Showing papers in "Journal of Hand Surgery (European Volume) in 2004"

Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient.

Abstract: Purpose Increased incidence of falls and osteoporosis combine to make distal radius fractures a major cause of morbidity for the elderly patient This report presents our experience treating distal radius fractures in the elderly population using a volar fixed-angle internal fixation plate Methods We reviewed retrospectively all patients older than 75 years treated during a period of 4 years and 7 months at our centers for unstable distal radius fractures using a volar fixed-angle plate Postoperative management included immediate finger motion, early functional use of the hand, and a wrist splint used for an average of 3 weeks Standard radiographic fracture parameters were measured and final functional results where assessed by measuring finger motion, wrist motion, and grip strength Results Of 26 patients that fit the inclusion criteria, we were able to evaluate 23 patients with 24 unstable distal radius fractures for an average of 63 weeks Final volar tilt averaged 6° and radial tilt 20°, and radial shortening averaged less than 1 mm The average final dorsiflexion was 58°, volar flexion 55°, pronation 80°, and supination 76° Grip strength was 77% of the contralateral side There were no plate failures or significant loss of reduction, although there was settling of the distal fragment in 3 patients (1–3 mm) Conclusions The treatment of unstable distal radius fractures in the elderly patient with a volar fixed-angle plate provided stable internal fixation and allowed early function This technique minimized morbidity in the elderly population by successfully handling osteopenic bone, allowed early return to function, provided good final results, and was associated with a low complication rate

Residual function in peripheral nerve stumps of amputees: implications for neural control of artificial limbs.

Abstract: Purpose It is not known whether motor and sensory pathways associated with a missing or denervated limb remain functionally intact over periods of many months or years after amputation or chronic peripheral nerve transection injury. We examined the extent to which activity on chronically severed motor nerve fibers could be controlled by human amputees and whether distally referred tactile and proprioceptive sensations could be induced by stimulation of sensory axons in the nerve stumps. Methods Amputees undergoing elective stump procedures were invited to participate in this study. Longitudinal intrafascicular electrodes were threaded percutaneously and implanted in severed nerves of human amputees. The electrodes were interfaced to an amplifier and stimulator system controlled by a laptop computer. Electrophysiologic tests were conducted for 2 consecutive days after recovery from the surgery. Results It was possible to record volitional motor nerve activity uniquely associated with missing limb movements. Electrical stimulation through the implanted electrodes elicited discrete, unitary, graded sensations of touch, joint movement, and position, referring to the missing limb. Conclusions These findings indicate that both central and peripheral motor and somatosensory pathways retain significant residual connectivity and function for many years after limb amputation. This implies that peripheral nerve interfaces could be used to provide amputees with prosthetic limbs that have more natural feel and control than is possible with current myoelectric and body-powered control systems.

Risk Factors in Carpal Tunnel Syndrome

Abstract: We have undertaken a large case-control study using the UK General Practice Research Database to quantify the relative contributions of the common risk factors for carpal tunnel syndrome (CTS) in the community. Cases were patients with a diagnosis of CTS and, for each, four controls were individually matched by age, sex and general practice. Our dataset included 3,391 cases, of which 2,444 (72%) were women, with a mean age at diagnosis of 46 (range 16-96) years. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR=2.29), rheumatoid arthritis (OR=2.23), osteoarthritis of the wrist and carpus (OR=1.89), obesity (OR=2.06), diabetes (OR=1.51), and the use of insulin (OR=1.52), sulphonylureas (OR=1.45), metformin (OR=1.20) and thyroxine (OR=1.36). Smoking, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS. The results were similar when cases were restricted to those who had undergone carpal tunnel decompression.

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

Abstract: Purpose To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint. Methods 183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery. Results The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed. Conclusions The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.

Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve.

