Anconeus Muscle Transfer to Correct or Prevent Wrist Radial Deviation in Radial and Posterior Interosseous Nerve Injuries.

PURPOSE: Wrist radial deviation is a possible complication of tendon transfer for restoration of wrist extension in cases of radial nerve paralysis. In posterior interosseous nerve (PIN) injury, this is because of the imbalance caused by the intact extensor carpi radialis longus and paralysis of the extensor carpi ulnaris (ECU). This deformity may also occur following transfer of the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) for radial nerve palsy. To address wrist radial deviation, we propose transferring the anconeus muscle, extended by the intermuscular septum between the ECU and the flexor carpi ulnaris (FCU), to the ECU tendon. METHODS: Through an incision over the ulna, the intermuscular septum between the ECU and FCU is harvested at the level of the periosteum and left attached to the anconeus proximally. The anconeus muscle is then released from the ulna, and the intramuscular septum extension is sutured to the ECU tendon under maximal tension. Anconeus muscle transfer was performed on two patients to correct chronic wrist radial deviation following PT to ECRB tendon transfer for radial nerve injury, as well as on two patients with PIN paralysis. In four patients, transfer was performed in addition to standard tendon transfers for radial nerve paralysis to prevent radial wrist deviation deformity. RESULTS: Wrist radial deviation was corrected or prevented in all but one patient at an average follow-up of 10 months. Patients with PIN lesions and those who had anconeus transfer concomitantly with radial nerve tendon transfers were capable of active ulnar deviation. No patient experienced elbow extension weakness, pain, or instability. CONCLUSIONS: Anconeus muscle transfer extended by intermuscular septum presents a viable alternative for addressing radial deviation of the wrist in cases of PIN nerve lesions or following PT to ECRB tendon transfer in radial nerve paralysis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Long-Term Donor-Site Morbidity Following Entire Sural Nerve Harvest for Grafting.

PURPOSE: The sural nerve is the autologous nerve used most commonly for grafting. However, recent studies indicate a high rate of complications and complaints after sural nerve removal. In this prospective study, we evaluated donor-site morbidity following full-length sural nerve harvesting on long-term follow-up. METHODS: Fifty-one legs from 43 patients who underwent complete sural nerve harvesting for brachial plexus reconstruction were included in the study. After an average of 5 years, with a minimum postoperative follow-up of 12 months, sensory deficits in the leg and foot were analyzed using 2.0-g monofilaments. Regions of sensory deficit were marked with a skin marker and photographed. Over these regions of decreased sensation, we tested nociception using an eyebrow tweezer. Patients were also asked about pain, cold intolerance, pruritis, difficulties walking, and foot swelling. RESULTS: Regions most affected (84% of patients) were over the calcaneus and cuboid. However, in these regions, nociception was preserved. Regions of decreased sensation extended to the calf region in 11 of 51 legs. In 13 patients, we also observed regions of decreased sensation on the proximal leg. In five feet, the sensation was entirely preserved. No patient had any complaints about pain, cold intolerance, itchiness, difficulties walking, or foot swelling. CONCLUSION: Decreased sensation with nociception preserved was most common along the lateral side of the foot over the calcaneus and cuboid. Removing the entire sural nerve produced no long-term complaints of pain. Sural nerve use appears safe. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Pectoralis Major Reinnervation by Retrograde Nerve Regeneration after Complete Paralysis of the Brachial Plexus.

Spontaneous neuronal recovery is an expected phenomenon in brachial plexus palsy patients. However, the spontaneous recovery owing to retrograde regeneration is an evolving phenomenon with dearth of adequate research on it. Pectoralis major contraction on stimulation of median nerve (in the arm) is an unexpected phenomenon, in the absence of any anomalous communication and with distal coaptation site of intraplexal nerve repair. We presumably attribute it to the retrograde regrowth of axons. The case described supports our hypothesis. Level of Evidence: Level V (Therapeutic).

Base of the Third Metacarpal as a Palpable and Reliable Landmark for Identifying the Median Nerve's Thenar Branch.

