Prevalence and Subtypes of Tenosynovial Amyloid in Patients Undergoing Carpal Tunnel Release.

PURPOSE: The purpose of this study was to determine the prevalence and subtypes of amyloid in tenosynovial biopsies of patients undergoing carpal tunnel release (CTR). METHODS: A retrospective review was performed involving patients who underwent CTR from June 2020 to July 2021. Prior to this period, a protocol had been established to obtain routine intraoperative tenosynovial biopsies. Tenosynovium was preserved in formalin and stained with Congo red for amyloid. Positive specimens were sent to an external laboratory for confirmation and subtyping by mass spectrometry. Men 50 years or older and women 60 or older were included for analysis. Acute, traumatic, and revision cases were excluded. RESULTS: Of 185 patients who underwent CTR with tenosynovial biopsy, 54 (29%) demonstrated positive Congo red stain, confirmed by the external laboratory. A subtype analysis revealed wild-type transthyretin (TTR) in 44 patients (80%), mixed wild-type TTR with κ light chains in 1 patient, and hereditary TTR in 1 patient. Patients with positive specimens were significantly older than those who tested negative (77 vs 68 years, respectively), and positivity increased by decade for both sexes. Male sex, atrial fibrillation, and spinal stenosis were significantly more prevalent among positive cases. There were no complications from the biopsies. CONCLUSIONS: We confirmed evidence of amyloidosis in the tenosynovium of 29% of men 50 years or older and women 60 or older who underwent CTR. The majority demonstrated wild-type TTR. As these patients are at risk of developing cardiomyopathy, there is an opportunity for early detection, monitoring, and interventions known to improve outcomes. Considering the low cost of Congo red staining and the potential value of subtyping with regard to treatment of cardiomyopathy, our findings support routine tenosynovial biopsy during CTR in patients who meet the age criteria. TYPE OF STUDY/LEVEL OF EVIDENCE: Differential diagnosis or symptom prevalence study II.

Prospective Evaluation of an Opioid Reduction Protocol in Hand Surgery.

PURPOSE: We investigated whether written guidelines for surgeons and educational handouts for patients regarding safe and effective opioid use after hand surgery could reduce prescription sizes while achieving high patient satisfaction and a low refill rate. METHODS: All patients undergoing isolated carpal tunnel release or distal radius volar locked plating in a hand surgery group practice during a 6-month period were prospectively enrolled. Surgeons prescribed analgesics at their own discretion based on written guidelines. Patients received an educational handout regarding safe opioid use and disposal, a diary to record daily pain visual analog scale score and consumption of opioid and over-the-counter (OTC) analgesics, and a pain catastrophizing scale questionnaire. Collected data were compared with a retrospective cohort of the same surgeons, procedures, and period 1 year earlier. RESULTS: In the carpal tunnel release group (121 patients), average prescription size was 10 opioid pills, compared with 22 in the prior year. Average consumption was 3 opioid pills, supplemented with 11 OTC pills. In the volar locked plating group (24 patients), average prescription size was 25 opioid pills, compared with 39 in the prior year. Average consumption was 16 opioid pills, supplemented with 20 OTC pills. Patient satisfaction was comparably high in both groups. Eight patients required opioid refills overall. Patients with pain catastrophizing scale greater than 10 used more than twice as many opioid pills. Of 109 patients with leftover opioids, 10 reported proper disposal. CONCLUSIONS: Written guidelines and educational handouts significantly reduced the number of prescribed opioid pills by 35% to 55% while achieving high patient satisfaction and a low refill rate. We recommend 5 to 10 opioid pills for carpal tunnel release and 20 to 30 for distal radius volar plating. Pain catastrophizing is associated with greater opioid consumption and may help target patients for additional support. Potential for opioid abuse and diversion may persist despite these interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Complications of the treatment of the acromioclavicular and sternoclavicular joint injuries, including instability.

