Endoscopic carpal tunnel release. In favor.

The many studies presented in this article demonstrate that ECTR is not a procedure to be taken lightly. It is a demanding surgical exercise that requires exacting knowledge of the anatomy of the hand. It is not something that should be carried out by the surgeon who does an occasional carpal tunnel release. For those who do not meet these criteria, OCTR remains the procedure of choice. For those surgeons who are well trained and aware of the anatomy of the hand, however, ECTR allows them to provide their patients with a safe, predictable solution to their carpal tunnel syndrome that will allow them a rapid return to normal activities. Further studies, however, will be required to see how well ECTR holds up to the test of time. Long-term studies currently are underway and should be available in the not-too-distant future.

Evaluation of chronic wrist pain.

Chronic wrist pain remains a challenge to diagnose and treat. A thorough history and physical examination are key. Various imaging techniques are essential to the evaluation of the patient with chronic wrist pain. Standard radiography, computed tomography, cinearthrography, magnetic resonance imaging, radionuclide imaging, arthroscopy, and arteriography all may have a role in assessment, and the orthopaedic surgeon should be familiar with the indications, strengths, and weaknesses of each. Laboratory tests may also be useful in evaluation. No all-inclusive algorithm can be applied in this setting; therefore, the physician must rely on his or her diagnostic acumen to successfully assess and treat chronic wrist pain.

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery.

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

Wrist arthrodesis with excision of the proximal carpal bones using the Ao/ASIF wrist fusion plate and local bone graft.

We present our series of 17 patients who underwent wrist arthrodesis with excision of the proximal row carpal bones using the AO wrist fusion plate and local bone graft obtained from the excised proximal carpal row. All patients were evaluated using a questionnaire to assess pain, function, ability to perform an occupation and satisfaction with the procedure. The mean follow-up was 17 months, at which time all the fusions had united. Clinical outcome scores showed that 14 and 15 of the 17 patients achieved good or excellent results with regard to their current condition and clinical improvement, respectively. Four patients required secondary surgery, two for fractures and two for instability of the distal radio-ulnar joint unrelated to the wrist fusion.

Triangular fibrocartilage complex tears in the athlete.

The treatment of triangular fibrocartilage tears in the athlete presents more of a rehabilitation challenge than a surgical technique challenge. The rehabilitation regimen is a function of the sport. Although injuries to the shoulder and knee can be career ending, injuries to the TFCC usually, but not always, can be treated successfully.

Scaphoid nonunion. Treatment with cancellous bone graft and Kirschner-wire fixation.

The wrist surgeon must be conversant with the many methods of treating scaphoid nonunions. Cancellous bone grafting combined with K-wire fixation is a relatively straightforward technique that has been shown in several studies to predictably produce healing of scaphoid nonunions. Although there may be a trend toward early use of vascularized bone grafts for the treatment of scaphoid nonunions, it would seem reasonable to reserve that procedure for cases in which the vascular supply to the scaphoid fragments is compromised, and for which there is little hope that a nonvascularized bone graft will succeed.

Arthroscopic treatment of degenerative tears of the triangular fibrocartilage.

The arthroscope permits treatment of degenerative tears of the TFC and associated lesions. It lends itself to the assessment and treatment of both "primary" and "secondary" ulnar impaction syndromes. Ulnocarpal, radiocarpal, and midcarpal synovitis can be excised, as can partial tears of the lunatotriquetral interosseous ligament. The primum movens of the ulnar impaction syndrome, a long ulna, can be shortened arthroscopically if the positive ulnar variance is less than 4 mm and no distal radioulnar joint instability or degenerative changes are noted. Although an arthroscopic "wafer" procedure is possible, more clinical studies are needed to allow an accurate assessment of its efficacy.

Laser-assisted wrist arthroscopy.

The use of arthroscopy to treat wrist arthritis is a relatively new approach to a common problem. Recent advances in arthroscopic surgery techniques and instrumentation have enabled the surgeon to improve the treatment of wrist pathology. Patients undergoing arthroscopic procedures potentially have better motion postoperatively because the dorsal carpal ligaments are preserved. This article reviews the techniques of arthroscopic proximal row carpectomy, radial styloidectomy, and wrist joint synovectomy.

Microsurgical reconstruction of fingers and fingertips.

Free transfers from the foot have good indications for finger reconstruction in young, healthy, and well-motivated patients. The toes provide a unique source to reconstruct amputated or partly destroyed fingers. If the range of motion of the toe joints is quite disappointing from the roll up needed on the ulnar side of the hand, it can provide strong pinch with good sensibility on the radial aspect. This article reviews the different types of transfers, their results, and indications, and provides a description of the authors' basic surgical technique.

Immediate silastic arthroplasty for non-salvageable intraarticular phalangeal fractures.

Fourteen patients with open non-salvageable intraarticular fractures of the proximal interphalangeal joint or metacarpophalangeal joint, underwent immediate silastic arthroplasty using Swanson H.P. hinged implants. The patients' ages ranged from 14 to 49 years, with an average of 29 years. Time from surgery to final examination ranged from 4 months to 6 years, with an average of 26 months. The active range of motion obtained at the metacarpophalangeal joint arthroplasties ranged from 45 to 80 degrees, with an average of 60 degrees. The active range of motion obtained at the proximal interphalangeal joint arthroplasties ranged from 0 to 70 degrees, with an average of 29 degrees. Better results were generally obtained at the metacarpophalangeal level, and in those arthroplasties performed in non-amputated digits. There were no post-operative infections and all but one joint were stable.

