Intensive training programme for ultrasound-guided minimally invasive synovial tissue biopsy on knees and wrists in different phases of inflammation.

OBJECTIVES: To develop an intensive training programme for ultrasound (US)-guided synovial tissue (ST) biopsy on knees and wrists in inflammatory arthritis and to assess the learning curve, patient tolerability, sample quality and trainees' expectations. METHODS: Active or remission rheumatoid arthritis patients were enrolled. Nine trainees joined the 4-month programme in a centre experienced in performing US-guided ST biopsies consisting of four sequential phases: (1) observation, (2) performance of guided step-by-step phases, (3) execution of the whole procedure on paired joints (knees or wrists) of the same patient in parallel with the trainer and (4) performance of the procedure autonomously. Sample representativity was assessed by histology, and procedure-related adverse events were recorded. Before and after the programme, trainees' expectations and perceptions were collected. RESULTS: 328 ST biopsy procedures were included. The rate of trainees' informative samples was: (1) comparable to the trainers in active and remission knees, but lower in active wrists (70% for trainees vs 100% for trainers, p=0.06) in phase 3; (2) excellent on active knees and wrists (91.9% and 90.9% respectively) but lower (77.6%, p=0.0089) on remission knees in phase 4. Procedures performed by trainees did not affect patient tolerability. Trainees' expectations about procedure-related invasiveness and pain infliction decreased while the difficulty of procedure execution on active wrists and remission knees remained perceived as moderately difficult. CONCLUSIONS: This intensive training programme develops advanced skills in the performance of US-guided ST biopsy on knees and wrists, yielding high-quality specimens available for basic and translational studies on inflammatory joint diseases.

Carpal tunnel syndrome secondary to a giant lipoma of the wrist and distal forearm.

In up to 2% of the population, benign tumours called lipomas can develop. When they are more than 5 cm, they are considered giant lipomas. Giant lipomas of the distal forearm and hand may cause compression to the underlying tissues, nerves and muscles, even though they are typically asymptomatic. An older woman with soft tissue swelling in her right wrist and forearm, and numbness and pain in her right hand presented to the general surgery outpatient clinic. Her numb fingers indicated that the median nerve was compressed, and an MRI scan of her wrist and forearm revealed median nerve compression due to a giant lipoma with a dimension of about 9.2×3.4×4 cm. A surgical excision was done with an intraoperative nerve stimulator, and the specimen sent for histopathology confirmed the diagnosis of lipoma. Pain, numbness and motor power improved within 1 week postoperatively, and the patient was discharged.

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients.

PURPOSE: Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury. MATERIALS AND METHODS: Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery. RESULTS: All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery. CONCLUSIONS: The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

Locally Invasive Pigmented Villonodular Synovitis of the Wrist Treated by Arthroscopic Resection and Bone Grafting.

Pigmented villonodular synovitis (PVNS) is a benign but locally aggressive neoplasm that can affect tendon sheath, bursae, or joint. The wrist joint however is uncommonly involved and here we present a case of chronic monoarticular joint pain and swelling in a healthcare professional that was later histologically verified to be PVNS of the radiocarpal joint. The patient had a magnetic resonance imaging (MRI) performed prior to surgery which showed a locally invasive bony tumor of the scaphoid. He subsequently underwent a wrist arthroscopic evaluation and resection with bone grafting as the index surgery and made an uneventful postoperative recovery. This is a novel technique to address PVNS of the wrist as these cases are usually managed using open procedures which can lead to additional scarring and disrupt the blood supply of the joint capsule.

Identifying anatomic landmarks and median nerve characteristics for the analysis of persistent carpal tunnel syndrome using magnetic resonance imaging (MRI).

