The prognosis for return to athletic function for Thoroughbred racehorses in Hong Kong with injuries to the palmaroproximal aspect of the metacarpus diagnosed using low-field magnetic resonance imaging

OBJECTIVE

To evaluate and compare the prognosis for Thoroughbred racehorses to return to galloping and racing with injuries to the palmaroproximal metacarpus diagnosed with MRI.

ANIMALS

29 flat racing Thoroughbreds at the Hong Kong Jockey Club that underwent MRI between 2014 and 2022.

METHODS

Clinical, radiographic, ultrasonographic, and MRI reports were collected from veterinary clinical records, and these were combined with training and racing data. Horses were categorized on the basis of MRI diagnosis: (1) proximal suspensory ligament (PSL) involvement only, (2) PSL and concurrent proximal third metacarpal (MC3) bone involvement, and (3) proximal MC3 bone involvement only. The following were compared for prognosis for return to athletic function: return to galloping or racing, and reinjury.

RESULTS

Overall, the prognosis for return to athletic function was fair, with 92% (22/24; P = .53) and 67% (16/24; P = .73) of horses returning to galloping and racing, respectively. There was a relatively low reinjury rate, with 18% (4/22) of horses reinjuring. Horses with concurrent injury to both the PSL and proximal MC3 bone (Category 2) took longer to return to gallop (median, 116; IQR, 100.5 to 160), when compared with horses having only PSL injury (median, 69; IQR, 43 to 80; P = .04). Of the 4 horses that reinjured, 3 (75%) were horses in Category 2.

CLINICAL RELEVANCE

The findings from this study suggest that injuries involving both PSL and proximal MC3 bone concurrently require a longer rehabilitation period than those with PSL involvement alone.

Current management of avascular necrosis of the metacarpal head: a comprehensive literature review

BACKGROUND

Avascular necrosis (AVN) of the metacarpal head is a rare disease that may lead to progressive destruction of the metacarpophalangeal joint and hand function. This study aimed to describe the epidemiology, possible risk factors, clinical presentation, diagnostic workup, and treatment of the rare condition of avascular necrosis of the metacarpal head.

METHODS

Articles were searched using the subject words "Dieterich disease","Mauclaire's disease", and "avascular necrosis of metacarpal head" in the PubMed and Scopus databases. Studies were retained for review after meeting the inclusion criteria. Those outcomes relevant to diagnose and assessing AVN of the metacarpal head and those related to curative management were extracted.

RESULTS

The literature search revealed 45 studies with 55 patients. Although the aetiology of osteonecrosis has not been clearly delineated, AVN of the metacarpal head most commonly arises from trauma but other risk factors may also be involved. Plain radiographs are often negative and therefore likely to be missed. Early-stage osteonecrosis of the metacarpal head was best assessed using MRI. Given the rarity of this condition, there is no clear consensus on the treatment.

CONCLUSIONS

Avascular necrosis of the metacarpal head should be considered in the differential diagnosis of painful metacarpophalangeal joints. An early understanding of this unusual disease will provide an optimal clinical outcome, restoring joint activity, and resolving pain. Nonoperative treatment cannot cure all patients. Surgical management is based on the patient and lesion characteristics.

DDX58(RIG-I)-related disease is associated with tissue-specific interferon pathway activation

BACKGROUND

Singleton-Merten syndrome (SGMRT) is a rare immunogenetic disorder that variably features juvenile open-angle glaucoma (JOAG), psoriasiform skin rash, aortic calcifications and skeletal and dental dysplasia. Few families have been described and the genotypic and phenotypic spectrum is poorly defined, with variants in DDX58 (DExD/H-box helicase 58) being one of two identified causes, classified as SGMRT2.

METHODS

Families underwent deep systemic phenotyping and exome sequencing. Functional characterisation with in vitro luciferase assays and in vivo interferon signature using bulk and single cell RNA sequencing was performed.

RESULTS

We have identified a novel DDX58 variant c.1529A>T p.(Glu510Val) that segregates with disease in two families with SGMRT2. Patients in these families have widely variable phenotypic features and different ethnic background, with some being severely affected by systemic features and others solely with glaucoma. JOAG was present in all individuals affected with the syndrome. Furthermore, detailed evaluation of skin rash in one patient revealed sparse inflammatory infiltrates in a unique distribution. Functional analysis showed that the DDX58 variant is a dominant gain-of-function activator of interferon pathways in the absence of exogenous RNA ligands. Single cell RNA sequencing of patient lesional skin revealed a cellular activation of interferon-stimulated gene expression in keratinocytes and fibroblasts but not in neighbouring healthy skin.

CONCLUSIONS

These results expand the genotypic spectrum of DDX58-associated disease, provide the first detailed description of ocular and dermatological phenotypes, expand our understanding of the molecular pathogenesis of this condition and provide a platform for testing response to therapy.

Unified mechanisms for self-RNA recognition by RIG-I Singleton-Merten syndrome variants

The innate immune sensor retinoic acid-inducible gene I (RIG-I) detects cytosolic viral RNA and requires a conformational change caused by both ATP and RNA binding to induce an active signaling state and to trigger an immune response. Previously, we showed that ATP hydrolysis removes RIG-I from lower-affinity self-RNAs (Lässig et al., 2015), revealing how ATP turnover helps RIG-I distinguish viral from self-RNA and explaining why a mutation in a motif that slows down ATP hydrolysis causes the autoimmune disease Singleton-Merten syndrome (SMS). Here we show that a different, mechanistically unexplained SMS variant, C268F, which is localized in the ATP-binding P-loop, can signal independently of ATP but is still dependent on RNA. The structure of RIG-I C268F in complex with double-stranded RNA reveals that C268F helps induce a structural conformation in RIG-I that is similar to that induced by ATP. Our results uncover an unexpected mechanism to explain how a mutation in a P-loop ATPase can induce a gain-of-function ATP state in the absence of ATP.

