Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis.

PURPOSE: Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS: This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS: 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION: WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION: PROSPERO: CRD42023404018.

Alteration of Ligamento-Muscular Reflex Patterns After Cutaneous and Periarticular Desensitization of the Basal Thumb Joint: An Electromyographic Study.

PURPOSE: Stimulation of the dorsoradial ligament (DRL) of the first carpometacarpal joint (CMC-1) has shown a ligamento-muscular reflex pathway between the DRL and CMC-1 stabilizing muscles in healthy volunteers. However, it remains unclear how this ligamento-muscular reflex pattern is altered after anesthetizing sensory skin receptors and administering a further periarticular block around the CMC-1 joint, which may influence the dynamic aspects of joint stability. METHODS: Ligamento-muscular reflexes were obtained from the extensor pollicis longus, abductor pollicis longus, abductor pollicis brevis, and the first dorsal interosseous muscles in 10 healthy participants after establishing superficial anesthesia of the skin around the CMC-1. The DRL was stimulated with a fine wire electrode while EMG activities were recorded during isometric tip, key, and palmar pinch. The measurements were repeated after an additional periarticular CMC-1 block using 5 ml of 1% lidocaine. Average EMG values were analyzed to compare the prestimulus and poststimulus activity. RESULTS: Statistically significant changes in poststimulus EMG activity were observed in all 4 muscles and all 3 tested thumb positions. A markedly reduced activity in all 4 muscles was observed in the palmar position, followed by the tip and key pinch positions. Almost no reactions were observed in the first 20 ms poststimulus for all muscles in all positions. CONCLUSIONS: Superficial skin anesthesia and an additional periarticular CMC-1 block anesthesia resulted in a reduced ligamento-muscular reflex pattern in all 4 muscles. CLINICAL RELEVANCE: Ligamento-muscular reflexes play an important role in dynamic CMC-1 joint stability. The elimination of early reactions, those considered joint-protective reflexes, is a potential risk factor for developing osteoarthritis or injury because it results in an inability to adequately protect and stabilize the joint in sudden movements.

Effect of lacertus fibrosus release on perineural pressure of the median nerve at the elbow: a cadaveric study.

PURPOSE: The lacertus fibrosus (or bicipital aponeurosis) is a potential site of proximal median neuropathy at the elbow. Lacertus syndrome with motor and/or sensory symptoms has been addressed with a minimally invasive surgical lacertus release. This study evaluates if a lacertus release alters the maximal perineural pressure (Pmax) of the median nerve at the level of the lacertus fibrosus during elbow flexion. METHODS: Seven upper limbs from four fresh cadavers were included. Perineural pressure of the median nerve at the level of the lacertus fibrosus was measured continuously during automated elbow flexions by the biceps brachii muscle. RESULTS: The mean Pmax before the lacertus release was significantly different than the mean Pmax after the lacertus release (669.15 mmHg vs 77.01 mmHg, p = 0.0180). The mean Pmax after the lacertus release decreased with an average 81.41%. CONCLUSION: A simple surgical release of the lacertus fibrosus significantly decreases the maximal perineural pressure of the median nerve at the level of the lacertus fibrosus during elbow flexion.

Lacertus syndrome: a ten year analysis of two hundred and seventy five minimally invasive surgical decompressions of median nerve entrapment at the elbow.

