The role of flexor tenolysis in the palm and digits

Seventy-seven digitis in 70 patients undergoing a technique of thorough flexor tenolysis, with instillation of local triamcinolone, and immediate motion were studied. Classification of the results utilized a method which determined the percentage of passive joint flexion potential actively achieved and by a second system which graded the results in the finger as a whole. A further categorization into three patient groups, depending on the etiology of the tendon adhesions, was carried out. Using these classifications 84% or the proximal interphalangeal joints, 86% of the distal interphalangeal joints, and 80% of the fingers as a whole were improved by this procedure. These results were comparable or superior to those of other published reports. Improvement in digital flexion was consistent, often with restoration of near-normal function. The incidence of tendon rupture, infection, and delayed wound healing have not been great.     

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2

Since 1989 we have performed 21 endoscopic hernia repairs in 19 female patients. One recurrent hernia occurred 3 months after laparoscopic preperitoneal patch repair using a single layer of resorbable mesh. Hernioscopy was developed as the transcutaneous endoscopic CO2-gas dissection and subsequent inspection of the preperitoneal hernial sac. Hernioscopic stuffing of the preperitoneal hernial sac using resorbable patch material was performed in seven direct inguinal hernias and in one femoral hernia. Postoperative pain was minimal and convalescence was short. No recurrent hernia occurred during a 1-9-month follow-up.     

A prospective study of flexor tendon repair in zone 5

A prospective study of postoperative mobilization of flexor tendon repairs in zone 5 was conducted over a 2-year period between 1994 and 1996 using a controlled active motion (active extension-active flexion) regimen of mobilization. Fifty-two patients, who had a total of 151 flexor digitorum superficialis (FDS) and 103 flexor digitorum profundus (FDP) divisions, were available for review at a mean follow-up of 10 months. Of the 161 fingers with division of one or both flexor tendons, 66% exhibited independent FDS function and 90% achieved good or excellent results of digital range of motion. No rupture of an FDP tendon repair occurred during the study period. The data allowed us to define a new method of classifying the results of treatment of these injuries in terms of the injured wrists as a whole and not simply as a series of isolated observations for each individual finger with divided flexor tendons. The results of recovery of independent FDS action and range of finger movement achieved for injuries in which the flexors of all four fingers had been divided indicate a statistically significant interdependence of injuries of finger flexors of adjacent fingers at the wrist. Multivariate analysis showed the presence of a "spaghetti wrist" injury to have a significant adverse effect on the recovery of the independent FDS action but not on the recovery of the digital range of motion.     

Extracellular matrices in peritendinous connective tissue after surgical injury to the chicken flexor tendon

Dichlorotriazinyl aminofluorescein (DTAF) has been used to stain corneal stromal collagen as part of in vivo animal experiments for many years. Toxicity of this drug, if present, might alter the observed wound healing. To determine if this drug has any deleterious effect on keratocytes, we evaluated it in vitro. Human keratocytes prepared in 24-well plates were exposed to varying concentrations of DTAF (10(-4), 10(-3), 10(-2), 1, 10, 10(2) micrograms/ml). Exposure times of 1 hour and 24 hours at each concentration of DTAF were evaluated. The cell number was measured 1 and 3 days after initiation of exposure to DTAF using a Coulter counter. Keratocyte proliferation was not affected by 1-hour exposure to DTAF, but keratocyte proliferation measured 3 days after initiation of exposure to DTAF for 24 hours was inhibited in a dose-dependent manner (p = 0.02) and was significantly inhibited at concentrations of 10 and 100 micrograms/ml (p < 0.05). Fluorescent microscopy showed binding of DTAF to keratocytes. We have demonstrated that prolonged exposure to DTAF inhibits proliferation of cultured keratocytes. These results suggest that DTAF-induced cytotoxicity may alter net production of collagen in the corneal stroma in animal models.     

Measurement of range of motion of the finger after flexor tendon repair in zone II of the hand

The purpose of this study was to compare classification systems of active range of motion of the finger after flexor tendon surgery in zone II of the hand. Active range of motion of 20 fingers (16 subjects) was classified according to five systems. Agreement between the systems was only fair. Strickland's original system and the Louisville system rated the results most strictly, followed by Strickland's adjusted system. Buck-Gramcko's systems (in centimeters and degrees) rated the results least strictly. Strickland's systems conformed most closely to measurement principles. This article concludes that at this time Strickland's original classification system is preferable for scientific and clinical purposes. However, additional research is needed to evaluate reliability of the measurement, the variability of the scaling factor of 175 degrees, the sensitivity of the measurement, and the validity of the measurement with regard to functional use of the finger and gliding of the repaired tendon.     

