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Patterson BM, Reed ER, Hill E, Buckwalter V JA, Bozoghlian MF, Mackinnon SE. Increasing Awareness of Complications of Nerve Injury Following Shoulder Surgery: Preventing Delays in Referral and Treatment. Hand (N Y) 2024; 19:352-360. [PMID: 36564992 PMCID: PMC11067847 DOI: 10.1177/15589447221142886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nerve injuries remain a challenging complication after shoulder surgery. While most resolve spontaneously, some require surgical intervention. This study describes the characteristics of patients sustaining nerve injuries following shoulder surgery, evaluates referral patterns to nerve surgeons, and characterizes nerve surgeries performed and their outcomes. Increased awareness of these injuries allows patients and providers to be better informed regarding the appropriate management when these complications occur. METHODS A retrospective review of referrals with nerve injuries following shoulder surgery between 2007 and 2015 was performed. The final analysis included 65 patients. Data reviewed included demographics, procedure and anesthesia type, and diagnosis of nerve injury. Time to referral to nerve surgeon and proportional changes in the Disabilities of the Arm, Shoulder, and Hand (DASH) scores were determined. Outcomes were categorized as failed, partially successful, and successful based on final follow-up. RESULTS Patients were referred following arthroscopic shoulder surgeries (35.4%), shoulder arthroplasties (24.6%), open shoulder procedures (21.5%), and combined open and arthroscopic procedures (18.5%). The mean time to referral was 7.6 months. Nerve injuries involved brachial plexus (33) and individual and multiple peripheral nerve branches (23 and 7, respectively). Twenty-five (38%) nerve injuries demonstrated spontaneous recovery. Thirty-five patients underwent surgical intervention, of which 27 were successful, 3 were partially successful, and 3 failed. CONCLUSIONS This is the largest series of patients with iatrogenic nerve injury following shoulder surgeries to date. Our data demonstrate a lack of timely referral to nerve surgeons, especially after arthroscopy. There continues to be a variable injury pattern even among similar surgeries. Despite this, timely surgical intervention, when indicated, can lead to favorable outcomes.
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Patterson JMM, Medina MA, Yang A, Mackinnon SE. Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis. Hand (N Y) 2024; 19:228-235. [PMID: 36082441 PMCID: PMC10953526 DOI: 10.1177/15589447221122822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm. METHODS This study reviewed 182 patients' medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02). CONCLUSIONS The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life.
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Affiliation(s)
| | | | - Alexander Yang
- Washington University School of Medicine, St. Louis, MO, USA
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Elmaraghi S, Taylor R, Tung I, Patterson MM, Mackinnon SE. Compression of the Ulnar Nerve by the Arcade of Struthers: Look and You Shall Find. Hand (N Y) 2024:15589447241232013. [PMID: 38390835 DOI: 10.1177/15589447241232013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND The arcade of Struthers was first proposed by Kane et al in 1973. Clinical investigations of this structure have been limited to small case series, focusing on the arcade as an isolated cause of compressive ulnar neuropathy. The purpose of our study was to investigate the incidence of this structure in patients undergoing ulnar nerve transposition. METHODS A retrospective chart review of prospectively maintained data in a single surgeon's practice was performed. Records of patients undergoing surgery for compressive ulnar neuropathy at the cubital tunnel were evaluated for documentation of a compressive arcade of Struthers. In addition, a scoping review of the literature was undertaken to better characterize current understanding of this structure and its recognition in clinical practice. RESULTS A total of 197 patients underwent ulnar nerve transposition. The overall incidence of a compressive arcade of Struthers was noted to be 67 out of 197 (34%). All patients with a compressive arcade were noted to have an internal brachial ligament running below the nerve. Patients undergoing revision surgery were found to have a compressive arcade 51% of the time (20/39), whereas 30% of patients undergoing primary surgery were found to have a compressive arcade (47/158). Only 12 clinical studies examining the arcade of Struthers have been published in the last 20 years, the majority being single case reports. CONCLUSIONS Compression of the ulnar nerve by the arcade of Struthers is a common finding and can contribute to compressive ulnar neuropathy at the elbow both in primary and revision cases.
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Affiliation(s)
- Shady Elmaraghi
- Department of Plastic and Reconstructive Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ruby Taylor
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Isaac Tung
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Megan M Patterson
- Department of Orthopedic Surgery, University of North Carolina, Chapel Hill, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Kim T, Lohse KR, Mackinnon SE, Philip BA. Patient Outcomes After Peripheral Nerve Injury Depend on Bimanual Dexterity and Preserved Use of the Affected Hand. Neurorehabil Neural Repair 2024; 38:134-147. [PMID: 38268466 PMCID: PMC10922924 DOI: 10.1177/15459683241227222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Little is known about how peripheral nerve injury affects human performance, behavior, and life. Hand use choices are important for rehabilitation after unilateral impairment, but rarely measured, and are not changed by the normal course of rehabilitation and daily life. OBJECTIVE To identify the relationship between hand use (L/R choices), motor performance, and patient-centered outcomes. METHODS Participants (n = 48) with unilateral peripheral nerve injury were assessed for hand use via Block Building Task, Motor Activity Log, and Edinburgh Handedness Inventory; dexterity (separately for each hand) via Nine-Hole Peg Test, Jebsen Taylor Hand Function Test, and a precision drawing task; patient-centered outcomes via surveys of disability, activity participation, and health-related quality of life; and injury-related factors including injury cause and affected nerve. Factor Analysis of Mixed Data was used to explore relationships between these variables. The data were analyzed under 2 approaches: comparing dominant hand (DH) versus non-dominant hand (NH), or affected versus unaffected hand. RESULTS The data were best explained by 5 dimensions. Good patient outcomes were associated with NH performance, DH performance (separately and secondarily to NH performance), and preserved function and use of the affected hand; whereas poor patient outcomes were associated with preserved but unused function of the affected hand. CONCLUSION After unilateral peripheral nerve injury, hand function, hand usage, and patient life arise from a complex interaction of many factors. To optimize rehabilitation after unilateral impairment, new rehabilitation methods are needed to promote performance and use with the NH, as well as the injured hand.
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Affiliation(s)
- Taewon Kim
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, United States
| | - Keith R Lohse
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Benjamin A. Philip
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, United States
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Pripotnev S, Pinni SL, Zhou S, Skolnick G, Mackinnon SE. The Medial Antebrachial Cutaneous Nerve Is a Low-Morbidity Alternative to the Standard Sural Nerve Autograft. Hand (N Y) 2024:15589447231218459. [PMID: 38179958 DOI: 10.1177/15589447231218459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Nerve interposition grafting is an important technique in nerve reconstructive surgery that is used when a primary repair is not feasible without significant tension. This study sought to evaluate the long-term morbidity of the medial antebrachial cutaneous (MABC) nerve as an alternative donor nerve in comparison with sural nerve harvest. METHODS A single surgeon and institution retrospective chart review was performed to identify all patients who underwent nerve autografting using the sural and MABC as donor nerves between January 1, 2000 and December 31, 2019. Surveys assessed overall patient satisfaction with surgery, as well as donor and recipient site morbidity, satisfaction, pain, numbness, and cold sensitivity. RESULTS Of the 73 patients contacted, 54 agreed to participate, and 43 of 73 (58.9%) ultimately completed the survey: 28 MABC (65.1%) and 15 sural (34.9%). There were no significant differences between the sural and MABC groups in overall satisfaction with surgery, donor and recipient site satisfaction, pain, cold sensitivity, and effect on quality of life. Even though 66.7% of sural donor sites and 75% of MABC donor sites had residual numbness, the effect this had on quality of life was very low (2 and 3, respectively). CONCLUSION The MABC is a safe alternative to the traditional sural nerve autograft. A small subset of patients undergoing nerve autograft harvest will experience long-term morbidity in the form of pain. Conversely, the more common presence of numbness is not reported as bothersome.
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Affiliation(s)
| | - Sai L Pinni
- Washington University School of Medicine, St. Louis, MO, USA
| | - Suzanne Zhou
- Washington University School of Medicine, St. Louis, MO, USA
| | - Gary Skolnick
- Washington University School of Medicine, St. Louis, MO, USA
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Skladman R, Tadisina KK, Bettlach CR, Currie KB, Tanaka SA, Mackinnon SE, Fox IK, Sacks JM, Pet MA. The Yearly Periodicity of Operative Upper Extremity Trauma: A Retrospective Study of "Trauma Season". Plast Reconstr Surg 2024; 153:101e-111e. [PMID: 37189241 DOI: 10.1097/prs.0000000000010689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Upper extremity (UE) trauma requiring operative care increases during the summer and fall months, which the authors colloquially refer to as "trauma season." METHODS CPT databases were queried for codes related to acute UE trauma at a single level-1 trauma center. Monthly CPT code volume was tabulated for 120 consecutive months and average monthly volume was calculated. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed data set to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in four age groups. RESULTS A total of 11,084 CPT codes were included. Monthly trauma-related CPT volume was highest in July through October and lowest in December through February. Time-series analysis revealed yearly oscillation in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming yearly periodicity. Multivariable modeling revealed R 2 attributable to periodicity of 0.53 ( P < 0.01). Periodicity was strongest in younger populations and weaker in older populations. R 2 was 0.44 for ages 0 to 17, 0.35 for ages 18 to 44, 0.26 for ages 45 to 64, and 0.11 for ages 65 and older. CONCLUSIONS Operative UE trauma volumes peak in the summer and early fall and reach a winter nadir. Periodicity accounts for 53% of trauma volume variability. The authors' findings have implications for allocation of operative block time and personnel and expectation management over the course of the year.
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Affiliation(s)
- Rachel Skladman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kashyap K Tadisina
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Carrie R Bettlach
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kelly B Currie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Shoichiro A Tanaka
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Ida K Fox
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Justin M Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Mitchell A Pet
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
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Philip BA, Fitzpatrick A, Thompson MR, Baune NA, Hyde M, Mackinnon SE. Response to: Letter to the Editor on "Failure to Compensate: Patients With Nerve Injury Use Their Injured Dominant Hand, Even When Their Nondominant is More Dexterous". Arch Phys Med Rehabil 2023; 104:2176-2177. [PMID: 37678446 DOI: 10.1016/j.apmr.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Benjamin A Philip
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO.
| | | | - Madeline R Thompson
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO; Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Nathan A Baune
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO
| | - Maureen Hyde
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
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Patterson JMM, Mackinnon SE. Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis. Hand (N Y) 2023:15589447231210334. [PMID: 37932906 DOI: 10.1177/15589447231210334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
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Pan D, Schofield JB, Schellhardt L, Snyder-Warwick AK, Mackinnon SE, Li X, Wood MD. A feasibility study transplanting macrophages to a segmental nerve injury. Muscle Nerve 2023; 68:894-900. [PMID: 37737007 PMCID: PMC10840956 DOI: 10.1002/mus.27977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 06/16/2023] [Accepted: 09/03/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION/AIMS Promoting regeneration after segmental nerve injury repair is a challenge, but improving angiogenesis could be beneficial. Macrophages facilitate regeneration after injury by promoting angiogenesis. Our aim in this study was to evaluate the feasibility and effects of transplanting exogenous macrophages to a segmental nerve injury. METHODS Bone marrow-derived cells were harvested from donor mice and differentiated to macrophages (BMDM), then suspended within fibrin hydrogels to facilitate BMDM transplantation. BMDM survival was characterized in vitro. The effect of this BMDM fibrin hydrogel construct at a nerve injury site was assessed using a mouse sciatic nerve gap injury. Mice were equally distributed to "fibrin+Mφ" (fibrin hydrogels containing culture medium and BMDM) or "fibrin" hydrogel control (fibrin hydrogels containing culture medium alone) groups. Flow cytometry (n = 3/group/endpoint) and immunohistochemical analysis (n = 5/group/endpoint) of the nerve gap region were performed at days 3, 5, and 7 after repair. RESULTS Incorporating macrophage colony-stimulating factor (M-CSF) improved BMDM survival and expansion. Transplanted BMDM survived for at least 7 days in a nerve gap (~40% retained at day 3 and ~15% retained at day 7). From transplantation, macrophage quantities within the nerve gap were elevated when comparing fibrin+Mφ with fibrin control (~25% vs. 3% at day 3 and ~14% vs. 6% at day 7). Endothelial cells increased by about fivefold within the nerve gap, and axonal extension into the nerve gap increased almost twofold for fibrin+Mφ compared with fibrin control. DISCUSSION BMDM suspended within fibrin hydrogels at a nerve gap do not impair regeneration.
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Affiliation(s)
- Deng Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jonathon Blake Schofield
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Chi D, Ha AY, Alotaibi F, Pripotnev S, Patterson BCM, Fongsri W, Gouda M, Kahn LC, Mackinnon SE. A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries. J Reconstr Microsurg 2023; 39:616-626. [PMID: 36746195 DOI: 10.1055/s-0042-1757752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.
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Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Fawaz Alotaibi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Stahs Pripotnev
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Brendan C M Patterson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Warangkana Fongsri
- Hand and Microsurgery Unit, Department of Orthopedic, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Mahmoud Gouda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Sharkia Governorate, Egypt
| | - Lorna C Kahn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
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Jacobson LA, Zhong SS, Mackinnon SE, Novak CB, Patterson JMM. Calling on Sponsorship: Analysis of Speaker Gender Representation at Hand Society Meetings. Plast Reconstr Surg 2023; 152:594-600. [PMID: 36912914 DOI: 10.1097/prs.0000000000010398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
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.
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Affiliation(s)
- Lauren A Jacobson
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Shuting S Zhong
- Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Christine B Novak
- Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto
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Burton JS, Mackinnon SE, McKee PB, Henderson KM, Goestenkors DM, Thompson RW. Rapid Functional Recovery After Thoracic Outlet Decompression in a Series of Adolescent Athletes With Chronic Atraumatic Shoulder-Girdle Pain, Scapular Winging/Dyskinesis, and Normal Electrodiagnostic Studies. Hand (N Y) 2023:15589447231187088. [PMID: 37522485 DOI: 10.1177/15589447231187088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND Spontaneous shoulder-girdle pain and scapular winging/dyskinesis can be caused by several neuromuscular disorders identifiable by electrodiagnostic studies (EDX). We describe a group of adolescent athletes with this clinical presentation but normal EDX, followed by later development of neurogenic thoracic outlet syndrome (NTOS). METHODS We identified patients referred for evaluation of NTOS that had a history of chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX. Each was refractory to conservative management and underwent supraclavicular decompression and brachial plexus neurolysis for NTOS. Functional disability was quantified by Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS There were 5 female patients with a mean age at symptom onset of 14.2 ± 0.4 years, including spontaneous severe pain in the shoulder, scapula, and arm, along with prominent scapular winging/dyskinesis, and normal EDX. Symptoms had persisted for 18.9 ± 4.0 months prior to referral, with pronounced upper extremity disability (mean QuickDASH, 54.6 ± 6.9). By 3 months after surgical treatment for NTOS, all 5 patients experienced near-complete symptom resolution, including scapular winging/dyskinesis, with markedly improved function (mean QuickDASH, 2.2 ± 1.3) and a return to normal activity. CONCLUSIONS A subset of patients with chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX may develop dynamic brachial plexus compression characteristic of NTOS, exhibiting an ischemic "Sunderland-zero" nerve conduction block for which surgical decompression can result in rapid and substantial clinical improvement. The presence of surgically treatable NTOS should be considered for selected patients with long-standing scapular winging/dyskinesis who fail conservative management.
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Linkugel AD, Mackinnon SE, Snyder-Warwick AK. Improving the Care of Our Patients: Twenty-Three Years of the James Barrett Brown Resident Research Day. Ann Plast Surg 2023; 91:8-11. [PMID: 37450856 PMCID: PMC10361623 DOI: 10.1097/sap.0000000000003619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND James Barrett Brown was one of the founders of Plastic and Reconstructive Surgery as a specialty in the United States. Susan Mackinnon started the James Barrett Brown Resident Research Day in 1997 in his honor to serve as an annual opportunity for trainees to present their research to the Division and a visiting contemporary leader in plastic surgery. We sought to determine the proportion of Resident Research Day projects that have progressed to publication. METHODS Available internal records from 1998 to 2019 were used to identify presenters and projects. Academic productivity of presenters was estimated with the h-index from the Scopus database. RESULTS One hundred forty-five students, residents, and fellows presented 276 projects at Resident Research Day from 1998 to 2019. These presentations were associated with 144 unique peer-reviewed publications, representing 52% of the presented projects. They were published an average of 1.8 years after presentation, and the presenter was the first or last author on 67% of them. The current average h-index of trainees who published at least 1 project (8.3) is significantly higher than the h-index of those who did not (5.0, P < 0.001). CONCLUSIONS The James Barrett Brown Resident Research Day not only honors the legacy of Brown but also enhances scholarly activity of trainees. The opportunity to present and publish research teaches project planning, implementation, and data analysis, followed by manuscript preparation and the publication process. This important skill set can provide the foundation for the academic careers of future leaders in plastic surgery.
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Affiliation(s)
- Andrew D. Linkugel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis; St. Louis, Missouri, United States of America
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis; St. Louis, Missouri, United States of America
| | - Alison K. Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis; St. Louis, Missouri, United States of America
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Stonner MM, Skladman R, Bettlach CLR, Kennedy C, Mackinnon SE. Recruiting hand therapists improves disposal of unused opioid medication. J Hand Ther 2023; 36:507-513. [PMID: 35909068 DOI: 10.1016/j.jht.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Opioids often remain unused after upper extremity surgery, and leftover prescriptions are frequently diverted. When administered in a hand surgery clinic, an educational brochure outlining a simple method of opioid disposal has been shown to improve disposal rates after surgery. PURPOSE To understand whether administration of an opioid disposal educational brochure in a hand therapy clinic would increase opioid disposal rates, compared to a hand surgery clinic. STUDY DESIGN Prospective cohort study. METHODS Patients who presented to a hand therapy clinic postoperatively were recruited to participate in this prospective cohort study. An educational brochure outlining a simple method of opioid disposal was made available at the hand therapy and surgery clinics. A questionnaire was later issued to obtain: location of brochure receipt, demographic information, pre- and post-operative opioid use history, and opioid disposal patterns. Chi-square tests and multivariable binary logistic regression assessed associations between medication disposal and explanatory variables. RESULTS Patients who received the brochure were significantly more likely to dispose of excess opioid medication, compared to those who did not receive the brochure (57.1% vs 10.8%, p < .001). Patients who received the brochure at the hand therapy clinic were significantly more likely to dispose of excess opioids (86.4%) compared to those who received the brochure at the surgery clinic (25.0%). Older age was predictive of increased disposal (p =.028*). There were no significant associations between gender, length of follow-up, or surgery type with the incidence of opioid disposal. CONCLUSION Recruiting both hand therapists and surgeons in the distribution of a simple, educational brochure on opioid disposal can increase disposal rates. Patients who received the brochure from the hand therapist were more likely to dispose of excess opioids. The longstanding patient-therapist relationship creates an opportunity for educational initiatives and discussion of stigmatized topics, such as opioid use.
