Multiple pilonidal sinuses of both hands in a dog groomer: A case report

OBJECTIVE

Pilonidal sinus of the hand is an occupational hazard for barbers, cow milkers, sheep shearers and dog groomers. Here, we report on a dog groomer who had four pilonidal sinuses.

CASE PRESENTATION

A 49-year-old woman working as a dog groomer complained of multiple non-erythematous and fluctuant nodules on both hands, associated with pain, which had been identified five years previously. On the skin of her right hand, three nodules were observed on the volar (diameter: 1.5 cm) and medial (diameter: 1.4 cm) sides of fifth metacarpophalangeal joint and the volar aspect of the distal phalanx of the small finger (diameter: 0.7 cm). On the left hand, a 2-cm diameter nodule was identified on the volar side of the fifth metacarpophalangeal joint region. The nodules were excised surgically. A 5-mm long hair was removed from one nodule. Histopathology confirmed pilonidal sinus, treated by excision. One month postoperatively, the wound had healed uneventfully.

CONCLUSION

When nodules are found in dog groomers, clinicians should consider the possibility of pilonidal sinus disease.

Thumb Metacarpophalangeal Joint Kinematics and Elongation of the Ulnar Collateral Ligament

PURPOSE

The purpose of the study was to determine if the sphericity of the thumb metacarpophalangeal (MCP) joint influences the joint's rotational axis (RA) and elongation patterns of the ulnar collateral ligament (UCL).

METHODS

Ulnar collateral ligament origins and attachments of 28 fresh-frozen cadaveric thumbs were marked with a radiopaque marker. Lateral radiographs were obtained in neutral and 20°, 40°, and 60° of flexion. The dorsal and palmar joint gap and the length of four different UCL portions were digitally measured in all flexion states. The RA was determined by the intersection of the midshaft axis of the proximal phalanx in neutral and flexion states. Sphericity of the MCP joint was assessed using morphometric parameters. Joints were grouped as round or flat. Differences in all measured parameters between groups were analyzed.

RESULTS

During flexion, the dorsal joint gap increased by 322% in flat joints and 163% in round joints. The palmar joint gap decreased to 45% in flat joints and to 87% in round joints. The RA was at 29% of metacarpal height and 96% of metacarpal length in flat joints and at 40% of height and 86% of length in round joints. Maximum UCL elongation (111%) was noted at 40° flexion in the dorsal proper UCL in flat joints and at 60° flexion in the accessory UCL (117%) in round joints.

CONCLUSIONS

In flat MCP joints, the RA is more dorsal and distal in the metacarpal head compared to round joints, resulting in a hinged flexion motion. Elongation of the UCL is highest at end flexion in round joints and highest at midflexion in flat joints.

CLINICAL RELEVANCE

The different kinematics of flat and round MCP joints may contribute to the understanding of the pathophysiology of UCL ruptures. The propensity of this injury and the position in which they occur may be affected by the MCP joint morphology.

Machine learning identifies right index finger tenderness as key signal of DAS28-CRP based psoriatic arthritis activity

Psoriatic arthritis (PsA) is a chronic inflammatory systemic disease whose activity is often assessed using the Disease Activity Score 28 (DAS28-CRP). The present study was designed to investigate the significance of individual components within the score for PsA activity. A cohort of 80 PsA patients (44 women and 36 men, aged 56.3 ± 12 years) with a range of disease activity from remission to moderate was analyzed using unsupervised and supervised methods applied to the DAS28-CRP components. Machine learning-based permutation importance identified tenderness in the metacarpophalangeal joint of the right index finger as the most informative item of the DAS28-CRP for PsA activity staging. This symptom alone allowed a machine learned (random forests) classifier to identify PsA remission with 67% balanced accuracy in new cases. Projection of the DAS28-CRP data onto an emergent self-organizing map of artificial neurons identified outliers, which following augmentation of group sizes by emergent self-organizing maps based generative artificial intelligence (AI) could be defined as subgroups particularly characterized by either tenderness or swelling of specific joints. AI-assisted re-evaluation of the DAS28-CRP for PsA has narrowed the score items to a most relevant symptom, and generative AI has been useful for identifying and characterizing small subgroups of patients whose symptom patterns differ from the majority. These findings represent an important step toward precision medicine that can address outliers.

Metacarpophalangeal joint angle of the thumb during maximal pinch strength: a study of healthy volunteers

Mean metacarpophalangeal joint angles of the thumb during maximal pinch were 9° greater in men than in women. More flexion was not associated with more force during key pinch, but a moderate association was found for palmar pinch, especially in men.

Efficacy of splinting the wrist and metacarpophalangeal joints for the treatment of Carpal tunnel syndrome: an assessor-blinded randomised controlled trial

OBJECTIVES

To compare the efficacy of a traditional cock-up splint, which supports the wrist only, with a modified splint that supports the wrist and the metacarpophalangeal (MCP) joints of the medial four digits in the treatment of carpal tunnel syndrome (CTS).

DESIGN

An assessor-blind randomised controlled trial.

SETTING

Hospital-based hand therapy clinics.

PARTICIPANTS

Fifty-nine adults with mild-to-moderate CTS were randomly assigned to wear a wrist splint (control group) or an MCP splint (intervention group) for 6 weeks.

OUTCOME MEASURES

The standardised outcome measures used included grip and pinch strength, the static two-point discrimination test, Phalen's manoeuvre test, Tinel's sign and the Boston CTS Questionnaire.

RESULTS

Both groups improved significantly from splint use in some clinical features. The wrist splint and the MCP splint groups had significant improvements in lateral pinch strength (p=0.032 and p=0.002, respectively), two-point discrimination of the thumb (p=0.003 and p=0.041, respectively), two-point discrimination of the index (p=0.035 and p=0.023, respectively) and the Phalen's manoeuvre symptoms (p=0.025 and p=0.002, respectively). The MCP splint group had additional improvements over the wrist splint group in tip pinch (p=0.012) and Palmar pinch (p=0.011) strength.

CONCLUSION

Splinting is a practical and effective intervention option for improving the symptoms of CTS. A wrist splint that incorporates the MCP joints is more effective than the traditional wrist-only splint, with long-lasting improvements that remained consistent after 6 months of the splint intervention. Using the more effective MCP splint may consequently reduce disability, facilitate return to work and lower the associated costs.

TRIAL REGISTRATION NUMBER

ISRCTN13189602.

MITEx: A Portable Hand Exoskeleton for Assessment and Treatment in Neurological Rehabilitation

This work describes the design and preliminary characterization of a novel portable hand exoskeleton for poststroke rehabilitation. The platform actively mobilizes the index-metacarpophalangeal (I-MCP) joint, and it additionally offers individual rigid support to distal degrees of freedom (DoFs) of the index and thumb. The test-bench characterization proves the capability of the device to render torques at the I-MCP level with high fidelity within frequencies of interest for the application (up to 3 Hz). The introduction of a feed-forward friction compensation at the actuator level lowers the output mechanical stiffness by 32%, contributing to a highly transparent behavior; moreover, the functionality of the platform in rendering different interaction strategies (patient/robot-in-charge) is tested with three healthy subjects, showing the potential of the device to provide assistance as needed.

The relative motion concept in acute and chronic boutonniere deformity: Invited commentary

STUDY DESIGN

Retrospective.

INTRODUCTION

Boutonniere deformity (BD) is a troublesome injury occurring from rupture of tissue connecting the extrinsic to intrinsic tendon systems. This causes loss of interphalangeal joint balance, and immobilization often results in adherence and difficulty restoring balance.

PURPOSES

Review of relative motion flexion (RMF) orthotic use for safe healing during functional activity in 23 patients, and explanation of the rationale.

METHODS

Anatomic rationale and clinical experience is reviewed in 8 acute BD patients utilizing RMF orthoses for 6 weeks, and for chronic BD patients, 3 months after serial casting.

RESULTS

All patients met the Strickland and Steichen criteria for "excellent" results following treatment, with an average of 35° increase in ROM.

DISCUSSION

The anatomic rationale for relative motion recognizes that altering relative positioning between adjacent metacarpophalangeal (MCP) joints produces a protective favorable impact on interphalangeal forces during hand function using 15°-20° greater MCP joint flexion. This provides dorsal and volar protective benefits because the extensor digitorum communis (EDC), a single-muscle-four-tendon system, attaches to the intrinsic lateral band (LB) tendons. With greater MCP flexion, dorsal EDC force is increased, pulling lateral bands medially, while on the volar surface the downward pull of the lumbrical on LB is relaxed due to origin from the flexor digitorum profundus tendon of the injured digit, also a single-muscle-four-tendon system. The RMF orthosis permits protected active motion during functional activity with acute BD. In patients with chronic BD and adequate passive extension, an RMF orthosis for 3 months also produced encouraging results.

