Treatment of Aseptic Necrosis of the Lunate Bone (Kienböck Disease) Using a Nickel-Titanium Memory Alloy Arthrodesis Concentrator: A Series of 24 Cases

Avascular necrosis of the lunate bone (Kienböck disease) is caused by loss of blood supply of the bone. This study aimed to evaluate the efficacy and safety of a novel nickel-titanium (Ni-Ti) memory alloy arthrodesis concentrator in the treatment of this disease.A consecutive 24 patients with stage IIIb aseptic lunate necrosis were treated with scapho-trapezio-trapezoeid (STT) arthrodesis using a Ni-Ti arthrodesis concentrator from August 2008 to December 2012. Wrist pain, grip strength, carpal height, and scapholunate angle were measured and compared before and after the surgery. The wrist functions were evaluated using the Mayo scale.Patients were followed up for a mean of 12 months (range, 6-24 months). Grip strength of the affected side was significantly improved after the surgery (18 ± 4.74 kg vs. 30.21 ± 7.14 kg, P < 0.0001). Wrist pain score was significantly decreased from 5.88 ± 0.9 to 0.5 ± 0.51 (P < 0.0001). Carpal height and Mayo score were also significantly increased after the surgery (P < 0.0001). Scapholunate angle was significantly decreased after the surgery (68.38 ± 7.28° vs. 49.91 ± 4.28°, P < 0.0001). No implant breakage, loose implant, wound infection, or nonunion occurred.STT arthrodesis is effective for the treatment of stage IIIb lunate necrosis. The Ni-Ti memory alloy arthrodesis concentrator is a convenient tool for STT arthrodesis with excellent and reliable results.

A portable system for quantitative assessment of parkinsonian rigidity

Rigidity is one of the primary symptoms of Parkinson's disease. Passive flexion and extension of the elbow is used to assess rigidity in this study. An examiner flexes and extends the subject's elbow joint through a rigidity assessment cuff attached around the wrist. Each assessment lasts for 10 seconds. Two force sensor boxes and an inertial measurement unit are used to measure the applied force and the state of the elbow movement. Elastic and viscous values will be obtained through a least squares estimation with all the data. 9 healthy subjects were tested with this system in two experimental conditions: 1) normal state (relaxed); 2) imitated rigidity state. Also the subjects were performed the assessment task with different frequencies and elbow movement ranges. The imitated rigidity action increases viscosity and elasticity. The effect sizes (Cohen's d) of the viscosity and elasticity between normal state and imitated state are 1.61 and 1.36 respectively, which means the difference is significant. Thus, this system can detect the on-off fluctuations of parkinsonian rigidity. Both wrist movement angle and frequency have small effect on the viscosity, but have elevated effect on the elasticity.

Wrist range of motion and motion frequency during toy and game play with a joint-specific controller specially designed to provide neuromuscular therapy: A proof of concept study in typically developing children

Upper extremities affected by hemiplegic cerebral palsy (CP) and other neuromuscular disorders have been demonstrated to benefit from therapy, and the greater the duration of the therapy, the greater the benefit. A great motivator for participating in and extending the duration of therapy with children is play. Our focus is on active motion therapy of the wrist and forearm. In this study we examine the wrist motions associated with playing with two toys and three computer games controlled by a specially-designed play controller. Twenty children (ages 5-11) with no diagnosis of a muscular disorder were recruited. The play controller was fitted to the wrist and forearm of each child and used to measure and log wrist flexion and extension. Play activity and enjoyment were quantified by average wrist range of motion (ROM), motion frequency measures, and a discrete visual scale. We found significant differences in the average wrist ROM and motion frequency among the toys and games, yet there were no differences in the level of enjoyment across all toys and games, which was high. These findings indicate which toys and games may elicit the greater number of goal-directed movements, and lay the foundation for our long-term goal to develop and evaluate innovative motion-specific play controllers that are engaging rehabilitative devices for enhancing therapy and promoting neural plasticity and functional recovery in children with CP.

Simultaneous Bilateral Functional Radiography in Ulnar Collateral Ligament Lesion of the Thumb: An Original Technique

In any thumb injury, particularly one caused by hyperabduction, an ulnar collateral ligament lesion (gamekeeper's or skier's thumb) must be considered. If the diagnosis is suspected, and radiographs show no fracture, comparative radiographs should be obtained in forced valgus. This examination, which uses a stress test to cause joint tilt, is crucial in making an accurate diagnosis and deciding on the most appropriate therapeutic approach. The forced valgus maneuver typically is performed by the examiner, who must stay with the patient in the radiography room and wear radiologic protection. We report on a simple, reliable, reproducible method that allows the patient's thumbs to be compared, under the same force application conditions, on a single radiograph. This technique reduces the patient's and examiner's exposure to x-rays and is well tolerated by the patient. Anesthesia for the thumb is usually not necessary.

The postural and control-display gain effects of distal pointing on upper extremity fatigue

Pointing at displays from a distance is becoming common in both work and domestic environments. Ray-casting interaction is easy for novices to learn and understand, but this technique can cause physiological fatigue. To address this issue, the present study aims to investigate the issue of fatigue caused by joint-based pointing methods and Control-Display gains (CD gains) via Fitts' task. Ten healthy subjects participated in the experiment and performed multi-directional tapping tests with three joint-based pointing methods and three CD gains. The experimental results indicated that the joint-based pointing methods indeed affected the physiological and subjective fatigue of the upper limb muscles and measured body parts during distal pointing tasks. The wrist-based pointing method, which can induce substantially lower physiological and subjective fatigue, appears to be superior to the other two methods. There were no significant main effects of CD gains on either physiological fatigue or subjective Borg's CR-10 rating.

PRACTITIONER SUMMARY

The present study investigates the issue of fatigue caused by joint-based pointing methods and CD gains via Fitts’ task. The pointing methods affected the physiological and subjective fatigue of the upper-limb muscles. There were no significant main effects of CD gains on either physiological fatigue or subjective Borg’s CR-10 rating.

A New Method for Functional Evaluation of Motor Commands in Patients with Cerebellar Ataxia

Quantitative evaluation of motor functions of patients with cerebellar ataxia is vital for evidence-based treatments and has been a focus in previous investigations of movement kinematics. Due to redundancy of the musculoskeletal system, muscle activities contain more information than the movement kinematics. Therefore, it is preferable to analyze causal anomalies of muscle activities to evaluate motor functions in patients. Here we propose a new method to evaluate the motor functions at the level of muscle activities and movement kinematics. Nineteen patients and 10 control subjects performed two movement tasks of the wrist joint, a step-tracking task and a pursuit task, with a manipulandum. The movements of the wrist joint and activities of the four wrist prime movers were recorded. We developed a linear model for the wrist joint to approximate the causal relationship between muscle activities and movement kinematics in terms of the wrist joint torque. We used a canonical correlation analysis to verify the causality between the muscle activities and the movement kinematics in the model. We found that the activities of the four muscles were related almost entirely to the position and velocity, with negligible correlation with the acceleration of the wrist joint. Moreover, the ratio of the weights for position- and velocity-related torque components characterized the contents of the muscle activities in terms of the movement kinematics. Next, we compared the ratios for the two movement tasks between the controls and patients. In control subjects, the ratios indicated clear task-specific changes that conformed to the functional requirements of the tasks. In contrast, in patients, the task-specific changes diminished highly significantly. The present results indicate that this ability to accommodate motor commands to the task requirements provides a novel quantitative parameter to characterize motor functions in patients with cerebellar ataxia.

Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review

We conducted a systematic review of studies reporting clinical outcomes after proximal row carpectomy or to four-corner arthrodesis for scaphoid non-union advanced collapse or scapholunate advanced collapse arthritis. Seven studies (Levels I-III; 240 patients, 242 wrists) were evaluated. Significantly different post-operative values were as follows for four-corner arthrodesis versus proximal row carpectomy groups: wrist extension, 39 (SD 11º) versus 43 (SD 11º); wrist flexion, 32 (SD 10º) versus 36 (SD 11º); flexion-extension arc, 62 (SD 14º) versus 75 (SD 10º); radial deviation, 14 (SD 5º) versus 10 (SD 5º); hand grip strength as a percentage of contralateral side, 74% (SD 13) versus 67% (SD 16); overall complication rate, 29% versus 14%. The most common post-operative complications were non-union (grouped incidence, 7%) after four-corner arthrodesis and synovitis and clinically significant oedema (3.1%) after proximal row carpectomy. Radial deviation and post-operative hand grip strength (as a percentage of the contralateral side) were significantly better after four-corner arthrodesis. Four-corner arthrodesis gave significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side. Wrist flexion, extension, and the flexion-extension arc were better after proximal row carpectomy, which also had a lower overall complication rate.

Measurement of ulnar variance and radial inclination on X-rays of healed distal radius fractures. With the axis of the distal radius or ulna?

Ulnar variance and radial inclination are radiological parameters frequently used to evaluate displacement of distal radius fractures. In most studies measurements are based on the long central axis of the distal radius, although the axis of the distal ulna can also be used. The purpose of this study was to determine which axis is more reliable. Four observers performed measurements on standard anteroposterior digital wrist X-rays of 20 patients taken 1 and 2 months after sustaining an extra-articular distal radius fracture. Intraobserver reliability was similar with both methods. No difference was found in interobserver reliability between both methods for ulnar variance, but for radial inclination it was better with the axis through the radius. Measurements on two X-rays of the same wrist taken at a different moment were similar with both methods. It can be concluded that the central axis of the distal radius can remain the basis to determine ulnar variance and radial inclination.

A vertical mouse and ergonomic mouse pads alter wrist position but do not reduce carpal tunnel pressure in patients with carpal tunnel syndrome

Non-neutral wrist positions and external pressure leading to increased carpal tunnel pressure during computer use have been associated with a heightened risk of carpal tunnel syndrome (CTS). This study investigated whether commonly used ergonomic devices reduce carpal tunnel pressure in patients with CTS. Carpal tunnel pressure was measured in twenty-one patients with CTS before, during and after a computer mouse task using a standard mouse, a vertical mouse, a gel mouse pad and a gliding palm support. Carpal tunnel pressure increased while operating a computer mouse. Although the vertical mouse significantly reduced ulnar deviation and the gel mouse pad and gliding palm support decreased wrist extension, none of the ergonomic devices reduced carpal tunnel pressure. The findings of this study do therefore not endorse a strong recommendation for or against any of the ergonomic devices commonly recommended for patients with CTS. Selection of ergonomic devices remains dependent on personal preference.

Dorsal nail plate versus percutaneous k-wire fixation in the treatment of displaced distal radius fractures

Distal radius fractures are the most common fractures in the elderly, yet the treatment is controversial and still debated in the literature. Twenty four patients aged older than sixty with distal radial fractures were treated by dorsal nail plate. We compared them with twenty four similar matched patients treated by percutaneous Kirschner wiring surgical method. The patients were operated on by a surgeon experienced in carrying out hand surgery. The purpose of this retrospective review was to compare the clinical and radiological outcomes in elderly patients with displaced distal radial fractures who were treated with either the dorsal nail plate or percutaneous Kirschner wiring surgical procedures. Both groups had high union rates and low complication rates for the treatment of displaced distal radius fractures in elderly patients. However, better functional results can be expected in dorsal nail plate.

Application of a three-dimensional computational wrist model to proximal row carpectomy

A three-dimensional (3D) computational model of the wrist examined the biomechanical effects of the proximal row carpectomy (PRC), a surgical treatment of certain wrist degenerative conditions but with functional consequences. Model simulations, replicating the 3D bony anatomy, soft tissue restraints, muscle loading, and applied perturbations, demonstrated quantitatively accurate responses for the decreased motions subsequent to the surgical procedure. It also yielded some knowledge of alterations in radiocarpal contact force which likely increase contact pressure as well as additional insight into the importance of the triangular fibrocartilage complex and retinacular/capsular structures for stabilizing the deficient wrist. As better understanding of the wrist joint is achieved, this model could serve as a useful clinical tool.

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

BACKGROUND

A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making.

QUESTIONS/PURPOSES

We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis?

METHODS

Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review.

RESULTS

With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision.

CONCLUSIONS

Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A modular low-clearance wrist orthosis for improving wrist motion in children with cerebral palsy

Children with Cerebral Palsy (CP) often exhibit impairments in the coordination of the grip and lift phases of arm movements that directly impact their ability to perform activities of daily living (ADLs). The application of assistive robotic therapy to children with spastic hemiplegic CP has shown that augmented movement training can lead to improved functional outcomes and improved arm kinematics. Assistive robotic therapy of the wrist has been shown to help improve motor skills in stroke patients, but the devices employed are often large and obtrusive, focusing on a repeated motion rather than a task-based itinerary. Here, we propose a lightweight low clearance wrist orthosis for use in children with Cerebral Palsy that actuates pronation/supination and flexion/extension of the wrist.

Upper limb functional assessment of children with cerebral palsy using a sorting box

We investigated the use of a sorting box to obtain a quantitative assessment of upper limb motor function in children with cerebral palsy. In our study, children with and without cerebral palsy placed and removed geometrical objects of a sorting-box while their wrist position was monitored by a camera-based, motion-tracking system. We analyzed three different smoothness metrics (logarithmic dimensionless jerk, spectral arc-length and number of peaks) together with time to task completion. Our results suggest that smoothness metrics are an effective tool to distinguish between impaired and non-impaired subjects, as well as to quantify differences between the affected and less-affected sides in children with hemiparetic cerebral palsy.

