Anatomic Relationship of Hand Intrinsic Tendons at the Metacarpal Head as It Relates to the Diagnosis of Saddle Syndrome: A Cadaveric Study.

PURPOSE: The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation. METHODS: Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion. RESULTS: The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits. CONCLUSIONS: There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas. CLINICAL RELEVANCE: These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML in vivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice.

Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study.

PURPOSE: To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR). METHODS: Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible. RESULTS: The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures. CONCLUSIONS: There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR. CLINICAL RELEVANCE: These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.

Optimal Position of the Bone Anchor for the Internal Brace Suspensionplasty Technique for Thumb Basal Joint Arthroplasty.

PURPOSE: Ligament reconstruction and tendon interposition is a common technique for thumb basal joint arthroplasty. Recently, a variation of this technique, a suture suspensionplasty, has been introduced. The goal of our study was to assess the optimal position of the bone anchor in the thumb metacarpal. We hypothesized that an anchor placed in the radial aspect of the thumb metacarpal base would provide improved stability and resist subsidence more effectively than an ulnar-based thumb anchor. METHODS: Eight fresh-frozen cadaver arms were imaged fluoroscopically in anteroposterior and lateral views centered over the thumb carpometacarpal joint before and after trapeziectomy and after the placement of radial-based and ulnar-based bone anchors. The intermetacarpal angle between the thumb and index metacarpals was measured on all images after the application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, and adduction were measured. Subsidence was calculated as the percentage loss of the trapezial space. RESULTS: Both radially and ulnarly placed internal brace constructs allowed more radial abduction, opposition, and palmar abduction than the pretrapeziectomy constructs. They both also reduced subsidence by approximately 20% to 29% compared with the posttrapeziectomy constructs. Comparing radial to ulnar constructs, motion and subsidence were similar. CONCLUSIONS: There was immediate stability of the thumb with respect to axial load and subsidence after anchor placement, and this was independent of the anchor position. The position of the bone anchor in the thumb metacarpal base did not affect the range of motion. Although the device can limit subsidence, it does not appear to restrict any range of motion of the thumb, irrespective of anchor position. CLINICAL RELEVANCE: This cadaver study can help hand surgeons understand the effect of positioning of bone anchors when performing a specific suture suspensionplasty technique.

Preoperative Exposure to Benzodiazepines or Sedative/hypnotics Increases the Risk of Greater Filled Opioid Prescriptions After Surgery.

BACKGROUND: The effect of the preoperative exposure to controlled substances such as benzodiazepines and sedative/hypnotics on prolonged opioid consumption after hand surgery is not known. QUESTIONS/PURPOSES: (1) Is preoperative exposure to benzodiazepines and sedative/hypnotics associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? (2) Is a positive history of the use of more than one controlled substance, a mood disorder, or smoking associated with greater numbers of filled opioid prescriptions after surgery? (3) Is preoperative exposure to opioids associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? METHODS: Patients undergoing upper extremity surgery at one academic outpatient surgical center were prospectively enrolled. The Pennsylvania Drug Monitoring Program (PDMP) website was used to document prescriptions of opioids, benzodiazepines, and sedative/hypnotics filled 6 months before and after the procedure. Patients were grouped into exposed or naïve cohorts depending on whether a prescription was filled 6 months before surgery. Smoking history (current or previous smoking was considered positive) and a history of mood and pain disorders (as noted in the medical history), were collected from the outpatient and the operating room electronic medical record. RESULTS: After controlling for age, gender, and other confounding variables, we found that a history of exposure to benzodiazepines is associated with a greater number of filled postoperative opioid prescriptions (not-exposed, 1.2 ± 1.3; exposed, 2.2 ± 2.5; mean difference, 1.0; 95% confidence interval [CI], 0.5-1.5; p < 0.001); likewise, exposure to sedative/hypnotics is associated with greater opioid prescription fills (not-exposed, 1.2 ± 1.4; exposed, 2.3 ± 2.9; mean difference, 1.1; 95% CI, 0.3-1.9; p = 0.006). Patients who had used more than one controlled substance had more filled opioid prescriptions when compared with those not using more than one controlled substance (3.9 ± 3.5 versus 2.1 ± 1.2; mean difference, 1.8; 95% CI, 0.8-2.8; p = 0.002); patients with mood disorders also had more filled prescriptions when compared with those without mood disorders (2.0 ± 2.5 versus 0.9 ± .8; mean difference, 1.1; 95% CI, 0.7-1.5; p < 0.001); and finally, smoking history is associated with more filled prescriptions (1.9 ± 2.3 versus 1.2 ± 1.5, mean difference, 0.8; 95% CI, 0-1.4; p = 0.040). CONCLUSIONS: Patients exposed to benzodiazepines and sedative/hypnotics have prolonged use of opioids after surgery. Undergoing outpatient upper extremity surgery and being prescribed an opioid did not change the patterns of controlled substance use. Based on the results of this study, we are now more aware of the potential problems of patients with exposure to controlled substances, and are more attentive about reviewing their history of substance use in the PDMP website, an important resource. In addition, we now provide much more detailed preoperative counseling regarding the use and abuse of opioid medication in patients with exposure to benzodiazepines, sedatives, and those with a smoking history and mood disorders.Level of Evidence Level II, therapeutic study.

