Results of Tri-Ligament Tenodesis: A Modified Brunelli Procedure in the Management of Scapholunate Instability

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7-year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1–8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. A total of 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD = 2.5). The loss in the arc of flexion–extension was due to a reduced range of flexion (mean loss 31%), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference ( P>0.05). in the range of movement or the grip strength between the static and dynamic group and patients with or without legal claims. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability.

Management of the Failed Biaxial Wrist Replacement

Nine cases of failed biaxial wrist replacement underwent revision surgery and subsequent clinical and radiographic assessment at a mean follow-up of 28 months. Clinical assessment included the hospital for special surgery (HSS) and activities of daily living scoring systems. Five patients had a revision biaxial wrist replacement, three had wrist fusions and two underwent an excision arthroplasty. The mean HSS score was 73 for the revision biaxial replacements, 63 for the wrist fusions and 92 for the excision arthroplasties. The mean activities for daily living score was 16 for the revision biaxial replacements, 14 for the wrist fusion and 20 for the excision arthroplasties. Despite the experience of implant failure, six patients would still choose a primary wrist replacement again. All patients in this small series appear to have had good clinical outcomes. Revision to another wrist replacement appears no worse than a wrist fusion in the short term and patients value the preservation of movement that an implant offers.

In Scaphoid Non-Union, Does the Source of Graft Affect Outcome? Iliac Crest Versus Distal End of Radius Bone Graft

Iliac crest bone grafts are sometimes preferred to other bone grafts for the treatment of non-unions of fractures of the scaphoid as they are claimed to have better osteogenic potential and biomechanical properties. We retrospectively studied a consecutive cohort of 68 symptomatic established scaphoid non-unions treated by bone grafting. An iliac crest graft was used in 44 cases and a distal radius graft in the other 24. The two treatment groups were comparable in terms of location of the fracture, duration of the non-union and the fixation implants used. Overall union was achieved in 45 of the 68 patients (66%) and the union rate was not influenced by the type of bone graft used. Twenty-nine of the 44 treated with iliac crest bone graft (66%) and 16 of the 24 (67%) treated with distal radial graft united. Donor site pain over the iliac crest was present in nine of the 44 patients in this group.

The outcome of wrist surgery: what factors are important and how should they be reported?

A prospective longitudinal study was carried out on a cohort of 86 patients who had undergone surgery for diverse wrist conditions. Disabilities of Arm Shoulder and Hand questionnaire, a pain assessment, a wrist functional score, range of movement and grip strength measures were completed. The Mayo Clinic wrist score was also calculated. The World Health Organization International Classification of Function was used as a framework for analysis. The responsiveness of each outcome measure was calculated in terms of distribution- and anchor-based methods. Pain was the most important factor in determining outcome. Changes in objective measures were less important. The responsiveness of the various measures was similar except for the Mayo Clinic wrist score, which was less responsive than the others. Patient-completed measures currently in use are multidimensional. Classifying the content according to the International Classification of Function would clarify the effects of wrist surgery on the different aspects of health.

Bone-cement interface strength in distal radii using two medullary canal preparation techniques: carbon dioxide jet cleaning versus syringed saline

PURPOSE

Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning.

METHODS

Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section.

RESULTS

The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10-650.05) as compared to the saline group (median 366.57N, IQR 271.05-502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group.

CONCLUSION

Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Geochemical investigations of metals release from submerged coal fly ash using extended elutriate tests

A storage pond dike failure occurred at the Tennessee Valley Authority Kingston Fossil Plant that resulted in the release of over 3.8 million cubic meters (5 million cubic yards) of fly ash. Approximately half of this material deposited in the main channel of the Emory River, 3.5 km upstream of the confluence of the Emory and Clinch Rivers, Tennessee, USA. Remediation efforts to date have focused on targeted removal of material from the channel through hydraulic dredging, as well as mechanical excavation in some areas. The agitation of the submerged fly ash during hydraulic dredging introduces river water into the fly ash material, which could alter the redox state of metals present in the fly ash and thereby change their sorption and mobility properties. A series of extended elutriate tests were used to determine the concentration and speciation of metals released from fly ash. Results indicated that arsenic and selenium species released from the fly ash materials during elutriate preparation were redox stable over the course of 10d, with dissolved arsenic being present as arsenate, and dissolved selenium being present as selenite. Concentrations of certain metals, such as arsenic, selenium, vanadium, and barium, increased in the elutriate waters over the 10d study, whereas manganese concentrations decreased, likely due to oxidation and precipitation reactions.

