Faculty Bibliography

PURPOSE: We examined the anatomic location of recurrences of digital glomus tumors treated with surgical excision to make inferences on the causes of recurrence. METHODS: We retrospectively reviewed 12 cases of glomus tumors of the hand treated surgically over an 8-year period. Two of these patients presented with recurrences after previous glomus tumor excision surgery elsewhere. The location of recurrences, duration of symptoms, gender, revision surgeries, and histological specimens were analyzed. RESULTS: All tumors developed in the periungual and subungual area of the digits. Five of the 12 patients had recurrences, with one of these patients having a second recurrence after revision surgery. All recurrent tumors occurred in new, separate locations from the original lesions. The recurrences presented from 2 months to 5 years after the initial surgery. All surgical specimens from the index surgeries, as well as revision procedures, were examined by a pathologist and confirmed to be glomus tumors. There were no discernible differences in the histology features of the tumors that recurred compared to those that did not. CONCLUSIONS: Traditionally, recurrences of digital glomus tumors after surgical excision are thought to be rare. Inadequate resection was considered the likely cause in most cases. However, recurrent symptoms might be attributed to small, synchronous, satellite lesions not detected during the original surgery. A careful preoperative and intraoperative examination for synchronous lesions should be made, and patients should be informed of the risk of recurrent symptoms

BACKGROUND: Scaphoid excision and four-corner fusion is commonly performed to reconstruct advanced scapholunate collapse and scaphoid nonunion with collapse. Metallic plates were introduced for achieving fixation of the four carpal bones. Although the developer reported high rates of fusion, several other early reports of circular plate fixation suggest higher complication rates and inferior outcomes compared with traditional fixation techniques. QUESTIONS/PURPOSES: To clarify the controversy in the literature we determined the fusion rates, complications, and functional outcomes of patients having circular plate fixation for four-corner fusion. METHODS: We retrospectively reviewed 15 patients treated for radioscaphoid arthritis with four-corner fusion using circular plate fixation. The minimum followup was 11 months (mean, 22 months; range, 11-39 months). RESULTS: Radiographic union was achieved by all 15 patients. There was only one postoperative complication. ROM was 71% and grip strength was 78% of the opposite normal side. CONCLUSIONS: Our results compare favorably with those using traditional fixation techniques. ROM measurements seem superior to those reported in the literature. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Twenty-six patients with mean age of 38.5 (range 18-59), from 1998 to 2005, with ulnar impaction syndrome who failed nonoperative treatments were included in our study. Patients' age, history of previous wrist fracture, presence of MRI signs and ulnar variance were recorded as variables. Also, patients' postoperative strength (compared to the contralateral wrist) and pain relief were collected as outcome measurements. Twenty-two patients (84.6%) had either good or excellent pain relief (median 4, range 1-4). Significant correlation was found between MRI findings and postop pain relief (r = 0.53, p </= 0.01). History of previous distal radius fractures was negatively correlated with pain relief (r = -0.50, p </= 0.01). No correlation was found between postop strength and any of the variables. Presence of MRI signs of UIS is a predictor of good outcome in arthroscopic wafer resection

PURPOSE: Proliferative tenosynovitis in the fourth extensor compartment is common in patients with rheumatoid arthritis. It may also occur in the absence of rheumatoid arthritis; the purpose of this study is to describe this clinical condition in a series of patients, to report the results of surgical intervention, and to compare histological findings to those typically seen in rheumatoid tenosynovitis. METHODS: This study presents a retrospective case series of 11 patients who do not have rheumatoid arthritis, who had proliferative tenosynovitis of the fourth extensor compartment treated surgically. Relevant features of the clinical presentation, physical examination, radiographic findings, and results of attempts at conservative treatment are described. Surgical pathology specimens were reviewed by a single pathologist to define common histological features and to compare the histology to that which is classically seen in rheumatoid tenosynovitis. RESULTS: All patients presented with a painful wrist mass over the fourth extensor compartment. Characteristic in physical examination was severe limitation of active wrist extension with the fingers extended, with improvement when the fingers were flexed into a fist. After tenosynovectomy, wrist extension and grip strength improved. Examination of the surgical pathology specimens revealed a spectrum of pathological findings generally consistent with traumatic tenosynovitis, but a few specimens had rheumatoid-like features. CONCLUSIONS: A review of this case series of patients with tenosynovitis but without rheumatoid arthritis demonstrates a distinct clinical condition of exuberant proliferative extensor tenosynovitis blocking proximal tendon excursion, thereby causing pain and limited active wrist extension, as well as a less distinct histological condition with a constellation of findings generally resembling traumatic tenosynovitis. In this group of patients, surgical tenosynovectomy generally yields excellent results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV

Small occult dorsal wrist ganglia, which are not visible or palpable, may be painful. Clinically, there is tenderness over the scapholunate ligament and pain with hyperextension of the wrist with normal radiographs and an otherwise normal examination. We reviewed 20 patients with suspected occult ganglia who underwent an MRI scan and subsequently underwent surgical excision of the cyst. We compared the MRI diagnosis with the intra-operative findings and the histological evaluation of the surgical specimen to determine the accuracy of MRI in identifying an occult ganglion. When intra-operative determination of disease was used as a standard, the sensitivity of MRI scanning was 83%, the specificity was 50%, the positive predictive value was 94% and the accuracy 80%. Using histology as the standard, the sensitivity was 80%, the specificity 20%, and the positive predictive value 75%

PURPOSE: Scaphoid nonunions are commonly repaired by an open surgical technique involving debridement, bone grafting, and internal fixation. The purpose of our study is to describe a small subset of scaphoid nonunions that are nondisplaced and might be suitable for a more limited, minimally invasive technique that might offer good results while potentially reducing soft tissue injury. METHODS: Nine patients seen over a 3-year period by a single surgeon were identified as having scaphoid nonunions without radiographic evidence of displacement, angulation, degenerative changes, osteonecrosis, or carpal instability. Two additional patients with well-aligned delayed unions of 4 months' duration were also studied. All had surgery through a tiny dorsal incision with reaming, local cancellous bone grafting, re-reaming, and compression screw fixation. This was performed under fluoroscopy but without arthroscopy. Pain, range of motion, and grip strength as well as radiographic evidence of healing were recorded. RESULTS: Patients treated for nonunions were followed up for an average of 27 months (range 10-45 months), and all 9 fractures healed at a mean time of 3 months. At final follow-up, there were no radiographic signs of nonunion. The mean arc of wrist motion was 124 degrees, or 91% of that of the contralateral, normal wrist. The mean postoperative grip strength was 29 kgf, or 85% of the value in the opposite hand. At final follow-up, all but 1 patient were pain free, and none had evidence of progression of degenerative changes or carpal instability on final radiographs. The 2 delayed union cases healed at 2 and 3 months with similar postoperative functional measurements. There were no complications. CONCLUSIONS: Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described. Patients who fit the strict inclusion criteria can expect a reliable healing rate and good functional outcome with a more limited procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV

PURPOSE: In patients having basal joint arthroplasty, rates of concomitant carpal tunnel syndrome may exceed 43%. Excision of the trapezium during basal joint arthroplasty partially releases the transverse carpal ligament. The objective of this study was to determine whether indirect release of the remaining fibers of the ligament at its insertion on the scaphoid tubercle through the same incision would adequately decompress the carpal canal. This would avoid the morbidity of a second incision. METHODS: We retrospectively reviewed 10 consecutive patients treated over a 2-year period who had concurrent ligament reconstruction, tendon interposition basal joint arthroplasty of the thumb with complete trapezial resection, and indirect carpal tunnel release through a single incision. Self-reported postoperative pain relief was documented. Preoperative and postoperative evaluations of light touch sensibility, Tinel's sign, Phalen's test, median nerve compression test, and Weinstein Enhanced Sensory Test monofilament testing were analyzed. All patients had preoperative electrodiagnostic testing. RESULTS: At mean 12 month follow-up (range, 5-35 months), numbness and paresthesias resolved in all cases: 9 patients had good or excellent pain relief and 1 reported fair pain relief despite transient postoperative reflex sympathetic dystrophy. Tinel's, Phalen's, and median nerve compression tests were each positive in 9 patients preoperatively and 0 patients postoperatively. Diminished light touch sensibility was present in 7 preoperatively and 1 postoperatively. WEST monofilament thresholds improved postoperatively in 8 patients. These improvements were statistically significant. One patient had postoperative nerve conduction studies performed to evaluate an ulnar nerve lesion at the elbow; the preoperative median nerve abnormalities had normalized. CONCLUSIONS: Carpal tunnel syndrome can be successfully managed with indirect release of the transverse carpal ligament during basal joint arthroplasty, thus avoiding a second incision, reducing operating time, and potentially reducing the possibility of perineural adhesions, recurrent motor branch injury, palmar cutaneous nerve damage, weakness, stiffness, and pillar pain. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV