Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation

Background

Acute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ).

Methods

A retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case–control study was performed comparing outcomes of both groups.

Results

The average age of patients was 51 ± 15 years, with an average follow-up of Group A at 49 ± 21 months versus Group B at 55 ± 20 months. The mean symptom severity scale score for Group A was 1.4 ± 0.4 and for Group B was 1.4 ± 0.4. The mean functional status scale score for Group A was 1.4 ± 0.5 and for Group B was 1.3 ± 0.4. The mean total BCTQ score for Group A was 26.5 ± 7.5 and for Group B was 24.9 ± 7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores.

Conclusions

Patients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.     

Basal joint arthroplasty decreases carpal tunnel pressure

Background

There is a well-documented association between carpal tunnel syndrome (CTS) and thumb carpometacarpal (CMC) arthritis, and these conditions commonly coexist. We have observed that patients who have previously undergone thumb basal joint arthroplasty (BJA) seem rarely to present subsequently with CTS. Our hypothesis is that BJA decreases the pressure within the carpal tunnel.

Methods

Twenty-eight patients (6 with coexistent CTS) undergoing BJA were enrolled in the study. The pressure within the carpal tunnel immediately before and after BJA was measured using a commercially available pressure monitor device (Stryker STIC; Kalamazoo, MI). In patients with concomitant CTS undergoing both BJA and carpal tunnel release (CTR), the pressure was measured after BJA but prior to release of the transverse carpal ligament.

Results

The pressure within the carpal tunnel decreased after BJA in all patients. There were 3 patients with stage II arthritis, 15 patients with stage III arthritis, and 10 patients with stage IV arthritis. The mean pressure prior to BJA among all patients was 23.9 mmHg and decreased to 11.0 mmHg after BJA. Patients with concomitant CTS had a mean pre-BJA pressure of 26.5 mmHg, which decreased to 7.3 mmHg after BJA.

Conclusions

BJA decompresses the carpal tunnel and decreases the pressure within. In patients with concomitant CTS, the BJA alone (without additional release of the transverse carpal ligament) decreases the carpal tunnel pressure. Further study is warranted to determine the need for discrete release of the transverse carpal ligament in patients with CTS who are undergoing BJA.

Level of Evidence

Level II, diagnostic.     

Immediate and durable clinical improvement in the non-operated hand after contralateral surgery for patients with bilateral Carpal Tunnel Syndrome

Background

Little is known about clinical improvement in the non-operated hand after unilateral surgery for patients who present with bilateral carpal tunnel syndrome (CTS). In this prospective study of patients with bilateral CTS, we evaluated the clinical effects on the non-operated hand following unilateral contralateral carpal tunnel surgical release.

Material and Methods

During a consecutive period of 22 months, 69 patients with bilateral CTS underwent unilateral open carpal tunnel release. Bilateral subjective and objective evaluations were performed pre-operatively, at days 2, 15 and 180 after surgery. Subjective evaluations, analysed with Student t test, included the Boston-Levine symptom severity score and a visual analogue scale including pain, nocturnal symptoms and numbness. A telephone survey was conducted 12 months after surgery.

Results

The Boston-Levine severity score of the contralateral non-operated hand decreased from 2.70 pre-operatively to 1.70 at 2 days (p < 0.001). The visual analogue pain score decreased at 2 days for 61 patients (88 %), whereas the nocturnal symptoms decreased or disappeared in 63 cases (91 %) and the paresthesia in 52 cases (75 %) (ps < 0.001). These beneficial effects were stable in time with no statistically significant change at 180 days. Overall, 58 patients (84 %) observed a total resolution or a significant improvement in their symptoms at 6 months. At 12 months, 100 % of patients responded to a telephone survey. Fifty one of them (74 %) reported minimal or no symptoms on the non-operated hand. Linear regression (analysis of variance [ANOVA]) showed that gender, age, professional status, duration of pre-operative symptoms and severity of electrophysiological disturbances were not predictive of post-operative evolution in the non-operated hand after unilateral surgery for CTS.     

