A preliminary report: cementless trapeziometacarpal arthroplasty.

A cementless ball and socket trapeziometacarpal arthroplasty was used for the treatment of Eaton and Littler stage II and III trapeziometacarpal osteoarthritis. Forty-two joints were placed in 36 patients between 1986 and 1992. Five joints in 4 patients required revision. Thirty-four joints in 30 patients were evaluated with a mean follow-up period of 47 months (range, 15-86 months). Of the 33 monitored patients (39 joints), 79% reported good to excellent pain relief and excellent functional improvement and 12% reported poor to fair pain relief and functional improvement. Five joints required revision surgery and constituted 13% of the original arthroplasties. Thirty-three functional tests were graded before and after surgery and improvement was noted in all categories. Dramatic improvement was noted in the typical complaints for trapeziometacarpal joint disease, which are encountered in the activities of daily living. Radiolucent lines were present in 13 of 25 implants (52%), which were radiographically monitored. Radiographic loosening was present in 32%; 12 were around the trapezial component and 1 was around the metacarpal component. Radiographic loosening did not correlate with less satisfactory clinical results. Cementless trapeziometacarpal arthroplasty provides an operative alternative to arthrodesis in properly selected patients with trapeziometacarpal joint osteoarthritis. This joint is not intended to replace excisional or ligament reconstruction tendon interposition arthroplasty in lower demand patients or in those with pantrapezial arthritis. It also is not recommended in patients with rheumatoid arthritis or poor bone stock. It offers the advantages of maintaining excellent motion and stability. The cementless arthroplasty failures can be effectively salvaged by converting them to ligament reconstruction tendon interposition arthroplasty.

Palmar lunate transtriquetral fracture dislocation.

A palmar lunate transtriquetral fracture dislocation with a concomitant radial styloid avulsion fracture has not been described before in the literature. This injury represents an interesting variation of stage IV perilunar instability. Treatment was complicated by persistent scapholunate dissociation (rotary subluxation of the scaphoid) after attempted closed reduction and percutaneous pinning. At open reduction, the proximal half of the triquetrum, which had been dislocated palmarward with the lunate and which had been thought to be reduced after our attempted closed reduction was indeed returned to its normal position. However, it was rotated 180 degrees on its transverse axis. Restoration of the normal scapholunate interval was not possible until the triquetral fracture was reduced.

Cerclage of the lateral malleolus in displaced fractures of the ankle.

When open reduction is indicated the lateral malleolus fracture should be reduced as accurately as the medial or posterior malleolar fragments. The cerclage for displaced oblique or spiral fractures of the lateral malleolus is a simple, effective way of internal fixation with a minimal amount of metal implanted. Under direct vision an anatomical reduction is achieved and maintained. The proper use of a 20- or 18 -gauge wire with a mechanical wire tightner-twister is mandatory. A below-the-knee plaster cast is necessary for support for an average of eight weeks. In this series, with correct technique, no wires have loosened or broken. There has been no resorption of bone or refracture at the wire-loop site. No second surgery has been needed for removal of wires. The case material included 50 cases of ankle fractures from 1964 through 1976. In a displaced bimalleolar or trimalleolar fracture, the cerclage can be used in conjunction with various other internal fixation screws or nails applied to the medial and/or posterior malleolar fragment. The exact method varies depending on the type of fracture present. With increasing recognition of the importance of anatomic reduction of the lateral malleolus in the ankle fracture management, cerclage technique will contribute further toward the restoration of the normal ankle joint mechanics.

Closed intramedullary nailing for ununited femoral shaft fractures.

Fifteen cases of ununited diaphyseal fractures of femurs were treated successfully by intramedullary reaming and closed Küntscher nailing through the small gluteal incision. The equipment used is the same as for nailing fresh shaft fractures. The cases included 10 nonunions, 2 delayed unions and 3 miscellaneous problems. All but one case had been initially treated by open reduction with some form of internal skeletal fixation. Two cases had been treated by 2 open procedures befor the closed Küntscher nailing. No supplemental bone graft or external immobilization was necessary. Two cases were nailed successfully in the presence of infection, resulting in solid union and no recurrence of infection. Five nails have been removed after union and no refracture has occurred. No important postoperative complication or instances of the fat embolism syndrome were encountered. No rotational deformity or further shortening of the femur occurred. Postoperatively, the patients ambulated with protected weight-bearing as early as possible. The average hospital stay was 15 days. In general, the patients had a functional extremity even while the fracture lines were still visible on roentgenographs; all have returned to their previous work.