PURPOSE OF THE STUDY Our study aimed to evaluate a group of patients who in the period from 2005 to 2014 underwent a four-corner arthrodesis of the wrist in our department. We also wanted to verify the hypothesis as to whether the use of conventional dorsal plate without the application of bone grafts leads to comparable results as the use of dorsal locking plates and routine application of bone grafts. MATERIAL AND METHODS Throughout the years 2005 to 2014 the four-corner arthrodesis of the wrist was performed in our department in a total of 62 patients, in two cases bilaterally. The indication was the diagnosis of SLAC/SNAC grade III. Normed RondoFix implant was used in all the cases. Following the surgery, the wrist was immobilized by a volar plaster splint for the period of 2 weeks and subsequently orthosis was applied for additional 4 weeks. The wrist mobilisation started in week seven when the orthosis was removed, the patients were allowed full load on the wrist 3 months after the surgery. Our group of patients was evaluated retrospectively, a total of 53 operated wrists in 51 patients were assessed. The assessment was carried out based on a radiograph of the wrist, range of motion, Mayo Modified Wrist Score, DASH Score and grip strength test. RESULTS The mean range of motion in sagittal plane was 63.7°, in frontal plane the mean value was 32.1°. According to the Mayo Modified Wrist Score 37 patients were rated "excellent" or "good". Due to the presence of moderate pain, the result in other 10 patients was assessed as "satisfactory". In a total of 4 patients the result was assessed as "weak", in two of them for a presence of non-union and in other two for severe pain under load. One of these patients underwent bilateral surgery and reported severe pain in both the wrists. Regarding DASH score, the best result equalled 0, the worst 65.83, with the mean of 20.5. The grip strength ranged from 8 to 54 kg, with the mean value of 27.5 kg. In two patients, a non-union occurred. In the first case the extraction of implant and re-arthrodesis was performed due to severe pain and screw migration. The patient is now 22 months after the surgery and the radiographs show that the arthrodesis has healed and the patient has no clinical difficulties. The second patient did not report any difficulties, therefore he is only subject to follow-up. No cases of screw or plate breakage were reported. In one case, the patient reported pain in the region of radial styloid process. A revision was indicated with radial styloidectomy and decompression of tendons of m. extensor pollicis brevis and m. abductor pollicis longus. As a result the patient had no clinical difficulty. One case of wrist radial deviation was recorded. It was managed by corrective wedge osteotomy and reosteosynthesis using a circular dorsal plate. In one patient dorsal impingement occurred, accompanied by limited range of motion and pain. Extraction of OS material was indicated and the patient was relieved of any difficulties. We have recorded aseptic necrosis of lunate bone in one case. DISCUSSION When comparing the functional results such as the range of motion and grip strength, our results are fully comparable to previously published papers. In papers where DASH was referred to, its value ranges from 13 to 29.82, which is fully consistent with our observations with the final value of 20.5. The incidence of non-union and the degree of complications is not deviating from the values included in other publications either. In all the mentioned publications the authors refer to routine use of bone grafts. The publications evaluating the use of locking plates do not report different results either. CONCLUSIONS In case of correct indication, the four-corner arthrodesis of the wrist represents a very good solution. In our group of patients, we confirmed the hypothesis that equally good results as with the use of locking plates can be achieved when using a non-locking plate system. Essential is the proper correction of DISI and primary good congruence between fused carpal bones instead of the use of bone grafts. Key words: SLAC wrist, SNAC wrist, four-corner arthrodesis, partial wrist fusion.
