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1.
J Hand Surg Am ; 45(2): 155.e1-155.e8, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31221517

RESUMO

PURPOSE: To report the clinical outcomes and describe the surgical technique of triceps muscle reinnervation using 2 different distal nerve transfers: the flexor carpi ulnaris (FCU) fascicle of the ulnar nerve and the posterior branch of the axillary nerve (PBAN) to the triceps nerve branch. METHODS: A retrospective review of patients undergoing FCU fascicle of ulnar nerve or PBAN to triceps nerve branch transfer was performed. Outcome measures included preoperative and postoperative modified British Medical Research Council (MRC) score, EMG results, and complications. RESULTS: Between September 2003 and April 2017, 6 patients were identified. Four patients with a traumatic upper trunk and posterior cord palsy underwent ulnar nerve fascicle to triceps nerve transfer. Two patients with a recovering upper trunk following a pan-brachial plexus palsy underwent PBAN to triceps nerve branch transfer. The median age was 30.0 years (range, 18-68 years). Surgery was performed at a median of 6.9 months (range, 5.0-8.9 months) postinjury, with a median follow-up of 18.4 months (range, 7.6-176.3) months. Before surgery, 4 patients exhibited grade M0 and 2 patients exhibited grade M1 triceps strength. Four patients had M5 donor muscle strength and 2 had grade M4. Postoperatively, 4 patients regained MRC grade M4 triceps muscle strength, 1 regained M3, and 1 regained M2. There was no noticeable donor muscle weakness. CONCLUSIONS: Nerve fascicles to the FCU and PBAN are viable options for obtaining meaningful triceps muscle recovery in a select group of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

2.
J Hand Surg Am ; 2019 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-31421939

RESUMO

PURPOSE: To determine, using a biomechanical cadaveric model, whether, in the treatment of thumb carpometacarpal and scaphotrapeziotrapezoid arthritis, partial trapezoid resection following trapeziectomy causes carpal, specifically lunocapitate and scapholunate, instability. MATERIALS AND METHODS: Eight fresh-frozen mid-forearm cadaver specimens with type I lunates and devoid of basilar thumb arthritis were used in the study. Specimens were mounted onto a wrist simulator applying cyclical wrist flexion/extension and radial/ulnar deviation motions. Carpal kinematics, specifically lunocapitate and scapholunate joint relationships, were measured at 4 different conditions: (1) a native intact state, (2) after trapeziectomy, (3) after 2-mm partial trapezoid resection, and (4) after 4-mm partial trapezoid resection. RESULTS: During both flexion/extension and radial/ulnar deviation of the wrist, the lunocapitate and scapholunate joint relationship did not show any notable change following any of trapeziectomy, 2-mm, or 4-mm trapezoid resection compared with the intact state. Changes to the lunocapitate and scapholunate angles were clinically insignificant-a maximum of 6° and 4° change, respectively. CONCLUSIONS: This biomechanical cadaveric study shows that performing a trapeziectomy followed by up to 4 mm of proximal trapezoid resection has a negligible effect upon carpal, specifically lunocapitate and scapholunate, stability. Further research is needed to elucidate the long-term clinical consequences of limited trapezoid resection in vivo. CLINICAL RELEVANCE: There may be no clinically relevant effects of resection of up to 4 mm of trapezoid in the surgical management of combined basilar thumb and scaphotrapeziotrapezoid arthritis.

3.
J Reconstr Microsurg ; 35(5): 362-371, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30695799

RESUMO

BACKGROUND: The necessity for routine preoperative imaging for free fibula harvest is controversial. The primary objective of this meta-analysis is to determine if lower extremity angiography is necessary to detect abnormalities that may alter flap selection. The secondary objective is to determine if physical examination alone is sufficient to predict these abnormalities. METHODS: A literature search was performed using Cochrane, CENTRAL, MEDLINE, CINAHL, and EMBASE. Studies were selected for inclusion if they included patients undergoing free fibula flap harvest with preoperative imaging, with or without physical examination findings. Data extraction was performed independently and in duplicate, including a change in flap selection and the level of agreement between physical examination and imaging. Pooled proportions were calculated using a random-effects model and 95% confidence intervals (CI). RESULTS: Sixteen studies were included for analysis. Mean sample size was 42 patients (range: 5-123). Included studies were of low methodologic quality. Pooled proportion of patients who had flap selection change secondary to abnormalities identified on preoperative angiography was 20.1% (95% CI: 9.6-33.2%). A pooled proportion of 71.5% (95% CI: 5-88.7%) of cases requiring change in flap selection was missed by physical examination findings alone. CONCLUSION: There is low-quality evidence suggesting a necessity for routine preoperative angiography for all patients undergoing free fibula flap harvest. Physical examination alone is insufficient in detecting vascular abnormalities that may result in limb compromise or an inability to successfully harvest a free fibula. Further investigation is warranted for cost-effectiveness of preoperative imaging protocols.


Assuntos
Angiografia , Fíbula/transplante , Retalhos de Tecido Biológico/irrigação sanguínea , Cuidados Pré-Operatórios , Coleta de Tecidos e Órgãos/métodos , Humanos , Procedimentos Cirúrgicos Reconstrutivos
4.
Plast Surg (Oakv) ; 26(2): 91-98, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29845046

RESUMO

Background: The necessity of a second venous anastomosis in free flap surgery is controversial. The purpose of this systematic review is to determine whether venous flap failure and reoperation rates are lower when 2 venous anastomoses are performed. The secondary objective is to determine whether venous flap failure and reoperation rates are lower when the 2 veins are from 2 different drainage systems. Methods: A comprehensive search of the literature identified relevant studies. Investigators independently extracted data on rates of flap failure and reoperation secondary to venous congestion. A meta-analysis was performed; odds ratios (ORs) were pooled using a random-effects model and 95% confidence intervals (CIs). Results: Of 18 190 studies identified, 15 were included for analysis. The mean sample size was 287 patients (minimum = 102, maximum = 564). No statistically significant difference in venous flap failure was found when comparing 1 versus 2 venous anastomoses (OR: 1.35; 95% CI: 0.46-3.93). A significant decrease in reoperation rate due to venous congestion was shown (OR: 3.03; 95% CI: 1.64-5.58). The results favor using 2 veins from 2 different systems over veins from the same system (OR: 0.16; 95% CI: 0.02-1.27). Conclusions: There is low-quality evidence suggesting that the use of 2 venous anastomoses will lower the rate of reoperation due to venous congestion. There are insufficient data published to meaningfully compare outcomes of flaps with 2 venous anastomoses from different systems to flaps with anastomoses from the same system.

5.
J Neurosurg Pediatr ; 17(2): 222-229, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26496634

RESUMO

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

6.
Plast Reconstr Surg ; 136(4): 765-79, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26090765

RESUMO

BACKGROUND: Nerve repair may be effective in improving function following obstetrical brachial plexus injury. No previous review has directly compared nerve repair to nonoperative management for similar patients, and no previous analysis has been adequately powered to determine whether nerve repair reduces impairment. METHODS: Electronic databases were searched (MEDLINE, Embase, CINAHL, and Cochrane Central). Eligible studies were randomized controlled trials, observational studies, and case series (n > 9); included patients younger than 2 years undergoing nerve repair or nonoperative management of obstetrical brachial plexus injury; and reported functional impairment. Two reviewers independently screened articles using objective a priori criteria. Bias was assessed for each study. Overall quality of evidence was evaluated for each outcome. RESULTS: Among nine cohort studies including 222 patients, nerve repair significantly reduced functional impairment compared with nonoperative management (relative risk, 0.58; 95 percent CI, 0.43 to 0.79; p < 0.001; I = 0 percent; absolute risk reduction, 19 percent; number needed to treat, six). Findings are consistent with comparison of similar patients from case series. With operative management, no deaths were reported; major adverse events were reported in 1.5 percent, and minor adverse events were reported in 5.0 percent of cases. Among demographic (all severities) samples managed nonoperatively, residual impairment remains in 27 percent (19 to 36 percent). CONCLUSIONS: Nerve repair reduces functional impairment in obstetrical brachial plexus injury. Nonoperative management in patients with a deficit at 3 months of age leads to a high proportion of functional impairment. Mortality is not a common risk of modern pediatric microsurgical nerve repair. Residual impairment with nonoperative management is underestimated in the reported literature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Traumatismos do Nascimento/cirurgia , Plexo Braquial/lesões , Procedimentos Neurocirúrgicos/métodos , Traumatismos dos Nervos Periféricos/cirurgia , Humanos , Lactente , Recém-Nascido , Resultado do Tratamento
7.
J Hand Surg Am ; 40(5): 997-1005, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25771479

RESUMO

PURPOSE: To systematically review the literature to determine if utilities (a quantitative way to express patient preferences for health outcomes) have been measured in hand surgery studies. METHODS: A literature search was conducted using Cochrane, EMBASE, HealthSTAR, MEDLINE, and CINAHL electronic databases (1966-2013). This search was supplemented by cited and manual reference searches and expert consultation to retrieve all relevant studies. Studies were selected by 2 independent reviewers if they pertained to hand or wrist surgery, were published in English, and measured utilities as an outcome. Descriptive data were extracted, including the hand surgery procedure investigated, study design, value of utilities, and methodology of utilities measurement. RESULTS: Eleven studies were included after reviewing 989 studies. Most hand conditions were associated with utilities less than 0.8. Utilities in the reviewed studies were measured using different methods and from different subjects. Three studies paradoxically mapped greater utilities for poorer heath states. CONCLUSIONS: Hand conditions cause impairment, as evidenced by their utilities. Measurement of utilities remains uncommon in hand surgery literature. Future studies should not only measure utilities but also do so with consistent and appropriate methodology to ensure that mapped values are valid and comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis III.