Abstract: Purpose In C5 and C6 brachial plexus avulsion lesions, elbow flexion, shoulder abduction, and external rotation are the functions that need to be restored. Because the proximal stumps are not available for grafting, surgical repair is based on nerve transfers. The purpose of this study was to describe and report the results of the use of multiple nerve transfers in the reconstruction of these avulsion injuries. Methods Ten patients had multiple nerve transfers: cranial nerve XI to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps long or lateral head motor branch to the axillary nerve. Triceps branch transfer was performed through a posterior arm incision. Results Two years after surgery, all the patients had recovered full elbow flexion; 7 scored M4 and 3 scored M3+ according to Medical Research Council scoring. All the patients had recovered active abduction and external rotation. Abduction recovery averaged 92° (range, 65°–120°) and external rotation, measured from full internal rotation, averaged 93° (range, 80°–120°). Shoulder abduction strength was graded M4 in 3 patients and M3 in the remaining 7 patients. Shoulder external rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients. No donor site deficits were observed. Conclusions The proposed nerve transfers constitute a valid strategy in C5-C6 avulsion injury reconstruction.

Tubular repair of the median or ulnar nerve in the human forearm: a 5-year follow-up.

Abstract: The long-term outcome from silicone tube nerve repair was compared with the outcome from routine microsurgical repair in a clinical randomized prospective study, comprising 30 patients with median or ulnar nerve injuries in the distal forearm. Postoperatively, the patients underwent neurophysiological and clinical assessments of sensory and motor function regularly over a 5-year period. After 5 years there was no significant difference in outcome between the two techniques except that cold intolerance was significantly less severe with the tubular technique. In the total group there was ongoing improvement of functional sensibility throughout the 5 years after repair. It is concluded that tubular repair of the median and ulnar nerves is at least as good as routine microsurgical repair, and results in less cold intolerance.

Measuring grip strength in normal adults: reference ranges and a comparison of electronic and hydraulic instruments

Abstract: Purpose To determine reference ranges for peak, average, and final adult grip strength over 10 seconds by using an electronic dynamometer, and to compare results from hydraulic and electronic dynamometers. Methods The hand-grip strengths of 476 healthy adult subjects were tested using the electronic (Grippit; AB Detektor, Goteborg, Sweden) and hydraulic (Jamar; Smith and Nephew, Memphis, TN) dynamometers. Results Age- and gender-specific reference ranges for the Jamar and Grippit dynamometers are presented. Bland-Altman analysis of the differences between the results obtained using the 2 instruments revealed a bias (mean difference) of 22 N (Jamar − Grippit) and limits of agreement of −86 to 129 N (mean ± 2 SD), which indicates that grip measurements may vary by up to 215 N between instruments. Conclusions The study yielded population reference ranges of peak, average, and final strength over a 10-second grip assessment using an electronic dynamometer. Results from the Grippit and Jamar dynamometers are similar; however, the dynamometers cannot be interchanged. The Grippit provides information about endurance and fatigue of grip over 10 seconds, showing differences between right- and left-dominant adults.

Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures.

Abstract: Purpose There have been few prospective studies of elderly patients with conservatively treated distal radius fractures and little is known about the relationship between acceptable radiographic reduction and functional outcomes in this population. We hypothesized that acceptable fracture reduction (according to standard radiographic dorsal/volar tilt criteria) would be associated with better functional outcomes and greater satisfaction. Methods Seventy-four patients who were at least 50 years of age with conservatively managed distal radius fractures were recruited from 2 large urban emergency departments from January 2001 to December 2001. Patients with wrist fractures treated in the emergency department and discharged home were included; patients admitted to the hospital or who required surgical reduction were excluded. Standard lateral radiographs were taken after the final cast was removed. These were reviewed independently by a reference-standard musculoskeletal radiologist and the degree of dorsal/volar tilt was recorded. This value was dichotomized according to standard published dorsal/volar tilt criteria as acceptable (dorsal tilt 10° or volar tilt >20°). The Medical Outcomes Study Short-Form 12 (SF-12); the Disabilities of the Arm, Shoulder, and Hand questionnaire; and a patient satisfaction survey were used to assess patient-reported outcomes 6 months after the injury. Results The average dorsal/volar tilt measured by the reference standard radiologist was 3.4° (SD = 13.6) dorsal; overall 47 patients (64%) were considered to have an acceptable radiographic reduction. Acceptable radiographic reduction was not associated with better generic physical or mental health status, lesser degrees of upper-extremity disability, or greater satisfaction with outcomes than was unacceptable reduction. Overall 44 of 74 patients (59%) reported being satisfied or very satisfied with their functional status at 6 months. Conclusions Contrary to our hypotheses we found that acceptable radiographic reduction (according to dorsal/volar tilt criteria) was not associated with better self-reported functional outcomes or increased satisfaction at 6 months in elderly patients with conservatively treated distal radius fractures.

