Impact of Body Mass Index and Comorbidities on Outcomes in Upper Extremity Nerve Transfers.

BACKGROUND: There is a paucity of research investigating the impact of patient comorbidities, such as obesity and smoking, on nerve transfer outcomes. The objective of this retrospective cohort study was to evaluate the impact of body mass index (BMI) and comorbidities on the clinical outcomes of upper extremity nerve transfers. METHODS: A retrospective cohort study was executed. Patients were eligible for inclusion if they had an upper extremity nerve transfer with a minimum of 12-months follow-up. Data was collected regarding demographics, comorbidities, injury etiology, nerve transfer, as well as preoperative and postoperative clinical assessments. The primary outcome measure was strength of the recipient nerve innervated musculature. Statistical analysis used the Mann-Whitney U test, Wilcoxon signed-rank test, and Spearman's rho. RESULTS: Thirty-eight patients undergoing 43 nerve transfers were eligible for inclusion. Patients had a mean age of 48.8 years and a mean BMI of 27.4 kg/m2 (range:19.7-39.0). Injuries involved the brachial plexus (32%) or its terminal branches (68%) with the most common etiologies including trauma (50%) and compression (26%). Anterior interosseous nerve to ulnar motor nerve (35%) was the most common transfer performed. With a mean follow-up of 20.1 months, increased BMI (p = 0.036) and smoking (p = 0.021) were associated with worse postoperative strength. CONCLUSION: This retrospective cohort study demonstrated that increased BMI and smoking may be associated with worse outcomes in upper extremity nerve transfers-review of the literature yields ambiguity in both regards. To facilitate appropriate patient selection and guide expectations regarding prognosis, further experimental and clinical work is warranted.

Branches From the "SEAD": Sustained and Feasible Expansion of the Surgical Exploration and Discovery Program.

PROBLEM: A predicted shortage of surgeons and attrition among surgical residents has highlighted the need to attract well-suited medical students to surgical specialties. Literature suggests that early exposure may increase interest by addressing misconceptions and allowing students more time to make an informed career decision. APPROACH: The Surgical Exploration and Discovery (SEAD) program was created in 2012 with the goal of providing medical students with comprehensive and multifaceted exposure to surgical specialties to develop their knowledge and skills, and in turn positively influence their interest in pursuing a surgical career. The purpose of this innovation report is to describe the challenges, successes, and evolution of the SEAD program. OUTCOMES: Since its inception, SEAD has expanded to include 5 North American institutions and has educated nearly 400 participants in 5 y. Through a replication strategy, SEAD has maintained its basic curriculum, while accommodating the constraints and innovative approaches unique to each institution. Short-term results have demonstrated improved knowledge of curricular objectives, student perception of significant value of the program, and the generation of interest in a career in surgery. CONCLUSIONS: Future directions include the evaluation of long-term impact on pursuing a career in surgery and continuing further expansion using the current replication model, while maintaining a high-quality surgical education program.

Clinical Outcomes of Nerve Transfers in Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Given the unsatisfactory outcomes with traditional treatments, there is growing interest in nerve transfers to reestablish ankle dorsiflexion in peroneal nerve palsy. The objective of this work was to perform a systematic review and meta-analysis of the primary literature to assess the effectiveness of nerve transfer surgery in restoring ankle dorsiflexion in patients with peroneal nerve palsy. METHODS: Methodology was registered with PROSPERO, and PRISMA guidelines were followed. MEDLINE, EMBASE, and the Cochrane Library were systematically searched. English studies investigating outcomes of nerve transfers in peroneal nerve palsy were included. Two reviewers completed screening and extraction. Methodological quality was evaluated with Newcastle-Ottawa Scale. RESULTS: Literature search identified 108 unique articles. Following screening, 14 full-text articles were reviewed. Four retrospective case series met inclusion criteria for meta-analysis. Overall, 41 patients underwent nerve transfer for peroneal nerve palsy. The mean age of the patients was 36.1 years, mean time to surgery was 6.3 months, and the mean follow-up period was 19.0 months. Donor nerve was either tibial (n = 36) or superficial peroneal branches/fascicles (n = 5). Recipient nerve was either deep peroneal (n = 24) or tibialis anterior branch (n = 17). Postoperative ankle dorsiflexion strength demonstrated a bimodal distribution with a mean Medical Research Council of 2.1. There were no significant differences in dorsiflexion strength between injury sites (p = 0.491), injury mechanisms (p = 0.125), donor (p = 0.066), or recipient nerves (p = 0.496). There were no significant correlations between dorsiflexion strength and patient age (p = 0.094) or time to surgery (p = 0.493). CONCLUSIONS: There is variability in dorsiflexion strength following nerve transfer in peroneal nerve palsy, whereby there appear to be responders and non-responders. Further studies are needed to better define appropriate patient selection and the role of nerve transfers in the management of peroneal nerve palsy.

