Isolation and quantitation of debris particles around failed silicone orthopedic implants.

Silicone elastomer implants have a relatively low rate of complications, but inflammatory reactions to debris have been reported. To characterize the size and number of debris particles, we isolated and quantified the debris particles present in the periarticular tissues of 10 patients with failed silicone wrist, elbow, or finger implants. Five rheumatoid synovia without implants were used for negative controls. The number of particles ranged from 0.99 to 24.8 x 10(9) per gram (dry weight) of tissue, and nearly all particles were silicone, as determined by x-ray spectroscopy. The implantation duration ranged from 3.2 to 10.6 years, and for the five wrist implants, the number of particles correlated with duration in vivo. The particles were small (mode particle diameter was 0.59 +/- 0.057 micron). These results suggest that billions of particles, most of which are smaller than 1 micron, are present adjacent to failed silicone implants, and may be associated with inflammation and bone resorption.

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: combined fasciectomy with capsuloligamentous release versus fasciectomy alone.

Severe proximal interphalangeal joint contracture in Dupuytren's disease presents a frustrating problem for hand surgeon. Some surgeons argue for fasciectomy alone, avoiding violation of the proximal interphalangeal joint, which may prolong morbidity and result in permanent limitation of flexion; this loss of flexion can be more disabling than a mild flexion contracture. Others favor capsulotomy in addition to fasciectomy, especially for severe contractures, to obtain additional release, arguing that one cannot completely correct secondary contracture by fasciectomy alone. We performed a retrospective review of severe flexion contractures (60 degrees or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 demographically similar patients underwent capsulotomy in addition to fasciectomy. In the noncapsulotomy group, preoperative contracture averaged 78.4 degrees. Postoperative contracture averaged 36.6 degrees, with a 53 percent improvement. In the capsulotomy group, preoperative joint contracture averaged 82.5 degrees. Postoperative contracture averaged 36.8 degrees, with a 55 percent improvement. Intraoperative residual contracture for 21 of the 27 joints in the noncapsulotomy group averaged 7 degrees compared with 8 degrees for 9 of the 15 joints in the capsulotomy group. Preoperative proximal interphalangeal joint flexion averaged 100.6 degrees in the noncapsulotomy group and 98.6 degrees in the capsulotomy group. Postoperative flexion averaged 92.2 degrees in the noncapsulotomy group, which was 91.7 percent of preoperative flexion, and 82.7 degrees, which was 83.9 percent of preoperative flexion, in the capsulotomy group. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group at follow-up. The degree of correction initially obtained at surgery using either method was not maintained during the short follow-up period. There was a significant decrease in postoperative proximal interphalangeal joint flexion compared with preoperative flexion following either surgical approach; however, there was no significant difference between the two groups with respect to the percentage of flexion lost. Complications developed in both groups but tended to occur more commonly in the capsulotomy group. This study failed to show any advantage to capsuloligamentous release in addition to fasciectomy in treating severe proximal interphalangeal joint contracture due to Dupuytren's disease.

Triquetrohamate arthrodesis for midcarpal instability.

To assess our results in the management of midcarpal instability with limited wrist arthrodesis, we retrospectively reviewed the records of 10 patients (11 wrists) who had undergone triquetrohamate arthrodesis for symptomatic midcarpal instability. Diagnosis was based on ulnar-side wrist pain, maximum tenderness over the triquetrohamate joint, and characteristic findings on cineradiographic examination. In nine patients, the proximal carpal row suddenly snapped into extension as the wrist was manipulated from radial to ulnar deviation. In one patient (both wrists), the distal carpal row could be dorsally subluxed by direct pressure and axial compression. Both these maneuvers reproduced the patients' symptoms. All cases had failed to improve with prior nonoperative treatment or soft tissue reconstruction. Triquetrohamate arthrodesis was performed to provide midcarpal joint stability. The follow-up time averaged 26 months (range, 6-72). There were two excellent, four good, three fair, and two poor results. Compared to the contralateral side, range of motion averaged 55% flexion, 69% extension, 61% radial deviation, and 64% ulnar deviation, and grip strength averaged 64%. The stability provided by triquetrohamate arthrodesis failed to control symptoms in almost 50% of cases.

