Impact of Patient-Reported Allergies on Post-operative Complications and Healthcare Utilization Following Carpal Tunnel Release

INTRODUCTION

Open carpal tunnel release (O-CTR) is associated with high patient satisfaction and low complication rates. Risk factors for complications are well-established. Recent studies have found that patient-reported allergies (PRAs) and psychiatric comorbidities may be associated with increased complication rates. The impact of these factors after elective hand surgery has not been evaluated. This study sought to identify whether PRAs and psychiatric comorbidities are associated with complications after O-CTR and to evaluate their association with prolonged follow-up and the need for post-operative occupational therapy (OT).

METHODS

Patient demographics, PRAs, Patient Health Questionnaire-2 score, Charlson Comorbidity Index, Carpal Tunnel Symptoms-6 score, postoperative complications, OT utilization, and time to final follow-up were recorded for patients who underwent elective O-CTR between 2014 and 2022. Multivariable binomial logistic regression analysis was used to determine pre-operative variables associated with increased risk for complication.

RESULTS

About 250 patients met the inclusion criteria. Fifty-one (20.4%) patients developed minor complications, including scar tenderness (N=34, 13.6%), superficial wound dehiscence (N=9, 3.6%), and superficial infection (N=8, 3.2%). There were no major complications. Independent risk factors for complications included PRAs (OR 1.80, p<0.01) and PHQ-2 score (OR 1.39, p=0.04). Five or more PRAs and PHQ-2 score ≥3 are significant independent risk factors for increased post-operative complications. Increased PRAs and PHQ-2 scores were associated with longer follow-up (p=0.01 and p<0.01, respectively) but not increased OT utilization.

CONCLUSION

An increased number of PRAs and higher PHQ-2 scores are significant, independent risk factors for minor complications following O-CTR. Risk adjustment and peri-operative counseling should incorporate and account for these variables.

Use of Biodegradeable Temporizing Matrix Dermal Template for Reconstruction of Upper Extremity Soft Tissue Defects with Associated Tendon Injury

In cases of complex upper extremity soft tissue defects with exposed bone or tendon, the surgeon needs to consider both restoration of stable soft tissue coverage and functional outcomes, which requires early motion and a wound bed suitable for tendon gliding. Often, local, regional, or free flaps are necessary; however, good outcomes have also been reported after staged reconstruction with a dermal template and split-thickness skin grafting. To our knowledge, staged reconstruction with a dermal template has not been described for soft tissue defects with an associated underlying tendon injury requiring tenorrhaphy. We have previously reported our experience with a synthetic dermal template [Novosorb BTM (Biodegradable Temporizing Matrix), Polynovo North America LLC. Carlsbad, Calif.] for the reconstruction of complex upper extremity defects with exposed tendon and showed that it consistently and reliably integrates even when these patients were treated with an early, active therapy protocol. As a result of these findings, we hypothesized that BTM could potentially be used over a tendon repair site without compromising functional outcomes. Here, we report on clinical outcomes for two patients with upper extremity injury where BTM was applied directly over a tendon repair or transfer site and resulted in stable soft tissue coverage with excellent tendon gliding. These early results show that this approach might be considered as an alternative to autologous tissue reconstruction in these patients and could reduce donor site morbidity associated with flap harvest.

Clinical Outcomes of "Paralyzed" Nerve Transfer for Treating Spinal Cord Injury: A Proof of Concept in a Human Model

Functional electrical stimulation (FES) is an option to restore function in individuals after high cervical spinal cord injury (SCI) who have limited available options for tendon or nerve transfer. To be considered for FES implantation, patients must possess upper motor neuron (UMN) type denervation in potential recipient muscles, which can be confirmed by response to surface electrical stimulation during clinical evaluation. Lower motor neuron (LMN) denervated muscles will not respond to electrical stimulation and, therefore, are unavailable for use in an FES system. Previous animal studies have demonstrated that a "paralyzed" nerve transfer of a UMN-denervated motor branch to an LMN-denervated motor branch can restore electrical excitability in the recipient. In this study, we report the indications, surgical technique, and successful outcome (restoration of M3 elbow flexion) after the first "paralyzed" nerve transfer in a human patient.