Efficacy and safety of bilateral thoracic paravertebral blocks in outpatient breast surgery.

Unilateral thoracic paravertebral blocks (TPVBs) have demonstrated reliable intraoperative analgesia, low postoperative pain scores, and an opioid-sparing effect in breast cancer surgery. However, secondary to the perceived risk of complications, bilateral TPVB have been less well accepted and are less frequently used. The purpose of this study was to evaluate the feasibility of using bilateral TPVBs in outpatient surgery for patients undergoing bilateral mastectomy with immediate implant-based reconstruction. Electronic medical records were retrospectively reviewed for patients receiving bilateral TPVBs for bilateral mastectomy with immediate implant-based reconstruction performed by a single surgeon from September 2012 to September 2015. Records were reviewed for incidence of complications, time to discharge, and incidence of unplanned admission or readmission. Clopper-Pearson method for binomial distribution was used to calculate confidence intervals for proportions. Forty-five patients undergoing bilateral mastectomy with immediate reconstruction received bilateral TPVBs. There were 4 TPVB-related complications, all of which were symptomatic hypotension or bradycardia (9%; 95% CI, 2%-21%). There was no incidence of symptomatic pneumothorax. Mean time to discharge readiness from the postanesthesia care unit (PACU) was 1.9 hours (SD = 1.0). Overall, 91% (n = 29) of the 32 patients scheduled for day surgery were discharged home as planned. Mean time from entry to PACU to home discharge for day surgery patients (n = 32) and planned admissions (n = 13) was 5.9 hours (SD = 4.3) and 16.3 hours (SD = 3.6), respectively. There was no incidence of readmission following discharge. Bilateral TPVBs can safely facilitate day surgery in carefully selected patients undergoing bilateral mastectomy with immediate implant-based reconstruction.

Anomalous Extratemporal Facial Nerve in Oculoauriculovertebral Spectrum.

Facial nerve dysfunction is common in oculoauriculovertebral spectrum (OAVS). However, the course of the nerve has rarely been described. A 23-year-old woman with OAVS underwent excision of microtic ear remnants in preparation for an osseointegrated prosthesis and suffered iatrogenic transection of the facial nerve-the pes anserinus was within the subcutaneous tissue 15 mm posterior and 15 mm cephalad to the external acoustic meatus. The patient underwent primary nerve repair and regained nearly complete preoperative function. When considering reconstruction for OAVS patients, clinicians should have a high index of suspicion for anomalous facial nerve anatomy.

Economic Comparison of Hand-Sutured and Coupler-Assisted Microvascular Anastomoses.

BACKGROUND: Compared with hand-sewn anastomoses, microvascular anastomotic coupling devices (MACDs) provide equivalent flap survival and reduced operative time. To date, an economic analysis of MACDs has not been reported. The objective of this study was to evaluate the economics of a venous anastomosis performed using a coupling device compared with a hand-sewn anastomosis. METHODS: Economics were modeled for a single free tissue transfer (FTT) requiring one venous anastomosis performed with either hand-sewn sutures or with a coupler-assisted anastomosis using the GEM COUPLER. Fixed and variable costs incurred with each anastomotic technique were identified with an activity-based cost analysis. Price lists were retrieved from suppliers to quantify disposable costs and capital expenditures. Two literature reviews were executed to identify microsurgical operating room (OR) costs and operating time reductions with coupler-assisted anastomoses. RESULTS: For each venous anastomosis, the use of the anastomotic coupler increased disposable costs by $284.40 compared with a hand-sutured anastomosis. Total fixed and variable OR costs were $30.82 per minute. Operating time was reduced by a mean of 16.9 minutes with a coupler-assisted anastomosis, decreasing OR costs by $519.29. Total savings of $234.89 were generated for each coupler-assisted anastomosis, recuperating the device's capital expenditure after 13 uses. CONCLUSION: Compared with a hand-sewn venous anastomosis, an MACD produces savings with each case and quickly recoups the device's capital expenditure. Despite its limitations and simplicity, this study provides a practical economic analysis that can help inform purchasing decisions, particularly for smaller volume centers where the economic rationale may be less clear.

