Crossed intrinsic transfer

A retrospective analysis of the long-term results of the crossed intrinsic transfer operation is presented. Twenty-one patients (30 hands) with rheumatoid arthritis and one patient (1 hand) with systemic lupus erythematosus were examined clinically and radiographically. The average follow-up was 12.7 years. The average postoperative ulnar drift for all fingers was 5 degrees. The magnitude of ulnar drift did not increase over time. The average active range of motion for the metacarpophalangeal joints was 47 degrees and for the proximal interphalangeal joints it was 58 degrees. The average radial deviation deformity of the wrist in the resting position was 2 degrees. These variables did deteriorate with time. Extensor carpi radialis longus to extensor carpi ulnaris tendon transfer with crossed intrinsic transfer produced the same result as crossed intrinsic transfer alone. The outcomes for crossed intrinsic transfer attached to the lateral band were similar to outcomes for transfers attached to the collateral ligament of the metacarpophalangeal joint. The crossed intrinsic transfer procedure effectively provides long-term correction of ulnar drift in the rheumatoid hand.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand

A swan-neck or boutonniere deformity occurs in approximately half of patients with rheumatoid arthritis. The cause of boutonniere deformity is chronic synovitis of the proximal interphalangeal joint. Swan-neck deformity may be caused by synovitis of the metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joints. Numerous procedures are available for the operative correction of these finger deformities. The choice of surgical procedure is dependent on accurate staging of the deformity, which is based on the flexibility of the proximal interphalangeal joint and the state of the articular cartilage. The patient's overall medical status and corticosteroid use, the condition of the cervical spine, the need for operative treatment of large joints, and the presence of deformities of the wrist and metacarpophalangeal joints must also be considered when planning treatment. In the later stages of both deformities, soft-tissue procedures alone may not result in lasting operative correction.     

Foot lengthening using the Ilizarov device: the transverse tarsal joint resection versus osteotomy

The aim of the study was the evaluation of both the foot correction and foot lengthening obtained using the distraction method with osteotomies versus distraction after the transverse tarsal joint resection. Ten patients (10 feet) aged from 5 years to 24 years (average, 10.5 years) were analyzed. Seven of them were treated for severe equinovarus deformity: six of congenital and one of post-traumatic etiology. In three patients, the indication for treatment was foot shortening due to hypoplasia with tibial shortening, combined with foot deformity. Preoperative shortening of the foot ranged from 1.5 cm to 10 cm (average, 4.5 cm). In four patients, osteotomy between the tarsometatarsal and transverse tarsal joints was carried out. In two cases, 'V-shaped' osteotomy through the hindfoot and midfoot was performed. In the remaining four patients, wedge resection of the transverse tarsal joint was performed. The follow-up was a mean of 32 months (range, 12-55 months). It was observed that foot lengthening after transverse osteotomy of the midfoot is difficult and unpredictable, because of distraction at the adjacent joints level instead of osteotomy site. The greatest lengthening of the foot (mean, 4 cm) was observed in the patients with the transverse tarsal joint resection. It was concluded that the transverse tarsal joint resection following callus distraction in the place of the resected joint is the effective method for foot lengthening, which can be combined with deformity correction.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

Surgical correction of extensor tendon subluxation and ulnar drift in the rheumatoid hand: long-term results

Subluxation of the extensor digitorum communis tendons in the rheumatoid hand causes ulnar digital drift. If passively correctable, the digit may be realigned by soft tissue rebalancing and extensor centralization, which may preserve a more functional arc of motion than achieved with arthroplasty. A total of 71 centralization procedures were done in 15 rheumatoid patients with a mean age of 55 years and an average follow-up of 9 years. A distally based central-third strip of extensor tendon was used. Correction of ulnar drift deformity was from an average of 47 degrees preoperatively to 7.9 degrees postoperatively, and correction of active range of motion of the metacarpophalangeal joints was from an average of 38 degrees to 56.2 degrees. Reoperation and complication rates were low. This technique corrects and maintains ulnar drift in the rheumatoid hand. Range of motion at the metacarpophalangeal joint level is improved and converted to a more functional one by decreasing the extensor lag.     

