Crosswalk between the PROMIS physical function CAT and PROMIS upper extremity CAT v1.2 in a hand surgery population.

BACKGROUND: There is no gold standard patient-reported outcome measure (PROM) in hand surgery. As a result, a diverse array of PROM instruments have been utilized across centers over time. Lack of score interchangeability limits the ability to compare or conglomerate scores when new instruments are introduced. Our aim was to develop a linkage for the PROMIS UE CAT v1.2 and PROMIS PF CAT scores and develop crosswalk tables for interconversion between these PROMs. METHODS: Retrospective review was conducted to identify adult (≥ 18y) patients seen by orthopaedic hand surgeons at a single academic tertiary care hospital who had completed PROMIS UE CAT v1.2 and PROMIS PF CAT score at the same visit. For those with multiple visits, only one randomly selected visit was included in the analyses. Pearson's correlation was calculated to determine the linear relationship between the scores. Linkage from PF to UE was performed utilizing several commonly utilized equating models (identity, mean, linear, equipercentile and circle-arc methods). The performance of the models was assessed using intraclass correlation (ICC) between observed PROMIS UE CAT v1.2 and estimated PROMIS UE CAT v1.2 scores generated using the model as well as Root Mean Square Error (RMSE). The model chosen as the 'best' was further assessed for population invariance using root expected mean squared difference (REMSD) where < 0.08 were considered good. RESULTS: Of 10,081 included patients, mean age was 48.3 (SD = 17.0), and 54% were female (5,477/10,081). Mean UE CAT v1.2 and PF CAT scores were 37 (SD = 9.8) and 46 (SD = 10.0), respectively. There was a strong correlation between the scores (Pearson correlation r = 0.70). All methods performed acceptably (ICC ≥ 0.66 and RMSE < = 7.52 for all). The equipercentile method had the highest ICC (ICC = 0.70 (95% CI 0.69-0.71)) while the mean and circle arc methods had the lowest RMSE. The circle arc method is the most reliable with the smallest standard error and has satisfactory population invariance across age group (REMSD 0.065) and sex (REMSD 0.036). CONCLUSIONS: Crosswalk tables to be used for bidirectional conversion between scores were created. LEVEL OF EVIDENCE: III.

Regional Anesthesia for Athletes Undergoing Upper Extremity Procedures: Techniques and Considerations.

Upper extremity injuries are frequent in athletes which may require surgeries. Regional anesthesia for postoperative analgesia is important to aid recovery, and peripheral nerve blocks for surgical anesthesia enable surgeries to be performed without general anesthetics and their associated adverse effects. The relevant nerve block approaches to anesthetize the brachial plexus for elbow, wrist and hand surgeries are discussed in this article. There is very limited margin for error when performing nerve blocks and multimodal monitoring approach to reduce harm are outlined. Lastly, the importance of obtaining informed consent prior to nerve block procedures should not be overlooked.

Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery.

Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.

Repair of a "long and narrow" skin defect of the upper extremity with a modified design of a compound SCIP flap: a series of 12 cases.

BACKGROUND: Large skin lesions of the upper extremity tend to be ''long and narrow'' in shape, and the currently used repair and reconstruction protocols still have some drawbacks, including difficulty in closure of the donor area, poor cosmetic appearance of the donor and recipient areas, and low flap survival rates. The ilioinguinal flap has been more widely used for repair and reconstruction of various complex conditions. In order to improve the versatility of the flap design and to achieve better aesthetic results, we report a study on the improved design of Compound SCIP flap for repairing "long and narrow" large skin defects of the upper extremity by using a modified design of the ilioinguinal flap for the procurement of perforating blood vessels and flap excision. METHODS: From April 2005 to August 2015, a total of 12 patients underwent this modified design procedure, in which the anterior branch of the fourth lumbar artery or the posterior intercostal artery was selected to provide blood supply for the perforator flap together with the superficial branch of the superficial iliac artery to meet the blood supply needs of the flap for the one-time repair of a large "long and narrow" skin defect in the upper limb. Patient demographics, flap characteristics, and associated complications were retrospectively analyzed. RESULTS: 3 females and 9 males were included in this study, the mean age of the patients was 31.7 years (range, 22-44 years), the mean follow-up period was 15.3 ± 5.6 months (range, 7-24 months), and all patients had complete closure of the defect site and donor area, and all flaps survived. CONCLUSIONS: The Compound SCIP flap presents some advantages in repairing 'long and narrow' skin defects in the upper limb. While ensuring the survival rate of the elongated ilioinguinal flap, it amplifies the benefits of the ilioinguinal flap and enhances skin utilization. This can serve as a beneficial choice for repairing 'long and narrow' skin defects in the upper limb.

