Low-Intensity Pulsed Ultrasound Versus Sham in the Treatment of Operatively Managed Scaphoid Nonunions: The SNAPU Randomized Controlled Trial.

BACKGROUND: The primary goal after open reduction and internal fixation of an established scaphoid nonunion is to achieve union. Low-intensity pulsed ultrasound (LIPUS) has been reported to increase the rate of union and to decrease the time to union for multiple fractures and nonunions in clinical and animal models. The evidence for LIPUS in the treatment of scaphoid nonunion, however, is sparse. The aim of this study was to assess whether active LIPUS (relative to sham LIPUS) accelerates the time to union following surgery for scaphoid nonunion. METHODS: Adults with a scaphoid nonunion indicated for surgery were recruited for a multicenter, prospective, double-blinded randomized controlled trial. After surgery, patients self-administered activated or sham LIPUS units beginning at their first postoperative visit. The primary outcome was the time to union on serial computed tomography (CT) scans starting 6 to 8 weeks postoperatively. Secondary outcomes included patient-reported outcome measures, range of motion, and grip strength. RESULTS: A total of 142 subjects completed the study (69 in the active LIPUS group and 73 in the sham group). The average age was 27 years, and the cohort was 88% male. There was no difference in time to union (p = 0.854; hazard ratio, 0.965; 95% confidence interval, 0.663 to 1.405). Likewise, there were no differences between the active LIPUS and sham groups with respect to any of the secondary outcomes, except for wrist flexion at baseline (p = 0.008) and at final follow-up (p = 0.043). CONCLUSIONS: Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Patient gender and rotator cuff surgery: are there differences in outcome?

BACKGROUND: Although rotator cuff syndrome is common and extensively studied from the perspective of producing healed tendons, influence of gender on patient-reported outcomes is less well examined. As activity and role demands may vary widely between men and women, clarity on whether gender is an important factor in outcome would enhance patient education and expectation management. Our purpose was to determine if differences exist in patient-reported outcomes between men and women undergoing rotator cuff surgery. METHODS: One hundred forty-eight participants (76 W:72 M) aged 35-75 undergoing surgery for unilateral symptomatic rotator cuff syndrome were followed for 12 months after surgery. Demographics, surgical data, and the Western Ontario Rotator Cuff (WORC) scores were collected. Surgery was performed by two fellowship-trained shoulder surgeons at a single site. RESULTS: There were no gender-based differences in overall WORC score or subcategory scores by 12 months post-op. Pain scores were similar at all time points in men and women. Women were more likely to have dominant-arm surgery and had smaller rotator cuff tears than men. Complication rates were low, and satisfaction was high in both groups. CONCLUSION: Patient gender doesn't appear to exert an important effect on patient-reported rotator cuff outcomes in this prospective cohort. Further work examining other covariates as well as the qualitative experience of going through rotator cuff repair should provide greater insight into factors that influence patient-reported outcomes.

Is Immobilization Necessary for Early Return to Work Following Distal Biceps Repair Using a Cortical Button Technique?: A Randomized Controlled Trial.

