Neurogenic Thoracic Outlet Syndrome: A Primer for Hand and Peripheral Nerve Surgeons.

Neurogenic thoracic outlet syndrome is a complex condition and is commonly misunderstood. Historically, much of this confusion has been because of its grouping with other diagnoses that have little in common other than anatomic location. Modern understanding emphasizes the role of small unmyelinated C type pain and sympathetic fibers. Diagnosis is primarily clinical, after ruling out other common conditions. Hand therapy is usually the first-line treatment with variable success. Local anesthetic, botulinum toxins, or steroid injections can aid in diagnosis and offer short-term relief. Although surgery can yield reliable results, it is technically challenging, and the preferred surgical approach is a matter of debate. Despite limitations in diagnosis and treatment, recognition and successful treatment of this condition can be highly impactful for the patient.

The effect of operative time on surgical-site infection following total shoulder arthroplasty.

BACKGROUND: Many factors contribute to the risk of surgical-site infection (SSI) following total shoulder arthroplasty (TSA). Operative time is a modifiable factor that may contribute to SSI occurrence after TSA. This study aimed to determine the correlation between operative time and SSI following TSA. MATERIALS AND METHODS: By use of the American College of Surgeons National Surgical Quality Improvement Program database, a total of 33,987 patient records were queried from 2006 to 2020 and sorted by operative time and the development of an SSI in the 30-day postoperative period. Odds ratios for the development of an SSI were calculated based on operative time. RESULTS: An SSI developed in the 30-day postoperative period in 169 of the 33,470 patients in this study, resulting in an overall SSI rate of 0.50%. A positive correlation was identified between operative time and the SSI rate. An inflection point was identified at an operative time of 180 minutes, with a significant increase in the rate of SSI occurrence for operative times >180 minutes. DISCUSSION AND CONCLUSION: Increased operative time was shown to be strongly correlated with an increased risk of SSI within 30 days following surgery, with a significant inflection point at 180 minutes. The target operative time for TSA should be <180 minutes to reduce the risk of SSI.

Design, Control, and Experimental Evaluation of A Novel Robotic Glove System for Patients with Brachial Plexus Injuries.

This paper presents the development of an exoskeleton glove system for people who suffer from brachial plexus injuries, aiming to assist their lost grasping functionality. The robotic system consists of a portable glove system and an embedded controller. The glove system consists of Linear Series Elastic Actuators (LSEA), Rotary Series Elastic Actuators (RSEA), and optimized finger linkages to provide imitated human motion to each finger and a coupled motion of the hand. The design principles and optimization strategies were investigated to balance functionality, portability, and stability. The model-based force control strategy compensated with a backlash model and model-free force control strategy are presented and compared. Results show that our proposed model-free control method achieves the goal of accurate force control. Finally, experiments were conducted with the prototype of the developed integrated exoskeleton glove system. Results from 3 subjects with 150 trials show that our proposed exoskeleton glove system has the potential to be used as a rehabilitation device for patients.

Personalized Voice Activated Grasping System for a Robotic Exoskeleton Glove ☠.

This paper proposes a novel human machine interface (HMI) and electronics system design to control a rehabilitation robotic exoskeleton glove. Such system can be activated with biometric authentication using the user's voice, take voice commands as input, recognize the command and perform biometric authentication in real-time with limited computing power, and execute the command on the exoskeleton. The electronics design is a stand-alone plug-and-play modulated design independent of the exoskeleton design. This personalized voice activated grasping system achieves better wearability, lower latency, and improved security than any existing exoskeleton glove control system.

Data Driven Calibration and Control of Compact Lightweight Series Elastic Actuators for Robotic Exoskeleton Gloves.

The working principle of a SEA is based on using an elastic material connected serially to the mechanical power source to simulate the dynamic behavior of a human muscle. Due to weight and size limitations of a wearable robotic exoskeleton, the hardware design of the SEA is limited. Compact and lightweight SEAs usually have noisy signal output, and can easily be deformed. This paper uses a compact lightweight SEA designed for exoskeleton gloves to demonstrate immeasurable strain and friction force which can cause an average of 34.31% and maximum of 44.7% difference in force measurement on such SEAs. This paper proposes two data driven machine learning methods to accurately calibrate and control SEAs. The multi-layer perception (MLP) method can reduce the average force measurement error to 10.18% and maximum error to 29.13%. The surface fitting method (SF) method can reduce the average force measurement error to 8.06% and maximum error to 35.72%. In control experiments, the weighted MLP method achieves an average of 0.21N force control difference, and the SF method achieves an average of 0.29N force control difference on the finger tips of the exoskeleton glove.

