Search

The FY11 Report to Congress on Annual Long-Range Plan for Construction of Naval Vessels (commonly known as the 30-Year Shipbuilding Plan) forecasts that the Navy's Attack Submarine (SSN) force structure will fall below the requirement of 48 SSNs in 2024, and will remain below the requirement throughout at least 2040 (the limit of the current report). Operating the fleet with fewer ships than necessary to meet commitments around the globe makes it imperative to maximize the mission time provided by each platform. Accordingly, the VIRGINIA Class Submarine Program Office (PMS 450) has developed a plan to mitigate this shortfall in force structure by designing reductions in depot-level maintenance, thereby improving operational availability and maximizing mission time. This plan is encompassed in the Program Office's Reduction of Total Ownership Cost (RTOC) goals. However, actions arising from pressure to reduce Total Ownership Cost (TOC) may have the potential to inadvertently limit available platform mission time if the full consequences, including indirect impacts, are not rigorously assessed and analyzed in advance. The VIRGINIA Class Submarine Program faced this challenge explicitly in implementing the RTOC program while simultaneously working through details of a class maintenance plan modification for later submarines that adds a deployment to the operating cycle. Reducing TOC, while making changes to both the maintenance plan and the platform design, requires an integrated analytic capability to assess the impact of potential changes to both cost and delivered mission time. Evaluating the impact of maintenance changes on mission time is complicated by interactions between multiple stakeholders involved in controlling and managing the lifecycle of the submarine—including those responsible for maintenance planning (and the ability of the maintenance facilities to execute the work), operations and training, and modernizations. An approach and analytic framework, which captures “TOC Effectiveness” (defined as Mission Time Delivered divided by Net Cost) is needed to balance divergent program and stakeholder goals. To capture TOC effectiveness, a time-phased dynamic simulation of the lifecycle employment of VIRGINIA Class Submarines (including depot maintenance time) has been developed to determine the likely submarine employment consequences of the plans, policies, and constraints of the stakeholders involved, and to ensure that the lifecycle maintenance plan targets are achieved. The simulation was validated against historical performance of LOS ANGELES Class maintenance execution at public shipyards, explicitly adjusting for known differences in VIRGINIA Class work packages (the first VIRGINIA Class depot maintenance availability did not start until October 2010). Simulation analysis has identified likely results of alternative plans and/or policies and provided insight into where changes can be made across multiple stakeholders to efficiently and effectively achieve program goals for deployments. The simulation is integrated into the VIRGINIA Class RTOC program process to identify specific areas where changes have high leverage to increase mission time, evaluate specific changes proposed by the RTOC effort, and track progress toward achieving mission time goals.

A surgical approach is described that has been used in nearly 200 primary cases of Dupuytren's disease treated by one surgeon. Special attention and comments are directed to the proximal interphalangeal joint, a notoriously difficult area to correct. Observations suggest that the pathologic anatomy of this area is more variable and complex than generally described. The importance of postoperative therapy is stressed.

The purpose of this study was to define the testing parameters that are most sensitive to sensory loss in carpal tunnel syndrome and then to track recovery of these sensations postoperatively. Two dozen patients underwent standard nerve decompression and were subsequently re-evaluated at six weeks, three months, and six months. The test battery included provocative maneuvers, light-touch threshold determined by manually applied monofilaments and skin indentation with the Automated Tactile Tester (ATT), manual two-point discrimination, manual high-frequency vibration and ATT low-frequency vibration, and ATT warmth detection. The most sensitive indicators of sensory abnormality were the ATT low-frequency vibration and skin indentation tests. Responses to all but these two tests returned to normal within two months postoperatively. The ATT indentation and vibration tests showed continual improvement over the study period, returning to nearly normal values by six months. Recommendations concerning the use of automated methods for testing sensory function are made in light of these findings.

The Automated Tacticle Tester (ATT) is a computer-controlled device designed to measure patients' cutaneous perception of touch, vibration, temperature, and pain. The ATT provides repeatable and precise control of the amplitude, rate of application, and duration of stimuli. Threshold values for skin indentation (touch), high- and low-frequency vibration, pinprick (sharpness), warmth, and two-point discrimination were obtained with the ATT from the fingers of 62 normal subjects. Manual monofilament and two-point discrimination tests were also performed on the same subjects. All the tests with the ATT, except pinprick, showed a statistically significant increase in threshold with age. There were no significant differences attributable to the hand or digit tested or the sex of the subject. These data were used to derive age-adjusted criteria for normal sensory function in the glabrous skin of the fingers. Thresholds were found to remain within normal limits when these subjects were retested at various time intervals. We conclude that the ATT provides repeatable and reliable measurements of sensory function in the skin and has potential application in the diagnosis and evaluation of compression and other peripheral neuropathies.

