A Cadaveric Study for the Improvement of Thread Carpal Tunnel Release.

PURPOSE: The thread carpal tunnel release (TCTR) technique has been improved and offers more precise control in dissecting thread placement. The purpose of this cadaveric study was to test the procedure operationally and verify the modified TCTR anatomically. METHODS: Eleven unembalmed cadaver wrists underwent the transverse carpal ligament (TCL) release by using the modified TCTR technique. An experienced observer dissected each specimen and assessed for completeness of release under direct visual assessment. Injury to the superficial palmar aponeurosis (SupPA), the Berrettini and common digital nerve branches were also recorded as a secondary outcome. RESULTS: Eleven out of 11 wrists (100%) underwent the modified TCTR with complete release of the TCL. All 11 wrists were released without damage to any vital neurovascular structure including the Berrettini branch and the common digital nerves. The SupPA remained intact in all 5 wrists performed with the preservation steps. CONCLUSIONS: The modified TCTR technique demonstrated complete division of the TCL while protecting the SupPA as well as the Berrettini and common digital nerve branches. CLINICAL RELEVANCE: The modified TCTR has the potential to offer a clinically safe and effective minimally invasive procedure for complete carpal tunnel release.

Musculoskeletal ultrasound objective structured clinical examination: an assessment of the test.

OBJECTIVE: To determine the reliability and validity of an objective structured clinical examination (OSCE) for musculoskeletal ultrasound (MSUS). METHODS: A 9-station OSCE was administered to 35 rheumatology fellows trained in MSUS and to 3 expert faculty (controls). Participants were unaware of joint health (5 diseased/4 healthy). Faculty assessors (n = 9) graded image quality with predefined checklists and a 0-5 global rating, blinded to who performed the study. Interrater reliability, correlation between a written multiple choice question examination (MCQ) and OSCE performance, and comparison of fellow OSCE results with those of the faculty were measured to determine OSCE reliability, concurrent validity, and construct validity. RESULTS: Assessors' interrater reliability was good (intraclass correlation coefficient [ICC] 0.7). Score reliability was good in the normal wrist and ankle stations (ICC 0.7) and moderate in the abnormal wrist and ankle stations (ICC 0.4). MCQ grades significantly correlated with OSCE grades (r = 0.52, P < 0.01). The fellows in the bottom quartile of the MCQ scored 3.07 on the OSCE, significantly worse than the top quartile fellows (3.32) and the faculty (3.29; P < 0.01). Scores also significantly discriminated bottom quartile fellows from faculty in the normal wrist and ankle stations (3.38 versus 3.78; P < 0.01), but not in the abnormal stations (3.37 versus 3.49; P = 0.08). CONCLUSION: MSUS OSCE is a reliable and valid method for evaluation of MSUS skill. Normal joint assessment stations are more reliable than abnormal joint assessment stations and better discriminate poorly performing fellows from faculty. Therefore, MSUS OSCE with normal joints can be used for the assessment of MSUS skill competency.

An atlas improves interobserver agreement regarding application of the ISCD vertebral body exclusion criteria.

Coexisting conditions such as osteoarthritis and compression fracture may spuriously elevate the dual-energy X-ray absorptiometry (DXA)-measured lumbar spine bone mass. To improve the diagnostic utility of lumbar spine DXA to diagnose osteoporosis, the International Society for Clinical Densitometry (ISCD) suggests excluding vertebrae affected by focal structural anomalies or unusual T-score discrepancies. However, we previously demonstrated only moderate agreement between physicians regarding vertebral body exclusion. We hypothesized that an atlas containing examples of vertebrae to exclude would improve interobserver agreement. Subsequently, we developed an interactive web-based atlas of lumbar spine DXA images with options to exclude vertebrae and compare one's answers to those derived by group consensus. Before and after review of the atlas, 5 ISCD-certified physicians applied the exclusion criteria to 90 DXA scans, recording the indications for vertebral exclusion on a standardized worksheet. After development and review of the atlas, interobserver agreement regarding vertebral body exclusion improved significantly (p<0.0001). We plotted the deviation of each physician's reported T-score vs the mean T-score for each of 90 scans, and demonstrated that the scatter from the mean is decreased after atlas review. Furthermore, correlations in T-score improved in 7 of 10 physician pairs after atlas review. We conclude that an interactive atlas promotes uniform lumbar spine DXA interpretation.