The use of resurfacing capitate pyrocarbon implants (RCPI) in chronic diseases of the wrist: outcomes of more than 100 cases

INTRODUCTION

In advanced chronic post-traumatic wrist pathology, the goal of surgery has always been to reduce pain while trying to preserve the function of the wrist itself as much as possible; numerous interventions have been developed to achieve these goals (partial arthrodesis, 4-angle arthrodesis, the use of prosthetic implants…).

PURPOSES

The purpose of the study is to evaluate outcomes and complications rate of proximal row carpectomy associated with the resurfacing capitate pyrocarbon implant (RCPI) for chronic diseases of the wrist.

MATERIALS AND METHODS

A retrospective analysis of the patients operated on between June 2004 and March 2021 was performed. Pain, wrist range of motion in flexion, extension, radial and ulnar deviation and grip strength were compared preoperatively and at 1, 6, 12 and 24 months. Complications and additional procedures were recorded.

RESULTS

A total of 112 patients underwent surgery for proximal row carpectomy and placement of RCPI with a mean follow-up of 6.6 years. Between the preoperative and the 2-year follow-up, a reduction in pain (VAS from 7.3 to 0.5), an increase in grip strength (from 8 to 17 kg) and an increase in ROM in all planes (flexion from 19° to 44°, extension from 20° to 46°, radial deviation from 7° to 14° and ulnar deviation from 13° to 28°) were recorded. Ten (8.9%) patients required additional surgery, with only 2 (1.8%) patients requiring revision of the implant.

CONCLUSIONS

Proximal row carpectomy associated with RCPI is an excellent surgical strategy to relieve pain and to improve wrist range of motion and grip strength in patients with chronic diseases of the wrist.

Osteoid Osteoma of the Hand: Surgical Treatment versus CT-Guided Percutaneous Radiofrequency Thermal Ablation

(1) Background: Osteoid osteoma (OO) is one of the most common benign bone tumors. This type of osteogenic tumor is generally characterized by a well-defined lytic area with a vascularized central nidus surrounded by sclerosis and bone thickening. The wrist and hand bones are infrequent sites for osteoid osteoma: only 10% of the cases arise in these areas. Standard treatments are surgical excision and radio-frequency ablation (RFA), both with advantages and disadvantages. This study aimed to compare the two techniques to prove if RFA could be a potential alternative to surgery in the treatment of OO of the hand. (2) Methods: Patients treated for OO of the hand between January 2011 and December 2020 were evaluated and data was collected regarding the lesions' characteristics and the treatment outcome. Each patient was followed up for 24 months and VAS pain (Visual Analogue Scale), DASH (Disability of the Arm, Shoulder and Hand), and PRWE (Patient-Related Wrist Evaluation) scores were collected. (3) Results: A total of 27 patients were included in the study: 19 surgical and 8 RFA. Both treatments showed a significant improvement in pain and functionality. Surgery was associated with a higher complication rate (stiffness and pain), while RFA was associated with a higher recurrence rate (2/8 patients). RFA allowed for a speedier return to work. (4) Conclusions: We believe that osteoid osteoma treatment with RFA in the hand should be an available alternative to surgery as it allows rapid pain relief and a swift return to work. Surgery should be reserved for cases of diagnostic uncertainty or periosteal localization.

Resurfacing Capitate Pyrocarbon Implant for the treatment of advanced wrist arthritis in the elderly: a retrospective study

OBJECTIVE

Advanced forms of wrist osteoarthritis in the elderly are quite common and often under-treated, preferring a conservative management of the condition due to the age of the patient. However, in elderly people who are still active, sporty and physically demanding, surgical management of wrist osteoarthritis should be considered. Proximal Row Carpectomy associated with a Resurfacing Capitate Pyrocarbon Implant (RCPI), allows the management of a wide range of wrist arthrosis, involving both the radio-carpal and the mid-carpal joints. This treatment has been already reported as a solution in younger people affected by degenerative pathologies of the wrist, giving overall good results. Authors aimed at verifying how this technique could be useful in elderly patients, resolving the severe pain often related to this pathology and letting them recover strength and motion.

PATIENTS AND METHODS

This is a retrospective analysis involving 7 cases of elderly men (mean age = 68 y.o.), suffering from severe wrist arthritis and treated with RCPI between 2016 and 2021.

RESULTS

All patients reported a return to manual activities between 6 and 12 months after surgery, significantly improving pain. Two patients complained moderate pain under strain at follow-up, with residual difficulty in performing manual tasks. In all cases, an increase of strength and improvement in terms of stiffness was registered. No cases of infections or implant mobilization were reported.

CONCLUSIONS

RCPI combined with proximal row carpectomy shows satisfying results in all published studies and it has been confirmed in our series as well. Indications for this procedure should be widened to elderly people, as useful alternatives to more aggressive salvage procedures, such as total prosthesis or arthrodesis.

Retrospective Review of Long-term Outcomes of Patients Undergoing CMC Arthroplasty With Interposition Scaffold

Background: The treatment of rhizarthritis involves several surgical techniques; among them, bioabsorbable scaffolds have begun to be proposed to avoid the use of other biological tissues or artificial permanent devices. Methods: In this study, we evaluated the long-term outcomes of poly-ld-lactic acid scaffold in interposition arthroplasty in a series of patients treated in our department. Results: Strength, range of motion, and pain improved after the intervention and lasted over the years; nonetheless, most of the radiographs showed a progressive collapse of the first metacarpal. Conclusions: Despite radiological findings, we believe that poly-ld-lactic acid scaffold can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results.

