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Background Scapholunate (SL) ligament injuries are rarely diagnosed in children. This study reports the outcomes of surgically treated SL ligament injuries in patients younger than 18 years. Methods A retrospective review was performed on 20 pediatric patients with SL ligament injuries. Records were reviewed for preoperative and postoperative radiographic data, intraoperative findings, classifications of interosseous ligament injury, and postoperative course. Results Thirteen girls and seven boys sustained SL injuries requiring operative intervention and were followed for an average of 26 months. Magnetic resonance imaging (MRI) was performed in 15 patients, which revealed an SL tear in 7 patients. Arthroscopically, SL injuries were classified as Geissler grade III in 12 patients and grade IV in 5 patients. Based on the Mayo Wrist Score, nine patients had excellent or good results, while six demonstrated fair results. The mean wrist flexion–extension arc was 109 degrees, while the mean grip strength was 82% of the unaffected side. Patients treated >1 year following injury had significantly decreased grip strength and Mayo Wrist Score. Conclusion In this study, worse results were seen in children with a protracted course prior to treatment of an SL injury. A high index of suspicion is necessary to detect an SL injury in the younger age group and should be in the differential for those with persistent dorsal wrist pain, tenderness over the dorsal SL joint, and/or positive Watson's test. MRI may assist in diagnosis but is not definitive to rule out injury. Arthroscopy is valuable to determine the extent of injury.

Background: Systematic reviews have identified the need for a patient-reported outcome measure for facial nerve paralysis (FNP). The aim of this study was to determine the psychometric properties of FACE-Q Craniofacial module scales when used in a combined sample of children and older adults with FNP. Methods: Data were collected between December 2016 and December 2019. We conducted qualitative interviews with children and adults with FNP. FACE-Q data were collected from patients aged 8 years and older with FNP. Rasch measurement theory analysis was used to examine the reliability and validity of the relevant scales in the FNP sample. Results: Twenty-five patients provided 2052 qualitative codes related to appearance, physical, psychological, and social function. Many patient concerns were common across age. The field-test sample included 235 patients aged 8-81 years. Of the 13 scales examined, all 122 items had ordered thresholds and good item fit to the Rasch model. For 12 scales, person separation index values were ≥0.79 and Cronbach's alpha values were ≥0.82. The 13th scale's reliability values were ≥0.71. Conclusion: The FACE-Q Craniofacial module scales described in this study can be used to collect and compare evidence-based outcome data from children and adults with FNP.

Background: To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario’s wait times for delayed surgical treatment of traumatic PNI. Methods: We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics. Results: Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001). Conclusion: The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

➤ Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common. ➤ The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury. ➤ Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries. ➤ Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers. ➤ Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

