Barry P. Simmons

A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome.

We developed a self-administered questionnaire for the assessment of severity of symptoms and functional status in patients who have carpal tunnel syndrome. The reproducibility, internal consistency, validity, and responsiveness to clinical change of scales for the measurement of severity of symptoms and functional status were evaluated in a clinical study. The scales were highly reproducible (Pearson correlation coefficient, r = 0.91 and 0.93 for severity of symptoms and functional status, respectively) and internally consistent (Cronbach alpha, 0.89 and 0.91 for severity of symptoms and functional status, respectively). Both scales had positive, but modest or weak, correlations with two-point discrimination and Semmes-Weinstein monofilament testing (Spearman coefficient, r = 0.12 to 0.42). In thirty-eight patients who were operated on in 1990 and were evaluated a median of fourteen months postoperatively, the mean symptom-severity score improved from 3.4 points preoperatively to 1.9 points at the latest follow-up examination, while the mean functional-status score improved from 3 to 2 points (5 points is the worst score and 1 point is the best score for each scale). Similar improvement was noted in twenty-six patients who were evaluated before and three months after the operation. We concluded that the scales for the measurement of severity of symptoms and functional status are reproducible, internally consistent, and responsive to clinical change, and that they measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve. These scales should enhance standardization of measurement of outcomes in studies of treatment for carpal tunnel syndrome.

How antibodies to a ubiquitous cytoplasmic enzyme may provoke joint-specific autoimmune disease

Arthritis in the K/BxN mouse model results from pathogenic immunoglobulins (Igs) that recognize the ubiquitous cytoplasmic enzyme glucose-6-phosphate isomerase (GPI). But how is a joint-specific disease of autoimmune and inflammatory nature induced by systemic self-reactivity? No unusual amounts or sequence, splice or modification variants of GPI expression were found in joints. Instead, immunohistological examination revealed the accumulation of extracellular GPI on the lining of the normal articular cavity, most visibly along the cartilage surface. In arthritic mice, these GPI deposits were amplified and localized with IgG and C3 complement. Similar deposits were found in human arthritic joints. We propose that GPI–anti-GPI complexes on articular surfaces initiate an inflammatory cascade via the alternative complement pathway, which is unbridled because the cartilage surface lacks the usual cellular inhibitors. This may constitute a generic scenario of arthritogenesis, in which extra-articular proteins coat the cartilage or joint extracellular matrix.

Cadherin-11 Provides Specific Cellular Adhesion between Fibroblast-like Synoviocytes

Cadherins are integral membrane proteins expressed in tissue-restricted patterns that mediate homophilic intercellular adhesion. During development, they orchestrate tissue morphogenesis and, in the adult, they determine tissue integrity and architecture. The synovial lining is a condensation of fibroblast-like synoviocytes (FLS) and macrophages one to three cells thick. These cells are embedded within the extracellular matrix, but the structure is neither an epithelium nor an endothelium. Previously, the basis for organization of the synovium into a tissue was unknown. Here, we cloned cadherin-11 from human rheumatoid arthritis (RA)-derived FLS. We developed L cell transfectants expressing cadherin-11, cadherin-11 fusion proteins, and anti–cadherin-11 mAb. Cadherin-11 was found to be expressed mainly in the synovial lining by immunohistologic staining of human synovium. FLS adhered to cadherin-11–Fc, and transfection of cadherin-11 conferred the formation of tissue-like sheets and lining-like structures upon fibroblasts in vitro. These findings support a key role for cadherin-11 in the specific adhesion of FLS and in synovial tissue organization and behavior in health and RA.

Congenital radioulnar synostosis.

Congenital radioulnar synostosis can be severely disabling, especially if it is bilateral or if severe hyperpronation exists. Functionally, patients with severe deformity have trouble getting a cup to the mouth, using eating utensils, or accepting objects in an open palm. Of 33 patients (17 bilateral and 7 unilateral) underwent derotational osteotomy, with the majority being performed through the synostosis held with, an intramedullary wire and secondary transfixing device. There were eight complications, four involving neurovascular compromise. In bilateral cases, the best end position appears to be 10% to 15% of pronation in the dominant extremity and neutral in the other. Eighty-two percent of the patients had good or excellent results.

