Clinical assessment of the thumb trapeziometacarpal joint.

Osteoarthritis of the basal joint of the thumb causes pain and disability for a huge segment of the adult population, particularly women. Radiographically, there is a spectrum of disease that has been staged according to severity of involvement of the TM and scaphotrapezial joints. The staging system proposed by Littler and Eaton is used most widely. The severity of clinical symptoms does not necessarily correspond with the radiographic stage of disease, however, so decisions about treatment are predicated upon the notion that we "treat patients, not x-rays." Treatment is based upon the extent to which the pain and functional limitations caused by the disease impact upon the patient's activities of daily living. The evaluation of basal joint disease has been reviewed and modalities of treatment outlined. Conservative treatment includes splinting, nonsteroidal anti-inflammatory drugs, thenar intrinsic strengthening exercise, and corticosteroid injection. Failure of conservative treatment and unremitting pain are indications for basal joint reconstruction by arthroplasty, osteotomy, or arthrodesis. Staging of basal joint disease provides a rationale for selecting the appropriate surgical procedure for a particular patient.

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.

Long-term results of volar ligament reconstruction for symptomatic basal joint laxity.

It has been hypothesized that instability of the thumb trapeziometacarpal joint is a major factor in the etiology of degenerative disease. Theoretically, surgically stabilized joints should be subject to less shear force and, hence, will be less likely to develop degenerative changes. The long-term results of volar ligament reconstruction were assessed in 19 patients (24 thumbs). The average age at surgery was 33 years (range, 18-55 years). Twenty-three thumbs were radiographic stage I; a preoperative x-ray was not available in 1. The follow-up period averaged 15 years (range, 10-23 years). At the final follow-up visit 15 thumbs were stage I, 7 were stage II, and 2 were stage III. Fifteen patients were at least 90% satisfied with the results of the surgery. Only 8% of thumbs advanced to radiographic arthritic disease, which compares favorably with the 17% to 33% reported incidence of stage III/IV basal joint arthritis in the general population.

Tomography versus computed tomography for assessing step off in intraarticular distal radial fractures.

Computed tomography scans have supplanted conventional tomography for many applications and often are considered the imaging study of choice for assessing intraarticular distal radial fractures. Concern about cost containment in healthcare delivery prompts the question of whether the two studies provide comparable information and at what cost. Common intraarticular distal radial fractures were created in 12 lightly embalmed cadaveric specimens. The fractures were fixed with radiolucent Kirschner wires. Articular step off was measured with a caliper. Plain radiographs, computed tomography scans, and trispiral tomograms were obtained of each specimen. Maximal step off was measured blindly by two musculoskeletal radiologists and four hand surgeons. The radiographic measurements were compared with the actual step off and expressed as a positive or negative deviation from the actual value. There was no statistically significant difference between computed tomography scans and tomograms in predicting step off. In addition, the difference between actual and radiographic measurements was insignificant in tomogram readings and different in one of the computed tomography measurements. In the authors' institution, a tomogram costs $200, and a computed tomography scan costs $562. Trispiral tomography is more accurate and cost effective than computed tomography, and thus when available should be considered the imaging modality of choice for assessing articular step off in distal radius fractures.

Splinting in the treatment of arthritis of the first carpometacarpal joint.

Although much has been written about surgical treatment of arthritis of the first carpometacarpal joint, no literature exists on splinting as a conservative treatment. One hundred fourteen patients (130 thumbs) were retrospectively reviewed to determine the efficacy of splinting. Patients were grouped according to their stage of disease and whether they had carpometacarpal joint surgery. Seventy-six percent of patients with stage I and II disease and 54% of patients with stage III and IV disease had improvement in their symptoms with splinting. There was no significant difference in the degree of improvement between the 2 groups. All patients who had initial improvement in their symptoms with splinting had between 54% and 61% average improvement in symptom severity 6 months after splinting. All groups were found to be equally tolerant of the splinting protocol and no group had a significantly higher rate of activity modification. Overall, splinting was found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of carpometacarpal joint arthritis and inflammation.

Palmar fracture dislocation of the proximal interphalangeal joint.