The two-point discrimination test – time for a re-appraisal?

Abstract: The two-point discrimination (2PD) test is the most frequently used test for the assessment of the sensory outcome after nerve repair. Here we focus on factors which explain the enormous and implausible variability in reported 2PD levels after nerve repair. We conclude that the 2PD testing technique is not at all standardized and that its use as the sole test for tactile gnosis recovery should be seriously questioned. Reports of 2PD results should always be accompanied by a detailed description of how the test was performed, especially with reference to the pressure applied and the testing protocol.

Clinical implications of growth factors in flexor tendon wound healing.

Abstract: Recent research has focused on the role of growth factors in flexor tendon wound healing. These basic science reports have described the identification and quantification of various growth factors in in vitro and in vivo models. Although these reports have begun to piece together the cascade of events involved in flexor tendon wound healing, the clinical relevance for the practicing hand surgeon is unclear. Growth factors are cell-secreted proteins that regulate cellular functions. These growth factors are involved in cell differentiation and growth, including the normal processes of development and tissue repair. Several growth factors recently have been identified as playing roles in tendon healing including vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor beta (TGF-beta). In addition, the transcription factor NF-kappaB has been implicated in the signaling pathways of these growth factors. The purpose of this article is to describe what is known about the molecular basis of flexor tendon wound healing, to review the most commonly studied growth factors, and to summarize likely clinical applications of these growth factors to flexor tendon repair.

Long-term assessmentof swanson implant arthroplasty in the proximal interphalangeal joint of the hand

Abstract: Purpose The purpose of this study was to evaluate the clinical results of Swanson silicone implant arthroplasty of the proximal interphalangeal (PIP) joint, specifically evaluating clinical results with long-term assessment. Methods A retrospective review of 70 silicone implants of the PIP joint in 48 patients was performed with an average follow-up period of 6.5 years (range, 3–20 y). Clinical assessment included motion, stability, and alignment. Radiographic assessment included implant fracture, deformity, and cystic bone resorption. The pathology consisted of degenerative joint disease in 14, posttraumatic arthritis (TA) in 11, rheumatoid arthritis (RA) in 13, and idiopathic arthritis (IA) associated with collagen disease in 12 patients. Swan neck and boutonniere deformities were assessed separately. Statistical analysis of preoperative risk factors was compared with the postoperative assessment of pain, motion, and function (return to work). Results There was no significant change in the active range of motion (ROM) before and after PIP arthroplasty (26° vs 30°). Correction of swan neck and boutonniere deformities was difficult, usually leading to poor results. There was improvement in maximum active extension before surgery lacking 32° to after surgery lacking 18°. From a statistical standpoint rheumatoid joint involvement with PIP arthroplasty had poorer results than degenerative or posttraumatic arthritis with respect to pain relief and ROM. Pain relief was present in 70% of replaced PIP joints with residual pain and loss of strength in 30%. Radiographic analysis showed abnormal bone formation (cystic changes) in 45%. There were 11 implant fractures and 9 joints that required revision surgery. Conclusions Silicone replacement of the PIP joint is effective in providing relief of pain from arthritis but does not provide improvement in motion or correction of deformity. It provided a poorer outcome in rheumatoid disease in comparison with degenerative, posttraumatic, or idiopathic arthritis.

Average versus maximum grip strength: which is more consistent?

