Clinical outcomes of extensor indicis proprius tendon transfer for extensor pollicis longus tendon rupture.

LEVEL OF EVIDENCE: IV.

Surgical Treatment for Patients with Post-traumatic Flexion Contracture of Proximal Interphalangeal Joint: Analysis of Various Affecting Factors.

Background: A flexion contracture (FC) of the proximal interphalangeal (PIP) joint can have a profound negative influence on daily activity. The outcomes of surgical release of the PIP joint in literature are based on small sample size studies done several decades ago. The aim of this study is to report the outcomes of surgical treatment for post-traumatic FC of the PIP joint and to identify factors that affect these outcomes. Methods: This single institute retrospective study included patients from 2000 to 2020. We only included patients with post-traumatic FC of the PIP joint. We evaluated the demographic characteristics, cause of FC, surgical approaches and the various procedures conducted. We surveyed postoperative complications. During the study period, we asked about their current symptoms and evaluated their operative outcomes as excellent, good, fair or poor through the phone. Results: The average FC recovery angle was 37.3°. The small finger was the most affected, and the most common cause of FC was a tendon laceration. The volar plate complex release was the most frequently conducted procedure. The FC improvement was positively correlated to the degree of preoperative FC. The more severe preoperative flexion-extension arc was presented, the more FC recovery was achieved after operation. Patients who underwent multiple procedures had a higher degree of preoperative FC, and better correction was achieved with multiple procedures than with a single procedure. The most critical complication was recurrence. Conclusions: We were able to obtain average 37.3° of extension by surgical treatment. The more severe the FC presented before surgery, the greater the need for multiple procedures, however, this resulted in a significant increase in joint extension. Nevertheless, caution should be exercised regarding recurrence and could occur even with an experienced surgeon. Level of Evidence: Level IV (Therapeutic).

Effect of Repetitive Corticosteroid Injection on Tennis Elbow Surgery.

BACKGROUND: Lateral epicondylitis is a chronic tendinopathy of humeral origin of the common extensor tendon. Most patients show improvement after nonoperative treatment. However, 4% to 11% of patients require surgical treatment. Although corticosteroid injection is one of the most commonly applied nonoperative treatment methods, to the authors' knowledge, no study has reported the effect of the number of preoperative corticosteroid injections on the final postoperative outcome. Thus, the objective of this study was to determine the effect of the number of preoperative corticosteroid injections on postoperative clinical outcomes. HYPOTHESIS: The number of corticosteroid injections before surgical treatment does not affect postoperative clinical outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: As a retrospective review, from January 2007 to December 2019, a total of 99 patients who had undergone surgical treatment of lateral epicondylitis with a modified Nirschl technique were enrolled. The number of preoperative corticosteroid injections was investigated by medical record review. Outcome measurements included visual analog pain scale; Disabilities of the Arm, Shoulder and Hand (DASH) score; Mayo Elbow Performance Score; and the Nirschl and Pettrone grade. Grip power and wrist extension power were measured using a digital dynamometer. RESULTS: A total of 99 patients were included in this study. The mean total number of injections of patients was 4.37 ± 2.46 times (range, 1-15 times). Total duration of nonoperative treatment before surgery was 25.4 ± 20.5 months (range, 4-124.8 months). The mean postoperative follow-up period was 42.8 ± 28.0 months (range, 12-110 months). For all injection numbers, clinical scores showed significant improvement in visual analog pain scale, DASH score, Mayo elbow score, grip power, and wrist extension power after surgery. Regression analysis showed that the degree of improvement according to the injection number was not statistically significant. The Nirschl and Pettrone grade was excellent in 82 (82.8%) patients, good in 14 (14.1%) patients, fair in 2 (2%) patient, and failure in 1 (1%) patient. CONCLUSION: The number of preoperative corticosteroid injections does not appear to affect postoperative clinical outcomes of patients with lateral epicondylitis who undergo surgery with a modified Nirschl technique.

