Symptomatic Heterotopic Bone Formation after 1,2 ICSRA in Scaphoid Nonunions.

Background We observed several cases of heterotopic bone formation after a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) distal radius vascularized bone graft (VBG) for the treatment of scaphoid nonunion. This adverse event seems underreported. Knowledge about factors associated with the formation of heterotopic bone after VBGs might help reduce this adverse event. Purpose What factors are associated with resected heterotopic bone formation after 1,2 ICSRA distal radius graft for the treatment of scaphoid nonunion? Patients and Methods We retrospectively reviewed all patients with a scaphoid nonunion treated with a 1,2 ICSRA distal radius graft between 2008 and 2019 in an urban level 1 trauma center in the Netherlands. We included 42 scaphoid nonunions in 41 people treated with the 1,2 ICSRA graft. We assessed potential correlation with patient, fracture, and treatment demographics. Results Heterotopic bone developed in 23 VBGs (55% [23/42]), of which 5 (12% [5/42]) were resected. Heterotopic bone was located radially (at the pedicle side) in all participants. Except a longer follow-up time ( p = 0.028), we found no variables associated with the development of heterotopic bone formation. Conclusion The location of the heterotopic bone at the pedicle site in all cases suggests a potential association with the periosteal strip. Surgeons might consider not to oversize the periosteal strip as a potential method to prevent heterotopic ossification after VBG. Level of Evidence Level II, prognostic study.

The pisotriquetral joint: osteoarthritis and enthesopathy.

Pisotriquetral (PT) osteoarthritis (OA) and enthesopathy of the flexor carpi ulnaris (FCU) are pathologies of the hypothenar eminence which both often remain undiagnosed, but can cause ulnar wrist pain. This study determined the prevalence of these pathologies in an older donor population. Twenty wrists were obtained from 10 cadavers with an age ranging from 65 to 94 years. Radiographs were taken of all wrists with the hand in pisotriquetral view and were assessed for osteoarthritic changes of the PT joint and signs of enthesopathy of the FCU. Ten wrists were grossly dissected and the other ten wrists were sagitally sectioned at a thickness of 10 µm. The wrists were analyzed for type and grade of osteoarthritis and signs of enthesopathy. On radiology, 2 out of 20 wrists showed no signs of osteoarthritis, 5 wrists showed severe changes. One wrist showed signs of enthesopathy. On macroscopy, 9 out of 10 wrists showed osteoartritic changes; 5 of these were severely osteoarthritic. On microscopy, all wrists showed some degree of osteoarthritis of which five showed severe changes. Signs of enthesopathy were seen in seven wrists. Pisotriquetral osteoarthritis has a high prevalence in the older donor population and may therefore be a cause of ulnar sided wrist pain. It should therefore always be considered in the differential diagnosis of ulnar sided wrist pain. By performing clinical examination with these pathologies in mind, diagnosis could be a lot faster. Furthermore, based on our results, radiographs seem to be not accurate in diagnosing osteoarthritis of the PT joint and enthesopathy of the FCU.

The fixation of a collagen type I/III membrane in the distal radioulnar joint of a human cadaver model.

Damage to the cartilage of the distal radioulnar joint frequently leads to pain and limitation of movement, therefore repair of this joint cartilage would be highly desirable. The purpose of this study was to investigate the fixation of scaffold in cartilage defects of this joint as part of matrix-assisted regenerative autologous cartilage techniques. Two techniques of fixation of collagen scaffolds, one involving fibrin glue alone and one with fibrin glue and sutures, were compared in artificially created cartilage defects of the distal radioulnar joint in a human cadaver. After being subjected to continuous passive rotation, the methods of fixation were evaluated for cover of the defect and pull out force. No statistically significant differences were found between the two techniques for either cover of the defect or integrity of the scaffold. However, a significantly increased mean pull out force was found for the combined procedure, 0.665 N (0.150 to 1.160) versus 0.242 N (0.060 to 0.730) for glue fixation (p = 0.001). This suggests that although successful fixation of a collagen type I/III scaffold in a distal radioulnar joint cartilage defect is feasible with both forms of fixation, fixation with glue and sutures is preferable.

Inflammatory mediators in posttraumatic radiocarpal osteoarthritis.

PURPOSE: To identify the mediator profile in healthy, pre-osteoarthritis (OA) and end-stage OA radiocarpal joints. We hypothesized that there would be an increase in soluble mediators in posttraumatic wrist OA. METHODS: We obtained radiocarpal synovial fluid samples from 3 groups of patients: healthy control (n = 12) samples were collected during wrist ganglion resection; pre-osteoarthritic (n = 16) samples, during a 3-ligament tenodesis procedure for complete scapholunate dissociation; and end-stage OA (n = 20) samples in patients with proven radiological OA changes. Using a multiplex enzyme-linked immunosorbent assay, we measured 12 mediators: interleukin (IL)-1ß, tumor necrosis factor-α, oncostatin-M, interferon-γ, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, IL-1RA, and osteoprotegerin. Statistical analysis was performed using analysis of variance and Bonferroni-corrected post hoc tests. RESULTS: Mediators IL-6, IL-10, and interferon-γ were increased in OA wrists compared to healthy and pre-OA samples. Tumor necrosis factor-α, oncostatin-M, osteoprotegerin, IL-8, and IL-1RA were detected but not at increased levels in OA wrists. We found no differences between healthy and pre-OA joints in all 12 mediators. Mediators IL-4, IL-7, IL-13, and IL-1ß were not detected in either healthy, pre-OA or end-stage OA samples. CONCLUSIONS: We identified no differences between healthy and pre-OA samples, suggesting no alteration in inflammatory status at the time of the 3-ligament tenodesis procedure. Consequently, mechanical disturbance seems to be the driving force toward OA and OA-associated inflammation in this stage of scapholunate dissociation. Increased levels of interferon-γ, IL-6, and IL-10 confirm inflammatory changes in the mechanically disturbed posttraumatic radiocarpal joint.

Interobserver agreement of the Eaton-Littler classification system and treatment strategy of thumb carpometacarpal joint osteoarthritis.

PURPOSE: To determine the interobserver agreement of the Eaton-Littler classification system for radiological osteoarthritis of the first carpometacarpal (CMC1) joint and the interobserver agreement of the most appropriate treatment modality. METHODS: Forty cases of CMC1 osteoarthritis were independently presented to 5 musculoskeletal-experienced radiologists and 8 hand surgeons. These observers were asked to stage the radiographs according to Eaton and Littler's classification system (stages I-IV). The hand surgeons were also asked to choose their treatment of choice (1, conservative; 2, ligament reconstruction or extension osteotomy; 3, hemitrapeziectomy with interposition; 4, arthrodesis; 5, trapeziectomy; 6, hemiarthroplasty or total arthroplasty). RESULTS: The overall mean interobserver agreement of the radiological classification was in the moderate range of agreement. The hand surgeons' mean interobserver agreement was just slightly better than the radiologists' mean. The mean interobserver agreement of treatment indicated fair strength of agreement. CONCLUSIONS: The moderate interobserver agreement of the radiological classification of Eaton and Littler for staging of CMC1 osteoarthritis questions the efficiency of Eaton and Littler's classification system. The interobserver agreement in choice of treatment shows a fair agreement. These varieties in classification and in choice of treatment indicate the need for evidence-based research to define optimal classification and treatment of CMC1 osteoarthritis.

Hammering versus drilling of sharp and obtuse trocar-point k-wires.

Kirschner wire characteristics affect the heating of bone during insertion and the subsequent strength of fixation. We inserted 90 sharp and 90 obtuse trocar-tip K-wires into 90 fresh frozen human cadaver metacarpals using either a drill or a pneumatic hammer. The temperature elevation, insertion time and extraction force were measured for four K-wire insertion combinations: drilling sharp; drilling obtuse; hammering sharp; hammering obtuse. Hammering resulted in significantly lower temperature elevations than drilling. Hammering sharp K-wires resulted in the highest extraction forces. The first and fifth metacarpals showed significantly lower temperature elevations than the other metacarpals, while the insertion time was significantly higher in the second and third metacarpal than in the other metacarpals. Hammering sharp trocar-tip K-wires minimises thermal damage to bone and gives the strongest fixation.