Perineurial cell hypertrophic mononeuropathy manifesting as carpal tunnel syndrome.

A 42-year-old man showed signs and symptoms suggestive of carpal-tunnel syndrome, but EMG showed an isolated motor axon-loss lesion affecting the right median nerve distally. After the MRI revealed a mass in the median nerve, surgical exploration showed a diffusely swollen median motor branch. Biopsy showed a lesion with marked onion-bulb formation composed of perineurial cells as identified by immunohistochemical analyses and electron microscopic examination. Although we previously coined the term "perineurioma" for this condition, re-reviews of our cases do not support the idea that the onion-bulb lesion is a benign tumor; instead, it appears to be reactive hyperplasia. Although rare, electromyographers and neurologists need to be aware of this problem because it is self-limited and does not require surgical resection.

Fractures of the hand and wrist in the athlete.

The challenge of treating fractures of the hand and wrist in the athlete is finding innovative ways of internal and external fixation that will allow the athlete to continue participation while the fracture is healing. The challenge is to provide enough immobilization or restriction to allow optimal fracture healing while providing enough freedom to allow the athlete to participate in his sport.

Sports-related fractures of the hand and wrist.

The challenge of treating fractures of the hand and wrist in the athlete lies in finding innovative ways of allowing the patient to participate in his sport while providing good fracture care. We are challenged to lay aside our traditional way of treating these fractures and to find new ways of reaching the same end result while allowing the patient to be more functional.

Office management of athletic injuries of the hand and wrist.

Most common hand injuries occurring in athletics can be simply treated and the athlete returned to participation at an early date. Delayed or inadequate treatment may result in an unacceptable outcome, including permanent deformity. The injured athlete must be carefully examined, treated, and monitored until fully rehabilitated.

Osteoarthritis of the distal interphalangeal joint.

DIP joint arthritis may be painful and interfere with function of a finger or the entire hand. When conservative measures are no longer adequate to control the symptoms, operative intervention may be recommended. Arthrodesis is the procedure of choice in most situations, although specialized functional requirements may justify an attempt to maintain motion. Treatment of mucous cysts requires removal of the offending osteophyte as well as the cyst itself. Technique of skin closure depends on the situation and the surgeon's preference. Careful attention to the indications for surgery, to the education of the patient, to the anatomy, and to the surgical technique will usually lead to a beneficial result and will minimize complications.

Fast axonal transport in amyotrophic lateral sclerosis: an intra-axonal organelle traffic analysis.

Fast transport of intra-axonal organelles was studied in motor nerve from amyotrophic lateral sclerosis (ALS) patients. Organelle traffic in ALS nerves demonstrated a significant increase in anterograde mean speed, while retrograde mean speed was decreased compared with that of controls. Retrograde traffic density (organelles per unit time) was also significantly decreased in the ALS specimens. Anterograde transport machinery is therefore intact and may be responding to the increased physiologic demand of larger motor units. Diminished retrograde speed and organelle traffic density are consistent with a defect in retrograde transport and could impair communication between axon terminals and perikarya.

Instabilities of the wrist.

Wrist instabilities are frequently underdiagnosed and undertreated because they are complex and difficult to understand. A study of the anatomy of the wrist and the pathomechanics of these injuries leads to a better understanding of these problems and to a more specific diagnosis. Treatment involves stabilization of the unstable segment by ligament repair in the acute injury and by limited intercarpal arthrodesis in the chronic case.

Proplast stabilized stemless trapezium implant.

