ASSH 75 Years: An Update of Progress Over the Past 25 Years.

This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.

Evaluating the sustained effectiveness of a multimodal intervention aimed at influencing PIVC insertion practices in the emergency department.

INTRODUCTION: Multimodal interventions (MMI) are frequently used in various healthcare settings to encourage change in healthcare personnel practices and improve patient safety. In 2013, an MMI conducted in an Australian metropolitan ED used clinician champions, guidelines, education sessions and promotional materials to encourage a reduction in unused and inappropriate peripheral intravenous cannulas (PIVC). A 60-day postintervention demonstrated a successful reduction in the number of unused PIVCs without changes in appropriate insertions. We aimed to investigate if this MMI produced a sustained effect in reducing the frequency of unused PIVCs inserted in this ED. METHODS: A single-centre retrospective cohort study of adult patients presenting to the above ED in Victoria, Australia, was conducted in April 2018. A random sample of 380 patients with a PIVC inserted in ED was assessed to determine if the PIVC was used (termed 'Long-term follow-up'). The appropriateness of unused PIVCs was assessed. Our findings were compared with previously collected data in 2013 ('Pre-Intervention' and 'Immediately Post-Intervention') to determine a sustained reduction in the frequency of unused PIVC insertions was achieved. Long-term analysis of the MMI, including the overall frequency of PIVC insertions in ED before and after the MMI, was also collected. RESULTS: In our Long-term follow-up cohort, 101 of 373 (27.1%, 95% CI 22.6% to 31.9%) PIVCs were unused (seven cases excluded). This was significantly lower than the Pre-Intervention cohort (139/376, 37.0%, 95% CI 32.1% to 42.1%). While not significant, the frequency of unused PIVCs in the Post-Intervention cohort was lower in comparison (73/378, 19.3%, 95% CI 15.4% to 23.7%). No significant change in the appropriateness of unused PIVCs was observed between the Post-Intervention and Long-term follow-up. The overall proportion of patients receiving a PIVC has remained low since the MMI. CONCLUSION: An MMI aimed at reducing unused PIVC insertions in ED has been effective in eliciting sustained change. Unused but appropriately inserted PIVCs seem unaffected by the intervention.

Nonoperative management of scleroderma of the hand with tadalafil and subatmospheric pressure wound therapy: case report.

Scleroderma, or systemic sclerosis (SS), is an autoimmune disease leading to ischemic fibrosis and widespread collagen deposition, invariably affecting the hands. Optimized medical management remains the mainstay of therapy for SS. Surgery can be considered in refractory or severely disabling cases. However, microvascular insufficiency and fibrosis can lead to wound complications and, ultimately, amputation. We present the case of a 61-year-old man with a known history of scleroderma who presented with pain, chronic infection, and ulcerations in the left hand. Initially, amputation seemed a reasonable intervention. After medical optimization with tadalafil, his ulcerations persisted. Instead of amputation, we applied a subatmospheric pressure wound therapy device to his hand. In 4 months, his wounds had healed, there was no evidence of infection, and no digits were amputated.

Human factor-designed multimodal intervention reduces the rate of unused peripheral intravenous cannula insertion.

OBJECTIVE: Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED. METHODS: A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures. RESULTS: Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42). CONCLUSION: Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions.

Wrist arthroscopy: current concepts.

Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The number of conditions that are amenable to arthroscopic treatment continues to grow. A detailed knowledge of the topographical and intracarpal anatomy, however, is essential to minimize complications and maximize the benefits. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition versus a pathologic lesion that is the cause of wrist pain. A thorough wrist examination is still integral to any arthroscopic assessment. This article focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.

Anomalous palmar cutaneous branch of the median nerve in the distal forearm: case report.

Variations exist in the anatomy of the palmar cutaneous branch of the median nerve about the wrist. We report an anatomic variation in the course of the palmar cutaneous branch of the median nerve identified in a 17-year-old girl undergoing surgery for a scaphoid nonunion. Instead of coursing ulnar to the flexor carpi radialis tendon, deep to the antebrachial fascia between the tendons of the flexor carpi radialis and palmaris longus, the palmar cutaneous branch of the median nerve was noted to cross volar to the distal aspect of the flexor carpi radialis to lie on its radial aspect. Knowledge of the anatomic variant described in this report should encourage surgeons to dissect carefully as they expose the flexor carpi radialis during the exposure of the distal radius or scaphoid.

