Rick Tosti

Comparison of Ultrasound and Electrodiagnostic Testing for Diagnosis of Carpal Tunnel Syndrome Study Using a Validated Clinical Tool as the Reference Standard

BACKGROUND Ultrasound examination is both accurate and cost-effective for the confirmation of a clinical diagnosis of carpal tunnel syndrome. Previous studies have shown electrodiagnostic testing and ultrasound to be similar with regard to sensitivity and specificity. The purpose of this study was to compare the sensitivity and specificity of ultrasound and electrodiagnostic testing by using a validated clinical diagnostic tool as the reference standard. METHODS All consecutive patients referred to an upper-extremity practice for electrodiagnostic testing for any reason over a three-month period were recruited to participate in this study. All patients were evaluated with the use of the Carpal Tunnel Syndrome 6 (CTS-6) clinical diagnostic tool, and a score of ≥12 was considered positive for carpal tunnel syndrome. A positive finding on ultrasound was considered to be a cross-sectional area of the median nerve, measured just proximal to the level of the pisiform, of ≥10 mm(2). A positive finding on electrodiagnostic testing was a distal motor latency of ≥4.2 ms and/or a distal sensory latency of ≥3.2 ms. Sensitivity, specificity, and accuracy were calculated for ultrasound and electrodiagnostic testing with use of the CTS-6 as the reference standard. RESULTS With use of the CTS-6 as the reference standard, ultrasound had a sensitivity of 89% and a specificity of 90% in our series of eighty-five patients. Electrodiagnostic testing had a sensitivity of 89% and a specificity of 80%. The positive predictive value of ultrasound was 94% compared with 89% for electrodiagnostic testing. The negative predictive value of ultrasound was 82% compared with 80% for electrodiagnostic testing. Ultrasound was accurate in seventy-six (89%) of the eighty-five cases whereas electrodiagnostic testing was accurate in seventy-three (86%) of the eighty-five cases (p = 0.5). CONCLUSIONS While ultrasound will not replace electrodiagnostic testing in complicated or unclear cases, in a select group of patients with a positive CTS-6, ultrasound can be used to confirm the diagnosis of carpal tunnel syndrome with better specificity and equal sensitivity as compared with those of electrodiagnostic testing. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is Antibiotic Prophylaxis Necessary in Elective Soft Tissue Hand Surgery

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).

Kirschner wire infections in pediatric orthopaedic surgery.

Background: Few studies have described the presentation, bacteriology, risk factors, and complications of Kirschner wire infections in pediatrics. The purpose of this study is to describe these factors to better understand, prevent, and treat infectious complications of smooth wires. Methods: A retrospective review was performed to identify all patients (birth to 16 y) who were hospitalized for Kirschner wire infection from 1995 to 2012. Presentation, hospital course, bacteriology, outcomes, and complications were recorded. A management algorithm was developed from the experience. Results: Kirschner wire infections were present in 12 patients: 5 supracondylar fractures, 3 lateral humeral condylar fractures, a distal tibia physeal fracture, a great toe open fracture, a distal radius fracture, and an elective osteotomy for hallux valgus. The patients presented with cellulitis in 3 cases, soft-tissue abscess in 4 cases, osteomyelitis in 4 cases, and 1 case of toxic shock syndrome. A history of missed appointments or wet dressing was present in 60% of cases. Reoperation was required in 5 patients with abscess, septic arthritis, or osteomyelitis. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen followed by Pseudomonas aeruginosa. Methicillin-resistant S. aureus was not seen. Complications were present in 5 patients and included: loss of range of motion, joint destruction, wound breakdown, catheter migration, and toxic shock syndrome. Conclusions: Infected Kirschner wires are rare and may be maintained in a nonunited bone if the infection is superficial. Infections in this series commonly had a history of missed appointments and wet dressings, which suggests that improved postoperative education may reduce the risk. Osteomyelitis was often preceded by pin-site drainage and failed oral antibiotic therapy. MSSA and Pseudomonas were most commonly cultured and should be considered when empiric antibiotic therapy is necessary. Level of Evidence: Prognostic level IV.

Acute Carpal Tunnel Syndrome

Acute carpal tunnel syndrome is characterized by rapid onset of median neuropathy caused by sudden increases in carpal tunnel pressures, which leads to ischemia of the median nerve. The most common cause is traumatic injury, although atraumatic sources should also be recognized. Patients generally complain of pain, lose two-point discrimination, and may demonstrate elevated compartment pressure on measurement. Prompt recognition and surgical decompression are imperative to spare median nerve viability.

