Patient-Reported Quality of Recovery after Local Anesthesia versus Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study.

BACKGROUND: Both local anesthesia (LA) and brachial plexus (BP) anesthesia are commonly used in hand surgery. LA has increased efficiency and reduced costs, but BP is often favored for more complex hand surgery, despite requiring greater time and resources. The primary objective of this study was to assess the quality of recovery of patients who received LA or BP block for hand surgery. Secondary objectives were to compare postoperative pain and opioid use. METHODS: This randomized, controlled, noninferiority study enrolled patients undergoing surgery distal to the carpal bones. Patients were randomized to either LA (wrist or digital block) or BP block (infraclavicular block) before surgery. Patients completed the Quality of Recovery-15 questionnaire on postoperative day (POD) 1. Pain level was assessed with a numeric pain rating scale, and narcotic consumption was recorded on POD1 and POD3. RESULTS: A total of 76 patients completed the study (LA, n = 46, BP, n = 30). No statistically significant difference was found for median Quality of Recovery-15 score between LA [127.5 (interquartile range, 28)] and BP block [123.5 (interquartile range, 31)]. The inferiority margin of LA to BP block at the 95% confidence interval was less than the minimal clinically important difference of 8, demonstrating noninferiority of LA compared with BP block. There was no statistically significant difference between LA and BP block for numeric pain rating scale scores or narcotic consumption on POD1 and POD3 ( P > 0.05). CONCLUSION: LA is noninferior to BP block for hand surgery with regard to patient-reported quality of recovery, postoperative pain, and narcotic use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release.

BACKGROUND: North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release. METHODS: Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management. RESULTS: The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences. CONCLUSIONS: Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy.

PURPOSE: Several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons; the present study investigates the role of radiation therapy in this context. METHODS: A systematic review was performed to evaluate the utility of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. RESULTS: Fifteen articles met the inclusion criteria for review. The mean incidence of gynecomastia was 70% in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Radiotherapy was shown to significantly reduce the incidence to a median of 23%, with all six randomized control studies assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. The median complication rate was 12.4% with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. While the efficacy of radiation therapy as a treatment modality for gynecomastia was also established, it was shown to be less effective than other available options. CONCLUSIONS: Low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients; further studies are indicated within the common gynecomastia population managed by plastic surgeons to assess the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients.

Lidocaine With Epinephrine Versus Bupivacaine With Epinephrine as Local Anesthetic Agents in Wide-Awake Hand Surgery: A Pilot Outcome Study of Patient's Pain Perception.

Purpose: Wide-awake local anesthesia hand surgery has many advantages over other forms of anesthesia, including faster recovery, lower cost, and improved patient safety; however, few studies compare postoperative pain and analgesic consumption after long- and short-acting anesthetics. This is important because surgeons seek to minimize opioid consumption during the opioid epidemic. Methods: This was a double-blinded, prospective, randomized, parallel design pilot study. We randomized 61 patients to receive carpal tunnel surgery with a short-lasting regional anesthetic (lidocaine, 29 patients) or a long-lasting one (bupivacaine, 32 patients). Primary outcomes were pain levels over the first and second 24 hours. Secondary outcomes were postoperative consumption of acetaminophen and opioids over the first and second 12 hours after surgery. Results: Pain intensity and acetaminophen consumption were significantly less in the bupivacaine group over the first 24 and 12 hours after surgery, respectively. The bupivacaine group consumed less opioids in the first 12 hours and delayed consumption of the first medication after surgery, but these results were not statistically significant. There was no difference in pain intensity or analgesic consumption between 24 and 48 hours after surgery. Conclusions: The use of a long-term anesthetic (bupivacaine) over a short-term one (lidocaine) in awake carpal tunnel release surgery decreases postoperative pain over the initial 12 hours after surgery and delays the initiation of analgesic consumption; however, this difference is small. The amount of opioid consumption was not significantly different between groups, but both groups consumed less than 10% of the prescribed opioids. It is important to reevaluate the need for opioids in minor hand surgery and favor the use of alternatives such as nonsteroidal anti-inflammatory drugs and acetaminophen. Type of study/level of evidence: Therapeutic I.

Optimizing Radiotherapy for Keloids: A Meta-Analysis Systematic Review Comparing Recurrence Rates Between Different Radiation Modalities.

