Surgical principles and planning for the rheumatoid hand and wrist

Each surgical procedure available for the rheumatoid hand has a score card. The most indicated and necessary procedures include: extensor tenosynovectomy and Darrach for the impending or already ruptured extensor tendons; flexor tenosynovectomy and carpal tunnel release for the patient with impaired median nerve function; stabilization of the deformed unstable thumb with MP or IP arthrodesis; and flexor tenosynovectomy in the palm and finger of a motivated patient with significant disparity between active and passive motion. Relative indications for surgery include arthrodesis for the unstable wrist; MP arthroplasty for the fixed MP volar and ulnar subluxation with inability to open the hand; synovectomy for the occasional patient with painful boggy synovitis of the MP or PIP joint; and reconstruction of the fixed swan neck deformity with relatively good PIP joints. Both MP and PIP joints can and should be operated on at the same time. Extensive wrist surgery, that is, tenosynovectomy and Darrach or arthrodesis, should not be performed at the same time as MP arthroplasty. Try to do the "winner operations" first.     

Failed total wrist arthroplasty. Analysis of failures and results of operative management

Nine metal on polyethylene total wrist arthroplasties were revised for failure, including eight trispherical devices and one Volz implant. Causes of failure include sepsis in one patient, progressive wrist flexion contracture in two patients, and mechanical failure in six patients. The most common mode of mechanical failure was metacarpal loosening with dorsal perforation of the stem. This was associated with an intact articulation between the third metacarpal and the capitate, with a proximal position of the metacarpal component in the shaft, and with poor cement fill of the metacarpal shaft. The one infected wrist was managed with resection arthroplasty. Five patients had conversion to a wrist arthrodesis and three patients underwent revision total wrist arthroplasty with custom trispherical components. Followup averaged 3.3 years. All patients undergoing arthrodesis attained a solid painless fusion after a single operation at an average of 4.8 months. The three patients treated with revision arthroplasty had wrists that were pain free, functional, and had no evidence of loosening at latest followup. Failed total wrist arthroplasties can be salvaged successfully to either a fusion or a revision arthroplasty in most patients.     

Radiohumeral arthrodesis for salvage of failed total elbow arthroplasty

Ulnohumeral arthrodesis is the standard technique for elbow fusion. The geometry and surface area of the distal humerus and proximal ulna enhance the chances of fusion while maintaining some wrist motion. A case of a patient with multiple failed elbow procedures in which the standard ulnohumeral fusion was not possible is presented. A radiohumeral arthrodesis was performed in an attempt to obtain a stable, nonpainful elbow. After complete healing of the fusion, the patient was able to use the arm for most functions. This technique is presented as an option for salvage failed elbow arthroplasty in the face of significant bone loss.     

Wrist arthrodesis for failed wrist implant arthroplasty

Thirteen wrist arthrodeses were performed for failed wrist implant arthroplasties between 1984 and 1992. Twelve patients were available for review, with an average follow-up period of 28 months. The original arthroplasties consisted of 8 silicone implants and 4 metal-plastic total wrist implants. The surgical method involved a tricortical iliac bone graft and an intramedullary Steinmann pin. There were 7 excellent results, 4 good results, and 1 poor result. All but 1 patient had markedly improved function with no or mild pain. Seven patients had solid fusions and 5 patients had pseudarthroses. Four pseudarthroses occurred at the graft-metacarpal junction and 1 occurred at the graft-radius junction. Each patient with a solid fusion had an excellent result. All graft-metacarpal pseudarthroses were painless and did not limit the patients' activities. There were 17 complications in 9 patients. Wrist arthrodesis can be a successful salvage procedure for failed wrist implant arthroplasty in patients with rheumatoid arthritis. However, the complication rate can be high. Owing to the high incidence of distal graft-metacarpal pseudarthrosis, we recommend using more rigid fixation techniques in patients with failed wrist arthroplasties.     

