Daniel B. Herren

Age- and Gender-Specific Normative Data of Grip and Pinch Strength in a Healthy Adult Swiss Population:

Assessment of hand strength is used in a wide range of clinical settings especially during treatment of diseases affecting the function of the hand. This investigation aimed to determine age- and gender-specific reference values for grip and pinch strength in a normal Swiss population with special regard to old and very old subjects as well as to different levels of occupational demand. Hand strength data were collected using a Jamar dynamometer and a pinch gauge with standard testing position, protocol and instructions. Analysis of the data from 1023 tested subjects between 18 and 96 years revealed a curvilinear relationship of grip and pinch strength to age, a correlation to height, weight and significant differences between occupational groups. Hand strength values differed significantly from those of other populations, confirming the thesis that applying normative data internationally is questionable. Age- and gender-specific reference values for grip and pinch strength are presented.

Palmar approach in flexible implant arthroplasty of the proximal interphalangeal joint.

Joint replacement is an established method in the treatment of destroyed, painful, proximal interphalangeal joints. A palmar approach was used in which the main collateral ligaments were preserved, allowing immediate active rehabilitation with enhanced primary lateral stability. Fifty-nine proximal interphalangeal joint silicone arthroplasties in 38 patients with a minimum followup of 12 months were reviewed. Thirty-eight of the 59 joints had implantation from a palmar approach and 21 joints from a dorsal approach. The two groups were well-matched in terms of indication, preoperative range of motion, and patient age. No significant increase in the range of motion was found in either of the patient groups, with an overall average range of motion of 51° postoperatively. There was also no significant difference in the postoperative stability in the two patient groups. The choice of surgical approach at the proximal interphalangeal joint level for the silastic type of implants does not appear to be important. With more sophisticated types of implants in which the integrity of the collateral ligaments is crucial, a palmar approach might be beneficial.

Rheumatoid arthritis of the wrist. Classification related to the natural course.

The authors introduce a new functional classification of rheumatoid arthritis of the wrist. Unlike the classifications used today, it includes the aspect of the natural course of rheumatoid arthritis. The goal of this paper is to identify radiologic indicators that will classify rheumatoid arthritis into stable forms of the disease (Types I and II) and unstable forms of the disease (Type III). Of 144 wrists examined, the first available radiograph and the radiograph obtained at the time of the first surgery were assessed. The indicators measured were: carpal height ratio, ulnar translocation, radial rotation, and scapholunate dissociation. Noting the changes that occurred each year in these indicators, it was possible to identify a significant difference between stable forms (Types I and II) and unstable forms (Type III) for the parameters carpal height ratio, ulnar translocation, and scapholunate dissociation. The distribution of the indicators allowed the definition of three values: the 100% value, the cut off point, and the lower threshold value. Combining the three radiologic parameters at those values markedly enhanced the possibility to classify rheumatoid arthritis of the wrist. With the help of the three radiologic indicators carpal height ratio, ulnar translocation, and scapholunate dissociation, it is possible to classify wrists with an early stage of rheumatoid arthritis according to the Schulthess classification. The early identification of destabilizing forms of rheumatoid arthritis becomes possible, making the choice and timing of the surgical intervention easier. Wrists with a progressive unstable form of rheumatoid arthritis may be stabilized earlier.

Evaluation of wrist and hand handicap and postoperative outcome in rheumatoid arthritis.