BACKGROUND: The high recurrence rate of keloids has lead to the use of multiple treatment adjuncts to improve cosmetic outcomes after surgery. To date, there has been no single, standardized modality agreed upon to produce the best results. The purpose of this study was to review the radiation-based treatments (brachytherapy, electron beam and X-ray) used for keloid management and compare their outcomes. METHODS: A literature review was performed from 1942 to October 2014 using the databases: PubMed database of the National Center of Biotechnology Information, MEDLINE, Biosis, Embase, Google scholar, and Cochrane database. Articles were reviewed for case numbers, patient demographics, keloid location, follow up, radiation modality, dose, keloid recurrence, and complications. RESULTS: A total of 72 studies met the inclusion criteria representing 9048 keloids. These studies were categorized by treatment: brachytherapy, electron, or X-ray. Meta-analysis demonstrated that radiotherapy after surgery had less recurrence when compared to radiotherapy alone (22% and 37%, respectively, P = 0.005). Comparison between modalities revealed that postoperative brachytherapy yielded the lowest recurrence rate (15%) compared with X-ray and electron beam (23% and 23%, respectively; P =0.04, P = 0.1). Subgroup analysis by location demonstrated chest keloids have the highest recurrence rate. The most commonly reported side effect of radiotherapy was changes in skin pigmentation. CONCLUSIONS: The results of this study reinforce postoperative radiotherapy as effective management for keloids. Specifically, brachytherapy was the most effective of the currently used radiation modalities.

Endoscopic Versus Open Cubital Tunnel Release: A Systematic Review and Meta-Analysis.

BACKGROUND: Several surgical techniques exist for treatment of cubital tunnel syndrome. Endoscopic cubital tunnel release (ECTuR) has been recently reported as a promising minimally invasive technique. This study aims to compare outcomes and complications of open cubital tunnel release (OCTuR) and ECTuR in the treatment of idiopathic cubital tunnel syndrome. METHODS: A systematic review of the literature (1980-2014) identified 118 citations. Studies including adults with idiopathic cubital tunnel treated exclusively by ECTuR or OCTuR were included. Outcomes of interest were postoperative grading, complications, number of reoperations, and the need for intraoperative conversion to another technique. Postoperative outcomes were combined into a uniform scale with 4 categories: "excellent," "good," "fair," and "poor." RESULTS: Twenty studies met the inclusion criteria (17 observational and 3 comparative), representing 425 open and 556 endoscopic decompressions. In the open group, 79.8% experienced "good" or "excellent" results with 12% complication rate and 2.8% reoperation rate. In the endoscopic group, 81.8% experienced "good" or "excellent" results with 9% complication rate and 1.6% reoperation rate. Meta-analysis of 3 comparative studies demonstrated a significantly lower overall complication rate with ECTuR. Subgroup analysis of complications revealed a significantly higher incidence of scar tenderness and elbow pain with OCTuR. CONCLUSIONS: The current study demonstrates similar effectiveness between the endoscopic (ECTuR) and open (OCTuR) techniques for treatment of idiopathic cubital tunnel syndrome with similar outcomes, complication profiles, and reoperation rates.

Vascularized proximal fibula epiphyseal transfer for distal radius reconstruction in children: A systematic review.

PURPOSE: Reconstruction of the distal radius in children is cumbersome, requiring simultaneous restoration of joint function and axial growth. Vascularized proximal fibular epiphyseal transfers (VFET) have been popularized over non-vascularized transfers and prosthesis. This systematic review aims to evaluate the effectiveness of VFET and its associated complications. METHODS: Electronic database of PubMed MEDLINE was searched between 1970 and 2014. Studies reporting VFET for distal radius reconstruction in children (<15 years old) with clear reporting of technique (vascular pedicle) and objective outcome measures were included. Outcomes of interest were rate of graft growth, bone union and complications. A one-way Analysis of Variance (ANOVA) test was used to compare growth rates between pedicle types. RESULTS: Fourteen studies met the inclusion criteria, representing 25 patients. Pedicles used were anterior tibial (44%), peroneal (16%), or bi-pedicled (40%) anastomosed in antegrade (64%) or reverse flow (36%) fashion. Among all pedicle types, best results were achieved using anterior tibial artery with reversed flow, yielding average growth rate of 0.83 cm/year (P = 0.01). Recipient complications included four premature epiphyseal plate closures, a flap loss, and six wrist radial deviations. Donor complications included six common peroneal nerve palsies (five temporary, a permanent), and a talocalcaneal instability. Overall complication rates between pedicle types were comparable (P = 0.062). CONCLUSION: VFET may be a surgical option capable of restoring joint function and axial growth potential in select patients. The reverse flow technique based on the anterior tibial artery may result in superior outcomes. However, the overall complication rate is high and permanent peroneal nerve palsy may result. LEVEL OF EVIDENCE: IV © 2015 Wiley Periodicals, Inc. Microsurgery 36:705-711, 2016.

Dupuytren contracture in the pediatric population: a systematic review.

