Brogan, David M.

BACKGROUND: Chronic entrapment neuropathy results in a clinical syndrome ranging from mild pain to debilitating atrophy. There remains a lack of objective metrics that quantify nerve dysfunction and guide surgical decision-making. Mechanomyography (MMG) reflects mechanical motor activity after stimulation of neuromuscular tissue and may indicate underlying nerve dysfunction. OBJECTIVE: To evaluate the role of MMG as a surgical adjunct in treating chronic entrapment neuropathies. METHODS: Patients 18 years or older with cubital tunnel syndrome (n = 8) and common peroneal neuropathy (n = 15) were enrolled. Surgical decompression of entrapped nerves was performed with intraoperative MMG of the hypothenar and tibialis anterior muscles. MMG stimulus thresholds (MMG-st) were correlated with compound muscle action potential (CMAP), motor nerve conduction velocity, baseline functional status, and clinical outcomes. RESULTS: After nerve decompression, MMG-st significantly reduced, the mean reduction of 0.5 mA (95% CI: 0.3-0.7, P < .001). On bivariate analysis, MMG-st exhibited significant negative correlation with common peroneal nerve CMAP ( P < .05), but no association with ulnar nerve CMAP and motor nerve conduction velocity. On preoperative electrodiagnosis, 60% of nerves had axonal loss and 40% had conduction block. The MMG-st was higher in the nerves with axonal loss as compared with the nerves with conduction block. MMG-st was negatively correlated with preoperative hand strength (grip/pinch) and foot-dorsiflexion/toe-extension strength ( P < .05). At the final visit, MMG-st significantly correlated with pain, PROMIS-10 physical function, and Oswestry Disability Index ( P < .05). CONCLUSION: MMG-st may serve as a surgical adjunct indicating axonal integrity in chronic entrapment neuropathies which may aid in clinical decision-making and prognostication of functional outcomes.

Background: The authors sought to determine the reliability of the Soong classification, which relates the position of the implant to the watershed line of the distal radius, for predicting flexor tendinopathy in distal radius fractures treated with volar plate fixation. Methods: Medical records were reviewed, including demographics, fracture and operative characteristics, tendon-related complications, and radiographic outcomes. Six hundred fifty-nine distal radius fractures were reviewed with a mean duration of clinical follow-up of 12.9 ± 0.7 months. Results: The incidence of isolated flexor tendinopathy and tendon rupture was 0.9 and 0.3 percent, respectively. The Soong classification failed to independently predict flexor tendon rupture or tendinopathy. Fractures classified as inadequately reduced were significantly associated with Soong grade 0 or grade 2, whereas adequately reduced fractures were significantly associated with Soong grade 1. Conclusion: The Soong classification is not the sole predictor of flexor tendinopathy and may be viewed as a reflection of the overall appropriateness of fracture reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: This study assessed the risk and factors of complications after volar locking plate fixation of distal radius fractures. Methods: A single-institution retrospective review of patients undergoing volar locking plate fixation of distal radius fractures between May of 2000 and May of 2015 was undertaken. Demographic data, major complications, minor complications, and radiographic parameters were evaluated. Results: Six hundred forty-seven distal radius fractures managed with volar plate fixation in 636 patients were reviewed. Mean follow-up was 9.1 months. Mean age was 56.5 years. Mean body mass index was 28.0, and 14.6 percent of patients had a body mass index greater than 35. Fractures were classified as Arbeitsgemeinschaft für Osteosynthesefragen class 23-C (67.2 percent), 23-A (26.6 percent), and 23-B (6.2 percent). The incidence of major and minor complications was 13.8 percent and 17.5 percent, respectively. The most common complication was transient paresthesia (9.7 percent). The incidence of tendon rupture or irritation was 0.5 percent or 2.5 percent, respectively. Hardware removal for painful/symptomatic hardware occurred in 6.2 percent at an average of 427.8 days after surgery. Major complications and minor complications were increased 2.2- and 1.9-fold, respectively, in patients with a body mass index greater than 35. Major complications were also increased 3.19 times in patients with residual intraarticular step-off. Hardware removal was 3.3 times more likely in patients with Soong grade 2 plate prominence and 2.9 times more likely in patients with a history of diabetes mellitus. Conclusions: Volar plate osteosynthesis of distal radius fractures is associated with an overall low complication rate. Patient factors, including diabetes mellitus and obesity, and intraoperative factors, including intraarticular fracture alignment and plate prominence, were associated with a higher rate of complications or revision surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