- MeSH
- artrodéza * MeSH
- kostní destičky * MeSH
- lidé MeSH
- poranění zápěstí patofyziologie chirurgie MeSH
- retrospektivní studie MeSH
- rozsah kloubních pohybů MeSH
- síla ruky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Neurofibromatosis von Recklinghausen typ 1 (NF1) je multisystémové, autozomálně dominantně dědičné neurokutánní onemocnění charakterizované postižením kůže, centrálního a periferního nervového systému, oka, kostí a cévní stěny. Incidence je 1:3000 živě narozených dětí. Příčinou rozvoje onemocnění je mutace tumor supresorového genu NF1 (17q11.2) a z toho vyplývající porucha tvorby neurofibrominu - cytoplazmatického proteinu, přednostně exprimovaného v neuronech, Schwannových buňkách, oligodendrocytech, astrocytech a leukocytech. Hlavní úkolem neurofibrominu je jeho funkce negativního regulátoru komplexu Ras. Porucha této funkce je u NF1 dávána do souvislosti s výskytem mnohočetných nádorových procesů, které histologicky odpovídají hamartomům nebo benigním nádorům. Nádory centrálního nervového systému jsou především gliomy nízkého gradu (pilocytární astrocytom, grade I), zvláště v průběhu zrakové dráhy. Tyto nádory jsou často klinicky asymptomatické. Gliomy bývají časté také v oblasti mozkového kmene a mohou být nalezeny také jinde v mozku a v míše. Hydrocefalus může být u NF1 komplikací gliomu nebo vzniká při stenóze distální části mokovodu. V periferním nervovém systému se objevují neurofibromy a plexiformní neurofibromy. Plexiformní neurofibromy mají významné celoživotní riziko malignizace. Klinická diagnóza NF1 je definována sedmi diagnostickými kriterii a ke stanovení diagnózy je nutný nález alespoň dvou z nich. Metodika přímé DNA analýzy rozsáhlého NF1 genu (61 exonů) je vypracována. Výsledky studií genotyp-fenotyp jsou ale málo průkazné a predikce průběhu onemocnění podle nalezené mutace není v současné době možná. Frekvence sporadického výskytu NF1 je vysoká (30 - 50 %). Variabilita fenotypu onemocnění je výrazná i v rámci jedné rodiny. Kauzální terapie není v současné době známa - léčba je symptomatická. Při progredujícím low-grade gliomu je metodou volby chemoterapie, pro plexiformní neurofibromy chirurgické řešení.
Neurofibromatosis von Recklinghausen type 1 (NF1) is a multisystem, autosomal dominant hereditary neurocutaneous disease characterized by skin, central and peripheral nervous system , eyes , bone, endocrine, gastrointestinal and blood vessel wall involvement. It has an estimated frequency of 1 in 3000. Neurofibromatosis type 1 is caused by mutations in the large NF1 gene located on chromosome 17q11.2, encoding the cytoplasmic protein neurofibromin. It is expressed in multiple cell types but is highly expressed in Schwann cells, oligodendrocytes, neurons, astrocytes and leukocytes. Neurofibromin is known to act as a tumor suppressor via Ras-GTPase activation, which causes down-regulation of cellular signaling via the Ras/mitogen-activated protein kinase (MAPK) pathway. Failure of this function is associated with a tendency to form tumors which are histologically hamartomas as well as benign tumors. Tumors of the central nervous system include low-grade gliomas (pilocytic astrocytomas grade I), especially optic pathway gliomas. They are often clinically asymptomatic. Other intracranial tumors are in the brain stem and also elsewhere in the brain and spinal cord. Hydrocephalus may be a complication of NF1 gliomas or due to stenosis of the distal part of the aqueduct Silvii. Cutaneous and subcutaneous neurofibromas or plexiform neurofibromas are localized in the peripheral nervous system. Plexiform neurofibromas have a significant lifetime risk of malignancy. The clinical diagnosis of NF1 is defined by diagnostic criteria. The NF1 diagnosis is satisfied when at least two of the seven conditions are met. The method of direct DNA analysis of large NF1 gene (61 exons) is available. The results of studies of genotype - phenotype established few correlations. But predicting the disease by finding mutations is not currently possible. NF1 exhibits a wide range of variability of expression and complete penetrance, even within the same family. About half of cases are new mutations. The treatment of patients with neurofibromatosis is symptomatic. Central nervous system symptomatic low-grade gliomas are most often treated with chemotherapy. For plexiform neurofibromas surgical removal is currently the only treatment option.
