Peter M. Murray

Long-Term Outcomes of Proximal Interphalangeal Joint Surface Replacement Arthroplasty

BACKGROUND Surface replacement arthroplasty is a reconstructive alternative for the treatment of pain and deformity due to osteoarthritis and rheumatoid arthritis of the proximal interphalangeal joint of the finger. This retrospective study was performed to examine long-term outcomes of proximal interphalangeal joint prosthetic surface replacement with a proximal cobalt-chromium (CoCr) and distal ultra-high molecular-weight polyethylene component over thirty years at a single institution. METHODS Sixty-seven prostheses were implanted in forty-seven patients between 1974 and 2007. The mean duration of follow-up was 8.8 years. There were fifty joints (75%) with osteoarthritis and seventeen (25%) with rheumatoid arthritis. Fifty-six prostheses (84%) were implanted via a dorsal approach, forty-eight (72%) were cemented, and nineteen (28%) were press-fit. Postoperative evaluation, consisting of a clinical history and examination, radiographs, the Short Form-36 (SF-36) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires, and a visual analog scale (VAS) pain score, was performed for thirty-six patients. Demographic, surgical, and implant failure data were obtained from the medical charts of eleven patients (sixteen implants) who had died prior to the time of postoperative follow-up. RESULTS At the time of follow-up, the median total active proximal interphalangeal joint motion was 40°. Eight prostheses had failed, yielding a cumulative incidence of implant failure of 3% at one year, 8% at three years, 11% at five years, and 16% at fifteen through twenty-five years. Prostheses implanted via a volar approach failed more often than those implanted via a dorsal approach (relative risk: 6.59, p = 0.004). The failure rate did not differ significantly between patients with rheumatoid arthritis and those with osteoarthritis (p = 0.17). The median VAS pain score at the time of follow-up was 3 (of a maximum of 100). There were twenty-two complications in fourteen patients, resulting in four interphalangeal fusions and two amputations. There were no infections. CONCLUSIONS Proximal interphalangeal surface replacement arthroplasty is a reliable treatment alternative for pain and deformity due to proximal interphalangeal joint osteoarthritis and rheumatoid arthritis. At the time of long-term follow-up, pain was minimal and joint motion was similar to preoperative levels.

Continuous regional anesthesia before surgical peripheral sympathectomy in a patient with severe digital necrosis associated with Raynaud's phenomenon and scleroderma.

Background and Objective Digital ischemia and necrosis caused by Raynaud’s phenomenon in patients with connective tissue diseases may not respond to medical therapy and may have major adverse effects on quality of life. We describe the use of continuous ambulatory regional anesthesia for diagnosis and treatment before peripheral sympathectomy in a patient with secondary Raynaud’s phenomenon. Case Report A 55-year-old man with progressive systemic sclerosis and secondary Raynaud’s phenomenon presented with severe pain and digital necrosis that were refractory to maximal medical treatment and thoracic sympathectomy. Continuous ambulatory regional analgesia increased digital temperature from 32.3°C at baseline to 34.4°C after 80 minutes. An increase in digital flow was documented by Doppler ultrasound measurements made ventrally at the point of greatest pulsation of the radial artery. Subsequent peripheral sympathectomy resulted in restoration of nutrient flow with healing of ulcers and alleviation of pain. Conclusions Continuous ambulatory regional anesthesia appears effective as a treatment bridge for vasospasm and ischemia associated with secondary Raynaud’s phenomenon. The enhancement of peripheral blood flow achieved with the regional anesthetic technique suggests that surgical peripheral sympathectomy may provide long-term benefits.

