Timely Shaver Treatment Removes Chronic Tophaceous Mass Improve Surgical Outcomes.

Background: Current treatments with urate-lowering therapy (ULT) are effective for most patients with gout. However, approximately 10% of these patients do not respond well to ULT and develop chronic tophus lesions. Objective: This study aimed to evaluate the efficacy of surgery involving the shaver technique against chronic tophus lesions. Methods: This single-center, retrospective cohort study included 217 patients who had cumulatively undergone 303 shaver-assisted procedures between 2002 and 2018. Surgical outcomes were assessed in terms of the length of hospital stay (LOS) and wound healing time. Results: LOS and wound healing time were longer in patients with a preoperative tophus infection and lower extremity lesions than in those without infection and with upper extremity lesions (respectively, LOS: 12.7 vs. 8.6 days; wound healing time: 22.7 vs. 16.3 days). However, factors such as age, sex, body mass index, renal function, or uricemia level exerted no significant effect on surgical outcomes. Conclusion: Surgery involving the shaver technique should be performed before tophus infection. Clinical outcomes tend to be better for upper extremity lesions than for lower extremity lesions.

Preoperative Evaluation for Free Functional Muscle Transfer in Upper Extremity Amyoplasia: A Multicenter Report of 3 Cases.

CASE: A multicenter series of 3 patients with amyoplasia of the upper extremity were indicated for gracilis free functional muscle transfer (FFMT) to restore elbow flexion and found to have an absent gracilis. A final case is discussed detailing standardized evaluation with ultrasound to confirm gracilis before surgical intervention. CONCLUSION: In amyoplasia, the gracilis muscle may be absent or have fatty infiltration, making this donor muscle inadequate. Preoperative ultrasound to determine the presence of the gracilis is noninvasive and recommended in patients with amyoplasia of the upper extremity being considered for FFMT.

Using Next-Generation Sequencing to Understand Infection Prevention in Surgical Treatment of Upper Extremity Fractures-A Prospective Cohort Study.

INTRODUCTION: Postoperative fracture site infection can lead to notable patient morbidity, increase cost of care, and further contribute to healthcare disparities globally. Dogma suggests surgical blades as a vehicle for introducing bacteria into the surgical site; however, there is a paucity of literature to support this claim. This study uses advanced DNA sequencing to detect bacterial DNA on surgical blades used in upper extremity fracture surgeries. METHODS: This was a prospective study, conducted at a high-volume level 1 trauma center. All acute, closed upper extremity fractures requiring surgical stabilization were consecutively enrolled in a prospective fashion. The primary end point was the presence of bacterial DNA on the surgical blade using next-generation sequencing (NGS). At the time of surgery, two blades were sterilely opened. One blade served as the control while the other was used for the initial skin incision. Two negative control blades were opened directly into a sterile container. Two positive control blades were used for skin incision through known infections. All samples were sent for NGS analysis. RESULTS: Forty patients were enrolled in this study. The median age was 33.5 years, and 30% were female; the median body mass index was 26.52. Humerus fractures were the most common injury (N = 17, 42.5%), followed by clavicle fractures (13, 32.5%) and radius/ulna fractures (10, 25.0%). NGS analysis revealed no contamination of test blades used for skin incision. Three control blades tested positive for bacterial DNA. Negative control blades tested negative for bacterial DNA (0/2); the positive control blades resulted positive for bacterial DNA contamination (2/2). CONCLUSION: Surgical blades used for skin incision in the upper extremity are not contaminated with bacterial DNA as analyzed by NGS. This finding challenges previous surgical dogma regarding surgical blade contamination and supports that the same surgical blade can safely be used for deeper dissection. LEVEL OF EVIDENCE: Level II study: IRB approval-IRB#848938.

Nerve Versus Tendon Transfers in the Management of Isolated Upper Extremity Peripheral Nerve Injuries.

Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries.

Optimizing Outcomes in Revision Peripheral Nerve Surgery of the Upper Extremity.

Peripheral nerve surgeries for compressive neuropathy in the upper extremity are generally successful. However, cases that either fail or have complications requiring revision surgery are challenging. During revision consideration, surgeons should perform a comprehensive preoperative workup to understand the etiology of the patient's symptoms and categorize symptoms as persistent, recurrent, or new in relation to the index procedure. Revision surgery often requires an open, extensile approach with additional procedures to optimize outcomes. Even with proper workup and treatment, clinical outcomes of revision surgeries are inferior compared to primary surgeries and patients should be well informed prior to undergoing such procedures.

The Mangled Upper Extremity-Algorithm for Salvage: My Workhorse Flaps.

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.

