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The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.

[Introduction][1] The step-cut ulnar shortening osteotomy for the treatment of ulnar impaction syndrome is a safe, reliable, and less expensive technique that uses a 7-hole 3.5-mm standard neutralization plate and a lag screw for fixation, thus avoiding the need for the special instrumentation that other ulnar shortening techniques require. [Indications & Contraindications][2] [Step 1: Preoperative Planning][3] Perform a physical examination and obtain imaging studies to identify all associated abnormalities. [Step 2: Wrist Arthroscopy][4] ([Video 1][5]) Verify the diagnosis of ulnar impaction syndrome and treat concurrent intra-articular abnormalities. [Step 3: Incision for the Ulnar Shortening Osteotomy][6] ([Video 2][7]) Make a longitudinal skin incision along the distal third of the ulna. [Step 4: Design the Step-Cut Ulnar Shortening Osteotomy][8] ([Video 2][7]) Design the step-cut ulnar shortening osteotomy. [Step 5: Perform the Step-Cut Ulnar Shortening Osteotomy][9] ([Video 2][7]) Create the step-cut ulnar shortening osteotomy using an oscillating saw. [Step 6: Fixation of the Osteotomy][10] ([Video 3][11]) Fix the osteotomy with a lag screw and volar plate. [Step 7: Wound Closure][12] Meticulously close the wound in layers. [Step 8: Postoperative Care][13] Protect the affected arm for the first 6 weeks. [Results][14] In our original study, 164 patients with symptomatic ulnar impaction syndrome were treated with a step-cut ulnar shortening osteotomy using a volar 3.5-mm standard neutralization plate and a lag screw[14][15]. [Pitfalls & Challenges][16] [Introduction][1] The step-cut ulnar shortening osteotomy for the treatment of ulnar impaction syndrome is a safe, reliable, and less expensive technique that uses a 7-hole 3.5-mm standard neutralization plate and a lag screw for fixation, thus avoiding the need for the special instrumentation that other ulnar shortening techniques require. [Indications & Contraindications][2] [Step 1: Preoperative Planning][3] Perform a physical examination and obtain imaging studies to identify all associated abnormalities. [Step 2: Wrist Arthroscopy][4] ([Video 1][5]) Verify the diagnosis of ulnar impaction syndrome and treat concurrent intra-articular abnormalities. [Step 3: Incision for the Ulnar Shortening Osteotomy][6] ([Video 2][7]) Make a longitudinal skin incision along the distal third of the ulna. [Step 4: Design the Step-Cut Ulnar Shortening Osteotomy][8] ([Video 2][7]) Design the step-cut ulnar shortening osteotomy. [Step 5: Perform the Step-Cut Ulnar Shortening Osteotomy][9] ([Video 2][7]) Create the step-cut ulnar shortening osteotomy using an oscillating saw. [Step 6: Fixation of the Osteotomy][10] ([Video 3][11]) Fix the osteotomy with a lag screw and volar plate. [Step 7: Wound Closure][12] Meticulously close the wound in layers. [Step 8: Postoperative Care][13] Protect the affected arm for the first 6 weeks. [Results][14] In our original study, 164 patients with symptomatic ulnar impaction syndrome were treated with a step-cut ulnar shortening osteotomy using a volar 3.5-mm standard neutralization plate and a lag screw[14][15]. [Pitfalls & Challenges][16] [1]: #sec-14 [2]: #sec-15 [3]: #sec-18 [4]: #sec-19 [5]: #media-1 [6]: #sec-20 [7]: #media-2 [8]: #sec-21 [9]: #sec-22 [10]: #sec-23 [11]: #media-3 [12]: #sec-24 [13]: #sec-25 [14]: #sec-26 [15]: #ref-14 [16]: #sec-27

The major complications of distal ulna resection, the Darrach procedure, are radioulnar impingement and instability. High failure rates have been reported despite published modifications of the Darrach procedure. Several surgical techniques have been developed to treat this difficult problem and to mitigate the symptoms associated with painful convergence and impingement. No technique has demonstrated clinical superiority. Recently, implant arthroplasty of the distal ulna has been endorsed as an option for the management of the symptomatic patient with a failed distal ulna resection. However, there are concerns for implant longevity, especially in young, active adults. Resection interposition arthroplasty relies on interposition of an Achilles tendon allograft between the distal radius and the resected distal ulna. Although this technique does not restore normal mechanics of the distal radioulnar joint, it can prevent painful convergence of the radius on the ulna. Achilles allograft interposition arthroplasty is a safe and highly effective alternative for failed distal ulna resections, especially for young, active patients, in whom an implant or alternative procedure may not be appropriate.