Partial trapeziectomy and pyrocarbon interpositional implant (Pyrodisk) for trapeziometacarpal osteoarthritis in the active working population: outcomes of a 10 years-experience

The treatment of trapeziometacarpal (TM) osteoarthritis is still debated, as many surgical options are available, and no technique has proven to be superior. Prosthetic treatment in this context has been described since the early 60s. Recently, the use of pyrolytic carbon-based prosthesis has revolutionized arthroplasty surgery in the hand. We performed a retrospective investigation of our surgical management of TM osteoarthritis since 2010 including the study only patients treated with partial trapeziectomy and Pyrodisk implant, with at least 5 years follow-up. After the application of inclusion criteria, 26 patients (6 males and 20 females) were retained. Despite the literature suggesting that implant TM surgery is well suited for older patients, in our experience, the procedure was mainly proposed to the young manual worker, with high demands in terms of thumb strength and stability (mean age of 53 years old, range 37-65). A statistically significant improvement in post-operative DASH, Kapandji and scores was observed. As well, strength measurements, particularly pinch strength and grip strength, increased significantly after the surgery. According to our findings, the Pyrodisk implant provides satisfactory results in terms of thumb strength and stability even in young and active patients and should therefore be considered as a valuable option in selected cases. Meticulous surgical procedure is mandatory in order to avoid complications and should therefore be executed by an expert surgeon. Abbreviation: IV: level of evidence.

Adaptive Proximal Scaphoid Implant stability despite a perilunate dislocation: a case report

BACKGROUND

We present the case of a 22 y.o. male patient suffering from scaphoid non-union with avascular necrosis of the proximal pole and initial degenerative arthritis.

CASE REPORT

He referred to our institution with functional impairment and persistent pain (VAS 8\10). The patient underwent the positioning of the small size Adaptive Proximal Scaphoid Implant (APSI), without fixation, through an open dorsal approach and radial styloidectomy. The post-operative course was uneventful, and the patient could resume his daily routine without limitations. 5 years later the patient returned to our department referring a dorsal perilunate dislocation on the same hand. Unexpectedly no implant dislocation occurred and we were able to reduce the perilunate dislocation maintaining the same implant. At 30-month follow-up the patient was pain free (VAS 0\10) with almost completely recovered function of the hand and wrist.

CONCLUSION

In order to minimize implant dislocation, both an adequate scaphoid resection and the choice of the right implant size (which should be lightly downsized compared to the scaphoid resection) are of paramount importance. At the same time, the capsuloplasty should be carefully performed at the right tension, providing adequate stability to the implant. This technique provided satisfactory functional results in a long-term follow-up, even in a young and active patient. Moreover, it does not preclude or complicate the possibility of resorting to different surgical procedures in case of necessity, whilst maintaining the same implant.

Resurfacing Capitate Pyrocarbon Implant Without Capitate Pole Resection to Improve Clinical Results in the Treatment of Chronic Wrist Arthritis

Proximal row carpectomy (PRC) is a long-time, well-accepted, easy-to-reproduce procedure for the treatment of several painful degenerative conditions of the wrist, when capitate pole and radius lunate fossa are preserved. It has been reported to relieve pain and preserve a substantial wrist range of motion, although a partial loss of strength has to be expected because of the decreased length of the carpus. Since 2010, a new technique has been described in the literature using the resurfacing capitate pyrocarbon implant, combined with PRC. This implant has been designed to perform PRC even in the presence of degenerate joint surfaces, and thus resolves the limited indications of this procedure; however, if a resection of the capitate pole is performed to set up the implant, similar to PRC it may not positively influence the recovery of strength. The authors propose an resurfacing capitate pyrocarbon implant technique without any capitate bone resection, to preserve as much as possible the carpus length and so to improve the functional recovery. The surgical technique, is described in detail and preliminary results are discussed.

Resurfacing capitate pyrocarbon implant as salvage procedure in several serious outcomes of carpal injuries. Clinical experience and follow-up

BACKGROUND AND AIM

Resurfacing Capitate Pyrocarbon Implant has been introduced in the surgical practice as an alternative method to restore wrist motion, strength and functions in patients suffering from wrist osteoarthritis. It has already been well described in the literature as a treatment for advanced stages of degenerative wrist diseases which follow scaphoid's and lunate's injuries such as scapho-lunate advanced collapse, scaphoid non-union advanced collapse, and advanced stages of Kienböck disease. Authors extended the use of RCPI to other selected cases of complicated wrist injuries, spreading out from the classic indications for which this device was designed.

METHODS

We discuss 8 cases with serious outcomes of carpal injuries treated with Resurfacing Capitate Pyrocarbon Implant as salvage procedure between 2005 and 2013 by the first author of this paper Results: Among the eight particular selected cases, at a mean 4.3 years follow-up (range 2-11) only one was considered a failure and underwent a total wrist arthrodesis, resolving pain after all. The seven other cases reported good results. Range of Motion, Visual Analogue Scale for pain, subjective satisfaction and radiographical outcomes are reported.

CONCLUSIONS

As a result of this heterogeneous clinical experience, validated by long-term follow-ups in most cases, we think that the use of a Resurfacing Capitate Pyrocarbon Implant can be suggested as an option in the outcomes of various carpal injuries.

