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Collagenase clostridium histolyticum (CCH) is a pharmaceutical, non-surgical treatment option for Dupuytren Disease. However, recurrence is common, and predictors of treatment outcome of CCH treatment are largely unknown. In this retrospective study, we analysed the possible correlation between Abe's Dupuytren Diathesis Score (DDS) and recurrence after treatment with CCH. In a total of 74 patients, with an average follow-up of 5 years, we found an overall recurrence rate of 67% after 5y but no correlation with DDS. Sub-scale analysis indicated that the presence of knuckle pads was associated with a reduced recurrence risk. Patient satisfaction after CCH was high. Deriving from our data, there is no correlation between DDS and recurrence following CCH treatment. Therefore, at this moment, we do not advocate the use of the DDS when informing patients about recurrence rates after CCH treatment. Level of evidence: IV: therapeutic cohort study.

The treatment of Dupuytren disease (DD) continues to evolve. New insights in risk factors for recurrence and new treatment modalities have changed the management strategies for DD over the past decades. However, several differences may remain between these insights and their clinical application. The current tendencies in management of Dupuytren disease, were investigated in a web-based survey. The survey was sent to all members of the Belgian Hand Group, the professional organisation of hand surgeons in Belgium. The participants indicated their preferred treatment for clinical cases and answered questions on the use and timing of splinting, physiotherapy, medication and adapting the management depending on fibrosis diathesis. These findings were compared to recommendations found in the literature. Forty out of 135 surveyed members of the Belgian Hand Group completed the survey and 7 responded incom- pletely, yielding a response rate of 35% for most questions. This is comparable to similar studies. There appeared to be still room for debate on surgical techniques for difficult cases. CCH use increased since reimbursement became available in Belgium, mainly due to satisfying clinical results for patient and surgeon. The survey demonstrated a wide variety in pre- and postoperative splinting protocols, but consensus existed with the literature on postoperative night-time application of orthoses for 7 to 12 weeks.

The purpose is to determine if ligament reconstruction with tendon interposition (LRTI) is a recommendable salvage option for failed total joint prosthesis of the first carpometacarpal joint. Twenty-two patients in our database met the in- clusion criteria for this retrospective study, with at least 6 months follow-up. Fourteen participated and were invited for a clinical examination and asked to fill out two questionnaires. They were evaluated for pain (VAS), impairment (NHS), disability (Quick DASH), opposition (Kapandji test) and grip strength (hydraulic dynamometer). Results of the questionnaires were compared to a cohort study of primary LRTI's. Kapandji test and grip strength were compared to the contralateral side. Compared to primary LRTI's, revision surgery showed mild deterioration of impairment and disability. The average VAS score was 2.9 out of 10. Twelve patients mentioned a sense of strength loss, which could be quantified with the dynamometer : a mean of 15.1 kg (operated thumb) versus 20.5 kg (contralateral). There was a relatively small decline of opposition with Kapandji 8.6 versus 9.9. The overall satisfaction was good for 8 patients, fair for 3 and poor for the remaining 3 (mainly based on strength loss). One patient needed a second revision. Failed first carpometacarpal joint replacement can be salvaged by ligament reconstruction with tendon interposition, providing an acceptable functional outcome in 79% of cases studied. However, compared to the functional outcome of primary LRTI's, mild aggravation of impairment and disability should be taken into account.

Osteoarthritis of the carpometacarpal joint of the thumb is a common disease, mostly affecting middle aged women. This article presents the results of a trapeziectomy with a ligament recontruction/tendon interposition procedure. We evaluated 60 male patients with 76 operated thumbs. The mean follow- up was 62 months (ranging from 13 to 133 months, with SD of 33 months). The outcome was measured with the disabilities of the arm, shoulder and hand score, a Nelson Hospital score, a Visual analogue scale score and range of motion. The preoperative height of the trapezium was measured and compared with the height of the trapezial space postoperativaly. The disabilities of the arm, shoulder and hand score improved from 25.6 to 16.1. The Visual analogue scale score for pain, satisfaction, dexterity and funcion were correlated with each other. On x-ray, there was an average loss of 67% of trapezial height compared preoperativaly with postoperativaly, but no correlation was found with clinical outcome parameters.

