Trigger Wrist.

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.

Complications and revision rate compared by type of total elbow arthroplasty.

BACKGROUND: This study evaluates the long-term results, including complication and revision rates, of different types of total elbow arthroplasty (TEA) with an average follow up of 13 years. METHODS: Since 1984, a total of 84 primary TEAs have been performed in 77 patients at our institution. The patient's average age was 54.2 years. We performed unlinked TEA in 35 cases (Pritchard ERS since 1984 [n = 18], Kudo type 3 since 1991 [n = 17]), and semi-linked TEA in 49 cases (Pritchard Mark II since 1997 [n = 14], Coonrad-Morrey since 2001 [n = 35]). We assessed the patients for compliance to daily living guidelines (not to exceed 2.25 kg for repetitive lifting and 4.5 kg for single episode lifting), and followed up with them for an average of 13 years after primary TEA. We analyzed their results with regard to complication and revision rates as the type of TEA. RESULTS: The mean Mayo Elbow Performance Score (MEPS) improved from preoperative 34 points to postoperative 84 points. The active flexion-extension elbow motion increased from 25°-94° preoperative to 12°-130° postoperative. The overall complication rate was 44.0% (37/84 cases); the rate was statistically higher in the unlinked group (62.9%, 22/35 cases) than in the semi-linked group (30.6%, 15/49 cases). The overall revision rate was 27.4% (23/84 cases); the rate was higher in the unlinked group (34.3%, 12/35 cases) than in the semi-linked group (22.4%, 11/49 cases). CONCLUSION: Semi-linked TEA has better outcomes than unlinked TEA with respect to complication and revision rates; but continuous efforts to develop a new TEA design for longevity, improved cementing technique, and supporting activities of daily living are needed to reduce complication and revision rates in the future.

Avulsion fracture of the calcaneal tuberosity: classification and its characteristics.

BACKGROUND: Not much is known regarding avulsion fractures of the calcaneal tuberosity. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features. METHODS: Out of 764 cases of calcaneal fractures, we examined 20 cases (2.6%) that involved the tuberosity of the calcaneus. Each case was classified depending on the avulsed fracture patterns as follows; type I is a 'simple extra-articular avulsion' fracture, type II is the 'beak' fracture, type III is an infrabursal avulsion fracture from the middle third of the posterior tuberosity, and finally in type IV there is the 'beak', but a small triangular fragment is separated from the upper border of the tuberosity. We examined the features of each avulsed type according to several criteria including patient age, gender, anatomical variances of the Achilles tendon, the fibers involved and the mechanism of injury. RESULTS: The type I fracture (8/20 cases) was the most common and likely to occur in elderly women. However, in other types, they were more common in relatively younger male patients. Type I were usually caused due to an accidental trip causing a fall by the patient. However, the dominant cause of type II (5/20 cases) fractures a direct blow or hit directly to the bone. Type III (4/20 cases) and IV (3/20 cases) fractures were likely to occur due to falling. All fibers within the Achilles tendon are involved in both type I and II fractures. However, only the superficial fibers are involved in type III fractures, whereas the deep fibers are involved in type IV fractures. CONCLUSIONS: The avulsion patterns of the calcaneal tuberosity fractures are the result of several factors including the bony density level, the mechanism of injury and the fibers of the Achilles tendon that transmit the force. Accurate diagnosis of type III and IV is dependant on MRI technology to confirm the specific location of the injury and provide proper patient treatment therapeutics.

Effect of nerve growth factor and its transforming tyrosine kinase protein and low-affinity nerve growth factor receptors on apoptosis of notochordal cells.

