Aims. The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a
To study in resolution of triggering 12 months after injection with either a soluble methylprednisolone acetate or dexamethasone for idiopathic
Background. Steroid injections can be used safely to treat
Introduction and Objectives: Release of the A1 pulley in
Objective. Surgical treatment of
Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit. We treated 43 patients, average age 57 years (range12-78). All trigger digits were grade III-IV (Quinnell classification). A mean duration of pre-operative symptoms was 7.3 months (range 2-13 months). A percutaneous release was performed with a 19-gauge hypodermic needle under local anaesthesia in the outpatient setting. All patients were evaluated with respect to clinical resolution of symptoms and general satisfaction. We report a 97% successful release and only one case of incomplete release. A result in terms of abolishing triggering was immediate and patient acceptance was excellent. By two weeks, all the patients had no pain at the operative site. After a mean follow-up of 30.2 months (range12-50), there had been no recurrences. There were no digital nerve injuries, flexor tendon injuries, and infections. The percutaneous release is a safe and effective technique, which provides significant cost savings. The time from onset of symptoms and grading prognostically is significant and affects the treatment outcome. We recommend the percutaneous technique for typical cases of
Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis. However, despite long historical experience with this procedure, there remains no guide in the literature as to the optimal dose of steroid. Furthermore, the accuracy of these injections has not been well established. Using a prospective, randomized, blinded design, this study compares the outcomes of high (20 mg) and low (10 mg) dose depomedrol injection. Furthermore, the accuracy of tendon sheath injections was assessed radiographically. The findings demonstrate increased effectiveness of the higher steroid dose and a significant learning curve associated with intra-thecal injections. Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis (trigger finger). However, despite long historical experience with this procedure, there remains no guide in the literature as to the safe and effective dose of steroid to be administered. Furthermore, the accuracy of digital tendon sheath injections has not been well established. One study has suggested that steroid injected outside the tendon sheath was as effective as intra-thecal injection and may result in reduced complications of infection and tendon rupture. Using a prospective, blinded design, patients were randomized to receive either high (20 mg) or low (10 mg) dose depomedrol injection. The accuracy of the steroid injections was determined radiographically using non-ionic radio-opaque dye. Outcome measures included pain, tenderness, presence of a palpable nodule, triggering, and limitation of activities (work, hobbies, ADLs). Complications such as pain, stiffness, bruising, thinning of the fat or skin, infection and tendon rupture were also recorded. Higher dose depomedrol (20 mg) was found to be more effective for relieving pain and triggering than lower dose depomedrol (10 mg). No increase in complication rate was encountered.
The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed.Aims
Methods
Closed tenotomy was used to treat triggering of the fingers and thumb in 54 patients. In 56 digits the method was successful; in seven it was a simple matter to proceed to open tenotomy. With experience, the closed procedure can be completed within minutes without risk of damaging the digital nerves.
