SIMULTANEOUS CARPAL DUPUYTREN’S
TUNNEL RELEASE FASCIECTOMY
AND
F. GONZALEZ and H. KIRK WATSON From the Division of Plastic and Reconstructive Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
Simultaneousoperations for carpal tunnel syndromeand Dupuytren’s diseasehave beenreported in only one study which recommendedstaged treatment becausethere was an 87% complication rate with simultaneous treatment. The present study reviewed simultaneous treatment of 30 patients during a 20-year period. Complications and unfavourable results were comparedto similar groups of patients who underwenteither Dupuytren’s fasciectomyor carpal tunnel releaseas sole procedures. Early complications (13%) were far less than iu previous studies and were easily corrected. The incidenceof recurrence and extension (20%) was lower than in the Dupuytren’s fasciectomy group and much lower than in previous reports. Simultaneous carpal tunnel release and Dupuytren’s fasciectomy are strongly recommendedwhen theseconditions are both presentin the samehand. Journal of Hand Surgery (British Volume, 1991) 16B : 175-l 78
Although carpal tunnel syndrome and Dupuytren’s contracture are two of the most common conditions seen in a general hand surgery practice, they rarely present simultaneously in the same hand. The surgical management of each condition has been exhaustively discussed in the literature, but only Nissenbaum and Kleinert (1980) have discussedsimultaneous operations on both. Nissenbaum and Kleinert (1980) reported their experience with 29 patients with co-existent carpal tunnel syndrome and Dupuytren’s contracture. They found an 87% complication rate in the 15 patients treated by simultaneous carpal release and fasciectomy. Their recommendation, therefore, was to treat the conditions in staged surgical procedures, not simultaneously. Since it has been the policy of one of the authors (H.K.W.) to perform both operations at the same sitting, a retrospective review was initiated to assess the complications and long-term results. Patients and methods The medical records of a busy hand surgery practice for a 20-year period (1968-1987)were examined for patients who had undergone simultaneous carpal tunnel release and Dupuytren’s fasciectomy. During that time, operations were performed on 2,749 hands with carpal tunnel syndrome and 623 with Dupuytren’s contracture. In 32 patients combined surgery was performed for coexistent disease. Two of these patients could not be located for long-term follow-up ; the remaining 30 comprised the basis of this study. Two patients who moved out of the area could only be interviewed by telephone. All other patients were personally examined and interviewed. Grip strength and range of motion were measured, and the surgical scar was evaluated by the same observer (F.G.) in each of the examined patients. A value was assignedto each surgical scar based on a scale from one to ten, where one denotes a grossly hypertrophic scar and ten an imperceptible VOL.
16B No. 2 MAY
1991
scar. For comparison, 30 patients who underwent carpal tunnel release and 30 who underwent Dupuytren’s fasciectomy were randomly selected, and subjected to a similar review of the notes and clinical examination. Surgical technique All surgical procedures were performed by the senior author. The operative techniques used have been described elsewhere(Ariyan and Watson, 1977,King et al., 1979; Baker and Watson, 1980). Salient aspects of the combined procedure are as follows : Carpal tunnel release
1. A longitudinal incision is made in the “fingerprint pattern” to mid-palm along the line of the fourth ray. 2. Guyon’s canal releasemay be performed. 3. The carpal tunnel is opened, with resection of a longitudinal strip about three mm. wide from the radial portion of the flexor retinaculum. 4. External neurolysis of the median nerve is performed, resecting about half the circumference of the epineurium without separation of the nerve bundles. 5. Running 4-O nylon closure of the skin. Dupuytren’s fasciectomy
Zig-zag incisions are made in the skin overlying the diseasedfascia in the palm and digits. Skin flaps are raised superficial to the fascia. Total accessible fasciectomy is performed, starting proximally and working distally. Closure is facilitated by performing Y-V advancements when necessary(Fig. 1). Post-operative care
1. A bulky fluff compression dressing is placed on the hand before deflation of the tourniquet. 175
F. GONZALEZ
Table l-Age,
AND
H. KIRK
WATSON
sex and length of follow-up io patient groups
Carpal tunnel release and Dupuytren’s fasciectomy Dupuytren’s fasciectomy Carpal tunnel release
No.