» Ulnar-sided wrist pain encompasses a variety of pathologies including arthritis, tendinopathy, ligament injuries, and instability. » A careful physical examination can narrow the differential diagnosis, and adjunctive imaging may prove useful to confirm clinical suspicion. » The mainstay of nonoperative treatment is immobilization, hand therapy, and corticosteroid injections; surgical intervention is dictated by the specific pathology identified, recognizing that multiple pain generators may be present. » In the absence of distal radioulnar joint instability, when indicated, peripheral capsular repair of the triangular fibrocartilage complex may be an effective procedure for relieving pain. If instability is noted, foveal repair is advocated to restore stability. » Treatment of distal radioulnar joint arthritis continues to evolve as new implants and techniques emerge. » Ulnar shortening osteotomy, when indicated, can be a reliable surgical option to reduce pain and improve function.

Purpose In the surgical treatment of thumb carpometacarpal (CMC) joint arthritis, the effect of mild preoperative metacarpophalangeal (MCP) hyperextension on postoperative functional outcomes is unknown. We sought to examine outcomes after surgical treatment of CMC arthritis in patients with and without mild preexisting MCP deformity. Methods A retrospective review was conducted to analyze the functional outcomes of patients treated for CMC arthritis at a single institution from March 1998 to May 2009. All patients were treated with one of two standard CMC arthroplasty procedures—either ligament reconstruction tendon interposition (LRTI) or a Weilby procedure—and none had additional procedures to address MCP hyperextension. Pre- and postoperative assessments included pinch and grip strength, degree of MCP hyperextension, and thumb radial and palmar abduction. A t-test was used to assume unequal variances. Results A total of 203 patients were followed for an average of 27.3 months. Patients were divided into two groups: (1) patients without preoperative MCP hyperextension (167 patients) and (2) patients with mild but untreated preoperative MCP hyperextension (≤ 30 degrees; 36 patients). All patients underwent either a Weilby procedure (118 patients) or an LRTI; 85 patients). The main difference between techniques was the use of the abductor pollicis longus tendon as a post to secure the flexor carpi radialis (Weilby) or the use of a bone tunnel in the first metacarpal (LRTI). Analysis of the preoperative data showed no difference in the baseline parameters among both the groups, with the exception of MCP hyperextension. Postoperatively, neither the type of CMC procedure nor the presence of MCP hyperextension demonstrated any significant differences in key pinch, tip pinch, grip strength, and radial or palmar abduction of the thumb between the groups. Conclusion There were no statistically significant differences in improvement of functional outcomes after surgery when comparing patients without preoperative MCP hyperextension to patients with untreated MCP hyperextension of less than 30 degrees. Level of Evidence Level III, retrospective comparative study.

Background Proximal pole scaphoid fractures are less common than waist fractures, and successful management can be difficult. We hypothesize that time to union is increased by delays in surgical fixation, greater initial displacement, and higher energy mechanisms of injury. Methods A retrospective review was conducted of all patients undergoing open reduction internal fixation (ORIF) of acute proximal pole scaphoid fractures at our institution over a 19-year period. A review of clinical as well as radiographic data was undertaken. The mechanism of injury, patient demographics, timing of surgery, initial displacement, fixation method, smoking status, and lunate morphology were recorded. Functional outcome measures were recorded when available. Univariate analysis using Kaplan-Meier survival curves was performed. Results A total of 10 out of 23 patients (43 %) showed evidence of union at 14 weeks post-injury. Rates of early union were higher in non-displaced fractures (70 %) when compared to displaced fractures (23 %). Similarly, fractures sustained via low energy mechanisms had a higher rate of early union compared to high energy mechanisms (69 versus 10 %). A delay in ORIF did not appear to influence rate of union. Conclusions Initial displacement and mechanism of injury have the most significant effects on early rates of union. Delay in ORIF of up to 28 days did not affect the rate of initial union, but the authors recommend early fixation of these fractures to prevent further displacement. Patients with widely displaced fractures or those with high energy mechanisms should be counseled regarding prolonged healing time. Level of Evidence: IV—therapeutic