Snapping Wrist From Bowstringing of the Digital Flexors After Carpal Tunnel Release: A Case Report.

Symptomatic bowstringing of digital flexor tendons is a rare complication of carpal tunnel release (CTR). Two weeks after open CTR, a 47-year-old man with severe carpal tunnel syndrome had relief of his preoperative median paresthesia but complained of new-onset painful snapping of the wrist and transient ulnar paresthesia occurring with wrist dorsiflexion and concomitant digital flexion. Physical examination localized the audible snapping to the hook of hamate (HOH) where manual pressure eliminated the wrist motion-induced snapping and the associated ulnar paresthesia. Wrist radiographs showed stage III scapholunate advanced collapse (SLAC) with marked palmar subluxation of the lunate. Wrist magnetic resonance imaging revealed palmar and ulnar subluxation of the digital flexors over the HOH due to the mass effect of the palmarly displaced lunate and the chronic carpal malalignment. The snapping wrist and accompanying ulnar paresthesia resolved after HOH excision, and no additional treatment for the asymptomatic SLAC wrist deformity was required. Satisfactory clinical outcome was observed at 5-year follow-up.

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery.

¼ Wide-awake local anesthesia no tourniquet (WALANT) technique featuring tumescent infiltration of lidocaine with epinephrine at the operative site has broad application in hand surgery including both soft-tissue and bone procedures.¼ The advantages of wide-awake anesthesia include high patient satisfaction, preserved intraoperative finger and wrist motion, cost-effectiveness, improved operating room efficiency, fewer opioids during recovery, and improved access to hand surgery, which may be performed in an office-based setting without the need for anesthesia personnel.¼ In properly selected patients, use of lidocaine with epinephrine in the hand and fingers is safe. Rare postprocedure digital ischemia may be effectively treated with phentolamine rescue.¼ Barriers to adopting wide-awake anesthesia may be overcome by educating resistant stakeholders, including hospital administrators, nurse leaders, and anesthesia colleagues, about the advantages of the WALANT method.¼ The risk of postoperative complications after hand procedures may be mitigated by using the wide-awake technique instead of regional anesthesia with sedation or general anesthesia.

Coronoid Fracture Reconstruction with Ipsilateral Olecranon Osteoarticular Autograft in the Acute Setting: A Case Report.

CASE: An 18-year-old male polytrauma patient sustained a high-energy posterior fracture dislocation of his left elbow associated with a comminuted and irreparable O'Driscoll type 2 subtype 3 anteromedial facet coronoid fracture. He underwent early coronoid reconstruction using ipsilateral olecranon osteoarticular autograft with incorporation of the sublime tubercle attachment of the medial collateral ligament and repair of the lateral ulnar collateral ligament. A 3-year follow-up revealed a functional, painless, congruent, and stable elbow. CONCLUSION: Early reconstruction of a highly comminuted coronoid fracture may be a useful salvage option for the polytrauma patient, thereby avoiding complications associated with late reconstruction of posttraumatic elbow instability.

Experience With Proximal Median Nerve Entrapment by the Lacertus Fibrosus.

BACKGROUND: Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF). METHODS: In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength. RESULTS: There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated (z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness. CONCLUSIONS: Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE.

Improving Medical Student Mentorship in Orthopaedic Surgery.