The December 2022 Wrist & Hand Roundup. 360. looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a
The June 2023 Wrist & Hand Roundup. 360. looks at: Residual flexion deformity after scaphoid nonunion surgery: a seven-year follow-up study; The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders; Bite injuries to the hand and forearm: analysis of hospital stay, treatment, and costs; Outcomes of acute perilunate injuries - a systematic review; Abnormal MRI signal intensity of the triangular fibrocartilage complex in asymptomatic wrists; Patient comprehension of operative instructions with a paper handout versus a video: a prospective, randomized controlled trial; Can common hand surgeries be undertaken in the office setting?; The effect of corticosteroid injections on postoperative infections in
The February 2023 Wrist & Hand Roundup. 360. looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a
In-office surgeries have the potential to offer high quality medical care in a more efficient, cost-effective setting than outpatient surgical centers for certain procedures. The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective. A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy,
This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting. The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records. The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were
In the field of hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the WALANT method. We seek to investigate the degree of patient satisfaction, out of pocket cost, convenience and comfort experienced with in-office hand procedures. A ten question survey consisting of a ten-point Likert scale of agreement and questions asking for a numerical answer was administered via phone call to 33 patients treated with minor hand operations in the office setting in the United States. There were 18 male and 15 female respondents with an average age of 65.59±12.64 years. Respondents underwent procedures including
The August 2015 Wrist &
Hand Roundup360 looks at: Scaphoid screws out?; Stiff fingers under the spotlight;
The April 2012 Wrist &
Hand Roundup. 360 . looks at releasing the
We describe a safe and easy percutaneous technique for release of
In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.Aims
Methods
Aim: To assess the efficacy of percutaneous needle bursting and limited percutaneous pulley division in the treatment of seed ganglia. Methods: A prospective cohort study was run. All patients in the study had ganglia bursting by lignocaine injection. If this failed a limited percutaneous release was performed as at open release for
The antidiabetic agent metformin inhibits fibrosis in various organs. This study aims to elucidate the effects of hyperglycaemia and metformin on knee joint capsule fibrosis in mice. Eight-week-old wild-type (WT) and type 2 diabetic (db/db) mice were divided into four groups without or with metformin treatment (WT met(-/+), Db met(-/+)). Mice received daily intraperitoneal administration of metformin and were killed at 12 and 14 weeks of age. Fibrosis morphology and its related genes and proteins were evaluated. Fibroblasts were extracted from the capsules of 14-week-old mice, and the expression of fibrosis-related genes in response to glucose and metformin was evaluated in vitro.Aims
Methods
Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Patients aged ≥ 18 years with a traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and data about injury, management, and outcome were collected. Statistical analysis was performed to assess mortality and between-group differences.Aims
Methods
Long-term regular haemodialysis for chronic renal failure is associated with amyloidosis. In this condition excess amounts of the unexcretable plasma protein beta-microglobulin are laid down in tendons, joints and bones. Amyloidosis presents with various musculoskeletal disorders only after several years of dialysis. We reviewed 83 patients who had been dialysed for at least 10 years. The commonest complaint was severe joint pain in the absence of radiological changes of arthritis (41%), the shoulders usually being the most affected (33%). Carpal tunnel syndrome had developed in 26 patients, and was bilateral in 14 of them; at operation the presence of amyloid was confirmed. Six of these patients had recurrent symptoms after a further two to three years and required another decompression. Other manifestations of amyloidosis included
Objective: The purpose of this study was to determine which factors may influence in the outcome of the surgical treatment of Carpal Tunnel Syndrome (CTS). Material and Methods: During 2005, 175 patients were treated with the diagnosis of CTS by open carpal release (short palmar incision) without ligament reconstruction. 113 cases were selected: 39 males and 74 females, with an average age of 41 years (21 to 64 years) and a follow-up of 24 months (12–36 months). The dominant hand was treated in 58%. The subcutaneous cellular tissue (SCT) was sutured in 14% and 11% were immobilized with a cast for 2 weeks after surgery. We considered factors such as: systemic conditions, functional work requirement, preoperative time, surgical technique, and their correlation with complications, clinical outcome and time to return to work and activity level. Results: Complications: 41% pillar pain, 9% suture dehiscence, 3,5% ulnar neuritis, 1,7%