The effect of epineurotomy on the median nerve volume after the carpal tunnel release: a prospective randomised double-blind controlled trial

Purpose

The purpose of this study was to evaluate the effects of epineurotomy on the post-surgical median nerve volume and clinical outcomes in carpal tunnel syndrome (CTS) patients with a prominent nerve narrowing.

Methods

This was a prospective, randomised, double-blind controlled trial. Patients (n = 50) were randomised (1:1) to open-field surgical carpal tunnel release followed by a longitudinal epineurotomy of the nerve (test), or to open-field release without epineurotomy (control).

Results

The nerve volume was slightly larger in the test group 90 days post-surgery (by 10.5 %, p = 0.157) but not 180 days post-surgery. No relevant electropyhsiological or clinical difference between groups and no effect of the nerve volume was observed. The subjective pain reduction was slightly more prominent in the control group at 180 days. Larger post-surgical nerve volume was associated with lower pain, but only in the control group.

Conclusions

Even in selected CTS patients, longitudinal epineurotomy confers no benefit regarding the nerve volume or clinical outcomes over a simple carpal tunnel release.     

Prospective comparison of the six-item carpal tunnel symptoms scale and portable nerve conduction testing in measuring the outcomes of treatment of carpal tunnel syndrome with steroid injection

Background

We prospectively studied patients clinically diagnosed with carpal tunnel syndrome (CTS) and treated with the injection of corticosteroid into their carpal tunnel in order to compare changes in the six-item CTS symptoms scale and portable nerve conduction study (NCS) parameters as outcome tools. Our pilot study was the first to assess the utility of the six-item CTS symptom scale (CTS-6) with steroid injections as a patient-directed outcome measure for the treatment of CTS.

Methods

We enrolled patients who presented to our county hospital orthopedic surgery clinic from August 2012 through August 2013. The patients were clinically diagnosed with CTS. After completing the six-item CTS symptoms scale questionnaire, portable NCS was obtained. Each patient then received an injection of 1 ml of triamcinolone acetonide 40 mg/ml mixed with 1 ml of 1 % lidocaine into the carpal tunnel. Six weeks postinjection, each patient repeated a CTS-6 questionnaire and underwent a repeat portable NCS. The CTS-6 and NCS results were analyzed using the paired samples t test. A Pearson correlation was used to assess the correlation between the changes in the CTS-6 and the NCS measurements. Statistical significance was set at P < 0.05.

Results

Thirty-two wrists in 20 patients were evaluated. There was a statistically significant difference between the CTS-6 scores before and after injection. There were also statistically significant changes in the five of the NCS parameters. None of the correlations between the CTS-6 and the NCS parameters were statistically significant.

Conclusions

The six-item CTS symptoms scale and portable NCS are both useful measures for evaluating the results of steroid injections. The CTS-6 is an effective tool because of its ease of use, low cost, correspondence with changes in NCS, and ability to monitor the outcome of steroid treatment for carpal tunnel syndrome.     

Treatment of carpal tunnel syndrome by members of the American Association for Hand Surgery

Background

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the upper extremity, yet evidence-based guidelines for its diagnosis and treatment are lacking. We set out to expose any potential discrepancies in CTS practice attitudes based on surgeon’s academic background, residency training, clinical experience, and other factors.

Methods

This was an online survey-based study. Members of the American Association for Hand Surgery (AAHS) were sent an electronic mail request (n = 817). The online questionnaire consisted of 12 questions that queried surgeons’ approaches to the diagnosis as well as operative and non-operative management of carpal tunnel syndrome.

Results

One hundred twenty-three surgeons responded to the survey (15.1 %). The locations of surgical practices varied within the United States and beyond. Most respondents were either orthopedic or plastic surgeons. With respect to practice duration, 15.4 % had been in practice for 5 years or less, 30.9 % of the respondents had been in practice between 6 and 15 years, 30.9 % had been in practice between 16 and 25 years, and 26.8 % had been in practice for more than 25 years. The most notable interspecialty differences were related to the use of operative antibiotics and the surgical approach. Plastic surgeons were less likely to recommend antibiotic use during surgery and more likely to utilize an open extensile approach during surgical release. Younger surgeons were more likely to employ a mini-open approach for carpal tunnel release.

