To compare the efficacy of local steroid injection with surgical decompression in treatment of carpal tunnel syndrome (CTS) in terms of frequency of pain. This randomized controlled study was conducted at the Department of Orthopaedics for a duration of 01 year, i.e. from 20th April 2016 to 19th April 2017. 130 patients with carpal tunnel syndrome with moderate (Grade 2) and severe (Grade 3) pain were included. Lottery method was used to allocate the patients randomly into two groups. Group A contained 65 patients who were subjected to surgical decompression and 65 patients were in Group B who were injected with local steroid injection. Complete history was obtained from all patients. All the surgical decompressions through mini incision technique and injections procedures were performed. Information were recorded in a pre designed Performa. Efficacy was observed significantly high in group B as compared to group A (87.7% vs. 72.3%, p=0.028). Carpal Tunnel syndrome symptoms were alleviated with surgical decompression as well as local steroid injection at a follow up done after 1 month. However the steroid injections seem to have greater efficacy than surgical decompression, hence we suggest it for routine treatment of all patients with CTS. For any reader queries, please contact . virgo_r24@hotmail.com

Carpal tunnel syndrome is the most frequent form of median nerve entrapment, accounting for 90% of all entrapment neuropathies. Routinely nerve conduction study (NCS) tests are ordered to confirm the diagnosis however; there are issues of long waiting periods and costs with it. We aimed to compare carpal tunnel questionnaire score (CTQS) by Kamath and Stothard (2003) to nerve conduction study result in the diagnosis of carpal tunnel syndrome. This prospective study involved analysis of data from all the patients referred to NHS Tayside (Dundee) hand clinic with signs and symptoms of Carpal tunnel syndrome (CTS) from September 2016 to February 2017. Statistical analysis was done using SPSS and sensitivity and specificity was calculated. The questionnaires were filled in by a team of specialist physiotherapists. Nerve conduction study tests were done by a team of consultant neurophysiologists. Both the groups were blinded to each other's assessment. We analysed 88 patients who filled in CTQS and also underwent NCS. We noted that CTQS of less than 3 correlated 100% to negative nerve conduction result. When the carpal tunnel questionnaire score was more than or equal to 5, 54 patients had positive NCS result and 6 patients had negative NCS result, giving a 90% predictability of a positive NCS result. Mean waiting period of carpal tunnel patients for NCS was 141 days. We noted from this prospective study that CTQS was sensitive enough to exclude carpal tunnel syndrome when the questionnaire score was less than 3. In addition, the questionnaire revealed a 90% probability of having carpal tunnel syndrome when CTQS was more than or equal to 5. Based on the present study, we would recommend that patients in grey zone of 3 to 4 on questionnaire should undergo NCS, resulting in only 20% of patients (based on the figures from the current study) being referred for NCS. The questionnaire can be used in primary health care or specialist physiotherapy screening clinic as a tool for diagnosing CTS with implications of cost saving and avoiding long waiting periods

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48-hours. We identified all patients treated at our trauma centre following this protocol between 1 January 2014 and 31 December 2019. All patients were clinically reviewed at least 12 months following surgery and assessed using the Brief Michigan Hand Outcomes Questionnaire (bMHQ), the Boston Carpal Tunnel Questionnaire (BCTQ) and sensory assessment with Semmes-Weinstein monofilament testing. The study group was made up of 35 patients. Thirty-three patients were treated within 36-hours. Patients treated with our unit protocol for early surgery comprising nerve decompression and bony stabilization within 36-hours, report excellent outcomes at medium term follow up. We propose that nerve decompression and bony surgical stabilization should be undertaken as soon as practically possible once the diagnosis is made. This is emergent treatment to protect and preserve nerve function. In our experience, the vast majority of patients were treated within 24-hours

Carpal tunnel syndrome (CTS) is said to be a condition of middle-aged women. Our experience is that it more commonly occurs in older people and also in a younger working population. The aim of this study is to describe the epidemiology of CTS requiring carpal tunnel decompression (CTD). Over a 10.5 year period 3073 CTD were performed on 2309 patients aged 15 – 93 years. This included all public, private and ACC funded cases in our region. During this period we had no restriction to access to CTD as all publicly funded cases were performed under local anaesthetic in a day surgery unit. Neurophysiological studies were performed pre-operatively by the same neurophysiologist. Population data from the national census (2006) was used to calculate the annual incidence of patients requiring CTD for each 5 year age band. There were 1418 females (61.4%) and 891 males (38.6 %). In contrast females comprised 116 of 306 (37.8%) patients who had their surgery funded by ACC. The mean age at surgery was 45 years for ACC cases compared with 56 years for non-ACC funded cases. The incidence of males having surgery funded by ACC was 1.7 times higher than females. There was a biphasic pattern in females with an incidence of 3.0/1000 at age 50–54 years, and a second higher peak of 3.1 to 3.4/1000 from 70 to 5 years. Males had a linear increase in incidence peaking at 3.1/1000 for age 65–69 years declining slightly to 2.8/1000 for age 70–85 years. The incidence was significantly higher in females than males overall (1.8 v 1.1/1000) and in patients under 65 years (1.4 v 0.8/1000). In patients over 65 years there was no significant difference in incidence (female 2.8, male 2.5/1000). Within our region, the incidence of surgically treated carpal tunnel syndrome increases with age. The highest rates are seen over the age of 70 in women and 65 years in men with no significant difference in rates between men or women over 65 years

