A Randomized-Controlled Trial Evaluating the Impact of a Web Tutorial on Perceptions and Usage of Opioids Post-Carpal Tunnel Release Surgery.

Purpose: The purpose of this study was to evaluate the efficacy of a web tutorial on perceptions of pain management and usage of opioids after carpal tunnel release surgery (post-CTR). Methods: A web tutorial was developed by the authors, and patients were consented and enrolled if they were over the age of 18 years, could speak and understand English, and were having CTR. Patients were randomized to either view or not view the web tutorial before surgery, and all patients took a 19-question online survey approximately 2 weeks after surgery to assess their views on pain management and their self-reported opioid usage. All patients received standard-of-care instructions for postoperative pain management and were prescribed fifteen 5 mg tablets of oxycodone. Independent sample t tests, Wilcoxon rank sum tests, and chi-square tests were used to evaluate variables of interest. Results: Sixty-seven patients were enrolled, with 17 lost to follow-up; therefore, 50 patients were included in the final study cohort and completed the online survey (n = 25/group). There were no statistically significant differences in age, gender (patient reported gender), race, and opioid use history between the groups, but there was a difference in education level with the group that did not watch the video having proportionally more participants whose highest level of education was postgraduate (36% vs 8%) and high school (24% vs 16%). There were no differences between groups in the perceptions of pain post-CTR based on survey statements, in reported opioid consumption on post-op day 1, or in perceived risk of prolonged opioid use. Conversely, on post-op days 2-6 (8% vs 28%) and 7-14 (0% vs 20%), fewer participants from the group that watched the video reported any opioid usage compared with the group that did not watch the video. Conclusions: Our web tutorial did not notably impact the way patients perceived pain management or opioid risks post-CTR. However, a smaller proportion of the group that watched our tutorial reported opioid consumption post-CTR relative to the group that did not view our tutorial, suggesting that web tutorials may be a viable way to encourage patients to confer to minimal opioid usage and pain management regimens. Type of study/level of evidence: Therapy/Prevention, Etiology/Harm IV.

Investigating the Relationship Between Neighborhood Social Deprivation and Time to Specialty Orthopedic Care for Pediatric Trigger Thumb.

Purpose: Pediatric trigger thumb is a common condition resulting in referral from primary care to specialty care. Access to pediatric hand specialty care is a complex issue influenced by a multitude of social factors, including socioeconomic status. The aim of this study is to investigate the relationship between area deprivation and the time from primary care referral to presentation to specialty care for pediatric trigger thumb. Methods: Participants were pediatric patients with trigger thumb. Patient-level area deprivation was reflected by the area deprivation index (ADI). We analyzed the relationship of the ADI to patient demographics (age and sex), trigger thumb treatment (surgical vs nonsurgical), and time to initial hand surgical visit after referral and surgical management when indicated. Results: Among 163 patients with trigger thumb, 52% were men. Mean age at referral for trigger thumb was 2.9 ± 1.7 years. Mean ADI for patients diagnosed with trigger thumb was 57.8 ± 23.4 for the 2018 data set and 57.3 ± 23.6 for the 2021 data set, on a scale of 1 (low) to 100 (high). The median time from referral from primary care to presentation to orthopedic care for trigger thumb was 34 days. Upon presentation to treating hand surgeon, 118 patients (72.4%) underwent surgical release. We found no difference in ADI between men and women nor between patients treated operatively or with nonsurgical management. We found a weak positive correlation between ADI and time from initial referral to presentation to the treating hand surgeon. There was no correlation between ADI and time from initial hand surgical evaluation and surgical management in patients indicated for surgery. Conclusions: Pediatric trigger thumb patients from areas with higher ADI have a slightly longer delay between initial referral and their initial visit with an orthopedic hand specialist. Although we found a delay in initial evaluation by the treating hand surgeon in patients with higher ADI, ADI status was not different between patients managed with surgical and nonsurgical treatment nor between men and women. Clinical relevance: Neighborhood ADI weakly correlated with increased time from referral to accessing specialty orthopedic care for trigger thumb. This may suggest a need for more equitable access to specialty care for patients with pediatric trigger thumb from high ADI areas.

Distal Scaphoid Excision for Chronic and Nonchronic Scaphoid Fracture Nonunion.

