Technique of Adolescent Shoulder Reanimation in Brachial Plexus Birth Injury.

BACKGROUND: Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI 2) untreated BPBI or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of eight patients who underwent shoulder reanimation. METHODS: A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion. To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For external rotation, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol. RESULTS: Eight patients (13.8±5.6 years, 35±24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction. Preoperatively, patients generally had 0-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90-180°) of abduction. Preoperatively, patients had 0-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients' FF increased to an average of 91° (20-170°). CONCLUSION: This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

Subpectoral proximal humeral anatomy: Guidance to decrease risk of fracture following subpectoral biceps tenodesis.

Background: Biceps tenodesis is used for a variety of shoulder and biceps pathologies. Humeral fracture is a significant complication of this procedure. This cadaveric anatomy study sought to determine the cortical thickness of the humeral proximal shaft to identify the optimal technique to decrease unicortical drilling and reduce the risk of fracture. Methods: A computed tomography (CT) of eight cadaveric humeral specimens was obtained with a metallic marker placed at the site of subpectoral tenodesis. These scans were examined to define the cortical thickness of the subpectoral region of the humerus and determine angular safe zones for reaming. Results: At the standard point of a subpectoral tenodesis, a mean angle relative to the coronal plane of 29.2° medially and 21.6° laterally from the deepest portion of the bicipital groove avoided unicortical drilling with a 7 mm reamer. These values varied slightly 1 cm proximal and distal to this level. The thickest regions of cortex in the subpectoral humerus correspond to the ridges of the bicipital groove. Discussion: To avoid unicortical tunnels, surgeons should limit deviation from the perpendicular approach to no more than 23° relative to the coronal plane medially and 11° relative to the coronal plane laterally.

Treatment Options for the Clinical Management of Axillary Breast Tissue.

Background: Axillary breast tissue includes any combination of fat, nipple, areolae, and glandular tissue alongside breasts and affects 2%-6% of women and 1%-3% of men. Patients may experience functional and/or cosmetic concerns due to axillary breast tissue. There are nonsurgical options for its removal, such as CoolSculpting and Kybella, and surgical options such as liposuction, BodyTite liposuction, and excision. Determining which technique to use in each case is critical in achieving an excellent outcome. Currently, there are no established treatment algorithms for the removal of axillary breast tissue. Methods: A retrospective review between January 1, 2013, and June 20, 2022, was performed. Data that were extracted included age, BMI, date of procedure, procedure, fat suctioned, tissue excised, and follow-up period. The authors analyzed outcomes and formulated a treatment algorithm based on tissue type (fat versus glandular), amount of tissue excess, skin laxity, and accessory nipple presence. Results: A total of 43 patients (83 axillae) met our inclusion criteria and were included in our analysis. All patients were female with a mean age of 35.5 ±â€…10.9 years, a mean BMI of 23.0 ±â€…3.1, and a mean follow-up period of 8.8 ±â€…11.1 months. For inclusion, patients had to have undergone CoolSculpting, liposuction, BodyTite liposuction, liposuction with excision, or excision alone. All patients tolerated the procedures well and reported no serious complications. Conclusions: Nonsurgical and surgical removal of axillary breast tissue is safe and effective. The algorithm presented can be utilized by plastic and reconstructive surgeons to ensure optimal results for axillary breast tissue removal.

Reducing opioid prescribing after ambulatory breast reconstruction surgery.

BACKGROUND: The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse. METHODS: Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker. RESULTS: Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively). CONCLUSION: Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.

Infectious causes and mimickers of meniere's disease.

