Stabilized subcutaneous ulnar nerve transposition with immediate range of motion. Long-term follow-up.

BACKGROUND: Anterior transposition of the ulnar nerve at the elbow produces generally good results regardless of whether the nerve is transposed subcutaneously, intramuscularly, or submuscularly. The eventual recovery of nerve function is related less to the specific surgical technique than to the severity of the intrinsic nerve pathology. A primary variable in surgical management is the duration of postoperative elbow immobilization. The purpose of this study was to review the longterm results of a specific technique of subcutaneous anterior transposition of the ulnar nerve that utilizes a stabilizing fasciodermal sling. The study compared the results of immediate and late institution of a range of motion postoperatively. METHODS: Forty-seven patients with fifty-one elbows were reexamined, by an investigator who had not been involved in their treatment, at a minimum of two years (range, twenty-four months to fourteen years) after an anterior transposition. Of the fifty-one elbows, twenty-one were immobilized for two to three weeks whereas thirty were managed with an immediate range of motion. RESULTS: At the latest follow-up evaluation, there were occasional, mild paresthesias in 16 percent of the limbs and there was still subjective weakness of 19 percent. Both pinch and grip strength had increased substantially. No patient had lost elbow motion. A positive Tinel sign persisted in 31 percent of the limbs, but it was mildly positive in most of them. The elbow flexion test was uniformly negative. The results for 92 percent of the limbs were satisfactory to the patients, who stated that they would undergo the same procedure again if necessary. Overall, 73 percent of the limbs had an excellent result; 18 percent, a good result; 4 percent, a fair result; and 6 percent, a poor result. With the numbers available, no significant difference could be detected, with regard to these outcomes, between the group managed with elbow immobilization and that managed with immediate elbow mobilization. However, patients treated with a postoperative cast returned to work at an average of thirty days after surgery whereas the group treated with immediate motion of the elbow returned to work at an average of ten days. CONCLUSIONS: This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately.

Basal joint arthritis of the thumb.

Thumb pain secondary to arthritis at the basal joint of the thumb is a common condition, especially in women, and can be quite disabling. An accurate diagnosis can be readily made from the history and examination. Radiographs are used to stage the severity of the arthritis. Splinting is the mainstay of conservative care. Reconstructive procedures for each stage of the disease are aimed at restoring thumb motion and strength. Partial or complete trapeziectomy with tendon interposition and ligament reconstruction to stabilize the metacarpal base is used for advanced disease. Secondary metacarpophalangeal joint hyper-extension deformity may need to be addressed. Surgery can reliably improve function and engender high patient satisfaction.

The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint.

The ultimate effectiveness of an arthroplasty is most accurately determined by a long-term review of the joints' function and freedom from pain. We examined 17 patients an average of 11.5 years (range, 4-26 years) following volar plate arthroplasty for a fracture-dislocation of the proximal interphalangeal joint. All surgeries were performed by the same surgeon. The average age was 36 years (range, 17-61 years). No patient complained of pain at rest or with activity. Patients having arthroplasty within 4 weeks of injury attained a total active range of motion of 85 degrees (50 degrees to 110 degrees ). Patients having arthroplasty more than 4 weeks after injury (average, 20 weeks) included several elderly women and averaged 61 degrees (30 degrees to 90 degrees ) total active range of motion. Four patients showed some degree of joint narrowing at the follow-up examination. This review suggests that volar plate arthroplasty continues to be of benefit on a long-term basis and provides satisfactory function and pain-free motion.

Long-term results of volar ligament reconstruction for symptomatic basal joint laxity.

It has been hypothesized that instability of the thumb trapeziometacarpal joint is a major factor in the etiology of degenerative disease. Theoretically, surgically stabilized joints should be subject to less shear force and, hence, will be less likely to develop degenerative changes. The long-term results of volar ligament reconstruction were assessed in 19 patients (24 thumbs). The average age at surgery was 33 years (range, 18-55 years). Twenty-three thumbs were radiographic stage I; a preoperative x-ray was not available in 1. The follow-up period averaged 15 years (range, 10-23 years). At the final follow-up visit 15 thumbs were stage I, 7 were stage II, and 2 were stage III. Fifteen patients were at least 90% satisfied with the results of the surgery. Only 8% of thumbs advanced to radiographic arthritic disease, which compares favorably with the 17% to 33% reported incidence of stage III/IV basal joint arthritis in the general population.

Splinting in the treatment of arthritis of the first carpometacarpal joint.

Although much has been written about surgical treatment of arthritis of the first carpometacarpal joint, no literature exists on splinting as a conservative treatment. One hundred fourteen patients (130 thumbs) were retrospectively reviewed to determine the efficacy of splinting. Patients were grouped according to their stage of disease and whether they had carpometacarpal joint surgery. Seventy-six percent of patients with stage I and II disease and 54% of patients with stage III and IV disease had improvement in their symptoms with splinting. There was no significant difference in the degree of improvement between the 2 groups. All patients who had initial improvement in their symptoms with splinting had between 54% and 61% average improvement in symptom severity 6 months after splinting. All groups were found to be equally tolerant of the splinting protocol and no group had a significantly higher rate of activity modification. Overall, splinting was found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of carpometacarpal joint arthritis and inflammation.

