[Osteoid Osteoma of the Upper Extremity]. / Osteoidní osteom v oblasti horní koncetiny.

PURPOSE OF THE STUDY Osteoid osteoma (OO) of the upper extremity is a rare pathology representing a major diagnostic challenge. The patients are often times incorrectly treated due to a misdiagnosis and therefore the final management of symptoms is delayed by several months. During this time the pain, which is the main symptom, increases. The surgical treatment is a fast and efficient solution. This paper aims to highlight the specificity of the OO of the upper extremity, evaluate our study group, the time to diagnosis and the benefits of individual imaging techniques. MATERIAL AND METHODS In the period 2007-2017, a total of 8 patients with a histologically verified OO of the upper extremity were consulted and treated at the authors departments. The group of patients was retrospectively evaluated based on the medical reports, surgical protocols, imaging examinations, histology results of preoperative samples and a postoperative questionnaire. Pain was assessed on the Visual Analogue Scale (VAS) preoperatively, at 2 weeks, 2 months and at one year postoperatively and in January 2018. The mean follow-up period was 48 months (range 16-78). The presence of swelling, synovitis and a limited range of motion were clinically assessed. The removed tissue was tested in an accredited biopsy laboratory. RESULTS 8 patients with OO of the elbow, wrist and hand were treated in the period 2007-2017. In 5 cases the OO was located in the wrist (scaphoid, 2x trapezoid, hamate and capitate) and in 2 cases in finger phalanges (middle and distal phalanx). The mean age of the patients was 24.5 years (median 21.5, range 18-42). The male to female ratio was 7:1. The mean interval between the onset of symptoms and the final diagnosis was 16.25 months (median 15.5, range 12-25). The CT examination proved to be the most beneficial imaging techniques. A plain radiograph led to a diagnosis in 1 case only. The preoperative mean pain VAS value 9.25 dropped to VAS 1 at two weeks after the surgery. No recurrence was reported. DISCUSSION The main challenge in treating the OO of the upper extremity is the diagnosis. Despite of the availability of advanced imaging techniques, the interval from the onset of symptoms to correct diagnosis did not change over the past decades. As to the treatment, despite the development of new procedures the method of choice continues to be the surgical excochleation. CONCLUSIONS Osteoid osteoma of the upper extremity is a rare pathology which shall be considered in case of an increasing pain, especially in young men. A plain radiograph of the anatomically complex terrain of the hand and wrist is mostly not useful in diagnosis, whereas the CT examination can visualise even a small size nidus. The surgical excochleation results in pain relief and early functional recovery with swelling disappearance. To diagnose the OO is not difficult provided we take it into consideration. Key words:osteoid osteoma, upper extremity, hand, wrist, diagnosis.

[Surgical Treatment for Advanced Rhizarthrosis. Comparison of Results of the Burton-Pellegrini Technique and Trapeziometacarpal Joint Arthroplasty]. / Srovnání výsledku operacní lécby rhizartrózy metodou interpozicní artroplastiky dle Burtona-Pellegriniho a implantací trapeziometakarpální endoprotézy.

PURPOSE OF THE STUDY: The aim of the study was to compare results of the Burton-Pellegrini trapeziectomy with ligamentoplasty using the flexor carpi radialis tendon with those of trapeziometacarpal joint replacement in the treatment of advanced rhizarthrosis. MATERIAL AND METHODS: A group of 17 patients, 15 men and two women, underwent trapeziectomy with ligamentoplaty; in 12 of them, the dominant hand was involved. The trapeziometacarpal joint prosthesis Beznoska was implanted in 11 patients (10 men and one woman) with seven dominant and four non-dominant hands. All patients pre-operatively experienced pain during thumb movement and hand grip. They were examined before surgery and at 3, 6 and 12 months after it; the values obtained before and at 1 year after surgery were compared. The methods of evaluation included pain intensity assessed using the visual analogue scale (VAS), the Kapandji thumb opposition test and the disabilities of the arm, shoulder and hand (DASH) score (total DASH score and its thumb-targeted module). RESULTS: In the group treated by the Burton-Pellegrini procedure, the average pre- and post-operative Kapandji scores were 6.4 and 8.9, respectively. The average VAS scores were 5/10 pre-operatively and 1/10 post-operatively. The average values for the total pre- and post-operative DASH scores were 58 and 19 points, respectively. The DASH score in a thumb-targeted module assessing basal joint-loading in the thumb was 63 points before and 21 points after surgery. In the patients with total joint replacement, the average pre- and post-operative values were as follows: Kapandji score, 7.4 and 9.8; VAS score, 5/10 and 1/10; total DASH score, 56 and 7 points; thumb module DASH score, 60 and 11 points. Two serious complications were recorded, an infection in resection interposition arthroplasty and a trauma associated with total joint replacement loosening. Four patients showed transient paresthesia. DISCUSSION: Several methods for surgical treatment of rhizarthrosis are available today. Arthrodesis is still a widely used procedure although it inhibits thumb movements. Resection arthroplasty provides sufficient pain-free thumb motion, but radial shortening and a loss of grip strength are its disadvantages. Resection interposition arthroplasty results in sufficient painless motion. Tendon interposition provides enough stability for the thumb and for sufficient grip and pinch strength. The disadvantages of this method include a potential for failure of the suspensory tendon during over exercising or a weakened attachment of the autologous tendon to the bone and thus a risk of rupture. Total joint replacement respects the thumb anatomy, preserves the articular capsule and fibrous structures during conservative resection of joint surfaces and keeps the biomechanics of the basal joint of the thumb. It combines advantages of the other surgery procedures, by allowing for a painless range of motion in the joint and vital pinching and gripping abilities, while avoiding their disadvantages such as movement restriction and loss of grip strength. However, the technique may still bear any of the risks associated with foreign material implantation (dislocation, replacement failure, infection, etc.). CONCLUSIONS: The two techniques present valuable contributions to the treatment of advanced rhizarthrosis. In our patients, better outcomes are shown in trapeziometacarpal joint replacement though, in comparison with resection interposition arthroplasty, the indication criteria for this surgery are limited by factors such as the height of the trapezium bone and bone quality necessary for good osseointegration.