Volume 3 REPORTS OF MEETINGS 135 Number 2

REPORTS OF MEETINGS

H A N D S U R G E R Y

blternational Symposium, hem #1 Gdteborg, June, 1971

The Pattern of Ramification of the Volar Digital Nerve in the Distal Segment of the Finger and the Relation- ship of this Pattern to the Maintenance of Sensibility following Kntler-type Revision of Distal Finger-tip Amputations: JAY B. H'ANN III, U.S.A.

A study of the distribution of nerves in the finger- tip suggests that when Kutler's flaps are used to close an amputation stump they should be right- angled triangular, with the right-angle near the angle between the nail and the cut surface. The hypotenuse faces proximally and towards the palm and this edge must be cut with due regard for the fact that the nerves cross this line to gain the flap. Kutler's method of closure should not be used to cover protruding bone. Advancing palmar skin might allow closure but the necessary undermining makes for poor sensibility.

The Cross-thumb Pedicle Flalr---a Study of its Func- tional Value: J. W. TUPr'ER, U.S.A.

A proximally based flap from the dorsum of the thumb was used for 70 persons with amputation through finger-tips. Twenty-two were studied at least 1 year after operation. All flaps regained pro- tective sensibility and 50 per cent were nearly normal in the pick-up test. Two-point discrimination varied a good deal and bore no relationship to the quality of function. Some stiffness of the thumb was not unusual.

Interdigital Butterfly Flap: DE WAYNE G. RICHEY, U.S.A.

The interdigital butterfly flap allows correction of scarred webs. It comprises a trapezial flap with a dorsal base. Contiguous with its palmar edge are two triangular flaps that meet point-to-point at the middle of that edge and have their bases laterally. The dorsal flap is advanced to lie between the tri- angular flaps.

Considerations on 17 Cases of Neurovascular Island Flap Transfer: CLAUDE VERDAN, Switzerland

In a span of l0 years 17 patients 05 male, 2 female) had a heterodigital neurovascular island flap trans- ferred to the pulp of the thumb or index finger. The method offers many advantages in autoplastic reconstruction of the thumb, irreparable proximal lesions of the median nerve, and injury to palmar collateral pedicles. Difficulty in integrating the transfer of sensation and some loss of tactile gnosis are the major drawbacks.

Small flaps are more likely to develop neuromata because so many nerves are cut in them. The quality of transferred sensibility is not usually perfect. The donor area usually retains some sensibility.

In discussion, Professor E. Moberg recommended advancing all the palmar skin when it was wished to restore sensibility to the tip of a short amputation stump. It was clear from the comments of several participants in discussion that initial enthusiasm for neurovascular island flaps had become tempered by the realism born of experience, while the devising of innervated flaps of more conventional nature had been stimulated.

Reconstruction of the Nail Fold destroyed after Burns: BENT BARFOD, Denmark

A lateral flap from each side of the pulp can be used to restore a nail fold that has been destroyed by scarring. The flaps are based near the tip and comprise little more than dermis. Having been raised they are then replaced over full-thickness grafts that have been applied to their beds. If this test of viability is passed, after 2-3 weeks the flaps are laid in place side-by-side over the base of the nail.

Dr. R. J. Smith suggested that a simple ' cross-bar f lap ' should be advanced to cover the base of the nail. Dr. J. Boyes appealed for simplicity whenever possible.

Cosmetic Surgery in the Hand with Maintenance of Function: BRUCE N. BAILEY, Aylesbury

The title referred to the excision of tattoo marks that had lost their appeal for the owners. Whenever possible a single sheet of thick split skin was used to resurface the raw area. Such operations on the backs of hands had something in common with the treat- ment of burns in the same area.

Volkmann's lschaemic Contracture: CATO HELLUM, Norway

Excision of the infarct in Volkmann's ischaemia is most successful when the remaining muscles are healthy and suffice for transplantation, and when the nerves have escaped serious damage. In discussion Dr. J. Boyes drew attention to the desirability of removing dead muscle before it had time to damage what survived.

