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Salvage of failed total wrist arthroplasty by arthrodesis may be difficult because of bone loss and poor quality of bone and soft tissues. We examined the outcomes of wrist arthrodesis for failed total wrist arthroplasty in a retrospective study of 21 wrists in 17 patients. Clinical data, radiographs, patient-reported outcomes and DASH questionnaires were used. Thirteen women and four men had undergone total wrist arthroplasty at an average age of 55 years. The mode of failure was aseptic loosening in 13 wrists. The average time from the index arthroplasty to wrist arthrodesis was 7.6 years. Autograft and/or allograft bone graft was used in all of the wrists. Arthrodesis was achieved in 11 wrists and ten had a nonunion. Six arthrodeses underwent eight revisions for nonunion, with two achieving union. The mean DASH score was 29 in wrists that fused and 36 in those that did not fuse. Pain scores averaged 2.1 in the wrists that fused and 3.3 in the nonunion group. Most patients had clinical improvement.

Although fractures of the fifth metacarpal neck (boxer's fractures) are common, their treatment can be problematic. A description of a technique utilizing traction reduction is presented in this paper. The records and radiographs of 59 patients who underwent reduction using longitudinal traction and subsequent immobilization in a specially molded cast were retrospectively reviewed. On average, 80% of initial fracture angulation in the sagittal plane was corrected, and only 1 degrees of this correction was lost at the discontinuation of casting (3-4 weeks). We have found this technique to be highly effective in the treatment of boxer's fractures. Advantages of this treatment include its efficacy, ease, and improved patient tolerance over other casting techniques.

Subcutaneous nodules occur in approximately 20-25% of rheumatoid factor (RF)-positive rheumatoid patients. In this paper, we present a unique case of a 47-year-old healthy RF-negative woman with a 3-year history of necrobiotic nodules over the dorsum of her hands, extensor forearms, and lower extremities. This may represent an atypical presentation or a new rheumatoid variant.

Purpose: Pyrolytic carbon implants have been successfully used in the treatment of osteoarthritis of the metacarpophalangeal and proximal interphalangeal joints. Recently, pyrolytic carbon hemiarthroplasties have been proposed for the treatment of osteoarthritis of the trapezial-metacarpal (TM) joint of the thumb. We wished to review our short-term outcomes for this device in the treatment of TM arthritis., Methods: Fifty-four arthritic TM joints in 49 patients, with a mean age of 59 years, were treated with use of a pyrolytic carbon hemiarthroplasty procedure. Underlying diagnoses included osteoarthritis in 44 thumbs, rheumatoid arthritis in 8 thumbs, psoriatic arthritis in 1 thumb, and juvenile rheumatoid arthritis in 1 thumb. The patients were followed up clinically as well as radiologically for an average of 22 months postoperatively., Results: The overall 22-month survival rate excluding scaphotrapezio-trapezoidal joint arthritis was 80% according to a Kaplan-Meier analysis. Ten metacarpal subluxations were observed. Seven of these cases were salvaged by increasing the depth of the trapezial cup. A total of 15 reoperations were required in this cohort. No complications were seen in the patients with inflammatory arthritis. Thirty-five patients were pain free at the latest follow-up, and 6 reported mild to occasional pain with repetitive activities. The overall satisfaction rate was 40 of 49 patients (81%). Grip strength recovered to 86% of that of the contralateral side. Apposition key and opposition pinch strength improved to 92% and 95%, respectively, of those of the contralateral hand., Conclusions: Pyrolytic carbon thumb arthroplasty may prove to be an acceptable option for the treatment of TM, although a high complication rate was observed in this early cohort, with many cases of subluxation attributed to the creation of a too shallow trapezial cup. Further comparative studies are warranted., Type of Study/level of Evidence: Therapeutic IV.

