional anomalies include

The Journal of HAND SURGERY

carpal coalitions, synostoses, and hypolasias of the extremity. The surgical priorities included (1) separation of the thumb from the digits, (2) lengthening of the thumb, and (3) mobilization of the fifth ray. There was no precise target regarding the exact number of digits to be separated from the complex syndactyly. Emphasis is upon function rather than cosmesis. This series included 31 patients ranging in age from 4 to 38 years with 62 involved hands. Twenty-eight patients underwent 261 operations on the hands. These procedures were often combined with correction of cranial or maxillofacial anomalies. An attempt was made to complete all major reconstruction before school age. Procedures of particular value were thumb lengthening by osteotomy and bone graft of the proximal phalanx and excision of the metacarpal synostosis between the fourth and fifth rays with interpositional carpometacarpal arthroplasty. ALFRED B. SwANSON, M.D., repeated the emphasis upon function rather than cosmesis. He indicated that the exact classification of this syndrome is not precise since the condition involves both a failure of differentiation and a failure of development. Dr. Swanson inquired about the mental status of these patients. Dr. Upton replied that, in 12 of 31 patients who had been extensively studied, the retardation factor appeared to be due to a severe physical handicap and not due to mental deficiency. Osteonecrosis of the scaphoid. CHARLES P. MELONE, JR., M.D., RoBERT W. BEASLEY, M.D., and GoEL GRAD, M.D., reported that osteonecrosis of 130 scaphoids had been evaluated to better understand the diagnosis, natural history, and treatment of the condition. Increased radiodensity was consistently diagnostic. Classification into clinical stages is proposed as follows: stage 1, increased radiographic density without collapse or arthritis; stage II, increased density of bone resorption with arthritis limited to the scaphoid articulations but minimal architectural changes; stage III, collapse deformity and/or diffuse arthritis. Of stage I patients, 90% obtained good radiographic and clinical recovery following appropriate immobilization, reduction of displaced fractures, or bone grafting for pseudoarthrosis. The contention that osteonecrosis at this stage is irreversible and that bone grafting is deleterious to revascularization and recovery were not supported. Evaluation of stage II and III patients clearly demonstrated that, with failure of revascularization, osteonecrosis consistently results in osteoarthritis. Implant arthroplasty was the most satisfactory treatment for the stage II group and was especially successful in preventing progression to stage III. Definite stage III patients

Vol. 7, No. 4 July 1982

required arthrodesis or proximal row carpectomy, but these patients usually continued to exhibit substantial impairment. The importance of early appropriate treatment is borne out by this study. RICHARD H. GELBERMAN, M.D., complimented the authors. He felt, however, that grip and pinch strength should be included in the reporting of the results. Pulsing electromagnetic field treatment of nonunions of the scaphoid. GARY K. FRYKMAN, M.D., BAsiL HELAL, EsQ., M.CH., ORTHO F.R.C.S., RICHARD KAUFFMAN, M.D., GREGORY A. PETERS, M.D., and Juuo TALEISNIK, M.D., evaluated 20 patients with an established nonunion of the scaphoid who were treated by a pulsing electromagnetic field. This is an entirely closed system in which coils are applied externally to a long arm thumb spica cast. Eighty-five percent of these patients achieved union. This is comparable to the union achieved by bone grafting. The advantages of this system are that it is totally noninvasive, surgery is avoided, and the technique can be applied to infected bone. It is not useful if there is degeneration or collapse of the scaphoid and it is not useful in the unreliable patient. F. WILLIAM BoRA, JR., M.D., complimented the authors on their work, but pointed out the need for a good double-blind study to fully evaluate the method. Anterior intramuscular transposition of ulnar nerves with a medial epicondylotomy. RANDY M. BussEY, M.D., ToDD CASE, GLORIA DEVORE, O.T.R., and JoHN W. MADDEN, M.D., reported their experience with 35 ulnar nerve transpositions in 31 patients with neuropathy of the elbow. The patients presented with intractable paresthetic pain, tender neuromata, ulnar motor weakness, and/or objective sensory disturbances in the distribution of the ulnar nerve. Technique involved osteotomy of the medial epicondyle, transposition of the nerve within the muscle substance, and reattachment of the epicondyle. In all instances there was resolution of the symptomatology. In most cases there was good objective return of nerve function. DAVID P. GREEN, M.D., noted that this was an intermuscular transposition rather than an intramuscular transposition. He questioned the need for fixation of the medial epicondyle. Compression of the musculocutaneous nerve at the elbow. JAMES A. NUNLEY, M.D., and FRANK H. BASSETT, III, M.D., have found 11 cases of this previously unrecognized and unreported clinical syndrome among 3,000 patients with nerve entrapment syndrome. In the acute-phase patients present with pain on attempting to extend the elbow with the forearm fully pronated. The pain limits extension of the elbow except

