A comparison of the early outcomes of surgery in patients with unilateral and bilateral carpal tunnel syndrome using standard outcome measures.

The Levine questionnaire is commonly used to assess the treatment outcomes of carpal tunnel syndrome (CTS). However, specific items in this questionnaire do not address symptoms or impairment in each hand separately. One concern is that patients with unilateral disease would experience greater improvement as a result of surgery than those with bilateral who have only one hand treated. The objective of this study was to compare the early outcomes of surgery for unilateral and bilateral CTS, after operation on only one hand, in order to determine if the disease in the untreated hand affects the subjective perception of treatment outcomes. A total of 372 patients, 186 with unilateral and 186 with bilateral CTS underwent minimally invasive carpal tunnel release under local anesthesia. None of the patients with bilateral CTS had the other hand operated on before the follow-up examination. The pre- and post-operative (at 3 months) measurements included subjective pain intensity in numeric rating scale and the Levine questionnaire. No statistically significant differences in declared pain intensity, as well as in the Levine symptom and function scores in patients with unilateral or bilateral CTS were noted. This suggests that subjective perception of the improvement experienced by patients as a result of surgery was independent of involvement of one or both of the patients' hands.

Are you better? A multi-centre study of patient-defined recovery from Complex Regional Pain Syndrome.

BACKGROUND: Complex Regional Pain Syndrome (CRPS) symptoms can significantly differ between patients, fluctuate over time, disappear or persist. This leads to problems in defining recovery and in evaluating the efficacy of therapeutic interventions. OBJECTIVES: To define recovery from the patients' perspective and better understand their priorities for treatment approaches. METHODS: Establishing an international consortium, we used a 2-Round Delphi-based study in eight countries across Europe and North America. Participants ≥18 years who met, or had met, Budapest clinical criteria were included. Round 1 participants completed the statement: 'I would/do consider myself recovered from CRPS if/because…' alongside demographic and health questionnaires. Data were thematically organised and represented as 62 statements, from which participants identified and ranked their recovery priorities in Round 2. RESULTS: Round 1 (N = 347, 80% female, 91% non-recovered) dominant ICF themes were: activities of daily living; bodily functions; external factors; participation and personal factors. The top five priority statements in Round 2 (N = 252) were: no longer having (1) CRPS-related pain, (2) generalised pain and discomfort, (3) restricted range of movement, (4) need for medication, (5) stiffness in the affected limb. With very few exceptions, priorities were consistent, irrespective of patient demographics/geography. Symptoms affecting daily activities were among those most frequently reported. CONCLUSIONS: Our data showed a small number of themes are of highest importance to CRPS patients' definition of recovery. Patients want their pain, movement restriction and reliance on medication to be addressed, above all other factors. These factors should therefore be foremost concerns for future treatment and rehabilitation programmes. SIGNIFICANCE: Those with longstanding CRPS may no longer meet diagnostic criteria but still be symptomatic. Defining recovery is therefore problematic in CRPS. Our study has identified patients' definition of recovery from CRPS, in order of priority, as relief from: their CRPS-related pain, generalised pain, movement restriction, reliance on medication, and stiffness.

An analysis of the course of carpal tunnel syndrome before operation.

This work reports the results of an analysis into the course of carpal tunnel syndrome before operation in 479 patients, predominantly women, aged a mean of 58 years, who were scheduled for carpal tunnel operation. The patients were asked to characterise in detail the course of the disease and what determined the decision to undergo surgery. RESULTS: We identified two specific patterns of CTS course: progressive and preservative/mild. Patients with short-lasting disease suffer first of all from symptoms, but the longer the duration, the more pronounced the functional impairment. In a proportion of patients with longer-lasting disease, spontaneous resolution may occur, for up to a year or more. Bilateral involvement is more common than unilateral and the interval between involvement of the other hand is a mean of 10 months. For most patients the primary motivation to undergo surgery is troublesome symptoms (pain and paraesthesia). Functional impairment is of secondary importance, however, its prominence increases in older patients and in those with longer-lasting disease.

Factors Affecting the Outcomes of Carpal Tunnel Surgery: A Review.