Limb bone histology records birth in mammals

The annual cyclicality of cortical bone growth marks (BGMs) allows reconstruction of some important life history traits, such as longevity, growth rate or age at maturity. Little attention has been paid, however, to non-cyclical BGMs, though some record key life history events such as hatching (egg-laying vertebrates), metamorphosis (amphibians), or weaning (suggested for Microcebus and the hedgehog). Here, we investigate the relationship between non-cyclical BGMs and a stressful biological event in mammals: the moment of birth. In the present study, we histologically examine ontogenetic series of femora, tibiae and metapodia in several extant representatives of the genus Equus (E. hemionus, E. quagga and E. grevyi). Our analysis reveals the presence of a non-cyclical growth mark that is deposited around the moment of birth, analogous to the neonatal line described for teeth. We therefore refer to it as neonatal line. The presence of this feature within the bone cross-section agrees with a period of growth arrest in newborn foals regulated by the endocrine system. The neonatal line is accompanied by modifications in bone tissue type and vascularization, and has been identified in all bones studied and at different ontogenetic ages. Our discovery of a non-cyclical BGM related to the moment of birth in mammals is an important step towards the histological reconstruction of life histories in extant and fossil equids.

Mutations in DDX58, which encodes RIG-I, cause atypical Singleton-Merten syndrome

Singleton-Merten syndrome (SMS) is an autosomal-dominant multi-system disorder characterized by dental dysplasia, aortic calcification, skeletal abnormalities, glaucoma, psoriasis, and other conditions. Despite an apparent autosomal-dominant pattern of inheritance, the genetic background of SMS and information about its phenotypic heterogeneity remain unknown. Recently, we found a family affected by glaucoma, aortic calcification, and skeletal abnormalities. Unlike subjects with classic SMS, affected individuals showed normal dentition, suggesting atypical SMS. To identify genetic causes of the disease, we performed exome sequencing in this family and identified a variant (c.1118A>C [p.Glu373Ala]) of DDX58, whose protein product is also known as RIG-I. Further analysis of DDX58 in 100 individuals with congenital glaucoma identified another variant (c.803G>T [p.Cys268Phe]) in a family who harbored neither dental anomalies nor aortic calcification but who suffered from glaucoma and skeletal abnormalities. Cys268 and Glu373 residues of DDX58 belong to ATP-binding motifs I and II, respectively, and these residues are predicted to be located closer to the ADP and RNA molecules than other nonpathogenic missense variants by protein structure analysis. Functional assays revealed that DDX58 alterations confer constitutive activation and thus lead to increased interferon (IFN) activity and IFN-stimulated gene expression. In addition, when we transduced primary human trabecular meshwork cells with c.803G>T (p.Cys268Phe) and c.1118A>C (p.Glu373Ala) mutants, cytopathic effects and a significant decrease in cell number were observed. Taken together, our results demonstrate that DDX58 mutations cause atypical SMS manifesting with variable expression of glaucoma, aortic calcification, and skeletal abnormalities without dental anomalies.

Transforming growth factor-β (TGF-β) expression is increased in the subsynovial connective tissue in a rabbit model of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is an idiopathic disease that results from increased fibrosis of the subsynovial connective tissue (SSCT). A recent study found overexpression of both transforming growth factor-β (TGF-β) and connective tissue growth factor (CTGF) in the SSCT of CTS patients. This study investigated TGF-β and CTGF expression in a rabbit model of CTS, in which SSCT fibrosis is induced by a surgical injury. Levels of TGF-β1 and CTGF at 6, 12, 24 weeks after injury were determined by immunohistochemistry A significant increase in TGF-β1 and a concomitant significant increase in CTGF were found at 6 weeks, in addition to higher cell density compared to normal (all p<0.05), Interestingly, CTGF expression was reduced at 12 and 24 weeks, suggesting that an initial insult results in a time limited response. We conclude that this rabbit model mimics the fibrosis found in human CTS, and may be useful to study pathogenetic mechanisms of CTS in vivo.

Chondromyxoid fibroma of the second metacarpal bone--a case report

This report describes a chondromyxoid fibroma of the second metacarpal bone in a 32-year-old female patient. Chondromyxoid fibroma is a rare, benign, slow-growing bone tumor of cartilaginous origin. Tumor has a high recurrance rate. Our aim was to show successful treatment of a metacarpal chondromyxoid fibroma with wide resection and implantation of finger join endoprosthesis.

Manifestations, diagnosis and surgical treatment of enchondroma--own experience

BACKGROUND

An enchondroma is a rather common benign tumour of bone that originates from cartilage.The course is usually benign but they have a tendency to recur and are sometimes invasive, especially when developing in long bones. The aim of the study was to analyze the manifestations and methods of treatment as well as to assess the results of surgical treatment in patients with enchondroma.

MATERIAL AND METHODS

A total of 150 patients with enchondroma, including 90 women and 60 men aged 10-74 years, were treated in the Regional Trauma Surgery Hospital in Piekary Slaskie between 1998 and 2006.

RESULTS

The tumours were mostly located in phalanges of the fingers--55 cases (37%), and metacarpal bones--21 cases (14%). Multiple locations were seen in 13 patients. A total of 170 surgical procedures were performed, mostly (120 procedures) tumour resections with bone graft implantation. A recurrence of enchondroma was observed in 17 patients (11%). There was also one case of malignant transformation in to a chondrosarcoma.

CONCLUSION

Total resection of the enchondroma combined with spongy bone grafting is the main treatment of chondroma.

Metacarpal bone measurements in renal transplant recipients, in corticosteroid-treated patients with polymyalgia rheumatica and in patients with primary hyperparathyroidism

Quantitative radiological measurements on the second left metacarpal bone were carried out in 23 patients with primary hyperparathyroidism, 22 corticosteroid-treated patients with polymyalgia rheumatica and 40 renal transplant recipients treated with prednisone and azathioprine. Women with primary hyperparathyroidism and corticosteroid-treated women showed significantly decreased mean values of metacarpal bone compared to normal controls, probably due to a higher bone resorption than formation at the endosteal surface. Bone loss was more pronounced in corticosteroid-treated women than in women with primary hyperparathyroidism, partly due to age difference. In renal transplant recipients, bone loss took place during the initial period after renal transplantation, probably due to increased endosteal bone resorption. During this period a periosteal new bone formation took place in female renal transplant recipients. The quantitative radiological measurements make it possible to determine whether bone loss is due to a higher ratio of bone resorption than of bone formation at the periosteal and/or endosteal surface.

