Showing papers in "Journal of Hand Surgery (European Volume) in 2003"

Autologous blood injections for refractory lateral epicondylitis.

Abstract: Purpose: Most nonsurgical treatments for lateral epicondylitis have focused on suppressing an inflammatory process that does not actually exist in conditions of tendinosis. An injection of autologous blood might provide the necessary cellular and humoral mediators to induce a healing cascade. The purpose of this study was to evaluate prospectively the results of refractory lateral epicondylitis treated with autologous blood injections. Method: Twenty-eight patients with lateral epicondylitis were injected with 2 mL of autologous blood under the extensor carpi radialis brevis. All patients had failed previous nonsurgical treatments including all or combinations of physical therapy, splinting, nonsteroidal anti-inflammatory medication, and prior steroid injections. Patients kept personal logs and rated their pain (0-10) and categorized themselves according to Nirschl staging (0-7) daily. Results: The average follow-up period was 9.5 months (range, 6-24 mo). After autologous blood injections the average pain score decreased from 7.8 to 2.3. The average Nirschl stage decreased from 6.5 to 2.0. For the 9 patients receiving more than one blood injection the mean pain score and Nirschl stage before injection were 7.2 and 6.6, respectively. After the second blood injection the pain and Nirschl scores were both 0.9. Two patients received a third blood injection that brought both pain and Nirschl scores to 0. Conclusions: After autologous blood injection therapy 22 patients (79%) in whom nonsurgical modalities had failed were relieved completely of pain even during strenuous activity. This study offers encouraging results of an alternative minimally invasive treatment that addresses the pathophysiology of lateral epicondylitis that has failed traditional nonsurgical modalities. (J Hand Surg 2003;28A:272-278. Copyright © 2003 by the American Society for Surgery of the Hand.)

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases.

Abstract: Purpose: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. Methods: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). Results: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124°. No notable weakness of elbow extension was observed. Conclusions: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.

Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study.

Abstract: Purpose: To compare the biomechanical properties of 6 dorsal and volar fracture fixation plate designs in a cadaver model. Method: Six different plating techniques were used on surgically simulated, unstable, extra-articular distal radius fractures in fresh-frozen cadavers. Specimens were tested to failure in axial compression with the Materials Testing System machine, and were analyzed with a motion analysis system. The 6 different fixation systems studied included an AO stainless steel Pi plate (group 1), an AO titanium Pi plate (group 2), a Forte plate (group 3), a dorsally placed Symmetry plate (group 4), a volarly placed Symmetry plate (group 5), and a volarly placed SCS/V plate (group 6). Results: All dorsal plates (groups 1, 2, 3, 4) failed in apex dorsal angulation and all volar plates (groups 5, 6) failed in apex volar angulation. No group developed an average angular deformity greater than 5° with a load of 100 N, which compares with the physiologic loads expected with active wrist motion. Only the volarly placed SCS/V plated specimens (group 6) resisted deformation of 5° or more at loads up to 250 N, which compares with the physiologic loads expected with active finger motion, and was significantly stronger and more rigid than the other 5 plate groups. Conclusions: The SCS/V plate fixation system is the most rigid of the systems tested and may offer adequate stability for the treatment of the distal radius fracture in which the anterior and/or posterior metaphyseal cortex is comminuted severely. (J Hand Surg 2003;28A:94-104. Copyright © 2003 by the American Society for Surgery of the Hand.)

Italian version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Cross-cultural adaptation and validation.

Abstract: An Italian version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire has been devised and its reliability and validity have been assessed in a cross-sectional study of 108 consecutive patients with upper extremity pathologies. A sub-sample of 30 patients was used to assess re-test reliability. The principal DASH scale showed a high correlation with other patient-oriented measures and demonstrated good reproducibility, consistency and validity, which were similar to those for other languages’ versions of DASH. These findings suggest that the evaluation capacities of the Italian DASH are equivalent to those of other language versions of the DASH.

