Treatment of Intractable Pillar Pain With Excision of the Hook of Hamate.

Introduction: A common consequence of carpal tunnel release (CTR) is ulnar palmar pain termed pillar pain. Some (very rare) patients do not improve with conservative treatment. We have been treating recalcitrant pain with excision of hook of the hamate. Our purpose was to evaluate a series of patients undergoing excision of the hook of the hamate for post CTR pillar pain. Methods: A retrospective review of all patients undergoing hook of hamate excisions over a 30-year period was performed. Data collected included: gender, hand dominance, age, time-to-intervention, preoperative and post-operative pain scores, and insurance. Results: Fifteen patients were included with a mean age of 49 (range 18-68) years, 7 female (47%). Twelve (80%) of the patients were right handed. Mean time between CTR and excision hook of hamate was 7.4 months (range 1-18 months). Pain prior to surgery was 5.44 (range 2-10). Post-operative pain was 2.44 (range 0-8). Mean follow-up was 4.7 months (range 1-19 months). Patients with a good clinical outcome were 14 (93%). Conclusions: Excision of hook of hamate seems to provide clinical improvement in patients who remain painful despite exhaustive conservative treatment. It may be considered as a very last resort for persistent pillar pain after CTR.

Introduction : Une conséquence fréquente de la libération du tunnel carpien (TC) est une douleur ulnaire palmaire appelée douleur du pilier. Quelques (très rares) patients ne sont pas améliorés par le traitement conservateur. Nous avons traité une douleur récalcitrante avec une ablation du crochet (ou hamulus) de l'os hamatum. Notre objectif était d'évaluer une série de patients subissant une ablation du crochet de l'os hamatum pour douleur du pilier après libération du TC. Méthodes : Une analyse rétrospective de tous les patients subissant une ablation du crochet de l'os hamatum a été menée sur une période de 30 ans. La collecte de données a inclus: le sexe des patients, la main dominante, l'âge, le délai jusqu'à l'intervention, les scores de douleur avant et après l'opération, ainsi que l'assurance. Résultats : Quinze patients ont été inclus; leur âge moyen était de 49 ans (18 à 68 ans); il y avait 7 femmes dans la population (47 %). Douze patients (80 %) étaient droitiers. Le délai moyen écoulé entre la libération du TC et l'ablation du crochet de l'os hamatum a été de 7,4 mois (extrêmes: 1 à 18 mois). Le score de douleur avant chirurgie était de 5,44 (extrêmes: 2 à 10). Le score de douleur postopératoire était de 2,44 (extrêmes: 0 à 8). Le suivi moyen a été de 4,7 mois (extrêmes: 1 à 19 mois). Un bon résultat clinique a été obtenu chez 14 patients (93 %). Conclusion : L'ablation du crochet de l'os hamatum semble procurer une amélioration clinique chez les patients qui restent douloureux malgré un traitement conservateur exhaustif. Cette option peut être envisagée en dernier ressort chez les patients ayant une douleur du pilier après libération du TC.

Spherical versus elliptical prosthetic humeral heads: a comparison of anatomic fit.

BACKGROUND: The aim of this study was to quantify the influence of prosthetic humeral head shape, as well as the number of available prosthetic head sizes, on replicating the normal humeral head anatomy during shoulder reconstructive surgery. METHODS: Computer modeling software was used to create virtual sets of both spherical and elliptical prosthetic heads, which were virtually implanted into 3-dimensional computed tomography scan-based models of 79 proximal humeri. Anatomic replication was considered successful if the measured parameters (diameters of the base of the head in the frontal and sagittal planes, radii of curvature in the frontal and sagittal planes, and humeral head height) were all reproduced within 3 mm. The Fisher exact test was used to compare the percentage of successful replications for both head types and to compare differences resulting from the use of sets with fewer or more available head sizes. Statistical significance was set at P ≤ .05. RESULTS: Regardless of the number of available head sizes per set, it was possible to replicate the normal anatomy within 3 mm in a higher percentage of specimens using elliptical (96%-100%) as opposed to spherical (41%-78%) prosthetic heads (P ≤ .0013). CONCLUSION: Compared with use of spherical prosthetic heads, use of elliptical heads resulted in improved replication of the normal humeral head shape. In light of the emerging evidence that use of anatomically shaped prosthetic humeral heads might lead to better shoulder function and possibly improved implant survivorship, the findings of this study may have important clinical and economic implications.

Fluorescent Imaging Evaluation of Lidocaine Distribution Following Bier Block in the Upper Extremity.