CONCLUSION

Management of acute BD with RMF orthoses provided earlier recovery of motion and hand function. Similar results occurred for chronic BD using serial casting for adequate extension followed by 3 months of RMF orthotic use and should be attempted prior to surgical intervention, with surgery remaining an alternative.

Open-source image analysis tool for the identification and quantification of cortical interruptions and bone erosions in high-resolution peripheral quantitative computed tomography images of patients with rheumatoid arthritis

Identification of bone erosions and quantification of erosion volume is important for rheumatoid arthritis diagnosis, and can add important information to evaluate disease progression and treatment effects. High-resolution peripheral quantitative computed tomography (HR-pQCT) is well suited for this purpose, however analysis methods are not widely available. The purpose of this study was to develop an open-source software tool for the identification and quantification of bone erosions using images acquired by HR-pQCT. The collection of modules, Bone Analysis Modules (BAM) - Erosion, implements previously published erosion analysis techniques as modules in 3D Slicer, an open-source image processing and visualization tool. BAM includes a module to automatically identify cortical interruptions, from which erosions are manually selected, and a hybrid module that combines morphological and level set operations to quantify the volume of bone erosions. HR-pQCT images of the second and third metacarpophalangeal (MCP) joints were acquired in patients with RA (XtremeCT, n = 14, XtremeCTII, n = 22). The number of cortical interruptions detected by BAM-Erosion agreed strongly with the previously published cortical interruption detection algorithm for both XtremeCT (r² = 0.85) and XtremeCTII (r² = 0.87). Erosion volume assessment by BAM-Erosion agreed strongly (r² = 0.95) with the Medical Image Analysis Framework. BAM-Erosion provides an open-source erosion analysis tool that produces comparable results to previously published algorithms, with improved options for visualization. The strength of the tool is that it implements multiple image processing algorithms for erosion analysis on a single, widely available, open-source platform that can accommodate future updates.

Validation of two-dimensional video-based inference of finger kinematics with pose estimation

Accurate capture finger of movements for biomechanical assessments has typically been achieved within laboratory environments through the use of physical markers attached to a participant’s hands. However, such requirements can narrow the broader adoption of movement tracking for kinematic assessment outside these laboratory settings, such as in the home. Thus, there is the need for markerless hand motion capture techniques that are easy to use and accurate enough to evaluate the complex movements of the human hand. Several recent studies have validated lower-limb kinematics obtained with a marker-free technique, OpenPose. This investigation examines the accuracy of OpenPose, when applied to images from single RGB cameras, against a ‘gold standard’ marker-based optical motion capture system that is commonly used for hand kinematics estimation. Participants completed four single-handed activities with right and left hands, including hand abduction and adduction, radial walking, metacarpophalangeal (MCP) joint flexion, and thumb opposition. The accuracy of finger kinematics was assessed using the root mean square error. Mean total active flexion was compared using the Bland–Altman approach, and the coefficient of determination of linear regression. Results showed good agreement for abduction and adduction and thumb opposition activities. Lower agreement between the two methods was observed for radial walking (mean difference between the methods of 5.03°) and MCP flexion (mean difference of 6.82°) activities, due to occlusion. This investigation demonstrated that OpenPose, applied to videos captured with monocular cameras, can be used for markerless motion capture for finger tracking with an error below 11° and on the order of that which is accepted clinically.

Earable Ω (OMEGA): A Novel Clenching Interface Using Ear Canal Sensing for Human Metacarpophalangeal Joint Control by Functional Electrical Stimulation

(1) Background: A mouth-free interface is required for functional electrical stimulation (FES) in people with spinal cord injuries. We developed a novel system for clenching the human metacarpophalangeal (MP) joint using an earphone-type ear canal movement sensor. Experiments to control joint angle and joint stiffness were performed using the developed system. (2) Methods: The proposed FES used an equilibrium point control signal and stiffness control signal: electrical agonist-antagonist ratio and electrical agonist-antagonist sum. An angle sensor was used to acquire the joint angle, and system identification was utilized to measure joint stiffness using the external force of a robot arm. Each experiment included six and five subjects, respectively. (3) Results: While the joint angle could be controlled well by clenching with some hysteresis and delay in three subjects, it could not be controlled relatively well after hyperextension in the other subjects, which revealed a calibration problem and a change in the characteristics of the human MP joint caused by hyperextension. The joint stiffness increased with the clenching amplitude in five subjects. In addition, the results indicated that viscosity can be controlled. (4) Conclusions: The developed system can control joint angle and stiffness. In future research, we will develop a method to show that this system can control the equilibrium point and stiffness simultaneously.

Research on Monocular-Vision-Based Finger-Joint-Angle-Measurement System

The quantitative measurement of finger-joint range of motion plays an important role in assessing the level of hand disability and intervening in the treatment of patients. An industrial monocular-vision-based knuckle-joint-activity-measurement system is proposed with short measurement time and the simultaneous measurement of multiple joints. In terms of hardware, the system can adjust the light-irradiation angle and the light-irradiation intensity of the marker by actively adjusting the height of the light source to enhance the difference between the marker and the background and reduce the difficulty of segmenting the target marker and the background. In terms of algorithms, a combination of multiple-vision algorithms is used to compare the image-threshold segmentation and Hough outer- and inner linear detection as the knuckle-activity-range detection method of the system. To verify the accuracy of the visual-detection method, nine healthy volunteers were recruited for experimental validation, and the experimental results showed that the average angular deviation in the flexion/extension of the knuckle was 0.43° at the minimum and 0.59° at the maximum, and the average angular deviation in the adduction/abduction of the knuckle was 0.30° at the minimum and 0.81° at the maximum, which were all less than 1°. In the multi-angle velocimetry experiment, the time taken by the system was much less than that taken by the conventional method.

[Impact of a simulated DIPJ Arthrodesis on Movement and Force Patterns]

PURPOSE

Distal interphalangeal joint (DIPJ) arthrodesis is a well-proven therapy for osteoarthritis in the DIPJ. Since the upper limb is effectively a linked chain which is moved by interlinked, joint-overlapping muscle-tendon units, impacts on movement and force patterns are expected to occur in response to arthrodesis. In this context, a real-time quantitative analysis has not been performed to date.

MATERIAL AND METHODS

Finger motion and force development during grasping were dynamically measured and quantitatively analyzed in 19 healthy volunteers with a simulated DIPJ arthrodesis using a TUB (Technische Universität Berlin) sensor glove during fist closure and evaluating two types of force grips compared with the physiological grip.

RESULTS

Typical motion patterns were found. During physiological fist closure, the average flexion angle was 71.5° in the metacarpophalangeal joint (MPJ), 76.8° in the proximal interphalangeal joint (PIPJ) and 37.3° in the distal interphalangeal joint (DIPJ). With DIPJ arthrodesis, the flexion angle decreased to 49.6° in the PIPJ, whereas it increased slightly to 77.3° in the MPJ. During force grip I, the average physiological flexion angles were 18.3° in the MPJ, 39.6° in the PIPJ and 42.6° in the DIPJ. With simulated DIPJ arthrodesis, the flexion angle in the MPJ increased to 28.4°, whereas it decreased to 25.2° in the PIPJ. Force grip II yielded physiological flexion angles of 30.9° in the MPJ, 36.6° in the PIPJ and 29.0° in the DIPJ. In response to simulated DIPJ arthrodesis, the angle in the MPJ increased to 34.4° while it decreased to 23.3° in the PIPJ. The forces measured with force grips were almost equally distributed under physiological conditions. In response to simulated DIPJ arthrodesis, the average decrease in the measured force of a finger was no more than 1.4%.

CONCLUSION

This study was the first to introduce a quantitative analysis of grasping with simulated DIPJ arthrodesis. Based on this analysis, the study demonstrates the dynamic interaction of the finger joints as well as force patterns on the individual finger rays of the hand in real-time.

