Predictors of Time to Return to Work Following Surgical Reconstruction of Upper Limb Injuries in a Cosmopolitan City in Western Nigeria.

BACKGROUND: The management of upper limb injury is aimed at a timely return to work, and other activities of daily living. The modified hand injury severity score (MHISS) has been found to predict a return to work. Upper limb injuries are common in our subregion, but there is little or no data on the time to return to work. AIM: This study, therefore, aimed to determine the prevalence of return to work and to identify the predictors of time to return to work following reconstruction of upper limb injuries. METHOD: This was a cross-sectional analytic study carried out between April 2022 and March 2023. The statistical test was at a confidence interval of 95%, and statistical significance set at a P value of <0.05. RESULT: A total of 49 upper-limb-injured patients had reconstruction in the time under review. Male-to-female ratio was 4.4:1. The mean MHISS was 87.9 ± 79.2. Of the 43 patients who participated in the return-to-work analysis, 41.9% had returned to work, with a mean time of 14.3 ± 10.5 weeks. Work-related injuries (r = 0.357, P = 0.019), male gender (r = 0.354, P = 0.020), and MHISS (r = 0.333, P = 0.029) correlated significantly with late return to work. On multiple logistic regression, work-related injuries (ß =0.321, P = 0.037), MHISS (ß =0.376, P = 0.032), and male gender (ß =0.326, P = 0.044) were found to be the significant predictors of late return to work. CONCLUSION: There is a low prevalence of return to work, with a high mean time to return. Work-related injuries, MHISS, and male gender are significant predictors of time to return to work.

Electric Scooter-Related Upper Limb Fractures: Analysis of 458 Cases.

PURPOSE: To perform an analysis of electric scooter (e-scooter)-related upper limb fractures (ULFs), which have increased dramatically in parallel with the rapid rise in the use of e-scooters and shared e-scooter services in recent years. METHODS: We retrospectively reviewed the medical charts of e-scooter-related emergency department visits between January 2017 and January 2020 at a level I trauma center. All patients with ULFs were included in the study, and their data were analyzed for demographics, fracture diagnosis, associated injuries, and required surgical treatment. RESULTS: This study included 356 patients (50% men) with 458 ULFs, of which 23 (5%) were open fractures. The mean age of the cohort was 32.9 years (standard deviation, 10.1 years). The most common mechanism of injury was rider fall (92.1%). The nondominant hand was injured in 53.1% of cases, and 32.1% of all fractures were treated with surgery. A total of 120 (33.7%) patients sustained more than 1 ipsilateral ULF, and 27 (7.6%) patients had a concomitant contralateral ULF. Radial head fracture was the most common fracture type (n = 123, 26.8%), of which 16 (13%) were bilateral. The fifth ray was injured most frequently among the metacarpal and phalangeal fractures (n = 33, 47.1%). Most of the nonextremity-associated injuries were those of the head and maxillofacial bones. CONCLUSIONS: The most common ULF associated with e-scooters was the radial head fracture. Physicians should be alert to and seek associated fractures during initial assessments of e-scooter-related upper limb injuries. Further investigation may be warranted to evaluate the effectiveness of protective measures in reducing the number of injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care.

PURPOSE: Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location. METHODS: We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS. RESULTS: There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay. CONCLUSIONS: The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation.

BACKGROUND: Distal biceps tendon rupture is a rare injury associated with decreased elbow flexion and forearm supination strength. This impairment is not tolerated by high-demand patients like athletes. PURPOSE: To review treatment and rehabilitation applied to injured athletes and study their impact in return to sports. METHODS: MEDLINE, Cochrane, Web of Science, and Scopus online databases were searched. A systematic review was conducted using the PRISMA guidelines; studies published on distal biceps tendon rupture treatment and rehabilitation of athletes until June 30, 2021, were identified. A quantitative synthesis of factor related to return to preinjury sport activity was made. RESULTS: Ten articles were identified, including 157 athletes. Mean age was 40.5 years, and the dominant arm was injured in 103 cases (66%). Rupture was acute in 121 athletes (77%), and the mean follow-up was 25.7 months. A hundred and fifty-three athletes (97.5%) successfully returned to sport within a mean time of 6.2 months. Surgical treatment was followed in all cases. One-incision technique was chosen in 115 (73%) and suture anchor fixation in 52 (33%) cases. No postsurgical immobilization was reported in 38 (24%) and immobilization for 2 weeks in 124 (79%) athletes. Decreased supination-pronation and flexion-extension arc was found in 63 (40%) and 27 (17%) cases, respectively. Earlier return to sport was associated with nondominant-side (P = .007) and acute (P < .001) injuries, participation in weightlifting (P = .001), double-incision approach (P = .005), cortical button fixation (P < .001), and absence of supination-pronation restriction (P = .032). Time of return to sport activity was independent of rehabilitation, including immobilization (P = .539) and strengthening (P = .155), and decreased flexion-extension arc (P = .059). CONCLUSION: Athletes sustaining distal biceps tendon rupture have a high postoperative return to sport rate, independently of selected surgical technique or rehabilitation program. However, a relation between the surgical technique and time of return to sport was found. Rehabilitation did not influence time of return to sport.

