Search

Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.

This review discusses the anatomy and biomechanics of the thumb carpometacarpal (CMC) joint. This articulation between the trapezium and first metacarpal is integral for opposition and other complex movements necessary for pinch and grasp maneuvers. Fortunately, this joint is well equipped to handle the extreme forces imposed by these movements, as it is stabilized by an elaborate arrangement of ligaments and muscles. Without this stability, thumb subluxation would occur with loading during pinch and grasp, and human prehension would be impossible. Understanding the interactions occurring within this joint is essential for adequately treating pathology arising in this crucial joint.

Purpose Nerve transfers for peripheral nerve injuries can result in variable outcomes. We investigated the neuroprotective effect of epineurial lidocaine injection in the donor nerve prior to transection, with the hypothesis that proximal axon loss would be decreased with consequent increased neuroregeneration and functional recovery. Methods A rat sciatic nerve model was used with 4 intervention groups: (1) lidocaine; (2) lidocaine/calcium gluconate (CG); (3) CG; or (4) saline (control). Behavioral testing and qualitative and quantitative histological evaluation was performed at 8 and 12 weeks. Histological assays included transmission electron microscopy, retrograde fluorogold labeling, and whole mount immunostaining. Results Functional assessments through the sciatic functional index and Basso, Beattie, and Bresnahan scale showed a statistically significant increase in recovery at 8 and 12 weeks with lidocaine treatment. Significantly higher axonal counts were obtained in the lidocaine-treated groups. Fragmentation and increased myelin damage was present in the CG and saline groups. Retrograde fluorogold labeling showed a statistically significant increase in the number of L4-6 dorsal root ganglion neurons in the lidocaine-treated groups. Whole mount immunostaining identified extension of the axonal growth cone past the nerve coaptation site in lidocaine-treated groups, but not in CG and saline groups. Conclusions Our results suggest that epineurial lidocaine injection prior to donor nerve transection for nerve transfer has a neuroprotective effect, resulting in increased proximal axon counts and improved functional recovery. Clinical relevance These findings may have direct clinical application because epineurial lidocaine can be used in surgery as a simple and inexpensive intervention for promoting improved clinical outcomes after nerve transfer.

Highlights • Myoepithelial carcinoma of the vulva and epithelioid sarcoma has overlapping histological, immunohistochemical and genetic features. • Similarities between two diagnoses in aggressive vulvar cancer should be noted as a sarcoma-based chemotherapy regimen should be considered. • We recommend immediate surgical resection with bilateral superficial and deep inguinal lymph node dissections in these aggressive cancers. • Identification of SMARCB1-deficiency trials of targeted therapies such as EZH2 inhibitors which show promise in halting further progression., Introduction Myoepithelial carcinoma and proximal-type epithelioid sarcoma of the vulva are two rare malignancies with known aggressive behavior. In addition to a similar clinical course, these two disease entities also have significant histologic and pathologic overlap. Given the rarity of these malignancies, there is limited literature on the appropriate treatment regimen. Nevertheless, there is a consensus that early surgical resection is beneficial in both cases. Presentation We present a case of a patient who was initially diagnosed with myoepithelial carcinoma of the vulva with a differential later expanded to include possible epithelioid sarcoma. Discussion We demonstrate the importance in early identification of a SMARCB1 deficiency. Additionally, we suggest an appropriate treatment regimen for these patients going forward. Specifically, we encourage consideration of bilateral superficial and deep inguinal lymphadenectomies. Furthermore, sarcoma based chemotherapy regimens in the appropriate clinical setting may be beneficial in treating SMARCB1 deficient tumors. Additionally, there are now clinical trials involving EZH2 Inhibitors which may offer benefit for similar patients going forward. Conclusion This case highlights the difficulty in making a definitive diagnosis, and the importance in identifying a SMARCB1 deficiency as it will affect treatment options and may allow for enrollment in ongoing clinical trials.

Summary Background This study aimed to describe the technique and report our experience with the reconstruction of combined proximal thumb amputations at the metacarpal base level and index finger amputation at the metacarpal level with pollicization and bilateral double toe composite transfer. Methods The technique consists of pollicization of the remnant index ray. Then a contralateral composite medial great toe pulp and vascularized second toe proximal interphalangeal joint flap are harvested to reconstruct the metacarpophalangeal joint of the thumb. Subsequently, an ipsilateral composite great toe wrap-around and second toe proximal interphalangeal joint flap are harvested to reconstruct the thumb interphalangeal joint and the distal thumb. A neurotized superthin anterolateral thigh flap is used to reconstruct the ipsilateral toe defect, while the bone defects of the bilateral second toes are reconstructed with corticocancellous iliac crest bone grafts. Between 2010 and 2014, eight patients underwent reconstruction. Four patients could be recalled for follow-up, with a mean duration of 22 months. Results All flaps survived. The contour and length of the reconstructed thumbs was similar to the contralateral one. The mean Michigan hand outcomes questionnaire score was 80.5. The mean disabilities of the arm, shoulder and hand score was 7.5. The mean foot and ankle disability index score was 94.2. Conclusions Reconstruction of thumb amputations at the metacarpal base level with pollicization and double toe composite transfer results in excellent contour and functional outcome, with a natural-appearing thumb. In addition, all toes are preserved. Level of evidence Therapeutic, Level IV

Purpose Staged separation of 3- and 4-finger syndactyly is commonly performed owing to concerns about vascular supply to the central digit and availability of flap skin. We performed single-stage separation of patients with incomplete syndactyly of multiple digits with adjacent contiguous dorsal gullwing flaps and avoided skin grafts in the majority of cases. Methods Seventy-four webs of 31 patients with more than 2-finger incomplete syndactyly were included. Median age at surgical separation was 12 months (range, 5–123 months). All cases were incomplete syndactyly that did not extend to the fingernail level, with no bony involvement. A dorsal gullwing flap was used for all cases, which reconstructed the interdigital webs and partly covered the lateral side of the proximal phalanx. The technique relies on perfusion of the flap through the dorsal metacarpal artery perforator to aid flap mobility and double radial and ulnar z-plasties on each side of the flap to aid flap advancement. Skin grafts were needed if there were any remaining skin defects. Results In 30 of 31 cases, a single-stage procedure was accomplished. One case was staged owing to abnormal digital arterial anatomy found on exploration. No skin graft was required in 21 out of 31 patients (67.7%). Median postoperative follow-up was 12 months (range, 6–36 months). All finger web depths were normal or slightly deepened. Conclusions One-stage separation for 3- and 4-finger syndactyly with a dorsal gullwing flap is feasible and safe as long as at least 1 proper digital artery is preserved in each finger. The need for skin grafting is minimized. Type of study/level of evidence Therapeutic IV.

Purpose To report our experience with the use of a digital artery perforator propeller flap based on a constant distal perforator in the middle phalanx for resurfacing of lateral oblique fingertip amputations. Methods Twelve fingertips in 10 patients underwent reconstruction, with a mean follow-up of 8 months (range, 8–12 mo). The size of the flaps ranged from 2.5 × 1.5 cm to 3.0 × 2.0 cm. Results All flaps survived entirely and restored a rounded fingertip contour. Mean static 2-point discrimination was 5 mm (range, 4–6 mm). With the exception of 1 patient with an amputation at the distal interphalangeal joint, the distal interphalangeal joint was preserved in all patients and had 30° to 60° of motion at final follow-up. No patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in patients who had remaining nailbed. Conclusions The digital artery perforator propeller flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90° rotation is required when inset, and the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. Type of study/level of evidence Therapeutic IV.

The role of the hand as the primary form of interaction with the surrounding physical environment is often underappreciated, and injuries to it can become especially debilitating. The hand has evolved into a complex, intricate structural conglomeration of bones, joints, tendons, ligaments, and neurovascular structures, with an overlying soft tissue envelope that is varied and adapted to particular functions. Wounds to the hand requiring flap coverage warrant careful planning. Increasing knowledge of anatomy has led to the description of many flaps. This article presents a review of the commonly used flaps in reconstruction of the hand and the various considerations involved.

Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

Purpose To report our technique and experience with use of free functioning muscle transfer (FFMT) in reconstruction of traumatic brachial plexus injuries (BPIs) in children as well as its complications and outcomes. Methods Twelve patients with complete BPI underwent FFMT for reconstruction between 2000 and 2012. Eight had single-stage gracilis transfer for restoration of elbow flexion, and 4 children had double free gracilis muscle transfer for restoration of elbow flexion and prehension. Mean duration of follow-up was 27 months (range, 14–55 mo). Results Eleven out of 12 patients achieved at least M3 elbow flexion, with 8 patients achieving M4 or greater elbow flexion. Eight of 12 patients had nerve transfers to the musculocutaneous nerve. Mean active elbow arc of motion was 79° (range, 30°–130°). Two patients aged 8 and 11 years with open growth plates developed elbow joint contractures, which limited range of motion, but they recovered M4 and M5 elbow flexion strength. Conclusions FFMTs can result in good outcomes following reconstruction for traumatic BPI. The use of FFMT should be carefully considered in children prior to skeletal maturity because of the risk of the development of an elbow flexion contracture. Type of study/level of evidence Therapeutic IV.

