Treatment of isolated injuries of the lunotriquetral ligament. A comparison of arthrodesis, ligament reconstruction and ligament repair.

We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22). The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain relief and satisfaction were significantly higher in the lunotriquetral repair and reconstruction groups than in those undergoing arthrodesis.

Kienböck's disease and gout.

A relationship between gout and Kienbock's disease has been proposed on the basis of a previously published case report. A review of patients at our institution identified a single case with the combination of both Kienbock's disease and gout. We believe that the association is coincidental.

Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment.

We reviewed the literature to determine the clinical outcomes of the treatment of closed fractures of the tibial shaft with immobilization in a cast, open reduction with internal fixation, or fixation with an intramedullary rod. We reviewed 2372 reports of comparative trials and uncontrolled studies of series of patients published between 1966 and 1993. Nineteen reports, involving six controlled trials and twenty-seven groups of patients, met our inclusion criteria. A structured questionnaire was used to assess the quality of the literature in terms of the experimental design and the method of assessment of outcome. Outcomes from controlled trials were summarized with odds ratios and risk differences, and outcomes from case series were summarized by the medians of the reported results. The studies that were reviewed generally had few subjects and were poorly designed. The comparative trials showed treatment with a cast to be associated with a lower rate of superficial infection than open reduction and internal fixation (mean difference, -5.81 per cent; p = 0.02) and open reduction and internal fixation to be associated with a higher rate of union by twenty weeks than treatment with a cast (mean difference, -18.07 per cent; p = 0.008). There were no other significant associations. There were insufficient data for us to evaluate any aspect of functional status, level of pain, or other patient-reported outcomes of any of the methods of treatment. The results of the present review suggest that the data from the published literature are inadequate for decision-making with regard to the treatment of closed fractures of the tibia.

Abdominal wall reconstruction.

Patients with abdominal wall reconstruction present a difficult management problem to the oncological surgeon. There were 36 patients treated for abdominal wall primary and secondary tumors between the years 1973 and 1982 at the Memorial Hospital. There were 25 abdominal wall sarcomas, 6 recurrent colon cancers, 2 recurrent bladder cancers, 1 cervical cancer, 1 recurrent endometrial cancer and 3 complications of radiotherapy treated by excision and reconstruction of the defect. The desmoid tumors were closed primarily. The recurrent sarcomas after radical excision, were reconstructed with Marlex mesh and local mobilization of skin and subcutaneous tissue. The recurrent colon bladder and endometrial cancers had been treated with over 5,000 cGy each. Three patients had significant full thickness skin loss secondary to radiotherapy. These patients comprised the group that required a myocutaneous flap to provide full thickness skin and fascia. The tensor fascia lata flap was used in eight patients. This group of patients did extremely well in contrast to the group of radiated patients with Marlex mesh reconstruction. There were less complications in the TFL group. We recommended the TFL flap for a large abdominal wall defect and for a previously radiated abdominal wall.