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The Journal of Hand Surgery (Eur) 40(2)
always repaired as much as possible to cover the plate. Post-operatively, patients were followed up in 13 days to allow gentle mobilization. The interval between subsequent follow-ups varied at the surgeon’s discretion; however all 86 patients were seen up to a minimum of 8 months post-operatively, when tendon function was clinically assessed. We observed an overall complication rate of less than 13% (11 of 86 patients), mainly in the form of carpal tunnel syndrome, neurapraxia, infection and joint stiffness. There were no cases of tendon rupture. Our low tendon rupture rate mirrors that of Ward et al. (2011). Their overall complication rate was 22%, mainly in the form of nerve dysfunction, with 6% of patients losing reduction. Although two patients experienced transient flexor pollicis longus dysfunction, there were no tendon ruptures. They suggested that possible explanations for the low incidence of tendon complications were increasing familiarity with the hardware, careful avoidance of screw penetration of the dorsal cortex and careful placement of the plate proximal to the watershed line. In the technique used in the present series, the distal screw length is routinely downsized by 2 mm from the depth at which the drill bit is noted to just penetrate the dorsal cortex when drilling, the intention being to prevent the screw tips from encroaching on the extensor compartment. A recent study advised surgeons not to trust the image intensifier when judging distal subchondral screw length (Park and Goldie, 2012). Using computed tomography and magnetic resonance image scans of the wrist, the study identified a consistent valley with a depth averaging 1.8 mm in the intermediate column between Lister’s tubercle and the sigmoid notch of the distal radius, making it difficult to rely on fluoroscopy to judge screw length. In view of this, the intra-operative technique described in this letter was advised; we have found it to have beneficial outcomes on the rate of tendon rupture. Conflict of interests None declared.
References Bell JSP, Wollstein R, Citron ND. Rupture of flexor pollicis longus tendon. A complication of volar plating of the distal radius. J Bone Joint Surg Br. 1998, 80: 225–6. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radius fractures with a volar locking screw plate system. Int Orthop. 2003, 27: 1–6. Park DH, Goldie BS. Volar plating for distal radius fractures- do not trust image intensifier when judging distal subchondral screw length. Tech Hand Up Extrem Surg. 2012, 16: 169–72.
Ward CM, Kuhl TL, Adams BD. Early complications of volar plating of distal radius fractures and their relationship to surgeon experience. Hand (NY). 2011, 6: 185–9.
K. Divani, P. Subramanian and B. Goldie Whipps Cross University Hospital, Leytonstone, London UK. Corresponding author: [email protected]
© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413511575 available online at http://jhs.sagepub.com
Objective results of median nerve decompression and tenosynovectomy for carpal tunnel syndrome in patients with mucopolysaccharidoses Types I and II Dear Sir, Carpal tunnel syndrome (CTS) has been well described in patients with mucopolysaccharidoses (MPS) and prospective studies (Kwon et al., 2011) have found bilateral CTS in about 96% of their cohort of MPS II patients. Children with MPS Type II often suffer from a magnitude of clinical symptoms and with the encouraging survival rate results of enzyme replacement therapy, hand function and functionality in everyday life activities becomes an increasingly important focus (Muenzer et al., 2006). Patients with MPS I or II can present with early onset of joint contractures especially affecting the distal interphalangeal joints (DIPJs). The increasing stiffness renders the patients incapable of grasping or feeding themselves. Making the diagnosis represents a particular challenge in MPS patients. In our group of MPS Type II patients, none had the intellectual maturity to report any symptoms or pain. Due to the shape of the ‘MPS I and II’ hand classic signs like thenar wasting are difficult to observe. Parents often commented on biting of fingers and loss of dexterity, and therefore clinicians need to have a high index of suspicion when reviewing patients with progressive finger deformities. Tenosynovectomy, along with carpal tunnel decompression of the flexor tendons, has been described as early as 1988 (Pronicka et al., 1988) and also advocated by Haddad (Haddad et al., 1997) who described the post-operative outcomes subjectively. The approach addresses the decompression of the median nerve and tenosynovectomy of the flexor tendons,
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
217
Short report letters
Table 1. Patient demographics, type of surgery and improvement in nerve conduction velocities pre- and post-operatively (m/s).
