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Determining the Optimal Dosage of Corticosteroid Injection in Trigger Finger

Bookman, Jared; Rocks, Madeline; Noh, Karen; Ayalon, Omri; Hacquebord, Jacques; Catalano, Louis; Glickel, Steven
BACKGROUND/UNASSIGNED:Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger. METHODS/UNASSIGNED:Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS/UNASSIGNED:A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group. CONCLUSIONS/UNASSIGNED:Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.
PMID: 37191248
ISSN: 1558-9455
CID: 5544232

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation

Chang, Andy L; Merkow, David B; Bookman, Jared S; Glickel, Steven Z
First described in 1955 as "gamekeeper's thumb," injuries to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint are common and can cause pain and instability, especially during key pinch and grasp. Although primarily diagnosed on physical examination, stress radiographs, ultrasonography, and magnetic resonance imaging can be used to diagnose UCL injuries and distinguish partial from complete tears. If complete rupture occurs, the adductor aponeurosis can become interposed between the retracted UCL stump and its insertion on the proximal phalanx, known as a "Stener lesion." When instability persists after a trial of nonsurgical management or in the setting of complete rupture, there are various methods of repair or reconstruction. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. Recently, suture tape augmentation has been used for the repair or reconstruction with excellent short-term results and earlier return to function, although there is a paucity of literature on longer term outcomes. The various methods of surgical treatment yield excellent outcomes with a low incidence of complications.
PMID: 36548149
ISSN: 1940-5480
CID: 5394712

Demographics of Common Compressive Neuropathies in the Upper Extremity

Rocks, Madeline C; Donnelly, Megan R; Li, Alexander; Glickel, Steven Z; Catalano, Louis W; Posner, Martin; Hacquebord, Jacques H
BACKGROUND/UNASSIGNED:The purpose of this study was to compare the demographic differences of the most common peripheral nerve compressions in the upper extremity-carpal tunnel syndrome (CTS), ulnar nerve compression (UNC) at the elbow, combined CTS and UNC, radial tunnel syndrome (RTS), and posterior interosseous nerve syndrome (PINS)-as a means to better understand the etiologies of each. METHODS/UNASSIGNED:< .05). RESULTS/UNASSIGNED:< .001). CONCLUSIONS/UNASSIGNED:The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies.
PMID: 35815639
ISSN: 1558-9455
CID: 5269012

A Prospective Analysis of Patient Characteristics Affecting the Outcome of Dorsal Splinting for Soft Tissue Mallet Injuries

Azad, Ali; Kegel, Gary; Phelps, James; Marshall, Astrid; Lafer, Marissa P; Rocks, Madeline; Catalano, Louis; Barron, O Alton; Glickel, Steven
BACKGROUND/UNASSIGNED:Much has been written about the diagnosis and treatment of soft tissue mallet injuries. However, there has been little regarding the characteristics of this injury affecting patients' prognosis. The purpose of this prospective study was to identify factors influencing the outcome of treatment of soft tissue mallet injuries. METHODS/UNASSIGNED:12 months. RESULTS/UNASSIGNED:15°. Those failing splint treatment were older compared with those successfully treated. Patient compliance was significantly associated with a successful outcome. Factors that did not significantly affect success included time to treatment, initial injury severity, splinting duration, sex, and ligamentous laxity. Disabilities of Arm, Shoulder, and Hand scores >0 were not associated with treatment failure. Radiographic and clinical extension lag were statistically comparable. CONCLUSIONS/UNASSIGNED:This study shows strong association between the success of splint treatment, younger patient age, and compliance with the treatment protocol. Despite this finding, most patients did not report any functional limitations, irrespective of the treatment success. In contrast to prior results, time to treatment and initial extensor lag did not significantly affect treatment success.
PMID: 35611505
ISSN: 1558-9455
CID: 5247982

Penlight versus Smartphone: Diagnostic Efficacy of Transillumination

Azad, Ali; DE Tolla, Jadie; Ayalon, Omri; Hacquebord, Jacques H; Glickel, Steven Z; Catalano, Louis W
PMID: 35404214
ISSN: 2424-8363
CID: 5205072