BACKGROUND: Improvements in surgical fixation to repair distal biceps tendon ruptures have not fully translated to earlier postoperative mobilization; it is unknown whether earlier mobilization affords earlier functional return to work. This parallel-arm randomized controlled trial compared the impact of early mobilization versus 6 weeks of postoperative immobilization following distal biceps tendon repair. METHODS: One hundred and one male participants with a distal biceps tendon rupture that was amenable to a primary repair with use of a cortical button were randomized to early mobilization (self-weaning from sling and performance of active range of motion as tolerated during first 6 weeks) (n = 49) or 6 weeks of immobilization (splinting for 6 weeks with no active range of motion) (n = 52). Follow-up assessments were performed by a blinded assessor at 2 and 6 weeks and at 3, 6, and 12 months. At 12 months, distal biceps tendon integrity was verified with ultrasound. The primary outcome was return to work. Secondary outcomes were pain, range of motion, strength, shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and tendon integrity. Intention-to-treat analysis was performed. A linear mixed model for repeated measures was used to compare pain, range of motion, strength, and QuickDASH between the groups over time; return to work was assessed with use of independent t tests. RESULTS: The groups were similar preoperatively (p ≥ 0.16). The average age (and standard deviation) was 44.7 ± 8.6 years. Eighty-three participants (82%) were followed to 12 months. There were no differences between the groups in terms of return to work (p ≥ 0.83). Participants in the early mobilization group had significantly more passive forearm supination (p = 0.04), with passive forearm pronation (p = 0.06) and active extension and supination (p = 0.09) trending toward significantly greater range of motion in the early mobilization group relative to the immobilization group. Participants in the early mobilization group had significantly better QuickDASH scores over time than those in the immobilization group (p = 0.02). There were no differences between the groups in terms of pain (p ≥ 0.45), active range of motion (p ≥ 0.09), or strength (p ≥ 0.70). Two participants (2.0%, 1 in each group) had full-thickness tears on ultrasound at 12 months (p = 0.61). Compliance was not significantly different between the groups (p = 0.16). CONCLUSIONS: Early motion after distal biceps tendon repair with cortical button fixation is well tolerated and does not appear to be associated with adverse outcomes. No clinically important group differences were seen. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Surgical outcomes and complications following distal biceps tendon reconstruction: a systematic review and meta-analysis.

BACKGROUND: Primary repair of chronic distal biceps tendon ruptures may not be possible because of tendon retraction, and there remains no clear consensus on the type of reconstruction technique used. The purpose of this study was to report the clinical outcomes and complication rates following reconstruction of chronic distal biceps tendon ruptures. METHODS: A systematic review was performed following PRISMA guidelines. The following databases were searched: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials. The primary outcomes of interest included range of motion, strength, and functional outcome scores. Secondary outcomes included complication, reoperation, and revision rates. Outcomes and complication rates of each graft type and fixation technique were aggregated and compared with nonparametric Wilcoxon signed rank and rank sum tests. Spearman rank coefficients were calculated for time from injury to surgery on all outcomes. RESULTS: There were no significant differences found between the graft type or fixation technique for postoperative range of motion, strength, and patient-reported outcomes. Postoperative complications were substantially higher in the autograft group (34%) as compared to the allograft group (14%). The fixation technique used also demonstrated a significantly increased complication rate in the weave group compared with the onlay group (34% and 9%, respectively). CONCLUSION: Our results do not reveal any statistically significant differences between groups in the primary outcomes. However, substantially higher complication rates were observed in the autograft and weave cohorts; more than half of the complications related to the use of autograft were associated with donor site morbidity. No specific graft type was identified as superior, although this may be due to the small patient numbers included within this study.

Serum Mast Cell Tryptase as a Marker of Posttraumatic Joint Contracture in a Rabbit Model.

OBJECTIVES: Mast cells have been identified as key mediators of posttraumatic joint contracture, and stabilizing medications (ketotifen) have been shown to decrease contracture severity. Serum mast cell tryptase (SMCT) levels are used clinically to monitor mast cell-mediated conditions. The goals of this study were to determine if SMCT levels are elevated in the setting of joint contracture, if they can be decreased in association with ketotifen therapy, and if they correlate with contracture severity. METHODS: This study used a previously developed rabbit model in which 39 animals were divided into 4 groups: operatively created joint contracture (ORC, n = 13), operatively created contracture treated with ketotifen at 2 doses (KF0.5, n = 9; KF1.0, n = 9), and healthy rabbits (NC, n = 8). Range of motion measures were performed at 8 weeks after the surgery. Serum samples were collected on postoperative days 1, 3, 5, 7, 21, 35, and 49. SMCT levels were measured using a rabbit-specific enzyme-linked immunosorbent assay. RESULTS: Levels of SMCT were highest in the operatively created joint contracture group and were significantly greater compared with both ketotifen groups (P < 0.001). Levels were highest at postoperative day 1 with a trend to decrease over time. A positive correlation between SMCT levels and contracture severity was observed in all operative groups (P < 0.05). CONCLUSIONS: Levels of SMCT are elevated in the setting of joint contracture, decreased in association with ketotifen therapy, and positively correlated with contracture severity. This is the first study to establish a relationship between SMCT and joint injury. Measurement of SMCT may be valuable in identifying those at risk of posttraumatic joint contracture.