Outcome of ''whiplash'' neck injury

In this study, the relationships between semen production and semen quality of Normande bulls in performance test station and in two IA centers were evaluated and the genetic characteristics and evolution of semen production of young bulls in station were calculated. When analysing the relationship between semen production of young and adult Normande bulls data from 2,677 bulls between 12 and 15 months of age exhibited large difference between 5 groups corresponding to an overall classification given by a technician. Correlations between corrected data collected in station and bull effect estimates in AZ studs were quite high for volume and concentration, and moderate for motility and number of doses per ejaculate or per month. The correlations calculated are underestimates of the true ones, as bulls with undesirable semen characteristics were culled before entering AI. Nevertheless, among the remaining bulls, important differences (40%) in semen output were observed between extreme groups, as classified by the technician. Genetic parameters evaluated from a subset of 1957 young Normande bulls confirms earlier results reported in the literature. The heritability of the average volume of the ejaculate is very high (h2 = 0.65 +/- 0.09). Sperm quality traits are moderately heritable (h2 = 0.23 +/- 0.08 for motility score to 0.37 +/- 0.09 for concentration) and strongly correlated. Total percentage of abnormal spermatozoa estimated from a selected subset seems less heritable (h2 = 0.19 +/- 0.07). A Best Linear Unbiased Prediction was then carried out on the records from 2,387 bulls using these estimates. No clear genetic trend could be detected in the population, although the phenotypic selection performed should be efficient. This apparent contradiction results from the increasing influence in the breed of one family of heavily used bull sires with a poor genetic merit on sperm production traits.     

Assessing disability after head injury: improved use of the Glasgow Outcome Scale

OBJECTIVE: The objective of this study was to assess somatic and inherited androgen receptor gene mutations in families with only one affected individual. METHODS: Molecular genetic analysis of the androgen receptor gene in DNA derived from blood leukocytes from 30 families with single-strand conformation analysis, direct sequencing, and restriction fragment analysis was performed. RESULTS: In 22 families the mothers and all investigated grandmothers were heterozygous carriers. However, within the sisters and aunts, both heterozygous carriers and noncarriers were present. In eight families a de novo mutation was characterized. In three of these patients indication for somatic mosaicism was found. CONCLUSIONS: De novo mutations occur at a high rate within the androgen receptor gene (8 of 30 = 26.7%); a high proportion (3 of 8) arise after the zygote stage. Thus only direct analysis of the underlying mutation of the androgen receptor gene in the proband and his or her family can provide the basis for genetic counseling.     

Magnetic resonance imaging scanning in the diagnosis of zone II flexor tendon rupture

This study was undertaken to determine the usefulness of magnetic resonance imaging (MRI) in the diagnosis of flexor tendon rupture in patients who had prior surgery. Magnetic resonance imaging scans were performed on 11 digits (16 tendons) with the clinical diagnosis of flexor tendon rupture. Clinical suspicion correlated with MRI and surgical findings. Clinical examination yielded a 60% accuracy in diagnosis. MRI differentiated rupture from adhesions with a 100% accuracy rate. The MRI scan is a valuable tool in diagnosing tendon ruptures and may help reduce the incidence of unnecessary tendon explorations.     

Outcome after polytrauma

BACKGROUND AND AIMS: Outcome refers to the different facets of consequences resulting from an event or intervention. These consequences may be relevant for an individual patient, but also for society. There is a growing recognition that clinical research needs to define and focus on the outcomes of medical care. Outcome research should help health care professionals to better evaluate the effectiveness of specific interventions or a therapeutic concept. This broader base of evidence should then benefit the patients. METHODS: The literature was reviewed with respect to concepts of outcome research as well as results of outcome research after major trauma. RESULTS: Measuring outcome might be relevant for research purposes as well as in daily surgical practice. In the past, clinical research in trauma care has tended to focus on survival. Mortality rates are not out, complication rates are not out, but their value is limited and restricted to given scenarios with high mortality rates. New outcomes have to be added: such a functional status, emotional health, social interaction, cognitive function, degree of disability and other indicators of health. CONCLUSION: Despite differences in injury pattern and severity of injury, there is strong evidence from the literature that the quality of life is significantly impaired after major trauma. This is true for functional outcome as well as for psycho-social outcome in up to 70% of patients.     

An audit of flexor tendon injuries in zone II and its influence on management

This paper reports the results of a one-year audit of flexor tendon injuries in zone II managed in a controlled mobilization program. It discusses the rationale for the use of this program and compares results with those of other units. On the basis of these results, the authors suggest that rehabilitation programs for patients with this type of injury should be tailored to individual needs and that trends in management should be carefully evaluated before implementation.     

Outcome of pregnancy after conization

The outcome of 635 pregnancies in 197 women before and after conization is reported. After conization a significant increase in premature deliveries occurred in young women (age 21-25), nulliparae representing the highest risk. The rate of premature deliveries in this age group was 4.4% before conization and 30.6% after conization. No such increase could be found in any other age group. Labor was notably short in non-parous women and in parous women it started with rupture of the membranes significantly more often after conization. In addition, a significant increase in the frequency of cervical stenosis was observed, but this was of clinical significance in only one case. Treatment in the form of prophylactic cerclage did not reduce the incidence of either premature delivery or of late spontaneous abortion.     

Bowstring injury of the flexor tendon pulley system: MR imaging

OBJECTIVE. The flexor tendon pulley system is often ruptured when a flexed finger is forcibly extended. In the acute phase, soft-tissue swelling and pain often make clinical evaluation difficult. These pulleys are not constantly visualized on MR imaging. Rupture of the pulley system can be inferred by observing bow stringing of the underlying flexor tendons when MR imaging is obtained with the finger in flexion. Our objective is to describe the flexor tendon pulley system and present our MR technique.     

