桡骨小头切除晚期并发症的原因及机制探讨

目的：研究桡骨小头切除后晚期并发症产生的原因、发病机制和预防措施。方法：对２８例桡骨小头切除术后进行２年以上随访。同时对２０例新鲜上肢标本进行生物力学检测。结果：发现桡骨小头切除术后的晚期并发症有肘外翻畸形、创伤性关节炎、桡尺远侧关节脱位等。肘关节内侧副韧带损伤、骨间膜撕裂伤和桡尺关节远侧脱位是桡骨小头切除术后引起或加重晚期并发症的主要原因。结论：桡骨小头切除时,应考虑上述三种组织损伤是否存在及对预后的影响;桡骨小头切除在青少年患者应视为禁忌     

Pigmented villonodular synovitis of the foot and ankle

BACKGROUND: Pigmented villonodular synovitis (PVNS) is a rare disease of uncertain etiology usually affecting the synovium of weightbearing joints. METHODS: We retrospectively evaluated 11 patients who were diagnosed and treated for PVNS of the ankle and foot over a 13-year period with a minimum of 2-year followup. Four patients with ankle joint PVNS and one patient with PVNS of the fifth metatarsophalangeal joint were seen initially at our institution and were treated with surgery alone. Six patients with ankle joint PVNS were referred to our institution for recurrent PVNS lesions; two of these patients were treated with excision alone, and the other four patients had surgical excision followed by radiation therapy with dosages ranging from 3600-4000 cGy. RESULTS: No recurrence was noted at a mean followup of 9 years for primary lesions and 3.5 years for recurrent lesions. CONCLUSION: Based on these results, surgical excision of primary lesions and excision with postoperative radiation for recurrent lesions are recommended.     

Elbow joint kinematics after excision of the radial head.

The contribution of the radial head to elbow joint kinematics was studied in 7 osteoligamentous elbow preparations. During unloaded flexion and extension, radial head excision induced a maximum varus displacement of 1.6 degrees with 20 degrees of joint flexion and a maximum external rotation of 3.2 degrees at 110 degrees of flexion. With application of a 0.75-Nm load, radial head excision induced a maximum laxity of 3.3 degrees at 20 degrees of flexion in forced varus and a maximum laxity of 8.9 degrees at 10 degrees of flexion in forced external rotation. No laxity was observed in forced valgus or internal rotation. The results were independent of the rotation of the forearm. This study indicates that the radial head acts as stabilizer to the elbow joint in forced varus and in forced external rotation. The results suggest that fractures of the radial head cannot be treated by simple excision without altering the basic kinematics of the elbow joint.     

A three-step technique to correctly identify the trapezium without the need for fluoroscopic imaging

Thumb pain secondary to degenerative arthritis of the carpometacarpal joint of the thumb is a common disabling condition. The key principles of successful basal joint arthroplasty involve trapezial excision, which is required for pain relief, with or without some form of ligament reconstruction. The majority of basal joint reconstructive procedures include partial or complete trapeziectomy, with and without some types of tendon transfer and ligament reconstruction and with or without tendon interposition and/or temporary wire stabilisation. When performing a trapeziectomy, it is important to identify the trapezium correctly before excising it. Excision of the incorrect bone during trapeziectomy for basal joint arthritis of the thumb has been reported within the NHS Litigation Authority database. We describe the senior author’s routinely used three-step technique to confirm the identity of the trapezium before excision. This technique has been reliably used in over 300 cases with successful excision of the trapezium without intraoperative fluoroscopy.     

A Simple Method for Identifying the Acromioclavicular Joint During Arthroscopic Procedures

Arthroscopic acromioclavicular joint excision is performed via an anterior portal and is technically demanding. We present a simple method for identifying the acromioclavicular joint during arthroscopic procedures.     

Hallux metatarsophalangeal arthroplasty in the rheumatoid forefoot

Surgical options for treatment of the hallux valgus deformity in the rheumatoid forefoot are numerous, but long-term results of many of these procedures have been less than satisfactory. Controversy exists as to whether excision or fusion is preferred for the treatment of the hallux metatarsophalangeal (MTP) joint. The role of replacement arthroplasty needs to be evaluated. The available surgical options for treatment of the arthritic first MTP joint in rheumatoid arthritis include arthrodesis, excision of the metatarsal head with or without interposition of the soft tissues, excision of the proximal phalanx, and silicone hinge replacement. This article discusses the various types of arthroplasty of the first MTP joint and the reported outcomes in the rheumatoid forefoot.     

Wrist flexion strength after excision of the pisiform bone

Diseases of the pisiform triquetral (P-T) joint and the pisiform itself are often treated with excision of the pisiform bone. The flexor carpi ulnaris (FCU) tendon inserts on the volar aspect of the pisiform, suggesting a loss of strength in wrist flexion following excision of the bone. Isometric and dynamic, isokinetical measurements were made using a strain-gauge dynamometer (Cybex II). Slight postoperative reduction of wrist flexion strength, compared with the contralateral wrist, was noted but not of clinical significance. It is concluded that one should not refrain from excision of the pisiform bone for fear of considerable strength loss in wrist joint flexion.     

桡骨头切除术后并发症分析

１５例桡骨头术获得３年以上随访，常见并发症有中酸软，疼痛及不适。患侧握力降低，肘关节伸屈和前臂旋转受限。Ｘ线发迹有提携角增大，下桡尺关节半脱位及肘关节炎。作者认为桡骨头切除应作为改善功能的最后造反少处儿童尽量避免采用此方法。     

A recurrent foot ganglion managed with extensor digitorum brevis muscle flap coverage

The case of a 42-year-old woman with a persistent ganglion cyst of the dorsolateral aspect of the foot is presented. After multiple aspirations and 4 attempts at excision, the lesion degenerated into a painful, persistently draining wound with communication to the calcaneocuboid joint. The case was treated with dissection of the lesion to the joint, excision, and coverage of the defect with an extensor digitorum brevis muscle flap. The rationale for this surgical approach and the literature regarding recurrent ganglia are discussed.     

First metatarsal-phalangeal joint arthrodesis: a biomechanical assessment of stability

BACKGROUND: First metatarsal phalangeal joint (MTP) arthrodesis is a commonly performed procedure for the treatment of hallux rigidus, severe and recurrent bunion deformities, rheumatoid arthritis and other less common disorders of the joint. There are different techniques of fixation of the joint to promote arthrodesis including oblique lag screw fixation, lag screw and dorsal plate fixation, crossed Kirschner wires, dorsal plate fixation alone and various types of external fixation. Ideally the fixation method should be reproducible, lead to a high rate of fusion, and have a low incidence of complications. METHODS: In the present study, we compared the strength of fixation of five commonly utilized techniques of first MTP joint arthrodesis. These were: 1. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical interfragmentary lag screw. 2. Surface excision with machined conical reaming and fixation with crossed 0.062 Kirschner wires. 3. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical lag screw and a four hole dorsal miniplate secured with 3.5 mm cortical screws. 4. Surface excision with machined conical reaming and fixation with a four hole dorsal miniplate secured with 3.5 mm cortical screws and no lag screw. 5. Planar surface excision and fixation with a single oblique 3.5 mm interfragmentary cortical lag screw. Testing was done on an Instron materials testing device loading the first MTP joint in dorsiflexion. Liquid metal strain gauges were placed over the joint and micromotion was detected with varying loads and cycles. RESULTS: The most stable technique was the combination of machined conical reaming and an oblique interfragmentary lag screw and dorsal plate. This was greater than two times stronger than an oblique lag screw alone. Dorsal plate alone and Kirschner wire fixation were the weakest techniques. CONCLUSIONS: First MTP fusion is a commonly performed procedure for the treatment of a variety of disorders of the first MTP joint. The most stable technique for obtaining fusion in this study was the combination of an oblique lag screw and a dorsal plate. This should lead to higher rates of arthrodesis.     

Die Akromioklavikulargelenkzyste

The acromioclavicular (AC) joint cyst is a rare sequela of complete supraspinatus tendon rupture and arthritis of the AC joint. It appears as a swelling on the AC joint and must be distinguished from tumours of the shoulder and neck region. Besides physical examination, magnetic resonance imaging is the most useful tool for correct diagnosis. As reported in the literature, therapeutic procedures include observation, aspiration, excision of the cyst with or without resection of the AC joint, and repair of the underlying supraspinatus tendon rupture. All procedures should be based on consideration of the comorbidity and recurrence of the cyst. Combinations of cyst excision and rotator cuff repair or AC resection seem to be the most promising therapeutic options. We report on a 75-year-old patient with a painless swelling over the AC joint who had suffered shoulder trauma 15 years previously.     

Saving the ankle in distal fibular giant cell tumour – A case report

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.     

The proximal interphalangeal joint in Dupuytren's disease

A precise excision of the diseased fascia corrects proximal interphalangeal joint deformity in many instances. When excision of the fascia results in a contracture of greater than 30 degrees that has not been corrected to this level by gentle manipulation, then a systematic release of the causative structures is occasionally indicated, paying particular attention to the check rein ligaments of the palmar plate and adherence of shortened collateral and accessory collateral ligaments. Postoperative physical therapy and splinting are necessary, particularly in those cases in which a joint release has been performed. These authors advise against a routine joint release. Ultimately, the failure to regain flexion may be a greater disability than the original loss of extension.     

Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision

Between June 1995 and May 1998, 37 patients underwent trapezium excision arthroplasty. Preoperative radiographic assessment for scaphotrapezoid arthritis was performed. At the time of surgery intraoperative inspection of the scaphotrapezoid joint allowed calculation of the true prevalence of arthritis as well as sensitivity and specificity of the radiographic diagnosis. The true prevalence of scaphotrapezoid arthritis was 62%. The sensitivity of the radiographic diagnosis was 44% and the specificity was 86%. Comparison of surgical results in 23 patients who underwent both trapezium excision arthroplasty and proximal trapezoid excision, with 14 patients who underwent the former procedure, only showed that there was no morbidity associated with the latter. Because of the potential that scaphotrapezoid arthritis may cause residual symptoms following trapezium excision arthroplasty, and in light of the low sensitivity of radiographs, routine intraoperative assessment of the joint is recommended so that proximal trapezoid excision can be performed if degenerative change is present.     

A new cause of trigger thumb.

We report a case of severe painful triggering in the thumb caused by intermittent locking of the interphalangeal joint by a sesamoid bone. The triggering was corrected by excision of the interphalangeal joint sesamoid bone.     

An unusual case of chondrolysis of the hip following excision of a torn acetabular labrum

Chondrolysis of the hip is a rare disorder, characterized by progressive and rapid destruction of articular cartilage from both joint surfaces resulting in secondary joint space narrowing and stiffness. The authors report an unusual case of chondrolysis of the hip following mini open excision of a symptomatic acetabular labral tear. After a symptom-free period of 1 month following the excision of the torn labrum the patient started complaining of progressive hip pain and loss of movements. The rapid deterioration of the clinical functions and concentric reduction of joint space to less than 3 mm, consistent with chondrolysis, in the absence of evidence of any other hip pathology, led to the diagnosis. Intraoperatively extensive degeneration of joint cartilage was observed. Cementless total hip arthroplasty relieved the pain and allowed return to activities. The authors suspect that the use of thermal electrocautery during labral excision may have been responsible for the subsequent chondrolysis. The case is being reported not only for its rarity but also to alert treating surgeons of keeping the possibility if this condition in mind as it can pose a diagnostic dilemma.     

Arthroscopic findings in patients with painful wrist ganglia.

The aetiology of painful dorsal wrist ganglia remains obscure. In a prospective study we investigated the link between a painful dorsal wrist ganglion and wrist joint abnormality with wrist arthroscopy before excision of the ganglion. Of 16 wrists arthroscoped 12 were abnormal, 10 had an abnormal scapholunate joint, and two had abnormal lunatetriquetral joints. We think that painful dorsal wrist ganglia, like popliteal cysts in the knee, are markers of underlying joint abnormalities. Surgeons who treat painful ganglia should be aware of a possible underlying cause so that they can target treatment more accurately, particularly in recurrent cases and those patients with persistent wrist pain after excision of the ganglion.     