Introduction: Owing to limited clinical clerkships and travel restrictions related to COVID-19, recent medical student mentorship in orthopaedic surgery has been impacted negatively. The purpose of this quality improvement (QI) project was to determine if medical student awareness of orthopaedics as a possible career field may be improved through a mentoring program designed and delivered by orthopaedic residents. Methods: A five-resident QI team developed four educational sessions aimed at a medical student audience. Forum topics included: (1) orthopaedics as a career, (2) fracture conference, (3) splinting workshop, and (4) residency application process. Pre- and post-forum surveys were administered to student participants to assess changes in their perceptions regarding orthopaedic surgery. Data derived from the questionnaires were analyzed with nonparametric statistical tests. Results: Of 18 forum participants, 14 were men and 4 were women. A total of 40 survey pairs were collected, averaging 10 per session. In the all-participant encounter analysis, there were statistically significant improvements in all outcome measures including interest in, exposure to, and knowledge of orthopaedics; exposure to our training program; and ability to interact with our residents. Those undecided regarding their specialty demonstrated larger increases in post-forum responses, suggesting that the learning experience was more impactful for that subgroup. Conclusions: This QI initiative was a successful demonstration of orthopaedic resident mentorship of medical students, wherein perceptions of orthopaedics were influenced favorably by the educational experience. For some students with limited access to orthopaedic clerkships or formal one-on-one mentoring, forums like these may be an acceptable alternative.

Clinical Rotation Handbook Promotes Orthopaedic Resident Wellness: A Quality Improvement Study.

Introduction: Transitioning from one clinical rotation to the next may be particularly stressful for orthopaedic residents attempting to navigate new work environments with new faculty mentors and new patients. The purpose of this quality improvement (QI) project was to determine if resident stress could be improved by using a handbook to disseminate key rotation-specific data during quarterly rotation transition periods. Methods: A comprehensive electronic handbook was created by residents to describe each rotation in our orthopaedic training program in terms of: (1) faculty and staff contact data, (2) daily clinic and surgery schedules, (3) resident responsibilities and faculty expectations, and (4) key resources and documents. At rotation transition, a session in the academic schedule was dedicated for outgoing residents to update the handbook and to sign-out to incoming residents. Pre- and post-handbook questionnaires were administered to assess resident perceptions of stress or anxiety, preparedness, and confidence before commencing the new rotation. Nonparametric data derived from the surveys were analyzed using the sign test choosing p < 0.05 for a two-tailed test as the level of statistical significance. Results: Most residents perceived improvements in stress/anxiety, preparedness, and confidence understanding rotation expectations after the handbook was implemented. Changes in these three outcome parameters were statistically significant. Conclusions: This rotation transition QI initiative consisting of a resident-authored, rotation-specific electronic handbook and dedicated verbal sign-out session enhanced resident wellness by decreasing stress, increasing preparedness, and improving confidence among residents starting a new rotation. Similar online resources may be useful for trainees in other specialties.

Experience with Diagnosis and Management of Distal Radioulnar Joint Instability.

Objective The aim of this study is to review our cumulative experience with diagnosis and treatment of distal radioulnar joint (DRUJ) instability and to present our treatment algorithm. Materials and Methods Retrospective review identified 112 patients who had 126 episodes of care for DRUJ instability at a single institution over a 21-year period. Those diagnosed acutely or subacutely were treated with immobilization of the wrist and elbow for 6 weeks, while those with chronic instability had anatomic reconstruction of the dorsal and palmar radioulnar ligaments with tendon autograft or an alternative arthroscopic treatment with our thermal annealing technique. Short-term treatment failures and surgical complications were recorded. Nonparametric statistical tests were used to analyze key long-term outcome measures including ulnar wrist pain and DRUJ stability indicated by the dorsopalmar stress test. Results At mean 7-year follow-up, eight patients in the acute-injury cohort had statistically significant improvements in wrist pain and DRUJ instability ( p < 0.001). In both the 22-patient anatomic reconstruction cohort and the 37-patient arthroscopically treated group, there were also statistically significant improvements in wrist pain and DRUJ stability ( p < 0.001) at mean 9-year follow-up. The majority of patients in all three groups was satisfied with treatment outcome, though some required secondary procedures. Conclusion Early clinical diagnosis of DRUJ instability using the dorsopalmar stress test provides an opportunity for effective nonsurgical treatment. For chronic presentation, we recommend our arthroscopic thermal annealing technique for mild or moderate instability and open anatomic reconstruction of the radioulnar ligaments for severe instability. Level of Evidence This is a Level IV, therapeutic study.