BACKGROUND The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective? METHODS A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime. RESULTS The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion. CONCLUSIONS The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Since 1965, the practice of digital replantation has seen great technical strides and become commonplace worldwide. However, some American authors have recently reported declining rates of replantation. We set out to characterize the patient population and describe treatment patterns from 2005 to 2016 at a large Canadian regional replantation center.A retrospective cohort of all patients undergoing digital replantation and revascularization from 2005 to 2016 was identified. Data were collected on demographics, injuries, procedures, and outcomes. Descriptive statistics were performed, followed by a comparison of two 5-year periods to evaluate temporal trends.A total of 234 patients were treated with 146 replantation and 204 revascularization procedures. Patients were largely male, healthy, and worked as manual labourers. Overall, the failure rate of individual repairs was 28.7%. Over time, there was a trend toward more crush or avulsion and multidigit injuries, and surgeries performed after 2011 were significantly longer. There was a significant downward trend in the number of patients treated at our center each year. Additionally, there was a statistically significant decrease in the proportion of replanted to revised digits in multidigit cases.Our observation of declining replantation rates is in line with recent American observations. The reason for this is not obvious but may represent a change in injury characteristics or surgeon attitudes.We suspect that these changes represent a change in workplace safety and injury characteristics, but further studies are needed to assess patient and surgeon treatment decisions.Depuis 1965, la replantation digitale a beaucoup progressé sur le plan technique et s'est généralisée dans le monde. Cependant, certains auteurs américains ont récemment signalé une baisse du taux de replantations. Les chercheurs se sont attachés à caractériser la population et à décrire les modes de traitement dans un grand centre de replantation canadien entre 2005 et 2016.Les chercheurs ont extrait une cohorte rétrospective de tous les patients qui ont subi une replantation digitale et une revascularisation entre 2005 et 2016. Ils ont colligé les données en matière de démographie, de blessures, d'interventions et de résultats cliniques et procédé à des statistiques descriptives, puis à une comparaison de deux périodes de cinq ans pour évaluer les tendances temporelles.Au total, 234 patients ont reçu un traitement, pour 146 replantations et 204 revascularisations. Ces patients étaient majoritairement des hommes en bonne santé qui exerçaient un travail manuel. Le taux d'échec des réparations individuelles s'élevait à 28,7 %. Au fil du temps, les chercheurs ont observé une tendance vers un plus grand nombre d'écrasements ou d'avulsions et de blessures de plusieurs doigts, et les opérations exécutées après 2011 étaient significativement plus longues. Les chercheurs ont constaté une tendance significative à la baisse du nombre de patients traités à leur centre chaque année. Ils ont également constaté une diminution statistiquement significative de la proportion de doigts replantés ou de réinterventions dans les cas de blessures de plusieurs doigts.Les observations des chercheurs à l'égard de la diminution du taux de replantations correspondent aux récentes constatations américaines. La raison de cette constatation n'est pas manifeste, mais pourrait représenter une modification aux caractéristiques des blessures ou aux attitudes des chirurgiens.

Health utility is a quantitative global measure of patients’ health status. This retrospective cohort study aimed to compare health utilities of patients with mild to moderate versus severe carpal tunnel syndrome and determine inter-instrumental agreement. Health utilities of 29 patients with varying severity of carpal tunnel syndrome were measured indirectly by Short-Form Sixth Dimension and EuroQol 5D questionnaire and directly by Chained Standard Gamble and a visual analogue scale. Health utility was 0.69 for Short-Form Sixth Dimension, 0.78 for EuroQol 5D Questionnaire, 0.98 for Chained Standard Gamble, and 0.76 for the visual analogue scale. There was a significant inter-instrumental agreement between three of the instruments, but not the Chained Standard Gamble. The difference in health utilities between patients with mild or moderate versus severe carpal tunnel syndrome was significant only for the EuroQol 5D questionnaire. We conclude based on our results that there are no clear indications on how health utilities can be integrated into decision analysis models and economic evaluation regarding carpal tunnel syndrome of various severities . Level of evidence: IV

Although aromatase inhibitors are the first-line treatment in postmenopausal women with hormone receptor-positive breast cancer, there is increasing evidence that they can induce carpal tunnel syndrome and stenosing tenosynovitis. This systematic review summarizes the risk factors, incidence, and management for patients with aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis compared to tamoxifen or placebo.A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review of PubMed/MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials was conducted (to March 19, 2020), supplemented with Google Scholar, Plastic and Reconstructive Surgery, and The Journal of Hand Surgery. Two reviewers independently completed the primary and secondary screens and the quality appraisal.This study reviewed 577 abstracts and included 19 studies. Risk factors for aromatase inhibitor-induced carpal tunnel syndrome or stenosing tenosynovitis included hormone replacement therapy before trial entry, history of musculoskeletal symptoms, age younger than 60 years, prior chemotherapy, and body mass index greater than 25 kg/m2. The incidence can be increased up to 10 times compared to tamoxifen. Patient discontinuation of aromatase inhibitor treatment because of carpal tunnel syndrome and stenosing tenosynovitis was reported. Nonsurgical management led to complete resolution of carpal tunnel syndrome symptoms in up to 67 percent of cases. Although most aromatase inhibitor-induced stenosing tenosynovitis original studies were low quality, all recommended surgical release for symptom resolution.This study provides current knowledge of the associated risk factors, management options, and quality of literature for aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis. Early recognition can prevent self-discontinuation of an aromatase inhibitor and long-term sequelae of poorly treated carpal tunnel syndrome and stenosing tenosynovitis.