The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps

Distally based DMCA flaps are well established in reconstructive hand surgery. They comprise the dorsal flap described by Quaba and the DMCA flaps described by Earley, Milner and others. The most frequent indications for these flaps are soft tissue defects of the dorsum of the proximal phalanx and the total length of the finger. Since its introduction several modifications have been developed to match specific defect requirements; these include: the development of pure fascial DMCA flaps, the use of DMCA flaps in dorsally grafted burned hands and modifications in design to avoid 'tunnelling' and to permit skin-skin defect closure. The purpose of this article is to provide an overview of the evolution and refinements of the DMCA flaps based on the experience of a single centre. The DMCA flaps provide one stage coverage of excellent quality with independent vascularisation and permit primary closure of the recipient site without sacrificing relevant arteries (e.g. proper digital artery). However, the DMCA flaps also possess drawbacks, for example, apart from the fact that this technique is quite demanding, possible hair growth and a visible scar on the exposed dorsal part of the hand present aesthetic problems for some patients. Despite these limitations, DMCA flaps are considered to be extremely useful.

Magnetic resonance imaging, ultrasonography and histology of the suspensory ligament origin: a comparative study of normal anatomy of warmblood horses

REASONS FOR PERFORMING STUDY

The diagnosis of lameness caused by proximal metacarpal and metatarsal pain can be challenging. Magnetic resonance imaging (MRI) offers the possibility for further diagnosis but there have been no studies on the normal MRI appearance of the origin of the suspensory ligament (OSL) in conjunction with ultrasonography and histology.

OBJECTIVES

To describe the MRI appearance of the OSL in fore- and hindlimbs of sound horses and compare it to the ultrasonographic and histological appearance. The findings can be used as reference values to recognise pathology in the OSL.

METHODS

The OSL in the fore- and hindlimbs of 6 sound horses was examined by ultrasonography prior to death, and MRI and histology post mortem. Qualitative evaluation and morphometry of the OSL were performed and results of all modalities compared.

RESULTS

Muscular tissue, artefacts, variable SL size and shape complicated ultrasonographic interpretation. In MRI and histology the forelimb OSL consisted of 2 portions, the lateral being significantly thicker than medial. The hindlimb SL had a single large area of origin. In fore- and hindlimbs, the amount of muscular tissue was significantly larger laterally than medially. Overall SL measurements using MRI were significantly higher than using histology and ultrasonography and histological higher than ultrasonographic measurements. Morphologically, there was a good correlation between MRI and histology.

CONCLUSIONS

MRI provides more detailed information than ultrasonography regarding muscle fibre detection and OSL dimension and correlates morphologically well with histology. Therefore, ultrasonographic results should be regarded with caution.

POTENTIAL RELEVANCE

MRI may be a diagnostic aid when other modalities fail to identify clearly the cause of proximal metacarpal and metatarsal pain; and may improve selection of adequate therapy and prognosis for injuries in this region.

Role of endochondral ossification of articular cartilage and functional adaptation of the subchondral plate in the development of fatigue microcracking of joints

The mechanisms that regulate functional adaptation of the articular ends of long bones are poorly understood. However, endochondral ossification of articular cartilage and modeling/remodeling of the subchondral plate and epiphyseal trabeculae are important components of the adaptive response. We performed a histologic study of the distal end of the third metacarpal/metatarsal bone of Thoroughbreds after bones were bulk-stained in basic fuchsin and calcified sections were prepared. The Thoroughbred racehorse is a model of an extreme athlete which experiences particularly high cyclic strains in distal limb bones. The following variables were quantified: microcrack boundary density in calcified cartilage (N.Cr/B.Bd); blood vessel boundary density in calcified cartilage (N.Ve/B.Bd); calcified cartilage width (Cl.Cg.Wi); duplication of the tidemark; and bone volume fraction of the subchondral plate (B.Ar/T.Ar). Measurements were made in five joint regions (lateral condyle and condylar groove; sagittal ridge; medial condylar and condylar groove). N.Cr/B.Bd was site-specific and was increased in the condylar groove region; this is the joint region from which parasagittal articular fatigue (condylar) fractures are typically propagated. Formation of resorption spaces in the subchondral plate was co-localized with microcracking. N.Ve/B.Bd was also site-specific. In the sagittal ridge region, N.Ve/B.Bd was increased, Cl.Cg.Wi was decreased, and B.Ar/T.Ar was decreased, when compared with the other joint regions. Multiple tidemarks were seen in all joint regions. Cumulative athletic activity was associated with a significant decrease in B.Ar/T.Ar in the condylar groove regions. N.Cr/B.Bd was positively correlated with B.Ar/T.Ar (P < 0.05, r(s) = 0.29) and N.Ve/B.Bd was negatively correlated with B.Ar/T.Ar (P < 0.005, r2 = 0.14) and Cl.Cg.Wi (P < 0.05, r2 = 0.07). We conclude that endochondral ossification of articular cartilage and modeling/remodeling of the subchondral plate promote initiation and propagation of site-specific fatigue microcracking of the joint surface, respectively, in this model. Microcracking of articular calcified cartilage likely represents mechanical failure of the joint surface. Propagation of microcracks into the subchondral plate is a critical factor in the pathogenesis of articular condylar fatigue (stress) fracture. Functional adaptation of the joint likely protects hyaline cartilage from injury in the short-term but may promote joint degeneration and osteoarthritis with ongoing athleticism.

Hemophilic pseudotumor

Bleeding diatheses are a hallmark of hemophilia. Hemophilic pseudotumor results from multiple episodes of hemorrhage into bones or soft tissue spaces. It is uncommon and is seen in severe cases of hemophilia only 1-2% of the time. Complications and symptoms arise due to pain and/or compression of surrounding structures. Pathologic fractures can be associated with intraosseous lesions and can result from bone destruction or resorption due to the chronic pressure of an osseous hemorrhage. Radiographs may demonstrate expansile lesions of the bones or increased soft tissue density that may be associated with extra osseous lesions. Bleeding may also occur within the joint space. These intra-articular hemorrhages can, over time, result in hemophilic arthropathy. The following case report demonstrates both an expansile lesion of a metacarpal as well as hemophilic knee arthropathy in an 11 year old.

