Lewis H. Millender

Arthrodesis of the Rheumatoid Wrist: An Evaluation Of Sixty Patients And A Description Of A Different Surgical Technique

In a series of sixty patients (seventy arthrodeses) a technique was developed in which freshened bone surfaces of the carpus and radius were coapted and immobilized by an intramedullary pin, supplemented as needed by staples or a Kirschner wire. Fusion was successful in all but two patients and all patients benefited by increased strength and function in the hand. The advantages of the operation are: short operating time, so that other procedures can be done concomitantly, and a short recuperation time, so that activity, such as walking with crutches, is not lost.

Silicone spacer or tendon spacer for trapezium resection arthroplasty—Comparison of results

A comparison study was done for 25 consecutive trapeziectomies in 21 women with silicone replacements and 25 consecutive trapeziectomies in 24 women without silicone replacements who were reviewed from 1 to 9 years postoperatively. The patients, who ranged from 35 to 75 years of age, were housewives and clerical workers. All had trapeziometacarpal osteoarthritis. Among the patients with silicone replacement of the trapezium, 90% reported pain relief; mean thumb abduction was 42.5 degrees, pronation was 37.5 degrees, and pinch strength averaged 5 kg. Among the patients without silicone replacement after trapeziectomy, 95% reported pain relief; mean thumb abduction was 46.8 degrees, pronation was 41.4 degrees, and pinch strength averaged 4.6 kg. For those patients with only one hand operated upon, pinch strength in that hand averaged 85% that of the opposite hand in patients with silicone trapezial replacement and 82% for those without silicone trapezial replacement. In this patient population, trapeziectomies with or without silicone replacement as treatment for trapeziometacarpal osteoarthritis appear to give similar results.

Flexor tendon ruptures in patients with rheumatoid arthritis

One hundred fifteen flexor tendon ruptures were reviewed in 43 hands with rheumatoid arthritis, one hand with psoriatic arthritis, and one hand with lupus erythematosis. Ninety-one tendons were ruptured at the wrist, four ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Those patients with multiple ruptures within the carpal canal had a worse prognosis. Ruptures of both tendons within the fibro-osseous canal had the worst prognosis. The severity of the patients disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

Ligamentous reconstruction for chronic intercarpal instability

Twenty-one patients with chronic intercarpal instability were operated on an average of 13.2 months after injury or onset of symptoms. Fourteen had reconstruction via dorsal approaches by use of radial wrist extensor or other tendon graft. Seven patients were approached dorsally and palmarly, three had ligament repair, and four had reconstructions. The average follow-up was 25.4 months. Pain decreased in 85.7% of patients, although only two were pain free. Range of motion (ROM) generally decreased, and grip strength increased slightly. Radiologically, there was significant improvement on the initial postoperative roentgenograms, much of which was lost by the time the final roentgenograms were obtained. A clinical and radiologic grading system was devised to evaluate results. The average clinical grade improved from poor (26.5%) preoperatively to fair (44.4%) postoperatively. The radiologic grade remained in the poor range postoperatively, although there was some improvement from 40.4% to 45.6%.

Arthroplasty of the rheumatoid wrist with silicone rubber: An early evaluation

A review of the results of 37 arthroplasties of the wrist with flexible silicone, done at least 6 months before, in patients with rheumatoid arthritis showed six (16%) to have residual discomfort and two (5%) to have recurrent deformity. Pain was the primary indication for treatment in 31 and deformity in six. Three of 37 wrists had prosthetic fractures (8%). Ten patients who had the opposite wrist fused before the arthroplasty felt the movable wrist was more functional. Contraindications are marked deformity, significant instability, excessive bone loss, and multiple tendon ruptures.

Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow.

Decompression of the ulnar nerve at the elbow with medial epicondylectomy was done in 43 patients and reviewed with an average follow-up of 2.3 years. Eight were graded as excellent, 23 as good, 9 as fair, and 3 as poor results. A special emphasis was placed on analysis of the potential disadvantages of medial epicondylectomy including bone tenderness at the osteotomy site, vulnerability of the ulnar nerve, ulnar collateral ligament instability, and weakness from disruption of the flexor pronator origin. Clinical assessment of strength including quantitative measurement of pinch strength, grip strength and endurance, and testing of forearm muscles did not show these potential disadvantages to be significant problems.

Failure of silicone rubber wrist arthroplasty in rheumatoid arthritis

Of 71 silicone rubber wrist arthroplasties performed between 1976 and 1983, 20% were found to have fractured, and an additional 5% required revision for deformity and pain. In most cases, no specific cause for the failure could be identified. However, excessive wrist motion, overuse, and inadequate surgical technique appear to be contributory. Prosthetic fracture is associated with increasing wrist pain, instability, and deformity with decreasing strength and function. Twelve of 14 fractured prostheses required revision. Eleven of these were revised with another silicone rubber implant, and two of these have refractured. Based on this review, we have narrowed our indications for silicone rubber wrist arthroplasty and now give greater consideration to alternative methods of treatment.

Bowstringing as a complication of trigger finger release

Bowstringing is a rare complication of trigger finger release caused by excessive loss of the proximal pulleys. As the flexor tendon moves away from the center of rotation of the metacarpophalangeal joint, the flexion moment arm is increased. Thus the flexors gain an increased mechanical advantage over the extensors resulting in limited digital extension. We describe a case of severe bowstringing progressing over 9 years resulting in pain, altered digital function, and loss of full extension.

Nonoperative treatment of anterior interosseous nerve paralysis

Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis is surgical decompression, there has been recent evidence in the neurologic literature that these lesions are examples of a neuritis. We followed 10 cases of spontaneous partial anterior interosseous nerve paralysis. All patients were seen initially with a typical history of pain. Seven had signs of other nerve involvement either on physical examination or electromyogram analysis. Eight patients treated by observation had signs of recovery in 6 months and full recovery within 1 year. Surgical decompression did not affect recovery time in the other patients. Our findings suggest that anterior interosseous nerve paralysis is a form of neuritis and can safely be treated without operation. These patients will achieve complete recovery.

Factors that determine reexploration treatment of carpal tunnel syndrome

Eighteen patients (20 hands) underwent reexploration of the carpal tunnel after a primary carpal tunnel release. The patients complained of unrelieved symptoms after their initial surgical procedures. We recommend reexploration for patients with unrelieved carpal tunnel syndrome if they have a positive Phalens test, have symptoms that cause nocturnal wakening or are exacerbated by activities, or have a short or transverse initial incision. If the incision is adequate and these symptoms are not present, we believe that reexploration will not result in a satisfactory outcome.