Amyloidosis and Considerations for the Hand Surgeon.

Amyloidosis can lead to cardiac, renal, and other multiorgan failure. New treatments have become available that can prolong survival but rely on early diagnosis. Manifestations of amyloidosis in hand surgery include carpal tunnel syndrome, trigger finger, peripheral neuropathy, and spontaneous distal biceps rupture. Often, these can predate systemic amyloidosis, offering hand surgeons an opportunity to diagnose patients with amyloidosis before systemic disease, refer them for treatment, and potentially alter disease course and prolong survival. In this review, we describe the pathophysiology and two most common subtypes of amyloidosis seen by hand surgeons. We provide guidance on biopsy practices and referral for patients with amyloidosis. Lastly, we provide a brief overview of the treatments for amyloidosis and their effect on disease course.

Ultrasound-guided percutaneous needle tenotomy using Tenex system for refractory lateral epicondylitis; short and long-term effectiveness and contributing factors.

BACKGROUND: Ultrasound-guided percutaneous needle tenotomy (USPNT) has been proposed as an alternative treatment to surgical intervention for lateral epicondylitis (LE). The Tenex system (Tenex Health Inc., Lake Forest, CA, USA) for USPNT is an ultrasonic device involving a needle which oscillates at high frequency to debride and aspirate diseased tendon under ultrasound image guidance. This investigation evaluates the efficacy of USPNT using the Tenex system for LE refractory to conservative management. We also seek to evaluate patient-specific factors which may correlate with treatment response. MATERIALS AND METHODS: PRTEE (Patient-Rated Tennis Elbow Evaluation) and DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaires were completed before performing the Tenex USPNT for all consecutive patients over a course of 38 months (Feb 2015-Mar 2018). Patients were contacted for follow-up evaluations. Paired t test was used to evaluate significant changes in treatment response (p < 0.05). The univariate Tobit regression model was applied followed by multivariate Tobit model with forward selection algorithm. All models were adjusted by preoperative score and follow-up duration. RESULTS: A total of 37 patients (average age 51± 9 years, M/F:15/22) with refractory LE were included (mean follow-up, 531 days; range, 65-1148 days). Tenex USPNT significantly improved PRTEE and DASH scores (p < 0.001). In some patients, this decrease persisted for up to 3 years after intervention. A significant association between treatment response and post-procedure physical therapy (PT) was present. Post-procedure PT contributes to 60, 68, 59, and 50% of reduction in PRTEE pain, function, total scores, and DASH score, respectively (p < 0.001). No tendon ruptures, post-procedural infections, or other complications were noted. CONCLUSION: USPNT with Tenex significantly improves symptoms and function in individuals with LE even with long-term follow-up for 3 years. Post-procedure PT is associated with improved treatment response and should be considered after USPNT.

Two-Screw Fixation of Scaphoid Waist Fractures.

Optimal fixation strategy for scaphoid waist fractures remains a contentious topic with options including using a single screw, 2 screws, or a scaphoid plate. Biomechanical studies favor 2-screw fixation with regards to higher load to failure, load to 2-mm displacement, energy absorbed, rotational stability, and stiffness. Furthermore, recent retrospective studies found increased union rate with 2 screws. Although conclusive clinical data are lacking, 2-screw fixation of a scaphoid waist fracture may theoretically allow the patient to start earlier range of motion and strengthening with greater confidence. Our experience with 2-screw fixation has been promising with all acute waist fractures healing and nonunions treated with 2 screws having high union and low reoperation rates.

Patient-Related Risk Factors for Infection Following Open Carpal Tunnel Release: An Analysis of Over 450,000 Medicare Patients.

