Total joint replacement at the base of the thumb.

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.

Iatrogenic compression of the thoracic outlet.

Arterial injury and brachial plexus nerve compression have been reported in association with surgical procedures in the area of the thoracic outlet. An initial report of iatrogenic injury was related to the operative correction of Sprengel's deformity, which required lowering of the scapula in a child. Compression of the neurovascular bundle between the clavicle and the first rib occurred during this surgical migration. The developmental anatomy of the costo-clavicular area and the descent of the upper limb from its initial cervical position are reviewed. This relationship between the clavicle and the first rib may also be altered by surgical procedures carried out on adults. Two cases of the iatrogenic injury to the brachial plexus are reported in association with operations performed in the area of the clavicle. Correction of these injuries resulted when the costoclavicular space was re-established.

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.

Palmaris longus tendon transfer for augmentation of the thenar musculature in low median palsy.

The palmaris tendon may be lengthened by a distal strip of palmar fascia and transferred subcutaneously to the tendon of insertion of the abductor pollicis brevis for augmentation of thumbs elevation from the palm. The transfer attempts to duplicate abductor brevis function in the complex act of opposition. The palmaris has appropriate strength, excursion, and direction for this purpose. It is properly phased for pinch activity and requires minimal retraining. Twenty-eight cases of transfer have been performed successfully and without difficulty. The uses of the transfer have included cases of carpal tunnel syndrome with thenar atrophy, injury to thenar muscles, and direct trauma to the median nerve in the forearm.

Stabilization of silastic implant arthroplasty at the trapezometacarpal joint.

Instability of the carpometacarpal joint of the thumb may accompany silastic implant arthroplasty. A collapse deformity of the thumb with resultant loss of pinch power impairs hand function. A procedure is described, which allows apical stabilization of the base of the thumb. Compressive forces may then act on the thumb to produce divergence in abduction without collapse instability and yet allow enough motion for convergence in oposition and restoration of asymptomatic three-point pinch.

Total joint replacement at the base of the thumb--preliminary report.

Twenty-nine patients have been studied after trapeziometacarpal total joint replacement with a system of the author's design using a titanium metacarpal component and a polyethylene trapezium component cemented to bone with polymethyl methacrylate. Replacement was performed for arthritis, failure of attempted arthrodesis, previous Silastic or total joint arthroplasty failure, or postparalytic fibrous ankylosis of the joint. Twenty-six patients have achieved a good range of painless motion since the study was initiated in 1974. There have been no cases of implant fracture or infection, but three cases have demonstrated loosening at the cement--bone interface. The results appear to warrant cautious optimism at this time.

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 author's ten-year experience with this system indicates that the concept is viable. Future modifications are discussed.

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.

Spontaneous bilateral median nerve compressions in the distal arm.

A case of bilateral median nerve compressions in the distal arm is described. The patient was seen initially with the spontaneous onset of paresis of the anterior interosseous nerve innervated muscles, as well as more proximal median nerve innervated muscles. There was no shoulder-girdle weakness or sensory abnormality. No systemic symptoms were identified. Surgical exploration in each extremity revealed enlarged communicating veins directly compressing the median nerve in the distal arms. Clinical improvement began 6 months after operation and was complete by 18 months.

Dynamic compression for small bone arthrodesis.

A technique providing dynamic compression for arthrodesis of the small joints in the hand uses a longitudinal wire for alignment and two 0.045 Kirschner wires and methyl methacrylate cement for continuous dynamic compression. Thirty-one joints, 12 metacarpophalangeal and 19 interphalangeal, were arthrodesed by this method. There were no angular malunions or nonunions. The technique is recommended as an alternative to current fixation methods in the hand for small joint arthrodesis.

Dorsal pin placement and external fixation for correction of dorsal tilt in fractures of the distal radius.

Insertion of a dorsal fixation pin was performed in 10 patients treated for distal radius fractures associated with dorsal angulation of the distal fragment. These fractures did not improve position with direct traction. Reduction was achieved with the use of a dorsal pin, used as a lever, to correct dorsal tilt of the fracture and to reestablish anterior angulation of 10 degrees in the distal joint surface of the radius. The dorsal pin was then fixed to an external fixator bar. All of these fractures healed in good position with appropriate alignment and without complications.