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Affiliation(s)
- Macyn M Stonner
- Program in Occupational Therapy, Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie L Roth Bettlach
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Varagur K, Jacobson L, Teixeira R, Patterson JMM, Skolnick GB, Mackinnon SE. Following a Surgical Paradigm Shift Through the Adoption of Nerve Transfers Among Board-Eligible and Practicing Plastic Surgeons. Hand (N Y) 2023:15589447231167582. [PMID: 37144823 DOI: 10.1177/15589447231167582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Nerve transfers represent a new paradigm in the treatment of nerve injuries. Their current level of adoption among surgeons is unknown. This study evaluates the incidence of nerve transfers on case logs of board-eligible plastic surgeons over the past 14 years and surveys practicing nerve surgeons regarding their use of this technique. METHODS We queried the American Board of Plastic Surgery case log database for all nerve reconstruction Current Procedural Terminology codes from 2008 to 2021 and assessed trends and relationships between geographic region, examination year, and nerve transfer use. We surveyed nerve surgery professional societies to assess trends in practice, compared with a 2017 survey. RESULTS A total of 1959 nerve reconstruction cases were logged by 738 candidates from 2008 to 2021. Twelve percent of cases included nerve transfers. The proportion of nerve transfer codes (Z = -11.57; P < .0001) and the proportion of candidates performing nerve transfers (Z = -9.21, P < .0001) increased over the study period. Nerve transfers were associated with geographic region (χ2 = 25.826, P = .0002), with most cases performed in the Midwest (26.4%). A higher proportion of practicing nerve surgeons reported performing nerve transfers in this survey than in our 2017 survey (χ2 = 16.7, P < .001). CONCLUSIONS There has been an increase in nerve transfers logged in the past 14 years by board-eligible plastic surgeons, as well as increased use among currently practicing nerve surgeons. Although nerve transfer use is increasing among both plastic and orthopedic surgeons, a greater proportion of nerve reconstructions include nerve transfers in the plastic surgery cohort.
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Liebendorfer A, Finnan MJ, Schofield JB, Pinni SL, Acevedo-Cintrón JA, Schellhardt L, Snyder-Warwick AK, Mackinnon SE, Wood MD. Loss of Gata1 decreased eosinophils, macrophages, and type 2 cytokines in regenerating nerve and delayed axon regeneration after a segmental nerve injury. Exp Neurol 2023; 362:114327. [PMID: 36682399 PMCID: PMC10189758 DOI: 10.1016/j.expneurol.2023.114327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
The immune system has garnered attention for its role in peripheral nerve regeneration, particularly as it pertains to regeneration across segmental injuries. Previous work demonstrated that eosinophils are recruited to regenerating nerve and express interleukin-4, amongst potential cytokines. These results suggest a direct role for eosinophils in promoting nerve regeneration. Therefore, we further considered eosinophils roles in nerve regeneration using a segmental nerve injury and Gata1 knockout (KO) mice, which are severely eosinophil deficient, compared to wild-type BALB/c mice (WT). Mice receiving a sciatic nerve gap injury demonstrated distinct cytokine expression and leukocytes within regenerating nerve. Compared to controls, Gata1 KO regenerated nerves contained decreased expression of type 2 cytokines, including Il-5 and Il-13, and decreased recruitment of eosinophils and macrophages. At this early time point during ongoing regeneration, the macrophages within Gata1 KO nerves also demonstrated significantly less M2 polarization compared to controls. Subsequently, motor and sensory axon regeneration across the gap injury was decreased in Gata1 KO compared to WT during ongoing nerve regeneration. Over longer observation to allow for more complete nerve regeneration, behavioral recovery measured by grid-walk assessment was not different comparing groups but modestly delayed in Gata1 KO compared to WT. The extent of final axon regeneration was not different amongst groups. Our data provide additional evidence suggesting eosinophils contribute to nerve regeneration across a nerve gap injury, but are not essential to regeneration in this context. Our evidence also suggests eosinophils may regulate cytokines that promote distinct macrophage phenotypes and axon regeneration.
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Affiliation(s)
- Adam Liebendorfer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael J Finnan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jonathon Blake Schofield
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Sai L Pinni
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jesús A Acevedo-Cintrón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Abstract
BACKGROUND Acellular nerve allografts have been used successfully and with increasing frequency to reconstruct nerve injuries. As their use has been expanded to treat longer gap, larger diameter nerve injuries, some failed cases have been reported. We present the histomorphometry of 5 such cases illustrating these limitations and review the current literature of acellular nerve allografts. METHODS Between 2014 and 2019, 5 patients with iatrogenic nerve injuries to the median or ulnar nerve reconstructed with an AxoGen AVANCE nerve allograft at an outside hospital were treated in our center with allograft excision and alternative reconstruction. These patients had no clinical or electrophysiological evidence of recovery, and allograft specimens at the time of surgery were sent for histomorphological examination. RESULTS Three patients with a median and 2 with ulnar nerve injury were included. Histology demonstrated myelinated axons present in all proximal native nerve specimens. In 2 cases, axons failed to regenerate into the allograft and in 3 cases, axonal regeneration diminished or terminated within the allograft. CONCLUSIONS The reported cases demonstrate the importance of evaluating the length and the function of nerves undergoing acellular nerve allograft repair. In long length, large-diameter nerves, the use of acellular nerve allografts should be carefully considered.
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Affiliation(s)
- Blair R. Peters
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health & Science Univeristy, Portland, OR, USA
| | - Matthew D. Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A. Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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18
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Evans A, Padovano WM, Patterson JMM, Wood MD, Fongsri W, Kennedy CR, Mackinnon SE. Beyond the Cubital Tunnel: Use of Adjunctive Procedures in the Management of Cubital Tunnel Syndrome. Hand (N Y) 2023; 18:203-213. [PMID: 33794683 PMCID: PMC10035096 DOI: 10.1177/1558944721998022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Our management of cubital tunnel syndrome has expanded to involve multiple adjunctive procedures, including supercharged end-to-side anterior interosseous to ulnar nerve transfer, cross-palm nerve grafts from the median to ulnar nerve, and profundus tenodesis. We also perform intraoperative brief electrical stimulation in patients with severe disease. The aims of this study were to evaluate the impact of adjunctive procedures and electrical stimulation on patient outcomes. METHODS We performed a retrospective review of 136 patients with cubital tunnel syndrome who underwent operative management from 2013 to 2018. A total of 38 patients underwent adjunctive procedure(s), and 33 received electrical stimulation. A historical cohort of patients who underwent cubital tunnel surgery from 2009 to 2011 (n = 87) was used to evaluate the impact of adjunctive procedures. Study outcomes were postoperative improvements in Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, pinch strength, and patient-reported pain and quality of life. RESULTS In propensity score-matched samples, patients who underwent adjunctive procedures had an 11.3-point greater improvement in DASH scores than their matched controls (P = .0342). In addition, patients who received electrical stimulation had significantly improved DASH scores relative to baseline (11.7-point improvement, P < .0001), whereas their control group did not. However, when compared between treatment arms, there were no significant differences for any study outcome. CONCLUSIONS Patients who underwent adjunctive procedures experienced greater improvement in postoperative DASH scores than their matched pairs. Additional studies are needed to evaluate the effects of brief electrical stimulation in compression neuropathy.
