Due to its remarkable mechanical properties and excellent biocompatibility, PyrocarbonTM is an ideal material for articular use. Various Pyrocarbon implants for the hand and wrist have been developed over the past 25 years. The Ensemble implant is unique in that it can be inserted as a minimally invasive hemiarthroplasty technique that does not require any preparation to insert a stem into the thumb metacarpal. The device has a unique three-dimensional design that locks onto the surface of the trapezium without requiring any internal fixation. We report on our first 12 cases with 1 year follow-up. There was significant improvement in the DASH score and pinch strength at 1 year follow-up (p< 0.5) with no significant decrease in thumb motion or instances of dislocation. One patient was revised due to rapid progression arthritis at the scaphoid trapezial interface that required revision to an arthroplasty with complete removal of the trapezium.

We compared the effectiveness of Wharton’s jelly versus steroid injection into the carpometacarpophalangeal joint by comparing 60 patients in two cohorts with a follow up evaluation at three months and then at one year. We evaluated preoperative and postoperative grip strength, pinch strength, thumb range of motion, Disabilities of Arm, Shoulder, and Hand (DASH) score and a Visual Analog (VAS) pain score before the injection and then at 3 months and 12 months after injection. The patients in the steroid injection group had substantial improvement in their DASH and VAS pain scores as well as their pinch strength at 3 months p < .05. However, by the 12-month evaluation the benefits of the steroid injection had completely dissipated. The patients in the Wharton’s jelly cohort had improvements at 3 months in terms DASH and VAS score and pinch strength and this improvement persisted at the one-year evaluation. However, grip strength and thumb range of motion did not substantially improve in either group

Background: The dorsal approach to the proximal interphalangeal (PIP) joint provides the advantage of improved visualization of the articular surface, while the disadvantage of a dorsal approach is the disruption of the central slip and extensor mechanism requiring a delay in range of motion exercises. A volar approach keeps the central slip and extensor mechanism intact, allowing for early range of motion. The goal of this study was to evaluate patient outcomes of surface replacement (SR) PIP joint arthroplasty performed through a volar approach. Methods: Twenty-one patients were evaluated with primary osteoarthritis of a single PIP joint and underwent SR arthroplasty using the Stryker SR PIP joint implants. Patients included in this study were exclusively treated through a volar approach. Preoperative range of motion, coronal plan deformity, Disabilities of the Arm, Shoulder and Hand (DASH), and patient satisfaction were measured and compared with postoperative measurements using a paired Student t test. Results: The average length of follow-up was 34 months (± 9 months). Postoperative arc of motion for the PIP and distal interphalangeal (DIP) joints measured 87° (±12°) and 36° (±11°), respectively. The average improvement in PIP arc of motion was 58°, DASH score measured 14 (±5), satisfaction measured 4 (±1), and coronal plane deviation measured 2° (±2°). No evidence of implant subsidence was found on postoperative radiographs. Four patients required an extensor tendon tenolysis, and 1 patient suffered a superficial surgical site infection. Conclusion: SR arthroplasty, when performed through a volar approach, allows for early range of motion and greater improvements in arc of motion, DASH score, and patient satisfaction.

A 68-year-old right-hand-dominant man presented 6 weeks after having a fall, tripping briefly before catching himself. He initially presented with pain, in the proximal left fifth metacarpal and middle finger, mild edema and ecchymosis extending to the distal phalanx of the middle finger, and along the hypo-thenar eminence. There was no complaint of sensory loss and he described no other injuries resulting from this event. On physical examination he had restricted active and passive range of motion of the left wrist, and middle finger secondary to pain and edema. Neurovascular examination was normal. Radiographs at the time of initial presentation confirmed the presence of a nondisplaced fracture at the base of his left middle finger proximal phalanx, and fracture in his left fifth metacarpal; despite only suffering what he described as minor trauma. The overall position of his fracture did not require open or closed reduction. Therefore he was treated with an orthosis for one month. Following his course of orthotic treament he presented with persistent pain over the middle finger proximal phalanx along with swelling and tenderness. Radiographs showed no healing of the proximal phalanx fracture and there was a lytic lesion adjacent to the fracture. His initial x-rays were reviewed but no lytic lesions were observed, suggesting that this was a new finding. A review of his past medical history revealed that he was in remission for over 12 years following the treatment with chemotherapy for multiple myeloma (Figure 1, Figure 2). Figure 2Oblique view of the left hand demonstrating collapse of the dorsal aspect of the proximal phalanx of the middle finger. The lytic lesion is apparent in the proximal aspect of the proximal phalanx. View Large Image Figure Viewer Download Hi-res image

Plastic deformation of the forearm is a rare injury in young adults that occurs when a slow bending or rotational force is applied to the arm, most commonly in the setting of an industrial workplace accident. There are currently no guidelines for treatment of the residual forearm deformity that often results in limitations of forearm supination and pronation. We present 2 cases demonstrating that deformity correction with single cortex, double-level osteotomies combined with rigid plate fixation and early range of motion exercise that results in good functional outcomes.

