Background Carpal tunnel syndrome (CTS) is the most commonly diagnosed compression neuropathy of the upper extremity. Current AAOS recommendations are to obtain a confirmatory electrodiagnostic test in patients for whom surgery is being considered. Ultrasound has emerged as an alternative confirmatory test for CTS; however, its potential role is limited by lack of adequate data for sensitivity and specificity relative to electrodiagnostic testing. Questions/purposes In this meta-analysis we determined the sensitivity and specificity of ultrasound in the diagnosis of CTS. Methods A PubMed/MEDLINE search identified 323 articles for review. After applying exclusion criteria, 19 articles with a total sample size of 3131 wrists were included for meta-analysis. Three groups were created: a composite of all studies, studies using clinical diagnosis as the reference standard, and studies using electrodiagnostic testing as the reference standard. Results The composite sensitivity and specificity of ultrasound for the diagnosis of CTS, using all studies, were 77.6% (95% CI 71.6-83.6%) and 86.8% (95% CI 78.9-94.8%), respectively. Conclusions The wide variations of sensitivities and specificities reported in the literature have prevented meaningful analysis of ultrasound as either a screening or confirmatory tool in the diagnosis of CTS. The sensitivity and specificity of ultrasound in the diagnosis of CTS are 77.6% and 86.8%, respectively. Although ultrasound may not replace electrodiagnostic testing as the most sensitive and specific test for the diagnosis of CTS given the values reported in this meta-analysis, it may be a feasible alternative to electrodiagnostic testing as the first-line confirmatory test.

Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound, nerve conduction studies, and CTS-6 have similar sensitivity and specificity for the diagnosis of carpal tunnel syndrome. The currently accepted reference standard (nerve conduction studies) had the lowest sensitivity and specificity of the three tests. These findings support previous studies that have suggested that CTS-6 and ultrasound are highly accurate in the diagnosis of carpal tunnel syndrome and that nerve conduction studies are not necessary in most cases.

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).

Scaphoid fractures are the most common carpal bone fracture, usually occurring in young men, although the incidence in women has increased over the past decade. Snuffbox tenderness and/or pain with axial loading of the thumb should be treated as a scaphoid fracture until proved otherwise and the diagnosis confirmed with serial radiographs and/or advanced imaging. Nearly all displaced scaphoid fractures should undergo operative intervention to reduce the risk of nonunion. Nondisplaced fractures have high union rates with cast treatment, but require extended periods of immobilization. Consideration may be given to operative fixation of these fractures to allow early return to sport.

Background The American Academy of Orthopaedic Surgeons (AAOS) recommends that surgeons obtain a confirmatory test in patients for whom carpal tunnel surgery is being considered. The AAOS, however, does not specify a preferred test. Ultrasound reportedly causes less patient discomfort and takes less time to perform, while maintaining comparable sensitivity and specificity to electrodiagnostic testing (EDX). Questions/purposes We determined whether ultrasound as a first-line diagnostic test is more cost-effective than using EDX alone or using ultrasound alone: (1) when used by a general practitioner; and (2) when used by a specialist. Methods A fictional population of patients was created and each patient was randomly assigned a probability of having true-positive, false-positive, true-negative, and truepositive ultrasound and EDX tests over an expected range of sensitivity and specificity values using Monte Carlo methods. Charges were assigned based on Medicare charges for diagnostic tests and estimates of missed time from work. Results The average charge for the use of ultrasound as a first-line diagnostic test followed by EDX for confirmation of a negative ultrasound test was $562.90 per patient in the general practitioner scenario and $369.50 per patient in the specialist scenario, compared with $400.30 and $428.30 for EDX alone, respectively. Conclusions The use of diagnostic ultrasound as a firstline test for confirmation of a clinical diagnosis of carpal tunnel syndrome is a more cost-effective strategy in the specialist population and results in improved false-negative rates in the generalist population despite increased cost. Level of Evidence Level III, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.

Background Previous studies have found fewer clinical infections in wounds closed with monofilament suture compared with braided suture. Recently, barbed monofilament sutures have shown improved strength and increased timesavings over interrupted braided sutures. However, the adherence of bacteria to barbed monofilament sutures and other commonly used suture materials is unclear.

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