PURPOSE OF REVIEW: To review the evidence of a possible viral etiology of Meniere's disease, the role of antiviral therapy, as well as other infectious disease processes that may mimic Meniere's disease. Better understanding of the etiology of Meniere's disease and the role of various infectious disease processes may allow for more effective diagnosis and management. RECENT FINDINGS: There is evidence that viral infections - to Herpes simplex virus, cytomegalovirus, Epstein Barr virus, influenza, adenovirus, Coxsackie virus B, and Varicella Zoster Virus - may be involved in the development of Meniere's disease, however the evidence is inconsistent and the underlying mechanism remains theoretical. Nevertheless, antiviral therapy may be effective for a subset of patients with Meniere's disease. Lastly, other infectious diseases including Lyme disease and syphilis can present with symptoms similar to Meniere's disease. It is important to discern these from Meniere's disease to determine the appropriate treatment. SUMMARY: There is a paucity of high-quality evidence to support a viral etiology of Meniere's disease, and the current evidence appears circumstantial and inconsistent. Additional research is necessary to establish the mechanism and causative pathogens. Antiviral therapy may provide therapeutic benefit for a subset of patients with Meniere's disease. Furthermore, clinicians should be aware of other infectious mimics of Meniere's disease and include them in the differential diagnosis of patients presenting with Meniere's-like symptoms. Research on this subject continues to evolve, and data from these studies represent a growing repository of evidence that can be used to guide clinical decision-making.

Recent Smoking History Is Not Associated with Adverse 30-Day Standardized Postoperative Outcomes following Microsurgical Reconstructive Procedures of the Upper Extremity.

Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.

Contexte: La reconstruction microchirurgicale du membre supérieur repose sur la bonne guérison de la plaie pour des résultats optimaux. Le tabagisme est associé à des complications pour la guérison des plaies; toutefois, les conclusions concernant ses répercussions sur les résultats microchirurgicaux (réimplantation, revascularisation et transfert de tissu libre) sont variables. Nous avons cherché à savoir quelles étaient les répercussions du tabagisme sur les résultats postopératoires standardisés à 30 jours après reconstruction microchirurgicale du membre supérieur. Méthodes: Utilisant le Programme national d'amélioration de la qualité de la chirurgie, tous les patients ayant subi (1) un transfert de lambeau libre du membre supérieur (n = 70) et (2) une réimplantation/revascularisation (n = 270) ont été identifiés. Pour chaque procédure, les patients ont été classés en fonction de leurs antécédents de tabagisme récent (fumeur actuel ≤ 1 an préopératoire). Les données démographiques initiales et les complications standardisées à 30 jours, les réinterventions et les réhospitalisations ont été comparées entre fumeurs et non-fumeurs. Résultats: Concernant les réimplantations/revascularisations, il n'y a pas eu de différences en termes de sexe, race ou IMC entre les fumeurs (n = 77) et les non-fumeurs. Les fumeurs avaient une plus grande prévalence d'insuffisance cardiaque congestive (5,2 % contre 1,0 %, P = 0,036) et les non-fumeurs étaient plus souvent sous hémodialyse (15,6 % contre 10,4 %, P = 0,030). Concernant les patients ayant eu un transfert de lambeau libre, il n'y a pas eu de différences en termes d'âge, de sexe ou de race entre les fumeurs (n = 14) et les non-fumeurs. La durée d'hospitalisation des fumeurs a été plus longue (6,6 jours contre 4,2 jours, P =0,001) avec une prévalence plus élevée de MPOC (7,1 % contre 0 %, P = 0,044). Le tabagisme récent n'a pas été associé à une augmentation de la probabilité de complications chirurgicales standardisées, majeures ou mineures, à 30 jours, de réhospitalisation ou reprises chirurgicales après reconstruction microchirurgicale du membre supérieur par transfert de lambeau libre ou réimplantation/revascularisation. Le diagnostic de MPOC à l'inclusion dans l'étude n'était pas non plus un facteur prédictif d'événements indésirables à 30 Jours après transfert de lambeau libre. Conclusion: Un antécédent de tabagisme récent n'a pas été associé à des résultats indésirables à 30 jours après reconstruction microchirurgicale du membre supérieur via réimplantation/revascularisation ou transfert de lambeau libre. À la lumière de ces constatations, des études supplémentaires portant particulièrement sur les événements indésirables propres aux procédures de lambeaux libres et de réimplantation/revascularisation sont justifiées.

Successful Use of WALANT in Local and Regional Soft Tissue Flaps: A Case Series.

The wide awake local anesthesia no tourniquet (WALANT) technique has been proven to be safe and effective for upper extremity surgery. WALANT does not require extensive medical clearance and allows for intraoperative assessment of range of motion. Additionally, it is frequently associated with lower costs and less postoperative pain when compared with traditional methods of anesthesia. Despite its expanded use for hand procedures, there are sparse data to support the use of WALANT in local and regional soft tissue flaps. Methods: A retrospective review was performed. Twenty-one patients who underwent a local or regional soft tissue flap surgery using the WALANT technique from February 2, 2018 to February 25, 2022 were included in our analysis. Results: Overall, one Louvre flap, two posterior tibial artery perforator propeller flaps, two reverse radial forearm flaps, two Quaba flaps, six cross finger flaps, one reverse homodigital island flap, three first dorsal metacarpal artery flaps, two thenar flaps, and two Moberg flaps were performed. Patients were followed up for an average of 11.9 ± 8.1 weeks. During this time, no postoperative complications occurred. All patients demonstrated appropriate healing at donor and recipient sites. Full range of motion was regained for all patients. Conclusions: WALANT is safe and effective for use in local and regional soft tissue flap surgery. Surgeons should consider this technique for more involved procedures such as flap surgery, as preliminary results demonstrate positive outcomes and potentially superior recovery for patients.

Journal Discipline Plays a Significant Role in Academic Attention But Not in Social Media Attention in the Peripheral Nerve Literature.

Evaluating the impact of articles can be performed through bibliometric analysis or social media impact using the Altmetric Attention Score (AAS). The purpose of this study was to report on the social media impact of peripheral nerve studies; how article demographic factors, such as journal specialty (hand, orthopedics, plastic surgery), affect AAS; and how AAS correlates with bibliometrics, namely citation number. While orthopedic journals received the highest academic attention, there was no significant difference in social media attention between journal groups. These findings suggest AAS may be useful to authors in deciding which journal in which to pursue publication. [Orthopedics. 2023;46(3):e143-e148.].

Proximal Interphalangeal Joint Congruity: A Biomechanical Study.

BACKGROUND: Surgical approaches to the proximal interphalangeal (PIP) joint often require disruption of soft tissue stabilizers. Additionally, PIP joint injuries frequently result in soft tissue disruption. This study evaluates the necessity of repairing soft tissue stabilizers by assessing their role in maintaining native joint congruity. METHODS: Eight specimens were used to evaluate congruity at 0° and 30° flexion when loaded with 2 N of valgus force. This was performed in the native joint and after sequential sectioning of the surrounding ligaments in order: volar plate (VP), radial collateral ligament (CL), and ulnar CL. The skin flap was sutured with the ligaments unrepaired and the load was reapplied. Radiographs were taken after each load and used to measure the joint line convergence angle (JLCA). RESULTS: Mean JLCA increased in both degrees of flexion after ligaments were sectioned but was only significantly different from the native joint after the VP was disrupted along with 1 CL. Joint congruity improved following repair of the skin flap in both degrees of flexion but was not significant. Joints were more congruent in 30° flexion for all subgroups, but none were significantly different compared to 0° flexion. CONCLUSIONS: Disruption of the VP is insufficient to significantly alter PIP joint congruity. While sectioning of both the VP and CLs resulted in a statistically significant change in joint congruity, mean JLCA demonstrated changes of minor clinical significance. The osseous anatomy of the phalanges imparts inherent stability that maintains a congruent joint despite loss of the soft tissue stabilizers.