Functional instruments in rheumatology should use standardized procedures and should be quantifiable, valid, reliable, and responsive/sensitive to change. For most assessment tools, these aspects have been considered and tested. One of the most important questions in assessing hand involvement in patients with RA is what the single assessment should be used for. There could be a substantial difference should hand assessment be done in a routine way in a hand practice or should it be performed within scientific studies on disease progression or the effect of operative interventions. Among other points, answering this question has a significant impact on the time the patient has to spend with the tests and on the time the hand therapist or hand surgeon is involved with it. In addition to aspects such as accuracy, reliability, and validity, therefore, in some evaluation tools the time needed to perform the clinical examination and assessment of hand function has also been considered to be of importance. In addition, it has to be considered that description of the anatomic status, measurements of impairment, and assessment of disability cannot simply be replaced by each other, and even measurements of single aspects often are not sufficient. It has been stated, therefore, that the combination of different discrete hand-function assessment methods provides a more complete picture of hand ability. Moreover, although better responsiveness of disability outcome measures over impairment measures has been demonstrated previously (eg, in patients treated for Colle fracture), the relationship between disability and impairment measures is not clearly established. Although some studies reported significant correlations between impairment and disability tests, other studies showed only poor or moderate correlations between disability scores, impairment, and disease activity measures when rheumatoid hands were assessed. It has been concluded that the relationship between impairment and disability is not straightforward. The new ICF-model addresses these two levels of health-related quality of life by different concepts of assessment. Because impairment reflects the consequences of the disease at the organ level, whereas disability reflects the consequences of the disease for functional performance and activity, for comprehensive assessment of hand handicap, measurement of disability is more comprehensive and closer to the patients needs for performing ADLs.

Changes in surgical intervention patterns in rheumatoid arthritis over 10 years in one centre

Clinical observations indicate that the course of disease in patients with rheumatoid arthritis (RA) has become milder during the past decade.1 Less severe symptoms2 as well as the declining need for orthopaedic interventions3 4 are most likely the result of more potent drugs. However, there is an ongoing debate to what extent single surgical options such as joint-sacrificing arthroplasties or prophylactic synovectomies are affected within the surgical treatment concept. Therefore, we reviewed the electronic medical records in our orthopaedic clinic, which serves a huge regional population and is regarded as a reference clinic for RA patients over many years. Special characteristics of the clinic are a common treatment philosophy5 and a low turnover rate …

Limited and complete fusion of the rheumatoid wrist

The correct surgical treatment of the rheumatoid wrist has an important impact on the function of the affected band. Surgical decisions should be based on individual deformity and poteustal progression of the disease. A classification of rheumatoid urist involvement is presented that considers the natural progression of the disease and helps to optimze the treatment of these pathents. If a destabilizing form of destruction is found, limited or complete wrist fusion is often the treatment of choice. Among partial fusions, the radiolunate arthrodesis gives consistent, good clinical results. Is preserves some wrist motion with realignment of the carpus and stabilization to prevent further dislocation. In cases of severe destruction and deformity, comples wrist fusion, preferably performed by using large-pin technique, gives pain-free long-term stability of the wrist.

Modeling and finite element analysis of a new revision implant for the elbow.

Failed total elbow arthroplasties often are associated with significant bone loss, especially at the level of both humeral condyles. Regular implants might not be ideal for those revision cases and either custom-made implants or complex bone reconstruction procedures with grafts are needed. The goal of the current study was to develop a new revision implant, based on an existing total elbow system (GSB III). The new revision humeral component, with an anterior flange instead of condylar flanges, was designed in a computer-aided design program and virtually implanted in a modeled humerus from a cadaver and subsequently was tested in a finite element model under different loading conditions. The overall distribution of the von Mises stress, as a generalized stress intensity factor, did not differ significantly between the GSB III and the new revision component. There was a tendency that the anterior flange, compared with the condylar flanges, protected the implant-cement-bone interface in the critical region of the distal stem. The finite element analysis suggests that the revision concept for failed total elbow arthroplasties, to rely on existing anterior humerus cortex instead of reconstruction of the condylar bone, seems to have no disadvantage in terms of stress distribution on the implant.

Shortening Osteotomy for Treatment of Metacarpophalangeal Joint Deformity

The results of a new subcapital shortening osteotomy for correction of metacarpophalangeal joint deformity in patients with rheumatoid arthritis of the hands are presented. Seven patients (16 joints) were followed up for a mean of 33.5 months. The mean shortening of the metacarpal bone was 4.6 mm (range, 4–8 mm), and seven joints had additional intrinsic release. Only four (25%) joints held the correction of the deformity; all other joints had recurrence of palmar subluxation with or without additional ulnar drift. The range of motion of the joints with preserved correction after surgery was 80° compared with 28° of the joints with recurrent deformity. The possible mechanism of failure was analyzed. The results of the current series suggest that subcapital shortening osteotomy may not be indicated for treatment of severe metacarpophalangeal joint deformity in patients with rheumatoid arthritis.