The use of resurfacing capitate pyrocarbon implants (RCPI) in chronic diseases of the wrist: outcomes of more than 100 cases.

INTRODUCTION: In advanced chronic post-traumatic wrist pathology, the goal of surgery has always been to reduce pain while trying to preserve the function of the wrist itself as much as possible; numerous interventions have been developed to achieve these goals (partial arthrodesis, 4-angle arthrodesis, the use of prosthetic implants…). PURPOSES: The purpose of the study is to evaluate outcomes and complications rate of proximal row carpectomy associated with the resurfacing capitate pyrocarbon implant (RCPI) for chronic diseases of the wrist. MATERIALS AND METHODS: A retrospective analysis of the patients operated on between June 2004 and March 2021 was performed. Pain, wrist range of motion in flexion, extension, radial and ulnar deviation and grip strength were compared preoperatively and at 1, 6, 12 and 24 months. Complications and additional procedures were recorded. RESULTS: A total of 112 patients underwent surgery for proximal row carpectomy and placement of RCPI with a mean follow-up of 6.6 years. Between the preoperative and the 2-year follow-up, a reduction in pain (VAS from 7.3 to 0.5), an increase in grip strength (from 8 to 17 kg) and an increase in ROM in all planes (flexion from 19° to 44°, extension from 20° to 46°, radial deviation from 7° to 14° and ulnar deviation from 13° to 28°) were recorded. Ten (8.9%) patients required additional surgery, with only 2 (1.8%) patients requiring revision of the implant. CONCLUSIONS: Proximal row carpectomy associated with RCPI is an excellent surgical strategy to relieve pain and to improve wrist range of motion and grip strength in patients with chronic diseases of the wrist.

Resurfacing Capitate Pyrocarbon Implant for the treatment of advanced wrist arthritis in the elderly: a retrospective study.

OBJECTIVE: Advanced forms of wrist osteoarthritis in the elderly are quite common and often under-treated, preferring a conservative management of the condition due to the age of the patient. However, in elderly people who are still active, sporty and physically demanding, surgical management of wrist osteoarthritis should be considered. Proximal Row Carpectomy associated with a Resurfacing Capitate Pyrocarbon Implant (RCPI), allows the management of a wide range of wrist arthrosis, involving both the radio-carpal and the mid-carpal joints. This treatment has been already reported as a solution in younger people affected by degenerative pathologies of the wrist, giving overall good results. Authors aimed at verifying how this technique could be useful in elderly patients, resolving the severe pain often related to this pathology and letting them recover strength and motion. PATIENTS AND METHODS: This is a retrospective analysis involving 7 cases of elderly men (mean age = 68 y.o.), suffering from severe wrist arthritis and treated with RCPI between 2016 and 2021. RESULTS: All patients reported a return to manual activities between 6 and 12 months after surgery, significantly improving pain. Two patients complained moderate pain under strain at follow-up, with residual difficulty in performing manual tasks. In all cases, an increase of strength and improvement in terms of stiffness was registered. No cases of infections or implant mobilization were reported. CONCLUSIONS: RCPI combined with proximal row carpectomy shows satisfying results in all published studies and it has been confirmed in our series as well. Indications for this procedure should be widened to elderly people, as useful alternatives to more aggressive salvage procedures, such as total prosthesis or arthrodesis.

Partial trapeziectomy and pyrocarbon interpositional implant (Pyrodisk) for trapeziometacarpal osteoarthritis in the active working population: outcomes of a 10 years-experience.

