Pedro Hernández-Cortés

Summary: Hyperextension deformity of the metacarpophalangeal joint of the thumb causes pain and loss of function. Although many treatments have been proposed, none of them are universally accepted as ideal. The authors report a study of 12 symptomatic hyperextension deformities of the thumb metacarpophalangeal joint in 10 patients who underwent surgical correction. The purpose of this study was to describe a new technique of tenodesis of the thumb metacarpophalangeal joint using the extensor pollicis brevis tendon. The technique consists of extensor pollicis brevis tenotomy at the wrist and tendon transfer through two bone tunnels to the palmar aspect of the metacarpophalangeal joint before metacarpal fixation with a flexor tenodesis effect. Correction of hyperextension and range of motion were assessed. Functional changes were evaluated by Quick Disabilities of the Arm, Shoulder, and Hand score, pain visual analogue scale, Kapandji opposition scheme, and pinch strength. The Wilcoxon test was used for statistical analysis. Mean preoperative and postoperative metacarpophalangeal joint hyperextension deformities were +50.83 ± 5.57 degrees and −17.91 ± 7.82 degrees, respectively. Thumb opposition improved by one point on Kapandji’s scheme. Mean perceived pain decreased from 7.66 to 1.16. On average, the Quick Disabilities of the Arm, Shoulder, and Hand score was reduced by 34.4 points and pinch strength increased by 50.42 percent. The authors found that extensor pollicis brevis transosseous tenodesis is a safe and minimally invasive method for successfully correcting the functionality and cosmetic appearance of metacarpophalangeal joint hyperextension deformities in posttraumatic and trapeziometacarpal osteoarthritis cases. The patients retained functional active flexion, even in deformities greater than 40 degrees. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Neuropathic pain is one of the most severe forms of chronic pain caused by the direct injury of the somatosensory system. The current drugs for treating neuropathies have limited efficacies or show important side effects, and the development of analgesics with novel modes of action is critical. The identification of endogenous anti-nociceptive factors has emerged as an attractive strategy for designing new pharmacological approaches to treat neuropathic pain. Cortistatin is a neuropeptide with potent anti-inflammatory activity, recently identified as a natural analgesic peptide in several models of pain evoked by inflammatory conditions. Here, we investigated the potential analgesic effect of cortistatin in neuropathic pain using a variety of experimental models of peripheral nerve injury caused by chronic constriction or partial transection of the sciatic nerve or by diabetic neuropathy. We found that the peripheral and central injection of cortistatin ameliorated hyperalgesia and allodynia, two of the dominant clinical manifestations of chronic neuropathic pain. Cortistatin-induced analgesia was multitargeted, as it regulated the nerve damage-induced hypersensitization of primary nociceptors, inhibited neuroinflammatory responses, and enhanced the production of neurotrophic factors both at the peripheral and central levels. We also demonstrated the neuroregenerative/protective capacity of cortistatin in a model of severe peripheral nerve transection. Interestingly, the nociceptive system responded to nerve injury by secreting cortistatin, and a deficiency in cortistatin exacerbated the neuropathic pain responses and peripheral nerve dysfunction. Therefore, cortistatin-based therapies emerge as attractive alternatives for treating chronic neuropathic pain of different etiologies.

The aim of this study was to characterize the morphology and immunophenotype of ganglion cysts (GCs) and explore their histogenetic origin. A cross-sectional morphological and immunohistochemical study of 354 GCs used the following antibody panel: vimentin, specific actin, β-actin, smooth-muscle actin, smoothelin, h-caldesmon, β-catenin, desmin, calponin, podoplanin, keratins 5/6, E-cadherin, cyclooxygenase 2 (COX-2), lysozyme, CD10, CD31, CD33, CD34, CD68, Ki-67, and PCNA. Double-blind semi-quantitative analyses were conducted to evaluate the immunopositivity on a 4-point scale. Samples from 10 synovial membranes and 10 scapholunate ligaments were compared. GCs showed a hyalinized wall with mesenchymal spindle cells and were intensely positive for vimentin, actins, h-caldesmon, calponin in all cases and for podoplanin in 53% of cases, suggesting features of early muscle differentiation, without ruling out a myofibroblastic origin. Focal cavity lining of non-synovial flat or raised cells (CD34/CD31/CD10/E-cadherin-negative and podoplanin-positive in 34% of cases) was detected in 93% of cases, showing differential expression with synovial membrane and scapholunate ligament cells. Nuclear positivity for proliferative markers was observed in GC wall cells (258.1±255; 1019.3±316 positive cells/mm², Ki-67 and PCNA, respectively) but positivity for these markers was significantly lower (p⟨0.001 Mann Whitney U-test) in scapholunate ligament samples. In this first immunohistochemical study of GCs, focal cellular lining of the cavity was observed in almost all cases, and the immunophenotype was identical to that of GC wall cells. These cells are immunohistochemically different from synoviocytes and scapholunate ligament cells and show characteristics of myofibroblasts or mesenchymal cells undergoing early muscle differentiation.

