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Biomedical subjects

Matthew M Tomaino

Publications and source records attributed to Matthew M Tomaino.

At least 19 recordsLinked to original sources
PubMed2006

Thumb by metacarpal extension osteotomy: rationale and efficacy for Eaton Stage I disease.

This article describes the rationale and results of a "biomechanical" strategy to restore trapeziometacarpal (TM) stability when symptomatic Eaton Stage I disease exists. Though the author has performed TM arthroscopy, synovectomy, and capsular shrinkage for such cases in 10 patients, the author has been dissatisfied with the outcomes, particularly pain relief. The author currently relies exclusively on extension osteotomy as treatment for this subset of patients. Thumb metacarpal extension osteotomy remains an effective treatment alternative for the hypermobile TM joint consistent with Eaton Stage I disease. This procedure alters forces, shifts load away from the volar compartment, and further engages the dorsoradial ligament. Clinical outcomes are favorable, and no bridges are burned should arthritic changes develop in the future.

Arthritis↗
PubMed2006

Suspensionplasty for basal joint arthritis: why and how.

Abductor pollicis longus suspensionplasty is a simple, effective treatment alternative forbasal joint arthritis. Use of a suspensionplasty technique acknowledges our current understanding of forces involved during pinch and grip, as well as the role of normal ligamentous anatomy. The primary rationale for performing suspensionplasty revolves around resisting the sagittal plane collapse that will occur when the thumb is loaded during pinch. In the absence of a volar-based suspension of the metacarpal, cantilever bending forces and axial force transmission will result in the dissipation of force along the thumb lever arm, and ultimately longitudinal collapse. Maximal grip and pinch strength require suspensionplasty, which can be performed using a variety of techniques. The author's current technique for suspensionplasty is described.

Arthroplasty↗
PubMed2006

Finger metacarpophalangeal joint disease: the role of resection arthroplasty and arthrodesis.

When finger MP joint arthrosis exists, it is indeed infrequent that implant arthroplasty is not the most optimal treatment alternative. When post-traumatic bone loss or postinfectious dysfunction require surgical intervention, however, the hand surgeon may need to consider the options of resection arthroplasty and arthrodesis. So long as the MP joint is pain-free and relatively stable, most patterns of functional prehension can be maintained.

Adult↗
PubMed2006

Distal interphalangeal joint arthrodesis with screw fixation: why and how.

Though DIP joint fusion can be successfully achieved with K-wires in both the osteoarthritic and rheumatoid patient, their use is often some-what of an inconvenience to the patient. They prohibit showering, may become infected, may back out and catch on clothing, and surely slowdown mobilization of the rest of the finger [1]. For optimal prehension, a modest amount of DIP joint flexion is required, however. Thus, one advantage of K-wires is that they allow fusion in 5 degrees to 10 degrees of flexion (Fig. 1). In the rheumatoid patient in particular, bone stock may be so com-promised that getting enough purchase with wires alone can be challenging. Since making the transition to the Herbert screw, hardware-related complications and patient dissatisfaction with obligatory postoperative functional limitations until union is achieved have been eliminated. Despite the fact that the fusion must occur without flexion-a necessity to ensure intramedullary placement of the screw-patients seem to adapt well (Fig. 2). One further potential disadvantage of screw fixation is the issue of size mismatch between phalanx and screw-especially in the small finger. Though cautious insertion is justified, precise technique allows use even in the small finger-a benefit when early motion is indicated; for example, when concomitant proximal interphalangeal (PIP) implant arthroplasty is performed in an adjacent digit. This device is contraindicated, obviously, if future PIP joint arthro-plasty is anticipated in the same finger (Fig. 3).

Arthritis↗
PubMed2006

Reconstruction of the interosseous ligament unloads metallic radial head arthroplasty and the distal ulna in cadavers.

