The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test.

De Quervain's disease has different clinical features. Different tests have been described in the past, the most popular test being the Eichhoff's test, often wrongly named as the Finkelstein's test. Over the years, a misinterpretation has occurred between these two tests, the latter being confused with the first. To compare the Eichhoff's test with a new test, the wrist hyperflexion and abduction of the thumb test, we set up a prospective study over a period of three years for a cohort of 100 patients (88 women, 12 men) presenting spontaneous pain over the radial side of the styloid of the radius (de Quervain tendinopathy). The purpose of the study was to compare the accuracy of the Eichhoff's test and wrist hyperflexion and abduction of the thumb test to diagnose correctly de Quervain's disease by comparing clinical findings using those tests with the results on ultrasound. The wrist hyperflexion and abduction of the thumb test revealed greater sensitivity (0.99) and an improved specificity (0.29) together with a slightly better positive predictive value (0.95) and an improved negative predictive value (0.67). Moreover, the study showed us that the wrist hyperflexion and abduction of the thumb test is very valuable in diagnosing dynamic instability after successful decompression of the first extensor compartment. Our results support that the wrist hyperflexion and abduction of the thumb test is a more precise tool for the diagnosis of de Quervain's disease than the Eichhoff's test and thus could be adopted to guide clinical diagnosis in the early stages of de Quervain's tendinopathy.

Treatment of a symptomatic trapezial dysplasia with metacarpal instability following thumb metacarpal lengthening with an addition-subtraction osteotomy.

The most important problem of trapezial dysplasia with thumb metacarpal instability is of bony origin. Together with the progressive capsuloligamentous decompensation it evolves in a progressive adduction deformity of the thumb metacarpal secondary to the dysplasia of the trapezium with its increased articular slope. The addition-subtraction osteotomy restores the anatomy combining two techniques: an abduction-extension osteotomy of the first metacarpal to correct the axis of the first metacarpal and an opening wedge osteotomy of the trapezium to reorientate the trapezial saddle. We present a case of an addition-subtraction osteotomy in a case of symptomatic trapezial dysplasia with metacarpal instability following a thumb metacarpal lengthening in a severely mutilated hand. This technique was especially effective in reducing the instability and pain but mainly in maintaining mobile the only remaining joint of the thumb.

Clinical and radiological outcomes of the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis with a minimum of 5 years of follow-up: a prospective single-centre cohort study.

We present the results of a 5 year prospective follow-up study on the functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Memometal, Stryker Corporate, Kalamazoo, Michigan, USA) in 22 patients. The female to male ratio was 21:1 and the mean age was 66 (range 54-78) years. The mean follow-up period was 67 (range 60-77) months after operation. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable to the contralateral thumb. Key pinch and grip strength improved by 13% and 31%, respectively. Overall function, according to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, improved by 59%. Pain decreased by 85% according to the numerical rating scale. Radiological evaluation revealed no loosening of the implant after 5 years except in one patient who required revision due to polythene wear with secondary joint instability. Another patient had asymptomatic polythene wear that required no revision but remains in follow-up. The 5 year overall survival of the prosthesis was 95%. These medium-term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal arthritis, because it appears to give a very good functional outcome and has the potential for long-term survival rates.

Vascularization of the trapeziometacarpal joint and its clinical importance: anatomical study.

Few studies have investigated the vascular anatomy of the trapeziometacarpal (TM) joint of the thumb. The aim of our study was to describe the supplying arteries of the trapezium and the TM joint since this knowledge is essential for trapezium osteotomies. Ten anatomical dissections in ten different cadavers using two different techniques (four macerations, six classic dissections) were performed. The arteries of the TM joint originated from the radial artery and the princeps pollicis artery. Four important branches were identified. The arteries formed a vascular network around the joint. The dorsoradial surface of the joint contained the richest arterial network. These findings present an important consideration when performing an osteotomy of the trapezium.

Addition-subtraction osteotomy with ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability.