Introduction: The choice of whether to use absorbable or non-absorbable suture in the closure of wounds following hand or upper limb surgery is usually surgeon dependent. In our unit both continuous absorbable subcutaneous suture and interrupted non-absorbable suture are utilised. The use of absorbable sutures offers a potential advantage to the patient and clinician in not requiring a clinic appointment for suture removal. The quality and aesthetic appearance of hand and upper limb surgical scars are of great importance to patients. Few studies have compared the aesthetic appearance of scars following the use of absorbable and non-absorbable suture in hand and upper limb surgical wound closure. Method: 50 consecutive patients having undergone day case hand surgery between August 2007 and May 2008 with absorbable suture wound closure were identified along with 50 consecutive patients over the same time period who underwent non-absorbable wound closure. Each was sent a questionnaire comprising a visual analogue scale (VAS) for wound satisfaction, a validated 6 point patient scar assessment tool and the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Results: 100 patients were contacted by post and 70 responses were received (37 absorbable, 33 non-absorbable). Both groups had undergone a similar spectrum of procedures including carpal tunnel decompression, Dupuytrens fasciectomy, excision of lesions and
Objective: This article describes the outcome of a nurseled service developed to manage patients referred with a presumptive diagnosis of carpal tunnel syndrome. We also describe the implementation of a nurse-led preoperative assessment and postoperative care clinic. Design: We assess the safety, efficacy and outcomes of 402 patients referred to the Department of Orthopaedic, University Hospital Lewisham for carpal tunnel decompression surgery prospectively. Patients and Methods: The service was developed around the role of a nurse practitioner providing a single practitioner pathway from first clinic appointment to discharge. General practitioners were advised of the service and the criteria for referral, which included patients with symptoms and physical signs, and some response to conservative treatment. Patients were assessed in the nurse-led preoperative assessment clinic and those deemed suitable for surgery were listed for operation. Results: 12.7 % patients (51 patients) were referred for electromyographic studies and 5.2% patients (21 patients) were referred to doctors for further consultations. Only 4 patients had
Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion. The study involved 274 patients who underwent open repair of the TFCC between December 2013 and December 2018. The patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and scored pain and function using a visual analogue scale (VAS). Range of motion (ROM) was assessed by experienced hand therapists.Aims
Methods
To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic. A strategy consisting of phased relaxation of clinical comorbidity criteria was developed. Patients from the orthopaedic waiting list were selected according to these criteria and observed recommended preoperative isolation protocols. Surgery was performed at green sites (two local private hospitals) under the COVID-19 NHS contract. The first 100 consecutive patients that met the Phase 1 criteria and underwent surgery were included. In hospital and postoperative complications with specific enquiry as to development of COVID-19 symptoms or need and outcome for COVID-19 testing at 14 days and six weeks was recorded. Patient satisfaction was surveyed at 14 days postoperatively.Aims
Methods
Few studies have examined the long-term outcome of carpal tunnel
release (CTR). The aim of this study was to evaluate the patient-reported
long-term outcome of CTR for electrophysiologically severe carpal
tunnel syndrome (CTS). We reviewed the long-term outcome of 40 patients with bilateral
severe CTS who underwent 80 CTRs (46 open, 34 endoscopic) between
2002 and 2012. The outcomes studied were patient-reported outcomes
of numbness resolution, the Boston Carpal Tunnel Questionnaire (BCTQ)
score, and patient satisfaction.Aims
Patients and Methods
The mucopolysaccharidoses (MPS) are a group of
inherited lysosomal storage disorders with clinical manifestations relevant
to the orthopaedic surgeon. Our aim was to review the recent advances
in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising
orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include
the recognition of slowly progressive, late presenting subtypes,
developments in life-prolonging systemic treatment and potentially
new indications for surgical treatment. The outcomes of surgery
in these patients are not yet validated and some procedures have
a high rate of complications which differ from those in patients
who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or
young adults with a previously unrecognised dysplasia of the hip.
Surgeons treating patients with a MPS should report their experience
and studies should include the assessment of function and quality
of life to guide treatment. Cite this article:
The United States and Canada are in the midst
of an epidemic of the use, misuse and overdose of opioids, and deaths
related to overdose. This is the direct result of overstatement
of the benefits and understatement of the risks of using opioids
by advocates and pharmaceutical companies. Massive amounts of prescription
opioids entered the community and were often diverted and misused.
Most other parts of the world achieve comparable pain relief using
fewer opioids. The misconceptions about opioids that created this epidemic are
finding their way around the world. There is particular evidence
of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that
the best pain relief is obtained through resilience. Opioids are
often prescribed when treatments to increase resilience would be
more effective. Cite this article:
Our purpose was to determine the quality of current randomised
controlled trials (RCTs) in hand surgery using standardised metrics. Based on five-year mean impact factors, we selected the six journals
that routinely publish studies of upper extremity surgery. Using
a journal-specific search query, 62 RCTs met our inclusion criteria.
