Treatment of Intractable Pillar Pain With Excision of the Hook of Hamate.

Introduction: A common consequence of carpal tunnel release (CTR) is ulnar palmar pain termed pillar pain. Some (very rare) patients do not improve with conservative treatment. We have been treating recalcitrant pain with excision of hook of the hamate. Our purpose was to evaluate a series of patients undergoing excision of the hook of the hamate for post CTR pillar pain. Methods: A retrospective review of all patients undergoing hook of hamate excisions over a 30-year period was performed. Data collected included: gender, hand dominance, age, time-to-intervention, preoperative and post-operative pain scores, and insurance. Results: Fifteen patients were included with a mean age of 49 (range 18-68) years, 7 female (47%). Twelve (80%) of the patients were right handed. Mean time between CTR and excision hook of hamate was 7.4 months (range 1-18 months). Pain prior to surgery was 5.44 (range 2-10). Post-operative pain was 2.44 (range 0-8). Mean follow-up was 4.7 months (range 1-19 months). Patients with a good clinical outcome were 14 (93%). Conclusions: Excision of hook of hamate seems to provide clinical improvement in patients who remain painful despite exhaustive conservative treatment. It may be considered as a very last resort for persistent pillar pain after CTR.

Introduction : Une conséquence fréquente de la libération du tunnel carpien (TC) est une douleur ulnaire palmaire appelée douleur du pilier. Quelques (très rares) patients ne sont pas améliorés par le traitement conservateur. Nous avons traité une douleur récalcitrante avec une ablation du crochet (ou hamulus) de l'os hamatum. Notre objectif était d'évaluer une série de patients subissant une ablation du crochet de l'os hamatum pour douleur du pilier après libération du TC. Méthodes : Une analyse rétrospective de tous les patients subissant une ablation du crochet de l'os hamatum a été menée sur une période de 30 ans. La collecte de données a inclus: le sexe des patients, la main dominante, l'âge, le délai jusqu'à l'intervention, les scores de douleur avant et après l'opération, ainsi que l'assurance. Résultats : Quinze patients ont été inclus; leur âge moyen était de 49 ans (18 à 68 ans); il y avait 7 femmes dans la population (47 %). Douze patients (80 %) étaient droitiers. Le délai moyen écoulé entre la libération du TC et l'ablation du crochet de l'os hamatum a été de 7,4 mois (extrêmes: 1 à 18 mois). Le score de douleur avant chirurgie était de 5,44 (extrêmes: 2 à 10). Le score de douleur postopératoire était de 2,44 (extrêmes: 0 à 8). Le suivi moyen a été de 4,7 mois (extrêmes: 1 à 19 mois). Un bon résultat clinique a été obtenu chez 14 patients (93 %). Conclusion : L'ablation du crochet de l'os hamatum semble procurer une amélioration clinique chez les patients qui restent douloureux malgré un traitement conservateur exhaustif. Cette option peut être envisagée en dernier ressort chez les patients ayant une douleur du pilier après libération du TC.

Using Extensor Retinaculum to Reconstruct the Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament.

Chronic complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal joint often require surgical reconstruction. The indications, materials used, and the methods for reconstruction remain controversial. We describe a technique for reconstruction that utilizes a slip of the extensor retinaculum for reconstruction. The advantages of extensor retinaculum as a graft choice are that it matches the native ligament with a synovial and nonsynovial surface, has elasticity similar to the ligament and minimal donor site morbidity. Reconstruction of the ulnar collateral ligament with this graft successfully restores pinch.

Trigger Fingers After Open Carpal Tunnel Release.

Trigger finger (TF) and carpal tunnel syndrome (CTS) are common conditions often occurring together with an unclear relationship. While some studies conclude that TFs occur as a result of carpal tunnel release (CTR), others have not established a causal relationship. Our purpose was to evaluate the prevalence and timing of TF development in the same hand after open CTR in our population. This was a retrospective review of 497 patients undergoing open CTR by a single surgeon. Two hundred twenty-nine charts were analysed for age, gender, handedness, BMI, workers' compensation status, and background disease. We analysed the specific digit involved and timing to development of triggering after CTR. Thirty-one patients developed triggering after CTR (13.5%). Mean age was 52.5 (14.0) years. Follow-up ranged from 1 to 53 months with a median follow-up of 6 months (interquartile range = 2-13). The thumb was the most common to trigger (42.22%), followed by the ring 24.44%, middle 22.22%, little 8.89%, and index fingers 2.22%. Trigger thumb occurred at 3.5 months (3.6) post-operatively, while other digits triggered at 7.5 months (4-10.25) after surgery (P = .022). No risk factors were associated with TF development. Our results suggest that a trigger thumb develops more frequently and earlier than other trigger digits after an open CTR. Further study is needed to clarify the mechanisms involved and may enable specific treatment such as local anti-inflammatory medication following CTR. We suggest educating prospective carpal tunnel surgery patients to high risk of triggering following CTR.

