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BACKGROUND: Studies addressing the utility of hemoglobin A1c (HbA1c) levels in predicting surgical complications have reported mixed results. In practice, many surgeons use HbA1c cutoffs to determine a patient's eligibility for elective surgery. The literature is especially limited in evaluating HbA1c as a risk factor in elective hand and upper extremity surgery. This study aims to evaluate the association of elevated HbA1c levels with the risk of postoperative complications in elective hand and upper extremity surgeries. METHODS: We performed a chart review of patients who underwent these elective operations performed by a single surgeon at a single institution. The outcomes of 930 surgeries were collected up to three months postoperatively, 334 of which had pre or postoperative HbA1c levels recorded. All 930 surgeries were evaluated for association between diabetes mellitus (DM) and complication rates using Fisher's exact test, absolute risk, odds ratio, and regression analysis. RESULTS: DM alone was not associated with an increased risk of postoperative complications. In diabetic patients with both diagnosed DM and HbA1c > 10%, the absolute risk of complications was significantly higher. None of the other HbA1c categories (between 6.5% and 10%) were associated with significantly higher odds of complications in patients with diagnosed DM. CONCLUSIONS: In the context of elective hand and upper extremity surgery, glycemic control (measured by HbA1c) should be included as an element of the surgical preparedness algorithm, rather than an independent disqualifying factor.
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Metacarpal fractures are common and may require operative treatment; however, there is no gold standard fixation technique. K-wires are used for simplicity and flexibility but require immobilization and can lead to complications. Dorsal plating provides greater stability than K-wires but is subject to its own limitations. Intramedullary threadless nails have reduced time to union and improved range of motion (ROM) but may not provide the stability of plating. Intramedullary screws allow rapid return to activity and increased stability; however, compression forces may shorten metacarpals, producing non-anatomic reduction. The ExsoMed INnateTM threaded intramedullary nail (ExsoMed, Aliso Viejo, CA, USA) was developed with tall threads, a diameter fitting the metacarpal canal cortical purchase, stability, and no compression to prevent fracture displacement and shortening. We designed a prospective study to evaluate INnateTM nail fixation in metacarpal fractures. Visual analog scale (VAS) pain score, total active motion (TAM), radiographic union, and return to normal activity were recorded at each postoperative visit. Descriptive statistics were performed for endpoints. Fifty-eight patients were included with a median age of 38.7 years. The INnateTM nail was used in 80 fractured metacarpals. The 4th and 5th metacarpals were most frequently involved. The most common mechanisms of injury were blunt trauma and motor vehicle collisions. Approximately 31% of patients had multiple, concurrent fractures (16 patients required two nails; two required three nails). The mean follow-up was 9.9 weeks. The mean time to radiographic union was 9.1 weeks. The final visual analog scale (VAS) pain score was 1.1. The mean time to return to work and/or normal activities was 9.7 weeks, and the mean percentage of normal activity resumed was 89.1%.
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BACKGROUND AND OBJECTIVES: The ability to maximize corpectomy cage endcap size and vertebral endplate coverage after corpectomy for lumbar burst fractures (L1-L5) is limited by the presence of lumbar nerve roots and the larger cross-sectional area of the lumbar endplates relative to the restrictive corridor for cage insertion. This work aims to provide details and clinical examples of a novel operative technique for 3-column reconstruction and stabilization of comminuted lumbar burst fractures. METHODS: Through a standard posterior midline approach and following posterior instrumentation and lateral extracavitary corpectomy, an in-situ assembly of a modular corpectomy cage that respects adjacent neural structures, restores segmental alignment, and maximizes endplate coverage across a lordotic segment is completed. RESULTS: Radiographic evidence of anatomic spinal reconstruction and stabilization with complete or near-complete endplate coverage without incurrence of new clinical deficit after this novel treatment of lumbar burst fractures. CONCLUSION: The fixation approach described in this report may be a valuable modification to a long-standing technique used for treating comminuted lumbar burst fractures (L1-L5) from a posterior-only approach without incurring additional neurological deficits and by improving endplate and apophyseal ring coverage.
