[Ulnar head prosthesis]. / Ulnakopfprothese.

The ulnar head prosthesis has been the subject of a prospective multicenter-study since 1995. Until 2000, it has been used in 57 patients by the study group. In 35 patients, the indication was painful instability of the distal end of the ulna following previous resection arthroplasties, and in 22 patients it was painful arthritis of the distal radioulnar joint (DRUJ). The mean follow-up was 38 months. Pronation increased from a preoperative mean of 63 degrees to a postoperative value of 78 degrees, while supination increased from 43 degrees to 76 degrees. Grip strength improved from a preoperative mean of 51% to a postoperative mean of 77% of the opposite limb. Pain, measured on the verbal pain scale (1-4), was reduced remarkably from a preoperative mean level of 3.6 to a postoperative mean of 1.7. Patient' satisfaction was evaluated using the visual analog scale (0-10) and improved from a preoperative mean of 2.1 to a postoperative mean of 7.9. With one exception of loosening, we consistently found bony integration of the shaft of the prosthesis. Stability of the DRUJ was achieved in all but three patients. This method has given reliable and excellent results as a salvage procedure for failed resection arthroplasties of the DRUJ with painful instability of the distal end of the ulna. We consider the method an alternative treatment option for the arthritically destroyed DRUJ. Sufficient soft tissue to stabilise the prosthesis is needed to successfully reconstruct the DRUJ.

Open volar repair of acute scaphoid fractures.

Internal fixation of acute scaphoid fractures has significant advantages over conservative treatment, using cast immobilization. Healing rates are improved, functional recovery is accelerated, and morbidity is reduced. Percutaneous fixation has become the treatment of choice for the majority of acute fractures, since it is an out-patient procedure, which produces virtually no scarring and enables an extremely-rapid recovery; however, in those cases where a stable and anatomical reduction cannot be achieved by closed means, open volar repair remains the best method of treatment. With careful attention to technique, and the avoidance of postoperative immobilization, excellent results can be achieved, even in the case of transscaphoid fracture-dislocation of the carpus.

Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis.

Twenty-three patients with painful instability following total or partial resection of the ulnar head were treated using a new ulnar head prosthesis combined with a simple soft tissue repair. Stability and marked symptomatic improvement were achieved in all patients. With a mean follow-up period of 27 months, this improvement has been maintained in all but 1 patient, whose prosthesis had to be removed because of a low-grade infection. These results suggest that the use of a prosthesis is a satisfactory way to restore stability and relieve secondary symptoms that may be associated with partial or total excision of the ulnar head.

The symptomatic carpal boss. Is simple excision enough?

We reviewed 48 patients with symptomatic carpal boss seen during the 10 year period 1985-1994. Thirty-one patients had undergone either local excision of the boss or arthrodesis of the affected carpometacarpal joint. The mean follow-up was 3 years and nine cases have been revised. Twenty-four patients remained symptomatic and considered that surgery had failed to relieve their symptoms. These findings are in sharp contrast to previous reports that suggest simple excision of the carpal boss gives uniformly good results.

Proximal scaphoid nonunion-osteosynthesis.

Proximal pole fractures of the scaphoid have a high incidence of nonunion and avascular necrosis. Because of their poor prognosis, the treatment of these fractures remains controversial. 102 patients with symptomatic nonunion of the proximal pole were treated by simple osteosynthesis, using retrograde screw fixation through a direct dorsal approach to the scaphoid. Fracture preparation and bone grafting were kept to a minimum, in order to preserve as much bone stock as possible, and to avoid damage to the already compromised vascularity of the proximal fragment. No postoperative splinting was used and most patients were able to return to their normal work within a few weeks of surgery. 69 patients were followed-up at an average of 34 months. 59 (85%) were asymptomatic, and had regained excellent wrist function, in spite of the fact that sound radiological union was present in only 50% of these. Union was often slow (3 to 36 months) and appeared to be related to the vascularity of the bone fragments. However, even when bone union was incomplete, the fracture remained stable, with no loss of fixation. The ten patients with unsatisfactory results had all developed late avascular necrosis of the proximal pole, requiring salvage surgery. Stable internal fixation of proximal pole nonunion leads to rapid symptomatic improvement in the majority of cases and sets the scene for revascularisation and healing. Even when union is incomplete the scaphoid remains intact, thus preserving excellent wrist function and, at the same time, offering the best possible long term prognosis.

