Augmentation of Rotator Cuff Repair Using Umbilical Cord Graft: A Preliminary Observational Study.

Due to the high rate of rotator cuff re-tear there is an extensive research on augmentation of rotator cuff repairs. The purpose of this single center, prospective study was to evaluate the results of augmentation of the rotator cuff repair with an umbilical cord allograft. The graft group in which the rotator cuff repair was augmented with the graft as an on-lay patch was consisted of 14 patients, while the control group was consisted of 10 patients. The primary outcome of the study was incidence of rotator cuff retears, while secondary outcomes included functional and pain scores. At 6 mo there was a significantly higher incidence of retears in the control group (30%) compared to the graft group (0%; P = 0.028), while at 12 mo the retear rates were statistically similar for the two groups (P = 0.46). The Constant-Murley scores, the ASES scores and the VAS score were similar (P > 0.05) for the two groups at all study times. The results of the study indicated that augmentation of the cuff repair with human umbilical cord graft can result in similar patient reported outcomes compared to a cuff repair without augmentation, but with a lower re-tear rate at 6 mo.

The impact of glenoid parameters and implant overstuffing on functional outcomes of shoulder hemiarthroplasty in patients with glenohumeral joint arthritis.

PURPOSE: The outcomes of shoulder hemiarthroplasty are highly dependent on the baseline glenoid morphology and the rotator cuff integrity. The objective of this study was to assess whether certain glenoid parameters and implant overstuffing are associated with worse clinical outcomes following shoulder hemiarthroplasty. METHODS: We retrospectively reviewed 25 patients who underwent shoulder hemiarthroplasty for shoulder arthritis, with a mean follow-up of 5.3 years. The baseline glenoid morphology, the glenoid wear rate, the proximal humeral head migration and implant overstuffing were evaluated radiologically in all patients. The radiological parameters were correlated with the functional outcomes. RESULTS: The Constant-Murley score, the ASES score, and the OSS score were significantly better for patients with a concentric baseline glenoid compared to those with an eccentric glenoid. The Constant-Murley score and the ASES score were also improved in patients without implant overstuffing compared to patients with implant overstuffing (p < 0.05). However, glenoid wear was not associated with worse functional outcomes (p = 0.23 for Constant-Murley score, p = 0.15 for ASES score and p = 0.27 for OSS score). Last, a worse Constant-Murley score was strongly correlated with proximal humeral head migration (p < 0.001), while worse ASES and OSS scores were moderately correlated with proximal humeral head migration (p < 0.001). CONCLUSION: Our findings indicate that the results of hemiarthroplasty can be improved through careful selection of patients upon the baseline glenoid type morphology and proper implant sizing to avoid implant overstuffing. Moreover, glenoid wear is not associated with worse clinical outcomes, therefore shoulder hemiarthroplasty should be reconsidered as an alternative in younger patients with shoulder arthritis.

Prospective Cohort Study Comparing Ligament Reconstruction with Tendon Interposition and Suture-Only Suspension Arthroplasty.

BACKGROUND: Basal joint arthritis is a common form of osteoarthritis. There is no consensus procedure for maintenance of trapezial height following trapeziectomy. Suture-only suspension arthroplasty (SSA) is a simple method for stabilizing the thumb metacarpal following trapeziectomy. METHODS: This single-institution, prospective, cohort study compares trapeziectomy followed by either ligament reconstruction with tendon interposition (LRTI) or SSA for the treatment of basal joint arthritis. Patients underwent LRTI or SSA from May of 2018 to December of 2019. Visual analogue scale pain scores; Disabilities of the Arm, Shoulder and Hand questionnaire functional scores; clinical thumb range of motion, pinch, and grip strength data; and patient-reported outcomes were recorded and analyzed preoperatively and at 6 weeks and 6 months postoperatively. RESULTS: Total number of study participants was 45 (LRTI, n = 26; SSA, n = 19). Mean ± SE age was 62.4 ± 1.5 years; 71% were female patients; and 51% underwent surgery on the dominant side. Visual analogue scale scores improved for LRTI and SSA ( P < 0.0001) over 6 months, with no differences between groups at any time point ( P > 0.3). Disabilities of the Arm, Shoulder and Hand questionnaire scores improved for LRTI and SSA over 6 months ( P < 0.0001), with no differences between groups at any time point ( P > 0.3). Following SSA, opposition improved ( P = 0.02), but not as well for LRTI ( P = 0.16). Grip and pinch strength decreased following LRTI and SSA at 6 weeks but recovered similarly for both groups over 6 months. Patient-reported outcomes were generally no different between groups at all time points. CONCLUSION: LRTI and SSA are similar procedures following trapeziectomy relative to pain, function, and strength recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Volar Plate Advancement and Abductor Pollicis Brevis Tenodesis for Thumb Metacarpophalangeal Joint Hyperextension Correction.