Background: Despite increased public awareness to dispose of unused narcotics, opioids prescribed postoperatively are retained, which may lead to drug diversion and abuse. This study assessed retention of unused opioids among hand surgery patients and describes disposal methods and barriers. Methods: Participants undergoing hand surgery were given an opioid disposal information sheet preoperatively (N = 222) and surveyed postoperatively to assess disposal or retention of unused opioids, disposal methods, and barriers to disposal. A binomial logistic regression was conducted to assess whether age, sex, pain intensity, and/or the type of procedure were predictors of opioid disposal. Results: There were 171 patients included in the analysis (n = 51 excluded; finished prescription or continued opioid use for pain control). Unused opioids were retained by 134 patients (78%) and disposal was reported by 37 patients (22%). Common disposal methods included returning opioids to a pharmacy (49%) or mixing them with an unwanted substance (24%). Reasons for retention included potential future use (54%), inconvenient disposal methods (21%), or keeping an unfilled prescription (9%). None of the patient factors analyzed (age, sex, type of procedure performed, or pain score) were predictors of disposal of unused narcotics ( P > .05). Conclusions: Most patients undergoing hand surgery retained prescribed opioids for future use or due to impractical disposal methods. The most common disposal methods included returning narcotics to a pharmacy or mixing opioids with unwanted substances. Identifying predictors of disposal may provide important information when developing strategies to increase opioid disposal.

Compared to other patient population groups, the field of amputation research in Canada lacks cohesion largely due to limited funding sources, lack of connection among research scientists, and loose ties among geographically dispersed healthcare centres, research institutes and advocacy groups. As a result, advances in clinical care are hampered and ultimately negatively influence outcomes of persons living with limb loss.To stimulate a national strategy on advancing amputation research in Canada, a consensus-workshop was organized with an expert panel of stakeholders to identify key research priorities and potential strategies to build researcher and funding capacity in the field.A modified Delphi approach was used to gain consensus on identifying and selecting an initial set of priorities for building research capacity in the field of amputation. This included an anonymous pre-meeting survey (The top three identified research priorities were: (1) developing a national dataset; (2) obtaining health economic data to illustrate the burden of amputation to the healthcare system and to patients; and (3) improving strategies related to outcome measurement in patients with limb loss (e.g. identifying, validating, and/or developing outcome measures). Strategies for moving these priorities into action were also developed.The consensus-workshop provided an initial roadmap for limb loss research in Canada, and the event served as an important catalyst for stakeholders to initiate collaborations for moving identified priorities into action. Given the increasing number of people undergoing an amputation, there needs to be a stronger Canadian collaborative approach to generate the necessary research to enhance evidence-based clinical care and policy decision-making.IMPLICATIONS FOR REHABILITATIONLimb loss is a growing concern across North America, with lower-extremity amputations occurring due to complications arising from diabetes being a major cause.To advance knowledge about limb loss and to improve clinical care for this population, stronger connections are needed across the continuum of care (acute, rehabilitation, community) and across sectors (clinical, advocacy, industry and research).There are new surgical techniques, technologies, and rehabilitation approaches being explored to improve the health, mobility and community participation of people with limb loss, but further research evidence is needed to demonstrate efficacy and to better integrate them into standard clinical care.

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure. Level of evidence: IV

Background The aim of this study was to evaluate the impact of increasing age on rates of digital failure. Method A retrospective cohort study of digital replantation or revascularization patients was undertaken from 2005 to 2016. Data collected consisted of patient demographics, smoking status, injury mechanisms, procedure types, and postoperative morbidity and mortality. Descriptive statistics and logistic regression were performed to assess outcomes. All comparisons were made between patients older than and younger than 60 years. Results Two hundred eighty-three patients underwent replantation or revascularization; 11 percent were older than 60 years. The majority of patients had multiple devascularized digits (70 percent), most commonly inflicted by a blade mechanism (77 percent). Approximately half of the patients underwent revascularization alone (54.4 percent). American Society of Anesthesiologists score and number of comorbidities were significantly greater in the older adult group. Overall, 88 patients (31 percent) experienced digital replantation or revascularization failure, with 12 failures in patients aged 60 years or older. Multivariate logistic regression demonstrated that age did not have an impact on failure rate. Older patients did not experience more major complications, but had significantly higher rates of minor complications (p = 0.0485). Conclusions Older patients presented with significantly higher American Society of Anesthesiologists physical status and number of comorbidities, but did not experience higher rates of digital failure, major perioperative complications, or 30-day mortality. Adults aged 60 years or older should be offered digital replantation or revascularization if medically or surgically indicated. Clinical question/level of evidence Risk, II.

