Excision of the trapezium is always followed by instability and proximal migration of the first metacarpal base. In the present report, a modification of a previously suggested technique of metacarpal fixation is presented. The base is trapped between the APL- and FCR-tendons by means of a strip from the ECRL-tendon. This technique was applied in 44 thumbs with trapezial arthrosis. Stability and mobility were restored in all thumbs and the results as to strength and freedom from pain were successful in 80%. The suggested procedure is simple both technically and in regard to post-operative care and is particularly suitable in older patients.

The present report is based on assessment of 48 patients who underwent carpal Silastic H.P. implant arthroplasty (trapezium, condylar, scaphoid, lunate and scapholunate implants). Mean follow-up period was 29 months (range 6-82). Recurrent pain and/or evidence of wrist synovitis and lytic lesions made early subsequent surgery necessary in 10 patients. In the remaining 38 patients the post-operative course was followed for an average period of 33 months (range 8-82). Severe giant-cell silicone synovitis combined with isolated or disseminated osteolytic lesions were found in 17/30 (56%) patients with scaphoid or lunate implants and in 2/18 (11%) with other types of Silastic carpal implants. Well-defined cysts were observed within 8 months of insertion of the implant. Morphologically, an erosive giant-cell synovitis was regularly seen, with large quantities of intra- and extracellular silicone debris. Abraded material was also observed in central parts of normal bone and in lymph node tissue distant from the implant. The ultimate tissue response to this propagation of silicone particles is unknown. The situation is of great concern and the continued use of proximal carpal Silastic H.P. implants should at present be seriously questioned.

A chicken toe experimental model was used to study the fate of flexor tendon grafts, introduced into intact tendon sheaths. After perfusion of the limb by India Ink, the vascular pattern of the graft and the synovial sheath could be identified. The grafts showed no or few adhesions to the sheath. With time, there was a conversion from a diffuse superficial vascular pattern towards a concentration of vessels on the dorsal aspect of the graft. In a control group, where the sheath had been resected, adhesions were more apparent, and could be observed still after 16 weeks. These results are in complete agreement with previous experimental findings and further confirm the importance of an intact tube system in the digit.

The results of lunate implant arthroplasty are unpredictable and many untoward postoperative problems are encountered. A retrospective review of 19 patients operated on for lunatomalacia (Kienböck's disease) by Silastic (HP) implant arthroplasty suggests that prevention of postoperative scapholunate dissociation seems to be the key to successful results. Knowledge of the predominant role played by the palmar ulnolunate and radiolunate ligaments is important to the understanding of this mechanism. The intrinsic stability accomplished by the geometry of the carpal bones requires adequate ligamentous support. This restraint, however, may be weakened by pre-existing absence of certain palmar fibres, by the disease process or by the surgery. In the present study three operative methods have been assessed: dorsal approach and implant stem fixation; dorsal approach, removal of implant stem and Kirschner-wire fixation; volar approach, removal of implant stem, no internal fixation but palmar capsuloligamentous reinforcement. Consistently good results have been obtained using the latter technique. It seems as if most of the usual postoperative problems of lunate implant arthroplasty can be avoided by this method which warrants continued trial.

In a series of 48 painfully restricted wrists denervation was used during a 6-year period on wide indications as a surgical alternative. The observation time averaged 2.4 years. Pain relief occurred in 56% of the patients. Considering the simplicity of the method and the lack of serious complications, it is concluded that denervation of the wrist is worth trying as a palliative measure prior to more extensive surgery.

In 11 patients with carpal bone cysts the course of the intraosseous lytic lesion could be followed over periods from 2 to 27 years. The cysts were found to develop from an area of sparse trabeculae of reduced mineral content to a well-defined cavity, in some instances surrounded by a sclerotic zone. In 2 instances the lytic process caused progressive destruction of the subchondral layers of the affected bone resulting in communication with the adjacent joint space. The findings support the theory that carpal bone cysts are intraosseous lesions probably caused by vascular disturbances from mechanical stress and repeated trauma. The term intraosseous ganglion is a misnomer and should be avoided.

Degenerative changes of the scaphotrapezial trapezoidal (ST) joint commonly cause pain and weakness. These patients do not respond to conservative treatment, and for several years effort has been made to find an easy way to relieve symptoms. In a previous report a silicone interposition arthroplasty was described and considered to be a useful method. However, the durability of the elastomer was insufficient, and implant fractures and migration of fragments occurred. Since then the procedure has been modified, and high performance Silastic has been used for interposition. Ten patients have been reviewed, with a follow-up from 6 to 36 months (average 15 months). All patients have had lasting relief from pain and consider they have full hand function, without stiffness or limited thumb or wrist motion. Roentgenographic reviews have neither revealed deterioration nor dislocation or migration of the implant. Untoward bone reactions have not been observed. Implant hemiarthroplasty is indicated only when the degenerative changes are solely confined to the ST joint.

An alternative method of thumb restoration is described, using a damaged finger of inferior functional value as a composite pedicle. After removing the proximal and distal phalangeal bones as well as the nail region, the finger, now carrying the midphalangeal bone only, is reversed and attached to the remnant of the thumb. The method is most useful after severe mutilations.