Four-corner arthrodesis using the Quad memory staple.

Range of motion, pain, consolidation and complications were evaluated for nine patients who underwent four-corner arthrodesis using the Quad Memory Staple (QMS) at a mean follow-up of 44 months. The mean pre-operative range of motion was 50 degrees extension, 62 degrees flexion, 9 degrees radial deviation and 24 degrees ulnar deviation. The postoperative range of motion was similar to previous studies at 32 degrees extension, 31 degrees flexion, 15 degrees radial deviation and 20 degrees ulnar deviation. The grip strength was 28 kg pre-operatively and 26 kg postoperatively. The mean pain score improved from 41 to 23 and the Disabilities of Arm, Shoulder, and Hand (DASH) score from 24 to 20. Non-union, haematoma and wound infection were not seen and eventually all four-corner fusions were consolidated. The main advantages of the QMS are its compressive property and the simple fixation technique. It gives good stability, enables early rehabilitation and avoids the risks of pin fixation methods.

Carpal boss: effect of wedge excision depth on third carpometacarpal joint stability.

PURPOSE: We hypothesize that carpal-metacarpal (CMC) instability after carpal boss wedge excision is not caused only by damage to the dorsal ligament but mainly depends on the depth of the bony resection. METHODS: To test our hypothesis, this study analyzes the effect of wedge excisions with different depths (0, 15%, 35%, 55% of the third CMC joint) and the effect of different forces (0, 50, 100 N.m) on the stability (measured as the passive flexion) of the third CMC joint using 12 fresh-frozen human cadaver wrists. The passive flexion is defined as the increase in angular motion of the third CMC joint and represents change in stability during flexion of the joint. RESULTS: The results show that the mean passive flexion measured in the wedge excisions of 15% and 35% of the joint did not differ from that of neutral controls. Joints analyzed after a 55% wedge excision showed a significant increase in angular motion (increased passive flexion). This relates to the 50 N.m as well as the 100 N.m loaded test position. CONCLUSIONS: This study shows that a wedge excision of clinically applicable depth of 35% does not create instability during flexion of the third CMC joint when loaded with physiologically relevant forces. Yet an extended and hardly clinically relevant 55% wedge excision results in a change in stability of the joint. To prevent instability when performing a wedge excision for symptomatic carpal boss, care must be taken to avoid excisions that exceed 35% of the third CMC joint.

Keeping osteocytes alive: a comparison of drilling and hammering k-wires into bone.

In this study, the insertion time and histological effects of drilling and hammering K-wires into bone are described. The insertion time was measured while drilling or hammering K-wires into the femurs and tibias of ten rabbits. Four K-wires, inserted into one hind limb, were used for histological examination directly after insertion and four K-wires inserted into the contralateral hind limb were used for the same measurements 4 weeks later. The specimens were scored for presence, or absence, of osteocytes, fragmentation of the bone edges, haemorrhage, microfractures, cortical reaction and callus formation around the pin track. The insertion time needed for drilling in K-wires was significantly longer than that of hammering. Drilling also resulted in the disappearance of the osteocytes in almost all sections while hammering did not have this effect but did result in more microfractures. Hammering K-wires may be a superior technique because it prevents osteonecrosis and requires a shorter insertion time.

Subchondral bone mineral density patterns representing the loading history of the wrist joint.

Ten cadaver wrists were examined with CT-Absorptiometry in order to assess bone density in the subchondral bone. In normal wrists the distal radius contained two centroids of bone density, one in the lunate fossa and another in the scaphoid fossa. Pathologically altered wrists showed a shift in bone density towards the scaphoid fossa, with the subchondral bone in the lunate fossa and distal ulna becoming less dense. Bone density patterns in the wrist reflect the long-term force transmission. As bone density alters according to loading conditions, this method can be used to determine force transmission patterns before and after wrist surgery.