Fungal periprosthetic joint infection following total elbow arthroplasty: a case report and review of the literature.

BACKGROUND: With improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections. CASE PRESENTATION: We present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus, is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty. CONCLUSIONS: Arthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.

Reconstruction of medial collateral ligament defects with a flexor-pronator fascia patch in complete open release of stiff elbows.

BACKGROUND: Because medial elbow stability is essential for stiff elbow release, surgical techniques have been reported for reconstructing medial elbow stability. However, medial collateral ligament (MCL) defects, caused by inevitable detachment and resection performed for complete release, make the reconstruction more challenging. To our knowledge, no study has evaluated the outcomes after using a flexor-pronator fascia patch in medial elbow reconstruction for open release of stiff elbows. We hypothesized that this technique is effective for repairing MCL defects. METHODS: We retrospectively reviewed the records of 10 patients. The MCL defects were all reconstructed with a flexor-pronator fascia patch. An external fixator was used in all patients. One patient could not be contacted and was thus excluded from the study. Outcome measures included stability, range of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, power grip, and radiographic findings. RESULTS: The mean follow-up period was 19.6 months; all elbows were stable by the last follow-up. One patient presented with moderate elbow instability and then regained stability 3 months after the external fixator was removed. The Mayo Elbow Performance Score improved from 58 points to 94 points, and the mean flexion arc improved from 40° to 133°. No radiographic manifestations of elbow dislocation or suture anchor looseness were observed. CONCLUSION: A flexor-pronator fascia patch provides sufficient stability for repairing MCL defects without restricting the range of motion gained during arthrolysis.

Open arthrolysis for elbow stiffness increases carrying angle but has no impact on functional recovery.

BACKGROUND: With the exception of normal anatomic changes in the medial collateral ligament and radial head, other factors related to carrying angle changes have not been systematically studied. We reviewed patients who underwent open arthrolysis of the elbow, and evaluated if open arthrolysis could change carrying angle. We then identified factors associated with carrying angle changes. METHODS: Fifty patients with a minimum of 24 months of follow-up after open arthrolysis were evaluated retrospectively. Preoperative and postoperative carrying angles were compared. RESULTS: The carrying angles of 36 elbows in 36 patients were unchanged after surgery (Group A), while the carrying angles of 14 elbows in 14 patients increased postoperatively (Group B). In Group A, mean postoperative extension and flexion were 7° (range 0-24°) and 125° (range 10-135°) respectively, while mean postoperative pronation and supination were 60° (range 50-80°) and 65° (range 30-85°), respectively. In Group B, mean postoperative extension and flexion were 25° (range 0-40°) and 128° (range 60-138°), while mean postoperative pronation and supination were 65° (range 45-85°) and 60° (range 45-75°), respectively. No significant difference in range of motion and Mayo Elbow Performance Score was observed between the two groups. CONCLUSIONS: During open arthrolysis, humeral trochlea debridement and techniques for improving forearm rotation could increase carrying angle. However, this had no impact on elbow functional recovery.

Neurologic complications of distal biceps tendon repair with 1-incision endobutton fixation.

Functional outcomes of biceps tendon rupture may be optimized with operative treatment. We conducted a retrospective study to determine the neurologic complications of using 1-incision Endobutton fixation to repair distal biceps tendon ruptures. Patients with distal biceps tendon ruptures treated with a 1-incision technique and Endobutton fixation were included. The primary outcome measure was frequency of neurologic complications. All 50 patients in the study were men. Mean age was 45 years. Twenty-one patients (42%) had at least 1 complication. Injury to the lateral antebrachial cutaneous nerve (LACN) was the most common (36%). Mean time to diagnosis was 17 days (range, 0 to 40 days). Posterior interosseous, anterior interosseous, and superficial radial nerve palsies each occurred at a 4% rate. Mean follow-up was 133 days. This study involved the largest cohort of patients with distal biceps tendon rupture repaired with Endobutton fixation using a 1-incision technique. The LACN injury rate (36%) was higher than in other studies using the same technique (0% to 22%). Injury rates for other neural structures near the elbow were comparable to those in the literature.

Posttraumatic elbow joint contractures: defining pathologic capsular mechanisms and potential future treatment paradigms.

