Biomedical subjects
Publications and source records attributed to M H Gonzalez.
Seventeen African-American patients were operated on for Dupuytren's contracture over a 14-year period. Six-month minimum follow-up was available for 16 patients. The initial deformity, and results of surgical release of Dupuytren's contracture in this population was similar to that described in North Europeans.
Forty cadaver hands (160 fingers) were dissected to study the morphology and variations of the chiasma of the flexor digitorum superficialis tendon. Ten types of chiasma were noted. One chiasma did not fit into any of the patterns. The long and ring fingers had a very similar distribution of types of chiasma but the index and small both had different patterns. The length of chiasma showed a marked variability which appeared to be independent of phalangeal length.
Twenty-eight proximal phalangeal fractures secondary to low-velocity gunshot wounds in 27 patients treated by stable fixation were retrospectively reviewed. Definitive fixation was performed within 1 week of injury. Fractures were stabilized with either a plate, intramedullary spacer, or a combination of both. When necessary, supplemental fixation was achieved with cerclage wires or interfragmentary screws. Twenty fractures with bone loss or comminution were primarily supplemented with iliac crest bone graft. After surgery, the fingers were splinted in 90 degrees of metacarpophalangeal (MP) flexion. An aggressive supervised therapy program was initiated within 24 hours of surgery. The average length of follow-up care was 9 months (range, 3-29 months). Primary union was achieved in all fractures. The average range of motion was 83 degrees for the MP joint and 66 degrees for the proximal interphalangeal joint. The average total active motion (TAM) for the involved digits was 200 degrees (range, 65 degrees-250 degrees). Fractures without intra-articular extension had a significantly better average TAM (213 degrees) than did those with intra-articular extension (169 degrees; p = .05). Primary bone grafting did not adversely effect the final TAM. There were no infections. Early stable fracture fixation of these injuries achieved union, alignment, and early rehabilitation with no appreciable increase in morbidity.
Twenty-eight patients with upper extremity infections and positive for the human immunodeficiency virus (HIV) were identified. The risk factor for HIV infection was intravenous drug injection in 24 patients, homosexual contact in 3, and heterosexual contact in 1. Eight of the patients had the acquired immunodeficiency syndrome. Two of the cases were prolonged herpetic infections of more than 6 months' duration that did not respond to oral acyclovir. The other 26 cases were bacterial in origin. Twenty-six of 28 cases responded to therapy with resolution of the infection. One patient refused surgical treatment and one died of systemic illness before resolution of the hand infection.
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Necrotizing fasciitis is a severe, fulminant infection most commonly encountered in patients with diabetes mellitus, alcohol abuse, and intravenous drug abuse. The infection can spread-unrecognized along fascial planes beneath seemingly normal skin. The relatively benign appearance of the extremity is misleading and often results in delay in diagnosis and increased morbidity or death. Immediate aggressive surgical debridement through extensile incisions in combination with antibiotic therapy is necessary for control of these limb- and life-threatening, soft-tissue infections. Gas gangrene, or clostridial myonecrosis, is encountered commonly in those extremity wounds that involve devitalized or necrotic soft tissues. Clostridial microorganisms are anaerobes that produce local and systemic toxins. Delay in treatment can lead to hemolysis, renal failure, and death. Treatment consists of immediate wound debridement, intravenous antibiotics, and hyperbaric oxygen therapy. Diabetic gangrene typically occurs in those diabetic patients with severe peripheral vascular or renal disease. The infections are usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation.
BACKGROUND: To understand how laparoscopic hernioplasty prevents early recurrence of hernia, we reviewed our first 1,000 patients. We analyzed the patients by age, sex, and hernia type and by whether their hernia was primary or recurrent. METHODS: The 1,000 patients had 1,336 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach. One thousand one hundred seventy-three hernias were primary and 163 were recurrent. The type of hernia found varied with the patient's age (p < 0.001), and with whether the hernia was primary or recurrent (p < 0.001); 14% of primary and 27% of recurrent hernias were complex, a surprisingly high incidence compared to historical controls. RESULTS: With a median follow-up of 2 years, five hernias have recurred and all were due to technical errors. CONCLUSIONS: The laparoscopic repair's success may partially be due to its unique ability to diagnose previously overlooked complex elements. The defects are repaired without creating tension and the groin is reinforced with mesh, eliminating inherent weakness.
Seventy cadaveric hands were dissected to study variations of the flexor digitorum superficialis tendon (FDS) to the little finger. Anatomical variations were present in 13% of hands and 10% of the hands showed an anatomical variation that would preclude independent FDS function in the little finger. The distance of the decussation from the metacarpophalangeal joint was measured. A ratio of this distance to proximal phalangeal length was calculated. The ratio indicated that decussation position was independent of phalangeal size.
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We retrospectively reviewed a series of 40 cementless total hip arthroplasties in 31 patients with advanced avascular necrosis. The average follow-up was 58 months (range, 24 months to 108 months). The clinical failure rate was 20% (8 hips in 7 patients). Three of 7 threaded cups failed, and 2 of 32 porous coated hemispherical cups failed. Of the 5 stem failures, 1 was due to technical error, and 4 were well ingrown porous stems that succumbed to progressive osteolysis.
BACKGROUND: Failure rates for recurrent hernioplasties vary from 3% to 30%. To help explain this high incidence of recurrence, we reviewed our 4-year experience using a laparoscopic approach and analyzed the characteristics of the recurrent hernias repaired. METHOD: One hundred fifty-two patients with 173 recurrent hernias and 942 patients with 1,230 primary hernias were laparoscopically repaired using either a transabdominal preperitoneal or a totally extraperitoneal laparoscopic approach. RESULTS: With a median follow-up of 24 months, one recurrence developed in the recurrent and four in the primary group. The incidence of bilateral disease (80% versus 46%), and the complexity of the hernias repaired (28% versus 14%) were significantly increased in the recurrent patients. CONCLUSION: The importance of intrinsic weakness and missed hernias as factors that contribute to the failure of recurrent hernioplasties was supported by our findings. The low early failure rate of our laparoscopic approach suggested that this technique may help in eliminating these causes of failure.