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when the forearm is placed in supination. In the subacute and chronic phase, pain is reproduced as the forearm moves from supination to pronation while the elbow is held in extension. Physical findings include direct tenderness over the nerve at the elbow and numbness of the distal palmar radial aspect of the forearm. Four patients responded to conservative measures consisting of splinting, anti-inflammatory drugs, local injection of steroid, and restriction of activities. Seven patients required surgical decompression of the nerve at the point of the junction of the biceps tendon with the lacertus fibrosis. All patients who were operated on experienced relief of their complaints. MORTON SPINNER, M.D., stated in discussion that he had seen four such patients. In two of these patients there was a coexistent partial lesion of the median nerve. He found this to be due to an accessory lacertus fibrosis arising from a three-headed biceps muscle. A model to study sympathetic dystrophy: Psychological testing and biofeedback results. WYNDELL H. MERRITT, M.D., and MAUREEN A. HARDY, M.S., R.P.T., stated that reflex sympathetic dystrophy is a poorly defined condition of unknown cause. This study model used measurable criteria for diagnosis including dysesthesia and greater than 4°F temperature alteration in the affected hand, greater than 10% increase in size, abnormal digital plethysmography, abnormal ninhydrine sweat test, tactile hy:)eresthesia, marked muscle atrophy, or marked osteoporosis. Pain was measured by the Visual Analogue Scale and by the Ischemic Ratio Test. Nine patients fulfilling these criteria were compared by psychological testing to eight control patients with hand injuries. Results differed significantly for five of the psychological tests as follows: somatization (p = .005), depression (p = .022), interpersonal sensitivity (p = .023), anxiety (p = .044), and body cathexis (p = .058). Five dystrophy patients underwent temperature biofeedback therapy and all developed temperature control and corrected digital plethysmography abnormalities. Although they reported symptomatic relief during the 2- to 12-month followup, pain measurement techniques did not confirm this improvement. DAVID E. PLEASURE, M.D., in discussion, stressed the importance of the symptomatic relief of biofeedback, but questioned whether the underlying psychological problems changed as the pain decreased. The use of regional intravascular sympathetic block with guanethidine (lsmelin) as an adjunct to the treatment of posttraumatic disturbances of function of the hand. WILLEM RuNDERS, M.D., and RENE GERRITSE, PH.D., reported that guanethidine serves as a peripheral postganglionic sympathetic

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nerve- blocking agent and has been used in the past in the treatment of hypertension. Hannington Kiff (1974) introduced guanethidine, following Bier's technique (1908) of intravenous regional anesthesia. Good results were reported in patients with reflex-sympathetic dystrophy (RSD) and in patients with pain syndromes after nerve lesions. The results of a series of 50 patients were reported. Classification of results (follow-up at at least I year) were: good, lasting improvement; promising, improvement up to 1 week; no, improvement only for 24 hours. Results were as follows: group I, patients with RSD (general and local, n = 18), good = 11, promising = 4, and no = 3. Group II, patients with pain syndromes after lesion of a small nerve (causalgia minor, n = 13), good = 0, promising = 2, and no = 11. Group III, patients with pain and loss of function after distortion of a single finger joint (n = 19), good = 12, promising = 2, and no = 5. The good results in patients in groups I and III has prompted the authors to earlier and wider use of the regional intravascular sympathetic block when indicated. ROBERT D. LEFFERT, M.D., emphasized that guanethidine is limited by the Food and Drug Administration in the United States for experimental use only. He questioned the efficacy of the use of guanethidine via Bier block vs the results obtained with standard sympathetic blocking. Anatomic localization of sympathetic nerves in the hand. RAY MoRGAN, M.D., NEAL R. REISMAN, M.D., and E. F. SHAW WILGIS, M.D., reported that the distal sympathetics have become implicated in chronic digital ischemia and causalgic disorders of the hand. The exact anatomical localization of the sympathetic nerves within the peripheral nerves and their relationship to the end arteries in the hand has not been fully evaluated. Fresh human tissue consisting of median and ulnar nerves and their arterial supply were utilized in the study. Sections of these were taken at multiple levels in the forearm, wrist, and hand after the tissue was frozen. The sections were then immersed in a glyoxalic acid solution in order to excite catacholamine fluorescence. Dark-field fluorescence microscopy was then used to view the sections. Light microscopy was also used to examine adjacent sections from the same specimens. The sympathetics are more plentiful in the median nerve as compared to the ulnar nerve at the wrist. They are mostly located in the peripheral aspect of the nerve in clusters. Control material consisting of motor nerve, sympathetic chain, and adrenal gland was used to standardize the fluorescence. Histofluorescence was then used to define the anatomy of the sympathetic nerves in the hand. GEORGE E. OMER, M.D., questioned whether this technique can separate