The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release

Kirby, David; Donnelly, Megan; Catalano, Will; Buchalter, Daniel; Glickel, Steven; Hacquebord, Jacques
BACKGROUND:Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. METHODS:A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. RESULTS:= .04). CONCLUSIONS:While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.
PMID: 34308719
ISSN: 1558-9455
CID: 5066622

Coding Practices in Hand Surgery and Their Relationship to Surgeon Compensation Structure

Coyle, Ryan M; Tawfik, Amr M; Green, Anna; Katt, Brian M; Glickel, Steven Z
Purpose/UNASSIGNED:To evaluate the coding practices of hand surgeons in the American Society for Surgery of the Hand with respect to practice compensation structure using common, representative hand surgery cases. Methods/UNASSIGNED:We developed a survey of demographic factors and 4 commonly encountered hypothetical hand surgery cases. This survey was emailed to the members of the American Society for Surgery of the Hand. Respondents were asked to code these cases using prepopulated applicable Current Procedural Terminology codes or any other codes of their choosing. The membership responses were then compared with those of 3 independent orthopedic coders. Results/UNASSIGNED:< .05). The 3 independent coders all chose a single Current Procedural Terminology code for the carpal tunnel release, distal radius fracture, and scaphoid nonunion cases. The percentages of physician responses that selected only these codes were 84.6% (carpal tunnel release), 61.0% (distal radius fracture), and 73.6% (scaphoid nonunion). Physicians were less likely to code in line with the independent coders for the distal radius fracture case compared with other cases, particularly those physicians with a collections-based model. Conclusions/UNASSIGNED:The compensation model may be associated with coding practices for more complicated hand cases. The additional work-related value units potentially billed can quickly accumulate for frequently performed procedures. This wide variation supports a need for more frequent and accessible communication and education on coding practices in hand surgery. Clinical relevance/UNASSIGNED:Improved communication and education regarding appropriate coding practices as well as easily accessible reference material may assist in minimizing coding discrepancies for surgical hand procedures.
PMCID:8991870
PMID: 35415564
ISSN: 2589-5141
CID: 5219032

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis

Bäcker, Henrik C; Freibott, Christina E; Rizzo, Marco; Lee, Donald H; Glickel, Steven Z; Strauch, Robert J; Rosenwasser, Melvin P
Background  The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective  The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods  A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results  A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520; p  < 0.001) and between grip strength (Pearson's correlation = -0.336; p  < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353' p  < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion  The TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence  This is a Level II, prospective comparative study.
PMCID:7263863
PMID: 32509424
ISSN: 2163-3916
CID: 4477772

Surgical Management of Scaphotrapeziotrapezoid Arthritis

Catalano, Louis W; Ryan, Devon J; Barron, Otis A; Glickel, Steven Z
Scaphotrapeziotrapezoid (STT) arthritis occurs commonly with basal joint arthritis, but can also occur in isolation or in conjunction with other patterns of wrist arthritis, such as scapholunate advanced collapse. Surgical options depend on the specific clinical scenario encountered. Isolated STT arthritis was classically managed with arthrodesis, but is now often addressed with distal scaphoid resection (open or arthroscopic), trapeziectomy (partial or complete) and partial trapezoid resection, or implant arthroplasty. Development of postoperative dorsal intercalary segment instability is a notable concern with any of these techniques. STT arthritis in conjunction with basal joint arthritis can be managed effectively with trapeziectomy and either partial trapezoid excision or distal scaphoid excision. STT arthritis with scapholunate advanced collapse is uncommon, but can be managed with proximal row carpectomy or scaphoidectomy and four-corner fusion. If basal joint arthritis is also present, trapeziectomy can additionally be performed, but grip strength is likely to be substantially diminished.
PMID: 31688428
ISSN: 1940-5480
CID: 4172542

Etiology, Evaluation, and Management Options for the Stiff Digit

Catalano, Louis W; Barron, O Alton; Glickel, Steven Z; Minhas, Shobhit V
The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.
PMID: 30475280
ISSN: 1940-5480
CID: 3501032