Combined radius addition osteotomy and ulnar shortening to correct extra-articular distal radius fracture malunion with severe radial deviation and ulnar plus

Malunion can occur in 11 to 28% of Distal Radius Fractures and can result in radius shortening and ulnar plus with wrist deviation, pain and disability. We aimed to report particular cases of extra-articular distal radius fracture malunion with severe radial deviation and ulnar plus treated by corrective osteotomy of distal radius with bone graft associated to ulnar procedure. One of these patients was firstly operated with ulna subtraction osteotomy synthesized with plate and in a second stage with distal radius corrective addition osteotomy with homologous bone graft, plate and external fixator. Two other cases were treated in a single-step by radius addition osteotomy and caput ulnae Darrach resection. These three patients were followed-up from 2 to 12 years, successfully observing the maintenance of anatomical correction and recovery of ROM and strength with good pain relief and return to daily activities. After Darrach procedure external-fixation wasn't needed and pronation-supination was better. Darrach procedure can solve ulna plus and improve ROM in pronation-supination with a quicker healing, avoiding the risk of ulnar non-union. Darrach's procedure associated to addition corrective osteotomy of distal radius can be a valid treatment for distal radius severe malunion, in patients with low-moderate functional demand. In conclusion, the surgeon should choose the right corrective treatment after the complete evaluation of the patient and his functional needs.

Ligamentous Reconstruction of Scapholunate Dislocation through a Double Dorsal and Palmar Approach

Six patients, were treated for scapholunate dissociation by reconstruction of both the palmar and dorsal parts of the scapholunate interosseous ligament through a combined palmar and dorsal approach. The mean active range of motion of the wrist at final follow-up was 44° of flexion and 58° of extension and the mean hand grip strengths was 88% of that of the contralateral hand. The average time to return to work was 105 days and the mean DASH score at a mean follow-up of 32 months was 18. At follow-up, radiographs showed maintenance of the anatomical reduction of the scapholunate articulation in all cases and the scapholunate angle was normal in five patients.

Italian translation, cultural adaptation and validation of the "American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale"

Background and Aim of the workAnkle and hindfoot injuries are common and may lead to functional impairment, disability, exclusion from occupational and daily activities. It's necessary a standardized method for assessing treatment outcomes in people with same condition and disease.American-Orthopaedics-Foot-and-Ankle-Society's-Ankle-Hindfoot-Evaluation-Scale (AOFAS-AHES) is specific to estimate clinical problems of the ankle-hindfoot.Outcome evaluation scales should be translated and culturally adapted into the language of the investigated patient.Our purpose was to translate and culturally adapt into Italian AOFAS-AHES, and to check its reproducibility and validity.MethodsAn Italian translation of the AOFAS-scale was retranslated into English by a native English and compared to the original to define a second correct Italian-version, that was submitted to 50 randomized patients operated at their ankle or hindfoot with a minimum follow-up of 6 months for cultural adaptation, and to 10 healthcare professionals to check comprehension of the medical part.To check intra and inter-observer reproducibility each patient underwent 2 interviews by interviewer-A and 1 by B. ShortForm(SF)-36-questionnaire for quality of life and Visual-Analogue-Scale (VAS) for pain were also compared for validation. The Pearson's-Correlation-Coefficient and the Intra-Class-Correlation coefficient were calculated to check inter and intra-observer reproducibility for validation.ResultsCultural adaptation revealed to be good. We obtained a good correlation of the inter and intra-observer reproducibility. Further validation of the Italian-AOFAS-AHES was obtained comparing AOFAS results to SF-36.ConclusionsItalian translation, cultural adaptation and validation of the AOFAS-AHES has been performed successfully and could be useful to improve assistance quality in care practice.

Transcapho perilunate dislocation with palmar extrusion of the scaphoid proximal pole

Perilunate fracture-dislocations usually combine ligament ruptures, bone avulsions, and fractures in different patterns. Rarely a displaced fracture of the scaphoid can coexist with a scapho-lunate dissociation and can result in enucleation of the proximal pole. We report about a case of trans-scaphoid perilunate dislocation with palmar extrusion/enucleation of the scaphoid proximal pole, treated with scaphoid fracture open reduction and internal fixation with screw, scapho-lunate ligament repair with an anchor and vascularization of the scaphoid proximal pole with the 2nd intermetacarpal artery. At 52 months follow up we had good clinical and radiographic results. In conclusion, scientific literature including our experience about this rare complex lesion of the wrist is too weak to support an effective strategy of management but we think that the careful analysis of the single problems can be the key to solve the complexity. Goal of the treatment should be complete revascularization and healing of the scaphoid, avoiding non union and avascular necrosis; simultaneously a proper ligament reconstruction is fundamental to re-establish carpal stability. Prevention of carpal collapse for a SNAC o SLAC situation is essential to reach a good level of Quality of Life and satisfaction of the patient.

Bone-ligament-bone Cuenod grafting technique modified by Saffar-Romano for the treatment of chronic scapho-lunate dissociation

BACKGROUND AND AIM OF THE WORK

The authors show their experience about six patients suffering of chronic scapho-lunate (S-L) dissociation treated with the Cuenod method modified by Saffar-Romano.

METHODS

Clinical assessment was performed in all patients and compared before and after surgery at follow-up measuring pain value through the VAS, ROM of the wrist with a goniometer, grip strength by Jamar test, functional outcome with the Italian version of the Disability of Arm, Shoulder and Hand (DASH) score. Radiological assessment consisted in measuring S-L angle and classifying radio-carpic and inter-carpic osteoarthritis.

RESULTS

At radiographic check-up the reduction of the dissociation remained within the normal range of S-L angle (30°-60°) in 5/6 patients (83%). Clinical results were satisfactory for all the patients due to complete absence of pain and a good recovery of wrist function with more than 80% of the force and mobility compared to the contralateral side for three patients, and a recovery of more than 60% of the force and mobility for another patient. Mean DASH score was 8. All the patients returned to their previous job after a mean time of 4 months.

CONCLUSIONS

Cuenod modified by Saffar-Romano grafting technique can be considered a brilliant solution for chronic S-L dissociation where S-L ligaments are completely worn included cases of SLAC I wrist.

Ibuprofen timing for hand surgery in ambulatory care

OBJECTIVE:

To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care.

METHODS:

Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h.

RESULTS:

Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085).