Endoscopically assisted excision of digital enchondroma.

We present 2 cases of endoscopically assisted curettage of enchondroma of the hand. After initial open curettage of the lesion, a 1.9-mm arthroscope was introduced through a small cortical window. Under arthroscopic guidance, residual pathologic material was freed from the cavity wall and evacuated with the aid of repeated saline lavage combined with suction. The saline was injected through an 18-gauge angiocatheter under direct endoscopic control. The endoscope was then used to observe the filling of the cavity with demineralized bone matrix (DBX; Synthes [USA], Paoli, PA). We believe that endoscopically assisted curettage presents several advantages over open curettage alone. First, direct visualization of the medullary canal permits accurate assessment of the extent of the enchondroma. Second, the endoscope permits accurate assessment of the adequacy of the curettage, thus avoiding the need to perform multiple, blind, and aggressive passes with a curette. Multiple passes can increase the risk of violation of the cortical shell and can prolong the procedure. Third, the ability to completely clear the medullary canal of all tumors should logically reduce the rate of recurrence. In conclusion, the addition of an endoscope is an inexpensive modification that promises to save time, decrease morbidity, and possibly improve long-term outcomes.

Complications of endoscopic and open carpal tunnel release.

PURPOSE: To compile the major complications of carpal tunnel surgery and compare reported complications for open and endoscopic techniques. METHODS: A literature assessment was performed for published complications of open and endoscopic carpal tunnel release procedures; 80 publications, representing a period from 1966 through 2001, were reviewed. Complications were identified as neurapraxia; nerve, tendon, or artery injury; and wound infection or dehiscence that required antibiotics or additional operative care. Differences in the proportions of complications between carpal tunnel release procedures were explored with the use of Fisher exact tests. RESULTS: The literature review yielded 22,327 cases of endoscopic carpal tunnel release and 5,669 cases of open carpal tunnel release. For structural damage to nerves, arteries, or tendons, the incidence for open carpal tunnel release is 0.49% and for endoscopic methods (transbursal and extra-bursal), 0.19%. This difference is statistically significant (P < .005; 2-tailed Fisher exact test) and suggests that the overall proportion of structural complications for open carpal tunnel release according to our complication selection criteria is greater than the overall proportion of complications for endoscopic carpal tunnel release. CONCLUSIONS: The proportion of complications for carpal tunnel release, performed through an endoscopic or open approach, is very low. Selection of an open versus an endoscopic approach on the basis of structural complications for nerve, arteries, or tendons is not supported by statistical analysis of published complications. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Exercise training alters length dependence of contractile properties in rat myocardium.

Myocardial function is enhanced by endurance exercise training, but the cellular mechanisms underlying this improved function remain unclear. Exercise training increases the sensitivity of rat cardiac myocytes to activation by Ca(2+), and this Ca(2+) sensitivity has been shown to be highly dependent on sarcomere length. We tested the hypothesis that exercise training increases this length dependence in cardiac myocytes. Female Sprague-Dawley rats were divided into sedentary control (C) and exercise-trained (T) groups. The T rats underwent 11 wk of progressive treadmill exercise. Heart weight increased by 14% in T compared with C rats, and plantaris muscle citrate synthase activity showed a 39% increase with training. Steady-state tension was determined in permeabilized myocytes by using solutions of various Ca(2+) concentration (pCa), and tension-pCa curves were generated at two different sarcomere lengths for each myocyte (1.9 and 2.3 microm). We found an increased sarcomere length dependence of both maximal tension and pCa(50) (the Ca(2+) concentration giving 50% of maximal tension) in T compared with C myocytes. The DeltapCa(50) between the long and short sarcomere length was 0.084 +/- 0.023 (mean +/- SD) in myocytes from C hearts compared with 0.132 +/- 0.014 in myocytes from T hearts (n = 50 myocytes per group). The Deltamaximal tension was 5.11 +/- 1.42 kN/m(2) in C myocytes and 9.01 +/- 1.28 in T myocytes. We conclude that exercise training increases the length dependence of maximal and submaximal tension in cardiac myocytes, and this change may underlie, at least in part, training-induced enhancement of myocardial function.

Regional differences in effects of exercise training on contractile and biochemical properties of rat cardiac myocytes.

Myocardial function is enhanced by endurance exercise training, but the cellular mechanisms underlying this improved function remain unclear. A number of studies have shown that the characteristics of cardiac myocytes vary across the width of the ventricular wall. We have previously shown that endurance exercise training alters the Ca2+ sensitivity of tension as well as contractile protein isoform expression in rat cardiac myocytes. We tested the hypothesis that these effects of training are not uniform across the ventricular wall but are more pronounced in the subendocardial (Endo) region of the myocardium. Female Sprague-Dawley rats were divided into sedentary control (C) and exercise trained (T) groups. T rats underwent 11 wk of progressive treadmill exercise. Myocytes were isolated from the Endo region of the myocardium and from the subepicardial (Epi) region of both T and C hearts. We found an increase in the Ca2+ sensitivity of tension in T cells compared with C cells, but this difference was larger in the Endo cells than in the Epi cells. In addition, we found a training-induced increase in atrial myosin light chain 1 (aMLC1) expression that was larger in the Endo compared with Epi samples. We conclude that effects of exercise training on myocyte contractile and biochemical properties are greater in myocytes from the Endo region of the myocardium than those from the Epi region. In addition, these results provide evidence that the increase in aMLC1 expression may be responsible for some of the training-induced increase in myocyte Ca2+ sensitivity of tension.

Laser-assisted arthroscopic ulnar shortening.

The purpose of this study is to evaluate arthroscopic ulnar shortening with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser for the treatment of ulnocarpal abutment syndrome (UAS). This is a retrospective review of the experience of a single surgeon using this technique between 1994 and 2000. Unloading the ulnocarpal joint is the recognized treatment of UAS. Ulnar shortening via a diaphyseal osteotomy and plating (USO) has been used with good results; however, nearly 50% of patients will require hardware removal. Researchers have reported similar results between open distal ulnar resection (the wafer procedure) and USO for the treatment of UAS. Researchers have also reported similar results with mechanical arthroscopic distal ulnar resections (arthroscopic wafer distal ulnar resection [AWP]) for UAS. Eleven patients who underwent Ho:YAG laser-assisted arthroscopic distal ulnar resection were retrospectively evaluated. The average follow-up time was 31 months, with a range of 7 to 61 months. Evaluation using Darrow' s criteria revealed 64% excellent (7 of 11), 18% good (2 of 11), 9% fair (1 of 11), and 9% poor (1 of 11) results. The average return to work time was 4.7 months, with a range of 1.5 to 16 months. Complications included 1 repeat surgery for ulnocarpal scar formation, 2 cases of transient tendonitis, and 1 portal site erythema without drainage that was treated with antibiotics. One patient (the one with a poor result) has not returned to work for unrelated reasons. chi- square analysis (P <.05) was unable to identify a statistical difference between the reported results of arthroscopic wafer procedures, USOs, and open wafer procedures. We concluded that Ho:YAG laser-assisted arthroscopic ulna shortening procedures show similar results to those reported for arthroscopic wafer procedures, open wafer procedures, and USOs. Return to work times are similar to those reported by other researchers, as is the return to preoperative occupation rate. There is no need for late removal of hardware, as is sometimes associated with USO. Our experience has been that the Ho:YAG laser removes hyaline cartilage and subchondral bone rapidly and with little debris, and thus facilitates the ulna shortening procedure.

Outcome of first-time endoscopic carpal tunnel release in a teaching environment.

PURPOSE: The purpose of this study was to dissect cadaver hands used in the teaching of the Chow endoscopic carpal tunnel release (ECTR) technique and determine the adequacy of transverse carpal ligament (TCL) release and any complications. TYPE OF STUDY: Cadaveric study. METHODS: ECTR was performed on 573 cadaver hands using either the transbursal Chow technique (n = 147) or the extrabursal Chow technique (n = 426). After dissection, the adequacy of the TCL release and any complications were recorded. RESULTS: With the transbursal technique, 58% of the specimens had a complete TCL release. Complications were noted in 11 specimens (7%). Using the extrabursal technique, 70% of the specimens had a complete TCL release. Complications were noted in 15 specimens (4%). The difference in complication rates between the transbursal and extrabursal techniques was significant (P <.05) as was the incidence of partial release (P <.01). CONCLUSIONS: The extrabursal Chow technique is preferred and practice on cadaver specimens is recommended before clinical application.