The Sp~mgberg and Thor~n Procedure for Bennett's Fractures: H. J. HAMBURY, Swansea

The Spfingberg and Thor6n procedure for Bennett's fractures was used for 18 fractures. A bent Kirschner wire was used like a hook to pull the displaced metacarpal into place, traction being applied from a metal loop over the hand. Traction was applied for 4-6 weeks and the patients were off work for 9 weeks on average.

136 INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY Injury Oct. 1971

Fracture-dislocations of the Base of the First and Middle Phalanges of the Fingers: EMANUEL TROJAN, Austria

Fracture-dislocatious of the base of the first and middle phalanges of the fingers are often unstable and need internal fixation with Kirschner's wire. Chip fractures of the flexor and extensor lips of the middle phalanx can usually be treated successfully in this way, but the comminuted fractures are usually better treated by early movement; uncorrected displacement is consistent with good function and radiological sign of degeneration is not synonymous with disability.

Accurate reduction and internal fixation by trans- fixing fragments with wire is theoretically attractive but requires a good deal of skill.

Free Tendon Graft and Extensor Apparatus Advance- ment in the Treatment of Metacarpophalangeal Joint Injuries of the Thumb: RICHARD J. SMITH, U.S.A.

Old ruptures of the ulnar collateral ligament of the thumb are not usually suitable for direct repair. A free tendon graft is taken through a hole drilled, usually in the base of the phalanx, woven through the capsule, and taken back to the phalanx. This repair can be reinforced by pleating the extensor apparatus.

The Treatment of the severely Stiff Proximal Inter- phalangeal Joint following Trauma by SUastic Re- placement Arthroplasty: HAROLD BOLTON, Manchester

From 50 to 80 ° of movement was restored to 10 very severely injured proximal interphalangeal joints by excising the joints and putting in Swanson's silicone rubber ' hinges '.

Concepts and Pitfalls in Flexible Implant Arthroplasty in the Hand: ALFRED B. SWANSON, U.S.A.

In the past eight years there have been designed, tested, and used 18 different implants in reconstructive surgery of the extremities. These have been for cushions for end-bearing amputations, for control of the overgrowth problem in the juvenile amputee, and implants to be used in association with joint reconstruction in both the upper and lower extremity.

There has been a considerable experience in the use of art intramedullary stemmed, silicone rubber, heat-moulded implant for the proximal interphalan- geal, and the metacarpophalangeal joint of the fingers. One hundred hands have been done and carefully analysed, and more than 4000 hands have been in- cluded in a study that includes more than 200 surgical clinics around the world. The concept of the flexible intramedullary stemmed implant is that it is mainly a space-occupier which improves a resection arthro- plasty. The implant maintains the appropriate joint space, provides a mould around which the liga- ment and capsule system can form, and helps maintain alignment and prevent excessive distortional move- ments. The implant is not, in itself, a joint, but became of its presence, it allows the resection arthro- plasty to perform as a more perfect joint system. With this concept in mind, the flexibility and a degree of movement of the implant is of importance. The small amount of movement and piston action that occurs around the implant improves the range of

motion and also improves the life of the material. There has been as much success with the proximal interphalangeal joint as with the metacarpophalangeal joint. The surgical technique and postoperative measures are slightly different. It is our opinion, on review of our cases and those of the other clinics, that these flexible implants can facilitate a stable, mobile, and painless joint with long life, satisfactory for most patients. I t should be emphasized that other surgical procedures are as important in implant resection arthroplasty as in any resection arthroplasty.

The pitfalls of improper employment of the im- plants for small joint arthroplasty are failure t o : - -

1. Release joint subluxation and contracture completely.

2. Prepare bone and seat implant adequately. 3. Select proper size implant. 4. Rebalance tendon and muscle forces around

joints. 5. Outline a rehabilitation programme including

dynamic bracing. 6. Avoid severe deforming forces in hand usage. The 1-2 per cent complication rate reported in my

survey can be avoided by careful surgery and post- operative care. The range of motion can be improved by a carefully supervised rehabilitation programme.