Ethical Considerations in Animal Research: The Principle of 3R's.

In the last century, progress in the knowledge of human diseases, their diagnosis and treatment have grown exponentially, due in large part to the introduction and use of laboratory animals. Along with this important progress, the need to provide training and guidance to the scientific community in all aspects related to the proper use of experimental animals has been indispensable. Animal research committees play a primary role in evaluating experimental research protocols, from their feasibility to the rational use of animals, but above all in seeking animal welfare. The Institutional Committee for the Care and Use of Animals (IACUC) has endeavored to share several relevant aspects in conducting research with laboratory animals. Here, we present and discuss the topics that we consider of utmost importance to take in the account during the design of any experimental research protocol, so we invite researchers, technicians, and undergraduate and graduate students to dive into the fascinating subject of proper animal care and use for experimentation. The main intention of these contributions is to sensitize users of laboratory animals for the proper and rational use of them in experimental research, as well as to disseminate the permitted and unpermitted procedures in laboratory animals. In the first part, the significance of experimental research, the main functions of IACUC, and the principle of the three R's (replacement, reduction, and refinement) are addressed.

Ethical Considerations in Animal Research: The Principle of 3R's.

In the last century, progress in the knowledge of human diseases, their diagnosis and treatment have grown exponentially, due in large part to the introduction and use of laboratory animals. Along with this important progress, the need to provide training and guidance to the scientific community in all aspects related to the proper use of experimental animals has been indispensable. Animal research committees play a primary role in evaluating experimental research protocols, from their feasibility to the rational use of animals, but above all in seeking animal welfare. The Institutional Committee for the Care and Use of Animals (IACUC) has endeavored to share several relevant aspects in conducting research with laboratory animals. Here, we present and discuss the topics that we consider of utmost importance to take in the account during the design of any experimental research protocol, so we invite researchers, technicians, and undergraduate and graduate students to dive into the fascinating subject of proper animal care and use for experimentation. The main intention of these contributions is to sensitize users of laboratory animals for the proper and rational use of them in experimental research, as well as to disseminate the permitted and unpermitted procedures in laboratory animals. In the first part, the significance of experimental research, the main functions of IACUC, and the principle of the three R's (replacement, reduction, and refinement) are addressed.

Effect of Prescription Size on Opioid Use and Patient Satisfaction After Minor Hand Surgery: A Randomized Clinical Trial.

OBJECTIVE: To determine the influence of initial prescription size on opioid consumption after minor hand surgeries. Secondary outcomes include efficacy of pain control, patient satisfaction, and refill requests. BACKGROUND: Retrospective studies have shown that opioid prescriptions for acute pain after surgical procedures are often excessive in size, which encourages misuse. This is the first prospective randomized trial on the influence of initial prescription size on opioid consumption in the setting of acute postsurgical pain. METHODS: In a prospective randomized trial at a single-academic institution, patients were provided an initial prescription of either 10 or 30 hydrocodone/acetaminophen (5/325 mg) pills after surgery. Two hundred opioid-naive patients, aged 19 to 69, undergoing elective outpatient minor hand surgeries were enrolled over 9 months, with a follow-up period of 10 to 14 days. RESULTS: One hundred seventy-four patients were included in this analysis. Patients initially prescribed 30 pills (n = 79), when compared with patients initially prescribed 10 pills (n = 95), used significantly more opioid (P = <0.001, mean 11.9 vs 6.4 pills), had significantly more leftover medication (P = <0.001, mean 20.0 vs 5.2 pills), and were over 3 times more likely to still be taking opioid at follow-up (15% vs 4%). There was no significant difference in refills requested, or in patient satisfaction with postoperative pain control. CONCLUSIONS: Providing large opioid prescriptions for the management of acute pain after minor upper extremity surgeries increases overall opioid use when compared with smaller initial prescriptions. The size of initial opioid prescription is a modifiable variable that should be considered both in patient care and research design.

Provision of a Home-Based Video-Assisted Therapy Program Is Noninferior to In-Person Hand Therapy After Thumb Carpometacarpal Arthroplasty.

