Joel C. Klena

Results of endoscopic carpal tunnel release relative to surgeon experience with the Agee technique.

PURPOSE To establish the rate of iatrogenic injury after endoscopic carpal tunnel release (ECTR) for a surgeon in the first 2 years of practice; to report the rate of conversion from ECTR to open carpal tunnel release (OCTR), the reason for conversion, and any increase in morbidity found in patients converted to OCTR; and to determine whether the conversion rate decreased with increasing surgeon experience. METHODS We conducted a retrospective review of patients undergoing ECTR by a single surgeon in the first 2 years of practice. Data collected or calculated included symptom relief, rate of conversion to OCTR, reason for conversion, and neurovascular complications. For patients converted to OCTR, we assessed satisfaction and function using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these results for 1 to 6 months, 7 to 12 months, and 12 to 24 months to determine whether a learning curve was present. RESULTS A total of 278 patients (358 procedures) underwent ECTR. Of these, 12 patients required conversion to OCTR during the index procedure over a 2-year period. In the first 6 months of practice, 8 of 71 ECTRs were converted to OCTR compared to 1 of 72 in the second 6 months. This was a statistically significant decrease (p = .017). In year 2, 3 of 215 patients were converted to OCTR. Average Disabilities of the Arm, Shoulder, and Hand score for patients converted from ECTR to OCTR was 9. No patients required repeat surgery for recurrence of carpal tunnel symptoms. We observed no major neurovascular complications. CONCLUSIONS A learning curve for ECTR was present. Rates of conversion significantly diminished with increased surgeon and anesthesia experience. Patients requiring conversion showed no variation in Disabilities of the Arm, Shoulder, and Hand scores from established values after OCTR. Patients may be at a higher risk of conversion to OCTR during the learning curve time period; nevertheless, we found no increased morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Predicting the Outcome of Revision Carpal Tunnel Release

PURPOSE To test the hypothesis that the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms would serve as a good predictor of the outcome of later carpal tunnel release (CTR). METHODS We conducted a retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome over a 2-year period at our institution. A total of 28 wrists in 23 patients met inclusion criteria. We evaluated patients to determine whether preoperative factors or the result of injection predicted the outcome of revision CTR. We used a multivariate logistic regression analysis to predict surgical success when multiple preoperative findings were considered. RESULTS Of the 23 wrists that had relief from injection, 20 had symptom improvement with surgery. Although they did not reach statistical significance, the sensitivity and positive predictive value for injection alone predicted outcome of revision CTR in 87%. No patient characteristic or physical examination finding predicted successful revision CTR. Multivariate logistic regression analysis combining preoperative injection results with physical examination findings (numbness and/or motor weakness in median nerve distribution, positive Durkin test, and positive Phalen test) provided a sensitivity of 100% and a specificity of 80%. CONCLUSIONS In a small group of patients with recurrent carpal tunnel syndrome, cortisone injection into the carpal tunnel was not, by itself, a statistically significant predictor of successful revision surgery. However, relief from injection as a diagnostic test for predicting successful revision CTR was found to have both a high sensitivity and a positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish surgical success with revision CTR. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Anomalous tendon to the middle finger for sagittal band reconstruction: report of 2 cases.

Multiple techniques with good outcomes have been described for sagittal band reconstruction. We describe 2 cases of sagittal band reconstruction using an anomalous slip of the extensor tendon to the middle finger. This anomalous slip can be a resource for surgical reconstruction that can add stability to primary sagittal band repair.

Clinical Outcomes of Endoscopic Carpal Tunnel Release in Patients 65 and Over

PURPOSE To examine outcomes of endoscopic carpal tunnel release (ECTR) in patients 65 and older. We hypothesized that this population could expect relief of pain, night pain/numbness, and numbness. METHODS A retrospective review was conducted of all patients 65 years of age and over who had ECTR for nerve conduction study-confirmed carpal tunnel syndrome (CTS) from October 2007 to July 2010. The charts were reviewed for demographic data, symptoms and physical findings, patient satisfaction, and 3 patient-reported outcome scores. Preoperative and postoperative results for pain, night pain/numbness, and numbness were compared. Logistic regression analysis was used to assess whether age influenced symptom resolution. Boston carpal tunnel, Short Form-36 and Disabilities of the Arm, Shoulder, and Hand scores were compared between patients with mild, moderate, or severe CTS. RESULTS A total of 78 patients had ECTR. Their ages ranged from 65 to 93 years (mean, 73 y). Before surgery 69% of patients had constant numbness. Night pain/numbness was present in 65 patients before surgery, and 61 had complete resolution. All 70 patients who presented with pain reported complete relief by the 6-month follow-up. Following ECTR, the average Boston carpal tunnel symptom severity, functional status, and Disabilities of the Arm, Shoulder, and Hand scores were 1.5,1.5, and 13, respectively. At final evaluation, 79% of patients were very satisfied or satisfied with their outcome. A significant number of patients were found to have improvement in pain, night pain/numbness, and numbness following ECTR. CONCLUSIONS This study has demonstrated relief of symptoms in a statistically significant number of patients following ECTR. We found that preoperative CTS severity, based on nerve conduction study result, did not significantly correlate with patient outcome following ECTR. Advanced symptoms at presentation do not preclude symptom resolution and should not be a contraindication to ECTR. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Pitfalls of Wrist MR Imaging

The radiologist serves as an indispensable consultant for those patients with wrist pain, by determining the causes of the pain and severity of the injury, helping to determine treatment options, and providing preoperative guidance for surgery, if planned. This article reviews normal anatomic variants and potential danger areas encountered by the radiologist when interpreting magnetic resonance imaging of the wrist.

