Journal of Bone Joint Surgery British Volume, Sep 1, 2012
Introduction The role of in-situ decompression in patients with severe ulnar nerve compression is... more Introduction The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning. Material/Methods Thirty patients (20 Male/10 Female) with severe degree of nerve compression, confirmed clinically by Dellon9s classification and by abnormal Nerve Conduction Study, underwent simple in-situ decompression under general anaesthesia as a day-case procedure. Through a 4cms incision and by moving the elbow the nerve is fully visualised and decompressed. Outcome was measured prospectively at three months and one year using Modified Bishop9s score, grip strengths and two point discrimination (2PD). Results/Statistics The average age of patients were 58.3 (26–87) and dominant hand was involved in 13 patients. Patients showed improvement greater at 1year than at 3 months. There was statistically significant improvement in power (p-0.01) and pinch grip strength (p-0.001) at one year after surgery. According to Modified Bishop9s scoring, 24 patients (80%) had good to excellent results at one year follow-up. Of the eight patients with fair results at three months four improved and two detiorated, leading to a total of four poor results (13.3%) at one year follow-up. The 2PD identified the patients with poor or good results according to the Modified Bishop score at three months follow-up. Conclusions Our results show that the minimally invasive in-situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The Modified Bishop score and 2PD were more reliable in assessing these patients at follow-up.
Journal of Bone Joint Surgery British Volume, Sep 1, 2012
Aims The objective of our study is to identify the causes for recurrence and to evaluate the resu... more Aims The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique. Material and Methods We retrospectively analysed 18 patients (12 females; 6 males) who had both clinical and electrophysiological confirmation (7 focal entrapments; 11 severe entrapments) of recurrent carpal tunnel syndrome. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from hypothenar region and sutured to the lateral cut end of flexor retinaculum. All the patients were assessed post-operatively for relief of pain, recovery of sensory and motor dysfunction. Results The average age was 61 years and dominant hand was involved in 13/18. The average time between the first and second surgery was fifty-nine months. Intra-operatively ten had completely reformed retinaculum, two partially reformed (proximally) and five had scar tissue between the cut ends and one had scar tissue and fibrosis around the nerve. All patients had improvement of symptoms post-operatively. Ten had complete recovery immediately after surgery, the remaining patients had severe focal entrapment and had scar tissue intraoperatively. The patients with delayed recovery had high incidence of a) Early recuurence (average of nine months), b) Diabetes mellitus c) Obese/over-weight and d) cervical spine problems. Conclusions The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that prevents scar formation and helps nerve gliding. 80% of the patients in whom recurrence occurred within a year are associated with poor outcome/delayed recovery.
European Journal of Orthopaedic Surgery & Traumatology, 2008
Over 30 separate clinical signs for the shoulder have been described, most with little evidence t... more Over 30 separate clinical signs for the shoulder have been described, most with little evidence to support their accuracy and reliability. The aim of our study was to evaluate the accuracy and reliability of some of the commonly used tests for rotator cuff disease. Two clinicians, a consultant with an established shoulder practice and a registrar with an interest in shoulder surgery, examined 63 patients with history suggestive of rotator cuff disease. A set of pre-determined clinical tests for impingement syndrome and rotator cuff tear were standardised and agreed upon before the study was commenced. The examination included eliciting a painful arc, the drop arm test, the Neer’s and the Hawkin’s sign for impingement syndrome. Integrity of the individual components of the rotator cuff was assessed by the strength of abduction initiation and at 90° abduction for supraspinatus tear (Jobe’s test), Speed’s and Yergason’s test for biceps pathology, strength of shoulder external rotation for infraspinatus tears and the Gerber lift-off test for subscapularis tears. Accuracy assessments were determined by comparing clinical findings against findings at arthroscopy in 50 of the 63 patients. The two observers did not differ significantly in their assessments. Un-weighted kappa values defining agreement between the two observers and the positive predictive values were evaluated. Our findings indicate that clinical signs can be relied upon for diagnosis of impingement but not for rotator cuff deficiency. Compared with other previously published studies, our study demonstrates that the inter observer agreement is better when the assessors have a special interest and understanding of shoulder disorders.