BACKGROUND: In-person hand therapy is commonly prescribed for rehabilitation after thumb carpometacarpal (CMC) arthroplasty but may be burdensome to patients because of the need to travel to appointments. Asynchronous, video-assisted home therapy is a method of care in which videos containing instructions and exercises are provided to the patient, without the need for in-person or telemedicine visits. The purpose of the present study was to evaluate the effectiveness of providing video-only therapy (VOT) as compared with scheduled in-person therapy (IPT) after thumb CMC arthroplasty. METHODS: We performed a single-site, prospective, randomized controlled trial of patients undergoing primary thumb CMC arthroplasty without an implant. The study included 50 women and 8 men, with a mean age of 61 years (range, 41 to 83 years). Of these, 96.6% were White, 3.4% were Black, and 13.8% were of Hispanic ethnicity. The primary outcome measure was the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) score. Subjects in the VOT group were provided with 3 videos of home exercises to perform. Subjects in the control group received standardized IPT with a hand therapist. Improvements in the PROMIS UE score from preoperatively to 12 weeks and 1 year postoperatively were compared. RESULTS: Fifty-eight subjects (29 control, 29 experimental) were included in the analysis at the 12-week time point, and 54 (27 control, 27 experimental) were included in the analysis at the 1-year time point. VOT was noninferior to IPT for the PROMIS UE score at 12 weeks and 1 year postoperatively, with a difference of mean improvement (VOT - IPT) of 1.5 (95% confidence interval [CI], -3.6 to 6.6) and 2.2 (95% CI, -3.0 to 7.3), respectively, both of which were below the minimal clinically important difference (4.1). Patients in the VOT group potentially saved on average 201.3 miles in travel. CONCLUSIONS: VOT was noninferior to IPT for upper extremity function after thumb CMC arthroplasty. Time saved in commutes was considerable for those who did not attend IPT. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Antibiotic Prophylaxis for Distal Interphalangeal Joint Arthrodesis.

Prior evidence is clear that in clean, elective soft-tissue hand procedures less than 2 hours, antibiotic prophylaxis is not indicated. However, there is a lack of consensus regarding the boney procedures of the hand involving implanted hardware. Previous studies reviewing complications after distal interphalangeal (DIP) joint arthrodesis did not analyze whether patients receiving antibiotics before surgery had a significant difference in the infection rate. Methods: A retrospective review of clean, elective DIP arthrodesis was conducted between September 2018 and September 2021. The subjects were aged 18 years and older and underwent elective DIP arthrodesis for the treatment of osteoarthritis or deformity of the DIP joint. All the procedures were performed using an intramedullary headless compression screw. The rates of postoperative infections and treatments required for infections were recorded and analyzed. Results: Overall, 37 unique patients had at least one case of DIP arthrodesis that met the criteria for inclusion in our analysis. Twenty of the 37 patients did not receive antibiotic prophylaxis, and 17 of the 37 patients received antibiotic prophylaxis. Five of the 20 patients who did not receive antibiotics prophylactically developed infections, and none of the 17 patients who received antibiotics prophylactically developed an infection. Fisher exact test revealed a significant difference in the infection rates between the two groups (P < 0.05). There was no significant difference in infections with respect to smoking or diabetes status. Conclusion: Antibiotic prophylaxis should be administered for clean, elective DIP arthrodesis, using an intramedullary screw.

What Factors Influence Variability in Thumb Carpometacarpal Arthroplasty Care? A Survey of ASSH Members.

BACKGROUND: The purpose of this study was to gather information regarding current practices in the care of carpometacarpal (CMC) arthroplasty including the use of hand therapy, immobilization, and surgical technique, and to determine which factors influence these patterns. METHODS: We conducted a survey from February 24, 2022, through March 26, 2022, of 3648 currently practicing members of the American Society for Surgery of the Hand. We developed an 11-item questionnaire that contained questions about surgical technique, immobilization, and postoperative therapy utilization. Results were analyzed using chi-square analysis and a Bonferroni correction was applied to account for multiple comparisons. Statistical significance was set at a P-value of less than .05. RESULTS: A total of 811 hand surgeons completed the survey (22% response rate). Surgeons who are employed by the same medical center as their hand therapist use more in-person hand therapy than surgeons with other types of business relationships. Surgeons with more than 25 years of experience are less likely to recommend therapy routinely, more likely to use ligament reconstruction and tendon interposition, and less likely to be an employee of the same medical center as their hand therapist. The length of immobilization and the time at which hand therapy began were related to surgical technique. CONCLUSIONS: Variability in hand therapy usage after CMC arthroplasty is at least partially explained by business relationships with hand therapists and surgeon experience. Variability in the length of immobilization and the beginning of hand therapy postoperatively was more associated with surgical technique.