The Results of Treatment of Synovitis of the Wrist Induced by Particles of Silicone Debris

Synovitis of the wrist induced by particles of silicone debris is a destructive inflammatory process. Many silicone-rubber carpal implants remain in place, and there are few reports regarding the treatment of this condition. The purpose of the present study was to examine the results of treatment of synovitis induced by particles of silicone debris. Twenty-eight patients were identified, with use of computerized indexing, as having been evaluated for silicone-induced synovitis between 1972 and 1992. Seventeen of the twenty-eight patients were included in the study. At the time of the latest follow-up, twelve of the seventeen patients had pain, thirteen of the fourteen patients for whom radiographs were available had evidence of osteolysis typical of that associated with debris-induced synovitis, and eight of the seventeen patients reported difficulty with activities of daily living because of problems with the wrist. Seven patients had been treated non-operatively, and ten had been treated operatively. With the small number of patients available for study, we could not detect a significant difference between the two groups with respect to pain, perceived limitation of motion, difficulty with activities of daily living, grip strength, or the total range of motion of the wrist. There was no significant difference between the two groups with regard to the age at the time of the initial procedure, the time to the diagnosis of the synovitis, and the duration of follow-up after treatment. There was no clear advantage to removal of the implant and débridement with or without arthrodesis of the wrist or other reconstructive procedures. We recommend caution when a reconstructive or salvage procedure in the wrist is selected for a patient who has synovitis induced by particles of silicone debris.

Current Concepts in the Treatment of Rheumatoid Arthritis of the Distal Radioulnar Joint

Rheumatoid arthritis (RA) may progressively affect all articulations of the wrist. Involvement of the distal radioulnar joint (DRUJ) is common and may be the first clinical signs of symptoms of RA. When the DRUJ is affected by RA, upper extremity function can be affected. Effective surgical management includes the Darrach procedure, the Suave-Kapandji procedure, the hemiresection interposition arthroplasty procedure and extensor tenosynovectomy. The long-term effectiveness of DRUJ arthroplasty is currently unknown.

Validity of conventional radiography in determining scaphoid waist fracture displacement.

Objective: This study examines interpreter accuracy and interobserver agreement in evaluating conventional radiographs for scaphoid waist fracture displacement. Methods: Six fresh-frozen cadaver arms were obtained transected above the elbow. A waist fracture was created in each scaphoid. In a random fashion, three of the fractures were displaced 1 mm in the radial-ulnar plane, whereas the other three were reapproximated to anatomic position before all fractures were stabilized with radiolucent adhesive glue. A three-view conventional radiography series consisting of a posterior-anterior, lateral, and ulnar-deviated elongated scaphoid view was obtained for each wrist. Each radiograph was then presented in the same sequence for interpretation to six independent observers: two hand surgeons, two musculoskeletal radiologists, and two senior orthopaedic surgery residents who were all blinded to the actual fracture pattern. Results: In 14 of the 18 (78%) displaced fracture radiographic series, the interpreters correctly recognized displacement being present. However, displacement was also reported in six of the 18 (33%) nondisplaced fracture series. The estimated overall accuracy of all readings for distinguishing between displaced and nondisplaced fractures was 72%. Of the 90 total possible pairwise agreements between interpreters regarding fracture displacement, there were 54 actual agreements (60%), and kappa was estimated to be 0.31. Taken together, these two measures of agreement can be interpreted as indicating poor to moderate agreement. Conclusion: Our results suggest that conventional radiography is not reliable in determining 1-mm scaphoid waist fracture displacement in the radioulnar plane and also indicated a lack of strong interobserver agreement.

Accuracy and Validity of Goniometer and Visual Assessments of Angular Joint Positions of the Hand and Wrist

PURPOSE To compare goniometric and visual assessments of angular hand joint and wrist joint positions measured by board-certified hand surgeons and certified hand therapists. We hypothesized that visual estimation would be similar to the goniometric measurement accuracy of digital and wrist joint positions. METHODS The wrist, index finger metacarpophalangeal (MCP) joint, and index finger proximal interphalangeal (PIP) joint were evaluated in different positions by 40 observers: 20 board-certified hand surgeons and 20 certified hand therapists. Each observer estimated the position of the wrist, index MCP joint, and index PIP joint of the same volunteer, who was positioned in low-profile orthoses to reproduce predetermined positions. Following visual estimation, the participants measured the same joint positions using a goniometer. The control measurement was digitally determined by a radiologist who obtained radiographs of the hand and wrist positions in each orthosis. Observers were blinded to the results of control measurements. RESULTS When considering all joints at all positions, neither visual assessments nor goniometer assessments were consistently within ± 5° of the measurements obtained on control radiographs. When considering individual joints, goniometer measurements were significantly closer to control radiograph measurements than the visual assessments for all 3 PIP joint positions. There was no difference for the measurements at the wrist or for 2 of the 3 MCP joint positions. Significant differences between surgeon and therapist joint angle measurements were not observed when comparing visual and goniometer assessments to radiograph controls. CONCLUSIONS Compared with radiograph measurements, neither visual nor goniometer assessment displayed high levels of accuracy. On average, visual assessment of the angular positions of the index MCP and wrist joint were as accurate as the goniometer assessment, whereas goniometer assessment of the angular position of the PIP joint was more accurate than visual assessment. There was a relatively high degree of between-observer variability in measurements, and therefore, no one persons measurements could be consistently relied upon to be accurate. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