Preliminary experiences on triscaphoid arthrodesis

The authors report their experience of 5 patients (4 males, 1 female) with a mean age of 36.4 years (min 25 years, max 45 years), undergoing triscaphoid arthrodesis between May 1989 and August 1993. The patients suffered from rotatory dislocation of the scaphoid (1 case) and stage 3A of Kienboeck's disease according to Lichtman's classification (4 cases). The paper describes the surgical technique used for partial arthrodesis of the wrist performed using plexual anesthesia. A dorsal access route is used through a curved longitudinal skin incision corresponding to the anatomical site of the scaphoid. The skin flaps are then peeled back revealing the surface veins and sensitive branches of the radial nerve which are isolated and conserved. Having cut through the retinaculum of the extensors, the extensor tendons are spread so as to reach the joint capsule which is sectioned crosswise. After the bone to be fused have been exposed, the cartilage is removed from the joint faces between the scaphoid, trapezium and trapezoid and, using a osteotribe, the subchondral bone is removed to reveal the spongy bone, leaving a space of approximately 6 mm between the spongy surface of the bones to be fused. Arthodesis is stabilised using Kirschner wires or metal minicambres enclosing scaphoid, trapezium and trapezoid. Spongy tissue is taken from the distal radial head and used as a graft to fill the spaces created between them which will consolidate over time. The wrist is immobilised in a plaster cast for 8 weeks before starting functional rehabilitation. Patients were checked both clinically and radiographically with a mean follow-up of 36.4 months (min 25, max 50 months). Using the assessment criteria proposed by Minami et al. excellent results were obtained in 4 patients (80%) with the disappearance of painful symptoms, joint excursion 50% greater than the normal wrist, and hand grip 70% greater than in the controlateral hand. There was good radiographical consolidation of the arthrodesis. Poor results were only recorded in one case (20%) with persisting pain and functional impotent. Radio-scaphoid arthrosis was observed radiographically consequent to hypercorrection of the scaphoid with a radio-scaphoid angle of less than 45 degrees. The authors underline the technical difficulty of this arthrodesis characterised by reduction of the scaphoid in a correct position in which the radio-scaphoid angle must be 45 degrees when measured from a lateral position. Lastly, the authors conclude that this from of arthrodesis may be used with good results to treat wrist pathologies such as rotatory scaphoid dislocation, triscaphoid arthrosis and Kien-boeck's disease at stage 3A according to Lichtman. They also affirm that arthrodesis limited to the wrist is preferable to total arthrodesis because it enables some joint movement to be conserved which is important for hand function.     

Urinary macromolecules are promoters of calcium oxalate nucleation in human urine: turbidimetric studies

In selected circumstances, especially those associated with pain and mechanical instability, early surgical therapy is indicated for patients with rheumatoid arthritis. Close consultation between the rheumatologist and surgeon enables identification of focused goals attainable by synovectomy, ligament or tendon reconstruction, joint replacement, or arthrodesis. If these goals are met, the result can be a gratifying return of function and independence. This article describes some of the more common deformities of the hand, wrist, and elbow in patients with rheumatoid arthritis. Current surgical therapy, along with outcome and complications, is also discussed. Emphasis is placed on decisions and indications for surgical evaluation.     

An unusual reaction to cold: a sporadic case of familial polymorphous cold eruption?

Denervation surgery has been a mainstay of our management of chronic pain in the wrist. If there is useful movement at the wrist we prefer denervation to arthrodesis. We have reviewed 22 patients at a mean of 50 months after such denervation surgery at the wrist. This was the only treatment in 16 patients; the other six also had other treatments. Pain was reduced in 16 patients, and 17 were satisfied or improved. None of the patients wished to have a supplementary arthrodesis. We stress the importance of preoperative blockade tests and of a very detailed knowledge of the local anatomy.     

