2005 JOINT ASSH/ ASHT MEETING ABSTRACTS

This booklet contains the abstracts for the Scientific/General Session papers as submitted by the authors. All abstracts are in presentation order by day and time.

These abstracts are also available on the ASSH website at www.assh.org

ii The Joint Annual ASSH/ASHT Meeting Financial Disclosure and FDA Status Symbol Key ●Something of Value—The authors of those presentations preceded by a ● have indicated that they have received something of value in the form of: research or institutional support, stock or stock options, equipment or services, paid travel, royalties or as a consultant or employee of a commercial company or institution related directly or indirectly to the subject of the presentation.

◆Nothing of Value—The authors of those presentations preceded by a ◆ have indicated that they have not received anything of value in the form of: research or institutional support, stock or stock options, equipment or services, paid travel, royalties or as a consultant or employee of a commercial company or institution related directly or indirectly to the subject of the presentation.

▲Documentation of FDA Status—The authors of those presentations preceded by a ▲ have indicated that the FDA has not cleared the listed pharmaceuticals and/or medical devices for the use described in this presentation or that the listed pharmaceuticals and/or medical devices are being discussed for an off-label use.

*AFSH Grant Research Acknowledgement—The authors of those presentations preceded by a * have indicated that research related to their presentation was supported by an AFSH Research Grant.

The ASSH does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the presentations.

Disclaimer The material presented in this continuing medical education program is being made available by the American Society for Surgery of the Hand and the American Society of Hand Therapists for educational purposes only. This material is not intended to represent the only, or neces- sarily the best, methods or procedures appropriate for the medical situation discussed, but rather is intended to present an approach, view, statement, or opinion of the authors or presenters, which may be helpful or of interest to other practitioners. The attendees agree to participate in this medical education program sponsored by ASSH and ASHT with full knowledge and awareness that they waive any claim they may have against ASSH and ASHT for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against ASSH and ASHT for any injury or other damage, which may result in any way from their participation in the program. ASSH and ASHT are not responsible for expenses incurred by an individual who is not confirmed and for whom space is not available at the meeting. Costs incurred by the registrant, such as airline or hotel fees or penalties, are the responsibility of the registrant. All of the proceedings of this joint ASSH/ASHT meeting, including the presentation of scientific papers, are intended for limited publication only, and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker, ASSH and ASHT. No statement of presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript, or other use of the material presented at this course without the permission of the speaker, ASSH or ASHT is prohibited to the full extent of common law copyright in such material. The approval of U.S. Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed and/or demonstrated in ASSH and ASHT educational programs may not yet have received FDA approval.

Meeting Abstracts 1 PAPER PAS01

Thursday, September 22, 3:00 p.m. PAS01 Ulna Head Replacement for Trauma and Arthiris of the Distal Radioulnar Joint

●▲ William P. Cooney, MD, Rochester, MN Richard A. Berger, MD, Rochester, MN

PURPOSE Resection of the ulnar head has been an was no pain in 80%, mild pain in 15% and unimproved pain accepted procedure for treatment of the painful distal in one patient (5%). Pronation averaged 75* and supination radioulnar joint (DRUJ). However, recent studies have 70*. Grip strength improved 10% as compared with the demonstrated significant resultant instability. The purpose of contralateral limb. Eighteen prostheses were press-fit and this study is to report our experience with a metallic ulnar ten were cemented. There were two acute complications; head endoprosthesis that was designed to restore the normal a nondisplaced ulnar shaft fracture secondary to press-fit anatomic relationships and kinematics at the DRUJ. impaction of the prosthesis and a sensory cutaneous nerve dysesthesia. There were four chronic complications; one METHODS A review of twenty-eight consecutive ulnar neuroma, two revision soft tissue stabilization, and four head arthroplasties was performed in twenty-six patients revision prostheses related to loosening between 7 and 16 (age 51 years, 32–75) with an average follow-up of 30 months months postoperatively. Mild “collar” resorption was noted (range 15–40 months). Pain was significant in all patients and in 8 cases without progression. A Mayo wrist score was used was characterized by DRUJ tenderness to palpation (65%), to assess objective outcomes. There were four excellent, instability (45%), positive lateral compression test (45%), and eighteen good and six poor results. The latter were related to crepitance with forearm rotation (35%). Pronation-supination reoperation for instability or loosening. range of motion averaged 138 degrees and grip strength was 66% of the opposite side. Twenty patients (70%) had CONCLUSIONS Ulnar head endoprosthetic arthroplasty an average of two (1–5) previous procedures. Indications is an effective means of providing pain relief, stability, and for surgery included DRUJ arthritis (40%), failed Darrach improvement in strength in patients with chronic instability procedure (25%), pain with instability (20%), and Rheumatoid and arthritis of the DRUJ. A high rate of patient satisfaction arthritis (15%). can be expected. Soft tissues repair or reconstruction (Adams procedure) are important components of the procedure to RESULTS Based on clinical assessment of pain relief, provide stability and strength. Bone cement is recommended stability and strength, 80% of patients were satisfied with in patients with previous fusion of the wrist. their procedure and 100% felt that they were improved. There

● Royalties, non-cash support, honoraria, or other funding received from AVANTA ORTHOPEDICS for William Cooney, MD.

▲ Presentation includes discussion of off-label or other non-FDA approved, investigational use of SIGMOID FOSS REPLACEMENT manufactured by AVANTA ORTHOPEDICS.

2 The Joint Annual ASSH/ASHT Meeting PAPER PAS02

Thursday, September 22, 3:07 p.m. PAS02 Outcome of Spherical Ceramic TMC Arthroplasty

◆ Brian D. Adams, MD, Iowa City, IA ◆ Jay Pomerance, MD, Arlington Heights, IL

PURPOSE Spherical, ceramic implant arthroplasty There were no early perioperative complications, including (Orthosphere, Wright Medical, Inc.) for the treatment of fractures, infections or prosthetic dislocations. Radiographs TMC osteoarthritis was retrospectively reviewed to assess showed implant subsidence in nearly all patients after two both clinical and radiographic outcomes. We were particularly years follow-up, which occurred in either the metacarpal or interested in skeletal response to the implant over time and trapezium but not both. Subsidence typically progressed over the correlation between clinical results and radiographic the first two years, then stabilized in some and continued to findings. progress in others. Early formation of a sclerotic line about the implant was associated with less subsidence. Osteopenia METHODS 50 arthroplasties were performed in 49 patients was associated with greater subsidence. Trapezium fractures by 2 surgeons between 1997 and 2003. Follow up averaged developed in 15 and complete trapezium resorption was seen 3.3 years (range, 1–7 years). Average patient age at surgery in one. Trapezial-metacarpal impingement due to subsidence was 59 years. 35 females and 15 males. Patient satisfaction occurred in two. Patient satisfaction and function did not (pain and function surgery), range of motion, pinch strength, correlate with radiographic findings, including subsidence and and grip strength were assessed. Radiographs were trapezium fractures. evaluated for preoperative arthritis, implant and metacarpal subluxation, implant subsidence, fractures, and adjacent CONCLUSIONS Spherical, ceramic implant TMC skeletal reactions. arthroplasty was found to have a substantial incidence of subsidence and eventual trapezium fracture. However, most RESULTS 47 of 50 thumbs achieved full opposition to the patients achieve a high level of satisfaction and function. base of the small finger and none lost MP or IP motion. 46 Clinical outcome did not correlate with adverse radiographic patients reported high satisfaction for pain relief and improved findings, suggesting that changes are slowly progressive function. Persistent unexplained pain was the cause for a poor and tolerated. Longer follow up is needed to determine if result in 4. Despite pinch strength measuring less than the further implant subsidence will occur and if it will be clinically opposite side, nearly all patients reported improved strength. problematic.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 3 PAPER JOINT 1

Thursday, September 22, 3:14 p.m. Joint 1 The Effectiveness of the ASTYM System in Improving Treatment Outcomes in Patients with Lateral Epicondylitis: A Single-Blinded Randomized Trial

● Sue A. Stover, MHS, PT, CSCS, Muncie, IN Bob H. Helfst, MS, PT, ATC, CSCS, Muncie, IN Thomas L. Sevier, MD, Muncie, IN Caroline W. Stegink Jansen, PhD, PT, Galveston, TX

PURPOSE Scientific evidence is lacking to support a of treatment. After giving consent, maximum voluntary and preferred treatment for patients with lateral epicondylitis pain-free grip strength, visual analog pain scale (VAS) at rest (LE). The ASTYM system is based on the premise that and during activity, VAS self-reported function, and DASH most cases of LE are degenerative rather than inflamed and (Disability of Arm, shoulder and Hand) were measured. The therefore would benefit from a stimulus to promote healing. rater was blinded during treatment assignment and the first This stimulus is provided non-invasively through utilization of four weeks of treatment. ANOVA analyses were performed hand-held instruments. The purpose of this study was to test as well as independent t-tests of the gain scores. Chi-square the effectiveness of the ASTYM system when added to a analysis was performed to test the differences in the number home exercise program (HEP) compared to a HEP alone in of subjects requesting crossover treatment. a single-blinded randomized clinical trial (ASTYM + HEP vs. HEP). The hypothesis was that treatment with the ASTYM RESULTS Subjects treated with the ASTYM system system in addition to a HEP would improve long and short- improved significantly better than HEP subjects in VAS at term outcomes for patients with LE. Design: The study rest, maximum grip strength and DASH in the first 4 weeks used a repeated measures design. Subjects were randomly (p<0.05). More HEP subjects requested crossover treatment assigned to the ASTYM + HEP or the HEP group and received than ASTYM subjects (p<0.005). Subjects who had received treatment over a four-week period. From four to eight weeks, the ASTYM treatment (either as initial or crossover treatment) subjects continued the same HEP. At eight weeks, subjects had less pain at rest (p<0.27) than subjects only exposed to who rated themselves as same or worse were offered the a HEP. option of receiving the other treatment intervention, surgical consultation or injection. Measures were taken at baseline, CONCLUSIONS The results suggest that ASTYM treatment four, eight and 12 weeks, and six and 12 months. may be beneficial, especially in the initial phase of treatment for patients with lateral epicondylitis. It was also effective METHODS A total of 127 subjects enrolled in the study, for those patients who did not improve with a HEP. with a resulting 84 cases completing at least the first phase

● Full-or part-time employment or consulting arrangement received from Performance Dynamics for Sue Stover, MHS, PT, CSCS.

4 The Joint Annual ASSH/ASHT Meeting PAPER PAS03

Thursday, September 22, 3:21 p.m. PAS03 Synvisc® versus Corticosteroid Versus Placebo for Treatment of Basal Joint Arthritis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial

*●▲ Melvin P. Rosenwasser, MD, New York, NY Benton E. Heyworth, MD, New York, NY Jonathan H. Lee, MD, New York, NY Robert J. Strauch, MD, New York, NY

PURPOSE Previous studies have suggested that intra- VAS, placebo and steroid groups demonstrated statistically articular injections of hyaluronic acid derivatives, such as significant improvement at 1 month but not at 6 months, Synvisc® (hylan G-F 20), can reduce osteoarthritic knee compared to baseline. In the hylan group, statistically symptoms, but significant controversy exists regarding their significant pain improvement occurred at 6 months, but not effectiveness and cost to the patient. The purpose of this at 1 month. Continuing this trend, the percentage of patients study was to investigate the efficacy of intra-articular hylan reporting symptom improvement at 1 month compared to injections in reducing the symptoms of basal joint OA (BJOA), baseline was: placebo 50%, steroid 68%, hylan 44%; at 6 when compared to corticosteroid and placebo injections. months, this trend shifted: placebo 47%, steroid 58%, hylan 68%. In all groups, there were DASH score improvements at METHODS Sixty patients with basal joint arthritis were both 1 and 6 months, compared to baseline. There were no randomized into one of three treatment groups (hylan, steroid, significant differences between groups, with regard to VAS, placebo), which received either two intra-articular Synvisc® subjective improvement, or DASH scoring at any time point. injections one week apart, one placebo injection followed There were no adverse events in any treatment groups. by one corticosteroid injection one week later, or two saline injections one week apart. Patients were evaluated at follow- CONCLUSIONS We are reporting a Level-I study, which up time points of two weeks, one month, three months, and has never been conducted to examine the non-operative six months, and assessed using patient satisfaction surveys, treatment of BJOA. Based on trends suggested by this Visual Analog Scores for pain (VAS), Disabilities of the Hand, prospective, randomized, double-blinded, placebo-controlled Arm, and Shoulder (DASH) scores, and physical examinations trial and previous studies1, hylan may demonstrate a delayed testing thumb range of motion (ROM), grip strength and and more prolonged effect in reducing symptoms of OA, when pinch strength. This study was approved by the Columbia compared to steroids, to as late as 6 months after injection University Medical Center Institutional Review Board. therapy. The significant gap in the literature regarding the effectiveness of conservative treatments of basal joint OA RESULTS The average patient age was 63 years with the lends considerable impact to this study. majority being females affected in the dominant hand. In the

● Research or institutional support received from Wyeth Pharmaceuticals for 1 Stahl S, Rosenberg N, Karsh-Zafrir I, Ratzon N. The Efficacy Melvin Rosenwasser, MD. of Steroid or Sodium Hyaluronate (Orthovisc) Injections in ▲ Presentation includes discussion of off-label or other non-FDA approved, Treatment of Symptomatic Trapeziometacarpal Joint Arthritis. investigational use of Synvisc manufactured by Wyeth Pharmaceuticals. A Prospective Comparative Study. 59th ASSH Meeting, NY, * Grant support received from Wyeth Pharmaceuticals. NY Sept 2004.

Meeting Abstracts 5 PAPER JOINT 2

Thursday, September 22, 3:28 p.m. Joint 2 Reasons for Prosthesis Rejection by Children with Unilateral Congenital Below Elbow Deficiency (UCBED)

*◆ Lisa V. Wagner, OTR/L, Greenville, SC Michelle James, MD, Sacramento, CA Anita Bagley, PhD, Sacramento, CA

PURPOSE Up to half of children with UCBED choose not to with UCBED scored above 85 except 2–4 year olds (average wear a prosthesis. Our hypothesis is that prosthetic wear is score 81). Non-wearers performed the same as or statistically not associated with better function, and that lack of functional significantly better than prosthesis wearers on every task of benefit is the primary reason for rejection. the UBET. Of the 157 subjects who had chosen not to wear a prosthesis at the time of the evaluation, the most frequent METHODS Four hundred ninety-four children with UCBED reason given (56%) was lack of function. Forty-nine percent and their parents were tested for satisfaction, quality of reported that they stopped wearing because the prosthesis life and function. One hundred fifty-seven (32%) of those was uncomfortable. tested had chosen not to wear a prosthesis. Reported upper extremity function was determined by the Upper Extremity CONCLUSIONS Children with UCBED report and (UE) Domain of the Pediatric Orthopaedic Data Collection demonstrate very good UE function, and a prosthesis does not Instrument (PODCI). Children with PODCI UE Domain scores assist them with functional tasks. Current therapy standards below the low 80’s (on a scale of 100) are functioning below assume that children with UCBED need a prosthesis to normal limits. UE function was measured using the Unilateral accomplish bilateral hand tasks particularly in the scheme of Below Elbow Test (UBET), which includes nine tasks for normal development. Prostheses may have other benefits, each of four age groups. Non-wearers scores for individual such as appearance or serving as a tool for specific high- tasks and average score for all nine tasks were compared level activities, but they should not be recommended to with wearers’ scores. Subjects were also asked the open- children with UCBED in order to improve function for daily ended question: what are the child and parent’s reasons for age-appropriate activities. Hand therapists should focus their not wearing a prosthesis?, and were allowed to give more treatment of this population on determining which higher than one response. level tasks may require a prosthesis as a tool, and should not consider a prosthesis necessary for children with UCBED to RESULTS There were no differences between PODCI perform everyday tasks. scores for wearers and wearers, and all age groups of subjects

◆ Speakers have nothing of value to disclose.

* Grant support received from Clinical Outcomes Study for Shriners Hospitals-Multi-Center Unilateral Congenital Below Elbow Deficiency.

6 The Joint Annual ASSH/ASHT Meeting PAPER PAS04

Thursday, September 22, 3:34 p.m. PAS04 Minimally Invasive Distal Radius Fracture Fixation with an Intramedullary Nail

● Virak Tan, MD, Newark, NJ John Capo, MD, Newark, NJ Mark Warburton, MD, High Point, NC

PURPOSE To determine the outcome of unstable distal RESULTS The average age of the group was 59 years old radius fractures treated with a fixed-angle implant that resides (range, 31–83). The average time of post-operative wrist completely within the medullary canal. immobilization was 9 days. The overall outcome regarding patient satisfaction, residual pain and activity levels and METHODS A prospective analysis of 23 consecutive radiographic measurements were highly satisfactory even at patients treated for unstable distal radius fractures using the early time points. At 8 weeks post-op, active wrist motion a novel intramedullary nail system is performed. The nail were: flexion 39°, extension 49°, radial deviation 16°, ulnar consists of three 2.5 mm distal fixed-angle locking screws that deviation 22°, supination 66° and pronation 77°. Grip strength buttress the subchondral plate and secure the distal fracture was 40% of the uninjured side. At 6 months, the motion fragment. There are two 2.7 mm proximal interlocking screws continued to improve and the average grip strength increased that resist axial migration and angulation fracture. The nail is to 76% of the opposite side. Radiographs showed an average inserted through a bone window at the radial styloid. Criteria volar tilt of 5°, radial inclination of 21°, ulnar variance of 0°, for operative treatment included 1) initial dorsal angulation and radial height of 13 mm. greater than 20° with comminution, 2) initial shortening greater than 5 mm, 3) displaced intra-articular component, or CONCLUSIONS This novel technique and implant system 4) loss of reduction with closed immobilization techniques. allow for secure internal fixation of unstable distal radius Exclusion criteria included inability to achieve near-anatomic fractures with minimal surgical dissection and morbidity. Even reduction of the fracture fragments by closed or percutaneous though the wrists were mobilized early in the post-operative means. Outcome was assessed with standard radiographic peroid, fracture reduction and alignment were maintained. parameters, wrist motion, grip strength, and the Disabilities This system is a valuable addition to the arsenal of distal of the Arm, Shoulder, and Hand score. radius fracture treatment options and can quickly get patients back on the road of recovery.

● Full- or part-time employment or consulting arrangement received from Wright Medical Technology for Virak Tan, MD.

Meeting Abstracts 7 PAPER PAS05

Friday, September 23, 8:00 a.m. PAS05 The Age of Onset and Incidence of Spontaneous Resolution of Congenital Trigger Digit

◆ Gillian D. Smith, FRCS, Louisville, KY Scott La Joie, PhD, MSPH, Louisville, KY Luis R. Scheker, MD, Louisville, KY

PURPOSE The purposes of this study were to ascertain months (range: 1–50 months). There was an equal sex ratio. the age at onset of the congenital trigger finger or thumb, Only one patient had a family history of triggering and eight the proportion of patients diagnosed which later resolve had a history of minor trauma. 72% presented with a flexion completely, either spontaneously or with conservative deformity of the digit, 14% with a nodule and only 25% measures, and the age beyond which spontaneous resolution with triggering. Five out of six of the trigger fingers resolved is unlikely to occur. spontaneously but only six of the 82 trigger thumbs followed up resolved (7%). Even if all those lost to follow up resolved, METHOD We performed a retrospective case note review the incidence of spontaneous resolution would only be 13% of all trigger thumbs and trigger fingers in pediatric patients of our population. There were no predicting factors, related to over a 10 year period, excluding those over the age of five age or length of history suggesting likelihood of spontaneous years or with otherwise abnormal thumbs. resolution.

RESULTS We had examined 81 patients with 95 trigger CONCLUSIONS Congenital trigger digits are a misnomer, digits (89 trigger thumbs, 6 trigger fingers)—one trigger finger frequently appearing long after birth and presenting with a and 13 trigger thumbs were bilateral. The mean age of onset flexion deformity or nodule rather than triggering. Trigger of the condition was at 14 months (range: birth–45 months). fingers will usually resolve spontaneously within two years The parents of twenty-seven patients noticed the problem but it is rare for spontaneous resolution of a trigger thumb. We within the first three months of life, another seven within would no longer routinely recommend a period of conservative the first year, but fourteen were over the age of eighteen treatment prior to operative management although we can months and another sixteen over the age of two when it present no evidence that deferred treatment has any adverse was first identified. The mean age of presentation was 22 long term effects.

◆ Speakers have nothing of value to disclose.

