I. Proubasta

Silicone Proximal Interphalangeal Joint Arthroplasty for Primary Osteoarthritis Using a Volar Approach

PURPOSE To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Distal radioulnar joint prosthesis for the treatment of giant cell tumor of the distal ulna: a case report and literature review.

Giant cell tumor (GCT) of the distal end of the ulna is an uncommon site for primary bone tumors. When it occurs, en-bloc resection of the distal part of the ulna with or without reconstruction stabilization of the ulnar stump is the recommended treatment. We present a case of a 56-year-old man with a GCT of the distal ulna treated successfully with an en-bloc resection of the distal ulna with reconstruction using radioulnar joint prosthesis. Although the experience with this type of treatment is limited, implantation of a metallic prosthesis to replace the distal part of the ulna can also be considered as a salvage procedure for the treatment of this difficult pathology.

Fat pad and "little finger pulp" signs are good indicators of proper release of carpal tunnel.

OBJECTIVEThe release of the transverse carpal ligament (TCL) for relief of carpal tunnel syndrome has been a standard operative procedure since the early 1950s. Although complications are not common after the open surgical technique, a small but significant group of patients will have similar symptoms after surgery or will experience new symptoms in the postoperative period. Incomplete section of the TCL is the major cause of these complications. The authors have described two signs that confirm a complete release of the TCL, called the “fat pad” and “little finger pulp” signs. METHODSBetween 2000 and 2003, we treated 643 hands in 611 patients (45 men and 566 women; age range, 32–76 yr; mean age, 58.2 yr). All patients were examined 6 months after the procedure, with special attention given to the persistence or recurrence of symptoms. The presence of palmar scar pain, residual numbness, patient satisfaction, and time to return to work were also evaluated. A longitudinal incision (2 cm) at the base of the palm was used to release the TCL. A good indicator that the distal TCL has been released is the visualization of a fatty tissue (“fat pad” sign). This fatty tissue is always present underneath the most distal fibers of the TCL, covering the sensory digital branches of the median nerve. To confirm the complete release of the proximal fibers of the TCL, we should be able to introduce the little finger pulp in a proximal direction underneath the distal flexion crease of the wrist (“little finger pulp” sign). When both signs are confirmed, we can be certain that the TCL is completely released. RESULTSNight pain disappeared immediately after surgery in all patients except three. There were seven complications (1%) not related to the palmar scar and 10 complications (1.5%) related to it. However, all of these complications disappeared an average of 3 months postoperatively. Patient satisfaction was 100%, and the mean time to return to work and full activity was 22 days (range, 14–36 d). CONCLUSIONTwo surgical observations that are reliable to confirm a complete release of the TCL were described. The first, called the “fat pad” sign, is useful to determine whether or not the distal end of the TCL has been adequately released, whereas the “little finger pulp” sign indicates whether or not the proximal end of the TCL has been fully divided.

Extra-articular arthrodesis of the carpometacarpal joint of the thumb.

ABSTRACT There are numerous surgical treatment options for instability and painful trapeziometacarpal arthrosis. The available surgical treatments are arthrodesis and trapeziectomy alone or with synthetic/biologic interpositions, osteotomy, and total joint replacement. However, there is no clear consensus regarding the appropriate surgical procedure, and a unique situation exists in which the surgeon can develop a successful hybrid technique based on his own philosophy and experience. Traditionally, ligament reconstruction and tendon interposition have been used for elderly patients with lower demands whereas arthrodesis has been reserved for the treatment of posttraumatic arthritis in high-demand, younger patients. Regarding the second case, when thumb carpometacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. However, it is important to know the indications and contraindications, as well as benefits and risks of this procedure. Therefore, the surgical technique is straightforward, and fusion may be performed with either a plate-and-screw construct, power staples, tension band wiring with or without Kirschner wires, or alone with multiple Kirschner wires. However, in all the techniques, it is necessary to remove the articular surfaces of the metacarpal and trapezium apart from the need of autogenous bone graft to fill the defect between those bones from either the distal radius or iliac crest. In addition, later in almost all the cases, it is necessary to remove the metal work because of protrusion or skin intolerance. The technique described in this article is a modification of a sliding inlay metacarpal bone graft technique originally described by Müller in 1949 and, 52 years after, perfected by Doyle. However, and as opposed to these, with the extra-articular arthrodesis technique, it is not necessary to remove the articular surfaces, and the graft fixation is performed by 2 Herbert screws which, when buried into the bone, avoid the need to remove the metal work because of the protrusion under the skin. Therefore, this intervention easily permits to convert the arthrodesis to another method of treatment (implant arthroplasty or tendon interposition arthroplasty) by means of the resection of the bone bridge between the metacarpal and trapezium and proceed to the chosen surgical intervention.