Dupuytren contracture of the palm is a relatively common benign fibroproliferative disease of the palmar fascia typically affecting the adult population. There have however been several reported cases of Dupuytren contracture in children. We sought to review the literature for Dupuytren contracture and highlight the main clinical features and management of the disease in children.

Abdominal compartment syndrome following abdominoplasty: A case report and review.

Abdominoplasty is among the most commonly performed aesthetic procedures in plastic surgery. Despite high complication rate, abdominal contouring procedures are expected to rise in popularity with the advent of bariatric surgery. Patients with a history of gastric bypass surgery have an elevated incidence of small bowel obstruction from internal herniation, which is associated with non-specific upper abdominal pain, nausea, and a decrease in appetite. Internal hernias, when subjected to elevated intra-abdominal pressures, have a high-risk of developing ischemic bowel. We present a case report of patient with previous laparoscopic Roux-en-y gastric bypass who developed acute ischemic bowel leading to abdominal compartment syndrome following abdominoplasty. To the best of our knowledge, this is the first reported case in the literature. We herein emphasise on the subtle symptoms and signs that warrant further investigations in prospective patients for an abdominal contouring procedure with a prior history of gastric bypass surgery.

Lipofibromatous hamartoma of the median nerve: a comprehensive review and systematic approach to evaluation, diagnosis, and treatment.

Many modalities exist for diagnosing and treating lipofibromatous hamartoma (LFH), with no clear consensus. This is the first comprehensive study to review the existing literature on LFH of the median nerve and to suggest a systematic approach to its diagnosis and treatment. An electronic and manual search was conducted on Medline, Embase, Google Scholar, Current Contents, and Science Citation Index for original and review articles in English or French, from 1946 to November 2012. After 2 levels of screening, 106 references containing case reports were retained. Data extraction included patient demographics, clinical information, diagnostic modalities, treatment, and follow-up. A total of 180 cases were reported in the literature. One third of patients had associated macrodactyly (32%). Gender distribution is equal in LFH with or without macrodactyly, with most patients (71%) presenting before age 30 years. The main presenting symptom is an enlargement (88%) over the volar forearm, wrist, or hand, with or without digital hypertrophy, followed by paresthesia (39%). A soft, mobile, nontender, nonfluctuant mass with variable degree of compressive median neuropathy is found on physical examination. Biopsy, which reveals abundant mature fat cells and fibrous connective tissue infiltrating between nerve fascicles and the space between the epineurium and the perineurium, is not necessary because the pathognomonic features of the mass on magnetic resonance imaging offer an accurate diagnosis. Treatment of nerve compression symptoms and macrodactyly should be addressed separately. Carpal tunnel release is the mainstay of treatment for neuropathy, and ray or digital amputation, wedge osteotomy, middle phalangectomy with arthroplasty, and epiphysiodesis are suggested options in the management of macrodactyly. Based on our review of the literature, we propose an algorithm for the diagnosis and treatment of LFH of the median nerve with or without macrodactyly.

Salter-harris type 2 fracture of the proximal phalanx of the thumb with a rotational deformity: a case report and review.

Hand fractures are the most common site of injury in the pediatric population. They commonly involve the epiphyseal growth plates, and their standard classification is that of Salter-Harris (SH). Rotational deformities after SH fractures are rarely reported in literature. However, only 5 degrees of angulation can cause evident rotational deformity. This could be seen clinically and reconfirmed with radiologic evaluation. Up to this date, there are only a few cases of SH fractures with rotational deformity that have been described. We present 2 cases of SH type 2 with evidence of rotational deformity, which were reduced under local anesthesia in the emergency department. A review of literature is performed. Thus, examination for rotational deformities in SH fractures should be kept in mind. A satisfactory closed reduction under local anesthesia can be obtained.

Unilateral absence of latissimus dorsi muscle.

Latissimus dorsi (LD) is the broadest muscle of the back responsible for extension and adduction of shoulder. The authors report a case of isolated unilateral absence of the latissimus dorsi muscle observed during an ablative surgical procedure and flap reconstruction. The left LD muscle was completely absent in our patient and no tendon fibers belonging to this muscle could be observable on further dissection. The surrounding muscle anatomy was normal and in place suggesting a developmental etiology for its absence. Awareness of this possible variation is of importance in considering reconstructive options.

General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis.