The Journal of HAND SURGERY

catacholamines that have originated from the adrenal gland from those which originate from peripheral nerves. He also stated that the long preterminal portion of the axone could be situated deep within the nerve, then branch to the periphery and terminate in the epineurium. Therefore, the technique may not demonstrate the anatomic localization of the total autonomic axon. Pattern of fibronectin deposition in the healing nerve. EARL Z. BROWNE, JR., M.D., and Guy GoLDICH, B.S., stated that fibronectin is a cell surface adhesive glycoprotein that is felt to play an important part in the early events of wound healing. It can be identified as a lacey pattern by immunofluorescent staining in the normal nerve and as a markedly distorted pattern with increased content in human neuromata. A study was performed in rats' sciatic nerves. Repaired, crushed, and terminally divided nerves with sequential specimens from 2 days to 4 weeks were examined in order to determine the pattern of deposition of fibronectin. It was found that as long as continuity of the nerve tube remained, no matter what type of nerve injury was inflicted upon the nerve, that fibronectin was laid down in a characteristic pattern and resumed a relatively normal configuration within 2 weeks. This occurred in spite of persistent disorganization of these same specimens on H and E staining. In specimens where disruption of the nerve tube occurred in the rat nerve, a whorled appearance was found similar to that, but not as pronounced as, specimens found in human neuromata. JoHN W. MADDEN, M.D., in discussion, noted that fibronectin has been recognized since 1948. He questioned whether fibronectin still has any clinical application at this point. Evaluation of the use of the argon laser in repairing rat and primate nerves. EDWARD E. ALMQUIST, M.D., ANN NACHEMSON, M.D., DAVIDAUTH, PH.D., STEPHEN HALL, and BRIAN ALMQUIST reported a study to evaluate the feasibility of repairing nerves with laserinduced coagulated blood to construct adherent fascicular minicuffs. With a fiberoptic argon laser developed in their laboratory, rat sciatic nerves and monkey and baboon median nerves were lacerated and a fascicular repair was then performed with only the laser. Autogenous blood was spread around the fasicle at the repair site. A 200 p, beam fiberoptic laser then coagulated this blood, forming an adherent minitubule around the fascicle. Evaluation by various microscopic techniques appeared to indicate a technically superior repair compared to control nerves that had been sutured. There appeared to be no untoward effects from the laser. The authors point out that, while this technique is feasible, quantita-

Vol. 7, No.4 July 1982

tive evaluation of sensability and muscle function would require evaluation with humans. H. BRUCE WILLIAMS, M.D., discussed some clinical applications of the laser. Experiences with upper extremity nerve repair with an electrical fascicle sensory/motor identification technique. J. STUART GAUL, JR., M.D., reported that 28 upper extremity nerves in 25 patients had been repaired with an electrical fascicle identification method; sensory fascicles in the proximal stump are identified by the patient's verbal response and motor fascicles in the distal stump are recognized by observing a contraction in the appropriate intrinsic muscles of the hand. Repair usually was by motor fascicle suture combined with epineurial suture. Ten median and five ulnar nerves were evaluated 2 to 4 years following repair. Median nerve results were the most impressive, with thenar motor recovery ranging 25% to 95% in nine of ten patients and usually confirmed by diagnostic ulnar nerve block. This technique requires considerable cooperation from the patient. It is not applicable in children. The author found a 92% success rate in identifying sensory portions in the proximal median and ulnar nerves and a 58% success rate in identifying motor components in the distal nerves. JACK W. TUPPER, M.D., agreed with the hopelessness of trying to differentiate sensory and motor fibers at the upper forearm. He indicated that he felt this technique was quite promising, although the number of cases was small. The use of lateral V-Y advancement flaps for fingertip reconstruction. BLENN H. SHEPARD, M.D., reported an anatomical study of the distal phalanx of monkeys and humans. He found that the radial bands on the lateral and dorsal aspect of the fingertips are much more dense and restrictive than those on the palmar aspect. A technique was described involving mobilization of these bands by a dorsal longitudinal incision that passes through the periosteal attachment of the bands. These bands are also released from the underside of a palmar V- Y advancement flap. With this technique distal advancement of the flap of 10 to 14 mm is possible. This technique has also been used electively to remodel deformities of the fingertip. A total of 37 fingers had been successfully repaired with this operation. JosEPH E. KuTz, M.D., discussed this paper and indicated that he thought that this method appeared to be useful and could be of some help in the management of this type of injury. The pathogenesis of Dupuytren's disease: Contractile mechanisms of the myofibroblasts. LAwRENCE C. HURST, M.D., MARIE A. BADALAMENTE, PH.D., and LAWRENCE STERN, M.D., reported that the role of myofibroblasts in the pathogenesis of Dupuy-

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tren 's contracture was investigated by light and electron microscopic histochemical methods. Dupuytren's myofibroblasts contain an intracellular contractile mechanism that is driven by the dephosphorylation of adenosine triphosphate (ATP). The study of the ATPase activities verifies that the site of this energy system is on the myofilaments of the myofibroblasts. The degree of ATPase activity, as determined by cell counts, statistically correlated with residual contracture as predicted by the Legge and McFarlane Outcome Standard Formula. Further, alcian blue staining on the ultrastructural level indicated that the myofibroblasts were associated to each other and to surrounding collagen by a glycosaminoglycan matrix 300 to 100 Athick. Collagen fibrils are attached by a similar matrix comprised of 100 A thick fibrils. The aggregation of multiple adjacent myofibroblasts with connections to surrounding collagen may provide a dynamic cellular architecture the contractile force of which is sufficient to explain the clinical deformities of this disease. JosEPH H. BoYES, M.D., in discussion, mentioned his own research in which the presence of a herpes simplex virus has been demonstrated. He indicated that the findings noted by the authors may be common, not only to Dupuytren's contracture, but to other types of granulation tissue as well. Canine epiphyseal growth-A study of the effects of variations in the vascular pedicle and accompanying bone grafts. Tsu-MIN TSAI, M.D., JosEPH E. KuTz, M.D., CuRTIS STEYERS, M.D., and YosHITSUGu ToMITA, M.D., reported that the ultimate longitudinal growth obtainable in free vascularized epiphyseal transfer remains difficult to predict with any degree of certainty. This may be due to variations in the transferred vascular pedicles as well as variations in the length of the accompanying transferred bone. This study was undertaken in order to investigate the effect of variations in these two factors on the growth of canine proximal fibular epiphyses. In group A a 1 em segment of proximal fibula was dissected free. This segment included its capsule, articular cartilage, epiphysis, growth plate, and metaphysis with a 1 em cuff of muscle. The epiphyseal vessel (lateral inferior genicular artery and vein) is well preserved for circulation to the proximal fibula. In group B a 3 em segment of proximal fibula was dissected. The inferior lateral genicular artery and diaphyseal nutrient vessels were undisturbed. The remaining soft tissue was separated. Group C animals were identical to those in group A with the exception that the inferior lateral genicular artery was ligated and divided. Group D comprised the control group. Only exploration for insertion of a wire

