A comparative study using electromyography to assess hand exercises for rehabilitation after ulnar nerve decompression.

Ulnar nerve (UN) entrapment is a common peripheral neuropathy and can lead to dysfunction of both sensory and motor function of the hand. Surgical release is the mainstay of treatment, but post-operative rehabilitation of UN innervated intrinsic muscles is lacking evidence. This cohort study utilized surface electromyography (EMG) and assessed the activation of UN innervated intrinsic and extrinsic hand muscles during four exercises in healthy participants. Exercises included rotating baoding balls, squeezing a stress ball or grip device every second, and repetitive finger abduction against a rubber band. Normalized percent activation of each muscle was calculated for each exercise. It was demonstrated that rubber band resistance (RBR) finger abduction showed significantly increased activation in both intrinsic muscles tested, while minimizing activation of the one tested UN innervated extrinsic muscle. Thus, to best target the intrinsic hand muscles without fatiguing extrinsic muscles, the inexpensive and practical RBR exercise is beneficial in post-UN release rehabilitation.

The Canadian Plastic Surgery Workforce Analysis: Forecasting Future Need.

BACKGROUND: Projecting the demand for plastic surgeons has become increasingly important in a climate of scarce public resource within a single payer health-care system. The goal of this study is to provide a comprehensive workforce update and describe the perceptions of the workforce among Canadian Plastic Surgery residents and surgeons. METHODS: Two questionnaires were developed by a national task force under the Canadian Plastic Surgery Research Collaborative. The surveys were distributed to residents and practicing surgeons, respectively. RESULTS: Two-hundred fifteen (49%) surgeons responded, with a mean age of 51.4 years (standard deviation [SD] = 11.5); 78% were male. Thirty-three percent had been in practice for 25 years or longer. More than half of respondents were practicing in a large urban center. Fifty-nine percent believed their group was going to hire in the next 2 to 3 years; however, only 36% believed their health authority/provincial government had the necessary resources. The mean desired age of retirement was 67 years (SD = 6.4). We predict the surgeons-to-population ratio to be 1.55:100 000 and the graduate-to-retiree ratio to be 2.16:1 within the next 5 to 10 years. Seventy-seven (49%) residents responded. Most were "very satisfied" with their training (61%) and operative experience (90%). Eighty-nine percent of respondents planned to pursue addqitional training after residency, with 70% stating that the current job market was contributing to their decision. Most residents responded that they were concerned with the current job market. CONCLUSIONS: The results of this study predict an adequate number of plastic surgeons will be trained within the next 10 years to suit the population's requirements; however, there is concern that newly trained surgeons will not have access to the necessary resources to meet growing demands. Furthermore, there is an evident shortage of those practicing in rural areas. Many trainees worry about the availability of jobs, despite evidence of active recruitment. The workforce may benefit from structured career mentorship in residency and improved transparency in hiring practices, particularly to attract young surgeons to smaller communities. It may also benefit from a coordinated national approach to recruitment and succession planning.

HISTORIQUE: Il est de plus en plus important de projeter la demande de plasticiens compte tenu des ressources publiques rares dans un système de santé à un seul payeur. La présente étude vise à présenter une mise à jour complète des effectifs et à décrire les perceptions de la main-d'œuvre chez les résidents et les chirurgiens canadiens en chirurgie plastique. MÉTHODOLOGIE: Un groupe de travail national relevant du Canadian Plastic Surgery Research Collaborative a créé deux questionnaires, qui ont été distribués respectivement aux résidents et aux chirurgiens en exercice. RÉSULTATS: Deux cent quinze chirurgiens (49 %), d'un âge moyen de 51,4 ans (ÉT = 11,5) ont répondu; 78 % étaient de sexe masculin. Trente-trois pour cent exerçaient depuis au moins 25 ans. Plus de la moitié exerçait dans un grand centre urbain. Cinquante-neuf pour cent pensaient que leur groupe embaucherait dans les deux à trois années suivantes, mais seulement 36 % étaient d'avis que leur autorité sanitaire ou leur gouvernement provincial possédait les ressources nécessaires. En moyenne, les répondants souhaitaient prendre leur retraite à 67 ans (ÉT = 6,4). Les chercheurs prédisent que le ratio entre les chirurgiens et la population serait de 1,55:100 000, et que le ratio entre les diplômés et les retraités serait de 2,16:1 d'ici cinq à dix ans. Soixante-dix-sept résidents (49 %) ont répondu. La plupart étaient « très satisfaits ¼ de leur formation (61 %) et de leur expérience opératoire (90 %). Quatre-vingt-neuf pour cent planifiaient poursuivre leur formation après la résidence, et 70 % affirmaient que le marché du travail actuel contribuait à leur décision. La plupart des résidents ont répondu qu'ils étaient inquiets du marché du travail actuel. CONCLUSIONS: Selon les résultats de cette étude, un nombre suffisant de plasticiens seront formés d'ici dix ans pour répondre aux besoins de la population, mais on craint que les chirurgiens nouvellement formés n'aient pas accès aux ressources nécessaires pour répondre à la demande croissante. De plus, on constate une pénurie évidente en région rurale. De nombreux résidents s'inquiètent de la disponibilité des emplois malgré des preuves de recrutement actif. La main-d'œuvre pourrait profiter d'un mentorat professionnel structuré en résidence et d'une plus grande transparence des pratiques d'embauche, particulièrement pour attirer de jeunes chirurgiens dans de plus petites localités. Elle pourrait également profiter d'une approche nationale coordonnée du recrutement et de la planification de la succession.