A retrospective follow-up study was performed on patients with degenerative joint disease (DJD) who underwent trapeziometacarpal arthroplasty of the thumb with 3-week immobilization and without the use of K-wire fixation. Pre- and post-operative pain, activities of daily living (ADLs), grip strength, and pinch strength were compared. Data were collected on 25 hands in 23 patients, 7 hands with full trapezium resections and 18 with hemi-trapezium resections. The median age was 60 years, with a range of 39 to 73 years, and the median follow-up period was 1 year 11 months, with a range of 3 months to 11 years. Grip and pinch strength were measured pre- and postoperatively. Pain was assessed on a visual analog scale (VAS), and ADLs were assessed by means of a 15-item survey. Both pain and ADLs were evaluated postoperatively with recall of preoperative status. Following surgery, all thumbs were immobilized in a static splint for 3 weeks and then allowed progressive use. Median improvements in hemi-trapezium resections included grip, 22.5 lb; pinch, 4.7 lb; and ADLs, 33%. Pain was reduced a median of 7.0 cm on the VAS. Median improvements in full trapezium resection included grip, 29.5 lb; pinch, 0 lb; ADLs, 60%; and pain reduction, 8 cm on the VAS. This follow-up study suggests that satisfactory results can be achieved in pain reduction, strength, and ADLs with an immobilization period of only 3 weeks and without the use of K-wires following carpometacarpal (CMC) arthroplasty.

This article reports the first randomized prospective multicenter evaluation of a bioabsorbable conduit for nerve repair. The study enrolled 98 subjects with 136 nerve transections in the hand and prospectively randomized the repair to two groups: standard repair, either end-to-end or with a nerve graft, or repair using a polyglycolic acid conduit. Two-point discrimination was measured by a blinded observer at 3, 6, 9, and 12 months after repair. There were 56 nerves repaired in the control group and 46 nerves repaired with a conduit available for follow-up. Three patients had a partial conduit extrusion as a result of loss of the initially crushed skin flap. The overall results showed no significant difference between the two groups as a whole. In the control group, excellent results were obtained in 43 percent of repairs, good results in 43 percent, and poor results in 14 percent. In those nerves repaired with a conduit, excellent results were obtained in 44 percent, good results in 30 percent, and poor results in 26 percent (p = 0.46). When the sensory recovery was examined with regard to length of nerve gap, however, nerves with gaps of 4 mm or less had better sensation when repaired with a conduit; the mean moving two-point discrimination was 3.7 +/- 1.4 mm for polyglycolic acid tube repair and 6.1 +/- 3.3 mm for end-to-end repairs (p = 0.03). All injured nerves with deficits of 8 mm or greater were reconstructed with either a nerve graft or a conduit. This subgroup also demonstrated a significant difference in favor of the polyglycolic acid tube. The mean moving two-point discrimination for the conduit was 6.8 +/- 3.8 mm, with excellent results obtained in 7 of 17 nerves, whereas the mean moving two-point discrimination for the graft repair was 12.9 +/- 2.4 mm, with excellent results obtained in none of the eight nerves (p < 0.001 and p = 0.06, respectively). This investigation demonstrates improved sensation when a conduit repair is used for nerve gaps of 4 mm or less, compared with end-to-end repair of digital nerves. Polyglycolic acid conduit repair also produces results superior to those of a nerve graft for larger nerve gaps and eliminates the donor-site morbidity associated with nerve-graft harvesting.

Seventy-five of 104 patients who underwent operative fixation of open hand fractures were reviewed between 6 months and 7 years after injury (average, 17 months). There were 140 fractures involving 125 fingers. Results, evaluated on the basis of total active range of digital motion achieved at final follow-up, correlated highly with severity of soft tissue injury. When open fractures of comparable severity were contrasted between groups that did and did not require additional extension by incision to achieve acceptable reduction and stabilization, there was some additional loss of active range of motion in the surgically treated group. Metacarpal fractures had significantly better outcomes than phalangeal fractures. Fractures involving the proximal phalanx or the proximal interphalangeal joint had the poorest prognosis, especially when they were associated with tendon injury. There were significant complications in 13 fingers. Infection and late amputation were related to wound severity.

