Intercarpal arthrodesis by dowel bone grafting.

Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alignment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity.     

Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis

Arthrodesis of the wrist may be indicated for a variety of conditions and can be achieved by many techniques. We have had experience with radiocarpal arthrodesis by fusion of the capitate to the radius after a modified proximal row carpectomy . The common feature in our 10 patients was a flexion deformity of the wrist. In five of the patients it was the result of spastic posturing. Five of the patients had a variety of other conditions. Primary arthrodesis occurred in all patients and the cosmetic improvement was appreciated by all patients. Functional improvement seemed to be most related to the preoperative condition. The follow-up evaluation averaged 5.4 years with a range from 6 months to 11 years.     

Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis

Degenerative joint disease affecting the radioscaphoid and radiolunate articulations while sparing the midcarpal joint may be best treated by a radioscapholunate arthrodesis. Limited wrist fusions have been shown to reliably improve pain and maintain some wrist motion. However, nonunion rates have been reported to be relatively high with traditional forms of fixation such as multiple Kirschner wires or cannulated screws. We report a technique of using two angled 2.4-mm distal radius plates to provide locking plate stabilization for radioscapholunate fusions. Our technique also features careful preparation of the planned fusion sites and the use of iliac crest bone graft. We have not had any instances of nonunion or delayed union with this technique thus far.     

Intercarpal arthrodesis for static and dynamic volar intercalated segment instability

Since 1982 seven patients with volar intercalary segment instability (VISI) have been operated on at the Massachusetts General Hospital. All had preoperative wrist pain and described a painful "clunk" with ulnar deviation. In each case there was palpable evidence of instability when the wrist was deviated ulnarly that produced a "buckling" sensation as the distal and proximal rows rotated with ulnar deviation. Arthrograms in six patients and a cineradiography in one patient confirmed that this buckling correlated with volar rotation of the lunate and triquetrum and dorsal rotation of the capitate and hamate. All the patients had some type of intercarpal arthrodesis including four capitate-lunate-triquetrum hamate (CLTH), one lunate-triquetrum (LT), one lunate-triquetrum-hamate (LTH), and one triquetrum-hamate (TH). Surgical findings included the position of the lunate that had rotated on the capitate so that it was tilting volarly and the major ligament instability was between the proximal and distal rows although ligament tears were also present between lunate and triquetrum. Arthrodesis of the proximal and distal rows provided relief of wrist pain in five of six patients. The one patient with the arthrodesis limited to the proximal row had a poor result. Of the five successful cases, the postoperative range of wrist motion was 81 degrees of extension/flexion arc (63% of the normal contralateral) and 35 degrees of radial and ulnar deviation arc (57% of the normal contralateral wrist). The grip strength postoperatively averaged 58 pounds (74% of the normal contralateral side).     

Combined radiocarpal arthrodesis and midcarpal (lunocapitate) arthroplasty for treatment of rheumatoid arthritis of the wrist

Arthroplasties for the wrist with rheumatoid arthritis are usually revised for the articulation between radius and carpus. The midcarpal joint is disregarded although it remains structurally better preserved and is therefore better suited for the preservation of stable motion. When the midcarpal surfaces are satisfactory, a radio-scapho-lunate fusion, accompanied by a midcarpal synovectomy, is an excellent procedure. When the midcarpal surfaces, particularly the head of the capitate, are also destroyed, the tendency has been to either perform a pan-arthrodesis, or to insert a wrist endo-prosthesis. For these severely unstable and destroyed wrists, a stabilization of the radiocarpal joint by arthrodesis, combined with preservation of motion at the midcarpal level by resection of the damaged head of the capitate and its replacement with a small implant has been done. This procedure has allowed all patients to retain a functional range of motion and to experience satisfactory relief of pain.     

Finger metacarpophalangeal joint disease: the role of resection arthroplasty and arthrodesis

When finger MP joint arthrosis exists, it is indeed infrequent that implant arthroplasty is not the most optimal treatment alternative. When post-traumatic bone loss or postinfectious dysfunction require surgical intervention, however, the hand surgeon may need to consider the options of resection arthroplasty and arthrodesis. So long as the MP joint is pain-free and relatively stable, most patterns of functional prehension can be maintained.     

