Pain Interference Prior to and 1 Year After Surgery for Adult Traumatic Brachial Plexus Injury.

PURPOSE: Pain after brachial plexus injury (BPI) can be severely debilitating and is poorly understood. We hypothesized that pain interference (PI) ("the extent to which pain hinders engagement in life") would be predicted by depression, anxiety, severity of pain symptoms, and poorer preoperative muscle function. METHODS: Among patients in a prospective multicenter BPI cohort study, 37 completed Patient-Reported Outcomes Measurement Information System (PROMIS) PI questionnaires before and 1 year after surgery. At both times, participants completed anxiety and depression questionnaires and BPI-specific measures of pain symptoms, physical limitations, and emotional recovery. Surgeon-graded muscle testing, injury severity, age at the time of injury, body mass index, and time from injury to surgery were included. We performed a bivariate analysis of predictors for preoperative and 1-year PROMIS PI followed by multivariable regression modeling using stepwise selection and Bayesian Information Criterion to select covariates. RESULTS: Before surgery, the mean PROMIS PI score was 60.8 ± 11.0, with moderate correlations between PROMIS PI and depression, as well as between PROMIS PI and functional limitations. At 1 year after surgery, the mean PROMIS PI score was 59.7 ± 9.5. There was no difference in preoperative and 1-year PROMIS PI. There were strong correlations between PROMIS PI and pain symptoms, functional limitations, and emotional aspects of recovery at the 1-year follow-up that remained significant in multivariable regression. There were no notable associations between muscle testing and PI. CONCLUSIONS: Pain interference remained substantial and elevated in BPI patients 1 year after surgery. We noted strong associations between PI and pain symptoms, functional limitations, and emotional aspects of recovery. These findings demonstrate the persistence of pain as a feature throughout life after BPI and that its treatment should be considered a priority alongside efforts to improve extremity function. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Factors Affecting Outcomes After Free Functional Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

PURPOSE: Free functional gracilis transfer (FFGT) is a useful option for reconstruction of elbow flexion following brachial plexus injury presenting late or with poor outcomes from previous nerve surgery. In this systematic review and meta-analysis, we aimed to investigate variables associated with superior outcomes. The efficacy of single versus double FFGT, where the first FFGT is performed to restore elbow flexion, and the choice of donor nerve for neurotization were evaluated. METHODS: A meta-analysis was conducted, including studies that provided postoperative Medical Research Council (MRC) grade for elbow flexion, Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores, quantitative elbow flexion strength, and range of motion. A random effects meta-regression analysis was performed to identify factors associated with improved outcomes. RESULTS: Thirty-seven studies, with 1,607 patients, were analyzed. Single FFGT was reported in 34 studies (n = 1,398), and double FFGT was reported in 10 studies (n = 209). The mean follow-up duration was 37.3 ± 21.1 months. Following single FFGT, 75.4% and 48.9% achieved MRC grades ≥3 and ≥4, respectively. Following double FFGT, 100% achieved an MRC grade ≥3 and 62.7% ≥4. The likelihood of achieving M3 and M4 was significantly greater for double FFGT. Overall, FFGT innervated by the spinal accessory nerve had significantly better recovery of MRC grade ≥3. When comparing only single and double FFGT innervated by spinal accessory nerve, there was no significant difference in recovery of elbow flexion. The meta-regression analysis showed a significant negative correlation between the patient's age and the probability of achieving an MRC grade of ≥3 and 4. CONCLUSIONS: In the overall analysis encompassing all innervating nerves, double FFGT was superior to single FFGT. Subgroup analysis of single and double FFGT innervated by the spinal accessory nerve showed no significant difference. Increasing age was a significant risk factor for poorer outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Factors correlating with positive electrodiagnostic findings for neurogenic thoracic outlet syndrome.

INTRODUCTION: Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report the EDX findings in a cohort of patients who underwent surgery for nTOS and also analyze patient-related and intraoperative factors associated with positive EDX findings supportive of nTOS diagnosis. METHODS: Baseline characteristics of patients, including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement, were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison. RESULTS: A total of 30 consecutive patients were included in this study comprising 11 (36.7%) men and 19 (63.3%) women, with a mean age of 44.6 ± 17.6 years. Twenty-two (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and 1 (3.3%) patient with type 2 nTOS. In terms of nTOS pattern, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P < 0.05) were significantly associated with positive EDX findings. CONCLUSIONS: Currently, EDX assessment may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX.