Ziel der vorliegenden Arbeit war es, unter Berücksichtigung der in Pubmed und Medline veröffentlichten Ergebnisse nach Eingriffen am Karpalkanal zu ermitteln, inwieweit ausgewählte Faktoren wie das Patientenalter, die Dauer der Symptome, die Ausprägung der klinischen und elektrophysiologischen Befunde, das Vorliegen von Begleiterkrankungen und medikolegale Momente die Ergebnisse beeinflussen. Letztlich konnte für keinen der zahlreichen untersuchten Faktoren ein signifikanter Einfluss auf das Langzeitergebnis nachgewiesen werden. Bestehen die Beschwerden länger, sind die klinischen und elektrophysiologischen Befunde ausgeprägter und liegen Begleiterkrankungen vor, so fallen die Ergebnisse weniger gut aus, was darauf hindeutet, dass die betroffenen Patienten etwas weniger von der Operation profitieren. Nur bei Vorliegen von medikolegalen Faktoren wie Rechtsstreit oder Schadenersatzansprüchen lässt sich definitiv ein schlechtes Ergebnis voraussagen.

Results of the Treatment of Chronic, Refractory CRPS with Ketamine Infusions: a Preliminary Report.

Chronic, refractory complex regional pain syndrome remains very difficult to treat. A sub-anaesthetic low-dose ketamine has shown promise in advanced CRPS. We investigated the efficacy of ketamine in anaesthetic dosage in chronic, refractory CRPS patients that had failed available standard therapies. 5 female patients, aged a mean of 34 years with long-standing, a mean of 8 years', CRPS received ketamine in anaesthetic dosage over 10 days. The patients received 1-5 ketamine courses. The effect of gradual pain reduction was observed beginning on the 4(th)-5(th) day of treatment, associated with a decrease in the intensity of the allodynia (pain at light touch). No improvement in function (finger range of motion, grip strength) of the affected hands was noted in any patient. This beneficial analgesic effect was confined to 1.5-2.5 months after treatment and then pain relapsed to the baseline level. The results of this study show a short-term analgesic effect for this therapy, with no effect on movement and function of the affected limbs. Nevertheless, this method brings hope to the most severely ill patients who cannot be offered any other reasonable treatment option.

Traumatic Loss of the Ulnar Condyle of the Proximal Phalanx of the Ring Finger Repaired with a Palmar Plate Flap: a Case Report.

We report on an acute, open PIP joint injury to the ring finger with associated loss of the ulnar condyle of the proximal phalanx, which was repaired by the removal of bone fragments and replacement of the bone defect with a proximally based palmar plate flap.

Successful replantation of 2 fingers in an 82-year-old patient: a case report.

We present the case of an 82-year-old patient who had successfully replanted 2 of his 4 amputated fingers in the left, non-dominant hand. Amputation was caused by a circular saw and the patient was delivered to the hospital 3 h after injury with amputated part of the hand appropriately stored. The patient's general health status was good, with no serious systemic diseases. He also did not smoke. Post-operative course was uneventful for the replanted fingers, but after his return home the patient developed left-sided pneumonia, treated successfully with i.v. antibiotics. 8 months after replantation the patient presented with slight movement in the replanted fingers (AROM 45°), a total grip strength 8 Kg and the qDASH score 24; however, he could firmly grasp objects due to having an intact, well-functioning thumb.

Modified proximal interphalangeal joint palmar plate arthroplasty after fracture dislocation: a case report.

We present the results of treatment of a neglected fracture of the base of the middle phalanx of the ring finger, with dorsal proximal interphalangeal joint dislocation. A modified palmar plate arthroplasty technique was used with the removal of bony remnants and non-anatomic palmar plate insertion to the fracture site. At one-year follow-up the patient showed excellent recovery with an active range of motion of the ring finger of 290° (93% of the other side), strong total grip (48 kg) and a quick DASH score of 11. X-ray images showed perfect re-building of the palmar lip of the base of the middle phalanx with no signs of arthritis. Other options for the treatment of acute and chronic PIP joint fracture dislocations are discussed.

Does ultrasonography contribute significantly to the diagnosis of carpal tunnel syndrome?

