What Patient-related Factors are Associated with an Increased Risk of Surgery in Patients with Stenosing Tenosynovitis? A Prospective Study.

BACKGROUND: Numerous patient-related risk factors have been identified as contributors to patient progression to operative treatment of stenosing tenosynovitis (STS). Identifying patients most at risk of undergoing surgery after receiving a corticosteroid injection would enable health care providers to identify patients most likely to benefit from nonsurgical treatment. QUESTIONS/PURPOSES: (1) What proportion of prospectively enrolled patients with a new diagnosis of STS did not require further intervention after a first, second, or third injection when offered up to three corticosteroid injections? (2) Which identifiable risk factors present at the initial evaluation in patients with STS are associated with the patient opting for surgical release after a trial of one, two, or three corticosteroid injections? METHODS: One hundred ninety-six patients with a presumed diagnosis of STS were evaluated between March 2014 and June 2015, and 160 patients with 186 affected fingers were prospectively enrolled after a new diagnosis of STS was made during the study period. STS was diagnosed by assessing for tenderness at the A1 pulley, passive or active triggering, and the absence of other confounding diagnoses. Only the affected finger received a corticosteroid injection, and these patients were followed up during the study period. Patients were followed for 2 years, and 135 of the 160 patients (84%) completed the final followup. Patients with recurrent symptoms were treated with up to three corticosteroid injections before undergoing A1 pulley release, although patients could elect to undergo surgery at any time. Bivariate comparisons and a multivariate logistic regression analysis were used for independent fingers (one per participant) to identify independent variables associated with progression to surgery after injection. The time between treatments (between injection and subsequent injection or between injection and surgery) for those with recurrent symptoms was also calculated. Information collected from the last time the patient could be contacted was carried forward in the analysis for all 160 patients. RESULTS: No further treatment was sought after the first, second, and third injections by 81 of 160 (51%), 16 of 45 (37%), and three of 10 patients (30%), respectively; 100 of 160 patients (63%) did not pursue further intervention. After the first, second, and third injections, 36 of 160 patients (23%), 17 of 43 patients (40%), and seven of 10 of patients, respectively, did not respond to treatment. After controlling for 21 potentially confounding patient- and disease-related variables, we found that only two risk factors at the initial presentation were protective against eventual progression to surgery: osteoarthritis in the fingers (odds ratio [OR], 0.26 [95% CI, 0.085-0.786]; p = 0.017) and a longer duration of symptoms (OR, 0.58 [95% CI, 0.38-0.89]; p = 0.012). There was no association between progression to surgery and hand dominance, finger type (thumb or other), whether the patient had diabetes, or whether the affected finger was one of multiple affected fingers. Patients who presented again for intervention (injection or surgery) did so at a mean of 153 ± 94 days. CONCLUSIONS: Although patients should be counseled that their risk of progressing to surgery after an initial corticosteroid injection is lower than for subsequently administered injections for recurrent symptoms, nonoperative treatment should not be bypassed for patients with any of the studied risk factors. LEVEL OF EVIDENCE: Level II, therapeutic study.

Bilateral snapping biceps femoris tendon: a case report and review of the literature.

Snapping biceps femoris tendon is an uncommon cause of lateral knee pain. We report the case of a 15-year-old athlete with bilateral snapping biceps femoris tendons, painful over his right lateral leg during exercise. He underwent elective exploration of the right knee which revealed an accessory biceps femoris tendon with attachment to the anterolateral tibia. The accessory tendon was released and reinserted onto the fibular head with a Krackow suture. There were no perioperative complications, and he returned to full sporting activities within 3 months. We describe the operative technique used and summarise the existing literature. Restoring the anatomy with release of the accessory tendon and reinsertion onto the fibular head is an effective technique in the management of knee pain due to snapping biceps femoris tendon. Other approaches include simple release of the anomalous tendon without reinsertion or partial resection of the fibular head. Partial resection of the fibular head is the only technique described in the literature with complication requiring a further operation on the same site. There remains a paucity of evidence in the literature regarding long-term outcomes required to inform the best operative approach. Further anatomical, intraoperative and radiological studies are required to delineate the true pathology of this condition.

Anomalous course and stenosing tenosynovitis of the extensor pollicis longus tendon at the radial styloid process: A case report.

