Mesenchymal PLAG1 Tumor With PCMTD1-PLAG1 Fusion in an Infant: A New Type of "Plagoma".

ABSTRACT: In the past decade, there have been major advances in knowledge related to mesenchymal tumors, and new genetic alterations are being delineated. We report a mesenchymal spindle cell neoplasm harboring a novel gene fusion in an infant. Histopathologically, the neoplasm shared some features with sclerosing perineurioma, but immunohistochemically, EMA was negative, whereas GLUT1, NK1-C3, and BCOR were positive. Next-generation sequencing revealed a PCMTD1-pleomorphic adenoma gene 1 (PLAG1) fusion. PLAG1 contributes to the expression of a variety of genes implicated in regulating cell proliferation, and PCMTD1 has been related to the development of certain carcinomas. Recently, other soft tissue tumors in young children associated with PLAG1 fusion variants have been reported. Perhaps, mesenchymal neoplasms presenting PLAG1 fusions with different genes would confirm a specific group (PLAG mesenchymal tumours or "plagomas") in the near future.

Collagenase Tenotomy for Dupuytren Boutonniere.

SUMMARY: Treatment of boutonniere Dupuytren disease is rare and is resistant to treatment because of altered tendon dynamics. The authors used a small dose of collagenase clostridium histolyticum for an enzymatic tenotomy of the distal interphalangeal joint and showed that hyperextension at the distal interphalangeal joint improved significantly. Fifteen patients with boutonniere Dupuytren disease with severe proximal interphalangeal joint contractures averaging -69 degrees of extension were included in the study. Ten patients had at least one previous intervention, including surgical fasciectomy, Digit Widget treatment, and needle aponeurotomy. Collagenase clostridium histolyticum enzymatic tenotomy was performed in-office as a wide-awake procedure. All patients received varying doses of collagenase clostridium histolyticum for volar Dupuytren disease enzymatic fasciotomy and 0.1 mg of collagenase clostridium histolyticum into the distal extensor tendon for tenotomy to treat boutonniere deformity at the same time. Collagenase clostridium histolyticum enzymatic tenotomy significantly improved total active motion of the finger by 41.0 degrees (p = 0.001). Loss of extension at both the metacarpophalangeal joint and the proximal interphalangeal joint also improved with gains of 11.7 (p = 0.04) and 20.7 degrees (p = 0.0005) of extension, respectively. The average distal interphalangeal joint hyperextension was improved from 29.7 degrees to 14.0 degrees (p = 0.002). The authors show that collagenase injection led to significant average improvement in joint contracture at all finger joints and significantly increased the arc of motion at the proximal interphalangeal joint and metacarpophalangeal joint. Although collagenase has been previously used for flexion contractures in Dupuytren disease, we believe it has a role in treating the distal interphalangeal joint hyperextension deformity associated with boutonniere deformity in Dupuytren disease as well. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A four-year community hospital experience regarding procedures for the replantation and revascularization of fingers.

OBJECTIVES: This study aims to evaluate the clinical results and experiences in a community hospital regarding procedures for the replantation and revascularization of fingers. PATIENTS AND METHODS: Between June 2015 and December 2019, a total of 58 patients (51 males, 7 females; mean age: 33.4±6.3 years; range, 23 to 46 years) who were followed after total and/or subtotal amputation and replantation were retrospectively analyzed. The patients were evaluated at nine months in terms of cold intolerance, static two-point discrimination, and functional results using the range of motion (ROM) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. RESULTS: The majority of the patients presented with work-related injuries (70%), most commonly by the mechanism of guillotine (64%), and to the dominant hand (76%) and the third finger (36%) most frequently. The overall success rate of digit salvage was 72.9% (n=51). Of 19 digits with unsuccessful surgical outcomes, seven were from total and 12 were from subtotal amputations. In the long-term, cold intolerance was observed in 14 patients (24.1%) according to the cold intolerance severity scale. The mean static two-point discrimination value was 6.0±0.7 mm and the mean QuickDASH score was 22.3±5.0. The mean ROM measured at nine months after surgery in the metacarpophalangeal and interphalangeal joints of the third and fourth digits was significantly lower than that in the others (p<0.05). CONCLUSION: The predictors of survival of a replanted digit indicated in this study can be used as a guide and decision-making aid for any attempts for replantation.

Acupotomy treatment for finger joint contracture after immobilization: Case report.