Mean age (yrs)
Male
Female
Length F/U (yrs)
30
61.7 (25-81)
18
12
4.9 (0.25-15)
30 30
62.0 (27-85) 60.3 (22-82)
19 14
11 16
5.8 (l-20) 7.7 (1-15)
Table 2-Undesirable
results (%) Complications
Carpal tunnel release and Dupuytren’s fasciectomy Dupuytren’s fasciectomy Carpal tunnel release
Fig. 1 Y-V plasty incisions in extensive fasciectomy for Dupuytren’s contracture.
2. The large dressing is removed after two to five days and mobilization of the hand is begun in a light gauze dressing. 3. Sutures are removed two weeks after the operation. 4. Patients are observed in therapy for at least six weeks or until function is normal. Results
The mean age of the 30 patients who underwent simultaneous Dupuytren’s fasciectomy and carpal tunnel releasewas 61.7 years (Table 1). There were 18 men and 12 women and the mean length of follow-up was 4.9 years. The mean ages of the patients undergoing carpal tunnel release alone or Dupuytren’s fasciectomy alone were 62.0 and 60.0 years respectively, not statistically different from the combined surgerygroup. There were three early complications in this series (Table 2), one in each group of 30 patients. In the group of patients with co-existentdisease,one patient developed a haematoma which was evacuated in the office without sequelae. A minor wound dehiscence in a patient who underwent fasciectomy alone healed without surgery, and a wound infection in a patient who underwent carpal tunnel releasealone was drained and healed uneventfully. Three patients developed symptoms of reflex sympa176
1 hematoma (3.3%) 3 RSD (10%) 1 wound dehiscence (3.3%) 1 wound infection. (3.3%)
Recurrences Extension 4 (13%)
2 (6.6%)
11(36%)
7 (23%)
0
N/A
thetic dystrophy, all in the combined group (10%). These patients were treated successfully,with complete resolution of their symptoms, by the Dystrophile (stressloading) reflex sympathetic dystrophy programme (Watson and Carlson, 1987). There were four cases(13%) of recurrent Dupuytren’s contracture in the combined group and 11 (36%) in the fasciectomy only group : in only one was there recurrence in the palm, the remainder occurring in the digits. Extension of Dupuytren’s diseasewas diagnosed when, at the time of follow-up, contracture was seen distal to the surgical incision. Extension of the diseasewas seen in two patients (7%) in the combined group and seven patients (23%) in the fasciectomy only group. Evaluation of scar appearanceat the time of follow-up resulted in a mean value of 7.7 in the combined group, 8.0 in the fasciectomy only group, and 9.0 in the carpal tunnel releaseonly group (Figs. 2 and 3). Discussion
The demographic composition of all three groups was similar. The length of follow-up in the single operations was longer, but this does not significantly alter the findings of this study as the time of follow-up in all cases was well past the period in which complications were seen. Only three early complications occurred in these 90 patients, one in each group. The complication rates after the single operations (3.3%)were not profoundly different from those in previous reports (Ariyan and Watson, 1977; King et al., 1979). The 3.3% complication rate in the combined group was equal after the single operations and lower than those previously reported for the combined operations (Nissenbaum and Kleinert, 1980). The incidence of haematomaformation with Dupuytren’s THE
JOURNAL
OF HAND
SURGERY
SIMULTANEOUS
Fig. 2
CARPAL
TUNNEL
RELEASE
Hand of 7%year-old man five years after combined carpal tunnel release and Dupuytren’s fasciectomy. Scar was rated 4.
fasciectomy alone has been reported as high as 15.8% (Tubiana et al., 1967). The fact that all operations were performed by the same surgeonusing the same technique may have contributed to the relatively low complication rate. Recurrence rates in long-term follow-up studies of patients who have undergone Dupuytren’s fasciectomy range from 25% to 63% (Rodrigo et al., 1976; Dickie and Hughes, 1967; Honer et al., 1971; Hakstian, 1974) and extension of diseasehas been reported in 20% to 66% of cases. In our patients who underwent Dupuytren’s fasciectomy alone, the recurrence rate was 36% and extension of disease occurred in 23% of cases. This is clearly within the range reported in the literature and is greater than the 11% recurrence and 7% extension rates in the patients who had the combined operations. Since the mean length of follow-up in the combined group was nearly a year shorter than that of the fasciectomy group, this may account for the discrepancy. The three casesof reflex sympathetic dystrophy were VOL.
