Outcomes of Revisions for Failed Trapeziometacarpal Joint Arthritis Surgery.

PURPOSE: We compare outcomes of revision surgery for trapeziometacarpal (TM) arthritis with outcomes for both primary and revision surgery for TM arthritis reported in the literature. We hypothesized that patients undergoing revision surgery for TM arthritis would demonstrate pain and functional outcome scores that were worse than those of patients undergoing primary TM surgery. METHODS: A retrospective analysis of all patients undergoing revision TM surgery at a single institution from 1995 to 2015 was performed. Eighty-three patients (86 hands) met the inclusion criteria. Of these, 25 patients (27 hands) were available for follow-up via phone survey or clinical examination; 58 patients (59 hands) were available for chart review only. Patients available for phone survey or clinical examination were evaluated with the visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, and the Conolly-Rath evaluation method. Patients available for clinical examination were also evaluated with grip strength, pinch strength, and radiographs. RESULTS: Median follow-up was 8.5 years (range, 2.0-21.2 years). Twenty percent of patients experienced postoperative complications, most commonly pin problems (7%). Of the 27 hands available for interview or clinical examination, 15 were dominant and 12 were nondominant. The average visual analog scale was 28.2 (SD, 29.7). Disabilities of the Arm, Shoulder, and Hand scores averaged 32.0 (SD, 20.8). According to the Conolly and Rath criteria, 10 patients had a good outcome, 7 were fair, and 10 were poor. For the group of 13 patients who underwent physical examination, average adduction was 42° in the affected side versus 51° in the nonaffected side. Radial abduction was 58° in the affected side versus 65° in the nonaffected side. Palmar abduction was 53° versus 85° in each group, respectively. Tip finger pinch was 3.4 kg for the affected hand versus 4.0 kg for the nonaffected side. Key pinch was 4.7 and 5.5 kg, respectively. Grip strength was measured as 22.1 kg in the affected side versus 27.6 kg in the contralateral side when adjusted for dominance. CONCLUSIONS: In our study group, revision surgery for unsuccessful primary TM surgery demonstrated results inferior to those previously reported for primary surgery for TM arthritis but similar to prior studies of revision TM surgery. Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Ligamentum flavum hypertrophy in asymptomatic and chronic low back pain subjects.

PURPOSE: To examine ligamentum flavum thickness using magnetic resonance (MR) images to evaluate its association with low back pain symptoms, age, gender, lumbar level, and disc characteristics. MATERIALS AND METHODS: Sixty-three individuals were part of this IRB-approved study: twenty-seven with chronic low back pain, and thirty-six as asymptomatic. All patients underwent MR imaging and computed tomography (CT) of the lumbar spine. The MR images at the mid-disc level were captured and enlarged 800% using a bilinear interpolation size conversion algorithm that allowed for enhanced image quality. Ligamentum flavum thickness was assessed using bilateral medial and lateral measurements. Disc height at each level was measured by the least-distance measurement method in three-dimensional models created by CT images taken of the same subject. Analysis of variance and t-tests were carried out to evaluate the relationship between ligamentum flavum thickness and patient variables. RESULTS: Ligamentum flavum thickness was found to significantly increase with older age, lower lumbar level, and chronic low back pain (p < 0.03). No difference in ligamentum flavum thickness was observed between right and left sided measurements, or between male and female subjects. Disc height and both ligamentum flavum thickness measurements showed low to moderate correlations that reached significance (p < 0.01). Additionally, a moderate and significant correlation between disc degeneration grade and ligamentum flavum thickness does exist (p <0.001). CONCLUSION: By measuring ligamentum flavum thickness on MR images at two different sites and comparing degrees of disc degeneration, we found that ligamentum flavum thickness may be closely related to the pathogenesis of pain processes in the spine.

Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand.

PURPOSE: To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. METHODS: An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N = 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. RESULTS: 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). CONCLUSIONS: When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis V.