We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological... more We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from January 2004 to December 2009. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from the hypothenar region and sutured to the lateral cut end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between first release and revision surgery and intra-operative findings were assessed against post-operative relief of pain, recovery of sensory and motor dysfunction. The average age of the patients was 58 years (43-81) and the dominant hand was involved in 22 patients. Intra-operatively the nerve was compressed by scar tissue connecting the previously divided ends of the retinaculum in 18 and nine had scar tissue and fibrosis around the nerve. Following surgery 16 patients had complete recovery (asymptomatic at the first follow-up), eight had delayed r...
The role of in situ decompression in patients with severe ulnar nerve compression is still contro... more The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26–87) years. Through incisions ≤4 cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop’s score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p = 0.01) and pinch grip (p = 0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.
diathermy and allowed to retract into the wound. Skin was closed with 6-0 Vicryl Rapide and a lig... more diathermy and allowed to retract into the wound. Skin was closed with 6-0 Vicryl Rapide and a light adhesive dressing was applied. The ages of 40 babies treated under local anaesthetic ranged from 3 to 18 weeks. A total of 58 accessory digits were excised. The mean duration of the procedure was 18 minutes (SD 1; range 2–20). In an audit of a group of 35 infants operated on under general anaesthesia, the ages ranged from 11 months to 2 years. The number of digits excised was 52. The mean duration of the procedure was 59 minutes (SD 6; range 10–97). The difference in duration of the procedure was statistically significant (P50.001, Student’s t-test). A telephone survey of 31 parents who were present in theatre during the operation revealed that 30 were glad the procedure had been carried out under local anaesthetic. One mother would have preferred a general anaesthetic and found the experience distressing. Two reported residual accessory skin that they felt did not warrant re-excision. Excision of minor accessory digits has been reviewed by Stewart et al. (2002) who excised ulnar duplication in infants up to 14 days old at the Aberdeen Royal Infirmary where maternity services were on the same site. They concluded that after this age babies are less passive and therefore excision under local anaesthetic is not feasible. In our practice it is inevitable that we operate on older babies, as maternity services are at other sites. We have not experienced difficulty operating on babies up to the age of 18 weeks. We have found excision of Stelling type 1 ulnar duplication up to 4 months of age under local anaesthetic to be a safe procedure associated with high satisfaction in parents.
Journal of Bone Joint Surgery British Volume, Sep 1, 2012
Introduction The role of in-situ decompression in patients with severe ulnar nerve compression is... more Introduction The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning. Material/Methods Thirty patients (20 Male/10 Female) with severe degree of nerve compression, confirmed clinically by Dellon9s classification and by abnormal Nerve Conduction Study, underwent simple in-situ decompression under general anaesthesia as a day-case procedure. Through a 4cms incision and by moving the elbow the nerve is fully visualised and decompressed. Outcome was measured prospectively at three months and one year using Modified Bishop9s score, grip strengths and two point discrimination (2PD). Results/Statistics The average age of patients were 58.3 (26–87) and dominant hand was involved in 13 patients. Patients showed improvement greater at 1year than at 3 months. There was statistically significant improvement in power (p-0.01) and pinch grip strength (p-0.001) at one year after surgery. According to Modified Bishop9s scoring, 24 patients (80%) had good to excellent results at one year follow-up. Of the eight patients with fair results at three months four improved and two detiorated, leading to a total of four poor results (13.3%) at one year follow-up. The 2PD identified the patients with poor or good results according to the Modified Bishop score at three months follow-up. Conclusions Our results show that the minimally invasive in-situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The Modified Bishop score and 2PD were more reliable in assessing these patients at follow-up.
Journal of Bone Joint Surgery British Volume, Sep 1, 2012
Aims The objective of our study is to identify the causes for recurrence and to evaluate the resu... more Aims The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique. Material and Methods We retrospectively analysed 18 patients (12 females; 6 males) who had both clinical and electrophysiological confirmation (7 focal entrapments; 11 severe entrapments) of recurrent carpal tunnel syndrome. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from hypothenar region and sutured to the lateral cut end of flexor retinaculum. All the patients were assessed post-operatively for relief of pain, recovery of sensory and motor dysfunction. Results The average age was 61 years and dominant hand was involved in 13/18. The average time between the first and second surgery was fifty-nine months. Intra-operatively ten had completely reformed retinaculum, two partially reformed (proximally) and five had scar tissue between the cut ends and one had scar tissue and fibrosis around the nerve. All patients had improvement of symptoms post-operatively. Ten had complete recovery immediately after surgery, the remaining patients had severe focal entrapment and had scar tissue intraoperatively. The patients with delayed recovery had high incidence of a) Early recuurence (average of nine months), b) Diabetes mellitus c) Obese/over-weight and d) cervical spine problems. Conclusions The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that prevents scar formation and helps nerve gliding. 80% of the patients in whom recurrence occurred within a year are associated with poor outcome/delayed recovery.