Background Bone reconstruction is frequently required for corrective osteotomy of the forearm long bones. Studies have evaluated long term outcomes but not the impact of these procedures on early postoperative complications and health care utilization. Questions/Purposes This study evaluated the early postoperative health care utilization following corrective osteotomy of the radius and/or ulna. Patients and Methods The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) was the primary data source to perform a comparative statistical analysis of the bone autograft and nonautograft (allograft, graft substitute, or no graft) procedures. We performed a review of the NSQIP database (2005–2013) to evaluate patients who underwent a corrective osteotomy of the radius and/or ulna. Results There were 362 cases; autograft (n = 117) and nonautograft (n = 245). There were no significant differences with demographics or comorbidities. The majority of cases were outpatient surgeries and there were no significant differences in anesthesia time, operative time, or hospital length of stay. Overall, the average length of stay was 0.6 days, readmission rate was 2%, and the total complication rate was 1% and there was no statistically significant difference between reconstruction groups. Harvesting of autograft was not associated with the overall 30-day complications and specific markers of health care utilization. Conclusions Our results are derived from the heterogeneous hospital setting of NSQIP contributing centers. The health care utilization and 30-day complications are low following corrective osteotomy of forearm long bones and autograft harvest did not influence the health care utilization. Level of Evidence Therapeutic Level II.

Vascularized composite allotransplantation of the hand is technically feasible and is the only option to recover a lost hand after amputation. However, universal acceptance of this surgical reconstruction as a medical standard of care has not been achieved for the uncertainty of outcome after surgery.1 We performed an exploratory study to examine the neurophysiologic changes in the somatosensory and primary motor cortices after hand transplant.

Background: Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013. Results: There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9). Conclusions: Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

The safety of elective hand surgery in breast cancer (BC) survivors is controversial because of concerns of developing upper extremity lymphedema. This study aimed to evaluate the risk of developing lymphedema after elective hand surgery among patients that underwent ipsilateral axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), and/or radiation therapy (RT).A retrospective cohort of BC patients treated with ALND, SLNB, and/or RT was identified (1997-2012). Patients with subsequent ipsilateral elective hand surgery were included if greater than 1 year of follow-up and no preexisting lymphedema. The primary outcome was lymphedema after hand surgery. Comparisons between patients with and without lymphedema were made to identify potential lymphedema risk factors. Dichotomous and continuous variables were compared with Fisher exact and Student t tests, respectively.The analysis included 103 patients, of which 4 (3.8%) had documented lymphedema after hand surgery. Lymphedema developed early and was self-limited. Lymphedema was not related to age and type of hand surgery. Tourniquet time was longer in the nonlymphedema group. The lymphedema group all received adjuvant chemotherapy and RT with either ALND or SLNB. Patients with lymphedema had a shorter interval between hand surgery and completion of BC surgery (2.1 vs 6.2 years) and RT (2.0 vs 3.3 years).Lymphedema is uncommon after elective hand surgery among survivors and was not associated with tourniquet use. The combination of adjuvant therapies and axillary procedures and a short temporal relationship of these to hand surgery may increase lymphedema risk.

