Osteosarcoma of the Trapezium.

Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.

A registry based analysis of the patient reported outcome after surgery for trapeziometacarpal joint osteoarthritis.

BACKGROUND: The aim of the study was to evaluate patient reported outcome measures (PROM) before and after trapeziectomy with or without ligament reconstruction and tendon interposition for trapeziometacarpal joint arthritis with special focus on possible differences due to gender, age and surgical method. METHODS: Data from the Swedish quality registry for hand surgery (HAKIR) was analyzed preoperatively, 3 months and 1 year postoperatively for 1850 patients (mean age 63 years, 79% women). RESULTS: One year postoperatively, mean pain at rest was reduced from 50 to 12 of maximum 100. However, pain on load and weakness had not abated to the same extent (mean 30 and 34 of 100, respectively). The mean improvement in PROM did not differ between age groups or gender. The result was similar after trapeziectomy with ligament reconstruction and tendon interposition (86% of the patients) and simple trapeziectomy but few patients were operated with the latter method. CONCLUSION: Pain on load and weakness remains to some extent 1 year after surgery for trapeziometacarpal joint arthritis. The result is similar after trapeziectomy with or without ligament reconstruction and tendon interposition and the same improvement can be expected after surgery regardless of age and gender.

Partial Trapezoid Excision in Thumb CMC Arthroplasty for STT Arthritis: A Cadaveric Study.

PURPOSE: Thumb carpometacarpal (CMC) joint arthroplasty is one of the most commonly performed surgeries by hand surgeons. A large portion of these patients also have scaphotrapezoidal (ST) arthritis in addition to CMC arthritis. The purposes of this study were to quantify the amount of transverse trapezoid resection necessary to prevent ST impingement and to compare an oblique with a transverse osteotomy of the trapezoid. METHODS: A total of 9 cadaveric specimens were used and were randomly placed into 2 groups. Group 1 had sequential transverse osteotomies and the space between the scaphoid and trapezoid was measured in various wrist positions. Group 2 had oblique osteotomies and the ST distance was measured in multiple wrist positions. RESULTS: In group 1, there was no contact between the scaphoid and trapezoid in neutral wrist position after any resection. The half and two-thirds transverse osteotomies did not have contact at 20° radial deviation (RD) and 30° wrist flexion (WF). In 1 of the 5 specimens, there was contact at one-third resection in either isolated RD or WF. In 3 specimens, there was contact at one-third resection with 20° of radial deviation combined with 30° WF. In group 2, there was no contact in any specimen in any wrist position tested. At neutral, there was 3.7 mm of space between the scaphoid and trapezoid measured at the radial side. In 20° RD and 0° WF, an average space remaining was 2.8 mm. In 0° RD and 30° WF, there was an average space of 2.3 mm remaining. At 20° RD and 30° WF, there was an average space remaining of 1.8 mm. At the extreme of RD and WF, there was an average space remaining of 1.4 mm. CONCLUSIONS: An oblique osteotomy of the trapezoid did not have any ST contact in 20° RD and 30° WF. The transverse osteotomies had contact with only one-third resection. Therefore, if a transverse osteotomy of the trapezoid is performed, more than one-third of the bone should be resected to minimize the risk for bony impingement in positions of WF, RD, or both. CLINICAL RELEVANCE: In ST arthritis, an oblique osteotomy of the trapezoid may prevent impingement while allowing for less overall bony resection compared with a transverse osteotomy.

T2 mapping of the trapeziometacarpal joint and triangular fibrocartilage complex: a feasibility and reproducibility study at 1.5 T.