The effect of video-assisted training on upper extremity problems and functions after rotator cuff repair: a randomized controlled trial.

Background/aim: The shoulder is the most mobile joint in the body, and is frequently exposed to injuries. The applied surgical treatments, protection of the shoulder after surgery, care in the use of the shoulder in activities of daily living (ADLs) and gradual exercise programs are all vital to the recovery process. The present study investigates the effect of video-assisted training (VAT) on upper extremity complications and functions after rotator cuff repair (RCR). Materials and method: Included in this prospective, parallel two-armed, randomized controlled study were an experimental group (n: 24) that received VAT detailing early postoperative care for RCR and instructions on performing ADLs, and that had access to a 90-day gradual exercise program, and a control group (n: 24) that received routine care. The primary outcomes were upper extremity problems and functions, as assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) and modified Constant-Murley scores (MCM), while secondary outcomes were complications that had developed within the past three months. The outcomes were measured at baseline, after six weeks and at three months. Results: After 3 months, a statistically significant difference was noted in the DASH-Work (p = 0.001) and MCM ADLs scores (p = 0.003) of the two groups, and significant changes in which the scale scores of both groups when compared to the initial measurement. Only one patient in the VAT group developed complications after RCR at one month; there were no significant differences in the complications of the two groups (p = 0.235). Conclusion: VAT can increase function in RCR patients. Healthcare professionals, especially nurses, can use the VAT method to improve shoulder function in patients after RCR.

Ergonomic interventions to reduce upper limb musculoskeletal pain during robotic surgery: a narrative review.

There is a high prevalence of upper limb musculoskeletal pain among robotic surgeons. Poor upper limb ergonomic positioning during robotic surgery occurs when the shoulders are abducted, and the elbows are lifted off the console armrest. The validated rapid upper limb assessment can quantify ergonomic efficacy. Surface electromyography and hand dynamometer assessment of strength are the most common methods to assess muscle fatigue. A literature review was performed to find evidence of ergonomic interventions which reduce upper limb musculoskeletal pain during robotic surgery. There is a paucity of studies which have reported on this topic. In other occupations, there is strong evidence for the use of resistance training to prevent upper extremity pain. Use of forearm compression sleeves, stretching, and massage may help reduce forearm fatigue. Microbreaks with targeted stretching, active ergonomic training, improved use of armrest, and optimal hand controller design have been shown to reduce upper limb musculoskeletal pain. Future studies should assess which interventions are beneficial in reducing surgeon upper limb pain during robotic surgery.

Is Upper Extremity or Lower Extremity Function More Important for Patient Satisfaction? An Analysis of 24-Month Outcomes from the QOD Cervical Spondylotic Myelopathy Cohort.

STUDY DESIGN: Retrospective analysis of a prospective, multicenter registry. OBJECTIVE: To assess whether upper or lower limb mJOA improvement more strongly associates with patient satisfaction after surgery for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: The modified Japanese Orthopaedic Association (mJOA) is commonly used to assess functional status in patients with CSM. Patients present with upper and/or lower extremity dysfunction, and it is unclear whether improvement in one and/or both symptoms drives postoperative patient satisfaction. METHODS: This study utilizes the prospective Quality Outcomes Database (QOD) CSM data set. Clinical outcomes included mJOA and North American Spine Society (NASS) satisfaction. The upper limb mJOA score was defined as upper motor plus sensory mJOA, and the lower limb mJOA as lower motor plus sensory mJOA. Ordered logistic regression was used to determine whether upper or lower limb mJOA was more closely associated with NASS satisfaction, adjusting for other covariates. RESULTS: Overall, 1141 patients were enrolled in the QOD CSM cohort. In all, 780 had both preoperative and 24-month mJOA scores, met inclusion criteria, and were included for analysis. The baseline mJOA was 12.1±2.7, and postoperatively, 85.6% would undergo surgery again (NASS 1 or 2, satisfied). Patients exhibited mean improvement in both upper (baseline:3.9±1.4 vs. 24 mo:5.0±1.1, P<0.001) and lower limb mJOA (baseline:3.9±1.4 vs. 24 mon:4.5±1.5, P<0.001); however, the 24-month change in the upper limb mJOA was greater (upper:1.1±1.6 vs. lower:0.6±1.6, P<0.001). Across 24-month NASS satisfaction, the baseline upper and lower limb mJOA scores were similar (pupper=0.28, plower=0.092). However, as satisfaction decreased, the 24-month change in upper and lower limb mJOA decreased as well (pupper<0.001, plower<0.001). Patients with NASS scores of 4 (lowest satisfaction) did not demonstrate significant differences from baseline in upper or lower limb mJOA (P>0.05). In ordered logistic regression, NASS satisfaction was independently associated with upper limb mJOA improvement (OR=0.81; 95% CI: 0.68-0.97; P=0.019) but not lower limb mJOA improvement (OR=0.84; 95% CI: 0.70-1.0; P=0.054). CONCLUSIONS: As the magnitude of upper and lower mJOA improvement decreased postoperatively, so too did patient satisfaction with surgical intervention. Upper limb mJOA improvement was a significant independent predictor of patient satisfaction, whereas lower limb mJOA improvement was not. These findings may aid preoperative counseling, stratified by patients' upper and lower extremity treatment expectations. LEVEL OF EVIDENCE: Level-III.

Reconstruction Strategy for Upper Extremity Defects After Bone Tumor Resection Based on 3D Customized Bone Cement Mold.

BACKGROUND: Reconstructing bone defects in the upper extremities and restoring their functions poses a significant challenge. In this study, we describe a novel workflow for designing and manufacturing customized bone cement molds using 3D printing technology to reconstruct upper extremity defects after bone tumor resection. METHODS: Computer tomography data was acquired from the unaffected upper extremities to create a detachable mold, which can be customized to fit the joint precisely by shaping the bone cement accordingly. Fourteen patients who underwent reconstructive surgery following bone tumor resection in the proximal humerus (13 cases) or distal radius (1 case) between January 2014 and December 2022 were retrospectively evaluated. The medical records of this case series were reviewed for the demographic, radiological, and operative data. Metastasis, local recurrence, and complication were also reviewed. Additionally, Musculoskeletal Tumor Society Score (MSTS) and Visual Analogue Scale (VAS) were used to assess clinical outcomes. RESULTS: The mean follow-up period was 49.36 ± 15.18 months (range, 27-82 months). At the end of follow-up, there were no cases of metastasis or recurrence, and patients did not experience complications such as infection, dislocation, or implant loosening. Two cases complicated with subluxation (14.3%), and 1 case underwent revision surgery for prosthetic fracture (7.1%). The average MSTS score was 23.2 ± 1.76 (77.4%, range, 66.7%-86.7%), and the postoperative VAS score was 1.86 ± 1.03 (range, 1-4), which was significantly lower than that before surgery (average preoperative VAS score was 5.21 ± 2.00 (range, 2-8)) (P < .001). CONCLUSION: Customized 3D molds can be utilized to shape bone cement prostheses, which may serve as a potential alternative for reconstructing the proximal humerus and distal radius following en bloc resection of bone tumors. This reconstruction strategy offers apparent advantages, including precise matching of articular surfaces and comparatively reduced costs.

The N-LVA Study: effectiveness and cost-effectiveness of lymphaticovenous anastomosis (LVA) for patients with cancer who suffer from chronic peripheral lymphoedema - study protocol of a multicentre, randomised sham-controlled trial.

