Medium-term outcomes of pyrocarbon arthroplasty of the proximal interphalangeal joint.

We evaluated the outcome of pyrocarbon arthroplasty for proximal interphalangeal joint osteoarthritis in 18 arthroplasties carried out by a single surgeon using the Ascension prosthesis (Ascension Orthopedics Inc., Austin, Texas) in 15 patients after a mean of 6.2 years. Significant and maintained improvements in pain scores at rest and on active movements were achieved for surviving implants, and the range of motion was comparable with preoperative measurements. The radiographs, which were evaluated for evidence of ongoing migration and potential failure, were of concern in 10 out of 18 joints. Two patients required implant removal.

A self-administered questionnaire for basal osteoarthritis of the thumb.

Basal osteoarthritis of the thumb is a common condition for which numerous operations have been proposed without any particular one having been shown to be superior. One of the problems in evaluating the results of surgery is that there is no validated outcome score specifically for the condition. The purpose of this study was to construct a self-administered questionnaire (the Nelson score) to assess the outcome following surgery for this condition and to test its properties. Correlating the questionnaire score with physical findings on clinical examination showed external validity and test-retest reliability was high. Simultaneous administration of the score with the DASH score, both before and after surgery, showed it to be more sensitive to change (P=0.056). In addition, it is shorter than the DASH score, which may make it more acceptable to patients.

Recurrence after surgery for Dupuytren's disease: a randomized trial of two skin incisions.

We studied the influence of the type of skin incision on the recurrence rate following fasciectomy for Dupuytren's disease. Patients were randomized to a longitudinal incision closed with Z-plasties or a modified Bruner incision closed by Y-V plasties. Follow-up was for at least 2 years or until a recurrence was noted. We found no statistical difference in recurrence rate between patients having these two skin incisions and closures.

Short-term results of the Ascension pyrolytic carbon metacarpophalangeal joint replacement arthroplasty for osteoarthritis.

INTRODUCTION: Osteoarthritis of the metacarpophalangeal joints is difficult to manage due to the high demands placed on any prosthesis. We report the preliminary results of our experience using the Ascension pyrolytic carbon implant. METHOD: A pyrocarbon metacarpophalangeal joint replacement was implanted into seven patients (10 metacarpophalangeal joints) with osteoarthritis. Patients were reviewed both clinically and radiologically. RESULTS: At a mean follow-up of 2.2 years (1-4 years) there were no implant failures nor loosenings. Pain scores improved from 68% to 3% postoperatively, and there was a very high rate of patient satisfaction. CONCLUSION: Pyrocarbon implants are a promising solution to a condition which may be otherwise difficult to treat surgically.

Fascial flap for recurrent ganglion.

INTRODUCTION: Recurrence of a dorsal wrist ganglion following surgery is not uncommon and we propose a technique to deal with the problem. METHOD: A flap of extensor retinaculum is used to fill the defect left in the wrist capsule following repeat radical excision of the recurrent ganglion. The flap is based on a distal arterial pedicle, usually the intercompartmental 2:3 supraretinacular artery or one of its branches. RESULTS: Eight patients have been operated with a mean follow-up of 28 months. So far there have been no recurrences. CONCLUSION: Full recovery of wrist function ocurred in all cases except one who had slight restriction of flexion. We believe this to be a useful technique but a larger series with longer follow up would be needed to show its true value.

Skin tension in the aetiology of Dupuytren's disease; a prospective trial.

Tension in the palmar fascia has been proposed as a factor causing Dupuytren's disease. If tension does stimulate the growth of new Dupuytren's tissue, relieving longitudinal tension should reduce the recurrence rate following surgery. Thirty patients with palmar Dupuytren's contracture of a single ray that affected only the metacarpophalangeal joint were divided into two groups. Both groups had a fasciotomy: one group through a transverse incision that was closed directly and the other through a longitudinal incision with Z-plasty closure. Half the patients (seven of 14) who had direct closure had recurrence at 2 years as compared to two of the 13 in the Z-plasty group. The trial was stopped at the interim analysis stage due to the high recurrence rate in the first group. These results are consistent with the tension hypothesis for the aetiology of Dupuytren's disease.

