Nasal monobloc osteotomy for correction of late nasal and orbital asymmetry of unicoronal synostosis: A morphometric and outcomes study.

BACKGROUND: Craniofacial asymmetry associated with unicoronal synostosis (UCS) may persist into the teenage years despite surgery in infancy. This study evaluated outcomes following a nasal monobloc procedure by mobilizing a united nasomaxillary and bilateral medial orbital segment of bone (nasal monobloc) to perform corrective translational and rotational movement for secondary correction of residual nasal-orbital asymmetry associated with UCS. METHODS: A retrospective review of all UCS patients treated with nasal monobloc at our institution was performed. Demographic information was recorded, and pre- and postoperative 2D imaging was used for morphometric outcome analysis. Outcomes and complications were tabulated. RESULTS: The study included 14 patients (5 males, 9 females; mean age 14.6 years; range 9.6 to 22.5 years; mean follow-up 70.6 months range 12 to 132 months). Ancillary procedures (scar revision, forehead/orbital contouring, MEDPOR® augmentation) were performed in all patients at the time of the nasal monobloc. One patient underwent a repeat procedure 6 years later following technique modification. Additionally, another patient experienced late overgrowth of the frontal sinus with forehead asymmetry. The morphometric analysis demonstrated significant (p < 0.05) pre-op to post-op improvements in naso-orbital asymmetry, as demonstrated by horizontal orbital aperture ratio (0.88 vs 0.99), midline to exocanthion ratio (0.91 vs 0.98), orbital index ratio (1.15 vs 1.01), and midline discrepancy (7.1 degrees vs 2.7 degrees). CONCLUSION: Nasal monobloc osteotomy provides a reasonable surgical treatment to improve both the nasal and orbital asymmetries associated with unicoronal synostosis, including frontal nasal deviation, basal nasal deviation, and orbital aperture asymmetry. It is important to note that confounding anatomic variables such as globe dystopia, strabismus, and scleral show may affect the perception of orbital symmetry.

Upper Extremity Surgery in Cervical Spinal Cord Injury: A Prospective Comparative Mixed Methods Study.

BACKGROUND: Cervical spinal cord injury (SCI) is a devastating injury. Restoring upper extremity function is a top priority, which can be accomplished by tendon transfer (TT) and nerve transfer (NT) surgeries. The purpose of this prospective comparative study was to assess long-term changes in UE function between surgical (TT or NT) and non-surgical groups through a comprehensive mixed methods approach. METHODS: This multicenter, cohort study compared data among three groups: those undergoing 1) no surgery 2) TT surgery, or 3) NT surgery. Quantitative data, the Spinal Cord Independence Measure (SCIM) and Short Form Health Survey (SF-36), was collected at baseline and long-term follow-up (6-24 months). Qualitative semi-structured interview data was also obtained from these participants and their identified caregivers at baseline, early follow-up (1 month), and long-term follow-up (6-24 months). RESULTS: Thirty-one participants had quantitative data across all timepoints: no surgery (n=14), TT (n=7), and NT (n=10). SCIM scores improved in TT and NT groups compared to the no surgery group (p<0.05). SF-36 scores did not differ among groups. Qualitative data analysis (n=168 interviews) corroborated SCIM findings: surgical participants and their caregivers reported improvement in transfers and ability to perform activities of daily living, including grooming and self-catheterization. Improved use of electronics and ability to operate a motor vehicle were also reported. Post-operative therapy was identified as a critical component of achieving gains. CONCLUSION: Both TT and NT surgery leads to quantitative and qualitative functional gains as compared to the no surgery group. This comparative information should be used to help surgeons discuss treatment options.

Comparing surgeries to restore upper extremity function in tetraplegia: Impact on function during the perioperative period.