Reconstruction of sacrectomy defects following ablative surgery remains a challenge, with high complication rates in the reported literature. The size of the defect is the primary consideration for flap choice; however, the cause of intra-abdominal and flap complications remains unclear. The aim of the study was to evaluate our results for sacrectomy flap reconstruction in order to determine predictive or protecting factors for complications.A 13-year retrospective review was performed of all patients who had reconstruction for partial and total sacrectomy defects at the Mayo Clinic in Rochester, MN, USA. Demographics, flap choice, and complications were analyzed. Multivariate analysis was used to determine factors causing flap and intra-abdominal complications.Fifty-four patients underwent reconstruction. Partial sacrectomy was performed in 38 (70.4%) patients, while total sacrectomy was performed in 16 (29.6%) patients. The average wound defect volume was 2136 cm(3) (range 196-13,980 cm(3)). Flaps used included gluteal (n = 15; 27.8%), rectus abdominis myocutaneous (RAM) (n = 37; 68.5%), and combined gluteal/RAM (n = 2; 3.7%). Obesity was significantly associated with intra-abdominal complications (p 0.05) while preoperative radiotherapy and chemotherapy were not. Flap and wound healing complications were not significantly associated with any factors.Gluteal advancement and vertical RAM or transverse RAM flaps are both reliable options for reconstruction of sacrectomy defects. The use of acellular dermal matrix (ADM) for reconstructing the posterior abdominal wall provides a barrier between the intra-abdominal contents and flap, preventing bowel adhesions/obstruction and fistulas as well as prevents sacroperineal hernia.

Summary Background Surgical correction of craniosynostosis aims to remodel the cranial vault to achieve a morphology approaching that of age-matched norms. However, current surgical technique is highly subjective and based largely on the surgeon's artistic vision in creating a normal head shape. Here, we present our technique and report our experience with the use of virtual surgery using computer-assisted design (CAD)/computer-assisted manufacturing (CAM) techniques to create a prefabricated template for the planning of osteotomies and the placement of bone segments, to achieve standardised, objective and precise correction of craniosynostosis. Methods Four patients who underwent cranial vault remodelling (CVR; three metopic synostosis and one sagittal synostosis) underwent virtual surgical planning (VSP) preoperatively using CAD/CAM techniques. VSP allows pre-planning of osteotomies to achieve the desired cranial vault shape. Surgical osteotomies and placement of bone segments were performed intra-operatively based on prefabricated templates. Results All patients demonstrated markedly improved head shape postoperatively. One patient developed a subdural haematoma 6 weeks postoperatively subsequent to a fall where he hit his head. The haematoma was drained and a soft spot was present in that location 3 months postoperatively. Conclusion The use of virtual surgery and prefabricated cutting guides allows for a more precise and rapid reconstruction. Surgical osteotomies are pre-planned and rapidly performed using a template, and precise placement of calvarial bone segments is achieved without the need for subjective assessment of the desired calvarial shape. In addition, patients and families have a significantly better understanding of the disease process and anticipated surgery preoperatively with the visualisation achieved through virtual surgery. This results in better alignment of hopes and expectations between the parents and surgeons.

A 5-year review of nosocomial infections, bacteraemia and wound colonization in patients admitted to a burn intensive care unit from June 2001 to May 2006 was carried out. All patients required intubation at some point, and ICU support. Data on bacterial and fungal isolates were entered prospectively into a hospital-wide computerized database. Nosocomial infections (NIs) were defined using standard CDC criteria. Seventy-six patients were admitted during the study period, with 57 qualifying for analysis. Forty-two patients (74%) developed 137 NIs, with 240 NIs/100 admissions. The most common NI was pneumonia (43%), followed by burn wound infection (34%), primary bloodstream infection (20%) and urinary tract infection (3%). The device specific rate of pneumonia was 143 infections per 1000 ventilator days. There were 113 episodes of bacteraemia and 173 episodes of wound colonization without infection. The most common organisms causing nosocomial infections were Acinetobacter sp. (n=33), followed by methicillin resistant Staphylococcus aureus (MRSA) (n=24) and Pseudomonas aeruginosa (n=22). A. baumannii isolates were highly multiresistant, with 82 distinct strains isolated from 47 patients (82% of patients). Data from this and other studies supports the hypothesis that A. baumannii is more common in tropical, warm climes necessitating vigorous infection control measures to optimise patient outcome.

We report a patient with a unique complex carpal dissociation involving complete and divergent dislocation of the hamate, capitate, and trapezium with total ligamentous disruption of the distal carpal row and midcarpal joint, associated with a transverse shaft fracture of the fifth metacarpal. The mechanism of injury was a sustained torsional force resulting in a simultaneous distraction and bidirectional dorsopalmar (ulnar)-palmodorsal (radial) crushing force at the carpus.