Consensus Recommendations for Neurogenic Thoracic Outlet Syndrome from the INTOS Workgroup.

Background: There is significant variation in methods used for diagnosis and treatment of neurogenic thoracic outlet syndrome (NTOS). The lack of definitions and criteria for diagnosis as well as controversy in treatment options hampers standardized reporting of outcomes. In the orthopedic and plastic hand surgery literature, there are not standardized guidelines to direct evidence-based practice for hand surgeons relating to NTOS. Hence, expert consensus may provide guidance for clinical practice. Methods: An international workgroup of 21 expert hand surgeons with cumulative experience of 5519 NTOS procedures was assembled. The Delphi method was used to arrive at consensus recommendations to guide diagnosis, treatment, surgery, and postoperative management of patients with NTOS. Results: The workgroup achieved majority (greater than 75%) consensus with 17 statements. A modified version of the Society for Vascular Surgery clinical diagnostic criteria is recommended for diagnosis of NTOS. The elevated arm stress test and Tinel sign are recommended as provocative maneuvers. A cervical spine or chest radiograph should be routinely obtained preoperatively. Conservative management should be first line for NTOS, except in patients with significant muscle atrophy or weakness. An anterior supraclavicular approach is recommended for exposure of the supraclavicular brachial plexus, with the necessity for an additional infraclavicular approach or adjunctive surgeries indicated for specific patients. Conclusions: Standardized consensus guidelines help guide management of NTOS by specialized hand surgeons, with an aim toward standardizing criteria for diagnosis and treatment of patients as well as measures and tools used for research and reporting of outcomes.

Thrombotic Consequences of COVID-19 Infection on Microsurgical Reconstruction.

BACKGROUND: Evidence has shown increased morbidity and mortality for patients with COVID-19 infection within 7 weeks of surgery. However, no studies have specifically investigated the effects of COVID-19 in microsurgical outcomes. This study evaluated thrombotic and overall complications after free tissue transfer for a variety of indications in patients with and without previous COVID-19 infection. METHODS: A retrospective cohort study was performed in adult patients with or without a history of COVID-19 infection who underwent microsurgical reconstruction between 2017 and 2022. Patients with a history of COVID-19 infection were matched to controls based on age, gender, race, body mass index, history of diabetes, coronary artery disease, hypertension, Caprini score, tobacco use, and flap indication. RESULTS: From 2017 to 2022, 35 patients had a documented history of COVID-19. Matched case analysis determined a 4.8 times increased odds ratio of postoperative complications in the COVID-19 group compared with controls (p = 0.002). Significantly, more patients with COVID-19 experienced total or partial flap loss and anastomotic issues (COVID-19: 7/35, Control: 0/35; p < 0.001). There was no significant difference in incidence of VTE (COVID-19: 1/35, Control: 0/35; p = 0.493). Of note, 62.9% of the COVID-19 group were discharged on anticoagulants (versus 14.3% in the control group [p < 0.001]). CONCLUSION: COVID-19 has dire, long-lasting effects on virtually every organ system, chief among them, the microcirculation. Further studies are needed to fully determine the extent and influence of COVID-19 on complex procedures such as free tissue transfer and how to optimize the screening, workup, and postoperative care to guard against the associated thrombotic consequences.

The Role of Computed Tomography Angiography in Perforator Flap Planning.

Preoperative computed tomography angiography (CTA) for perforator free flaps is accurate, precise, and reliable in mapping perforator anatomy that can be used in the intraoperative domain. CTA holds important clinical value as a tool in surgical decision making and surgical innovation, enabling reconstructive surgeons to tailor complex flap designs for extensive defects. Integration into existing infrastructure for virtual surgical planning is feasible, and future efforts to characterize the association of preoperative CTA with postoperative outcomes and cost-analyses for perforator flaps are warranted.

Caution Regarding ChatGPT's Appropriateness and Reliability Regarding Surgery for Wrist Arthritis.

BACKGROUND: Chat Generative Pre-Trained Transformer (ChatGPT), an artificial intelligence (AI) program, is widely used for information compilation. This study sought to analyze the quality and consistency of the information generated by ChatGPT regarding common procedures for wrist arthritis. METHODS: 32 standardized questions regarding wrist osteoarthritis and related procedures (4-corner-fusion [4CF], proximal row carpectomy [PRC], resurfacing capitate pyrocarbon implant, wrist denervation, and total wrist arthrodesis and arthroplasty) were presented to the ChatGPT-3.5 interface 3 separate times, without feedback. ChatGPT's answers were evaluated for medical accuracy by 3 reviewers and rated as "appropriate," "appropriate but incomplete," or "inappropriate." Ratings were then converted to numerical values to calculate an intraclass correlation coefficient (ICC). A DISCERN score was used to assess quality, and Flesch-Kincade Grade Level and Flesch Reading Ease Score for readability. RESULTS: 75% of the responses were deemed "appropriate," with 23 questions receiving unanimous appropriate ratings across all responses. The ICC was 0.97 (95% CI [0.46, 0.98]), indicating excellent reliability. DISCERN score was 60 (good). The Flesch-Kincaid Grade Level was 14.6 ± 1.9, and the Flesch Reading Ease Score was 25.3 ± 6.7, implying a college reading level. The information that ChatGPT provided for PRC and total wrist arthrodesis and arthroplasty, appeared to be more reliable than for 4CF and denervation. CONCLUSION: ChatGPT's reliability and accuracy of information varied across procedures, possibly due to unknown and diverse sources. Furthermore, while some answers were factually correct, many provided generic information across differing questions, limiting usefulness. ChatGPT must be used cautiously and the limitations understood.

Challenges and Advances in the Diagnosis and Management of Neurogenic Thoracic Outlet Syndrome: A Comprehensive Review.

Neurogenic thoracic outlet syndrome (nTOS) is caused by brachial plexus compression in the thoracic outlet. It accounts for 85%-95% of thoracic outlet syndrome (TOS) cases, which may also be caused by compression of the subclavian artery and vein. Compression occurs in the interscalene triangle, costoclavicular space or subpectoralis minor space, with congenital anomalies and repetitive overhead activities as contributing factors. Diagnosis is challenging due to overlapping symptoms with other conditions. Patients commonly report pain, numbness, tingling and weakness in the neck, shoulder and arm, exacerbated by arm elevation. Symptoms related to nTOS may manifest in the distribution of the upper (C5-C6), middle (C7) and lower plexus (C8-T1). Although widely used, provocative tests have varying degrees of sensitivity and specificity and may have high false-positive rates, complicating the diagnosis. Patterns on electrodiagnostic studies provide key diagnostic clues, such as reduced sensory response in the medial antebrachial cutaneous nerve and low compound motor action potential in the median nerve. Imaging techniques like magnetic resonance imaging (MRI), alongside procedures like diagnostic and therapeutic anterior scalene blocks, assist in identifying anatomical abnormalities and predicting surgical outcomes. Management of nTOS involves lifestyle changes, physical therapy, medication and botulinum toxin injections for symptomatic relief. Surgical options may include supraclavicular, transaxillary and infraclavicular approaches, each offering specific benefits based on patient anatomy and surgeon expertise. Minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, enhance exposure and dexterity, leading to better outcomes. Future research should focus on developing precise diagnostic tools, understanding nTOS pathophysiology, standardising diagnostic criteria and surgical approaches, comparing long-term treatment outcomes and exploring preventive measures to improve patient care and quality of life. Level of Evidence: Level V (Therapeutic).

Targeted Muscle Reinnervation: Factors Predisposing to Successful Pain Score Reduction.

BACKGROUND: Targeted muscle reinnervation (TMR) has demonstrated efficacy in reducing neuroma and chronic pain. In this article, we investigated postoperative outcomes in our patient cohort, with a focus on the role of nonmodifiable factors such as patient age and gender. METHODS: Patients who had extremity TMR from April 2018 to October 2022 were reviewed. Outcomes of interest included patient age, gender, cause and type of amputation, delayed versus immediate TMR, as well as postoperative improvement in pain as assessed by numerical rating score (NRS). RESULTS: A total of 40 patients underwent TMR on 47 limbs. Mean age was 46.2 ± 17.0 years. Delayed TMR (27, 57.4%) was most commonly performed, followed by immediate and delayed-immediate at 11 (23.4%) and 9 (19.1%), respectively. Amputation level was most commonly above-knee in 20 (42.6%) patients, followed by below-knee (12, 25.5%), transhumeral (8, 17.0%), transradial (6, 12.8%), and shoulder (1, 2.1%). The median time interval between amputation and TMR was 12 months. The median preoperative NRS assessing residual limb pain (RLP) for patients who underwent delayed TMR was 10. The median postoperative NRS assessing RLP for all patients was 0 (interquartile range25-75: 0-5) and significantly improved compared with preoperative NRS (P < 0.001). At the last follow-up for limbs that had delayed and delayed-immediate TMR (n = 36), 33 (91.7%) limbs had more than 50% resolution of RLP. There was a significant difference in median postoperative NRS by gender (4 in men and 0 in women) (P < 0.05). Postoperative median NRS also favored younger patients (0, <50 years compared with 4.5, >50 years) (P < 0.05). Multiple linear regression analysis showed that, of different variables analyzed, only male gender and older age were predictive of poorer postoperative outcomes. CONCLUSION: TMR showed high efficacy in our cohort, with improved short-term outcomes in women and younger patients.