Symptoms, functional status, and neuromuscular impairment following carpal tunnel release

This study examined the resolution of symptoms, functional limitations and neuromuscular impairments following carpal tunnel release. Thirty-five patients were evaluated preoperatively and 6 weeks, 3 months, 6 months, and a mean of 27 months postoperatively. Evaluation consisted of physical examination (performed in a subset of patients) and previously validated questionnaire scales measuring symptoms, functional limitations, and satisfaction. Nocturnal pain, tingling, and numbness improved within 6 weeks after surgery. Weakness and functional status improved more gradually. Grip and pinch strength worsened initially, returned to pre-operative levels after about 3 months, and improved significantly by 24 months. The Tinel and Phalen signs remained positive in two and seven patients, respectively, after 2 years, and two-point discrimination remained abnormal in over half of patients after 2 years. These temporal patterns should be discussed with patients to foster realistic expectations of the response to surgery.

Treatment of posttraumatic radioulnar synostosis with excision and low-dose radiation

Two cases of posttraumatic radioulnar synostosis treated with excision and low-dose radiation are presented. Routine postoperative hand therapy was employed. Nearly full range of motion was restored in both cases. No wound healing problems were encountered. We suggest that low-dose radiation may be a useful method of prophylaxis against recurrence after excision of radioulnar synostosis.

Symptomatic carpal coalition

The carpus is initially a cartilaginous structure that subsequently demarcates into separate carpal bones. Failure of differentiation of parts results in carpal coalition, the most common of which occurs between the lunate and triquetrum. Lunate-triquetral coalitions can be subdivided into four types according to the degree of union. Four types are identified. A case report of type I is presented that responded to a lunate-triquetral fusion.

A broad screen for targets of immune complexes decorating arthritic joints highlights deposition of nucleosomes in rheumatoid arthritis

Deposits of Ig and complement are abundant in affected joints of patients with rheumatoid arthritis (RA) and in animal models of RA in which antibodies are demonstrably pathogenic. To identify molecular targets of the Igs deposited in arthritic joints, which may activate local inflammation, we used a combination of mass spectrometry (MS) and protein microarrays. Immune complexes were affinity-purified from surgically removed joint tissues of 26 RA and osteoarthritis (OA) patients. Proteins complexed with IgG were identified by proteomic analysis using tandem MS. A striking diversity of components of the extracellular matrix, and some intracellular components, copurified specifically with IgG from RA and OA tissues. A smaller set of autoantigens was observed only in RA eluates. In complementary experiments, IgG fractions purified from joint immune complexes were tested on protein microarrays against a range of candidate autoantigens. These Igs bound a diverse subset of proteins and peptides from synovium and cartilage, different from that bound by normal serum Ig. One type of intracellular protein detected specifically in RA joints (histones H2A/B) was validated by immunohistology and found to be deposited on the cartilage surface of RA but not OA joints. Thus, autoantibodies to many determinants (whether deposited as “neoantigens” or normal constituents of the extracellular matrix) have the potential to contribute to arthritic inflammation.

Subcondylar fossa reconstruction for malunion of fractures of the proximal phalanx in children

Subcondylar fractures of the proximal or middle phalanx occur at the neck of the phalanx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral radiograph is not obtained. If malunion occurs, there is a block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this bony block. Three patients are presented in whom this procedure allowed an average increase in flexion of 41.7 degrees.

CAMPTODACTYLY : CLASSIFICATION AND RESULTS OF NONOPERATIVE TREATMENT

To assess the relationship between clinical presentation and response to treatment, we reviewed the management of 59 involved proximal interphalangeal (PIP) joints in 22 patients with camptodactyly at a mean follow-up of 33 months. This population represented 24 cases of isolated infantile camptodactyly (type I), five cases of adolescent camptodactyly (type II), and 30 cases of syndromic camptodactyly (type III). Treatment response was assessed through passive range of motion measurements. Splinting and close adherence to an occupational therapy program were particularly effective for type I digits. We also recommend this approach for type II and type III camptodactyly, although severe deformities and well-established contractures are more common in these patients. We reserve operative intervention for only those patients who fail nonoperative management.