PURPOSE: This study aims to assess the clinical presentation and surgical outcomes of lacertus syndrome (LS) and concomitant median nerve entrapments. METHODS: A retrospective study of prospectively collected data was conducted on patients undergoing lacertus release (LR) from June 2012 to June 2021. Available DASH (Disability of the Arm Shoulder Hand questionnaire) scores and post-operative Visual Analogue Scale (VAS) of pain, numbness, subjective satisfaction with surgical outcome, and intra-operative return of strength were analyzed. RESULTS: Two-hundred-seventy-five surgical cases were identified of which 205 cases (74.5%) underwent isolated LR, and 69 cases (25.1%) concomitant lacertus and carpal tunnel release. The three most common presenting symptoms in LS patients were loss of hand strength (95.6%), loss of hand endurance/fatigue (73.3%), and forearm pain (35.4%). Numbness in the median nerve territory of the hand was found in all patients with combined LS and carpal tunnel syndrome. Quick-DASH significantly improved (pre-operative 34.4 (range 2.3-84.1) to post-operative 12.4 (range 0-62.5), p < 0.0001) as did work and activity DASH (p < 0.0001). The postoperative VAS scores were pain VAS 1.9 and numbness VAS 1.8. Eighty-eight percent of patients reported good/excellent satisfaction with the surgical outcome. Intra-operative return of strength was verified in 99.2% of cases. CONCLUSION: LS is a common median nerve compression syndrome typically presenting with loss of hand strength and hand endurance/fatigue. Minimally invasive LR immediately restores hand strength, significantly improves DASH scores, and yields positive outcomes regarding VAS pain, numbness, and subjective satisfaction with surgery in patients with proximal median nerve entrapment at a minimum six month follow-up.

Patient-oriented educational Sports Medicine YouTube videos in Arabic have higher view counts in the Middle East and North Africa than their English versions.

PURPOSE: The present study aims to assess the impact of the local language on the view count of patient-oriented educational Sports Medicine videos in an Orthopaedic and Sports Medicine Hospital in the Middle East and North Africa. METHODS: An observational study on English and Arabic versions of Aspetar's YouTube channel patient-oriented educational video series was conducted in February 2023, comparing the view count and viewer characteristics. Included videos were posted either simultaneously or in English version first, in both languages, and shared on the same media platforms. Collected data of interest included video title, view count in each language, age and sex of the viewers, location, and traffic source. RESULTS: Eleven videos of the patient-oriented educational video series were included in the present study. Except for one, the view count was significantly higher in the Arabic version of all 11 videos (minimum sevenfold, P = 0.03). Viewers were predominantly males (73.9%) and between 18 and 44 years old (81.1%). Eleven out of 19 countries of the Middle East and North Africa region [11] were among the viewers' top 20 countries. Traffic sources included YouTube search (45.9%), YouTube suggested videos (17%), external sources (14.4%), YouTube browse features (8.5%), and YouTube advertising (6%). CONCLUSION: Patient-oriented educational Sports Medicine videos in Arabic yield higher view counts than their English version in young adult viewers from 11 countries in the Middle East and Africa among the top 20. Content creation on languages with limited online representation could effectively reach the targeted population by breaking language barriers.

Wrist proprioception-An update on scientific insights and clinical implications in rehabilitation of the wrist.

The field of wrist proprioception, as it relates to rehabilitation and surgery, has gone through a period of intense growth in the past decade. From being primarily focused on the function of the joint and ligaments in patients with wrist trauma or after wrist surgery, the understanding is now that of a greater complexity in treating not just the wrist but the hand and arm as a whole. Proprioception is derived from the Latin words "proprius" - belonging to (oneself) and "-ception" to sense. In other words, how to sense ourselves. To have a complete sense of self, multiple sensory afferents originating from joints, ligaments, muscles, tendons, nerves, skin, vision, and hearing work together to orchestrate a balanced integration of sensorimotor functions, with the true goal to perceive and adapt to the physical world around us. In this update on wrist proprioception, we review current developments in the understanding of proprioception, with an implication for our everyday work as hand therapists and hand surgeons. Each contributing sense-joint, ligaments, muscles, skin, and brain-will be reviewed, and the clinical relevance will be discussed. An updated wrist rehabilitation protocol is proposed where the therapist is guided to rehabilitate a patient after wrist trauma and/or surgery in 4 stages: (1) basic hand and wrist rehabilitation with a focus on reducing edema, pain, and scar formation; (2) proprioception awareness to improve the sense of joint motion and position; (3) conscious neuromuscular rehabilitation where isometric exercises of muscles that are beneficial for a particular injury are promoted, whereas others that are potentially harmful are avoided; and (4) unconscious neuromuscular rehabilitation with training of the reflex and joint protective senses.

