Stabilized subcutaneous ulnar nerve transposition with immediate range of motion. Long-term follow-up.

BACKGROUND: Anterior transposition of the ulnar nerve at the elbow produces generally good results regardless of whether the nerve is transposed subcutaneously, intramuscularly, or submuscularly. The eventual recovery of nerve function is related less to the specific surgical technique than to the severity of the intrinsic nerve pathology. A primary variable in surgical management is the duration of postoperative elbow immobilization. The purpose of this study was to review the longterm results of a specific technique of subcutaneous anterior transposition of the ulnar nerve that utilizes a stabilizing fasciodermal sling. The study compared the results of immediate and late institution of a range of motion postoperatively. METHODS: Forty-seven patients with fifty-one elbows were reexamined, by an investigator who had not been involved in their treatment, at a minimum of two years (range, twenty-four months to fourteen years) after an anterior transposition. Of the fifty-one elbows, twenty-one were immobilized for two to three weeks whereas thirty were managed with an immediate range of motion. RESULTS: At the latest follow-up evaluation, there were occasional, mild paresthesias in 16 percent of the limbs and there was still subjective weakness of 19 percent. Both pinch and grip strength had increased substantially. No patient had lost elbow motion. A positive Tinel sign persisted in 31 percent of the limbs, but it was mildly positive in most of them. The elbow flexion test was uniformly negative. The results for 92 percent of the limbs were satisfactory to the patients, who stated that they would undergo the same procedure again if necessary. Overall, 73 percent of the limbs had an excellent result; 18 percent, a good result; 4 percent, a fair result; and 6 percent, a poor result. With the numbers available, no significant difference could be detected, with regard to these outcomes, between the group managed with elbow immobilization and that managed with immediate elbow mobilization. However, patients treated with a postoperative cast returned to work at an average of thirty days after surgery whereas the group treated with immediate motion of the elbow returned to work at an average of ten days. CONCLUSIONS: This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately.

Basal joint arthritis of the thumb.

Thumb pain secondary to arthritis at the basal joint of the thumb is a common condition, especially in women, and can be quite disabling. An accurate diagnosis can be readily made from the history and examination. Radiographs are used to stage the severity of the arthritis. Splinting is the mainstay of conservative care. Reconstructive procedures for each stage of the disease are aimed at restoring thumb motion and strength. Partial or complete trapeziectomy with tendon interposition and ligament reconstruction to stabilize the metacarpal base is used for advanced disease. Secondary metacarpophalangeal joint hyper-extension deformity may need to be addressed. Surgery can reliably improve function and engender high patient satisfaction.

Proximal interphalangeal joint fracture dislocations.

Proximal interphalangeal joint fracture dislocations are complex, potentially disabling injuries for any patient, especially the competitive athlete. Dorsal fracture dislocations are fairly common and volar fracture dislocations are rare. Stable injuries often heal with minimal functional deficit, whereas unstable injuries can result in limitation in range of motion, joint incongruity, and degenerative joint disease. A number of surgical procedures have been described to treat the unstable dorsal fracture dislocation, including ORIF, extension block pinning, external fixation, dynamic traction, and volar plate arthroplasty. Volar fracture dislocations are usually amenable to closed or open reduction and internal fixation. The results of treatment of both volar and dorsal fracture dislocations can be unpredictable.

Iatrogenic posterior tibial nerve division during ankle arthroscopy.

Ankle arthroscopy has been increasingly applied to the diagnostic and therapeutic treatment of ankle disorders. Owing to the complex cutaneous anatomy of the ankle, neurological injuries are a potential complication of this procedure. All reports of neurological complications resulting from ankle arthroscopy have attributed them to use of a distractor pin or to portal placement. Several authors have noted the possibility of damage to the deep peroneal nerve from the use of motorized arthroscopic tools within the anterior ankle joint capsule. We present what we believe to be the first reported case of complete division of the posterior tibial nerve resulting from an apparently overaggressive intra-articular manipulation during ankle arthroscopy performed for loose body removal.

Save the trapezium: double interposition arthroplasty for the treatment of stage IV disease of the basal joint.

