A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release.

PURPOSE: Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. METHODS: We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. RESULTS: A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). CONCLUSIONS: Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Sensitivity, Specificity, and Reliability of the CTS-6 for Carpal Tunnel Syndrome Administered by Medical Assistants.

PURPOSE: The CTS-6 can be used clinically to diagnose carpal tunnel syndrome (CTS) and has demonstrated high levels of interrater reliability when administered by nonexpert clinicians. Our purpose was to assess sensitivity (Sn), specificity (Sp), and interrater reliability of the CTS-6 when administered by medical assistants (MAs). METHODS: A series of patients presenting to an academic, upper-extremity surgery clinic were screened using CTS-6 between May and June of 2023. The CTS-6 was first administered by one of seven MAs and then by one of four fellowship-trained upper-extremity surgeons. In addition to recording baseline demographics, the results of each of the six history and examination components of the CTS-6 were recorded, as was the cumulative CTS-6 score (0-26). Surgeons were blinded to the scores obtained by the MAs. Interrater reliability (Cohen's kappa) was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 items. Sensitivity/specificity was calculated for the MA-administered CTS-6, using the score obtained by the surgeon as the reference standard. A CTS-6 score >12 was considered diagnostic of CTS. RESULTS: Two hundred eighteen patients were included, and 26% had a diagnosis of CTS. The MA group demonstrated a Sn/Sp of 84%/91% for the diagnosis of CTS. Interrater reliability was substantial (Cohen's kappa: 0.72, 95% confidence interval: 0.62-0.83) for MAs compared with hand surgeons for the diagnosis of CTS. For individual CTS-6 components, agreement was lowest for the assessment of two-point discrimination (fair) and highest for the assessment of subjective numbness (near perfect). CONCLUSIONS: The CTS-6 demonstrates substantial reliability and high Sn/Sp when administrated by MAs in an upper-extremity clinic. These data may be used to inform the development of CTS screening programs and future investigations in the primary care setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

A Comparison of Tenosynovial and Transverse Carpal Ligament Biopsy for Amyloid Detection in Open Carpal Tunnel Release.

PURPOSE: Our purpose was to compare differences in the incidence of amyloid deposition in tenosynovium (TS) versus transverse carpal ligament (TCL) biopsies obtained during open carpal tunnel release. We hypothesized that the incidence of amyloid would be similar between TCL and TS when obtaining both specimens from the same patient. METHODS: All primary, elective open carpal tunnel release cases that underwent biopsy for amyloid between January 2022 and September 2023 were reviewed. Tenosynovial and TCL specimens were independently evaluated by a pathologist to assess for amyloid. Demographic data were collected, and incidence of amyloid deposition was compared between the two samples. Agreement statistics, sensitivity, and specificity were calculated for TCL, using TS as the reference standard. RESULTS: A total of 196 cases met either Tier 1 (n=180) or Tier 2 (n=16) biopsy criteria. Forty-eight cases were excluded for missed biopsies or laboratory processing errors, leaving 148 cases available for analysis. Amyloid deposition was present in 31 out of 148 (21%) TS specimens and 33 out of 148 (22%) TCL specimens. Overall, the results of the TS biopsy agreed with TCL biopsy in 138 out of 148 cases (93%). In the 10 cases for which the results of the TCL and TS biopsy differed, six cases had (+) TCL and (-) TS, and four cases had amyloid deposition in TS without evidence of deposition in the TCL. Sensitivity and specificity values for the TCL specimen were 87% and 95%, respectively. Positive and negative predictive values were 82% and 97%, respectively. CONCLUSIONS: For cases of open carpal tunnel release undergoing biopsy, amyloid deposition was noted in 21% of TS specimens and 22% of TCL specimens. Results of TS and TCL biopsies obtained from the same patient agreed in 93% of cases. Single-source biopsy for amyloid represents a reasonable diagnostic approach. Future cost analyses should be performed to determine whether the addition of two biopsy sources to improve diagnostic accuracy is justified. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

A Comparison of Early Complication Rates of Endoscopic Carpal Tunnel Release With and Without Resident Involvement.