CONTEXT/OBJECTIVE: To assess short-term changes in health outcomes in people with cervical-level spinal cord injury (SCI) who underwent upper extremity (UE) reconstruction via either novel nerve transfer (NT) or traditional tendon transfer (TT) surgery with individuals who did not undergo UE surgical reconstruction. DESIGN: Prospective, comparative cohort pilot study. PARTICIPANTS: 34 participants with cervical SCI met the following inclusion criteria: age 18 or older, greater than 6 months post-injury, and mid-cervical level SCI American Spinal Injury Association Impairment Scale (AIS) A, B or C. SETTING: Two tertiary academic hospitals and their affiliated veterans' hospitals. METHODS: Health outcomes were assessed using two previously validated measures, the Spinal Cord Independence Measure (SCIM) and Short-Form Health Survey (SF-36). Demographic, surgical, and survey data were collected at the initial evaluation and one month postoperatively/post-baseline. RESULTS: 34 participants with cervical SCI were recruited across three cohorts: no surgery (n = 16), NT (n = 10), and TT (n = 8). The TT group had a decline in SCIM and SF-36 scores whereas the NT and no surgery groups experienced little change in independence or health status in the immediate perioperative period. CONCLUSIONS: Surgeons and rehabilitation providers must recognize differences in the perioperative needs of people with cervical SCI who chose to have restorative UE surgery. Future work should focus on further investigation of health outcomes, change in function, and improving preoperative counseling and cross-disciplinary management.

Morphometric analysis and outcomes following posterior cranial vault distraction in syndromic and multisuture craniosynostosis.

BACKGROUND: Turribrachycephaly is a common feature in many syndromic and multisuture craniosynostoses and is traditionally treated with total cranial vault reshaping and fronto-orbital advancement. A staged approach with posterior cranial vault distraction as a primary procedure followed by anterior cranial vault reshaping has the advantage of reducing the vertical dimension of the skull in a controlled and gradual manner while expanding the cranial volume. The purpose of this study was to evaluate outcomes following posterior cranial vault expansion using distraction osteogenesis at a single tertiary pediatric center. METHODS: This retrospective review included all cases of posterior cranial vault distraction at a single institution from 2008 to 2022 performed by one surgeon. Morphometric outcomes such as Turricephaly Index (TI) and posterior cranial volume (PCV) were assessed from pre- and postoperative computerized tomography scans for patients who underwent posterior cranial vault distraction as a primary first-stage operation. Clinical outcomes and complications were collated. RESULTS: A total of 41 patients (25 females, 16 males; mean age 11 months) with syndromic craniosynostosis (n = 32) and nonsyndromic craniosynostosis (n = 9) were included. The main indication for posterior cranial vault distraction in this cohort was turricephaly (63%). The mean distraction distance was 25.9 mm and the mean decrease in TI was 18%. The estimated increase in PCV from distraction in this cohort was 19.7%. In this cohort of patients, 13 patients (32%) experienced complications but there were no mortalities. CONCLUSION: Posterior cranial vault distraction osteogenesis is an effective surgical procedure to increase intracranial volume and correct turricephaly in children with syndromic and nonsyndromic craniosynostosis. This procedure is considered a safe and effective first-stage cranial operation in children with syndromic craniosynostosis with increased intracranial pressure and or turricephaly.

Quantifying Tenodesis Hand Function in Cervical Spinal Cord Injury: Implications for Function.