PURPOSE: To assess the feasibility and reproducibility of T2 relaxation time measurements of the trapeziometacarpal joint (TM) and triangular fibrocartilage complex (TFCC) on healthy subjects at 1.5 T MR. MATERIALS AND METHODS: Thirty-four healthy volunteers underwent an axial oblique multislice multiecho spin-echo sequence of the wrist at 1.5 T, with 10 of them having performed another MR scan on a different 1.5 T scanner. Regions of interest were independently manually drawn by two musculoskeletal radiologists to include the cartilaginous part of the TM and TFCC. Intra-observer, inter-observer and inter-scanner reproducibility of T2 relaxation time measurements was tested using the Bland-Altman method. RESULTS: The mean T2 values obtained by the two radiologists were 29.9 ± 6.5 ms and 30.0 ± 6.1 ms in the TM and 24.5 ± 2.3 ms and 24.6 ± 2.8 ms in the TFCC, respectively. The mean values of the second series of T2 measurements obtained by the senior radiologist were 29.9 ± 6.5 ms and 30.0 ± 6.3 ms in the TM and 24.3 ± 2.9 ms in the TFCC. Inter-observer reproducibility in the TM and in the TFCC was 76% and 82%, respectively. Intra-observer reproducibility in the TM and TFCC was 71% and 76%, respectively. Inter-scanner reproducibility of T2 measurements was 36% in the TM and 85% in the TFCC, respectively. CONCLUSION: The assessment of T2 relaxation time measurements of the cartilage of the TM and the TFCC seems to be feasible and reproducible, although the inter-scanner reproducibility of T2 measurements of the TM is suboptimal. Further studies including patients are warranted to prove the utility of this tool.

The surgical management for isolated scaphotrapeziotrapezoid (STT) osteoarthritis : a systematic review of the literature.

We performed a systematic review to find out the safety and efficacy of various procedures for isolated scaphotrapeziotrapezoid osteoarthritis. Eleven articles were included. The most common procedure was arthroplasty with pyrocarbon implant (28%), followed by resection of distal pole of scaphoid with proximal trapezium and trapezoid resection (18%). The other procedures included trapeziectomy with ligament reconstruction and tendon interposition (LRTI) (14%), arthroscopic resection of distal scaphoid (11%), trapezium and trapezoid resection with LRTI (10%) and arthrodesis (10%). Complications were noted in 18 (15%) patients. The most common complication (7.5%) was asymptomatic dorsal intercalated segmental instability (DISI) followed by dislocation of the pyrocarbon implant (3%). Fusion resulted in decreased range of motion and grip strength. The distal scaphoid resection was related to high rate of DISI. Although the pyrocarbon implant has a higher dislocation rate which requires revision surgery, this complication is avoidable with good surgical technique. Arthroplasty with pyrocarbon implant may be the first choice in younger patients.

Psychologic Factors Do Not Affect Placebo Responses After Upper Extremity Injections: A Randomized Trial.