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis.

INTRODUCTION: Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals. METHODS: This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed. RESULTS: Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE. CONCLUSION: The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

Proximal Row Carpectomy with and without Capitate Resurfacing: A Preliminary Systematic Review and Meta-Analysis.

BACKGROUND: In wrist salvage, proximal row carpectomy (PRC) has increasingly shown superior outcomes to four-corner fusion (4CF). Furthermore, PRC with resurfacing capitate pyrocarbon implants (PRC + RCPIs) provides a treatment option that may allow patients to avoid 4CF or wrist arthrodesis and help restore natural joint function and distribute loads evenly across the implant, though RCPI has yet to be evaluated on a large scale. We aimed to compare outcomes between PRC and PRC + RCPI for the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists. METHODS: A systematic review and meta-analysis was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on PRC and PRC + RCPI performed for SLAC and SNAC wrist with minimum 12-month follow-up. Primary outcomes included wrist range of motion (ROM), grip strength, and outcome scores including Disabilities of Arm, Shoulder, and Hand (DASH) and QuickDASH scores, Patient-Rated Wrist and Hand Evaluation (PRWHE), and visual analog scale pain scores. RESULTS: Twenty-two studies reporting on 1,804 wrists were included (1,718 PRC alone, 86 PRC + RCPI). PRC + RCPI was associated with greater postoperative radial deviation, but poorer flexion. PRC + RCPI also had significantly lower postoperative QuickDASH (less disability and symptoms) and postoperative PRWHE (lower pain and disability) scores and an improvement in PRWHE compared with PRC. There was no significant difference in grip strength. CONCLUSION: PRC + RCPI demonstrated similar postoperative ROM to PRC alone. While PRC + RCPI was associated with more favorable outcome scores, further research is needed to confirm these findings and assess the incidence and profile of complications related to RCPIs. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Safety and Efficacy of Dorsal Root Entry Zone Lesioning for Pain Management in Patients With Brachial Plexus Avulsion: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Persistent neuropathic pain after brachial plexus avulsion (BPA) is common and generally nonresponsive to medical management. Dorsal root entry zone (DREZ) lesioning is the last resort for pain management in patients with BPA. This study aims to investigate and compare the outcomes and complications of DREZ procedures. METHODS: A systematic literature search was conducted to identify all related studies. Comparisons were based on the number of patients with preoperative pain vs postoperative pain, with the effect size calculated using the risk ratio. Mean visual analog scale (VAS) scores were extracted and analyzed between interventions. A meta-regression analysis was performed to identify risk factors for final outcomes. The rates of complications were also assessed and analyzed between interventions. RESULTS: A total of 30 studies with 917 patients (90.0% male and 10.0% female, mean age: 42.9 ± 16.6) were included in this systematic review. Of the 917 patients who underwent surgery, 655 (71.4%) patients had significant pain reduction at the last follow-up ( P < .05). The weighted mean preoperative VAS score was 8.3 ± 1.3, compared with postoperative VAS scores (1.9 ± 2.2); a significant improvement was observed ( P < .05). The subgroup analysis showed that microsurgical DREZotomy (MDT) is associated with better outcomes in terms of VAS score improvements compared with radiofrequency (RF)-assisted DREZ lesioning ( P < .05). Meta-analysis showed that the relative risk of motor deficits was significantly lower in the MDT group, compared with the RF-assisted group ( P < .05). Meta-regression showed that older age is correlated with an elevated risk of postoperative motor deficits compared with the incidence of sensory loss. CONCLUSION: DREZ lesioning is effective for intractable pain alleviation after BPA. Compared with RF-assisted DREZ lesioning, MDT is associated with better VAS score improvements and a lower rate of postoperative motor weakness.

Evolution and Application of Ultrasound for Flap Planning in Upper Extremity Reconstruction.