An overview of common peroneal nerve dysfunction and systematic assessment of its relation to falls.

PURPOSE: Compression of the peroneal nerve is recognized as a common cause of falls. The superficial course of the peroneal nerve exposes it to trauma and pressure from common activities such as crossing of legs. The nerve can be exposed also to distress due to metabolic problems such as diabetes. The purpose of our manuscript is to review common peroneal nerve dysfunction symptoms and treatment as well as provide a systematic assessment of its relation to falls. METHODS: We pooled the existing literature from PubMed and included studies (n = 342) assessing peroneal nerve damage that is related in any way to falls. We excluded any studies reporting non-original data, case reports and non-English studies. RESULTS: The final systematic assessment included 4 articles. Each population studied had a non-negligible incidence of peroneal neuropathy. Peroneal pathology was found to be consistently associated with falls. CONCLUSION: The peroneal nerve is an important nerve whose dysfunction can result in falls. This article reviews the anatomy and care of the peroneal nerve. The literature review highlights the strong association of this nerve's pathology with falls.

Alterated ligamento-muscular reflex pattern after stimulation of the anterior talofibular ligament in functional ankle instability.

PURPOSE: Ligamento-muscular reflex pattern following stimulation of the anterior talofibular ligament (ATFL) was examined. METHODS: The peroneus longus (PL), the tibialis anterior (TA), and tibialis posterior (TP) muscles were investigated in sixteen patients with functional ankle instability (FAI) and 16 age- and gender-matched controls. The ATFL was stimulated with a fine wire electrode while electromyographic (EMG) activities were recorded during isometric foot contraction of 20% maximal force in plantarflexion, dorsiflexion, supination and pronation. The complete measurement was repeated after a peroneal block anesthesia. RESULTS: Statistically significant changes in post-stimulus EMG activity were observed in all three muscles and all four tested foot positions. In supination, the PL showed no reactions in both groups before and after anesthesia. The post-stimulus inhibition of the TA seen after 80 and 180 ms disappeared in controls after anesthesia. The TP had similar inhibitory responses in both groups. CONCLUSION: Ligamento-muscular reflex pattern is alterated in FAI. While early reactions are essential in protecting the ankle joint in sudden movements, the later responses indicate a supraspinal control of neuromuscular stability of the ankle joint. Proprioceptive rehabilitation of the PL, TA, and TP is crucial in FAI to compensate for post-traumatic ligamentomuscular reflex deficiencies. LEVEL OF EVIDENCE: II.

Degeneration of the articular disc in the human triangular fibrocartilage complex.

INTRODUCTION: Traumatic injuries of the triangular fibrocartilage complex (TFCC) are frequent reasons for ulnar wrist pain. The assessment of the extent of articular disc (AD) degeneration is important for the differentiation of acute injuries versus chronic lesions. MATERIALS AND METHODS: The AD of the TFCC of eleven human cadaver wrists was dissected. Degeneration was analyzed according to the grading of Krenn et al. Hematoxylin-eosin was used to determine the tissue morphology. Degeneration was evaluated using the staining intensity of alcian blue, the immunohistochemistry of the proteoglycan versican and the immunoreactivity of NITEGE, an aggrecan fragment. RESULTS: The staining homogeneity of HE decreased with higher degeneration of the AD and basophilic tissue areas were more frequently seen. Two specimens were characterized as degeneration grade 1, five specimens as grade 2, and four specimens as grade 3, respectively. Staining intensity of alcian blue increased with higher degeneration grade of the specimens. Immunoreactivity for NITEGE was detected around tissue fissures and perforations as well as matrix splits. Immunoreactivity for versican was found concentrated in the tissue around matrix fissures and lesions as well as loose connective tissue at the ulnar border of the AD. Specimens with degeneration grade 2 had the strongest immunoreactivity of NITEGE and versican. Cell clusters were observed in specimens with degeneration grade 2 and 3, which were stained by alcian blue and immunoreactive for NITEGE and versican. Increasing age of the cadaver wrists correlated with a higher degree of degeneration (p < 0.0001, r = 0.68). CONCLUSIONS: The fibrocartilage of degenerated ADs contains NITEGE and versican. The amount of the immunoreactivity of these markers allows the differentiation of degenerative changes into three grades. The degeneration of the AD increases with age and emphasizes its important mechanical function.