A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome.

PURPOSE: Treatment of ulnocarpal abutment (UAS) syndrome involves decompression of the pressure and impingement, or abutment of the ulnocarpal articulation. Debridement of triangular fibrocartilage complex (TFCC) tears alone in the patient with UAS may have a failure rate of as much as 25% to 30%. Ulnar shortening osteotomy (USO) can be an effective treatment of failed TFCC debridement. Good results have been reported with combined arthroscopic TFCC debridement and mechanical arthroscopic distal ulnar resection. Similar results have been reported with both ulnar shortening osteotomy and open wafer distal ulnar resections in the UAS patient. Because all of these treatment choices appear to yield similar relief of symptoms, determination of the optimal treatment protocol remains a point of debate. The purpose of this study was to evaluate 2 different surgical treatments for UAS. TYPE OF STUDY: Retrospective review. METHODS: Eleven combined arthroscopic TFCC debridement and arthroscopic distal ulna resections (arthroscopic wafer procedures; AWP) were compared with 16 arthroscopic TFCC debridement and USOs. All patients had diagnostic wrist arthroscopy and arthroscopic TFCC debridement. All patients presented with ulnar wrist pain or neutral or positive ulnar variance, and all experienced at least 3 months of failed conservative management. RESULTS: At mean follow-up times of 21 and 15 months, respectively, 9 of 11 patients showed good to excellent results after arthroscopic TFCC debridement and AWP compared with 11 of 16 after arthroscopic TFCC debridement and USO. A statistically significant difference (P <.05) in the complication rates was identified, including secondary procedures and tendonitis. One secondary procedure and 2 cases of tendonitis were seen in the arthroscopic wafer group. CONCLUSIONS: Combined arthroscopic TFCC debridement and arthroscopic wafer procedure provides similar pain relief and restoration of function with fewer secondary procedures and tendonitis when compared with arthroscopic TFCC debridement and USO, for the treatment of UAS. LEVEL OF EVIDENCE: Level III.

Endoscopic carpal tunnel release.

Endoscopic carpal tunnel release is not a procedure to be taken lightly. Like many surgical procedures, it is a demanding exercise that requires exacting knowledge of the anatomy of the hand, attention to detail, and the ability to manipulate three-dimensional objects while observing them in two dimensions on a video screen. In the hands of well trained surgeons, ECTR provides patients with a safe, predictable solution to their carpal tunnel sydrome that will allow them a rapid return to normal activities with minimal postoperative discomfort.

First carpometacarpal arthroplasty with ligamentous reconstruction: a long-term follow-up.

BACKGROUND: The purpose of the present study is to evaluate a single surgeon's short, intermediate, and long-term clinical, functional, and radiographic outcomes with a trapeziectomy with flexor carpi radialis (FCR) suspension arthroplasty without tendon interposition (LRSA). METHODS: Twenty-one patients underwent 26 FCR suspension arthroplasties without tendon interposition by a single senior surgeon. All patients had Eaton stage III and IV carpometacarpal (CMC) osteoarthritis. The Patient-Rated Wrist and Hand Evaluation (PRWHE) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) were used to evaluate functional outcomes. A comprehensive strength and range of motion evaluation was performed to evaluate clinical outcomes. Plain radiographs at rest and with maximal pinch were performed to evaluate for arthroplasty space subsidence. RESULTS: The LRSA exhibited consistent clinical and functional outcomes throughout postoperative follow-up. As the average patient age and time from surgery increased, range of motion (ROM) and PRWHE scores stayed relatively constant, while lateral tip and tip pinch strength deteriorated with time. The LRSA prevented the proximal migration of the first metacarpal in all but one patient. No patients required revision arthroplasty following LRSA. CONCLUSIONS: This study demonstrates the consistent short, intermediate, and long-term clinical, functional, and radiographic outcomes following a trapeziectomy with FCR suspension arthroplasty.