The frequency and pathogenesis of median nerve compression complicating the Rush pin method of fusing the rheumatoid wrist was evaluated retrospectively. This complication was encountered in 14/50 wrists (28%). In 7 hands the carpal tunnel was explored, mostly within 2 weeks after fusion. In addition to signs of acute entrapment of the median nerve the most constant finding was that the volar edge of the resected distal end of the radius was prominent and projected into the bottom of the carpal tunnel caused by too vigorous correction of the subluxed carpus. Obviously the median nerve was squeezed or angulated at the volar edge of the radius. After median nerve release and resection of the bony prominence all patients regained full sensibility within the period of observation (in average 2.5 years). It is concluded that this mechanism of nerve entrapment should be realized when fusion of a severely destructed rheumatoid wrist is considered.

Hyperextension of the thumb metacarpophalangeal joint may be congenital or result from an injury to the volar ligamentary system. The usual complaints are local pain, joint instability and weakness of the pinch and grip. The present paper describes a simple method of correcting this instability by using a palmaris longus-tenodesis as a hyperextension checkrein for the joint.

A case of eosinophilic fasciitis in a 64-year-old woman had all the characteristics of severe fascial involvement and was complicated by bilateral carpal tunnel syndrome requiring surgical decompression. The course was followed with repeat biopsies and biochemical analyses. No medication was given except for occasional nonsteroidal antiinflammatory agents. The patient recovered completely and remains well at an age of 69 years.

Three patients with tuberculosis of the hand are reported. In each patient the onset and course of the disease was insidious and the diagnosis was obscured by lack of systemic symptoms and the absence of other foci of infection. The diagnosis was established only after open biopsy and synovial tissue culture. The wounds healed without complications even prior to appropriate chemotherapy. Combined conservative and surgical treatment resulted in definitive cure of the local manifestation in two of the patients.

Avascular necrosis may affect a number of different bones. In the wrist necrosis of the lunate (Kienböck's disease) is a well known entity. A rarely seen but analogous condition may, however, also affect the scaphoid (Preiser's disease). The mechanism producing ischemia is unknown, although in most cases the initiating event is mostly likely loss of blood supply by a mechanical insult. Two cases of idiopathic avascular necrosis of the scaphoid are reported, manifested by insidious wrist pain and progressing roentgenologic changes. Despite early diagnosis and prolonged immobilization irreversible collapse of the affected bone could not be prevented.

An intraosseous hemangioma of the lunate was diagnosed as the cause of wrist complaints. At angiography considerable arteriovenous shunting within the bone was shown. Replacement of the lunate by a SILASTIC implant relieved the pain. The intraosseous hemangioma, however, appeared to be only a part of more wide-spread disease which fulfilled the criteria for a Klippel-Trénaunay syndrome.

Malignant hemangioendothelioma is a tumour of vascular origin with wide distribution in various organs and tissues of the body. However, it is seldom localized primarily in bone. In this report our experience with a case of primary multifocal malignant hemangioendothelioma of the metacarpal bones is reported. Because of the focal pattern of malignancy excisional biopsy failed to give the diagnosis which was not established until the tumour was radically removed.

A current review of flexor tendon repair, with emphasis on difficult cases, is presented. The authors base their discussion on studies of the microanatomy and microvasculature of the human flexor tendon system as well as on experimental studies in flexor tendon nutrition and healing. A two-stage operation is described in which the tendon sheath is first restored by transplantation of autologous synovial tissue, then tendon grafting is performed.

The repair of flexor tendons which have been divided within the digital sheath remains an unsolved problem. Adhesions occur at would sites and points of tendon trauma. It is well known that an intact digital canal prevents formation of adhesions. Previous studies in chickens have shown that autologous tendon sheath tissue can successfully be transplanted from one digit to another with preserved vitality and that by this technique the continuity of an injured tendon sheath can be restored. The present series represent a clinical application of this new concept. 40 patients with flexor tendon injuries within the critical zone in the finger were treated by the use of a two-stage tendon grafting procedure. In the first stage operation the continuity of the tendon sheath was restored by transplantation of autologous synovial tissue. In the second procedure 3 months later a conventional tendon grafting was performed. Using the criteria of Boyes & Stark (1971) successful results were obtained in 88%. It can be concluded that the present method of tendon grafting provides a favourable recipient bed and improved gliding conditions.

The repair of flexor tendons which have been divided within the digital sheath remains an unsolved problem. Adhesions occur at would sites and points of tendon trauma. It is well known that an intact digital canal prevents formation of adhesions. Previous studies in chickens have shown that autologous tendon sheath tissue can successfully be transplanted from one digit to another with preserved vitality and that by this technique the continuity of an injured tendon sheath can be restored. The present series represent a clinical application of this new concept. 40 patients with flexor tendon injuries within the critical zone in the finger were treated by the use of a two-stage tendon grafting procedure. In the first stage operation the continuity of the tendon sheath was restored by transplantation of autologous synovial tissue. In the second procedure 3 months later a conventional tendon grafting was performed. Using the criteria of Boyes & Stark (1971) successful results were obtained in 88%. It can be concluded that the present method of tendon grafting provides a favourable recipient bed and improved gliding conditions.

Eight patients with malacia of the lunate treated by shortening of the radius have been reviewed after follow-up ranging from 2 to 7 years. The results were highly satisfactory and only one patient with fragmentation and collapse of the diseased bone did not obtain long-lasting pain relief. In all cases the progressive collapse of the lunate was arrested, an effect which is considered to be the result of reduced pressure on the lunate obtained by the radius shortening procedure.