Current and Future Directions for Upper Extremity Amputations: Comparisons Between Regenerative Peripheral Nerve Interface and Targeted Muscle Reinnervation Surgeries.

Upper extremity amputation can lead to significant functional morbidity. The main goals after amputation are to minimize pain and maintain or improve functional status while optimizing the quality of life. Postamputation pain is common and can be addressed with regenerative peripheral nerve interface surgery or targeted muscle reinnervation surgery. Both modalities are effective in treating residual limb pain and phantom limb pain, as well as improving prosthetic use. Differences in surgical technique between the 2 approaches need to be weighed when deciding what strategy may be most appropriate for the patient.

Bone Grafts and Flaps in the Management of Complex Upper-Extremity Defects: Indications and Outcomes.

Reconstruction of bony defects is challenging. Most cases can be solved by means of nonvascularized bone grafts, either corticocancellous or cancellous. However, when the defect is long, there is a combined soft tissue defect, infection, a poor scarred bed, and when a piece of cartilage needs to be included, a vascularized bone graft is preferred. This article features a review of the most useful flaps for small and long defects in the hand and upper limb.

Immediate effects of upper limb exercises with and without deep breathing on lung function after cardiac surgery - a randomized crossover trial.

BACKGROUND: Open heart surgery, involving median sternotomy, may cause diminished chest wall motion and restrictive pulmonary function in the early postoperative period. Thoracic and upper extremity range of motion (ROM) exercises are often recommended after surgery but have not been evaluated regarding effect on lung volumes and oxygenation. The objective of this study was to evaluate the immediate effect of upper limb elevations, with or without simultaneous deep breathing, on lung function after cardiac surgery. METHODS: In a randomized 2 × 2 crossover trial, 22 adult patients (> 18 years old) were assessed during one of the first days after surgery in the spring of 2022 at Örebro University Hospital, Sweden. Exercises involving five bilateral upper limb elevations, performed either with simultaneous deep breathing (ROM-DB) or without (ROM), while sitting in an upright position at the edge of the bed, were evaluated. Peripheral oxygen saturation (Rad-5v; Masimo, Irvine, USA) was the primary outcome. Tidal volume and respiratory rate were recorded continuously during the exercises (Spiropalm; Cosmed, Rome, Italy). Heart rate, pain, exertion and dyspnoea were evaluated before and after the exercises. RESULTS: Both ROM-DB and ROM momentarily increased peripheral oxygen saturation (+ 1% ± 1, p = 0.004 and + 1% ± 1, p < 0.001, respectively), with no significant differences between these exercises (p = 0.525). ROM-DB significantly increased the VT compared with ROM (798 ± 316 vs. 602 mL ± 176, p = 0.004). However, ROM-DB induced more pronounced pain (p = 0.012), exertion (p = 0.035) and dyspnoea (p = 0.013) than ROM. CONCLUSIONS: Upper limb elevations improved oxygenation momentarily, both performed with and without simultaneous deep breathing, with no significant differences between these exercises. The additive deep breathing improved tidal volume compared with upper limb elevations alone, but induced more pain, exertion and dyspnoea during the performance of exercise. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05278819).

Factors Affecting 30-Day Outcomes in Patients Undergoing Nontraumatic Upper Extremity Amputation: A Retrospective Descriptive Longitudinal Study.

BACKGROUND: Current literature concerning upper extremity amputations (UEAs) is very sparse. In this study, we conducted the first multicenter retrospective analysis aiming to identify risk factors associated with unfavorable outcomes in patients undergoing nontraumatic UEAs. METHODS: A retrospective cohort study was conducted using the National Surgical Quality Improvement Program database. Adult patients who underwent nontraumatic UEAs between 2005 and 2021 were divided into two cohorts based on whether they experienced 30-day major morbidity (MM). Thereafter, multivariable binary logistic regression analysis was used to identify risk factors of MM. RESULTS: From a total of 2984 cases, MM was observed in 8.7% of patients. Factors associated with MM included American Society of Anesthesiologists classes 3 (odds ratio [OR], 2.974 [1.862 to 4.748]) and 4 (OR, 4.736 [2.857 to 7.848]), being underweight (OR, 2.370 [1.251 to 4.491]), and suffering from insulin-dependent diabetes (OR, 1.390 [1.018 to 1.898]). In addition, an infectious surgical indication was associated with an increased risk of MM compared with having a benign (OR, 0.648 [0.488 to 0.682]) or malignant (OR, 0.205 [0.091 to 0.462]) indication. Moreover, patients undergoing shoulder amputations were at an increased risk of MM compared with those undergoing amputations of the forearm/wrist (OR, 0.243 [0.072 to 0.819]) and hands/fingers (OR, 0.286 [0.095 to 0.861]). CONCLUSION: The risk factors identified for MM after nontraumatic UEAs should guide surgeons toward appropriately identifying high-risk patients and adequately counseling them preoperatively.