The Clinical Outcomes of Radiocapitellar Reconstruction With Radiocapitellar Arthroplasty: A Systematic Review and Meta-Analysis.

Background: Radiocapitellar arthroplasty fills a treatment void for young patients who experience isolated capitellar fractures or radiocapitellar osteoarthritis who are not candidates for total elbow arthroplasty. The outcomes of this procedure are sparsely reported. We designed a meta-analysis to determine the utility of radiocapitellar arthroplasty with respect to functional and patient reported outcomes. Methods: The PubMed database was searched for relevant studies. Only studies published in English language that assessed patient reported outcomes following radiocapitellar arthroplasty were included in this study. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for 2020. Results: The initial review yielded 562 studies that met the criteria. After excluding duplications and confounding factors, eight case series were identified for review. Of the eight studies, seven were eligible for inclusion in the meta-analysis for Mayo Elbow Performance Score, flexion-extension arc, and pronation-supination arc. The pooled standard mean difference was found to be statistically significant between pre-operative and post-operative outcomes for Mayo Elbow Performance Score (SMD = 3.04, 95% CI [2.40, 3.67]), flexion-extension arc (SMD = 1.28, 95% CI [0.73, 1.83]), and pronation-supination arc (SMD = 0.81, 95% CI [0.43, 1.18]). Cochran's Q-test and I2 statistics indicated statistically significant heterogeneity for Mayo Elbow Performance Score (p = .04, I2 = 54%) and flexion-extension arc (p < .01, I2 = 67%). Conclusions: Patients undergoing radiocapitellar arthroplasty showed statistically significant improvements in flexion-extension arc, pronation-supination arc, and Mayo Elbow Performance Scores compared to pre-operative measures.

Management of combined soft tissue and osseous defect of the midfoot with a free osteocutaneous radial forearm flap: a case report.

Extensive soft tissue and osseous defects of the foot are difficult to manage and often result in amputation. Most of these wounds are created by trauma, but other causes, such as infection and malignancy, can create similar defects. A variety of wound management options exist for the treatment of these challenging wounds, including negative pressure wound therapy, autogenous skin grafting, and the use of skin substitutes, as well as internal and external fixation methods. In the present report, we describe the use of a free osteocutaneous radial forearm flap to manage a 10-cm × 5-cm dorsal soft tissue defect and a 2.5-cm second metatarsal diaphyseal defect in an adult male.

Development and Experimental Evaluation of a Novel Portable Haptic Robotic Exoskeleton Glove System for Patients with Brachial Plexus Injuries.

This paper presents the development and experimental evaluation of a portable haptic exoskeleton glove system designed for people who suffer from brachial plexus injuries to restore their lost grasping functionality. The proposed glove system involves force perception, linkage-driven finger mechanism, and personalized voice control to achieve various grasping functionality requirements. The fully integrated system provides our wearable device with lightweight, portable, and comfortable characterization for grasping objects used in daily activities. Rigid articulated linkages powered by Series Elastic Actuators (SEAs) with slip detection on the fingertips provide stable and robust grasp for multiple objects. The passive abduction-adduction motion of each finger is also considered to provide better grasping flexibility for the user. The continuous voice control with bio-authentication also provides a hands-free user interface. The experiments with different objects verify the functionalities and capabilities of the proposed exoskeleton glove system in grasping objects with various shapes and weights used in activities of daily living (ADLs).

Neonatal Forearm Compartment Syndrome Secondary to Intrauterine Brachiocephalic Arterial Thrombosis: A Case Report.

CASE: A newborn presented with necrotic skin lesions and contractures of the right upper extremity. Ultrasonography indicated the presence of a brachiocephalic artery thrombosis, and clinical examination demonstrated a neonatal forearm compartment syndrome. Surgical treatment included decompressive fasciotomy of the right forearm. The right-sided brachiocephalic thrombosis resulted in left hemiplegic cerebral palsy. At the 3-year follow-up, the patient had near-normal function of the right upper extremity. This case has detailed preoperative video and follow-up to illustrate this rare but modifiable condition. CONCLUSION: This case demonstrates a unique cause of neonatal forearm compartment syndrome (brachiocephalic arterial thrombosis) and the results of prompt surgical treatment.

