Comparative results of resection of the distal ulna in rheumatoid arthritis and post-traumatic conditions.

The purpose of this study was to determine whether the results of resection of the distal ulna differed depending upon the underlying aetiology of the condition. Patients with rheumatoid arthritis were compared with patients with post-traumatic wrist complaints. Fifty resections in 40 patients (eight male, 32 female) were assessed with respect to pain, range of motion, and grip strength. Of the 23 rheumatoid wrists, 86% were pain-free following surgery; however, only 36% of the patients in the trauma group reported pain relief postoperatively. Pain relief in post-traumatic patients was more predictable when distal radioulnar joint arthrosis was identified as the sole cause of wrist pain.

Long-term results of carpal tunnel release.

To determine the long-term results of carpal tunnel release, we retrospectively reviewed 60 cases, an average of 5.5 years after surgery. 87% reported a good or excellent overall outcome; the average time to maximum improvement of symptoms was 9.8 months. However, 30% reported poor to fair strength and long-term scar discomfort, and 57% noted a return of some pre-operative symptoms, most commonly pain, beginning an average of 2 years after surgery. We found no correlation between pre-operative symptoms or extent of surgical dissection (internal neurolysis) and outcome. Carpal tunnel syndrome was job related in 42%; of these, 26% changed from heavy to lighter work following surgery. Although occupational cases were slower to improve and remained off work longer, the long-term subjective results were the same for both groups. We found significant morbidity from the surgical scar and decreased strength, and often considerable delay until ultimate improvement, especially in patients with job-related carpal tunnel syndrome.

In vivo experimental analysis of silicone implants used with titanium grommets.

This study evaluated the titanium grommets recommended to reduce breakage by protecting hinge implants from bone edges. Silastic HP-100 (Dow Corning Wright, Arlington, TN) flexible finger implants (size 5) were used to replace one knee of 10 rabbits, and implants plus titanium grommets were used in another 10. X-ray films were taken monthly; deaths from each group were 1 animal at 2 and 4 months, 2 animals at 6, and 3 each at 12 and 16 months. X-ray films revealed that 4 of 10 implants from each group had fractured. Silicone fractures occurred identically at the proximal stem-hinge junction in both groups, destruction was always most pronounced at the dorsal surface of the proximal stems. The time from surgery to x-ray film evidence of implant fracture without grommets was an average of 9 months and with grommets 13 months. Although grommets delayed x-ray film evidence of fracture onset, after 14 months all implants in both groups of animals fractured. These findings do not support the hypothesis that grommets prevent silicone hinge implant wear or fracture in this experimental model.

In vivo experimental analysis of silicone implants on bone and soft tissue.

We report experimentally produced silicone microparticles (synovitis) in 47 white rabbits and discuss the implications for clinical practice. Silastic HP100 (Dow Corning Wright, Arlington, TN) finger hinges (size 5) were inserted in 20 rabbit's knees. The upper tibia was replaced with Swanson design great toe implants in another 15 rabbits; articular cartilage was removed and endosteal drilling was performed in 6 animals as a "sham" arthroplasty. Small silicone blocks were inserted in the proximal tibial endosteal canal of 6 others. Animals were followed by monthly x-ray films and killed at 2, 4, 6, 12, and 16 months. Implant wear, bone surfaces, and soft tissue were examined under the operating microscope and by light microscopy; implant surfaces were examined with scanning electron microscopy. X-ray changes included reactive endosteal bone formation around implant stems as early as 1 month postoperatively; at 2-3 months the new bone line was clearest but it became progressively homogeneous and less evident. Extensive cortical erosion around the stems was observed in one third of the animals. Neither ossification nor lysis was observed around the silicone block. Proliferative synovitis was found at post-mortem examination beginning after 4 months; femoral condylar erosions were observed in most animals after 12 months. Wherever there was bone destruction, silicone particles were confirmed by x-ray spectrography.

Wrist position and extensor tendon amplitude following repair.

After primary repair of severed extensor tendons, various methods are used to limit tendon adhesions and avoid rupture. Early passive digital motion with wrist extension (a "reverse Kleinert" protocol) has been advocated. However, there are no data to support an optimum wrist position or to indicate how much finger motion may safely be permitted. In this study we used eight fresh cadaver limbs to measure extensor tendon gliding in Verdan's zones 3 to 8 when active grip and passive extension were simulated at different wrist positions. We found that if the wrist is extended more than 21 degrees, the extensor tendon glides with little or no tension in zones 5 and 6 throughout full simulated grip to full passive extension, permitting "passive motion" exercises to minimize tendon adhesions without risking rupture. In addition, we found that up to 6.4 mm of tendon can be debrided safely and full grip can still be permitted postoperatively if the wrist is splinted at 45 degrees extension.