PURPOSE: Longitudinal radioulnar dissociation may result when a compressive load to the hand results in excessive proximal migration of the radius with interosseous ligament (IOL) disruption and radial head fracture. Interosseous ligament reconstruction has been proposed to restore more normal forearm mechanics. The objective of this study was to evaluate the effect of IOL reconstruction on compressive load transfer through the forearm after excision and metallic replacement of the radial head in cadavers. METHODS: In 8 cadaveric forearms, 138 N of compressive load was applied to the hand in neutral forearm rotation and neutral elbow varus-valgus alignment. We measured proximal radial migration and 3-dimensional force vectors acting on the distal radius, distal ulna, IOL, proximal radius, and proximal ulna. The experiment was repeated in order for 5 conditions: (1) with the IOL intact, (2) with the IOL reconstructed with a double-bundle flexor carpi radialis construct, (3) with the radial head excised, (4) after metallic radial head arthroplasty, and (5) after cutting the IOL reconstruction. Analysis of variance was used for statistical comparisons. RESULTS: With the IOL intact the resultant load in the distal radius was 94% +/- 3% of hand load, with 75% +/- 2% transmitted to the proximal radius. Double-bundle flexor carpi radialis reconstruction effectively restored this relationship. After radial head excision the resultant distal radius load decreased whereas great increases were seen in the resultant distal ulna load, the resultant load in the IOL reconstruction, the resultant load in the proximal ulna, and proximal radial migration. Force continued to transfer through the proximal radius transversely, with a 400% increase in transverse force, a consequence of abutment of the radial stump caused by proximal radioulnar convergence (there was no contact at the capitellum). After radial head arthroplasty loads transferred across the wrist remained closer to intact but the resultant load on the distal ulna and proximal radius remained increased. With cutting of the IOL reconstruction transverse forces in the forearm became negligible, the resultant distal ulna load increased by 50%, and the resultant radial head load increased by 25%. Proximal migration of the radius was small and was increased by 4.6 mm with radial head excision and by 1 mm after radial head replacement compared with the IOL-reconstructed, radial head-intact state. CONCLUSIONS: Interosseous ligament reconstruction may help improve treatment of longitudinal radioulnar dissociation but remains an experimental procedure.

Aged↗
PubMed2005

Gene transfer to human joints: progress toward a gene therapy of arthritis.

This article describes the clinical application of gene therapy to a nonlethal disease, rheumatoid arthritis (RA). Intraarticular transfer of IL-1 receptor antagonist (IL-1Ra) cDNA reduces disease in animal models of RA. Whether this procedure is safe and feasible in humans was addressed in a phase I clinical study involving nine postmenopausal women with advanced RA who required unilateral sialastic implant arthroplasty of the 2nd-5th metacarpophalangeal (MCP) joints. Cultures of autologous synovial fibroblasts were established and divided into two. One was transduced with a retrovirus carrying IL-1Ra cDNA; the other provided untransduced, control cells. In a dose escalation, double-blinded fashion, two MCP joints were injected with transduced cells, and two MCP joints received control cells. One week later, injected joints were resected and examined for evidence of successful gene transfer and expression by using RT-PCR, ex vivo production of IL-1Ra, in situ hybridization, and immunohistochemistry. All subjects tolerated the protocol well, without adverse events. Unlike control joints, those receiving transduced cells gave positive RT-PCR signals. Synovia that were recovered from the MCP joints of intermediate and high dose subjects produced elevated amounts of IL-1Ra (P = 0.01). Clusters of cells expressing high levels of IL-1Ra were present on synovia of transduced joints. No adverse events occurred. Thus, it is possible to transfer a potentially therapeutic gene safely to human rheumatoid joints and to obtain intraarticular, transgene expression. This conclusion justifies additional efficacy studies and encourages further development of genetic approaches to the treatment of arthritis and related disorders.

Aged↗
PubMed2005

Ulnar impaction syndrome.

Although Palmer's classification of TFCC lesions differentiates post-traumatic central perforations (IA tears) from degenerative tears secondary to ulnocarpal impaction (IIC) [3], the distinction is not always clear clinically. In the final analysis, the literature suggests that as many as 25% of wrists with TFCC tears have residual symptoms following arthroscopic debridement alone [23], and it is likely that static or dynamic ul-nar positive variance plays a role [2,5,17,25]. The authors' results suggest that combined arthroscopic TFCC debridement and wafer resection are feasible and efficacious as treatment for all stages of ulnar impaction syndrome. When class II A and B changes are observed, that is, when a TFCC perforation has not yet developed, the authors have observed favorable results in most patients following arthroscopic TFCC central disc excision and wafer resection as an alternative to ulnar shortening osteotomy [33] or open wafer excision [10].