Plastic deformation of the forearm is a rare injury in young adults that occurs when a slow bending or rotational force is applied to the arm, most commonly in the setting of an industrial workplace accident. There are currently no guidelines for treatment of the residual forearm deformity that often results in limitations of forearm supination and pronation. We present 2 cases demonstrating that deformity correction with single cortex, double-level osteotomies combined with rigid plate fixation and early range of motion exercise that results in good functional outcomes. (J Hand Surg 2011;36A:639-646. Copyright (c) 2011 by the American Society for Surgery of the Hand. All rights reserved.)

BACKGROUND Protective antiself response to nervous system injury has been reported to be mediated by a T-cell subpopulation that can recognize self-antigens. Immune cells have been shown to play a role in the regulation of motor neuron survival after a peripheral nerve injury. The objective of the present study was to evaluate the effects of immune system augmentation with use of the antigen glatiramer acetate, which is known to affect T-cell immunity, on peripheral nerve regeneration. METHODS Wild-type and nude-type (T-cell-deficient) rats underwent crush injury of the sciatic nerve. Three and six weeks after the injury, the sciatic nerve was examined, both functionally (on the basis of footprint analysis and the tibialis anterior muscle response and weight) and histologically (on the basis of axon count). RESULTS Significantly greater muscle responses were measured after three weeks in the group of wild-type rats that were treated with glatiramer acetate (control limb:injured limb ratio, 0.05 for the glatiramer acetate group [n = 9], compared with 0.51 for the saline solution group [n = 8]; p < 0.05). Higher axon counts were also found in this group (control limb:injured limb ratio, -0.07 for the glatiramer acetate group [n = 10], compared with 0.29 for the saline solution group [n = 8]; p < 0.05). The nude-type rats showed no response to the intervention after three weeks but showed a delayed response after six weeks. A second dose of glatiramer acetate, delivered forty-eight hours after the injury, did not result in an improved response as compared with the control groups. CONCLUSIONS We found that a single treatment with glatiramer acetate resulted in accelerated functional and histological recovery after sciatic nerve crush injury. The role of T-cell immunity in the mechanism of glatiramer acetate was suggested by the partial and late response found in the T-cell-deficient rats.

The triangular fibrocartilage complex (TFCC) is an important and complex anatomic structure. At the distal radioulnar joint (DRUJ), the TFCC provides mechanical stability and absorbs axial and translational forces. Discrete anatomic structures impart specific functions. By adulthood, the blood supply is limited to the peripheral border, and the radial origin of the TFCC has minimal vascularity. Acute traumatic tears frequently follow high-force injuries onto an outstretched hand and are classified according to Palmer. Tears occurring along the radial border of the TFCC (Palmer class 1D) have poor healing potential because of the lack of vascularity. Magnetic resonance arthrogram has high sensitivity and specificity for TFCC injuries. Palmer class 1D lesions are identified by standard wrist arthroscopy. TFCC tears are debrided, with the radial TFCC origin is resected to bleeding bone. Meniscal repair sutures are carefully placed through the TFCC via an ulnar-based cannula. Bone tunnels are then created in the appropriate orientation, and the sutures are passed through the radius. A small radial-sided incision is made overlying the exiting sutures, which are tensioned and tied over bone or a biotenodesis screw. Patients are immobilized in a long-arm splint for 2 weeks followed by a graduated rehabilitation program. Oper Tech Sports Med 18:173-180 (C) 2010 Elsevier Inc. All rights reserved

Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare cartilaginous neoplasm that often presents in the long bones of the hands and feet. BPOP is a benign but locally aggressive fibro-osseous mass that has striking clinical, radiographic, and histologic similarities with osteochondroma. Differentiating between the two lesions is important as BPOP often requires more extensive surgical resection and has a higher recurrence rate compared to osteochondroma. This report presents two cases of BPOP where initial clinical diagnosis of osteochondroma was made even after appropriate imaging and histologic samples were evaluated. This report reviews clinical, radiographic, and histologic characteristics that can differentiate between the two lesions.

Purpose: The goal was to determine whether locking screws (LS) or smooth locking pegs (SP), optimize fixation of 4-part intraarticular distal radius fractures. The secondary goal was to determine which combinations of LS and SP influence construct stability. Method: In anatomic radius models, 4-part intraarticular distal radius fractures were fixed using volar locking plates. For the first part, 16 specimens were randomized to receive either 2 LS or 2 SP in each of the 3 pairs of holes in the plate. For the second part, 30 specimens were randomized to receive any 4 combinations of LS and SP in each of the 3 pairs of holes. Axial loading to failure was applied. Results: Constructs consisting of 4 SP within the lunate fragment were significantly weaker than constructs with 4 LS (mean 626.18 N vs. mean 980.76 N, p=0.01283). Constructs with SP in the ulnar positions of the lunate fragment were weaker than with LS in these positions (mean 736.73 N vs. 977.37 N respectively, p=0.00866). LS in the subchondral position of the lunate fragment were stronger than SP in these positions (mean 1226.99 N vs. 933.64 N, p= 0.00468) and any other combination (mean 1226.99 N vs. 941.97 N, p=0.0027). Conclusion: The use of LS as opposed to SP for 4-part intraarticular distal radius fractures, particularly subchondral and in ulnar side of the lunate fragment, optimizes construct stability. This may have implications on postoperative rehabilitation protocols and may limit costs related to the use of volar locking plates.

