Patient-Reported and Clinical Outcomes After Tendon Autograft Reconstruction of the Thumb Ulnar Collateral Ligament.

PURPOSE: This study aimed to report clinical and patient-reported outcomes collected in a registry after thumb ulnar collateral ligament (UCL) reconstruction with a free tendon autograft. Furthermore, the patient-reported outcomes of patients with persistent instability after reconstruction and patients with concomitant metacarpophalangeal joint arthritis diagnosed during surgery were analyzed. METHODS: Patients undergoing reconstruction with a tendon autograft between December 2011 and February 2021 were included. Michigan Hand Outcomes Questionnaire (MHQ) scores at baseline were compared with those at 3 and 12 months after surgery. Stability was tested at 3 months after surgery. Tip and key pinch strength and metacarpophalangeal joint range of motion were measured at baseline and 12 months after surgery. RESULTS: We included 31 patients with thumb UCL insufficiency or failed UCL surgery who underwent reconstruction. The MHQ total score improved significantly from 62 at baseline to 75 at 3 months and continued to increase to 84 at 12 months after surgery. The MHQ function and pain scores improved significantly from intake to 3 and 12 months after surgery. Twenty-six of 31 patients (84%) regained postoperative metacarpophalangeal stability. Key pinch strength improved significantly 12 months after surgery from 5.2 kg at baseline to 6.4 kg at 12 months. The MHQ total, pain, and function scores of patients with persistent instability remained similar from baseline to 12 months after surgery. In four patients with metacarpophalangeal arthritis, the MHQ total and pain score improved significantly from baseline to 3 and 12 months after surgery. CONCLUSIONS: Patient-reported outcomes, including pain and function, improved after thumb UCL reconstruction with a tendon autograft. Although the sample size of patients with thumb metacarpophalangeal arthritis diagnosed during surgery was small, they reached adequate patient-reported outcomes at 12 months after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment.

PURPOSE: Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied. METHODS: The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year. RESULTS: A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks. CONCLUSIONS: Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Two-, Three-, or Four-Corner Arthrodesis for Midcarpal Osteoarthritis: A Systematic Review and Meta-Analysis.

PURPOSE: Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis. METHODS: A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications. RESULTS: Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group. CONCLUSIONS: Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Patient-Reported Outcomes and Function After Surgical Repair of the Ulnar Collateral Ligament of the Thumb.

PURPOSE: The purpose of this study was to report prospectively collected patient-reported outcomes of patients who underwent open thumb ulnar collateral ligament (UCL) repair and to find risk factors associated with poor patient-reported outcomes. METHODS: Patients undergoing open surgical repair for a complete thumb UCL rupture were included between December 2011 and February 2021. Michigan Hand Outcomes Questionnaire (MHQ) total scores at baseline were compared to MHQ total scores at three and 12 months after surgery. Associations between the 12-month MHQ total score and several variables (i.e., sex, injury to surgery time, K-wire immobilization) were analyzed. RESULTS: Seventy-six patients were included. From baseline to three and 12 months after surgery, patients improved significantly with a mean MHQ total score of 65 (standard deviation [SD] 15) to 78 (SD 14) and 87 (SD 12), respectively. We did not find any differences in outcomes between patients who underwent surgery in the acute (<3 weeks) setting compared to a delayed setting (<6 months). CONCLUSIONS: We found that patient-reported outcomes improve significantly at three and 12 months after open surgical repair of the thumb UCL compared to baseline. We did not find an association between injury to surgery time and lower MHQ total scores. This suggests that acute repair for full-thickness UCL tears might not always be necessary. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Routinely-Collected Outcomes of Proximal Row Carpectomy.

