Aims

The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.

The treatment of scapholunate (SL) ligament injuries is addressed by surgical procedures to stabilize the carpal joint. Open techniques include bone-ligament-bone transfers, tenodesis, partial fusions and carpectomies. Innovative procedures using wrist arthroscopy, offer minimally invasive fixation without full exposure of carpal bones; however, the success of the technique and its impact on the reduction on the range of carpal movement is as yet not well known. In this work, the performance of Corella tenodesis technique to repair the SL ligament is evaluated for a wrist type II by numerical methods. Human wrist can be classified based on the lunate morphology: type I for lunate that articulates with radius, scaphoid, capitate and triquetrum, and type II which has an extra surface to articulate with the hamate. A finite element model was constructed from CT-scan images, the model includes cortical and trabecular bones, articular cartilage and ligaments. Three scenarios were simulated representing healthy wrist, SL ligament sectioning and the Corella technique. The performance of the technique was assessed by measure the SL gap in dorsal and volar side as well as the SL angle to be compared to cadaveric studies. In intact position, the SL gap and the SL angle predicted by the numerical model is 2.8 mm and 44.8º, these values are consistent to the standard values reported in cadaveric experiments (2.0 ± 0.8 mm for SL gap and 45.8 ± 9.7 for SL angle). Virtual surgeries may help to understand and evaluate the performance of the techniques at clinical application.

Introduction

Total Wrist Arthroplasty (TWA) for Rheumatoid Arthritis (RA) of wrist allows pain relief and preservation of the movements.

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7 year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1-8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD=2.5)). The loss in the arc of flexion-extension was due to a reduced range of flexion (mean 31% loss), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference (p>0.05) in the range of movement or the grip strength between the static and dynamic group or the claims and non-claims group. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability

Between 1994 and 2002, 81 patients underwent ulnohumeral arthroplasty for elbow arthritis at our institution. All patients were sent a questionnaire with a request to attend for a clinical evaluation. Forty replied and 34 attended for clinical examination, 6 females and 34 males with an average age of 63 years (32-80) and a mean follow-up of 6 years (2-10). There were 22 (55%) patients with primary osteoarthritis, 14 (35%) with osteoarthritis secondary to trauma, two patients with rheumatoid arthritis and one patient each with arthrogryphosis multiplex congenital and post-septic arthritis of the elbow.

Using the VAS (0-10), the pain score was seen to improve from a mean pre-operative score of 8 (6-10) to 4 (0-9). 21 patients (50%) were on minimal or no analgesia and 31 (75%) patients felt they would have the surgery again for the same problem. The arc of motion as regards flexion/extension was found to increase by 19% while prono-supination was found to increase by 30%. There was one patient each with superficial infection, anterior interosseous nerve neuropathy and myositic ossificans while two patients had triceps rupture. Radiological examination showed that in 12 cases the trephine hole was partially obliterated while in 4 cases it was completely obliterated. This could not be correlated clinically. Patients with loose bodies seemed to do better in the post-operative phase.

Ulnohumeral arthroplasty has a role in the management of the arthritic elbow as it provides pain relief in the post-operative period; however, the improvement in the range of movement is limited particularly as regards the arc of extension.

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results.

Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength.

Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique.

Objective: To determine if the anatomical location of a tendon (hand or forearm) influences fibroblast function in the presence of physical forces.

Introduction Tendons are anatomical structures specialized to transmit high tensile loads from muscle to bone. When damaged, clinical recovery is slow and incomplete. Various authors have shown that application of tensile loading during recovery (such as in early active motion following hand flexor tendon repair) will accelerate the recovery of tensile strength. The mechanism is unknown and the optimum loading regime has not been quantitated. It is likely that similar influences are working in rheumatoid arthritis but there is clinical evidence that the response to applied load is very different. In this study a commercial system (Bio stretch) was used to apply different strain regimes to cells in culture, and then to assess the response by a series of quantitative methodologies

