The role of patient-reported outcomes in peripheral nerve surgery

Measuring the outcome of peripheral nerve surgery is challenging because of the spectrum of functional impairment is dependent on the level and severity of the lesion. There are no nerve-specific patient-reported outcome measures, and no universally accepted outcome measurement both in terms of the parameters to be assessed and the methods and timing of the assessment. Nevertheless, the use of patient-reported outcome measures is fundamental to better understand the needs and expectations of patients, to take advantage of all treatment opportunities to offer the best possible support to these patients. This paper outlines current concepts in the measurement of outcome in peripheral nerve surgery.

Robotic Microsurgery in Extremity Reconstruction - Experience With a Novel Robotic System

Background: Robotic systems have successfully been introduced into other surgical fields in the past. First attempts with different setups are made in the field of microsurgery. The Symani® Surgical System, a flexible platform consisting of two robotic arms, features motion scaling with tremor filtration to address the demands and complexity of microsurgery. Symani's NanoWrist Instruments are the world's smallest, wristed surgical instruments, intended to improve a surgeon's range of motion beyond the capability of the human hand. This combination allows surgeons to scale their hand movements while seamlessly articulating the robotic micro instruments. Purpose: We report on our experience in extremity reconstruction with this novel system.Research Design: The Symani Surgical System® was used for 6 cases of extremity reconstruction. The surgeon controlled the manipulators along with the footswitch while either sitting away from the operating table relying on 3D visualization with an exoscope or sitting at the operating table using a standard microscope.Data Collection: Microsurgical anastomoses were performed in 4 patients (3 end-to-end arterial anastomoses and one end-to-side arterial anastomosis) and nerve grafting was performed in 2 patients.Results: Microvascular anastomoses were slower vs conventional microsurgery, but all anastomoses were patent. Epineural coaptation showed proper fascicle alignment and tissue manipulation could be kept to a minimum. The platform's motion scaling allows the surgeon to perform precise micro-movements with only minimal tissue manipulation and hard-to-reach anatomy becomes accessible more easily.Conclusions: Robotic microsurgery might gain importance in the nearer future but more data will need to be collected.

Neuropathic pain of the superficial branch of the radial nerve - Factors influencing surgical outcome and patient satisfaction

BACKGROUND

Due to its partially superficial course, the superficial branch of the radial nerve is vulnerable to injury by trauma or surgery, potentially leading to painful neuroma. Surgical treatment is difficult. Among other factors, smoking and duration of pain before revision surgery have been suggested as risk factors for persistent pain after surgical revision, without concrete evidence. The aim of this study was therefore to identify factors influencing the outcome of revision surgery in SBRN neuropathic pain in our department.

METHODS

All 51 patients receiving revision surgery of the superficial branch of the radial nerve for neuropathic pain from 2010 to 2020 were contacted; 19 agreed to return for assessment. A medical chart review was performed to collect patient-, pain- and treatment-specific factors. Outcomes were recorded. In an outpatient consultation, clinical follow-up was performed and patients filled out the DASH, MHQ and painDETECT questionnaires.

RESULTS

After revision surgery, all patients experienced persistent pain. On multivariate logistic regression evaluating the risk of persistent pain, only smoking emerged as an independent risk factor. Age, gender, dominant side, location, time between trigger and surgery or diagnosis did not emerge as risk factors. No predictor for successful return to work could be identified.

CONCLUSIONS

Treatment of painful neuroma of the superficial branch of the radial nerve is a challenge. Patients with neuropathic pain should be coached toward smoking cessation before neuroma surgery. Surgery can show benefit even after long symptom duration. No correlations between study clinical variables or test results and return to work could be identified, suggesting that other factors play a role in return to work.

Flexor Tendon Repair Techniques: M-Tang Repair

The authors present the methods and outcomes from six institutes where M-Tang repairs with early active flexion exercise are used for zone 2 digital flexor tendon repair. The authors had close to zero repair ruptures, and few digits needed tenolysis. The excellent to good results are generally between 80% and 90%. In the pandemic period, less stringent therapy supervision might have allowed some patients to move too aggressively, with repair ruptures not seen before the pandemic in one institute. In Nantong, Yixing, and Saint John, the rupture incidence is zero to 1%. In Florence and Heidelberg, the rupture incidence was 3%.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

10-Year single center experience in lower limb reconstruction with free muscle flaps - factors influencing complications in 266 consecutive cases

The anatomy and technique of free muscle flaps - in particular gracilis flap and latissimus dorsi flap - in lower extremity reconstruction have been well described. There is a paucity of data on potential risk factors in larger patient series that affect the outcome. The objective of this study was to address this lack of knowledge by reporting outcomes and complications of free muscle flaps as a primary option in lower extremity reconstruction. From 2009 to 2020, a total of 253 consecutive patients with soft tissue defects of the lower limb from trauma, infection or malignancies underwent lower extremity reconstructive surgery with 266 free muscle flaps. Complications requiring revision surgery were noted in 36.1% of cases. Total flap loss occurred in 10.5% of cases. Patients requiring revision surgery were older, more likely to be female, more likely to be active smokers, and more likely to have a higher ASA score. Lower extremity reconstruction with free muscle flaps has a relevant complication rate that both patient and reconstructive surgeon need to be aware of. Prospective studies should try to further assess the factors affecting the outcome.

[Bite Injuries - Diagnosis and Treatment]

Bite Injuries - Diagnosis and Treatment Abstract. In Switzerland 50% of the people get bitten by an animal once in their lifetime. Almost 20% of all bite injuries lead to infections. All bite wounds should be debrided and irrigated with saline. Primary wound management is critical in terms of reducing the risk of infection. Injuries to the hands and face should be treated by a hand or plastic surgeon.

A cohort study on neuropathic pain of the saphenous nerve—factors influencing surgical outcome

Background

Due to its partially superficial course, the saphenous nerve is vulnerable to injury by trauma or surgery potentially leading to painful neuroma formation. Different surgical techniques to treat neuroma have been described, but so far, no one has proven to be superior to the others. The aim of this study was therefore to identify factors influencing the outcome of revision surgery in saphenous nerve neuropathic pain in our department.

Methods

From 2010 to 2020, a total of 29 consecutive patients with neuropathic pain and suspected neuroma of the saphenous nerve underwent revision surgery. A medical chart review was performed to collect patient-, pain-, and treatment-specific factors. Outcomes were registered.

Results

Post revision surgery in neuropathic pain of the saphenous nerve, 16 (55.2%) patients suffered from persisting pain. In multivariable logistic regression models evaluating the risk of persisting pain post saphenous nerve revision surgery, both smoking and preoperative opiate consumption represented independent predictors of higher risk for persisting pain.

Conclusions

Patients with injury to the saphenous nerve should be coached toward smoking cessation. Whenever possible, forgoing opiate treatment might be beneficial.

Level of evidence: Level IV, Risk/Prognostic.

[Pain In the Thumb and Other Fingers]

Pain In the Thumb and Other Fingers Abstract. As the population ages, symptoms of osteoarthritis in the hand are seen with increasing frequency. It can lead to substantial pain, physical disability and impair the patient's capacity to work in a population with an increasing retirement age. This article gives an overview about the most prevalent forms of osteoarthritis in the hand, its diagnosis and current treatment options, stressing that the multimodal form of therapy is the most effective.

[Tendinopathies - Common Diagnoses in Hand Surgery]

Tendinopathies - Common Diagnoses in Hand Surgery Abstract. Tendinopathies are among the most frequent reasons for consulting a hand surgeon. The diagnosis can usually be made clinically. A supplementary ultrasound examination helps to visualize the pathology. Most of these diseases respond to non-surgical treatment. If surgical treatment is necessary, it can usually be performed as an outpatient procedure under local anesthesia. This article provides an overview of the most common tendinopathies of the hand and wrist, their diagnosis and treatment.

[The Painful Wrist]

The Painful Wrist Abstract. Wrist pain is a problem that can significantly limit patients in their daily activities. The causes are manifold, and treatment is often challenging. A systematic approach is therefore helpful in working up the correct diagnosis. This article aims to demonstrate a straightforward approach to the evaluation of wrist pain in adults.

[Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective]

Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective Abstract. Neuropathic pain of the wrist and hand can be caused by a multitude of pathologies, such as trauma, iatrogenic damage, local peripheral nerve compression, nerve tumors and systemic diseases. Neuropathic pain can lead to chronification and disability, severely affecting the patients' quality of life and the ability to work. A precise diagnosis is the key to an adequate therapy with satisfactory functional results. An interdisciplinary and multimodal approach is a prerequisite when treating neuropathic pain. This review article provides an insight into the diagnosis and therapy of pathologies associated with neuropathic pain of the wrist and hand.

Arthroscopic three-corner or lunocapitate arthrodesis: technical tips and early outcomes

The purpose of the study is to present a technical approach for arthroscopic three-corner or lunocapitate arthrodesis with mini-open scaphoid excision and to report about the early clinical and functional results. The median surgery time was 112 min with shorter times achieved once mastering the technique. Radiological and clinical union was observed in 11 out of 12 patients in a median time of five months. For final assessments nine patients were included with a median follow-up of 15 months. Wrist extension and flexion after surgery decreased to 58 and 62% of preoperative measurements and represented 37 and 42% of the unaffected side. Grip strength also decreased to 80% of the preoperative value and 57% of the unaffected side. All patients reported significant pain relief and functional improvement. Arthroscopic three-corner or lunocapitate arthrodesis was a safe, reliable and minimally invasive technique for treating wrist osteoarthritis, while it was technically demanding and time-consuming during learning curve.

YouTube as a resource for surgical education with a focus on plastic surgery - a systematic review

Surgery trainees use videos as a means to learn about surgical procedures. YouTube is the biggest online video platform and used for educational content as well but the medical information provided does not undergo peer review or other forms of scientific screening and can thus be of poorer quality. We performed a systematic review that examined the quality of educational videos about surgery and plastic surgery in particular on YouTube. The focus was towards studies on the benefit of YouTube videos for surgical trainees. A literature review was performed to determine the educational quality of plastic surgery videos found on YouTube. Articles reviewing the educational quality of videos about surgical procedures, their accuracy, and their utility for surgical trainees were included. An additional review was performed evaluating the literature about the quality of educational plastic surgery videos. Eleven articles were selected reviewing the educational quality of videos about surgical procedures. Six studies were fully assessed and evaluated concerning the quality of educational plastic surgery videos. There currently seems to be a lack of comprehensive educational surgery and in particular plastic surgery-related information on YouTube. The popularity of YouTube among surgical trainees is high. The quality of available educational surgical video content varies widely. It is in the interest of plastic surgery teaching institutions to provide trainees with high-quality educational video material.

Management of posterior interosseous nerve (PIN) palsies after distal biceps tendon repair using a single incision technique- a conclusive approach to diagnostics and therapy

Complete distal ruptures of the biceps brachii tendon are rather rare and surgical reinsertion is the gold standard. Recently, one incision approaches for the refixation of the distal biceps tendon have been popularized with the introduction of a single-incision approach employing a trans-radial cortical button fixation. Since the introduction of this fixation technique we have seen more iatrogenic lesions to the posterior interosseous nerve (PIN) after not having seen any PIN lesions with 2 incision biceps refixation techniques over the last 5 years. Several patients with iatrogenic PIN affections after one incision refixation techniques of the distal biceps tendon were referred to our level 1 department of Plastic surgery and hand surgery from different orthopedic surgeons. Over the course of 6 months we saw 5 patients with a similar history. We decided to analyze this problem and propose a course of action to regain function of the PIN innervated muscles as good and fast as possible. If there is a loss of function in the PIN innervated muscles after distal biceps refixation a neurological evaluation including electrophysiology needs to be conducted. An ultrasound assessment of the nerve itself should guide the clinician in the decision between a conservative and a surgical treatment in the early postoperative phase. If surgical exploration is warranted intraoperative neurography should be the basis on which ground (partial) grafting or solely neurolysis is performed. Postoperatively all patients need to follow a rehabilitation protocol to help with nerve regeneration and regaining of motor function.

