Factors Influencing Surgical Decision Making in Trapeziometacarpal Osteoarthritis.

Purpose: With trapeziometacarpal osteoarthritis (TMC OA), the relationship between disease severity and pretreatment dysfunction, patient expectations, and preferred patient treatment and management remains unclear. This study aimed to assess the association between functional status, pretreatment expectations, and demographic and clinical characteristics of TMC OA patients who decide to undergo operative management. Methods: Patients diagnosed with TMC OA (n = 96) were administered the Thumb Arthritis Expectations Survey and the Brief Michigan Hand Questionnaire (bMHQ) during their initial office visit. Demographic data (sex, age, race, education level, marital status, comorbidities, and hand dominance) and clinical characteristics (prior injury, and therapeutic interventions including splinting, steroid injections, therapy, and anti-inflammatory medication) were collected. Multiple logistic regression was used to assess the association between surgical treatment and expectation scores. Results: Our logistic regression model found that lower bMHQ scores, high thumb arthritis expectation survey scores, and prior treatments for TMC OA were associated significantly with the surgical treatment of TMC OA. After controlling for all possible covariates, the odds of having surgery was 3.9 times higher among patients with high expectations (above median) compared to patients with low expectations (adjusted odds ratio [AOR], 3.9; 95% confidence interval [CI], 1.3-11.2). Patients with average function, as measured by bMHQ scores, were 74.5% less likely to elect for surgery than those with the lowest bMHQ (AOR, 0.3; 95% CI, 0.1-0.9). Patients treated previously with steroids were 13 times more likely to elect for surgery than those who were never treated for TMC arthritis (AOR,13.1; 95% CI, 2.2-77.0). Conclusions: Patients with TMC OA who elect to proceed with surgical management have lower bMHQ (greater perceived dysfunction) and higher expectations, and have had prior treatment. Age was not a significant predictor of surgical management of TMC OA. Type of study/level of evidence: Prognostic IV.

Technique of Tendon Interposition Arthroplasty for Chronic Volar Dislocation of the Distal Radioulnar Joint.

Volar distal radioulnar joint (DRUJ) dislocations are uncommon wrist injuries. Failed diagnosis or treatment can result in irreversible damage to the articulating surfaces and ultimately lead to chronic degenerative arthritis. When the DRUJ is reducible, and the cartilage is preserved, ligament reconstruction and ulnar osteotomy are surgical options for residual wrist instability or pain. When destruction of the native DRUJ has already occurred, surgical treatment options are salvage procedures. Here we present treatment for a chronic volarly dislocated DRUJ with open reduction and internal fixation using an alternative joint-preserving surgical technique with tendon allograft interposition arthroplasty.

Micro Screw Fixation for Small Proximal Pole Scaphoid Fractures with Distal Radius Bone Graft.

Background Achieving adequate fixation and healing of small proximal pole acute scaphoid fractures can be surgically challenging due to both fragment size and tenuous vascularity. Purpose The purpose of this study was to demonstrate that this injury can be managed successfully with osteosynthesis using a "micro" small diameter compression screw with distal radius bone graft with leading and trailing screw threads less than 2.8 mm. Patients and Methods Patients with proximal pole scaphoid fragments comprising less than 20% of the entire scaphoid were included. Fixation was accomplished from a dorsal approach with a micro headless compression screw and distal radius bone graft. Six patients were included. Average follow-up was 44 months (range, 11-92). Results Mean proximal pole fragment size was 14% (range, 9-18%) of the entire scaphoid. The mean immobilization time was 6 weeks, time-to-union of 6 weeks, and final flexion/extension arc of 88°/87°. All patients had a successful union, and no patient had deterioration in range of motion, avascular necrosis, or fragmentation of the proximal pole. Conclusion Small diameter screws with a maximal thread diameter of ≤ 2.8 mm can be used to fix the union of proximal pole acute scaphoid fractures comprising less than 20% of the total area with good success. Level of Evidence Therapeutic case series, Level IV.

Cadaveric Testing of a Novel Scapholunate Ligament Reconstruction.

