Latissimus Dorsi Tendon Transfer and Superior Capsular Reconstruction for Irreparable, Posterosuperior Rotator Cuff Tears.

BACKGROUND: The purpose of this study was to compare latissimus dorsi tendon transfer (LDTT) and arthroscopic superior capsular reconstruction (SCR) to determine if one is superior to the other regarding improvement in range of motion (ROM) or patient-reported outcomes (PROs). METHODS: A multicenter, retrospective cohort study was conducted on 43 patients with an irreparable, posterosuperior rotator cuff tear who underwent either LDTT or SCR. Preoperative and postoperative forward flexion and external rotation, as well as PROs including ASES, VAS, and SSV, were assessed. Student t-test and chi-square statistical analyses were performed. RESULTS: 16 LDTT, at mean follow-up of 18 months, and 27 SCR, at mean follow-up 15 months, were studied. Mean active forward flexion significantly improved from 85.2° to 137.6° in the SCR cohort (P=0.001). SCR patients demonstrated a significantly greater increase in forward flexion as compared to LDTT patients (52.4° vs 14.1°, P=0.001). Mean active external rotation amongst the LDTT group significantly improved from 41.7° to 61.5° (P=0.032). LDTT demonstrated significantly greater improvement in external rotation as compared to SCR (19.4° vs 0.8°, P=0.011). There were no significant differences in reported ASES, VAS, or SSV scores. CONCLUSION: This study demonstrates successful clinical and patient-reported outcomes with both LDTT and SCR for irreparable, posterosuperior rotator cuff tears, with greater improvement in forward flexion with SCR and greater improvement in external rotation with LDTT.

Prevalence of Carpal Tunnel Syndrome in a Hand Surgeon's Practice.

Purpose Additional methods of diagnosing carpal tunnel syndrome (CTS) are increasingly being investigated, such as ultrasound or diagnostic tools such as carpal tunnel syndrome 6 (CTS-6), and the sensitivity and specificity of these tests are determined by the pretest probably and thereby the prevalence of a condition. It is critical that the prevalence used in these calculations accurately reflects the population undergoing these tests for a true assessment of their quality. Orthopaedic surgeons and, specifically, upper extremity specialists are most often studying these diagnostic methods, and given referral patterns, these physicians likely have a greater prevalence of CTS in their clinics than previously published for only the general population (5%). The purpose of this study is to define the prevalence of CTS in a hand surgery practice consisting of three fellowship-trained orthopaedic hand surgeons for use in future assessing the accuracy of diagnostic tests for CTS among patients presenting to a hand surgeon for evaluation. Methods All the adult patients (≥ 18 years) who had a face-to-face encounter with an orthopaedic surgeon in this practice between January 1 and December 31, 2014 were identified. The ICD-9 code 354.0 was used to identify all patients diagnosed with CTS. The medical records of all patients with ICD-9 code were reviewed and the results of electrodiagnostic testing (EDX) documented. Results A total 56,641 patients were evaluated by the orthopaedic department from January 1 to December 31, 2014. Of these patients, 812 (1.4%) had EDX-confirmed CTS. The prevalence of EDX-confirmed CTS was 0.2% for nonhand orthopaedic specialists and 10.7% for hand specialists. Of those seen by the hand subspecialists, 66% were female, 34% were male with the right hand affected in 42%, left in 26%, and bilateral upper extremities in 32%. Conclusion Current literature demonstrates a prevalence of CTS among the general population of 5%. The authors have demonstrated a prevalence of CTS in an orthopaedic surgical practice to be 1.4% with a prevalence of only 0.2% noted among nonupper extremity orthopaedic specialists. They have determined the prevalence of EDX confirmed CTS in a tertiary referral hand practice to be 10.7%, much higher than the prevalence in the general population. Accurate identification of the prevalence of CTS within these patient groups is critical for statistical analysis of new diagnostic tools being developed to assess for CTS. Level of Evidence Level IV, cross-sectional, prognostic.

A Prospective Comparison of Diagnostic Tools for the Diagnosis of Carpal Tunnel Syndrome.

PURPOSE: Nerve conduction studies (NCS), CTS-6, Wainner, Kamath, and Lo are diagnostic tests that are used to diagnose carpal tunnel syndrome (CTS). To our knowledge, no study has compared the sensitivity and specificity of these 5 tests with one another. The purpose of this study is to compare NCS, CTS-6, Wainner, Kamath, and Lo using clinical diagnosis by a hand fellowship-trained orthopedic surgeon as reference standard. METHODS: A hand fellowship-trained surgeon completed the CTS-6, Wainner, Kamath, and Lo diagnostic tools. Cutoff values for a positive test were based on values in the literature, if available. The NCS were performed by a certified electrodiagnostic physician according the standards of the American Association of Neuromuscular and Electrodiagnostic Medicine and were interpreted using absolute latencies, relative latencies, and combined sensory index. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated for the tests using clinical diagnosis as the reference standard. RESULTS: A total of 408 wrists from 250 patients were analyzed in the study. The NCS had the highest sensitivity (94%) but also the lowest specificity (50%) of any of the diagnostic tests. Using a cutoff of 18, CTS-6 had the highest specificity (99%). The NCS had the highest area under the curve at 74%, followed closely by the Kamath at 69%. CONCLUSIONS: The NCS were traditionally felt to be a strong confirmatory test given their high specificity. However, this prospective series demonstrated that NCS had the lowest specificity of any diagnostic test. CLINICAL RELEVANCE: Consideration should be given to using alternative diagnostic tests/tools based on the results of this study.

Thumb Injuries in Athletes.

Thumb injuries are common in athletes and present a challenging opportunity for upper extremity physicians. Common injuries include metacarpal base fractures (Bennett and Rolando types), ulnar and radial collateral ligament injuries, dislocation of the carpometacarpal and metacarpophalangeal joints, and phalanx fractures. This review, although not exhaustive, highlights some of the most common thumb injuries in athletes. The treating physician must balance pressure from athletes, parents, coaches, and executives to expedite return to play with the long-term well-being of the athlete. Operative treatment may expedite return to play; however, one must carefully weigh the added risks involved with surgical intervention.

Correlating Median Nerve Cross-sectional Area With Nerve Conduction Studies.

PURPOSE: To determine whether there is a correlation between the cross-sectional area (CSA) of the median nerve, as measured using ultrasound, and the distal motor and/or sensory latencies as measured on nerve conduction studies. METHODS: Patients with clinical signs and symptoms of carpal tunnel syndrome were prospectively enrolled in this study. Subjects underwent ultrasound measurement of the CSA of the median nerve at the carpal tunnel inlet by a fellowship-trained hand surgeon, followed by nerve conduction studies (NCS) by a certified electrodiagnostic technician who was blinded to the results of the ultrasound examination. Pearson correlations were performed to compare CSA and NCS. RESULTS: Pearson correlation was r = 0.57 between CSA and distal motor latency and r = 0.47 between CSA and distal sensory latency. Correlation was r = 0.81 between distal motor latency and distal sensory latency. CONCLUSIONS: There is a correlation between CSA of the median nerve and NCS. Further research is necessary to determine which test correlates better with patient symptoms and function. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Staged treatment of high energy midfoot fracture dislocations.

BACKGROUND: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. METHODS: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. RESULTS: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. CONCLUSION: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.