Faculty Bibliography

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: 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

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

Trapeziectomy, ligament reconstruction and tendon interposition arthroplasty is one of the most commonly performed procedures to address pain and instability due to osteoarthritis at the basal joint of the thumb. To determine the effect of stress on first metacarpal subsidence, 15 ligament reconstruction and tendon interposition basal joint arthroplasties were evaluated after a mean follow-up of 32 months. Radiographs were obtained of the arthroplasty at rest and then with maximal effort key pinch stress, which is known to subject the first carpometacarpal joint to considerable axial compression stress. Compared with the preoperative x-rays, the first metacarpal had subsided 21% of the arthroplasty space at rest. Under stress, the first metacarpal was found to subside another 10.5% in height. No subluxation of the metacarpal base could be detected. Key pinch strength improved 17% from the preoperative strength. Tip-to-tip pinch strength improved 17% from the preoperative measurement. Grip strength improved 17% from the preoperative measurement. Grip strength was 9% greater than the preoperative grip strength. There was no statistical association between the amount of first metacarpal subsidence and follow-up key pinch, tip pinch, or grip strength. With axial compressive loading of the arthroplasty, such as in lateral pinch, there is some further proximal migration of the first metacarpal, but this is minimal and does not correlate with functional outcome

Custom-designed miniature load-cells were inserted into the distal end of the ulna and the proximal end of the radius in ten fresh-frozen forearms from cadavera. The forces transmitted through the bones at these sites were measured under 134 newtons of constant axial load that was applied through the metacarpals as the forearm was rotated from 60 degrees of supination to 60 degrees of pronation. The simultaneous measurements of these forces allowed the calculation of radioulnar load-sharing at the wrist and the elbow as well as the calculation of the amount of force that was transferred from the radius to the ulna through the interosseous membrane. With the elbow in valgus alignment (that is, with contact between the radial head and the capitellum), the main pathway for load transmission through the forearm was direct axial loading of the radius; measurements from both load-cells were unaffected by the angle of elbow flexion. When the forearm was in neutral rotation, the mean force in the distal end of the ulna averaged 2.8 per cent of the load applied to the wrist and the mean force in the proximal end of the ulna averaged 11.8 per cent; this indicated that only a small amount of tension developed in the interosseous membrane. With the elbow in varus alignment (that is, with no contact between the radial head and the capitellum), load was transmitted through the forearm by a transfer of force from the radius to the ulna through the interosseous membrane. When the forearm was in neutral rotation, the force in the distal end of the ulna averaged 7.0 per cent of the load applied to the wrist and the force in the proximal end of the ulna averaged 93.0 per cent; the force through the interosseous membrane decreased with supination of the forearm. Testing with the elbow in valgus alignment and shortening of the distal end of the radius in two-millimeter increments produced corresponding increases in force in the distal end of the ulna and decreases in force in the radial head. The forces through the interosseous membrane remained low after each amount of radial shortening