Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis.

Twenty-one patients with symptomatic scaphotrapeziotrapezoid osteoarthritis were treated with partial distal scaphoid excision. In 12 wrists the joint defect was filled with either capsular or tendinous tissue, while in nine no fibrous interposition was done. At an average follow-up time of 29 (range, 12-61) months, 13 wrists were painfree, while eight had occasional mild discomfort. Mean wrist flexion-extension was 119 degrees. Grip and pinch strength improved by an average of 26% and 40% respectively compared with their preoperative status. Fifteen patients returned to their original jobs, while six, who were unemployed, felt unrestricted for activities of daily living. Although patient satisfaction was comparable for both types of treatment, the wrists without fibrous interposition showed significantly greater wrist flexion-extension than patients with soft-tissue interposition. Removal of the distal scaphoid resulted in a DISI pattern of carpal malalignment in 12 wrists. At follow-up, none of these wrists showed further joint deterioration due to residual malalignment.     

Proximal row carpectomy: study with a minimum of ten years of follow-up

BACKGROUND: Proximal row carpectomy is an accepted motion-sparing surgical procedure for the treatment of degenerative conditions of the wrist. However, there is little information regarding the long-term clinical and radiographic results following this procedure. METHODS: Twenty-two wrists in twenty-one patients underwent proximal row carpectomy for the treatment of degenerative arthritis between 1980 and 1992. Objective and subjective function was assessed after a minimum duration of follow-up of ten years (average, fourteen years). RESULTS: There were four failures (18%) requiring fusion at an average of seven years. All four failures occurred in patients who were thirty-five years of age or less at the time of the proximal row carpectomy (p = 0.03). The wrists that did not fail had an average flexion-extension arc of 72 degrees , associated with an average grip strength of 91% of that on the contralateral side. The patients were very satisfied with fourteen of the eighteen wrists that did not fail and were satisfied with the remaining four. The patients rated nine wrists as not painful, four as mildly painful, five as moderately painful, and none as severely painful. The average Disabilities of the Arm, Shoulder and Hand score was 9 points. Radiographs revealed no loss of the radiocapitate space in three of the seventeen wrists for which radiographs were made, reduced space in seven, and complete loss of the space in seven. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function. CONCLUSIONS: At the time of long-term follow-up, all patients older than thirty-five years of age at the time of a proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief and were satisfied with the result. Caution should be exercised in performing the procedure in patients younger than thirty-five years of age. Although degeneration of the radiocapitate joint was seen radiographically in fourteen of the seventeen wrists, it did not preclude a successful clinical result.     

Proximal row carpectomy: a motion-preserving procedure in the treatment of advanced Kienbock's disease

Kienbock's disease is an isolated disorder of the lunate bone resulting from vascular compromise to the bone. In stage IV, degenerative changes are present at the midcarpal joint, the radiocarpal joint, or both. The goal of proximal row carpectomy (PRC) is the creation of a new joint between the capitate and the radius. The aim of this prospective study was to evaluate the functional outcome after PRC in late stage Kienbock's disease. The evaluation included assessment of range of motion, grip strength, and pain reduction. Twelve wrists in 12 patients underwent proximal row carpectomy for the treatment of stage IV Kienbock's disease between 2002 and 2005. Objective and subjective function was assessed. The average length of follow-up was 2 years (range, 9 months to 4 years). There was one failure (8.3%) requiring fusion at three years. The eleven wrists that did not fail (91.7%) had an average flexion-extension are of 70 degrees, associated with an average grip strength of 80% of the contralateral side; all patients were very satisfied. The patients rated nine wrists as not painful, two as mildly painful, and one as moderately painful. Radiographs revealed reduced radiocapitate space in five and complete loss of the space in one. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function. Overall, proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief, and all twelve patients with Kienbock's disease, except one, were satisfied with the results and returned to their previous occupations. Caution should be exercised in performing the procedure in a young, heavy manual working patient.     

Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure.