Background Existing scapholunate interosseous ligament (SLIL) reconstruction techniques include fixation spanning the radiocarpal joint, which do not reduce the volar aspect of the scapholunate interval and may limit wrist motion. Questions/Purpose This study tested the ability of an SLIL reconstruction technique that approximates both the volar and dorsal scapholunate intervals, without spanning the radiocarpal joint, to restore static scapholunate relationships. Materials and Methods Scapholunate interval, scapholunate angle, and radiolunate angle were measured in nine human cadaveric specimens with the SLIL intact, sectioned, and reconstructed. Fluoroscopic images were obtained in six wrist positions. The reconstruction was performed by passing tendon graft through bone tunnels from the dorsal surface toward the volar corner of the interosseous surface. After reduction of the scapholunate articulation, the graft was tensioned within the lunate bone tunnel, secured with an interference screw in the scaphoid, and sutured to the dorsal SLIL remnant. Differences among testing states were evaluated using repeated measures ANOVA. Results There was a significant increase in the scapholunate interval in all wrist positions after complete SLIL disruption. Compared with the disrupted state, there was a significant decrease in scapholunate interval in all wrist positions after reconstruction using a tendon graft and interference screw. Conclusion Our SLIL reconstruction technique reconstructs the volar and dorsal ligaments of the scapholunate joint and adequately restores static measures of scapholunate stability. This technique does not tether the radiocarpal joint and aims to optimize volar reduction. Clinical Relevance Our technique offers an alternative option for SLIL reconstruction that successfully restores static scapholunate relationships.

What Demographic and Clinical Characteristics Correlate With Expectations With Trapeziometacarpal Arthritis?

BACKGROUND: Pretreatment variables have been shown to be associated with the fulfillment of patient expectations, yet in treating thumb trapeziometacarpal osteoarthritis (OA) it remains unclear how patient expectations correlate with the effectiveness of treatment. An increased understanding of the variables that affect patient expectations enables tailored patient education and patient-provider communication. QUESTIONS/PURPOSES: (1) Is there a correlation between patient demographics and clinical characteristics, and the expectations the patients have when seeking treatment for trapeziometacarpal OA? (2) What factors are independently associated with the total expectations score and frequency of expecting "back to normal" among patients treated for trapeziometacarpal OA? METHODS: Between March 2011 and October 2013, 89 patients of all 96 eligible patients seeking treatment for trapeziometacarpal OA were approached and agreed to participate in this study. Participants completed a validated expectations survey measuring the number of expectations and the degree of improvement expected. Comparative analysis of demographic and clinical characteristics and multivariate regression analysis against patients' expectations were performed to assess and identify factors that correlate with the number and degree of expectations. Sample size was determined with an a priori power analysis (with 80% power and statistical significance set at p < 0.05), which showed that 88 patients were needed to detect the minimal clinical difference of 12 points in the Michigan Hand Questionnaire; we then increased this by 10% to allow for potential dropouts. RESULTS: After controlling for potential confounding variables such as age, hand dominance, and work status, the following factors were associated with a higher expectations score: choice of surgery (ß = 11.5; 95% CI, 0.7-23.8; p = 0.044), female gender (ß = 19.0; 95% CI, 5.3-32.7; p = 0.007), and dominant side affected (ß = -41.6; 95% CI, -63.7 to -19.5; p < 0.001). For the frequency of "back to normal" responses, surgical treatment (ß = 7.4; 95% CI, 2.3-12.4; p = 0.005) and history of previous injury (ß = 8.2; 95% CI, 0.1-16.3; p = 0.047) were independently associated factors after controlling for confounding variables. There were no independent associations with age, marital status, work status, depression or anxiety, or prior contralateral surgery. CONCLUSIONS: Patients whose dominant side was affected, were female, and chose surgical treatment, had higher total expectations. Patients who reported an antecedent injury and chose surgical treatment more frequently expected a return to normal. With identification of these factors, orthopaedic surgeons can recognize patients who are prone to higher expectations, and, thus, have the opportunity to implement efficient pretreatment education. In addition, identification of specific factors enables a focused measure of the effect of these factors on the fulfillment of expectations. LEVEL OF EVIDENCE: Level II, prognostic study.

Evaluation of Physical Examination Tests for Thumb Basal Joint Osteoarthritis.

