Ali M. Soltani

Trends in the Surgical Treatment of Cubital Tunnel Syndrome: An Analysis of the National Survey of Ambulatory Surgery Database

PURPOSE To ascertain trends in the surgical treatment of ulnar nerve compression at the elbow within the United States. METHODS We analyzed the National Survey of Ambulatory Surgery to study trends in the treatment of cubital tunnel syndrome from 1994 to 2006. The National Survey of Ambulatory Surgery provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other. The data were then statistically analyzed for trends in treatment, utilization, and demographics. RESULTS A total of 52,133 surgical procedures were recorded in the National Survey of Ambulatory Surgery for the treatment of ulnar nerve compression in 2006. This represents an increase from 26,283 in 1994 and 35,406 in 1996. In the 11 years from 1996 to 2006, the total surgical procedures on the ulnar nerve increased by 47%. Transposition went from 49% of all cubital tunnel procedures in the 1990s to 38% in 2006. In 2006, women were much more likely to have a simple decompression (70%) than a transposition or other technique. Decompression had a mean surgical time of 48 minutes, and transposition had a mean surgical time of 59 minutes. CONCLUSIONS The percentage of transpositions used in the treatment of cubital syndrome has decreased to 37% in the last survey. Possible reasons include expanded indications or changing surgical preferences. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome.

Background: Recurrent and persistent carpal tunnel syndrome is an uncommon but potentially difficult surgical dilemma. Many surgical treatment options have been described in the literature without comparative data on outcome. Methods: A systematic review on recurrent carpal tunnel syndrome was performed for all articles from 1946 to 2012 in MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists from all identified articles. Twenty-three articles were screened and identified from the time period 1972 to 2012, representing two general treatment groups: decompression with flap interposition and repeated open decompression. A meta-analysis was then performed, generating forest and funnel plots of the data. Results: In total, 294 patients from 14 studies in the flap arm of the meta-analysis had a weighted success rate of 86 percent (95 percent CI, 0.75 to 0.96), and 364 patients from nine studies in the nonflap arm had a weighted 75 percent success rate (95 percent CI, 0.66 to 0.84). Heterogeneity was statistically analyzed and revealed low heterogeneity with the I2 statistic. Forest plots were created and analyzed between subgroups, and chi-square analysis revealed a highly statistically significant difference (p = 0.001). The odds ratio of success in the nonflap group was 0.50 (95 percent CI, 0.33 to 0.75). Conclusions: Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression. The relevance of these data is pertinent to all hand surgeons, as they could have an impact on treatment guidelines for this relatively uncommon but problematic condition, but further prospective study is needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Revision Decompression and Collagen Nerve Wrap for Recurrent and Persistent Compression Neuropathies of the Upper Extremity

BackgroundRecurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen conduits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy. MethodsPatients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were retrieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome. ResultsThe mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 postoperatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recurrent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group. ConclusionsHere we report on the novel technique of using a collagen matrix wrap in recurrent compression neuropathies with good success. The collagen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching.

The Variation in the Absence of the Palmaris Longus in a Multiethnic Population of the United States: An Epidemiological Study

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Merkel cell carcinoma of the hand and upper extremity: Current trends and outcomes

Merkel cell carcinomas represent an uncommon yet aggressive skin cancer. We sought to identify changes in incidence and predictors of outcomes and survival of patients with Merkel cell carcinomas of the hand and upper extremity. The Surveillance, Epidemiology and End Results database was used to identify all patients with Merkel cell carcinomas of the skin located specifically in the hand and upper extremity. Overall, 5211 cases were identified in the period from 1986 through 2009. The age-adjusted incidence of Merkel cell carcinoma of the hand and upper extremity increased from 0.02 cases per 100,000 in 1986 to 0.14 cases per 100,000 in 2009. The mean age of these patients was 75 years and positive regional lymph nodes were identified in 33%. Rate of metastasis was 4.1%. Overall survival for the study cohort was 49%. Multivariate analysis identified tumor size >5 cm, positive regional lymph nodes and metastasis at diagnosis as independent predictors of mortality. The incidence of Merkel cell carcinomas has increased substantially over the study period. Overall survival for Merkel cell carcinomas of the body and hand and upper extremity is related to tumor size and extent of disease at time of clinical presentation. Merkel cell carcinomas of the hand and upper extremity tend to be diagnosed at an earlier stage with lower rates of regional and systemic spread, and subsequently have a higher overall survival rate.

Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

AbstractPeripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Metastasis of Hepatocellular and Renal Cell Carcinoma to the Hand

Summary: Malignant carcinoma metastasis to the skeleton is the third most common site of metastasis after lung and liver, usually involving the axial skeleton and the proximal ends of long bones, ribs, and vertebrae. Acrometastasis, metastasis to hands or feet, comprises only 0.1% of all metastases. Here, we present 2 cases of acrometastasis, one from hepatocellular carcinoma and the other from renal cell carcinoma. We describe the presentation, radiographs, surgical treatment, and outcomes for each patient. Patients presented with swelling and pain at the tumor sites and were treated with amputations. The second patient’s disease progressed resulting in death shortly after amputation indicating acrometastasis may be a poor prognostic indicator of survival. We review the literature and discuss the importance of disease process recognition and prognosis.

Abstract 217: RECURRENT AND PERSISTENT CARPAL TUNNEL SYNDROME

Purpose: Electrode containing Regenerative Peripheral Nerve Interfaces (RPNIs) along with wireless technology are in development to control prosthetic devices. RPNIs are implanted surgically grafted muscle neurotized with nerve fascicles in the residual limb. Current prosthetic algorithms are derived from surface electromyography; they code for only a few degrees of freedom. RPNIs based on individual fascicles will transmit multiple, independent, isolated motor and sensory signals allowing more degrees of freedom and sensory feedback from prosthetic devices. Our purpose is to characterize individual mixed nerve fascicles and end organ contributions to closed loop neural control.

Trends in the Surgical Treatment of Cubital Tunnel Syndrome: An Analysis of the NSAS Database

Methods: The National Survey of Ambulatory Surgery (NSAS) was analyzed to study current trends in the treatment of compression neuropathy of the ulnar nerve, or cubital tunnel syndrome. The NSAS provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the NSAS database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other.