The value of scapho-trapezio-trapezoid arthrodesis combined with "de la Caffinière" arthroplasty for the treatment of pan-trapezial osteoarthritis.

13 patients, 12 female and one male (mean age 63) with pan-trapezial osteoarthritis were treated by a "de la Caffinière" arthroplasty of the first carpometacarpal joint, combined with a scapho-trapezio-trapezoid (STT) arthrodesis. 11 could be reviewed at least 3 years after surgery (average 3 years and 8 months). Non-union of the arthrodesis occurred twice, once when no internal stabilization was used, once with the use of the staplizer. No impingement syndrome was recorded, and there was no correlation between the angular position of the scaphoid and mobility of the wrist. Two out of 11 "de la Caffinière" implants had to be removed. Loosening of the stem is unusual, but the cup remained only perfectly in place in two cases. There was no correlation between radiological and clinical findings and the overall result was good or excellent in 8 out of 13 (62%) of the cases. The grip and pinch strength were comparable to the results of the literature. This method cannot be further recommended because of the high rate of re-operation and the risk to the trapezium which has to be further evaluated.

[Osteomalacia of the lunate bone--indications for and limitations of radial shortening and ulnar lengthening]. / Lunatummalazie--Indikation und Grenzen der Niveauoperation.

Increased pressure on the lunate bone due to anatomical variance seems to be an important etiological factor in Kienböck's disease. Early diagnosis and treatment may prevent the development of carpal collapse. Ulnar lengthening and radial shortening have proven helpful in stages I-III of Kienböck's disease.

[The painful wrist joint: alloplastic joint replacement]. / Das schmerzhafte Handgelenk: Alloplastischer Gelenkersatz.

The analysis of the etiology of the painful wrist demonstrates quite clearly an increasing number of "carpal collapse" as a sequence of trauma (perilunar dislocation), of congenital disorders and rheumatoid arthritis. The deterioration of the wrist joint may start locally but may end up with generalised deforming osteo-arthritis. In addition to traditional salvage operations (partial/total fusion, carpectomy) the total wrist prosthesis by Meuli (ball and socket joint) has its definite place in the treatment of the painful destruction and instability of the wrist.

[Pathophysiology of perilunate dislocation]. / Pathophysiologie der perilunären Luxation.

The anatomy of the palmar scapho-triquetral ligament was studied: on 15 hand specimens by means of gross anatomical dissections and MR imaging; and on a further 10 foetal wrist specimens, microanatomically. This ligament allows us to present the proximal carpal row as a socket, consisting of an upper part (the triquetrum, distal part of the scaphoid, and the dorsal and palmar scapho-triquetral ligament), and a base (the concave parts of the lunatum and scaphoid, connected by the scapho-lunate ligament). With a hyperextension wrist injury the upper part follows the distal part of the carpus, while the base remains fixed at the radius. The upper part slips away from the base, consequently, injuring the ligamentous structure, or causing a scaphoid fracture. The luno-triquetral and the palmar scapho-triquetral ligaments are also frequently torn. The overall prognosis depends on the grade of ligament damage. The arthroscopy allows us to estimate the state of the ligament structures, therefore, it is indicated before any reconstructive operation.

[Extirpation of the pisiform bone: indications and results]. / Pisiformeexstirpation: Indikation und Resultate.

We have treated 26 patients with pain around the pisiform bone. From this experience, we have attempted to define diagnostic criteria and a therapy rationale. The diagnosis was made from clinical, radiographical and scintigraphic data. Therapy consisted of denervation combined with extirpation alone, or arthrodeses. The results correlated with the etiology of the pisiform bone pathology. The outcome in patients with idiopathic arthrosis and in patients with instability was good; the result was fair in patients with insertion-tendinitis of the flexor carpi ulnaris. In patients with posttraumatic arthrosis the results were unsatisfactory; however, the number of patients in this last group was small.

[Surgical indications for partial inpatient and ambulatory surgery of the lower extremities]. / Operationsindikationen für teilstationäre und ambulante Chirurgie der unteren Extremitäten.

Outpatient (ambulatory) surgery has become widely accepted in free-standing outpatient surgery centres and in hospitals covering the field of hand surgery as well as, increasingly, the field of lower-extremity surgery. Three factors are decisive for secure ambulatory surgery: adequate material and personal resources guaranteeing a round-the-clock medical service, outpatient anesthesia which focuses mainly on the perioperative care of outpatient surgery, and a well-informed patient. Under these prerogatives the majority of surgical procedures of the lower extremities are performed on an outpatient basis without any undue risk. This includes also the diagnostic and operative arthroscopy of different joints.

[The medical record at the center of medical informatics]. / Die Krankengeschichte im Zentrum der medizinischen Informatik.

Several areas in medical institutions, particularly the technical and administrative ones have been governed by computers for a long time. The proper medical work field (diagnosis, treatment, follow-up, correspondence and billing) however has hitherto mostly been ignored by data processing. We describe an electronic medical record introduced 4 years ago. All aspects of medical practise and all the specialists involved in patient care are integrated in the electronic document. In the center is a medical base of knowledge adaptable to all specialties as well as an expert system for direct control of the data entered by all concerned persons.

[Electronic organization of patient records as a component of integrated medical informatics]. / Elektronischer Aufbau einer Krankengeschichte als Bestandteil integraler medizinischer Informatik.