Prevalence and Distribution of Hand Fractures

Abstract: A retrospective survey of the medical charts of all 36,518 patients attending the Accident and Emergency Department of the VU University Medical Centre, in Amsterdam, from January 1 to December 31, 1996 was performed. Of these, 4303 sustained one or more fractures, and hand fractures accounted for 19% of all fractures. Patients with hand fractures were typically men aged between 15 and 35 years. The right hand was involved as often as the left. Most of the hand fractures involved the metacarpals but, as a group of bones, the combined phalanges were most commonly fractured. The little finger ray was most commonly injured of the hand. We found no seasonal variability in the incidence of hand fractures.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft.

Abstract: Purpose: This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations. Methods: Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2–175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months. Results: The average arc of motion at the PIP joint was 85° (range, 65° to 100°). The distal interphalangeal (DIP) joint average arc of motion was 60° (range, 35° to 80°). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0–10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up. Conclusions: When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.

Endoscopic versus open carpal tunnel release: a randomized trial.

Abstract: Purpose: This study compared the outcomes in patients assigned to either endoscopic carpal tunnel release (ECTR) or traditional open carpal tunnel release (OCTR). Methods: An unbalanced randomized clinical trial (91 endoscopic, 32 open) was conducted. Short-term and long-term outcomes were evaluated by a blinded assessor. The primary outcome measures were symptom severity measured on a self-report scale and nerve/vascular complications. Secondary outcomes included the McGill pain questionnaire, grip strength, pinch strength, sensory threshold (NK PSSD device, NK Biotechnical Corp, Minneapolis, MN), and time to return to work. Results: Both groups improved on all outcomes. No differences were observed in primary outcomes between the groups at either baseline or follow-up at 1 week, 6 weeks, or 12 weeks after surgery. No significant complications occurred in either group. Grip strength and pain were significantly better at 1 and 6 weeks in the endoscopic group although differences dissipated by 12 weeks. No significant differences occurred in other secondary outcomes. Long-term satisfaction was lower in the endoscopic group, attributable to a 5% rate of re-operation. Lower rates of endoscopic release have occurred at our center once these results were available to surgeons and patients. Conclusions: No substantive difference in benefit was shown for these 2 methods of carpal tunnel release. (J Hand Surg 2003;28A:475-480. Copyright © 2003 by the American Society for Surgery of the Hand.)

Comparative responsiveness of the disabilities of the arm, shoulder, and hand, the carpal tunnel questionnaire, and the SF-36 to clinical change after carpal tunnel release.

Abstract: Purpose: The objective of this study was to compare the responsiveness (ability to accurately detect change) of 3 self-administered questionnaires to changes produced by carpal tunnel release. Method: The Disabilities of the Arm, Shoulder and Hand (DASH), the Brigham and Women's Carpal Tunnel Questionnaire, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were completed by 34 subjects before surgery and at 6 and 12 weeks after carpal tunnel release. Results: The instrument most sensitive to clinical change at 12 weeks as judged by effect size and standardized response means was the Carpal Tunnel Questionnaire (effect size/standardized response means, 1.71/1.66) followed by the DASH (1.01/1.13) and the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (0.57/0.52) and role physical (0.39/0.39) subscales. There was good correlation between DASH and Carpal Tunnel Questionnaire change scores (Spearman correlation coefficient 0.87). Conclusions: The Carpal Tunnel Questionnaire is the most sensitive to clinical change, but the DASH is sufficiently responsive for use in outcome studies of carpal tunnel syndrome done 12 or more weeks after surgery. (J Hand Surg 2003;28A:250-254. Copyright © 2003 by the American Society for Surgery of the Hand.)