A 59-year-old woman underwent plate fixation of her 2-part anatomic neck proximal humerus fracture through an open anterolateral approach. The fixation subsequently failed, and the operation resulted in a dense axillary nerve palsy. Six weeks after her initial procedure, she was returned to the operating room. Exploration of the nerve revealed that it was compressed beneath the plate and irreparably damaged. Sural nerve cable grafting was required in an attempt to salvage deltoid function. The recent introduction of proximal humeral locking plates provides an opportunity for surgeons to reevaluate their methods of managing proximal humerus fractures. Indications for operative fixation have broadened, and a renewed interest in the anterolateral surgical approach has been reported. This case is the first description of an axillary nerve injury occurring in association with the open anterolateral approach when used for the treatment of a proximal humerus fracture and serves as a reminder that surgeons considering the use of a lateral approach must have a thorough understanding of axillary nerve anatomy. An additional review of the case provides a forum for discussion of the anterolateral approach to the proximal humerus and an opportunity to highlight the methods that can be used to optimize fixation when locked plates are employed. It must be emphasized that our enthusiasm for advances in technique and technology should not distract from basic surgical principles when treating these fractures.

PURPOSE:Repair of both flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons is commonly performed in zone II flexor tendon injuries; however, the bulk of the repair may impair tendon gliding. We evaluated whether repairing 1 slip of FDS tendon and resecting the other would significantly decrease work of flexion and whether suture material affected this interaction in an in vitro study. METHODS:The index, middle, and ring fingers from 10 fresh-frozen human cadaveric hands were disarticulated and their tendon sheaths opened. Baseline work of flexion was tested. Lacerations were made in zone II, and then the FDP tendon was repaired with 3 different suture materials: FiberWire, Ticron, and prolene. Work of flexion was again measured and the percentage increase calculated. Further iterations were performed with both slips of FDS tendon repaired and with one slip of FDS tendon repaired and the other resected. RESULTS:There was no significant difference in the work of flexion after repairs done with FiberWire, Ticron, or Prolene. Work of flexion after repair of both FDP and FDS tendons increased 51% compared with an increase of 21% after FDP-only repair and an increase of 9% after repair of one and resection of the other slip of FDS. Repair of both FDP and FDS tendons significantly increased work of flexion. CONCLUSIONS:Resection of 1 slip of FDS tendon significantly reduces work of flexion in zone II flexor tendon repair. Suture material had no effect on this interaction.

I read with interest the article in the July–August issue, entitled, “Volar plating of AO C3 distal radius fractures: biomechanical evaluation of locking screw and locking smooth peg configurations.”1Martineau P.A. Waitayawinyu T. Malone K.J. Hanel D.P. Trumble T.E. Volar plating of AO C3 distal radius fractures: biomechanical evaluation of locking screw and locking smooth peg configurations.J Hand Surg. 2008; 33A: 827-834Google Scholar I was very disappointed in the conclusion drawn from the article, that “it may be justified for hospitals and surgery centers to equip their locking distal radius plate sets only with the locking screw option and thus decrease costs and inventory.” This conclusion cannot be drawn from the results of this article, for the following reasons:1This was not an in vivo study. Although I understand the reason for using sawbones (decreasing variables of different bones owing to osteoporosis, etc.), there are some limitations in testing with sawbones rather than cadaver bones, which have differences in cortical and cancellous bone.2The load applied to the bones in this study was “axial compression perpendicular to the sagittal axis of the articular surface.” This is not the load that patients normally place on their distal radius after an open reduction internal fixation.3This study does not address the fact that locking pegs may be safer than screws. One can achieve support at the dorsal cortical bone without worrying about the sharp tip of a screw irritating the extensor tendons. Moreover, if there is some settling of the fracture, I feel it is better for a smooth peg to be intra-articular than to be a screw. I use smooth locking pegs almost exclusively when fixing distal radius fractures with a volar plate. To date, I have not had a problem with loss of reduction, nor have I had a problem with tendon irritation or rupture. In this day and age, when our own research studies are used by administrators to determine care for patients, we need to be careful that the conclusions we publish are supported by the results in our studies. This study proves that in sawbones, locking screws optimize construct stability when axial compression is applied. One cannot conclude from this that locking screws optimize fixation when applied in vivo to distal radius fracture. Moreover, the safety of having a smooth surface, rather than a sharp one, is not addressed. In ReplyJournal of Hand SurgeryVol. 34Issue 2PreviewWe would like to thank the author of the letter for his interest in our article. We acknowledge that the use of a sawbone model has inherent limitations; however, there remain several advantages to having a uniform homogeneous study population. In addition, the use of a synthetic model for the study and biomechanical testing of distal radius fractures is supported by previously published papers.1–3 Full-Text PDF