Distal radial and ulnar landmarks used in percutaneous pin fixation: anatomical relationship to the superficial radial and ulnar nerves

BACKGROUND

The radial and ulnar styloids as well as Lister's tubercle are important surgical landmarks in the surgical treatment of distal forearm fractures. There have been limited studies assessing their relative safety in terms of their distance from superficial nerves which are in danger during surgical procedures. The aim of this cadaveric study was to assess and compare the distance of superficial nerves to these important surgical landmarks.

METHODS

Twenty embalmed cadaveric upper limbs were dissected exposing the nerves and tendons around the wrist. The radial styloid, Lister's tubercle, ulnar styloid and nerve branches were marked with pins. The distance of the nearest nerve branch to each landmark was measured with a digital calliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc., Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests.

RESULTS

The median distance of the nearest nerve branch to the radial styloid was 5.42 mm, to the Lister's tubercle was 16.68 mm and to the ulnar styloid was 13.56 mm. There was unequal safety for these three surgical landmarks regarding proximity to nerve branches (p < 0.00001). Paired comparison using Wilcoxon Signed Ranks Test showed that the Lister's tubercle was safer than the radial styloid (p < 0.0001) and ulnar styloid (p = 0.04). In addition, the ulnar styloid was safer than the radial styloid (p < 0.001).

CONCLUSIONS

There is a higher risk of injury to superficial nerves when operating near the radial styloid as it is significantly closer to nerve branches as compared to Lister's tubercle and ulnar styloid.

Tendon graft--ulna fixation in distal radio-ulnar joint stabilisation; biomechanical comparison of three graft-bone fixation methods

A common distal radio-ulnar joint (DRUJ) stabilisation procedure uses a tendon graft running from the lip of the radial sigmoid notch to the ulnar fovea and through a bony tunnel to the ulnar shaft, before being wrapped round the distal ulna and sutured to itself. Such graft fixation can be challenging and requires a considerable tendon length. The graft length could be reduced by fixing the graft to the ulna using a bone anchor or interference screw. The aim of this study was to compare the strength of three distal ulna graft fixation methods (tendon wrapping and suturing, bone anchor and interference screw). Four human cadaveric ulnae were used. A tendon strip was run through a tunnel in the distal ulna and secured by: (1) wrapping round the shaft and suturing it to itself, (2) a bone anchor and (3) an interference screw in the bone tunnel. Load to failure was determined using a custom-made apparatus and an Instron machine. Maximum failure load was highest for the bone anchor fixation (99.3 +/- 23.7 N) followed by the suturing (96.2 +/- 12.1 N), and the interference screw fixation (46.9 +/- 5.6 N). There was no significant difference between the tendon suturing and bone anchor methods, but the tendon suturing was statistically significantly higher compared to the interference screw (P = 0.028). In performing anatomical stabilisation of the DRUJ fixation of the tendon graft to the distal ulna with a bone anchor provides the most secure fixation. This may make the stabilisation technique less demanding and require a smaller tendon graft.

Posterolateral rotatory laxity following surgery to the head of the radius: biomechanical comparison of two surgical approaches

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.

Wrist Osteoarthritis

Osteoarthritis of the wrist is one of the commonest conditions encountered in clinical orthopaedic practice. This article looks at our approach to this problem including clinical assessment, radiographic analysis and the management of wrist osteoarthritis.

Posterolateral rotatory instability of the elbow

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.

Use of the Stanley jig for large ulnar shortenings

We describe the use of a readily available ulnar shortening guide to perform large ulnar shortenings.

The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10−6) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

Early results of the Acclaim elbow replacement

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function.

No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).

