Faculty Bibliography

We have developed a classification system for osteoarthritis (OA) of the scaphotrapeziotrapezoidal (STT) joint that can be used on posteroanterior, lateral, and oblique wrist radiographs. It can be used to communicate the degree of severity of arthritis, and to study arthritis in the wrist further. Currently we know of no classification system for OA of the STT. We devised a classification system and made an initial study to assess the reproducibility of the system. It was compared with a classification system similar to the Eaton classification of carpometacarpal OA of the thumb. Cohen's kappa test and the sign test were used for comparison. Thirty-seven of the 46 wrists evaluated (80%) showed radiographic evidence of osteoarthritis of the scaphotrapeziotrapezoidal joint. Most kappa values for intrarater and inter-rater reliability lay between 0.87 and 0.95. There was absolute agreement between both systems about the existence of osteoarthritis. When we compared the two classification systems, ours tended to underestimate the arthritic stage. This classification may be helpful for communication, comparison, and evaluation of osteoarthritis of the STT joint among surgeons. Further study is needed to define the clinical and mechanical relevance of osteoarthritis in this joint.

Cubital tunnel syndrome (CUTS) is usually considered one entity. We suggest that CUTS is not homogeneous, and that patient presentation depends on age.A retrospective review of patients with CUTS was performed. Demographic information and characteristics of presentation were recorded. Logistic regression analysis evaluated the relationship between age and factors of CUTS presentation.Seventy-four patients were included. Average age was 55 (+/-12.5). A statistically significant relationship between age at presentation and interosseous muscle weakness P = 0.01 and muscle atrophy on presentation (P = 0015) was found. There was a trend towards an inverse relationship between age and signs of ulnar irritation such as a positive elbow flexion test.CUTS is typically evaluated as a homogenous pathology. Our results support a condition that presents differently in patients, correlating with age. This concept may be used for evaluation of the treatment approach for CUTS, since different pathologies may require different forms of treatment.

Mucormycosis is an opportunistic infection that is often fatal, requiring aggressive local control as well as systemic therapy. A rare case of a forearm infection originating in a traumatic intravenous access portal is described in the present study. The Mucor species infection prevented liver transplant, and the patient passed away. In the present case, it was decided to limit the resection to the skin and subcutaneous tissue based on a frozen section and the viability of the biopsied tissue. With consistently rising numbers of immunocompromised patients, awareness and familiarity with mucormycosis in the extremities is important. Knowing that a minimal traumatic event may precede the infection could assist in prevention and early diagnosis. Guidelines for pathological and clinical diagnosis and treatment need to be further clarified.

Civilian gunshot injuries often consist of relative soft-tissue sparing and minimal contamination. Primary bone grafting with allograft for wounds limited to the digits was used in a one-stage reconstruction enabling bony union with minimal complications in this specific population. All patients suffering from small-calibre gunshot wounds to the hand treated between 2004 and 2006 with a single-stage surgery were reviewed. Surgery consisted of limited debridement and bone grafting of the fracture. Allomatrix was used in all of the patients. There were 12 patients; seven with isolated wounds to a finger. All of the patients had devastating bony injuries. The average follow-up period was 14 weeks. All patients progressed to bony healing. One patient had a second surgery for additional bone grafting. There were no complications. Relatively low contamination allows for primary bone grafting without increasing the risk of infection. This one-step approach to civilian gunshot wounds to the hand has minimal complications and allows for healing, while addressing the problem of non-compliance in this specific population.

BACKGROUND: Carpal tunnel syndrome (CTS) and trigger finger (TF) are common conditions that may occur in the same patient. The etiology of most cases is unknown. The purpose of this study was to evaluate the rate of concomitant occurrence of these two conditions at presentation and to compare the concomitant occurrence in normal and diabetic patients. METHODS: One-hundred and eight consecutive subjects presenting to our hand clinic with CTS and/or TF were evaluated. The existence of both of these conditions was documented through a standard history and physical examination. The definition of trigger finger was determined by tenderness over the A1 pulley, catching, clicking or locking. CTS was defined in the presence of at least two of the following: numbness and tingling in a median nerve distribution, motor and sensory nerve loss (median nerve), a positive Tinel's or Phalen's test and positive electrophysiologic studies. RESULTS: The average age of the participants was 62.2 +/- 13.6 years. Sixty-seven patients presented with symptoms and signs of CTS (62%), 41 (38%) subjects with signs and symptoms of TF. Following further evaluation, 66 patients (61%) had evidence of concomitant CTS and TF. Fifty-seven patients (53% of all study patients) had diabetes. The rate of subjects with diabetes was similar among the groups (p = 0.8, Chi-square test). CONCLUSION: CTS and TF commonly occur together at presentation though the symptoms of one condition will be more prominent. Our results support a common local mechanism that may be unrelated to the presence of diabetes. We recommend evaluation for both conditions at the time of presentation.

The purpose of this study was to assess ulnar translation in perilunate dislocation injuries. Twenty-five patients with perilunate dislocations were assessed after surgical reduction. Ulnar translation of the carpus and carpal collapse were measured using standard methods. Measurements before and after pin removal were compared. The average Gilula score for ulnar translation was 54%. Eighty percent of patients had ulnocarpal translation (above 50% of lunate uncovering) after reduction. Measurements of lunate uncovering in perilunate dislocations were significantly higher than normal values (P<0.01). Scores for patients in whom the ulnar translocation component was addressed by pinning during initial treatment were significantly improved. Measurements before and after pin removal were not significantly different irrespective of the method of measurement. IRB approval was obtained prior to study preparation.