The Original Anatomic Reconstruction of Palmar and Dorsal Radioulnar Ligaments for Distal Radioulnar Joint Instability.

Thirty years ago, the first anatomic reconstruction of the palmar and dorsal radioulnar ligaments for chronic distal radioulnar joint (DRUJ) instability was proposed by Sanders. In this surgical technique, the midpoint of a free tendon autograft is firmly secured in a bony tunnel at the ulnar fovea. The 2 graft limbs anchored at the fovea traverse the DRUJ and are securely woven into the periarticular soft tissues radially, reproducing the ligamentous anatomy while not overconstraining the joint. This report documents the original anatomic DRUJ reconstruction technique described by Sanders and our procedure modifications.

Outcomes after anatomic reconstruction of the radioulnar ligaments for distal radioulnar joint instability.

This retrospective study investigated the clinical outcomes of patients treated for chronic distal radioulnar joint instability with open anatomic reconstruction of the palmar and dorsal radioulnar ligaments. After the midpoint of a tendon graft is anchored at the ulnar fovea, the two graft limbs traverse the distal radioulnar joint. One limb is woven into the palmar wrist capsule and the other is secured to the dorsal wrist capsule and retinaculum to stabilize the joint. Of 30 patients (31 wrists) treated with this technique, 19 were followed longitudinally for a mean of 10 years (range 3-21). In this long-term cohort, there were statistically significant improvements in ulnar-sided wrist pain on the visual analogue scale and in distal radioulnar joint stability on the dorsopalmar stress test. The modified Mayo Wrist Scores were classified as three excellent, 12 good, three fair and one poor. Of the 30 patients studied, failure occurred in four patients, two from graft rupture and two from distal radioulnar joint arthrosis. We conclude that anatomic reconstruction of the palmar and dorsal radioulnar ligaments is an effective treatment for distal radioulnar joint instability and is associated with high satisfaction and durable outcomes.Level of evidence: IV.

Arthroscopic thermal stabilization for distal radioulnar joint instability: 3 to 19 years follow-up.

This retrospective study investigated the clinical outcomes of patients treated for chronic distal radioulnar joint instability with arthroscopic thermal annealing of the superficial radioulnar ligaments, ulnar palmar wrist ligaments, and dorsoulnar wrist capsule using a radiofrequency probe. Sixty patients (62 wrists) were treated over an 18-year period. At mean follow-up of 10 years (range 3 to 19), 30 of 33 patients were satisfied with their surgical outcomes. There were statistically significant improvements in ulnar-sided wrist pain on a visual analogue scale and in distal radioulnar joint stability on the dorsopalmar stress test after surgery compared with preoperative status. The modified Mayo Wrist Score and Quick Disabilities of the Arm, Shoulder, and Hand score of the patients were favourable. Early failure occurred in 11 of 62 wrists. Nine of these 11 wrists needed a secondary procedure. We conclude that arthroscopic thermal shrinkage is effective for the majority of the patients with mild to moderate chronic distal radioulnar joint instability in long-term follow-up. Secondary open ligament reconstruction is an option in the case of early failure.Level of evidence: IV.

Exceptional Regression of Malignant Pleural Mesothelioma with Pembrolizumab Monotherapy.

The lead author with clinical stage I malignant pleural mesothelioma, epithelioid type, highly programmed cell death ligand 1 (PD-L1) positive, and BAP1 negative, experienced a prompt and exceptionally favorable response to pembrolizumab monotherapy. After cessation of treatment due to immune-related endocrinopathies, complete metabolic response on interim PET/CT scan was achieved. Two years after initial diagnosis, unifocal tumor reactivation was addressed with successful pembrolizumab monotherapy rechallenge. Immunotherapy, typically not used as frontline treatment for malignant pleural mesothelioma, may provide an effective and durable response for some patients. Based on this single case study, epithelioid type tumors with strongly positive PD-L1 and BAP1-negative immunohistochemical markers may be well suited for treatment with immune checkpoint inhibitors such as pembrolizumab.

