Being a Better Starfish Thrower, Carpal Tunnel Syndrome, and Cardiac Amyloidosis: The Hand Surgeon's Opportunity to Make a Profound Difference.

In recent years, there is increasing literature in cardiac and hand surgery journals demonstrating a stronger association between seemingly idiopathic carpal tunnel and amyloidosis. Despite this, it can be difficult for hand surgeons to identify who need biopsies, and this is further complicated by the cost of a biopsy and the low likelihood that a patient has cardiac amyloidosis. In patients with cardiac amyloidosis and carpal tunnel syndrome (CTS), CTS is typically diagnosed 5-10 years prior. Early diagnosis of cardiac amyloidosis is crucial, as current medications work to slow disease progression, but do not treat existing amyloid deposits. Hand surgeons can play an essential role in early diagnosis. The patient case discussed describes a man who had a carpal tunnel biopsy because of his bilateral CTS, recurrent trigger fingers, and his age. After confirmation of amyloidosis, he was referred for cardiac amyloidosis evaluation. Testing confirmed this diagnosis, and he was started on tafamidis, which studies show provide patients an opportunity for increased survival and quality of life. The responsibility falls on cardiologists and hand surgeons to continue refining the indications for carpal tunnel biopsy and spreading awareness of carpal tunnel biopsy and amyloid testing, as much work is still needed.

The Effect of Thumb Metacarpophalangeal Hyperextension on Thumb Axial Load and Lateral Pinch Force in a Cadaver Model of Thumb Trapeziectomy and Flexor Carpi Radialis Suspensionplasty.

PURPOSE: The purpose of our study was to investigate, in a cadaver model, the effect of increasing thumb metacarpophalangeal (MCP) joint hyperextension on thumb axial load and key pinch force after thumb trapeziectomy and flexor carpi radialis suspensionplasty. We developed a cadaveric model to test whether thumb MCP joint hyperextension after trapeziectomy would have a negative effect on key pinch force and increase loads across a reconstructed thumb carpometacarpal (CMC) joint. METHODS: We created a cadaveric biomechanical model that varied thumb MCP joint hyperextension while measuring thumb CMC axial and key pinch force under standardized loads. Direct observations were made of how key pinch and axial thumb CMC force change with increasing thumb MCP joint hyperextension. We measured the thumb key pinch force and axial thumb CMC joint load with the thumb MCP joint in 0°, 10°, 20°, 30°, 40°, 50°, and 60° of hyperextension. RESULTS: There was a 0.88 N (2.4%) increase in axial force across the thumb CMC per every 10° of increasing thumb MCP joint hyperextension. We found a 0.53 N (4.4%) reduction in key pinch force for every 10° of increasing thumb MCP joint hyperextension. Therefore, at 60° of thumb MCP joint hyperextension, the axial force across the thumb CMC increased by 5.3 N (14.6%) and the key pinch force was weakened by 3.2 N (26.6%). CONCLUSIONS: With progressive thumb MCP joint hyperextension after thumb CMC arthroplasty, we found a decrease in key pinch force and an increase in axial thumb CMC joint force. The decrease in key pinch force was larger than the relatively small increase in thumb CMC force. CLINICAL RELEVANCE: This study helps elucidate the biomechanics of the thumb CMC joint after resection arthroplasty with thumb MCP joint hyperextension and helps understand the interplay between these 2 conditions.

Evaluation of the Acquisition of Ultrasound Proficiency in Hand Surgery Fellows.

OBJECTIVES: To evaluate hand surgery fellow ultrasound (US) evaluations and performance of clinically relevant tasks after brief instruction. METHODS: Six hand surgery fellows completed an US assessment and a survey on US use before and 1 month after a 30-minute US course. RESULTS: The time to obtain an adequate image decreased from 4 minutes 42 seconds (4:42; range, 3:57-7:55) to 0:52 (range, 0:30-1:14; P < .001). Participants' performance for structure identification improved from 9.7 (range, 8-13) to 12 (range, 10-13) of 14 structures (P < .05). The average time to completion decreased from 14:6 (range, 12:08-18:30) to 9:34 (range, 4:40-15:54; P < .01). After instruction, all 6 participants identified and measured the cross-sectional area of the median nerve, identified and measured a zone 3 flexor tendon gap, and identified a simulated flexor digitorum profundus avulsion and its level of retraction (P < .05). Five of 6 successfully administered an US-guided injection to the extensor carpi ulnaris subsheath. CONCLUSIONS: After a 30-minute instructional session, hand surgery fellows can achieve a basic level of US competency.

Relationship between Smoking and Outcomes after Cubital Tunnel Release.

PURPOSE: Several studies have drawn a connection between cigarette smoking and cubital tunnel syndrome. One comparison article demonstrated worse outcomes in smokers treated with transmuscular transposition of the ulnar nerve. However, very little is known about the effect that smoking might have on patients who undergo ulnar nerve decompression at the elbow. The purpose of this study is to evaluate the effect of smoking preoperatively on outcomes in patients treated with ulnar nerve decompression. MATERIALS AND METHODS: This study used a survey developed from the comparison article with additional questions based on outcome measures from supportive literature. Postoperative improvement was probed, including sensation, strength, and pain scores. A thorough smoking history was obtained. The study spanned a 10-year period. RESULTS: A total of 1,366 surveys were mailed to former patients, and 247 surveys with adequate information were returned. No significant difference was seen in demographics or comorbidities. Patients who smoked preoperatively were found to more likely relate symptoms of pain. Postoperatively, nonsmoking patients generally reported more favorable improvement, though these findings were not statistically significant. CONCLUSION: This study finds no statistically significant effect of smoking on outcomes after ulnar nerve decompression. Finally, among smokers, there were no differences in outcomes between simple decompression and transposition.

The use of a sliding bone graft in the upper extremity for long bone nonunions.

Nonunions of the upper extremity are a source of significant morbidity and can be difficult to treat. This paper describes a sliding bone graft technique that offers several significant advantages over other techniques for nonunions.

Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group.

OBJECTIVE: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). DESIGN: Prospective cohort followed for 1 year. SETTING: Clinics. PARTICIPANTS: Patients diagnosed with UNE (N=55). INTERVENTION: All subjects had simple decompression surgery. MAIN OUTCOME MEASURES: The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. RESULTS: Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01). CONCLUSIONS: Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.

Trend of recovery after simple decompression for treatment of ulnar neuropathy at the elbow.

BACKGROUND: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow. METHODS: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau. RESULTS: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months. CONCLUSION: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months.

An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group.

BACKGROUND: Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE: We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression. METHODS: Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS: Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION: Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Measurement scales in clinical research of the upper extremity, part 1: general principles, measures of general health, pain, and patient satisfaction.

Measurement is a fundamental cornerstone in all aspects of scientific discovery, including clinical research. To be useful, measurement instruments must meet several key criteria, the most important of which are satisfactory reliability, validity, and responsiveness. Part 1 of this article reviews the general concepts of measurement instruments and describes the measurement of general health, pain, and patient satisfaction.

Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow.

Part 1 of this article outlined the basic characteristics of useful clinical measurement instruments and described scales used to measure general health, pain, and patient satisfaction. Part 2 describes the features of some of the scales most commonly used in clinical research in the hand, wrist, elbow, and shoulder.

A three-dimensional finite element analysis of finger joint stresses in the MCP joint while performing common tasks.

The goal of this study was to develop a three-dimensional finite element model of the metacarpophalangeal (MCP) joint to characterize joint contact stresses incurred during common daily activities. The metacarpal and proximal phalanx were modeled using a COMSOL-based finite element analysis. Muscle forces determined from a static force analysis of two common activities (pen grip and carrying a weight) were applied to the simulation to characterize the surface stress distributions at the MCP joint. The finite element analysis predicted that stresses as high as 1.9 MPa, similar in magnitude to stresses experienced at the hip, may be experienced by the subchondral bone in the MCP joint. The internal structure and material properties of the phalanges were found to play a significant role in both the magnitude and distribution of stresses, but the dependence on cancellous bone modulus was not as severe as predicted by previous two dimensional models.

A biomechanical analysis of finger joint forces and stresses developed during common daily activities.

The problem of modelling stresses incurred at the finger joints is critical to the design of durable joint replacements in the hand. The goal of this study was to characterise the forces and stresses at the finger and thumb joints occurring during activities such as typing at a keyboard, playing piano, gripping a pen, carrying a weight and opening a jar. The metacarpal and proximal phalanx were modelled using a COMSOL-based finite element analysis. Analysis of these activities indicates that joint forces in excess of 100 N may be common at the metacarpophalangeal joint (MCP) due to carrying objects such as groceries or while opening jars. The model predicted that stresses in excess of 2 MPa, similar to stresses at the hip, occur at the MCP with the properties of cancellous bone playing a significant role in the magnitude and distribution of stress.

Benign bony and soft tissue tumors of the hand.

It is important to be familiar with the wide variety of benign tumors that may present in everyday hand surgery practice. The treatment of many of these tumors in the hand is based on studies with small numbers of patients or the treatment of similar lesions elsewhere in the body. The purpose of this review is to summarize the recent literature relevant to benign bony and soft tissue tumors in the hand.

Arthroscopic treatment of lateral epicondylitis.

Lateral epicondylitis refractory to conservative care can be effectively treated by arthroscopic release of the extensor carpi radialis brevis origin. Advantages to the technique include the ability to address other intra-articular sources of pain (capsular tears, radiocapitellar plica, etc.), a potentially faster return to work and sports, and a smaller incision. This article provides step-by-step descriptions and illustrations of the surgical technique.

Carpal growth and function after pediatric transcarpal hand replant: case report.

This case discusses the technique, postoperative course, and functional outcomes 5 years after an amputation between the cartilaginous anlages of the growing carpus in a 7-year-old boy. The lunate remained attached to the arm, whereas the scaphoid and the remainder of the carpus were contained within the amputated part. After 5 years, the patient had 94% growth compared to the other side, a Minnesota dexterity test in the 75th percentile, 0/10 pain, near-normal sensation, grip strength 17% of the other side, and lateral pinch 79% of the other side.

Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions.

Percutaneous surgical intervention for scaphoid fractures and some nonunions is increasingly common. There is a considerable learning curve for these procedures. Here we review basic and advanced techniques for volar and dorsal fixation of acute nondisplaced and displaced fractures as well as nonunions with minimal resorption and no humpback deformity.

Development of a femoral non-union model in the mouse.

OBJECTIVES: Advancements in our knowledge of fracture healing have occurred in large part by the understanding of this process on a microscopic level. The ability to develop experimental non-union models in animals will assist in the investigation of this problem and are likely to lead to novel treatments. We report on a technique for developing experimental non-unions in mice. METHODS: Femoral fractures were created in 48 CD1 mice, 24 mice underwent standard closed femoral fractures, and 24 mice underwent creation of a femoral non-union through an open osteotomy and fracture devascularisation method. All fractures were subsequently rodded. Histological examinations of the fractures were then conducted at eight time points post-operatively. RESULTS: The control group showed normal fracture healing with histological evidence of bony fracture bridging by 28 days and mature bony remodelling at 63 days. The non-union group showed delayed fracture healing at all time points and no evidence of bony healing at 63 days. CONCLUSION: This is the first report of a reliable method to develop fracture non-union in mice. We believe this technique will be critical to further the investigation of fracture non-union in normal mice and provides the great advantage of using the plethora of transgenic and knockout mouse models to analyse non-union at the cell and molecular level.

Hip arthroscopy without a perineal post: a safer technique for hip distraction.

Pudendal nerve palsy is a reported complication of hip arthroscopy. We report a technique using a deflated taped beanbag rather than a perineal post. The patient is placed in the supine or lateral position on a fracture table. The beanbag is contoured around the patient's flank and thorax. The distal aspect of the beanbag is placed no further than the iliac crest, and care is taken to avoid compression of the posterior aspect of the axillary region or the posterior humerus. The molded beanbag is deflated, a blanket is positioned over the abdomen and lower thorax, and with the use of 3-in-wide cloth tape, the patient and beanbag are secured to the operative table circumferentially. The superior margin of the deflated beanbag remains firm, preventing compression of the thorax and avoiding compromised ventilation. The arm on the operative side is placed across the chest and secured to avoid obstruction of the operative field. This patient positioning provides sufficient stability for adequate traction and good visualization while minimizing the risk of a pudendal nerve palsy.

Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach.

BACKGROUND: Preliminary reports have indicated that selected scaphoid nonunions-i.e., those that are well aligned and without extensive sclerosis or bone resorption at the nonunion site-can be treated effectively with internal fixation alone. We examined the feasibility of percutaneous fixation in a series of such nonunions. METHODS: A consecutive series of fifteen patients with fibrous union or nonunion of a carpal scaphoid fracture with minimal sclerosis or resorption at the nonunion site were treated with rigid fixation alone (without bone graft) with a headless compression screw inserted with a dorsal percutaneous technique. RESULTS: Clinical examination, standard radiographs, and computed tomography scans confirmed union in all patients at an average of fourteen weeks. Nonunions treated less than six months after the injury healed faster than those treated later (p < 0.02). According to the Mayo modified wrist score, there were twelve excellent and three good results. CONCLUSIONS: The results in our series were due to careful examination and grading of the scaphoid nonunions preoperatively. The findings in this small series support the observation in earlier reports that percutaneous repair of selected scaphoid nonunions requires only rigid fixation to achieve healing.

Infrainguinal bypass conduit: autogenous or synthetic--a national perspective.

Numerous studies have compared autogenous versus synthetic grafts for infrainguinal bypasses. Synthetic grafts are associated with shorter operating times, comparable reimbursement, and despite inferior patency rates, remain in frequent use. Therefore, this study was undertaken in an effort to characterize, from a national perspective, the practice patterns and the drivers of practice variation in the use of synthetic grafts for infrainguinal bypass. Two data sets were obtained: 1) Medicare billings of infrainguinal bypasses in 49 states, years 1995 through 1997 (number of procedures, 254,677). Procedures were defined by nine CPT billing codes. 2) Hospitals over 150 beds in six states (CA, CO, CT, IA, MN, MS) were asked for volume statistics on the same CPT codes. Data were received from 27 institutions, comprising 1,063 procedures. Variations in graft use were analyzed by hospital type (teaching versus non-teaching) and correlated with the prevalence of diabetes mellitus and smoking. Nationwide, 41% of infrainguinal bypasses in 1997 were performed using synthetic grafts. Interstate synthetic conduit use ranged from 27% to 80%. These differences were similar for bypasses to popliteal or infrapopliteal vessels. Admission to a teaching hospital was associated with a lower use of synthetic grafts (21% vs 51%, odds ratio 0.26, p<0.0001). No correlation was seen between the prevalence of diabetes mellitus or smoking, and synthetic graft use. Synthetic graft use was significantly lower at teaching hospitals, and there was substantial interstate and intrastate variations. These findings suggest that there is wide variation in practice patterns. Further studies appear warranted to define the role of patient demographics and physician preference in explaining these differences.