Faculty Bibliography

Lunotriquetral (LT) synchondrosis is an uncommon variant of congenital LT coalition. Unlike complete LT fusions, this incomplete pseudoarthrosis-like coalition can become symptomatic. Surgical LT arthrodesis is a described treatment for this variant of LT coalition (Minnaar type I). We report 4 patients who underwent LT fusion with a second-generation headless compression screw and distal radius cancellous autograft. Fusion was achieved in all cases at an average of 2.5 months postoperatively. All the patients were satisfied with complete pain relief in 2 patients and minimal pain in 2 patients, and all improved their range of motion. We recommend this procedure, and report the techniques for this limited wrist arthrodesis as treatment for the symptomatic LT synchondrosis.

The volar Henry approach is most commonly used for surgical fixation of distal radius fractures. However, this approach is limited in achieving adequate exposure for the fixation of the volar-ulnar portion of the distal radius, rendering it difficult for the ideal placement of the fixation construct. We propose the use of the extensile volar-ulnar approach for fixation of distal radius fracture involving a small volar-ulnar fragment. This approach allows optimal reduction of the sigmoid notch and the volar lunate facet, which anatomically reduces both the radiocarpal joint and the sigmoid notch. In addition, extension of this approach may safely be performed if concomitant carpal tunnel release is necessary.

Background: The purpose of this study was to determine the factors that affect hand surgeon operating room (OR) turnover time. We hypothesized that surgeon presence in the OR, decreased American Society of Anesthesiologists (ASA) class, smaller case type, and earlier case time, as well as other factors, decreased OR turnover time. Methods: A total of 685 hand surgery cases performed by 5 attending hand surgeons between September 2013 and December 2014 were identified. Turnover time, patient comorbidities (ASA class), surgeon, prior OR surgical procedure, current OR surgical procedure, location of the surgery (ambulatory surgical center [ASC] vs orthopedic specialty hospital [OSH]), time of surgery, and order of OR cases were recorded. The effect of surgeon routine variables, OR case factors, and patient health status on OR turnover was analyzed. Results: Turnover time was significantly shorter in cases where the surgeon remained in the OR during turnover (27.5 minutes vs 30.4 minutes) and when the surgeon incentivized OR staff (24 minutes vs 29 minutes). The ASC was found to have shorter turnover times than the OSH (27.9 minutes vs 36.4 minutes). In addition, ASA class, type of prior OR procedure, type of current OR procedure, and case order all significantly affected turnover time. Comparison of OR turnover time among the 5 surgeons revealed a statistically significant difference at the OSH but not at the ASC. Conclusion: OR turnover time is significantly affected by surgeon routine, location of surgery, patient ASA class, procedure type, and case order. Interestingly, the effect of hand surgeon routine on OR turnover time may be amplified at an academic OSH versus an ASC.

Background An accessory slip arising from the extensor carpi ulnaris (ECU) tendon that inserts on the fifth metacarpal bone has been identified. We describe the frequency of this accessory slip arising from the ECU tendon and provide both qualitative and quantitative description of the slip via cadaveric examination. Methods Fifty (28 males and 22 females) cadaveric upper extremity specimens were examined after loupe-aided dissection of the dorsoulnar wrist and hand with identification of the ECU tendon. The presence of an accessory slip arising from the ECU tendon was noted. The insertion and morphology of the accessory slip was also described. Results An accessory slip arising from the ECU tendon at the level of the radiocarpal joint was found to insert on the fifth metacarpal bone in 11 (22%) specimens. Nine accessory slips inserted at the base of the fifth metacarpal (Nakashima Type A) and two inserted at the fifth metacarpal head (Nakashima Type C). Mean width of the accessory slip was 1.2 +/- 0.4 mm. No evidence of sexual dimorphism was found regarding the morphology of the accessory slip. Conclusion The current study demonstrates the relative frequency and morphology of the accessory slip arising from the ECU tendon. This variant should be of diagnostic consideration in ailments of the dorsoulnar wrist and hand. Hand surgeons should be aware of this anatomic variant and its potential for clinical manifestation.

We present a series of eight patients who underwent wrist arthroscopy for presumed solitary tears of the triangular fibrocartilage (TFC) and were, instead, found to have combined 1A (central tear) and 1B (ulnar avulsion) tears. The Palmer Classification does not currently categorize this combined pattern. All but one patient had a traumatic injury. Each subject had preoperative radiographs and MRI scans. TFC tears were evident on all MRI scans, though only one was suggestive of a combined tear pat - tern. Surgical management included arthroscopic central tear debridement and ulnar peripheral repair. Average follow-up was 22 months. Grip strength in the affected hand improved from 16% deficit as compared to the unaffected side, to 3.5% deficit postoperatively (p = 0.003), and visual analog scores (VAS) decreased from an average of 7.1/10 preoperatively to 2.3/10 postoperatively (p < 0.001). There was no statistically significant change in wrist range of motion (ROM), however. Arthroscopic debridement of the central perforation (1A lesion) with concomitant repair of the ulnar detachment (1B lesion) resulted in functional and symptomatic improvement. This combined 1A/1B TFC injury is not reliably diagnosed preoperatively and should be considered a new subset in the Palmer classification, as this will raise awareness of its presence and assist in preoperative planning of such lesions.

BACKGROUND: Review of the recent literature suggests substantial use of the Internet by patients seeking health care information despite questionable accuracy and readability of information presented on some websites. The purpose of our study was to assess the accuracy, quality, and readability of online information regarding trigger finger. METHODS: Three terms ("trigger finger", "stenosing tenosynovitis", and "finger locking") were used to query three Internet search engines to evaluate websites regarding information about trigger finger. Three hand surgery fellows independently assessed website accuracy and quality using standardized scoring criteria. The Fleisch-Kincaid reading grade level score was used to assess website readability. Website authorship and commercial association were also noted. RESULTS: Sixty-nine unique websites were assessed. Internet information obtained using the search term "stenosing tenosynovitis" was written at a significantly higher reading level than information found using "finger locking" or "trigger finger". Website quality and accuracy were both significantly better in websites authored by physicians compared to websites authored by non-physicians. However, website accuracy was significantly poorer in websites featuring commercial association. Additionally, websites presenting information written below the 8(th) grade reading level demonstrated poorer accuracy. CONCLUSIONS: Search term has a significant effect on the readability of online information regarding trigger finger. Despite the terminology used in searches, most websites are largely inaccurate and may not be easily understandable by the general population. This demonstrates a substantial barrier to accessing accurate health care information and may impact patient outcomes. Hand surgeons should direct patients towards websites presenting accurate information with easily readable content.

Trapezial excision arthroplasty with ligament reconstruction and tendon interposition (LRTI) modified to include proximal trapezoid excision was performed on 12 wrists in 10 patients with symptomatic, isolated scaphotrapezial-trapezoid (STT) arthritis. Wrist range of motion, lateral pinch and grip strength, and analog pain scores were measured pre- and post-operatively. Mean follow-up was 18 (11-42) months. Post-operatively, reported pain scores uniformly decreased (p < 0.0001). Mean range of wrist flexion increased from 48 to 53 degrees (p < 0.05) and extension from 51 to 55 degrees (p < 0.05). There was also an overall increase in mean grip strength from 15.6 to 19.2 kg and pinch strength from 3.5 to 4.3 kg. Modified Mayo Wrist Scores were excellent in six cases, good in three, and fair in one. Our results suggest that modified total trapezial, partial trapezoidal excision and LRTI could be an effective surgical alternative in cases of isolated STT arthritis.

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