Purpose: To review early outcomes of arthritic metacarpophalangeal (MCP) joints treated with nonconstrained pyrolytic carbon implants to evaluate efficacy, clinical outcomes, and durability., Methods: One hundred forty-two consecutive arthroplasties (61 patients) were retrospectively reviewed. Diagnoses included osteoarthritis (OA), traumatic arthritis, and inflammatory arthritis. One hundred thirty were primary joint replacements, and 12 were prior-silicone revisions. The average patient age was 55 years (range, 21-77 years); 36 patients were women and 25 were men. Average follow-up period was 17 months (range, 3-42 months), and 43 patients were followed up for a minimum of 1 year., Results: For OA patients, according to the analog pain scale used, pain decreased from 73.0 to 8.5 of 100, functionality increased from 20.1 to 86.6 of 100, and appearance improved from 62.7 to 93.6 of 100. The rheumatoid arthritis (RA) group showed decreased pain from 43.1 to 8.9 of 100, functional improvement from 26.7 to 83.3 of 100, and increased appearance from 25.2 to 77.1 of 100. At 1 year, satisfaction was greater than 90% for both groups. Arc of motion for OA patients improved from 44 degrees to 58 degrees . Oppositional pinch increased 126%, and grip strength improved 40%. Rheumatoid arthritis patients increased their MCP joint motion arc from 32 degrees to 45 degrees . Oppositional pinch increased 89%, but grip strength decreased. Radiographs at 1 year demonstrated stable prostheses in all of the OA joints. The RA group overall demonstrated evidence of axial subsidence (10.5% of joints) and periprosthetic erosions (16.4% of joints). In RA joints with greater than 1-year follow-up period, 55.0% had axial subsidence, 95.0% had an increased radiolucent seam, and 45.0% had periprosthetic erosions. The overall implant survivorship is 141 joints to date. The overall minor complication rate was 6%, and major complication rate was 9%., Conclusions: Preliminary results suggest that pyrolytic carbon MCP joint arthroplasty provides good pain relief, patient satisfaction, and functional improvement in managing OA and select cases of RA. Longer follow-up evaluation will help validate these promising early results., Type of Study/level of Evidence: Therapeutic IV.

Aim: Prosthetic replacement in the hand must address such unique challenges as preservation of the collateral ligaments, tendon balancing,and Stability. Surface replacement arthroplasty can be an alternative to other current implants. The purpose of this study was to evaluate the metacarpophalangeal joint kinematics after surface replacement arthroplasty., Method: The kinematics of pyrolytic carbon as a surface replacement implant for the metacarpophalangeal joint (MCP) was compared with the intact MCP joint in eight fresh cadaver long fingers by means of an electromagnetic tracking system (Polhemus, Colchester, VT). The eight human cadaver MCP joints were tested before implantation, after implantation, after collateral ligaments resection, and after collateral ligaments reconstruction., Results: The kinematics of the MCP joint is reproduced by the joint surface replacement arthroplasty when normal ligament tension was present. The maximum angular displacement of the pyrocarbon implant was 378 for lateral deviation and 338 for rotation during the passive flexion and extension motion. The instantaneus center of rotation (ICR) after implant insertion was nearly identical to the center of rotation of the normal joint. The results also indicated that the collateral ligaments provide the primary stability of the MCP joint. No significant differences in lateral and rotational stability after surface replacement arthroplasty were noted. While collateral ligaments resection significantly affected the stability of the MCP joint., Conclusion: The ICR of the pyrocarbon implant most closely matched that of the intact MCP joint. The pyrocarbon implant provides suitable stability to radio-ulnar deviation and rotational stresses as a resurfacing implant and it simulates the kinematics of the intact MCP joint. By using new materials and taking the anatomical and biomechanical requirements into consideration, the endoprosthesis of the finger joints has created an option to achieve good long-term results. The inadequate results of earlier and current prostheses are a consequence of their mechanical construction and their materials. The success of the new implants could be proven by preferably long-term, controlled studies.