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Affiliation(s)
- Adam Evans
- Washington University in St. Louis, MO, USA
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Lieberdorfer A, Shivakumar N, Stonner MM, Brogan DM, Ray WZ, Mackinnon SE, Dy CJ. Expectant Management, Tendon Transfer, or Nerve Transfer Surgery for Radial Nerve Injury: A Qualitative Study Exploring Patient Expectations, Goals, and Treatment Experiences. J Bone Joint Surg Am 2023; 105:600-606. [PMID: 36795855 DOI: 10.2106/jbjs.22.01201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND After a radial nerve injury, patients must weigh a complicated set of advantages and disadvantages to observation or surgery. We conducted semistructured interviews to characterize the decision-making process that these patients undertake. METHODS We recruited participants who were treated with expectant management (nonoperatively), received only a tendon transfer, or received a nerve transfer. Participants completed a semistructured interview that was transcribed and coded to identify recurring themes, to describe the influence of qualitative findings on treatment decision-making. RESULTS We interviewed 15 participants (5 expectant management, 5 tendon transfer only, and 5 nerve transfer). Participants' primary concerns were returning to work, hand appearance, regaining motion, resuming activities of daily living, and enjoying hobbies. Delayed diagnosis and/or insurance coverage led 3 participants to change treatment from nerve transfer to isolated tendon transfer. Interactions with providers early in diagnosis and treatment had strong effects on how members of the care team were perceived. The hand therapist was the primary person who shaped expectations, provided encouragement, and prompted referral to the treating surgeon. Participants valued debate among the care team members regarding treatment, provided that medical terminology was explained. CONCLUSIONS This study highlights the importance of initial, collaborative care in setting expectations for patients with radial nerve injuries. Many participants named returning to work and hand appearance as primary concerns. Hand therapists were the primary source of support and information during recovery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Adam Lieberdorfer
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nirmala Shivakumar
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Macyn M Stonner
- Milliken Hand Therapy Center, Washington University School of Medicine, St. Louis, Missouri
| | - David M Brogan
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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Marsh EB, Schellhardt L, Hunter DA, Mackinnon SE, Snyder-Warwick AK, Wood MD. Electrical stimulation or tacrolimus (FK506) alone enhances nerve regeneration and recovery after nerve surgery, while dual use reduces variance and combines strengths of each in promoting enhanced outcomes. Muscle Nerve 2023; 67:78-87. [PMID: 36333946 DOI: 10.1002/mus.27748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Repaired nerve injuries can fail to achieve functional recovery. Therapeutic options beyond surgery, such as systemic tacrolimus (FK506) and electrical stimulation (E-stim), can improve recovery. We tested whether dual administration of FK506 and E-stim enhances regeneration and recovery more than either therapeutic alone. METHODS Rats were randomized to four groups: E-stim, FK506, FK506 + E-stim, and repair alone. All groups underwent tibial nerve transection and repair. Two sets of animals were created to measure outcomes of early nerve regeneration using nerve histology (n = 36) and functional recovery (n = 42) (21- and 42-day endpoints, respectively). Functional recovery was measured by behavioral analyses (walking track and grid walk) and, at the endpoint, muscle mass and force. RESULTS Dual E-stim and FK506 administration produced histomorphometric measurements of nerve regeneration no different than either therapeutic alone. All treatments were superior to repair alone (FK506, P < .0001; E-stim, P < .05; FK506 + E-stim, P < .05). The E-stim and FK506 + E-stim groups had improved behavioral recovery compared with repair alone (at 6 weeks: E-stim, P < .05; FK506 + E-stim, P < .01). The FK506 group had improved recovery based on walking-track analysis (at 6 weeks: P < .001) and muscle force and mass (P < .05). The concurrent use of both therapies ensured earlier functional recovery and decreased variability in functional outcomes compared with either therapy alone, suggesting a moderate benefit. DISCUSSION Dual administration of FK506 and E-stim showed minimal additive effects to further improve regeneration or recovery compared with either therapy alone. The data suggest the combination of FK506 and E-stim appears to combine the relative strengths of each therapeutic.
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Affiliation(s)
- Evan B Marsh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel A Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Currie KB, Tadisina KK, Mackinnon SE. A Review of Common Hand Conditions-Reply. JAMA 2022; 328:1772. [PMID: 36318135 DOI: 10.1001/jama.2022.16539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Kelly Bettina Currie
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, Missouri
| | | | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, Missouri
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Abstract
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.
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Affiliation(s)
| | | | - Madi El-Haj
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Abstract
BACKGROUND Traumatic peripheral nerve injuries cause chronic pain, disability, and long-term reductions in quality of life. However, their incidence after extremity trauma remains poorly understood. METHODS The IBM® MarketScan® Commercial Database from 2010 to 2015 was used to identify patients aged 18 to 64 who presented to emergency departments for upper and/or lower extremity traumas. Cumulative incidences were calculated for nerve injuries diagnosed within 2 years of trauma. Cox regression models were developed to evaluate the associations between upper extremity nerve injury and chronic pain, disability, and use of physical therapy or occupational therapy. RESULTS The final cohort consisted of 1 230 362 patients with employer-sponsored health plans. Nerve injuries were diagnosed in 2.6% of upper extremity trauma patients and 1.2% of lower extremity trauma patients. Only 9% and 38% of nerve injuries were diagnosed by the time of emergency department and hospital discharge, respectively. Patients with nerve injuries were more likely to be diagnosed with chronic pain (hazard ratio [HR]: 5.9, 95% confidence interval [CI], 4.3-8.2), use physical therapy services (HR: 10.7, 95% CI, 8.8-13.1), and use occupational therapy services (HR: 19.2, 95% CI, 15.4-24.0) more than 90 days after injury. CONCLUSIONS The incidence of nerve injury in this national cohort was higher than previously reported. A minority of injuries were diagnosed by emergency department or hospital discharge. These findings may improve practitioner awareness and inform public health interventions for injury prevention.
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Affiliation(s)
| | - Jana Dengler
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Andrew Yee
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Matthew D. Wood
- Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Washington University School of Medicine, St. Louis, MO, USA
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24
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Abstract
Importance Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability. Observations Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments. Conclusions and Relevance Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.
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Affiliation(s)
- Kelly Bettina Currie
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Kashyap Komarraju Tadisina
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
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Keane AM, Larson EL, Payne RM, Cooke S, Zubovic E, Patel KB, Mackinnon SE, Snyder-Warwick AK. Dispose with dish soap: a simple and convenient method to increase proper opioid disposal in postoperative pediatric patients. J Plast Reconstr Aesthet Surg 2022; 75:3845-3852. [DOI: 10.1016/j.bjps.2022.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 03/09/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
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26
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Keane GC, Pan D, Roh J, Larson EL, Schellhardt L, Hunter DA, Snyder-Warwick AK, Moore AM, Mackinnon SE, Wood MD. The Effects of Intraoperative Electrical Stimulation on Regeneration and Recovery After Nerve Isograft Repair in a Rat Model. Hand (N Y) 2022; 17:540-548. [PMID: 32666827 PMCID: PMC9112755 DOI: 10.1177/1558944720939200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Therapeutic electrical stimulation (ES) applied to repaired nerve is a promising treatment option to improve regeneration. However, few studies address the impact of ES following nerve graft reconstruction. The purpose of this study was to determine if ES applied to a nerve repair using nerve isograft in a rodent model could improve nerve regeneration and functional recovery. Methods: Adult rats were randomized to 2 groups: "ES" and "Control." Rats received a tibial nerve transection that was repaired using a tibial nerve isograft (1.0 cm length), where ES was applied immediately after repair in the applicable group. Nerve was harvested 2 weeks postrepair for immunohistochemical analysis of axon growth and macrophage accumulation. Independently, rats were assessed using walking track and grid-walk analysis for up to 21 weeks. Results: At 2 weeks, more robust axon regeneration and greater macrophage accumulation was observed within the isografts for the ES compared to Control groups. Both walking track and grid-walk analysis revealed that return of functional recovery was accelerated by ES. The ES group demonstrated improved functional recovery over time, as well as improved recovery compared to the Control group at 21 weeks. Conclusions: ES improved early axon regeneration into a nerve isograft and was associated with increased macrophage and beneficial M2 macrophage accumulation within the isograft. ES ultimately improved functional recovery compared to isograft repair alone. This study supports the clinical potential of ES to improve the management of nerve injuries requiring a nerve graft repair.
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Affiliation(s)
| | - Deng Pan
- Washington University in St. Louis, MO, USA
| | - Joseph Roh
- Washington University in St. Louis, MO, USA
| | | | | | | | | | | | | | - Matthew D. Wood
- Washington University in St. Louis, MO, USA,Matthew D. Wood, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University in St. Louis, Campus Box 8238, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Philip BA, Thompson MR, Baune NA, Hyde M, Mackinnon SE. Failure to Compensate: Patients With Nerve Injury Use Their Injured Dominant Hand, Even When Their Nondominant Is More Dexterous. Arch Phys Med Rehabil 2022; 103:899-907. [PMID: 34728192 PMCID: PMC11034713 DOI: 10.1016/j.apmr.2021.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/02/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify how individuals respond to unilateral upper extremity peripheral nerve injury via compensation (increased use of the nondominant hand). We hypothesized that injury to the dominant hand would have a greater effect on hand use (left vs right choices). We also hypothesized that compensation would not depend on current (postinjury) nondominant hand performance because many patients undergo rehabilitation that is not designed to alter hand use. DESIGN Observational survey, single-arm. SETTINGS Academic research institution and referral center. PARTICIPANTS A total of 48 adults (N=48) with unilateral upper extremity peripheral nerve injury. Another 14 declined participation. Referred sample, including all eligible patients from 16 months at 1 nerve injury clinic and 1 hand therapy clinic. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Hand use (% of actions with each hand) via Block Building Task. Dexterity via Jebsen-Taylor Hand Function. RESULTS Participants preferred their dominant hand regardless of whether it was injured: hand usage (dominant/nondominant) did not differ from typical adults, regardless of injured side (P>.07), even though most participants (77%) were more dexterous with their uninjured nondominant hand (mean asymmetry index, -0.16±0.25). The Block Building Task was sensitive to hand dominance (P=2 × 10-4) and moderately correlated with Motor Activity Log amount scores (r2=0.33, P<.0001). Compensation was associated only with dominant hand dexterity (P=3.9 × 10-3), not on nondominant hand dexterity, rehabilitation, or other patient and/or injury factors (P>.1). CONCLUSIONS Patients with peripheral nerve injury with dominant hand injury do not compensate with their unaffected nondominant hand, even if it is more dexterous. For the subset of patients unlikely to recover function with the injured hand, they could benefit from rehabilitation that encourages compensation with the nondominant hand.
