Carpal replacement or arthrodesis?
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Arthritis↗
Biomedical subjects
R G Eaton
Publications and source records attributed to R G Eaton.
A Darrach procedure for distal ulnar pathology derangements.
Despite technologic advancements including arthrography, arthroscopy, and magnetic resonance imaging, pain in the distal radioulnar and ulnar carpal joints continues to baffle clinicians. Before the wide use of these diagnostic tests, the authors based their diagnosis of distal ulnar carpal joint derangement on the physical examination, history, and plain film roentgenographs. For eight patients who did not respond to conservative measures, a limited Darrach procedure was performed with highly satisfactory results. The specific technical aspects of this procedure are described. The postoperative results of the patients are presented with one to eight years of follow-up evaluation.
Adult↗
Surgical management of basal joint disease of the thumb.
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Aged↗
The Darrach procedure defended: technique redefined and long-term follow-up.
Thirty-three patients with pain and decreased range of motion after traumatic derangement of the distal radioulnar and ulna-carpal joint were treated with a modified Darrach distal ulnar resection. Their ages ranged from 22 to 75 years (average, 50 years). Twenty-seven patients had Colles' or other distal radius fractures. Seven patients had ulnar resection for treatment of distal ulnar-carpal derangement. Follow-up averaged 54.4 months. The patients showed an average increase in extension of 58% and flexion increased by 40% (p less than 0.01). Pronation increased by 40% and supination increased by 60% (p less than 0.01). Average grip strength increased by 38% (p less than 0.05). Ninety-one percent good or excellent results were achieved with this procedure. The Darrach resection can predictably provide pain relief while improving strength and motion when attention is paid to minimal bony resection and meticulous soft tissue reconstruction.
Adult↗
Predictive factors in the non-surgical treatment of carpal tunnel syndrome.
To identify which patients are likely to respond the medical management of carpal tunnel syndrome, 331 hands in 229 patients were evaluated. They were then treated with a wrist splint and anti-inflammatory medication. Follow-up averaged 15.4 months (minimum six months). Treatment was successful in 18.4%. Statistical evaluation identified five factors which were important in predicting response to treatment: age over 50 years, duration over ten months, constant paraesthesiae, stenosing flexor tenosynovitis, and a Phalen's test positive in less than 30 seconds. When none of these factors was present, two-thirds of patients were cured by medical therapy. 59.6% of patients with one factor, 83.3% with two factors, and 93.2% with three factors failed. No patient with four or five factors present was cured by medical management.
Adrenal Cortex Hormones↗
Surgical treatment of infections and lesions of the perionychium.
This article will discuss acute and chronic bacterial, viral, and fungal infections involving the perionychium. Special emphasis will be placed on the surgical treatment of these entities including the surgical approach to subungual tumors and the technique of total onychectomy.
Acute Disease↗
Fascial implant arthroplasty for treatment of radioscaphoid degenerative disease.
Twenty patients were evaluated up to 9 years (average, 3.8 years) after a hemiscaphoid fascial arthroplasty. All were men. Twelve had a chronic scaphoid nonunion, six had radioscaphoid arthritis from chronic scapholunate advanced collapse deformity, and two had irreducible transscaphoid perilunate dislocations. The degenerated or impinging portion of the scaphoid was replaced by a slightly oversized fascial implant; 4 being constructed of autograft and 16 of allograft fascia. Postoperative motion included a 30 degree or 73% gain in extension and a 19 degree or 38% gain in flexion, producing an overall 140 degree average arc motion. Grip strength increased 17% after operation. Pain was completely or dramatically relieved in all but one patient. All other patients returned to their preoperative occupations.
Adult↗
Thumb metacarpophalangeal capsulodesis: an adjunct procedure to basal joint arthroplasty for collapse deformity of the first ray.
Thirteen patients had thumb metacarpophalangeal (MP) capsulodesis in conjunction with basal joint arthroplasty. The indication for capsulodesis was an MP hyperextension deformity of at least 30 degrees. The minimum follow-up period was 12 months, and the average follow-up was 39 months. Nine patients had an excellent result, three had a good result, and one patient had a result that was rated as fair. Ten patients had complete correction of the MP hyperextension deformity. The average increase in pinch strength was 50%. This procedure enhances the result of a basal point arthroplasty by improving the transmission of force along the thumb ray and by correcting the metacarpal collapse, which produces dorsal subluxation stress on the metacarpotrapezial joint.
Adult↗
Ligament reconstruction for the painful "prearthritic" thumb carpometacarpal joint.
An extraarticular ligament reconstruction to stabilize the painful, hypermobile trapeziometacarpal (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the thumb metacarpal has been performed in 25 "prearthritic" (Stage I) and 17 minimally involved (Stage II) basal joints. At an average follow-up examination of 5.2 years, 100% of the Stage I patients had achieved good or excellent results, having little or no pain with return of strength and stability. Eighty-two percent of Stage II patients had similar results. Intractable pain was the primary surgical indication. Pain was dramatically relieved in all Stage I cases and in 70% of the Stage II cases. The presence and degree of crepitus correlated closely to the result and was a good prognostic indicator. Direct inspection of both the basal and scaphotrapezial joints is essential to determine whether ligament reconstruction or another surgical procedure is the procedure of choice. The procedure was particularly useful in patients with untreated Bennett's fractures. Follow-up roentgenograms showed no further degeneration, suggesting that the procedure was reliable, reproducible, and durable, and that it might even retard future joint degeneration.
Adolescent↗
Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment.