Purpose: To retrospectively review the surgical technique, postoperative therapy/splinting protocols, and clinical and radiographic outcomes of patients who had pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty., Methods: A total of 50 PIP joint replacements in 35 patients were performed with a minimum follow-up period of 27 months. Indications for surgery included pain, decreased range of motion, instability, and/or deformity. The preoperative diagnosis was osteoarthritis in 14, rheumatoid arthritis in 11, and posttraumatic arthritis in 10. There were 20 women and 15 men affected. The average age at the time of surgery was 53 years. The fingers replaced included the index (15), middle (18), ring (10), and small (7). The preoperative arc of motion averaged 40 degrees (0 degrees-60 degrees ), and the pinch and grip measurements averaged 3 and 19 kg, respectively. The preoperative pain scores averaged 6 (scale, of 0-10) on a visual analog space scale., Results: The arc of motion was 47 degrees after surgery, and the average pinch and grip measurements were 4 and 25 kg, respectively. Pain scores improved to 1. At the final follow-up evaluation the overall patient satisfaction was nearly 80%. The results of index finger PIP replacements are compatible with other digits. Fourteen joints (in 14 patients) to date have required additional procedures to improve or maintain joint motion/function or pain; 5 for minor reasons and 9 for major complications. The revision arthroplasty rate was 8%. No infections were noted. Although not medically necessary, 2 patients requested and had an amputation. Radiographic subsidence and subsequent settling (in accordance with Wolff's law) without apparent loosening occurred in 20 joints., Conclusions: Our 2-year minimum follow-up evaluation of pyrolytic carbon implant arthroplasty showed improved pain relief and good overall patient satisfaction. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. Radiographs showed gross changes in implant and eventual settling to a stable position in 40% of the joints. A longer follow-up period will help to better determine the efficacy of this implant., Type of Study/level of Evidence: Therapeutic, Level IV.

Unconstrained pyrolytic surface replacement arthroplasty provides the benefits of a more natural center of rotation with preservation of native ligamentous joint stability. Initial short-term results show excellent motion, pain relief, and restoration of pinch and grip strength. These results are encouraging, and suggest that pyrolytic carbon arthroplasty may be a reasonable option for joint salvage in patients suffering from MP joint osteoarthritis.

As early as the 1970s, pyrocarbon became a point of focus in the search for materials for alternative finger replacement. This type of material had already proven its biocompatibility and excellent wear behaviour in its use for artificial heart valves. The first trials with pyrocarbon surface replacement implants for the small finger joints in baboons showed good biocompatibility as well as good functional results. The first patient series confirmed theses results in long-term follow-up. Meanwhile, the surface replacement implants made of pyrocarbon are an interesting alternative to silicon spacers. Further developments for other joints in the hand are under evaluation.

Purpose: To evaluate the results of Biaxial (DePuy Orthopedics, Inc., Warsaw, IN) total wrist arthroplasty (TWA) with a long metacarpal stem., Methods: A retrospective review of the results of 17 long-stem metacarpal components for the Biaxial TWA implanted between 1993 and 1997 is presented., Results: After surgery pain and grip strength improved markedly. Overall motion improved but only radial deviation was significantly better. All of the patients were satisfied. At the most recent follow-up evaluation 4 cases showed evidence of radiographic lucency about the cement mantle, but with no gross loosening or settling. No failures at a greater than 6-year average (4-year minimum) follow-up period have been noted. Two cases of intraoperative third metacarpal fracture and one case of dorsal metacarpal component placement were encountered but did not affect the outcomes., Conclusions: To date the survivorship of the Biaxial TWA with the long stem is favorable compared with previous reports with the standard Biaxial distal component.

Purpose: To evaluate the results of a single surgeon's treatment of mucoid cysts, comparing outcomes between injection and surgery., Methods: One hundred thirty-four cysts were treated, with a minimum 2-year follow-up period. Thirty-one patients had nail ridging or deformity at presentation. Eighty patients had multiple soft-tissue punctures into the cyst with a 25-gauge needle and injection with local anesthetic and steroid. Fifty-four patients had surgical excision and joint debridement., Results: In the injection group, complete resolution of the cyst occurred in 48 cases (60%). Among the 32 that recurred, repeat injections were performed in 8 cases; 3 resolved. No recurrences were noted in the surgery group. Nail ridging resolved after surgery in 25 digits; the remaining 6 digits had partial improvement or persistent ridging. Five infections occurred and were treated successfully with antibiotics (4) or debridement (1), or both., Conclusions: Aspiration and injection was convenient but had a 40% recurrence rate. Surgery provided definitive treatment with no major long-term problems.