In my opinion, the design of the implant is well worked out. Improving the silicone polymer by increasing its toughness and tear resistance is impor- tant and is progressing.

The flexible implant resection arthroplasty is a useful addition to the armamentarium of the hand surgeon. Its success depends in great measure on the appreciation of the implant as a dynamic spacer in a resection arthroplasty.

Prosthetic Finger-joint Replacement in the Rheumatoid Hand: F. V. NICOLLE, London

A new design of the prosthetic finger-joint is described which has been developed at the Royal Postgraduate Medical School, London. This is an integral hinge made of polypropylene, fitted with a spherical capsule of silicone rubber which prevents direct soft-tissue contact between the hinge and the surrounding soft tissue. The capsule is perforated, allowing active circulation of the interstitial fluid which forms within it. A description of the design features, laboratory testing, and animal experiments was given, also a report of clinical results during the past year, in which 70 joints have been implanted into the metacarpophalangeal and proximal inter- phalangeal joints. All cases showed improved func- tion with good range of active flexion and extension as well as lateral stability.

A New Buried Compression Arthrodesis Device for Use on Small Joints of the Fingers and Hands: J. W. TUPPER, U.S.A.

Dental traction pins and eyelet wires were used to provide compression and accurate bone-to-bone contact in arthrodesis of small joints. Fusion took about 3 months but the device could be buried.

' Compression Plate ' Fixation for Barton's or Smith's Type H Fractures: EDWARD E. A.LMQUIST, U.S.A..

Six persons with Smith's or Barton's fractures were treated with a stout plate screwed to the flexor

Volume 3 Number 2 REPORTS OF

surface, beneath pronator quadratus. A light plaster splint was applied as well.

Problems of Reconstructive Surgery of the Wrist- joint: H. CH. MEULI, Switzerland

An AO plate was used for arthrodesis of the wrist, being screwed to the radius and to the second metacarpal bone.

Median Nerve as Free Tendon Graft: J. GELDMACHER, Germany

Following Geldmacher's report of a single case it became evident that several surgeons present had seen cases in which the median nerve had been used in error as a tendon graft. One explanation was that the palmaris longus, though present, was so small as to be overlooked when the graft was taken.

Results of 10 Years ' Experience with Artificial Tendons: JAMES M. HUNTER, U.S.A.

The concept of using movable artificial tendon to provoke the formation of a gliding sheath in badly scarred fingers was published in 1965. The implant is made of silicone rubber reinforced with dacron. It is secured distally and left free at its proximal end. It is stiff enough to slide through the tissues--as was shown by cineradiography--and it is the gliding that induces the surrounding tissues to form an orderly synovial layer. A standard tendon graft is in due course drawn through the new sheath in the wake of the implant.

Results of staged flexor tendon reconstruction in 74 patients using Boyes' preoperative classification showed that in the less than optimal Grades 2-5, 80 per cent of cases flexed to within 1 in. of the distal palmar crease.

The improved results obtained in this review led the author to conclude that the two-stage procedure described is the one of choice in properly selected old injuries where the conditions are less than opti- mal for tendon grafting.

Square Wave Electrical Impulses in Electro-diagnosis of Skin Denervation--Application in Hand Surgery: GIUSEPPE BURATTI, Italy

The electrical resistance of skin stimulated by square waves depends upon the degree of activity of sudomotor nerves and can be used as a measure of the extent and degree of denervation. The tech- nique was described.

The EPL.test of Ulnar Nerve Paralysis: L. MANN- ERFELT, Sweden

This new technique for demonstration of paralysis in adductor pollicis and first dorsal interosseous in cases of total ulnar nerve lesions is based on the fact that the EPL muscle and tendon is the true adductor substitute.

