Association between radioulnar impingement and salvage surgical procedures of the distal radioulnar joint: influence of confounding variables.

We conducted an ambispective cohort study to assess the association between symptomatic radioulnar impingement syndrome (SRUIS) and distal radioulnar joint (DRUJ) salvage surgery to examine the influence of confounders on the final effect. The outcome variable was the incidence of SRUIS and the exposure variable was the surgical procedure. Seventy-two patients with median age of 48 years (IQR 25-78) were examined using bivariate and logistic regression multivariate analyses, and confounders were analysed in 15 multivariate models. Overall, SRUIS occurred in 21 patients (29%). Bivariate analysis showed a significant association between SRUIS and type of surgical procedure, observed in 71% after Sauvé-Kapandji, 50% after Bowers and 15% after Darrach procedure. When adjusted for age, aetiology and previous surgery, the significant association disappeared. Confounding is an important factor when accounting for SRUIS after DRUJ salvage surgery. The risk of SRUIS did not depend on the procedure, but rather on patient's age, aetiology and previous surgery.Level of evidence: II.

Extensor Pollicis Brevis Transosseous Tenodesis Technique for Treatment of Acquired Metacarpophalangeal Hyperextension Deformity of the Thumb: A Preliminary Report.

SUMMARY: Hyperextension deformity of the metacarpophalangeal joint of the thumb causes pain and loss of function. Although many treatments have been proposed, none of them are universally accepted as ideal. The authors report a study of 12 symptomatic hyperextension deformities of the thumb metacarpophalangeal joint in 10 patients who underwent surgical correction. The purpose of this study was to describe a new technique of tenodesis of the thumb metacarpophalangeal joint using the extensor pollicis brevis tendon. The technique consists of extensor pollicis brevis tenotomy at the wrist and tendon transfer through two bone tunnels to the palmar aspect of the metacarpophalangeal joint before metacarpal fixation with a flexor tenodesis effect. Correction of hyperextension and range of motion were assessed. Functional changes were evaluated by Quick Disabilities of the Arm, Shoulder, and Hand score, pain visual analogue scale, Kapandji opposition scheme, and pinch strength. The Wilcoxon test was used for statistical analysis. Mean preoperative and postoperative metacarpophalangeal joint hyperextension deformities were +50.83 ± 5.57 degrees and -17.91 ± 7.82 degrees, respectively. Thumb opposition improved by one point on Kapandji's scheme. Mean perceived pain decreased from 7.66 to 1.16. On average, the Quick Disabilities of the Arm, Shoulder, and Hand score was reduced by 34.4 points and pinch strength increased by 50.42 percent. The authors found that extensor pollicis brevis transosseous tenodesis is a safe and minimally invasive method for successfully correcting the functionality and cosmetic appearance of metacarpophalangeal joint hyperextension deformities in posttraumatic and trapeziometacarpal osteoarthritis cases. The patients retained functional active flexion, even in deformities greater than 40 degrees. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Modification of intra-carpal tunnel pressure after Z-lengthening of the transverse carpal ligament.

Background Flexor retinaculum reconstruction techniques or simply Flexor Retinaculum Z-lengthening have been proposed to preserve Flexor Retinaculum continuity after carpal tunnel release. Their effectiveness is based solely on symptom relief. There has been no analysis of the effects on intra-carpal tunnel pressure of Flexor Retinaculum-lengthening techniques. Objective was to compare intra-carpal tunnel pressure outcomes between complete division and Z-lengthening of the Retinaculum in a cadaveric model of carpal tunnel release. Methods Experimental study of carpal tunnel pressure after surgical Flexor Retinaculum modification in 10 fresh-frozen forearm and hand cadaveric specimens. The Kyphon™ Balloon Kyphoplasty system was used to measure the pressure before and after infusing 1, 2, 3, 4 and 5 ml of saline solution when untreated (Flexor Retinaculum continuity stage I), when Z-lengthened (Flexor Retinaculum continuity stage II), and after complete Flexor Retinaculum division (Flexor Retinaculum continuity stage III). Finding Intra-carpal tunnel pressure increased with larger volume of infused saline solution, although mean pressures were lower after Z lengthening or complete division of the Retinaculum than at baseline. Analysis of linear regression coefficients indicated significant differences as a function of FR continuity stage (F(2,18) = 18.38, p < 0.001), while the Bonferroni test revealed significant differences in slopes between stages I and III (p = 0.003), between stages I and II (p < 0.02), but not between stages II and III (p > 0.05). Interpretation The effectiveness of carpal tunnel release and the reduction in intra-carpal tunnel pressures obtained by Z-lengthening of the FR were similar to those observed after its complete division, while preserving FR continuity.