A retrospective survey on the long-term outcomes of both proximal row carpectomy (PRC) and scaphoidectomy with 4-corner arthrodesis (4CA) was conducted. Seventeen PRC and nine 4CA wrists were retrieved with a minimal follow-up of 9 years. Pain, satisfaction and disability were not significantly different. There was a better flexion and ulnar deviation in the PRC wrists. Conclusion : at long term, the outcome for PRC remains stable despite some series recently reported worsening of the results due to progressive degenerative arthritis. PRC seems to yield comparable clinical results compared to 4CA but a slightly better range of motion than 4CA.

Trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal prosthesis are two commonly used procedures for first carpometacarpal joint osteoarthritis. The purpose of this study is to compare the short-term outcome of trapeziectomy with ligament reconstruction and tendon interposition to trapeziometacarpal prosthesis. Pubmed, Cochrane library and science direct database were searched with adequate search terms. Used parameters were force, pain, mobility, functionality and complication. All papers describing short-term outcome of ligament reconstruction and tendon interposition or trapeziometacarpal prosthesis were included in this review. Trapeziometacarpal prostheses showed faster pain relief compared with trapeziectomy and ligament reconstruction and tendon interposition. Overall, there was a better strength in the trapeziometacarpal prosthesis group. A lack of information was found about the short- term functionality. The mobility recovers faster in the prosthesis group, although different scoring scales were used for measurement. We could confirm the faster pain relief in the prosthesis group and generally a faster recovery of strength and mobility. In the prosthesis group were more short-term complications. More studies are required to evaluate the short-term recovery of strength, the mobility, functionality and satisfaction.

Recurrence after primary resection of a dorsal wrist ganglion may necessitate a reintervention. A technique was introduced in 2004 in which a flap of the extensor retinaculum is used to cover the defect left in the wrist capsule following repeat radical excision. This retrospective study presents the follow-up 4.6 years after this surgery in 20 patients. Recurrence, grip strength and possible flexion deficit are measured in 13 patients who attended clinic, as well as pain and satisfaction scores. Disability scores have been evaluated in 18 patients. One refractory patient was ascertained. A flexion deficit ≤ 10° was observed in 7 patients. Overall, mild pain, very mild disability, a flexion deficit of 14.2° and a loss of grip strength of 3.6 kg was observed. The retinaculum flap for recurrent dorsal wrist ganglion is a reliable procedure with limited risk for flexion deficit after surgery, high satisfaction rate and low recurrence risk.

The ligamentous reconstruction according to Eaton and Littler (7) was designed to restore the stability of the carpometacarpal joint of the thumb. We evaluated the patients' satisfaction after an Eaton and Littler-procedure as well as possible risk factors in the development of thumb basal joint instability. A retrospective chart review and clinical assessment or telephone survey are executed in 33 patients, with a mean follow-up of 7 years. Only 45% of the patients were satisfied. Within the group of clinical assessed patients, there were significant differences in thumb function comparing operated with not operated side. Overall joint hypermobility can be a contributing factor for this thumb basal joint instability, but has no effect on the outcome after an Eaton-Littler procedure.

The outcome of a metaphyseal ulnar shortening osteotomy, reported by Sennwald as an alternative option for ulnar abutment syndrome, was evaluated with -regard to the functional results, pain relief and incidence of complications., Method: We conducted a review of 12 patients ; measured parameters were DASH score, PRWE, VAS for pain, grip force and wrist motion., Results: Only disability improved significantly with a DASH score of 42 (p = 0.03). The function and pain assessment scores did not improve in 3 patients. We found no correlation between change in functional scores and other measured variables. Six patients were reoperated for prominent screw heads or new-onset distal radioulnar joint osteoarthritis., Conclusion: All osteomies healed fast and uneventfully and disability improved in most patients but 25% did not improve and 50% were re-operated. Further investigation is needed to evaluate the value of the metaphyseal osteotomy as an alternative treatment for ulnar abutment syndrome.

Mucous cysts of the interphalangeal joints are common. Several surgical techniques have been described, but none has proven to be superior. We compared three techniques that entail complete removal of the cyst together with the concomitant osteophytes. In group A wound closure was obtained by full thickness skin graft, in group B by primary closure and in group C by a local skin graft. Sixty-four patients with 70 cysts were reviewed. An overall recurrence rate of 8.6% was observed. Forty-five of the studied patients received a full thickness skin graft (4 out of 45 recurred), 23 were closed primarily (2 out of 23 recurred) and 2 by a local skin graft (no recurrences). Full thickness skin graft showed no significant higher recurrence compared to primary closure. Full thickness skin graft showed no significant higher pain or satisfaction compared to primary closure. Patients with a recurrent cyst were less satisfied and had more pain than those without recurrences.