16B No. 2 MAY
1991
AND
Fig. 3
DUPUYTREN’S
FASCIECTOMY
Hand of a 77-year-old woman eight years after combined Dupuytren’s fasciectomy and carpal tunnel release. Scar was rated 9.
the only undesirable results which occurred more often after the combined than the single operations. Since patients are seen by hand therapists early in the postoperative period, R.S.D. is usually diagnosed in its early stages.Use of the Dystrophile R.S.D. program (Watson and Carlson, 1987) resulted in complete resolution of symptoms in all three cases. A combination of early vigilance and the employment of the stress loading program significantly reduces the number of persistent R.S.D. problems. It might be theorised that performing both carpal tunnel release and Dupuytren’s fasciectomy would increase the extent of scar formation. To test that hypothesis, an arbitrary scalewas utilised to evaluate the cutaneous scar in each patient at the time of follow-up. As would be expected, there was less scar formation in the carpal tunnel only group than either of the other two groups. When the incision for carpal tunnel release is placed in the palm and not extending proximal to the fingerprint pattern of the palm, the resulting scar is 177
F. GONZALEZ
AND
hardly noticeable in most cases after complete healing. Although the values for the scars in the fasciectomy and combined groups were lower (i.e. worse) than the mean scar value in the carpal hand group, they were not significantly different from each other. Although this is an arbitrary scale, it shows that there is little difference in appearance of the scars in these patients upon longterm follow-up. Conclusion
A review of 30 patients in whom carpal tunnel release and Dupuytren’s fasciectomy were performed as a combined procedure has demonstrated no greater morbidity than after Dupuytren’s fasciectomy alone. The incidence of unfavourable results, even after a mean follow-up of 4.9 years, was far less than the 87% reported previously. It is our recommendation that these two proceduresbe performed simultaneously whenever both conditions are present in the same hand. With this approach, an extra operation and progression of symptoms will be avoided.
H. KIRK
WATSON
BAKER, G. C. and WATSON, H. K. (1980). Relieving the skin shortage in Dupuytren’s disease by advancing a series of triangular flaps: how to design and use them. British Journal of Plastic Surgery, 33 : 1-3. DICKIE, W. R. and HUGHES, N. C. (1967). Dupuytren’scontracture. A review of the late results of radical fasciectomy. British Journal of Plastic Surgery, 20: 311-314. HAKSTIAN, R. W. (1966). Long term results of extensive fasciectomy. British Journal of Plastic Surgery, 19: 140-49. HONNER, R. LAMB, D. W. and JAMES, J. I. P. (1971). Dupuytren’s contracture. Long-term results after fasciectomy. Journal of Bone and Joint Surgery, 538: 2: 240-246. KING, E. W., BASS, D. N., and WATSON, H. K. (1979). Treatment of Dupuytren’s contracture by extensive fasciectomy through multiple Y-V plastyincisions: Short-term evaluationof 170consecutiveoperations. Journal of Hand Surgery, 4: 3 : 234-241. NISSENBAUM, M. and KLEINERT, H. E. (1980). Treatment considerations in carpal tunnel syndrome with coexistent Dupuytren’s disease. Journal of Hand Surgery, 5 : 6 : 544547. RODRIGO, J. J., NEIBAUER, J. J., BROWN, R. L. andDOYLE, J. R. (1976). Treatment of Dupuytren’s contractwe. Long-Term Results after Fasciotomy and Fascial Excision. Journal of Bone and Joint Surgery, 58A: 3 : 38s-387. TUBIANA, R., THOMINE, J. M. and BROWN, S. (1967). Complications in Surgery of Dupuytren’s Contractwe. Plastic and Reconstructive Surgery, 39 : 6: 603-612. WATSON, H. K. and CARLSON, L. (1987). Treatment of reflex sympathetic dystrophy of the hand with an active “stress loading” program. Journal of Hand Surgery, 12A: 5(l): 779-785.
References ARIYAN, S. and WATSON, H. K. (1977). The pahnar approach for the visualization and release of carpal tunnel. An analysis of 429 cases. Plastic and Reconstructive Surgery, 60: 4: 539-547.
