Chondrocalcinosis

Zusammenfassung Chondrocalcinosis oder Pseudogicht wurde durch die Arbeiten von McCarty und itan als selbständiges Krankheitsbild erkannt und von den degenerativen arthrotischen Gelenksprozessen abgegrenzt. Eigene Beobachtungen an Hand von zehn Fällen wurden berichtet. Die Synovialanalyse und Kristalluntersuchungen als diagnostische Hilfsmittel und die Behandlungsmethoden in unserem Krankengut wurden beschrieben.Der Begriff einer Kristall-Gelenksentzündung ist ein weiterer wichtiger Schritt in unserem Wissen über Gelenkserkrankungen. Noch kann kein Urteil über die Häufigkeit von Chondrocalcinosis abgegeben werden, doch scheint es bei verfeinerter Diagnostik, daß es kein seltenes Krankheitsbild ist.

---

Summary Chondrocalcinosis or Pseudogout has been recognized as a new entity by McCarty and itan and had been separated from the degenerative joint diseases. Our own observations in ten cases has been reported. The synovial fluid analysis and examination of crystals in joint fluid specimens as diagnostic means as well as the treatment of our patients has been described.The entity of crystal joint disease is a further step in the knowledge of joint diseases. No final conclusion as to the frequency of chondrocalcinosis can be derived, however, it appears that with improved diagnostic means the disease is not a rare one.

---

Résumé La chondrccalcinose ou pseudogoutte a été reconnue comme diagramme nosographique autonome, et separée des maladies arthrotiques dégénératives dans les travaux de McCarty et de itna.Dans le travail présent on rapporte de prpres observations concernant dix cas. Puis on décrit l'analyse de liquide synovial et des examens de cristaux comme auxiliaires diagnostiques ainsi que la méthode de traitement appliquée aux biopsies.La notion de l'inflammation d'articulation de cristal signifie un nouveau pas vers le complètement de nos connaissances des maladies articulaires. Cependant on ne peut pas encore prononcer un jugement sur la fréquence de la chondrocalcinose, mais il semble que celle-ci ne serait pas une maladie très rare pour un diagnostic plus amélioré.

     

Ultrasonography in Chondrocalcinosis

Ultrasonography can visualize calcific deposits within soft tissues. The appearance and location of the deposits distinguishes articular chondrocalcinosis from other crystal deposition diseases. The most common findings are hyperechoic dots or lines running parallel to the joint surface, hyperechoic images within fibrous cartilage (menisci and triangular fibrocartilage complex), and deposits within tendons (Achilles tendon). Studies found that ultrasonography was highly sensitive and specific for detecting calcifications, using calcium pyrophosphate dihydrate crystal detection in joint fluid as the reference standard. Good agreement has been demonstrated between radiographs and ultrasonography for the detection of calcifications. Thus, ultrasonography is valuable for diagnosing articular chondrocalcinosis via the detection of calcifications within the joint cartilage, fibrocartilage, and tendons. In addition, ultrasonography is a noninvasive, widely available, inexpensive investigation that requires no radiation exposure.     

Chondrocalcinosis following osteochondritis dissecans in the femur condyles

Chondrocalcinosis, defined as radiopaque deposits in the joint cartilages and in semilunar cartilages of the knee joint, develops frequently in patients in whom osteochondritis dissecans is diagnosed after the epiphyseal line of the distal end of the femur is closed. Chondrocalcinosis occurred in 2/3 of the cases surgically treated for osteochondritis. The incidence was greater than in knees treated by arthrotomy for ruptured semilunar cartilages. However, the latter show chondrocalcinosis much more frequently in patients without history of injury or arthrotomy. Osteochondritis patients with chondrocalcinosis more often may have joint effusion than patients with other conditions. The chondrocalcinosis is not confined to that part of the joint which was the site of the osteochondritis lesion. The presence of chondrocalcinosis can be correlated with a poor prognosis of the knee including severe gonarthrosis.     

Difficult wrist fractures. Perilunate fracture-dislocations of the wrist

Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result.     

Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist

Introduction

Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients.

Patients and methods

The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire.

Results

Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients.

Conclusions

Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.     

Instabilities of the wrist

Carpal instability is the result of ligamentous injury to the wrist. Although any ligament may be injured, certain recurring patterns are frequently seen. Common to the treatment of all instability patterns is the need to transfer load from the capitate to the radius: reliably, without stressing normal joints, and while preserving functional motion. Limited wrist arthrodesis fulfills these needs. The radius and carpal bones are shaped so that in their "normal" position, they are preloaded. Were it not for complex ligamentous systems, the bones would immediately assume unloaded "neutral anatomic" positions. Because the shape of the wrist bones tends to displace them with significant forces, current ligamentous reconstructions are inadequate. Common radial side instabilities invariably lead to degenerative arthritis.     