Incidence and pattern of concurrent capitellum fracture associated with radial head and neck fractures.

BACKGROUND: Radial head and neck fracture is a common fracture around the elbow. It is mostly caused by axial or valgus loading after a fall in elbow extension and forearm pronation. When a radial head and neck fracture occurs, the capitellum collides with the radial head and experiences a shear force, leading to capitellum fracture. The primary aim of this study was to evaluate the incidence of concurrent capitellum fracture and analyze its patterns among patients treated for radial head and neck fractures based on computed tomography. Secondary aim is to determine factors associated with concurrent capitellum fractures. HYPOTHESIS: Capitellum fractures are more common than expected in radial head and neck fractures and show a consistent pattern. With the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture will be shown. METHODS: A total of 101 patients treated surgically (27 patients) or non-surgically (74 patients) for radial head and neck fractures from January 2017 to December 2020 were retrospectively analyzed. Initial computed tomography was reviewed to identify concurrent capitellum fractures. A fracture was diagnosed when the bone continuity was lost in two consecutive images in any one of the three directions of computed tomography scan images. Seventeen patients with capitellum fractures were classified as group 1 and 84 patients without capitellum fractures as group 2. Each group of patients was assessed using Mason classification, whether fracture extended to the radial neck or not, fracture location, and treatment method. To determine the fracture location, radial head was trisected using three anatomical landmarks: safe zone, posteromedial zone, and anteromedial zone. And it was determined as the location where the fracture was most comminuted. RESULTS: The average age of the 101 patients was 44.6 years old. There were 54 (53.5%) males and 47 (46.5%) females. Capitellum fracture was accompanied in 17 cases. Its incidence was 16.8%. The rate of accompanying capitellum fracture was 9.5% (6/63) for Mason type 1, 25.0% (6/24) for Mason type 2, and 41.7% (5/12) for Mason type 3. The ratio of radial neck extension of fracture was significantly higher in group 2. There was no isolated radial neck fracture in group 1. However, there were 33 in group 2. After eliminating isolated radial neck fracture patients, significantly more fractures were located in the safety zone in group 1. Group 1 had a significantly higher rate of surgical treatment than group 2 (52.9% (9/17) vs. 21.4% (18/84) p=0.007). CONCLUSION: For radial head and neck fractures, the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture. When the fracture extended to the radial neck, the comorbidity of the capitellum fracture was decreased. Among radial head fractures, when the fracture was located in the safe zone, the comorbidity of capitellum fracture was increased. The rate of surgical treatment was higher in radial head and neck fracture patients with concurrent capitellum fractures. LEVEL OF EVIDENCE: IV; diagnostic study.

The Association of Low Skeletal Muscle Mass with Complex Distal Radius Fracture.

Objectives: Sarcopenia is a skeletal muscle loss disease with adverse outcomes, including falls, mortality, and cardiovascular disease (CVD) in older patients. Distal radius fractures (DRF), common in older people, are strongly related to falls. We aimed to investigate the correlation between DRF and low skeletal muscle mass, which strongly correlated to sarcopenia. Methods: We performed a retrospective review of data from patients diagnosed with or without DRF in our institute between 2015 and 2020. Finally, after propensity score matching, data from 115 patients with and 115 patients without DRF were used for analyses. Multivariate logistic regression analysis was performed for sex, body mass index (BMI), the presence of low skeletal muscle mass, bone quality measured by dual-energy X-ray absorptiometry (DXA), and comorbidities (diabetes mellitus, CVD). Results: We found that female sex (odds ratio = 3.435, p = 0.015), CVD (odds ratio = 5.431, p < 0.001) and low skeletal muscle mass (odds ratio = 8.062, p = 0.001) were significant predictors for DRF. BMI and osteoporosis were not statistically significantly related to DRF. Conclusions: Women with low skeletal muscle mass and CVD may be more responsible for DRF than osteoporosis.