Prosthetic replacement of the proximal interphalangeal joints is an operative treatment for osteoarhtritis, to preserve the range of motion and the function of the hand. The purpose of this study is to detect the differences regarding pain and function between a silicone implant using a volar approach and a resurfacing implant, placed through a dorsal approach. Patients were reviewed clinically and scored. We found no significant differences in outcome between the two types of implants. However, the complication rate in the resurfacing group was significantly higher. Also, the economic cost of both implants was significantly different. The resurfacing implants were more expensive than the silicone implants.

A retrospective survey for debridement with or without wafer distal ulna resection was performed. Forty six patients responded to a questionnaire on pain, disability and time off work. The mean DASH score decreased from 42 to 28 on average. Thirty two patients were satisfied. The pain was considered severe in 12 patients. There were significant differences in the outcome between debridement only and debridement with wafer resection of the distal ulna.

The effect of correction of metacarpophalangeal (MCP) joint hyperextension on the outcome of reconstructive surgery for basal joint osteoarthritis of the thumb was studied. Impairment, pain and satisfaction were similar after a combined surgical treatment of MCP hyperextension and basal thumb osteoarthritis in 33 patients, as in a series of 233 patients at the same institution after osteoarthritis surgery with a normal MCP joint.

Despite its high prevalence, the clinical presentation and severity of Dupuytren disease is extremely variable. The disease features a broad spectrum of symptoms, from simple nodules without the slightest clinical impact towards an extremely disabling form requiring multiple surgical procedures, sometimes even partial hand amputations. Recurrence after surgery is considered a failure for both patient and surgeon, but its definition is vague. The term 'recontracture' was coined by a patient and reflects the disappointment of recurrent disease. Wether or not a treatment option will insure a definite result, may depend more on the severity of the disease, which is patient specific, than on the treatment method itself. If a patient presents with Dupuytren disease, one should not merely evaluate his hands. Different clinical and personal history features may uncover a severe fibrosis diathesis and both correct information to the patient and an individualized treatment plan are needed. In the near future, a simple genetic test may help to identify patients at risk. Similar to the evolving knowledge and treatment modalities seen in rheumatoid arthritis, treatment of Dupuytren disease is likely to advance in the direction of disease control with pharmacotherapy and single shot minimal invasive enzymatic fasciotomy with collagenase to correct established contractures.

The effect of the three-ligament tenodesis on the scapholunate angle and scapholunate gap was studied. A comparison was made between these angles preoperatively and postoperatively in 12 patients. There was a significant decrease in the scapholunate angle from 77 to 68 degrees, and the scapholunate gap was reduced from 4.25 mm to 3.29 mm. We also studied the correlation between scapholunate angle and scapholunate gap postoperatively in a cohort of 25 patients and found a significant correlation. This suggests that the principle of the procedure is correct, but the aims are not fully achieved, and that the procedure has a similar effect on SL gap and SL angle.

Several surgical techniques are available to treat thumb basal joint arthritis. In this study, we compare the long-term results of a thumb basal joint prosthesis (de la Caffinière or Roseland type prosthesis) with those of trapeziectomy with ligament reconstruction and tendon interposition (LRTI). We could not find any difference between both techniques with respect to impairment, pain reduction, patient satisfaction and disability.

Failure of the distal radioulnar joint leads to significant dysfunction of the upper limb. Numerous surgical procedures have been suggested to address this problem. In degenerative arthritis, joint instability and ulnar stump dislocation after salvage procedures such as Darrach distal resection or Sauvé-Kapandji distal fusion, an ideal solution may not be available. The ultimate option to restore distal ulna stability in these cases is to fuse the ulna and radius. Obviously, the morbidity of one bone forearm with complete loss of pronation - supination is very high and such a decision is never taken lightly. We present a challenging case series of gross radioulnar arthritis and instability with an acceptable medium-term outcome after semiconstrained Scheker arthroplasty of the distal radioulnar joint. We conclude that in selected cases with unsolvable distal radio-ulnar instability and loss of the DRUJ joint, the Scheker arthroplasty may offer a valuable solution.