Intrarater reliability test of the ISOmetric power device-A new instrument for assessment of isometric force in six directions of wrist motion.

STUDY DESIGN: Descriptive reliability study. INTRODUCTION: A well-functioning wrist requires sufficient range of motion accompanied by adequate strength in every movement and direction-factors that are not regularly measured simultaneously in patients with wrist problems today. The ISOmetric Power device (ISOP) is a new instrument that measures isometric wrist force in all six directions of motion, but its intrarater reliability in a healthy population has not yet been evaluated. PURPOSE OF THE STUDY: The purpose of this study was to perform an intrarater reliability test of the ISOP in healthy participants. METHODS: Thirty-two healthy study participants (16 women/16 men; mean age 38.3 years; SD 6.5) were included. With a standardized testing protocol, the three planes of wrist motion- wrist flexion/extension, radial/ulnar deviation, pro/supination-were measured at one time interval (T1) and repeated after one week (T2). The results were analyzed using the intraclass correlation coefficient (ICC). A paired-samples t-test was also performed to determine if a statistically significant difference (P < .05) existed between the first and the second test values. Measurements with Jamar Dynamometer were performed at both time intervals, for internal control of measurement intrarater reliability. RESULTS: Excellent correlations (ICC: 0.90-0.99) were found for all test-retests performed. The lowest value (ICC: 0.90) was seen for supination and the highest value (ICC: 0.99) for flexion of the left hand. No statistically significant differences were found in any of the pairs (P > .05) in terms of test-re-test, which additionally strengthen the correlation between the first and second test values. DISCUSSION: Contrary to the Jamar Dynamometer, the ISOP is not designed for measuring grip strength, but for assessing the isometric muscle force in flexion, extension, pronation, supination, and radial and ulnar deviation. A systematic review has reported a moderate to strong correlation between isometric strength and dynamic performances. Thus, the ISOP is a more complete and applicable instrument for evaluating the functional strength in different directions in the upper extremity. CONCLUSIONS: The ISOmetric Power device shows excellent intrarater reliability and is proposed to be a possible valuable wrist strength assessment tool to aid in both diagnostics and outcome measures of wrist and upper extremity disorders.

Carpometacarpal and metacarpophalangeal joint collapse is associated with increased pain but not functional impairment in persons with thumb carpometacarpal osteoarthritis.

INTRODUCTION: Due to the complex shape of the carpometacarpal (CMC) joint, a fixed joint collapse deformity of the thumb CMC (CMC1) and metacarpophalangeal (MCP1) joint can present in advanced stages of CMC1 osteoarthritis (OA), resulting in adduction of the first metacarpal (MC1) and hyperextension of the MCP1. PURPOSE OF THE STUDY: To determine whether joint collapse deformity is associated with worse pain and/or functional impairment. STUDY DESIGN: Cross-sectional. METHODS: This study used the baseline data from 140 patients enrolled in a longitudinal study of treatment for CMC1 OA. (efficacy of combined conservative therapies on clinical outcomes in patients with CMC1 OA). Joint collapse was determined at baseline using a pinch gauge. Pain was assessed on a visual analog scale (0-100) and function was assessed using the Functional Index for Hand Osteoarthritis questionnaire (0-30). Pain and function and the presence of joint collapse were entered in a univariate logistic regression. The final adjusted model for pain and joint collapse included age and sex. The final adjusted model for function and joint collapse included Kellgren Lawrence grade and grip strength. RESULTS: About 20% of participants demonstrated joint collapse on the tip-pinch test. The presence of joint collapse was associated with increased pain in the unadjusted [P = .047, OR = 2.45, 95% CI (1.01, 5.910)] and adjusted model [P = .049, OR = 2.45, 95% CI (1.00, 5.98)]. CONCLUSION: CMC1 patients with joint collapse reported increased pain compared with those without joint collapse. Future studies should determine the relationship between thumb hypermobility and joint collapse and how to manage these conditions effectively.

