Alberto L. Lluch

Universal Total Wrist Arthroplasty: Midterm Follow-Up Study

PURPOSE We reviewed 21 consecutive patients who underwent a total wrist arthroplasty as a primary procedure between October 2001 and February 2007. The purposes of the present study were to communicate our midterm results and to compare them with previously published series. METHODS We evaluated all patients clinically and radiologically. We used the Patient-Related Wrist Evaluation a primary outcome measure. The mean follow-up was 5.5 years (range, 3-8 years). A total of 14 patients had rheumatoid arthritis, including 1 with juvenile arthritis, and 1 each had psoriatic arthritis, systemic lupus erythematosus, and undifferentiated spondyloarthropathy. Of the remaining 4 patients, 2 had grade IV Kienböck disease, 1 had degenerative arthrosis, and 1 had chondrocalcinosis. RESULTS Postoperative Patient-Related Wrist Evaluation scores averaged 24 points (SD, 21 pints) out of 100 (worst score). When the patients were specifically asked about pain and function of the arthroplasty, 20 claimed to be satisfied or very satisfied with the procedure. Two early and 3 late complications occurred. One patient had a wound hematoma and another had a superficial wound infection, both of which resolved with no further complications during the immediate postoperative period. In 2 patients, there was some osteolysis around the screw inserted into the medullary canal of the index metacarpal, but not in the trapezoid bone. One patient had a slight loosening of the distal component with subsidence on the ulnar side of the carpus. There have been no dislocations or surgical revisions of the components. CONCLUSIONS Based on our study, a total wrist arthroplasty should be considered as a good alternative to arthrodesis for patients who wish to preserve some degree of mobility of the wrist. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Dynamic changes of the transverse carpal arch during flexion-extension of the wrist: Effects of sectioning the transverse carpal ligament

The width of the carpal arch, represented in this study by the distance between the tips of two Kirschner wires--one inserted into the trapezium and another into the hook of the hamate--was measured with precision calipers in 21 patients with carpal tunnel syndrome, both before and after sectioning of the transverse carpal ligament and in different wrist positions. With the ligament intact, most of the wrists showed a decrease in the distance in both flexion and extension. The distance increased an average of 11% after sectioning of the transverse carpal ligament. The dynamic behavior of the carpal arch, however, was not substantially modified by this procedure.

Treatment of dysesthesia of the sensory branch of the radial nerve by distal posterior interosseous neurectomy

Complete injuries to the sensory branch of the radial nerve may lead to the development of an area of dysesthesia in the dorsoradial aspect of the hand. However, lesions of the radial nerve proximal to the elbow level, affecting both the sensory branch and the posterior interosseous nerve, will never develop an area of distal dysesthesia. Therefore, it seems likely that the dysesthesia observed in isolated injuries of the sensory branch of the radial nerve is transmitted to the cortical receptors through the intact posterior interosseous nerve. On the basis of the above clinical observations, we have successfully treated 43 patients with radial dysesthesia by division of the distal posterior interosseous nerve. There have been no complications or functional deficits related to this procedure.

The Sauvé-Kapandji procedure: indications and tips for surgical success.

Arthrodesis is the most reliable and durable surgical procedure for the treatment of a joint disorder, with the main disadvantage of loss of motion of the fused joint. The distal radioulnar joint can be arthrodesed, while forearm pronation and supination are maintained or even improved by creating a pseudoarthrosis of the ulna just proximal to the arthrodesis. This is known as the Sauvé-Kapandji procedure. This procedure is not void of possible complications, such as nonunion or delayed union of the arthrodesis, fibrous or osseous union at the pseudoarthrosis, and painful instability at the proximal ulna stump. All of these can be prevented if a careful surgical technique is used.

Transverse loaded pronosupination test

A new test to evaluate the ability of the distal radioulnar joint to sustain transverse loads while the forearm rotates from pronation to supination is described. Both arms were tested in 100 normal volunteers. The average weight-bearing capability of the normal unsupported forearm was 5.07 kg, equating to a force of 49.8 N. The test may be useful in the assessment of pathological conditions involving weakness of the forearm rotator muscles, with or without joint incongruity, as well as being an indirect way to assess the load-bearing capacity of radioulnar implants.

Treatment of radial neuromata and dysesthesia.