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Procedimentos de Cirurgia Plástica , Titânio , Humanos , Titânio/uso terapêutico , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgiaRESUMO
Background Peripheral nerve function is often difficult to assess given the highly variable presentation and subjective patient experience of nerve injury. If nerve assessment is incomplete or inaccurate, inappropriate diagnosis and subsequent treatment may result in permanent dysfunction. Objective As our understanding of nerve repair and generation evolves, so have tools for evaluating peripheral nerve function, recovery, and nerve-related impact on the quality of life. Provocative testing is often used in the clinic to identify peripheral nerve dysfunction. Patient-reported outcome forms provide insights regarding the effect of nerve dysfunction on daily activities and quality of life. Methods We performed a review of the literature using a comprehensive combination of keywords and search algorithms to determine the clinical utility of different provocative tests and patient-reported outcomes measures in a variety of contexts, both pre- and postoperatively. Results This review may serve as a valuable resource for surgeons determining the appropriate provocative testing tools and patient-reported outcomes forms to monitor nerve function both pre- and postoperatively. Conclusion As treatments for peripheral nerve injury and dysfunction continue to improve, identifying the most appropriate measures of success may ultimately lead to improved patient outcomes.
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Objective Injuries resulting from trauma or tumor resection may cause length alterations in the bones of the upper extremities (UE) requiring reconstruction. Direct contralateral bone is often used to determine the appropriate length for reconstruction but fails to account for potential asymmetry. Given the paucity of data assessing asymmetry in living populations and the need for accurate length approximation, we developed a study evaluating UE long bone asymmetry using radiographic imaging in living subjects. Methods Bilateral X-ray images previously obtained for traumatic injury or chronic osseous conditions were retrospectively collected for adult subjects (ages 18-81). After screening, 61 patients met the inclusion criteria: 28 radii, 29 ulnae, and 19 humeri. Three serial measurements were taken, and the median was used for subsequent analysis. Wilcoxon signed-rank tests were performed to assess differences in contralateral bone lengths. Bootstrapping was utilized to obtain sample sizes of 200, 500, and 1000 for each bone. Results The difference in mean absolute length was 27.0 mm for the humerus, 8.6 mm for the radius, and 7.5 mm for the ulna. Neither the left side nor the right side was significantly longer for any bone. In 57.9% (11/19) of patients, the right humerus was longer than the left; in 60.7% (17/28), the right radius was longer than the left; and in 48.3% (14/29), the right ulna was longer than the left. All other measurements showed the left was longer than the right. Wilcoxon signed-rank tests did not find significant differences between contralateral pairs in any direct measurement group. In bootstrap samples, significant differences in length (p ≤ 0.05) were seen in all samples (n = 200, 500, and 1000) for both humerus and radius but only the 1000 sample group for the ulna. Conclusions Direct contralateral measure may be an appropriate method of length estimation for the humerus, radius, and ulna in post-industrial humans.
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Revision nerve decompression remains a challenge for surgeons. Avive Soft Tissue Membrane is processed human umbilical cord membrane that may reduce inflammation and scarring, thereby improving tissue gliding. Although synthetic conduits have been reported in revision nerve decompression, the use of Avive has not. Methods: Prospective study of revision nerve decompression with Avive application. VAS pain, two-point discrimination, Semmes-Weinstein, pinch and grip strength, range of motion, Quick Disability of Arm, Shoulder & Hand (QuickDASH), and satisfaction were recorded. Using a propensity-matched cohort, VAS pain and satisfaction were retrospectively collected to compare with cohort outcomes. Results: In the Avive cohort, 77 patients (97 nerves) were included. Mean follow-up was 9.0 months. Avive was applied to the median nerve in 47.4%, ulnar nerve in 39.2%, and radial nerve in 13.4%. VAS pain was 4.5 preoperatively and 1.3 postoperatively. S4 sensory recovery was achieved in 58% of patients, S3+ in 33%, S3 in 7%, S0 in 2%, and improvement from baseline in 87%. Strength improved in 92%. Mean total active motion was 94.8%. Mean QuickDASH score was 36.1, and 96% reported improved or resolved symptoms. Preoperative pain was not significantly different between Avive cohort and controls (P = 0.618). Postoperative pain was significantly lower in cohort patients (1.3 ± 2.2 versus 2.7 ± 3.0, P = 0.001). In the Avive cohort, more had improved or resolved symptoms (P < 0.0001). Clinically important improvement in pain was reported in 64.9% of Avive group patients versus 40.8% of controls (P = 0.002). Conclusion: Avive contributes to improved outcomes in revision nerve decompression.