RATIONALE: Anomalous course and tenosynovitis of extensor pollicis longus (EPL) tendon is a rare condition that presents clinical symptoms very similar to de Quervain's disease. Herein we report a case of anomalous course and tenosynovitis of the extensor pollicis longus (EPL) tendon associated with symptoms of de Quervain's disease. PATIENT CONCERNS: A 44-year-old right-handed man visited the clinic because of radial pain associated with the left wrist, which was aggravated during the previous 10 days. The patient tested positive on the Finkelstein's test and displayed a limited range of motion of the left wrist. Motion of the thumb and wrist aggravated pain. DIAGNOSES: Magnetic resonance imaging (MRI) of the left wrist suggested mild tenosynovitis at the third extensor compartment and intersection syndrome. However, clinical symptoms failed to match the MRI findings. INTERVENTIONS: A zig-zag skin incision on the radial styloid process was made. The operative findings revealed stenosing tenosynovitis with partial tearing. Retraction of the tendon extended the thumb interphalangeal joint, suggesting that the tendon was the EPL tendon rather than EPB tendon. After operation, we reviewed the MRI of the patient, which revealed that the oblique course of the EPL tendon originated from the ulnar side of the forearm to the radial styloid at the radial and proximal site of Lister's tubercle. No EPB tendon was present. OUTCOMES: At 12 months of follow-up, the patient's radial styloid process was completely asymptomatic and resumed full daily activities. LESSONS: Anomalous course of the EPL tendon is rarely reported associated with similar symptoms of de Quervain's disease. However, the knowledge and understanding of this potential anomaly in the course of EPL tendon is very important for the treatment of de Quervain's disease to decrease patient dissatisfaction after surgery.

Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis.

BACKGROUND: The aim of the present study is to determine whether an animation glove can be utilized to provide a reliable and reproducible assessment of dynamic hand function and whether this assessment is altered in the setting of hand pathology. METHODS: Ten subjects without known hand pathology and 11 subjects with known stenosing tenosynovitis were assessed on tasks involving hand function at varied speeds, including forceful and gradual making of a fist and the quick and slow grip of a baseball using an animation glove to record range of motion and measures of velocity (CyberGlove II). RESULTS: In normal subjects, peak extension and flexion velocity of the index and middle finger was highest in the metacarpophalangeal and lowest in the distal interphalangeal; however, the converse was true in the ring finger. In those subjects with stenosing tenosynovitis, the animation glove was able to detect a triggering event during assessment. Furthermore, there was a significant decrease in the maximum velocity of the proximal interphalangeal joint observed with the slow fist task in both flexion and extension (55%, P < .01) in the affected hand when compared with the unaffected hand. CONCLUSIONS: The CyberGlove II can be utilized in the dynamic functional analysis of the hand and is able to detect a triggering event in subjects with known stenosing tenosynovitis. Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology.

Síndrome de Haglund. A propósito de 2 casos / Haglund's syndrome. Two case reports

El síndrome de Haglund es una causa de atrapamiento tendino-bursal posterior del talón, producida por una exostosis posterosuperior del calcáneo, denominada deformidad de Haglund, asociada a tendinitis aquílea y bursitis retrocalcánea. Su patogenia es desconocida. Se presentan 2 casos, diagnosticados clínicamente, confirmados radiológicamente, y tratados conservadoramente uno y con cirugía el otro. El diagnóstico se realiza por la clínica y por las imágenes radiológicas con el método de medición de las líneas de inclinación paralelas, en una radiografía lateral del tobillo. El tratamiento inicial suele ser conservador e incluye antiinflamatorios o analgésicos, fisioterapia y zapatos con talón abierto y sin tacón alto. Si el tratamiento conservador no alivia el dolor, puede ser necesaria la cirugía (AU)

Haglund's syndrome produces posterior impingement of the heel, which is caused by a posterosuperior calcaneal exostosis, known as Haglund's deformity, associated with Achilles tendinitis and retrocalcaneal bursitis. Its pathogenesis is unknown. We report two cases that were diagnosed clinically and confirmed radiographically. One patient was treated conservatively and the other underwent surgery. The diagnosis is based on clinical signs and radiological images, using the measurement of the parallel pitch lines, in a lateral radiograph of the ankle. Initial treatment is usually conservative and includes anti-inflammatory or analgesic agents, physiotherapy and low-heeled, open-heeled shoes. If conservative treatment does not relieve the pain, surgery may be necessary (AU)

Effect of Tire Pressure to Physical Workload at Operating a Manual Wheelchair.

It is often experienced that low tire pressure of the wheelchair not only increases running resistance, but also reduces parking brake performance. In this study, the required driving forces for different tire pressures were experimentally measured and evaluated. It was indicated from the result that the wheelchair with proper tire pressure could be run with less workload of wheelchair-user. Then it was also indicated that the wheelchair with a lower tire pressure needed more workload of wheelchair-user even on hard level surface.

Effect of triggering and entrapment on tendon gliding properties following digital flexor tendon laceration: in vitro study on turkey tendon.