Denervation of the wrist

In a series of 48 painfully restricted wrists denervation was used during a 6-year period on wide indications as a surgical alternative. The observation time averaged 2.4 years. Pain relief occurred in 56% of the patients. Considering the simplicity of the method and the lack of serious complications, it is concluded that denervation of the wrist is worth trying as a palliative measure prior to more extensive surgery.     

Radiography of the wrist

The painful wrist frequently poses a diagnostic dilemma. Although increased understanding of normal carpal motion has led to more constructive use of roentgenography, the diagnostic acumen of the examiner is greatly enhanced by the standardization of radiographic views as well as by the use of special projections and when indicated, arthrograms.     

Osteoarthritis of the wrist

Osteoarthritis of the wrist is one of the most common conditions encountered by hand surgeons. It may result from a nonunited or malunited fracture of the scaphoid or distal radius; disruption of the intercarpal, radiocarpal, radioulnar, or ulnocarpal ligaments; avascular necrosis of the carpus; or a developmental abnormality. Whatever the cause, subsequent abnormal joint loading produces a spectrum of symptoms, from mild swelling to considerable pain and limitations of motion as the involved joints degenerate. A meticulous clinical and radiographic evaluation is required so that the pain-generating articulation(s) can be identified and eliminated. This article reviews common causes of wrist osteoarthritis and their surgical treatment alternatives.     

Arthrography of the wrist

Eighty-four wrist arthrograms were performed on 76 patients with posttraumatic wrist pain. Instillation of a small amount of contrast media into the radiocarpal joint under fluoroscopic control was helpful in delineating specific areas of pathology about the wrist. Comparison of the arthrographic findings with the plane films of 74 patients and the operative findings of 24 patients revealed that the arthrogram was most helpful in delineating perforations of the scapholunate ligament, the lunotriquetral ligament, the triangular fibrocartilage complex, and the wrist joint capsule.     

Histoplasmosis of the wrist

We present a case of synovitis of the wrist due to histoplasmosis, diagnosed only after extensive surgery and culturing. Treatment with amphotericin B in combination with radical surgery was effective in curing the disease. This manifestation was probably an exacerbation of a latent chronic infection with Histoplasma capsulatum, although it was unclear why the exacerbation occurred. Synovitis resistant to treatment should be assessed with great care, especially in view of the growing number of immunocompromised patients. Close collaboration between surgeon, rheumatologist, pathologist and microbiologist is paramount in such cases.     

Arthrodesis of the wrist

In a retrospective study, the wrists of 18 patients who underwent arthrodesis by the AO technique were assessed clinically, for hand strength and function. Follow-up averaged 4 years (range from 1 to 7 years). Although wrist arthrodesis improved grip strength, it was still only 50% to 60% of normal. Hand function improved to within normal limits in 78% of patients and bony union occurred in 94.4%. Thirteen patients were back at work within 18 months. The AO technique of wrist arthrodesis allows correction of deformity, relief of pain, increased grip strength and improved hand function.     

月骨周围进行性不稳定的腕运动力学研究

目的探索腕月骨周围进行性不稳定的运动力学变化。方法对１４具新鲜冷冻尸体腕关节，用计算机辅助测量了正常腕和各阶段月骨周围不稳定时腕动力肌腱在腕屈伸、尺桡偏时滑动幅度，根据肌腱滑动幅度和关节运动范围计算动力肌腱力臂。结果月骨周围进行性不稳定时屈腕肌腱力臂明显增大，屈指肌腱力臂减小；桡侧腕动力肌腱力臂以增大为主，尺侧肌腱力臂以减小为主。桡侧腕屈肌腱在腕屈伸或尺桡偏时均显著增大。结论腕运动力学变化对月骨周围不稳定的形成、运动力学变化、腕部塌陷起重要起动作用。     

Physical examination of the wrist

Physical examination of the wrist requires knowledge of wrist anatomy and pathology to make a diagnosis or narrow the differential diagnosis. Symptoms are provoked by palpation and signs are produced by manipulation. Negative findings elsewhere in the wrist are important. Final diagnosis may require diagnostic imaging. By having all three methods of assessment agree one is assured of correct diagnosis. The physical examination of the wrist is not unlike that of other joints, in that a systematic approach includes observation, range of motion, palpation, and special tests.