Detection of Osteoarthritis from Multimodal Hand Data

Osteoarthritis (OA) describes a degenerative joint disorder that is prevalent among older people and typically results in swollen and inflamed joints. The aim of this paper is to develop a method using images, videos and thermal data of 100 patients taken at Keio University Hospital to detect OA in hands. By using hand pose estimation on the video data, joint angles can be calculated and subsequently transformed into feature vectors. For the thermal and RGB images, hand keypoint detectors were trained to identify and crop the appropriate joints within the images. The resulting extracted features are combined and further trained on Support Vector Machines and Convolutional Neural Networks to obtain the final binary classification for each joint. While the proposed method generally shows favorable accuracy and F1-scores on the Proximal (PIP) and Distal Interphalangeal (DIP) joints, the performance on the Metacarpophalangeal (MCP) joints is limited by the low occurrence of affected joints in the dataset. We further compare the different modalities and found that, apart from the combined approach, using video data provides the best results. Clinical Relevance- The proposed method shows promising first results for the usage of visual and thermal data in combination with machine learning in order to detect OA.

Hand Motion Analysis during the Execution of the Action Research Arm Test Using Multiple Sensors

The Action Research Arm Test (ARAT) is a standardized outcome measure that can be improved by integrating sensors for hand motion analysis. The purpose of this study is to measure the flexion angle of the finger joints and fingertip forces during the performance of three subscales (Grasp, Grip, and Pinch) of the ARAT, using a data glove (CyberGlove II^®) and five force-sensing resistors (FSRs) simultaneously. An experimental study was carried out with 25 healthy subjects (right-handed). The results showed that the mean flexion angles of the finger joints required to perform the 16 activities were Thumb (Carpometacarpal Joint (CMC) 28.56°, Metacarpophalangeal Joint (MCP) 26.84°, and Interphalangeal Joint (IP) 13.23°), Index (MCP 46.18°, Index Proximal Interphalangeal Joint (PIP) 38.89°), Middle (MCP 47.5°, PIP 42.62°), Ring (MCP 44.09°, PIP 39.22°), and Little (MCP 31.50°, PIP 22.10°). The averaged fingertip force exerted in the Grasp Subscale was 8.2 N, in Grip subscale 6.61 N and Pinch subscale 3.89 N. These results suggest that the integration of multiple sensors during the performance of the ARAT has clinical relevance, allowing therapists and other health professionals to perform a more sensitive, objective, and quantitative assessment of the hand function.

Pharmacokinetics of ceftiofur in the metacarpophalangeal joint after standing intravenous regional limb perfusion in horses

This study investigated the pharmacokinetics of ceftiofur after intravenous regional limb perfusion (IVRLP). Six horses were involved in 3 IVRLP sessions. For each session, operators with varying clinical experience placed the tourniquet. A wide-rubber tourniquet was applied in the antebrachium as 2 g of ceftiofur in a total volume of 100 mL was injected into the cephalic vein. Plasma and metacarpophalangeal synovial fluid samples were obtained to evaluate perfusate leakage and synovial fluid concentrations of ceftiofur over 24 h. Overall, mean plasma concentrations were not significantly different before and after tourniquet removal. Mean synovial fluid ceftiofur concentrations were significantly higher 5 min and 8 h after tourniquet removal versus 24 h, after which values above the minimum inhibitory concentration (MIC) (1 μg/mL) were not detected. Concentrations above the MIC were detected in 72% and 50% of the horses at 5 min and 8 h, respectively. Overall, higher synovial fluid concentrations were obtained for the operator with the most recent clinical experience performing IVRLP.

A case report of monoarthritis in a COVID-19 patient and literature review: Simple actions for complex times

RATIONALE

COVID-19 presentation is multifaceted and up to 44% of patients affected by COVID-19 experience musculoskeletal complaints, mostly in the form of diffuse aspecific arthromyalgias. Nevertheless, only a few cases of arthritis following SARS-CoV2 infection are reported.

PATIENT CONCERNS

A 27-year-old man affected by nail psoriasis presented with monoarthritis 2 weeks after being diagnosed with COVID-19.

DIAGNOSES

Diagnostic work-up and differential diagnosis were made difficult by patient isolation, absence of lab tests, and his visit via telemedicine, even though signs of first metacarpophalangeal joint involvement were clear.

INTERVENTIONS

Due to the inefficacy of acetaminophen and nonsteroidal anti-inflammatory drugs, the patient was prescribed oral steroids with a rapid benefit.

OUTCOMES

The patient's response to oral steroid was prompt and maintained even after therapy tapering. Even so, a formal diagnosis was not possible due to a difficult diagnostic work-up and lack of a long-term follow-up.

LESSONS

Like many other viral diseases, SARS-CoV2 can play as a causative agent or as a trigger for inflammatory arthritis development in predisposed individuals.

Biomechanical and wearability testing of novel legwear for variably limiting extension of the metacarpophalangeal joint of horses

OBJECTIVE

To evaluate the ability of novel legwear designed to limit extension of the metacarpophalangeal joint (MCPJ) to redirect loading forces from the flexor apparatus during walk, trot, and canter on a treadmill and during unrestrained and restrained activity in a stall.

ANIMALS

6 adult horses without musculoskeletal disease.

PROCEDURES

Legwear-derived force data were recorded under 4 conditions: inactive state (unlimited legwear extension) and 3 active (restrictive) states (mild, 30° extension; moderate, 20° extension; or maximum, 10° extension). Associations between peak legwear loads and torques among legwear states and treadmill gaits and stall activities were assessed. The hair coat and skin of the forelimbs were examined for any legwear-induced adverse effects after testing.

RESULTS

During the treadmill exercises, moderate restriction of legwear extension resulted in significantly higher peak load and torque than mild restriction, and faster speeds (canter vs walk or trot and trot vs walk) yielded significantly higher peak load and torque. During in-stall activity, maximum restriction of legwear extension yielded significantly higher peak load and torque than moderate restriction. Unrestrained in-stall activity resulted in significantly higher peak load and torque than restrained activity. The legwear caused minimal adverse effects on the hair coat and skin of the forelimbs.

CONCLUSIONS AND CLINICAL RELEVANCE

Findings suggested that the legwear variably reduced peak loads on the flexor apparatus. Extension of the MCPJ may be incrementally adjusted through the legwear such that return to activity may be controlled, and controlled return to activity is crucial for rehabilitating flexor apparatus injuries.

Kinematic and kinetic analyses of the gait of horses wearing novel legwear for variably limiting extension of the metacarpophalangeal joint

OBJECTIVE

To investigate the effects of novel legwear designed to limit metacarpophalangeal joint (MCPJ) extension and redirect loading forces from the flexor apparatus through analyses of 2-D kinematic and kinetic data.

ANIMALS

6 adult horses without musculoskeletal disease.

PROCEDURES

Horses were subjected to 4 treatments: control (no legwear), inactive legwear (unlimited legwear extension), and active legwear with mild (30°) and moderate (20°) legwear extension limitation. Two-dimensional kinematic data were collected for the right forelimb (FL) during walk and trot and from leading and trailing FLs during canter on a treadmill. Ground reaction force (GRF) data were collected from FLs during overground walk and trot. Peak MCPJ angle and angular velocity were calculated from kinematic data, and peak force and average loading rate were calculated from vertical GRF data during the stance phase of the gait. Interactions between gait and treatment were determined via ANOVA.

RESULTS

Interactions between gait and treatment for peak MCPJ angle were significant. Significant reductions in MCPJ angle were noted between the control treatment and legwear with moderate extension limitation for trot and canter (leading and trailing FL) and between inactive legwear and legwear with moderate extension limitation for trot and leading FL during canter. Interactions among peak MCPJ angular velocity, peak vertical GRF, and average loading rate of the vertical GRF showed nonsignificance.

CONCLUSIONS AND CLINICAL RELEVANCE

Significant reductions in MCPJ extension without significant alterations to peak vertical GRF suggested the legwear's ability to redistribute internal forces. Findings suggested that the legwear may be beneficial for horses rehabilitating from flexor apparatus injuries.

Chikungunya arthritis - should we expect it to become more common in Portuguese rheumatology?

Chikungunya virus is known to cause acute disease characterized by fever, rash, myalgias, conjunctivitis and arthritis, having potential to cause chronic musculoskeletal disease, namely persistent arthritis. The area of spread of the virus in the world has been increasing and the migratory flows make the occurrence of Chikungunya induced chronic arthritis more and more scattered. Data regarding the experience of Portuguese rheumatology centres in identifying and treating chronic ChikV induced arthritis are not available. The authors describe the diagnosis and treatment aspects of three cases of "imported" Chikungunya induced chronic arthritis, briefly discuss its approach in the light of current knowledge and alert to the possibility this situation may become more prevalent in the Portuguese rheumatology setting.