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Carpometacarpal (CMC) fracture-dislocations are uncommon hand injuries, with few studies available regarding their treatment. The current operative treatment options include fixation with K-wires, mini-screws, or plates, though there is no standardized approach because of varying injury patterns and complications associated with each device. The INnate™ threaded intramedullary nail is a relatively novel treatment option that has shown promise in metacarpal fracture fixation by facilitating faster mobilization and recovery with enhanced rotational stability and no compression to prevent fracture displacement and shortening. This study assesses the efficacy of the INnate™ nail for fixation of CMC fracture-dislocations of the second through fifth joints. Nine patients with fourteen CMC fracture-dislocations treated with the INnate™ nail at the University Medical Center between 2019 and 2021 were enrolled in the study. We evaluated postoperative outcomes in terms of pain, total active range of motion (TAM), and return to normal activities. Of the nine patients, seven returned for follow-up. The average time to radiographic union was 11.5 weeks. At final follow-up, no patient reported pain (n = 6). Four patients had 100% TAM, 1 had 95% TAM, and 1 had 25% TAM. The average percentage of normal activity resumed was 84.0% (n = 5). No significant complications were reported. One patient had a dorsal spanning plate; hence, we were unable to record outcomes measures regarding the CMC injury. An additional patient had diminished ROM of the injured hand, but his last follow-up was only 1 month postop. Our pilot data overall suggest that the INnate™ threaded intramedullary nail has the potential to improve treatment algorithms for CMC fracture-dislocations.
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Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.
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Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.
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Zone II flexor tendons present unique challenges for repair because of their complex anatomy in a confined space. The approach for zone II injuries is often dictated by preexisting traumatic skin lacerations, with a midaxial or volar approach being most common. In some injuries, this approach is not viable, and alternative approaches must be considered. A 45-year-old man presented with a traumatic crush injury that caused complete disruption of the skin, tendon, capsule, collateral ligament, and volar plate and laceration of the flexor digitorum profundus in zone II near the proximal interphalangeal joint. Given the large, near-circumferential zone of injury, we used the traumatic dorsal wound for the flexor tendon for repair. There are no reports of this approach in the literature. Postoperatively, the proximal interphalangeal joint was immobilized for 6 weeks with a K-wire. The patient was followed in the clinic and prescribed occupational therapy. At the 4-month postoperative visit, the patient had a healed incision, no signs of infection, and intact median/radial sensations. Functional testing showed a loose composite fist, improved range of motion, and 2-cm tip-to-palm deficiency of the index finger. Grip strength was 85 lb in the right hand and 60 lb in the left hand. Although patients are not always expected to regain full function, their postoperative course may be further complicated by adhesion and the need for tenolysis. Given these historical complications of tendon repair and our patient's ability to return to work with satisfactory functional outcomes, this approach may be a viable option for treating this unique injury pattern. [Orthopedics. 2022;45(4):e216-e219.].
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Traumatismos dos Dedos , Procedimentos Ortopédicos , Traumatismos dos Tendões , Traumatismos dos Dedos/diagnóstico por imagem , Traumatismos dos Dedos/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Tendões/cirurgiaRESUMO
INTRODUCTION: The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications. METHODS: PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data. RESULTS: A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers). CONCLUSION: Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario. LAY SUMMARY: Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.