PURPOSE: Cervical spinal cord injury (SCI) has a profound effect on upper-extremity function. Individuals with stiffness and/or spasticity may have more, or less, useful tenodesis function. This study examined the variability present before any reconstructive surgery. METHODS: Tenodesis pinch and grasp were measured with the wrist in maximal active extension. Tenodesis pinch was the contact point of the thumb with the index finger proximal phalanx (T-IF:P1), middle phalanx (T-IF:P2), distal phalanx (T-IF:P3), or absent (T-IF:absent). Tenodesis grasp was the distance from the long finger to the distal palmar crease (LF-DPC). Activities of daily living function was assessed using the Spinal Cord Independence Measure (SCIM). RESULTS: The study included 27 individuals (4 females, 23 males; mean age 36 years, mean time since SCI 6.8 years). The mean International Classification for Surgery of the Hand in Tetraplegia (ICSHT) group classification was 3. In the dominant hand, individuals with a T-IF tenodesis pinch to P1 or P2 had significantly higher total SCIM scores (43.7 and 34.2, respectively) compared to those with absent T-IF tenodesis pinch (SCIM 17.8). Shorter LF-DPC distance with tenodesis grasp (improved finger closing) also correlated with improved SCIM mobility and total scores. No association was found between the ICSHT group and SCIM score or tenodesis measures. CONCLUSIONS: Quantifying tenodesis with pinch (T-IF) and grasp (LF-DPC) is a simple method to characterize hand movement in individuals with cervical SCI. Better tenodesis pinch and grasp were associated with improved activities of daily living performance. CLINICAL RELEVANCE: Differences in grasp function have implications for mobility, and differences in pinch function have implications for all functions, particularly self-care. These physical measurements could be used to assess movement changes after nonsurgical and surgical treatment in tetraplegia.

Calling on Sponsorship: Analysis of Speaker Gender Representation at Hand Society Meetings.

BACKGROUND: The paucity of leadership diversity in surgical specialties is well documented. Unequal opportunities for participation at scientific meetings may impact future promotions within academic infrastructures. This study evaluated gender representation of surgeon speakers at hand surgery meetings. METHODS: Data were retrieved from the 2010 and 2020 meetings of the American Association for Hand Surgery (AAHS) and American Society for Surgery of the Hand (ASSH). Programs were evaluated for invited and peer-reviewed speakers excluding keynote speakers and poster presentations. Gender was determined from publicly available sources. Bibliometric data (Hirsch index) for invited speakers were analyzed. RESULTS: In 2010 at the AAHS ( n = 142) and ASSH meetings ( n = 180), female surgeons represented 4% of the invited speakers and in 2020 increased to 15% at AAHS ( n = 193) and 19% at ASSH ( n = 439). From 2010 to 2020, female surgeon invited speakers had a 3.75-fold increase at AAHS and 4.75-fold increase at ASSH. Representation of female surgeon peer-reviewed presenters at these meetings was similar (2010 AAHS, 26%; and 2010 ASSH, 22%; 2020 AAHS, 23%; 2020 ASSH, 22%). The academic rank of women speakers was significantly lower ( P < 0.001) than for male speakers. At the assistant professor level, the mean Hirsch index was significantly lower ( P < 0.05) for female invited speakers. CONCLUSIONS: Although there was a significant improvement in gender diversity in invited speakers at the 2020 meetings compared with 2010, female surgeons remain underrepresented. Gender diversity is lacking at national hand surgery meetings, and continued effort and sponsorship of speaker diversity is imperative to curate an inclusive hand society experience.

Catastrophic and Critical Intraoperative Events during Pediatric Craniofacial Surgery.

Pediatric craniofacial surgery performed in tertiary care centers by dedicated teams is associated with high levels of safety and low rates of mortality. However, catastrophic and life-threatening events may occur as a result of surgical management of these complex patients. This study reviewed the incidence and acute outcomes of catastrophic and critical events during craniofacial surgery at a single high-volume center. Methods: The data reviewed included the operative procedures of two senior craniofacial surgeons over an 18-year period at a tertiary care pediatric craniofacial center. Catastrophic or critical intraoperative events were defined as events requiring the activation of an emergency code during surgery. The operative details and acute outcomes were reviewed and analyzed. Results: This study reviewed 7214 procedures performed between January 2002 and January 2019. There were 2072 (29%) cases classified as major craniofacial procedures (transcranial, mixed trans-and-extracranial, or major extracranial facial osteotomies), and code events occurred in 14 cases (0.67%; one in 148 patients): venous air embolism (n = 4), cardiac complications (n = 3), major hemorrhage (n = 3), trigeminocardiac reflex (n = 2), acute intracranial hypertension (n = 1), and acute airway obstruction (n = 1). Two cases (14%) experienced a critical event that was anesthesia-related. Cardiac arrest requiring compressions and/or defibrillation was necessary for eight patients. There were no mortalities. Surgery was curtailed in seven cases and successfully completed in seven patients. Conclusions: Catastrophic life-threatening events during pediatric craniofacial surgery are, fortunately, rare. In our institution, experienced teams in the management of catastrophic and critical intraoperative events during major pediatric craniofacial procedures resulted in no mortalities.