Surgical Treatment for Recurrent Dupuytren Disease.

BACKGROUND: Revision procedures for recurrent Dupuytren disease (DD) can be difficult and carry a high risk of complications. Our goal was to describe surgical strategies used for cases of recurrence and report on their outcomes. METHODS: We reviewed 1 surgeon's operative cases for recurrent DD performed at 1 institution. Prior procedures included collagenase injection, percutaneous needle fasciotomy, or open surgical fasciectomy in the same digit or area of the hand. RESULTS: From January 1981 to December 2020, 54 procedures were performed on 33 patients for recurrent DD. Most patients were men (82%), had bilateral involvement (64%) and family history (52%), and some had ectopic disease in their feet (24%). The small finger was involved in 76% of the cases, and the proximal interphalangeal (PIP) joint was involved in 83% of these digits. The procedures included 38 partial fasciectomies (72%), 12 dermofasciectomies (23%), 3 radical fasciectomies (6%), 1 of each needle fasciotomy, ray amputation, and PIP joint arthrodesis (2%). Twenty-three patients (43%) required full thickness skin grafts with an average area of 7.1 cm2 (range: 1-20 cm2). CONCLUSIONS: This study highlights the complexity of recurrent DD case management and found the treatment required for 95% of patients in this series was open partial fasciectomy with or without demofasciectomy. Full thickness skin grafting was necessary in nearly half of the cases.

Early Revision Rate Following Primary Carpal Tunnel Release.

Purpose: The published revision rates after carpal tunnel release (CTR) vary from 0.3% to 7%. The explanation for this variation may not be fully apparent. The purpose of this study was to determine the rate of surgical revision within 1-5 years following primary CTR at a single academic institution, compare it with rates reported in the literature, and attempt to provide explanations for these differences. Methods: We identified all patients who underwent primary CTR at a single orthopedic practice by 18 fellowship-trained orthopedic hand surgeons from October 1, 2015, through October 1, 2020, using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD), 10th Revision, codes. Patients who underwent CTR because of a diagnosis other than primary carpal tunnel syndrome were excluded. Patients who required revision CTR were identified using a practice-wide database query using a combination of CPT and ICD-10 codes. Operative reports and outpatient clinic notes were reviewed to determine the cause of revision. Data on patient demographics, surgical technique (open vs single-portal endoscopic), and medical comorbidities were collected. Results: A total of 11,847 primary CTR procedures were performed during the 5-year period on 9,310 patients. We found 24 revision CTR procedures among 23 patients, resulting in a revision rate of 0.2%. Of 9,422 open primary CTRs performed, 22 cases (0.23%) went on to undergo revision. Endoscopic CTR was performed in 2,425 cases, with 2 cases (0.08%) ultimately undergoing revision. The average length of time from primary CTR to revision was 436 days (range, 11-1,647 days). Conclusions: We noted a substantially lower rate of revision CTR within 1-5 years of primary release (0.2%) in our practice than that noted in previously published studies, although we accept that this does not account for out-of-area migration. There was no significant difference in the revision rates between open and single-portal endoscopic primary CTR. Type of study/level of evidence: Therapeutic III.

Variable expression and incomplete penetrance of developmental dysplasia of the hip: clinical challenge in a 71-member multigeneration family.