Psychometrics of the wrist stability and hand mobility subscales of the Fugl-Meyer assessment in moderately impaired stroke

BACKGROUND

There remains a need for a quickly administered, stroke-specific, bedside measure of active wrist and finger movement for the expanding stroke population. The wrist stability and hand mobility scales of the upper extremity Fugl-Meyer Assessment (w/h UE FM) constitute a valid, reliable measure of paretic UE impairment in patients with active wrist and finger movement.

OBJECTIVE

The aim of this study was to determine performance on the w/h UE FM in a stable cohort of survivors of stroke with only palpable movement in their paretic wrist flexors.

DESIGN

A single-center cohort study was conducted.

METHOD

Thirty-two individuals exhibiting stable, moderate upper extremity hemiparesis (15 male, 17 female; mean age=56.6 years, SD=10.1; mean time since stroke=4.6 years, SD=5.8) participated in the study, which was conducted at an outpatient rehabilitation clinic in the midwestern United States. The w/h UE FM and Action Research Arm Test (ARAT) were administered twice. Intraclass correlation coefficients (ICCs), Cronbach alpha, and ordinal alpha were computed to determine reliability, and Spearman rank correlation coefficients and Bland-Altman plots were computed to establish validity.

RESULTS

Intraclass correlation coefficients for the w/h UE FM and ARAT were .95 and .99, respectively. The w/h UE FM intrarater reliability and internal consistency were greater than .80, and concurrent validity was greater than .70. This also was the first stroke rehabilitative study to apply ordinal alpha to examine internal consistency values, revealing w/h UE FM levels greater than .85. Concurrent validity findings were corroborated by Bland-Altman plots.

CONCLUSIONS

It appears that the w/h UE FM is a promising tool to measure distal upper extremity movement in patients with little active paretic wrist and finger movement. This finding widens the segment of patients on whom the w/h UE FM can be effectively used and addresses a gap, as commonly used measures necessitate active distal upper extremity movement.

Effect of Tire Pressure to Physical Workload at Operating a Manual Wheelchair

It is often experienced that low tire pressure of the wheelchair not only increases running resistance, but also reduces parking brake performance. In this study, the required driving forces for different tire pressures were experimentally measured and evaluated. It was indicated from the result that the wheelchair with proper tire pressure could be run with less workload of wheelchair-user. Then it was also indicated that the wheelchair with a lower tire pressure needed more workload of wheelchair-user even on hard level surface.

Proximal row carpectomy in the third millenium: is it still a valid indication?

Proximal row carpectomy (PRC), which was initially described by Stamm in 1944, is a surgical procedure for degenerative disorders of the proximal carpal row of the carpus. Despite the good results reported in the literature, this technique has been gradually replaced over the years by others considered more modern and actual, such as wrist arthroplasty and arthrodesis. In this context the authors performed the following study and analyzed retrospectively 14 patients who underwent PRC during an eighteen years period, between June 1996 and June 2013, in order to determine if this surgical operation can be considered still indicated. The results of this study confirm that PRC, more or less associated with the use of capsular flaps and/or osteochondral grafts, is nowadays a valid and simple procedure in selected patients, ensuring a satisfactory functional recovery and regression of pain.

[Case-control study on tibetan Baimai ointment (see symbol in text) for the treatment of wrist-dysfunction after distal radius fracture]

OBJECTIVE

To evaluate efficacy and safety of Baimai ointment (see symbol in text) in the treatment of wrist-dysfunction after distal radius fracture.

METHODS

From April, 2011 to June, 2012, 43 patients with distal radius fracture were treated with plaster fixation. All the patients were divided into two group: test group and control group. Twenty-one patients in test group and 22 in control group, and the baseline was balance (P > 0.05). The 21 patients in test group were treated with Baimai ointment (see symbol in text), fomentation, functional exercises. The 22 patients in control group were treated with placebo, fomentation, functional exercises. Foment affected side wrist with wet towel in 20 min before medication, with the temperature between 50 degrees C and 60 degrees C. Smear drugs uniformly in range of 3 cm in the vicinity of palm stripes after drying (about 3 g) and take functional exercises for the activities of wrist and hand. Continuous follow the program per 8 hours once and follow-up for 8 weeks. The Wrist's pain was assessed with VAS. The wrist's activities were measured with the protractor of orthopedic. Measure The grip strength was measured with dynamometer. The wrist's function were assessed with the table of Cooney.

RESULTS

The test group had a significantly better results than those of control group in the extent of wrist's pain throughout the treatment (P < 0.001), and grip strength on the 28th day and the 56th day (P < 0.05), and Cooney functional assessment on the 56th day (P < 0.05). Wrist's activities had no significane difference throughout the 8 weeks (P > 0.05). There were no drug adverse reactions occurred.

CONCLUSION

Tibetan Baimai ointment (see symbol in text) has the treatment of wrist-dysfunction after distal radius fracture for external use, which can reduce the extent of wrist's pain, promote grip strength recovery in the middle and late of process, promote wrist's function recovery latterly, and safety for external use.

Understanding of Tendon Transfer in Radial Nerve Palsy in Leprosy

Involvement of Radial Nerve in leprosy is not very common. Only 0.2% of Radial Nerve deformities is observed. There are various procedure to correct the wrist function. We have analyzed various motor units to correct the wrist function as per the patient requirement.

Radiological and clinical analysis of Madelung's deformity in children

INTRODUCTION

Madelung's deformity is a bone dysplasia that occurs predominantly in adolescent females, characterized by early epiphyseal growth arrest in the medial part of the distal radius. This leads to an upward and medial displacement of the radial joint surface, restricting range of motion.

OBJECTIVES

The objective of this study was to determine whether there was a link between clinical and radiological data in children with Madelung's deformity and to test the hypothesis of a relation between the deformity and a genetic mutation.

METHODS

A retrospective study recruited 13 patients with Madelung's deformity, with a mean age of 13.2 years (range, 8-18 years). Assessment comprised level of pain, range of motion and grip force, with standard AP and lateral wrist X-rays. Every patient except one underwent molecular genetic screening, adhering to current recommendations.

RESULTS

Pronation-supination, radial inclination and grip force were significantly impaired compared to normal results. All X-ray measurements were significantly abnormal, except for the lunate-covering ratio. Genetic mutation (SHOX) was systematic in the 12 patients screened.

DISCUSSION

Radiological deformity did not correlate with functional disturbance or pain. Non-acquired Madelung's deformity requires molecular screening for SHOX or XO mutation, which definitively diagnoses Léri-Weill dyschondrosteosis or Turner syndrome.

CONCLUSION

A larger series is necessary to confirm these preliminary results, which nevertheless suggest that non-acquired Madelung's deformity is not isolated but syndromic. Early detection of Léri-Weill or Turner syndrome is essential, due to their therapeutic specificities. LEVEL: IV.

