Magnetic resonance imaging of the humpback scaphoid: the technique and a mathematical performance evaluation.

Surgical treatment of scaphoid nonunion and malunion with excessive intrascaphoid angulation (humpback deformity) usually involves a bone graft that is intended to correct the deformity. The volar bone graft length determines the degree of angular correction and scaphoid elongation. It is recommended that the length of the graft be determined by careful preoperative measurement of the deformity. Previous imaging techniques are inherently limited. The present paper describes a technique using three-dimensional magnetic resonance imaging. Scaphoid fracture angulation is calculated from measurements of comparable sagittal slices of the patient's fractured and normal scaphoid. Optimal bone graft length is determined by using simple trigonometric principles. Magnetic resonance imaging provides additional important information regarding vascularity of the proximal pole and the status of the periscaphoid ligaments and hyaline cartilage. Mathematical performance evaluation indicates that this technique is a promising method for planning reconstructive surgery of the scaphoid.

A randomized prospective study of posterolateral lumbar fusion. Outcomes with and without pedicle screw instrumentation.

STUDY DESIGN: A prospective evaluation of the clinical and radiographic outcomes of 71 patients who underwent lumbar fusion, with or without transpedicular instrumentation. The patients completed a questionnaire that determined pain relief, medication use, return to work, and overall satisfaction with surgery. OBJECTIVES: To explore the effect, if any, of instrumentation on the outcome of lumbar fusion surgery, according to reports of the patients, and whether there is a correlation between the radiographic determination of a solid fusion and the same patient-reported outcome. SUMMARY OF BACKGROUND DATA: The literature on this topic reports pseudarthrosis rates from 0% to 57% and good to excellent results from 56% to 95%. These studies provide no clear-cut recommendations concerning the effect of added lumbar instrumentation on patient-reported outcome in a prospective manner using concurrent control subjects. METHODS: The patients were randomized to groups with and without instrumentation after deciding to undergo a lumbar fusion and consenting to enter the study. Radiographs were obtained and questionnaires filled out at 6 weeks, 6 months, 1 year, and 2 years after surgery. RESULTS: There was no statistical difference in patient-reported outcome between the two groups. There was a slight nonsignificant trend toward increased radiographic fusion rate in the group with instrumentation that did not correlate with an increased patient-reported improvement rate. CONCLUSIONS: These results do not provide data that indicate a benefit in outcome from added instrumentation in elective lumbar fusions.

The utility of spine surgery instrumentation in decompression of the suprascapular notch.

Decompression of the suprascapular nerve through the posterior approach minimizes muscular damage and postoperative scar. The difficulty with this approach is that the depth of the exposure makes operating around the delicate structures of the suprascapular artery and nerve challenging. Spine surgery instrumentation is very helpful in circumventing this problem. Once exposure is achieved, a nerve root retractor is used to retract the suprascapular artery and vein. A number 2 Woody Woodson elevator is used to protect the suprascapular nerve. A number 1 or 2 Kerrison rongeur is then used to resect the suprascapular ligament. The Kerrison rongeur is a particularly useful instrument if an ossified ligament is encountered.

Trigger finger: the effect of partial release of the first annular pulley on triggering.

A prospective, randomized study was performed on 19 patients, in whom the proximal, middle, or distal third of the first annular pulley was divided to determine if a specific portion of the first annular pulley was responsible for the clinical triggering associated with restrictive flexor tenosynovitis. In all 19 patients, a partial resection of the first annular pulley resulted in continued clinical triggering with active digital flexion. At this point, a standard complete first annular pulley release was performed, with resolution of clinical triggering of the involved digit in all patients. We conclude that there is no "critical third" of the first annular pulley responsible for clinical digital triggering.

Ulnar styloid impaction syndrome.

A series of 8 patients each with an excessively long ulnar styloid that was impacting the triquetrum, causing chondromalacia, synovitis, and pain, is presented. Four patients developed symptoms as a result of an injury and 4 had no definable acute precipitating injury. The average age at the time of surgery was 34 years. There were 3 male and 5 female patients. The average follow-up period was 34 months. All patients were treated by open partial ulnar styloidectomy. Outcome was evaluated clinically and by means of patient questionnaire and radiographs. Pain decreased from a preoperative average score of 3.5 to a postoperative average score of 1.3, which equates to mild pain requiring no medication. All but 1 patient returned to their previous employment unrestricted. The average preoperative ulnar styloid length was 7.4 mm and the average ulnar styloid process index was 0.41, which is almost twice normal. There were no complications. It is likely that an excessively long ulnar styloid has important implications for the kinematics of the lunatotriquetral interval. Details of the diagnosis of this condition, including a new provocative test, and operative management are discussed.

Symptomatic adhesions of the index interosseous-lumbrical tendons: a case report.

A patient presented with activity-related pain in the distal radial palm. Surgical exploration revealed adhesion of the index lumbrical tendon to the metacarpophalangeal joint capsule and the tendon of the first dorsal interosseous. Symptoms were relieved by lysis of adhesions and immediate postoperative motion therapy.

Necrotizing myonecrosis and polymicrobial sepsis. The role of adjunctive hyperbaric oxygen.

A 19-year-old man, who was involved in a motorcycle accident, sustained a combined bony and vascular injury to his right lower extremity that required emergency surgery. Postoperatively, the patient developed a life-threatening, necrotizing, soft-tissue infection and sepsis. Hyperbaric oxygen therapy was used with surgery and antibiotics to control this rapidly progressive infection and to limit the extent of debridement needed. It was found to reverse the patient's deteriorating status and to halt the progression of the necrotizing infection. The scientific evidence for the use of hyperbaric oxygen in such cases is discussed.