High-Grade Chondrosarcoma of the Proximal Phalanx: an Unusual Case of a Rare Entity.

Chondrosarcoma of the hand is a rare disease, but is one of the more common malignancies of the hand. Biopsies and imaging are a fundamental step in determining correct diagnosis, grading and selection for best treatment. We describe the case of a 77-year-old male complaining of a painless swelling in the proximal phalanx of the third ray of left hand. A biopsy was performed and the histology revealed a G2 chondrosarcoma. The patient underwent III ray amputation with metacarpal bone disarticulation and sacrifice of the radial digit nerve of the fourth ray. Definitive histology revealed grade 3 CS. Eighteen months after surgery, the patient is apparently disease-free with a good functional and aesthetic outcome although with persistent paresthesia of the fourth ray. Although there is no agreement in the literature for the treatment of low-grade chondrosarcomas, wide resection or amputation can be considered the mainstay treatment for high-grade tumors. Key words: chondrosarcoma, proximal phalanx, ray amputation, surgical treatment, tumor hand.

Wide resection for giant-cell tumor of the distal radius: which reconstruction? A systematic review of the literature and pooled analysis of 176 cases.

Giant-cell tumor (GCT) is often more aggressive when located in the distal radius, and wide resection is then the gold-standard. No single reconstruction protocol is recommended, and the technique depends upon the surgeon's preferences. The aim of the present review was to determine the recurrence rate of GTC of the distal radius after intralesional treatment, to assess the results, advantages and complications of the various surgical techniques, and to draw up a decision-tree for surgical indications. The review of literature was performed in the main healthcare databases, searching for studies that reported results of wide resection and reconstruction of distal radius GCT. Local recurrence rates, metastasis rates, reconstruction techniques and respective results and complications were evaluated and analyzed. Sixteen studies were selected, for a total population of 226 patients; 6.0% and 0.9% experienced local recurrence and lung metastasis, respectively. Arthroplasty with non-vascularized or vascularized ipsilateral fibula were the most common techniques and were associated with the highest satisfaction rates: 86.4% and 88.0%, respectively. Arthroplasty with allograft presented a MusculoSkeletal Tumor Society (MSTS) score of 79.2% and arthroplasty with custom-made prosthesis presented an MSTS score of 81.8%. Arthrodesis was performed in 46 cases, with an MSTS score of 82.7%. Arthroplasty techniques are the most common in literature; they are used in patients who wish to conserve joint motion. Reconstruction with non-vascularized fibula seems to provide the best results, with lower morbidity. Arthrodesis is usually reserved for heavy manual workers or in case of arthroplasty failure.

Massive bone allograft engineered with autologous vessels: A new perspective for the future.

Reconstruction is very important to ensure good function and quality of life after bone tumor resection. For metacarpals and phalanges, amputation and toe transfer are the gold-standard indications; nevertheless, allograft reconstruction must also be taken into account. Unfortunately, because of its inert biological behavior, it undergoes progressive resorption, with frequent fracture. Several attempts have been made to induce new vascularization in massive bone allograft, with poor results. However, neo-angiogenesis was reported with vascular loops, and we therefore hypothesized that heterologous graft integration could be enhanced by creating a vascular loop through the graft. A 50-year-old male with chondrosarcoma of the ring finger of the left hand underwent wide resection. An allogenic middle phalanx of comparable size was then prepared to fill the defect. Two small windows were performed proximally and distally on the radial surface of the allogenic phalanx, and a 4 cm-long vein graft was inserted inside the medullary canal. Metacarpophalangeal joint stability was achieved by collateral ligament reconstruction with micro-anchors. The distal part of the allograft was then stabilized to the middle phalanx with a 1.5 mm-thick micro-plate and screws. The radial proper palmar digital artery was proximally and distally sutured end-to-end to the vein graft, under microscopy. At 12-month follow-up, the allograft was fused, and histology performed at plate removal at 18 months revealed viable spindle cells with osteoblastic differentiation, without evidence of atypia, in a dense fibrous stroma. At 22 months' follow-up, the patient was apparently disease-free, and satisfied with his manual function.

A novel local adipofascial flap for the management of recalcitrant ulnar tunnel syndrome.