Predictors of Time to Return to Work Following Surgical Reconstruction of Upper Limb Injuries in a Cosmopolitan City in Western Nigeria.

BACKGROUND: The management of upper limb injury is aimed at a timely return to work, and other activities of daily living. The modified hand injury severity score (MHISS) has been found to predict a return to work. Upper limb injuries are common in our subregion, but there is little or no data on the time to return to work. AIM: This study, therefore, aimed to determine the prevalence of return to work and to identify the predictors of time to return to work following reconstruction of upper limb injuries. METHOD: This was a cross-sectional analytic study carried out between April 2022 and March 2023. The statistical test was at a confidence interval of 95%, and statistical significance set at a P value of <0.05. RESULT: A total of 49 upper-limb-injured patients had reconstruction in the time under review. Male-to-female ratio was 4.4:1. The mean MHISS was 87.9 ± 79.2. Of the 43 patients who participated in the return-to-work analysis, 41.9% had returned to work, with a mean time of 14.3 ± 10.5 weeks. Work-related injuries (r = 0.357, P = 0.019), male gender (r = 0.354, P = 0.020), and MHISS (r = 0.333, P = 0.029) correlated significantly with late return to work. On multiple logistic regression, work-related injuries (ß =0.321, P = 0.037), MHISS (ß =0.376, P = 0.032), and male gender (ß =0.326, P = 0.044) were found to be the significant predictors of late return to work. CONCLUSION: There is a low prevalence of return to work, with a high mean time to return. Work-related injuries, MHISS, and male gender are significant predictors of time to return to work.

A novel approach for predicting usability of upper limb prostheses.

Limb amputation can lead to significant functional challenges in daily activities, prompting amputees to use prosthetic devices (PDs). However, the cognitive demands of PDs and usability issues have resulted in user rejections. This study aimed to create a Human Performance Model for Upper-Limb Prosthetic Devices (HPM-UP). The model used formulations of learnability, error rate, memory load, efficiency, and satisfaction to assess usability. The model was validated in an experiment with 30 healthy participants using a bypass prosthetic device. Findings indicated that the HPM-UP successfully predicted the usability of prosthetic devices, aligning with human subject data. This research proposes a quantitative approach to predict upper limb prosthetic device usability by quantifying each dimension and computationally connecting them. The model, available on Github and executable with Rstudio, could enable clinicians to assess and analyze the human performance of various commercial prostheses, aiding in recommending optimal devices for patients.

Comparison of the effects of axillary brachial plexus block, inhalation anesthesia, and total intravenous anesthesia on tourniquet-induced ischemia-reperfusion injury in upper extremity surgery.

BACKGROUND: Post-ischemia reperfusion can lead to oxidative stress and an increase in oxidative markers. Employing preventive strategies and antioxidant agents may help mitigate ischemia-reperfusion injury (IRI). The use of a tourniquet in extremity surgery has been associated with IRI. This study aims to investigate the impact of three different approaches- brachial plexus block, total intravenous anesthesia (TIVA), and inhalation anesthesia-on IRI during upper extremity surgery using a tourniquet. METHODS: Patients aged 18 to 45 with American Society of Anesthesiologists (ASA) I-II scores were randomly assigned to one of three groups: Group A received an axillary block with bupivacaine; Group I underwent inhalation anesthesia with sevoflurane; and Group T received TIVA with propofol and remifentanil infusion. Blood samples were collected to measure glucose, lactate, total anti-oxidant status (TAS), total oxidant status (TOS), and ischemia-modified albumin (IMA) levels at various time points: before anesthesia (t1), 1 minute before tourniquet release (t2), 20 minutes after tourniquet release (t3), and 4 hours after tourniquet release (t4). RESULTS: In Group I, lactate levels at t3, and glucose levels at t2 and t3, were higher compared to the other groups. Group A exhibited lower IMA levels at t2, t3, and t4 than the other groups. Additionally, Group I had lower IMA levels at t2, t3, and t4 compared to Group T. TAS levels were higher in Group I at t2, t3, and t4 compared to the other groups. TOS levels at t2 and t3 were lower in Group A than in Group I. CONCLUSION: Axillary anesthesia results in a sympathetic block, promoting better perfusion of the upper extremity. This study demonstrated lower levels of oxidative stress markers with axillary plexus block. Therefore, these results suggest that the axillary block has the potential to mitigate IRI.

Compressive Neuropathies of the Upper Extremity: Anatomy for the Peripheral Nerve Surgeon.