PURPOSE: To describe patient-reported pain and function 12 months after proximal row carpectomy (PRC). Secondary outcomes included return to work, grip strength, range of wrist motion, satisfaction with treatment results, and complications. METHODS: This cohort study was part of the British Society for Surgery of the Hand Studyathon 2021, using ongoing routinely-collected data of 304 eligible patients who underwent PRC (73% scapholunate advanced collapse, 11% scaphoid nonunion advanced collapse wrist; 11% Kienböck, 5% other indications) from Xpert Clinics, the Netherlands between 2012-2020. The primary outcome was the Patient Rated Wrist/Hand Evaluation total score (range, 0-100, lower scores indicate better performance). RESULTS: Of the 304 patients, the primary outcome was available in 217 patients. The total Patient Rated Wrist/Hand Evaluation score improved from 60 (95% confidence interval [CI], 57-63) to 38 (95% CI, 35-41) at 3 months, and 26 (95% CI, 23-29) at 12 months. The pain and function subscales improved by 18 (95% CI, 17-20) and 16 (95% CI, 14-18) points, respectively. At 12 months, 82% had returned to work at a median time of 12 (95% CI, 9-14) weeks following PRC. Grip strength did not improve. Wrist flexion and extension demonstrated a clinically irrelevant decrease. Satisfaction with treatment result was excellent in 27% of patients, good in 42%, fair in 20%, moderate in 6%, and poor in 5%. Complications occurred in 11% of patients, and conversion to wrist arthroplasty occurred in 2 patients. CONCLUSION: A clinically relevant improvement in patient-reported pain and function was observed at 3 months after PRC, with continued improvement to 12 months. These data can be used for shared-decision making and expectation management. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Prevalence and Risk Factors for Postoperative Complications Following Open A1 Pulley Release for a Trigger Finger or Thumb.

PURPOSE: Although A1 pulley release is an effective treatment to reduce pain and improve hand function, complications may occur. More insight into risk factors for complications is essential to improve patient counseling and potentially target modifiable risk factors. This study aimed to identify factors associated with complications following A1 pulley release. METHODS: Patients completed baseline questionnaires, including patient characteristics, clinical characteristics, and the Michigan Hand outcomes Questionnaire. We retrospectively reviewed medical records to identify complications classified using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions tool. Grade 1 complications comprise treatment with additional hand therapy, splinting, or analgesics, grade 2 treatment with antibiotics or steroid injections, grade 3A minor surgical treatment, grade 3B major surgical treatment, and grade 3C complex regional pain syndrome. Logistic regression analyses were performed to examine the contribution of patient characteristics, clinical characteristics, and patient-reported outcome measurement scores to complications. RESULTS: Of the included 3,428 patients, 16% incurred a complication. The majority comprised milder grades 1 (6%) and 2 (7%) complications, followed by more severe grades 3B (2%), 3C (0.1%), and 3A (0.1%) complications. A longer symptom duration (standardized odds ratio [SOR], 1.09), ≥3 preoperative steroid injections (SOR, 3.22), a steroid injection within 3 months before surgery (SOR, 2.02), and treatment of the dominant hand (SOR, 1.34), index finger (SOR, 1.65), and middle finger (SOR, 2.01) were associated with a higher complication rate. CONCLUSION: This study demonstrates that ≥3 preoperative steroid injections and a steroid injection within 3 months before surgery were the most influential factors contributing to complications. These findings can assist clinicians during patient counseling and may guide preoperative treatment. We recommend that clinicians should consider avoiding steroid injections within 3 months before surgery and to be reluctant to perform >2 steroid injections. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Management of Recurrent Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis.