8 The Joint Annual ASSH/ASHT Meeting PAPER PAS06

Friday, September 23, 8:07 a.m. PAS06 Effect of Corticosteroid Injection on Blood Glucose Level in Diabetic Patients

◆ Angela Wang, MD, Salt Lake City, UT Douglas Hutchinson, MD, Salt Lake City, UT

PURPOSE The purpose of this study was to determine how glucose levels were still increased, with an average increase corticosteroid injections in the upper extremity affected blood of 19% over pre-injection levels. This trend was particularly glucose in diabetic patients, and the results of that injection. marked in Type I patients, with a 215% average increase in blood glucose the first morning post-injection, decreasing METHODS 18 patients with diabetes who underwent an over the next five days to 36% above baseline levels. Seven upper extremity corticosteroid injection were prospectively out of eighteen patients (39%) needed surgery, as of last included in the study. Diagnoses included trigger finger (14), chart review average 34 months (range 3–51 months) after Dequervain’s tenosynovitis (2), lateral epicondylitis (1), and injection. thumb carpometacarpal arthritis (1). 5 patients had Type I (juvenile-onset) diabetes, and 13 patients had Type II (adult- CONCLUSIONS Corticosteroid injection in the upper onset) diabetes. Patients were asked their usual morning extremity is commonly performed, but may be avoided in and afternoon blood glucose measurements, and then diabetic patients due to fear of iatrogenic hyperglycemia and recorded their blood glucose measurements in the morning poor results (as shown in trigger fingers). We could not find and afternoon for 5 days after the injection. We also noted any documentation of blood glucose rise after corticosteroid whether or not these patients ended up needing surgery for injection in diabetic patients, so this study was an attempt to that condition. quantify this hyperglycemic effect, and secondarily determine injection efficacy. We found that blood glucose levels peaked RESULTS There were 4 males and 12 females with an the first day after injection but remained elevated up to five average age of 59 years (range 28–83 years). Blood glucose days later, especially in Type I diabetic patients. We feel these increased after injection for all patients. The first morning data are important for patient education. In addition, we feel after injection showed the biggest increase in blood glucose, corticosteroid injection may still be worthwhile as a treatment with an average increase of 78% compared to average pre- in diabetic patients, as less than half of our patients needed injection. This increase gradually decreased over the next 5 surgery for their condition. days, but even by the fifth afternoon post-injection, blood

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 9 PAPER PAS07

Friday, September 23, 8:14 a.m. PAS07 A Multicenter Prospective Study of 3110 Consecutive Cases of Elective Epinephrine Use in the Fingers and Hand

◆ Donald H. Lalonde, MD, Saint John, NB, Canada Micheal S.G. Bell, MD, Ottawa, ON, Canada Keith Denkler, MD, Larkspur, CA Gerald L. Sparkes, MD, Saint John, NB, Canada

PURPOSE There continues to be a commonly held belief RESULTS 3110 consecutive cases of elective injection of that epinephrine injection is contraindicated in the finger low dose epinephrine (1:100,000 or less) in the hand (1770 and hand in spite of a lack of valid evidence to support this cases) and fingers (1340 cases) did not produce one case of concept in the literature. The purpose of this study was to digital infarction. Just as importantly, phentolamine was not prospectively examine the incidence of digital infarction in a required even once to reverse the vasoconstriction in any of large series of consecutive patients in whom local anesthesia the cases. with adrenaline was injected electively into the hand and fingers. CONCLUSIONS The true incidence of finger infarction in elective low dose epinephrine injection into the hand and METHOD From July 2002 to July 2004, 9 hand surgeons in finger is likely to be remote, particularly with the possible 6 cities prospectively kept accurate records of each rescue with phentolamine. consecutive case of elective hand and finger epinephrine injection. The authors were prepared to use phentolamine to reverse the adrenaline induced vasoconstriction should this be required.

◆ Speakers have nothing of value to disclose.

10 The Joint Annual ASSH/ASHT Meeting PAPER PAS08

Friday, September 23, 8:21 a.m. PAS08 High Pressure Injection Injuries to the Upper Extremity

◆ Gillian D. Smith, FRCS, Louisville, KY Ray G. Hart, MD MPH, Louisville, KY Russell A. Shatford, MD, Louisville, KY

PURPOSE High pressure injection injuries may result in RESULTS There were 71 male and 5 female patients, amputation despite an innocuous appearance. Traditional with a mean age at time of injury of 40 years (range: 19– teaching suggests that a high pressure injection injury is 64 years). Sixty-one (81%) had been injured at work. The an acute surgical emergency and that delay in treatment injected substance was hydraulic fluid in 18 (23%), paint in 16 increases the risk of amputation. We wished to ascertain (21%), solvents in 13 (17%), grease in 12 (16%), water in 10 whether there was an association between the time interval (13%), kerosene in 3 (4%), transmission fluid in 2 (3%) and between injury and surgical debridement and subsequent air in 2 cases (3%). Thirty patients (40%) underwent surgical amputation. exploration within 10 hours of the injury, 17 (22%) within 24 hours and 29 (38%) greater than 24 hours after the injury. METHODS We performed a historical cohort study of Twenty (27%) underwent more than one debridement and high pressure injection injuries in the upper extremity. We 9 digits were amputated (12%). No association was found identified the charts of 76 patients with 62 injuries to digits between amputation and the delay. There was a non-significant and 17 injuries to the hand that had occurred over the previous association between injectate and outcome. The mean time 12 years. Cox regression analysis was performed to detect to soft tissue healing was five weeks. Those digits presenting the degree of association of time delay to surgery, injectate, without vascularity were all ultimately amputated. site of injection and smoking with risk of amputation and time to healing. CONCLUSIONS The prognosis for digits presenting without vascularity is poor. However, the expected association between amputation and the delay between injury and surgical intervention was not demonstrated.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 11 PAPER PAS09

Friday, September 23, 8:28 a.m. PAS09 Upper Extremity Mucormycosis Infections in Non-Immunocompromised Patients

◆ Steven L. Moran, MD, Rochester, MN Justin Strickland, MD, Rochester, MN Alexander Shin, MD, Rochester, MN

PURPOSE Mucormycosis can produce an aggressive and resulted from conveyer belt injuries in agricultural facilities. All sometimes fatal soft tissue infection most commonly seen patients had significant upper extremity soft tissue loss and in immunocompromised individuals. Eradication consists of 5 of the 6 patients had upper extremity fractures. All were surgical resection and antifungal chemotherapy. Knowledge initially treated with broad spectrum gram positive and gram regarding infectious mucormycosis in the upper extremity has negative antibiotics. Patients underwent an average of 10 been limited to case reports involving immunocompromised operative debridements (range 4–20). 3 infections resulted in individuals. This article reviews the growing numbers of amputations: one below the elbow, one above the elbow and invasive mucormycosis infections of the upper extremity one at the glenohumeral joint. The 3 surviving limbs required seen in non-immunocompromised individuals. flap coverage for definitive closure. Average hospital stay was 34 days. All cases of limb salvage were associated with early METHODS A 10-year retrospective review of all fungal and aggressive debridements in addition to amphotericin infections involving the upper extremity was conducted in our chemotherapy. institution. From 1994 to 2004, 925 fungal infections of the upper extremity were identified. Utilizing our microbiology CONCLUSIONS Mucormycosis can produce limb database, we identified 6 immunocompetent patients with threatening infections in the immunocompetent host. The infectious mucormycosis of the upper extremity. Average hand surgeon must have a high index of suspicion for such patient age was 40. All patients were previously healthy infections in cases of grossly contaminated open wounds. with no history of diabetes or significant medical problems. Intraoperative fungal cultures and tissue pathology must be Culture and pathologic specimens showed mucormycosis as obtained. These infections require early and frequent surgical the dominant pathogen in all cases. All cases occurred within debridements and antifungal chemotherapy for successful the past 3 years. limb salvage. Even with aggressive debridements one-half of our patients required an upper extremity amputation to RESULTS In the 6 patients, 3 infections resulted from heavy eradicate the infection. soil contamination following motor vehicle accidents and 3

◆ Speakers have nothing of value to disclose.

12 The Joint Annual ASSH/ASHT Meeting PAPER PAS10

Friday, September 23, 9:27 a.m. PAS10 Radial Triangular Fibrocartilage Tears: Debride or Repair?

◆ A. L. Osterman, MD, Villanova, PA

PURPOSE The question of whether to repair or debride manipulations. Postoperative protocols differed in that Radial Triangular Fibrocartilage (TFC) tears remains unclear. Group II patients were immobilized for three weeks, while This study addresses that question by retrospectively Group I patients, with the exception of the 3 peripheral comparing the two techniques in a series of patients. repairs, were allowed free wrist motion tolerated. Follow-up averaged 4.2 years for Group I and 3.6 years METHODS Group I consisted of 10 patients with simple for Group II. 80% of Group I patients were asymptomatic arthroscopic debridement, Group II included 9 patients with compared to 67% of Group II. Wrist ROM, grip strengths, arthroscopically assisted repair. All injuries were chronic. Two Mayo wrist scores were equivalent. Minor complications patients in Group I and 3 in Group II had a history of prior distal were slightly higher in Group II : 2 patients with DRSN irritation radius fracture. No patient had frank instability of the DRUJ. that resolved and 1 patient with protracted wrist stiffness. No Preoperative demographics, symptoms, physical exam, and patient in either group showed evidence of instability. imaging were similar for the two groups. CONCLUSIONS In summary, this study suggests that RESULTS Intraoperative findings, aside from the radial debridement of radial TFC tears is equally effective and TFC tear, Included peripheral TFC tears (5), ligament equivalent to TFC repair. Debridement is simpler not only perforations (2), and chondromalacia (7). All 5 (3 in Group surgically but postoperatively. I, 2 in Group II) were repaired but no other arthroscopic

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 13 PAPER PAS11

Friday, September 23, 9:34 a.m. PAS11 A Comparison between Dorsal Capsulodesis and Tenodesis for the Treatment of Chronic Scapholunate Instability

◆ Steven L. Moran, MD, Rochester, MN William P. Cooney, MD, Rochester, MN Kerry S. Ford, MD, Rochester, MN Corey A. Wulf, MD, Rochester, MN

PURPOSE The ideal treatment for chronic scapholunate RESULTS Post-operative wrist motion decreased in (SL) instability is not yet established. Several soft tissue both groups following surgery. Final wrist range of motion procedures have been described to limit scaphoid flexion in was 64% of the normal side in the capsulodesis group and the hopes of preventing further rotatory subluxation and the 65% of normal side in the tenodesis group. Post-operative progression to radiocarpal arthritis. The purpose of this study grip strength remained unchanged in both groups; with was to compare the long-term results of dorsal capsulodesis post operative grip strength measuring 88% of normal in (Mayo technique) and flexor carpi radialis tenodesis (Brunelli the capsulodesis group and 92% of the normal side in the technique) as a primary treatment for chronic scapholunate tenodesis group. Average Mayo wrist scores were 75 in both dissociation. groups. Most patients had improvement in pain, but only 7 patients were completely pain free. Complications occurred in METHODS A retrospective analysis was conducted, 7% of capsulodesis patients and 13% of tenodesis patients. examining all dorsal capsulodesis and Brunelli tenodesis One frank failure occurred in the tenodesis group resulting in procedures performed for chronic SL instability between secondary wrist fusion. Radiographic parameters tended to January 1995 and February of 2003. Wrist pain had to be deteriorate over time in both groups. There was no statistical present for greater than three months. Patients were excluded difference in overall wrist motion, grip strength or wrist scores if they had undergone previous treatment or had evidence between the capsulodesis and tenodesis groups. of SLAC arthritis. 29 patients were identified with isolated chronic SL instability. Of the 29 patients, 14 underwent a CONCLUSIONS The Mayo capsulodesis and Brunelli Mayo dorsal capsulodesis procedure and 15 underwent a tenodesis provided improvement for patients with chronic Brunelli procedure. Time from injury to surgery averaged 20 SL instability. Both procedures appear to provide equivalent months in both groups. There were no significant differences results in the treatment of this difficult problem, but an ideal seen between groups for age, gender or pre-operative risk surgical solution has yet to be found. factors. Follow up averaged 36 months in the capsulodesis group and 22 months in the tenodesis group. Results were reviewed clinically and radiologically. Groups were compared with a student t-test.

◆ Speakers have nothing of value to disclose.

14 The Joint Annual ASSH/ASHT Meeting PAPER PAS12

Friday, September 23, 9:41 a.m. PAS12 Medium Term Results of a Modified Brunelli Procedure for Scapho-Lunate Instability

◆ Sumedh C. Talwalkar, Mch (Orth), Manchester, United Kingdom Michael J. Hayton, FRCS (Orth), Manchester, United Kingdom Ian A. Trail, MD, FRCS, Wigan, United Kingdom John K. Stanley, FRCS, FRCSE, Manchester, United Kingdom

PURPOSE To study the results of a modified Brunelli of Flexion - Extension and 13 degrees (12%) loss in Radial- procedure in the management of scapho-lunate instability. Ulnar deviation when compared with the non-operated side. This was found to be significant (p<0.05) using the t- METHODS 162 patients with a diagnosis of scapholunate test. Four patients had persistent mechanical pain. Two of instability who underwent a modified Brunelli procedure these patients subsequently underwent scapho-capitate between 1995 and 2002 at our institution. 117 patients were fusion while the other two had wrist fusions. Two patients assessed with the help of a questionnaire and of these 55 developed persistent ulnar sided symptoms which were were assessed with a clinical review. The average age was treated with ulnar shortening while one patient developed a 38 years with a minimum follow-up of 2 years (2–8 years). reflex sympathetic dystrophy which needed physiotherapy There were 74 males and 88 females. At clinical review pain and a guanethedine block. On subjective evaluation 90 (79%) was assessed using the visual analogue scale (0–10). Wrist patients who responded were very satisfied to satisfied with function was assessed using the Wrightington wrist function the result of the surgery and overall 88% of the patients felt score while the active and passive range of radial and ulnar that they would have the same surgery again. Four patients deviation and flexion and extension at the wrist was also had persistent tender scars over the volar incision near the recorded. Grip strength was measured and compared with base of the thumb. This led to exploration and excision of that of the contra lateral uninjured wrist and patient satisfaction neuroma in three patients. was recorded using the visual analogue scale (0–10). CONCLUSIONS Despite the reduced range of movement, RESULTS Pain assessment showed that 72 (62%) patients patient satisfaction remains high. We believe that the had no pain to mild pain, 20 patients had moderate pain, while modified Brunelli procedure has a role in the management 8 (6%) patients had severe pain. The mean grip strength of scapholunate dissociation in the absence of degenerative on the operated side was 79% of the non-operated side changes and in those situations where it is possible to reduce the average grip strengths being 25.7 (4–52) kgf and 32.5 the scapholunate dissociation at surgery. (15–51) kgf respectively. There was a 35 degree (26%) loss

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 15 PAPER PAS13

Friday, September 23, 9:41 a.m. PAS13 Scaphoid Non Union with or without Avascular Necrosis of the Proximal Pole: Treatment with a Vascularized Bone Graft from the Distal Radius

◆ Stephane Barbary, MD, Nancy, France Francois Dap, MD, Nancy, France Laurence Darbelley, MD, Nancy, France Gilles Dautel, MD, Nancy, France

PURPOSE The purpose of this study was to analyse the the group with AVN. Internal fixation with one, two or three rate and the delay of consolidation of 37 scaphoid non union K-wires was performed. The wrist was immobilized for 8 to treated with vascularized bone graft (VBG) from the distal 10 weeks. radius. RESULTS Union was achieved in 31/37 after 15 weeks. The METHODS From October 1998 to January 2001, 37 mean delay to achieve union was longer in the group with patients with scaphoid non union have been operated using AVN (17 weeks, range 7–40) than in the group without AVN a pedicled vascularized bone graft from the distal radius. (12 weeks, range 8–20). Union was achieved in the group with 32 times the VBG was harvested from the dorsal aspect of AVN 15/20 (75%) and in the group without AVN 15/17 (88%). the radius and supplied through the “1-2” supra retinacular Internal fixation with only one K-Wire was unsuccessful for artery (Zaidemberg technique) and 5 times the graft was 3 cases on 5. Union was achieved in 6/10 patients who had harvested from the volar aspect of the radius (described previous non-vascularized bone graft. Pain was present in by Kuhlman). In 20 of these 37 patients, avascular necrosis cases of scapho-styloid arthritis. of the proximal pole was documented in preop (either on MRI or on conventional X-rays). During the procedure, after CONCLUSIONS The dorsal VBN of Zaidemberg is the most release of the tourniquet, in all these patients, bleeding suitable VBG for scaphoid non union with AVN. The VBG was limited to very few punctuate bleeding points in permits the treatment of chronic scaphoid non union where cancellous bone or was even totally absent (Green criteria). a conventional bone graft has failed. Internal fixation must be Ten patients had unsuccessful previous surgical procedure performed with at least 2 K-wires. Alternative or additional and 4 had scapho-styloid arthritis. The treatment was delayed procedure is necessary for cases with established arthritis. to 6.5 years for the group without AVN and to 5.5 years for

◆ Speakers have nothing of value to disclose.

16 The Joint Annual ASSH/ASHT Meeting PAPER PAS14

Friday, September 23, 9:48 a.m. PAS14 Treatment of Scaphoid Nonunions of the Proximal Third with Conventional Bone Grafting and Mini-Herbert-Screws: An Analysis of Clinical and Radiological Results

◆ Kai O. Megerle, MD, Ludwigshafen, Germany Xavier Keutgen, MD, Ludwigshafen, Germany Günter Germann, MD, PhD, Ludwigshafen, Germany Michael Sauerbier, MD, PhD, Ludwigshafen, Germany

PURPOSE This study was designed to assess the clinical nonunions 9 patients refused further operations or already and radiological outcomes after treatment of scaphoid had arthritic changes, so that no reconstructive procedure nonunions of the proximal third by nonvascularized bone was suggested. Of the remaining 3 patients one patient had grafts and stabilization by Mini-Herbert screws. another attempt to reconstruct the scaphoid, one patient received a four corner fusion and the third patient received METHODS Forty-one patients (1 woman, 40 men) treated a partial denervation of the wrist. The origin of the bone for scaphoid nonunions of the proximal third between 10/97 graft had no influence on union rates. Average DASH-scores and 7/03 were retrospectively reviewed at a mean of 34 improved from 26 preoperatively to 11 in patients with months. Mean delay to surgery was 380 days. All patients osseous union and increased to 32 in patients with persistent were treated by resection of the nonunion from a dorsal nonunion. As expected, latter patients showed significantly approach, interposition of a nonvascularized bone graft from lower ranges of motion and grip strength (76° for extension/ the radius or iliac crest, stabilization by a Mini-Herbert-screw flexion at 28 kg grip strength compared to 88°/37 kg). Average and immobilisation for at least 6 weeks in a forearm cast. All postoperative Mayo-Wrist-scores and Krimmer-scores were patients received pre- and postoperative CT-scans to assess 69 and 83. No significant alterations in radiologic parameters osseous union. Apart from demographic data, range of motion, were detected. grip strength, Krimmer-score, Mayo-wrist-score, DASH-score and radiologic parameters (carpal height, scapholunate and CONCLUSIONS Treatment of scaphoid nonunions of radiolunate angles) were obtained. A p-value of 0.05 was the proximal third remains a clinical challenge. Our study regarded as significant. demonstrates that acceptable union rates can be achieved even without the use of vascularized bone grafts and RESULTS Osseous union could be achieved in 29 therefore compares favorably with the literature. For reliable patients (71%). Complications occurred in 5 patients (12%) detection of bony union CT-scans are mandatory. Radiological and consisted of screw protrusion into adjacent joints (3), osseous union is highly predictive for patient satisfaction and secondary excision of radial osteophyts (1) and severe functional outcome. radiocarpal contracture (1). Of the 12 patients with persistent

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 17 PAPER PAS15

Friday, September 23, 10:47 a.m. PAS15 Extended, Reverse, Pedicled Posterior Interosseous Flap

◆ Michael Hausman, MD, New York, NY Carlos Zaidenberg, MD, Buenos Aires, Argentina

The reverse, pedicled posterior interosseous artery flap, We describe the anatomy and our experience in 22 cases described by Zancolli and Angrigriani1, has proven very useful with an extended reverse PIA flap, based on the dorsal for soft tissue reconstruction in the hand. The flap is based carpal arch branching from the radial artery, rather than the on the communicating vessel between the anterior and communicating branch to the AIA. This modification moves posterior interosseous arteries just proximal to the DRUJ, the pivot point 4–8 cm distal to the DRUJ, permitting the flap which is its rotation point. It will generally reach the distal to reach the fingertips, thus extending the arc of rotation and dorsal, distal metacarpal area, but cannot reach the digits indications for this reliable, pedicled fascial or fasciocutaneous nor the distal palm when rotated about the communicating flap. vessel. Digital or distal palmar coverage therefore generally requires microvascular free tissue transfer. 22 consecutive cases of this extended flap were performed successfully without loss of the flap or significant partial necrosis.

FIGURE 1 FIGURE 2 Arterial dissection showing communicating branch to Extended PIA flap based on the dorsal carpal artery showing anterior interosseous artery (thin arrow) and more distal rotation point extended by 6 cm (thick arrow), permitting communication of the PIA with the radial artery via the the flap to reach the fingertips. The usual point of rotation is dorsal carpal artery (thick arrow). shown (thin arrow) for comparison.

1 Zancolli EA, Agrigriani C: Posterior interosseous island forearm flap. JHS [Br], 13:130, 1988.

◆ Speakers have nothing of value to disclose.

18 The Joint Annual ASSH/ASHT Meeting PAPER PAS16

Friday, September 23, 10:54 a.m. PAS16 Radiofrequency Ablation of Osteoid Osteoma in the Upper Extremity

◆ Maximillian Soong, MD, Boston, MA Jesse B. Jupiter, MD, Boston, MA Daniel Rosenthal, MD, Boston, MA

BACKGROUND Radiofrequency ablation (RFA) for the up was 42 months (range 12–136). The lesions included: treatment of osteoid osteoma has been proven safe, 17 humerus, 5 scapula, 2 radius, 1 ulna. No lesions were effective, and by some measures superior to surgery. The in the hand. Average lesion size was 8mm (range 3–20). vast majority of experience is from the lower extremity, for Pathology confirmed the diagnosis in 14 patients (56%) which significant benefits include shorter hospitalization and and was nondiagnostic in the remainder. There were no quicker rehabilitation. However, few published data exist complications. Two patients required an overnight admission for the upper extremity. Proximity to clinically important for post-procedure pain or nausea. Nineteen patients were neurovascular structures and unfamiliarity with this modality rated successful (76%). Four were rated partially successful are possible obstacles to such treatment. (16%), including one who received decreased RFA intensity due to the proximity of a neurovascular bundle. There were PURPOSE To determine the results of RFA of osteoid two failures (8%). One received decreased RFA duration due osteoma in the upper extremity. to the proximity of a neurovascular bundle, and ultimately required surgical excision three months later. The other METHODS Twenty-nine patients who underwent RFA of patient, who had failed two surgical procedures prior to RFA, upper extremity osteoid osteoma by the senior investigator developed a third recurrence at 1.5 years, and was eventually prior to 2004 were included. Records were reviewed for treated successfully by a third surgical procedure. Outcomes patient age and sex, lesion size and location, prior treatment, did not appear correlated with age, sex, size, location, or and pathology results. Outcomes were determined by pathology results. mailed questionnaires and/or telephone follow-up. Success was defined as complete resolution of pain without further CONCLUSIONS Radiofrequency ablation is a safe and treatment. Partial success was defined as resolution except effective treatment for the majority of osteoid osteomas for occasional pain with activities. Failure was defined as in the upper extremity. For lesions which are recurrent or recurrence, no change in symptoms, and/or need for another do not allow a safe distance between the electrode and a procedure. major neurovascular structure, surgical excision should be considered. This may be of particular importance in lesions RESULTS Follow-up data were available for 25 patients of the hand. (mean age 20, males 76%). Average length of follow-

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 19 PAPER PAS17

Friday, September 23, 11:01 a.m. PAS17 Dorsal Marginal Shearing (Reverse-Barton’s) Fractures

*◆ Santiago Lozano-Caldron, MD, Boston, MA David Ring, MD, Boston, MA Job Doornberg, MS, Boston, MA

PURPOSE Volar shearing fractures of the articular surface RESULTS At an average follow-up of 28 months, 20 of the distal radius with volar radiocarpal subluxation fractures healed without substantial loss of alignment and one (eponymically known as Barton’s fracture) are well recognized patient had recurrent dorsal subluxation after plate removal. and substantial data are available to guide treatment. In Average wrist flexion was 58°, wrist extension 55°, pronation contrast, dorsal shearing fractures with dorsal radiocarpal 86°, and supination 87°. Average grip strength was 83% of subluxation (sometimes called reverse Barton’s fractures) are the non-involved hand (71 lbs). The final functional result rarely mentioned and very little data exist to guide treatment. according to the system of Gartland and Werley was rated Are these injuries under-recognized or are they under- excellent or good in 17 patients, fair in 3 patients and poor in reported? 1 patient. Average Modified Mayo Wrist score was 74.2, and the average DASH score was 16.2. There were no tendon METHODS A single surgeon treated 24 patients with dorsal ruptures, implant problems, infections, or nerve injuries. marginal shearing fractures of the distal radius with dorsal radiocarpal subluxation over a four-year period. One could not CONCLUSIONS Shearing fractures of the dorsal articular be located and two others had less than 6 months of follow-up margin of the distal radius (dorsal Barton’s fractures) may leaving 21 available for study. A spectrum of volar injury was be more common than previously recognized. There is observed: 5 patients had torn volar ligaments, 10 had failure a spectrum of volar injury and central articular impaction through bone (displaced, rotated volar marginal lip fracture), is common. Given the central articular impaction, dorsal and 6 had impaction of the volar aspect of the articular marginal shearing fragment, and dorsal radiocarpal instability, surface with minimal displacement of the volar metaphyseal this represents one fracture type that may be difficult to treat fracture line. Fifteen of 21 patients (75%) also had impacted through a volar exposure and plating alone. central articular fragments. All patients had dorsal exposure, reconstruction of the articular surface, and dorsal buttress plating. Eleven patients also had a volar exposure and fixation. Dorsal implants were routinely removed.

◆ Speakers have nothing of value to disclose.

* Grant support received from AO Unrestricted Grant.

20 The Joint Annual ASSH/ASHT Meeting PAPER PAS18

Friday, September 23, 11:08 a.m. PAS18 Biomechanical Stability of a Volar Locking Plate versus Fragment Specific Fixation System in an Inra-Articular Dorsal Comminution Distal Radius Fracture Model

◆ Kenneth F. Taylor, MD, Washington, DC Brent G. Parks, MSc, Baltimore, MD Keith A. Segalman, MD, Baltimore, MD

PURPOSE To establish a cadaveric model of physiologic plate systems for the ulnar segment in both the pre-cycle cyclic loading through the carpus and to use this model to (344.5 N/mm versus 78.9 N/mm respectively) and post-cycle compare the biomechanical stability of two recently introduced (355.48 N/mm versus 141.97 N/mm respectively) values fixation systems in an intra-articular, dorsal comminution distal (p≤0.05). No other comparisons were significant with respect radius fracture model. to stiffness. No significant difference was found between failure loads for the fragment specific or volar locking plate METHODS Ten matched pairs of fresh-frozen cadaveric systems with respect to ulnar, radial or overall fragment arms were dissected, preserving capsuloligamentous displacement. structures from forearm to transverse metacarpal ligament. AO/ASIF type C2 fractures were simulated. Specimens were CONCLUSIONS Previous studies of distal radius fracture randomized between locking volar plate (Hand Innovations) fixation focus on load to failure, which simulates a single and fragment specific fixation (TriMed) systems. Specimens event such as fall on outstretched hand. A significant were loaded in extension cyclically from 0 to 50N at a rate advantage claimed by these two systems is the ability to of 1 Hz for 2000 cycles, then monotonically to failure at a begin early range of motion. This study represents the first rate of 10 mm/sec. Failure was defined as that load required model of cyclic loading with a physiologic load encountered to create a gap deformation of 2.0 mm. Pre and post-cycle during rehabilitation. Fracture specific fixation demonstrated stiffness values were obtained from the initial linear portion improved stiffness characteristics with respect to the smaller of the load versus gap deformation curves. Failure load values ulnar sided fragment. Of note, stiffness values of ulnar and were obtained from the load versus gap deformation curves radial fragments each increased in both fracture specific and at the point where the deformation reached 2.0 mm. volar locking plate systems. For the volar locking plate system, this was likely due to settling of the subchondral plate onto RESULTS One specimen from each group failed the distal pegs. With respect to fragment specific fixation, a catastrophically at approximately 300 cycles. The remaining similar finding could be reasonably explained by a tension- eighteen specimens completed cyclic loading and subsequent band like effect of the pin plate fixation. This is a potential load to failure. A significant difference in stiffness was topic of further investigation. observed between the fragment specific and volar locking

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 21 PAPER PAS19

Friday, September 23, 11:15 am. PAS19 Operative Treatment of Fractures of the Distal Radius: A Comparison of two Methods

◆ Jeffrey J. Brooks, MD, New York, NY Steven Z. Glickel, MD, New York, NY O. Alton Barron, MD, New York, NY Louis W. Catalano, MD, New York, NY

PURPOSE This study retrospectively compares outcomes reduction. There were no statistically significant differences in following operative treatment of displaced distal radius radiographic measurements, degenerative changes, strength, fractures using either closed reduction and percutaneous or wrist motion. DASH, VAS scores, and satisfaction were pinning with several (3–5) smooth pins in multiple planes also similar. There was a significant difference in operative (CRPP), Group I, or open reduction with internal fixation time (Group I: 36 minutes, Group II: 90 minutes, [P=0.03]). (ORIF) using the TriMed® Fixation System, Group II. There was a significant difference in time to postoperative motion (Group I=40 days, Group II=25 days, [P<0.00001]). METHODS 43 patients were included; 22 patients Group II patients had a re-operation rate over 50% (mostly underwent CRPP (Group I), and 21 patients had ORIF for symptomatic hardware). Complications included loss of (Group II). Evaluation at 14 months postoperatively included reduction requiring reoperation (one patient in each Group), measurement of wrist motion, tenderness, deformity, and pin-track infection (one case in Group I), one radial sensory strength of the injured and uninjured wrists. The initial injury neuroma (Group II), one case of broken retained hardware was classified radiographically using the AO-ASIF system. Final (Group II), and postoperative carpal tunnel syndrome (1 case radiographs were assessed for loss of reduction, degenerative in Group I, 2 cases in Group II). changes, and radiographic measurements including volar tilt, radial inclination, ulnar variance, and articular incongruity. CONCLUSIONS Both treatment methods result in similar Pain levels were assessed with a Visual Analog Scale (VAS), outcomes after one year. Treatment of fractures with CRPP and patients rated their satisfaction on a scale of 0–100%. is equally safe and efficacious when compared with ORIF. Patients also completed a D.A.S.H. questionnaire. Charts Radiographic measurements, strength, range of motion and were reviewed for patient demographics and comorbidities, subjective outcomes are comparable at one year. However, operative findings, surgical time, procedure cost, and CRPP requires approximately 50% less operative time and complications. The need for revision surgery or hardware has a lower re-operation rate and cost. Group II had a greater removal was also noted. than 50% reoperation rate for removal of symptomatic hardware. The benefits of earlier postoperative motion in RESULTS Age and fracture types were comparable between Group II are unclear. Groups. At 14 months follow-up (range 12–60 months), there were no differences between groups regarding loss of

◆ Speakers have nothing of value to disclose.

22 The Joint Annual ASSH/ASHT Meeting PAPER PAS20

Friday, September 23, 1:00 p.m. PAS20 Prospective Outcomes of Thumb Carpometacarpal Arthritis Treated with Arthroscopic Hemitrapeziectomy: Minimum Follow-Up of two Years

◆ Scott G. Edwards, MD, Alexandria, VA

PURPOSE Arthroscopic hemitrapeziectomy offers several RESULTS Operative time averaged 48 minutes. At twelve theoretical advantages over open techniques including faster weeks, average preoperative DASH scores improved from recovery, preservation of joint stability, less postoperative 60.8 to 9.6 postoperatively. Postoperative grip and pinch scarring and joint contracture, less risk of neurovascular strength improved 15 lbs and 3 lbs, respectively, from injury, and reduced thumb column height subsidence and preoperative measurements, and represented 85% and consequent deformity and weakness. The purpose of this 70%, respectively, of the contralateral side. Wrist and digital study was to prospectively evaluate the subjective and motion remain unchanged from preoperative measurements. objective results of thumb carpometacarpal arthritis treated Average opposition to the fifth metacarpal head decreased with arthroscopic hemitrapeziectomy. 15 mm from preoperative values, and two-thirds of patients reported to be “pleased” with both the cosmetic and overall METHODS Fifteen consecutive patients with isolated outcomes of their surgery. One patient developed a painful trapeziometacarpal arthritis were treated with arthroscopic neuroma due to pin placement. Otherwise, there were hemitrapeziectomy after nonoperative modalities failed to relieve no complications. At two years, DASH scores, grip and their symptoms. Minimum follow-up was two years. Patients pinch strengths, motion, and patient satisfaction remained with thumb MP hyperextension deformity of greater than 30° unchanged. There were no revision surgeries. or obvious pantrapezial arthritic degeneration as evidenced by plain radiographs were excluded from the study. Patients with CONCLUSIONS Arthroscopic hemitrapeziectomy is a safe subchondral cysts, trapeziometacarpal subluxation, mild STT procedure that offers patients with isolated trapeziometacarpal degeneration discovered at the time of arthroscopy, Workers arthritis significant increases in function and decreases in pain Compensation claims, and unrelated ipsilateral pathologies within three months postoperatively. These initial results are requiring operative intervention were included. Six weeks of maintained over a minimum of two years. By preserving the postoperative immobilization were followed with six weeks thumb column height and integrity of the joint capsule, the of physical therapy. At twelve weeks and at two years, grip recovery is accelerated, strength and motion are optimized, and pinch strengths, wrist and digital motions, and DASH and deformity is prevented. scores were compared to preoperative values. Cosmetic consideration and overall patient satisfaction were also graded. Any occurrences of complications were noted.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 23 PAPER PAS21

Friday, September 23, 1:07 p.m. PAS21 An in vitro Analysis of the Effect of Ligament Reconstruction or Extension Osteotomy on Trapeziometacarpal Joint Stability and Contact Area

*◆ Robert J. Strauch, MD, New York, NY Melvin Rosenwasser, MD, New York, NY Thomas Gardner, ME, New York, NY Matthew Koff, PhD, New York, NY

BACKGROUND Symptomatic laxity of the minimally the dorsal-volar direction. The total ligament reconstruction osteoarthritic thumb carpometacarpal (CMC) joint can be significantly reduced joint laxity in the radial-ulnar, dorsal- successfully treated by either ligament reconstruction or volar and prono-supination directions. The dorsal ligament metacarpal extension osteotomy. In this study, the laxity of reconstruction reduced laxity in the dorsal-volar direction cadaveric thumb CMC joints was measured and the influence only, the volar ligament reconstruction reduced laxity in both of ligament reconstruction and metacarpal osteotomy on joint dorsovolar and radioulnar directions. The 10 and 15 degree laxity and contact area was determined. osteotomies produced a dorsal shift of the weighted centroid of contact on the metacarpal and trapezium, while the METHODS The baseline laxity of CMC joints from 25 ligament reconstruction did not produce such an effect. human cadaveric specimens (average age 42, range 18–55) was measured in the position of lateral pinch on a custom- CONCLUSIONS In the position of lateral pinch, the 15 degree designed CMC joint laxity tester. Joint laxity was measured osteotomy and total ligament reconstruction significantly again after two surgical simulations consisting of either a reduced laxity of the thumb CMC joint in all directions tested. metacarpal extension osteotomy, or an Eaton-Littler ligament The isolated dorsal or volar ligament reconstructions both reconstruction. Joint laxity was measured for the individual reduced dorsal-volar laxity. volar and dorsal limbs of the ligament reconstruction as well as for the total ligament reconstruction. Contact area between Clinical Relevance: Metacarpal extension osteotomy may the thumb metacarpal and trapezium during testing was stabilize the thumb CMC joint in lateral pinch to a degree determined using the technique of stereophotogrammetry. similar to a standard ligament reconstruction.

RESULTS The 15 degree extension osteotomy significantly reduced CMC joint laxity in the radial-ulnar, dorsal-volar, prono-supination and distraction directions in the position of lateral pinch. The 10 degree osteotomy reduced laxity only in

◆ Speakers have nothing of value to disclose.

* Grant support received from NIH (AR41020).

24 The Joint Annual ASSH/ASHT Meeting PAPER PAS22

Friday, September 23, 1:14 p.m. PAS22 Repair of Ulnar Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint with Pull-Out Button and Cast Immobilization Versus Bone Anchor and Early Mobilization

◆ Leonid I. Katolik, MD, Seattle, WA Thomas Trumble, MD, Seattle, WA

PURPOSE Disruption of the ulnar collateral ligament (UCL) side compared to 86% and 87% respectively for the button of the thumb metacarpohhalangeal (MCP) joint is a common group. For the anchor group, pinch strength averaged 101% injury. An increasing body of evidence supports surgical repair of the contralateral side compared to 95% for the button of complete UCL disruptions. The use of intraosseous suture group. No significant difference was noted between the two anchors in the treatment of UCL ruptures in the thumb has groups for grip strength. Average tourniquet time for the been previously described. However, no direct comparisons anchor group was 28 minutes compared to 43 minutes. Soft of UCL repair with bone anchor versus repair with a pull out tissue complications were present in 21% (8/30) patients button and immobilization exist. in the pull-out button group compared to 7% (2/30) in the anchor group. METHODS Our study compares two cohorts of patients with complete rupture of the UCL of the thumb MCP joint. CONCLUSIONS Both methods of repair are safe and Thirty patients in each cohort underwent repair of the UCL effective for the treatment of thumb UCL injuries. The use with either an intraosseous suture anchor followed by early of suture anchors allows for an accelerated rehabilitation mobilization or a pull-out suture tied over a button with cast protocol which may account for the improved range of motion immobilization. Average follow-up was 29 months. and pinch strength at follow-up.

RESULTS At follow up, range of motion at the MCP and IP joints for the anchor group averaged 97% of the contralateral

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 25 PAPER PAS23

Friday, September 23, 1:21 p.m. PAS23 Results of Osteotomy under Visual Control for Malunited Impacted Fractures of the Base of the Middle Phalanx

◆ Francisco Piñal, MD, Santander, Spain Francisco J. García-Bernal, MD, Santander, Spain Julio Delgado-Martinez, MD, Santander, Spain Marcos Sanmartin, MD, Santander, Spain

PURPOSE Intra-articular malunions of the base of the RESULTS Ten out of 11 patients were followed up longer middle phalanx present a formidable management dilemma. than 1 year (maximum 5.2 years, mean 28.3 months). The Late osteotomy has been rarely reported in the literature. other with volar lateral impaction fracture was lost 4 weeks The purpose of this study is to present our results in the after the surgery and was excluded from the results. All except treatment of late presenting impaction fractures of the base one achieved a functional range of motion of the PIP joint of the middle phalanx treated by osteotomy under direct (AROM: 77.3°± 26.9). Moderate limitations of the DIP joint visual control to restore the normal anatomy. were common (AROM: 54.8°± 25.6). Grip and pinch strength were 94.7 and 89.7% of the healthy side. The average pain METHODS Eleven patients with a malunited (impacted) level (as rated on a visual analog scale of 0–10) improved form fracture of the base of the middle phalanx were treated by a preoperative 9.1 (7–10) to 0.8 (0–4) postoperatively. One osteotomy more than three weeks after the injury (5 weeks patient was somewhat dissatisfied; all others were satisfied to 4 months). In seven the injury occurred at work and was or very satisfied. All returned to their previous work at an covered under workers´ compensation. All fractures had average of 13 weeks after the surgery. variable degrees of impaction, comminution and dorsal subluxation. There were 6 predominantly volar compression CONCLUSIONS This study showed that osteotomy is a fractures-dislocations and 5 volar-lateral compression valid alternative in the treatment of late presenting impaction (average impacted surface as measured intraoperatively: fracture dislocation of the PIP joint. The procedure is technically 52.3±12.6%). The malunited joint surface was visualized by a demanding with minimal margin of error. Favorable results shot-gun approach. Anatomic reduction was accomplished by have been achieved in this challenging scenario in the short osteotomy and mobilization of the fragments. Rigid fixation and middle-term in 9 out of 10 patients. Previous surgery and was carried out by cerclage wire, screws or combinations. moderate to severe wearing of the cartilage of the proximal Distal radius bone graft was used in 9 patients. phalanx head negatively affected the results.

◆ Speakers have nothing of value to disclose.