Save the trapezium: double interposition arthroplasty for the treatment of stage IV disease of the basal joint.

Twenty patients with symptomatic stage IV basal joint (pantrapezial) arthritis were treated with double interposition arthroplasty, a new technique that resurfaces the degenerative trapeziometacarpal and scaphotrapezial joints after minimal distal trapezial resection. The results of the 21 procedures were reviewed clinically and radiographically after a mean follow-up period of 34 months (minimum, 1 year). Ninety-one percent of the patients were completely satisfied. Seventy-one percent were entirely free of pain, and an additional 24% noted only occasional, mild, high-stress pain that did not limit their activities. One case was a clinical failure. Objectively, all 21 basal joints were stable, with active range of motion to within 90% of normal. Mean grip strength increased 32%, from a force of 26.1 kg to 33.9 kg (p < .01). Key pinch strength increased from a force of 5.3 kg to 6.0 kg (an 11% increase; p = .05). A new method of determining changes in basal joint height indicated a mean decrease in height of 5.3% (range, 0%-12%) at rest and 8.1% (range, 0%-20%) under axial compression. This difference was statistically but not functionally significant. Overall, there were 95% good or excellent results and 1 poor result. We believe this technique is simple and preserves the osseous foundation of the basal joints. These results compare favorably with arthroplasties that include trapezium excision for the treatment of stage IV basal joint arthritis.

Evaluation of "neocollateral" ligament formation by magnetic resonance imaging after total excision of the proximal interphalangeal collateral ligaments.

The presence of palpable thickening and maintenance of stability within weeks of total excision of the proximal interphalangeal (PIP) joint collateral ligaments is an established, although somewhat mysterious, phenomenon. To further investigate this postoperative thickening, magnetic resonance imaging (MRI) scans were obtained on 10 joints in 9 patients who had undergone total ligament excision for posttraumatic stiff PIP joints 3 months to 14 years earlier. Although the ultrastructure of these newly formed structures is yet unknown, their palpable consistency, MRI contour, distribution, and signal intensity suggest the formation of a new soft tissue structure, albeit scar, which has all the attributes of a collateral ligament. This MRI of a "neocollateral ligament" would help explain the consistent observation of complete joint stability within weeks following total excision of both PIP joint collateral ligaments. All patients from the 14-year span sampled were found to have a similar, consistent, linear low signal density structure crossing the joint margins and essentially identical to that of a normal collateral ligament.

Proximal row carpectomy with partial capitate resection.

Twelve patients who had undergone proximal row carpectomy with partial resection of the capitate were reviewed. Ten patients had degenerative arthritis secondary to scapholunate advanced collapse deformity or chronic scaphoid nonunion. Seven of these patients had significant lunocapitate and three had radiolunate degenerative disease. An additional two patients underwent an immediate modified proximal carpectomy for acute complex radiocarpal trauma. At follow-up evaluation after a mean of 55 months, seven patients reported no pain and four patients had only occasional pain with strenuous activity. There was a trend toward increase of the total active flexion/extension arc, from 80 degrees before to 94 degrees after operation. The improvement in flexion from 38 degrees to 46 degrees was significant (p = .01). In the final four patients, who also had interposition of the dorsal capsule, however, the final arc of motion averaged 111 degrees. Grip strength improved from 19 to 26 kg following surgery. This strength gain was statistically significant (p = .01 by paired t-test analysis). The favorable results of this partial capitate resection technique may be due to a broader distribution of radiocarpal compression forces. Interposition of the thickened dorsal capsule may also contribute to an improved radiocarpal interface. The intermediate-term results of this review would suggest that lunocapitate and radiolunate disease need not contraindicate a modified proximal row carpectomy.

Degenerative changes of the trapeziometacarpal joint: radiologic assessment.

The trapeziometacarpal joint is particularly prone to osteoarthritis due to the great amount of stress applied with everyday activities with the hands. In this essay, radiologic assessment and staging of "basal joint" osteoarthritis, treatments based on radiologic staging and intraoperative findings, and surgical complications are described.

Kirschner wire placement in the emergency room. Is there a risk?

To evaluate the safety of inserting Kirschner wires into bones or across joints in a setting other than a completely sterile operating theatre, a prospective study of all hand fractures treated by closed reduction and internal fixation was conducted in a mid-city Emergency Department. Indications for percutaneous fixation were displaced, unstable long bone fractures of the hand. 71 fractures in 68 patients were treated, and in 91% the fixation crossed a joint. No patient developed osteomyelitis or pyarthrosis, and there was no deep pin track sepsis. Seven patients with open fractures healed without infection or delayed union. Patients in whom data were available obtained 90% to 95% of the motion of the contralateral digit. The taboo against percutaneous fixation of fractures in a non-operating theatre setting is not warranted. The procedure can be performed with minimal complications in an out-patient setting.