First carpometacarpal (CMC1) osteoarthritis can be accompanied by the collapse of the first ray, with hyperextension of the first metacarpophalangeal (MCP1) joint. It is suggested that failure to address substantial MCP1 hyperextension during CMC1 arthroplasty may diminish post-operative capability and increase collapse reoccurrence. An arthrodesis is recommended in case of severe MCP1 joint hyperextension (>400). We describe a novel combination of a volar plate advancement and abductor pollicis brevis tenodesis to address MCP1 hyperextension at the time of CMC1 arthroplasty as an alternative to joint fusion. In 6 women, mean MCP1 hyperextension with pinch before surgery was 450 (range 300-850) and improved to 210 (range 150-300) of flexion with pinch six months after surgery. No revision surgery has been necessary to date, and there were no adverse events. Long-term outcome data is needed to establish the longevity of this procedure as an alternative to joint fusion, but early results are promising.

Radiographic Thumb Metacarpal Subsidence Following Ligament Reconstruction With Tendon Interposition and Suture-Only Suspension Arthroplasty in the Treatment of Basal Joint Arthritis.

BACKGROUND: The thumb carpometacarpal (CMC) joint is a common source of osteoarthritis. Following trapeziectomy, ligament reconstruction with tendon interposition (LRTI) is considered a "gold standard" treatment, but suture-only suspension arthroplasty (SSA) has recently emerged as a simpler alternative. Currently, there is no objective radiographic study comparing subsidence following these 2 techniques. METHODS: This study is a retrospective review of 23 patients (10 LRTI, 13 SSA) that had at least 6 months of radiographic follow-up following thumb CMC arthroplasty. Posteroanterior radiographs at a preoperative timepoint, and at the 2-week and greater than 6-month postoperative timepoints were evaluated for actual trapezial height, as well as trapezial height normalized to capitate, thumb metacarpal, and proximal phalangeal heights. Normalized trapezial heights were calculated, and preoperative values were compared with greater than 6-month postoperative values. In addition, actual and normalized trapezial heights following LRTI and SSA were compared at each timepoint. RESULTS: Mean trapezial height decreased from approximately 12 to 5 mm (reduction of ~60%, P < .05) in both groups with no differences when comparing LRTI and SSA at each timepoint. All normalized trapezial heights revealed differences from preoperative to greater than 6-month postoperative timepoints, but no differences between LRTI and SSA. CONCLUSIONS: Ligament reconstruction with tendon interposition and SSA exhibit equivalent actual and normalized trapezial heights over a greater than 6-month postoperative time course.

Surgical Management of Extensor Digitorum Brevis Manus Anomaly with a Dorsal Ganglion Cyst.

Background The most common soft tissue tumor of the hand is the dorsal ganglion cyst and often is an indication for surgical excision. The differential diagnoses for dorsal hand masses include but are not limited to tenosynovitis, epidermoid cyst, abscess, lipoma, xanthoma, rheumatoid nodule, tophus, carpal boss, myositis ossificans, foreign body granuloma, neoplasm, and anomalous muscles. Case Description Our case report reflects the latter, a 33-year-old female who presented with a 3-year history of a symptomatic dorsal ganglion cyst of her left wrist. She is a female in her 30s, with progressive, worsening pain on wrist extension. Intraoperatively, it was determined that an anomalous extensor digitorum brevis manus (EDBM) was present and may have contributed to her pain and was excised. Literature Review The literature is sparse with the surgical management of EDBM. This case study aims to explore algorithms for managing simultaneous EDBM with a dorsal wrist ganglion, which is clinically relevant for any hand surgeon, when faced with a similar intra-operative management situation.

Evaluation of Cartilage in the Wrist using Magnetic Resonance Imaging.