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Affiliation(s)
- Benjamin A Philip
- Program in Occupational Therapy, Washington University School of Medicine, St Louis, Missouri.
| | - Madeline R Thompson
- Program in Occupational Therapy, Washington University School of Medicine, St Louis, Missouri; Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Nathan A Baune
- Program in Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Maureen Hyde
- Program in Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri
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Peters BR, Pripotnev S, Chi D, Mackinnon SE. Complete Foot Drop With Normal Electrodiagnostic Studies: Sunderland "Zero" Ischemic Conduction Block of the Common Peroneal Nerve. Ann Plast Surg 2022; 88:425-428. [PMID: 34864748 DOI: 10.1097/sap.0000000000003053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Common peroneal neuropathy is a peripheral neuropathy of multifactorial etiology often left undiagnosed until foot drop manifests and electrodiagnostic abnormalities are detected. However, reliance on such striking symptoms and electrodiagnostic findings for diagnosis stands in contrast to other commonly treated neuropathies, such as carpal tunnel and cubital tunnel syndrome. Poor recognition of common peroneal neuropathy without foot drop or the presence of foot drop with normal electrodiagnostic studies thus often results in delayed or no surgical treatment. Our cases document 2 patients presenting with complete foot drop who had immediate resolution after decompression. The first patient presented with normal electrodiagnostic studies representing an isolated Sunderland Zero nerve ischemia. The second patient presented with severe electrodiagnostic studies but also had an immediate improvement in their foot drop representing a Sunderland VI mixed nerve injury with a significant contribution from an ongoing Sunderland Zero ischemic conduction block. In support of recent case series, these patients demonstrate that common peroneal neuropathy can present across a broad diagnostic spectrum of sensory and motor symptoms, including with normal electrodiagnostic studies. Four clinical subtypes of common peroneal neuropathy are presented, and surgical decompression may thus be indicated for these patients that lack the more conventional symptoms of common peroneal neuropathy.
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Affiliation(s)
| | - Stahs Pripotnev
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
| | - David Chi
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
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Roh J, Schellhardt L, Keane GC, Hunter DA, Moore AM, Snyder-Warwick AK, Mackinnon SE, Wood MD. Short-Duration, Pulsatile, Electrical Stimulation Therapy Accelerates Axon Regeneration and Recovery following Tibial Nerve Injury and Repair in Rats. Plast Reconstr Surg 2022; 149:681e-690e. [PMID: 35139047 PMCID: PMC8969122 DOI: 10.1097/prs.0000000000008924] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Repair of nerve injuries can fail to achieve adequate functional recovery. Electrical stimulation applied at the time of nerve repair can accelerate axon regeneration, which may improve the likelihood of recovery. However, widespread use of electrical stimulation may be limited by treatment protocols that increase operative time and complexity. This study evaluated whether a short-duration electrical stimulation protocol (10 minutes) was efficacious to enhance regeneration following nerve repair using rat models. METHODS Lewis and Thy1-green fluorescent protein rats were randomized to three groups: 0 minutes of electrical stimulation (no electrical stimulation; control), 10 minutes of electrical stimulation, and 60 minutes of electrical stimulation. All groups underwent tibial nerve transection and repair. In the intervention groups, electrical stimulation was delivered after nerve repair. Outcomes were assessed using immunohistochemistry, histology, and serial walking track analysis. RESULTS Two weeks after nerve repair, Thy1-green fluorescent protein rats demonstrated increased green fluorescent protein-positive axon outgrowth from the repair site with electrical stimulation compared to no electrical stimulation. Serial measurement of walking tracks after nerve repair revealed recovery was achieved more rapidly in both electrical stimulation groups as compared to no electrical stimulation. Histologic analysis of nerve distal to the repair at 8 weeks revealed robust axon regeneration in all groups. CONCLUSIONS As little as 10 minutes of intraoperative electrical stimulation therapy increased early axon regeneration and facilitated functional recovery following nerve transection with repair. Also, as early axon outgrowth increased following electrical stimulation with nerve repair, these findings suggest electrical stimulation facilitated recovery because of earlier axon growth across the suture-repaired site into the distal nerve to reach end-organ targets. CLINICAL RELEVANCE STATEMENT Brief (10-minute) electrical stimulation therapy can provide similar benefits to the 60-minute protocol in an acute sciatic nerve transection/repair rat model and merit further studies, as they represent a translational advantage.
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Affiliation(s)
- Joseph Roh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Grace C. Keane
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Daniel A. Hunter
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Amy M. Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH
| | - Alison K. Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew D. Wood
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
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Heary KO, Wong AWK, Lau SCL, Dengler J, Thompson MR, Crock LW, Novak CB, Philip BA, Mackinnon SE. Quality of Life and Psychosocial Factors as Predictors of Pain Relief Following Nerve Surgery. Hand (N Y) 2022; 17:193-199. [PMID: 32188297 PMCID: PMC8984711 DOI: 10.1177/1558944720911213] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
| | - Alex W. K. Wong
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | | | | | - Lara W. Crock
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | | | - Susan E. Mackinnon
- Washington University School of
Medicine, St. Louis, MO, USA,Susan E. Mackinnon, Division of Plastic and
Reconstructive Surgery, Department of Surgery, Washington University School of
Medicine, 660 S. Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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31
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Hill EJ, Patterson JMM, Yee A, Crock LW, Mackinnon SE. What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve Pain. J Hand Surg Glob Online 2022; 5:126-132. [PMID: 36704371 PMCID: PMC9870794 DOI: 10.1016/j.jhsg.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/30/2021] [Indexed: 01/29/2023] Open
Abstract
Neuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories-compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain-and offer an illustrative clinical vignette and strategies for optimal management of each. Further, we delineate the reasons why compression neuropathy and neuroma are amenable to surgery, while painful hyperalgesia and phantom nerve pain are not.
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Affiliation(s)
- Elspeth J.R. Hill
- Department of Orthopedic Surgery, Division of Hand and Microsurgery, Washington University in St. Louis School of Medicine, St. Louis, MO,Corresponding author: Elspeth J.R. Hill, MD, PhD, Department of Orthopedic Surgery, Division of Hand and Microsurgery, Washington University in St. Louis School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110.
| | | | - Andrew Yee
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Lara W. Crock
- Division of Pain Management, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
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32
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Bettlach CLR, Hasak JM, Santosa KB, Larson EL, Tung TH, Fox IK, Moore AM, Mackinnon SE. A Simple Brochure Improves Disposal of Unused Opioids: An Observational Cross-Sectional Study. Hand (N Y) 2022; 17:170-176. [PMID: 33025827 PMCID: PMC8721787 DOI: 10.1177/1558944720959898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND We evaluated the effectiveness of a simple, low-cost educational brochure in improving disposal rates of unused opioids after outpatient upper extremity surgery. METHODS This cross-sectional study enrolled eligible adult patients from a peripheral nerve clinic between November 2017 and September 2018. Patients either received or did not receive the educational brochure, which outlined a simple method to dispose of unused opioids and completed a survey at 2 weeks after surgery. We compared the proportion of patients who disposed of unused opioids after surgery between the group that had received the brochure and the group that had not. Categorical data were analyzed with χ2 test, proportions data with binomial tests, and numerical data with Mann-Whitney U test, all with a significance level of P < .05. RESULTS There were 339 survey respondents. Nineteen patients who did not meet inclusion criteria were excluded. Of the 320 remaining patients, 139 received the brochure and 181 did not. An additional 55 patients were excluded due to preoperative opioid use. Overall, 35.3% of recipients and 38.3% of those who did not receive the brochure used all of their prescribed opioid medication (P = .625; confidence interval = -14.6%-8.8%). Among patients with unused opioid medication, a significantly higher proportion of brochure recipients disposed of the medicine compared with those who did not receive the brochure (46.7% vs 19.6%, P < .001). CONCLUSIONS Distribution of an educational brochure significantly improved disposal of unused opioids after surgery. This easily implemented intervention can improve disposal of unused opioids and ultimately decrease excess opioids available for diverted use in the community.