Flexor tendon lacerations in zone V.

Twenty-three patients with zone V flexor tendon lacerations rehabilitated by the Kleinert protocol were studied at an average of 46 months after trauma. Hand function was subjectively normal in only eight. Of fourteen patients who were employed at the time of injury, eight returned to their original occupations. Eight others were working at other jobs, and we considered six more capable of employment. Only one had a poor functional result that precluded occupational use of the hand. Pinch/grip strengths recovered to 85%/79% of the uninvolved side. Independent flexor digitorum superficialis/flexor digitorum profundus action was present in only seven patients. Sixteen regained full digital flexion. Extension loss averaged 25% at the wrist and 10% in each digit. As assessed by static two-point discrimination, sensibility was poor after associated median and ulnar nerve transections; this did not preclude good objective functional results. Complications included two tendon ruptures, proximal interphalangeal hyperextension in the presence of an unrepaired flexor digitorum superficialis, and limited motion in two patients after poor compliance in therapy. Tenolysis was needed in 4 of the 23. We now use a modified Duran technique for noncompliant patients and in those who are unable to extend their PIP joints because of weak intrinsic muscles.

Ideal scaphoid angle for intercarpal arthrodesis.

This experimental study was conducted to determine the best scaphoid position, measured as the radioscaphoid (RS) angle for optimum wrist motion after scapho-trapezio-trapezoid (STT) and scaphocapitate (SC) fusion and to assess the implications of radial styloidectomy on motion after STT fusion. STT and SC fusions were simulated in six fresh cadaver hands with the scaphoid in horizontal, neutral, and vertical positions with respect to the long axis of the radius seen on lateral x-rays. RS angle and wrist motion were measured on x-ray films before and after each simulated arthrodesis. Radial deviation and wrist extension increased as the RS angle increased (i.e., increased as the scaphoid became more nearly vertical). Ulnar deviation and flexion decreased as the scaphoid became more nearly horizontal. We found no statistically significant differences in RS angle between SST and SC fusions with respect to ulnar deviation, flexion, or extension. However, radial deviation was more sensitive to RS angle after STT fusion than after SC fusion, but the differences were not statistically significant. The ideal radioscaphoid angle (range) for maximal wrist motion when STT fusion is performed is 41 to 60 degrees; when SC fusion is performed, it is 30 to 57 degrees. Motion is not improved by radial styloidectomy after simulated STT fusion.

Reconstruction of traumatic or congenital amputation of the thumb by distraction-lengthening.

Reconstruction of the traumatically or congenitally amputated thumb presents a significant challenge. The individual needs of the patient must be matched with the armamentarium available to the surgeon. Metacarpal elongation via the distraction-lengthening technique, which uses local tissue without sacrificing any adjacent digits or toes, is a reliable means of increasing thumb length by 3 to 3.5 cm. The optimal situation for performing this procedure is the presence of an amputation in the perimetacarpophalangeal joint region. Although neo-osteogenesis has been shown to be useful in pediatric patients, bone grafting is recommended in those individuals aged 25 years and older with gaps of 3 cm or more. The patient must be carefully observed during the distraction period because of the potential problems that may arise from the use of an external fixation device.

Tenosynovial injection for carpal tunnel syndrome.

Although local steroid injection into the tenosynovium is a frequent treatment for carpal tunnel syndrome, it involves some risk and is not always effective. We simulated injection on 16 fresh cadaver forearms, instilling 1 ml (group 1) or 2 ml (group 2) of methylene blue at 1 cm or 3 cm proximal to the most distal wrist crease. Passive flexion and extension were simulated 2 minutes after injection by application of traction to the appropriate digital tendons. Specimens were dissected under loupe magnification from midpalm to midforearm, dye diffusion was quantified and photographed, sections of the carpal tunnel and contents were graded for presence of dye, and average values were determined for each of the four groups. Diffusion of dye was best in group 2B in which 2 ml was injected 3 cm proximal to the distal wrist flexion crease.

Reduction osteotomy for triphalangeal thumb: an 11-year review.