OBJECTIVE: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy in the USA. In this study, we define anatomical landmarks to assess symptomatic and asymptomatic cohorts with persistent CTS using MRI imaging. MATERIALS AND METHODS: Distal vs proximal incomplete release was determined using the distal most aspect of the hook of hamate and the distal wrist crease. An incomplete release showed the transverse carpal ligament (TCL) intact at either boundary. Twenty-one patients with persistent CTS were analyzed for incomplete release, median nerve enlargement and T2 signal hyperintensity, and flattening ratio using postoperative wrist MRI. These findings were compared to a ten-patient asymptomatic persistent CTS control group. Fisher's exact and a Student's two-tailed t-tests were used to determine statistical significance. RESULTS: In the symptomatic persistent CTS group, 13 (61.9%) incomplete releases were identified, 5 (38.5%) incomplete distally, and 1 (7.7%) incomplete proximally. There was no statistical significance in the rate of incomplete releases when compared to the asymptomatic group (p = 1.00). T2 signal hyperintensity and enlargement at the site of release showed no statistical significance, (p = 0.319 and p = 0.999, respectively). The mean flattening ratio at the site of release in the symptomatic group (2.45 ± 0.7) was statistically significant compared to the asymptomatic group (1.48 ± 0.46), (p = 0.007). CONCLUSION: Utilizing the established landmarks, the full length of the TCL can be assessed via MRI. Additionally, evaluation of the median nerve flattening ratio at the level of the incomplete release may be utilized as an aid to the clinical management of persistent CTS.

A Giant Lipoma in the Distal Forearm of a Cadaver.

OBJECTIVE: Lipomas are very common tumors which usually prefer the upper limbs and, depending on their size, may cause nerve compression, or may be asymptomatic. The current cadaveric report describes a giant lipoma in the distal forearm area. CASE REPORT: A large mass (5.1 × 3.2 × 1.6 cm) was identified on the palmar surface of the distal forearm, during dissection of a 63-year-old male cadaver. The mass caused anteromedial displacement and flattening of the median nerve (MN). Despite the lack of information about the subject's medical history, MN compression was assumed on the basis of the lipoma's size, its vicinity to neural structures, and the MN displacement and flattening. CONCLUSION: The enlarged distal forearm lipoma, located adjacent to the carpal tunnel, displaced and flattened the MN. The cadaveric finding described is clinically relevant for both differential diagnosis and surgical treatment of carpal tunnel syndrome.

[Ulnocarpal Wrist Pain - Tips for the Daily Practice].

INTRODUCTION: Ulnar wrist pain is a frequent symptom with many possible traumatic and non-traumatic causes. The complex anatomy and biomechanics of the wrist with the ulnocarpal complex including the triangular fibrocartilaginous complex (TFCC), the distal radio-ulnar joint (DRUJ) and the ulnar carpal bones make the differentiation between the possible causes difficult. A precise clinical investigation and appropriate imaging studies are essential for detecting the most important differential diagnoses, the first therapeutical steps and an early and appropriate referral to the hand surgeon.

Bone SPECT/CT in Advanced Diffuse Tenosynovial Giant Cell Tumor of the Wrist.

ABSTRACT: Tenosynovial giant cell tumor, previously known as pigmented villonodular synovitis, is a benign low-grade fibrohistiocytic proliferation with hemosiderin deposits in synovial joints. Mostly affecting the knee, it can also manifest in other synovial joints, infrequently also in the wrist. Tenosynovial giant cell tumor typically causes intense radionuclide uptake in all phases in planar bone scintigraphy, making a differentiation from other bone tumors or osteomyelitis difficult, especially in cases associated with extensive bone destruction. We present a case of an unusually advanced and extended tenosynovial giant cell tumor of the wrist in bone scintigraphy, SPECT/CT, radiograph, and MRI.

Clinical characteristics and treatment outcomes of tuberculous tenosynovitis of the hand and wrist.

Objective: Vietnam is endemic with tuberculosis (TB), which is highly prevalent in the community. TB tenosynovitis of the wrist and hand is uncommon. Because of its insidious progression and atypical presentations, it is often difficult to diagnose, leading to treatment delays. This study investigates the characteristics of clinical and subclinical signs and treatment outcomes of patients with TB tenosynovitis in Vietnam. Patients and Methods: This prospective longitudinal cross-sectional study included 25 TB tenosynovitis patients in the Rheumatology Clinic at University Medical Center Ho Chi Minh City. The diagnosis was made based on a tuberculous cyst in histopathological specimens. The data were collected through medical history, physical examination, and medical records, including demographics, signs, symptoms, condition duration, and related laboratory tests and imaging. The outcomes of all participants were assessed after 12 months of treatment. Results: The most common symptom of TB tenosynovitis was swelling of the hand and wrist, which was present in all patients. Its other symptoms included mild pain and numbness of the hand in 72% and 24% of patients, respectively. It can affect any site on the hand. Hand ultrasound findings included thickening of the synovial membrane (80%), peritendinous effusion (64%), and soft tissue swelling (88%). Most patients (18/22) had a good outcome after the treatment with anti-tubercular drugs. Conclusions: TB tenosynovitis progression is often insidious. Its most common symptoms are swelling of the hand and mild pain. Ultrasound is a useful tool to support the diagnosis. A histological examination confirms the diagnosis. Most cases respond and have a good outcome after 9-12 months of anti-tuberculosis treatment.