CONCLUSION:

Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

Personal technique for wrist dorsal approach

In hand disorders surgical procedures are more and more widely used and often it's necessary to approach the wrist by the dorsal way. Beneath anatomy of this region is well known, there is still room enough to develop new surgical exposure techniques mostly related to physiology and biomechanics. Our goals are to present an innovative surgical dorsal exposure of the wrist, to show its use for different problems solving, and to evaluate its mini-invasive and functional outcome. Our inedited surgical technique is presented. Since November 1999 to February 2008, this technique has been used by the same surgeon in 60 cases for different pathologies and procedures: 14 SNAC-SLAC wrists III-IV treated by proximal row resection and Resurface-Capitate Pyrocarbon Implant (RCPI), 2 Fenton syndromes by bone graft and RCPI, 6 SNACSLAC II by proximal row resection +/- radial styloidectomy, 2 SLAC III by scaphoidectomy and capito-lunate arthrodesis, 12 scapho-lunate recent dissociations by ligamentoplasty (double approach), 4 scapho-lunate inveterate dissociations by Cuenod Saffar-Romano modified technique and 4 by synthetic ligaments, 1 fracture of the scaphoid proximal pole by synthesis-revascularization-S.L.ligament reconstruction, 15 Kienbock's diseases revascularized by II m.c. artery +/- radial osteotomy. Patients have been evaluated at follow up through the DASH disability questionnaire, the Mayo score for the force, ROM, pain, satisfaction grade. Results are good and encouraging for these applications. In conclusion this new technique with its limited exposure permits an early mobilization with a lower risk of stiffness and can be considered mini-invasive.

Salvage of a post-traumatic arthritic wrist using the scaphoid as an osteochondral graft

The authors describe a case of post-traumatic wrist arthritis with an osteochondral defect in the scaphoid fossa of the radius. The patient was treated with proximal row carpectomy, radial styloidectomy and reconstruction of the defect using the proximal half of the scaphoid as an autologous osteochondral graft. Pain relief was achieved while wrist motion and strength were improved. The carpal bones are a source of osteochondral grafts and can be used to expand the indications of motion-preserving wrist salvage procedures.

The use of a pyrocarbon capitate resurfacing implant in chronic wrist disorders

The present study describes the technique and results of proximal row carpectomy with resection of the head of the capitate and replacement with a pyrocarbon capitate resurfacing implant. The major indication for surgical treatment was arthritic changes on the head of the capitate. Patients were assessed by range of motion, grip strength, pain and functional scoring, and radiographic studies. In most patients, wrist function was improved and pain relief was obtained. This surgical procedure may represent a good alternative to total and partial wrist arthrodesis.

Leiomyoma of the hand: a case report

We report a case of leiomyoma of the finger in the right hand of a 12-year-old boy: a rare site for localization and unusual for age. This is a benign tumor originating from non-striated muscle that is very uncommon in the hand. The uterus is considered the most common location for leiomyoma and when it occurs in the extremities, it is more common in the leg, ankle and foot. It usually occurs in the third and fourth decades of life and it is rarely diagnosed before surgery as the diagnosis can only be confirmed histologically.

Megaesophagus in an asthmatic patient and beta2 stimulant treatment by inhalation

Megaesophagus is a severe esophageal malformation. We report a case of megaesophagus in an asthmatic patient affected by congenital non-haemolytic anaemia and undergoing beta2 stimulant treatment by inhalation. Our case could be due to chronic beta2 receptor stimulation with imbalance of alpha and beta receptor, without any implication of favism.

Osteoid osteoma of the hand and wrist

Eighteen cases of osteoid osteoma of the hand and wrist were treated between 1985 and 1999. The diagnosis was confirmed pre-operatively with X-rays, bone scintigraphy, CT, and MRI, and all the diagnoses were later confirmed by histological examination. The authors highlight the difficulties in the diagnosis of the osteoid osteoma of the hand and wrist. An accurate clinical history and a high index of suspicion are required. Three phase bones scans are highly sensitive for osteoid osteoma and should be used in conjunction with CT examination to facilitate diagnosis and pre-operative planning. All the patients were treated surgically, by removal of the tumour, with complete resolution of all symptoms.

Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand

OBJECTIVE

To assess the utility of toe-to-finger transfers (TFTs) for post-traumatic reconstruction of the fingerless hand.

DESIGN

A case series.

SETTING

A regional trauma centre.

PATIENTS

Eight men, mean age was 36 years (range from 25-59 yr), who had lost all the fingers from a hand due to a crush-degloving injury (6 patients), frostbite (1 patient) or a burn injury (1 patient).

INTERVENTION

TFT. Twelve TFTs were cone and the mean time from injury to reconstruction was 17.2 months.

MAIN OUTCOME MEASURES

Objective (range of motion, moving 2-point discrimination, grip strength, key pinch, Jebsen-Taylor hand assessment, return to work) and subjective (activities of daily living and a questionnaire) measures.

RESULTS

Eleven of the 12 transfers survived. Six of the 7 in whom the transfer was successful were available for follow-up (mean 45 mo). Range of motion was 10 degrees at the distal interphalangeal joint, 18 degrees at the proximal interphalangeal joint and 59 degrees at the metacarpophalangeal joint. Sensation was protective in all. Grip strength and key pinch were 26.1% and 70.2% of the contralateral hand respectively. Jebsen-Taylor assessment indicated that basic activities were possible but slowed. All 6 patients returned to work and could perform 92.6% of the activities of daily living unassisted. Hand and foot symptoms were mild. Two-thirds were appearance conscious, 5 of the 6 went on to altered vocations and all reported overall satisfaction as high.