Arthrodesis of the metacarpophalangeal joint of the thumb using a Herbert screw.

We describe a technique for thumb metacarpophalangeal joint arthrodesis by using a Herbert screw. This method of fixation helps in avoiding some of the potential problems associated with wire fixation, tension-band arthrodesis, or plate fixation. Therefore, it eliminates the risk of pin track infection, pin breakage, and painful protrusion under the skin requiring metalwork removal.

Tratamiento quirúrgico de las fracturas diafisarias y conminutas de la clavícula mediante placa anatómica de bajo perfil

OBJECTIVES In this study we evaluate the treatment of displaced mid-shaft clavicle fractures or comminuted fractures with a third fragment using a superior anatomic plate. MATERIALS AND METHODS A retrospective study was conducted on 34 patients operated on between January 2006 and June 2010 with this type of fracture. Mean follow up was 25 months (6-54 months). By Robinson Classification, 12 cases were type 2B, 17 type 2B1 and 5 type 2B2. Clinical evaluation was performed with the VAS and Constant test. For the radiological evaluation, we used neutral AP projections, and another with 30 degrees of cranio-caudal inclination. RESULTS The mean pre-operative VAS was 6.5 (4-8) and the postoperative was 1 (0-2). The mean Constant test score was 85, with 30% good results and 70% excellent results. The mean consolidation time was 14 weeks. CONCLUSION Internal fixation of comminuted fractures with an anatomic plate, particularly those with a vertical third fragment and fractures type 2B, 2B1 and 2B2, provides a good treatment option, as it gives good functional results and minimises the incidence of non-union.

Treatment of Midshaft Clavicular Non-unions by Means of the Herbert Cannulated Bone Screw

The incidence of non-union of the clavicle is reported to be between 0.1% and 15%. Various surgical procedures have been proposed for the treatment of this potentially disabling condition, including interfragmentary screws or wire suture, intramedullary pinning with Kirschner wires, Knowles pins, Steinmann pins, modified Hagie pins, external fixation, and compression plates with or without bone grafting. We present an alternative technique for the successful treatment of non-union of the midshaft of the clavicle, consisting of open intramedullary fixation using a Herbert cannulated bone screw, a technique that avoids the need for removing the implant after bone union occurs.

Estudio biomecánico del tornillo canulado de Herbert en el tratamiento de la pseudoartrosis de clavícula

Objetivo Valorar biomecanica y clinicamente una tecnica alternativa quirurgica para el tratamiento de la pseudoartrosis del tercio medio de la clavicula. Material y metodo Estudio mecanico: diecinueve especimenes de claviculas humanas fueron divididos en tres grupos: grupo A, 5 claviculas intactas, grupo B, 5 claviculas osteotomizadas perpendicularmente al eje longitudinal del hueso, en su parte media, y tratadas con placas DCP de 3,5 mm y 6 orificios, y grupo C, 9 claviculas osteotomizadas y tratadas con clavo canulado de Herbert, de 4,5 mm. Todas las claviculas fueron sometidas a ensayos mecanicos en una maquina de ensayos servohidraulica obteniendo la resistencia maxima (N), la rigidez (N/Mm) y la tension maxima (Mpa). Resultados Estudio mecanico: tanto la placa recta DCP como el tornillo canulado de Herbert se comportaron mecanicamente de forma similar. Conclusiones La ventaja de la sintesis intramedular con tornillo canulado de Herbert es que no requiere una segunda operacion para retirar el implante una vez conseguida su consolidacion.

The Pathophysiology of the Osteoarthritis of the Thumb Joint Stability and Role of the Main Carpometacarpal Ligaments

