Hemiarthroplasty for trapeziometacarpal arthritis - a useful alternative?

We performed hemiarthroplasty using the Swanson titanium implant for treatment of isolated and advanced trapeziometacarpal joint osteoarthritis Nineteen implants were placed in 18 patients (mean age: 57 years) between 1995 and 1999. One joint required revision and conversion to trapeziectomy. Eighteen joints in 17 patients were evaluated with a mean follow-up period of 34 (range, 14-60) months. Good pain relief was noted in 13 hands. All patients had good hand function as scored using validated questionnaires. Radiographic loosening occurred with five implants and trapezial wear in ten joints. Though radiographic loosening or trapezial wear did not correlate with less satisfactory clinical results, failure of the implant is a concern in the long term. Preliminary results indicate that hemiarthroplasty can be a useful treatment alternative in selected, relatively young patients with isolated trapeziometacarpal osteoarthritis and good bone stock. Good motion and stability can be preserved Failures can be effectively salvaged by trapeziectomy.

Trapeziectomy for basal thumb joint osteoarthritis: 3- to 19-year follow-up.

A consecutive series of 40 trapeziectomies in 30 patients with basal thumb joint osteoarthritis was reviewed. Sixteen thumbs had pan-trapezial and 24 thumbs trapeziometacarpal osteoarthritis. Simple excision without soft tissue interposition was performed by the same surgeon using an identical surgical technique. Twenty-eight patients were female (mean age 57 years) with a mean follow-up of 11 (3-19) years. Twenty-eight patients were satisfied with their operation, with 26 thumbs being pain free. Thumb pinch strength was improved by 40% compared to preoperative values, but still remained 22% weaker than the non-operated side.

Pre-admission clinic in an orthopaedic department: evaluation over a 6-month period.

A pre-admission clinic for patients undergoing elective orthopaedic surgery has been used at the Royal Surrey County Hospital, Guildford, for the past 3 years. This report audits the activities of the clinic over a period of 6 months. Data regarding the patients who were invited to the pre-admission clinic during the study period were analysed. In all, 232 patients were asked to attend the clinic and a total of 221 (95.2%) attended. Of these patients, 10 had their operations cancelled and three had their operations postponed in the clinic due to various medical and social reasons. Another 28 operations were cancelled or postponed at a later stage. All of the postponed procedures were eventually performed within 3 months. Of the 232 patients, 180 (77.5%) underwent their operation on the arranged day without any complications. The pre-admission clinic in our orthopaedic department helps us to prevent a significant number of operation cancellations on the day of admission. It also facilitates an extensive pre-operative assessment of the patients and reduces the ward-based workload of the junior medical staff. More extensive use of the pre-admission clinic is recommended.

Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation.

We reviewed 26 consecutive men of mean age 28 years who had wedge bone grafting and Herbert screw fixation for symptomatic established nonunion of the waist of the scaphoid. The period between injury and operation averaged 30 months (10 to 96), and 11 of the 26 patients had had previous operations, seven with bone grafts. At a mean follow-up of 14 months (6 to 42) 25 fractures (95%) had united at a median time of four months. Symptoms were improved in all patients. The outcome was not related to the time between injury and surgery or to pre-existing degenerative changes. Previous surgery carried a worse prognosis. The technique is difficult but can achieve union even when previous surgery and bone grafting have failed. The usual result is improved function and some relief of pain.

Deep hand infection complicating chickenpox in an otherwise healthy infant.

Chickenpox is a common childhood infection, and complications are rare in the healthy child. This report describes a significant complication of varicella in an otherwise healthy infant.

Axial movement and tibial fractures. A controlled randomised trial of treatment.

Diaphyseal fractures of the tibia in 80 patients were treated by external skeletal fixation using a unilateral frame, either in a fixed mode or in a mode which allowed the application of a small amount of predominantly axial micromovement. Patients were allocated to each regime by random selection. Fracture healing was assessed clinically, radiologically and by measurement of the mechanical stiffness of the fracture. Both clinical and mechanical healing were enhanced in the group subjected to micromovement, compared to those treated with frames in a fixed mode possessing an overall stiffness similar to that of others in common clinical use. The differences in healing time were statistically significant and independently related to the treatment method. There was no difference in complication rates between treatment groups.

The management of the painful first metatarsophalangeal joint in the older patient. Arthrodesis or Keller's arthroplasty?

We report a prospective randomised trial comparing Keller's arthroplasty and arthrodesis of the first metatarsophalangeal joint for the management of symptomatic hallux valgus and hallux rigidus in the older patient. In 81 patients (110 feet), with a minimum of two years follow-up, both procedures gave a similar degree of patient satisfaction and symptom relief. The incidence of metatarsalgia was also similar. As there were no obvious advantages to arthrodesis, and since six out of 50 arthrodesed toes required revision, we suggest that Keller's arthroplasty is the better operation in these patients.

Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon.

We reviewed 21 patients with 22 ruptures of the extensor pollicis longus at a mean of 5.3 years after transfer of the extensor indicis proprius tendon. Of these, 19 with 21 transfers described the result as good, and two as fair. The mean deficit of extension between the operated and unoperated thumbs was 1.4 cm, and the mean flexion deficit 0.6 cm. Pressure gauge measurements showed that the strength of the transfer was 51% of that of the uninjured extensor. The two fair results had an extensor lag of over 1.5 cm. Independent extension of the index was maintained in all patients, none having a discernible lag, but the strength of index extension was reduced to 49% of that of the normal finger. There was no evidence of functional loss. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon is a simple and reliable procedure with few complications. It gives satisfactory long-term extension of the thumb.

Cementless PCA unicompartmental joint arthroplasty for osteoarthritis of the knee. A prospective study of 51 cases.

The authors report a prospective study of the first 51 cementless P.C.A. unicompartmental arthroplasties performed for osteoarthritis of the knee by one surgeon. Forty-two medial prostheses in 38 patients and 9 lateral prostheses in 9 patients were reviewed at a minimum of 2 years after surgery. Patients were assessed using the HSS score. In the medial joint replacement group, 37 (88%) had an excellent or good result, 3 (7%) were fair, and 2 (5%) poor. Subjectively 37 (88%) were good, 2 (5%) were fair, and 3 (7%) had a poor result. All of the lateral joint replacements had an excellent or good result. This improvement was due to pain relief and increased functional ability; preoperative range of movement was maintained or only slightly improved. There were five unsatisfactory results, three due to technical errors (one requiring revision), one a failure of patient selection, and the last an unexplained synovitis causing persistent discomfort. The early results for the cementless PCA unicompartmental knee arthroplasty are encouraging, with a satisfactory result in 90% of patients.

Palmar cutaneous branch of the median nerve.

The palmar cutaneous branch of the median nerve was dissected in 25 fresh cadavers. The origin from the median nerve, the course, termination, and variability of the palmar cutaneous nerve are described in relation to two reference lines. In no case did a branch of the palmar cutaneous nerve extend ulnar to the axial line of the ring finger. The planning of incisions around the palmar aspect of the palm and wrist should be based on this anatomical knowledge.