CONCLUSION

This study supports TFT for reconstruction of the fingerless hand in that, although transferred toe function may be poorer than a normal finger, the hand is restored to a useful, sensate and versatile functional unit, such that global hand and patient function, as well as patient satisfaction, are very good.

[MRI in the postoperative assessment of pseudoarthrosis of the scaphoid bone treated by corticocancellous bone graft. Report of 31 cases]

Thirty one scaphoid pseudarthroses treated by corticocancellous bone graft between November 1985 and December 1988 were reviewed with a mean follow-up of 33.9 months. Clinical examination assessed pain, wrist mobility, and strength of grip. Radiological assessment evaluated consolidation of the corticocancellous graft, the presence or absence of graft resorption and the possible presence of radiocarpal osteoarthritis. A discordance between clinical and radiographic results was observed. Six patients had an excellent or good clinical result, but a poor radiological result and one patient with a poor clinical result presented an excellent radiological result. We therefore decided to use MRI to more clearly define the cause of this discordance and to verify the viability of the graft.

A role of p75 in NGF-mediated down-regulation of the A(2A) adenosine receptors in PC12 cells

Nerve growth factor (NGF) induces differentiation of the rat pheochromocytoma clone (PC12) by activating the high affinity receptor, p140(trkA), linked to mitogen-activated protein kinase. While the physiological role of the low affinity NGF receptor (p75) has not been clearly defined, this receptor promotes activation of nuclear factor (NF) kappaB in Schwann cells. PC12 cells express the A(2A) adenosine receptor (AR), whose expression is significantly decreased by NGF treatment. In this study, we determined whether TrkA or p75 is involved in NGF-mediated regulation of A(2A)AR expression. NGF treatment decreased A(2A)AR in a time-dependent manner, with maximal effects observed by 1 day, and continued down-regulation of the receptor for up to 3 days in the presence of NGF. The decrease in A(2A)AR was associated with a more delayed decrease in the steady-state levels of the A(2A)AR mRNA. Down-regulation of the A(2A)AR at 1 day was mimicked by activators of NFkappaB, such as H(2)O(2), and ceramide, and was attenuated by the inhibitor pyrrolidine dithiocarbamate or following transient transfection of PC12 cells with a dominant negative IkappaBalpha mutant. Moreover, NGF stimulated nuclear accumulation of p65 subunits of NFkappaB (but not p50 subunits) in PC12 cells, as determined by electrophoretic mobility shift assays and by Western blotting. In contrast, inhibition of TrkA by AG879 or of TrkA-dependent mitogen-activated protein kinase mitogen-activated protein kinase kinase with PD98059 blocked PC12 cell differentiation without affecting A(2A)AR down-regulation, suggesting dissociation between these two phenomena. Taken together, these data provide strong support for the involvement of the p75/NFkappaB pathway in NGF-mediated down-regulation of A(2A)AR in PC12 cells.

Oxidative stress increases A1 adenosine receptor expression by activating nuclear factor kappa B

The A1 adenosine receptor (A1AR) contributes to the cytoprotective action of adenosine under conditions known to generate reactive oxygen species (ROS). Pharmacological manipulation of A1AR expression has been shown to modulate this cytoprotective role. In this study, we provide evidence that ROS generated could increase the expression of the A1AR and thereby offset the detrimental effects of ROS. Incubation of DDT1MF-2 smooth muscle cells with ROS-generating chemotherapeutic agents, such as cisplatin (2.5 microM) or H2O2 (10 microM), elicited an increase in A1AR expression within 24 hr. The induction by H2O2 was reduced by the ROS scavenger catalase but not superoxide dismutase. Inhibition of nuclear factor kappa B (NF kappa B) by pyrrolidine dithiocarbamate (200 microM), dexamethasone (100 nM), or genistein (1 microM) abrogated the cisplatin-mediated increase in A1AR. Cisplatin promoted rapid translocation of NF kappa B (but not AP-1) to the nucleus, as detected by electrophoretic mobility shift assays and by Western blotting. A putative NF kappa B sequence in the A1AR promoter effectively competed with labeled kappa B probe for binding in nuclear preparations derived from DDT1MF-2 cells. Transient transfection of DDT1MF-2 cells with the A1AR promoter coupled to firefly luciferase reporter gene led to cisplatin-inducible and pyrrolidine dithiocarbamate-sensitive luciferase activity, suggesting the presence of functional NF kappa B binding site(s) in the A1AR promoter sequence. Treatment of cells with (R)-phenylisopropyladenosine (1 microM), an agonist of the A1AR, reduced cisplatin-mediated lipid peroxidation, which was reversed after blockade of the A1AR. These data suggest that ROS can increase the expression of the A1AR by activating NF kappa B regulatory site(s) on this gene and thereby enhance the cytoprotective role of adenosine.

A survey of Canadian hand therapists: demographics, roles, and educational needs

A questionnaire was mailed to 236 occupational therapists (OTs) and physical therapists (PTs) practicing hand rehabilitation in Canada, to develop a demographic profile of practitioners, determine the scope of practice in Canada, and study educational and certification issues. The response rate was 78%, which provided an accurate profile. Sixty-two percent of respondents were OTs, 35% PTs, and 3% combined P/OTs. While 82% of respondents supported a certification process, only 13% were certified hand therapists. Forty-two percent practice with both OT and PT skills. Most respondents held bachelor's degrees and reported formal OT or PT education as their primary mode of acquiring knowledge. The high response rate indicated that commitment to and interest in the practice of hand therapy are strong in Canada. Therapists would like to see more continuing education offered in Canada, and a certification process to ensure professional standards.