The Impact of Perceived Upper Extremity Severity and Prior Surgery on Patient-Reported Outcomes.

Background: The recently validated Hand Questionnaire (HAND-Q) is a multifaceted patient-reported outcome measure (PROM) for hand/upper extremity (UE) pathology and treatment. Here, we conduct a pilot study utilising data collected as a participating site for the Phase II HAND-Q Pilot Multicenter International Validation Study. We hypothesised that self-reported hand functionality, symptom/disease severity, hand appearance, emotional dissatisfaction and treatment satisfaction would be worse in patients who perceived their disease severity to be more severe but would not differ between patients based on prior surgical history. Methods: Patients were prospectively enrolled for HAND-Q participation from September 2018 to August 2019. Patients were included in this analysis if they responded to the following scales of HAND-Q: Hand Functionality Satisfaction, Symptom Severity, Hand Appearance Satisfaction, Emotional Dissatisfaction and Treatment Satisfaction. Composite scores (CS) were created for each section. Surgical versus non-surgical CS and mild versus moderate/severe CS were compared with t-tests. Bi-variate comparisons of responses were performed between surgical and non-surgical groups, and between mild and moderate/severe groups. Results: HAND-Q individual question analysis revealed significant differences in functionality and symptom severity for patients with prior surgery (p < 0.047). CS analysis confirmed greater overall impairment in surgical patients, but no overall impact on symptom severity. Regarding disease severity HAND-Q individual question analysis, moderate/severe patients reported worse outcomes for specific aesthetic qualities and symptoms for almost all items (p < 0.05). CS analysis revealed significantly worse overall hand appearance satisfaction, hand functionality, emotional satisfaction and symptom severity for patients with moderate/severe hand conditions. Conclusions: HAND-Q revealed worsened outcomes for UE patients with self-reported moderate/severe conditions or previous surgical history. Understanding how previous surgery and disease severity may impact clinical outcomes is important for crafting appropriate treatment. Level of Evidence: Level II (Prognostic Study).

Negative Ulnar Variance Lessens DRUJ Instability After DRUJ Disruption: A Biomechanical Analysis.

BACKGROUND: The purpose of this study was to perform a biomechanical investigation on the effect of ulnar variance (UV) on the stability of the distal radioulnar joint (DRUJ) prior to and after DRUJ sectioning. METHODS: Ten cadaveric forearm specimens were included in the study and baseline UV was assessed radiographically. Radial motion relative to the ulna was evaluated using Intel real sense cameras and a custom developed program. The forearms were dissected, and a radial osteotomy was performed. Using a custom-made plate, radial stability was assessed with an UV of + 4, 0, and -4 mm by measuring the maximum and minimum radial position relative to the ulna during a simulated Shuck test. The volar radioulnar ligaments and triangular fibrocartilage complex (TFCC) were then sectioned, and testing was repeated at each UV state. RESULTS: Sectioning significantly increased radial translation at neutral (P = .008), +4 mm UV (P = .008), and -4 mm UV (P = .018). There were no significant differences in translation between the 3 UV groups with the DRUJ intact (P = .124). The ulnar negative (-4 mm) state had significantly lower translation compared to the positive (+4 mm) (P < .001) and the neutral (0 mm) (P = .026) UV states. There were no significant differences between the positive and neutral UV groups with the DRUJ sectioned. CONCLUSIONS: Fixating the radius in -4 mm of ulnar negativity significantly decreased radial translation after sectioning the volar radioulnar ligament and TFCC. Ulnar variance had no effect on stability with an intact DRUJ. STUDY TYPE: Biomechanical Study.

Sexual Dissatisfaction after Hand Surgery.