Substance P Inhibitor Promotes Tendon Healing in a Collagenase-Induced Rat Model of Tendinopathy.

BACKGROUND: The substance P-neurokinin 1 receptor pathway has been proposed as a therapeutic target for tendinopathy. However, there is a lack of evidence regarding its practical applications. PURPOSE: To investigate the therapeutic effects of substance P inhibitor (SPI) on inflamed tenocytes in vitro and in a collagenase-induced rat model of tendinopathy in vivo. STUDY DESIGN: Controlled laboratory study. METHODS: We analyzed the mRNA levels of inflammatory (cyclooxygenase [COX]-2 and interleukin [IL]-6) and tenogenic (Mohawk and scleraxis [SCX]) markers using reverse transcription quantitative polymerase chain reaction to demonstrate the effects of SPI on lipopolysaccharide-treated (inflamed) tenocytes. A collagenase-induced rat model of tendinopathy was created by injecting 20 µL of collagenase into the Achilles tendon. A behavior test using an incapacitance apparatus was performed to detect changes in postural equilibrium. The tendon specimens were obtained, and their gross findings were examined. The tensile strength was measured, and histopathological evaluation was performed (hematoxylin and eosin, alcian blue, and immunohistochemical staining). RESULTS: The mRNA levels of COX-2, IL-6, Mohawk, and SCX differed significantly between inflamed tenocytes and those treated with SPI. SPI improved the weight burden in a rat model of tendinopathy in a behavioral test. The specimens of the SPI group showed a normal tendon-like appearance. In the biomechanical test, the tensile strength of the SPI group was significantly greater than that of the tendinopathy group. In the histopathological evaluation, the degree of collagen matrix breakdown was mild in the SPI group. In alcian blue staining, only small focal depositions of proteoglycans and glycosaminoglycans were observed in the SPI group. The SPI group showed decreased expression of IL-6 and neurokinin 1 receptor. CONCLUSION: This study suggests that SPI has therapeutic effects on tendon healing and restoration in a collagenase-induced rat model of tendinopathy. CLINICAL RELEVANCE: SPI is a promising agent for tendinopathy in humans.

Radial nerve entrapment after fracture of the supracondylar humerus: a rare case of a 6-year-old.

Supracondylar fracture of the humerus is one of the most common fractures seen in children, and posteromedial displacement of the distal fragment in extension-type supracondylar humerus fractures can cause injury to the radial nerve. A 6-year old girl who presented with symptoms of radial nerve injury after a supracondylar fracture of the right humerus with complete posteromedial displacement of the distal fragment (Gartland type III) underwent surgery where closed reduction and percutaneous pinning was performed. The patient was routinely followed up and at 6 months postoperatively no neurological improvement was seen. Exploratory surgery revealed complete discontinuation of the radial nerve at the fracture site and entrapment of the nerve stumps in healed bone callus. A gap of 2 cm was observed between nerve stumps, and sural nerve cable grafting was performed with good results. If neurological symptoms do not improve over time, appropriate differential diagnosis and, if necessary, exploratory surgery should be considered. Despite limited reports and their conflicting outcomes, sural nerve cable grafting could be a useful option to bridge the gap of discontinued nerve injury. Level of Evidence: Level IV, Case Report.

Factors affecting contralateral wrist surgery after one carpal tunnel release in bilateral carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) can be bilateral, with varying incidence. Carpal tunnel release (CTR) in one wrist may relieve the symptoms of the contralateral wrist, avoiding the need for second surgery; conversely, the symptoms may persist or worsen, requiring contralateral surgery in some cases. The present study investigated whether surgical treatment was finally required for the non-operated CTS wrist, and in what cases non-operative treatment was possible. We compared baseline characteristics, risk factors and electrodiagnostic data between CTS patients who underwent only unilateral CTR and those who subsequently underwent bilateral surgery at various time intervals. This single-center retrospective study included 188 patients with bilateral CTS managed between 2010 and 2020; 137 patients (group 1, 73%) underwent only unilateral CTR, and 51 (group 2, 27%) subsequently underwent contralateral CTR. In group 1, contralateral CTS symptoms were assessed in 4 categories and compared to the presenting symptoms in the index wrist. There were no significant differences in age, gender, preoperative symptom duration, body status, addictive behavior, electrodiagnostic study or comorbidities, other than a higher rate of dialysis in group 2. The contralateral wrist showed partial or complete symptom relief in 57% of patients undergoing unilateral CTR. High BMI and history of diabetes were risk factors for persistent severe CTS or subsequent contralateral CTR.

