An Approach to Surgery for Cubital Tunnel Syndrome A Pilot Series.

BACKGROUND: Cubital tunnel syndrome and the resulting loss of hand dexterity and strength may necessitate surgical management. Studies have demonstrated no difference in outcome between surgical techniques. In an attempt to leave more ulnar nerves in situ while providing for stability within the cubital tunnel, we suggest a surgical treatment approach. METHODS: The approach addresses individual anatomy methodically, eliminating muscular obstruction first and providing further decompression and stability as required. A retrospective review of 27 adult patients with ulnar neu- ropathy treated according to this method was performed. RESULTS: The mean duration of symptoms prior to surgery was 2.75 years (SD = 2.4). The mean follow-up was 17.1 months (SD = 16.9). All patients improved following surgery. Two revision surgeries were performed 4 years following the original surgery. CONCLUSIONS: We believe the nerve recovers best when left in situ, provided it is stable and not compressed within the cubital tunnel. A further comparison study is necessary to substantiate the advantage of this "personalized" approach over other surgical techniques for cubital tunnel release.

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.

Missed childhood-onset carpal tunnel syndrome diagnosed as chronic pain: case report.

We report the case of a 15-year-old girl with a red, swollen, and painful right hand. She first developed symptoms when she was 7 years old. Numerous physicians evaluated her at various institutions but were able to classify her only with chronic pain syndrome. She continued with regular occupational therapy and had to use special aids to compensate throughout school. After 8 years of treatment with no improvement, she presented to our office, where we diagnosed carpal tunnel syndrome. Intraoperative findings revealed a large proximal muscle belly of the index lumbrical, a thickened transverse carpal ligament, and marked compression of the median nerve. Two weeks after the surgery, her symptoms cleared; at 5 months, she remained symptom free.

Long-term durability of tendon arthroplasty with excision of the trapezium in stage 1 osteoarthritis of the thumb CMC joint.

Basal joint arthritis of the thumb is commonly treated surgically. Although the results are good, there is still controversy regarding the treatment of young people with low radiographic stages of disease. Our purpose was to evaluate the durability of a tendon arthroplasty procedure in this population. Thirty patients aged 55 years or under, with early stage arthritis, were evaluated. Eight patients were available for long-term (average 86 months) follow-up. No deterioration in the strength and mobility of the operated thumbs in the long-term was found. There was a significant increase in tip pinch strength between short- and long-term follow-up evaluations. This study supports the durability of this surgery in younger patients, potentially reducing the need for multiple surgeries.

Surgical technique for the treatment of radial wrist pain.

Chronic radial wrist pain with no radiographic evidence of scapholunate instability or other wrist disease can be difficult to diagnose and treat. Our purpose was to evaluate the results of an operation to treat chronic radial or periscaphoid wrist pain that has failed to respond to conservative treatment. We examined the scapholunate ligament and performed a dorsal capsulodesis. One hundred-and-two patients were reviewed retrospectively. Casenotes were available for 88 patients. Function, pain, range of movement (ROM), and grip and pinch strengths were evaluated. Twenty (23%) of the patients were found to have a scapholunate ligament tear of 0-30%, 55 (61%) had a tear of 30%-60%, and 14 (16%) had a tear of 60%-100%. Mean postoperative grip strength was 29.5 kg (80% of the normal side). Postoperative range of movement was significantly limited in flexion compared with the normal side. All patients returned to their previous employment. Seventy (80%) of the patients described improvement in pain and function. Twenty-two (25%) required further operation on the same wrist. This procedure may be indicated in patients with chronic radial wrist pain and no overt instability that is resistant to conservative treatment. It has minimal morbidity and gives good results.

Use of quantitative abductor pollicis brevis strength testing in patients with carpal tunnel syndrome.

BACKGROUND: Diagnosis of carpal tunnel syndrome remains clinical, despite many objective clinical and electrophysiologic tests. There is also a need to objectively assess the severity of involvement and the need for surgery, and to document response to treatment. The authors evaluated a hand-held strength-testing device for assessment of abductor pollicis brevis strength in patients with carpal tunnel syndrome. METHODS: Sixty-two hands in 50 patients (39 women and 11 men) aged 26 to 57 years were examined. All hands were evaluated before and 6 weeks after surgery. Nineteen hands were available for 7-year follow-up. RESULTS: Abductor pollicis brevis strength following carpal tunnel release increased significantly from a mean of 2.3 kg to 3.1 kg. The strength further increased in all long-term follow-up patients. CONCLUSIONS: Quantitative strength testing can be used to document changes in abductor pollicis brevis strength in response to treatment in patients with carpal tunnel syndrome. Further study is needed to assess the reliability of this testing method using multiple examiners in patients with carpal tunnel syndrome, and to evaluate the utility of using this device in tracking the long-term outcome of patients after carpal tunnel release.