Developmental dysplasia of the hip is a crippling condition that affects children and adults. Identical twin studies support a strong causative genetic component. Although clinical tests for newborns can detect gross malformations, it is the subtle malformations that are often not detected, resulting in early onset osteoarthritis of the hip in adults. As a first step in identifying the causative mutation, we have recruited the largest documented affected family with 71 members spanning generations. Clinical and radiographic signs of developmental dysplasia of the hip are described, and the diagnostic challenge of identifying affected family members is discussed.Variable expression of disease allele is evident in several members of the family and greatly contributes to the diagnostic challenge facing clinicians.

Benzodiazepines and Related Drugs in Orthopaedics.

➤: Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants. ➤: The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic. ➤: Benzodiazepines can increase the risk of prolonged opioid use and abuse. ➤: Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications. ➤: Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.

Optimal Position of the Suture Button Suspensionplasty (TightRope) for Thumb Basal Joint Arthritis.

Background: Surgical treatment of basal joint arthritis commonly consists of trapeziectomy followed by various suspensionplasty techniques to provide stability to the thumb ray. Our study goal was to assess the motion and stability of the thumb ray after trapeziectomy and placement of a suture button (Mini TightRope®, Arthrex, Naples, Florida) in a high- or low-angle trajectory. We hypothesized that a low-angle trajectory would yield the greatest stability while providing maximal motion of the thumb. Methods: Eleven fresh-frozen cadaver arms were imaged fluoroscopically in anterior-posterior and lateral views before and after trapeziectomy, and after placement of low- and high-angle suture buttons. The intermetacarpal angle between the thumb and index metacarpals was measured after application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, adduction, and subsidence were measured. Results: Compared to posttrapeziectomy constructs, low- and high-angle TightRope constructs demonstrated less subsidence, low-angle TightRopes had less palmar abduction, and high-angle TightRope constructs had less radial abduction and adduction. High-angle TightRopes allowed more palmar abduction than low-angle constructs. The high-angle TightRopes trended toward more subsidence than low-angle constructs, although it was not significant. Conclusions: Both TightRope constructs provided improved axial stability after trapeziectomy while not excessively limiting any one motion of the thumb. Compared to the high-angle trajectory, the low-angle TightRope placement provided a more stable construct with respect to subsidence and angular motion. Given the concern for excessive motion of the first metacarpal base with the high-angle construct, we recommend a low-angle trajectory TightRope placement.

Overall Opioid Consumption Is Not Associated With the Amount of Opioids Administered and Prescribed on the Day of Upper Extremity Surgery.

Background: Orthopedic surgeons need to better understand the effect their opioid-prescribing habits have on patients. The purpose of our study was to evaluate whether the type of procedure or initial amount of opioids prescribed postoperatively leads to increased consumption of opioids. Methods: Consecutive patients undergoing upper extremity surgery were enrolled. The medical record and Pennsylvania Prescription Drug Monitoring Program Web site were used to record all prescriptions of controlled substances consumed intraoperatively, in the recovery room, and in prescriptions filled 6 months postoperatively. Morphine equivalent units (MEUs) were used to quantify the amount of opioids. Results: Two hundred ninety patients were included in the study. The mean MEU administered intraoperatively was 25.1 (0-50). The MEU provided in the recovery room was 2.9 (0-60). The MEU prescribed on the day of surgery was 155.6 (137-178). We used the Pearson correlation coefficient of r = 0, meaning no/weak correlation, and r = 1, meaning a strong correlation. Neither MEUs provided intraoperatively or in recovery, nor MEUs prescribed postoperatively correlated with prescriptions filled (r = 0.13, 0.02, 0.09, respectively). Although patients undergoing bony procedures were prescribed more opioids (P < .001), opioid consumption intraoperatively, in recovery, and in prescriptions filled was not significantly different. Conclusions: The MEUs administered and prescribed on the day of surgery did not affect the amount of prescriptions filled postoperatively. Finally, patients undergoing bony procedures were prescribed more opioids than those undergoing soft tissue procedures, but they did not consume or fill more opioids postoperatively.

Tension Band Wiring in Upper Extremity Surgery.