Purpose The use of intravenous heparin after digit replantation or revascularization (DRR) varies greatly. The insufficient evidence presents a lack of clinical equipoise needed for a randomized trial; as such, a matched propensity score analysis was performed to evaluate the role of postoperative anticoagulation after DRR. The purpose of this study was to determine if the use of postoperative therapeutic anticoagulation reduced the risk of digit failure. Methods A retrospective cohort of patients who underwent DRR from 2005 to 2016 was identified. A propensity score was calculated based on age, smoking, injury mechanism, procedure type, vein graft, and number of digits injured. Patients were matched 1:2 by propensity score to create 2 groups with similar risks of receiving anticoagulation postoperatively. Generalized estimating equation logistic model was used to determine differences in digit failure between groups. Results Digit replantation or revascularization was performed on 282 patients (92% male; median age, 43 years). Postoperative anticoagulation was administered in 69 (24%) patients, with continuous IV heparin in 34 patients and intravenous heparin with dextran in 35 patients. Digit failure occurred in 88 patients overall, representing 38% of patients receiving anticoagulation and 29% of those not. Major complications were higher among the anticoagulated patients (13% vs 3.3%). After propensity score matching, use of anticoagulation was not associated with digit failure (odds ratio, 0.79; 95% confidence interval, 0.47-1.32). Conclusions Among DRR patients with similar predisposing characteristics for postoperative therapeutic heparin or dextran, the use of therapeutic anticoagulation does not have a protective effect against digit failure. Studies are needed to define the role of postoperative IV anticoagulation in DRR and to justify the risk of its administration.

There are few studies supporting supercharge end-to-side nerve transfer for high ulnar nerve injury. The current study hypothesized that patients with a supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer would demonstrate superior return of intrinsic function compared with conventional treatment only.A retrospective matched-cohort study matched supercharge end-to-side transfer patients based on age, level of injury, and mechanism to ulnar nerve injury patients who did not have the transfer. The primary outcome was return of ulnar intrinsic function, based on clinical examination and/or electromyography. Dichotomous and continuous variables were compared with Fisher's exact and t tests, respectively.Thirteen supercharge end-to-side patients were identified (1 year follow-up). The average age of both cohorts was 35 years. Ulnar nerve transection above the proximal third of the forearm represented 54 percent of patients; compressive injuries represented 46 percent. Eleven supercharge end-to-side transfer patients (84 percent) demonstrated intrinsic function recovery compared with five (38 percent) non-supercharge end-to-side patients (p0.05). Average time to initial motor recovery was similar between the two groups (supercharge end-to-side, 2.9 months; non-supercharge end-to-side, 3.8 months; p0.2). Intrinsic function return was more likely following nerve transection with the supercharge end-to-side procedure (85 percent versus 14 percent; p = 0.03), whereas compression injuries had comparable intrinsic function return regardless of the supercharge end-to-side transfer (67 percent versus 67 percent; p = 1.0).This matched cohort study demonstrates that the supercharge end-to-side transfer results in increased ulnar intrinsic reinnervation following ulnar nerve injury. This finding may be most relevant following transection injuries. Improved outcomes associated with supercharge end-to-side and ulnar nerve repair warrant further investigation.Therapeutic, III.

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.

Deltoid paralysis following isolated axillary nerve injury can be managed with triceps motor branch transfer or interpositional grafting. No consensus exists on the treatment that results in superior deltoid function. The purpose of this study was to review the authors' experience with axillary nerve injury management and compare functional outcomes following these two treatment options.Twenty-nine adult isolated axillary nerve injury patients that had either interpositional nerve grafting or triceps motor branch transfer with greater than 1 year of follow-up between 2002 and 2013 were reviewed for demographic and clinical factors and functional outcomes of deltoid reinnervation, including clinical examination (shoulder abduction and forward flexion graded by the Medical Research Council system) and electromyographic recovery. Disabilities of the Arm, Shoulder, and Hand scale grades were also compared.Twenty-one patients had a triceps motor transfer and eight had interpositional nerve grafting. At a mean follow-up of 22 months, Medical Research Council scores were greater in the grafting group compared with the nerve transfer group (4.3 versus 3.0), and more graft patients achieved useful deltoid function (Medical Research Council score ≥3) recovery (100 percent versus 62 percent); however, both groups had similar improvement in self-reported disability: change in Disabilities of the Arm, Shoulder, and Hand score of 11 following nerve transfer versus 15 following nerve graft.Although the question of nerve transfer versus grafting for restoration of axillary nerve function is controversial, this study demonstrates that grafting can result in good objective functional outcomes, particularly during an earlier time course after injury. This question requires further investigation in a larger, prospective patient population.Therapeutic, III.

