H. Kirk Watson

The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis

Four thousand wrist x-ray films were reviewed to establish the pattern of sequential changes in degenerative arthritis of the wrist. After eliminating all other arthritides, we studied 210 cases of degenerative arthritis. The most common pattern (57%) was arthritis between the scaphoid, lunate, and radius; 27% of cases occurred between the scaphoid, trapezium, and trapezoid; a combination of these two patterns occurred in 15%. Twenty operations were performed on 19 patients with the scapholunate advanced collapse pattern. Eighteen of 19 patients had less pain postoperatively and none required pain medication. Flexion-extension and radial-ulnar deviation motions showed considerable improvement after the operation.

Degenerative change in symptomatic scaphoid nonunion

A retrospective radiographic analysis of 64 patients with symptomatic scaphoid nonunions without previous surgical treatment was accomplished. The results showed a high frequency of degenerative changes occurring in a predictable sequence. For nonunions of 4 years duration, 75% of patients had radioscaphoid changes, and for those of 9 years duration 60% of the patients had midcarpal changes. The pattern of arthritis in scaphoid nonunion is that of scapholunate advanced collapse (SLAC) wrist resulting from rotary subluxation of the distal scaphoid fragment. The radius-proximal scaphoid fragment joint and the radiolunate joint were consistently spared from degenerative changes, even with severe arthritis. Instability was progressive and associated with an earlier onset of arthritis. Patients with symptomatic scaphoid nonunions appear to have a significant likelihood of arthritis developing.

Scapholunate advanced collapse wrist salvage

Patients with scapholunate advanced collapse (SLAC) wrist do not have to undergo total wrist arthrodesis; the SLAC pattern spares the radiolunate articulation, providing a basis for salvage. We report the results of 100 cases in which a technique comprised of scaphoid excision and limited wrist arthrodesis was used. The average followup period of 44 months revealed excellent functional status and a high rate of patient satisfaction. The majority of employed patients were able to return to their original jobs, and many chose to resume wrist-related recreational activities. Pain relief was good to excellent in most cases. Extension/flexion averaged 72 degrees (53% of a normal opposite wrist), radioulnar deviation 37 degrees (59%), and grip strength 80% of the opposite side. X-ray films revealed only two instances of radiolunate destruction, both in conjunction with ulnar translation of the carpus. The other 98 patients demonstrated a well-preserved radiolunate joint regardless of followup interval. Complications were few. Nonunion occurred in three cases. A dorsal impingement of the capitate and radius (12%) was felt to be technique-related and avoidable by careful capitolunate alignment.

Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint

In 1985 we published the results of the matched ulna resection in 44 patients, the majority of whom had rheumatoid arthritis. The matched ulna resection maintains the continuity of the distal ulna to the ulnar sling mechanism, including the triangular fibrocartilage complex (TFCC), and resects the distal ulna in a smooth, curved, convex fashion to match the contour of the radius throughout forearm rotation. This article presents the results of the procedure in patients with posttraumatic and mechanical disorders of the distal radioulnar joint. Good to excellent results were noted in 24 of 32 patients. The outcome was related to the severity of the patients initial problem.

Treatment of reflex sympathetic dystrophy of the hand with an active stress loading program

Reflex sympathetic dystrophy (RSD) is a syndrome characterized by pain out of proportion to injury, vasomotor and trophic changes, stiffness, and decreased function. It is important to separate the active disease process of RSD from its resultant state of contracture and fibrosis. Our treatment program is based on active stress loading, which consists of active traction and compression exercises that provide stressful stimuli to the extremity without joint motion. Fifty-two patients with RSD were treated during a 3-year period. Their results and long-term follow-up on 41 patients are presented. The stress loading program has been used consistently during the past 20 years. The advantages of the program are its effectiveness, simplicity, safety, and noninvasiveness.