The biomechanics of knuckle-walking: 3-D kinematics of the chimpanzee and macaque wrist, hand and fingers

The origin and evolution of knuckle-walking has long been a key focus in understanding African ape, including human, origins. Yet, despite numerous studies documenting morphological characteristics potentially associated with knuckle-walking, little quantitative three-dimensional (3-D) data exist of forelimb motion during knuckle-walking. Nor do any comparative 3-D data exist for hand postures used during quadrupedalism in monkeys. This lack of data has limited the testability of proposed adaptations for knuckle-walking in African apes. This study presents the first 3-D kinematic data of the wrist, hand and metacarpophalangeal joints during knuckle-walking in chimpanzees and in macaques using digitigrade and palmigrade hand postures. These results clarify the unique characteristics of, and commonalities between, knuckle-walking and digitigrady/palmigrady in multiple planes of motion. Notably, chimpanzees utilized more wrist ulnar deviation than any macaque hand posture. Maximum extension of the chimpanzee wrist was slight (5-20 deg) and generally overlapped with macaque digitigrady. Metacarpophalangeal joint motion displayed distinct differences between digits in both species, likely related to the timing of force application. These data also reveal that maximum metacarpophalangeal extension angles during knuckle-walking (26-59 deg) were generally higher than previously considered. In macaques, maximum metacarpophalangeal extension during digitigrady and palmigrady overlapped for most digits, highlighting additional complexity in the interpretation of skeletal features that may be related to limiting metacarpophalangeal motion. Most importantly, however, these new 3-D data serve as a fundamental dataset with which evaluation of proposed musculoskeletal adaptations for knuckle-walking can be tested.

A quasi-experimental trial

STUDY DESIGN

A quasi-experimental trial.

INTRODUCTION

Orthoses are effective to decrease pain and improve function in patients with carpometacarpal osteoarthritis (CMC OA). However, current research does not support one design of an orthosis as more effective and/or more favorable than another.

PURPOSE OF THE STUDY

The aim of this study was to compare the effectiveness of 2 different static orthosis on pain and functional abilities on CMC OA.

METHODS

Eighty-four patients, 91.7% females (mean ± standard deviation age, 60.1 ± 9.6 years), with thumb CMC OA were randomized into 1 of 2 groups. For group A, a Ballena orthotic was constructed, and for group B, a Colditz orthotic was constructed. Both static orthoses were worn for 3 months. The outcome measures included pain with activity measured with the visual analog scale and functional abilities assessed with the Disabilities of the Arm, Shoulder and Hand.

RESULTS

Both orthoses improved pain level and functional abilities (F_[1.0] = 413.327 and F_[1.0] = 211.742; both P < .001). There was no statistically significant difference between 2 groups regarding to pain recovery and functional improvement (F_[1.0] = 0.075 and F_[1.0] = 7.248; both P > .05).

DISCUSSION

The main purpose was to compare the effect of 2 different thermoplastic thumb orthoses. Previous studies support the use of CMC orthoses to decrease hand pain and improve hand function, but different orthoses have been described and in most cases, orthotic interventions were accompanied by other medical treatments.

CONCLUSIONS

A clinically significant reduction in pain intensity and improvement in functional abilities was achieved with both orthoses in patients with thumb CMC OA.

LEVEL OF EVIDENCE

2.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT02780999.

Comparison of efficacy and safety of single versus repeated intra-articular injection of allogeneic neonatal mesenchymal stem cells for treatment of osteoarthritis of the metacarpophalangeal/metatarsophalangeal joint in horses: A clinical pilot study

The purpose of this prospective study was to evaluate the effects of single and repeated intra-articular administration of allogeneic, umbilical cord-derived, neonatal mesenchymal stem cells (MSC) in horses with lameness due to osteoarthritis (OA) of a metacarpophalangeal joint (MPJ).

Twenty-eight horses were included. Horses were divided into two groups. Horses in group MSC1 received an MSC injection at M0 and a placebo injection at M1 (1 month after M0). Horses in group MSC2 received MSC injections at M0 and at M1. Joint injections were performed with a blinded syringe. Clinical assessment was performed by the treating veterinarian at M1, M2 and M6 (2 and 6 months after M0), including lameness evaluation, palpation and flexion of the joint. Radiographic examination of the treated joints was performed at inclusion and repeated at M6. Radiographs were anonymized and assessed by 2 ECVDI LA associate members. Short term safety assessment was performed by owner survey. A 2-month rehabilitation program was recommended to veterinarians. There was a significant improvement of the total clinical score for horses in both groups. There was no significant difference in the total clinical score between groups MSC1 and MSC2 at any time point in the study. There was no significant difference in the total radiographic OA score, osteophyte score, joint space width score and subchondral bone score between inclusion and M6. Owner-detected adverse effects to MSC injection were recorded in 18% of the horses. Lameness caused by OA improved significantly over the 6-month duration of the study after treatment with allogeneic neonatal umbilical cord-derived MSCs combined with 8 weeks rest and rehabilitation. There is no apparent clinical benefit of repeated intra-articular administration of MSCs at a 1-month interval in horses with MPJ OA when compared to the effect of a single injection.

A Modular Hybrid Exoskeletal-Soft Glove for High Degree of Freedom Monitoring Capability

In this paper, we present a hybrid exoskeletal-soft glove for the application of on-axis angle sensors that can be placed close to the center of rotation of the digit joints. 3D printed exoskeletal digit segments that run medially on most digits connect to low friction bearings. Exoskeletal segments and bearings provide rigid fixation points for a variety of traditional angle sensors, while a combination of textile and rigid structure fixate exoskeletal digits to the digits and hand. Exoskeletal digits are designed modularly so that only required digits are used and to reduce difficulty in donning and doffing. On-axis measurement may prove useful in control or assessment tasks in rehabilitation. The articulation of the digits while wearing the glove is demonstrated, albeit without sensors, showing little restriction at an early stage of the design process. Exoskeletal metacarpophalangeal joints of the 3rd and 4th digits require more work as the flexion/extension joint axis is inaccessible and moves when he digits are articulated. The proposed device must be customized for an individual and will facilitate an alternative approach to existing hand posture monitoring techniques.

Fully Automatic Finger Extensor Tendon Segmentation in Ultrasound Images of the Metacarpophalangeal Joint

In this work a fully automatic system to identify the extensor tendon on ultrasound images of the metacarpophalangeal joint is proposed. These images are used to diagnose rheumatic diseases which are one of the main causes of impairment and pain in developed countries. The early diagnosis of these conditions is crucial to a proper treatment and follow-up and so, a system such as the one proposed here, could be useful to automatically extract relevant information from the resulting images. This work is an extension of a previous published work which uses manual annotations of the skin line, metacarpus and phalange to guide the extensor tendon segmentation. By introducing automatic segmentations of all structures, we expect to create a fully automatic system, which is more interesting to the possible end-users. Results show that, despite an expected loss in the performance, it is still possible to correctly identify the extensor tendon with a Confidence of 88% considering a maximum allowed Modified Hausdorff Distance of 0.5mm.

Long-Term Outcomes of Huber Opposition Transfer for Augmenting Hypoplastic Thumb Function

PURPOSE

This study was conducted to report the functional outcomes of the Huber opposition transfer (abductor digiti minimi muscle) in types II and IIIA hypoplastic thumbs.

METHODS

Patients who had undergone a Huber opposition transfer with at least 5 years of follow-up were included in this study. There were 21 thumbs included; 12 returned for a detailed evaluation and 9 were included with a medical record review. Outcome measures included range of motion and pinch strength; Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected on those who could return. There were 15 type II and 6 type IIIA thumbs.

RESULTS

Range of motion was significantly less than normal for both the interphalangeal and the metacarpophalangeal joints. For the returning cohort, key and tripod pinch were 44% and 65% of normal. The median Kapandji score was 9 (range, 6-10). The PODCI scores were high for global, upper extremity function, happiness, and pain. The PROMIS scores were similar to normal, except for parent reports of physical function. For all included patients, there was a revision surgery rate of 22%, primarily related to persistent instability.