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marker was done. After the above procedures were performed, all dogs had a wire marker placed at the proximal tip of the fibular epiphysis and distal aspect of the accompanying metaphysis or diaphysis. Monthly radiographs were obtained over a 6-month period. Absolute growth was measured and calculated. Group B showed a little better growth than the control group D, but these differences were not statistically significant. Both groups showed better growth (twice) than group A. Group C showed early growth arrest. This study suggests that the proximal diaphysis with its vascular pedicle should be included, in addition to the epiphysis with its vascular pedicle, in order to ensure normal longitudinal growth in the free vascularized transfer of a proximal fibular epiphysis. DANIEL C. RIORDAN, M.D., agreed with the concepts presented in this paper and emphasized that the nutrient vessels in the diaphysis should be included along with the epiphyseal nutrient vessels if epiphyseal closure is to be avoided. A total approach to thumb reconstruction. WAYNE A. MoRRISON, F.R.A.C.S., BERNARD McC. O'BRIEN, F.R.C.S., F.R.A.C.S., and ALLAN M. MACLEOD, F .R.A.C.S., reviewed 50 thumb reconstructions done by conventional and microvascular techniques. Both congenital and acquired loss of the thumb were included in this series. There were 11 segmental, 30 subtotal, and 4 total losses of the thumb in this series. Comparisons were made to determine the indications for each procedure. Patients who had received neurovascular island pedicle flaps regularly had problems, including those of finger identification, diminished two-point discrimination, and paraesthesia. Bone grafts of conventional osteoplastic reconstructions atrophied markedly. For adult segmental and subtotal losses, big toe pulps and wrap-around flaps, respectively, provided the best reconstruction with the least morbidity. For total reconstructions, index finger pollicization best corrects congenital deformities while second toe transplantation, with the metacarpal shaft preceded by a skin flap, is the best compromise procedure in adults. JosEPH E. KuTZ, M.D., agreed with these concepts. He emphasized the need to individualize the treatment in each patient and the necessity for microsurgical techniques in the reconstruction process. Functioning free muscle transplantation. RALPH T. MANKTELOW, M.D., RoNALD M. ZUKER, M.D., and NANCY H. McKEE, M.D., reviewed 12 cases of free muscle transplantation to the forearm to restore finger flexion. The average follow-up of these patients was 4 years. Functioning muscle transplantation of the upper extremity is technically feasible. The procedure requires microvascular anastomosis and fascicular nerve

The Journal of HAND SURGERY

repair. Eleven of the 12 patients recovered excellent forceful contraction of the transplanted muscle. Nine of the 12 had a full range of finger flexion. Strength of grasp varied between 20% and 50% of normal and maximum recovery did not occur for 2 to 5 years. The gracilis muscle was the transplant in 10 of the 12 patients. In one patient the sternal head of the pectoralis major muscle was the transplant. Results were rated as nine excellent, two good, and one poor. An aggressive postoperative exercise program is necessary. Technical details were emphasized. Specifically, placement of the muscle at optimum tension, a good fascicular nerve repair, and adequate flap coverage of the distal muscle tendon junction are most important. Spectacular postoperative results were demonstrated by a movie. LYNN D. KETCHUM, M.D., in discussion, commented upon the need for improvement of the measurement of muscle bulk. He further suggested that, in some cases, tendon transfer procedures might be used to augment the results. Toxic lesions of the hand associated with chemotherapy. ALAN E. SEYFER, M.D., presented four cases of unusual chemotherapy toxicity, which was localized to the hands and upper extremities. Bleomycin caused pain, swelling, and sloughing of the pulp and palmar regions of both hands. This has been encountered in approximately 15% of patients who have received bleomycin. Nitrogen mustard caused immediate dark pigmentary changes over the veins of the entire upper extremity and chest. These were alarming to both the physician and the patient. 5-Fluorouracil resulted in permanent darkening of the skin of the hands. BCG immunotherapy caused chronic, localized ulcerations of the skin of the forearm that were extremely painful and that healed slowly. In discussion, RoBERT M. McCoRMACK, M.D., stated that, as use of these drugs increases, these upper extremity lesions will become more common since the upper extremity is the preferential site for administration of these drugs. He asked if any local measures such as injection of 8.4% sodium bicarbonate or steroids had been of help in the shortterm situation. Dr. Seyfer answered that the local steroids are of no value at the present time. Osteochondromas of the hand in children: An experience with 10 cases. J. RussELL MooRE, M.D., and RAYMOND M. CURTIS, M.D., stated that osteocartilaginous exostoses are considered to be one of the most common neoplasms of bone. Their occurrence in the hand is infrequent. The osteochondromas in this series most nearly resembled the perichondroma or echondroma of Virchow. These cartilage tumors occurred in the edges of bones near tendon insertions.

