Outcome comparison of primary trapeziectomy versus secondary trapeziectomy following failed total trapeziometacarpal joint replacement.

PURPOSE: To compare the clinical outcome between secondary trapezial excision after failed total trapeziometacarpal joint replacement and primary trapeziectomy. METHODS: Between October 2003 and July 2008, we performed 16 revision procedures in our institution because of failed trapeziometacarpal joint replacements. Of these patients, 15 were followed up. We compared clinical outcomes between this group and 15 patients treated with primary trapeziectomy in a matched-pair analysis. The matching criteria were sex, age, and time from surgery. The mean follow-up period was 48 months. We evaluated mobility (radial and palmar abduction, opposition, and Kapandji score), grip strength, and patient self-assessment (pain; satisfaction; Disabilities of the Arm, Shoulder, and Hand score; and activity restriction). RESULTS: According to most of the clinical evaluation methods (range of motion and Kapandji score) and subjective assessments (pain; Disabilities of the Arm, Shoulder, and Hand), outcome did not differ considerably between the 2 study groups. In particular, the results of strength testing were not significantly different between groups. CONCLUSIONS: The present study showed that the outcomes of secondary trapeziectomy after failed trapeziometacarpal joint replacement arthroplasty generally do not differ from the primary trapeziectomy results. Although it shows high revision rates in the literature, trapeziometacarpal total joint arthroplasty might be a treatment option. In the case of failure, the outcome of secondary trapeziectomy is comparable to that of primary trapeziectomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The effect of defect localization on spontaneous repair of osteochondral defects in a Gottingen minipig model: a retrospective analysis of the medial patellar groove versus the medial femoral condyle.

Various animal models for experimental osteochondral defect healing have been used in orthopaedic research. Two main defect locations were chosen: the patellar groove or the central part of the medial femoral condyles (MFC). To date, it is not clear whether both locations display similar patterns in critical size osteochondral defect healing. We retrospectively analysed both locations in our minipig model hypothesizing that they show similar healing pattern. Thirty-five defects were analysed after three or 12 months. Osteochondral defects were 10 mm deep and 6.3 mm (MFC, n = 19) in diameter or 8 mm and 5.4 mm, respectively (trochlear groove [TG], n = 16). Semi-quantitative histological scoring and histomorphological evaluation were carried out. Both defect locations showed fillings of fibrous and fibrocartilage-like repair tissue. The osseous defect was closed by endochondral bone formation in the MFC. Semi-quantitative scoring did not show differences, whereas qualitative histomorphological analysis more frequently showed cartilaginous repair tissue in MFC defects. There was more frequent subchondral bone cyst formation in MFC location (P = 0.05), TG defects resulted in lower postoperative pain. Both defect localizations are suitable for studies on osteochondral healing. Since regenerating with less hyaline-like repair tissue and less subchondral cyst formation, TG is more favourable for experimental osteochondral defect healing in this model.

Proximal row carpectomy: an adequate procedure in carpal collapse.

Proximal row carpectomy (PRC) is an established procedure in the treatment of advanced radiocarpal arthritis. The aim of this study was to evaluate the individual, functional and radiological results in relation to the initial diagnosis. Seventeen patients (15 men, two women), who had undergone PRC, were evaluated. Their average age at the time of the operation was 48 years (range 21-70 years). The most frequent diagnosis leading to PRC was scaphoid non-union advanced collapse (SNAC), which was observed in nine patients, while in three cases each the condition treated had been scapholunate advanced collapse (SLAC) and perilunate dislocation, and in two cases, Kienboeck's disease. At the time of the follow-up examination (median 65.41 months), a significant improvement in the range of movement was seen. While only four (36%) of the patients with SNAC had radiological signs of arthrosis of the radiocapitate joint, visible radiological involvement was noted in all patients who underwent PRC due to scapholunate dissociation and perilunate dislocation. The results of this study show that PRC is a good way of achieving long-term improvement of the degree of subjective freedom from symptoms and of the functional range of movement. Interruption of ligamentous structures, as in scapholunate dissociation and perilunate dislocation, seems to influence the radiological outcome.

Comparison of cobalt chromium, ceramic and pyrocarbon hemiprosthesis in a rabbit model: Ceramic leads to more cartilage damage than cobalt chromium.