[Necrotising fasciitis and myositis as serious complications after liposuction]. / Necrotiserende fasciitis en myositis als ernstige complicaties na liposuctie.

Three days after liposuction of the lower abdomen, a 41-year-old woman was admitted for toxic shock-like syndrome with necrotising fasciitis and myositis, caused by Lancefield-group-A beta-haemolytic streptococci. The patient was treated by radical debridement of the skin, subcutis, fasciae and part of the pectoral muscle, plus antibiotics. Postoperatively she required artificial respiration for respiratory insufficiency. One week after the operation the wound was covered by transplantation of autologous skin. The patient survived, but was seriously disfigured. Necrotising fasciitis is a progressive soft-tissue infection, characterised by widespread necrosis of the superficial and deep fascia, often associated with severe systemic toxic reactions. Unless quickly recognised and aggressively treated, the course is often fatal. Due to the absence of cutaneous findings in the early stages, diagnosis is difficult. Important diagnostic aids are routine laboratory tests, contrast-MRI and a combination of the finger test and frozen-section biopsy. Treatment consists of early radical debridement, broad-spectrum antibiotics and supportive care. In a later stage, soft-tissue reconstruction with autografts or artificial skin grafts and skin transposition can be performed.

[Proximal row carpectomy: a 'salvage' procedure for radio-carpal arthritis of the wrist]. / Proximale-rijcarpectomie als behandeling voor radiocarpale artrose van de pols.

In 4 patients, a woman aged 46 years, and 3 men aged 58, 28 and 60 years, respectively, a proximal row carpectomy was done for pain and loss of function due to scapho-lunate dissociation, scaphoid nonunion, Kienböck's disease and scapho-lunate advanced collapse wrist deformity (bilateral). Pain relief was achieved post-operatively in all patients, allowing patients to return to their previous work and activities. Proximal row carpectomy involves the removal of the os scaphoideum, the os lunatum and the os triquetrum. This improves wrist extension and ulnar deviation. Intensive postoperative treatment is essential to achieve good mobility and strength.

Arthrodesis after osteosynthesis and infection of the ankle joint.

Nineteen patients with a severely infected ankle joint after previous osteosynthesis were treated with arthrodesis in our institution. Their notes and X-rays were reviewed. Goals of treatment were eradication of infection by aggressive débridement of infected tissues, obtaining adequate soft-tissue coverage, preservation/restoration of bonelength, and finally consolidation of the arthrodesis. Thirteen men and six women were treated, with a median age of 46 (17-69) years. Arthrodesis took place after a median of 6 months (0.5-40) post-accident, and after one to six earlier operative procedures. Primarily there had been four bimalleolar, five trimalleolar and ten pilon tibial fractures. Fifteen fractures were open with severe soft tissue damage. Seven free muscle transfers were performed, and ten cancellous bone graftings. Finally 29 attempts at arthrodesis were performed. Ultimately we had to perform two amputations. After a mean follow up of 3.5 years, one patient has an aseptic but asymptomatic pseudarthrosis, for which no further surgery is scheduled. Sixteen extremities are free from infection while full weightbearing is possible. The limb-threatening problem of deep infection after osteosynthesis of an ankle fracture can be resolved by consistent but prolonged treatment. After successful arthrodesis a weightbearing extremity without infection remains in the majority of cases.

Assessment of ulnar variance: a radiological investigation in a Dutch population.

