Discrepancy between Radiographic and Arthroscopic Findings of Thumb Basilar Joint Arthritis: A Preliminary Clinical Report.

The radiographic staging of arthritic changes in the thumb carpometacarpal (CMC) joint is known to have poor correlation with pain level. This may be due to the limited ability of radiographs to evaluate degenerative changes. The purpose of this study was to examine the relationship between radiographic versus arthroscopic findings of thumb CMC and scaphotrapeziotrapezoidal (STT) joint arthritis. Methods: Twenty patients with symptomatic thumb CMC arthritis underwent arthroscopy of thumb CMC and STT joints with concomitant synovectomy or arthroplasty depending on the degree of articular degeneration found. All patients had preoperative radiographs of the thumb CMC and STT joints. Radiographic degeneration was graded based on the Eaton-Glickel classification. Intraoperative arthroscopic images were reviewed and graded based on the Brown grading system. Results: At the thumb CMC joint, five patients had discordant radiographic and arthroscopic findings of arthritis. At the STT joint, one patient had discordant radiographic and arthroscopic findings of arthritis. Conclusions: In comparing the two staging systems, we found a small subset of patients that demonstrated significant discrepancies. Clinical evaluation remains essential, and patients should be informed that radiographs may underestimate the actual severity of arthritis.

Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial.

The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release. Methods: Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates. Results: POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups. Conclusions: Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique.

Endoscopic Retrograde Approach for Trigger Finger Release: A Cadaver Study.

Trigger finger is one of the most common causes of disability and pain in the hand. Current surgical techniques for trigger finger release fall short in that they are performed blindly with trauma to, or require incision of, the palmar fascia, which can be a source of significant and long-lasting morbidity. Retrograde endoscopic release of the A1 pulley was performed through a single incision at the proximal digital crease in cadaveric specimens. The fingers were then dissected to assess for completeness of release and inspected for injury to nearby structures. Complete release of the A1 pulley was noted in 16 of 16 fingers. No significant injuries to the A2 pulley and flexor tendon were found, and no injuries to the digital nerves or vasculature occurred. The described technique, as demonstrated in cadaveric specimens, is a feasible alternative approach in the treatment of trigger finger. The technique allows complete visualization of A1 pulley release through a single palmar fascia sparing incision.

Distal Radius Fractures: AAOS Appropriate Use Criteria Versus Actual Management at a Level I Trauma Center.

BACKGROUND: The aim of this study is to determine whether the American Academy of Orthopaedic Surgeons' (AAOS) Appropriate Use Criteria (AUC) for distal radius fractures correlates with actual treatment by orthopedic hand surgeons at a level I trauma center. METHODS: ICD-9 codes were used to retrospectively identify patients who presented with wrist fractures over 1 year. Patients with isolated distal radius fractures were evaluated using the AAOS AUC application for distal radius fractures. Actual treatment was then compared with treatment recommended by the AUC. RESULTS: Of the 112 patients, 64 (57%) received treatment that matched the AAOS AUC recommendation as an "appropriate treatment." Actual management matched the AUC recommendation 100%, 7%, and 50% of the time, for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type A, B, and C fractures, respectively. Surgery was performed for type A, B, and C fractures 30%, 7%, and 50% of the time, respectively. For type B fractures, only the 2 cases that were managed operatively were in agreement with the AUC. For type C fractures, increased patient age (57 years and older) was significantly associated with nonoperative treatment decisions. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 40% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 97% of the time. CONCLUSIONS: We found low agreement between actual treatment decisions and the AUC-recommended "appropriate" treatments, especially for the type B and C fractures that were managed nonoperatively. The AUC favors surgery for all intra-articular fractures, while we emphasized age and fracture displacement in our decision-making process.

Hip arthroscopy for extra-articular hip disease.

The increasing popularity and success of hip arthroscopy has led to the development of related techniques for treating hip pathologies external to the joint proper. These minimally invasive endoscopic procedures serve in a diagnostic role to complement clinical evaluations and offer a therapeutic alternative to traditional open techniques. The indications for extra-articular hip endoscopy continue to expand. Recent literature describes applications for treating greater trochanteric pain syndrome, internal snapping hip, deep gluteal syndrome, and subspine impingement and for diagnosing and treating extra-articular sources of hip pain in patients who have undergone hip arthroplasty.

Estrogen and growth factor receptor interactions in human breast and non-small cell lung cancer cells.

Extranuclear estrogen receptors may mediate rapid effects of estradiol that communicate with nuclear receptors and contribute to proliferation of human cancers bearing these signaling proteins. To assess these growth-promoting pathways, we undertook controlled homogenization and fractionation of NIH-H23 non-small cell lung cancer cells. As many breast tumors, NIH-H23 cells express estrogen receptors (ER), with the bulk of specific estradiol binding in nuclear fractions. However, as in breast cells, a significant portion of specific, high-affinity estradiol-17beta binding-sites are also enriched in plasma membranes of lung tumor cells. These estrogen binding-sites co-purify with plasma membrane-marker enzymes and are not significantly contaminated by cytosol or nuclei. On further purification of membrane caveolae from lung tumor cells, proteins recognized by monoclonal antibodies to nuclear ER-alpha and to ER-beta were identified in close association with EGF receptor in caveolae. In parallel studies, ER-alpha and ER-beta are also detected in nuclear and extranuclear sites in archival human breast and lung tumor samples and are noted to occur in clusters at the cell membrane by using confocal microscopy to visualize fluorescent-labeled monoclonal antibodies to ER-alpha. Data on site-directed mutagenesis of cysteine-447 in ER-alpha suggest that association of ER forms with membrane sites may depend on acylation of cysteine by palmitate. Estrogen-induced growth of MCF-7 breast cancer and NIH-H23 lung cancer cells in vitro correlated closely with acute hormonal activation of mitogen-activated protein kinase signaling and was significantly reduced by treatment with Faslodex, a pure anti-estrogen. Further, combination of Faslodex with selected growth factor receptor inhibitors elicited a more pronounced inhibiton of tumor cell growth. Thus, extranuclear forms of ER play a role in promoting downstream signaling for hormone-mediated proliferation and survival of breast, as well as lung, cancers and offer a new target for anti-tumor therapy.