MPS Type Gender Age at time of surgery Type of surgery NCV (motor) m/s NCV (sensory)m/s
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
I F 19 (R) 15 (L) Extended vs. standard —
II M 10 (R) 8 (L) Extended vs. standard 2.3
II M 10 (R) 9 (L) Extended vs. standard —
II M 6 (R) 7 (L) Bilateral extended 6.8
II M 3 (R) 4 (L) Early bilateral standard 6.25
II M 10 (L) Late extended —
I M 4 (R) 4 (L) Early bilateral extended 3.5
—
13.5
—
18.5
14.3
—
28.8
Extended: carpal tunnel decompression along with tenosynovectomy and partial epineurectomy; Standard: simple carpal tunnel decompression; MPS: mucopolysaccharidoses; NCV: nerve conduction velocities; —: unable to perform as declined by patients.
Table 2. Mean improvement in joint range of movement at each joint level at 2 years follow-up (in degrees to nearest 5°).
MCPJ PIPJ DIPJ IPJ
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 7
10 5 5 5
15 10 35 20
25 15 30 20
15 15 20 10
–20 20 25 20
–20 20 30 20
Negative value indicates deterioration. MCPJ: metacarpophalangeal joint; PIPJ: proximal interphalangeal joint; DIPJ: distal interphalangeal joint; IPJ: interphalangeal joint.
thus improving tendon gliding. We also include a partial epineurectomy in our technique. We present a case series of seven MPS I and II patients, all on enzyme replacement therapy, with clinically and electrophysiologically diagnosed CTS during a 2-year period (Table 1). Six patients underwent an extended release including partial epineurectomy, one patient underwent an early standard release. We have recorded pre-operative and 6 month and 2 years postoperative passive range of movement joint measurements at the metacarpophalangeal joint, proximal interphalangeal joint and DIPJ along with post-operative nerve conduction studies. Patients 1–3 had undergone previous standard releases and gone on to have contralateral extended releases. We report no complications following the extended release or standard carpal tunnel surgeries performed. During surgery we found that the flexor retinaculum was not noted to be excessively thickened. The median nerve consistently showed a typical hourglass deformity. The flexor digitorum profundus tendons, were encased in extensively fibrosed tenosynovium, limiting tendon excursion and corresponding with DIPJ contractures. We also noted that older patients tended to have more excessive fibrosis surrounding the flexor digitorum profundus tendons compared with younger patients.
In patients that had previous standard releases, the greatest improvement was seen by patient 2 who, at 2 years follow-up, had a mean improvement of 20° overall in his range of movement measurements, with the greatest improvement seen at the DIPJs of 35° (Table 2). In the extended release group the greatest improvement was seen in Patient 7, who underwent an early bilateral extended release and showed an improvement of 20° that was maintained 2 years postoperatively, and an improvement in nerve conduction velocities. Patient 6 was a late diagnosis of MPS II at 10 years of age. On attempted tenosynovectomy and nerve decompression, he was found to have a severe hourglass deformity of the median nerve, with a concretelike encasement around the flexor digitorum profundus tendons making a complete tenosynovectomy difficult. Due to deteriorating health we were unable to gain long-term follow-up results. We feel this surgical approach has not reached a wider audience within clinicians dealing with inherited metabolic diseases. Surgical hand intervention is still being critically appraised by the clinicians caring for these children, as it is not clear as to whether any surgical intervention would have a lasting effect. Equally, there is no
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
218
The Journal of Hand Surgery (Eur) 40(2)
data on optimum timing for hand surgical interventions in this group of patients. Our observations both intra-operatively and post-operatively have demonstrated that outcomes are improved if diagnosis and subsequent surgery are undertaken early. The results 2 years post-operatively showed an overall sustained improvement from pre-operative measurements in flexibility of the DIPJs and proximal interphalangeal joints. Notably the metacarpophalangeal joint stiffness varies over time, as the extended approach itself does not address the mechanisms relating to flexibility at the metacarpophalangeal joint, but the passive stretching exercise regime may improve this. Due to the follow-up period (6 months–2 years) we are not yet able to comment on whether improved range of motion of proximal interphalangeal and DIPJs remains stable over a much longer time, but the increased range of movement indicates benefits and supports early surgical intervention. Conflict of interests None declared. Informed consent was obtained from each patient, as per trust guidelines, prior to all interventions.