PURPOSE: To establish the rate of postoperative infection after open carpal tunnel release (CTR) on a national level using an administrative database and define relevant patient-related risk factors associated with its occurrence. METHODS: The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files retrospectively from 2005 to 2012 for patients undergoing open CTR using Current Procedural Terminology code 64721. Postoperative infection within 90 days of surgery was assessed using both International Classification of Diseases, Ninth Revision codes for diagnoses of postoperative infection or pyogenic arthritis of the wrist and Current Procedural Terminology codes for procedures for these indications, including either open or arthroscopic irrigation and debridement. We used a multivariable binomial logistic regression model that allows for assessment of the independent effect of a variable while controlling for remaining variables to evaluate which patient demographics and medical comorbidities were associated with an increased risk for postoperative infection. Adjusted odds ratios and 95% confidence intervals were calculated for each risk factor, with P < .05 considered statistically significant. RESULTS: A total of 454,987 patients met all inclusion and exclusion criteria. Of these patients, 1,466 developed a postoperative infection, corresponding to an infection rate of 0.32%. Independent positive risk factors for infection included younger age, male sex, obesity (body mass index of 30 to 40), morbid obesity (body mass index greater than 40), tobacco use, alcohol use, and numerous medical comorbidities including diabetes, inflammatory arthritis, peripheral vascular disease, chronic liver disease, chronic kidney disease, chronic lung disease, and depression. CONCLUSIONS: The current study reinforced conventional wisdom regarding the the overall low infection rate after CTR and revealed numerous patient-related risk factors that are independently associated with an increased risk of infection after open CTR in patients enrolled in Medicare. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Radial Head Fracture Fixation Using Tripod Technique With Headless Compression Screws.

Radial head and neck fractures are one of the most common elbow fractures, comprising 2% to 5% of all fractures, and 30% of elbow fractures. Although uncomplicated Mason type I fractures can be managed nonsurgically, Mason type II-IV fractures require additional intervention. Mason type II-III fractures with 3 or fewer fragments are typically treated with open reduction and internal fixation using 2 to 3 lag screws. Transverse radial neck involvement or axial instability with screw-only fixation has historically required the additional use of a mini fragment T-plate or locking proximal radius plate. More recently, less invasive techniques such as the cross-screw and tripod techniques have been proposed. The purpose of this paper is to detail and demonstrate the proper implementation of the tripod technique using headless compression screws.

Effect of Obesity on Complication Rate After Elbow Arthroscopy in a Medicare Population.

PURPOSE: To use a national insurance database to explore the association of obesity with the incidence of complications after elbow arthroscopy in a Medicare population. METHODS: Using Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision (ICD-9) procedure codes, we queried the PearlDiver database for patients undergoing elbow arthroscopy. Patients were divided into obese (body mass index [BMI] >30) and nonobese (BMI <30) cohorts using ICD-9 codes for BMI and obesity. Nonobese patients were matched to obese patients based on age, sex, tobacco use, diabetes, and rheumatoid arthritis. Postoperative complications were assessed with ICD-9 and Current Procedural Terminology codes, including infection, nerve injury, stiffness, and medical complications. RESULTS: A total of 2,785 Medicare patients who underwent elbow arthroscopy were identified from 2005 to 2012; 628 patients (22.5%) were coded as obese or morbidly obese, and 628 matched nonobese patients formed the control group. There were no differences between the obese patients and matched control nonobese patients regarding type of elbow arthroscopy, previous elbow fracture or previous elbow arthroscopy. Obese patients had greater rates of all assessed complications, including infection (odds ratio [OR] 2.8, P = .037), nerve injury (OR 5.4, P = .001), stiffness (OR 1.9, P = .016) and medical complications (OR 6.9, P < .0001). CONCLUSIONS: Obesity is associated with significantly increased rates of all assessed complications after elbow arthroscopy in a Medicare population, including infection, nerve injury, stiffness, and medical complications. LEVEL OF EVIDENCE: Therapeutic Level III, case-control study.

Distal ulna fractures.

In isolation, distal ulna fractures are rare. They are often found in conjunction with distal radius fractures, and the complexity of the interaction of the distal ulna with the radioulnar joint and triangular fibrocartilage complex makes understanding and treatment of distal ulna fractures challenging. Fixation of distal ulna fractures can be problematic owing to comminution making reduction challenging. A thin soft tissue can lead to hardware prominence and necessitate implant removal. In this Current Concepts article, we review the anatomy, pathology, and treatment of distal ulna fractures as well as potential complications and salvage procedures.

Nerve conduits for nerve repair or reconstruction.

