Lunotriquetral arthrodesis using cancellous bone graft.

Previous reports of lunotriquetral arthrodesis suggest relatively low rates of primary fusion without the use of permanent fixation and/or prolonged immobilization. We performed 26 lunotriquetral arthrodeses in 24 patients with a technique using cancellous bone graft to fill a biconcave space created in the adjoining bones with parallel K-wire fixation. The indications included symptomatic lunotriquetral instability and degenerative arthritis. All patients received conservative treatment before surgery. Primary fusion was achieved in all wrists in an average of 50 days. Postoperative wrist flexion/extension averaged 77%/80% of unaffected sides. Radial/ulnar deviation averaged 95%/91% of unaffected sides. Pain relief was good or very good in 83%. Eight-eight percent returned to the workforce. This study shows reliable, effective results with a technique that adheres to the principles of intercarpal arthrodesis and avoids permanent internal fixation.

One thousand intercarpal arthrodeses.

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienbock's disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

Temporary scapho-trapezoidal joint fixation for Kienböck's disease in a 12-year-old girl: a case report.

Temporary scapho-trapezoidal joint fixation with Kirschner wires was performed for stage IIIB Kienböck's disease in a 12-year-old girl. Preoperative evaluation with radiographs and magnetic resonance imaging confirmed the diagnosis. After 4 months of fixation, wrist range of motion was improved and pain was decreased. Postoperative magnetic resonance imaging revealed revascularization and fracture healing. Temporary scapho-trapezoidal fixation may be useful in the treatment of selected cases of Kienböck's disease in children.

Sagittal band reconstruction.

Extensor tendon subluxation at the metacarpophalangeal joint occurs only rarely in patients without rheumatoid arthritis. Almost all reported cases involve disruption of the radial sagittal band with ulnar subluxation of the extensor tendon. A technique of sagittal band reconstruction is described that entails weaving a retrograde segment of extensor tendon upon itself after passing it through the deep transverse metacarpal ligament. Twenty-one sagittal band reconstructions were performed in 16 patients. This series included 18 cases of ulnar subluxation secondary to radial sagittal band disruption and 3 cases of radial subluxation secondary to ulnar sagittal band disruption. Using this technique, pain was eliminated in every case and there has been no recurrence of extensor tendon subluxation.

Lateral lunate morphology: an x-ray study.

The lunate has been described by Kauer as being thinner dorsally than volarly when measured proximal to distal. We used an x-ray method to measure the shape of the lunate in order to compare dorsal and volar thicknesses after recognizing clinically a group of patients with scapholunate dissociation in whom volar flexed lunates were present. Using this method, 292 standard lateral views of the lunate were collected randomly and measured. The shape of the lunate could be classified into 3 types: type D lunates have a thinner dorsal segment and correspond to Kauer's description; type V lunates have a thinner volar segment; type N lunates have equal dorsal and volar segments. There were 196 type D lunates (67%), 67 type V lunates (23%), and 29 type N lunates (10%). The radiolunate angles were measured in a random selection from type D and type V lunates to determine any relationship between the volar segment to dorsal segment thickness (wedge) ratio. No relationship within these groups was identified. However, there was a significant difference in the radiolunate angles between these two groups. Recognition of the prevalence of the type V lunate alters concepts proposed by Kauer and warrants further investigation of factors influencing lunate position.

Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage.

Atherosclerosis of the lower extremity frequently leads to limb-threatening ischemic soft-tissue wounds. Over the past 44 months, 30 selected patients with arterial disease documented by angiography were treated with combined vascular reconstruction and free-tissue transfer for limb salvage. Soft-tissue defects occurred on the plantar and dorsal surfaces of the foot and distal tibia with significant bone, tendon, or joint exposure. Thirteen patients had osteomyelitis. Eighteen patients underwent simultaneous soft-tissue and vascular reconstruction, while 12 patients underwent delayed soft-tissue reconstruction. The free-flap tissues included the rectus abdominis flap in 13, the latissimus dorsi flap in 7, the radial forearm flap in 5, the scapular flap in 3, and the omentum flap in 2. Autogenous venous bypass was performed to the popliteal segment in 6 patients and the infrapopliteal arteries in 18. Five patients had inadequate outflow for complete vascular reconstruction and were treated with proximal vein grafts directed into the free flap. Twenty-two patients (73 percent) had successful free-tissue transfer and bypass graft patency and were independent ambulators over the mean follow-up period of 22 months. Of the 8 unsuccessful reconstructions, 3 patients had early free-flap and graft failure. Five patients developed new areas of ischemic disease despite graft and flap patency. All 8 patients were treated with amputation; 7 never regained ambulation. The combined application of vascular and free-flap soft-tissue reconstruction for the threatened ischemic lower extremity has produced excellent functional results in the majority of our patients.

Comparison of the operating microscope and loupes for free microvascular tissue transfer.

A retrospective study of 200 consecutive free microvascular tissue transfers over a 3-year period was done to compare the performance of free-tissue transfers with loupes and with the operating microscope. One-hundred and nineteen flaps (59.5 percent) were performed under 3.5 x loupe magnification and 81 under the operating microscope (40.5 percent). The magnification selection process was based on cumulative past experience, with all early anastomoses performed with the microscope and the vast majority of the more recent operations performed with loupe magnification. Loupes were used preferentially for head and neck reconstruction and breast reconstruction. The microscope was required for performing vascular anastomoses on children and on vessels less than or equal to 1.5 mm in diameter. Results were compared with respect to etiology of defect, type of flap, age of patient, free-flap success, complications, and overall success of the reconstruction. There was no difference in outcome between the two groups, with free-flap success rates of 99 percent for both the loupe and the microscope groups. We believe that our success with loupe-only free-tissue transfers is attributable to our prior considerable experience with the microscope. We would caution that comfort and experience with microanastomoses under the operating microscope should be obtained prior to beginning a loupe-only experience.

Modified technique for dual chamber pacemaker insertion.

Insertion of a permanent dual chamber pacemaker by the Seldinger technique usually requires two needle punctures of the vein or the use of a large introducer, thus increasing the risks associated with this procedure. We describe a modified technique using a relatively small introducer and a single subclavian vein puncture that we have found to be safe and simple to perform.