Continuing professional development needs in pain management for Canadian health care professionals: A cross sectional survey.

Background: Continuing professional development is an important means of improving access to effective patient care. Although pain content has increased significantly in prelicensure programs, little is known about how postlicensure health professionals advance or maintain competence in pain management. Aims: The aim of this study was to investigate Canadian health professionals' continuing professional development needs, activities, and preferred modalities for pain management. Methods: This study employed a cross-sectional self-report web survey. Results: The survey response rate was 57% (230/400). Respondents were primarily nurses (48%), university educated (95%), employed in academic hospital settings (62%), and had ≥11 years postlicensure experience (70%). Most patients (>50%) cared for in an average week presented with pain. Compared to those working in nonacademic settings, clinicians in academic settings reported significantly higher acute pain assessment competence (mean 7.8/10 versus 6.9/10; P < 0.002) and greater access to pain specialist consultants (73% versus 29%; P < 0.0001). Chronic pain assessment competence was not different between groups. Top learning needs included neuropathic pain, musculoskeletal pain, and chronic pain. Recently completed and preferred learning modalities respectively were informal and work-based: reading journal articles (56%, 54%), online independent learning (44%, 53%), and attending hospital rounds (43%, 42%); 17% had not completed any pain learning activities in the past 12 months. Respondents employed in nonacademic settings and nonphysicians were more likely to use pocket cards, mobile apps, and e-mail summaries to improve pain management. Conclusions: Canadian postlicensure health professionals require greater access to and participation in interactive and multimodal methods of continuing professional development to facilitate competency in evidence-based pain management.

Contexte: Le développement professionnel continu est un moyen important d'améliorer l'accès à des soins efficaces pour les patients. Bien que le contenu lié à la douleur ait augmenté de manière significative dans les programmes préalables à l'autorisation d'exercer, on sait peu de choses sur la façon dont les professionnels de la santé après licenciés améliorent ou maintiennent leurs compétences en matière de gestion de la douleur.Objectifs: Étudier les besoins, les activités et les préférences de développement professionnel continu des cliniciens canadiens en matière de gestion de la douleur.Méthodes: Enquête Web transversale d'auto-évaluation.Résultats: Le taux de réponse au sondage était de 57 % (230/400). Les répondants étaient principalement des infirmières (48 %), des diplômés universitaires (95 %), des employés en milieu hospitalier universitaire (62 %), avec ≥11 ans d'expérience après l'obtention du permis (70 %). La plupart des patients (> 50 %) pris en charge dans une semaine moyenne présentaient des douleurs. Comparativement à ceux qui travaillent dans des milieux non universitaires, les cliniciens en milieu universitaire ont signalé une compétence d'évaluation de la douleur aiguë significativement plus élevée (moyenne de 7,8/10 contre 6,9/10; P < 0,002) et un meilleur accès aux consultants en gestion de la douleur (73 % contre 29 %; P < 0,0001). La compétence d'évaluation de la douleur chronique n'était pas différente entre les groupes. Les principaux besoins d'apprentissage comprenaient la douleur neuropathique, la douleur musculo-squelettique et la douleur chronique. Les modalités d'apprentissage récemment achevées et préférées étaient respectivement informelles et basées sur le travail: lecture d'articles de journaux (56 %, 54 %), apprentissage indépendant en ligne (44 %, 53 %) et participation à des visites à l'hôpital (43 %, 42 %); 17 % n'avaient effectué aucune activité d'apprentissage de la douleur au cours des 12 derniers mois. Les répondants hors les médecins et ceux employés dans des milieux non universitaires étaient plus susceptibles d'utiliser des cartes de poche, des applications mobiles et des résumés par e-mail pour améliorer la gestion de la douleur.Conclusions: Les professionnels de la santé canadiens après l'obtention du permis d'exercice ont besoin d'un meilleur accès et d'une plus grande participation aux méthodes interactives et multimodales de développement professionnel continu pour faciliter la compétence en gestion de la douleur fondée sur des données probantes.

