Complete digital amputations undergoing replantation surgery: a 10-year retrospective study.

BACKGROUND: As a result of growing expertise and skill, replantation surgery has evolved to more than the technical reattachment of an amputated part. METHODS: A retrospective study of complete digital amputations undergoing replantation surgery was conducted for the purpose of assessing trends in these complex cases. All incomplete and partial amputations were excluded. RESULTS: A total of 171 patients who had replantation surgery between January 1, 1994 and December 31, 2003 for 278 completely amputated digits were reviewed. Of the 171 patients, 91 (53 %) had work-related injuries. The main mechanism of injury was saw injury (95 patients) for both occupational- and non-occupational-related injuries. The proximal phalanx was the most common level of amputation and the thumb was most frequently involved. The injuries happened more commonly in the summer months. Microvascular failure occurred in 29 % of the replanted digits and was most commonly associated with avulsion-type injuries. CONCLUSIONS: Complete amputations represent a more complex injury than incomplete amputations, with a higher failure rate.

Compression of the deep palmar branch of the ulnar nerve by a ganglion : a case report.

A ganglion originating from the pisotriquetral joint is the most common cause of distal ulnar nerve compression. Midpalmar ganglions causing ulnar nerve compression are rare. This case describes a ganglion arising from the third carpometacarpal joint causing compression of the deep motor branch of the ulnar nerve.

Serial fMRI of adaptive changes in primary sensorimotor cortex following thumb reconstruction.

Serial fMRI was performed in a patient who underwent transfer of the left great toe to the hand following amputation of the right thumb. Motor activation within the primary sensorimotor cortex (SMC) of both hemispheres was quantified over 2 years, showing a transient increase in contralateral but not ipsilateral primary SMC. The temporal pattern of motor cortical activation observed in this patient may represent a "signature" of good functional recovery.

Visual-spatial abilities in surgical training.

As surgery continues to advance, we will need to better understand the role visual-spatial abilities play in the acquisition of technical skills. Many universities have established surgical skills centers with specific curricula to teach residents technical skills as adjuncts to operating room learning. Yet, as educators we do not fully understand the role visual-spatial abilities plays in the acquisition of surgical skills. This paper summarizes the research to date on the relevance of visual-spatial abilities to surgical training.

Isolated and combined lesions of the axillary nerve. A review of 146 cases.

We have assessed the final strength of the deltoid in 121 patients who had repair of isolated or combined lesions of the axillary (circumflex) nerve and were available for statistical analysis. Successful or useful results were achieved in 85% after grafting of isolated lesions. The strength was statistically better when patients had grafting of the axillary nerve within 5.3 months from the time of injury. The dramatic decrease in the rate of success seen with longer delays suggests that surgery should be undertaken within three months of injury. A statistically significant downward trend of the rate of success was noted with increasing age. The force and level of injury to the shoulder play an important role in the type, combination and level of nerve damage and the incidence of associated rotator-cuff, vascular and other injuries to the upper limb. Management of isolated and combined lesions of the axillary nerve after injury to the shoulder needs to be thorough and systematic.

Assessment of technical skills transfer from the bench training model to the human model.

BACKGROUND: This study examines whether technical skills learned on a bench model are transferable to the human cadaver model. METHODS: Twenty-three first-year residents were randomly assigned to three groups receiving teaching on six procedures. For each procedure, one group received training on a cadaver model, one received training on a bench model, and one learned independently from a prepared text. Following training, all residents were assessed on their ability to perform the six procedures. RESULTS: Repeated measures analysis of variance revealed a significant effect of training modality for both checklist scores (F(2,44) = 3.49, P <0.05) and global scores (F(2,44) = 7.48, P <0.01). Post-hoc tests indicated that both bench and cadaver training were superior to text learning and that bench and cadaver training were equivalent. CONCLUSIONS: Training on a bench model transfers well to the human model, suggesting strong potential for transfer to the operating room.

Computed tomography artifacts associated with craniofacial fixation devices: an experimental study.

This study compares the artifacts caused by eight different craniofacial fixation devices in computed tomography (CT) images. Using a Teflon CT phantom model, part I of this study involved the quantitative evaluation of the X-ray absorption properties of each fixation device. Part II utilized a human cadaveric model to determine the degree to which the artifact interfered with the visualization of anatomic structures. In part I, each fixation device was secured to the surface of the phantom and then scanned. All artifacts were compared on the basis of standard deviation in CT number. The severity of the artifact was related to the physical size of the fixation device and its composition. Vitallium devices generated a greater degree of CT artifacts than titanium devices of comparable size. In part II, fixation devices were secured to the orbital rims of human cadaveric heads and then scanned. Visualization of specified anatomic structures was graded independently. The results revealed that titanium fixation devices did not cause significant bone or soft-tissue image degradation, whereas all vitallium fixation devices, except micro mesh and micro (1.0 mm) straight plates, generated an artifact that resulted in some image degradation. The extent of image degradation was related to the fixation device size. Only the thickest vitallium fixation device, mini fragmentation (2.0 mm), resulted in bony image degradation. The degree of soft-tissue image degradation decreased as the size of vitallium fixation devices decreased such that micro fragmentation (0.8 mm) and pan fixation (1.3 mm) devices interfered with soft-tissue visualization only in the immediate vicinity of the plate. The results of this study confirm the previous work of Sullivan and colleagues and Fiala and associates. The data indicate that when postoperative imaging is an important clinical consideration: (1) the fewest number of internal fixation devices should be used to achieve rigid bony fixation, (2) the proximity of fixation devices to the regions of interest should be considered at the time of fixation, (3) titanium implants produce less artifacts than vitallium implants of comparable size, and (4) vitallium micro mesh and micro (1.0 mm) straight fixation devices do not produce artifacts resulting in significant image degradation.

The structured oral examination as a method for assessing surgical residents.

The purpose of this study was to determine the overall reliability, inter-rater reliability, and criterion validity of the structured oral examination (SOE) for assessing surgical residents. An SOE consisting of four predetermined clinically oriented scenarios was administered to 23 second postgraduate year surgical residents. Each scenario had five to six questions, each with a specific marking scheme. Candidates were assessed by two examiners and scores were derived independently. Overall reliability (Cronbach's alpha) was 0.75. Inter-rater reliability was significant for each pair of examiners and each question (r = 0.78 to 0.91: p less than 0.0001). Criterion validity was measured by correlating SOE scores with multiple-choice examination (MCQ) and objective structured clinical examination (OSCE) scores. Correlations between the SOE and MCQ and OSCE were significant and fell into the moderate range (0.48 to 0.51). The results of this study show that the SOE is useful in the assessment of clinical knowledge and problem-solving abilities of the surgical resident. Overall and inter-rater reliabilities achieved exceed those of traditional oral examination formats.

Severe peripheral burn polyneuropathy: a case report.

This report describes a 30-year-old man with a 45 per cent mixed deep partial and full thickness flame burn, who--following sepsis and multisystem failure--developed a severe polyneuropathy affecting the left median and both ulnar nerves, and both peroneal and posterior tibial nerves. The neurological alterations were significantly reversible, early reinnervation in all limbs was demonstrated by electromyography at 8 months, with subsequent progressive reinnervation at 1 year. The most likely cause of this polyneuropathy was the acute development of uraemia, at day 33 post-burn.