Arthralgia↗
PubMed2005

Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers.

PURPOSE: Longitudinal radioulnar dissociation may result when compressive load to the hand causes excessive proximal migration of the radius with interosseous ligament (IOL) disruption and radial head fracture. Although radial head salvage or arthroplasty and temporary distal radioulnar joint pinning constitute the current treatment for this injury IOL reconstruction has been proposed to restore normal forearm mechanics. To help provide a biomechanical basis for IOL reconstruction we measured load transfer and proximal migration of the radius with the IOL intact, cut, and reconstructed while leaving the radial head intact. METHODS: We dissected the central third of 12 normal cadaveric forearms to bone-IOL-bone. We applied 136 N of compressive load to the hand and measured proximal radial migration and 3-dimensional force vectors acting in the distal radius, distal ulna, IOL, proximal radius, and proximal ulna. Experiments were performed in neutral forearm rotation and neutral elbow varus-valgus. The protocol was repeated with the IOL intact, cut, and reconstructed with single and double flexor carpi radialis allografts. RESULTS: With the IOL intact 94% +/- 3 % of hand load was in the distal radius with 75% +/- 2% was transmitted to the proximal radius. With the IOL cut 92% +/- 2% of hand load was in the distal radius and this was unchanged at the proximal radius. With single flexor carpi radialis reconstruction 94% +/- 3% of hand load was in the distal radius and 80% +/- 2% was in the proximal radius; with double flexor carpi radialis reconstruction these numbers changed to 95% +/- 3% and 74% +/- 2%, respectively. Forces in the forearm were mainly in the longitudinal and transverse directions with negligible components in the dorsal-volar direction. Transverse force in the IOL was about half that of the longitudinal force in the intact and reconstructed states. CONCLUSIONS: When the IOL is cut and load is applied to the hand the unloading of the proximal radius and the transversely directed force that compresses normally across the proximal and distalradioulnar joints is lost. Reconstruction of the IOL can restore the normal load transfer characteristics. These data help provide a biomechanical basis for IOL reconstruction. Further research on the biomechanics of IOL reconstruction in the setting of radial head replacement along with clinical evaluation is needed.

Aged↗
PubMed2005

Structural properties of reconstruction constructs for the interosseous ligament of the forearm.

PURPOSE: The Essex-Lopresti fracture-dislocation, also termed longitudinal radioulnar dissociation (LRUD), results in major functional impairment from pain and limitation of motion at the wrist and elbow. Interosseous ligament (IOL) reconstruction has been proposed to help treat LRUD and restore forearm stability. The objective of this study was to evaluate the biomechanical structural properties of 3 different IOL reconstruction constructs and of the intact IOL for comparison. METHODS: Structural tensile testing was performed on 24 fresh-frozen cadaveric forearms with 4 different forearm conditions: IOL intact and IOL reconstructed with Achilles tendon, flexor carpi radialis (FCR) tendon, and bone-patellar tendon-bone. Isolated radius-IOL-ulna constructs were loaded to failure in a materials testing machine with force applied along the local fiber direction. RESULTS: Stiffness in the intact IOL was 129 +/- 31 N/mm, which was significantly stiffer than any of the constructs tested. The intact IOL was 8 times stiffer than the Achilles tendon construct, 7 times stiffer than the FCR construct, and 3 times stiffer than the bone-patellar tendon-bone construct. The Achilles tendon and FCR constructs were similar to each other biomechanically but the bone-patellar tendon-bone construct was slightly stiffer than the Achilles tendon and FCR constructs. CONCLUSIONS: All graft constructs tested were inferior structurally to the intact IOL. The results of this study provide a biomechanical basis for graft selection for reconstruction of the IOL.

Aged↗
PubMed2004

Principles of limb salvage surgery of the upper extremity.