Cell behavior and cell-matrix interactions of human palmar aponeurotic cells in vitro

The present investigation has been performed to better characterize, in vitro, normal aponeurotic cells in comparison with dermal fibroblasts and with cells derived from Dupuytren's affected aponeuroses. Cells were cultured in monolayer and/or into three-dimensional collagen gels. Cell structure, adhesion, and spreading capability on different substrates, as well as integrin expression were investigated by light and electron microscopy and by flow cytometry. Cell-matrix interactions were also analyzed by gel retraction experiments in the presence, or absence, of RGD peptides and anti-integrin antibodies. Normal aponeurotic cells, compared with dermal fibroblasts, exhibited in vitro peculiar structural features, which were substantially maintained in Dupuytren's aponeurotic cells, irrespective of the substrate they were grown on. By contrast, the aponeurotic cell behavior was different in normal and diseased cells, these latter approaching that of dermal fibroblasts. Normal aponeurotic cells, in fact, were characterized by low efficiency in retracting the collagen gel, low alpha 2, alpha 1, and alpha 5 integrin subunit expression and low adhesion properties onto collagen and fibronectin, whereas cells isolated from the aponeuroses of Dupuytren's patients exhibited higher capability of retracting the collagen gel, increased adhesion properties toward collagen and fibronectin, and higher levels of integrin expression. No differences were observed between dermal fibroblasts from Dupuytren's patients or from normal subjects. These in vitro results are consistent with those previously obtained in situ, suggesting that palmar aponeurotic cells have a peculiar phenotype and that changes in cell-matrix interactions occur in Dupuytren's contracture. Moreover, by comparing data obtained from the retracted fibrotic cords and the still clinically unaffected aponeuroses of the same patients, it may be noted that Dupuytren's disease is not only confined to the clinically involved branches, but includes the whole aponeurosis of the affected hand.

[An experimental study of a cyanoacrylate biological adhesive in view of its use in the fixation of various fractures of the fingers]

Following certain interesting results reported in publications by researchers from the nineteen-sixties up to the present time, we decided to experiment a particular adhesive with high adhesive properties: this is composed of monomers of alpha-cyanoacrylate éthyl-2-alpha-cyanoacrylate. For this end, experiments were performed on 15 adult chickens, aged around 4 months, weighing 2 kg, divided into 5 groups of 3 chickens each. In each chicken, a rectangular bone fragment from the proximal-middle third of the tibia was prepared, completely separated, and then subsequently re-positioned and fixed with the adhesive plus collagen. At pre-established intervals (7, 14, 21, 30 and 60 days), each group of chickens was examined by x-rays and then killed, so that the particular anatomical part under examination could be studied both microscopically and macroscopically. The aim of these experiments was to evaluate the ability of cyanoacrylate adhesive to ensure setting of small bone-fragments that would otherwise be unstable. The results obtained showed the following: good stability of the bone fragment; good bone consolidation; absence of foreign body reactions. The positive nature of these results leads us to propose the use of this adhesive in hand surgery. Nevertheless, duty requires that further experiments be performed in order to acquire even greater guarantees for the positive results obtained.

OSTEOSARCOMA OF THE SCAPHOID

We describe a case of osteosarcoma of the scaphoid bone, which to our knowledge is only the second reported case of osteosarcoma in the carpus. A 38-year-old man complained of intense pain in the right wrist and had curettage and a bone graft for a lesion in the scaphoid. Histological examination showed this to be an osteosarcoma. Below-elbow amputation was performed and adjuvant chemotherapy given. There has been no evidence of recurrence or metastases at 33 months after amputation.

Osteosarcoma of the scaphoid. A case report and review of the literature

We describe a case of osteosarcoma of the scaphoid bone, which to our knowledge is only the second reported case of osteosarcoma in the carpus. A 38-year-old man complained of intense pain in the right wrist and had curettage and a bone graft for a lesion in the scaphoid. Histological examination showed this to be an osteosarcoma. Below-elbow amputation was performed and adjuvant chemotherapy given. There has been no evidence of recurrence or metastases at 33 months after amputation.

[Preliminary experiences on triscaphoid arthrodesis]

The authors report their experience of 5 patients (4 males, 1 female) with a mean age of 36.4 years (min 25 years, max 45 years), undergoing triscaphoid arthrodesis between May 1989 and August 1993. The patients suffered from rotatory dislocation of the scaphoid (1 case) and stage 3A of Kienboeck's disease according to Lichtman's classification (4 cases). The paper describes the surgical technique used for partial arthrodesis of the wrist performed using plexual anesthesia. A dorsal access route is used through a curved longitudinal skin incision corresponding to the anatomical site of the scaphoid. The skin flaps are then peeled back revealing the surface veins and sensitive branches of the radial nerve which are isolated and conserved. Having cut through the retinaculum of the extensors, the extensor tendons are spread so as to reach the joint capsule which is sectioned crosswise. After the bone to be fused have been exposed, the cartilage is removed from the joint faces between the scaphoid, trapezium and trapezoid and, using a osteotribe, the subchondral bone is removed to reveal the spongy bone, leaving a space of approximately 6 mm between the spongy surface of the bones to be fused. Arthodesis is stabilised using Kirschner wires or metal minicambres enclosing scaphoid, trapezium and trapezoid. Spongy tissue is taken from the distal radial head and used as a graft to fill the spaces created between them which will consolidate over time. The wrist is immobilised in a plaster cast for 8 weeks before starting functional rehabilitation. Patients were checked both clinically and radiographically with a mean follow-up of 36.4 months (min 25, max 50 months). Using the assessment criteria proposed by Minami et al. excellent results were obtained in 4 patients (80%) with the disappearance of painful symptoms, joint excursion 50% greater than the normal wrist, and hand grip 70% greater than in the controlateral hand. There was good radiographical consolidation of the arthrodesis. Poor results were only recorded in one case (20%) with persisting pain and functional impotent. Radio-scaphoid arthrosis was observed radiographically consequent to hypercorrection of the scaphoid with a radio-scaphoid angle of less than 45 degrees. The authors underline the technical difficulty of this arthrodesis characterised by reduction of the scaphoid in a correct position in which the radio-scaphoid angle must be 45 degrees when measured from a lateral position. Lastly, the authors conclude that this from of arthrodesis may be used with good results to treat wrist pathologies such as rotatory scaphoid dislocation, triscaphoid arthrosis and Kien-boeck's disease at stage 3A according to Lichtman. They also affirm that arthrodesis limited to the wrist is preferable to total arthrodesis because it enables some joint movement to be conserved which is important for hand function.