Acute distal biceps tendon rupture: retrospective analysis of two different approaches and fixation techniques.

PURPOSE: The aim of our study is to compare the modified double incision (DI) with bone tunnel reinsertion with the single-incision (SI) double tension slide technique in terms of clinical and functional outcomes and complication rates. METHODS: A retrospective comparative analysis was performed on 65 patients treated for total distal biceps tendon rupture. The surgical technique adopted for each patient was based on the preference of two experienced elbow surgeons. The DASH and MAYO questionnaires, functional outcome and ROM were recorded in all subjects. RESULTS: Of 65 patients, we collected data of a cohort of 54 distal biceps tendon ruptures that satisfied inclusion criteria. Twenty-five were treated by modified DI and 29 SI techniques. The recovery of the complete ROM in terms of flexion/extension and prono-supination occurred in the 79.6% of the patients, without statistical significant difference between the adopted technique. We reported a complication rate of 12% and 20.7% for DI and SI techniques, respectively, without statistical correlation (P = 0.84). The average DASH score was similar for DI and SI techniques without significant differences (P = 0,848). The Mayo score results were excellent in the majority of the patients. No significant difference in MAYO results was reported comparing the surgical techniques (P = 1). CONCLUSION: Both techniques provide a reliable and strong repair with an optimal recovery of ROM returning to preinjury activity with substantially overlapping timelines.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review.

INTRODUCTION: Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction. PATIENT AND METHODS: A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed. CONCLUSION: Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

Continuous External Tissue Expansion Closure Technique for Management of Forearm Compartment Syndrome Releases and Simple Upper-Extremity Wounds.

Upper-extremity wounds from various etiologies such as trauma and fasciotomies can prove to be problematic for the upper-extremity surgeon. These defects can result in considerable morbidity often requiring prolonged wound care and the eventual use of skin grafting from a separate painful donor site. Tissue expansion takes advantage of the viscoelastic properties of skin to provide additional tissue for reconstruction. The authors present a technique using a continuous external tissue expansion device for closure of upper-extremity wounds.

Understanding and Addressing Psychiatric Comorbidities and Upper-Extremity Trauma: Surgeons in a Multidisciplinary Care Model.

Psychiatric disorders are a common cause of disability and represent an important risk factor for upper-extremity trauma. The review provides an overview of psychiatric illnesses as both contributors and sequelae of 4 major injury patterns: self-inflicted wrist lacerations, self-amputation, upper-extremity fractures, and burns. The authors develop a multidisciplinary model for upper-extremity surgeons to care for patients with psychiatric disorders, with an overview of capacity assessment, optimal psychiatric comanagement, and collaboration with allied health professionals.

Clinical and sonographic evaluation of Endobutton distal biceps brachii tendon repair: what constitutes normal post-operative appearances?