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Affiliation(s)
| | | | | | - Ellen L. Larson
- Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas H. Tung
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ida K. Fox
- Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E. Mackinnon
- Washington University School of Medicine, St. Louis, MO, USA,Susan E. Mackinnon, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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Pan D, Schellhardt L, Acevedo-Cintron JA, Hunter D, Snyder-Warwick AK, Mackinnon SE, Wood MD. IL-4 expressing cells are recruited to nerve after injury and promote regeneration. Exp Neurol 2022; 347:113909. [PMID: 34717939 PMCID: PMC8887027 DOI: 10.1016/j.expneurol.2021.113909] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 10/24/2021] [Indexed: 01/03/2023]
Abstract
Interleukin-4 (IL-4) has garnered interest as a cytokine that mediates regeneration across multiple tissues including peripheral nerve. Within nerve, we previously showed endogenous IL-4 was critical to regeneration across nerve gaps. Here, we determined a generalizable role of IL-4 in nerve injury and regeneration. In wild-type (WT) mice receiving a sciatic nerve crush, IL-4 expressing cells preferentially accumulated within the injured nerve compared to affected sites proximal, such as dorsal root ganglia (DRGs), or distal muscle. Immunohistochemistry and flow cytometry confirmed that eosinophils (CD45+, CD11b+, CD64-, Siglec-F+) were sources of IL-4 expression. Examination of targets for IL-4 within nerve revealed macrophages, as well as subsets of neurons expressed IL-4R, while Schwann cells expressed limited IL-4R. Dorsal root ganglia cultures were exposed to IL-4 and demonstrated an increased proportion of neurons that extended axons compared to cultures without IL-4 (control), as well as longer myelinated axons compared to cultures without IL-4. The role of endogenous IL-4 during nerve injury and regeneration in vivo was assessed following a sciatic nerve crush using IL-4 knockout (KO) mice. Loss of IL-4 affected macrophage accumulation within injured nerve compared to WT mice, as well as shifted macrophage phenotype towards a CD206- phenotype with altered gene expression. Furthermore, this loss of IL-4 delayed initial axon regeneration from the injury crush site and subsequently delayed functional recovery and re-innervation of neuromuscular junctions compared to wild-type mice. Given the role of endogenous IL-4 in nerve regeneration, exogenous IL-4 was administered daily to WT mice following a nerve crush to examine regeneration. Daily IL-4 administration increased early axonal extension and CD206+ macrophage accumulation but did not alter functional recovery compared to untreated mice. Our data demonstrate IL-4 promotes nerve regeneration and recovery after injury.
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Affiliation(s)
- Deng Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jesús A Acevedo-Cintron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Daniel Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Sayanagi J, Acevedo-Cintrón JA, Pan D, Schellhardt L, Hunter DA, Snyder-Warwick AK, Mackinnon SE, Wood MD. Brief Electrical Stimulation Accelerates Axon Regeneration and Promotes Recovery Following Nerve Transection and Repair in Mice. J Bone Joint Surg Am 2021; 103:e80. [PMID: 34668879 DOI: 10.2106/jbjs.20.01965] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical outcomes following nerve injury repair can be inadequate. Pulsed-current electrical stimulation (ES) is a therapeutic method that facilitates functional recovery by accelerating axon regeneration. However, current clinical ES protocols involve the application of ES for 60 minutes during surgery, which can increase operative complexity and time. Shorter ES protocols could be a strategy to facilitate broader clinical adoption. The purpose of the present study was to determine if a 10-minute ES protocol could improve outcomes. METHODS C57BL/6J mice were randomized to 3 groups: no ES, 10 minutes of ES, and 60 minutes of ES. In all groups, the sciatic nerve was transected and repaired, and, in the latter 2 groups, ES was applied after repair. Postoperatively, changes to gene expression from dorsal root ganglia were measured after 24 hours. The number of motoneurons regenerating axons was determined by retrograde labeling at 7 days. Histomorphological analyses of the nerve were performed at 14 days. Function was evaluated serially with use of behavioral tests up to 56 days postoperatively, and relative muscle weight was evaluated. RESULTS Compared with the no-ES group, both ES groups demonstrated increased regeneration-associated gene expression within dorsal root ganglia. The 10-minute and 60-minute ES groups demonstrated accelerated axon regeneration compared with the no-ES group based on increased numbers of labeled motoneurons regenerating axons (mean difference, 202.0 [95% confidence interval (CI), 17.5 to 386.5] and 219.4 [95% CI, 34.9 to 403.9], respectively) and myelinated axon counts (mean difference, 559.3 [95% CI, 241.1 to 877.5] and 339.4 [95% CI, 21.2 to 657.6], respectively). The 10-minute and 60-minute ES groups had improved behavioral recovery, including on grid-walking analysis, compared with the no-ES group (mean difference, 11.9% [95% CI, 3.8% to 20.0%] and 10.9% [95% CI, 2.9% to 19.0%], respectively). There was no difference between the ES groups in measured outcomes. CONCLUSIONS A 10-minute ES protocol accelerated axon regeneration and facilitated functional recovery. CLINICAL RELEVANCE The brief (10-minute) ES protocol provided similar benefits to the 60-minute protocol in an acute sciatic nerve transection/repair mice model and merits further studies.
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Affiliation(s)
- Junichi Sayanagi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Abstract
Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.
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Affiliation(s)
- Madi El-Haj
- Washington University School of Medicine, St. Louis, MO, USA
| | - Wei Ding
- Shanghai Ninth People’s Hospital, China
| | - Ketan Sharma
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - J. Megan M. Patterson
- University of North Carolina School of Medicine, Chapel Hill, USA
- J. Megan M. Patterson, Department of Orthopaedics, University of North Carolina School of Medicine, 3135 Bioinformatics Building, Campus Box 7055, Chapel Hill, NC 27599-7055, USA.
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Yee A, Coombs DM, Hildebrandt S, Seidelman WE, Coer JH, Mackinnon SE. Nerve Surgeons' Assessment of the Role of Eduard Pernkopf's Atlas of Topographic and Applied Human Anatomy in Surgical Practice. J Biocommun 2021; 45:E7. [PMID: 36407922 PMCID: PMC9139514 DOI: 10.5210/jbc.v45i1.10823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
(Reprinted with permission from NEUROSURGERY, Volume 84, Number 2, February 2019).
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Affiliation(s)
- Andrew Yee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine St. Louis, Missouri
| | | | - Sabine Hildebrandt
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - William E Seidelman
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Henk Coer
- Department of Plastic, Reconstructive, and Hand Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Mackinnon SE, Yee A. Before and After I Knew: Disclosure, Respect, Gratitude, and Solemnity. J Biocommun 2021; 45:E9. [PMID: 36407924 PMCID: PMC9139076 DOI: 10.5210/jbc.v45i1.10853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The Pernkopf anatomical atlas has contributed significantly to the specialty of nerve surgery through its infiltration in surgical training and the development of novel procedures due to the accurate depiction of the nervous system. Until the recent advancements of the Pernkopf controversy, nerve surgeons have struggled with the ethical dilemma presented with its use in surgery and clinical practice. In this article, we explore a personal story and reflection by an individual nerve surgeon, their contribution to the advancement of the Pernkopf controversy, and how different professional domains (surgery, anatomy, ethics, religion, and education) were able to collaborate to address the historical crimes against humanity and issues in the anatomical sciences. This required a structured approach to address this ethical dilemma in surgery, which included (1) an assessment of the use of the Pernkopf atlas in specific surgical specialties (nerve surgery and oral and maxillofacial surgery) and (2) the development of a graduated ethical framework with a religious framework (the Vienna Protocol), if the Pernkopf atlas was to be used in surgery. These studies are reviewed in the context of evolving paradigms in nerve surgery (nerve repair, grafting, and transfers) and influence of anatomy in the advancement of this surgical specialty.
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Affiliation(s)
| | - Andrew Yee
- Washington University School of Medicine
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38
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Yee A, Hill EJR, Brown D, Mackinnon SE. Reply: The Effect of Surgical Video on Resident Performance of Carpal Tunnel Release: A Cadaveric Simulation-Based, Prospective, Randomized, Blinded Pilot Study. Plast Reconstr Surg 2021; 148:311e-312e. [PMID: 34228029 DOI: 10.1097/prs.0000000000008130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew Yee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Elspeth J R Hill
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Douglas Brown
- Center for Humanism and Ethics in Surgical Specialties, Department of Surgery, Washington University School of Medicine
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
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Abstract
Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.
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Affiliation(s)
- Emily M. Krauss
- University of British Columbia, Victoria, Canada,The University of Victoria, BC, Canada
| | | | | | - Susan E. Mackinnon
- Washington University in St. Louis, MO, USA,Susan E. Mackinnon, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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Jacobson LA, Wood MD, Mackinnon SE. Editorial Commentary of "Nerve Reconstruction Using Processed Nerve Allograft in the US Military". Mil Med 2021; 186:148-151. [PMID: 33433561 DOI: 10.1093/milmed/usaa497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lauren A Jacobson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Abstract
Dislocation of the native knee represents a challenging injury, further complicated by the high rate of concurrent injury to the common peroneal nerve (CPN). Initial management of this injury requires a thorough neurovascular examination, given the prevalence of popliteal artery injury and limb-threatening ischemia. Further management of a knee dislocation with associated CPN palsy requires coordinated care involving the sports surgeon for ligamentous knee reconstruction and the peripheral nerve surgeon for staged or concurrent peroneal nerve decompression and/or reconstruction. Finally, the foot and ankle surgeon is often required to manage a foot drop with a distal tendon transfer to restore foot dorsiflexion. For instance, the Bridle Procedure-a modification of the anterior transfer of the posterior tibialis muscle, under the extensor retinaculum, with tri-tendon anastomosis to the anterior tibial and peroneus longus tendons at the anterior ankle-can successfully return patients to brace-free ambulation and athletic function following CPN palsy. Cross-discipline coordination and collaboration is essential to ensure appropriate timing of operative interventions and ensure maintenance of passive dorsiflexion prior to tendon transfer.