The Automated Tactile Tester (ATT) was used to measure threshold values for trapezoidal skin indentation (light touch), low- and high-frequency vibration (50 and 150 Hz), pinprick (sharpdull transition point), warming (temperature awareness), and two-point discrimination in 61 patients with symptoms of median nerve compression at the wrist. We compared these data with values obtained in the same patients with manual monofilament tests, manual two-point discrimination measurements, and electrophysiologic nerve conduction studies. The ATT detected abnormal sensation in 71% of the hands tested, nerve conduction velocity was abnormal in 44% of the cases, and the manual tests indicated abnormality in 42% of the hands. The most indicative single test among those included in the present study for detecting sensory abnormality in these patients was threshold to a 50 Hz vibration administered by the ATT. We conclude that the ATT is a sensitive tool for the diagnosis and evaluation of compressive peripheral neuropathy and may allow objective documentation in a higher percent of patients than do more traditional testing methods.

Techniques for including muscle flaps and musculocutaneous flaps in the repair of difficult vesicocutaneous, urethrocutaneous, and vesicovaginal fistulas are described. These methods have been uniformly successful in 10 consecutive patients. The incorporation of such healthy, well-vascularized tissue into the standard techniques of urologic repair can be a major factor in the successful management of these problems.

Peripheral nerve repair may be the last frontier in the treatment of injuries to the hand and forearm. The author discusses the current “state of the art” and outlines principles and techniques of surgical management of transected nerves, including indications for epineurial suture and group funicular suture.

Several enzymes participating in glucose metabolism and some of the acid hydrolases were assayed in palmar fascia and Dupuytren's contracture with fluorometric microanalytical methods. The enzyme activities of glucose metabolism were lower in normal palmar fascia than in dermis. The fascia of Dupuytren s contracture exhibited a general increase in the enzyme activities of glucose catabolism. Little alteration was found in alanine aminotransferase and UDP-glucose dehydrogenase activity in the lesion. Lysosomal hydrolytic enzyme activities were increased five to ten times in Dupuytren's tissue. The dermis overlying Dupuytren s contracture exhibited an increase in the enzyme activities of glucose catabolism, but to a lessser degree than did the fascia of the lesion. The epidermis of involved palmar skin displayed normal enzyme activities.

Cancer of the auditory system is primarily cancer of the auricle. The surgeon who would treat malignant tumors of the ear must consider the functional and esthetic qualities of the auricle, yet appreciate that cure is the primary objective of treatment. The ideal operation should have as high a cure rate as possible, yet leave an ear that looks and functions as near normal as possible.

Open type III fractures of the hand or wrist with severe bone and soft tissue loss justify aggressive treatment to restore anatomy, assure healing, and maximize functional recovery. The techniques of modern wound excision used at initial surgery predictably result in a decompressed and surgically clean wound within a few days from injury in the vast majority of cases. This allows a safe application of delayed primary internal fixation and bone grafting for fracture restoration or joint arthrodesis as well as early wound closure or coverage. The immediate or early application of stable external devices, internal fixation, or combinations of the two along with early bone grafting restores the structural integrity of the skeleton, reduces pain, protects other repaired and reconstructed tissues, promotes the healing, and supports early and intensive functional rehabilitation of the hand and wrist. Early wound closure or coverage minimizes scar formation. Together, the early sequencing of effective wound debridement with skeletal stabilization and bone grafting and early wound closure or coverage provide the most favorable circumstances for healing and functional recovery of the seriously damaged hand and wrist.

SUMMARY We have completed and analyzed recent studies on the internal topography of the median and ulnar nerves of the forearm and hand. These findings have been compared with the classic studies of Sir Sydney Sunderland and more recent work by other authors has been included. Our studies confirm that there is a complex interfascicular relationship between the various components of the median and ulnar nerves in the forearm and hand, but, with careful dissection, several anatomic relationships can be defined. Individual branches and bundles can be traced within the main nerve trunks for considerable distances without significant trauma to the conducting fibers. These include the recurrent branch of the median nerve, the branches to the lumbrical muscles, the motor and sensory components of the ulnar nerve, and the dorsal sensory branch of the ulnar nerve. These findings have a direct relationship to the clinical repair of fresh nerve injuries as well as those injuries that require nerve grafting for significant gaps in the neural tissue. Intraneural neurolysis can be safely performed if detailed knowledge of the internal topography of the peripheral nerves is understood. This knowledge may also be applied to the dissection and management of neuromas in continuity. 21 The increased awareness of the interfascicular relationships of the peripheral nerves may well influence a more favorable outlook in the care of patients with nerve injuries.