INTRODUCTION: Contractures frequently occur in the finger joints after immobilization. This report describes the effect of acupotomy treatment in patients with joint contracture due to immobilization of the finger joints. PATIENT CONCERNS AND CLINICAL FINDINGS: Case 1 was of a 39-year-old male patient who had flexion limitation of the left thumb and difficulty in grasping. Case 2 was of a 41-year-old female patient who had flexion limitation of the right index finger and difficulty in typing. Stiffness occurred after tendon repair surgery and cast immobilization in both cases. In Case 1, the patient had limited flexion movement of the first metacarpophalangeal and interphalangeal joints after 5 weeks of immobilization of the left thumb in a cast. In Case 2, the patient had limited flexion movement after 3 weeks of immobilization of the second proximal interphalangeal joint of the left hand in a cast. DIAGNOSIS, INTERVENTIONS, AND OUTCOMES: We diagnosed both patients with finger joint contracture due to immobilization. Conservative treatment for approximately 4 weeks did not lead to improvement in either patient. Acupotomy is the key treatment for improving movement in Korean Medicine. Therefore, acupotomy was performed, and joint stiffness markedly improved without adverse events. Both patients reported that the daily use of the damaged fingers became comfortable. CONCLUSION: We found that acupotomy may be effective for finger joint contracture due to improper immobilization. We suggest it as a simple and safe treatment for joint contracture.

Kirscner wire fixation versus suture anchor technique for mallet finger: A meta-analysis.

PURPOSE: Though the previous studies had described various surgical techniques for the treatment of mallet finger injuries, consensus on which technique was the most effective and appropriate surgical methods had not yet reached. This review aimed to systematically compare the effectiveness and safety of the treatment for mallet finger injuries via Kirschner wire fixation versus suture anchor technique to recommend an optimum option. METHODS: All literatures published until December 31, 2019 compared Kirschner wire fixation versus suture anchor technique to treat mallet finger were acquired through a comprehensive search in multiple databases. A meta-analysis was performed by the Cochrane Collaboration's RevMan 5.3 software. RESULTS: A total of 8 trials with 362 cases consisted of 4 randomized controlled trials and 4 prospective studies. The results suggested that the groups treated with kirschner wire fixation experienced more significant advantage in less complications than suture anchor groups (P  < .05). On the other hand, no significant differences were found in terms of the total active range motion of the distal interphalangeal joint, the average distal interphalangeal joint extensor lag, Visual Analogue Scale scores, recurrence, as well as functional assessment at the final follow-up (P > .05, respectively) between the two surgical procedures. CONCLUSIONS: No obvious superiority were shown for the effectiveness between the two surgical interventions based on the above results. But in view of the less economic spending and complications, Kirschner wire fixation should be a better alternative relative to the suture anchor technique for inevitable surgical treatment of mallet finger lesions. However, a prudent attitude is still necessary to choose the two operative managements before a large sample and high-quality randomized controlled trials had been performed.

Validation of new measures of arm coordination impairment in Wheelchair Rugby.

This study aims were twofold: (1) to evaluate the construct validity of the Repetitive Movement Test (RMT) a novel test developed for Wheelchair Rugby classification which evaluates arm coordination impairment at five joints - shoulder, elbow, forearm, wrist and fingers - and (2), pending sufficiently positive results, propose objective minimum impairment criteria (MIC). Forty-two WR athletes with an eligible coordination impairment, and 20 volunteers without impairment completed the RMT and two clinically established coordination tests: the finger-nose test (FNT) and the spiral test (ST). Coordination deduction (CD), an ordinal observational coordination scale, currently used in WR classification, was obtained. Spearman-rank correlation coefficients (SCC) between RMT and ST (0.40 to 0.67) and between RMT and CD (0.31 to 0.53) generally supported RMT construct validity, SCC between RMT and FNT were lower (0.12-0.31). When the scores on ST, FNT and RMT from the sample of WR players were compared with the scores from volunteers without impairment, 93.5% to 100% of WR players had scores > 2SD below the mean of volunteers without impairment on the same test. In conclusion, RMT at the elbow, forearm, wrist and fingers have sufficient construct validity for use in WR. MIC were recommended with ST and RMT.

PsART-ID inception cohort: clinical characteristics, treatment choices and outcomes of patients with psoriatic arthritis.