Emerging Multidrug Resistance of Methicillin-Resistant Staphylococcus aureus in Hand Infections

BACKGROUND Methicillin-resistant Staphylococcus aureus has been the most commonly identified pathogen in hand infections at urban centers, but the evolving antibiotic sensitivity profiles of methicillin-resistant Staphylococcus aureus are not known. The purposes of this study are to determine if multidrug resistance in methicillin-resistant Staphylococcus aureus is emerging and to provide current recommendations for empiric antibiotic selection for hand infections in endemic regions. METHODS An eight-year longitudinal, retrospective chart review was performed on all culture-positive hand infections encountered by an urban hospital from 2005 to 2012. The proportions of all major organisms were calculated for each year. Methicillin-resistant Staphylococcus aureus infections were additionally analyzed for antibiotic sensitivity. RESULTS A total of 683 culture-positive hand infections were identified. Overall, methicillin-resistant Staphylococcus aureus grew on culture in 49% of cases; the annual incidence peaked at 65% in 2007. Over the study period, methicillin-resistant Staphylococcus aureus was universally resistant to penicillin, oxacillin, and ampicillin. Clindamycin resistance significantly increased, approaching 20% by 2012 (p = 0.02). Levofloxacin resistance linearly increased from 12% to 50% (p < 0.01). Resistance to trimethoprim-sulfamethoxazole, tetracycline, gentamicin, and moxifloxacin was only sporadically observed. Resistance to vancomycin, daptomycin, linezolid, and rifampin was not observed. CONCLUSIONS Significant increases in resistance to clindamycin and levofloxacin were observed in recent years, and empiric therapy with these drugs may have limited efficacy, especially in urban centers. CLINICAL RELEVANCE Hand infections caused by methicillin-resistant Staphylococcus aureus may be developing increasing resistance to clindamycin and levofloxacin in recent years. This longitudinal study examines the effectiveness of a variety of antibiotics to methicillin-resistant Staphylococcus aureus.

Risk Factors Associated With Clindamycin-Resistant, Methicillin-Resistant Staphylococcus aureus in Hand Abscesses

PURPOSE To identify risk factors for clindamycin resistance in acute hand abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS We performed a retrospective review of 247 consecutive culture-positive hand abscesses from 2010 to 2012 at an urban hospital. Historical and laboratory data from patients with abscesses that grew MRSA with and without clindamycin resistance were compared in a multivariate analysis. RESULTS Methicillin-resistant Staphylococcus aureus grew on culture from 103 abscesses; 16% of those isolates were resistant to clindamycin. Multivariate analysis showed that younger age, intravenous drug use, and nosocomial acquired MRSA were significant risk factors for concurrent clindamycin resistance. Patients with a history of intravenous drug use and nosocomial acquired MRSA were, respectively, 11 and 5 times more likely to have concurrent clindamycin resistance. History of MRSA infection and human immunodeficiency virus were not identified as risk factors. CONCLUSIONS Patients with a history of intravenous drug use or recent contact with health care facilities appear to be a potential reservoir for emerging multidrug-resistant MRSA. Selection of clindamycin as an empiric antibiotic should be especially avoided for these groups. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Surgical Management Principles of Gunshot-Related Fractures

This article discusses contemporary management strategies for gunshot-related fractures with special attention paid to the initial evaluation, role of debridement, principles of fixation, need and duration of antibiotic therapy, and management of sequelae. Pertinent sequelae detailed are fractures associated with vascular injury, compartment syndrome, massive loss of soft tissue and bone, nerve injury, and lead toxicity.

The Effects of Early Antibiotic Administration on Bacterial Culture Growth From Hand Abscesses

Background: Traditional management of hand abscesses consists of withholding antibiotics prior to drainage to optimize bacterial culture growth and outcome. The purpose of this study was to determine the effect of preoperative empiric antibiotics on the rate of culture growth and rate of adverse events in patients with acute hand abscesses. Methods: We performed a retrospective review of prospectively collected data on 88 consecutive hand abscesses that received empiric antibiotics prior to incision and drainage from 2012 to 2013 at an urban academic institution. We analyzed patient demographics, bacteriology, culture growth results, time to surgery, and frequency of adverse events. Results: The overall rate of positive culture growth was 90% (n = 79) despite running the antibiotics for a mean of 31 hours prior to debridement. Furthermore, 96% of the isolates were given a susceptible antibiotic during that time. The mean number of debridements was 1.5 per patient, but 4 re-operations were necessary for wound complications. No patients required an amputation or were upgraded to intensive care. Conclusions: Preoperative empiric antibiotic administration does not appear to greatly reduce bacterial culture growth from hand abscesses. The adverse events are relatively few for simple abscesses treated with pre-surgical antibiotics and decompression within 24 hours.

Arthroscopic Treatment of Lateral Epicondylitis

Lateral epicondylitis is a common disorder in recreational athletes during their fifth and sixth decades. Insidious onset of lateral elbow pain provoked by resisted wrist extension is the typical presentation. The diagnosis is made by history and physical exam, but adjunctive tests, such as MRI, can be considered if concomitant intra-articular pathology is suspected. With a combination of physical therapy, NSAIDs, and activity modification, nonsurgical treatment is effective in up to 90 % of cases. Athletes may also benefit from equipment modifications or a technique coach. Steroid injections may be useful in short-term management; biologic injectables, such as platelet-rich plasma or whole blood, have shown promising early results but are still being investigated. Refractory cases can be treated with a percutaneous, open, or arthroscopic release with good success rates. Arthroscopic release may be advantageous in the athlete because of purported faster recovery times and the ability to address concomitant intra-articular disease.