Jack Choueka

The Negative Effect of Carpal Tunnel Syndrome on Sleep Quality

Objective. Sleep disturbances are common in patients with carpal tunnel syndrome (CTS). This study investigates the impact of CTS on sleep quality and clarifies the magnitude of this relationship. Methods. This is a prospective investigation of patients with CTS. Patients responded to the Levine-Katz Carpal Tunnel and the Pittsburgh Sleep Quality Index (PSQI) questionnaires to assess symptom severity and quality, respectively. Descriptive and bivariate analyses summarized the findings and assessed the correlations between CTS severity and sleep quality parameters. Results. 66 patients (53F, 13M) were enrolled. Patients reported a sleep latency of 30.0 (±22.5) minutes, with a total sleep time of 5.5 (±1.8) hours nightly. Global PSQI score was 9.0 (±3.8); 80% of patients demonstrated a significant reduction in sleep quality (global PSQI score >5). Increased CTS symptom and functional severity both resulted in a significant reduction in quality and time asleep. Both significantly correlated with subjective sleep latency, sleep disturbance, use of sleep promoting medications, daytime dysfunction, and overall global PSQI score. Conclusions. The findings confirm the correlation of sleep disturbances to CTS, that is, significant reduction of sleep duration and a correlation to sleep quality. Patients sleep 2.5 hours less than recommended and are at risk for comorbid conditions.

Synovial Chondromatosis of the Upper Extremity

Synovial chondromatosis is a rare, benign, proliferative cartilaginous lesion arising from the synovial tissue or bursal lining of or near joints. This disease process can be classified into intra-articular and extra-articular, or tenosynovial, subtypes. Diagnosis can often be delayed due to the rarity of the disease and its nonspecific symptoms of pain, reduced range of motion, or swelling. This article reviews the literature and describes the classification, clinical course, demographics, diagnosis, histology, and treatment of synovial chondromatosis and tenosynovial chondromatosis in the upper extremity.

The Posterior Bundle’s Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study

PURPOSE There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligaments effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. METHODS We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. RESULTS At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. CONCLUSIONS An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. CLINICAL RELEVANCE The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically.

Fluoroscopy-assisted stress testing of the thumb metacarpophalangeal joint to assess the ulnar collateral ligament

BackgroundDiagnostic stress testing of ulnar collateral ligament (UCL) injuries of the thumb metacarpophalangeal (MCP) joint is pivotal to determining treatment. Comparison to the uninjured extremity and fluoroscopy-assisted examination are readily available modalities in the assessment of these patients, with 5–10° differences impacting treatment. Comparative examination, however, assumes that both extremities are normally equal, which has never been verified experimentally. Comparison of clinical and fluoroscopic examination has also never been scrutinized.MethodsOne hundred asymptomatic participants underwent both fluoroscopic and traditional stress examinations to determine maximum passive radial deviation at neutral MCP flexion.ResultsAbsolute clinical vs. fluoroscopic differences demonstrated a significant difference of 5.6° (SD 5.1°). Absolute variability between left-to-right measurements was 4.5° (SD 4.1°) and increased significantly as baseline stress deviation increased (R = 0.43; p < 0.001). Left-to-right difference exhibited no correlation to age, gender, or BMI.ConclusionsThe current investigation demonstrates right–left differences and differences between clinical and fluoroscopic testing of which practitioners should be aware when making treatment decisions for UCL injury of the thumb MCP joint.

The epidemiology of finger dislocations presenting for emergency care within the United States

Background: There are little demographic data on finger dislocation injuries. This study examines the epidemiological characteristics of patients presenting for emergency care of finger dislocations within the United States. Methods: The National Electronic Injury Surveillance System was queried for finger dislocation injuries treated in US emergency departments between 2004 and 2008. Weighted estimates, in conjunction with Census data, were used to analyze patient demographics, injury locales, and incidence rates within and between, demographic groups. Results: During the 5-year study period, an estimated 166 561 finger dislocations were treated in 1 499 222 917 person-years: an incidence rate of 11.11 per 100 000 person-years. Males were predominantly affected (78.7%) at an incidence rate of 17.8 per 100 000. The rate in females was 4.65 per 100 000 person-years. Most dislocations occurred in the 15- to 19-year age group (38.6 dislocations per 100 000 person-years). Among racial groups, blacks (16.8) were affected more than whites (7.72) or patients characterized as “other” (4.90). In terms of injury venue, 35.9% of cases took place at a sporting or recreational facility. In addition, 44.7% of sports-related dislocations occurred while playing either basketball or football. Conclusions: In the United States, finger dislocations appear to occur most often in black males 15 to 19 years of age and among sports participants, particularly basketball and football players.