BACKGROUND: Thoracic paravertebral block (TPVB) offers an attractive alternative to general anaesthesia (GA) for ambulatory breast surgery. The aim of this meta-analysis was first to evaluate the safety and efficacy of TPVB for breast surgery, and second to compare TPVB with GA with regard to postoperative pain, nausea and vomiting, opioid consumption and length of hospital stay. METHODS: An electronic and manual search of English- and French-language articles on TPVB in breast surgery (published from January 1980 to June 2010) yielded 41 citations. Two levels of screening identified 11 relevant studies. The Mantel-Haenszel method (fixed effect) was used to perform the meta-analysis. RESULTS: Eleven studies were retained for analysis. When TPVB was used instead of GA, pain scores were significantly decreased at 1 and 6 h postoperatively (mean difference of 2.48 (95%confidence interval (CI): 2.20-2.75) and 1.71 (95%CI: 1.64-1.78), respectively). Furthermore, postoperative analgesic consumption was significantly lower in patients who received TPVB compared with GA (relative risk (RR) 0.23, (95%CI: 0.15-0.37)). TPVB was also associated with significantly less postoperative nausea and vomiting (RR 0.27 (95%CI: 0.12-0.61)). Increased patient satisfaction and a shorter hospital stay also favoured TPVB over GA. CONCLUSIONS: TPVB provides effective anaesthesia for ambulatory breast surgery and can result in significant benefits over GA. However, further studies are required to determine whether these advantages would still be present if an optimal technique for outpatient GA is employed. Adjunctive ultrasonography may contribute to improve the safety of TPVB in breast surgery and requires further investigation.

Percutaneous fasciotomy for the treatment of Dupuytren's disease-a systematic review.

BACKGROUND: Dupuytren's disease is described as a thickening of the palmar fascia. It typically affects men of Northern European descent in their fifties. The disease process starts as a nodule at the distal palmar crease that progressively gives rise to a cord invading distally toward the finger. Historically, different treatments have been described. Our purpose was to perform a meta-analysis of the evidence published on the percutaneous fasciotomy (PCF) treatment. METHODS: We searched Medline, PubMed, and the Cochrane Library for articles evalu ating the use of PCF for Dupuytren's disease. No study was excluded based on quality. RESULTS: The search yielded nine studies. Because of their different methodologies, a meta-analysis could not be performed. However, we were able to extract common qualitative conclusions. PCF is an effective treatment modality for patients in whom general anesthesia is contraindicated, with a good outcome especially at the metacarpophalangeal joint, a low recurrence rate in the short term, and few complications. CONCLUSIONS: Similar conclusions were reached by all the articles under study. Nevertheless, there remains the need for a prospective study with a higher statistical power and standardized clinical evaluation and surgical methods in order to achieve more objective quantitative results. It would also be pertinent to compare the outcomes and complication rates of PCF with the new collagenase treatment.

Extracellular signal-regulated kinase mediates phosphorylation of tropomyosin-1 to promote cytoskeleton remodeling in response to oxidative stress: impact on membrane blebbing.

Oxidative stress induces in endothelial cells a quick and transient coactivation of both stress-activated protein kinase-2/p38 and extracellular signal-regulated kinase (ERK) mitogen-activated protein kinases. We found that inhibiting the ERK pathway resulted, within 5 min of oxidative stress, in a misassembly of focal adhesions characterized by mislocalization of key proteins such as paxillin. The focal adhesion misassembly that followed ERK inhibition with the mitogen-activated protein kinase kinase (MEK) inhibitor PD098059 (2'-amino-3'-methoxyflavone) or with a kinase negative mutant of ERK in the presence of H(2)O(2) resulted in a quick and intense membrane blebbing that was associated with important damage to the endothelium. We isolated by two-dimensional gel electrophoresis a PD098059-sensitive phosphoprotein of 38 kDa that we identified, by mass spectrometry, as tropomyosin-1. In fact, H(2)O(2) induced a time-dependent phosphorylation of tropomyosin that was sensitive to inhibition by PD098059 and UO126 (1,4-diamino-2,3-dicyano-1,4-bis[2-aminophenylthio]butanediane). Tropomyosin phosphorylation was also induced by expression of a constitutively activated form of MEK1 (MEK(CA)), which confirms that its phosphorylation resulted from the activation of ERK. In unstimulated cells, tropomyosin-1 was found diffuse in the cells, whereas it quickly colocalized with actin and stress fibers upon stimulation of ERK by H(2)O(2) or by expression of MEK(CA). We propose that phosphorylation of tropomyosin-1 downstream of ERK by contributing to formation of actin filaments increases cellular contractility and promotes the formation of focal adhesions. Incidentally, ML-7 (1-[5iodonaphthalene-1-sulfonyl]homopiperazine, HCl), an inhibitor of cell contractility, inhibited phosphorylation of tropomyosin and blocked the formation of stress fibers and focal adhesions, which also led to membrane blebbing in the presence of oxidative stress. Our finding that tropomyosin-1 is phosphorylated downstream of ERK, an event that modulates its interaction with actin, may lead to further understanding of the role of this protein in regulating cellular functions associated with cytoskeletal remodeling.