Carpal tunnel release by the Agee endoscopic technique. Results at 4 year follow-up.

Ninety-five hands (86 patients) were treated by endoscopic carpal tunnel release using the technique of Agee. They were the first ones operated on by the senior author (GF) using this technique. The patients were interviewed at a mean follow-up of 4.5 years: 72% of hands were free of symptoms and 94% were described by the patients as functionally normal. Seventeen hands (out of 27) with residual or recurrent symptoms were examined. Nine hands (nine patients) were only partially improved (mean 6.7 on a 10 point scale) and in eight hands (seven patients), some symptoms had recurred after a mean delay of 3.8 years. It was possible to find a second pathology in most of these cases. It is necessary to inform the patient before operation that incomplete relief or recurrence of symptoms can occur after endoscopic carpal tunnel release, as with conventional release.

Nonunion of tibial stress fractures in patients with deformed arthritic knees. Treatment using modular total knee arthroplasty.

In two years we treated four women with ununited stress fractures of their proximal tibial diaphyses. They all had arthritis and valgus deformity. The stress fractures had been treated elsewhere by non-operative means in three patients and by open reduction and internal fixation in one, but had failed to unite. After treatment with a modular total knee prosthesis with a long tibial stem extension, all the fractures united. A modular total knee prosthesis is suitable for the rare and difficult problem of ununited tibial stress fractures in patients with deformed arthritic knees since it corrects the deformity and the adverse biomechanics at the fracture site, stabilises the fracture and treats the arthritis.

Long-term outcome of neurovascular palmar advancement flaps for distal thumb injuries.

Thirteen neurovascular palmar flaps for thumb tip coverage were reviewed: six O'Brien and seven Moberg flaps with a mean follow-up of 81 months. Both techniques were found to be safe and effective in preserving pulp sensibility, with a mean 2PD of 5 mm and a Semmes-Weinstein identical to the contralateral side in nine cases. The interphalangeal joint regained a normal range of motion, and did not seem to be affected by the perioperative flexion. The main residual complaints were persistent cold intolerance (present in all cases and severe in three), pulp instability (present in six and severe in two), and nail deformity. This last problem was more related to the injury. Despite these drawbacks, O'Brien and Moberg flaps remain the first choice for coverage of 1-2 cm pulp defects of the thumb.

Patterns of healing of scaphoid fractures. The importance of vascularity.

We studied 45 patients with 46 fractures of the scaphoid who presented sequentially over a period of 21 months. MRI enabled us to relate the pattern of the fracture to the blood supply of the scaphoid. Serial MRI studies of the four main patterns showed that each followed a constant sequence during healing and failure to progress normally predicted nonunion.

Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius.

We report three complete ruptures and one partial rupture of the flexor pollicis longus tendon in association with the insertion of a volar plate for the treatment of fracture of the distal radius. Rupture was associated with the chronic use of steroids.

The use of skeletal traction in the treatment of severe primary Dupuytren's disease.

In 13 patients (18 fingers) we used two types of external fixator as progressive static splints for the preoperative correction of the deformities of severe Dupuytren's disease before conventional fasciectomy. The duration of treatment was from one to four weeks. At a mean follow-up of 18 months the mean total fixed flexion deficit had been reduced from 138 degrees to 39 degrees and the mean proximal interphalangeal joint contracture from 80 degrees to 29 degrees. The mean total active range of movement had increased from 123 degrees to 175 degrees. These preliminary results are promising, but continued follow-up is needed since recurrence is common.

Local symptoms after open carpal tunnel release. A randomized prospective trial of two incisions.

We report a randomized trial of two skin incisions for carpal tunnel decompression, namely a standard incision and an ulnar L incision. We looked particularly at the resolution of local symptoms namely pillar pain and scar sensitivity. There were 47 patients in the trial. No difference was found in pillar pain between the two incisions, but one had a lower incidence of scar sensitivity. These results give a baseline for comparison of local postoperative symptoms following open release with those following endoscopic release.

Isolated subluxation of the extensor pollicis longus tendon. A cause of 'boutonnière' deformity of the thumb.

