Acupuncture for de Quervain's tenosynovitis: A randomized controlled trial.

BACKGROUND: Acupuncture has been an alternative approach for de Quervain's tenosynovitis (DQt), but trial evidence is still lacking. PURPOSE: This study aimed to assess the efficacy of acupuncture in patients with DQt. STUDY DESIGN: A randomized controlled trial. METHODS: A total of 68 subjects with DQt were recruited from outpatients of Department of Orthopaedics and Traumatology, and Chinese medicine clinics, The University of Hong Kong, and were randomized into the acupuncture group (n = 34) and the waitlist group (n = 34). Subjects in the acupuncture group received 5 acupuncture sessions over 2 weeks, followed by a 10-week follow-up. The waitlist control group received assessments only in the first 6 weeks of the waiting period and received the same acupuncture treatment and follow-up as the treatment group in the next 12 weeks. The primary outcome was the general pain intensity using the Visual Analogue Scale (VAS) at the end of treatment (week 2). Secondary outcomes were grip and pinch strengths of affected hands, the quick Disabilities of the Arm, Shoulder and Hand Score (Q-DASH), and the World Health Organization Quality of Life-brief Questionnaire (WHOQOL-BREF) at weeks 2 and 6. RESULTS: From baseline to 2 weeks, the mean VAS score decreased by 19.5 points in the acupuncture group and by 3.4 points in the waitlist group. The difference for acupuncture vs waitlist control was -16.2 points (95% CI, -26.7 to -5.6, p = 0.003). Acupuncture effects sustained for 10 weeks (mean difference compared with baseline, -30.6; 95% CI, -39.6 to -21.7). Secondary outcomes showed that acupuncture reduced pain intensity, improved grip and pinch strength of affected hands, and Q-DASH scores, but not the scores of WHOQOL-BREF in patients. No serious adverse event occurred during the study period. CONCLUSIONS: Our findings support that 2-week of acupuncture is safe and effective in the reduction of pain intensity, and improvement of strengths and disabilities of hand in DQt patients. Acupuncture also has long-term effects on DQt. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov (NCT03472443).

Endoscopic cubital tunnel decompression: state of the art.

Cubital tunnel syndrome is a common compressive neuropathy of the upper limb. Surgical decompression is indicated for patients who failed conservative therapy. Decompression in situ has shown to achieve comparable outcomes as decompression with anterior transposition in idiopathic cubital tunnel syndrome. Endoscopic cubital tunnel decompression has gained popularity in recent years, as surgeons can attain decompression of the ulnar nerve along its course using a small incision. Results from randomised controlled studies and systematic reviews, comparing endoscopic with open decompression in situ, are promising. Cases in which anterior transposition of the ulnar nerve is needed, an endoscopic technique can still be used by creating an additional volar portal, for the mobilisation of ulnar nerve. Early short-term results are encouraging. Further adequately powered, prospective, preferably double-blinded, randomised study are needed.

The medium term outcomes of an all-arthroscopic triangular fibrocartilage complex foveal reconstruction using tendon graft.

PURPOSE: In patients with symptomatic chronic tear of the triangular fibrocartilage complex (TFCC), reconstruction with a tendon graft is indicated. We propose an arthroscopic-assisted technique to reconstruct the TFCC and to stabilize the distal radioulnar joint. METHODS: Patients with a chronic foveal TFCC tear of which it is deem not reparable were recruited. TFCC reconstruction was performed by making use of the TFCC remnants and a palmaris tendon graft under arthroscopic guidance. RESULTS: Twelve patients with an average age of 29 years old were evaluated. Three patients had concomitant ulnar shortening procedure. The average follow-up period was 29 months. All patients had stable DRUJ. Significant improvement was noted for pain score (from 4 to 1), DASH score (from 31 to 9.5), and Mayo modified wrist score (from 82 to 95). Grip strength was improved and the range of movement of the wrist was maintained. No complication nor graft re-rupture was noted. CONCLUSION: This is a viable arthroscopic technique of TFCC reconstruction in a selected group of patients who had chronic foveal TFCC tear.

Endoscopic cubital tunnel decompression - Review of the literature.

Cubital tunnel syndrome is the second most common compressive neuropathy of the upper limb. Endoscopic cubital tunnel decompression has gained popularity in recent years as this enables surgeons to achieve decompression of the ulnar nerve along its course using a small incision. This article describes the technical peals in performing endoscopic cubital tunnel decompression. In conditions which anterior transposition of the ulnar nerve is needed, subcutaneous transposition can be performed under endoscopic guidance. In addition, current literature is reviewed, and outcomes are presented. While short term results are encouraging, further prospective randomized study with longer follow-up is recommended.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire.