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a midcareer researcher who is dedicated to advancing patient care in the field of hand surgery. This essay, awarded the Weiland Medal in 2012, focuses on posttraumatic elbow joint contractures. Joint contractures are well known to hand surgeons because they limit function of our patients. There is a thorough understanding of the pathoanatomy underlying joint contractures. However, the mechanisms leading to the pathoanatomy are either unknown or partially understood, depending on the etiology of the particular clinical condition. This review describes our research over the past 14 years on posttraumatic elbow joint contractures. It defines pathologic cellular, matrix, and growth factor changes in the joint capsule, elaborates on the development of an animal model of posttraumatic joint contractures, presents an evaluation of a potential prevention strategy based on our research, and outlines future plans to bring this work to the clinical realm for the benefit of patients.

A retrospective cohort study of displaced segmental radial head fractures: is 2 mm of articular displacement an indication for surgery?

HYPOTHESIS: Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. MATERIALS AND METHODS: We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. RESULTS: The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm (P = .8) or even 3 mm (P = .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. CONCLUSIONS: This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome.

Triceps tendon fascia for collateral ligament reconstruction about the elbow: a clinical and biomechanical evaluation.

In this article, we report on a cohort of patients who underwent elbow ligament reconstruction using triceps tendon fascia (TRI) and compare this alternative graft to a standard, the palmaris longus tendon (PL). The biomechanical properties of 8 TRI grafts were compared with those of 8 PL grafts, and 10 patients with TRI elbow ligament reconstructions were retrospectively clinically evaluated. Compared with PL, TRI had significantly more creep, but significantly less cross-sectional area and ultimate failure stress. Ultimate failure load and stiffness did not differ between grafts. Median (SD) postoperative Patient-Rated Elbow Evaluation score (0 = worst, 100 = best) was 79.3 (52). There was no statistical difference between preoperative and postoperative motion. All 10 patients had full triceps strength, and 9 of 10 elbows were stable on examination. With different graft morphology taken into account, PL had a statistically smaller cross-sectional area and double the ultimate failure stress. When compared using the proportions that would be used during surgical reconstruction, however, the grafts were comparable in ultimate failure strength and stiffness. It is unclear whether the statistically significant 0.8-mm difference in creep translates into clinical relevance. Clinically, patients reported good functional outcomes, motion, strength, and stability.

Intramuscular myxoid lipoma in the proximal forearm presenting as an olecranon mass with superficial radial nerve palsy: a case report.

BACKGROUND: Extremity lipomas may occur in any location, including the proximal forearm. We describe a case of a patient with an intramuscular lipoma presenting as an unusual posterior elbow mass. CASE PRESENTATION: We discuss the case of a 57-year-old Caucasian man who presented with a tender, posterior elbow mass initially diagnosed as chronic olecranon bursitis. A minor sensory disturbance in the distribution of the superficial radial nerve was initially thought to be unrelated, but was likely caused by mass effect from the lipoma. No pre-operative advanced imaging was obtained because the diagnosis was felt to have already been made. At the time of surgery, a fatty mass originating in the volar forearm muscles was found to have breached the dorsal forearm fascia and displaced the olecranon bursa. Tissue diagnosis was made by histopathology as a myxoid lipoma with no aggressive features. Post-operative recovery was uneventful. CONCLUSION: We present a case of an unusual elbow mass presenting with symptoms consistent with chronic olecranon bursitis, a relatively common condition. The only unexplained pre-operative finding was the non-specific finding of a transient superficial radial nerve deficit. We remind clinicians to be cautious when diagnosing soft tissue masses in the extremities when unexplained physical findings are present.

Neuropeptide, mast cell, and myofibroblast expression after rabbit deep flexor tendon repair.