Then three blinded reviewers used the Jadad and revised Coleman Methodology
Score (RCMS) to assess the quality of the manuscripts.Aims
Materials and Methods
Diabetes mellitus is recognised as a risk factor
for carpal tunnel syndrome. The response to treatment is unclear,
and may be poorer than in non-diabetic patients. Previous randomised
studies of interventions for carpal tunnel syndrome have specifically
excluded diabetic patients. The aim of this study was to investigate
the epidemiology of carpal tunnel syndrome in diabetic patients,
and compare the outcome of carpal tunnel decompression with non-diabetic
patients. The primary endpoint was improvement in the QuickDASH
score. The prevalence of diabetes mellitus was 11.3% (176 of 1564).
Diabetic patients were more likely to have severe neurophysiological
findings at presentation. Patients with diabetes had poorer QuickDASH
scores at one year post-operatively (p = 0.028), although the mean
difference was lower than the minimal clinically important difference
for this score. After controlling for underlying differences in
age and gender, there was no difference between groups in the magnitude of
improvement after decompression (p = 0.481). Patients with diabetes
mellitus can therefore be expected to enjoy a similar improvement
in function.
To investigate the appropriate dose and interval for the administration
of triamcinolone acetonide (TA) in treating tendinopathy to avoid
adverse effects such as tendon degeneration and rupture. Human rotator cuff-derived cells were cultured using three media:
regular medium (control), regular medium with 0.1 mg/mL of TA (low
TA group), and with 1.0 mg/mL of TA (high TA group). The cell morphology,
apoptosis, and viability were assessed at designated time points.Objectives
Methods
The April 2013 Shoulder &
Elbow Roundup360 looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow.
The purpose of this study was to compare the
outcome and complications of endoscopic We conclude that endoscopic release for de Quervain’s tenosynovitis
seems to provide earlier improvement after surgery, with fewer superficial
radial nerve complications and greater scar satisfaction, when compared
with open release. Cite this article:
The osteoinductive properties of demineralised
bone matrix have been demonstrated in animal studies. However, its therapeutic
efficacy has yet to be proven in humans. The clinical properties
of AlloMatrix, an injectable calcium-based demineralised bone matrix
allograft, were studied in a prospective randomised study of 50
patients with an isolated unstable distal radial fracture treated
by reduction and Kirschner (K-) wire fixation. A total of 24 patients
were randomised to the graft group (13 men and 11 women, mean age
42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18
women, mean age 45.0 years (17 to 69)). At one, three, six and nine weeks, and six and 12 months post-operatively,
patients underwent radiological evaluation, assessments for range
of movement, grip and pinch strength, and also completed the Disabilities
of Arm, Shoulder and Hand questionnaire. At one and six weeks and
one year post-operatively, bone mineral density evaluations of both
wrists were performed. No significant difference in wrist function and speed of recovery,
rate of union, complications or bone mineral density was found between
the two groups. The operating time was significantly higher in the
graft group (p = 0.004). Radiologically, the reduction parameters
remained similar in the two groups and all AlloMatrix extraosseous leakages
disappeared after nine weeks. This prospective randomised controlled trial did not demonstrate
a beneficial effect of AlloMatrix demineralised bone matrix in the
treatment of this category of distal radial fractures treated by
K-wire fixation. Cite this article:
We have developed an illustrated questionnaire, the Hand20, comprising 20 short and easy-to-understand questions to assess disorders of the upper limb. We have examined the usefulness of this questionnaire by comparing reliability, validity, responsiveness and the level of missing data with those of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. A series of 431 patients with disorders of the upper limb completed the Hand20 and the Japanese version of the DASH (DASH-JSSH) questionnaire. The norms for Hand20 scores were determined in another cross-sectional study. Most patients had no difficulty in completing the Hand20 questionnaire, whereas the DASH-JSSH had a significantly higher rate of missing data. The standard score for the Hand20 was smaller than the reported norms for the DASH. Our study showed that the Hand20 questionnaire provided validation comparable with that of the DASH-JSSH. Explanatory illustrations and short questions which were easy-to-understand led to better rates of response and fewer missing data, even in elderly individuals with cognitive deterioration.