Upper Extremity Wounds Treated with Biodegradable Temporizing Matrix versus Collagen-Chondroitin Silicone Bilayer

Objective  This study aims to compare outcomes between Novosorb Biodegradable Temporizing Matrix (BTM) and Integra collagen-chondroitin silicone for upper-extremity wound reconstruction. Methods  This retrospective study analyzed adult patients who underwent wound reconstruction with either BTM or Integra at our institution between 2015 and 2020. Results  Forty-eight patients were included: 31 (64.6%) BTM and 17 (35.4%) Integra. Mean age was 44.0 (range: 18-68) years. Age, race, sex, smoking, comorbidities, and defect size were similar between groups. Wound etiologies included 12 (25.0%) burn, 22 (45.8%) trauma, and others. Median template size was 133 cm 2 for BTM and 104 cm 2 for Integra ( p  = 0.526). Skin grafting was performed after 14 (45.2%) and 14 (82.4%) wounds treated with BTM and Integra, respectively ( p  = 0.028). Template complications of infection and dehiscence were comparable. Skin-graft complications occurred in five (35.7%) and three (21.4%) wounds in BTM and Integra, respectively ( p  = 0.031). Skin-graft failure rates were comparable ( p  = 0.121). Mean number of secondary procedures required after template placement was higher in the Integra group (BTM, 1.0; Integra, 1.9; p  = 0.090). Final healing was achieved in 17 (54.8%) BTM and 11 (64.7%) Integra wounds ( p  = 0.694). Median time to healing was 4.1 months after BTM and 2.6 months after Integra placement ( p  = 0.014). Conclusion  Compared with Integra, BTM achieved comparable wound healing and complication rates. Fewer secondary procedures and skin grafts were observed in BTM wounds, likely as a result of the coronavirus disease 2019 pandemic. At our institution, 100 cm 2 of product costs $850 for BTM and $3,150 for Integra, suggesting BTM as an economical alternative to fulfill the high functional and aesthetic requirements of upper-extremity wounds.

Preoperative evaluation of nerve transfer recipients after spinal cord injury using stimulated manual muscle testing

Nerve transfer after spinal cord injury has become increasingly popular. Accurate preoperative identification of lower motor neuron involvement in potential recipient nerves is critical. Electrodiagnostic testing has been shown to correlate with intraoperative findings; however, it is time-consuming, costly and may not be readily available. Stimulated manual muscle testing is an alternative diagnostic approach. It is inexpensive and easily done by the surgeon or therapist in the office; however, correlation with intraoperative stimulation has not been reported. A retrospective review was conducted for patients who underwent nerve transfer for tetraplegia with recorded preoperative stimulated manual muscle testing and intraoperative stimulation results. Nine patients including 37 nerve transfers were included. Of the 37 nerve transfers, 36 were accurately graded preoperatively by stimulated manual muscle testing. Stimulated manual muscle testing had a sensitivity of 89%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 97%. This study supports stimulated manual muscle testing for preoperative distinction between upper versus lower motor neuron injuries.Level of evidence: IV.

Tendon Transfers: Techniques to Minimize Complications

Outcomes after tendon transfer to restore upper extremity function can be optimized using a standardized, multidisciplinary approach to the patient preoperatively, augmented intraoperative decision-making, and an early postoperative mobilization therapy protocol.

Mass-like calcific peri-arthritis in the wrist: a rare case presenting as acute carpal tunnel syndrome and requiring surgical intervention

Hydroxyapatite deposition disease (HADD) is a common localized disorder characterized by deposition of hydroxyapatite in soft tissues. These hydroxyapatite deposits can be found in the periarticular soft tissues such as bursae, joint capsules, tendon sheaths, and ligaments as well as within the tendons themselves, and intra-articular involvement has also been described [1,2]. We present a case of a 50-year-old female with acute symptoms of carpal tunnel syndrome secondary to partially liquified, mass-like, inflammatory calcific peri-arthritis. The case is supplemented with the use of multimodality imaging, a surgical perspective, and histopathologic correlation.

