Thrombin and topical local anesthetic for postoperative pain management.

PURPOSE: Local anesthetic is often used for perioperative pain control. Thrombin serves as a carrying medium for sustained release of antibiotics, chemotherapy, and growth factors. We tested the hypothesis that local anesthetic pain relief can be prolonged with the adjunct use of thrombin. METHODS: A prospective single-blinded clinical study was performed. Patients undergoing elective hand surgery inclusive of carpal tunnel release, excision of ganglion cyst, trigger finger release, and excision of mucous cyst under local block were enlisted. Before closure, patients received 1 of the following combinations: (1) control with oral analgesics, (2) 5 mL of 2% xylocaine, (3) 5 mL of 0.5% bupivacaine, (4) 2.5 mL of 2% xylocaine with 2.5 mL of 0.5% bupivacaine (XB), (5) thrombin with 5 mL of 2% xylocaine (XT), (6) thrombin with 5 mL of 0.5% bupivacaine (BT), and (7) thrombin with 2.5 mL of 2% xylocaine and 2.5 mL of 0.5% bupivacaine (XBT). There were 7 patients in each group, and patient demographics were similar between groups. Outcome measures included postanesthesia care unit (PACU) time, pain level, and number of pain pills required. RESULTS: Compared with oral analgesics alone, mean (SD) postoperative pain levels were reduced by 33.3% (8.9%) by xylocaine, 69.1% (8.7%) by bupivacaine, and 45.7% (9.4%) by XB. When thrombin was added, pain levels were further reduced by 69.9% by XT (P < 0.001), 23.1% by BT (P = 0.071), and 50.5% by XBT (P < 0.001) compared with their nonthrombin counterparts. In addition, PACU time was decreased by 34.8% by XT (P = 0.003) and 19.7% by XBT (P = 0.013) compared with xylocaine and XB, respectively. However, there was no difference in total pain pills needed between xylocaine, bupivacaine, and XB when administered with and without thrombin. CONCLUSIONS: The addition of topical thrombin to local anesthetic at the end of elective hand surgery provides for sustained postoperative pain control. Patients in this study who received thrombin and local anesthetic before wound closure had lower pain levels and were discharged from the PACU sooner than those who received local anesthetic alone. LEVEL OF EVIDENCE: Therapeutic level 2.

The Lambda Cord: An Anatomic Configuration of Radial-Sided Dupuytren Disease.

The thumb and first webspace are involved in a relatively low proportion of cases of Dupuytren disease of the hand (3%-28%). Given the rarity, there has been a paucity of literature regarding anatomic cord configurations and the surgical technique for the management of such radial-sided diseases. There are unique anatomic considerations in the thumb that warrant understanding prior to safe surgical exploration. A case of an anatomic variant of Dupuytren disease involving the thumb and first webspace treated with a webspace skin-sparing partial fasciectomy is described. The current literature regarding surgical management of Dupuytren disease affecting the thumb and first webspace is also briefly presented.

Autogenic heterotopic vascularized proximal interphalangeal joint transplantation in children.

The proximal interphalangeal joint (PIP) joint is the most crucial joint for the functionality of a finger. For a child with complex injury of the hand every effort should be exercised to maximize function restoration. If the PIP joint is irreparably damaged, its reconstruction is indicated. The technique of autogenic heterotopic vascularized toe joint transplantation provides unique advantage of a composite transfer of skin, tendons, bone and joint alone with growth plate and its efficacy has been affirmed in children. It has been suggested that such transfers require intact flexor tendon to achieve satisfactory results, our experience however indicates quite the contrary. As evidenced by this report of a 7-year-old boy with abrasion and avulsion injury to his dominant right hand resulting in a complex defect with skin lose, extensor, flexor avulsion along with cominution of the PIP joint of his long finger. A surgical formulation of staged reconstruction scheme including an autogenic heterotopic vascularized toe joint transplantation led to complete functional restoration to his right hand.

Adipose Tissue-preserved Skin Grafts for Lower Extremity Defects: Recommendations to Optimize Outcomes.