Monoblock trabecular metal cups are made of a novel porous material intended to enhance ingrowth and improve fixation. We prospectively followed 223 consecutive patients with 245 trabecular metal acetabular cups implanted during primary total hip arthroplasties to determine the overall survivorship of the implant, and any association of survivorship to primary diagnosis and age, and to determine the fate of polar gaps and cysts. Minimum followup was 36 months (mean, 60 months; range, 36-112 months). Patients were assessed with the Harris Hip score and the Oxford questionnaire and radiographically with standardized serial radiographs. At last followup, all cups were radiographically stable with no evidence of migration or progressive radiolucencies. The survivorship with reoperation as the end point was estimated at 98.75% with a 95% confidence interval. Three reoperations occurred during the first 36 months. The Harris hip score increased from 48 to 94 and the Oxford score was 16.4 at the last examination. We observed no difference in terms of survivorship among patients with osteoarthritis, osteonecrosis, or hip dysplasia. Seven of 14 (50%) osteoarthritis cysts and 10 of 33 (33.3%) polar gaps detected on postoperative radiographs decreased or filled, whereas none of the remainder deteriorated with time. Our midterm results suggest this implant may enhance fixation, but long-term followup is needed to confirm our findings.Level IV Therapeutic study.

Summary Objective To investigate leptin's effect on cartilage metabolism and the pathophysiology of osteoarthritis (OA). Methods Messenger RNA (mRNA) expression and protein levels of leptin and leptin's receptor isoforms were measured by real-time reverse transcription-PCR and Western blot in osteoarthritic and normal cartilage. Osteoarthritic cartilage samples were obtained from two locations of the knee ( n =11) and hip ( n =6); from the main defective area (advanced OA) and from adjacent macroscopically and histological intact regions (minimal OA). Paired serum and synovial fluid (SF) leptin levels were measured. The effect of leptin was evaluated on chondrocyte proliferation, IL-1β (interleukin-1β), NO and metalloproteinases 9 and 13 (MMP-9, MMP-13) protein expression. Results Leptin's and leptin's receptor (Ob-Rb) expression levels were significantly increased in advanced OA cartilage compared to minimal. Leptin was significantly increased in SF than serum samples. Also, leptin had a detrimental effect on chondrocyte proliferation and induced IL-1β production and MMP-9 and MMP-13 protein expression. Furthermore, leptin's mRNA expression in advanced OA cartilage was significantly correlated with BMI of the patients. Conclusion The increased leptin levels in SF point toward a local effect of leptin in articular cartilage, while the observed intrajoint differences of leptin and Ob-Rb mRNA expression may be related to the grade of cartilage destruction. The observed production of IL-1β, MMP-9 and MMP-13 by chondrocytes after leptin treatment indicates a pro-inflammatory and catabolic role of leptin on cartilage metabolism. Furthermore, the observed correlation of leptin's mRNA expression with BMI suggests that leptin may be a metabolic link between obesity and OA.

Background Combined scaphoid and capitate fractures of the wrist are rare entities, and delayed diagnosis is frequent. Scaphocapitate fractures may be associated with reversal of the capitate head 90° or 180° (Fenton syndrome). Different treatment options have been proposed, with variable results. Case Description We report two cases of scaphocapitate fractures of the wrist, diagnosed 3 and 15 days after the injury. The first patient suffered from Fenton syndrome, a combined displaced fracture of the waist of the scaphoid with 180° reversal of capitate head. The second patient had combined fractures of the scaphoid, capitate, and distal radius. In both our cases, anatomic reduction and internal fixation were achieved, resulting in union of all fractures. The long-term results, after 5.5 and 7 years respectively, were very satisfactory, both clinically and radiographically, without signs of avascular necrosis of the head of the capitate or the scaphoid. Literature Review Few reports of scaphocapitate fractures were found in literature. Mechanism of injury, treatment, and outcomes of the reported cases in correlation to our cases are discussed. Clinical Relevance Given the high rate of complications of scaphocapitate fractures, long-term follow-up is important to assess the natural history of the wrist joint after such injuries. The restoration of normal anatomic relationships can lead to a successful long-term functional outcome despite the severity of the injury.