Purpose: The indications for distal scaphoid excision are limited to localized wrist arthritis surrounding the scaphoid, as a result of scaphoid nonunion advanced collapse or scapho-trapezio-trapezoid joint arthritis. The procedure historically has led to relief of symptoms and improvement in strength. Our aim was to examine the outcomes of this procedure in patients with scaphoid fracture nonunion. Methods: This is a single-center retrospective case series of 12 consecutive patients who underwent distal scaphoid excision after scaphoid fracture nonunion. Patients were divided into the following two groups based on nonunion chronicity: chronic (more than a year) and nonchronic (less than a year). Clinical and radiographic data were examined using descriptive statistics. Results: Our cohort consisted of 12 patients, 10 men (83%) and 2 women (17%), with a mean age of 37.6 ± 13.6 years. Eight patients had a chronic scaphoid fracture nonunion (six had a neglected scaphoid fracture and two had a nonunion after scaphoid open reduction and internal fixation with bone graft), and four patients had a nonchronic fracture nonunion (two had failed cast treatment and two had nonunion after scaphoid open reduction and internal fixation with bone graft). Before surgery, all patients complained of pain and four had numbness (all in the chronic group). After an average of 21 weeks after surgery, seven patients (58%) reported continued pain, two patients reported ulnar side pain, and one underwent arthroscopic synovectomy. All patients who started with a normal radiolunate angle continued to have a normal angle, whereas patients who had dorsal intercalated segmental instability prior to surgery persisted with it after surgery, except for a patient who underwent midcarpal fusion and had their radiolunate angle corrected. Conclusions: Distal scaphoid excision is an effective procedure for carefully selected patients with periscaphoid wrist arthrosis. Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. Type of study/level of evidence: Therapeutic V.

Surgical Management of Hook of Hamate Fractures: A Systematic Review of Outcomes.

Purpose: This review aimed to compare the postoperative outcomes of open reduction internal fixation (ORIF) versus excision in the surgical treatment of hook of hamate fractures. Methods: A systematic review of PubMed and EMBASE databases from 1954 to 2023 was performed using the search term "hook of hamate fracture" to identify all publications regarding the use of ORIF or excision in the treatment of hook of hamate fractures. Outcomes included a return to sport, pain, ulnar nerve dysfunction, flexor tendon dysfunction, union rate, wrist range of motion (ROM; % of contralateral hand), grip strength (% of contralateral hand), and quick disabilities of arm, shoulder, and hand scores. Results: Twenty-seven of the 705 total screened articles were included. Excision of the hook of hamate (n = 779) resulted in a shorter return to sport time (6 vs 7.8 weeks), lower rates of postoperative pain (6.1% vs 33.3%), higher rates of ulnar nerve sensory dysfunction (4.2% vs 0%), and higher rates of ulnar nerve motor dysfunction (1.5% vs 0%) relative to ORIF (n = 51). Chronic fractures had a longer return to sport time (7.2 vs 5.7 weeks) relative to nonchronic injuries. Conclusions: Both surgical procedures appear to yield acceptable outcomes in the treatment of hook of hamate fractures. However, based on the sparsity of available data, we are unable to determine a consistent difference between hook of hamate excision and ORIF. Clinical relevance: To our knowledge, no current consensus on the optimal surgical treatment for hook of hamate fractures exists. Our findings emphasize the need for a large prospective cohort study using standardized outcomes to provide strong evidence as to whether surgical excision or ORIF yields greater outcomes in the treatment of hook of hamate fractures.

Diabetes Increases Median Nerve Cross-Sectional Area but Not Disease Severity in Patients with Carpal Tunnel Syndrome.