Complications associated with open reduction and internal fixation for adult distal humerus fractures: a multicenter retrospective study.

BACKGROUND: Open reduction and plate fixation are the preferred treatment options for most distal humerus fractures in adults. However, it is often challenging for orthopedic surgeons because of the complex anatomy and the difficulty in achieving stable fixation. This multicenter study aimed to analyze the complication types and rates of patients with distal humerus fractures treated with open reduction and plate fixation, and compare the results with those found in the literature. In addition, we describe the clinical outcomes. METHODS: This retrospective multicenter study was conducted between September 2001 and March 2021 and included data from four hospitals. In total, 349 elbows underwent surgical treatment at these hospitals during the study period. Patients > 17 years of age who were treated by plate fixation were included, and patients who were treated by other fixation methods were excluded. A total of 170 patients were included in the study. The following types of complications were investigated: (1) nerve related; (2) fixation and instrument related; (3) osteosynthesis related; (4) infection; and (5) others. RESULTS: The following complications were found: (1) 26 (15.3%) cases of postoperative ulnar nerve symptoms; 4 (2.4%) of postoperative radial nerve symptoms; (2) one (0.6%) case of screw joint penetration and screw loosening; and eight (4.7%) cases of hardware removal due to instrument skin irritation; (3) seven (4.1%) cases of nonunion; (4) two (1.2%) and four (2.2%) cases of superficial and deep infection, respectively, and seven (3.9%) cases of wound complication; and (5) 37 (21.8%) cases of heterotrophic ossification, 79 (46.5%) cases of elbow stiffness (did not achieve functional range of motion [ROM]), and 41 (24.1%) cases of osteoarthritis over Broberg and Morrey Grade I. Paradoxically, the postoperative ulnar nerve symptoms were more frequent in the prophylactic ulnar nerve anterior transposition group. However, this difference was not statistically significant (p = 0.086). The mean ROM was 123.5° flexion to 9.5° extension. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 14.5 ± 15.6. CONCLUSIONS: Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. Surgeons must be vigilant about ulnar nerve complications. Level of Evidence Therapeutic Level III.

Characteristics of surgically treated Guyon canal syndrome: A multicenter retrospective study.

Guyon canal (GC) syndrome is a rare peripheral neuropathy involving the distal part of the ulnar nerve. Several causes are associated with GC syndrome, including anatomic variations, space-occupying tumors, and trauma. Because of disease rarity, the only reported studies of GC syndrome are case series with small sample size. We conducted a multicenter study to identify the basic characteristics of patients with surgically treated GC syndrome and the risk factors for the disease. This retrospective multicenter study was conducted between January 2001 and December 2020. We screened 70 patients who underwent GC release surgery by seven hand surgeons at six institutes. A total of 56 patients were included in this study, including 38 patients (67.9%) who underwent isolated GC decompression and 18 (32.1%) who underwent combined peripheral nerve decompression. The mean patient age was 48.4 years (range: 20-89 years), and 40 patients (71.4%) were male. The average preoperative symptom duration was 18.5 months, and most patients were office workers. Ultrasound was positive for GC syndrome in 7/10 patients evaluated, CT in 2/5, MRI in 17/23, and electrodiagnostic studies in 35/44. The most common cause of GC syndrome was tumor (n = 23), followed by idiopathic (n = 17), trauma (n = 12), anatomic variants (n = 3), and inflammation (n = 3). In conclusion, most patients with GC syndrome in this study were male and had symptoms in one wrist. The most common cause of GC syndrome in this study was a tumor, including a ganglion cyst. Level of Evidence: Level IV case series.

