Journal - The Journal of hand surgery (United States )

Abstract :

PURPOSE: A retrospective review of 50 ceramic, spherical implants for the treatment of trapezial-metacarpal osteoarthritis in 49 patients assessed clinical and radiographic outcome. METHODS: Thirty-five patients returned for a clinical examination and completed an outcome survey at a mean follow-up of 3 years. A radiographic review was available for all 50 implants with a mean follow-up of 3 years. Average patient age at surgery was 59 years (35 women and 15 men). Twenty-five patients were retired and 24 were regularly employed preoperatively. RESULTS: Overall satisfaction was between "very satisfied" and "satisfied" for 32 patients, and none were dissatisfied. Twenty-nine patients rated both frequency and severity of pain as "less than before surgery" or "much less than before surgery." Average rating for thumb and hand strength was the "same as before surgery." Thumb pinch strength averaged 40 N (91% that of the opposite thumb). Postoperative thumb opposition was Kapandji stage 8 or better in 34 of 50 thumbs and stage 6 or better in patients who had an interphalangeal joint or metacarpophalangeal joint fusion. All 24 employed patients returned to work, but 2 required substantial modifications of pinch and grasp movements. Implant subsidence occurred in 47 of 50 thumbs, ranging from 1 to 13 mm. Trapezium fractures occurred in 15 thumbs. Eleven additional thumbs showed erosions and cystic changes within the trapezium or metacarpal. There was no evidence of arthritis developing in surrounding joints. In addition to adverse radiographic changes, there were 10 complications in 10 patients, including implant subluxation in 7 patients. CONCLUSIONS: Although most patients were satisfied with their function and pain relief, adverse radiographic findings were nearly universal. Implant subsidence, especially into the trapezium, was often severe, with some resulting in a trapezium fracture. Based on the radiographic outcome at this medium-term follow-up, we no longer use this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Journal - The Journal of the American Academy of Orthopaedic Surgeons (United States )

Abstract :

The ligament reconstruction technique described closely reconstructs the anatomic origin and insertion of the palmar and dorsal radioulnar ligaments. In a series of 14 patients, stability was completely restored in 12. Patients were able to return to their previous work, athletic activities, and avocations without limitations. Recovery of strength and motion was at least 85%. One patient with initial bidirectional instability and good early surgical correction developed recurrent volar instability. Another patient had persistent preoperative ulnocarpal instability and an insufficient volar rim of the sigmoid notch from a previous fracture, but the DRUJ was stabilized. Ligament reconstruction is effective for DRUJ instability but requires a competent sigmoid notch; however, it may not fully correct ulnocarpal instability.

Journal - Techniques in hand & upper extremity surgery (United States )

Abstract :

Normal wrist motion is accomplished by a complex interaction of multiple articulations involving the radius, ulna, and carpal bones. Total wrist arthroplasty cannot duplicate this intricate system, but it can potentially produce a stable, pain-free joint with functional range of motion. Achieving a functional and durable outcome requires proper patient selection, careful preoperative planning, and accurate implantation. Because arthroplasty poses greater risks than arthrodesis, low demand patients with special needs or desires for wrist motion are the best candidates. In particular, patients with arthritis involving multiple joints of the upper limbs often find tasks of daily living easier when some wrist motion is preserved. Other patients may choose arthroplasty over arthrodesis to better maintain their ability to perform vocational and avocational activities. Regardless of a patient's desire for arthroplasty, he or she must accept the lifetime of restricted activities imposed by an artificial wrist, which are similar to any other joint replacement. Complications may include infection, imbalance, implant breakage, dislocation, and loosening. Revision arthroplasty or conversion to an arthrodesis are options for the failed total wrist.

Journal - Techniques in hand & upper extremity surgery (United States )

Journal - Orthopedics (United States )

Abstract :

With the advent of newer prosthetic designs, total wrist arthroplasty provides a functional range of motion, better wrist balance, reduced risk of loosening, and better implant stability.

Journal - Instructional course lectures (United States )

Abstract :

Wrist destruction by rheumatoid arthritis adversely affects hand function and increases the risk of finger deformities. Surgical management is indicated not only for salvage of end-stage wrist deformity but to alleviate pain and reduce progression of deformity at earlier stages. Available procedures include arthroscopic synovectomy, partial and complete arthrodesis, and implant arthroplasty. Procedure selection is highly dependent on disease characteristics and patient needs.

Journal - The Journal of hand surgery (United States )

Abstract :

PURPOSE: To quantify and compare the disabilities caused by reduced and absent wrist motion using objective measurements of task performance and perceived disability, and to assess the compensatory motions of the shoulder, elbow, forearm, and trunk caused by impaired wrist motion. METHODS: A clinical study of 21 normal subjects was done to measure physical performance and to assess wrist function under conditions of reduced (30 degrees flexion and 30 degrees extension) and nearly absent wrist motion using established physical tests and questionnaires (Disabilities of the Arm, Shoulder, and Hand [DASH], Patient Rated Wrist Evaluation [PRWE], and a study-specific survey). The clinical study also measured compensatory motions of the shoulder, elbow, forearm, and trunk. RESULTS: Average times to perform the Jebsen test and activities of daily living (ADLs) test increased for both motion-restricted conditions of the wrist but did not differ significantly between the conditions. Questionnaire scores regarding function were significantly worse for both motion-restricted conditions and poorest for nearly absent motion. Average compensatory motions in the extremity and trunk statistically increased for both motion-restricted conditions but were not marked and did not differ between the conditions. High variability among subjects occurred in all physical tests and questionnaires for both motion-restricted conditions. CONCLUSIONS: Perceived disability from reduced wrist motion appeared greater than measured functional loss using common physical tests and outcome surveys.