A case of carpal tunnel syndrome is presented in which an abnormally high origin of a lumbrical muscle seemed to be the cause. Since the patient and author are the same, the symptoms of compression and during the postoperative period are well documented. Evoking the symptoms by exercise or active motion is suggested for future diagnostic tests. A surgical incision more ulnarward is recommended.

Subcapital metacarpal fractures result from direct impact, usually in a fist. They tend to angulate because of the pull of the intrinsic muscles. Volar comminution accentuates the deformity and adds to the instability. It tends to cause the fracture to settle back to its original position. For these reasons, reduction can be difficult to maintain, and, indeed, the more severe and angulated the original fracture, the more difficult it is to maintain.

Most mallet finger injuries, whether of bony or tendinous origin, can be treated by splinting in full extension for 6 weeks. Occasionally, at the discretion of the surgeon, the splint should be internal in the form of a linear longitudinal Kirschner wire inserted percutaneously from the fingertip across the reduced distal interphalangeal joint in retrograde fashion.

Fixing the thumb in a position of palmar abduction is an operation of last resort. It is reserved for those cases of paralysis in which there are no transferable muscles, where there are spastic paralysis and adduction contracture, and where there is severely scarred thumb-web space but in which there is still some chance for useful hand function if the thumb can be placed in an abducted position (Figs. 47-1 A Figs. 47-1 B Figs. 47-1 C-I).

When possible, closed reduction and percutaneous Kirschner wire fixation are preferred for displaced spiral and oblique phalangeal shaft fractures. The functional derangement that results from such fractures is so great, however, that when closed reduction cannot be either achieved or maintained satisfactorily, open reduction is indicated. The potential for mischief of this fracture configuration is considerable. For example, soft tissue interposition often may prevent reduction. The distal spike of the proximal fragment may impale the collateralligaments of the proximal interphalangeal joint or may block flexion of the middle phalanx, and the proximal spike of the distal fragment may easily become entrapped in the flexor tendons. Most important, the tendency of the fragments to rotate and override guarantees digital crossing or scissoring and a contracture of the volar plate with flexion deformity.

Although a patient with polyfractures of the hand has multiple injuries, they are at least localized to one area. The poly traumatized patient has one or more fractures of the hand or wrist in association with multiple fractures or other multiple injuries. When such a patient has one or more serious fractures ofthe hand or wrist, open reduction and internal fixation can be advantageous provided it does not put the patient at any additional risk for his life and provided it does not interfere with any other priorities of treatment.

Delayed union occurs when a bone fails to unite within an average anticipated time. For a given fracture, healing time varies with location and configuration as well as the specific bone and age group. These criteria apply to reconstructive procedures as well as fractures (Figs. 41-1 A-D and 41-2 A-C). If the condition persists for 3 consecutive months with no evidence of progression toward healing, the condition is arbitrarily defined as a nonunion. The clinical signs of nonunion may be pain, tenderness, erythema, heat, swelling, and instability at the fracture site, although not all are present in all cases. Stiffness, deformity, and contracture may occur secondarily. Stress x-ray films or fluoroscopy will show motion at the fracture site. Nonunions are rare in the hand, presumably because of the relatively good blood supply there. When nonunions do occur in the hand, reduced blood supply by severe injury is a relatively frequent cause, along with inability to stabilize bone fragments.

This essay describes the internal topographical anatomy of peripheral nerves and outlines the use of this information in the specific steps of nerve suture. Repair is detailed in the context of overall wound management and those factors are emphasized which can be controlled by the surgeon and which have a definite effect on the functional outcome.

Two-stage Hunter tendon reconstruction is used in instances of old tendon lacerations when scarring would preclude a one-stage tendon graft and in some acute injuries when primary tendon repair is not possible. Ovoid implants 3 to 6 millimeters in diameter are used for 3 to 4 months in the first stage to develop a tendon sheath. One implant has a metal endplate that can easily be fixed to the distal phalanx with a 2.0 mm cortical fixation screw (Figs. 61-1 A Figs. 61-1 B Figs. 61-1 C Figs. 61-1 D-F). Stable fixation of the distal portion of the implant while the proximal end glides freely in the palm or distal forearm allows passive gliding to aid in the development of the synovial tendon sheath. When a tendon is harvested for the second stage of the tendon graft, its distal end can be secured into the enlarged screw hole.