INTRODUCTION: The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture. METHODS: This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes. RESULTS: Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores. CONCLUSION: Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Carpal Instability Nondissociative Following Acute Wrist Fractures.

PURPOSE: Carpal malalignment following intra-articular fractures has been reported in the literature, with no clear description of possible ligamentous injury leading to the radiological appearance. This study presents a series of patients that developed carpal instability nondissociative (CIND) following acute wrist fractures. The mechanism of injury is postulated by using a cadaveric laboratory investigation. METHOD: Twelve patients with average age of 32 years were identified with CIND, between 2013 and 2018. Ten patients with a normal carpal alignment in the initial postoperative radiographs exhibited CIND-palmar radiographically at different postoperative periods, and 2 patients showed CIND-dorsal in the initial postoperative x-rays. Four cadaveric specimens were used to validate this injury pattern. RESULTS: In cadaveric dissections, CIND-palmar could be reproduced by applying an axial loading and dorsal shearing force on a wrist with sequential sectioning of dorsal and palmar extrinsic wrist ligaments. For the intra-articular fractures with CIND-dorsal, the cause is likely a result of volar radiocarpal extrinsic ligament injury combined with intra-articular incongruity of the scaphoid fossa. Eight out of the 12 patients had severe wrist pain and underwent additional surgery. Three patients with reducible CIND-palmar had open capsular repair, and 5 patients with fixed nonreducible malalignment were treated with radioscapholunate arthrodesis. At an average follow-up of 2.3 years, pain relief was noted, together with an improvement in grip strength and range of movement. Radiographically, the wrist alignment was corrected and maintained. CONCLUSIONS: This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity, associated with acute intra-articular fractures and radiocarpal fracture-dislocations, that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. Early detection of this condition may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Midterm Outcomes of the Use of a Spherical Ulnar Head Prosthesis for Failed Sauvé-Kapandji Procedures.

PURPOSE: The use of a spherical ulnar head prosthesis (UHP) for the treatment of symptomatic radioulnar convergence after Sauvé-Kapandji (SK) procedure has shown promising results in the short term. This study aims to evaluate the midterm outcome of the original cohort of patients treated with this technique. METHODS: Seventeen patients with unstable ulnar stumps confirmed both clinically and radiographically were studied. The etiology for the initial SK procedure included posttraumatic distal radioulnar joint (DRUJ) incongruity, primary DRUJ arthrosis, and dysplastic DRUJ. Fourteen of the 17 patients had a minimum of 2, and a maximum of 6, operations prior to having a spherical UHP. All patients suffered from severe pain with difficulty in performing work and daily activities. Ceramic UHP was used for all patients, except 2 in whom a cobalt chrome head was used. RESULTS: The average follow-up was 6 years (range, 4-17 years). A marked reduction in pain was observed with 11 patients reporting that they remained pain free. The range of motion of the wrist and power grip was maintained and showed a statistically significant improvement at the late follow-up. The Disabilities of the Arm, Shoulder, and Hand score also significantly improved from 77 to 41. There were no signs of prosthetic loosening at the midterm follow-up. The 2 patients with cobalt chrome prostheses had pain and osteolysis requiring revision to total DRUJ prosthesis. Two patients with dorsal prosthetic subluxation were successfully treated with distal radial osteotomy. CONCLUSIONS: The midterm results of ceramic spherical UHP for failed SK procedures in this small patient series are encouraging. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The status of triangular fibrocartilage complex after the union of distal radius fractures with internal plate fixation.

PURPOSE: Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance. METHODS: Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old. RESULTS: Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC. CONCLUSIONS: A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.

Ligaments Reconstruction for Posttraumatic Ulnar Translocation of the Carpus: A Case Report.

Background Posttraumatic ulnar translocation of the carpus, a result of radiocarpal ligament tear is a relatively rare condition that may lead to persistent wrist pain and loss of function. Case Description We report a case of radiocarpal ligament tear of which we reconstruct it with a vascularized interosseous membrane with 13 years of follow-up. Literature Review Many treatment options have been proposed for the posttraumatic ulnar translocation, ranging from open repair to partial wrist fusion. However, the long term results have been disappointing. Clinical Relevance Though this technique of reconstruction is technically demanding, it shows promising long term clinical outcome.

Fatal bilateral lower-limb deep vein thrombosis and pulmonary embolism following single digit replantation.

Venous thromboembolism in hand surgery is rare. There is no report in the literature on postoperative mortality from venous thromboembolism following microsurgery in upper limbs. We report the case of a 56-year-old Chinese man who died from pulmonary embolism as a result of bilateral lower-limb deep vein thrombosis following prolonged surgery under general anaesthesia after replantation of a finger. This case raises awareness of the need for precautions against venous thromboembolism following prolonged microsurgery and identification of high-risk patients.

Chronic scapholunate instability treated with temporary screw fixation.

PURPOSE: To determine the efficacy of scapholunate (SL) temporary screw fixation to maintain the reduction of SL interval after ligament debridement, repair, or reconstruction. METHODS: A total of 36 patients who had chronic SL instability were included. Arthroscopic debridement was performed for dynamic instability, and primary repair or reconstruction of the SL ligament was performed for static instability. We then used SL screw fixation for the protection of the repair or reconstruction. Screws were removed when loosening was noted on x-ray. RESULTS: The average patient age was 43 years. Eleven had dynamic instability, and 25 had static instability. The average follow-up was 7.9 years. Nearly 95% of the patients had no more than mild pain. The average ranges of movement of the wrist were 55° extension, 51° flexion, 26° ulnar deviation, and 15° radial deviation. Postoperative x-ray revealed an average SL angle of 56°. The average SL gap was 2.5 mm. Both of these radiographic parameters were maintained at final follow-up. Dorsal intercalated segmental instability (DISI) deformity was not corrected in 2 patients. One patient had avascular changes in the proximal scaphoid and lunate but remained asymptomatic at 7 years postoperatively. There was no further intercarpal and radiocarpal degeneration. CONCLUSIONS: Temporary SL screw fixation together with arthroscopic debridement, ligament repair, or reconstruction provided a stable closure of the SL interval and satisfactory clinical and functional results along with a low incidence of complication. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Current management of hand enchondroma: a review.

Enchondromas are benign bone tumours originating from cartilages. It is mainly discovered incidentally in radiographs or due to symptoms like pathological fracture or pain. Conservative treatment through regular check-up and surgical excision using curettage are the two major treatment methods for enchondromas. This review concludes that small localized asymptomatic lesions can be treated conservatively while most expanding or symptomatic lesions should be treated with simple curettage. Adjuvant treatments like high-speed burring or alcohol instillation are not recommended.

Insertional torque and pullout strength of pedicle screws with or without repositioning: a porcine study.

PURPOSE. To evaluate the insertion torque and pullout strength of pedicle screws with or without repositioning. METHODS. 20 fresh porcine lumbar vertebrae of similar size were used. The entry point was at the site just lateral and distal to the superior facet joint of the vertebra, and to a depth of 35 mm. A 6.2-mm-diameter, 35-mm-long pedicle screw was inserted parallel to the superior end plate on one side as control. On the other side, an identical screw was first inserted 10º caudal to the superior end plate, and then repositioned parallel to the superior end plate. The insertional torque and pullout strength were measured. RESULTS. Three of the specimens were excluded owing to pedicle fractures during the pullout test. Repositioned pedicle screws were significantly weaker than controls in terms of the maximum insertional torque (3.20 ± 0.28 vs. 2.04 ± 0.28 Nm, 36% difference, p<0.01) and pullout strength (1664 ± 378 vs.1391 ± 295 N, p<0.01). CONCLUSION. Repositioning pedicle screws should be avoided, especially when the pedicle wall is breached. If repositioning is deemed necessary, augmentation with polymethyl methacrylate or a screw with a larger diameter should be considered.

A new building block: costo-osteochondral graft for intra-articular incongruity after distal radius fracture.

Even with the invention of locking plates, intra-articular fractures of distal radius with extreme comminution remain a challenge for orthopaedic surgeons. Osteochondral graft is a potential choice to reconstruct the articular defect. We report a patient who had a fracture of distal radius with costo-osteochondral graft for articular reconstruction which has not yet been described in the English literature. At nine-year follow-up, he was pain free and had full range of movement of the wrist. The authors suggest that costo-osteochondral graft could be an option with satisfactory result.

Schwannoma in the upper limbs.