Conclusions

We conclude that background training and generational differences contribute to the varied approaches observed in the diagnosis and management of CTS.     

Open versus Endoscopic Carpal Tunnel Release: A Meta-analysis of Randomized Controlled Trials

Background

Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial.

Questions/purposes

The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time.

Methods

The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included.

Results

Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08–5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33–1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35–0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08–7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, −8.73 days [−12.82 to −4.65]; p < 0.001); and reduced operative time (MD, −4.81 minutes [−9.23 to −0.39]; p = 0.03).

Conclusions

High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.     

Is the Control of Applied Digital Forces During Natural Five-digit Grasping Affected by Carpal Tunnel Syndrome?

Background

The impaired sensory function of the hand induced by carpal tunnel syndrome (CTS) is known to disturb dexterous manipulations. However, force control during daily grasping configuration among the five digits has not been a prominent focus of study. Because grasping is so important to normal function and use of a hand, it is important to understand how sensory changes in CTS affect the digit force of natural grasp.

Questions/purposes

We therefore examined the altered patterns of digit forces applied during natural five-digit grasping in patients with CTS and compared them with those seen in control subjects without CTS. We hypothesized that the patients with CTS will grasp by applying larger forces with lowered pair correlations and more force variability of the involved digits than the control subjects. Specifically, we asked: (1) Is there a difference between patients with CTS and control subjects in applied force by digits during lift-hold-lower task? (2) Is there a difference in force correlation coefficient of the digit pairs? (3) Are there force variability differences during the holding phase?

Methods

We evaluated 15 female patients with CTS and 15 control subjects matched for age, gender, and hand dominance. The applied radial forces (F_r) of the five digits were recorded by respective force transducers on a cylinder simulator during the lift-hold-lower task with natural grasping. The movement phases of the task were determined by a video-based motion capture system.

Results

The applied forces of the thumb in patients with CTS (7 ± 0.8 N; 95% CI, 7.2–7.4 N) versus control subjects (5 ± 0.8 N; 95% CI, 5.1–5.3 N) and the index finger in patients with CTS (3 ± 0.3 N; 95% CI, 3.2–3.3 N) versus control subjects (2 ± 0.3 N; 95% CI, 2.2–2.3 N) observed throughout most of the task were larger in the CTS group (p ranges 0.035–0.050 for thumb and 0.016–0.050 for index finger). In addition, the applied force of the middle finger in patients with CTS (1 ± 0.1 N; 95% CI, 1.3–1.4 N) versus the control subjects (2 ± 0.2 N; 95% CI, 1.9–2.0 N) during the lowering phase was larger in CTS group (p ranges 0.039–0.050). The force correlations of the thumb-middle finger observed during the lowering phase in the patients with CTS (0.8 ± 0.2; 95% CI, 0.6–0.9) versus the control subjects (0.9 ± 0.1; 95% CI, 0.8–1.0; p = 0.04) were weaker in the CTS group. The thumb-little finger during holding in the patients with CTS (0.5 ± 0.2; 95% CI, 0.3–0.7) versus the control subjects (0.8 ± 0.2; 95% CI, 0.6–0.9; p = 0.02), and the lowering phase in the patients with CTS (0.6 ± 0.2; 95% CI, 0.3–0.8) versus the control subjects (0.9 ± 0.1; 95% CI, 0.8–1.0; p = 0.01) also were weaker. The force variabilities of patients with CTS were greater in the CTS group than in the control subjects: in the thumb ([0.26 ± 0.11 N, 95% CI, 0.20–0.32 N] versus [0.19 ± 0.06 N; 95% CI, 0.16–0.22 N], p = 0.03); index finger ([0.09 ± 0.07 N; 95% CI, 0.05–0.13 N] versus [0.05 ± 0.03 N; 95% CI, 0.04–0.07 N], p = 0.03); middle finger ([0.06 ± 0.04 N; 95% CI, 0.04–0.08 N] versus [0.03 ± 0.01 N; 95% CI, 0.02–0.04 N], p = 0.02), and ring finger ([0.04 ± 0.03 N; 95% CI, 0.20–0.06 N] versus [0.02 ± 0.01 N; 95% CI, 0.02–0.02 N], p = 0.01).