Forty-three rheumatoid wrists in 43 patients with bilateral wrist involvement were treated with synovectomy of the extensor tendons and wrist joint combined with a Darrach procedure in the period from 1966 to 1986. Clinical and radiologic assessment of the wrists was carried out after an average follow-up period of 11 years, with comparison of the treated and the opposite untreated wrists. The authors confirmed what others have concluded regarding the operation: pain was generally decreased, forearm rotation increased, and wrist extension and palmar flexion changed little. Radiologically, carpal collapse and palmar carpal subluxation progressed nearly parallel to the opposite wrists, but ulnar carpal shift was much greater in the surgically treated wrists. Therefore it is suggested that some measure to prevent ulnar carpal shift, such as Clayton's tendon transfer or radiolunate arthrodesis, should be included in this operation.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

Prospective study of a new total wrist arthroplasty: short term results

We present early results (average 32 months follow-up, minimum 12 months) of a prospective study of the ReMotion? total wrist arthroplasty in a series of 20 wrists (19 patients) with end-stage arthritic wrists (of whom 13 were rheumatoid). Overall there were no intra-operative complications, dislocations or reoperations. We observed one carpal and one radial loosening--both in rheumatoid patients. Neither was symptomatic enough to warrant reoperation. In the rheumatoid group of 13 wrists there was an average of 41% clinical score improvement. According to the Meuli score there were seven excellent, five good and one poor result. In the non-rheumatoid group of seven wrists there was an average of 27% clinical score improvement. According to the Meuli score there were two excellent, two good, two fair and one poor result. In the short term follow-up of this series, the ReMotion? total wrist arthroplasty provided better results and less devastating complications than the old generation total wrist arthroplasties. Longer follow-up is needed to validate these early results.     

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.     

Hemiresection-interposition arthroplasty of the distal radioulnar joint associated with repair of triangular fibrocartilage complex lesions.

Sixteen wrists of 15 patients with traumatic triangular fibrocartilage complex tears were treated by hemiresection-interposition arthroplasty of the distal radioulnar joint combined with repair of the torn triangular fibrocartilage complex. The surgical procedure was performed to avoid impingement of the ulnar head against the reconstructed triangular fibrocartilage complex. Most of the wrists showed a positive ulnar variance. The average age of the patients was 39 years. Follow-up averaged 41 months. Complete relief of pain was obtained in 10 wrists. Slight pain persisted in 6 wrists, although it was less than before surgery. The range of motion of the wrist joint and forearm improved postoperatively. Grip strength in all wrists increased. Postoperative complications occurred in 7 wrists of 6 patients: reoperation in 2 wrists, fracture in 1, and tendinitis of the extensor carpi ulnaris in 4. All 15 patients subsequently returned to their previous occupations.     

Long-term results of Swanson interpositional wrist arthroplasty: Part II

Fifty-eight Swanson silicone interpositional wrist arthroplasties were done in 47 patients between 1974 and 1984. Thirty-nine of these original wrists were available for follow-up an average of 5.8 years after operation. This is a continuation of our study previously published in this Journal. With increased follow-up, progressive deterioration of clinical results was noted. With a follow-up of less than 2.5 years, 75% had relief of pain. After a follow-up of 4.8 years, 67% had relief of pain. Finally, with an average follow-up of 5.8 years, only 51% had relief of pain. Progressive radiographic changes are now obvious in each case compared with 70% of those cases reviewed at 4.8 years. Furthermore, we now have noted cystic changes in a significant proportion of the wrists radiographically. In several of these, silicone synovitis has been documented histologically. Our indications for this procedure have drastically narrowed.     

Stabilization of the Proximal Ulnar Stump after the Darrach or Sauvé-Kapandji Procedure by Using the Extensor Carpi Ulnaris Tendon

The Darrach and Sauvé-Kapandji procedures are considered to be useful treatment options for distal radioulnar joint disorders. Postoperative instability of the proximal ulnar stump and radioulnar convergence, however, may cause further symptoms. From October 1999 to May 2002, a total of 19 wrists in 15 men and four women, with an average age of 48.3 years, were treated by stabilizing the proximal ulnar stump with a half-slip of the extensor carpi ulnaris tendon using modified Darrach and Sauvé-Kapandji procedures. The average follow-up period was 77 months (range, 62 to 91 months). No patient complained of symptoms due to instability of the proximal ulnar stump. Grip strength improved in all wrists after surgery. Postoperative X-rays, including loading X-rays, showed improved alignment in both coronal and lateral planes. We concluded that stabilization of the proximal ulnar stump with ECU tenodesis is an effective procedure for treating distal radioulnar joint disorder after the Darrach and Sauvé-Kapandji procedures.     