CONCLUSIONS

At a minimum 5-year follow-up, the Huber opposition transfer for types II and IIIA thumbs was shown to provide good subjective outcomes, despite limited range of motion and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[« My joints are cracking, is it serious doctor ? » A review about sounds produced by joints]

The sounds produced by joints are a common source of questioning for doctors and their patients. Two major types are identified : cracks and crepitus. Few investigations have been carried out on these manifestations, while they potentially have clinical implications, especially for patellar crepitus in patellofemoral osteoarthrosis, and may generate anxiety. Knuckle cracking appears to be caused by the sudden and temporary occurrence of an intra-articular gaseous cavity, called tribonucleation. Other researches on these sounds are focused on the knees and their links with osteoarthritis, as well as on the spine. Many questions still arise but it seems important to talk about it with patients without trivializing them.

Collagenase injections for Dupuytren's disease: prospective cohort study assessing 2-year treatment effect durability

OBJECTIVES

To assess 2-year durability of joint contracture correction following collagenase injections for Dupuytren's disease.

DESIGN

Prospective cohort study.

SETTING

Orthopaedic Department in Sweden.

PARTICIPANTS

Patients with palpable Dupuytren's cord and active extension deficit (AED) ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. A surgeon injected 0.80 mg collagenase into multiple cord parts and performed finger manipulation under local anaesthesia after 24-48 hours. A hand therapist measured joint contracture before and 5 weeks after injection in all treated patients. Of 57 consecutive patients (59 hands), 48 patients (50 hands) were examined by a hand therapist 24-35 months (mean 26) after injection. Five of the patients had received a second injection in the same finger within 6 months of the first injection.

OUTCOME MEASURES

Primary outcome was proportion of treated joints with ≥20° worsening in AED from 5 weeks to 2 years.

RESULTS

Between the 5-week and the 2-year measurements, AED had worsened by ≥20° in seven MCP and seven PIP joints (28% of the treated hands; all had received a single injection). Mean AED for the MCP joints was 54° before injection, 6° at 5 weeks and 9° at 2 years and for the PIP joints 30°, 13° and 16°, respectively. For joints with ≥10° contracture at baseline, mean (95 % CI) baseline to 2 years AED improvement was for MCP 49° (41-54) and for PIP 25° (17-32). No treatment-related adverse events were observed at the 2-year follow-up evaluation.

CONCLUSIONS

Two years after collagenase injections for Dupuytren's disease, improvement was maintained in 72% of the treated hands. Complete contracture correction was seen in more than 80% of the MCP but in less than half of the PIP joints.

Effects of regional limb perfusion volume on concentrations of amikacin sulfate in synovial and interstitial fluid samples from anesthetized horses

OBJECTIVE To evaluate the effect of volume of IV regional limb perfusion (IVRLP) on amikacin concentrations in synovial and interstitial fluid of horses. ANIMALS 8 healthy adult horses. PROCEDURES Each forelimb was randomly assigned to receive IVRLP with 4 mL of amikacin sulfate solution (250 mg/mL) plus 56 mL (total volume, 60 mL) or 6 mL (total volume, 10 mL) of lactated Ringer solution. Horses were anesthetized, and baseline synovial and interstitial fluid samples were collected. A tourniquet was placed, and the assigned treatment was administered via the lateral palmar digital vein. Venous blood pressure in the distal portion of the limb was recorded. Additional synovial fluid samples were collected 30 minutes (just before tourniquet removal) and 24 hours after IVRLP began; additional interstitial fluid samples were collected 6 and 24 hours after IVRLP began. RESULTS 30 minutes after IVRLP began, mean amikacin concentration in synovial fluid was significantly greater for the large-volume (459 μg/mL) versus small-volume (70 μg/mL) treatment. Six hours after IVRLP, mean concentration in interstitial fluid was greater for the large-volume (723 μg/mL) versus small-volume (21 μg/mL) treatment. Peak venous blood pressure after large-volume IVRLP was significantly higher than after small-volume IVRLP, with no difference between treatments in time required for pressure to return to baseline. CONCLUSIONS AND CLINICAL RELEVANCE Study findings suggested that large-volume IVRLP would deliver more amikacin to metacarpophalangeal joints of horses than would small-volume IVRLP, without a clinically relevant effect on local venous blood pressure, potentially increasing treatment efficacy.

Finite-Element Analysis of Bone Stresses on Primary Impact in a Large-Animal Model: The Distal End of the Equine Third Metacarpal

OBJECTIVE

To assess whether the transient stresses of foot impact with the ground are similar to those found during midstance loading and if the location of high stress correlate with the sites most commonly associated with mechanically induced osteoarthritis (OA). We compared impact stresses in subchondral bone between two subject-specific, three-dimensional, finite-element models of the equine metacarpophalangeal (MCP) joint-one with advanced OA and one healthy, and with similar published data on the stresses that occur at midstance.

METHODS

Two right MCP joints (third metacarpal and proximal phalanx) were scanned using micro-computed tomography (μCT). Images were segmented, and meshed using modified 10-node quadratic tetrahedral elements. Bone material properties were assigned based on the bone density. An impact velocity of 3.55 m/s was applied to each model and contact pressures and stress distribution were calculated for each. In a separate iteration, the third metacarpal was loaded statically. A sampling grid of 160 equidistant points was superimposed over selected slices, and average peak stresses were calculated for 6 anatomical regions. Within-region maximal peak and average von Mises stresses were compared between healthy and OA bones in both midstance and impact loading.

RESULTS

Average impact stresses across all regions, in both locations (palmar and dorsal) were greater in the OA model. Highest impact stresses were located in the dorsal medial condyle in the healthy (12.8 MPa) and OA (14.1MPa) models, and were lowest in the palmar medial and lateral parasagittal grooves in the healthy (5.94 MPa) and OA (7.07 MPa) models. The healthy static model had higher peak (up to 49.7% greater) and average (up to 38.6% greater) stresses in both locations and across all regions compared to the OA static model.

CONCLUSIONS

Under simulated footfall a trot, loading on the dorsal aspect of the third metacarpal at impact created stresses similar to those found during midstance. The high accelerations that occur under impact loading are likely responsible for creating the high stresses, as opposed to midstance loading where the high stresses are the result of high mass loading. Although the stress magnitudes were found to be similar among the two loading conditions, the location of the high stress loading occurred in sites that are not typically associated with osteoarthritic changes.

Efficacy of treatments and pain management for trapeziometacarpal (thumb base) osteoarthritis: protocol for a systematic review

INTRODUCTION

The thumb is essential for daily activities. Unfortunately, this digit is commonly affected by trapeziometacarpal osteoarthritis (TMO), handicapping a large number of individuals. TMO constitutes an increasing human and economic burden for our society whose population is ageing. Limited access to adequate treatment is among the most important obstacles to optimal TMO management. Poor understanding of TMO characteristics, lack of knowledge about evidence-based treatments, simplistic pain management plans based solely on the patient's physical condition, absence of interprofessional communication and lack of multidisciplinary treatment guidelines contribute to inadequate TMO management. On the long term, our research project aims at improving the quality of care and services offered to patients with TMO by developing a patient-centred, evidence-based multidisciplinary management clinical pathway coordinated across the healthcare system. This proposed systematic review is a prerequisite to ensuring evidence-based practices and aims to document the efficacy of all the existing modalities for TMO management.

METHODS AND ANALYSIS

The protocol of the systematic review is registered with PROSPERO and will be conducted using the guidelines Cochrane Handbook for Systematic Reviews of Interventions. We will identify studies in English and French concerning TMO treatments through searches in Cochrane Central, EMBASE, MEDLINE, PsychINFO, CINHAL, PubMed, OT Seekers, PEDRO and the grey literature. 2 reviewers will independently screen study eligibility, extract data and appraise studies using published assessment tools. Meta-analyses will be undertaken where feasible; otherwise, narrative syntheses will be carried out. The robustness of evidence will be assessed using the GRADE system.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. A comprehensive knowledge exchange and transfer plan incorporating effective strategies will be used to disseminate the findings of this review and utilise them to optimise TMO management.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015015623.

Segmentation of bones & MCP joint region of the hand from ultrasound images

Rheumatic arthritis (RA) is an autoimmune disease that causes irreversible damage to joints and other physiological structures. The Metacarpophalangeal (MCP) joint is one of the first regions to suffer alterations. These alterations are visible with high frequency ultrasound devices, which are used to quantify inflammatory activity in the MCP due to RA. The accurate segmentation of the bone surface and the identification of the MCP capsule region remains a challenge in ultrasound image processing. In this article we aim to make a contribution to this problem by incorporating prior knowledge of the bone and joint regions anatomy into our segmentation algorithm. The log Gabor filter is used for speckle noise reduction and to extract ridge-like structures from the images, while the phase is left unchanged. After thresholding, scores are generated, based on the intensities and areas of the resulting regions, enabling the selection of the structure that best matches the bone. Finally, segmented joint bones are processed to calculate the initial seeds of joint capsule region. Experimental results demonstrate the accuracy of the proposed segmentation algorithm. The mean pixel error between the automatic segmentation and the reference images were 4.4 pixel. The bone regions not segmented were, on average, 5.4%.

