Christian Grimsgaard

Complications in knee arthroscopy.

All simple arthroscopic procedures during 1999 through 2001 performed at Baerum community hospital were retrospectively examined. Procedures were excluded when being part of more complex procedures. A total of 876 procedures performed on 785 patients were left for examination. Complications were registered from the patient record and all received a written questionnaire or phone call. The answer was obtained from 97.6%. The overall complications rate was low, giving total of 5.00%. A total of 0.68% of the complications had therapeutic consequences. There were two superficial infections, one thromboembolic event/pulmonary embolus and one reoperation due to scar tissue. Other complications were considered minor, and had none or little consequence for the patient comprising preoperative bradycardial episodes, asthmatic events, subcutaneous infusion of total intravenous anaesthetics (TIVA), instrument breakage and conversion to arthrotomi. Postoperatively registered complications included swelling, haemarthros, portal bleeding and fistulation, temporary sensory loss and longstanding pain. Duration of surgery was the only predicting factor for postoperative complications. Simple arthroscopic surgery is safe and has few serious complications. The use of TIVA or tourniquet does not increase the morbidity or complication rate, and prophylaxis against thromboembolism was not necessary.

Long-term Results of Scaphoid Nonunion Surgery: 50 Patients Reviewed After 8 to 18 Years

Objectives: Untreated scaphoid nonunions are a hazard to the wrist, resulting in deteriorating function and radiologic degenerative changes with increasing time. Long-term results after surgery of scaphoid nonunion reporting clinical, radiologic, and subjective outcomes are scarce. Design: Retrospective follow-up study. Patients: From 1990 to 1998, 53 patients were operated on for persistent scaphoid nonunion; three patients were excluded from the follow-up (one expelled foreigner, another died of an unrelated cause, one never appeared after surgery), leaving 50 patients eligible for follow-up. Intervention: All patients were operated on with open reduction and internal fixation; the majority also received a bone graft. Main Outcome Measurements: Radiology and computed tomography verified union, degenerative wrist changes, and final salvage treatment. Range of motion, grip strength, key pinch, and subjective outcome (QuickDASH, visual analog scale). Results: Fifty patients were followed up after a mean of 12.2 years (standard deviation [SD], 3.0), 47 by clinical and radiologic examination; three were interviewed by telephone and completed QuickDASH and visual analog scale forms. Union was achieved in 45 of 50 scaphoids and an additional two after a second attempt. Five patients (one persistent and four healed nonunions) underwent salvage procedures. Grip strength (41 vs 45 kg, P = nonsignificant), key pinch (11.5 vs 12.4, P = nonsignificant), and active range of motion (186° vs 214°, P < 0.001) were slightly reduced compared with the uninjured side. The subjective outcome was good (mean visual analog scale = 7, mean QuickDASH = 9.1). Minor degenerative changes were seen in nine wrists at surgery and 22 at follow-up. Conclusion: Healing of a scaphoid nonunion provides long-term pain relief, excellent wrist function, and halts degenerative changes in the majority of patients. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

SCAPHOID NON-UNIONS, WHERE DO THEY COME FROM? THE EPIDEMIOLOGY AND INITIAL PRESENTATION OF 270 SCAPHOID NON-UNIONS

Scaphoid injury and subsequent non-union is a well documented and researched subject. This article gives an overview of the epidemiology and results of the patients we have treated for scaphoid non-union at a University Hospital. 283 scaphoid non-unions in 268 patients (83% men) were operated upon, 230 as a primary and 47 as a secondary. The median age at time of surgery was 27 years. One-third of the non-unions were located in the proximal part of the scaphoid and the remaining two-thirds in the middle part. Of the 146 patients (55%) who contacted a doctor at the time of injury, 53 fractures where diagnosed (20%). Fourteen (5%) were operated primarily while 39 (15%) (seven dislocated) were immobilized in plaster casts. Thirty-two (12%) were under the age of 16 at the time of injury. The average time from the injury to the initial non-union surgery was 1.5 years with 2.8 years to the second procedure. The risk of osteoarthritis increased time from injury to surgery (both primary and secondary procedures). The greatest potential for the reduction of scaphoid non-union is an increased awareness amongst younger men. There is also potential for improved accuracy in the diagnosis of scaphoid fractures (better clinical tests, the use of radiographs, CTs and MRIs) in order to identify the fracture and evaluate dislocation at the initial injury. Early diagnosis and treatment of fractures and non-unions will reduce the development of degenerative wrist changes.