Introduction: More than 16 ligaments around the joint have been described by Bettinger et al. (1999); four ligaments and the joint capsule are the main stabilizers of the trapeziometacarpal (TM) joint. These ligaments are the dorsoradial (DRL), intermetacarpal (IML), anterior oblique (AOL), and posterior oblique ligaments (POL). The importance of each of these ligaments in the stability of the TM joint is debatable. The purpose of the study was (1) to describe the anatomy and dimension of the thumb carpometacarpal (CMC) joint ligaments, (2) to assess the ligament lesions and the degree of subluxation of the CMC joint, and (3) to measure cartilage thickness in the trapezium and metacarpal and pattern of chondromalacia and osteoarthritis (OA). We investigated the role that these ligament ruptures play in the pathophysiology of the OA. Methods: Twenty-five fresh-frozen cadaver hands were dissected of all soft tissue to expose the joint capsule and ligaments of the TM joint. There were 14 male and 11 female with mean age of 67 years (range, 51-94 years). The dissection was performed under ×4.5 loupe magnification. We showed the main ligaments and also the ligament ruptures in IML, AOL or beak ligament, dorsal oblique ligament (DOL), and DRL. We described the location of the ligament tears and whether these ruptures were partial or total. The ligament ruptures and the metacarpal translation associated with these ruptures were measured (mm). Cartilage thickness in the trapezium and metacarpal of specimens was assessed. We described the degree of degenerative changes using the stanging protocol to describe visual degeneration by Koff et al. (2003). We investigated the relationship between the ligament ruptures and the area of chondromalacia and OA. Statistical analysis of data was performed with the chi-square test, and the level of significance was P < .05. Results: Seven principal ligaments of the thumb CMC joint were identified using Berger’s principles (200s1). Ligament lesions were found in all 25 specimens. Isolated rupture of the AOL was found in 7 (28%), isolated rupture of the DRL was found in 10 (40%), isolated rupture of the IML was found in 2 (8%). Combined rupture of the AOL and IML was found in 2 (8%) and combined rupture of the DRL and IML in 4 (16%) joints. The mean metacarpal displacement due to isolated rupture of the ligaments was DRL 17 mm (P = .006), AOL 11 mm, POL 0.5 mm, and IML 0.4 mm. We found 2 cases OA stage I, 7 cases OA stage II (1 IIa, 3 lib, and 3 IIc), 9 OA stage III, and 7 OA stage IV. There was a relationship between the presence of a tear in the DRL and the presence of OA in the radial quadrants (P = .032). Conclusion: These observations suggest a translation of metacarpal on trapezium in the production of arthritic lesions and support a hypothesis that pathologic joint instability could be a cause of CMC OA. This study suggests that repairing the DRL during ligament reconstruction of the CMC joint should be considered.

Histopathological Analysis of the Lunate in Rheumatoid Disorders: Role of the Angiogenesis and Synovitis in Kienböck Disease

Introduction: Avascular necrosis of the lunate in Systemic Lupus Erythematous (SLE) and rheumatoid arthritis (RA) are not rare. Our study aimed to describe the histopathology of the lunates after removing them in the operating room in patients with rheumatoid diseases and lunate palmar dislocation. We correlated the histopathological findings with magnetic resonance imaging (MRI), radiological parameters, and blood test parameters. Methods: From January 2006 to January 2015, 12 patients were operated for rheumatoid disorders, 8 RA, 1 SLE, and 3 psoriatic arthritis (PA). There were 8 female and 4 male with a mean age 65 (53-79) years. Antinuclear antibodies and other relevant tests were performed. Anticardiolipin antibody, anti-double-stranded DNA, and anti-β-2 glycoprotein I were measured by enzyme-linked immunosorbent assay (ELISA). All patients underwent MRI study. T1-weighted images were evaluated for bone necrosis of the lunate. In the operating room, we excised whole lunates and we studied the macroscopical aspect inside and outside. We evaluated the size, cartilage surfaces, number of foraminas, and ligament insertions. After that, we cut the bone and showed the bleeding bone and collapse areas. Histopathological analysis was performed with lunate sections. The lunates were fixed in formalin, decalcified, embedded in paraffin, and cut in 5 microm sections, and stained with hematoxylin and eosin. We visualized lunates sections by microscope. The surgical treatment was a wrist arthrodesis in 8 cases and wrist arthroplasty in the other 4 cases. We evaluated x-rays data such as lunate morphology, Stahl Index, Carpal Height ratio (CHR), and Carpal Ulnar distance ratio (CUDR). We correlated preoperative x-rays and MRI data with histopathological findings. We correlated blood test parameters with the histology. Statistical analysis of data was performed with chi-square test (significance level P < .05). Results: In 2 cases, we showed a lunate flattening associated with a partial hypointensity in coronal sections in T1-weighted images in MRI. Microscopic analysis showed synovial hyperplasia, fatty marrow, and fibrovascular tissue. We did not find avascular necrosis in any complete lunate but we found a focal necrosis (empty lacunae) in 2 cases. Mean CHR was 0.385, CUDR 0.301, Index Stahl 56.95, and radio-scaphoid angle 76°. We showed more ulnar translation in RA than in other rheumatoid disorders (CUDR P = .002). The correlation focal lunate necrosis with MRI was P = .371. The correlation focal lunate necrosis with scapholunate ligament rupture was P = .640. We showed 2 blood test parameters statistically significant with focal lunate necrosis (C reactive Protein P = .046 and Rheumatoid Factor P = .053). Conclusion: Neoangiogenesis and wrist synovitis in rheumatoid disorders, with an increased number of synovial cells and vessels, seem to contribute to the progression of autoimmune diseases. It is possible that the patients with rheumatoid wrists have hypervascularity and therefore a chronic adaptation to a decrease number of vessels in the lunate and to ligament injuries. This could avoid to have Kienböck disease in a chronic palmar lunate dislocation in rheumatoid disorders.