Description: With the wrist in maximal velar flexion the patient is unable to adduct his thumb because of the fact that the EPL tendon is dislocated radial to the dorsal-velar axis of movement of the thumb. If the patient extends his wrist-joint the EPL tendon slips to the ulnar side of the axis and is then able to abduct the thumb towards the velar part of the index finger. Limitations of the test depend on the patient's ability to flex the wrist-joint in velar direction and on the condition of the EPL

MEETINGS 137

tendon. A positive EPL test when the thumb is unable to adduct towards the index finger is a proof of paralysis of the muscles mentioned above.

Neurosis and Neurones in the Hand: P. S. LONDON, Birmingham

So-called ' neu roma ta ' in the digits are usually no more than scars that include stumps of nerves. Not many patients will use percussion to relieve the tenderness, but an operation to free the nerve-end or to divide the nerve above it is usually successful. Such neuromata should be prevented by cutting the nerves before sewing up either an accidental or a surgical amputation stump.

Multiple neuromata sometimes occur round a neurovascular island flap to spoil a good-looking reconstruction.

Clearly to be distinguished from those with tender stumps of nerves are persons of an anxious disposi- tion and an over-protective attitude towards an amputation stump, however skilfully fashioned. This is an expression of personality rather than of an unreasonable desire for money to compensate for injury. An unsatisfactory stump should be re- fashioned, but it is unwise to do this until the surgeon feels that the relationship between himself and the patient is such that the patient understands that it is for him to make a success of the operation that the surgeon proposes to carry out. Many so-called neurotic reactions owe something to the fact that amputations of fingers are looked upon as minor surgery, and are in consequence carried out by juniors who lack experience both in the correct method of amputation and in the correct subsequent management of patients who need an attitude of firm assurance when all is well.

Median Nerve Repair--Primary Nerve Isolation using Silastic followed by Early Secondary Repair: W. M. McQUILLAN, Scotland

By enclosing a freshly cut nerve in a silicone rubber tube it is possible to avoid adhesions and bulbous neuroma. Secondary suture after about 3 weeks is facilitated by the fact that the nerve-ends are free and unscarred.

Dr. J. W. Tupper added that a silicone rubber tube could be used to promote the formation of a sheath after stripping up the cut part of a partly cut nerve.

High Median Nerve Injuries with Associated Arterial Injury: JOHN A. BOSWlCK, U.S.A.

When the median nerve is the only nerve injured by laceration or gunshot in the arm, the brachial artery is commonly involved. Findings in these patients included : - -

1. Decreased sensibility over the velar aspect of the thumb, index, long, and part of the ring finger as well as part of the dorsal aspect of all these digits.

2. Atrophy of the forearm flexor mass and thenar musculature.

3. Lack of interphalangeal flexion in the thumb and index finger, but in no other digit.

4. Inability to rotate the thumb for adequate grasp in about 30 per cent.

5. Weakened forearm pronation. When the artery was damaged as an associated

injury, distal ischaemia was never apparent.

138

Following arterial repair, distal pulses always returned; some were delayed for as long as 3 days. Patency at the site of anastomosis was demonstrated in all cases by arteriograms.

After nerve suture (both primary and secondary) the ability to distinguish between a sharp and a blunt object always returned. Normal two-point discrimination returned in 3 patients within 30 months. Digital flexion returned in all patients. However, the ability to rotate the thumb to a posi- tion adequate for grasp was restored in only I patient.

Damage to the hand by heat during nerve regenera- tion occurred in about half of the patients. The other notable complication was the development of a grasp pattern that excluded the index finger.

Injury INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY Oct. 1971

This persisted in some patients after the ability to flex the digit actively had been restored. Tendon transfer was effective in restoring thumb rotation in those patients in whom it was lost. Early tendon transfer should be considered in all these patients to minimize the development of poor grasp patterns and to restore optimal hand activity as early as possible.