We report three patients with an unusual pattern of rupture of the extensor tendon. All were found to have previously undiagnosed Kienböck disease. Radiographic study of the wrist is essential before treating any closed rupture of an extensor tendon. Lesions may be progressive and extend to adjacent tendons and should be treated urgently.

The aim of this study was to evaluate clinical and radiographic outcomes of Elektra® trapeziometacarpal prostheses after 2 years. We present a longitudinal cohort study of 19 prostheses for the treatment of Eaton stage II and III osteoarthritis (mean follow-up of 29 months). QuickDASH score, pinch strength and mobility were determined, and radiographs were analysed. Isotope scans were taken in patients with persistent pain or suspected loosening. Although the QuickDASH score was 69 before and 38 after surgery, nine patients had pain at the trapeziometacarpal joint with radiographic osteolysis around the trapezium component and a positive bone scan uptake at subsequent follow-up. The implant was revised in three of these nine patients and another patient underwent surgery for periprosthetic fracture. Only ten of the 19 implants showed no sign of failure. Most problems derived from the trapezium cup. Because of these poor outcomes after only 2 years, we cannot recommend this implant.

The authors report an unusual case of flexor tenosynovitis, severe carpal tunnel syndrome, and triggering at the carpal tunnel as the first manifestation of gout. A 69-year-old man presented with digital flexion contracture and severe carpal tunnel syndrome of his right hand and was treated surgically. A flexor tenosynovectomy and a median nerve neurolysis were performed through an extended carpal tunnel approach. The sublimis and the profundus tendons were involved. Partial ruptures and multiple whitish lesions suggestive of tophacceous infiltration of the flexor tendons were seen. Macroscopically, the removed synovial tissue was involved by multiple whitish nodules that were milimetric in size and was suggestive of monosodium urate crystals deposits. By light microscopy examination, numerous nonnecrotizing granulomas of different sizes were observed that were compounded by large aggregations of acellular nonpolarized material, surrounded by epithelioid histiocytes, mononuclear cells, and foreign body multinucleated giant cells. Postoperatively, the patient recovered with resolution of the median nerve symptoms and a near-to-full range of motion of the affected digits. To the authors’ knowledge, this patient is the first case report with flexor tendons tophacceous infiltration as the first clinical sign of gout. Gouty flexor tenosynovitis can occur in the absence of a long history of gout. A high index of suspicion is paramount to the initiation of proper management. Operative treatment of gouty flexor tenosynovitis is mandatory to debulk tophaceous deposits, improve tendon gliding, and decompress nerves. Routine uric acid determination could be helpful in the preoperative evaluation of patients with flexor tenosynovitis.

It is difficult to prevent and treat intra- and peri-neural fibrosis after peripheral nerve surgery. Many authors have attempted to develop and verify the effectiveness of substances to decrease the formation of adherences in different tissues. this study aimed to assess the effectiveness of a barrier of oxidized regenerated cellulose (ORC) to reduce adherence and perineural fibrosis in a model of surgical perineural induced fibrosis in rat sciatic nerve in 40 rats. After tissue aggression, the nerve of the right rear limb was wrapped in ORC and the left limb served as control. Animals were killed at 3 and 6 weeks, and nerves and muscle mass were extracted en bloc. Connective tissue was quantified by conventional histopathological techniques and Fibrosis HR(R) automatic image analysis. No significant differences were found in intra- or peri-neural induced fibrosis between control nerves (6.88% and 8.90%, respectively) and treated nerves (6.57% and 9.90%) at 3 or 6 weeks (10.41% and 12.51% in controls; 11.85% and 15.72% in treated nerves). Inflammatory phenomena and granulomatous reactions were more frequent in treated animals. ORC conferred no advantage in prevention of nerve fibrosis and might have interfered with healing.

Objective.: To assess whether blockade of tumor necrosis factor-α (TNF-α) influences surgical wound healing in a normal mouse experimental model.Methods.: Wound healing time course and degree of surgical wound collagenization were measured by morphological techniques and digital image analysis in 80 male SWISS-OF1 mice (40 received subcutaneous etanercept at a dose of 0.1 mg/25g/ at −7, 0, 7, and 14 days).Results.: No significant differences were observed between treated and untreated animals in wound healing, re-epithelialization, or formation of inflammatory infiltrate or granulation tissue at days 7, 15, or 20 after surgery. At 20 days, the collagen area was larger in treated versus untreated mice (109029 ± 28489 μm² vs 79305 ± 19798 μm², p = 0.026, Mann-Whitney U test).Conclusion.: Surgical wounds showed a higher degree of collagenization at 20 days in etanercept-treated versus untreated mice, with no differences in the time course of wound healing. These data suggest that biological therapies to block TNF-α do not affect wound healing and do not need to be suspended during the perioperative period.