PURPOSE: The objective of this study was to investigate whether the base of the third metacarpal can predict the location of the thenar branch (TB) of the median nerve and the accuracy of palpating the base of the third metacarpal. METHODS: In 15 patients with ulnar nerve lesions around the elbow, we transferred the opponens motor branch to repair the deep terminal division of the ulnar nerve (DTDUN). Before surgery, we located the TB by palpating the base of the third metacarpal volarly. During surgery, we placed three needles at the following places: one at the entrance of the TB into the abductor pollicis brevis, another at the point where the TB contacted the thenar muscles, and third at the DTDUN's trajectory over the third metacarpal. We obtained fluoroscopic images and measured distances between the needles and structures with image software. We also examined the relationship between the TB, DTDUN, and the volar tubercle of the base of the third metacarpal in cadaver hands. Finally, we invited 22 surgeons to palpate the base of the third metacarpal on volunteer hands and verified their accuracy using fluoroscopy. RESULTS: During surgery, after dissection and palpation of the TB, under fluoroscopy, we confirmed that the palpable bone prominence was the base of the third metacarpal. In cadaver dissections, we observed the TB crossing the volar tubercle of the base of the third metacarpal superficially from proximal to distal and from ulnar to radial. The DTDUN was, on average, 14 mm distal to the base of the third metacarpal distal limit. In total, 19 of the 22 surgeons correctly identified the base of the third metacarpal and consequently the trajectory of the TB. CONCLUSIONS: The palpable base of the third metacarpal can be used to determine the trajectory of both the TB and DTDUN. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Birth Brachial Plexus Palsy: An Indian Perspective.

Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can often lead to long-lasting upper limb impairments. Spontaneous recovery may or may not occur. Timely diagnosis of the condition and initiation of the appropriate treatment can be instrumental in decreasing the functional impact. The management begins right from the day the child presents first and ranges from physiotherapy to surgical intervention such as nerve repair/transfer or grafts. The sequelae of the condition are also quite common and need to be detected preemptively with initiation of appropriate treatment. However, prevention is the key to reducing the incidence of secondary deformities. In this study, the team of authors, based on their considerable experience, discuss their approach to the management of BBPP. This is done in the background of Indian cultural practices and social constraints. A detailed discussion has been done on importance of preoperative passive joint mobilization regime and role of botulinum toxin in the authors' preferred ways of surgical correction of primary as well as secondary deformities. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles, and systematic review of the subject. Good results are possible with early and appropriate intervention even in severe cases.

A Tardy Ulnar Palsy with an Anomalous Course of Ulnar Nerve.

Variations are inherent feature of the intricate brachial plexus. They can be at the level of origin, the course, or the innervation pattern of each peripheral nerve. Knowledge of the various described variations can be worthwhile during the routine hand surgery procedures. We present a case of an elderly patient with anomalous intramuscular course of the ulnar nerve presenting with ulnar neuropathy at the elbow. Level of Evidence: IV.

Influence of racial and ethnic identity on overall survival in patients with chronic lymphocytic leukemia.

Overall survival for chronic lymphocytic leukemia (CLL) patients by race; propensity score matched by age, Charlson-Deyo comorbidity score, insurance, and income and education level of zip code of residence.

Secondary malignancies in non-Hodgkin lymphoma survivors: 40 years of follow-up assessed by treatment modality.

BACKGROUND: Survivors of non-Hodgkin lymphoma (NHL) have increased secondary malignancy (SM) risk. We quantified this risk by patient and treatment factors. METHODS: Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio) were assessed in 142,637 NHL patients diagnosed from 1975 to 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Comparisons were made between subgroups in terms of their SIRs relative to respective endemic populations. RESULTS: In total, 15,979 patients developed SM, more than the endemic rate (O/E 1.29; p < 0.05). Compared with white patients, relative to respective endemic populations, ethnic minorities had a higher risk of SM (white O/E 1.27, 95% CI 1.25-1.29; black O/E 1.40, 95% CI 1.31-1.48; other O/E 1.59, 95% CI 1.49-1.70). Relative to respective endemic populations, patients who received radiotherapy had similar SM rates to those who did not (O/E 1.29 each), but irradiated patients had increased breast cancer (p < 0.05). Patients who received chemotherapy had higher SM rates than those who did not (O/E 1.33 vs. 1.24, p < 0.05) including more leukemia, Kaposi sarcoma, kidney, pancreas, rectal, head and neck, and colon cancers (p < 0.05). CONCLUSIONS: This is the largest study to examine SM risk in NHL patients with the longest follow-up. Treatment with radiotherapy did not increase overall SM risk, while chemotherapy was associated with a higher overall risk. However, certain subsites were associated with a higher risk of SM, and they varied by treatment, age group, race and time since treatment. These findings are helpful for informing screening and long-term follow-up in NHL survivors.