INTRODUCTION: Cancer-related lymphoedema is one of the most debilitating side-effects of cancer treatment with an overall incidence of 15.5%. Patients may suffer from a variety of symptoms, possibly resulting in a diminished health-related quality of life (HRQoL). A microsurgical technique known as lymphaticovenous anastomosis (LVA) might be a promising treatment option. The objective of this study is to evaluate whether LVA is effective and cost-effective compared with sham surgery in improving the HRQoL. METHODS AND ANALYSIS: A multicentre, double-blind, randomised sham-controlled trial conducted in three university hospitals in the Netherlands. The study population comprises 110 patients over the age of 18 years with unilateral, peripheral cancer-related lymphoedema, including 70 patients with upper limb lymphoedema and 40 patients with lower limb lymphoedema. A total of 55 patients will undergo the LVA operation, while the remaining 55 will undergo sham surgery. The follow-up will be at least 24 months. Patients are encouraged to complete the follow-up by explaining the importance of the study. Furthermore, patients may benefit from regular monitoring moments for their lymphoedema. The primary outcome is the HRQoL. The secondary outcomes are the limb circumference, excess limb volume, changes in conservative therapy, postoperative complications, patency of the LVA and incremental cost-effectiveness. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethical Committee of Maastricht University Medical Center on 20 September 2023 (NL84169.068.23). The results will be presented at scientific conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT06082349.

Is Tourniquet Pain the Result of Increased Compartment Pressure in the Forearm?

ABSTRACT: The pneumatic tourniquet has been a mainstay in upper extremity surgery by allowing the surgeon to operate in a blood-free field. Many upper extremity surgical procedures are done under local anesthesia or minimal sedation, and the problem of tourniquet pain is a vexing one. The question is posed: Is tourniquet pain the result of increased compartment pressure in the forearm? This study measured compartment pressures of the volar forearm in 10 healthy normotensive volunteers before inflation of a pneumatic tourniquet and compared it with pressure measurements taken while the tourniquet was still inflated after 15 minutes. Compartment pressures were measured using a Stryker needle manometer; all measurements were taken in the volar forearm by the senior author (C.H.M.). There was no increase in the volar/flexor compartment pressure of the forearm after 15 minutes of tourniquet inflation. All subjects complained of pain of the forearm, characteristically what is commonly called "tourniquet pain." We therefore conclude that in the upper extremity, at least for relatively short operating times, appropriate inflation of a tourniquet does not induce the early onset of increased compartment pressure in the forearm.

Timing of surgery in peripheral nerve injury of the upper extremity.

Peripheral nerve injuries present a complex clinical challenge, requiring a nuanced approach in surgical management. The consequences of injury vary, with sometimes severe disability, and a risk of lifelong pain for the individual. For late management, the choice of surgical techniques available range from neurolysis and nerve grafting to tendon and nerve transfers. The choice of technique utilized demands an in-depth understanding of the anatomy, patient demographics and the time elapsed since injury for optimized outcomes. This paper focuses on injuries to the radial, median and ulnar nerves, outlining the authors' approach to these injuries.Level of evidence: IV.

The effect of time from injury to fasciotomy in patients with acute upper extremity compartment syndrome.

BACKGROUND: Acute compartment syndrome of the upper extremity is a surgical emergency, and timely diagnosis with immediate fasciotomies is essential for the preservation of function. This retrospective study aimed to compare the complication rates of patients who underwent fasciotomy before and after 6 hours following the initial trauma. METHODS: The medical records of the patients who underwent fasciotomy for surgical treatment of ACS of the upper extremity between 2016 and 2022 were retrospectively analyzed for age, gender, dominant hand, mechanism of injury, injury level, affected compartments, associated injuries, time elapsed till fasciotomy, and complications. The patients were divided into two groups according to the timing of fasciotomy. RESULTS: A total of 32 patients underwent fasciotomies for upper extremity ACS. The mean age of patients who underwent fasciotomy ≤ 6 hours (group 1; 10 males, 7 females) and patients who underwent fasciotomy > 6 hours (group 2; 13 males, 2 females) was 31.1 and 34.8, respectively. The most common etiology was crushing injury. There was a significant difference in complication rates between group 1 (1/17) and group 2 (10/15) (p<0.001). The length of hospitalization stay in group 2 was statistically higher than in group 1 (p=0.005). CONCLUSION: Fasciotomies for ACS of the upper extremity should be performed in less than 6 hours following the initial trauma to prevent complications.

Socioeconomic factors and outcome after repair and reconstruction of digital and major nerve trunk injuries in the upper limb.