Osteomyelitis der Mittelhand- und Handwurzelregion

AIM

Because of the low prevalence, there is poor evidence on the effective management of bone and joint infections of the carpus and metacarpus. We therefore studied the outcomes of patients undergoing surgical treatment at our department.

METHOD

We conducted a retrospective study on all patients operated on because of osteomyelitis of the carpus and metacarpus between January 1998 and June 2004. Main study endpoint were the infection control rate at end of treatment and at time of follow-up.

RESULTS

Of eleven subjects (nine men, two women) with a median age of 43 years (range, 19 to 79 years) serial débridement with temporary wound closure and surgical fixation proved successful in ten cases. We identified causative pathogens in ten cases (S. aureus: n = 3, P. aeruginosa: n = 3, mixed: n = 4) by intraoperative biopsy. Eight subjects received local or free tissue flaps. A 73 year old man died in hospital. Follow-up information was available for eight patients after a median of 19.5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection.

CONCLUSION

Adhering to accepted standards of treating osteomyelitis, satisfactory control rates in carpal and metacarpal infection can be achieved while salvaging the hand.

Osseous sarcoidosis of the hand: pathologic analysis and review of the literature

A destructive granulomatous process involving the right fifth metacarpal and the soft tissues of the right thumb and nose of an African-American woman without pulmonary disease is described. The initial biopsy examination of the metacarpal showed caseating and noncaseating granulomata. After a fifth-ray amputation the disease progressed, leading to the referral of the patient to our institution. A biopsy examination of this recurrence showed a predominance of solid noncaseating granulomata. The diagnosis of sarcoidosis was made on the basis of the morphology of the granulomata and by exclusion of infectious and neoplastic causes. Steroid therapy has resulted in cessation of clinical and radiographic disease progression at a 3-year clinical follow-up evaluation.

Efficacy of periodontal disease and tooth loss to screen for low bone mineral density in Japanese women

The relationship between oral indicators and bone mineral density (BMD) has been studied by many investigators, with mixed and complex results. The purpose of the present cross-sectional study was to evaluate the associations of periodontal conditions and tooth loss with metacarpal BMD (m-BMD) in a community-based cohort and the usefulness of tooth count as a potential screening tool to detect low BMD. Subjects were 356 Japanese women (171 premenopausal, mean age 37.9+/-8.0 years; 185 postmenopausal, mean age 63.3+/-7.7 years). Periodontal status was evaluated by the Community Periodontal Index of Treatment Needs (CPITN). m-BMD was measured by computerized X-ray densitometry. The proportion of subjects with periodontitis (CPITN 3 or 4) increased as m-BMD decreased. The odds ratio (OR) of osteopenia or osteoporosis in relation to periodontitis was 3.2 (95% confidence interval [CI], 2.0--5.3). After adjustment for age and menopausal status, the OR was 2.0 (95% CI, 1.1--3.7). Among postmenopausal women, those having fewer than 20 teeth were 1.6 times more likely to have low m-BMD than those having more than 20 teeth (chi-square for trend in postmenopausal group, 4.27; P<0.05). Receiver-operating curve (ROC) analysis indicated that number of teeth remaining or CPITN score had a greater than 50/50 chance to correctly identify women with osteoporosis or osteopenia, but the areas under the curve (0.72 and 0.67, respectively) are considered less than highly accurate screening tools. These results indicate that periodontitis and tooth loss after menopause may be useful indicators of m-BMD loss in Japanese women.

Up-regulation of site-specific remodeling without accumulation of microcracking and loss of osteocytes

Functional adaptation of bone normally protects the skeleton from fracture during daily activity. Accumulation of microcracking and loss of osteocytes have been implicated in the regulation and initiation of targeted (reparative) remodeling of bone and, in certain situations, the development of fatigue or stress fracture. We performed a histologic study of the dorsal cortex of the mid-diaphysis of the third metacarpal (Mc-III) bone of Thoroughbred racehorses after bones were bulk-stained in basic fuchsin and transverse calcified sections were prepared. The Thoroughbred racehorse is an extreme athlete whose Mc-III bone experiences particularly high cyclic strains during training and racing. A group of non-athletic horses was also included in the experiment. The following variables were quantified: activation frequency (Ac.f); bone formation rate (BFR); resorption space density (Rs.N/T.Ar); microcrack density (Cr.Dn); microcrack mean length (Cr.Le); microcrack surface density (Cr.S.Dn); osteocyte density (Ot.N/T.Ar; Ot.N/B.Ar); and bone volume fraction (B.Ar/T.Ar). Ac.f and BFR were estimated using a mathematical algorithm. Using confocal microscopy, bones were examined for fine microcracks, diffuse matrix injury, and disruption of the osteocyte syncytium. Low values for Cr.Dn (#/mm2) were found in both groups (0.022+/-0.008 and 0.013+/-0.006 for racing Thoroughbreds and non-athletic horses, respectively). There was no significant relationship between Cr.Dn and Ot.N/T.Ar; Ot.N/B.Ar, B.Ar/T.Ar, and Ot.N/T.Ar; Ot.N/B.Ar, and remodeling (Ac.f, Rs.N/T.Ar) and Ot.N/T.Ar; Ot.N/B.Ar. Intense remodeling of the Mc-III dorsal cortex was found in the racing Thoroughbreds (Ac.f 12.8+/-7.4 #/mm2/year; BFR 31.5+/-15.6%; Rs.N/T.Ar 0.19+/-0.09 #/mm2) and was significantly increased compared with non-athletic horses. Overall, remodeling was weakly correlated with Cr.Dn (r2=0.15, P<0.05). Subtle matrix injury, not detectable by bright-field microscopy, was particularly evident adjacent to resorption spaces in Thoroughbred bone. In non-athletic horses, disruption of the dendritic cell processes of osteocytes associated with cement lines and interstitial fragments was more evident. Taken together, these findings suggest that site-specific (targeted) induction of remodeling during functional adaptation of bone in a high-strain skeletal site is not dependent on accumulation of microcracking or loss of osteocytes. We hypothesize that athleticism can directly influence bone turnover in this extreme athlete through pathways that do not involve classical linear microcracks.