The outcome of ulnar shortenings was compared to the outcome after arthroscopic wafer resections for ulnar impaction (or abutment) syndrome in patients with a positive ulnar variance. Both surgical techniques are described. The outcome was measured by the DASH score, the visual analogue score for pain and the working incapacity. The mean DASH score in the ulnar shortening group was 26, in the wafer group it was 36. The VAS were respectively 4.4 and 4.6. The working incapacity was 7 months in the ulnar shortening group and 6.1 months in the wafer group. The differences between the two groups were not statistically significant.

The elbow joint needs to be both mobile and stable to exercise its hinge function, which is the key to a normal upper limb. Loss of motion in the elbow joint leads to an exponential functional handicap. Elbow trauma is a common cause of elbow stiffness. Open elbow arthrolysis with release of the capsule has been demonstrated to be a very useful treatment. Arthroscopic elbow arthrolysis has now gained popularity, along with the rapid evolution in elbow arthroscopy. The authors present the preliminary results of this technique in 12 patients, with a mean follow-up of 19.4 months. The range of motion significantly increased from an extension lag of 39.2 degrees and a flexion limited to 115 degrees to an extension lag of 17.9 degrees and a flexion of 131.7 degrees. On average, a 38 degrees gain in range of motion was achieved. This result is comparable with a gain of 40 degrees after open arthrolysis, reported by the senior author in a previous study. The DASH score improved from 39 to 28, but not significantly, and the VAS for pain from 5.5 to 3.4 (significantly). All patients would undergo the procedure again and they experienced a mean subjective improvement of 63.6%. A literature review showed that open and arthroscopic arthrolysis yield a gain of about 44.10 degrees and 31.25 degrees, respectively. The conclusion is that there certainly is a place for arthroscopic elbow arthrolysis.

Primary haematogenous nontraumatic arthritis of the wrist is uncommon. We report four such cases. All had a spontaneous onset with a delay in diagnosis. Treatment consisted of an open debridement and systemic antibiotics. Outcome appeared to be related to the delay between onset and treatment.

We retrospectively reviewed 13 patients who had successfully undergone three-ligament tenodesis for scapholunate instability, and compared the radiological outcome with 14 failed cases. The scapholunate angle in the failed group increased from 73 degrees to 81 degrees with a scapholunate gap of 532 mm, compared to a decrease in the successful group from 76 degrees to 66 degrees with a scapholunate gap of 2.94 mm. Postoperative radiographs may thus have a prognostic value and can also be used if confronted with a patient with persisting symptoms after operation. Salvage procedures may offer a better solution when tenodesis has failed and reduction is insufficient on radiographs, and we believe that redo operations are not indicated, when the initial reduction already failed.

The free vascularised corticoperiosteal flap from the medial femoral condyle, as described by Doi and Sakai, can be used for difficult non-unions. This flap is supplied by the Descending Genicular Artery (DGA) and the Superomedial Genicular Artery (SMA). In this anatomical study we describe the anatomy of these arteries. The DGA was dominant in 24 of 34 cases (70%). If the DGA was absent or too small, the SMA was sufficiently large for an adequate supply of the graft area. We concluded that of all the dissected specimens the arteries were sufficiently large and long enough to be suited for microsvascular anastomosis.

Wrist arthroscopy is not only a diagnostic tool; it has also developed into a valuable treatment alternative for several wrist disorders. All of the standard portals are dorsally located, leaving the dorsal sector of the radiocarpal and midcarpal joint partially invisible. A volar portal has been developed through the bed of the flexor carpi radialis tendon, thus expanding the therapeutic possibilities. We report our personal experience with the use of a volar portal in 28 of 206 (14%) wrist arthroscopies. No technical problems or neurovascular complications were encountered. We think the standardized approach as described is valuable and safe.

In order to investigate the prognostic value of possible risk factors for Dupuytren's diathesis, clinical parameters on disease presentation in an operated group of patients were compared with self-reported recurrence after a minimum 2 years follow-up. In order of significance, the following factors were found to be significantly correlated with disease recurrence : age of onset under 50 years (p = 0.01), bilateral disease (p = 0.01), Ledderhose disease (p = 0.01), first ray involvement (p = 0.02), multiple ray involvement (more than 2 digits, p = 0.02), ectopic fibromatosis (p = 0.02), family occurrence (p = 0.04) and male gender (p = 0.05). No correlation of self-reported disease recurrence was seen with diabetes, frozen shoulder syndrome or epilepsy. An insight in the significance of the influence of specific risk factors on recurrence rates, helps in creating a clearer representation of Dupuytren's diathesis. This will help the surgeon to more accurately inform the patient and possibly to reconsider and adjust the choice in treatment options.