Exposure of the head of the radius using the Wrightington approach

Surgical access to the head of the radius is usually performed through a lateral approach. We present an alternative technique through a modified posterior approach which was developed following dissections of 22 human cadavers. An osteotomy of the supinator tuberosity was performed and reflected as a single unit with the attached annular ligament. Excellent exposure of the head of the radius was achieved, replacement of the head was undertaken and the osteotomy site repaired. The elbows were stable and had a full range of movement. The approach was then carried out on 13 patients for elective replacement of the head and was found to be safe and reproducible. In the patient group all osteotomies united, the elbows were stable and had an improved range of supination and pronation. There was no change in flexion and extension of the elbow. Complications included a haematoma and a reflex sympathetic dystrophy.

The modified posterior approach provides excellent access to the head and neck of the radius, gives good stability of the elbow and allows early mobilisation of the joint.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

Tenodesis of the extensor carpi ulnaris for chronic, post-traumatic lunotriquetral instability

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist.

We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.

Estabilización escafolunar mediante la técnica «3LT». Indicaciones, técnica quirúrgica y resultados

La rotura traumática o degenerativa de los ligamentos escafolunares suele inducir un cuadro de inestabilidad progresiva del carpo en el curso de la cual el escafoides sufre un colapso en flexión y pronación, mientras que el semilunar y el piramidal adoptan una postura anómala en extensión, supinación y traslación cubital. Si la lesión es diagnosticada en la fase aguda, y sus características permiten una reparación eficaz, los resultados que pueden obtenerse suelen ser satisfactorios. Lamentablemente, las roturas escafolunares suelen pasar desapercibidas de entrada con lo que aparece la denominada disfunción escafolunar crónica caracterizada por pérdida de fuerza, disminución progresiva de la movilidad, y la presencia de resaltes esporádicos dolorosos. Con el tiempo dicha disfunción genera cambios artrósicos siguiendo un patrón característico, denominado SLAC («scaphoid-lunate advanced collapse»). El tratamiento de la disfunción escafolunar crónica depende del grado evolutivo en que se encuentre. En este artículo se describe un algoritmo que resulta útil en el momento de diseñar un tratamiento para cada caso concreto de inestabilidad escafolunar.

Uno de los grados de inestabilidad escafolunar más difíciles de tratar es aquel en el cual el ligamento escafolunar dorsal es irreparable, y sin embargo la pérdida de alineación es reducible y no existe todavía artrosis. Para este tipo de inestabilidad (grado 4, según el algoritmo que proponemos), la muñeca puede recuperar un buen grado de función indolora mediante la técnica 3LT («Three-ligament-tenodesis»). En este artículo se detalla este tipo de tenodesis, así como los resultados obtenidos en 38 pacientes, con un seguimiento promedio de 47 meses, destacando una movilidad global superior al 70% de la contralateral, una fuerza de prensión del 65%, y mínimas molestias residuales en la gran mayoría de casos.

Wrist fusion versus limited carpal fusion in advanced Kienbock's disease

We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.

Survivorship of the Souter-Strathclyde elbow replacement in the young inflammatory arthritis elbow

We divided 309 patients with an inflammatory arthritis who had undergone primary elbow replacement using the Souter-Strathclyde implant into two groups according to their age. The mean follow-up in the older group (mean age 64 years) was 7.3 years while in the younger patients (mean age 42 years) it was 12 years. Survivorship for three different failure end-points (revision, revision because of aseptic loosening of the humeral component, and gross loosening of the humeral implant), was compared in both groups.

Our findings showed that there was no significant difference in the incidence of loosening when young rheumatoid patients were compared with an older age group.

Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study

BACKGROUND

A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. To test this theory, we performed a double-blind, randomized, controlled, pilot trial comparing injections of botulinum toxin type A with those of a placebo (normal saline solution) in the treatment of chronic tennis elbow.

METHODS

Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. Half the patients received 50 units of botulinum toxin type A, and the remainder received normal saline solution. The intramuscular injections were performed 5 cm distal to the maximum point of tenderness at the lateral epicondyle, in line with the middle of the wrist. The two solutions used for the injections were identical in appearance and temperature. The results of a quality-of-life assessment with the Short Form-12 (SF-12), the pain score on a visual analogue scale, and the grip strength measured with a validated Jamar dynamometer were recorded before and three months after the injection.

