Arthritis of the basal joint of the thumb. A critical analysis of treatment options

The basal joint of the thumb is commonly afflicted with degenerative changes, especially in postmenopausal women. This can be debilitating because of the importance of the thumb to overall hand function. There are a variety of treatment options for the patient with arthritis of the basal joint of the thumb. Most patients can successfully be treated conservatively, which includes splinting, antiinflammatory medications, physical therapy, and activity modification. For those who fail conservative therapy, surgical treatment is based on clinical staging. Patients with early degenerative changes are candidates for ligament reconstructive procedures or arthrodesis. Those with more advanced disease may benefit from excision, tendon interposition arthroplasty, suspensionplasty, silicone implant arthroplasty, or total joint arthroplasty. The advantages and disadvantages of each procedure, as well as the relative indications and contraindications of each, are critically assessed.

A behavioral perspective on conduct disorders

THIS paper provides a selective overview of behavioral approaches for conduct-disordered behavior. Although no definitive statement can be made regarding etiology, some empirical support exists for behavioral strategies. Assessment approaches discussed include the behavioral interview, behavioral observations, and behavioral checklists. Decisions regarding types of behavioral interventions to be employed directly follow from assessment data. Assessment information can be formulated in terms of a behavioral excess/skill deficit model. Hence, conduct-disordered behavior can be a function of excessive disruptive behavior and/or a lack of requisite skills necessary to obtain satisfaction. Parental training strategies in contingency management and contingency contracting are discussed regarding behavioral excesses. Relative to skill deficits, contingency procedures along with skills training in communication, problem-solving and self-control are reviewed, using parental training and cognitive-behavioral frameworks. In general, these interventions have empirically demonstrated efficacy. However, future research is required to identify specific factors that account for successful treatment, and attention should be directed toward preventive issues. Important data could be obtained from the identification of high-risk environmental situations. A predictive understanding of high-risk populations could result in the development of early intervention programs, which might to some extent obviate the occurrence of conduct disorders.

Preventing oxygen free-radical injury in ischemic revascularized bone grafts

Superoxide radicals have been shown to play a role in the cellular injury of reperfused ischemic tissues. We examined the protective effect of superoxide dismutase (SOD), a superoxide radical scavenger, on the reperfusion injury of replanted vascularized bone grafts after 4- and 8-hour periods of ischemia in a rat model. Histologic, fluorochrome, and histomorphometric analyses showed no difference between 4-hour superoxide dismutase-treated and control grafts, with both groups appearing viable. Similar analyses of the 8-hour ischemic grafts revealed both a qualitative and statistically significant quantitative difference (p less than 0.001) between the superoxide dismutase-treated and control grafts in parameters related to viability. Our results indicated that the administration of superoxide dismutase to free vascularized grafts by means of intraarterial perfusion after prolonged periods of warm ischemia significantly enhances the survival of these grafts.

Slowly enlarging pedunculated mass on the edentulous maxillary alveolar ridge

Peripheral ossifying fibroma is a fairly common, benign, reactive lesion that should be included in the differential diagnosis of slow-growing, nonaggressive tumors arising in the tooth-bearing areas of the jaws. The variations in terms and descriptions may require that the clinician communicate with the pathologist to determine the true nature of the lesion. Although peripheral ossifying fibroma is a benign, reactive lesion, the recurrence rate is fairly high and postoperative follow-up is needed.

Congenital pseudarthrosis of the forearm

Congenital pseudarthrosis of the forearm is a rare condition in which traditional treatment methods have proven unsatisfactory. We report a case of congenital pseudarthrosis of the radius and ulna successfully treated by resection of the distal ulna and excision of the radial pseudarthrosis with replacement by an interpositional free vascularized fibular graft.

Extensor tendon repair: a reconstructive technique

Extensor tendon injuries are commonly encountered and are frequently treated with less regard than flexor tendon injuries. However, several factors make them as difficult to treat and more prone to suture line rupture than their palmar counterparts. A technique is described to protect a tendon juncture on the back of the hand following tendon disruption. This allows early finger motion to prevent joint stiffness while preventing suture line disruption.

Sex-linked recessive congenital ataxia

A family is reported in which three boys, two full brothers and a half brother, presented with marked delay in motor milestones, severe limb and truncal ataxia, nystagmus, speech delay and moderate global retardation. Autosomal recessive and sex linked recessive forms of cerebellar hypoplasia are reviewed and it is suggested that this family may have a rare, if not unique, form of sex-linked cerebellar ataxia.

Intrafamilial variation in Cohen syndrome

Three sibs with Cohen syndrome are presented. Abnormalities present in all three children include mental retardation, hypotonia, and short philtrum with open mouth and prominent lips. The older two sibs have a similar facies and an engaging personality. The youngest child shows a different facial appearance and marked behavioural problems, thereby illustrating the intrafamilial variability which may occur in this disorder.

Neuraminidase deficiency: case report and review of the phenotype

A 12 year old boy with neuraminidase deficiency (sialidosis, mucolipidosis I) is described. His clinical features included coarse facies, cherry red spot, ataxia, myoclonus, and dysotosis multiplex. The level of neuraminidase activity in cultured fibroblasts was very low and intermediate levels were observed in both parents. The clinical disorders associated with neuraminidase deficiency are reviewed.

