Rheumatoid flexor tenosynovitis and rupture.

Rheumatoid flexor tenosynovitis at the wrist can cause locking, limitation of motion, nerve compression, and rupture of tendons. To prevent and treat these conditions, a flexor tenosynovectomy, combined with nerve decompression and tendon reconstruction as indicated, is necessary. If tendons are ruptured, the flexor pollicis longus and profundus to the index finger are most commonly affected. On the fingers flexor tenosynovitis can also cause locking, decrease in range of motion and rupture tendons. Flexor tenosynovitis of the fingers should be treated with decompression of the tendons health with preservation of the pulley system.

Results of CFV total wrist arthroplasty: review and early report.

Articulated total wrist arthroplasties have been used in the United States since 1974. In the 1980s the CFV wrist was developed in an attempt to reduce the incidence of imbalance, loosening, and bone resorption that has been seen in the early implants, and also to eliminate the use of bone cement. Since 1988, we have implanted 15 of these wrists. To date, nine patients are satisfied because of pain relief and motion; however, there have been 6 failures: 2 for infection, 3 because of a loose distal component, and 1 because of balance. Other problems that have been observed are flexor tenosynovitis, carpal tunnel syndrome, and a balancing problem.

Salvage of failed total elbow arthroplasty.

We had to revise 14 total elbow arthroplasties, three for infection, six for aseptic loosening, four for instability, and one for a failed bearing mechanism. All of the infected elbows were converted to resection arthroplasty with elimination of infection but with poor function; in one acceptable motion was achieved after a fascial arthroplasty. Those that failed aseptically were salvaged with reimplantation of other devices, either a custom implant or a semiconstrained device, which was also used in those nonconstrained elbows that failed because of dislocation. All of the noninfected elbows were successfully revised with relief of pain and motion comparable to or better than that present before revision.

Salvage for failed implant arthroplasty of the wrist.

We have had to revise 19 wrist arthroplasties--seven silicone implants and 12 metal-on-plastic total wrist arthroplasties. Each of the seven silicone implants was successfully revised in one operation; the four fusions and three total wrist implants were functioning 6 or more years after surgery. Nineteen operations were needed to revise the total wrist implants. Four had failed because of loosening, six had become unbalanced, and two had become infected. All of the loose prostheses eventually required fusion. Four of the unbalanced wrists were rebalanced, but two of these patients have pain; the other two cases required fusion. One infected wrist required fusion, and one is stable with an implant.

Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up.

Twenty-three Swanson silicone rubber implants in patients with stage III or stage IV rheumatoid arthritis were reviewed at an average of 72 months after surgery. Minimum follow-up in patients with unrevised implants was 44 months. Results were rated good or excellent in 48%, fair in 4%, and poor in 48%. Pain was the primary indication for surgery. Patient satisfaction and pain relief were achieved in 63%. Implant fracture occurred in 52%. Revision rate was 30%, including one recommended revision. Radiographic changes consistent with particulate synovitis were seen in 30%. Prosthesis settling and bony resorption were seen in more than 75% of the patients. Survivorship analysis demonstrated 42% survival at 77 months. Progressive clinical and radiologic deterioration was seen. Swanson silicone rubber implant is recommended only in the very low demand patient with stage III or stage IV rheumatoid arthritis and in those with insufficient bone stock to allow total wrist arthroplasty with a metal-on-plastic design.

Proximal row carpectomy: review of rheumatoid and nonrheumatoid wrists.

Proximal row carpectomy was first done in 1939 and was indicated for treatment of posttraumatic problems or Kienböck's disease. Use of this procedure in patients with rheumatoid arthritis has not been reported. Our series consists of eighteen wrists, nine with rheumatoid arthritis, and nine with other various nonrheumatoid conditions. Follow-up ranged from 12 to 120 months and included x-ray films and assessment of pain, range of motion, balance, grip strength, and patient satisfaction. Our results showed only two of the eight rheumatoid wrists to be satisfactory; failure was caused by pain and imbalance. Of the nonrheumatoid wrists, six of the eight were satisfactory, although in one of the six sclerosis is developing between the capitate and radius. Proximal row carpectomy is not recommended for the rheumatoid wrist but may be useful where other pathologic conditions are involved if the remaining articular surfaces are uninvolved.

Epineural ganglion of the ulnar nerve at the elbow.

Ganglion cysts of peripheral nerves in the upper extremity are rare. Cysts located in the substance of the nerve and extraneural ganglia that cause symptomatic nerve compression have been reported. Intraneural ganglia may be difficult to separate from the neural elements without resultant nerve injury. This case involved a ganglion cyst confined to the epineurium of the ulnar nerve at the elbow. Because of the peripheral location, it was removed without damage to the underlying nerve.

Dissociation of the glenoid component in the Macnab/English total shoulder arthroplasty.

Three episodes of mechanical glenoid component failure in two patients are presented. The glenoid component that failed is a two-piece polyethylene metal-backed design, with a snap-fip interlock of the polyethylene insert. The mode of failure with this design should caution both orthopaedic surgeons and implant manufacturers that mechanical dissociation of a snap-fit glenoid liner can occur, and that discretion is advised in their design, fabrication, and use.

Capitello-Condylar total elbow arthroplasty for rheumatoid arthritis.

Twenty-one total elbow arthroplasties using the Capitello-Condylar design of Ewald were performed at the Denver Orthopedic Clinic from 1977 to 1986. Indications for operation included intractable pain unrelieved by medical therapy as well as late state III or IV rheumatoid arthritis. The average total elbow score at 48 months after operation was 89.5 points, including excellent pain and function ratings. Modest gains in motion occurred with lesser gains in patients with juvenile rheumatoid arthritis than those of the adult variety. Forty percent of the elbows suffered some type of complication although most are successfully manageable. There was one clinical failure due to deep infection in a renal deficient patient.

Survivorship of unconstrained total shoulder arthroplasty.

The results of fifty-three unconstrained (Neer-II or Gristina) total shoulder arthroplasties were reviewed with the use of survivorship analysis. Failure was defined as the need for revision or the onset of the patient's dissatisfaction. The method of survivorship analysis is presented in detail. Fifty-one total shoulder arthroplasties were followed for a minimum of two years (average, sixty-seven months). The results are reported with the use of the American Shoulder and Elbow Surgeons' rating form. After eleven years, the survivorship was 73 per cent for all prostheses, 71 per cent for the Neer prostheses, and 92 per cent for all prostheses in patients who had rheumatoid arthritis. Data on survivorship of the Gristina prosthesis were available after four years only, at which time it was 100 per cent. The relief of pain, which was the primary reason for the operation, was good or excellent in 82 per cent, improved in 6 per cent, and poor in 12 per cent of the shoulders in these patients.

Boutonniere deformities in rheumatoid arthritis.

The emphasis in rheumatoid hand surgery has been on the MP joints, but the PIP joints are often involved with the boutonniere deformity being one common pattern. The pathology of the boutonniere begins with a synovitis of the joint, followed by elongation al the central slip, subluxation of the later bands, and contracture of the retinacular ligaments. Treatment in the early stages can include synovectomy and tendon reconstruction. In the later stages, when the joint is fixed or there is articular surface damage, a joint replacement or arthrodesis is necessary.

Idiopathic avascular necrosis of the scaphoid: Preiser's disease?

Although avascular necrosis after fracture of the scaphoid is common, it rarely develops without apparent trauma. Preiser's disease is commonly associated with avascular necrosis of the scaphoid without fracture or trauma. A critical review of Preiser's original article reveals that all of his cases, as well as three of seven additional cases in the literature, were associated with fracture or trauma. Preiser's disease, therefore, should be traumatic avascular necrosis and differentiated from truly nontraumatic avascular necrosis. Five additional cases in four patients with nontraumatic avascular necrosis of the scaphoid are presented.

A long-term retrospective study of the modified Bristow procedure.

A retrospective follow-up study is presented on the results in 51 patients who underwent the modified Bristow procedure for recurrent anterior shoulder dislocation or subluxation between 1972 and 1982. The average follow-up period was 95 months. Postoperatively, 6% of the patients had recurrent anterior dislocation and 4% had recurrent anterior subluxations. Another 4% of the patients developed posterior subluxation after surgery. Seventy-six percent of the patients felt that there was no postoperative limitation in their activities. Eighteen percent felt limited in throwing sports and 4% felt limited in swinging sports. Fourteen percent of the patients had screw complications that involved screws causing pain (6%), fractured screws (4%), bent screws (2%), and loose screws (2%). Additional surgical procedures were required in 14% of patients: screw removal (8%), hematoma drainage (2%), and reoperation using the modified Bristow procedure (4%). Ninety-two percent of the patients assessed their surgical results as excellent or good.

Arthroplasty of the basal joint of the thumb using a silicone prosthesis. Long-term follow-up.

Thirty-three hands were followed for an average of 7.8 years after arthroplasty of the basal joint of the thumb using a silicone prosthesis. The minimum length of follow-up was 5.6 years. All of the patients had relief of pain, but three complained of weakness. Radiographs of twenty hands showed that four prostheses had subluxated, three had dislocated, and thirteen had evidence of wear. Ten hands had destructive changes in the adjacent bones. We now recommend the use of a silicone prosthesis for arthroplasty of the basal joint only in elderly patients or in patients who have a low level of functional activity. In younger or more active patients, interpositional arthroplasty using tendon is recommended.

Elbow synovectomy in rheumatoid arthritis. Long-term results.

Fifty-seven elbows in 46 rheumatoid arthritis patients were followed from one to 20 years, with an average follow-up period of 86 months, and were treated with synovectomy and radial head resection. A silicone radial head prosthesis was inserted in 13 elbows. Surgery was performed through a lateral incision. Long-term follow-up study showed 77% of the elbows to fall in the excellent and improved categories. A trend toward better results was seen if the surgery was done at an earlier stage of the disease. The radial head prosthesis did not influence the results of synovectomy.

Implant arthroplasty of the rheumatoid wrist.

Implant arthroplasty of the rheumatoid wrist is indicated for relief of pain in those patients with advanced destruction of the joint. Two types of implant arthroplasty are useful in selected cases: silicone interpositional arthroplasty and total wrist replacement.

Osteoarthritis associated with a ball-and-socket ankle joint. A case report.

A ball-and-socket joint is an unusual disturbance of normal ankle development. Previous reports have noted good function and the absence of osteoarthritic change in ankles with this configuration. A 50-year-old man with no history of injury developed an osteoarthritic ball-and-socket deformity of the ankle joint. Associated musculoskeletal anomalies included toe syndactylization, genu valgum deformity, and tarsal coalition, a condition that may predispose to the development of this ankle anomaly. Associated valgus deformity of the ankle contributed to the osteoarthritic changes. The conspicuous absence of osteoarthritis in other joints of patients previously reported with this abnormality may be explained by the lack of long-term follow-up examinations.