A Summer Bonanza of Upper Extremity Articles

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