26 The Joint Annual ASSH/ASHT Meeting PAPER PAS24

Friday, September 23, 1:28 p.m. PAS24 In Vivo Radioscaphoid and Radiolunate Kinematics and The Dart Thrower’s Motion

*◆ Joseph J. Crisco, PhD, Providence, RI Edward Akelman, MD, Providence, RI Arnold-Peter C. Weiss, MD, Providence, RI ◆ Scott W. Wolfe, MD, New York, NY

PURPOSE While the complex articulations of the carpus the dart thrower’s motion than in any other arc of motion. permit a full range of wrist motion, the kinematics of the At wrist positions along the arc of the dart thrower’s motion carpal bones have only been studied in limited arcs of wrist the rotation of the scaphoid and lunate approached a zero motion. The purpose of this study was to determine the 3-D value. In all wrist positions, the scaphoid and lunate primarily in vivo kinematics of the radioscaphoid and radiolunate joints either flexed or extended. Scaphoid and lunate rotations in throughout the entire range of wrist motion in uninjured supination/pronation and radial/ulnar deviation were minimal. subjects and to test the hypothesis that the dart thrower’s When the scaphoid and lunate extended they translated in a motion is achieved with unique radiocarpal kinematics. radial direction. Translations were minimal when they flexed.

METHODS The 3-D kinematics of the capitate, scaphoid and CONCLUSIONS The dart thrower’s motion is the functional lunate were measured in vivo at a total of 504 various wrist direction of the radiocarpal joint, and is oriented obliquely positions of both wrists of 14 male (25.6 years; range 22–34), to the anatomical axes of flexion/extension and radioulnar and 14 female (23.6 years; range 21–28) healthy subjects deviation. The finding that the scaphoid and lunate rotate using CT volume images and established segmentation and minimally during this motion demonstrates that the dart registration procedures for noninvasive markerless bone thrower’s motion is accomplished with maximal radiocarpal motion tracking. The 3D kinematics of the scaphoid and stability. The ability to accomplish several important aspects lunate were analyzed as a function of wrist position, defined of wrist motion while minimizing radiocarpal joint motion may by the position of the capitate, with special focus on the wrist play an important role with respect to cartilage preservation. positions of the dart thrower’s motion from radial extension This study provides new fundamental insight into the in vivo to ulnar flexion. Multiple linear regression was used to test mechanisms of the carpus and supports the suggestion that our hypothesis. specific rehabilitation protocols can be designed to minimize radiocarpal motion and thereby protect ligament repairs and RESULTS Radioscaphoid and radiolunate rotations were fractures of the proximal carpal row. significantly less (P < 0.01 for both carpal bones) during

◆ Speakers have nothing of value to disclose.

* Grant support received from NIH AR044005.

Meeting Abstracts 27 PAPER PAS25

Friday, September 23, 2:20 p.m. PAS25 Carpal Tunnel Syndrome in Pregnancy: Establishing Incidence and Natural History

◆ Glen D. Seidman, MD, South Weymouth, MA Lizbeth Noyes, BS, South Weymouth, MA Rebecca Dunk, BS, MS, South Weymouth, MA Patrick J. Nugent, MD, South Weymouth, MA

PURPOSE The purpose was to establish the incidence and with persistent symptoms post-partum, 76.3% worked natural history of carpal tunnel syndrome (CTS) in pregnancy, outside the home, and 73% were breast-feeding (compared a topic not well defined in the literature. to 85% breast-feeders in non-CTS post-partum women). Of those persistently symptomatic patients, 33.9% required METHODS A descriptive retrospective cohort study was therapeutic intervention. designed to interview all patients presenting to Labor and Delivery at our institution in a six month period, with follow- CONCLUSIONS Carpal tunnel syndrome in pregnancy had up interviews at six weeks post-partum. Patients were an incidence of 11.95%, with the most frequent symptoms at questioned about symptoms, risk factors, treatment and 24–28 weeks of gestation. Symptoms persisted greater than 6 possible etiologies. weeks post-partum in 36% of patients. CTS in pregnancy does not appear to have a hormonal etiology since persistent RESULTS 2,112 women presented to Labor and Delivery symptoms post-partum did not correlate significantly with in the six month period. 1,926 (91%) completed the initial breast-feeding, a condition that perpetuates the hormonal screening. 230 of the screened women had symptoms changes of pregnancy. There was a correlation with working of CTS in pregnancy, an incidence of 11.95%. The most outside the home. This study assisted in formulating future common presentation of symptoms was at 24 to 28 weeks studies to further define the natural history of CTS in of gestation. 36% of women with CTS during pregnancy had pregnancy. symptoms still present at six weeks post-partum. In those

◆ Speakers have nothing of value to disclose.

28 The Joint Annual ASSH/ASHT Meeting PAPER PAS26

Friday, September 23, 2:27 p.m. PAS26 Segmental Carpal Canal Pressure in Patients with Carpal Tunnel Syndrome

◆ Kazuo Ikeda, MD, Kanazawa, Japan Tomita Katsuro, MD, Kanazawa, Japan Osamura Naoki, MD, Kanazawa, Japan

PURPOSE Previous studies using the constant infusion 2 cm proximal to the distal wrist crease (DWC) using an image technique measured pressure in a carpal canal like an artery. intensifier to guide the progress. The wire was then retracted However, a carpal canal is not closed environment and not in 5 mm increments to 2 cm distal to the DWC for recording uniform structure. The precise pressure must be measured canal pressure using pressure sensor. The purpose of this study is to clarify the grade of compression to the median nerve using an RESULTS The average and standard deviation of the carpal inching technique with a new pressure guide wire system. canal pressure at each location were as follows: the pressure at 20 mm distal to the DWC was 4.2±6.3 mmHg, at 15 mm METHODS Nine patients (8 female and one male) with was 27.2±16.2 mmHg, at 10 mm was 36.8±20.3 mmHg, at 5 idiopathic carpal tunnel syndrome, ranging in age from 29 mm was 31.2±20.7 mmHg, at DWC was 11.7±10.9 mmHg, to 73 years (mean, 59 years) were studied using a new at 10 mm proximal to the DWC was 7.3±10.6 mmHg, and at pressure guide wire system. This device is usually reserved 20 mm was 4.6±2.5 mmHg. for measuring of coronary-artery pressures (WaveWire™, Volcano Therapeutic Inc, USA) and consists of a 0.3 mm CONCLUSIONS Our study showed that the most diameter wire connected to a pressure monitor. Pressure compressed part of the median nerve in the carpal canal was measurement was carried out under axillary block. We at 10 mm distal to the DWC. This point was coincided to the performed open carpal tunnel release with one incision on thickest part of the flexor retinaculum. Since normal condition the palm. A 2 cm incision on the palm was made and the wire of the carpal canal pressure is considered to be 14 mmHg, a was introduced at the distal part of the flexor retinaculum. forearm fascia should be released by 10 mm proximal to the Before performing the release, the wire was adjusted to DWC (7.3±10.6 mmHg) considering the deviation.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 29 PAPER PAS27

Friday, September 23, 2:34 p.m. PAS27 Surgical Management of Cubital Tunnel Syndrome: A Comparative Analysis of Outcome Using Four Different Techniques

◆ Michel Saint-Cyr, MD, Louisville, KY Andrew S. LaJoie, PhD, Louisville, KY D Tan, MD, Louisville, KY Tsu-Min Tsai, MD, Louisville, KY

PURPOSE Compare the outcome of four different surgical 60 R vs 57 L. Average patient age was 45.7 years ± 12.5. techniques: 1. Simple decompression 2. Endoscopic Diabetes and hypertension were present in 6.0% (7/117) and decompression 3. Subcutaneous decompression and 12.8% (15/117) of patients respectively. Average duration 4. Submuscular decompression for the treatment of cubital of symptoms prior to consultation was 11.5 months ± 14.5. tunnel syndrome. Mean follow-up was 404 ± 568 days. Conservative treatment prior to surgery was 339 days. Dellon’s classification at initial METHODS One-hundred seventeen patients with cubital consultation was: 29.9% mild, 32.5% moderate and 37.6% tunnel syndrome were reviewed from 1986 to 2000. Inclusion severe. Correlation between severity of nerve compression criteria included all patients with cubital tunnel syndrome and symptom duration was not statistically significant. A refractory to conservative treatment. Patients with previous significant positive correlation existed between the SSS and cubital tunnel surgery were excluded. Parameters measured Dellon score, 0.32. Carpal tunnel syndrome was the most included: signs and symptoms, medical comorbidity, other commonly associated nerve compression. Bishop’s rating nerve compressions, and anatomical pathology. Severity was was 46.5% excellent, 39.5% good, 7.9% fair and 6.1% poor evaluated using the Dellon classification and the symptom overall. A significant positive correlation existed between severity score SSS (pain, clawing, Froment, Wartenberg’s). the Bishop rating and Dellon score, Rho=0.28 with P=0.003. Bishop’s rating was measured at final follow-up. Duration of The average Bishop score was 1.74 ± 0.85 and no significant symptoms, conservative treatment prior to surgery, and follow- difference existed when comparing each surgical technique up were all recorded. Statistical analysis included Student’s T to one another. No significant association was found between and Kruskall-Wallis tests and Spearman’s Rho for correlation. the severity of compression (Dellon) and the surgery type Parameters correlated included: duration of symptoms vs performed. Dellon, SSS vs Dellon, and Bishop vs Dellon. Other outcomes measured included: other nerve compression vs Dellon, CONCLUSIONS Increasing severity of ulnar nerve surgery type vs Bishop, and surgery type vs Dellon. compression negatively influenced outcome (Bishop rating). No significant differences were found between the type of RESULTS Of the 117 cases treated (61 men, 56 women), 9 surgeries performed in regard to outcome and Dellon score. were bilateral with right and left sides being equally affected

◆ Speakers have nothing of value to disclose.

30 The Joint Annual ASSH/ASHT Meeting PAPER PAS28

Friday, September 23, 2:41 p.m. PAS28 Submuscular versus Subcutaneous Anterior Ulnar Nerve Transposition: A Rat Histologic Study

◆ Steve K. Lee, MD, New York, NY Sheel Sharma, MD, New York, NY George Kleinman, MD, New York, NY Michael Hausman, MD, New York, NY

PURPOSE Two common methods of ulnar nerve anterior RESULTS Nerve health was classified into four parts where transposition are submuscular and subcutaneous. The purpose 1 = normal nerve, 2 = 1/3 abnormal axons, 3 = 2/3 abnormal of this study was to examine the histologic differences axons, 4 = 100% abnormal nerve. Peri-neural scar formation between them. was classified into a three part classification where 1 = no scar, 2 = scar partially surrounding nerve, 3 = scar completely METHODS Ten Sprague-Dawley rats underwent ulnar encasing nerve. nerve transpositions; one side subcutaneous and the other side submuscular. Animals were sacrificed six weeks after CONCLUSIONS Based on this rat model, the submuscular the index operation and the forelimbs sectioned and stained method of ulnar nerve anterior transposition displayed with hematoxylin and eosin. histologically healthier axons and less peri-neural scar tissue when compared to the subcutaneous method.

FIGURE 1 FIGURE 2 An example of nerve health III and scar III. An example of nerve health I and scar I.

FIGURE 3 FIGURE 4 The submuscular method displayed significantly healthier The submuscular method also displayed significantly less ulnar nerve axons (p<0.03). peri-neural scar tissue (p<0.0001).

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 31 PAPER PAS29

Friday, September 23, 2:48 p.m. PAS29 Long Term Outcomes of Radial Tunnel Release—the Influence of Coexisting Lateral Epicondylitis, Multiple Nerve Compression Syndromes and Workers’ Compensation

◆ JuiTien Lee, MD, Los Angeles, CA Neil F. Jones, MD, Los Angeles, CA

PURPOSE Surgical decompression of radial tunnel extremities in 4 patients (15%); and poor in 5 extremities in syndrome remains controversial because the results are 5 patients (18%). The outcome was better in patients with unpredictable. This study is a retrospective analysis of the simple radial tunnel syndrome (86% good results) compared long term outcomes of radial tunnel release with a specific with patients with associated multiple nerve compression emphasis on whether coexisting lateral epicondylitis, multiple syndromes (only 57% good results) or with coexisting lateral nerve compression syndromes and workers’ compensation epicondylitis (only 40% good results). Those patients who have any negative influence on the outcome. were receiving workers’ compensation achieved 58% good outcomes compared with 73% good outcomes in patients METHODS Over a 10-year period, 33 extremities in not receiving workers’ compensation. Outcomes did not 31 patients underwent decompression for radial tunnel correlate with the site of compression and were not affected syndrome, from which 27 extremities in 25 patients were by the presence of gross anatomical changes in the radial available for long term follow up, after an average of 4 years nerve or posterior interosseous nerve. and 9 months (16 to 106 months). Outcome parameters of pain and function were evaluated according to the criteria of CONCLUSIONS In our experience, surgical decompression Ritts. is worthwhile for simple radial tunnel syndrome, but it may be less successful if multiple nerve compression syndromes or RESULTS 82% of the patients achieved relief of their pain, lateral epicondylitis are also present. Outcomes are slightly but one third of patients still had moderate or severe disability less optimistic in patients receiving workers’ compensation, which affected their ability to work. The outcome was rated but not as disappointing as previous studies have suggested. as good in 18 of 27 extremities in 16 patients (67%); fair in 4

◆ Speakers have nothing of value to disclose.

32 The Joint Annual ASSH/ASHT Meeting PAPER PAS30

Saturday, September 24, 8:30 a.m. PAS30 Dynamic EMG Analysis Following Biceps to Triceps Tendon Transfer

*◆ Scott Kozin, MD, Philadelphia, PA David Hutchinson, PT, Philadelphia, PA MJ Mulcahey, OTR/L, Philadelphia, PA Theresa Duffy, OTR/L, Philadelphia, PA

INTRODUCTION Restoration of elbow extension is an possible with full range) frequency of alternating movement. integral part of upper extremity reconstruction in persons Conventional manual muscle testing (MMT) grades were with tetraplegia. Active elbow extension increases available tabulated pre and 1-year post surgery. workspace, enhances mobility in bed, promotes independent transfer, and improves manual wheelchair use. Surgical RESULTS The median preoperative MMT score for elbow options include deltoid to triceps or biceps to triceps tendon extension was 0/5 (range 0/5–1+/5) prior to biceps transfer transfer. The purpose of this study was to evaluate the biceps and 4/5 (range: 2/5–5/5) 1-year following surgery (p<.05). In muscle after tendon transfer for elbow extension. Specifically, ALL patients, qualitative analysis revealed EMG recruitment to determine if the biceps can be trained to act as an elbow of the biceps during the extensor phase in both self-selected extensor. and rapid alternating movements. In contrast, the biceps was quiescent during elbow flexion. METHODS Nine subjects (15 arms) underwent biceps to triceps transfer with an average age of 17+/– 1.4 years. All CONCLUSION Following biceps to triceps transfer, there participants consented to fine wire EMG assessment of the is a reversal of the ordinary action of the biceps muscle. biceps and surrounding musculature at 21 +/– 6.4 months The biceps is active during elbow extension and relatively after surgery. Subjects performed alternating elbow flexion quiescent during self-selected and rapid elbow flexion. and extension in a gravity neutral position under conditions of The EMG results EMG data correlates with the significant both self-selected (comfortable full range) and rapid (as fast as improvement in MMT.

◆ Speakers have nothing of value to disclose. * Grant support received from ASSH Foundation.

Meeting Abstracts 33 PAPER PAS31

Saturday, September 24, 8:37 a.m. PAS31 Wrist Pain after Radial Head Excision for Congenital Radial Head Dislocation

◆ Emily A. Hattwick, MD, MPH, McLean, VA Michelle A. James, MD, Sacramento, CA

PURPOSE To evaluate changes at the wrist before and a series of complications after radial head resection due to after radial head resection for congenital dislocation of the complete incompetence of the interosseous membrane. This radial head. patient underwent five operations culminating in the creation of a one-bone forearm. METHOD We present a retrospective series of six patients with radiographically and clinically confirmed congenital CONCLUSIONS The problem of proximal migration of the dislocation of the radial head with a minimum of two-year radius in the pediatric population has not been thoroughly follow-up after radial head excision for congenital dislocation. evaluated in this patient population. Current literature supports Pre and postoperative radiographs of the wrist and clinical radial head resection for symptomatic congenital dislocation evaluation of range of motion and wrist pain were obtained. of the radial head, but is divided with respect to postoperative wrist symptoms, especially in the skeletally immature patient. RESULTS Four of six of our patients had wrist pain post- Our experience suggests that the skeletally immature patient operatively and all four of them have radiographs that show may be at higher risk of proximal migration of the radius. Wrist post-operative proximal migration of the radius at the DRUJ. radiographs should be obtained preoperatively and followed Postoperative increases in arc of motion reflected previously post-operatively in this population and this complication published results (6 degree increase in flexion-extension arc should be discussed with the family before surgery. A larger and 31 degree increase in pronosupination arc). Two patients series of patients with documented wrist radiographs are with postoperative wrist pain were skeletally immature at needed to better understand this complication. the time of radial head resection. One of these patients had

◆ Speakers have nothing of value to disclose.

34 The Joint Annual ASSH/ASHT Meeting PAPER PAS32

Saturday, September 24, 8:44 a.m. PAS32 Accuracy of Plain Radiographs in assessing Radial Head Fractures

◆ Kian Riaszadeh, MD, Newark, NJ ◆ John T. Capo, MD, Newark, NJ Ken Swan, MD, Newark, NJ Virak Tan, MD, Newark, NJ

PURPOSE The radial head plays a critical role in forearm RESULTS The percentage of radial head involvement rotation and joint stability of the elbow and wrist. While estimated by plain radiographs was in error by an average treatment is based largely on the type of radial head fracture amount of 17% as compared to intra-operative findings. seen on plain radiographs, the reliability of radiographic In ten cases the percentage of head involvement classification is unknown. The purpose of our study is to was underestimated while in the remaining six it was examine the accuracy in determining the character of radial overestimated. The average number of radial head fragments head fractures with plain radiographs alone, in comparison to estimated was found to have a one fragment difference computed tomography and intra-operative observation. as compared to CT scans and intra-op examination. It was overestimated in seven, underestimated in six and correct METHODS Seventeen patients who sustained radial head in three cases. The presence of a coronoid fracture was fractures were included in the study. Standard pre-operative correctly determined in all six cases, but the size and type AP and lateral elbow radiographs alone were used as our test was incorrect in 45% of the responses. A portion of the radial data. Three independent, blinded physicians (junior resident, head was still attached to the shaft in 8 of 16 cases studied. senior resident, attending physician) assessed various However, in these cases the examiners incorrectly stated fracture characteristics using these radiographs. These that the head was not intact to the neck 29% of the time. included: percentage of radial head involvement, number of fragments, displacement of the largest fragment, articular CONCLUSIONS This report demonstrates the inaccuracy step-off, and associated injuries (i.e., coronoid fractures). Pre- of correctly characterizing radial head fractures with plain operative CT scans with 3D reconstructions were obtained radiographs alone. When using the often quoted critical on twelve patients, and detailed intra-operative findings were values of 20–30% of head involvement, greater than three available on all patients. Findings from these two sources fragments and two mm of articular step-off as clinical were utilized to determine various parameters relating to the treatment guidelines, very small errors in interpretation of fracture pattern and were compared with the results from the x-rays, as seen in this study, can incorrectly alter treatment plain radiographs. choices.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 35 PAPER PAS33

Saturday, September 24, 8:51 a.m. PAS33 A Bipolar Radial Head Prosthesis Tracks Differently Than a Monoblock Prosthesis during Forearm Rotation; A Biomechanical Study

* Mark E.. Baratz, MD, Pittsburgh, PA Karol Galik, PhD, Pittsburgh, PA Mark Miller, PhD, Pittsburgh, PA Adrian Butler, MD, Pittsburgh, PA

PURPOSE A monopolar prosthetic radial head will track magnitude increased by 25% (p<0.05) in both directions. differently than a bipolar prosthesis. The mean pronation-supination axis was 0.3 +/– 2.6 mm medial and 0.3 +/– 1.9 mm anterior from the center of the METHODS Six cadaveric elbows were used to study travel capitellum and 0.1 +/– 2.8 mm medial and 2.4 +/– 1.8 mm of the native radial head with and without annular ligament, anterior to the ulnar styloid. This axis did not change when with a monoblock prosthesis (Evolve, Wright Medical) and with the annular ligament was transsected or with either radial a bipolar prosthesis (Katalyst, Kinetos Medical Inc.) Marker head replacement. Differences in travel of the prosthetic head arrays were attached to the distal radius, distal ulna, radial were observed when comparing the monoblock to the bipolar head, and humerus. Specimens were mounted on a custom radial head prostheses. With both pronation and supination, frame with the elbow fixed at 90 degrees. A constant force the radial head traveled laterally and anteriorly from the of 22 N was applied to the triceps and brachialis. Forearm neutral position. With the monoblock implant, an average rotation was initiated via traction on the pronator teres and increase of 0.7 mm (p < 0.05) in medial-lateral translation biceps tendons. Analysis of excursion was performed with a was observed when compared to the native radial head. No passive marker motion analysis system (Peak5). After each statistically significant difference in medial-lateral translation experiment, the specimen was disarticulated and digitized was appreciated between the bipolar and native radial head. using a coordinate measuring machine. This permitted When the monoblock and bipolar implants were compared, calculation of radial head travel, location of the pronation- the bipolar medial-lateral translation was 1.1 mm less than supination axis, and the distance of this axis from the ulnar translation of the monoblock head (p < 0.05). styloid and center of the capitellum. Statistical analysis was performed with the paired t-test. CONCLUSIONS Translation of a bipolar prosthestic radial head on the capitellum more closely approximated that of RESULTS Mean translations of the native radial head were the native head than did a monoblock prosthesis. These 1.5 +/– 0.7 mm medial-lateral and 2.3 +/– 1.0 mm anterior- findings may implications for post-operative pain and implant posterior. After transsection of the annular ligament, the longevity. pattern of radial head travel was not altered, however the

* Grant support received from ASSH research grant.

36 The Joint Annual ASSH/ASHT Meeting PAPER PAS34

Saturday, September 24, 8:58 a.m. PAS34 Type 1 Coronoid Fractures: Does Suture Fixation Improve Elbow Stability?

*◆ Daphne M. Beingessner, BMath, BSc, MSc, MD, FRCSC, Seattle, WA Cynthia E. Dunning, MSc, PhD, PEng, London, ON, Canada James A. Johnson, PhD, PEng, London, ON, Canada Graham JW. King, MSc, MD, FRCSC, London, ON, Canada

PURPOSE The objective of the current study was to loaded positions. Two-way repeated measures ANOVA’s and determine the effect of suture fixation of Type 1 coronoid post-hoc Student-Newman-Keuls tests were carried out with fractures on elbow kinematics in ligamentously intact and significance defined at p<0.05. medial collateral ligament (MCL) deficient elbows combined with radial head replacement. RESULTS With intact ligaments, there was an increase in valgus angulation following a Type 1 coronoid fracture (p<0.05) METHODS Eight fresh-frozen cadaveric upper extremities that was not corrected with fixation. With MCL deficiency, were mounted in a specialized testing apparatus. Kinematic there was no change in valgus angulation for all coronoid data were collected from an electromagnetic tracking system. states. For both ligament states, there was an increase Medial epicondyle osteotomy was performed to simulate MCL maximum varus-valgus laxity after a Type 1 coronoid fracture insufficiency. Lateral epicondyle osteotomy and radial head with forearm pronation (p=0.03) that was not corrected with resection were performed to gain access to the coronoid. Ten fixation (p=0.4). percent of the coronoid was removed from the tip to simulate a Type 1 fracture. The avulsed coronoid tip, together with the DISCUSSION We demonstrated a change in elbow adjacent anterior capsule, was repaired with suture over a kinematics and laxity with a Type 1 coronoid fracture with bone bridge on the subcutaneous border of the ulna. Metallic intact ligaments. These changes were small and suture repair radial head arthroplasty was performed and the lateral of the coronoid did not correct the kinematics and laxity to osteotomy was repaired. Testing was performed in the stable baseline. Similarly, with MCL disruption, a Type 1 fracture elbow (both osteotomies repaired) and the MCL deficient had no effect on elbow kinematics and a very small effect on elbow (lateral osteotomy repaired) with an intact coronoid, laxity that was not corrected with coronoid repair. Therefore, a Type 1 coronoid fracture, and with the coronoid fracture our findings suggest that suture fixation of Type 1 coronoid repaired. Valgus stability was determined for simulated active fractures is probably not necessary as long as the lateral elbow motion. Maximum varus-valgus laxity was measured ligaments have been repaired and the lateral column has during passive motion with the arm in the horizontal gravity- been restored with either radial head replacement or repair.

◆ Speakers have nothing of value to disclose.

* Grant support received from Canadian Institute of Health Research.

Meeting Abstracts 37 PAPER PAS35

Saturday, September 24, 9:50 a.m. PAS35 Varus Posteromedial Rotational Elbow Injuries

*◆ David Ring, MD, Boston, MA Job Doornberg, MS, Boston, MA

PURPOSE Varus posteromedial rotational elbow injury is a it was not repaired (subsequently reconstructed with a recently described and incompletely characterized pattern of fragment of radial head in one patient) traumatic elbow instability. RESULTS Four patients had malalignment of the METHODS A single surgeon participated in the treatment anteromedial facet of the coronoid with varus subluxation of sixteen patients with a varus posteromedial rotational of the elbow—two because the fracture was not specifically injury pattern. All of the injuries were characterized by varus treated, and two due to loss of fixation (one screw and one angulation of the elbow without dislocation and fracture plate treated patient). One of these patients and one additional of the anteromedial facet of the coronoid process. All but patient had a deep infection. All four patients with coronoid three patients had avulsion of the origin of lateral collateral malalignment and residual subluxation had arthrosis and a ligament complex from the lateral epicondyle (two patients fair or poor result according to the Mayo Elbow Performance with olecranon fractures and one with a concomitant fracture Index. The remaining twelve patients regained an average of the base of the coronoid process did not have LCL injury). of 120 degrees of elbow flexion and had good or excellent Associated fractures included 3 olecranon fractures, 3 radial elbow function. head fractures, 1 fracture of the medial trochlear lip, and one fracture at the base of the coronoid process. There were 14 CONCLUSIONS Varus posteromedial rotational elbow men and 2 women with an average age of 49 years (range injuries are a distinct type of elbow fracture-dislocation 18 to 85). Twelve patients were treated for the acute fracture that must be recognized and adequately treated to restore and four were managed after initial treatment elsewhere. good elbow function. In particular, inadequate fixation of the The initial treatment was operative in 14 patients and non- anteromedial facet of the coronoid—best treated with a plate operative in 2 patients. In twelve patients the coronoid was on the medial surface of the coronoid—is associated with repaired with a plate applied to the medial surface of the subluxation, arthrosis and a poor result. coronoid, in one it was repaired with a screw, and in three

◆ Speakers have nothing of value to disclose.

* Grant support received from AO Unrestricted Grant.

38 The Joint Annual ASSH/ASHT Meeting PAPER PAS36

Saturday, September 24, 9:57 a.m. PAS36 Posterolateral Rotatory Instability of the Elbow in Association with Lateral Epicondylitis

◆ David M. Kalainov, MD, Chicago, IL Mark S. Cohen, MD, Chicago, IL

Lateral stability of the elbow is dependent upon the integrity subsequent clinical findings consistent with posterolateral of the lateral collateral ligament and secondary soft-tissue rotatory instability of the elbow. Two of the patients had restraints. Posterolateral rotatory elbow subluxation has been visible synovial fistulas and MRI studies indicative of lateral recognized in association with elbow trauma, surgery for collateral ligament insufficiency. All three patients eventually epicondylitis, and congenital cubitus varus deformity. While underwent an examination of the elbow under anesthesia abnormal signal changes on magnetic resonance imaging confirming posterolateral rotatory subluxation. Surgery in (MRI) have been shown to include the lateral collateral each case involved debridement and repair/reconstruction ligament in patients with tennis elbow, we are aware of of the common extensor tendon origin and lateral collateral no reports of elbow instability detected in patients with ligament. Pain was relieved at a minimum follow-up of eight epicondylitis managed nonoperatively. months with no clinical or radiographic evidence of recurrent joint instability. The potential role of corticosteroid injections We describe the cases of three healthy middle-aged women in the pathogenesis of combined lateral epicondylitis and who presented with atraumatic lateral epicondylitis and rotatory instability of the elbow is discussed.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 39 PAPER PAS37

Saturday, September 24, 10:04 a.m. PAS37 Autologous Osteochondral Mosaicplasty for Capitellar Osteochondritis Dissecans in Teenage Patients

◆ Norimasa Iwasaki, MD, Sapporo, Japan Akio Minami, MD, Sapporo, Japan Jyunichi Ishikawa, MD, Sapporo, Japan Hiroyuki Kato, MD, Matsumoto, Japan

PURPOSE Osteochondritis dissecans of the humeral mean follow-up of 24 months, all patients were evaluated capitellum (capitellar OCD) is typically found in baseball clinically and radiographically. The clinical assessment players in their early teens. Although several treatment was based on the elbow rating system of Timmerman and options involving operative resurfacing are available to treat Andrews (a maximum of 200 points). Five of the eight patients the lesions, the postoperative outcomes are still controversial. underwent magnetic resonance imaging (MRI). Autologous osteochondral mosaicplasty (mosaicplasty) is a new technique to provide hyaline or hyaline-like repair for RESULTS Seven of the eight patients were free from articular defects. Recent studies have reported the successful elbow pain and the remaining one had mild pain occasionally. treatment of articular defects in the knee and ankle joints The mean clinical score significantly improved from 140 with this surgical procedure. However, little attention has points to 183 points postoperatively. All patients except been given to the surgical efficacy of mosaicplasty against one had excellent clinical results. No patients complained capitellar OCD. The objective of this study was to clarify the of any donor site symptoms at follow-up. Radiographically, clinical outcomes of mosaicplasty for teenage patients with the graft incorporation and a normal contour of the articular advanced lesions of capitellar OCD. surface were found in all patients. There were no secondary degenerative changes of the elbow in any patient. In each METHODS Eight male patients (average age, 13.9 patient, an MRI showed that the preoperative heterogeneity years) with advanced lesions of capitellar OCD underwent of the lesion had disappeared and the signal intensity returned mosaicplasties. All patients were baseball players who were to normal. affected on the right side, which was also their throwing side. Indications for this operation included failure of conservative CONCLUSIONS Mosaicplasty for advanced lesions of treatment and radiographic evidence of unstable fragments capitellar OCD in teenage baseball players can provide in the elbow. The surgical technique involves obtaining small excellent clinical and radiographic results. Although the results sized (2.7 mm–6.0 mm in diameter) cylindrical osteochondral were based on relatively short-term follow-up, mosaicplasty grafts from the lateral periphery of the femoral condyles and appears to be a promising novel surgical option for advanced transplanting them to prepared osteochondral defects. At a lesions of capitellar OCD.

◆ Speakers have nothing of value to disclose.

40 The Joint Annual ASSH/ASHT Meeting PAPER PAS38

Saturday, September 24, 10:11 a.m. PAS38 The Effect of Derotational Humeral Osteotomy on Global Shoulder Function and Glenohumeral Deformity in Brachial Plexus Birth Palsy

*◆ Donald S. Bae, MD, Boston, MA Peter M. Waters, MD, Boston, MA

PURPOSE Derotational humeral osteotomies (DHO) have RESULTS Average amount of external rotation achieved been employed in older children with brachial plexus birth with osteotomy was 68 degrees (range 35–90 degrees). Mean palsy and glenohumeral joint deformity to place the upper aggregate Mallet classification scores improved from 13 to 19 extremity in a more functional position. The purpose of this following DHO. Mean individual element Mallet classification study was to determine the effects of these procedures on scores similarly demonstrated improvement following shoulder function and joint morphology. osteotomy, with greatest gains in hand-to-mouth, hand-to- neck, and external rotation motions. Mean glenohumeral METHODS Forty-three patients underwent DHO for deformity classification was 4 pre- and post-operatively, functional impairment in the setting of internal rotation signifying presence of a pseudoglenoid. There were no contracture and glenohumeral joint deformity at our institution nonunions. One patient required revision DHO for inadequate from 1996 to 2004. Osteotomies were performed proximal initial correction. One patient sustained a humeral fracture to the deltoid insertion and stabilized with plate and screw below the plate fixation due to sports-related trauma. fixation. Average age at the time of surgery was 6.6 years (range 1.8–16 years). Shoulder function was graded according CONCLUSIONS DHO improves shoulder function in to the modified Mallet classification. Glenohumeral deformity patients with brachial plexus birth palsy, internal rotation was graded according to the classification scheme of Waters contracture, and underlying glenohumeral joint deformity. et al.1 The results in 27 patients with minimum 2 year follow- DHO provides an attractive treatment option for brachial plexus up (average 3.3 years) are reported here. birth palsy patients with advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.

◆ Speakers have nothing of value to disclose. 1 Waters PM, Smith GR, Jaramillo D. Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg * Grant support received from American Society for Surgery of the Hand Outcomes Studies Grant. [Am] 1998; 80: 668–77.

Meeting Abstracts 41 PAPER PAS39

Saturday, September 24, 10:18 a.m. PAS39 Preoperative and Postoperative MRI Findings after Tendon Transfers about the Shoulder for Residual Brachial Plexus Birth Palsy

◆ Scott Kozin, MD, Philadelphia, PA Ross Chafetz, DPT, MPH, Philadelphia, PA Diane Barus, MS, OTR/L, Philadelphia, PA

INTRODUCTION A lesion of the upper brachial plexus (C5 113.1 ± 38.7°, which improved post-operatively to 149.5 and C6) is the most common type of birth palsy. Damage to ± 30.2°. Corresponding improvements for active external the upper trunk often results in incomplete recovery of the rotation and abduction were seen in the Mallet scores. The rotator cuff and deltoid muscles. Residual lesions result in beneficial effects of motion did not correlate with similar diminished shoulder abduction and external rotation along improvement in joint configuration. There were no significant with glenohumeral joint dysplasia. The purpose of this study changes in glenoid version (- 25.3 + 14.0° pre-operative to was to assess tendon transfers about the shoulder in children - 24.5 ± 13.9 postoperative) or humeral head position (29.5 ± with residual brachial plexus palsy with regards to MRI 15.2% pre-operative to 28.4 ± 14.6 % to post-operative). findings and clinical outcome. CONCLUSION The enhanced motion following tendon METHODS Twenty-three children were included with an transfers motion did not correlate with similar improvement average age at surgery of 5.3 +1.7 years. Surgery consisted in MRI findings with respect to joint configuration. This lack of transfer of the latissimus dorsi and teres major to the of association is most likely related to the inability to restore posterior rotator cuff. Average time of follow-up was 1.1 adequate glenohumeral joint alignment in the presence years. of considerable glenoid retroversion and humeral head subluxation. Early open or arthoscopic reduction appears to RESULTS Average pre-operative passive external range of be required to center the humeral head within the glenoid, motion was -1.8 ± 20.6°, which improved post-operatively which can encourage and promote glenoid remodeling. to 19.9 ± 30.4°. Average pre-operative active abduction was

◆ Speakers have nothing of value to disclose.

42 The Joint Annual ASSH/ASHT Meeting PAPER PAS40

Saturday, September 24, 2:15 p.m. PAS40 Long-Term Functional Outcome after Distal Radius Fractures in Young Adults

◆ Charles A. Goldfarb, MD, St Louis, MO Jonas R. Rudzki, MD, St Louis, MO Louis W. Catalano, MD, New York, NY Joseph Borrelli, MD, St Louis, MO

PURPOSE To determine the long-term functional and Sort. There was no significant change in upper extremity radiographic outcome of young adults treated operatively for motion or strength compared to previous evaluation. displaced intraarticular fractures of the distal radius. Radiocarpal arthrosis was noted in 13 of the 16 (86%) wrists and the arthrosis worsened in those patients previously noted METHODS We previously reported the outcome of 21 to have joint space narrowing. The joint space was more than patients evaluated at an average of 7 years after the operative 33% decreased compared to the 7-year follow-up and the treatment of intraarticular distal radius fractures. While arthrosis grade was significantly worse (p<.05). There was radiocarpal arthrosis was noted in 76% of those patients, no correlation noted between the presence or degree of function remained high and was not correlated with the arthrosis and upper extremity function. arthrosis. To assess the effect of additional time on both arthrosis and function, we re-evaluated 15 (71%) of these CONCLUSIONS Radiocarpal arthrosis is associated with patients (16 wrists) at an average of 15 years (range 13–17 intra-articular step and gap deformity after distal radius fracture years) after surgery. All patients were evaluated with the and can be expected to worsen with time. Between seven Musculoskeletal Functional Assessment (MFA) and the Hand year and 15-year follow-up, radiocarpal arthrosis significantly Function Sort, all underwent physical examination, and all had progressed with a marked decrease in joint space. However, plain radiographs and CT scans. as shown at seven-year follow-up, function remained very good with near normal DASH scores, high-level performance RESULTS Functional status remained very good: on the Hand Function Sort, and maintenance of upper DASH scores averaged 10.3 and 13 of the patients extremity range of motion and strength. performed at a high demand level on the Hand Function

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 43 PAPER PAS41

Saturday, September 24, 2:22 p.m. PAS41 Fragment Specific Fixation for Intra-articular Distal Radius Fractures: Up to 4 Year Follow-up

● Keith P. Minihane, MD, Chicago, IL Leon S. Benson, MD, Glenview, IL Erik B. Eller, BS, Glenview, IL

PURPOSE To assess the clinical, radiographic, and functional to work data was variable, being influenced the most by outcome of treating intra-articular distal radius fractures with whether the patient had other injuries, and to some additional fragment specific fixation. degree, by whether the patient was receiving workmen’s compensation. However, in situations where the distal radius METHODS A retrospective review was performed by fracture represented the only injury and patients did not recalling 80 patients treated with fragment specific fixation have a disability claim pending, 80% returned to work with for an intra-articular fracture of the distal radius. Formal IRB within 4 weeks of their injury date. Follow-up radiographic approval was obtained for all aspects of this study. At follow- data demonstrated maintenance of reduction and there were up examination, average time since surgery was 2.8 years. no statistically significant changes in alignment between All patients were examined by a single investigator. Both immediate post-op and final follow-up films. wrists were tested for grip strength and range of motion and radiographs were obtained of both wrists. Comparisons were CONCLUSIONS Fragment specific fixation is a reasonable also made between the immediate post-op films with those alternative for treating intra-articular fractures of the distal taken at final follow-up. Patients completed a questionnaire radius. At long term follow-up, patients demonstrated designed specifically to focus upon wrist function and also excellent results with respect to range of motion, grip strength, completed a standard DASH outcome survey. radiographic alignment, and satisfaction scores. Part of the post-operative protocol involved starting a range of motion RESULTS Range of motion for the operated wrist at final program for the wrist within four days of surgery, which we follow-up was 89% of the uninjured wrist. Grip strength on believe had a significant impact in shortening recovery and the operative side was 87% of the control wrist. Average improving outcomes. DASH outcome score for the injured wrist was 9.1. Return

● Royalties, non-cash support, honoraria, or other funding received from Trimed for Keith Minihane, MD.

44 The Joint Annual ASSH/ASHT Meeting PAPER PAS42

Saturday, September 24, 2:29 p.m. PAS42 A Prospective Outcome Study of Treating 100 Unstable Distal Radius Fractures with the Volar Locking Plating System

◆ Zvi Margaliot, MD, Ann Arbor, MI Andrew J. Watt, MD, Ann Arbor, MI Amy L. Holland, PA-C, Ann Arbor, MI ◆ Kevin C. Chung, MD, MS, Ann Arbor, MI

PURPOSE To obtain prospective outcomes data for open data are presented in Table 1; the plating system maintained reduction and internal fixation (ORIF) of unstable distal radius anatomic reduction at the follow-up periods. There were no fractures using the volar approach. statistically significant differences between the injured versus the uninjured (control) arm in grip strength (p=0.21) or pinch METHODS Consecutive patients with unstable distal strength (p=0.45) at the 6-month follow-up period, but total radius fractures were treated over a one-year period using active wrist motion was significantly better for the uninjured the volar plating system (Hand Innovations, Inc.: Miami, FL). than the injured arm at this time point (126.7° versus 106.7°) The study protocol was designed a priori and patients were (p=0.03). The MHQ data are presented in Table 2. The evaluated at 6 weeks, 3 months, 6 months and one year after scores for all the domains approached normal range at the the procedure. Outcome measures include grip strength, 6-month period. The only complication was a case of transient lateral pinch strength, wrist range of motion, radiographic dysfunction of the median thenar branch. parameters, Jebsen-Taylor test, and the Michigan Hand Outcomes Questionnaire (MHQ). The data were analyzed CONCLUSIONS The volar locking plating system is highly using paired Student’s t-tests. effective in maintaining anatomic reduction for unstable distal radius fractures. The objective and patient-based RESULTS One hundred patients with unstable distal radius outcomes scores approached near normal range at the fractures were enrolled. The mean age at enrollment was 6-month interval. The volar plating technique represents a 48 (range 19–83); 48% of the patients were classified as major advance in the treatment of distal radius fracture. AO type A, 11% type B, and 41% type C. The radiographic

◆ Speakers have nothing of value to disclose.