INTRODUCTION: Bier block regional anesthesia has been used as an alternative to general anesthesia for years. Despite multiple theories and multiple techniques to delineate the location of the action of lidocaine during Bier block anesthesia, there has not been a consensus on the location of action. The purpose of this study was to use fluorescent imaging to further investigate the site of action of lidocaine during Bier block. MATERIALS AND METHODS: Three patients with carpal tunnel syndrome underwent open carpal tunnel release with Bier block anesthesia performed in the standard fashion with 1cc of Indocyanine green (IcG) mixed with lidocaine. Fluorescent images were obtained at the time of injection and after 10 minutes to allow patients to reach the level of surgical anesthesia. Repeated imaging was obtained at the time of completion of the procedure or at 30 minutes of tourniquet time. RESULTS: At time 0, IcG was distributed along the superficial venous system of the hand and forearm. At 10 minutes, the distribution of IcG was within the capillary system and infiltrating the dermis. The distribution later saturated the capillary beds and remained present until release of the tourniquet. CONCLUSIONS: The authors demonstrate that some lidocaine action occurs at the cutaneous level during the administration of a Bier block. Due to limited field depth of view provided by the SPY® Elite System (Novadaq Technologies Inc., Mississauga, Canada), we are unable to draw any conclusions as to the distribution of the IcG or lidocaine at the level of the larger nerves at the site of the tourniquet.

Case Report: Angiosarcoma in the Upper Extremity Related to a Nonfunctioning Arteriovenous Fistula.

BACKGROUND: Angiosarcoma is a rare but aggressive malignancy with a high predilection for the head and neck. There have been few case reports of the development of angiosarcoma in a nonfunctional arteriovenous fistula in a hemodialysis patient. METHODS: After institutional review board approval, a retrospective chart analysis is conducted to present the case of a patient who received plastic surgical treatment at our hospital. RESULTS: We present the case of a 44-year-old male who presented with ischemic changes and paresthesias of the upper extremity associated with the development of angiosarcoma in an arteriovenous fistula. CONCLUSIONS: Angiosarcoma remains a rare but important diagnosis to include in the differential diagnosis for upper extremity pain and paresthesias in chronic renal failure and nonfunctioning arteriovenous fistula.

Comparison of Kinematics and Tibiofemoral Contact Pressures for Native and Transplanted Lateral Menisci.

BACKGROUND: Lateral meniscus transplantation is a proven treatment option for the meniscus-deficient knee, yet little is known about meniscal kinematics, strain, and tibiofemoral contact pressure changes after transplantation or the effect of altered root position in lateral meniscus transplantation. PURPOSE: To compare the native lateral meniscal kinematics, strain, and tibiofemoral contact pressures to a best-case scenario meniscus transplant with perfectly matched size and position and to determine how sensitive these factors are to subtle changes in shape and position by using a nonanatomic meniscus transplant position. STUDY DESIGN: Controlled laboratory study. METHODS: The lateral menisci of 8 cadaveric knees were circumferentially implanted with radiopaque spherical markers. They were mounted to a testing apparatus applying muscle and ground-reaction forces. The meniscus was evaluated at 0°, 30°, 90°, and 115° of knee flexion using Roentgen stereophotogrammetric analysis (RSA), with a pressure sensor affixed to the lateral tibial plateau. Measurements were recorded for 3 states: the native lateral meniscus, an anatomic autograft transplant, and a nonanatomic autograft transplant with an anteriorized posterior root position. RESULTS: After transplantation, there was less posterior displacement in both the anatomic and nonanatomic transplant states compared with the native meniscus, but this was not significant. The largest lateral translation in the native state was 2.38 ± 1.58 mm at the anterolateral region from 0° to 90°, which was increased to 3.28 ± 1.39 mm (P = .25) and 3.12 ± 1.18 mm (P = .30) in the anatomic and nonanatomic transplant states, respectively. Internal deformations of the transplant states were more constrained, suggesting less compliance. The native meniscus distributed load over 223 mm2, while both the anatomic (160 mm2) and nonanatomic (102 mm2) states concentrated pressure anteriorly to the tibial plateau centroid. CONCLUSION: This study is the first to characterize kinematics in the native lateral meniscus compared with a transplanted state utilizing RSA. Results demonstrate increased meniscal constraint and pressure concentrations even after an ideal size and position matched transplantation, which further increased with a nonanatomic posterior root position. CLINICAL RELEVANCE: The results show that kinematics are similar in both transplanted states when compared with the native meniscus at various flexion angles. Because both transplanted states were more constrained with less deformation compared with the native state, this should allow for relatively safe postoperative range of motion. However, in the transplanted states, peak pressures were distributed over a smaller area and shifted anteriorly. This pattern was exacerbated in the nonanatomic state compared with anatomic. This could have detrimental effects with regard to articular cartilage degeneration, and ultimately result in a failed transplantation.

Commentary: Exploring the space between.

Commentary on: Kang KK, Shen MS, Zhao W, et al. Retrolisthesis and lumbar disc herniation: a postoperative assessment of patient function. Spine J 2013;13:367-72 (in this issue).