OBJECTIVE: Distal biceps brachii tendon (DBBT) rupture is an uncommon but functionally significant injury given the loss of supination, flexion strength and pain that often result. Prompt surgical repair is preferred in most patients. Clinicoradiological post-operative follow-up is typically performed to assess DBBT repair integrity and function, frequently using ultrasound, though to date, no studies have described post-operative DBBT repair sonographic appearances. The purpose of this study was to evaluate post-operative DBBT sonographic appearances in the context of Endobutton repair with the following aims:i.Establish typical ultrasound appearances 12 months post-surgeryii.Establish the relationship between ultrasound appearances and clinical/functional outcomes. MATERIALS AND METHODS: Sixty patients between February 2016 and October 2017 undergoing DBBT repair were prospectively recruited, all undergoing clinical and sonographic assessment 12 months post-surgery. Ultrasound data was collected on tendon integrity, tendon calibre and presence of intratendinous calcification, peritendinous fluid and peritendinous soft tissue/scarring. Clinical data was collected on active range of motion (ROM) (flexion, extension, supination, pronation) and strength (flexion and supination). RESULTS: A total of 57/60 patients had intact DBBT repairs identified sonographically and clinically at 12 months. DBBT repairs had significantly increased cross-sectional area (mean 260%, 95% CI: 217%, 303%) compared with non-operated DBBT. Ninety-three percent of DBBT repairs were hypoechoic. Thirty percent contained intratendinous calcification. Peritendinous fluid/soft tissue was rarely observed. There was no significant correlation between DBBT calibre and strength/ROM parameters. CONCLUSION: Normal post-operative sonographic appearances of Endobutton DBBT repair comprise a hypoechoic tendon significantly increased in calibre compared with non-operated tendon ± intratendinous calcification. DBBT repair calibre varies greatly, but is not associated with any significant difference in strength/ROM.

Chronic distal biceps avulsion treated with suture button.

BACKGROUND: Distal biceps tendon avulsions account for 3%-10% of all biceps ruptures. Treated nonoperatively, these injuries lead to a loss of endurance, supination strength, and flexion strength compared with operative repair or reconstruction. Operative management of chronic injury has classically been with graft tissue to augment the contracted muscle. We present our results for chronic distal biceps avulsions secured with suture button through a single transverse incision in high flexion without the need for allograft augmentation. MATERIALS AND METHODS: This was a retrospective review of 20 patients with 21 injuries who underwent primary surgical repair of chronic distal biceps tendon avulsions at an average of 10 weeks (range 4-42 weeks). All patients were treated with a single transverse incision with a suture button armed with nonabsorbable no. 2 core sutures. Postoperatively patients were found to have 50°-90° flexion contracture. All patients were placed in a simple sling postoperatively with gentle extension to gravity as tolerated immediately and no formal physical therapy. Patients were surveyed regarding pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and overall satisfaction. Range of motion (ROM), flexion, and supination strength compared to the contralateral uninjured extremity were evaluated at final follow-up. RESULTS: Mean clinical follow-up was 26 months. All patients regained full ROM and 5/5 flexion and supination strength at final follow-up. MEPSs were 100 for all responding patients compared with an average 47.5 preoperatively (P < .0001). The mean postoperative ASES score was 97.2 compared with 41.9 preoperatively (P < .0001). Mean OESs pre- and postoperatively were 24.2 and 48, respectively (P < .0001). The mean VAS score was 4.4 preoperatively and was reported as 0 by all patients at final follow-up (P < .0001). Two patients had transient sensory radial nerve neuropathy, and 1 patient has persistent palsy. No synostoses occurred. Four patients reported supination fatigue postoperatively compared with the uninjured extremity. CONCLUSION: Given these results, we feel that chronic distal biceps tendon ruptures can be repaired successfully with a single incision using suture button technique without the use of a graft. Though the flexion contracture is significant postoperatively, all patients regained full ROM and had excellent postoperative functional outcome scores.

Is the flexion-abduction-supination magnetic resonance imaging view more accurate than standard magnetic resonance imaging in detecting distal biceps pathology?

BACKGROUND AND HYPOTHESIS: Partial biceps tendon pathology is difficult to diagnose. The flexion-abduction-supination (FABS) magnetic resonance imaging (MRI) view has been advocated to improve the accuracy of MRI investigation. The purpose of this study was to evaluate the accuracy of the FABS view MRI in the diagnosis of distal biceps tendon pathology. METHODS: The study included 50 patients with surgically confirmed distal biceps tendon pathology and 50 patients with other elbow disorders. In both groups, standard elbow MRI (retrospective review of previously obtained MRI data) was performed in half of the patients whereas FABS views MRI were obtained in the other half. These were evaluated by 2 independent musculoskeletal radiologists. The sensitivity and specificity of both MRI views were determined. Tendinosis and grade of rupture were reported from MRI and then compared with surgical findings. RESULTS: There were no significant differences in sensitivity and specificity in detecting partial distal biceps injuries when the FABS view MRI (sensitivity, 84%; specificity, 86%) and standard MRI (sensitivity, 76%; specificity, 98%) were compared. The interobserver reliability was 92% for the FABS view MRI with biceps pathology and 68% for standard MRI. In the control group, the interobserver reliability was 88% for the FABS view MRI and 96% for standard MRI. FABS MRI was significantly better regarding grade of injury. CONCLUSIONS: No significant differences in sensitivity and specificity were found between the FABS view and standard elbow MRI in the diagnosis of partial distal biceps tendon injuries, with high sensitivity and specificity for both views. Inter-rater reliability was better for FABS views, and FABS views were significantly more accurate than surgical findings in grading the extent of pathology.