Wrist pain is a common patient complaint with a myriad of clinical conditions that can explain the underlying cause. Short of wrist arthroscopy, no technique other than formal wrist arthrotomy exists for direct examination of the hyaline cartilage coating the articular surfaces of the carpal bones. Magnetic resonance imaging (MRI) has been proven accurate in evaluating joint surfaces of large joints such as the shoulder, hip, and knee with articular cartilage surface thickness is in excess of 1 mm. However, in the carpus the thickness of the cartilage and the contours present have precluded accurate imaging. Advances in MRI technology over the last several decades are now making imaging of small joint surfaces, such as the carpus, an area worth revisiting. Herein we provide a review of these efforts with a specific focus on the evaluation of the wrist.

Proximal Interphalangeal Joint Silicone Arthroplasty for Osteoarthritis: Midterm Outcomes.

Background: Osteoarthritis of the proximal interphalangeal (PIP) joint affects a large percentage of the population and can lead to significant functional disability. The purpose of this study is to evaluate the midterm clinical effectiveness of PIP joint arthroplasty for nonrheumatic arthritis. Methods: A single-center retrospective cohort study evaluating preoperative and postoperative objective and subjective measures was conducted. Range of motion (ROM), Disabilities of the Arm, Shoulder and Hand scores, key pinch strength, grip strength, and satisfaction with respect to pain, deformity, function, and strength were measured. Results: Forty-five fingers in 25 patients were followed up for a mean period of 42 months. Preoperative and postoperative mean ROM was equivalent at 59.1° and 59.2°, respectively. Postoperative grip and key pinch strength showed significant improvement and near normalization compared with contralateral extremity. Complication rate was 37% with 20% requiring revision surgery. Patients with diabetes mellitus had higher odds of requiring revision surgery. Pain scores improved from 7.4 to 1.9 on a visual analog scale. Overall satisfaction was high at 84%, and 91% of patients would have the surgery performed again. Conclusions: Silicone arthroplasty for osteoarthritis of the PIP remains a good option for pain relief. Our study presents midterm follow-up data that support significant pain relief, increased grip and key pinch strength, and high satisfaction associated with this implant.

Safety of Outpatient Shoulder Surgery at a Freestanding Ambulatory Surgery Center in Patients Aged 65 Years and Older: A Review of 640 Cases.

INTRODUCTION: With increasing utilization of surgery centers, it is important to demonstrate the safety of outpatient shoulder surgery in freestanding ambulatory surgery centers. No studies have specifically looked at the Medicare-age population and the rate of outpatient shoulder procedure complications in these patients at an ambulatory surgery center. METHODS: Six hundred forty patients were included in our study between 2000 and 2015. The incidence of major complications was identified, including acute infection requiring intravenous antibiotics or irrigation and débridement, postoperative transfer to a hospital, wrong-site surgical procedures, retention of a foreign object, postoperative symptomatic thromboembolism, medication errors, and bleeding/wound complications. RESULTS: There was a total of seven occurrence reports in seven patients, for a reported adverse event rate of 1.01%. CONCLUSIONS: Our findings are consistent with currently reported outpatient hospital-based data and illustrate the safety of outpatient shoulder procedures at a freestanding ambulatory surgery center in Medicare-age patients.

Motor Examination in the Diagnosis of Carpal Tunnel Syndrome.

The relative importance and use of motor evaluation to diagnose carpal tunnel syndrome (CTS) is not clear. Because the ulnar nerve is not affected in CTS, we evaluated comparing the strength of the median-nerve innervated muscles to the ulnar innervated muscles in the same patient, through manual muscle testing (MMT) and a handheld dynamometer. Our purpose was to evaluate whether this method, which takes into account patient-dependent factors that would affect both groups of muscles equally, can provide better assessment of CTS. A retrospective case-control review of MMT and dynamometer-measured strength for CTS was performed. The study was performed retrospectively but prior to surgery or other treatment. There were 28 cases (CTS) and 14 controls (without CTS). Positive nerve conduction tests defined cases. MMT of the thenar musculature was found to be unreliable as a test for CTS. Comparisons to ulnar nerve innervated muscle strength did not improve sensitivity or specificity of the MMT examination. Use of the dynamometer improved sensitivity and specificity of motor testing in CTS over MMT. Motor evaluation is important for the diagnosis of CTS, but further study is warranted, specifically to define the method of motor evaluation and delineate the subgroup of patients (predominantly thenar motor presentation) that would benefit most from motor testing and motor-focused treatment.

Modified McCash Technique for Management of Dupuytren Contracture.

