Pedro K. Beredjiklian

Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome.

Background: The Internet has become a popular source of medical information for patients. Authors of health-related web pages are not required to adhere to any standard for medical content or accuracy. The goal of the present study was to assess the type, quality, and reliability of information about carpal tunnel syndrome that is available on the Internet.Methods: The search phrase carpal tunnel syndrome was entered into five commonly used World Wide Web search engines. The search results then were given as an ordered list of universal resource locators, or web-site addresses. The top (first) fifty web sites from each of the five searches were combined to create a master roster of 250 web-site addresses. These web sites then were evaluated for authorship and content, and an informational value score ranging from 0 to 100 points was assigned to each.Results: Thirty-three percent of the sites sold commercial products for the evaluation or treatment of carpal tunnel syndrome. An additional 30 percent were commercial web sites that did not sell products. Only 23 percent of the sites were authored by a physician or an academic organization. Fewer than half of the sites offered conventional information. Twenty-three percent of the sites offered unconventional or misleading information. The mean informational value of the web sites was 28.4 of a possible 100 points.Conclusions: The information about carpal tunnel syndrome on the Internet is of limited quality and poor informational value. The public and the medical communities need to be aware of these limitations so that the quality of medical information available on the World Wide Web can be improved.

Operative Treatment of Malunion of a Fracture of the Proximal Aspect of the Humerus

We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.

Regenerative versus reparative healing in tendon: a study of biomechanical and histological properties in fetal sheep.

AbstractPrevious studies have shown fetal tissues heal in a regenerative fashion without scar formation. The objective of this study is to compare the healing properties of adult and fetal tendons. Time-mated pregnant ewes at 80–85 days of gestation were utilized. A partial, midsubstance tenotomy was performed in the lateral extensor fetal tendons, and analogous tenotomies were created in the maternal limbs. One week after injury, the fetal and adult animals were sacrificed, and tendons were histologically and mechanically evaluated. Immunohistochemical staining for transforming growth factor beta isoform 1 (TGF-β1) was performed. Histologically, a gap with granulation tissue and inflammatory cells was visible in the site of wounding in the adult tendons. In the fetal tendons, no abnormalities were noted in the wound, with reconstitution of collagen architecture. TGF-β1 expression was low in fetal but upregulated in the adult wounds. No significant differences were found in the biomechanical properties between groups. We identified regenerative healing properties in injured fetal tendon, while adult tendon tissue healed reparatively with scar formation. Fetal tendons demonstrated a limited recovery of mechanical properties after injury that was no better than that of the adult tendons at seven days. A better understanding of the mechanisms of fetal healing may lead to novel therapeutic strategies in the clinical setting.

A comparison of the inflammatory potential of particulates derived from two composite materials

In order to develop total joint prostheses with moduli of elasticity close to bone while retaining excellent strength characteristics, composite materials are being developed. Composites consist of graphite fibers embedded in a polymer matrix. We studied the inflammatory potential of particulates derived from two composites with different matrix components, polysulfone (PFS) and polyetherketoneketone (PEKK), in the rat subcutaneous air pouch model. Neat components of the composites were studied separately in the air pouch. Particulates also were studied in culture using the macrophage cell line RAW 264.7, adherent synovial cells (ASC), and human polymorphonuclear neutrophils (PMNs). Particles derived from the PEKK-containing composite material consistently were less inflammatory than the PFS composite-derived particles, as measured by PMN infiltration, neutral metalloprotease activity, tumor necrosis factor (TNF) activity, and prostaglandin E2 (PGE2) accumulation. Results from the neat materials confirmed the findings in the composite-derived material. PEKK composite-derived material produced less TNF from macrophage cultures, but there were no significant differences noted in PGE2 production from ASC or in superoxide anion generation from PMNs. Particles from both PSF and PEKK produced minimal inflammatory responses in the rat subcutaneous air pouch. PEKK elicited a response virtually the same as the saline control and significantly less than that produced by particles of PSF.

Intra- and interobserver reliability of sensibility testing in asymptomatic individuals.

&NA; Threshold and innervation density tests are common clinical tools used in the evaluation of peripheral nerve injuries and compression syndromes. The purpose of this study is to determine the inter‐ and intraobserver reliability of Semmes‐Weinstein monofilaments and static and moving two‐point discrimination in 48 volunteers. Kappa coefficients of inter‐ and intraexaminer agreement were generated for each test and investigator. The interexaminer reliability for the Semmes‐Weinstein monofilaments ranged from fair to moderate in the ulnar and median nerve distributions, and slight to moderate in static and moving two‐point discrimination testing. Intraobserver reliability for Semmes‐Weinstein monofilaments and static and moving two‐point discrimination was slight to fair for both examiners. Our data indicate that Semmes‐Weinstein monofilaments and two‐point discrimination tests yield unreliable measurements in asymptomatic individuals. Although useful in monitoring neurological function in pathological states, threshold and innervation density measurements from an unaffected digit or extremity may not represent a reliable standard for comparison of abnormal values. Rozental TD, Beredjiklian PK, Guyette TM, Weiland AJ. Intra‐ and interobserver reliability of sensibility testing in asymptomatic individuals. Ann Plast Surg 2000;44:605‐609

Radiographic assessment of small finger metacarpal neck fractures.