RESULTS

Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life.

CONCLUSIONS

With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow.

Does the orientation of the distal radioulnar joint influence the force in the joint and the tension in the interosseous membrane?

OBJECTIVE

To investigate the effect of change in the orientation of the distal radioulnar joint on the force in the joint and the strain in the interosseous membrane.

DESIGN

Biomechanical study in fresh frozen cadavers.

BACKGROUND

The articular surfaces of the distal radioulnar joint may be orientated in parallel with the long axis of the forearm (a Type I joint) or at an oblique angle opening distally to the ulnar side (a Type II joint).

METHODS

Three cadaveric upper limbs were held on a custom built frame allowing measured rotation and axial loading across the wrist. Measurements of force in the distal radioulnar joint and strain in the interosseous membrane were taken and repeated after replacement of the distal radioulnar joint with prosthetic Type I and Type II joints.

FINDINGS

The force in the joint and the strain in the interosseous membrane increased with increasing load across the wrist (P < 0.0001). The force in the Type I joint was reduced compared to the normal or Type II joint. This difference was greater with increasing load and was significant at 8 kg (P < 0.001). The strain in the interosseous membrane was maximal at neutral forearm rotation and decreased with increasing pronation and supination.

INTERPRETATION

The force in the joint is greater with the Type II distal radioulnar joint. We believe this compressive force increases joint stability and this orientation of the articular surfaces should be considered in the design of a total distal radioulnar joint arthroplasty.

Seventeen-year survivorship analysis of silastic metacarpophalangeal joint replacement

We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture.

A new clinical test for radial tunnel syndrome--the Rule-of-Nine test: a cadaveric study

PURPOSE

Radial tunnel syndrome refers to pain on the lateral aspect of the forearm as a result of compression of the posterior interosseous nerve within a tunnel with specific anatomical boundaries. Diagnosis of the condition is difficult because of its close association with lateral epicondylitis, which warrants different methods of treatment. Based on a cadaveric study, a new clinical test, the Rule-of-Nine test, is proposed to improve the diagnostic accuracy in radial tunnel syndrome. The test involves constructing 9 equal squares on the anterior aspect of the forearm and noting those squares where tenderness can be elicited.

METHODS

19 upper limbs were dissected to delineate the path of the posterior interosseous nerve through the radial tunnel, and the relationship of the path of the nerve with the 9 squares.

RESULTS

A consistent mapping of the posterior interosseous nerve to the lateral column of 3 squares was observed.

CONCLUSION

The Rule-of-Nine test is proposed as a reliable method of diagnosing radial tunnel syndrome.

Post-traumatic instability of the trapeziometacarpal joint of the thumb. Diagnosis and the results of reconstruction of the beak ligament

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully.

Post-traumatic instability of the trapeziometacarpal joint of the thumb

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully.

A review of peripheral nerve blockade as local anaesthesia in the treatment of palmar hyperhidrosis

Injection of botulinum toxin type A (BTX-A) is an effective method of controlling palmar hyperhidrosis. It is, however, an uncomfortable procedure without adequate anaesthesia. We outline the techniques used, the reasons for them and potential pitfalls that can be avoided, with an outline of the neural anatomy relevant to the palmar injection of BTX-A. We have been using peripheral nerve blockade as local anaesthesia during BTX-A treatment of palmar hyperhidrosis for the last few years, and have found it an effective method of providing pain relief during the procedure, giving greater anaesthesia than that given by topical anaesthetic cream under occlusion and ice. It has been our experience that patients prefer wrist blockade to topical anaesthesia and ice when receiving BTX-A injections for treatment of palmar hyperhidrosis.

The natural history of an untreated isolated scapholunate interosseus ligament injury

The natural history of an untreated isolated scapholunate interosseus ligament injury remains unclear, although it is commonly assumed that patients continue to suffer with pain, stiffness and weakness of the wrist and ultimately develop secondary osteoarthritis (SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with an arthroscopically proven interosseus scapholunate ligament injury, but without any radiological signs of either DISI deformity or scapholunate gapping, who had declined further treatment at an average follow-up of 7 years. Whilst there was on going pain and functional limitation in all cases, there was no rapid progression to degenerative change (SLAC wrist).