Are Outcomes Comparable for Repair of AO/OTA Type 13C1 and Type 13C2 Distal Humeral Fractures Using the Paratricipital Approach?

Background: Studies have reported favorable outcomes using the paratricipital approach for fixation of distal humeral intra-articular fractures. However, literature evaluating the clinical results of the approach remains limited. The objective of this study was to compare clinical outcomes between type 13C2 and type 13C1 distal humeral fractures after open reduction and internal fixation performed using the same approach and same type of plate. Methods: A total of 52 adults with type 13C1 or 13C2 distal humeral fractures were treated surgically at our institution during 2006 to 2018. We retrospectively analyzed data from 29 of these patients (19 with type 13C1 fractures and 10 with 13C2 fractures) who met the inclusion criteria. All subjects were followed for a minimum of 2 years postoperatively. Clinical and radiologic results were analyzed to determine differences in outcomes between the two types of fractures. Clinical results were evaluated using elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. Alignment, fracture union, and presence of posttraumatic arthritis were evaluated radiologically. Results: The patients' mean age was 51 years, and the mean duration of follow-up was 29 months. Mean ROM was 129.5° ± 21.5° in the type 13C1 group and 123.0° ± 20.6° in the 13C2 group (p = 0.20). Mean Q-DASH score was 12.6 ± 11.7 in the 13C1 group and 16.2 ± 19.8 in the 13C2 group (p = 0.60). Mean MEPS was 92.9 ± 8.5 in the 13C1 group and 85.0 ± 14.1 in the 13C2 group (p = 0.09). Carrying angle did not differ significantly between the 13C1 and 13C2 groups. No patient in either group exhibited nonunion or posttraumatic arthritis. Conclusions: Although the paratricipital approach has the disadvantage of limited visualization of articular surfaces, there were no differences in surgical outcomes between type 13C1 and type 13C2 distal humeral fractures after fixation using this approach. Thus, surgeons may need to consider using the paratricipital approach for open reduction and internal fixation of 13C2 distal humeral fractures.

Complete Occlusion of Radial and Ulnar Arteries Following Hand Crush Injury with Multiple Carpometacarpal Joint Fracture-Dislocations.

Multiple dorsal fracture-dislocations of the carpometacarpal joints (CMCJ) occur from very high-energy trauma and are often associated with soft tissue injury or ischaemia. We report a 54-year-old male manual worker and a smoker who presented to the emergency room with history of compression of his right hand in a press machine. Radiographs showed dorsal fracture-dislocations of the scapho-trapezio-trapezoidal and third to fifth CMCJ's. Despite emergent Guyon canal and carpal tunnel release and closed reduction and pinning, skin pallor persisted in all digits. Brachial angiography revealed total occlusion of the radial and ulnar arteries and loss of the palmar arch at the level of the fracture. Heparin and Alprostadil were injected directly. On follow-up angiography three weeks later, the vessels were still occluded and collaterals provided digital circulation. Although digital sensations recovered, cold intolerance and stiffness resulted in a poor functional outcome. Level of Evidence: Level V (Therapeutic).

The inter-and intra-observer reliability of volar angulation measurements in a fifth metacarpal neck fracture.