PURPOSE: Few comparisons have been performed between the outcomes of surgical techniques for recurrent carpal tunnel syndrome. Using a meta-analysis, this study aimed to compare the outcomes of different surgical techniques using the Boston Carpal Tunnel Questionnaire (BCTQ) and visual analog scale (VAS) for pain as outcomes. METHODS: The following categories were used to define the study's inclusion criteria: population, intervention, comparator, outcomes, and study design. Studies were examined by 2 reviewers, and the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed. The studies were assigned to 1 of the following treatment groups: decompression with or without neurolysis, autologous fat transfer, hypothenar fat pad, pedicled or free flap, and "other." For our primary outcome, we compared improvement using the BCTQ and VAS for pain between the treatment groups. For our secondary outcome, postoperative BCTQ and VAS pain values were compared. RESULTS: Fourteen studies were included: 5 case series with postoperative data only and 9 pre-post studies without a control group. With regard to our primary outcome, the studies reported an average improvement of 1.2 points (95% confidence interval [CI][1.5, 0.9]) on a scale of 1-5 on the symptoms severity scale (SSS) of the BCTQ, 1.9 points (95% CI [1.37, 0.79]) on a scale of 1-5 on the function severity scale of the BCTQ, and 3.8 points (95% CI [4.9, 2.6]) on a scale of 1-10 on the VAS for pain. We only found significantly lesser improvement in the "other" treatment group than in the hypothenar fat pad group and autologous fat transfer group using the SSS. The hypothenar fat pad group had the best reported postoperative SSS score of 1.75 (95% CI [1.24, 2.25]), function severity scale score of 1.55 (95% CI [1.20, 1.90]), and VAS pain score of 1.45 (95% CI [0.83, 2.07]). CONCLUSIONS: All the techniques showed clinically important improvements in all the outcomes. We found lesser improvement in the "other" treatment group than in the hypothenar fat pad group and autologous fat transfer group using the SSS. We found that the hypothenar fat pad group had the best reported postoperative values in our secondary analysis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparing Patient-Reported Outcomes on Three-Ligament Tenodesis between Partial and Complete Scapholunate Ligament Injuries: A Cohort Study.

PURPOSE: Multiple studies report outcomes after 3-ligament tenodesis (3-LT) in treating traumatic scapholunate interosseous ligament injury (SLIL). However, investigators do not differentiate between patients with partial or complete SLIL injury. The relation between the extent of SLIL disruption and surgical outcomes and if this should be considered when treating a patient with SLIL injury remains unknown. We aimed to evaluate differences in patient-rated wrist evaluation (PRWE) scores, satisfaction and return to work between patients with partial or complete chronic traumatic SLIL injury treated with 3 ligament tenodesis at 12 months after surgery. METHODS: All patients with chronic SLIL injury (partial and complete) who were treated with 3-LT at our clinic and received the same postoperative management between December 2011 and December 2019 were studied. Only patients who had completed the PRWE and return to work questionnaires preoperatively and 12 months after surgery were included. Patients were allocated to the partial (classified as Geissler 2 or 3) or complete SLIL injury group (classified as Geissler 4) by retrospectively assessing wrist arthroscopy reports. RESULTS: Thirty-nine patients with partial and 90 with complete SLIL injuries were included. At 1-year follow-up, PRWE scores had significantly improved in both groups. When adjusting for clinical baseline characteristics, there was no statistically significant difference between patients with partial or complete SLIL injury. Patients with complete SLIL injury had a 70% higher return to work within the first 12 months after 3-LT; however, satisfaction with the treatment result was similar for both study groups 1 year after surgery. CONCLUSIONS: Patients with complete and partial traumatic SLIL injury report better PRWE total scores at 12 months after 3-LT, but there was no statistically significant difference between the groups in PRWE scores or satisfaction with the treatment result. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements.