Percutaneous needle aponeurotomy: complications and results☆

Abstract: Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

Functional outcome of AO type C distal humeral fractures

Abstract: Purpose: To review the functional outcome of AO type C distal humeral fractures (bicondylar fractures) managed with dual orthogonal plate fixation. Method: Twenty-three patients were reviewed retrospectively at a mean of 45.1 months. Patient-rated outcomes (Disabilities of the Arm Shoulder and Hand [DASH], Patient Rated Ulnar Nerve Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and Short Form-36 [SF-36]), clinical, radiographic, and objective evaluations were used to assess outcomes. Results: Almost 40% of patients required a third plate for adequate fixation. Patients identified minimal subjective deficits (10%) with a mean satisfaction of 93%. The arc of motion was decreased in the flexion-extension plane (122° relative to 138°, p Conclusions: Outcomes of AO type C distal humeral fractures were good with dual orthogonal plating, ulnar nerve transposition, and early motion. Additional plating may be required with distal fracture patterns or osteopenic bone. (J Hand Surg 2003;28A:294-308. Copyright © 2003 by the American Society for Surgery of the Hand.)

Distal biceps tendon repair: comparison of surgical techniques.

Abstract: Purpose: Various surgical repair techniques for distal biceps tendon ruptures have been reported, however, the optimal technique is unknown. Methods: Over a 4-year period 19 distal biceps tendon ruptures were repaired: 9 using a single anterior incision and 10 using a modified 2-incision Boyd and Anderson technique. The patients were followed-up prospectively and independently reviewed. Results: Patient-rated elbow evaluation and Short Form-36 (SF-36) scores improved with time independent of surgical technique. At 1 year the 1-incision group regained more flexion (142.8° vs 131.1°) than the 2-incision group. There was no difference between groups in supination motion, supination strength, or flexion strength, although recovery of flexion strength was initially more rapid for the 2-incision group. Complications were encountered in 44% of cases treated with a 1-incision technique and in 10% of cases treated with the 2-incision technique; however, most of these were minor transient paresthesias. Conclusions: The differences between the 2 groups were relatively minor with the Morrey 2-incision technique showing a slightly more rapid recovery of flexion strength and fewer complications as compared with the 1-incision technique. (J Hand Surg 2003;28A:496-502. Copyright © 2003 by the American Society for Surgery of the Hand.)

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study.

Abstract: Purpose: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach. Methods: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation. Results: The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26–62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30–69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233. Conclusions: Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.

Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate--a biomechanical study in a cadaveric model.

Abstract: The stability of palmar plate fixation using a locking compression T-plate was compared with that of a conventional palmar T-plate and a dorsal T-plate in a cadaveric model of an AO type C2 fracture of distal radius. The wrist axial load transmission through the radius was tested for each fixation. The results show that, under 100N axial load, the palmar locking compression T-plate restores stability comparable to that of the intact radius, and is superior to conventional palmar or dorsal T-plates.

Flexor Tendon Healing in the Rat: A Histologic and Gene Expression Study

Abstract: Purpose: To establish a rat flexor tendon laceration and repair model to investigate the molecular mechanisms of flexor tendon healing. Methods: Surgery was performed on rat flexor digitorum longus tendons from both hind feet. Repaired tendons were harvested at 0, 3, 7, 14, 21, 28, 42, 56, and 84 days after surgery. Histologic study (first 84 days) and gene expression study (first 28 days) of several collagens and matrix metalloproteinases (MMPs) were performed. Results: In the histologic study pre-existing collagen bundles were degraded between days 7 to 21. Newly formed collagen fibers crossed the repair site by day 28. Remodeling of the collagen fibers continued until day 84. Gene expression of type I collagen decreased initially and then returned gradually to the initial level by day 28, whereas expression levels of types III, V, and XII collagen were increased after surgery. The expression levels of MMP-9 and MMP-13 peaked between days 7 to 14, whereas MMP-2, MMP-3, and MMP-14 levels increased after surgery and maintained high levels until day 28. Conclusions: The rat tendon laceration model represented the entire tendon healing process. The results of this study suggest that MMP-9 and MMP-13 participate only in collagen degradation, whereas MMP-2, MMP-3, and MMP-14 participate not only in collagen degradation but also in collagen remodeling.

Proximal row carpectomy: a minimum 10-year follow-up study.