Ulnar tunnel syndrome is the second most common upper-limb peripheral nerve compression syndrome. Recurrence or persistence of symptoms after primary surgery is found in 9.9%-21% of cases. The main cause of failure is peri- and endo-neural fibrosis, and management is difficult and controversial. Revision of nerve neurolysis combined with freestyle adipofascial flap provides nerve decompression and coverage with vascularized tissue, which prevents scar tissue formation around the nerve and restores glide. We performed a preliminary vessel-injected cadaver study. The perforating vessels from the posterior recurrent ulnar artery vascularize the medial adipose and fascial tissues of the elbow, allowing elevation of an adipofascial flap which is able to reach the ulnar nerve. Eight patients with neuropathic ulnar nerve pain in recalcitrant ulnar tunnel syndrome due to peri- and/or endo-neural fibrosis were treated by neurolysis, and the nerve was covered with an ulnar adipofascial flap. All patients were evaluated by percussion test, visual analog scale for pain, electromyography, electroneurography and ultrasound, and were classified according to the McGowan classification as modified by Goldberg. The study was approved by the review board. All patients had good 4-year outcome, with complete return to daily activity, work and sports 4 months after surgery. The results of this novel surgical technique were encouraging, without complications or donor site morbidity. Adipofascial flap combined with neurolysis could be a valid solution in the treatment of recalcitrant ulnar tunnel syndrome.

Proper-motion age dating of the progeny of Nova Scorpii AD 1437.

'Cataclysmic variables' are binary star systems in which one star of the pair is a white dwarf, and which often generate bright and energetic stellar outbursts. Classical novae are one type of outburst: when the white dwarf accretes enough matter from its companion, the resulting hydrogen-rich atmospheric envelope can host a runaway thermonuclear reaction that generates a rapid brightening. Achieving peak luminosities of up to one million times that of the Sun, all classical novae are recurrent, on timescales of months to millennia. During the century before and after an eruption, the 'novalike' binary systems that give rise to classical novae exhibit high rates of mass transfer to their white dwarfs. Another type of outburst is the dwarf nova: these occur in binaries that have stellar masses and periods indistinguishable from those of novalikes but much lower mass-transfer rates, when accretion-disk instabilities drop matter onto the white dwarfs. The co-existence at the same orbital period of novalike binaries and dwarf novae-which are identical but for their widely varying accretion rates-has been a longstanding puzzle. Here we report the recovery of the binary star underlying the classical nova eruption of 11 March AD 1437 (refs 12, 13), and independently confirm its age by proper-motion dating. We show that, almost 500 years after a classical-nova event, the system exhibited dwarf-nova eruptions. The three other oldest recovered classical novae display nova shells, but lack firm post-eruption ages, and are also dwarf novae at present. We conclude that many old novae become dwarf novae for part of the millennia between successive nova eruptions.

A case of psoriasis with secondary amyloidosis, associated symbrachydactyly of the hand and a transverse deficiency of the foot.

Secondary amyloidosis is associated with a variety of chronic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, familial Mediterranean fever, osteomyelitis, inflammatory bowel diseases and infective or neoplastic conditions. Few cases of secondary amyloidosis complicating psoriasis have been reported. We describe a 58-year-old patient with secondary amyloidosis, psoriasis, an associated symbrachydactyly of the hand and a transverse deficiency of the foot. To the best of our knowledge, no case of this association has been previously reported.

[Arthroscopic distal ulna resection after post traumatic ulno carpal abutment.] / Résection arthroscopique distale de l'ulna dans les conflits.

Ulno carpal abutments secondary to the sequels of a fracture of the radius are often due to the inversion of the distal radio ulnar index by shortening relative to the radius. This positive ulnar variance eventually leads to an abutment between the head of the ulnar and the proximal articular face of the lunate with alteration of the cartilaginous carpal surfaces. The wrist arthroscopy makes diagnosis and treatment possible in a less invasive way. The patients are operated on as outpatients under local regional anaesthetic using a pneumatic tourniquet. The arthroscope is positioned using the 3-4 radio carpal opening permitting exploration of the joint. The surgical treatment is performed by arthroscopy using a burr and going in through the 6R radio carpal opening. In this way we use the technique of partial resection of the distal ulna. We have a series of 62 patients who have benefited from the technique of partial resection of the ulnar head by arthroscopy. There were 30 men and 32 women. The average age was 66 years old (between 45 and 82). Our average follow-up is 32 months (between 12 and 60 months). Recovery of mobility was immediate in all cases with persistent pain in the radio ulnar joint in 8 cases. Arthroscopic treatment of ulno carpal abutment has proved itself effective and innocuous. It should nevertheless be reserved for operations on small sized inversions of the distal radio ulnar index (less than 5 mm). In the event of larger ulnar variances we prefer ulnar shortening osteotomy. The other techniques will be restricted to cases where the distal radio ulnar joint has been impaired.