Advances in treating peripheral nerve lesions have resulted from research in nerve regeneration and the use biomaterials as well as synthetic materials. When direct tensionless repair of peripheral nerve lesions is not possible, nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm. Nerve autograft is the benchmark for larger, longer, mixed, or motor nerve defects. Biologic, autogenous conduits-typically veins or, rarely, arteries-have demonstrated their utility in nerve gaps <3 cm in length. Three types of bioabsorbable conduit have been approved by the US Food and Drug Administration, constructed of collagen, polyglycolic acid, or caprolactone. Caprolactone conduits have been found to be equivalent in results to autograft. Collagen conduits are next best, and polyglycolic acid conduits are functionally inferior. Further research and prospective, multicenter, large-scale trials are needed to help establish the role of synthetic, bioabsorbable conduits in peripheral nerve reconstruction.

Soft-tissue coverage of complex dorsal hand and finger defects using the turnover adipofascial flap.

Complex hand wounds with exposed tendon or bone often require free tissue transfer. We report results in 13 patients with complex dorsal hand or digital wounds who underwent soft-tissue reconstruction using a turnover adipofascial flap and skin grafting over a 35-month period. The mean patient age was 44 years. Mechanism of injury included the following: three gunshot, four degloving, one table saw, three chain saw, one thumb avulsion, and one crush. Flap sizes varied from 2 × 4 to 10 × 18 cm, involving the dorsum of the hand in four patients, thumb in two patients, index finger in one patient, long finger in three patients, long and ring fingers in one patient, and web space in two patients. Skin graft survival was 100% in 12 patients. One patient died of sepsis from unrelated medical conditions. All fractures were healed at follow-up, and there were no donor site complications. The adipofascial flap is a good alternative to free tissue transfer for the coverage of complex dorsal hand and finger soft-tissue defects and is associated with technical ease, good cosmetic results, and minimal donor site morbidity.

Mycobacterium Immunogenum Flexor Tenosynovitis: A Case Report.

Background Nontuberculous mycobacterial (NTM) flexor tenosynovitis represents a rare but potentially devastating manifestation of upper extremity infection. We present a novel case of NTM flexor tenosynovitis in which Mycobacter iumimmunogenum was found to be the causative agent. Case Description The patient presented with pain and insidiously progressive swelling and required multiple operative interventions and a complex antimicrobial regimen based on susceptibility profiles. Specifically, our patient was managed with three debridements and empiric antimicrobial agents based on inherent macrolide sensitivity, with later conversion to a complex antimicrobial regimen tailored to sensitivity. Literature Review The diagnosis and management of NTM tenosynovitis arechallenging because of low suspicion, nonspecific presentation, and cumbersome laboratory identification techniques. M. immunogenum was only characterized in the past two decades, and, to our knowledge, this is the first reported case of the pathogen causing a musculoskeletal infection. Clinical Relevance We present this case primarily because of the novelty of the organism and to demonstrate the recalcitrant nature of the infection. Due to the extensive resistant patterns of M. immunogenum , management requires complex antimicrobial preparations and almost certainly needs multispecialty collaboration between orthopaedic surgery and infectious diseases.

Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients.

Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m2, depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.

Effect of intra-articular pressurization associated with arthroscopy on the immature physis: investigation in an animal model.

BACKGROUND: Despite the increased use of arthroscopy in pediatric orthopaedics, there is a paucity of data regarding the potential long-term effects of this procedure on the immature physis. The purpose of this study was to test the hypothesis that elevated intra-articular pressures used during arthroscopic surgery do not result in growth disturbances or morphologic alterations in the epiphyseal plate. METHODS: Twenty-seven 6-week-old skeletally immature New Zealand white rabbits were divided into experimental (n=21) and control groups (n=6). In the experimental group, a hydraulic pump was used to pressurize 1 randomly assigned knee joint per rabbit to intra-articular pressures of 120 mm Hg for 2 hours. In the control group, rabbits received a sham intervention. All rabbits were killed at 6 months of age (skeletal maturity), and their tissues were evaluated grossly, radiographically, and histologically. Data collection included gross measurements (femur and tibia lengths, evaluation of varus/valgus angulation, and knee joint range of motion) and histologic analyses to determine whether morphologic changes were present in the articular cartilage or physis. Confidence intervals were used to test for statistical equivalence. RESULTS: The pressurized and control groups had statistically equivalent gross measurements. No significant articular cartilage or physeal lesions were identified in histologic sections or radiographic studies. CONCLUSION: This study provided no evidence that arthroscopic pressurization of the knee joint to 120 mm Hg for 2 hours significantly affected physeal growth in a skeletally immature rabbit model. CLINICAL RELEVANCE: This study provides the first direct evidence that arthroscopic pressurization of immature joints has no clinically significant adverse long-term effects. Therefore, novel uses of arthroscopy in pediatric patients should be explored without undue concern with regard to premature physeal closure.

