Proximal Row Carpectomy Modifications for Capitate Arthritis: A Systematic Review.

Introduction Proximal row carpectomy (PRC) is a motion-sparing procedure for radiocarpal arthritis with reliable results. Traditionally, proximal capitate arthritis is a contraindication to PRC; however, PRC with modifications are proposed to circumvent this contraindication. PRC modifications can be broadly grouped into capitate resurfacing (CR) and capsular interposition (CI) procedures which could expand PRC indications. Our primary question was to characterize the outcomes achievable with various PRC modifications. Our secondary question was to determine which PRC modification was the optimal procedure when capitate arthritis was present. Methods A systematic review was conducted to examine the outcomes of modified PRC procedures. Independent reviewers appraised multiple databases for PRC studies with modifications for capitate arthritis in adult patients (age >18 years) with a minimum of three cases and extractable outcomes. Modified PRC procedures included capsular/allograft interposition, resurfacing capitate pyrocarbon implants, and osteochondral grafting. Pertinent outcomes included patient demographics, range-of-motion, grip strength, patient-reported outcomes, and complications, including salvage rates. Results Overall, 18 studies met the inclusion criteria-10 studies ( n = 147) on CI and 8 studies on CR ( n = 136). PRC with CI had the greatest flexion-extension arc and grip strength. Complications were marginally higher in the CR group (4%), while the CI group had a higher conversion to total wrist arthrodesis (10%). Conclusion Techniques to address capitate arthritis center around resurfacing or soft tissue interposition. PRC modifications with CI produces better range-of-motion and grip strength but higher conversion to total wrist arthrodesis. Higher conversion rates may be attributable to longer follow-up periods in studies examining CI compared with CR. Level of Evidence This is a Level III study.

The Utility and Efficiency of a Resident Hand Clinic for the Management of Acute Hand Trauma at the University of Alberta.

BACKGROUND: The University of Alberta established a resident-run hand clinic in 2005 to expeditiously manage the growing numbers of patients with traumatic hand injuries. The purpose of this study was to examine the clinical volume and types of cases assessed and treated in the clinic, as well as gauge patient satisfaction with care received. METHODS: A retrospective chart review and patient satisfaction questionnaire were conducted for patients assessed in the hand clinic in 2015. Demographic data, referral data, and treatment required were recorded. Patients were asked to complete a survey on their experience at the end of their visit. RESULTS: A total of 1022 charts were reviewed. The most common reason for referral was a fracture or dislocation (57%), followed by tendon injury (18%). The average wait time to be seen in clinic was 2.97 ± 2.13 days in the winter and 4.12 ± 2.14 days in the summer. Forty-seven percent of patients required splinting, 17% required a procedure, and 21% of patients were referred for surgery. Patient satisfaction on average was 9.29 ± 0.87 on a satisfaction scale of 10. CONCLUSION: In a 6-month period, residents attending hand clinic assessed and treated 1022 patients, providing timely management of acute injuries. A resident-run hand clinic is an effective model to decrease wait times for patients, to decrease time spent assessing nonemergent injuries in the emergency department, and to concentrate hand trauma in a setting conducive to resident training, while still maintaining high patient satisfaction.

HISTORIQUE: En 2005, l'université de l'Alberta a mis sur pied une clinique de la main dirigée par des résidents pour accélérer la prise en charge du nombre croissant de patients ayant des lésions traumatiques des mains. La présente étude visait à examiner le volume clinique et le type de cas évalués et traités en clinique, ainsi qu'à évaluer la satisfaction des patients à l'égard des soins reçus. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers et ont distribué un questionnaire sur la satisfaction des patients qui avaient été évalués dans la clinique de la main en 2015. Ils ont consigné les données démographiques, les données sur l'envoi vers un médecin et le traitement requis. Les patients ont été invités à remplir un sondage sur leur expérience à la fin de leur rendez-vous. RÉSULTATS: Au total, les chercheurs ont examiné 1 022 dossiers. La principale raison de l'orientation vers un médecin était une fracture ou une dislocation (57 %), suivie d'une lésion du tendon (18 %). Le temps d'attente moyen pour être vu en clinique était de 2,97 ± 2,13 jours pendant l'hiver et de 4,12 ± 2,14 jours pendant l'été. De plus, 47 % des patients ont eu besoin d'une attelle, 17 % ont eu besoin d'une intervention et 21 % des patients ont été envoyés en chirurgie. En moyenne, la satisfaction des patients était de 9,29 ± 0,87 sur une échelle de satisfaction de 10. CONCLUSION: Sur une période de six mois, les résidents qui ont travaillé à la clinique de la main ont évalué et traité 1 022 patients, assurant une prise en charge rapide des lésions aiguës. Une clinique de la main dirigée par des résidents est un modèle efficace pour réduire les temps d'attente pour les patients, réduire le temps passé à évaluer des blessures non urgentes à l'urgence et concentrer les traumatismes de la main dans un milieu favorable à la formation des résidents tout en assurant une satisfaction élevée des patients.