Anomalous Extensor Tendons to the Long Finger: A Cadaveric Study of Incidence

PURPOSE To evaluate the incidence and anatomic insertion sites of extensor medii proprius and extensor indicis medii communis tendons to the long finger in cadaveric dissection and to describe the insertion of the extensor medii proprius. METHODS Thirty randomly selected adult cadavers, 44 upper extremities, were examined for the presence or absence of an anomalous extensor tendon to the long finger. If present, tendon origin and insertion sites were documented, and the width of the tendon was evaluated. RESULTS The extensor medii proprius was observed in 4 of 44 extremities, an incidence of 9%. The extensor indicis medii communis was observed in 7 of 44 extremities, an incidence of 16%. Tendon widths for both the extensor medii proprius and extensor indicis medii communis specimens ranged from 1.5 to 3.0 mm. CONCLUSIONS The incidence of an anomalous slip of tendon to the long finger might be higher than previously reported, with a combined incidence of 25% in this cadaveric study. This anomalous slip can be a resource for surgical reconstruction. CLINICAL RELEVANCE The presence of anomalous tendinous slips to the long finger can be easily overlooked. Understanding the anatomical relationships, incidence, and donor tendon availability of these anomalous tendons might aid with surgical planning.

Closed reduction and treatment of 2 volar thumb metacarpophalangeal dislocations: report of 2 cases.

Volar dislocation of the metacarpophalangeal joint of the thumb may be irreducible by closed means. We describe 2 patients with volar dislocation of the thumb metacarpophalangeal joint treated with closed reduction and casting.

Levels of evidence have increased for musculoskeletal trauma questions on the orthopaedic in-training examination.

OBJECTIVE The purpose of this study was to determine if the levels of evidence for primary journal articles used as references for musculoskeletal trauma questions on the Orthopaedic In-Training Examination (OITE) have increased over a 15-year period. DESIGN Basic science article. SETTING Geisinger Medical Center (Danville, PA), tertiary referral center. PARTICIPANTS All 329 questions in the musculoskeletal trauma content domain on the OITE from 1995 to 1997 and 2010 to 2012 were reviewed. Baseline characteristics for each question and each reference were recorded. References were categorized as a textbook, a journal review article, an instructional course lecture, or a primary journal article. For each primary journal article, the level of evidence for the article was determined in accordance with the American Academy of Orthopaedic Surgeons Levels of Evidence Guidelines. RESULTS The level of evidence used for primary journal articles demonstrated a statistically significant increase from 1995 to 1997 to 2010 to 2012. Overall, 27% of primary journal articles cited on the 1995 to 1997 OITEs were level I, II, or III studies, increasing to 43% during the 2010 to 2012 period (p = 0.04). The Buckwalter classification for the OITE questions changed significantly between the 2 periods, with questions from 2010 to 2012 including more T1 questions (25% vs 39%) and fewer T3 questions (46% vs 39%, p = 0.016). The Journal of Bone and Joint Surgery and the Journal of Orthopaedic Trauma were the most frequently cited journals overall. CONCLUSIONS The levels of evidence for primary journal articles cited on the OITE for questions within the musculoskeletal trauma content domain have increased between 1995 and 2012. Our analysis can be used as a guide to help examinees prepare for musculoskeletal trauma questions on the OITE and as an aid in core curriculum development.

Magnetic Resonance Imaging After Endoscopic Carpal Tunnel Release

PURPOSE To determine with magnetic resonance imaging (MRI) the morphologic changes in the carpal tunnel and median nerve 3 months after endoscopic carpal tunnel release (ECTR). METHODS We enrolled patients who had complete resolution of numbness and pain by 6 weeks after ECTR. Patients who met these inclusion criteria received an MRI at 3 months after surgery. Images were analyzed to determine whether median nerve morphology changes and discrete gap or separation of the flexor retinaculum could be appreciated on MRI. RESULTS There were 17 patients screened and 15 met the inclusion criteria. Three-month MRI in all patients demonstrated changes in the flexor retinaculum over the median nerve. In all 15 patients, a distinct gap or separation in the fibers of the flexor retinaculum overlying the median nerve could not be appreciated. Median nerve width-to-height ratios at the level of the pisiform and at the hook of the hamate were 2.4 and 2.1, respectively. Median nerve cross-sectional area was 14.1 at the pisiform and 13.3 at the hook of the hamate. CONCLUSIONS MRI of patients 3 months after successful ECTR does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures

PURPOSE Standard 0.58 mg (0.25 mL) collagenase Clostridium histolyticum (CCH) preparations result in unused CCH that is often discarded. Our purpose was to assess the results on Dupuytren contractures affecting both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the same digit utilizing an injection containing the maximum CCH volume that can be withdrawn from a single vial. METHODS A consecutive series of patients with MCP and PIP cords in the same digit received a single treatment with 2 injections totaling 0.30 mL distributed between the MCP and the PIP cords and underwent manipulation approximately 24 hours later. Reduction in contracture, clinical success, and complications were assessed 30 days after manipulation. RESULTS Thirty-one patients (34 digits) had a mean preinjection flexion contracture of 50° at the MCP joint and 53° at the PIP joint. Clinical success (reduction in joint contracture to 0°-5° of full extension 30-days postmanipulation) was noted in 65% of MCP cords and 38% of PIP joint cords. We had a 24% incidence of skin tears, which correlated with the degree of preinjection contracture. CONCLUSIONS For Dupuytren contractures involving the MCP and PIP joints in the same digit, distributing the maximum amount of CCH that can be withdrawn from a single vial provides efficacy at both joints that is similar to that reported in previously published series, with a comparable complication rate. Utilizing excess CCH typically discarded may provide cost savings. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.