Adam C. Watts

Patient-Rated Outcome of Ulnar Nerve Decompression: A Comparison of Endoscopic and Open In Situ Decompression

PURPOSE To report patient-rated outcomes after ulnar nerve decompression at the elbow and to compare the outcome after open in situ decompression with that after endoscopic in situ decompression. METHODS Patients having ulnar nerve decompression were evaluated using patient-rated outcome measures. Fifty-five patients were recruited; 3 were lost to follow-up, and 18 were excluded because they had anterior transposition. Of the thirty-four patients followed up for 12 months, 19 had endoscopic decompression and 15 had open in situ decompression. Patient demographics, presenting symptoms, range of elbow movement, grip and pinch strength, and sensation were recorded preoperatively and at 12 months by an independent observer. Postoperative patient satisfaction, pain, and ongoing paresthesia were recorded using visual analog scales. Subgroup analysis was performed to compare the outcome of open in situ decompression with that of endoscopic in situ decompression. RESULTS At 12 months after surgery, the proportion of patients satisfied with the outcome was 9 of 15 (60%) for open in situ surgery and 15 of 19 (79%) for endoscopic in situ surgery. The postoperative complication rate was significantly higher after open in situ decompression than that after endoscopic in situ decompression surgery (10%). Preoperative function scores were predictive of patient-rated satisfaction and were related to McGowan grade. CONCLUSIONS The patient-reported outcome of surgical treatment of cubital tunnel syndrome is good but is affected by preoperative symptom severity. Outcomes after open and endoscopic in situ decompression, including the proportion of patients reporting satisfaction and functional improvement, are equivalent, but more patients reported complications after open decompression. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

The Outcome of Scaphoid Excision and Four-Corner Arthrodesis for Advanced Carpal Collapse at a Minimum of Ten Years

PURPOSE Scaphoid excision and 4-corner arthrodesis is a salvage option for patients with advanced carpal collapse. This study aims to compare the clinical outcomes of 4-corner arthrodesis (FCA) at one year, 2 years, and a minimum of 10 years. METHODS A cohort study was performed of patients having scaphoid excision and FCA procedure by a single surgeon. Thirty-one of 35 recruited were followed up for 10 years. The mean patient age was 47 years. All patients had scaphoid excision and FCA, using bone graft and 3M Shapiro staples (3M, St Paul, MN). Patients were followed up prospectively at one year, 2 years, and a minimum of 10 years after surgery by an independent observer. Three patients were lost to follow-up between the 2-year and 10-year assessments because they were untraceable, and one patient died at 7 years, without any further intervention. Before surgery, pain scores measured with a visual analog scale, range of wrist movement, grip and pinch strength, and scores from a self-assessment functional questionnaire were recorded prospectively. These measures were repeated at each time point, in addition to patient satisfaction scores measured on a visual analog scale. RESULTS The pain scores decreased from a median preoperative score of 6/10 to 0/10 at one year. Grip strength did not change significantly. Wrist flexion decreased significantly after surgery, by an average of 22%. The average patient-reported satisfaction score was 8/10. There was no significant change in pain, wrist function, satisfaction, or arc of motion between one and 10 years. Two of 35 patients recruited had gone on to a total wrist arthrodesis for ongoing pain. CONCLUSIONS The outcome of scaphoid excision and 4-corner arthrodesis is favorable at one year and does not deteriorate significantly between one and 10 years. There is a low rate of conversion to total wrist arthrodesis. Pain scores are reduced at the cost of reduced wrist flexion.

Pyrocarbon Proximal Interphalangeal Joint Arthroplasty: Minimum Five-Year Follow-Up