Cortical activation deficits during facial emotion processing in youth at high risk for the development of substance use disorders.

BACKGROUND: Recent longitudinal studies demonstrate that addiction risk may be influenced by a cognitive, affective and behavioral phenotype that emerges during childhood. Relatively little research has focused on the affective or emotional risk components of this high-risk phenotype, including the relevant neurobiology. METHODS: Non-substance abusing youth (N=19; mean age=12.2) with externalizing psychopathology and paternal history of a substance use disorder and demographically matched healthy comparisons (N=18; mean age=11.9) were tested on a facial emotion matching task during functional MRI. This task involved matching faces by emotions (angry, anxious) or matching shape orientation. RESULTS: High-risk youth exhibited increased medial prefrontal, precuneus and occipital cortex activation compared to the healthy comparison group during the face matching condition, relative to the control shape condition. The occipital activation correlated positively with parent-rated emotion regulation impairments in the high-risk group. CONCLUSIONS: These findings suggest a preexisting abnormality in cortical activation in response to facial emotion matching in youth at high risk for the development of problem drug or alcohol use. These cortical deficits may underlie impaired affective processing and regulation, which in turn may contribute to escalating drug use in adolescence.

Exclusion of the hamate in 4-corner fusion: technique and outcomes of a novel approach to intercarpal arthrodesis.

Scapholunate ligament disruptions and scaphoid nonunions are known to follow predictable patterns of arthritis. Advanced cases of such degenerative arthritis have traditionally been treated by either 4-corner fusion or proximal row carpectomy. Four-corner fusion has relied on the surface area provided by the capitate, lunate, triquetrum, and hamate to achieve a union. Earlier attempts in decreasing the involved surface area, that is, through fusion of only the capitolunate joint were not met with great success. With the advent of compression screws, however, we feel it is possible to achieve union while incorporating less surface area into the fusion block. We propose a novel procedure, the "2-corner, 3-carpal" fusion, which fuses only the capitate, lunate, and triquetrum, excluding the hamate. By taking advantage of compression screw technology we were able to achieve union and acceptable range of motion in 10 patients in our institution who underwent this procedure.

Scaphoid excision and 4-corner fusion using retrograde headless compression screws.

Scapholunate advanced collapse is a predictable form of wrist arthritis resulting from longstanding scapholunate instability. Four-corner fusion and scaphoid excision is a reliable procedure used to treat scapholunate advanced collapse wrist that improves pain and preserves range of motion. Multiple methods of achieving fixation have been described for the procedure including K-wires, staples, and headless compression screws. In previously described techniques, the compression screws are inserted in an antegrade manner, breaching the articular surface of the lunate. Even small areas of chondral damage may undermine the long-term durability of the radiocarpal joint. Given the 4-corner fusion relies on the integrity of the radiolunate articulation for success, it would seem advantageous to preserve the articular cartilage of the lunate. The technique described here involves retrograde insertion of headless compression screws to achieve a 4-corner fusion. Although it is still early, we anticipate that this procedure will result in similar fusion rates to other forms of fixation.

The use of laser Doppler imaging as a predictor of burn depth and hypertrophic scar postburn injury.