BACKGROUND: Studies on how psychologic factors influence the placebo effect have shown conflicting results in an experimental setting. Pessimists are more likely to experience a nocebo effect (feel worse after an inert intervention), whereas other studies suggest that patients with more symptoms of depression or anxiety or greater neuroticism have a greater response to a placebo. This is important because treatment benefits are potentiated by placebo effects, and optimal utilization of this phenomenon may improve clinical outcomes. QUESTIONS/PURPOSES: (1) What psychologic factors are associated with a decrease in magnitude of limitations (Disabilities of the Arm, Shoulder and Hand [DASH] score) and pain intensity (visual analog scale [VAS] for pain) after placebo injections for the treatment of painful nontraumatic upper extremity conditions? (2) What psychologic factors are associated with achieving a minimum clinically important difference (MCID) in disability and pain intensity? METHODS: We performed a secondary analysis of data acquired in two prospective, double-blind, randomized controlled trials of patients with lateral elbow pain, trapeziometacarpal arthrosis, and de Quervain tendinopathy who received a single injection of dexamethasone and lidocaine or lidocaine alone (placebo). One hundred six patients were included between June 2003 and February 2008. Sixty-three patients (59%) received dexamethasone and lidocaine, and we analyzed the subset of 43 patients (41%) who received lidocaine alone. The primary outcomes of interest were the DASH questionnaire and the VAS for pain measured three times: when they received the injection, between 1 and 3 months after the injection, and between 5 and 8 months after the injection. Seven patients missed the first followup visit and 14 patients missed the second visit. Based on previous research, we chose a MCID threshold of 10 for the DASH and a threshold of 1.0 for the VAS score. In bivariate analysis, we accounted for sex, race, marital status, degree, education, work status, pretreatment pain, diagnosis, symptoms of depression (Center of Epidemiologic Studies-Depression Scale), coping strategies in response to nociception (Pain Catastrophizing Scale), and personality traits (measured with the Multidimensional Health Locus of Control scale and the Eysenck Personality Questionnaire-Revised score). Variables with p values < 0.10 in bivariate analysis were included in the multivariable regression models. An a priori power analysis showed that a sample of 43 participants provides 80% statistical power, with α set at 0.05, for a regression with five predictors if the depression score would account for 15% or more of the variability in pain score. We used multiple imputations (imputations = 50) for a total of 66 (8.5%) missing or incomplete questionnaires. RESULTS: In the final multivariable models, no psychologic factors were associated with a change in DASH score between injection and followup, and no factors were associated with greater decrease in pain intensity. After injection, no psychologic factors were independently associated with achieving a MCID in the DASH and VAS. CONCLUSIONS: Our study confirms that patient factors are less important mediators of the placebo effect than clinician factors. In other words, clinician warmth and competence can help diminish symptoms and limitations of people in various states of mind, even when using inert or ineffective treatments. LEVEL OF EVIDENCE: Level II, therapeutic study.

Capitate-trapezoid synostosis: analysis of an Early Bronze Age case and review of the literature.

BACKGROUND: Carpal synostoses are congenital defects characterised by complete or incomplete coalition of two or more carpal bones. Although most of these defects are discovered only incidentally, sometimes they become clinically manifest. Among the different types of carpal coalition, the synostosis between capitate and trapezoid bones is quite rare, with only sparse data available in the literature. The aim of this report was to describe a case of capitate-trapezoid synostosis (CTS) observed in an ancient human skeleton, as well as to scrutinise the pertinent literature in order to assess for the characteristics of this type of defect, including its potential relevance to clinical practice. MATERIALS AND METHODS: We studied the skeletal remains of an Early Bronze Age male warrior affected by incomplete CTS. Macroscopic and radiological examination of the defect was carried out. We also performed a comprehensive PubMed search in the Medline and other specialty literature databases to retrieve and analyse data relevant to the subject under consideration. RESULTS AND CONCLUSIONS: The present case is the most ancient CTS ever found. In those literature-reported cases accompanied by careful anatomical description, such as the present one, incomplete coalition invariably occurs between the dorsal surfaces of the two bones, this characteristic emerging as a distinctive morphological trait. Literature analysis further suggests that the true prevalence of CTS is likely to be higher than estimates based on data gathered from radiology series, and that this defect may be associated with pain and carpal bossing more frequently than generally thought.

Dorsal dislocation of the trapezoid with carpo-metacarpal dislocations: a case report and a description of the "missing carpal sign" on radiographs.

BACKGROUND: A case report of dorsal trapezoid dislocation with index and middle carpometacarpal dislocation is described. OBJECTIVES: On review of the literature, this rare injury is often misdiagnosed on presentation, with difficulty in reviewing initial radiographs being a key factor. CASE REPORT: We present our case report of trapezoid dislocation and describe the "missing carpal sign" on radiographs as an aid to suspicion of diagnosis. CONCLUSION: Trapezoid dislocation is an often-overlooked diagnosis; we present a sign to increase suspicion of injury and hence promote further investigation.

Isolated fractures of the trapezoid as a sports injury.