INTRODUCTION: The fifth metacarpal neck fracture is the most common metacarpal fracture. The palmar angulation from the fracture displacement is critical for determining treatment, yet there is no consensus regarding the angulation measurement method or the surgical cut-off value. This study aimed to identify a reliable measurement method for assessing palmar angulation. We evaluated inter-observer and intra-observer validation of measuring palmar angulation in oblique plain X-ray and computed tomography (CT) sagittal cuts. MATERIALS AND METHODS: We identified surgically treated patients for acute isolated fifth metacarpal neck fracture between January 1, 2008, and December 31, 2020, and obtained preoperative, opposite hand, and final follow-up oblique X-rays and sagittal computed tomography (CT) radiograms. The oblique radiograph was taken with a 45° posteroanterior pronation. The metacarpal neck palmar angulation was measured in the radiograms using the metacarpal neck-shaft center (MNSC) angle and the shaft articular surface (SAS) angle methods by three orthopedic surgeons in two sessions. For the CT radiograms, each measurer selected the sagittal slot at their discretion to measure the angle. The final palmar angulation was the average of six measurements (two sessions, three measurers per session). RESULTS: The study included 51 patients; the average age was 32.5 (range 18-73) years, with 46 men and 5 women. The MNSC angle inter-observer reliability was better than the SAS angle. The MNSC angle inter-observer reliability was better than that of SAS angle. Intraclass coefficients (ICCs) for the MNSC angle demonstrated an excellent inter-observer agreement among the three measurers in the first (0.93) and second (0.88) session compared to ICCs for the SAS angle in the first (0.81) and second (0.87) session. The MNSC angle intra-observer reliability was also better than the SAS angle, with higher ICCs. Preoperative CT radiograms were available for 42 patients. Using CT scans for measurements, in the two sessions, the MNSC angle inter-observer reliability was higher than that of the SAS angle [MNSC: 0.83; SAS: 0.35], second [MSNC: 0.85; SAS: 0.81]. The intra-observer reliability was also better in the MNSC angle. When comparing average value among obtained radiograms, the physiologic angulation of the opposite hand oblique X-ray had the smallest average value, followed by preoperative CT and preoperative oblique radiography. Overall, the SAS angle measurement had a slightly larger angle than the MNSC method in the fractured and non-fractured hand measurements. Finally, a serial comparison of the oblique X-rays (pre-and postoperative, final follow-up, and the opposite hand with closed reduction and internal fixation) indicated that the angulation significantly decreased, and the post-operative values did not differ from the final follow-up X-ray for either method. CONCLUSIONS: The palmar angulation measurement in 45° pronated oblique X-ray using the MNSC angle method had good-to-excellent reliability, with superior results to sagittal CT radiograms. Although the angle is likely overestimated, the MNSC method is reliable for judging the fracture degree and reduction adequacy after surgery compared to the non-fractured hand physiologic angulation.

Substance P, A Promising Therapeutic Target in Musculoskeletal Disorders.

A large number of studies have focused on the role of substance P (SP) and the neurokinin-1 receptor (NK1R) in the pathogenesis of a variety of medical conditions. This review provides an overview of the role of the SP-NK1R pathway in the pathogenesis of musculoskeletal disorders and the evidence for its role as a therapeutic target for these disorders, which are major public health problems in most countries. To summarize, the brief involvement of SP may affect tendon healing in an acute injury setting. SP combined with an adequate conjugate can be a regenerative therapeutic option in osteoarthritis. The NK1R antagonist is a promising agent for tendinopathy, rheumatoid arthritis, and osteoarthritis. Research on the SP-NK1R pathway will be helpful for developing novel drugs for osteoporosis.

Distal interphalangeal Joint Arthrodesis using only Kirschner Wires in small distal Phalanges.