Despite the obvious success of arthroplasty trapeziectomy with or without interposition and prosthesis--in the treatment for trapeziometacarpal osteoarthritis, one may question the value of an arthrodesis in particular situations. In most reported series the outcome is reasonably successful, but when comparing the results of arthrodesis with arthroplasty, there is convincing evidence that the latter gives better outcomes. Considering the overall complication rate, and more specifically the incidence of nonunion after trapeziometacarpal fusion, it can be reasonably concluded that the latter should be reserved for specific indications.

The radiological outcomes of 31 corrective osteotomies for malunion of the distal radius were assessed. The procedure re-established normal anatomy in the majority of cases. There was no significant difference in outcome between the dorsal and the palmar approach, but more secondary procedures for hardware removal were necessary with the dorsal approach.

The aim of this retrospective study was to assess the mid- and long-term functional and radiological results following latissimus dorsi transfer for symptomatic irreparable tears of the supra- and infraspinatus tendons (postero-superior cuff tears). Twenty-six shoulders with an irreparable posterosuperior rotator cuff tear were assessed preoperatively and after latissimus dorsi transfer, using the Constant score and standard radiographs to determine the degree of osteoarthritis and to measure the acromio-humeral distance. After a minimal follow-up of one year (range: 13 to 124 months) we observed a significant increase in Constant score from 39 to 60 points at the time of the last follow-up (p < 0.00001). Eighty-five percent of the patients were satisfied or very satisfied with the result and would undergo the same surgery again. An increase in the grade of gleno-humeral osteoarthritis was noted in 38.5% of the operated shoulders, and this was associated with a lower Constant score. We noted a decrease in acromio-humeral distance, indicating further proximalisation of the humeral head, but this was not significant (p = 0.049).

We evaluated the results of the arthroscopic Outerbridge-Kashiwaghi procedure in a retrospective review of 20 elbows in 19 patients with a mean followup of 2 years (range : 6 months - 4 years). Range of motion improved from 94 degrees (range: 15 degrees-140 degrees) to 123 degrees (range: 110 degrees-140 degrees). Visual analogue scales for pain improved from 5.8 (range: 2 -8) to 1.8 (range: 0-8). The Mayo Performance Index increased from 54 (range: 15-85) to 88 (range: 45-100). The results were good to excellent in 16 elbows, fair in two and poor in two. Seventeen patients were better (85%), 3patients remained unchanged (15%). In elbows with severe arthritis, pain relief was minimal. The arthroscopic Outerbridge-Kashiwaghi procedure appeared in this study as a good surgical option in mild to moderate elbow arthritis, with significant pain relief and increased elbow mobility and function.

Dupuytren's disease has been the subject of numerous epidemiological surveys attempting to expand our knowledge on its origin and spread. In Flanders, although numerous studies on surgical outcome have been reported, information on prevalence of Dupuytren's disease is lacking. Therefore, Flanders' population in a non-hospital environment was studied by a clinical evaluation performed by a single hand specialist. Five different market places spread geographically in the 5 Flemish provinces of Belgium were visited to examine the hands of randomly chosen individuals over 50 years old visiting the market. In all, 500 people were examined; Dupuytren's disease was found to be present in 32% of the population. Nodules without finger contractures (stage 1) were seen in 24% of the population, in comparable proportions in males (28%) and females (20%). However, finger contractures (stage 2) were seen in 8%, significantly more often in males (11%) than in females (4%). The prevalence of stage 1 is somewhat lower in individuals over 80 years old. In men, the incidence of stage 2 was found to increase with age. These findings were compared with literature data on the prevalence of Dupuytren's disease in other countries and populations. It appears that, similar to northern Europe, Dupuytren's disease is also a common disease in Flanders.

Plain radiography can help in confirming the clinical diagnosis of a subungual glomus tumour, as erosive changes in the distal phalanx are present in 22% of cases. Such changes will be more easily identified on a lateral radiograph with the painful finger and its contralateral counterpart pointing toward each other: discrete scalloping of the distal phalanx will thus be made more evident.