BACKGROUND: Recent studies have demonstrated ultrasonography as a valuable tool for confirming the diagnosis of carpal tunnel syndrome. The objective of this study was to investigate sonographic parameters of the median nerve in patients diagnosed clinically with carpal tunnel syndrome. PATIENTS AND METHODS: 185 wrists in 185 patients, 149 women (81%) and 36 men (19%), with a mean age of 59 years, with the clinical diagnosis of carpal tunnel syndrome were examined sonographically. We measured cross-sectional area (CSA) of the median nerve at the forearm and at the carpal tunnel inlet, as well as the height (a-p dimension) of the nerve at the tunnel inlet and in the narrowest site in the carpal tunnel. Moreover, in all patients the severity of the disease was assessed by the Levine questionnaire. RESULTS: A significant variability of sonographic data characterizing the median nerve was found: the mean CSA at the tunnel inlet was 17.6 mm2 (range: 7-36) and height of the nerve at the tunnel inlet was a mean of 2.7 mm (range: 1.3-4.5). No correlation was found between sonographic data and severity of the syndrome as expressed by the Levine scores. CONCLUSION: Sonography of the median nerve contributes little to the diagnosis of a clinically relevant carpal tunnel syndrome and its routine use is not justified.

A comparison of outcomes after K-wire fixation of distal radius fractures with and without associated ulnar styloid fracture.

PURPOSE: A prospective study was carried out to compare outcomes after K-wire fixation of distal radius fractures without and with associated ulnar styloid fracture, but without fixation of the styloid fracture. PATIENTS AND METHODS: 70 patients, 60 women (86%) and 10 men (14%) with a mean age of 63 years were enrolled. 35 patients had an isolated fracture of the distal radius and 35 had an associated fracture of the ulnar styloid. All patients underwent percutaneous, "augmented" K-wire fixation of the distal radius fracture; the ulnar styloid fracture was left untreated. The patients were followed-up at 3 and 6 months. The stability of the distal radioulnar joint and the DASH scores were considered to be primary outcome measures. RESULTS: Instability of the distal radioulnar joint was diagnosed in 2 patients with ulnar styloid fracture. No significant and clinically meaningful differences were found between the groups in clinical (pain, wrist mobility, grip strength, DASH score) and radiological outcomes. The rate of non-union of the ulnar styloid was 77% at final assessment. CONCLUSION: An unrepaired ulnar styloid fracture does not affect the outcome of a distal radius fracture which is fixed by the "augmented" K-wire method.

No correlation between sonographic and electrophysiological parameters in carpal tunnel syndrome.

A prospective study was carried out to investigate any correlation between electrophysiological and sonographic findings in patients with a clinical diagnosis of carpal tunnel syndrome. A total of 113 patients (113 wrists) in 90 women and 23 men, with a mean age of 60 years, underwent sonographic and electrophysiological examination. Fifty-five patients (48%) had mild, 43 (38%) moderate and 12 (11%) had severe conduction disturbances and three patients had normal conduction. Sonographic measurements showed a cross-sectional area of the median nerve of 9.9 mm(2) at the forearm and 17.8 mm(2) at the tunnel inlet. The mean anteroposterior diameter (height) of the nerve at the tunnel inlet was 2.7 mm, and the lowest height inside the tunnel was 1.8 mm. No correlation was found between sonographic and electrophysiological parameters.

Common variants of the EPDR1 gene and the risk of Dupuytren's disease.

The object of this study was the investigation of 3 common variants of single nucleotide polymorphisms of the ependymin-related gene 1 and its association with the occurrence of Dupuytren's disease. DNA samples were obtained from the peripheral blood of 508 consecutive patients. The control group comprised 515 healthy adults who were age-matched with the Dupuytren's patients. 3 common variants were analysed using TaqMan® genotyping assays and sequencing. The differences in the frequencies of variants of single nucleotide polymorphisms in patients and the control group were statistically tested. Additionally, haplotype frequency and linkage disequilibrium were analysed for these variants. A statistically significant association was noted between rs16879765_CT, rs16879765_TT and rs13240429_AA variants and Dupuytren's disease. 2 haplotypes: rs2722280_C+rs13240429_A+rs16879765_C and rs2722280_C+rs13240429_G+rs16879765_T were found to be statistically significantly associated with Dupuytren's disease. Moreover, we found that rs13240429 and rs16879765 variants were in strong linkage disequilibrium, while rs2722280 was only in moderate linkage disequilibrium. No significant differences were found in the frequencies of the variants of the gene between the groups with a positive and negative familial history of Dupuytren's disease. In conclusion, results of this study suggest that EPDR1 gene can be added to a growing list of genes associated with Dupuytren's disease development.