Carpal Tunnel Syndrome Secondary to Tuberculous Tenosynovitis With Rice Bodies: A Case Report.

CASE: We report the case of a 34-year-old African man who presented with severe symptoms of recurrent left carpal tunnel syndrome (CTS) and left hand swelling after previous open decompression. Considering the recurrent unilateral affection of the left hand in a patient working in a slaughterhouse in an area with a moderate burden for tuberculosis, tuberculous infection was suspected. Open surgery and biopsy revealed tuberculous tenosynovitis of flexor tendon sheath and shiny white rice bodies. CONCLUSION: Tuberculous tenosynovitis should be considered as a differential diagnosis of the CTS when there is evidence of proliferative tenosynovitis in patients from an endemic area for tuberculosis.

[Endoscopic release of the carpal tunnel using the Agee technique modified by Neumann]. / Endoskopische Dekompression des Karpaltunnels in der Agee-Technik modifiziert nach Neumann.

OBJECTIVE: Decompression of the median nerve by complete endoscopic release of the transverse carpal ligament (TCL) and the distal antebrachial fascia. Minimization of surgical trauma results in decreased postoperative morbidity and earlier return to work and daily activities. INDICATIONS: Symptomatic carpal tunnel syndrome. CONTRAINDICATIONS: Revision surgery after open or endoscopic procedure, rheumatic diseases. SURGICAL TECHNIQUE: Small transverse incision at the ulnar border of the palmaris longus tendon, and proximal to the distal wrist flexion crease. Exposure and incision of the antebrachial fascia, dilatation of the carpal tunnel and dissection of synovial tissue from the undersurface of the TCL. With the wrist in extension, the endoscopic blade assembly with integrated camera is inserted into the canal. Exposure of TCL and short incision in the middle portion. Gradually, dissection of the distal portion of the TCL then completion by retraction of the blade distally to proximally. POSTOPERATIVE MANAGEMENT: Slightly compressive dressing, selfcare on day 1 after procedure. RESULTS: More than 25 years of experience, more than 8000 treated patients, and 3 documented cases with intraoperative lesions of the median nerve requiring revision. High acceptance and patient satisfaction in AQS1 patient-reported surveillance.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review.

OBJECTIVES: The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research. METHODS: A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy. RESULTS: Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported. CONCLUSIONS: This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Tuberculous flexor tenosynovitis of wrist and hand.

A woman in her 40s presented with a swelling over her left distal forearm and hand since 7 months, progressively increasing in size. She had history of difficulty in moving her wrist and fingers with no associated pain. She had no immune or chronic conditions except for hypothyroidism for which she was on regular medication. On examination, there was an 8×7 cm swelling on the radial side of the volar surface of her left distal forearm extending till the thenar eminence. MRI of the left upper limb was suggestive of a soft tissue swelling arising from the flexor tendon.The patient was planned for surgical excision of the swelling. Intraoperatively, there was a mass arising from the flexor tendons of flexor digitorum superficialis, flexor digitorum profundus (FDP) and flexor pollicis longus (FPL), extending distally up to the mid palm region. On incising the flexor tendon sheath, it was observed that multiple yellowish rice like granules extended across the tendons. The lesion was excised completely and sent for histopathology examination. The lax FDP of little and ring fingers were plicated following proper tension adjustment and defect in FPL was primarily repaired. Postoperatively, the patient recovered well with no local wound complications. The biopsy report was suggestive of tuberculosis. The patient completed a course of antituberculosis treatment in 6 months.

Flexor tenosynovitis of the wrist with carpal tunnel syndrome.