The treatment of trapeziometacarpal (TM) osteoarthritis is still debated, as many surgical options are available, and no technique has proven to be superior. Prosthetic treatment in this context has been described since the early 60s. Recently, the use of pyrolytic carbon-based prosthesis has revolutionized arthroplasty surgery in the hand. We performed a retrospective investigation of our surgical management of TM osteoarthritis since 2010 including the study only patients treated with partial trapeziectomy and Pyrodisk implant, with at least 5 years follow-up. After the application of inclusion criteria, 26 patients (6 males and 20 females) were retained. Despite the literature suggesting that implant TM surgery is well suited for older patients, in our experience, the procedure was mainly proposed to the young manual worker, with high demands in terms of thumb strength and stability (mean age of 53 years old, range 37-65). A statistically significant improvement in post-operative DASH, Kapandji and scores was observed. As well, strength measurements, particularly pinch strength and grip strength, increased significantly after the surgery. According to our findings, the Pyrodisk implant provides satisfactory results in terms of thumb strength and stability even in young and active patients and should therefore be considered as a valuable option in selected cases. Meticulous surgical procedure is mandatory in order to avoid complications and should therefore be executed by an expert surgeon. Abbreviation: IV: level of evidence.

Stage IV Kienböck's disease: Proximal row carpectomy and application of RCPI implant.

Kienböck disease is an aseptic osteonecrosis of the lunate, which gradually leads to total carpal collapse. Lichtman's classification relates radiographic evidence of wrist damage to four different stages and supports surgical decision-making. This study pertains to six patients (2 males and 4 females) affected by stage IV Kienböck's disease who underwent proximal row carpectomy and received an RCPI implant. The clinical outcomes consisted of wrist range of motion (ROM), pain on a VAS scale (0-10), the DASH score and the patient's level of satisfaction. The mean follow-up was 27.6 months (16-36). Pain relief and improvements in wrist flexion - extension ROM, radial - ulnar deviation and strength were achieved in every patient. There were no cases of implant failure or dislocation. Considering the good results obtained, we believe that proximal row carpectomy associated with the use of a pyrocarbon RCPI implant is a valid surgical technique for the treatment of stage IV Kienböck's disease. It is a good alternative to carpal fusion, which leads to wrist immobility, and to total wrist joint replacement, which has a high incidence of dislocation and fracture.

Personal technique for wrist dorsal approach.

In hand disorders surgical procedures are more and more widely used and often it's necessary to approach the wrist by the dorsal way. Beneath anatomy of this region is well known, there is still room enough to develop new surgical exposure techniques mostly related to physiology and biomechanics. Our goals are to present an innovative surgical dorsal exposure of the wrist, to show its use for different problems solving, and to evaluate its mini-invasive and functional outcome. Our inedited surgical technique is presented. Since November 1999 to February 2008, this technique has been used by the same surgeon in 60 cases for different pathologies and procedures: 14 SNAC-SLAC wrists III-IV treated by proximal row resection and Resurface-Capitate Pyrocarbon Implant (RCPI), 2 Fenton syndromes by bone graft and RCPI, 6 SNACSLAC II by proximal row resection +/- radial styloidectomy, 2 SLAC III by scaphoidectomy and capito-lunate arthrodesis, 12 scapho-lunate recent dissociations by ligamentoplasty (double approach), 4 scapho-lunate inveterate dissociations by Cuenod Saffar-Romano modified technique and 4 by synthetic ligaments, 1 fracture of the scaphoid proximal pole by synthesis-revascularization-S.L.ligament reconstruction, 15 Kienbock's diseases revascularized by II m.c. artery +/- radial osteotomy. Patients have been evaluated at follow up through the DASH disability questionnaire, the Mayo score for the force, ROM, pain, satisfaction grade. Results are good and encouraging for these applications. In conclusion this new technique with its limited exposure permits an early mobilization with a lower risk of stiffness and can be considered mini-invasive.

Salvage of a post-traumatic arthritic wrist using the scaphoid as an osteochondral graft.

The authors describe a case of post-traumatic wrist arthritis with an osteochondral defect in the scaphoid fossa of the radius. The patient was treated with proximal row carpectomy, radial styloidectomy and reconstruction of the defect using the proximal half of the scaphoid as an autologous osteochondral graft. Pain relief was achieved while wrist motion and strength were improved. The carpal bones are a source of osteochondral grafts and can be used to expand the indications of motion-preserving wrist salvage procedures.

The use of a pyrocarbon capitate resurfacing implant in chronic wrist disorders.