[Arthroscopic distal ulna resection after post traumatic ulno carpal abutment]. / Résection arthroscopique distale de l'ulna dans les conflits.

Ulno carpal abutments secondary to the sequels of a fracture of the radius are often due to the inversion of the distal radio ulnar index by shortening relative to the radius. This positive ulnar variance eventually leads to an abutment between the head of the ulnar and the proximal articular face of the lunate with alteration of the cartilaginous carpal surfaces. The wrist arthroscopy makes diagnosis and treatment possible in a less invasive way. The patients are operated on as outpatients under local regional anaesthetic using a pneumatic tourniquet. The arthroscope is positioned using the 3-4 radio carpal opening permitting exploration of the joint. The surgical treatment is performed by arthroscopy using a burr and going in through the 6R radio carpal opening. In this way we use the technique of partial resection of the distal ulna. We have a series of 62 patients who have benefited from the technique of partial resection of the ulnar head by arthroscopy. There were 30 men and 32 women. The average age was 66 years old (between 45 and 82). Our average follow-up is 32 months (between 12 and 60 months). Recovery of mobility was immediate in all cases with persistent pain in the radio ulnar joint in 8 cases. Arthroscopic treatment of ulno carpal abutment has proved itself effective and innocuous. It should nevertheless be reserved for operations on small sized inversions of the distal radio ulnar index (less than 5 mm). In the event of larger ulnar variances we prefer ulnar shortening osteotomy. The other techniques will be restricted to cases where the distal radio ulnar joint has been impaired.

Long-term results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy.

Transfer of the latissimus dorsi to the rotator cuff is widely used for restoring shoulder abduction and external rotation in sequelae of brachial plexus palsy; however, its long-term results are not well known. Because persistence of clinical benefits is crucial for children with brachial plexus palsy, the aim of our study was to evaluate retrospectively the long-term results of this transfer in 203 children. Patients were classified according to type of paralysis (C5-C6, C5-C6-C7, and complete), degree of preoperative shoulder function according to Gilbert, and age at surgery. Active abduction and external rotation were measured at 1, 3, 6, 10, and 15 years and the results were analyzed statistically. Children with sequelae of C5-C6 palsy gained in abduction and external rotation more than children with C5-C6-C7 or complete palsy. Patients with mild preoperative shoulder dysfunction achieved the best results. The data showed the clinical results were related to the type of paralysis and to preoperative shoulder function, but not to age at surgery. They also showed progressive deterioration of abduction began at 6 years despite preserved active external rotation.

Investigation of work-related disorders in truck drivers using RULA method.

A high incidence of spinal disorders is observed in professional drivers; in particular, back and neck pain result in high rates of morbidity and low retirement age. A sample of 77 drivers, of rubbish-collection vehicles who sit in a standard posture and of road-washing vehicles, who drive with the neck and trunk flexed, bent and twisted, was studied using RULA, a method for the evaluation of the exposure to risk factors associated with work-related upper-limb disorders. Results showed a significant association between trunk and neck scores and all self-reported pains, aches or discomforts in the trunk or neck regions in all subjects. In particular, the neck score was significant in both postures, reflecting high loading of the neck. Significantly different posture scores were also recorded for drivers using an adjustable vs. a non-adjustable seat. In this first RULA study of the working posture of professional truck drivers, the method proved to be a suitable tool for the rapid evaluation of the loading of neck and trunk.

Expression of NGF, Trka and p75 in human cartilage.

Nerve growth factor (NGF) exerts its action through two types of receptor: high-affinity tyrosine kinase A receptor (trkA) and low-affinity p75 receptor. NGF has a neurotrophic role in central and peripheral nervous system development, but there is also clear evidence of its involvement in the developing skeleton. The aim of the present immunohistochemical study was to investigate the expression and distribution of NGF, trkA, and p75 in normal cartilaginous tissues from adult subjects: articular and meniscal cartilage of the knee, cartilage from the epiglottis, and intervertebral disc tissue. Detection of NGF mRNA was also performed by in situ hybridization. Immunoreaction for NGF and the two receptors in articular chondrocytes, chondrocyte-like cells of meniscus and annulus fibrosus, and chondrocytes of the epiglottis demonstrated that they are all expressed in hyaline, fibrous and elastic cartilaginous tissues, suggesting that they could be involved in cartilage physio-pathology.