PET-CT in Clinical Adult Oncology: I. Hematologic Malignancies.

PET-CT is an advanced imaging modality with many oncologic applications, including staging, assessment of response to therapy, restaging and evaluation of suspected recurrence. The goal of this 6-part series of review articles is to provide practical information to providers and imaging professionals regarding the best use of PET-CT for the more common adult malignancies. In the first article of this series, hematologic malignancies are addressed. The classification of these malignancies will be outlined, with the disclaimer that the classification of lymphomas is constantly evolving. Critical applications, potential pitfalls, and nuances of PET-CT imaging in hematologic malignancies and imaging features of the major categories of these tumors are addressed. Issues of clinical importance that must be reported by the imaging professionals are outlined. The focus of this article is on [18F] fluorodeoxyglucose (FDG), rather that research tracers or those requiring a local cyclotron. This information will serve as a resource for the appropriate role and limitations of PET-CT in the clinical management of patients with hematological malignancy for health care professionals caring for adult patients with hematologic malignancies. It also serves as a practical guide for imaging providers, including radiologists, nuclear medicine physicians and their trainees.

Second Primary Malignancies in Diffuse Large B-cell Lymphoma Survivors with 40 Years of Follow Up: Influence of Chemotherapy and Radiation Therapy.

Purpose: Previous studies have shown an increased risk of second primary malignancies (SPMs) in survivors of diffuse large B-cell lymphoma (DLBCL). Survivors live longer due to the intensification of and improvements in therapy; thus, we aimed to characterize SPM patterns in patients with DLBCL by treatment modality. Methods and Materials: Standardized incidence ratio and absolute excess risk of SPMs were assessed in patients with primary DLBCL from 1975 to 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. A subgroup analyses based on, sex, race, age at the time of diagnosis, latency, and treatment modality were performed. Propensity score-adjusted cumulative incidence curves were generated, stratified by treatment and accounting for death as a competing risk. Results: In total, 45,946 patients with DLBCL were identified with a mean follow up of 70 months. Overall, 9.2% of patients developed an SPM with a standardized incidence ratio of 1.23 (95% confidence interval, 1.20-1.27). There was no difference in SPM risk between men and women or Black and White patients. Patients age <25 years were particularly susceptible to the development of SPMs, with a risk 2.5 times greater than patients aged 50 to 74 years. Temporal patterns showed increasing risk of solid malignancies and decreasing risk of hematologic malignancies over time, with bladder cancer posing the greatest absolute excess risk of any cancer type after 15 years. Patients treated with radiation therapy (RT), chemotherapy (CT), and chemoradiation therapy (CRT) all had an increased risk of SPM development compared with the general population. The cumulative incidence of SPMs was the lowest in patients treated with RT and the highest when treated with CRT. In the modern treatment era, the cumulative incidence of SPM for patients treated with CT versus CRT was not significantly different. Conclusions: In this large population-based study, we demonstrate unique SPM risk patterns based on age, latency, and treatment modality that have important implications for the treatment and screening of patients diagnosed with DLBCL.

Maxillary Sinus Vascular Malformation or Metastatic Renal Cell Carcinoma: The Importance of Differential Diagnosis.

Epistaxis is a common presenting complain with varied differentials. Our case is of epistaxis due to maxillary sinus vascular malformation which could be managed with embolization and endoscopic excision. Histopathologically, the lesion had features of metastatic renal cell carcinoma (RCC). A RCC metastatic lesion masquerading as a maxillary sinus vascular malformation (VM) has been extremely rare in published literature. We present this interesting case of maxillary sinus VM and also briefly review the relevant literature.

Is there a role for anti-CD20 antibodies in CLL?

