Richard I. Burton

Surgical management of basal Joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplast

Palmar oblique ligament reconstruction combined with tendon interposition (LRTI) arthroplasty with part of the flexor carpi radialis tendon was developed for advanced osteoarthritis of the thumb basal joint. Twenty-five procedures are reviewed with an average follow-up of 2 years, ranging from 1 to 4 1/2 years. LRTI arthroplasty more consistently improved pinch strength, increased grip strength endurance, and restored thumb web space than did silicone implant arthroplasty. Proximal metacarpal migration averaged only 11% of the initial arthroplasty space versus nearly 50% loss of height with silicone implants. Subluxation averaged only 7% of the width of the thumb metacarpal base relative to the scaphoid versus subluxation of 35% of the base of the implant with silicone arthroplasty. Excellent results were achieved in 23 thumbs or 92% of cases. No deterioration of function or stability has been noted over time, and no revisional procedures have been necessary. On the basis of these encouraging early results, LRTI arthroplasty has become our preferred surgical treatment for advanced basal joint osteoarthritis of the thumb.

Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition.

Twenty-four thumbs of twenty-two patients were evaluated at an average of nine years (range, eight to eleven years) after a ligament reconstruction-tendon interposition arthroplasty for osteoarthrosis at the base of the thumb. The same group had also been examined two and six years postoperatively. The procedure had been performed as a primary operation in twenty-one thumbs and as a revision of a failed implant arthroplasty in three. Twenty-one (95 per cent) of the twenty-two patients had excellent relief of pain and were satisfied with the outcome. The average grip strength increased ten kilograms (p < 0.005), reflecting a 93 per cent improvement compared with the preoperative values. Similarly, the average tip pinch strength steadily improved, with an increase at the most recent examination of nearly one kilogram (p < 0.005) (65 per cent improvement). Improvements in the average key pinch strength, however, were first noted at the six-year follow-up examination and then tapered slightly; the most recent values reflected an average gain of 34 per cent but were not significantly different from the preoperative values. The tip of twenty-two (92 per cent) of the twenty-four thumbs was able to touch the base of the little finger, and the most recent average web angle (40 degrees) was unchanged from the value at the two-year follow-up examination. Stress radiographs showed an average subluxation of the metacarpal base of 11 per cent at nine years compared with 7 and 8 per cent at two and six years, respectively. Similarly, these radiographs demonstrated an average loss of height of the arthroplasty space of 13 per cent at nine years compared with 11 per cent at both of the earlier follow-up examinations. This modest deterioration of radiographic parameters was not predictive of an unsatisfactory outcome. The ligament reconstruction-tendon interposition arthroplasty provided a stable and functional reconstruction of the thumb, resulting in excellent relief of pain and a significant increase in strength for as long as eleven years after the procedure.

Scapholunate advanced collapse wrist : proximal row carpectomy or limited wrist arthrodesis with scaphoid excision ?

Proximal row carpectomy (PRC) and limited intercarpal arthrodesis with scaphoid excision (LWF) are useful alternatives to wrist arthrodesis for treatment of degenerative wrist disorders secondary to scapholunate advanced collapse. Because consensus regarding the ideal motion-preserving option is lacking, we sought to better define the indications for and relative merits of PRC versus LWF. Twenty-four wrists treated for symptomatic scapholunate advanced collapse arthritis between 1980 and 1990 with either PRC or LWF were retrospectively reviewed at an average of 5.5 years postoperatively. At follow-up evaluation, satisfactory pain relief, grip strength, and functional performance were observed except in three patients with PRC, one of whom had developed symptomatic radiocarpal arthritis requiring conversion to arthrodesis. Differences in subjective and objective results between the two treatment groups were not statistically significant except for residual range of motion. Incomplete correction of lunate extension when LWF was performed resulted in diminished wrist extension, compared to PRC. Improvements in grip strength and range of motion were noted for at least 1 year after both procedures, and neither declined with time. A stage-dependent surgical approach to the symptomatic scapholunate advanced collapse wrist is advocated in light of comparable outcomes following both PRC and LWF. For wrists without capitolunate arthritis, PRC avoids the technical demands, lengthy postoperative immobilization, and risk of nonunion associated with LWF, but for stage III disease (capitolunate arthritis) pain relief may be unsatisfactory, and LWF is recommended.

Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty

Seventy-two procedures in 53 patients with advanced basal joint arthritis are retrospectively evaluated with follow-up ranging from 12 months to 8 years. Follow-up of a subset of 32 silicone implant arthroplasties in osteoarthritic thumbs averaged 3.9 years with a 25% failure rate. Despite providing early symptomatic relief, silicone implants lost nearly 50% of vertical height at the ulnar margin secondary to cold flow and wear and subluxed 35% of the width of the prosthesis during the study period. Dynamic tendon transfers did not prevent implant subluxation and had no effect on the magnitude or pattern of implant wear. Ligamentous reconstruction reduced implant instability, but was accompanied by an increase in silicone wear and cold flow. Reactive giant cell synovitis with silicone particulates and adjacent bone resorption was seen in some cases of implant arthroplasty failure. Forces across the osteoarthritic basal joint would seem to preclude a stable silicone implant arthroplasty in the absence of eventual wear and symptomatic foreign body synovitis. Because of this unresolved conflict between implant stability and wear, at the present time we seldom use silicone in the osteoarthritic basal joint, but continue to utilize the silicone hemitrapezium or the cannulated trapezium replacement with satisfactory results in the low-demand rheumatoid thumb.

Osteoarthritis of the proximal interphalangeal joint of the hand: Arthroplasty or fusion?