Supracondylar fractures with circulatory failure after reduction, pinning, and entrapment of the brachial artery: excellent results more than 1 year after open exploration and revascularization.

Objectives: Neurovascular injuries in children with dislocated supracondylar humeral fractures are not uncommon. Closed reduction and pin fixation usually will restore the circulation. In some patients, there is still compromised circulation and a neurologic deficit, and they are treated with open exploration and microvascular reconstruction. We have investigated the clinical and functional outcome more than 1 year after the injury in this most serious group of patients. Design: Retrospective follow-up study. Patients: During 2001 to 2007, five patients were referred to our department with a pale, pulseless hand and circulatory impairment with absent or slow capillary refill after primary treatment with closed reduction and cross pinning at their local hospital for Gartland Type III supracondylar fractures. Two of the patients also had clinical signs of nerve injury. Intervention: All were reoperated on with open exploration and release of the entrapped brachial artery. Vascular reconstruction was performed in four patients (vasodilating agent was sufficient in one patient) and release of the median nerve from the fracture in two. One of these two also had a Kirschner wire pierced through the ulnar nerve. All fractures were rereduced and cross-pinned. No intra- or postoperative complications were seen. Outcome/Results: At follow-up more than 1 year after the injury, all patients exhibited normal and symmetric function in their upper extremities, including circulation, neurologic status, range of motion, grip strength, and key pinch strength. Clinical and radiologic appearance was normal. Conclusion: Pulseless arms after repositioning of dislocated supracondylar humeral fractures are a medical emergency. After open release and, if necessary, microvascular reconstruction of vessels and nerves, fracture reduction, and fixation, excellent clinical long-term outcome can be expected. The procedure can be carried out with a low rate of complications.

Is revision bone grafting worthwhile after failed surgery for scaphoid nonunion? Minimum 8 year follow-up of 18 patients

Eighteen patients who underwent revision non-vascularized bone grafting and internal fixation after failed surgery for scaphoid nonunion were reviewed after a minimum of 8.2 years. Eleven of the nonunions were located in the middle and seven in the proximal third of the scaphoid. The mean interval between injury and the revision procedure was 6 years. Sixteen of the 18 nonunions healed, two after a third attempt. Three patients with healed nonunions and one patient with persistent nonunion required salvage procedures for progressive radiocarpal arthrosis. In the remaining 14 cases, the mean loss of wrist flexion/extension arc compared to the contralateral wrist was 36 °. Mean reduction of grip strength and key pinch was 9.3 kg and 0.9 kg respectively. The QuickDASH score was 18 and a visual analogue pain score was 21/100 at follow-up. Wrist degeneration increased in all but one case during the observation period. Thirteen of 16 patients with union and one patient with a persisting nonunion experienced moderate symptoms.

New concept for total wrist replacement

Abstract Wrist prostheses have never achieved the sort of clinical outcomes found with those of hips and knees. We have developed a novel uncemented modular wrist prosthesis with screw fixation, metal-on-metal coupling, and ball-and-socket articulation. Eight patients admitted for wrist arthrodesis to treat primary or secondary osteoarthritis (not rheumatoid) were operated on. The prosthesis reduced the amount of bone removed and spared the distal radioulnar joint. After 7 to 9 years we found that the fixed centre of the ball-and-socket articulation provided good stability and mobility, and relief of pain and grip strength were satisfactory. We saw no luxations, metacarpal fractures or cut-outs, or mechanical failures of the implants. Two distal screws loosened (revised with new distal screws), and one early inflammation and one late infection occurred (revised to arthrodesis). We propose modifications to the implant with reduction in the diameter of the screws and the height of the threads, and rounding of the distal tip. The technique should include release of the third carpometacarpal joint, alignment of the capitate and the third metacarpal, and arthrodesis of the joint with bone chips.