Acute posterior interosseous nerve palsy caused by a synovial haemangioma of the elbow joint

A case is described of spontaneous posterior interosseous nerve palsy of acute onset. The initial symptoms made it difficult to distinguish the condition from tendon rupture. The diagnosis was established using ultrasound, nerve conduction studies and MRI. The patient underwent surgery to decompress the posterior interosseous nerve and the histological examination identified the tumour as a synovial haemangioma. 12 months after the operation, the patient had made a complete recovery, confirmed by EMG.

Kiloh-Nevin syndrome: a clinical case of compression of the anterior interosseous nerve

Anterior interosseous nerve syndrome is a rare occurrence. One particular case, in terms of its etiopathogenesis, and its clinical findings that involved isolated lesion of the long flexor muscle of the thumb is reported. Healing occurred after approximately 10 months. Medical and physiotherapeutic treatment were carried out.

Partial arthrodeses of the wrist

The authors report 16 cases of partial arthrodeses of the wrist for the treatment of Kienboeck's disease, pseudarthrosis of the scaphoid, rotatory subluxation of the scaphoid, rheumatoid arthritis, etc. Based on the good results obtained (76.6%) the authors believe that partial arthrodeses constitute the type of treatment indicated for the treatment of pathologies that involve only some of the carpal bones, and they also emphasize that this type of surgery represents a valid alternative to total arthrodesis of the wrist.

[A reverse vascular autograft finger island flap. A review of 15 cases and of the literature]

The authors discuss the indications for homodigital island flap with a reverse vascular pedicle. This flap is based on the anastomoses between the radial and ulnar digital arteries. These anastomotic branches lie between the posterior wall of the tendon sheath and the periosteum to form an arch and are named the "digitopalmar arches". The vascularization of the reverse homodigital island flap is derived by using the middle transverse palmar arch. This flap was performed successfully in 14 patients involving 15 fingers to resurface amputation of the distal phalanx. In 6 cases the flap was used as an "artery" flap, and in 9 cases as a "sensitive" homodigital island flap. The pedicle in these cases was neurovascular also containing the digital nerve. The sensitivity of the flap was obtained by neurorraphy between the transposed digital nerve of the flap and the receiving digital nerve of the recipient finger. This technique achieves cover of the tactile pad in one operative stage and provides well vascularized skin allowing early mobilization. Sensation of the flap can be restored rapidly when neurorraphy of the transposed digital nerve is performed.

An AP1 binding site upstream of the kappa immunoglobulin intron enhancer binds inducible factors and contributes to expression

Expression of the kappa immunoglobulin light chain gene requires developmental- and tissue-specific regulation by trans-acting factors which interact with two distinct enhancer elements. A new protein-DNA interaction has been identified upstream of the intron enhancer, within the matrix-associated region of the J-C intron. The binding activity is greatly inducible in pre-B cells by bacterial lipopolysaccharide and interleukin-1 but specific complexes are found at all stages of B cell development tested. The footprinted binding site is homologous to the consensus AP1 motif. The protein components of this complex are specifically competed by an AP1 consensus motif and were shown by supershift to include c-Jun and c-Fos, suggesting that this binding site is an AP1 motif and that the Jun and Fos families of transcription factors play a role in the regulation of the kappa light chain gene. Mutation of the AP1 motif in the context of the intron enhancer was shown to decrease enhancer-mediated activation of the promoter in both pre-B cells induced with LPS and constitutive expression in mature B cells.

Ultrastructural and immunocytochemical study on normal human palmar aponeuroses

BACKGROUND

Human palmar aponeurosis can be affected by a fibrotic process whose aetiopathology is unknown. As the organization of that normal tissue has not been completely investigated, the aim of the present study was to define the ultrastructure of the aponeurosis in order to better understand its biology and behaviour in pathology.

METHODS

Bioptic samples from normal subjects of different ages were analysed by optical and electron microscopy and by immunocytochemistry.

RESULTS

The aponeurotic branches consisted of thick, almost parallel collagen bundles containing columns of prominent cells, characterized by long cytoplasmic projections. Cells did not change in number and distribution with age and appeared longer and slighter in the old than in the young subjects. They exhibited plasma membrane almost completely decorated by pinocytic vesicles, intracytoplasmic bundles of thin filaments with zonal thickenings close to the cell membrane, and well-developed subcellular structures. Cells expressed smooth muscle cell alpha-actin, as revealed by immunostaining. The external surface of the plasma membrane was underlined by a discontinuous basement membrane-like structure and by a thick coat of interwoven filaments, highly positive to hyaluronan-recognizing antibodies. Immunocytochemical analyses revealed that collagen fibrils were positive for collagen types I, III, and VI and that elastin fiber composition was rather complex.

CONCLUSIONS

Independently of the age, normal palmar aponeurotic cells show peculiar morphological features and peculiar cell-matrix interactions, very likely mediated by hyaluronan. These findings indicate that normal aponeurotic cells cannot be regarded as typical tenocytes and suggest the need for a better definition of their phenotype in order to understand their behaviour in pathological processes.