Since 1977 we have operated on 13 of 15 triphalangeal thumbs in nine children (five boys, four girls). Follow-up ranged from 22 to 134 months (mean, 65 months). Total active motion averaged 63 degrees at the interphalangeal joint and 79 degrees at the metacarpophalangeal joint. There was no evidence of instability or laxity of ligaments. Reduction osteotomy was insufficient to shorten grossly long thumbs of two patients, and it was necessary to shorten the metacarpal. Premature closure of the phalangeal physis occurred in two thumbs but did not result in inadequate length; one postoperative pin-tract infection resulted in nonunion that required reoperation. This long-term experience supports reduction osteotomy for triphalangeal thumbs because it addresses the deformities and preserves both motion and stability.

Pathologic fractures: a complication of microparticulate synovitis.

We report seven cases of pathologic fracture in adult patients that were seen an average of 5 years (range from 33 to 114 months) after silicone wrist (three) and trapezial (four) arthroplasty. All patients had initially done well after their operation. At return, all had radiographic evidence of generalized implant and intramedullary bone destruction, the latter always including endosteal scalloping and widening from cortical resorption. These radiographic changes may be less striking than the discrete osteolytic lesions seen after degeneration of carpal implants. Our patients represent examples of pathologic fracture as the end stage of untreated microparticulate synovitis, a consequence of prosthetic wear. Our experience suggests that careful and continuous follow-up justified after insertion of stemmed silicone implants, and that patients should be informed of the potential late complications of this procedure, including pathologic fracture.

De Quervain's syndrome: surgical and anatomical studies of the fibroosseous canal.

Anatomical variations of the first dorsal fibroosseous compartment were studied in 70 patients (38 women, 32 men) who underwent surgical release of the tendons. Seventy-one dissected forearms were also studied. De Quervain's tenosynovitis was the only diagnosis for two thirds of the patients. Nonoperative treatment for all of these patients failed. Forty-three patients (61%) had job-related symptoms. Recovery ranged from 3 to 36 months postoperatively (mean: 4.5 months). Multiple subcompartments were recorded in 47% of patients and in 75% of anatomic specimens. In 94% of the specimens, the abductor pollicis longus (APL) tendon had two to four slips, but in only two were there multiple extensor pollicis brevis (EPB) tendons. Surgeons must recognize that multiple APL tendon slips and two subcompartments are the rule, rather than the exception, in normal anatomy.

Brachioradialis transfer for digital palsy.

Although brachioradialis tendon transfer is thought to offer limited tendon excursion and finger motion, we have used it to restore active thumb and digital function in eight patients. Three had Volkmann's contracture, one avulsion of forearm muscles and four had tetraplegia resulting in inability to perform activities of daily living and loss of pinch or grasp and extrinsic extension. The brachioradialis was transferred to the flexor pollicis longus, to the flexor digitorum profundus or to the common digital extensors. Except for one patient who had unremitting pain, all were pleased with their improved motion, pinch, grip, and independence. Function, however, remained abnormal in all but one.

Determining and maintaining competence: an obligation of allied health education.

In a climate of growing concern about the costs and quality of health care, there is increasing evidence that the health care system lacks effective controls to assure the continuing competence of health practitioners. The assumption that educational institutions, and specifically those that prepare allied health professionals, can meet obligations to the clinical community and the public by means of the present haphazard system of voluntary continuing education is questioned. Instead, the author suggests that schools of allied health may have to collaborate with professional organizations in identifying individual deficiencies in clinical practice and in offering remedial, continuing education programs that address these deficiencies. The rationale for the assumption of this unique responsibility for determining and maintaining clinical competence by schools of allied health is explored.

Perspectives on the pain of the hospice patient.

Behind the physical disfigurement and emotional ravages of advanced malignancy, it is the pain of cancer that is most dreaded. Severe biological pain is experienced by fewer than half of patients dying from cancer. Hospice physicians have the expertise to control the pain of those cancer patients who do experience it. The cancer patient may experience other forms of pain that can be equally devastating: pain of isolation, pain of abandonment, and pain of loss of role. It is important for the occupational therapist working in a hospice setting to understand all aspects of pain management, and the occupational therapy treatment strategies which can improve the quality of life and perception of pain for the hospice patient. Through presentation of case studies, the authors illustrate applications of occupational therapy assessments and interventions in respect to two hospice patients. The occupational therapy treatment strategies effected an improvement in the quality of life for these patients and consequently their perception of pain of loss of role. Occupational therapists, as part of the hospice team, play an important part in giving patients an opportunity to live out their lives in as dignified and purposeful a manner as their disease permits.