Fibromyalgia as a Predictor of Complex Regional Pain Syndrome After Distal Radius Fracture.

Background: Complex regional pain syndrome (CRPS) can be a devastating complication following extremity injury, but risk factors are not well understood. The purpose of this study was to investigate the association between fibromyalgia and the development of CRPS after distal radius fracture. Methods: The PearlDiver Medicare database was queried using International Classification of Diseases, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes for diagnoses and treatments of distal radius fractures. Patients were separated into fibromyalgia and control cohorts, and the prevalence of CRPS was measured at 3, 6, 9, and 12 months from the date of injury or procedure. Demographic factors, treatment modality, and comorbid conditions were analyzed by multivariable logistic regression to reduce confounding and identify additional risk factors. Results: Database queries yielded 853 186 patients diagnosed or treated for distal radius fracture, with 6% having previous diagnosis of fibromyalgia. The prevalence of CRPS following distal radius fracture was increased at 3, 6, 9, and 12 months in the fibromyalgia cohort compared with the control c, with a 1-year incidence of 0.51% compared with 0.20% (odds ratio [OR], 2.54, P < .001). Multivariable logistic regression supported the association, with estimated OR of 2.0 (P < .001). In addition, female gender, surgical or manipulative treatment, and anxiety were positively associated with CRPS, and age >65, diabetes, and heart failure were negatively associated. Conclusions: While the basis of the association between fibromyalgia and CRPS is unknown, our data suggest that it could serve as a useful predictor of CRPS risk, promoting increased vigilance for CRPS symptoms and earlier recognition and treatment, thereby improving patient outcomes.

The Association of Perioperative Glycemic Control With Postoperative Surgical Site Infection Following Open Carpal Tunnel Release in Patients With Diabetes.

BACKGROUND: The primary goal of the study was to evaluate the association of hemoglobin A1c (HbA1c) levels in diabetic patients with the incidence of surgical site infection (SSI) following open carpal tunnel release (CTR). Our secondary objective was to calculate an HbA1c level in diabetic patients that predicted SSI after open CTR. METHODS: A national private-payer insurance database was queried for patients who underwent open CTR using Current Procedural Terminology (CPT) code 64721. Patients who underwent concomitant procedures were excluded. Diabetic patients who had their HbA1c level checked within 3 months of surgery were stratified into 6 mutually exclusive groups based on HbA1c levels in 1.0 mg/dL increments from <6.0 to >10 mg/dL. The incidence of SSI was determined for each group by either a diagnosis or procedure for SSI within 1 year using CPT and International Classification of Diseases, 9th Revision (ICD-9) codes. A receiver operating characteristic (ROC) analysis was performed to determine an HbA1c level above which the risk of postoperative SSI was significantly increased. RESULTS: 7958 diabetic patients who underwent open CTR and had an HbA1c recorded within 3 months of surgery were assessed. The incidence of SSI within 1 year was associated with HbA1c levels. The inflection point of the ROC curve corresponded to an HbA1c level between 7 and 8 mg/dL. CONCLUSIONS: Increased HbA1c levels are associated with increased SSI rates in diabetic patients undergoing open CTR. A perioperative HbA1c between 7 and 8 mg/dL could serve as a threshold for an increased risk of SSI following open CTR.

Use of Particulated Juvenile Articular Cartilage Allograft for Osteochondral Lesions of the Wrist.