178
Accepted: 3 April, 1990 H. Kirk Watson, M.D., 85 Seymour Street, Hartford, Corm. 06106, USA 0 1991 The British Society for Surgery of the Hand
THE
JOURNAL
OF HAND
SURGERY
TUNNEL RELEASE FASCIECTOMY
AND
F. GONZALEZ and H. KIRK WATSON From the Division of Plastic and Reconstructive Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
Simultaneousoperations for carpal tunnel syndromeand Dupuytren’s diseasehave beenreported in only one study which recommendedstaged treatment becausethere was an 87% complication rate with simultaneous treatment. The present study reviewed simultaneous treatment of 30 patients during a 20-year period. Complications and unfavourable results were comparedto similar groups of patients who underwenteither Dupuytren’s fasciectomyor carpal tunnel releaseas sole procedures. Early complications (13%) were far less than iu previous studies and were easily corrected. The incidenceof recurrence and extension (20%) was lower than in the Dupuytren’s fasciectomy group and much lower than in previous reports. Simultaneous carpal tunnel release and Dupuytren’s fasciectomy are strongly recommendedwhen theseconditions are both presentin the samehand. Journal of Hand Surgery (British Volume, 1991) 16B : 175-l 78
Although carpal tunnel syndrome and Dupuytren’s contracture are two of the most common conditions seen in a general hand surgery practice, they rarely present simultaneously in the same hand. The surgical management of each condition has been exhaustively discussed in the literature, but only Nissenbaum and Kleinert (1980) have discussedsimultaneous operations on both. Nissenbaum and Kleinert (1980) reported their experience with 29 patients with co-existent carpal tunnel syndrome and Dupuytren’s contracture. They found an 87% complication rate in the 15 patients treated by simultaneous carpal release and fasciectomy. Their recommendation, therefore, was to treat the conditions in staged surgical procedures, not simultaneously. Since it has been the policy of one of the authors (H.K.W.) to perform both operations at the same sitting, a retrospective review was initiated to assess the complications and long-term results. Patients and methods The medical records of a busy hand surgery practice for a 20-year period (1968-1987)were examined for patients who had undergone simultaneous carpal tunnel release and Dupuytren’s fasciectomy. During that time, operations were performed on 2,749 hands with carpal tunnel syndrome and 623 with Dupuytren’s contracture. In 32 patients combined surgery was performed for coexistent disease. Two of these patients could not be located for long-term follow-up ; the remaining 30 comprised the basis of this study. Two patients who moved out of the area could only be interviewed by telephone. All other patients were personally examined and interviewed. Grip strength and range of motion were measured, and the surgical scar was evaluated by the same observer (F.G.) in each of the examined patients. A value was assignedto each surgical scar based on a scale from one to ten, where one denotes a grossly hypertrophic scar and ten an imperceptible VOL.
16B No. 2 MAY
1991
scar. For comparison, 30 patients who underwent carpal tunnel release and 30 who underwent Dupuytren’s fasciectomy were randomly selected, and subjected to a similar review of the notes and clinical examination. Surgical technique All surgical procedures were performed by the senior author. The operative techniques used have been described elsewhere(Ariyan and Watson, 1977,King et al., 1979; Baker and Watson, 1980). Salient aspects of the combined procedure are as follows : Carpal tunnel release
1. A longitudinal incision is made in the “fingerprint pattern” to mid-palm along the line of the fourth ray. 2. Guyon’s canal releasemay be performed. 3. The carpal tunnel is opened, with resection of a longitudinal strip about three mm. wide from the radial portion of the flexor retinaculum. 4. External neurolysis of the median nerve is performed, resecting about half the circumference of the epineurium without separation of the nerve bundles. 5. Running 4-O nylon closure of the skin. Dupuytren’s fasciectomy
Zig-zag incisions are made in the skin overlying the diseasedfascia in the palm and digits. Skin flaps are raised superficial to the fascia. Total accessible fasciectomy is performed, starting proximally and working distally. Closure is facilitated by performing Y-V advancements when necessary(Fig. 1). Post-operative care
1. A bulky fluff compression dressing is placed on the hand before deflation of the tourniquet. 175
F. GONZALEZ
Table l-Age,
AND
H. KIRK
WATSON
sex and length of follow-up io patient groups
Carpal tunnel release and Dupuytren’s fasciectomy Dupuytren’s fasciectomy Carpal tunnel release
No.
