Arthroscopic synovectomy of the metacarpophalangeal joint in refractory rheumatoid arthritis: a technique.

Arthroscopic synovectomy was performed on 29 metacarpophalangeal joints belonging to 21 patients with refractory rheumatoid arthritis. This article describes the method of anesthesia, landmarks, and operative technique. Short-term (12-month) results and patient satisfaction have been excellent. No complications were noted. We conclude that arthroscopic synovectomy of the metacarpophalangeal joints in patients with refractory rheumatoid arthritis can be performed safely and effectively. Possibilities for improvement of the technique as well as possible uses of the technique in research are discussed.

Metacarpophalangeal arthroscopy.

Although small joint arthroscopy has become commonplace over the past decade, relatively little attention has been paid to the investigation and clinical utility of metacarpophalangeal (MP) joint arthroscopy. The literature is scant in this area and consists of only a handful of case reports. In addition, the arthroscopic anatomy of the MP joint has not as yet been reported. Six cadaveric hands (24 joints) were rigorously studied in the laboratory using standard 2.5-mm small joint arthroscopic instrumentation and 5 lb of overhead traction. Radial and ulnar portals were used with care not to injure the extensor tendons. Arthroscopic anatomic landmarks include: (1) A consistent tripartite configuration of the main radial and ulnar collateral ligaments with characteristic changes in relative fiber orientation as the digit goes from extension to flexion, (2) nonvisualization of the accessory collateral ligament from inside the joint, (3) transitional amorphous capsular fibers connecting the collateral ligaments to the volar plate and dorsal capsule, (4) four synovial recesses (radial, ulnar, volar, and dorsal-proximal), (5) metacarpal head and proximal phalanx, (6) a consistent circumferential meniscal equivalent around the margin of the proximal phalanx articular surface, and (7) the sesamoid-metacarpal articulation in the thumb MPjoint. There are published case reports on the utility of MP joint arthroscopy for synovectomy in rheumatoid arthritis and hemachromatosis and realigning Stener lesions in gamekeepers' thumbs. The current clinical series reveals preliminary experience with the technique. MP joint arthroscopy was useful in relieving a locked MP joint from a loose osteochondral body and sagittal tear in the volar plate that enfolded into the joint surface. Intra-articular release of post-traumatic volar plate and dorsal capsular contracture were readily accomplished using this technique. Juxta-articular bone lesions such as osteoid osteomas can be removed with careful preoperative planning. Gamekeeper's thumbs that are unstable on stress radiographs can undergo arthroscopy with excellent sensitivity to determine the presence of a Stener lesion before an open or arthroscopic repair. The advantages of arthroscopic versus open techniques are similar to those experienced in larger joints. With time, more indications will emerge.

Overuse tendinitis of the intrinsic muscles.

Repetitive strain injuries are currently the leading cause of occupational illnesses. This report describes seven patients who presented with the sole symptom of hand pain and subsequently were diagnosed with intrinsic tendinitis. Six of the 7 patients were given injections of a local anesthetic and steroid solution into the region of the lumbrical tunnels for both diagnostic and therapeutic purposes. All 6 patients had immediate short-term resolution of their symptoms in the office, thereby confirming the diagnosis. Complete resolution of symptoms after both the injection and other treatment interventions occurred in 4 patients, and partial resolution of symptoms occurred in the remaining two patients. Follow-up ranged from 3 to 20 months for 6 patients, and the seventh patient was lost to follow-up. The clinical presentation, diagnostic work-up, and treatment of intrinsic tendinitis are described.

Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.

While developments continue in the surgical management of carpal tunnel syndrome, little emphasis has been placed on the evaluation of a comprehensive non-surgical treatment. In this study, 197 patients (240 hands) presenting for treatment of carpal tunnel syndrome were divided into two groups. Patients in both groups were treated by standard conservative methods, and those in one group were also treated with a program of nerve and tendon gliding exercises. Of those who did not perform the nerve and tendon gliding exercises, 71.2% underwent surgery compared with only 43.0% of patients who did perform them. Patients in the experimental group who did not undergo surgery were interviewed at an average follow-up time of 23 months (range, 14-38 months). Of these 53 patients, 47 (89%) responded to this detailed interview. Of the 47 who responded, 70.2% reported good or excellent results, 19.2% remained symptomatic, and 10.6% were non-compliant. Thus, a significant number of patients who would otherwise have undergone surgery for failure of traditional conservative treatment were spared the surgical morbidity of a carpal tunnel release (p = 0.0001).

Treatment of subungual myxoma preserving the nail matrix: a case report.

Subungual myxomas are uncommon, benign, expansile lesions that club the fingertip. Traditionally the nail matrix is incised, which results in permanent nail deformity. This report describes a midlateral approach that not only spares the nail apparatus but demonstrates that the nail can remodel even if a void is left under the nail matrix after excision of the tumor. The histologic examination of the tumor is described.

The workplace athlete.

Repetitive strain injury is rapidly becoming a problem of epidemic proportions in today's high technology workplace. It can take many forms and require a variety of different treatments. However, it is only with a combined, multidisciplinary approach that this problem can be prevented and tackled.

Upper extremity disorders in performing artists.

Studies in the past decade have shown that a significant proportion of instrumentalists report musculoskeletal problems severely affecting their musical performance. Musicians endure daily intensive use of their upper extremities, frequently placing them in bizarre positions. Their training schedules are rigorous and long term Predisposing factors to, and treatment for, overuse syndromes, tendinitis, and tendon trauma commonly encountered by musical performers are discussed at length. Nerve entrapment has also surfaced as a major problem in musicians, and the means of evaluation and treatment and the role of surgery are put forth. Techniques for studying and analyzing the difficulties faced by instrumentalists are summarized.

Intraosseous glomus tumor in the ulna. A case report.

Glomus tumors are benign vascular tumors composed of round to oval uniform cells associated with vascular structures, usually found in the soft tissue of the nail bend. A 24-year-old woman with a two-year history of progressive right elbow pain and swelling was found to have a histologically characteristic intraosseous glomus tumor in this unusual location. Excision was followed by complete relief of symptoms.