[MRI of the thumb collateral ligament at the metacarpophalangeal joint: anatomy and injuries]

OBJECTIVE

To explore the anatomy and injuries features of the thumb collateral ligamentat the metacarpophalangeal (MCP) joints.

METHODS

The study was reviewed and approved by an institutional review board of hospital. Clinical imaging data of 7 healthy volunteers who without injuries and 20 patients with thumb collateral ligament injuries were retrospectively analyzed. All subjects underwent magnetic resonance examination, then comparative analysis of the normal anatomy and the thumb collateral ligament injury at MCP joints of MRI features in healthy volunteers and patients with injury. Imaging findings were compared with the surgical results and confirmed by followed up in patients.

RESULTS

Seven volunteers without ligament injures showed homogeneous low-signal-intensity on T1-weighted and proton fat saturation sequence (PD-FS) images. The average thickness of the ulnarcollateral ligament is about 2.0 to 2.3 mm, however, the normal radial collateral ligament is thinner, the average thickness is about 1.4-1.5 mm. There were 20 patients with thumb collateral ligament injuresat MCP joints, including 12 cases of ulnar collateral ligament injury and 8 cases of radial collateral ligament injury, which demonstrated poor definition, discontinuity and heterogeneously increased signal intensity in proton fat saturation sequence (PD-FS) of the involved collateral ligament. There was edema in the soft tissues surrounding the injured sites.

CONCLUSION

MRI is an accurate method for evaluation of the anatomy and pathologic conditions of the thumb collateral ligamentsat MCP joints, and it is a useful tool for early diagnosis and treatment of the thumb collateral ligaments injuries.

[APPLICATION OF WRIST CREASE ISLAND FLAP BASED ON THE SUPERFICIAL PALMAR BRANCH OF THE RADIAL ARTERY FOR THUMB RECONSTRUCTION]

OBJECTIVE

To investigate the effectiveness of the island flaps based on the superficial palmar branch of the radial artery (SPBRA) to repair the thumb wound.

METHODS

Between February 2012 and November 2013, 8 cases of thumb defects and bilateral artery defect were treated. There were 5 males and 3 females with an average age of 30.5 years (range, 19-51 years). The injury was caused by crush (4 cases), avulsion (3 cases), and twist (1 case). The injury located at the metacarpophalangeal joints in 3 cases, at the proximal palmar side in 2 cases, and at the interphalangeal joints in 3 cases. The defect size ranged from 3.5 cm x 1.5 cm to 6.5 cm x 2.0 cm. The digital artery defect was 2.5-8.5 cm (mean, 5.3 cm). The disease duration was 2.0-4.5 hours (mean, 3.2 hours). The reversed island flaps based on the SPBRA were designed, which size was 4.0 cm x 2.0 cm to 7.5 cm x 3.0 cm. The donor sites were closed directly.

RESULTS

The operation was successfully completed in 7 patients except 1 patient having vascular variation. All flaps survived completely. Wound and incision at the donor site healed by first intention. All patients were followed up 6-18 months (mean, 13 months). The flaps had similar color and texture to adjacent skin. Linear scar was seen at the donor site in 1 patient, with no functional limitation. According to the functional assessment criteria of upper limb by the Hand Surgery Branch of Chinese Medical Association, the results were excellent in 6 cases, good in 1 case, and fair in 1 case, with an excellent and good rate of 87.5%.

CONCLUSION

The reversed island flap based on the SPBRA is an ideal flap for the thumb reconstruction because the advantages of reliable blood supply, easy dissection, less injury at donor site, and good repair results.

[PROCEDURE OF RECONSTRUCTING TRANSVERSE ARCH OF THE FOREFOOT BY TRANSFERING TENDONS FOR CORRECTING HALLUX VALGUS]

OBJECTIVE

To explore the effectiveness of the procedure of reconstructing the transverse arch of the forefoot by anastomosing adductor hallucis and abductor hallucis tendons in correcting hallux valgus.

METHODS

A retrospective analysis was made on the clinical data from 28 patients (40 feet) with hallux valgus treated with the procedure of reconstructing the transverse arch of the forefoot by anastomosing adductor hallucis and abductor hallucis tendons between January 2010 and January 2014. There were 3 males (6 feet) and 25 females (34 feet), with an average age of 51.7 years (range, 20-71 years). The unilateral foot was involved in 16 cases and bilateral feet in 12 cases. The mean disease duration was 8.9 years (range, 1-30 years). All the cases had pain of the first metacarpophalangeal joint; 22 feet had collapsed transverse arch of the forefoot combined with plantar callus, and 8 feet had collapsed transverse arch of the forefoot combined with hammer toe deformity. American Orthopaedic Foot and Ankle Society (AOFAS) score was 59.07 +/- 8.49. Preoperative X-ray showed that the hallux valgus angle (HVA) was (33.68 +/- 8.10) degrees, and the intermetatarsal angle (IMA) was (15.60 +/- 4.07) degrees. According to classification of the hallux valgus by Mann, 9 feet were rated as mild, 23 feet as moderate, and 8 feet as severe.

RESULTS

Superficial infection of incision occurred in 1 case (1 foot) after surgery, and healing by first intention was obtained in the others. Two cases (3 feet) had numbness in the toes. All of 28 cases were followed up from 6 months to 4 years (1.8 years on average). Based on the AOFAS score, the results were excellent in 24 feet, good in 9 feet, fair in 4 feet, and poor in 3 feet, and the excellent and good rate was 82.5%. At last follow-up, the HVA, IMA, and AOFAS score were (15.10 +/- 5.28), (9.05 +/- 2.42) degrees, and 86.03 +/- 7.45 respectively, showing significant differences compared with preoperative ones (P=0.00). The collapsed transverse arch of the forefoot was recovered to some extent, plantar callus disappeared (14 feet), or decreased (8 feet). Recurrence of hallux valgus deformity was observed in 2 cases (3 feet) at 2 and 3 months after surgery respectively, and no hallux varus was found.

CONCLUSION

This procedure not only can effectively reduce the increased hallux valgus angle, and narrow the angle between the 1st and 2nd metatarsal, but also can relocate the sesamoid system, reconstruct the transverse arch of the forefoot, and effectively restore the physiological anatomy structure and biological function of the forefoot.

Patients' expectations, experiences and the determinants of satisfaction related to metacarpophalangeal arthroplasty

PURPOSE

Most previous research has used quantitative patient-rated outcome measures to identify patients' perceptions related to metacarpophalangeal (MCP) arthroplasty. However, little is known about the lived experience of this procedure. The present study aimed to gain an in-depth understanding of patients' expectations and experiences, and the determinants of satisfaction related to MCP arthroplasty and postoperative rehabilitation.

METHODS

Semi-structured interviews were conducted with six participants from two London hospitals at four months to three years post-surgery. Interviews were transcribed verbatim and analysed using descriptive phenomenological analysis.

RESULTS

Participants' reasons for surgery varied considerably and their expectations were informed by previous surgical experience and information from healthcare professionals. Diverse, and occasionally ambivalent, perceptions of various aspects of postoperative treatment were expressed and all participants emphasized the importance of reassurance and understanding by the healthcare team. When describing the effect of surgery on their lives, all experienced a period of 'frustrating dependence' and adopted a variety of psychological and practical coping mechanisms. Experience of recovery and long-term outcome was influenced by factors extraneous to MCP arthroplasty, including medical condition and disease at adjacent joints. Factors influencing satisfaction included participants' evaluation of the extent to which goals and preoperative expectations had been met and the impact of surgery on their lives.

CONCLUSIONS

Joint goal-setting is essential for understanding patients' unique reasons for undergoing MCP arthroplasty and facilitating realistic expectations. Education on all aspects of postoperative care is vital. Patients should be made aware of variability in outcome and the potential for deterioration due to the chronic nature of rheumatoid arthritis.