Ligamento-Muscular Reflex Patterns Following Stimulation of a Thumb Carpometacarpal Ligament: An Electromyographic Study.

PURPOSE: The dorsoradial ligament (DRL) is essential for stability of the first carpometacarpal joint (CMC1) and is innervated with nerve endings and mechanoreceptors known to contribute to joint proprioception. The influence of these nerve endings on the neuromuscular stability of CMC1 is not yet known. This study investigated whether a ligamento-muscular reflex pathway is present between the DRL and CMC1 muscles. METHODS: Ten healthy subjects (5 women and 5 men, mean age 28 years; range, 24-37 years) were included. Four primary CMC1 stabilizing muscles were investigated: the extensor pollicis longus, abductor pollicis longus (APL), abductor pollicis brevis, and first dorsal interosseous. Needle electrodes were inserted into each muscle and a fine-wire electrode was inserted into the DRL. The DRL was stimulated at 200 MHz while EMG activities in the muscles were recorded during isometric tip, key, and palmar pinch. Average EMG values were analyzed to compare prestimulus (t1) with post-stimulus (t2) activity. RESULTS: Poststimulus changes were observed in all 4 muscles and 3 positions tested. During tip pinch we observed mass inhibition with a decrease in all muscle amplitudes. In key pinch we observed a rapid co-contraction response. Rapid inhibitory response of antagonistic musculature was observed during palmar pinch. The APL was the only muscle to react within 20 ms after stimulation. CONCLUSIONS: We identified CMC1 ligamento-muscular reflexes. The mass inhibition of activity observed during tip pinch indicated a protective ligamento-muscular relation that affects all 4 muscles. The co-contractions observed promote joint stability. The fast response in the APL, coupled with its neuroanatomical proximity to the DRL, indicate a particular role in CMC1 proprioception. CLINICAL RELEVANCE: Proper ligamentous support and retained innervation is likely important for adequate joint function; their innate functions ought to be considered when planning surgical or orthotic treatments.

Similar results comparing early and late surgery in open repair of traumatic rotator cuff tears.

PURPOSE: The purpose was to investigate whether surgical repair earlier or later than 3 months after injury may result in similar outcomes and patient satisfaction. METHODS: Seventy-three patients (75 shoulders, 58 males, mean age 59) who had undergone surgical intervention for traumatic rotator cuff tears from 1999 to 2011 were assessed by MRI, clinical examination and Western Ontario Rotator Cuff Index (WORC) as a primary outcome measure and Oxford Shoulder score (OSS), Constant-Murley score (CS) and EQ-5D as secondary. The patients treated less than 3 months after injury (n = 39) were compared with patients treated more than 3 months after injury (n = 36). The average follow-up time was 56 months (range 14-149), and the average time from injury to repair for all patients was 16 weeks (range 3-104). A single senior radiologist performed a blinded evaluation of all the MRIs. Rotator cuff integrity, presence of arthritis, fatty degeneration and muscle atrophy were evaluated. RESULTS: No differences were found for any of the assessed outcomes (WORC, OSS, CS and EQ-5D) between the two groups. The mean WORC % was 77 % for both groups. Re-tear frequency was 24 %, nine in both groups. Patients with re-tear reported less satisfaction with their outcome. CONCLUSIONS: The surgical treatment of symptomatic traumatic rotator cuff tears repairable later than 3 months after injury yields a good functional outcome, a high level of subjective patient satisfaction, and at the same level for patients receiving earlier treatment. Based on our findings, surgical repair could be encouraged whenever technically possible. LEVEL OF EVIDENCE: Retrospective Comparative Study, Level III.

Immunohistochemical Mapping of Sensory Nerve Endings in the Human Triangular Fibrocartilage Complex.

BACKGROUND: The triangular fibrocartilage complex is the main stabilizer of the distal radioulnar joint. While static joint stability is constituted by osseous and ligamentous integrity, the dynamic aspects of joint stability chiefly concern proprioceptive control of the compressive and directional muscular forces acting on the joint. Therefore, an investigation of the pattern and types of sensory nerve endings gives more insight in dynamic distal radioulnar joint stability. QUESTIONS/PURPOSES: We aimed to (1) analyze the general distribution of sensory nerve endings and blood vessels; (2) examine interstructural distribution of sensory nerve endings and blood vessels; (3) compare the number and types of mechanoreceptors in each part; and (4) analyze intrastructural distribution of nerve endings at different tissue depth. METHODS: The subsheath of the extensor carpi ulnaris tendon sheath, the ulnocarpal meniscoid, the articular disc, the dorsal and volar radioulnar ligaments, and the ulnolunate and ulnotriquetral ligaments were dissected from 11 human cadaver wrists. Sensory nerve endings were counted in five levels per specimen as total cell amount/cm(2) after staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, and S-100 protein and thereafter classified according to Freeman and Wyke. RESULTS: All types of sensory corpuscles were found in the various structures of the triangular fibrocartilage complex with the exception of the ulnolunate ligament, which contained only Golgi-like endings, free nerve endings, and unclassifiable corpuscles. The articular disc had only free nerve endings. Furthermore, free nerve endings were the predominant sensory nerve ending (median, 72.6/cm(2); range, 0-469.4/cm(2)) and more prevalent than all other types of mechanoreceptors: Ruffini (median, 0; range, 0-5.6/cm(2); difference of medians, 72.6; p < 0.001), Pacini (median, 0; range, 0-3.8/cm(2); difference of medians, 72.6; p < 0.001), Golgi-like (median, 0; range, 0-2.1/cm(2); difference of medians, 72.6; p < 0.001), and unclassifiable corpuscles (median, 0; range, 0-2.5/cm(2); difference of medians, 72.6; p < 0.001). The articular disc contained fewer free nerve endings (median, 1.8; range, 0-17.8/cm(2)) and fewer blood vessels (median, 29.8; range, 0-112.2/cm(2); difference of medians: 255.9) than all other structures of the triangular fibrocartilage complex (p ≤ 0.001, respectively) except the ulnolunate ligament. More blood vessels were seen in the volar radioulnar ligament (median, 363.62; range, 117.8-871.8/cm(2)) compared with the ulnolunate ligament (median, 107.7; range, 15.9-410.3/cm(2); difference of medians: 255.91; p = 0.002) and the dorsal radioulnar ligament (median, 116.2; range, 53.9-185.1/cm(2); difference of medians: 247.47; p = 0.001). Free nerve endings were obtained in each structure more often than all other types of sensory nerve endings (p < 0.001, respectively). The intrastructural analysis revealed no differences in mechanoreceptor distribution in all investigated specimens with the numbers available, showing a homogenous distribution of proprioceptive qualities in all seven parts of the triangular fibrocartilage complex. CONCLUSIONS: Nociception has a primary proprioceptive role in the neuromuscular stability of the distal radioulnar joint. The articular disc and ulnolunate ligament rarely are innervated, which implies mainly mechanical functions, whereas all other structures have pronounced proprioceptive qualities, prerequisite for dynamic joint stability. CLINICAL RELEVANCE: Lesions of the volar and dorsal radioulnar ligaments have immense consequences not only for mechanical but also for dynamic stability of the distal radioulnar joint, and surgical reconstruction in instances of radioulnar ligament injury is important.

Ultrastructure and innervation of thumb carpometacarpal ligaments in surgical patients with osteoarthritis.

BACKGROUND: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. QUESTIONS/PURPOSES: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. METHODS: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. RESULTS: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. CONCLUSIONS: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. CLINICAL RELEVANCE: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.

The 2014 ABJS Nicolas Andry Award: The puzzle of the thumb: mobility, stability, and demands in opposition.