The assembly of inflammatory lesions in rheumatoid arthritis is highly regulated and typically leads to the formation of lymphoid follicles with germinal center (GC) reactions. We used microdissection of such extranodal follicles to analyze the colonizing T cells. Although the repertoire of follicular T cells was diverse, a subset of T cell receptor (TCR) sequences was detected in multiple independent follicles and not in interfollicular zones, suggesting recognition of a common antigen. Unexpectedly, the majority of shared TCR sequences were from CD8 T cells that were highly enriched in the synovium and present in low numbers in the periphery. To examine their role in extranodal GC reactions, CD8 T cells were depleted in human synovium-SCID mouse chimeras. Depletion of synovial CD8 T cells caused disintegration of the GC-containing follicles. In the absence of CD8 T cells, follicular dendritic cells disappeared, production of lymphotoxin-alpha1beta2 markedly decreased, and immunoglobulin (Ig) secretion ceased. Immunohistochemical studies demonstrated that these CD8 T cells accumulated at the edge of the mantle zone. Besides their unique localization, they were characterized by the production of interferon (IFN)-gamma, lack of the pore-forming enzyme perforin, and expression of CD40 ligand. Perifollicular IFN-gamma+ CD8 T cells were rare in secondary lymphoid tissues but accounted for the majority of IFN-gamma+ cells in synovial infiltrates. We propose that CD8+ T cells regulate the structural integrity and functional activity of GCs in ectopic lymphoid follicles.

A retrospective evaluation of the Steffee metacarpophalangeal (MCP) thumb joint prostheses was performed to determine the long-term outcome and survivorship of the prosthesis. Fifty-four primary thumb arthroplasties (49 patients) were performed for pain, weakness, or instability involving the thumb MCP joint secondary to arthritis. Underlying etiology included rheumatoid (49 thumbs), psoriatic (1 thumb), scleroderma (2 thumbs), and degenerative (2 thumbs) arthritis. Thirty-one thumbs had concomitant interphalangeal joint instability and underwent interphalangeal joint fusions. At an average follow-up period of 57 months, the average motion of the MCP joint was 21 degrees (range, 0 degrees to 40 degrees ), with a significant improvement in position and stability. Thumb axis length was maintained or increased in 98%. Although there was not a consistent long-term improvement in grip or pinch strength, 87% of the patients reported subjective improvement in strength and function as a result of surgery. Pain was relieved in all thumbs with preoperative pain. Complications included a periprosthetic fracture, 2 late infections, and 1 gross loosening of the implant. The survivorship of the implant was 93% survivorship at 5 years and 89% survivorship at 10 years, with only 4 failures in 54 thumbs. The Steffee thumb MCP arthroplasty resulted in excellent long-term survivorship, patient satisfaction, and functional outcome.