Forty-five stemless Proplast-covered silicone rubber trapezium implants were used in 40 patients after trapeziectomy for either osteoarthritis, rheumatoid arthritis, or trauma. Three implants were later removed from two patients because of traumatic dislocations. One implant was removed from a patient after trauma because of persistent pain. Five patients were followed from 40 to 44 months; nine patients were followed from 31 to 39 months; 15 patients were followed from 20 to 29 months; six patients were followed from 14 to 19 months; five patients were followed from 6 to 9 months. The average follow-up time was 24 7/10 months. Before surgery 5% of the patients had continuous spontaneous pain, 35% of the patients had pain with all motion, and 60% of the patients had pain with limited normal daily use. At this time of our report, 65% of the patients are without symptoms, 21% of the patients have slight intermittent pain, and 14% of the patients have pain with strenuous use only. Tripod pinch improved 243% in male patients and 113% in female patients. All patients have good circumduction and metacarpophalangeal (MP) and interphalangeal (IP) joint motion. The stemless feature permits relatively free metacarpal joint motion without great stress being applied to the capsule that is covering the implant.

Blood supply of the flexor pollicis longus tendon.

The blood supply of the flexor pollicis longus tendon was investigated by arterial injections of india ink--latex-barium-solution in 15 fresh, adult cadaver upper extremities. In the digital area vascularity was by way of two vincula (V1 and V2). V1, located just proximal to the metacarpophalangeal joint and the A1 pulley, originated either from both digital arteries or from the princeps pollicis artery alone. V2, located at the interphalangeal joint level under the A2 pulley, originated from both digital arteries. In the predigital area branches of the median nerve artery supplied the area from the base of the thumb to the musculotendinous junction; in addition, the microvascular network of the mesotendon contributed to this area. Intratendinous vascularization was more abundant in the predigital area.

Extensor pollicis and indicis communis tendon: a rare anatomic variation revisited.

This case report describes the finding of a rare supernumerary extensor tendon supplying both the index finger and thumb; previous descriptions have been reported only in cadaver dissections. Such anatomic variations are important to maintain proper surgical orientation. These extra tendons may also prove to be of value in tendon transfer procedures.

Modified treatment of thumb ray dysplasia: a case report.

The abnormality of the carpometacarpal joint and lack of opposition are two of the more difficult components to treat in the thumb ray dysplasia syndrome. A trapezium arthroplasty and an extensor indicis proprius opponensplasty were used in a typical case. Active opposition was obtained.

Combined posterior interosseous and ulnar nerve compression in a hemophiliac.

A case is reported of a combined posterior interosseous nerve and ulnar nerve decompression in a patient with hemophilia after appropriate blood factor replacement. The importance of avoiding unnecessary delay in surgical intervention and careful attention to details of operative and postoperative care are stressed.

Flexor digitorum superficialis rupture: a case report.

A rupture of the musculotendinous junction of the flexor digitorum superficialis to the index finger in a baseball pitcher is described. No underlying abnormality could be detected. Because of loss of strength and dexterity, repair of the rupture was accomplished with an improved result.

Chondrosarcoma of the hand arising from a pre-existent benign solitary enchondroma.

Chondrosarcomas of the hand are relatively rare. Chondrosarcomas may arise by malignant transformation of a pre-existing enchondroma, but this causal relationship has been difficult to establish in solitary enchondroma. This is a case report of a chondrosarcoma of the proximal phalanx of the right index finger in a 66-year-old woman demonstrating histologic evidence of malignant transformation of a pre-existent benign solitaary enchondroma. Careful analysis of the preoperative X-ray for punctate endosteal calcification or cortical expansion and ample histologic sampling of the endosteal component of chondrosarcomas arising from within bone may demonstrate a greater incidence of preexistent enchondroma.

The role of trochanteric osteotomy in total hip replacement.

In a study of 225 hip replacements, 126 had trochanteric osteotomy and 99 did not. Trochanteric osteotomy was found to be invaluable in approaching the difficult, previously operated hip. Even though 81 hips without trochanteric osteotomy had no complications directly related to the operative technique, 19 had significant operative problems. Hips with fixed flexion or external rotation contractures preoperatively presented technical difficulties and postoperative problems avoidable only by trochanteric osteotomy. Complications are encountered with and without osteotomy and various indications for osteotomizing the greater trochanter through a lateral approach to the hip are reviewed on the basis of experience with 184 patients with an average age of 61 years.