Proton therapy for prostate cancer: why and what orthopaedic surgeons need to know about it.

Most orthopaedic surgeons are unfamiliar with proton therapy or the difference between proton radiation and photon (X-ray) radiation. After they perform a total hip replacement or metallic hip implant, their patient cannot have proton therapy for prostate cancer because the protons must pass exclusively through the hips and are blocked by metal. Proton therapy is a sophisticated and expensive technology with growing demand and limited supply. In proton therapy, heavy protons are accelerated to almost the speed of light in a synchrotron (particle accelerator) down a magnetic beam the length of a football field to radiate cancers. Proton therapy is a remarkably safe and effective treatment for prostate cancer, the most common cancer in men, although treatment superiority has yet to be proved in randomized studies. There are currently only 10 proton centers in the United States.

Current concepts of the anatomy of the thumb trapeziometacarpal joint.

This review article describes the anatomy of the thumb trapeziometacarpal joint. In the final phase of opposition screw home torque rotation of the volar beak of the thumb metacarpal in the pivot area of the trapezium recess and tension on the dorsal ligament complex create stability for power pinch and power grip. The resulting compressive shear forces can lead over time to trapeziometacarpal joint osteoarthritis.

Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb.

The surgeon treating traumatic injuries to the TMC joint should be aware of the fundamental misconceptions and pervasive axiomatic myths perpetuated in the medical literature: namely that the volar beak ligament is the prime stabilizer, that the dorsal ligament complex plays no significant role in TMC joint function, and that the APL is a deforming force in Bennett fractures. On the contrary, stability of the TMC joint in power pinch and power grasp depends on the TMC joint's two prime stabilizers, the volar beak of the thumb metacarpal and the dorsal radial ligament complex; and the APL is not a deforming force in a Bennett fracture. Screw-home-torque occurs in the final phase of opposition; the acute Bennett fracture can be treated closed and percutaneously fixed if the screw-home-torque technique is used to anatomically reduce the fracture. After soft tissue interposition, if a semi-acute Bennett fracture is diagnosed late, it should be treated open with a volar approach, the screw-home-torque reduction technique, and screw or pin fixation. Rolando multipart fractures of the thumb metacarpal into the TMC joint are best treated closed, with traction in opposition with pin fixation; pure dislocations of the TMC joint that tear the dorsal ligament complex and Bennett fractures with an associated dorsal ligament complex tear (as diagnosed by the screw-home-torque technique) require open reduction and dorsal ligament complex repair. The current literature is so replete with myths and folklore regarding the anatomy that a conscientious surgeon treating a traumatic dislocation or in-stability of the TMC joint should return to the cadaver room and carefully review and understand TMC joint anatomy.

Polydactyly of the hand.

Polydactyly is considered either the most or second most (after syndactyly) common congenital hand abnormality. Polydactyly is not simply a duplication; the anatomy is abnormal with hypoplastic structures, abnormally contoured joints, and anomalous tendon and ligament insertions. There are many ways to classify polydactyly, and surgical options range from simple excision to complicated bone, ligament, and tendon realignments. The prevalence of polydactyly makes it important for orthopedic surgeons to understand the basic tenets of the abnormality.