Schwannomas are the commonest tumours of peripheral nerves. Despite the classical description that schwannomas are well encapsulated and can be completely enucleated during excision, a portion of them have fascicular involvement and could not be completely shelled out. A retrospective review for 8 patients was carried out over 10 years. 75% of schwannoma occurred over the distal region of upper limb (at elbow or distal to it). It occurs more in the mixed nerve instead of pure sensory or motor nerve. 50% of patients had mixed nerve involvement. Fascicular involvement was very common in schwannoma (75% of patients). Removal of the tumour with fascicles can cause functional deficit. At present, there is no method (including preoperative MRI) which can predict the occurrence of fascicular involvement; the authors therefore proposed a new system to stratify patients who may benefit from interfascicular nerve grafts. In this group of patients, the authors strongly recommend that the possibility and option of nerve graft should be discussed with patients prior to schwannoma excision, so that nerve grafting could be directly proceeded with patient consent in case there is fascicular involvement of tumour found intraoperatively.

Ten-year results using a dynamic treatment for proximal phalangeal fractures of the hands.

Fractures of the proximal phalanges of the hands can be treated by many methods. With surgical intervention, a loss in proximal interphalangeal joint movement is common. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and an external device such as a thermoplastic metacarpophalangeal block splint, proximal phalangeal fractures can be stabilized in terms of axis, length, and rotation.This study reports the authors' 10-year results managing these fractures with dynamic treatment. All patients with closed fractures of the proximal phalanges admitted to Queen Mary Hospital, Hong Kong, China, between July 2000 and June 2010 were analyzed. Fractures with rotational deformities or displaced intra-articular configurations were excluded. A dynamic splint that kept the metacarpophalangeal joint maximally flexed while allowing free movement of the proximal and distal interphalangeal joints of the injured finger was applied for at least 4 weeks. Results were evaluated using the Belsky classification and grip strength assessment. The results of 97 patients (103 fractures) were analyzed. At a minimum 1-year follow-up, 75% of patients attained excellent or good results. Neither nonunion nor delayed fracture union was noted. The 25% of patients who attained poor results were older than those who attained excellent or good results (average age, 53.1 vs 35.1 years, respectively) and tended to comply poorly with the rehabilitation program. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and a metacarpophalangeal block splint, bone healing and movement recovery can be achieved simultaneously.

The beauty of stability: distal radioulnar joint stability in arthroscopic triangular fibrocartilage complex repair.

The triangular fibrocartilage complex (TFCC) has an important role in the stability of the distal radioulnar joint (DRUJ) stability. We designed a new method of TFCC tear repair that has satisfactory post-operative DRUJ stability. From May 2004 to August 2010, 14 patients who underwent this operation were reviewed. The average post-operative follow-up period was 8.2 months; 66.7% of the patients with TFCC tear in sigmoid notch had clinical DRUJ instability, while only 50% of tear in fovea and 16.7% of tear in base of ulnar styloid had clinical DRUJ instability. Transosseous suture via inside-outside technique was used for repair. At the final follow-up, all 14 patients have soft end point with < 5 mm translations of the DRUJ shown by the stress test. Based on this small sample with satisfactory outcome assessed by the Mayo modified wrist score and DRUJ stability, we recommend TFCC tear in sigmoid notch, which has a higher chance of DRUJ instability, to be repaired by transosseous suture.

The accuracy of sizing of the femoral component in total knee replacement.

PURPOSE: Femoral sizing in total knee replacement is important. Either undersizing or oversizing may result in deleterious effects to the clinical outcome after the surgery. There has been no study on the precision and accuracy of femoral sizing and the effect of measurement at different landmarks over the distal femur. This study assesses the intra-observer and inter-observer error of femoral sizing and identifies the effect of the placement site of the anterior referencing tool on femoral sizing. METHODS: Five investigators with different clinical experience measured the femoral size of 10 cadaveric specimens twice using three anterior referencing tool. The measurement of the femoral size was repeated at nine designated points on the anterior cortex of the cadaveric femora. RESULTS: Excellent intraobserver and interobserver agreements were obtained using the three anterior referencing tools. When the size on which the majority agreed was regarded as the actual size of the specimen, measurement at the nine designated points on the anterior cortex showed a deviation from the actual size from 6.2 to 46.2 %. Placing the femoral sizer stylus at the middle and 2 cm above the proximal margin of the anterior femoral condyle yielded the highest precision and accuracy. CONCLUSION: Regardless of the experience of the surgeons, measurement of the femoral size using the three anterior referencing tools is very accurate. Placing the stylus of the femoral sizer at the middle and 2 cm above the proximal margin of the anterior femoral condyle best reflects the actual size of the femur. LEVEL OF EVIDENCE: Experimental study.