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.

Ultrasound Cross-Sectional Area in Median Nerve Axonal Loss and Demyelination in Carpal Tunnel Syndrome.

Introduction: Ultrasound is an effective diagnostic tool for carpal tunnel syndrome (CTS). However, it is unclear how ultrasound correlates with axonal loss and/or demyelination on electrodiagnostic studies (EDS). The objective of this study is to determine whether ultrasound cross-sectional area (CSA) of the median nerve varies between patients with axonal loss or demyelination. Methods: A retrospective review was completed of patients who presented to an orthopaedic hand clinic with numbness/paresthesias over a 6-year period. Demographics, CTS symptoms scale 6 (CTS-6) scores, Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores, EDS results, and ultrasound results were collected. Median neuropathies were graded as normal, demyelination, or axonal loss using EDS reports. The data were analyzed with chi-square and t-tests. Results: In all, 383 hands were included (92 axonal loss, 182 demyelination only, and 108 neither). The average patient age was 52.2 and the average body mass index (BMI) was 31.7. The group consisted of 70.7% females, and 23.2% had diabetes. Patients with either axonal loss or demyelination had larger CSA and higher CTS-6 and BCTQ scores than patients with negative EDS. Patients with axonal loss also had larger CSA and higher CTS-6 and BCTQ scores than patients with demyelination only. The rates of positive ultrasound results between axonal loss and demyelination groups did not differ until the ultrasound cutoff was increased from 10 to 12 mm2. Conclusion: Rates of positive ultrasound results (CSA ≥ 10 mm2) do not differ between wrists with axonal loss or demyelination alone. Therefore, the character of carpal tunnel neuropathy does not affect ultrasound's diagnostic ability. Additionally, CSA increases as wrists develop axonal loss, and an increased ultrasound cutoff of 12 mm2 is correlated with this pathology.

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.

Effect of Capitolunate Positioning on Outcomes in Scaphoid Excision and 4-Bone Fusion Patients.

BACKGROUND: Scaphoid excision and 4-bone fusion (4BF) is a surgical procedure to treat scapholunate advanced collapse. Some surgeons align the lunate over the capitates, whereas others leave the capitate in its uncovered native position. The capitolunate angle may affect long-term outcomes. This study examined whether postsurgical outcomes differed based on these differences in positioning. METHODS: A retrospective analysis was performed for patients that underwent a 4BF between 2006 and 2020. Wrist range of motion; pain (0-10); and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were recorded. The width of the capitate, the width of the lunate contacting the capitate, and the capitolunate angle were measured. Pearson correlations and t tests were performed. For t tests of capitolunate uncovering, patients were divided into 2 groups: patients with 0% capitate uncovering and patients with >0% uncovering. For capitolunate angle, the 2 groups were patients with a capitolunate angle of ≤10° and patients with a capitolunate angle of >10°. RESULTS: There was a significant correlation between capitate coverage and wrist extension, but no correlation for flexion, pain, or DASH scores. Group 1 (0% uncovering) had increased wrist extension and decreased pain compared with group 2 (>0% uncovering). There were no significant correlations or differences in the analyses of capitolunate angle's impact on outcomes. CONCLUSIONS: In patients undergoing 4BF, those who had the lunate aligned to completely cover the capitate head had improved wrist extension and pain compared with patients where the capitate head was left partially uncovered. Capitolunate angle was not predictive of postsurgical outcomes.

Comparison of Patient-Reported Outcomes With or Without Prophylactic Carpal Tunnel Release After Distal Radius Fracture Stabilization.

Distal radius fractures (DRFs) are frequently complicated by acute carpal tunnel syndrome (CTS), which, if unrecognized, can cause permanent median neuropathy. Some surgeons recommend "prophylactic" carpal tunnel release (CTR) during open reduction and internal fixation (ORIF) of DRF. Patient-reported outcomes (PROs) and safety data regarding prophylactic vs symptomatic CTR strategies during DRF fixation are lacking. We conducted a retrospective review of two management strategies for DRFs at our institution (2017 to 2019). Group 1 consisted of patients operated on by two surgeons performing ORIF and symptomatic CTR only for acute CTS. Group 2 consisted of patients operated on by a third surgeon performing ORIF and prophylactic CTR on all patients irrespective of median nerve symptoms. The PROs included QuickDASH Wrist and PROMIS physical/mental health preoperatively vs at final follow-up. Demographic information, complications, and return to the operating room were recorded. Group 1 (36 patients) and group 2 (76 patients) were demographically similar. The mechanism of injury was more severe in group 1 (P<.05), but preoperative PROs were similar between the two groups. Eight patients (22.2%) in group 1 had symptomatic CTR for acute CTS. Significant improvement occurred within both groups from preoperative to final follow-up for PROMIS physical function and QuickDASH Wrist scores (P<.05). Intergroup PROs were not significantly different at either time point. One patient in group 1 (2.8%) and 2 patients in group 2 (2.6%) returned to the operating room due to median nerve symptoms (P>.05). A prophylactic CTR strategy is not associated with improved PROs compared with a symptomatic strategy during ORIF of DRF. [Orthopedics. 2023;46(6):e362-e368.].

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.

A "Clear" Carpal Tunnel Syndrome Diagnosis on Ultrasound Examination Does Not Predict Improved Outcomes When Compared With a "Borderline" Diagnosis.