Abstract: Purpose: To assess the long-term clinical and radiographic results after a proximal row carpectomy (PRC). Methods: Twenty patients with various degenerative and posttraumatic disorders of the wrist were evaluated. The evaluation consisted of a physical examination, plain radiographs, and completion of a questionnaire that assessed patient satisfaction, return to work status, occupational and recreational activities and restrictions, and pain level. Results: Two patients (10%) had persistent pain after a PRC requiring a radiocapitate arthrodesis. The remaining 18 patients were evaluated at an average follow-up of 13.1 years (range, 10.0–17.2 y). The average wrist range of motion was 63% and the average maximal grip strength was 83% of the opposite extremity, respectively. Seventeen patients were satisfied with their outcome. One patient complained of persistent pain and was not satisfied but did not want further surgery. All but 2 patients returned to their original occupation and activity level including all 5 patients involved in workers' compensation. Follow-up radiographs showed flattening of the proximal capitate in 6 patients. Radiocapitate arthrosis was absent/minimal in 13 patients and moderate/severe in 4 patients. The presence of radiographic changes did not correlate with patient satisfaction or degree of wrist pain. Conclusions: Proximal row carpectomy is a dependable and durable procedure that results in satisfactory pain relief in the majority of patients, maintenance of functional wrist motion and grip strength, high patient satisfaction, and ability to return to work. Progressive symptomatic deterioration of the radiocapitate articulation was not observed.

Longitudinal Sliding of the Median Nerve in Patients with Carpal Tunnel Syndrome

Abstract: In nerve compression syndromes restricted nerve sliding may lead to increased strain, possibly contributing to symptoms. Ultrasound was used to examine longitudinal median nerve sliding in 17 carpal tunnel syndrome patients and 19 controls during metacarpophalangeal joint movement. Longitudinal movement in the forearm averaged 2.62 mm in controls and was not significantly reduced in carpal tunnel syndrome (CTS) patients (mean=2.20 mm). In contrast, CTS patients had a 40% reduction in transverse nerve movement at the wrist on the most, compared to least, affected side and nerve areas were enlarged by 34%. Normal longitudinal sliding in the patients indicates that nerve strain is not increased and will not contribute to symptoms.

Predictors for return to work in patients with median and ulnar nerve injuries

Abstract: Purpose: One of the consequences of median and ulnar nerve trauma is delayed return to work. The aim of this study was to determine return to work (RTW) and risk factors for delayed RTW in addition to time off work (TOW). Differences among median, ulnar, and combined median-ulnar nerve injuries were examined. Method: In this study 96 patients who were employed at the time of injury and who had undergone surgery for median, ulnar, or combined nerve injuries between 1990 and 1998 were evaluated. The response rate was 84% (n = 81). Results: Within 1 year after injury, 59% (n = 48) returned to work. Mean TOW was 31.3 weeks. Return to work after combined nerve injuries was 24% versus after isolated median (80%) and ulnar (59%) nerve injuries. Level of education, type of job, and compliance to hand therapy were predictors for RTW. Furthermore, grip strength loss, tip pinch strength loss, and sensory recovery differed strongly between the RTW and no-RTW population. Conclusions: The predictors found in this study increase our understanding of delayed RTW after median and ulnar nerve injury and may be used to optimize postinjury rehabilitation. (J Hand Surg 2003;28A:28–34. Copyright © 2003 by the American Society for Surgery of the Hand.)

Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, single-surgeon study including outcomes measures.