PURPOSE: To evaluate the patient-reported outcome measures of patients with primary cubital tunnel syndrome and to assess whether they are affected by preoperative symptom severity. METHODS: Patients who underwent simple decompression for primary cubital tunnel syndrome were selected from a prospectively maintained database. Outcome measurements consisted of the Boston Carpal Tunnel Questionnaire at intake and at 3 and 6 months after surgery. Also, 6 months after surgery, the patients received a question about their satisfaction with the treatment result. To determine a possible influence of preoperative symptom severity on postoperative outcomes, the sample was divided into quartiles based on symptom severity at intake. RESULTS: One hundred and forty-five patients were included in the final analysis. On average, all patients improved on the Boston Carpal Tunnel Questionnaire. The subgroup of patients with the mildest symptoms at intake did not improve significantly on symptom severity but did improve significantly on their functional status. In addition, the patients with the most severe symptoms at intake did improve on both aspects. Moreover, no difference in satisfaction with treatment result between the severity of symptoms at intake was found. CONCLUSIONS: The patients with the mildest symptoms at intake may not improve on symptom severity, but they do improve on functional status after simple decompression for cubital tunnel syndrome. In addition, patients with the most severe symptoms at intake do improve on both symptom severity and functional status. Moreover, all patients reported to be equally satisfied with the treatment result, which suggests that satisfaction is not dependent on the symptom severity at intake. Even those patients with both the mildest symptoms before surgery and the least improvement still seem to benefit from simple decompression. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Biomechanical Study Comparing Pulvertaft, Double Side-to-Side, and Locking Side-to-Side Tendon Suture Techniques.

PURPOSE: In this study, we present a single-sided locking side-to-side (STS) suture technique as a possible alternative for the Pulvertaft weave in tendon transfers. The aim of the study was to compare the biomechanical characteristics of the single-sided locking STS reconstruction with Pulvertaft and double-sided nonlocking STS reconstructions. METHODS: Twenty-four human cadaveric extensor digitorum communis tendons and 24 flexor digitorum superficialis tendons were randomly assigned to 1 of 3 groups, resulting in a total of 8 flexor tendons and 8 extensor tendons per group: Pulvertaft, double-sided nonlocking STS, and single-sided locking STS reconstructions. Load to failure was measured with a tensile testing machine. Increase in cross-sectional area was used as a measure of bulkiness at the reconstruction site. RESULTS: In extensor tendons, single-sided locking STS reconstructions showed a higher load to failure than Pulvertaft reconstructions, whereas no difference was found in load to failure between single-sided locking and double-sided nonlocking STS reconstructions. In flexor tendons, single-sided locking STS reconstructions showed a higher load to failure than Pulvertaft reconstructions. However, load to failure of single-sided locking STS reconstructions was less than double-sided nonlocking STS reconstructions. In both extensor and flexor tendons, the percent increase in cross-sectional area at the reconstruction site was higher in Pulvertaft reconstructions than single-sided locking STS reconstructions, whereas no difference was found between single-sided locking STS and double-sided nonlocking STS reconstructions. CONCLUSIONS: Single-sided locking and double-sided nonlocking STS reconstructions are suitable alternatives to the Pulvertaft technique for tendon transfers owing to a higher strength and less bulkiness. Because load to failure of both STS reconstructions did not differ in extensor tendon transfers, the single-sided locking STS reconstruction seems especially suitable for extensor tendon transfers. CLINICAL RELEVANCE: This study provides anatomical evidence that the single-sided locking STS reconstruction yields a higher strength and is less bulky than the Pulvertaft reconstruction in tendon transfers.

Carpal tunnel syndrome caused by an interosseous ganglion of the lunate.

We present a case of a 29-year-old woman with diffuse, unilateral wrist pain and carpal tunnel syndrome secondary to an interosseous ganglion of the lunate and aim to highlight uncommon aetiologies when assessing patients with atypical carpal tunnel symptoms.

Necrotizing Soft Tissue Infection Following a Closed Distal Radius Fracture: A Case Report and Literature Review.

Necrotizing soft tissue infections (NSTIs), characterized by extensive soft tissue destruction, are rare but life-threatening. We present a case of a NSTI in a healthy 65-year-old woman following a closed distal radius fracture. The patient presented with severe pain, fever, and lethargy 4 days after her index injury, with physical examination of the right upper limb revealing erythema and swelling to the mid-humeral level and blisters of the fingers and hand. Multiple surgical debridements were required to control the infection, which was caused by Streptococcus pyogenes. This case highlights the rapid progression and devastating consequences of NSTI, which can occur even in the setting of closed injuries in patients without comorbidities. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are crucial in managing this pathology.Level of Evidence: Level 5.

