Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition.

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

The dorsal tangent line - A new approach in the radiological analysis of metacarpal fractures.

Traditionally, the angle between the intersecting central axes (lateral projection intersecting central axes - LCA) of the proximal and distal fragments of metacarpal fractures is measured on radiographs. We recommend using the angle between the intersecting dorsal tangent lines instead (lateral projection intersecting dorsal tangent lines - LDT). We analyzed radiographs of 25 fractures of the fifth metacarpal bone shaft in three planes. Intraclass correlation coefficients (ICC) were used to estimate inter-rater and intra-rater reliability. Mean palmar tilt was 35.6° ± 12.5° according to LCA and 27.6° ± 12.0° according to LDT. There were no differences during repeated measurements. Intra-rater reliability was high: ICC (95% CI) for LDT was 0.82 (0.74-0.88) and for LCA it was 0.71 (0.51-0.83). Mean values of palmar tilt using LCA exceeded those using LDT by 8.0° ± 7.7° (p < 0.001). Only LDT measurements provided comparable results between all raters. In conclusion, we demonstrated the feasibility and reliability of intersecting dorsal tangent lines for measuring palmar tilt in fifth metacarpal fractures as an alternative to the commonly used angle between the intersecting central axes.

Autoantibodies against P29ING4 are associated with complex regional pain syndrome.

INTRODUCTION: Complex regional pain syndrome (CRPS) is a complication following trauma or surgery and may be difficult to diagnose since biomarkers are lacking. Using protein array technology, we found antibodies binding to p29ING4, which we further characterized using ELISA. METHODS: Thirty-six sera of early-stage type 1 CRPS, 66 sera of rheumatoid arthritis (RA), 53 sera of axial spondyloarthritis (axSpA), 29 sera of psoriatic arthritis (PsA), 22 sera of patients after radial fractures (trauma control), and 100 sera of blood donors (BD) were analyzed for anti-p29ING4. We established ELISAs with 7 different antigens and using different secondary antibodies binding to IgG, IgG1, IgG2, IgG3, IgG4, IgA, and IgM, and 2 different tests to detect immune complexes (IC) of p29ING4 and IgG or IgG1. RESULTS: The highest likelihood ratios versus CRPS and trauma control were observed considering the A1-23 (sensitivity 19%, specificity 100%, LR > 19) using IgG as a secondary antibody, the A120-165 (sensitivity 17%, specificity 100%, LR = 17) using IgG as a secondary antibody and the A120-165 (sensitivity 31%, specificity 95%, LR = 6.2) using IgA as a secondary antibody. IC of p29ING4 and IgG were present in 11/36 (31%) CRPS sera, 17/64 (27%) RA sera, 13/53 (25%) SpA sera, 5/29 (17%) PsA sera, 1/22 (5%) trauma control sera, and 4/100 (4%) sera of BD. IC of p29ING4 and IgG1 were present in 14/36 (39%) CRPS sera, 19/64 (30%) RA sera, 13/53 (25%) SpA, 1/29 (3%) PsA, 2/22 (9%) trauma control, and 4/100 (4%) of the BD sera. CONCLUSION: Due to the lack of other biomarkers of type 1 CRPS, P29ING4 autoantibodies could be helpful in its diagnostic work-up.

[Histopathological classification principles of rheumatic joint diseases : Contribution of pathology to the diagnosis]. / Histopathologische Klassifikationsprinzipien rheumatischer Gelenkerkrankungen : Beitrag der Pathologie zur Diagnose.

Even though the diagnostics of rheumatic joint diseases are mostly based on clinical, immunoserological and imaging criteria, histopathology can also make a significant contribution. This is particularly true for clinically unclear monoarticular and periarticular diseases. The contribution of histopathology to the diagnosis of rheumatic diseases is manifold since the histopathological differential diagnosis includes the complete spectrum of synovial diseases. This heterogeneous pathogenetic spectrum is described in the joint pathology algorithm, which includes inflammatory and non-inflammatory diseases. To the latter group belong certain benign tumors such as the diffuse variant of the tenosynovial giant cell tumor, lipoma, hemangioma, vascular malformations and synovial chondromatosis. Additionally, the rare group of storage diseases should be kept in mind. Inflammatory diseases can be discriminated into crystal-induced arthropathies mainly such as gout and pseudogout, into granulomatous diseases such as tuberculosis and foreign-body inoculations, and finally into the large group of non-granulomatous, non-infectious synovitis. This large group is by far the most common, and it often causes difficulties in assigning the histopathological findings to a concrete rheumatologic diagnosis. In this context the synovitis score should be applied as a diagnostic device in these cases, leading to the diagnosis of a low-grade synovitis (which is associated with degenerative arthropathies) or of a high-grade synovitis (associated with rheumatic diseases). Identification of crystals and crystal-like deposits should be carried out with the application of the joint particle algorithm which addresses the identification of endogenous and non-endogenous particle deposits in the synovial tissues. Additionally, the synovitis-score may be used for evaluation of arthritis-progresssion and for the evaluation of inflammation-regression as a consequence of therapy with biologicals.

Establishing an optimal trajectory for calcaneotibial K-wire fixation in emergent treatment of unstable ankle fractures.