The aim of this work is to describe the radiographic findings of isolated trapezoid fractures and determine the utility of these findings in guiding treatment. A second aim is to heighten awareness of an uncommon sports-related injury that is often radiographically occult because of the lack of primary or overt secondary radiographic findings. A retrospective review of radiology reports at our institution from 2007 to 2010 was performed to identify isolated trapezoid fractures. Two musculoskeletal radiologists and one orthopedic hand surgeon reviewed the patient presentations, images, treatments, and outcomes of the patients' injuries. This project had institutional review board approval. We describe three patients who presented with isolated sports-related trapezoid fractures. Each patient was successfully treated with activity modification, cast immobilization, and/or surgery based on their specific radiographic findings. Isolated sports-related trapezoid fractures are rare injuries. Only one prior case report in the English literature exists. Treatment success in patients with trapezoid fractures depends upon the degree of activity modification, splint protection, and especially fragment displacement. We report the largest series to date of isolated trapezoid fractures, all of which resulted from sports participation, and we analyze the success of diagnostic and treatment interventions.

Management of Scaphotrapeziotrapezoid Osteoarthritis: A Critical Analysis Review.

¼ The scaphotrapeziotrapezoid (STT) joint is a common location of degenerative osteoarthritis (OA) in the wrist.¼ STT OA may occur in isolation or with concomitant thumb carpometacarpal joint (CMCJ) OA or scapholunate advanced collapse (SLAC) and other wrist OA patterns.¼ Nonoperative management strategies include activity modification, bracing, anti-inflammatory medications, occupational therapy, and injections.¼ Surgical treatment may be determined by whether the STT OA occurs in isolation or with concomitant thumb CMCJ or SLAC OA and includes STT arthrodesis, distal scaphoid excision with or without interposition or implant arthroplasty, trapeziectomy with proximal trapezoid excision, four-corner fusion in combination with scaphoid/radial column excision, and proximal row carpectomy.

Trapezoid fractures: report of 11 cases.

PURPOSE: Trapezoid fractures are rare. Mostly single cases reports appear in the literature. The purpose of this study was to review 11 patients treated for trapezoid fractures at our center. METHODS: We reviewed all trapezoid fractures that presented over the past 10 years at our institution. We reviewed case notes regarding mechanism of injury, fracture pattern, mode of diagnosis, and time to diagnosis and treatment. RESULTS: We treated 11 patients for trapezoid fractures over the 10-year period. A correct diagnosis was made in 5 cases on initial evaluation. Most trapezoid fractures were diagnosed on computed tomographic scan. The fracture plane was predominantly sagittal. Coronal fractures could not be diagnosed on plain radiographs. CONCLUSIONS: Fractures of the trapezoid should be suspected from the mechanism of injury, in particular, axial force, and from local tenderness. These fractures may be underdiagnosed. We recommend computed tomography rather than plain radiography alone in case of clinical suspicion. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Scaphotrapeziotrapezoid arthrodesis and lunate excision for advanced Kienböck disease.

PURPOSE: To analyze the outcomes of lunate excision combined with scaphotrapeziotrapezoid arthrodesis for the treatment of advanced Kienböck disease. METHODS: Sixteen patients with Lichtman stage IIIB Kienböck disease were treated with scaphotrapeziotrapezoid arthrodesis and lunate excision and were followed for a mean of 67 months (range, 49 to 108 mo). The indications for lunate excision included pain and limited motion associated with a collapsed lunate. Clinical evaluation included range of motion, grip strength, and modified Mayo wrist score. Based on plain radiographs, the carpal height ratio, ulnar carpal distance ratio, scaphoid translation ratio, and radioscaphoid angle were measured and any presence of degenerative changes was assessed. To investigate the effects of lunate excision on the radiologic results, we compared 12 patients with stage IIIB Kienböck disease who had only scaphotrapeziotrapezoid arthrodesis as the control group. RESULTS: Range of motion tended to be preserved, with a trend toward an increase in extension after surgery. Grip strength and modified Mayo score improved significantly. Fourteen patients with lunate excision demonstrated radiographic ulnar translation of the scaphoid beyond the scapholunate ridge, and radioscaphoid arthritis was observed in 4 patients. Compared to initial postoperative radiographs, the scaphoid translation ratio was significantly decreased, but neither ulnar carpal distance ratio nor radioscaphoid angle showed significant differences. In the control group, neither ulnar translation of the scaphoid nor significant changes of radiologic parameters was found between initial postoperative and final radiographs. CONCLUSIONS: Scaphotrapeziotrapezoid arthrodesis with lunate excision for advanced Kienböck disease provided favorable clinical results in terms of pain relief and functional improvement. With the absence of the lunate, however, the scaphoid had a tendency to shift toward the lunate fossa. This study suggests the risk of early development of radioscaphoid arthritis as a negative effect of lunate excision.