Hypertrophic scarring (HTS) is a fibroproliferative disorder that commonly develops after severe burn injuries. Overexpression of transforming growth factor-ß (TGF-ß) by an increased number of fibrocytes has been associated with increased extracellular matrix molecule expression leading to HTS. The most widely accepted adjuvant to clinical assessment of burn depth is laser Doppler imaging (LDI) and may predict injury to the dermis that corresponds to cellular and molecular changes associated with HTS. A prospective, blinded, control trial was performed comparing LDI and clinical assessment for the decision to operate. Immunohistochemistry and real-time reverse transcription polymerase chain reaction was performed to determine whether there is a correlation between histological assessment of burn depth and LDI, and the presence of fibrocytes was detected using confocal microscopy. The positive predictive value for a burn requiring a graft was calculated to be >90%. Immunohistochemistry on biopsy samples revealed an increased expression of TGF-ß, connective tissue growth factor, heat shock protein 47, and collagen type I in deep burn wounds compared to superficial burns. Using the fibrocyte-specific markers procollagen type I and lymphocyte-specific protein-1, there was an increased number of fibrocytes in deep burn areas compared to superficial burn. In deep burn injuries, increased infiltration of fibrocytes occurs leading to an overexpression of TGF-ß1 and connective tissue growth factor. More importantly, LDI was >90% accurate at predicting the need for excision and grafting. The accuracy of the decision to debride deep dermal burns to avoid HTS using both clinical parameters and LDI was supported by histological and biochemical measurements.

Carotid rupture following electrical injury: a report of two cases.

Electrical injuries often result in extensive tissue damage where vascular damage may occur and result in thrombosis and spontaneous rupture of blood vessels. Rupture of the brachial, radial, ulnar, internal mammary, and obturator arteries has been reported in the literature. The authors present two cases of carotid artery rupture following high-voltage electrical injuries. The first case is a 21-year-old man who was climbing a fence near a high-voltage power line when a gold chain he was wearing around his neck caught on the power line, resulting in a 10% circumferential electrical injury to his neck. He presented with visible arterial bleeding from the large neck wound and was taken to the operating room, where a 1-cm laceration to the carotid artery was repaired with a vein patch. On the second postoperative day, the patch dislodged, and a spontaneous rupture of the common carotid artery occurred. The damaged artery was subsequently ligated. The patient recovered with no neurological sequelae. The second case is a 43-year-old man who suffered a high-voltage injury while working on an electrical panel, resulting in a 50% TBSA full-thickness burn to the face, scalp, trunk, and extremities. Four weeks after admission, a latissimus dorsi myocutaneous free flap was used for coverage of exposed outer table of the skull. Intraoperatively, the carotid artery spontaneously ruptured proximal to where the dissection was being carried out. The patient recovered with no neurological sequelae. High-voltage electrical injury results in significant damage to blood vessels via a number of mechanisms. Rupture of a major vessel is a rare, life-threatening sequelae of electrical injury.

Insulin granule recruitment and exocytosis is dependent on p110gamma in insulinoma and human beta-cells.

OBJECTIVE: Phosphatidylinositol 3-OH kinase (PI3K) has a long-recognized role in beta-cell mass regulation and gene transcription and is implicated in the modulation of insulin secretion. The role of nontyrosine kinase receptor-activated PI3K isoforms is largely unexplored. We therefore investigated the role of the G-protein-coupled PI3Kgamma and its catalytic subunit p110gamma in the regulation of insulin granule recruitment and exocytosis. RESEARCH DESIGN AND METHODS: The expression of p110gamma was knocked down by small-interfering RNA, and p110gamma activity was selectively inhibited with AS605240 (40 nmol/l). Exocytosis and granule recruitment was monitored by islet perifusion, whole-cell capacitance, total internal reflection fluorescence microscopy, and electron microscopy in INS-1 and human beta-cells. Cortical F-actin was examined in INS-1 cells and human islets and in mouse beta-cells lacking the phosphatase and tensin homolog (PTEN). RESULTS: Knockdown or inhibition of p110gamma markedly blunted depolarization-induced insulin secretion and exocytosis and ablated the exocytotic response to direct Ca(2+) infusion. This resulted from reduced granule localization to the plasma membrane and was associated with increased cortical F-actin. Inhibition of p110gamma had no effect on F-actin in beta-cells lacking PTEN. Finally, the effect of p110gamma inhibition on granule localization and exocytosis could be rapidly reversed by agents that promote actin depolymerization. CONCLUSIONS: The G-protein-coupled PI3Kgamma is an important determinant of secretory granule trafficking to the plasma membrane, at least in part through the negative regulation of cortical F-actin. Thus, p110gamma activity plays an important role in maintaining a membrane-docked, readily releasable pool of secretory granules in insulinoma and human beta-cells.