Arthroscopic synovectomy in rheumatoid arthritis of the wrist

Almost all patients with rheumatoid arthritis have progressive destructive arthritis of the wrist involving all wrist compartments. Arthroscopic synovectomy of the wrist has been proposed as a therapeutic modality for rheumatoid wrist affection and in our study we evaluate its role and value in the management of such condition. Arthroscopic synovectomy of the wrist was undertaken on 17 patients [with 24 wrists] with rheumatoid arthritis after failure of splinting and medical treatment to control pain and swelling. All patients were classified as stage I and Stage II according to Steinbrocker's classification. The mean follow-up was 30 months [ranging from 18 to 54 months] Arthroscopic wrist synovectomy was performed using a 2.7mm 30° arthroscope and a motorized shaver system with 2.7mm and/or 3.5mm diameter synovial resector blades and medical treatment was continued. There were no complications. All patients showed persistent symptomatic improvement with decreased postoperative pain score after surgery and improved patient satisfaction although radiological progression of disease continued. Arthroscopic synovectomy of the wrist is a simple procedure with little postoperative that resulted in reliable symptorratic improvement however no positive impact on disease or radiological progression could be seen

Carpal tunnel decompression: a randomised controlled trail of endoscopic versus open release

Carpal tunnel Syndrome is the most common compression neuropathy of the upper extremity. Open carpal tunnel release [OCTR] with longitudinal incision reaching or crossing the wrist crease has been the golden standard of surgical treatment of carpal tunnel syndrome. Many reports indicated that the endoscopic carpal tunnel release [ECTR] techniques are associated with reducing postoperative morbidity with minimal incision, minimal pain and scarring, a shortened recovery period and high level of patient satisfaction. We conducted a randomised controlled trail to evaluate endoscopic 2-portal carpal tunnel release [ECTR] technique against the traditional open carpal tunnel release [OCTR]. One hundred and twenty two patients who were diagnosed to have carpal tunnel syndrome were randonised into 2 groups. In the trail ECTR group, there were 18 males [29%] and 44 females [71%]; their mean age was 44.6 years while the control OCTR group there were 18 males [30%] and 42 females [70%]; their mean age was 45.9 years. Patients were evaluated at baseline, 1,2,6 and 12 weeks and at 1 year after surgery for symptomatic relief by the Symptom Severity Scale[9] and incidence of serious complications [vascular or nerve injury] as well as McGill pain questionnaire[10], interval between the operation and return to their daily activities and work, scar tenderness and pillar pain, and grip strength which was assessed by a Jamar dynamometer as well as overall patient satisfaction. There was no significant difference in the Symptom Severity Score between both groups. However, there was one significant complication [laceration of a digital nerve] in the ECTR group while there was none in the OCTR group. McG ill pain score and grip strength were found to be significantly better in the ECTR group at 1, 2 and 6 weeks but almost identical at 12 weeks however scar tenderness and pillar pain was better in ECTR group at 12 weeks. The interval between surgery and return to usual daily activities and work was significantly less [P value < 0.01] in the endoscopic group than OCTR group. ECTR is associated with less pain and better function in the early postoperative period reflected by earlier return to usual daily activities and work as well as less scar tenderness and pillar pain. However these benefits may be outweighed not only with the higher expense of additional operative equipment and longer operating time but with a higher re-operation rate as well as a higher complication rate

Volar vascularized graft from the distal radius in management of ununited scaphoid fractures

Scaphoid fracture nonunions often present a therapeutic challenge. This is because the vascular supply of the scaphoid renders the proximal pole in many of these fractures avascular. Recently, vascularized bone grafts for the scaphoid have gained increasing popularity and many methods have been described based on different pedicles aiming to achieve union in these difficult nonunions associated with proximal pole diminished vascularity. In this study, a vascularizsed bone graft from the volar aspect of the distal radius based on the radial portion of the palmar carpal arterial arch was used to treat scaphoid nonunion. Between 1999 and 2004, 31 cases of ununited fractures of the scaphoid were managed by using a vascularized bone graft from the volar aspect of the distal radius and internal fixation using Herbert screws with or without an additional K-wire to hold the graft. There were 29 males and 7 females with a mean age of 31 years [18-46]. Nineteen fractures were associated with DISI. The mean follow up duration was 19 months [11-31]. Bone union was achieved in all patients in an average of 13 weeks [9-20]. There were 13 excellent, 9 good, 8 fair and 1 poor result had it corrected in the postoperative X-ray. Vasculariszed graft from the volar aspect of the distal Radius was found to be a reliable source of bone grafting with the advantage of being simple to harvest with little or no donor site morbidity and associated with a high union rate as well as other advantages as allowing simultaneous correction of humpback deformity and DISI