Trapeziectomy With Ligament Reconstruction and Tendon Interposition Versus a Trapeziometacarpal Prosthesis for the Treatment of Thumb Basal Joint Osteoarthritis.

Numerous surgical procedures have been described to treat trapeziometacarpal osteoarthritis, but no approach is currently considered superior. Good long-term outcomes have been reported with multiple procedures. No studies have been published comparing outcomes of the Arpe joint replacement (Biomet, Valence, France) with those of ligament reconstruction and tendon interposition (LRTI) using the Burton-Pellegrini technique. The study objective was to compare clinical outcomes between these techniques. Sixty-five patients with Eaton stage III osteoarthritis of the thumb were included in this retrospective follow-up study. Patients were assigned to LRTI (LRTI group) or total joint replacement (Arpe group) and were followed for a mean of 4.8 years. The LRTI group included 34 patients and the Arpe group included 31. Clinical outcome variables were determined preoperatively and every 6 months postoperatively. Pain relief and functional improvement were similar between groups. Pinch strength and range of motion were superior in the Arpe group. Metacarpophalangeal hyperextension appeared to be prevented in the Arpe group but increased over the follow-up period in the LRTI group. However, the complication rate was higher in the Arpe group. Arthroplasty with the Arpe prosthesis can be considered in selected patients who require greater strength and range of motion, although it has been associated with a higher complications rate. [Orthopedics. 2017; 40(4):e681-e686.].

Evaluación clínico radiográfica de una serie de 18 carpectomías de la primera hilera / Functional and radiographic outcomes following proximal row carpectomy in 18 patients

Objetivos: Analizar los resultados funcionales y grado de satisfacción de la carpectomía en una serie de 18 pacientes. Material y métodos: Estudio retrospectivo de una serie de 18 pacientes sometidos a una carpectomía (4-SNAC, 6-SLAC, 5-Kiembock, 1-pseudoartrosis de escafoides, 1-Preisser, y 1-luxación perilunar del carpo crónica), seguimiento medio de 34 meses. Se realizó una evaluación clínica mediante Mayo Wrist Score, Quick DASH, EVA, rango de movilidad, grado de satisfacción; y una valoración de los cambios radiográficos. Resultados: Tras la intervención el dolor preoperatorio mejora en 4,13 puntos, y la puntuación del Quick Dash se reduce en 39,41. El rango de movilidad medio es de 38º de flexión, 46º de extensión, 11º de desviación radial y 22º de desviación cubital. La fuerza de prensión media fue de 33.2 kg. Existen diferencias significativas entre el EVA y Quick DASH (p<0.001), además de una correlación positiva entre la edad y el dolor postoperatorio. Conclusiones: La carpectomía es un procedimiento con pocas complicaciones, que proporciona resultados de movilidad, mejoría del dolor y fuerza superiores a los criterios funcionales de Palmer. Hemos observado los mejores resultados en mujeres y pacientes de mayor edad. La aplicación de un colgajo de interposición no evita una degeneración radiográfica

Objectives: To analyze functional outcomes and satisfaction in a series of 18 carpectomies. Materials and Methods: Retrospective study of a series of 18 cases who underwent proximal row carpectomy (4-SNAC, 6-SLAC, 5 Kienböck, 1-scaphoid nonunion, 1-Preisser, and 1-perilunar chronic carpal dislocation), mean follow- up of 34 months. Clinical evaluation through Mayo Wrist Score, Quick DASH, VAS, range of motion, degree of satisfaction; and an assessment of radiographic changes. Results: Preoperative pain improved 4.13 points, and Quick Dash score was reduced 39.41 points. The range of motion average was: flexion 38º , extension 46 º, 11 º 22 º radial and ulnar deviation. The mean grip strength was 33.2 kg after surgery. There were signifi cant differences between preoperative VAS and Quick DASH and postoperative scores (p <0.001). A positive correlation between age and postoperative pain was found. Conclusions. The carpectomy is a procedure with low complication rate, which preserve funtional mobility and grip strength acording to Palmer’s criteria, and provides sustantial pain improvement. We observed the best results in women and older patients. The flap interposition doesn't prevent radiographic degeneration

Sauvé-Kapandji and reverse Sauvé-Kapandji procedures for treating chronic longitudinal radioulnar dissociation with capitellum fracture.