Surgery to restore upper extremity function in tetraplegia-Preferences for early and frequent access to information.

INTRODUCTION: People with cervical spinal cord injury (SCI) identify improving upper extremity (UE) function as a top priority. In addition to comprehensive rehabilitation, UE surgeries, including nerve and tendon transfers, enhance function. However, barriers exist to disseminating information about surgical options to enhance UE function. OBJECTIVE: To assess the experiences and preferences of people with cervical SCI and their caregivers in accessing information about surgery to enhance UE function. DESIGN: Prospective cohort study. Participants were followed up for 24 months and completed up to three interviews. SETTING: Tertiary care at academic and affiliated Veterans Administration Health Care Centers. PARTICIPANTS: Adults with cervical SCI (n = 35) ages 18 to 80 years with mid-cervical SCI American Spinal Injury Association Impairment Scale A, B, or C (at least 6 months post-injury) and their caregivers (n = 23) were eligible to participate. Participants were enrolled in three groups: nerve transfer, tendon transfer, or no UE reconstructive surgery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Semi-structured interviews about surgical knowledge and experiences. RESULTS: Data were analyzed and three themes were identified. First, providing information about UE surgical options early post-injury was recommended. The acute or inpatient rehabilitation phases of recovery were the preferred times to receive surgical information. Second, challenges with information dissemination were identified. Participants learned about UE surgery through independent research, medical provider interactions, or peers. Third, peers were identified as valuable resources for SCI needs and surgical information. CONCLUSIONS: Following cervical SCI, information about UE reconstructive surgeries should be a standard component of education during rehabilitation. An increased understanding of the reconstructive options available to improve UE function is necessary to educate stakeholders. Future research is needed to support the development of strategies to effectively present surgical information to individuals with SCI and health care providers.

Opioid Medication Disposal Among Patients Following Hand Surgery.

BACKGROUND: Despite increased public awareness to dispose of unused narcotics, opioids prescribed postoperatively are retained, which may lead to drug diversion and abuse. This study assessed retention of unused opioids among hand surgery patients and describes disposal methods and barriers. METHODS: Participants undergoing hand surgery were given an opioid disposal information sheet preoperatively (N = 222) and surveyed postoperatively to assess disposal or retention of unused opioids, disposal methods, and barriers to disposal. A binomial logistic regression was conducted to assess whether age, sex, pain intensity, and/or the type of procedure were predictors of opioid disposal. RESULTS: There were 171 patients included in the analysis (n = 51 excluded; finished prescription or continued opioid use for pain control). Unused opioids were retained by 134 patients (78%) and disposal was reported by 37 patients (22%). Common disposal methods included returning opioids to a pharmacy (49%) or mixing them with an unwanted substance (24%). Reasons for retention included potential future use (54%), inconvenient disposal methods (21%), or keeping an unfilled prescription (9%). None of the patient factors analyzed (age, sex, type of procedure performed, or pain score) were predictors of disposal of unused narcotics (P > .05). CONCLUSIONS: Most patients undergoing hand surgery retained prescribed opioids for future use or due to impractical disposal methods. The most common disposal methods included returning narcotics to a pharmacy or mixing opioids with unwanted substances. Identifying predictors of disposal may provide important information when developing strategies to increase opioid disposal.

Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia.

PURPOSE: Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT. METHODS: This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living. RESULTS: Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (-5.6% at early and -4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (-46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up. CONCLUSIONS: Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Developing a Video-Based Learning Module to Teach Decision-Making for Cubital Tunnel Surgery.