The Sauve-Kapandji procedure for reconstruction of the rheumatoid distal radioulnar joint

Our experience with the Sauve-Kapandji procedure for reconstruction of the rheumatoid distal radioulnar joint is reported. Twenty-one wrists in 17 patients were followed for an average of 39 months postoperatively. Average range of motion at follow-up evaluation was pronation to 78° and supination to 86°. X-ray films demonstrated that significant ulnarward and palmarward translocation of the carpus was prevented. The Sauve-Kapandji procedure provides a stable ulnar side support in the rheumatoid wrist with distal radioulnar degeneration.     

手法间接复位掌侧锁定板固定治疗桡骨远端C3型骨折

目的 ：探讨手法间接复位后AO 2.4 mm桡骨远端锁定板联合经皮穿针固定治疗C3型（AO/OTA分型）桡骨远端骨折的临床疗效及操作技巧。方法：自2009年5月至2012年3月采用手法间接复位AO 2.4 mm桡骨远端掌侧锁定板联合经皮穿针固定治疗桡骨远端骨折AO/OTA分型C3型患者19例21腕（双侧2例）。年龄31~66岁,平均（45.3±17.4）岁;并发尺骨茎突骨折14腕,下尺桡关节不稳6腕;均为闭合性骨折;发病时间4.5~9 d,平均（6.7±3.5）d。采用Henry切口显露骨折部位,保留关节囊、韧带连续性,手法间接复位,C形臂X线透视关节面复位情况,仍存在塌陷者予以撬拨复位后桡骨远端掌侧锁定板固定。下尺桡关节发现不稳定和并发尺骨茎突骨折者均予前臂旋后位石膏托固定6周。结果：19例（21腕）获得随访,时间7~17个月,平均10.5个月。X线示患者桡骨远端骨折均达到骨性愈合,尺骨茎突骨折未愈合3例,下尺桡关节不稳0例,1例出现背侧伸肌腱激惹,内固定取出后激惹消除。术后随访观测患者掌倾角、尺偏角、桡骨茎突高度、关节面和下尺桡关节情况,按照Batra和Gupta评分标准行影像学评定：70分以下3腕,70~79分5腕,80分以上13腕。同时对患者进行主观和客观疗效评定,观测残留畸形和腕关节活动度、并发症情况等,根据Sarmiento改良的Gartland-Werley评分系统评定术后疗效：优17腕,良3腕,可1腕。结论：AO/OTA分型C3型桡骨远端骨折手法间接复位可获得良好复位效果,应用锁定板联合穿针可为其提供内固定架支撑式固定以满足早期功能锻炼要求,患腕功能预后良好。     

Kienböck''s disease — late results by non-surgical treatment : A follow-up study

Two groups of patients with Kienb?ck's disease were followed. Twenty-three wrists had been immobilised with plaster and twenty-six had no treatment. At follow up there was a marked improvement in both groups. Eighty-three percent of the wrists in the new treated group were pain free, or reported pain only on heavy work, and in the nontreated group this was valid for 77%. Examining X-rays at follow up we did not find a single wrist in which the lunate was normal or less deformed than at the time of diagnosis. In all forty-nine wrists the lunate was deformed and in 67% osteoarthrosis in the radiocarpal joint was evident. It is concluded, that Kienb?ck's disease has a naturally benign course, the remaining symptoms at follow-up might be caused by osteoarthrosis and nothing seems to be gained by rigorous immobilisation. If pain persists efficient treatment must be based on surgical methods.     

Distal ulnar recession for disorders of the distal radioulnar joint

Thirty-six wrists of 35 patients were treated with distal ulnar recession for pain and limitation of motion associated with chondromalacia of the ulnar head, triangular fibrocartilage complex tears, ulnocarpal impingement, and instability of the distal radioulnar joint. Contributing factors were positive ulnar variance in 31 wrists, fracture of the distal radius in five, sprains in 14, premature closure of the distal radial epiphysis in five, and lax ligamentous habitus in five. The ages of the patients averaged 33 years. Clinical findings were local tenderness, crepitus, and instability evident by a positive "piano key" effect. Roentgenographic findings were positive ulnar variance (29 of 36), zero ulnar variance (four), negative ulnar variance (three), positive arthrogram (11 of 19), and "forme fruste" Madelung's deformity (two). The surgical procedure is a modification of the Milch cuff resection with the use of a dynamic compression plate. Recession ranged from 2 to 13 mm (average of 4 mm). Findings at surgery included chondromalacia of the ulnar head (19), tears of the triangular fibrocartilage complex (11), and excessive mobility of the ulnar head (10). At an average follow-up of 24.5 months, results were excellent in 7 wrists, good in 21, fair in four, and poor in four. Poor results in two wrists were upgraded to good after osteosynthesis of a nonunion in one and recessional osteotomy of the radial sigmoid notch in the other. Ulnar recession offers a less destructive alternative to disorders of the distal radioulnar joint than the Darrach resection.     

