Carpal tunnel release: a randomized comparison of three surgical methods.

A single-blind, randomized, controlled trial was done to compare the results of carpal tunnel release using classic incision, short incision, or endoscopic technique. In total, 90 consecutive cases were included. Follow-up was 24 weeks. We found a significantly shorter sick leave in the endoscopic group. No significant differences in pain, paraesthesiae, range of motion, pillar pain, and grip strength could be found at 24 weeks of follow-up, although intermediate significant differences were seen, especially in grip strength, in favour of endoscopic technique. No major advantage to using a short incision could be found. There were no serious complications in either group. The results indicate that the endoscopic procedure is safe and has the benefit of faster rehabilitation and return to work.

Elektra prosthesis for trapeziometacarpal osteoarthritis: a follow-up of 39 consecutive cases.

We present a prospective follow-up of 39 Elektra prostheses in 37 patients (32 women and five men), with a mean age of 56.5 (range 46-71) years; 34 patients had osteoarthritis and three had rheumatoid arthritis. Patients were followed using clinical examination, including measurement of pain on a visual analogue scale, mobility, and strength, after 6, 12, 26, and 52 weeks, and annually thereafter. Radiological examination was done preoperatively and after 6, 26, and 52 weeks, and annually thereafter. The mean follow-up time was 48 (range 3-91) months. Although we observed a fast recovery, including maintenance of mobility and a gradual increase in grip strength, there was a revision rate of 7/38 (24%) after 36 months, increasing to 17/38 (44%) after 72 months. The main reason for revision was loosening of the trapezial component, and biomechanical properties of the trapezial fixation may be the key problem in treating trapeziometacarpal osteoarthritis using a total prosthesis.

Low-profile plate fixation in arthrodesis of the first metacarpophalangeal joint.

Fifty-one consecutive arthrodeses (46 patients) of the first metacarpophalangeal joint were retrospectively reviewed, after fixation with a Leibinger low-profile titanium plate, using a cup-and-cone technique. Primary bone union was achieved in 98%. Three cases required removal of the plate and one case a tenolysis. Follow-up time was 13-92 months (mean 52). There was no correlation between patient satisfaction and position of fusion. We conclude that this technique gives a high rate of union, a short period of immobilization and rehabilitation, and a reliable position at the site of fusion.

Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.

One hundred and six consecutive cases of osteoarthritis of the trapeziometacarpal joint, treated by tendon interposition arthroplasty as described by Weilby, were followed prospectively, with assessment of pain, mobility, pinch and grip strength at 6, 12, 26 and 52 weeks. Patient satisfaction was reviewed at 26 and 52 weeks. Preoperative visual analogue scores for pain averaged 65 and decreased postoperatively to an average of 12 at 52 weeks. The main decrease in pain occurred during the first 3 months after operation. Mobility was improved or unaltered in 82%. Average grip and pinch strength reached preoperative values (41 kPa and 20 kPa respectively) between 12 and 26 weeks after surgery and were significantly greater (58 kPa and 34 kPa) at 52 weeks. Recovery after suspension arthroplasty takes 3-6 months, which may be a disadvantage to be considered when advising patients who are considering operative treatment.

The clenched fist syndrome: a presentation of eight cases and an analysis of the medicolegal aspects in Denmark.

Clenched fist is a rare disorder of the hand associated with fixed contractures of fingers. The condition is often preceded by minor trauma or surgery, but these do not explain the severity of the contractures. Extension of the fingers is painful and hygienic problems can be considerable. Psychiatric disease is frequent in clenched fist patients. The patients may express a strong wish for amputations. In a review of eight patients with clenched fist who had claimed economic compensation from the Danish Patient Insurance Association, four patients had amputations. Three of them subsequently developed new contractures.

Repeated digital nerve block for pain control after tenolysis.

We describe a way of achieving immediate painfree mobilisation after tenolysis or tenosynovectomy in Zone II. Bupivacaine is instilled along the flexor tendon sheath through a thin percutaneous catheter with an antibacterial filter.