Hip fusion in young adults. Using a medial displacement osteotomy and cobra plate

Eight consecutive patients, mean age 17.25 years, underwent a medial displacement osteotomy and hip arthrodesis with a nine-hole Cobra plate. A transverse innominate osteotomy facilitated medial displacement of the femoral head and acetabulum. Alignment of the lower limb at 25 degrees flexion, neutral abduction, and neutral rotation was assisted by a long-limbed protractor and Steinmann pins placed in both anterior superior iliac spines. The greater trochanter was reattached to the Cobra plate so that hip abductor function could be restored should the fusion ever be converted to an arthroplasty. No postoperative immobilization was required. All patients had radiographic evidence of union by 12 months. One patient had a postoperative brachial plexus neuropraxia that resolved at three months. One patient required an ipsilateral femoral lengthening for limb-length inequality secondary to collapse of his femoral head before hip fusion. At a mean follow-up interval of 2.8 years (range, one to 4.5 years), all patients had significant improvements in pain (p < 0.05), function (p < 0.01), and gait (p < 0.01). The average preoperative Harris Hip Score of 45 points +/- 8 points (mean +/- SEM) improved to 84 points +/- 2 points (p < 0.01).     

Total wrist arthroplasty

Although arthroplasty is a well-established procedure for many joints, its use in the wrist is less common, and the indications are less well defined. The standard procedure for the painful arthritic wrist remains radiocarpal arthrodesis. However, as technology and surgical procedures improve, wrist arthroplasty is being used more frequently. The authors provide a brief history of total wrist arthroplasty and review the arthroplasties most commonly used in the United States. Results with total wrist implants, the complications related to arthroplasty, technical aspects of the procedure, and salvage options are also discussed.     

Arthrodesis of finger joints by dynamic external compression using dorsoventral Kirschner wires and rubber bands

A new method is presented for arthrodesis of small joints in the hand. In this method Kirschner wires are inserted dorsoventrally through the phalanges on either side of the joint, and the external ends bent into hooks. Longitudinal compression is achieved by connecting these hooks with rubber bands. This technique gives a solid and painless immobilization in a proper position, and the latter can be corrected easily when necessary. We arthrodesed 46 joints in 39 patients by this method in 1975 and 1976. The fusion time was 4 to 6 weeks, and the method produced a good bony arthrodesis in 42 of the 46 fingers.     

Deformity correction and arthrodesis of the midfoot with a medial plate

Nine feet in eight patients undergoing tarsometatarsal (Lisfranc) or other midfoot arthrodeses for posttraumatic or degenerative arthritis were reviewed retrospectively. All patients were treated using a medial one-third tubular plate spanning the midfoot joints to be fused. Three feet underwent fusion in situ while six feet underwent correction of residual planus, planovalgus, or cavovarus deformity at the time of fusion. All patients achieved fusion within 12 weeks. A good or excellent result was achieved in seven of nine feet. There was no radiographic or clinical evidence of pseudarthrosis or medial hardware failure in any patient. No patient to date has required hardware removal for a painful or prominent implant. The talus first metatarsal angle was improved an average of 15.5 degrees in the lateral plane and 10 degrees in the AP plane in patients undergoing deformity correction. The technique of using a medial plate for midfoot arthrodesis allows for reliable fusion in patients who require salvage for midfoot arthritis. This technique also allows for correction of deformity in patients with residual midfoot deformity.     

Co-regulative effect of PKA-RII and PKC-alpha kinase subspecies on expression of c-myc and c-H-ras in human gastric cancer cells (MGC 80-3)]

OBJECTIVE: To investigate the effect of 3 commercial wrist orthoses on finger dexterity and hand function of patients with rheumatoid arthritis (RA). METHODS: Forty-two patients with definite RA participated in the cross-over study comparing 3 styles of commercial wrist orthoses. Finger dexterity and hand function of the dominant hand were assessed while splinted and unsplinted, at the initial session and after 1 week of intermittent orthosis use. Finger dexterity was assessed using two subtests from the Purdue Pegboard Test (Purdue) and hand function was assessed using the Jebsen-Taylor Hand Function Test (Jebsen-Taylor). RESULTS: Both finger dexterity and hand function were reduced by splinting; men and women were affected similarly. There was no difference in finger dexterity or hand function afforded by the 3 orthoses. Results on both the Purdue and Jebsen-Taylor tests showed a significant learning effect across time. CONCLUSIONS: The 3 commercial wrist orthoses studied reduce dexterity similarly and significantly. When commercial wrist orthoses are to be used during tasks that require maximum dexterity, this reduction should be weighed against the known benefits of splinting.     

Protection from carcinogenic agents in work environments: considerations on Title VII of Legislative Decree 626/94

A variety of techniques are available for reconstruction of the wrist. The efficacy of wrist arthroplasty, however, is met with narrowed indications and does not enjoy the success that total joint replacement in other joints, such as the hip and knee, has enjoyed. With design improvements during the last decade, good short-term results from total wrist arthroplasty can be expected in the low-demand patient with rheumatoid arthritis. Wrist arthrodesis, either pancarpal or limited, is considered the primary surgical alternative in patients with most arthritic conditions of the wrist. The pancarpal arthrodesis is a predictable, durable alternative to a variety of post-traumatic, degenerative, or neoplastic conditions of the wrist; however, some authors report that complications may be prevalent. This procedure also may be modified and applied to the destroyed rheumatoid wrist. Overall, selection of fixation mode depends on bone quality. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although technically demanding, successful results may be expected, especially in conditions of carpal instability. With the current wide array of surgical alternatives, the surgeon must consider each case carefully and select the procedure that best applies to each particular situation. Furthermore, it is extremely important that the surgeon educate the patient on the limitations of each procedure.     

Total wrist arthroplasty in rheumatoid arthritis. A long-term clinical review

Fourteen total wrist arthroplasties performed in 13 patients with rheumatoid arthritis between 1978 and 1982 were reviewed to evaluate long term outcome. Most patients had Stages III or IV rheumatoid arthritis at the time of surgery. Pain was the primary presenting complaint in 87%. Average followup was 6.5 years (range, 3.5-11.5 years). Pain relief was achieved in 86% of patients. Using objective data obtained from their wrist scores, 72% of the patients had a good result, 14% had a fair result, and 14% had a poor result. No patient had an excellent result. Twenty-seven percent suffered postoperative complications related to their surgical procedure. Although these results help confirm the usefulness of total wrist arthroplasty as an alternative to arthrodesis of the wrist, it is a technically demanding procedure, and should be reserved for the patient who has severely involved arthritis. Additional improvements are needed to decrease the currently high complication and failure rate.     

Compartment syndromes of the hand

We retrospectively reviewed the records of nineteen patients who had been managed with fasciotomy because of compartment syndrome of the hand. The patients were five months to sixty-seven years old and included ten adults and nine children. Seventeen patients were followed for an average of twenty-one months (range, one to fifty-eight months), one patient was lost to follow-up after discharge, and one patient died four days postoperatively. All of the patients had a tense, swollen hand and elevated pressure in at least one interosseous compartment. Eight patients also had a compartment syndrome of the forearm. The compartment syndromes developed after intravenous injections (eleven patients); after a gunshot wound, a crush injury, or a complication related to the use of an arterial line (two patients each); and after a complication related to an arthrodesis of the wrist or a crush injury due to prolonged pressure on the upper extremity secondary to a drug overdose (one patient each). Fifteen patients had an obtunded sensorium-either because of a serious illness or injury or secondary to prolonged anesthesia-when the compartment syndrome was recognized. In thirteen of these patients, including eight children and five adults, the compartment syndrome developed because of a complication related to the intravenous or intra-arterial administration of drugs. Carpal tunnel release and decompression of the involved compartments led to a satisfactory result for thirteen of the seventeen patients who were followed. The remaining four patients (including two children who had an amputation, one child who had impaired function of the hand secondary to brain damage, and one adult who had extensive involvement of the forearm and complete loss of function of the hand) had a poor result. All four of these patients had been obtunded when the compartment syndrome developed. The treating physician should maintain a high index of suspicion for a compartment syndrome of the hand when managing seriously ill, obtunded patients-particularly children-who are receiving multiple intravenous or intra-arterial injections.     

