Min Bom Kim

Patients' Preferred and Retrospectively Perceived Levels of Involvement During Decision-Making Regarding Carpal Tunnel Release

BACKGROUNDnPatient-centered care requires physicians to respond to patients preferences, including their preferences regarding treatment decision-making. The authors surveyed patients to determine their preoperative preferences and their retrospectively perceived levels of involvement in decision-making for carpal tunnel release, and they attempted to identify factors that affect patient preferences and experiences.nnnMETHODSnSeventy-eight patients who underwent carpal tunnel release for carpal tunnel syndrome were requested to indicate their preferred level of involvement preoperatively and to assess their actual levels of involvement postoperatively, using a Control Preferences Scale containing five levels that range from fully active to fully passive. Clinical and demographic factors that potentially affected patients preoperative preferences and postoperative assessments of levels of involvement were analyzed.nnnRESULTSnFifty-nine patients (76%) indicated preoperatively that they preferred shared decision-making, and sixty-six (85%) thought postoperatively that they had experienced this type of decision-making. The correlation between preoperative and postoperative Control Preferences Scale assessments was significant (r = 0.525, p < 0.001). A history of a surgical procedure was independently associated with a preoperative preference for a more active role (odds ratio = 4.2), and patients with a caregiver (odds ratio = 4.0) or private insurance (odds ratio = 2.6) were more likely to experience an active role. Patients who preferred a collaborative role had lower scores on the Disabilities of the Arm, Shoulder and Hand questionnaire than those who preferred a fully active role (p = 0.002) or a fully passive role (p = 0.009).nnnCONCLUSIONSnThe majority of patients with carpal tunnel syndrome preferred to share surgical decision-making with the surgeon, and those who preferred a collaborative role had less severe symptoms than those who preferred a fully active or a fully passive role. A history of a surgical procedure, having a caregiver, and having private insurance were associated with a more active role. This information may assist the establishment of patient-centered consultation in patients with carpal tunnel syndrome.

Outcomes after flap reconstruction for extremity soft tissue sarcoma: a case-control study using propensity score analysis.

BACKGROUNDnBecause of the complexity of flap reconstruction and the magnitude of soft tissue defects, patients undergoing flap reconstruction for extremity soft tissue sarcoma (STS) may have increased morbidity and poor outcome compared with those undergoing primary closure. However, to examine the accurate impact of flap reconstruction on extremity STS patients, the potential bias by confounding factors should be minimized.nnnMETHODSnWe used propensity score analysis to match 37 patients who underwent flap reconstruction to 111 patients who underwent primary closure (1-3 ratio) based on patient and tumor characteristics at presentation. Treatment, functional, and oncologic outcomes were compared between the two groups.nnnRESULTSnFlap reconstruction group showed a lower Musculoskeletal Tumor Society functional score (P < 0.001), higher wound complication rate (P < 0.001), and longer hospital stay (P < 0.001); but had better local control (P = 0.015) than the primary closure group. Although failing to reach the statistical significance, the flap group tended to secure a wider surgical margin than the primary closure group (P = 0.051).nnnCONCLUSIONSnPatients who underwent flap reconstruction had increased morbidity associated with flap reconstruction, but better local control. These findings may have implications for treating extremity STS patients.

Lateral transmalleolar approach and miniscrews fixation for displaced posterolateral fragments of posterior malleolus fractures in adults: a consecutive study.

Objectives: To evaluate the lateral transmalleolar (LTM) approach for a displaced posterolateral fragments of a posterior malleolus fracture. Design: Prospective, consecutive. Setting: Level 1 trauma center. Patients: Thirty-six patients. Outcome Measures: The x-rays, evaluation of arthritic changes of the ankle joint, range of motion, and Short Musculoskeletal Function Assessment questionnaire (SMFA). Intervention: The LTM approach followed by multiple interfragmentary miniscrew-only fixation. Results: No patients experienced intraoperative or postoperative complications that required a revision operation. All fractures healed. There were no infections, and no patient required implant removal. The median range of motion showed no significant difference as compared with the uninjured side. Patients achieved a mean SMFA dysfunction index of 8.2 ± 2.4 points and a mean SMFA bother index of 3.2 ± 1.2 points. All patients performed normal daily life activities at averagely 3 (range, 2–5) months postoperatively. Conclusions: Direct visualization with the LTM approach followed by fixation with multiple miniscrews may be an alternative option for the treatment of ankle fractures with a posterolateral fragment associated with a posterior malleolar fracture. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of acute distal radioulnar joint instability associated with distal radius fractures

This study investigates the question of whether open repair of acute distal radioulnar joint instability at the time of volar plating of distal radius fractures would enable early mobilization of the wrist without the risk of distal radioulnar joint instability. We evaluated 29 patients of mean age 53u2009years with a distal radius fracture and acute distal radioulnar joint instability who underwent volar plating of the radius combined with surgical repair of the triangular fibrocartilage complex or an ulnar styloid base fracture, followed by active motion exercise of the wrist at 1u2009week after surgery. At 1u2009year after treatment, all patients had a stable distal radioulnar joint and grip strength averaged 90% of the normal side. This study demonstrates that surgical repair of the triangular fibrocartilage complex or ulnar styloid fracture followed by early mobilization did not result in distal radioulnar joint instability, and suggests that the surgical treatment of distal radioulnar joint instability may permit early mobilization of the wrist in patients who are considered suitable for rapid rehabilitation after surgery. Type of study: Therapeutic Level IV