PURPOSE: The purpose of this study was to compare the complication rates of endoscopic carpal tunnel release (ECTR) relative to orthopedic resident trainee involvement in the procedure. METHODS: All patients undergoing isolated, elective ECTR by two attending surgeons within a 59-month period were analyzed. Cases were categorized as the following according to the degree of resident involvement: ECTR performed by attending with either no resident or a resident as an assistant (group 1), resident performing a portion of the procedure (group 2), and resident performing the entire procedure (group 3). Early postoperative complications and/or intraoperative conversion to an open procedure were the outcomes of interest. We used a noninferiority design, hypothesizing that resident involvement would not be associated with inferior outcomes compared with cases without resident involvement. Multiple logistic regression models, adjusted for patient demographic and surgical characteristics, were fit to assess the relationship between resident involvement groups and complication/conversion outcomes. RESULTS: A total of 1,167 ECTR cases (895 patients) were performed and returned for postoperative follow-up for at least 2 weeks after surgery. Operative time was significantly shorter for group 1 cases versus group 2 and 3 cases. The early postoperative complication and conversion rates were 1.7% and 1.0%, respectively. Superficial infection (1.2%), deep infection (0.3%), and transient neuropraxia (0.3%) occurred infrequently and did not differ relative to resident involvement. No differences in the odds of complication and/or conversion relative to resident involvement were observed. CONCLUSIONS: The results of ECTR performed entirely or in part by attending-supervised resident trainees were not inferior to ECTR performed by an attending surgeon regarding the odds of experiencing complications or conversion to an open procedure. With appropriate supervision, ECTR can be performed safely by orthopedic and plastic surgery residents. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The Effect of an Intraoperative Real-Time Counter on Radiation Exposure Events During Operative Treatment of Distal Radius Fractures.

PURPOSE: Occupational radiation exposure can have adverse health consequences for surgeons. The purpose of this study was to determine if utilization of an intraoperative, real-time radiograph counter results in decreased radiation exposure events (REEs) during open reduction and internal fixation (ORIF) of distal radius fractures (DRFs). METHODS: We reviewed all cases of isolated ORIF DRFs performed at a single center from January 2021 to February 2023. All cases performed on or after January 1, 2022 used an intraoperative radiograph counter, referred to as a "shot-clock" (SC) group. Cases prior to this date were performed without a SC and served as a control group (NoSC group). Baseline demographics, fracture, and surgical characteristics were recorded. Final intraoperative radiographs were reviewed to record reduction parameters (radial inclination, volar tilt, and ulnar variance). REEs, fluoroscopy exposure times, and total radiation doses milligray (mGy) were compared between groups. RESULTS: A total of 160 ORIF DRF cases were included in the NoSC group, and 135 were included in the SC group. The NoSC group had significantly more extra-articular fractures compared with the SC group. Reduction parameters after ORIF were similar between groups. The mean number of REEs decreased by 48% in the SC group. Cases performed with the SC group had significantly lower total radiation doses (0.8 vs 0.5 mGy) and radiation exposure times (41.9 vs 24.2 seconds). Mean operative times also decreased for the SC group (70 minutes) compared with that for the NoSC group (81 minutes). CONCLUSIONS: A real-time intraoperative radiograph counter was associated with decreased REEs, exposure times, and total radiation doses during ORIF DRFs. Cases performed with a SC had significantly shorter operative times without compromising reduction quality. Using an intraoperative SC counter during cases requiring fluoroscopy may aid in decreasing radiation exposure, which serves as an occupational hazard for hand and upper-extremity surgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Race and Ethnicity Reporting in Randomized Controlled Trials Published in Upper-Extremity Journals.

PURPOSE: Hand surgery remains one of the least racially and ethnically diverse subspecialties in all of medicine, and minority patients demonstrate overall worse health care outcomes compared with White patients. Our purpose was to determine the frequency of race and ethnicity reporting in randomized controlled trials (RCTs) published in journals with an upper-extremity (UE) focus. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching EMBASE and MEDLINE for RCTs contained in peer-reviewed journals with an UE focus. All articles from 2000 to 2021 were included. Information such as article sample size, center type, funding, and location was recorded. We assessed each article to determine whether demographic information, including race and ethnicity, was reported for study participants. RESULTS: A total of 481 RCTs in 9 UE journals were included. For UE RCTs, 96% of studies reported age, 90% reported sex, and 5% reported either race or ethnicity. Demographic information about economic status, insurance status, mental health, educational level, and marital status were each reported in <10% of RCTs. Racial representation was highest for White participants (80%) and lowest among American Indian participants. Of studies conducted within the United States, all racial groups except for White patients were underrepresented compared with census data. CONCLUSIONS: Demographic data related to race and ethnicity for patients involved in UE RCTs are infrequently reported. When reported, the racial demographics of UE RCT patients do not match the demographics of the patients in United States. Black patients remain underrepresented in RCTs. CLINICAL RELEVANCE: Academic journals mandating the reporting of demographic data related to race may aid in improved reporting and allow for subsequent aggregation within systematic reviews to assess outcomes for racial minorities.