Palmar fracture dislocation of the proximal interphalangeal joint is uncommon. Thirteen patients treated for this injury were retrospectively reviewed. There were 9 acute injuries. Seven were treated by closed reduction and percutaneous pin fixation and 2 were treated by open reduction and internal fixation. The 4 chronic injuries (more than 1 month after injury) were treated with open reduction and soft tissue reconstruction. The length of follow-up averaged 55 months. Eight patients were free from pain. Postoperative proximal interphalangeal motion averaged 91 for the acute injuries and 70 degrees for the chronic injuries. Follow-up radiographic findings were notable for an increased height of the middle phalangeal base in 6 patients, articular irregularity in 4, and residual subluxation in 2; however, these changes did not correlate with the clinical results. Complications included loss of reduction in 1 patient, progressive swan neck deformity in 1, and development of an average 25 degrees extension lag of the distal interphalangeal joint in 5.

Degenerative changes of the trapeziometacarpal joint: radiologic assessment.

The trapeziometacarpal joint is particularly prone to osteoarthritis due to the great amount of stress applied with everyday activities with the hands. In this essay, radiologic assessment and staging of "basal joint" osteoarthritis, treatments based on radiologic staging and intraoperative findings, and surgical complications are described.

Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.

Static and dynamic procedures have been described for reconstruction of chronic instability of the ulnar collateral ligament of the thumb metacarpophalangeal joint. This study presents a technique of ligament replacement utilizing a free tendon graft passed through two gouge tracks in the proximal phalanx and one in the metacarpal in a manner that closely approximates normal anatomy. We retrospectively reviewed 26 patients who underwent replacement. The follow-up period averaged 4.5 years. In 24 of 26 cases the joint was rendered stable by the replacement and the patient was relieved of pain. Eighty-five percent of the arc of motion was maintained. Postoperative key pinch measured 20 lb. on the operated side compared to 21 lb. on the unoperated side. Results were excellent in 20 patients, good in 4, and fair in 2. This technique successfully restores stability to the ulnar collateral ligament of the thumb metacarpophalangeal joint, diminishes pain and weakness with minimal loss of motion, and holds up over time.

Arthroscopic assisted internal fixation of volar intraarticular wrist fractures.

Open reduction internal fixation of displaced volar intraarticular distal radius fractures traditionally require sacrificing the volar ligaments to visualize the articular surface. We present a modification of standard arthroscopy that facilitates visualization of the radiocarpal joint while preserving these ligaments.

Results of treatment of severe carpal tunnel syndrome.

A retrospective study was undertaken to determine the efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome. The criteria for inclusion in this study were unobtainable median sensory-evoked response and absent or prolonged median motor distal latency. Fifteen hands in 13 patients met these criteria. All patients had symptoms, including pain, weakness, or decreased sensation. Postoperative follow-up averaged 27 months. Symptomatic improvement was obtained in 14 of the 15 hands, and sensory-evoked response improved in 13 hands. Preoperative thenar atrophy was present in 10 of the 15 hands and was completely resolved in 2 of the 10 patients. These results indicate that carpal tunnel decompression is of benefit to patients with severe carpal tunnel syndrome. Long-standing symptoms, thenar atrophy, virtual anesthesia, and the absence of demonstrable sensory and motor-evoked responses are not contraindications to surgery.

Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease.

Visualization of the scaphotrapezial joint during basal joint arthroplasty has been recommended to establish the stage of degeneration. This study attempts to clarify that recommendation and evaluate whether moderate wear of the joint precludes a good result of trapeziometacarpal hemiarthroplasty. To assess the need for inspection of the scaphotrapezial joint, x-ray films, tomograms, and operative findings in 23 cases of basal joint arthroplasty were reviewed. X-ray findings agreed with operative findings at the scaphotrapezial joint in only 76% of the cases. We also evaluated 18 thumbs in 15 patients who underwent interposition arthroplasty of the trapeziometacarpal joint and at surgery had moderate degenerative changes of the scaphotrapezial joint. The scaphotrapezial joints were left intact and the trapeziometacarpal joints were reconstructed. Follow-up averaged 8 years. In no case was there x-ray or symptomatic progression of the disease at the scaphotrapezial joint. Clinically, 78% were rated excellent, 17% good, and 5% fair.

Basal joint arthroplasty using the Roosevelt Hospital techniques.

