First metacarpal lengthening following traumatic amputation of the thumb: long-term follow-up

Thumb amputation is a relatively frequent injury in industrial accidents, producing a significant effect on hand function. The long-term results of 18 first metacarpal elongations in patients who had had a non-replantable thumb amputation at the metacarpophalangeal level are reported. Lengthening was performed using a unilateral external fixator. After a learning curve with a high complication rate and prolonged treatment, good functional results were obtained after some technical modifications, with eight patients returning to their previous occupation, and the rest requiring a change in their job.

Sagittally split fracture of trapezium associated with subluxated carpo-metacarpal joint of thumb

Trapezial fractures are uncommon, and require careful clinical and radiological assessment and treatment. Poor or inadequate treatment of displaced fractures of trapezium can lead to long-term morbidity. We report two displaced fractures of the trapezium. The clinical and radiological features are discussed. Both fractures were treated operatively and a good functional outcome was achieved.

Autologous Osteochondral Grafting (Mosaic Arthroplasty) for Treatment of Subchondral Cystic Lesions in the Equine Stifle and Fetlock Joints

OBJECTIVE

To describe treatment of equine subchondral bone cysts (SBCs) by reconstruction of the articular surface with osteochondral grafts.

STUDY DESIGN

Case series of horses with SBCs unresponsive to conservative therapy.

ANIMALS

Eleven horses (1-12 years).

METHODS

SBCs were identified in 4 locations: medial femoral condyle (5 horses), lateral femoral condyle (1), distal epiphysis of the metacarpus (4), or metatarsus (1). Osteochondral autograft transplantation (mosaic arthroplasty) was performed, taking grafts from the abaxial border of the medial femoral trochlea of the unaffected limb. Graft implantation was achieved through a small arthrotomy or by arthroscopy depending on SBC location.

RESULTS

All horses improved postoperatively; 10 horses had successful outcomes with radiographic evidence of successful graft incorporation and 7 returned to a previous or higher activity level. On follow-up arthroscopy (5 horses) there was successful reconstitution of a functional gliding surface. One horse had delayed incorporation of a graft because of a technical error but became sound. One horse had recurrence after 4 years of work and soundness. One stallion was used for breeding and light riding because of medial meniscal injuries on the same limb.

CONCLUSIONS

Implantation of osteochondral grafts should be considered for SBC when conservative management has not improved lameness and there is a risk of further joint injury and degeneration.

CLINICAL RELEVANCE

Mosaic arthroplasty should be considered for treatment of subchondral bone cysts of the femoral condyle and distal articular surface of the metacarpus/tarsus in horses that are refractory to non-surgical management.

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE

To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint.

METHODS

183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery.

RESULTS

The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed.

CONCLUSIONS

The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.

[Recurrent highly-differentiated eccrine carcinoma of the thumb -- a case report]

The eccrine carcinoma is a rare tumour originating from the sweat glands. They are mainly located in the palm of the hand and the sole of the foot, the digits, the head and the trunk. We report on a now 68-year-old male, who underwent partial amputation of the thumb at the level of the proximal phalanx due to an eccrine carcinoma in 1990. In the following years, three local recurrences were excised. After the exclusion of metastases an amputation at the MP I level was performed at our institution. To restore grip function, we performed a distraction of the first metacarpal bone followed by deepening of the first web space. So far, there are no defined treatment recommendations due to the rarity of the tumor. In some cases, metastatic disease has been reported, and in most cases, a high rate of local recurrence. After diagnostic biopsy, we recommend staging to exclude metastatic spread of the tumor followed by aggressive local surgical treatment.

Chondrosarkome der Hand

BACKGROUND

The diagnosis of a chondrosarcoma of the hand can be difficult for the surgeon as well as for the pathologist. The histological criteria for differentiation between chondrosarcoma and chondroma are not well-defined. Nevertheless, distinguishing the two entities is clinically relevant, as chondrosarcomas of the hand, despite their low tendency for metastatic spread, require a prompt and more radical treatment than chondromas.

METHOD AND MATERIAL

From 1996 to 2003, we treated four patients with a histologically diagnosed chondrosarcoma of the metacarpal bones and phalanges. Two patients were female and two male with a mean age of 42 years. The duration between the first clinical symptoms and first surgery ranged from two months to 30 years. Three out of four patients underwent primary treatment in other institutions, always under the histologic diagnosis of a chondroma. The mean follow-up ranged from nine months to seven years.