The radiographic files of 70 patients with Kienbock's disease were analyzed. Ulnar variance, carpal height and Kienbick stage were determined. A significant difference in ulnar variance was seen between early and late stages of the disease. In later stages there is a marked negative ulnar variance, not caused by bone apposition on the radius. We hypothesize that negative ulnar variance encourages further progression of the collapse of the lunate, while neutral or positive ulnar variance seems to protect the lunate against deformation.

We report 6 cases of recalcitrant non-union of forearm bones treated with a free vascularized thin corticoperiosteal graft harvested from the medial condyle of the femur. All non-unions healed. In one 58-year-old patient a fracture of the femur occurred.

Twenty eight patients with advanced carpal collapse (20 with scapho-lunate advanced collapse [SLAC] and 8 with scaphoid-nonunion advanced collapse [SNAC]) who were treated with a four-corner arthrodesis were reviewed; 23 had a good or excellent outcome. The mean DASH score was 41. The flexion/extension arc decreased from 72 degrees to 52 degrees. Gripping force increased from 46% to 72%. The range of motion was better in those with a traditional fixation (K-wires or screws) compared to the newer circular plates. There was no significant difference concerning pain relief, gripping force and disability.

Pollicisation of the index finger for absence or severe hypoplasia of the thumb has been reported as a good procedure to recreate a new "thumb" with good cosmesis and acceptable function. The purpose of this study is to evaluate the outcome of our series. Seventeen patients with 24 involved hands agreed to come back for evaluation. The mean age at operation was 12 months. In 8 hands there was also a radial club hand. Buck Gramcko's technique was used with slight modifications. The mean follow-up time was 53 months (range, 6-142 months). The outcome was determined in a variety of ways: objective assessment of function and cosmesis (measurement of thumb length, girth and nail size), and subjective evaluation of function and aspect done with a patient/parent questionnaire and a visual analogue score. The mean functional score was excellent for one hand, good for eleven, fair for five and poor for five. The mean length was 96%, the width was 93%, the nail width was 85% as compared with the contralateral thumb. There was no significantly different outcome in the syndrome-related thumbs versus the isolated cases, nor in unilateral versus bilateral cases. A significantly worse outcome was seen for function and subjective evaluation in the radial clubhand associated thumbs and for the functional score for the more severe Blauth group.

Four patients with complete paralysis of the deltoid muscle with irrepairable axillary nerve lesion and one with traumatic destruction of the shoulder cap were treated with a bipolar latissimus dorsi muscle transfer. The latissimus dorsi muscle was prepared as an island flap, turned over and sutured to the trapezius proximally and to the original deltoid insertion on the humerus distally. Function and cosmesis were excellent in two patients; in one case the goal was only to achieve soft-tissue coverage, and was successfully achieved. One patient only had partial survival of the muscle and in one case the procedure failed to restore active functional abduction.

Although total elbow arthroplasty is a reliable treatment method for the arthritic joint, revision is necessary if loosening, instability, wear, fracture or infection occurs. We report 12 patients with 19 months (10-29) follow-up after revision arthroplasty for painful loosening in six cases, periprosthetic fracture in three, gross instability in one and skin perforation with possible infection in two. All cases presented with severe metallosis. Fractures were seen in four, triceps insufficiency in three and skin perforation in two. All patients were treated with exchange arthroplasty using the Coonrad-Morrey prosthesis. Three patients had in addition strut-allografting. The two patients with skin perforation and possible infection had a staged procedure. Mayo Elbow Performance Score improved from 24 to 87 with uneventful healing, fracture consolidation and allograft incorporation. At follow-up, triceps insufficiency persisted in all three cases. Transient neuropathy was present in five patients (4 ulnar, 1 radial). Metallosis in total elbow arthroplasty may be associated with severe tissue damage. A staging method is presented.

The DASH (Disability of Arm, Shoulder and Hand) score is being used increasingly as an outcome measure for upper limb pathology. In our clinical practice the DASH score has been used to study the outcome of several common upper limb disorders. We reviewed the literature and applied the principles of the World Health Organization on this scoring system.