PURPOSE To report the outcomes, complications, and survivorship of pyrocarbon proximal interphalangeal joint arthroplasty at a minimum of 5-year follow-up. METHODS A review of 97 implants in 72 consecutive patients from our joint arthroplasty database was undertaken. Patient demographics, complications, further surgery, and implant revision were recorded. Objective outcome was assessed by grip strength, range of motion, and radiological assessment of alignment, loosening, and subsidence. Subjective outcome was assessed by Patient Evaluation Measure; Quick Disabilities of the Arm, Shoulder, and Hand score; and visual analog scores (0, best; 10, worst) for appearance, satisfaction, and pain. RESULTS Diagnosis was osteoarthritis in 60 joints, rheumatoid arthritis in 12 joints, psoriatic arthritis in 11 joints, and trauma in 14 joints. The average follow-up was 118 months (range, 60-164 months). The mean arc of motion was 35° (range, 0° to 90°). There was no difference in grip strength between operated and nonoperated side. Of the 97 implants, 36 required additional surgery, of which 14 were revised and 22 required reconstruction around a retained implant. The average Patient Evaluation Measure and Quick Disabilities of the Arm, Shoulder and Hand scores were 33 (range, 10-69) and 35 (range, 0-93), respectively. Mean visual analog scores for pain, satisfaction, and appearance were 2 (range, 0-8), 7 (0-10), and 8 (0-10), respectively. All implants had a lucent line with nearly all classified as either Herren grade 2 or 3. Progressive loosening was seen in 48% of implants. Implant survival as assessed by Kaplan-Meier was 85% at both 5 and 10 years. CONCLUSIONS Good pain relief and maintenance of preoperative arc of motion was achieved with no major deterioration over time. Most implant revisions were performed within 24 months of the index procedure. Currently progressive loosening was not translated into revision surgery. Implant revision rate was higher than with other prostheses. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

MEDIUM-TERM OUTCOME FOLLOWING INTRA-ARTICULAR CORTICOSTEROID INJECTION IN FIRST CMC JOINT ARTHRITIS USING FLUOROSCOPY

First carpometacarpal joint osteoarthritis (1(st) CMCJ OA) is a common condition with variable results reported from local corticosteroid injection. This study aims to explore the medium-term outcome with respect to pain relief, patient satisfaction and the need for subsequent surgical intervention. A prospective review was performed of patients undergoing fluoroscopically guided corticosteroid injection by one surgeon, with postal questionnaires for medium-term follow-up. Forty-one patients were included. Thirty-one were female and ten male, with a mean age of 60 years. In the short term 76% of patients reported pain relief with an average duration of four weeks and 69% of the patients reported benefit from injection. After a median follow-up of 36 months 76% of patients reported continuing pain but 59% reported satisfaction with the outcome. Twenty-eight per cent of the patients had undergone surgery. Local corticosteroid injection of the CMCJ provides only short-term pain relief, but few patients go on to surgical intervention.

Arthroscopic Core Decompression of the Lunate in Early Stage Kienbock Disease of the Lunate

Since the first description of Kienbock disease in 1910, the etiology and treatment have remained controversial topics. Core decompression is an accepted treatment option in early-stage avascular necrosis of the femoral head, and more recently the humeral head. This paper reports the technique of arthroscopic fluoroscopically guided core decompression of the lunate with 6-year results.

An objective assessment of safety to drive in an upper limb cast

Patients managed with upper limb cast immobilization often seek advice about driving. There is very little published data to assist in decision making, and advice given varies between healthcare professionals. There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to patients. Six individuals (three male, three female; mean age 36 years, range 27–43 years) were assessed by a mobility occupational therapist and driving standards agency examiner while completing a formal driving test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast incorporating the thumb [Bennett’s cast]) on both left and right sides. Of the 36 tests, participants passed 31 tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However, driving in a left above-elbow cast was considered unsafe.

Reconstructing the interosseous membrane: a technique using synthetic graft and endobuttons.

Reconstruction of the interosseous membrane is an emerging procedure designed to help restore anatomic and biomechanical relationships within the forearm after a longitudinal instability injury. The indication for this reconstruction is proven acute or chronic longitudinal instability of the forearm. This technique uses a synthetic braided graft tied over endobuttons at radial and ulnar tunnels. It can also be combined with other procedures such as radial head replacement, wafer procedures, and even ulnar shortening osteotomies for comprehensive management of the condition. Early results indicate that this reconstruction can produce clinical improvement in some patients. Further follow-up is required to determine the long-term durability of the construct, but early results are encouraging in a complex patient population.

Cable-augmented, quad ligament tenodesis scapholunate reconstruction: rationale, surgical technique, and preliminary results.