RESULTS

The histological diagnosis of chondrosarcoma was followed by ray resection in three cases. Two tumors were grade 1 and two tumors grade 2. During follow-up, the patients showed no local recurrence and no metastatic spread.

CONCLUSION

Since the differentiation between chondroma and chondrosarcoma is difficult, a good cooperation between surgeon, radiologist and pathologist is required. Despite the low metastatic potential of chondrosarcomas of the hand in comparison with other sites, ray resection or digital amputation is recommended to avoid local recurrence. In cases with only local excision, close follow-up is recommended.

Plating of metacarpal fractures: unicortical or bicortical screws?

Mid-shaft transverse osteotomies were performed in 18 cadaveric metacarpals and randomly divided into two groups. Using dorsally applied plates for repair, one group was secured using 6mm unicortical screws, while bicortical screws were used in the second group. The metacarpals were tested to failure with a four-point bending protocol using a servo-hydraulic testing machine and a 1kN load cell. The mean load to failure was 596N (SD=142) for the unicortical and 541N (SD=171) for the bicortical group. The stiffness was 333N/mm (SD=116) for the unicortical and 458N/mm (SD=158) for the bicortical group. Both load to failure and stiffness were not statistically significant between the two groups. Failure occurred by fracture at the screw-bone interface in all specimens: no screw pull-out was observed. No biomechanical advantage was found when using bicortical screws in metacarpal fracture plating.

[A comparative study on two different absorbable intramedullary nails in treating metacarpal and phalanx fractures]

OBJECTIVE

To study the effect of two different absorbable intramedullary nails in treatment of metacarpal and phalanx fractures.

METHODS

From January 2002 to December 2002, open reduction and internal fixation were done with two different absorbable intramedullary nails in 60 cases of metacarpal and phalanx fractures (52 cases of open fractures and 8 cases of closed fractures). The fracture locations were metacarpal in 24 cases, proximal phalanx in 22 cases and media phalanx in 14 cases. The emergency operation was performed in 47 cases, selective operation in 13 cases. Out of 60 patients, 24 were treated with intramedullary nails of poly-DL-lactic acid (PDLLA) (PDLLA group), 36 with intramedullary wire of PDLLA composed of chitosan(PDLLA+chitosan group).

RESULTS

In the PDLLA group(n = 24), the rejection occurred in 8 cases 3-4 weeks after operation. PDLLA nails were taken out in 6 of the 8 cases after 5-10 days of operation and bone healing was achieved 2 months after re-fixation by Kirschner wire; the rejection subsided in the other 2 cases after 25 days of conservative treatment, and bone fracture healed after 14 weeks. No rejection was observed with primary healing in the other 16 cases of the PDLLA group. In PDLLA + chitosan group(n = 36), the rejection occurred in 1 case 19 days after operation, but the rejection subsided after 3 days of conservative treatment. No rejection was observed in the other 35 cases with primary healing. All patients were followed up 4-11 months with an average of 6 months. No rejection was observed and bone healing was achieved during the follow-up. The time of bone healing was 6-16 weeks (8 weeks on average). There was statistically significant difference in the curative result between two groups(P < 0. 05). Conclusion Intramedullary nail of PDLLA was very suitable to fix fractures of metacarpal and phalanx. During the degradation of PDLLA, the acidic products can cause rejection. When PDLLA mixed with chitosan, PDLLA can not only strengthen the intensity but also neutralize the acidity. So the rejection can be decreased. PDLLA intramedullary nails composed of chitosan were better than PDLLA intramedullary nails in clinical treatment of metacarpal and phalanx fractures.

Predicted effects of metacarpal shortening on interosseous muscle function

PURPOSE

Metacarpal fractures are common in hand surgery. Metacarpal shortening ranging from 2 mm to as much as 10 mm has been deemed acceptable in the literature. We examined the effect of metacarpal shortening on interosseous muscle architecture and predicted force production capacity based on the standard muscle length-tension curve (commonly known as the Blix curve).

METHODS

The dorsal interosseous muscles between the middle and ring finger metacarpals from 9 adult human cadaver hands were exposed and studied. The ring finger metacarpal was translated proximally in 2-mm increments in relation to a stationary middle finger metacarpal. Digital images were obtained and analyzed to define the length and orientation of individual muscle fibers with each incremental change in position.