Background: Ultrasonography (US) is a useful diagnostic modality for diagnosis of carpal tunnel syndrome (CTS). Diabetes mellitus is increasingly prevalent and is a risk factor for CTS. Given the increasing use of US in the diagnosis of CTS, our goal was to evaluate the influence of diabetes on CTS severity and the cross-sectional area (CSA) of the median nerve in patients with CTS. Methods: Patients with clinically diagnosed CTS were seen in the outpatient setting from October 2014 to February 2021. Median nerve CSA and patient reported severity measures were obtained: Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and CTS-6. For patients with diabetes, additional parameters were collected including most recent A1c, insulin pharmacotherapy, and polypharmacy. Results: Ninety-nine patients (122 nerves) without diabetes and 55 patients (82 nerves) with diabetes were recruited for the study. Patients in the diabetes group were more obese and older and had a significantly increased median nerve CSA compared with patients without diabetes. Obesity was associated with higher median nerve CSA in all patients but not in patients with diabetes. There was no difference in disease severity in patients with and without diabetes as reported by BCTSQ or CTS-6 scores. In patients with diabetes, there was significantly decreased median nerve CSA with A1c of 6.5 or higher and a trend to decreased CSA with polypharmacy. There was no influence of insulin therapy on median nerve CSA. Conclusion: Diabetes is associated with higher median nerve CSA in patients with CTS of similar disease severity. The increased median nerve CSA in patients with diabetes may be reflective of diabetes-related microvascular changes. Interestingly, the trend to decreased median nerve CSA in patients with suboptimal diabetic control (A1c ≥ 6.5) may suggest eventual degenerative changes to the median nerve. In summary, clinicians should be cautious with interpreting a larger median nerve CSA as more severe CTS in patients with diabetes. Level of Evidence: Level 3 Diagnostic.

Characteristics of Patients with Clinical Signs and Symptoms of Carpal Tunnel Syndrome but Negative Diagnostic Testing.

Background: Carpal tunnel syndrome (CTS) is a clinical diagnosis involving numerous confirmatory diagnostic tools, including patient questionnaires, ultrasound (US), and electrodiagnostic studies (EDX.) Patients may experience clinical symptoms of CTS with false negative diagnostic testing. The purpose of this study was to identify characteristics of patients with clinical symptoms of CTS with negative diagnostic testing. Methods: An existing database of 295 hands containing the six-item CTS-6, US of the median nerve, and EDX was queried. Patients with symptoms of carpal tunnel scoring 12.5 or higher on CTS-6 were sorted into those with all positive testing or negative testing. Results: In 60 patients, 103 hands had both positive US and EDX and a CTS-6 of 12.5 or higher. Twenty-nine hands in 25 patients had a CTS-6 of 12.5 or higher and both negative ultrasound and EDX. There was a significantly younger average age of 43 (P = 0.007) and lower average BMI of 28 (P < 0.0001) of patients in the negative diagnostic study group, compared with the average age of 53, and a body mass index (BMI) of 34 in the positive diagnostic study. Conclusions: In this series, patients with symptoms of carpal tunnel syndrome and negative diagnostic studies were on average younger and had a lower BMI. These patients may warrant more careful consideration of CTS clinical diagnosis and counseling regarding a higher risk of false-negative confirmatory testing. Further studies are needed to determine possible effects of age and BMI on electrodiagnostic studies and ultrasound testing in CTS.

The Diagnostic Utility of Ultrasound and Electrodiagnostic Studies in The Young and Old.

Purpose: Carpal tunnel syndrome is the most common compressive neuropathy. The diagnostic parameters currently used for the general adult population may not be valid in elderly or younger cohorts. The purpose of this study is to determine the diagnostic accuracy of nerve conduction studies (NCS) and ultrasound (US) in different age groups utilizing the 6-item Carpal tunnel syndrome (CTS) symptoms scale (CTS-6) as the reference standard. Methods: A retrospective database of patients who underwent US and NCS as part of the diagnostic work-up for suspected peripheral nerve compression was reviewed. Subjects were separated into three groups based on the median age of carpal tunnel syndrome patients (55 years of age) and two standard deviations (standard deviation 13.5 years) above and below the median. The young group was 28 years of age or less, the middle group was 29-71 years of age, and the old group was 72 years of age or greater. CTS-6 and Boston Carpal Tunnel Syndrome Questionnaire scores were recorded. Using CTS-6 as a reference standard, the sensitivity and specificity were calculated for NCS and US. Results: A total of 295 hands were included in the analysis with 23 hands in the young group and 24 hands in the old group. NCS showed 31% sensitivity and 100% specificity in the young group compared to 54% sensitivity and 90% specificity for US. NCS showed 94% sensitivity and 25% specificity in the old group compared to 81% sensitivity and 38% specificity for US. Overall accuracy for US and NCS was 66% for both tests when looking at all age groups. The accuracy in the young group was 70% for US and 61% for NCS, whereas the accuracy in the old group was 67% for US and 71% for NCS. Conclusions: US has comparable sensitivity and specificity to NCS in patients two or more standard deviations above or below the mean age for presentation of CTS. US may be more accurate in younger patients, although NCS limits the number of false positive tests. There remains a substantial amount of inaccuracy for both tests when using a validated clinical diagnostic tool (CTS-6) as the reference standard. Type of study/level of Evidence: Diagnostic IV.

