Compressive median neuropathy caused by brachial artery pseudoaneurysm.

Background: Brachial artery pseudoaneurysms (PSAs) are a rare complication of trauma and medical intervention, estimated to constitute 0.3-0.7% of all PSAs. Although neurologic symptoms are common in patients undergoing hemodialysis, direct nerve compression by large PSAs is rare. Case Description: We report a case of median nerve compression by a brachial artery PSA treated by PSA resection and distal nerve transfer of the extensor carpi radialis brevis nerve to the anterior interosseous nerve. Conclusion: This case illustrates the successful use of distal nerve transfers for the treatment of median neuropathy secondary to brachial PSA. In addition, this case highlights the importance of imaging before any exploratory nerve surgery in the setting of a mass and/or prior vascular procedure. Embarking on a nerve release/ repair surgery in the absence of a vascular surgeon would be disastrous.

Cutaneous Mucormycosis of the Upper Extremity: Case Reports Highlighting Rapid Diagnosis and Management.

ABSTRACT: Mucormycosis is a devastating fungal infection known for its angioinvasive spread and hematogenous dissemination, quickly resulting in multiorgan involvement and potentially fatal complications. Timely diagnosis is essential to facilitate early, aggressive debridement, yet the diagnosis remains difficult to obtain because of the need for culture and microscopy diagnosis. We provide case examples, which highlight diagnostic pearls and the multidisciplinary approach that are critical for improving local outcomes, preventing systemic spread, and reducing mortality.

Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation.

PURPOSE: Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation. METHODS: Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted. RESULTS: Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission. CONCLUSIONS: In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Surgical Treatment for Thumb CMC Joint Arthritis.

Thumb carpometacarpal (CMC) joint arthritis is a common and debilitating condition. The mainstay of treatment is conservative management. Surgery is only indicated following failure of a prolonged and comprehensive trial of nonoperative treatment. Once surgery has been designated, an array of surgical alternatives exist, all of which provide specific benefits and disadvantages. The different surgical options and their results are reviewed. The specific surgery will vary depending on the surgeon`s experience and preference taking into account the patient`s specific needs. The most commonly performed operative management at this time consists of trapeziectomy with ligament reconstruction, but most procedures can produce high patient satisfaction and in general, the results of surgical treatment are good.

Limited surgical treatment of suspected necrotizing fasciitis of the upper extremity with a benign clinical presentation.

Necrotizing fasciitis is a rapidly evolving, potentially fatal infection. Current recommendations advocate antibiotic administration and early aggressive surgical debridement. Aggressive surgery is associated with significant morbidity, leaving patients with substantial tissue loss and complex wounds. A case of suspected necrotizing fasciitis treated with minimal surgery is described. A previously healthy 48-year-old man presented with increased erythema, swelling and blistering of his left upper extremity. Despite a benign systemic clinical presentation, the hand and forearm were suspicious for necrotizing fasciitis, prompting surgical treatment. Surgical exploration found a significant amount of intradermal and subdermal clear fluid. It was decided to limit the amount of debridement. The diagnosis was Wells syndrome, eosinophilic cellulitis. Treated with steroids, the wounds healed uneventfully. It is important to consider the complete clinical picture before aggressive surgical treatment. A negative history for diabetes, atypical clinical presentation and benign operative findings are suggestive of a more benign diagnosis.

La fasciite nécrosante est une infection à l'évolution rapide et au potentiel fatal. Selon les recommandations actuelles, il faut administrer des antibiotiques et procéder à un débridement chirurgical rapide et agressif. Une opération agressive s'associe à une morbidité élevée, qui laisse les patients avec une importante perte de tissus et des plaies complexes. Les auteurs décrivent un cas de fasciite nécrosante présumée traité au moyen d'une chirurgie minimale.Un homme de 48 ans auparavant en santé a consulté en raison d'un érythème, d'un œdème et d'une vésication croissants du bras gauche. Malgré une présentation clinique systémique bénigne, la main et l'avantbras laissaient croire à une fasciite nécrosante, ce qui a suscité un traitement chirurgical. L'exploration chirurgicale a révélé une grande quantité de liquide intradermique et subdermique clair. Il a été entendu de limiter l'importance du débridement. On a posé un diagnostic de syndrome de Wells, ou cellulite à éosinophiles. Traitées aux stéroïdes, les plaies ont guéri sans incident.Il est important d'envisager le bilan clinique complet avant d'entreprendre un traitement chirurgical agressif. Des antécédents négatifs de diabète, une présentation clinique atypique et des observations chirurgicales bénignes sont évocatrices d'un diagnostic plus bénin.

Ethical considerations in face transplantation.

Human face transplantation is now a clinical reality. The surgical techniques necessary to perform these procedures have been used routinely in reconstructive microsurgery for many years. From an immunological standpoint since face and hand contain mostly the same tissues it is reasonable to assume that the same immunosuppressive regimen found to be effective in human hand transplants should also work in face transplantation. It is the ethical issues associated with the risks and benefits of performing facial transplantation that have posed the greatest challenges leading up to performing this new procedure. In this editorial, we will review some of the main events that have led to the recently performed human face transplants, specifically focusing on the key ethical issues at the center of this debate. We will discuss how the research and clinical experience in human hand transplantation laid the foundation for performing face transplantation and describe the research and the ethical guidelines upon which a team at the University of Louisville based their position "to move ahead" in spite of much criticism. Finally we will outline some of the key arguments against face transplantation, and conclude with a discussion on what comes next now that the first human face transplants have been performed.

Research and events leading to facial transplantation.

Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.

Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery.

Each year an estimated 7-million people in the USA need composite tissue reconstruction because of surgical excision of tumors, accidents and congenital malformations. Limb amputees alone comprise over 1.2 million of these. This figure is more than double the number of solid organs needed for transplantation. Composite tissue allotransplantation in the form of hand and facial tissue transplantation are now a clinical reality. The discovery, in the late 1990s, that the same immunotherapy used routinely in kidney transplantation was also effective in preventing skin rejection made this possible. While these new treatments seem like major advancements most of the surgical, immunological and ethical methods used are not new at all and have been around and routinely used in clinical practice for some time. In this review of composite tissue allotransplantation, we: (i) outline the limitations of conventional reconstructive methods for treating severe facial disfigurement, (ii) review the history of composite tissue allotransplantation, (iii) discuss the chronological scientific advances that have made it possible, (iv) focus on the two unique clinical scenarios of hand and face transplantation, and (v) reflect on the critical issues that must be addressed as we move this new frontier toward becoming a treatment in mainstream medicine.