Evaluating Periarticular Screw Margins for Locking Plate Osteosynthesis of Proximal Humerus Fractures

Introduction: The purpose of this study was to determine whether placing screws farther from the articular cortex could achieve comparable levels of purchase to the more deeply buried configurations currently recommended (between 5 and 8 mm from the articular surface), thus lowering the risk of screw cutout. Methods: Locking screws were inserted into synthetic composite models of osteoporotic bone at depths corresponding to 8, 11 and 14 mm from the articular surface of an anatomic reference model and subjected to mechanical testing. This protocol was then recapitulated in 24 paired cadaveric humeral specimens to assess the forces required to dislodge screws at depths of 8 and 14 mm from the articular surfaces. Results: The average pullout strengths of screws positioned 8, 11 and 14 mm from the articular surface in the synthetic bone composites were 145.64, 140.31 and 140.36 N respectively, demonstrating no significant difference. Pullout testing was performed with screw depths of 8 and 14 mm from the articular surfaces in 24 paired proximal humerus samples. The mean pullout strength of screws 8 and 14 mm from the articular surface were 23.92 and 21.79 N respectively (p=0.37). Conclusion: This study demonstrates no significant difference in locking screw purchase up to 14 mm of the articular margin. Increasing the periarticular distance of locking screws can help confer strength and stability to the implant, while simultaneously mitigating the risk of screw cutout. Clinical relevance: Biomechanical study comparing screw purchase of varying periarticular margins to decrease risk of screw cutout without sacrificing fixation.

Intracompartmental Versus Extracompartmental Transposition of the Extensor Pollicis Longus for Treating Thumb-in-Palm Deformity: A Biomechanical Comparison

PURPOSE Transecting the extensor pollicis longus (EPL) tendon and rerouting it through the first extensor compartment is an established technique for treating thumb-in-palm deformity (TIPD). An alternative technique that approximates the trajectory of the first extensor compartment without violating the compartment or transecting the EPL tendon can be accomplished by creating an artificial sheath from the extensor retinaculum to radialize the tendon glide path. This study compares this extracompartmental (EC) EPL transposition to the established, intracompartmental (IC) transposition by evaluating, in a cadaver model, the extent of thumb extension in both techniques. METHODS Eighteen fresh-frozen cadaveric hands were each tested under 3 different conditions: EPL in situ (baseline); EPL rerouted above the first extensor compartment (EC); and EPL rerouted through the first extensor compartment (IC). A controlled traction of 10 N was applied to the EPL under each condition. The range of thumb extension with respect to the fixed index finger was recorded utilizing infrared reflective markers and digital video capture. RESULTS The mean extension of the thumb with the EPL tendon in situ was 16.7°. The mean extension of the thumb was 22.0° with the EC transposition versus 25.0° with the IC technique. The measured thumb extension in both the EC and the IC techniques were found to be similar because both EPL transpositions yielded a significant difference in thumb extension when compared with baseline. CONCLUSIONS This biomechanical model demonstrates that radial transposition of the EPL tendon enhances extension of the thumb regardless of whether the tendon is routed through, or superficial to, the first extensor compartment. CLINICAL RELEVANCE A novel technique, the EC EPL transposition, offers a similar enhancement in measured thumb extension as the already-described IC EPL transposition.

