Combined Diagnostic Yield of Tilt Table Test And Implantable Loop Recorder to Identify Patients Affected by Severe Clinical Presentation of Neurally-Mediated Reflex Syncope who Could Respond to Cardiac Pacing.

In this study we wanted to verify the diagnostic value of tilt table test (TTT) to predict the efficacy of cardiac pacing (PM) for preventing recurrences of neurally mediated reflex syncope (NMS) in patients with cardioinhibitory activity (CI) documented by implantable loop recorder (ILR). Among patients selected by ILR in the context of severe clinical presentation of NMS, we analysed those who underwent PM implantation. In this observational and retrospective study we wanted to verify the results of TTT in the groups of treated patients with and without recurrences. We analysed 24 patients treated using a PM (10 male and 14 female, mean age 70 years). During an average follow-up period of 35 months the recurrence of syncope occurred in 7 patients (29%). 17 patients (71%) had not recurrences. TTT was negative in 15 patients out of 17 without recurrences (88%). Among the 7 patients with recurrences TTT was positive in 4 patients (57%). In conclusion, in this selected group of patients, a positive response to TTT is more likely correlated with a higher frequency of recurrences of syncope, while a negative response seems to predict the success of the pacing therapy. Consequently, PM could be insufficient to prevent the recurrences in the group of patients with positive TTT.

Implantable Loop Recorder: Diagnostic Yield And Possible Therapeutic Effect In Patients With Neurally Mediated Reflex Syncope.

Through a retrospective study concerning the experience of our center in patients affected by Neurally Mediated reflex Syncope (NMS) we wanted to verify not only the diagnostic yield of the Implantable Loop Recorder (ILR) but its possible placebo therapeutic effect. In the context of patients affected by a severe clinical presentation of NMS identified through a careful clinical evaluation, we selected those who followed a diagnostic iter using the ILR. We analysed 84 patients (39 male and 45 female, mean age 71 years), during the period 2009-2013. 34 patients (40.5%) had no recurrences after a mean follow-up (FU) of 35 months, among these 17 concluded a FU of 4 years. 50 patients (59.5%) had recurrences and a specific diagnosis after an average period of 7 months. We found an important number of patients who showed a disappearance of syncope during an observation period of 2-3 and 4 years. At first glance this results could be explained considering the possible placebo therapeutic effect of ILR.

Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with triangular fibrocartilage complex tears and positive ulnar variance.

Because a certain percentage of patients with positive ulnar variance experience incomplete pain relief after triangular fibrocartilage complex (TFCC) debridement alone, we prospectively evaluated the feasibility and efficacy of combining arthroscopic TFCC debridement with arthroscopic wafer resection in such wrists as part of the same surgical procedure. We enrolled 12 patients between July 1998 and July 2000 and performed both subjective and objective assessment at follow-up with a minimum of 6 months and an average of 14 months. Seven posttraumatic and 5 degenerative tears were identified. Preoperative ulnar variance with a pronated grip x-ray averaged 2 mm and ranged between 1 and 4 mm. At final review 8 patients experienced complete pain relief and 4 experienced only minimal symptoms. The ulnocarpal stress test failed to elicit pain in any wrist. Nine patients were very satisfied, and 3 were satisfied. Grip strength improved 8 kg (36%). This procedure should be considered in the treatment of ulnar wrist pain when TFCC tears and positive ulnar variance coexist.

The rationale for and efficacy of surgical intervention for electrodiagnostic-negative cubital tunnel syndrome.

Because conservative management of McGowan grade 1 cubital tunnel syndrome (symptoms only) may be successful in a high percentage of patients, normal electrodiagnostic studies and the absence of intrinsic muscle weakness or decreased sensation or both may be viewed as contraindications to operative intervention. Because the results of surgery are known to be inferior once objective motor weakness and abnormal 2-point sensory discrimination (McGowan grades 2 and 3) develop, however, we advocate surgical intervention for patients with symptoms only, even when electrodiagnostic studies are normal. We enrolled 16 patients (18 elbows) with McGowan I cubital syndrome who underwent in situ ulnar nerve release and medial epicondylectomy. Paresthesias resolved in all cases, and both elbow range of motion and grip strength returned to normal in 17 of 18 elbows. The elbow flexion test resolved in all cases, and a Tinel's sign was present at final review in 5 elbows (28%). One patient required another operation to address a neuroma of a posterior branch of the medial antebrachial cutaneous nerve, but additional morbidity was not identified after objective review and patient self-assessment.