Intraoperative migration of a foreign body within the tendon sheath of the flexor pollicis longus Dear Sir, A 50-year-old fisherman was referred to the plastics and reconstructive surgical team by his local doctor for the removal of a retained elephant fish spine from his left thumb. Preoperative X-rays revealed the foreign body was lying within the soft tissue overlying the proximal phalanx. A Brunner incision was made over the presumed location. Despite meticulous dissection and concurrent intraoperative imaging, localizing and retrieving the fish spine proved to be challenging. The fish spine was noted to be oriented with its sharp end directed proximally and was tracking proximally between the sheath and tendon of the flexor pollicis longus. This necessitated extension of the original incision and further dissection. The final retrieval point of the fish spine was just distal to the carpal tunnel, having migrated 10 cm (Figure 1). The patient had an uneventful follow-up with no wound complications. We believe that intraoperative migration occurred due to two factors: the characteristic of the foreign body and anatomy of the injury site. Firstly, the
References Haddad FS, Jones DHA, Vellodi A et al. Carpal tunnel syndrome in the mucopolysaccahridoses and mucolipidoses. J Bone Joint Surg Br. 1997, 79: 576–82. Kwon JY, Ko K, Sohn YB et al. High prevalence of carpal tunnel syndrome in children with mucopolysaccharidosis type II (Hunter syndrome). Am J Med Genet A. 2011, 155: 1329–35. Muenzer J, Wraith JE, Beck M et al. A phase II/III clinical study of enzyme replacement therapy with idursulfase in mucopolysaccharidosis II (Hunter syndrome). Genet Med. 2006, 8: 465–73. Pronicka E, Tylki-Szymanska A, Kwast O et al. Carpal tunnel syndrome in children with mucopolysaccharidoses: needs for surgical tendons and median nerve release. J Intellect Disabil Res. 1988, 32: 79–82.
R. Aslam1, C. J. Hendriksz2, A. Jester1 1Department
of Hand Surgery, Birmingham Children’s Hospital, Birmingham, UK 2Department of Inherited Metabolic Disease, Birmingham Children’s Hospital, Birmingham, UK Corresponding author: [email protected]
© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414523356 available online at http://jhs.sagepub.com
Figure 1. Final retrieval point of fish spine (left arrow), original incision site (right arrow), and the retrieved elephant fish spine.
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
The Journal of Hand Surgery (Eur) 40(2)
always repaired as much as possible to cover the plate. Post-operatively, patients were followed up in 13 days to allow gentle mobilization. The interval between subsequent follow-ups varied at the surgeon’s discretion; however all 86 patients were seen up to a minimum of 8 months post-operatively, when tendon function was clinically assessed. We observed an overall complication rate of less than 13% (11 of 86 patients), mainly in the form of carpal tunnel syndrome, neurapraxia, infection and joint stiffness. There were no cases of tendon rupture. Our low tendon rupture rate mirrors that of Ward et al. (2011). Their overall complication rate was 22%, mainly in the form of nerve dysfunction, with 6% of patients losing reduction. Although two patients experienced transient flexor pollicis longus dysfunction, there were no tendon ruptures. They suggested that possible explanations for the low incidence of tendon complications were increasing familiarity with the hardware, careful avoidance of screw penetration of the dorsal cortex and careful placement of the plate proximal to the watershed line. In the technique used in the present series, the distal screw length is routinely downsized by 2 mm from the depth at which the drill bit is noted to just penetrate the dorsal cortex when drilling, the intention being to prevent the screw tips from encroaching on the extensor compartment. A recent study advised surgeons not to trust the image intensifier when judging distal subchondral screw length (Park and Goldie, 2012). Using computed tomography and magnetic resonance image scans of the wrist, the study identified a consistent valley with a depth averaging 1.8 mm in the intermediate column between Lister’s tubercle and the sigmoid notch of the distal radius, making it difficult to rely on fluoroscopy to judge screw length. In view of this, the intra-operative technique described in this letter was advised; we have found it to have beneficial outcomes on the rate of tendon rupture. Conflict of interests None declared.
References Bell JSP, Wollstein R, Citron ND. Rupture of flexor pollicis longus tendon. A complication of volar plating of the distal radius. J Bone Joint Surg Br. 1998, 80: 225–6. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radius fractures with a volar locking screw plate system. Int Orthop. 2003, 27: 1–6. Park DH, Goldie BS. Volar plating for distal radius fractures- do not trust image intensifier when judging distal subchondral screw length. Tech Hand Up Extrem Surg. 2012, 16: 169–72.