Journal - The Journal of hand surgery (United States )

Abstract :

Fourteen patients with posttraumatic distal radioulnar joint instability were treated with a reconstruction of the distal radioulnar ligaments. The technique is anatomically accurate, is reproducible, and requires less dissection than previously described techniques. Candidates for the procedure had joint instability and an irreparable triangular fibrocartilage complex. Ten patients had bidirectional instability. Two patients had a concurrent corrective osteotomy of the distal radius for a malunion. The procedure restored stability and relieved symptoms in 12 of 14 patients at 1 to 4 years' follow-up evaluation. One patient with a deficient sigmoid notch and one with ulnocarpal ligament injury did not achieve full stability. All patients attained near full pronation and supination. The procedure is an effective treatment for an unstable distal radioulnar joint when its articular surfaces are intact and the other wrist ligaments are functional, and it can be used in combination with a distal radius corrective osteotomy.

Journal - The Orthopedic clinics of North America (United States )

Abstract :

Although not a common problem, the posttraumatic unstable distal radioulnar joint can be difficult to treat. This article focuses on the various methods for reconstruction of the unstable distal radioulnar joint. Attention focuses specifically on anatomic reconstruction of distal radioulnar ligaments. The authors' technique is presented in detail.

Journal - Instructional course lectures (UNITED STATES )

Journal - The American journal of sports medicine (UNITED STATES )

Abstract :

In the treatment of ulnar collateral ligament injuries in the metacarpophalangeal joint of the thumb, a cast or splint is often molded with the thumb and hand positioned so the patient can return quickly to a particular sport or activity. However, it is unknown whether a given position of immobilization or whether an early rehabilitation program will compromise ligament healing by causing undue tension in the ligament. To better define acceptable positions for thumb immobilization and a safe range of motion, this laboratory study measured strain in the ulnar collateral ligament at different degrees of metacarpophalangeal joint flexion. Ligament strain was found to increase with increasing joint flexion; the most significant increases in strain occurred as the joint moved from 0 degree to 25 degrees of flexion, with the dorsal portion of the ligament demonstrating greater strain than the palmar portion. Based on these results, immobilization of the metacarpophalangeal joint in excessive flexion and unrestricted early rehabilitation exercises should be done with caution and guided by the grade of injury or the quality of repair.

Journal - The Journal of hand surgery (UNITED STATES )

Abstract :

A potential injury mechanism for triangular fibrocartilage tears and ulnar styloid fractures was investigated in cadaver specimens. The distal radioulnar joint was distracted to failure, thus applying a tensile force to the triangular fibrocartilage. During distraction, strains in the triangular fibrocartilage and the anatomic site of disruption were recorded with an image analysis system. Complete avulsion of the triangular fibrocartilage from the ulnar head occurred in 7 of 10 specimens. No ulnar styloid fractures occurred. Although strains were high in the radial portion of the disk (28%), no tears occurred in the substance of the disk or at its attachment to the radius. These findings suggest that distal radioulnar joint distraction can cause avulsion of the triangular fibrocartilage. However, ulnar styloid fractures and tears within the disk are more likely caused by injury mechanisms that include shear or compressive forces. Since complete avulsions of the triangular fibrocartilage occurred without a fracture, the absence of a fracture does not rule out a destabilizing injury to the distal radioulnar joint.

Journal - The Journal of hand surgery (UNITED STATES )

Abstract :

The articular disk of the triangular fibrocartilage complex was studied using a video imaging system in a cadaveric laboratory experiment. Changes in disk configuration consistently occurred during pronation and supination and resulted in a nonuniform strain distribution that was dependent upon forearm position. Strains occurred primarily in the radioulnar axis of the disk, with dorsoanterior strains being negligible. Strains were concentrated in the radial portion of the disk and were highest with the forearm pronated. Application of a distraction load to the distal radioulnar joint to simulate the effect of axial wrist loading caused strains to increase the most in the radial portion. These findings suggest that joint distraction loading and forearm pronation are important components of the injury mechanism for the most common type of traumatic tear that occurs near the radial attachment of the disk.

Journal - The Journal of hand surgery (UNITED STATES )

Abstract :

A cadaver experiment was performed to study the effects of radial deformity on the kinematics of the distal radioulnar joint and the anatomic configuration of the triangular fibrocartilage. Radial shortening caused the greatest disturbance in kinematics and the most distortion of the triangular fibrocartilage. Decreased radial inclination and dorsal angulation caused intermediate changes. Dorsal displacement produced minimal changes. Radial deformity did not produce distal radioulnar joint dislocation. These results provide biomechanical evidence of an important relationship between radial malunion and persistent symptoms in the distal radioulnar joint.