Independent index extension after extensor indicis proprius transfer

The extensor indicis proprius was used to restore mobility to a variety of hand movements in 27 patients. Retained independent index finger extension was obtained in a majority of patients postoperatively. Potential postoperative complications of index extension lag and deviation may be avoided if the extensor indicis proprius is sectioned immediately proximal to the dorsal hood. A corresponding laboratory study was undertaken to better define the anatomic constraints limiting independent finger extension. Distinct differences between juncturae tendinum and extensor compartment musculature help explain why the index finger may function as a relatively independent unit.

Extraskeletal osteochondromas of the wrist

Extraskeletal osteochondromas of the wrist are described in two patients. They both had painless, slow-growing wrist masses, one palmar and one dorsal. Radiographs demonstrated the presence of an extraskeletal, radiopaque mass. Excisional biopsy showed extraskeletal, firm, calcified masses. Histologic examination revealed mature hyaline cartilage, with extensive ossification consistent with the diagnosis of extraskeletal osteochondroma. The ambiguous nomenclature for this cartilage lesion and the differential diagnosis of extraskeletal calcification are reviewed.

Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive technique

Ulnar subluxation of the extensor digitorum communis over the metacarpal head can compromise the function of the extensor mechanism to the affected digit. Extensor displacement can be posttraumatic, developmental, congenital, or caused by arthritis of the metacarpophalangeal joint. A tendon centralizing procedure was performed on five digits in three patients who had posttraumatic ulnar subluxation of the extensors at the metacarpophalangeal joint after conservative management failed. No recurrences of subluxation have been noted in this series, and all patients have regained full range of motion.

Experimental vascularized bone allografting

Presented here is a compendium of studies investigating the fate of vascularized bone allografts. The first set of experiments employ the posterior rib graft in two canine models. The rib-to-mandible model was used to evaluate the rejection phenomena of vascularized bone allografts in an outbred dog model. This ascertained the time course of rejection and histological characteristics of the grafts. Immunosuppression of the graft recipients was attempted with azathioprine and cyclosporine. The results demonstrated that azathioprine was not an effective immunosuppressant, whereas cyclosporine resulted in survival of cortical osteons. The use of the vascularized rib allograft, with and without azathioprine, to bridge the defect in the dog femur was met with failure. Further studies employed a genetically defined rat model to determine the effect of different histocompatibilities on the survival of vascularized knee allografts. Grafts were transplanted from Lewis rats to syngeneic Lewis rats as isografts and to Fischer-344 rats (F-344) and Brown-Norway rats (BN) as allografts. Grafts across a major histocompatibility barrier to BN were rejected by 7 days, whereas grafts across a weak histocompatibility barrier to F-344 were rejected more slowly. The use of cyclosporine in this model abrogated the rejection response when administered to both groups continuously. However, a short course of cyclosporine was effective in preventing rejection in the F-344 animals. Efforts to induce tolerance by blood transfusions, from the donor strain or from a third-party donor, were not effective in preventing rejection.

Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients

Seventy-six reconstructive procedures were performed to treat tendon rupture in 60 patients with rheumatoid arthritis. Tendon rupture commonly occurred in the extensors to the ring and small fingers. However, ruptures of extensors and several flexor tendons were also encountered. Single or double tendon ruptures responded successfully to a variety of tendon transfers. Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall function. Early aggressive treatment of distal radioulnar joint derangements in the rheumatoid wrist is recommended to forestall many cases of tendon rupture.

Leiomyosarcoma of the forearm: treatment with wide local excision and a lateral arm flap

Leiomyosarcomas of the subcutaneous tissues in the upper extremity are extremely rare tumors. We report a subcutaneous leiomyosarcoma of the forearm in a 52-year-old man who was treated with wide local excision and reconstruction with a free lateral arm flap.

Vascularized tissue transfer in the treatment of osteomyelitis

In conclusion, the efficacy of free tissue transfer in the treatment of osteomyelitis is geared mainly at enabling the surgeon to perform a wide radical debridement of infected and nonviable soft tissue and bone. Definitive bony management does not have to be performed concurrently with the soft-tissue coverage procedure and may be effectively staged. The type of free tissue transfer employed will depend upon the size and location of the defect, the condition of the contiguous structures, and the experience of the surgeon. Free tissue transfer that is used judiciously after the eradication of all infected bone and soft tissue appears to be a useful technique for controlling osteomyelitis.

Lipomas compressing the radial nerve at the elbow

Four patients have been treated for compression of the radial nerve by lipomas at the elbow. The treatment of all cases was surgical excision with complete resolution. Lipomas are a very common tumor but infrequently cause nerve compression symptoms.

Free vascularized bone and muscle flaps for osteomyelitis

Chronic, post-traumatic osteomyelitis remains an unsolved problem for orthopedists. With improved knowledge of skin and muscle flap circulation, surgeons are now capable of covering wide defects left by debridement. Early clinical experience with muscle and skin flaps to improve vascularity and achieve a stable, closed wound have been encouraging. Management of wounds with infected bone is primarily aimed at resection of infected or nonviable tissue. Antibiotics are of value, however are of secondary importance to a thorough debridement. It is uncertain as to whether osteomyelitis is a curable entity. However, free tissue transfer affords the surgeon the opportunity to perform a thorough debridement and achieve a stable closed wound.

Familial calcification of the basal ganglia with cerebrospinal fluid pleocytosis

Two related infants with microcephaly, spastic quadriplegia, and profound retardation are reported. Both showed extensive bilateral symmetrical calcification of the basal ganglia with cerebrospinal fluid pleocytosis.