Comparison of Fusion Rates/Complications Between Different Types of Thumb Metacarpophalangeal Fusion Techniques.

BACKGROUND: Thumb metacarpophalangeal (MP) fusion is generally successful; however, complications have been reported to occur in 0% to 30% of cases, whereas nonunion rates vary by method but, overall, are reported to occur in 0% to 15% of cases. Many fixation techniques have been described, but there is no consensus on the optimal fusion technique. Our goal was to compare complication and union rates of different thumb MP arthrodesis techniques. METHODS: We performed a retrospective review of patients who underwent primary thumb MP fusion between 2000 and 2022. Patients who underwent revision fusion, fusion for infection, or amputation were excluded. Fusions of MP joints of other fingers were also excluded. Data collection consisted of demographic data, complications, time to fusion, rate of delayed union and rate of nonunion. Five different fusion constructs were evaluated during our study period: staples, Kirschner wires (K-wires), cerclage, K-wires with cerclage, and intramedullary screw. RESULTS: Forty-seven patients underwent fusion with staples, 16 with K-wires, 14 with cerclage, 9 with K-wires and cerclage, and 6 with an intramedullary screw. The individual complication and nonunion rates differed significantly among the groups with the intramedullary screw group having a statistically higher rate of nonunion (P = .004). Furthermore, smoking, diabetes, and being overweight were associated with nonunions. CONCLUSION: Union rates were significantly lower in patients treated with an intramedullary screw and those who are smokers, diabetics, and/or overweight. Caution should be exercised when using intramedullary screw fixation for MP fusion, especially in patients with these comorbidities.

Characterization of Unpublished Manuscripts by Applicants to an Orthopedic Hand Surgery Fellowship.

Purpose: Obtaining a hand surgery fellowship is becoming increasingly competitive, and research is an important factor when assessing applications. Given the competitive nature of the fellowship application process, applicants may feel the need to bolster their application by misrepresenting their research experience. One form of misrepresentation rarely discussed in prior studies is the listing of submitted works under a "Publications" heading in curricula vitae. This study examines the prevalence of misclassification of manuscripts by applicants to a hand surgery fellowship and identifies factors that might be associated with incorrect classification. Methods: A retrospective review of 122 applicants to the 2020-2021 cycle for hand surgery fellowship was performed. Names and identifiable information were redacted prior to review. Demographic data collected included sex, United States Medical Licensing Examination Step 1 score, medical school rank, residency specialty, total publications, presence of submitted manuscripts in the "Publications" section, total number of submitted manuscripts, and total published abstracts and poster presentations. Results: A total of 1,098 listed publications across the 122 applicants were reviewed with a median of five publications per applicant. Submitted manuscripts were listed as publications by 33 applicants (27%). No observable differences by age, United States Medical Licensing Examination Step 1 score, or total number of publications were seen. Misclassification rates were not associated with publication totals. Conclusions: More than one-quarter of applicants incorrectly listed submitted or unaccepted manuscripts as publications. It is our hope that making fellowship applicants aware of this issue will decrease the rates of misrepresentation in future application cycles. Clinical relevance: The competition for hand surgery fellowships has become more intense, and this may explain our finding that 27% of applicants misrepresent the status of research on hand surgery fellowship applications.

Corticosteroid Injection in the Operative Hand Prior to a Trigger Finger or Carpal Tunnel Release: If It Is Not at the Surgical Site Then What Is the Big Deal?

BACKGROUND: Patients who have had a corticosteroid injection at the surgical site within 90 days of trigger finger release (TFR) or carpal tunnel release (CTR) have an elevated risk of postoperative infection. Currently, it remains unknown if a preoperative injection in proximity to the surgical site for a separate complaint alters the risk of a postoperative infection. METHODS: A retrospective chart review was performed on all patients who underwent TFR or CTR between 2010 and 2022. Patients who had a corticosteroid injection at or near the surgical site within 90 days of surgery were included. Outcome measures included uncomplicated healing, superficial infection requiring antibiotics, and deep infection (DI) requiring surgical debridement. RESULTS: There were 564 cases in which a corticosteroid injection was performed within 90 days of TFR or CTR. Superficial infections occurred in 12 (2.1%), and DIs occurred in 6 (1.1%) cases. There was no significant difference in infection rates between the two groups relative to the location of the injection nor timing of the injection (0-30, 31-60, or 61-90 days prior to surgery). CONCLUSIONS: Patients who had an injection at the surgical site within 90 days of TFR or CTR had an elevated rate of postoperative infection compared with published rates in the literature. This study is unique in that preoperative injections at an adjacent site in the palm also correlated with an elevated rate of infection, similar to patients who had an injection at the surgical site. LEVEL OF EVIDENCE: Level 4.

