Flexor Tenosynovial Fistula as a Complication after Endoscopic Trigger Finger Release: A Case Report.

OBJECTIVE: We report a rare case of flexor tenosynovial fistula secondary to endoscopic release of the A1 pulley for treatment of trigger finger. CASE PRESENTATION: A 72-year-old woman underwent endoscopic release of the A1 pulleys of her left ring and right middle fingers. Nine days after surgery, the wound at the base of the proximal phalanx of the ring finger (distal portal) remained open and a clear liquid discharge was seen. The volume of discharge increased with active finger motion. However, there was no evidence of infection. The patient was diagnosed with tenosynovial fistula as a complication of endoscopic release of the A1 pulley. At day 30, the fistula and drainage persisted and the condition was managed by surgical excision of the fistula and primary closure. The wound then healed completely. CONCLUSION: Our report alerts hand surgeons to the potential development of flexor tenosynovial fistula as a very rare complication following endoscopic release of the A1 pulley for the treatment of trigger finger.

Buried bumper syndrome: A critical analysis of endoscopic release techniques.

Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the "push" and the "push and pull T" techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.

Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions?

Carpal tunnel syndrome (CTS) is a multifactorial compression neuropathy. It is reported to be very common and rising globally. CTS's treatment varies from conservative measures to surgical treatments. Surgery has shown to be an effective method for more severe cases. However few unclear aspects and room for further research and improvements still remains. We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS. The simple algorithm of leaving the choice of the surgical method to surgeons' preference and experience (together with consideration of patients' related factors) seem to be the best available option, which is supported by the most recent metanalysis and systematic reviews. We suggest that surgeons (unless in presence of precise indications towards endoscopic release) should tend to perform a minimally invasive open approach release, favoring the advantage of a better neurovascular structures visualization (and a consequent higher chance to perform a complete release with long term relief of symptoms) instead of favoring an early reduction (in the first postoperative days) of immobilization and pain. Research towards a universally accepted standardization should be aimed for by the researchers, who have failed to date to sufficiently limit bias and limitations.

Sonographic Follow-Up of Patients With Cubital Tunnel Syndrome Undergoing in Situ Open Neurolysis or Endoscopic Release: The SPECTRE Study.

Background:The measurement of cross-sectional area (CSA) is a diagnostic tool to detect entrapments syndrome. The aim of this study was to compare the clinical outcome in elbows undergoing endoscopic and "in situ" open cubital tunnel release for cubital tunnel syndrome (CuTS) using ultrasound-related changes in the largest CSA of the ulnar nerve. The purpose is to determine the association between clinical outcome and CSA. Methods: From May 2011 to April 2016, 60 patients with CuTS were prospectively followed and not randomly divided in two groups: 30 patients undergoing an endoscopic release (ER) and 30 patients with "in situ" open neurolysis (OR). A sonographic examination was performed by the senior authors at baseline and 3, 6, and 12 months after surgical decompression. Results: CSA values were statistically significantly lower in the ER. Hand grip strength difference with Jamar test was not statistically significant a 12 months (39 kg vs 27 kg). Static-2 point discrimination test difference was only statistically significant lower in the endoscopic group at 3, 6 and 12 months but not clinically relevant (5 mm vs 6 mm). The American Shoulder and Elbow Surgeons-Elbow questionnaire (ASES-e) function score, ASES-e Pain score, and ASES-e Satisfaction score were not statistically significant different between the two groups at 3, 6, and 12 months post operatively. Conclusions: The study confirms that in spite of lower values of CSA in the ER, there is not a statistically significant difference between the two techniques in terms of subjective outcomes. Ultrasound (US) measurements seem to have a limited value in clinical results of patients treated for entrapment neuropathy of the ulnar nerve.Type of study/LOE: Prognostic Level III.

Endoscopic Carpal Tunnel Release: Indications, Technique, and Outcomes.

Carpal tunnel is the most common peripheral compressive neuropathy. Nonoperative management may provide temporary alleviation of symptoms, but in most cases surgical decompression is warranted. There are a multitude of approaches ranging from open release under general anesthesia to wide awake in-office endoscopic carpal tunnel release. The present article describes the technical considerations for the single incision, antegrade approach to endoscopic carpal tunnel release using the SEGWay system and technique.

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Clinical results of a new technique using an endoscopic carpal tunnel release device.

Exertional compartment syndrome of the forearm is a rare pathology, occurring almost exclusively in motorcycle racers. The results of endoscopic techniques are similar to those of open fasciotomies, but they are less invasive and leave smaller scars. The aim of our study was to present a new endoscopic technique for superficial fasciotomy using the Agee® system and to describe the results. This was a single-center, retrospective descriptive study of 21 patients (36 forearms) operated on between 2006 and 2016. All patients but one were competitive motorcycle racers. The mean operating time was 38.2min (standard deviation (SD), 10.5min). The QuickDASH score was 23.3±10.2% preoperatively versus 1±2% postoperatively (mean±SD). Among the 18 patients who came back for a follow-up visit after 4.9±2.7 years, 17 (94%) were satisfied or very satisfied. The mean time before returning to sport was 4.3 weeks (SD, 1.8 weeks), 9 patients (50%) at the same level as before surgery, 8 (44%) at a higher level, and one at a lower level. There were a few minor complications (superficial vascular lesions, hematoma, transitory hypoesthesia) and symptoms recurred in two patients. Our technique yields outcomes similar to those of other published endoscopic procedures and allows early return to sport. It has the advantage of being based on the Agee endoscope, which is commonly used to treat carpal tunnel syndrome, making the procedure easy to master.

Recent Advances in the Understanding and Management of Carpal Tunnel Syndrome: a Comprehensive Review.

PURPOSE OF REVIEW: Carpal tunnel syndrome (CTS) is an entrapment neuropathy that involves the compression of the median nerve at the wrist and is considered the most common of all focal entrapment mononeuropathies. CTS makes up 90% of all entrapment neuropathies diagnosed in the USA and affects millions of Americans. RECENT FINDINGS: Age and gender likely play a role in the development of CTS, but additional studies may further elucidate these associations. Of known associated risk factors, diabetes mellitus seems to have the greatest association with CTS. One of the most commonly reported symptoms in CTS is a "pins-and-needles" sensation in the first three fingers and nocturnal burning pain that is relieved with activity upon waking. Treatment for CTS is variable depending on the severity of symptoms. Conservative management of CTS is usually considered first-line therapy. In cases of severe sensory or motor deficit, injection therapy or ultimately surgery may then be considered. Still CTS is often difficult to treat and may be reoccurring. Novel treatment modalities such as laser and shockwave therapy have demonstrated variable efficacy though further studies are needed to assess for safety and effect. Given the unknown and potentially complex etiology of CTS, further studies are needed to explore combinations of diagnostic and therapeutic modalities.

Dedifferentiated Liposarcoma in a Giant Esophageal Polyp: A Case Report and Review of the Literature.

Soft tissue sarcomas represent an extremely rare cause of esophageal masses, and undifferentiated sarcomas are rarer. The proportion of dedifferentiated liposarcomas (DDL) is even lower. The case of a 58-year-old male who complained of dysphagia and was found to have an 18-centimeter long esophageal mass/polyp on esophagogastroduodenoscopy is presented. The lesion was resected endoscopically and a diagnosis of DDL was confirmed by fluorescence in situ hybridization. Due to its rarity, the treatment experience with esophageal DDLs is limited. However, based on our experience, endoscopic resection of the lesion can be considered as the treatment of choice when feasible. We performed a review of the literature to identify and analyze similar reported cases.

Comparison between single portal endoscopic and 1-cm open carpal tunnel release.

Given the controversy about the best surgical technique for carpal tunnel release, this study tested the hypothesis that no significant differences would be observed between single-portal endoscopic release and a short, 1-cm incision open release in a large sample of patients. Consecutive patients were assigned to one of the two techniques. Preoperative and postoperative measurements included grip and pinch strength, a visual analog scale for pain and a satisfaction questionnaire. Eighty-seven patients completed the study: 35 with an endoscopic release and 52 with an open release. Both techniques were effective and safe: grip and pinch strength decreased 1 month after surgery in both techniques but improved significantly at 6 and 12 months (P < 0.05) while the complication rate was low. Subjective results were judged to be "excellent or good" by more than 90% of patients in both groups. No significant between-technique differences in outcomes were observed thus, surgical decisions may be based on criteria other than effectiveness. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Endoscopic cubital tunnel release: a systematic review.

INTRODUCTION: Theoretical advantages of endoscopic cubital tunnel release are the short incision, lower risk of nerve damage, reduced manipulation of the nerve and possible faster recovery. SOURCES OF DATA: We systematically searched Medline (PubMed), Web of Science and Scopus databases using the following keywords: 'endoscopic ulnar nerve', 'endoscopic cubital nerve', 'endoscopic ulnar compression' and 'endoscopic ulnar neuropathy'. Twenty-one studies were included in this review. The quality of the studies was assessed using the Coleman Methodological Score. AREAS OF AGREEMENT: Endoscopic release is effective for cubital tunnel entrapment and allows adequate visualization of the site of entrapment. There is a negative association between the severity of the compression and reported outcomes. Injury to the medial branch of the antebrachial cutaneous nerve is less frequent thanks to the limited dissection. The most frequent complication is the development of a hematoma. AREAS OF CONTROVERSY: It is unclear whether ulnar nerve instability is a contraindication to simple decompression. GROWING POINTS: The shorter time to return to work and the cosmetic appearance of the scar can be considered advantages of the endoscopic technique. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need to perform randomized clinical trials with common and validated scoring system with a longer duration of follow-up. The literature pertinent to endoscopic cubital tunnel release is lacking in the evaluation of the learning curve. Further investigations are necessary to assess the role of ulnar nerve instability.

Endoscopic plantar fasciotomy versus injection of platelet-rich plasma for resistant plantar fasciopathy.

BACKGROUND: Resistant plantar fasciopathy is a common orthopedic problem. AIM: Comparing two different methods of treatment. METHODS: Fifty patients with chronic resistant plantar fasciopathy were divided into two groups. The first included 23 patients treated by endoscopic release of plantar fascia (EPF) and the second included 27 patients treated by injection of platelet-rich plasma (PRP). RESULTS: In the EPF group, the average VAS improved from 8.28 to 2.35. The average AOFAS improved from 65 to 94. In the PRP group, average VAS improved from 8.22 to 2.9 and the average AOFAS improved from 66 to 92. CONCLUSION: Both methods gave comparable results at late follow-up.

Artrosis patelofemoral: tratamiento quirúrgico no protésico / Patellofemoral osteoarthritis. Non-prosthetic surgical treatment

La artrosis patelofemoral es una entidad clínica frecuente y muy incapacitante. Numerosos tratamientos han sido propuestos para el tratamiento quirúrgico de esta patología cuando fracasa el tratamiento ortopédico. Los hemos dividido en tratamientos quirúrgicos menores (liberación retináculo lateral- resección osteofito lateral y resección de la faceta lateral) y mayores (osteotomía de la TAT-cultivo de condrocitos- remplazos articulares). El objetivo de este trabajo es realizar una actualización de esta entidad clínica, y presentar una serie de casos mostrando la experiencia personal en el manejo de esta patología. Nivel de Evidencia: V

Patellofemoral osteoarthritis is a common and very disabling clinical entity. Several treatments have been proposed for the surgical treatment of this disease when the orthopedic one fails We’ve divided these treatments into minor surgery (lateral retinaculum release- laterally osteophyte resection and resection of the lateral facet) and major (osteotomy TAT-ACI- joint replacements). The aim of this work is an update of this clinical entity, and presents a series of cases showing personal experience in the management of this condition. Evidence Level: V

Artrosis patelofemoral: tratamiento quirúrgico no protésico / Patellofemoral osteoarthritis. Non-prosthetic surgical treatment

La artrosis patelofemoral es una entidad clínica frecuente y muy incapacitante. Numerosos tratamientos han sido propuestos para el tratamiento quirúrgico de esta patología cuando fracasa el tratamiento ortopédico. Los hemos dividido en tratamientos quirúrgicos menores (liberación retináculo lateral- resección osteofito lateral y resección de la faceta lateral) y mayores (osteotomía de la TAT-cultivo de condrocitos- remplazos articulares). El objetivo de este trabajo es realizar una actualización de esta entidad clínica, y presentar una serie de casos mostrando la experiencia personal en el manejo de esta patología. Nivel de Evidencia: V (AU)

Patellofemoral osteoarthritis is a common and very disabling clinical entity. Several treatments have been proposed for the surgical treatment of this disease when the orthopedic one fails WeÆve divided these treatments into minor surgery (lateral retinaculum release- laterally osteophyte resection and resection of the lateral facet) and major (osteotomy TAT-ACI- joint replacements). The aim of this work is an update of this clinical entity, and presents a series of cases showing personal experience in the management of this condition. Evidence Level: V (AU)

An anatomical basis for endoscopic cubital tunnel release and associated clinical outcomes.

PURPOSE: To study the ulnar nerve in fresh-frozen cadavers as related to endoscopic release of the cubital tunnel and to present a retrospective review of patients treated with decompression via endoscopic visualization. METHODS: To further our understanding of relevant anatomy, we dissected 26 cadaver limbs. We paid special attention to fascial membranes as potential sites of constriction as well as the position of nerves, vessels, and aberrant anatomy. These findings facilitated our understanding of the extent of release in 80 patients (92 cases) with endoscopic cubital tunnel simple decompression. Outcome measures included Disabilities of the Arm, Shoulder, and Hand score, Gabel and Amadio score, and grip and pinch strengths. RESULTS: We noted fascial bands proximal to the medial epicondyle in 12 of 26 cadaver specimens, 2 of which could be the so-called arcade of Struthers. We observed a high degree of variability in the anatomy of the flexor pronator aponeurosis distal to the medial epicondyle. Where present (n = 10), medial antebrachial cutaneous nerve branches crossed the ulnar nerve at an average distance of 2.9 cm from the medial epicondyle (range, 1.0-4.5 cm). Aberrant structures were noted in 8 of the 26 specimens, including an anconeus epitrochlearis muscle in 2 specimens, a basilic vein crossing the ulnar nerve in 4 specimens, and an accessory origin of the medial head of the triceps from the medial intermuscular septum in 2 specimens. In the clinical portion of this study, the average Disabilities of the Arm, Shoulder, and Hand score before surgery was 49 (n = 34) and after surgery was 25 (n = 56). The Gabel and Amadio outcome scores were 24 excellent, 40 good, 25 fair, and 3 poor (n = 92). Average follow-up was 8.2 months (range, 0.1-35 mo). CONCLUSIONS: Cadaveric dissections shed light on vulnerable anatomical structures during release, including branches of the medial antebrachial cutaneous nerve, ulnar nerve, brachial artery, fascial bands, and basilic vein. The high degree of anatomical variability in this study highlights the advantage of endoscopic visualization in allowing surgeons to minimize surgical trauma. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Atrapamiento del nervio ciático en el espacio subglúteo: tratamiento endoscópico / Deep gluteal syndrome. Endoscopic treatment

Se ha sugerido el término síndrome de glúteo profundo (deep gluteal syndrome) (SGP) para definir la compresión del nervio ciático en la región anatómica del espacio glúteo, o aquellas ciáticas no discogénicas con origen en esta región. Este síndrome tiene una alta prevalencia pero un bajo diagnóstico. Existen numerosas causas que pueden originar su afectación y compresión a nivel de dicho espacio. El uso rutinario de los test de evaluación, junto con una sospecha diagnóstica, determinará la incidencia real de este síndrome. La cirugía abierta ha sido descripta y utilizada como tratamiento. El tratamiento endoscópico es efectivo y disminuye el índice de morbilidad y eficacia en comparación con la cirugía abierta. El objetivo del trabajo es presentar una actualización de las características clínicas, test diagnósticos, métodos complementarios, causas y alternativas de tratamiento del SGP, haciendo hincapié en los detalles técnicos del procedimiento endoscópico.(AU)

The term Deep Gluteal Syndrome (DGS) has been suggested to define the compression of the sciatic nerve in the anatomical region of the gluteal space, or those ciatic non-discogenic pain with origin in this region. Pathology that is presented with a high prevalence, but at the moment underdiagnosed. There are numerous causes that can originate their affectation and compression at level of this space. The routine use of the evaluation test, together with a diagnostic suspicion, it will determine the real incidence of this problem. The open surgery has been described and used as treatment. The endoscopic treatment is effective and adds less morbidity and effectiveness in comparison with the open surgery. The objective of this article is to present an upgrade of the clinical features, diagnostic test, complementary methods, causes and alternative of treatment of the DGS, making stress in the surgical technique of the endoscopic release.(AU)

Atrapamiento del nervio ciático en el espacio subglúteo: tratamiento endoscópico / Deep gluteal syndrome. Endoscopic treatment

Se ha sugerido el término síndrome de glúteo profundo (deep gluteal syndrome) (SGP) para definir la compresión del nervio ciático en la región anatómica del espacio glúteo, o aquellas ciáticas no discogénicas con origen en esta región. Este síndrome tiene una alta prevalencia pero un bajo diagnóstico. Existen numerosas causas que pueden originar su afectación y compresión a nivel de dicho espacio. El uso rutinario de los test de evaluación, junto con una sospecha diagnóstica, determinará la incidencia real de este síndrome. La cirugía abierta ha sido descripta y utilizada como tratamiento. El tratamiento endoscópico es efectivo y disminuye el índice de morbilidad y eficacia en comparación con la cirugía abierta. El objetivo del trabajo es presentar una actualización de las características clínicas, test diagnósticos, métodos complementarios, causas y alternativas de tratamiento del SGP, haciendo hincapié en los detalles técnicos del procedimiento endoscópico.

The term Deep Gluteal Syndrome (DGS) has been suggested to define the compression of the sciatic nerve in the anatomical region of the gluteal space, or those ciatic non-discogenic pain with origin in this region. Pathology that is presented with a high prevalence, but at the moment underdiagnosed. There are numerous causes that can originate their affectation and compression at level of this space. The routine use of the evaluation test, together with a diagnostic suspicion, it will determine the real incidence of this problem. The open surgery has been described and used as treatment. The endoscopic treatment is effective and adds less morbidity and effectiveness in comparison with the open surgery. The objective of this article is to present an upgrade of the clinical features, diagnostic test, complementary methods, causes and alternative of treatment of the DGS, making stress in the surgical technique of the endoscopic release.

Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months.

BACKGROUND: Cubital tunnel syndrome is the second most frequent entrapment syndrome. Physiopathology is mixed, and treatment options are multiple, none having yet proved superior efficacy. OBJECTIVES: The present retrospective multicenter study compared results and rates of complications and recurrence between the 4 main cubital tunnel syndrome treatments, to identify trends and optimize outcome. MATERIALAND METHODS: Patients presenting with primary clinical cubital tunnel syndrome diagnosed on electroneuromyography were included and operated on using 1 of the following 4 techniques: open or endoscopic in situ decompression, or subcutaneous or submuscular anterior transposition. Four specialized upper-limb surgery centers participated, each systematically performing 1 of the above procedures. Subjective and objective results and rates of complications and recurrence were compared at end of follow-up. RESULTS: Five hundred and two patients were included and 375 followed up for a mean 92 months (range, 9-144 months); 103 were lost to follow-up and 24 died. Whichever the procedure, more than 90% of patients were cured or showed improvement. There was a single case of scar pain at end of follow-up, managed by endoscopic decompression; there were no other long-term complications. None of the 4 techniques aggravated symptoms. There were 6 recurrences by end of follow-up: 1 associated with open in situ decompression and 5 with submuscular transposition. CONCLUSION: Surgery was effective in treating cubital tunnel syndrome. Submuscular anterior transposition was associated with recurrence. In contrast to literature reports, subcutaneous anterior transposition, which is a reliable and valid technique, was not associated with a higher complication rate than in situ decompression. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective.

Endoscopic release of the cubital tunnel.

It is safe to say that in situ decompression of the ulnar nerve in cubital tunnel syndrome has been demonstrated to achieve equivalent functional results when compared with more elaborate techniques, such as decompression with nerve transposition. The evolution toward procedures associated with less patient morbidity is reflected by the introduction of endoscopic techniques for the treatment of cubital tunnel syndrome. The authors have incorporated the endoscopic approach as proposed by Hoffmann and Siemionow into their practice and have obtained favorable results. Although the skin incision can frequently be kept to a minimum (<2 cm), superior visualization associated with this approach allows for in situ decompression of the ulnar nerve along a distance of up to 30 cm. Despite the extent of decompression performed, operative morbidity is minimal, with return to full duty being the rule even in manual laborers within 10 to 14 days postoperatively.

Endoscopic versus open release in patients with de Quervain's tenosynovitis: a randomised trial.

The purpose of this study was to compare the outcome and complications of endoscopic versus open release for the treatment of de Quervain's tenosynovitis. Patients with this condition were randomised to undergo either endoscopic (n = 27) or open release (n = 25). Visual Analogue Scale (VAS) pain and Disabilities of Arm, Shoulder, and Hand (DASH) scores were measured at 12 and 24 weeks after surgery. Scar satisfaction was measured using a VAS scale. The mean pain and DASH scores improved significantly at 12 weeks and 24 weeks (p < 0.001) in both groups. The scores were marginally lower in the endoscopic group compared to the open group at 12 weeks (p = 0.012 and p = 0.002, respectively); however, only the DASH score showed a clinically important difference. There were no differences between the groups at 24 weeks. The mean VAS scar satisfaction score was higher in the endoscopic group at 24 weeks (p < 0.001). Transient superficial radial nerve injury occurred in three patients in the endoscopic group compared with nine in the open release group (p = 0.033). We conclude that endoscopic release for de Quervain's tenosynovitis seems to provide earlier improvement after surgery, with fewer superficial radial nerve complications and greater scar satisfaction, when compared with open release.