G. R. Sennwald

Fasciectomy for treatment of Dupuytren's disease and early complications

This review of 103 cases of hands operated on for treatment of Dupuytrens disease demonstrates the significant increase of postoperative stiffness as related to recurrences and staging of the disease, but not to sex. On the contrary, the frequency of reflex sympathetic dystrophy after fasciectomy is sex related affecting females. The protective effect of guanethidine may be a valuable therapeutic adjunct for female patients. We propose that the disease be staged on the basis of anatomic findings, inasmuch as staging based on degree of contracture alone is insufficient for comparative studies.

Cemented and non-cemented replacements of the trapeziometacarpal joint

We performed 88 primary ball-and-socket arthroplasties of the trapeziometacarpal joint in 84 patients (69 women and 15 men) with a mean age of 61 years (37 to 81). Cemented de la Caffinière prostheses were implanted in 43 joints from 1988 to 1991 and 45 cementless Ledoux implants were used between 1992 and 1994. Of the 61 surviving prostheses still in situ, 51 were reviewed clinically and radiologically with a mean follow-up of 25 months for the Ledoux and 63 months for the de la Caffinière implant. The survival rate for the Ledoux prosthesis was 58.9% at 16 months and for the de la Caffinière implant 66.4% at 68 months. Loosening occurred in 15% of the Ledoux stems, in 46% of the Ledoux cups, in 24% of the de la Caffinière stems and in 28% of the de la Caffinière cups. Both prostheses behaved similarly, and it is clear that a constrained ball-and-socket prosthesis is not suitable for the trapeziometacarpal joint.

Scaphocapitate arthrodesis for the treatment of Kineböck's disease

Eleven consecutive patients, ten men and one woman (median age, 26 years) presenting with Kienböcks disease, were treated with scaphocapitate arthrodesis. Ten patients had grade III, and one had grade II disease by Lichtman classification. The average follow-up period was 36 months (minimum, 1 year). The lunate was left in situ and scaphocapitate arthrodesis was performed with two lag screws and corticocancellous bone graft. The ulnar variance of the affected wrist was negative (-2.23 mm) and significantly different from the unaffected side. Ten patients had complete pain relief and one had persistent pain. Nine returned to their previous vocations.

Kinematics of the wrist and its ligaments

Precise anatomic dissections of unembalmed physiologically intact cadaver specimens were carried out before proceeding with the kinematic investigations on further specimens. Carpal flexor and extensor tendons were used to move the wrist. The analysis of the carpal bone movements was performed according to the finite helical axis motion concept for increments of 10 degrees for each main carpal motion. Separate axes of rotation for each of the bones in the proximal carpal row were found; however, the axes for the lunate and triquetrum bones were close, and the magnitudes of rotation and translation almost equal. One finding was that the axes of rotation of the bones in the proximal carpal row often cross at some particular point. Because the axes of the scaphoid are differently oriented than those of the lunate and triquetrum, shear might occur during wrist motion. This indicates also that the scaphoid and lunate cannot be considered rigidly coupled elements. We also assume that the individual bones of the proximal carpal row self-align themselves as long as they are not constrained by torsion. Several potential mechanisms of flexion motion of the proximal carpal row during radioulnar deviations of the hand were considered. The ligament function is still an unsolved problem. Compensation mechanisms may mask clear correlations between a lesion and the instability pattern associated with it. The proximal carpal row should be studied as one system.

A New Technique of Reattachment after Traumatic Avulsion of the TFCC at Its Ulnar Insertion

One female and seven male patients (median age 25.5) presented with traumatic avulsion of the triangular fibrocartilage complex (TFCC), type 1B according to Palmer’s classification. Reattachment of the TFCC near its anchoring point was combined with an intraarticular shortening osteotomy of the ulnar head. This provides an excellent approach to the TFCC and a well vascularized anchoring surface. The mooring point is biomechanically appropriate and the tissues with the best biomechanical properties are used. The functional results with a mean follow-up of 3 years were encouraging, as demonstrated by the significant improvement of pain (P = 0.017). All patients were able to return to their previous occupation; no further surgery was necessary to the distal radio-ulnar joint and no impairment of pronation and supination was detected. The final wrist score reflects the subjective results defined by the patient. However the correlation is not linear and the wrist scores are superior to the degree of satisfaction defined by the patient.