Intraoperative Conversion From Endoscopic to Open Carpal Tunnel Release: A Systematic Review and Case Series.

PURPOSE: The purpose of this study was to assess the incidence, outcomes, and complications associated with conversion from endoscopic carpal tunnel release (ECTR) to open carpal tunnel release (OCTR). METHODS: A retrospective case review of all patients who underwent ECTR over 4 years by 2 fellowship-trained hand surgeons at a single academic center was performed. We recorded outcomes and the reason for conversion in patients who underwent conversion to an OCTR. Baseline demographics and surgical complications were compared between the 2 groups. A systematic review was performed to define the incidence and reasons for conversion from ECTR to OCTR. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included clinical studies of ECTR from 2000 to 2021. RESULTS: In the retrospective series, 9 of 892 (1.02%) ECTR cases underwent conversion to an OCTR at the time of the index procedure. One of 9 converted cases had transient neurapraxia involving the recurrent motor branch after surgery compared with 0 cases in the group that underwent ECTR without conversion. Improvements in the visual analog scale for pain and QuickDASH were noted at a mean of 46 weeks after surgery in the group that underwent conversion to OCTR. The systematic review identified an incidence of conversion of 0.62%. The most common reasons for conversion to OCTR in the case series and systematic review were poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy. CONCLUSIONS: The overall incidence of intraoperative conversion from ECTR to OCTR during the index procedure was 1.02%, with the most common reasons for conversion being poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy. Patients who undergo conversion from ECTR to OCTR demonstrate improvements in pain and disability, similar to patients who undergo ECTR without conversion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Analysis of driving simulator performance for post-call orthopaedic surgery residents.

PURPOSE: Despite the associations between workhours, fatigue and motor vehicle accidents, driving abilities for residents post-call have been infrequently analysed. Our purpose was to compare orthopaedic surgery resident performance on a driving simulator after a night of call compared with their baseline. STUDY DESIGN: All residents from a single orthopaedic programme were asked to complete baseline and post-call driving simulator assessments and surveys. The primary outcome measure was brake reaction time (BRT) and secondary outcome measures included lane variance, speed variance and accidents on the driving simulator. RESULTS: All 19 orthopaedic residents agreed to participate. Compared with the baseline assessment, residents demonstrated significantly higher levels of sleepiness on the Stanford Sleepiness Scale post-call (1.6 vs 3.4; p<0.0001). Despite higher levels of fatigue post-call, there was no statistically significant differences between baseline and post-call assessments for mean BRT, accidents, lane variation and speed variation. CONCLUSIONS: These data suggest that for orthopaedic residents, driving simulator performance does not appear to be worse after a single night of call compared with baseline. Future collaborative, multicentre investigations on post-call driving safety that incorporate different call types and frequencies are necessary to better define the impact of post-call fatigue on driving performance. Recognising that motor vehicle accidents remain the leading cause of death for people under the age of 30 years, these continued areas of study are necessary to truly establish a culture of resident safety.

A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release.

PURPOSE: We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR. METHODS: All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment. RESULTS: A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time. CONCLUSIONS: Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Trends in the Management of Fifth Metacarpal Neck Fractures.

PURPOSE: To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED). METHODS: We identified all 5MCN fractures within our system for the years 2012-2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only. RESULTS: There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery. CONCLUSIONS: Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Reliability of the CTS-6 for Examiners With Varying Levels of Clinical Experience.