Cartilage wear after hemiarthroplasty remains a problem in orthopedic surgery. The main cause of cartilage wear, apart from incongruency of the joint partners, is generally considered to be the tribology of the material surfaces. This study evaluates in 27 rabbits the degree of cartilage wear of the tibia plateau after hemiarthroplasty with proximal interphalangeal prostheses made of three different materials [cobalt chromium (CoCr), pyrocarbon (PyCa), and ceramic (Cer)]. Three months after hemiarthroplasty, the articulating tibial cartilage was histomorphologically examined and degenerative damage was graded using the modified Mankin score. The mechanical capacity of the cartilage was assessed by stress relaxation testing. The biomechanical properties of the cartilage were significantly superior in the CoCr group as compared with the Cer group (p < 0.03), indicating less damage to the articulating cartilage surface. The Mankin score showed significantly lower values in the CoCr compared with Cer group (p = 0.011), whereas no differences were found between PyCa and CoCr or PyCa and Cer. In contrast to earlier reports, in this hemiarthroplasty model, the CoCr alloy showed less cartilage damage than a ceramic surface. Further, in vivo experiments are necessary to elucidate the controversial issue of the most suitable material for hemiarthroplasty.

Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality.

INTRODUCTION: The aim of the study was to compare the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN). PATIENTS AND METHODS: Clinical records including X-rays of all patients with trochanteric femoral fractures, except pathologic fractures and a minimum age of 60 years, which were treated between 1992 and 2005 were entered in this retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS and 42 with a PFN. Survival after 1 year and complications, which had to be treated within this period were our main outcome measurement. Influencing cofactors such as age, gender and comorbidities were reduced by multivariate logistic regression analysis. RESULTS: Mortality was significantly influenced by age, gender and amount of comorbidities but not by fracture classification. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with DHS and PFN were cutting out of the hip screw and non-union with a revision rate of 12.8%. With the introduction of hemiarthroplasty, the postoperative dislocation rate decreased from 12 to 0%. CONCLUSION: For stable fractures a dynamic hip screw (DHS) and for unstable fractures a short proximal femoral nail (PFN) can be recommended. The mortality risk of primary cemented arthroplasty did not differ significantly from the other treatment groups and because of its low complication rate it is a viable treatment option for trochanteric fractures if osteoporosis prevents from full weight bearing or if osteoarthritis makes further operations likely. Primary total hip replacement should be handled with care due to its significantly higher dislocation rate compared with hemiarthroplasty especially in unstable fractures.

Reconstruction of Lower Extremity Fractures with Soft Tissue Defects.

Reconstruction of osseous and soft tissue defects after high-energy lower extremity trauma remains a challenge in trauma surgery. An initial planning of the reconstruction management is crucial in the therapeutic concept of these severe injuries. In Gustilo type II and IIIa fractures with minimal contamination a primary definite osseous stabilization by internal fixation along with primary soft tissue reconstruction is preferable. A variety of local, regional, and even free microvascular flaps are available for acute wound closure in such cases. Staged reconstruction with initial external fixation and vacuum-assisted wound closure is recommended for severe contaminated wounds and extended defects. Early secondary osseous reconstruction of larger osseous defects can be performed either by distraction lengthening technique or by a free vascularized bone graft. Early secondary soft tissue reconstruction necessitates a wide therapeutic repertoire in order to plan the optimal individual strategy. With a modern therapeutic strategy limb salvage with an adequate function after reconstruction of lower extremity fractures with soft tissue defects can be achieved in the majority of patients.

Amount of ulnar resection is a predictive factor for ulnar instability problems after the Sauvé-Kapandji procedure: a retrospective study of 44 patients followed for 1-13 years.

BACKGROUND: The Sauvé-Kapandji procedure can result in instability of the proximal ulnar stump. PATIENTS AND METHODS: We reviewed 44 patients (mean follow-up time 6 (0.6-13) years) to investigate predictive factors for ulnar instability after Sauvé-Kapandji operation. We used several scores including an instability score specifically designed for this study. RESULTS: Patients with a longer proximal ulnar stump had significantly lower instability scores, significantly better Mayo Modified wrist scores and DASH scores, and also less pain than those with shorter proximal ulna. INTERPRETATION: If the shortening of the proximal stump is less than 35 mm, a reliable improvement in motion and a high patient satisfaction can be expected. The risk of a painful ulnar instability is related to the amount of resection, and can be reduced by creating a long upper ulnar stump.

