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We report a case of amniotic band syndrome complicated by constriction bands and marked distal swelling of both lower extremities. Color Doppler interrogation of the right lower extremity revealed complete lack of blood flow below the level of the constriction. Upon fetoscopic survey, the right lower extremity beyond the constriction band appeared dusky red and discolored with desquamation, consistent with a necrotic appearance. The constriction bands were cut in utero using endoshears, thereby allowing restoration of blood flow on postoperative day 1. The patient was counseled extensively regarding the possibility of limb dysfunction or amputation. However, the baby was born with functional lower extremities, and at 21 months of age, the child was cruising and jumping on his own. This case demonstrates that there is unique plasticity in fetal limb recovery after a severe ischemic injury that is not otherwise seen in postnatal life. Reperfusion of the necrotic-appearing limb resulted in restoration of appearance and function without apparent deleterious effects on the fetus. We believe the favorable outcome in this case was likely due to timeliness of the in utero lysis of amniotic bands and the plasticity of fetal healing.

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An unusual and previously unreported case of partially reversible ischemic myelopathy after limited unilateral segmental vessel ligation during scoliosis surgery is described. Intravenous lidocaine, used intraoperatively for its vasoactive properties, induced an immediate and meaningful recovery of neurologic function. The conceptual and pharmacologic basis for this intervention is discussed in view of this exceedingly rare complication of segmental vessel ligation.

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Compared with other surgical literature published after the Vietnam and Persian Gulf wars, hand surgery literature has been relatively void of information regarding projectile injury. Wound ballistics research of the past 10 years has shown that objective evaluation of tissue disruption is the only valid guide to treatment. The hand's anatomy requires hand surgeons to be more careful in tissue excision. Hand surgeons, therefore, do not have the luxury of "cutting till it bleeds." The purpose of this article is to support the methods that hand surgeons have traditionally used and to caution the inexperienced surgeon who may be inclined to excise uninjured tissue.

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We reviewed 15 patients with an arthrodesis of the elbow using an AO compression-plate technique, after an average follow-up of 24 months. The most common indication was an open, infected high-energy injury with associated bone loss. Arthrodesis was successful in all but one patient in whom severe deep infection necessitated amputation. Eight patients were treated with the metal partly exposed in an infected wound. After removal of the metal, all wounds healed secondarily and none had clinical or radiographic signs of sepsis at latest review. Compression-plate arthrodesis of the elbow is a generally applicable method that can be used even in cases of severe bone loss. There appears to be greater certainty of union than with other techniques, and no increased risk of subsequent fracture.

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We studied the long-term histologic results of a new method for autogenous vein grafting to examine whether stenosis at the anastomosis is maintained over time. Nineteen rat inferior epigastric veins were grafted into the femoral artery using a telescoping sleeve technique at both the proximal and the distal anastomoses. Specimens were studied macroscopically and histologically three months later. Stenosis at the anastomosis was located near the tip of the inserted vessel. The smallest inner diameters of the proximal and distal anastomoses were about 80% of the corresponding femoral artery diameter; no statistically significant difference was found between the two anastomoses. The grafts had a thickened wall due to intimal hypertrophy and fibrosis of the media. The inner diameter of the graft was, however, about twice that of the femoral artery, and these graft changes did not create any apparent constriction within the graft.

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An experimental study was performed to examine whether a microsurgical telescoping anastomotic technique could be applied twice in one vessel, for use in autogenous vein grafting. The rat inferior epigastric vein was grafted into a defect created in the femoral artery. The original telescoping method of Lauritzen was used, with two additional suture placements, to allow anastomosis at both proximal and distal sites. By placing the four sutures symmetrically and carefully timing the removal of the proximal and distal clamps, we achieved a patency rate of 77.3%. This is a new method for autogenous vein grafting that may serve as a prototype for an easier and possibly faster vein grafting technique. Our results appear to indicate that complete coaptation of the severed vessel ends is not necessarily required for patency in microvascular repair.

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Hand surgeons and therapists were faced with a new clinical entity in the 1980s with the emergence of hand and upper extremity infections in patients with AIDS and HIV disease. This entity has become a worldwide epidemic of vast proportions and has proven to be one of the major health concerns of the 1990s. It seems likely that treatment of patients with this devastating disease for hand infections or more routine upper extremity problems will become routine in the future. The reality of surgical treatment and hands-on rehabilitative therapy for patients with a life-threatening infectious disease has been a concern voiced publicly by very few health care professionals, yet discussed quietly among colleagues quite frequently. Our aim must be to provide the highest quality of health care to this group of hand patients, just as we do for all other patients, while at the same time providing the safest possible environment for all members of the health care team. It appears that there is a higher incidence of HIV infection among hand patients than is noted in the general public; therefore, the hand surgeon and medical team should pay particular attention to the rapidly advancing front of new information available regarding care for this challenging group of patients. Hand surgeons and therapists are entering the 1990s armed with a wealth of new and valuable information about HIV disease that has been produced by intensive basic science research and clinical observations accumulated over the last 10 years. The fears generated by the initial misinformation and lack of information concerning modes of transmission of HIV have generally been supplanted by a more rational approach to patient care, fostered by the more accurate scientific information currently becoming available. Unfortunately, the rational approach to the HIV-related political and socioeconomic issues has not yet overtaken the discrimination and stereotyping of the populace stricken with HIV disease. It remains the responsibility of the medical community to continue research efforts aimed at delineating the clinical deficiencies manifested by these patients and determining their effects on treatment regimens for both the unique and commonplace medical and orthopedic problems noted in this patient population.