Abstract: Purpose: Many surgeons have abandoned the simple trapeziectomy as a surgical treatment option for thumb basal joint arthritis secondary to reports of postoperative weakness. The thumb metacarpal subsiding into the trapezial void has been proposed as the causative factor. The goal of the present study was to evaluate the results of trapeziectomy and postoperative K-wire immobilization of the thumb metacarpal in a distracted position without the use of ligament reconstruction or tendon interposition. Methods: Twenty-six thumbs in 26 patients from a single surgeon's practice were entered into a prospective single-arm study for surgical treatment of peritrapezial arthritis. Treatment consisted of piecemeal excision of the entire trapezium and 5 weeks of K-wire immobilization of the first metacarpal in slight distraction and opposition. No ligament reconstruction or tendon interposition was used. Motion, strength, stress radiographs, standardized dexterity tests, and outcomes questionnaires including the Arthritis Impact Measurement Scales 2 (AIMS2) were evaluated before surgery and 6 and 24 months after surgery. Results: At 6 months 19 of 26 patients (73%) reported complete relief of pain and at 24 months 92% were entirely pain free. Range of motion evaluation showed 24 of 26 thumbs adducted fully into the plane of the palm and 25 of 26 opposed to the fifth metacarpal head. Comparisons between preoperative and 24-month postoperative strength measurements showed an average 47% increase in grip strength, 33% increase in key pinch strength, and a 23% increase in tip pinch strength over preoperative values. AIMS2 data showed postoperative improvement in "hand and finger function" and "arthritis pain" scales. Conclusions: After trapezial excision K-wire immobilization in a slightly overcorrected position without tissue interposition or ligament reconstruction restores a stable, pain-free thumb that has superior strength and motion compared with published reports of the more complicated interventions. (J Hand Surg 2003;28A:381-389. Copyright © 2003 by the American Society for Surgery of the Hand.)

Early Outcome and Cost-Effectiveness of Endoscopic Versus Open Carpal Tunnel Release: A Randomized Prospective Trial

Abstract: Proponents of endoscopic carpal tunnel release have been advocating the technique for more than 10 years but there is still debate about its efficacy, safety and cost-effectiveness. We have performed a randomized, prospective, blind trial to compare early outcome after single portal endoscopic or open carpal tunnel surgery and to assess the cost-effectiveness of the procedures. There were no significant differences in symptom and functional activity scores, grip strength or anterior carpal pain in the first 3 months. For those in employment, we found a statistically significant difference between the two treatment groups with the endoscopic group returning to work, on average, 8 (95% CI, 2-13 days) days sooner than the open group. This translates into a cost saving to industry. There were no major neurovascular complications in either group. On the basis of these findings, we recommend that endoscopic carpal tunnel release should be considered in the employed as a cost-effective procedure, but perhaps not in the general population as a whole.

Computer-assisted distal radius osteotomy

Abstract: Purpose To establish the accuracy, precision, and clinical feasibility of a novel technique of computer-assisted distal radius osteotomy for the correction of symptomatic distal radius malunion. Methods Six patients underwent a computer-assisted distal radius osteotomy and were followed-up for an average of 25 months. Objective radiographic measurements and functional outcomes, as measured by clinical examination including grip strength and range of motion, and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, were used. Results The mean radiographic parameters included an increase of radial inclination to 21° from 12° (normal, 23°). Dorsal and volar tilt (malunion) were corrected to 9° from −30° and 21°, respectively (normal, 10°). Ulnar variance was corrected to 1.9 mm from 7.5 mm (normal, +1.5 mm). Normal is defined as the average of the contralateral limb radiographs. The mean clinical outcome measures at an average of 25 months included a DASH global score of 14, a DASH individual item average score of 1.6, and an average affected side grip strength of 79% when compared with the unaffected side. Conclusions The results of the computer-assisted technique were comparable with published results of traditional non-computer-assisted opening wedge osteotomy techniques. This technique allows a surgeon to accurately and precisely recognize and correct 3-dimensional deformities of the distal radius including axial malalignment (supination). The technique has the added benefit of reducing radiation exposure to the patient and surgical team because fluoroscopy is not used during the procedure. Additional benefits of the computer-assisted technique include the ability to perform multiple surgical simulations to optimize the alignment plan, and it serves as an excellent teaching tool for less-experienced surgeons.