OBJECTIVES: Our aim is to understand clinical characteristics, real-life treatment strategies, outcomes of early PsA patients and determine the differences between the inception and established PsA cohorts. METHODS: PsArt-ID (Psoriatic Arthritis- International Database) is a multicentre registry. From that registry, patients with a diagnosis of PsA up to 6 months were classified as the inception cohort (n==388). Two periods were identified for the established cohort: Patients with PsA diagnosis within 5-10 years (n = 328), ≥10 years (n = 326). Demographic, clinical characteristics, treatment strategies, outcomes were determined for the inception cohort and compared with the established cohorts. RESULTS: The mean (s.d.) age of the inception cohort was 44.7 (13.3) and 167/388 (43.0%) of the patients were male. Polyarticular and mono-oligoarticular presentations were comparable in the inception and established cohorts. Axial involvement rate was higher in the cohort of patients with PsA ≥10 years compared with the inception cohort (34.8% vs 27.7%). As well as dactylitis and nail involvement (P = 0.004, P = 0.001 respectively). Both enthesitis, deformity rates were lower in the inception cohort. Overall, 13% of patients in the inception group had a deformity. MTX was the most commonly prescribed treatment for all cohorts with 10.7% of the early PsA patients were given anti-TNF agents after 16 months. CONCLUSION: The real-life experience in PsA patients showed no significant differences in the disease pattern rates except for the axial involvement. The dactylitis, nail involvement rates had increased significantly after 10 years from the diagnosis and the enthesitis, deformity had an increasing trend over time.

Clinical Characteristics and Surgical Outcomes of Congenital Ulnar-deviated Thumbs: Delta Triphalangeal Thumbs and Irregular Epiphyses.

BACKGROUND: Delta triphalangeal thumbs (DTPT) and irregular epiphysis thumbs (IET) had different anatomic deformities. Our primary purpose was to evaluate the clinical and radiographic outcomes of surgical treatment in DTPT and IET. METHODS: In total, 43 ulnar-deviated thumbs were included and categorized into 2 types according to x-ray and exploration during surgery, DTPT and IET. Surgical excision of the delta phalanx in DTPT and intraepiphysis osteotomy in IET was conducted. RESULTS: In total, 23 ulnar-deviated thumbs were classified as DTPT and 20 as IET. Ten thumbs that could not be classified initially were followed-up until they could be categorized at the mean age of 24 months. The preoperative mean degrees of ulnar deviation at the interphalangeal joints were 40 and 33 degrees, in DTPT and IET, respectively. The mean degrees were 2 and 5 degrees in final follow-up, showing significant improvement (DTPT, P<0.05; IET, P<0.05). Complications during the study included residual ulnar deviation, overcorrection, and nonunion. The stability and range of movement at the interphalangeal joint were good overall. According to the Japanese Society for Surgery of the Hand scoring system, results were excellent in 29 cases, good in 13, and fair in 1. CONCLUSIONS: Ulnar clinodactyly of the thumb occurs because of different anatomic features such as DTPT or IET. We recommend surgical treatment be postponed until the anatomic abnormality can be ascertained. Furthermore, almost all patients with ulnar-deviated thumbs had significant improvement in clinical and radiographic outcomes after surgery.

Two-Year Changes in Magnetic Resonance Imaging Features and Pain in Thumb Base Osteoarthritis.

OBJECTIVE: To investigate the two-year course of pain and osteoarthritic features on magnetic resonance imaging (MRI) in the thumb base. METHODS: Patients in the Hand Osteoarthritis in Secondary Care (HOSTAS) cohort who had received radiographic examination, MRI, and clinical examination of the right thumb base at baseline and who had a 2-year follow-up period were studied. Pain on palpation of the thumb base was assessed on a 0-3 scale. MRIs were analyzed with the Outcome Measures in Rheumatology (OMERACT) thumb base osteoarthritis MRI scoring system for synovitis, bone marrow lesions (BMLs), subchondral bone defects, cartilage space loss, osteophytes, and subluxation. Radiographs were assessed for osteophytes and joint space narrowing. We studied the associations of changes in synovitis and BMLs with changes in pain using a logistic regression model adjusted for radiographic damage, with values expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: Of 165 patients, 83% were women and the mean age was 60.7 years. At baseline, 65 patients had thumb base pain. At 2-year follow-up, pain had decreased in 32 patients and increased in 33 patients. MRI features remained stable in most patients. Structural MRI features generally deteriorated, while synovitis and BMLs improved in some individuals and deteriorated in others. Change in radiographic osteophytes rarely occurred (n = 10). Increased synovitis (odds ratio [OR] 3.4 [95% CI 1.3-9.3]) and increased BMLs (OR 5.1 [95% CI 2.1-12.6]) were associated with increased pain. Decreased BMLs appeared to be associated with decreased pain (OR 2.7 [95% CI 0.8-8.9]), and reductions in synovitis occurred too infrequently to calculate associations. CONCLUSION: Over 2 years, thumb base pain fluctuated, while MRI features changed in a minority of patients with hand osteoarthritis. Changes in synovitis and BMLs were associated with changes in pain on palpation, even after adjustment for radiographic damage.

