The Risk of Lymphedema After Breast Cancer Surgery Should Not Restrict Necessary Hand Surgery Interventions.

BACKGROUND: The purpose of this study was to evaluate the incidence of lymphedema onset or exacerbation in patients undergoing upper extremity interventions, both nonoperative and operative, after breast cancer surgery. METHODS: The study inclusion criteria were the following: (1) prior history of breast cancer surgery or lymphedema from the cancer; (2) upper extremity intervention, ipsilateral to the breast cancer side; and (3) follow-up of at least 1 month. Patients were evaluated for demographic information, type of breast cancer procedure and hand intervention, number of lymph nodes dissected, preexisting lymphedema, exacerbation of lymphedema, and new-onset lymphedema. RESULTS: A total of 161 patients undergoing 385 hand interventions (300 injections, 85 surgeries) were reviewed. Median follow-up was 31 months (range: 1-110). Nineteen patients had preexisting lymphedema ipsilateral to the hand procedure and none experienced an exacerbation of their lymphedema. Three patients developed new-onset lymphedema ipsilateral to their hand intervention at an average follow-up of 30 months (range: 4-67). One patient had a single injection and developed lymphedema over 5 years later. One had 2 injections in the same hand on the same date and developed lymphedema 3 months later. The third patient had 2 injections in the right hand, 1 injection and 1 surgery in the left hand, and developed either lymphedema or swelling due to rheumatoid arthritis in the right hand 1 year after the injections. CONCLUSIONS: Patients who have undergone breast cancer surgery can safely undergo upper extremity intervention with low risk of lymphedema exacerbation or onset.

Tendon Transection Healing Can Be Improved With Adipose-Derived Stem Cells Cultured With Growth Differentiation Factor 5 and Platelet-Derived Growth Factor.

BACKGROUND: As hand surgeons, tendon injuries and lacerations are a particularly difficult problem to treat, as poor healing potential and adhesions hamper optimal recovery. Adipose-derived stem cells (ADSCs) have been shown to aid in rat Achilles tendon healing after a puncture defect, and this model can be used to study tendon healing in the upper extremity. We hypothesized that ADSCs cultured with growth differentiation factor 5 (GDF5) and platelet-derived growth factor (PDGF) would improve tendon healing after a transection injury. METHODS: Rat Achilles tendons were transected and then left either unrepaired or repaired. Both groups were treated with a hydrogel alone, a hydrogel with ADSCs, or a hydrogel with ADSCs that were cultured with GDF5 and PDGF prior to implantation. Tissue harvested from the tendons was evaluated for gene expression of several genes known to play an important role in successful tendon healing. Histological examination of the tendon healing was also performed. RESULTS: In both repaired and unrepaired tendons, those treated with ADSCs cultured with GDF5/PDGF prior to implantation showed the best tendon fiber organization, the smallest gaps, and the most organized blood vessels. Treatment with GDF5/PDGF increased expression of the protenogenesis gene SOX9, promoted cell-to-cell connections, improved cellular proliferation, and enhanced tissue remodeling. CONCLUSIONS: Adipose-derived stem cells cultured with GDF5/PDGF prior to implantation can promote tendon repair by improving cellular proliferation, tenogenesis, and vascular infiltration. This effect results in a greater degree of organized tendon healing.

Single Incision Modified Tension Slide Technique in Distal Biceps Repair: Improved Load to Failure While Reducing Surgical Pitfalls.

Historically, distal biceps tendon repair through the tension slide technique (TST) using a cortical button has yielded the strongest published repair measured by observed gap formation in both cyclic and maximal load to failure. The modified tension slide technique (MTST) was developed in order to provide the surgeon with a technically simpler and biomechanically more effective way to reduce gap formation and consistently seat/bottom-out the tendon within the bone tunnel through a more direct line of pull. In order to compare the biomechanics of the MTST to the TST, we used 24 matched bovine extensor tendons, and conducted maximal load to failure and cyclical load to failure testing using an Instron 5566 machine. The mean maximal load to failure for the MTST was 444 N versus 229 N for the TST ( P <0.004) while no gap formation was observed in either group after cyclic load testing. These findings indicate that the MTST has a statistically significant increased load to gap formation of ∼2-fold in comparison to TST. In the MTST both limbs of suture are passed back through the tendon, before button implantation, eliminating the "operating in a hole" effect required in the TST, and making for a simpler surgical procedure.

Management of de Quervain Tenosynovitis: A Critical Analysis Review.

¼: Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments. ¼: For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby. ¼: When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision. ¼: For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury. ¼: Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Did COVID-19 related delays in surgical management lead to patient morbidity in the orthopaedic oncological population?

AIMS: The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. METHODS: A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. RESULTS: Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. CONCLUSION: COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236-242.

Parastomal hernia repair using the "top hat" technique - An initial experience in 30 patients at Memorial Sloan Kettering Cancer Center.

Parastomal hernia repair remains a significant surgical challenge. Recurrence after standard "keyhole" or primary suture repair is common. We adopted and modified a new technique using a construct shaped like an inverted top hat. We review our experience over the last six years in the first 30 patients (31 consecutive procedures). Of these 31 procedures, six (19%) resulted in a parastomal hernia recurrence with a median follow-up of 31 months (range 0.5-80). Four of the recurrences occurred in our initial experience, when we constructed the top hat of xenograft alone. When the technique was modified, using a synthetic composite mesh for the underlay portion of the hat, there were only two subsequent recurrences in 16 patients (13%) with a median follow-up of 22 months. One of these "recurrences" was secondary to infection of the top hat construct, which had to be removed. This initial success in preventing recurrence of parastomal hernia is probably due to the design of the construct, for it occludes the vulnerable stoma/fascial angle, through which most parastomal hernia recurrences occur.

Myoepithelial carcinoma of the extremity: Response to isolated limb infusion.

We report our experience with two patients with myoepithelial carcinoma (MEC) of the extremity. An 83-year-old male and a 35-year-old female were treated with standard isolated limb infusion (ILI), using melphalan and dactinomycin. The first patient had a complete response (CR) that was sustained for two and a half years, until he developed a regional lymph node metastasis. The second patient had a 4.7 cm tumor located on her left hand with metastasis to the ipsilateral axillary lymph nodes. Initial treatment consisted of ILI and left axillary lymphadenectomy. The primary tumor regressed and showed signs of central necrosis, measuring 2.8 cm after 1 month. Though she was continuing to respond, a decision was made by her orthopedic surgeon to administer neoadjuvant radiation followed by surgical resection.