- MeSH
- delece genu MeSH
- diferenciální diagnóza MeSH
- genetické techniky * MeSH
- geny neurofibromatózy 1 * MeSH
- gliom zrakového nervu MeSH
- gliom MeSH
- hydrocefalus MeSH
- kožní nemoci MeSH
- lidé MeSH
- neurofibrom MeSH
- neurofibromatóza 1 * diagnóza genetika MeSH
- neurofibromin 1 fyziologie nedostatek MeSH
- plexiformní neurofibrom MeSH
- příznaky a symptomy MeSH
- zárodečné mutace MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
- přehledy MeSH
PURPOSE OF THE STUDY: Arthrodesis of the trapeziometacarpal joint is the method of choice in the treatment of degenerative arthritis of this joint. This procedure was indicated most frequently in middle-age patients doing hard manual labor. Methods for achieving a solid fusion of the trapeziometacarpal joint are known and often reported in the literature. Frequently, they are associated with some failure rate, particularly as concerns bone union. Our study presents a simple and effective method verified in cadaver specimens and then currently used at our department. MATERIAL AND METHODS: The procedure for arthrodesis of the trapeziometacarpal joint was verified fist in fixed wrist and hand specimens at the Institute of Anatomy, 1 st Faculty of Medicine, Charles University in Prague. If the original shape of the basal thumb joint between the trapezium and the metacarpal is maintained, it allows for correct reduction and subsequent arthrodesis in a required position. In patients, surgical treatment included the use of implants, two DePuy shape-memory staples, which facilitate sufficient fragment compression and provide stable fixation. The staples were inserted in pre-drilled and gauged tunnels in the body of the trapezium and in the proximal metaphysis of the fist metacarpal. RESULTS: Between 2011 and 2014, the procedure was used in 14 patients diagnosed with primary arthritis of the trapeziometacarpal joint. The group comprised nine women and five men, the average age was 52 years and the range was 44 to 69 years. Surgery was most frequently carried out on the dominant upper extremity (85%); there was no bilateral surgery. The average follow-up was 18.3 months (range, 5 to 39 months). Solid fusion was recorded at 7 weeks after surgery in all patients except for the one still treated at the time of this paper submission. All patients were free of pain, ten reported satisfaction with grip strength and hand function, the rest would have preferred improvement in fine motor skills of the thumb. All of them found the cosmetic appearance of the hand satisfactory.. DISCUSSION: The methods generally used for trapeziometacarpal joint arthrodesis are reported to carry some risk of pseudarthrosis development. A lot of modifications have been described, from conventional procedures using AO lag screws or Kirschner wires to up-to-date plate systems involving angle-stable fixation. Total fusion of the trapeziometacarpal joint is disputable in patients with rheumatoid arthritis from the technical point of view as well as the relevance of indication criteria. Some authors consider this procedure a contraindication for patients with rheumatoid arthritis. The use of joint replacement in treating trapeziometacarpal joint arthritis is another complex issue. CONCLUSIONS: An arthrodesis of the trapeziometacarpal joint based on careful assessment of indication criteria proved to be a simple, effective and low-cost method of stable osteosynthesis that provided good conditions for solid fusion of the trapezium with the base of the fist metacarpal. It allowed for sufficient abduction and opposition of the thumb, thus permitting satisfactory hand grip strength and full involvement in everyday life activities and occupations. It provided stability of the thumb, its painless movement and good cosmetic looks.
- MeSH
- artrodéza metody MeSH
- dospělí MeSH
- estetika MeSH
- karpometakarpální klouby chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- osteoartróza chirurgie MeSH
- senioři MeSH
- síla ruky MeSH
- spokojenost pacientů MeSH
- trapézová kost chirurgie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- anglický abstrakt MeSH
- časopisecké články MeSH
Naše kazuistika referuje o 64leté nemocné s revmatoidní artritidou, u které se 7 měsíců po implantaci totální endoprotézy zápěstí projevil infekt této náhrady. Kultivace prokázala Staphylococcus koaguláza negativní. Pacientka byla zpočátku léčena konzervativně (antibiotika podle citlivosti), následně byla provedena operační revize a aplikována proplachová laváž. To ovšem nevedlo ke zvládnutí infektu, a proto bylo 9 měsíců po primoimplantaci provedeno odstranění endoprotézy, opět byla zavedena proplachová laváž a následovalo zklidnění na volární sádrové dlaze za současné intravenózní aplikace antibiotik. Za dalších 8 měsíců, po úpravě zánětlivých markerů, kostní konsolidaci a po opakovaně negativní kultivaci, byla provedena totální artrodéza karpu naší vlastní metodou pomocí autokompresní L dlahy Poldi určené pro artrodézu zápěstí. Vzhledem ke kostnímu defektu byl výkon kombinován s modifikovanou Brunelliho metodou přemosťujícího kortikospongiózního štěpu odebraného z dorzální části distálního radia. Ten byl posunut ve svém lůžku distálně nad dorzální část karpu. Současně byla provedena rekonstrukce spontánně vzniklé ruptury extenzoru IV. prstu end-to-side suturou k extenzoru III. prstu a přiložena volární sádrová dlaha na 4 týdny. Dalších 6 týdnů používala nemocná zápěstní ortézu. Rána se zhojila per primam, vhojování štěpu bylo rentgenologicky sledováno. V současné době je déza karpu zhojena plnohodnotným svalkem v osově neutrální poloze, úchopová schopnost ruky není podstatně omezena, supinačně-pronační pohyby jsou volné.