The Natural History of an Untreated Isolated Scapholunate Interosseus Ligament Injury

Abstract: The natural history of an untreated isolated scapholunate interosseus ligament injury remains unclear, although it is commonly assumed that patients continue to suffer with pain, stiffness and weakness of the wrist and ultimately develop secondary osteoarthritis (SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with an arthroscopically proven interosseus scapholunate ligament injury, but without any radiological signs of either DISI deformity or scapholunate gapping, who had declined further treatment at an average follow-up of 7 years. Whilst there was on going pain and functional limitation in all cases, there was no rapid progression to degenerative change (SLAC wrist).

Extension block pinning for large mallet fractures

Abstract: Purpose: The purpose of this report is to review the results of displaced mallet fractures treated with an extension block pin and transarticular fixation of the distal interphalangeal joint. Methods: We retrospectively reviewed 23 patients with 24 fractures to determine the results of treatment, time to union, range of motion, and associated complications. Results: The average patient age was 24 years and the average fracture size was 40% of the joint surface. Ten patients were treated acutely (less than 10 days), 10 subacutely (10-30 days), and 3 chronically (greater than 30 days). Average time to fracture union was 35 days. At 1-year or greater follow-up evaluation the average extension loss was 4° and the average flexion was 77°. There were no major complications and there were 5 minor complications. Using the established outcome criteria for mallet injuries, 92% had excellent or good results. Conclusions: The results of this study showed that this surgical technique resulted in rapid fracture union with only minor complications and has excellent functional outcome based on established criteria. (J Hand Surg 2003;28A:453-459. Copyright © 2003 by the American Society for Surgery of the Hand.)

Prevalence of anatomic variations encountered in elective carpal tunnel release.

Abstract: Purpose: To determine the prevalence of aberrant or unexpected anatomic structures within one surgeon's elective experience of carpal tunnel releases and their association with pathologic compression. Methods: A total of 31 anomalies of median nerve, muscle, and tendon, median artery persistence, and ulnar nerve were documented in 30 hands during the course of 526 elective carpal tunnel releases in one surgeon's practice. The data collected were reviewed retrospectively. All carpal tunnel releases were performed open, exposing the median nerve from the palmar arch to the proximal wrist crease. Anomalies were categorized into those involving the median nerve and its motor and sensory branches, the ulnar nerve, a persistent median artery, and anomalies of muscle/tendon units traversing the carpal tunnel area. Results: Seven hands were noted to have aberrant muscle/tendon variations within the carpal tunnel region (1.3%). Anomalies of the median nerve or its palmar cutaneous or motor branches were observed in 5 hands (1.0%). An anomaly of the ulnar nerve with an aberrant branch crossing the carpal tunnel incision occurred in one hand. A persistent median artery (≥1 mm) was noted in 18 hands (3.4%). One hand had 2 anomalies present. One anomaly was high bifurcation of the median nerve and the second anomaly was an anomalous muscle to the long finger superficialis. Conclusions: The specific anatomic variations described may be anticipated and more readily recognized by hand surgeons during such open surgery, thus increasing the efficacy and safety of this common procedure.

In vivo analysis of carpal kinematics and comparative review of the literature.

Abstract: PURPOSE: Techniques have been developed very recently with which it is possible to quantify accurately in vivo 3-dimensional (3-D) carpal kinematics. The aim of this study was to evaluate the feasibility of our novel 3-D registration technique by comparing our data with data found in the literature. METHOD: The right wrists of 11 healthy volunteers were imaged by spiral computed tomography (CT) during radial-ulnar deviation and 5 of those wrists were imaged also during flexion-extension motion. With a matching technique relative translations and rotations of the carpal bones were traced. We compared our in vivo results with data presented in the literature. RESULTS: We found our in vivo data largely to concur with in vitro data presented in the literature. In vivo studies revealed only larger out-of-plane motions within the proximal carpal row than described in most in vitro studies. In vivo studies also showed larger interindividual variations. CONCLUSIONS: A single functional model of carpal kinematics could not be determined. We expect that in vivo 3-D CT studies on carpal kinematics, especially when applied to dynamic wrist motion, will have future diagnostic applications and provide information on long-term results of surgical interventions.