Assuntos
Mãos/cirurgia , Preferência do Paciente , Avaliação da Deficiência , Humanos
8.
J Hand Surg Am ; 40(1): 8-14, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25534832

RESUMO

PURPOSE: To measure the desirable health outcome, termed utility, and the expected quality-adjusted life years (QALYs) gained with hand composite tissue allotransplantation (CTA) using hand amputee patients and the general public. METHODS: Using the standard gamble (SG) and time trade-off (TTO) techniques, utilities were obtained from 30 general public participants and 12 amputee patients. The health utility and net QALYs gained or lost with transplantation were computed. A sensitivity analysis was conducted to account for the effects of lifelong immunosuppression on the life expectancy of transplant recipients. Higher scores represent greater utility. RESULTS: Hand amputation mean health utility as measured by the SG and TTO methods, respectively, was 0.72 and 0.80 for the general public and 0.69 and 0.70 for hand amputees. In comparison, hand CTA mean health utility was 0.74 and 0.82 for the general public and 0.83 and 0.86 for amputees. Hand CTA imparted an expected gain of 0.9 QALYs (SG and TTO) in the general public and 7.0 (TTO) and 7.8 (SG) QALYs in hand amputees. A loss of at least 1.7 QALYs was demonstrated when decreasing the life expectancy in the sensitivity analysis in the hand amputee group. CONCLUSIONS: Hand amputee patients did not show a preference toward hand CTA with its inherent risks. With this procedure being increasingly adopted worldwide, the benefits must be carefully weighed against the risks of lifelong immunosuppressive therapy. This study does not show clear benefit to advocate hand CTA.


Assuntos
Transplante de Mão , Mãos/cirurgia , Anos de Vida Ajustados por Qualidade de Vida , Adolescente , Adulto , Amputação , Amputados , Técnicas de Apoio para a Decisão , Feminino , Transplante de Mão/efeitos adversos , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Medição de Risco , Resultado do Tratamento , Adulto Jovem
9.
BMC Musculoskelet Disord ; 12: 289, 2011 Dec 23.
Artigo em Inglês | MEDLINE | ID: mdl-22196211

RESUMO

BACKGROUND: The optimal treatment of displaced femoral neck fractures in patients over 60 years is controversial. While much research has focused on the impact of total hip arthroplasty (THA) and hemiarthroplasty (HA) on surgical outcomes, little is known about patient preferences for either alternative. The purpose of this study was to elicit surgical preferences of patients at risk of sustaining hip fracture using a novel decision board. METHODS: We developed a decision board for the surgical management of displaced femoral neck fractures presenting risks and outcomes of HA and THA. The decision board was presented to 81 elderly patients at risk for developing femoral neck fractures identified from an osteoporosis clinic. The participants were faced with the scenario of sustaining a displaced femoral neck fracture and were asked to state their treatment option preference and rationale for operative procedure. RESULTS: Eighty-five percent (85%) of participants were between the age of 60 and 80 years; 89% were female; 88% were Caucasian; and 49% had some post-secondary education. Ninety-three percent (93%; 95% confidence interval [CI], 87-99%) of participants chose THA as their preferred operative choice. Participants identified several factors important to their decision, including the perception of greater walking distance (63%), less residual pain (29%), less reoperative risk (28%) and lower mortality risk (20%) with THA. Participants who preferred HA (7%; 95% CI, 1-13%) did so for perceived less invasiveness (50%), lower dislocation risk (33%), lower infection risk (33%), and shorter operative time (17%). CONCLUSION: The overwhelming majority of patients preferred THA to HA for the treatment of a displaced femoral neck fracture when confronted with risks and outcomes of both procedures on a decision board.


Assuntos
Artroplastia de Quadril/métodos , Comportamento de Escolha , Técnicas de Apoio para a Decisão , Fraturas do Colo Femoral/cirurgia , Osteoporose/complicações , Preferência do Paciente , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/mortalidade , Medicina Baseada em Evidências , Feminino , Fraturas do Colo Femoral/diagnóstico , Fraturas do Colo Femoral/etiologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Osteoporose/diagnóstico , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Resultado do Tratamento
10.
Can J Plast Surg ; 19(4): 143-4, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-23204886

RESUMO

The present report describes a recent case of recurrent infection in a breast reconstruction patient with a history of psoriasis. Following surgery, the patient developed psoriatic plaques along the incision scars. This phenomenon is known as Koebnerization, and has been found to affect surgical incisions. Cases of psoriatic patients being denied surgical procedures because of their inherent risk to Koebnerize have been previously reported. Similarly, such patients have been denied surgical procedures because of their increased risk of infection. The present case and literature review on this subject is described.

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