One-hundred and four patients with fractures of the metacarpals and phalanges have been treated with rigid internal fixation over a 6-year period. Patients with both open and closed injuries had their fractures fixed by tension band wires, interosseous compression screws (lag screws), or plates and screws. The concepts of primary bone healing and its variations, methods of fixation, and the importance of interfragmentary compression are defined and stressed. Illustrative cases of each technique are described and the applicable principles are enunciated.

After repair, nerve stains of skin and subcutaneous tissue biopsies of 23 fingertips contained identifiable axons in all patients. The level of recovery was more advanced in some patients than in others, as manifested by identifiable nerve in various plexuses and receptors. Meissner's corpuscles were observed to be reinnervated in 12 of 17 patients and in 16 of 23 fingertips. The degree and level of reinnervation did not correlate with clinical testing or subjective impression of the result. The authors conclude that sensibility is the result of several factors active in the peripheral and central nervous system. Axonal regrowth is but one of these.

Arthroplasty has not been refined sufficiently to achieve a predictably good result in the distal interphalangeal joint of the fingers. Furthermore, distal interphalangeal motion plays a relatively small role in the overall function of a reconstructed hand. Arthrodesis has been predictable and effective for salvaging those situations with instability, destruction, or deformity of the distal interphalangeal joint (Figs. 52-1 A Figs. 52-1 B Figs. 52-1 C, and 52-3 A-F).

Arthrodesis of the badly damaged or unstable proximal interphalangeal joint of the finger can be useful for the functional salvage of this joint, although arthroplasty of the index proximal interphalangeal joint is frequently unsatisfactory because of instability of pinch. Arthroplasty of internal fingers is usually more satisfactory because they are protected by adjacent normal fingers. Arthroplasty of the proximal interphalangeal joint of the small finger may be worthwhile because this finger is not often subjected to ulnar-deforming forces in pinch. Thus, with the ulnar three fingers, arthroplasty may be a valuable method for reconstruction and useful integration of a single operated finger for participation in grip. On some occasions, however, arthroplasty will lead to instability, angulation, or other deformity, or sufficient motion simply may not be regained. In these instances, function may be salvaged by arthrodesis.

Seventeen patients had 21 bone graft operations as part of the overall delayed primary management of hand and wrist wounds. All bone graftings were performed within 10 days of injury. Internal or external fixation was used in all cases, and all wounds healed without infection. Complications included a fibrous union at one bone graft juncture and one malunion. Follow-up was from 3 months to 7 years. Successful delayed primary bone grafting requires a well-decompressed and surgically-clean wound, good blood supply, adequate fixation, and secure soft-tissue cover. If these conditions cannot be met, bone grafting should be deferred and performed in the conventional manner. The advantages of delayed primary bone grafting are: primary bone healing, a shorter rehabilitation period, fewer operations, avoidance of wound contracture, and bone grafting in a well-vascularized scar-free bed.

Restoration of anatomic relations correlates highly with functional outcome in the hand. The priorities in treatment are a stable, well-maintained reduction and early motion. Prolonged immobilization, especially in a nonfunctional cast, can lead to a vicious cycle of pain, swelling, and unresolved edema. Edema fluid is a proteinaceous exudate that will congeal into scar tissue around joints and tendons and cause joint stiffness, contracture, and tendon adhesions. Muscle atrophy, brawny skin /induration, and osteoporosis follow. Reflex sympathetic dystrophy may sometimes occur and further complicate the picture. This constellation of symptoms and physical changes has been called “fracture disease.” Like proud flesh and suppuration in soft tissue healing, it is not a necessary part of fracture repair and can be avoided. Prevention is the best treatment. All fracture treatment, whatever the method, must be geared to achieve stability and function to prevent these complications.

Bicondylar fractures of the proximal phalanx are approached dorsally by incising between the extensor slip and the lateral band on either side of the fracture. Alternatively, osteotomy of the dorsal lip of the proximal portion of the middle phalanx can be performed, and the insertion ofthe central slip can be reflected proximally by dissecting on either side of it, providing excellent visualization of the joint surfaces. A screw hole should be predrilled before the osteotomy so that the dorsal lip can be secured at the end of the procedure.