Replacement of the distal radio-ulnar joint with a semi-constrained Scheker DRUJ prosthesis.

OBJECTIVE: To describe the indications, operative technique, and long-term outcomes of patients treated with the Scheker (Aptis) distal radio-ulnar joint (DRUJ) prosthesis. INDICATIONS: The Scheker prosthesis is intended to replace the DRUJ in patients with rheumatoid, degenerative, or posttraumatic arthritis of the sigmoid notch and/or ulnar head, or in cases of gross instability of the DRUJ. Moreover, a Scheker prosthesis can be used to treat failed salvage procedures, such as the Sauvé-Kapandji procedure, ulnar head resection, and ulnar head arthroplasty. CONTRAINDICATIONS: Severe osteoporosis, active infection, immature skeleton, less than 14 cm of the proximal ulna remaining. SURGICAL TECHNIQUE: In supine position with the forearm in full pronation, an ulnar S­shaped incision is made. The ulnar head is resected and the proximal part is brought to the palmar side to enable visualization of the sigmoid notch. Following preparation of the sigmoid notch and the proximal ulnar part of the radius, a radial plate is attached. When the position is verified with fluoroscopy, screw holes are drilled together with a separate hole for the radial peg. A metal stem is inserted in the ulnar shaft. A polymer ball is then slid on to a polished peg on top of the ulnar stem. This polymer ball is seated in the socket of the radial plate and fixed with a small metal cap. Radiographic images are made for confirmation of correct positioning and full pro- and supination is tested, after which the wound is closed. POSTOPERATIVE MANAGEMENT: After 48 h of pressure bandages, patients are instructed to start with full range of motion and weight-bearing exercises under the guidance of a hand therapist. Weight-bearing is constrained to 10 kg. RESULTS: We retrospectively assessed 50 Scheker prostheses in 48 patients treated between 2016 and 2021. The median age was 56 years (IQR: 50-65) and 30 (60%) were female. Median follow-up was 29 months (IQR: 12-48). The primary outcome was the PRWE score. The median PRWE score at the final follow-up was 23 (IQR: 4-52) for the operated side versus a median PRWE score of 5 (IQR: 0-25) for the non-operated side (p < 0.005). Six patients had a complication. Three patients developed extensor carpi ulnaris tendinitis with one patient requiring additional surgery. One patient developed a neuroma of the distal branch of the ulnar nerve that was surgically removed. One synovectomy was performed because of synovitis and one endoscopic ulnar release was performed because of hyperesthesia of the ulnar area. None of the prostheses had to be removed.

[A black wound on the lower arm]. / Een zwartgekleurde wond aan de onderarm.

A 19-year-old man presented on the Emergency Room on New Year's Eve with a 2 cm-wide black burn located on his lower arm. Earlier that evening he was hit by a piece of firework. Even though he immediately felt a sharp burning pain, he did not realize the severity of the injury. He presented with numbness in the digiti 4 and 5 and the Wartenberg sign, which are signs of an ulnar nerve injury. An exploration of the ulnar nerve was performed. Extensive burns and gunpowder were seen on the flexor carpi radialis and ulnaris muscle, the fascia and the epineurium of the ulnar nerve. However, the ulnar nerve was intact. A week later a babysitting procedure was performed because of absent intrinsic muscle activity, with an end-to-side anastomosis of the anterior interosseous nerve to the motor branch of the ulnar nerve. Hand physiotherapy was started after the operation.

Modification of the use of the extensor retinaculum for reducible distal radioulnar joint instability: technique and results.

Different surgical techniques have been described for chronic distal radioulnar joint instability: they are often complicated, quite invasive and may not be recommended for bidirectional instability. We describe a procedure using a radial-based extensor retinaculum strip and a capsular plication. This is a simple technique and less invasive than 'anatomic' radioulnar ligament reconstructions. We report the results of 38 patients (38 wrists) who we treated. After a minimum of 8 months we quantified the outcomes of the patients objectively by assessing ranges of motion, grip strength and clinical assessment of stability, and subjectively using questionnaires. Overall, 36 out of 38 patients were stable after surgery. The operated forearm and wrist had approximately 3° less range of motion in all planes and 3 kgf less grip strength compared with the unoperated side. The median Mayo modified wrist score was 90; the median visual analogue scale score was 2. This surgical technique appears to successfully treat patients with chronic reducible distal radioulnar joint instability. Anatomic reconstruction of both radioulnar ligaments is not always necessary. LEVEL OF EVIDENCE: IV.

Prevalence and severity of cold intolerance in patients after hand fracture.

Cold intolerance is a well-known phenomenon that develops in the first months after hand injury and generally does not decrease over time. In this study, we evaluated the prevalence and severity of cold intolerance after hand fracture in 129 patients using the Cold Intolerance Symptom Severity (CISS) questionnaire. Patients with nerve and/or vascular injuries were excluded. The response rate was 59%. The mean CISS score was 23. Pathological cold intolerance, defined as a CISS score over 30, was experienced by 38% of the patients. Cold intolerance is common after hand fractures and can be severely disabling in some patients.

Digital rewarming patterns after median and ulnar nerve injury.