Augmentation of partially regenerated nerves by end-to-side side-to-side grafting neurotization: experience based on 8 late obstetric brachial plexus cases

With or without previous early neurotization, the brachial plexus in obstetric palsy regenerates partially leading to variable degrees loss of function and deformity necessitating secondary correction. Correction after latissimus dorsi to rotator cuff transfer is not maintained. Posterior shoulder dislocation occurs after humeral rotation osteotomies. Both presuppose some degree of shoulder abduction. Further, corrective surgery will not benefit a flail wrist. Improving muscle power is the solution. End-to-side neurorrhaphy allows neurotization of partially injured recipient nerves without downgrading already regained recipient muscle power, a technique we called nerve augmentation. The aim was to investigate the effect of nerve augmentation on improving motor power in late obstetric brachial plexus lesions. 8 obstetric brachial plexus palsy cases aged 3-7 years were operated upon and followed up for 4 years. 5 patients were C5, 6 ruptures C7, 8T1 avulsions; 1 a C5,6,7,8 rupture T1 avulsion and 1 a C5,6,8T1 rupture C7 avulsion; 1 presented to us 3 years having undergone neurotization at the age of 3 months for a C5,6,7 rupture, C8 T1 compression. Patients were evaluated for deformities, muscle function, cocontractions. Root avulsions were evaluated by CT cervical myelography and confirmed intraoperatively. Shoulder, elbow and hand functions were scored using the modified Gilbert shoulder and elbow evaluation scales, and the Raimondi hand evaluation scale respectively. All nerves to Grades 1-3 muscles were selected for neurotization. Nerves to Grade 0 muscles were neurotized, if the electromyogram showed scattered motor unit action potentials on voluntary contraction without interference pattern. After exploration, the following donor nerves were selected for intertwining neurotization or closed loop grafting 25: The phrenic [7 cases], the accessory [2 cases], the descending and ascending loops of the ansa cervicalis [2 cases] and the 3[rd] and 4[th] intercostals [1 case]. Long length contact contralateral C7 neurotization [25] was performed in 5 cases. In the revision case, an external rotation humeral osteotomy and a Hoffer transfer preceded neurotization. Superior proximal to distal regeneration was observed firstly, shoulder and elbow muscles improving more than forearm, wrist and finger muscles. Differential regeneration of muscles supplied by the same nerve was observed secondly, the supraspinatus muscle regenerating superior to the infraspinatus. Differential regeneration of antagonistic muscles was observed thirdly; there was superior biceps to triceps and pronator teres to supinator recovery. Differential regeneration of fibres within the same muscle was observed fourthly, the anterior and middle fibres of the deltoid muscle regenerating better than its posterior fibres. Differential regeneration of muscles having different preoperative motor powers was noted fifthly. Functional improvement [i.e. to Grade 3 or more] in the forearm and hand occurred more in Grade 2 than in Grade 0 or Grade 1 muscles. Improvements of cocontractions and of shoulder, forearm and wrist deformities were noted sixthly. The shoulder, elbow and hand scores improved in 4 cases. First, the sample size is small [8 cases]. Second, controls are necessary to rule out any natural improvement of the lesion. Third, there is marked intra- and interobserver variability in testing muscle power and cocontractions. Nerve augmentation improves muscle power in the biceps, pectoral muscles, supraspinatus, anterior and lateral deltoids, triceps and in Grade 2 or more forearm muscles. It is also expected to improve cocontractions. As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer. Function to non improving Grade 0 or 1 forearm muscles should be restored by free muscle transplantation. Notwithstanding all of the above, end-to-side neurorrhaphy needs reconsideration. Donor and recipient nerve channel carrying capacities have to be increased by cotrophism, cotropism and cotransplantation. Cell biologic procedures for restoring recipient muscle mass should be contemplated. Level IV, prospective case series

Surgical management of low to moderate grade isthmic spondylolisthesis

In this study, 50 patients with low to moderate grade lytic spondylolisthesis underwent a single staged surgical procedure. The average age at surgery was 43 years. Both plain X-rays and an MRI were done for all patients. All patients had a wide decompression, pedicle screw instrumentation and posterolateral fusion. The patients were followed up for an average of 2.5 years. Forty patients had a favorable outcome. The fusion rate was 92%. There was no permanent deterioration in the neurological state postoperatively in any patient. The study demonstrated that an instrumented posterolateral arthrodesis in combination with a wide laminectomy and nerve root decompression results in a high rate of fusion and satisfactory clinical success