PURPOSE: The disappearance of notochordal cells by apoptosis is thought to be the starting point of intervertebral disc degeneration. The aim of this study was to determine the apoptotic pathway of notochordal cells as well as the anti-apoptotic potential of caspase inhibitors. METHODS: Rat notochordal cells were isolated, cultured, and placed in either 0 % (apoptosis-promoting condition) or 10 % (normal control) foetal bovine serum (FBS). We identified and quantified apoptotic cell deaths and caspase activities. In addition, we examined the cells for expression of nerve growth factor (NGF) and its two receptors--TrkA (survival signal) and p75 (apoptotic signal)--and downstream pathways. Finally, we analysed the degree of anti-apoptotic effects of caspase inhibitors on the cells. RESULTS: The apoptotic rate and expressions of caspase-8 (extrinsic pathway), -9 (intrinsic pathway), and -3 (common executioner) of notochordal cells were increased in 0 % FBS compared with those in 10 % FBS. Expressions of NGF, p75 receptor and JNK downstream pathways were also increased in 0 % FBS. In contrast, expressions of the TrkA receptor and Akt and MAPK downstream pathways were decreased in 0 % FBS. Pancaspase, capase-9 and capase-8 inhibitors significantly reduced apoptotic cell death. CONCLUSIONS: Our results suggest that notochordal cells undergo apoptosis through both the intrinsic and extrinsic pathways by activation of NGF, p75 receptor, and the JNK downstream pathway. We also found that apoptosis of notochordal cells can be attenuated by caspase inhibitors. Caspase inhibitors may play a therapeutic role in delaying the starting point of disc degeneration that is due to inappropriate or premature excessive apoptosis of notochordal cells.

Metastatic malignant tumour in the hand.

Skeletal metastasis is a common event during the advanced stage of a malignant tumour, but metastasis to the hand is rare (about 0.1% incidence). We have seen seven cases of metastatic malignant tumour of the hand since 1983, and report them here.

Genetic traits of avascular necrosis of the femoral head analyzed by array comparative genomic hybridization and real-time polymerase chain reaction.

In an attempt to observe the genetic traits of avascular necrosis of the femoral head, we analyzed the genomic alterations in blood samples of 18 patients with avascular necrosis of the femoral head (9 idiopathic and 9 alcoholic cases) using the array comparative genomic hybridization method and real-time polymerase chain reaction. Several candidate genes were identified that may induce avascular necrosis of the femoral head, and we investigated their role in the pathomechanism of osteonecrosis of bone. The frequency of each candidate gene over all the categories of avascular necrosis of the femoral head was also calculated by real-time polymerase chain reaction. The highest frequency specific genes in each category were FLJ40296, CYP27C1, and CTDP1. FLJ40296 and CYP27C1 had the highest frequency (55.6%) in the idiopathic category. FLJ40296 had a high frequency (44.4%) in the alcoholic category, but CYP27C1 had a relatively low frequency (33.3%) in the alcoholic category. However, CTDP1 showed a significantly high frequency (55.6%) in the alcoholic category and a low frequency (22.2%) in the idiopathic category. Although we statistically analyzed the frequency of each gene with Fisher's exact test, we could not prove statistical significance due to the small number of samples. Further studies are needed with larger sample numbers. If the causal genes of avascular necrosis of the femoral head are found, they may be used for early detection, prognosis prediction, and genomic treatment of avascular necrosis of the femoral head in the future.

Ankle deformity secondary to acquired fibular segmental defect in children.

BACKGROUND: The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children. METHODS: Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs. RESULTS: In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2 degrees (range, 5 degrees to 35 degrees) and 10 degrees (range, 5 degrees to 12 degrees), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times. CONCLUSIONS: A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiöld supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.

Extension limitation and deviation of fingers by the scarred junctura tendinum: a case report.

The juncturae tendinum (inter-extensor connections) are structures connecting each of the extensor digitorum communis (EDC) tendons. Nine months before the presentation to us, this 21-year-old man had painful swelling on the dorsum of the right hand after punching. At present, the patient showed an ulnar deviation of the long finger and a limited extension of the ring finger. The scarred junctura tendinum between long and ring fingers inhibited proximal sliding of the EDC tendon of ring finger, and affect the functions of adjacent metacarpophalangeal joint. The scarred junctura tendinum was resected, while the sagittal band was preserved to prevent subluxation of the EDC tendon of long finger. One year after operation, the range of motion of fingers was full.

Transplanted xenogenic bone marrow stem cells survive and generate new bone formation in the posterolateral lumbar spine of non-immunosuppressed rabbits.