Bone lengthening of the radius with temporary external fixation of the wrist for mild radial club hand

BACKGROUND

We report the utility of a surgical approach to treat mild (Bayne type I or II) radial club hand with a combination of radial bone lengthening and temporary external fixation between the ulna and the metacarpals.

METHODS

We evaluated five radial club hands that received a new procedure involving radius lengthening with external fixation to support the radial side of the wrist. The evaluation included an assessment of radial deficiency deformity recurrence from the anteroposterior radiographs and a measurement of the passive range of wrist motion with the use of a goniometer before surgery and at the time of the final follow-up. We recorded complications such as infection and nerve palsy.

RESULTS

The healing index of the radius was from 72.2 to 298.9 day/cm (mean, 176.8 day/cm). The mean radial/ulnar deviation was 84.0/-14.0° before surgery and 37.0/13.0° at the time of the final follow-up. No correction loss was detected during the follow-up. All patients were able to hold and bring an object to the mouth after surgery. No patient had a postoperative infection and there were no cases of nerve palsy.

CONCLUSIONS

All cases demonstrated a better range of motion despite a poor healing index in the present series. Our novel technique can be performed for cases with mild radial deficiency and with mild radius deficiency including growth plate injuries.

[Long-term effectiveness of vascularized capitate osteotomy transposition for advanced Kienböck's disease]

OBJECTIVE

To evaluate the long-term effectiveness of lunate excision and vascularized capitate osteotomy transposition for advanced Kienböck's disease.

METHODS

Between June 2004 and January 2008, 16 patients with Kienböck disease in Lichtman stages IIIB-IV were treated with lunate excision and vascularized capitate osteotomy transposition. There were 10 males and 6 females at the age of 27-59 years (mean, 38.8 years). The disease was caused by trauma in 10 cases, and unknown reason in 6 cases. The main clinical symptoms were pain and limited activity of the wrist joint, and the disease duration was 5-32 months (mean, 26.5 months). The carpal height index was 0.88 ± 0.05; the radioscaphoid angle was (63.8 ± 9.1)degrees. The visual analogue scale (VAS) score, range of motion (ROM), grip strength, Evans score, and radiographic changes were used to assess the effectiveness during follow-up.

RESULTS

All patients obtained healing of incision by first intention and were followed up 5 years and 4 months to 9 years (mean, 5.8 years). VAS score was 2.0 ± 1.5 at the final follow-up. The ROM of the flexion and extension of the wrist joint at the affected side were significantly less than those at the normal side (P < 0.05). However, no significant difference was found in the grip strength and Evans score between the affected side and normal side (t = -0.997, P = 0.327; t = -1.852, P = 0.077). Postoperative radiographs showed that the carpal height index was 0.94 ± 0.03, and the radioscaphoid angle was (48.4 ± 4.8) degrees, which were improved significantly when compared with preoperative ones (t = -3.927, P = 0.000; t = 5.987, P = 0.000). Osteophyte at the dorsal side of the radius and scaphoid rotation occurred in 6 cases and 2 cases, respectively.

CONCLUSION

Lunate excision and vascularized capitate osteotomy transposition is a reliable method for advanced Kienböck's disease, with favorable improvement in wrist pain and grip strength for long-term follow-up.

The effect of pisiform excision on wrist function

PURPOSE

To investigate the effect of pisiform excision on wrist function compared with age- and sex-matched control subjects.

METHODS

The authors evaluated the charts of 11 consecutive patients who had undergone pisiform excision. Nine of these patients could be included and clinically examined, and results were compared with 9 matched controls. Measurements included range of motion, strength measurements, neurological examination, and questionnaires.

RESULTS

Extension in the operated wrist was reduced in patients compared with controls. The Disabilities of the Arm, Shoulder, and Hand and Michigan Hand Outcomes Questionnaires were significantly different between patients and controls. All other entities were equal between groups. Subjectively, patients experienced impairments in function of the operated wrist, but these could not be identified objectively.

CONCLUSIONS

Although great care must be taken in handling the surrounding soft tissue, pisiform excision is a well-tolerated, safe treatment for pain in the pisotriquetral joint resulting from arthrosis and not controlled by nonsurgical means.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Wrist arthroplasty--a systematic review

INTRODUCTION

Severely painful or dysfunctional destroyed wrists can be reconstructed by fusion, interposition of soft-tissue or by arthroplasty using artificial materials. Total and partial wrist arthroplasty (T/PWA) has been used on a regular basis since the 1960's. The objective of this study was to review the literature on second, third and fourth generation implants.

METHODS

The review was conducted according to the PRISMA-guidelines. A search was made using a protocolled strategy and well-defined criteria in PubMed, in the Cochrane Library and by screening reference lists.

RESULTS

37 publications describing a total of 18 implants were selected for analysis. 16 of the publications were useful for the evaluation of implant longevity. Despite methodological shortcomings in many of the source documents, a summary estimate was possible.

CONCLUSION

It seems that T/PWA has a good potential to improve function through pain reduction and preservation of mobility. The risk of severe complications - deep infection and instability problems - is small with the available implants. Implant survival of 90-100% at five years are reported in most series - if not all - using newer second generation and third generation implants, but declines from five to eight years. Periprosthetic osteolysis/radiolucency is frequently reported. Its causes and consequences are not clarified.

[Minimally invasive treatment for distal radial fracture and dislocation of type IV based on Fernandez classification]

OBJECTIVE

To investigate the effects of external fixation combined with minimally invasive internal fixation for the treatment of distal radial fracture and dislocation of type IV based on Fernandez classification.

METHODS

From January 2007 to October 2012,19 patients with the distal radius fracture and dislocation of type IV according to Fernandez classification were reviewed. There were 14 males and 5 females,ranging in age from 22 to 42 years old,with an average of 36.5 years old. All the patients were treated with minimally invasive reduction, and external fixation with finite internal fixation. The K-wire was used to fix radiolunate articular surface for correcting the instability of dorsal and volar intercalated segment. The radiolunate angle, scapholunate angle, and the length of the radial shorting were measured by the standard X-ray. Gartland and Werley evaluation system was used to evaluate recovery of function.

RESULTS

No complications such as injury of blood vessels and radial nerves and pin track infections occurred. After operation, the radiolunate angle, scapholunate angle and the length of the radial shorting time were (9.5 +/- 3.3) degrees, (51.3 +/- 11.2) degrees and (11.2 +/- 1.8) mm by the standard X-ray. On the 3rd month after operation, GW score was 3.02 +/- 3.05. There was no re-displacement and subluxation occurred during the follow-up period. Good functional recovery were improved wrist function significantly.

CONCLUSION

External fixation combined with minimally invasive internal fixation can treat distal radial fracture and dislocation of type IV based on Fernandez classification. Wrist joint stability depends on the structure of the bone and ligament around wrist joint. Emphasis on the diagnosis and treatment of carpal instability, and postoperative functional rehabilitation can improve wrist function.