BACKGROUND: Although intraoperative educational videos have become increasingly popular, comparatively few videos teach clinical reasoning for surgical procedures. The objectives of this study were to develop an engaging online video-based module to teach decision-making for cubital tunnel surgery, including supercharge nerve transfer, using a multimedia learning framework; and evaluate its effectiveness and use for continuing professional development. METHODS: The educational module consisted of a prelecture knowledge assessment, choice of two self-guided video lectures (7 minutes and 28 minutes), and a postlecture knowledge assessment. An additional assessment examined knowledge retention 3 months after module completion. Surgeon surveys were administered after each knowledge assessment. RESULTS: A total of 279 surgeons participated in the educational module (75 percent practicing surgeons, 25 percent trainees), 112 surgeons completed the postlecture assessment, and 71 surgeons completed the knowledge retention assessment. Median score on the prelecture assessment was five out of 10 (interquartile range, four to seven). Scores improved by three points (10-point scale; p < 0.0001) in the postlecture assessment. Median score on the knowledge retention assessment was eight out of 10 (interquartile range, six to nine), with participants maintaining a two-point increase from their prelecture score ( p = 0.0002). Among surgeons completing this assessment, 68 percent reported that the module had changed their management of cubital tunnel syndrome. CONCLUSIONS: This study introduces a framework for the development of online multimedia modules for surgical education. It also underscores a demand among surgeons for easily accessible, reusable educational resources. Similar video-based modules may be developed to address this demand to facilitate continuing professional development in surgery.

Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To quantify spontaneous upper extremity motor recovery between 6 and 12 months after spinal cord injury (SCI) to help guide timing of nerve transfer surgery to improve upper limb function in cervical SCI. SETTING: Nineteen European SCI rehabilitation centers. METHODS: Data was extracted from the European Multicenter Study of SCI database for individuals with mid-level cervical SCI (N = 268). Muscle function grades at 6 and 12 months post-SCI were categorized for analysis. RESULTS: From 6 to 12 months after SCI, spontaneous surgically-relevant recovery was limited. Of all limbs (N = 263) with grade 0-2 elbow extension at 6 months, 4% regained grade 4-5 and 11% regained grade 3 muscle function at 12 months. Of all limbs (N = 380) with grade 0-2 finger flexion at 6 months, 3% regained grade 4-5 and 5% regained grade 3 muscle function at 12 months. CONCLUSION: This information supports early (6 month) post-injury surgical consultation and evaluation. With this information, individuals with SCI can more fully engage in preference-based decision-making about surgical intervention versus continued rehabilitation and spontaneous recovery to gain elbow extension and/or hand opening and closing.

Aromatase Inhibitor-Induced Carpal Tunnel Syndrome and Stenosing Tenosynovitis: A Systematic Review.

BACKGROUND: Although aromatase inhibitors are the first-line treatment in postmenopausal women with hormone receptor-positive breast cancer, there is increasing evidence that they can induce carpal tunnel syndrome and stenosing tenosynovitis. This systematic review summarizes the risk factors, incidence, and management for patients with aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis compared to tamoxifen or placebo. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review of PubMed/MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials was conducted (to March 19, 2020), supplemented with Google Scholar, Plastic and Reconstructive Surgery, and The Journal of Hand Surgery. Two reviewers independently completed the primary and secondary screens and the quality appraisal. RESULTS: This study reviewed 577 abstracts and included 19 studies. Risk factors for aromatase inhibitor-induced carpal tunnel syndrome or stenosing tenosynovitis included hormone replacement therapy before trial entry, history of musculoskeletal symptoms, age younger than 60 years, prior chemotherapy, and body mass index greater than 25 kg/m2. The incidence can be increased up to 10 times compared to tamoxifen. Patient discontinuation of aromatase inhibitor treatment because of carpal tunnel syndrome and stenosing tenosynovitis was reported. Nonsurgical management led to complete resolution of carpal tunnel syndrome symptoms in up to 67 percent of cases. Although most aromatase inhibitor-induced stenosing tenosynovitis original studies were low quality, all recommended surgical release for symptom resolution. CONCLUSIONS: This study provides current knowledge of the associated risk factors, management options, and quality of literature for aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis. Early recognition can prevent self-discontinuation of an aromatase inhibitor and long-term sequelae of poorly treated carpal tunnel syndrome and stenosing tenosynovitis.

