Pachydermodactyly: A Case Report Including Histopathology.

Pachydermodactyly (PDD) is a rare form of digital fibromatosis characterized by painless soft tissue swelling, primarily about the proximal interphalangeal joints. The skin at the metacarpophalangeal joints, the palm, and the dorsum of the hand may also be involved. Because swelling can occur over the proximal interphalangeal and metacarpophalangeal joints, PDD may be confused with juvenile inflammatory arthropathy and may even occur concurrently. We present the clinical and histopathologic findings of a case of PDD characterized by bilateral proximal phalangeal involvement of the index through little fingers.

The anatomy and histology of the bicipital tunnel of the shoulder.

BACKGROUND: The bicipital tunnel is the extra-articular, fibro-osseous structure that encloses the long head of the biceps tendon. METHODS: Twelve cadaveric shoulder specimens underwent in situ casting of the bicipital tunnel with methyl methacrylate cement to demonstrate structural competence (n = 6) and en bloc harvest with gross and histologic evaluation (n = 6). The percentage of empty tunnel was calculated histologically by subtracting the proportion of cross-sectional area of the long head of the biceps tendon from that of the bicipital tunnel for each zone. RESULTS: Cement casting demonstrated that the bicipital tunnel was a closed space. Zone 1 extended from the articular margin to the distal margin of the subscapularis tendon. Zone 2 extended from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon. Zone 3 was the subpectoral region. Zones 1 and 2 were both enclosed by a dense connective tissue sheath and demonstrated the presence of synovium. Zone 3 had significantly greater percentage of empty tunnel than zones 1 and 2 did (P < .01). CONCLUSION: The bicipital tunnel is a closed space with 3 distinct zones. Zones 1 and 2 have similar features, including the presence of synovium, but differ from zone 3. A significant bottleneck occurs between zone 2 and zone 3, most likely at the proximal margin of the pectoralis major tendon. The bicipital tunnel is a closed space where space-occupying lesions may produce a bicipital tunnel syndrome. Careful consideration should be given to surgical techniques that decompress both zones 1 and 2 of the bicipital tunnel.

Wear particles and osteolysis in patients with total wrist arthroplasty.

PURPOSE: To determine whether the amount of polyethylene debris in the interphase tissue between prosthesis and bone in patients with total wrist arthroplasty correlated with the degree of periprosthetic osteolysis (PPO); and to investigate the occurrence of metal particles in the periprosthetic tissue, the level of chrome and cobalt ions in the blood, and the possible role of infectious or rheumatoid activity in the development of PPO. METHODS: Biopsies were taken from the implant-bone interphase in 13 consecutive patients with total wrist arthroplasty and with at least 3 years' follow-up. Serial annual radiographs were performed prospectively for the evaluation of PPO. We collected blood samples for white blood cell count, C-reactive protein, and metallic ion level. RESULTS: A radiolucent zone of greater than 2 mm was observed juxta-articular to the radial component in 4 patients and at the carpal component in 3. The magnitude of the radiolucent zone tended to level out over time. We observed subsidence of the implant in 3 patients on the carpal side and in none on the radial side. The amount of polyethylene and metallic debris was generally small and did not correlate with the width of the radiolucent zone. The blood levels of chrome and cobalt ions were normal. There was no evidence of infectious or rheumatoid activity. CONCLUSIONS: Polyethylene wear has been accepted as a major cause of osteolysis in total hip arthroplasty, and metallic debris has also been cited to be an underlying cause. However, our hypothesis that polyethylene debris correlated with the degree of PPO could not be confirmed. Also, metallic debris and infectious or rheumatoid activity did not correlate with PPO. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Membranous lipodystrophy: skeletal findings on CT and MRI.

Membranous lipodystrophy, also known as Nasu-Hakola disease, is a rare hereditary condition with manifestations in the nervous and skeletal systems. The radiographic appearance of skeletal lesions has been well described in the literature. However, CT and MRI findings of lesions in the bone have not been documented to date. This report describes the radiographic, CT, MRI, and histopathologic skeletal findings in a case of membranous lipodystrophy. With corroborative pathologic findings, a diagnosis of membranous lipodystrophy on imaging allows for appropriate clinical management of disease manifestations.

Fibromyxoid pseudotumor of the ligamentum teres treated with fresh osteochondral allograft.

Intra-articular tumors and tumor-like conditions of the hip are rare. When they occur, they can interrupt normal articular congruency, leading to pain and joint dysfunction. If these conditions result in large osteochondral defects, they pose challenging reconstructive problems in young patients. We describe a case of a 29-year-old man who presented with a 2-year history of right hip pain. Advanced imaging demonstrated an expansile lesion in the region of his ligamentum teres (LT), eroding a significant portion of his femoral head and expanding the cotyloid fossa. He was treated with surgical hip dislocation, excision of the lesion, and femoral head reconstruction with fresh osteochondral (OC) allograft transplantation via press-fit technique. Histologic examination of the mass showed a benign fibromyxoid pseudotumor. Although non-neoplastic masses have been described in almost all organ systems, to our knowledge this is the first description of this entity affecting the native hip joint. It is only the second description of using press-fit OC allografting in the femoral head. This case adds to the body of literature defining symptomatic LT pathology that may benefit from surgical management. It underscores the need to study the ligament further, as the ability to diagnose and treat intra-articular hip pathology has improved with modern imaging and methods of open and arthroscopic hip surgery.