Altered median nerve deformation and transverse displacement during wrist movement in patients with carpal tunnel syndrome

RATIONALE AND OBJECTIVES

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. Strong pinch or grip with wrist flexion has been considered a risk factor for CTS. Studying median nerve displacement during wrist movements may provide useful information about median nerve kinematic changes in patients with CTS. The purpose of this study was to evaluate the deformability and mobility of the median nerve in patients with CTS compared to healthy subjects.

MATERIALS AND METHODS

Dynamic ultrasound images were obtained in 20 affected wrists of 13 patients with CTS. Results were compared to complementary data obtained from both wrists of 10 healthy subjects reported in a previous study. Shape and position of initial and final median nerve were measured and analyzed for six defined wrist movements. The deformation ratios for each movement were defined as the median nerve area, perimeter, and circularity of the final position normalized by respective values assessed in the initial position. The median nerve displacement vector and magnitude were also calculated.

RESULTS

The deformation ratio for circularity was significantly less in patients with CTS compared to healthy subjects during wrist flexion (P < .05). The mean vector of median nerve displacement during wrist flexion was significantly different between patients with CTS and healthy subjects (P < .05). The displacement magnitude of the median nerve was found to be less in patients with CTS compared to healthy subjects during most movements, with the exception of wrist extension with fingers extended.

CONCLUSIONS

Patients with CTS differ from normal subjects with regard to mobility and deformability of the median nerve.

Position-dependent characterization of passive wrist stiffness

Because the dynamics of wrist rotations are dominated by stiffness, understanding wrist rotations requires a thorough characterization of wrist stiffness in multiple degrees of freedom. The only prior measurement of multivariable wrist stiffness was confined to approximately one-seventh of the wrist range of motion (ROM). Here, we present a precise nonlinear characterization of passive wrist joint stiffness over a range three times greater, which covers approximately 70% of the functional ROM of the wrist. We measured the torque-displacement vector field in 24 directions and fit the data using thin-plate spline smoothing optimized with generalized cross validation. To assess anisotropy and nonlinearity, we subsequently derived several different approximations of the stiffness due to this multivariable vector field. The directional variation of stiffness was more pronounced than reported previously. A linear approximation (obtained by multiple linear regression over the entire field) was significantly more anisotropic (eigenvalue ratio of 2.69 ± 0.52 versus 1.58 ± 0.39; ) though less misaligned with the anatomical wrist axes (12.1 ± 4.6° versus 21.2 ± 9.2°; ). We also found that stiffness over this range exhibited considerable nonlinearity-the error associated with a linear approximation was 20-30%. The nonlinear characterization over this greater range confirmed significantly greater stiffness in radial deviation compared to ulnar deviation. This study provides a characterization of passive wrist stiffness better suited to investigations of natural wrist rotations, which cover much of the wrist's ROM. It also provides a baseline for the study of neurological and/or orthopedic disorders that result in abnormal wrist stiffness.

[Acutrak headless compression screw fixation for the treatment of scaphoid non-union]

OBJECTIVE

To evaluate the early clinical and radiographic outcome of scaphoid non-unions treated with Acutrak headless compression screw.

METHODS

From January 2008 to July 2011,21 patients with scaphoid non-union were treated in our department. There were 18 males and 3 females with a mean age of (23.6 +/- 4.6) years; 12 cases were on right hand and 9 were on left. According to Herbert-Fisher classification, there were 10 cases with type D1, 7 cases with type D2, 3 cases with type D3, and 1 case with type D4. The mean time from injury to operation was (12.4 +/- 2.7) months. All patients were treated with Acutrak headless compression screw fixation (6 cases received 2 screws fixation, 15 cases received 1 screw fixation, and Matti-Russe bone grafting was applied in 7 cases). The carpal height, the scaphoid index and changes of the scapholunate angle were assessed before and after the operation. Range of motion and grip strength were recorded and the wrist function was assessed according to the Patient-Rated Wrist Evaluation (PRWE).

RESULTS

Average duration of follow-up was (21.3 +/- 3.6) months. All the patients attained radiological union in a mean time of (13.3 +/- 2.4) weeks following the operation. No obvious complications were recorded. The surgical treatment allowed the preoperative mean scaphoid index of 0.61 +/- 0.13 and the preoperative mean scapholunate angle of (59.4 +/- 6.8) degree to be improved to 0.69 +/- 0.10 and (44.3 +/- 8.2)degree postoperatively, respectively. There was a substantial improvement in grip strength and pain amelioration after surgery. The preoperative mean PRWE score of 45.2 +/- 4.7 was improved to 76.1 +/- 5.2 postoperatively. All patients returned back to the original work,the average time from surgery to work was (6.0 +/- 1.1) months.

CONCLUSION

For scaphoid non-unions, Acutrak headless compression screw fixation can provide anatomical reduction, provide satisfactory results with a high union rate, well return of function and minimal complications in the early stage.

[Percutaneous fixation for the treatment of un-displaced scaphoid fractures with herbert cannulated screws through volar approach]

OBJECTIVE

To summarize the experience of percutaneous fixation of scaphoid fractures with Herbert screws through volar approach, and provide a reliable and efficient treatment method for scaphoid fractures.

METHODS

From April 2008 to September 2012,15 patients with scaphoid fractures were treated by percutaneous fixation with Herbert cannulated screws through volar approach including 14 males and 1 female with an average age of 35 years ranging from 25 to 45 years old. Among them, 10 cases were on left side and 5 cases were on right side. Durations from injury to operation ranged from 3 to 10 days with an average of 5 days. All these cases were identified as B2 type according to the Herbert classification based on X-ray and CT scan. In order to assess the function of wrist, all patients were calculated according to Krimmer's score postoperatively.

RESULTS

The follow-up period were from 5 to 18 months with an average of 10 months. At 3 months after operation,X-ray was re-checked every month. All the patients achieved bone union with a mean time of 10 weeks (ranged from 7 to 14 weeks) postoperatively. According to Krimmer's score, 14 cases gained 100 scores as perfect and one case got 90 scores as good. The small volar incision of all patients were union at the first period. No operation complications such as infection and nonunion occurred.

CONCLUSION

Percutaneous fixation with Herbert cannulated screws through volar approach is a reliable and efficient treatment method for scaphoid fractures with small invasion, high bone union rate, and fewer complications.

Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers

BACKGROUND

Endoscopic maneuvers are associated with a high incidence of musculoskeletal injuries.

OBJECTIVE

To quantify wrist motion patterns during simulated endoscopic procedures to identify potential causes of endoscopy-related overuse injury.

DESIGN

Twelve endoscopists with different levels of experience were tested on 2 simulated endoscopic procedures that differed in their level of difficulty.