Intercarpal arthrodesis in the management of chronic carpal instability after trauma

A retrospective review of five patients with chronic carpal instability resulting from trauma suggests that this condition can be successfully treated by intercarpal arthrodesis. Scaphoid-lunate fusion was used to treat chronic dorsal intercalary segment instability, while scaphoid-capitate-lunate fusion was used to treat chronic palmar intercalary segment instability. Results after intercarpal arthrodesis were consistently good, with restoration of painless function, preservation of grip strength, and a high degree of patient satisfaction. Although a fibrous union was obtained in two of the three scaphoid-lunate arthrodeses, this did not prejudice a good clinical outcome. These results compare favorably to those with other treatment modalities, including ligamentous reconstructions with tendons. Based on these findings, a more extensive clinical trial of intercarpal arthrodesis to treat chronic carpal instability appears warranted.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy

PURPOSE: The purpose of this study was to assess wrist pain, range of motion, and the presence of radiographic midcarpal degenerative joint disease (DJD) in patients who had a distal scaphoidectomy in association to a radioscapholunate (RSL) arthrodesis and to compare these findings with prior studies of patients with only an RSL fusion. METHODS: Sixteen patients with radiocarpal DJD treated by RSL arthrodesis and distal scaphoidectomy were evaluated retrospectively for pain relief and range of motion at an average follow-up period of 37 months (range, 12-84 mo). Radiographs were assessed for the presence of secondary radiographic midcarpal DJD. RESULTS: Complete pain relief was obtained in 10 patients, 3 patients complained of slight pain during strenuous loading, and 3 patients had occasional pain with regular activities. The average postoperative ranges of motion were 32 degrees of flexion, 35 degrees of extension, 14 degrees of radial deviation, and 19 degrees of ulnar deviation. Two patients exhibited secondary midcarpal DJD. These results are significantly better compared with those previously published about RSL arthrodesis alone in terms of residual pain and decrease of wrist radial deviation and flexion. CONCLUSIONS: Patients who require an RSL arthrodesis for the treatment of severe localized radiocarpal DJD appear to have less pain and to retain more flexion and radial deviation if the distal scaphoid is excised concomitantly. This associated procedure also may help prevent secondary midcarpal DJD.     

Flexible implant arthroplasty of the radiocarpal joint

The radiocarpal, distal radioulnar, and intercarpal joints can be affected individually or in combination. Selection of the appropriate treatment method is based on accurate evaluation of the extent and severity of involvement. The durability of flexible implant resection arthroplasty of the radiocarpal joint has been further enhanced by the use of titanium grommets to protect the implant midsection, by secure dorsal and palmar capsuloligamentous reconstruction to restrict the mobility of 30 degrees flexion/30 degrees extension and 10 degrees ulnar/10 degrees radial deviation, by 6 weeks' postoperative immobilization, and by avoidance of abusive hand usage.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis: long-term follow-up

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22-28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.     

四角融合术对桡腕关节内应力的影响

目的 比较四角融合前后桡腕关节内应力值、受力面积和平均压强的变化,研究四角融合术对桡腕关节内应力的影响.方法 8例新鲜正常腕关节标本通过夹具固定于支架上,将150 N负荷按比例加载于经过腕关节的各肌腱上,调节腕关节于不同位置,测量桡舟、桡月关节内的应力大小、受力面积和平均压强,测量结束后对标本行四角融合术,以同样方法进行测量,比较四角融合前后数据,分析四角融合对桡腕关节的影响.结果 正常时,桡舟关节内受力面积占其关节面的3%～43%,桡月关节为6%～30%;四角融合后,桡舟关节为0%～30%,桡月关节为7%～32%.正常时和四角融合后,桡腕关节内的应力值、受力面积和平均压强随腕关节位置的变化而呈现相似的变化趋势,但正常时应力柔和渐变,四角融合后明显剧烈而僵硬.结论 正常桡舟、桡月关节内有各自独立的应力承受区,其面积不等于实际的关节面积,根据腕关节的位置不同而有变化;四角融合后桡腕关节内的应力变化较正常时剧烈、僵硬,长期作用可能使腕关节内软骨发生退行性变化.     

Knee arthrodesis for failed total knee arthroplasty

The use of arthrodesis to salvage failed total knee arthroplasty is reviewed in nine patients. Prosthetic failure was due to infection in six cases, aseptic loosening in two cases, and instability in one case. The techniques of arthrodesis included six Hoffman external fixators, two fluted intramedullary rods (3M-Orthopedic Products Division, St Paul), and one pulsing electromagnetic field stimulator. Arthrodesis was successful in eight of nine patients, averaging 5.4 months to union. All eight patients resumed a painfree functional level of activity. Meticulous surgical technique and appropriate method of arthrodesis are emphasized.