OBJECTIVE: A radiological study was performed to evaluate ulnar variance in 68 Dutch patients using an electronic digitizer compared with Palmer's concentric circle method. Using the digitizer method only, the effect of different wrist positions and grip on ulnar variance was then investigated. Finally the distribution of ulnar variance in the selected patients was investigated also using the digitizer method. DESIGN AND PATIENTS: All radiographs were performed with the wrist in a standard zero-rotation position (posteroanterior) and in supination (anteroposterior). Palmer's concentric circle method and an electronic digitizer connected to a personal computer were used to measure ulnar variance. The digitizer consists of a Plexiglas plate with an electronically activated grid beneath it. A radiograph is placed on the plate and a cursor activates a point on the grid. Three plots are marked on the radius and one plot on the most distal part of the ulnar head. The digitizer then determines the difference between a radius passing through the radius plots and the ulnar plot. RESULTS AND CONCLUSIONS: Using the concentric circle method we found an ulna plus predominance, but an ulna minus predominance when using the digitizer method. Overall the ulnar variance distribution for Palmer's method was 41.9% ulna plus, 25.7% neutral and 32.4% ulna minus variance, and for the digitizer method was 40.4% ulna plus, 1.5% neutral and 58.1% ulna minus. The percentage ulnar variance greater than 1 mm on standard radiographs increased from 23% to 58% using the digitizer, with maximum grip, clearly demonstrating the (dynamic) effect of grip on ulnar variance. This almost threefold increase was found to be a significant difference. Significant differences were found between ulnar variance when different wrist positions were compared.

Ulnar variance and the shape of the lunate bone. A radiological investigation.

The authors designed a study to test the hypothesis that the length of the ulna might affect the shape of the lunate bone because of long-term molding during life. This might then be useful to predict the presence or absence of a dynamic or static ulna plus by the shape of the lunate bone. In a prospective study, posterior-anterior wrist x-rays were taken in a standard fashion in 68 patients with a mean age of 34.5 years. Dominance, grip strength, ulnar variance and the shape of the lunate were recorded. Lunate shape, type 1, which is the least molded, was seen most frequently on both the left and right side and did not correlate with the dominant side. The most molded, type 3, was seen less frequently and almost exclusively on the nondominant side. No correlation was found between dynamic ulna plus and the type 3 lunate. Following statistical analysis, no correlation between ulnar variance and lunate shape was found, indicating that the shape of the lunate bone had no predictive value for predicting the presence or absence of a dynamic ulna plus variance. The hypothesis that the length of the ulna might influence the ultimate shape of the lunate could not be demonstrated.

Reversed palmaris longus muscle on MRI: report of four cases.

Muscle anomalies around the wrist, in particular the palmaris longus muscle, may cause effort-related median nerve compression. A search of the medical records at our university hospital between 1994 and 1999 revealed four patients with an effort-related median nerve compression due to a reversed palmaris longus muscle. Magnetic resonance imaging was used in the patient work-up and showed an anomalous muscle in each case that had been missed initially. All four patients were free of pain after simple excision of the anomalous muscle. Awareness of muscle anomalies at the wrist on MR imaging is essential in evaluating patients with nerve compressions at the wrist. The purpose of this article is to heighten this awareness in radiologists.

Neurotmesis of the lateral femoral cutaneous nerve when coring for iliac crest bone grafts.

Two patients are presented suffering from meralgia paresthetica, owing to neurotmesis of the lateral femoral cutaneous nerve following bone-graft harvesting from the iliac crest with a cylindrical osteotome. Despite this donor-site complication, the advantages of a coring technique as compared with traditional bone-graft harvesting techniques are numerous: better cosmetic results, less pain, no need for general anesthesia, shorter hospitalization, and a minimum of donor-site morbidity. Also, this technique has proven itself easy and effective. To minimize donor-site morbidity, some clinical recommendations to avoid neurotmesis are given with regard to the anatomy and anatomic variations of the lateral femoral cutaneous nerve.

Reversed palmaris longus muscle causing effort-related median nerve compression.

Two cases of effort-related distal median nerve compression in the dominant forearm caused by a reversed palmaris longus muscle are presented. Simple resection of the muscle belly was performed. Carpal tunnel release was done in one case, but in retrospect this was probably not necessary.

Auricular hypermobility due to agenesis of the extrinsic muscles.

A patient is presented with complaints of a hypermobile right ear due to agenesis of the superior and posterior auricularis muscles and a thin concha cartilage. Suturing the concha cartilage to the mastoid bone and temporal fascia gave sufficient support of the external ear without creating a gross difference in appearance of both ears.