Massive perirenal and intra-abdominal bleeding after shock-wave lithotripsy: case report

Complications of extracorporeal shock-wave lithotripsy are rare, with an incidence of symptomatic perinephric hematoma ranging from 0.2% to 0.66%. A 59-year-old man had massive symptomatic retroperitoneal and intra-abdominal bleeding 24 hours after lithotripsy. The hemorrhage was managed successfully by conservative measures, which consisted of packed red blood cells and fresh frozen plasma. The literature on the bleeding complications of lithotripsy is reviewed and the risk factors are identified.

A clinical, ultrastructural and immunochemical study of Dupuytren's disease

Aponeurotic tissue from seven normal subjects and from apparently unaffected branches, nodules and cords of 16 Dupuytren's patients were compared. Control tissue was characterized by polymorphous cells, showing cytoplasmic microfilament bundles, numerous pinocytic vesicles, basement membrane-like structures, and a thick coat of interwoven filaments, and by type I- and III-positive heterogeneous collagen fibrils, fibronectin, vitronectin, decorin and proteoglycans. The clinically normal branches consisted of fibroblast-like cells, small type III-highly positive collagen fibrils, fibronectin and proteoglycans. Nodules and fibrotic cords contained fibroblast-like cells, type I and III collagen, fibronectin and proteoglycans. Myofibroblast-like cells in only five out of 16 patients were present. There was no relation between clinical stage and structural alterations; the whole aponeurosis always seemed to be involved; cord retraction would seem to depend on the interactions among fibroblast-like cells and matrix components and among matrix macromolecules themselves.

Transcellular activation of the human immunodeficiency virus type 1 long terminal repeat in T lymphocytes requires CD4-gp120 binding

Cells expressing human immunodeficiency virus type 1 (HIV-1) tat can transactivate the HIV-1 long terminal repeat (LTR) in cocultured T lymphocytes. In this report, we describe the molecular requirements for transcellular activation of the LTR in Jurkat cells. An analysis with deletion mutants and blocking antibodies demonstrated a requirement for env expression in addition to tat expression for transcellular activation to occur. The results suggest that the transient association of CD4 and gp120 in cocultured cells is required for tat-mediated transcellular activation. The events that follow CD4-gp120 binding in transactivation, however, do not require the gp120-neutralizing domain, in contrast to HIV-mediated fusion and infection. The consequences of this interaction on cellular function are currently under investigation.

Transcellular activation of the human immunodeficiency virus type 1 long terminal repeat in cocultured lymphocytes

One of the unexplained aspects of the progression of AIDS is that immunological abnormalities are detectable before CD4+ T-helper cell depletion occurs (A.R. Gruters, F.G. Terpstra, R. De Jong, C.J.M. Van Noesel, R.A.W. Van Lier, and F. Miedema, Eur. J. Immunol. 20:1039-1044, 1990; F. Miedema, A.J. Chantal-Petit, F.G. Terpstra, J.K.M.E. Schattenkerk, F. de Wolf, B.J.M. Al, M. Roos, J.M.A. Lang, S.A. Danner, J. Goudsmit, and P.T.A. Schellekens, J. Clin. Invest. 82:1908-1914, 1988; G.M. Shearer, D.C. Bernstein, K.S. Tung, C.S. Via, R. Redfield, S.Z. Salahuddin, and R.C. Gallo, J. Immunol. 137:2514-2521, 1986). In this report, we describe a mechanism by which human immunodeficiency virus type 1 (HIV-1)-infected cells can influence neighboring HIV-1-infected T lymphocytes and uninfected T cells as well. We have examined the interaction of T-cell and macrophage cell lines that are transfected with HIV-1 DNA by using cocultured lymphocytes. The HIV-1 constructs we used lack a functional pol gene and therefore do not produce infectious virus. Cocultivation results in the transcellular activation of the HIV long terminal repeat in the cocultured T cells. This transcellular activation is evident in as little as 3 h of cocultivation, at ratios of HIV-expressing cells to target cells as low as 1:1,000, and is dependent on the Tat-responsive element. The demonstration that a small number of HIV-expressing cells can affect a large number of uninfected bystander cells in a short period of time suggests a mechanism by which global immune dysfunction can precede the high prevalence of infected cells.

[Correlation between Dupuytren's disease and arcus senilis: is dyslipidemia a common etiopathological factor?]

Because of the frequent presence of corneal arcus senilis in patients affected by Dupuytren's disease in order to evaluate this association, the authors conducted a biomicroscopic examination of the cornea in 336 patients treated surgically for Dupuytren's disease, at the Hand Surgery Unit of the University of Modena from November 1985 to December 1989. They observed corneal arcus senilis in 259 patients, i.e. in 77.1% of patients with Dupuytren's disease. Due to the statistically significant correlation between arcus senilis and hyperlipidemia as reported by Tschetter (1980) and Felder (1981), the Authors collected a blood sample from all 336 patients to evaluate serum cholesterol and tryglicerides. This study revealed a dyslipidemia in 54.8% of patients with Dupuytren's disease and in 60.2% of patients suffering from both Dupuytren's disease and arcus senilis. Because of the high frequency of dislipidemia in patients with Dupuytren's disease and arcus senilis, which are apparently two well-distinguished disease, the authors suggest that a lipid disorder may be a common aetiopathogenic factor. In particular, in favour of the possible role of hyperlipidemia in Dupuytren's disease, Electron Microscope Studies revealed lipid inclusions within fibroblasts and in the extracellular connective tissue of all pathologic palmar aponeurosis from 11 patients with Dupuytren's disease: these lipid inclusions were never seen in the normal aponeurosis taken from 5 control patients treated for traumatic palmar injuries.