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Langdell HC, Zeng SL, Pidgeon TS, Mithani SK. Recalcitrant Neuropathies in the Upper Extremity. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023. [PMID: 37521539 PMCID: PMC10382871 DOI: 10.1016/j.jhsg.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
Abstract
Carpal and cubital tunnel syndrome can cause debilitating pain and weakness in the hand and upper extremities. Although most patients have a resolution of their symptoms after primary decompression, managing those with recalcitrant neuropathies is challenging. The etiology of persistent, recurrent, or new symptoms is not always clear and requires careful attention to the history and physical examination to confirm the diagnosis or consider other causes prior to committing to surgery. Nevertheless, revision surgery is often needed in the setting of recalcitrant neuropathies in order to improve patients' symptoms. Revision surgery typically entails wide exposure and neurolysis to release residual compression. In addition, vascularized tissue and nerve wraps have been routinely used to create a favorable perineural environment that decreases recurrent scar formation. This review discusses the etiologies of recalcitrant upper extremity neuropathies, the current treatment options, and surgical outcomes.
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Smit JA, Hu Y, Brohet RM, van Rijssen AL. Identifying Risk Factors for Recurrence After Cubital Tunnel Release. J Hand Surg Am 2022; 48:514.e1-514.e7. [PMID: 35184920 DOI: 10.1016/j.jhsa.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 10/31/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE This study investigated specific risk factors for recurrent surgery of ulnar nerve entrapment (ie, ipsilateral clinical symptoms within 5 years after initial cubital tunnel release [CuTR]) in a large cohort. We hypothesized that recurrence is associated with lifestyle variables (eg, smoking, drinking alcohol, a high body mass index [BMI]) or comorbidities). METHODS A retrospective cohort study was performed using the Current Procedural Terminology codes for all patients who underwent CuTR between January 2012 and November 2018. Demographic data, including sex, age, weight, height, BMI, comorbidities, smoking, and alcohol consumption, were collected. The primary outcome was the need for revision surgery after initial CuTR. Univariate and multivariate analyses were performed to identify potential risk factors for revision surgery. RESULTS Of the 678 patients who underwent CuTR, 120 patients (18%) needed revision surgery within 5 years. Sixty-six patients required subfascial transposition (55%) and 47 patients (39%) received in situ releases. Also, sex, BMI, smoking, alcohol consumption, and comorbidities (except for spinal disc herniation) were similar between the primary and revision subgroup. Age at first occurrence was significantly lower in the revision group (48 years for revision vs 52 years for primary surgery). Moreover, cervical spinal disc herniation was associated with revision surgery (13% vs 6% in the primary group). CONCLUSIONS Age and medical history of cervical spinal disc herniation are associated with an increased risk of revision surgery. More importantly, BMI, smoking, alcohol consumption, and other comorbidities are not associated with increased risk of revision surgery within our sample. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Johannes A Smit
- Department of Plastic Surgery, Isala Hospital, Zwolle, The Netherlands.
| | - Yaxi Hu
- Department of Plastic Surgery, Isala Hospital, Zwolle, The Netherlands
| | - Richard M Brohet
- Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands
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Heinzel JC, Dadun LF, Prahm C, Winter N, Bressler M, Lauer H, Ritter J, Daigeler A, Kolbenschlag J. Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions. J Pers Med 2021; 11:jpm11111200. [PMID: 34834552 PMCID: PMC8624495 DOI: 10.3390/jpm11111200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 01/12/2023] Open
Abstract
Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.
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Affiliation(s)
- Johannes C. Heinzel
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
- Correspondence: ; Tel.: +49-7071-6061038
| | - Lucy F. Dadun
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Cosima Prahm
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Natalie Winter
- Department of Neurology, Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany;
| | - Michael Bressler
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Henrik Lauer
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Jana Ritter
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Adrien Daigeler
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Jonas Kolbenschlag
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
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Spalkit S, Sinha A, Prakash M, Tripathy S. Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand. BMJ Case Rep 2021; 14:14/5/e242773. [PMID: 33958369 PMCID: PMC8103949 DOI: 10.1136/bcr-2021-242773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 59-year-old woman was referred with weakness, paraesthesia, numbness and clawing of the little and ring fingers for the last 2 years. MRI of the cervical spine was normal and nerve conduction velocity revealed abnormality of the ulnar nerve. Ultrasound and MRI showed medial osteophytes and effusion of the elbow joint with stretched and thinned ulnar nerve in the cubital tunnel. The patient underwent release and anterior transposition of the ulnar nerve with significant relief of symptoms.
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Affiliation(s)
- Stanzin Spalkit
- Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anindita Sinha
- Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh Prakash
- Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Satyaswarup Tripathy
- Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Features of the Ulnar Nerve Predicting Postoperative Prognosis in Idiopathic Cubital Tunnel Syndrome: Three Distinct Features of the Ulnar Nerve. Ann Plast Surg 2020; 85:50-55. [PMID: 31977531 DOI: 10.1097/sap.0000000000002236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE This retrospective case-control study was performed to determine the relationships between features of the ulnar nerve and postoperative outcomes following in situ decompression in idiopathic cubital tunnel syndrome (CuTS). METHODS The study population consisted of 86 patients who had undergone surgery for CuTS. We evaluated demographic factors, hand dominance, symptom onset time, time from diagnosis to surgery, findings of electrodiagnosis (nerve conduction velocity/electromyography), and preoperative clinical status. Intraoperatively, the ulnar nerve was defined as a definitively compressed, abnormally enlarged, or inflammatory lesion. Clinical improvements were evaluated at least 2 years after surgery. RESULTS Fifty-four patients showed improvement after surgery in terms of the modified McGowan grade and were designated as group 1. Meanwhile, 32 patients with unchanged or aggravated status were classified as group 2. Preoperative status, as determined by the modified McGowan grade, Boston Symptom Severity Scale score, severity of electrodiagnosis, and predominant symptoms were similar between the groups (all, P > 0.05). On regression analysis, only the classification of nerve lesions and the time from diagnosis to surgery had an impact on postoperative outcome (all, P < 0.05). Especially, enlarged ulnar lesion predicted poor prognosis (P = 0.003). CONCLUSIONS Ulnar nerve enlargement, grossly detected intraoperatively, and long interval between diagnosis and surgery were independently associated with poor prognosis of CuTS. Among the anatomic structures involved in the generation of CuTS, the medial epicondyle showed a strong association with enlarged nerve lesions.
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Clinical features affecting the patient-based outcome after minimal medial epicondylectomy for cubital tunnel syndrome. J Plast Reconstr Aesthet Surg 2018; 71:1446-1452. [DOI: 10.1016/j.bjps.2018.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/12/2018] [Accepted: 05/26/2018] [Indexed: 02/03/2023]
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Grandizio LC, Maschke S, Evans PJ. The Management of Persistent and Recurrent Cubital Tunnel Syndrome. J Hand Surg Am 2018; 43:933-940. [PMID: 29891267 DOI: 10.1016/j.jhsa.2018.03.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy in the upper extremity. There are considerable diagnostic and therapeutic challenges associated with treating patients after a failed primary procedure for CuTS. Distinguishing cases of recurrence versus persistence and identifying concomitant pathology can guide treatment. Conditions that mimic CuTS must be carefully ruled out and coexisting dysfunction of the medial antebrachial cutaneous nerve needs to be addressed. Results of revision procedures are not as reliable as primary procedures for CuTS; however, improvements in pain and paresthesias are noted in approximately 75% of patients. Nerve wraps represent a promising adjuvant treatment option, but long-term outcome data are lacking. External neurolysis and anterior transposition after failed CuTS procedures are supported by case series; multicenter, prospective randomized trials are needed to guide treatment further and improve outcomes.
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Affiliation(s)
| | - Steven Maschke
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Peter J Evans
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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Lauretti L, D'Alessandris QG, De Simone C, Legninda Sop FY, Remore LM, Izzo A, Fernandez E. Ulnar nerve entrapment at the elbow. A surgical series and a systematic review of the literature. J Clin Neurosci 2017; 46:99-108. [PMID: 28890032 DOI: 10.1016/j.jocn.2017.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/10/2017] [Indexed: 12/30/2022]
Abstract
Chronic compression of the ulnar nerve at the elbow is the second most common entrapment neuropathy. Various surgical options have been described. Timing of surgery is also debated. In this study we report the long-term results of a consecutive surgical series of anterior subcutaneous transpositions and review the pertinent literature. Sixty consecutive patients underwent anterior subcutaneous transposition at our Institution to treat ulnar nerve compression at the elbow. McGowan scale was used in the neurological exam before surgery. Bishop rating system was used to assess outcome. Seventy-eight% of patients scored good-excellent. None of the patients worsened. No complications and no recurrences were reported. Young age and good pre-operative neurological status (McGowan grade 1) were predictive of favorable outcome both at univariate and at multivariate analysis. No differences in outcome were observed between patients with intermediate (McGowan grade 2) and severe (McGowan grade 3) neuropathy. Thirty-four studies assessing outcome of different surgical techniques were reviewed. Anterior subcutaneous transposition had the lowest recurrence rate with an excellent effectiveness and safety profile. The favorable predictive role for outcome of preoperative neurological status was confirmed. The good long-term clinical results of the present series and the results of literature analysis confirm the value of anterior subcutaneous transposition of the ulnar nerve at the elbow. This technique has a particular effectiveness in most severe compressions, where outcomes are comparable with intermediate neuropathy cases. Moreover, our results suggest an aggressive attitude towards ulnar nerve compression at the elbow, particularly in younger patients.