Ward CM, Kuhl TL, Adams BD. Early complications of volar plating of distal radius fractures and their relationship to surgeon experience. Hand (NY). 2011, 6: 185–9.
K. Divani, P. Subramanian and B. Goldie Whipps Cross University Hospital, Leytonstone, London UK. Corresponding author: [email protected]
© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413511575 available online at http://jhs.sagepub.com
Objective results of median nerve decompression and tenosynovectomy for carpal tunnel syndrome in patients with mucopolysaccharidoses Types I and II Dear Sir, Carpal tunnel syndrome (CTS) has been well described in patients with mucopolysaccharidoses (MPS) and prospective studies (Kwon et al., 2011) have found bilateral CTS in about 96% of their cohort of MPS II patients. Children with MPS Type II often suffer from a magnitude of clinical symptoms and with the encouraging survival rate results of enzyme replacement therapy, hand function and functionality in everyday life activities becomes an increasingly important focus (Muenzer et al., 2006). Patients with MPS I or II can present with early onset of joint contractures especially affecting the distal interphalangeal joints (DIPJs). The increasing stiffness renders the patients incapable of grasping or feeding themselves. Making the diagnosis represents a particular challenge in MPS patients. In our group of MPS Type II patients, none had the intellectual maturity to report any symptoms or pain. Due to the shape of the ‘MPS I and II’ hand classic signs like thenar wasting are difficult to observe. Parents often commented on biting of fingers and loss of dexterity, and therefore clinicians need to have a high index of suspicion when reviewing patients with progressive finger deformities. Tenosynovectomy, along with carpal tunnel decompression of the flexor tendons, has been described as early as 1988 (Pronicka et al., 1988) and also advocated by Haddad (Haddad et al., 1997) who described the post-operative outcomes subjectively. The approach addresses the decompression of the median nerve and tenosynovectomy of the flexor tendons,
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
217
Short report letters
Table 1. Patient demographics, type of surgery and improvement in nerve conduction velocities pre- and post-operatively (m/s).
MPS Type Gender Age at time of surgery Type of surgery NCV (motor) m/s NCV (sensory)m/s
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
I F 19 (R) 15 (L) Extended vs. standard —
II M 10 (R) 8 (L) Extended vs. standard 2.3
II M 10 (R) 9 (L) Extended vs. standard —
II M 6 (R) 7 (L) Bilateral extended 6.8
II M 3 (R) 4 (L) Early bilateral standard 6.25
II M 10 (L) Late extended —
I M 4 (R) 4 (L) Early bilateral extended 3.5
—
13.5
—
18.5
14.3
—
28.8
Extended: carpal tunnel decompression along with tenosynovectomy and partial epineurectomy; Standard: simple carpal tunnel decompression; MPS: mucopolysaccharidoses; NCV: nerve conduction velocities; —: unable to perform as declined by patients.
Table 2. Mean improvement in joint range of movement at each joint level at 2 years follow-up (in degrees to nearest 5°).
MCPJ PIPJ DIPJ IPJ
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 7
10 5 5 5
15 10 35 20
25 15 30 20
15 15 20 10
–20 20 25 20
–20 20 30 20
Negative value indicates deterioration. MCPJ: metacarpophalangeal joint; PIPJ: proximal interphalangeal joint; DIPJ: distal interphalangeal joint; IPJ: interphalangeal joint.
thus improving tendon gliding. We also include a partial epineurectomy in our technique. We present a case series of seven MPS I and II patients, all on enzyme replacement therapy, with clinically and electrophysiologically diagnosed CTS during a 2-year period (Table 1). Six patients underwent an extended release including partial epineurectomy, one patient underwent an early standard release. We have recorded pre-operative and 6 month and 2 years postoperative passive range of movement joint measurements at the metacarpophalangeal joint, proximal interphalangeal joint and DIPJ along with post-operative nerve conduction studies. Patients 1–3 had undergone previous standard releases and gone on to have contralateral extended releases. We report no complications following the extended release or standard carpal tunnel surgeries performed. During surgery we found that the flexor retinaculum was not noted to be excessively thickened. The median nerve consistently showed a typical hourglass deformity. The flexor digitorum profundus tendons, were encased in extensively fibrosed tenosynovium, limiting tendon excursion and corresponding with DIPJ contractures. We also noted that older patients tended to have more excessive fibrosis surrounding the flexor digitorum profundus tendons compared with younger patients.