Using the hand questionnaire (HAND-Q) patient-reported outcome measure, the effects of upper extremity surgery on patients' perception of their sex life were explored. The hand is a uniquely sexual organ, and we hypothesized that self-reported measures of disease severity, quality of life, and emotional impact would correlate with sexual dissatisfaction among patients receiving treatment for hand/upper extremity conditions. Methods: Patients were prospectively enrolled for hand questionnaire participation. Patients with valid responses to the following questions were included: functionality, hand appearance satisfaction, symptom severity, emotional dissatisfaction, sexual dissatisfaction, and treatment satisfaction. Composite scores were created and scored. Sexual dissatisfaction composite scores were compared through Spearman correlation coefficient analysis to quality of life, emotional dissatisfaction, hand appearance, symptom severity, and hand functionality. Results: High levels of diminished quality of life correlated with sexual dissatisfaction (rs = 0.748, P < 0.001). Increased emotional dissatisfaction correlated with sexual dissatisfaction (rs = 0.827, P < 0.001). Increased satisfaction with hand appearance negatively correlated with sexual dissatisfaction (rs = -0.648, P = 0.001). Increased levels of dissatisfaction with hand functionality correlated with sexual dissatisfaction (rs = 0.526, P = 0.005). Conclusions: The correlation between sex life and quality of life may allow surgeons to improve patient satisfaction when treating hand/upper extremity issues. The relationship between sex life and emotional dissatisfaction emphasizes the impact that sexual dissatisfaction has on patients' lives. Evaluating the relationship between hand appearance and sexual dissatisfaction may indicate that patient self-perception of hand attractiveness plays a role in sex life.

Proximal Row Carpectomy Does Not Alter Contact Pressures of the Lunate Fossa: A Cadaveric Study.

BACKGROUND: Previous studies have suggested that proximal row carpectomy (PRC) results in increased contact pressures and decreased contact areas in the radiocarpal joint. Such experiments, however, used older technologies that may be associated with considerable measurement errors. The purpose of this study was to determine whether there was a significant difference in contact pressure and contact area before and after PRC using Tekscan, a newer pressure sensing technology. METHODS: Ten nonpaired cadaveric specimens were dissected proximal to the carpal row and potted. An ultra-thin Tekscan sensor was secured in the lunate fossa of the radius. The wrists were loaded with 200 N of force for 60 seconds to simulate clenched-fist grip; contact pressure and area was assessed before and after PRC. RESULTS: Performing a PRC did not significantly increase mean contact pressure at the lunate fossa compared to the native state (mean increase of 17.4 ± 43.2 N/cm2, P = .184). Similarly, the PRC did not significantly alter peak contact pressures at the lunate fossa (intact: 617.2 ± 233.46 N/cm2, median = 637.5 N/cm2; PRC: 707.8 ± 156.6 N/cm2, median = 728.5 N/cm2; P = .169). In addition, the PRC (0.46 ± 0.15 cm2, median = 0.48 cm2) and intact states (0.49 ± 0.25 cm2, median = 0.44 cm2) demonstrated similar contact areas (P = .681). CONCLUSIONS: In contrast to prior studies that demonstrated significant increases in contact pressure and decreases in contact area after PRC, our findings propose that performing a PRC does not significantly alter the contact pressures or area of the lunate fossa of the radiocarpal joint.

Radiocarpal Contact Pressures Are Not Altered after Scapholunate Ligament Tears.