BACKGROUND: Nerve conduction studies (NCS) and ultrasound (US) remain imperfect compared with clinical diagnosis and/or diagnostic tools such as carpal tunnel syndrome-6 (CTS-6) for diagnosis of carpal tunne syndrome (CTS). One potential reason for the discrepancy between clinical diagnosis and testing is "borderline" case inclusion. This study aims to compare clinical outcomes after carpal tunnel release (CTR) between "borderline" and "clear" patients with CTS determined by NCS and US. METHODS: This was a retrospective review of patients who underwent CTR. We collected NCS and US measurements of the median nerve cross-sectional area (MNCSA) at the carpal tunnel inlet, and the Boston Carpal Tunnel Questionnaire (BCTQ) scores comprised of the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS). Ultrasound measurements defined patients as having "borderline" (MNCSA < 13 mm2) or "clear" (MNCSA ≥ 13 mm2) CTS. RESULTS: The study included 94 unilateral patients with CTS. "Borderline" CTS was diagnosed in 58 patients (62%), and "clear" CTS was diagnosed in 36 patients (38%). No significant differences in BCTQ scores were found between groups. At greater than 6-month follow-up, the mean FSS was 1.44 and 1.45 for clear and borderline groups, respectively (P = .97) and the mean SSS was 1.47 and 1.51, respectively (P = .84). However, a significant difference between groups when comparing distal motor latency (DML) and distal sensory latency (DSL) existed. The mean DSL was 3.71 and 4.44 for the clear and borderline groups, respectively (P = .02). The mean DML was 4.59 and 5.36 (P = .048). CONCLUSION: Categorizing CTS diagnosis into "borderline" and "clear" based on preoperative US and NCS testing did not correlate with BCTQ changes after CTR. It remains unclear whether the BCTQ is a valid postoperative assessment tool, despite its frequent use in literature.

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.

Ultrasound Measurements of the Median Nerve at the Distal Wrist Crease Correlate With Electrodiagnostic Studies.

Background: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy and is commonly evaluated using electrodiagnostic studies (EDSs). Ultrasound (US) has emerged as a potentially easier and more comfortable alternative to EDSs. The purpose of this study is to evaluate whether measurements of the cross-sectional area (CSA) of the median nerve via US correlate with the severity rating of CTS based on EDSs. Methods: A retrospective review of patients aged 18 years or older who underwent US and EDSs of the median nerve for CTS was performed. Sensory nerve action potential, distal motor latency, and compound muscle action potential were measured, and severity was graded on American Association of Neuromuscular and Electrodiagnostic Medicine guidelines. Cross-sectional area of the median nerve was measured via US at the wrist crease. Results: There was a significant association between increasing CSA and increasing EDS severity (P < .0001). The mean CSA for normal, mild, moderate, and severe CTS was 7.48 ± 2.00, 10.36 ± 2.53, 12.01 ± 3.64, and 14.34 ± 4.77 mm2, respectively. The area under the curve demonstrated the ability of median nerve CSA to discriminate between normal and abnormal EDSs with an optimal cutoff CSA of ≥10 mm2, as well as, the ability to discriminate between mild CTS and moderate to severe CTS at a cutoff CSA of greater than or equal to 12 mm2. Conclusions: The results of this study show that US measurements of the median nerve at the distal wrist crease discriminate between normal and abnormal EDSs, and between mild CTS and moderate to severe CTS.

Comparison of Diagnostic Accuracy of Electrodiagnostic Testing and Ultrasonography for Carpal Tunnel Syndrome.

BACKGROUND: Confirmatory methods such as electrodiagnostic testing (EDX) and ultrasonography (US) are currently used to support a clinical diagnosis of carpal tunnel syndrome (CTS). Scientific consensus long has preferred nerve conduction studies (NCS); however, recent studies have advocated for a diagnostic niche for ultrasound examination. This study seeks to compare diagnostic accuracies, sensitivity, and specificity between these 2 diagnostic tools. METHODS: An institutional database was retrospectively analyzed to reveal 402 upper extremity cases (265 patients) with potential for CTS diagnosis. Demographics, NCS results, and US findings were determined for each patient case. Sensitivity and specificity values were determined for each diagnostic modality using Carpal Tunnel Syndrome 6 (CTS-6), a validated clinical CTS scoring system, as the reference standard. Demographic and diagnostic values were compared between positive and negative CTS groups using the 2-tailed t test and χ2 test. RESULTS: Electrodiagnostic testing resulted in a sensitivity of 87% and a specificity of 27%, whereas US produced a sensitivity of 76% and a specificity of 51%. No statistical difference was found in CTS-6 scores between NCS-positive and NCS-negative patient hands, whereas CTS-6 scores were significantly greater in US-positive CTS cases than US-negative cases (15.2 and 13.1, respectively, P < .001). CONCLUSIONS: Electrodiagnostic testing yields a greater sensitivity for CTS than US examination. However, US testing aligns more closely with CTS-6 scores and results in a greater specificity and positive predictive value. These findings suggest that US holds a non-trivial niche in CTS diagnosis and that EDX is not clearly preferable for all CTS diagnoses and cases.

Ultrasound Use by Upper Extremity Surgeons in 2020: A Survey of ASSH Members.

BACKGROUND: The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015. METHODS: In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US. RESULTS: A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections. CONCLUSIONS: Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons.