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Purpose of reviewAs our population ages, patients with arthritic basilar thumb joints will become an ever-increasing part of the practices of those treating hand problems. The gold standard for the surgical treatment of basilar thumb arthritis is the ligament reconstruction, tendon interposition art

Twelve cadaver extremities were used to study the effect of scaphoid and lunate facet depressions on the contact characteristics of the radiocarpal joint. Pressure-sensitive film was inserted into radiocarpal joints with varying degrees of depression, and the specimens were loaded statically in neutral position, radial deviation, and ulnar deviation. The film was removed and analyzed for contact area and pressure. The only statistically significant effect of a lunate fossa depression was an increase in scaphoid fossa pressure with a 3-mm step-off and the hand in neutral position. Scaphoid fossa depression had more significant effects. With a 1-mm scaphoid fossa depression, lunate fossa pressures increased in neutral position and in radial deviation. Lunate fossa contact area increased, compared to intact joints, in ulnar and radial deviation with 1-mm scaphoid fossa depressions and in all loading positions with 3-mm scaphoid fossa depression. Therefore, it appears that the most significant effect on radiocarpal joint contact characteristics occurs with a depression of the scaphoid side of the joint. Even with depressions as small as 1 mm, significant changes on the lunate side of the joint were observed.

Achieving satisfactory digital motion after suturing severed flexor tendons remains a challenge. Although a suture technique proposed by Savage is stronger in vitro than a true Kessler repair, the Savage technique has not been previously tested in vivo. We repaired 96 severed canine tendons using either of two modifications of the Kessler technique or the Savage technique. The tensile strength of these repairs were compared at 0, 1, 3, and 6 weeks after suturing. The Savage technique provided a significantly stronger repair than the "suture locking" method in vitro and at 1 and 3 weeks after repair. We found no significant differences between the tensile strengths of the Kessler-Tajima and suture-locking methods at any time.

Seventy-three patients were treated with either intrafocal pinning (Kapandji technique) alone or in combination with external fixation between 1988 and 1993 for extra-articular fractures of the distal radius (with or without a nondisplaced extension into the radiocarpal articular surface) with inadequate alignment after initial closed reduction. Sixty-one patients were available for follow-up examination at an average of 34 months (range, 24-71 months). The average age was 52 years (range, 16-84 years). Thirty-three of the patients were female. The patients all had dorsally displaced extra-articular fractures, although 56% had a nondisplaced extension of the fracture into the radiocarpal joint and 46% had a nondisplaced fracture extending into the distal radioulnar joint. The patients were separated into groups based on age, degree of comminution, and whether external fixation was also used. In the older patients, range of motion, grip strength, and pain relief were significantly better when external fixation was used, even when only 1 cortex of the radius demonstrated comminution. In the younger patients, good results in terms of range of motion, grip strength, and pain relief were obtained when percutaneous intrafocal pins were used alone in patients with comminution of only 1 surface of the radius (50% of the metaphyseal diameter). Whenor = 2 sides of the radial metaphysis were comminuted, the patients with external fixation had better results than those without external fixation. Although the correction of palmar tilt and radial tilt did result in better functional results, the restoration of radial length had the most significant effect on range of motion and grip strength.

SUMMARY Todetermine theindependent influence oftheextentandsite ofresidual disease on late survival, we analyzed thefate of1448consecutive patients whohadcoronary arterybypass surgery during 1968-1974. There were 1274males, mean age53.4+ 8years(range 24-75years). Females were excluded fromfurther analysis. Twohundred twenty-six patients (17.7%) hadone-vessel disease, 492(38.6%)had two-vessel disease, 408(32.0%) hadthree-vessel disease and148(11.6%) hadleft mainstenosis. Survival was determined ata follow-up ofatleast 5years. Survival data wereanalyzed byKaplan-Meier survival curvesforthepatients withtwo-andthree-vessel disease according totheextent ofresidual disease. Forpatients withtwo-vessel disease andgoodventricular function, survival was similar at5years,89.1 % and87.7 % forno andone residual lesion; forthose with two-vessel disease andpoor ventricular function, 5-year survival was 84.5%and52.6%forno andone residual lesion; forthose withthree-vessel disease andgoodventricular function, itwas 92.0%,83.4 %, and 75.0 % forno,oneandtworesidual lesions, respectively. Withpoorventricular function, thecorresponding results were 83.1%,72.5%and23.1%. TheCoxmultivariate analysis technique was usedtoanalyze theinfluence ofage atoperation, numberof vessels diseased preoperatively, preoperative left ventricular function, period ofsurgery,andthenumber andsite ofresidual lesions after operation. Residual disease, ageatoperation andleft ventricular function werethemostimportant variables affecting survival ofpatients withtwo-andthree-vessel disease. Residual lesions oftheleft anterior descending orcircumflex coronaryarteries werethemostimportant predictors of survival; residual lesions oftheright coronaryartery exerted a lesser influence. Theresults ofthis study suggest thatthegreatest benefit intermsofimproved survival may come fromthefirst twotothree grafts placed. EARLYinourexperience withcoronary bypass, we observed, asdidothers, that operation inpatients with multivessel coronary disease appeared tohaveamore favorable outcome whenmultiple grafts wereplaced.'-' Thus, theconcept developed that ifall significant coronarylesions werebypassed, i.e., complete revascularization wasachieved, superior relief ofsymptoms and enhanced survival wouldresult. However, thevalidity ofthis concept isdifficult to prove, particularly withregard tosurvival. Incomplete revascularizatio n hasbeenmorelikely tooccurinpatients withother variables knowntoaffect survival adversely, suchasextensive multivessel coronary disease, which itself isassociated withhigher prevalence ofpoorleft ventricular function.7 Therefore, despite observations that suggest thebenefits ofcomplete revascularization,6 'analysis oftheinfluence ofresidual disease onsurvival according tothepresence orabsence ofresidual disease alone, without adjustment for other variables, maynotprovide anaccurate assessmentoftheinfluence ofresidual disease onsurvival. Furthermore, theinfluence ofresidual disease ofspecific vessels hasnotbeenexamined. Theaimofthisstudy wastodetermine whether

• Over a 30-year period, 190 consecutive patients had repair of coarctation of the descending thoracic aorta at a mean age of 25 years (range, 1 to 60 years); 130 were male. Median preoperative blood pressure (BP) was as follows: systolic, 160 mm Hg (range, 94 to 300 mm Hg) and diastolic, 90 mm Hg (range, 50 to 160 mm Hg). Dacron grafts were used in 64.7% of patients. Follow-up was obtained at a mean interval of 84.9 months, range, one to 360 months. Survival status was established for 86.1% (163/190) of patients. Postoperatively, the median BP was 133 mm Hg systolic (range, 90 to 195 mm Hg) and 80 mm Hg diastolic (range, 50 to 120 mm Hg). Overall, 80% of patients were either normotensive or had mild hypertension after operation. The best BP response and late survival were in patients operated on under 13 years of age. This study further confirms that early operation (below 5 years of age) is desirable. However, contrary to some previous reports, patients operated on as adolescents, despite some mild residual hypertension, had an excellent long-term prognosis. Patients over 21 years of age at operation had a high rate of persistent hypertension and experienced other serious cardiovascular complications. ( Arch Surg 1981;116:1557-1560)