Narrow Results

Between 1994 and 2000, the senior author performed 1245 endoscopic carpal tunnel decompressions. There were 291 bilateral cases. A telephone review was conducted of those patients who had not had an early excellent result, or conversion to an open procedure. Ninety-four per cent follow-up of patients in this group was achieved; 88% had an early excellent result with no subsequent problems. In 33 hands (3%) the carpal tunnel was opened, because of abnormal anatomy or poor view. A further 5% had a late excellent result. Seventeen hands (1%) have required subsequent open decompression, with adherence of the median nerve often found at revision surgery. Another 24 hands (2%) had a poor result. Fourteen hands (1%) had minor symptoms and 26 (2%) had another diagnosis of upper limb pathology. In contrast to other series, there was only one case of damage to an important structure — the radial digital nerve of the thumb.

The aim was to study the relationship between impairment (function) and disability (participation) in wrist surgery, according to the WHO definitions.

The outcome of 205 wrist operations were studied. The impairment was expressed as range of motion (ROM) and gripping force, the disability as the DASH score.

There was a significant correlation between DASH and gripping force (R = 0.47). The correlation between ROM and DASH was weaker (R = 0.24).

In manual workers, shorter temporary disability periods were significantly associated with lower DASH score.

In (reconstructive) wrist surgery, impairment, disability and working status are significantly correlated. Gripping force measurement is a reliable tool for evaluation and gives a good impression of the disability. Preservation of some mobility is important, however the amount of ROM is not essential for the disability.

Six cases of culture-proven Mycobacterium chelonae tenosynovitis were identified through retrospective chart review. Fifteen cases were identified using computerised Medline search. Clinical features, treatment and outcome were described. Infection control was achieved in our patients with an average of 3.2 surgeries each and antibiotic treatment for six months to one year. Eleven published cases were managed by combined surgery and systemic antibiotics, with an average of 1.73 surgeries per patient and seven weeks to 24 months of antibiotics. All our patients were disease free on final follow-up. Thirteen cases were resolved. Functional outcomes were reported for eight cases. Comparison of functional outcome was not possible because different parameters were used in different reports. Aggressive debridement, susceptibility-guided antibiotics, and supervised rehabilitation resulted in infection control and acceptable hand function for our patients. Standardised data collection on subsequent cases would facilitate outcome monitoring and formulation of a treatment guideline for this disease.

First carpometacarpal joint osteoarthritis (1^st CMCJ OA) is a common condition with variable results reported from local corticosteroid injection. This study aims to explore the medium-term outcome with respect to pain relief, patient satisfaction and the need for subsequent surgical intervention. A prospective review was performed of patients undergoing fluoroscopically guided corticosteroid injection by one surgeon, with postal questionnaires for medium-term follow-up. Forty-one patients were included. Thirty-one were female and ten male, with a mean age of 60 years. In the short term 76% of patients reported pain relief with an average duration of four weeks and 69% of the patients reported benefit from injection. After a median follow-up of 36 months 76% of patients reported continuing pain but 59% reported satisfaction with the outcome. Twenty-eight per cent of the patients had undergone surgery. Local corticosteroid injection of the CMCJ provides only short-term pain relief, but few patients go on to surgical intervention.

Isolated radial styloid fractures occur relatively infrequently, with non-union of such fractures, especially when undisplaced, being highly unusual. Smoking of tobacco, a common habit which is decreasing in prevalence in the developed world, has been proven to exert many adverse effects on tissue healing including bone union. We present a case of non-union of an undisplaced radial styloid fracture in the dominant hand of a young and healthy heavy smoker, emphasising the negative impact of tobacco smoke and its association with bone repair. We suggest that heavy tobacco users should also be followed up more vigilantly with this complication in mind, with smoking cessation modalities being offered on presentation.