Abstract: The average of three consecutive measurements is the most frequently used method for grip strength assessment. The purpose of this study was to compare the consistency of the maximum value with that of the average value of three consecutive measurements of grip strength. One hundred healthy volunteers participated in this study. Three measurements of grip strength were taken on two occasions separated by 2 weeks. For each hand, two average values and two maximum values were obtained. Ninety-five per cent limits of agreement for the average method were - 8.3 (-23%) to +7.2 (+20%)kg and for the maximum method were - 8.8 (-23%) to + 8 (+21%)kg. Both methods of grip strength assessment were found to be highly consistent with no statistically significant difference.

The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability.

Abstract: Purpose Scapholunate instability (SLI) is the most common carpal instability. Recent studies have suggested that the dorsal intercarpal (DIC) and the dorsal radiocarpal ligaments play an important role in stabilization of the scaphoid and lunate. Differences between dynamic SLI and static SLI with a dorsal intercalated segment instability (DISI) are clearly described in the clinical literature; however, there has never been a clear explanation of the anatomic differences. This study describes the role of the DIC in the development of dynamic and static SLI with DISI in a cadaver model. Methods Five fresh cadavers were studied radiographically and by 3-dimensional digitization. Six increasing stages of instability were developed by sectioning progressively the following structures: the dorsal capsule, the palmar and proximal (membranous) portion of the scapholunate interosseous ligament, the DIC from its insertion on the scaphoid and trapezium, the dorsal scapholunate interosseous ligament from the scaphoid, the DIC ligament from its attachment on the lunate, and the lunotriquetral interosseous ligament. Results The scaphoid position and the scapholunate gap changed significantly after sectioning the entire scapholunate interosseous ligament and DIC from the scaphoid when a 5-kg load was applied. The lunate position was unchanged in both the loaded and the unloaded conditions. After detaching the DIC from the lunate, both the scaphoid and lunate moved and the scapholunate gap increased significantly in both loaded and unloaded conditions and showed a DISI deformity. Conclusions This study describes an anatomic difference between dynamic and static scapholunate instability. Complete disruption of the scapholunate ligament did not result in the development of a static collapse of the lunate. The DIC had an important role in stabilizing the scaphoid and lunate and preventing DISI deformity. This study suggests that in the clinical setting the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction of the DIC ligament attachments to both the scaphoid and the lunate.

Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires.

Abstract: This prospective, randomized trial compares the infection rates of Kirschner wires left percutaneously and those buried deep to the skin in a group of patients with isolated distal radial fractures. Percutaneous wires had a significantly greater infection rate than wires which were buried deep to the skin.

Assessment of instability factors in adult distal radius fractures.

Abstract: Background The purpose of this study was to evaluate the radiographic outcome of unstable distal radius fractures treated by closed reduction and sugar tong splinting and to quantitatively evaluate Lafontaines' criteria of instability. Methods Fifty patients with 3 or more instability factors as described by Lafontaine were treated by finger trap traction, closed reduction, and sugar-tong splinting. They were evaluated radiographically for initial angulation, radial inclination, radial length, and palmar tilt at the time of injury, after reduction, and 1 week, 2 weeks, and 4 weeks after reduction. The fracture either maintained an adequate reduction or failed to maintain an adequate reduction and showed secondary displacement based on specific criteria. Results At 4 weeks after reduction 46% of these unstable distal radius fractures maintained an adequate reduction. Of the 54% of fractures that failed to maintain an adequate reduction, age was the only statistically significant predictor of secondary displacement. After obtaining an acceptable initial closed reduction, patients 58 years of age were found to be at 50% risk for secondary displacement. The risk for displacement with an unacceptable radiographic result was found to increase with increasing age and decrease with decreasing age. Conclusion In the closed management of these potentially unstable distal radius fractures, age was the only statistically significant risk factor in predicting secondary displacement and instability. These data help guide treatment by closed reduction and immobilization with serial x-rays or by surgical stabilization.

Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire?

