Andrew L. Terrono

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome

Partial resection of the distal ulna (wafer resection) has been used to treat patients with symptomatic tears of the triangular fibrocartilage complex or mild ulna impaction syndrome. In this procedure, the distal 2 to 4 mm of the distal ulnar head is resected while preserving the ulnar styloid process and the ligaments attached to it. The triangular fibrocartilage is debrided, repaired, or partially excised as necessary. The procedure is contraindicated if there is more than 4 mm of positive ulnar variance. Thirteen wafer resections of the distal ulna were performed in 12 patients. All had good to excellent results after a minimum follow-up of 1 year. Wafer resection has specific advantages and avoids many of the potential complications of distal ulna recession and ulnar head resection for patients with the conditions described. The procedure is not indicated if instability or degenerative arthritis of the distal radioulnar joint is present or if there is carpal instability.

Nonoperative treatment of anterior interosseous nerve paralysis

Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis is surgical decompression, there has been recent evidence in the neurologic literature that these lesions are examples of a neuritis. We followed 10 cases of spontaneous partial anterior interosseous nerve paralysis. All patients were seen initially with a typical history of pain. Seven had signs of other nerve involvement either on physical examination or electromyogram analysis. Eight patients treated by observation had signs of recovery in 6 months and full recovery within 1 year. Surgical decompression did not affect recovery time in the other patients. Our findings suggest that anterior interosseous nerve paralysis is a form of neuritis and can safely be treated without operation. These patients will achieve complete recovery.

Factors that determine reexploration treatment of carpal tunnel syndrome

Eighteen patients (20 hands) underwent reexploration of the carpal tunnel after a primary carpal tunnel release. The patients complained of unrelieved symptoms after their initial surgical procedures. We recommend reexploration for patients with unrelieved carpal tunnel syndrome if they have a positive Phalens test, have symptoms that cause nocturnal wakening or are exacerbated by activities, or have a short or transverse initial incision. If the incision is adequate and these symptoms are not present, we believe that reexploration will not result in a satisfactory outcome.

Camitz palmaris longus abductorplasty for severe thenar atrophy secondary to carpal tunnel syndrome

This is a retrospective review of 29 patients (33 hands) who underwent a palmaris longus transfer because of severe thenar atrophy secondary to median nerve entrapment at the wrist. The mean follow-up was 17 months. Ninety-four percent of our patients were satisfied because their thumb function improved. Twenty-six of the patients had the transfer at the time of initial release of the carpal tunnel, and three patients had the transfer when the carpal tunnel was released a second time. The transfer helps with thumb palmar abduction, and the palmaris longus is an expendable muscle for transfer.

Injury to the Deep Motor Branch of the Ulnar Nerve During Carpal Tunnel Release

Complications following carpal tunnel release have been reported to occur in 12-20%’ of cases and are numerous and varied. Neurologic complications that have been reported usually involve the palmar cutaneous or motor branch of the median nerve.’ Ulnar nerve injury during carpal tunnel release has been reported rarely. The only cases reported include cases of injury to the main ulnar palmar cutaneous nerve,* the ramus communicans3 (a normal sensory communication between the ulnar and median nerve in the palm), and a partial ulnar nerve injury in Guyon’s cana1.4 We have encountered three cases of injury to the deep motor branch of the ulnar nerve just distal to the hook of the hamate in the midpalmar space. All injuries occurred during routine carpal tunnel release performed by experienced orthopaedic surgeons and were not appreciated intraoperatively. Case Reports

Boutonniere rheumatoid thumb deformity

The boutonniere deformity is the most common rheumatoid thumb deformity. It can be classified into early, moderate, and advanced types, depending on whether the deformity is passively correctable. Fifty-three patients with 74 procedures form the basis of these recommendations. The early type treated with metacarpophalangeal joint synovectomy and extensor pollicis longus rerouting have a high recurrence rate of 64%. Metacarpophalangeal joint fusion is the procedure of choice for the moderate type with isolated metacarpophalangeal joint involvement. Metacarpophalangeal joint arthroplasty is best suited for the low-demand, older patients with borderline proximal and distal joints. Interphalangeal joint releases done with metacarpophalangeal joint fusions have a high recurrence rate and are not recommended. In advanced cases metacarpophalangeal joint arthroplasty and interphalangeal joint fusion is our procedure of choice.

Evaluation and Treatment of the Rheumatoid Wrist

Operative treatment of the rheumatoid wrist ineludes both preventive and reconstructive procedures. It is undertaken only after the problems. deformity. and needs of the individual patient have been carefully evaluated. In some patients. preventive procedures, such as a synovectomy of the nadiocanpal joint or the distal radio-ulnar joint. or both. is appropriate. In others, a reconstructive procedure. such as a tendon transfer, a reconstruction of the distal radio-ulnan joint. a partial or total arthrodesis of the wrist, on a wrist arthnoplasty, is indicated. Some patients need a combination of procedunes from both categonies”23554’ ’.

Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis

Boutonniere finger deformities occur frequently in patients with rheumatoid arthritis. The deformity consists of flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint. Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. Treatment options can then be based on the classification of the deformity; options consist of corrective splinting, injections, synovectomy, terminal tenotomy, extensor reconstruction, or salvage surgery (arthrodesis or arthroplasty).

Superficialis Sling (Flexor Digitorum Superficialis Tenodesis) for Swan Neck Reconstruction

Swan neck deformity, or hyperextension of the proximal interphalangeal joint, may occur secondary to trauma, rheumatoid arthritis, cerebral palsy, or Ehlers-Danlos syndrome, and can be treated with tenodesis of one slip of the flexor digitorum sublimis tendon. This technique has several variations, differing primarily in the specific location and method that a single slip of the flexor digitorum sublimis tendon is secured, but they all serve to create a static volar restraint against hyperextension. Options include tunneling the tendon through the bone of the proximal phalanx, attaching the tendon to the A1 or A2 pulley, or securing the tendon with bone anchors in the proximal phalanx.

Soft tissue procedures for the rheumatoid swan neck finger deformity.

wan neck deformity may occur in as many as 14% of rheumatoid patients with established disease (1). The classic swan neck deformity is easily recognized by proximal interphalangeal (PIP) hyperextension, distal interphalangeal (DIP) flexion, and metacarpophalangeal (MP) flexion (Fig. 1). The inciting lesion may occur at any one of these joints and may be exacerbated by pathology a1 the wrist (12). The most deformed joint typically reflects the location of the inciting lesion. Surgical intervention begins with the most proximal area of involvement. Oftentimes, this means surgery at the wrist or MP joint should precede surgery in the digits. The primary goal of surgical intervention in this population is improvement of function. Digital function is frequently improved with soft tissue procedures alone (3,4,11,14). The present report summarizes the soft tissue techniques that we employ to treat finger swan neck deformities. Disease progression is not uncommon, especially in the joints with early arthritic changes (3,4). However, improvement in range of motion, even if temporary, is worth the small risks of these procedures. These procedures do not “burn bridges.” Salvage procedures (arthrodesis or arthroplasty) may be performed subsequently, as indicated. These techniques are representative of a system of treatment that has evolved from 40 years of experience at a major referral center for the treatment of rheumatoid hands.