Vol. 7, No.4 July 1982

They may result from an overgrowth of permanent cartilage. Osteochondromas of the hand in children may limit function, cause cosmetic deformity, or alter growth of the digit. They may pose a problem in diagnosis. The 10 children in this series were between 1.5 and 16 years of age. These tumors were encountered at the ends of the phalanges at either the proximal interphalangeal or distal interphalangeal joint level. All patients had some degree of deviation or early rotation of the involved digit. Treatment consisted of removal of the lesion and joint contouring when necessary. Follow-up ranged from 0.5 to 12 years. There was good functional result, minimal growth disturbance, and no recurrence in any patient. In discussion, HAROLD M. DICK, M.D., was in general agreement with the paper, but he had some question about classification. Management of aggressive tumors of the hand and wrist. LAWRENCE M. LUBBERS, M.D., reviewed 35 patients with malignant tumors of the hand that were treated surgically. In 20 cases hemiamputation of the hand was valuable in local eradication of the tumor while preserving significant hand function. When indicated, reconstructive procedures are usually carried out at the time of the definitive surgery. Optimal use of retained function and minimal complaint characterized the patient response. In discussion, RICHARD J. SMITH, M.D., complimented the authors. He emphasized the need for more careful frozen-section monitoring of tumor margins during surgery. Chondrosarcoma of the han :I. FRANK LANZON, M.D., presented this paper for THOMAS J. PALMIERI, M.D. The paper reviewed 18 consecutive patients with a histologic diagnosis of chondrosarcoma. This was the most common malignant bone tumor of the hand. Follow-up on these patients was from 1 to 10 years. The primary tumor originated without a preexisting lesion in 78%. Secondary tumors arose in patients who had multiple enchondromas in 27%. In no case did a chondrosarcoma arise from a solitary enchondroma. The age of onset was usually between 60 and 80 years. These tumors most frequently occurred in the epiphyseal area of the proximal phalanx (56%) or the metacarpals (39%). Resection of the tumor is the treatment of choice. There were local recurrences in 11%, but there were no distant metastases. RoNALD L. LINSCHIED, M.D., stressed the need for correlation between the histology of these tumors and the roentgenographic appearance. He felt that this was essential to accurate diagnosis. Lymphangioma of the forearm and hand. WILLIAM F. BLAIR, M.D., MICHAEL MICKELSON, M.D., and GEORGE E. OMER, M.D., found nine patients with

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lymphangioma of the forearm and hand in the records of two institutions over a 30-year period. In every case the tumor was seen in the first few weeks of life. Five patients had experienced an episodic pain syndrome of simultaneous pain, swelling, induration, erythema, and fever. All patients responded favorably to elevation, analgesics, and antibiotics. Nine patients underwent a total of 17 operations including incisional and excisional biopsy and excision of recurrent tumor. There was a 24% complication rate. None of the tumors underwent malignant degeneration. Following attempted excision of cavernous lymphangioma of the forearm and hand tumor recurrence, hypertrophic scars, and persistence of symptoms may be anticipated. GRAHAM D. LISTER, M.D., pointed out in discussion the similarities between lymphangioma and hemangioma and emphasized the importance of differentiating between capillary lesions and cavernous lesions. Bioengineering and robotic aids. RoBERT A. CHASE, M.D., LARRY J. LEIFER, M.D., and CHUCK BucKLEY demonstrated the current state of the art with integrated circuits on silicon microchips for the activation of robotic aids for the severely disabled. Wheelchairs that respond to ultrasonic sensors were demonstrated. Robotic arms that respond to verbal commands were presented in a movie. FRANK W. CLIPPINGER, JR., M.D., stated that these robotic aids are still fairly experimental and that they need to be developed to the point where they are reliable, repairable, and portable for the severely disabled. Arthrography of the wrist-A detailed review of 84 clinical cases. ANDREW K. PALMER, M.D., E. MARK LEVINSOHN, M.D., and GARY R. KuzMA, M.D., reported that invasive wrist arthrography was used to evaluate 84 wrists in 76 patients who had chronic pain following trauma. The arthrography findings were compared to the plain radiograph findings and 24 patients had surgery. The operative findings were compared with the findings on arthrography. Correlation of the plain films or motion studies with the arthrographic findings revealed that the triangular fibrocartilage complex perforations were more commonly seen in the ''ulnar plus'' wrist. Scapholunate ligament disruption was seen in 10 wrists despite an average scapholunate angle of 57°. The lunotriquetral ligament was perforated in eight instances in which routine radiographs and motion studies revealed no abnormalities. Surgical correlation of the 24 patients who underwent operative procedures with the 76 patients undergoing arthrographic studies revealed that the arthrogram was 100% accurate in predicting scapholunate disruption, lunotriquetralligament disruption, and

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Proceedings

triangular fibrocartilage complex perforations. Wrist arthrography has been found to be an accurate, relatively pain free, simple procedure. The presence of an arthrographic abnormality such as a scapho-lunate ligament perforation or triangular fibrocartilage complex perforation does not necessarily indicate significant pathology requiring surgical intervention. CHITRANJAN S. RANAWAT, M.D., in his discussion, indicated that arthrography was a reliable method of identifying communication between the radiocarpal and the midcarpal joints. He felt that further studies of this and further correlation of arthrographic and clinical findings were required.