Anti-CD20 monoclonal antibodies (mAbs) have revolutionized the treatment of chronic lymphocytic leukemia (CLL) by improving survival of patients with CLL in conjunction with chemotherapy. However, the novel targeted agents such as Bruton tyrosine kinase inhibitors (BTKis) and venetoclax have now mostly replaced chemotherapy in frontline treatment of CLL. Several clinical trials have been conducted to examine the role of anti-CD20 mAbs in combination with BTK inhibitors and venetoclax. Addition of rituximab to ibrutinib does not improve progression-free survival (PFS) of treatment-naive patients with CLL, possibly related to ibrutinib's antagonistic effect on anti-CD20 antibodies. Alternatively, addition of a glycoengineered anti-CD20 mAb obinutuzumab to a more selective BTKi acalabrutinib may improve PFS but does not improve overall survival of patients with CLL in the frontline setting, pending long-term follow-up. Thus, we suggest that the addition of an anti-CD20 mAb to a BTKi is of most benefit to patients with autoimmune cytopenia or rapidly progressive disease. In contrast to BTKis, combination of fixed-duration venetoclax and anti-CD20 mAb can induce deep remission with high rates of undetectable minimal residual disease, correlating with improved survival of patients with CLL in both frontline and relapsed/refractory settings. In this review, we discuss clinical trials of BTKis and venetoclax that have investigated the role of anti-CD20 mAbs in frontline and relapsed settings of CLL treatment. We also provide an algorithm suggesting how anti-CD20 mAbs may be incorporated in the treatment of patients with CLL, including specific scenarios.

A Method of Shoulder Spica Cast Application In Shoulder Muscle Transfer Patients In Supine Position.

Background Children with birth brachial plexus injury (BBPI) often require secondary surgery for the shoulder. The shoulder spica is necessary after shoulder muscle transfer surgery in babies with BBPI. However, its application can be difficult in the supine position under anesthesia. The authors describe a simple and cost-effective method of applying the shoulder spica cast without changing the supine position under anesthesia. Technique While still under anesthesia, the child is placed in a supine position and then elevated on the wooden bar. The POP roll is wrapped around in a cylindrical manner, starting from the level one inch above the anterior superior iliac spine. The contralateral shoulder is also incorporated into the cast. Conclusion The spica application technique described comprises commonly available materials, such as a wooden plank, pair of bolsters, plaster of Paris rolls, and dressing materials overcoming the need for customized apparatus or the operation table. The materials are easy to assemble and thereby applicable just about anywhere. The task also becomes less challenging for the anesthetic in the supine position. This technique is easily reproducible and cost-effective.

The Association Of Race With Outcomes Among Parturients Undergoing Cesarean Section With Perioperative Epidural Catheter Placement: A Nationwide Analysis.

BACKGROUND: In obstetrical health care, disparities have been documented in different aspects of maternal care and outcomes. Prior epidemiological studies have shown that labor analgesia is underused in African-American and Hispanic groups, which means there may be inadequate labor pain control in these groups. Differences in usage have been attributed primarily to insurance, educational levels and perceptional influences such as fear of paralysis and chronic low back pain. In cesarean section deliveries, race and ethnicity affect the choice of anesthesia considered. How race and ethnicity affect maternal outcomes in cesarean sections with epidural placements generally has been unexplored. Disparities in health care utilization are shown to contribute to the disparities in health outcomes. METHODS: This is a retrospective analysis using data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (AHRQ-HCUP), the National Inpatient Sample (NIS) database from January 2003 to December 2013, which is a 20% stratified sample of the nonfederal hospitals in the United States. Women undergoing cesarean section (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes 74.0, 74.1, 74.2, 74.4, 74.99) with perioperative epidural catheter placement (ICD-9-CM procedure codes 3.90, 3.91) were included for analysis. RESULTS: The final cohort used for analysis included 87,076 patients. There were significant differences in the distribution of patient characteristics across the race groups. The majority of health care coverage for Caucasians and Asians was private insurance, while for African-American, Hispanic and Native American was Medicare and Medicaid. Almost all the examined comorbid conditions were statistically significant and highest in the African-American group, including hypertension, obesity, diabetes, and renal failure, except for congestive heart failure that was highest in the Asian group. Cesarean sections took place mostly in an urban teaching hospital across all groups. Discharge to home was the predominant destination after recovery. The mean cost of hospitalization was 14,604 dollars per stay and the mean length of stay was 3.7 days. In our cohort, the adverse event rate was very small. Our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013. CONCLUSION: From using the NIS database, our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013. Further population studies are warranted to determine the biological or perception etiologies that are contributing to these disparities.