Adipose tissue-preserved skin grafts (ATPSGs) are full-thickness skin grafts with inclusion of a thin layer of adipose tissue. ATPSGs are recommended for reconstruction of anatomic areas that are cosmetically sensitive and for areas that functionally benefit from additional soft tissue thickness compared to traditional skin grafts. Careful intraoperative technique and postoperative care are mandatory for ATPSG success, given the expected higher metabolic demands compared to traditional grafts. A strict postoperative protocol is especially important after reconstruction of lower extremity defects. METHODS: Detailed descriptions of intraoperative and postoperative care for ATPSG reconstructions are provided. A case is presented displaying lower extremity reconstruction with an ATPSG. The intraoperative technique includes meticulous hemostasis of the recipient site, atraumatic handling of recipient skin edges, anatomical epidermal-to-epidermal reapproximation, avoidance of tissue strangulation during inset, and careful bolster placement. The postoperative protocol after lower extremity reconstruction includes strict elevation, non-weight-bearing status, and eventual dangle protocol. RESULTS: An 85-year-old woman was treated with an ATSG for a middle-third leg resection of squamous cell carcinoma resulting in a 9 × 5 cm defect. The strict postoperative protocol was initiated, but the patient was noncompliant with elevation and weight-bearing restrictions. She had postoperative congestion and epidermolysis that was treated with local wound care without need for additional surgery. CONCLUSIONS: There are many benefits to ATPSG reconstruction when chosen for the appropriate candidate. The meticulous technique and strict adherence to the postoperative protocol are crucial when these reconstructions are performed. Detailed descriptions of intraoperative and postoperative recommendations to optimize outcomes after ATPSG are presented.

The Impact of Microsurgery on the Treatment of Ring Avulsion Injuries.

BACKGROUND: Treating ring avulsion injuries continues to challenge the reconstructive hand surgeon. The complex operation draws from plastic surgery and orthopedic surgery principles to provide soft-tissue coverage, skeletal fixation, tendon repair, and neurovascular reconstruction. Furthermore, the application of microsurgical techniques has enabled the revascularization and replantation of completely avulsed fingers. METHODS: A retrospective review of 22 consecutive ring avulsion injuries (seven amputations, five replantations, and 10 revascularizations) from 1987 to 2015 performed by a single senior surgeon (D.T.W.C.) was conducted. RESULTS: Of these 22 ring avulsions, 10 revascularizations, five replantations, and seven amputations (five because of clinical factors, and two because of patient request) were performed. None of the 15 replantations and revascularizations resulted in loss of the ring finger or necrosis of the revascularized tip. CONCLUSIONS: With proper patient selection, appropriate level of injury identification, and meticulous surgical execution, the restoration of form and function to the hand is feasible in ring avulsion injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Relative Motion Flexion Splinting for Flexor Tendon Lacerations: Proof of Concept.

BACKGROUND: The principle of relative motion has allowed patients to regain a higher degree of hand function, while protecting extensor tendon repairs. The purpose of this study was to determine whether the principle of relative motion could be a viable method to protect a flexor tendon repair. METHODS: Four fresh-frozen cadaver arms were each mounted on a testing apparatus (wrist in 30° of extension, metacarpophalangeal [MCP] joints blocked to 70°-80°). A minimum of 11 N was used to cyclically load the flexor digitorum profundus and extensor digitorum communis tendons to maximum allowable flexion and extension for 25 cycles. Measurements of elongation of the tendons were obtained through the use of differential variable reluctance transducers. Testing was performed in both intact and repaired (single 6-0 nylon suture) middle finger tendons (zone 3) with and without a relative motion flexion splint (RMFS), which placed the affected finger in 15° to 25° of relative flexion at the MCP joint. RESULTS: In all 4 hands, elongation was restricted to less than 1.3 mm in repaired tendon in the RMFS compared with elongation >2 mm in the nonsplinted condition. Average elongation was 0.86 mm (SD = 0.45). Visual examination of the tendons demonstrated no gapping with the use of the RMFS in any of the hands. All repairs had suture breakage and repair rupture without the RMFS. CONCLUSIONS: This study demonstrates that the RMFS decreases elongation and eliminates tendon-repair gapping after flexion/extension cycling in a cadaver model. It provides proof of concept that the RMFS may be a viable protective mechanism for flexor tendon repairs in zone 3.

The Impact of Microsurgery on Congenital Hand Anomalies Associated with Amniotic Band Syndrome.

BACKGROUND: Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality. METHODS: In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed. RESULTS: There was no flap loss. The hands were sensate with effective simple prehensile function. CONCLUSION: Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.

Adipose Tissue-Preserved Skin Graft: Applicability and Long-Term Results.

BACKGROUND: Composite grafts consisting of adipose tissue and skin have been reported in the literature but have been restricted to areas smaller than 4 to 5 cm. The senior author (D.T.W.C.) has developed a technique of adipose tissue-preserved full-thickness skin grafts for larger areas with success similar to that achieved with conventional full-thickness skin grafts. METHODS: All cases of the senior author involving a full-thickness skin graft were identified and reviewed to identify cases in which adipose tissue-preserved full-thickness skin grafts were used. Indication for skin grafting, anatomical location of recipient and donor sites, size of graft, total number of grafts received by each patient, and percentage take were extracted from patient charts. Graft take was measured between days 5 and 14. RESULTS: A total of 72 adipose tissue-preserved skin grafts on 47 patients were identified from 1994 to 2009, with a median follow-up of 8 years. The size of defect ranged from 0.7 to 210 cm, with a median area of 6 cm (interquartile range, 2.5 to 15 cm). Only six of 72 grafts were found to have less than 100 percent take. The lowest take percentage was 85 percent in a graft with an area of 2.6 cm. There were no graft failures. CONCLUSIONS: This study confirms the proof-of-concept that both larger and distant donor- site adipose tissue-preserved skin grafts are a viable alternative to conventional defatted full-thickness skin grafting. It appears that there is a low complication rate with respect to graft failure or incomplete graft take. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Engineering novel spinal circuits to promote recovery after spinal injury.

