- Email: [email protected]
Dissatisfaction After First Dorsal Compartment Release for de Quervain Tendinopathy
EVIDENCE-BASED MEDICINE
Dissatisfaction After First Dorsal Compartment Release for de Quervain Tendinopathy Benjamin Rogozinski, MD,* Gary M. Lourie, MD†
THE PATIENT A 45-year-old woman sanitation engineer with de Quervain tendinopathy of her right dominant wrist was unsatisfied with nonsteroidal anti-inflammatory drugs, orthosis fabrication, modification of work activities, and corticosteroid injection, and requested first dorsal compartment release. Three months after surgery by another surgeon, she is not satisfied with the surgery. She is not working and has difficulty with activities of daily living. THE QUESTION What are the most common causes of dissatisfaction after first dorsal compartment release for de Quervain tendinopathy and how are they diagnosed and treated? CURRENT OPINION Release of the first dorsal compartment is an effective treatment of de Quervain tendinopathy. Dissatisfaction can be due to incomplete release of subcompartments of the first dorsal compartment, tendon subluxation, injury to the superficial branch of the radial sensory nerve, or impatience for resolution of symptoms. THE EVIDENCE In one retrospective review, 38 of 43 patients (88%) were satisfied with first dorsal compartment release even though 18 patients (42%) had wrist pain, weakness, scar tenderness, numbness and tingling at the surgical site, or restricted range of motion for at least 3 months after surgery.1 Two patients (5%) had From the *Department of Orthopaedic Surgery, Atlanta Medical Center; and †The Hand and Upper Extremity Center of Georgia, Atlanta, GA. Received for publication September 2, 2015; accepted in revised form September 7, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Benjamin Rogozinski, MD, Atlanta Medical Center, 303 Parkway Dr. NE, Atlanta, GA 30306; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.09.003
recurrent de Quervain disease, 1 patient (2%) had a radial sensory nerve injury, and 1 patient (2%) had a painful scar for longer than 3 months. Preoperative steroid injection, compartment septation, and occupation were not linked to satisfaction. In another review, all 94 consecutive patients evaluated an average of 16 years after first dorsal compartment release had complete relief of symptoms and returned to normal daily activities.2 There was 1 superficial infection, 1 delayed wound healing, and 4 transient lesions of the radial sensory nerve. In another retrospective study, 24 wrists treated with endoscopic release had less pain and disability than 26 wrists treated with open release at an average of about 20 months after surgery.3 Superficial radial nerve injury (5 wrists), scar tenderness (3 wrists), and unsightly scar (6 wrists) occurred in the open-release group but not in the endoscopic group. It was suggested in a series of 6 patients that maximal abduction of thumb metacarpal and flexion of the proximal phalanx during the Finklestein maneuver can eliminate action of the abductor pollicis longus (APL) and identify incomplete extensor pollicis brevis (EPB) compartment release.4 Among 200 wrists with de Quervain tendinopathy, 110 had more pain with resisted metacarpophalangeal extension than with the Finklestein maneuver (EPB entrapment test).5 Twenty-six wrists had surgery and 22 had a separate EPB subcompartment. Eighteen of the 22 wrists had a positive EPB entrapment test prior to surgery. A study of patient wrists in which the first dorsal compartment was released for de Quervain tendinopathy and dissected cadaveric specimens found a significant correspondence between a separate EPB subcompartment and interphalangeal joint extension by the EPB.6 Intraoperative testing of the EPB demonstrating interphalangeal joint extension should reinforce to the surgeon to explore the first dorsal compartment for a separate subcompartment if not already identified. In patients with symptomatic tendon subluxation following first dorsal compartment release, several case
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
DISSATISFACTION AFTER DE QUERVAIN RELEASE
OUR CURRENT CONCEPTS FOR THIS PATIENT In our practice, patients who are dissatisfied with first dorsal compartment release are offered surgery only when discrete, treatable pathophysiology is identified. It is our impression that most dissatisfied patients are unhappy with the duration of recovery and that a second surgery is unusual. Our patient had persistent radial-sided wrist pain worse with ulnar deviation, snapping on the radial side of the wrist with palmar flexion, and “tingling” over the dorsum of the thumb. On examination, she was tender over the first dorsal compartment, has a positive Finkelstein test, and pain with abduction of the thumb and forced flexion of the metacarpophalangeal joint. There was a positive Tinel sign at the incision, and with wrist flexion, the APL was visualized to subluxate over the radial styloid. We diagnosed 3 discrete sources of pathophysiology that we felt might improve with surgery: subluxation of the APL, incomplete release of the EPB subcompartment, and neuroma of the superficial radial nerve. We recommended repeat first dorsal compartment release ensuring release of any first dorsal subcompartments, reconstruction of the first dorsal compartment using a radial-based flap of extensor retinaculum, and neuroma excision with tension-free approximation and collagen-based nerve wrap conduit of the superficial radial sensory nerve. Surgical findings were consistent with preoperative diagnoses and our patient underwent complete release of the EPB subcompartment, reconstruction of the first compartment with extensor retinacular sling, and neuroma excision. At the most recent follow-up, she was satisfied with her function, had 75% improvement in pain, and had returned to work.
reports describe salvage procedures that reconstruct the action of the first dorsal compartment to prevent tendon subluxation with wrist flexion while allowing full tendon excursion using a swath of extensor retinaculum7,8 or a split brachioradialis tendon.9 Operative injury to the superficial radial nerve ranges from 2% to 27%.1,2,10 A study of 20 fresh cadavers found the superficial radial nerve entered the subcutaneous layer an average of 9.0 cm proximal to the radial styloid and bifurcated an average of 5.1 cm proximal to the radial styloid. On average, the nearest branch was 0.4 cm from the first dorsal compartment and directly overlaid the first compartment in 35% of cases.11 In a second study of 20 cadavers, the numbers were 8.6 cm and 5.3 cm, respectively.12 A longitudinal incision overlying the radial styloid for a de Quervain release encountered the dorsal radial sensory nerve branches in 75% of specimens studied. In a third study of 25 cadavers, the numbers were 8.3 cm and 4.9 cm, with all specimens having branches underlying a transverse incision.13 A 2.5-cm longitudinal incision at the radial styloid extending proximally over the first dorsal compartment avoided the superficial radial nerve in 68% of specimens. In a fourth study of 20 cadavers, the superficial radial sensory nerve bifurcated 5.0 cm proximal to the radial styloid with branches overlying the first dorsal compartment in all wrists.14 SHORTCOMINGS OF THE EVIDENCE There is a paucity of evidence regarding dissatisfaction after first dorsal compartment release for de Quervain tendinopathy. An unidentified and unreleased EPB subsheath is the one discrete source of dissatisfaction that is easily addressed with a second surgery. Radial sensory nerve branch laceration and volar tendon subluxation are uncommon and not clearly related to technical variations (eg, the orientation of the incision). It is expected that scar tenderness and numbness from neurapraxia will improve for a year after surgery, but it is not clear which patients find this unsatisfying.
REFERENCES 1. Ta KT, Eidelman D, Thompson JG. Patient satisfaction and outcomes of surgery for deQuervain’s tenosynovitis. J Hand Surg Am. 1999;24(5):1071e1077. 2. Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain’s stenosing tenosynovitis. Int Orthop. 2009;33(5):1301e1303. 3. Kang HJ, Hahn SB, Kim SH, Choi YR. Does endoscopic release of the first extensor compartment have benefits over open release in de Quervain’s disease? J Plast Reconstr Aesthet Surg. 2011;64(10): 1306e1311. 4. Louis DS. Incomplete release of the first dorsal compartment—a diagnostic test. J Hand Surg Am. 1987;12(1):87e88. 5. Alexander RD, Catalano LW, Barron OA, Glickel SZ. The extensor pollicis brevis entrapment test in the treatment of de Quervain’s disease. J Hand Surg Am. 2002;27(5):813e816. 6. Alemohammad AM, Yazaki N, Morris RP, Buford WL, Viegas SF. Thumb interphalangeal joint extension by the extensor pollicis brevis: association with a subcompartment and de Quervain’s disease. J Hand Surg Am. 2009;34(4):719e723.
DIRECTIONS FOR FUTURE RESEARCH Randomized controlled trials might help compare the relationship of satisfaction to specific incisions, open versus endoscopic release, postoperative orthosis fabrication, and other factors. Several psychosocial factors related to satisfaction, symptom intensity, and magnitude of disability also merit study including patient-rated and objectively rated surgeon empathy, catastrophic thinking, kinesiophobia, and symptoms of depression. J Hand Surg Am.
r
Vol. -, - 2015
DISSATISFACTION AFTER DE QUERVAIN RELEASE
11. Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implications. J Hand Surg Am. 1992;17(6):1037e1041. 12. Auerbach DM, Collins ED, Kunkle KL, Monsanto EH. The radial sensory nerve. An anatomic study. Clin Orthop Relat Res. 1994;308: 241e249. 13. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clin Anat. 2008;21(1):38e45. 14. Gurses IA, Coskun O, Gayretli O, Kale A, Ozturk A. The relationship of the superficial radial nerve and its branch to the thumb to the first extensor compartment. J Hand Surg Am. 2014;39(3):480e483.
7. Ramesh R, Britton JM. A retinacular sling for subluxing tendons of the first extensor compartment. A case report. J Bone Joint Surg Br. 2000;82(3):424e425. 8. White GM, Weiland AJ. Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: a case report. J Hand Surg Am. 1984;9(5):704e706. 9. McMahon M, Craig SM, Posner MA. Tendon subluxation after de Quervain’s release: treatment by brachioradialis tendon flap. J Hand Surg Am. 1991;16(1):30e32. 10. Mellor SJ, Ferris BD. Complications of a simple procedure: de Quervain’s disease revisited. Int J Clin Pract. 2000;54(2):76e77.
J Hand Surg Am.
3
r
Vol. -, - 2015
Dissatisfaction After First Dorsal Compartment Release for de Quervain Tendinopathy Benjamin Rogozinski, MD,* Gary M. Lourie, MD†
THE PATIENT A 45-year-old woman sanitation engineer with de Quervain tendinopathy of her right dominant wrist was unsatisfied with nonsteroidal anti-inflammatory drugs, orthosis fabrication, modification of work activities, and corticosteroid injection, and requested first dorsal compartment release. Three months after surgery by another surgeon, she is not satisfied with the surgery. She is not working and has difficulty with activities of daily living. THE QUESTION What are the most common causes of dissatisfaction after first dorsal compartment release for de Quervain tendinopathy and how are they diagnosed and treated? CURRENT OPINION Release of the first dorsal compartment is an effective treatment of de Quervain tendinopathy. Dissatisfaction can be due to incomplete release of subcompartments of the first dorsal compartment, tendon subluxation, injury to the superficial branch of the radial sensory nerve, or impatience for resolution of symptoms. THE EVIDENCE In one retrospective review, 38 of 43 patients (88%) were satisfied with first dorsal compartment release even though 18 patients (42%) had wrist pain, weakness, scar tenderness, numbness and tingling at the surgical site, or restricted range of motion for at least 3 months after surgery.1 Two patients (5%) had From the *Department of Orthopaedic Surgery, Atlanta Medical Center; and †The Hand and Upper Extremity Center of Georgia, Atlanta, GA. Received for publication September 2, 2015; accepted in revised form September 7, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Benjamin Rogozinski, MD, Atlanta Medical Center, 303 Parkway Dr. NE, Atlanta, GA 30306; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.09.003
recurrent de Quervain disease, 1 patient (2%) had a radial sensory nerve injury, and 1 patient (2%) had a painful scar for longer than 3 months. Preoperative steroid injection, compartment septation, and occupation were not linked to satisfaction. In another review, all 94 consecutive patients evaluated an average of 16 years after first dorsal compartment release had complete relief of symptoms and returned to normal daily activities.2 There was 1 superficial infection, 1 delayed wound healing, and 4 transient lesions of the radial sensory nerve. In another retrospective study, 24 wrists treated with endoscopic release had less pain and disability than 26 wrists treated with open release at an average of about 20 months after surgery.3 Superficial radial nerve injury (5 wrists), scar tenderness (3 wrists), and unsightly scar (6 wrists) occurred in the open-release group but not in the endoscopic group. It was suggested in a series of 6 patients that maximal abduction of thumb metacarpal and flexion of the proximal phalanx during the Finklestein maneuver can eliminate action of the abductor pollicis longus (APL) and identify incomplete extensor pollicis brevis (EPB) compartment release.4 Among 200 wrists with de Quervain tendinopathy, 110 had more pain with resisted metacarpophalangeal extension than with the Finklestein maneuver (EPB entrapment test).5 Twenty-six wrists had surgery and 22 had a separate EPB subcompartment. Eighteen of the 22 wrists had a positive EPB entrapment test prior to surgery. A study of patient wrists in which the first dorsal compartment was released for de Quervain tendinopathy and dissected cadaveric specimens found a significant correspondence between a separate EPB subcompartment and interphalangeal joint extension by the EPB.6 Intraoperative testing of the EPB demonstrating interphalangeal joint extension should reinforce to the surgeon to explore the first dorsal compartment for a separate subcompartment if not already identified. In patients with symptomatic tendon subluxation following first dorsal compartment release, several case
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
DISSATISFACTION AFTER DE QUERVAIN RELEASE
OUR CURRENT CONCEPTS FOR THIS PATIENT In our practice, patients who are dissatisfied with first dorsal compartment release are offered surgery only when discrete, treatable pathophysiology is identified. It is our impression that most dissatisfied patients are unhappy with the duration of recovery and that a second surgery is unusual. Our patient had persistent radial-sided wrist pain worse with ulnar deviation, snapping on the radial side of the wrist with palmar flexion, and “tingling” over the dorsum of the thumb. On examination, she was tender over the first dorsal compartment, has a positive Finkelstein test, and pain with abduction of the thumb and forced flexion of the metacarpophalangeal joint. There was a positive Tinel sign at the incision, and with wrist flexion, the APL was visualized to subluxate over the radial styloid. We diagnosed 3 discrete sources of pathophysiology that we felt might improve with surgery: subluxation of the APL, incomplete release of the EPB subcompartment, and neuroma of the superficial radial nerve. We recommended repeat first dorsal compartment release ensuring release of any first dorsal subcompartments, reconstruction of the first dorsal compartment using a radial-based flap of extensor retinaculum, and neuroma excision with tension-free approximation and collagen-based nerve wrap conduit of the superficial radial sensory nerve. Surgical findings were consistent with preoperative diagnoses and our patient underwent complete release of the EPB subcompartment, reconstruction of the first compartment with extensor retinacular sling, and neuroma excision. At the most recent follow-up, she was satisfied with her function, had 75% improvement in pain, and had returned to work.
reports describe salvage procedures that reconstruct the action of the first dorsal compartment to prevent tendon subluxation with wrist flexion while allowing full tendon excursion using a swath of extensor retinaculum7,8 or a split brachioradialis tendon.9 Operative injury to the superficial radial nerve ranges from 2% to 27%.1,2,10 A study of 20 fresh cadavers found the superficial radial nerve entered the subcutaneous layer an average of 9.0 cm proximal to the radial styloid and bifurcated an average of 5.1 cm proximal to the radial styloid. On average, the nearest branch was 0.4 cm from the first dorsal compartment and directly overlaid the first compartment in 35% of cases.11 In a second study of 20 cadavers, the numbers were 8.6 cm and 5.3 cm, respectively.12 A longitudinal incision overlying the radial styloid for a de Quervain release encountered the dorsal radial sensory nerve branches in 75% of specimens studied. In a third study of 25 cadavers, the numbers were 8.3 cm and 4.9 cm, with all specimens having branches underlying a transverse incision.13 A 2.5-cm longitudinal incision at the radial styloid extending proximally over the first dorsal compartment avoided the superficial radial nerve in 68% of specimens. In a fourth study of 20 cadavers, the superficial radial sensory nerve bifurcated 5.0 cm proximal to the radial styloid with branches overlying the first dorsal compartment in all wrists.14 SHORTCOMINGS OF THE EVIDENCE There is a paucity of evidence regarding dissatisfaction after first dorsal compartment release for de Quervain tendinopathy. An unidentified and unreleased EPB subsheath is the one discrete source of dissatisfaction that is easily addressed with a second surgery. Radial sensory nerve branch laceration and volar tendon subluxation are uncommon and not clearly related to technical variations (eg, the orientation of the incision). It is expected that scar tenderness and numbness from neurapraxia will improve for a year after surgery, but it is not clear which patients find this unsatisfying.
REFERENCES 1. Ta KT, Eidelman D, Thompson JG. Patient satisfaction and outcomes of surgery for deQuervain’s tenosynovitis. J Hand Surg Am. 1999;24(5):1071e1077. 2. Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain’s stenosing tenosynovitis. Int Orthop. 2009;33(5):1301e1303. 3. Kang HJ, Hahn SB, Kim SH, Choi YR. Does endoscopic release of the first extensor compartment have benefits over open release in de Quervain’s disease? J Plast Reconstr Aesthet Surg. 2011;64(10): 1306e1311. 4. Louis DS. Incomplete release of the first dorsal compartment—a diagnostic test. J Hand Surg Am. 1987;12(1):87e88. 5. Alexander RD, Catalano LW, Barron OA, Glickel SZ. The extensor pollicis brevis entrapment test in the treatment of de Quervain’s disease. J Hand Surg Am. 2002;27(5):813e816. 6. Alemohammad AM, Yazaki N, Morris RP, Buford WL, Viegas SF. Thumb interphalangeal joint extension by the extensor pollicis brevis: association with a subcompartment and de Quervain’s disease. J Hand Surg Am. 2009;34(4):719e723.
DIRECTIONS FOR FUTURE RESEARCH Randomized controlled trials might help compare the relationship of satisfaction to specific incisions, open versus endoscopic release, postoperative orthosis fabrication, and other factors. Several psychosocial factors related to satisfaction, symptom intensity, and magnitude of disability also merit study including patient-rated and objectively rated surgeon empathy, catastrophic thinking, kinesiophobia, and symptoms of depression. J Hand Surg Am.
r
Vol. -, - 2015
DISSATISFACTION AFTER DE QUERVAIN RELEASE
11. Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implications. J Hand Surg Am. 1992;17(6):1037e1041. 12. Auerbach DM, Collins ED, Kunkle KL, Monsanto EH. The radial sensory nerve. An anatomic study. Clin Orthop Relat Res. 1994;308: 241e249. 13. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clin Anat. 2008;21(1):38e45. 14. Gurses IA, Coskun O, Gayretli O, Kale A, Ozturk A. The relationship of the superficial radial nerve and its branch to the thumb to the first extensor compartment. J Hand Surg Am. 2014;39(3):480e483.
7. Ramesh R, Britton JM. A retinacular sling for subluxing tendons of the first extensor compartment. A case report. J Bone Joint Surg Br. 2000;82(3):424e425. 8. White GM, Weiland AJ. Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: a case report. J Hand Surg Am. 1984;9(5):704e706. 9. McMahon M, Craig SM, Posner MA. Tendon subluxation after de Quervain’s release: treatment by brachioradialis tendon flap. J Hand Surg Am. 1991;16(1):30e32. 10. Mellor SJ, Ferris BD. Complications of a simple procedure: de Quervain’s disease revisited. Int J Clin Pract. 2000;54(2):76e77.
J Hand Surg Am.
3
r
Vol. -, - 2015