Volar Dislocation of Trapezoid with Coronal Fracture - A Case Report and Review of Literature.

Volar dislocation of the trapezoid is a rare injury and is easily missed. It is more common to have a dorsal dislocation of trapezoid or multiple carpometacarpal joint dislocations. The rare nature of the injury also means that there is little guidance in literature regarding optimal treatment. We are reporting the presentation, management and a 3-year follow-up of this rare injury in a 19-year-old male. Level of Evidence: Level V (Therapeutic).

Bilateral avascular necrosis of the trapezoid.

We present a 5-year follow-up of a patient with bilateral necrosis of the trapezoid that improved clinically and radiographically with nonoperative treatment.

Excisional arthroplasty for scaphotrapeziotrapezoidal osteoarthritis.

Symptomatic scaphotrapeziotrapezoidal (STT) joint osteoarthritis may occasionally require surgery. In the absence of dorsal midcarpal instability, acceptable results may be obtained by an excisional STT joint arthroplasty. After distal scaphoid resection, however, forces are no longer transmitted along the radial column of the wrist. This often results in slight malrotation of the proximal row into extension. To mitigate this problem, different strategies have been proposed (dorsal midcarpal capsulodesis, palmar radioscaphoid capsulodesis, tendon interposition, or pyrocarbon implant interposition). As compared to STT fusion, excisional arthroplasty is less technically demanding, requires less prolonged immobilization, and has fewer complications.

Carpal coalition: symptomatic incomplete bony coalition of the capitate and trapezoid--case report.

We present a case of symptomatic, incomplete bony carpal coalition between capitate and trapezoid. We describe previous case reports and possible therapeutic options.

Arthroscopic resection arthroplasty for treatment of combined carpometacarpal and scaphotrapeziotrapezoid (pantrapezial) arthritis.

PURPOSE: Arthroscopy of the carpometacarpal (CMC) and scaphotrapeziotrapezoid (STT) joints has been described for the purpose of diagnosing, staging, and treating CMC and STT pathology. This study evaluates the short-term outcome of arthroscopic resection arthroplasty (ARA) for pantrapezial arthritis. METHODS: Thirty-five cases of ARA of the CMC and STT joints were performed in 34 patients with one year minimum follow-up. There were 27 women and 7 men. Average age was 63 (range, 46 to 79). All patients had simultaneous ARA of both the CMC and STT joints. A 2- to 3-mm section of bone was resected from the proximal and distal aspect of both the CMC and STT joints. Preoperative data collected included 10-point self-reported pain scale, Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, range of motion, grip strength, key and chuck pinch, length of symptoms, and treatment. Postoperative data included the same data plus patient satisfaction, graded on a 0 to 5 scale. Data were collected at postoperative months 1, 3, 6, and 12. RESULTS: Average time of postoperative immobilization was less than 3 weeks (range, 2-6). The DASH scores averaged 46 before surgery, and 51, 30, 20, and 19 respectively, for the aforementioned postoperative intervals. The mean improvement in key pinch was 1.3 kg. The mean improvement in grip was 4.3 kg. Pain improved from 7 before surgery to 1 at one-year follow-up. CONCLUSIONS: Short-term analysis suggests that ARA for pantrapezial arthritis provides satisfactory pain relief and return of strength and function.

Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy, arthroplasty, and arthrodesis.

Osteoarthritis of the first carpometacarpal joint is the second most common site of osteoarthritis in humans. Symptomatic isolated scaphotrapeziotrapezoid joint arthritis, though less common overall, is also frequently observed by the hand surgeon. Investigations on the etiology, pathophysiology, natural history, outcomes of traditional treatments, and new forms of surgical techniques have been attracting more interest in the field of hand surgery. The goal of this article is to sort through the current prevailing ideas using recently available literature and to offer a concise, updated guide to further enhance the understanding of thumb carpometacarpal and scaphotrapeziotrapezoid arthritis.

Arthroscopic Distal Scaphoid Resection for Scapho-Trapezium-Trapezoid Arthritis.

Background: The purpose of this study was to describe the technique of arthroscopic resection of the scaphoid head and evaluate both the clinical and radiographic results of scapho-trapezium-trapezoid osteoarthritis cases. Methods: Seventeen cases (13 men and 4 women) with a mean age of 57 years (24-74 years) were operated on from 2002 to 2015. Inclusion criteria were nontraumatic radial-sided wrist pain without improvement after 4 months of conservative treatment and positive radiographic images demonstrating the presence of osteoarthritis. All cases were evaluated preoperatively and postoperatively using visual analog scale, wrist range of motion (ROM), grip strength, and patient's work status (Mayo Wrist Score). Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) questionnaires were also administered. The technique consisted of performing a 3- to 4-mm round-shaped scaphoid head resection via arthroscopy while preserving the scaphotrapezial and scaphocapitate ligament insertions. Results: At an average follow-up of 24 months, all the patients were satisfied. The results showed statistically significant improvement in pain at rest (P = .001), under maximal load (P = .0001), and in Mayo Wrist Score (MWS) (P = .0001). Wrist ROM, grip strength, DASH, and PRWHE showed an improvement without reaching statistical significance. The mean preoperative radiolunate (RL) X-ray measurement angle was 17° (-10° to 35°). The postoperative mean value was 25° (0°-45°). In the preoperative radiographic evaluation, 11 cases exceeded the "critical" 15° RL angle. At follow-up, the RL angle increased in 10 cases and remained unchanged in 7 cases. None of these cases became symptomatic. Transitory neurapraxia of the dorsal superficial branch of the radial nerve was observed in 1 case. Damage of the dorsal branch of the radial artery was immediately fixed. Conclusions: Arthroscopic resection of the distal portion of the scaphoid due to scapho-trapezium-trapezoid osteoarthritis demonstrated an effective and safe technique with less complications than open surgery.

Trapezoidal bony correction of the femoral neck in the treatment of severe acute-on-chronic slipped capital femoral epiphysis.

PURPOSE: To present the first technical description of a modified surgical technique for trapezoidal bony correction of the femoral neck in the treatment of slipped capital femoral epiphysis (SCFE), performed entirely by arthroscopy. METHODS: From December 2005 to January 2008, 5 patients with severe SCFE underwent trapezoidal femoral neck bone correction through arthroscopy. Their mean age at the time of surgery was 13.2 years. The time for postoperative follow-up ranged from a minimum of 12 months to a maximum of 39 months (mean, 26 months). The study analyzed data regarding the type of slip, degree of correction obtained, clinical and functional outcomes, and complications. RESULTS: Analysis with the modified Harris Hip Score criteria showed a mean of 17.2 points preoperatively and 86.6 points at the last assessment. The mean epiphyseal deviation ranged from 82° at the initial presentation to 14° postoperatively. There were no intraoperative complications, and there was 1 case of avascular necrosis. CONCLUSIONS: Arthroscopic treatment of SCFE resulted in correction of the angles of epiphyseal slip (from a mean epiphyseal-diaphyseal angle of 82° before surgery to 14° after surgery), with no immediate complications and 1 case of a late complication (avascular necrosis) in this 5-patient series. Clinical improvement was shown by a mean 69.4-point increase in the modified Harris Hip Score. LEVEL OF EVIDENCE: Level IV, therapeutic case series.