What Is the Infection Rate of Carpal Tunnel Syndrome and Trigger Finger Release Performed Under Wide-Awake Anesthesia?

BACKGROUND: High infection rates have been reported in hand procedures using the wide-awake local anesthesia no tourniquet (WALANT) method, causing some to question the validity of this approach. However, little evidence exists surrounding the direct use of WALANT compared with monitored anesthetic care (MAC). This study was conducted to directly compare the postoperative infection rates of carpal tunnel syndrome (CTS) and trigger finger (TF) release surgeries performed under WALANT and MAC. METHODS: A retrospective study comparing postoperative infection rates between patients undergoing CTS and TR releases was conducted. Our primary outcome measure was postoperative infection. Our secondary outcome was postoperative complications. Comparative statistics were used to compare means of infection between the groups. RESULTS: A total of 526 patients underwent CTS release (255 with WALANT and 271 with MAC), and 129 patients underwent TF release (64 with WALANT and 65 with MAC). Patients undergoing WALANT and MAC were statistically comparable in terms of sex, smoking status, diabetes, and American Society of Anesthesiologists physical status classification. In patients undergoing CTS release, there were no infections with WALANT and 6 infections (2.2%) with MAC. In patients undergoing TF release, there were no infections in either group. There were similar rates of complications in patients undergoing WALANT and MAC for CTS and TF releases. CONCLUSION: There was no increased risk of infection with WALANT compared with MAC in CTS or TR surgeries. These surgeries can be safely conducted with lidocaine and epinephrine without a concern for increased risk of infections or complications.

Doble compresión del nervio mediano en el brazo: Revisión crítica de la bibliografía / Double crush syndrome of the median nerve in the arm: A critical review of the literature

La compresión mecánica de un nervio periférico en dos sitios diferentes a lo largo de su trayecto se define como síndrome de doble compresión. Esta enfermedad se basa en la teoría de la mayor susceptibilidad que tendría un nervio a nivel distal cuando este también se encuentra comprimido, en forma asintomática, a nivel proximal, debido a una alteración en el flujo axonal. Si bien la descompresión del túnel carpiano es una cirugía con resultados previsibles, hay pacientes operados por síndrome del túnel carpiano que no mejoran después de una cirugía, como cabría esperar. Si se excluye de este análisis a las comorbilidades, como diabetes, casos avanzados con atrofia muscular o descompresiones insuficientes, muchos de estos fracasos terapéuticos podrían estar fundamentados por el escaso diagnóstico de un segundo sitio de compresión concomitante. No obstante, existe gran controversia alrededor del síndrome de doble compresión que involucra no solo a su existencia, sino también a su incidencia y fisiopatología. El objetivo de esta publicación es presentar una revisión bibliográfica crítica del síndrome de doble compresión centrada en el compromiso del nervio mediano tanto en la muñeca como en el codo.

Double crush syndrome is the mechanical compression of a peripheral nerve at two different sites and is based on the hypothesis that a nerve that has been compressed at a distal site is especially susceptible to also be compressed, asymptomatically, at a more proximal site. While carpal tunnel release is a surgical procedure with predictable results, some patients do not improve as expected after surgery. If comorbidities such as diabetes, advanced cases presenting with muscle atrophy or incomplete decompressions are excluded from the analysis, many of these treatment failures could be explained by a second concomitant compression site, which is often underdiagnosed. The very existence of double crush syndrome is highly questioned, but also its incidence and pathophysiology. The objective of our paper is to perform a critical review of the literature available on double crush syndrome involving mainly the median nerve in the wrist and the elbow.

Treatment of terrible triad injuries at a mean follow-up of nine years.

BACKGROUND: To evaluate the sustainability of the early clinical and radiological outcomes of terrible triad injuries at long-term follow-up. METHODS: Twelve consecutive patients who underwent fixation of terrible triad injuries with minimum of seven years of follow-up. Functional and radiological outcomes at one year and final follow-up were compared. We assessed Mayo Elbow Performance Score, Quick-Disability of the Arm Shoulder and Hand, and modified-American Shoulder and Elbow Surgeons Scores. Radiological evaluation included Broberg and Morrey classification and Hastings classification for heterotopic ossification. RESULTS: The mean age of patients was 55 years, with a median follow-up of 9.3 years. At final evaluation, mean flexion, extension, supination, and pronation were 145°, 6°, 82°, and 80°, respectively; mean Mayo Elbow Performance Score, modified-American Shoulder and Elbow Surgeons Scores, and Quick-Disability of the Arm Shoulder and Hand scores were, respectively, 97, 92, and 4.9 points. There was no statistical difference between early and final follow-up range of motion, Mayo Elbow Performance Score, and Quick-Disability of the Arm Shoulder and Hand. However, radiological changes were observed in 66% of the patients at final follow-up. Two patients underwent reoperation, with final satisfactory results. CONCLUSION: Our results suggested that using a standardized protocol, satisfactory clinical outcomes at early follow-up could be maintained over time. However, early complications and osteoarthritic changes at long-term follow-up can be expected. LEVEL OF EVIDENCE: Therapeutic IV Cases series.

Combined Tenodesis-Capsulodesis for Scapholunate Instability: Minimum 2-Year Follow-Up.