Osseointegrated silicone implants for joint reconstruction after septic arthritis of the metacarpophalangeal joint: a 10-year follow-up.

Seven men mean age 37 years (range 24-45) who had destroyed metacarpophalangeal joints as a result of pyogenic infection underwent reconstruction of the joint with osseointegrated silicone implants. The interval from infection to reconstruction varied from 5 months to 13 years. At mean follow-up 10 (8-12) years postoperatively the titanium fixtures were all well osseointegrated. The silicone spacer had fractured in one case. The extension lag was 16 (10-20) degrees and the range of movement (ROM) 34 (30-40) degrees. Our data confirm previous observations about the successful long-term osseointegration of titanium fixtures used for the attachment of joint prostheses in the hands of patients with rheumatoid arthritis or osteoarthritis. We conclude that titanium fixtures can be used successfully to fix joint mechanisms for reconstruction of small joints after pyogenous arthritis of the hand and can be used for fixation of joint mechanisms in such cases.     

Can We Abandon Saw Wedge Resection in Lapidus Fusion? A Comparative Study of Joint Preparation Techniques Regarding Correction of Deformity,Union Rate,and Preservation of First Ray Length

The traditional joint preparation technique for Lapidus fusion involves wedge resection using a saw to achieve correction of intermetatarsal angular deformity. The main drawback of this approach is undesirable shortening of the first ray, which can predispose to second ray overload that may preclude the procedure for a subset of patients or may necessitate second metatarsal shortening osteotomy. The goal of this study was to determine whether a first ray length-preserving joint preparation technique (curette and bur) achieves equivalent correction of deformity and fusion rate without first ray shortening compared with the standard saw wedge resection technique. A retrospective review of consecutive cases from January 2007 to August 2014 identified 62 patients who underwent 65 Lapidus fusions for hallux valgus correction with crossed-screw fixation. All patients treated from 2007 to 2010 had saw wedge resection, whereas all patients treated from 2011 to 2014 had curette and bur joint preparation without use of a saw. The mean intermetatarsal angle correction was 9.06° (range 5° to 14.7°) in the saw wedge resection group and 8.11° (range 2.8° to 15.5°) in the curette and bur group, a difference that was not statistically significant. The mean amount of first ray shortening was –3.14 (range –6.1 to 0) mm in the saw wedge resection group and –0.86 (range –2.3 to 4.2) mm in the curette and bur group, a result that was statistically significant. Osseous union was confirmed radiographically at 10 weeks postoperatively in all cases. These findings suggest that first ray length can be preserved using a more conservative joint preparation technique regardless of preoperative deformity, without compromising correction of deformity or union rate.     

Hallux valgus and first ray mobility: a cadaveric study

BACKGROUND: Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device). METHODS: Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site. RESULTS: The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm). CONCLUSION: After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.     

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis. A long-term assessment

BACKGROUND: The long-term results of silicone metacarpophalangeal arthroplasty in patients with rheumatoid arthritis are uncertain. The purpose of this investigation was to evaluate the subjective, objective, and radiographic outcomes at the time of long-term follow-up. METHODS: Patients with rheumatoid arthritis who underwent simultaneous silicone metacarpophalangeal joint arthroplasties of all four fingers by one surgeon were eligible for inclusion in the study. The results of a total of 208 arthroplasties in fifty-two hands of thirty-six patients were evaluated at an average of fourteen years postoperatively. Active metacarpophalangeal joint motion, ulnar drift, and radiographs were assessed. The radiographs were reviewed for changes in bone length, erosions, and implant fractures. The Michigan Hand Outcomes Questionnaire (MHQ) was administered to the patients. RESULTS: The mean arc of motion of the metacarpophalangeal joints improved from 30 degrees preoperatively to 46 degrees immediately after the surgery but decreased to 36 degrees at the time of final follow-up. The mean extension deficit of the metacarpophalangeal joints improved from 57 degrees preoperatively to 11 degrees immediately after the surgery but worsened to 23 degrees at the time of final follow-up. The mean ulnar drift improved from 26 degrees preoperatively to <5 degrees in the immediate postoperative period and then recurred to an average of 16 degrees at the time of final follow-up. Implant fractures were associated with increased ulnar drift (p < 0.001). Bone reaction adjacent to the implant was demonstrated by bone-shortening in most patients and by erosions in 29% of the patients. One hundred and thirty implants (63%) were broken and forty-five (22%) more were deformed at the time of final follow-up. The MHQ score averaged 48 of 100 points. The patients expressed satisfaction with the function of only 38% of the hands, and only 27% of the hands were pain-free at the time of final follow-up. A greater degree of ulnar drift was associated with decreased patient satisfaction and a decreased score for the cosmetic appearance (p 相似文献   