A comparison of the results of carpal tunnel release in patients in different age groups.

BACKGROUND AND PURPOSE: The age of the patient at the onset of the disease may influence its course and outcome of the treatment. The objective of this study was to compare outcomes of carpal tunnel release in patients in different age ranges. MATERIAL AND METHODS: The records from the register of patients with carpal tunnel syndrome who were operated on in the authors' department over a period of two years (between 2009 and 2011) were analyzed. A total of 386 patients with carpal tunnel syndrome, 322 female (83%) and 64 male (17%) with a mean age of 57 (range: 30-81) years were divided into three sub-groups according to their age: 40 years or less (n = 28), 41-65 years (n = 248) and over 65 years (n = 73). All patients received mini-open carpal tunnel release. The results were assessed at 6 months after the operation by the Levine questionnaire and measurements of grip and pinch strengths as well as sensation of a light touch by the filament test. RESULTS: At the six-month follow-up, all patients showed significant resolution of symptoms as assessed by the Levine symptom score (from 3.3 to 1.4) and significant improvement of the dexterity of the hand, as assessed by the Levine function score (from 3.0-3.2 to 1.6-1.8). All patients showed significant improvement of sensation of a light touch and in-crease of grip and pinch strengths. However, patients older than 60 years showed less improvement of the total grip strength of the hand. CONCLUSION: Patients with carpal tunnel syndrome at any age may expect a similar benefit from surgery.

Chronic, refractory CRPS involving 3 limbs: a case report.

We report the case of a 26-year-old woman with CRPS involving consecutively 3 extremities during 8 years. None of the treatments used was effective and each CRPS episode resulted in persistence and chronification of the disease. We suggest that this patient presents a specific subtype of the disease, called "chronic, refractory CRPS" which is extremely severe, disabling and resistant to treatment.

Common variants of the ALDH2 and DHDH genes and the risk of Dupuytren's disease.

The object of this study was the investigation of four common variants of single nucleotide polymorphisms of the aldehyde dehydrogenase H2 gene and dihydrodiol dehydrogenase gene and their association with the occurrence of Dupuytren's disease. DNA samples were obtained from the peripheral blood of 300 consecutive patients. The control group comprised 300 healthy adults who were age matched with the Dupuytren's patients. All four common variants were analysed using TaqMan® genotyping assays and sequencing. The differences in the frequencies of variants of single nucleotide polymorphisms in patients and the control group were statistically tested. No significant differences were found in the frequencies of the variants of the aldehyde dehydrogenase H2 and dihydrodiol dehydrogenase genes between the groups. Likewise, no significant differences were found in the frequencies of the variants of the genes between men and women. We noted a statistically significantly higher prevalence of the variants of the dihydrodiol dehydrogenase gene (rs2270941 and rs11666105) in the group with a positive familial history of Dupuytren's disease, in comparison with the group with a negative familial history.

The results of carpal tunnel release for carpal tunnel syndrome diagnosed on clinical grounds, with or without electrophysiological investigations: a randomized study.

We compared the results of carpal tunnel release in patients with the diagnosis of carpal tunnel syndrome based on only clinical grounds and those diagnosed on clinical and electrophysiological grounds. Ninety-three patients, 83 women (89%) and ten men (11%), meeting the criteria of 'typical' carpal tunnel syndrome, were randomly assigned to receive carpal tunnel release with (n = 45, 48%) or without (n = 48, 52%) nerve conduction studies. Patients were followed-up at 1 and 6 months, by assessments that included the Levine scores, filament tests, grip and pinch strength. No significant differences in Levine scores were found at the 1 and 6 months assessments. Statistically significant differences were noted in three-point pinch strength and sensation; however, they were not of clinical importance. The results of the study show that the results of carpal tunnel release in patients with typical symptoms are no better after nerve conduction studies and, therefore, nerve conduction studies can be omitted.