We have developed an innovative way to establish a functional bridge around a spinal lesion. We disconnected the T13 nerve from its muscle targets, leaving the proximal end intact. The cut end was inserted either into an intact spinal cord, to assess regeneration of T13 axons into the cord and synapse formation with spinal neurons, or caudal to a hemisection at L2/3, to assess restoration of function below the injury. Four to 28 weeks later, anterograde tracers indicated that axons from the inserted T13 nerve regenerated into the ventral horn, the intermediate zone, and dorsal horn base, both in intact and hemisected animals. Antibodies to cholinergic markers showed that many regenerating axons were from T13 motoneurons. Electrical stimulation of the T13 nerve proximal to the insertion site 4 weeks or more after insertion into the intact cord evoked local field potentials in the intermediate zone and ventral horn, which is where T13 axons terminated. Stimulation of T13 in 71% of the animals (8 hemisected, 7 intact) evoked contraction of the back or leg muscles, depending on the level of insertion. Animals in which T13 was inserted caudal to hemisection had significantly less spasticity and muscle wasting and greater mobility at the hip, knee, ankle, and digits in the ipsilateral hindlimb than did animals with a hemisection only. Thus, T13 motor axons form novel synapses with lumbosacral motor circuits. Because the T13 motor neurons retain their connections to the brain, these novel circuits might restore voluntary control to muscles paralyzed below a spinal lesion.

The effect of residency and fellowship type on hand surgery clinical practice patterns.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery- and plastic surgery-based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. METHODS: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. RESULTS: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. CONCLUSIONS: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns.

Neurotropism revisited.

The purpose of this study is to re-examine the probable directive effect of the distal stump of a severed peripheral nerve on regenerating axons. Forssman postulated the existence of such a directive influence and Cajal interpreted it as chemotactic in nature. This view was subsequently refuted by Weiss and Taylor. In our study the proximal stumps of transected rodent sciatic nerve were inserted into the single inlet end of a Y-shaped autogenous inferior vena cava graft. Into one limb of the double outlet end, namely the common iliac nerve bifurcation, the distal stump of the same sciatic nerve was inserted, while the counter limb was ligated in one group, left open in the second group, inserted with a segment of autogenous tendon in the third, and grafted with a segment of autogenous nerve in the fourth group. Both outlets were left unoccupied in yet another group as the control. The vena cava conduit was prepared so that a 1.5 cm gap existed between the proximal stumps of the sciatic nerve and the distal sciatic nerve stumps and the tendon grafts respectively. The grafted sciatic nerves were explored and biopsied after 12 weeks. The direction of nerve tissue regeneration in each group was analyzed histologically. Predilection of the regenerating nerve fibers toward the distal stumps was observed in each of the test groups. These results indicate the existence of a guiding influence at the distal stump toward the regeneration nerve fibers.

Evaluation of the hormonal function and histological features of heterotopic isogenic ovarian transplantation in rats.

The purpose of the study was to determine the feasibility of preserving ovarian function after heterotopic transplantation by means of microvascular anastomosis of the transplanted vascular pedicles to a set of preselected vessels. Six groups of 10 Sprague-Dawley inbred rats were used in this study. Group I underwent bilateral ovariectomy operation and served as the ovariectomy control. Group II underwent bilateral ovariectomy followed by heterotopic isogenic ovarian implantation. Group III underwent bilateral ovariectomy and isogenic heterotopic ovarian transplantation by means of microvascular anastomosis. Group IV served as the laparotomy sham-operated control. Group V served as the ovarian donor for group II. Group VI served as the donor of the ovarian-kidney vascular pedicle complex for group III. Postoperative ovarian estradiol levels were measured, and histological characteristics were elucidated in groups I, II, III, and IV. The results demonstrated that the estradiol level of the transplantation group was comparable to that of the sham operation group and was significantly higher than that of the implantation group. Histologically normal ovarian architecture was observed in the sham group (IV) and also in the transplantation group (III). Altered architecture was observed in the implantation group (II). These findings indicate that extraabdominal heterotopic ovarian transplantation with microvascular anastomosis led to normal ovarian hormonal function and was effective in preserving oocyte production capacity.