Abstract: This prospective study evaluates if the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is an adequately responsive outcome measure in carpal tunnel syndrome by comparing it with the disease-specific Boston questionnaire (BQ). To measure responsiveness (sensitivity to clinical change), 57 patients with a clinical diagnosis of carpal tunnel syndrome completed the DASH and BQ preoperatively and again 3 months after open carpal tunnel decompression. A second group of 31 patients completed the questionnaires in the outpatient clinic and again 2 weeks later to assess test-retest reliability. The time to complete all questionnaires was recorded. Responsiveness of the DASH is comparable with the BQ with standardized response means of 0.66, 1.07 and 0.62 for the DASH, BQ-symptoms and BQ-function, respectively. Test-retest data show both questionnaires are reliable. Mean times to complete questionnaires were 6.8minutes (DASH) and 5.6minutes (BQ). This study concludes that the DASH questionnaire is a reliable, responsive and practical outcome instrument in carpal tunnel syndrome.

Basal Joint Osteoarthritis of the Thumb: A Prospective Trial of Steroid Injection and Splinting

Abstract: Purpose There have been few prospective studies evaluating the results of nonsurgical treatment of a well-defined patient cohort with symptomatic basal joint osteoarthritis of the thumb. This prospective study uses a validated outcome instrument to examine the effectiveness of a single steroid injection and 3 weeks of splinting in patients with osteoarthritis in Eaton stages 1 to 4 with a minimum of 18 months of follow-up evaluation. Methods Thirty consecutive patients (30 thumbs) were studied prospectively to evaluate the efficacy of a single injection of corticosteroid into the trapeziometacarpal joint, followed by immobilization in a thumb spica splint for 3 weeks. All patients answered an outcome-based questionnaire (Disabilities of the Arm, Shoulder, and Hand) and were examined before injection, 6 weeks after injection, and at final follow-up examination (minimum, 18 months). Eaton radiographic stage was recorded by 3 independent observers. Results At 6 weeks 13 patients had improvement in pain intensity and 17 patients reported no symptomatic improvement. Twelve of those with relief at 6 weeks continued to have relief at long term follow-up evaluation (mean, 25 months). Of patients with long-term relief average grip strength of the affected thumb was 95% of contralateral side, whereas those without relief had grip strength values that were 60% of contralateral side. For those patients without relief at 6 weeks there was no improvement seen at later follow-up evaluation. Five patients with Eaton stage 1 disease had an average of 23 months of relief with nonsurgical treatment. In stage 2 and stage 3 disease 7 thumbs improved at 6 weeks after injection and 6 thumbs had long-term relief. In stage 4 disease, 6 thumbs had neither short-term nor long-term relief with the injection. Disease side, handedness, and smoking did not affect outcomes. At final follow-up evaluation 12 thumbs had had surgical treatment. Conclusions Steroid injection with splinting for the treatment of basal joint arthritis of the thumb provided reliable long-term relief in thumbs with Eaton stage 1 disease but provided long-term relief in only 7 of 17 thumbs with Eaton stage 2 and stage 3 basal joint arthritis.

Radial nerve palsy associated with high-energy humeral shaft fractures.

Abstract: Purpose To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis. Methods Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open—6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration. Results All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1–25 weeks). The average time to full recovery was 6 months (range, 1–21 months). Conclusions Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.

Dupuytren’s Disease Risk Factors

Abstract: Dupuytren's is a common problem, but little is known about its aetiology. We have undertaken a large case-control study to assess and quantify the relative contributions of diabetes and epilepsy as risk factors for Dupuytren's in the community. Cases were patients with a diagnosis of Dupuytren's disease and, for each, two controls were individually matched by age, sex, and general practice. Our dataset included 821 cases and 1,642 controls. Five hundred and eighty-eight (72%) of the cases were men. The mean age at diagnosis was 62 (range 24-97) years. Diabetes was a significant risk factor for Dupuytren's disease (OR=1.75) and there was an increased risk for medicinally treated diabetes (metformin--OR=3.56; sulphonylureas--OR=1.75) and particularly insulin controlled (OR=4.38) rather than diet-controlled diabetes. Epilepsy (OR=1.12) and anti-epileptic medications were not associated with Dupuytren's disease. Ascertainment bias in previous studies may explain the reported association with epilepsy.

Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow.

Abstract: Purpose To review the results of surgical reconstruction of posttraumatic elbow instability in the setting of either intact or repaired olecranon process using a protocol incorporating hinged elbow fixation. Methods Thirteen consecutive patients with ulnohumeral instability after a fracture-dislocation of the elbow, adequate articular surfaces, and adequate, stable alignment of the olecranon were treated with temporary hinged external fixation, preservation, or reconstruction of both the coronoid process and radiocapitellar contact and with repair or reconstruction of the lateral collateral ligament complex. There were 9 men and 4 women with an average age of 45 years. Seven patients had a terrible triad pattern injury and 6 had a posterior Monteggia pattern injury. All 13 patients had fracture of the radial head and 10 patients had fracture of the coronoid process. Results At an average follow-up period of 57 months stability was restored in every patient. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15 and the average Mayo score was 84, with 6 excellent, 4 good, and 3 fair results. The average arc of ulnohumeral motion was 99°. Six patients had radiographic signs of arthrosis including 5 of 6 patients with olecranon fracture-dislocations. Conclusions A stable, functional elbow can be restored in most patients with persistent instability after fracture-dislocation of the elbow using a treatment protocol incorporating hinged external fixation.

Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study.

Abstract: Purpose Distal radioulnar joint (DRUJ) stability is dependent on osseous anatomy, soft-tissue stabilizers, and muscle activity. The relative importance of DRUJ soft-tissue stabilizers remains controversial and has not been examined in the more physiologic setting of simulated muscle loading in the intact specimen. The purpose of this study was to examine the role of static stabilizers on the kinematics of the DRUJ during active simulated motion. Methods Twelve cadaveric upper extremities underwent computer-controlled, simulated, active forearm rotation. Joint kinematics were measured in the intact specimen and after sequential sectioning of soft-tissue stabilizers including the dorsal and palmar radioulnar ligaments (RULs) and the triangular fibrocartilage (TFC), dorsal and palmar capsule, ulnocarpal ligaments (UCL), extensor carpi ulnaris (ECU) subsheath, pronator quadratus (PQ), and the interosseous membrane (IOM). Results After sectioning of soft tissues significant changes in the DRUJ kinematics were observed. With a distal to proximal sectioning sequence significant alterations in kinematics were not identified until sectioning of the IOM; with a proximal to distal sectioning sequence intact DRUJ kinematics were maintained until the final soft-tissue (RULs and TFC) sectioning. Conclusions Sectioning of all soft-tissue stabilizers produced significant DRUJ instability and abnormal joint kinematics. The RULs and TFC play a key role in DRUJ kinematics because they can help to maintain normal joint rotation in the absence of all other soft-tissue stabilizers. With the preservation of other soft-tissue stabilizers, however, the RULs and TFC are not essential for the maintenance of normal kinematics of the DRUJ.

Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach

Abstract: In a prospective study, eight consecutive patients with nine ruptures of the distal biceps tendon underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radio-ulnar synostoses. Isokinetic testing, after correction for dominance, demonstrated a 6% strength deficit, but 7% higher endurance in the repaired extremity for the flexion-concentric test, and no strength deficit and 13% higher endurance for supination. The improved endurance is probably explained by initial reduced effort due to apprehension which minimized subsequent fatigue.

Scaphoid and lunate motion during a wrist dart throw motion.

Abstract: Purpose The primary purpose of this study was to measure the in vitro scaphoid and lunate motion during 9 different variations of a wrist dart throw motion. Another goal was to determine the specific dart throw motion that minimized scaphoid and lunate motion. Methods Scaphoid and lunate motion were recorded in 7 cadaver forearms during various combinations of wrist dart throw motions caused by a wrist joint motion simulator. Results During wrist flexion and extension the scaphoid and lunate motions follow the wrist motion. During wrist radial and ulnar deviation the scaphoid and lunate correspondingly flex and extend. During intermediate motions the scaphoid and lunate move as little as 26% of the total third metacarpal motion and do not necessarily follow a planar motion. Conclusions These findings suggest that there may be a dart throw motion during which there may be minimal scaphoid and lunate motion. If a subject's wrist motion could be clinically restricted to this dart throw motion, early hand mobility might be possible after surgery on the scaphoid and lunate.