The Effect of Timing Between Traumatic Flexor Tendon Injury of the Hand and Surgical Intervention on Repair Failure Rates.

Flexor tendon injuries of the hand, especially in zone II, pose a challenge for hand surgeons because of the region's intricate pulley mechanism and local avascularity, and post-surgical complications such as repair failure are not uncommon. One proposed predictor of outcomes following flexor tendon repair has been timing of surgery from initial injury. However, the effect of the timing of flexor tendon repair on failure rates remains controversial and understudied. The purpose of this study was to compare the failure rates of zone II flexor tendon repairs in patients at various time intervals from onset of injury. A retrospective chart review was conducted using data from hand surgery specialists at our level 1 trauma center from January 1, 2010, through May 31, 2020. This retrospective review included 407 zone II flexor tendon repairs. The primary outcome was failure of repair. Among 407 flexor tendon repairs, there were 12 reported repair failures. The failure rate was 2.9%. In the non-failure group, the mean number of days between the date of injury and the date of surgery was 7±13 days. For the failure group, this value was 14±17 days. Repairs occurring within 14 days had a failure rate of 2.3%, while repairs occurring beyond 14 days had a failure rate of 7.7%. This study demonstrates that there is a benefit to repairing the tendon within a 14-day window, as evidenced by a lower failure rate. More research is required to determine if other complications and overall health of the hand are also improved when a repair is performed in a more expedient manner. [Orthopedics. 2024;47(2):113-117.].

A Logistic Regression Analysis of Factors Associated with Guarded Outcome after Carpal Tunnel Release in Symptomatic Carpal Tunnel Syndrome.

BACKGROUND: The Boston Carpal Tunnel Questionnaire (BCTQ) is a validated measurement tool to assess the severity of carpal tunnel syndrome, and improvements in the BCTQ after carpal tunnel release (CTR) have been demonstrated to influence patient satisfaction. The authors hypothesized that patient-related factors influence response in BCTQ subscales, including the Symptom Severity Scale and the Functional Status Scale, after CTR. METHODS: Patients who underwent surgery with follow-up BCTQ were identified from a prospectively maintained database. Paired t tests were used to compare BCTQ subscales at each follow-up time point. Minimal clinically important differences were set. Patients below these thresholds were deemed as having failure to improve after CTR. Univariate analysis was used to identify risk factors for failure to improve after CTR. Multivariate logistic regression was used to identify independent predictors for failure to improve after CTR. RESULTS: A total of 106 patients met inclusion criteria. Patients demonstrated significant improvements at all follow-up time points. The factor most associated with improvement beyond the minimal clinically important differences was a more severe score in the respective domain assessed. Other independent factors that influenced outcome after CTR included race, concomitant cubital tunnel release, sex, and age. CONCLUSIONS: CTR results in significant improvements in BCTQ and its subscales, with improvements stabilizing after 6 weeks. In a select cohort of patients, failure to improve after CTR occurs with factors independently associated with a lower degree of improvement. Identification of patients with these risk factors will provide a basis for counseling and increased monitoring of patients at risk for a guarded prognosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Subjective and Objective Differences in Patients with Unilateral and Bilateral Carpal Tunnel Syndrome and the Role of Obesity in Syndrome Severity.

