Faculty Bibliography

To identify which patients are likely to respond the medical management of carpal tunnel syndrome, 331 hands in 229 patients were evaluated. They were then treated with a wrist splint and anti-inflammatory medication. Follow-up averaged 15.4 months (minimum six months). Treatment was successful in 18.4%. Statistical evaluation identified five factors which were important in predicting response to treatment: age over 50 years, duration over ten months, constant paraesthesiae, stenosing flexor tenosynovitis, and a Phalen's test positive in less than 30 seconds. When none of these factors was present, two-thirds of patients were cured by medical therapy. 59.6% of patients with one factor, 83.3% with two factors, and 93.2% with three factors failed. No patient with four or five factors present was cured by medical management.

Eight patients are reported with hand infections and a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). Seven patients had AIDS and one ARC. Four were homosexually active males, three were intravenous drug abusers, and one was the wife of a presumed drug abuser. The hand infections were not truly opportunistic; three patients had herpes, two had osteomyelitis, one had septic arthritis, and two had bacterial abscesses. The presentation or course of the infection was atypical in the majority of patients. The infections were seen early in the course of the disease and in one half of the patients preceded the diagnosis of AIDS. Unusual hand infections, then, may suggest the development of AIDS in a patient at risk.

Painful arthrosis of the basal joints of the thumb covers a spectrum of arthritic disease. The painful hypermobile thumb with articular cartilage preserved requires an entirely different type of treatment than does the similarly painful basal joint, which has stiffness and degeneration of more than one facet of the trapezium. By careful radiographic evaluation of the trapezial articulations, particularly in the lateral projection, a reasonable set of radiographic guidelines for staging of the degenerative process can be provided. One must be prepared to adjust this preoperative staging should direct inspection of the articular surfaces at surgery indicate more damage than perceived on the radiograph. Once the ultimate staging of the disease has been established, the means of treatment is considerably simplified and the multiple procedures that have been proposed for "basal joint arthritis" can be applied more accurately.

Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.

Twenty-one patients with chronic intercarpal instability were operated on an average of 13.2 months after injury or onset of symptoms. Fourteen had reconstruction via dorsal approaches by use of radial wrist extensor or other tendon graft. Seven patients were approached dorsally and palmarly, three had ligament repair, and four had reconstructions. The average follow-up was 25.4 months. Pain decreased in 85.7% of patients, although only two were pain free. Range of motion (ROM) generally decreased, and grip strength increased slightly. Radiologically, there was significant improvement on the initial postoperative roentgenograms, much of which was lost by the time the final roentgenograms were obtained. A clinical and radiologic grading system was devised to evaluate results. The average clinical grade improved from poor (26.5%) preoperatively to fair (44.4%) postoperatively. The radiologic grade remained in the poor range postoperatively, although there was some improvement from 40.4% to 45.6%.

The case is presented of a 28-year-old woman with systemic vasculitis, aortic insufficiency, and an aneurysm of the proximal right coronary artery. More than 100 patients with coronary artery aneurysm have been reported, and this represents the twenty-first case treated surgically. Coronary artery aneurysms occur more frequently than previously realized and are seen in approximately 1.5% of patients with coronary artery disease. In addition to arteriosclerotic aneurysm, other common types of coronary aneurysm include those occurring congenitally or from mycosis, dissection, trauma, vasculitis, or periarteritis nodosa. Because of the risk of thrombosis and rupture, aneurysmectomy and saphenous vein bypass grafting are recommended for all but small, diffuse, or multiple aneurysms or dissecting aneurysms.