J. Field

A report on the early failure of the LPM proximal interphalangeal joint replacement.

The LPM (Van Straten Medical, Netherlands) proximal interphalangeal joint replacement was introduced to the United Kingdom in October 2000, and 257 implants were sold. We have audited the results of this prosthesis, and obtained data for 164 of the 257 implants. Forty-seven (29%) of the 164 have been revised and another 33 (20%) are showing clinical and radiological signs of failure at a maximum follow-up of 6 years. Massive osteolysis leading to aseptic loosening is the commonest cause of failure. We believe that all patients who have had this prosthesis inserted should be kept under regular clinical and radiographic review.

Complex Regional Pain Syndrome: a review

Complex regional pain syndrome, formally known as reflex sympathetic dystrophy, is a poorly understood condition that describes a collection of clinical symptoms and signs occurring in the peripheries most commonly after trauma. Pain is the main problem. It is generally out of proportion to the degree of injury and can be unresponsive to narcotics. In addition joint stiffness, temperature and colour changes, and swelling occur. The diagnosis and treatment are challenging for any clinician and a multidisciplinary approach is often necessary with physiotherapy, occupational therapy, and the pain team. The hand surgeon is involved for two reasons, firstly as the upper limb is the most frequently involved, and secondly because the condition may be a complication of the patient’s surgery and result in a much prolonged recovery. This review elucidates the recent advances in the knowledge of the aetiology, classification and treatment of this fascinating condition.

Comparison of MRI and Wrist Arthroscopy for Assessment of Wrist Cartilage

In order to perform motion-preserving procedures for wrist arthritis rather than total joint fusion, it is important to determine the integrity of specific areas of wrist cartilage. This is generally performed using a wrist arthroscope and by directly visualising the cartilage. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Kappa analysis was used to compare the two methods of cartilage assessment. There is only a fair correlation (K = 0.38) between the two methods. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist.

SCAPHOID BONE BRUISING – PROBABLY NOT THE PRECURSOR OF ASYMPTOMATIC NON-UNION OF THE SCAPHOID

The MRI finding of bone marrow oedema, without fracture, following trauma to the scaphoid has been called a ‘bone bruise’. A similar injury is found in the knee, considered benign and managed conservatively. In the scaphoid, there is the concern that this lesion may lead to scaphoid non-union. This study addresses that concern. The clinical and radiological findings of 41 patients with a scaphoid bone bruise on MRI are described, an MRI classification system proposed and clinical outcomes investigated. Patients were immobilised for 6 weeks. At 3 months, 8 remained symptomatic and had repeat MRI. Four of these showed complete resolution of the bruise, the others improvement. At 6 months, 2 of the 8 complained of minor, intermittent discomfort but progressed to resolution of symptoms. This study suggests that the scaphoid bone bruise is a benign injury with predictable recovery and is unlikely to result in long-term morbidity in the form of non-union.

Does postoperative hand elevation reduce swelling? A randomized study

The purpose of this study was to assess the effect of limb elevation on hand swelling after surgery. We prospectively randomized 113 patients undergoing fasciectomy or a trapeziectomy into one of two groups. The first group had the hand elevated postoperatively and the hands of the second group were not elevated. Hand swelling was assessed using a volumetric method. Although the swelling was less in the elevated group this did not reach statistical significance. Subgroup analysis revealed no further significant differences. There were no complications in patients who did not have limb elevation. This study does not support the routine use of elevation for 24 hours after fasciectomy for Dupuytrens disease and trapeziectomy to reduce hand swelling.

Analysis of failed Van Straten LPM proximal interphalangeal prostheses

The two-piece Van Straten Leuwen Poeschmann Metal (LPM) prosthesis was intended for the proximal interphalangeal joints. However, revision rates of 29% after 19 months were reported, as well as massive osteolysis. Five failed LPM titanium–niobium coated cobalt chromium components were obtained, three distal and two proximal, and subjected to a forensic retrieval analysis. Components were analyzed using a Talysurf contacting profilometer, ZYGO noncontacting profilometer, and environmental-scanning electron microscope. All components were heavily worn. In some regions the titanium–niobium coating had been scratched and penetrated. Elsewhere this coating had been removed where there was minimal scratching, which may have been due to corrosion between the coating and substrate. The osteolysis reported clinically was likely to be linked to the wear debris from the failed titanium–niobium coating and substrate.

Warm or refrigerated local anaesthetic for open carpal tunnel release: a single blind randomized controlled study

The aim of this randomized controlled study was to determine whether administration of lignocaine with adrenaline is less painful when injected at room temperature compared to refrigerated temperature. A cohort of 50 patients undergoing unilateral carpal tunnel decompression was randomized to room temperature or refrigerated local anaesthetic. Pain scores were assessed using a 10 mm visual analogue scale. Mean pain scores were 4.0 (SD ± 1.5) for room temperature and 6.5 (SD ± 1.7) for refrigerated local anaesthetic (P < 0.001). This study demonstrates that patients experience greater pain levels with administration of local anaesthetic at refrigerated temperatures prior to open carpal tunnel release.