Many reconstructive procedures have been developed to treat osteoarthritis of the basal joint of the thumb. The current article describes techniques used at the Hand Surgery Center at Roosevelt Hospital in New York City. A tonometry applanation radiographic staging system is outlined; it serves as a rationale for selecting which form of arthroplasty is appropriate for a particular patient and is predicated on the extent of involvement of the trapezial articulations. Stage 1 disease implies symptomatic laxity of the trapeziometacarpal joint with normal articular surfaces and is most appropriately treated with volar ligament reconstruction. Stage 2 is an intermediate category and amenable to either volar ligament reconstruction or interpositional arthroplasty of the trapeziometacarpal joint, based on the condition of the articular cartilage at surgery. In stage 3 disease there are significant degenerative changes of the trapeziometacarpal joint with preservation of the articular surfaces of the scaphotrapezial joint. Two variations on ligament reconstruction with interpositional arthroplasty of the trapeziometacarpal joint are described; they have consistently good results. Finally, stage 4 is characterized by pantrapezial degenerative disease and necessitates trapezial resection. Reconstruction may be by silicone rubber implant arthroplasty using a stemmed trapezial implant stabilized by an abductor pollicis longus tenodesis. The alternative is a procedure in which the thumb metacarpal is tethered to the index metacarpal by a ligament reconstruction.

Predictive factors in the non-surgical treatment of carpal tunnel syndrome.

To identify which patients are likely to respond the medical management of carpal tunnel syndrome, 331 hands in 229 patients were evaluated. They were then treated with a wrist splint and anti-inflammatory medication. Follow-up averaged 15.4 months (minimum six months). Treatment was successful in 18.4%. Statistical evaluation identified five factors which were important in predicting response to treatment: age over 50 years, duration over ten months, constant paraesthesiae, stenosing flexor tenosynovitis, and a Phalen's test positive in less than 30 seconds. When none of these factors was present, two-thirds of patients were cured by medical therapy. 59.6% of patients with one factor, 83.3% with two factors, and 93.2% with three factors failed. No patient with four or five factors present was cured by medical management.

Hand infections in patients with acquired immunodeficiency syndrome.

Eight patients are reported with hand infections and a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). Seven patients had AIDS and one ARC. Four were homosexually active males, three were intravenous drug abusers, and one was the wife of a presumed drug abuser. The hand infections were not truly opportunistic; three patients had herpes, two had osteomyelitis, one had septic arthritis, and two had bacterial abscesses. The presentation or course of the infection was atypical in the majority of patients. The infections were seen early in the course of the disease and in one half of the patients preceded the diagnosis of AIDS. Unusual hand infections, then, may suggest the development of AIDS in a patient at risk.

Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment.

Painful arthrosis of the basal joints of the thumb covers a spectrum of arthritic disease. The painful hypermobile thumb with articular cartilage preserved requires an entirely different type of treatment than does the similarly painful basal joint, which has stiffness and degeneration of more than one facet of the trapezium. By careful radiographic evaluation of the trapezial articulations, particularly in the lateral projection, a reasonable set of radiographic guidelines for staging of the degenerative process can be provided. One must be prepared to adjust this preoperative staging should direct inspection of the articular surfaces at surgery indicate more damage than perceived on the radiograph. Once the ultimate staging of the disease has been established, the means of treatment is considerably simplified and the multiple procedures that have been proposed for "basal joint arthritis" can be applied more accurately.

Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb.

Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.

Ligamentous reconstruction for chronic intercarpal instability.

Twenty-one patients with chronic intercarpal instability were operated on an average of 13.2 months after injury or onset of symptoms. Fourteen had reconstruction via dorsal approaches by use of radial wrist extensor or other tendon graft. Seven patients were approached dorsally and palmarly, three had ligament repair, and four had reconstructions. The average follow-up was 25.4 months. Pain decreased in 85.7% of patients, although only two were pain free. Range of motion (ROM) generally decreased, and grip strength increased slightly. Radiologically, there was significant improvement on the initial postoperative roentgenograms, much of which was lost by the time the final roentgenograms were obtained. A clinical and radiologic grading system was devised to evaluate results. The average clinical grade improved from poor (26.5%) preoperatively to fair (44.4%) postoperatively. The radiologic grade remained in the poor range postoperatively, although there was some improvement from 40.4% to 45.6%.

Coronary artery aneurysm.

The case is presented of a 28-year-old woman with systemic vasculitis, aortic insufficiency, and an aneurysm of the proximal right coronary artery. More than 100 patients with coronary artery aneurysm have been reported, and this represents the twenty-first case treated surgically. Coronary artery aneurysms occur more frequently than previously realized and are seen in approximately 1.5% of patients with coronary artery disease. In addition to arteriosclerotic aneurysm, other common types of coronary aneurysm include those occurring congenitally or from mycosis, dissection, trauma, vasculitis, or periarteritis nodosa. Because of the risk of thrombosis and rupture, aneurysmectomy and saphenous vein bypass grafting are recommended for all but small, diffuse, or multiple aneurysms or dissecting aneurysms.