[Results of rheumatoid wrist surgery (arthrodesis excepted): 16 patients with more than 20 year follow-up]. / Devenir à plus de 20 ans de recul des poignets rhumatoïdes opérés (arthrodèses exclues).

PURPOSE OF THE STUDY: The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist. MATERIAL AND METHODS: Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up. RESULTS: Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force. CONCLUSION: There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

[Compensatory carpal malalignments]. / Les désaxations carpiennes d'adaptation.

This new nosological chapter deals with carpal malalignments due to osseous disorders which are secondary to alterations of the spatial coherence of the carpus with respect to variations in the form or in the volume of the carpal complex. The authors have included as well, the compensatory realignments which are secondary to modifications of the radial buttress. The malalignments secondary to disorders of the lunate (excision of the lunate, Kienböck's disease, lunar implants), scaphoid (excision of the scaphoid, nonunion, implants) as well as those due to proximally located malunions of the lower extremity of the radius, are studied. The therapeutic rationale which may be concluded from this study is exposed.

The surgical treatment of the rheumatoid wrist. Current perspectives.

The authors stress the prevalence and severity of wrist involvement in rheumatoid disease. Improved knowledge of aetiopathogenesis and deformities had led to identification of the importance of the distal consequences on the digital joints of decentralization of the wrist. Synovectomy retains an important place at the onset of the disease. This may be completed by stabilization procedures (tendon transfer and partial arthrodesis). At the advanced stage of the disease, arthroplasty is currently overtaking arthrodesis. Interposition arthroplasty, with its rare indications, is now well developed. Although the solution of the future, arthroplasties lack sufficient follow up in terms of their results. The Swanson implant offers limited mobility but ensures freedom from pain and a good wrist axis. The ideal treatment of the rheumatoid wrist is oriented towards early conservative surgery and later, at an advanced stage, towards arthroplasty, the ideal technique of which remains to be discovered.

First results of arthroplasty of the wrist by Swanson's implant. Twenty-five cases.

We have carried out 25 arthroplasties of the wrist using the Swanson implant since 1976. The indications were primarily in rheumatoid arthritis. The operation was done for severe pain and deformity of the wrist. Results were analysed in 19 patients with a follow-up of 21-54 months. Post-operative pain relief is good. Although mobility is fair, the return of the balance of wrist motions has been recovered. The results of the Swanson implant arthroplasty are compared to dorsal synovectomy and wrist arthrodesis.

[Conservative treatment of deformities of the anterior chest wall]. / Traitement orthopédique des déformations thoraciques vers l'avant Résultats.

The authors have treated 55 deformities of the anterior chest wall in children. There were 37 cases of symmetrical pectus carinatum, 15 cases of asymmetrical pectus carinatum and 3 cases of pectus arcuatum. Associated lesions of the ribs, scapulae and spine are described. Treatment in every case was by plaster casts followed by a plaster jacket and exercises. The results were much more satisfactory in deformities associated with prominence than with depression of the sternum. In pectus carinatum, the results were better when the apex of the deformity was more distal. The best age for treatment was between 12 and 13 years. No patient was treated by operation.