Visual Estimation of Dupuytren's Flexion Contractures-A Prospective Comparative Trial.

PURPOSE: Surgeons and resident physicians in a clinic setting often visually estimate Dupuytren flexion contractures of the hand to follow disease progression and decide on management. No previous study has compared visual estimates with a standardized instrument to ensure measurement reliability. METHODS: Consecutive patients consulted for Dupuytren flexion contractures of the hand had individual joint contractures estimated in degrees (°) by both a resident physician and staff surgeon. Estimates were compared with goniometer measurements to generate intraclass correlation coefficients (ICCs), and residents and surgeons were compared based on their accuracy. RESULTS: Twenty-eight patients enrolled in this study, which provided a total of 80 hand joints for analysis. Resident physicians achieved an ICC of 0.42, which indicates poor reliability. The hand surgeon achieved an ICC of 0.86, which indicates high reliability. The surgeon also had better accuracy than the residents. CONCLUSION: Hand surgeons should be mindful of the limitations of visual estimates of Dupuytren flexion contractures, particularly when conducted by trainees. Joint angle measurements taken for the purposes of research should be done with a goniometer at minimum.

OBJECTIFS: Les chirurgiens et les résidents en milieu clinique font souvent une évaluation visuelle des contractures de Dupuytren pour suivre l'évolution de la maladie et prendre des décisions thérapeutiques. Aucune étude n'a comparé les évaluations visuelles à un instrument standardisé pour garantir la fiabilité de la mesure. MÉTHODOLOGIE: Des patients consécutifs qui avaient consulté en raison de contractures de Dupuytren avaient des contractures articulaires individuelles qu'un résident et un plasticien ont évaluées en degrés. Les auteurs ont ensuite comparé les résultats à des mesures goniométriques pour produire des coefficients de corrélation intraclasse (CCI), puis ont comparé la précision des résidents à celle des plasticiens. RÉSULTATS: Vingt-huit patients ont participé à l'étude, pour un total de 80 articulations de la main pouvant être analysées. Les résidents ont obtenu un CCI de 0,42, ce qui fait foi d'une faible fiabilité. Le plasticien de la main a obtenu un CCI de 0,86, ce qui est indicateur d'une fiabilité élevée. Les résultats du plasticien étaient également plus précis que ceux des résidents. CONCLUSION: Les plasticiens de la main devraient être conscients des limites des évaluations visuelles des contractures de Dupuytren, particulièrement lorsqu'elles sont effectuées par des stagiaires. À tout le moins, il faudrait utiliser un goniomètre pour effectuer les mesures d'angle des articulations obtenues aux fins de la recherche.

Variations in the Anatomical Structures of the Guyon Canal.

BACKGROUND: Compression neuropathy of the ulnar nerve at the Guyon canal is commonly seen by hand surgeons. Different anatomical variations of structures related to the Guyon canal have been reported in the literature. A thorough knowledge of the normal contents and possible variations is essential during surgery and exploration. OBJECTIVES: To review the recognized anatomical variations within and around the Guyon canal. METHODS: This study is a narrative review in which relevant papers, clinical studies, and anatomical studies were selected by searching electronic databases (PubMed and EMBASE). Extensive manual review of references of the included studies was performed. We also describe a case report of an aberrant muscle crossing the Guyon canal. RESULTS: This study identified several variations in the anatomical structures of the Guyon canal reported in the literature. Variations of the ulnar nerve involved its course, branching pattern, deep motor branch, superficial sensory branch, dorsal cutaneous branch, and the communication with the median nerve. Ulnar artery variations involved its course, branching pattern, the superficial ulnar artery, and the dorsal perforating artery. Aberrant muscles crossing the Guyon canal were found to originate from the antebrachial fascia, pisiform bone, flexor retinaculum, the tendon of palmaris longus, flexor carpi ulnaris, or flexor carpi radialis; these muscles usually fuse with the hypothenar group. CONCLUSION: The diverse variations of the contents of the Guyon canal were adequately described in the literature. Taking these variations into consideration is important in preventing clinical misinterpretation and avoiding potential surgical complications.