PURPOSE: Increased numbers of myofibroblasts, mast cells, and neuropeptide-containing nerve fibers have been found in a number of fibrotic processes in connective tissues. The purpose of the present study was to investigate the occurrence of factors implicated in a hypothesized profibrotic neuropeptide-mast cell-myofibroblast pathway in deep flexor tendon healing. METHODS: In a rabbit model of flexor tendon injury, with repair of the sharply transected deep flexor tendon using a modified Kessler and a running circumferential peripheral suture, segments of flexor tendons and sheaths were analyzed. The time points chosen-3, 6, 21, and 42 days after tendon repair-represent different stages in tendon healing. The messenger RNA levels of transforming growth factor-ß1 and α-smooth muscle actin were measured with conventional reverse transcription-polymerase chain reaction, and the numbers of myofibroblasts, mast cells, and neuropeptide-containing nerve fibers were determined with immunohistochemistry. RESULTS: The messenger RNA levels for transforming growth factor-ß1 and the myofibroblast marker α-smooth muscle actin were significantly increased in deep flexor tendons after injury and repair, at all studied time points, but remained unchanged or even down-regulated in the sheaths. Myofibroblasts, mast cells, and neuropeptide-containing nerve fibers all increased significantly in the healing tendons, exhibiting similar patterns of change in percentages of total cell number over time, reaching levels resembling that of the tendon sheaths with 33% to 50% of the total cell population. CONCLUSIONS: After injury to the deep flexor tendon in a rabbit model, the proportion of myofibroblasts, mast cells, and neuropeptide-containing nerve fibers increases significantly. These findings support the hypothesis that the profibrotic neuropeptide-mast cell-myofibroblast pathway is activated in deep flexor tendon healing.

The mast cell stabilizer ketotifen fumarate lessens contracture severity and myofibroblast hyperplasia: a study of a rabbit model of posttraumatic joint contractures.

BACKGROUND: The propensity of joints to become stiff after trauma is widely appreciated, and the joint capsule is commonly recognized as the major motion-limiting anatomical structure. Affected joint capsules become fibrotic, characterized by myofibroblast and collagen hyperplasia. Mast cell hyperplasia is common within fibrotic tissue, and mast cells are known to synthesize many profibrotic mediators. We hypothesized that mast cell inhibition after skeletal injury would lessen contracture severity and reduce myofibroblast hyperplasia within the joint capsule. METHODS: Posttraumatic contractures of the knee were created with use of a combination of intra-articular injury and internal immobilization in skeletally mature New Zealand White rabbits. Four groups of animals were studied: a nonoperative control group, a group with the operatively created contracture and no pharmacological treatment (the operative contracture group), and two groups with the operatively created contracture that were treated with a mast cell stabilizer, ketotifen fumarate, at a dose of either 0.5 or 1.0 mg/kg twice daily (the 0.5-mg/kg and 1.0-mg/kg ketotifen groups). After eight weeks of immobilization, flexion contractures were measured and the posterior aspect of the joint capsule was harvested for quantification of myofibroblast and mast cell numbers. RESULTS: Flexion contractures developed in the operative contracture group (mean and standard deviation, 58 degrees +/- 14 degrees ), and the severity of the contractures was reduced in both the group treated with 0.5 mg/kg of ketotifen (42 degrees +/- 17 degrees ) and the group treated with 1.0 mg/kg of ketotifen (45 degrees +/- 10 degrees ) (p < 0.02). The joint capsule myofibroblast and mast cell numbers in the operative contracture group were significantly increased compared with the values in the control group (p < 0.001), and the myofibroblast and mast cell numbers in both ketotifen groups were significantly reduced compared with the values in the operative contracture group (p < 0.001). CONCLUSIONS: The use of a mast cell stabilizer, ketotifen, was effective in reducing the biomechanical and cellular manifestations of joint capsule fibrosis in a rabbit model of posttraumatic joint contracture. This finding suggests that an inflammatory pathway, mediated by mast cell activation, is involved in the induction of joint capsule fibrosis after traumatic injury.

The interobserver reliability of classification systems for radial head fractures: the Hotchkiss modification of the Mason classification and the AO classification systems.