Acute compartment syndrome of the deltoid: a case report and systematic review of the literature

Background

Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review.

Methods

Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included.

Results

Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%).

Conclusion

Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

Psychiatric Disease after Isolated Traumatic Upper Extremity Amputation

Introduction  Psychiatric disease after traumatic limb loss impacts rehabilitation, prosthesis use, and quality of life. The purpose of this study was to evaluate the prevalence of psychiatric disease in civilians after isolated, traumatic upper extremity amputation and determine if any risk factors are associated with developing psychiatric disease.

Materials and Methods  Demographics, time since injury, mechanism of injury, amputation level, hand affected (dominant vs. nondominant), Bureau of Workers’ Compensation (BWC) status, and prosthesis use were retrospectively reviewed for all patients treated from 2012 to 2017. For patients with an International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosed psychiatric disease, the diagnosis and length of treatment were recorded. Patients were grouped by presence or absence of psychiatric diagnosis and data analysis was performed using descriptive statistics, Fisher’s exact test, and relative risk.

Results  Forty-six patients met the inclusion criteria. Thirty-one patients (67.4%) had at least one diagnosed psychiatric condition. Major depressive disorder was the most common ( n = 14), followed by posttraumatic stress disorder ( n = 11), adjustment disorder ( n = 11), anxiety ( n = 6), and panic disorder ( n = 2). No statistically significant correlation was seen between psychiatric illness and gender, age at the time of injury, time since injury, current employment status, BWC status, hand injured (dominant vs. nondominant), prosthetic use, or level of amputation.

Conclusion  The rates of depression and anxiety after traumatic upper limb loss in the civilian population are similar to reported rates after combat injury. While we were unable to identify a statistically significant association with any of the studied variables, upper extremity surgeons should be aware of the high prevalence of psychiatric disease after traumatic upper extremity amputation.

Report of a Transligamentous Ulnar Nerve Sensory Branch

Background: Several anatomical variations of the median nerve recurrent motor branch have been described. No previous reports have described the anatomical variation of the ulnar nerve with respect to transverse carpal ligament. In this article, we present a patient with symptomatic compression of the ulnar nerve found to occur outside the Guyon canal due to a transligamentous course through the distal transverse carpal ligament. Methods: A 59-year-old, right-hand-dominant male patient presented with right hand pain, subjective weakness, and numbness in both the ulnar and the median nerve distributions. Electromyography revealed moderate demyelinating sensorimotor median neuropathy at the wrist and distal ulnar sensory neuropathy. At the time of planned carpal tunnel and Guyon canal release, a transligamentous ulnar nerve sensory common branch to the fourth webspace was encountered and safely released. Results: There were no surgical complications. The patient's symptoms of numbness in the median and ulnar nerve distribution clinically improved at his first postoperative visit. Conclusions: We have identified a case of transligamentous ulnar nerve sensory branch encountered during carpal tunnel release. To our knowledge, this has not been previously reported. While the incidence of this variant is unknown, hand surgeons should be aware of this anatomical variant as its location puts it at risk of iatrogenic injury during open and endoscopic carpal tunnel release.

Transfer of a Radial Nerve Branch to the Brachialis Nerve for Restoration of Elbow Flexion

Nerve transfers for brachial plexus reconstruction and the treatment of peripheral nerve injury have demonstrated excellent clinical outcomes and may be superior to nerve grafting. Previously described nerve transfers for restoration of elbow flexion include the Oberlin (ulnar to musculocutaneous) and double fasicular (median to biceps and ulnar to brachialis) transfers. However, these transfers cannot be performed in patients with loss of elbow flexion and concomitant high median and ulnar nerve injury. Other transfers utilizing the thoracodorsal or intercostal nerves have been described; however, this requires sacrifice of the latissimus dorsi muscle or potential nerve donors for a free, functioning gracilis muscle transfer. The triceps lower medial head and anconeus motor branch is a frequently used nerve donor with minimal morbidity. As an alternative for this specific patient population, we report the transfer of the triceps lower medial head and anconeus motor branch to the brachialis nerve as an option to restore elbow flexion.