Lunotriquetral arthrodesis : a controversial procedure

12 male (mean age 28) and 11 female (mean age 32) patients treated with lunotriquetral (LT) arthrodesis were reviewed with a median follow-up of 28 months (range 18–40 months) for this retrospective study. At first presentation 12 patients were unable to work, and at follow-up only three men remained out of work. The relief of pain was significant (P < 0.001) and the median Culp (1993) wrist score obtained 74 (min. 45, max. 96); however, only one patient was totally free of pain and seven men had to change their occupations. Men lost 455 working days, women 191, a highly significant difference (P = 0.006). This loss correlated (P = 0.007) with the LT angle measured in the frontal plane: all patients but one with a LT angle of less than 31° returned to work within 1 year, but only four with a greater angle (P=0.007). This emphasizes the importance of correct positioning of the triquetrum, which seems hard to achieve with two AO lag screws. Furthermore, even two screws seem unable to ensure solid fusion as shown by the high rate of pseudarthrosis (57%). LT fusion cannot be considered as a routine procedure and results are not yet predictable. According to these results, we feel that a bone graft placed in a slot from lunate to triquetrum is the procedure of choice. In the presence of a chondromalacia in the ulnar midcarpal joint, a four bone fusion is primarily recommended.

The Value of Scapho-Trapezio-Trapezoid Arthrodesis Combined with “De La Caffinière” Arthroplasty for the Treatment of Pan-Trapezial Osteoarthritis

13 patients, 12 female and one male (mean age 63) with pan-trapezial osteoarthritis were treated by a “de la Caffinière” arthroplasty of the first carpometacarpal joint, combined with a scapho-trapezio-trapezoid (STT) arthrodesis. 11 could be reviewed at least 3 years after surgery (average 3 years and 8 months). Non-union of the arthrodesis occured twice, once when no internal stabilization was used, once with the use of the staplizer. No impingement syndrome was recorded, and there was no correlation between the angular position of the scaphoid and mobility of the wrist. Two out of 11 “de la Caffinière” implants had to be removed. Loosening of the stem is unusual, but the cup remained only perfectly in place in two cases. There was no correlation between radiological and clinical findings and the overall result was good or excellent in 8 out of 13 (62%) of the cases. The grip and pinch strength were comparable to the results of the literature. This method cannot be further recommended because of the high rate of re-operation and the risk to the trapezium which has to be further evaluated.

A comparison of diaphyseal and metaphyseal techniques of ulna shortening

The aim of this retrospective study was to compare two techniques of ulna shortening for ulnocarpal abutment. The technique performed initially was diaphyseal osteotomy. Subsequently, a metaphyseal osteotomy was performed to avoid the drawbacks related to the plate. The study group consisted of 29 patients: 13 with diaphyseal and 16 with metaphyseal osteotomies. The pre-operative diagnosis was ulnocarpal abutment in all cases. The results were graded according to the scoring system of Chun and Palmer and patients’ self-assessment. Both rankings were related to indications, age, gender, occupation, and surgery. Final follow-up occurred at a median of 54 (range 15–144) months after surgery. There was no delayed union or non-union, necrosis of the ulnar head, or infection. Pain relief was the main benefit. Both techniques gave similar outcomes for pain relief, satisfaction, and objective results. The shortening was significantly greater in the metaphyseal group without any apparent consequence on function or pain. No screw removal was needed after metaphyseal osteotomy; in contrast, plate removal was required in all patients. We conclude that both techniques are valuable alternatives for treating ulnocarpal abutment.

De l'utilité des substituts osseux : à propos de 101 fractures du radius distal

The aim of the present retrospective study was to evaluate the performance of bone graft substitutes currently in use. After exclusion of those with inadequate data for comparison, 70 out of the 101 operated fractures remained available for statistical analysis. Grafts were used in 38 cases: 23 were bone substitutes and 15 autogenous grafts. Distal radial inclination and lateral angles showed no significant difference. Analysis of ulnar variance showed the relative inability of intramedullary pinning to maintain radial length in the absence of graft. In contrast external fixators preserved radial length both with and without bone grafts, and with all types of graft material. TCH (hydroxyapatite and calcium phosphate) or autogenous bone grafts allowed intramedullary pinning to maintain radial length; whereas collagen matrix material was ineffective. We conclude that TCH and autogenous bone grafts have equivalent effectiveness despite potential bias in this study.

A new radiographic method of measuring carpal collapse.

We assessed carpal collapse by measuring the capitate-radius (CR) distance on standard plain radiographs. This new method required validation of diagnostic accuracy, so we compared it with the method of Nattrass et al known as revised carpal height (RCH). We studied wrist radiographs from 16 normal subjects and 11 patients with unilateral Kienböcks disease. We found that there was a significant difference in the left/right CR index between the normal wrists and those with Kienbocks disease (p < 0.001). The use of left/right RCH index showed no significant difference (p = 0.30). Diagnostic accuracy was shown to be higher for the CR index using ROC curves. We then assessed 40 normal wrists and found the mean CR index to be 0.999 +/- 0.034, and suggest that values less than 0.92 are abnormal. The CR index can be used for diagnosis in unilateral carpal collapse, and for monitoring progress where the condition is bilateral.