Prognostic factors for finger interphalangeal joint osteoarthritis: a systematic review.

OBJECTIVE: Radiographic hand OA affects one in five adults. Symptomatic hand OA can result in functional impairment, pain and reduced quality of life. A prevalent form of hand OA is IP joint OA, however prognostic factors for IP joint OA remain poorly understood. This systematic review aimed to identify prognostic factors for IP joint OA, and to summarize the diagnostic criteria for IP joint OA in prognostic studies. METHODS: EMBASE, MEDLINE, Scopus and The Cochrane Library were searched from inception until 19 February 2020 (PROSPERO CRD42019116782). Eligible studies described diagnostic criteria defining IP joint OA, and assessed potential prognostic factors for IP joint OA. Risk of bias was assessed using a modified Quality in Prognosis Studies (QUIPS) tool and a best evidence synthesis was used. RESULTS: Eighteen studies were included (risk of bias: eight high, three moderate, seven low). All defined OA radiographically, and three studies incorporated clinical symptoms into their definition of OA. Forty-nine potential prognostic factors were assessed. Eight were prognostic: older age in women, female gender (both moderate evidence); family history of Heberden's nodes, Kashin-Beck disease, older age in men, dental occupation in men, finger fracture, parity (all limited evidence). Higher BMI in women (limited evidence) was prognostic for symptomatic radiographic OA. No prognostic factors for symptomatic OA were identified. CONCLUSION: IP joint OA is most commonly defined radiographically, yet criteria were heterogeneous. Eight prognostic factors for radiographic IP joint OA and one for symptomatic radiographic IP joint OA were identified, all with limited or moderate evidence. Further studies on causality and on prognostic pathways are needed.

Replantation for multiple digit amputations: A retrospective analysis of the clinical results.

PURPOSE: Replantation of multidigit amputations is difficult to perform due to severe damage to the digits, prolonged operative time, and ischemia. This study aimed to report the clinical results of multidigit replantation. METHODS: A retrospective case series of 34 digits belonging to 12 consecutive patients who underwent multidigit replantation was conducted. Patients with injury in at least one or more amputated fingers proximal to the insertion of the flexor digitorum superficialis tendon were included. The mean follow-up duration was 18.1 months. The number of amputated digits, mechanism and zone of injury, survival rate, and clinical outcomes, including the range of motion, grip strength, and sensory recovery, at the final follow-up were reviewed and analyzed. RESULTS: The mean number of amputated digits per patient was 2.8. Complete survival was achieved in 27 of 31 digits (87.1%). The mean final percentage of total active motion of injured digits was 47.0%, and the mean percentage of grip strength was 45.9% of the contralateral uninjured side. The comparison between patients with two and three amputated digits showed that there was no significant difference in both survival rates and functional outcomes. CONCLUSIONS: The results showed that both the survival rates and functional outcomes of multidigit replantation were as good as those of single-digit replantation, and there was no significant difference for outcomes between patients with two and three amputated digits. These results suggested that all multidigit replantations should be performed regardless of the number of injured digits or amputation zones.

Modified homodigital dorsolateral proximal phalangeal island flap for the reconstruction of finger-pulp defects.