Tension band wiring is a simple, inexpensive, and effective technique to treat many upper extremity fractures. When tension forces result in a mechanical failure of bone, tension band wiring provides stability and promotes early mobilization by converting tensile forces across a fracture into compressive forces. The tension band principle has distinct advantages of reducing periosteal stripping, technical ease, and cost effectiveness when compared with other operative strategies. This technique can be implemented in a variety of fractures and avulsions about the upper extremity as well as small bone arthrodeses.

Fragment-Specific Fixation in Distal Radius Fractures.

PURPOSE OF REVIEW: Fragment-specific fixation can be a useful tool in treating distal radius fractures. In order to best utilize these techniques, surgeons require an understanding of the normal anatomy, fracture patterns, approaches, and fixation strategies. RECENT FINDINGS: Fragment-specific fixation may be appropriate for certain fracture patterns particularly when monoblock plating techniques are not sufficient. Radial styloid, volar rim, dorsal wall, dorsal-ulnar corner, and impacted intraarticular fragments may be secured with implants designed specifically for each individual fragment. Although more technically demanding, advantages include accurate articular reconstruction, minimal hardware irritation, and reliable functional outcomes.

Validation of the prescription drug monitoring program Web site.

OBJECTIVE: Evaluate the accuracy of the Pennsylvania Prescription Drug Monitoring Program (PA PDMP) in patients undergoing upper extremity procedures. The authors hypothesized that the PA PDMP would provide an accurate account of the prescriptions that were filled. DESIGN: The authors prospectively collected post-operative pain prescription information of patients undergoing outpatient upper extremity surgery over a 2-week period. Patient-reported prescription-filling of opioid was cross-referenced with the PA PDMP information. SETTING: The study was performed at one private institution. PATIENTS: One hundred and thirty-nine consecutive patients undergoing upper extremity procedures. MAIN OUTCOME MEASURE(S): The PA PDMP information was cross-referenced with the post-operative prescription in the medical record to confirm the patient filled the surgeon's prescription. RESULTS: Of the 111 patients who reported filling their prescription, 107 (96.4 percent) of these were confirmed on the PA PDMP Web site (96.4 percent sensitivity; 95% confidence interval [CI]: 91.0-99.0 percent). None of 28 patients who did not fill their prescription appeared in the database search, resulting in 100 percent specificity (95% CI: 87.7-100 percent). Consequently, the overall accuracy of the PA PDMP was shown to be 97.1 percent (95% CI: 92.8-99.2 percent). CONCLUSIONS: The authors' results suggest that the PA PDMP and its many supplementary databases are accurate as it relates to monitoring opioid prescriptions.

Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery.

BACKGROUND: Managing postoperative pain is important for patients and surgeons. However, there is concern over opioid dependency. Cubital tunnel decompression is among the most common upper extremity surgeries. Our study aimed to analyze opioid use after cubital tunnel decompression to guide postoperative opioid prescribing. METHODS: We prospectively collected opioid consumption for 16 consecutive months (February 2016 to June 2017) for cubital tunnel decompression patients. Data on demographics, insurance type, surgery performed, functional questionnaires (Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH]), and electrodiagnostics (electromyography) were collected. Opioid consumption was reported at first postoperative visits. RESULTS: One hundred patients consumed a mean of 50 morphine equivalent units (MEUs) (range, 0-300), or 7 oxycodone 5-mg pills, postoperatively. Cubital tunnel release (CuTR) patients consumed fewer than ulnar nerve transposition (UNT) patients (40.4 vs 62.5 MEUs or 5.4 vs 8.3 pills, P = .08). Patients undergoing submuscular UNT consumed more than CuTR (115.0 vs 40.4 MEUs or 15.3 vs 5.4 pills, p = 0.003) and more than subcutaneous UNT patients (37.8 MEU or 5.0 pills, p = 0.03). Medicare patients consumed less than privately insured (42.7 vs 54.1 MEUs, 5.7 vs 7.2 pills, P = .02) and less than workers' compensation patients (76.8 MEU or 10.2 pills, P = .04). Older patients consumed fewer than younger patients ( P = .03). Postoperative QuickDASH score was positively related to opioid intake ( P = .009). CONCLUSIONS: Patients consumed 7 oxycodone 5-mg pills after cubital tunnel decompression. Younger, privately insured, and workers' compensation patients, and those with worse functional scores and those undergoing UNT (specifically the submuscular technique) consumed more opioids.