The Relative Contribution to Small Finger Abduction of the Ulnar Versus Radial Slip of the EDM: Implications for Tendon Transfers

Background: The extensor digiti minimi (EDM) tendon is commonly divided into a radial slip (EDM-R) and an ulnar slip (EDM-U). To our knowledge, the degree to which each EDM slip concomitantly abducts the small finger with active extension has not been formally tested. This study sought to characterize the comparative contributions of finger abduction inherent to each slip of the EDM to observe the sequelae of active small finger extension following transfer of the contralateral slip. Methods: Eighteen fresh-frozen cadaveric hands were used in this study. Starting with the hand in resting position, a controlled traction of 10 N was applied to each slip of the EDM tendon. The range of small finger abduction with respect to the fixed ring finger was recorded utilizing infrared reflective markers tracked through the range of motion using a digital video camera. Results: The mean abduction of the small finger when the radial slip of the EDM tendon was tested was 13.33° (95% confidence interval [CI]: 10.10°-16.55°), which was significantly different (P ≤ .001) than small finger abduction produced by the ulnar slip of the EDM, with a mean of 23.72° (95% CI: 19.40°-28.04°). Conclusions: Given the fact that the ulnar slip of the EDM tendon is shown to be the major contributor of aberrant abduction with active small finger extension, as traction on this slip produces almost twice as much abduction as the radial slip, the EDM-U is the ideal donor graft with respect to tendon transfers of the EDM.

Utilization and Impact of Social Media in Hand Surgeon Practices

Background: Social media is an effective tool to enhance reputation and brand recognition and is being used by more than 40% of patients when selecting a physician. This study aimed to evaluate the use of social media in hand surgeon practices, and to assess the impact that one’s social media presence has on physician-rating website scores (PRWs). Methods: Randomly selected hand surgeons from across the United States were identified. Sequential searches were performed using the physicians name + the respective social media platform (Facebook, LinkedIn, YouTube, Twitter, Instagram, personal website, group website). A comprehensive social media utilization index (SMI) was created for each surgeon. Utilizing descriptive statistics, we assessed the effect of social media on the PRW. Results: A total of 116 board-certified hand surgeons were included in our study. The sample identified 10.3% of the population used Facebook, 1.7% used Twitter, 25.8% used YouTube, 22.4% used LinkedIn, 27.5% used a personal website, and 36.2% used a group website, 0% used Instagram. The average SMI was 1.53 ± 1.42 (0-6). Physicians with a personal website received higher Healthgrades scores than those without one (P < .05). Analysis of SMI demonstrated that hand surgeons with an index less than 3 received lower Healthgrades scores compared to those with an SMI above 3 (P < .001). Conclusion: Hand surgeons underutilize social media platforms in their practice. A personal website is single most important social media platform to improve HealthGrades score in hand surgeons.

Retrospective Analysis of Geriatric Patients Undergoing Hip Fracture Surgery: Delaying Surgery Is Associated With Increased Morbidity, Mortality, and Length of Stay

Introduction: Hip fractures are common in elderly patients. However, this population frequently presents with significant medical comorbidities requiring extensive medical optimization. Methods: This study sought to elucidate optimal time to surgery and evaluate its effect on postoperative morbidity, mortality, and length of stay (LOS). We performed a retrospective analysis of data collected from 2008 to 2010 on 841 patients who underwent hip fracture surgery. Patients were classified based on time to surgery and were also classified and analyzed according to the American Society of Anesthesiologists (ASA) physical classification system. Results: Patients with a delay of greater than 48 hours had a significant increase in overall LOS, postoperative days, and overall postoperative complications. Patients classified as ASA 4 had an odds ratio for postoperative morbidity of 3.32 compared to the ASA 1 and 2 group (P = .0002) and 2.26 compared to the ASA 3 group (P = .0005). Delaying surgery >48 hours was also associated with increased in-hospital mortality compared to 24 to 48 hours (P = .0197). Increasing ASA classification was also associated with significantly increased mortality. Patients classified as ASA 4 had 5.52 times the odds of ASA 1 and 2 (P = .0281) of in-hospital mortality. Those classified ASA 4 had 2.97 times the odds of ASA 3 (P = .0198) of an in-house mortality. Anesthetic technique (spinal vs general) and age were not confounding variables with respect to mortality or morbidity. Discussion: Surgical timing and ASA classification were evaluated with regard to LOS, number postoperative days, morbidity, and mortality. Conclusions: Delaying surgery >48 hours, especially in those with increased ASA classification, is associated with an increase in overall LOS, postoperative days, morbidity, and mortality. However, rushing patients to surgery may not be beneficial and 24 to 48 hours of preoperative optimization may be advantageous.