Carpal tunnel release for advanced disease in patients 70 years and older: does outcome from the patient's perspective justify surgery?

Because more advanced stages of nerve compression are likely to result in intraneural changes including intrinsic fibrosis and axon loss, we hypothesised that carpal tunnel release for advanced carpal tunnel syndrome might not result in satisfactory resolution of symptoms. We were particularly interested in evaluating a population of elderly patients 70 years and older for whom relief of symptoms is the overwhelming objective of surgery. Our retrospective assessment of symptom resolution and patient satisfaction in 13 patients with advanced carpal tunnel syndrome utilized a validated self-administered questionnaire and revealed minimal symptoms in 11 patients. Although carpal tunnel release is unlikely to result in the total elimination of symptoms when performed in elderly patients with advanced disease, outcome from the patient's perspective appears to be satisfactory and the surgery quite justified.

Treatment of Eaton stage I trapeziometacarpal disease. Ligament reconstruction or thumb metacarpal extension osteotomy?

Although the cause of TM joint hypermobility may be multifactorial, translational laxity and instability appear to be related to degeneration of the beak ligament. Indeed, the forces experienced at the normal TM joint with grip and pinch are magnified several fold and are concentrated in the palmar aspect of the joint. The TM stress test used in preoperative assessment of thumbs with hypermobile TM joints reflects nonphysiologic dorsal translation and correlates with histologic evidence of detachment of the metacarpal origin of the beak ligament. Ligament reconstruction of the painful TM joint reflects the importance of the beak ligament in providing stability and in limiting dorsal translation of the metacarpal that normally occurs during dynamic pinch activity. Metacarpal extension osteotomy, by contrast, shifts mechanical loading at the TM joint more dorsally and redirects force vectors. Its precise role in the treatment of TM disease has long remained ill-defined because of a lack of correlation between preoperative disease status and postoperative functional result. It appears now, however, that for stage I disease, metacarpal extension osteotomy may result in satisfactory pain relief and improved grip and pinch strength--at least in the short term. Indeed, extension osteotomy may be an efficacious alternative to ligament reconstruction, but long-term follow-up and additional clinical studies will be helpful in shedding additional light on this topic.

Ligament reconstruction tendon interposition arthroplasty for basal joint arthritis. Rationale, current technique, and clinical outcome.

The literature unequivocally supports the LRTI arthroplasty. Indeed, thumb stability, pain relief, and improvements in strength are the expected outcomes. Although some investigators believe that ligament reconstruction is not necessary, trapezium excision alone, or in combination with facial or tendon interposition, is less likely to provide long-term stability or restore satisfactory pinch and grip strength. Some hand surgeons may be apprehensive about harvesting the entire width of the FCR tendon because of fear that wrist function may be impaired or that a larger bony channel in the metacarpal might result in fracture. In that light, Coleman and the author recently reported the results of a prospective evaluation that rather convincingly showed there was no morbidity accompanying harvest of the entire FCR tendon, from the standpoint of wrist strength or endurance. Furthermore, technical modification by which the end of the FCR is tapered or trimmed obviates the need for an excessively large bony channel through the metacarpal. Preliminary pin fixation of the metacarpal, with its base suspended at the level of the index CMC joint, in the fisted position, is still recommended to allow accurate tensioning of the new ligament, and protection in the early postoperative period. Proximal migration of only 13% at an average of 9 years after surgery may very well reflect the value of this particular practice. In conclusion, attention to technical detail and compliance with the postoperative therapy program, in the author's opinion, are intricately related to the favorable outcomes he has observed during 5 years of seeing Burton perform the LRTI arthroplasty and more than 6 years of performing the procedure in his own practice.

Surgical treatment of the rheumatoid thumb.

Rheumatoid arthritis commonly affects the thumb. Deformity does not require surgical intervention unless pain is present or a functional deficit exists, but if bony erosion develops and surgical treatment may be compromised in the future, earlier intervention may be indicated. When the pathogenesis and pathoanatomy of the impaired rheumatoid thumb are appreciated, and appropriate treatment is selected, surgical intervention is likely to provide a favorable outcome for the patient.