Bone marrow stem cells (BMSCs) are pluripotent cells that have been used to facilitate bone repair because of their capability of differentiating into osteoblasts. However, it is well known that the number of BMSCs with osteogenic potential decreases in patients with old age, osteoporosis, and metabolic diseases. In such conditions, xenogenic BMSCs may provide an alternative to autologous BMSCs. In the current study, we investigated the potential of transplanted xenogenic BMSCs to survive and generate new bone formation in the posterolateral lumbar spine of non-immunosuppressed rabbits. The BMSCs were obtained from bilateral femurs of four male rats, cultured and expanded in medium with osteoinduction supplement. The BMSCs (1,000,000 cells) of male rats loaded onto 5 cc compression resistant matrix (CRM; Medtronic Sofamor Danek, USA) were implanted bilaterally onto the L4-5 intertransverse processes of 16 female rabbits (xenogenic BMSCs + CRM group). The 16 female rabbits that received 5 cc CRM alone were used as controls (CRM alone group). To exclude the possibility of migration of BMSCs from the transverse processes of the recipient rabbits, we did not decorticate the transverse processes. No rabbits received any immunosuppressive medications during the experiment. Four rabbits each in both of the experimental and control groups were killed at 1, 2, 4, and 6 months postimplantation, and the lumbar spine underwent radiological and histological analyses for evaluation of new bone formation. The polymerase chain reaction (PCR) for Sry gene (Y-chromosome-specific marker) was used to evaluate the survival of transplanted xenogenic BMSCs. The expression of Sry gene was clearly identified in the lumbar spines of all the 16 rabbits in the xenogenic BMSCs + CRM group at 1-6 months postimplantation. Serial plain radiographs showed gradual resorption of CRM; however, it was difficult to clearly identify the presence of new bone formation due to the radiopacity of the remaining CRM. Histologically, mature lamellar and woven bone with osteoblasts and osteocytes were identified in all eight rabbits in the xenogenic BMSCs + CRM group at 4 and 6 months postimplantation, but in none of the eight rabbits at 1 and 2 months postimplantation. None of CRM alone group showed new bone formation at 1-6 months postimplantation. Mild-to-moderate infiltration of inflammatory cells was identified around the CRM carriers in both the groups. No post-operative wound infection was found in either group. Our results indicate that xenogenic BMSCs loaded onto CRM survive and generate new bone formation when placed into the posterolateral lumbar spine of rabbits without immunosuppression. To determine if a solid fusion can be achieved with such techniques, further studies are needed to investigate the appropriate dose of xenogenic BMSCs, amounts of CRM, and the requisite incubation time.

Cystic fibrous dysplasia in the long bone.

Prominent osteolysis associated with "ground glass" density of fibrous dysplasia may indicate cystic change or sarcomatous transformation. This complication has been reported only sporadically in the long bones. This article presents clinical, radiographic, and pathologic findings, and outcome of simple curettage and bone graft observed in a series of 8 patients with prominent cystic fibrous dysplasia of the long bone. Magnetic resonance imaging features provide a basis for separation of benign cystic change from malignant transformation. However, biopsy is necessary to distinguish nonspecific cystic degeneration from secondary aneurysmal bone cyst. Simple curettage with allo-chip-bone graft is an effective treatment for cystic fibrous dysplasia.

Gastric cancer acrometastases to all digits of one hand following closed intramedullary nailing.

Metastatic malignant tumor of the hand is unusual and the most common site of the primary cancer is lung. Acrometastases to the phalanges of the hand usually involve a single bone, while those proximal to the phalanges often involve multiple bones. Metastasis to the hand from gastrointestinal cancer, particularly from gastric cancer, is extremely rare. To our knowledge, only five cases have been reported in the literature to date and there has been no reported case following closed intramedullary nailing for metastatic diaphyseal fracture of an ipsilateral long bone. We present a very unusual case of gastric cancer, which metastasized to all fingertips of the ipsilateral hand after closed interlocking intramedullary nailing of a pathologic fracture of the humerus.