The purpose of this study was to compare the outcomes of volar plating using two different implants for distal radius fractures. Fifty-two patients with AO type C fractures were placed in either of two groups: the AO LDRS group (26 patients) or the Acu-Loc group (26 patients). Radiological parameters including radial length, radial inclination, volar tilt, and intra-articular step-off were significantly improved after surgery. The mean Mayo Wrist Performance Score was 84.6 in the AO LDRS group and 81.1 in the Acu-Loc group. The mean Subjective Wrist Value was 86.7% in the AO LDRS group and 86.3% in the Acu-Loc group. There were no significant differences between the two groups with respect to both radiological and clinical outcomes at the final follow-up evaluation. Volar fixed-angle plating for unstable distal radius fractures had satisfactory radiological and clinical outcomes. The difference of implant design did not influence overall final outcomes.

The purpose of this study was to compare the initial and final outcome range of motion in the MCP-J and PIP-J of single digit Dupuytren's Contracture treated with either open surgical excision or manipulation after collagenase clostridium histolyticum (CCH; Xiapex) injection. Material: Ten patients in either group. The range of motion measurements were statistically compared using the student t-test with a p-value of 0.05. There was no statistical difference in the pre-treatment status of the total active range of movement (TAM) between the two groups. Results: Open surgical release achieved a statistically better initial outcome in combined total passive range of movement than the xiapex group (p = 0.0047), but at the final outcome the better TAM measurement at the MCP-J after surgery was not statistically significant. However, the total active range of movement was statistically better at the PIP-J level in the xiapex group (p = 0.01) and the MCP-J and PIP-J combined total active range of movement was statistically better in the xiapex group (p = 0.0258). Conclusion: Surgery achieved better initial outcome at both MCP-J and PIP-J levels, and at discharge, only extension in the MCP-J level was statistically better after open excision. However the final outcome was statistically better at the PIP-J level in extension (p = 0.006) and total active movement (TAM) (p = 0.008) after treatment with collagenase clostridium histolyticum. Further studies are required to assess the long-term differences between the two groups and to investigate the outcomes for patients with multi-digit involvement.

Background: The aim of this study was to compare clinical outcomes, and identify predictors thereof, after fasciectomy for Dupuytren’s disease in a series of diabetic patients compared with non-diabetic patients.

Methods: Thirty-eight patients were examined following partial palmar and/or digital fasciectomy for Dupuytren’s disease (11 diabetics, 27 non-diabetics). Each patient was assessed for degree of pre- and post-operative flexion contractures at the MCP and PIP joints, post-operative Patient Evaluation Measure (PEM) total score, post-operative grip strength, limited joint mobility (LJM), recurrence, extension, and a composite outcomes score based upon grip strength and the degree of joint contractures. All measurements in the diabetic cohort were compared to those in the non-diabetic group, and a logistic regression analysis was performed to identify the predictive value of several variables on outcomes.

Results: Complication rates between the two groups were statistically similar (p = 0.67). There were no significant differences in pre-operative MCP (p = 0.69), post-operative MCP (p = 0.39), pre-operative PIP (p = 0.40), or post-operative PIP (p = 0.13) joint flexion contractures between the two groups. Additionally, there was no significant difference in extension (p = 0.35) or recurrence (p~1) rates, post-operative grip strengths (p = 0.64), or PEM total scores (p = 0.32). However, the rate of LJM was significantly higher in the diabetic population (p = 0.02). Both female gender (p = 0.01) and a non-smoking status (p = 0.04) were found to be predictive of better outcomes following fasciectomy. Diabetes was not found to be an independent predictor of outcome (p = 0.73).

Conclusions: Clinical results after fasciectomy for Dupuytren’s disease in diabetic patients are not different from results obtained in non-diabetic patients. Diabetes is not independently predictive of surgical outcomes. Female gender and non-smoking status are independent predictors of a better outcome following fasciectomy.