'Viewer discretion advised when preparing for surgery' - why YouTube cannot teach you how to do an upper blepharoplasty. An evaluation of the educational potential of surgical videos on blepharoplasty on YouTube

Over the last years, the layout of surgical training has significantly changed. Surgical residents rely on YouTube videos to prepare for upcoming cases. Eyelid surgery including blepharoplasty ranks among the 5 most often performed cosmetic surgeries. It will be one of those surgeries regularly researched by plastic surgery residents. Therefore, the aim of this study was to evaluate the educational value of the most viewed upper lid blepharoplasty videos on the most popular video broadcasting website, YouTube. A video scoring system consisting of 8 items was developed in accordance with the technical details described in the literature. Video scores were categorized into 3 groups, namely as 'poor', 'moderate; or 'good' in terms of their contribution to surgical education. The first 300 videos were evaluated for the search results for 'blepharoplasty'. After exclusion and summarization of video fragments, a total number of 36 videos were included in the study. Multivariable logistic regression models found no correlation between likes, views, comments and the attributed educational score. The quality of available educational surgical video content varies widely, and surgical trainees need to be critically aware of this as view counts as well as the number of likes and comments will not necessarily relate to videos' educational quality. There is a need for high-quality educational videos.

Surgical management of isolated orbital floor and zygomaticomaxillary complex fractures with focus on surgical approaches and complications

Zygomaticomaxillary complex (ZMC) and orbital blow out fractures are commonly encountered midfacial fractures that may result in aesthetic and functional impairment. This retrospective study reports on the surgical treatment and associated postoperative complications in our patient collective. We evaluated 100 patients who underwent open reduction and internal fixation of midfacial fractures between 2010 and 2015. Preoperative clinical features, surgical technique and postoperative complications were analyzed. Surgery was performed with a mean latency of 7 days after trauma. We used titanium mesh and polydioxanone sheets to reconstruct the orbital floor. Most ZMC fractures were stabilized with two point fixation with titanium plates. Preoperative symptoms were present in 70 patients (70%). Infraorbital hypesthesia occurred in 49 patients, diplopia in 41 patients and ocular motility impairment in 24 patients. Postoperative symptoms persisted during a mean follow-up time of 4.5 months in 47 patients (47%) showing infraorbital hypesthesia in 24%, diplopia in 17%, ectropion in 7% and ocular motility impairment in 4%. Complications requiring revision were retrobulbar hematoma 3% (n = 3), ectropion 3% (n = 3), diplopia 1% (n = 1), exophthalmos 1% (n = 1), implant dislocation 1% (n = 1), implant discomfort 2% (n = 2), persisting fracture dislocation 1% (n = 1). All patients recovered without significant impairment. Surgery is required in the majority of the patients with midfacial fractures. Among others ectropion is challenging due to its aesthetic and functional impact on patients. To prevent ectropion, additional canthopexy or the transconjunctival surgical approach are reasonable options in selected cases. Level of Evidence: Level V, descriptive study. AbbreviationsCTcomputed tomographyOForbital floorPDSpolydioxanoneORIFopen reduction and internal fixationZMCzygomaticomaxillary complex.

Finger reconstruction with dorsal metacarpal artery perforator flaps and dorsal finger perforator flaps based on the dorsal branches of the palmar digital arteries - 40 consecutive cases

Since the first description many variations of the dorsal metacarpal reverse island flap have been published but there is still uncertainty about which vascular component should be included for an optimal result. Therefore, it was the aim of this study to analyze vascular reliability and ischemic complications of dorsal metacarpal artery perforator (DMAP) flaps and dorsal finger perforator (DFP) flaps in our patient collective. We performed 40 of these flaps from the dorsum of hand and fingers for finger injuries. The choice of donor site was made according to the defect's location. Patients were analyzed with respect to flap necrosis, ischemic complications and achievement of overall reconstruction goals. In addition, we divided our patients in two groups, one group where we raised the flap from the dorsum of the proximal phalanx and a second one where the flaps were raised from the intermetacarpal space to identify complication rates based on the pedicles location. Of the 40 flaps, 36 survived completely. 4 partial necroses were observed in flaps transferred to more distal defects and in one flap that was used in a wrap-around technique for both dorsal and palmar proximal phalanx. These perforator flaps are a reliable method to cover finger defects and the dorsal metacarpal artery is not necessary for their survival, since the blood supply comes from perforating branches of the palmar vascular system. There is a clear trend for a higher complication rate in flaps raised from the dorsum of the fingers compared to the intermetacarpal space.