The optimal management of partial flexor tendon laceration is controversial and remains a clinical challenge. Abnormal tendon gliding (triggering and entrapment) was assessed at the A2 pulley in 40 turkey tendons in three groups: intact, partially divided (palmar or lateral), and trimmed. Testing was of gliding resistance and friction coefficient at 30° and 70° of flexion, loaded with 2 and 4 N. We observed for triggering and entrapment. The changes in gliding properties were compared and analysed using Wilcoxon matched pair testing. A significant difference was found in the change in gliding properties of intact to lacerated and lacerated to trimmed tendons and between tendons that glided normally compared with those exhibiting triggering or entrapment. This suggests that palmar and lateral lacerations which, through clinical examination and visualization, are found to glide normally should be treated with early mobilization. However, partial lacerations that exhibit triggering or entrapment should be trimmed.

Predictors of stenosing tenosynovitis in the hand and hand-related activity limitations in patients with rheumatoid arthritis.

OBJECTIVES: To identify early predictors of stenosing tenosynovitis in the hand and hand-related activity limitations in patients with rheumatoid arthritis (RA). DESIGN: A longitudinal study of an inception cohort. SETTING: A large outpatient clinic. PARTICIPANTS: Consecutive patients who attended the Early Arthritis Clinic for at least 2 years and fulfilled the American College of Rheumatology criteria for RA at baseline and/or at the 1-year follow-up were invited to participate until 200 patients were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stenosing tenosynovitis, assessed by means of a standardized physical examination. Hand-related activity limitations, assessed with the Disabilities of Arm, Shoulder and Hand questionnaire (DASH). A DASH score above the upper limit of the 95% range of the normative score was defined as abnormal. Prognostic factors: demographic and disease activity-related variables, radiographic damage, the Health Assessment Questionnaire (HAQ) total score and category scores at the 2-year follow-up. RESULTS: The mean age ± SD of the patients was 59.7±10.7 years (75% female). The mean time ± SD between the 2-year follow-up and the assessment of the dependent variables was 3.9±2.7 years. Stenosing tenosynovitis was present in 33%. The median (interquartile range) DASH score was 26.7 (10.8-42.5); 30% were abnormal. Stenosing tenosynovitis was predicted by the HAQ subscale regarding the use of hands (HAQ-hand) at the 2-year follow-up (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.2-4.2). Hand-related activity limitations were predicted by the Disease Activity Score in 28 joints (OR, 1.8; 95% CI, 1.3-2.4) and HAQ-hand (OR, 2.4; 95% CI, 1.3-5.8) at the 2-year follow-up. CONCLUSIONS: Stenosing tenosynovitis in patients with RA was predicted by HAQ-hand at the 2-year follow-up, and hand-related activity limitations were predicted by disease activity and HAQ-hand at the 2-year follow-up.

A lateral meniscus tear incarcerated behind the popliteus tendon: a case report.

A 51-year-old male, sustained an injury to his left knee after being pinned between his motorcycle and a road barrier. In the ER, the patient complained of medial knee pain, and had a significant joint effusion. MRI demonstrated an ACL injury, medial meniscal tear, bone bruising and impaction at the lateral femoral condyle and tibial plateau, and a tear of the posterior horn of the lateral meniscus that was displaced behind the popliteus. Unfortunately, the patient also presented with a deep vein thrombosis and thus could not proceed to the operating room for two months. During this time, scar tissue developed around the lateral meniscus. The purpose of this report is to present an unusual variant of a common injury pattern previously unreported where the posterior horn of the lateral meniscus became incarcerated behind the popliteus tendon and was left in place. It is likely that our patient will develop osteoarthritis in the future, but considering the circumstances he received a favorable early clinical outcome. Early recognition and a mobile fragment are essential restoring a patient's original anatomical features and achieving an optimal clinical outcome.

Interobserver reliability of the Amsterdam Severity Scale in Stenosing Tenosynovitis (ASSiST).

STUDY DESIGN: Interobserver reliability study. INTRODUCTION: A scale was developed to measure the severity of stenosing tenosynovitis: the Amsterdam Severity Scale in Stenosing Tenosynovitis (ASSiST). PURPOSE OF THE STUDY: To study the interobserver reliability of the ASSiST. METHODS: Patients suffering from various impairments in hand function were referred to our outpatient hand clinic. The grading of stenosing tenosynovitis was assessed independently. The observers were blinded for each other's results. The ASSiST distinguishes between a nodular and a diffuse form. The severity was graded from grades 0 to 3. RESULTS: Kappa coefficient for the distinction between the four grades was 0.72 (95% confidence interval [CI] 0.59-0.85) and for the distinction between the nodular and the diffuse forms 0.16 (95% CI 0.13-0.18). CONCLUSION: The ASSiST can be used to reliably assess the severity of stenosing tenosynovitis in both nodular and diffuse forms, but it does not differentiate between these two forms. LEVEL OF EVIDENCE: Not applicable.