PURPOSE: To assess the interrater reliability of the CTS-6 for examiners with varying levels of clinical expertise. We also aimed to analyze this instrument's sensitivity (Sn) and specificity (Sp), using the CTS-6 score obtained by a hand surgeon as a reference standard. METHODS: Three examining groups consisting of medical students, occupational hand therapists, and hand surgeons examined a consecutive series of patients in an academic upper-extremity clinic. A total of 3 examiners (1 from each group) recorded a CTS-6 score for each patient. The examiners were blinded to the scores from the other groups. The interrater reliability was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 components. Sn and Sp were calculated for each of the groups using the CTS-6 obtained by the hand surgeons as the reference standard. RESULTS: Two hundred seven patients were included. For the diagnosis of CTS (CTS-6 score of 12 or greater as determined by a hand surgeon), there was substantial agreement between the 3 groups (Fleiss kappa 0.73; 95% CI [0.65 -0.82]; P < .05). For individual CTS-6 components, the agreement between the groups was highest for assessing subjective numbness and lowest for assessing a Tinel sign (Fleiss kappa of 0.77 and 0.49, respectively). The Sn/Sp for diagnosing CTS was 87%/91% for the medical student group and 81%/95% for the occupational hand therapist group. CONCLUSIONS: The CTS-6 can be reliably used as a screening and diagnostic tool for CTS by clinicians with a variety of experience levels and without specific fellowship training in upper-extremity surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Analysis of Gender Diversity Within Hand Surgery Fellowship Programs.

PURPOSE: To define and compare gender diversity among faculty and trainees within hand surgery fellowship programs. METHODS: We determined the gender of each program director for all orthopedic residency and fellowship programs. Specific to hand fellowship programs, we determined the gender of the fellowship director and all faculty members for all plastic surgery and orthopedic hand fellowship programs. Lists of prior hand surgery fellows from 2014 to 2019 were obtained from official program websites or program coordinators. The gender distribution of the hand fellowship program directors and faculty was compared to the prior fellows. RESULTS: Hand surgery fellowship programs had the second highest percentage of female fellowship directors (13%) behind orthopedic oncology (27%). Within hand surgery, 614 total faculty positions were identified, and 15% were female. Of the 89 hand surgery programs evaluated, 36 (60%) had at least 1 female faculty member. For the 849 prior fellows identified, 213 (25%) were female, and 79% of programs had at least 1 female fellow. Hand programs led by a female director did not have a higher percentage of prior female fellows compared to programs led by a male director (26% vs 25%). Programs with a female fellowship director were as likely to have had at least 1 prior female fellow compared to programs with a male fellowship director. CONCLUSIONS: For orthopedic subspecialties, hand surgery fellowship programs had the second highest percentage of female fellowship directors (13%). While mentorship plays an important role in surgical education, hand fellowship programs with female faculty did not appear to attract more female fellows or faculty. CLINICAL RELEVANCE: Hand fellowship programs should recognize that the presence of female faculty may not be a primary factor in fellowship selection for female applicants, and further study into recruiting qualified female candidates should be encouraged.

The Ability of Upper Extremity Surgeons to Assess Patient's Functional Status.

PURPOSE: To compare surgeon and patient assessment of upper extremity functional status at the time of initial consultation. We hypothesized that surgeons and patients demonstrate low levels of agreement with respect to assessing pain scores, functional status, and self-efficacy. METHODS: One hundred forty-three consecutive new patients were evaluated by 1 of 5 fellowship-trained upper extremity surgeons. Patients completed a Numeric Pain Rating Scale as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy (SE) instruments. Surgeons provided their own estimates of patient function on each questionnaire at the conclusion of the visit and were blinded to the results of the patient-reported outcome measures (PROMs) for the duration of the study. Estimation errors, which represent the absolute value of the difference between the patient's actual score and the surgeon's estimated score on each questionnaire, were calculated for each questionnaire. RESULTS: As a group, surgeons assumed that the PROMIS UE and SE scores were higher than the patients' actual scores and assumed that patients had lower PROMIS PI scores than were actually reported. Mean estimation errors for all PROMIS instruments were greater than 10 points and larger than the SD for these instruments in the general population. CONCLUSIONS: Upper extremity surgeons demonstrate difficulty assessing their patient's self-reported functional status, pain interference, and level of self-efficacy during initial consultations. CLINICAL RELEVANCE: Although formalized PROMs are infrequently administered in orthopedic clinics, increased utilization of these questionnaires would allow for a more accurate baseline functional assessment. When evaluating new patients in the outpatient clinic, surgeons should recognize the potential limitations of their assessments of patient-reported function.