Tubercular tenosynovitis of the wrist with carpal tunnel syndrome (CTS) is a rare occurrence. The authors present a case of tubercular flexor tenosynovitis of the wrist with CTS. A 60-year-old female presented with complaints of swelling in the volar aspect of the right wrist with numbness of the first three fingers for the past 6 months. Clinical and radiological diagnosis of chronic flexor tenosynovitis with median nerve compression neuropathy was made. The patient was operated with carpal tunnel release and total tenosynovectomy. Histopathology showed features suggestive of Koch's etiology. The patient was started with antitubercular therapy (ATT) and followed up regularly. Carpal tunnel symptoms subsided immediately after surgery and there was no recurrence of swelling at the last follow-up. Carpal tunnel release and tenosynovectomy should be performed at the earliest possible and followed up with ATT for better outcomes in tubercular tenosynovitis of the wrist with CTS.

Outcome of Multidisciplinary Treatment of Merkel Cell Carcinoma of the Hand and Wrist.

BACKGROUND/AIM: Skin cancers are the most common malignancy of the hand and wrist. Merkel cell carcinoma (MCC) is a rare, aggressive non-melanoma skin cancer arising from cutaneous neuroendocrine cells and is known for local and distant recurrence. The purpose of the current study was to examine the treatment outcome of patients with MCC of the hand and wrist. PATIENTS AND METHODS: We reviewed 25 patients (18 males:7 females) with MCC that occurred in the hand and wrist. The mean age at the time of biopsy of 71±11 years. RESULTS: Tumors were located on the hand (n=13), finger/thumb (n=9), and wrist (n=3). Local control included wide local excision (n=22). This included 21 non-amputation resections and one 5th digit ray amputation. Sentinel lymph node biopsy was performed in 21 patients with positive nodal disease in seven cases. Adjuvant radiotherapy was delivered to the primary site in 17 patients and additionally to the regional lymph node basin in six patients. Recurrence within five years was noted in 40% of patients (mean time to recurrence 18.4±20.6 months). Recurrence-free and disease-specific survival rates at 5-years were 54.8% and 67.6%. CONCLUSION: MCC is a rare cutaneous neuroendocrine carcinoma with a high propensity for regional nodal spread. Despite aggressive local treatment, adjuvant radiotherapy to the primary site and regional nodes, MCC of the hand and wrist has a high rate of recurrence and mortality within five years of diagnosis.

Solitary Radio-Opaque Lesion of Wrist (Tumoral Calcinosis) Disappears Spontaneously After Causing Acute Carpal Tunnel Syndrome: A Case Report.

CASE: We describe the case of a 53-year-old male patient with a history of acute carpal tunnel syndrome (CTS) provoked by a radio-opaque mass on the palmar side of the wrist. Although the mass disappeared in new radiographs 6 weeks later without any intervention apart from the carpal tunnel release, excisional biopsy was conducted on the residue, revealing tumoral calcinosis. CONCLUSION: Both acute CTS and spontaneous resolution are clinical manifestations of this rare condition on suspicion of which biopsy can be avoided by following a "wait and see" strategy.

Ultrasonography of fibroma of the tendon sheath in the hand and wrist.

BACKGROUND: The purpose of our study was to explore the sonographic characteristics of fibromas of the tendon sheath of the hand and wrist and to evaluate the value of high frequency ultrasound in the diagnosis of FTS. METHODS: We retrospectively reviewed the sonography of 42 patients with surgically proven FTS, including one with a relapsing tumor (43 lesions in total). The location, size, distribution, relationship with the surrounding tissue, two-dimensional gray-scale sonographic appearance and internal color blood flow of all lesions were analysed. RESULTS: The maximum diameter ranged from 0.4 to 2.8 cm, with an average of 1.5 ± 0.6 cm. Twenty-eight lesions (65%) were associated with an adjacent tendon, while the other 15 lesions (35%) were next to the joint. Spindle or oval lesions were common, followed by irregular shape. The nodules with clear boundaries were hypoechoic and had posterior echo enhancement. Thirty-seven lesions (86%) were homogeneous, while 6 lesions (14%) had cystic components with no echo inside. Seventeen lesions (40%) had a large amount of blood flow. Nine lesions (20%) had a small amount of blood flow. The other 17 lesions (40%) had no significant blood flow. CONCLUSIONS: The diagnosis of fibroma of the tendon sheath can be considered when ultrasound examination reveals a focal nodular mass adjacent to a tendon sheath with homogeneous hypoechogenicity and no or small or large amounts of blood flow.