Advance knowledge of anatomy is a prerequisite for the peripheral nerve surgeon. This article serves to provide an outline of anatomic regions where nerve entrapment or compression can occur. Each section is subdivided into anatomic regions where the etiology, indications, and relevant and aberrant anatomy are discussed, as well as common surgical approaches to the problematic anatomic site. The purpose is to provide an overview for the peripheral nerve surgeon and offer a valuable resource to provide a better understanding and optimal care for this patient population.

Subdural Spread of Local Anesthetic Mimicking Cerebrovascular Accident: A Case Report of Horner's Syndrome, Upper Limb Paresthesia, and Motor Weakness After Thoracic Epidural Analgesia.

A 53-year-old woman underwent a thoracic epidural placement for a scheduled laparotomy. Postoperatively the patient had no appreciable epidural level after multiple epidural boluses and was noted to be severely hypotensive with right upper extremity weakness and numbness. She subsequently developed right-sided Horner's syndrome with worsening right upper extremity weakness and decreased sensation from C6 to T1. She regained full motor and sensory function in her right upper extremity with epidural removal. This unusual case raises awareness of the variability in the presentation of subdural spread and provides an example of an epidural complication that can mimic a cerebrovascular accident (CVA).

Three-dimensional analysis of bone site grafting on the upper extremity on computed tomography scans.

PURPOSE: To perform a quantitative analysis of the amount of cancellous bone in the distal radius and olecranon process by segmentation of computed tomographic scans. As a secondary analysis, the bone density by Hounsfield units was evaluated at the same sites. METHODS: Computed tomography angiography images of the upper extremity were analyzed using 3-D Slicer™ medical imaging software. Bone volume (cm3) and density (Hounsfield units) from the cancellous bone between the distal radius and the olecranon process were compared by creating an advanced three-dimensional model. The images were analyzed in duplicate, and an intraclass correlation was performed to assess measurement consistency. RESULTS: Twenty subjects were included. A total volume of 5.01 ± 1.21 cm3 and 5.81 ± 1.61 cm3 for the distal radius and the olecranon process (p < .0001), respectively, was found. Regarding Hounsfield units, the density of the olecranon process was 303.1 ± 73.26, and the distal radius was 206.5 ± 63.73 (p < .0001). All intraclass correlation coefficients were >0.992. CONCLUSION: These results suggest that the olecranon process has a greater volume and a higher bone mineral density than the distal radius. With these results, the surgeon will have the ability to decide the quantity and quality of bone grafts according to the surgical procedure.

Reconstruction techniques for upper extremity crush injuries with massive tissue loss and open fractures: a prospective study.

OBJECTIVE: Crush injuries and open fractures are often accompanied by extensive tissue loss, rendering clinical and surgical management quite challenging, particularly in the upper extremities. The primary goal in these cases is to obtain a functional and cosmetically acceptable limb. However, the management of complex crush injuries (involving extensive tissue loss and open fractures) is associated with a variety of complications, ranging from infection to amputation. In this study, we aimed to analyze the clinical outcomes of reconstruction for managing complex upper extremity crush injuries. PATIENTS AND METHODS: We reviewed the clinical and surgical data of patients with complex upper extremity crush injuries who were treated at five Level III trauma centers between July 2012 and December 2022. Patients with an injury that could not be replanted at the time of trauma, those who succumbed to the injuries before reconstruction, and patients with a postoperative follow-up time of < 1-year, missing data, or lost to follow-up were excluded. Data regarding demographic characteristics, clinical examination, radiological images, mechanism of injury, orthopedic or non-orthopedic injuries, comorbidities, tissue loss size, surgical procedures, number of debridement and first debridement time, complications, number of days of hospitalization and, if any, intensive care unit stay, were recorded. RESULTS: Twenty-one patients were included in the study (mean age = 37.4 ± 7.25; range = 16-62 years; 17 males, 4 females). Road traffic accidents were the most frequently documented cause of injury. The mean time to the first reconstruction was 4.2 ± 1.2 days. Tissue defect sizes ranged from 6 × 4 cm to 18 × 12 cm. Anterolateral thigh flaps, latissimus dorsi flaps, radial forearm, and lateral arm flaps, with sizes ranging from 3 × 6 cm to 18 × 26 cm, were used in the patients. CONCLUSIONS: Simple reconstruction techniques, such as skin grafts or island flaps, can provide satisfactory results in terms of both appearance and function in upper extremity crush injuries with significant bone exposure and large soft tissue defects.

[Macroreplantation of the upper extremity: Inventory in 2024]. / Macro-réimplantation du membre supérieur : état des lieux en 2024.

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.

Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes.

BACKGROUND: Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites. METHODS: We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies. RESULTS: A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection. CONCLUSIONS: Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.