Mean age (yrs)
Male
Female
Length F/U (yrs)
30
61.7 (25-81)
18
12
4.9 (0.25-15)
30 30
62.0 (27-85) 60.3 (22-82)
19 14
11 16
5.8 (l-20) 7.7 (1-15)
Table 2-Undesirable
results (%) Complications
Carpal tunnel release and Dupuytren’s fasciectomy Dupuytren’s fasciectomy Carpal tunnel release
Fig. 1 Y-V plasty incisions in extensive fasciectomy for Dupuytren’s contracture.
2. The large dressing is removed after two to five days and mobilization of the hand is begun in a light gauze dressing. 3. Sutures are removed two weeks after the operation. 4. Patients are observed in therapy for at least six weeks or until function is normal. Results
The mean age of the 30 patients who underwent simultaneous Dupuytren’s fasciectomy and carpal tunnel releasewas 61.7 years (Table 1). There were 18 men and 12 women and the mean length of follow-up was 4.9 years. The mean ages of the patients undergoing carpal tunnel release alone or Dupuytren’s fasciectomy alone were 62.0 and 60.0 years respectively, not statistically different from the combined surgerygroup. There were three early complications in this series (Table 2), one in each group of 30 patients. In the group of patients with co-existentdisease,one patient developed a haematoma which was evacuated in the office without sequelae. A minor wound dehiscence in a patient who underwent fasciectomy alone healed without surgery, and a wound infection in a patient who underwent carpal tunnel releasealone was drained and healed uneventfully. Three patients developed symptoms of reflex sympa176
1 hematoma (3.3%) 3 RSD (10%) 1 wound dehiscence (3.3%) 1 wound infection. (3.3%)
Recurrences Extension 4 (13%)
2 (6.6%)
11(36%)
7 (23%)
0
N/A
thetic dystrophy, all in the combined group (10%). These patients were treated successfully,with complete resolution of their symptoms, by the Dystrophile (stressloading) reflex sympathetic dystrophy programme (Watson and Carlson, 1987). There were four cases(13%) of recurrent Dupuytren’s contracture in the combined group and 11 (36%) in the fasciectomy only group : in only one was there recurrence in the palm, the remainder occurring in the digits. Extension of Dupuytren’s diseasewas diagnosed when, at the time of follow-up, contracture was seen distal to the surgical incision. Extension of the diseasewas seen in two patients (7%) in the combined group and seven patients (23%) in the fasciectomy only group. Evaluation of scar appearanceat the time of follow-up resulted in a mean value of 7.7 in the combined group, 8.0 in the fasciectomy only group, and 9.0 in the carpal tunnel releaseonly group (Figs. 2 and 3). Discussion
The demographic composition of all three groups was similar. The length of follow-up in the single operations was longer, but this does not significantly alter the findings of this study as the time of follow-up in all cases was well past the period in which complications were seen. Only three early complications occurred in these 90 patients, one in each group. The complication rates after the single operations (3.3%)were not profoundly different from those in previous reports (Ariyan and Watson, 1977; King et al., 1979). The 3.3% complication rate in the combined group was equal after the single operations and lower than those previously reported for the combined operations (Nissenbaum and Kleinert, 1980). The incidence of haematomaformation with Dupuytren’s THE
JOURNAL
OF HAND
SURGERY
SIMULTANEOUS
Fig. 2
CARPAL
TUNNEL
RELEASE
Hand of 7%year-old man five years after combined carpal tunnel release and Dupuytren’s fasciectomy. Scar was rated 4.
fasciectomy alone has been reported as high as 15.8% (Tubiana et al., 1967). The fact that all operations were performed by the same surgeonusing the same technique may have contributed to the relatively low complication rate. Recurrence rates in long-term follow-up studies of patients who have undergone Dupuytren’s fasciectomy range from 25% to 63% (Rodrigo et al., 1976; Dickie and Hughes, 1967; Honer et al., 1971; Hakstian, 1974) and extension of diseasehas been reported in 20% to 66% of cases. In our patients who underwent Dupuytren’s fasciectomy alone, the recurrence rate was 36% and extension of disease occurred in 23% of cases. This is clearly within the range reported in the literature and is greater than the 11% recurrence and 7% extension rates in the patients who had the combined operations. Since the mean length of follow-up in the combined group was nearly a year shorter than that of the fasciectomy group, this may account for the discrepancy. The three casesof reflex sympathetic dystrophy were VOL.