Genetic susceptibility to Dupuytren's disease: transforming growth factor beta receptor (TGFbetaR) gene polymorphisms and Dupuytren's disease

Dupuytren's disease (DD) is a benign fibroproliferative disease of unknown cause. It is a familial condition that commonly affects Caucasians. Genetic studies have yet to identify the genes involved in DD. Transforming growth factor beta (TGFbeta) family members are multifunctional; some play a central role in wound healing and fibrosis. Previous studies have implicated TGFbeta cytokines and receptors in DD. In the light of this evidence, TGFbeta receptors represent candidate susceptibility genes for this condition. In this study, we investigated the association of single nucleotide polymorphisms (SNPs) in TGFbeta receptors one, two and three (TGFbetaRI, RII and RIII) with the risk of DD formation. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping novel and known TGFbeta receptor polymorphisms. DNA samples from 183 DD patients and 181 controls were examined. There was a statistically significant difference (p<0.05) in genotype frequency distributions between cases and controls for TGFbetaRI polymorphisms in the recessive model. However, there were no significant difference in genotype or allele frequency distributions between cases and controls for the TGFbetaRII and TGFbetaRIII SNPs.

Novel single nucleotide polymorphisms in the 3'-UTR of the TGFbetaRI and TGFbetaRIII genes

Transforming growth factor beta (TGFbeta) family members are multifunctional cytokines that play a key role in cellular growth, proliferation and differentiation. Transmembrane signalling by TGFbeta occurs via a complex of the serine/threonine kinases TGFbeta type 1 (TGFbetaRI), type 2 (TGFbetaRII), and type 3 (TGFbetaRIII) receptors. Previous studies have implicated TGFbeta receptors (TGFbetaR) in a variety of important hereditary clinical disorders. Mutations of the TGFbetaR genes have been observed in several human cancers. The aim of this study was to identify and confirm novel single nucleotide polymorphisms (SNPs) in TGFbetaRI and RIII and to determine the relative allele and genotype frequencies of these SNPs. SNPs were identified from the examination of sequence alignments held in databases and were confirmed by DNA sequencing. A polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was devised for genotyping TGFbeta receptor polymorphisms. DNA samples from 91 controls were examined. The observed heterozygosities of TGFbetaRI and TGFbetaRIII gene polymorphisms in the control population were 43 and 33%, respectively, suggesting these SNPs could be useful markers in disease association studies.

Biaxial total wrist replacement in patients with rheumatoid arthritis. Clinical review, survivorship and radiological analysis

We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist replacements. On the basis of the Hospital for Special Surgery scoring system, 49 wrists (74%) were graded as fair to excellent. More than half of the 27 patients who had an arthrodesis on the contralateral wrist would have preferred a second arthroplasty. Five replacements were revised or fused because of loosening and a further nine showed signs of radiological loosening, three of which were asymptomatic. The probability of survival of the biaxial total wrist replacement at eight years was 83% with revision surgery as the terminal event, 78% with radiological loosening as the endpoint and 82% with dorsal migration and displacement from the metacarpal as the terminal event. There was a linear relationship between subsidence of the component and distal loosening. There was no evidence that the length of the stem of the carpal component, within the third metacarpal, affected any of the terminal events. The position and alignment of the carpal component within the bone at the time of surgery significantly affect the outcome and can be used to predict failure.

Comparison of survivorship between standard and long-stem souter-strathclyde total elbow arthroplasty

This study compared 107 cases of rheumatoid arthritis that had the long-stem humeral component of the Souter-Strathclyde total elbow arthroplasty introduced as a primary procedure with a similar group of 202 cases that had the standard component. Both groups were comparable with regard to age range and sex ratio. Follow-up of the longer-stem component was somewhat shorter, being a mean of 4.4 years as opposed to 9.3 years. Kaplan-Meier survival analyses were undertaken for both revision and radiologic loosening of components as terminal events. There was no significant difference between the cumulative survival of the standard and long-stem humeral implants when revision was the endpoint. Although survival of both implants was similar, the reasons for this were different. More specifically, for the standard humeral component, 25 out of 32 revisions were for humeral loosening. For the long stem, however, 5 out of a total of 7 revisions were due to instability; no long-stem humeral component had been revised for loosening. In addition, linking the components by way of a snap-fit component was associated with a higher rate of loosening; more specifically, 5 out of 16 cases were revised. As a result of this study, we recommend the use of a long-stem Souter-Strathclyde humeral component as a primary implant. Other crucial components for long-stem survival, however, are surgical technique and alignment of the implant.

