Carpal tunnel syndrome.

Patients with carpal tunnel syndrome should be told that it is a progressive condition that, if not treated, probably will worsen as time goes on. When release is performed properly, they have an excellent chance for substantial improvement, although some always may have a degree of residual numbness at the fingertips. Initial relief of pain is rapid, with subsequent improvement in numbness and weakness occurring more slowly. Carpal tunnel syndrome is a very common problem. Although there may be a distinct cause in some patients, the underlying reason for the increased bulk of synovium is not known in most. Conservative treatment gives temporary relief, but surgical release remains the most effective treatment. Complications are not common, and proper attention to details minimizes them. The results generally are excellent.

MRI of the Stener lesion.

OBJECTIVE: To assess the utility of MR in detecting surgically induced Stener lesions (displaced thumb ulnar collateral ligaments) in cadaveric models. DESIGN: Six cadaver thumbs had ulnar collateral ligament (UCL) tears created surgically. MR examinations (2D STIR and 3D GRASS) were performed identically on all specimens both before displacement (non-Stener) and after displacement (Stener lesion) of the UCL. The MR images were then randomly numbered. Each image was evaluated separately in blinded fashion by four musculoskeletal radiologists for the presence or absence of a Stener lesion. Each radiologist reinterpreted the images after an interval of several days. The interpretation was based on previously published criteria for Stener lesion diagnosis by MR. RESULTS: The sensitivity of GRASS ranged from 0.17 to 0.67 with the most experienced reader scoring the lowest. The specificity of GRASS ranged from 0.33 to 1.0 (most experienced reader 0.67, 0.83). STIR had a sensitivity of 0.00-0.17 and a specificity of 0.53-0.83. The kappa values for inter- and intraobserver agreement were measured. The intraobserver kappa for GRASS was 0.27-0.75 (most experienced reader 0.75). CONCLUSIONS: 2D imaging is probably inadequate for the evaluation of Stener lesions. The most likely reason is that the STIR slice thickness of 3 mm limits resolution of small UCLs. The poor sensitivity and specificity of GRASS as well as poor interobserver agreement suggest that MR may not be sufficiently accurate for Stener lesion evaluation.

Heterotopic ossification following primary total knee arthroplasty.

Heterotopic ossification is a rare complication following primary total knee arthroplasty and may be symptomatic if massive enough. The authors retrospectively reviewed 158 primary total knee arthroplasties from 1985 to 1989 and found 6 cases (3.8%) of heterotopic ossification. Patients were graded before and after surgery according to the Hospital for Special Surgery total knee arthroplasty score and their histories were reviewed for the presence of recognized risk factors for heterotopic ossification and whether a manipulation under anesthesia was performed. This report describes the incidence of, appearance of, and clinical risk factors for heterotopic ossification following primary total knee arthroplasty in this series. A radiographic grading system is proposed.

Works in progress #7. Clinical experience with the Accu-Path threaded acetabular cup. A preliminary report.

Clinical experience with the Accu-Path threaded titanium hemispheric cup is presented. A series of 62 cases was followed for an average of 28.1 months (range, 6 to 48). Primary surgery was performed in 50 cases and revision surgery in 12. The surgical technique is described in detail. Preoperative Harris scores improved from 28 to 93 in primary cases and from 24 to 84 in revision cases. Complications included 3.2% dislocation, 3.2% loss of cup position, and 1.6% recurrent subluxation. The overall reoperation rate was 8% (8% in primary surgery and 8.3% in revision surgery). Roentgenographic analysis is discussed. The importance of preservation of the subchondral plate and a rim fit in the use of this implant is stressed. It is not indicated in those with loss of the plate due either to prior surgery (as in revision) or in aggressive over-reaming in primary cases. Although the overall results were encouraging, caution was recommended--especially in revision surgery or in the patient with severe osteopenia.

Management of ipsilateral femoral shaft fractures following hip arthroplasty.

Femoral shaft fractures following hip arthroplasty can be difficult to manage, particularly in elderly patients. Nine patients were treated with open reduction and rigid internal fixation using cement augmentation for screw fixation in the distal shaft. The stability achieved allowed all patients to be mobilized in the immediate postoperative period. No incidences of reduction loss or implant failure occurred, and all fractures had healed by the time of review. The results obtained support this method of treatment for ipsilateral femoral shaft fractures when prosthetic stability has not been compromised.

Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly.

The results of primary Bateman-Leinbach bipolar prosthetic replacement for comminuted intertrochanteric fractures of the hip in the elderly are examined. In an effort to avoid the postoperative complications seen in open reduction and internal fixation of severely comminuted fractures with osteoporotic bone, and to avoid postoperative restrictions when fixation is suboptimal, a group of 58 patients were treated with a bipolar Bateman-Leinbach prosthesis. They were followed for an average of 28 months. Surgery was performed using an anterolateral approach, which is recommended. A detailed description of the surgical approach and operative technique are provided. Eighty-eight percent of patients were able to ambulate within the first week, weight bearing as tolerated with no postoperative restrictions, except for a simple abduction pillow for 2 weeks while in bed. Ninety-one percent of patients ambulated prior to discharge. Morbidity and mortality was no greater in this group than in groups treated by open reduction and internal fixation for these types of fractures. Complications were few. Primary Bateman-Leinbach bipolar prosthetic replacement is recommended as the preferred treatment of selected unstable comminuted intertrochanteric fractures in the elderly.

Infected uncemented hip arthroplasty. Preserving the femoral stem with a two-stage revision procedure.

Revision of an infected uncemented hip arthroplasty can be significantly complicated by the presence of extensive bony ingrowth. Although removal of the prosthesis is desirable, technical difficulties in extracting a well anchored prosthesis can be extreme. Femoral windowing or splitting may be necessary. In these cases, treatment alternatives that avoid destruction of the femoral cortex are desirable. A 47-year-old man presented with a deep infection of a virtually fully coated porous implant two years postoperatively. Radiographs revealed extensive bony ingrowth and an arthrogram revealed no dye tracking down the femoral canal. The infecting organism was Staphylococcus epidermis. In order to avoid the possible complications of extraction of this fully coated stem, treatment was carried out initially with removal of the bipolar head, joint debridement, and placement of antibiotic impregnated beads. After seven weeks of intravenous antibiotic therapy with the patient in tibial pin traction, a revision was undertaken and the acetabulum was revised with a threaded uncemented acetabular component. The patient recovered and at 18 month follow-up is without evidence of infection and back to full function. Revision with a two-stage femoral stem preserving procedure is presented as an alternative in the management of infected uncemented hip arthroplasty.

A retrospective study of 125 cases of slipped capital femoral epiphysis.

A series of 125 cases of slipped capital femoral epiphysis in 94 patients was followed an average of 4.7 years. Initial treatment consisted of closed reduction with internal fixation in 13 cases, cervical cuneiform osteotomy with internal fixation in nine, and in situ fixation in the remainder. The end-results were good in 82% of the cases. Of the nine failures, eight were due to avascular necrosis or chondrolysis. Closed reduction should be performed only in acute or acute-on-chronic slippings. Chronic slippings should be nailed in situ. The use of more involved procedures, such as cuneiform osteotomy, is not recommended because of the risk of avascular necrosis and because they do not allow the natural forces of remodeling to improve the deformity. Using this method, only three slippings required subsequent osteotomy.

Long-term results of dorsal stabilization in the rheumatoid wrist.

Dorsal stabilization was performed on 85 rheumatoid wrist in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.