Accurate preoperative localization of dominant perforators provides crucial information about their location and diameter, leading to reduced surgical time, improved flap viability, and decreased complications. Ultrasound has increased in popularity in recent years, with the advantages of providing reproducible, accurate, cost-effective, and real-time information while reducing radiation exposure. Precise preoperative mapping of perforators allows for rapid and safe elevation of suprafascial, thin, and superthin flaps. This review focuses on the role of ultrasound as a tool for preoperative flap planning in the upper extremities.

Thin Profunda Artery Perforator Flap for Hand and Upper Extremity Coverage.

The profunda artery perforator (PAP) flap provides a good option for hand and upper extremity reconstruction. The reliable quality, caliber, and number of perforators in the posteromedial thigh support large flaps with long pedicles. The PAP flap has been widely used for breast reconstruction, although its use in the extremities has been slower to catch on due to the bulk and thickness of the subcutaneous tissue. The authors discuss evolution of thin flaps and our application of the thin and superthin PAP flap for upper extremity reconstruction.

Four-Corner Fusion Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrist: A Systematic Review and Meta-Analysis.

PURPOSE: Although proximal row carpectomy (PRC) has increasingly been shown to have superior features to four-corner fusion (4CF), individual surgeons may remain convinced of the superiority of one procedure based on personal experience and individual biases. Hence, we sought to perform an updated meta-analysis with some of the largest studies to date to compare outcomes and complications between these procedures in the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. METHODS: A systematic review and meta-analysis was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on PRC and 4CF performed for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist. Primary outcomes included wrist range of motion; grip strength; outcome measures, including Disabilities of Arm, Shoulder, and Hand and Quick Disabilities of Arm, Shoulder, and Hand scores, Patient-Rated Wrist and Hand Evaluation, and visual analog scale pain scores; and surgical complications. RESULTS: Sixty-one studies reported on 3,174 wrists, of which 54% were treated with PRC and 46% were treated with 4CF. The weighted mean follow-up was 61 months (range, 12-216 months). Meta-analysis comparing PRC and 4CF demonstrated that PRC had significantly greater postoperative extension; ulnar deviation; postoperative improvement in extension, flexion, ulnar deviation; and visual analog scale score. No comparisons showed significant differences in grip strength. The percentage of wrists requiring arthrodesis was 5.2% for PRC and 11% for 4CF. There was an 8.9% (57/640 wrists) 4CF nonunion rate and 2.2% (17/789) hardware removal rate after 4CF. CONCLUSIONS: In the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists, PRC results in better outcomes and a lower complication rate compared to 4CF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Scalp Closure in Midline Cutis Aplasia-An Absolute Indication for Preoperative Imaging.

The ideal evaluation and treatment of aplasia cutis congenita remains disputed. We present a case of midline scalp cutis aplasia that healed by secondary intention, leaving an area of residual alopecia. There were no clinical indicators of an underlying calvarial defect. Tissue expansion of the scalp was done in preparation for scalp closure. However, on the removal of the expanders and scalp advancement, an unrecognized midline calvarial defect in which a scar tract of herniated dura was found. This resulted in a dural tear, repaired with minimal hemorrhage. However, manipulation of the sagittal sinus resulted in a right subdural hemorrhage followed by cerebral ischemia and a stroke. On the basis of this clinical scenario, we recommend that all cases of midline scalp cutis aplasia undergo preoperative imaging with thin slices of the calvaria before performing scalp advancement-even if the only clinical indication for surgery is scalp alopecia without a palpable skull defect.

Axial-Radial-Ulnar Carpal Dislocation with Divergent Intermetacarpal Dislocations, Peritrapezoid and Scaphotrapezial Dislocations: A Case Report.

We report a patient with a severe axial-radial-ulnar (ARU) fracture dislocation of the carpus, involving multiple intermetacarpal dislocations as well as divergent carpometacarpal dislocations involving the index, long, ring and small fingers and peritrapezoid and scaphotrapezial dislocations. She also had a degloving injury involving the dorsal hand. Emergent debridement followed by open reduction and internal fixation of all injuries was performed, followed by soft tissue management. At 6-year follow-up, the patient had adequate active range of motion with the ability to make a full fist and was able to use her wrist and hand for most activities of daily living. Disabilities of the arm, shoulder and hand (DASH) score was 47.5. Michigan hand outcomes questionnaire (MHQ) score was 66.8. Mayo wrist score was 65. Patient-rated wrist evaluation (PRWE) score was 42. Severe ARU fracture dislocations of the carpus can result in adequate functional recovery on long-term follow-up. Level of Evidence: Level V (Therapeutic).