A randomized biomechanical study of zone II human flexor tendon repairs analyzed in an in vitro model

Human telomerase, a ribonucleoprotein enzyme is known to be associated with immortalized cancer cells but is absent in most normal tissues. Thus, telomerase appears to be an attractive new target for anticancer agents and an important diagnostic marker of human cancers. Here, we describe an improved telomerase assay method based on the Dynabead biomagnetic separation theory. In this method, 5'-biotinylated (TTAGGG)3 was used as a primer for the telomerase reaction. Telomerase reaction products were then immobilized on streptavidin-coated Dynabeads and washed intensively to eliminate excess [alpha-32P]dGTP. Using this method, without the amplification of telomerase reaction products by the PCR, we were able to quantitatively detect telomerase activity in human HeLa cell extracts equivalent to between 200-500 cells. This method is anticipated to be useful for the measurement of telomerase activity in various tumor cells, for assessing potential telomerase and for understanding the biochemical aspects of the telomerase reaction.     

Outcome after multiple colorectal tumours

BACKGROUND: Patients with primary colorectal cancers have a higher risk of development of second tumours synchronously or metachronously. This special group of patients raise a particular interest in their characteristics and outcome. METHODS: The records of 1009 patients with colorectal cancer were scrutinized. A group with multiple cancers was identified. Perioperative investigations, patterns of follow-up, pathological variables and outcome were noted. RESULTS: There were 22 patients with metachronous tumours and 39 with synchronous tumours following 'curative' operations in 20 and 28 respectively. There was no difference in Dukes classification between the two groups: Polyps were associated with metachronous lesions in ten of 22 patients and synchronous lesions in 17 of 39 patients. Five-year survival was 75 per cent for patients with metachronous tumours and only 18 per cent for those with synchronous tumours. CONCLUSION: In this study patients with metachronous tumours seemed to do very well while those with synchronous lesions did very badly. There were no identifiable demographic or clinical characteristics to account for this. There is a need to study this group of patients and identify factors like tumour biology or host resistance which prevent spread of tumour.     

Outcome of pregnancy after clomiphene therapy

Of 159 pregnancies conceived after clomiphene therapy, 141 ended in childbirth, including seven sets of twins. There was a probable increase in the number of infants born with major malformations. These were exclusively to women who had not previously borne a normal infant. The incidence of malformed infants compares well with that published after gonadotropin therapy. The possibly higher incidence of malformations seen after drug-induced ovulation would therefore seem to be due to the underlying subfertility state and thus not a direct drug effect.     

Outcome in elderly injured patients: injury severity versus host factors

To evaluate the differences between the outcome of elderly patients with severe injuries and that of their contemporaries with a less severe injury, we reviewed 42 severely injured elderly patients and compared them with 76 patients with a femoral neck fracture. We analysed the influence of injury severity and host factors (age, sex and pre-injury medical status) on outcome. The in-hospital mortality rate was 31 per cent in the severely injured patients and 3 per cent in those with a femoral neck fracture. Home was the main discharge destination in the severely injured elderly (34 per cent) and a nursing home in patients with a femoral neck fracture (65 per cent). Functional outcome 1 year after injury was better in the severely injured elderly group. Long-term survival was mainly determined by host factors and not by injury severity. Physicians and policy makers should be careful in predicting the outcome of elderly injured patients merely on the basis of injury severity, because host factors are of greater importance.     

Outcome of severe brain injury: a multimodality neurophysiologic study

We screened all head-injured trauma patients admitted to Lehigh Valley Hospital during a 2-year period. From 725 screened patients, 69 patients in a coma on the second day after trauma were entered into this study. During the first week, these patients underwent electroencephalography (EEG), evoked potentials, ocular pneumoplethysmography, and transcranial Doppler (TCD) sonography. Clinical examinations were undertaken 2 and 7 days after trauma. Test results were correlated with functional clinical outcome at 6 months. In a multiple regression analysis, EEG was the major independent variable that significantly predicted 6-month outcome based on Glasgow Outcome Scale score. Transcranial Doppler sonography contributed a small additional component. Though EEG was the most significant predictive factor in this neurophysiological battery, it did not add significantly to the predictive power of Glasgow Coma Scale score determined at day 7. These findings suggest that in neurophysiologic testing in this type of patient is not useful in improving predictive outcome data.     

Colour Doppler ultrasound in the diagnosis, management and follow-up of a digital flexor pulley injury

We present the case of a rock climber with a rupture of the A3 flexor sheath pulley. The diagnosis was confirmed with Colour Doppler Imaging (CDI) and with B-mode ultrasound imaging, and the surgical repair was evaluated in the same way. Vertical displacement of the flexor tendon meant that using CDI measurements of the longitudinal movements was not possible. However, using computer analysis of digitized B-mode images from texture patterns identified in the tendons, the vertical and longitudinal components of movement during flexion were calculated. The repair of the pulley was shown to produce tendon movement ratios nearer those of the control digit of the opposite hand.