Almost all reported cases of longitudinal radioulnar dissociation have involved fracture of the radial head, rupture of the interosseous membrane, and disruption of the distal radioulnar joint, although unusual patterns of Essex-Lopresti injury have also been described. To our knowledge, this is the first report of a chronic Essex-Lopresti variant including fracture of the capitellum. A displaced capitellum fracture must alert to the possibility of longitudinal radioulnar dissociation, even without concomitant radial head fracture or symptoms at the forearm and ulnar wrist. Successful mid-term results can be achieved by treating malunion of humeral condyle and proximal migration of the radius with simultaneous Sauvé-Kapandji procedure at the wrist and reverse Sauvé-Kapandji at the elbow.

Comparative review of vertebroplasty and kyphoplasty.

The aim of this review is to compare the effectiveness of percutaneous vertebroplasty and kyphoplasty to treat pain and improve functional outcome from vertebral fractures secondary to osteoporosis and tumor conditions. In 2009, two open randomized controlled trials published in the New England Journal of Medicine questioned the value of vertebroplasty in treating vertebral compression fractures. Nevertheless, the practice of physicians treating these conditions has barely changed. The objective of this review is to try to clarify the most important issues, based on our own experience and the reported evidence about both techniques, and to guide towards the most appropriate choice of treatment of vertebral fractures, although many questions still remain unanswered.

Rupture of extensor tendon secondary to previously undiagnosed Kienböck disease.

We report three patients with an unusual pattern of rupture of the extensor tendon. All were found to have previously undiagnosed Kienböck disease. Radiographic study of the wrist is essential before treating any closed rupture of an extensor tendon. Lesions may be progressive and extend to adjacent tendons and should be treated urgently.

Rupture of small finger flexor tendons secondary to asymptomatic nonunion of the hamate hook.

The incidence of fractures of the hamate hook (hamulus) has been reported to be between 2% and 4% of all carpal fractures. Untreated hamulus nonunion can cause attritional rupture of the ulnar digits' flexor digitorum profundum tendons. Rupture of flexor tendons due to nonunion of the hook of the hamate is an uncommon injury. Most surgeons treat the tendon lesion by a graft, transfer of the superficial flexor of the ring finger, or terminolateral suture of the distal stump of the deep flexor tendon of the little finger to the deep flexor tendon of the ring finger. This article reports a case of a 52-year-old right-handed man who presented with weakness of grip and loss of active flexion of both distal and proximal interphalangeal joints of the right small finger lasting 2 weeks due to grip strength while working. The clinical history and the physical examination were dissonant, and a computed tomography scan revealed a nonunion of the hamulus. Intraoperatively, the nonunion of the hamate hook was identified and the bony ossicle excised. The flexor digitorum profundus and superficialis to the small finger were both ruptured. The flexor digitorum profundus tendon was repaired with a termino-terminal suture. The patient returned to work within 3 months without restriction. Six months postoperatively, the patient had no pain and achieved full active flexion of the small finger.

Oxidized regenerated cellulose does not prevent the formation of experimental postoperative perineural fibrosis assessed by digital analysis.

INTRODUCTION: It is difficult to prevent and treat intra- and peri-neural fibrosis after peripheral nerve surgery. Many authors have attempted to develop and verify the effectiveness of substances to decrease the formation of adherences in different tissues. MATERIAL AND METHODS: this study aimed to assess the effectiveness of a barrier of oxidized regenerated cellulose (ORC) to reduce adherence and perineural fibrosis in a model of surgical perineural induced fibrosis in rat sciatic nerve in 40 rats. After tissue aggression, the nerve of the right rear limb was wrapped in ORC and the left limb served as control. Animals were killed at 3 and 6 weeks, and nerves and muscle mass were extracted en bloc. Connective tissue was quantified by conventional histopathological techniques and Fibrosis HR(R) automatic image analysis. RESULTS: No significant differences were found in intra- or peri-neural induced fibrosis between control nerves (6.88% and 8.90%, respectively) and treated nerves (6.57% and 9.90%) at 3 or 6 weeks (10.41% and 12.51% in controls; 11.85% and 15.72% in treated nerves). Inflammatory phenomena and granulomatous reactions were more frequent in treated animals. CONCLUSIONS: ORC conferred no advantage in prevention of nerve fibrosis and might have interfered with healing.

Ischemic contracture of deep posterior compartment of the leg following isolated ankle fracture.

Compartment syndromes and ischemic contractures after ankle fractures are exceedingly rare. We report a case in which a Weber type-C ankle fracture resulted in an unrecognized compartment syndrome and ischemic contracture of deep posterior compartment of the leg. Six weeks after injury, the patient had an obvious deformity and clawing of the toes. The deformities were corrected by lengthening the flexor hallucis longus and the flexor digitorum longus. Full correction of all clawed toes was evident. A deep posterior compartment syndrome may follow an ankle fracture and should be considered in any patient with unrelenting pain in the immediate postoperative period.