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A 19-year-old Arab woman who was previously operated on to desyndactylize her right second and third digits is presented in this case report. The patient's toes resyndactylized postoperatively and a keloid scar developed on the dorsum of her incision site. Syndactylism of digits is often discussed when involving the hand. However, it is much less frequently presented when it involves the foot, because surgical intervention is seldom necessary unless foot function is affected. Keloid scars are commonly encountered and pose a challenge to the podiatric physician because of their recalcitrant and recurrent tendency. This paper, detailing complete podiatric surgical treatment, is presented with a review of literature aiming to consolidate the presently known facts about syndactylism and keloids, and their treatment in the foot.

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In this paper, we direct attention to the systemic effect of low-power helium-neon (HeNe) laser irradiation on the recovery of the injured peripheral and central nervous system, as well as healing of cutaneous wounds and burns. Laser irradiation on only the right side in bilaterally inflicted cutaneous wounds enhanced recovery in both sides compared to the nonirradiated control group (P less than .01). Similar results were obtained in bilateral burns: irradiating one of the burned sites also caused accelerated healing in the nonirradiated site (P less than .01). However, in the nonirradiated control group, all rats suffered advanced necrosis of the feet and bilateral gangrene. Low-power HeNe laser irradiation applied to a crushed injured sciatic nerve in the right leg in a bilaterally inflicted crush injury, significantly increased the compound action potential in the left nonirradiated leg as well. The statistical analysis shows a highly significant difference between the laser-treated group and the control nonirradiated group (P less than .001). Finally, the systemic effect was found in the spinal cord segments corresponding to the crushed sciatic nerves. The bilateral retrograde degeneration of the motor neurons of the spinal cord expected after the bilateral crush injury of the peripheral nerves was greatly reduced in the laser treated group. The systemic effects reported here are relevant in terms of the clinical application of low-power laser irradiation as well as for basic research into the possible mechanisms involved.

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The degree of regeneration in surgically repaired sciatic nerves in rats was measured using a simple new electrophysiologic method: comparison of the size of nerve responses evoked by stimulation distal and proximal to the anastomosis. Five different repair procedures were evaluated. After simple end-to-end suture anastomosis, about 40% of the severed parent fibers regenerated past the suture line. The result was substantially improved when the anastomosis was covered with a newly designed thinwall silicone sheath which incorporated a narrow longitudinal slit. The presence of suture material at the point of anastomosis had no effect. Finally, regeneration across a 5-mm gap ensheathed in silicone (67%) was better than regeneration through a 5-mm autograft (45%).

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In order to improve gliding function of damaged flexor tendons in chickens, we topically applied enriched collagen solution (ECS) to the tendon sheaths of severed tendons. Previous studies using the same experimental model showed improvement of gliding function in the damaged tendons biomechanically and increased collagenolytic activity in the area of the damage after application of ECS. In the present study we evaluated the influence of ECS on peritendinous adhesion formation and on the healing process of the tendons histologically. We found that topically applied ECS reduced adhesion formation, mostly during the first week, without adversely affecting tendon healing or scar maturation.

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Two infants with hypernatremic dehydration (HD) who developed peripheral gangrene are described. A review of the literature revealed 10 infants who had HD and gangrene of the extremities. This combination could occur because of hypoperfusion and sluggish blood movement due to hyperviscosity, which coexist in HD, resulting in a disturbed microcirculation. We feel that the association of peripheral gangrene with HD may be a more frequent phenomenon than previously believed.

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Mycobacterium fortuitum was isolated from the synovial tissues of the dorsum of the hand after a dog bite. Caseating granulomas with Langhans' type giant cells were demonstrated microscopically. Healing followed prolonged treatment with antituberculosis drugs. It is suggested that the organism was forced into the patient's tissues by the dog's bite.