Complications of wrist arthroscopy.

Abstract: Purpose To determine the incidence and nature of complications after arthroscopy of the wrist joint. Methods The outpatient records and surgical reports of 211 patients who had wrist joint arthroscopy were reviewed to determine type of procedure, type of anesthetic, portals used, and incidence and nature of postsurgical complications. Results We identified a total of 11 complications in our patient group (5.2%). Of these, 2 patients (0.9%) developed major complications and 9 patients (4.3%) developed minor complications. Five complications 45% were identified in the immediate postsurgical period and 6 (55%) were delayed complications. All of the minor complications resolved at latest follow-up evaluation with conservative care. Conclusions Wrist arthroscopy is a safe procedure with a low rate of major and minor complications. In spite of its limitations wrist arthroscopy remains an invaluable tool in the diagnosis and treatment of wrist joint disorders.

Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period.

Abstract: Purpose The purpose of this report is to review the results of arthroscopic resection of dorsal wrist ganglions. Methods Forty-one patients with dorsal wrist ganglions had arthroscopic resection: 24 women and 17 men. The average patient age was 29.8 years. All of the patients had some or all of the following: pain, localized swelling, and limited range of motion. Along with clinical examination, 19 wrists had ultrasound or magnetic resonance imaging to confirm diagnosis. Twelve patients had previous injections with recurrence. The average follow-up time to date is 47.8 months (range, 28–97 months). Results Overall postoperative motion improved compared with preoperative values. No cases of scapholunate instability were noted. The average postoperative grip strength improved significantly. Only 2 ganglions recurred and required 2 attempts at open resection for successful eradication the ganglion. No major intraoperative or postoperative complications occurred. Conclusion Arthroscopic ganglionectomy is a safe and reliable alternative to open resection.

Giant-cell tumor of the distal forearm

Abstract: Purpose Many authorities express concern that giant-cell tumors of the distal forearm are more frequently recurrent and difficult to treat chiefly because of the proximity to the carpus and the resultant diminished range of motion in the hand and forearm. We have studied the results from our institution for 49 patients with giant-cell tumors of the distal forearm treated from 2 to 28 years (mean, 14 ± 7 years) and compared the results for different methods of treatment. Methods Through the computer database 49 patients with giant-cell tumors of the distal forearm (46 of the radius, 3 of the ulna) were identified. By using material from patient visits, chart review, and when necessary telephone interviews it was possible to gather demographic and outcome data for the 49 patients. For the radial lesions, 15 of the patients had a marginal resection of the distal radius along with the periosteum and ligamentous structures and implantation of cadaveric allografts. Twenty-six patients had intralesional curettage and insertion of polymethylmethacrylate (PMMA) and 5 had curettage and autograft insertion. The 3 patients with ulnar lesions were treated with Darrach resections. Results There were no deaths, infections, metastases, or amputations. In addition to the 49 original surgeries, the patients required 41 additional surgical procedures, 17 of which were for recurrent disease. The greatest numbers of recurrences were in the patients who underwent curettage with autograft or PMMA implantation. Only 2 recurrences were in patients who had a marginal resection and implantation of cadaveric allografts. The overall results for the patients showed that many had mostly minor complaints referable to function or pain and that only 18 of the 49 patients were asymptomatic. Conclusions Although the patients with distal forearm giant-cell tumors have had a difficult course in terms of local recurrence and subsequent surgeries required for treatment failures, the ultimate outcomes for both allograft transplantation and curettage and insertion of PMMA are satisfactory. The patients with complete distal radial allografts had a better record for prevention of recurrence than the patients treated with curettage and PMMA insertion but the percentages of currently asymptomatic patients are approximately the same for both series (40% [6/15], 35% [9/26]). These data support the concept that marginal resection and complete distal radial allograft implantation should be used for patients with tumors that have destroyed much of the bone and have extensive soft tissue components and that curettage and PMMA insertion should be reserved for patients where the structural alteration of the bone is minimal.