Our case report focuses on a 64 year old patient with rheumatoid arthritis after implantation of a total wrist replacement. The implant got infected and the infection was confirmed approximately 7 months after implantation. Cultivation revealed the presence of coagulase negative streptococcus. The patient was initially treated conservatively (antibiotics administered according to microbial sensitivity), followed by revision surgery with continuous closed irrigation-suction system. However, this did not cure the infection and implant had to be removed 9 month after the primary implantation with application of another continuous closed irrigation-suction system, volar cast immobilization and intravenous antibiotics administration. Wrist fusion was performed after another 8 months as soon as the inflammation markers were normalized, the bone substrate was consolidated and cultivation was repeatedly negative. We have used our own method using special L-shaped plate designed for wrist arthrodesis, manufactured by the Poldi company. Due to the large bone defect, we had to perform modified Brunelli method of bridging corticospongious graft taken from distal part of the radius. In our modification we distalised the graft in its bed so that it could reach the dorsal aspect of the carpus. We also had to perform reconstruction of extensor tendon of IV. digit due to spontaneous rupture. We used end-to-side suture to extensor tendon of III. digit. Wrist was immobilized by volar cast for 4 weeks followed by bracing for another 6 weeks. Wound was closed per-primam, graft healing was observed by x-ray. Currently the fusion is fully healed in neutral position. There is no significant impairment to hand grip and supination-pronation movements are free.
- Klíčová slova
- náhrada zápěstí, chirurgie zápěstí, infekt kloubní náhrady,
- MeSH
- artroplastiky kloubů * škodlivé účinky MeSH
- infekce v ráně farmakoterapie ošetřování MeSH
- lidé středního věku MeSH
- lidé MeSH
- pooperační komplikace mikrobiologie terapie MeSH
- reoperace metody MeSH
- revmatoidní artritida chirurgie komplikace terapie MeSH
- zápěstí * chirurgie mikrobiologie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- Klíčová slova
- chirurgie zápěstí,
- MeSH
- artroplastiky kloubů * metody přístrojové vybavení MeSH
- dospělí MeSH
- hodnocení výsledků zdravotní péče statistika a číselné údaje MeSH
- lidé středního věku MeSH
- lidé MeSH
- ortopedické výkony metody MeSH
- peroperační komplikace MeSH
- pooperační komplikace MeSH
- prospektivní studie MeSH
- protézy - design dějiny trendy MeSH
- protézy kloubů * MeSH
- revmatoidní artritida MeSH
- rozsah kloubních pohybů MeSH
- senioři MeSH
- spokojenost pacientů statistika a číselné údaje MeSH
- zápěstí chirurgie radiografie MeSH
- zápěstní kloub * chirurgie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- práce podpořená grantem MeSH
- Klíčová slova
- chirurgie ruky, revmatochirurgie,
- MeSH
- artroplastika prstů * metody přístrojové vybavení MeSH
- biokompatibilní materiály terapeutické užití MeSH
- dospělí MeSH
- kloub prstu ruky chirurgie patologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- měření bolesti MeSH
- mladý dospělý MeSH
- pooperační komplikace MeSH
- prospektivní studie MeSH
- protézy kloubů MeSH
- revmatoidní artritida * komplikace MeSH
- rozsah kloubních pohybů MeSH
- senioři MeSH
- spokojenost pacientů MeSH
- uhlík MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