Background: The metacarpophalangeal joint is the most commonly involved joint when rheumatoid arthritis affects the hand. Many prosthetic implants have been designed for the replacement of this joint. Although studies of these implants have shown relief of pain, they have generally demonstrated a poor range of motion, progression of ulnar drift, and bone loss, as well as failure, fracture, and dislocation of the implant., Methods: From December 1979 to February 1987, 151 pyrolytic carbon metacarpophalangeal implants were inserted in fifty-three patients. The implants had an articulating, unconstrained design with a hemispherical head and grooved, offset stems. Forty-four patients had rheumatoid arthritis; five, posttraumatic arthritis; three, osteoarthritis; and one, systemic lupus erythematosus. Three patients (eleven implants) were lost to long-term follow-up, and twenty patients (fifty-one functioning implants) died after the implant had been in situ for an average of 7.2 years. Eighteen implants (12 percent) in eleven patients were revised. Fourteen of the eighteen implants were replaced with a silicone-elastomer or another type of implant, and the remaining four were removed and a pyrolytic carbon implant was reinserted with the addition of bone cement or bone graft, or both. Twenty-six patients (seventy-one implants) were available for long-term review at an average of 11.7 years (range, 10.1 to 16.0 years) after implantation., Results: The implants improved the arc of motion of the fingers by an average of 13 degrees and elevated the arc by an average of 16 degrees. As a result, fingers were in a more functional, extended position. A complete set of preoperative, postoperative, and follow-up radiographs was available for fifty-three of the seventy-one implants that were followed long term. There was a high prevalence of joint stability: fifty (94 percent) of the fifty-three implants were in a reduced position postoperatively, and forty-one (82 percent) of those fifty implants were still in the postoperative reduced position at the time of long-term follow-up. Ulnar deviation averaged 20 degrees preoperatively and 19 degrees at the time of follow-up, with only the long finger having an increase in deviation. No adverse remodeling or resorption of bone was seen. Fifty (94 percent) of the fifty-three implants had evidence of osseointegration, with sclerosis around the end and shaft of the prosthetic stems. Radiolucent changes were seen adjacent to twelve implants. There was minimum-to-moderate subsidence (four millimeters or less) of thirty-four implants; most of the subsidence occurred immediately postoperatively. Survivorship analysis demonstrated an average annual failure rate of 2.1 percent and a sixteen-year survival rate of 70.3 percent. The five and ten-year survival rates were 82.3 percent (95 percent confidence interval, 74.6 to 88.2 percent) and 81.4 percent (95 percent confidence interval, 73.0 to 87.8 percent), respectively. None of the revised implants had any visible changes of wear or deformity of the surfaces or stems. Four instances of chronic inflammatory tissue and three instances of proliferative synovitis were noted histologically. Focal pigment deposits were seen in three fingers, one of which had removal of the implant two months after a fracture. No evidence of intracellular particles or particulate synovitis was found., Conclusions: The results of this study demonstrate that pyrolytic carbon is a biologically and biomechanically compatible, wear-resistant, and durable material for arthroplasty of the metacarpophalangeal joint.

Rheumatoid arthritis (RA) is a chronic inflammatory disease with primary manifestations in the synovial membrane. Tissue infiltrates are composed of T cells, B cells, and macrophages, but histopathological appearances vary widely and are rarely pathognomonic. Mechanisms underlying the phenotypic heterogeneity of rheumatoid synovitis are not known. To explore whether a correlation exists between the microscopic patterns of rheumatoid synovitis and in situ production of cytokines, tissue samples from 21 consecutive patients with clinically active RA were examined. Based upon the organization of the lymphocyte infiltrate, the synovial biopsies were categorized into three distinct subsets. Ten samples were characterized by diffuse lymphoid infiltrates without further microarrangement. In seven samples, lymphoid follicles with germinal center formation were detected, and in four specimens, granuloma formation was identified. In all specimens, cytokine transcription of interferon (IFN)-gamma, interleukin (IL)-4, IL-1 beta, tumor necrosis factor (TNF)-alpha, IL-10, and transforming growth factor-beta 1 was semiquantified with polymerase chain reaction and liquid phase hybridization. Each of the morphologically defined variants of synovitis displayed a unique cytokine profile. Low-level transcription of IFN-gamma, IL-4, IL-1 beta, and TNF-alpha was typical of diffuse synovitis. In follicular synovitis, IFN-gamma was the dominant cytokine, IL-4 was virtually undetectable, and IL-10 was abundant. Granulomatous synovitis demonstrated high transcription of IFN-gamma, IL-4, IL-1 beta, and TNF-alpha and could be clearly distinguished from the other phenotypes. To investigate whether differences in the synovial lesions were related to host factors, patients were compared for clinical parameters. Diffuse synovitis was seen in most of the patients with seronegative RA, the mildest form of the disease. In contrast, extra-articular spreading of RA with nodule formation was typically associated with granulomatous synovitis. In summary, RA patients display reproducible patterns in the organization and activity of synovial infiltrates. The correlation of microanatomy with tissue cytokine production suggests that several pathomechanisms can modulate the expression of the immune response in the synovial membrane.