PURPOSE: Posttraumatic cold intolerance (CI) is a frequent and important sequel after peripheral nerve injury. In this study, it is hypothesized that altered rewarming patterns after peripheral nerve injury are related to the degree of posttraumatic CI. This hypothesis is tested by quantitatively comparing rewarming patterns of the digits in controls and in median or ulnar nerve injury patients and by investigating relationships between rewarming patterns, sensory recovery, and CI. METHODS: Twelve median or ulnar nerve injury patients with a follow-up of 4 to 76 months after nerve repair and 13 control subjects had isolated cold stress testing of the hands. Video thermography was used to analyze and compare rewarming patterns of the injured and uninjured digits after cold stress testing. Temperature curves were analyzed by calculating the Q value as an indicator of heat transfer (temperature added during the first 10 minutes after start of active rewarming) and the maximum slope. RESULTS: Test-retest reliability was 0.64 and 0.79, respectively, for the Q value and maximum slope. High Q values and maximum slopes were interpreted as the presence of active rewarming. Patients with return of active rewarming had better sensory recovery and lower Blond McIndoe Cold Intolerance Severity Scale (CISS) scores. Better sensory recovery was correlated with lower CISS scores. CONCLUSIONS: Test-retest reliability of cold stress testing was good, and we found a difference in rewarming patterns between nerve injury patients and controls. The presence of active rewarming in the nerve injury patients was related to sensory recovery and fewer complaints of posttraumatic CI.

Cold intolerance following median and ulnar nerve injuries: prognosis and predictors.

This study describes the predictors for cold intolerance and the relationship to sensory recovery after median and ulnar nerve injuries. The study population consisted of 107 patients 2 to 10 years after median, ulnar or combined median and ulnar nerve injuries. Patients were asked to fill out the Cold Intolerance Severity Score (CISS) questionnaire and sensory recovery was measured using Semmes-Weinstein monofilaments. Fifty-six percent of the patients with a single nerve injury and 70% with a combined nerve injury suffered abnormal cold intolerance. Patients with no return of sensation had dramatically higher CISS-scores than patients with normal sensory recovery. Females had higher CISS scores post-injury than males. Cold intolerance did not diminish over the years. Patients with higher CISS scores needed more time to return to their work. Age, additional arterial injury, site or type of the injury and dominance of the hand were not found to have a significant influence on cold intolerance.

Cold intolerance of the hand measured by the CISS questionnaire in a normative study population.

Cold intolerance has been recognized as one of the most disabling sequelae of upper extremity trauma, especially when neurovascular structures are involved. In this study, we aimed to describe cold intolerance in a normative study population, validate the Cold Intolerance Symptom Severity (CISS) questionnaire and define the threshold for abnormal cold intolerance. One hundred and eight volunteers participated in our study. In addition to the CISS score, information about age, gender and previous surgery or trauma to the upper extremity was obtained. There were no volunteers with previous peripheral nerve injury and subjects with a history of Raynaud's disease, upper extremity injury or surgery were excluded (n=40). The CISS scores of the study population (n=68) averaged 12.9 (SD 8.2). Age and gender were not correlated with CISS score. The upper 95% confidence interval of the CISS scores for healthy subjects is about 30. We suggest this value as a threshold for pathological cold intolerance.

Clinical value of electrodiagnostic testing following repair of peripheral nerve lesions: a prospective study.

This study prospectively assessed the level of correlation between functional and electrophysiological recovery after median and ulnar nerve lacerations. Motor and sensory recovery were recorded clinically and electrophysiologically every 3 months in 24 patients with 29 complete median or ulnar nerve lacerations. The strength of agreement between the clinical motor score and the electrophysiological score was "fair", but in 41% a discrepancy was identified (kappa factor 0.39). Regeneration was not detected earlier by electrophysiology than by a thoroughly performed clinical evaluation. This suggests that electrophysiologic testing is of value as an adjunct to clinical assessment for evaluating cases in which there is clinical doubt as to the progress of regeneration and secondary surgery is contemplated.

Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity.

BACKGROUND: Forearm and wrist injuries are a common cause of morbidity and are often associated with suboptimal recovery of hand function. This study describes and compares outcome after median, ulnar, or combined median-ulnar nerve injuries. METHODS: Three hundred thirteen wrist and forearm nerve injuries operated on between 1980 and 1997 in a large university hospital were reviewed in relation to complications, return to work, and sensor and motor recovery. Of these 313 patients, 220 (age range, 5-73 years) met the inclusion criteria. RESULTS: Motor recovery, progress of sensory reinnervation, and number of severed structures were related to the type of injury (p < 0.05). Multiple linear regression analysis revealed a relation between the appearance of sensory reinnervation and motor recovery (beta = 0.02; 95% confidence interval, 0.01-0.04; p = 0.01). A probability of 24% of work loss, after a mean follow-up of 17.7 months, was found. Poor sensory and motor recovery were associated with work disability (odds ratio [OR], 2.9; p = 0.002; and OR, 2.9; p = 0.007, respectively). No relationship was found between type of injury and return to work (p = 0.47). Level of injury (OR, 2.6; p = 0.01), type of work (OR, 3.1; p = 0.002), number of complications (p < 0.001), and hand-therapy (OR, 0.24; p = 0.001) were found to influence return to work. CONCLUSION: It may be concluded that peripheral nerve injuries at the forearm level can result in substantial functional loss and have major social consequences. This study identified factors influencing return to work that can be used to optimize postoperative treatment strategy.