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An experimental model was designed in order to compare the results of wound healing after skin incision by CO2 laser and scalpel. The skin of 36 rabbits was incised by a CO2 laser with a 15-W current output and by scalpel. The wounds were tested for tensile strength and histology after healing up to 4 weeks to determine if scalpel wounds differed from those made by the laser beam. Tensile strength tests showed that the wound incised by the laser beam was initially stronger up to 3 weeks; thereafter, the strength of both types of wounds was equal. Histologic preparations showed partial necrosis of the wound edges and a more extensive inflammation response in laser beam incisions which disappeared gradually from 2 weeks after incision. Because of initial stronger scar following laser beam incision as compared with scalpel incision, early mobilization of the operated limb is possible.

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Fifty patients with painful hands due to inflammation, trauma, or surgery were treated by means of a Neurogar nerve stimulator. In 82% of the cases the results were satisfactory. Early physiotherapy was possible, and yielded best recovery and healing.

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A semirigid silicone cuff was investigated in rats to prevent scar entrapment of the sciatic nerve. Scar was induced by crushing or burning the surrounding muscles. On one side, the nerve was covered by a longitudinally split semirigid silicone tube. On the other side, the same procedure was done without silicone coverage of the nerve. At different time periods the animals were sacrificed and the nerve with surrounding tissues examined. The protected nerve was found gliding freely during mobilization of the limb. The blood supply to the nerve was maintained through the split in the silastic cuff by formation of new mesoneurium. On the control side, the nerve was surrounded by a fibrous tissue in various stages of maturation depending upon the time postinjury. The nerve structure showed reduced vascularity and progressive degenerative changes of the axons. Clinical tests on the silicone cuff method are proposed fo selected patients with extensive soft tissue injury around nerves.

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A forearm tourniquet for i.v. regional analgesia of the hand, using doses of bupivacaine smaller than in the conventional (upper arm) method, produced successful analgesia in 98 of 102 patients. In 63 patients bupivacaine 50 mg or less was adequate, while in 33 the dosage was between 60 and 75 mg. No toxic effect was noted. This technique permits surgery of the hand, wrist and distal forearm.

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A simple radiological grading of osteoporosis of the hand using a postero-anterior radiograph is presented as a screening technique. Five gradings are discussed, and the relationship of osteoporosis between the hand and axial portions of the skeleton is underlined.

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One-stage surgery in which an abdominal flap is used for coverage of the leg in the presence of fractured femur is suggested in cases of avulsion injury of the leg with multiple fractures. The efficacy of this concept was proved by experimental work.

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Impressions of two different regional anesthetic techniques used in the management of 670 cases in a hand surgery unit are described. For operations at or below the wrist, subcutaneous ring anesthesia for the forearm tourniquet, together with local nerve block or local infiltrative anesthesia using Lignocaine, is very satisfactory. It is effective, simple, and safe, and it permits patient cooperation with the surgeon, who can readily evaluate motor activity because the flexor and extensor extrinsic muscles of the hand are then not paralyzed. For more extensive upper limb surgery, intravenous regional anesthesia with Bupivacaine is very effective, though toxicity might result if the tourniquet is unreliable or is released too rapidly. These effects are minimized by the intravenous infection of diazepam (5 to 10 mg) immediately prior to release the tourniquet.

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Intrinsic hemangiomas of peripheral nerves are extremely rare. Eight cases have been reported in the literature and only two of them involved the median nerve. An extensive cavernous hemangioma with carpal tunnel symptomatology is reported.

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The long flexor tendons of the second, third and fourth toes of 94 chickens were cut and sutured. After operation the birds were divided into three groups. To reduce peritendinous adhesions, an aqueous solution of beta-aminopropionitrile (BAPN) was added to a solution of enriched native collagen (ECS) and applied to the cut tendons of one group; untreated controls and controls treated with collagen solution alone comprised the other groups. Chickens from each group were killed one, two, three, four and five weeks after operation. The results were evaluated both biomechanically and biochemically. It was found that the collagen solution alone had the same effect as the treatment with BAPN. It is suggested that the exogenous collagen present at the site of injury binds the collagenase inhibitor released by tendon cells, thus providing enough active collagenase to control the formation of fibrous adhesions. The inefficiency of BAPN in these experiments might have been due to either inadequate dosage or wrong timing, or both.

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