Surgery Provides Modest Benefit for Carpal Tunnel Syndrome

In this multicenter trial, researchers studied 116 people with idiopathic carpal tunnel syndrome.

The primary outcome was hand function measured by the Carpal Tunnel Syndrome Assessment Questionnaire at 12 months.

Nonsurgical treatment consisted mainly of hand therapy and wrist splinting.

To patients who experienced no improvement, investigators offered treatment with ultrasound.

The researchers report an advantage of surgery at 12 months.

They observed no clinically important adverse events or surgical complications.

A previous randomized controlled trial reported in the Journal of the American Medical Association also suggested greater efficacy of surgery compared with splinting in patients with carpal tunnel syndrome (2002;288:1245–1251).

Investigators led by Annette Gerritsen, PhD, from the Vrije University Medical Center in Amsterdam, the Netherlands, reported a 90% success rate after 18 months in the surgery group vs 75% in the splinting group.

Despite these consistent reports, however, investigators are urging caution.

The superior efficacy of surgery in today’s report and the previous surgery-versus-splinting trial should not necessarily imply that, in patients with moderately severe carpal tunnel syndrome, physicians should always advocate surgery without initial non-surgical treatment.

Nonsurgical Treatment May Still Be Indicated

The results could still justify initial wrist splinting in view of the fact that in both trials, about 60% of nonsurgical patients did not require surgery after 12 months, and the differences in symptom severity score (<0.5 in intention-to-treat analyses) were moderate.

When comparing surgical and nonsurgical treatments for the improvement in carpal tunnel syndrome, speed, degree, and sustainability are important.

Initial nonsurgical treatment has advantages. It is appropriate when symptom duration is short and diagnosis is less certain.

Potential surgical complications are avoided even though serious ones are uncommon.

Surgery can be followed by prolonged work disability.

Persistent pain in the proximal palm 5 years after surgery is reported in 6% of patients.

In addition, although uncommon, recurrence after surgery can be difficult to treat.

Future studies should compare the overall costs of surgical and non-surgical treatments to take into consideration all relevant aspects.

Patient Preference

Still, these 2 trials suggest that hand–wrist exercises and ultrasound do not provide additional benefit beyond that offered by splinting alone.

Patients’ preference is important : faced with the need to wear a splint  ach night and during daytime for weeks, some prefer early surgery while others prefer partial recovery to potential surgical risk.

My own conclusion is that patients with carpal tunnel syndrome who do not have satisfactory improvement with nonsurgical treatment should be offered surgery.

My own study (hundreds of surgical patients and many years island follow up)  is not  supported by any  National Institutes of Health.

As a freelance researcher, I disclose no relevant financial relationships.

Short term treatment with clarithromycin resulting in colchicine-induced rhabdomyolysis.

A case of colchicine-induced rhabdomyolysis is reported.

A 48 year old African-American male with history of hypertension and chronic gout on colchicine 0.6 mg daily presented with symptoms of a community acquired pneumonia.

The patient was started on 500 mg of clarithromycin orally twice daily and represented to the emergency room after 3 days complaining of severe muscle pain.

Investigations confirmed the presence of rhabdomyolysis and discontinuation of colchicine and clarithromycin resulted in resolution of clinical and biochemical features of rhabdomyolysis. By hospital day four, his muscle soreness had improved markedly.

Metabolism of colchicine by the cytochrome P450 3A4 system has been previously described, but this is the first published report of colchicine associated rhabdomyolysis secondary to drug metabolism interactions with an antibiotic.

A review of medications that are metabolized via the cytochrome 3A4 and A-SLAVED-LIVER (Amiodarone, Simvastatin, Lovastatin, Atorvastatin, Verapamil, Erythromycin, Diltiazem, Clarithromycin, Itraconazole, Voriconazole, colchicinE, Ritonavir) pneumonic is established.

Question of The Day

Midfoot dislocation

Appropriate treatment of the acute injury depicted is:

(A)		Open reduction, internal fixation
(B)		Traction
(C)		Closed reduction and casting
(D)		Primary midfoot arthro

Tarsal Bones are the seven bones which form the tarsus – namely, CALCANEUS, TALUS, cuboid, navicular, and the internal, middle, and external cuneiforms (Ankle Bones / Cuboid Bone / Cuneiform Bones / Navicular Bone of Foot).

