The follow-up of trapeziometacarpal arthrodesis using V-shaped osteotomy for osteoarthritis of the first carpometacarpal joint.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint, also known as the thumb carpometacarpal joint, is one of the most common anatomic sites of arthritis in the human body. Many surgical techniques to address this problem have been developed; including, trapeziectomy with or without ligament reconstruction tendon interposition, implant arthroplasty, and arthrodesis. No methods have yet proven superior to the others, and each has associated limitations and complications. The primary complication found in the literature after arthrodesis of the trapeziometacarpal joint is nonunion; with a reported incidence in the literature as 13% (8% to 39%). METHODS: In 2010, a new surgical technique for this procedure was published by Wolff and Duerinckx in Techniques in Hand Surgery. In summary, a V-shaped osteotomy is made at the base of the first metacarpal and, together with a matching osteotomy of the trapezium, creates a more stable fusion site. Our current research looks at a minimum of 2-year follow-up of patients treated with this technique between 2004 and 2012. RESULTS: Twenty-one patients, including 3 who had bilateral procedures, have participated in the study. The average age is 62.6 years (range, 51 to 76 y) with an average follow-up of 4.6 years (range, 2 to 8 y). Sixteen are female and 5 are male, with a variety of occupations. In these patients, the Quick DASH score improved 51% (49.8 to 24.2; P=0.0006), and the Quick DASH Work score improved 56% (52.8 to 23.2; P=0.0035). Nineteen of 21 patients said that they wound have the procedure again. Range of motion and strength of the operated versus nonoperated thumbs were compared and showed very similar capabilities. Seventy-five percent (18 of 24) were able to lay their hand flat. There were 4 fibrous unions, resulting in an 83% complete fusion rate. There were no infections or reoperations for nonunion. CONCLUSION: The data suggest that this procedure is a highly successful, pain-relieving, strength-preserving, reproducible arthrodesis with a nonunion rate similar to that of the published literature.

Combined common extensor and supinator aponeurotomy for the treatment of lateral epicondylitis.

Pain at the lateral epicondyle and the extensor origin that is attributable to lateral epicondylitis can be successfully treated with a combined aponeurotomy of the supinator and the extensor muscles. This technique has been used at our institution for over 3 decades with good results. Aponeurotomy of the supinator decompresses the posterior interosseous nerve, whereas the extensor aponeurotomy relieves the stresses on the extensor carpi radialis brevis origin. We retrospectively reviewed a series of 56 patients clinically diagnosed with resistant lateral epicondylitis who underwent surgery by a single surgeon with our technique between 2002 and 2010. Patients experienced a subjective improvement in symptoms, visual analog pain score, and grip strength (Jamar II). Only 3% of patients experienced recurrence requiring further treatment.

A new concept for thumb basal joint arthrodesis: the V-shaped osteotomy.

Nonunion is a common complication after trapeziometacarpal joint arthrodesis. Classically, arthrodesis involves the apposition of the trapezium to the metacarpal after excision of the diseased joint surfaces producing either a cone-in-cup configuration or 2 opposing flat surfaces. With these techniques, it is difficult to achieve good coaptation of the bony surfaces in the desired angle of arthrodesis. Additional bone grafting is often required. We describe a new technique to shape the trapeziometacarpal joint surfaces that provides inherent stability, a larger contact area, and that allows easy positioning of the thumb in the ideal position for fusion.

The ''two fleck sign'' for an occult Stener lesion.

We report a case of distal pull-off of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb with two fracture fragments. The more obvious fracture fragment, seen on plain X-ray to be lying adjacent to the expected location of the attachment of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, was, in fact, unassociated with it and was part of the attachment of the adductor pollicis muscle. A second smaller fleck of bone which was attached to the displaced collateral ligament was only observed on plain X-ray on retrospective review. This second fleck of bone identified that this was a Stener lesion, requiring surgical reattachment of the ligament. Similar cases in the literature are reviewed and the use of MRI in detecting these lesions is discussed.

A comparative study of ulnar-shortening osteotomy by the freehand technique versus the Rayhack technique.

PURPOSE: To compare the results of ulnar shortening by the traditional freehand method with those achieved by the Rayhack technique. METHODS: A historical cohort of 95 patients (97 ulnas) who had ulnar shortening for the treatment of ulnar-impaction syndrome was evaluated. Forty-three patients (45 ulnas) were treated by the freehand technique and 52 patients (52 ulnas) by the Rayhack technique. Both groups were well matched in terms of age, gender, prior history of trauma, and associated injuries. The following variables were compared: duration of surgery, relief of pain, return to work, postoperative complications, time elapsed between surgery and return to work, union of the osteotomy, collinear alignment of the ulnar shaft, and alignment of the plate against the bone. These variables were compared by using the independent-groups t test, chi-square test, and Fisher exact test, as appropriate. RESULTS: Statistical analysis of the compared parameters: duration of surgery, relief of pain, return to work, postoperative complications, time elapsed between surgery and return to work, and union of the osteotomy, showed that none was significant. There were no cases of malalignment of the ulnar shaft or malalignment of the plate against bone in either group. Our calculations show that one would need a cohort of at least 300 patients in each group to show meaningful differences between the groups provided the same proportions held true. CONCLUSIONS: There was a trend toward a higher incidence of nonunion in patients who had the freehand technique although we were unable to show a statistical difference. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.

Slipper cast management of emergency foot problems.

Foot conditions are frequently seen in the emergency department. In many cases, although weight bearing is painful, it is not precluded, per se. When a soft dressing does not provide sufficient support, a below knee walking cast may be applied. We present an alternative dressing that may be of benefit in selected foot injuries. The dressing is fashioned with cast padding, foam sheeting and plaster. It is designed and molded to fit like a slipper. The plaster slipper has distinct advantages in that it is comfortable, lighter for the patient, and avoids the problem of ankle stiffness. We believe that this option is underused in the emergency setting.

Preventing tourniquet effect when dressing finger wounds in children.

Hand and finger injuries are common injuries in children seen in emergency departments. Many of these are soft tissue injuries, which are often caused by household items, such as doors and exercise equipment. Once these injuries are repaired, usually they are covered with a simple dressing using a material such as Coban (3M, Minneapolis, MN). This dressing often is applied by winding it circumferentially around the digit. However, with very little manipulation, this dressing can be lifted and rolled up the digit in a distal direction, creating a tourniquet effect, which can cause hypoxia and tissue necrosis. To prevent the tourniquet effect, the dressing must include the hand and wrist.