Alternative Nerve Coaptations: End-To-Side and Beyond.

Modern end-to-side (ETS) nerve transfers have undergone several permutations since the early 1990's. Preclinical data have revealed important mechanisms and patterns of donor axon outgrowth into the recipient nerves and target reinnervation. The versatility of ETS nerve transfers can also potentially address several processes that limit functional recovery after nerve injury by babysitting motor end-plates and/or supporting the regenerative environment within the denervated nerve. Further clinical and basic science work is required to clarify the ideal clinical indications, contraindications, and mechanisms of action for these techniques in order to maximize their potential as reconstructive options.

Outcomes of Nerve Transfers in Peroneal Nerve Palsy.

Background: The objective of this work is to: (i) evaluate the postoperative outcomes after lower extremity nerve transfer (LENT) in patients with peroneal nerve palsy, and (ii) evaluate the patient and surgical factors that best predict successful restoration of ankle dorsiflexion following nerve transfer. Methods: A retrospective cohort of prospectively collected data included all patients who underwent LENT (2010-2018). Two independent reviewers performed data collection. Primary outcome measures were: (i) clinically with British Medical Research Council (MRC) strength assessments, and (ii) electrodiagnostically with nascent motor unit potentials. Statistical analysis was performed using descriptive and nonparametric statistics. Results: Nine patients (56% male, mean age 38.3, range 18-57 years) underwent LENT surgery a mean of 4.3 months following injury (range 2.2-6.4 months). Mean follow-up was 15.6 months (range 9.1-28.2 months). Postoperatively, ankle dorsiflexion (P = .015) and ankle eversion (P = .041) increased significantly. After surgery, 44% achieved MRC 4, 33% obtained MRC 1 motor recovery, and 22% sustained MRC 0. A shorter time to surgery was associated with significantly better outcomes (P = .049). Conclusions: It appears that there is a bimodal distribution between responders and nonresponders to LENT for foot drop. Further research is required to elucidate patient and surgical factors that prognosticate success.

Contexte: Les objectifs de cette étude étaient les suivants : (i) évaluer les résultats postopératoires après un transfert de nerf dans le membre inférieur (LENT; lower extremity nerve transfer) chez des patients ayant une paralysie du nerf péronier et (ii) évaluer les facteurs propres au patient et à la chirurgie qui permettent de prédire le mieux possible le succès d'une restauration de la dorsiflexion de la cheville après le transfert nerveux. Méthodes: Une cohorte rétrospective de données collectées de façon prospective a inclus tous les patients ayant bénéficié d'un LENT de 2010 à 2018. Deux réviseurs indépendants ont réalisé la collecte des données. Les critères de jugement principaux étaient les suivants : (i) cliniques avec des évaluations de la force selon l'échelle MRC et (ii) électrodiagnostiques avec potentiels d'unités motrices naissantes. Une analyse statistique a été réalisée au moyen de statistiques descriptives et non paramétriques. Résultats: Neuf patients (hommes : 56%, âge moyen : 38,3 ans, extrêmes : 18 à 57 ans) ont subi une LENT, en moyenne 4,3 mois après une blessure (extrêmes : 2,2 à 6,4 mois). Le suivi moyen a été de 15,6 mois (extrêmes : 9,1 à 28,2 mois). En postopératoire, la dorsiflexion de la cheville (P = 015) et l'éversion de la cheville (P = 041) ont augmenté de façon significative. Après l'intervention chirurgicale, 44% des patients ont atteint un score de 4 sur l'échelle MRC, 33% ont obtenu une récupération motrice cotée à 1 et 22% ont conservé une cote MRC de 0. Un délai plus court avant la chirurgie a été associé à des résultats significativement meilleurs (P = .049). Conclusions: Il semble y avoir une répartition bimodale entre les répondeurs et les nonrépondeurs à la chirurgie de LENT pour la chute du pied. Des recherches supplémentaires sont nécessaires pour renseigner les facteurs pronostiques de succès liés au patient et à l'intervention chirurgicale.

Elevated Body Mass Index Negatively Impacts Recovery of Shoulder Abduction Strength in Triceps Motor Branch to Axillary Nerve Transfers.

