Biomedical subjects
Publications and source records attributed to A J Weiland.
We report a patient with rheumatoid arthritis who developed late catastrophic failure of the hinge mechanism of her trispherical total wrist arthroplasty. This was associated with synovitis secondary to wear debris from Titanium, cement, and polyethylene which produced exuberant flexor and extensor tendon synovitis and median nerve compression.
A patient with a tear of the thumb ulnar collateral ligament and simultaneous extensor pollicis brevis and extensor pollicis longus disruptions is reported. No report of a similar constellation of injuries was found in the literature.
Trapeziectomy, ligament reconstruction and tendon interposition arthroplasty is one of the most commonly performed procedures to address pain and instability due to osteoarthritis at the basal joint of the thumb. To determine the effect of stress on first metacarpal subsidence, 15 ligament reconstruction and tendon interposition basal joint arthroplasties were evaluated after a mean follow-up of 32 months. Radiographs were obtained of the arthroplasty at rest and then with maximal effort key pinch stress, which is known to subject the first carpometacarpal joint to considerable axial compression stress. Compared with the preoperative x-rays, the first metacarpal had subsided 21% of the arthroplasty space at rest. Under stress, the first metacarpal was found to subside another 10.5% in height. No subluxation of the metacarpal base could be detected. Key pinch strength improved 17% from the preoperative strength. Tip-to-tip pinch strength improved 17% from the preoperative measurement. Grip strength improved 17% from the preoperative measurement. Grip strength was 9% greater than the preoperative grip strength. There was no statistical association between the amount of first metacarpal subsidence and follow-up key pinch, tip pinch, or grip strength. With axial compressive loading of the arthroplasty, such as in lateral pinch, there is some further proximal migration of the first metacarpal, but this is minimal and does not correlate with functional outcome.
A complete assessment of the entire patient along with a clear understanding of the progression of rheumatoid deformities is the key to success when contemplating surgical intervention for rheumatoid arthritis of the hand. The decision to perform surgery must be made following careful evaluation of the patient's signs and symptoms weighed against the potential benefits likely to be gained. The surgical plan will vary from patient to patient and should be tailored accordingly. Early in the disease process, conservative measures including pharmacologic intervention, steroid injections, and hand therapy, including splinting and wrist use modification, are indicated. Surgical intervention, however, should not be avoided for so long that the benefit of successful intervention is diminished. Hand surgery has proven to be effective in correcting deformity and maintaining or increasing function in patients with rheumatoid arthritis. The indications for synovectomy, tenosynovectomy, tendon repair or realignment, arthroplasty, and arthrodesis have been well established. Superior results are possible when surgical reconstruction is performed before tendon rupture, severe fixed contractures, subluxation, or dislocation.
A 41-year-old man developed a 3 x 4 cm wound after corrective osteotomies of his distal tibia and fibula. The wound was debrided and covered with a free gracilis muscle flap. Seven days after flap transfer, the arterial pedicle ruptured adjacent to the anastomosis. Attempted repair of the aneurysm failed and the graft was subsequently debrided. Intraoperative wound cultures grew Pseudomonas and Enterobacter cloacae, which were attributed to formation of the aneurysm.
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Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.
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PURPOSE: To evaluate the efficacy of magnetic resonance (MR) imaging in the assessment of the normal and abnormal ulnar band of the lateral collateral ligament for diagnosis of posterolateral rotatory instability. MATERIALS AND METHODS: In nine symptomatic patients and nine asymptomatic subjects, MR imaging was performed with three-dimensional gradient-recalled and fast spin-echo sequences. The nine patients had clinical symptoms suggestive of subtle elbow instability. RESULTS: The components of the lateral collateral ligament were identified; tears of the ulnar band were noted in all symptomatic patients. The anterior fibers of the lateral collateral ligament, including the annular ligament, were intact. All symptomatic patients subsequently underwent surgical exploration and reconstruction. Positive clinical findings were demonstrated at examination performed while the patients were under anesthesia. All tears of the ulnar band were confirmed. CONCLUSION: With use of appropriate pulse sequences, MR imaging is an effective tool in the preoperative, noninvasive diagnosis of posterolateral rotatory instability.
