Proximal Trapezoidectomy and Scaphotrapezoid Joint Tendon Interposition at the Time of Ligament Reconstruction and Tendon Interposition for Pan Trapezial Osteoarthritis Does Not Increase Proximal Carpal Row Malalignment.

Background Surgical options for osteoarthritis (OA) of the first carpometacarpal include excision, replacement arthroplasty, and arthrodesis. However, in pan trapezial OA, optimal management of residual scaphotrapezoidal articulation has remained unclear. Purpose The purpose of this study was to evaluate whether removing the proximal trapezoid from the scaphotrapezoid joint (STJ) and interposing tendon when performing a ligament reconstruction and tendon interposition (LRTI) for pan trapezial arthritis resulted in any clinical or radiographic compromise compared with LRTI alone in isolated carpometacarpal joint arthritis. Methods In a prospective consecutive cohort, 122 thumbs were selected to generate two matched cohorts and a cross-sectional review was completed at an average of 24 months (range: 5-203 months). Fifty-six thumbs had LRTI alone and 66 thumbs also had resection of the proximal portion of the trapezoid with tendon interposition in the residual gap. Results The cohorts showed no significant differences in subjective and objective outcome measures and imaging. Excision of the STJ was not associated with poorer clinical outcomes or the development of a dorsal intercalated segment instability deformity. Conclusions The management of pan trapezial arthritis with LRTI and proximal trapezoid excision and STJ interposition appears satisfactory on short- to medium-term clinical and radiographic follow-up. Level of Evidence: This is a Level III, consecutive cross-sectional cohort study.

Correlation of magnetic resonance and arthroscopy in the diagnosis of shoulder injury.

BACKGROUND: Advances in shoulder magnetic resonance imaging (MRI) and arthrography (MRA) have revolutionised musculoskeletal diagnosis and surgical planning. Despite this, the overall accuracy of MRI, with or without intra-articular contrast, can be variable. METHODS: In this prospective non-randomised analysis, 200 participants (74.5% males) with suspected shoulder injuries underwent MRI (41.0%) or MRA followed by arthroscopy. A study specific proforma was developed to ensure consistency of reporting by radiologists and surgeons. The reports were compared to assess the predictive power of MRI/MRA. Specific assessment of rotator cuff tendon appearance, long head of biceps (LHB) tendon appearance, position and anchor, subacromial space, glenoid labrum and humeral cartilage grade were included. RESULTS: Shoulder MRA demonstrated a higher agreement with arthroscopy than MRI for supraspinatus, infraspinatus and subscapularis tendon appearance (κ = 0.77 vs. κ = 0.61, κ = 0.55 vs. κ = 0.53 and κ = 0.58 vs. κ = 0.46 respectively). There were also superior agreement rates with MRA compared to MRI for LHB tendon appearance (κ = 0.70 vs. κ =0.54) and position (κ = 0.89 vs. κ = 0.72). As an overall assessor of shoulder pathology we found significantly higher total agreement scores when MRA was used (p = 0.002). DISCUSSION: Whilst magnetic resonance imaging with arthrography is an extremely useful tool to assess underlying pathological shoulder states it does not confer 100% accuracy. In cases whereby this modality is inconclusive, an examination under anaesthesia and diagnostic arthroscopic assessment for the detection of intra-articular shoulder pathology may be considered.

Clinical features and outcomes of young patients with head and neck non-rhabdomyosarcoma soft tissue sarcomas.

BACKGROUND: The history, prognostic factors, and outcome of young patients with head and neck non-rhabdomyosarcoma soft tissue sarcoma (NRSTS) have not been adequately characterized. METHODS: Medical records of 58 patients with head and neck NRSTS treated at St. Jude Children's Research Hospital were reviewed. RESULTS: The majority of tumors were ≤5 cm and high grade. Lymph node and/or distant metastases were present in 17% at presentation. Patients received a combination of surgery, chemotherapy, and radiotherapy. The 10-year event-free and survival rates were 53.1% ± 7.3% and 63.2% ± 7.1%, respectively. Features associated with inferior survival included high histologic grade (p = .006), tumor diameter >5 cm (p < .001), invasiveness (p < .001), and incomplete resection at diagnosis (p = .005). CONCLUSION: Most head and neck NRSTS in young patients are small, high grade, and nonmetastatic. The outcome is poor compared to NRSTS at other anatomic sites. Innovative approaches to local control and improved systemic therapy are needed.

Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures.