RESULTS

Interosseous muscle fiber length increased and pennation angle decreased uniformly with increasing proximal translation of the ring finger metacarpal. At 10 mm of shortening the fiber length had increased to 20.8 +/- 1.8 mm, or to approximately 125% of optimum fiber length, and the pennation angle had decreased to 6.7 degrees +/- 2.2 degrees or by approximately 50%.

CONCLUSIONS

The interosseous muscles have been shown to have a high fiber-to-muscle length ratio. This ratio indicates that these muscles function optimally over a short range of lengths, leaving them vulnerable to derangement in function owing to alteration in the surrounding bony architecture. Based on the standard muscle length--tension relationship we had predicted a steady linear decrease in interosseous power with proximal translation of the metacarpal. The results indicate an initial linear progression with a plateau at approximately 8 mm of shortening. At 2 mm of shortening there is an approximately 8% loss of power generation, at 10 mm of metacarpal shortening we predict the interosseous muscle to be capable of only approximately 55% of its optimum power compared with the resting position.

Quantification of Staphylococcus aureus Adhesion to Equine Bone Surfaces Passivated with Plasmalytetm and Hyperimmune Plasma

OBJECTIVE

To quantify the adhesion of Staphylococcus aureus to 4 equine bone surfaces passivated in a balanced polyionic solution (Plasmalyte) or hyperimmune equine plasma (Polymune plasma).

STUDY DESIGN

In vitro comparative study.

SAMPLE POPULATION

Third metacarpal bone (MC3) surface explants from 9 equine cadavers.

METHODS

Approximately 1 cm(2) sections of periosteum were removed from MC3 and stapled to sterile stainless steel screens. Three bone surface explants were cut using a surgical saw to present 1 cm(2) surfaces of subperiosteal bone, cut cortical bone, or endosteum. Duplicate explants of each surface were immersed for 1 hour in Plasmalyte or hyperimmune equine plasma. Each explant was then placed in a well of a 6-well sterile tissue culture plate with the surface of interest exposed. Each surface was inoculated with approximately 100 colony-forming units of S. aureus in 10 microL of Mueller Hinton broth and incubated for 6 hours at 37 degrees C. After gentle rinsing to remove non-adherent bacteria, samples were sonicated for 5 minutes at 60 kHz to loosen adhered bacteria. The number of adherent bacteria was determined by serial dilutions and incubation of the sonicate. Scanning electron microscopy (SEM) was performed on samples identically treated from an additional horse to confirm bacterial removal by sonication from all surfaces and support quantitative culture results.

RESULTS

Less S. aureus adhered to periosteum than to cortical bone, cut cortical bone, and endosteal surfaces, which were all similar. Exposure of all surfaces to hyperimmune plasma reduced S. aureus adherence compared with Plasmalyte exposure; SEM supported these conclusions.

CONCLUSION

Less bacteria adhere to periosteum than other bone surfaces. Hyperimmune plasma reduces bacterial adhesion to all bone tissue surfaces.

CLINICAL RELEVANCE

Understanding the factors that affect bacterial adhesion to bone will facilitate development of improved intraoperative lavage solutions to reduce the morbidity and mortality associated with postoperative infection.

Résultats à plus de cinq ans d'une série consécutive de 44 trapézectomies avec ligamentoplastie et interposition

BACKGROUND

Surgical management of trapeziometacarpal joint osteoarthritis remains controversial. There have been few long term studies of trapeziectomy combined with ligamentoplasty and interposition arthroplasty (TLIA). Our results are based on a five year minimum follow-up study.

METHODS

We carried out a study of 44 TLIA in 39 consecutive patients. A physical and radiological assessment was undertaken after on average of 6.9 years by a independent observer.

RESULTS

A durable physical improvement was obtained in 18 cases in less than six months and in five cases after more than one year. Thereafter there was no secondary deterioration. A standard pain measurement gave an average result of 1.4 on a ten point scale. Pain was independent of displacement of the first metacarpal bone but had a tendency to be greater where associated with scaphotrapezoidal joint osteoarthritis. Strength was improved in 36 cases. The patients were satisfied and considered their grip to be normal in 41 cases. These variables did not change over time.