BACKGROUND: It remains unclear whether physiologic differences exist in musculoskeletal ultrasound nerve measurements when comparing bilateral and unilateral carpal tunnel syndrome (CTS) patients. Similarly, the influence of body mass index on CTS severity is not well characterized. METHODS: Unilateral and bilateral CTS patients were seen from October of 2014 to February of 2021. Obese and nonobese CTS patients were compared. Median nerve cross-sectional area (CSA), Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ), and six-item Carpal Tunnel Symptom Score (CTS-6) measures were obtained. Nerve conduction studies recorded distal motor latency (DML) and distal sensory latency (DSL). Statistical analysis used Wilcoxon signed rank testing for paired continuous variables, Mann-Whitney U testing for nonpaired continuous variables, and chi-square testing for continuous variables, with a significance level of P < 0.05. RESULTS: A total of 109 (218 nerves) bilateral and 112 (112 nerves) unilateral CTS patients were reviewed. Bilateral patients had larger median nerve CSAs on their more symptomatic side, when defined by BCTSQ score ( P < 0.0001), CTS-6 score ( P < 0.0001), DML ( P < 0.0001), and DSL ( P < 0.01). Bilateral patients also had higher symptom severity scale ( P < 0.01) and DSL ( P < 0.001) outcomes compared with unilateral patients. Obese patients had higher median nerve CSA ( P < 0.01), prolonged DML, and prolonged DSL ( P < 0.0001) values despite similar CTS severity (BCTSQ and CTS-6). CONCLUSIONS: Ultrasound identifies the more symptomatic side in bilateral patients, which correlates with increasing severity (NCS and BCTSQ). Obesity increases median nerve CSA and prolongs nerve conduction studies without influencing CTS severity. This information can be used when considering which diagnostic test to order for CTS.

Patients Prefer Ultrasound to Nerve Conduction Studies for the Diagnosis of Carpal Tunnel Syndrome.

Background: The net promoter score (NPS) allows analysis of patient satisfaction and preference between treatment and/or diagnostic testing. Electrodiagnostic testing (EDX) and ultrasound (US) are commonly used diagnostic tests for carpal tunnel syndrome. Although EDX is reliable for diagnosing carpal tunnel syndrome (CTS), it can be uncomfortable and inconvenient for patients. We aimed to determine whether patients preferred US or EDX studies for the diagnosis of CTS, using the NPS. Methods: Seventy-five patients presenting to the clinic for evaluation of CTS complaints who had EDX were prospectively studied. US evaluation of the median nerve was then completed at time of evaluation. Patient satisfaction was determined by asking, "how likely are you to recommend this procedure to a friend or relative?" for both EDX and US. Patient demographics, comorbidities, CTS-6 questionnaire (CTS-6), and functionality assessed through patient-reported qDASH were also recorded. Results: Sixty-five patients were included in the study. Most patients did not have any comorbidities and were nonsmokers. The gender composition was similar, and the average age of the enrolled patients was 58. The NPS for US was significantly higher than EDX (P < 0.0001). Patients with diabetes mellitus rated their EDX experience significantly lower than those without diabetes mellitus. Conclusions: Patients are more likely to recommend US instead of EDX in the evaluation of CTS complaints. This allows for shared decision-making between the patient and provider if ordering diagnostic testing for CTS.

Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound.

BACKGROUND: Although idiopathic median neuropathy at the carpal tunnel (IMNCT) is objective and verifiable, distinction of normal and abnormal nerves is imprecise and probabilistic. The associated symptoms and signs (carpal tunnel syndrome [CTS]) vary, particularly for nonsevere (mild and moderate) median neuropathy. Discordance between diagnosis of mild or moderate median neuropathy at the carpal tunnel using symptoms and signs and diagnosis based on objective tests is a measure of the potential for overdiagnosis and overtreatment. QUESTION/PURPOSE: What is the difference in the estimated prevalence of mild-to-moderate IMNCT using nonsevere signs and symptoms compared with the estimated prevalence using electrodiagnostic studies (EDS) and ultrasound (US)? METHODS: We used data from an existing cross-sectional data registry. To create this registry, between January 2014 and January 2019, we considered all new adult English-speaking people who had an EDS that included the median nerve or people with a diagnosis of CTS who did not have surgery yet. A small and unrecorded number of people declined participation. The cross-sectional area of the median nerve at the distal wrist crease using US in people who already had EDS was measured. People with a diagnosis of CTS underwent both EDS and US. The six signs and symptoms of Carpal Tunnel Syndrome 6 (CTS-6, a validated tool to estimate the probability of IMNCT using ratings of symptoms and signs of CTS) were recorded. This resulted in a registry of 185 participants; we excluded 75 people for obvious, severe IMNCT (defined as nonrecordable nerve conduction velocity, thenar atrophy, or greater than 5 mm 2-point discrimination). Three of the 110 qualifying patients had missing information on ethnicity or race, but we accounted for this in our final analysis. Without a reference standard, as is the case with IMNCT, latent class analysis (LCA) can be used to establish the probability that an individual has specific pathophysiologic findings. LCA is a statistical method that identifies sets of characteristics that tend to group together. This technique has been used, for example, in diagnosing true scaphoid fractures among suspected fractures based on a combination of demographic, injury, examination, and radiologic variables. The prevalence of mild-to-moderate IMNCT was estimated in two LCAs using four signs and symptoms characteristic of mild-to-moderate IMNCT, as well as EDS and US measures of median neuropathy. RESULTS: The estimated prevalence of mild-to-moderate IMNCT based on signs and symptoms was 73% (95% CI 62% to 81%), while the estimated prevalence using EDS and US measurements was 51% (95% CI 37% to 65%). CONCLUSION: The notable discordance of 22% between the estimated prevalence of mild-to-moderate IMNCT using signs and symptoms and prevalence based on EDS and US criteria, and the overlapping CIs of the probability estimations, indicate considerable uncertainty and a corresponding notable potential for underdiagnosis or overdiagnosis. When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. We might benefit from a more accurate and reliable diagnostic strategy or tool for mild-to-moderate IMNCT; this might be the focus of a future study. LEVEL OF EVIDENCE: Level III, diagnostic study.