Trispherical total wrist arthroplasty in rheumatoid arthritis

Thirty-four patients, with 35 trispherical total wrist arthroplasties for treatment of rheumatoid arthritis, were evaluated at an average follow-up of 9 years (range, 5 to 11 years). The average preoperative score was 25 points inasmuch as all patients had severe pain and loss of function. The average postoperative score improved to 87 points since 30 wrists were free of pain. Twenty-eight wrists rated as a good-to-excellent result. The average arc of flexion and extension improved from 35 to 50 degrees. There were no deep infections or dislocations. Two wrists required revision, one for loosening and one for persistent pain, both requiring removal of the implant and arthrodesis. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucencies in seven wrists, including seven around the metacarpal stem and one around the radial stem. The optimum results were achieved in those patients with intact extensor tendons before operation.     

The scaphotrapezio-trapezoidal joint. Part 1: An anatomic and radiographic study

To evaluate anatomic variations and distribution of degenerative changes in the scaphotrapezio-trapezoidal (STT) joint, 165 embalmed cadaver wrists were examined. An interfacet ridge on the distal scaphoid was found in 81% of the wrists and the shape of the distal joint surface of the scaphoid was classified into 3 types. Underdevelopment of the capitate-trapezium ligament was found in 15% of the wrists. A new skeletal measurement for the inclination of the joint surface of the trapezium-trapezoid in the STT joint (TT inclination) was investigated anatomically and radiographically. Degenerative changes were found in 39% of the wrists. The most common location of degenerative changes was on its ulnar aspect on the distal scaphoid and on the radial and central aspect of the trapezoid on the TT side. The presence of degenerative changes had a significant correlation with a higher anatomic and/or radiographic TT inclination and/or underdevelopment of the capitate-trapezium ligament.     

Radio-lunate arthrodesis

Radio-lunate arthrodesis has been carried out in 15 rheumatoid patients whose radiographs showed localised arthritis around the radio-lunate joint. Six patients had insertion of a Stanley-Shelley plate. The results were assessed from 1 to 3 1/2 years after operation and were excellent in nine wrists, good in three, fair in one and poor in three wrists. Continued carpal degeneration in 12 wrists suggests that long-term follow-up is required before this procedure can be generally recommended.     

Modification of the Sauvé-Kapandji procedure with extensor carpi ulnaris tenodesis

The Sauvé-Kapandji procedure is a useful treatment option for osteoarthritis of the distal radioulnar joint. Recent reports of a painful unstable proximal ulnar stump prompted us to develop a method of stabilizing the proximal stump of the ulna during the Sauvé-Kapandji procedure by using a half-slip of the extensor carpi ulnaris. Thirteen osteoarthritic wrists (8 primary and 5 traumatic) in 8 men and 5 women with an average age of 50 years were treated by this method. The length of the follow-up periods averaged 36 months. Pain improved in all patients after surgery but pain was elicited over 1 ulnar stump by direct pressure. Both pronation/supination and flexion/extension had statistically significant improvement with the exception of flexion. Grip strength improved in all wrists after surgery. Postoperative x-rays improved alignment in both coronal and lateral planes. Stabilization of the proximal ulnar stump associated with Sauvé-Kapandji procedure is a useful procedure to prevent an unstable ulnar stump in the treatment of osteoarthritis of the distal radioulnar joint.     

Limited wrist fusions

Seventeen patients had wrist fusions done for diseases other than rheumatoid arthritis of the wrist and carpal bones. Arthrodesis was done at the radiocarpal joint in five wrists and at the midcarpal joint in 12. There were 12 men and five women. Ages at the time of operation averaged 42 years. Follow-up ranged from 6 months to 5 years and 5 months, and with an average of 1 year and 10 months. Overall postoperative results were excellent in five wrists, good in seven, fair in two, and poor in three. Wrists with the midcarpal fusion fared better than those wrists with the radiocarpal fusion. Complications included one pseudoarthrosis and one rupture of the flexor pollicis longus tendon. In one of the 17 wrists new osteoarthritic changes surrounding the arthrodesed joints occurred.