Chung-Jung Shao

An Ultrasonographic and Anatomical Study of Carpal Tunnel, with Special Emphasis on the Safe Zones in Percutaneous Release

We examined 40 wrists of 12 embalmed and eight fresh cadavers and defined the relative position of the flexor retinaculum to the neurovascular structure, ultrasonographic markers and safe zones by ultrasonography and anatomical dissection. Both longitudinal and transverse ultrasonographic sections clearly depicted the flexor retinaculum, neurovascular bundles, median nerve, flexor tendons and bony boundaries of the underlying joints. Topographic measurement showed [i] good correlation between the actual extent of the flexor retinaculum and the ultrasonographically determined distance between bony landmarks in all hands, and [ii] the widths and lengths of well-defined safe zones. A comparison study confirmed the accuracy of ultrasonography. We conclude that these ultrasonographic landmarks can locate the flexor retinaculum and facilitate safe and complete carpal tunnel release with open or minimally invasive techniques.

Cadaveric study of sonographically assisted percutaneous release of the A1 pulley.

The purpose of this study was to assess the value of using intraoperative sonography to assist percutaneous release of the A1 pulley in cadavers. By detailed sonographic examination and anatomical exploration, the authors determined the correlation of the actual A1 and A2 pulleys (and adjacent neurovascular bundles not visualized by sonography) to the clearly visualized flexor tendons and the metacarpophalangeal joint. The authors also evaluated their effectiveness as landmarks and the effectiveness of real-time sonographic monitoring during percutaneous release. Experiments were performed on 80 fingers and 20 thumbs in 10 cadavers. All digits were sonographically examined. The clearly delineated bony landmarks of the metacarpophalangeal joint were measured and marked. The A1 and A2 pulleys and the neurovascular bundles were surgically exposed, and their relation to the markers made during sonographic examination was measured. Using these parameters, sonographically assisted percutaneous release of the A1 pulley with a custom-made hook knife was performed on the contralateral side. The completeness of the A1 release and the potential risk of injuries to the A2, flexor tendon, and neurovascular bundles in each digit were examined. Results showed good correlation between the actual length of the A1 pulleys and the sonographically determined distance between the bony prominences of the metacarpophalangeal joint in all digits. Release was complete in 48 of the 50 digits (96 percent) and partial in two, with no injuries to neurovascular bundles. Sonography can clearly delineate the flexor tendon and underlying bony boundary of the metacarpophalangeal joint, which is useful in directing the percutaneous release of the A1 pulley. Sonography can also provide real-time intraoperative monitoring. The results using this new release technique were adequate. The method is safe and its clinical application should be encouraged.

A Cadaveric and Preliminary Clinical Study of Ultrasonographically Assisted Percutaneous Carpal Tunnel Release

The aim of this study was to assess the effectiveness and safety profile of a new technique for ultrasonographically assisted percutaneous carpal tunnel release. Experiments were performed on 40 hands in 20 cadavers. We first performed a detailed ultrasonographic examination and correlation study that included surgical dissection of the transverse carpal ligament, the related neurovascular structures and the bony landmarks of the radiocarpal, midcarpal and carpometacarpal joints of the right hand. We then used the measurements we made for percutaneous carpal tunnel release of the transverse carpal ligament using intra-operative ultrasonography for guidance and a hook knife on the left-hand side. The completeness of the release and the potential risks of injury to the flexor tendon and neurovascular bundles were examined. Using real-time intra-operative ultrasonographic monitoring to clearly delineate these targets, we were able to percutaneously release the transverse carpal ligament completely in 18 (90%) of the 20 hands and partially release it in 2 without injuring any neurovascular bundles. We then performed the procedure on 91 consecutive cases of carpal tunnel syndrome and found that the sensory disturbances disappeared in 100% patients 12 mo post-operatively; only 2 hands were graded as unsatisfactory. There were no intra- or post-operative complications. Based on the results from the cadaveric studies and our successful preliminary clinical outcomes, we conclude that this method is tolerable and that its clinical application can be encouraged.

Inflammation is present in de Quervain Disease--correlation study between biochemical and histopathological evaluation

BackgroundDe Quervain disease is a stenosing condition of the sheath of the abductor pollicis longus and extensor pollicis brevis tendons at the radial styloid process. Previous studies consistently reported that the pathological change of this condition is thought to be primarily an extensor retinaculum thickened by fibrosis and angiogenesis instead of inflammation. Contradictorily, the conservative treatment for de Quervain disease is anti-inflammatory medication. The inflammatory response may be involved in this disease; however, there is no present study directly evidencing whether the inflammatory responses exist in de Quervain disease or not. The histopathology of de Quervain disease is yet to be elucidated clearly. PurposeTo grade all specimens in the different stages and characterize specific inflammatory cell and factors to examine whether inflammatory response is involved in de Quervain disease. MethodsRetinaculum samples were collected from 13 patients with de Quervain disease after surgery. The specimens were evaluated histologically by collagen structure grading and immunohistochemically by quantifying the presence of neutrophil elastase, macrophages, cyclooxygenase, and vascular endothelium. ResultsNeutrophil elastase and cyclooxygenase occur in the de Quervain disease retinaculum and increased with the grade of collagen structure. After angiogenesis, macrophage infiltration occurs in the grade II matrix worse than grade III matrix. ConclusionsInflammation is present in de Quervain disease. This study provides direct evidence for inflammatory cell and infiltration factors and offer valuable clues for specific pharmacological therapies for de Quervain disease.

Sonographically Assisted Percutaneous Removal of Screws in Dynamization of the Interlocking Intramedullary Nail

Dynamization is a method of removing the interlocking screw(s) farthest from the fracture site for improving healing in femoral and tibial fractures that show delayed healing after static interlocking nailing. We describe a simple sonographically assisted technique for percutaneous dynamization of deep‐seated impalpable screws.

Synovial fluid biomarkers: association with chronic rotator cuff tear severity and pain

BACKGROUND We tested the hypothesis that biomarkers in the synovial fluid of the glenohumeral (shoulder) joint are correlated with visual analog scale (VAS) scores, functional scores, and ultrasound findings of chronic rotator cuff tear (RCT) severity. METHODS We measured biomarkers in shoulder joint synovial fluid of 42 patients with partial-thickness (21), nonmassive full-thickness (10), and massive full-thickness (11) RCTs. Pain duration, tear severity, and VAS and functional scores were compared with interleukin (IL) 1β, IL-6, matrix metalloproteinase (MMP) 1, and MMP-13 levels. RESULTS Both MMP-1 and MMP-13 levels were significantly highest in the massive full-thickness group. MMP-13 levels were significantly different between groups, but proinflammatory cytokine IL-1β and IL-6 levels were not. However, IL-1β levels were significantly positively correlated with VAS (r = 0.66; P <.01) and functional scores (r = 0.61; P <.01), but IL-6, MMP-1, and MMP-13 levels were not. CONCLUSIONS IL-1β levels in shoulder synovial fluid correlated positively with shoulder pain and functional scores in patients with chronic RCTs. Both MMP-1 and MMP-13 levels were altered and increased with cuff tear severity.