Biomechanical analysis of an ovine rotator cuff repair via porous patch augmentation in a chronic rupture model.

BACKGROUND: Rotator cuff repair is a commonly performed procedure, but many of these repairs fail in the postoperative term. Despite advances in surgical methods to optimize the repair, failure rates still persist clinically, thereby suggesting the need for novel mechanical or biological augmentation strategies. Nonresorbable implants provide an appealing approach because patch materials may confer acute mechanical stability and act as a conductive scaffold for tissue ingrowth at the site of the tendon insertion. HYPOTHESIS: The polyurethane scaffold mesh will confer greater biomechanical function relative to a nonaugmented repair after 12 weeks in vivo using a chronic ovine model of rotator cuff repair. STUDY DESIGN: Controlled laboratory study. METHODS: After development of the chronic rupture model, the tensile failure properties of the nonresorbable mesh-augmented repair (n, 9) were compared with those of a surgical control in an ovine model (n, 8). RESULTS: Rotator cuff repair with the scaffold mesh in the chronic model resulted in a significant 74.2% increase in force at failure relative to the nonaugmented surgical control (P = .021). Apparent increases in stiffness (55.4%) and global displacement at failure (21.4%) in the mesh-augmented group relative to nonaugmented controls were not significant (P = .126 and P = .123, respectively). At the study endpoint, the augmented shoulders recovered 37.8% and 40.7% of the force at failure and stiffness, respectively, of intact, nonoperated controls. CONCLUSION: Using the previously described chronic rupture model, this study demonstrated that repair of a chronic tendon tear with the polyurethane scaffold mesh provides greater mechanical strength in the critical healing period than that of traditional suture anchor repair. CLINICAL RELEVANCE: This device could be used to enhance the surgical repair of the rotator cuff and consequently improve long-term clinical outcome.

Radiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty.

HYPOTHESIS: This study analyzed clinical, radiographic, and histologic data from failed total shoulder arthroplasties (TSAs) to determine factors associated with osteolysis. MATERIALS AND METHODS: From 1985 to 2005, 52 patients (mean age, 61.6 years) underwent revision TSA at a single institution at a mean of 4.3 years after their index surgery. Patients were retrospectively assigned to 2 cohorts based on the presence (n = 10) or absence (n = 42) of osteolysis around their implants on the last prerevision surgery radiographs. Clinical information, associated histopathology from tissues obtained at revision surgery, and polyethylene wear data from the retrieved glenoid components were compared between groups. RESULTS: In the osteolysis group, 20% had screw fixation compared with 2.5% without osteolysis (P = .039). The radiolucency score was significantly higher in the osteolysis group: 12.7 +/- 2.0 vs 8.7 +/- 3.7 (P = .003). Wear analysis of the osteolysis group demonstrated significant increases in third-body particles compared with those implants without osteolysis (P = .004). Histology available from retrieved implants demonstrated particulate debris in 62% of patients with osteolytic lesions vs 67% without osteolytic lesions (P > .05). DISCUSSION: Significant differences were found in patients with osteolytic lesions compared with patients undergoing TSA revision surgery without such lesions, specifically with regard to glenoids that used adjuvant screw fixation, the presence of increased radiolucent lines, and an abundance of third-body wear. No significant differences were found in particulate wear debris despite the prevailing notion that osteolysis is associated with particulate debris from implant wear. CONCLUSION: Screw fixation and third-body wear were associated with osteolysis after TSA.

Extensive implant reaction in failed subtalar joint arthroereisis: report of two cases.

Foreign body synovitis with extensive granulomatous giant cell reaction to refractile polyethelene debris is a complication of subtalar arthroereisis not previously reported. We present two cases whereby STA-peg implants were used to treat bilateral painful flexible flatfoot deformities in children. Two boys, presented at 7 and 10 years of age, 2 years after STA-peg procedures and tendo-Achilles lengthening for painful flatfeet. They each had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus with surrounding high signal on the magnetic resonance imaging (MRI) in the subchondral bone of the calcaneus and talus. Both patients failed conservative management and had their implants removed with good relief of their pain. Histology was submitted at the time of implant removal. We present the radiographic and pathologic findings seen in these two patients with failed subtalar arthroereisis due to extensive implant reaction. The pathologic process seen in these patients is a previously unreported complication of this procedure. We do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.

Intra-articular fibroma of tendon sheath involving the scapholunate and radiocarpal joints.

Fibroma of tendon sheath is an uncommon benign soft tissue tumor with a predilection for the hand. A unique case involving the scapholunate and radiocarpal joints with bone erosion is reported. The patient presented with a transilluminating mass over the volar radial wrist associated with neuropathy in the superficial radial nerve distribution. Magnetic resonance imaging demonstrated a heterogeneous and lobulated mass with nonspecific signal characteristics closely associated with the scapholunate interval and the volar wrist soft tissues. Histologically it represented a fibroma of tendon sheath. The tumor is discussed and the relevant literature is reviewed.