Painful arthrosis of the basal joints of the thumb covers a spectrum of arthritic disease. The painful hypermobile thumb with articular cartilage preserved requires an entirely different type of treatment than does the similarly painful basal joint, which has stiffness and degeneration of more than one facet of the trapezium. By careful radiographic evaluation of the trapezial articulations, particularly in the lateral projection, a reasonable set of radiographic guidelines for staging of the degenerative process can be provided. One must be prepared to adjust this preoperative staging should direct inspection of the articular surfaces at surgery indicate more damage than perceived on the radiograph. Once the ultimate staging of the disease has been established, the means of treatment is considerably simplified and the multiple procedures that have been proposed for "basal joint arthritis" can be applied more accurately.
Arthroplasty↗
Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb.
Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.
Adult↗
The dangerous chip fracture in athletes.
Chip of avulsion fractures in the hand range in severity from dorsal cortical avulsion of the carpal triquetrium to Bennett's fracture dislocation. Recognition of the fragment's size, displacement, and relationship to an articular surface is essential for proper management. Accurate roentgenograms play a key role in this evaluation. The hands of athletes have special requirements for strength and dexterity and can ill afford the casual diagnosis and frequent undertreatment of these chip fractures that represent articular surfaces.
Adolescent↗
Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment.
An extra-articular ligament reconstruction to stabilize the thumb carpometacarpal (CMC) (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal has been performed on more than 100 patients since 1967. This study reviews the first 50 consecutive reconstructions with an average follow-up of 7 years. Intractable pain was the primary indication for surgery. Each joint was examined both pre and postoperatively and rated as a stage I through stage IV according to the radiographic appearance. Of the patients with zero or minimal articular changes (stages I and II), 95% achieved good or excellent results because of having little or no postoperative pain. Of the patients with moderate to advanced degenerative changes (stages III and IV), 74% achieved good or excellent results. All stage I cases and 82% of stage II cases were free of recognizable degeneration on follow-up radiographs up to 13 years postoperatively. These findings suggest that ligament reconstruction that is now recommended only for stage I or stage II disease will restore stability, reduce pain, and possibly even retard joint degeneration in a large proportion of patients with painful instability of the thumb CMC joint.
Finger Joint↗
Closed reduction and internal fixation of proximal phalangeal fractures.
Displaced fractures of the shaft of the proximal phalanx can lead to marked deformity and disability when poor results are obtained. Despite the attention popular concepts of open reduction and internal fixation have received, a less invasive technique has been our standard approach. A prospective study of closed reduction and percutaneous Kirschner wire fixation in 100 consecutive fractures yielded good or excellent results in 90% of cases when treated within 5 days of injury.
Finger Injuries↗
Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study.
The accuracy of radiographic evaluation of the pantrapezial joints and the anatomic incidence of pantrapezial arthrosis, were studied by comparing radiographs with anatomic dissections of 68 cadaver hands. When the trapezium-thumb metacarpal joint demonstrated degenerative changes, multitrapezial joint changes were noted in 73% radiographically, but in only 46% anatomically. The major reason for this discrepancy was a radiographic misinterpretation of the nature of osteophytes near the trapezium-index metacarpal joint. Anatomic changes of degenerative joint disease were noted in 60% of the trapezium-thumb metacarpal joints and 34% of the trapezium-scaphoid joints. Degenerative joint changes were rare in the trapezium-index metacarpal and trapezium-trapezoid joints. Routine anteroposterior, lateral, and oblique radiographs of the hand cannot be depended upon to provide adequate visualization of all the trapezial joints.
Aged↗
Volkmann's ischemia.
The posttraumatic syndrome of Volkmann's ischemia and infarction is the end result of compromise of muscle perfusion within the osteofascial compartments of the forearm. The "closed space" arrangement as well as the particular neurovascular anatomy make the flexor forearm muscles particularly susceptible to the cyclic derangement of blood flow, which ultimately results in muscle ischemia and infarction. Only strong clinical awareness will allow appropriate early diagnosis and treatment by surgical decompression. Fasciotomy and epimysiotomy serve to interrupt the cycle. The successful treatment of Volkmann's ischemia requires an understanding of the pathophysiologic mechanisms at work, an appreciation of the subtleties of the clinical presentation, and strong grounding in the details of forearm anatomy and techniques of surgical decompression.
Adult↗
Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years' experience.
In 10 years 24 patients had a volar plate advancement arthroplasty for acute or chronic fracture dislocations of the proximal interphalangal joint. Seven were done within 6 weeks of injury, 17 at 6 weeks to 2 years following injury. Final ranges of motion averaged 95 degrees for the former and 78 degrees for the latter group. Radiographs frequently demonstrated a marked remodeling of the disrupted contour of the joint surface of the middle phalanx.
Adolescent↗
Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling.
Sixteen elbows of fourteen patients were analyzed five to sixty months after treatment for ulnar neuritis or neuropathy by anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling to maintain the anterior position. This procedure creates a septum in the mid-lateral plane that lies posterior to the transposed nerve at the level of the medial epicondyle. Unlike previous procedures, no structure other than subcutaneous fat is located superficial to the nerve. Seven patients were baseball pitchers who had experienced transient but severe ulnarnerve paresthesias during the act of throwing. Of the sixteen extremities only one, the limb of a severely diabetic patient with bilateral ulnar neuropathy, was not relieved of preoperative complaints. There were no complications. The procedure is simple, postoperative immobilization is needed for only a brief period, and rehabilitation is rapid.
Adolescent↗