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Affiliation(s)
- Liverana Lauretti
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | | | - Celestino De Simone
- Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Francois Yves Legninda Sop
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Luigi M Remore
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.
| | - Alessandro Izzo
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Eduardo Fernandez
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
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Effect of Preoperative Opioid Exposure on Healthcare Utilization and Expenditures Following Elective Abdominal Surgery. Ann Surg 2017; 265:715-721. [PMID: 28151795 DOI: 10.1097/sla.0000000000002117] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the extent to which preoperative opioid use is correlated with healthcare utilization and costs following elective surgical procedures. SUMMARY BACKGROUND DATA Morbidity and mortality associated with prescription opioid use is escalating in the United States. The extent to which chronic opioid use influences postoperative outcomes following elective surgery is not well understood. METHODS Truven Health Marketscan Databases were used to identify adult patients who underwent elective abdominal surgery between June 2009 and December 2012 (n = 200,005). Generalized linear regression was used to determine the effect of preoperative opioid use on postoperative healthcare utilization (length of stay, 30-d readmission, and discharge destination) and cost (hospital stay, 90-, 180-, and 365-d) after adjusting for number of comorbidities, psychological conditions, and demographic characteristics. RESULTS In this cohort, 8.8% of patients used opioids preoperatively. Compared with non-users, patients using opioids preoperatively were more likely to have a longer hospital stay (2.9 d vs. 2.5 d, P <0.001) and were more likely to be discharged to a rehabilitation facility (3.6% vs. 2.5%, P <0.001), adjusting for covariates. Preoperative opioid use was also correlated with a greater rate of 30-day readmission (4.5% vs. 3.6%, P <0.001) and overall greater expenditures at 90- ($12036.60 vs. $3863.40, P <0.001), 180- ($16973.70 vs. $6790.60, P <0.001), and 365- ($25495.70 vs. $12113.80, P <0.001) days following surgery, adjusted for covariates. Additionally, dose-effects were observed regarding readmission, discharge destination, and late healthcare expenditures. CONCLUSIONS Preoperative interventions focused on opioid cessation and alternative analgesics may improve the safety and efficiency of elective surgery among chronic opioid users.
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Camp CL, Ryan CB, Degen RM, Dines JS, Altchek DW, Werner BC. Risk factors for revision surgery following isolated ulnar nerve release at the cubital tunnel: a study of 25,977 cases. J Shoulder Elbow Surg 2017; 26:710-715. [PMID: 28094192 DOI: 10.1016/j.jse.2016.10.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/19/2016] [Accepted: 10/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The literature investigating risk factors for failure after decompression of the ulnar nerve at the elbow (cubital tunnel release [CuTR]) is limited. The purpose of this study was to identify risk factors for failure of isolated CuTR, defined as progression to subsequent ipsilateral revision surgery. METHODS The 100% Medicare Standard Analytic Files from 2005 to 2012 were queried for patients undergoing CuTR. Patients undergoing any concomitant procedures were excluded. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for ipsilateral revision surgery. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated for each risk factor. RESULTS A total of 25,977 patients underwent primary CuTR, and 304 (1.4%) of those with ≥2 years of follow-up required revision surgery. Although the rate of primary procedures is on the rise (P = .002), the revision rate remains steady (P = .148). Significant, independent risk factors for revision surgery included age <65 years (OR, 1.5; P < .001), obesity (OR, 1.3; P = .022), morbid obesity (OR, 1.3; P = .044), tobacco use (OR, 2.0; P < .001), diabetes (OR, 1.3; P = .011), hyperlipidemia (OR, 1.2; P = .015), chronic liver disease (OR, 1.6; P = .001), chronic anemia (OR, 1.6; P = .001), and hypercoagulable disorder (OR, 2.1; P = .001). CONCLUSIONS The incidence of failure requiring ipsilateral revision surgery after CuTR remained steadily low (1.4%) during the study period. There are numerous patient-related risk factors that are independently associated with an increased risk for revision surgery, the most significant of which are tobacco use, younger age, hypercoagulable disorder, liver disease, and anemia.
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Affiliation(s)
- Christopher L Camp
- Sports Medicine Center, Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | - Claire B Ryan
- Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Ryan M Degen
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - David W Altchek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Brian C Werner
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.
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Gaspar MP, Abdelfattah HM, Welch IW, Vosbikian MM, Kane PM, Rekant MS. Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping. J Shoulder Elbow Surg 2016; 25:2057-2065. [PMID: 27751716 DOI: 10.1016/j.jse.2016.09.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/24/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS. METHODS We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained. RESULTS Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients. CONCLUSIONS Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.
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Affiliation(s)
- Michael P Gaspar
- Department of Orthopaedic Surgery, The Philadelphia Hand Center, P.C., Thomas Jefferson University, Philadelphia, PA, USA.
| | - Hesham M Abdelfattah
- Department of Orthopaedic Surgery, The Philadelphia Hand Center, P.C., Thomas Jefferson University, Philadelphia, PA, USA; Department of Orthopaedic Surgery and Sports Medicine, Temple University Health System, Philadelphia, PA, USA
| | - Ian W Welch
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael M Vosbikian
- Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Patrick M Kane
- Department of Orthopaedic Surgery, The Philadelphia Hand Center, P.C., Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark S Rekant
- Department of Orthopaedic Surgery, The Philadelphia Hand Center, P.C., Thomas Jefferson University, Philadelphia, PA, USA
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