Results after surgery for severe Dupuytren's contracture: does a dynamic extension splint influence outcome?

Seventy-six consecutive patients were operated on for advanced Dupuytren's contracture and the results evaluated after nine months with special reference to the use of a dynamic extension splint. The patients were separated into three groups: those in whom the splint was used according to our guidelines (n = 15); those in whom the splint was used, but inadequately (n = 15); and those who did not require splinting (n = 24). Our results nine months postoperatively were similar to those of other studies in showing that the fifth proximal interphalangeal joint constituted the greatest problem. Comparison of the three groups indicated that splinting the way we used it did not influence the natural course of the disease after operation.

Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series.

The purpose of this study was to evaluate the reported rate of complications after endoscopic carpal tunnel release by means of an analysis of 54 publications, reporting a total of 9516 endoscopic and 1203 open releases. Endoscopic release was comparable to open release in the rate of irreversible nerve damage (0.3% and 0.2% respectively) but case reports may indicate a small risk of unacceptable complications with endoscopy, such as transection of the median nerve. Reversible nerve problems were more common after endoscopic release. Tendon lesions were extremely rare (0.03%) and the rate of other complications (reflex sympathetic dystrophy, haematoma, wound problems, etc.) was about the same with endoscopic as with open release.

Hyperextension injury to the PIP joint or to the MP joint of the thumb--a clinical study.

We present a prospective study of the diagnosis and clinical course of 60 patients with 57 pure hyperextension injuries to the proximal interphalangeal (PIP) joint of the long fingers (fingers 2-5) and seven injuries to the metacarpophalangeal (MP) joint of the thumb. Thirty four of the injuries (57%) were related to ball sports, and the ulnar fingers of the non-dominant hand were usually affected. There were 24 avulsion fractures at the site of the insertion of the volar plate on to the middle phalanx. Twelve (20%) initially presented with hyperextension instability, and this was usually associated with an avulsion fracture. Thirty four of the patients (57%) had symptoms for less than one month, while 10 (17%) complained of symptoms six months after the injury. Severe complications such as daily pain and stiffness were encountered in three cases. The triad sign (pain on extreme flexion and extension) was of no use as a diagnostic or prognostic factor, nor did the radiographic stress-view help to identify acute instability of the joint.

[Infectious arthritis in a patient with rheumatoid arthritis]. / Infektiøs arthritis hos en patient med reumatoid arthritis.

Patients with rheumatoid arthritis are at greater risk of developing joint infections than any other group of patients. Diagnosis is often delayed because of the difficulties in distinguishing between a flare-up and a septic affection of the joint. A case of septic arthritis with multiple joint involvement and lethal outcome despite extensive antibiotic treatment and successive surgical procedures is presented. The patient developed osteomyelitis and multiple organ failure. In order to reduce morbidity and mortality from septic arthritis, early joint puncture and subsequent antibiotic treatment is essential.

[Reconstructive joint surgery and rheumatoid arthritis. Status over a developing field]. / Rekonstruktiv ledkirurgi og reumatoid arthritis. Status over et udviklingsområde.

Rheumatoid arthritis has a prevalence of between 1% and 2%. The majority of patients face the prospect of surgical treatment of joints, that do not respond to medical treatment. With respect to the extensive development in joint surgery during the last decade, today's recommendations for surgical treatment of the individual joints are surveyed.

[Simultaneous occurrence of trigger fingers and carpal tunnel syndrome]. / Samtidig forekomst af springfingre og karpaltunnelsyndrom.

We report an unusual case of trigger fingers and carpal tunnel syndrome occurring simultaneously; both conditions were caused by space-occupying fibrosis of the flexor tendon sheath. Following operation the patient was relieved of his symptoms. In case of simultaneously occurring trigger fingers and carpal tunnel syndrome, one should be aware that both conditions can be caused by space-occupying lesions beneath the carpal tunnel. Endoscopic surgery should be avoided in these cases.