BACKGROUND: Articular cartilage injuries are a common injury among young, active patients, and the most appropriate treatment for these injuries remains controversial. A promising new technology in the treatment of high-grade cartilage injuries is particulated juvenile articular cartilage (PJAC) allograft (DeNovo NT, Zimmer, Warsaw, Indiana). This has been shown to be successful in multiple joints including the knee, talus, and elbow. No studies or case reports exist in supporting or discouraging its use in injuries of the wrist, in specific, the scaphoid. METHODS: The use of PJAC allograft is described for the treatment of an active 21-year-old male with an Outerbridge Grade IV chondral lesion on the proximal pole of his right scaphoid and right distal radius scaphoid facet who had failed conservative management. The patient was followed clinically and radiographically for 21 months. RESULTS: The patient had return to full sport (jujutsu) and full range-of-motion, both of which represented an improvement from his preoperative exam. Radiographically, the chondral lucency seen had decreased in size and was almost completely absent on radiographs after 21 months. CONCLUSIONS: The results of this case suggest that PJAC can be used safely and effectively in the wrist thereby potentially broadening the indications for its use.

Dual Inhibition of Activin/Nodal/TGF-ß and BMP Signaling Pathways by SB431542 and Dorsomorphin Induces Neuronal Differentiation of Human Adipose Derived Stem Cells.

Damage to the nervous system can cause devastating diseases or musculoskeletal dysfunctions and transplantation of progenitor stem cells can be an excellent treatment option in this regard. Preclinical studies demonstrate that untreated stem cells, unlike stem cells activated to differentiate into neuronal lineage, do not survive in the neuronal tissues. Conventional methods of inducing neuronal differentiation of stem cells are complex and expensive. We therefore sought to determine if a simple, one-step, and cost effective method, previously reported to induce neuronal differentiation of embryonic stem cells and induced-pluripotent stem cells, can be applied to adult stem cells. Indeed, dual inhibition of activin/nodal/TGF-ß and BMP pathways using SB431542 and dorsomorphin, respectively, induced neuronal differentiation of human adipose derived stem cells (hADSCs) as evidenced by formation of neurite extensions, protein expression of neuron-specific gamma enolase, and mRNA expression of neuron-specific transcription factors Sox1 and Pax6 and matured neuronal marker NF200. This process correlated with enhanced phosphorylation of p38, Erk1/2, PI3K, and Akt1/3. Additionally, in vitro subcutaneous implants of SB431542 and dorsomorphin treated hADSCs displayed significantly higher expression of active-axonal-growth-specific marker GAP43. Our data offers novel insights into cell-based therapies for the nervous system repair.

Ice reduces edema. A study of microvascular permeability in rats.

BACKGROUND: Ice is applied following a soft-tissue injury on the basis of clinical information. This study investigates the relationship between ice therapy (cryotherapy) and edema by determining microvascular permeability before and after contusion with and without ice therapy and provides data supporting a reduction in edema following cryotherapy. METHODS: A dorsal microvascular chamber was created in rats to allow the direct examination of microvascular parameters in intact, pre-established microvascular beds of the cutaneous maximus muscle in conscious rats. The rats received a contusion or sham contusion and were treated with cryotherapy or were not treated. Microvascular permeability (edema) was assessed by measuring fluorescent-labeled albumin in the interstitial fluid before and after contusion. RESULTS: Microvascular permeability following contusion was significantly increased in the group that received the contusion without cryotherapy compared with that in the group that received the sham contusion without cryotherapy (control) (p < 0.001). When ice was applied fifteen minutes after the contusion for twenty minutes, microvascular permeability (edema) decreased significantly (p < 0.001) compared with that in the group that did not receive cryotherapy after contusion. Permeability was increased in the group that received cryotherapy following the contusion compared with that in the control group (p = 0.012), although the increase was not as great as that between the group that received the contusion without cryotherapy and the control group. Sham contusion with cryotherapy significantly reduced microvascular permeability compared with that in the control group (p = 0.004). Sham contusion without cryotherapy did not cause a significant change in the microvascular permeability of postcapillary venules after 300 minutes compared with baseline measurements. CONCLUSIONS: The application of ice significantly decreased microvascular permeability following striated muscle contusion. The results of this study demonstrated that microvascular permeability is increased following a contusion coincident with significant leukocyte-endothelial interactions. However, microvascular permeability was significantly reduced following cryotherapy, a treatment demonstrated to reduce the number of rolling and adherent leukocytes. This association suggests that the reduction in edema in injured skeletal muscle following cryotherapy may be due to a reduction in leukocyte-endothelial interactions.