Biomedical subjects
Publications and source records attributed to R C Wray.
Entrapment of a sesamoid in a complex dislocation of the index metacarpophalangeal joint is a rare finding that may make even open reduction difficult. A case of unusual anatomic derangement of the volar plate is reported that highlights the underlying pathophysiology of complex dislocations.
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A retrospective study of 200 consecutive free microvascular tissue transfers over a 3-year period was done to compare the performance of free-tissue transfers with loupes and with the operating microscope. One-hundred and nineteen flaps (59.5 percent) were performed under 3.5 x loupe magnification and 81 under the operating microscope (40.5 percent). The magnification selection process was based on cumulative past experience, with all early anastomoses performed with the microscope and the vast majority of the more recent operations performed with loupe magnification. Loupes were used preferentially for head and neck reconstruction and breast reconstruction. The microscope was required for performing vascular anastomoses on children and on vessels less than or equal to 1.5 mm in diameter. Results were compared with respect to etiology of defect, type of flap, age of patient, free-flap success, complications, and overall success of the reconstruction. There was no difference in outcome between the two groups, with free-flap success rates of 99 percent for both the loupe and the microscope groups. We believe that our success with loupe-only free-tissue transfers is attributable to our prior considerable experience with the microscope. We would caution that comfort and experience with microanastomoses under the operating microscope should be obtained prior to beginning a loupe-only experience.
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We report a unique patient with true asymmetrical hypersensitivity to bovine collagen. Hypersensitivity is the development of an inflammatory response at a treatment site after a negative skin test. She developed an inflammatory response in only one of two simultaneously injected sites. About 1.5% of patients with a negative skin test have a hypersensitivity reaction consisting of firmness, erythema, and swelling. The signs and symptoms generally resolve spontaneously in a few months.
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Collateral ligament injuries of the proximal interphalangeal joint are common. A significant number of these injuries result in complete rupture of the ligament. The forces that damage the ligaments are abduction and adduction stresses. Previous studies have investigated laxity, angulation, and patterns of failure, but detailed biomechanical rupture studies are scant. Sixty-eight proximal interphalangeal joints from fresh human cadaver fingers (average age, 67 years) were stressed at velocities of 1 mm/sec, 4 mm/sec, and 10 mm/sec. Sectioning studies were also done. Four distinct rupture patterns were noted: midsubstance tear, proximal detachment, distal detachment, and distal avulsion fracture. The prevalence of these patterns differed with the rate at which the ligaments were stressed. Lower speeds tended to produce midsubstance tears, while higher speeds yielded distal damage. The study confirmed that the lateral collateral ligament is the primary restraint against medial-lateral stress and that other supporting structures (the extensor hood and the palmar plate) did not contribute significantly to side-to-side stability.
Trapezium-scaphoid-trapezoid subluxations and trapezoid-capitate-scaphoid-trapezium subluxations or dislocations are rare. A single case combining these two injuries is presented. The mechanism may have been axial loading in extension or flexion. Two modes of treatment, closed and open, were needed for the two injuries.
This study documents that reduction mammoplasty is a procedure with excellent long-term patient satisfaction. This has not been previously well documented. One hundred nine patients after reduction mammoplasty were surveyed by questionnaire. Results of the questionnaire indicated that the majority of patients were pleased with their breast size and breast shape. The majority had equal-sized breasts. Most were comfortable after surgery and had an easier time buying clothes. Ninety-four percent of patients would have the procedure again. Multiple techniques for reduction mammoplasty were used and there were no significant differences with the exception of a change in nipple sensation. Nipple sensation was best preserved by using the inferior pedicle technique.
We conducted a double-blind, retrospective comparison between low-bleed and non-low-bleed (conventional) mammary implants because no controlled study has shown a difference in the degree of capsular contracture between the two types of implants. Twenty-five patients had conventional implants and form group A; twenty-eight patients had low-bleed implants and form group B. All patients had submuscular augmentation. The mean Baker score was 1.51 for group A and 1.04 for group B for the entire patient population and 1.65 for group A and 1.07 for group B for patients with more than 1 year of follow-up. For the entire population, 34 percent of group A and 3.6 percent of group B had a Baker score of 2 or greater. For the population with more than 1 year of follow-up, 42 percent of group A and 7 percent of group B had a Baker score of 2 or greater. There was significantly (p less than 0.007) less contracture with the low-bleed implants for the entire population as well as for those patients with greater than 1 year of follow-up (p less than 0.015).
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Nonunion occurs in less than 1% of phalangeal fractures. Despite this rarity we have accumulated a series of 14 proximal and middle phalangeal delayed unions, nonunions, and malunions. All patients but 1 were initially treated by a physician other than the senior author. All patients developed loss of active motion following their primary treatment. Secondary treatment was by open reduction and internal fixation with Kirschner wires. The mean and median total active motion before secondary treatment were 130 and 90 degrees, respectively. Following secondary treatment, the total active motion increased significantly (p less than 0.05) to a mean of 215 degrees and a median of 255 degrees. We recommend secondary treatment of delayed union, nonunion, and malunion of phalanges of the hand. Open reduction and internal fixation followed by early (two to three weeks) active motion leads to a significant improvement in finger function.
A 54-year-old, right-handed man developed spontaneous rupture of his flexor digitorium profundus at the level of the lumbrical. There was no history to suggest rheumatoid arthritis, abnormality of the carpal bones, fractures, or gout. No evidence of any of these disorders was found at the time of surgery. He was treated with a "mini" interposition flexor tendon graft and regained normal motion. Although the cause of his tendon rupture is unclear, we postulate that the blood supply to the tendon at the level of the lumbrical was compromised by an undefined mechanism.
Forty-four patients with 47 mallet fingers were reviewed to compare the results of operative (24 fingers) and nonoperative (23 fingers) treatment. Distal interphalangeal (DIP) joint extension, DIP flexion, total active motion of the DIP joint, proximal interphalangeal (PIP) extension, PIP flexion, total active motion of the PIP joint, cold intolerance, and persistent pain after treatment were not significantly different in patients treated by surgery or splinting. Secondarily, we compared fingers with and without a fracture of the distal phalanx, and the variables mentioned above were also unaffected by the presence or absence of fractures of the distal phalanx. About one-third of all patients had decreased PIP joint motion following treatment. In about 16% of all patients this loss of PIP motion was more important in determining finger function than DIP motion or symptoms related to the DIP joint. We recommend careful examination of the PIP joint and repeated monitoring of the joint motion. If the PIP joint becomes stiff, therapy and splinting should be used to minimize permanent stiffness. We believe a prospective randomized comparison of operative and nonoperative treatment of mallet finger should be conducted. Such a study would help determine the ideal treatment for mallet finger.