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Affiliation(s)
- Christopher J Dy
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Paul M Inclan
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Susan E Mackinnon
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Jeffrey E Johnson
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
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Hong T, Wood I, Hunter DA, Yan Y, Mackinnon SE, Wood MD, Moore AM. Neuroma Management: Capping Nerve Injuries With an Acellular Nerve Allograft Can Limit Axon Regeneration. Hand (N Y) 2021; 16:157-163. [PMID: 31137979 PMCID: PMC8041431 DOI: 10.1177/1558944719849115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Management of painful neuromas continues to challenge clinicians. Controlling axon growth to prevent neuroma has gained considerable traction. A logical extension of this idea is to therefore develop an approach to control and arrest axon growth. Given the limits in axonal regeneration across acellular nerve allografts (ANAs), these constructs could provide a means to reliably terminate axon regeneration from an injured nerve. The purpose of this study was to determine if attaching an ANA to an injured nerve could provide a means to control and limit axon regeneration in a predictable manner. Methods: Twenty (20) adult rats received a sciatic nerve transection, where only the proximal nerve was repaired using an ANA of variable length (0.5, 2.5, and 5.0 cm) or left unrepaired (control). The nerves were harvested 5 weeks post-operatively for gross and histomorphometric analysis. The extent of myelinated axons in regenerated tissue was quantified. Results: At 5 weeks, limited axon regeneration within the ANAs was observed. All lengths of ANAs lead to reduced myelinated axon numbers in the most terminal tissue region compared to untreated injured nerve (P = .002). Additionally, ANA length 2.5 cm or greater did not contain any axons at the most terminal tissue region. Conclusions: This study demonstrates a proof of concept that ANAs attached to the proximal end of an injured nerve can limit axon growth in a controlled manner. Furthermore, the extent of axon growth from the injured nerve into the ANA is dependent on the ANA length.
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Affiliation(s)
- Thomas Hong
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ian Wood
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Ying Yan
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Matthew D. Wood
- Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Washington University School of Medicine, St. Louis, MO, USA,Amy M. Moore, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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Yee A, Li J, Lilly J, Hildebrandt S, Seidelman WE, Brown D, Kopar P, Coert JH, Mackinnon SE, Israel HA. Oral and maxillofacial surgeons' assessment of the role of Pernkopf's atlas in surgical practice. Ann Anat 2020; 234:151614. [PMID: 33171220 DOI: 10.1016/j.aanat.2020.151614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of the Pernkopf atlas of human anatomy in surgery presents ethical challenges due to the author's association with the Nazi regime and the potential depiction of victims of this regime. The atlas was of particular utility to two surgical specialties: nerve surgeons and oral and maxillofacial surgeons. The representation of peripheral nerves and complex head and neck anatomy is probably unequaled in any other atlas of anatomy. While the ethical implications of the use of Pernkopf's atlas among nerve surgeons have been previously assessed, this study focuses on the volume dedicated to detailed images of head and neck dissections, and the ethical implications of using this atlas by oral and maxillofacial surgeons. OBJECTIVE To (1) assess the role of the Pernkopf atlas in oral and maxillofacial surgeons' current practice and (2) determine whether a proposal of four conditions would provide ethical guidance for use in surgery and education. METHODS Members of three American oral and maxillofacial surgical societies (ACOMS, ASTMJS, AAOMS) were surveyed and 181 responses collected. The survey introduced the historical origin of the Pernkopf atlas, and respondents were asked whether they would use the atlas under specific conditions that could be a recommendation for its ethical handling. An anatomical plate comparison between Netter's and Pernkopf's atlases was performed to compare accuracy and surgical utility. RESULTS Forty-nine percent of respondents were aware of the Pernkopf atlas, and 9% of respondents were currently using it. Amongst those aware of the historical facts, 42% were comfortable using the atlas, 33% uncomfortable, and 25% undecided. The four conditions involving disclosure, bioethical and religious considerations, and remembrance led to 75% of those "uncomfortable" and "undecided" becoming "comfortable" with use. CONCLUSIONS Amid recent developments and controversy regarding the Pernkopf atlas, a proposal detailing conditions for an ethical approach may provide guidance in surgical planning and education. Furthermore, this approach has implications for the future preparation and publication of anatomical atlases and their use.
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Affiliation(s)
- Andrew Yee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Jessica Li
- Oral and Maxillofacial Surgery, Touro College of Dental Medicine, New York Medical College, Hawthorne, NY, USA
| | - Joshua Lilly
- Oral and Maxillofacial Surgery, Touro College of Dental Medicine, New York Medical College, Hawthorne, NY, USA
| | - Sabine Hildebrandt
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William E Seidelman
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Doug Brown
- Center for Humanism and Ethics in Surgical Specialties, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Piroska Kopar
- Center for Humanism and Ethics in Surgical Specialties, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J Henk Coert
- Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, Netherlands
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Howard A Israel
- Oral and Maxillofacial Surgery, Touro College of Dental Medicine, New York Medical College, Hawthorne, NY, USA
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Pan D, Sayanagi J, Acevedo-Cintrón JA, Schellhardt L, Snyder-Warwick AK, Mackinnon SE, Wood MD. Liposomes embedded within fibrin gels facilitate localized macrophage manipulations within nerve. J Neurosci Methods 2020; 348:108981. [PMID: 33075327 DOI: 10.1016/j.jneumeth.2020.108981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/03/2020] [Accepted: 10/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Understanding the role of macrophages at discrete spatial locations during nerve regeneration after injury is important. But, methodologies that systemically manipulate macrophages can obscure their roles within discrete spatial locations within nerve. NEW METHOD Liposomes were embedded within fibrin gels to construct a delivery system that facilitated macrophage-specific manipulations at a sole spatial region, as macrophages accumulated within the fibrin. Clodronate liposomes were characterized for their toxicity to specific cells composing nerve in vitro, then tested for macrophage-specific depletion in vivo. This delivery system using clodronate liposomes was used to repair a mouse sciatic nerve gap to evaluate its efficacy and effects. RESULT Clodronate liposomes showed specific toxicity to macrophages without affecting dorsal root ganglia (DRG)-derived neurons, endothelial cells, or Schwann cells in culture. The delivery system demonstrated sustained release of liposomes for more than 7 days while still retaining liposomes within the fibrin. In vivo, the delivery system demonstrated macrophages were targeted by liposomes, and the use of clodronate liposomes minimized macrophage accumulation within fibrin, while not affecting macrophage accumulation within DRG. Nerve regeneration across the nerve gap repaired using this delivery system was associated with decreased angiogenesis, Schwann cell accumulation, axon growth, and reinnervation of affected muscle. COMPARISON WITH EXISTING METHODS This delivery system allowed specific perturbation of macrophages locally in nerve. This method could be applicable across species without the need for genetic manipulations or systemic pharmaceuticals. CONCLUSION Liposomes embedded within fibrin gels locally target macrophages at the site of nerve injury, which enables greater precision in conclusions regarding their roles in nerve.
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Affiliation(s)
- Deng Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Junichi Sayanagi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jesús A Acevedo-Cintrón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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Pan D, Hunter DA, Schellhardt L, Fuchs A, Halevi AE, Snyder-Warwick AK, Mackinnon SE, Wood MD. T cells modulate IL-4 expression by eosinophil recruitment within decellularized scaffolds to repair nerve defects. Acta Biomater 2020; 112:149-163. [PMID: 32434080 DOI: 10.1016/j.actbio.2020.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 12/20/2022]
Abstract
Decellularized nerve, or acellular nerve allografts (ANAs), are an increasingly used alternative to nerve autografts to repair nerve gaps to facilitate regeneration. The adaptive immune system, specifically T cells, plays a role in promoting regeneration upon these ANA scaffolds. However, how T cells promote regeneration across ANAs is not clear. Here, we show that T cells accumulate within ANAs repairing nerve gaps resulting in regulation of cytokine expression within the ANA environment. This in turn ultimately leads to robust nerve regeneration and functional recovery. Nerve regeneration across ANAs and functional recovery in Rag1KO mice was limited compared to wild-type (WT) mice. Prior to appreciable nerve regeneration, ANAs from Rag1KO mice contained fewer eosinophils and reduced IL-4 expression compared to ANAs from WT mice. During this period, both T cells and eosinophils regulated IL-4 expression within ANAs. Eosinophils represented the majority of IL-4 expressing cells within ANAs, while T cells regulated IL-4 expression. Finally, an essential role for IL-4 during nerve regeneration across ANAs was confirmed as nerves repaired using ANAs had reduced regeneration in IL-4 KO mice compared to WT mice. Our data demonstrate T cells regulate the expression of IL-4 within the ANA environment via their effects on eosinophils. STATEMENT OF SIGNIFICANCE: The immune system has been emerging as a critical component for tissue regeneration, especially when regeneration is supported upon biomaterials. The role of T cells, and their roles in the regeneration of nerve repaired with biomaterials, is still unclear. We demonstrated that when nerves are repaired with decellularized nerve scaffolds, T cells contribute to regeneration by regulating cytokines. We focused on their regulation of cytokine IL-4. Unexpectedly, T cells do not produce IL-4, but instead regulate IL-4 by recruiting eosinophils, which are major cellular sources of IL-4 within these scaffolds. Thus, our work demonstrated how IL-4 is regulated in a model biomaterial, and has implications for improving the design of biomaterials and understanding immune responses to biomaterials.
