The Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Treatment of Thumb Carpometacarpal Osteoarthritis.

PURPOSE: Biopsychosocial factors are associated with patient-reported upper extremity disability; however, their impact on postoperative outcomes remains less clear. Our purpose was to test the hypothesis that high levels of preoperative patient-reported upper extremity and psychological disability are associated with lower magnitudes of improvement following trapeziectomy with ligament reconstruction tendon interposition (LRTI). METHODS: Adult patients undergoing LRTI by fellowship-trained hand surgeons between February 2014 and March 2017 were considered for inclusion. Patient-reported outcomes were collected by tablet computer, including the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Computer Adaptive Test (CAT), PROMIS Depression CAT, and PROMIS Anxiety CAT. Univariate and multivariable linear regression analyses were performed to identify factors associated with QuickDASH improvement. RESULTS: Of 119 included patients, the mean age was 62.7 ± 7.2 years and 74% were women. At a mean of 14 weeks after surgery, the QuickDASH improved by a mean of -10 ± 20 points. The QuickDASH improvement was significantly greater for patients with preoperative QuickDASH scores greater than the median (score change, -19 ± 20) versus those at or below the median (-2 ± 16), and for patients with preoperative PI CAT scores greater than the median (-17 ± 21) versus at or below the median (-4 ± 17). No differences were observed between groups when Anxiety or Depression CAT baseline scores were similarly dichotomized. Multivariable modelling revealed that higher preoperative QuickDASH scores were associated with greater improvement on the QuickDASH; however, no association was observed for preoperative PI CAT, Depression CAT, and Anxiety CAT scores. CONCLUSIONS: Patients with higher levels of preoperative upper extremity disability experienced more improvement in the early postoperative period following LRTI. Baseline pain interference, depression, and anxiety were not associated with early outcomes. These findings may be useful when identifying patients who may experience the most functional improvement in the immediate postoperative period following LRTI. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Four-Strand Versus 2-Strand Suture-Button Constructs in First Carpometacarpal Arthroplasty: A Biomechanical Study.

Background: Suture-button fixation is an alternative to no fixation, first metacarpal distraction techniques, or Kirschner wire fixation after trapeziectomy in treatment of first carpometacarpal (CMC) arthritis. A 4-strand suture-button construct requires a 2.7-mm tunnel, whereas a 2-strand construct requires a 1.1-mm tunnel, potentially decreasing the risk of metacarpal fracture. We compared stability and failure criteria of 4-strand versus 2-strand construct in a biomechanical model of first CMC joint arthroplasty. Methods: Ten fresh-frozen matched pairs of human cadaveric hands were randomized to receive a 4-strand or 2-strand suture-button device. Trapeziectomy and fluoroscopic measurement of the fixed posttrapeziectomy space was performed before and after cycling 1000 times at 0.2 Hz in a custom loading device. The constructs were loaded to failure and failure mechanism was noted. Results: There was no significant difference between the groups in unfixed posttrapeziectomy, fixed precyclic loading, or postcyclic loading height. No difference in pinch pressure was found in any group. No difference in load to failure was observed. The 4-strand device failed through the first ray in 8 of 11 specimens, and the suture of the 2-strand device failed in 5 of 9 specimens. Conclusions: The 4-strand and 2-strand suture-button constructs provide comparable biomechanical stability for first CMC arthroplasty. If construct stability is similar between these procedures, the smaller tunnel used with the 2-strand construct may offer an advantage.

Principles of Billing for Diagnostic Ultrasound in the Office and Operating Room.

Ultrasound is becoming more prevalent as physicians gain comfort in its diagnostic and therapeutic uses. It allows for both static and dynamic evaluation of conditions and assists in therapeutic injections of joints and tendons. Proper technique is necessary for successful use of this modality. Appropriate coding for physician reimbursement is required. We discuss common wrist and hand pathology for which ultrasound may be useful as an adjunct to diagnosis and treatment and provide an overview of technique and reimbursement codes when using ultrasound in a variety of situations.

Novel, non-gadolinium-enhanced magnetic resonance imaging technique of pedal artery aneurysms.

Non-gadolinium-enhanced magnetic resonance angiography (nMRA) is a noninvasive, contrast-free imaging modality used for visualizing pedal arterial anatomy. We report application of the nMRA technique for detailed arterial imaging in a patient with dorsalis pedis aneurysm. Compared with digital subtraction angiography, we demonstrate that nMRA provides sufficient arterial detail needed to develop a complex operative plan before vascular intervention without risk of contrast agent or ionizing radiation exposure.

Use of diagnostic modalities for assessing upper extremity vascular pathology.

Vascular pathology of the upper extremity requires consideration of constitutional, anatomic, and functional factors. The medical history and physical examination are essential. The Allen test can be performed alongside a handheld Doppler for arterial mapping. Useful studies include digital-brachial index measurements, digital plethysmography, laser Doppler, and color ultrasounds. Three-phase bone scintigraphy still plays a role in the evaluation of vascularity after of frostbite injury. Angiogram remains the gold standard radiographic instrument to evaluate vascular pathology of the upper extremity, but computed tomography and magnetic resonance scans have an increasing role in diagnosis of vascular pathology.

Ectopic production of HCG by a benign ovarian mature cystic teratoma simulating an extra-uterine pregnancy: a case report.

UNLABELLED: Physicians should consider a benign mature cystic teratoma in their differential diagnosis of a patient with an elevated serum human chorionic gonadotropin concentration. BACKGROUND: Following tubal ligation, a woman with amenorrhea and elevated serum human chorionic gonadotropin (HCG) concentrations may be experiencing either an ectopic or an intrauterine pregnancy. Other sources of HCG production can include ovarian germ cell tumors or gestational trophoblastic disease such as a complete or partial molar pregnancy. A rare source of HCG production is a benign mature ovarian teratoma. CASE: A 31-year old Gravida 2 para 2 presented with a positive home pregnancy test three years after she had experienced a Pomeroy tubal ligation. Her serum HCG was 57,914 mlU/mL but a transvaginal ultrasound did not find an intrauterine pregnancy. Laparoscopy was performed due to a suspicion of an ectopic pregnancy and an 11-cm benign mature cystic teratoma (dermoid cyst) within the right ovary was removed. An ectopic pregnancy was not visualized. Post-operatively, her serum HCG levels decreased and were negative within four weeks. CONCLUSION: Mature ovarian cystic teratomas have rarely been reported to secrete HCG. They can be an infrequent source of HCG production and may lead to emergency surgery to treat a suspected extra-uterine pregnancy.

Colloid cyst: a case report.

Colloid cysts are a rare clinical finding with a unique clinical presentation: non-specific paroxysmal headaches. The current recommended treatment is microsurgery, which poses the greatest risk to the patient but allows complete removal of the cyst to prevent recurrence. A 41-year old man presented with a colloid cyst located in the foramen of Monro causing obstructive hydrocephalus. He had paroxysmal headaches and memory and personality changes. Transcortical transventricle microsurgery was performed to remove the entire cyst. A temporary shunt was placed to prevent post-operative hydrocephalus. Normal neurological function returned upon cyst removal.