BACKGROUND: We compare the ability of 3 diagnostic tests to reproduce the pain of basilar joint arthritis (BJA): the grind test, the lever test (grasping the first metacarpal just distal to the basal joint and shucking back and forth in radial and ulnar directions), and the metacarpophalangeal extension test. METHODS: Sixty-two patients with thumb BJA were enrolled. The 3 tests were performed in a random order on both hands of each patient. Prior to testing, patients reported their typical pain level and subsequently rated their pain after each test on a 0 to 10 scale, also specifying the extent to which the test reproduced their thumb pain (fully, partially, not at all). All patients had radiographs that displayed basal joint arthritis. A test was defined as positive for BJA if pain produced was greater than 0. Sensitivity and specificity for each test were calculated using the patients' history of pain localized to the basal joint and BJA diagnosis on radiographs as the gold standard. RESULTS: The lever test produced the greatest level of pain and best reproduced the presenting pain. The lever test also had the highest sensitivity, high specificity, and the lowest false-negative rate. The grind test had the lowest sensitivity, highest specificity, and highest false-negative rate. CONCLUSIONS: The lever test was the diagnostic test that best reproduced the pain caused by thumb basal joint osteoarthritis. We recommend using the lever physical examination test when evaluating the patient with suspected basal joint osteoarthritis. The often-quoted grind test is of limited diagnostic value.

Patients With Thumb Carpometacarpal Arthritis Have Quantifiable Characteristic Expectations That Can Be Measured With a Survey.

BACKGROUND: Although patient expectations associated with major orthopaedic conditions have shown clinically relevant and variable effects on outcomes, expectations associated with thumb carpometacarpal (CMC) arthritis have not been identified, described, or analyzed before, to our knowledge. QUESTIONS/PURPOSES: We asked: (1) Do patients with thumb CMC arthritis express characteristic expectations that are quantifiable and have measurable frequency? (2) Can a survey on expectations developed from patient-derived data quantitate expectations in patients with thumb CMC arthritis? METHODS: The study was a prospective cohort study. The first phase was a 12-month-period involving interviews of 42 patients with thumb CMC arthritis to define their expectations of treatment. The interview process used techniques and principles of qualitative methodology including open-ended interview questions, unrestricted time, and study size determined by data saturation. Verbatim responses provided content for the draft survey. The second phase was a 12-month period assessing the survey for test-retest reliability with the recruitment of 36 participants who completed the survey twice. The survey was finalized from clinically relevant content, frequency of endorsement, weighted kappa values for concordance of responses, and intraclass coefficient and Cronbach's alpha for interrater reliability and internal consistency. RESULTS: Thirty-two patients volunteered 256 characteristic expectations, which consisted of 21 discrete categories. Expectations with similar concepts were combined by eliminating redundancy while maintaining original terminology. These were reduced to 19 items that comprised a one-page survey. This survey showed high concordance, interrater reliability, and internal consistency, with weighted kappa values between 0.58 and 0.78 (95% CI, 0.39-0.78; p < 0.001); intraclass correlation coefficient of 0.94 (95% CI, 0.94-0.98; p < 0.001), and Cronbach's alpha values of 0.94 and 0.95 (95% CI, 0.91-0.96; p < 0.001). The thumb CMC arthritis expectations survey score is convertible to an overall score between 0 to 100 points calculated on the basis of the number of expectations and the degree of improvement expected, with higher scores indicating higher expectations. CONCLUSIONS: Patients with thumb CMC arthritis volunteer a characteristic and quantifiable set of expectations. Using responses recorded verbatim from patient interviews, a clinically relevant, valid, and reliable expectations survey was developed that measures the physical and psychosocial expectations of patients seeking treatment for CMC arthritis. The survey provides a calculable score that can record patients' expectations. Clinical application of this survey includes identification of factors that influence fulfilment of these expectations. LEVEL OF EVIDENCE: Level II, prospective study.

Operative Treatment of Acute Scaphoid Fractures.

Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.

Biomechanical Analysis of Scapholunate Ligament Repair Techniques.

PURPOSE: To evaluate the biomechanical properties of 3 scapholunate repair techniques. METHODS: In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. RESULTS: The mode of failure was suture pullout through the substance of the ligament in 22 specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. CONCLUSIONS: Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. CLINICAL RELEVANCE: In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance in vivo.

Neurotization to innervate the deltoid and biceps: 3 cases.