Surgical Treatment of Neuropathic Chronic Postherniorrhaphy Inguinal Pain: A Systematic Review and Meta-Analysis.

Background/Objectives: Neuropathic chronic postherniorrhaphy inguinal pain (CPIP) is a serious adverse outcome following inguinal hernia repair surgery. The optimal surgical treatment for neuropathic CPIP remains controversial in the current literature. This systematic review aims to evaluate the effectiveness of various surgical techniques utilized to manage neuropathic CPIP. Methods: The electronic databases Medline, Embase, Web of Science, Cochrane Central, and Google Scholar were searched. Inclusion criteria were defined to select studies reporting on the efficacy of surgical interventions in patients with neuropathic CPIP. The primary outcome was postoperative pain relief, as determined by postoperative numerical or nonnumerical pain scores. Results: Ten studies met the inclusion criteria. Three surgical techniques were identified: selective neurectomy, triple neurectomy, and targeted muscle reinnervation. Proportions of good postoperative results of the surgical techniques ranged between 46 and 88 percent. Overall, the surgical treatment of neuropathic CPIP achieved a good postoperative result in 68 percent (95% CI, 49 to 82%) of neuropathic CPIP patients (n = 244), with targeted muscle reinnervation yielding the highest proportion of good postoperative results. Conclusions: The surgical treatment of neuropathic CPIP is generally considered safe and has demonstrated effective pain relief across various surgical techniques. Targeted muscle reinnervation exhibits considerable potential for surpassing current success rates in inguinal hernia repair surgery.

Anatomy of the Superficial Radial Nerve and Its Target Nerves for Targeted Muscle Reinnervation: An Anatomical Cadaver Study.

BACKGROUND: Targeted muscle reinnervation (TMR) is a surgical procedure for treating symptomatic neuroma, in which the neuroma is removed and the proximal nerve stump is coapted to a donor motor branch innervating a nearby muscle. This study aimed to identify optimal motor targets for TMR of the superficial radial nerve (SRN). METHODS: Seven cadaveric upper limbs were dissected to describe the course of the SRN in the forearm and motor nerve supply-number, length, diameter, and entry points in muscle of motor branches-for potential recipient muscles. RESULTS: The radial nerve provided three (three of six) motor branches, two (two of six) motor branches, or one (one of six) motor branch to the brachioradialis muscle, entering the muscle 21.7 ± 17.9 to 10.8 ± 15 mm proximal to the lateral epicondyle. One (one of seven), two (three of seven), three (two of seven), or four (one of seven) motor branches innervated the extensor carpi radialis longus muscle, with entry points 13.9 ± 16.2 to 26.3 ± 14.9 mm distal from the lateral epicondyle. In all specimens, the posterior interosseous nerve gave off one motor branch to the extensor carpi radialis brevis, which divided into two or three secondary branches. The distal anterior interosseus nerve was assessed as a potential recipient for TMR coaptation and had a freely transferable length of 56.4 ± 12.7 mm. CONCLUSIONS: When considering TMR for neuromas of the SRN in the distal third of the forearm and hand, the distal anterior interosseus nerve is a suitable donor target. For neuromas of the SRN in the proximal two-thirds of the forearm, the motor branches to the extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis are potential donor targets.

Lumbosacral Plexogram: An Aid to Reconstructive Nerve Possibilities in the Lower Extremity.