Trispiral tomography enhances the staging of Kienböck's disease and aids in surgical planning. The clinical records, plain x-rays, and trispiral tomograms of 105 patients with Kienböck's disease were reviewed. When tomograms were used, upward revision of the classification stage was indicated in 73% of patients with stage I or stage II disease and in 10% of those with stage III disease. On tomograms, 91% of patients had lunate fractures, compared with 55% on plain films. The most common lunate fracture seen on trispiral tomograms was a transverse shear fracture that represented lunate collapse; the next most common was a midcoronal fracture that may be displaced, causing fragment extrusion palmarly or dorsally. The most common instability pattern was nondissociative proximal row flexion, seen in stage III. Indices of carpal collapse and ulnar translation may be useful in following up patients, but values vary widely among patients.

Sixty-six surface replacement proximal interphalangeal prostheses with a CrCo proximal and an ultrahigh-molecular-weight polyethylene distal component were used in the hands of 47 patients (mean age, 58 years) over a 14-year period. There were 37 fingers with degenerative arthrosis, 16 with traumatic arthrosis, and 13 with rheumatoid arthritis. The mean follow-up period was 4.5 years (range, 1-14 years). The results based on pain relief, motion, and deformity were good in 32 fingers, fair in 19, and poor in 15. Poor results occurred primarily in fingers with previous extensive injury or static deformity. Results with a dorsal approach were better than those with a lateral or palmar approach. Component loosening at the bone-cement junction beyond a minimal radiolucent line was seen in one late x-ray. Results in individuals changed little after the first year of follow-up care, but results overall improved during the course of the study, perhaps because of improvements in surgical technique and experience.

Sixty-four consecutive biaxial total wrist arthroplasties performed in 52 patients between March 1983 and June 1988 were reviewed. Fifty-seven cases involving 45 patients were followed for a minimum of 5 years or until failure. Of the remaining 7 patients, 6 had died and 1 was lost to follow-up study. For the 46 intact implants in living patients, the mean follow-up period was 6.5 years (range, 5-9.9 years). The mean patient age at operation was 58 years. The underlying diagnosis was rheumatoid arthritis in 63 cases and juvenile rheumatoid arthritis in 1 case. At follow-up evaluation, pain was reported as none in 75%, mild in 19%, moderate in 3%, and severe in 3%. Patients rated their improvement as much better in 62%, better in 30%, some improvement in 4%, and worse in 4%. Range of motion at last follow-up averaged 36 degree extension, 29 degree flexion, 10 degree radial deviation, and 20 degree ulnar deviation. Grip strength improved from 4.1 kg preoperatively to 5.9 kg at last follow-up evaluation. Pain was likewise significantly improved at 1 year and 5 years. Failures occurred in 11 cases. The causes of failure were loosening of the distal implant in 8 cases and infection, dislocation, and progressive soft tissue imbalance in 1 case each. An abnormal resting stance and distal implant subsidence (> or = to 3 mm) at 1 year were associated with implant failure at final follow-up evaluation. The Kaplan-Meier probability of survival free of revision was 83% at last follow-up evaluation

Revision total-wrist arthroplasty has a high incidence of complications. Loosening is a significant problem for the distal implant. Because of the high failure rate of single-pronged distal implants after revision total-wrist arthroplasty, a custom multipronged distal component (biaxial total-wrist implant) was designed for use in patients with deficient bone stock who undergo revision operation. Ten cases of total-wrist arthroplasty with a custom long-stemmed multipronged distal component are presented. The preoperative diagnosis was failed total-wrist arthroplasty in 9 cases. Mean time from previous total-wrist arthroplasty to revision procedure was 5.6 years. At follow-up evaluation (mean, 3.8 years; range, 3.0-4.8 years), 2 patients had undergone arthrodesis: 1 patient at an outside institution 1 year after surgery for periprosthetic fracture of the radius, and 1 patient at our institution for distal implant loosening. The 8 other patients had functional total-wrist arthroplasties. At follow-up evaluation, all patients reported they were satisfied. Six patients reported no pain and 2 reported mild pain. Mean range of motion at follow-up evaluation was within the previously defined limits that allow patients to function in activities of daily living: 78 degrees for supination, 77 degrees for pronation, 39 degrees for extension, 17 degrees for flexion, 12 degrees for radial deviation, and 18 degrees for ulnar deviation. Revision total-wrist arthroplasty with custom long-stemmed, multipronged distal components offers an alternative to those patients with deficient bone stock who refuse arthrodesis. Early results demonstrate greater longevity compared with single-pronged components for revision total-wrist arthroplasty.