Androgen receptors in Dupuytren's contracture.

Palmar fascia tissue and cultured cells from patients with Dupuytren's contracture and from normal subjects were characterized and analyzed for androgen receptor expression. Androgen receptors have never been studied in Dupuytren's myofibroblasts and may have a role in its high male predominance. Surgical samples were collected from eight patients undergoing surgery for Dupuytren's contracture and from four patients with carpal tunnel syndrome, used as control tissue. Immunohistochemical analysis was performed on tissue samples and on cell cultures with anti-androgen receptor, anti-alpha-smooth muscle actin, anti-fibronectin, and anti-type I and III collagen antibodies using the biotin avidin peroxidase method as revelatory system. Immunostaining for androgen receptors in tissue samples and cultured cells revealed nuclear reaction in many Dupuytren's myofibroblasts, but in few fibroblasts of the normal palmar fascia. In a double-labeling study, androgen receptors were seen to co-localize with alpha-actin in both cell cultures and tissue samples. We present the first evidence that the palmar fascia is a target tissue for androgen action and that the expression of androgen receptors in Dupuytren's contracture is considerably higher than in the normal palmar fascia. Further studies will need to evaluate whether the androgen-responsive state of the tissue is related to the high incidence of Dupuytren's contracture in the male sex.

Effect of air breathing on acid-base and ion regulation after exhaustive exercise and during low pH exposure in the bowfin, Amia calva.

To explore a potential conflict between air breathing and acid-base regulation in the bowfin (Amia calva), we examined how individuals with access to air differed from fish without air access in their response to acidosis. After exhaustive exercise, bowfin with access to air recovered significantly more slowly from the acidosis than fish without air access. While arterial blood pH (pH(a)) of fish without air access recovered to resting levels by 8 h, pH(a) was still significantly depressed in fish having access to air. In addition, Pco(2) was slightly more elevated in fish having air access than those without it. Fish with access to air still had a significant metabolic acid load after 8-h recovery, while those without air access completely cleared the load within 4 h. These results suggest that bowfin with access to air were breathing air and, consequently, were less able to excrete CO(2) and H(+) and experienced a delayed recovery. In contrast, during exposure to low pH, air breathing seemed to have a protective effect on acid-base status in bowfin. During exposure to low pH water, bowfin with access to air developed a much milder acidosis than bowfin without air access. The more severe acidosis in fish without air access was caused by an increased rate of lactic acid production. It appears that enhanced O(2) delivery allowed air-breathing bowfin to avoid acidosis-induced anaerobic metabolism and lactic acid production. In addition, during low pH exposure, plasma Na(+) and Cl(-) concentrations of fish without air access fell slightly more rapidly than those in fish with air access, indicating that the branchial ventilatory changes associated with air breathing limited, to some degree, ion losses associated with low pH exposure.

Characterization of human bone cells in culture.

Osteoblast-like cells isolated from human bone bioptic specimens were established in culture. Their osteoblast-like phenotype was studied by biochemical, histochemical and immunohistochemical methods and by electron microscopy examination. Third-passage cell cultures exhibited high level of alkaline phosphatase activity and the exposure to human parathyroid hormone produced an increase of intracellular cAMP. Cultured cells were immunoreactive for type I and type III collagen, osteonectin, and fibronectin; when ascorbic acid and beta-glycerophosphate were added, they synthesized a rich extracellular matrix. This characterization ensures the reliability of osteoblast-like cultures when they are used as experimental models.

Characterization of cultured human ligamentum flavum cells in lumbar spine stenosis.

To investigate the pathogenesis of the degenerative changes of the ligamentum flavum occurring in lumbar spine stenosis, yellow ligament cells from patients with lumbar spine stenosis were cultured for the first time and subjected to biochemical, histochemical and immunohistochemical study. Stenotic ligamentum flavum (SLF) cells were seen to express high levels of alkaline phosphatase (ALP) activity and to produce a matrix rich in type I and III collagen, fibronectin and osteonectin. The matrix mineralized only following beta-glycerophosphate (betaGP) and ascorbic acid supplementation. Stimulation with human parathyroid hormone (PTH) increased intracellular cAMP concentration. These findings indicate that there was significant evidence of osteoblast-like activity in these cells. SLF cells also stained for S100 protein, type II and type X collagen, and co-localized type II collagen and ALP labelling, reflecting the presence of hypertrophic chondrocyte-like cells. Cultures from control patients showed neither osteoblastic nor chondrocytic features: they expressed type I and type III collagen and fibronectin, but did not stain for osteonectin, nor were bone-like calcifications observed in presence or absence of betaGP. Normal ligamentum flavum (NLF) cells did not synthesized S100 protein or type II or type X collagen, and showed a weaker response to PTH stimulation. Our data demonstrated the presence of hypertrophic chondrocytes with an osteoblast-like activity in the ligamentum flavum of patients with spinal stenosis suggesting that they could have a role in the pathophysiology of the heterotopic ossification of ligamentum flavum (OLF) in lumbar spine stenosis.