Dupuytren's disease is very common, with a prevalence of up to 40% in the Scandinavian population. Although many epidemiological surveys have been conducted, little is known about its aetiology. Multiple risk factors in Dupuytren's disease have been identified. About 80% of the affected patients are male. Even though recent data suggest similar outcome after surgical treatment in the female patient, recurrence after surgery is more frequent. To assess Dupuytren's disease in women, a record analysis and a survey of risk factors was conducted in 130 female patients surgically treated at our institution between 1988 and 2005. With a response rate of 52%, 65 women were included (6 patients were confirmed dead). The mean age of onset of the disease was 50 years and 6 months. After a mean follow-up of 7 years and 7 months (2y1m to 21y9m), recurrent disease after surgery was reported in 42%. Bilateral disease was present in 54%, unilateral in 26% right and 20% left hands. The fifth finger was involved in 77%, the 4th finger in 48% and the 1st ray in 14%. Ectopic lesions were seen in 19%, with a positive family history in 55%. Only one patient had a confirmed alcohol abuse; 22% were smokers. There were 32% manual workers. Shoulder pain was present in 54% of the patients, with confirmed diagnosis of frozen shoulder syndrome in 45%. High cholesterol was diagnosed in 39% and only 6% had diabetes. Epilepsy was seen in 5%. High disease recurrence and factors related to an aggressive course of the disease are present in female patients with Dupuytren's contracture, with a high family history occurrence, bilateral disease and associated Ledderhose disease. Several known risk factors were present: high cholesterol, smoking and manual work. Frozen shoulder showed a very high prevalence in women with Dupuytren's disease.

In a retrospective survey, 16 patients with 18 established nonunions of the scaphoid treated with a sandwich graft and Herbert screw fixation, were reviewed: 14 patients were very satisfied with the outcome. The mean DASH score was 17 (SD 18.4). Flexion was 76%, extension 79% and gripping force 85% of the contralateral side. Union was achieved in 13 scaphoid bones. There was a significant increase in carpal height. Despite these findings there was also an increase in osteoarthritis. However this was not related to the correction or absence of correction of the preoperatively existing DISI. There was no correlation between radiological presence of osteoarthritis and clinical outcome.

The purpose of this study was to correlate wrist motion (ROM) and disability of the upper limb. A total number of 205 patients who had undergone various wrist operations were included in this study, in which the range of motion of the wrist was correlated with the DASH (disability of arm, shoulder and hand) score. There was a significant correlation between the DASH score and the ROM of the wrist, but the correlation was rather weak (r = 0.24). Inclusion of patients with wrist arthrodesis resulted in a stronger correlation. Preservation of some ROM of the wrist is worthwhile. Evaluation of corporeal damage should be adapted in a more functional way.

Kiloh-Nevin syndrome was first described in 1948 by Parsonage and Turner and further defined in 1952 by Kiloh and Nevin. The aetiology is highly debated. Two common causes of Kiloh-Nevin syndrome are compression neuropathy and brachial plexus neuritis. In this study the results in six patients who were treated operatively and were evaluated after a mean follow-up of 42 months (range: 24 to 60), are presented. Retrospectively, two subgroups could be identified based on initial clinical presentation and EMG: one subgroup of patients presented with a compression neuropathy and the other subgroup presented with brachial plexus neuritis. An important difference in outcome was seen between the two subgroups. There were excellent results after surgical decompression in the patients with a compression neuropathy, whereas the results after surgical decompression in the subgroup presenting with brachial plexus neuritis were less predictable. The data presented here and the data found in the literature, suggest that if the clinical image and the EMG suggest a compression neuropathy, surgical decompression, after two months of conservative treatment, will give excellent results. If the clinical image and EMG suggest brachial plexus neuritis, a conservative treatment may be more appropriate.

A series of 10 patients with reducible chronic post-traumatic scapholunate dissociation, treated with the modified Brunelli technique, is presented. The general outcome was good with a mean DASH score of 12, a range of motion of 69% and gripping force of 77% compared with the contralateral side.

In this study of 38 patients, we assessed the clinical result following surgical treatment of Dupuytren's disease with isolated fifth ray involvement, particularly with respect to the proximal interphalangeal joint. Three surgical techniques were used: limited fasciectomy, segmental fasciectomy and dermofasciectomy. At a mean follow-up time of 53.6 months, there were no residual deformities nor recurrences in the metacarpophalangeal joint. At the proximal interphalangeal joint, there was an overall improvement of 45 degrees in movement with a residual flexion deformity avering 30 degrees. The recurrence rate in this series was 39%. There was no significant difference in residual deformity or recurrence rate between the various surgical techniques used. Fifth ray involvement in Dupuytren's disease remains a surgical challenge, especially at the proximal interphalangeal joint. Residual deformity and recurrence rate remain high, irrespective of the surgical technique used.

