Educational and Clinical Outcome Measures in an Integrated Hand Service.

Background: We recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients. Materials and Methods: Program director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes. Results: For both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved. Conclusion: To improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

A 10-Year Update of Outcome Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature.

HYPOTHESIS: Outcomes reporting for the surgical release of ulnar nerve cubital tunnel entrapment have variability in subjective, objective, and validated measures. The aim of this study is to review the literature to reassess the measures used to report surgical outcomes for ulnar neurolysis at the elbow. METHODS: This study was conducted in accordance with the PRISMA guidelines on systematic reviews. Six electronic databases were queried from the past 10 years using specific search terms and Boolean operators. Two independent reviewers assessed 4290 unique titles and abstracts that were screened for inclusion criteria. Sixty-eight full text articles were included for analysis. RESULTS: Statistical significance was noted in the number of outcome measures reported between studies from journals of impact factor within the first and third quartiles (P = 0.0086) and first and fourth quartiles (P = 0.0247), although no significance exists in the number of cubital tunnel-specific measures based on impact factor (P = 0.0783). Seventy-nine percent (n = 54) of the included studies report subjective measures; 54% (n = 37) included objective measures. Seventy percent (n = 48) of the studies report disease-specific outcome measures. CONCLUSION: There exists a discordance within the literature regarding the most appropriate, descriptive, and translational measures for reporting surgical outcomes of cubital tunnel syndrome. We recommend journal editors implement a requirement that authors reporting outcomes of ulnar nerve decompression must use a standard, validated measure to make comparisons across the literature universal. Furthermore, a minimum of at least 1 subjective and 1 objective measure should be standard.

Anomalous Course of the Brachial Plexus Identified During Ultrasound-Guided Brachial Plexus Nerve Block.

Knowledge of brachial plexus anatomy is essential when performing upper-extremity regional anaesthesia. Anomalous brachial plexus anatomy has been reported in up to 35% of patients. Variants include anomalous course of the roots anterior to, or within, the scalene musculature and abnormal separation of the cords around the subclavian artery. These anomalies have been detected with ultrasound, a valuable tool for delineating anatomy and providing imaging guidance during regional anaesthesia. We report a previously undescribed course of the brachial plexus relative to the subclavian artery within the supraclavicular fossa identified by ultrasound prior to peripheral nerve blockade.

Failed Thumb Carpometacarpal Arthroplasty: Common Etiologies and Surgical Options for Revision.

Carpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms.

Quality of Surgical Outcomes Reporting in Plastic Surgery: A 15-Year Analysis of Complication Data.

BACKGROUND: Postoperative complication data are integral to assessing patient outcomes and identifying areas for improving quality in surgical care. Accurate appraisal of surgical techniques requires consistency and reliability in complication data reporting. The purpose of this study was to analyze the quality of complication reporting in plastic surgery. METHODS: The authors critically reviewed the literature from January 1, 2000, to December 31, 2014, to identify articles reporting surgical outcomes after three index procedures: autologous breast reconstruction, prosthetic breast reconstruction, and reduction mammaplasty. Studies were extracted from the journals Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Two authors independently analyzed data using a modification of established criteria for complication reporting that incorporates 10 critical elements. RESULTS: Two hundred ninety-six articles reporting outcomes for 299,819 procedures in 249,942 patients were analyzed. Of the 10 reporting criteria, no articles met all criteria, fewer than 1 percent met nine, 16 percent met seven to eight, 43 percent met five to six, 35 percent met three to four, and 6 percent met one to two (mean, five criteria met). Commonly underreported criteria included complication definitions (37 percent of articles reported), aesthetic or patient-reported outcome (28 percent), and complication severity (16 percent). Only 46 studies (16 percent) reported complication severity, with 15 different definitions of what constituted a "major" complication. Risk factors for complications were absent in 37 percent of articles. CONCLUSIONS: Inconsistency in reporting complications in the plastic surgery literature confounds the comparison of surgical outcomes. The use of standard guidelines to accurately, efficiently, and reproducibly report complication data is essential for quality assurance and improvement.

Femoral nerve transfers for restoring tibial nerve function: an anatomical study and clinical correlation: a report of 2 cases.

Sciatic nerve injuries cause debilitating functional impairment, particularly when the injury mechanism and level preclude reconstruction with primary grafting. The purpose of this study was to demonstrate the anatomical feasibility of nerve transfers from the distal femoral nerve terminal branches to the tibial nerve and to detail the successful restoration of tibial function using the described nerve transfers. Six cadaveric legs were dissected for anatomical analysis and the development of tension-free nerve transfers from femoral nerve branches to the tibial nerve. In 2 patients with complete tibial and common peroneal nerve palsies following sciatic nerve injury, terminal branches of the femoral nerve supplying the vastus medialis and vastus lateralis muscles were transferred to the medial and lateral gastrocnemius branches of the tibial nerve. Distal sensory transfer of the saphenous nerve to the sural nerve was also performed. Patients were followed up for lower-extremity motor and sensory recovery up to 18 months postoperatively. Consistent branching patterns and anatomical landmarks were present in all dissection specimens, allowing for reliable identification, neurolysis, and coaptation of donor femoral and saphenous nerve branches to the recipients. Clinically, the patients obtained Medical Research Council Grade 3 and 3+ plantar flexion by 18 months postoperatively. Improved strength was accompanied by improved ambulation in both patients and by a return to competitive sports in 1 patient. Sensory recovery was demonstrated by an advancing Tinel sign in both patients. This study illustrates the clinical success and anatomical feasibility of femoral nerve to tibial nerve transfers after proximal sciatic nerve injury.