See tables 1 & 2 on page 48.

Meeting Abstracts 45 PAPER PAS42

Saturday, September 24, 2:29 p.m. PAS42 (cont.) A Prospective Outcome Study of Treating 100 Unstable Distal Radius Fractures with the Volar Locking Plating System

◆ Zvi Margaliot, MD, Ann Arbor, MI Andrew J. Watt, MD, Ann Arbor, MI Amy L. Holland, PA-C, Ann Arbor, MI ◆ Kevin C. Chung, MD, MS, Ann Arbor, MI

TABLE 1. RADIOGRAPHIC DATA

Pre- Post- 6-Week 3-Month Reference Operative Operative Follow-Up Follow-Up

Absolute Displacement of Radial Inclination 0° ± 3° 8° ± 8° 3° ± 3° 3° ± 3° 3° ± 2°

Absolute Displacement of Volar Tilt 0° ± 4° 26° ± 16° 3° ± 4° 3° ± 2° 4° ± 4°

Absolute Displacement Radial Height (mm) 0 ± 2 5 ± 5 2 ± 3 2 ± 2 2 ± 2

Ulnar Variance (mm) 0 ± 1 2 ± 4 -1 ± 2 -1 ± 2 0 ± 2

Absolute Displacement of Radial Inclination = |22°- measured radial inclination| Absolute Displacement of Volar Tilt = |11°- measured volar tilt| Absolute Displacement Radial Height = |12mm - measured radial height| Calculations utilized radiographic measures drawn from the existing literature: Radial Inclination = 22°1; Volar Tilt = 11°2; Radial Height = 0mm.3 Reported values represent the distal radial displacement from accepted measures irrespective of the direction of displacement.

TABLE 2. MICHIGAN HAND OUTCOMES QUESTIONNAIRE DATA

3-month Post-Operative 6-month Post-Operative Test Mean ± Standard Deviation Mean ± Standard Deviation

Overall MHQ Score 82.3 ± 12.6 78.3 ± 14.4

Function 76.2 ± 19.5 71.2 ± 14.2

Activities of Daily Living 88.4 ± 13.5 82.7 ± 18.4

Work 72.5 ± 23.2 76.5 ± 23.8

Pain 9.6 ± 15.9 10.8 ± 17.2

Aesthetics 82.8 ± 16.9 78.4 ± 19.2

Satisfaction 84.2 ± 15.3 71.9 ± 19.8

All of the MHQ scales are based on a score of 0 to 100. For all of the scales except Pain, the higher the scores, the better the subject’s hand performance.

1 DiBenedetto MR, Lubbers LM, Ruff ME, Nappi JF, 3 Mann FA, Raissdana SS, Wilson AJ, Gilula LA. The Coleman CR. Quantification of error in measurements of influence of age and gender on radial height. J Hand Surg radial inclination and radial-carpal distance. J Hand Surg 1992; 18a: 711–713. 1991; 16a: 399–400.

2 Gartland JJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1952; 34a: 651–662.

46 The Joint Annual ASSH/ASHT Meeting PAPER PAS43

Saturday, September 24, 2:36 p.m. PAS43 Functional Outcome and Complications Following Volar Plating for Dorsally Unstable Fractures of the Distal Radius

◆ Tamara D. Rozental, MD, Boston, MA Philip E. Blazar, MD, Boston, MA

INTRODUCTION The purpose of this study is to determine 11.2 mm, mean radial inclination was 20.9° and mean volar tilt the functional outcome of patients treated with volar plating was 4.8°. The average score on the DASH and Gartland and for dorsally displaced, unstable distal radius fractures. Werley questionnaire revealed minimal impairment in activities of daily living. A total of 10 patients (23%) experienced post- METHODS The records of all patients treated at our operative complications. There were 4 instances of loss of institution with internal fixation using volar plates for dorsally reduction with fracture collapse. Four patients developed displaced, comminuted distal radius fractures were reviewed. FCR tenosynovitis and two required hardware removal. One Patients with follow-up less than 12 months were excluded patient developed a wound dehiscence and one patient had from the study. Outcomes were evaluated at latest follow- MP joint stiffness. up using the DASH and the Gartland and Werley scoring systems. CONCLUSIONS Despite the recent popularity of volar plating for dorsally displaced distal radius fractures, there is RESULTS 42 patients (27 women, 15 men), with a mean age a paucity of data documenting the results of this treatment of 54 years form the basis of this study. Average follow-up: 14 method. Our series revealed a 23% complication rate, months. Patients were treated with Hand Innovations DVR compared to 32% in a similar cohort treated with dorsal plates (n=38) or Synthes locking plates (n=4). Radiographs in plating. When compared to dorsal plates, volar plating resulted the immediate post-operative period revealed a mean radial in a higher incidence of fracture collapse (9.5% vs. 0%, p=0.1) height of 11.1 mm, mean radial inclination of 21° and mean but a lower rate of hardware-related complications (9.5% vs. volar tilt of 4°. At fracture healing, mean radial height was 32%, p=0.025).

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 47 PAPER PAS44

Saturday, September 24, 2:43 p.m. PAS44 Problems and Complications of Pin-Plate “Fragment Specific Fixation” For Distal Radius Fractures

◆ William H. Seitz, MD, Cleveland, OH Hideaki Matsuoka, MD, Shizuoka, Japan Kraig Burgess, DO, Cleveland, OH

INTRODUCTION Twenty-two acute fractures of the distal METHOD Fragment specific fixation provides a new tool radius and five reconstructive procedures for nonunion or to provide fixation for the individual fracture fragments malunion were performed using the Tri-Med fixation system. encountered in distal radius fractures. Although tensioning of All fractures and osteotomies went on to heal primarily, the Kirschner wires about the pin plate provides early rigid however fourteen (14) complications and/or problems were fixation, resorption appears to take place around these pins encountered during the postoperative management phase. over time and can allow migration and backing out of the Five patients demonstrated pins which backed out and became pins. Additionally, it is technically quite demanding to place prominent and had to be removed. Two patients lost initial the pins at the exact proper length resulting in prominence. reduction and settled into a mal-reduced position, one did not Finally, internal fixation even with limited approaches requires have significant untoward postoperative compromise and one dissection about the joint which can enhance visualization required arthrodesis. One patient whose pins were slightly for articular restoration but which may cause increased peri- prominent demonstrated a tendon rupture and hardware capsular fibrosis and decreased end ranges especially in flexion caused irritation of the extensor tendons in the first dorsal and extension. Based on these observations, techniques have compartment in two patients. Removal of the prominent and/ subsequently been employed to identify pitfalls and minimize or painful hardware was required in four patients and resulted complications in the use of this technique. in alleviation of symptoms. Overall, patients demonstrated a mean 10% decrease in flexion and 20% decrease in CONCLUSION Successful use of the “pin-plate” fragment extension, while the average arch of pronation and supination specific fixation system requires careful attention to detail to was 155° and radial and ulnar deviation was 20°. avoid complications; nonetheless, pin migration and some stiffness can be expected.

◆ Speakers have nothing of value to disclose.

48 The Joint Annual ASSH/ASHT Meeting PAPER PAT01

Thursday, September 22, 8:15 a.m. PAT01 Hand Therapy: From Practice to Theory

◆ Barbara Winthrop Rose, MA, OTR, CVE, CHT, FAOTA, Bellaire, TX

BACKGROUND Currently, hand therapy is a partnership examined through WHO’s ICF components. A rating scale of occupational therapy theory and physical therapy theory was developed and a pilot study involving six occupational as defined by the Hand Certification Commission (HTCC) therapists confirmed reliability. All scientific articles in the (Muenzen 2002, p. 223). A theory for hand therapy does not Journal of Hand Therapy were included as well as a sample exist. Scientific research in occupational therapy and physical of non-Journal of Hand Therapy articles. therapy is typically based on theory as its underpinnings. The journal that is most widely recognized as the primary RESULTS The results of this study revealed that the primary journal that publishes scientific research in hand therapy is focus of hand therapy practice and research is the WHO’s ICF the Journal of Hand Therapy. This publication was originally category of body functions and structures. sponsored by the American Society of Hand Therapists (ASHT) and designed to publish peer reviewed scientific work CONCLUSION The most prevalent focus of hand regarding hand therapy (Mackin 1987). It can be considered therapy practice and research is the WHO’s ICF category to be the voice for hand rehabilitation and, therefore, is the of body functions & structures. This category is addressed most appropriate source to investigate if a theory for hand consistently in both physical therapy and occupational therapy therapy has emerged. theory. However, other WHO ICF categories which are more commonly found in Occupational Therapy theory and reflected PURPOSE The purpose of this paper is to examine the in HTCC’s definition of hand therapy, are not as prevalent in scientific articles in the Journal of Hand Therapy from the articles published in the Journal of Hand Therapy. More 1987 through 2003 using the World Health Organization’s submissions to the Journal of Hand Therapy are needed to International Classification of Functioning Disability and span all domains of the WHO and reflect HTCC’s definition Health (WHO’s ICF) (WHO 2001) terminology and comparing of hand therapy, so that hand rehabilitation can benefit from the results to HTCC’s definition of hand therapy. the full scope of its parent disciplines. The findings from this work may serve as a springboard for the development of a METHODS The roles that occupational therapy theory theory for hand therapy. and physical therapy theory play in hand therapy were

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 49 PAPER PAT02

Thursday, September 22, 8:20 a.m. PAT02 The Association between Wrist Ratios and a Case Definition of Carpal Tunnel Syndrome

*● Gail N. Groth, MHS, OTR, CHT, Watertown, WI Matthew S. Thiese, MSPH, Salt Lake City, UT Kurt T. Hegmann, MD, MPH, Salt Lake City, UT Jacqueline Wertsch, MD, Milwaukee, WI

PURPOSE Wrist ratios have previously been correlated with the right hand, abnormal NCS findings were present in 256 median sensory latency in those with carpal tunnel syndrome (29.6%) and 110 (12.7%) of subjects met the case definition (CTS), though not uniformly confirmed. The purpose of this of CTS. Mean wrist ratio was 0.701 in males and 0.695 in report was to examine the relationships between wrist females. The sensitivity of a higher wrist depth/width ratio ratios, and nerve conduction abnormalities, as well as a case compared to a case definition of CTS was 60.6%, specificity definition of probable CTS in a large epidemiological study. 52.5% and positive predictive value 34.8%. The sensitivity of wrist depth/width ratio compared to a case definition of METHODS All subjects (n=868 workers, 67.3% female, CTS was 60.0%, specificity 49.95% and positive predictive with a median age of 41.5 ± 11.2 years from 12 manufacturing value 14.8%. Logistic regression analyses were performed plants in two states) underwent laptop based questionnaires, with Odds Ratios (OR) of 1.76 (95% Confidence Interval structured interviews, two standardized physical examinations [CI] 1.28, 2.43) for an association between a higher ratio and measurement of wrist width and depth at distal wrist and abnormal NCS findings after adjusting for age, gender, creases using digital calipers. Nerve conduction studies body mass index, osteoarthritis of the wrist, and diabetes. (NCS) were done in all subjects with normal findings defined Female gender was statistically insignificant (p=0.54) for this as: transcarpal delta < 0.4 msec, motor latency ≤ 4.4 msec, association after adjustment. The adjusted odds ratio for the and sensory latency ≤ 3.7 msec. Wrist ratio was calculated CTS case definition was 1.48 (95% CI 0.97, 2.25). by dividing wrist depth by width. The case definition of CTS was paresthesias in two or more median nerve served digits CONCLUSIONS The wrist ratio is not helpful clinically based (1-4) in the prior month and an abnormal NCS. Utility of the on the low positive predictive value. However, it is statistically wrist ratio was ascertained by 2x2 table analyses stratified by significantly associated with abnormal NCS findings on a gender using the midpoint of the ratio to separate into two population basis, and remains important for epidemiological categories. research.

RESULTS For brevity, only right handed data are reported and left handed data will be reported with the results. In

● Research or institutional support received from University of Wisconsin- Milwaukee for Gail Groth, MHS, OTR, CHT.

* Grant support received from CDC Grant #1 UO1 OH007917-01 Upper Limb Musculoskeletal Disorders: Quantifying Risk.

50 The Joint Annual ASSH/ASHT Meeting PAPER PAT03

Thursday, September 22, 8:25 a.m. PAT03 Outcome of Forearm Level Incomplete Amputation and Revascularization after Shark Attack: A Case Study

◆ Peggy Boineau, OTR, CHT, Sweeny, TX

PURPOSE To report outcome of an 11-year-old patient with appropriate, function-based treatment plan. The outcomes revascularization of a near mid-forearm amputation as a result were very successful and are summarized below. of shark attack. FUNCTION (DESCRIPTIVE) At 3½ wks post-op, the patient METHOD Presentation of a single case-study, including had no functional use of his RUE. At 12 weeks post-op, he literature review, case history, surgical report, rehabilitation, demonstrated the following: spontaneous use of the RUE, and outcomes. writing with dominant right hand without assistive device (minimal difficulty), use of right hand to hold the bow when CASE SUMMARY AND RESULTS During a shark attack, playing the violin, throwing a baseball with minimal difficulty, this patient’s right (dominant) upper extremity was severed and independent self-care (including buttoning buttons and at the forearm, with the exception of the radius and ulna tying shoes) (minimal difficulty). which sustained greenstick fractures. The extremity was successfully revascularized. Outpatient rehabilitation, began CONCLUSION / RELEVANCE TO HAND THERAPY The 3½ weeks post-op. The therapist worked closely with the outcome of this unusual case demonstrates that the pediatric family and key professionals at the patient’s school to allow patient with a revascularized hand can attain a good functional a smooth transition back to school, including resumption of recovery and return to age-appropriate activities in a relatively Physical Education and Orchestra class. ADL’s and handwriting short period of time when given proper care in the field, in the were important issues in the early outpatient phase, and later, OR, and in rehabilitation. The combination of specialized hand a return to sports and normal social activities became an therapy skills with specialized pediatric Occupational Therapy emphasis. The Hand Therapist collaborated with the patient, skills was important in the rapid and successful functional the family, and the physician to develop a comprehensive, age- recovery of this patient.

◆ Speakers have nothing of value to disclose.

See table on page 52.

Meeting Abstracts 51 PAPER PAT03

Thursday, September 22, 8:25 a.m. PAT03 (cont.) Outcome of Forearm Level Incomplete Amputation and Revascularization after Shark Attack: A Case Study

◆ Peggy Boineau, OTR, CHT, Sweeny, TX

3 ½ wk 5 wk 8 wk 12 wk 16 wk

TAM: IF 60 230

MF 60 230

RF 75 240

SF 70 245

WRIST: FLEX 15A 32A

EXT 20 55

GRIP: R 0 7 11

L 17 18 25

KEY PINCH: R 5 6 8

L 10 12 12

3 JAW: R 4 6 8

L 10 11 11

SEMMES: T 2.83 2.83

IF 4.56 2.83/3.61

MF 4.31 2.83

RF 2.83 2.83

SF 2.83 2.83

PRWE* 78 8

*total wrist score

52 The Joint Annual ASSH/ASHT Meeting PAPER PAT04

Thursday, September 22, 8:30 a.m. PAT04 Using the Force-Time Curve to Detect Submaximal Effort

*◆ Orit Shechtman, PhD, Gainesville, FL Bhagwant Sindhu, MHS, Gainesville, FL

PURPOSE The force-time curve, a graphical representation Paired t-tests were used to compare between the slopes of of force exerted by contracting muscles over time, has been maximal and submaximal efforts. Sensitivity and specificity used to identify changes in maximal effort as a result of values were calculated and a receiver operating characteristic training. The force-time curve consists of an initial rapid rise (ROC) curve was generated to find the optimal cutoff value of force (force-generation phase), a smooth peak curve, and for the slope. a gradual decrease in force (force-decay phase). The purpose of this study was to examine if the slope of the force-time RESULTS There were significant differences in slope curve can differentiate between maximal and submaximal between maximal and submaximal efforts for both the force- grip strength effort. generation phase (t=46.77; p<0.0001) and the force-decay phase (t=79.16; p<0.0001). METHODS Thirty healthy volunteers performed three maximal and three submaximal 6-second grip strength CONCLUSIONS The slopes of the force-generation and trials with their dominant hand in a random order using a force-decay phases differentiated between maximal and specialized dynamometer (Biopac Instruments) connected to submaximal grip strength efforts. For example, for a slope a signal processor (PowerLab, ADI Instruments), computer, of –0.075 during the force-decay phase, none of the male and software (Chart, ADI Instruments). A force-time curve subjects were wrongly classified as exerting a submaximal was generated for every grip strength trial. The slopes of effort while only 7% were wrongly classified as giving a the curve were calculated during the force-generation phase maximal effort. Thus, the force-time curve provides a valid (from initial increase in force to peak-force) and the force- and effective measure of sincerity of effort. decay phase (from peak-force to the end of contraction).

Slope of Force- Slope of Force- Effort Generation Decay

Maximal Trials 2.61+1.40 -0.16+0.08

Submaximal Trials 0.98+0.44 -0.04+0.03

Optimal cutoff values of the slopes were found using the ROC curve.

Phase Males (n=15) Females (n=15)

Slope Sensitivity Specificity Slope Sensitivity Specificity

Force-generation 1.45 0.80 0.87 1.2 0.80 0.93

Force-decay -0.075 0.93 1.00 -0.05 0.80 0.87

◆ Speakers have nothing of value to disclose.

* Grant support received from Opportunity Grant, University of Florida.

Meeting Abstracts 53 PAPER PAT05

Thursday, September 22, 8:35 a.m. PAT05 Reliability of the Derma-Durameter in the Assessment of Scar Pliability

*● Carla K. Cleary, MPT, CHT, Jackson, MS Anna K. Sanders, PT, CHT, Jackson, MS Todd G. Nick, PhD, Jackson, MS

PURPOSE Controlled trials on scar modification have been certified hand therapists tested the subjects independently limited by the inability to objectively measure scar properties. and were blinded as to the result of the other rater. Testing One desired property of skin scar is to be supple or pliable locations were standardized using a wound tracing device enough to permit motion. The purpose of our study was to (Hill-ROM, a Hillenbrand Industry, Batesville, IN). determine the intrarater and interrater reliability of the NK Derma-Durameter (NK Biotechnical Corp., Minneapolis, RESULTS Intrarater reliability was excellent for both raters Minnesota), a tool to measure scar pliability. for all points tested on both extremities (ICC > 0.88, table 2). On the involved side, moderate interrater reliability was METHODS Twenty three volunteers (13 males, 10 females, found for the most adherent point (ICC = 0.79) and the most 10 African-American, 13 Caucasians) for a total of 25 scars distal point (ICC = 0.77). Poor interrater reliability was found were recruited from a regional hand center. Scars were for the most proximal point on the involved side (ICC = 0.29) included if there were no open areas and were between 2 and all the points on the unscarred contralateral extremity. and 20 weeks of age (mean age, 9 weeks). Exclusion criteria The instrument was effective in identifying and quantifying included: patients with history of infection, keloids, radiation, significantly lower pliability (10.7%) of scars when compared routine steroid use, non-union fracture, or tendinitis in the to normal skin. areas near the scar. All but two of the scars resulted from surgery. Scar pliability was determined using the NK Derma- CONCLUSIONS The NK Derma-Durameter is a valid tool Durameter in three trials at three points on 25 scars and the that demonstrates excellent intrarater reliability and moderate corresponding areas on the uninvolved upper extremities. Two interrater reliability for measuring scar pliability.

● Research or institutional support received from American Hand Therapy Foundation: Burkhalter Research Award for Carla Cleary, MPT, CHT.

* Grant support received from Burkhalther Research Award, American Hand Therapy Foundation.