BACKGROUND: Radial head fractures are common injuries, and there is little information on the reliability of classification systems for such injuries. The purpose of our study was to report the interobserver reliability of 2 commonly used classification systems: the Hotchkiss modification of the Mason classification and the AO classification systems. METHODS: We compiled the radiographs from a cohort series of 43 patients with radial head fractures, and 5 observers classified the radiographs according to both classification systems. Additionally, we collapsed the systems, with types II and III combined for the Hotchkiss classification and the final digit dropped for the AO classification. We calculated percent agreement, the kappa statistic and the associated 95% confidence intervals (CIs). RESULTS: The mean percent agreement was 72.3% (95% CI 65.8%-78.9%) for the Hotchkiss classification and 37.7% (95% CI 30.5%-44.9%) for the AO classification. The kappa statistic was 0.585 (0.541-0.661) for the Hotchkiss classification and 0.261 (0.240-0.350) for the AO classification. The mean percent agreement was 89.3% (86.6%-92.0%) for the consolidated Hotchkiss classification and 67.4% (54.6%-80.3%) for the consolidated AO classification. The kappa statistic was 0.760 (0.691-0.805) for the consolidated Hotchkiss classification and 0.455 (0.372-0.521) for the consolidated AO classification. CONCLUSION: The interobserver reliability for the Hotchkiss modification of the Mason classification was moderate, and that for the AO classification was fair according to the criteria of Landis and Koch. Collapsing the Hotchkiss classification improved the reliability to substantial, and collapsing the AO system improved reliability to the lower end of moderate.

Chronic volar distal radioulnar joint instability: joint capsular plication to restore function.

BACKGROUND: Volar instability of the distal radioulnar joint (DRUJ) is uncommon, and there is little written about it. The purpose of this study is to describe a new procedure to treat volar DRUJ instability and to present the outcomes of patients who received this unique surgical repair at a minimum of 1 year follow-up. METHODS: We performed a retrospective case series of 6 consecutive patients treated with a volar and dorsal capsular plication procedure by an upper extremity specialist surgeon at a teaching hospital between April 1999 and October 2004. We evaluated measures, including wrist range of motion, grip strength, radiographs, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Patient-Rated Wrist Evaluation (PRWE), at final follow-up. RESULTS: Five of 6 patients had resolution of pain and instability symptoms. The average difference in range of motion between operative and contralateral sides was -7 degrees flexion, 2 degrees extension, 4 degrees radial deviation, 2 degrees ulnar deviation, -17 degrees supination and -2 degrees pronation. Average grip strength measured 83% of the uninjured side. The average DASH score was 13.5 (range 0-46.7), and the average PRWE score was 26.7 (range 0-70). One patient had a low ulnar neuropathy, which resolved. One patient fractured the temporary DRUJ stabilization screw and had radiographic evidence of nonbridging heterotopic ossification. CONCLUSION: Joint capsular plication for DRUJ has not yet been described in the literature. It is less elaborate in that it does not require a tendon graft with bone tunnels. The results at an average 16.5 months postoperatively are promising.

Joint capsule mast cells and neuropeptides are increased within four weeks of injury and remain elevated in chronic stages of posttraumatic contractures.

The purpose of this article was to determine mast cell and neuropeptide nerve fiber numbers in joint capsules in posttraumatic contractures, as elevated numbers have been implicated in other fibrotic and contracture conditions. Twelve skeletally mature rabbits had intraarticular cortical windows removed from the medial and lateral femoral condyles and the knee joint immobilized. The contralateral unoperated limb served as a control. Equal numbers of rabbits were sacrificed 4 weeks after surgery or 40 weeks after the first surgery that included 32 weeks of remobilization. Six patients with chronic posttraumatic elbow joint contractures and six age-matched organ donor controls free of elbow contractures were also studied. Joint capsule myofibroblast, mast cell, and neuropeptide containing nerve fiber numbers were assessed with immunohistochemistry. The numbers of myofibroblasts, mast cells, and neuropeptide containing nerve fibers expressed as a percentage of total cells were significantly greater in the contracture capsules when compared to the control capsules at all time points (p < 0.0001). The range of percentages for the three components in the contracture capsules versus the controls were 41-48% versus 9-10%, 44-50% versus 11-13%, and 45-50% versus 10-12% for the acute and chronic stages of the rabbit model and the chronic stages in the human elbows, respectively. These data support the hypothesis that a myofibroblast-mast cell-neuropeptide fibrosis axis may underlie some of the pathologic changes in the joint capsule in posttraumatic contractures. Approaches designed to manipulate this axis, such as preventing degranulation of mast cells, warrant further investigation.