Restoration of a Functional Prehension in Patients with a Cervical Spinal Cord Injury by means of Orthoses: GOTTLEIB ZRUBECKY, Austria

Zrubecky showed the high technical standard of the mechnical aids provided in Austria for the victims of tetraplegia.

P.S.L.

O R T H O P A E D I C S U R G E R Y

Eighteenth Congress of the South African 1971

The Blood-supply of the Lumbar Spine and its applica- tion to the Technique of lntertransverse Lumbar Fusion: D. DALL and I. MACNAB, Cape Town and Toronto

Dall and Macnab used intertransverse fusion for painful instability of the lumbar spine, having used discography to show the extent of fusion neces- sary. Previous dissections, using corrosion casting had shown that there were two arteries just lateral to the zygapophyseal joint line and one more just lateral to the pars interarticularis. If these were avoided there was much less bleeding.

Halopelvic Traction for the Correction of Spinal Curves: A. R. HODOSON, Hong Kong

Although halopelvic traction has been developed in order to correct scoliosis it can also be used to correct deformity resulting from injury and it can be worn over a year if necessary. Inserting the pelvic pin requires suitable apparatus and a clear understanding of the anatomy of the area.

Recurrent Posterior Dislocation of the Shoulder: H. B. BOYD, Campbell Clinic, U.S.A.

Only about 2 per cent of recurrent dislocations were posterior. Some followed injury, others could be ascribed to loose joints, in which case they affected both shoulders and were found more often in women than in men. Dislocation should not be operated on if the patient is able to cause and correct it volun- tarily. McLaughlin's operation should be used for long-standing dislocations with much-deformed heads. Otherwise the tendency of the long tendon of biceps brachii to press the head backwards and downwards should be removed by cutting the tendon and stap- ling it to the back of the neck. The operation had been performed succe.ssfully 11 times on 10 persons.

The Assessment of Progress in Osteomyelitis: E. E. G. LAUTENBACH, Johannesburg

The usual diagnostic criteria could be misleading. In 20 per cent of cases no growth was obtained from swabs. Only 54 per cent of first swabs were

Orthopaedic Association, held in Johannesburg, June,

positive; the percentage rose to 80 if four swabs were examined. Blood-culture was persistently negative in just over one-third of acute infections. The white count did not exceed 10,000 per c.mm. in 60 per cent of cases. The E.S.R. was raised in 80 per cent of acute cases but in only 50 per cent of the chronic ones.

Antistaphylococcal titres rose early in acute disease but were of no value for assessing progress in chronic cases. In short, simple signs such as local warmth and swelling were as reliable as those investigated but healing of sinuses did not mean that the disease had been cured. Antibiotics should be continued for I month after all signs of activity have gone, but not for more than 4 months.

The Prevention and Management of Thrombo- embolism: P. S. LONDON, Birmingham

Phlebography, radio-iodinated fibrinogen, and post-mortem dissection of the venous tree have shown that even the most vigorous application of conventional methods to prevent venous thrombosis fails in at least one-quarter of cases. Electrical stimu- tion of the calf during operation may be of value. The proven success of phenindione and warfarin depends on their being started in time and is limited by any undue tendency of the patient to bleed; there may also be difficulty in stabilizing dosage.

Once thrombosis has occurred, which happens about twice as often as there are physical signs of it, most thrombi can be dispersed in time by the use of anticoagulant drugs. Streptokinase is best reserved for acute and dangerous conditions such as phlegmasia caerulea dolens. Thrombectomy is disappointingly often followed by fresh thrombosis. Ligation of the inferior vena cava is of questionable value. Pulmonary embolectomy should be considered when there is no time to institute medical treatment or if such treatment does not lead to improvement.

The Prevention and Treatment of Painful Amputation Neuromata: S. L. BIDDULPH, Johannesburg

All neuromata showed similar histological feat~es, but if the nerve-ends were stitched into snugly fitting