Management of Gout in the Hand and Wrist.

Gout, or monosodium urate deposition disease, is the most common form of inflammatory arthritis that affects almost 4% of adults in the United States.Medical management involves lifestyle modifications and urate-lowering therapy to reduce the frequency of gout flares, decrease the tophi size, and improve upper extremity function. Goals for surgical management of gout include functional optimization, symptomatic treatment, and cosmetic restoration.This article focuses on the medical and surgical treatment of the common manifestations of gout in the upper extremity including tophi, tenosynovitis, joint contractures, neural compression, and arthropathy.

Application of Tendon With Z-Lengthening Technique.

Tendon deficiency limits repair and reconstructive options after tendon and nerve injuries of the upper extremity. Current treatment options include intercalary tendon autograft, tendon transfers, and two-stage tenodesis, with sacrifice of the flexor digitorum superficialis. These reconstructive techniques are associated with donor site morbidity and limited in the setting of multiple tendon deficiencies. The tendon with z-lengthening (TWZL) technique is presented here as an alternative treatment method for tendon injuries and tendon transfer reconstruction after nerve injuries. The TWZL technique involves splitting a tendon longitudinally, reflecting the freed tendon limb distally, and suture augmentation at the bridge site located at the distal end of the native tendon. The TWZL technique has applications throughout the upper extremity-flexor and extensor tendons injuries, biceps and triceps tendon injuries, and tendon transfers for restoration of hand function after nerve injuries. An illustrative case example is also provided. The experienced hand surgeon should consider the TWZL technique as a potential treatment option when faced with difficult clinical conditions of the hand and upper extremities.

Weight-Bearing Computed Tomography of the Foot and Ankle in the Pediatric Population.

BACKGROUND: Newer cone-beam computed tomography (CT) technology has grown in popularity for evaluation of foot and ankle pathology in the weight-bearing (WB) position. Many studies have demonstrated its benefits within the adult population, but there is a paucity of its use within the pediatric literature. The purpose of this study was to describe the indications and clinical findings of WBCT within a pediatric population. METHODS: A retrospective cohort of 68 patients (86 extremities) who underwent WBCT for a variety of conditions were compared with 48 patients (59 extremities) who underwent traditional supine nonweight-bearing (NWB) CTs. Clinical indications, demographic data, radiation doses, and cost were obtained from the medical record. WBCTs were obtained in a private outpatient orthopaedic clinic, and the conventional NWBCTs were obtained within a hospital-based system. RESULTS: The most common indications for obtaining a WBCT and NWBCT in our study were fracture, tarsal coalition, and Lisfranc injury. The average WBCT radiation dose was 0.63 mGy for patients <100 lbs and 1.1 mGy for patients >100 lbs undergoing WBCT. For NWBCTs, the average radiation dose was 7.92 mGy for patients <100 lbs and 10.37 mGy for patients greater than 100 lbs. There was a significant reduction in radiation dose for all patients who underwent WBCT (P<0.0001 vs. 0.002). The average reimbursement for NWBCTs was $505 for unilateral studies and $1451 for bilateral studies. The average reimbursement for the WBCTs was $345 for unilateral studies and $635 for bilateral studies. CONCLUSIONS: WBCT offers a new modality for studying complex foot and ankle pathoanatomy in the pediatric population at a reduced radiation exposure and reduced cost. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review.

Prompt diagnosis and treatment of acute injury to the median nerve after wrist trauma are paramount to a successful outcome. Neuropathy can occur primarily at the time of injury, secondary to unreduced fracture fragments or callus, or from prolonged immobilization in palmar flexion. Acute carpal tunnel syndrome is a surgical emergency that requires decompression. Progressively worsening pain and sensory disturbances in the median nerve distribution are findings that will distinguish an acute carpal tunnel syndrome from the less severe median nerve neurapraxia. This article describes the key differences between neurapraxia and acute compartment syndrome and their respective treatment.

Common Complications of Distal Radial Fractures.

Distal radial fractures are associated with good outcomes; however, although they occur at low rates, complications can significantly impair treatment success. Therefore, the treating surgeon should be aware of potential complications associated with each treatment type and how to best prevent them. Although certain patient-specific and fracture-specific factors may increase the risk of adverse outcomes, most are nonmodifiable risk factors at the time of presentation, so it is imperative that every effort is made to mitigate these risk factors to prevent long-term morbidity. Patients should be well-informed about these complications and potential symptoms so that they can be addressed expeditiously.

Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons.

The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].

Technique of Dynamic Flexor Digitorum Superficialis Transfer to Lateral Bands for Proximal Interphalangeal Joint Deformity Correction in Severe Dupuytren Disease.

Pseudo-boutonniere deformity is an uncommon complication from long-standing proximal interphalangeal (PIP) joint contracture in Dupuytren disease. Prolonged flexion contracture of the PIP joint can lead to central slip attenuation and resultant imbalances in the extensor mechanism. We present a technique of flexor digitorum superficialis (FDS) tendon transfer to the lateral bands to correct pseudo-boutonniere deformity at the time of palmar fasciectomy for the treatment of Dupuytren disease. The FDS tendon is transferred from volar to dorsal through the lumbrical canal and sutured into the dorsally mobilized lateral bands. This technique presents an approach to the repair of pseudo-boutonniere deformity in Dupuytren disease.

Cost Analysis of Sending Routine Pathology Specimens following Total Joint Arthroplasty in the Age of Bundled Payments.

Bundled payment plans are being developed as a means to curb healthcare spending. Routine histology following total hip arthroplasties (THA) and total knee arthroplasties (TKA) is standard practice at many institutions. Recently, the value of this practice has been questioned as histologic diagnoses in THA and TKA rarely differ from the clinical diagnoses. The goal of this study is to identify discrepant and discordant diagnoses following THA and TKA at an academic medical center and to calculate the cost-saving potential in the setting of a bundled payment plan. A retrospective chart review was conducted on 1,213 primary THA and TKA performed by two orthopaedic surgeons from 2012 to 2014. The clinical and histologic diagnoses were compared and classified as concordant, discrepant, or discordant. Cost information was obtained from the institutional billing office. One thousand one hundred and sixty-six THA and TKA were analyzed in the final cohort. Nineteen (1.6%) diagnoses were classified as discrepant while none were discordant. The cost of histologic examination per specimen was estimated to be $48.56. The total cost of all arthroplasties was $14,999,512.46, of which histologic examination made up 0.31% of the total cost. The results of this study corroborate the results of previous studies and support the proposition that routine histologic examination is not cost-effective. The cost incurred to perform histologic examination will become a cost deduction from future bundled payments. The practice of sending routine histologic specimens following TJA should be decided upon by the operating orthopaedic surgeon.