Osseointegration and mechanical stability of pyrocarbon and titanium hand implants in a load-bearing in vivo model for small joint arthroplasty.

PURPOSE: To test the mechanical stability and histologic osseointegration under load-bearing conditions of 2 different materials, pyrocarbon (Py) and titanium (Ti), in a rabbit model. METHODS: Proximal interphalangeal implants (9 Ti, 8 Py) were placed into rabbit knees and the animals were killed after 3 months. Subsidence was assessed by monthly x-rays. Mechanical stability was measured with a nondestructive pullout test. Implant osseointegration was evaluated by an analysis of the relative implant-calcified bone contact surface on microradiographs and by a histomorphometric analysis of the percentage of bone and connective tissue contact with the implant surface. Histologic examination included assessment of bone apposition on the basis of fluorochromes. RESULTS: Subsidence was found in all 8 Py implants but in none of the Ti group. All 9 Ti implants were mechanically stable; all 8 Py implants were loose. A significantly higher implant-bone contact was found for the Ti group compared with the Py group. Bone apposition increased with time and was highest for the Ti implants 6 weeks after implantation. CONCLUSIONS: In the rabbit model osseointegration of implants was highly dependent on the material. A reliable osseointegration was found for Ti implants. For Py implants no osseointegration or implant stability was achieved. For use of small joints of the hand we therefore recommend Ti-based implants.

Vascularized os pisiform for reinforcement of the lunate in Kienböck's Disease: an average of 12 years of follow-up study.

PURPOSE: Little is known about the long-term results of vascularized bone transplantation for Kienböck's disease. This retrospective study investigated the long-term results of vascularized pisiform transfer. METHODS: We reviewed 23 patients to analyze results after vascularized pisiform transposition to a cored-out lunate for Lichtman stages II and III. Patients with ulnar-minus variance received additional radial shortening. RESULTS: Pain improved in 20 of 23 patients. Range of motion increased significantly relative to preoperative values but was only 80% that of opposite side. Grip power was 84% of the contralateral hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15.3 +/- 17.9 and the mean Cooney score was 82.4 +/- 10.0. Radiologically, out of 20 patients with preoperative x-rays Lichtman stage was unchanged in 11, improved in 3, and progressed in 6 patients. No patient showed radiologic signs of arthritis before surgery. At follow-up evaluation osteoarthritis was found in 7 of 22 patients. The majority of degenerative changes were of low grade and were seen at the radiocarpal joint. CONCLUSIONS: The results show high patient satisfaction and good function after vascularized bone transplantation for Kienböck's disease. In the long term vascularized pisiform transfer prevented lunate collapse in 16 of 22 patients.

Occurrence of carpal osteoarthritis after treatment of scaphoid nonunion with bone graft and herbert screw: a long-term follow-up study.

PURPOSE: To determine the occurrence, progression, and clinical results of osteoarthritis (OA) after bone grafting and Herbert screw fixation for scaphoid nonunion. METHODS: Fifty patients were reviewed (mean follow-up period, 12.0 +/- 1.6 y) to analyze degenerative changes of the wrist after use of Herbert screws for scaphoid nonunion. RESULTS: Radiologic signs of OA were observed in 15 of 50 patients before surgery and in 23 of 50 after 10 years or more. The majority of degenerative changes were low grade. No OA at follow-up evaluation was seen in 27 of 35 patients with no preoperative degenerative changes. In 6 of 8 patients with OA its occurrence was either subsequent to concomitant injury, occurred after incorrect scaphoid reconstruction, or was caused by persistent nonunion. Of 15 wrists with OA at the time of surgery 9 remained unchanged and 6 increased in severity. Healing of nonunion was achieved in 42 of 50. Range of motion, however, was reduced to 88% of that of the opposite hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand score was 9 +/- 13 and the mean Cooney score was 80 +/- 10. CONCLUSIONS: The results show high patient satisfaction and good function after healing of scaphoid nonunion. In the long term correct anatomic reconstruction of the nonarthritic carpus with a Herbert screw prevents onset of OA in most patients.

Lunate resection and vascularized Os pisiform transfer in Kienböck's Disease: an average of 10 years of follow-up study after Saffar's procedure.