PURPOSE: To report the clinical and radiographic results of arthrodesis of relatively small-sized distal interphalangeal joints (DIPJs) using only K-wire fixation. PATIENTS AND METHODS: Between January 2000 and December 2018 28 arthrodesis in 21 patients (9 males and 12 females with an average age of 52.1 years) with relatively small-sized DIPJs were performed using only K-wires. Data on patient's characteristics, such as age, sex, affected finger, and the number and size of the used k-wires were collected from the medical database. The narrowest diameter of the cortex and medulla of the distal phalanx was measured on preoperative plain radiographs. The time to union and the arthrodesis angle was determined using serial X-ray radiography follow-up. Preoperatively and at the latest follow-up examination, pain using the visual analogue scale (VAS) and the quick DASH score was registered. In addition, complications were investigated. RESULTS: Average follow-up period was 11.4 months. The small finger was mostly affected (n = 12; 42.9 %). The narrowest diameters of the distal phalanx cortex and the medulla measured on preoperative X-ray images were 2.8 mm (SD 0.5) and 1.2 mm (SD 0.4), respectively. Seven fusions were done with use of 1 K-wire, 20 with 2 (71.4 %), and 1 with 3 K-wires. The most common K-wire sizes were 1.1-inch (24 K-wires = 48 %), and 0.9 inch (21 K-wires = 42 %) The preoperative VAS score and quick DASH score improved from 6.1 (range: 0-9) and 25.8 (range: 2-38) to 0.4 (range: 0-2) and 3.4 (range: 0-10.2), respectively. 25 (89.3 %) out of 28 fingers achieved bony union in an average of 96.1 days (range: 58-114) with three non-union. CONCLUSION: Arthrodesis of small DIPJs with K-wire fixation has a high success rate. Therefore, we suggest K-wire fixation as an acceptable alternative for patients with a small phalanx which may be at risk of mismatch with bigger implants. However, concerns remain in terms of fusion delay with K-wire only fixation.

Similar appearance of different multifocal carpal bone destructing disease entities in 3 patients: A case report.

RATIONALE: Several diseases feature tumors, or tumor-mimicking lesions, that further invade the bone and surrounding joints of the wrist region. Here, we describe 3 rare cases of multiple destructed carpal bones and adjacent joints in different disease entities confirmed via pathologic diagnosis. PATIENT CONCERNS: All 3 cases were examined between January 2016 and December 2019. Three patients presented with similar clinical manifestations and radiographic features, with multiple osteolytic lesions in the carpal bones and metacarpal bone base. DIAGNOSES: The 3 cases were diagnosed as diffuse type tenosynovial giant cell tumor, calcifying aponeurotic fibroma, and rheumatoid arthritis. INTERVENTIONS: Separate, experienced radiologist and pathologist took part in the interpretation and compartmentalization of radiographs and pathological findings, respectively. Even magnetic resonance imaging could not achieve a diagnosis; surgical excision was therefore required, with subsequent pathological assessment for treatment and final diagnosis. OUTCOMES: functional outcomes also differed among patients, poorest in rheumatoid arthritis patient. LESSONS: We report 3 rare disease entities, presenting with multifocal osteolytic lesions in the wrist. They all presented with similar clinical manifestations, and the final diagnoses were made via pathological evaluation. Compared with tenosynovial giant cell tumor and calcifying aponeurotic fibroma, rheumatoid arthritis had the poorest outcome.

Anatomic Repair of the Central Slip with Anchor Suture Augmentation for Treatment of Established Boutonniere Deformity.

BACKGROUD: The rupture of the central slip of an extensor tendon of a finger causes a boutonniere (or buttonhole) deformity, characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Currently, there are no standard treatment guidelines for this deformity. This study aimed to report clinical results of surgery to correct chronic boutonniere deformity. METHODS: This retrospective case series was conducted between January 2010 and December 2018 and only 13 patients with trauma-induced chronic deformity were included. After excision of elongated scar tissue, a direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation was conducted. Total active motion was assessed before and after surgery and self-satisfaction scores were collected from phone surveys. RESULTS: All patients presented with Burton stage I deformities defined as supple and passively correctable joints. The initial mean extension lag of the PIP joint (43.5°) was improved by an average of 21.9° at the final follow-up (p < 0.001). The mean hyperextension of the DIP joint averaged 19.2° and improved by 0.8° flexion contracture (p < 0.001). The average total active motion was 220.4° (range, 160°-260°). Based on the Souter's criteria, 69.2% (9/13) of the patients had good results. Only 1 patient reported fair outcome and 23.1% (3/13) reported poor outcome. The average Strickland formula score was 70 (range, 28.6-97.1). In total, 10 patients (77%) had excellent or good results. Of 10 patients contacted by phone, self-reported satisfaction score was very satisfied in 2, satisfied in 3, average in 3, poor in 1, and very poor in 1. Three patients reported a relapse of the deformity during range of motion exercises, 1 of whom underwent revision surgery. One patient complained of PIP joint flexion limitation, and 2 complained of DIP joint flexion limitation at final follow-up. CONCLUSIONS: In chronic boutonniere deformity, central slip reconstruction with anchor suture augmentation can be an easily applicable surgical option, which offers fair to excellent outcome in 77% of the cases. The risk of residual extension lag and recurrence of deformity should be discussed prior to surgery.