[INFLUENCE FACTORS ANALYSIS OF SURGICAL EFFECTIVENESS FOR SOLITARY ENCHONDROMA OF HAND WITH PATHOLOGIC FRACTURE]

OBJECTIVE

To expore the influence factors of the surgical effectiveness for solitary enchondroma of the hand with pathologic fracture.

METHODS

A retrospective analysis was made on the clinical data of 65 patients with solitary enchondroma of the hand with pathologic fracture who were treated with operation and were accorded with selective standard between March 2010 and June 2013. There were 26 males and 39 females, aged 17 to 63 years (mean, 36 years). The left hands were involved in 32 cases and the right hands in 33 cases. The tumor located at the metacarpus in 18 cases, and at the phalanx in 47 cases (at the proximal phalanx in 30 cases, at the middle phalanx in 9 cases, and at the distal phalanx in 8 cases). The duration from fracture to operation was 2 days to 2 years (mean, 56 days). The operative methods were curettage and bone grafting. The ratios of the total active range of motion (ROM) of the metacarpophalangeal joint and interphalangeal joint between ipsilateral and contralateral fingers were used to evaluate the ipsilateral fingers' function. The time of returning to work was recorded. The multiple linear regressions were performed to analyze the risk factors of the effectiveness.

RESULTS

A total of 65 cases were followed up 5-44 months (mean, 24 months). All incisions achieved primary healing. No infection, re-fracture, or recurrence occurred. The X-ray films showed fracture healing, the healing time was 5-10 weeks (mean, 6.5 weeks). All the bone grafts healed well. At last follow-up, the ROM ratio of the fingers was 0.46-1.00 (mean, 0.90). The time of returning to work was 92-180 days (mean, 130 days). Multiple linear regressions showed that internal fixation was risk factor for the ROM ratio of the fingers (P = 0.013). The duration from fracture to operation, internal fixation, and the tumor site were risk factors for the time of returning to work (P < 0.05).

CONCLUSION

To obtain good effectiveness for patients with solitary enchondroma of the hand with pathologic fracture, it is suggested that immediate operative treatment including tumor curettage, open reduction, and internal fixation with plate and screws of the fracture.

[CLINICAL RESEARCH OF POSTOPERATIVE DEVIATION SECONDARY TO THUMB DUPLICATION RESECTION]

OBJECTIVE

To study the causes and treatment of postoperative deviation secondary to thumb duplication resection.

METHODS

Between February 2007 and June 2013, 32 cases (33 thumbs) of postoperative deviation secondary to thumb duplication resection were treated, and the clinical data were retrospectively analyzed. There were 13 males and 19 females, aged 2-34 years (median, 8 years). The left thumbs were involved in 7 cases, the right thumbs in 24 cases, and bilateral thumbs in 1 case. Of 33 thumbs, 2 were rated as type II, 4 as type III, 10 as type IV, 7 as type V, and 10 as type VII according to Wassel classification. The average time between duplicated thumb resection and admission was 6.5 years (range, 1-29 years). Nine thumbs only had ulnar deviation of the metacarpophalangeal (MP) joint; 8 thumbs only had radial deviation of the interphalangeal (IP) joint; 10 thumbs only had ulnar deviation of the IP joint; and 6 thumbs had ulnar deviation of the MP joint combined with radial deviation of the IP joint. The mean deviation degree of the MP joint was 32.3 (range, 20-40*), and the mean deviation degree of the IP joint was 42.5° (range, 30-110°). Operation methods were chosen specially according to the deformity, including remnant bone or cartilage resection, restoring normal alignment, and soft tissue balance.

RESULTS

All wounds got first stage healing and there was no complication associated with operation. Postoperative follow-up period ranged from 6 to 70 months (mean, 34 months). The skeleton alignment of the thumbs was improved on the X-ray images; all osteotomy got union at 5-10 weeks (mean, 6 weeks). Deviation was completely corrected in 31 thumbs; the preoperative deviation degree was too large to correct completely in 2 thumbs with a postoperative deviation degree of 10°. The motion degree was similar to that at preoperation in 13 thumbs; the motion degree decreased in 20 thumbs, which did not affect the function of the thumbs. Nineteen cases (20 thumbs) were followed more than 2 years, there was no recurrence of deviation and all thumbs developed well, but the size of affected thumb was smaller than that of the contralateral side in 14 cases (14 thumbs).

CONCLUSION

Getting good result and preventing postoperative deviation for thumb duplication resection acquires appropriate preoperative design, reconstruction of the insertion of the abductor poll icis brevis, transposition of the flexor and extensor pollicis longus insertion, and essential osteotomy play important roles in preventing postoperative deviation after thumb duplication resection. Individualized treatment plan for deviation should be made according to the degree and the cause of deviation.

[Short-term effectiveness of Swanson artificial joint replacement in treating posttraumatic metacarpophalangeal joint stiffness]

OBJECTIVE

To investigate the short-term effectiveness of Swanson artificial joint replacement in treating post-traumatic metacarpophalangeal joint stiffness.

METHODS

Between August 2007 and May 2010, 11 cases (13 fingers) of metacarpophalangeal joint stiffness with soft tissue defects underwent Swanson artificial joint replacement. There were 7 males (9 fingers) and 4 females (4 fingers), aged 43 to 65 years with an average of 49 years. The involved fingers included 4 thumbs, 4 index fingers, 3 middle fingers, and 2 ring fingers. The types of injury included open and crush injury in 8 fingers, fracture of the metacarpophalangeal joint in 3 fingers, metacarpophalangeal joint severing in 2 fingers. The time from joint stiffness to hospitalization was 12 to 48 weeks (mean, 24 weeks). The joint activity was (136.82 +/- 28.96) degrees. According to total active motion (TAM) assessment, included good in 1 finger, fair in 6 fingers, and poor in 6 fingers before operation. The activities of daily living were assessed by Sollerman score, which was 45.64 +/- 11.04. The X-ray films and CT scan showed traumatic arthritis of the metacarpophalangeal joint.

RESULTS

The incision healed by first intention. All patients were followed up 12 to 34 months (mean, 24.1 months). At last follow-up, the joint activity was (194.64 +/- 28.86) degrees, showing significant difference when compared with preoperative value (t = 25.214, P = 0.000). According to TAM assessment, including excellent in 1 finger, good in 4 fingers, fair in 7 fingers, and poor in 1 finger. The Sollerman score was 67.45 +/- 8.20 postoperatively, showing significant difference when compared with the preoperative score (t = -10.470, P = 0.000). X-ray examination showed no prosthesis fracture, periprosthetic fracture, or joint dislocation occurred at last follow-up.

CONCLUSION

Swanson artificial joint replacement can be applied to treat post-traumatic metacarpophalangeal joint stiffness, which can improve the joint activity and has satisfactory short-term effectiveness.

Index rotation flap for palmar thumb release in arthrogryposis

The soft tissue envelope in congenital contractural conditions such as clasped or arthrogrypotic thumbs is often deficient in 2 planes, the thumb-index web and the flexor aspect of the thumb. Small local transposition flaps borrow tissue from 1 plane to augment the other and are likely to worsen 1 contracture whereas improving the other. Tissue must be added to the thumb envelope from outside the contracted areas. A flap based on the index finger can be designed to both open the thumb-index web and augment skin on flexor aspect of the thumb metacarpophalangeal joint. This flap is particularly useful in the congenital contractural conditions that have the appearance of a small ptyerigium or increased skin in the dorso-palmar plane of the index finger. After a comprehensive release of all the tight structures, this technique for skin closure is straightforward and the donor site can usually be closed primarily.

Metacarpophalangeal arthroscopy: technique and applications

Metacarpophalangeal joint arthroscopy is an emerging and useful tool for the upper extremity surgeon. Equipment, operating room set-up, and techniques are reviewed. Indications for diagnostic and therapeutic metacarpophalangeal joint arthroscopy are presented, including several relevant applications.

