BACKGROUND AND AIMS:

Evidence suggests tumor necrosis factor-alpha (TNF-α) mediates, at least in part, symptoms and signs in complex regional pain syndrome (CRPS). Here, we present a case series of patients with CRPS type 1, in whom the response to the anti-TNF-α adalimumab was assessed.

METHODS:

Ten patients with CRPS type 1 were recruited. Assessments were performed before treatment, at 1 week, and 1, 3, and 6 months following 3 biweekly subcutaneous injections (40 mg/0.8 mL) adalimumab (Humira(®) ) and included the followings: Pain intensity using a 0-10 cm visual analog scale; the Short Form of the McGill Pain Questionnaire; the Beck Depression Inventory; the SF-36 questionnaire and mechanical and thermal thresholds (Von frey hair and Thermal Sensory Analyzer, respectively). In addition to the description of individual patient responses, both intention to treat (ITT) and per-protocol (PP) analyses were performed for the entire group.

RESULTS:

Three subgroups of patients were identified (3 patients in each): "nonresponders", "partial responders", and "robust responders" in whom improvement in almost all parameters was noted. Both the ITT and PP analyses demonstrated only a trend toward improvement in mechanical pain thresholds following treatment (ITT χ² = 13.83, P = 0.008; PP χ² = 10.29, P = 0.036).

CONCLUSION:

These results suggest adalimumab, and possibly other anti-TNF-α, can be potentially useful in some (although not in all) patients with CRPS type 1. These preliminary results along with the growing body of evidence which points to the involvement of TNF-α in the pathogenesis of CRPS justify further studies in this area.

Several painful conditions throughout the human body-such as interstitial cystitis, Dupuytren's contracture, and complex regional pain syndrome-have been shown to exhibit tissues with an increase in mast cell population. One such painful condition-where the pain is not considered proportionate to the tissue changes-is tendinopathy. One study has shown that activation via protease-activated receptor 4 (PAR4) can lead to an increased nociception in joints, and similar mechanisms may be at play in tendinopathy, where substances released by mast cells may activate the PARs. Mast cells are also known mediators of inflammatory responses to injury, but have also been found to regulate cell proliferation and vasodilation in certain tissues via PARs, and tendinopathies are known to exhibit tissue characteristics involving hypercellularity and vascular changes. The aim of this study was to determine whether tissues surrounding the Achilles tendon exhibit PAR4, as a basis for further studies on interactions between the tendon, vascularity and nerves, and the mast cell population found in tendinopathy tendons.Biopsies of about 5×5 mm were taken from the ventral part of the Achilles tendon and the paratendinous tissues of this area, from two groups. One group consisted of patients suffering from mid-portion tendinopathy with tendinosis (n=8). Normal controls (n=2) donated biopsies from the same area. Both procedures were guided by ultrasound and performed through a minimal skin incision. These biopsies were later sectioned and immunocytochemistry was used to study the expression patterns of PAR4. Double-staining with PAR4 and substance P (SP) was performed.The sections showed strong reactivity for PAR4 in the blood vessels both in the tendon tissue proper as well as in the more abundant vascular areas ventral to the tendon in biopsies from both normal tendons and those from patients diagnosed with tendinosis. Tenocytes expressed PAR4 to a varying degree (figure 1), with it being expressed more in cells with a rounded nuclei, primarily in tendons from the tendinosis group. PAR4 was expressed on SP-positive nerve fibres in the paratendinous tissue (figure 2). Figure 1.(a) Tenocytes show reactions for PAR4 (in red). Counterstained with DAPI. (b) Vessels positive for PAR4. Figure 2.(a) A nerve fibre and vessel positive for PAR4. In b the nerve fibre shows reactivity for substance P.These findings give basis for further studies into the interactions of SP-positive nerves and mast cells in tendon pathology. Earlier studies have shown regulation of vascular permeability and dilation, as well as fibroblast proliferation through activation of PARs. The PAR4 may, through activation of proteases released from mast cells, to some extent be responsible not only for tenocyte proliferation and vascular regulation, but also for an enhanced pain signalling in tendinopathy through SP-positive afferents.

<span style="font-weight: bold"><⁄span> Historically, in both adult and pediatric populations, a lack of knowledge regarding complex regional pain syndrome (CRPS) and absence of clear diagnostic criteria have contributed to the view that this is a primarily psychiatric condition. <span style="font-weight: bold"><⁄span> To test the hypothesis that children with CRPS are more functionally disabled, have more pain and are more psychologically distressed than children with other pain conditions. <span style="font-weight: bold"><⁄span> A total of 101 children evaluated in a tertiary care pediatric pain clinic who met the International Association for the Study of Pain consensus diagnostic criteria for CRPS participated in the present retrospective study. Comparison groups included 103 children with abdominal pain, 291 with headache and 119 with back pain. Children and parents completed self-report questionnaires assessing disability, somatization, pain coping, depression, anxiety and school attendance. <span style="font-weight: bold"><⁄span> Children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions. They reported greater functional disability and more somatic symptoms than children with headaches or back pain. Scores on measures of depression and anxiety were within normal limits and similar to those of children in other pain diagnostic groups. <span style="font-weight: bold"><⁄span> As a group, clinic-referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions. However, overall psychological functioning as assessed by self-report appears to be similar to that of children with other chronic pain diagnoses. Comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS.