Conclusions

Patients with CTS grasped with greater digit force associated with weaker correlation and higher variability on specific digits in different task demands. These altered patterns in daily grasping may lead to secondary problems, which will need to be assessed in future studies with this model to see if they are reversible in patients undergoing carpal tunnel release.

Clinical Relevance

The current results helped to identify altered patterns of grasping force during simulated daily function in patients with CTS and to provide the clinician with potential information that might help guide the rehabilitation of grasp in these patients.     

Assessing the complications and effectiveness of open carpal tunnel release in a tertiary care centre in a developing country

INTRODUCTION

Open surgical release for carpal tunnel syndrome is not devoid of complications and its quantitative assessment with the Boston questionnaire in a developing country had not been conducted, where, lack of facilities and surgical technique can influence the outcome.

PRESENTATION OF CASE

This was a prospective study in which all cases of carpal tunnel syndrome undergoing open release between June 2007 and June 2012 and who returned for follow up were included. Each patient was requested to fill out the Boston questionnaire twice both pre and post op at 3 months. All complications were recorded as well as bio-data of patients and co morbidities. Follow up was at 2 weeks and at 3 months. Those reporting complications at 3 months were further followed up until 6 months. 373 patients were included in the study. Twenty four patients developed complications. Of these, 12 experienced pain resulting from reflex sympathetic dystrophy. Three patients developed wound dehiscence, 2 cases acquired infections, 4 patients developed immediate post-operative haemorrhage and in 3 patients there was late recurrence of median nerve compression. The symptom severity score pre-operatively was 3.30 (±0.60) and it improved to 1.65 (±0.75) post-operatively indicating a significant change (p < 0.0001). The preoperative functional status score was 2.58 (±0.75) and post-op it became 1.60 (±0.80) again implying a good improvement with an effect size of 1.3.

DISCUSSION

All of the complications produced were well managed. The complication incidence was low. The open release procedure produced good improvement in hand function and in decreasing the symptom severity.

CONCLUSION

Conducting open release for carpal tunnel syndrome in a tertiary referral centre in a developing country offers a good outcome.     

Contralateral electrodiagnosis in patients with abnormal median distal sensory latency

Background

We hypothesized that electrodiagnostic evidence of carpal tunnel syndrome (CTS) on the contralateral, less-severe side correlates with disease severity.

Methods

We retrospectively reviewed 285 adults that had bilateral electrodiagnostic testing and a median distal sensory latency (DSL) greater than 3.6 ms on at least one side. Variables associated with abnormal contralateral median DSL were analyzed in bivariable and multivariable analysis.

Results

Patients with a nonrecordable median DSL on the worst side were significantly more likely to have electrodiagnostic evidence of contralateral CTS compared to patients with a prolonged DSL on the worst side (90 versus 65 %, respectively; p < 0.001). Bilateral symptoms were reported by 75 % of patients. The best logistic regression model for electrodiagnostic evidence of contralateral CTS included nonrecordable median DSL of the worst side and polyneuropathy (p < 0.001 and p = 0.14, respectively).

Conclusions

The finding that disease severity relates to the probability of contralateral abnormalities is consistent with the concept that CTS is typically bilateral. Patients with CTS on one side should be advised of the likelihood that it can be present or may develop on the other side.     

Olecranon tip osteoarticular autograft transfer for irreparable coronoid process fracture: a biomechanical study

Background

We hypothesized that transfer of the olecranon tip for simulated type III coronoid fracture would restore posterior ulnohumeral translation to a level not different from that in the intact state.

Methods

The collateral ligaments were left intact in 12 fresh-frozen cadaveric elbows, and all other soft tissues were removed. The entire coronoid process was osteotomized flush with the ventral aspect of the ulna and was reconstructed using the tip of the olecranon process. Specimens were tested with an axial load of 100 N at 0.25 mm/s in 15° increments from 15 to 120° of flexion. Intact, osteotomized, and reconstructed posterior ulnohumeral displacement was measured.

Results

The bony reconstruction did not obstruct range of motion of the elbow. Intact translation (mean ± SD) ranged from 0.3 ± 0.1 to 1.1 ± 0.6 mm, and translation in the osteotomized state ranged from 1.3 ± 1.0 to 2.0 ± 1.0 mm. Resection of the coronoid resulted in a significant increase in posterior ulnar translation compared with intact at all flexion angles (p < 0.05) except at 75°. Reconstruction decreased translation versus the osteotomized state at all flexion angles, significantly at 60 and 120°. No significant difference in translation was found between reconstructed and intact states at five of eight positions tested.

Conclusions

In this biomechanical study of irreparable coronoid fracture, autograft olecranon tip transfer restored posterior elbow stability to a level not significantly different from the intact elbow in five of eight elbow positions tested.     

Minimally invasive partial fasciectomy for Dupuytren’s contractures

Background

Numerous options exist for the treatment of Dupuytren’s contracture. This study describes the technique and early results of partial fasciectomy through a mini-incision approach as an additional treatment option for Dupuytren’s disease.

Methods

This procedure involves the excision of diseased Dupuytren’s tissue with the use of multiple 1 cm transverse incisions. Patient demographics, digit involvement, the number of incisions required to release each digit, and complications were recorded for all patients. Range of motion data was obtained from a subgroup of patients that had at least 6 months of follow-up. A paired t test was used to compare preoperative and postoperative contracture.

Results

Sixty-seven patients underwent 75 procedures that involved 119 digits. The mean patient age at the time of surgery was 63 years (range, 33–95 years). A total of 32 digits (47 joints) were available for range of motion analysis. After a mean of 2.2 years following surgery, metacarpophalangeal joint contractures maintained correction (34° preoperatively, 19° postoperatively, p = 0.008). After a mean postoperative duration of 2.0 years, proximal interphalangeal joint contractures trended worse than preoperative levels (39° preoperatively, 45° postoperatively, p = 0.319). There was one major complication, which consisted of a nerve laceration that was identified and repaired intraoperatively.

Conclusions

Partial fasciectomy through the described mini-incision approach provides an additional surgical option for patients who desire a less invasive surgical procedure than traditional fascietomy. Although this procedure is safe and effective at achieving immediate cord release, maintenance of correction for proximal interphalangeal joint contractures remains problematic.     

The carpal stretch test

Objective

To compare the sensitivity of traditional motion studies, bone scintigraphy and radiocarpal arthrography to a “carpal stretch test,” for evaluation of dynamic dissociative carpal instability.

Design

Experimental study comparing the results of the tests to the findings of arthroscopy, the “gold standard.”

Setting

A university hospital-based upper extremity practice.

Patients

Six patients with chronic wrist pain, arthroscopically confirmed proximal row ligamentous disruption and radiographs not suggestive of proximal row instability.

Interventions

The carpal stretch test: both affected and unaffected wrists were subjected to the same testing, wherein the wrist was suspended from finger traps for 10 minutes by a 4.5-kg weight. Standardized posteroanterior radiographs were taken of the suspended wrists.

Main outcome measures

Disruption of Gilula’s arcs I and II, and sensitivity of the carpal stretch test compared with other investigations.

Main results

Step deformities ranging from 2.5 to 6 mm (average 3.7 mm) were recorded in the affected wrists and 0 to 4 mm (average 1.5 mm) in the “unaffected” wrists. The test was more sensitive than traditional radiography, arthrography and scintigraphy in defining both presence and site of proximal carpal row ligamentous tears and was almost as sensitive as arthroscopy.