We performed a prospective study in order to assess the utility of high-resolution magnetic resonance imaging in the detection and specific localization of tears of the triangular fibrocartilage complex. Seventy-seven patients who had pain in the wrist were studied with use of a dedicated surface coil and three-dimensional gradient-recalled techniques with a field of view of eight centimeters and a slice thickness of one millimeter. The patients had pain on the ulnar side of the wrist, ligamentous instability, occult ganglia, or a combination of these. Magnetic resonance images were assessed for radial or ulnar avulsion, or both; central defects; degenerative intrasubstance changes; and complex tears of the triangular fibrocartilage complex. Partial tears were differentiated from complete tears. The findings on the magnetic resonance images were then compared with the arthroscopic findings. Fifty-seven of the fifty-nine tears that were suspected on magnetic resonance images were confirmed with arthroscopy; the two suspected tears that were not confirmed had been interpreted as small partial tears on the magnetic resonance images. With use of arthroscopy as the standard, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-seven of fifty-seven), a specificity of 90 per cent (eighteen of twenty), and an accuracy of 97 per cent (seventy-five of seventy-seven) for the detection of a tear (kappa = 0.93, p < 0.00001). Fifty-three of the fifty-seven tears were localized correctly with use of magnetic resonance imaging. With regard to the location of the tear, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-three of fifty-three), a specificity of 75 per cent (eighteen of twenty-four), and an accuracy of 92 per cent (seventy-one of seventy-seven) (kappa = 0.9, p < 0.0001). We concluded that high-resolution magnetic resonance imaging permits accurate depiction and localization of tears of the triangular fibrocartilage complex. When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist.
The necessity of tendon interposition for the maintenance of joint space after basal joint resection arthroplasty with ligament reconstruction has not been established. A prospective, randomized study was performed. In Group I (nine patients), ligament reconstruction was performed to suspend the first metacarpal in addition to placement of a rolled tendon interposition to fill the void created by resection of the trapezium. In Group II (11 patients), ligament reconstruction alone was performed, with use of a Mitek suture anchor. No tendon interposition was performed. This allowed use of a more limited incision and shorter length of tendon graft. Average followup was 23 months. There was no difference between the two groups in range of motion of the thumb, grip strength, lateral pinch strength, the ability to perform activities of daily living, or subjective satisfaction with the procedure. Two- and three-point pinch strength was statistically significantly greater in Group II. Lateral radiographs of the basal joint at followup, at rest and with pinch, showed maintenance of the joint space, and no difference between the two groups. Tendon interposition is not necessary for maintenance of joint space after basal joint resection arthroplasty if ligament reconstruction is performed.
The ability of recombinant human bone morphogenetic protein 2 to remain osteoinductive and stimulate appositional bone formation on a porous coated implant was tested in a rat quadriceps muscle pouch. Implants with or without hydroxyapatite were used to compare the effects on bone formation of two different does (23 micrograms or 46 micrograms) of recombinant human bone morphogenetic protein 2 against controls as evidenced by contact radiography, histologic examination, and backscatter scanning electron microscopic analysis. Cylindrical plasma sprayed porous titanium implants were placed bilaterally within a muscle pouch surgically created in 48 Lewis rats. Implants treated with recombinant human bone morphogenetic protein 2 formed significantly more bone than did control implants independent of the dose or presence of hydroxyapatite. In all implants with bone formation, osteoinduction via endochondral ossification began within 7 days. By 21 days, cartilage largely was replaced by bone and marrow. The results of this ectopic, nonweightbearing in vivo assay suggest that recombinant human bone morphogenetic protein 2 remains biologically active after application to a titanium implant and may be used to enhance appositional bone formation by direct application to the implant surface.
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Mirror hand is one of the rarest congenital differences of the upper extremity. Typically, there is absence of the radius, duplication of the ulna, and 7 digits in mirrored symmetry about the middle finger. We report a case of a rarer subset of hand duplication in which there is a normal radius and ulna and a hand with 8 digits. The patient underwent surgery to excise the radial 3 digits and to reconstruct the remaining radial digit to function as an opposable, 2 phalanx thumb. Wrist extension was augmented by transferring the digital extensors from the excised fingers to the radial wrist extensors.
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An anatomical study was performed to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. In ten cadaveric specimens, the radial nerve was found to cross the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. As it crossed the posterior aspect of the humerus in each specimen, the nerve had several branches to the lateral head of the triceps; however, no branches were found innervating the medial head of the triceps in the posterior aspect of any of the specimens. At the lateral aspect of the humerus, the nerve trifurcated into a branch to the medial head of the triceps, the lower lateral brachial cutaneous nerve, and the continuation of the radial nerve into the distal part of the upper arm and the forearm. Three operative approaches were performed in each specimen. The posterior triceps-splitting approach exposed an average of 15.4 +/- 0.8 centimeters of the humerus from the lateral epicondyle to the point at which the radial nerve crossed the posterior aspect of the humerus. For the second approach, the radial nerve was mobilized proximally to allow an additional six centimeters of the humeral diaphysis to be visualized. The third approach (the modified posterior approach) involved the identification of the radial nerve distally as it crossed the lateral aspect of the humerus, followed by reflection of both the lateral and the medial heads of the triceps medially. This exposure permitted visualization of 26.2 +/- 0.4 centimeters of the humeral diaphysis from the lateral epicondyle proximally. The results after use of the modified posterior approach in seven patients were also reviewed.