BACKGROUND: The purpose of this work was to evaluate the clinical outcomes of triceps motor branch to axillary nerve transfers and to identify prognostic factors which may influence these outcomes. METHODS: A retrospective cohort included all patients who underwent a triceps motor branch to axillary nerve transfer (2010-2019) with at least 12 months of follow-up. The primary outcome measure was shoulder abduction strength assessed with British Medical Research Council (MRC) grade. RESULTS: Ten patients were included with a mean follow-up of 19.1 (SD 5.9) months. Compared with preoperative MRC shoulder abduction strength (0.2 SD 0.4), patients significantly improved postoperatively (2.8 SD 1.6; P = .005). Increased body mass index (BMI) was significantly associated with worse postoperative MRC (P = .014). CONCLUSION: Triceps motor branch to axillary nerve transfer is a beneficial procedure for restoring shoulder function in patients presenting with either isolated axillary nerve or brachial plexus pathology. Patients with elevated BMI may not have as robust strength recovery and should be counseled carefully regarding prognosis.

Clinical Outcomes of Upper Extremity Nerve Transfers in Neuralgic Amyotrophy.

SUMMARY: Neuralgic amyotrophy (NA) is a disease affecting peripheral nerves. Treatment has historically been conservative, as the natural course of the disease was thought to be self-limiting. Recent work has demonstrated that as many as two-thirds of people with NA have persistent pain, fatigue, or weakness. At the authors' center, supercharged end-to-side (SETS) nerve transfers are commonly performed in patients with NA to optimize motor recovery while allowing for native axonal regrowth. The authors describe the technique and clinical outcomes of patients with NA affecting the anterior interosseous nerve (AIN) who were treated with SETS nerve transfer from extensor carpi radialis brevis to AIN. Ten patients (90% male; mean age, 51.3 ± 9.7 years) underwent extensor carpi radialis brevis-to-AIN transfer at a mean period of 6.4 ± 1.4 months after onset of symptoms. Mean postoperative follow-up duration was 14.8 ± 3.2 months. Before surgery, all patients demonstrated clinically significant weakness in the flexor pollicis longus (FPL), flexor digitorum profundus muscle to the index finger (FDP2), or both. FPL strength improved from a median Medical Research Council (MRC) grade of 1.5 to 4 ( P = 0.011) and FDP2 strength improved from a median MRC grade of 1 to 5 ( P = 0.016). A postoperative MRC grade of 4 or greater was achieved in nine of 10 (90%) FPL and 10 of 10 (100%) FDP muscles. This is the first report of SETS nerve transfer for the treatment of NA. The outcomes of this work suggest that SETS nerve transfers may be an option to optimize motor outcomes in patients with NA. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

National Multidisciplinary Survey of Regional Anesthesia Preferences in Breast Reconstruction.

BACKGROUND: The purpose of this work was to determine the regional anesthesia preferences of plastic surgeons (PS) and anesthesiologists (A) involved in breast reconstruction in Canada. METHODS: Online surveys were sent to members of the Canadian Society of Plastic Surgeons (CSPS) and the Canadian Anesthesiologists Society (CAS). The primary outcome was regional anesthesia preferences in breast reconstruction (delayed, immediate, alloplastic, autologous). Secondary outcomes included the availability and the influence of specialty and academic status on preferences. Statistical analysis used descriptive statistics and Pearson χ2 test. RESULTS: Responses from CSPS and CAS totaled 141 (response rate = 30%) and 217 (response rate = 14%), respectively. Compared with non-academic centres (NAC), academic centres (AC) had significantly greater access to (AC = 60%, NAC = 39%, P = .001) and preferred to use regional anesthesia more often (AC = 36%, NAC = 10%, P < .001). The following proportions of physicians preferred to use regional anesthesia: 40% (PS = 32%, A = 44%, P = .081) for immediate alloplastic reconstruction, 23% (PS = 24%, A = 22%, P = .821) for delayed alloplastic reconstruction, 34% (PS = 18%, A = 41%, P < .001) for immediate autologous reconstruction, and 19% (PS = 13%, A = 21%, P = .195) for delayed autologous reconstruction. Regional anesthesia preferences were significantly different between plastic surgeons and anesthesiologists (P < .001)-anesthesiologists favoured paravertebral blocks for all reconstructions, while plastic surgeons favoured pectoral nerve blocks for immediate alloplastic reconstruction and intercostal nerve blocks for all other reconstructions. CONCLUSIONS: Plastic surgeons and anesthesiologists prefer not to use regional anesthesia in the majority breast reconstructions. Among those who deploy regional anesthesia, plastic surgeons and anesthesiologist have divergent preferences with respect to modality. There is a need for a prospective study comparing paravertebral blocks and intercostal nerve blocks.

