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Clinical Research: Hand Surgery
Selected Abstracts 2008-2009
Philadelphia Hand Center:
A. Lee Osterman, MD
John S. Taras, MD
John M. Bednar, MD
Randall W. Culp, MD
David S. Zelouf, MD
Stephanie Sweet, MD
Mark S. Rekant, MD
Phani K. Dantaluri, MD
Eon K. Shin, MD
Leonid Katolik, MD

Rothman Institute:
Pedro K. Beredjiklian, MD
Charles Leinberry, Jr., MD
Emran S. Sheikh, MD
Jonathan F. Rosenfeld, MD

Trapezium-sparing option for thumb carpometacarpal joint arthritis.
Adams JE, Steinmann SP, Culp RW.
Am J Orthop. 2008 Aug;37(8 Suppl 1):8-11.

Thumb carpometacarpal joint arthritis is a common condition, particularly in middle-aged women. There are many treatment options, ranging from joint arthroplasty to arthrodesis to arthroscopic debridement. Trapezium preservation has been increasingly recognized as desirable for maintaining length of the digit and strength in pinch and grasp. In this article, we review trapezium-sparing options for treatment of thumb carpometacarpal joint arthritis. These techniques allow surgeons to recontour or resurface the arthritic joint. Joint stability is critical to long-term success.

Treatment of thumb metacarpophlangeal and interphalangeal joint arthritis.
Shin EK, Osterman AL.
Hand Clin. 2008 Aug;24(3)239-50, v.

Degenerative joint disease affecting the thumb metacarpophalangeal and interphalangeal joints is a debilitating condition, which can significantly restrict activities of daily living. Conservative measures to address symptoms include oral anti-inflammatory medications, activity modification and splinting, and intraarticular corticosteroid injections. Surgical interventions include arthroscopic synovectomy, arthroplasty, and finally arthrodesis of the affected articulations. Although short-term resutslf from syncovetcomy and arthroplasty seem promising, long-term data are not yet available. Arthrodesis of the metacarpaophalangeal and interphalangeal joints yields a stable yet functional thumb with reliably good pain relief.

A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair.
Yao J, Dantuluri P, Osterman AL.
Arthroscopy. 2007 Dec;23(12):1357.e1-4. Epub 2007 May 7.

techniques include prolonged recovery and button or knot intolerance. We present a novel technique of an all-inside repair using existing technology (FasT-Fix; Smith & Nephew Endoscopy, Andover, MA) to circumvent these complications. This technique is faster, easily performed, safe, and potentially stronger than current repairs. Earlier motion and rehabilitation are instituted after this repair. The tear is debrided to stimulate angiogenesis. The FasT-Fix is inserted through the 3-4 portal with the arthroscope in the 6R portal. The first poly-L-lactic acid block is deposited peripheral to the repair. Upon penetration of the wrist capsule, a distinct decreased in resistance is felt.

The introducer is withdrawn, depositing the block outside the capsule. The trigger on the introducer advances the second block into the deployment position. It is advanced and deposited central to the tear, forming a vertical mattress configuration. The introducer is removed, leaving the pre-tied suture. The knot is tightened and cut by use of the knot pusher/cutter. Postoperative care involves a sugartong splint for 2 weeks followed by a short arm cast for 4 weeks. Range of motion is begun thereafter with strengthening started at 10 weeks.

Repair of lacerated peripheral nerves with nerve conduits.
Taras JS, Jacoby SM.
Tech Hand Up Extrem Surg. 2008 Jun;12(2):100-6.

Peripheral nerve lesions are relatively common injuries encountered by hand surgeons. These injuries are notorious for causing significant and potentially long-standing impairment to hand function. Numerous surgical techniques with varying degrees of success have been described to treat this injury. The evolution of peripheral nerve repair has led to the development of the nerve conduit, a surgical technique that functionally bridges the gap between transected nerves. We discuss a brief history and evolution of nerve conduits and offer our preferred technique for peripheral nerve repair with a collagen nerve conduit. In addition, we offer case studies and postoperative rehabilitation goals and present early results associated with this type of repair.

Kienböck's disease.
Beredjiklian PK.
J Hand Surg [Am]. 2009 Jan;34(1):167-75.

Osteonecrosis of the lunate, Kienb�ck's disease, is a progressive, debilitating disease process that can lead to chronic pain and dysfunction. Despite its recognition almost 100 years ago, the etiology remains unidentified, although mechanical, vascular, and traumatic factors have been implicated. The natural history of this disease is poorly defined, and the radiographic appearance does not always correlate with the clinical findings. Some progress has been made in the identification and an understanding of the progression of the avascular process and its deleterious effects on wrist mechanics. Initial treatment is nonsurgical. Advances in surgical techniques with vascularized pedicled grafts from the distal radius may lead to an improvement in outcomes for patients in the earlier stages of disease, although much more work is needed to determine whether this surgical option represents an improvement over conventional treatment alternatives. Recent reports of long-term outcomes of radial shortening osteotomy for earlier stages of osteonecrosis and proximal row carpectomy for advanced Kienb�ck's disease reveal that these procedures provide reliable options for the long-term management of this difficult clinical problem.