Objective/Hypothesis: Arthritis at the distal interphalangeal (DIP) joint often results in pain and deformity. Arthrodesis of the DIP joint is commonly performed for symptomatic arthritis that has not responded adequately to nonoperative treatment. Although a variety of techniques have been described for DIP joint arthrodesis, the end result is a motionless joint. DIP fusion also carries the risk of malunion, nonunion, and implant-related complications. We hypothesize that an alternative technique involving an open dorsal cheilectomy and DIP joint debridement would result in adequate pain relief and cosmesis, while preserving joint motion and avoiding the potential complications associated with DIP arthrodesis. We present our experience with 78 patients with symptomatic osteoarthritis of the DIP joint who underwent an open dorsal cheilectomy and debridement of the DIP joint. Materials and Methods: There were 70 women and 8 men with a mean age of 64 years (range, 52-74 years) at the time of the surgery. The dominant hand was involved in 59 patients. The most common fingers were the middle (36 patients) and index (33 patients). Preoperative radiographic assessment demonstrated Kellgren and Lawrence grade 3 osteoarthritis in 44 patients and grade 4 in 34 patients. In all patients, through a lazy “S” incision over the dorsal DIP joint, an arthrotomy was performed on each side of the extensor tendon and debridement of the joint was performed removing osteophytes from the DIP joint, while preserving the insertion of the extensor mechanism. At completion, the DIP joint was immobilized in an extension splint. At 4 weeks postoperatively, the splint was removed and physical therapy was initiated for active range of motion. At the final follow-up, pain level, satisfaction, and DIP joint range of motion were assessed. Results: The mean final follow-up was 37 months (range, 24-62 months). All clinical parameters demonstrated statistically significant improvement at final follow-up. Mean patient pain visual analogue scale scores improved from 8.3 preoperatively to 1.2 postoperatively. Patient satisfaction scores significantly improved by an average of 7 points. Mean flexion contracture of the DIP joint significantly improved from 11.4° preoperatively to 4.6° postoperatively. There were no postoperative infections or tendon rupture. Six patients experienced mild extensor tendon weakness at the DIP joint. No patients required additional surgery. No other complications were encountered. Conclusions: Open dorsal cheilectomy and debridement of the DIP joint in patients with symptomatic DIP joint osteoarthritis is a safe and reliable alternative procedure. This surgical technique reduces pain while preserving DIP joint motion.

Background Dupuytren’s disease (DD) is a slow, progressive fibroproliferative disorder affecting the palms of the hands. The disease is characterized by the formation of collagen rich- cords which gradually shorten by the action of myofibroblasts resulting in finger contractures. It is a disease that is confined to humans, and a major limiting factor in investigating this disorder has been the lack of a faithful animal model that can recapitulate its distinct biology. The aim of this study was to develop such a model by determining if Dupuytren’s disease (DD)- and control carpal tunnel (CT)-derived fibroblasts could survive in the forepaw of the nude rats and continue to exhibit the distinct characteristics they display in in vitro cultures. Methods 1x107 fluorescently labeled DD- and CT-derived fibroblasts were transplanted into the left and right forepaws of nude rats respectively. Cells were tracked at regular intervals for a period of two months by quantifying emitted fluorescent signal using an IVIS imaging system. After a period of 62 days rat forepaw connective tissues were harvested for histology and total RNA was isolated. Human-specific probes were used to perform real time RT-PCR assays to examine the expression patterns of gene products associated with fibrosis in DD. Rat forepaw skin was also harvested to serve as an internal control. Results Both CT- and DD-derived fibroblasts survived for a period of 62 days, but DD-derived cells showed a significantly greater level of persistent fluorescent signal at the end of this time than did CT-derived cells. mRNA expression levels of α-smooth muscle actin (α-SMA), type I- and type III- collagens were all significantly elevated in the forepaw receiving DD cord-derived fibroblasts in comparison to CT-derived fibroblasts. Masson’s trichrome stain confirmed increased collagen deposition in the forepaw that was injected with DD cord-derived fibroblasts. Conclusions For the first time we describe an animal model for Dupuytren’s disease at the orthotopic anatomical location. We further show that gene expression differences between control (CT) and diseased (DD) derived fibroblasts persist when these cells are transplanted to the forepaw of the nude rat. These preliminary findings indicate that, with further refinements, this animal model holds promise as a baseline for investigating novel therapeutic regimens to determine an effective strategy in treating DD.