HISTORIQUE: Les chirurgiens de la main observent souvent une neuropathie par compression du nerf ulnaire au niveau de la loge de Guyon. Les publications font état de diverses variations anatomiques des structures liées à la loge de Guyon. Il est essentiel d'avoir une connaissance approfondie des contenus normaux et des variations possibles pendant l'opération et l'exploration. OBJECTIFS: Analyser les variations anatomiques connues dans la loge de Guyon et à proximité. MÉTHODOLOGIE: La présente étude est une analyse narrative pour laquelle les auteurs ont sélectionné les articles pertinents, les études cliniques et les études anatomiques après des recherches dans des bases de données électroniques (PubMed et EMBASE). Ils ont procédé à un dépouillement manuel approfondi des études retenues. Ils décrivent également le rapport de cas d'un muscle aberrant traversant la loge de Guyon. RÉSULTATS: La présente étude a permis de constater plusieurs variations des structures anatomiques de la loge de Guyon exposées dans les publications. Les variations du nerf ulnaire incluaient le trajet, le mode de ramification, la branche motrice profonde, la branche sensorielle superficielle, la branche cutanée dorsale et la communication avec le nerf médian. Les variations de l'artère ulnaire incluaient le trajet, le mode de ramification, l'artère ulnaire superficielle et l'artère perforante dorsale. Les muscles aberrants qui traversaient la loge de Guyon provenaient du fascia antébrachial, de l'os pisiforme, du rétinaculum des fléchisseurs, du tendon du fléchisseur radial du carpe, du fléchisseur ulnaire du carpe ou du fléchisseur radial du carpe. Ces muscles fusionnent habituellement avec le groupe de l'éminence hypothénar. CONCLUSION: Les diverses variations des contenus de la loge de Guyon étaient bien décrites dans les publications. Il est important d'en tenir compte pour prévenir les mauvaises interprétations cliniques et éviter les complications chirurgicales.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review.

PURPOSE: To determine the role of night orthosis use after surgical correction of Dupuytren contracture. METHODS: We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument. RESULTS: Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups. CONCLUSIONS: The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sensory outcomes following brachial plexus birth palsy: A systematic review.

BACKGROUND: Brachial plexus birth palsy (BPBP) affects approximately 1.5 in 1000 live births and can lead to significant functional impairment and reduced quality of life. To date, studies have focused on grading motor function and strength to assess patient outcomes, with less attention paid to sensory recovery. The authors aimed to systematically review the current literature on sensory outcomes following BPBP. METHODS: A systematic review of the best evidence available assessing sensory outcomes following BPBP was conducted. Two independent reviewers used a predefined search strategy to query Cochrane, MEDLINE, EMBASE, and Web of Science databases. Articles written in English reporting sensory outcomes in patients with BPBP, such as tactile sensation, pain, and proprioception, were included for review. A kappa score was calculated to ensure reviewer agreement. RESULTS: Twenty-nine reports with 1647 cases were included. Tactile sensation was most frequently assessed (75.9%), followed by pain (44.8%) and proprioception (17.2%). Among all cases included in the analysis, 75.8% of articles were found to have patients with suboptimal results in sensory outcomes. The majority of articles (86.2%) were case series or case reports; no level 1 or 2 evidence studies were identified. CONCLUSION: Sensory outcomes are underreported following BPBP, and significant deficits and neuropathic pain are not uncommon and likely underappreciated in this patient population. The current report underscores the need for prospective studies that look beyond motor recovery alone and evaluate sensory outcomes following BPBP.

Structured simulation improves learning of the Fundamental Use of Surgical Energy™ curriculum: a multicenter randomized controlled trial.