BACKGROUND: Reconstruction of finger-pulp defects remains a challenge, although the treatment varies widely. The homodigital island flap based on dorsal branches of the proper digital artery (PDA) is one of the most popular methods for repair of finger-pulp defects. The aim of this study was to introduce our experiences of using modified dorsolateral proximal phalangeal island flaps for reconstruction of finger-pulp defects. METHODS: From July 2016 to November 2018, 16 modified dorsolateral proximal phalangeal (MDPP) island flaps were performed for finger-pulp reconstruction. The comparison group included 11 patients treated with homodigital dorsal perforator (HDP) flaps. Flap survivals were assessed and active range of motion (ROM) of the joints, time to return to work, static 2-point discrimination and hand performance were analysed at final follow-up. RESULTS: Both the Group MDPP and the Group HDP had similar satisfactory flap survival. There were no differences in static 2-point discrimination, time to return to work and the ROM of the injured fingers. However, the Michigan Hand Outcomes Questionnaire (MHQ) summary scores of the satisfaction and aesthetics were much better in Group MDPP. CONCLUSIONS: The modified homodigital dorsolateral proximal phalangeal island flap is a reliable alternative for finger-pulp reconstruction with good functional and cosmetic outcome.

Risk factors for the progression of finger interphalangeal joint osteoarthritis: a systematic review.

Progressive hand interphalangeal joint (IPJ) osteoarthritis is associated with pain, reduced function and impaired quality of life. However, the evidence surrounding risk factors for IPJ osteoarthritis progression is unclear. Identifying risk factors for IPJ osteoarthritis progression may inform preventative strategies and early interventions to improve long-term outcomes for individuals at risk of IPJ osteoarthritis progression. The objectives of the study were to describe methods used to measure the progression of IPJ osteoarthritis and identify risk factors for IPJ osteoarthritis progression. MEDLINE, EMBASE, Scopus, and The Cochrane Library were searched from inception to 19th February 2020 (PROSPERO CRD42019121034). Eligible studies assessed potential risk factor/s associated with IPJ osteoarthritis progression. Risk of bias was assessed using a modified QUIPS Tool, and a best evidence synthesis was performed. Of eight eligible studies, all measured osteoarthritis progression radiographically, and none considered symptoms. Eighteen potential risk factors were assessed. Diabetes (adjusted mean difference between 2.06 and 7.78), and larger finger epiphyseal index in males (regression coefficient ß = 0.202) and females (ß = 0.325) were identified as risk factors (limited evidence). Older age in men and women showed mixed results; 13 variables were not risk factors (all limited evidence). Patients with diabetes and larger finger epiphyseal index might be at higher risk of radiographic IPJ osteoarthritis progression, though evidence is limited and studies are biased. Studies assessing symptomatic IPJ osteoarthritis progression are lacking.

The Effect of Ring Finger Distal Interphalangeal Joint Stiffness on Grip Strength: A Simulated Study in Normal Participants.

Background: Pain of the hand distal interphalangeal joints may result from trauma, osteoarthritis or inflammatory arthritis. When symptoms are not controlled by non-operative means, surgical arthrodesis may be performed, resulting in complete stiffness of the joint and possible weakening of grip strength. This study aims to quantify the effect of a stiff ring finger distal interphalangeal joint on overall grip strength. Methods: One hundred participants were screened to exclude upper limb pathology. A Jamar dynamometer was used to assess overall hand grip strength. A splint was used to prevent distal interphalangeal joint flexion, thus replicating a fused distal interphalangeal joint. Participants were tested with and without the splint and the results compared. The mean of three grip strength tests was taken. Results: The participants included 55 females. Mean age was 31 (18-60 years). 76 participants had a reduction in grip strength with splinting, with a significant difference seen (p < 0.05) on Wilcoxon signed rank test. The median reduction in grip strength with splinting was 1.67 kg. However only 10 participants (10%) had a grip strength loss of greater than 6.5 kg, which is the minimal clinically important difference. Conclusions: This study found a significant loss in overall hand grip strength when the ring finger distal interphalangeal joint was stiffened. However, despite this significant change, only 10 (10%) participants experienced a reduction of greater than 6.5 kg. This is the level of weakness felt to be required to reduce function. Thus our results suggest that 90% of patients with a stiff ring finger distal interphalangeal joint are unlikely to have a clinically identifiable functional reduction in grip strength as a result.

Phenotypic spectrum and genetic analysis in the fatal cases of Schaaf-Yang syndrome: Two case reports and literature review.

