Transcutaneous and Direct Electrical Stimulation of Mouse Sciatic Nerve Accelerates Functional Recovery After Nerve Transection and Immediate Repair.

BACKGROUND: Electrical stimulation can accelerate peripheral nerve regeneration after injury and repair. Clinically, direct electrical stimulation (DES) may involve longer operating times, increasing risks of perioperative complications. Transcutaneous electrical stimulation (TCES) is a noninvasive alternative. In this study, we investigate how transcutaneous and DES compare for accelerating functional nerve recovery in a mouse sciatic nerve model. METHODS: Twenty-eight mice were divided into sham (n = 4), axotomy (n = 8), DES (n = 8), and TCES (n = 8) groups. After sciatic nerve transection and repair, the proximal nerve was subjected to DES or TCES at 20 Hz for 1 hour. Sciatic functional index was measured before the injury, and at weeks 1, 2, 4, 6, 8, 10, and 12 by walking-track analysis. Electrophysiological measures were taken at week 12. RESULTS: Kinematic studies showed significant improvement from the 8th week to the 12th week for both electrical stimulation groups compared with the axotomy group (P < 0.05), with no difference between the electrical stimulation groups. At the 12th week, both DES and TCES groups had significantly faster average conduction velocity than the axotomy group. CONCLUSIONS: Functional recovery was significantly better from 8 weeks onward in mice receiving either DES or TCES stimulation when compared with axotomy and repair alone. Transcutaneous electrical stimulation is a minimally invasive alternative treatment for accelerating functional recovery after peripheral nerve injury.

Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial.

BACKGROUND: Carpal tunnel syndrome and trigger finger are two of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures. METHODS: This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a numerical rating scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates. RESULTS: A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, anti-platelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared with the no tourniquet group (3.58 versus 1.68, respectively, P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (1.14 versus 1.90, respectively, P = 0.001). CONCLUSIONS: The application of wide awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.

Factors Influencing the Rate of Post-Mastectomy Breast Reconstruction in a Canadian Teaching Hospital.

BACKGROUND: Post-mastectomy breast reconstruction (PMBR) improves psychosocial well-being, quality of life, and body image. Reconstruction rates vary widely (up to 42% in the United States), but the few Canadian studies available report rates of 3.8% to 7.9%. We sought to evaluate the current state of breast reconstruction in 1 Canadian teaching hospital and factors determining patients' access to reconstruction. METHODS: We performed a retrospective chart review of all patients with breast cancer undergoing mastectomy alone or mastectomy and reconstruction at a Canadian hospital between 2010 and 2013. We calculated rates of breast reconstruction and compared patient characteristics between the 2 groups, and then performed a multiple logistic regression to determine factors increasing the odds of receiving breast reconstruction. RESULTS: A total of 152 patients underwent 154 total or modified radical mastectomies. We obtained a rate of PMBR of 21%, 14% immediate reconstruction, and 8% delayed. Statistical analysis showed that compared to patients with mastectomy alone, patients who received PMBR were significantly younger, with a larger percentage having bilateral mastectomies, non-invasive breast cancer, and residing further from the hospital. Patients less than 50 years old and those with bilateral mastectomies had significantly greater odds of having a reconstruction. CONCLUSIONS: Our Canadian tertiary care institution has a high volume of breast surgery and an active breast reconstruction team. However, the rate of immediate reconstruction remains low compared to similar centers in the United States. We recommend a united effort to increase awareness regarding PMBR and address common misconceptions hindering patients' access to breast reconstruction. LEVEL OF EVIDENCE: Epidemiologic study, Level III.

HISTORIQUE: La reconstruction mammaire postmastectomie (RMPM) améliore le bien-être psychosocial, la qualité de vie et l'image corporelle. Le taux de reconstructions varie considérablement (jusqu'à 42 % aux États-Unis), mais les quelques études canadiennes signalent un taux de 3,8 % à 7,9 %. Les auteurs ont cherché à évaluer la situation relative aux reconstructions mammaires dans un hôpital universitaire canadien et les facteurs déterminant l'accès à la reconstruction. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers de toutes les patientes atteintes d'un cancer du sein qui avaient subi une simple mastectomie ou une mastectomie suivie d'une reconstruction dans un hôpital canadien entre 2010 et 2013. Ils ont calculé le taux de reconstructions mammaires et comparé les caractéristiques des patientes des deux groupes, puis ont procédé à une régression logistique multiple pour déterminer les facteurs qui accroissaient la probabilité de reconstruction mammaire. RÉSULTATS: Au total, 152 patients ont subi 154 mastectomies radicales totales ou modifiées. Les chercheurs ont obtenu un taux de RMPM de 21 %, soit 14 % de reconstructions immédiates et 8 % de reconstructions tardives. L'analyse statistique a révélé que, par rapport aux patientes qui avaient subi une simple mastectomie, celles qui avaient reçu une RMPM étaient considérablement plus jeunes, et un plus fort pourcentage avait subi une mastectomie bilatérale, était atteint d'un cancer du sein non invasif et habitait loin de l'hôpital. Les patientes de moins de 50 ans et celles qui avaient subi une mastectomie bilatérale couraient une plus grande chance de subir une reconstruction. CONCLUSIONS: Notre établissement de soins tertiaires canadien effectue un fort volume de chirurgies du sein et dispose d'une équipe de reconstruction mammaire active. Cependant, le taux de reconstructions immédiates demeure faible par rapport à celui de centres similaires aux États-Unis. Nous recommandons d'adopter un front uni pour mieux faire connaître la RMPM et calmer les erreurs courantes qui empêchent les patients d'avoir accès à la reconstruction mammaire. Qualité des preuves : Étude épidémiologique, niveau III.

Extending the indications for primary nerve surgery in obstetrical brachial plexus palsy.

PURPOSE: This study identifies a small subset of patients with obstetrical brachial plexus palsy who, while they do not meet common surgical indications, may still benefit from primary nerve surgery. METHODS: Between April 2004 and April 2009, 17 patients were offered primary nerve surgery despite not meeting the standard surgical indications of the authors. The authors performed a retrospective analysis of these 17 patients using prospectively collected data. RESULTS: This group of 17 patients were identified as having poor shoulder function at about 9 months of age despite passing the Cookie Test. Fourteen patients underwent surgical intervention and three families declined surgery. All patients in the operative group regained some active external rotation after surgery. Five patients in this group have required further interventions. Two of the three patients for whom surgery was declined have had no subsequent spontaneous improvement in active external rotation. DISCUSSION: The commonly used indications for primary nerve surgery in obstetrical brachial plexus palsy may not adequately identify all patients who may benefit from surgical intervention. Patients who pass the Cookie Test but have poor spontaneous recovery of active shoulder movements, particularly external rotation, may still benefit from primary nerve surgery.

Passive contribution of the rotator cuff to abduction and joint stability.

PURPOSE: The purpose of this study is to compare shoulder joint biomechanics during abduction with and without intact non-functioning rotator cuff tissue. METHODS: A cadaver model was devised to simulate the clinical findings seen in patients with a massive cuff tear. Eight full upper limb shoulder specimens were studied. Initially, the rotator cuff tendons were left intact, representing a non-functional rotator cuff, as seen in suprascapular nerve paralysis or in cuff repair with a patch. Subsequently, a massive rotator cuff tear was re-created. Three-dimensional kinematics and force requirements for shoulder abduction were analyzed for each condition using ten abduction cycles in the plane of the scapula. RESULTS: Mediolateral displacements of the glenohumeral rotation center (GHRC) during abduction with an intact non-functioning cuff were minimal, but massive cuff tear resulted in significant lateral displacement of the GHRC (p < 0.013). Similarly, massive cuff tear caused increased superior migration of the GHRC during abduction compared with intact non-functional cuff (p < 0.01). From 5 to 30° of abduction, force requirements were significantly less with an intact non-functioning cuff than with massive cuff tear (p < 0.009). CONCLUSION: During abduction, an intact but non-functioning rotator cuff resulted in decreased GHRC displacement in two axes as well as lowered the force requirement for abduction from 5 to 30° as compared with the results following a massive rotator cuff tear. This provides insight into the potential biomechanical effect of repairing massive rotator cuff tears with a biological or synthetic "patch," which is a new treatment for massive cuff tear.

Final results of grafting versus neurolysis in obstetrical brachial plexus palsy.

BACKGROUND: The authors previously showed that neurolysis in obstetrical brachial plexus palsy resulted in improved function in some patients at 1 year's follow-up. In this study, the hypothesis that the long-term outcome of neuroma-in-continuity resection and nerve grafting yields better results than neurolysis was tested. METHODS: Obstetrical brachial plexus palsy patients treated with primary nerve surgery with a minimum follow-up of 4 years were studied. Patients were classified as undergoing neurolysis (n = 16) or resection and grafting (n = 92) and separated into Erb's or total palsy groups. The Active Movement Scale was used for patient evaluation. Changes in Active Movement Scale scores were analyzed using the Wilcoxon signed rank test. Fifteen movements were tested, and the proportion of patients in each group with scores deemed functionally useful (6 or 7) was compared using McNemar's exact test. RESULTS: After 4 years' follow-up, Erb's palsy neurolysis patients showed no improvement in function. Conversely, Erb's palsy grafting patients had improved function in seven movements. Total palsy neurolysis patients showed no improvement in function, whereas grafted patients showed improved function in 11 of 15 movements. CONCLUSIONS: Early improvements in function produced by neurolysis in Erb's palsy were not sustained over time. Neuroma-in-continuity resection and nerve grafting for both Erb's and total palsy produced significant improvements in Active Movement Scores and in the proportion of patients demonstrating functionally useful scores. Neurolysis as a complete surgical treatment for obstetrical brachial plexus palsy should be abandoned in favor of neuroma resection and nerve grafting.