Comparison of dual X-ray absorptiometry (DXA), digital X-ray radiogrammetry (DXR), and conventional radiographs in the evaluation of osteoporosis and bone erosions in patients with rheumatoid arthritis

OBJECTIVE

To compare the relationship between bone mineral density (BMD) in the metacarpal bones and forearm measured by dual X-ray absorptiometry (DXA) and digital X-ray radiogrammetry (DXR) and radiological alterations in patients with early and established rheumatoid arthritis (RA).

PATIENTS AND METHODS

In each of the three disease duration groups, 11 female RA patients were included. The patients were further divided into two groups according to bone erosions. BMD in the metacarpals was evaluated by DXA and DXR.

RESULTS

A significant relationship between DXA-BMD and DXR-BMD was observed. DXR-BMD and the individually combined cortical thickness (CT) of the metacarpo-phalangeal (MCP) joints were related to disease duration and erosions. Patients with erosive disease had lower values of age- and sex-adjusted BMD measured with DXA, but most significantly with DXR.

CONCLUSION

DXR appears to be a more sensitive method than DXA in detecting early bone loss in patients with RA. The relationship of DXR-BMD to disease duration and bone damage indicates that the DXR method may be useful in the evaluation of disease activity and progression.

Chronic sclerosing osteomyelitis of a metacarpal

Chronic sclerosing osteomyelitis in a metacarpal is presented. Bacterial cultures were negative, and radiographs and an isotope scan were non-specific. Histopathological assessment confirmed the diagnosis. Iliac bone grafting resulted in symptomatic relief to the patient.

Results from a degradable TMC joint Spacer (Artelon) compared with tendon arthroplasty

PURPOSE

A new spacer for the trapeziometacarpal joint (TMC) based on a biological and tissue-preserving concept for the treatment of TMC osteoarthritis (OA) has been evaluated. The purpose was to combine a spacing effect with stabilization of the TMC joint.

METHODS

Artelon (Artimplant AB, Sweden) TMC Spacer is synthesized of a degradable polyurethaneurea (Artelon), which has been shown to be biocompatible over time and currently is used in ligament augmentation procedures. Fibers of the polymer were woven into a T-shaped device in which the vertical portion separates the bone edges of the TMC joint and the horizontal portion stabilizes the joint. Fifteen patients with disabling pain and isolated TMC OA were included in the study. Ten patients received the spacer device and the remaining 5 (control group) were treated with a trapezium resection arthroplasty with abductor pollicis longus (APL) stabilization. The median ages of the 2 groups were 60 and 59 years, respectively. Pain, strength, stability, and range of motion were measured before and after surgery. Radiographic examination was performed in all patients before and after surgery. At follow-up evaluation 3 years after surgery an unbiased observer evaluated all patients. Biopsy specimens were obtained from 1 patient 6 months after surgery.

RESULTS

All patients were stable clinically without signs of synovitis. In both groups all patients were pain free. The median values for both key pinch and tripod pinch increased compared with before surgery in the spacer group but not in the APL group. The biopsy examinations showed incorporation of the device in the surface of the adjacent bone and the surrounding connective tissue. No signs of foreign-body reaction were seen.

CONCLUSIONS

This study showed significantly better pinch strength after Artelon TMC Spacer implantation into the TMC joint compared with APL arthroplasty.

The EULAR-OMERACT rheumatoid arthritis MRI reference image atlas: the metacarpophalangeal joints

This paper presents the metacarpophalangeal (MCP) joint magnetic resonance images of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. The illustrations include synovitis in the MCP joints (OMERACT RA magnetic resonance imaging scoring system (RAMRIS), grades 0-3), bone oedema in the metacarpal head and the phalangeal base (grades 0-3), and bone erosion in the metacarpal head and the phalangeal base (grades 0-3, and examples of higher grades). The presented reference images can be used to guide scoring of MCP joints according to the OMERACT RA MRI scoring system.

Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium Kansasii

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

Robusticity and osteoarthritis at the trapeziometacarpal joint in a Bronze Age population from Tell Abraq, United Arab Emirates

Osteoarthritis (OA) is a progressive disease of the joints and can cause pain, reduced range of motion and strength, and ultimately loss of function at affected joints. Osteoarthritis often occurs at sites where biomechanical stress is acutely severe or moderate but habitual over the course of a lifetime. Skeletal remains from an Umm an-Nar tomb at Tell Abraq, United Arab Emirates (ca. 2300 BC), were recovered and represented over 300 individuals of all ages. The remains were disarticulated, commingled, and mostly fragmented. An analysis of 650 well-preserved adult metacarpal and carpal bones, from the tomb's western chamber, revealed that over 53% of the trapeziometacarpal joint facets showed signs of OA varying from mild to severe. The first and second metacarpals and trapezium bones were sided and evaluated for OA at the trapeziometacarpal joint articulations. Osteoarthritis was detected on 53% of the first metacarpals, 40% of the second metacarpals, and 57% of the trapezium bones. All specimens appeared enlarged, and the first metacarpals were assessed for sexual identification and robusticity. Eighty-five percent of the bones were probable males, and more than 80% of them had a robusticity index of 60 or higher. A strong correlation was found between OA, sex, and robusticity. High levels of OA and robusticity at the thumb suggest that the people of Tell Abraq were habitually involved in biomechanically challenging work with their hands.