Trapeziometacarpal instability with trapezial dysplasia is a disabling condition long before the radiological changes of osteoarthritis appear. In dysplastic joints surgical soft tissue correction fails to prevent the instability, requiring a correction of the bony anatomy. We combined two techniques described in the past, an abduction osteotomy of the first metacarpal and an opening wedge osteotomy of the trapezium, to which we added a ligament reconstruction. The combination of both osteotomy techniques restores the anatomy and centres the forces acting across the joint. We have done this procedure 21 times since 2003 in 18 patients. Seventeen thumbs were reviewed prospectively with a mean follow-up of 39 (range 16-65) months. Mean QuickDASH improved by 33.9 points, the key pinch improved by 1.8 kg and the grip strength improved by 8.7 kg. The visual analogue scale for pain improved from 7.9 preoperatively to 2 postoperatively. This technique preserves the trapeziometacarpal joint, allowing other techniques to be used if painful arthritis should develop in the middle to long term.

Calcification provides mechanical reinforcement to whale baleen alpha-keratin.

Hard alpha-keratins such as hair, nail, wool and horn are stiff epidermal appendages used by mammals in a variety of functions including thermoregulation, feeding and intraspecific competition. Hard alpha-keratins are fibre-reinforced structures consisting of cytoskeletal elements known as 'intermediate filaments' embedded in an amorphous protein matrix. Recent research has shown that intermediate filaments are soft and extensible in living keratinocytes but become far stiffer and less extensible in keratinized cells, and this stiffening may be mediated by air-drying. Baleen, the keratinous plates used by baleen whales during filter feeding, is an unusual mammalian keratin in that it never air dries, and in some species, it represents the most heavily calcified of all the hard alpha-keratins. We therefore tested the hypothesis that whale baleen is stiffened by calcification. Here, we provide, to our knowledge, the first comprehensive description of baleen material properties and show that calcification contributes to overcoming the shortcomings of stiffening this hard alpha-keratin without the benefit of air-drying. We also demonstrate striking interspecies differences in the calcification patterns among three species of baleen whales and provide novel insights into the function and evolution of this unusual biomaterial.

[Addition-subtraction osteotomy combined with ligamentoplasty for symptomatic trapezial dysplasia with instability]. / Traitement des dysplasies trapéziennes symptomatiques instables par ostéotomie d'addition-soustraction et ligamentoplastie.

INTRODUCTION: Trapezometacarpal instability with trapezial dysplasia is an incapacitating condition long before radiological changes appear. Most of the patients are young and demanding. Treatment is often conservative. Surgical treatment options are relatively classic, starting with a ligamentoplasty of the base of the first metacarpal or a tenotomy of the transarticular accessory slip of the abductor pollicis longus. Other options such as arthrodesis and arthroplasty have not been so successful in this situation. METHOD: The idea arose to combine two techniques described previously. In 1973 Wilson published his technique of abduction osteotomy of the first metacarpal as a treatment for basal osteoarthritis of the thumb. In 2002, Kapandji and Heim published their opening wedge osteotomy of the trapezium in order to correct the slope of a dysplastic trapezium. The combination of both of these techniques avoids closing of the first web by utilising the abduction osteotomy of the first metacarpal. Moreover, the opening wedge osteotomy corrects the dysplastic lateral rim of the trapezium by correcting its slope. RESULTS: We have been performing this technique since 2001 and 2005 in six patients. The preliminary results are encouraging, 5 of them were able to resume their work. A fair result was achieved in a young patient. DISCUSSION: The described technique is relatively easy and has the advantage of preserving the trapezometacarpal joint. In addition, it leaves the door open for other techniques if it eventually should fail in the long term.

Small bowel obstruction due to a persistent omphalomesenteric duct.

We report a case of a Meckel diverticulum connected with the umbilicus through a fibrotic cord causing small bowel obstruction. On admission, the patient presented with an acute abdomen. A plain upright radiography of the abdomen, an ultrasonography of the abdomen, and an enema with gastrografin were performed, showing a small bowel obstruction at the level of the pre-terminal ileum, without revealing the cause. Urgent surgery followed, showing a persistent omphalomesenteric duct connected to the abdominal wall through a fibrotic cord, with a secondary volvulus of the small bowel. The remnant was resected and the volvulus reduced. The post-operative course was uneventful. Because of the serious complications and even possible mortality due to ischemic disease of the affected small bowel the possibility of a complicated persistent omphalomesenteric duct should be kept in mind, even if the preoperative work-up does not reveal a Meckel diverticulum.