Peripheral nerve injuries in the upper limb can lead to substantial disability and pain. We aimed to assess how socioeconomic factors affect outcomes after repaired or reconstructed digital or major nerve trunk injuries in the upper limb. We identified 670 individuals, who underwent surgical nerve repair or reconstruction using sensory nerve autografts, in the Swedish National Quality Registry for Hand Surgery 2010-2018. Socioeconomic factors, including education, cohabitation, type of work, sick leave, immigrant status and income, were gathered from the Swedish statistical agency ( www.scb.se ) and National Diabetes Register (NDR). We calculated prevalence ratios (PR) to assess the relationship between socioeconomic factors and surgical outcomes for the nerve injuries. Individuals with a major nerve trunk injury had higher QuickDASH scores and lower income compared to those with digital nerve injury. Individuals with immigration background (adjusted PR = 2.0, 95% CI 1.2-3.2), history of > 4 weeks of sick leave the year before surgery (adjusted PR = 1.8, 95% CI 1.1-3.1), or education level below tertiary (adjusted PR = 2.8, 95% CI 1.7-4.7) had significantly higher QuickDASH scores. Recognizing impact of non-biological factors, including immigration, prior sick leave, and education level, on outcome after nerve surgery is crucial for improving prognosis in socioeconomically deprived individuals.

Recent Advances in Upper Extremity Microsurgery: From Traditional to Perforator Flaps.

The upper extremity has unique functional and aesthetic requirements. Reconstruction of upper extremity soft tissue defects should ideally provide coverage for vital structures, facilitate early mobilization, be thin and pliable to match its slim contour, and reestablish sensation. Perforator flaps can be raised on the superficial fascia, which creates a thin and pliable yet durable and supple flap option to match the contour and functional needs of the upper extremity. Comparisons to traditional reconstructive methods should be performed to assess whether these innovations in microsurgical reconstruction of upper extremity defects provide an improved functional and aesthetic benefit over traditional methods.

Evolution and Application of Ultrasound for Flap Planning in Upper Extremity Reconstruction.

Accurate preoperative localization of dominant perforators provides crucial information about their location and diameter, leading to reduced surgical time, improved flap viability, and decreased complications. Ultrasound has increased in popularity in recent years, with the advantages of providing reproducible, accurate, cost-effective, and real-time information while reducing radiation exposure. Precise preoperative mapping of perforators allows for rapid and safe elevation of suprafascial, thin, and superthin flaps. This review focuses on the role of ultrasound as a tool for preoperative flap planning in the upper extremities.

Thin Profunda Artery Perforator Flap for Hand and Upper Extremity Coverage.

The profunda artery perforator (PAP) flap provides a good option for hand and upper extremity reconstruction. The reliable quality, caliber, and number of perforators in the posteromedial thigh support large flaps with long pedicles. The PAP flap has been widely used for breast reconstruction, although its use in the extremities has been slower to catch on due to the bulk and thickness of the subcutaneous tissue. The authors discuss evolution of thin flaps and our application of the thin and superthin PAP flap for upper extremity reconstruction.

Superficial Circumflex Iliac Artery Perforator Flap Reconstruction of the Upper Extremity.

The superficial circumflex iliac artery perforator (SCIP) flap is thin, pliable tissue well suited for reconstruction of injuries of the hand and upper extremity. Based upon perforators from the superficial circumflex iliac artery, the SCIP flap has advantages over the traditional groin flap due to reduced need for secondary procedures and improved donor site morbidity This article offers a detailed exploration of the SCIP flap design and technique, its advantages over traditional methods, and its potential applications in reconstructive surgery. Post-operative care and critical points are also discussed, and case examples are provided to guide readers through the intricacies of the technique, emphasizing the surgical skill and precision required for successful implementation.

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction.

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

Evolution and Diversity of Medial Sural Artery Perforator Flap for Hand Reconstruction.

The free medial sural artery perforator (MSAP) flap is a recently popularized flap. It has evolved from a composite myocutaneous flap to a pedicled perforator flap for lower limb reconstruction. It is also a versatile free perforator flap for extremity and head and neck reconstruction. The diversity of the flap designs with options for harvest of non-vascularized grafts enhances the versatility for hand and upper limb reconstruction. The adjunctive use of endoscopy and indocyanine green fluorescence imaging studies can assist and demystify the flap anatomy. The authors present their experience using free MSAP flaps for complex mutilated hand and upper extremity reconstruction.

Surgical Treatment of Lymphedema in the Upper Extremity.

The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.