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

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

Chondrosarkome der Hand

BACKGROUND

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

METHOD AND MATERIAL

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

RESULTS

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

CONCLUSION

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

Use of magnetic resonance imaging to identify suspensory desmitis and adhesions between exostoses of the second metacarpal bone and the suspensory ligament in four horses

Four horses were examined because of chronic forelimb lameness. In all horses, the cause of the lameness was localized to the metacarpus by means of physical examination and diagnostic anesthesia, and radiography of the affected limb revealed a small exostosis of the second metacarpal bone. Magnetic resonance imaging revealed suspensory desmitis in the region of this exostosis in all 4 horses. In addition, an abnormal area of low signal intensity, suggestive of an adhesion, was seen between the exostosis and the suspensory ligament. In all horses, an adhesion between the suspensory ligament and the exostosis on the second metacarpal bone was identified and transected at surgery, and the exostosis and distal portion of the second metacarpal bone were removed. All horses were able to return to their previous athletic use following a 6-month rest and rehabilitation program for treatment of the suspensory desmitis. Findings in these horses suggest that adhesions between the suspensory ligament and an exostosis of the second metacarpal bone may be a cause of chronic or recurrent forelimb lameness in horses.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Avascular necrosis of the third metacarpal head: a case report]

Avascular necrosis of the third metacarpal head is a rare entity. It may remain asymptomatic, but may also be painful and lead to restricted range of motion. A-thirteen-year-old male patient presented with a painful and restricted range of motion in the third metacarpophalangeal (MCP) joint. There was no history of any trauma or a predisposing factor such as systemic lupus erythematosus or steroid use. The range of motion of the involved joint was minimally restricted (flexion range, 10 to 80 degrees). Mild tenderness was found on palpation over the dorsal aspect of the third MCP joint. Radiographs showed flattening and sclerosis of the third metacarpal head together with cystic lesions. The symptoms were controlled with non-steroidal anti-inflammatory drugs and splinting for four weeks. The range of motion of the MCP joint increased, along with regression on radiographs.

An assessment of equine cartilage degeneration

Millions of Americans suffer from osteoarthritis, a joint disease characterized by cartilage degradation and subchondral bone sclerosis. However, little is known about its pathology. It remains to be discovered which comes first in the progression of osteoarthritis: subchondral bone remodeling or cartilage degeneration. This study assessed equine cartilage degeneration, based upon measurements of cartilage thickness and Indian ink stain uptake. By gaining a greater understanding of the determining factors in cartilage degeneration, we may be able to better understand the pathomechanics of osteoarthritis. In seven horses, joint regions of interest were harvested bilaterally and isolated into planar osteochondral samples using a band saw and stored at -20 degrees C. After thawing, the samples' articular surfaces were dyed using an Indian ink stain to highlight articular cartilage degeneration. Digital images of the samples were taken before and after the staining, and mean pixel values for the pre- and post-ink images were measured using image analysis software. Reflectance Score (RS) was calculated using mean pixel values normalized between grayscale calibration standards. Articular cartilage thickness was measured at five random locations on each sample from images taken in the transverse orientation. Statistical analysis found no significant effect of limb side for either RS values or thickness, allowing data from right and left limbs to be grouped for analysis. There is a statistically significant correlation between joint region and thickness, as well as between joint region and RS; however, there was no statistical correlation between thickness and RS.

Scanning Electron Microscopic Examination of Third Metacarpal/Third Metatarsal Bone Failure Surfaces in Thoroughbred Racehorses with Condylar Fracture

OBJECTIVE

To examine the fracture failure surfaces from Thoroughbred horses that had sustained a catastrophic condylar fracture.

SAMPLE POPULATION

Bone specimens from the failure surface were obtained from 12 Thoroughbred racehorses with catastrophic injury and 2 non-racing horses with accidental long bone fracture.

METHODS

Bone specimens from the failure surface of each fracture were incubated with gold microspheres to label microcracks before examination at x50 to x60,000 using scanning electron microscopy. Microcracking at the failure surface was assessed using a visual analog scale.

RESULTS

Branching arrays or clusters of microcracks were seen over a range of magnifications in adapted subchondral bone in the distal end of the MC3/MT3 bone from racing Thoroughbreds with a catastrophic displaced condylar fracture. In the palmar/plantar region, microcracking was associated with the formation of an array of macroscopic cracks in the condylar groove. A different pattern of microcracking was seen in specimens of bone from distal metaphyseal and diaphyseal MC3/MT3 failure surfaces from Thoroughbred racehorses with catastrophic fracture and non-racing horses with an accidental diaphyseal long bone fracture. Few microcracks were seen and typically did not form branching arrays.

CONCLUSION

These data suggest that propagation of condylar fracture in Thoroughbred racehorses is initiated by the formation of nanoscale microcracks in adapted subchondral bone that form during exercise-induced bone adaptation.

CLINICAL RELEVANCE

Accumulation and coalescence of branching microcracks into arrays or clusters appears to eventually lead to the development of macroscopic subchondral cracks in the condylar groove and initiation of a condylar fracture.

Van Buchem disease: lifetime evolution of radioclinical features

OBJECTIVE

The purpose of this study was to evaluate the lifetime evolution of the radioclinical features in a large family with van Buchem disease.

DESIGN AND PATIENTS

The study population included 13 patients, ranging between 6 and 69 years. The evolution of the clinical features has been assessed by retrospective analysis of the clinical records of the patients. The age-related evolution of the cortical hyperostosis and defective modeling at the tubular bones was evaluated by morphometric analysis of hand films in 9 patients, compared with 9 control individuals. Progression of sclerosis of the craniofacial bones was evaluated by analysis of the skull radiographs of eleven van Buchem patients, taken at different age.

RESULTS AND CONCLUSIONS

Radioclinical features, including sclerosis of the cranial and tubular bones and cranial nerve deficit, become more prominent in older patients. Defective modeling of tubular bones, cortical thickness and medullary width progress with age. Radioclinical abnormalities of van Buchem patients become more prominent in older patients, which suggests that the van Buchem gene is very actively involved in bone metabolism throughout life. Morphometric analysis of the plain films supports the hypothesis that the physiological function of the van Buchem gene is to inhibit bone formation and possibly to regulate bone remodeling.

Motion and morphology of the thumb metacarpophalangeal joint

PURPOSE

To determine the variability in the flexion/extension motion of the thumb metacarpophalangeal (MCP) joint in a normal volunteer population and to determine any correlation between the shape of the thumb metacarpal head, gender, age, thumb interphalangeal (IP) joint range of motion (ROM), and thumb MCP joint ROM in a population of fresh-frozen cadaver arms.