CT scan performed 4 weeks after treatment of undisplaced scaphoid fractures can help orthopedists predict outcome

Thirty-seven of 43 undisplaced fractures were classed as “united” on their respective week 4 CT scans, and all 37 of these fractures were united, despite 25 of those fractures only being immobilized for 4 weeks.

Only one of the six undisplaced fractures classed as “not yet united” on the week-4 CT scan failed to unite.

The week-4 CT scan had 88% sensitivity, 100% specificity, and 100% positive and 17% negative predictive values in predicting the outcome of the undisplaced fractures.

The 4-week CT scan of the one undisplaced fracture that developed a nonunion clearly showed that the fracture had not yet united.

A 4-week scan does predict union. If it looks united, the fracture will unite, but it is not so good at predicting nonunion.

This paper outlines the difficulty in generalizing our treatment of the scaphoid and confirms that there is a subset of nondisplaced fractures that have a likelihood to heal within 4 weeks.

Researchers are now  contemplating just doing CT initially and treating according to [the scan results].

If one can just distinguish fractures as displaced or undisplaced initially and treat them in plaster for 4 weeks, that would be OK…

Ultrasound guidance for sciatic nerve blocks shown to have a 99% success rate

The investigators found no needle paresthesia, neurologic deficits or intravascular injections.

Teachable Software May Help Diagnose Endocarditis

Artificial neural networks —teachable software designed to mimic the human brain — could one day be used to diagnose endocarditis related to implanted cardiac-rhythm devices.

This artificial neural network correctly identified only a handful of CRMD-IE cases, and it was more successful in pinpointing generator pocket infections, which are fairly easy for clinicians to recognize.

But it’s a novel and innovative approach, and it clearly warrants further investigation…

Studies of antihypertensive efficacy of olmesartan medoxomil or valsartan in combination with amlodipine

Combination antihypertensive therapy with AML+OM+/-HTCZ, up-titrated as necessary, allowed a majority of patients to achieve BP goal.

Alendronate reduces the excretion of risk factors for calcium phosphate stone formation in postmenopausal women with osteoporosis.

Potential approach with BPs may be associated with thiazide diuretics or indapamide in the management of post-menopausal women with HC and associated bone loss.

Studies on the larger sample size are needed to demonstrate the efficacy on the fracture outcome.

ALN not only improves BMD and osteoporosis, but also reduces the risk of calcium phosphate stone formation in postmenopausal women.

Researchers cite potential of bacteria to improve implants

While current implant manufacturing methods involve spraying HA on the device, the researchers noted that the bacteria can facilitate adhesion in hard-to-reach areas that spray-on techniques may miss.

They also noted that bacterial-produced HA nanocrystals are smaller than chemically produced HA nanocrystals and, therefore, have a high mechanical strength, according to the release.

Lack of cortical contact in fragments of radial head fractures indicative of complex injury

Radial head fractures are usually classified according to the size and displacement of the fracture fragments, but stability is not considered.

At the Combined Annual Meeting of the American Society for Surgery of the Hand (ASSH) and the American Society of Hand Therapies, researchers propose a radiographic definition of stability: complete loss of cortical contact between the fracture fragment and the rest of the proximal radius.

The investigators used a prospective trauma database and billing records to identify 296 consecutive skeletally mature patients with radial head fractures treated over a 6-year period.

Researchers investigated whether or not there was a complete lack of cortical contact between a fracture fragment and the rest of the proximal radius and used this information to classify 121 consecutive fractures of part of the radial head displaced by more than 2 mm.

Study parameters included predictors of an isolated vs. a complex injury pattern in bivariate and multivariable analyses.

30 of the 121 fractures (25%) were classified as having cortical contact, with the remaining 91 displaying no cortical contact.

Ten of 30 fractures with cortical contact were part of a complex elbow injury, while 83 of 91 fractures (91%) without cortical contact were reported to be part of a complex elbow injury with an odds ratio of 21.

Lack of cortical contact with at least one radial head fracture fragment has fair reliability, but the diagnostic performance characteristics suggest that this concept may be useful and it deserves further study.