A CENTRALIZATION PROCEDURE FOR RADIAL CLUBHAND

A modified centralization procedure for radial club hand caused by partial or total absence of the radius is presented. This technique differs from the methods presently used in that no carpal bones are resected. Adequate release of the wrist from the fibrotic radial anlage is provided through two Z-plasty incisions to allow the hand to move easily to the new position. Stabilization is then obtained with a Kirschner wire placed via the lunate and capitate into the long finger metacarpal and then directed in a retrograde fashion into the ulna. A total of 12 centralization procedures with the above technique have shown very good results. Long-term follow-up results demonstrate remodeling of the ulna, which becomes broad in its distal end, resembling a radius.

Trapezoidal osteotomy of the distal radius for unacceptable articular angulation after Colles' fracture

Loss of radial palmar tilt in malunion of Colles fractures alters wrist biomechanics, abnormally loading the tenuous dorsal ligament complex. This can result in midcarpal instability with synovitis, pain, weakness, and possible articular degeneration. An osteotomy to correct radius alignment using a trapezoidal corticocancellous bone graft has been devised. The graft is harvested from the dorsal radius adjacent to the osteotomy and malunion site. When turned 90 degrees, a properly designed trapezoidal graft restores radial length, inclination, and palmar tilt in one step. Functional results in 15 patients at 46 months (range, 18 to 116) were comparable with a series using iliac crest graft and plate- and-screw fixation. This simple technique avoids disruption of the extensor retinaculum and reoperation for hardware removal as Kirschner-wire fixation proved adequate.

Composite toe (phalanx and epiphysis) transfers in the reconstruction of the aphalangic hand

Twenty children with ectrodactyly have had 36 digits reconstructed with toe phalanges inserted into the existing soft tissue finger pouches or pouches constructed with local tissue. Care is taken to preserve the periosteum, epiphyseal plate, and collateral ligaments of the transfers. No surgical microvascular anastomoses are performed, and the entire procedure takes less than 30 minutes. Epiphyseal patency rates in children with a mean follow-up of 3.4 years and a median of 4 years are 90% for those operated on at 6 months to 1 1/2 years of age, 67% in those operated on at 1 1/2 to 5 years, and 50% in children operated on at 5 to 13 years of age. Radiographic growth measurements show average growths greater than 90% of the expected growth based on measurements of the contralateral donor phalanx for all transfers with open epiphyses. These reconstructed digits provide fingers that are sensate, capable of pinch and grasp, and able to tolerate heavy use.

The Moberg volar advancement flap for digital reconstruction

The volar advancement flap described by Moberg in 1964 has been used to restore normal sensation to soft tissue deficits of the thumb. Application of this same technique for finger tip injuries was later suggested by Snow, but differences in digital blood supply led to dorsal tip necrosis and selection of other reconstructive techniques by many surgeons. Other methods have the disadvantages of widened two-point discrimination, a tender pulp scar, or an unacceptable donor site. The volar advancement flap applied to fingers restores normal to nearly normal sensation, an adequate pulp with minimal deformity. Our experience with the volar advancement flap in 69 digits from 1969 to 1978 is reviewed. Preservation of the dorsal perforating vessels is most important in successfully executing this procedure. No dorsal tip or flap necrosis occurred. Two-point discrimination was normal or within 2 mm of contralateral values in every digit. Full range of motion, or less than 5 degrees extension loss, was recorded in all fingers that were normal prior to operation. Our results suggest this to be a safe as well as effective adjunct in the treatment of finger tip injuries.

Dorsal approach to scaphoid nonunion

The surgical approach for treatment of scaphoid nonunion usually involves various combinations of screws and Kirschner wires, with or without bone grafts. This article reports our results with 36 dorsal-approach bone grafting procedures for treatment of scaphoid nonunion with Kirschner wires. Union was achieved in 89%. The average follow-up was 5 years. Flexion/extension averaged 76% of the opposite wrist, and grip strength was 88% of the opposite hand. Ninety-one percent of the employed patients returned to their original jobs. The dorsal approach provides satisfactory exposure for fragment reduction and bone grafting.