Traumatic ulnar translocation of the carpus: early recognition and treatment.

This study evaluated the clinical outcomes and radiographic features of surgically treated traumatic ulnocarpal translocation in nine patients (ten cases). All ligament and fracture repairs were completed within 2 months of injury. Seven cases were examined at a mean of 6.5 years, and information in three cases was obtained from medical records at a mean of 13 months after injury. At final evaluation, the mean disabilities of the arm, shoulder, and hand score was 6 (range, 0-16), and the mean Mayo modified wrist score was 76 (range, 40-100). Ulnocarpal translocation was evident in nine of the injured wrists, six of which showed arthritis, and in four of the uninjured wrists. Ulnar variance measured negative in nine cases and neutral in one case. Pre-existing medial alignment of the carpus and ulnar minus variance may predispose to traumatic ulnocarpal translocation. Early injury repair does not assure restoration of radiocarpal alignment or prevent joint deterioration; however, these changes do not always portend a suboptimal result.

Wrist arthroscopy: indications and results.

The results of 84 wrist arthroscopies in 74 patients (performed by the same surgeon) were reviewed retrospectively. Arthroscopies were categorized as "diagnostic"--to identify unknown pathology, "staging"--to assess the severity of known pathology, and "operative"--to treat known pathology. Ninety-eight percent of diagnostic arthroscopies accurately established details of the pathology in question. Ninety-six percent of staging arthroscopies helped guide future clinical management. Of the patients in the operative category, 35% improved after treatment with arthroscopy alone, requiring no further surgical intervention. This study shows that wrist arthroscopy is a powerful diagnostic and staging tool and suggests that it may also develop into a valuable treatment modality.

Accelerating recovery after trauma with free flaps.

Free flap versatility and dependability make the final result of microvascular reconstruction highly predictable. Free tissue transplantation should be considered as a primary treatment after trauma. The early use of free tissue transfer will result in fewer operations and a shortened duration of hospitalization in the initial post-trauma period.

The sural artery and vein as recipient vessels in free flap reconstruction about the knee.

The sural artery and vein were used successfully as recipient vessels in nine patients who required free flap reconstruction about the knee. The anatomy of the sural vessels and the potential advantages of their use as free flap recipients are reviewed and discussed. Indications include popliteal vessels that are absent or severely damaged, as determined by preoperative angiography. No anastomotic complications were encountered in this series, indicating that the sural artery and vein can be used successfully as recipient vessels.

Free flap reconstruction of the lower back and posterior pelvis: indications, principles, and techniques.

Reconstructive microsurgery can be successfully applied to major defects of the lower back and posterior pelvis. When present, the superior and inferior gluteal vessels can be excellent free flap recipient vessels. However, if they are absent as a result of trauma or tumor ablation, a wrist carrier can be used to transfer large blocks of tissue in a staged procedure. Five patients are presented with challenging defects for which these techniques were used.

Wide excision of the distal ulna: a multicenter case study.

Excision of the distal ulna to treat degenerative disease or instability has fallen into disfavor following reports of radioulnar impingement, carpal instability, and distal ulnar instability. Alternative procedures for reconstruction of the painful distal ulna have been developed to address these problems; the results have been generally favorable. When faced with distal ulnar reconstruction that has failed after multiple surgical procedures, or a distal ulnar neoplasm, the surgeon is left with few treatment options. Creation of a one-bone forearm, free fibular transfer, and allograft replacement have been attempted, with mixed outcomes. We report the results of 5 men and 7 women who underwent wide excision of the distal ulna, defined as surgical excision of 25% to 50% of the ulnar length. The diagnosis was failed distal radioulnar reconstruction or excision in 8 patients, osteomyelitis in 1, congenital pseudoarthrosis of the radius in 1, and neoplasm in 2. No soft tissue reconstruction was performed. Patients were examined at an average of 22 months after surgery for radiocarpal and radioulnar instability, functional outcome, pain relief, grip strength, and range of motion. Nine of the 12 procedures resulted in good or excellent results; 1 patient had a fair result after resection for osteosarcoma, and the procedure in 2 patients failed, requiring conversion to a one-bone forearm. Grip strength was restored to 75% of the normal side and range of motion was restored to 86% of the normal side. Wide excision of the distal ulna without soft tissue reconstruction is a simple and durable treatment of neoplasms of the distal ulna or salvage of the failed reconstruction of the distal radioulnar joint. We do not recommend its use in patients with incompetency or disruption of the interosseous membrane.

A multicenter prospective review of 640 endoscopic carpal tunnel releases using the transbursal and extrabursal chow techniques.

A prospective study involving eight institutions was performed, incorporating 640 cases of carpal tunnel release using a dual portal endoscopic technique. The original transbursal technique described by Chow was used in 110 cases (17%), and the modified extrabursal technique was used in 530 cases (83%). An overall complication rate of 11% was found in the patients in whom the transbursal technique was used, compared with 2.2% in the patients in whom the extrabursal technique was used. The return-to-work status was followed in 291 cases (199 non-worker's compensation cases and 92 worker's compensation cases). The worker's compensation patients returned to work in an average of 57 days, compared with 22 days for non-worker's compensation patients. This study suggests the extrabursal dual portal endoscopic technique is associated with fewer complications than the transbursal approach, and patients covered by worker's compensation return to work later than non-worker's compensation patients.