SETTING

Right wrist movement patterns were recorded during simulated colonoscopies by using a magnetic motion-tracking device. Analysis focused on 3 wrist degrees of freedom: abduction/adduction, flexion/extension, and pronation/supination.

INTERVENTIONS

Subjects were tested on 2 GI lower endoscopies (colonoscopies) on a simulator.

MAIN OUTCOME MEASUREMENTS

Time spent within ranges of the entire wrist range of motion for 3 wrist degrees of freedom.

RESULTS

Endoscopists spent up to 30% of the duration of the procedures at the extremes of the wrist joint range of motion. Endoscopic experience did not affect the time spent at the extremes of the wrist joint of motion. The time spent within each range of motion differed depending on the wrist degrees of freedom and difficulty of procedure.

LIMITATIONS

This study examined only 1 upper limb joint in a limited number of subjects and did not measure interaction forces with endoscopic tools.

CONCLUSIONS

We identified wrist movement patterns that can potentially contribute to the occurrence of musculoskeletal injury in endoscopists. This study lays the foundation for future work on establishing links between upper limb movement patterns and the occurrence of overuse injury caused by repetitive performance of endoscopic procedures.

Kinematic analysis of upper extremity movement during drinking in hemiplegic subjects

BACKGROUND

It is necessary to analyze the kinematic properties of a paralyzed extremity to quantitatively determine the degree of impairment of hemiplegic people during functional activities of daily living (ADL) such as a drinking task. This study aimed to identify the kinematic differences between 16 hemiplegic and 32 able-bodied participants in relation to the task phases when drinking with a cup and the kinematic strategy used during motion with respect to the gravity direction.

METHODS

The subjects performed a drinking task that was divided into five phases according to Murphy's phase definition: reaching, forward transport, drinking, backward transport, and returning. We found that the groups differed in terms of the movement times and the joint angles and angular velocities of the shoulder, elbow, and wrist joints.

FINDINGS

Compared to the control group, the hemiplegic participants had a larger shoulder abduction angle of at most 17.1° during all the phases, a larger shoulder flexion angle of 7.6° during the reaching phase, and a smaller shoulder flexion angle of 6.4° during the backward transporting phase. Because of these shoulder joint patterns, a smaller elbow pronation peak angle of at most 13.1° and a larger wrist extension peak angle of 12.0° were found in the motions of the hemiplegic participants, as compensation to complete the drinking task. The movement in the gravity direction during the backward transporting phase resulted in a 15.9% larger peak angular velocity for elbow extension in the hemiplegic participants compared to that of the control group.

INTERPRETATION

These quantitative kinematic patterns help provide an understanding of the movements of an affected extremity and can be useful in designing rehabilitation robots to assist hemiplegic people with ADL.

[Articular external fixation for chronic dorsal instability of distal radioulnar joint]

OBJECTIVE

To discuss the clinical result of extrinsic radioulnar tether combined with anchoring nail fixation for treating chronic dorsal instability of the distal radioulnar joint (DRUJ).

METHODS

Between July 2011 and December 2012, 6 patients with chronic dorsal instability of the DRUJ were treated with extrinsic radioulnar tether combined with anchoring nail fixation. There were 1 male and 5 females with the average age of 27.3 years (range, 22-35 years). All of 6 patients had a wrist trauma history. The average disease duration was 4.8 years (range, 6 months to 15 years). Radiographs were taken postoperatively to observe the anchoring nail loosening. The stress test and forearm rotation test were used to evaluate the function of DRUJ. The complications, the grip power, range of motion, and visual analogue scale (VAS) scores were recorded at last follow-up. And the joint function was evaluated by disability of arm, shoulder, and hand (DASH) score.

RESULTS

Primary healing of incision was obtained in all cases, without any complications such as infection and ulnar neck fracture. All 6 patients were followed up 6-24 months (mean, 13.7 months). Stability was achieved in all patients. Radiographs showed that the joint space was widened and dislocation of the ulnar head was improved at 3 and 6 months after operation. The results of the stress test and forearm rotation test were negative. At last follow-up, the grip power, DASH score, VAS score, and range of motion of the wrist were significantly improved when compared with preoperative ones (P < 0.05).

CONCLUSION

Extrinsic radioulnar tether combined with anchoring nail fixation is an easy method of surgical revision to treat chronic dorsal instability of DRUJ, which can maintain the stability and protect the blood supply of triangular fibrocartilage complex.

Motion analysis of throwing Boccia balls in children with cerebral palsy

Boccia is a sport suitable for children with cerebral palsy (CP). Throwing Boccia balls requires upper extremity and torso coordination. This study investigated the differences between children with CP and normally developed children regarding throwing patterns of Boccia balls. Thirteen children with bilateral spastic CP and 20 normally developed children participated in this study. The tests in this study were a pediatric reach test and throwing of Boccia balls. A 3D electromagnetic motion tracking system and a force plate were synchronized to record and analyze biomechanical parameters of throwing Boccia balls. The results of the pediatric reach test for participants with CP were significantly worse than those for normally developed participants. The 2 groups of participants did not significantly differ regarding the distance between a thrown Boccia ball and a target ball (jack). Participants with CP demonstrated significantly longer movement duration, smaller amplitude of elbow movement, greater amplitudes of shoulder abduction and flexion, slower maximal velocity of torso flexion and the linear velocity of moving the wrist joint forward, faster maximal velocity of head flexion, and smaller sway ratio compared with normally developed participants when throwing Boccia balls. Participants with CP seemed to mainly use head and shoulder movements to bring the Boccia balls forward with limited torso movement. Normally developed participants brought the Boccia ball forward with faster torso and greater elbow movement while stabilizing head and shoulder movements. Nevertheless, participants with CP did not demonstrate significantly worse performance in the throwing accuracy of Boccia balls.

[Intra-articular radioulnar ligament reconstruction for chronic instability of distal radioulnar joint]

OBJECTIVE

To evaluate the effectiveness of intra-articular radioulnar ligament reconstruction in the treatment of chronic instability of the distal radioulnar joint.

METHODS

Between January 2006 and June 2012, the intraarticular radioulnar ligament reconstruction was used to treat chronic instability of the distal radioulnar joint in 12 patients. Of 12 cases, 8 were males and 4 were females with an average age of 37.3 years (range, 22-54 years). The causes of injury were tumble in 9 patients, traffic accident in 2 patients, and sprain in 1 patient. The average time from initial injury to operation was 6.2 months (range, 2-13 months). The pain and function of the wrists were assessed with Patient-Rated Wrist Evaluation (PRWE) (27.5 +/- 4.7). Broadening of the distal radioulnar joint space was seen on the anteroposterior radiograph in all the patients. Lateral view showed dorsal instability in 10 patients and palmar instability in 2 patients. There was no radial fracture, ulnar fractures or degeneration of the distal radioulnar joint.