Endoscopic detection of compressing fascial bands around the ulnar nerve within the FCU.

BACKGROUND: The aim of this study is to endoscopically evaluate the ulnar nerve proximal and distal to the cubital tunnel after in situ decompression to identify and eventually release fascial bands capable of compressing the ulnar nerve. METHODS: We performed a retrospective review of 16 ulnar nerve compression cases in 12 patients. Eight men and four women with a mean age of 52 years (range, 23-77 years) were clinically diagnosed and confirmed with neurophysiologic studies. A 4-6-cm curvilinear incision was made at the medial elbow, and the ulnar nerve was identified and decompressed at the cubital tunnel. Then, a 2.7-mm endoscope was passed 8 to 10 cm proximal and distal to the medial epicondyle allowing for visualization of the ulnar nerve and its surrounding soft tissues. RESULTS: The endoscopic evaluation of the 16 ulnar nerves demonstrated no compressive bands outside of the cubital tunnel. All patients had satisfactory outcomes. CONCLUSIONS: The good results reported after in situ ulnar nerve decompression have questioned the need for endoscopically assisted decompression of the ulnar nerve proximal and distal to the cubital tunnel. Some authors suggest the existence of fascial bands within the flexor carpi ulnaris (FCU) capable of compressing the ulnar nerve. This study would suggest that fibrous bands deep in the FCU capable of compressing the ulnar nerve do not exist. Our satisfactory outcomes would support the perception that extensive decompression of the ulnar nerve beyond the cubital tunnel is not routinely needed.

Correlation between preoperative Kimura inching studies and intraoperative findings during endoscopic-assisted decompression of the ulnar nerve at the elbow.

BACKGROUND: During the evolution of the senior author's technique of ulnar nerve transposition to in situ decompression for ulnar neuropathy at the elbow, nerve conduction studies (NCS) including the Kimura inching method were performed preoperatively in an effort to ensure that all potential sites of compression were investigated intraoperatively. The purpose of this study is to compare the results of the Kimura inching technique with the intraoperative findings noted during decompression of the ulnar nerve at the elbow. METHODS: The medical records of consecutive patients who underwent in situ decompression of their ulnar nerves combined with endoscopic examination between March and December of 2009 were retrospectively reviewed. The site of ulnar nerve compression noted using the Kimura inching technique was compared with the intraoperative findings. RESULTS: Twelve consecutive patients (four with bilateral symptoms) underwent endoscopic ulnar nerve compression in the study period for a total of 16 cases analyzed. In 12 cases, the Kimura method localized the site of compression to Osborne's bands and/or the aponeurosis of the flexor carpi ulnaris (FCU). Intraoperatively, compression was noted at Osborne's bands, the FCU aponeurosis, and/or the FCU) muscle proper in all 16 patients. There was partial or full correlation between the nerve conduction data and intraoperative findings in 13/16 cases. CONCLUSIONS: There was good but not perfect agreement between the NCS and intraoperative findings, perhaps because transcutaneous NCS are less accurate when a nerve is surrounded by muscle. The information obtained in this study is valuable when planning surgery to address ulnar nerve compression.

Endoscopic-assisted Fascial Decompression for Forearm Exertional Compartment Syndrome: A Case Report and Review of the Literature.

A case of chronic exertional compartment syndrome of the forearm treated with endoscopic-assisted fascial decompression is presented. The diagnosis of exertional compartment syndrome of the forearm was confirmed by direct measurement of intracompartmental pressures. Following endoscopic-assisted fascial decompression, the patient was able to begin rehabilitation therapy within 2 weeks. There were no wound-related complications. The patient reported no recurrence of symptoms after returning to work requiring heavy lifting, and morbidity associated with open decompression was avoided. Endoscopic release is not an option in traumatic compartment syndrome, but a minimally invasive approach may be considered in cases of exertional compartment syndrome. Reports of endoscopic-assisted fascial decompression in exertional compartment syndrome of the forearm are relatively scarce. Confirmation of the safety and efficacy of these evolving techniques in the hand surgery literature remains important.