The role of surgery in the management of radiation-induced brachial plexopathy: a systematic review.

This systematic literature review of the clinical characteristics of radiation-induced brachial plexopathy and outcomes after intervention includes 30 trials with 611 patients. The mean radiation dose to the brachial plexus was 56 Gy, and the mean duration of radiation was 4 weeks. The mean time from radiation to the onset of symptoms was 35 months. The most commonly reported symptom was sensory loss (n = 323, 62%), followed by motor deficits (n = 294, 56%) and neuropathic pain (n = 284, 54%). In total, 65 (56%) patients had panplexus involvement and 51 (44%) patients had partial plexus involvement. The most common surgical procedure was neurolysis with flap coverage (n = 108, 6%), followed by neurolysis alone (n = 71, 30%). Of the 237 patients who underwent surgery, 125 (53%) reported an improvement in pain. Motor and sensory deficits were improved in 46 (19%) and 39 (16%) patients, respectively, suggesting that surgery is beneficial in relieving pain, but not as beneficial in restoring motor and sensory function.

Evaluation of Different Surgical Techniques for Revision Cubital Tunnel Release: A Meta-Analysis of Patient-Reported Symptoms.

PURPOSE: Controversy exists regarding the best option for revision surgery in refractory cubital tunnel syndrome (CuTS). The purpose of this systematic review was to evaluate the effectiveness of revision surgery and determine the optimal surgical approach for patients requiring revision surgery for CuTS. METHODS: A literature search was conducted. Characteristics of the included studies were summarized descriptively. The risk ratio between patient-reported preoperative and postoperative outcomes relating to pain, motor, and sensory deficits was calculated. A meta-regression analysis was performed to evaluate the postoperative symptom improvements based on the type of secondary surgery. Random-effects meta-analysis and descriptive statistics were used when appropriate. RESULTS: A total of 471 patients were evaluated in 20 studies. In total, 254 (53.9%) male and 217 (46.1%) female patients, with an average age of 49.2 ± 14.1 years, were included in this study. Pain was the most common symptom (n = 346, 81.6%), followed by sensory and motor dysfunction in 342 (80.6%) and 223 (52.6%) patients, respectively. Meta-analysis comparing preoperative and postoperative symptoms between patients who had submuscular transposition (SMT), subcutaneous transposition (SCT), and neurolysis showed that a significant subgroup difference exists between the types of revision surgery in sensory and motor improvements. Meta-regression showed that SMT was associated with better outcomes compared with SCT in motor and sensory improvements. CONCLUSIONS: Revision surgery for CuTS can be useful for addressing recurrent and persistent symptoms. Compared with neurolysis and SCT, SMT seems to be the superior option for revision surgery, demonstrating substantial improvement in all symptom domains. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Patient-Reported Outcome Measures After Endoscopic Cubital Tunnel Release With At Least 1-Year Postoperative Follow-up.

BACKGROUND: The primary objective of this study was to investigate midterm outcomes following endoscopic cubital tunnel release (ECuTR) with the Seg-Way system using patient-reported outcome measures (PROMs). A secondary aim was to evaluate symptom resolution as assessed through Dellon's stage, McGowan's grade, and Messina's criteria and recurrence following ECuTR. METHODS: Functional outcomes were assessed in 38 patients who underwent 43 surgeries. Details on baseline characteristics as well as preoperative and postoperative symptoms were collected. Patient-reported outcome measures were administered with at least 1-year follow-up in all patients. RESULTS: Mean age of patients was 50.2 ± 16.1 years, with 20 men (52.6%) and 18 women (47.4%). Postoperatively, pain completely resolved in 21 (72.4%), while sensory and motor deficits improved completely in 22 (56.4%) and 11 (64.7%) patients, respectively. Mean time interval between ECuTR and PROMs was 26.3 (13-63) months. Median Michigan Hand Outcomes Questionnaire score was 73.2 (48-91). Median Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale (NRS) scores were 12.9 (7-35) and 2.5 (0-5), respectively. Most of the patients were satisfied postoperatively with a median satisfaction score of 4 (3-5). There was a significant difference in median DASH and NRS scores between patients with and without concomitant proximal nerve disease. CONCLUSION: Endoscopic cubital tunnel release is a safe and effective option for surgical management of primary cubital tunnel syndrome. The presence of other proximal nerve disease is associated with poorer outcomes, less symptom resolution, and higher recurrence rates. One-year postoperative PROMs show equivalence to those reported in other studies following open cubital tunnel release.