Kakar, Sanjeev

Aims Dupuytren’s contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition. Materials and Methods A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included. Results PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH. Conclusion Currently there remains limited evidence to guide the management of patients with Dupuytren’s contracture. Cite this article: Bone Joint J 2018;100-B:1138–45.

Background: The purpose of this study is to determine the effects of proximal hamate transfer for proximal pole scaphoid reconstruction upon carpal kinematics. Methods: Eight fresh-frozen cadaveric wrists underwent evaluation of their radiocarpal and midcarpal motion after proximal hamate osteotomy. A wrist simulator was used to apply cyclical tension to the flexor carpi ulnaris (FCU), flexor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis stitched together (ECR). Kinematic motion was captured using Moiré Phase Tracking 3-dimensional motion-tracking sensors (MPT, Metria Innovation, Inc, Milwaukee, Wisconsin) to evaluate the lunocapitate and scapholunate angles for each condition. Results: During wrist flexion-extension and radial-ulnar deviation, there were no statistically significant differences about the lunocapitate or scapholunate axis between the intact and post-hamate osteotomy conditions. Conclusions: The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics.

* The thumb carpometacarpal joint is one of the most common locations for degenerative osteoarthritis in the hand. * Conservative therapies include hand therapy, nonsteroidal anti-inflammatory drugs, splinting, activity modification, and corticosteroid injections. * Surgical treatment is divided into trapezium-preserving procedures in addition to trapezium-sacrificing procedures. Trapezium-preserving procedures, which should be performed when the scaphotrapeziotrapezoidal joint is free of disease, include joint arthroscopy and its associated procedures, carpometacarpal arthrodesis, and implant arthroplasty. When pantrapezial disease is noted, a trapezium-sacrificing technique such as trapeziectomy with ligament reconstruction and tendon interposition should be used. In cases in which the scaphotrapeziotrapezoidal joint is involved, a resection of the most proximal aspect of the trapezoid is beneficial.

Background We designed a survey to ascertain the current perspectives of hand surgeons on the evaluation and management of ulnar nerve instability at the elbow. The secondary aim was to assess the concordance of hand surgeons on definitions of the terms “subluxated” and “dislocated” for classification of ulnar nerve instability. Methods A questionnaire, including demographic practice variables, cubital tunnel practice patterns, preoperative imaging and electrodiagnostic evaluation, and a series of standardized intraoperative photographs of ulnar nerve instability at the elbow were developed and distributed to the current American Society for Surgery of the Hand (ASSH) membership. Results A total of 690 (26.8%) members completed the survey; 84.2% of respondents indicated that they evaluate for ulnar nerve instability preoperatively with clinical examination, whereas only 6.1% indicated they routinely obtained dynamic ultrasound. Respondents indicated that the factors most strongly influencing their decision to proceed with anterior transposition of the ulnar nerve were subluxation on physical examination (89.6%), history consistent with ulnar nerve subluxation (85.8%), and muscle atrophy (43.2%). On review of clinical photographs, respondents demonstrated varying degrees of agreement on the terms “subluxated” or “dislocated” and recommendations for ulnar nerve transposition at intermediate degrees of ulnar nerve instability. Conclusion ASSH members routinely evaluate for ulnar nerve instability with history and clinical examination without uniform use of preoperative ultrasound, and nearly half of the time the decision to transpose the ulnar nerve is made intraoperatively. Definitions for the degree of ulnar nerve instability at the elbow are not uniformly agreed upon, and further development of a classification system may be warranted to standardize treatment.

Background: This study reviews long-term outcomes of partial wrist denervation focusing on need for and time to revision procedure. Methods: A retrospective study was conducted of all patients undergoing partial wrist denervation between 1994 and 2014. At average latest follow-up of 6.75 years (range, 1-21 years), clinical and radiographic data and need for revision surgery were recorded. Results: There were 100 wrists in 89 patients (61 male, 28 female) with average age at surgery of 54 years (range, 26-80). Principal diagnoses were arthritis (58%), inflammatory (19%), and posttraumatic arthritis (7%). Average flexion-extension arc was 83% and grip strength 75% of unaffected extremity. Average Mayo Wrist Scores improved from 48 preoperatively to 77 postoperatively. Sixty-nine percent of patients did not undergo other procedures during the time interval studied. Thirty-one percent underwent revision at an average of 26 months following denervation (range, 2-165). Conclusions: Partial wrist denervation is a motion-preserving procedure for patients with refractory wrist pain with 69% in this series requiring no further procedures. The remaining 31% experienced average symptom relief for 2 years prior to ultimately undergoing revision operation.

