Richard M. Braun

Total joint replacement at the base of the thumb—Preliminary report

Total joint replacement at the base of the thumb has been used for almost two decades in cases of trapezium-metacarpal arthritis. The procedure involves the insertion of a titanium metacarpal component and a polyethylene trapezium implant. The system articulates in a semiconstrained ball and socket joint that allows a full range of motion with inherent stability. Methylmethacrylate cement is optional for the metacarpal component and is routinely used in the trapezium. Revision components are available if excision of the trapezium is required because of fracture, severe arthritic deterioration, or loss of bone stock. A trapezium revision procedure converts the system into a spacer arthroplasty, which requires standard soft tissue stabilization. There have been no implant fractures or evidence of excessive wear, infections, or unstable articulated components in 80 cases that have been carefully followed up for over 10 years. Trapezium components loosening in cement cases and metacarpal subsidence in uncemented cases have a complication rate of less than 10%. These cases respond to revision procedures that permit continued functional use of the thumb. Total joint replacement appears to be safe and reliable. It is especially helpful in older patients in whom host tissues are not optimal for joint stabilization and early mobilization is desired. Total joint replacement can also be combined with associated procedures such as metacarpal phalangeal joint capsulodesis, carpal tunnel release, and tendon transfers in performing complex reconstruction of the thumb.

Surgical Treatment of the Painful Shoulder Contracture in the Stroke Patient

Spastic hemiplegic patients are frequently afflicted with painful shoulder contractures. Although most patients will respond to a limited exercise program and mild analgesics, there are some patients who continue to demonstrate increasing localized shoulder pain associated with spasticity of the internal rotator mechanism. These patients can be assisted with surgical release and an immediate postoperative exercise regimen. The results of such a program designed to diminish pain and increase range of asymptomatic motion are presented.

Preliminary experience with superficialis-to-profundus tendon transfer in the hemiplegic upper extremity.

Twenty-four hands in twenty-three patients in the Stroke Service at Rancho Los Amigos Hospital had a superficialis and profundus release procedure with transfer of the proximal ends of the superficialis to the distal ends of the profunds for severe pronation flexion deformities in the forearm and hand. The initial goal of improved position in the hand and wrist was achieved in twenty-one of the twenty-four patients operated on. In three patients who demonstrated volitional flexor control prior to surgery, that control was maintained after the operation.

Treatment of shoulder deformity in acquired spasticity.

Cerebrovascular accidents and traumatic brain injury produce most of the deformities seen in patients with spastic imbalance of the shoulder. A general awareness of the global neurologic defect is required to understand appropriate treatment alternatives. Conservative treatment techniques include early initiation of therapy exercises. Muscle or nerve block treatments may prevent severe shoulder contractures. Diagnostic blocks may help differentiate between deformity caused by spasticity and that caused by fixed soft tissue contracture. Operative release procedures are described. These operations, when combined with appropriate postoperative therapy programs, permit correction of contractures caused by unbalanced muscle forces around the shoulder in patients with severe spasticity who do not respond to conservative care.

Total Joint Arthroplasty at the Carpometacarpal Joint of the Thumb

A series of 50 cases of total joint arthroplasty at the carpometacarpal joint of the thumb demonstrate surgical procedure and cement technique. Most patients showed a full range of motion within four weeks of suture removal and continue to demonstrate good long-term results. Less motion is anticipated in patients with contractures or systemic disease. Five patients showed clinical or radiographic evidence of loosening. Revision procedures document the retrieval potential of a failed implant. The authors ten-year experience with this system indicates that the concept is viable. Future modifications are discussed.

Flexor-origin Release for Pronation-flexion Deformity of the Forearm and Hand in the Stroke Patient: An Evaluation Of The Early Results In Eighteen Patients

Eighteen patients on the Stroke Service at Rancho Los Amigos Hospital were operated on for pronation-flexion deformities of the forearm and hand. Nine patients with severe spasticity, contracture, and poor sensation were operated on to improve appearance and hygiene, and to relieve pain. Nine patients with moderate spasticity, selective motor control of the extremity, and adequate sensation were operated on to improve function in their affected extremity. The results of flexororigin release and associated procedures in this series demonstrate that reasonable improvement can be expected in properly selected stroke patients.

Phenol Nerve Block in the Treatment of Acquired Spastic Hemiplegia in the Upper Limb

Direct exposure of motor nerves and injection of 3 to 5 per cent phenol into their sheaths in doses of two to five milliliters has been shown to reduce the spasticity in twenty-three patients, but the benefit lasted less than six months. The present study of twenty-four adult patients and of ten children who had the injections and then had either transfer of the flexor carpi ulnaris into the extensor carpi radialis brevis or had a vigorous physical therapy program including the use of plaster splints. The phenol injection proved to be a valuable supplement to both regimens and also permitted better evaluation of indications for further therapy.

Posterior deltoid-to-triceps transfer in quadriplegia.

Provided that the patient selection criteria, surgical procedure, and postoperative care recommended by Moberg are strictly observed, the posterior deltoid-to-triceps transfer is an excellent surgical procedure for improving the level of function of the C5 or C6 quadriplegic. Before surgery, patients should be thoroughly counseled in realistic expectations, the possible functional results, and the long period of time required to attain the goals of surgical treatment.

Epineurial nerve suture.

The final chapter on the results of peripheral nerve suture has not been written. Continued interest of investigators in this area will probably lead to improve results in the future. The biology of repair remains a determining factor once meticulous technique has been exercised by the surgeon. Epineurial neurorrhaphy is the standard technique today for peripheral nerve suture.

The distal joint of the radius and ulna : diagnostic studies and treatment rationale

Three areas of functional anatomy are present in the distal ulna. Each of these has a specific function in load bearing of the wrist, rotation of the forearm, and maintenance of the relationship between the radius and ulna. The distal portion of the ulna serves as a suspensory post for ligaments that stabilize the ulnar border of the wrist. The midportion of the distal ulna contains the load-bearing triangular fibrocartilage complex. The proximal portion of the distal ulna articulates with the radius at the sigmoid notch and participates in forearm rotation. Each of these areas is assessed in problems related to ligament instability, load bearing, and range of motion. Mechanical problems that affect the distal joint of the radius and ulna include the affects of trauma, degenerative change, and inflammatory disease. Each of these requires evaluation in the treatment of joint derangement. Diagnostic studies that relate to problems in the distal radioulnar joint area include standard roentgenographs, arthrograms, magnetic resonance (MR) scanning, and arthroscopy. Each of these studies has particular advantages and disadvantages in providing data for analysis of joint malfunction. A medical history, physical examination, and use of proper diagnostic studies will assist in an appropriate diagnosis of problems in the distal joint of the radius and ulna.