Background The aim of this study is to evaluate the clinical and radiological midterm results of a combined dorsal tenodesis-capsulodesis for static and reducible scapholunate dissociation (SLD). Patients and Methods We evaluated 20 of 22 consecutive patients with static SLD minimum with follow-up of 2 years operated between 2003 and 2012. The mean age was 40 years (range: 23-65 years). Seventeen were men. Final evaluation included comparative wrist range of motion (ROM) and grip strength, pre- and postoperative pain and function by visual analog scale, and QuickDASH and Wrightington scores. Radiographs included preoperative, early postoperative, and final X-rays. Scapholunate space (SLS) and scapholunate and radioscaphoid angles (SLA and RSA) were measured. Statistical significance was evaluated with Student t-test, considered significant when p < 0.05. Results Mean follow-up was 67 months (range: 24-126 months). Mean final ROM was: flexion 55 degrees (73%), extension 62 degrees (90%), radial deviation 19 degrees (82%), and ulnar deviation 44 degrees (90%). Mean grip strength was 44 kg (92%). Pain at rest improved from 3.4 to 0.5 (p < 0.05). Pain in activity improved from 7 to 1.7 (p < 0.05). Final function was 8.5 (preoperative, 5.2; p < 0.05). Mean QuickDASH score improved from 38 to 8 (p < 0.05). Functional Wrightington score was as follows: 13 excellent, 3 good, 1 regular, and 3 poor. There were three postoperative minor complications. Radiological results (preoperative/early postoperative/final follow-up) were as follows: SLS, 4.7/1.6/1.8 mm; and SLA, 60/50/62 degrees; RSA, 39/45/37 degrees. Four patients showed arthritic changes (two SLAC wrist). Conclusion The clinical and radiological results with more than 2-year follow-up suggest that this technique may be effective, reproducible, and safe for symptomatic static and reducible SLD. Level of Evidence Level IV, case series.

Ganglion dorsal de muñeca: reseccion artroscopica con tecnica "en seco". Seguimiento minimo de dos años / Dorsal wrist ganglion: arthroscopic resection with "dry" technique. Minimum follow-up of two Years

Introducción: El objetivo de este estudio fue comunicar los resultados a mediano plazo de la reseccion artroscopica de gangliones dorsales de muneca utilizando la tecnica "en seco". Materiales y Métodos: Se evaluo retrospectivamente a 22 pacientes (22 munecas) con un seguimiento minimo de 2 años. Once mujeres y 11 hombres con una edad promedio de 29 anos (rango 18-57). Se realizaron evaluaciones clinicas preoperatoria, al mes de la cirugia y en el ultimo control. Se evaluaron la movilidad y la fuerza de puno comparativas, el dolor y la funcion segun la escala analogica visual, los puntajes funcionales QuickDASH y de Wrightington, el retorno laboral y las complicaciones intraquirurgicas y posquirurgicas. Seguimiento promedio: 42 meses (rango 24-60). Se realizo un analisis estadistico mediante la prueba t. Resultados: Hubo 2 recidivas del ganglion. No se registraron otras complicaciones. La movilidad y la fuerza de puno comparativas mejoraron significativamente, 99% y 100%, respectivamente. El dolor y la funcion tambien mejoraron significativamente, al igual que el puntaje QuickDASH. Segun la escala de Wrightington, 18 casos resultaron excelentes; 3, buenos, y uno fue malo. Veintiuno de los 22 pacientes retornaron a sus tareas laborales sin limitaciones, 20 refirieron estar satisfechos con el resultado. Conclusión: La reseccion artroscopica utilizando la tecnica "en seco" representa una alternativa segura y eficaz para el tratamiento de los gangliones dorsales de muneca, logra aliviar el dolor, y una mejoria funcional y estetica en la mayoria de los pacientes mediante una rehabilitacion temprana, con una baja incidencia de recidiva. Nivel de Evidencia: IV

Introduction: The purpose of this study is to describe the medium-term results of arthroscopic resection of dorsal wrist ganglia using the "dry technique". Methods: Twenty-two patients (22 wrists) were retrospectively evaluated with a minimum follow-up of 2 years. Eleven women and 11 men with an average age of 29 years (range 18-57). A clinical evaluation was performed preoperatively, at one month, and at the last control visit. Comparative wrist motion and grip strength, pain and function according to the visual analogue scale, functional QuickDASH and Wrightington scores, return to work, and intra and postoperative complications were evaluated. Mean follow-up was 42 months (range 24-60). Statistical analysis was performed using t test. Results: Two cases of ganglion recurrence were observed. No other complication was reported. Wrist motion and grip strength improved significantly, reaching 99% and 100%, respectively. Pain and function also improved significantly, as the functional QuickDASH score. According to Wrightington score, 18 cases were excellent, 3 were good, and one poor result. Twenty-one patients returned to their tasks without limitation, 20 of them refered to be satisfied with the final result. Conclusion: Arthroscopic resection using the "dry technique " represents a safe and effective alternative for the treatment of dorsal wrist ganglia, achieving pain relief, and functional and aesthetic improvement in most patients with early rehabilitation and a low incidence of recurrence. Level of Evidence: IV

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis.

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.

Four-corner arthrodesis: influence of the position of the lunate on postoperative wrist motion: a cadaveric study.

PURPOSE: Evaluate the influence of the position of the lunate on postoperative wrist motion in four-corner arthrodesis. METHODS: Six upper cadaveric limbs were evaluated, comparing the total arc of motion in each wrist after simulating four-corner arthrodesis. The lunate was fixed in 3 different positions: neutral (0 degrees ), extended (30 degrees ), and flexed (20 degrees ). Statistical analyses (ANOVA and Bonferroni tests) were carried out to establish the significance of differences in articular motion in these 3 positions. RESULTS: Significant statistical differences were observed in full wrist extension. No significant differences, however, were found in flexion-extension total arc of motion, radial deviation, or ulnar deviation. CONCLUSIONS: According to our results in this cadaveric model, the position of the lunate affects postoperative wrist flexion and extension after four-corner arthrodesis. The flexed lunate position increases postoperative wrist extension and restrains wrist flexion. Inversely, the extended lunate position improves articular flexion and limits extension. Total arc of motion of the fused wrist does not vary in the 3 lunate positions.