Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.

Effects of radiofrequency probe application on irrigation fluid temperature in the wrist joint.

PURPOSE: Radiofrequency (RF) probes used in wrist arthroscopy may raise joint fluid temperature, increasing the risk of capsular and ligamentous damage. The purposes of the current study were to measure joint fluid temperature during wrist arthroscopy with the use of RF probes, and to determine whether using an outlet portal will reduce the maximum temperature. METHODS: We performed wrist arthroscopy on 8 cadaveric arms. Ablation and coagulation cycles using RF probe were performed at documented locations within the joint. This was done for 60-second intervals on both the radial and ulnar side of the wrist, to mimic clinical practice. We used 4 fiberoptic phosphorescent probes to measure temperature (radial, ulnar, inflow-tube, and outflow-tube probes) and measured joint fluid temperature with and without outflow. RESULTS: There was a significant difference between wrists with and without outflow when examining maximum ablation temperatures (p < .002). All specimens showed higher maximum and average ablation temperatures without outflow. Maximum joint temperatures, greater than 60 degrees C, were observed in only no-outflow conditions. CONCLUSIONS: In performing RF ablation during wrist arthroscopy, the use of an outlet portal reduces the joint fluid temperature. Without an outlet portal, maximum temperatures can exceed desirable levels when using ablation; such temperatures have the potential to damage adjacent tissues. It is useful to maintain adequate outflow when using the radiofrequency probes during wrist arthroscopy.

Unstable fracture-dislocations of the elbow.

Fracture-dislocations of the elbow are devastating injuries. The surgeon must maintain a high index of suspicion when evaluating an elbow dislocation to avoid missing critical associated injuries. Patterns of unstable fracture-dislocations include the "terrible triad" injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. Complex fracture-dislocations of the elbow are treated surgically and are challenging injuries to manage. Elbow stability must be restored by addressing the specific components of the injury. The proximal ulna must be anatomically reduced and internally fixed, the radial head must be repaired or replaced, and substantial coronoid fractures must be repaired or reconstructed. Soft-tissue injuries must also be treated. The lateral ulnar collateral ligament and extensor origin reattachment can be easily performed. The next critical step is to intraoperatively assess the stability of the elbow with a range-of-motion assessment with the forearm in pronation. If the elbow remains unstable, application of a hinged elbow external fixator or repair of the medial collateral ligament must be considered. The goal of reconstruction is early mobilization within a stable arc of motion. This treatment protocol has the potential to improve the suboptimal outcomes reported in the literature for such injuries.

Open surgical treatment of post-traumatic elbow contractures in adolescent patients.

The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Twelve adolescent patients (mean age 16.7 years, range 13-21) that had open release of post-traumatic elbow contractures were followed-up for a mean of 18.9 months (range 10-42 months). All releases were performed through a lateral approach (sparing the lateral ulnar collateral ligament) with anterior joint release (in twelve) supplemented by posterior release (in four patients). An additional medial approach was used in three patients. In three patients the radial head was excised. A mean gain of 54 degrees in the flexion-extension arc was observed at final follow-up and all patients achieved a functional ROM of at least 100 degrees. The patients maintained 93% of the motion that was achieved intraoperatively. No patient lost motion. Open release in adolescent patients with post-traumatic elbow contractures and no intarticular incongruence or erosion, yielded satisfactory results, similar to those achieved in adults.

Distal biceps tendon reconstruction in chronic ruptures.

The purpose of this retrospective study was to evaluate the results of anatomic reattachment with reconstruction of the distal biceps tendon using an Achilles tendon allograft in 7 male patients with chronic distal biceps ruptures. Through a 1-incision anterior approach, the tendon allograft was attached to the bicipital tuberosity by using suture anchors and then secured to the biceps remnant. Follow-up averaged 29 months. Mean elbow flexion was 145 degrees, an extension deficit of 20 degrees was observed in 1 patient, and mean pronosupination was 170 degrees. All patients had 5/5 strength in flexion and supination on manual testing, and all returned to their employment. Mean supination strength was 87% of the contralateral healthy extremity. Six achieved an excellent and 1 a good rating in the Mayo elbow performance score. No complications were encountered. This technique is an excellent alternative to nonanatomic reattachment to the brachialis muscle for patients with high functional demands in pronosupination.

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis.

PURPOSE: To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions. METHODS: Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw. RESULTS: After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred. CONCLUSIONS: Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability.