54 The Joint Annual ASSH/ASHT Meeting PAPER PAT06

Thursday, September 22, 8:40 a.m. PAT06 A Scale to Profile Carpal Tunnel Syndrome Severity Symptoms: the CTS3

*◆ Caroline S. Jansen, PhD, PT, Galveston, TX Steven F. Viegas, MD, Galveston, TX Kimberly G. Staines, OTR, CHT, Houston, TX David T. Netscher, BSc, MB, BCh, Houston, TX

BACKGROUND Patients with carpal tunnel syndrome statistical analyses were used: Cronbach’s alpha (internal (CTS) experience various symptoms such as pain, tingling and consistency) and Spearman’s correlation coefficients. numbness. Currently, no measure exists to systematically Sensitivity and specificity were calculated for patients and quantify these symptoms. Lack of a systematic measure normals, respectively. for the severity of symptoms limits studies of intervention effectiveness, because core CTS symptoms such as pain or RESULTS Internal consistency was good to excellent numbness may not similarly respond to interventions. We (alpha > 0.84), test-retest reliability was good to excellent developed a scale that is designed to systematically quantify (rho > 0.78). Sensitivity was greater than 85% for all domains the severity of core symptoms of CTS as perceived by except burning and coldness of the hand and difficulty with patients, including pain, numbness, tingling, burning, coldness functional use. Specificity was greater than 89% for all of the hand, weakness/dropping objects, and perceived loss domains. Correlation between the gold standard and the of function, the CTS3. CTSs was 0.5 (p<0.05) for the total severity scale. Domains of core symptoms that correlated highest with the gold standard PURPOSE The purpose of this study was to assess internal were sense of weakness (rho=0.7, p<0.05), difficulty with consistency, test-retest reliability, sensitivity and specificity functional use (rho =0.7, p<0.05) and pain (rho=0.4; p<0.05), of the CTS3, and the correlation between the gold standard numbness and tingling correlated the least (rho < 0.11, NS). to measure symptom severity (Levine et al. 1993) and the CTS3. The criteria were that: 1) Cronbach’s alpha is > 0.7, CONCLUSIONS The CTS3 met our set criteria with few 2) test-retest reliability is >0.75, and 3) sensitivity and exceptions. Reliability was excellent. Total scores on the scale specificity exceed 0.8. correlated fair to good with Levine’s scale, especially in the area of function and pain. Scores on numbness and tingling METHODS Subjects: Ninety patients with CTS, and 13 did not correlate well, which urges the necessity to measure normal subjects participated in the series of studies. All core symptoms separately and not as a collective. Use of subjects provided consent. Procedures: The scale was the CTS3 will improve systematic understanding of the CTS administered once for all testing, except for test-retest disease process, giving a symptom profile for each patient. reliability, when it was administered twice. The following Funded in part by the American Hand Therapy Foundation.

◆ Speakers have nothing of value to disclose.

* Grant support received from American Hand Therapy Foundation.

Meeting Abstracts 55 PAPER PAT07

Thursday, September 22, 9:32 a.m. PAT07 A National Survey on the Administration and Interpretation of the Rapid Exchange Grip Test

◆ Orit Shechtman, PhD, Gainesville, FL

PURPOSE The rapid exchange grip (REG) test is used to (“mySQL” database) was used for collecting the data. Data determine sincerity of effort. Research studies do not possess were analyzed for descriptive statistics and frequencies and standardized administration protocols and/or interpretation written comments were tallied and summarized. procedures for the REG. These inconsistencies may lead to discrepancies in the clinical use of the REG. The purpose of RESULTS A total of 67 participants responded to the the present study was to determine which administration and survey, yielding a response rate of 34.5%. Faxed respondents interpretation protocols are used by therapists nationwide. totaled 24 (57%) while email respondents totaled 43 (28%). The sample consisted of 87% females, 90% occupational METHODS A questionnaire regarding administration therapists, 10% physical therapists, 84% certified hand and interpretation of the REG was sent to hand therapists therapists, and 30% Masters degrees. Twenty respondents randomly selected from the “ASHT 2002 Directory of (30%) had never administered the REG. The results showed Members”. Approximately 2000 of 2145 members (93%) very variable administration and interpretation protocols used had listed their email address and/or fax number. Of those, by hand therapists nationwide. For example, the number of we randomly selected 10% or 200 participants, only 194 of grip repetitions ranged from 3 to 10 and cueing for switch which were practicing therapists (152 were contacted via rate was done either verbally (74%) or with computer (22%) email and 42 via fax). The survey contained four sections. or metronome (4%). The first involved demographic information and the second determined experience with the REG. Respondents who had CONCLUSIONS We found a lack of uniformity in the never administered the REG were instructed to stop at the administration and interpretation protocols of the REG among end of this section. The third section dealt with administration therapists nationwide. These inconsistencies have serious and the fourth with interpretation of the REG. The variables implications for clinical practice. We clearly demonstrated for administration include patient position, test instructions, that the REG test is an assessment tool that lacks basic handle setting, handling of the dynamometer, hand switch measurement criteria, such as a standardized administration rate, number of repetitions, and technique used to record protocol and instructions for interpretation. Basing clinical the score. Interpretation variables included comparative tests judgment on the REG test is thus susceptible to bias and and perceived effectiveness. Web-based database software errors.

◆ Speakers have nothing of value to disclose.

56 The Joint Annual ASSH/ASHT Meeting PAPER PAT08

Thursday, September 22, 9:37 a.m. PAT08 The Effectiveness of Iontophoresis with Iodide or Saline for the Treatment of Adherent Scars: Preliminary Results of a Randomized, Placebo Controlled Trial

*◆ Carla K. Cleary, MPT, CHT, Jackson, MS Anna K. Sanders, PT, CHT, Jackson, MS Maureen Hardy, MS, PT, CHT, Jackson, MS

PURPOSE Iontophoresis has been used clinically in However, mean differences in pliability (saline: +2.8%, treatment of adherent scars despite limited support in iodide: +0.6%, control: –0.5%) were not significant among the literature. The purpose of this study was to determine the treatment groups after controlling for baseline pliability whether iontophoresis with either iodide or saline produced (P=0.77). When controlling for active MP motion at baseline, improved scar pliability, range of motion, and patient rated there was a significant treatment effect (P=0.03). Saline outcomes when compared to sham iontophoresis. cases showed significant improvement in active MP motion over the sham treatment (mean difference: 22°, 95% C.I., METHODS Thirty subjects with adherent, hand and forearm 6° to 38°; P=0.01). Scars phoresed with iodide improved scars present for 3 weeks to 6 months were recruited. Scar but the mean difference was not statistically significant compliance was measured using the NK Derma-Durameter. (mean difference: 14°, 95% C.I., –2° to 30° ; P=0.07). When Testing locations were standardized using a wound-tracing controlling for active PIP motion at baseline, there was not a device. ROM was measured and the DASH assessed patient significant treatment effect (P=0.26). Average improvement rated outcomes. The evaluators were blinded to the subject’s in PIP motion over the sham was 16o with saline (95% C.I., treatment. Subjects were randomized and blinded to one of –11° to 43° ; P=0.23) and 22° with iodide (95% C.I., –7° to three iontophoresis treatments: 10% potassium iodide, 2.5% 51 °; P=0.13). Data for PROM and the DASH will be presented sodium chloride, or sham. Participants received 6 treatments at the meeting. sessions utilizing an Empi Dupel iontophoresis unit and electrodes. Active treatments had a total dosage of 40 mA/ CONCLUSIONS Based on this preliminary data, treatment min. The sham treatment involved electrode placement and of adherent scars with saline iontophoresis is effective in lead wire attachment to the Empi unit for 15 minutes without increasing active MP motion. Tendencies were noted for any electricity application. An ANCOVA was performed on the both iodide and saline iontophoresis to improve PIP motion pliability and AROM measures. and improve pliability, however, these were not statistically significant. More subjects will be recruited to establish more RESULTS There was a tendency for the saline treatment precise treatment effects. to demonstrate the most improvement in scar pliability.

◆ Speakers have nothing of value to disclose.

* Grant support received from Burkhalther Research Award, American Hand Therapy Foundation.

Meeting Abstracts 57 PAPER PAT09

Thursday, September 22, 9:42 a.m. PAT09 Prosthetic Prescription for Children with Unilateral Congenital Below Elbow Deficiency (UCBED)

*◆ Lisa V. Wagner, OTR/L, Greenville, SC Michelle James, MD, Sacramento, CA Anita Bagley, PhD, Sacramento, CA

PURPOSE Standard recommendations for prosthesis score 81). There were no differences between PODCI scores prescription for children with UCBED include fitting at an early for wearers and non-wearers, and non-wearers performed age, and wearing during waking hours. We hypothesized that the same as or better than prosthesis wearers on every UBET children whose prosthetic management fits these criteria will task. There were no differences in UBET scores based on age report and demonstrate better function than those who do of fit or amount of wear-time. For global reported function not. (PUFI Part I), there was no difference based on age of first fit. Higher reported function was associated with wear time METHODS Four hundred ninety-four children with UCBED greater than 4 hours per day. For specific tasks (PUFI Part II), from 10 hospitals were tested. Two-thirds were wearers, performance was higher for later fit for two tasks, and there and one-third chose not to wear a prosthesis. Age at first fit, were no differences for the remaining 26 (younger children) number of hours worn per day, and reported and measured or 38 (older children) tasks. Wear time of greater than 4 hours function were studied. Reported upper extremity (UE) per day was associated with better reported performance on function was determined by the Prosthetic Use Functional more than half of the tasks assessed. PODCI scores favored Index (PUFI) and the Pediatric Orthopedic Data Collection more wear time and later fit for only one Domain (Expectations Instrument (PODCI) and measured function by the Unilateral Domain); there were no other differences on the remaining Below Elbow Test (UBET), which requires children to perform eight PODCI Domains, including the UE Function Domain. nine age-appropriate tasks. PODCI scores for the general population indicate that children with scores below the low CONCLUSIONS Early fit is not associated with higher 80’s (out of 100 points) have below normal function. Mann- reported or measured function. Wearing more than four Whitney tests were used to analyze PUFI and UBET scores; hours per day is associated with higher reported but not t-tests were used for PODCI scores. A p value of < 0.01 was measured function. Therapeutic focus should be directed used. toward providing the appropriate prosthesis for specific child needs rather than for everyday activities or developmental RESULTS All age groups of subjects with UCBED scored progression. above 85 on all PODCI Domains except 2–4 year olds (average

◆ Speakers have nothing of value to disclose.

* Grant support received from Clinical Outcomes Study for Shriners Hospitals-Multi-Center Unilateral Congenital Below Elbow Deficiency.

58 The Joint Annual ASSH/ASHT Meeting PAPER PAT10

Thursday, September 22, 9:47 a.m. PAT10 Inter-Rater Reliability for the Unilateral Below Elbow Test

*● Wendy A. Tomhave, OTR/L, Minneapolis, MN Lisa Wagner, OTR/L, Greenville, SC Michelle A. James, MD, Sacramento, CA Anita Bagley, PhD, Sacramento, CA

PURPOSE The Unilateral Below Elbow Test (U-BET) 12 therapists participated in additional reliability testing, viewing compares function of children with unilateral congenital videotapes of 12 children performing the U-BET. below elbow deficiency (UCBED) who wear a prosthesis with those who do not, and assesses how children who wear a RESULTS Completion of Task and Method of Use scores prosthesis accomplish tasks with and without it. The U-BET were statistically compared for both testing sessions. For consists of four age-specific categories (2–4 years, 5–7 years, Completion of Task, an overall Spearman rho coefficient of .98 8–10 years, and 11–21 years) with nine tasks per category. The was achieved on both test dates, demonstrating high inter- test has two scores. The Completion of Task Score uses an rater reliability. Reliability was not task-dependent and scores ordinal scale (ranging from 0 if the child is unable to complete were comparable for wearers and non-wearers. For method the task to 4 if they are able to complete the task without of use, the overall Cohen kappa coefficient value was .64 for difficulty) and focuses on ease of completion and quality of the first session and .62 for the second session, which shows movement. The Method of Use Score uses a nominal scale fair to good correlation between raters. The kappa scores for that correlates how wearers and non-wearers complete a each task varied in part because tasks were not designed to task by describing methods of grasp and stabilization (A for have similar qualities across the four age groups. Reliability active use, P passive use, E for elbow or trunk grasp, and N was better for wearers than non-wearers because prosthetic for no use of affected side). action is easier to discern than residual limb manipulation.

METHODS To determine inter-rater reliability, six occupational CONCLUSIONS The U-BET shows excellent inter-rater therapists familiar with the U-BET viewed videotapes of 10 reliability for Completion of Task Scoring and fair to good children performing the U-BET. The therapists rated each reliability for Method of Use scoring. It was given to 494 child’s performance on each task for Completion of Task and children as part of a Shriners Hospitals for Children multi- Method of Use. Scoring correlation indicated that scoring center study. We recommend the use of this test for definitions needed to be more detailed. After this modification, evaluating the performance of children with UCBED, with and without a prosthesis.

● Research or institutional support received from Shriners Hospitals Clinical Outcomes Studies Advisory Board for Wendy Tomhave, OTR/L.

* Grant support received from Shriners Hospitals for Children Clinical Outcomes Studies Advisory Board.

Meeting Abstracts 59 PAPER PAT11

Thursday, September 22, 9:52 a.m. PAT11 Children with Unilateral Congenital below Elbow Deficiency (UCBED) and Prosthesis Wear: Does Availability of More than one Type of Prosthesis Improve Satisfaction, Quality of Life and Function?

*● Wendy A. Tomhave, OTR/L, Minneapolis, MN Robin Crandall, MD, Minneapolis, MN Anita Bagley, PhD, Sacramento, CA Michelle James, MD, Sacramento, CA

PURPOSE It seems logical that having several prosthetic RESULTS Of the 58 wearers who used more than one style arms or different activity-specific terminal devices would of prosthesis, the most frequent combinations were the body- be an advantage for children who have unilateral congenital powered and sports arm (43%), and the body-powered and below elbow limb deficiency (UCBED). Options could include passive prosthesis (26%). Prosthesis type for those wearers a cosmetic arm to change the appearance of their limb, a of a single device is being analyzed and will be presented. body-powered prosthesis that allows grasp to improve their Single and multiple prosthesis wearers were comparable in function, or a special terminal device to enable them to excel their abilities to complete all UBET function testing. Only two in a sport or hobby. There are no firm data that have compared items on the PUFI differentiated between single and multiple pediatric below elbow prosthesis wearers who wear only prosthesis wearers. There were no differences between one prosthesis to wearers who prefer to alternate between groups for PODCI or PedsQL scores. For the PSI, the only two or more devices. This prospective cross-sectional study difference noted between groups was that parents of children evaluates how these two groups compare in function, quality ages 5–7 with more than one prosthesis scored better when of life, satisfaction, and prosthetic preferences. asked about their satisfaction with prosthetic follow up care.

METHODS During 2002 and 2003, 494 children with CONCLUSIONS Single and multiple prosthesis users UCBED, both prosthesis wearers and non-wearers, and their had comparable actual and reported function. In addition, parents participated in this multi-center study, which included both groups reported equivalent quality of life and musculo- administration of a demographics survey, the Prothetic Upper skeletal well-being. A prosthesis is a tool that only has one Extremity Functional Index (PUFI), the Pediatric Outcomes type of grasp pattern. Providing additional activity-specific Data Collection Instrument (PODCI), the Pediatric Quality devices to children may enable them to find more uses for of Life Inventory (PedsQL) and the Unilateral Below Elbow a prosthesis in specialized activities such as sports, but their (UBET) function test. We compared questionnaire results daily function and quality of life is not impeded by the use of of 264 prosthesis wearers of a single prosthetic device to a single prosthesis type. 58 wearers who alternate between several prostheses and terminal devices.

● Research or institutional support received from Shriners Hospitals for Children Clinical Outcomes Studies Advisory Board for Wendy Tomhave, OTR/L.

* Grant support received from UCBED Study.

60 The Joint Annual ASSH/ASHT Meeting PAPER PAT12

Thursday, September 22, 10:07 a.m. PAT12 Proximal Interphalangeal Joint Stiffness Affected by Metacarpophalangeal Joint Position

◆ Zong-Ming Li, PhD, Pittsburgh, PA Gregg Davis, MS, Pittsburgh, PA Robert J. Goitz, MD, Pittsburgh, PA Norman P. Gustafson, BS, OTR/L, CHT, Pittsburgh, PA

PURPOSE Bunnell-Littler test for intrinsic muscle tightness flexion curve. PIP joint stiffness was calculated as the slope involves an evaluation of PIP joint resistance against of the induced flexion curve in a 20-degree window starting a manually applied force at both full extension and full from the equilibrium angle. flexion of the MCP joint. The objective of this study was to quantitatively study finger joint stiffness with the MCP joint RESULTS An increase of MCP joint flexion angle caused (1) at different position. an decrease in equilibrium angle, (2) an decrease in flexion torque at a given PIP joint position, and (3) an increase in METHODS A testing system was constructed to collect extension torque at a given PIP joint position. For the induced passive PIP joint torque-angle data of the index finger with flexion, the average equilibrium angle changed significantly the MCP joint at extended (0 degrees) or flexed (60 degrees) from 47.6 ± 15.0 degrees with the MCP joint extended to positions. A low payload robotic arm induced cyclic motion 21.9 ± 11.4 degrees with the MCP joint flexed (p < 0.001). about the PIP joint. A miniature torque transducer measured The PIP joint showed a significant increase in stiffness from PIP joint torque. A lockable linkage with a finger clamp was 0.44 ± 0.24 N-mm/degree with the MCP joint flexed to 0.69 ± mounted on the splint to prescribe the desired MCP joint angle. 0.22 N-mm/degree with the MCP joint extended (p < 0.01). Ten young male subjects without intrinsic muscle tightness participated in this study. The angular motion was applied to CONCLUSIONS We have successfully developed a the PIP joint in a cyclic manner between full extension and quantitative measure of PIP joint stiffness. PIP joint stiffness 90 degrees of flexion at 7 degrees/s. Throughout testing, the is dependant on the MCP joint angle, supporting the regulation subject was instructed to remain relaxed and offer no voluntary role of the intrinsic muscles on PIP joint stiffness, and the use resistance to the induced motion. The equilibrium angle of the of Bunnell-Littler test for the evaluation of intrinsic muscle PIP joint was determined by the zero torque intercept of the tightness.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 61 PAPER PAT13

Thursday, September 22, 10:39 a.m. PAT13 Early Functional Results Using a Structured Therapy Protocol in Patients who Have Undergone Surgery with the Avanta U-Head Endoprosthesis

● Gretchen L. Kaiser, MBA, OTR/L, CHT, Phoenix, AZ Leonard S. Bodell, MD, FACS, Phoenix, AZ Richard A. Berger, MD, PhD, Rochester, MN

INTRODUCTION Resection of the distal ulna is a common the degenerative and post-traumatic groups. Rheumatoid salvage procedure. Because of problems with this procedure, patients are held in Muenster type splints 4–6 weeks alternatives have been devised. Several of these techniques depending upon intraoperative stability and the quality of the have been shown to be ineffective in decreasing the problem soft tissue. Splint use in the non-rheumatoid is decreased to of convergence. A laboratory investigation demonstrated intermittent use by 6 weeks, and a progressive strengthening the efficacy of the use of an ulna head endoprosthesis in program begins once functional pain-free range of motion has controlling convergence (Sauerbier, et al, 2003). The use of a been achieved. structural implant to replace the ulna head has proven helpful in some clinical settings (van Schoonhoven, et al, 2000). RESULTS Follow-up period was from 12 to 71 months. All patients reported marked improvement of pain and function PURPOSE This paper seeks to present our early experience using the VAS and DASH. Two patients reported pain upon with the use of the AVANTA U-Head™ endoprosthesis in a exertion. Two patients were on worker’s compensation and clinical series. The presentation will emphasize the therapy both have returned to their premorbid work status. Time to protocol and short term functional benefits of using this functional use of the extremity was achieved by 2 to 6 weeks, implant. Long term clinical efficacy and survival of the implant with a mean of 4 weeks. Maximum medical improvement need a longer experience. with good to excellent early results was achieved in all patients by 16 weeks. METHOD Our series consists of 9 patients treated consecutively with Darrach Resection and U-head™ CONCLUSION It appears that with a specified directed Arthroplasty. The age range was from 19 to 73. There were therapy protocol, patients undergoing ulna head resection 4 males and 5 females. Preoperative diagnoses included along with implantation of the U-head™ endoprosthesis are inflammatory arthritis, ulna impaction syndrome, and 6 noted to have a rapid recovery and an ability to return to ADL post-trauma. Concomitant surgeries included distal radius activities in a predictable manner. There appears to be strong corrective osteotomy and wrist fusion. Active range of efficacy in the short term for the use of an endoprosthesis in motion was started by two weeks in patients with stable selected patients undergoing ulna head resection. intraoperative constructs. These patients were typically of

● Royalties, non-cash support, honoraria, or other funding received from Avanta Orthopaedics for Gretchen Kaiser, MBA, OTR/L, CHT.

