Thomas R. Kiefhaber

Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: Proximal row carpectomy versus four-corner arthrodesis*

Seventeen patients were treated with scaphoid excision and four-corner arthrodesis (lunate, capitate, hamate, triquetrum) for scapholunate advanced collapse wrist and followed for a mean of 27 months. Eleven wrists in 10 patients had a proximal row carpectomy for scapholunate advanced collapse wrist and were followed for a mean of 37 months. The total arc of motion averaged 95 degrees in the four-corner arthrodesis patients and 115 degrees in the proximal row carpectomy patients, which was 47% and 64%, respectively, of the range of motion of the opposite wrist. Grip strength averaged 74% of the opposite wrist in the four-corner arthrodesis group and 94% in the proximal row carpectomy group. Three wrists in the four-corner arthrodesis group failed and were successfully converted to a total wrist fusion; two additional patients were awaiting arthrodesis. There were no failures in the proximal row carpectomy group. Proximal row carpectomy showed a high degree of patient satisfaction and is our motion-preserving procedure of choice except in those wrists with advanced capitolunate arthritis.

Proximal row carpectomy: Study with a minimum of ten years of follow-up

BACKGROUND Proximal row carpectomy is an accepted motion-sparing surgical procedure for the treatment of degenerative conditions of the wrist. However, there is little information regarding the long-term clinical and radiographic results following this procedure. METHODS Twenty-two wrists in twenty-one patients underwent proximal row carpectomy for the treatment of degenerative arthritis between 1980 and 1992. Objective and subjective function was assessed after a minimum duration of follow-up of ten years (average, fourteen years). RESULTS There were four failures (18%) requiring fusion at an average of seven years. All four failures occurred in patients who were thirty-five years of age or less at the time of the proximal row carpectomy (p = 0.03). The wrists that did not fail had an average flexion-extension arc of 72 degrees , associated with an average grip strength of 91% of that on the contralateral side. The patients were very satisfied with fourteen of the eighteen wrists that did not fail and were satisfied with the remaining four. The patients rated nine wrists as not painful, four as mildly painful, five as moderately painful, and none as severely painful. The average Disabilities of the Arm, Shoulder and Hand score was 9 points. Radiographs revealed no loss of the radiocapitate space in three of the seventeen wrists for which radiographs were made, reduced space in seven, and complete loss of the space in seven. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function. CONCLUSIONS At the time of long-term follow-up, all patients older than thirty-five years of age at the time of a proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief and were satisfied with the result. Caution should be exercised in performing the procedure in patients younger than thirty-five years of age. Although degeneration of the radiocapitate joint was seen radiographically in fourteen of the seventeen wrists, it did not preclude a successful clinical result.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft.

PURPOSE This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations. METHODS Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2-175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months. RESULTS The average arc of motion at the PIP joint was 85 degrees (range, 65 degrees to 100 degrees ). The distal interphalangeal (DIP) joint average arc of motion was 60 degrees (range, 35 degrees to 80 degrees ). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0-10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up. CONCLUSIONS When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.

Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition

Background: There has been considerable controversy regarding the procedure of choice for treatment of any given stage of osteoarthritis of the thumb carpometacarpal joint. This study was designed to directly compare the clinical results of two common surgical procedures for this condition, trapeziometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition, in similar patient populations. Methods: Between 1988 and 1998, 109 patients (141 thumbs) who were less than sixty years old were treated with one of the two procedures. In a retrospective review, forty‐two patients (fifty‐eight thumbs) treated with arthrodesis completed an outcome questionnaire and twenty‐nine patients (forty‐four thumbs) treated with arthrodesis completed the questionnaire and were examined. In the group treated with trapezial excision with ligament reconstruction and tendon interposition, thirty‐nine patients (forty‐nine thumbs) completed the questionnaire and thirty patients (thirty‐eight thumbs) completed the questionnaire and were examined. The average duration of follow-up was sixty‐nine months. The groups were similar with regard to age, gender, hand dominance, and duration of follow‐up. Results: Subjective evaluation of pain, function, and satisfaction demonstrated no significant difference between the two groups, with >90% of patients satisfied following either procedure. Although grip strength did not differ between the groups, the arthrodesis group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01). The group treated with ligament reconstruction and tendon interposition had a better range of motion with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001). There was a higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications. However, despite a persistent nonunion in six thumbs, those thumbs and the thumbs in which union was obtained did not differ with regard to pain; all of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome. Peritrapezial arthritis developed in nine patients (fourteen thumbs). This finding was not related to age and did not affect overall pain, function, or satisfaction. Conclusions: Although traditionally arthrodesis and ligament reconstruction and tendon interposition have been indicated in two different patient populations, we compared them in a homogeneous group and found that the two procedures had similar results with regard to pain, function, and satisfaction despite minimal differences in strength and motion. Although complications were more frequent following arthrodesis, most did not affect the overall outcome.