PURPOSE: For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure. METHODS: Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. RESULTS: The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability. CONCLUSIONS: The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage.

PURPOSE: To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist. METHODS: Sixteen patients with a mean age of 34 years (range, 18-54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49 degrees ) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe. RESULTS: The mean follow-up period was 19 months (range, 9-34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142 degrees and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53 degrees ). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result. CONCLUSIONS: Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure.

Step-cut distal ulnar-shortening osteotomy.

PURPOSE: Several techniques for ulnar-shortening osteotomies have been described in recent years, reflecting the difficulties that sometimes are encountered in what seems to be a relatively simple procedure. We describe the use of a simple step-cut ulnar-shortening osteotomy stabilized with a lag screw and a palmarly placed 3.5-mm neutralization plate. METHODS: Twenty-nine patients had the surgery. The indication was ulnar-impaction syndrome in 23 patients and symptomatic ulnar-plus variance secondary to trauma in 6 patients (4 with previous distal radius fractures, 2 with Essex-Lopresti injuries). The preoperative ulnar variance ranged from +1 mm to +6 mm. RESULTS: The mean follow-up period was 34 months. All osteotomies healed uneventfully. The mean postoperative ulnar variance was +0.2 mm (range, -1 mm to +1.5 mm). Three patients had hardware removal. CONCLUSIONS: The step-cut osteotomy resulted in solid union in all patients. It provides ample bone-to-bone contact and easier control of rotation, and no special instrumentation is necessary. Stable fixation permitted early mobilization of the wrist and palmar placement of the plate minimized the need for plate removal. This is a simple and effective technique for ulnar shortening.

Two-stage flexor tendon reconstruction in zone 2 of the hand in children.

Two-stage flexor tendon reconstruction (Hunter) is indicated in children with extensive adhesions in zone 2 of the hand, with some reservations concerning the patient's age and cooperation. Nine children (mean age 6.9 years) were treated with the modified Paneva-Holevich technique, which has advantages over the classic Hunter reconstructions. It involves an intrasynovial graft (FDS of the injured finger) that is anatomically stable and morphologically more appropriate compared with free grafts. The size of the silicone rod is precisely assessed in the first stage, the proximal tenorrhaphy has healed by the time the second stage is performed, and donor site morbidity is minimized. After a mean follow-up of 40.1 months, the mean total active motion was 196 degrees, and eight patients achieved a good or excellent result according to the Buck-Gramcko and the revised Strickland scale. Staged flexor tendon reconstruction is technically feasible even in very young children. Results in children are comparable to those achieved in adults.

Ipsilateral radial shaft, head, and medial epicondyle fractures.

A patient with a unique combination of ipsilateral midradial shaft (AO/OTA 22-A2), radial head (21-A2), and medial epicondyle (13-A1) fractures, without a recorded elbow dislocation or distal radioulnar joint disruption, is presented. The injury was treated surgically with a dorsal approach to the forearm and a lateral approach to the elbow through a single dorsolateral skin incision. The radial shaft fracture was stabilized using a 3.5-mm limited contact, dynamic compression plate; the radial head, using a 1.2-mm Luhr plate; and the medial epicondyle, using a partially threaded cancellous screw through a limited medial approach. The shaft fracture consolidated by 10 weeks, whereas radiographic consolidation of the radial head fracture was seen at 7 months. At the 15-month follow-up, the patient had achieved an excellent functional result. Awareness of the possibility of double injuries even in yet-unrecognized patterns is warranted when evaluating forearm and elbow trauma.

Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.

PURPOSE: To evaluate the results of a modified Paneva-Holevich technique for flexor tendon reconstruction in zone II. METHODS: Twenty patients (22 digits) with poor prognosis injuries (Boyes grade 2-5) were reconstructed. The technique included placing a silicone rod and creating a loop between the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) in the first stage and reflecting the latter as a pedicled graft through the pseudosheath created around the silicone rod in the second stage. RESULTS: After a follow-up period of at least 1 year (mean, 50 mo) the rate of good and excellent results was 82% according to the Buck-Gramco scale and 73% using the modified Strickland scale. CONCLUSIONS: These results compare favorably with those using the classic (Hunter) 2-stage reconstructions with a silicone rod and a free tendon graft. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity, and a low rate of postreconstruction tendon ruptures and tenolysis.