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INTRODUCTION: When the metacarpal bones sustain severe osseous injury requiring reconstruction, functional recovery relies on the precise distribution of tension throughout full range of motion. While the small scale of hand structures compounds the effects of altering normal anatomy, literature lacks consensus recommendations for the acceptable degree of length alteration and/or appropriate methods of length estimation in reconstructive procedures. Length asymmetry has been reported in human metacarpal bones; however, studies assessing this phenomenon in living subjects with attention to functional implications or length prediction are lacking. METHODS: Hand X-rays were obtained for 34 patients aged 25-80 without history of metacarpal trauma, joint degeneration, or pathologic bone metabolism. A scaled bivariate model predicted metacarpal length using an ipsilateral paired metacarpal and matching contralateral ratio: Estimate_Dx_R = Median_Dy_R * (Median_Dx_L/Median_Dy_L). A second set of predictions used the contralateral metacarpal as a control. Pearson correlation coefficients, paired t-tests, and chi-square tests evaluated the symmetry between bilateral metacarpal lengths and paired metacarpal ratios as well as the accuracy of each predictive method. RESULTS: The contralateral control and target metacarpal differed significantly in digits 1, 2, 3, and 5. No significant difference in matched metacarpal ratios of the right and left hands was found. For all digits except 5D, bivariate model predictions generated were more strongly correlated with actual target length. Chi-square tests did not detect a significant difference in predictive value of the two models. CONCLUSION: The scaled bivariate model we describe may be useful and economic in generating accurate length estimates of metacarpals for reconstructive procedures.
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BACKGROUND: Treatment of patients with traumatic axonotmesis presents challenges. Processed human umbilical cord membrane has been recently developed with improved handling and resorption time compared to other amniotic membrane wraps, and may be beneficial in nerve reconstruction. This study evaluates postoperative outcomes after traumatic peripheral nerve injury after placement of commercially available processed human umbilical cord membrane. METHODS: We performed a prospective, single-center pilot study of patients undergoing multi-level surgical reconstruction for exposed, non-transected peripheral nerve. Functional outcomes including pain, range of motion, pinch and grip strength, and the QuickDASH and SF-36 patient-reported outcome measures were recorded, when possible, at the 1-week and 3, 6, and 9 months postop visit. One-tailed paired t-tests were performed to evaluate outcome improvement at final follow-up. RESULTS: Twenty patients had processed human umbilical cord membrane placement without surgical complications. Mean follow-up was 7.5 months (range: 3-10 months) and mean age was 39 years (range: 15-65). Twelve (67%) patients were male, and the majority of placement sites were in the upper extremity (85%). Mean preoperative visual analog scale pain score was significantly reduced at most recent follow-up, as were QuickDASH scores. All patients had improved functional outcomes at the 9-month follow-up, and SF-36 outcomes at 9 months showed improvement across all dimensions. CONCLUSION: This study indicates that processed human umbilical cord membrane may be a useful adjunct in nerve surgery with noted improvements in postoperative function, pain, and patient-reported outcome measures. Future studies are needed to assess long-term outcomes after traumatic nerve injury treated with processed human umbilical cord membrane.
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Few multifocal hand chondrosarcomas have been reported. To our knowledge, this report is the first to describe multifocal hand chondrosarcoma in a patient with no evidence of prior enchondroma, Ollier's disease, or Maffucci syndrome.
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ABSTRACT: Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.
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COVID-19 , Procedimentos de Cirurgia Plástica , Humanos , Procedimentos Neurocirúrgicos , Pandemias , SARS-CoV-2RESUMO
Primary malignant tumors of the sternum are rare among bone tumors. Even with radical resection, the survival rate for sternal tumors remains low. Resection often results in significant bone defects in the chest wall, and reconstruction must provide adequate protection for pulmonary and respiratory structures. Flexible materials have historically been used for sternal reconstructions following failed sternotomies in cardiac surgery. Although these have had some success, they fail to provide adequate support for patients undergoing reconstruction secondary to tumor resection, who are otherwise healthy and active. Although rigid materials offer greater protection, they frequently cause chronic pain and respiratory complications. More recently, bone grafts have been used to reconstruct sternal defects, and the limited published reports are promising. METHODS: We present the case of a patient diagnosed with an extramedullary solitary bone plasmacytoma who underwent a sternal resection and reconstruction with an autogenous bone graft taken from the iliac crest and secured in place with 5 plates (3 sternal and 2 mandibular). RESULTS: At 9-month follow-up, bone marrow biopsy showed no evidence of multiple myeloma. X-ray, computed tomography, and Pulmonary Function Test (PFT) scans confirmed graft stability, and the patient has returned to normal activities. CONCLUSIONS: Sternal resection and reconstruction is an effective method for treating extramedullary solitary plasmacytoma when radiation is ineffective. In cases of significant segmental defects, iliac crest bone graft may be a viable option for repairing sternal defects following tumor resection.