Visualization and reduction of a mensical capsular junction tear in the knee: an arthroscopic surgical technique.

Meniscal injuries commonly occur concomitantly with anterior cruciate ligament (ACL) injuries. Although many types of meniscal injuries have been described in the literature, there has not been much focus on meniscal capsular junction (MCJ) tears. This lack of attention is concerning given that, in a survey of 67 orthopedic surgeons, 88% indicated that MCJ tears could be a source of chronic pain. In addition, we reviewed 781 ACL reconstructions at our clinic and found a 12.3% incidence of MCJ tear with primary ACL injury and a 23.6% incidence of MCJ tear with revision ACL reconstruction. In this article, we describe an arthroscopic repair technique for MCJ tears at the posterior aspect of the medial meniscus root. The repair uses an accessory posterior medial portal. The technique can also be used for significant posterior medial capsular tears.

In vivo pilot study evaluating the thumb carpometacarpal joint during circumduction.

BACKGROUND: Analysis of arthrokinematics may have clinical use in the diagnosis of dynamic instability of the thumb and wrist. Recent technological advances allow noninvasive, high-resolution imaging of skeletal (thumb and carpal bones) structures during motion. QUESTIONS/PURPOSES: The primary purpose of this study is to define the arthrokinematics, estimated joint contact patterns, and distribution ratios of the carpometacarpal joint of the thumb using four-dimensional CT (three-dimensional CT + time) and registration algorithms. The second purpose is to validate the accuracy of the approach. METHODS: Four-dimensional CT scans were obtained using a nongated sequential scanning technique. Eighteen image volumes were reconstructed over a 2-second cycle during thumb circumduction in one healthy volunteer. Using a registration algorithm, serial thumb motions as well as estimated joint contact areas were quantified. To evaluate the accuracy of our approach, one cadaveric hand was used. RESULTS: During circumduction, the ranges of motion of the thumb carpometacarpal joint were: flexion-extension, 27.3°; adduction-abduction, 66.9°; and pronation-supination, 10°. The magnitude of the translation of the center of the estimated joint contact area of the metacarpal was 4.1, 4.0, 1.0, and 1.5 mm when moving from the initial key pinch position to adduction, adduction to palmar abduction, palmar abduction to opposition, and opposition to the initial key pinch position, respectively. The maximum estimated contact area on the trapezium and on the metacarpal was in palmar abduction; the minimum was in adduction. Dominant central-volar contact patterns were observed on both the trapezium and the metacarpal bone except in adduction. This analysis approach had an average rotational error of less than 1°. CONCLUSIONS: During circumduction, the estimated joint contact area was concentrated on the central-volar regions of both the trapezium and the metacarpal bones except when the thumb was adducted. CLINICAL RELEVANCE: This tool provides quantification of estimated joint contact areas throughout joint motion under physiological dynamic loading conditions; this tool may, in future studies, help to clarify some of the ways that joint mechanics might or might not predispose patients to arthritis.

Vitamin D deficiency in cord plasma from multiethnic subjects living in the tropics.

BACKGROUND: Vitamin D deficiency is commonly reported in high-latitude areas and in dark-pigmented individuals. However, nothing is known about vitamin D in cord blood from multiethnic subjects living in the tropics. OBJECTIVE: Our study objective was to determine the prevalence of vitamin D deficiency in summer and winter in cord blood from multiethnic individuals in Hawai'i where sufficient sun irradiance occurs year-round for cutaneous vitamin D production. METHODS: 25-Hydroxyvitamin D (25(OH)D) levels were quantified by enzyme immunoassay in 100 cord plasma samples from apparently healthy full-term newborns and their mothers. Stratification was performed by birth season and ethnicity. RESULTS: Mean 25(OH)D levels were 24.5 ng/mL (9.1-68.3 ng/mL). Overall, 28% of samples were vitamin D deficient (<20 ng/mL) and 50% were insufficient (20-30 ng/mL). 25(OH)D levels (ng/mL) were highest in Caucasians (30.5, n = 19), followed by Asians (25.1, n = 43), Hispanics (21.5, n = 3), Pacific Islanders (20.0, n = 25), and African Americans (19.6, n = 2). Differences among groups were significant (p = 0.008). Cord plasmas from summer versus winter were higher overall (p = 0.001) and among Asians (p = 0.0003). Seasonal changes were correlated with sun irradiance overall (r = 0.43, p = 0.0001), among Caucasians (r = 0.45, p = 0.05), and among Asians (r = 0.45, p = 0.0001). CONCLUSION: Our results suggest that prenatal supplement recommendations of 400 IU vitamin D/day do not protect against vitamin D deficiency, even in subjects living in the tropics where ample sun irradiance exists for cutaneous vitamin D synthesis. The high prevalence of vitamin D deficiency we observed emphasizes the necessity for regular 25(OH)D monitoring, particularly during pregnancy and lactation, in dark-pigmented individuals, and during winter months.