Biaxial total wrist replacement in patients with rheumatoid arthritis

We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist replacements. On the basis of the Hospital for Special Surgery scoring system, 49 wrists (74%) were graded as fair to excellent. More than half of the 27 patients who had an arthrodesis on the contralateral wrist would have preferred a second arthroplasty. Five replacements were revised or fused because of loosening and a further nine showed signs of radiological loosening, three of which were asymptomatic.

The probability of survival of the biaxial total wrist replacement at eight years was 83% with revision surgery as the terminal event, 78% with radiological loosening as the endpoint and 82% with dorsal migration and displacement from the metacarpal as the terminal event. There was a linear relationship between subsidence of the component and distal loosening. There was no evidence that the length of the stem of the carpal component, within the third metacarpal, affected any of the terminal events. The position and alignment of the carpal component within the bone at the time of surgery significantly affect the outcome and can be used to predict failure.

Genetic susceptibility in Dupuytren's disease. TGF-beta1 polymorphisms and Dupuytren's disease

Dupuytren's disease is a benign fibroproliferative disease of unknown aetiology. It is often familial and commonly affects Northern European Caucasian men, but genetic studies have yet to identify the relevant genes. Transforming growth factor beta one (TGF-beta1) is a multifunctional cytokine which plays a central role in wound healing and fibrosis. It stimulates the proliferation of fibroblasts and the deposition of extracellular matrix. Previous studies have implicated TGF-beta1 in Dupuytren's disease, suggesting that it may represent a candidate susceptibility gene for this condition. We have investigated the association of four common single nucleotide polymorphisms in TGF-beta1 with the risk of developing Dupuytren's disease. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-beta1 polymorphisms. DNA samples from 135 patients with Dupuytren's disease and 200 control subjects were examined. There was no statistically significant difference in TGF-beta1 genotype or allele frequency distributions between the patients and controls for the codons 10, 25, -509 and -800 polymorphisms. Our observations suggest that common TGF-beta1 polymorphisms are not associated with a risk of developing Dupuytren's disease. These data should be interpreted with caution since the lack of association was shown in only one series of patients with only known, common polymorphisms of TGF-beta1. To our knowledge, this is the first report of a case-control association study in Dupuytren's disease using single nucleotide polymorphisms in TGF-beta1.

Genetic susceptibility in Dupuytren’s disease

Dupuytren’s disease is a benign fibroproliferative disease of unknown aetiology. It is often familial and commonly affects Northern European Caucasian men, but genetic studies have yet to identify the relevant genes.

Transforming growth factor beta one (TGF-β1) is a multifunctional cytokine which plays a central role in wound healing and fibrosis. It stimulates the proliferation of fibroblasts and the deposition of extracellular matrix. Previous studies have implicated TGF-β1 in Dupuytren’s disease, suggesting that it may represent a candidate susceptibility gene for this condition.

We have investigated the association of four common single nucleotide polymorphisms in TGF-β1 with the risk of developing Dupuytren’s disease. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-β1 polymorphisms. DNA samples from 135 patients with Dupuytren’s disease and 200 control subjects were examined.

There was no statistically significant difference in TGF-β1 genotype or allele frequency distributions between the patients and controls for the codons 10, 25, −509 and −800 polymorphisms.

Our observations suggest that common TGF-β1 polymorphisms are not associated with a risk of developing Dupuytren’s disease. These data should be interpreted with caution since the lack of association was shown in only one series of patients with only known, common polymorphisms of TGF-β1. To our knowledge, this is the first report of a case-control association study in Dupuytren’s disease using single nucleotide polymorphisms in TGF-β1.