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Joint sepsis and osteomyelitis have potentially devastating consequences in the hand. Local tissue and systemic immune system compromise increase vulnerability. Early and accurate diagnosis with specific organisms(s) retrieval is emphasized. Treatment includes drainage, debridement, appropriate antibiotics, and reconstruction when necessary.

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Nuclear angiograms were used to determine early and delayed patency rates following primary microvascular repair of 12 radial and 24 ulnar arteries in 36 patients. All patients had nuclear angiograms within 1 week after repair, demonstrating an early patency rate of 86.1%. Nineteen patients had additional nuclear angiograms at various intervals from 30 days to 2 years, showing a delayed patency rate of 68.4% at an average of 5.4 months follow up. Survival analysis showed that patency fell steadily during the first 90 days postoperatively, after which no further arterial occlusions occurred. Patency rates were not significantly affected by age or sex of the patient, level of forearm injury, total tourniquet time, treatment delay, or the diameter of nylon suture used for arterial repair. At follow up, there were statistically insignificant trends for higher patency rates in patients with partial vessel lacerations and in nonsmokers.

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Six patients with full-thickness skin loss complicating traumatic problems of the hand each had a retrograde forearm fascia flap transfer. Fascial pedicle flaps were used, because more conventional means of coverage had failed or were deemed inappropriate. Four patients had an uncomplicated one-stage flap transfer. Two patients had postoperative hematoma, but no further procedures were required. One patient had superficial necrosis of more than one fourth of the flap. Hematoma and necrosis were considered to be a result of a reversed flow occurring in the radial artery and its vena comitant and to the increased vascular pressure of the flap. This technique provides soft tissue reconstruction of the hand in one stage, with the advantage of early rehabilitation.

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We treated twenty-two consecutive patients for an open fracture and segmental loss of bone in the upper extremity by delayed insertion of a graft of iliac corticocancellous bone. All of the wounds were left open and healed by secondary intention. Sixteen patients (nineteen grafts) had long-term follow-up. Ten injuries were secondary to a gunshot wound. The ten patients (twelve grafts) who had an injury to the hand were followed for an average of 24.1 months. No patient in this group had an infection, and all had primary union after an average of 13.3 weeks. Nine had a satisfactory result. The other six patients (seven grafts) had an injury to the arm or forearm and were followed for an average of 30.2 months. There were four non-unions, one refracture, and no persistent infections. The final result was satisfactory in five and unsatisfactory in one patient. Fourteen of the nineteen grafts were inserted within seventeen days after the initial injury. All nine of the grafts in the hand that were inserted early did well, but three of the other five (in the arm or forearm) became infected. The method that was used in the patients who had an open injury of the hand allowed early active motion and quick rehabilitation. The exposed cortical bone was not prone to infection. The technique has limited application in patients who have an open injury of the arm or forearm because of a high incidence of complications.

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A case report of a cutaneous larva migrans caused by the nematode, Gnathostoma spinigerum, in which the worm was visualized at surgery and successfully removed, is presented. To the best of our knowledge, this is the second case of documented subcutaneous gnathostomiasis in the Western Hemisphere and the first in the upper extremity.

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This study correlates the excursion of the extrinsic finger extensors in zones V, VI, and VII and the extensor pollicis longus tendon in zones T IV and T V ("T" is used to designate thumb zones) with joint motion. Excursion was estimated by review of the literature, biomechanic calculations, and intraoperative observations. A simple equation determines extrinsic extensor tendon excursion in zone V, VI, and VII. This equation is substantiated by Brand's work on radians and by intraoperative studies. Guidelines are suggested for controlled motion for extrinsic finger extensors and the extensor pollicis longus tendon on the basis of our 6 years experience of treating extensor tendon injury with early passive motion.

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An elbow arthrodesis was performed as a salvage procedure in seven patients with an open elbow arthrosis resulting from open trauma and the multiple surgeries that had followed. Patients had undergone an average of four previous elbow operations since their initial injury. Patients had pain, limited motion and instability that seriously compromised ipsilateral upper extremity function. Hardware was placed posteriorly in five patients, and in two patients with predominantly posterior pathology and infection, it was placed anteriorly. All but one case was fused at 90 degrees of elbow flexion. Wounds were all left open and spontaneously healed by secondary intention. Six patients were available for an average follow up of 4 years. Time to fusion ranged from 4 to 9 months (mean 6 months). Patients were graded in terms of relief of symptoms, clinical fusion, radiographic fusion, return to employment, wound healing, shoulder and hand function, and forearm rotation. Three patients had an excellent result, two good, and in one, the result was fair. In our view, the surgical procedure of choice for a salvage elbow is an elbow arthrodesis.

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Initial operative care of mutilating injuries is discussed as well as reconstructive procedures for partial hand amputees, including digital transposition and bone grafting.

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