Effect of interleukin-10 overexpression on the properties of healing tendon in a murine patellar tendon model.
Ricchetti ET, Reddy SC, Ansorge HL, Zgonis MH, Van Kleunen JP, Liechty KW, Soslowsky LJ, Beredjiklian PK.
J Hand Surg [Am]. 2008 Dec;33(10):1843-52.

PURPOSE: Interleukin-10 (IL-10) is a potent anti-inflammatory cytokine shown to inhibit scar formation in fetal wound healing. The role of IL-10 in adult tendon healing and scar formation, however, remains unknown. The objective of this study is to investigate the effect of IL-10 overexpression on the properties of adult healing tendon using a well-established murine model of tendon injury and a lentiviral-mediated method of IL-10 overexpression.

METHODS: A murine model of patellar tendon injury was used and animals divided into 3 groups. Mice received bilateral patellar tendon injections with a lentiviral vector containing an IL-10 transgene (n = 34) or no transgene (n = 34). Control mice (n = 34) received injections of sterile saline. All animals then were subjected to bilateral, central patellar tendon injuries 2 days after injection and were killed at 5, 10, 21, and 42 days after injury. IL-10 content was analyzed by immunohistochemistry (n = 4/group). Tendon healing was evaluated by histology (n = 4/group) and biomechanical analysis (n = 10/group).

RESULTS: Overexpression of IL-10 in patellar tendon was confirmed after injection of the lentiviral vector. IL-10 immunostaining was increased at day 10 in the IL-10 group relative to that in controls. Histologically, there was no significant difference in angular deviation between groups at day 21, but a trend toward decreased angular deviation in controls relative to that in empty vector group mice was seen at day 42. Biomechanically, the IL-10 group showed significantly increased maximum stress at day 42 relative to that in controls. Percent relaxation showed a trend toward an increase at day 10 and a significant increase at day 42 in the IL-10 group relative to that in controls.

CONCLUSIONS: This study demonstrates successful gene transfer of IL-10 into adult murine patellar tendon using a lentiviral vector. Although the effects of overexpression of IL-10 on adult tendon healing have not yet been fully elucidated, the current study may help to further clarify the mechanisms of tendon injury and repair.

Physical diagnosis and radiographic examination of the thumb.
Tsai P, Beredjiklian PK.
Hand Clin. 2008;24(3):231-7.

Arthritis of the thumb joints is a common problem and remains a significant cause of morbidity in the adult population. Careful physical examination is critical in the assessment of these patients, given the large differential diagnosis of conditions affecting the thumb and the radial side of the wrist. Because treatment should be specifically directed at the area of pathology, adequate diagnosis is vital. Plain radiograph evaluation remains the diagnostic modality of choice in the evaluation of patients with degenerative conditions about the hand and wrist.

Variation in digital rotation and alignment in normal subjects.
Tan V, Kinchelow T, Beredjiklian PK.
J Hand Surg [Am]. 2008 Jul-Aug;33(6):873-8.

PURPOSE: The purpose of this study is to quantify finger/digit rotation, overlap, parallelism, and convergence to the scaphoid tuberosity in normal volunteers to establish standards for comparison.

METHODS: We examined 240 uninjured fingers in 30 volunteers. There were 14 men and 16 women with an average age of 35 years. Rotation was determined with the palm flat and fingers extended. Digit overlap, parallelism (angular relationship between the index, ring, and small fingers with respect to the middle finger) and scaphoid convergence were determined with simultaneous flexion of metacarpophalangeal and proximal interphalangeal joints. Linear and angular measurements were performed with imaging software.

RESULTS: Rotation, parallelism, and scaphoid convergence measurements were similar comparing left with right hands. Rotation: All digits were found to be in supination relative to the horizontal plane; the small fingers averaged 9 degrees, the ring fingers 4 degrees, the middle fingers 8 degrees, and the index fingers 12 degrees. Parallelism: Angular measurements between the middle finger and the small finger averaged 19 degrees, between the middle finger and the ring finger 9 degrees, and between the middle finger and the index finger 11 degrees. Scaphoid convergence: In no hand did all 4 fingers converge onto scaphoid tuberosity. Whereas small and ring finger trajectories averaged -0.1 to 1.2 mm from the scaphoid tubercle, the middle finger averaged 4.0 to 4.6 mm and the index finger 8.1 to 9.5 mm. Overlap: Ninety percent of individuals demonstrated digit overlap, although none covered more than 50% of the adjacent nail plate. Seventy-seven percent of these were bilateral, and 73% were asymmetric.

CONCLUSIONS: This study establishes the normal parameters for digit rotation, overlap, parallelism, and scaphoid convergence. For digit rotation, parallelism, and scaphoid convergence, the contralateral (uninjured) hand can be used reliably for comparison. However, for digit overlap, the contralateral hand should not be used for comparison because of side-to-side asymmetry and variability.
© 2010 Thomas Jefferson University Hospital Department of Orthopaedic Surgery.