Excision Arthroplasty With Interpositional Achilles Tendon Autograft: A Novel Approach to Talonavicular Joint Osteoarthritis Associated With Ankle Arthrodesis

Talonavicular joint arthritis is a great concern after ankle fusion. Although arthrodesis is the gold standard treatment for this complication, it could initiate a vicious cycle of further adjacent joint arthritis. An alternative that may delay or eliminate the need for arthrodesis is excision arthroplasty; however, there are only a few reports on its application on a talonavicular joint. We report 3 cases of excision arthroplasty with interpositional Achilles tendon autograft for the treatment of end-stage talonavicular osteoarthritis in low-demand elderly patients. In 1 patient, excision arthroplasty was performed after tibiotalocalcaneal arthrodesis, and in 2 patients, it was performed after tibiotalar arthrodesis, in which the subtalar joints were also damaged and fused simultaneously on performance of the interpositional arthroplasty of the talonavicular joint. In all cases, pain relief and functional activities of daily living improvement were achieved with this procedure. At a minimum follow-up of 1 year, no patient reported adjacent joint symptoms or flatfoot progression. These cases show that interpositional arthroplasty with Achilles tendon autograft is an effective treatment for end-stage talonavicular arthritis in patients with fused ankle and subtalar joints. This procedure was helpful in relieving pain and improving activities of daily living function in low-demand elderly patients with the preservation of movement of the talonavicular joint. Autograft was considered to be superior to other grafts with respect to availability, graft rejection, or allergy development. Fused subtalar joint resolved the concerning issues, such as flatfoot progression and muscular weakness of ankle plantar flexion, associated with this procedure.     

Fractures of the olecranon: an in vitro study of elbow joint stresses after tension-band wire fixation versus proximal fracture fragment excision

BACKGROUND: Displaced fractures of the olecranon usually require operative treatment, by either open reduction with internal fixation (ORIF) or excision of the proximal fragment. However, the relative merits of these treatment options have not been fully delineated. One treatment outcome measure of joint function is residual intra-articular stress. The purpose of this study was to evaluate the effect of these two types of olecranon fracture treatment on humeroulnar joint stress. METHODS: Eight matched pairs of fresh frozen cadaveric upper extremities were thawed; stripped of skin, muscular, and neurovascular tissue; and potted in polymethylmethacrylate. The intra-articular humeroulnar joint peak pressures were measured at 90 degrees of elbow flexion using pressure-sensitive film after application of a 0.15 kg-m torque through the remaining triceps muscle attachment. First, pretreatment (normal) pressures were obtained from the major contact regions of the humeroulnar joint. A 50% olecranon osteotomy was then performed simulating a fracture, and the elbows from each of the paired specimens were randomly assigned to one or the other of two treatment groups: ORIF (using a tension-band wiring technique) and proximal fragment excision. Joint pressures were remeasured. A two-tailed paired t test was used for statistical analysis. RESULTS: After osteotomy, the peak pressures were higher, overall, in the excision group. Comparing each posttreatment experimental group to its pretreatment (normal) counterpart revealed that the peak pressures in the distal medial and distal lateral articular subzones were significantly higher for the fragment excision group (p = 0.005 and p= 0.0008, respectively), but were not significantly different in the ORIF group (p = 0.545 and p= 0.153, respectively). CONCLUSION: The findings of this study indicate that ORIF restores the normal biomechanics of the elbow joint and proximal fragment excision results in abnormally elevated joint stresses. These elevated joint stresses may, over time, contribute to the development of elbow pain and osteoarthrosis. Therefore, ORIF should continue to be regarded as the treatment of choice for displaced fractures of the olecranon involving large proximal fracture fragments similar in size to those in this study.     

Arthroscopic findings in patients with painful wrist ganglia

The aetiology of painful dorsal wrist ganglia remains obscure. In a prospective study we investigated the link between a painful dorsal wrist ganglion and wrist joint abnormality with wrist arthroscopy before excision of the ganglion. Of 16 wrists arthroscoped 12 were abnormal, 10 had an abnormal scapholunate joint, and two had abnormal lunatetriquetral joints. We think that painful dorsal wrist ganglia, like popliteal cysts in the knee, are markers of underlying joint abnormalities. Surgeons who treat painful ganglia should be aware of a possible underlying cause so that they can target treatment more accurately, particularly in recurrent cases and those patients with persistent wrist pain after excision of the ganglion.