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis

Although metacarpophalangeal joint arthroplasty is occasionally performed for joints affected by osteoarthritis, it is most often done in patients with rheumatoid arthritis. The metacarpophalangeal joint is critical for proper finger function but is the most common site of involvement in the rheumatoid hand. A thorough understanding of the anatomy, pathophysiology, and mechanics of the metacarpophalangeal joint is a prerequisite for the evaluation and treatment of patients requiring metacarpophalangeal arthroplasty. Silicone rubber implants are the most frequently used device for treatment of revised metacarpophalangeal arthroplasty. Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction.     

A Plantarflexory-Shortening Osteotomy for Hallux Rigidus: A Retrospective Analysis

This retrospective study reported the clinical and radiographic findings of a plantar-flexor-shortening first metatarsal osteotomy for treatment of hallux rigidus. Twenty-six patients (33 feet) were evaluated with a mean 34.4 months follow-up (range, 18-65 months). Assessment consisted of clinical measurements of total range of first metatarsophalangeal joint motion and radiographic measurements of first metatarsophalangeal joint space, including plantarflexion and shortening of the first metatarsal. Patients were evaluated postoperatively using the American Orthopedic Foot and Ankle Society's Hallux Metatarsophalangeal-Interphalangeal Scoring System. The mean preoperative first metatarsophalangeal joint total range of motion was 33.5 degrees (5 degrees -60 degrees ), and postoperatively increased to 72.1 degrees (50-100 degrees ), a mean increase of 38.6 degrees at follow-up (range, 25 degrees -60 degrees ) (P < .001). This range of motion was observed despite a lack of significant improvement in radiographic joint space measurements, (preoperative mean 1.26; postoperative mean 1.82). Postoperative radiographs also demonstrated 1-4 mm of plantarflexion of the first metatarsal head, and a mean 6.1 mm shortening of the first metatarsal. At last follow-up, 85% (22/26) of patients rated their result as very good to excellent, 8% (2/26) reported a good result, 4% (1/26) a fair result, and 4% (1/26) a poor result. The mean postoperative rating scale score was 78.1/100. No patient required revisional surgery for hallux rigidus. Four patients had postoperative lesser metatarsalgia, 3 of which were self-limiting, and one that resolved following surgery. The results of this study show the plantar-flexor-shortening first metatarsal to be an effective surgical treatment for hallux rigidus with reproducible deformity correction and patient satisfaction.     

Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of -13.3 degrees was converted to +13.4 degrees . The ranges of motion of the proximal and DIP joints were significantly different (Student's t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.     

Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the "classic" surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.     

The Nicolle finger joint prosthesis: a reappraisal

The Nicolle prosthesis was used to replace 101 metacarpophalangeal joints in patients with rheumatoid arthritis over a ten-year period. Mean active flexion achieved was 30 degrees. Mean ulnar deviation was 27 degrees. 4% of joints had to be removed after a mean interval of 42 months, for infection. None of the implants had fractured.     

