Contested claims in carpal tunnel surgery: outcome study of worker's compensation factors.

UNLABELLED: We retrospectively analyzed the importance of factors relating to worker's compensation for 273 wrists in 211 consecutive patients who underwent primary carpal tunnel release. Patients were divided into three groups: non-work related, worker's compensation-uncontested, and worker's compensation-contested. Contested claims were those in which the worker's compensation carrier denied authorization for surgery, and in which such authorization was given following intervention by a plaintiff's attorney. RESULTS: there were no statistically significant differences in postoperative return of grip strength and in postoperative return to work intervals in comparing groups I and II. However, the contested worker's compensation patients were much less likely (and much slower) to return to light duty and to return to full duty work. Return of grip strength was slower and less complete in this group as well. Within worker's compensation, a contested claim portends a poorer prognosis. Uncontested worker's compensation claimants have nearly as good a prognosis as non-compensation patients.

Radial recession osteotomy for Kienböck's disease.

Sixty-eight patients underwent radial recession osteotomy for avascular necrosis of the lunate were retrospectively evaluated after an average follow-up period of 52 months. Twenty-five patients had undergone 1 or more additional procedures concurrently for treatment of Kienböck's disease. Pain diminished in 93% of patients, grip strength improved, and wrist motion was preserved; 75% of patients continued in their original occupations, including heavy labor. Surgical complications were uncommon. Four patients subsequently underwent salvage procedures, including 2 total wrist arthrodeses. Three of these 4 patients were receiving workers' compensation. One third of patients demonstrated lunate healing after joint leveling. Preliminary results suggest that concomitant lunate revascularization or vascularized bone grafting may improve the radiographic result. With rare exceptions, radial recession osteotomy relieves pain and improves function in Kienböck's disease.

Trispiral tomographic staging of Kienböck's disease.

Trispiral tomography enhances the staging of Kienböck's disease and aids in surgical planning. The clinical records, plain x-rays, and trispiral tomograms of 105 patients with Kienböck's disease were reviewed. When tomograms were used, upward revision of the classification stage was indicated in 73% of patients with stage I or stage II disease and in 10% of those with stage III disease. On tomograms, 91% of patients had lunate fractures, compared with 55% on plain films. The most common lunate fracture seen on trispiral tomograms was a transverse shear fracture that represented lunate collapse; the next most common was a midcoronal fracture that may be displaced, causing fragment extrusion palmarly or dorsally. The most common instability pattern was nondissociative proximal row flexion, seen in stage III. Indices of carpal collapse and ulnar translation may be useful in following up patients, but values vary widely among patients.

Arthrodesis of the wrist for post-traumatic disorders.

We retrospectively reviewed the records of eighty-nine consecutive patients (ninety wrists) who had had a total arthrodesis of the wrist for the treatment of a post-traumatic disorder at one center. Fifty-six patients (fifty-seven wrists) had the arthrodesis with plate fixation, and thirty-three patients (thirty-three wrists) had the arthrodesis with a variety of other techniques. The average age of the patients at the time of the arthrodesis was forty-two years, and the dominant wrist was treated in forty-two patients. Fifty-six (98 per cent) of the fifty-seven wrists that had been fixed with a plate had a successful union at an average of 10.3 weeks postoperatively. Twenty-seven (82 per cent) of the thirty-three wrists that had been treated with other methods had a successful union at an average of 12.2 weeks postoperatively. The difference in the rates of union between the wrists fixed with a plate and those treated with alternative techniques was significant (p = 0.009; Fisher exact test). A total of thirty-nine complications were associated with twenty-nine (51 per cent) of the fifty-seven arthrodeses with plate fixation. Sixteen (41 per cent) of the complications (thirteen wrists) resolved with non-operative treatment. Twenty-six (79 per cent) of the thirty-three arthrodeses with alternative methods of fixation were associated with a total of twenty-nine complications. Twenty-three (79 per cent) of those complications (twenty wrists) resolved with non-operative treatment. The difference between the rate of complications associated with the arthrodeses with plate fixation and that associated with the arthrodeses with alternative methods of fixation was significant (p = 0.03; Fisher exact test).

Ulnar lengthening and radial recession procedures for Kienböck's disease. Long-term clinical and radiographic follow-up.

Twenty patients with Kienböck's disease who had undergone a joint levelling procedure, were reviewed at a mean of 11 years following surgery. Clinical and radiological evaluation revealed good long-term results with all patients complaining of less pain than before surgery and with statistically significant increases in range of motion and grip strength. Radiologically a significant number of patients were found still to have lunate fractures and fragmentation. In addition, 13 patients have developed new bone formation in the lunate fossa, and 12 show osteoarthritic changes, particularly at the radioscaphoid interface. Radial shortening was felt to be superior to ulnar lengthening in that there were fewer problems with bone union.

Upper extremity function after wrist arthrodesis.

Several studies have examined the normal range of wrist motion used to accomplish activities of daily living. Little information is present, however, on what functional limitations might be experienced by patients actually undergoing formal wrist arthrodesis. This study undertook comprehensive functional evaluation of 23 patients who underwent wrist arthrodesis for post-traumatic conditions. Follow-up evaluation averaged 54 months and consisted of a clinical questionnaire, the Jebsen Hand Function Test, and a functional rating devised by Buck-Gramcko/Lohmann. Fifteen of the 23 patients returned to their original jobs, and all patients noted that although the vast majority of tasks could still be performed, these tasks were undertaken in a modified fashion. The most difficult daily tasks for patients with a wrist arthrodesis to perform involved perineal care and manipulating the hand in tight spaces. The Jebsen Hand Function Test demonstrated a 64% task completion rate with the fused wrist compared to a 78% task completion rate for the normal wrist. The Buck-Gramcko/Lohmann evaluations demonstrated an average score of 8.3 out of a possible 10. Patients who have undergone wrist arthrodesis can accomplish most activities of daily living and other functional requirements, although some adaptation to accomplish these tasks is required.

Ulnar lengthening procedures.

Ulnar lengthening redistributes axial compressive forces partially relieving those on the lunate, slowing or halting further progressive collapse. Long-term results are satisfactory, although restitution of the carpal anatomy is not obtained.