The goals of limb salvage surgery in the upper extremity are to achieve resection of the tumor and preserve hand function without the risk for local recurrence. Historically, amputation was the treatment of choice for a neoplasm of the hand, wrist, and forearm, but limb-sparing procedures have become feasible largely because of advances in diagnostic imaging, reconstructive microsurgery, and adjuvant radiotherapy and chemotherapy. Because preservation of hand function, even modest levels thereof, is clearly superior to amputation from a functional standpoint, the authors review the principles of limb salvage in this article.

Bone Neoplasms↗
PubMed2004

Passive strain distribution in the interosseous ligament of the forearm: implications for injury reconstruction.

PURPOSE: For severe forearm injuries such as an Essex-Lopresti fracture-dislocation, functional reconstruction necessitates repair of the interosseous ligament (IOL) to restore normal load sharing between the radius and ulna. Locating or tensioning such a reconstruction improperly can lead to abnormal load sharing and/or restriction of forearm rotation. The normal IOL strains should indicate the proper location of reconstruction grafts and the proper forearm rotation for tensioning the grafts. The objective of this study was to quantify the passive strain distribution of the IOL of the forearm with passive rotation of the forearm throughout the range of motion. METHODS: The 3-dimensional motions of the radius with respect to the ulna were measured throughout forearm rotation in 10 cadaveric forearms by using an instrumented spatial linkage. From the bone motions and ligament insertion site geometry from dissection and computed tomographic scanning, insertion site motions were determined and used to calculate changes in ligament fiber lengths. RESULTS: The measured strain distribution in the IOL was nonuniform and varied with forearm rotation. The overall magnitude of IOL strain was found to be greatest in supination and smallest in pronation. In supination the strains varied across fibers with strains being greatest in the distal fibers and lowest in the proximal fibers. Strains in neutral rotation were uniform across fibers. Although fibers were generally slack in pronation proximal fibers were less slack than distal fibers. CONCLUSIONS: The results of this study indicate that fiber strains in the IOL vary from proximal to distal and depend on forearm rotation. Our data suggest that to prevent restriction of forearm rotation all grafts should be tensioned in supination, where measured strains were generally highest. Our data also suggest that a 2-bundle IOL reconstruction may be necessary for proper load transfer between the radius and ulna in both supination and pronation.

Biomechanical Phenomena↗
PubMed2004

Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70.

PURPOSE: Advanced stages of nerve compression are likely to result in irreversible intraneural changes including intrinsic fibrosis and axon loss, and advanced age is expected to compromise nerve regeneration and recovery. Although satisfactory outcomes have been reported we hypothesized that carpal tunnel release in an elderly population with advanced carpal tunnel disease might not significantly improve symptom severity, functional status, or grip strength compared with before surgery. Our purpose was to evaluate these 3 parameters both before and after surgery to assess the efficacy of surgical intervention. METHODS: Between October 2000 and January 2002 a total of 13 patients (14 hands) were enrolled into a prospective longitudinal study. Entry criteria included advanced carpal tunnel syndrome based on neurophysiologic studies (absent sensory latencies and positive fibrillation potentials), clinical examination (thenar atrophy), and age over 70 years. Exclusion criteria included cervical disease, prior surgery, concomitant surgery, diabetic neuropathy, and associated cubital tunnel syndrome. There were 7 men and 6 women with an average age of 79 years (range, 72-90 y). With the help of a neutral observer each patient completed the Brigham and Women's validated carpal tunnel syndrome questionnaire before and 6 and 12 months after surgery to assess symptom severity and functional status. Grip strength was measured before and at 1 year after surgery and each patient also was asked to rate their level of satisfaction with their outcome at 1 year after surgery. RESULTS: Before surgery the mean symptom severity score was 29 based on a scale in which a minimum score of 11 reflects no symptoms and a maximum score of 55 reflects severe symptoms. The mean functional status score was 18 on a scale in which a minimum score of 8 reflects no difficulty and a high score of 40 reflects severe impairment. Six months after surgery the mean symptom severity score decreased from 29 to 15 (11 reflects no symptoms) and the average functional status score decreased from 18 to 11 (8 reflects no difficulty). One year after surgery the symptom severity score decreased from 15 to 14 and the functional status score decreased from 11 to 9. Compared with scores before surgery the improvements at 6 months and 1 year were statistically significant. Patient satisfaction was noted for 13 of 14 hands. Average grip strength remained unchanged after surgery. CONCLUSIONS: Carpal tunnel release is unlikely to result in a total elimination of symptoms and complete restoration of function when performed in elderly patients with advanced disease. Although grip strength did not improve at final follow-up evaluation, symptom severity and functional status did improve from the patient's perspective. We conclude that carpal tunnel release is efficacious in this subset of patients.