Effects of Distal Radius Bone Graft Harvest on the Axial Compressive Strength of the Radius

PURPOSE The effect of metaphyseal cancellous bone graft harvest on distal radius compressive strength is unknown. The purpose of this study was to analyze, in a cadaveric model, changes in distal radius axial compressive strength after distal radius metaphyseal cancellous bone graft harvest. METHODS We randomized 15 matched pairs of cadaveric radiuses into 2 groups. In group I, a target harvest of 25% of the total metaphyseal cancellous bone volume was attempted through a standardized oval cortical window. In group II, a target of 50% harvest was attempted. The study specimens and their matched controls from the contralateral side were loaded to failure in axial compression. The amount of bone graft harvested was calculated. The resulting ultimate loads to failure were measured, then expressed as ultimate stress (millipascals--MPa). We analyzed data for the 2 groups and the matched controls using paired Students t-tests. RESULTS A smaller amount of bone was harvested than anticipated in both groups. The final average distal radius bone graft harvest for group I was 10%, and for group II, 22.5%. Group I had no statistically significant difference in ultimate stress compared with the contralateral specimens that acted as matched controls (p = .273). Group II had a statistically significant decrease in ultimate stress values compared with matched controls (p = .002). The ultimate stress of group I averaged 92.67% of its matched control, whereas the ultimate stress of group II was 74.8% of its matched control (p = .027). CONCLUSIONS A significant decrease in distal radius ultimate stress occurs when approximately 23% of the metaphyseal cancellous bone is removed through a standardized oval cortical window. When the distal radius is chosen as the bone graft harvest site, we recommend harvest of less than 25% of the total available distal radius metaphyseal cancellous bone to prevent alteration of the load characteristics of the bone.

Cline’s Contracture: Dupuytren Was a Thief – A History of Surgery for Dupuytren’s Contracture

There are no records in Greek or Roman literature describing the condition of Dupuytren’s disease. The gesture of legality or truth as seen in Roman statues mirrors the classic contracture seen in Dupuytren’s (Fig. 24.1).

Dislocations of the wrist: carpal instability complex

Abstract Dislocations involving the carpus are among the most devastating injuries of the wrist. The more commonly encountered perilunate dislocations occur as the final stage of a mechanism progressing in a radial to ulnar direction. These injuries often are missed initially, potentially leading to serious complications. Patients presenting with high energy injuries about the wrist must be scrutinized carefully using standard wrist radiography and occasionally tomography. All dislocations of the carpus require prompt reduction. Better results from perilunate and lunate dislocations can be expected when dorsal and volar surgical approaches are used and the scapholunate interosseous ligament is repaired. Wrist stiffness, posttraumatic arthritis, and median nerve dysfunction may complicate carpal dislocations, even after early surgical attention.

A Rare Case of Primary High-Grade Large B-Cell Lymphoma of the Sciatic Nerve

Primary high-grade large B-cell lymphoma of the sciatic nerve without any systemic or central nervous system manifestations is rare, and the natural history of the disease is reported to be aggressive. There is a paucity of data on the optimal treatment strategies for primary sciatic nerve lymphoma. Combined modality dose-adjusted R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) followed by involved field radiation treatment to the sciatic nerve might result in functional and sustained complete remission and is an alternative treatment option. Neurolymphomatosis should be considered in the differential diagnosis of sciatic nerve tumors, and its accurate diagnosis is based on clinical features, expert hematopathology review, and functional imaging modalities including positron emission tomography-computed tomography scan.