A management strategy for giant cell tumor of the metacarpal: A single-center series of 11 cases.

BACKGROUND: Primary giant cell tumor (GCT) arising from bones of hand are rare to occur. Metacarpals are often the most common site of involvement among hand bones. There are no uniform guidelines for treatment of GCT involving metacarpals due to lack of relevant literature. OBJECTIVE: To suggest a management strategy for GCT involving metacarpals. METHODS: Retrospective review of cases of GCT involving metacarpals over a period of 15 years from 2005 to 2019 managed at department of Orthopaedics, All India Institute of Medical Sciences, New Delhi. RESULTS: A total of 12 cases of GCT involving metacarpal were included, out of which one was lost to follow-up. Four cases were recurrent, and seven were primary at the time of surgery. All the patients were operated with wide excision of the tumor. In seven patients reconstruction of the metacarpal and MCPJ was done using fibular strut graft and silastic artificial joint, while in two patients, MCPJ arthrodesis was performed using fibula and/or iliac crest bone graft. In another two patients, the MCPJ was reconstructed using reversed vascularised toe transfer. Mean follow up of the patients was 3.22 ± 2.07 years. Mean Quick DASH score at latest follow-up of patients operated with silastic joint reconstruction, reversed vascularised toe transfer and arthrodesis of MCP joints were 30.5 ± 9.5, 25 ± 2.3 and 39.8 ± 3.4 respectively. Local recurrence occurred only in one patient at one year after surgery. All the patients were pain free at latest follow-up with quite functional and cosmetically acceptable hand. CONCLUSION: Reversed vascularised metatarsal transfer has obtained better functional results compared to reconstruction with fibular grafting and silicone joint replacement but due to technical difficulties, vascularised joint transfer may not be performed in every setting and there is risk of donor site morbidities with this technique. Our strategy for the treatment of GCT involving metacarpal was to do vascularised joint transfer or arthrodesis for border digits and reconstruction with silicone joint for central digits.

Comparison of Magnetic Resonance Arthrography and Wrist Arthroscopy in the Evaluation of Chronic Wrist Pain in Indian Population.

BACKGROUND: The purpose of our study was to compare magnetic resonance arthrography (MRA) as a diagnostic modality against the gold standard of wrist arthroscopy in the evaluation of chronic wrist pain. MATERIALS AND METHODS: Thirty three patients with chronic wrist pain suspected to have ligament injuries of the wrist were prospectively recruited. They underwent MRA examinations followed by wrist arthroscopy. Arthroscopic findings were compared with radiological findings focusing on three important structures - triangular fibrocartilage complex (TFCC), scapholunate ligament (SLL), and lunotriquetral ligament (LTL). RESULTS: For the 17 patients with TFCC tears/perforations on arthroscopy, MRA gave a sensitivity (SEN) = 88%, specificity (SPE) = 87.5%, positive predictive value (PPV) = 88%, and negative predictive value (NPV) = 87.5%. For the 13 patients with SLL tears on arthroscopy, MRA gave SEN = 77%, SPE = 100%, PPV = 100%, and NPV = 87%. For the 7 patients with LTL tears on arthroscopy, MRA gave SEN = 29%, SPE = 100%, PPV = 100%, and NPV = 84%. A composite correlation between findings on MRA and wrist arthroscopy revealed an overall SEN = 73%, SPE = 96%, PPV = 93%, and NPV = 85% for MRA, with overall accuracy = 88%. CONCLUSIONS: The presented diagnostic results of MRA are superior to those of magnetic resonance imaging quoted in literature. MRA is a potent tool for evaluating chronic wrist pain but tends to miss lesions of intrinsic carpal ligaments (SLL and LTL) more than TFCC. Wrist arthroscopy may be recommended when the clinical suspicion is strong.

Glomus tumours of the hand: Review of literature.

Glomus tumours are rare benign vascular neoplasms commonly found in the hand particularly in subungual region. Though, its aetiology remains largely unknown, several hypotheses have been made to explain the etiopathogenesis and cause of pain. These tumours usually present as a bluish or pinkish red discolouration of the nail plate with classical triad of localised tenderness, severe pain, and cold sensitivity. Nevertheless, differential diagnosis of other painful tumours, such as leiomyoma, eccrine spiradenoma, haemangioma, neuroma, osteochondroma, or mucous cyst should always be kept in mind while evaluating a patient with severe pain in the tip of the finger. In addition to the different clinical tests including Love's pin test, Hildreth's test, and trans-illumination test, imaging studies such as magnetic resonance imaging (MRI), ultrasonography, and radiography are often helpful in the diagnosis. Complete surgical excision is a must to get complete relief from the symptoms and to avoid recurrence. Several approaches have been described in the literature. Different surgeons may have different choices and may prefer one approach over the other depending on the anatomical location of the tumours. The purpose of this article is to review the important aspects of glomus tumours in hand concerning their aetiology, clinical presentation, diagnosis, management, and recurrence.

Mother's fibula in son's forearm: use of maternal bone grafting for aneurysmal bone cyst not amenable to curettage - a case report with review of literature.

It has always been a challenge to reconstruct large bone gaps. The aim of this case report is to highlight the success of homologous maternal bone grafting in a large cystic lesion. A six and half years old boy presented to us with an aneurysmal bone cyst (ABC) of the right radius, not amenable to curettage. We excised the lesion in toto, which created an 11 cm bone loss. Considering the age of the patient, we reconstructed the bone gap with maternal fibular graft. Accordingly, 12 cm of fibular graft was harvested and fashioned to fit into the bone gap. It was fixed with an intramedullary K-wire. No cancellous graft was used in the procedure. The limb was kept in the above elbow cast till incorporation of the fibula was noted on the radiographs. Six months following surgery the skiagram showed that the fibula was incorporated. Mobilization of the elbow and wrist was started along with strengthening of the forearm muscles. K-wire was removed at nine months. At the latest follow up of 24 months, the fibula is fully incorporated, the child regained full range of motion and strength of elbow. We discuss the techniques adopted in this particular case along with the review of literature.

Comparison of conventional MRI and MR arthrography in the evaluation wrist ligament tears: A preliminary experience.

AIMS: To compare conventional magnetic resonance imaging (MRI) and direct magnetic resonance (MR) arthrography in the evaluation of triangular fibrocartilage complex (TFCC) and intrinsic wrist ligament tears. MATERIALS AND METHODS: T1-weighted, fat suppressed (FS) proton density plus T2-weighted (FS PD/T2), 3D multiple-echo data image combination (MEDIC) sequences and direct MR arthrography were performed in 53 patients with wrist pain. Images were evaluated for the presence and location of TFCC, scapholunate ligament (SLL) and lunatotriquetral ligament (LTL) tears, and imaging findings were compared with operative findings in 16 patients who underwent arthroscopy or open surgery (gold standard). RESULTS: SIXTEEN PATIENTS UNDERWENT ARTHROSCOPY/OPEN SURGERY: 12 TFCC tears were detected arthroscopically out of which 9 were detected on FS PD/T2 sequence, 10 on MEDIC sequence, and all 12 were detected on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in the detection of TFCC tears were 75%, 83.3%, and 100%, respectively. Out of the eight arthroscopically confirmed SLL tears, three tears were detected on FS PD/T2 sequence, five on MEDIC sequence, and all eight were visualized on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in detecting SLL tears were 37.5%, 62.5%, and 100%, respectively. One arthroscopically confirmed LTL tear was diagnosed on FS PD/T2 sequence, three on MEDIC sequence, and all five arthroscopically confirmed LTL tears were detected with MR arthrography. The sensitivities of PD, MEDIC sequences, and MR arthrography in detecting LTL tears were 20%, 40%, and 100%, respectively. CONCLUSIONS: MR arthrography is the most sensitive and specific imaging modality for the evaluation of wrist ligament tears.

Ewing's Sarcoma of the Sacroiliac Joint Presenting as Tubercular Sacroiliitis: A Diagnostic Dilemma.

We report a case of Ewing's sarcoma of the sacroiliac joint in a 21-year-old male mimicking tubercular sacroiliitis, a rare entity not reported in literature. He presented with pain in the lower back radiating to the right lower limb along with constitutional symptoms of 3 months duration. On examination, the right sacroiliac joint was tender. The laboratory investigations showed anaemia, leukocytosis and raised erythrocyte sedimentation rate. On X-ray, features of right sacroiliitis were seen. This was further investigated with magnetic resonance imaging (MRI), which showed features consistent with tubercular sacroiliitis. Patient was then started on antitubercular treatment, but the improvement was not consistent. So, a contrast MRI was done, which indicated features of primary sarcoma. It was then further confirmed by a computed tomography-guided biopsy, which showed features consistent with Ewing's sarcoma of the sacroiliac joint.

Primary repair of capsuloligamentous structures of trapeziometacarpal joint: A preliminary study.