Kienb?ck's disease. Follow-up studies and therapeutic considerations (author's transl)

This paper presents a follow-up of patients with Kienb?ck's disease up to 30 years after their first symptoms. Only the shortening of the radius and the grafting of the lunate with cancellous bone offers some kind of basic therapy. The intercarpal arthrodesis, the arthrodesis of the wrist and the operation named after Steinh?user should only be considered in cases with severe deformation and disabling pain.     

Lunotriquetral arthrodesis

Lunotriquetral arthrodesis has been recommended for the treatment of disabling pain at the lunotriquetral joint after more conservative measures have failed. We retrospectively analyzed a series of 22 patients treated with a lunotriquetral arthrodesis for presence of fusion, method of fixation, duration of immobilization, carpal alignment, pain relief, and ability to return to work. Fixation with a Herbert screw supplemented with a Kirschner wire (K-wire) was superior to fixation with K-wires alone. Immobilization longer than 6 weeks was superior to immobilization less than 6 weeks. Combined use of a Herbert screw supplemented with a K-wire and immobilization longer than 6 weeks resulted in union in all patients, even when performed for nonunion after a prior attempted arthrodesis. Pain was improved in all patients; all patients who previously were working returned to work. Routine posteroanterior and lateral x-ray films often failed to adequately profile the arthrodesis site. We recommend using a Herbert screw supplemented with a K-wire for lunotriquetral arthrodesis and keeping the patient in a cast until fusion is documented, usually at least 8 weeks. Fluoroscopic spot views or tomograms are recommended to demonstrate bone fusion.     

Vascularized fibular graft for reconstruction of the wrist after excision of giant cell tumor

Seven patients with a giant-cell tumor involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. Two patients with stage 2 disease of Enneking's surgical staging and grade 2 of Campanacci's radiographic grading system were reconstructed with an articular fibular head graft. Five patients with stage 3 and grade 3 disease underwent wrist arthrodesis using fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. No local recurrence was seen in any of the patients at the most recent follow-up examinations. There were six good and one excellent functional results. Wrist arthroplasty using a vascularized fibula head graft is the best procedure for a stage 2 or grade 2 giant-cell tumor of the distal end of the radius. In cases of stage 3 or grade 3 disease, wrist arthrodesis using a vascularized fibular shaft graft is indicated.     

Congenital scoliosis with posterior spinal arthrodesis T2-L3 at age 3 years with 41-year follow-up. A case report

STUDY DESIGN: A case report. OBJECTIVES: To document the long-term effects of early fusion for progressive congenital scoliosis. SUMMARY OF BACKGROUND DATA: There is concern about fusion at an early age causing torso shortening and possible crankshaft phenomenon. METHODS: A review of medical and radiologic records. RESULTS: A 3-year old girl with progressive congenital scoliosis had posterior spinal arthrodesis in 1955. A pseudarthrosis was repaired at age 4, and at age 8 she had an osteotomy of the fusion mass because of bending of the fusion mass. In a follow-up 41 years after fusion, she has no back pain and no history of pulmonary problems. Despite the long fusion at a young age, her torso-to-leg ratio was remarkably good. The thoracic lordosis had improved to a normal thoracic kyphosis. CONCLUSION: Early arthrodesis was life saving and caused no long-term problems. Because significant spinal growth has occurred by age 3, no adverse effects on torso-leg ratio with an early long arthrodesis, and in addition the crankshaft phenomenon is rare in congenital scoliosis.     

The diagnosis of early gastric cancer. A survey of experience in the United States

Some general techniques in arthrodesis of finger joints are described. Then biomechanical measurements were made after compression arthrodesis with screws, crossed KIRSCHNER wires, tension band wiring, compression plates (Swiss AO), and self compression plates, creascent shaped (MITTELMEIER). By screws, a maximal compression between 25 and 34 kp is achieved. Using a selfcompressing, bent, crescent shaped plate, one gets a compression of about 18 kp. This osteosynthesis resists a high deflection momentum if edgewise inserted.