Quality of Life and Psychosocial Factors as Predictors of Pain Relief Following Nerve Surgery.

Background: Peripheral nerve injuries may result in pain, disability, and decreased quality of life (QoL). Pain is an incompletely understood experience and is associated with emotional and behavioral qualities. We hypothesized that pain following peripheral nerve surgery could be predicted by changes in emotions or QoL postoperatively. Methods: Using prospectively collected data, a retrospective study design was used to evaluate the relationships among pain, QoL, and psychosocial factors in patients who underwent peripheral nerve surgery. Patients completed questionnaires rating pain; impact of pain on QoL, sadness, depression, frustration, anger, and hopefulness before surgery; and each postoperative follow-up visit. Multilevel modeling was used to assess the concurrent and lagged relationships between pain and psychosocial factors. Results: Increased pain was concurrently associated with decreased hopefulness (P = .001) and increased the impact on QoL, sadness, depression, and anger (P < .001). In lagged analyses, the impact on QoL and anger prospectively predicted pain (P < .001 and P = .02, respectively). Pain predicted subsequent scores of QoL, sadness, depression, anger, and hopefulness (P < .01). Having an upper limb nerve injury and self-report of "no comment for childhood trauma" were predictors of postsurgical pain. Conclusion: Psychosocial measures and pain are reciprocally related among patients who underwent surgery for peripheral nerve injuries or compression. Our study provides evidence of the important relationships among psychosocial factors, pain, and outcome and identifies treatment targets following nerve surgery.

Evaluation of Cold Sensitivity in Patients With Upper Extremity Nerve Compression Syndromes: A Scoping Review.

PURPOSE: The aim of this study was to review the literature to determine the prevalence of cold sensitivity in upper extremity nerve compression syndromes and the impact of treating nerve compression syndromes on cold sensitivity. METHODS: Following a standardized scoping review protocol, this study included interventional and observational study designs assessing patients with cold sensitivity and upper extremity nerve compression syndromes. Review articles, case reports, and small case series (n < 5) were excluded. The abstracts and eligible full texts were screened by 2 independent reviewers. Data were extracted and reported according to PRISMA extension for scoping reviews statement. RESULTS: Three databases were searched (Ovid MEDLINE, Ovid EMBASE, and CINAHL on EBSCO); 274 references were reviewed. Fifteen studies from the database search and 8 studies from the reference search were eligible for this review (n = 23). Two interventional and 21 observational studies were identified. The most common method for assessing cold sensitivity was cold pain threshold testing (n = 12), followed by subjective patient reporting (n = 4). The Cold Intolerance Symptom Severity questionnaire was the most common validated patient-reported outcome questionnaire used in the studies (n = 3). Cold sensitivity was most commonly reported in carpal tunnel syndrome (96% of the studies). The prevalence of cold sensitivity in nerve compression syndromes ranged from 20% to 69%. Nerve decompression improved the severity of cold sensitivity in 5 of 6 studies where cold sensitivity was studied. CONCLUSIONS: There is heterogenicity in the studies assessing cold sensitivity in nerve compression syndromes. Despite moderate prevalence in patients with carpal tunnel syndrome, cold sensitivity is understudied. Within the limitations of eligible studies reviewed, surgical decompression improved the severity of cold sensitivity in some studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radial Nerve Palsy: Nerve Transfer Versus Tendon Transfer to Restore Function.

BACKGROUND: Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. METHODS: A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. RESULTS: For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. CONCLUSIONS: The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

Ontario wait times for delayed surgical treatment of traumatic peripheral nerve injury.