FRACTURE DISLOCATIONS OF THE PROXIMAL INTERPHALANGEAL JOINT

Fracture dislocations of the proximal interphalangeal joint may occur by several different mechanisms of injury and are of 3 basic fracture patterns: palmar lip fractures, dorsal lip fractures, and pilon fractures. Proper treatment of these injuries is predicated on maintenance of concentric reduction of the joint, restoration of joint stability, and institution of early motion. Anatomic reconstitution of the articular surface, though ideal, is less important. Many methods are available to treat these injuries. Understanding the fracture within the context of a stability-based classification system helps to guide in the selection of the most appropriate treatment. Copyright

Pilon fractures of the proximal interphalangeal joint

A pilon fracture is an uncommon intraarticular fracture of the proximal interphalangeal (PIP) joint resulting in comminution, central depression, and splay, sagittally and coronally, of the articular surface of the base of the middle phalanx. This study reviews three treatment methods and results in 20 patients. Injury was produced by an axial load and occurred primarily to the ulnar digits. Clinical and radiographic follow-up averaged 25 months. Treatment was divided into three categories: splint (four patients), skeletal traction through the middle phalanx (seven patients), and open reduction with Kirschner pins (nine patients). Anatomic restoration of PIP articular contour was not achieved, regardless of technique. No patient regained full mobility at either interphalangeal joint. Treatment by immobilization is undesirable. Open reduction should be approached cautiously and may result in significant complications. Skeletal traction is safe and gives results that are radiographically and clinically comparable to those achieved with open reduction.

Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation

Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78° and was corrected to a normal 47° at surgery. The average final scapholunate angle was 72°, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.

Trapeziometacarpal joint arthrodesis: a functional evaluation.

Over a 10-year period, 39 trapeziometacarpal (TM) joint fusions were performed in 37 patients. Pin fixation was used in 27 fusions and staple fixation in 12; all were bone grafted. There were five delayed unions (greater than 3 months) and three nonunions. Twenty-four fusions were evaluated at an average of 4 years. Subjectively, there were 11 excellent, 7 good, 5 fair, and 1 poor result. Grip and pinch strength were symmetrical, and the nine-hole peg test (a measurement of dexterity) was slightly better on the treated side. X-ray films were taken and compared with 25 normal films to assess metacarpal mobility. There was a 72% reduction in the adduction/abduction arc and a 61% reduction in the flexion/extension arc. Despite the marked decrease in motion, subjective functional complaints were minimal. X-ray films were evaluated independently by a radiologist to assess progression of degenerative changes. Only two patients were noted to have changes at the scaphotrapezial joint.

Hemi-Hamate Arthroplasty Provides Functional Reconstruction of Acute and Chronic Proximal Interphalangeal Fracture–Dislocations

PURPOSE Hemi-hamate resurfacing arthroplasty is a treatment alternative for the management of severe acute and chronic dorsal proximal interphalangeal (PIP) fracture-dislocations. This study was designed to determine whether this procedure would successfully restore function after such injuries. METHODS Hemi-hamate reconstructions were performed on 33 patients (mean age, 34 years) who presented to 1 hand surgery practice with dorsal PIP fracture-dislocations. Eligible patients experienced unstable dislocations with comminuted metaphyseal fractures involving at least 50% of the volar middle phalangeal surface that was not amenable to open reduction and internal fixation. We evaluated 22 patients with 14 acute (<6 weeks) and 8 chronic (mean, 30 weeks) injuries at a mean of 4.5 years (range, 1-7 years). Functional outcomes were assessed by objective and subjective measures: joint alignment/motion/stability, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and visual analog scales (VAS) of pain and function. RESULTS After hemi-hamate reconstruction, active PIP motion averaged 70 degrees (acute 71 degrees , chronic 69 degrees ) with a mean flexion contracture of 19 degrees (range, 0 degrees to 80 degrees ). Active distal interphalangeal motion averaged 54 degrees (acute 56 degrees , chronic 51 degrees ). The mean VAS score for digit pain was 1.4 (acute 0.7, chronic 2.5). The mean DASH score of 5 (acute 2, chronic 9) and VAS functional score of 1.9 (acute 1.4, chronic 2.6) indicated little functional impairment (acute 2, chronic 9). Grip strength averaged 95% of the opposite hand. Mean coronal plane angulation at the PIP joint was 3 degrees . Ten patients reported aching with cold temperatures. One dissatisfied patient underwent revision surgery. Chronic reconstructions were associated with increased VAS pain ratings (p = .02) and higher DASH scores (p = .06). CONCLUSIONS Hemi-hamate reconstruction represents a valuable surgical procedure to address severe PIP joint fracture-dislocations. Reconstruction of chronic injuries by this method restores PIP function, albeit with more modest outcome performance. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Lateral stability of the proximal interphalangeal joint

Current diagnostic criteria and therapeutic guidelines for injuries to the collateral ligaments of the proximal interphalangeal (PIP) joint are imprecise and vague. Laxity determinations, failure analysis, radiographic stress testing, and microscopic dissections were performed on 112 PIP joints. The lateral collateral ligament (LCL) is the primary restraint to varus and valgus angulation of the PIP joint. Its palmar fibers are tight in joint extension and provide the first line of resistance to lateral angulation. Failure of the LCL almost always occurs proximally in a sequential fashion that begins with the palmar fibers and progresses to the more dorsal bundles. Proximal LCL disruption is followed by separation of the accessory collateral-LCL junction and finally by failure of the distal palmar plate. Midsubstance tears of the LCL are rare. If the lateral stress test shows more than 20 degrees of varus or valgus angulation, the LCL can be presumed to be completely disrupted. Angulation of less than 20 degrees is associated with a 53% chance of partial LCL failure and a 47% chance of complete disruption, but the proper position of the LCL will be maintained by the overlying connective tissues. A clinical investigation will be necessary to define the criteria for surgical intervention.