Trauma or surgical procedures involving the dorsoradial aspect of the wrist and hand can injure the sensory branch of the radial nerve (SBRN). This lesion may be responsible for the following three clinical manifestations: a sensory deficit, a painful neuroma, and an area of skin dysesthesia. The area of anesthesia tends to diminish in time because of the overlap of the intact neighboring nerves. The remaining sensory loss is not a matter of much concern to the patient, as it does not involve the working surface of the hand, and does not interfere in any way with hand function. Therefore, hypoesthesia after lesions to the SBRN seldom requires surgical treatment. All severed nerves will form a neuroma, but only sensory fibers develop painful neuromas. Neuromas are asymptomatic at rest, and are painful only under mechanical stimulation, such as contusion or traction. The neuromas that form after lesions to the SBRN are particularly troublesome because of their superficial location, as direct contusion can easily occur. These neuromas rest over a hard bony surface and are only covered by a thin layer of adipose subcutaneous tissue and skin to give protection from external impacts. This coverage hardens by the postraumatic fibrotic repairing process in the majority of cases. Another cause of pain is traction during activities that require ulnar inclination of the wrist. However, the most peculiar manifestation is the development of an area of dysesthesia after most of these lesions, which can be described as an unpleasant sensation upon normal stimuli, such as light touch, when applied to the skin innervated by the injured nerve. Dysesthesia may be the main cause of a patient seeking medical attention, because its extent and intensity does not diminish with time. This is unlike anesthesia, which does diminish with time. More than 100 methods for the treatment of painful neuromas have been proposed. The reason for their failure is the lack of understanding that neuroma formation is a physiological response after a nerve injury. A peripheral nerve lesion does not cause the death of the cell body, but just that part of the nerve fiber distal to the lesion, which will undergo Wallerian degeneration. Within 6 hours after the injury, the cell body starts to adapt, increasing its metabolic rate and shifting from production of neuroeffector substances to protein synthesis. These proteins are required for the elaboration of axoplasm, which will flow distally, trying to enter the distal endoneural tubes and eventually reach their end organs. If the regenerating axons or dendrites do not reach the nerve distal to the lesion, they continue to grow and branch in all directions, forming an irregular mass at the end of the proximal stump, the nodule known clinically as neuroma. No method, either by physical, chemical or biologic means, applied to the end of the severed nerve, has been proven to be universally successful, because only the destruction of the cell body would completely inhibit nerve fiber regeneration. The capacity of the cell body and the proximal nerve fiber to reinnervate the distal divided fiber is retained for several years, and it does not seem to diminish even after repeated injury to the proximal nerve fibers. For this reason, it seems obvious that the best way to minimize neuroma formation is by careful repair, to provide the regenerating nerve fibers the best chances to enter the empty distal endoneural tubes and reach the end organs. When the distal stump is not present, such as after amputation, or when the distal sensory deficit is clinically insignificant, as after divisions of the SBRN, a repair is not required. In these cases, the best treatment of a painful neuroma is by its translocation into an area well protected from external impacts. We believe that this “mechanical” approach to neuroma management is the most appropriate, as the neuroma is not painful at rest but only after irritation from physical forces, namely traction and pressure. This is also the recommended management by other investigators. The most peculiar manifestation after sectioning the SBRN is the development of an area of dysesthesia in the skin innervated by the sectioned nerve, mainly because Address correspondence and reprint requests to Alberto Lluch, M.D., Institut Kaplan, Paseo Bonanova, 9 08022 Barcelona, Spain; e-mail: lluch@filnet.es Techniques in Hand and Upper Extremity Surgery 5(4):188–195, 2001

Treatment of Little Finger Carpometacarpal Posttraumatic Arthritis With a Silicone Implant

PURPOSE To evaluate the short-term clinical and radiographic outcome of a flexible silicone proximal interphalangeal joint implant between the hamate and the metacarpal, to treat posttraumatic little finger carpometacarpal (CMC) osteoarthritis. METHODS We treated 3 men with a mean age of 30 years by means of a proximal interphalangeal silicone implant arthroplasty for CMC osteoarthritis of the little finger. Indications were disabling pain on the ulnar side of the hand, grip weakness, loss of CMC joint mobility, and disability for work and daily activities. RESULTS All patients were free of pain at a mean follow-up of 20 months. Transverse metacarpal arch mobility and grip strength were restored. The appearance was acceptable, without misalignment, malrotation, or shortening of the little finger ray. Radiographic evaluation showed no fractures or dislocations of the implant and no signs of foreign body reaction to silicone particles. CONCLUSIONS This technique offers the advantages of eliminating pain, maintaining length, and restoring mobility of the transverse metacarpal arch, and results in acceptable function and grip strength.

Arthroplasty of the Scaphoid-Trapezium-Trapezoid and Carpometacarpal Joints

Resection arthroplasty is an old, and yet reliable, solution for the isolated osteoarthritis (OA) of some joints of the hand. With complication low rates, this technically undemanding option is ideal for scapho-trapezial-trapezoidal joint OA, as well as for the OA of the carpometacarpal joints of the fingers. This paper reviews its indications, surgical technique, and results.