Impact of impaired wrist motion on hand and upper-extremity performance

Abstract: Purpose: To quantify and compare the disabilities caused by reduced and absent wrist motion using objective measurements of task performance and perceived disability, and to assess the compensatory motions of the shoulder, elbow, forearm, and trunk caused by impaired wrist motion. Methods: A clinical study of 21 normal subjects was done to measure physical performance and to assess wrist function under conditions of reduced (30° flexion and 30° extension) and nearly absent wrist motion using established physical tests and questionnaires (Disabilities of the Arm, Shoulder, and Hand [DASH], Patient Rated Wrist Evaluation [PRWE], and a study-specific survey). The clinical study also measured compensatory motions of the shoulder, elbow, forearm, and trunk. Results: Average times to perform the Jebsen test and activities of daily living (ADLs) test increased for both motion-restricted conditions of the wrist but did not differ significantly between the conditions. Questionnaire scores regarding function were significantly worse for both motionrestricted conditions and poorest for nearly absent motion. Average compensatory motions in the extremity and trunk statistically increased for both motion-restricted conditions but were not marked and did not differ between the conditions. High variability among subjects occurred in all physical tests and questionnaires for both motion-restricted conditions. Conclusions: Perceived disability from reduced wrist motion appeared greater than measured functional loss using common physical tests and outcome surveys. (J Hand Surg 2003;28A: 898 –903. Copyright © 2003 by the American Society for Surgery of the Hand.)

The noncircular shape of the radial head

Abstract: Purpose The purpose of this study was to define the shape of the radial head by identifying the relationship between precisely defined axes of the radial head. Methods An anatomic study was done to define the shape of the radial head and specifically the relationship between the long and the short axis. Twenty-seven cadaveric upper extremities were used. The x and y axes of the radial head were defined in relationship to the radial notch of the ulna, with the forearm in neutral position. Outer diameters of the x and y axis were measured. These were compared with the actual maximum and minimum diameters of the radial head. X and y diameters of the articulating surface of the radial head also were measured. Paired 1-tailed Student's t -tests were used to compare the x and y diameters of the radial head. Regression analysis of x and y diameters of the radial head was done to identify a correlation between these parameters. Results Paired 1-tailed Student's t -tests showed a significant difference between X and Y diameters of the radial head. Regression analysis of x and y diameters of the radial head showed a strong correlation between these 2 axes. Conclusions The radial head is not round. A strong correlation exists between the x and y diameters of the radial head. The orientation of the long axis is perpendicular to the radial notch with the forearm in neutral rotation. This finding will make it possible to approach the anatomy of the radial head more closely when designing radial head prostheses. The definition of the axes can be used as a guide when implanting the radial head prosthesis.

Causes of ulnar tunnel syndrome: a retrospective study of 31 subjects.

Abstract: Purpose: The purposes of this study were to determine the distribution of causes and sites of nerve compression in the ulnar tunnel (Guyon's canal), and investigate the relationship between ulnar tunnel syndrome (UTS) and other conditions associated with it. Methods: We performed a retrospective review of 31 patients diagnosed with and treated for UTS to determine the most common cause of compression and the sites of compression, systemic illnesses associated with UTS, and postoperative results. Results: The cause of ulnar nerve compression was idiopathic in 14, trauma in 8, a thrombosis in 2, proliferation of synovium in 2, a prominent hook of the hamate in 1, a schwannoma in 1, postoperative swelling in 1, an aberrant fibrous band in 1, and a ganglion in 1. The sites of compression were classified into 3 zones. Twenty-eight cases had compression in zone 1, 6 in zone 2, and 19 in zone 3. Seventeen cases (55%) had compression in more than 1 zone. Twenty-two cases (71%) were associated with carpal tunnel syndrome (CTS). Twelve (86%) of the 14 idiopathic UTS cases were associated with CTS. The relationship between idiopathic UTS and CTS was not statistically significant. Six cases were associated with diabetes mellitus. Conclusions: The most common cause of UTS in our series was idiopathic. Most idiopathic UTS cases were associated with CTS. The clinical symptoms of UTS improved after surgery in all cases. Therefore because of the presence of multiple compression sites of the ulnar nerve in the hand, for UTS patients we believe that the release of Guyon's canal and/or the pisohamate tunnel is an effective way not only to relieve symptoms but also to determine the real cause of compression.