BACKGROUND: The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA. QUESTIONS/PURPOSES: What evidence links ligament structure, forces, and motion to progressive CMC disease? Specifically: (1) Do unique attributes of the bony and ligamentous anatomy contribute to OA? (2) Can discrete joint load patterns be established that contribute to OA? And (3) can thumb motion that characterizes OA be measured at the fine and gross level? METHODS: We addressed the morphology, load, and movement of the human thumb, emphasizing the CMC joint in normal and arthritic states. We present comparative anatomy, gross dissections, microscopic analysis, multimodal imaging, and live-subject kinematic studies to support or challenge the current understanding of the thumb CMC joint and its predisposition to disease. RESULTS: The current evidence suggests structural differences and loading characteristics predispose the thumb CMC to joint degeneration, especially related to volar or central wear. The patterns of degeneration, however, are not consistently identified, suggesting influences beyond inherent anatomy, repetitive load, and abnormal motion. CONCLUSIONS: Additional studies to define patterns of normal use and wear will provide data to better characterize CMC OA and opportunities for tailored treatment, including prevention, delay of progression, and joint arthroplasty.

Prospective analysis of glucose metabolism in patients with hand infection.

BACKGROUND: Type-2 diabetes influences the course and severity of hand infections. METHODS: We prospectively examined glucose metabolism in 90 patients with hand infection, distinguishing between normal, prediabetic and diabetic states. HbA1c-levels were evaluated prior to surgery. Patients with normal levels took an oral glucose tolerance test and those diagnosed with prediabetes were retested after the infection subsided. Hospital stay, number of surgical interventions and inflammatory markers were examined per group. RESULTS: Sixty-two patients (68.8%) had abnormal glucose metabolism: 17 (18.9%) with history of diabetes and 11 (12.2%) newly diagnosed. Prediabetes was observed in 34 patients (37.8%). At follow-up, prediabetes and diabetes were diagnosed in 7 cases each, and physiological glucose metabolism was observed in 3 patients. For the 11 patients unable to undergo a second oral glucose tolerance test, detailed phone calls confirmed absence of diabetes. C-reactive protein levels were significantly elevated in diabetic patients compared to those with normal glucose metabolism (p = 0.001) or prediabetes (p = 0.034). Patients with history of diabetes were significantly older than those with normal glucose tolerance (p = 0.001) or prediabetes (p = 0.017). There were no significant intergroup differences in thrombocyte count, length of hospital stay, interval from injury to admission or the number surgical interventions. CONCLUSION: Glucose metabolism should be assessed in patients with hand infections and reassessed after the infection has subsided in prediabetic cases.

Effectiveness of supervised physiotherapy versus a home exercise program in patients with distal radius fracture: a randomized controlled trial with a 2-year follow-up.

OBJECTIVE: To determine in the long term whether supervised physiotherapy is more effective than a home exercise program for functional improvement and pain relief in patients with distal radius fracture (DRF). DESIGN: Randomized controlled trial. SETTING: Rehabilitation hospital. PARTICIPANTS: A total of 74 patients older than 60 years with extra-articular DRF were randomly allocated into two groups. INTERVENTIONS: The experimental group received 6 weeks of supervised physiotherapy (n = 37) and the control group received 6 weeks of home exercise program (n = 37). MAIN OUTCOME MEASURES: The primary outcome was wrist/hand function assessed using the Patient-Rated Wrist Evaluation (PRWE) questionnaire; secondary outcomes were the pain visual analogue scale (VAS), grip strength and wrist flexion-extension active range of motion. RESULTS: All patients completed the trial. For the primary outcome, at 6-weeks and 1-year follow-up, the PRWE questionnaire showed a mean difference between groups of 18.6 (95% CI 12.8 to 24.3) and 18.5 points (95% CI 12.7 to 24.2) respectively, these differences are clinically important. Conversely, at 2-year follow-up this effect decreases to 3.3 points (95% CI -2.4 to 9.0). For secondary outcomes, at 6-weeks and 1-year follow-up, in all measurements the effect size range from medium to large. Conversely, at 2-year follow-up only grip strength showed large effect size in favor of supervised physiotherapy, the rest of outcomes did not show difference between groups. CONCLUSION: At the 6-week and 1-year follow-up, supervised physiotherapy was more effective for functional improvement and pain relief compared with a home exercise program in patients older than 60 years with extra-articular DRF. However, this effect decreases over time, at the 2-year follow-up, only grip strength showed a difference in favor of supervised physiotherapy. TRIAL REGISTRATION: Brazilian registry of clinical trials UTN no. U1111- 1249-2492. Registered 17 March 2020. CONTRIBUTION OF THE PAPER.