Arthrodesis of the wrist has been considered as the gold standard for osteoarthritis of the wrist. In 1984 Watson and Ballet identified a specific pattern of carpal collapse (scapholunate advanced collapse = SLAC) with progressive osteoarthritis. In order to preserve some motion, other alternative procedures have been proposed: proximal row carpectomy (PRC) and scaphoidectomy combined with a four-corner arthrodesis (4CA). In this cohort of 63 patients, three types of surgical treatment were performed (arthrodesis in 19, PRC in 26 and scaphoidectomy with 4CA in 18). The DASH questionnaire was used to evaluate the residual disability. PRC had a significantly better outcome (DASH=16), while there were no significant differences between full arthrodesis (DASH=45) and four corner arthrodesis (DASH=39). In PRC and in four corner arthrodesis a functional range of motion could be preserved (resepectively 44 degrees and 52 degrees flexion/extension arc). Gripping force remained inferior to the non operated side. There was a significant increase in gripping force in the PRC group, but not in the others. The final gripping force was not significantly different in the three treatment regimes.

Rheumatoid arthritis (RA) involves the wrist in up to 80% of cases; up to 95% of patients have signs of wrist arthritis after 12 years of disease. The distal radioulnar joint (DRUJ) is involved in 31% to 75% of these patients and is often the first compartment of the wrist involved. The inflammatory sequence of events leads to the "caput ulnae syndrome" described by Backdahl in 1963. Extensor tendon ruptures are frequently associated. The presence of the "scallop" sign on radiographs is an alerting sign for tendon attrition. The gold standard in treatment remains resection of the distal ulnar head, known as Darrach's procedure. The most frequent complication is instability of the proximal ulnar stump. In order to restore stability or to prevent instability, several stabilisation techniques have been reported with free tendon grafts, the extensor carpi ulnaris, the flexor carpi ulnaris, the joint capsule and the pronator quadratus muscle. There is no evidence that stabilisation of the proximal ulnar stump during the initial operation gives better results. Another drawback of ulnar head resection is the progression of ulnar translation of the carpus. There are however several surveys showing that this ulnar translocation is the consequence of the disease rather than the result of the Darrach procedure. Several features such as an increased radial slope (> 23 degrees) and/or destruction of the ulnar corner of the distal radial epiphysis have been mentioned as predictive elements for further ulnar slide of the carpus. The Sauvé Kapandji procedure is in these cases a useful alternative choice. Another advantage of this technique is that it provides a larger surface so that other (radial) procedures can be more easily combined (Chamay partial radiocarpal fusion, wrist prosthesis).

We retrospectively reviewed 37 cases of resection of the olecranon bursa and noted wound healing problems in 10 (27%) and recurrence in 8 (22%). A lateral arm flap was necessary in one patient. Conservative treatment remains the treatment of choice for olecranon bursitis. Differentiation between septic and non-septic cases is challenging. The risk of wound healing problems and recurrence should be taken into account when planning surgical resection.

During the diagnostic investigation of a patient with ulnar wrist pain, a hot spot in the proximal ulna was revealed on the technetium scintigram, which was found on radiographs to correspond to an osteolytic lesion in the proximal ulna. The lesion was resected and the histological diagnosis was an osteoblastoma. The wrist symptoms disappeared after resection of the lesion in the proximal ulna.

In this retrospective study, a latissimus dorsi transfer as first described by Gerber in 1988 was performed in 12 patients with massive, irreparable rotator cuff tears. Their average age was 59 years and the preliminary results are reported here after an average follow-up of 39 months. In 50% of the patients there was no pain and 41% had mild to moderate pain at follow-up. Functional Constant scoring was excellent in 42%, good in 8%, moderate in 42% and poor in 8%. Active range of motion in the shoulder improved significantly in external rotation and abduction. Abduction force as measured with Atlantech and Cybex systems showed weak results. In two patients these tests could not be performed due to lack of force, in 9 patients abduction force was much weaker than on the contralateral side and in one patient the operated arm was stronger than the other side. We conclude that in most patients good pain relief and functional improvement can be achieved after latissimus dorsi transfer for irreparable rotator cuff tear. A good active range of motion can be expected but a lack of force persists. However, it remains difficult to conclude for which patients this surgery can be predictably successful.