The natural history of wrist disease in rheumatoid arthritis. GARY RANDALL CHAMBERS, M.D., presented a clinical and radiologic study of 500 patients with progressive untreated rheumatoid disease. A computer-program analysis of the disease stage and deformity was advanced by the author. His study attempted to correlate the clincial significance of the findings with prognostic features. EDWARD A. NALEBUFF, M.D., in discussion, indicated that it was probable that this classification would not come into common use because of its relative complexity. The effects of wrist synovectomy on parameters of hand function. THOMAS RooTs, M.D., TiMOTHY PAYNE, M.D., and JULES S. SHAPIRO, M.D., reviewed 46 wrist synovectomies 6 months to 10 years after surgery. They concluded that, in addition to pain relief, carpal synovectomy decreased the expansive effects of carpal synovitis, minimized carpal collapse, and maintained wrist motion and grip strength. DoNALD C. FERLIC, M.D., in discussion, indicated that it is important to keep all of the dorsal retinaculum beneath the extensor tendons. He felt that this study had potential value, but that it needed to be continued. Host tolerance in flexible implant arthroplasty for the digits. ALFRED B. SwANSON, M.D., and LuciANO POITEVIN, M.D., evaluated local and systemic host tolerance to silicone implants in animals and humans by pathological and radiological studies. Autopsies of three dogs and a human showed benign local tissue reaction with a mainly collagen encapsulation, occasional silicone particles in giant cells, minimal inflammatory cells, and no focal necrosis. No distant silicone metastasis was found. With continued inflammatory disease, silicone particles could escape in the lymph system, but appeared trapped and well tolerated in regional nodes as seen in an axillary node in the human autopsy. Axillary node involvement was present in 3 of 3,417 clinical cases. A 5-year postoperative radiological study of 120 metacarpophalangeal (MP)

The Journal of HAND SURGERY

arthroplasties showed that the low-modulus implant protects against excessive bone absorption and helps maintain the shape of the amputated bone end by promoting new bone formation during the remodeling process. The unfixed encapsulated flexible hinge appears to be well accepted by host tissues. ADRIAN E. FLATT, M.D., stated that, although the implant sometimes fractured at the MP joint, it did not seem to affect the function of the joint. When a wrist implant fractures, however, the problem is different. Greater pain and more reaction are encountered about a fracture wrist implant.

Results of ligamentous reconstruction for chronic intercarpal instability. STEVEN Z. GucKEL, M.D., and LEWIS H. MILLENDER reviewed 21 patients with chronic intercarpal instability who were operated on an average of 13.2 months after injury or onset of symptoms. Fourteen patients underwent reconstruction via a dorsal approach with radial wrist extensor or other tendon graft. Seven patients were approached dorsally and palmarly; three underwent ligament repair and four had ligamentous reconstructions. The average follow-up was 25.4 months. Pain decreased in 85.7% of patients, although only two were pain free. Range of motion generally decreased and grip strength increased slightly. Radiologically there was significant improvement on the initial postoperative roentgenograms, much of which was lost by the time final roentgenograms were obtained. According to a clinical and roentgenographic grading system, the average clinical grade improved from poor (26.5%) preoperatively to fair (44.4%) postoperatively. The radiologic grade remained in the poor range postoperatively with only minimal improvement from 40.4% to 45.6%. Juuo T ALEISNIK, M.D., in discussion, stated that reconstruction of the ligaments is unpredictable and unreliable. He recommended that, until better methods of ligament reconstruction are devised, these problems be treated by intercarpal fusion. Proximal-row carpectomy. RoBERT J. NEVIASER, M.D., reported that 24 patients from 19 to 64 years old, underwent proximal-row carpectomy following carpal injuries. Twenty-three were men. The injuries were ten transscaphoid perilunate dislocations with late subluxation and arthritis, ten ununited scaphoid fractures with arthritis, three scapholunate dissociations with arthritis, and one acute carpal dislocation. All were followed for from 3 to 10 years. Although the result depended on the original injury, wrist extension was 65% to 70% of normal, flexion 48% to 65%, ulnar deviation 85%, and radial deviation 17%. Grip strength was equal to that in the opposite hand. There was one failure that was converted to a successful fusion. H. KIRK WATSON, M.D.,