Background: The etiology of multifocal osteonecrosis is not definitively known; however, hypercoagulable state is a very plausible cause. Methods: We present an unusual case of a 12-year-old boy with a history of Legg-Calve-Perthes disease presenting with right wrist pain who was subsequently diagnosed with Kienbock’s disease. The finding of multifocal osteonecrosis prompted testing for a hypercoagulable state that was positive for Factor V Leiden thrombophilia. A thorough literature review using Medline database was conducted to investigate associations between inherited hypercoagulable states and multifocal osteonecrosis. Results: Our literature review identified 2 similar cases of multifocal osteonecrosis associated with a hypercoagulable disorder in adult patients. There were no reports among the pediatric patient population. Meta-analysis has demonstrated a potential link between Legg-Calve-Perthes disease and Factor V Leiden thrombophilia. Conclusions: This study offers further evidence to support the theory that multifocal osteonecrosis may be linked to a hypercoagulable state. Patients presenting with multifocal osteonecrosis should undergo screening for hypercoagulable states. Further investigation is needed to ascertain the potential benefit of prophylactic anticoagulation in patients with a known hypercoagulable state and multifocal osteonecrosis.

Purpose Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results. Methods Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included “clinically useful ER” (motion ≥ −35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation. Results EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: −60° to 90°) and MRC grade 2.2 (2–4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P

FDP avulsion injuries are a type of Zone I flexor tendon injury, leaving patients unable to flex the distal interphalangeal joint. Patients with untreated injuries may experience weakened grip strength or DIP joint instability. These injuries are classified by the Leddy-Packer system, which is based on the presence and extent of bony involvement of the distal phalanx and the level of retraction of the avulsed tendon. All FDP avulsion injuries should receive early referral to a hand surgeon to facilitate prompt surgical reconstruction. Delayed initial management may prevent primary repair or decrease the likelihood of an optimal postoperative outcome. In addition to early referral and treatment, rehabilitation and therapist-directed mobilization programs are critical for optimizing outcomes. It is important to explain to patients the potential complication of stiffness and limited range of motion at the interphalangeal joints. For these injuries, patient and surgeon shared decision-making is necessary to determine the most appropriate treatment plan.

PURPOSE Despite the common use of intraoperative vasopressors in hand microsurgery, the association between intraoperative vasopressor use and digital replant failure has not yet been examined. Our study aims to examine the association between intraoperative vasopressor use (phenylephrine and/or ephedrine) and postoperative digital failure of replanted or revascularized digits. METHODS All patients from a single tertiary hand center who underwent unilateral digital replantation or revascularization procedures between 2005 and 2016 were included in this retrospective cohort study. The relationship between intraoperative vasopressors used to maintain hemodynamic stability and digit failure was then evaluated using logistic regression. Specifically, phenylephrine (total dose 10-3,600 mcg) and ephedrine (5-110 mg) use were evaluated. RESULTS During the study period, 281 patients underwent digital replantation or revascularization. Of those, 86 (31%) were given an intraoperative vasopressor. Digit failure was more likely in patients with crush or avulsion injuries compared to clean-cut mechanism (odds ratio [OR] 2.02, p = .02), and in patients with replantation (OR 7.85, p

Background Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence This is a Level III study.

Background Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Methods MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Results Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. Conclusions The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. Clinical question/level of evidence Therapeutic, IV.