Twenty patients with symptomatic stage IV basal joint (pantrapezial) arthritis were treated with double interposition arthroplasty, a new technique that resurfaces the degenerative trapeziometacarpal and scaphotrapezial joints after minimal distal trapezial resection. The results of the 21 procedures were reviewed clinically and radiographically after a mean follow-up period of 34 months (minimum, 1 year). Ninety-one percent of the patients were completely satisfied. Seventy-one percent were entirely free of pain, and an additional 24% noted only occasional, mild, high-stress pain that did not limit their activities. One case was a clinical failure. Objectively, all 21 basal joints were stable, with active range of motion to within 90% of normal. Mean grip strength increased 32%, from a force of 26.1 kg to 33.9 kg (p < .01). Key pinch strength increased from a force of 5.3 kg to 6.0 kg (an 11% increase; p = .05). A new method of determining changes in basal joint height indicated a mean decrease in height of 5.3% (range, 0%-12%) at rest and 8.1% (range, 0%-20%) under axial compression. This difference was statistically but not functionally significant. Overall, there were 95% good or excellent results and 1 poor result. We believe this technique is simple and preserves the osseous foundation of the basal joints. These results compare favorably with arthroplasties that include trapezium excision for the treatment of stage IV basal joint arthritis.

Arthroscopic distal clavicle resection from a bursal approach.

We retrospectively reviewed 117 consecutive patients who underwent arthroscopic acromioclavicular joint (ACJ) arthroplasties. Only patients who underwent ACJ arthroplasties from a bursal approach in conjunction with subacromial decompression were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these rigid criteria for inclusion in the study. After an arthroscopic subacromial decompression, the distal clavicle was visualized and resected through a standard bursal approach. In addition, an anterosuperior portal was used in 50% of the patients to confirm adequate clavicle resection. Postoperative follow-up averaged 32.5 months (range, 24 to 70 months). Preoperative and postoperative pain were rated subjectively on a 5-point scale (1, incapacitating pain; 5, no pain). Operative reports and postoperative radiographs were reviewed to determine technical factors that may have influenced outcome. Seventeen patients had excellent results (71%), 4 good (16.5%), and there were 3 failures (12.5%). Average preoperative pain rating was 1.8 and was improved to 4.3 postoperatively. The average amount of clavicle resection was only 5.4 mm. Given smooth, even, and complete bone removal, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, additional use of an anterosuperior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients.

A rapid response microviscosimeter.

An in vitro instrument is described which is designed to measure effective viscosity of blood in arteriolar size tubes at physiologically nominal flow rates, mimicking flow in the microcirculation. The 41-micron microviscosimeter is accurate within 2% when tested against viscosity standards and is reproducible within 2% using blood samples. Because the full-scale instrument response time is 3 s, either fresh or anticoagulated blood samples may be used. Measured over the nominal range of blood flow rate (Q), effective blood viscosity was found to be an increasing, decreasing, or flat function of Q, depending upon the particular individual being tested. A reference group of 81 young, healthy subjects was used to define viscous resistance (VR), a new parameter that provides for quantitative viscosity comparisons between individuals or groups without hematocrit manipulation of blood samples. As examples of the microviscosimeter's use, a group of 118 subjects was used to test for VR variation between various group subsets. No difference in VR was found between men and women; exercisers had lower VR than nonexercisers; and overweight subjects had more viscous blood than non-overweight subjects. The instrument will be useful for in vitro investigations of effective viscosity and viscous resistance in the microcirculation.

Assessing the need for extensive supervised rehabilitation following arthroscopic ACL reconstruction.

To determine the necessity of extensive supervised therapy, we reviewed the records of 39 consecutive patients who underwent arthroscopic anterior cruciate ligament reconstruction using mid-1/3 bone-patellar tendon-bone autograft, followed by a minimal therapy program. This study group was subdivided into a noncompliant group averaging 1.7 visits over 6 months (range, 0 to 5), (subgroup I), and a minimally compliant group averaging 12 visits over 6 months (range, 5 to 24), (subgroup II). Thirty patients who underwent similar surgeries and postoperative protocols, but participated in an extensive supervised outpatient therapy program, served as controls. The control group was fully compliant and averaged 60 visits over 6 months. After 6 months, the minimally compliant study subgroup was equivalent to the fully compliant control group in Lysholm score, patient satisfaction, and return to preoperative activity level. Both of these groups fared better in all of these indices than did the noncompliant subgroup. These results suggest that extensive supervised rehabilitation does not afford a measurable advantage over a minimally supervised program of two visits monthly. Complete noncompliance, however, was associated with suboptimal outcome.

Revision instability surgery.

Revision instability is a complex clinical problem. A successful outcome is dependent on several factors, including an accurate diagnosis clearly delineating the different pathologic conditions contributing to the failure. Also, from a technical aspect, an attempt should be made to restore the normal anatomic relationships while achieving glenohumeral stability in a functional range of motion. The purpose of this article is to assist the clinician in the evaluation and treatment of failed instability surgery by combining the authors' personal experience with an extensive review of the literature.