Despite recent advancements in the nonsurgical treatment for Dupuytren contracture, a number of patients remain poor nonsurgical candidates or elect for surgical management. The traditional McCash technique releases contractures while leaving open palmar wounds. Although successful in alleviating contractures, these wounds are traditionally large, transverse incisions across the palm. A modification of this technique has been performed that permits the surgeon to utilize smaller wounds while eliminating debilitating contractures.

Baseline Characteristics of the Median Nerve on Ultrasound Examination.

Background: Previous studies using ultrasound for diagnosis of carpal tunnel syndrome have reported on relatively small series of patients, leading to large standard deviations and/or confidence intervals for the mean cross-sectional area of the median nerve. The purpose of this study is to define the CSA of the median nerve in a large cohort of patients. Methods: Patients (n = 175) without history of carpal tunnel release were recruited. All participants were evaluated using the Carpal Tunnel Syndrome-6 questionnaire, a validated clinical diagnostic tool, with a score of 12 or greater considered positive for CTS. Ultrasound examination was performed on both wrists of all participants using a 13-6 MHz linear array transducer. Results: The mean median nerve CSA was significantly larger (P < .001) for patients with a positive (mean = 11.16, SD = 2.51) versus negative CTS-6 result (mean = 6.91, SD = 2.06). There was a significant correlation (.527, P < .001, n = 349) between CSA and CTS-6 score. Logistic regression analysis determined that a CSA of 10 mm2 optimized sensitivity and specificity at 80% and 88%, respectively. Accuracy was 87.9%. Conclusions: A significant difference in mean CSA was found between patients with and without CTS. Median nerve CSA showed a statistically significant positive correlation with CTS-6. Similar to prior studies, a CSA of 10 mm2 was determined to be the optimal cutoff. In this large series of patients, ultrasound was a sensitive, specific, and accurate test for confirmation of a clinical diagnosis of CTS.

Silicone Arthroplasty After Ankylosis of Proximal Interphalangeal Joints in Rheumatoid Arthritis: A Case Report.

Rheumatoid arthritis (RA) can cause severe disability of the hand and fingers. Ankylosis of the finger joints is a known yet underreported manifestation of RA of the hand. We report the case of a patient who had RA and developed autofusion of the proximal interphalangeal (PIP) joints. At presentation, the PIP joints were fused in 15° of flexion. Silicone PIP arthroplasty was performed. Function improved with 60° of PIP joint motion and no pain.

The Safety of Hand and Upper-Extremity Surgical Procedures at a Freestanding Ambulatory Surgery Center: A Review of 28,737 Cases.

BACKGROUND: More procedures are being completed on an outpatient basis at freestanding ambulatory surgery centers. The purpose of our study was to determine the safety and rate of adverse events in outpatient hand and upper-extremity surgical procedures. METHODS: A retrospective review of cases at a single, freestanding ambulatory surgery center over an eleven-year period was performed. In our analysis, 28,737 cases were performed and were included. Adverse events were defined as serious complications causing harm to a patient or leading to additional treatment. Using state-reportable adverse events criteria as a guideline, we divided the adverse events into seven categories: infection requiring intravenous antibiotics or return to the operating room, postoperative transfer to a hospital, wrong-site surgical procedure, retention of a foreign object, postoperative symptomatic thromboembolism, medication error, and bleeding complications. These adverse events were then analyzed to determine if they led to additional laboratory testing, hospital admission, return to the operating room, emergency department visits, or physical or mental permanent disability. RESULTS: There were fifty-eight reported adverse events, for an overall rate of 0.20%. There were no deaths. There were fourteen infections, eighteen postoperative transfers to a hospital, twenty-one hospital admissions after discharge, one medication error, and four postoperative hematomas. There were no cases of wrong-site surgical procedures or retained foreign bodies. CONCLUSIONS: Our study shows that, with a selected patient population, a very low adverse event rate (0.20%) can be achieved. Our review showing few adverse events, no deaths, and no wrong-site surgical procedures supports our view that hand and upper-extremity surgical procedures can be completed safely in the outpatient setting at a freestanding ambulatory surgery center. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Midcarpal and Scaphotrapeziotrapezoid Arthritis in Patients with Carpometacarpal Arthritis.