Lower Extremity Reconstruction with Free Gracilis Flaps.

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8-30 days in 11 patients, 31-90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury.

BACKGROUND: With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome. METHODS: A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion. RESULTS: Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes. CONCLUSION: Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017.

Decompression of the superficial peroneal nerve: clinical outcomes and anatomical study.

OBJECTIVE The authors of this study sought to determine the outcomes of patients undergoing superficial peroneal nerve (SPN) release to treat lower-extremity pain and describe consistent anatomical landmarks to direct surgical planning. METHODS This retrospective cohort study examined 54 patients with pain in the SPN distribution who were treated with decompression between 2011 and 2014. Patients rated pain and the effect of pain on quality of life (QOL) on the visual analog scale (VAS) from 0 to 10. Scores were then converted to percentages. Linear regression analysis was performed to assess the impact of the preoperative effect of pain on QOL, age, body mass index (BMI), and preoperative duration of pain on the postoperative effect of pain on QOL. Measurements were made intraoperatively in 13 patients to determine the landmarks for identifying the SPN. RESULTS A higher BMI was a negative predictor for improvement in the effect of pain on QOL. A decrease in pain compared with the initial level of pain suggested a nonlinear relationship between these variables. A minority of patients (7 of 16) with a preoperative pain VAS score ≤ 60 reported less pain after surgery. A large majority (30 of 36 patients) of those with a preoperative pain VAS score > 60 reported improvement. Intraoperative measurements demonstrated that the SPN was consistently found to be 5 ± 1.1, 5 ± 1.1, and 6 ± 1.2 cm lateral to the tibia at 10, 15, and 20 cm proximal to the lateral malleolus, respectively. CONCLUSIONS A majority of patients with a preoperative pain VAS score > 60 showed a decrease in postoperative pain. A higher BMI was associated with less improvement in the effect of pain on QOL. This information can be useful when counseling patients on treatment options. Based on the intraoperative data, the authors found that the SPN can be located at reliable points in reference to the tibia and lateral malleolus.

Intraneural Median Nerve Anatomy and Implications for Treating Mixed Median Nerve Injury in the Hand.

Background: Nerve transfers have resulted in increased interest in the microanatomy of peripheral nerves. Herein, we expand our understanding of the internal anatomy of the digital nerve to the ulnar index and long fingers, the radial long and ring fingers, and the nerves to the second and third web spaces. Methods: The median nerve was dissected from the digital nerves to the antecubital fossa in 14 fresh upper extremities. The distance of proximal internal neurolysis of the fascicles to the second and third web space and proper digital nerves was measured relative to the radial styloid. Plexi encountered during proximal lysis were noted. Results: Digital nerves to the ulnar index and radial long fingers were lysed 2.4 ± 0.5 cm (mean ± SD), and digital nerves to the ulnar long and the radial ring fingers were lysed 3.0 ± 0.6 cm distal to the radial styloid. Fascicles to the third web space were lysed to the takeoff of the anterior interosseous nerve, 21.1 ± 1.4 cm. Plexus groupings were encountered at 4.5 ± 1.6 cm, 8.3 ± 1.2, cm and 16.1 ± 1.9 cm proximal to radial styloid. The fascicles to the second web space were lysed to 5.0 ± 1.2 cm proximal to radial styloid where a plexus grouping was encountered. Another plexus group was found at 3.3 ± 1.3 cm. Conclusions: We demonstrate that extended internal neurolysis of second web space, along with the digital nerves, is technically and clinically feasible. This technique can be used to treat mixed median nerve injury in the hand and wrist.

Direct radial to ulnar nerve transfer to restore intrinsic muscle function in combined proximal median and ulnar nerve injury: case report and surgical technique.

A distal median to ulnar nerve transfer for timely restoration of critical intrinsic muscle function is possible in isolated ulnar nerve injuries but not for combined ulnar and median nerve injuries. We used a distal nerve transfer to restore ulnar intrinsic function in the case of a proximal combined median and ulnar nerve injury. Transfer of the nonessential radial nerve branches to the abductor pollicis longus, extensor pollicis brevis, and extensor indicis proprius to the motor branch of the ulnar nerve was performed in a direct end-to-end fashion via an interosseous tunnel. This method safely and effectively restored intrinsic function before terminal muscle degeneration.

Do chronic liver disease scoring systems predict outcomes in trauma patients with liver disease? A comparison of MELD and CTP.

BACKGROUND: Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma. METHODS: A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant. RESULTS: The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70). CONCLUSION: Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.