DISCUSSION

TLIA give an excellent result in more than 90% of cases. This remains unchanged seven years after surgery. As opposed to prostheses, there is no secondary deterioration once healing is achieved. Algodystrophy is the main drawback.

CONCLUSION

In our opinion, TLIA remains the best available surgical treatment of trapeziometacarpal joint osteoarthristis.

Bizarre parosteal osteochondromatous proliferation (Nora's lesion) in the hand

PURPOSE

The purpose of this study was to review our experience with a benign surface bone lesion referred to as bizarre parosteal osteochondromatous proliferation (BPOP) or Nora's lesion, named for the pathologist who described it in 1983. The lesion may be confused with a variety of tumors, particularly solitary osteochondromas, which are rare.

METHODS

The files in the Department of Pathology at the Hospital for Joint Diseases were reviewed over a 21-year period for all surface bone lesions involving the tubular bones in the hand. There were a total of 10 cases of BPOP compared with only a single case of an osteochondroma.

RESULTS

Radiographs generally showed a well-marginated uniformly dense mass arising from the surface of the affected bone without any disruption in its bony architecture. Surgical excision is the definitive treatment and included the fibrous pseudocapsule over the lesion, any periosteal tissue beneath the lesion, and any area of the cortex of the host bone that appeared abnormal. Although in the medical literature the recurrence rate for BPOP is high, we had only one recurrence in our series.

CONCLUSIONS

BPOP is a benign surface bone lesion that may be confused with benign and malignant tumors. Although there is a cleavage plane between the lesion and host bone, we recommend excising the pseudocapsule over the lesion, any periosteal tissue beneath the lesion, and decorticating any abnormal-appearing areas in the underlying host bone. This may explain the low recurrence rate in our series.

Surgical Management of the Hand in Apert Syndrome

In patients with Apert syndrome, the hands demonstrate many disturbances of soft tissue and bony structures. These include a short thumb with radial clinodactyly, complex syndactyly with a bony fusion involving the index, long and ring fingers, symphalangism and simple syndactyly of the fourth web space. The soft tissue anomalies involve the intrinsic muscles, the extrinsic tendon insertions and the neurovascular bundles. We have reviewed 52 patients who underwent surgical reconstruction of their hands. The aim of this study is to propose a better surgical management in the light of recent publications and to improve our understanding of the syndrome, attempting to reduce the number of procedures and to select the best possible procedures for each patient.

[Tumors of the hand bones]

The article is devoted to an actual problem of surgical treatment of hand bone tumors. It presents a classification of hand bone tumors, pathogenesis, clinical course of the most common tumors, methods of surgical treatment. Results of treatment of 108 patients with hand bone tumors are described.

Pollicization in Congenital Differences

Pollicization of the index finger is a well established procedure for some cases of thumb hypoplasia. We reviewed our experience of 27 "normal" index-finger pollicizations with a mean follow-up of seven years, excluding those cases with more extensive radial hypoplasia and abnormal fingers. Even in such an "ideal" situation, strength was deceptive and the frequently slender aspect of the new thumb with quite extensive dorsal scar formation and the "cleft" appearance of the first web disappointing. In a prospective series of 32 cases, we tried to improve both the function and appearance of the thumb by modifying the classical incision as well as the transferred muscles and tendons.

Simulated extension osteotomy of the thumb metacarpal reduces carpometacarpal joint laxity in lateral pinch

PURPOSE

To assess the effect of an extension osteotomy of the thumb metacarpal on thumb carpometacarpal (CMC) joint laxity with respect to the lateral pinch position.

METHODS

Seven fresh-frozen specimens were dissected. The metacarpal, trapezium, and trapezoid were removed en bloc and rigidly fixed proximally and distally. The laxity of each specimen was measured by cyclically loading the CMC joint in a custom-built laxity testing device designed to allow relative movement of the trapezium and first metacarpal in 4 directions. The position of the CMC joint in lateral pinch was used as the baseline joint position. An extension osteotomy then was simulated by flexing the metacarpal base 30 degrees, thus placing the joint in the relationship it would assume if an extension osteotomy was performed and the specimen was positioned in lateral pinch. Laxity measurements then were repeated.

RESULTS

The simulated extension osteotomy reduced laxity in all directions tested: dorsal-volar (40% reduction), radial-ulnar (23% reduction), distraction (15% reduction), and pronation-supination (29% reduction).