BACKGROUND: Isolated trapezio-metacarpal joint dislocation is uncommon and challenging since controversy still exists regarding its management. DESCRIPTION: We present a short case series in which direct repair of trapezio-metacarpal ligaments was done in three patients who had isolated, unstable dislocation of the thumb carpometacarpal joint. All of them were engaged in tasks where no compromise in hand functions and grip strength was affordable. The dislocation was addressed primarily by repair of volar oblique and dorsoradial ligaments with suture anchors. The joint was immobilised in a cast for 4 weeks followed by gradual mobilisation. RESULTS: At an average follow up of 15 months, all the three patients have no restriction in the range of motion. There are no symptoms and signs of instability. In two patients, there is no pain at all; while one patient has occasional pain which is mild and does not interfere with the hand function. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis. CONCLUSION: Repair of the capsuloligamentous complex with suture anchors may be considered as a treatment option in unstable trapezio-metacarpal joint dislocations in high demand patients.

Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study.

The aim of the study is to find whether there is any superiority of the iliac crest bone graft over the distal radius bone graft, in surgery of nonunion of scaphoid fractures. This is a prospective randomized controlled trial comparing 50 patients treated with internal fixation and distal radius bone graft (group 1) and 50 patients in whom iliac crest bone graft was used instead (group 2). The patients donor site pain in the postoperative period was assessed using visual analogue scale. At each follow-up, each patient was evaluated using Quick DASH score and Mayo's scoring system. Minimum follow-up was 3 years. Mean value of visual analogue scale for pain was 7.1 for group 2 and 4.2 for group 1. There was no statistically significant difference between the two groups in terms of range of wrist joint motion, functional scores, union rate and fracture reduction. There is no advantage of the iliac crest over the distal radius graft to justify its greater morbidity.

Triple jeopardy: transscaphoid, transcapitate, transtriquetral, perilunate fracture dislocation.

Carpal injuries are frequently underdiagnosed and underreported injuries of the hand. Scapholunate perilunate dissociation is the most common perilunate instability pattern seen in clinical practice. Transscaphoid, transtriquetral, transcapitate dislocation with a volar intercalated segment instability pattern is a very rare pattern of carpal injury. We describe a case with this unique pattern of injury, explaining its mechanism and treatment. Good outcome can be achieved in these injuries following open reduction and internal fixation with ligamentous repair.

Clinical comparative study: efficacy and tolerability of tolperisone and thiocolchicoside in acute low back pain and spinal muscle spasticity.

STUDY DESIGN: We performed a multicentric, randomized, comparative clinical trial. Eligible patients were randomly assigned to receive 150 mg of Tolperisone thrice daily or 8 mg of Thiocolchicoside twice daily for 7 days. PURPOSE: To assess the efficacy and tolerability of Tolperisone in comparison with Thiocolchicoside in the treatment of acute low back pain with spasm of spinal muscles. OVERVIEW OF LITERATURE: No head on clinical trial of Tolperisone with Thiocolchicoside is available and so this study is done. METHODS: The assessment of muscle spasm was made by measuring the finger-to-floor distance (FFD), articular excursion in degrees on performing Lasegue's maneuver and modified Schober's test. Assessment of pain on movement and spontaneous pain (pain at rest) of the lumbar spine was made with the help of visual analogue scale score. RESULTS: The improvement in articular excursion on Lasegue's maneuver was significantly greater on day 3 (p = 0.017) and day 7 (p = 0.0001) with Tolperisone as compared to Thiocolchicoside. The reduction in FFD score was greater on day 7 (p = 0.0001) with Tolperisone. However there was no significant difference in improvement in Schober's test score on day 3 (p = 0.664) and day 7 (p = 0.192). The improvement in pain score at rest and on movement was significantly greater with Tolperisone ((p) = 0.0001). CONCLUSIONS: Tolperisone is an effective and well tolerated option for treatment of patients with skeletal muscle spasm associated with pain.

Staged reduction of neglected transscaphoid perilunate fracture dislocation: a report of 16 cases.

BACKGROUND: Transscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome. MATERIAL & METHODS: 16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1 mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation. RESULTS: The mean duration between two surgeries was 2.4 weeks (range 2-4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results. CONCLUSION: Staged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.

Zone 2 flexor tendon injuries: Venturing into the no man's land.

Flexor tendon injuries are seen commonly yet the management protocols are still widely debated. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics have resulted in better outcomes. There has been a trend toward the active mobilization protocols with development of multistrand core suture techniques. Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2.

Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial.

A prospective, randomised, controlled trial was performed to compare the outcome of treatment of unstable trochanteric fractures with either a short proximal femoral nail antirotation (PFNA) or dynamic hip screw (DHS). Eighty one patients with unstable fracture of the proximal part of the femur were randomised, at the time of admission, for fixation with either a short PFNA (n=42) or DHS (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Clinical and radiological follow-up was undertaken for a minimum of 36 months. Any changes in the position of the implant or fixation failure were recorded. Hip range of motion, pain in the hip or thigh and return to work were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. The mean operative time was significantly less in PFNA group (25 min) than in the DHS group (38 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. Six patients in DHS group had implant failure while none experienced this in PFNA group. The PFNA group had a better functional outcome than the DHS group.

Giant cell tumour of the tendon sheath of the hand.

PURPOSE: To review outcomes of 106 patients after complete excision of the giant cell tumour of the tendon sheath of the hand, with or without postoperative radiotherapy. METHODS: Records of 77 women and 29 men aged 11 to 61 (mean, 31) years who underwent excision of giant cell tumours of the tendon sheath of the hand were reviewed. All patients presented with gradually progressive swelling; only 3 of them also presented with pain. The lesions were located on the dorsal aspect (n=11), the palmar aspect (n=66), both aspects (n=10), or circumferentially (n=14). No patient had multiple lesions. Five patients had bony erosion and 3 had neurovascular bundle involvement. RESULTS: The mean follow-up period was 12 (range, 4-22) years. 56 patients with well-encapsulated giant cell tumour in the palmer and/or dorsal aspects were classified as at low risk of recurrence. The remaining 50 patients were classified as at high risk of recurrence and underwent postoperative radiotherapy. None of the patients at low risk had any recurrence; 4 of those at high risk had recurrence despite radiotherapy. No complication was attributable to the irradiation, except that 3 patients had some dark pigmentation around the wound scar. CONCLUSION: Postoperative radiotherapy may have a role in reducing recurrence of the giant cell tumour of the tendon sheath of the hand.

Nontraumatic osteonecrosis of the distal pole of the scaphoid.

Post traumatic osteonecrosis of distal pole of scaphoid is very rare. We present a case of 34 years old male, drill operator by occupation with nontraumatic osteonecrosis of distal pole of the scaphoid. The patient was managed conservatively and was kept under regular follow-up every three months. The patient was also asked to change his profession. Two years later, the patient had no pain and had mild restriction of wrist movements (less than 15 degrees in either direction). The radiographs revealed normal density of the scaphoid suggesting revascularization.

Radiolabeled oligosaccharides nanoprobes for infection imaging.

Breast milk oligosaccharides act as soluble receptors for different pathogens which protect the newborn child from infection. The differentiation between loosening of prosthesis due to infective pathology septic or otherwise aseptic plays an important role in the patient management. We have labeled hydroxypropyl-ß-cyclodextrin, oligosaccharide derivative, with technetium-99m ((99m)Tc-HPßCD). The quality control of (99m)Tc-HPßCD was done by ITLC and characterized by electron microscopy and (1)H-nuclear magnetic resonance. The route of excretion of (99m)Tc-HPßCD nanoparticulate radiopharmaceutical was assessed in rats. Nanoparticles (99m)Tc HPßCD were injected in human subjects with clinically confirmed infected knee joints. Docking studies were done for ligand - protein interaction. The (99m)Tc-HPßCD was stable with good radiochemical yield (>98%) at pH 4.0 and 6.5. For single patient dose, 0.5-1.0mg HPßCD quantity was sufficient. (99m)Tc HPßCD was observed to form nanoparticles of 60-180 µm. The (1)H NMR studies revealed the binding of (99m)Tc at C-8/H-8 position of HPßCD. The excretion of (99m)Tc HPßCD showed renal route of excretion. Docking studies demonstrated the interaction between HPßCD and bacterial maltose binding protein (MBP). The differentiation between septic and aseptic loosening was also evident on single photon emission tomography (SPET). In conclusion, these data indicated that (99m)Tc HPßCD is a promising radiopharmaceutical and may serve as molecular nanoprobe for infection imaging.

Idiopathic bilateral acetabular labral ossification.

Acetabular labral ossification is an uncommon condition. We present a case of bilateral idiopathic acetabular labral ossification with no predisposing factor. The differential diagnosis of its plain radiographic appearance is discussed.