Faculty Bibliography

Incision of the dorsal side of the tendon sheath in release of De Quervain's tenosynovitis has traditionally been advocated to prevent the risk of volar tendon subluxation. We describe a novel technique of complete excision, rather than simple incision, of the first dorsal compartment tendon sheath. Over a 10-year period, 147 patients (154 wrists) underwent first dorsal compartment release using this technique of complete excision of the sheath. No postoperative immobilization is used. Patients were followed for a mean of 7.0 months. Records were assessed for any complications including reoperation, tendon subluxation, recurrence, wound complications, scar tenderness, and superficial radial sensory nerve paresthesias. There were no cases of recurrence, reoperation, or tendon subluxation after release with this technique. Postoperatively, 7 (4.5%) patients had scar tenderness and 5 (3.2%) of these patients also had superficial radial sensory nerve parasthesias, which all resolved at the time of final follow-up. Mean range of motion was 73±11 degrees of flexion and 69±10 degrees of extension. In contrast to simple incision, we propose that this technique provides a more complete release of the compartment without risk of symptomatic subluxation or bowstringing and provides a complete release of a separate extensor pollicis brevis subsheath or any concomitant retinacular cysts associated with the tendonitis. There is an immediate removal of the symptomatic swelling and visible, painful bump associated with the thickened retinaculum with this technique. Furthermore, no immobilization is required after surgery.

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.

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.

Isolated fractures of the trapezoid are an exceedingly rare injury, and stress fractures of the carpus are similarly uncommon. An 18-year-old competitive baseball player presented with atraumatic, progressive hand pain. He was found to have a stress fracture of the trapezoid. Symptoms resolved with rest and immobilization.

Regional blocks are being increasingly utilized for anesthesia for various orthopedic procedures. Several studies have shown that regional anesthesia has fewer side effects and improved postoperative pain relief compared to general anesthesia, but regional blocks are not without risks. We present case reports of 2 patients who experienced posterior shoulder instability, one of whom had a posterior shoulder dislocation, immediately in the postanesthesia care unit after undergoing hand surgery with regional anesthesia. This paper highlights the importance of being aware that patients might be at increased risk of shoulder instability after upper extremity regional anesthesia, and appropriate perioperative precautions should be taken.

Major peripheral nerve injuries are devastating and represent a very challenging clinical problem. Despite many years of advancement in peripheral nerve research, results so far have been fair at best, with only 50% of patients regaining useful function. Advancement of techniques in imaging, better understanding of the physiology of nerve recovery, improved repair and grafting options, and secondary reconstructive techniques, including tendon and nerve transfers, have helped facilitate a degree of more effective treatment. This article presents current concepts regarding the principles of management, expected outcomes, and new advancements in major upper extremity peripheral nerve injuries.

Rehabilitation after surgical repair of flexor injuries is a controversial topic. Motion at the repair site decreases risk for adhesions but increases risk for rupture. We review the current concepts behind various rehabilitation protocols based on zone of injury and the evidence behind each.

BACKGROUND:Routine immediate postoperative laboratory studies, including metabolic panels and hematologic profiles, are commonly ordered after arthroplasty procedures. However, their values only occasionally influence management. This study investigated the clinical utility and value of these tests. METHODS:A large retrospective cohort study of 18,935 patients spanning a 6-year period from 2008 to 2013 from a single high-volume institution was evaluated. Only immediate postoperative labs drawn on postoperative day 0 in the recovery room were included in the study. Complete blood counts (CBC) and basic metabolic panels (BMP) were reviewed, and ranges of abnormal were set for each lab test based on values significant enough to impact patient management. Cost effectiveness calculations were made based on current cost of the laboratory tests. RESULTS:Actionably low hemoglobin values ( < 8 g/dL) were found in 1.44% of the overall cohort. Unilateral primary total knee arthroplasty was associated with the fewest hemoglobin abnormalities at 0.59%. Primary unilateral total hip arthroplasty was associated with abnormal hemoglobin values in 1.81% of cases. Significant electrolyte abnormalities were far less common, with hyperkalemia (> 6.5 mEq/L) in 0.19%, hyponatremia ( < 120 mEq/L) in 0.01% and elevated creatinine (> 2.0 mg/dL) was found in 0.25%. Hemoglobin values were calculated at a cost of $1,710 to detect a single significantly abnormal result. The cost to detect a single actionably abnormal BMP value was $1,000. CONCLUSIONS:Routine immediate postoperative laboratory tests represent a high institutional cost and are seldom abnormal enough to warrant a change in patient management. The routine use of these tests can likely be safely eliminated in uncomplicated primary unilateral arthroplasty procedures.

BACKGROUND:The advent of highly cross-linked polyethylene (HCLPE) has significantly improved total hip arthroplasty survivorship. HCLPE has been shown to improve wear properties in midterm outcomes when compared to traditional polyethylene liners; however, there is a paucity of studies evaluating long-term outcomes. In addition, there is concern that wear rates may accelerate as the implant ages. Thus, the aims of this study are to report on the longest-to-date follow-up of a specific first-generation HCLPE liner and to determine whether there is a change in the annual wear rate over time. METHODS:Forty hips in 38 patients which were previously reported on in a midterm study were included in this long-term follow-up study. Patients in this cohort all received total hip arthroplasty between March 1999 and August 2004 using the Crossfire HCLPE liner. Annual wear rates (mm/y) were calculated for this cohort. Patients were contacted and asked about complications or revision procedures they may have had since the index procedure. RESULTS:Clinical follow-up averaged 12.9 years with a range of 7-18 years. The average follow-up duration was 12.5 years with a range of 10-17 years. Linear wear was found to be 0.056 ± 0.036 mm/y. Osteolysis was not observed in any of the patients with greater than 10-year radiographic follow-up. Furthermore, only 1 patient required revision surgery following a mechanical fall. CONCLUSION/CONCLUSIONS:Our study demonstrates the long-term wear rates associated with HCLPE liners continue to match rates published in midterm studies. Previously, we have reported that this cohort had an average annual wear rate of 0.05 mm/y over 10 years. This most recent report demonstrates a similar wear rate with up to 18-year follow-up.

While yoga has been widely studied for its benefits to many health conditions, little research has been performed on the nature of musculoskeletal injuries occurring during yoga practice. Yoga is considered to be generally safe, however, injury can occur in nearly any part of the body-especially the neck, shoulders, lumbar spine, hamstrings, and knees. As broad interest in yoga grows, so will the number of patients presenting with yoga-related injuries. In this literature review, the prevalence, types of injuries, forms of yoga related with injury, specific poses (asanas) associated with injury, and preventive measures are discussed in order to familiarize practitioners with yoga-related injuries.