RESULTS

All patients achieved primary healing of incision. No complication of deep infection or nerve injury occurred. They were followed up from 12 to 30 months (mean, 20.6 months). Pain and the clicking sound of the wrists disappeared; grip strength increased; the range of motion values of the wrist and forearm were restored. PRWE score was 5.8 +/- 2.1 at last follow-up, showing significant difference when compared with preoperative score (t = 14.215, P = 0.000). Imaging examination showed good appositions of the distal radioulnar joint, with no dislocation or subluxation.

CONCLUSION

Intra-articular radioulnar ligament reconstruction can rebuild the anatomic stability of the distal radioulnar joint, which does not damage the adjacent structures of the joints and can obtain satisfactory function of the reconstructed joint. It is a good choice for chronic instability of the distal radioulnar joint without articular degeneration.

Distal radius fixation through a mini-invasive approach of 15 mm. PART 1: a series of 144 cases

The volar Henry approach is becoming the gold standard for distal radius fracture fixation. It decreases the incidence of nonunion, limits complications especially complex regional pain syndrome (CRPS) type I, and allows early mobilization of the wrist. Nonetheless, it has some disadvantages such as the size of the incision, which is not esthetically pleasing, and the loss of ligamentotaxis. This is why some authors have developed a mini-invasive approach. The aim of this work was to evaluate the feasibility of the anterior mini-invasive approach of 15 mm in a clinical series of 144 cases of distal radius fracture. All patients were operated under regional anesthesia using the same techniques by five surgeons of the same team. According to the AO classification, there were 83 type A fractures, 2 type B, and 59 type C. A volar plate (Step One(®), Newclip Technics™, Haute-Goulaine, France) was used in all cases. The 2 proximal metaphyseal screws and the 2 distal central epiphyseal screws were monoaxial locking. The 2 distal ulnar and radial epiphyseal screws were placed in polyaxial locking at 20° angulation maximum. Skin closure without drainage was performed. No postoperative immobilization was prescribed, and patients were encouraged to use their upper limb immediately postoperative. No postoperative physiotherapy was prescribed. The mean follow-up was 4.1 months. The final size of the incision was on average 16.1 mm. Mean pain score was 1.8. The Quick DASH score was average 25. Average range of motion was more than 85 %, and global force of the hand was 67 % compared with contralateral side. On X-ray, the mean radial slope was 22°, the mean radial tilt was 8.3°, and the mean radioulnar variance/index was -0.4 mm. There were nine cases of CRPS type I, which all resolved. Specific complications included two secondary displacements and nine tenosynovitis cases. No tendon rupture was noted. Two intra-articular distal radioulnar joint screws had to be removed at 3 months. One epiphyseal screw required removal 1 month postoperative due to loosening. There were no intra-articular radiocarpal screws. Distal radius fracture fixation using a mini-invasive approach is a reliable and reproducible procedure with few complications. It allows anatomical reduction in the distal radius fractures including intra-articular ones. It can be associated with arthroscopy, scaphoid screw fixation or even percutaneous pinning. Thus, most traumatic lesions of the wrist bony or soft tissue can be treated through this mini-invasive approach.

Ligamentous hyperlaxity and dorsal wrist ganglions

PURPOSE

To determine whether symptomatic dorsal wrist ganglions are associated with generalized ligamentous hyperlaxity.

METHODS

Ninety-six patients (61 females) presenting to hand surgeons for a symptomatic dorsal wrist ganglions were prospectively enrolled in this case-control investigation. Beighton scores were calculated to quantify generalized ligamentous laxity in each patient, and a scaphoid shift test (scapholunate capsuloligamentous laxity evaluation) was performed. A positive scaphoid shift test was defined by both pain and a palpable clunk. Ninety-six individuals without ganglions were then enrolled to form an age and sex frequency-matched control cohort. The control group was similarly assessed for Beighton score and scaphoid shift test. Binary logistical regression was performed to assess the association of ganglions with generalized ligamentous hyperlaxity (Beighton score ≥ 4) while accounting for effects of age and sex.

RESULTS

Patients with symptomatic dorsal wrist ganglions demonstrated significantly increased rates of generalized ligamentous hyperlaxity. Among those with ganglions, 27 of 96 (28%) patients exhibited generalized ligamentous hyperlaxity, compared with 12 of the 96 (13%) age- and sex-matched individuals in the control group. Patients with symptomatic dorsal wrist ganglions were also significantly more likely to demonstrate localized scapholunate hyperlaxity with a positive scaphoid shift test (25% positive scaphoid shift test with ganglions vs 1% in controls). In logistical modeling, patients with dorsal wrist ganglions had 2.9 (95% confidence interval [CI] 1.3-6.2) times greater odds of generalized ligamentous hyperlaxity compared with patients without a dorsal wrist ganglion after accounting for patient age and sex.

CONCLUSIONS

Symptomatic dorsal wrist ganglions were associated with both generalized ligamentous hyperlaxity and a positive scaphoid shift test. Although an association between wrist ganglions and ligamentous hyperlaxity does not prove causation, the possibility of the same underlying pathological entity causing both can be envisioned (ie, abnormal formation or organization of dense regular connective tissue).

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Quantitative evaluation of cerebellar ataxia based on pathological patterns of the muscle activities

Quantitative evaluation of cerebellar ataxia is crucial for precise evaluation of cerebellar diseases. In particular, it is essential to capture anomaly of the causal motor commands as well as the resultant movement for the ataxia. In this paper, we propose a new method to make a quantitative evaluation of the cerebellar ataxia based on EMG signals. As an experimental task, we asked subjects to perform step-tracking wrist movements with a manipulandum, and recorded wrist joint movements and muscle activities of four wrist prime movers with surface electrodes. The subjects included fourteen patients with cerebellar diseases and thirteen normal controls. We succeeded to extract two parameters from the EMG signals of the four wrist prime movers, which characterize the pathological patterns of muscle activities for the cerebellar ataxia, Total Co-contraction Level (TCL) and Directionality of Muscle Activity (DMA). We found that the two parameters were useful to characterize pathological patterns of muscle activities in cerebellar ataxia. Consequently, it is expected that our proposed method is useful not only in tracking condition of cerebellar patients but also in evaluating the effects of a treatment or neuro-rehabilitation aiming at the normalization of motor commands.