Primary tendon sheath enlargement and reconstruction in zone 2: an in vitro biomechanical study on tendon gliding resistance.

PURPOSE: To investigate our hypothesis that primary pulley enlargement and repair using an extensor retinaculum graft will reduce tendon repair gliding resistance. The benefit of pulley enlargement has been tested in experimental animals, but its effect on gliding resistance in vitro using human fingers is not known. METHODS: In vitro gliding resistance in the proximal tendon sheaths (A1 through A3) was measured and compared in 7 cadaver fingers using the method of Uchiyama and colleagues at a fixed 50 degrees over the proximal sheath under 3 conditions: (1) intact tendons with intact proximal sheath; (2) laceration and 2-strand core plus running epitenon repair of the tendons with intact sheath; and (3) repaired tendons with enlargement of the A2 pulley and adjacent proximal sheath by incision and repair with an extensor retinacular graft. Results were analyzed statistically. RESULTS: Gliding resistance increased from an average of 0.44 N +/- 0.07 in the intact condition to an average of 1.51 N +/- 0.23 (a mean increase of 243%) when the tendons were cut and repaired. Enlarging the proximal sheath by sheath incision and graft repair reduced the gliding resistance from the repair condition to 1.04 N +/- 0.15 (a mean decrease of 31%). These changes are statistically significant. CONCLUSIONS: In vitro, repaired tendons had a greater resistance to gliding than that of the intact tendons through the proximal sheath when tested by the method of Uchiyama and colleagues. Enlargement and repair with an extensor retinacular graft of the A2 pulley and adjacent sheath significantly reduced resistance to repaired tendon gliding. These findings support further investigation into the concept that primary pulley enlargement may improve tendon function after repair.

Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome.

PURPOSE: To evaluate the short-term results of 2 different techniques of endoscopic iliopsoas tendon release for the treatment of internal snapping hip syndrome. METHODS: Between January 2005 and January 2007, a consecutive series of patients with the diagnosis of internal snapping hip syndrome was treated with endoscopic release of the iliopsoas tendon. The patients were randomized into 2 different groups. Patients in group 1 were treated with endoscopic iliopsoas tendon release at the lesser trochanter, and patients in group 2 were treated with endoscopic transcapsular psoas release from the peripheral compartment. Hip arthroscopy of both the central and peripheral compartments was performed in both groups using the lateral approach. Associated injuries were identified and treated arthroscopically. Postoperative physical therapy was the same for both series, and each patient received 400 mg of celecoxib daily for 21 days after surgery. Preoperative and postoperative Western Ontario MacMaster (WOMAC) scores and imaging studies were evaluated. RESULTS: Nineteen patients were included in the study: 10 in group 1 (5 male and 5 female; average age, 29.5 years) and 9 in group 2 (8 female and 1 male; average age, 32.6 years). No statistical difference was found in group composition. Associated injuries were found and treated in 8 patients in group 1 and 7 patients in group 2. No statistical difference was found between groups in preoperative WOMAC scores, and every patient in both groups had an improvement in the WOMAC score. Improvements in WOMAC scores were statistically significant in both groups, and no difference was found in postoperative WOMAC results between groups. No complications were seen. CONCLUSIONS: Iliopsoas tendon release at the level of the lesser trochanter or at the level of the hip joint using a transcapsular technique is effective and reproducible. We found no clinical difference in the results of both techniques.

Long-term results of surgical release of de Quervain's stenosing tenosynovitis.

The management of de Quervain's disease (DD) is nonoperative in the first instance, but surgery should be considered if conservative measures fail. We present the long-term results of operative treatment of DD. From July 1988 to July 1998, 94 consecutive patients with DD were treated operatively by a single surgeon. There were 80 women and 14 men. Average age at the time of operation was 47.4 years (range 22-76). The right wrist was involved in 43 cases, the left in 51 cases. All operations were done under tourniquet control with local infiltration anaesthesia using a longitudinal incision and partial resection of the extensor ligament. There were six perioperative complications, including one superficial wound infection, one delayed wound healing, and four transient lesions of the radial nerve. A successful outcome was achieved in all cases with negative Finkelstein's test. Simple decompression of both tendons and partial resection of the extensor ligament with a maximum of 3 mm can be recommended in operative treatment of DD with excellent long-term results.