Background The scapholunate interosseous ligament (SLIL) couples the scaphoid and lunate, preventing motion and instability. Prior studies suggest that damage to the SLIL may significantly alter contact pressures of the radiocarpal joint. Questions/Purposes The purpose of this study was to investigate the contact pressure and contact area in the scaphoid and lunate fossae of the radius prior to and after sectioning the SLIL. Methods Ten cadaveric forearms were dissected distal to 1-cm proximal to the radiocarpal joint and a Tekscan sensor was placed in the radiocarpal joint. The potted specimen was mounted and an axial load of 200 N was applied over 60 seconds. Results Sectioning of the SLIL did neither significantly alter mean contact pressure at the lunate fossa ( p = 0.842) nor scaphoid fossa ( p = 0.760). Peak pressures were similar between both states at the lunate and scaphoid fossae ( p = 0.301-0.959). Contact areas were similar at the lunate fossa ( p = 0.508) but trended toward an increase in the SLIL sectioned state in the scaphoid fossa ( p = 0.055). No significant differences in the distribution of contact pressure ( p = 0.799), peak pressure ( p = 0.445), and contact area ( p = 0.203) between the scaphoid and lunate fossae after sectioning were observed. Conclusion Complete sectioning of the SLIL in isolation may not be sufficient to alter the contact pressures of the wrist. Clinical Relevance Injury to the secondary stabilizers of the SL joint, in addition to complete sectioning of the SLIL, may be needed to induce altered biomechanics and ultimately degenerative changes of the radiocarpal joint.

WALANT Hand and Upper Extremity Procedures Performed With Minor Field Sterility Are Associated With Low Infection Rates.

Background: The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases. Methods: This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery. Results: Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility. Conclusion: Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety.

Historique: Il est démontré que le recours à un champ stérile mineur dans les interventions de la main et des extrémités supérieures améliore le déroulement du travail tout en maintenant la sécurité du patient. Comme cette observation se limite à des interventions particulières, les chercheurs ont examiné la sécurité d'un large éventail d'interventions de la main et des extrémités supérieures au moyen de la technique d'anesthésie de WALANT (acronyme anglais d'anesthésie locale en plein éveil sans tourniquet) hors de la salle d'opération principale. Pour ce faire, ils ont évalué le taux d'infections superficielles et profondes dans une série de cas variés. Méthodologie: La présente série de cas a été réalisée entre octobre 2017 et juin 2020. Au total, 217 patients ont subi une intervention mineure de la main ou des extrémités supérieures exécutée dans une salle d'intervention mineure sur champ stérile au moyen de la technique d'anesthésie de WALANT. Les mesures de résultat primaire incluaient des infections superficielles et profondes au foyer chirurgical dans les 14 jours suivant l'intervention. Résultats: Au total, 217 patients ont participé à l'étude. Un seul chirurgien a effectué 265 opérations consécutives de la main ou des extrémités supérieures, d'une diversité remarquable. La majorité des patients (n = 215, 99,1 %) n'ont pas déclaré ni présenté de signes d'infection avant ou après leur opération. Les chercheurs ont déclaré un taux d'infection de 0 % au foyer chirurgical au bout de 14 jours et de 0,37 % au bout de 30 jours pour les interventions de la main et des extrémités exécutées sur champ stérile dans une salle d'intervention mineure. Conclusion: Les interventions de la main et des extrémités supérieures exécutées sur champ stérile par la technique d'anesthésie de WALANT dans une salle d'intervention mineure sont liées à un faible taux d'infection au foyer chirurgical. Ces taux sont comparables à ceux des infections au foyer chirurgical lors d'interventions semblables exécutées dans une salle d'opération principale dotée d'interventions de stérilisation standard. Ainsi, la mise en œuvre de cette technique pourrait améliorer le déroulement du travail et réduire le gaspillage, tout en maintenant la sécurité du patient.

The top 50 most cited articles in both-bone forearm open reduction internal fixation in the skeletally mature patient.

PURPOSE: Both-bone forearm fractures in the adult population frequently and usually necessitate an operative reduction. The purpose of this study was to identify the 50 most cited publications regarding both-bone ORIF and evaluates their level of evidence to help guide the best treatment and management practices, as well as gauge the current level of inquiry into this topic. METHODS: The Clarivate Analytics Web of Knowledge Database was queried. The top 50 most cited articles identified as relevant were analyzed. Aggregate citation counts, citation density, type of study, and level of evidence were documented for each of the 50 articles. Abstracts from the last decade of prominent orthopaedic meetings were analyzed to determine the current level of inquiry into this area. RESULTS: The initial search yielded 408 results. There were 27 articles published before 2000 and 23 after. The total summation of citations for the top 50 articles totaled 2062. Each study was classified according to its study design and level of evidence. The most common was case series (34). Level IV studies were most numerous (34). Since 2010, the subject of both-bone forearm fracture ORIF was presented 8 times at prominent orthopaedic conferences. CONCLUSION: Our work demonstrated 54% of top-50 studies are pre-2000 and the majority are Level IV evidence. Additionally, despite the established treatment, there is active inquiry into this topic. Higher quality research can be helpful to validify treatment and management options.