Nonsurgical Treatment for Acute Posttraumatic Distal Radioulnar Joint Instability: A Case Series.

Purpose: We investigated the clinical outcomes of patients with acute posttraumatic distal radioulnar joint (DRUJ) instability who were treated with our nonsurgical protocol. Methods: The electronic database of our community-based orthopedic practice was queried to identify patients with posttraumatic wrist pain and DRUJ instability who presented for treatment less than 6 weeks after injury. Medical records review defined a cohort of 16 patients treated between November, 2000 and December, 2016 with immobilization of the wrist and elbow for 6 weeks and gradual return to full activity at 6 months after injury. Data from the medical records were compiled and analyzed to assess short-term outcomes. Eight patients with a minimum 2-year follow-up completed questionnaires and underwent a wrist-focused examination to assess long-term outcomes. We used Wilcoxon signed-ranks exact test and McNemar chi-square exact test to confirm the statistical significance of observed trends in key outcome measures. Results: At a mean long-term follow-up of 6.7 years, there was statistically significant improvement in ulnar-sided wrist pain and all eight subjects examined demonstrated a negative dorsopalmar stress test indicating improved DRUJ stability. Analysis of the entire cohort showed that 11 of 16 patients (69%) were overall improved with respect to wrist pain and DRUJ stability at final follow-up evaluation. Ulnar-positive variance was a relative contraindication to nonsurgical treatment. Conclusions: Prompt above-elbow immobilization of patients with acute posttraumatic DRUJ instability may result in a good clinical outcome without operative treatment. Type of study/level of evidence: Therapeutic IV.

Outcomes of ulnar nerve anterior transmuscular transposition and significance of ulnar nerve instability in cubital tunnel syndrome.

BACKGROUND: We investigated the experience of a single surgeon with ulnar nerve anterior transmuscular transposition with the patient in the lateral decubitus position for cubital tunnel syndrome. METHODS: The medical records of all patients who underwent primary or revision ulnar nerve anterior transmuscular transposition were screened to define a cohort of 156 patients (162 limbs) for further study of demographic and disease-specific data and retrospective assessment of short-term outcomes. Ulnar neuropathy severity was stratified by McGowan grade. A prospective cohort composed of 49 patients (51 limbs) with a minimum 2-year follow-up volunteered to complete patient outcome surveys, and some presented for an ulnar nerve-focused examination to assess long-term outcomes. RESULTS: The overall patient satisfaction rate was 92%, with statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Outcomes were better for lower McGowan grades than for higher grades and better in primary cases than in revision cases. Ulnar nerve instability was observed in 69 of 162 cases (43%) in this series. A major complication occurred in 7 cases (4.3%), but all were mitigated by contributory patient-related factors. Reoperation for recurrent ulnar paresthesia was required in 4 cases (2.5%). No operations or outcomes were compromised by the lateral decubitus position. DISCUSSION AND CONCLUSION: Ulnar nerve anterior transmuscular transposition in the lateral decubitus position is a good surgical option for primary or recurrent cubital tunnel syndrome and remains our preferred procedure. The high prevalence of ulnar nerve instability observed in this study is a factor worthy of consideration by surgeons and patients weighing the surgical options for ulnar neuropathy at the elbow.

Ulnar Nerve Anterior Transmuscular Transposition in the Lateral Decubitus Position.

Ulnar nerve anterior transmuscular transposition is a well-accepted surgical technique for the treatment of ulnar nerve entrapment or subluxation at the elbow. The procedure, which addresses both compression and traction forces on the nerve, may be performed with the patient in the lateral decubitus position, allowing direct access to and excellent visualization of the ulnar nerve through an incision on the posteromedial aspect of the elbow. This report reviews the surgical indications and contraindications, pertinent anatomy, patient positioning rationale and method, surgical technique, postoperative management, and potential complications for this ulnar nerve transposition procedure. Discussion of the technique and an illustrative case are also provided.