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.

Skeletal alterations following irradiation for Wilms' tumor: with particular reference to scoliosis and kyphosis.

The roentgenographic changes in the axial skeleton after irradiation for Wilms' tumor were studied in eighty-one patients. In addition to the initial alterations found in the individual vertebrae within the field of irradiation, spinal deformity subsequently developed in fifty-nine patients (pure scoliosis in thirty-eight, kyphoscoliosis in nineteen, and pure kyphosis in two). Unitl the adolescent growth spurt these deformities tended to remain slight, but some progression did occur. In seven patients the scoliosis became severe enough to require spine fusion. A Milwaukee brace used in three patients failed to correct the curve. The trapezoidal shape of the vertebrae and scarring of the soft tissues within the concavity made correction difficult. Recognizable roentgenographic alterations failed to develop in twenty-two patients who, in general, were older and had received less irradiation. There appeared to be a correlation between the amount of irradiation and the severity of the spinal deformity (p is less than 0.05) and between the age of irradiation and the amount of deformity (p is less than 0.02).

Nerve entrapments of the upper extremity: A surgical perspective.

The surgeon's perspective of nerve entrapment lesions in the upper extremity is discussed in this article. The focus is on the most common lesions of the median, ulnar, and radial nerves. An understanding of the anatomy and the potential pathologies provide the basis for surgical treatment. Current treatment protocols are discussed with the authors' recommendations that are based upon experience and literature review.

Avoiding pitfalls in the diagnosis of the acutely injured proximal interphalangeal joint.

Closed injuries to the proximal interphalangeal joint are very common. Many anatomic structures are located in this small area; any one or several may be injured. Each causes a painful, swollen joint. A precise diagnosis of which structures are damaged is important for rational treatment. It is essential to distinguish between injuries to the flexor or extensor tendon mechanism, fractures about the proximal phalangeal joint, and ligamentous and volar plate injuries. The examining physician must understand the functional anatomy of this joint, perform a detailed evaluation, obtain the proper roentgenographic views, and render treatment according to a specific diagnosis. Accurate diagnosis with early appropriate treatment favors good recovery.

Basal joint arthritis. Fusion, implant, or soft tissue reconstruction?

The basal joint of the thumb is often afflicted with arthritis with significant resultant disability. Many reconstructive procedures are available. Many factors must be considered to choose the best procedure for the individual patient.

Complications following surgery on the basal joint of the thumb.

Basal joint arthritis of the thumb is common and can be disabling. Effective surgical treatment is realistic, and most patients will obtain predictably gratifying results. With attention to detail, most problems can be prevented. Occasionally, however, in spite of excellent care, complications do occur. Fortunately, such complications will usually respond to prompt recognition and treatment.

Basal joint implant arthroplasty in osteoarthritis. Indications, techniques, pitfalls, and problems.

Implant arthroplasty is a valuable surgical procedure for some patients with basal joint arthritis of the thumb. Those patients for whom it seems to be the most useful are the low-demand osteoarthritic and the rheumatoid. Should this type of arthroplasty be selected, the associated soft tissue reconstruction is of paramount importance in determining the success of the surgical effort.

Small joint injuries of the hand. Dynamic and functional implications.

An injury to one of the small joints of the hand may have a major impact on hand function and thus have major implications for career and avocation. Proper treatment demands a knowledge of hand anatomy and dynamic function. Proper primary treatment usually yields better results than attempted late reconstruction; however, even with the best of primary care, long-range significant disability may result.

Discovering the right questions--our call to action--who will define health care rationing, and how?

Will the citizens and legislators of our country be accurately informed in enough detail to decide wisely on the proposed health care plans? If we cannot afford all health care for all people, how can we make the government use the words "rationing health care" and be certain that the rationing is done by the stakeholders (patients and providers)? Changes in the health care system are needed and it must be improved, but does that justify totally changing a system providing the best care in the world for 200 million people? Or should we build on and improve that which is good and extend it to the remaining 10-15% who are currently without insurance? Can the government guarantee good health? Does this imply we are to guarantee health, then food, and then housing and clothing? Or, rather, should we guarantee the right to pursue a job that allows the purchase of health care insurance, just as we have the right to purchase housing, food, and clothing? Can we guarantee health to our citizens, or must we guarantee the right to pursue good health? How much should we spend on health care? Is the health care industry a growth industry with the product a healthier population? If so, should it be punished or encouraged? Is what we spend out of line with what is spent on entertainment, tobacco, and alcohol? When viewed from that perspective is health care too expensive or a bargain? Will the individual citizen accept his/her individual obligation to change habits and lifestyle? Do the people of this country really want a health care service with the regulatory simplicity of the tax law, the frugality of the Pentagon, the efficiency of the Post Office, and the compassion of the IRS? To be consistent with the Vice President's efforts to downsize government should government involvement in health care be increased or decreased? Are the proper innovations underway on the state level? Is federal law necessary now at all, or should Washington just monitor the emerging new programs at the regional and state levels? If England and Sweden are backing away from socialism and starting to privatize, and if major cities in our own country are acknowledging governmental failure and inability to deliver cost-effective quality service for such simple things as trash collection and maintenance of park systems, how can our federal government run health care?(ABSTRACT TRUNCATED AT 400 WORDS)

Credentialing for international fellowships.

The common market may provide a unique opportunity to develop certification models between countries as some of the economic, social, and language barriers begin to soften. International fellowships must be encouraged, especially those from the third world, but with the understanding that the purpose of such international education is for the fellow to return to the country of origin and improve the health care delivery there, not to improve the personal finances of the fellow in an adopted country. The autocratic dogmatic certification by the decreed blessing of the department chair must give way to objective examination by impartial boards. There are too many differences now to establish an international certifying process, but everyone must encourage and work toward common professional, educational, political, national, and economic goals so that eventually such certifying might be possible. Dialogue between boards in the United States and analogous bodies in other countries (such as colleges of surgeons) to nurture the definition of necessary core knowledge, standardize examination design and technique, and eventually develop reciprocity for requirements to take examinations should also be encouraged.

Malignant fibrous histiocytoma of the forearm: report of a case and review of the literature.

The tissue histiocyte can give rise to a variety of lesions, either benign or malignant, and the latter often is confused with other sarcomas. The multipotential nature of the histiocyte results in the presence of at least five different cell types in these tumors, and all may be derived from a common precursor cell. The anaplasia of elements which differentiate as fibroblasts appears to correlate with survival. The tumors may be highly malignant, and the 10 year survival rate approximates 40%. Aggressive surgical management of these tumors is mandatory, with either wide en bloc resection or primary amputation of the involved extremity. Should the tumor recur locally after a wide resection and there be no detectable metastases, prompt amputation is indicated.

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.

Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty.

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.