Hand surgery is a unique subspecialty in which one can train after completion of either a plastic, orthopedic, or general surgical residency. This study compared hand surgery experience in residency ...among these different training pathways.
The Accreditation Council for Graduate Medical Education case logs of graduating residents in general surgery, orthopedics, and plastic surgery were evaluated for years 2009 through 2018. Cases were grouped according to the Accreditation Council for Graduate Medical Education-defined categories for hand surgery. Comparisons between specialties were made using a one-tail analysis of variance with a 95 percent confidence interval.
There were 19,159 total residents studied: 11,189 general surgery, 7290 orthopedic, and 1040 plastic surgery. General surgery performed the fewest total hand surgeries per individual resident, while plastic surgery performed the most. Plastic surgery performed more operations than orthopedics in all categories studied including tendon, nerve, amputation, soft tissue, fracture, vascular cases, with p < 0.01 for each category.
There are significant differences in the preparation of resident trainees for entry into a hand surgery fellowship, and the lack of uniform exposure to hand surgery represents an opportunity for improvement. Fellowship directors and the tripartite specialty board should embrace the differences among general surgery, orthopedic, and plastic surgery graduates early in the fellowship year and address the expected differences. Trainees' education should be optimized on an individualized basis with targeted education, additional educational courses, and encouraging trainees to seek out clinical challenges to foster their continued professional growth.
Proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) are common salvage procedures for the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse. This study ...aimed to assess rates of reoperation and conversion to wrist fusion and to assess the factors associated with reoperation and conversion to wrist fusion for patients treated with PRC and FCA.
A retrospective chart review was performed evaluating 266 adult patients undergoing PRC or FCA at a single institutional system from 2002 to 2016. Demographic data, patient- and injury-specific data, reoperation and conversion rates, and complications were collected. Potential factors associated with reoperation or wrist fusion were evaluated using a bivariate, followed by a multivariable, analysis.
Reoperation was more commonly performed in FCA (34%) than in PRC (11%) (odds ratio OR, 3.4; 95% confidence interval 95% CI, 1.7–6.8) and occurred at a shorter postoperative interval. In a multivariable analysis for reoperation, manual labor was associated with reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5–19.1). In those undergoing PRC, anterior interosseous nerve (AIN) and/or posterior interosseous nerve (PIN) neurectomy was associated with a lower rate of reoperation (OR, 0.18; 95% CI, 0.06–0.57). In a multivariable analysis for conversion to wrist arthrodesis, intraoperative AIN and/or PIN neurectomy (OR, 0.18; 95% CI, 0.06–0.57) was associated with a lower rate of conversion to wrist fusion, and smoking (OR, 4.9; 95% CI, 1.8–13.5) was associated with a higher rate of conversion to wrist fusion. In the subanalysis of patients who underwent PRC, only AIN and/or PIN neurectomy was associated with lower rates of conversion to wrist arthrodesis (OR, 0.15; 95% CI, 0.04–0.56).
In our cohort, we observed that AIN and/or PIN neurectomy reduced the risk of reoperation and conversion to wrist arthrodesis after PRC. Smoking increased the odds of conversion to wrist arthrodesis in the combined PRC/FCA cohort; however, it is unclear whether this was due to smoking itself or whether the indications for PRC or FCA were affected, leading to this result.
Prognostic IV.
The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries ...includes debridement & lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48–72 h.
Active treatment (targeted muscle reinnervation TMR or regenerative peripheral nerve interfaces RPNIs) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following ...amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation.
Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology (
= 53, 37%) and trauma (
= 45, 32%), with transhumeral amputations (
= 44, 30%) and shoulder amputations (
= 37, 25%) being the most prevalent.
Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio OR: 4.1,
= 0.015), transhumeral amputations (OR: 3.9,
= 0.024), and forequarter amputations (OR: 8.4,
= 0.003) were independently associated with the development of neuropathic pain.
In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.
BACKGROUND:The first aim of this study was to determine the rate of revision carpal tunnel release in five urban hospitals over a period of 14 years. The secondary aim was to assess what demographic, ...condition-related, and treatment-related factors are associated with revision carpal tunnel release.
METHODS:Between 2002 and 2015, 7464 patients underwent carpal tunnel release. After manually reviewing the medical records, the authors identified 113 patients who underwent revision surgery. Multivariable logistic regression analysis was performed to study association with demographics (age, sex, and race), unilateral or bilateral treated wrist(s) (including carpal tunnel release performed simultaneously and separately), and type of surgery (open or endoscopic). To gain further insight into these factors, a matched case-control analysis in a 1:3 ratio was performed.
RESULTS:One hundred thirteen of 7464 patients (1.5 percent) underwent revision carpal tunnel surgery. The median (interquartile range) time to revision surgery was 1.23 years (0.47 to 3.89 years). In multivariable logistic regression analysis, older age, male sex, bilateral carpal tunnel release, and endoscopic carpal tunnel release were independently associated with higher odds for revision surgery. Multivariable conditional logistic regression of the matched case-control cohort showed that smoking and rheumatoid arthritis were independently associated with revision carpal tunnel release. Splint treatment before the initial surgery was independently associated with single carpal tunnel release.
CONCLUSION:Endoscopic release, male sex, smoking, rheumatoid arthritis, and undergoing staged or simultaneous bilateral carpal tunnel release are risk factors for revision surgery.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.
Under conditions of starvation and disease, the gut barrier becomes impaired, and trophic feeding to prevent gut mucosal atrophy has become a standard treatment of critically ill patients. However, ...the mechanisms responsible for the beneficial effects of enteral nutrition have remained a mystery. Using in vitro and in vivo models, we demonstrate that the brush-border enzyme, intestinal alkaline phosphatase (IAP), has the ability to detoxify lipopolysaccharide and prevent bacterial invasion across the gut mucosal barrier. IAP expression and function are lost with starvation and maintained by enteral feeding. It is likely that the IAP silencing that occurs during starvation is a key component of the gut mucosal barrier dysfunction seen in critically ill patients.
The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a ...comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR.
The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire.
A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery.
Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.
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