An objective method to evaluate the risk of recurrence and extension of dupuytren's disease

Abstract: This study was undertaken to assess the influence of the factors related to Dupuytren's diathesis on the rates of recurrence and extension of Dupuytren's disease after surgery. The records of 65 patients who underwent surgery for Dupuytren's disease were retrospectively studied and the presence of factors related to diathesis were recorded. The sensitivity and specificity of each factor for predicting recurrence and extension were calculated. Odds ratios and 95% confidence intervals were also calculated and a discriminant analysis was performed to explore correlations between recurrence and extension and the significant variables. Our results confirmed the prognostic value of diathesis. The results have been used to develop a new scoring system for evaluating the risk of recurrence and extension.

Open Reduction and Screw Fixation of Mallet Fractures

Abstract: Twelve patients with mallet fractures treated by open reduction and internal fixation with small screws were reviewed at an average of 31 months after surgery. The indication for surgery was a fracture involving more than one-third of the distal phalanx articular surface or with subluxation of the distal interphalangeal joint. Loss of reduction occurred in one patient and in another one screw loosened slightly without loss of reduction. There were no nail deformities, infections, or secondary procedures. The mean range of motion was from 6° (range, 0–30°) (extensor lag) to 70° (range, 60–90°) flexion. Ten patients had no evidence of degenerative changes, one had minor joint space narrowing and one had significant deformity. Open reduction and screw fixation with small screws can lead to satisfactory outcome in appropriate patients.

A Comparative Analysis of the Biomechanical Behaviour of Five Flexor Tendon Core Sutures

Abstract: Five core suture techniques were compared by static tensile testing in vitro. Fifty porcine tendons were used. The core sutures were performed with 3-0 or 4-0 braided polyester suture (Ticron®) and the over-and-over running peripheral sutures with 6-0 monofilament polypropylene (Prolene®). The core sutures were: (1) Pennington modified Kessler (3-0), (2) Double Pennington modified Kessler (3-0), (3) 4-strand Savage (3-0), (4) 4-strand Savage (4-0), and (5) 6-strand Savage (4-0). Repairs were compared as paired in regard to one variable: the number of core suture strands, the suture calibre, or the suture configuration. Biomechanical differences between the repair groups started during the linear region, with the yield force and stiffness increasing along with the number of core suture strands. All three variables influenced the strain at the yield point. Thus, the strength of the intact repair can be improved by modifying the core suture. In all repairs gap formation started near the yield point after failure of the peripheral suture. The yield force represents the strength of the intact repair composite and should be considered the strength of the tendon repair.

The distal radioulnar joint as a load-bearing mechanism--a biomechanical study

Abstract: Purpose A biomechanical study was performed to define the normal profiles of force transmission across the distal radioulnar joint (DRUJ) and their alteration as the result of surgical modification of the joint and its ligaments. Methods Twelve cadaver arms were used in this investigation. A custom-made jig was designed to hold the arm and allow axial loading of the hand. Force transmitted across the DRUJ was measured with sensor film. The axial force transmitted through the ulna and radius was measured with strain gauges mounted to the surface of each bone and the strain in the dorsal and volar distal radioulnar ligaments (DRUL) was measured with differential variable reluctance transducers. Measurements of force and strain with the DRUJ in the surgically unmodified condition were performed in various positions of forearm rotation and with sequential loads. Subsequently, the same series of measurements was performed after DRUL division and after reconstruction of the ligament. The effect of excision of the ulna head (Darrach's procedure) was also studied. Results Force varied significantly (p Conclusions The data show consistent and characteristic force transmission profiles across the DRUJ and through both ulna and radius. The joint is important in the transmission of load and its anatomic integrity should be respected in surgical procedures if normal biomechanics are to be preserved.