Evidence of type II estrogen receptor in human osteoblast-like cells.

Osteoblast-like cells isolated from human bone bioptic specimens were characterized and analysed for the presence of type II estrogen receptor (type II EBS). The amount of type II EBS was measured by a whole-cell assay at 4 degrees C for 2.5 h using [(3)H]-estradiol as tracer. Saturation analysis, used to investigate the binding characteristic of type II EBS, resulted in a sigmoid curve. Scatchard analysis showed the binding affinity of the estrogen receptor, yielding a concave plot. The dissociation constant (K(d)), determined from the [(3)H]-estradiol concentration required for half saturation was about 12+/-2 nM (SD). The number of type II EBS, estimated at maximum binding, was 197,000+/-8800 sites per cell. If the regulation of the receptor by flavonoids would be confirmed, the evidence of type II EBS in osteoblast-like cells could suggest a direct action of ipriflavone and others flavonoids on bone density in postmenopausal osteoporosis.

The effect of a static wrist orthosis on hand function in individuals with rheumatoid arthritis.

OBJECTIVE: To determine the effect of a wrist orthosis on work performance, hand dexterity, and pain during task performance, 40 individuals with rheumatoid arthritis were studied using a 2 period, crossover design. METHODS: Each patient was fitted with a Futuro wrist orthosis. Dexterity was measured with and without the orthosis using the Jebsen Hand Function Test. Work performance was assessed using 2 tasks (one simulating the use of shears, the other the use of a screwdriver) on a work simulator. All tasks were performed both with and without the orthosis, with the order of orthosis versus no orthosis randomly assigned. Pain before and after performing tasks was assessed using a 10 cm horizontal visual analog scale. RESULTS: While on the screwdriver task work performance was less with the orthosis (p = 0.0002); on the shears task there was no significant difference in work performance with and without the orthosis. The average pain after performing both tasks was significantly less with the orthosis on. A 2 factor analysis of variance model with repeated measures suggested that taking into account the reduced work performance during splint wear, pain was still significantly reduced with splint wear. The average time to complete all 7 tasks on the Jebsen Hand Function Test was longer when the subjects wore the splint compared to when they did not (62.0 vs 57.6 s, respectively; p = 0.0086). CONCLUSION: The results suggest that the effect of splint wear on work performance is highly task specific, and thus the ergonomic demands of the individual's daily life must be considered if a splint is to provide maximal effectiveness.

The role of blood glucose in the restoration of muscle glycogen during recovery from exhaustive exercise in rainbow trout (Oncorhynchus mykiss) and winter flounder (Pseudopleuronectes americanus).

The role of blood-borne glucose in the restoration of white muscle glycogen following exhaustive exercise in the active, pelagic rainbow trout (Oncorhynchus mykiss) and the more sluggish, benthic winter flounder (Pseudopleuronectes americanus) were examined. During recovery from exhaustive exercise, the animals were injected with a bolus of universally labelled [14C]glucose via dorsal aortic (trout) or caudal artery (flounder) catheters. The bulk of the injected label (50-70%) remained as glucose in the extracellular fluid in both species. The major metabolic fates of the injected glucose were oxidation to CO2 (6-8%) and production of lactate (6-8%), the latter indicative of continued anaerobic metabolism post-exercise. Oxidation of labelled glucose could account for up to 40% and 15% of the post-exercise MO2 in trout and flounder, respectively. Exhaustive exercise resulted in a reduction of muscle glycogen stores and accumulation of muscle lactate. Glycogen restoration in trout began 2-4h after exercise, whereas in flounder, glycogen restoration began within 2h. Despite a significant labelling of the intramuscular glucose pool, less than 1% of the infused labelled glucose was incorporated into muscle glycogen. This suggests that blood-borne glucose does not contribute significantly to the restoration of muscle glycogen following exhaustive exercise in either trout or flounder and provides further evidence against a prominent role for the Cori cycle in these species.