Anatomy of the flexor digitorum profundus insertion

PURPOSE

To describe the anatomical insertion of the flexor digitorum profundus (FDP) on the distal phalanx.

METHODS

The FDP insertion to the index, middle, ring, and little fingers were dissected in 10 fresh-frozen cadavers. The FDP tendon was dissected off the volar plate, which was elevated from proximal to distal, before the distal phalanx was disarticulated. The distal phalanx was then inked and the FDP was sharply dissected from bone. The insertion length, width, and distance of the insertion from the joint were measured and the insertion surface area and centroid of the FDP insertion were calculated.

RESULTS

The average insertion length and width were 6.2 mm (range, 5.1-7.0 mm) and 7.9 mm (range, 6.9-8.4 mm), respectively. The average surface area of the distal phalanx occupied by the FDP tendon, for all fingers, was 20% (range, 15%-27%). The average distance from the most proximal insertion to the joint surface was 1.2 mm (range, 0.4-2.1 mm) and the calculated centroid of the FDP insertion from the distal interphalangeal joint was 3.6 mm (range, 2.5-5.1 mm) or approximately 20% of the distal phalangeal length.

CONCLUSIONS

These findings may aid anatomical attachment of the FDP tendon in the treatment of zone I injuries.

CLINICAL RELEVANCE

A better understanding of the anatomy of the FDP insertion may aid proper repair positioning in the treatment of zone I injuries.

Late complications of chest wall reconstruction: management of painful sternal nonunion

Although rare, sternal nonunion after median sternotomy or traumatic injury is associated with a high rate of morbidity. Pain and sternal clicking are two of the most common complaints and reasons these patients seek evaluation and treatment. Diagnosis of sternal nonunion is based on a thorough history and physical examination and can be confirmed with subsequent radiographic imaging. The treatment for symptomatic sternal nonunion requires stable fixation of the bony fragments and chest wall after the debridement of all nonviable bony and soft tissue by the cardiothoracic or reconstructive surgery team. Multiple fixation techniques have been described and incorporate a wide variety of materials including combinations of wires, cables, pins, bands, staples, and plates. Most recently, several new commercially available plating systems have demonstrated low recurrence and complication rates and resolution of the patient's symptoms on follow-up evaluation. Included in this review are three cases demonstrating the management of symptomatic sternal nonunion using these new techniques and review the history, diagnosis, risk factor, and classification, as well as several of the previously described fixation methods.

Clinical outcomes following supraorbital foraminotomy for treatment of frontal migraine headache

BACKGROUND

Although 92 percent of patients who undergo surgical decompression of the supraorbital nerve for treatment of frontal migraine headaches through resection of the glabellar muscle group achieve at least 50 percent improvement, only two-thirds demonstrate complete resolution of symptoms. The authors investigated the role of additional decompression methods by comparing surgery outcomes between patients who underwent glabellar myectomy alone and patients who also underwent supraorbital foraminotomy.

METHODS

Outcome measures including migraine headache frequency, severity, and duration; Migraine Headache Index score; and forehead pain were reviewed retrospectively and analyzed statistically for 43 age-matched control patients who underwent glabellar myectomy for release of the supraorbital nerve and 43 patients who underwent glabellar myectomy with supraorbital foraminotomy from 2002 to 2010.

RESULTS

The myectomy group statistically matched the myectomy with foraminotomy group for age, number of surgical sites, and preoperative headache characteristics (p > 0.05). For the myectomy and myectomy with foraminotomy groups, postoperative migraine frequency was 7.8 per month versus 4.1 per month, severity was 5.6 versus 4.4, Migraine Headache Index score was 26.5 versus 11.1, and persistent forehead pain was 48.8 percent versus 25.6 percent, respectively. These differences were all statistically significant (p < 0.05). Duration of headache was unchanged (p = 0.17).

CONCLUSIONS

The supraorbital foramen is a potential site of supraorbital nerve compression that can trigger frontal migraine headache. If it is present, the authors strongly recommend foraminotomy to ensure complete release of the supraorbital nerve to optimize outcomes. Their results also support consideration of release of any fibrous bands across the supraorbital notch.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.