The authors evaluated the motor latency values of 72 median nerves assessed with the compact, hand-held, battery-powered NervePace Electroneurometer. Results of this test were compared to those of clinical examination, standard electrodiagnostic tests, and median nerve findings of compression at the time of surgery in 23 patients. The motor latency values obtained with an electroneurometer correlated positively with those from routine electromyography (EMG): sensitivity and specificity were calculated for the ability to diagnose carpal tunnel syndrome (CTS) (> 3.9 ms considered abnormal). This study identified a sensitivity of 85.7% and a specificity of 87.5% in predicting CTS, as confirmed by complete EMG and electroconduction studies.

During the past 3 decades implant arthroplasty of the destroyed wrist has become a reliable and satisfying procedure. However, the first total wrist replacement was performed in Berlin as early as 1890. This paper describes the history of resection and interposition arthroplasty of the wrist leading to the first total wrist implant arthroplasty performed by Themistocles Gluck. An overview of recent designs is given, and the relevant historical cases are reported.

Biaxial design total wrist arthroplasty was used to salvage 13 failed total wrist arthroplasties of various designs. After a follow-up period of 31 months, two wrists had undergone further prosthetic revision for loosening and one wrist was arthrodesed. In the remaining 10 wrists, 8 had no pain, 1 had mild pain, and 1 had moderate pain. Eight patients reported feeling much better, one reported feeling better, and one reported no change. Postoperative range of motion averaged 36 degrees of extension, 19 degrees of flexion, 6 degrees of radial deviation, and 15 degrees of ulnar deviation. X-ray films at follow-up evaluation showed that two revision arthroplasties still in place were loose. The majority of patients had a satisfactory clinical result after revision total wrist arthroplasty with a biaxial design. Loosening of the revision is a significant problem.

In four cases, proximal radioulnar synostosis developed as a complication of distal biceps tendon reattachment through a two-incision technique. The synostosis was excised in all four cases but recurred in two. In each case, the initial reattachment exposed the bicipital tuberosity of the radius anteriorly and exposed the ulna extraperiosteally through a second incision along its subcutaneous border. This two-incision approach may place the patient at risk for synostosis. If two incisions are to be used for distal biceps tendon reattachment, then a limited muscle-splitting approach through the extensor muscle mass, which avoids exposure of the ulna, may be preferable.

During the 50-year period 1928 to 1977, 1,250 Rochester, Minnesota residents experienced 1,355 proximal femur (hip) fractures. The incidence of these fractures appeared to rise during the first 15 years of the study, but this was most likely due to underascertainment of cases in the early period since there was no evidence of a cohort effect. From 1943 onward, there was no significant increase in the incidence rates which remained relatively level for total hip fractures, initial hip fractures alone, and for initial hip fractures due to moderate trauma. Thus, we found no evidence to support the contention that hip fracture incidence has risen dramatically in recent years. Secular changes in incidence cannot account for the observation that hip fracture rates in Rochester are greater than those reported from earlier population-based studies.

Clinical trials with cemented polyethyiene and metal total joint arthroplasties were initiated in 1973. Replacements have been developed for the wrist, carpometacarpal joint of the thumb, metacarpophalangeal joints of the thumb and fingers, and the proximal interphalangeal joints of the fingers. Results, evaluated by pain relief and joint stability, were excellent at all sites. Motion, however, averaged only 50% of normal. Significant problems included abnormal posture in the wrist, roentgenographic evidence of loosening in the finger metacarpophalangeals, extensor lag in the metacarpophalangeal of the thumb, and lack of motion in the proximal interphalangeal joint of the finger.

Total wrist arthroplasty has been performed at the Mayo Clinic for the past 5 years. The procedure has necessitated the development of a dynamic wrist splint for post-operative care. This article provides a step-by-step outline for construction of this splint.