A technique for the repair of chronic volar plate avulsion of the proximal interphalangeal joint: a review of 54 cases.

BACKGROUND: The authors delineate a subgroup of proximal interphalangeal joint injuries with chronic pain and limitation of movement, despite a stable joint, and describe and evaluate a surgical procedure. METHODS: Through a volar approach, the volar plate is freed from scar but remains connected on either the ulnar or radial border. A new connection to the middle phalanx is established by creating a bony groove, and the volar plate is loosely attached distally. Fifty-four joints with chronic volar plate avulsion injuries of the proximal interphalangeal joint were evaluated. All patients had chronic pain and limitation of motion and function in a stable and congruent joint. Patients were examined at 6 weeks, 3 months, and 1 year after surgery. Range of motion, grip strength, and pain were evaluated. The average time to surgery was 10.5 +/- 11.8 months (range, 2 to 65.4 months). The mean postoperative follow-up period was 10.0 +/- 12.8 months (range, 3 to 73.5 months). RESULTS: All patients had an improved range of motion following surgery. The difference from the preoperative range of motion was statistically significant (p < 0.0001). None of the patients reported pain on rest after surgery, and five patients reported activity pain. The mean grip strength was 32.4 +/- 13.4 kg for hand that had been operated on and 41.0 +/- 14 kg for the hand that had not been operated on. CONCLUSIONS: This technique for repair of chronic volar plate avulsion injuries allows early motion and results in significant improvement in range of motion, pain, and overall function in this subgroup of patients.

A radiographic view of the scaphotrapezium-trapezoid joint.

Traditionally the scaphotrapezium-trapezoid joint is imaged through a posteroanterior view of the wrist. We describe an x-ray view that is aimed directly at the joint, which gives better visualization than the standard views.

Scaphotrapeziotrapezoid arthrodesis for arthritis.

The main indications for scaphotrapeziotrapezoid (STT) fusion are STT arthritis, rotary subluxation of the scaphoid, and Kienbock disease. The results of this procedure in the literature for each indication are discussed, as are the advantages, disadvantages,and alternative procedures. This article discusses the authors' surgical technique and results. The authors believe this procedure is a viable one in specific clinical scenarios.

Digital glomus tumors: a 29-year experience with a lateral subperiosteal approach.

The excision of distal digital glomus tumors has traditionally been performed directly over the involved nail bed. This can lead to nail deformities that are often unacceptable for the surgeon and the patient. The authors describe their experience with successful excision of digital glomus tumors using a lateral subperiosteal approach, which creates a dorsal flap. In 29 years, 19 patients were diagnosed with digital glomus tumors. All patients underwent excision using the lateral subperiosteal approach. The mean tumor size was 0.52 cm. The tumors were located on the pulp of the distal phalanx in two patients (10.5 percent) and subungually in 17 patients (89.5 percent). In all patients, preoperative clinical diagnosis was confirmed postoperatively with the biopsy result. Complications occurred in only two patients and included one paronychia and one temporary nail loss. The overall recurrence rate was 15.7 percent. All patients remained asymptomatic after surgery and regained full active and passive range of motion. There were no nail deformities by this approach. This technique represents a safe and effective approach to excising digital glomus tumors.

Bilateral symptomatic supernumerary muscle belly syndrome.

A 32-year-old woman with a longstanding history of bilateral forearm pain had been unable to open her fingers and use her left arm (treated as reflex sympathetic dystrophy) since the age of 14. On physical examination there was fullness and tenderness of the distal volar forearms bilaterally; the quadriga test (when the patient was asked to make a tight fist quickly, with one finger fully extended passively) elicited burning pain. Operation confirmed that she had anomalous reversed forearm muscles bilaterally, and these were successfully resected.

Microarray gene analysis and expression profiles of Dupuytren's contracture.

Dupuytren's disease, although not altogether uncommon, has eluded scientists who have sought to explain the cause of this palmar fibroproliferative disorder. It can lead to severe limitations of hand function if left untreated. This study is the first broad genetic survey using microarray technology to find gene products that are overexpressed or underexpressed in diseased tissues. The authors found 23 genes with levels that differ consistently from control levels. Nine were selected for further verification using reverse transcription-polymerase chain reaction. These genes hold potential promise in explaining some of the demographic trends seen with disease, such as correlation with alcoholism and the striking predisposition for the male gender.

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.