PURPOSE: To describe our experience using direct muscle neurotization as a treatment adjunct during delayed surgical reconstruction for traumatic denervation injuries. METHODS: Three patients who had direct muscle neurotization were chosen from a consecutive series of patients undergoing reconstruction for brachial plexus injuries. The cases are presented in detail, including long-term clinical follow-up at 2, 5, and 10 years with accompanying postoperative electrodiagnostic studies. Postoperative motor strength using British Medical Research Council grading and active range of motion were retrospectively extracted from the clinical charts. RESULTS: Direct muscle neurotization was performed into the deltoid in 2 cases and into the biceps in 1 case after delays of up to 10 months from injury. Two patients had recovery of M4 strength, and the other patient had recovery of M3 strength. All 3 patients had evidence on electrodiagnostic studies of at least partial muscle reinnervation after neurotization. CONCLUSIONS: Direct muscle neurotization has shown promising results in numerous basic science investigations and a limited number of clinical cases. The current series provides additional clinical and electrodiagnostic evidence that direct muscle neurotization can successfully provide reinnervation, even after lengthy delays from injury to surgical treatment. CLINICAL RELEVANCE: Microsurgeons should consider direct muscle neurotization as a viable adjunct treatment and part of a comprehensive reconstructive plan, especially for injuries associated with avulsion of the distal nerve stump from its insertion into the muscle.

Features of grade 3 giant cell tumors of the distal radius associated with successful intralesional treatment.

PURPOSE: The goal of this study was to identify radiographic and anatomic features of Campanacci grade 3 distal radius giant cell tumors that are associated with an acceptable rate of local recurrence after intralesional treatment. METHODS: We retrospectively reviewed 15 grade 3 distal radius giant cell tumors treated with intralesional curettage, cryosurgery, and cementation (CCC) (n = 9) or with wide en bloc excision and reconstruction (WEE) (n = 6). Success was defined as local control after CCC without conversion to wide excision, and as a recurrence rate comparable with rates in the scientific literature. Preoperative radiographic evaluation and intraoperative determination of tumor extension guided the choice of treatment. Tumor width on x-rays and tumor volume on magnetic resonance imaging were measured. Outcome was assessed with postoperative motion and grip strength, and the Disabilities of the Shoulder, Arm and Hand, the visual analog pain score, and a satisfaction questionnaire. RESULTS: Local recurrence occurred in 2 of 9 patients after primary CCC, in none with repeat CCC, and in none of the 6 with WEE. No patient treated with secondary CCC had unresectable recurrence requiring conversion to WEE. Patients with a single site of cortical perforation who received CCC treatment achieved local control with intralesional treatment alone. Average tumor volume was 12 cm(3) (range, 9-17 cm(3)) with CCC and 43 cm(3) (range, 29-57 cm(3)) with WEE. Postoperative motion and strength, Disabilities of the Shoulder, Arm and Hand score, and visual analog pain scale score were acceptable in all and superior with CCC. All patients were highly satisfied. CONCLUSIONS: Tumor volume measured with magnetic resonance imaging and anatomically defined limits of soft tissue extension may help identify grade 3 lesions that can be treated with with CCC with an acceptable rate of local recurrence. We propose subclassification of Campanacci grade 3 lesions. Under this classification, tumors with extension assessed by preoperative imaging and confirmed by intraoperatively to be limited to a single site of palmar cortical perforation are classified as grade 3(p), where (p) denotes a single site bound by the pronator quadratus. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Extensor tendon centralization at the metacarpophalangeal joint: surgical technique.

Injury to the extensor hood at the level of the dorsal metacarpophalangeal joint with instability and subluxation of the extensor tendon might require surgical treatment after failing conservative methods. Surgical techniques for chronic injuries have used local tissue or nearby tendon slips as grafts for tendon realignment, with or without soft tissue release and imbrication. Here we present a technique that creates a bone tunnel for a graft that is sutured upon itself and effectively creates a new pulley.

Patients with workers' compensation claims have worse outcomes after rotator cuff repair.