Day care surgery for advanced Dupuytren's contracture.

Seventy-six consecutive patients suffering from advanced Dupuytren's contracture were analysed in order to evaluate the safety of day care surgery. The complication rates for haematoma, necrosis, infection and reflex sympathetic dystrophy were acceptable, but we found an unacceptably high percentage of nerve lesions. Day care treatment was achieved in all but seven cases. We concluded that advanced Dupuytren's contracture can be treated by day care surgery but the operations should be performed by surgeons who are skilled in hand surgery, and individual selection of patients with recurrence seems advisable.

Epiphysiodesis for bilateral irregular closure of the distal radial physis in a gymnast.

Wrist pain is a common complaint in gymnasts. Repetitive stress on the distal radial physis may lead to either gradual slipping of the epiphysis or growth disturbances. In some cases growth disturbances of the distal radial physis lead to triangulation of the distal radius and secondary ulnar overgrowth, and eventually a Madelung-like deformity. The present case report is the first to describe the outcome of epiphysiodesis of the distal radial and ulnar growth plates in a skeletally immature gymnast as a surgical treatment to prevent Madelung's deformity.

Operative treatment of carpal tunnel syndrome in Denmark. Results of a questionnaire.

The aim of our study was to determine the incidence of operative treatment for carpal tunnel syndrome in Denmark and to see whether there was a consensus about the place of preoperative electromyography and nerve conduction studies. A questionnaire was mailed to all surgical departments (n = 70) and all registered private surgical practices (n = 214) in Denmark. The incidence of operation was about 0.61 per 1,000 population. Most surgeons used preoperative electromyograms and nerve conduction studies in less than 50% of cases. The use of preoperative testing was related to the surgical speciality.

Piroxicam spares buprenorphine after total joint replacement. Controlled study of pain treatment in 81 patients.

In a blinded, placebo-controlled study, the nonsteroidal antiinflammatory drug piroxicam, in combination with the partial morphine agonist/antagonist buprenorphine, was compared with buprenorphine alone for analgesic effect and side-effects in a 10-day period following total replacement of the hip or knee. 117 patients entered and 81 completed the study. The patients receiving piroxicam consumed less buprenorphine. There were no differences concerning side-effects between the two treatment groups, apart from a tendency towards less nausea after the third postoperative day in the group receiving piroxicam.

The natural course of radionuclide bone scanning in the evaluation of total knee replacement--a 2 year prospective study.

In order to establish the natural course of radionuclide bone scanning images after total knee replacement 41 consecutive patients were scheduled for examination 3, 7, 12 and 24 months after surgery. The mean age was 69 years (range 50-80 years); the female:male ratio was 4:1. Thirty-two patients completed the entire program. A total of 143 99Tcm medronic acid complex scintigrams was performed. No significant difference between the grades of total scintigraphic uptake at any of the four examinations nor any difference between the first and the last examinations could be demonstrated (P = 0.58, Friedman test and P = 0.20, Wilcoxon test, respectively). Twelve months after surgery one fifth of the knees still demonstrated definitely increased scintigraphic uptake and 24 months after surgery 12.5% of the knees had definitely increased uptake. We believe that the increased uptake seen for a variable length of time after surgery limits the usefulness of radionuclide bone scanning in the evaluation of total knee replacement.

Replacement of the trapeziometacarpal joint with a cemented (Caffinière) prosthesis.

Between 1978 and 1985, 31 Caffinière prostheses were implanted in the first carpometacarpal joints of 28 patients for treatment of degenerative osteoarthritis (26 patients) or rheumatoid arthritis (2 patients). At follow-up an average of 48 (13 to 77) months after operation, four hands had reoperation, with the replacement of six components, five cups and one metacarpal component. In addition, there were x-ray signs of component loosening in three other cases. Of the 29 thumbs that could be evaluated with regard to pain, 27 had no pain at all or only slight pain, and two patients had moderate pain. No patient suffered from severely disabling pain. Mobility and strength were satisfactory.