HISTORIQUE: La présente étude visait à déterminer le type d'anesthésie régionale que préfèrent les plasticiens (P) et les anesthésiologistes (A) qui font de la reconstruction mammaire au Canada. MÉTHODOLOGIE: Les membres de la Société canadienne des chirurgiens plasticiens (SCCP) et de la Société canadienne des anesthésiologistes (SCA) ont reçu un sondage en ligne. Les préférences d'anesthésie régionale pour la reconstruction mammaire (reportée, immédiate, alloplastique, autologue) étaient le résultat primaire et l'accès à ce type d'anesthésie et l'influence des spécialités et des statuts universitaires sur les préférences, les résultats secondaires. Les chercheurs ont recouru aux statistiques descriptives et au test du chi carré pour procéder à l'analyse statistique. RÉSULTATS: Les membres de la SCCP et de la SCA ont donné 141 (30 %) et 217 (14 %) réponses, respectivement. Par rapport aux centres non universitaires (CNU), les centres universitaires (CU) avaient un accès considérablement supérieur (CU = 60 %, CNU = 39 %, p = 0,001) à l'anesthésie régionale et l'utilisaient plus souvent (CU = 36 %, CNU = 10 %, p < 0,001). Les proportions suivantes de médecins préféraient utiliser l'anesthésie régionale : 40 % (P = 32 %, A = 44 %, p = 0,081) pour la reconstruction alloplastique immédiate, 23 % (P = 24 %, A = 22 %, p = 0,821) pour la reconstruction alloplastique reportée, 34 % (P = 18 %, A = 41 %, p < 0,001) pour la reconstruction autologue immédiate et 19 % (P = 13 %, A = 21 %, p = 0,195) pour la reconstruction autologue reportée. Les préférences quant à l'anesthésie régionale différaient considérablement entre les P et les A (p < 0,001). En effet, les A préféraient les blocs paravertébraux pour toutes les reconstructions et les P, les blocs nerveux pectoraux pour la reconstruction alloplastique immédiate et les blocs nerveux intercostaux pour toutes les autres reconstructions. CONCLUSIONS: Les P et les A préfèrent ne pas recourir à l'anesthésie régionale lors de la majorité des reconstructions mammaires. Chez ceux qui optent pour l'anesthésie régionale, les P et les A ont des préférences divergentes quant à la modalité à retenir. Une étude prospective comparant les blocs paravertébraux aux blocs nerveux intercostaux s'impose.

The rule of thirds: Determining the ideal areolar proportions.

BACKGROUND: Breast surgery often requires changing the diameter of the areola. Recommended areolar size is commonly based on population averages, or surgical judgement. An ideal areola size has not been previously been described. We hypothesized that the ideal areolar diameter would be proportional to two breast measurements not commonly altered during breast surgery: the nipple diameter and breast base width. METHODS: 'The Sun' newspaper (London, UK) publishes photographs of topless models which are selected based on the aesthetic appeal of their non-operated breasts. The publication's archive, from March 2014 to January 2017, was independently reviewed by three authors to identify photographs that presented a clear anterior view of the breast. The base width, nipple diameter and areolar diameter were measured independently by each reviewer. Measurements were pooled, and the mean was included for analysis. Ratios of the areolar diameter to the base width and the nipple diameter were calculated. RESULTS: The photographs of 58 models were eligible for inclusion. The average areolar diameter to base width was 0.29 (SD = 0.05). The average nipple to areolar diameter was 0.29 (SD = 0.06). CONCLUSIONS: In aesthetically pleasing breasts, the areolar diameter is proportional to both the breast base width and nipple diameter. Breast base width is commonly measured preoperatively in aesthetic breast procedures, and is not typically modified. Breast base width can therefore be used to determine the ideal areolar size using the ratio of areola:base width ratio of 0.29 identified in this study.

Evaluation of Intrinsic Hand Musculature Reinnervation following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer.

Supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer is commonly performed in the authors' institution to augment intrinsic hand function. Following observations of recovery patterns, the authors hypothesized that despite its more distal innervation, the first dorsal interosseous muscle recovers to a greater extent than the abductor digiti minimi muscle. The objective of this work was to evaluate the clinical and electrodiagnostic pattern of reinnervation of intrinsic hand musculature following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. A retrospective cohort of prospectively collected data included all patients who underwent a supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. Two independent reviewers performed data collection. Reinnervation was assessed with two primary outcome measures: (1) clinically, with serial Medical Research Council strength assessments; and (2) electrodiagnostically, with serial motor amplitude measurements. Statistical analysis was performed using nonparametric statistics. Seventeen patients (65 percent male; mean age, 56.9 ± 13.3 years) were included with a mean follow-up of 16.7 ± 8.5 months. Preoperatively, all patients demonstrated clinically significant weakness and electrodiagnostic evidence of denervation. Postoperatively, strength and motor amplitude increased significantly for both the first dorsal interosseous muscle (p = 0.002 and p = 0.016) and the abductor digiti minimi muscle (p = 0.044 and p = 0.015). Despite comparable preoperative strength (p = 0.098), postoperatively, the first dorsal interosseous muscle achieved significantly greater strength when compared to the abductor digiti minimi muscle (p = 0.023). Following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer, recovery of intrinsic muscle function differs between the abductor digiti minimi and the first dorsal interosseous muscles, with better recovery observed in the more distally innervated first dorsal interosseous muscle. Further work to elucidate the underlying physiologic and anatomical basis for this discrepancy is indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Harvesting the 'SEAD': Long-Term Follow-Up of the Surgical Exploration and Discovery Program.

OBJECTIVE: The Surgical Exploration and Discovery (SEAD) program was established to facilitate career decision-making by providing preclerkship students with comprehensive exposure to surgical specialties. Our short-term findings demonstrated that, compared to a control group, SEAD participants showed significantly greater career-related learning. The purpose of this study was to understand the long-term impact of the SEAD program. DESIGN: This was a prospective cohort study. One group of students participated in a 2-week surgical curriculum (SEAD group) while another group read only the program manual (Manual group). Students were surveyed following their residency selection 3 years later. The outcome measures were final specialty preference (medical or surgical), program utility, and program satisfaction. SETTING: Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada. PARTICIPANTS: A total of 18 medical students in the SEAD group, and 18 in the Manual group. RESULTS: Survey response rate was 100%. There was no significant difference in the number of students who pursued surgical careers in the SEAD and Manual groups. All students who pursued a surgical residency were 'very interested' in surgery prior to SEAD-initial interest in surgery had a significant influence on final residency preference. Ninety-four percent (n = 17) of SEAD participants described the SEAD program as valuable to facilitating their career decision-making. CONCLUSIONS: Although SEAD does not generate sustained new interest in surgical disciplines, graduating students believe the program is valuable in facilitating career decision-making and perceive the program as a worthwhile time investment. These findings were true for students who selected both surgical and medical specialties, suggesting that early, multifaceted, exposure to surgery is a valuable addition to career exploration even for students who ultimately don't pursue surgical specialties. Going forward, integrating a longitudinal mentorship program may further improve the value of SEAD.

Economics of Lymphovenous Bypass.

BACKGROUND: The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema. METHODS: Economics were modeled for a patient with breast cancer-related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated. RESULTS: The estimated net present value of all costs for a patient with breast cancer-related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient's life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy. CONCLUSIONS: Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone-the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.

Reinnervation of Extrinsic Finger Flexors and Brachioradialis 22 and 36 Months Following Traumatic Pan-Brachial Plexopathy: A Case Report.

A 25-year-old man sustained a right-sided brachial plexus injury from a high-velocity motocross accident. Physical examination and electromyography were consistent with a pan-brachial plexopathy with no evidence of axonal continuity. The patient underwent a spinal accessory to suprascapular nerve transfer and an intercostal to musculocutaneous nerve transfer with interpositional sural nerve grafts. He recovered MRC 4/5 elbow flexion and MRC 2/5 shoulder abduction and external rotation. Twenty-two months post-injury the patient displayed a flicker of flexion of his flexor pollicis longus and flexor digitorum profundus to his index finger - he went on to recover a functional pinch. Thirty-six months post-injury the patient displayed a flicker of contraction in brachioradialis with motor unit potentials on electromyography. This case demonstrates that some patients may have capacity for functional recovery after prolonged denervation and highlights the potential impact of anatomical anomalies in the assessment and treatment of peripheral nerve injuries.