PURPOSE: To assess the safety and efficacy of 2 concurrent injections of collagenase clostridium histolyticum (CCH) in the same hand to treat multiple Dupuytren flexion contractures. METHODS: In a multicenter, open-label phase IIIb study, 60 patients received two 0.58-mg CCH doses injected into cords affecting 2 joints in the same hand during 1 visit, followed by finger extension approximately 24 hours later. Efficacy at postinjection day 30 (change in flexion contracture and active range of motion, patient satisfaction, physician-rated improvement, and rates of clinical success [flexion contracture 5° or less]) and adverse events were summarized. RESULTS: The concurrent injections were most commonly administered in cords affecting metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints on the same finger (47%) or 2 MCP joints on different fingers of the same hand (37%). Mean total (sum of the 2 treated joints) flexion contracture decreased 76%, from 87° to 24° (MCP joints: 86%; PIP joints: 66%). Mean total range of motion increased from 100° to 161°. Clinical success was 76% for MCP joints and 33% for PIP joints. Most patients were very satisfied (60%) or quite satisfied (28%) with treatment. Most investigators rated treated joints as very much improved (55%) or much improved (37%). The most common treatment-related adverse events (> 75% of patients) were contusion, pain in extremity, and edema peripheral (local edema). Most adverse events were mild to moderate in severity. Serious complications included 1 pulley rupture related to study medication and 1 flexor tendon rupture (following conclusion of the study). There were no systemic complications. CONCLUSIONS: Results suggest that 2 affected joints can be effectively and safely treated with concurrent CCH injections. There was an increased incidence of some adverse events with concurrent treatment (pruritus, lymphadenopathy, blood blister, and skin laceration) compared with treatment of a single joint. High degrees of patient satisfaction and physician-rated improvement were reported. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Multiple concurrent collagenase clostridium histolyticum injections to Dupuytren's cords: an exploratory study.

BACKGROUND: Dupuytren's contracture (DC) is a progressive fibroproliferative disorder characterized by development of nodules and collagen cords within the palmar fascia of the hand. Collagenase clostridium histolyticum (CCH) is currently approved in adults with DC for the nonsurgical treatment of a single palpable cord during a 30-day treatment cycle. This open-label pilot study was designed to examine the safety, efficacy, and multiple-dose pharmacokinetics of injecting two cords (affected joints) with multiple doses of CCH concurrently into the same hand in subjects with DC and multiple contractures. METHODS: Twelve subjects with DC were enrolled, each with ≥3 contractures caused by palpable cords. Efficacy assessments were taken 30 days after treatment and adverse events (AEs) were recorded throughout. In the first treatment period, all subjects were injected with a single dose of CCH (0.58 mg) into a single cord. The same subjects entered a second treatment period 30 days later, where two different cords (affected joints) were injected concurrently on the same hand. A finger extension procedure was performed 24 hours after each administration of CCH to disrupt the enzymatically weakened cord. RESULTS: For metacarpophalangeal (MP) joints, mean contracture reduction per joint treated was 29.0 ± 20.7 degrees following single injection vs 30.3 ± 10.9 degrees per treated joint following multiple injections. For proximal interphalangeal (PIP) joints, mean reduction in contracture was 30.7 ± 21.1 and 22.1 ± 4.9 degrees per treated joint, respectively, for the two periods. All patients (100%) were either "quite satisfied" or "very satisfied" following either treatment cycle. The most common treatment-related AEs were edema peripheral, contusion, and pain in the treated extremity; the differences in severity for local effects of the injections were minimal between treatment periods. No serious treatment-related AEs or systemic complications were reported. CONCLUSION: These results provide preliminary evidence that two cords (affected joints) can be treated concurrently with CCH with similar efficacy and safety as cords treated individually in a sequential fashion. Multiple concurrent injections would eliminate the 30-day wait between single treatments and allow for rapid and effective treatment of patients with multiple affected joints, a significant advantage for both patient and physician. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry #ACTRN12610001045000.

Transmastoid extradural-intracranial approach for repair of transtemporal meningoencephalocele: a review of 31 consecutive cases.