Deltoid paralysis after axillary nerve injury results in limitations in shoulder function and stability. In the setting of an isolated axillary nerve injury with no clinical or electromyographic evidence of recovery that is within 6 to 9 months postinjury, the authors' preferred technique to reinnervate the deltoid is to reconstruct the axillary nerve with sural nerve grafting. Intraoperative neuromuscular electrophysiology is critical to determine the continuity of the axillary nerve before proceeding with reconstruction. The majority of the time, both an anterior and posterior incision and dissection of the axillary nerve is required to adequately delineate the zone of injury. This also ensures that both proximally and distally, uninjured axillary nerve is present before graft inset and also facilitates the ability to perform a meticulous microsurgical inset of the nerve graft posteriorly. The nerve graft must be pulled through from posterior to anterior to span the zone of injury and reconstruct the axillary nerve. Careful infraclavicular brachial plexus dissection is necessary to prevent further injury to components of the brachial plexus in the setting of a scarred bed. Patients will require postoperative therapy to prevent limitations in shoulder range of motion secondary to postoperative stiffness. This paper presents a detailed surgical technique for axillary nerve reconstruction by an anterior-posterior approach with a pull-through technique of a sural nerve cable graft.

Pediatric plastic and reconstructive surgery , Pediatric plastic and reconstructive surgery , کتابخانه دیجیتال دانشگاه علوم پزشکی اصفهان

Chronic infection by herpes simplex virus type 2 (HSV-2) increases HIV susceptibility, perhaps due to HSV-2-associated increases in activated mucosal immune cells. A small number of Kenyan female sex workers (FSWs) exhibit relative HIV resistance. We examined whether relative HIV resistance was related to differences in the prevalence or mucosal immune impact of HSV-2. Participants were recruited from an open cohort of HIV-uninfected FSWs in Nairobi, Kenya. Women who had been practicing sex work in the cohort for >or=3 years without acquiring HIV were defined as relatively HIV resistant. HSV-2 diagnostics were performed, and cervical immune cell subsets were examined by flow cytometry in a subset of participants. The study population comprised 139 HIV-uninfected FSWs. HSV-2 seroprevalence was actually higher in FSWs meeting criteria for relative HIV resistance than in non-resistant FSWs (75/80, 94% vs 46/59, 78%; LR = 7.5; P = 0.006), likely due to the increased age and longer duration of sex work in the resistant subgroup. Late HIV acquisition was not associated with recent HSV-2 infection, and HSV-2 associated increases in HIV-susceptible cervical immune cell populations were similar in both groups. Relative HIV resistance in Kenyan FSWs was not due to a reduced prevalence or mucosal immune impact of HSV-2 infection.

Reconstruction of the proximal interphalangeal (PIP) joint in the setting of post-traumatic joint arthritis is a challenging problem. When there is little range of motion preoperatively within the PIP joint, arthrodesis can be performed. Amputation can be offered in the setting of a stiff painful finger, but is generally not the first-line treatment and is rather a salvage procedure in the setting of a failed joint reconstruction. In patients wishing to maintain some range of joint motion and avoid fusion, PIP joint reconstruction can be performed with a variety of techniques including vascularized toe joint transfer, autologous non-vascularized hemi-hamate transfer, and replacement joint arthroplasty. A variety of materials have been tried for PIP joint arthroplasty including silicone [1], titanium [2], cobalt, chrome, and polyethylene [3]. While silicone PIP arthroplasty has the longest track record within the United States, its nonanatomic design, limited durability, and limited stability make it a less than ideal choice for younger, more active patients. New options for PIP joint arthroplasty include the use of pyrocarbon. This chapter will examine the use of pyrocarbon arthroplasty following PIP trauma.

Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results.Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included "clinically useful ER" (motion ≥ -35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation.EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: -60° to 90°) and MRC grade 2.2 (2-4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P 0.03).Although 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5-C6 root/upper trunk pattern. In patients with greater than C5-6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365-370, 2017.

Supplemental Digital Content is available in the text., Summary: Advances in microsurgical instruments and techniques have allowed for introduction of lymphaticovenous anastomosis as a potential surgical treatment for patients with upper and lower extremity lymphedema. This article reviews the approach to lymphaticovenous anastomosis patient selection and technical modifications that improve the ease and efficiency of the procedure.