Reproducibility of metacarpophalangeal bone mass measurements obtained by dual-energy X-ray absorptiometry in healthy volunteers and patients with early arthritis

The prognostic value of measuring hand bone mineral density (BMD) in patients with early arthritis (EA) has been recently assessed. In this work, we evaluate the reproducibility of measuring juxta-articular BMD by dual-energy X-ray absorptiometry (DXA) at the second to fifth metacarpophalangeal (MCP) joints. We obtained whole hand (WH) and MCP joint BMD measurements from 16 healthy subjects and from 22 patients with EA. The coefficient of variation, intraclass correlation coefficient (ICC), and smallest detectable difference (SDD) were calculated. The coefficient of variation ranged from 1.3% to 0.7% at MCP joints and from 1.4% to 0.9% in the WH measurements, respectively. The intra- and interobserver ICC for both WH and MCP joints ranged from 0.97 to 0.99. The SDD at the different anatomical locations analyzed ranged from 0.006 to 0.022 g/cm2 in healthy controls and from 0.005 to 0.010 g/cm2 in EA. Interestingly, patients who fulfilled rheumatoid arthritis criteria showed a lower bone mass than those with undifferentiated arthritis. Therefore, BMD measurements obtained by DXA at MCP joints were reproducible and it might be useful in the study of patients with EA.

Oncogenic osteomalacia

A 59-year-old gentleman presented with symptoms of progressively worsening low back pain associated with difficulty in rising from a squat over a period of two years. Biochemical tests confirmed the initial clinical diagnosis of osteomalacia. Blood pool scanning revealed a focal hot spot on the site of the clinically visible swelling close to the metacarpo-phalangeal joint of the left index finger. The biopsy of the specimen obtained by excision was reported to be consistent with a phosphaturic mesenchymal tumour. The patient had complete resolution of symptoms six months following excision of the lesion.

Engraftment of cutaneous fibroblasts within synovial membrane in a nonhuman primate: Short-term results

OBJECTIVES

Gene therapy using cells as vectors to achieve secretion of therapeutic proteins may hold promise in the treatment of chronic diseases. Cell-based gene therapy with xenogeneic cells secreting antiinflammatory cytokines (IL-4, IL-13, or IL-1 receptor type II) has been found effective in mice with collagen-induced arthritis (CIA), a model for human rheumatoid arthritis. Autologous cells engineered to produce antiinflammatory cytokines were also effective in the mouse CIA model. In all these experiments, the cells were grafted into the subcutaneous tissue of the back, resulting in systemic treatment. To evaluate the feasibility of cell-based gene therapy confined to the joints, we performed intraarticular injections of autologous cells in a rhesus monkey with CIA, a model more similar to human RA.

METHODS

We prepared ex vivo cultures of skin fibroblasts from the animal then transfected the cells with a plasmid carrying the lacZ gene. We injected these marker cells into metacarpophalangeal, metatarsophalangeal, and interphalangeal joints.

RESULTS

Kinetic evaluation of synovial tissue X-gal labeling, which reflected reported gene expression by skin fibroblasts present within the synovium, showed significant labeling by transfected cells up to 6 days after intraarticular injection. Xenogeneic fibroblasts (Chinese hamster ovary cells) injected intraarticularly were also detected within synovial specimens; however, labeling intensity was less marked than with autologous cells. Our findings establish the feasibility of skin fibroblast grafting into the synovium.

CONCLUSION

This preliminary study opens the door to studies of heterotopic autologous transfected cells for the treatment of CIA in monkeys by direct gene transfer within joints.

Evidence for a different anatomic basis for joint disease localization in polymyalgia rheumatica in comparison with rheumatoid arthritis

OBJECTIVE

The anatomic basis for joint disease localization in polymyalgia rheumatica (PMR) is poorly understood. This study used contrast-enhanced and fat suppression magnetic resonance imaging (MRI) to evaluate the relationship between synovial and extracapsular inflammation in PMR and early rheumatoid arthritis (RA).

METHODS

Ten patients with new-onset PMR and 10 patients with early RA underwent dynamic contrast-enhanced MRI and conventional MRI of affected metacarpophalangeal (MCP) joints. Synovitis and tenosynovitis were calculated based on the number of enhancing voxels, initial rate of enhancement, and maximal enhancement of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Periarticular bone erosion and bone edema were scored according to the OMERACT (Outcome Measures in Rheumatology Clinical Trials) scoring system in both groups. The degree of extracapsular Gd-DTPA enhancement was assessed in both conditions using semiquantitative scoring.

RESULTS

No significant differences were seen in the volume of synovitis (P = 0.294), degree of flexor tenosynovitis (P = 0.532), periarticular erosions (P = 0.579), or degree of bone edema (P = 0.143) between RA and PMR joints. However, despite comparable degrees of synovitis, the proportion of MCP joints showing extracapsular enhancement was higher in the PMR group (100%) than in the RA group (50%) (P = 0.030). One PMR patient, but none of the RA patients, had bone edema at the capsular insertion.

CONCLUSION

Despite degrees of synovitis and tenosynovitis comparable with those in RA, PMR-related hand disease is associated with prominent extracapsular changes, suggesting that inflammation in these tissues is more prominent than joint synovitis, which is common in both conditions. This suggests that the anatomic basis for joint disease localization differs between RA and PMR.

Kinematics of the fingers and hands during computer keyboard use

BACKGROUND

Although there has been extensive research about the kinematics of the neck, arm, and wrist during computer keyboarding, there is almost no information concerning the kinematics of the fingers, thumbs, and hands. The purpose of this descriptive study was to establish normative values of the kinematics of the fingers and hands during computer keyboard use.

METHODS

This study describes the angles, angular velocities, and angular accelerations of the metacarpophalangeal joints and proximal interphalangeal joints for the right and left hands of 20 computer keyboard users during a word-processing task. A new kinematic variable for computer keyboard use, hand/wrist displacement, is also defined and examined. Hand/wrist displacement refers to the translational movements of the hands in which the entire hand is repositioned to strike the keys. Kinematics of both hands of the keyboard users were captured using a three-dimensional motion capture system.

FINDINGS

Metacarpophalangeal joint kinematics in flexion/extension and abduction/adduction are reported during typing. Proximal interphalangeal joint kinematics in flexion/extension are also reported. The means and standard deviations for finger postures, velocities and acceleration were generally not significantly different between the right and left hands, with the exception of the 1st digit (thumb). Hand/wrist displacement was significantly different between the right and left hands for side to side movements. Differences in kinematics among the fingers are discussed in view of their potential to be a risk factor for musculoskeletal disorders.

INTERPRETATION

This study establishes baseline understanding of the kinematics of computer keyboard use. This information will be useful in future studies of potential risk factors associated with keyboard use.

Locking of the metacarpophalangeal joint of the thumb by a loose body: a case report

We report a case with locking of the metacarpophalangeal (MP) joint of the thumb in a 15-year-old high school baseball catcher, which was caused by an intra-articular loose body arising from osteochondritis dissecans. The loose body was removed arthroscopically, enabling early return to full MP joint function.

Effect of pulsed electromagnetic fields on proteoglycan biosynthesis of articular cartilage is age dependent

OBJECTIVE

To investigate the effects of a pulsed electromagnetic field (EMF) on articular cartilage matrix biosynthesis with regard to age and cartilage damage using a matrix depleted cartilage explant model.

METHODS

Cartilage explants were obtained from metacarpophalangeal joints of calves and adult cows. After depletion of the extracellular matrix by trypsin digestion, samples were maintained in serum-free basal medium with and without the addition of interleukin 1beta (IL1beta). Half the samples were subjected to an EMF for 24 minutes daily; the other half were left untreated. Undigested and untreated explants served as negative controls. After 7 days, biosynthesis of matrix macromolecules was assessed by [35S]sulphate incorporation and values were normalised to hydroxyproline content.

RESULTS

The EMF increased matrix macromolecule synthesis in undigested, untreated explants (p<0.009). In matrix depleted samples the EMF had no stimulatory effect on proteoglycan biosynthesis. IL1beta significantly decreased the de novo synthesis of matrix macromolecules (p<0.00004) in young and adult samples, but an EMF partly counteracted this inhibitory effect in cartilage samples from young, but not old animals.

CONCLUSION

EMF promoted matrix macromolecule biosynthesis in intact tissue explants but had no stimulatory effect on damaged articular cartilage. The supressive effects of IL1beta were partially counteracted by EMF exposure, exclusively in cartilage derived from young animals. An EMF has age dependent chondroprotective but not structure modifying properties when cartilage integrity is compromised.

Malignant fibrous histiocytoma arising in a gouty tophus at the second metacarpophalangeal joint

We report a case of concomitant malignant fibrous histiocytoma (MFH) and tophaceous deposit at the second metacarpophalangeal joint in a 76-year-old man. The patient underwent surgical treatment, local radiotherapy and adjuvant chemotherapy and was disease free at the time of his last examination. We use this case to highlight the features of this clinical entity, which has never previously been described in the surgical literature.