Conclusion

In patients with chronic wrist pain and dynamic dissociative wrist instability, the carpal stretch test may prove to be a valuable screening tool for detecting ligamentous tears of the proximal carpal row.     

Compression screw fixation without bone grafting for scaphoid fibrous nonunion

Purpose

Bone graft is often recommended as an adjuvant for treatment of scaphoid nonunions. However, recent literature has suggested that fibrous nonunion may be suited to treatment with rigid fixation without bone grafting. This work reported on outcomes of compression screw fixation for established scaphoid fibrous nonunions without bone graft.

Methods

Fourteen patients underwent surgical compression screw fixation without bone grafting of scaphoid fibrous nonunion between January 1, 2000, and December 31, 2012, with minimum follow-up until the time of clinical and radiographic healing. Fibrous nonunion of the scaphoid was defined as a scaphoid fracture with all of the following features: (1) persistent tenderness, (2) incomplete trabecular bridging on three X-ray views, (3) injury that had occurred at a minimum of 6 months prior to surgery, and (4) identification of fibrous union at the time of surgery. Outcomes were assessed with range of motion assessment, Disability of the Arm, Shoulder and Hand (DASH) scores, and plain radiographs.

Results

Twelve of the 14 patients healed successfully, while two patients required secondary vascularized bone grafting. Both unhealed patients sustained proximal pole fractures and had a duration of ≥1 year from injury to surgery. Average time to healing was 4.4 ± 2.0 months. Average flexion was 73 ± 22° and average extension was 66 ± 22° postoperatively. Average grip strength was 90 ± 25 lbs on the operative side. Mean postoperative pain score was 1.4 (range, 0 to 7). Mean postoperative DASH score was 10.2 (range, 0 to 52). Increasing age and an interval from injury to surgery of >1 year correlated with worse DASH and pain scores.

Conclusions

Patients with fibrous scaphoid nonunion demonstrated good results with rigid fixation without bone grafting. Increasing age and >1-year interval between injury and surgery resulted in lower self-assessed outcomes.

Level of Evidence

Therapeutic Level IV, retrospective case series     

Transurethral cystolitholapaxy with the AH-1 stone removal system for the treatment of bladder stones of variable size

Background

The treatment of large volume bladder stones by current equipments continues to be a management problem in both developing and developed countries. AH-1 Stone Removal System (SRS) invented by us is primarily used to crush and retrieve bladder stones. This study evaluated the safety and efficiency of transurethral cystolitholapaxy with SRS for the treatment of bladder stones of variable size.

Methods

SRS, which was invented by Aihua Li in 2007, composed by endoscope, continuous-flow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. 112 patients with bladder stones were performed by transurethral cystolitholapaxy with SRS since 2008. We compare the surgical outcome to bladder stones of variable size, and evaluate the surgical efficiency and safety.

Results

Characteristics of patients and stone removal time in variable size were evaluated. To patients with single stone, stone size was 1.35 ± 0.37 cm and the operating time was 5.50 ± 3.92 min in Group A. Stone size was 2.38 ± 0.32 cm and the operating time was 11.90 ± 9.91 min in Group B. Stone size was 3.30 ± 0.29 cm and the operating time was 21.92 ± 9.44 min in Group C. Stone size was 4.69 ± 0.86 cm and the operating time was 49.29 ± 30.47 min in Group D. The difference was statistically significant between the four groups. Among them, 74 (66.07%) patients accompanied with benign prostatic hyperplasia (BPH) were treated by transurethral resection of the prostate (TURP) simultaneously. Compared between the four groups, the difference of the TURP time was not statistically significant, P >0.05. No significant complication was found in the surgical procedure.

Conclusions

Transurethral cystolitholapaxy with SRS appears to be increased rapidity of the procedure with decreased morbidity. It is a safe and efficient surgical management to bladder stones. This endoscopic surgery best fits the ethics principle of no injury; meanwhile, the accompanied BPH could be effectively treated by TURP simultaneously.     