RATIONALE: Schaaf-Yang syndrome, a rare imprinted hereditary disease caused by MAGEL2 variants, manifests as developmental delay/intellectual disability, neonatal hypotonia, feeding difficulties, contractures, and autism spectrum disorder. PATIENT CONCERNS: Patient 1 and 2 were infant girls presenting facial dysmorphisms, contractures of interphalangeal joints, neonatal hypotonia, feeding difficulties, congenital heart diseases, and respiratory complications. Besides, Patient 2 presented with delayed psychomotor development. DIAGNOSIS: Whole-exome sequencing was performed and heterozygous mutations of the MAGEL2 gene were detected in the patients. They were diagnosed as Schaaf-Yang syndrome. INTERVENTIONS: The patients received supportive treatment including mechanical ventilation, parenteral nutrition and gastric tube feeding. OUTCOMES: Whole-exome sequencing revealed de novo heterozygous c.1996dupC pathogenic mutations in the MAGEL2 gene in the 2 patients. They died due to respiratory failure at the age of 20 days and 98 days, respectively. LESSONS: Our results indicate that MAGEL2 variants can cause congenital heart disease and fatal respiratory complications, broadening the phenotypic spectrum and adding to the fatal cases of Schaaf-Yang syndrome. We highly suggest that the MAGEL2 gene should be added to gene-panels or gene-filters in next-generation sequencing-based diagnostics, which is of great significance for early diagnosis and early intervention of Schaaf-Yang syndrome patients.

New Functional Evaluation Scheme - Modality of the Results of Forearm Tendon Transfers Evaluation in Cases of Irreparable Radial Nerve Injury.

INTRODUCTION: There are several evaluation schemes for the results of tendon transfers in case of radial nerve paralysis, and the most logical and commonly used are evaluation schemes that use the range of active joint movements to evaluate the results. AIM: Present an original evaluation scheme for tendon transfer results based on functional wrist and fingers joint movements. The aim of the article is to present the advantages of our own Functional scheme in comparison with other schemes, its simplicity and applicability in the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated, and to present the ease of comparison of the achieved results with other authors who would possibly use our scheme because it minimizes the subjective error of the examiner. The secondary aim is to compare the results of flexor carpi radialis (FCR) vs. flexor carpi ulnaris (FCU) tendon transfers (TT). METHODS: The study was conducted as clinical and retrospective. The study included 60 patients with isolated radial nerve palsy operated by two tendon transfer surgical methods (FCR and FCU) over a 10-year period. The evaluation of the results was performed by using Zachary, Neimann-Pertecke, Tajima evaluation schemes, our own Functional Evaluation Scheme as well as subjective patient evaluation. RESULTS: The time elapsed from injury to surgery ranged from 105 to 956 days in case of FCR tendon transfer and from 109 to 712 days in cases of FCU tendon transfer. The overall average age of patients is 36.71 years. A statistically significant difference in values with t -test based on the Functional Evaluation Scheme was found in the variables of ulnar deviation (p=0.000731), extension of the MP fingers joints II-V (p=0.04610) and extension of the MP of the thumb joint (p=0.0475). Evaluation of the total results with t-test (p=0.007532) and with U-test (p=0,00433) showed statistically better FCR tendon transfer results. A statistically significant difference in value measured by the t-test was found in the evaluation of the overall results (p=0.022) with Zachary and Neumann-Pertecke schemes and by the Tajima evaluation Scheme (p=0.042) in favor of better FCR tendon transfer results. With a use of Functional Evaluation Scheme, it is possible to evaluate all the results unlike most available schemes. CONCLUSION: The functional evaluation scheme is based on the functional joint movements evaluated and incorporating radial and ulnar deviation of the wrist (RD and UD), extension of the metacarpophalangeal (MCP) joint and flexion of the intephalangeal (IP)joint of the thumb in the final evaluation becomes completely original. A functional evaluation scheme is simply applicable for the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated. FCR tendon transfer achieves better results than FCU TT.

Intrinsic plus hand: Painful Finger flexion and extension.

Intrinsic plus hand describes a rare and painful contracture of the intrinsic hand muscles with excessive flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Resulting from many causes to include trauma and neurologic injury, intrinsic plus hand can involve any number of fingers. Emergency department (ED) assessment should include evaluation for cerebrovascular injury, infection, compartment syndrome, and deep vein thrombosis (DVT). Conservative splinting is generally unsuccessful and ultimately requires operative intervention. We highlight the case of a 61-year-old otherwise healthy male who awoke to a painful and mildly swollen left hand with his fingers held in a contracted position. Evaluation in the ED found no active range of motion in the digits, severe pain with any passive motion, and a negative upper extremity ultrasound for DVT. Ultimately, orthopedic and neurology consults in the ED agreed upon a diagnosis of intrinsic plus hand.