AbstractTendon graft healing in bone tunnels for the fixation of intra‐articular ligament reconstructions may limit clinical outcome by delaying healing. This study assesses the effects of hydrogel‐mediated delivery of bone anabolic growth factors in a validated model of tendon‐to‐bone tunnel healing. Forty‐five Wistar rats were randomly allocated into three groups (BMP2‐treated, GSK126‐treated, and placebo). All animals underwent a tendon‐to‐bone tunnel reconstruction. Healing was evaluated at 4 weeks by biomechanical assessment, micro‐computed tomography (bone mineral density, bone volume, cross sectional area of bone tunnels), and traditional histology. Adverse events associated with the hydrogel‐mediated delivery of drugs were not observed. Results of our biomechanical assessment demonstrated favorable trends in animals treated with bone anabolic factors for energy absorption (P = 0.116) and elongation (P = 0.054), while results for force to failure (P = 0.691) and stiffness (P = 0.404) did not show discernible differences. Cross sectional areas for BMP2‐treated animals were reduced, but neither BMP2 nor GSK126 administration altered bone mineral density (P = 0.492) or bone volume in the bone tunnel. These results suggest a novel and positive effect of bone anabolic factors on tendon‐to‐bone tunnel healing. Histological evaluation confirmed absence of collagen fibers crossing the soft tissue‐bone interface indicating immature graft integration as expected at this time point. Our study indicates that hydrogel‐mediated delivery of BMP2 and GSK126 appears to be safe and has the potential to enhance tendon‐to‐bone tunnel healing in ligament reconstructions.

Background Scapholunate (SL) joint instability is one of the most common injuries of the wrist and may result from a fall or high-energy mechanism on the outstretched hand. The purpose of this case report is to describe the outcome of a 360-degree tenodesis to the SL joint with an internal brace (SLITT) for the treatment of SL instability. Case Description A 42-year-old male patient underwent SL ligament reconstruction with the SLITT procedure 12 months after injury. Given the intrinsic stability of the reconstruction, Kirschner (K) wires were not used and an early range of motion protocol was initiated. Thirteen months after his reconstruction, he was back at work with maintenance of his carpal alignment. Discussion Since its initial description, a myriad of different surgical techniques for SL instability have been devised with varied success. These include capsular shrinkage, dorsal capsulodesis, reduction-association with a screw of the scapholunate joint (RASL), scapholunate axis method (SLAM), bone ligament bone grafts, and a variety of tendon reconstructions. Possible explanations for this varied outcome may be related to the use of soft tissue reconstructions for irreducible injuries and reconstruction of only the dorsal SL ligament. In addition, many of these techniques involve prolonged immobilization with the use of K-wires. Clinical Relevance The SLITT procedure reconstructs both the volar and dorsal SL ligament. Given the added stability afforded by intrinsic bracing, we feel that this reconstruction may permit earlier range of motion without the need for K-wire stabilization.

ABSTRACTPhlpp protein phosphatases are abnormally abundant within human osteoarthritic articular chondrocytes and may contribute to the development of osteoarthritis. Mice lacking Phlpp1 were previously shown to be resistant to post‐traumatic osteoarthritis. Here a small molecule with therapeutic properties that inhibits Phlpp1 and Phlpp2 was tested for its ability to slow post‐traumatic OA in mice and to stimulate anabolic pathways in human articular cartilage from OA joints. PTOA was induced in male C57Bl/6 mice by surgically destabilizing the meniscus. Seven weeks after surgery, mice received a single intra‐articular injection of the Phlpp inhibitor NSC117079 or saline. Mechanical allodynia was measured with von Frey assays, mobility was tracked in an open field system, and cartilage damage was assessed histologically. A single intra‐articular injection of the Phlpp inhibitor NSC117079 attenuated mechanical allodynia and slowed articular cartilage degradation in joints with a destabilized meniscus. Animals treated with the Phlpp inhibitor 7 weeks after injury maintained normal activity levels, while those in the control group traveled shorter distances and were less active 3 months after the joint injury. NSC117079 also increased production of cartilage extracellular matrix components (glycosaminoglycans and aggrecan) in over 90% of human articular cartilage explants from OA patients and increased phosphorylation of Phlpp1 substrates (AKT2, ERK1/2, and PKC) in human articular chondrocytes. Our results indicate that Phlpp inhibitor NSC117079 is a novel osteoarthritis disease modifying drug candidate that may have palliative affects. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1487–1497, 2018.