Introduction. The association of occupation and carpal tunnel syndrome (CTS) is unclear. Population based studies have failed to prove causal relationships between certain types of work and the onset of CTS. The aim of this study was to compare the incidence of CTS with the underlying regional occupational profile and assess differences in disease severity. Methods. The study took place from 2004 to 2010 in a regional hand unit that was the sole provider of hand services to a health board. Occupation was classified according to the SOC2000 classification as published by the Office for National Statistics and compared with the National Census 2000 statistics. 1564 patients were diagnosed with CTS during the study period of which 852 were aged 16 to 74, in full time employment. Results. CTS was less common among managers, directors and senior officials (< 0.001), associated professional and technical occupations (< 0.001), and process plant and machine operatives (p=0.013). It was higher than expected in professional occupations (p< 0.001), skilled trade occupations (p< 0.001) and caring and other service occupations and elementary occupations (p< 0.001). Bilateral disease was highest in the skill trades group (80%). Process, plant and machine operatives had the highest rate of compensation claims (15.2%, p=0.001), while the highest rate of exposure to vibration was in the skilled trades group (67%). There was a difference in preoperative grip strength (p< 0.001) and DASH score (p< 0.001). Conclusions. The incidence of CTS varied between occupational groups. This study demonstrated a higher incidence of CTS in skilled trades and elementary occupations. There was also a higher than expected rate of CTS observed in professional groups and caring, leisure and other service occupations, but lower in machine and plant operatives. Disease severity varied according to occupational group

The aim of the study was to assess the validity of the new device [BREVIO] [AEND] [Level 2 evidence] in diagnosing carpal tunnel syndrome in the outpatient setting when used by personnel not trained previously in neurophysiologic methods. We prospectively compared the results from a portable handheld automated electroneurodiagnostic devices (AEND) the BREVIO with those from conventional nerve conduction studies. We calculated specificity and sensitivity. We also studied the limits of agreement and correlation between measured latencies. Patient satisfaction with new device was recorded. Twenty-seven participants (42 hands) were tested. The average age was 56.43 years (38-79). There were 16 females and 11 males. The sensitivity and specificity of the BREVIO as compared to conventional methods were 80% and 75% using distal motor latencies; using distal sensory latencies the sensitivity and specificity were 90% and 60% respectively. The limits of agreement between the sensory and motor latencies using Bland Altman plots were good. Similarly there was good correlation between values measured with the Pearson's correlation coefficient. The position of the baseline cursor was questionable in 19 hands. Repositioning the cursor reduced the number of false positive results which would increase the specificity of the device. The average pain score, VAS on a scale of 1-10, with the BREVIO was 1.69 (1-4) and 3.11(1-5) with conventional testing. The average satisfaction rating on a scale of 1-5 was 1.39 with the BREVIO and 2.73 with the conventional nerve conduction testing. The BREVIO is an interesting device. We recommend its use by untrained persons only under the supervision of someone trained in neurophysiology who is aware of potential pitfalls

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome

Introduction/aims. Carpal tunnel decompression is common at the world's largest lamb processing plant. The purpose of this study was to establish whether lamb boning caused carpal tunnel syndrome, whether expeditious rehabilitation was possible and current New Zealand Orthopaedic practice. Method. The incidences/relative risks of carpal tunnel syndrome were calculated. Kaplan-Meier survival analysis was performed examining six seasons. Comparison with a standard idiopathic population was performed. Retrospective review of five seasons established rate of return to work/complications using an accelerated rehabilitation programme. A prospective study qualified pre/postoperative symptoms using validated techniques. An email survey of the NZOA was also performed. Medical statistician advice was provided throughout. Results. Median five-year survival for a lamb boner's carpal tunnel was 44%; boners were 120% more likely to need decompression than non-knife hands (p<0.01). The incidence of carpal tunnel syndrome in lamb boners was 10% (person-seasons): twice that of non-knife hands. This population is entirely different to the published idiopathic population (female, mean age 55). In both retrospective and prospective cohorts, postoperative return to work was 28 days: more rapid than NZOA practice. Rapid return did not cause further absenteeism nor high complication rates. There were no failed decompressions. Conclusions. This study provides good evidence that carpal tunnel syndrome can be occupational. Our unique population has allowed a culture to develop whereby early postoperative return to is expected. This culture, good patient education and coordinated efforts at all levels of the care pathway is necessary for this level of achievement. Declaration. In relation to the conduct of this study, no funding has been received from any source to support the cost of this study

Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Objective. The aim of this retrospective study is to assess the functional and radiological outcome of a multi-planar corrective osteotomy, distraction and locking fixed angle volar plate as the standard of treatment of distal radius mal-unions that require multi-planar correction. Methods. We conducted a retrospective study on 13 consecutive patients – 4 males, 9 females (mean age 49). All patients underwent volar approach, open wedge distraction osteotomy locking fixed angle volar plate and cancellous bone grafting Radiographic measurements and functional assessments were taken preoperatively, 3, 6 months and one year. Results. Time to surgery from the original fracture had a mean of 17.4 months (range 8–36 months). Mean follow-up was 16.4 months (range from 6 to 45 months). Osteotomy healing time was 11.3 weeks on average. All radiographic measurements improved postoperatively, ten patients had an average of 18.84 degrees of dorsal tilt which was corrected to a volar tilt of 9.17 degrees on average. Ulna variance was initially positive in all patients with an average of 2.6 mm which was corrected to less than one (0.96 mm); three patients had radial angulations of 20.6 degrees on average, which were fully corrected postoperatively. Flexion-extension arc has improved with significant difference and so has the grip and pinch strength. The average DASH and SF12 scores has shown figures comparative to the normal population post deformity correction. Complications included one case of low grade wound infection and one case of postoperative symptoms of carpal tunnel syndrome. Conclusion. The described technique is a useful means to correct distal radius anatomy and function; however patients should be aware that it is not always possible to regain full function and anatomy

Hypothesis. Does the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms provide a good predictor of the outcome of later carpal tunnel release (CTR). Methods. A retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome (CTS) over a two year period was conducted. A total of 23 patients and 28 wrists met inclusion criteria. Patients were evaluated to determine if pre-operative factors or result of injection predicted the outcome of revision CTR. A multivariate logistic regression analysis (MLRA) was used to predict surgical success when multiple pre-operative findings were considered. Results. No patient characteristic or physical exam finding was found to predict successful revision CTR. Twenty-two (86.4%) of patients who had relief from injection had symptom relief/improvement with revision CTR whereas only 4 (13.6%) were not improved by the surgery; the difference was not statistically significant. The sensitivity and positive predictive value for injection alone predicting outcome of revision CTR was 86.4%. MLRA combining injection results with physical exam findings (Numbness and/or motor weakness in median nerve distribution, Positive Durkin's, and Positive Phalen's test) provided a sensitivity of 100% and specificity of 80%. Conclusions. In contrast to primary CTS, cortisone injection into the carpal tunnel in the face of recurrent CTS is not, by itself, a statistically significant predictor of successful revision surgery. However, patients with a positive result from injection had an 86.4% success with revision CTR with an average DASH score of 28.87. Relief from injection as a diagnostic test for success from revision CTR was found to have both high sensitivity and positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish success with revision CTR, sensitivity of 100% and specificity of 80%

Aims

Patients undergoing limb reconstruction surgery often face a challenging and lengthy process to complete their treatment journey. The majority of existing outcome measures do not adequately capture the patient-reported outcomes relevant to this patient group in a single measure. Following a previous systematic review, the Stanmore Limb Reconstruction Score (SLRS) was designed with the intent to address this need for an effective instrument to measure patient-reported outcomes in limb reconstruction patients. We aim to assess the face validity of this score in a pilot study.

Aims

To describe the incidence of adverse clinical outcomes related to COVID-19 infection following corticosteroid injections (CSI) during the COVID-19 pandemic. To describe the incidence of positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing, positive SARS-COV2 IgG antibody testing or positive imaging findings following CSI at our institution during the COVID-19 pandemic.

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects.

A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.

A total of 38 patients with leprosy and localised nerve damage (11 median at the wrist and 37 posterior tibial at the ankle) were treated by 48 freeze-thawed skeletal muscle autografts ranging between 2.5 cm and 14 cm in length. Sensory recovery was noted in 34 patients (89%) and was maintained during a mean period of follow-up of 12.6 years (4 to 14). After grafting the median nerve all patients remained free of ulcers and blisters, ten demonstrated perception of texture and eight recognised weighted pins. In the posterior tibial nerve group, 24 of 30 repairs (80%) resulted in improved healing of the ulcers and 26 (87%) demonstrated discrimination of texture. Quality of life and hand and foot questionnaires showed improvement; the activities of daily living scores improved in six of seven after operations on the hand, and in 14 of 22 after procedures on the foot. Another benefit was subjective improvement in the opposite limb, probably because of the protective effect of better function in the operated side. This study demonstrates that nerve/muscle interposition grafting in leprosy results in consistent sensory recovery and high levels of patient satisfaction. Ten of 11 patients with hand operations and 22 of 25 with procedures to the foot showed sensory recovery in at least one modality.