Isolated Trapezoid Fracture in Adolescent Goalkeepers: A Scoping Review of the Literature and a Report of Two Cases.

Purpose: Isolated trapezoid fractures are rare injuries, particularly among adolescents, constituting only 0.4% of all carpal bone fractures. This study aims to present two cases of isolated trapezoid fracture in adolescent goalkeepers and a scoping review of the literature to provide guidelines for the management of this injury. Methods: Following PRISMA-ScR guidelines, a scoping review of reported cases was conducted. Two hundred and twenty articles were found using PubMed and Google Scholar. After full-text review, a total of 30 cases from 22 articles along with our 2 cases were analyzed based on demographics, injury mechanism, method/timing of diagnosis, prognosis, and time to recovery. Results: Thirty-two reported cases of trapezoid fractures with a mean age of 26.7 years (75% male) were found, with pain as the most common presenting symptom. A majority (78%) had initial negative findings on radiography, and the diagnosis was primarily established through computed tomography (59%; n = 19) or magnetic resonance imaging (50%; n = 16). There was a substantial delay in diagnosis (mean 26 days), primarily because computed tomography/magnetic resonance imaging was frequently ordered late. The majority of cases (78%) were managed conservatively, with immobilization periods ranging from 4 to 12 weeks. The average duration for full recovery was 4.5 months, with operative management taking 7.3 months and conservative management taking 3.5 months. Conclusion: Trapezoid fractures, though rare, are often not promptly diagnosed on initial plain radiographs, leading to a potential underreporting of cases. Because of the risk of complications associated with this type of injury, clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents. Further research and guidelines are needed to enhance our understanding and management of this uncommon injury in the future. Type of study/level of evidence: Differential diagnosis/symptom prevalence IIIb.

Revisions after trapeziometacarpal joint resection arthroplasty: A systematic literature review.

BACKGROUND: The aim of this systematic literature review was to describe current indications and interventions for revisions after trapeziometacarpal joint (TMJ) resection arthroplasty. METHODS: The literature search was conducted by an experienced librarian in the Medline, EMBASE, Cochrane Library, Web of Science and Scopus databases. We included all articles that investigated any TMJ arthroplasty procedure in which the trapezium was completely resected and if any subsequent revision procedure including joint-related and soft-tissue surgeries was mentioned. Two independent reviewers selected the articles and were involved in data extraction. RESULTS: Sixty-two articles reporting on 5,284 operated thumbs and 434 revision surgeries were included. We extracted 24 indications for revision and 31 revision techniques. Most revisions were performed because of subsidence/impingement of the first metacarpal bone (n=194 thumbs) followed by unspecified pain (n=53), metacarpophalangeal joint problems (n=28) and scaphotrapezoidal osteoarthritis (n=17). Eleven treatment strategies were found for subsidence/impingement of the first metacarpal, the most frequent being revision of the existing interposition using autologous tendon (n=46) and soft tissue interposition with distraction pinning (n=28). CONCLUSIONS: There are a wide variety of indications and even more surgical techniques described in the literature to treat persisting or recurrent pain after TMJ resection arthroplasty. Currently, there is no uniform treatment guideline available how to diagnose and treat such cases. Therefore, the results of this literature review will form the basis for a Delphi study aiming to develop recommendations for the diagnosis and treatment of persistent / recurrent pain after TMJ resection arthroplasty. LEVEL OF EVIDENCE: IV.