BACKGROUND: Carpometacarpal arthroplasty provides well-documented pain relief with preservation of thenar function in basal joint arthritis treatment. Nevertheless, some patients continue to have pain following surgery. The authors hypothesize that unrecognized midcarpal (capitolunate) arthritis is a contributor to persistent pain after carpometacarpal arthroplasty. The prevalence of midcarpal arthritis in patients with basal joint arthritis is unknown. This article establishes the radiographic prevalence of midcarpal arthritis in patients with carpometacarpal arthritis. METHODS: Patients with basal joint arthritis were identified from a search using International Classification of Diseases, Ninth Revision code 716.94. Hand radiographs were reviewed and graded using the Eaton classification and Sodha classification for carpometacarpal arthritis. Scaphotrapeziotrapezoid arthritis and midcarpal arthritis were graded using the Sodha classification for arthritis as follows: grade 1, no or nearly no arthrosis; grade 2, definite arthrosis but not severe; and grade 3, severe arthrosis. RESULTS: Eight hundred ninety-six radiographs were reviewed. The prevalence of scaphotrapeziotrapezoid arthritis in this population was 64 percent. The prevalence of midcarpal arthritis in this population was 23.5 percent. The prevalence of midcarpal arthritis in patients with radiologic evidence of carpometacarpal arthritis was 25.4 percent. The prevalence of severe midcarpal arthritis was 7 percent. CONCLUSIONS: The prevalence of midcarpal arthritis in patients with basal joint arthritis is 24 percent. The presence of two locations of arthritis may explain persistent hand and wrist pain in this population despite carpometacarpal arthroplasty. Clinically, these data will allow hand surgeons to better educate patients with basal joint arthritis regarding the possibility of incomplete pain relief following carpometacarpal arthroplasty.

Case Report: 35-Year Follow-up for Nonvascularized Toe Phalangeal Transfer for Multiple Digit Symbrachydactyly.

Background: A case is discussed in which a young girl was born with symbrachydactyly of multiple digits in whom nonvascularized proximal toe phalanges were transferred to the aphalangic digits at the age of four. At 39 years of age, she presented incidentally to our clinic and was observed to have a very functional hand with mobile metacarpophalangeal joints in all reconstructed digits. Methods: We present a case report which is discussed in the context of long-term follow-up, and phalangeal growth in the absence of distraction, and a review of the current literature in regards to outcomes for this modality of treatment. Results: We document growth of the transplanted phalanges, despite surgery occurring after the reported optimum age of before 18 months, and the patient not undergoing distraction. The patient reported no donor site morbidity in regards to function or psychosocial impact. Furthermore, we observed active function at the metacarpophalangeal joints of all operated digits. Conclusions: We report the longest follow-up (35 years) following nonvascularized proximal toe phalangeal transfer for short finger type symbrachydactyly. We highlight the long-term functional outcome of nonvascularized toe phalangeal transfers, and present an overview of the current outcome literature for this type of procedure, advocating that nonvascularized toe phalangeal transfers remain a viable treatment option for select cases of symbrachydactyly.

Osteochondral resurfacing with proximal row carpectomy: 8-year follow-up.

Degenerative arthrosis of the proximal row remains a challenging problem for both patients and surgeons. Proximal row carpectomy is a motion-preserving treatment option, with studies documenting acceptable long-term outcomes. Proximal row carpectomy is an attractive option because there is no need for fusion to occur between the carpal bones, as in 4-corner fusion. As a result, laborers and smokers may be able to return to work more quickly. However, capitate chondrosis traditionally has been considered a contraindication to proximal row carpectomy. The goal of this study was to review the long-term follow-up of patients who underwent osteochondral resurfacing of capitate chondrosis performed in the same setting as proximal row carpectomy. Final follow-up was obtained in 5 of 8 (63%) patients at an average of 101 months (range, 99-102) after surgery. Grip strength improved at each time point, but wrist flexion and extension decreased. The average Mayo Wrist Score was 74 (range, 65-85) and remained stable or improved in all patients between the 18-month visit and the final visit. The Disabilities of the Arm, Shoulder and Hand (DASH) score was unchanged at final follow-up compared with 18-month follow-up (P=.7). This study found that osteochondral resurfacing of the capitate in the setting of proximal row carpectomy for patients with capitate chondrosis offers good outcomes compared with standard proximal row carpectomy in patients without capitate chondrosis on patient-directed outcome tools (DASH, Mayo Wrist Score) at long-term follow-up of 101 months.

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.