Treatment recommendations for metacarpal neck fractures of the small finger are generally based on the degree of apex dorsal angulation at the fracture site. We evaluated the variability of measurement of fracture angulation and the effect this variability has on treatment recommendations for these injuries. A total of 96 radiographs (anteroposterior, lateral, oblique views) of 32 patients with fractures of the small finger metacarpal neck were evaluated independently by 3 fellowship-trained orthopedic hand surgeons. Treatment recommendations for each fracture were tabulated. This process was repeated 6 weeks later to evaluate intraobserver variability. Kappa coefficients of inter- and intraobserver reliability of fracture angulation measurement and treatment plans were generated. The mean reliability coefficient of the measurement of fracture angulation between the 3 different observers was slight. Similarly, the reproducibility of fracture angulation measurement within observers was fair. Agreement between observers for appropriate treatment recommendations for each fracture was fair and agreement within observers for treatment was only slightly better. The measurement of fracture angulation of small finger metacarpal neck fractures seems to be subject to a high degree of inter- and intraobserver variability.

CD44 deficiency improves healing tendon mechanics and increases matrix and cytokine expression in a mouse patellar tendon injury model.

CD44 plays an important role in inflammation and healing. Previous studies investigated its role in inflammatory diseases and skin wounds; however, the role of CD44 in tendon healing is unknown. Therefore, we investigated the effect of CD44 in the healing of the patellar tendon in a knockout mouse model. We hypothesized that in comparison to wild‐type counterparts, CD44 knockout mice would have decreased material parameters, increased organization, decreased expression of proinflammatory cytokines, and increased expression of matrix components during healing. These hypotheses were tested through an in vivo surgical model and mechanical, organizational, and gene expression analyses. Material strength and tissue organization were significantly improved in the CD44 knockout mouse. This could be attributed to increased expression of cytokines and matrix components that are also elevated in regenerative healing. Our study showed that the absence of CD44 in a mouse patellar tendon injury creates an environment that is conducive to regenerative healing through altered gene expression, resulting in superior material properties and reduced cross‐sectional area. Therefore, limiting the role of CD44 may improve healing parameters in adult tendon injury.

Osteochondritis dissecans of the capitellum in fraternal twins: case report.

The etiology of osteochondritis dissecans (OCD) of the capitellum is unknown but has generally been attributed to repetitive microtrauma or ischemia. We present a case report of fraternal twins with OCD lesions in their nondominant arms without a known history of repetitive injury to the elbow. This report provides evidence to support the idea of genetic predisposition for OCD lesions.

Serum-dependent effects on adult and fetal tendon fibroblast migration and collagen expression.

Cell migration and extracellular matrix synthesis play an important role in the wound‐healing response to injury. Several studies have described differences in migratory behavior and collagen biosynthetic activity in adult vs. fetal skin fibroblasts. The objective of this study was to examine the serum‐ and age‐dependent effects on cell migration and collagen expression in tendon fibroblasts. Medial tendon fibroblasts were isolated from pregnant ewes and their fetuses, and cultured with and without serum for up to 7 days. Cell migration was determined by quantitative image analysis, and collagen expression was assessed by reverse transcription‐polymerase chain reaction and immunohistochemical staining. In serum‐containing medium, tendon fibroblasts migrated significantly faster than cells in serum‐free medium. Additionally, fetal tendon fibroblasts migrated significantly faster than adult tendon fibroblasts under both culture conditions. The expression of types I and III collagen mRNA was significantly up‐regulated in tendon cell populations in serum‐free medium compared with those in serum‐containing medium. Quantitative assessment of collagen staining indicated that fetal tenocytes produced more type I collagen than adult tenocytes under both culture conditions. These findings suggest that there is an inherent difference between adult and fetal tendon fibroblasts, which may have implications in the wound‐healing response in tendons.

Physical Diagnosis and Radiographic Examination of the Thumb

Arthritis of the thumb joints is a common problem and remains a significant cause of morbidity in the adult population. Careful physical examination is critical in the assessment of these patients, given the large differential diagnosis of conditions affecting the thumb and the radial side of the wrist. Because treatment should be specifically directed at the area of pathology, adequate diagnosis is vital. Plain radiograph evaluation remains the diagnostic modality of choice in the evaluation of patients with degenerative conditions about the hand and wrist.