INTEGRATED AND CONFIGURABLE VOICE ACTIVATION AND SPEAKER VERIFICATION SYSTEM FOR A ROBOTIC EXOSKELETON GLOVE.

Efficient human-machine interface (HMI) for exoskeletons remains an active research topic, where sample methods have been proposed including using computer vision, EEG (electroencephalogram), and voice recognition. However, some of these methods lack sufficient accuracy, security, and portability. This paper proposes a HMI referred as integrated trigger-word configurable voice activation and speaker verification system (CVASV). The CVASV system is designed for embedded systems with limited computing power that can be applied to any exoskeleton platform. The CVASV system consists of two main sections, including an API based voice activation section and a deep learning based text-independent voice verification section. These two sections are combined into a system that allows the user to configure the activation trigger-word and verify the user's command in real-time.

A NOVEL DESIGN OF A ROBOTIC GLOVE SYSTEM FOR PATIENTS WITH BRACHIAL PLEXUS INJURIES.

This paper presents the design of an exoskeleton glove system for people who suffer from the brachial plexus injuries in an effort to restore their lost grasping functionality. The robotic system consists of an embedded controller and a portable glove system. The glove system consists of Linear Series Elastic Actuators (SEA), Rotary SEA and optimized finger linkages to provide motion to each finger and a coupled motion of the hand and the wrist. The design is based on various functionality requirements such as being lightweight and portable for activities of daily living, especially for grasping. The contact force at each fingertip and bending angle of each finger are measured for future implementation of intelligent control algorithms for autonomous grasping. To provide better flexibility and comfort for the users, abduction and adduction of each finger as well as flexion of the thumb were taken into consideration in the design. The glove system is adjustable for different hand sizes. The micro-controllers and batteries are integrated on the forearm in order to provide a completely portable design solution.

Management Accounting for Healthy Nutrition Education: Meta-Analysis.

Unequal economic growth shapes food systems. Nutrition problems incorporate inappropriate practices, so nutrition education is key to empowering consumers to choose healthy foods. However, increasing the accessibility of healthy diets is related to reducing the cost of nutritious foods. The accounting management of healthy nutrition should allow for optimal global decision-making. The evolution of scientific production and global research trends on this topic between 1968 and 2019 have been studied. Statistical and mathematical methods have been applied to 1738 documents from the Scopus database. The results provided data on the agents that participate in the development of the theme. Data reveal an exponential trend, especially in the previous decade, with more than 50% of scientific production. Future lines of research have been identified: investment in health systems; green label education; early impact of food insecurity; WIC (Women, Infants, and Children) nutrition education; food waste audit; and ecological footprint of food. The central contribution of the study has been to detect the main future directions of research, providing critical points that will allow us to identify the themes of future publications, in addition to providing an instrument for decision-making carried out by the research funding sponsors.

Mechanical Properties and Seismic Performance of Wood-Concrete Composite Blocks for Building Construction.

Recent catastrophes that occurred during seismic events suggest the importance of developing new seismic-resistant materials for use in building construction. Ordinary concrete is one of the most common materials in buildings. However, due to its low ductility and flexural strength, its seismic behavior can be improved upon by different additives. In this regard, wood-concrete composites exhibit desirable structural properties not achievable by either wood or concrete alone, making it an interesting material from a seismic point of view. This work analyzes and compares the performance of blocks built with ordinary concrete versus blocks built using different wood additives (sawdust and wood shavings). This includes the construction of concrete blocks in a lab, determination of their construction and seismic-resistant properties, as well as an analysis of their performance in buildings with a different number of storeys. The results show how blocks with wood aggregates comply with current regulations for structural materials in a seismic country like Chile, while also considerably outperforming traditional concrete blocks in the event of an earthquake.

Amniotic band syndrome of the upper extremity: diagnosis and management.

Amniotic band syndrome, a condition involving fetal entrapment in strands of amniotic tissue, causes an array of deletions and deformations. Band formation most frequently affects the distal segments, including the hand. Because of the heterogeneous nature of expression of this disease, treatment is individualized. Timing of repair and surgical planning are important in improving functional outcome. In the patient with distal edema and acrosyndactyly, early repair portends better prognosis. Improvements in prenatal diagnosis and fetoscopic surgical technique may eventually allow treatment of amniotic band syndrome in utero.