BACKGROUND: Previous studies have demonstrated varying correlations between Workers' Compensation status and the outcome of rotator cuff repair. However, none of those studies have formally accounted for potential confounding factors with multivariable analysis. We hypothesized that patients with Workers' Compensation claims who undergo rotator cuff repair have worse outcomes, even after controlling for confounding factors. METHODS: One hundred and twenty-five patients (including thirty-nine with Workers' Compensation claims) who underwent unilateral primary repair of a chronic rotator cuff tear by a single surgeon were studied prospectively and were evaluated one year postoperatively, prior to the settlement of any claims. Outcomes were assessed with the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) index; three visual analog scales (shoulder pain, shoulder function, and quality of life); and the Short Form-36 (SF-36). RESULTS: Patients in the Workers' Compensation group were significantly younger, had greater work demands, and had lower marital rates, education levels, and preoperative expectations for the outcome of treatment as compared with those in the non-Workers' Compensation group (p = 0.001 to 0.016). Preoperatively, patients in the Workers' Compensation group had significantly lower scores on the SST, the SF-36 Physical Function scale, and the SF-36 Social Function scale (p = 0.01 to 0.038). One year postoperatively, those patients reported worse performance on the SST, the DASH, all three visual analog scales, and the SF-36 (p = 0.0007 to 0.05) and had worse improvement on the DASH, the visual analog scales for shoulder pain and function, and the SF-36 Bodily Pain and Role Emotional scales (p = 0.0028 to 0.038). Multivariable analysis controlling for age, sex, comorbidities, smoking, marital status, education, duration of symptoms, work demands, expectations, and tear size confirmed that Workers' Compensation status was an independent predictor of worse DASH scores. CONCLUSIONS: Patients with Workers' Compensation claims report worse outcomes, even after controlling for confounding factors. The present study provides further evidence that the existence of a Workers' Compensation claim portends a less robust outcome following rotator cuff repair. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain.

PURPOSE: The purpose of this study was to compare the postoperative rates of ganglion recurrence between arthroscopic and open techniques of dorsal ganglion (DG) excision. METHODS: A total of 72 patients had either arthroscopic or open excision of a primary, simple DG by 1 of 2 senior hand surgeons. Three prospective postoperative assessments were performed. The first examination was performed at 5 to 7 days, the second at 4 to 8 weeks, and the third assessment was performed at a minimum of 1 year after surgery. Percentages of ganglion recurrence at the second and third assessments were recorded. RESULTS: Forty-one patients had arthroscopic excision, and 31 patients had open excision. Baseline patient age, gender, and surgical side were similar between the 2 groups. Recurrence of the DG at the second postoperative assessment was 1 of 41 patients in the arthroscopic group and none in the open excision group, and, after a minimum of 12 months after excision, recurrence was 3 of 28 in the arthroscopic group and 2 of 23 in the open group. CONCLUSIONS: This study compares the rates of ganglion recurrence between arthroscopic and open DG excision. Our results demonstrate that at 12 months follow-up, the rates of recurrence with arthroscopic DG excision are comparable with and not superior to those of open excision. Our results suggest that additional long-term comparative studies are needed to accurately differentiate the efficacy of open and arthroscopic techniques.

Patients' preoperative expectations predict the outcome of rotator cuff repair.

BACKGROUND: We are not aware of any previous studies of the relationship between patients' expectations regarding rotator cuff repair and the actual outcome. We hypothesized that preoperative expectations are predictive of the outcome of rotator cuff repair. METHODS: One hundred and twenty-five patients who underwent unilateral primary repair of a chronic rotator cuff tear were included in the study. All operations were performed by a single surgeon. Each patient prospectively completed the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; three visual analogue scales for shoulder pain, shoulder function, and quality of life; and the Short Form-36 (SF-36) preoperatively and at one year (mean and standard deviation, 54.1 +/- 7.6 weeks) postoperatively. Preoperative expectations were quantified with use of six questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. RESULTS: Greater preoperative expectations correlated with better postoperative performance on the SST, DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.0001 to 0.03) as well as with greater improvement from the baseline scores on the DASH and SF-36 (p values ranging from <0.0001 to 0.018). A rigorous multivariate analysis controlling for age, gender, smoking, Workers' Compensation status, symptom duration, number of previous operations, number of comorbidities, tear size, and repair technique confirmed that greater expectations were a significant independent predictor of both better performance at one year and greater improvement on the SST, the DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.001 to 0.042). CONCLUSIONS: Patients' preoperative expectations regarding rotator cuff repair are associated with their actual self-assessed outcome. Variations in patient expectations may help to explain divergent results in published series as well as among various patient populations.