Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach.

A combined volar-dorsal approach was used to treat 11 perilunate dislocations and fracture dislocations between 1989 and 1994. The mean average age of the patients was 38 years, and the mean average time between injury and surgery was 13 hours. Outcome was assessed after an average of 30 months. Results were based on measurements of grip strength, range of motion, radiographs, and patient satisfaction. Patient satisfaction was high in 9 of 11 patients. Seven had satisfactory pain relief, and 5 had returned to their previous occupation without limitation. The wrist flexion-extension arc and grip strength averaged 71% and 77%, respectively, compared to the opposite side. Follow-up radiographs demonstrated complete union of all 8 wrist fractures. For all 11 patients, the carpal height ratio averaged 0.50. Neither scapholunate dissociation nor significant dorsal intercalated segmental instability existed, but 1 wrist developed scapholunate advanced collapse arthritis. Although perilunate instability patterns of injury create significant derangement in carpal anatomy and are among the most challenging of traumatic wrist injuries to correct, our results show that a combined volar-dorsal approach can be used safely and effectively to restore normal intercarpal relationships and provide fixation for accompanying fractures. For the majority of patients, the outcome after this procedure is characterized by acceptable pain relief as well as functional motion and grip strength.

Major limb replantation in children.

After the first successful replantation of a completely amputated extremity in a 12-year-old boy undertaken by Ronald Malt at the Massachusetts General Hospital in 1962 (Malt and McKhann, Journal of the American Medical Association, 189:716-722, 1964) numerous series of major limb replantations have been reported in adults. The reports of major limb replantation in children are relatively rare and are usually included in adult series. During the last 14 years, 18 children with major limb amputations were treated at the Microsurgical and Replantation Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School. Of these, 13 were complete amputations (11 upper extremity and 2 lower extremity), while 5 were incomplete nonviable amputations (3 upper extremity and 2 lower extremity). The success rate following replantation of the complete amputations was 76.9%, while for the incomplete, nonviable amputations success was 80%. Preoperative evaluation, operative management, postoperative care, and the results of this difficult but rewarding procedure are analysed and discussed in this review.