16B No. 2 MAY
1991
AND
Fig. 3
DUPUYTREN’S
FASCIECTOMY
Hand of a 77-year-old woman eight years after combined Dupuytren’s fasciectomy and carpal tunnel release. Scar was rated 9.
the only undesirable results which occurred more often after the combined than the single operations. Since patients are seen by hand therapists early in the postoperative period, R.S.D. is usually diagnosed in its early stages.Use of the Dystrophile R.S.D. program (Watson and Carlson, 1987) resulted in complete resolution of symptoms in all three cases. A combination of early vigilance and the employment of the stress loading program significantly reduces the number of persistent R.S.D. problems. It might be theorised that performing both carpal tunnel release and Dupuytren’s fasciectomy would increase the extent of scar formation. To test that hypothesis, an arbitrary scalewas utilised to evaluate the cutaneous scar in each patient at the time of follow-up. As would be expected, there was less scar formation in the carpal tunnel only group than either of the other two groups. When the incision for carpal tunnel release is placed in the palm and not extending proximal to the fingerprint pattern of the palm, the resulting scar is 177
F. GONZALEZ
AND
hardly noticeable in most cases after complete healing. Although the values for the scars in the fasciectomy and combined groups were lower (i.e. worse) than the mean scar value in the carpal hand group, they were not significantly different from each other. Although this is an arbitrary scale, it shows that there is little difference in appearance of the scars in these patients upon longterm follow-up. Conclusion
A review of 30 patients in whom carpal tunnel release and Dupuytren’s fasciectomy were performed as a combined procedure has demonstrated no greater morbidity than after Dupuytren’s fasciectomy alone. The incidence of unfavourable results, even after a mean follow-up of 4.9 years, was far less than the 87% reported previously. It is our recommendation that these two proceduresbe performed simultaneously whenever both conditions are present in the same hand. With this approach, an extra operation and progression of symptoms will be avoided.
H. KIRK
WATSON
BAKER, G. C. and WATSON, H. K. (1980). Relieving the skin shortage in Dupuytren’s disease by advancing a series of triangular flaps: how to design and use them. British Journal of Plastic Surgery, 33 : 1-3. DICKIE, W. R. and HUGHES, N. C. (1967). Dupuytren’scontracture. A review of the late results of radical fasciectomy. British Journal of Plastic Surgery, 20: 311-314. HAKSTIAN, R. W. (1966). Long term results of extensive fasciectomy. British Journal of Plastic Surgery, 19: 140-49. HONNER, R. LAMB, D. W. and JAMES, J. I. P. (1971). Dupuytren’s contracture. Long-term results after fasciectomy. Journal of Bone and Joint Surgery, 538: 2: 240-246. KING, E. W., BASS, D. N., and WATSON, H. K. (1979). Treatment of Dupuytren’s contracture by extensive fasciectomy through multiple Y-V plastyincisions: Short-term evaluationof 170consecutiveoperations. Journal of Hand Surgery, 4: 3 : 234-241. NISSENBAUM, M. and KLEINERT, H. E. (1980). Treatment considerations in carpal tunnel syndrome with coexistent Dupuytren’s disease. Journal of Hand Surgery, 5 : 6 : 544547. RODRIGO, J. J., NEIBAUER, J. J., BROWN, R. L. andDOYLE, J. R. (1976). Treatment of Dupuytren’s contractwe. Long-Term Results after Fasciotomy and Fascial Excision. Journal of Bone and Joint Surgery, 58A: 3 : 38s-387. TUBIANA, R., THOMINE, J. M. and BROWN, S. (1967). Complications in Surgery of Dupuytren’s Contractwe. Plastic and Reconstructive Surgery, 39 : 6: 603-612. WATSON, H. K. and CARLSON, L. (1987). Treatment of reflex sympathetic dystrophy of the hand with an active “stress loading” program. Journal of Hand Surgery, 12A: 5(l): 779-785.
References ARIYAN, S. and WATSON, H. K. (1977). The pahnar approach for the visualization and release of carpal tunnel. An analysis of 429 cases. Plastic and Reconstructive Surgery, 60: 4: 539-547.
178
Accepted: 3 April, 1990 H. Kirk Watson, M.D., 85 Seymour Street, Hartford, Corm. 06106, USA 0 1991 The British Society for Surgery of the Hand
THE
JOURNAL
OF HAND
SURGERY