The lumbosacral plexus is the network of nerves responsible for the motor and sensory function of the pelvis and lower limb. Our observation is that the anatomy of this plexus is less familiar to surgeons than that of the brachial plexus. Damage to the lumbosacral plexus and its terminal branches may have a significant impact on locomotion, posture, and stability. We have designed a visual representation of the lumbosacral plexus to aid clinicians treating peripheral nerve disorders. The utility is illustrated with a case report in which a patient underwent nerve transfers in the lower limb to restore function. A visual representation of the lumbosacral plexus is a valuable adjunct to a clinical examination and helps make sense of clinical signs. The color-coding of each root level and the arrangement of muscles from proximal to distal helps with visual recall. A clear assessment of complex lumbosacral plexus patients is essential for diagnosis and planning. As with the case described, a sound knowledge of the "plexogram" can identify solutions for complex patients and result in significant functional improvements. We hope it helps advance the field of nerve surgery and, particularly, nerve transfers.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Reconstruction of Partial Hypopharyngeal Defects following Total Laryngectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Various operative techniques exist to reconstruct partial hypopharyngeal defects following total laryngectomy. The current study aimed to investigate and compare complications and functional results following commonly used reconstructive techniques. METHODS: A systematic review and meta-analysis were performed using studies that investigated outcomes after the reconstruction of a partial hypopharyngeal defect. The outcomes of interest were fistulas, strictures, flap failure, swallowing function and postoperative speech. RESULTS: Of the 4035 studies identified, 23 were included in this review. Four common reconstructive techniques were reported, with a total of 794 patients: (1) pectoralis major myocutaneous and (2) myofascial flap, (3) anterolateral thigh free flap and (4) radial forearm free flap. Fistulas occurred significantly more often than pectoralis major myocutaneous flaps (34%, 95% CI 23-47%) compared with other flaps (p < 0.001). No significant differences in the rates of strictures or flap failure were observed. Pectoralis major myofascial flaps were non-inferior to free-flap reconstructions. Insufficient data were available to assess speech results between flap types. CONCLUSION: Pectoralis myocutaneous flaps should not be the preferred method of reconstruction for most patients, considering their significantly higher rate of fistulas. In contrast, pectoralis major myofascial flaps yield promising results compared to free-flap reconstructions, warranting further investigation.

Surgical Techniques in Non-Traumatic Midcarpal Instability: Evaluating the Dorsal Capsulodesis and Three-Ligament Tenodesis Technique.

BACKGROUND: Surgical management of midcarpal instability (MCI), also referred to as carpal instability nondissociative, remains controversial due to limited evidence on different techniques. This study aimed to assess and compare differences in patient-reported pain, hand and wrist function, patient satisfaction, range of motion, and return to work in patients with non-traumatic MCI who underwent surgical treatment either through dorsal wrist capsulodesis or three-ligament tenodesis (3LT). METHODS: Patients with MCI and persisting complaints after conservative therapy treated with 3LT or dorsal capsulodesis were included. Patients with posttraumatic instability were excluded. Primary endpoints included the Patient Rated Wrist Evaluation (PRWE) and Satisfaction with Treatment Result Questionnaire at 12 months postoperative. All data were retrospectively analyzed. RESULTS: A total of 91 patients treated with dorsal capsulodesis and 21 treated with 3LT between December 2011 and December 2019 were included. At twelve months postoperative, both treatment groups reported significant improvements in pain and function scores. However, at three months postoperative, the dorsal capsulodesis group exhibited significantly better outcomes, followed by a greater return to work (72%) compared to the 3LT group (50%). However, the capsulodesis group demonstrated a decreased range of motion at three months which was restored at 12 months postoperative. No significant difference in satisfaction with treatment was observed. CONCLUSIONS: Both 3LT and dorsal capsulodesis demonstrate promising results for addressing non-traumatic MCI. However, considering the quicker recovery and faster return to work associated with dorsal capsulodesis, we recommend favoring capsulodesis over 3LT when both surgical options are deemed suitable for the patient. LEVEL OF EVIDENCE: III.

Fasciocutaneous and jejunal free flaps for circumferential hypopharyngeal defect reconstruction: A 22-year multicenter cohort study.

BACKGROUND: It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects. METHODS: All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications. RESULTS: In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007). CONCLUSIONS: The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.