Isolated ulnar subluxation of the extensor pollicis longus (EPL) tendon occurs when there is damage to the radial side of the extensor hood on the dorsum of the metacarpophalangeal joint of the thumb. The thumb collapses into a pseudoboutonnière deformity because the EPL tendon subluxes and comes to lie palmar to the centre of rotation of the metacarpophalangeal joint to act as a flexor instead of an extensor. The extensor pollicis brevis tendon which lies in a deeper plane to the EPL is unaffected. We describe four cases and propose conservative treatment as being effective in recent injuries.

A modified open palm technique for Dupuytren's disease. Short and long term results in 54 patients.

Fifty-four patients with Dupuytren's disease were operated on using transverse and Bruner incisions, leaving the transverse palmar and digital wounds open. The mean follow up was 6.6 years (minimum 5 years). The mean percentage correction of the overall fixed flexion deformity was 71%. The incidence of recurrence and extension of the disease were similar to other series of limited aponeurectomy. However, the postoperative complications were very much lower and the method is particularly suitable for patients over 50 years of age.

The natural history of adult trigger thumb.

30 consecutive adult patients presenting with trigger thumb (31 thumbs) were entered prospectively into a study to determine the natural history of the condition. Five patients insisted on treatment and could not be followed to resolution, but the rest resolved spontaneously after an average duration of symptoms of 6.8 months (range 2-15). There was a small but non-functional reduction in movement of the thumb in some of the patients: six lost an average of 7 degrees of abduction and ten had an average loss of opposition of 1.4 (Kapandji grade). The remaining patients made a full recovery.

Factors affecting the strength of flexor tendon repair.

The effects of different thicknesses and configurations of core sutures were studied in human cadaveric flexor tendon repairs. Both straight and cyclic load tests were employed. To exploit the full strength of 4/0 suture material, the Kessler repair using four locked single knots would seem to be appropriate.

[Compound vascularized island joint transfer in hand surgery. Apropos of a series of 16 cases]. / Le transfert articulaire vascularisé en îlot composite en chirurgie de la main. A propos d'une série de 16 observations.

Sixteen compound island joint transfers performed in 14 patients were reviewed with a mean follow up of 37.6 months. 15 were harvested from a non conservable "finger bank" and one as an homodigital islanded DIP to PIP transfer. The "donor" joint was an MP joint (7 cases), a PIP joint (5 cases) and DIP joint (4 cases). The reconstructed joint was the MP joint (10 cases) or the PIP joint (6 cases). If we exclude one failure (arthrodesis), the average range of flexion was 45 degrees for MPJ and 42 degrees for PIPJ. In selected cases with good patient motivation, available "donor" finger and intact flexor tendon in recipient digit, this technique provided a one stage composite reconstruction, a good lateral stability in pinch with possibility of growth in children and long term preservation of the articular cartilage.

Free vascularized toe-joint transfer in hand reconstruction: a series of 25 patients.

Twenty-eight vascularized toe-joint transfers performed on 25 patients were reviewed. A number of different techniques were used: proximal interphalangeal joint or metacarpophalangeal joint reconstruction, one-stage double joint transfer, and interphalangeal thumb or trapezometacarpal joint replacement. Using these types of vascularized joint transfer allows one-stage composite transfer (including skin, bone, and extensor tendon) and provides rapid bone healing, potential growth in the young, good long-term cartilage preservation, normal lateral stability in pinch, and limited but useful range of motion (mainly at the proximal interphalangeal level).

Excision arthroplasty for infected constrained total knee replacements.

We have reviewed 15 patients with infected total knee replacements after removal of the prosthesis, rigorous debridement, antibiotic irrigation, and prolonged systemic antibiotics. Infection was permanently eradicated in all patients; they were left with a functioning limb, on which they could walk with either a caliper (8 patients), a simple splint (3), crutches, or sticks. Three were disappointed because of residual pain. We believe that, if exchange arthroplasty is inappropriate, this procedure is preferable to arthrodesis or amputation for persistent and disabling infection, particularly where constrained artificial joints have been used.