What's New in Pediatric Orthopaedic Trauma: The Upper Extremity.

BACKGROUND: Upper extremity fractures are the most common fractures in children. Many high-quality studies have been reported regarding operative and nonoperative treatment of different upper extremity fractures in children. This review will summarize the literature on 4 major upper extremity fractures in children over the past 5 years. METHODS: PubMed and Embase databases were queried for publications in the English language on supracondylar humerus (SCH) fractures, lateral humeral condyle fractures, medial epicondyle fractures, and clavicle fractures from January 1, 2013 until November 1, 2018. Papers believed to yield significant findings to our profession were included in this review. RESULTS: A total of 1150 studies were related to the search terms, and after cursory assessment, the authors elected to fully review 30 papers for this publication: 12 related to SCH fractures, 10 related to lateral condyle humerus fractures, 3 related to medial epicondyle humerus fractures, and 5 involving clavicle fractures. The level of evidence for these studies was either level III or IV. CONCLUSIONS: SCH fractures are increasingly being treated at trauma centers or pediatric hospitals in the United States. The rate of open reduction in this fracture type is decreasing overall, but the flexion type SCH fractures (especially in the setting of ulnar nerve injury) continue to be at increased risk of requiring open reduction. There has been a paradigm shift in the treatment of lateral condyle humerus fractures, wherein authors have demonstrated successful management with closed reduction and percutaneous pinning when an adjunct arthrogram is performed demonstrating articular congruity. More studies are needed to find the optimal treatment for displaced medial epicondyle and clavicle fractures in adolescents, as results to date do not necessarily mirror those seen in the adult population. LEVEL OF EVIDENCE: Level IV.

Supraclavicular Brachial Plexus Block for Upper Limb Fracture Fixation:A Comparison of Nerve Stimulation, Ultrasound-Guided Technique and a Combination of both Techniques.

BACKGROUND: Nerve stimulation and ultrasound-guided techniques for supraclavicular block have been widely studied but information on the effectiveness of the combination of both techniques is limited. AIMS AND OBJECTIVES: This study compared the success rate and block characteristics of 3 techniques for supraclavicular brachial plexus block. DESIGN: Prospective randomized control trial. SETTING: In a tertiary teaching hospital in which patients scheduled for upper limb surgeries were recruited. MATERIALS AND METHODS: Sixty-six eligible patients were randomized into nerve stimulation, ultrasound-guided technique and their combination groups. Each received 40 ml of equal volumes of 0.5% plain bupivacaine and 2% lidocaine with 1:200,000 adrenaline. The primary outcome was the success rate of block and secondary outcomes included block characteristics. Data were subjected to statistical analysis (2-tailed tests), p-value < 0.05 significant. RESULTS: Seventy subjects were recruited, 66 completed the study. The success rates include: Ultrasound-guided technique + Nerve Stimulator (100%), Ultrasound-guided technique (90.9) and Nerve stimulator (81.8%). The onset of motor block was faster in the ultrasound guided technique (p = 0.043). The quality of sensory block and full motor block was superior in the combination group at 10th and 15th minute respectively. There were no complications and patient satisfaction with care was comparable in the groups. CONCLUSION: This study shows that combining ultrasound-guided technique and nerve stimulator resulted in the highest success rate, better sensory and motor block within 15minutes at C8 dermatome. Thus, hand surgeries can commence early, minimizing waiting time.

Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm.

BACKGROUND: Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS. METHODS: Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2. RESULTS: The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170-309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9-28.5). CONCLUSIONS: Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.

Individual Treatment of Delayed Distal Biceps Tendon Rupture: Case Report and Literature Review.

