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:This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS/UNASSIGNED:Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS/UNASSIGNED:One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION/UNASSIGNED:Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE/UNASSIGNED:Level IV.

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.

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.

Carpometacarpal (CMC) arthritis of the thumb is one of the most common pathologies encountered in clinical hand and orthopedic surgery practices. Anatomy of the CMC joint and its biomechanics are theorized to predispose the articulation to laxity and subsequent degenerative changes. Diagnosis of CMC arthritis is primarily based on history, physical examination, and imaging findings, all of which coalesce to guide treatment. There are a multitude of treatment options for CMC arthritis, each with its own set of pearls and pitfalls with treatment decision making shared by surgeon and patient. Continued research and longitudinal data on outcome measures will assist in determining the ultimate "rule of thumb" for the treatment of CMC arthritis.

Bicondylar distal humerus fractures are difficult injuries requiring a comprehensive treatment strategy. Nonoperative treatment is generally reserved for elderly, low demand patients and those whose medical co-morbidities preclude surgery. Considerations for surgery include fracture morphology, osteoporotic bone quality, and degree of articular comminution. Surgical treatment with plate fixation is a reliable solution to facilitate early mobilization for a functional recovery. In fractures not amenable to operative fixation, implant arthroplasty may provide improved functional results. Satisfactory outcomes following such injuries can be achieved through surgical fixation and arthroplasty, allowing for early rehabilitation and elbow motion to facilitate a functional recovery. Postoperative complications remain a concern in managing these fractures. In this review, we share our recommendations for management of bicondylar fractures of the distal humerus.

PURPOSE/OBJECTIVE:This article presents the outcomes of repairs of flexor tendon lacerations within digital sheaths performed more than 2 weeks after injury. METHODS:A retrospective review of 46 patients; 37 with finger lacerations involving a total of 54 severed tendons in 42 fingers and nine with thumb lacerations of the flexor pollicis longus (FPL). In those patients with finger lacera- tions, 30 lacerations were isolated to the flexor digitorum profundus (FDP; 17 in Zone I and 13 in Zone II), and 12 involved both FDP and flexor digitorum superficialis (FDS) for a total of 24 tendon lacerations. RESULTS:The delay in surgery for finger lacerations ranged from 2 to 96 weeks (average: 8.5 weeks) and for thumb lacerations, 2 to 17 weeks (average: 5.5 weeks). In Zone I finger lacerations, postoperative flexion of the distal interphalangeal (DIP) joint averaged 35° with 82% of patients regaining total active motion (TAM) in the good to excellent range. In Zone II injuries isolated to the FDP tendon, postoperative DIP joint flexion averaged 36.5° with 73% of patients regaining good to excellent TAM. In Zone II injuries involving both flexor tendons, final average DIP flexion was 37° with only 45% of patients regaining good to excellent TAM. All patients with FPL lacerations regained at least 30° (average: 46°) of active interphalangeal joint flexion. CONCLUSION/CONCLUSIONS:When certain conditions exist that are deter- mined at surgery, delayed repairs of isolated FDP lacera- tions in fingers and FPL lacerations in thumbs can restore satisfactory mobility. Results are less favorable when both flexor tendons in the finger are lacerated and only the FDP repaired.