Herniated nucleus palposus is a common and important cause of low back pain. Despite over 90% of the patients responding to conservative treatment, some patients still need operation. This study aimed to analyze the clinical predictors for the outcome of conservative treatment in herniated nucleus palposus. Two hundred and fifty-one patients who were diagnosed as lumbar herniated nucleus palposus and admitted to Prince of Songkla University during the period of 1995–2000 were included in the study. Patients who had absolute indications for surgery or had previous back surgery were excluded. Data were collected on demographic characteristics (age, sex, occupation, level of study, marital status), patient symptoms (including duration, characteristic and severity of pain) and result of physical examination (including result of straight leg raising test (SLRT), cross SLRT, motor power, sensory deficit and reflex). The mean age of the patients was 38 years and the mean duration of pain was 4.1 months. Eighty percent of the patients had positive SLRT and abnormal neurological function was found in 73%. One hundred and eighty-six patients underwent surgery owing to failure of conservative treatment. From multivariate logistic analysis, five independent factors affecting failure of conservative treatment of herniated nucleus palposus were pain intensity, duration of symptoms, positive cross SLRT, grade of muscle power and number of dermatome deficit. When constructing the parameters into a scoring system, we found that if the patient had a score less than 45, 80% of them respond to conservative treatment, in contrast to those who scored more than 65, the probability of conservative failure was 80%. This study implies that clinical predictors can be used for determining probability of conservative failure in herniated nucleus palposus.

Background: Quality of reduction in distal radius fractures (DRF) is assessed using radiographic parameters, however few studies examine the association between radiographic measurements and functional outcomes. Our purpose was to evaluate the relationship between radiographic measurements and clinical outcome measures following surgery for DRF using detailed testing to demonstrate further associations between post-surgical radiographic measurements and function.

Methods: Measurements were performed on postoperative radiographs of 38 patients following ORIF of DRF. Measurements included: radial inclination, radial height, ulnar variance, volar tilt, radiocarpal interval (d2/w2), and the intra-articular step-off. Clinical outcome measures included motion, grip strength, functional dexterity testing, Moberg pick-up test, specific activities of daily living, DASH score, pain scale, manual-assessment questionnaire.

Results: Different radiographic parameters correlated with different specific tasks. The parameter correlated with most functional tasks was ulnar-variance. Radial inclination, radial-styloid scaphoid distance, and fracture classification correlated with some functions. Intraarticular step-off, and radial height were not associated with functional testing.

Conclusions: Surgical radiographic results may affect post-operative function. Detailed task specific testing may enable a better evaluation of surgical outcomes. Further study and refinement of functional assessment may change our surgical goals in DRF.

Background: Outcome reporting following flexor tendon repair has historically concentrated on range of movement. Recently, there has been an increase in the use of patient-reported outcome measures (PROMs). At present, there is no agreed set of outcomes to report following flexor tendon repair. The aim of this study is to review outcome reporting practices after flexor tendon repair in zones 1 and 2.

Methods: A search of Ovid MEDLINE, Ovid EMBASE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between 1 January 1980 and 31 December 2019 was performed to identify the studies that reported outcomes following the repair of flexor tendons in zones 1 and 2. Study characteristics and data with regard to the reporting of eight outcome domains was extracted: functional outcome (quantitative), functional outcome (subjective), activities of daily living (ADL), satisfaction/quality of life, post-treatment recovery, resources, aesthetics and safety.

Results: A total of 94 out of 4,118 articles identified were included in the review. All studies reported range of motion using 17 different methods of measurement. Eleven studies defined measurement methods incorrectly or unclearly. Only 16 studies reported PROMs, with only one reporting data on assessment of quality of life. Eighteen studies reported time away from employment. Minimal data on resource utilisation and aesthetics were included.

Conclusion: This review highlights wide heterogeneity and paucity of data reporting clinical outcomes of flexor tendon surgery. The development of a core outcome set that would ensure essential outcomes are correctly defined, measured and reported is required.

Level of Evidence: Level IV (Prognostic)

Clinical registries are increasingly common and have value in conditions such as congenital upper limb differences where collection of adequate data for scientific study can be challenging due to small numbers and clinical, surgical and psychosocial heterogeneity. This article discusses the motivation, purpose and development of the Australian Hand Differences Register before examining some of the challenges faced during its implementation and considering limitations of registry-derived data.

Level of Evidence: Level V (Diagnostic)