INTRODUCTION: Complicated elbow injuries (elbow injuries with bone and soft tissue injury) with distal biceps tendon ruptures (DBTRs) are not uncommon. There are several treatment modalities in different situations of injuries. In this article, we reported 3 successful individual treatments of delayed DBTR with complicated elbow injuries. MATERIALS AND METHODS: Three cases of complicated elbow injuries treated between 2010 and 2016 were reviewed. The delayed DBTR cases were summarized and treated. Mayo Elbow Performance Score value, range of motion, and visual analog scale score were used to assess outcomes after a minimum follow-up of 12 months. RESULTS: All 3 patients were male, aged 47 to 54 years (mean, 49.6 years). Patients received surgical treatments. After a mean follow-up of 13.7 months, in cases 1 and 2, Mayo Elbow Performance Score values improved by 50% and 100%, elbow flexion-extension arc were 115 degrees and 110 degrees, pronation-supination arc were 130 degrees and 120 degrees. Arthrodesis case reported pain relief; visual analog scale score for pain was 0 to 1. No postoperative complications were observed, and all patients were satisfied with the results. CONCLUSIONS: Individual treatment is advised in DBTR with complicated elbow injuries. Secondary treatment of DBTR can achieve satisfactory results using individual strategies depending on patients' overall condition.

Snapping of the annular ligament: a uncommon injury characterised by snapping or locking of the elbow with good surgical outcomes.

PURPOSE: Snapping annular ligament is an uncommon cause of lateral elbow pain. The purpose of this case series was to evaluate the clinical presentation and surgical outcomes for snapping annular ligament. METHODS: Included were 23 patients with snapping annular ligament who received surgical treatment between 2007 and 2016. There were two treatment groups with either resection (arthroscopic or open procedure, n = 15) or open annular ligament reconstruction (n = 8). Patients were assessed with the Mayo Elbow Performance Index and the Oxford Elbow Score. Preoperative and postoperative scores were compared with a paired t test. RESULTS: Pain was located laterally in nine patients (39.1%), anteriorly in three patients (13.0%), anterolaterally in two patients (8.7%), and diffusely in nine patients (39.1%). In total, 16 patients (69.6%) experienced a snapping sensation and ten patients (43.5%) locking of the elbow. According to the patients' reported outcomes, their symptoms improved significantly after both procedures. CONCLUSIONS: This is the largest case series in the literature on snapping annular ligament, an uncommon cause of lateral elbow pain. Good treatment results are expected with resection of the interpositioned part of the annular ligament or annular ligament reconstruction. LEVEL OF EVIDENCE: IV.

Factors Associated With the Cost of Care for the Most Common Atraumatic Painful Upper Extremity Conditions.

PURPOSE: To help strategize efforts to optimize value (relative improvement in health for resources invested), we analyzed the factors associated with the cost of care and use of resources for painful, nontraumatic conditions of the upper extremity. METHODS: The following were the most common upper extremity diagnoses in the Truven Health MarketScan database: shoulder pain and rotator cuff tendinopathy, shoulder stiffness, shoulder arthritis, lateral epicondylitis, hand arthritis, trigger finger, wrist pain, and hand pain. Multivariable generalized linear regression models were constructed accounting for sex, age, employment status, enrollment year, payer type, emergency room visit, joint injection, magnetic resonance imaging (MRI), physical or occupational therapy, outpatient and inpatient surgery, and insurance type. In addition, we assessed the use of the following 4 diagnostic and treatment interventions: joint injection, surgery, MRI, and physical or occupational therapy. RESULTS: Inpatient and outpatient surgery are the largest contributors to the total amount paid for most diagnoses. Older patients had more injections for the majority of conditions. CONCLUSIONS: Efforts to improve the value of care for nontraumatic upper extremity pain can focus on the relative benefits of surgery compared with other treatments and interventions to lower the costs of surgery (eg, office surgery and limited draping for minor hand surgery). TYPE OF STUDY/LEVEL OF EVIDENCE: Economic II.

Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety.