Technology, Social Media, and Telemedicine Utilization for Rural Hand and Upper-Extremity Patients.

PURPOSE: To define technology and social media use among rural upper-extremity patients. In addition, we aimed to assess how patients use social media in relation to health care and their willingness to participate in telemedicine programs. METHODS: An anonymous multiple-choice written survey was administered to 550 upper-extremity patients at 4 rural outreach clinics. Demographic information was obtained, as was social media use, habits and interests. We compared both users and nonusers of social media to define demographic differences between these groups. RESULTS: A total of 412 patients completed surveys and were included in our analysis (75%); 225 reported using social media (55%). Of the respondents, 67% had a high school education or less and 60% reported an income of less than $50,000/y with an unemployment rate of 58%. In addition, 28% reported not owning a smartphone and 20% lacked home Internet access. Multivariable regression demonstrated that age, female sex, and home Internet access were all independently associated with increased social media use. Facebook was the most frequently used social media platform. Moreover, 42% were interested in telemedicine and social media users were significantly more likely to be interested in telemedicine programs compared with non-social media users. CONCLUSIONS: Within a population of rural and economically disadvantaged upper-extremity patients, 55% currently use social media; 32% used these platforms to research health conditions. Whereas younger female patients with home Internet access were more likely to use social media, older patients were more likely to use these platforms to research health conditions. CLINICAL RELEVANCE: As more health information moves on-line and as telemedicine programs continue to evolve, some rural upper-extremity patients may still have technological barriers in the form of smartphone and computer ownership as well as a lack of home Internet access.

Telemedicine in Hand and Upper-Extremity Surgery.

Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.

The Use of Preoperative Dynamic Ultrasound to Predict Ulnar Nerve Stability Following In Situ Decompression for Cubital Tunnel Syndrome.

PURPOSE: To assess the use of preoperative, dynamic ultrasound to predict ulnar nerve instability following in situ decompression for cubital tunnel syndrome. METHODS: Prior to undergoing in situ decompression, 43 consecutive patients underwent dynamic ultrasound to assess the stability of the ulnar nerve during elbow flexion. The dynamic ultrasound findings were compared with the intraoperative assessment of nerve stability following in situ decompression. RESULTS: The preoperative dynamic ultrasound agreed with intraoperative findings in 38 of 43 patients (88%). Physical examination of ulnar nerve stability agreed with the intraoperative findings in 5 of 43 patients (12%). For the 5 of 43 cases in which the dynamic ultrasound did not correlate with the degree of ulnar nerve stability after in situ decompression, dynamic ultrasound overestimated the degree of ulnar nerve stability in 4 cases. CONCLUSIONS: Preoperative dynamic ultrasound can be used to accurately predict the degree of ulnar nerve instability following in situ decompression. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures.