Conventional patient records are not only inconvenient to store, their structure is often not consistent and faulty, research is difficult and quality control is not possible. One solution to this problem is the computerized patient record. It contains all necessary data beginning with the first medical statements and ending with the final results of treatment. At any time and from any with the system connected computer terminal it allows immediate access to all medical records. In addition to medical information also administrative data are stored. The here presented system of a computerized medical record has proven to be an effective tool in the daily work as well for clinical, administrative and research tasks.

Determining carpal collapse. An improved method.

The carpal height index (carpal height ratio of the diseased wrist divided by that of the normal wrist, as described by Kato et al.) was calculated in forty normal subjects, ten patients who had Stage-III lunatomalacia, and eight patients who had non-union of a fracture of the scaphoid. The method of Youm et al. for determining the carpal height index was altered to include the use of defined points of reference and a standardized radiographic technique. Two tests of reproducibility demonstrated the reliability of the method. The carpal height index was found to be superior to the carpal height ratio for the evaluation of unilateral disease. The mean carpal height index of diseased wrists differed significantly from that of normal wrists. The carpal height index (for unilateral disease) or the carpal height ratio (for bilateral disease) can be used to describe the progression of collapse of the wrist quantitatively and to evaluate and compare various forms of treatment.

[Arthrodesis of the metacarpophalangeal joint of the thumb. Indications, technic, arthrodesis angle and functional effect]. / Arthrodese des Metakarpophalangealgelenkes am Daumen. Indikation, Technik, Arthrodesenwinkel und funktionelle Auswirkung.

The metacarpophalangeal joint of the thumb has less range of motion than any other digital joint. Its stability is more important than its mobility. Thus, arthrodesis of this joint causes relatively little loss of function, provided only that the joint is fused in the correct position. The authors reviewed all MP joint fusions of the thumb which were done at their hospital between 1974 and 1985. They examined individually forty-one of the fifty patients and studied the indications, surgical techniques and difficulties, and the complications. Furthermore, they measured all angles of fusion and concluded that the optimal position is fifteen degrees of flexion and ten degrees of pronation. The use of tension band wiring facilitates the achievement and maintenance of the desired position. The stability of the fusion permits exercise immediately after the operation; this helps to avoid a tenodesis of the long extensor tendon of the thumb.

[Arthrodesis of the central support of the carpus. Indications, technic, results]. / Arthrodèse de la colonne centrale du carpe. Indications, technique, résultats.

We have used this operation for the management of pain due to osteoarthritic changes at the radio-scaphoid and capitate-lunate joints. It allows correction of the carpal height by reposition of the flexed lunate, preserves the load bearing capitate-lunate axis, and decompresses the radio-scaphoid joint. We have carried out the procedure in 25 cases. Perilunate instability with osteoarthritic changes were present in 14 wrists; the remainder were consequent to non-union of fractures of the scaphoid with osteoarthrosis, or following complex fracture dislocations. At review 10 patients were free of pain, 12 had occasional pain and 3 were not improved. The mean residual range of movement in the wrist was 49 degrees, with a range from 20 degrees to 80 degrees. Bony union was not achieved in 5 wrists. At operation the lunate is reduced and carpal height restored with realignment of the weight bearing axis. Bone grafts and internal fixation are used.

[Electronic medical history: utopia or reality?]. / Elektronische Krankengeschichte: Utopie oder Realität?

With the advent of computers in medicine, the patient's chart has a more varied function. The basic use has been as the physician's instrument to provide information about diseases and their evolution. In order to link the physician with the capacity of a computer, a common language was elaborated based on the patient's chart. Computerized charting now makes possible not only improved communication and administration but also serves as a statistical databank. Important applications of a medical databank are statistical analysis of the chart, quality control of medical practice and facilitation of scientific studies. The patient's chart becomes a powerful multifunctional instrument in the clinic, the practice, and in research.

The late reconstruction of the ligament of the metacarpo-phalangeal joint of the thumb.

The disruption of the ligaments at the level of the MP-joint jeopardizes the function by lack of stability. The reconstruction by free tendon grafting, anchored in a dorso-lateral plane in the metacarpal an in the proximal phalanx, restores stability and good functional results in spite of a slight amount of loss of flexion. Two out of 25 operated thumbs failed and fusion of the MP-joint was necessary. A minimal limitation of flexion may be desirable since a tendon graft never restores a full physiological function. Our data show no need for K-wire transfixation of the MP-joint, since there is no evidence of a difference in late stability with or without such additional fixation. The mean pinch-grip pressure, restored to normal in the majority of cases, was not influenced by the mentioned reduction of flexion nor by the amount of stability restored.

[Anatomic basis of a new concept of stability of the carpus]. / Base anatomique d'un nouveau concept de stabilité du carpe.

Based on anatomical and biomechanical evidence, we conclude that the stability of the carpus relies on the lunate bone which is the centre of the longitudinal as well as the transverse functional axis. The lunate is firmly stabilised proximally to the radius and the radio-ulnar ligament complex by the proximal V-ligament, and so becomes a weight bearing structure. It is anchored by strong ligaments to the scaphoid on one side and the triquetrum on the other, thus forming a 3-bone intercalary system, which is in turn guided by the palmar distal V-ligament and the dorsal radio-triquetral ligament.