Prediction of three-dimensional arm trajectories based on ECoG signals recorded from human sensorimotor cortex

Brain-machine interface techniques have been applied in a number of studies to control neuromotor prostheses and for neurorehabilitation in the hopes of providing a means to restore lost motor function. Electrocorticography (ECoG) has seen recent use in this regard because it offers a higher spatiotemporal resolution than non-invasive EEG and is less invasive than intracortical microelectrodes. Although several studies have already succeeded in the inference of computer cursor trajectories and finger flexions using human ECoG signals, precise three-dimensional (3D) trajectory reconstruction for a human limb from ECoG has not yet been achieved. In this study, we predicted 3D arm trajectories in time series from ECoG signals in humans using a novel preprocessing method and a sparse linear regression. Average Pearson’s correlation coefficients and normalized root-mean-square errors between predicted and actual trajectories were 0.44∼0.73 and 0.18∼0.42, respectively, confirming the feasibility of predicting 3D arm trajectories from ECoG. We foresee this method contributing to future advancements in neuroprosthesis and neurorehabilitation technology.

Comparison of the reaction time of wrist flexion and extension between patients with stroke and age-matched healthy subjects and correlation with clinical measures

BACKGROUND

Brain injury had an effect on reaction time (RT) and brain-injured patients were normally significantly slower than normal controls. The RT of the paretic upper limb (UL) in patients with stroke was slower than in a control group. The present study was designed to compare the RTs of the unaffected and affected sides in stroke survivors and those of normal subjects. This study also explores the relationships among wrist flexion and extension RTs in the affected side and the motor deficits of the UL as measured by clinical Composite Spasticity Index (CSI), Associated Reaction Rating Score (ARRS), and Wolf Motor Function Test (WMFT) scores.

METHODS

Ninety-eight hemiparetic stroke survivors and 20 normal subjects participated in the study. Abnormal muscle tone was measured by CSI. Associated reaction was measured by ARRS. Motor function was measured by WMFT. The subject was asked to flex or extend the affected and non-affected wrists as fast as possible, following an auditory "go" signal. An electrogoniometer attached to the wrist measured wrist flexion and extension angle. RT was defined as the time from the "go" signal to a change in wrist angle denoting movement onset. Clinical assessments and RT were conducted within one day. Differences in the variables between normal subjects and the unaffected sides of the stroke patients were analyzed using analysis of variance. Correlations were assessed by computing Spearman's correlation coefficient. The significance level was set at 5%.

RESULTS

RTs of wrist flexion and extension in the stroke survivors' affected hands were significantly longer than those in normal subjects and their unaffected hands (P < 0.01 for both). The wrist flexion RT moderately correlated with CSI (ρ = 0.412, P < 0.001) and ARRS (ρ = 0.341, P < 0.001) and with WMFT functional ability (negatively; ρ = -0.531, P < 0.001) and time score (ρ = 0.504, P < 0.001). Similarly, the wrist extension RT moderately correlated with CSI (ρ = 0.429, P < 0.001), ARRS (ρ = 0.374, P < 0.001), and with WMFT functional ability (negatively; ρ = -0.531, P < 0.001) and time score (ρ = 0.486, P < 0.001).

CONCLUSIONS

RTs of wrist flexion and extension on the stroke survivors' affected sides were significantly longer than those on the unaffected sides and those of normal subjects. The wrist flexion and extension RTs moderately correlated with CSI and ARRS and inversely with motor functional performance of the UL in patients with stroke.

An alternative treatment option for scaphoid nonunion advanced collapse (SNAC) and radioscaphoid osteoarthritis: early results of a prospective study on the pyrocarbon adaptive proximal scaphoid implant (APSI)

INTRODUCTION

Scaphoid nonunion advanced collapse (SNAC) and radioscaphoid osteoarthritis are difficult to treat. Options include proximal row carpectomy (PRC), four corner fusion (4CF) and wrist arthroplasty or arthrodesis. However, with inevitable disease progression, a significant proportion of patients undergo total wrist fusion. This reduces function by abolishing wrist movement. We review the preliminary results of a pyrocarbon interpositional radiocarpal implant in a small cohort of patients from our prospective study and challenge the assumption that there are no surgical alternatives.

MATERIALS AND METHODS

This study prospectively studied 12 consecutive pyrocarbon Interpositional arthroplasty day cases over 3 years. Patients were assessed using level of pain, ranges of motion, grip strength, key pinch, type of and time to return to work and the disabilities of the arm, shoulder and hand (DASH) score, both preoperatively and postoperatively. Radiographs were also taken and patient satisfaction recorded.

RESULTS

All 12 patients could be contacted and were satisfied with their surgery. There were no immediate, early or late postoperative complications associated with the procedure. Promising results were noted in terms of pain, ranges of motion, grip strength, key pinch, type of and time to return to work, DASH scores, photographs and radiographs. The mean follow-up was 18 months, range between 11 months and 3 years.

CONCLUSION

Our early results are encouraging, warrant further and longer studies and support the use of pyrocarbon implants as a primary procedure in what is a generally young and active subgroup of patients.

PURLs: Suspect carpal tunnel? Try this

An easy-to-administer modification of the traditional Phalen’s test for carpal tunnel syndrome increases the value of this diagnostic tool.

Vascular calcification in a young patient with end-stage renal disease

Vascular calcification in children with long-standing dialysis is a unique phenomenon. Hyperphosphataemia and hyperparathyroidism are the major pathogenic risk factors. We describe a young patient with end-stage renal disease diagnosed since childhood and underwent prolonged dialysis therapy. He was admitted for recurrent episodes of acute joint pain. Investigations confirmed diffuse periarticular, vascular, and intracardiac calcifications which were rarely seen in the young population. He underwent parathyroidectomy and incidentally found to have a co-existing papillary carcinoma of thyroid. After parathyroidectomy, serial X-rays showed resorption of these calcifications.

A rare case of massive carpal osteoblastoma requiring complex reconstructive surgery

An osteoblastoma is a rare, commonly benign, osteoid-producing neoplasm of the bone with an incidence of 2% of all primary bone tumours. We present a case of a 54-year-old patient with persisting carpal pain and massive swelling of the hand for a period of 4 years. Incision biopsies revealed the histopathological finding of a carpal osteoblastoma. After complete tumour excision, including the carpal and, in parts, metacarpal bones, reconstructive surgery was performed with a free osteocutaneous iliac crest flap to obtain a natural hand contour and the best possible hand function. Follow-up revealed improvement of the hand function in terms of flexion, extension and strength without discomfort or further pain. Thus, ongoing carpal pain should lead to an intensive search with further diagnostic measures such as magnetic resonance imaging (MRI) scan as well as biopsies, if necessary, to obtain the correct diagnosis.

Distal radioulnar joint instability: a review of literature

Distal radioulnar joint instability most commonly accompanies fractures of the distal radius and is directly caused by lesion of the triangular fibrocartilage complex, which is the major structure responsible for congruity of the distal radioulnar joint. Acute instability accompanying fractures of the distal radius usually does not require separate management, if the fracture itself is firmly fixated. Chronic instabilities causing persistent pain and wrist dysfunction are treated by arthroscopic reinsertion of the torn attachments of the triangular fibrocartilage. If not possible, radioulnar functional tenodesis is performed using palmaris longus tendon graft, thus restoring joint stability.