The present study describes the technique and results of proximal row carpectomy with resection of the head of the capitate and replacement with a pyrocarbon capitate resurfacing implant. The major indication for surgical treatment was arthritic changes on the head of the capitate. Patients were assessed by range of motion, grip strength, pain and functional scoring, and radiographic studies. In most patients, wrist function was improved and pain relief was obtained. This surgical procedure may represent a good alternative to total and partial wrist arthrodesis.

Chronic transscaphoid, transcapitate perilunate fracture dislocation of the wrist: Fenton's syndrome.

The authors report about chronic Fenton's syndrome. This rare injury of the wrist is characterized by scapho-capitate fracture accompanied by 180° rotation of the head of capitate and associated perilunate dislocation. Two patients suffering from chronic Fenton's syndrome were treated with pyrocarbon capitate resurfacing prosthesis. Patients were evaluated according to the wrist range of motion, Mayo modified wrist and DASH scores. In conclusion, prosthetic surgery may achieve satisfactory results for this rare and diagnostically challenging syndrome.

A comparative analysis of serologic parameters and oxidative stress in osteoarthritis and rheumatoid arthritis: reply to Mishra and colleagues.

In chronic diseases such as rheumatoid arthritis and osteoarthritis, the progression of the disease is characterized by stress oxidative, inflammation, and elevated levels of cholesterol. In mevalonate kinase deficiency, an auto-inflammatory disease, the correlation between inflammation and cholesterol levels is opposite. The metabolic pathway that underlies the production of cholesterol is the mevalonate pathway; it is also essential for the biosynthesis of isoprenoids involved in the control of several cell functions. This divergence of cholesterol levels, associated with these two inflammatory disorders, is probably due to a different etiology, pathogenesis, and progression.

Evolutionary hypothesis of the Mevalonate Kinase Deficiency.

Mevalonate Kinase Deficiency (MKD) is an autosomal-recessively inherited disorder of cholesterol biosynthesis with higher prevalence in the Netherlands and other North European countries. MKD is due to mutations in the second enzyme of mevalonate pathway (mevalonate kinase, MK/MVK) which results in reduced enzymatic activity and in the consequent shortage of downstream compounds. In most severe cases the deregulation of mevalonate pathway is associated with a decrease in serum cholesterol. More than 100 pathological mutations have been described in the MVK gene so far, and a founder effect has been hypothesized as responsible for the diffusion of the most frequent disease-associated mutations. In the acute phase of disease, patients affected with MKD present low cholesterol levels comparable to their basal physiologic conditions, already characterized by lower cholesterol levels when compared to healthy individuals. Low cholesterol levels are widely known to correlate with the reduction of cardiovascular events. We hypothesize a selective advantage for heterozygote carriers of the most frequent MVK mutations in those countries where the diet is characterized by high consumption of saturated animal fats rich in cholesterol. This could explain the maintenance in North European population of the main mutations leading to MKD and the distribution world-wide of these mutations that followed the migrations of North European populations.

[Scaphoidectomy (instead of trapezectomy) in the treatment of rhizoarthrosis. Report of a case]. / Scaphoïdectomie par erreur (à la place d'une trapézectomie) dans le traitement d'une rhizarthrose. À propos d'un cas.

INTRODUCTION: Surgery site errors and technical errors in hand surgery are rare and not often published. OBSERVATION: A 46-year-old patient with rhizoarthrosis of the left hand was initially treated by mistake in another center by a scaphoidectomy instead of a trapezectomy. She was seen in consultation 6months later, still suffering from her rhizoarthrosis and with carpal instability, clinically symptomatic and radiologically confirmed. The instability of the wrist was treated by a hamatocapito-lunar arthrodesis and a trapeziometacarpal arthrodesis was performed to treat the rhizoarthrosis. The clinical and radiological results were acceptable. DISCUSSION: Besides the paradigmatic error, this observation confirms that the excision of the scaphoid quickly leads to a destabilization of the wrist, the capitatum no longer maintaining its alignment under the lunatum, and leads to a limitation of the wrist mobility and a loss of strength. The hamato-capito-lunate arthrodesis described in 1997 can treat wrist instability and only the trapeziometacarpal arthrodesis can, in the absence of scaphoid, treat the problem of rhizoarthrosis. CONCLUSION: The authors recommend to always carry out a radiography of the wrist during trapezectomy surgery when there is doubt about the identification of the trapezium.