METHODS

The ROM of the thumb MCP joints of 100 volunteers (200 thumbs) was measured. The thumb MCP joints of 70 fresh-frozen cadaver arms were examined. Posteroanterior and lateral radiographs were taken of 64 MCP joints. Passive flexion and extension at the MCP and IP joints were measured with a standard goniometer starting at neutral (0 degrees ) with the metacarpal, proximal, and distal phalanges axially aligned. The distance from the volar to the dorsal edge of the articular surface (A) and the radius of curvature of the articular surface (r) of the metacarpal head were measured on the lateral view. The shape of the metacarpal head was given a value using the A/r ratio. Regression analysis was used to determine the correlation between the head shape and joint motion. The thumbs were categorized into a round group (A/r ratio > 1.7) or a flat group (A/r ratio of < 1.7) to facilitate statistical analysis.

RESULTS

The volunteer population mean thumb MCP maximum flexion was 77 degrees range, 40 degrees -126 degrees ). Range of motion in hyperextension varied from 0 degrees to 72 degrees, with a mean of 35 degrees. Total ROM was from 55 degrees to 176 degrees, with a mean of 110 degrees. In the cadaver population studied the average MCP joint ROM was 94 degrees (mean flexion, 70 degrees; mean extension, 24 degrees ). The A/r ratio had a range of 1.1 to 2.2. There were 37 round and 27 flat thumb metacarpal heads. Regression analysis showed a significant correlation between metacarpal head shape and ROM; MCP joints with rounder metacarpal heads had greater motion. Round and flat metacarpal heads had significantly different motion arcs averaging 106 degrees and 77 degrees, respectively. Female gender was associated both with significantly greater MCP joint ROM (99 degrees women/87 degrees men) and a significantly higher incidence of round metacarpal heads (66% of women/36% of men). No significant correlation existed between specimen age, MCP, and/or IP joint ROM.

CONCLUSIONS

There is a wide range in the magnitude of the thumb MCP joint ROM and the normal shape (round vs flat) of the thumb metacarpal head. A rounder thumb metacarpal head has greater thumb MCP joint ROM than a flatter thumb metacarpal head. Clinically we have found this information helpful in predicting posttraumatic recovery of thumb MCP joint ROM and selecting candidates for and predicting patient satisfaction with thumb MCP joint arthrodesis.

Talo-patello-scaphoid osteolysis, synovitis, and short fourth metacarpals in sisters: a new syndrome?

Osteolysis syndromes are characterized by resorption of affected bones with associated swelling and pain. Various forms of multicentric osteolysis syndromes including autosomal dominant and recessive carpal-tarsal osteolysis, Torg, François, Whyte-Hemingway, Hajdu-Cheney, Winchester, and other forms have been described. Most present in pre-school years with extensive involvement and destruction of multiple bones. We present a sister-pair, both of whom presented in early teenage, i.e., 13 and 15.5 years, respectively, with bilateral ankle, knee, and later, wrist pain. Radiological examination revealed bilateral osteolysis of tali, scaphoids, and patellae, and short fourth metacarpals in both sisters. Further investigation revealed absence of renal involvement, a normal excretion of amino acids, mucopolysaccharides and oligosaccharides, and presence of chronic synovitis in both sisters. Both parents and a younger brother were without radiographic or clinical evidence of the disease and there was no history of consanguinity. Thus, our sister-pair presented with the same carpal and tarsal bone involvement at a much later age, with evidence of chronic synovitis, along with short fourth metacarpals (brachydactyly type E changes) and without renal disease, suggesting a new syndrome with probable autosomal recessive inheritance.

New radiographic bone erosions in the wrists of patients with rheumatoid arthritis are detectable with magnetic resonance imaging a median of two years earlier

OBJECTIVE

In a 5-year followup study, we investigated the temporal relationship between development of wrist joint erosions as visualized by magnetic resonance imaging (MRI) versus conventional radiography (CR), in patients with rheumatoid arthritis. We also evaluated the risk of erosive progression on CR associated with the presence of MRI erosions.

METHODS

In 10 patients with rheumatoid arthritis, MRI and CR of the dominant wrist were performed annually for 5 years. In each image set, each wrist bone (metacarpal bases, carpal bones, radius, and ulna) was assessed for the absence or presence of bone erosions.

RESULTS

Nine bones showed radiographic erosions at baseline. Twenty-seven new radiographic erosions developed during the 5-year followup period. Of these 27 new erosions, 21 were detected 1-5 years earlier by MRI than by CR, 3 were simultaneously detected by both methods, 2 were detected 1-2 years later by MRI than by CR, and 1 erosion (radiographically detected at 5-year followup) was not visualized with MRI. MRI detection of new radiographic erosions preceded CR detection by a median of 2 years. In bones with MRI erosions at baseline, the relative risk of radiographic erosions at 5-year followup was 4.5 (95% confidence interval [95% CI] 2.6-7.6), compared with bones without baseline MRI erosions. If bones with baseline radiographic erosions were excluded from the analysis, the relative risk was 4.1 (95% CI 2.2-7.5).

CONCLUSION

Most new radiographic bone erosions (78%) were visualized at least 1 year earlier by MRI than by CR. This illustrates that the information on joint destruction provided by CR is considerably delayed compared with that provided by MRI. A significantly increased risk of progression of radiographic erosion in bones with baseline MRI erosions was observed, demonstrating a prognostic value of MRI with respect to long-term radiographic outcome.

Management of metacarpal fractures

Fractures of the hand are the most common fractures of the human skeleton. Metacarpal fractures account for 30% to 50% of all of hand fractures. The mechanisms of these injuries vary from axial loading forces to direct blows to the dorsal hand. Resulting deformities include malrotation, angulation, and shortening. Treatment modalities vary from nonoperative reduction to open reduction and internal fixation. The treatment algorithm is guided by the location of the fracture, the stability of the fracture, and the resultant deformity. Operative procedures, although they may lead to excellent radiographic reduction of fractures, often lead to debilitating stiffness from the inflammatory reaction of the surgical procedure. Operative fixation must be employed judiciously and offered only when confident that non-operative therapy can be improved on with operative intervention. This article reviews the various types of metacarpal fractures, with the treatment options available for each fracture. The indications for each treatment modality, postoperative care, and rehabilitation are presented.

