Joint Denervation in the Digits: Technique and Patient Satisfaction.

BACKGROUND: Traditional approaches to treating painful osteoarthritis of the fingers include arthrodesis and arthroplasty. Although highly effective for pain control, arthrodesis sacrifices joint motion and can be complicated by nonunion, malunion, and infection.Implant arthroplasty preserves motion but is likewise subject to complications-particularly at the level of the proximal interphalangeal joint. In contrast, finger joint denervation is a simple outpatient procedure that maintains joint motion. In this study, we describe our surgical techniques for joint denervation and review our survey of patient satisfaction. METHODS: A retrospective review was performed of all patients undergoing finger joint denervation for osteoarthritis at our institution from 2012 to 2014. Each patient was contacted by phone and asked to rate their pre- and postoperative pain and function.Patients were also asked about any complications experienced and if they would choose to undergo the operation again. RESULTS: Over the 2-year period, 12 patients underwent denervation of 23 joints. Of the 12 patients in the study, 11 undergoing 22 joint denervations were available for our survey. Patient-reported pain scores fell from a median of 5/5 preoperatively to 0/5 after recovery (P < 0.001). Perceived hand function improved from a preoperative reported median of 2/5 to a postoperative median of 5/5 (P < 0.001). Complications were few, and 9 of 11 patients said they would choose to have the operation again. CONCLUSIONS: Joint denervation is a safe and effective treatment modality for osteoarthritis of the digits, resulting in good pain relief and high patient satisfaction with low complication rates.

Axillary Lymph Node Dissection Is a Risk Factor for Major Complications After Immediate Breast Reconstruction.

BACKGROUND: Complications after immediate breast reconstruction pose a significant challenge to the reconstructive surgeon. Known risk factors include smoking, obesity, age, and adjuvant oncologic therapies. Less is known about the association between axillary lymph node dissection (ALND) and the development of postoperative complications. METHODS: We conducted a retrospective study of all patients who underwent immediate breast reconstruction after mastectomy at our institution over a 10-year period. Our outcome was an occurrence of a major complication within 90 days postoperatively. For each patient, we recorded data on demographics, smoking status, pertinent medical history, reconstruction type, adjuvant chemotherapy and radiation, tumor pathology, and whether an ALND was performed. Odds ratios (OR) were calculated to estimate the risk of a complication if an ALND was performed. RESULTS: One hundred eighty-four women, with 270 surgically treated breasts, were identified as having mastectomy with immediate reconstruction between 2002 and 2012. Mean age was 49.4 years (range, 25-84 years). There were 71 mastectomies with ALND performed, with 22 complications, and 199 mastectomies without ALND, with 20 complications (31% complication rate vs 10%, respectively; OR, 3.84; P < 0.001). When adjusted for reconstruction type, smoking history, obesity, age, presence of invasive disease, chemotherapy, and radiation therapy, the OR for complications was 3.49 (P < 0.01). The most common complication was infection in both groups. CONCLUSIONS: Mastectomy with ALND is associated with a 3-fold increase in risk of major complications in women undergoing immediate breast reconstruction, even after adjustment for known risk factors and confounders. Further studies are warranted to elucidate how ALND leads to these complications and what measures can reduce their occurrence.

Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BACKGROUND: The pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. METHODS: Fifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. RESULTS: Forty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. CONCLUSIONS: Overall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.