Correspondence of the Boston Carpal Tunnel Questionnaire with severity of median neuropathy.

The Boston Carpal Tunnel Questionnaire is one of the most popular patient-reported outcome measures designed specifically for people with idiopathic median neuropathy at the carpal tunnel. We used electrophysiological and ultrasound measures of median neuropathy from one hand in 185 people to create a single measure of median neuropathy severity as a continuum (through exploratory factor analysis). We assessed if our single measure of median neuropathy severity is independently associated with Boston Carpal Tunnel Questionnaire item groupings. Median neuropathy severity measured as a continuum had modest independent associations with Boston Carpal Tunnel Questionnaire magnitude of capability (adjusted R2 0.063) and paraesthesia intensity (adjusted R2 0.12) items but not with items related to pain intensity. Considering the lack of association of Boston Carpal Tunnel Questionnaire pain items with objective pathophysiology, combined with their notable association with mental health measures in previous studies, it is probably best to omit items related to pain.Level of evidence: III.

Metastatic Melanoma: A Consequence of the COVID-19 Pandemic.

Metastatic melanoma, though less common than other skin cancers, remains one of the deadliest, particularly in late-stage disease. Our report aims to highlight the importance of early detection and treatment to reduce the morbidity, mortality, and significant disfigurement associated with advanced melanoma. The subject of this case is an 81-year-old female who presented to our emergency department as a trauma patient after being found lying down by a neighbor for an unknown amount of time. She was discovered to have a large fungating nasal mass which was subsequently diagnosed as highly invasive melanoma. A thorough workup revealed a metastatic cerebellar lesion, a large ulcerated basal cell carcinoma eroding her calvarium, and a hemorrhagic lesion within her internal capsule that left her with right-sided hemiparesis. During hospitalization, she underwent palliative resection of the primary nasal mass with flap reconstruction, radiation therapy for her cerebellar lesion, and daily physical therapy. Additional surgery was required for hematoma evacuation and pedicle dissection. Though lockdowns were an important part of the pandemic, they were not without their drawbacks, many of which are still being elucidated. Particularly, by utilizing telehealth services, our patient may have had earlier recognition of her melanoma and a better outcome. Regardless, enhancing patient education and maintaining access to care even through lockdowns poses a potential target for improving melanoma survivability while decreasing associated morbidity.

Area Deprivation Index Is Not Associated With the Severity of Carpal Tunnel Syndrome.

