David M. Lichtman

Complications of surgical release for carpal tunnel syndrome.

Review of a series of 186 operative cases of carpal tunnel release revealed 34 complications in 22 patients, for an incidence of 12%. Complications were grouped into seven categories: (1) inadequate section of the transverse carpal ligament (associated with both transverse and curved incisions), (2) symptoms related to damage to the palmar cutaneous branch of the median nerve, (3) reflex sympathetic dystrophy, (4) unsightly hypertrophic scar due to inappropriate incision, (5) damage to the superficial palmar arch following blind sectioning of the transverse carpal ligament, (6) bowstringing of the flexor tendons after excision of the transverse carpal ligament, and (7) adherence of the flexor tendons following excision of the mesotenon. Except for four of the complications, two each of bowstringing and reflex sympathetic dystrophy which occurred in our own practice, all of the complications were seen in patients referred for care. Most complications can be prevented by proper operative technique.

Ulnar midcarpal instability—Clinical and laboratory analysis

Patients with ulnar midcarpal instability have a characteristic pattern of clinical signs and symptoms related to the midcarpal joint. The usual presenting complaint is a painful wrist click which can be reproduced by ulnar deviation, axial compression, and pronation of the wrist. Routine x-rays are usually normal, but cinefluoroscopy reveals sudden dissociation between the proximal and distal carpal rows resulting in a dorsiflexion collapse deformity. In six of our patients, conservative therapy sufficed to relieve symptoms. Four other patients required surgical stabilization. We close to stabilize the triquetrohamate joint because it was a relatively easy procedure and eliminated instability in most instances. Laboratory studies aided in understanding the pathomechanics of midcarpal instability, which consisted of dorsal subluxation of the capitate and hamate on the lunate and triquetrum. We believe that midcarpal instability is not a rare condition but may often be confused clinically with more common carpal dissociations.

Proximal row carpectomy: A multicenter study

Twenty patients underwent proximal row carpectomy and were retrospectively evaluated for pain, motion, grip strength, functional activity, and x-ray changes at a mean follow-up of 3 1/2 years. For nonrheumatoid patients, motion decreased 15% after surgery, mean grip strength improved 22%, and 82% believed their conditions were improved and said they would repeat the procedure. The procedure failed in all three patients with rheumatoid arthritis. Patients with mild preoperative arthritic changes had better results than those with advanced disease.

The Elmslie-Trillat procedure: Evaluation in patellar dislocation and subluxation

The Elmslie-Trillat procedure for correction of patello femoral malalignment was evaluated in 27 knees in 22 patients with an average followup of 42 months (mini mum of 24 months). Preoperative and postoperative pain and activity levels were recorded for all knees. The quadriceps angle was recorded in 22 knees preopera tively and in 19 knees postoperatively. Good or excel lent results were obtained in 81% overall and in 91 % of those knees with patella alta. The postoperative quadriceps angle (Q-angle) correlated with the result. Correction of 10° or less was always associated with a good or excellent result. In contrast, all patients with a fair or poor result had Q-angles of 15° or greater. The preoperative Q-angle did not correlate with the eventual result. We concluded that inadequate medial displacement of the anterior tibial tuberosity may lead to unsatisfac tory results and that this may be avoided by intraoper ative measurement of the Q-angle; that significant distal advancement of the tibial tuberosity is not required in patella alta; and that correction of the Q-angle to 10° or less correlates with a good or excellent result from the Elmslie-Trillat procedure for treatment of patella subluxation and dislocation.

Palmar midcarpal instability : results of surgical reconstruction

We reviewed the cases of 13 patients who underwent 15 surgical procedures for palmar midcarpal instability from 1981 to 1989. Six patients had a limited midcarpal arthrodesis, and nine patients had one of four different soft tissue reconstructive procedures. One hundred percent clinical follow-up was obtained at an average of 48 months. All six of the limited midcarpal arthrodeses were successful. Six of the nine soft tissue reconstructions failed. However, one procedure, a distal advancement of the ulnar arm of the arcuate ligament combined with a dorsal capsulodesis, restored stability in three of five wrists. We concluded that patients with palmar midcarpal instability may have significant disability that may be refractory to nonsurgical management. Limited midcarpal arthrodesis provides definitive treatment.

Carpal tunnel release under local anesthesia: Evaluation of the outpatient procedure

In 100 consecutive cases of carpal tunnel release done under local anesthesia in an outpatient ambulatory care operating room, 93 had satisfactory results at 6 months without any complications. Two patients developed a neuroma of the palmar cutaneous branch of the median nerve, and five showed early signs of reflex sympathetic dystrophy. These complications are discussed, as well as the prevention of other complications of this procedure.

The classification and treatment of Kienböck’s disease: the state of the art and a look at the future

The proper treatment of Kienböck’s disease, a disorder that displays slow progression with eventual collapse of the lunate and alteration of the surrounding carpal architecture, requires an understanding of its aetiology and natural history. A reproducible classification system assists the surgeon in making appropriate treatment choices. In this discussion, we review the history and rationale for the four-stage step-wise classification system, along with our current treatment algorithm. We also discuss emerging classification systems and speculate on future directions in treatment and research.

Lunate silicone replacement arthroplasty in Kienböck's disease: A long-term follow-up☆☆☆

We report a long-term follow-up (average, 5 years) of 10 patients who had lunate silicone replacement arthroplasty for treatment of Kienböcks disease. Clinical results were assessed on relief of pain, return to normal occupation, and range of motion. At 18- to 20-months follow-up, eight patients had satisfactory results, whereas at final follow-up only five of the patients had satisfactory results. Three of five patients with radiographs averaging 57 months after operation had evidence of particulate synovitis. Contrary to our previous publications on silicone replacement arthroplasty, it was concluded that the success rate for silicone replacement arthroplasty and the incidence of particulate synovitis do not warrant the continued use of silicone replacement arthroplasty as a primary treatment modality for Kienböcks disease.

Fibular autografts for distal defects of the radius

A protocol for osteoarticular grafting was established to avoid fracture, nonunion, and loss of motion when replacing the distal radius. Proximal fibular autografts were used and stabilized proximally by compression plating and, at the wrist, by ligamentous reconstruction. Postoperative splinting and therapy were coordinated with graft healing, which was monitored by bone scans and roentgenograms. Graft incorporation in three patients appeared to be well-established within 1 year, but functional use of the extremity and return to duty were achieved much earlier.

Flexor tendon repair and rehabilitation in zone II open sheath technique versus closed sheath technique

A comparative prospective study of the surgical management of the tendon sheath after repair of flexor tendons in zone II is reported. The study included only patients with lacerations of both flexor tendons and no other associated injuries. A modified Kessler suture was used to repair the profundus tendon and the superficialis tendon was repaired with a horizontal mattress suture. In 48 fingers the flexor tendon sheath was left open and it was closed in the second group of 42 fingers. When it was impossible to close the tendon sheath, a vein patch was taken from the dorsal veins of the hand. Both groups of patients were treated with the same regimen of controlled motion rehabilitation and supervised by the same hand therapist. Results were evaluated by the Strickland formula for total active motion of the proximal and distal interphalangeal joints. There was no statistical difference between the results of open sheath versus closed sheath in these two groups of patients treated postoperatively with the same controlled motion rehabilitation program.