BACKGROUND: To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario's wait times for delayed surgical treatment of traumatic PNI. METHODS: We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics. RESULTS: Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001). CONCLUSION: The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

COVID-19 Restrictions Presented Opportunities and Challenges for Plastic Surgery Residents.

BACKGROUND: Restrictions placed during the COVID-19 pandemic to prevent viral spread led to substantial changes in surgical resident education. The aim of this study was to assess the positive and negative impact of COVID-19 on plastic surgery education and training and provide recommendations for continued competency. METHODS: A cross-sectional online survey of plastic surgery residents across Canada was used to evaluate the impact of COVID-19 on clinical exposure, experience with virtual education, and long-term impact of COVID-19 on surgical training. RESULTS: This study included 61 plastic surgery residents (40% participation rate). Common educational modalities used during COVID-19 included online seminars (95%) and workshops (58%). Teaching sessions were effective if structured around patient cases (72%), recorded (66%), and limited to 1 hour (64%). There were mixed reactions towards online education sessions; residents reported feeling grateful (54%), motivated (38%), enthusiastic (28%), overwhelmed (41%), pressured to participate (23%), and anxious (13%). There were significantly less residents who felt that their clinical exposure was sufficient during (21%) versus before (72%) pandemic restrictions (P < .001). Overall, 87% of residents felt that the pandemic had a negative impact on their training, surgical skill development, fellowship plans, and job prospects. CONCLUSIONS: During the initial wave of COVID-19, residents faced altered educational opportunities, which elicited positive and negative emotions with concern regarding surgical skill development and impact on future career plans. Characterizing early educational impact on residency training to identify opportunities for change is worthwhile as the overall effect of the pandemic is ongoing and remains uncertain.

HISTORIQUE: Les restrictions imposées pendant la pandémie de COVID-19 pour en éviter la propagation virale ont entraîné des changements importants dans la formation des résidents en chirurgie. La présente étude visait à évaluer les répercussions positives et négatives de la COVID-19 sur l'enseignement et la formation en chirurgie plastique et à formuler des recommandations sur le maintien des compétences. MÉTHODOLOGIE: Les chercheurs ont utilisé un sondage transversal en ligne auprès des résidents en chirurgie plastique du Canada pour évaluer les répercussions de la COVID-19 sur l'exposition clinique, l'expérience de l'enseignement virtuel et les conséquences à long terme de la COVID-19 pour la formation en chirurgie. RÉSULTATS: La présente étude incluait 61 résidents en chirurgie plastique (pour un taux de participation de 40%). Les modes d'enseignement couramment utilisés pendant la COVID-19 incluaient les séminaires en ligne (95%) et les ateliers (58%). Les séances d'enseignement étaient efficaces si elles étaient structurées autour de cas de patients (72%), enregistrées (66%) et se limitaient à une heure (64%). Les réactions étaient mitigées quant aux séances de formation en ligne. Les résidents ont déclaré se sentir reconnaissants (54%), motivés (38%), enthousiastes (28%), dépassés (41%), poussés à participer (23%) et anxieux (13%). Beaucoup moins de résidents avaient l'impression que leur exposition clinique avait été suffisante pendant les restrictions liées à la pandémie (21%) qu'auparavant (72%; p<0,001). Dans l'ensemble, 87% des résidents trouvaient que la pandémie avait un effet négatif sur leur formation, l'acquisition de leurs compétences chirurgicales, leurs projets de surspécialité et leurs perspectives professionnelles. CONCLUSIONS: Pendant la première vague de COVID-19, les résidents ont dû composer avec des modifications à leurs possibilités de formation, qui ont donné lieu à des émotions positives et négatives et à des inquiétudes quant à l'acquisition de leurs habiletés chirurgicales et aux répercussions sur leur plan de carrière. Il est intéressant de caractériser les répercussions précoces sur la formation en résidence pour déterminer les occasions de changement, car l'effet global de la pandémie se poursuit et demeure incertain.