INTRODUCTION:

Palmar plate fixation of unstable distal radial fractures is quickly becoming the standard treatment for this common injury. The literature reporting complications consists mainly of isolated case reports or small case series.

METHOD:

Between February 2004 and December 2009 palmar plate fixation was performed in 665 cases. The overall complication rate was 11.3 % (75 complications). Revision surgery was necessary in 10 % (65 procedures).

RESULTS:

The reasons for revision surgery were: postoperative median nerve compression (22 patients) and secondary dislocation (9 patients). An ulna shortening osteotomy for ulnar impingement syndrome was necessary in eight cases. Intraarticular screw placement occurred in three patients. There were two flexor pollicis longus, one finger flexor and three extensor pollicis longus tendon ruptures. Posttraumatic compartment syndrome of the forearm requiring fasciotomy occurred in four cases. There were three cases of infection. Nonoperative treatment was necessary in nine patients, who developed a complex regional pain syndrome. Hardware failure occurred in three cases. Hardware removal was performed in 232 (34 %) cases.

CONCLUSION:

Palmar plate fixation of distal radius fractures is a safe and effective procedure. Nevertheless, complications necessitating a second intervention are relatively common. A proportion of these complications is iatrogenic and can be avoided by improving the surgical technique.

BACKGROUND:

The Weber derotation osteotomy is an uncommon procedure that typically is reserved for patients with engaging Hill-Sachs defects who have had other surgical treatments for shoulder instability fail. It is unknown whether the desired humeral derotation actually is achieved with the Weber osteotomy. QUESTIONS/

PURPOSES:

The purposes of this study were to answer the following questions: (1) What are the complication (including redislocation) and reoperation rates of the Weber osteotomy? (2) What are the American Shoulder and Elbow Surgeons (ASES) and functional (ROM in internal rotation, self care) results? (3) What fraction of the patients had humeral derotation within 10° of the desired rotation?

METHODS:

A chart review of 19 Weber osteotomies and clinical assessment of 10 Weber osteotomies were performed by independent clinicians. The chart review, at a mean followup of 51 months (range, 13-148 months), focused on the complication rate and the frequency of redislocation. The clinical and CT assessments, at a mean followup of 54 months (range, 26-151 months), focused on ASES scores, ability of patients to perform self care with the affected arm, and CT scans to measure change in humeral retroversion.

RESULTS:

There were 25 complications and nine reoperations in 17 patients (19 shoulders), including pain (six patients, of whom one had complex regional pain syndrome), hematoma, infection, nonunion, delayed union, reoperations related to hardware and other noninstability-related causes (five patients), and internal rotation deficit. Redislocation occurred in one patient, who underwent repeat surgery, and subjective instability developed in two others. The mean ASES score was 78 points (of 100 points); six of the 10 patients (11 procedures) evaluated in person found it difficult or were unable to wash their backs with the affected arm. Humeral derotation varied from 7° to 77°; only three of the nine patients for whom CT scans were available had derotation within 10° of the desired rotation.

CONCLUSIONS:

Complication rates with the Weber osteotomy were much higher than previously reported. Because seven of 17 patients were lost to followup, the redislocation rate may be higher than we observed here. Given the unpredictable variability in humeral derotation achieved with a Weber osteotomy, an improved surgical technique is critical to avoid osteoarthritis and loss of internal rotation associated with overrotation.

LEVEL OF EVIDENCE:

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used.To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS).We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence.We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn.There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.

BACKGROUND:

Several studies show that hallux valgus has a female preponderance and that approximately 50% of patients have an adolescent onset of deformity. However, little is known about male adolescent-onset hallux valgus. We evaluated the radiologic characteristics and the result of deformity correction in male adolescent-onset hallux valgus (MAHV).

METHODS:

We evaluated 31 feet with MAHV that received corrective osteotomies (16 scarf, 11 distal chevron, 4 proximal chevron, and 21 Akin). The patients' mean age was 22 years. Using standard weight-bearing radiographs, we measured hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), proximal phalangeal angle (PPA), metatarsus adductus angle (MAA), and congruency, preoperatively and at an average of 21 months after surgery. We assessed the clinical outcome at follow-up with regard to patient satisfaction using the American Orthopedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal score.

RESULTS:

The mean HVA, IMA, DMAA, and PPA decreased from 28.8, 12.0, 11.9, and 6.5 degrees to 10.9, 4.2, 9.7, and 6.3 degrees, respectively (P < .05). Preoperative congruency was 68% (21 of 31 feet). All feet had metatarsus adductus, and the mean MAA was 26.7 degrees. The mean AOFAS score increased from 64.3 to 92.7. Excellent and good satisfaction rate was 94% (29 of 31 feet). We had 2 complications: 1 patient with acute deep infection and 1 patient with complex regional pain syndrome type II accompanying neuralgia of the hallux.

CONCLUSIONS:

Most of the patients with MAHV had congruent first metatarsophalangeal joints consistent with increased MAA and DMAA. They also had high PPA and relatively lower IMA. MAHV has high MAA, high PPA, and relatively lower IMA. Metatarsal osteotomy with lateral translation and phalangeal corrective osteotomy for MAHV was a reliable technique with successful outcomes and low complication rates.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.