Ligamentous reconstruction of scapholunate dislocation through a double dorsal and palmar approach.

Six patients were treated for scapholunate dissociation by reconstruction of both the palmar and dorsal parts of the scapholunate interosseous ligament through a combined palmar and dorsal approach. The mean active range of motion of the wrist at final follow-up was 44 degrees of flexion and 58 degrees of extension and the mean hand grip strengths was 88% of that of the contralateral hand. The average time to return to work was 105 days and the mean DASH score at a mean follow-up of 32 months was 18. At follow-up, radiographs showed maintenance of the anatomical reduction of the scapholunate articulation in all cases and the scapholunate angle was normal in five patients.

Leiomyoma of the hand: a case report.

We report a case of leiomyoma of the finger in the right hand of a 12-year-old boy: a rare site for localization and unusual for age. This is a benign tumor originating from non-striated muscle that is very uncommon in the hand. The uterus is considered the most common location for leiomyoma and when it occurs in the extremities, it is more common in the leg, ankle and foot. It usually occurs in the third and fourth decades of life and it is rarely diagnosed before surgery as the diagnosis can only be confirmed histologically.

Megaesophagus in an asthmatic patient and beta2 stimulant treatment by inhalation.

Megaesophagus is a severe esophageal malformation. We report a case of megaesophagus in an asthmatic patient affected by congenital non-haemolytic anaemia and undergoing beta2 stimulant treatment by inhalation. Our case could be due to chronic beta2 receptor stimulation with imbalance of alpha and beta receptor, without any implication of favism.

Osteoid osteoma of the hand and wrist.

Eighteen cases of osteoid osteoma of the hand and wrist were treated between 1985 and 1999. The diagnosis was confirmed pre-operatively with X-rays, bone scintigraphy, CT, and MRI, and all the diagnoses were later confirmed by histological examination. The authors highlight the difficulties in the diagnosis of the osteoid osteoma of the hand and wrist. An accurate clinical history and a high index of suspicion are required. Three phase bones scans are highly sensitive for osteoid osteoma and should be used in conjunction with CT examination to facilitate diagnosis and pre-operative planning. All the patients were treated surgically, by removal of the tumour, with complete resolution of all symptoms.

Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand.

OBJECTIVE: To assess the utility of toe-to-finger transfers (TFTs) for post-traumatic reconstruction of the fingerless hand. DESIGN: A case series. SETTING: A regional trauma centre. PATIENTS: Eight men, mean age was 36 years (range from 25-59 yr), who had lost all the fingers from a hand due to a crush-degloving injury (6 patients), frostbite (1 patient) or a burn injury (1 patient). INTERVENTION: TFT. Twelve TFTs were cone and the mean time from injury to reconstruction was 17.2 months. MAIN OUTCOME MEASURES: Objective (range of motion, moving 2-point discrimination, grip strength, key pinch, Jebsen-Taylor hand assessment, return to work) and subjective (activities of daily living and a questionnaire) measures. RESULTS: Eleven of the 12 transfers survived. Six of the 7 in whom the transfer was successful were available for follow-up (mean 45 mo). Range of motion was 10 degrees at the distal interphalangeal joint, 18 degrees at the proximal interphalangeal joint and 59 degrees at the metacarpophalangeal joint. Sensation was protective in all. Grip strength and key pinch were 26.1% and 70.2% of the contralateral hand respectively. Jebsen-Taylor assessment indicated that basic activities were possible but slowed. All 6 patients returned to work and could perform 92.6% of the activities of daily living unassisted. Hand and foot symptoms were mild. Two-thirds were appearance conscious, 5 of the 6 went on to altered vocations and all reported overall satisfaction as high. CONCLUSION: This study supports TFT for reconstruction of the fingerless hand in that, although transferred toe function may be poorer than a normal finger, the hand is restored to a useful, sensate and versatile functional unit, such that global hand and patient function, as well as patient satisfaction, are very good.