Restoration of functional prehension after radial hemihand amputation in a three-year-old child: rationale for and long-term result after great toe transfer.

Partial hand amputations are rare injuries among children, causing significant functional impairment. Reports on thumb reconstruction in children and adults are used to develop a reconstruction plan for restoring prehension. While either first or second toe transplantation may be indicated to restore prehension in adults with thumb loss, near universal reluctance to use the great toe in children centers around concern regarding the subsequent function and appearance of the foot. This report details the reconstruction of functional prehension after radial hemihand amputation in a 3-year-old child. Great toe transplantation was used and resulted in neither objective nor subjective donor site morbidity. The rationale for use of the great toe in this child and long-term functional outcome are described.

Carpal impaction with the ulnar styloid process: treatment with partial styloid resection.

Carpal impaction with the ulnar styloid process (stylocarpal impaction) occurs less frequently than with the ulnar head (ulnocarpal impaction), and more commonly develops in wrists with negative ulnar variance. Physical examination, radiographic evaluation, and wrist arthroscopy are all helpful in excluding alternative causes of ulnar wrist pain. When an ulnocarpal stress test elicits pain, and radiographs suggest that this is due to carpal impaction with the ulnar styloid, partial resection of the styloid process provides successful treatment, so long as the insertion of the triangular fibrocartilage at the base of the styloid is not disrupted.

Amputation or salvage of type 3B/3C tibial fractures: what the literature says about outcomes.

Reconstructive microsurgical techniques, improvements in skeletal fixation, and aggressive bone grafting have been successful in salvaging high-energy open tibial fractures that would have been amputated in the past. Although limb salvage is often feasible, it is not always advisable-functional outcomes and patient satisfaction are not merely a matter of achieving union and restoring a soft-tissue envelope. This article examines current literature that addresses the complex interplay of salvage and restoration of a functional limb.

Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: a description of treatment protocol and evaluation of results.

Although the literature suggests that palmar sympathectomy (PS) with or without vascular reconstruction may improve ischemic digital pain, fingertip ulceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both early (6 months) and long-term (average, 2.5 years) outcome after PS in combination with decompression arteriolysis of the radial and ulnar arteries proximal to the wrist. When preoperative digital blood flow was inadequate based on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement in cold intolerance resulted in eight hands, and at final follow-up, this was sustained in seven hands. Preoperatively, digital ulcerations were present in six hands. After digital debridement and/or amputation, all wounds healed, but in one patient with bilateral disease who continued to smoke, ulcerations recurred without the need for subsequent surgery. Five of six patients were no longer dependent on narcotic analgesics, but use of vasodilator medication did not change. Five of six patients claimed significant improvement in the quality of life after surgery and reported that they would undergo the surgery again. PS in combination with radial and ulnar arteriolysis appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular reconstruction is recommended if possible. We review our treatment protocol in this complex population of patients.

Growth factor may decrease muscle atrophy secondary to denervation.

Despite modern microsurgical techniques, functional outcomes following brachial-plexus reconstruction and peripheral-nerve repair are usually unsatisfactory, because irreversible muscle atrophy develops before reinnervation occurs. Insulin growth factor-1 (IGF-1) has been shown to improve muscle regeneration after injury, and may have a role in muscle preservation following denervation. This study evaluated the histologic, immunohistochemical, and electrophysiologic differences between normal and denervated muscle over an 8-week time period, and also evaluated the effects of injecting IGF-1 into denervated muscle. Denervated mice gastrocnemius muscles demonstrated a decrease in muscle diameter, a decrease in muscle weight, early nuclear proliferation, and a decrease in fast twitch and maximum tetanic strength, compared to normal gastrocnemius muscle up to 8 weeks following denervation. Four weeks after denervated muscle was injected with IGF-1 at time zero, however, relative preservation of muscle diameter and weight, and maintenance of electrophysiologic contractile properties were observed. These preliminary data suggest that IGF-1 may prevent muscle atrophy secondary to denervation.

Treatment of ulnar impaction syndrome with the wafer procedure.