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Affiliation(s)
- Deng Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Daniel A Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Lauren Schellhardt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alexandra E Halevi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Abstract
Background: Intrinsic atrophy and debilitating sensory loss are prominent features of severe ulnar neuropathy with limited surgical options to reliably improve recovery. Restoration of sensation is important to provide protection for the vulnerable ulnar border of the hand. Here, we report our experience with side-to-side sensory nerve grafting from the median to ulnar nerve in the palm to enhance ulnar sensory recovery. Methods: A retrospective chart review identified patients with severe ulnar neuropathy who underwent cross-palm nerve grafting. Included patients had objective loss of protective sensation in the ulnar distribution with 2-point discrimination >8 mm, Semmes-Weinstein monofilament testing (SWMT) >4.56, or no sensory response on nerve conduction testing. Cross-palm side-to-side tension-free grafting from median to ulnar sensory components was performed using short-segment allograft or autografts. Analysis included patient etiology, procedures, nerve conduction studies, objective sensory testing, and Disabilities of the Arm, Shoulder, and Hand Disability score. Results: Forty-eight patients with severe ulnar neuropathy underwent cross-palm nerve grafting between 2014 and 2017. Twenty-four patients had adequate follow-up for inclusion. Of the 24 patients, 21 (87%) had return of protective sensation, 16 (66.7%) had return of diminished light touch sensation, and 6 (25%) had return to normal range sensation within 1 year as assessed by SWMT and/or 2-point discrimination. Patients treated with autograft demonstrated referred sensation to the median nerve distribution. Conclusions: Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy. Further study to quantify differences in sensory recovery between traditional operative techniques and cross-palm nerve grafting is required.
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Affiliation(s)
- John M. Felder
- Washington University School of Medicine in St. Louis, MO, USA,John M. Felder, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, 1150 Northwest Tower, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
| | | | - Hollie A. Power
- Washington University School of Medicine in St. Louis, MO, USA
| | - Jessica Hasak
- Washington University School of Medicine in St. Louis, MO, USA
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Pan D, Acevedo-Cintrón JA, Sayanagi J, Snyder-Warwick AK, Mackinnon SE, Wood MD. The CCL2/CCR2 axis is critical to recruiting macrophages into acellular nerve allograft bridging a nerve gap to promote angiogenesis and regeneration. Exp Neurol 2020; 331:113363. [PMID: 32450192 DOI: 10.1016/j.expneurol.2020.113363] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/24/2020] [Accepted: 05/19/2020] [Indexed: 12/30/2022]
Abstract
Acellular nerve allografts (ANAs) are increasingly used to repair nerve gaps following injuries. However, these nerve scaffolds have yet to surpass the regenerative capabilities of cellular nerve autografts; improved understanding of their regenerative mechanisms could improve design. Due to their acellular nature, both angiogenesis and diverse cell recruitment is necessary to repopulate these scaffolds to promote functional regeneration. We determined the contribution of angiogenesis to initial cellular repopulation of ANAs used to repair nerve gaps, as well as the signaling that drives a significant portion of this angiogenesis. Wild-type (WT) mice with nerve gaps repaired using ANAs that were treated with an inhibitor of VEGF receptor signaling severely impaired angiogenesis within ANAs, as well as hampered cell repopulation and axon extension into ANAs. Similarly, systemic depletion of hematogenous-derived macrophages, but not neutrophils, in these mice models severely impeded angiogenesis and subsequent nerve regeneration across ANAs suggesting hematogenous-derived macrophages were major contributors to angiogenesis within ANAs. This finding was reinforced using CCR2 knockout (KO) models. As macrophages represented the majority of CCR2 expressing cells, a CCR2 deficiency impaired angiogenesis and subsequent nerve regeneration across ANAs. Furthermore, an essential role for CCL2 during nerve regeneration across ANAs was identified, as nerves repaired using ANAs had reduced angiogenesis and subsequent nerve regeneration in CCL2 KO vs WT mice. Our data demonstrate the CCL2/CCR2 axis is important for macrophage recruitment, which promotes angiogenesis, cell repopulation, and subsequent nerve regeneration and recovery across ANAs used to repair nerve gaps.
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Affiliation(s)
- Deng Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jesús A Acevedo-Cintrón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Junichi Sayanagi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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48
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Abstract
Background: Impairment of the dominant hand should lead to greater disability than impairment of the nondominant hand, but few studies have tested this directly, especially in the domain of upper-extremity peripheral nerve disorder. The aim of this study was to identify the association between hand dominance and standardized measures of disability and health status after upper-extremity peripheral nerve disorder. Methods: An existing database was reanalyzed to identify the relationship between affected-side (dominant vs nondominant) on individuals with unilateral upper-extremity peripheral nerve disorder (N = 400). Primary measure of disability was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Results: We found no differences in standardized measures of disability or health status between patients with affected dominant hand and patients with an affected nondominant hand. However, a post hoc exploratory analysis revealed that patients with an affected dominant hand reported substantially reduced ability to perform 2 activities in the DASH questionnaire: "write" and "turn a key." Conclusions: Following unilateral upper-extremity peripheral nerve disorder, impairment of the dominant hand (compared with impairment of the nondominant hand) is associated with reduced ability to perform specific activities, but this reduced ability is not reflected in standardized measures of disability and health status. To adequately identify disability following unilateral impairment of the dominant hand with the DASH, individual items must be used instead of the total score. New or alternative measures are also recommended.
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Affiliation(s)
- Benjamin A. Philip
- Washington University School of Medicine, St. Louis, MO, USA,Benjamin A. Philip, Washington University School of Medicine, 4444 Forest Park Avenue, Campus Box 8505, St. Louis, MO 63108, USA.
| | - Vicki Kaskutas
- Washington University School of Medicine, St. Louis, MO, USA
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Poppler LH, Yu J, Mackinnon SE. Subclinical Peroneal Neuropathy Affects Ambulatory, Community-Dwelling Adults and Is Associated with Falling. Plast Reconstr Surg 2020; 145:769e-778e. [PMID: 32221217 DOI: 10.1097/prs.0000000000006637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peroneal neuropathy with an overt foot drop is a known risk factor for falling. Subclinical peroneal neuropathy caused by compression at the fibular neck is subtler and does not have foot drop. A previous study found subclinical peroneal neuropathy in 31 percent of hospitalized patients. This was associated with having fallen. The purpose of this study was to determine the prevalence of subclinical peroneal neuropathy in ambulatory adults and investigate if it is associated with falling. METHODS A cross-sectional study of 397 ambulatory adults presenting to outpatient clinics at a large academic hospital was conducted from 2016 to 2017. Patients were examined for dorsiflexion weakness and signs of localizing peroneal nerve compression to the fibular neck. Fall risk was assessed with the Activities-Specific Balance Confidence Scale and self-reported history of falling. Multivariate logistic regression was used to correlate subclinical peroneal neuropathy with fall risk and a history of falls. RESULTS The mean patient age was 54 ± 15 years and 248 patients (62 percent) were women. Thirteen patients (3.3 percent) were found to have subclinical peroneal neuropathy. After controlling for various factors known to increase fall risk, patients with subclinical peroneal neuropathy were 3.74 times (95 percent CI, 1.06 to 13.14) (p = 0.04) more likely to report having fallen multiple times in the past year than patients without subclinical peroneal neuropathy. Similarly, patients with subclinical peroneal neuropathy were 7.22 times (95 percent CI, 1.48 to 35.30) (p = 0.02) more likely to have an elevated fall risk on the Activities-Specific Balance Confidence fall risk scale. CONCLUSION Subclinical peroneal neuropathy affects 3.3 percent of adult outpatients and may predispose them to falling. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Louis H Poppler
- From the Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine
| | - Jenny Yu
- From the Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine
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Abstract
Background: Clenched fist syndrome is a rare disorder, often attributed to a conversion disorder without anatomic basis. Here, we review the literature surrounding clenched fist syndrome and challenge the assumption it is always psychiatric in origin, via description of a case of clenched fist syndrome responsive to surgical nerve decompression. Methods: An unusual case of clenched fist syndrome is reviewed and discussed. Results: A child presenting with clenched fist syndrome failed conservative measures consisting of formal hand therapy, multidisciplinary pain management, and psychiatric treatment. On clinical examination, she had findings consistent with median nerve entrapment. After undergoing surgical decompression of the median nerve in the forearm and carpal tunnel, the clenched fist resolved immediately. Conclusions: Nerve compression may be an unrecognized factor underlying some cases of clenched fist syndrome. Evaluation by a hand surgeon or a hand therapist skilled in the detection of peripheral nerve entrapment or injury should be considered as part of the workup for this rare disorder.
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Affiliation(s)
- Elspeth J.R. Hill
- Washington University School of Medicine, Saint Louis, MO, USA,Elspeth J. R. Hill, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 1150 Northwest Tower, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
| | - Lorna C. Kahn
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Lynne M. Sterni
- Washington University School of Medicine, Saint Louis, MO, USA
| | | | - John M. Felder
- Washington University School of Medicine, Saint Louis, MO, USA
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