Aged↗
PubMed2004

Bi-directional mechanical properties of the human forearm interosseous ligament.

Interest in reconstruction of the interosseous ligament (IOL) of the forearm in the setting of longitudinal radio-ulnar dissociation has increased in recent years with hopes of improving clinical outcomes. This increased interest has been accompanied by research on biomechanics of the IOL. However, little is known about stress and strain in the IOL under externally applied forearm loads. This information is needed to help guide reconstruction. Mechanical properties of the IOL are needed to properly model the IOL for analyses such as finite element models. The objective of this study was to document the bi-directional mechanical properties along the fiber direction (longitudinal) and perpendicular to the fiber direction (transverse). Twenty specimens were mounted in a materials testing machine to perform preconditioning and a load to failure tensile test in each direction. Strain markers on the surface of the specimens were tracked with a video system. Data analysis provided stress-strain curves for each specimen. The elastic moduli of longitudinal and transverse specimens were 515+/-277 and 1.82+/-2.93 MPa, respectively. The tensile strength and ultimate strain of longitudinal and transverse specimens were 54.1+/-25.2 and 0.18+/-0.20 and 16+/-5% and 34+/-32%, respectively. The bi-directional mechanical properties of the IOL compared well with those published for the medial collateral ligament of the knee. The mechanical properties in the longitudinal direction were much greater than those in the transverse direction, which is indicative of the IOL's role in resisting longitudinal loading. The results of this study can be used to generate mathematical models of stress and strain in the IOL.

Aged↗
PubMed2004

Clinical presentation and radiographic findings of distal biceps tendon degeneration: a potentially forgotten cause of proximal radial forearm pain.

For patients who present insidiously with proximal-radial forearm pain, the differential diagnosis should include distal biceps tendon degeneration. If radial tunnel and pronator syndromes, lateral epicondylitis, and radiocapitellar arthritis are eliminated as potential causes, tenderness over the proximal radius, supination weakness, and characteristic radiographic or magnetic resonance imaging findings may facilitate correct diagnosis of distal biceps tendon degeneration. In this article, we describe the clinical presentation and radiographic findings for 5 patients who presented with distal biceps degeneration.

Aged↗
PubMed2004

Preliminary lunate reduction and pinning facilitates restoration of carpal height when treating perilunate dislocation, scaphoid fracture and nonunion, and scapholunate dissociation.

Carpal collapse potentially accompanies greater and lesser arc perilunate injuries; unstable, acute scaphoid fracture; scaphoid nonunion with humpback deformity; and scapholunate dissociation. When surgical treatment is elected, preliminary reduction of the lunate from extension to neutral--to correct dorsal intercalated segment instability deformity--facilitates restoration of carpal height and decreases the risk of carpal malalignment and scapholunate advanced-collapse arthritis. This simple technique is described.

Bone Nails↗
PubMed2003

Reconstruction of the interosseous ligament of the forearm reduces load on the radial head in cadavers.

Excision of the radial head after fracture may be complicated by longitudinal radio-ulnar instability (Essex-Lopresti lesion) if the forearm interosseous ligament has also been torn. In such cases proximal migration of the radius occurs, and ulnar impaction at the wrist and radiocapitellar contact at the elbow may impair function. Although metal radial head arthroplasties are now used for irreparable radial head fractures, the long-term clinical outcome may still be unsatisfactory because of excessive radiocapitellar load causing pain. Interosseous ligament reconstruction might improve outcome by restoring normal load transfer from the radius to ulna, but the biomechanical effect of reconstruction has not been reported. This study evaluated forearm load transfer following interosseous ligament reconstruction with an Achilles tendon allograft in a cadaveric model with the radial head intact. Interosseous ligament reconstruction reduced proximal radius loading by transferring force to the proximal ulna, but force transfer by the reconstruction was only half that by the intact ligament.

Achilles Tendon↗