Twelve cases of necrotizing fasciitis were identified retrospectively over a 5-year period. All were associated with a history of substance abuse by injection or with diabetes. Eleven of the 12 infections were associated with beta-hemolytic Streptococcus, a mixed anaerobic aerobic infection, or both. Three of five patients tested for human immunodeficiency virus had positive test results. A wide extensile approach was used to debride necrotic fascia. An average of 3 debridements were necessary, with a range of 1-6 debridements. Two patients under-went shoulder disarticulation because of uncontrollable infection. The rapid and destructive nature of this disease makes early recognition, aggressive debridement, and antibiotic therapy necessary to minimize morbidity.
An anatomic study was performed to better delineate the extensor tendons of the index finger. Seventy-two cadaver hands were dissected. Classically, a single slip of the extensor digitorum communis (EDC) and a single slip of the extensor indicis proprius (EIP) are said to run to the index finger. The EIP is said to be ulnar to the EDC at the level of the metacarpal head. In dissections in this study, the classic description was noted in 58 of the hands. Ten hands had a double slip of the EIP. Two hands had a double slip of the EDC running to the index. Two hands had a single slip of the EIP either volar or radial to the EDC at the level of the metacarpal head. Thirteen hands (19%) showed anatomic variants of the EIP and EDC tendons at the level of the metacarpal head, differing from the classic description. Additionally, two hands showed aberrant tendons. A knowledge of these variants when performing tendon repair or EIP transfer is necessary.
The use of intramedullary fixation for fixation of fractures of the metacarpal and proximal phalanx is reported. Flexible intramedullary rods are used for unstable transverse and short oblique diaphyseal fractures of the proximal phalanx and metacarpal. The fracture site is not opened and the rods are introduced under xray control. The rods are cut flush with the bone so that there is no soft tissue tethering. Intramedullary spacers are used in comminuted metacarpal fractures associated with crush injuries and gunshot wounds. The fracture site is opened and a single rod is placed to fill the intramedullary canal. A supplementary plate may be used to control rotation, and bone graft is usually necessary. A new spacer has been designed that has proximal and distal locking screws to control length and rotation. This also is used routinely with bone graft. The techniques outlined stabilize the fracture site allowing immediate motion postoperatively.
Thirty-seven embalmed, unpaired cadaver hands were dissected to delineate and classify the innervation of the hypothenar musculature. The deep branch of the ulnar nerve passed between the abductor digiti minimi and flexor digiti minimi and then pierced the opponens in all specimens. All branching occurred on the ulnar aspect of the deep branch of the ulnar nerve. A classification based on proximity of the different branches is prepared. Five different patterns have been noted.
To test the hypothesis that retaining the posterior cruciate ligament during total knee arthroplasty helps preserve the threshold of proprioceptive sensation, a machine was designed that permitted direct measurement of passive angular deflection from a resting point to the threshold of patient perception. Sixty patients with unilateral primary total knee arthroplasties were evaluated; 30 with posterior cruciate ligament retaining prostheses and 30 with posterior cruciate ligament substituting prostheses. All patients had a minimum postoperative followup of 1 year, a good or excellent result as defined by the Hospital for Special Surgery Knee Score, and no evidence of peripheral neuropathy. The gender and age distributions were equivalent between groups. The average threshold of perception for the posterior cruciate ligament retention group was 2.4 degrees. The average threshold of perception for the posterior cruciate ligament substitution group was also 2.4 degrees. Substitution or retention of the posterior cruciate ligament makes no clinical difference in proprioception as measured by threshold testing. This study provides new information for surgeons performing total knee arthroplasty to aid in the decision to retain or substitute the posterior cruciate ligament. Previous proprioception evaluation in patients with posterior cruciate ligament retaining versus posterior cruciate ligament substituting arthroplasties, using different testing methods, has revealed different results.
This study compares the results of two laparoscopic hernioplasties: the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Over a 43-month period 1,115 laparoscopic hernioplasties, 733 TAPP and 382 TEP, were performed in 866 patients. There were 11 major complications in the TAPP group (2 recurrences, 6 trocar hernias, 1 small-bowel obstruction, 1 trocar, and 1 dissection injury of the small bowel) compared to 1 recurrence and no intraperitoneal complications in the TEP group. Five TEP procedures required conversion to the TAPP approach, resulting in one umbilical hernia. The median time to return to work did not vary with the approach, but was prolonged in patients compensated for time off, 16 vs 8 days for noncompensated patients. Results suggested that both techniques shortened recovery and eliminated most early failures, but the totally extraperitoneal approach reduced the potential for intraperitoneal complications and may be the procedure of choice in most situations.
A 5-year retrospective review of 83 patients with 98 metacarpal fractures was performed. Fractures of the thumb metacarpal were excluded. Ninety-six closed metacarpal fractures were reduced closed and fixed with flexible intramedullary fixation, using multiple 0.8-mm prebent rods. Two open metacarpal fractures were also fixed with this technique. Fractures amenable to flexible intramedullary fixation include short oblique and transverse fractures. Contraindications include long oblique and bicortical comminuted fractures. The average follow-up time was 9 months (range, 2 to 34 months) with 15 patients lost to follow-up examination. All fractures went on to heal. Three complications occurred: backing out of a rod in one case and bending of the rods after repeat trauma in two. There were no infections. Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.