62 The Joint Annual ASSH/ASHT Meeting PAPER PAT14

Thursday, September 22, 10:44 a.m. PAT14 Modeling Length Increase of the Pectoralis Major Muscle to Provide Precautions for Patients after Mastectomy and Breast Reconstruction

◆ William L. Buford, PhD, Galveston, TX Rita M. Patterson, PhD, Galveston, TX Lisa J. Gould, MD, Galveston, TX Caroline W. Jansen, PhD, Galveston, TX

PURPOSE The surgical removal of the breast and is rotated (see the Figure). The total excursions of the central subsequent reconstruction include removal of fascia, incision fiber relative to the arm at neutral in a relaxed standing of the pectoralis major muscle, and dissection of the axilla. A position are reported here. common complication is that patients develop shoulder pain and stiffness on the side of the surgery. Post-operatively, RESULTS The “safe” post-operative motion of abduction women are empirically instructed to limit shoulder motion to 90 degrees with no external rotation resulted in 57 mm to 90 degrees of abduction, but no information is available increase of central fiber length. External rotation alone from about limitations in other directions of range of motion the same neutral position resulted in a 28 mm increase. (ROM). Our purpose was to contrast pectoralis major muscle Flexion and extension each resulted in 50 to 55 mm increase. excursion during shoulder movements to that observed Abduction combined with external rotation resulted in an during the commonly accepted “safe” postoperative motion. increase of 77 mm. The motions are: abduction from a resting neutral position, external rotation from the same position, flexion and extension CONCLUSIONS From these simulation results it can be from the same position and external rotation with the arm concluded that women can externally rotate, flex, and extend abducted to 90 degrees. the shoulder in isolation and fall within the “safe” guidelines for pectoralis major muscle length increase. However, METHODS A 3-dimensional model of the shoulder and the combined motions, such as abduction with external rotation pectoralis major muscle was used to interactively generate may fall outside of the “safe” region. This information will the total muscle excursion during the simulated motions [1]. help physicians and therapists instruct patients to maintain as The shoulder and muscle are part of a complete simulation of much glenohumeral joint motion as possible while protecting the human musculoskeletal system. The muscle models are the pectoralis major muscle from overstretching. This study B-Spline curve paths that deform in real time as the shoulder does not address muscle contraction.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 63 PAPER PAT15

Thursday, September 22, 10:49 a.m. PAT15 Radiographic Evidence of the Effectiveness of a Trapeziometacarpal Orthotic Design

◆ Elizabeth F. de Herder, OTR/L,CHT, Mt. Pleasant, SC John A. McFadden, MD, Charleston, SC

PURPOSE The purpose of this paper is to describe MP flexion angle was 22 degrees without the orthosis. With the biomechanical rational, with radiographic evidence, the orthosis the mean was 26.6 degrees. This demonstrated of a custom fabricated orthotic design that supports the a 4.6 degree increase in MP flexion with the orthosis. trapeziometacarpal (TM joint) and changes the MP joint flexion Individually, 9 subjects demonstrated an increase in resting angle. The orthosis allows full wrist, MP, IP, and limited TM MP joint flexion with the orthosis, with a mean of 9 degrees. joint thumb motion. Four subjects decreased their MP flexion during pinch with the orthosis with a mean of –4.3 degrees; however, METHODS 10 subjects, 9 female and 1 male, were selected 3 subjects continued to demonstrate MP flexion, 1 subject based on physician findings of early osteoarthritis or pain in demonstrating hyperextension of the MP joint with and the TM joint. Age range of the subjects was 31 to 83. A single without the orthosis during pinch. provider used a systematic fabrication process to provide all participants with a custom orthosis. Radiographic lateral CONCLUSIONS The orthotic design demonstrated 90% and fluoroscopic views were taken and the MP joint flexion effectiveness in increasing MP flexion at rest, 60% with lateral measured to compare the thumb position at rest and during pinch. Only 1 subject’s MP flexion failed to reach normal pinch lateral pinch with and without the orthosis. Current literature parameters. The relevance to hand therapy is a systematic documents that the normal MP flexion during pinch is 0–40 TM joint orthotic design which limits TM joint motion and degrees and that MP flexion effectively unloads the palmer creates biomechanical changes to MP joint flexion without surface of the TM joint. crossing the joint. The proposed design helps to limit motion and decrease the load on the palmer surface of the TM joint RESULTS As a group, the mean resting MP flexion angle was at rest and during pinch activities. The study also suggested 17.9 degrees without the orthosis. With the orthosis the mean that patients with hypermobility in the MP joints may require was 26.9 degrees. This demonstrated a 9 degree increase in a modification of the orthosis with an MP dorsal block. MP flexion with the orthosis. As a group, the mean lateral pinch

◆ Speakers have nothing of value to disclose.

64 The Joint Annual ASSH/ASHT Meeting PAPER PAT16

Thursday, September 22, 10:54 a.m. PAT16 Agreement between Parent and Child Scoring on Assessments of Satisfaction and Function in the Upper Congenital below Elbow Deficient Population

*◆ Cheryl A. Hanley, BS OT, Sacramento, CA Michelle James, MD, Sacramento, CA Anita Bagley, PhD, Sacramento, CA

PURPOSE Although it is typical for parents to serve as questions that address how the prosthesis looks, fits, works, proxies in pediatric health care evaluations, it is important to helps in ADL’s, and fabrication time. The children rated higher examine the level of parent/child agreement because these satisfaction than their parents except for fabrication time. findings may be used as the basis for clinical decisions. PedsQL: The only significant difference between 5–7 year Satisfaction and function are major components of positive olds and their parents was in the area of School Function for quality of life outcomes, so tools that assess those aspects non-wearers. In the 8–10 year old group wearers disagreed of treatment were chosen for this study. with their parents in Physical Health, Emotional, Social, School Function, Psychosocial and Total Scale. In the non-wearers, the METHODS Four hundred and ninety four children with only disagreement was in School Functioning. For the 11–21 UCBED, ages 2–20, participated in the study which included year old population, there was disagreement in all areas for the administration of the Prosthetic Satisfaction Inventory (PSI; wearers except for Physical Health and for the non-wearers for wearers), Pediatric Quality of Life Inventory (PedsQL) and in the area of Physical Health and School Function. Parents Pediatric Outcomes Data Collection Instrument (PODCI) to scored higher than non-wearers and lower than wearers. both parent and child. Parent-child responses were paired as PODCI: Overall, wearers rated themselves higher than their follows: PSI: 8–10 year old (61 pairs), 11–21 year old (107 parent and did not agree in any category but Satisfaction. Non- pairs), PedsQL: 5–7 year old wearers (56 pairs) and non- wearers rated themselves lower that their parents in the areas wearers (23 pairs), 8–10 year old wearers (63 pairs) and non- of: Sports/Physical Function, Pain/Comfort, Expectations, and wearers (25 pairs), and 11–21 year old wearers (33 pairs) and Global Function. non-wearers (57 pairs); and PODCI: 11–21 year old wearers (125 pairs) and non wearers (52 pairs). Levels of agreement CONCLUSIONS There are significant differences between were measured using correlation coefficients (Pearson or parent and child responses in each of the assessments Spearman) with significance set at p<.01. studied. The younger population has the greatest level of child/parent agreement. Agreement decreases as the child’s RESULTS PSI: The 8–10 and 11–21 year old groups age increases. Areas of disagreement vary between wearers showed significant disagreement with their parents on the and non-wearers.

◆ Speakers have nothing of value to disclose.

* Grant support received from Clinical Outcomes Assesment of Children with Unilateral Congenital Below Elbow Deficiency.

Meeting Abstracts 65 PAPER PAT17

Thursday, September 22, 10:59 a.m. PAT17 Flexor Digitorum Superficialis, Flexor Pollicus Longus to Flexor Digitorum Profundus Tendon Transfer with Fractional Lengthening of Wrist Flexors and Neurectomy of The Motor Branch of The Ulnar Nerve Allows for Decreased Pain and Tenodesis Effect

◆ Beth U. Coon, PT, CHT, Lexington, KY Constantine P. Charoglu, MD, Lexington, KY

PURPOSE Flexor spasticity is common in the upper and splinting. Active wrist extension improved from neutral extremity after insult to the central nervous system. to 30 degrees after the surgical release of the extrinsic flexor Decreased function and hygiene problems occur with tone. The hand without active motion presented with wrist the inability to extend the wrist or move the digits. Flexor extension to neutral from 30 degrees wrist flexion when the Digitorum Superficialis and Flexor Pollicus Longus tendon elbow was extended. Hygiene was improved in both hands transfer to Flexor Digitorum Profundus and fractional without wound infections or wound dehiscence. lengthening of the wrist flexors was performed to assist with pain and hygeine problems. Two patients were treated RESULTS The superficialis to profundus transfer has been postoperatively, one with active wrist extension the other a time-honored treatment of spasticity in nonfunctional hands without active motion. Neurectomies of the motor branch of (Keenan 1996). Comprehensive surgical correction consisting the ulnar nerve in Guyon’s canal were performed for control of of superficialis, flexor pollicus longus, to profundus transfer, intrinsic spasticity in both of the predominantly nonfunctional fractional lengthening of wrist flexors, and ulnar motor hands, one with hygiene problems and the other with wrist branch neurectomy allowed a hand with minimal active and joint pain (Keenan 1987). Both patients had no potential wrist extension to present with pinching and grasp using a for further neurologic recovery. tenodesis pattern. The second patient previously without active motion in any plane presented with wrist extension METHODS The hands were casted postoperatively for during elbow extension. four weeks and had little or no return of spasticity and required no further surgical treatment. The hand was then CONCLUSIONS The comprehensive protocol allowed immobilized using a forearm based resting hand splint with correction of severe spasticity of the hand and wrist by a thumb SPICA support implemented to manage spasticity a single operation with improved care and function of a and allow for healing of the tendon repair. Hand function was previously nonfunctional hand. improved in the hand with active extension, after scar control

◆ Speakers have nothing of value to disclose.

66 The Joint Annual ASSH/ASHT Meeting PAPER PAT18

Thursday, September 22, 11:04 a.m. PAT18 Contrast Baths: New Thinking About an old Modality—A Study of the Effects of Contrast Baths in Pre- and Post-Operative Carpal Tunnel Release Patients

◆ Robert G. Janssen, Certificate in OT, Marlton, NJ Deborah A. Schwartz, Bachelor of Science in Occupational Therapy, Marlton, NJ

PURPOSE The purpose of this study is to examine the RESULTS Preliminary data was collected on a total of 27 effects of contrast baths on hand volume, grip and pinch hands: 11 right and 16 left. Ages ranged from 31 to 82 with a strength, functional dexterity and pain in pre- and post- mean age of 54. There were 9 males and 18 females. Although operative carpal tunnel release patients. data has been collected on all of the parameters, only hand volume was statistically analyzed at this time. Paired sample METHODS A multi-group pretest-posttest control group t-tests reveal that pre-operatively hand volume increased study design was developed. Patients diagnosed with carpal after treatment, (t(24)=.994, p<.001). Paired sample t-test tunnel syndrome who had elected to proceed with carpal also revealed that post-operatively, hand volume increased tunnel release were considered for the study. Protocols after treatment, (t (18)=.996, p<.001). were established based upon current understanding of clinical practices. Subjects were randomized to one of three CONCLUSIONS Contrast baths have been traditionally treatment groups: contrast baths with exercise, contrast used in the clinic as a method of reducing edema. However, baths without exercise and exercise alone. Data was initial data analysis conducted thus far suggests that hand collected for both hands on the following parameters before volume increases post treatment regardless of treatment and after treatment: hand volume, functional dexterity, wrist group. Clinicians may want to consider this information when range of motion, grip and pinch strength and the visual analog developing a treatment plan for their patients. These results scale of pain. Treatment was then rendered to the involved are preliminary. All parameters will be analyzed pre and post side only. Data was collected again. Testing was performed treatment for statistical significance once data collection is preoperatively and post operatively at the time of suture complete. Pre- versus post-operative parameters will also be removal. The authors performed all data collection and were examined in future analysis. blinded to the treatment received by the subject.

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 67 PAPER PAT19

Friday, September 23, 9:50 a.m. PAT19 Patient-Directed Post-Operative Rehabilitation Protocol for Elbow Contracture

◆ Michael R. Hausman, MD, New York, NY ◆ Steve K. Lee, MD, New York, NY Candida Iodice, OTR/CHT, New York, NY

PURPOSE Increasing financial pressures and constraints RESULTS There was an average improvement in ROM have complicated rehabilitation of major joint contractures. of approximately 200% with the average arc of motion The need for greater patient-directed exercise requires a increasing from 62 degrees to 127 degrees. There were no system of simple, static splints and protocols involving the complications or cases of skin breakdown. One patient who application of sustained force over extended periods of time. had undergone previous arthroscopic surgical release was The purpose of this study was to evaluate our experience unable to maintain the full ROM achieved at surgery. Re- with a patient-directed post-operative rehabilitation protocol release and prolonged post-operative care with an indwelling for elbow contracture. brachial plexus catheter resulted in a good result (15–140 degrees). METHODS Over a 10-year period, 84 elbow contractures were treated with surgical release followed by a rehabilitation CONCLUSIONS We report our post-operative rehabilitation program of long-cycle AAROM combined with static splinting protocol for elbow contractures in detail and suggest that performed by the patient. Simple, static extension splints this simplified, patient-directed program may be helpful for (Figure 1) and an elastic bandage flexion protocol (Figure 2) treating these challenging problems with reduced resources. were used to apply prolonged force. The patient alternatively applied these devices depending upon whether flexion or extension was prioritized.

FIGURE 1 FIGURE 2

◆ Speakers have nothing of value to disclose.

68 The Joint Annual ASSH/ASHT Meeting PAPER PAT20

Friday, September 23, 9:55 a.m. PAT20 10-Year Results of Endoscopic Carpal Tunnel Release, Using the Single Portal Technique

◆ Soo-Heong Tan, FAMS (Hand Surgery), FRCSEd, FRCSGlas, Singapore, Singapore Kawee Pataradool, MBBS, Singapore, Singapore Fok-Chuan Yong, FAMS (Hand Surgery), FRCSGlas, MBBS, Singapore, Singapore Lam-Chuan Teoh, FAMS (Hand Surgery), M Med(Surg), FRCSGlas, MBBS, Singapore, Singapore

PURPOSE Endoscopic carpal tunnel release (ECTR) is 68). Eighteen patients (64%) were completely asymptomatic a recent alternative to open carpal tunnel release in the and 15 patients (54%) had no functional deficit. The mean treatment of carpal tunnel syndrome (CTS). It has been symptom severity score was 1.41 (SD ± 0.68) and the mean reported to be effective in relieving CTS in short termed functional status score was 1.32 (SD±0.5). The operation studies. However, no long term reports about the results and was rated as excellent by 13 patients (46%) and good by the its continued effectiveness has been done. rest (54%). Twenty-seven patients (96%) had no persisting scar pain and the remaining single patient had only mild pain. METHODS 135 patients underwent ECTR by the Agee There were no complications. We then compared our results single portal technique between 1991 to 1994. Seventy- with that extracted from the literature of long term results of six patients (94 hands) were traced and sent the Boston open carpal tunnel release. questionnaire to evaluate their symptoms, functional status and patient satisfaction. This was followed up by telephone CONCLUSION Long term results of endoscopic carpal interviews. 4 patients (3%) had developed recurrence, were tunnel release by the single portal technique are comparable re-operated and were excluded. to the “gold standard” open carpal tunnel release. There is however better patient satisfaction from endoscopic release. RESULTS 28 patients (36 hands) responded and were In our hands, the recurrence rate of endoscopic carpal tunnel involved in the study. There were 23 females and 5 males. release is 3%. The average age of the patients were 55 years old (range 37 to

◆ Speakers have nothing of value to disclose.

Meeting Abstracts 69 PAPER PAT21

Friday, September 23, 10:00 a.m. PAT21 A Carpal Tunnel Survey. To Determine the Effectiveness of Full Hand Resting Splints on Carpal Tunnel Syndrome

◆ Helia S. Sillem, BScOT, CHT, CEES, Nanaimo, BC, Canada

Occupational Therapists have been fabricating custom wrist were referred to the Nanaimo Regional General Hospital splints for patients with carpal tunnel symptoms for years. Outpatient Occupational Therapy Department within the The theory that positioning the wrist in neutral and the MCP’s time period of 18 months were admitted into this study. in slight flexion minimizes the pressure in the carpal tunnel All outpatients received the same treatment, a full hand is well known. Our OT department wanted to know if our resting splint. outpatients found the full hand resting splints helpful in dealing with their carpal tunnel symptoms. RESULTS The CTQ scores were analyzed using chi-squared and Wilcoxin tests. As well the grip strength, sensation and PURPOSE The purpose of this study was to measure the manual muscle testing were analyzed. Interestingly the CTQ effectiveness of the splints on patients’ reported symptoms. scores improved over the 6 week period, however when This was done by giving the patients a Carpal Tunnel the outpatients were asked verbally if they found the splint Questionnaire (CTQ) (designed by the Brigham Hospital for helpful, more than half reported the splints were not helpful. Women) at their initial appointment and again at a 6-week follow-up appointment. We also included several objective CONCLUSIONS Outpatients reported improved function measurements: sensation, grip strength and manual muscle and less severity of symptoms after 6 weeks of wearing a full strength of the APB. hand resting splint at night, however the majority reported they found that the splint was not helpful. One reason they METHODS The Carpal Tunnel Study was a prospective may have been disappointed is that they expected their community based study of the effect of a full hand resting splint symptoms to resolve completely with splint usage. on carpal tunnel symptoms. We used a one group experimental design where we measured the symptoms initially, provided RELEVANCE TO HAND THERAPY Splinting is a common subjects with a splint and then took measurements again. technique used in the treatment of CTS, however there have The method for sampling was one of convenience. All not been many studies to demonstrate the effects of splinting outpatients who met the criteria of having a doctor’s on patients’ symptoms. With emphasis on evidence based diagnosis of Carpal Tunnel Syndrome, reported symptoms practice, therapists need to question the rationale behind of paraesthesia in the median nerve distribution and splinting certain joints and certain positions.

◆ Speakers have nothing of value to disclose.

70 The Joint Annual ASSH/ASHT Meeting PAPER PAT22

Friday, September 23, 10:05 a.m. PAT22 The Presence of Substance P in Forelimb Tendons in a Model of Upper Extremity Work-Related Musculoskeletal Disorder

*● Jane Fedorczyk, MS, PT, CHT, ATC, Philadelphia, PA Ann E. Barr, PT, PhD, Philadelphia, PA Mamta Amin, BS, Philadelphia, PA Mary F. Barbe, PhD, Philadelphia, PA

PURPOSE To determine the presence of substance P in epitenon, but at an attenuated level compared to HRHF. No forelimb tendons of rats that performed a high repetition-high SP immunoreactivity was observed in LRNF tendons at 3 or 6 force (HRHF) or low repetition-negligible force (LRNF) reaching weeks of task performance, or in the 0 week control tendons. and grasping task. The increased presence of substance P The level of SP immunoreactivity was associated with motor (SP) has been observed in patients with chronic tennis elbow, behavior degradation. and may be associated with prolonged or abnormal pain states, e.g. hyperalgesia. CONCLUSIONS Our findings demonstrate that SP increases in tendon tissues as a consequence of performing METHODS Forelimb tendons were collected from highly repetitive and forceful tasks. The response is young adult Sprague-Dawley rats that had performed exposure dependent (HRHF>LRNF) and tissue dependent either a HRHF or a LRNF reaching and grasping task for 3, (epitenon>endotenon). The presence of increased SP in the 6 or 12 weeks. Tendons were examined bilaterally using HRHF nonreach limb, albeit less than the reach limb, is likely immunohistochemical techniques and compared to results due to sustained postural loading during task performance. from 0 week controls. SP immunoreactivity was measured The tissue response is also dependent upon duration of task using a bioquantification system interfaced with a microscope. exposure. For all statistical analyses, the factors exposure group, week and limb were used in a 3-way ANOVA (p≤ 0.05) to determine RELEVANCE TO HAND THERAPY Despite increased differences in SP immunoreactivity. Post-hoc analyses were awareness of ergonomic risk factors in the workplace, carried out using Bonferroni method. incidence and costs of WMSDs are high. Tendinopathies are associated with repetitive movement with and without force. RESULTS SP immunoreactivity was significantly increased The incidence of tendinopathies increases with age and the in epitenon and endotenon in HRHF forelimb tendons. The amount of exposure to forceful repetitive movement. Animal response was greatest in 12 week HRHF epitenon tissues models provide an opportunity to examine tissue effects of distal forelimbs, and greater in reach forelimb tendons under controlled experimental conditions. The relationship of than nonreach. We observed increased SP in the following a neurochemical response with motor degradation supports amounts: HRHF 12 week>6 week>3 week, and epitenon> the idea that peripheral neurochemical changes (i.e. SP) endotenon>paratenon. SP was also present in LRNF 12 week contributes to the signs and symptoms of tendinopathies.

● Research or institutional support received from Temple University for Jane Fedorczyk, MS, PT, CHT, ATC.

* Grant support received from CDC-NIOSH OH 03970 to MFB.

Meeting Abstracts 71