PURPOSE: Standard 0.58 mg (0.25 mL) collagenase Clostridium histolyticum (CCH) preparations result in unused CCH that is often discarded. Our purpose was to assess the results on Dupuytren contractures affecting both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the same digit utilizing an injection containing the maximum CCH volume that can be withdrawn from a single vial. METHODS: A consecutive series of patients with MCP and PIP cords in the same digit received a single treatment with 2 injections totaling 0.30 mL distributed between the MCP and the PIP cords and underwent manipulation approximately 24 hours later. Reduction in contracture, clinical success, and complications were assessed 30 days after manipulation. RESULTS: Thirty-one patients (34 digits) had a mean preinjection flexion contracture of 50° at the MCP joint and 53° at the PIP joint. Clinical success (reduction in joint contracture to 0°-5° of full extension 30-days postmanipulation) was noted in 65% of MCP cords and 38% of PIP joint cords. We had a 24% incidence of skin tears, which correlated with the degree of preinjection contracture. CONCLUSIONS: For Dupuytren contractures involving the MCP and PIP joints in the same digit, distributing the maximum amount of CCH that can be withdrawn from a single vial provides efficacy at both joints that is similar to that reported in previously published series, with a comparable complication rate. Utilizing excess CCH typically discarded may provide cost savings. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Incidence and Risk Factors for Extensor Pollicis Longus Rupture in Elastic Stable Intramedullary Nailing of Pediatric Forearm Shaft Fractures.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is an effective means of fixation for unstable, pediatric forearm shaft fractures with the benefit of smaller incisions, less soft tissue manipulation, and ease of removal. This study was designed to evaluate the incidence of and risk factors for extensor pollicis longus (EPL) rupture after fixation of pediatric radial shaft fractures with ESIN. METHODS: A retrospective review of all patients younger than 19 years who had a repair of a forearm fracture with flexible intramedullary nailing between 2006 and 2011 was performed. Nineteen consecutive patients were identified from the electronic medical record. All patients were treated with a titanium elastic nailing system using a dorsal approach to the radius. The patients were followed postoperatively for at least 2 years, and all fractures healed. An extensive chart review assessing for persistent pain, EPL function, and risk factors for EPL rupture was performed. Implants were removed in all but 1 patient. RESULTS: Seventeen records were available for review. Fourteen (82%) were male, and the mean age at time of fracture was 10 years old (range, 5 to 14 y). Follow-up averaged 5.5 years (range, 2.9 to 7.8 y). The mean weight was 32.7 kg for males and 50.6 kg for females corresponding to the 61st and 60th percentile respectively of weight-for-age (range, 8th to 99.9th percentile). Hardware was removed in all but 1 case, and the median time from surgery to hardware removal was 21 weeks (range, 8 to 63). Three of the 17 patients (18%) experienced rupture of the EPL. Two were treated with additional surgery following hardware removal, and one was untreated due to patient preference. None of the 17 patients (including those with rupture) had independent risk factors for tendon rupture: inflammatory arthritis, diabetes, or prior steroid use. Time to removal, patient age, and percentile of weight-for-age did not correlate with EPL rupture. CONCLUSIONS: Although ESIN of pediatric forearm shaft fractures has gained acceptance as a treatment option, our series of 17 patients revealed an 18% rate of EPL rupture. With this small patient cohort, no patient characteristics proved to be significant risk factors for predicting tendon rupture. However, awareness should be raised for an increased risk of EPL rupture with this fixation method. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Airborne Exposure of Methyl Methacrylate During Simulated Total Hip Arthroplasty and Fabrication of Antibiotic Beads.

As the use of cement remains prevalent in orthopedic surgery, so do concerns over the safety of its active ingredient, methyl methacrylate (MMA). The Occupational Health and Safety Agency (OSHA) limits the airborne exposure to 100 parts per million (ppm) averaged over an 8 hour period. We measured MMA exposure to operating room personnel during simulated total hip arthroplasty (THA), antibiotic bead fabrication and simulated spill of MMA. Cumulative and peak exposures during simulated THA and antibiotic bead fabrication did not exceed OSHA limits of 100ppm. Vacuum mixing and greater distance from the vapor source reduced measured MMA exposure. Spilled MMA led to prolonged and elevated MMA levels. MMA levels returned to a negligible level in all scenarios by 20 minutes after mixing.

The incidence of trigger digit after carpal tunnel release in diabetic and nondiabetic patients.

PURPOSE: To determine whether patients with diabetes mellitus (DM) are at greater risk for developing postoperative trigger digits (TD) after carpal tunnel release (CTR) compared with patients without diabetes. METHODS: A retrospective review of our electronic medical records identified all patients who had undergone CTR by a single hand fellowship-trained surgeon from September 2007 through May 2012. For patients with DM, additional information regarding method of disease control and hemoglobin A1c (HbA1c) level was recorded. We recorded HbA1c levels 3 months before and 3 months after CTR. The location and time to development of postoperative, new-onset TD were recorded for each case. Statistical testing included chi-square or Student t test and multivariate logistic regression analysis. RESULTS: Of the 1,217 CTRs, 214 had DM. Of the 1,003 CTRs in cases without DM, 3% developed TD within 6 months of CTR and 4% within 1 year of CTR, compared with 8% and 10%, respectively, for diabetic cases. A multivariate regression analysis revealed DM as a significant risk factor for developing TD after CTR at 6 and 12 months. We found no significant association between HbA1c level at the time of CTR and the likelihood of developing TD. CONCLUSIONS: The incidence of TD after CTR was higher in the diabetic population compared with a nondiabetic cohort. The presence of DM rather than its severity was the most important factor for developing TD. Preoperative counseling for patients with DM undergoing CTR may alert them to the possibility of developing TD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.