BACKGROUND: Energy devices can result in devastating complications to patients. Yet, they remain poorly understood by trainees and surgeons. A single-institution pilot study suggested that structured simulation improves knowledge of the safe use of electrosurgery (ES) among trainees (Madani et al. in Surg Endosc 28(10):2772-2782, 2014). The purpose of this study was to estimate the extent to which the addition of this structured bench-top simulation improves ES knowledge across multiple surgical training programs. METHODS: Trainees from 11 residency programs in Canada, the USA and UK participated in a 1-h didactic ES course, based on SAGES' Fundamental Use of Surgical Energy™ (FUSE) curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediately and 3 months after) knowledge of the safe use of ES was assessed using separate examinations. Data are expressed as mean (SD) and N (%), *p < 0.05. RESULTS: A total of 289 (145 control; 144 Sim) trainees participated, with 186 (96 control; 90 Sim) completing the 3-month assessment. Baseline characteristics were similar between the two groups. Total score on the examination improved from 46% (10) to 84% (10)* for the entire cohort, with higher post-curriculum scores in the Sim group compared with controls [86% (9) vs. 83% (10)*]. All scores declined after 3 months, but remained higher in the Sim group [72% (18) vs. 64% (15)*]. Independent predictors of 3-month score included pre-curriculum score and participation in a goal-directed simulation. CONCLUSIONS: This multi-institutional study confirms that a 2-h curriculum based on the FUSE program improves surgical trainees' knowledge in the safe use of ES devices across training programs with various geographic locations and resident volumes. The addition of a structured interactive bench-top simulation component further improved learning.

Nerve entrapment: update.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the pathophysiology of chronic nerve compression. 2. Describe the evaluation of a patient presenting with compression neuropathy. 3. Discuss the current controversies in the management of compression neuropathies. 4. Describe the treatment of common compression neuropathies, including carpal and cubital tunnel syndromes. SUMMARY: Nerve entrapment syndromes are common in the general population, and are managed by a wide variety of medical and surgical specialists. A thorough understanding of the pathophysiology of nerve compression and appropriate clinical workup are critical in the overall management of these conditions. There remain several topics of controversy regarding the surgical management of nerve entrapment syndromes, including multiple points of nerve compression, carpal tunnel release under local anesthesia, open versus endoscopic decompression surgery, the "best" operation for primary cubital tunnel surgery, and revision decompression surgery. This article attempts to provide a concise summary of the advances in the basic and clinical science of peripheral nerve entrapment.

Delayed immediate surgery for orbital floor fractures: Less can be more.

Orbital floor fractures can result in diplopia, enophthalmos, hypoglobus and infraorbital dysthesia. Currently, the most common treatment for orbital floor fractures is immediate surgical intervention. However, there are a number of well-documented cases of unoperated orbital floor fractures in the literature, culminating in diplopia or enophthalmos in few patients. Of these, none reported the diplopia or enophthalmos to be bothersome. As reported previously in the ophthalmology literature, most orbital floor fracture-induced diplopia resolves as the swelling settles, and the few patients with remaining diplopia can successfully be treated with surgery on the uninvolved eye. It has also been commented that most patients with enophthalmos are asymptomatic. The authors' institution has more than 50 surgeon-years experience with delaying immediate surgery for two weeks to allow time for the swelling-induced diplopia to resolve. In the authors' experience, true entrapment of the inferior rectus muscle is rare. The present article describes a study of late follow-up (average 945 days) of 11 nonoperated patients with orbital floor fractures. In the eight patients who initially presented with diplopia, there was resolution of functionally limiting double vision. Only one patient had asymptomatic, but measurably significant, enophthalmos at -3 mm. All patients had full restoration of extraocular movements and resolution of infraorbital dysthesia. None of the patients were exposed to the operative risks of ectropion, infection, implant extrusion, bleeding or blindness. The present study provides level IV evidence that delaying surgery up to two weeks after orbital floor fracture may avoid unnecessary surgical risks and inconveniences in many patients with orbital floor fracture.

Explicit warnings reduce but do not eliminate the continued influence of misinformation.

Information that initially is presumed to be correct, but that is later retracted or corrected, often continues to influence memory and reasoning. This occurs even if the retraction itself is well remembered. The present study investigated whether the continued influence of misinformation can be reduced by explicitly warning people at the outset that they may be misled. A specific warning--giving detailed information about the continued influence effect (CIE)--succeeded in reducing the continued reliance on outdated information but did not eliminate it. A more general warning--reminding people that facts are not always properly checked before information is disseminated--was even less effective. In an additional experiment, a specific warning was combined with the provision of a plausible alternative explanation for the retracted information. This combined manipulation further reduced the CIE but still failed to eliminate it altogether.