Active Treatment of Pediatric Ganglia of the Wrist: What is the Risk of Recurrence?

BACKGROUND: Ganglion cysts are the most common soft tissue mass in the hand and wrist in both adults and children. More is known about wrist ganglia and their treatment outcomes in adults than in children. Current literature to guide the management of pediatric wrist ganglia is limited. The purpose of this study is to report on the rates of recurrence of pediatric wrist ganglia after active intervention-aspiration or surgical excision-at a single center, as well as to explore factors associated with recurrence in one of the largest samples to date of pediatric wrist ganglia. METHODS: In all, 205 pediatric patients with wrist ganglia from our institution with at least 2-year follow up were included. The primary outcome was the recurrence rate after treatment type (aspiration vs. surgery). Secondary outcomes were demographic factors (age, sex, etc.), cyst location (volar vs. dorsal), duration of cyst before intervention, and surgeon specialty training (hand vs. non-hand). RESULTS: Recurrence was seen in 58.4% (n=94) of patients undergoing their first aspiration.Recurrence was seen in 34% (n=97) of patients after the first surgery, but there was a significant difference in recurrence rate based on the surgeon's fellowship training. CONCLUSION: In conclusion, surgery does appear to offer a higher chance of definitive resolution of pediatric wrist ganglia. Differences in technique among surgeons should be explored as a possible factor to explain the range of recurrence rates described in the limited literature on this topic. LEVEL OF EVIDENCE: Level III-Retrospective Review.

The Prevalence of Depression and PTSD in Adults With Surgically Managed Traumatic Upper-Extremity Amputations.

BACKGROUND: Upper-extremity limb loss has been associated with serious psychological sequelae. Despite advancements in surgical procedures and prostheses for upper limb amputees, it is critical to recognize the psychosocial component of these patients' care. Although the role of psychological factors in outcomes is increasingly acknowledged, little is known about the prevalence of depression and post-traumatic stress disorder (PTSD) in the civilian population after traumatic upper-extremity amputation. METHODS: In this retrospective observational single-center study, adult patients evaluated for traumatic upper limb amputations from 2016 to 2019 completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual Analogue Scale, the Center for Epidemiologic Studies Depression Scale, and the Primary Care PTSD Screen during visits. All data underwent descriptive statistical analysis. RESULTS: Thirty-nine adult patients treated for upper-extremity traumatic amputation completed patient-reported outcomes (PROs) questionnaires. The median final follow-up time for our cohort was 17 months from amputation. Twenty patients (51%) screened positive for depression and 27 (69%) for PTSD during follow-up. The median time from amputation to first positive screening was 6.5 months for depression and 10 months for PTSD. The physical component score of Veterans RAND 12-Item Health Survey (VR-12) was significantly worse for patients with depression. The Median DASH and mental component score of VR-12 were significantly worse for patients with PTSD. CONCLUSION: Upper-extremity limb loss has a significant impact on mental health, which in turn affects PROs. The high prevalence of depression and PTSD in traumatic upper-extremity amputees underscores the necessity for screening and multidisciplinary treatment.

Examination of Ulnar-sided Wrist Pain.

This article reviews the pertinent history and physical examination maneuvers necessary to arrive at the proper diagnosis of patients with ulnar-sided wrist pain. Surface anatomy is stressed along with provocative maneuvers for maximal efficacy.

Flexor Tenosynovitis of the Hand Caused by Mycobacterium tuberculosis.

Infectious tenosynovitis of the hand is a serious condition with a high risk of morbidity. Mycobacterium tuberculosis is a rare cause of tenosynovitis, especially in regions where tuberculosis is no longer endemic, and presents significant diagnostic challenges. We present the case of a 42-year-old woman with no known history of or exposure to tuberculosis and a medical history of systemic lupus erythematosus on chronic immunosuppressive therapy who presented with swelling and erythema in the fifth finger of the left hand of 1-month duration. She underwent tenosynovectomy, and intraoperative cultures grew M tuberculosis. The patient completed an appropriate antibiotic regimen, and systemic workup revealed ring-enhancing lesions on brain MRI consistent with tuberculoma. We review the literature and current trends in the management of mycobacterial tenosynovitis, as well as the important teaching points of the case.

Defining the "Critical Elements" for the Most Common Procedures in Spine Surgery: A Consensus of Orthopedic and Neurosurgical Surgeons.

STUDY DESIGN: Survey. OBJECTIVE: To define the critical elements of common spine surgeries. SUMMARY OF BACKGROUND DATA: Despite significant relevance to the field of spine surgery, the term "critical element" of surgery has not been clearly defined. Every surgical procedure involves numerous steps, each with its own potential for complications and harm to the patient. Despite its crucial role in surgical training, billing, and the ethicality of concurrent surgery, the term "critical element" of surgery has not been defined. METHODS: A survey was administered to surgeons associated with AO Spine North America and the Society for Minimally Invasive Spine Surgery to determine the critical elements for four common spine procedures: open lumbar laminectomy and fusion, microdiscectomy, anterior cervical discectomy and fusion (ACDF), and posterior cervical laminectomy and fusion. Respondents were asked which steps necessitated their direct supervision. Surgical subspecialty, level of experience, and practice demographics were also recorded. RESULTS: For all applicable procedures, decompression, instrumentation, and fusion were designated as critical elements. Patient positioning and fascial closure were not. Radiographic localization was considered critical for all procedures, except posterior cervical laminectomy and fusion. Exposure was not considered critical for any procedures, except ACDF. Certain substeps of decompression in ACDF and open lumbar laminectomy and fusion were not considered critical. Orthopaedic surgeons considered exposure and fusion in ACDF procedures to be critical whereas neurosurgeons did not. Surgeons operating in private practice considered every step of these common procedures to be critical elements. CONCLUSION: Decompression, instrumentation, and fusion were considered critical elements of common spine surgeries. There were significant differences in responses according to surgical specialty and practice setting. Future research is necessary to determine the implications of these findings and guide the definition of the "critical portions" of surgery. LEVEL OF EVIDENCE: 1.

A Novel Cadaveric Model of the Quadriga Effect.

INTRODUCTION: The quadriga phenomenon results from excessive shortening of the flexor digitorum profundus (FDP) tendon to the middle, ring, or small finger. METHODS: Five cadaveric specimens were used to create a model for quadriga. The FDP tendons to the middle, ring, and small fingers were shortened in 5-mm increments, and the tip-to-palm (TTP) distance of adjacent fingers was recorded. RESULTS: Shortening of the middle finger FDP by 10 mm resulted in an average TTP distance of 6 mm in the ring finger and 5 mm in the small finger. Shortening the ring finger FDP by 10 mm produced an average TTP distance of 11 mm in the middle finger and 9 mm in the small finger. Shortening of the small finger FDP by 10 mm resulted in an average TTP distance of 14 mm in the middle finger and 10 mm in the ring finger. DISCUSSION: Shortening the FDP by as little as 10 mm produced a significant quadriga effect, which was more pronounced with shortening of the small and ring FDP tendons compared to the middle finger.