Vol. 7, No.4 July 1982

indicated in discussion of this paper that all methods of reconstruction of the wrist, with preservation of cartilage surfaces that are still healthy, should be exhausted before resorting to removal of carpal bones. Arthodesis of the wrist with a compression plate. AHMAD HAJJ, MD., WILLIAM E. BURKHALTER, M.D., and DAVID DoRIN, M.D., presented a technique of arthrodesis of the wrist in which a compression plate, extending from the distal radius to the second or third metacarpal bones, was used. Fusion of the wrist was in the neutral position and external fixation was not required. Occasionally an osteotomy of the ulna was required. Because of the rigid fixation that is obtained, other reconstructive procedures can be carried out at the same time. ROBERT G. CHUINARD, M.D., stated in discussion that he felt that external immobilization might be necessary to protect the fusion and that longer immobilization might also be helpful. Metacarpohamate arthrodesis for posttraumatic arthritis. MICHAEL B. CLENDENIN, M.D., and RicHARD J. SMITH, M.D., studied seven patients with symptomatic posttraumatic osteoarthritis of the fifth metacarpohamate joint. Arthrodesis was performed with an iliac bone graft while holding the fifth metacarpal in mild flexion. Follow-up averaged 2 years. There was complete or marked relief of pain in all patients. Grip strength improved in six of the seven patients. There was no loss of finger or wrist motion. Six patients returned to their original jobs. A theoretical objection to arthodesis is the risk of limiting palmar mobility by causing the ulnar side of the hand to become rigid. However, normal metacarpal descent (flexion) is not lost with arthrodesis, as compensatory intercarpal motion occurs. This procedure appears to be a safe and effective method of treatment of posttraumatic osteoarthritis of the fifth metacarpohamate joint. GERALD BLATT, M.D., questioned the need for fusion of the normally mobile fifth carpometacarpal joint and described his technique of Silastic interpositional arthroplasty. Dysfunction of the pisotriquetral joint: Treatment by excision of pisiform. MICHAEL P. CoYLE, JR., M.D., and RoBERT E. CARROLL, M.D., reported that, over a 30-year period, 67 painful pisotriquetral joints were treated by excision of the pisiform. Preoperative symptoms included pain, clicking, tenderness, and crepitus. Local anesthetic injection of the joint relieved these complaints. The pisotriquetral joint is best shown in a 30° supination view of the wrist or in a carpal tunnel view. Forty-two of the painful pisotriquetral joints had a previous history of trauma. Twenty-two of these painful joints had associated symptoms of ulnar

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nerve neuropathy. At surgery, 29 joints had chrondromalacia and an additional 20 had osteoarthritis. Excision of the pisiform produced uniformly good clinical results, with complete relief of hypothernar pain and no loss of mobility nor strength. NoRMAL P. ZEMEL, M.D., noted that six of the excised pisiform bones were reported to be normal on pathology examination and he wondered why these patients improved postoperatively. He did, however, agree that the pisotriquetral joint is important as a possible source of chronic wrist pain. Isolated tear of triangular fibrocartilage of the wrist joint: Results of excision. JA YASANKER MENON, M.D., and HERMAN R. ScHOENE, M.D., reported that excision of the triangular fibrocartilage was done in 14 patients for isolated tears of the cartilage during a period of 1962 to 1979. Diagnosis was made clinically and by a process of exclusion. Arthrogram was considered positive if there was a communication between the radiocarpal joint and the distal radioulnar joint. Follow-up ranged from 2 to 18 years with a mean of 8 years. Eleven patients (78.5%) were completely asymptomatic and were able to engage in their preoperative activities. None of the patients developed subluxation or dislocation of the distal radioulnar joint. Degenerative changes were noted in the distal radioulnar joint in five patients, but only one of them required further treatment. In the absence of any osseous or ligamentous pathology, tears of triangular fibrocartilage should be considered as a potential source of chronic wrist pain. ANDREW K. PALMER, M.D., agreed that the entire cartilage complex should not be disturbed because of the potential instability. He urged that arthrogram be used more frequently in the diagnosis of this lesion. In reply to a question from Dr. Palmer, the author stated that only one case was reexplored. This was 2.5 years following surgery and there was no articular cartilage destruction noted at the time of reexploration. Palmar arthroplasty for the treatment of the stiff swan-neck deformity. FRANK A. ScoTT, M.D., and JoHN A. BosWICK, M.D., reported that palmar arthroplasty for the treatment of stiff swan-neck deformity in rheumatoid arthritis is designed to correct the mechanical block to flexion produced both by palmar plate adhesions, which obliterate the retrocondylar recess, and by collateral ligament contracture and adhesions. This operation can be performed along with correction of the primary cause of proximal interphalangeal (PIP) hyperextension (e.g., intrinsic tightness or flexor tenosynovitis) and also supplemented with superficialis tenodesis. Postoperative dynamic flexor traction, which is started at 24 to 48 hours and continued for a mini-

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mum of 3 to 4 weeks, is critical to the maintenance of motion. Arthroplasty in 47 PIP joints in 14 hands of 9 patients demonstrate an increase in motion from + 20° hyperextension and 9.5° flexion preoperatively to -7° extension and 72° flexion postoperatively. RAYMOND M. CURTIS, M.D., agreed that the palmar approach was applicable in rheumatoid patients but not in posttraumatic cases. He agreed that the capsule should be incised rather than excised. In response to questions from Dr. Curtis, Dr. Boswick stated that the main collateral ligaments could be divided to enhance flexion. The optimal position for superficialis tenodesis is 15° to 20° of flexion. Anterior dislocation of the proximal interphalangeal joint. CLAYTON A. PEIMER, M.D., DONNA J. SuLLIVAN, M.S., O.T.R., and DANIEL R. WILD, M.D., have reviewed 13 patients with closed anterior dislocations of the proximal interphalangeal (PIP) joint. The review took place from 6 to 45 months following treatment (average, 17 months). Disruption of the extensor mechanism, palmar plate, and one collateral ligament was found in all patients. The loss of static and dynamic joint support caused palmar subluxation, malrotation, and boutonniere deformity. Two dislocations were irreducible and two were associated with dorsal avulsion fractures from the middle phalanx. The serious nature of the injuries from this dislocation were initially unrecognized and most patients were casually treated; delay from injury to referral averaged more than 13 weeks. Eleven of the 13 patients required surgery for joint reduction and tendon and ligament repair and two treated early were managed by closed reduction and percutaneous pinning. Joint alignment, comfort, and stability were restored and all returned to full activities, including heavy labor. However, a full range of PIP motion was not recovered in any case. WILLIAM H. BOWERS, M.D., said in discussion that only two of the three structures need to be tom to produce this dislocation. He agreed that late surgery often produces satifactory results. Dislocations of the metacarpophalangeal joint, excluding the thumb. ALBERT R. SwAFFORD, M.D., LEE MILFORD, M.D., and CHARLES N. HUBBARD, M.D., have reviewed 52 patients with 62 dislocations. Two-thirds of the patients were under 30 years old, although the age span was from 2 to 81 years. The authors were able to reduce 60% of these dislocations by closed techniques with general or axillary block anesthesia. Forty percent required open reduction by either the dorsal or palmar approach. Results were 75% of normal motion achieved in 62% of the closed and 60% of the open reductions. Fair results (with 50% to

