UPPER LIMB

Carpal tunnel syndrome

This is very common in menopausal or pregnant women. It is characterized by pain and loss of sensitivity in the hand, especially at night, and is caused by a compression of the median nerve in the wrist. The operation entails freeing the nerve by making a small incision at the base of the palm, under local anesthetic. It generally results in rapid improvement, unless action has been delayed so long that the nerve is already compromised. In its early stages a local injection of corticosteroids may be sufficient.

Tendonitis: trigger finger, de Quervain’s disease, epicondylitis

Degenerative and inflammatory diseases of the tendons of the hand are fairly common and may have various localizations. "Trigger" or "jerk" finger is one of the most frequently encountered and — as its name suggests — the most obvious symptom is a jerk when the finger or the thumb is unbent. This occurs when the tendon has difficulty sliding through its sheath. Pain is experienced when pressure is exerted on the base of the finger. It typically develops in middle age, but can occur in the thumb even in children. The operation, under local anesthesia, involves making a small incision of about one centimeter in order to release the sheath through which the tendon slides. The result is generally good and immediate. A similar problem can be encountered in the wrist (de Quervain’s disease or radial styloid tendovaginitis) when one of the extensor tendons of the thumb is unable to slide easily through its sheath: marked pain is felt above the wrist and there is often swelling as well. The operation is similar to the one for trigger finger. Tennis elbow or epicondylitis can happen even to people who never play the game. It is characterized by pain on the outer surface of the elbow, either spontaneous or when that point is pressed by the hand. This is due to degeneration of one of the extensor tendons attached to the elbow. Around 85% of cases of epicondylitis can be cured with noninvasive treatments, one of the most effective is infiltration with cortisone. The 15% that do not respond to this treatment, especially among sportsmen and women, may require an operation to remove the degenerate part of the tendon. Success is almost guaranteed but it may be two or three months before the patient is able to play again.

Tendon Injuries

Tendon injuries are often difficult to treat and are close competence of the hand surgeon.

Arthrosis of the base of the thumb

This the most common location for arthrosis of the hand. Frequently encountered in women over the age of forty, it is caused by a progressive slackening of the ligaments that stabilize the joint between trapezium and first metacarpus.

As a result the base of the metacarpus is subluxated and loses its perfect fit with the trapezium, leading in turn to a progressive wearing away of the cartilage and thus arthrosis. The pain can be more or less bearable; in those cases in which it is excessive in relation to the use that has to be made of the hand, an operation of arthroplasty is indicated. Various techniques can be adopted. The trend today is toward biological arthroplasty, without the use of prostheses.

Results are generally good in the sense that the thumb is able to move freely and the pain disappears completely or to a great extent; the effect remains constant over the years. It is a relatively complex operation lasting for abut an hour and a half and requires analgesia of the brachial plexus (the whole arm is numbed). About one month of physiokinesitherapy is required after the operation.

Rheumatoid arthritis

This is a serious autoimmune disease, chiefly affecting the joints and tendons.

It requires medical treatment in the first place by the physician and rheumatologist, who can use various drugs to cure it or more frequently just to slow its progress. The surgeon is brought in when the medical treatment has already yielded its maximum benefit.

Those joints which have not responded fully to treatment with drugs are subjected to "synovectomy," i.e. removal of the pathological synovial tissue that tends to destroy the affected joint. Hence it is a preventive operation that has to be carried out at a fairly early stage: about six months after the start of the disease and its medical treatment.

When the wear of the joints and of the tendons is very advanced because the synovectomy has not been carried out in time, the surgeon is still able to repair the damage with articular prostheses and tendon transplants.

The areas most susceptible to rheumatoid arthritis are the hands and the feet, but the major articulations of the upper and lower limbs can also be affected. Synovectomies and Arthroplasty of the minor joints can be carried out without hospitalization.

Synovial ganglion of the wrist

The typical location of this pathology is the wrist, where a roundish neoformation ranging in size from a chickpea to a hazelnut appears. It is not painful, but tends to grow and become very unsightly. It is quite common in the young. The neoformation has to be removed in radical fashion as it has a great tendency to recur. The operation is typical day surgery procedure. Today only a few centers are able to carry out this procedure arthroscopically, but even when the traditional technique is used the resulting scar is often barely visible.

Stiffness of the elbow

The elbow can lose some of its mobility following a fracture or dislocation or even as a result of disease (arthrosis, condromathosis). If the stiffness exceeds certain limits it can become extremely disabling. Hence there is a fairly complex type of operation, known as "arthrolysis" from the Greek for "loosening the joint," that is able to restore much of the lost mobility. Such operations are carried out under peripheral anesthesia and therefore on outpatients as well. They require a great deal of physiotherapy.

Peripheral Nerves Injuries

Peripheral Nerves Injuries must be operated as soon as possible. Using an optical magnification and a microscope is essential.

Rotator cuff of the shoulder

Up until just a few years ago this painful syndrome localized in the shoulder was known as scapulo-humeral periarteritis: with a tendency to worsen at night, it is fairly common in the middle aged and elderly. The pain is accentuated by the movements of raising or rotating the arm outward and in the most serious cases is associated with a restriction of movement: it becomes difficult to put on a coat or brush the hair. It used to be called periarteritis as it was thought to be due to inflammation of the periarticular soft tissue, given that the heads of the bones in the joint generally appeared normal in X-rays. Then it was recognized that it involved a lesion in a thick layer of tendon that runs from the muscles of the scapula to the humerus, passing between the acromial process and the head of the humerus itself, so that it looks as the latter is capped by these tendons (rotator cuff). Friction on the tendon in this restricted space leads to wear and then the breaking of the tendon itself, resulting in pain and stiffness.