The volar plate reconstruction for fracture-dislocation of the proximal interphalangeal joint.

This article discusses the volar plate arthroplasty utilized to resurface the proximal interphalangeal joint, for fracture subluxations involving the lower 60%. The procedure is effective when open reduction and internal fixation are not feasible because of excessive comminution or delay in treatment. The procedure has been used up to 2 years postinjury if certain conditions are met. The article also emphasizes the volar approach to the joint as an optimal exposure to fix these fractures.

Vascular leiomyomas in the hand.

Vascular leiomyomas or angioleiomyomas are benign solitary smooth muscle tumors that occur uncommonly in the hand. The peak incidence is in the third to fifth decades of life, and men are more often affected than women. This tumor is rarely diagnosed before surgery. The usual treatment is simple excision of the mass and ligation of feeder vessels. Although the tumors occur anywhere in the hand, there are only two previous cases of vascular leiomyoma involving the digital artery. A recent case of this tumor involving a digital artery documented by arteriography and treated by excision of the mass and end-to-end anastomosis of the artery is presented. The authors review their experience with vascular leiomyomas in the hand and present four cases along with a review of 105 cases found in the English literature.

Wheels-in-line roller skating injuries.

Injuries sustained by patients using wheels-in-line roller skates were reviewed in a survey of 57 cases collected by the Roosevelt Hospital Hand Service and 444 cases compiled by the Consumer Product Safety Commission. Most patients were novice skaters in the second and third decades of life. Severe distal radius fractures and upper extremity soft-tissue trauma were the most common injuries in both groups. The distal radius (44.9%), scaphoid (13.9%), and radial head (10.4%) were the three most common fracture sites in the Roosevelt survey. Most (80%) skaters in this group did not wear protective equipment. In-line roller skating can and does produce disabling injuries. Also, several deaths were reported among skaters traveling in heavy traffic. To reduce the number of injuries, all skaters should wear protective gear, especially wrist and elbow pads. Splints reduce but do not eliminate the potential for trauma. In our study most injured skaters had not mastered controlled skating and stopping techniques. This new recreational sport is increasing in popularity and more injuries are expected if skaters fail to protect themselves properly.

Excision and fascial interposition arthroplasty in the treatment of Kienböck's disease.

Capitate shortening with capitate-hamate fusion is a joint leveling procedure designed for patients with Kienböck's disease who are in the early phases of this disease; that is, they have minimal or no fragmentation of the lunate, no arthritis, and no ulnar-minus variance. The long-term clinical results have been very good, and revascularization occurs in a high percentage of cases.

Total collateral ligament excision for contractures of the proximal interphalangeal joint.

The complete excision of scarred proximal interphalangeal collateral ligaments as the cornerstone of surgical treatment for proximal interphalangeal joint contractures was evaluated. Supplemental palmar plate distal release, extensor tenolysis, and flexor sheath release were performed as needed. Sixteen patients with primary proximal interphalangeal joint contractures treated by this method were reviewed with the use of preoperative data obtained from chart review and postoperative data from direct patient examination. The average range of motion increased from 38 degrees to 78 degrees. No patients had instability of the proximal interphalangeal joints on manual testing and x-ray examination. This radical surgical approach to contracted proximal interphalangeal joints is justified by the improved range of motion without instability.

Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease.

Visualization of the scaphotrapezial joint during basal joint arthroplasty has been recommended to establish the stage of degeneration. This study attempts to clarify that recommendation and evaluate whether moderate wear of the joint precludes a good result of trapeziometacarpal hemiarthroplasty. To assess the need for inspection of the scaphotrapezial joint, x-ray films, tomograms, and operative findings in 23 cases of basal joint arthroplasty were reviewed. X-ray findings agreed with operative findings at the scaphotrapezial joint in only 76% of the cases. We also evaluated 18 thumbs in 15 patients who underwent interposition arthroplasty of the trapeziometacarpal joint and at surgery had moderate degenerative changes of the scaphotrapezial joint. The scaphotrapezial joints were left intact and the trapeziometacarpal joints were reconstructed. Follow-up averaged 8 years. In no case was there x-ray or symptomatic progression of the disease at the scaphotrapezial joint. Clinically, 78% were rated excellent, 17% good, and 5% fair.

A Darrach procedure for distal ulnar pathology derangements.

Despite technologic advancements including arthrography, arthroscopy, and magnetic resonance imaging, pain in the distal radioulnar and ulnar carpal joints continues to baffle clinicians. Before the wide use of these diagnostic tests, the authors based their diagnosis of distal ulnar carpal joint derangement on the physical examination, history, and plain film roentgenographs. For eight patients who did not respond to conservative measures, a limited Darrach procedure was performed with highly satisfactory results. The specific technical aspects of this procedure are described. The postoperative results of the patients are presented with one to eight years of follow-up evaluation.