Materials Cells were obtained by the explant technique from tendons of the hand and forearm to generate confluent cultures. In this experiment fibroblasts cultured from intra-synovial tendons (Group 1)were compared with cultured fibroblasts of forearm tendons (Group II). We used the Biostretch Apparatus (ICCT Technologies Canada), to stretch fibroblasts in a gel foam (Helistat, Integra TM ) construct. The Biostretch apparatus uses a magnetic field to stretch cells within the gel foam. After seeding the gel foam pieces (1cm2) with a concentrated cell suspension (4 x105 cells/100 μlitre) , the apparatus was used at 40% stretch, with a burst time of 15 minutes and a rest time of 45 minutes at 37° C and 60 cycles a second for 24 hours. The experiment was performed in triplicate for both type of cells (Group I & II), with another group of cells serving as controls. At the end of 24 hours the BCA method was used to estimate Total Protein content while the Sircol method was used to determine Type 1 Collagen levels.

Results: Preliminary results indicate that there is a trend towards increased secretion of proteins and collagen in the stretched samples compared to the controls. Similarly the fibroblasts obtained from intra-synovial tendons seemed to produce more total protein and collagen as compared to the forearm. However both these observations failed to reach statistical significance.

Conclusions: Previous work (Evans CE et al. 2001) has shown no difference between collagen and protein production between flexor and extensor tendon, even under strain,. In this study the increased production of matrix proteins and collagen under the influence of physical strain may explain why flexor tendon injuries in the hand tend to heal with the formation of adhesions and poor functional results as compared with the forearm where the results tend to be uniformly better. However it must be stressed that these are preliminary results and further work will be required to provide definitive data.

Purpose: We report a locally invasive tenosynovial haemangioma infiltrating the flexor digitorum sublimis of the non dominant little finger in a sixteen year old student which was excised with part of the sublimis tendon and the A2 pulley.

Patients and Methods: Haemangiomata developing in the hand in relation to tendon and the tenosynovium (tendon sheath) are very rare. To our knowledge only three cases have been described arising in relation to the tenosynovium of the tendons of the hand only one of which showed infiltration of the underlying tendon. We report the case of a sixteen year old right hand dominant student who presented to her family doctor with a swelling on her left little finger. A magnetic resonance scan was arranged which confirmed a soft tissue lesion between the flexor tendons and the proximal phalanx of the left little finger with appearance similar to giant cell tumour of the tendon sheath. Surgical exploration demonstrated a dark red fleshy tumour that appeared to infiltrate the flexor digitorum ublimes tendon, and extend around either side of the proximal phalanx. For complete excision of the lesion the infiltrated sublimis tendon and a part of the A2 pulley were sacrificed. There was no resultant bowstringing of the profundus tendon.

Histologically the tenosynovium was expanded by a vascular lesion consisting of dilated, thin-walled vascular channels within fibrous tissue The appearances were those of a synovial haemangioma of the tenosynovium of the flexor tendons

Conclusion: Our case illustrates the pitfalls in diagnosis and the invasive potential of a synovial haemangioma which in our case had infiltrated the flexor sublimis tendon and the area around the A2 pulley. A complete surgical excision is critical to prevent recurrence.

Purpose: We present a 12 year follow up of a patient who presented with a multiple plexiform schwannoma of the median nerve with multiple recurrences, where it was possible to salvage the limb.

Patients and Methods: Multiple plexiform Schwannomas are rare nerve sheath tumours. In this case the tumour presented as a soft non-tender swelling in the palm of a child. On exploration the lesion was found to involve the median nerve from the digital nerves to the antecubital fossa. Histology confirmed a plexiform schwannoma.

The tumour was locally very aggressive with multiple recurrences initially in the median nerve and ulnar nerves and later in the nerve grafts used following excision of the primary tumour.

We present a pictorial review of the mode of presentation of the tumour; discuss different modalities used for limb salvage and the differential diagnosis of this rare tumour.

Conclusion: There are very few reports of PS involving main nerve trunks and none describe the long term follow-up. We report a twelve year follow up of a PS involving the main nerve trunks of the upper limb with salvage despite multiple recurrences. The clinical course of the tumour is presented up to the age of sixteen where the growth tumour appears to have regressed.