Surgical approaches to the trapeziometacarpal joint for the insertion of implants and prostheses (non-arthroscopy)

The two approaches most often used for placing implants and trapeziometacarpal prostheses are the laterodorsal approach and the lateropalmar approach. The advantages and disadvantages of these two approaches are set out. Each one allows optimal joint exposure while preserving or repairing the peritrapezial musculotendinous structures. They allow the insertion of partial or total trapeziometacarpal implants and modern coupled trapeziometacarpal prostheses. Each approach must be practiced and mastered on cadaver specimens before being used for trapeziometacarpal surgery.

Luxation carpométacarpienne antérieure des deuxième et troisième rayons

Anterior dislocations of the second and third carpometacarpal joints are extremely rare. The authors report a case of an anterior dislocation of the bases of the second and third metacarpals of the right hand treated by closed reduction and percutaneous wiring. The result was excellent and the authors think that this type of carpometacarpal dislocation does not need open reduction.

[Anatomy of crucifixion]

Crucifixion was developed and abolished during the roman empire. The historical and pagan works are rare, and the story of Christianity gave us the firsts elements of knowledge of this punishment. Crucifixion of the upper limbs was represented a lot of time, because the importance of this theme in the art. The anatomical work of the artists was then widely used, but it is only during the twentieth century that anatomists and surgeons studied with precision the fixation of the upper limbs on the cross. Lastly the modem imagery with computerised reconstruction allowed a direct vision of the nail in the different structures of the wrist.

Devenir à plus de 20 ans de recul des poignets rhumatoïdes opérés (arthrodèses exclues)

PURPOSE OF THE STUDY

The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist.

MATERIAL AND METHODS

Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up.

RESULTS

Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force.

CONCLUSION

There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

[A adaptive proximal scaphoid implant]

INTRODUCTION

In this study, the insertion of a pyrocarbon implant (APSI) has been described, which is shaped to allow adaptive mobility during carpal movement in the first row of carpals. This implant replaces the proximal part of the scaphoid; it is designed to treat styloscaphoid arthritis, and to prevent further deterioration and carpal collapse by restoring the first carpal row to its original height, i.e., 'SNAC wrist' after scaphoid pseudoarthritis, and 'SLAC wrist' following scapho-lunate dissociation.

MATERIALS AND METHOD

This retrospective series included 25 cases which were examined and analyzed at an average of six years post-surgery (between three and ten years) by an independent observer using the EVAL expert database system: 1) 14 cases involved pseudoarthritis, which developed from the scaphoid ('SNAC wrist'); 2) ten cases were connected with scapho-lunate nonunion ('SLAC wrist'); 3) one case involved carpal collapse with siliconite, which had previously been inserted as a scaphoid silicone partial implant for the treatment of pseudoarthritis involving a stage II fracture.

RESULT

In all cases, the reason for the preoperative-consultation for degenerative arthritis was the presence of pain, which post-surgery was no longer apparent in 60% of cases, and only persisted during effort in 28% of cases. Thus 88% of the patients were satisfied with the results, and were able to resume their normal professional and sports activities at the same level as before. Strength connected with digitopalmar grip and pinch force were found to have increased compared to the function in the healthy hand. No implant dislocation was detected by radiological investigation. Dynamic X-rays of the implant in flexion, extension, and frontal inclination confirmed this adaptive mobility. Carpal height was in all cases maintained. The radio-lunate angle remained unchanged in 15 cases, was improved in six cases, and was worse in four cases. Two poor results were connected with severe ligament lesions prior to surgery.

CONCLUSION

The preliminary results regarding the APSI implant seem to be promising for cases of polar pseudoarthritis in which curative treatment is no longer possible. This technique avoids further deterioration and carpal collapse ('SNAC wrist'). However, in cases of scapho-lunate nonunion ('SLAC wrist') where ligament lesions are severe, this method does not resolve the problem of ligament destabilization, which requires further treatment.

[Radial paralysis of the arm after muscular effort. 4 case reports. Clinical and physiopathological study]

Radial palsy following muscular effort is uncommon and often related to a fibrous arch at the lower part of the humeral groove; they usually resolve spontaneously. In the absence of improvement, operation consists of neurolysis and resection of the fibrous arch; nerve graft is rarely necessary even in cases of severe hourglass compression.

[Role of scapho-trapezo-trapezoidal arthrodesis in the treatment of Kienbock disease. 11 cases]

11 patients with Decoulx stage III Kienböck's disease with rotatory subluxation of the scaphoid were treated with scapho-trapezo-trapezoid arthrodesis. The associated procedures were lunate implant resection arthroplasty in 6 cases, lunate resection in 3 cases, shortening of the radius in 1 case. The average follow-up was 40 months (12 to 84 months). There was no complication of the arthrodesis. Relief of pain is satisfactory in 7 of the 11 patients. The average grip strength is 66% of that observed on the affected side. The range of movement was decreased especially for radial deviation. There was a positive correlation between, the exact scaphoid reduction, a wrist without preoperative degenerative arthritis and the good clinical results. No differences were observed in the results between the associated lunate procedures. STT fusion seems to be a useful procedure in the treatment of stage III Kienböck's disease with carpal malalignment as it removes compressive stress from the diseased lunate and treats, the accompanying rotatory subluxation of the scaphoid.

A double nidus osteoid osteoma in a finger

The diagnosis of an osteoid osteoma in the proximal phalanx of the right index finger was suggested by the patient's history and the initial radiographs. The diagnosis was histologically confirmed postoperatively. One year later, however, persistent symptoms and typical radiographic findings, again suggested the presence of an osteoid osteoma. Subsequent en bloc resection of the second nidus, which was again histologically confirmed as an osteoid osteoma, was followed by complete resolution of the symptoms. The definitive diagnosis of a double-nidus osteoid osteoma was suggested after careful analysis of the initial radiographs demonstrated the existence of two distinct intracortical nidi.

[Intra-osseus phalangeal epidermoid cyst: general review and description of 2 cases]

The authors report two cases of epidermoid cyst of the distal phalanx together with a general review of the literature and the principal steps in the diagnosis of distal phalangeal benign tumours.

[Osteoid osteoma of the hand. Apropos of 46 cases]

On the basis of a multicentre study, 46 cases of osteoid osteoma of the hand were reviewed on behalf of the GETO. The phalangeal localization is unusual both clinically (segmental digital hypertrophy, pseudo-hippocratism), radiologically (cortical hypertrophy with poorly or non-visible nidus) and therapeutically. The preoperative diagnosis is difficult, but must be as precise as possible in order to select the site of incision and to accurately resect the nidus. Treatment must consist of block resection of the lesion followed, when necessary, by autologous bone graft with arthrodesis of an adjacent joint.