Le doigt à ressort et le syndrome du canal carpien sont des affections courantes et souvent conjuguées, sans qu'on en comprenne exactement le lien. Selon certaines études, le doigt à ressort se produit après une libération du canal carpien (LCC), mais selon d'autres, ce lien n'existe pas. Les chercheurs ont voulu évaluer la prévalence et le moment d'apparition des doigts à ressort après une LCC de la même main au sein de leur population. Les chercheurs ont réalisé la présente étude rétrospective auprès de 497 patients chez qui le même chirurgien avait effectué une LCC ouverte. Ils ont examiné 229 dossiers pour tenir compte de l'âge, du genre, de la manualité, de l'indice de masse corporelle, du droit ou non à l'indemnisation des travailleurs et des maladies sous-jacentes. Ils ont analysé le doigt touché et le moment de l'apparition du problème après la LCC. Trente et un patients, d'un âge moyen de 52,5 ans (14,0), ont présenté un doigt à ressort après une LCC (13,5 %). Les suivis ont duré de un à 53 mois, pour une médiane de six mois (intervalle interquartile = 2 et 13). Le pouce était le plus touché (42,22 %), succédé par l'annulaire, à 24,44 %, le majeur, à 22,22 %, l'auriculaire, à 8,89 %, et l'index, à 2,22 %. Le pouce à ressort se déclarait 3.5 mois (3 et 6) après l'opération, mais les autres doigts étaient touchés 7,5 mois (4 et 10,25) après l'opération (P = 0,022). Aucun facteur de risque n'a été associé à l'apparition du doigt à ressort. Selon les résultats, le pouce à ressort est le plus fréquent après une LCC ouverte, plus tôt que les autres doigts. Des études plus approfondies pourraient révéler le mécanisme d'occurrence conjuguée et favoriser l'utilisation d'un traitement particulier, comme une médication anti-inflammatoire localisée après la LCC. Les chercheurs proposent d'informer les patients candidats à une LCC du risque élevé de doigt à ressort après l'intervention.

The Effect of Age on Fracture Healing Time in Metacarpal Fractures.

Background: Older patients are treated for fracture with increasing frequency. Although studies on animals suggest that older mice and rats heal fractures more slowly, the clinical implications remain unclear. A better understanding of differences in healing with age can help customize fracture treatment. Our purpose was to retrospectively evaluate metacarpal fractures for healing time looking specifically at age-related differences. Methods: A retrospective review of patients treated for metacarpal fractures was conducted. Patients with incomplete charts or inadequate follow-up were excluded. One hundred ninety-eight charts were analyzed. Demographic and other patient factors were documented. Fracture characteristics and treatment type were documented. Fracture healing was determined clinically. Plain radiographs and examination were used in decision making. Results: Age was not associated with fracture healing time as a continuous variable (P = .09). Patients above 75 years were not associated with increased healing time (P = .58). Fracture characteristics were related to healing time: minimally displaced and comminuted fractures healed faster than oblique fractures, spiral fractures, or transverse fractures (P = .048). Patients undergoing surgery healed faster than those without surgery (P = .046). Renal failure negatively affected fracture healing time (P = .03). Diabetes, hypothyroidism, and gender were not associated with healing time. Complications were not associated with age or other patient or fracture-related factors. Conclusions: Age does not affect clinical fracture healing time in adult. Therefore, older patients do not require disparate treatment. Other fracture-related factors and considerations such as functional demand and support systems might influence treatment decisions in fracture care.

Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist.

BACKGROUND: Scapholunate advanced collapse (SLAC) of the wrist is the most common degenerative condition of the wrist. Four-corner fusion (4CF) is performed as salvage surgery, though there is limited information on its long-term results. We hypothesized that 4CF is a durable surgery with good clinical long-term function. METHODS: A retrospective chart review of patients undergoing 4CF as well as an interview and recent radiographs were obtained. Patients with a follow-up period of less than 10 years were excluded. Long-term evaluation included standard wrist radiographs, wrist range of motion, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were evaluated and described by the Kellgren-Lawrence classification. RESULTS: Four hundred eighty-nine wrists underwent a 4CF for SLAC wrist from 1982 to 2003. Twelve patients (15 wrists) were available for follow-up. Average age at surgery was 49.1 years (range, 25-67 years). Average follow-up postsurgery was 18 years (11-27). Scapholunate advanced collapse was the etiology in 13 wrists and scaphoid nonunion advanced collapse in 2 wrists. Average extension/flexion arc was 68.6° (0°-96°), and radial/ulnar deviation arc was 32.9° (0°-5°). QuickDASH scores averaged 7.8 (range, 0-32.5), with only 1 score above 16. Seventy-three percent of radiographs showed minimal to moderate joint destruction, and 27% showed severe joint destruction. CONCLUSIONS: Scaphoid excision and 4CF remains a reliable procedure for patients with advanced wrist arthritis. Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. Patient satisfaction was high, and functional impairment was low.

Scaphotrapeziotrapezoid arthrodesis: a follow-up study.

PURPOSE: The purpose of this study was to review the results of 800 scaphotrapeziotrapezoid fusions performed over a 27-year period. METHODS: The patients were evaluated for postoperative range of motion, grip and pinch strength, pain, return to work, arthritis, and complications. RESULTS: The overall range of motion was 70% to 80% of the nonoperated side and strength was 69% to 89%. Of the patients 88% returned to previous employment. Arthritis developed in 1.8% of the patients. The overall complication rate was 13.4%. CONCLUSIONS: Scaphotrapeziotrapezoid fusion is a viable treatment option especially for a high-functional-demand young population with significant wrist pathology. Complications, specifically nonunion, can be minimized with careful technique.