BACKGROUND: While living in a socially disadvantaged neighborhood is linked with numerous health outcomes, its effect on patient-reported outcome scores and diagnostic measures in carpal tunnel syndrome (CTS) is not fully understood. This study examines the effect of neighborhood socioeconomic deprivation on CTS severity as measured by the Boston Carpal Tunnel Questionnaire (BCTQ), 6-item Carpal Tunnel Symptoms Scale (CTS-6), and diagnostic testing modalities. METHODS: This was a retrospective analysis of patients who presented to the hand clinic at a single hospital system with symptoms consistent with CTS. Ultrasound cross-sectional area (CSA) of the median nerve, CTS-6, Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the BCTQ, and the Area Deprivation Index (ADI) national rank percentile were collected. Patients were grouped into 4 quartiles based on their ADI national percentile. Analyses of variance (ANOVAs) were conducted to test for statistical differences between the 4 quartiles based on the average values of median nerve CSA, CTS-6, SSS, and FSS score. The bottom quartile was compared with the upper 75% of the sample (26th-100th percentile) and to the upper quartile via Student t test. Statistical significance was set at P < .05. RESULTS: Analyses of variance revealed no statistically significant differences between the 4 quartiles for either median nerve CSA, CTS-6, SSS, or FSS. When comparing the bottom quartile with the upper 75% of the sample and the upper quartile, no significant statistical differences were identified. CONCLUSIONS: No relationships were found between social deprivation (ADI) and patient-reported outcomes, CTS-6 scores, or median nerve CSA.

Prospective Cohort Study Comparing Ligament Reconstruction with Tendon Interposition and Suture-Only Suspension Arthroplasty.

BACKGROUND: Basal joint arthritis is a common form of osteoarthritis. There is no consensus procedure for maintenance of trapezial height following trapeziectomy. Suture-only suspension arthroplasty (SSA) is a simple method for stabilizing the thumb metacarpal following trapeziectomy. METHODS: This single-institution, prospective, cohort study compares trapeziectomy followed by either ligament reconstruction with tendon interposition (LRTI) or SSA for the treatment of basal joint arthritis. Patients underwent LRTI or SSA from May of 2018 to December of 2019. Visual analogue scale pain scores; Disabilities of the Arm, Shoulder and Hand questionnaire functional scores; clinical thumb range of motion, pinch, and grip strength data; and patient-reported outcomes were recorded and analyzed preoperatively and at 6 weeks and 6 months postoperatively. RESULTS: Total number of study participants was 45 (LRTI, n = 26; SSA, n = 19). Mean ± SE age was 62.4 ± 1.5 years; 71% were female patients; and 51% underwent surgery on the dominant side. Visual analogue scale scores improved for LRTI and SSA ( P < 0.0001) over 6 months, with no differences between groups at any time point ( P > 0.3). Disabilities of the Arm, Shoulder and Hand questionnaire scores improved for LRTI and SSA over 6 months ( P < 0.0001), with no differences between groups at any time point ( P > 0.3). Following SSA, opposition improved ( P = 0.02), but not as well for LRTI ( P = 0.16). Grip and pinch strength decreased following LRTI and SSA at 6 weeks but recovered similarly for both groups over 6 months. Patient-reported outcomes were generally no different between groups at all time points. CONCLUSION: LRTI and SSA are similar procedures following trapeziectomy relative to pain, function, and strength recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Surgical Management of Lateral Epicondylitis: A Retrospective Review of Technique Success.

BACKGROUND: Lateral epicondylitis usually stems from overuse and failed tendon healing. Following attempt of conservative management, surgery is often considered, although there is variation in techniques and outcomes cited in the literature. METHODS: This retrospective review analyzed 293 operative patients for lateral epicondylitis following conservative management. The primary outcome was change in pain from preoperative status, including pain-free, improved, unchanged, or worse. Positive outcomes included pain-free or improved symptoms postoperatively. Negative outcomes were unchanged or worse pain. Patients returned 2 weeks, 6 weeks, and 3 months postoperatively. We analyzed patients' profession, handedness, operating surgeon, surgical technique, sex, magnetic resonance imaging findings, concomitant procedures, age, race, revisions, and complications. One surgeon repaired the common extensor using a suture anchor, whereas 2 surgeons performed a side-side repair of the extensor carpi radialis longus and extensor digitorum communis interval. RESULTS: By the 3-month visit, 41% were pain-free and 52% improved compared with preoperatively. None were worse, and 7% were unchanged. Mean pain scores at the 2-week, 6-week, and 3-month visits were 4.22/10, 3.61/10, and 3.44/10, respectively. There were 7 revisions (2.4%) and 6 complications (2%). Manual laborers experienced more negative outcomes than sedentary workers (P = .04). The remaining parameters were insignificant, including the operative technique. CONCLUSIONS: Surgery is successful for both techniques, with 93% positive outcomes by 3 months. There was no statistical difference in postoperative pain between patients who had suture repair versus anchor repair. Therefore, surgeons should consider suture-only repair given the cost of anchors.