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist.

Abstract: Purpose: To compare the outcomes of wrist arthrodesis and arthroplasty in the treatment of rheumatoid arthritis using validated outcome patient surveys and a review of surgical complications in 2 matched cohorts. Methods: Forty-six patients with 51 operated wrists (24 arthrodeses and 27 arthroplasties) were reviewed retrospectively at a follow-up range of 1 to 5 years. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory, the Patient-Rated Wrist Evaluation (PRWE), and a questionnaire designed specifically for this study. Surgical complications were obtained by chart review. Results: Treatment groups were well matched by patient characteristics and radiographic staging. There were no statistical differences in the survey scores between the 2 groups. Patients in the arthroplasty group, however, reported a trend toward greater ease with personal hygiene and fastening buttons. Complication rates were similar with a 56% complication rate in the arthrodesis group (22% major, 35% minor) and a 52% complication rate in the arthroplasty group (11% major, 41% minor). Conclusions: The DASH and PRWE may not be designed properly to measure impairment caused by wrist disease in patients with generalized arthritis. The results show that patients with rheumatoid arthritis can and do accommodate to a wrist arthrodesis. It should not be construed, however, that these patients would not prefer or obtain greater benefit from a wrist arthroplasty or that they would not obtain greater benefit from an arthrodesis.

The Lichtman classification for Kienböck's disease: an assessment of reliability.

Abstract: Purpose: The correct identification of Lichtman stage 3A and 3B Kienbock's disease is crucial for treatment purposes. The present study evaluates the reliability of the Lichtman classification, with specific attention to differentiating stage 3A and 3B. Methods: Four reviewers evaluated wrist radiographs from 39 patients with Kienbock's disease. Radiographs were graded according to the traditional Lichtman classification, a modification of the Lichtman classification using a radioscaphoid angle of 60° to subdivide stage 3, and 8 other radiographic measures. Results: The interobserver reliability of the Lichtman classification was substantial (κ coefficient 0.63), but Stage 3A was less reliably identified (κ 0.38). The new modification of the Lichtman classification increased both the overall (κ 0.81) and the stage 3A (κ 0.75) interobserver reliability. Conclusion: The use of the radioscaphoid angle increases the interobserver reliability of the Lichtman classification. This should allow a better understanding of the clinically important distinction between stage 3A and 3B disease. (J Hand Surg 2003;28A:74-80. Copyright © 2003 by the American Society for Surgery of the Hand.)

Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists.

Abstract: Purpose: Surgical management of rheumatoid hand diseases is controversial with large variation in practice pattern in the U.S. The purpose of this study is to evaluate the attitudes of hand surgeons and rheumatologists toward the effectiveness of rheumatoid hand surgery. Methods: We designed a survey instrument to examine physicians' opinions about the effectiveness of different surgical treatments for rheumatoid hand deformities. The self-administered survey was mailed to a national random sample of 500 members of the American Society for Surgery of the Hand and 500 members of the American College of Rheumatology. Results: Of survey responders, 82.5% of hand surgeons versus 34.1% of rheumatologists believe metacarpophalangeal joint arthroplasty improves hand function; 93.2% and 54.6%, respectively, believe prophylactic extensor tenosynovectomy prevents tendon rupture; and 52.5% and 12.6%, respectively, believe small joint synovectomy delays joint destruction. Conclusions: Rheumatologists view rheumatoid hand surgery as significantly less effective than do hand surgeons, which highlights the disagreements between the 2 specialties about the management of this clinical problem. (J Hand Surg 2003;28A:3–11. Copyright © 2003 by the American Society for Surgery of the Hand.)