CONCLUSIONS

The beneficial clinical effects of a thumb metacarpal extension osteotomy may be partially due to reduced joint laxity in the position of lateral pinch.

[Intramedullary Kirschner wire osteosynthesis in treatment of distal metacarpal fractures]

The intramedullary Kirschner wire fixation of distal metacarpal fractures reported by Foucher et al. combines the known advantages of intramedullary implants with a reduction of iatrogenic soft tissue trauma. We applied this minimal invasive internal fixation technique in 38 patients with fractures dislocated by more than 20 degrees and/or with rotatory deformity. After opening the intramedullary cavity from the base of the respective metacarpal bone and after fracture reduction, two pre-bent Kirschner wires were intramedullary inserted in an orthograde fashion. The pre-bent distal end of the wire in the form of a hockey club allows an additional closed reduction of the displaced distal fracture fragment. Intraoperative complications did not occur. A fixation in a plaster splint followed for one week only. The elastic fixation of the wires working as springs is stable enough to allow physiotherapeutic exercises. After the third postoperative week, the intensity of physical exercise was increased. 36 of the 38 patients were followed. With one exception, all fractures were healed in a proper position. The wires were removed under local anaesthesia on an outpatient basis after six to eight weeks and full mobility of the fingers was achieved in 34 patients at that time. Complications included one redislocation and one distal wire perforation.

Phalangeal osteotomy for the treatment of metacarpal synostosis: a case report

Congenital synostosis between the fourth and fifth metacarpals is a rare congenital anomaly. We present a case of type IIIB metacarpal synostosis according to the Buck Gramcko's classification with the camptodactyly of the little finger. It was treated successfully with the phalangeal angulation osteotomy and soft tissue release procedures.

Role of soft tissues in metacarpal fracture fixation

The contribution of soft tissues in stabilizing fracture fixation in metacarpals is appreciated clinically, but no quantitative biomechanical study of their role has been done. All previous studies of fracture fixation in vitro have been done on metacarpals denuded of soft tissues. To quantify the role of soft tissues in metacarpal fracture fixation, the biomechanical effectiveness of four fixation devices was examined in human cadaver metacarpals with and without soft tissues. Values were compared for three nonrigid methods (expandable intramedullary fixation devices, crossed Kirschner wires, and single half-pin frames) and one rigid method (dorsal plates) in 45 disarticulated metacarpals stripped of soft tissues (denuded) and in 46 metacarpals in whole hands with all soft tissues remaining (intact). Mechanical testing to complete failure in three-point apex dorsal bending was done in all specimens. Ultimate moment (strength) of each of the four fixation methods was significantly greater in intact specimens than in denuded specimens. Crossed Kirschner wires were most stable in intact specimens, and dorsal plates were more stable in denuded specimens. The results show that soft tissues contribute to the strength of fracture fixation. Clinically, surgeons may be able to use a less invasive fixation method than plating without compromising the strength of metacarpal fixation in patients whose soft tissues are not severely disrupted and the fracture configuration allows. Plating may offer optimum stability in patients whose soft tissues are damaged severely and provide less strengthening of the fracture construct.

Results of biaxial total wrist arthroplasty with a modified (long) metacarpal stem

PURPOSE

To evaluate the results of Biaxial (DePuy Orthopedics, Inc., Warsaw, IN) total wrist arthroplasty (TWA) with a long metacarpal stem.

METHODS

A retrospective review of the results of 17 long-stem metacarpal components for the Biaxial TWA implanted between 1993 and 1997 is presented.

RESULTS

After surgery pain and grip strength improved markedly. Overall motion improved but only radial deviation was significantly better. All of the patients were satisfied. At the most recent follow-up evaluation 4 cases showed evidence of radiographic lucency about the cement mantle, but with no gross loosening or settling. No failures at a greater than 6-year average (4-year minimum) follow-up period have been noted. Two cases of intraoperative third metacarpal fracture and one case of dorsal metacarpal component placement were encountered but did not affect the outcomes.

CONCLUSIONS

To date the survivorship of the Biaxial TWA with the long stem is favorable compared with previous reports with the standard Biaxial distal component.

Lateral fracture dislocation of the second and third carpometacarpal joints

We report a case of a rare injury, lateral fracture dislocation of the second and third carpometacarpal joints, which presented late and was managed by fusion of the involved joints.