A role of p75 in NGF-mediated down-regulation of the A(2A) adenosine receptors in PC12 cells.

Nerve growth factor (NGF) induces differentiation of the rat pheochromocytoma clone (PC12) by activating the high affinity receptor, p140(trkA), linked to mitogen-activated protein kinase. While the physiological role of the low affinity NGF receptor (p75) has not been clearly defined, this receptor promotes activation of nuclear factor (NF) kappaB in Schwann cells. PC12 cells express the A(2A) adenosine receptor (AR), whose expression is significantly decreased by NGF treatment. In this study, we determined whether TrkA or p75 is involved in NGF-mediated regulation of A(2A)AR expression. NGF treatment decreased A(2A)AR in a time-dependent manner, with maximal effects observed by 1 day, and continued down-regulation of the receptor for up to 3 days in the presence of NGF. The decrease in A(2A)AR was associated with a more delayed decrease in the steady-state levels of the A(2A)AR mRNA. Down-regulation of the A(2A)AR at 1 day was mimicked by activators of NFkappaB, such as H(2)O(2), and ceramide, and was attenuated by the inhibitor pyrrolidine dithiocarbamate or following transient transfection of PC12 cells with a dominant negative IkappaBalpha mutant. Moreover, NGF stimulated nuclear accumulation of p65 subunits of NFkappaB (but not p50 subunits) in PC12 cells, as determined by electrophoretic mobility shift assays and by Western blotting. In contrast, inhibition of TrkA by AG879 or of TrkA-dependent mitogen-activated protein kinase mitogen-activated protein kinase kinase with PD98059 blocked PC12 cell differentiation without affecting A(2A)AR down-regulation, suggesting dissociation between these two phenomena. Taken together, these data provide strong support for the involvement of the p75/NFkappaB pathway in NGF-mediated down-regulation of A(2A)AR in PC12 cells.

Oxidative stress increases A1 adenosine receptor expression by activating nuclear factor kappa B.

The A1 adenosine receptor (A1AR) contributes to the cytoprotective action of adenosine under conditions known to generate reactive oxygen species (ROS). Pharmacological manipulation of A1AR expression has been shown to modulate this cytoprotective role. In this study, we provide evidence that ROS generated could increase the expression of the A1AR and thereby offset the detrimental effects of ROS. Incubation of DDT1MF-2 smooth muscle cells with ROS-generating chemotherapeutic agents, such as cisplatin (2.5 microM) or H2O2 (10 microM), elicited an increase in A1AR expression within 24 hr. The induction by H2O2 was reduced by the ROS scavenger catalase but not superoxide dismutase. Inhibition of nuclear factor kappa B (NF kappa B) by pyrrolidine dithiocarbamate (200 microM), dexamethasone (100 nM), or genistein (1 microM) abrogated the cisplatin-mediated increase in A1AR. Cisplatin promoted rapid translocation of NF kappa B (but not AP-1) to the nucleus, as detected by electrophoretic mobility shift assays and by Western blotting. A putative NF kappa B sequence in the A1AR promoter effectively competed with labeled kappa B probe for binding in nuclear preparations derived from DDT1MF-2 cells. Transient transfection of DDT1MF-2 cells with the A1AR promoter coupled to firefly luciferase reporter gene led to cisplatin-inducible and pyrrolidine dithiocarbamate-sensitive luciferase activity, suggesting the presence of functional NF kappa B binding site(s) in the A1AR promoter sequence. Treatment of cells with (R)-phenylisopropyladenosine (1 microM), an agonist of the A1AR, reduced cisplatin-mediated lipid peroxidation, which was reversed after blockade of the A1AR. These data suggest that ROS can increase the expression of the A1AR by activating NF kappa B regulatory site(s) on this gene and thereby enhance the cytoprotective role of adenosine.