The Journal of HAND SURGERY

75% of normal motion) were achieved in 24% of the closed reductions and 23% of the open reductions. Poor results (with less than 50% of normal motion) were achieved in 14% of the closed and 7% of the open reductions. JAMES L. BECTON, M.D., commented that he has had a somewhat different experience with this injury and he has found that his patients usually required an open reduction. Intra-articular metacarpal head fractures. EoWARD C. McELFRESH, M.D., and JAMES H. DoBYNS, M.D., presented 103 intra-articular metacarpal head fractures in 100 patients. These fractures were classified by anatomical involvement on roentgenographic examination. The fractures were epiphyseal (SalterHarris type III), 4; ligament avulsion from metacarpal head, 17; osteochondral, 8; vertical oblique (sagittal), 22; vertical (coronal), 4; transverse (horizontal), 4; comminuted, 31; boxer's fracture with extension into the joint, 3; loss of substance, 6; and occult compression with avascular necrosis, 4. The authors' experience with fractures involving large intra-articular defects suggested that they should be reconstructed to give a congruous metacarpal head; the digit should then be mobilized as early as technically feasible. J. LEONARD GoLDNER, M.D., raised several questions, but agreed in general with the authors and thanked them for a valuable study. Displaced phalangeal shaft fractures: Is open reduction necessary? MARK R. BELSKY, M.D., and RicHARD G. EATON, M.D., presented their experience with 91 displaced proximal phalangeal shaft fractures. Fracture of the proximal phalanx is a common problem that frequently results in significant disability. One large recent series reported an open reduction rate of 67% with a 19% complication rate. The recent trend has been towards open reduction for these fractures. The authors' management of these fractures differs. This prompted a prospective study of a consecutive series of 91 displaced proximal phalangeal shaft fractures. All fractures were treated with a closed manipulative reduction and percutaneous K-wire fixation. No open reductions were required. Follow-up ranged from 3 to 6 months. Eighty-nine percent of all fingers had good or excellent result. Sixty-five percent of all patients were treated in the emergency room. Inability to accomplish a satisfactory closed reduction remains an indication for open reduction. When treated within 5 days of the injury with closed manipulative reduction and percutaneous K-wire fixation satisfactory results can be expected in a high percentage of cases. The paper was discussed by JAMES W. STRICKLAND, M.D., who noted that the placing of the pins may be more

Vol. 7, No.4 July 1982

difficult than the authors implied. He also indicated that a great deal of manipulation may be as traumatic as an open reduction with internal fixation.

Proceedings

423

Delayed primary bone grafting in the hand and wrist after traumatic bone loss. ALAN E. FREELAND,

and bone grafting in a well-vascularized, scar-free bed. NoRMAN HILL, M.D., stated in discussion that this should be viewed with some caution because, if surgeons adopt this principle without caution, they may get into some difficulties.

M.D., MICHAEL E. JABALEY, M.D., and ANDRE M. V. CHAVES, M.D., reported that thirteen patients underwent bone grafting as a portion of the overall delayed primary management of their hand and wrist wounds. All bone grafts were performed within 10 days of wounding. Internal or external fixation was used in all cases and all wounds healed without infection. There was one instance of a mild malunion, but no nonunions. Follow-up was from 3 months to 5 years. Successful delayed primary bone grafting requires predictable wound control, adequate fixation, and secure soft tissue cover. If these conditions cannot be met, bone grafting should be deferred and performed in the conventional manner. The advantages of delayed primary bone grafting are: a shorter rehabilitation period, fewer operations, avoidance of wound contracture,

DONALD C. FERLIC, M.D., BARRY D. TURNER, M.D., and MACK L. CLAYTON, M.D., reported that a retrospective study of all patients who had undergone thumb arthrodesis at the Denver Orthopedic Clinic since 1972 was undertaken to determine the incidence of satisfactory results with the Micks External Compression Fixator. Sixty-six patients underwent 82 metacaropphalangeal and interphalangeal arthrodeses that resulted in bony fusion in 81 cases. Of the 81 with solid union, three required a second procedure, two for loss of position and one for nonunion. There were eight cases of pin-tract drainage; these did not influence the outcome. Joints arthrodesed by this method formed bony union in about 6 weeks without other methods of external fixation.

Results of compression arthrodeses of the thumb.