BACKGROUND: The aim of this study was to evaluate outcome and safety of free flaps to the upper extremity by pooled, summarized rates, compared with the existing pooled results of the lower extremity from literature, and to improve the level of evidence in a meta-analysis. METHODS: A literature search of PubMed and Embase was conducted addressing publications between January 2000 and April 2018. Publications were selected by inclusion/exclusion criteria on safety and outcome. Postoperative complications were statistically analyzed: flap loss, vessel thrombosis; recipient-site infection, hematoma, seroma, wound dehiscence, dysesthesia; donor-site morbidity. RESULTS: Two hundred and seventy-nine patients with 283 free flaps from 23 publications were extracted and eligible for this meta-analysis. The predominant donor site was the lower extremity (56%), with the anterolateral thigh flap as the major workhorse (30%). The summarized rate of total and partial flap loss was 6.0% (95% CI = 3.0-9.0%, PQ = 1.0000) and 8.0% (95% CI = 6.0-13.0%, PQ = 0.9973), respectively. The rate of arterial and venous thrombosis was 5.0% (95% CI = 3.0-9.0%, PQ = 0.9999) and 8.0% (95% CI = 9.0-37.0%, PQ = 0.9804), respectively. Complication rates of recipient site were: early infection with 7.0% (95% CI = 4.0-11.0%, PQ = 0.9788), hematoma with 6.0% (95% CI = 3.0-8.0%, PQ = 1.0000), seroma with 6.0% (95% CI = 4.0-10.0%, PQ = 0.9948), dehiscence with 7.0% (95% CI = 4.0-11.0%, PQ = 0.9988), and dysesthesia with 6% (95% CI = 4.0-10.0%, PQ = 0.9988). The rate of donor-site morbidity was 14% (95% CI = 8.0-21.0%, PQ = 0.0895). CONCLUSIONS: Soft tissue free flaps to the upper extremity have comparable success rates, but higher perioperative complication rates (e.g., partial flap loss, infection, and wound dehiscence) compared to the pooled data of lower extremity reconstruction from existing meta-analysis.

Reduced Anterolateral Thigh Flap Donor-Site Morbidity Using Incisional Negative Pressure Therapy.

BACKGROUND: Primary closure of the donor-site after harvest of a large anterolateral thigh flap (ALT) is associated with significant morbidity. Incisional negative pressure therapy (INPT) may decrease complications in high-risk incisions. This study assessed if the incidence of complications after primary closure of the ALT flap donor-site decreases with INPT. METHODS: Retrospective cohort study of a prospectively maintained database including patients who underwent upper and lower limb reconstruction, using an ALT free flap with primary closure of the donor-site. Two groups were defined: primary closure and INPT (study group) and primary closure with traditional dressings (control group). Nonparametric statistics were employed to identify prognostic factors, p < 0,05. RESULTS: Fifty-eight free ALT flaps in 58 patients (study group n = 28; control group n = 30) were included. Median flap width and length were 9 cm (range: 5-14) and 25 cm (range: 10-48), respectively. Median follow-up was 19 months (range: 3-78 months). No significant differences in age or flap size were identified in both groups (p > 0.05). The global complication rate was 7.14% (n = 2) in the INPT group, and 37% (n = 11) in the control group (p = 0.007). The study group had a lower dehiscence and skin necrosis rate (p < 0.05). Multivariate logistic regression analysis showed IPNT was associated with a significant reduction of donor-site complications (p = 0.006), especially in patients with defects > 8 cm (p = 0.003). CONCLUSION: In this cohort study the use of INPT significantly reduced the donor-site morbidity after ALT flap harvest.

Flow-Through Flaps in the Absence of an Arterial Gap for Extremity Defect Reconstruction: Minimizing the Donor-Site Morbidity.

BACKGROUND: The use of flow-through flaps was popularized in the early 1990s by Costa, Soutar and Lamberty in cases where an arterial gap was present or a major artery of the limb was damaged. We hypothesized that flow-through flaps can be used in all extremity reconstruction cases, where there is an indication for a free-flap, irrespective of the existence of arterial defect due to its many advantages while not increasing the flap loss significantly. METHODS: A retrospective study was performed by examining patient status and surgery reports of all patients who underwent extremity reconstruction with a flow-through flap from January 2011 to January 2016. This procedure was applied to all the patients, irrespective of the presence of an arterial gap. RESULTS: Forty-seven patients were included. The most frequently used flaps were the anterolateral thigh flap and the latissimus dorsi flap. Reconstructions were either posttraumatic or after oncological resection. Two cases of flap loss were encountered. The mean total operating time was 480 ± 153 minutes. The mean follow-up was 10 ± 3 months. There were no donor-site wound complications. CONCLUSION: Based on our results, the flow-through flap technique can be considered a safe alternative to the end-to-side technique for complex extremity defect reconstruction irrespective of the vascular status. The additional arterial anastomosis, even in the absence of an arterial gap or a vascular compromised extremity, did not increase the complication rate in the hands of experienced microsurgeons.