The "terrible triad" of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced.The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation.Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author's (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24-56 months). The mean patient age was 52 years (range, 32-58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system.The mean arc of ulnohumeral motion at final followup was 123° (range, 75°-140°) and mean forearm rotation was 145° (range, 70°-170°). The mean Broberg and Morrey score was 90 of 100 (range, 70-100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0-38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively.These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion.Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.

Objective/Hypothesis: Extra-articular ulnar-shortening osteotomy is a common procedure for the surgical treatment of ulnar impaction syndrome. Several techniques for this osteotomy have been developed to avoid the morbidity associated with a standard transverse osteotomy. However, these techniques require special instrumentation and are expensive. The purpose of this study was to evaluate the outcome of step-cut ulnar-shortening osteotomy without special jigs for ulnar impaction syndrome. Materials and Methods: A retrospective review was performed of 164 consecutive patients who underwent step-cut ulnar-shortening osteotomy between 2000 and 2010. Eighty-eight patients were female and 76 were male with a mean age of 36.8 years. Idiopathic ulnar impaction syndrome was diagnosed in 116 patients, while a posttraumatic etiology was seen in 48 patients. The step-cut osteotomy had its long arm oriented in the coronal plane parallel to the long axis of the ulna. The short arms of the osteotomy were perpendicular to the long axis in the axial plane. Fixation was performed with a palmar 3.5 mm standard neutralization plate and a lag screw. The goal of the osteotomy was to reduce ulnar variance by shortening the ulna 2 to 3 mm and not to create neutral variance. Ulnar variance was assessed radiographically preoperatively and postoperatively with the pronated grip view in all patients. The preoperative ulnar variance ranged from +1 mm to +6 mm. Results: Mean follow-up was 62.4 months (24-86 months). Union of the osteotomy was achieved with a mean of 8.2 weeks. The union rate was 98.78%. There were 2 cases of nonunion, which required additional surgery. The mean postoperative ulnar variance was +0.2 mm (range, −1 mm to +1.5 mm) after a mean overall shortening of 2.5 mm. Modified Mayo Wrist Scores improved significantly from a mean of 47.3 (25-65) preoperatively to 88.8 (60-100) postoperatively. All patients returned to their work in a mean of 4 months. Hardware removal was performed in 12 patients (7.3%) due to plate-related symptoms. No other complications were encountered. Conclusions: The step-cut ulnar-shortening osteotomy provides ample bone-to-bone contact and simplifies control of rotation. Stable internal fixation with standard techniques allowed early return to functional activities. Palmar placement of the plate diminishes the need for plate removal caused by irritation. The step-cut ulnar-shortening osteotomy is a simple and cost-effective technique for ulnar-shortening without the use of special instrumentation in patients with ulnar impaction syndrome.

Bone hypoxia resulting from impaired blood flow is the final pathway for the development of osteonecrosis (ON). The aim of this study was to evaluate if HIF-1α, the major transcription factor triggered by hypoxia, is genetically implicated in susceptibility to ON. For this we analyzed frequencies of three known HIF-1α polymorphisms: one in exon 2 (C111A) and two in exon 12 (C1772T and G1790A) and their association with ON in a Greek population. Genotype analysis was performed using PCR-RFLP and rare alleles were further confirmed with sequencing. We found that genotype and allele frequency of C1772T and G1790A SNP of HIF-1α (SNPs found in our cohort) were not significantly different in ON patients compared to control patients. Furthermore these SNPs could not be associated with the different subgroups of ON. At the protein level we observed that the corresponding mutations (P582S and A588T, respectively) are not significant for protein function since the activity, expression and localization of the mutant proteins is practically indistinguishable from wt in HEK293 and Saos-2 cells. These results suggest that these missense mutations in the HIF-1α gene are not important for the risk of developing ON.