OBJECTIVE: In unstable ankle fractures the associated soft tissue damage can be a therapeutic challenge. The aim of this study was to optimize planning of minimally invasive stabilization of ankle fractures by calcaneotibial transfixation, which is a demanding technique due to the complex hind foot anatomy. METHODS: In a retrospective radiographic analysis the angles and dimensions of a safe drill tunnel for calcaneotibial K-wire insertion were defined on standard radiographs of the ankle joint. 165 lateral weight-bearing radiographs (77 right; 88 left) and 147 (80 right; 67 left) mortise views of 186 (90 right; 96 left) uninjured feet from 123 patients (74 women (114 feet); 49 men (72 feet)) were included in this study. The average patient age was 49 (range, 13-85) years. Inter- and intra-observer reliability was evaluated on 20 randomized radiographs that were analyzed in a default set, three times, by two different examiners on three different days. RESULTS: In the lateral view the drilling tunnel was orientated at 59.4° to the plantar plane with a maximum proximal variance of 7.1 image-mm. Distal variance cannot be tolerated since an ankle joint injury would ensue. In the mortise view the drill tunnel was directed with a mean angle of 18.4° to the distal tibial articular surface. At most a mean of 11° fibular- and 13.4° tibial- expansion can be tolerated. Intra- and inter-observer reliability was higher for the angles than for the drill corridors. CONCLUSION: The three-dimensional (3D) orientation for safe K-wire placement for calcaneotibial transfixation should adhere to the drill tunnels established in this study.

[Abdominal wall injury - risk of seat belt use]. / Bauchwandzerreißung - Risiko Sicherheitsgurt?

Abdominal seat belt marks can be an indication of abdominal wall rupture. The focused assessment with sonography for trauma (FAST) and computed tomography (CT) scanning are the diagnostic tools of choice in hemodynamically stable patients. The typical mechanism of trauma frequently leads to additional intra-abdominal injuries, spinal injuries and in some cases aortic rupture. Abdominal wall injuries of grade IV according to Dennis should be surgically treated. The increasing numbers of obese vehicle occupants and the resulting special risk of injury warrant optimization of technical restraint systems.

Union of the ulnar styloid fracture as a function of fracture morphology on conventional radiographs.

OBJECTIVE: In a retrospective radiological study, the authors aimed to detect the influence of fracture morphology on the union rate of ulnar styloid fractures associated with distal radial fractures. MATERIALS AND METHODS: Eighty-two out of 101 ulnar styloid fractures were included in the final statistical analysis. Initially, they were grouped into six different morphological types based on a novel classification system. They were also classified as per the established Fernández and Frykman classification systems. Furthermore, the initial ulnar styloid displacement was measured in conventional anteroposterior radiographs. Union of the ulnar styloid fracture was evaluated after at least 6 months of follow-up. RESULTS: The current investigators demonstrated that the various ulnar styloid fracture patterns have no significant predictive value for ulnar styloid union. In contrast, it could be attested, that an initial fragment dislocation of greater than 2.4 mm in the conventional AP radiographs has a significantly lower chance of successful union (p = 0.022). CONCLUSION: Initial displacement of the ulnar styloid should be measured in each distal radial fracture with a concomitant ulnar styloid fracture. This could be useful to inform the decision regarding surgical fixation of the ulnar styloid fragment in patients with an unstable distal radioulnar joint (DRUJ) or persistent symptoms at the ulnar aspect of the wrist.

The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid.

Two hundred distal radial fractures, with a mean follow up of 20 months (range 6-49), were divided into three groups according to the presence and healing status of an ulnar styloid fracture. The patients underwent both clinical and radiological examination and completed two different questionnaires. One hundred and one, of 200 distal radial fractures, were associated with an ulnar styloid fracture. Forty-six of these developed an ulnar styloid nonunion. The authors encountered significantly higher pain scores (ulnar sided pain p = 0.012), a higher rate of DRUJ instability (p = 0.032), a greater loss of motion and grip strength (p = 0.001), and a poorer clinical outcome in cases with an ulnar styloid fracture, but no differences were apparent when those with healed ulnar styloid fractures or ulnar styloid nonunions were compared (p > 0.05). The investigators propose that the incidence of ulnocarpal complaints following distal radial fracture depends on the presence but not the healing status of an ulnar styloid fracture.

[Adult onset septic coxitis : etiology, diagnostics, indication for and technique of open revision of the hip]. / Die septische Koxitis des Erwachsenen : Ätiologie, Diagnostik, Operationsindikation und Operationstechnik der offenen Hüftgelenkrevision.

Septic arthritis of the hip can be caused via a hematogenous route, by penetration of periarticular infections, open hip trauma, injections or operations. Ultrasound, hip puncture and elevation of inflammatory parameters lead to the diagnosis. Differentiation of septic arthritis from gout and chondrocalcinosis may be difficult. Nevertheless, early revision of the hip has to be performed to avoid joint destruction. Open revision is the therapy of choice in the majority of cases.

[Is routine implant removal after trauma surgery sensible?]. / Ist eine routinemäßige Implantatentfernung nach unfallchirurgischen Eingriffen sinnvoll?

We present a literature review about implant removal after operative extremity and spine fracture treatment. The indication for implant removal procedures has become less frequent in recent years, but is still more common in Europe than for example in North America. The time required to perform a implant removal can easily exceed the planned amount. Implant removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the implant should be made with great care. Therefore good communication with the patient and thorough information about risks and benefits are essential.

[Conservative functional treatment of Achilles tendon ruptures]. / Konservativ-funktionelle Behandlung der Achillessehnenruptur.

The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.