Primitive neuroectodermal tumor of the thumb metacarpal bone: a case report and literature review

A 27-year-old otherwise healthy patient was diagnosed with a primitive neuroectodermal tumor of the thumb metacarpal bone of the left hand. Based on a common chromosomal translocation this tumor shows a close relationship to Ewing's sarcoma. Its occurrence in the extremities is uncommon and involvement of the hand is extremely rare. The treatment consisted of neo- and adjuvant chemotherapy and marginal resection of the affected thumb metacarpal bone including periosseous soft tissue and reconstruction of the thumb by an intercalated segmental index pollicization.

Osteoid osteoma of the metacarpal bone presenting after an injury

We present a case of osteoid osteoma of the right third metacarpal bone in a 23-year-old man. He had an apparent history of initial injury, followed by pain and swelling. He was initially treated for post-traumatic periostosteitis, so that the diagnosis of osteoid osteoma was delayed. Computed tomography and histology confirmed the latter diagnosis. En bloc resection of the nidus was followed by complete resolution of his symptoms. This case report emphasises the difficulties in diagnosis, particularly after an injury, and illustrates its effective treatment.

Idiopathic avascular necrosis of the metacarpal head

Avascular necrosis of the metacarpal head is a rare condition. Although the condition is associated with trauma, systemic lupus erythematosus, and steroid use, it can occur spontaneously without any obvious cause. Any metacarpal may be affected and the pathologic changes are similar to those described in other bones such as the femur. The diagnosis requires an index of suspicion in a young patient with spontaneous onset of symptoms localized to a metacarpophalangeal joint. Magnetic resonance imaging is a useful early diagnostic tool when the radiographic findings are nonspecific or absent. The natural history of the condition is not known. Although symptoms may resolve with nonoperative treatment, progressive collapse of the metacarpal head and subsequent degenerative arthritis is a possible long-term outcome. Curettage of the lesion and supplementary cancellous bone grafting has been reported to provide symptomatic relief in cases resistant to nonoperative treatment. A case is presented of idiopathic avascular necrosis of the head of the dominant ring finger metacarpal in a 27-year-old woman. The purpose of this report is to highlight the clinical presentation, radiographic features, pathologic findings, and outcome at 2 years after curettage and bone grafting.

Magnetic resonance imaging characteristics of bizarre parosteal osteochondromatous proliferation of the hand: a case report

Bizarre parosteal osteochondromatous proliferation (BPOP) is a reactive lesion of cortical bone. A case of fifth metacarpal BPOP with intramedullary inflammatory extension is shown by magnetic resonance imaging. Histologically the intramedullary extension showed fibrosis with inflammatory cell infiltration. The surrounding adipose tissue showed fibrosis, focal inflammatory cell infiltration, and vascular proliferation. It is important to recognize that BPOP can bear radiologic resemblance to malignant lesions or osteomyelitis when there is an intramedullary inflammatory extension. Preservation of cortical bone under the osteocartilaginous mass on T1-weighted magnetic resonance imaging, and homogenous intramedullary enhancement with gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA), can be helpful for distinguishing BPOP from malignant lesions.

Mycetoma caused by Fusarium solani with osteolytic lesions on the hand: case report

Eumycetoma is a mycotic disease caused by saprophytic soil fungi that are usually inoculated through minor injuries. A case of mycetoma in a Brazilian farmer aged 71 years is reported. This patient presented erythema and edema on the dorsal surface of the left hand with multiple crusted and cicatricial lesions. No macroscopic grains were observed. The histopathological findings showed grains consisted of numerous hyphae which stained well with Gomori-Grocott method. This material obtained by cutaneous biopsy was submitted to culture on Sabouraud's medium and the colonies were identified as Fusarium solani. The radiological studies revealed bone osteolytic lesions and the ultrasound showed pseudocysts and fistulae at the site of this infection. The patient was treated with oral ketoconazole with a good clinical response.

[Total carpometacarpal dislocations. Two case reports]

We report two cases of carpometacarpal dislocation of the four long fingers. They were diagnosed in emergency and treated by open reduction and stabilization by intramedullary pinning. They were followed for an average of 30 months. The results were rated good, and the two patients had an excellent grip strength, no deformity, no instability, no disabling or limited prehension. Dislocation or fracture-dislocation of the carpometacarpal joints are uncommon injuries. The diagnosis can be easily missed. The authors recommend closed or open reduction and fixation by pins and immobilisation in a plaster cast. The results was good in the two cases without complications.

Stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction

INTRODUCTION

Trapeziometacarpal pre-arthrosis is a common condition with only limited therapeutic possibilities. Eaton and Littler designed a tendon stabilization.

MATERIALS AND METHODS

A series of 21 thumbs with painful carpometacarpal joints, treated with a ligament reconstruction according to Eaton and Littler, is described. Three failed and further surgery was required. The outcome of 18 is evaluated. There were 11 women, 7 men with a mean age of 33.7 years, all having stages I or II of osteoarthritis. Six (30%) had a traumatic event in their history.

RESULTS

In the early stages of degenerative osteoarthritis, the overall outcome was good with a mean DASH score of 23.2. The carpometacarpal joint was stable but a 43% progression of radiographic osteoarthritic deterioration of the joint occurred.

CONCLUSION

Stabilization of a painful pre-arthritic trapeziometacarpal joint is useful and reliable. A traumatic instability had worse results and probably is a contraindication to this technique.

[Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases]

INTRODUCTION

The main goal of first carpometacarpal arthritis surgical treatment is to relieve pain. The main disadvantages of the usual techniques (trapeziectomy, implant arthroplasty) are loss of strength or presence of a prosthetic device. It is difficult to propose such extensive surgery at an early stage of the disease. Selective denervation of the first carpometacarpal joint seems to be an interesting choice. We propose a new technique of denervation based on our previous anatomical investigations.

TECHNIQUE

Two incisions are needed to cut all the articular branches derive from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve and the lateral ante brachial cutaneous nerve.

MATERIAL

Fourteen patients were prospectively included in our study with a mean follow-up of 5 months.

RESULTS

Pain relief was very satisfying in 12 cases (mean decrease 84%). An increase in grip and key pinch strength was noted. Complications were uncommon, excepted temporary paresthésia in the radial nerve area.

DISCUSSION

This technique seems to be promising and a good indication for patients with no disabling deformity, but only long-term results will confirm the place of denervation in the treatment of first carpometacarpal arthritis.