Forty-three procedures on the proximal interphalangeal joint in 24 patients are retrospectively reviewed. A diagnosis of erosive osteoarthritis accounted for 83% of the joints that had operation. Flexible silicone interposition, cemented Biomeric arthroplasty, or arthrodesis were done based on the individual functional needs of each patient and involved digit. All cemented Biomeric devices, preferentially implanted in the radial digits for optimal lateral stability, failed through the elastomer hinge at an average of 2.25 years after operation. Arthrodesis of the proximal interphalangeal joint in the radial digits provided greatest improvement in lateral pinch strength. Flexible silicone interposition arthroplasty in the ulnar digits provided an average flexion arc of 56 degrees with satisfactory pain relief. Although none required revision, radiographically evident bone resorption adjacent to the silicone implant was progressive over time; 35% of implants followed-up longer than 2 years demonstrated periarticular erosion and 20% followed-up beyond 4 years had extensive endosteal resorption along the intramedullary prosthetic stems. Surgical treatment of the osteoarthritic proximal interphalangeal joint remains an unsolved problem.

Long-term results following proximal row carpectomy☆

The functional outcome, patient satisfaction, and x-ray film status for 23 wrists were examined an average of 6 years following proximal row carpectomy. Surgery was performed for Kienbocks disease, scapholunate dissociation with periscaphoid arthritis, and scaphoid nonunion not suitable for bone grafting. Twenty patients were satisfied with functional performance and pain relief. Wrist flexion-extension arc averaged 74 degrees, or 61%, of the opposite wrist at a later examination. Grip strength, corrected dor dominance, averaged 79% of the opposite side, reflecting an average improvement of 15 kg force. Radiocarpal arthritis developed in three wrists, but only one required arthrodesis for pain relief. The majority of patients experienced satisfactory pain relief, functional wrist motion, and effective grip strength following proximal row carpectomy. The results did not decline at an average of 6 years after surgery.

Surgical management of the rheumatoid wrist—Fusion or arthroplasty

Forty-eight patients with 33 wrist fusions and 37 silicone wrist arthroplasties were reviewed and compared. Of those who had arthrodesis 97% showed a good or excellent result. Follow-up time averaged 82 months. All patients had a decrease in pain. Most patients had stronger wrists but complained of decreased dexterity. There were no pseudarthroses. The complication rate was 18%. Of patients in the arthroplasty group, 78% had a good or excellent result. Follow-up time averaged 51 months. Most patients in the arthroplasty group had improved dexterity and adequate wrist strength. Average flexion/extension was 32 degrees/29 degrees. The complication rate was 25%, which included four revisions. Of patients who had arthroplasties, 14% had bone resorption about the stem, and 11% of the patients with arthroplasties had x-ray evidence of settling. Factors that did not influence the result of the arthroplasty were patient age, duration of disease before surgery, finger extensor tendon rupture, preoperative motion, and hand dominance. Factors that were associated with failure and/or a fair result in arthroplasty patients were the use of ambulatory aids, the older and narrower prosthetic design, dislocated wrist preoperatively, and the chronic use of steroids.

The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the thumb

Basal joint arthritis of the thumb and carpal tunnel syndrome are common conditions with an acknowledged coexistence. This article attempts to quantify the prevalence of carpal tunnel syndrome in patients with basal joint arthritis and to examine some of the etiologic factors that affect the coexistence of the two disorders. Of 246 patients who had surgery about the basal joint, 95 patients (39%) were identified by chart review as having carpal tunnel syndrome. Eleven of 122 remaining patients contacted had symptomatic carpal tunnel syndrome confirmed by nerve-conduction studies, bringing the total to 106 (43%). The prevalence was higher in workers compensation patients and those with diabetes mellitus. The prevalence was lower in men than in women, and patients with inflammatory joint disease were at less risk than those with osteoarthritis. Given this high association, great care should be taken to diagnose or exclude coexistent carpal tunnel syndrome in patients scheduled for basal joint surgery so that, if present, it can be treated at the same time, diminishing the risk of postoperative morbidity and delayed symptoms.

Comparative effects of growth factors on fibroblasts of Dupuytren's tissue and normal palmar fascia

Recent experimental evidence implicates various growth factors in the pathophysiology of Dupuytrens disease. This study describes a technique to produce an in vitro cell culture system from both normal palmar fascia and Dupuytrens fascia. The cells were separately exposed to basic fibroblast growth factor (bFGF), transforming growth factor beta (TGF-beta), and platelet-derived growth factor (PDGF), after which the effects of these growth factors on proliferation rate and collagen production were determined. Basic FGF and PDGF were found to be mitogenic for both cell types, and TGF-beta was a potent stimulator of collagen production for both cell types. There were quantitative and qualitative differences between the cell types, with Dupuytren cells being more metabolically active and more sensitive to the growth factors tested. We present a theoretical model based on previous investigations and incorporating the contribution of growth factors as it relates to the pathophysiology of Dupuytrens disease.

Small-joint arthrodesis in the hand

Arthrodesis of selected small joints of the hand is often indicated; however, in previously reported series nonunion is not uncommon. There were 171 consecutive arthrodeses of small joints performed on 134 patients. The operative method employed was essentially the method described by Littler. Emphasis was placed on the accurate coaptation of bone surfaces, the use of cancellous bone graft when needed, maintenance of the coaptation with Kirschner wires, and the need for postoperative immobilization. This technique resulted in union of 170 out of 171 arthrodeses (a nonunion rate of 0.6%). There were no infections. There were four delayed unions.