The operation, carried out through a small incision or using an arthroscope, entails reducing the protuberance of the upper bone (acromioplasty) and repairing the torn tendons. Results are generally good as far as the elimination or reduction of pain is concerned. However, the recovery of strength and movement is dependent on effective postoperative rehabilitation and the state of the lesion in the tendons: it will be more difficulty

Treatment of instable shoulder

A number of patients, generally in their youth, experience episodes of instability of the shoulder, often with actual dislocations. This may be the consequence of a previous trauma that has caused a lesion in the ligaments of the shoulder, but it can also stem from a congenital laxity of the ligaments themselves.

This is often disabling for the patient and can be treated surgically to restore the tension of the ligaments.

The operation entails repairing or tightening the ligaments that have been damaged.

It is done under general or partial (interscalenic) anesthesia and takes about an hour. In certain cases the arthroscopic technique can be used: by this means cutaneous incisions are kept to a minimum.

The postoperative program requires immobilization for three weeks followed by a precise, gradual course of rehabilitation.

It is generally possible for the patient to return to normal, everyday activities after forty days, although it may require three or four months before sporting activities can be resumed, depending on the sport.


LOWER LIMB

Lesion of the menisci

The menisci (two for each knee) are "gaskets" that serve to cushion the pressure exerted on the joint.

They are soft (made of a special type of cartilage) and therefore liable to tear, both as a result of acute trauma from injuries received while playing sport, or of progressive wear, as happens in more elderly people.

The lesion causes pain and often disability and therefore requires surgical treatment in the majority of cases. The surgical treatment of lesions of the meniscus is carried out with a special "probe" called Arthroscope and entails removal of the damaged portion of the cartilage, preserving the remaining healthy part. The operation is always done as day surgery and the patient is able to go home after just a few hours.

A specific program of rehabilitative therapy is mandatory after the operation in order to attain the best results.

Lesions of the cartilage of the knee

Cartilage is a sort of sheathing, a "skin" that covers the bone in the joint. It may suffer from various degrees of wear and tear, to the point of being worn away completely and leaving the bone underneath exposed. This results in pain in the knee, effusions and a sensation of jerking and blocking of the joint.

The surgical treatment of this lesion by arthroscopy requires various types of operation, depending on the severity of the damage: it may entail no more than a "cleaning" of the worn area with the aim of stimulating the healing of the cartilage, or it may be necessary to replace the missing cartilage by transplanting healthy parts taken from elsewhere in the same knee.

Postoperative recovery from these types of operation certainly takes longer than after an operation for lesion of the meniscus. Usually two or three months are required for a gradual, progressive return of articular function.

Lesion of the anterior cruciate ligament

The anterior cruciate ligament (ACL) is the most important ligament in the knee: tearing it results in an instability of the joint that can prevent participation in many sports.

It has also been observed that a knee with a torn ACL may suffer premature wear, with the emergence of significant arthrosis.

The surgical techniques used for reconstruction of the ACL have developed rapidly in recent years, as have protocols of rehabilitation.

Surgical technique: the torn ligament cannot be repaired, but has to be replaced by a substitute that will be inserted instead of the damaged and now useless one. The "spare part" is always natural and taken from another part of the knee (patellar tendon or tendons of the flexor muscles).

Apart from the removal of this replacement part, which requires making an incision of about five centimeters, the whole procedure is carried out by arthroscope. This means that the knee does not undergo much trauma (although it is still a fairly major operation) and rehabilitation and recovery are rapid.

The operation lasts for around one hour, under peripheral anesthesia (affecting only the legs) and can also be carried out as day surgery: thus the patient is able to leave the surgical center after about five to six hours. There is no need for either a plaster cast or a knee brace: the knee remains free and rehabilitation should start the day after the operation.

If everything proceeds normally, the patient will be able to run gently after about two months. It will usually be possible to play sport after about six months.

Hallux valgus

This is a fairly common deformity, especially in middle-aged women, in which the hallux is bent toward the other toes and a bony protuberance forms on the medial side. This is often painful and enflamed.

Surgical correction is used to remove the pain, not just for aesthetic reasons.

There are various types of operation, depending on the degree of deformity of the hallux. Protected by a semi-rigid bandage and wearing a shoe with the toe cut off, the patient will be able to walk after a few days. Complete recovery may take two months.

Rigid hallux

This is caused by arthrosis of the joint at the base of the hallux. It results in pain and slight lameness: it is no longer possible to walk on tiptoe. In its early stages the problem can be solved by an operation of partial resection of the head of the metatarsus. At an advanced stage it is necessary to resort to a prosthesis or to arthrodesis (joint fusion).

Morton’s neuroma

This is a painful syndrome that affects the forefoot. It is characterized by pain that moves up to the leg from the toes; pain arises when walking, especially in tight shoes, but disappears when resting at night. More common in middle-aged women, it is caused by the compression of a digital nerve between two metatarsi. The operation involves removal of the compressed nerve through a small incision on the upper surface of the forefoot under local anesthetic. It is possible to start walking with a little care the day after the operation.

The results are generally very good if the diagnosis was correct.