European Journal of Orthopaedic Surgery & Traumatology, 2008
Over 30 separate clinical signs for the shoulder have been described, most with little evidence t... more Over 30 separate clinical signs for the shoulder have been described, most with little evidence to support their accuracy and reliability. The aim of our study was to evaluate the accuracy and reliability of some of the commonly used tests for rotator cuff disease. Two clinicians, a consultant with an established shoulder practice and a registrar with an interest in shoulder surgery, examined 63 patients with history suggestive of rotator cuff disease. A set of pre-determined clinical tests for impingement syndrome and rotator cuff tear were standardised and agreed upon before the study was commenced. The examination included eliciting a painful arc, the drop arm test, the Neer’s and the Hawkin’s sign for impingement syndrome. Integrity of the individual components of the rotator cuff was assessed by the strength of abduction initiation and at 90° abduction for supraspinatus tear (Jobe’s test), Speed’s and Yergason’s test for biceps pathology, strength of shoulder external rotation for infraspinatus tears and the Gerber lift-off test for subscapularis tears. Accuracy assessments were determined by comparing clinical findings against findings at arthroscopy in 50 of the 63 patients. The two observers did not differ significantly in their assessments. Un-weighted kappa values defining agreement between the two observers and the positive predictive values were evaluated. Our findings indicate that clinical signs can be relied upon for diagnosis of impingement but not for rotator cuff deficiency. Compared with other previously published studies, our study demonstrates that the inter observer agreement is better when the assessors have a special interest and understanding of shoulder disorders.
We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological... more We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from January 2004 to December 2009. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from the hypothenar region and sutured to the lateral cut end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between first release and revision surgery and intra-operative findings were assessed against post-operative relief of pain, recovery of sensory and motor dysfunction. The average age of the patients was 58 years (43-81) and the dominant hand was involved in 22 patients. Intra-operatively the nerve was compressed by scar tissue connecting the previously divided ends of the retinaculum in 18 and nine had scar tissue and fibrosis around the nerve. Following surgery 16 patients had complete recovery (asymptomatic at the first follow-up), eight had delayed r...
The role of in situ decompression in patients with severe ulnar nerve compression is still contro... more The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26–87) years. Through incisions ≤4 cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop’s score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p = 0.01) and pinch grip (p = 0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.
diathermy and allowed to retract into the wound. Skin was closed with 6-0 Vicryl Rapide and a lig... more diathermy and allowed to retract into the wound. Skin was closed with 6-0 Vicryl Rapide and a light adhesive dressing was applied. The ages of 40 babies treated under local anaesthetic ranged from 3 to 18 weeks. A total of 58 accessory digits were excised. The mean duration of the procedure was 18 minutes (SD 1; range 2–20). In an audit of a group of 35 infants operated on under general anaesthesia, the ages ranged from 11 months to 2 years. The number of digits excised was 52. The mean duration of the procedure was 59 minutes (SD 6; range 10–97). The difference in duration of the procedure was statistically significant (P50.001, Student’s t-test). A telephone survey of 31 parents who were present in theatre during the operation revealed that 30 were glad the procedure had been carried out under local anaesthetic. One mother would have preferred a general anaesthetic and found the experience distressing. Two reported residual accessory skin that they felt did not warrant re-excision. Excision of minor accessory digits has been reviewed by Stewart et al. (2002) who excised ulnar duplication in infants up to 14 days old at the Aberdeen Royal Infirmary where maternity services were on the same site. They concluded that after this age babies are less passive and therefore excision under local anaesthetic is not feasible. In our practice it is inevitable that we operate on older babies, as maternity services are at other sites. We have not experienced difficulty operating on babies up to the age of 18 weeks. We have found excision of Stelling type 1 ulnar duplication up to 4 months of age under local anaesthetic to be a safe procedure associated with high satisfaction in parents.
Uploads
Papers by rajesh nanda