Treatment of AC joint injuries and SC joint injuries continues to evolve. The risk of complications of both the operative and nonoperative management of these injuries can be minimized by the treating physician if the physician thoroughly evaluates and understands the problem. Making an accurate diagnosis of the underlying pathology and then selecting the appropriate treatment for this will minimize the risk of an associated complication. Paying attention to detail and using the appropriate technique before any operative intervention is chosen will decrease the risk of failure and complication. Close follow-up and early detection of complications will lead to less severe sequelae. AC joint injuries are more common and operative management is accepted for specific indications. Most Orthopaedic Surgeons are comfortable treating these. SC joint injuries are less common and nonoperative treatment is the mainstay. As our approach to these complex problems evolves, we must keep a wary eye towards avoiding and minimizing the complications of the new techniques.

Clostridium infection in a knee extensor mechanism allograft: case report and review.

An unusual case of Clostridium perfringens infection after an allograft reconstruction of an extensor mechanism in a multiply revised total knee arthroplasty is reported. The case occurred in an elderly patient with an underlying bleeding dyscrasia who had previously undergone two revision total knee arthroplasties. The patient was treated by open irrigation, debridement, removal of allograft and prosthesis, intravenous antibiotics, and implantation of an antibiotic impregnated cement spacer utilizing an intramedullary rod.

Heterotopic ossification after total hip arthroplasty: a critical analysis of the Brooker classification and proposal of a simplified rating system.

We evaluated the reproducibility of the Brooker classification for heterotopic ossification (HO) and, based on the results and weaknesses observed, proposed a simplified system with addition of objective criteria. Six observers classified radiographs of 169 total hip arthroplasties, using the Brooker classification and a modified system consisting of i) absence of HO or islands measuring <1 cm in length, ii) islands >1 cm or spurs leaving at least 1 cm between femur and pelvis, and iii) spurs leaving <1 cm between opposing surfaces or bony ankylosis. Reproducibility was calculated using kappa statistics. For the Brooker classification, interobserver kappa averaged 0.43 (range, 0.74-0.18) (poor). Intraobserver kappa averaged 0.74 (fair). For the modified classification, interobserver kappa averaged 0.59 (range, 0.51-0.76) (fair). Intraobserver kappa averaged 0.78 (good). Interobserver differences were significant (P=.0085). Interobserver consistency to detect severe HO (Brooker 3 and 4, or grade C) improved from 52% to 76% with the modified system. The new classification showed adequate interobserver reproducibility, less variability, and improved consistency for classification of significant HO.

Renal cell carcinoma with metastases to the triquetrum: case report.

Metastatic tumors of the hand are rare, with fewer than 200 cases reported in the literature. Renal cell carcinoma is among the most common tumors to metastasize, but we are not aware of reports of this tumor metastasizing to the carpal bones. We describe a case of renal cell carcinoma that metastasized to the triquetrum to draw attention to the potential for such lesions developing within the hand and wrist.

Tibiotalocalcaneal fusion with a retrograde intramedullary nail: clinical and functional outcomes.

Severe arthrosis and deformity of the ankle and subtalar joints are debilitating problems that can be difficult to treat. We retrospectively reviewed and functionally assessed 15 patients who had undergone tibiotalocalcaneal fusion with a retrograde intramedullary nail. The procedure had been a salvage procedure for severe arthrosis and deformity of the ankle and subtalar joints. Minimum follow-up was 2 years. Solid fusion was achieved in 14 of 15 patients. Mean time to union was 16.5 weeks. Ankle-Hindfoot Scale scores showed excellent pain relief at union. Subjective gait disturbances were common postoperatively, though patient satisfaction and the return-to-work rate were high (93% and 80%, respectively). The 12 complications included nonunion, malunion, skin problems, plantar pain, infection, and painful hardware. We advocate using a retrograde nail as a salvage technique in complex posttraumatic or postsurgical settings.