Evidence has shown that bacterial genomes have undergone random shuffling of genomic elements consisting of one to two genes. In order to delineate such genome-shuffling events in mammals, we constructed a high-resolution map of Sus scrofa chromosome 3 (SSC3) with a total of 116 genes/markers. Alignment of this pig map to orthologous regions in human, dog, mouse and rat led to the identification of 31 provisional conserved ancestral blocks (CABs) in these five species. Among them, only 3 CABs (10%) had one gene, indicating that one-gene shuffling is not frequent in mammals. The sizes of CABs vary significantly within a species, but each may be relatively consistent in different species with a scale to species-genome evolution. The type and frequency of rearrangement events that takes place, either intra- or interchromosomal, depends on the evolutionary regions and species under comparison. Characterization of 36 tentative breakpoint regions flanking these 31 CABs indicated that they occupied approximately 43 Mb in length and featured genome deserts, gene duplications, and birth/death of species-specific genes in humans. Identification of CABs provides an alternative for further determination of the evolutionary make-up of mammalian genomes.

Prophylactic nipple-areolar complex (NAC)-sparing mastectomy (NSM) in BRCA1/2 mutation carriers is controversial over concern regarding residual fibroglandular tissue (FGT) with malignant potential. The objective of this study was to model the volume of FGT in the NAC at a standard retroareolar margin (5 mm) and examine the change in this amount with a greater retroareolar margin or areola-sparing technique.A segmentation protocol was applied to breast MRIs from 105 BRCA1/2 patients to quantify volumes of FGT for total breast and NAC. The proportion of FGT in the NAC relative to the breast was calculated as the primary outcome and was compared for 5 mm versus 10 mm retroareolar depths. The proportion of FGT in the areola was compared with the NAC.At 5 mm retroareolar thickness, residual NAC FGT comprised 1.3 % of the total breast FGT. This amount was not significantly greater than the proportion in the areola (p = 0.3, d = 0.1). Increasing the retroareolar thickness to 10 mm led to a statistically and possibly clinically significant increase in the amount of NAC FGT (p0.001, d = 1.1).The proportion of FGT remaining in the spared NAC with a 5 mm margin is extremely small, suggesting that leaving the entire NAC would create very little added risk. Doubling the retroareolar margin may translate into a clinically meaningful increase. Overall, our findings support the safety of the current trend toward increased rates of prophylactic NSM performed in this high-risk population.

1507 Background: Prophylactic nipple sparing mastectomy (NSM) in BRCA 1/2 mutation carriers is an option for risk reduction but is controversial over concern that residual fibroglandular tissue (FGT) with malignant potential remains in the spared nipple. Since the volume of FGT in the nipple has not been formally evaluated, the objective of this study is to measure the residual volume of FGT in the spared nipple at a standard retroareolar margin (5mm) and identify sources of variability, including a greater margin and patient factors. Methods: A segmentation protocol was applied to breast MRIs from 105 consecutive BRCA 1/2patients. The MRI segmentation quantified volumes for total breast and nipple FGT. The nipple FGT volume was determined by setting the retroareolar margin (depth on MRI). The proportion of FGT in the nipple with 5mm retroareolar margin relative to the breast was calculated as the primary outcome and compared to 10mm margins. Associations between the proportion of FGT in the nipple (5mm) and patient characteristics were examined using uni- and multivariable analyses. Effect size was measured where appropriate. Results: At 5mm and 10mm retroareolar thickness, residual FGT comprised 0.24% (0.02-0.9%) and 0.42% (0.0.2-01.2%), respectively, of the total breast FGT (p < 0.001, Cohen d = 0.03). Smaller breast volume, lower BMI and parity (p < 0.001, p < 0.009, p < 0.009 respectively) were predictive of greater proportion of residual FGT on univariate analysis, while breast volume and parity were predictive with multivariate (R2 = 0.28, F = 16.5, p < 0.0005). Conclusions: The proportion of FGT remaining in the spared nipple with a 5mm margin is extremely small, suggesting very little added risk over a skin sparing mastectomy. This proportion may be influenced by breast volume and childbearing. Doubling the retroareolar margin statistically increases the proportion, yet this likely does not translate into a clinically meaningful increase and may support a slightly thicker retroareolar margin. Overall, our findings support safety of the current trend toward increased rates of prophylactic NSM performed in the BRCA 1/2 patient population.