Vein implantation for treatment of painful cutaneous neuromas. A preliminary report.

Based on the theory that recurrent neuroma formation can be prevented if the cut nerve end is implanted into the lumen of a vein, 14 patients have been treated by neuroma excision followed by proximal vein implantation over the last 5 years. Thirteen patients reported dramatic pain relief following surgery, and this was sustained in all but one case. Both failures were re-explored, when it was found that the nerve had pulled out of the vein, leading to recurrent neuroma formation. Both cases were revised successfully using the same technique. With a mean follow-up of 15 months, 11 patients remain symptom-free, whilst three have minor residual symptoms which are not severe enough to require further surgery.

Congenital synchondrosis of the scaphotrapezio-trapezoidal joint.

Incomplete cavitation of the cartilaginous precursor of the carpus during the fourth to eighth weeks of intrauterine life results in carpal synostosis or synchondrosis, which becomes radiographically apparent as the carpus ossifies. Such anomalies occur rarely, are generally believed to be asymptomatic, and are usually discovered as incidental radiographic findings. We present two cases of symptomatic, nonsyndromic congenital synchondrosis of the scaphotrapezio-trapezoidal joint, a type of carpal coalition not previously reported.

Total wrist fusion. A functional assessment.

Twenty cases of total wrist fusion, performed for post-traumatic conditions, were reviewed objectively, subjectively and radiologically. All patients were satisfied with the position of the fused wrist and had good pain relief. All patients would have had the procedure sooner, having had an average of three operations on the wrist before the fusion. There was a high complication rate (45%), although only four patients required further procedures for those complications. Hand function, as assessed by the Jebsen and Purdue tests, was found to be poor; this may be due to a reduced range of finger movements. There was no correlation between position of fusion, carpal height or number of joints radiologically fused, and the pain score, grip strength or Buck-Gramcko score.

Herbert screw fixation of scaphoid fractures.

We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery. On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved. Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment.

Avascular necrosis of the proximal scaphoid after fracture union.

We report four cases of late avascular necrosis (AVN) of the proximal part of the scaphoid following apparent healing of acute scaphoid fractures. One patient had been treated conservatively, by plaster immobilization, and the other three had undergone internal fixation of their acute fractures. The onset of symptoms associated with AVN varied, being as late as 2 years in one patient. Late AVN following healing of a scaphoid fracture does not appear to have been previously recognized, perhaps due to the fact that patients are seldom followed up for long enough. We feel that this condition is in many ways analogous to late AVN following femoral neck fractures and as such is a special complication related to the fact that both bones are intracapsular and have a precarious blood supply.

Silicone synovitis. A perspective.

Silicone implant arthroplasty is, arguably, the most effective treatment for the majority of patients with symptomatic arthritis in the hand and wrist. In 1985 the problem of silicone synovitis was first brought to our attention. Since that time there have been numerous reports on this condition leading to a worldwide trend against the use of silicone implants. However, the true incidence and effects of silicone synovitis have not been clearly defined. For this reason, we have undertaken a survey of all patients who have undergone silicone implant arthroplasty in the wrist and hand in our Unit between 1975 and 1990. Patients with rheumatoid arthritis and those undergoing MP or IP joint arthroplasty were excluded. Of the 289 implant arthroplasties remaining, we have been able to review personally 229 implants with a mean follow-up of 3.8 years (range 1-15). Although 40% of cases showed significant radiological changes, only 11 patients (4.8%) developed symptoms requiring treatment. Of these, two were managed conservatively whilst the rest underwent revision surgery, all with entirely satisfactory results. We conclude that silicone implant arthroplasty remains the treatment of choice for patients with painful joint disease in the hand and wrist.

Idiopathic avascular necrosis of the scaphoid.

Idiopathic avascular necrosis of the scaphoid is a rare condition. A review of the literature shows a variety of conditions labelled as spontaneous avascular necrosis or Preiser's disease. In this paper we report on a study of eight patients with idiopathic avascular necrosis affecting only the proximal pole of the scaphoid. Seven of these patients had positive ulnar variance. The possible aetiology is discussed and the natural history has been studied. A staging system is proposed, as this helps to determine the prognosis and appropriate management. Two of our patients were managed conservatively; the others were treated successfully by partial silastic replacement of the scaphoid.

Spontaneous correction of dorsal intercalated segment instability deformity with scaphoid malunion in the skeletally immature.

This is a report on two children with dorsal intercalated segment instability deformity of the carpus associated with malunited fracture of the scaphoid. The patients were observed over 4 years, and spontaneous improvement was noted in association with growth.

The Swanson ulnar head prosthesis for post-traumatic disorders of the distal radio-ulnar joint.

20 Swanson ulnar head prostheses inserted for post-traumatic disorders of the distal radio-ulnar joint were reviewed at a mean of 44.2 months post-operatively (range 12-104 months). The indication for surgery was painful loss of forearm rotation with or without ulno-carpal impingement and ulno-carpal instability. Symptoms in 16 patients were the result of malunion following severe distal radial fractures (two Frykman 7 fractures and 14 Frykman 8 fractures), and in the remainder were due to unreduced dislocations in the distal radio-ulnar joint (two patients) or unsatisfactory Darrach procedures (two patients). 70% of patients achieved excellent or good clinical results despite the fact that radiographs showed bone resorption in all cases, tilting of the prosthesis in 40% and implant fractures in 15%.

The Herbert bone screw: a ten year perspective.

It is now over ten years since the Herbert bone screw was first released in Australia. In 1984, Herbert and Fisher first published their experience with the use of this new bone screw in the management of scaphoid fractures. Since that time, there has been a growing interest in the technique and over 60 articles have appeared in the English literature. The purpose of this paper is to review and comment on the relevant publications as they relate to the biomechanical properties of the screw, to its use in the management of scaphoid fractures and to other applications in surgery of the hand.

Acute rotary dislocation of the scaphoid: a new technique of repair using Herbert screw fixation across the scapho-lunate joint.

Acute rotary dislocation of the scaphoid is commonly misdiagnosed and, if untreated, leads to progressive osteoarthritis of the wrist. The diagnosis requires a high degree of awareness and an understanding of the pathomechanics of the injury. To date, no single method of treatment has been shown to produce consistently satisfactory results. This paper presents a new surgical technique involving open reduction and reattachment of the ligament to the bone, combined with Herbert screw fixation across the scapho-lunate joint. The screw is normally left in situ for 12-18 months, allowing sufficient time for ligament healing and restoration of carpal stability. Using this technique early postoperative wrist motion is possible. Although excellent results have been achieved in the majority of cases, a few patients have developed increasing carpal collapse deformity in spite of adequate internal fixation, presumably due to inadequacy of the volar carpal ligaments. However, although the technique is a demanding one, the Herbert bone screw appears to offer significant advantages over standard Kirschner wire fixation in the treatment of acute rotary dislocation of the scaphoid.

Bilateral arthrography of the wrist.

In order to determine the true significance of a positive arthrogram in the investigation of wrist pain, a prospective trial was carried out in 60 patients, using the opposite asymptomatic wrist as a control. Of the 46 patients with positive findings in the symptomatic wrist, 34 (74%), had positive arthrograms in the opposite, asymptomatic, wrist. As a result of this, we conclude that a unilateral arthrogram is of little diagnostic value and we recommend the use of the opposite, asymptomatic, wrist as a control.