Our objective was to evaluate the efficacy of wafer resection of the distal ulna (the wafer procedure) as treatment for ulnar impaction syndrome. Between 1995 and 1997, 26 patients were surgically treated for refractory wrist pain secondary to ulnar impaction syndrome. The diagnosis was based on physical examination, radiologic imaging, and wrist arthroscopy, and confirmatory pathoanatomy was identified at the time of surgery in all cases. The study population consisted of 18 women and 8 men, and patient age averaged 42 years. Follow-up averaged 27 months (range, 17-41 months). Twenty-three patients were completely satisfied with pain relief and the functional status of their wrists at final follow-up. Range of motion returned to baseline in the majority of cases, usually by 3 months, and grip strength increased an average of 11 kg (P < or = .005). The wafer procedure is an effective treatment alternative to ulnar-shortening osteotomy for ulnar impaction syndrome and avoids the risk of nonunion and hardware-related complications.

A method for measuring joint kinematics designed for accurate registration of kinematic data to models constructed from CT data.

A method for measuring three-dimensional kinematics that incorporates the direct cross-registration of experimental kinematics with anatomic geometry from Computed Tomography (CT) data has been developed. Plexiglas registration blocks were attached to the bones of interest and the specimen was CT scanned. Computer models of the bone surface were developed from the CT image data. Determination of discrete kinematics was accomplished by digitizing three pre-selected contiguous surfaces of each registration block using a three-dimensional point digitization system. Cross-registration of bone surface models from the CT data was accomplished by identifying the registration block surfaces within the CT images. Kinematics measured during a biomechanical experiment were applied to the computer models of the bone surface. The overall accuracy of the method was shown to be at or below the accuracy of the digitization system used. For this experimental application, the accuracy was better than +/-0.1mm for position and 0.1 degrees for orientation for linkage digitization and better than +/-0.2mm and +/-0.2 degrees for CT digitization. Surface models of the radius and ulna were constructed from CT data, as an example application. Kinematics of the bones were measured for simulated forearm rotation. Screw-displacement axis analysis showed 0.1mm (proximal) translation of the radius (with respect to the ulna) from supination to neutral (85.2 degrees rotation) and 1.4mm (proximal) translation from neutral to pronation (65.3 degrees rotation). The motion of the radius with respect to the ulna was displayed using the surface models. This methodology is a useful tool for the measurement and application of rigid-body kinematics to computer models.

Carpal tunnel release under intravenous regional or local infiltration anaesthesia.

Fifteen patients with bilateral carpal tunnel syndrome underwent surgery using intravenous regional anaesthesia (IVRA) on one hand and local infiltration anaesthesia (LA) on the other. All 30 carpal tunnel releases were performed without complication. Patient tolerance for IVRA and LA was similar. Six patients preferred the LA, eight preferred IVRA and one had no preference. Tourniquet time averaged 16 minutes when LA was used and 24 minutes with IVRA (P<0.05). Use of local anaesthesia allows more expeditious surgery and limits costs, but intravenous regional anaesthesia is recommended if epineurotomy, internal neurolysis or flexor tenosynovectomy are planned.

Intraneural ganglion of the peroneal nerve: importance of timely diagnosis.

Peroneal nerve ganglion cysts typically present because of a palpable mass or symptoms and signs of entrapment neuropathy, including pain, diminished sensation, and motor weakness. Surgical treatment is usually successful when performed early, but, when diagnosis is delayed, intraneural growth and invasion may cause irreversible axonal injury and footdrop. This case report illustrates the importance of timely diagnosis when treating a ganglion of the peroneal nerve and reviews the appropriate workup, differential diagnosis, and treatment.

Intercarpal fusion for the treatment of scaphoid nonunion.

Salvage of the ununited scaphoid may not always be feasible or advisable, hence the availability of a number of alternative techniques which prioritize restoration of pain relief and range of motion. The role of intercarpal fusion reflects the importance of midcarpal stabilization when the scaphoid is resected. While scaphocapitate and scaphocapitolunate fusions have been described, these techniques provide less pain relief than midcarpal fusion with scaphoid excision, and are associated with an increased risk of radioscaphoid arthritis. In this article, the author will address the rationale for, technique of, and outcome after midcarpal arthrodesis and scaphoid excision.