Management of the Hand Tumors.

Tumors in the hand are relatively uncommon but 95% are benign. Tumors occurring in the hand, forearm and arm often have unique growth patterns and potential for metastasis that may be different from those seen elsewhere in the body. Secondary metastatic tumors in the hand are very rare (0.1%). Diagnosis is mainly clinical, but X-ray, USG and MRI help as a diagnostic aid. The aim of the study was to early diagnosis, see the pattern and proper management of the hand tumor and ensure good hand function. This prospective study was done from January 2004 to July 2019. We found 220 hand tumors in the hand unit, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Bangladesh. Among 220 patients, male were 114(51.81%) and female were 106 (48.19%). Out of 220 patients we found 190(86.36%) benign tumor and tumor like lesions and 30(13.64%) was malignant hand tumors. Out of 190 benign lesions, benign tumor was 158(83.15%) and 32(16.85%) was tumor like lesions. Among 158 benign tumor, bone tumors were 40(25.31%) and soft tissue tumours were 138(74.69%). Out of soft tissue tumor, peripheral nerve tumor was 20(12.66%). Enchondroma and Giant cell tumors are the most common among the benign bone tumors, on the other hand giant cell tumors of tendon sheath, Glomus tumor, haemangioma, neurofibroma, schwanoma are the common soft tissue tumors. Compound palmar ganglion, fibromatosis and tuberculosis of phalanx are the most common tumor like lesions. Synovial sarcoma 10(33.33%), osteosarcoma 03(10%), chondrosarcoma 03(10%), ewings sarcoma 02(6.66%), fibrosarcoma 04 (13.33%), Malignant fibrous histocytoma 01(3.33%), soft tissue sarcoma 01(3.33%), Merkel cell tumor 01(3.33%), pleomorphic Rabdomyosarcoma 01(3.33%), malignant melanoma 01(3.33%), clear cell sarcoma of tendon and aponeurosis 01(3.33%), undifferentiated carcinoma 01(3.33%) and extra skeletal chondro sarcoma 01(3.33%) were the malignant tumors. Most of the benign lesions recovered fully after excision except neurofibroma and malignant tumors were treated with excision (including amputation) and chemo-radiotherapy successfully, but 4 patients were refereed to higher center due to recurrence and deteriation of hand function and one patient died due to metastasis. Malignant hand tumor management is very difficult even after amputation with multidisciplinary approach. Hand tumor is uncommon and malignant tumors are rare but any abnormal lump or bump in the hand or wrist is considered as tumor. Early detection and intervention are essential for better prognosis and survival for malignant tumors of hands and upper limbs.

Superficial Angiomyxoma of the Wrist: Case Report and Literature Review.

BACKGROUND/AIM: Superficial angiomyxoma (SAM) is a rare benign soft-tissue tumor that usually occurs in the trunk, head and neck, and lower extremity of middle-aged adults. Herein, we describe an unusual case of SAM of the wrist, which was initially diagnosed as a ganglion cyst on imaging. CASE REPORT: The patient was a 71-year-old man with no history of trauma who presented with a 2-year history of a palpable mass in the left wrist. Physical examination revealed a 2.5-cm, elastic hard, mobile, nontender mass. Magnetic resonance imaging revealed a well-defined mass with iso-signal intensity relative to skeletal muscle on T1-weighted sequences and very high signal intensity on T2-weighted fat-suppressed sequences. Subtle internal enhancement was seen following gadolinium administration. Complete excision was performed under general anesthesia with tourniquet control. Histologically, the lesion was composed of bland spindle to stellate-shaped cells in an abundant myxoid stroma. Immunohistochemically, the lesional cells were positive for CD34 but negative for S-100 protein, smooth-muscle actin, desmin, epithelial membrane antigen and pancytokeratin. These findings were consistent with a diagnosis of SAM. There was no clinical evidence of recurrence during a follow-up period of 3 months. CONCLUSION: Although extremely rare, SAM should be considered in the differential diagnosis of a cyst-like solid lesion near small joints.