OBJECTIVE: To review the clinical presentation, surgical techniques, and outcomes of the transmastoid extradural-intracranial (TMEDIC) approach for the treatment of transtemporal meningoencephalocele. HYPOTHESIS: The TMEDIC is a safe and effective approach to repair meningoencephalocele originating from the middle or posterior cranial fossa. STUDY DESIGN: Retrospective chart review. SETTING: Academic neurotologic tertiary referral center. PATIENTS: Thirty-one consecutive patients diagnosed with transpetrous meningo(encephalo)cele, with or without cerebrospinal fluid leak, between January of 2003 and October of 2010. INTERVENTION: TMEDIC approach for repairing herniated neural tissue through the tegmen or posterior fossa plate using the combination of autologous cartilage, fascia, and tissue sealant. MAIN OUTCOME MEASURES: Anatomic location, size, and number of defects, presence of herniated brain tissue, pre- and postoperative hearing thresholds, and failure rate. RESULTS: Mean age was 62 ± 26 years. The etiology was spontaneous in 25/31 (80%), congenital in 3/31 (10%), chronic otitis media in 2/31 (6%), and posttraumatic in 1/31 (4%). Posttympanostomy tube clear otorrhea was the presenting sign in 21/31 (68%) of patients. The mean duration of symptoms was 26 months (range: 1-240). The defect involved the middle fossa (MF) floor in 25/31 (90%). Both the tegmen tympani and mastoideum were involved in 12/31 (39%) of patients and multiple dehiscences were seen in 7/31 (22%). In 17/31 (55%) of cases the size exceeded 1 cm. No recurrences were seen. CONCLUSION: The TMEDIC is a safe and effective method to repair transtemporal meningoencephalocele obviating the need for a middle fossa craniotomy in certain cases.

Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren's disease.

PURPOSE: The Collagenase Option for the Reduction of Dupuytren's (CORD) II study investigated the efficacy and safety of injectable Xiaflex (collagenase clostridium histolyticum), in patients with Dupuytren's contracture. METHODS: This was a prospective, randomized, placebo-controlled trial with 90-day double-blind and 9-month open-label phases. We randomized patients with contractures affecting metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joints 2 to 1 to collagenase (0.58 mg) or placebo. Cords received a maximum of 3 injections. Cord disruption was attempted the day after injection using a standardized finger extension procedure. Primary end point was reduction in contracture to 0° to 5° of normal 30 days after the last injection. RESULTS: We enrolled 66 patients; 45 cords (20 MCP to 25 PIP joints) received collagenase and 21 cords (11 MCP to 10 PIP joints) received placebo in the double-blind phase. Statistically significantly more cords injected with collagenase than placebo met the primary end point (44.4% vs 4.8%; p <. 001). The mean percentage decrease in degree of joint contracture from baseline to 30 days after last injection was 70.5% ± 29.2% in the collagenase group and 13.6% ± 26.1% in the placebo group (p < .001). The mean increase in range of motion was significantly greater in the collagenase (35.4° ± 17.8°) than in the placebo (7.6° ± 14.9°; p < .001) group. Efficacy after open-label treatment was similar to that after the double-blind phase: 50.7% of all joints achieved 0° to 5° of normal. More patients were satisfied with collagenase (p < .001). No joint had recurrence of contracture. One patient had a flexion pulley rupture and one patient underwent routine fasciectomy to address cord proliferation and sensory abnormality. No tendon ruptures or systemic allergic reactions were reported. Most adverse events were related to the injection or finger extension procedure. CONCLUSIONS: Collagenase clostridium histolyticum is the first Food and Drug Administration-approved, nonsurgical treatment option for adult Dupuytren's contracture patients with a palpable cord that is highly effective and well tolerated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Scaffold-free tissue-engineered cartilage implants for laryngotracheal reconstruction.

OBJECTIVES/HYPOTHESIS: Donor site morbidity, including pneumothorax, can be a considerable problem when harvesting cartilage grafts for laryngotracheal reconstruction (LTR). Tissue engineered cartilage may offer a solution to this problem. This study investigated the feasibility of using autologous chondrocytes to tissue-engineer scaffold-free cartilage grafts for LTR in rabbits to avoid degradation that often arises from an inflammatory reaction to scaffold carrier matrix. STUDY DESIGN: Animal study. METHODS: Auricular cartilage was harvested from seven New Zealand white rabbits, the chondrocytes expanded and loaded onto a custom-made bioreactor for 7 to 8 weeks to fabricate autologous scaffold-free cartilage sheets. The sheets were cut to size and used for LTR, and the rabbits were sacrificed 4, 8, and 12 weeks after the LTR and prepared for histology. RESULTS: None of the seven rabbits showed signs of respiratory distress. A smooth, noninflammatory scar was visible intraluminally; the remainder of the tracheal lumen was unremarkable. Histologically, the grafts showed no signs of degradation or inflammatory reaction, were covered with mucosal epithelium, but did show signs of mechanical failure at the implantation site. CONCLUSIONS: These results show that autologous chondrocytes can be used to fabricate an implantable sheet of cartilage that retains a cartilage phenotype, becomes integrated, and does not produce a significant inflammatory reaction. These findings suggest that with the design of stronger implants, these implants can be successfully used as a graft for LTR.

