Impact of Septated First Dorsal Compartments on Symptomatic de Quervain Disease.

BACKGROUND: The authors conducted this study to determine whether septation of the first dorsal compartment is more prevalent in de Quervain tenosynovitis, and whether this contributes to failure of corticosteroid injection therapy. METHODS: A retrospective review of 79 consecutive patients (85 wrists) with symptomatic de Quervain tenosynovitis treated with surgical release was performed. The number of corticosteroid injections performed preoperatively and the presence of first dorsal compartment septation determined intraoperatively were recorded. Correlation between the number of steroid injections and the presence of septation was evaluated. In addition, 48 matched cadaver upper extremities (96 wrists) that had not previously undergone surgery for de Quervain disease were evaluated for the presence of first dorsal compartment septation. The prevalence of septation was compared between matched wrists and against the surgically treated clinical cohort. RESULTS: In the clinical cohort, 61.2 percent of wrists contained a septated first dorsal compartment. There was no correlation between the presence of a septated first dorsal compartment and the number of steroid injections before surgical release. In the cadaver portion of the study, 72.9 percent of wrists contained septa. There was no significant difference in the prevalence of septated first dorsal compartments between groups. CONCLUSIONS: In the present study, the majority of wrists contained a septated first dorsal compartment, with no difference in the prevalence of septa between surgically treated patients and a cadaver sample that had not undergone prior surgical release. Furthermore, there was no correlation between the presence of septa and the number of preoperative corticosteroid injections administered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Dorsal Aponeurosis of the Thumb.

PURPOSE: To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences between the fingers and thumb will provide an improved clinical understanding of the thumb dorsal aponeurosis anatomy. METHODS: Ten fresh cadaver hands from 5 patients with an average age of 31.6 (range, 22-41) years were dissected. The thenar muscles were identified and insertion sites were documented. The fibers of the dorsal aponeurosis and contributions were identified. RESULTS: The flexor pollicis brevis superficial head contributed to the radial fibers of the dorsal aponeurosis in 8 specimens and contributed to the deep head in 1 specimen. The abductor pollicis brevis provided fibers to the radial dorsal aponeurosis in all 10 specimens. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. CONCLUSIONS: This investigation provides a detailed anatomic study of the dorsal aponeurosis of the thumb with observation of both intrinsic and extrinsic contributions. CLINICAL RELEVANCE: Understanding the anatomy of the dorsal aponeurosis of the thumb remains important not only for evaluation of the classic Stener lesion, but also for the appropriate treatment of deformity, contracture, and neuromuscular disorders involving the thumb.

Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates.

BACKGROUND: Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections. METHODS: A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed. RESULTS: Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006). CONCLUSIONS: The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.