Excellent results after bone grafting and K-wire fixation for scaphoid nonunion surgery in skeletally immature patients: a midterm follow-up study of 11 adolescents after 6.9 years.

Objectives: Scaphoid nonunion is relatively rare in children and adolescents, and no long-term follow-up has been reported. Design: Retrospective follow-up study. Patients: Eleven patients (10 boys and 1 girl), mean 15.2 (13.9–15.9) years of age, with scaphoid nonunion and open growth plates were operated with bone grafting, Kirschner-wire fixation and 12 weeks of cast immobilization. Main Outcome Measurements: Bony union, degenerative wrist changes, and restoration of the carpal architecture were assessed with CT and radiographs. Clinical parameters included active range of motion, grip strength, key pinch strength, and subjective outcome scores (quick disabilities of arm, shoulder and hand (DASH), visual analog scale). Results: The patients were followed up after mean 6.9 (3.1–15.1) years; all patients attended. Radiographs and CT confirmed healing of all nonunions, the carpal anatomy was restored, and the wrists were rated as 0 according to the scaphoid nonunion advanced collapse, without degenerative changes. The clinical result was excellent with visual analog scale at rest = 1, at activity = 6, and quick DASH score = 3.3. Active range of motion and grip strength were insignificantly reduced (14 degrees and 2 kg); the key pinch strength remained similar. Conclusions: Healing of a scaphoid nonunion can be expected in adolescents after open reduction, Kirschner-wire fixation, bone grafting, and plaster immobilization, resulting in pain relief and excellent wrist function without degenerative changes after longer term follow-up. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Healing of ununited scaphoid fractures by Kirschner wires and autologous structural bone grafts

Abstract Untreated ununited scaphoid fractures are a hazard to the wrist because of increasing degenerative changes with time. We have treated 81 consecutive ununited scaphoid fractures by open reposition, autologous bone transplantation, and Kirschner wire fixation, 2.7 years after the primary injury. Sixty-nine were men and the mean age at operation was 29 (range 15-71) years. Anatomy of the wrist was restored and radiological healing confirmed in 72/81 patients. There were two deep infections, and the fractures did not heal. Patients with moderate preoperative arthritic wrist changes (scaphoid non-union advanced collapse (SNAC) stage 2) or ununited fractures of the proximal 1/6 of the scaphoid had worse healing than the remainder. Two of nine scaphoids that did not heal were reoperated on with autologous bone grafting and fixation with screws or pins, both of which healed successfully. Three salvage procedures (two wrist arthrodeses and one four corner fusion) were done and the remaining four declined further treatment. Our overall results are comparable to results published where alternative fixation methods have been used. We find that our standard method using Kirschner (K) wires and bone grafting is reliable and inexpensive for most scaphoid pseudarthroses and our results are comparable to published results when alternative fixation methods have been used.

Successful conversion of wrist prosthesis to arthrodesis in 11 patients

From 2001 to 2015, 11 wrists in 11 patients with osteoarthritis of the wrist had failed wrist arthroplasties, which were subsequently converted to arthrodesis using intercalated corticocancellous autograft from the iliac crest and fixation with an arthrodesis plate or a customized peg. Clinical and radiological bone union was achieved in all the operated wrists. At final follow-up of ten patients after 6 years, they had a substantial reduction in pain and improvement in daily function and grip strength compared with those before arthrodesis. We conclude from outcomes of this series that the conversion to arthrodesis after failed wrist arthroplasty is worthwhile and reliably improve wrist function over failed wrist arthroplasty. The results suggest that the patients who will have wrist arthroplasty can be assured that in case of failure the conversion to arthrodesis will produce outcomes comparable with those after primary arthrodesis. Level of evidence: IV