Head and neck cancer: an overview.

Ablative surgery for malignancies of the upper aerodigestive tract is the most common reason why the reconstructive surgeon is called upon to reconstruct adult head and neck defects. An understanding of the pathophysiology and treatment of head and neck malignancy is vital to the reconstructive surgeon so that restoration of both form and function can be achieved. It is important to understand the behavior of cancers of each head and neck subsite, as staging and ultimately the treatment of tumors from each subsite is different. Historically, the standard treatment of head and neck cancer was surgery and/or primary radiation therapy with surgical salvage for failure. Beginning in the 1980s, advances in chemotherapy and concurrent delivery with radiation offered new options to standard surgical therapy. Over the past two decades, the concept of organ preservation using chemotherapy together with radiation therapy has been definitively established. Yet, even with the strides made over these two decades with chemoradiation, surgical treatment of head and neck cancer and reconstruction thereof will be an important treatment option for the foreseeable future. Therefore, the relationship between the extirpative and reconstructive surgeon is vital, and a clear understanding of the biology and behavior of head and neck malignancy is crucial to successful patient outcomes.

Tissue-engineered trachea for airway reconstruction.

OBJECTIVES/HYPOTHESIS: Scaffold-free cartilage has been used to engineer biocompatible and mechanically stable neotracheas in vivo. The purpose of this animal study was to determine if neotracheal constructs, implanted paratracheally, could successfully be used for segmental tracheal reconstruction. STUDY DESIGN: Animal study. METHODS: Culture-expanded auricular rabbit chondrocytes were used to engineer scaffold-free cartilage sheets. Cartilage and a strap muscle flap were wrapped around a tube and implanted paratracheally. At 12 to 14 weeks postimplantation neotracheas were used to reconstruct 20 mm tracheal defects. Surgical technique was modified several times in an attempt to decrease the amount of neotracheal obstruction and fibrosis. In one of the six rabbits, neotrachea with its intact strap muscle flap was dropped into the defect followed by an end-to-end anastomosis; in two animals the muscle flap was partially, and in one rabbit completely removed. In two animals the muscle flap was partially removed, the tube reinserted, and the construct reimplanted for 5 weeks to allow formation of a fibrous lining over the exposed cartilage followed by tracheal reconstruction. RESULTS: All implants developed into vascularized and mechanically sound neotracheas. Following reconstruction, none of the animals showed immediate signs of respiratory distress; however, one died after 24 hours due to extensive endotracheal muscle flap edema, whereas rabbits who had undergone partial or complete muscle flap removal survived up to 39 days before developing cicatricial stenosis. CONCLUSIONS: Tissue-engineered neotracheas proved to have excellent biocompatibility and stability to function under physiologic conditions, but lacked adequate endotracheal lining resulting in neotracheal stenosis.

Cyclooxygenase products stimulate carbon monoxide production by piglet cerebral microvessels.

Products of arachidonic acid (AA) metabolism by cyclooxygenase (Cox) are important in regulation of neonatal cerebral circulation. The brain and cerebral microvessels also express heme oxygenase (HO) that metabolizes heme to carbon monoxide (CO), biliverdin, and iron. The purpose of this study in newborn pig cerebral microvessels was to address the hypothesis that Cox products affect HO activity and HO products affect Cox activity. AA (2.0-20 microM) increased prostaglandin E2 (PGE2) measured by radioimmunoassay (RIA) and also CO measured by gas chromatography/mass spectrometry (GC/MS). Further, 10(-4) M indomethacin, which inhibited Cox, reduced both AA and heme-induced CO production. Conversely, neither exogenous 2 x 10(-6) M heme, which markedly increased CO production, nor the inhibitor of HO, chromium mesoporphyrin, altered PGE2 synthesis. Because AA metabolism by Cox generates both prostanoids and superoxides, we determined the effects of the predominant prostanoid and superoxide on CO production. Although PGE2 caused a small increase in CO production, xanthine oxidase plus hypoxanthine, which produces superoxide, strongly stimulated the production of CO by cerebral microvessels. This increase was mildly attenuated by catalase. These data suggest that Cox-catalyzed AA metabolites, most likely superoxide and/or a subsequent reactive oxygen species, increase cerebrovascular CO production. This increase seems to be caused, at least in part, by the elevation of HO-2 catalytic activity. Conversely, Cox activity is not affected by HO-catalyzed heme metabolites. These data suggest that some cerebrovascular functions attributable to Cox activity could be mediated by CO.