Revascularization and dynamic distraction for a complex finger injury

Abstract

discoid pyrocarbon implant for scaphotrapeziotrapezoid arthritis (Pequignot and Allieu, 2000).We report the use of the radio-capitate pyrocarbone implant (RCPi) for two patients presenting with combined mid-and radiocarpal osteoarthritis of the wrist with or without carpal collapse as an alternative to wrist fusion with a follow-up of 5 years. The surgery was done without denervation. The head of the capitate was sectioned with 1 mm of the hamate to insure a good surface for the prosthesis. This section has to take into account the slope of the implant and the length of the stem which must not extend beyond the capitate. The smallest implant was used. As there were no special instruments to fit the stem into the capitate, the position was checked on radiological imaging. An important shortcoming of the system is the lack of instruments to centre and ream. The elevated radiotriquetral ligament was sutured to the capsular attachments of the hamate. Proper implant placement was checked radiologically before and after closure in various wrist positions. A bulky dressing and a short-arm palmar splint were used. Passive assisted mobilization was started as soon as pain allowed. After radiological assessment at 4 weeks, unrestricted wrist motion was allowed. Two to five months of physiotherapy was needed. Two patients had this implant over 5 years ago.The first was an active, 65-year-old, female farmer, without a history of trauma, who presented with wrist pain at night which disturbed her sleep and she was unable to use her hand. The wrist was swollen, warm and painful when moved in any direction. She had 20 each of flexion and extension, and 80 each of painful pronation and supination. She had no measurable grip strength using the Jamar dynamometer set at the second position. The opposite wrist was normal and no further systemic joint pathology was noted. The patient refused a total wrist fusion and an RCPi implant was advocated but the patient was informed that no long-term results were available. She had her wrist replaced and at present she is still active on the farm, without pain, impairment, swelling or tenderness. Her wrist motion was limited to 40 each of flexion and extension but her grip strength was now equal to the opposite normal wrist and the quick DASH score was 9.5. The cyst within the radius resolved without any bony change around the stem on radiographs.The second patient, a 62-year-old nurse, had sustained a fall on the outstretched right dominant hand some months previously. She was unable to return to work and had a scapholunate rupture with radiocarpal and midcarpal arthritis. She accepted the RCPi implant well aware that a mishap would lead to a total wrist fusion. At final follow-up 6 years later she was still active, without any pain, swelling or limitation. Radiographs did not show radiolucency around the stem or axial deviation of the stem. Her grip strength was 20 kg (25 kg opposite hand), and flexion and extension of the wrist was 40 each, her forearm rotation was equal to the opposite sid...