Genetic susceptibility in Dupuytren's disease: lack of association of a novel transforming growth factor beta(2) polymorphism in Dupuytren's disease

The genes involved in the pathogenesis of Dupuytren's disease have yet to be identified. In this study, we tested for an association between Dupuytren's disease (DD) and a novel insertion polymorphism within the 5'-untranslated region (5'-UTR), of the TGFbeta(2) gene. DNA samples from 179 DD patients and 187 ethnically matched controls were examined. There was no statistically significant difference in TGFbeta(2) allele frequency distributions between cases and controls for the TGFbeta(2) polymorphism.

The value of crossed intrinsic transfer after metacarpophalangeal silastic arthroplasty: a comparative study

Seventy three hands in patients with rheumatoid arthritis undergoing primary index to small finger metacarpophalangeal joint replacements were studied retrospectively. In twenty eight hands a crossed intrinsic transfer was performed and in forty five hands it was not. A similar splintage and rehabilitation programme was followed in each group. The two treatment groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees). At a mean follow up of 50 months the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group mean 14 degrees, P=0.01). There were no other significant differences at follow up.

Revision total elbow replacement using the Souter-Strathclyde prosthesis

The Souter-Strathclyde prosthesis was used in 52 evisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable relief of pain, and the range of movement was preserved. There was a considerable incidence of adverse events associated with revision (30%), and 12 further procedures have been required. Nonetheless, a revision is the preferred salvage procedure for failed primary arthroplasty in the absence of sepsis.

Revision total elbow replacement using the Souter-Strathclyde prosthesis

The Souter-Strathclyde prosthesis was used in 52 revisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable relief of pain, and the range of movement was preserved. There was a considerable incidence of adverse events associated with revision (30%), and 12 further procedures have been required. Nonetheless, a revision is the preferred salvage procedure for failed primary arthroplasty in the absence of sepsis.

The effect of epidemiologic and intraoperative factors on survival of the standard Souter-Strathclyde total elbow arthroplasty

Previously published work has revealed an 87% survivorship after 12 years for the standard Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis. Of the 13% that were revised, 75% were due to loosening of the humeral component. The aim of this research was to identify the specific epidemiologic and intraoperative factors that predisposed to this humeral loosening. Specifically, factors such as age, sex, radiologic staging of the disease, position of the implant in bone, and size of the implant inserted were evaluated. After analysis of 186 cases, we concluded that the position of the humeral component within the humerus is crucial for long-term survivorship. Specifically in the lateral plane, the stem should be aligned in the plane of the humerus and the implant inserted to the correct depth. The articular surface of the implant should lie at the level of the normal trochlea. At the anteroposterior plane, the implant should sit centrally and not be lateralized. We conclude that good surgical technique is crucial to the long-term effectiveness of this implant.

Kienböck's disease: conservative management versus radial shortening

Avascular necrosis of the lunate, first described by Kienbock, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9). Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease. We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse.

Kienböck’s disease

A vascular necrosis of the lunate, first described by Kienböck, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9).

Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease.

We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse.

Hamato-lunate impingement: an uncommon cause of ulnar-sided wrist pain

It has been reported that almost 50% of lunates have a separate medial facet on the distal surface for articulation with the hamate; about a quarter of these have erosion of the cartilage with exposed subchondral bone on the proximal pole of the hamate. We describe 4 cases of ulnar-sided wrist pain caused by hamato-lunate impingement that resulted in chondromalacia. The pain could be reproduced by a modification of the Lichtman test. The diagnosis was confirmed by arthroscopy. All 4 patients responded favorably to resection of the head of the hamate.

Dowel Fusion of the Scapho-Trapezio-Trapezoid Joint: A Description of a New Technique

We describe a modification of the technique for arthrodesis of the joints between the scaphoid, the trapezoid and the trapezium (the S-T-T joint) described by Sandow, that involves the en bloc resection of a cylinder of bone incorporating a portion of each of the scaphoid, trapezoid and the trapezium, using a hollow mill, and replacing it with a cylindrical graft of exactly the same size taken from the distal radius. The procedure is relatively quick and easy with a high rate of fusion and must be regarded as a preferable alternative to other, more complex procedures.