PURPOSE: To investigate the long-term results of lunate replacement by vascularized bone transfer in advanced Kienböck's disease. METHODS: Twenty-one patients were reviewed (mean follow-up period +/- SD, 9.9 +/- 3.5 y) to analyze results after lunate replacement by vascularized pisiform transposition (Saffar's procedure) for Lichtman stages III and IV. RESULTS: Pain was improved in 16 of 21 patients but range of motion did not improve after surgery. Range of motion was reduced to 68% and grip power to 80% of that of the opposite hand. At follow-up evaluation the mean score on the Disabilities of the Arm, Shoulder, and Hand Questionnaire was 22.3 +/- 17.9 and the mean Cooney score was 75.4 +/- 13.2. Radiologically, Lichtman stage persisted in 8, improved in 1, progressed in 8, and could not be evaluated in 3 patients. Two patients had radiologic signs of arthritis before surgery. At follow-up examination osteoarthritis was found in 50% of patients. The majority of degenerative changes were associated with carpal collapse. CONCLUSIONS: The replacement of the lunate by vascularized pisiform transposition maintained preoperative ranges of motion. At follow-up examination both patient satisfaction and wrist function were high. In the long term, however, Saffar's procedure can restore alignment of the carpus only partly and also results in osteoarthritis in half of all patients.

Osteosarcoma of the hand and forearm: experience of the Cooperative Osteosarcoma Study Group.

BACKGROUND: Osteosarcoma is extremely rare in the hand and forearm. Therefore, only limited data are available for planning treatment or predicting the outcome and prognosis of osteosarcoma in the peripheral upper extremity. METHODS: Epidemiological, clinical, and histopathologic data were analyzed in 39 patients with osteosarcoma of the forearm or hand who were enrolled in studies of the Cooperative German-Austrian-Swiss Osteosarcoma Study Group from 1977 to December 2000. In patients with high-grade osteosarcoma, the treatment entailed surgical resection in combination with chemotherapy, whereas patients with low-grade osteosarcoma underwent only surgery. RESULTS: The 5-year overall survival rate among the 33 patients with high-grade central osteosarcoma of the distal upper extremity was 86.2% +/- 6.4%. The 5-year event-free survival rate was 65.4% +/- 9.6%. Five of the eight patients with secondary metastases were in remission at the time of analysis. Four patients died of their disease, and two patients died of chemotherapy-related complications. The mean overall survival rate was 88.0% +/- 6.5% in patients treated by wide or radical tumor resection and was 75.0% +/- 21.7% in patients with nonwide margins of resection. Whether amputation or local resection was performed had no significant influence on the prognosis. All six patients whose osteosarcoma was not classified as high-grade central osteosarcoma were in remission at the time of analysis. CONCLUSIONS: The results demonstrate a remarkably high survival rate for patients with high-grade osteosarcoma of the hand and forearm and confirm that multiagent chemotherapy in combination with wide excision is a highly effective treatment for this malignant tumor.

Ewing's sarcoma and primitive neuroectodermal tumor of hand and forearm. Experience of the Cooperative Ewing's Sarcoma Study Group.

PURPOSE: Because Ewing's sarcoma (EWS) is extremely rare in the hand and forearm, only limited data are available for planning treatment or predicting prognosis. METHODS: Data of 33 patients with EWS of the forearm or hand who were enrolled in studies of the German Association for Paediatric Oncology/Haematology and the European Intergroup Cooperative Ewing's Sarcoma Study Group were analyzed. Patients received neoadjuvant multi-agent chemotherapy according to the valid protocol. Local treatment consisted of surgery (n=7), radiotherapy (n=7), or a combination of both (n=19). RESULTS: The 5/10-year overall survival rate was 84.1% (95% CI: 71.2-96.9)/74.1% (95% CI: 56.8-91.5), and both 5/10-year event-free survival rate were 71.3% (95% CI: 55.4-87.1). Only one of seven patients with secondary metastases was in remission at the time of analysis. One patient with local recurrence and another with primary metastases died. Altogether, eight of 33 patients died of their disease. The event-free survival rate was 80.6% in patients with good response to chemotherapy and 33.3% in patients with poor response. Surgery in combination with radiotherapy achieved a higher survival rate compared with radiotherapy or surgery alone. One out of two patients with non-wide margins of resection died of disease. CONCLUSIONS: The results demonstrate a remarkably high survival rate for patients with EWS of the hand and forearm.