Eight patients underwent scapholunate reconstruction using tensionable suture anchors. Adapted from a modified Brunelli technique, the anchors provide a fixed cable that reduces the scapholunate diastasis and maintains reduction during the healing phase. The flexor carpi radialis tendon graft is advanced through the scaphoid and stabilizes the volar scaphotrapezial ligament, dorsal scapholunate ligament, dorsal intercarpal ligament, and dorsal radiocarpal ligament. The ligament-sparing approach is closed using an ulnar advancement capsulodesis that further reinforces the dorsal intercarpal and dorsal radiocarpal ligament. Good clinical results were obtained. Measured on a visual analog scale (0 to 10), the average pain score improved from 5.8 to 2.1, average patient satisfaction was 7.6, average extension was 56 degrees (91% of contralateral side), flexion was 44 degrees (70% of contralateral side), and grip was strength 41 kg (95% of contralateral side). Radiographic parameters were less favorable. The average scapholunate angle was 71 degrees, radiolunate angle 16 degrees, and scapholunate interval 3.0 mm. The cable-augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages over previously published techniques, but long-term follow-up is required.

Pyrocarbon Metacarpophalangeal Joint Arthroplasty in Noninflammatory Arthritis: Minimum 5-Year Follow-Up

PURPOSE To report the outcomes, complications, and survivorship of pyrocarbon metacarpophalangeal joint arthroplasty in noninflammatory arthropathy at a minimum 5-year follow-up. METHODS A retrospective review of 51 implants in 36 patients was undertaken. Patient demographics, complications, further surgery, and implant revision were recorded. Objective outcome was assessed by grip strength, range of motion, and radiological assessment of alignment, loosening, and subsidence. Subjective outcome was assessed by Patient Evaluation Measure, Quick Disabilities of the Arm, Shoulder and Hand score, and visual analog scores (0, best; 10, worst) for appearance, satisfaction, and pain. RESULTS There were 35 index and 16 middle fingers. The average follow-up was 103 months (range, 60-172 months). The mean arc of motion was 54° (range, 20° to 80°). There was no difference in grip strength between operated and nonsurgical side. Six implants were revised, and 3 of these required additional surgery. The average Patient Evaluation Measure and Quick Disabilities of the Arm, Shoulder and Hand scores were 27 (range, 10-54) and 29 (range, 0-57), respectively. Mean visual analog scores for pain, satisfaction, and appearance were all 1 with the respective ranges being 0-7, 0-4, and 0-6. Most implants were Herren grade 1 lucency with the remaining 5 proximal and 12 distal implants being grade 2. Mean subsidence in the proximal component was 2 mm (range, 0-4 mm) and 1 mm (range, 0-3 mm) in the distal component. The degree of loosening or subsidence did not correlate with outcome. Implant survival as assessed by Kaplan-Meier was 88% at 10 years. CONCLUSIONS Good pain relief, a functional range of motion, and high satisfaction were seen in the majority of patients. All implant revisions were performed within 18 months of the index procedure. This may represent technical issues rather than problems with the implant.

Pain and Carpal Tunnel Syndrome

PURPOSE Pain is not a classical symptom of carpal tunnel syndrome (CTS), with the exception of numbness that is so intense that it is described by patients as painful. The primary aim of our study was to determine which factors correlated with pain for patients diagnosed with CTS. METHODS We prospectively assessed all patients diagnosed with CTS in our unit over a 1-year period. We recorded demographic details for all patients, including past medical history, body mass index, smoking, and occupation. The diagnosis and severity of carpal tunnel syndrome were established through a combination of history, clinical assessment, and nerve conduction studies. Of 275 patients diagnosed and treated for CTS, 183 were women (67%), the mean age was 55 years (range, 22-87 y), and 166 cases were bilateral (60%). The mean body mass index was 29.5 kg/m2 (range, 17-48 kg/m2), and 81 patients smoked (30%). Patients completed a Short Form-McGill pain questionnaire (SF-MPQ) as a measure of pain at initial presentation. We assessed outcome 1 year after intervention using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. RESULTS We found no association between pain according to the SF-MPQ and the positive clinical signs of CTS or positive nerve conduction studies. Multivariate analysis demonstrated that smoking and bilateral disease independently correlated with the overall SF-MPQ, with similar findings on subanalysis. Independent factors associated with an increased improvement in the QuickDASH at 1 year were the presentation QuickDASH score, positive nerve conduction studies, and smoking. CONCLUSIONS The only independent factors that correlated with pain at presentation of CTS were smoking and bilateral disease. Pain according to the SF-MPQ was not associated with classical clinical findings of the disease or with positive findings on nerve conduction testing. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.