Compound f: the history of hydrocortisone and hand surgery.

Hydrocortisone (cortisol) is used daily in the practice of medicine and hand surgery. It has an effective use in a number of orthopedic conditions, including tendinitis, tenovaginitis, bursitis, carpal tunnel syndrome, and joint inflammation. But are surgeons aware of how this important pharmaceutical agent was discovered and prepared for clinical trial and who was responsible for its first clinical application? How did medical doctors determine that, like penicillin, cortisone and its derivative hydrocortisone would have such a life-changing effect on certain medical conditions? The purpose of this review is to relate the story of the development of cortisone (Compound E) and hydrocortisone (Compound F) and how both influenced the practice of hand surgeons in the treatment of rheumatoid arthritis and related inflammatory conditions. This history of cortisone and hydrocortisone also relates to the importance of partnership between physician and research scientist and of the principle at Mayo Clinic that the only concern--or the first concern--is the concern for the patient.

Long-term outcomes of proximal interphalangeal joint surface replacement arthroplasty.

BACKGROUND: Surface replacement arthroplasty is a reconstructive alternative for the treatment of pain and deformity due to osteoarthritis and rheumatoid arthritis of the proximal interphalangeal joint of the finger. This retrospective study was performed to examine long-term outcomes of proximal interphalangeal joint prosthetic surface replacement with a proximal cobalt-chromium (CoCr) and distal ultra-high molecular-weight polyethylene component over thirty years at a single institution. METHODS: Sixty-seven prostheses were implanted in forty-seven patients between 1974 and 2007. The mean duration of follow-up was 8.8 years. There were fifty joints (75%) with osteoarthritis and seventeen (25%) with rheumatoid arthritis. Fifty-six prostheses (84%) were implanted via a dorsal approach, forty-eight (72%) were cemented, and nineteen (28%) were press-fit. Postoperative evaluation, consisting of a clinical history and examination, radiographs, the Short Form-36 (SF-36) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires, and a visual analog scale (VAS) pain score, was performed for thirty-six patients. Demographic, surgical, and implant failure data were obtained from the medical charts of eleven patients (sixteen implants) who had died prior to the time of postoperative follow-up. RESULTS: At the time of follow-up, the median total active proximal interphalangeal joint motion was 40°. Eight prostheses had failed, yielding a cumulative incidence of implant failure of 3% at one year, 8% at three years, 11% at five years, and 16% at fifteen through twenty-five years. Prostheses implanted via a volar approach failed more often than those implanted via a dorsal approach (relative risk: 6.59, p = 0.004). The failure rate did not differ significantly between patients with rheumatoid arthritis and those with osteoarthritis (p = 0.17). The median VAS pain score at the time of follow-up was 3 (of a maximum of 100). There were twenty-two complications in fourteen patients, resulting in four interphalangeal fusions and two amputations. There were no infections. CONCLUSIONS: Proximal interphalangeal surface replacement arthroplasty is a reliable treatment alternative for pain and deformity due to proximal interphalangeal joint osteoarthritis and rheumatoid arthritis. At the time of long-term follow-up, pain was minimal and joint motion was similar to preoperative levels.

Total wrist replacement: a retrospective comparative study.

Purpose Total wrist arthroplasty (TWA) is an evolving procedure for the treatment of arthritis of the wrist joint. The purpose of this study is to compare outcomes of three different total wrist implants. Methods A retrospective review of the Biaxial, Universal 2, and Re-Motion total wrist arthroplasties was performed. Patients were evaluated for clinical outcome, radiographic analysis, review of complications (incidence and type), and conversion to wrist fusion. Patient function measures included: the Mayo wrist score, the Patient Related Wrist Evaluation, and Disabilities of Arm, Shoulder, and Hand (DASH) score. Results Forty-six wrist implants were performed in 39 patients. There were 36 rheumatoid and 10 posttraumatic cases. The average follow-up was 6 years (3.5 to 15). The total wrist inserted included 16 resectional arthroplasties (Biaxial) and 30 resurfacing designs (Universal 2 and Re-Motion). Nine implant failures were noted. Causes for arthroplasty failure included distal component implant loosening and wrist instability. Salvage procedures included revision TWA or wrist fusion. In successful cases, flexion and extension motion averaged 30 and 38 degrees, respectively, and grip strength improved by 3 kg. Mayo wrist scores, in successful cases, increased from 40 (preoperative) to 76 (postoperative). The Mayo wrist scores for posttraumatic conditions averaged 87 points versus 71 points for rheumatoid arthritis. The average DASH score for the two resurfacing designs were 20 and 37, and 48 for the resectional arthroplasty design. Discussion Total wrist replacement maintains itself and provides good pain relief and functional motion in over 80% of all cases and in 97% of resurfacing implants. Better results were correlated with improved distal component fixation and minimal resection of the distal radius. Level of Evidence Level 3 Case Control.