Ligament regeneration using an absorbable stent-shaped poly-l-lactic acid scaffold in a rabbit model

Purpose

Ligaments are frequently damaged in sports activities and trauma, and severe ligament injury can lead to joint instability and osteoarthritis. In this study, we aimed to regenerate the medial collateral ligament (MCL) using an absorbable stent-shaped poly-l-lactic acid (PLLA) scaffold in a rabbit model to examine the biocompatibility and mechanical properties.

Methods

Twenty-three Japanese white rabbits were used in this study. MCL defects were surgically created in the knee joints and then reconstructed using stent-shaped PLLA scaffolds. As controls, flexor digitorum longus (FDL) tendons were implanted into the contralateral knees. Seven rabbits were sacrificed at three time points, conducted four, eight and 16 weeks after the operation. The regenerated tissues were histologically evaluated using fibre alignment scoring, morphology of fibroblast scoring and immunohistochemical analysis of types I and III collagen. The regenerated tissues were also biomechanically evaluated by measuring the ultimate failure load and stiffness.

Results

At four weeks post-operation, spindle-shaped cells were observed on the inside of the scaffolds. At eight weeks, maturation of the regenerated tissues and collagen fibre alignment parallel to the ligaments was observed. At 16 weeks, the fibre alignment had become denser. The fibre alignment and morphology of fibroblast scores significantly increased in a time-dependent manner. Expression of type I collagen was more strongly observed in the scaffold group at eight and 16 weeks post-operation than at four weeks. Type III collagen was also observed at four, eight and 16 weeks post-operation. A thin layer of fibrocartilage was observed at the ligament-bone junction at eight and 16 weeks. The ultimate failure load of the scaffold group was 46.7 ± 20.7 N, 66.5 ± 11.0 N and 74.3 ± 11.5 N at four, eight and 16 weeks post-operation, respectively. There was no statistical difference between the normal MCL and the scaffold group at 16 weeks post-operation.

Conclusions

The stent-shaped PLLA scaffold allowed for MCL regeneration with type I collagen expression and fibrocartilage formation and resulted in sufficient mechanical function.     

Implanted passive engineering mechanism improves hand function after tendon transfer surgery: a cadaver-based study

Purpose

The purpose of this study was to investigate if a new tendon transfer surgical procedure that uses an implanted passive engineering mechanism for attaching multiple tendons to a single donor muscle in place of directly suturing the tendons to the muscle improves hand function in physical interaction tasks such as grasping.

Methods

The tendon transfer surgery for high median ulnar palsy was used as an exemplar, where all four flexor digitorum profundus (FDP) tendons are directly sutured to the extensor carpi radialis longus (ECRL) muscle to restore flexion. The new procedure used a passive hierarchical artificial pulley system to connect the muscle to the tendons. Both the suture-based and pulley-based procedures were conducted on N = 6 cadaver hands. The fingers’ ability to close around four objects when the ECRL tendon was pulled was tested. Post-surgery hand function was evaluated based on the actuation force required to create a grasp and the slip between the fingers and the object after the grasp was created.

Results

When compared with the suture-based procedure, the pulley-based procedure (i) reduced the actuation force required to close all four fingers around the object by 45 % and (ii) improved the fingers’ individual adaptation to the object’s shape during the grasping process and reduced slip by 52 % after object contact (2.99° ± 0.28° versus 6.22° ± 0.66°).

Conclusions

The cadaver study showed that the implanted engineering mechanism for attaching multiple tendons to one muscle significantly improved hand function in grasping tasks when compared with the current procedure.     

Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease

Background

With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient.

Methods

We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock’s disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013.

Results

Twelve patients were included with a mean age of 41.6 years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1 months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20–110°). The average ulnar deviation was 9° (range 5–15°), and the average radial deviation was 13° (range 5–25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05).

Conclusions

Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock’s disease.     

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet

Background

In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia—producing maximal vasoconstriction and visualization—is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection.

Methods

In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes.

Results

There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + −0.03 ml/cm of incision, compared to 0.17 + −0.08 ml/cm, respectively) (P = 0.03).

Conclusions

Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding—making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.