The rate and reporting of fracture after biceps tenodesis: A systematic review.

BACKGROUND: The purpose of this systematic review was to (1) define the cumulative humerus fracture rate after BT and (2) compare how often fracture rate was reported compared to other complications. METHODS: A systematic review was performed using the PRISMA guidelines. RESULTS: 39 studies reported complications and 30 reported no complications. Of the 39 studies that reported complications, 5 studies reported fracture after BT (n = 669, cumulative incidence of 0.53%). The overall non-fracture complication rate was 12.9%. DISCUSSION: Due to the relatively high incidence of fracture, surgeons should ensure that this complication is disclosed to patients undergoing BT.

FFF Utilizing an Arteriovenous Vascular Loop of Two Peroneal Venae Comitantes for a PAM.

Vascularized bone grafting is widely used for reconstruction of osseous defects of the forearm. Fibular free flap (FFF) is one option, which relies on harvesting the peroneal artery. This procedure is subject to lower extremity anatomic variants; therefore, some recommend preoperative angiography. However, high quality evidence for this approach and its cost-effectiveness are lacking and instead one can diligently assess the vascular anatomy intraoperatively. Here, we describe a case of a 73-year-old man who was found to have a peronea arteria magna intraoperatively during an FFF for a left radius reconstruction secondary to an infectious nonunion. We describe an approach to performing an FFF using an arteriovenous vascular loop through the fibula employing the two accompanying peroneal venae comitantes. The patient had no complications and was found to have appropriate healing of the upper extremity without lower extremity compromise at 3-month follow-up. This report illustrates an alternative to using an interpositional venous graft for peronea arteria magna found intraoperatively during FFFs.

Wide-awake Local Anesthesia with No Tourniquet: An Updated Review.

The wide-awake local anesthesia with no tourniquet (WALANT) technique has become popularized for various hand/upper extremity procedures. Before surgery, patients receive local anesthetic, consisting of lidocaine with epinephrine, and remain awake for the entire procedure. The purpose of this review was to investigate the advantages, diverse application, outcomes, cost benefits, use in challenging environments, patient considerations, and contraindications associated with WALANT. METHODS: A comprehensive review of the literature on the WALANT technique was conducted. Search terms included: WALANT, wide-awake surgery, no tourniquet, local anesthesia, hand, wrist, cost, and safety. RESULTS: The WALANT technique has proven to be successful for common procedures such as flexor tendon repair, tendon transfer, trigger finger releases, Depuytren disease, and simple bony procedures. Recently, the use of WALANT has expanded to more extensive soft-tissue repair, fracture management, and bony manipulation. Advantages include negating preoperative evaluation and testing for anesthesia clearance, eliminating risk of monitored anesthesia care, removal of anesthesia providers and ancillary staff, significant cost savings, and less waste produced. Intraoperative evaluations can be performed through active patient participation, and postoperative recovery and monitoring time are reduced. WALANT is associated with high patient satisfaction rates and low infection rates. CONCLUSIONS: The WALANT technique has proven to be valuable to both patients and providers, optimizing patient satisfaction and providing substantial healthcare savings. As its application continues to grow, current literature suggests positive outcomes.

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist.

INTRODUCTION: Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection. METHODS: Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection. RESULTS: 90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation. DISCUSSION/CONCLUSION: The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.