The results of treatment of hallux valgus with subcapital osteotomy of the first metatarsal bone]

This paper presents results of wedge subcapital osteotomy of the first metatarsal bone with lateral and plantar translation of the distal fragment in 47 feet (44 women age 37-72) operated for hallux valgus deformity. Bone fragments were stabilized with Kirschner wire introduced obliquely from lateral side of the head to the shaft. Protruding out of the skin part of the wire between I and II toe was shaped parallel to the lateral side of hallux preventing from valgisation. The mean AOFAS score improved from the preoperative value of 49 points to 86 points postoperatively. Hallux valgus angle improved from the mean preoperative value of 38 degrees to 17 degrees after operation. The mean postoperative AOFAS score in the group with major deformity (over 40 degrees valgity and 14 degrees intermetatarsal angle) was 76 points. Proposed method of stabilization allows limited activity without fear of correction loss during bone healing. Clinical and radiological results are similar to other authors' results, indicating that subcapital osteotomy gives satisfactory results in correction of medium grade deformity and disappointing results in severe deformities.     

Effect of increasing distal medial closing wedge metatarsal osteotomies on the distal metatarsal articular angle

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.     

Silicone rubber implant arthroplasty of the metacarpophalangeal joint in rheumatoid arthritis: a follow-up study of 32 patients

A retrospective analysis of silicone rubber implant arthroplasty of the metacarpophalangeal joint in 32 patients with rheumatoid arthritis is reported. One hundred seven implants were followed in 37 hands for an average of 44 1/2 (12 to 120) months. Active motion of the metacarpophalangeal joint averaged 34 degrees, with a mean extension deficit of 7 degrees and a mean flexion 41 degrees. Ulnar deviation recurred to more than 10 degrees in 33 of 107 fingers (31%). Fracture of the spacer was confirmed in four joints (4%). One fracture of the proximal phalanx and one of the metacarpal head had occurred. Bone resorption around the stem or a hinge and migration of the implant were found in 26 (24%) fingers. Patient satisfaction was high; 27 patients experienced significant pain relief, the functioning of 31 hands (84%) was improved, and 28 patients (32 hands) thought that the cosmetic appearance of the hand was improved.     

A comparative study of outcome between the Neuflex and Swanson metacarpophalangeal joint replacements

This prospective double blind trial compares the clinical findings of Swanson and Neuflex metacarpophalangeal joint replacements in patients with rheumatoid arthritis, up to 2 years follow-up. There were 37 joints (10 patients) in the Swanson group and 40 joints (12 patients) in the Neuflex group. Assessments of range of movement, grip strength and hand function were undertaken in a double blind fashion, pre-operatively and up to 2 years following implantation. The mean and standard deviation of the data were calculated. A two-tailed student's t-test was used when comparing groups of data. An X-ray analysis was also undertaken to identify any implant failure. There was no significant difference between the two groups with respect to flexion and extension before surgery. At follow-up there was also no significant difference in the extensor lag, with mean extension lags of 19 degrees and 16 degrees for the Swanson and Neuflex implants, respectively. However, there was a significant difference in flexion, with mean active flexion values of 59 degrees and 72 degrees for the Swanson and Neuflex implants, respectively. There were no differences between the two groups in respect to arc of metacarpophalangeal joint motion, ulnar deviation, grip strength or the SODA function test at follow-up. At this early stage there was no evidence of any case of implant failure. In conclusion, patients who underwent Neuflex metacarpophalangeal joint replacements obtained greater flexion than those who underwent a Swanson replacement.     

The effect of the additional use of grommets in silicone implant arthroplasty of the metacarpophalangeal joints

After silicone arthroplasty of the metacarpophalangeal (MP) joint there is increasing osteolysis, subsidence and fracture of the implants in the longer postoperative term. In 44 patients with rheumatoid arthritis (54 hands) 151 arthroplasties of the metacarpophalangeal joint were assessed at a mean of 3.9 years postoperatively. In 57 arthroplasties titanium protectors (grommets) were used. There were no significant differences in the clinical outcomes with respect to swelling, correction of ulnar deviation, range of active movement and grip strength. The additional use of grommets in MP joint arthroplasty slightly reduced reactive osteolysis, protected the spacers from breakage and slightly reduced the amount of pain with only a few additional complications in the midterm follow-up.