Recent Injuries of the Ligaments of the Knee Joint in Children

The author's series comprises 17 cases of fresh ligamental injuries to the knee joint in growing individuals, i.e., patients with residual epiphyseal cartilage.

A clear difference seems to exist between the ligamental injuries to the knee joint of the adult and those of the child in such a way that children exhibit isolated ruptures to a greater degree. Combined injuries in the strict sense did not occur in the author's series. The general picture is dominated by injuries to the anterior cruciate ligament (11 cases) and these are all located to the tibial attachment and possess bony fragments.

Although in adults the tendency is towards a reconstruction and suturing of the ligamental injury in the acute stage we were more conservatively minded with child patients.

Only 4 of the 17 cases were given operative treatment, and in all cases an anterior cruciate injury was involved.

The collateral ligamental injuries in this series were all of the partial type, localised to the femoral attachments. We did not see in a fresh condition any total injury of the type relatively common in adults. However, we encountered the residual condition of a non-treated injury to the medial collateral ligament with considerable consequences. This case is reported, hut does not belong to the series.

Sixteen of the seventeen cases were followed-up and it was found that on isolated occasions one individual had very slight subjective discomfort from the injured knee when playing football, while the others declared themselves to be completely free from subjective trouble. In two cases a slight quadriceps atrophy was ascertained, and one of these two exhibited slightly increased “forward drawer” by comparison with the healthy side.

We interpreted the result to mean that it was correct to treat these injuries more conservatively in children than in adults.     

Partial arthrodesis of the wrist: An investigation in cadavers

Partial arthrodesis of the wrist was performed on six cadavers in order to study the residual excursion of the wrist. Arthrodesis between the radius and scaphoid left 40 per cent extension/flexion and 61 per cent radial/ulnar deviation. Arthrodesis between the radius, scaphoid and lunate left 36 per cent extension/flexion and 59 per cent radial/ulnar deviation. Arthrodesis between the capitate, scaphoid and lunate left 59 per cent extension/flexion and 91 per cent radial/ulnar deviation.     

Effect of static wrist position on grip strength

Background:

Grip strength after wrist arthrodesis is reported to be significantly less than normal. One of the reasons suggested for this decrease in grip strength is that the arthrodesis was performed in a suboptimal position. However, there is no consensus on the ideal position of wrist fusion. There is a paucity of studies evaluating the effect of various fixed positions of the wrist on grip strength and therefore, there is no guide regarding the ideal position of wrist fusion. The authors′ aim was to determine the grip strength in various fixed positions of the wrist and subsequently to find out in which position of wrist fusion the grip strength would be maximal.

Materials and Methods:

One hundred healthy adults participated in the study. For the purpose of this study, the authors constructed splints to hold the wrist in five different fixed positions: 45, 30 and 15 degrees of wrist extension, neutral and 30 degrees of wrist flexion. The grip strength in all the participants was measured bilaterally, first without a splint and then with each splint sequentially.

Results:

The average grip strength without the splint was 34.3 kg for right and 32.3 kg for the left hand. Grip strength decreased by 19–25% when the wrist was splinted. The maximum average grip strength with a splint on was recorded at 45 degrees of extension (27.9 kg for right and 26.3 kg for left side). There was a gradual increase in the grip strength with increase in wrist extension but the difference was not statistically significant (P = 0.29). The grip strength was significantly less in flexed position of the wrist (P < 0.001).     

Wrist arthrodesis using a Synthes wrist fusion plate

Thirty-nine patients were retrospectively reviewed after a wrist arthrodesis using a Synthes wrist fusion plate and iliac crest bone graft. Information was obtained from review of patient files, a questionnaire to assess pain, function and work status, and clinical assessment of grip strength, forearm rotation and fingers motion. All wrist fusions united except that the index carpometacarpal joint failed to unite in one patient. Thirty-seven patients were satisfied with the procedure, noting a reduction in wrist pain after fusion, but all reported some limitation of function. The wrist fusion plate was removed in six patients and a further four patients experienced minor symptoms over the dorsal aspect of the middle finger metacarpal.     

Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients

Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m², depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.     

Management of the scaphoid during four-corner fusion-a cadaveric study

PURPOSE: To examine the effects of scaphoid retention, inclusion, and excision on wrist motion and radiolunate contact characteristics in a cadaveric model after simulated 4-corner fusion with rigid internal fixation. METHODS: Seven fresh-frozen cadaveric upper extremities were examined. For all surgical manipulations the motion was measured and contact characteristics were assessed using ultra-low prescale pressure-sensitive film. RESULTS: Compared with the intact specimen, simple 4-corner fusion with scaphoid retention led to a significant decrease in extension, radial deviation, and ulnar deviation, but no change in radiolunate contact characteristics. After 4-corner fusion there was no significant difference in motion or radiolunate contact characteristics between scaphoid retention and scaphoid inclusion. After 4-corner fusion scaphoid excision allowed significantly greater radial deviation compared with scaphoid retention and scaphoid inclusion. Compared with the intact specimen 4-corner fusion with scaphoid excision also led to a significant increase in radiolunate contact area and mean contact pressure. CONCLUSIONS: When performing 4-corner arthrodesis in the absence of radioscaphoid arthritis, scaphoid excision may improve motion at the cost of increased mean radiolunate contact pressure.     

腕关节部分融合治疗退行性腕关节炎的疗效

目的评价头骨、月骨、三角骨及钩骨四关节融合治疗退行性腕关节炎的效果。方法1997年7月～2002年12月应用腕关节部分融合术创伤性腕关节炎治疗20例,术后随访15个月,随访检查包括术后腕关节疼痛程度、腕关节活动度、握力以及患侧X线检查。视觉模拟评分法评价疼痛程度。腕关节总体功能评价采用Krimmer腕关节评分表。结果腕疼痛值静息时为2.1,用力后为5.3;屈伸活动度为64°(对侧126°);尺桡偏为30°(对侧57°);平均握力为24kg(对侧40kg)。Krimmer腕关节评分值为67。X线检查头、月、三角及钩骨均融合。结论腕关节部分融合后能保存腕关节部分功能,是治疗退行性腕关节炎有效的方法。     

Partial Carpal Arthrodesis as Treatment of Local Degenerative Changes in the Wrist Joints

Twelve patients with partial arthrodesis of the wrist were re-evaluated. The follow-up time ranged from 1 year 2 months to 13 years. In 10 cases the indication for operation was isolated scapho-trapezial osteoarthritis, and in two cases isolated degenerative changes following perilunar luxation. Bony union was achieved in 9 cases, and these patients experienced relief of pain. One of the patients with non-union did not improve at all, another used a stabilizing bandage at work and the third had no complaints.

Degenerative changes in the adjacent joints of the wrist were not seen. A disadvantage of this operation seems to be the long period of treatment.     

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-Wire and Circular Plate Fixation

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.     

Pisotriquetral arthrodesis as an alternative to excision for pisotriquetral instability in high-demand patients: a case report in a gymnast

A gymanast developed ulnar wrist pain caused by pisotriquetral instability. Pisotriquetral arthrodesis resulted in pain relief and sufficient functional return to allow her to return to gymnastics. Pisotriquetral arthrodesis is a feasible alternative to pisiform excision worth consideration in high-demand patients with symptomatic pisotriquetral instability or arthrosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level V.