A study of eight patients and 20 cadaveric limbs identified the deep aponeurosis of the flexor carpi ulnaris as a potential site for constriction of the ulnar nerve. The ulnar nerve passes through this aponeurosis approximately 5 cm distal to the medial epicondyle and 2 to 3 cm distal to the cubital tunnel. In two cases of isolated compression at this level, local decompression was successful in relieving the symptoms of ulnar nerve compression. Submuscular transposition is also effective because it places the ulnar nerve deep to this aponeurosis throughout its entire course.

Forty-six patients with Kienböck's disease were evaluated over a 2- to 27-year period; 72% had a history of wrist injury prior to diagnosis; 67% had evidence of fracture or fragmentation of the lunate. Documented fractures of the lunate were identified followed by both the presence and absence of subsequent Kienböck's disease and this may be explained by the variable blood supply of the lunate. Ten patients were not treated; 36 patients were treated surgically. Patients were relieved of pain and had functional wrists whether they were treated or not and regardless of the type of surgical treatment.

The management of giant cell tumors involving the distal radius has always been a difficult problem. After resection to eradicate a primary or recurrent lesion, transplantation of a nonvascularized fibular autograft was used in 12 patients. Of these patients, ten had good to excellent functional results. The procedure can restore a functionally useful wrist.

Prosthetic replacement of the wrist requires careful consideration of anatomic and mechanical factors, appreciation of the techniques of implant fixation, and recognition of soft tissue imbalance across the wrist. Cemented wrist implants have an unacceptably high rate of failure (15%-30%) with a five-year progressively decreasing prosthesis "survival rate." Three different implant designs have been studied and analyzed with respect to long-term success. In the revision of failed wrist implants, the surgeon must evaluate requirements for a stable wrist and appropriately reconsider resection, a more stable total joint arthroplasty, and wrist arthrodesis.

Carpal instabilities are generally the result of a hyperextension injury. The deformities are mediated through the internal compressive force supplied by the musculotendinous units and are dependent on the extent of injury as well as the precise structures that are disrupted. The scaphoid inherently tends to palmar flex. It will pull the lunate with it if the lunotriquetral integrity has been interrupted, and conversely the lunate and triquetrum will dorsiflex if the scapholunate integrity is disrupted. If the integrity of the oblique external ligaments, particularly the volar (palmar) radiolunate, is disrupted, the entire carpus has a tendency to translate ulnarly. Carpal instabilities are invariably associated with weakness, limitation of motion, and pain.

The principles ot total joint arthroplasty recently have been expanded to the upper extremity, following the dramatic success with total hip and total knee replacement procedures. New problems have been encountered with the rebalancing of the soft tissues and the technical nature of joint mechanics in the upper extremities. Work on shoulder joint replacement is in the very early stages and of unknown success. Several prostheses are being used and tested. For elbow and wrist replacement, early and predictable success has been accomplished, enabling relief of pain and satisfactory motion. Total joint replacement in the fingers and thumb has provided excellent relief of pain but has been hindered by difficulties in rebalancing the soft tissues in patients with rheumatoid arthritis. It appears that total reconstruction of arthritic upper-extremity joints will be commonplace in the not-too-distant future. Clinical trials are being expanded, with increasing success.

Evaluation of 26 Meuli total wrist arthroplasties in 22 patients 7 to 17 months after operation revealed that 92 percent (24 wrists) were relieved of pain. Postoperative motion averaged 32 degrees of dorsiflexion. 27 degrees of palmar flexion, 2 degrees of radial deviation, and 23 degrees of ulnar deviation. Failure of the prosthetic design to place the center of rotation properly in the capitate resulted in a tendency toward flexion and ulnar deviation deformities. Reoperation was required in nine (35 percent) of the 26 wrists. After reoperation of these nine wrists, 77 percent (20 wrists) of the total group had good or excellent results, 11.5 percent (three wrists) fair, and 11.5 percent (three wrists) poor.

Implant arthroplasty in deforming arthritis of the hand and wrist is a useful procedure that provides pain relief and mobility. Resection arthroplasty enhanced by silicone elastomer interpositional implants remains the standard of comparison and procedure of choice in most areas. Articulated and nonarticulated fixed-fulcrum implants have had limited success. Soft tissue disease significantly limits the eventual success of implant arthroplasty in the rheumatoid hand and wrist.