In patients that had previous standard releases, the greatest improvement was seen by patient 2 who, at 2 years follow-up, had a mean improvement of 20° overall in his range of movement measurements, with the greatest improvement seen at the DIPJs of 35° (Table 2). In the extended release group the greatest improvement was seen in Patient 7, who underwent an early bilateral extended release and showed an improvement of 20° that was maintained 2 years postoperatively, and an improvement in nerve conduction velocities. Patient 6 was a late diagnosis of MPS II at 10 years of age. On attempted tenosynovectomy and nerve decompression, he was found to have a severe hourglass deformity of the median nerve, with a concretelike encasement around the flexor digitorum profundus tendons making a complete tenosynovectomy difficult. Due to deteriorating health we were unable to gain long-term follow-up results. We feel this surgical approach has not reached a wider audience within clinicians dealing with inherited metabolic diseases. Surgical hand intervention is still being critically appraised by the clinicians caring for these children, as it is not clear as to whether any surgical intervention would have a lasting effect. Equally, there is no
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
218
The Journal of Hand Surgery (Eur) 40(2)
data on optimum timing for hand surgical interventions in this group of patients. Our observations both intra-operatively and post-operatively have demonstrated that outcomes are improved if diagnosis and subsequent surgery are undertaken early. The results 2 years post-operatively showed an overall sustained improvement from pre-operative measurements in flexibility of the DIPJs and proximal interphalangeal joints. Notably the metacarpophalangeal joint stiffness varies over time, as the extended approach itself does not address the mechanisms relating to flexibility at the metacarpophalangeal joint, but the passive stretching exercise regime may improve this. Due to the follow-up period (6 months–2 years) we are not yet able to comment on whether improved range of motion of proximal interphalangeal and DIPJs remains stable over a much longer time, but the increased range of movement indicates benefits and supports early surgical intervention. Conflict of interests None declared. Informed consent was obtained from each patient, as per trust guidelines, prior to all interventions.
Intraoperative migration of a foreign body within the tendon sheath of the flexor pollicis longus Dear Sir, A 50-year-old fisherman was referred to the plastics and reconstructive surgical team by his local doctor for the removal of a retained elephant fish spine from his left thumb. Preoperative X-rays revealed the foreign body was lying within the soft tissue overlying the proximal phalanx. A Brunner incision was made over the presumed location. Despite meticulous dissection and concurrent intraoperative imaging, localizing and retrieving the fish spine proved to be challenging. The fish spine was noted to be oriented with its sharp end directed proximally and was tracking proximally between the sheath and tendon of the flexor pollicis longus. This necessitated extension of the original incision and further dissection. The final retrieval point of the fish spine was just distal to the carpal tunnel, having migrated 10 cm (Figure 1). The patient had an uneventful follow-up with no wound complications. We believe that intraoperative migration occurred due to two factors: the characteristic of the foreign body and anatomy of the injury site. Firstly, the
References Haddad FS, Jones DHA, Vellodi A et al. Carpal tunnel syndrome in the mucopolysaccahridoses and mucolipidoses. J Bone Joint Surg Br. 1997, 79: 576–82. Kwon JY, Ko K, Sohn YB et al. High prevalence of carpal tunnel syndrome in children with mucopolysaccharidosis type II (Hunter syndrome). Am J Med Genet A. 2011, 155: 1329–35. Muenzer J, Wraith JE, Beck M et al. A phase II/III clinical study of enzyme replacement therapy with idursulfase in mucopolysaccharidosis II (Hunter syndrome). Genet Med. 2006, 8: 465–73. Pronicka E, Tylki-Szymanska A, Kwast O et al. Carpal tunnel syndrome in children with mucopolysaccharidoses: needs for surgical tendons and median nerve release. J Intellect Disabil Res. 1988, 32: 79–82.
R. Aslam1, C. J. Hendriksz2, A. Jester1 1Department
of Hand Surgery, Birmingham Children’s Hospital, Birmingham, UK 2Department of Inherited Metabolic Disease, Birmingham Children’s Hospital, Birmingham, UK Corresponding author: [email protected]
© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414523356 available online at http://jhs.sagepub.com
Figure 1. Final retrieval point of fish spine (left arrow), original incision site (right arrow), and the retrieved elephant fish spine.
Downloaded from jhs.sagepub.com at University of Ulster Library on March 27, 2015