Current concepts and treatment for the rheumatoid wrist.

Wrist involvement in rheumatoid arthritis (RA) is common. Within 2 years of diagnosis, more than half of patients will have wrist pain, and more than 90% will have wrist disease by 10 years. Although wrist involvement is generally thought to be less disabling than RA of the fingers and hand, it can be a significant cause of pain and disability. Severe disease with bony destruction and synovitis in the wrist can also result in soft-tissue problems including tendon ruptures. In addition to musculoskeletal involvement, systemic manifestations of RA can occur. Felty syndrome can result in a low white blood count and splenomegaly in association with RA. New generation, disease-modifying pharmacologic agents offer promise in controlling the disease progression. Surgical treatments for the diseased wrist are aimed at relieving pain and restoring function. Common procedures include: synovectomy and tenosynovectomy, tendon reconstruction, distal ulnar resection and/or distal radioulnar joint reconstruction, partial and full wrist arthrodesis, and total wrist arthroplasty.

Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: a case series.

BACKGROUND: Chronic longitudinal radioulnar dissociation has been associated with unpredictable and generally unfavorable outcomes. Metallic radial head replacement may address this treatment deficiency. METHODS: Eight patients were treated with a metallic radial head replacement for chronic longitudinal radioulnar dissociation. The average treatment delay was 3.3 years. All eight patients were seen for a clinical and radiographic assessment. RESULTS: Five of the 8 failed after a mean of 3 years (range, 1-5.7). Revision to bipolar metallic radial head replacement was successful in the short term in 2 of 3 that failed from aseptic loosening. One of 2 failures due to painful radiocapitellar arthritis was salvaged with a capitellar replacement. DISCUSSION: Reconstruction for symptoms following an Essex-Lopresti injury remains problematic. A metallic radial head implant appears to be an effective adjunct, but not a perfect solution in all patients. Recognition of the negative impact of residual lateral ulnar collateral ligament laxity is an important observation and should be specifically addressed with the reconstructive procedure. CONCLUSION: Metallic monoblock radial head replacement did not reliably address the functional deficiency from chronic radioulnar dissociation primarily due to malalignment and implant loosening. A cemented bipolar radial head implant may provide a better alternative as a long-term solution. Regardless, ligamentous integrity at the elbow should also be addressed at the time of the reconstruction.

Radial head fractures and the role of radial head prosthetic replacement: current update.

Radial head fractures are often secondary to a direct axial force, such as that involved in motor vehicle accidents and falls on an outstretched hand. The Hotchkiss-modified Mason classification is an excellent assessment tool in that it provides commonly accepted direction regarding treatment. For more unstable, comminuted displaced radial head fractures that cannot be reconstructed, replacement of the radial head is warranted. The surgeon should attempt open reduction and internal fixation with restoration of the radial head in anatomical alignment for most type II and some type III fractures, and this treatment is recommended over radial head resection without replacement, as the latter is associated with both elbow and forearm instability over the long term and should be avoided. New radial head replacement designs, including bipolar designs and radial head and capitellar replacements, are available but have limited reported clinical results.

Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears.

PURPOSE: To determine whether traumatic triangular fibrocartilage complex (TFCC) tears treated by arthroscopic repair have improved functional outcome scores, range of motion, grip strength, and pain relief compared with those repaired using an open surgical technique. METHODS: From 1997 to 2006, 75 patients had repair of traumatic TFCC tears. Thirty-six patients had arthroscopic TFCC repair, and 39 patients had open repair. One patient was lost to follow-up. Evaluation included range of motion, grip strength, preoperative and postoperative Mayo Modified Wrist Score (MMWS), and patient-reported Disabilities of the Arm, Shoulder, and Hand score and visual analog scale score. Data were analyzed using chi-square tests or 2-sample t-tests; significance was set at p < .05. RESULTS: Mean follow-up was 43 months +/- 11. Mean MMWS improved 6.5 points +/- 19.9 after surgery. Fifty-seven percent of patients improved at least 1 level in the MMWS pain score. No statistical difference was found between open and arthroscopic repair in the improvement of MMWS or visual analog scale pain scores. There was increased postoperative nerve pain (ulnar nerve branch) in the open group (14 out of 39 patients) compared with the arthroscopic group (8 out of 36 patients), but this was not found to be statistically significant. Reoperation for distal radioulnar joint instability was performed in 17% of patients. No statistical association was observed between surgery type and the rate of reoperation for instability. Female gender was significantly associated with a higher rate of total reoperation. CONCLUSIONS: There was no statistical difference in clinical outcomes after open versus arthroscopic TFCC repair. Although not statistically significant, there was an increased rate of postoperative superficial ulnar nerve pain in the open group (14 out of 39 patients) compared with the arthroscopic group (8 out of 36 patients). After TFCC repair, 13 out of 75 patients required reoperation for distal radioulnar joint instability in this sample. A statistically significant association was found between reoperation rate and female gender.