Long-term outcomes of the modified Nirschl technique for lateral Epicondylitis: a retrospective study.

BACKGROUND: Although the Nirschl technique was introduced approximately 40 years ago, only limited information is available about the long-term results, especially concerning extensor power changes after surgery. The purpose of this study was to investigate long-term clinical results of surgical treatment of lateral epicondylitis using the modified Nirschl technique. The main outcome variable was muscle strength for wrist extension because the extensor origin was not reattached after removal of the degenerative extensor tendon. METHODS: Data from 99 patients who underwent surgical lateral epicondylitis treatment between 2007 to 2012 were included in the study. The mean follow-up period was 8.5 years (5 to 10, ± 1.1 years) and the mean age at surgery was 44.8 years (32 to 70, ± 9.8 years). The surgeries were performed using the modified Nirschl method and did not include extensor origin reattachment. Outcome measurements included the Visual Analogue Scale (VAS) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, the MAYO elbow performance score, and Nirschl and Pettrone's grades. Wrist extension and grip strength were analyzed using a digital handgrip dynamometer (microFET2TM system) and JAMA hand dynamometer. RESULTS: Mean time required to return to work was 2.4 months after surgery. At the last follow-up after surgery, the mean VAS score had significantly improved, from 4.9 to 1.1. Mean MAYO elbow performance scores significantly improved, from 64 to 90, and mean DASH scores improved from 50 to 13. The Nirschl and Pettrone's grades were 80% rated as 'excellent' and 16% rated as 'good'. After adjusting for power differences between the dominant and non-dominant arms, the difference between wrist extensor power of the operated elbow and the non-operated opposite elbow at the final follow-up was not statistically significant. No patients complained about wrist extension weakness. CONCLUSION: Although reattachment of the extensor origin was not performed during the modified Nirschl surgical technique, there was no significant weakness in wrist extension power and the long-term follow-up revealed favorable clinical results. LEVEL OF EVIDENCE: Level IV (case series). Retrospective study.

The expression of substance P and calcitonin gene-related peptide is associated with the severity of tendon degeneration in lateral epicondylitis.

BACKGROUND: In this study, we investigated whether substance P (SP) or calcitonin gene-related peptide (CGRP) expression is associated with tendon degeneration in patients with lateral epicondylitis. METHODS: Twenty-nine patients who underwent surgical treatment for lateral epicondylitis were enrolled in the final analyses. Extensor carpi radialis brevis tendon origins were harvested for histological analysis. RESULTS: SP and CGRP immunostaining were negative in healthy tendons but positive in degenerative tendons; moreover, their immunoreactivity increased with degeneration severity. Univariate analysis indicated that variables such as the preoperative visual analog scale (VAS) score or SP or CGRP expression levels were significantly associated with the Movin score. However, multivariate analysis revealed that only higher SP and/or CGRP signals were associated with higher Movin scores. Elevations in SP or CGRP expression were also linked with significantly severe preoperative VAS scores. CONCLUSION: We demonstrated that tendon degeneration severity is associated with increased SP and CGRP expression in the biopsy samples of lateral epicondylitis.