Resurfacing the distal radioulnar joint with rib perichondrium-a novel method.

Background Osteoarthritis in the distal radioulnar joint (DRUJ) is a challenging condition with few really reliable surgical options, particularly in young individuals. Traditional methods as hemiresection, the Darrach procedure, and the Sauvé-Kapandji procedure have less favorable results in the nonrheumatoid patient. The results after implant arthroplasty have improved, but long-term results are yet to be presented before implant arthroplasty can be recommended to young individuals with osteoarthritis in the DRUJ. An alternative method to treat osteoarthritic joints is surface replacement with free costal perichondrium. The technique has been used since the 1970s for other joints. Case Description We adapted the method and used it in two female patients (37 and 38 years old) with nontraumatic osteoarthritis in the DRUJ. Both patients had severe pain and were unable to work. The eroded joint surfaces were resected down to bleeding subchondral cortex. Perichondrium from the seventh rib was osteo-sutured and glued to the ulnar head and the sigmoid notch. Results The maximum follow-up-time in this retrospective review is 25 months. Our short-term results are encouraging in terms of pain relief, motion, grip strength, and return to work. The first patient had an excellent result and was completely normalized. The second patient has improved significantly and experiences only slight pain on heavy lifting and rotational load. Clinical Relevance Free costal perichondrium may be a useful alternative for treating osteoarthritis in the DRUJ, especially in young individuals. The option for a later implant arthroplasty is preserved because most of the anatomy of the joint and all the soft tissue stabilizers are intact. Level of Evidence Therapeutic IV, Case series.

Ectopic bone formation after medial femoral condyle graft to scaphoid nonunion.

Free vascularized bone graft from the medial femoral condyle has been described as a superior method for treatment of recalcitrant scaphoid nonunion with proximal pole avascularity and humpback deformity. Few complications and high union rates have been reported. In a series of three patients we describe an undesired volar ossification as a potential complication of the method. The risk of developing the ectopic bone formation can be minimized if the surgeon is aware of the strong osteogenic capacity of the periosteum. Meticulous dissection of the vascular bundle to the graft is mandatory to avoid the complication. Caution is warranted so as not to leave a periosteal sleeve under the vessels at the margin of the graft.

Multiple brown tumours of the upper extremity in a patient with secondary hyperparathyroidism as a result of chronic renal failure.

A man with chronic renal failure was referred to the hand clinic because of massive osteolytic tumours in his right arm. Secondary hyperparathyroidism and brown tumours were suggested, and he was treated by subtotal parathyroidectomy. Rapid reduction of the vast tumours was noted postoperatively.

Brain activation due to postoperative pain from the right hand measured with regional cerebral blood flow using positron emission tomography.

Background Brain activation resulting from acute postoperative pain has to our knowledge not previously been studied using positron emission tomography, except from one case study. The aim of this study was to monitor activation in brain sensory pathways during acute pain after surgery of the hand. A secondary aim was to compare brain activation in clinical postoperative pain to that previously reported, by the same research group, for a model of experimental pain from the same body area. Increase in regional cerebral blood flow (rCBF) is presumed to indicate neuronal activation and decrease in blood flow decreased neuronal firing. An increase in blood flow in a brain region may represent stimulatory activity as well as inhibitory. Methods Brain activity was measured during clinical postoperative pain and a pain free state in six patients with positron emission tomography (PET) as changes in regional cerebral blood flow (rCBF). rCBF during pain from surgery of the right thumb base was compared with a pain free state achieved by regional anaesthesia of the painful area. Results In postoperative pain, patients had a significantly higher CBF in the contralateral/primary and secondary somatosensory cortices as well as in the contralateral motor cortex compared to the pain free stat during local regional anaesthesia. Relatively lower rCBF during the pain state was observed in clusters in the contralateral tertiary sensory cortex, ipsilateral and contralateral secondary visual cortex, prelimbic cortex, ipsilateral prefrontal as well as anterior cingulate cortex and contralateral secondary somatosensory cortex. The increased rCBF in primary and somatosensory cortices probably correspond to pain localizing processing. We also compared the findings in cerebral activation patterns of the postoperative pain state as described above, with the results from a previously published study by the same research group, using an experimental pain model when pain was inflicted with application of mustard oil in the same location, the thumb base region of the right hand. Since no formal statistical analysis was carried out between the two studies, the data are not very strong, but the differences reported were obvious when comparing the two situations. The comparison gave the following outcome: Digit activation occurred in identical sensory brain areas, i.e. primary and secondary somatosensory cortices, as compared to the changes in this study, supporting that pain localization processes use similar sensory pathways in a nociceptive acute experimental pain model, and in clinical acute postoperative nociceptive pain. Dissimilarities were observed between the models in activation of brain areas coding of the emotional pain qualities, indicating some differences between the experimental and "real" acute nociceptive pain. Conclusion We have reported a distinct cerebral activation pattern produced by acute postoperative pain following hand surgery. The findings were compared to data obtained in a previously published report of the cerebral activation pattern from an acute experimental pain model in volunteers. We found similarities as well as some differences in the activation pattern between the two situations.

Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial.

BACKGROUND: Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment. METHODS: During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically. RESULTS: All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group. CONCLUSIONS: This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.

Comparison of direct and indirect costs of internal fixation and cast treatment in acute scaphoid fractures: a randomized trial involving 52 patients.

BACKGROUND: The most cost-effective treatment of scaphoid fractures has not yet been determined. METHODS: In a prospective trial, 52 employed or selfemployed patients with scaphoid fractures were randomized to closed (cast) or surgical treatment. RESULTS: There were 3 complications in the surgical group and 1 in the cast group. Median time off work was numerically but not statistically significantly greater after cast than after surgery (74/39 days). Manual workers (manuals) had a longer time away from work than non-manual employees/individuals who were selfemployed (non-manuals; median 84 days and 16 days, respectively; p < 0.001) and they had a longer time off work after cast than after surgery (median 100 days and 61 days; p = 0.03). Hospital costs were lower after cast than after surgery (p < 0.001). Work disability costs were numerically but not statistically significantly higher after cast than after surgery, and similarly, the total costs were lower after cast than after surgery. Work disability costs and total costs were higher in manuals than in non-manuals (p < 0.001). Non-manuals had lower total costs after cast than after surgery (p = 0.05). INTERPRETATION: There was a longer period of absence from work after cast than after surgery in manuals, but not in non-manuals. In non-manuals, total costs were lower after cast than after surgery. Socioeconomic classification had a greater influence on cost than mode of treatment.

Patient-rating of long term results of silicone implant arthroplasty of the scaphoid.

Thirty-two patients had silicone implant arthroplasty of the scaphoid in our unit between 1974-1988. Ten years later eight had had their implants removed because they had failed. Twenty-four of the 32 were reviewed at an intermediate clinical follow up examination between 1988-89 and 21 by patient rated wrist evaluation 10 years later. Grip strength compared to the non-injured hand varied between 38% and 136% (mean (SD) 78 (25)%). Nine of the 24 wrists showed no signs of bone cysts, while 15 had intraosseous cysts of various sizes. Patient-rated evaluation gave a median subjective long term overall wrist score of 25, a pain score of 27, and a function score of 22 on a scale from 0 (best) to 100 (worst). Nine out of 21 patients had little or no pain, and 13 out of 21 had total scores of under 25. Many of these patients reported good subjective benefit from silicone scaphoid arthroplasty.