Poor prognostic factors in predicting abatacept response in a phase III randomized controlled trial in psoriatic arthritis.

In ASTRAEA (NCT01860976), abatacept significantly increased American College of Rheumatology criteria 20% (ACR20) responses at Week 24 versus placebo in patients with psoriatic arthritis (PsA). This post hoc analysis explored relationships between prospectively identified baseline characteristics [poor prognostic factors (PPFs) ] and response to abatacept. Patients were randomized (1:1) to receive subcutaneous abatacept 125 mg weekly or placebo for 24 weeks; those without ≥ 20% improvement in joint counts at Week 16 switched to open-label abatacept. Potential predictors of ACR20 response were identified by treatment arm using multivariate analyses. Likelihood of ACR20 response to abatacept versus placebo was compared in univariate and multivariate analyses in subgroups stratified by the PPF, as defined by EULAR and/or GRAPPA treatment guidelines. Odds ratios (ORs) were generated using logistic regression to identify meaningful differences (OR cut-off: 1.2). 424 patients were randomized and treated (abatacept n = 213; placebo n = 211). In abatacept-treated patients, elevated C-reactive protein (CRP), high Disease Activity Score based on 28 joints (CRP), presence of dactylitis, and ≥ 3 joint erosions were identified as predictors of response (OR > 1.2). In placebo-treated patients, only dactylitis was a potential predictor of response. In the univariate analysis stratified by PPF, ACR20 response was more likely (OR > 1.2) with abatacept versus placebo in patients with baseline PPFs than in those without; multivariate analysis confirmed this finding. Response to abatacept versus placebo is more likely in patients with features indicative of high disease activity and progressive disease; these characteristics are recognized as PPFs in treatment guidelines for PsA.

Lateral stability in healthy proximal interphalangeal joints versus surface replacement and silicone arthroplasty: Results of a three-dimensional motion analysis study.

The objective of this study was to quantify the lateral stability of healthy proximal interphalangeal (PIP) joints using a three-dimensional motion capture system and compare it to affected joints after surface replacement or silicone arthroplasty. Three study groups comprised healthy participants, patients with PIP joint osteoarthritis treated with a surface replacing implant (CapFlex-PIP) and those with a silicone arthroplasty. All participants were matched on gender and finger, and the two patient groups were also matched on length of follow-up. An optical tracking system was used to measure lateral stability. Radial and ulnar stability of the PIP joint was measured as the maximal lateral deviation angle of the middle phalanx under loads of 40 g, 90 g and 170g at 0°, 20° and 45° PIP joint flexion. Measurement reliability was evaluated with a test-retest trial [intraclass correlation coefficient (ICC)]. A total of 30 joints were assessed with 5 index and 5 middle fingers per test group. Lateral deviation increased proportionally with applied weight. Silicone arthroplasty joints had a higher median lateral deviation angle of 5.1° (range 0.7-7.9) than healthy [3.0° (0.5-11.0)] and surface replacement joints [3.3° (0.3-7.4)] at 45° flexion and under 170g load. Test-retest reliability was high with an ICC of 0.93. Lateral PIP joint stability is highly variable in both healthy participants and patients after PIP joint arthroplasty. PIP joint surface replacement arthroplasty tends to achieve better anatomical stability compared to flexible silicone implants.

A New Proximal Dorsal Approach for DIP Arthroplasty.

Degenerative changes of the distal interphalangeal (DIP) joints can be painful, disabling, and disfiguring. Swanson spacers can be used for DIP arthroplasty. The standard approach for Swanson spacer implantation at the DIP joint involves transecting the extensor tendon close to its insertion, which necessitates a 6-week period of postoperative immobilization. Another DIP approach involves sparing the extensor tendons, as already published. Both techniques lead to a similar range of motion of the replaced DIP joints. We present a novel approach for DIP joint arthroplasty with division of the extensor tendon in zone 2 with only 2 weeks of postoperative immobilization. Optimizing the motion-preserving operative approaches is of value to our high-demand patients. Postoperative results do not differ from the postoperative range of motion published in the literature for both tendon-sparing and standard approaches. But our approach is technically easy and requires a significantly shorter time of immobilization.