Locked tension band wiring using ring pins for patellar fractures: a method of minimising implant migration

BackgroundA modified K-wire attached with ring (ring pin) was used to treat a displaced patellar fracture, and the ring pin was locked with tension band wiring. The purpose of this study was to evaluate the surgical outcome of this method with respect to its procedural safety.MethodsThe authors retrospectively reviewed 36 patients treated for a displaced patellar fracture and assessed bone union, fixation failure, postoperative pain, range of motion, and incidence of hardware removal. Clinical outcome was evaluated using the Böstman scoring system. The mean follow-up period was 27 (range 13–47) months.ResultsBony union was achieved in all patients. No fixation failure and pin migration were detected. Hardware was removed in three cases (8.3xa0%). Reasons for removal were pain in one case and vague discomfort in two cases. The average Böstman scores at 12xa0months postoperatively were 29.6, with 34 (94.4xa0%) patients graded as excellent. The average active flexion of the knee joint was 130.4° (range 125°–150°), with an average flexion contracture of 3° (range 0°–10°).ConclusionsThis implant could facilitate satisfactory fixation, restore the integrity of the extensor mechanism, and reduce the possibility of implant migration and implant-related discomfort.

Distally Based Adipofascial Flaps Covering Soft-tissue Defects of the Dorsal Foot and Ankle in Children

AbstractDorsal soft-tissue defects of the foot and ankle are difficult to cover adequately, particularly in children, although multiple options for reconstruction are available. This study reports the long-term clinical outcomes of the use of distally based adipofascial flaps for these injuries in children. Fourteen children, all younger than 9 years, had relatively homogenous local lesions on the dorsum of the foot and ankle or on the distal lower leg. All 14 defects were covered with distally based adipofascial flaps, either lateral supramalleolar flaps (11 cases) or sural flaps (3 cases), after thorough wound debridement. The minimum follow-up interval was 5 years. The appearance of the reconstructed feet aesthetically and functionally satisfied the patients and their parents. Some patients exhibited a growth mismatch between grafted skin and the recipient site, resulting in mild extension contracture of the metatarsophalangeal joints; however, motion of the ankle joints was excellent.

Contribution of the proximal nerve stump in end-to-side nerve repair: in a rat model.

Background The aim of this study was to evaluate the contribution of the proximal nerve stump, in end-to-side nerve repair, to functional recovery, by modifying the classic end-to-side neurorrhaphy and suturing the proximal nerve stump to a donor nerve in a rat model of a severed median nerve. Methods Three experimental groups were studied: a modified end-to-side neurorrhaphy with suturing of the proximal nerve stump (double end-to-side neurorrhaphy, Group I), a classic end-to-side neurorrhaphy (Group II) and a control group without neurorrhaphy (Group III). Twenty weeks after surgery, grasping testing, muscle contractility testing, and histological studies were performed. Results The grasping strength, muscle contraction force and nerve fiber count were significantly higher in group I than in group II, and there was no evidence of nerve recovery in group III. Conclusions The contribution from the proximal nerve stump in double end-to-side nerve repair might improve axonal sprouting from the donor nerve and help achieve a better functional recovery in an end-to-side coaptation model.

Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection

Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommendations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipelas and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets community-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline.

Distally Based Abductor Hallucis Adipomuscular Flap for Forefoot Plantar Reconstruction

AbstractSoft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based adipomuscular abductor hallucis flap for the treatment of 7 patients with soft tissue defect on the plantar forefoot after diabetic ulcer (n = 2), excision of melanoma at the medial forefoot (n = 3), and posttraumatic defects of the plantar forefoot (n = 2). The size of the defects ranged from 6 to 36 cm2. All defects were covered successfully without major complications. The distally based adipomuscular flap from the abductor hallucis muscle provides a reliable coverage for small and moderate defects of the plantar and medial forefoot. This flap is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.

Innervated Reverse Digital Artery Island Flap through Bilateral Neurorrhaphy using Direct Small Branches of the Proper Digital Nerve.

Background: The reverse digital artery flap uses the radial or ulnar surface of the proximal phalanx of the involved digit and has been applied to sensate flaps using the superficial sensory nerve branch and the dorsal branch of the proper digital nerve. As these nerve branches innervate the dorsal surface of the finger, however, hypesthesia of the dorsal side of the middle phalanx is inevitable. Methods: Thirty fingers of 25 patients who had the innervated reverse digital artery flap using direct small branches of the proper digital nerve were included in this study. The minimum follow-up duration was 24 months, and the average defect size was 2.8 cm2. Results: In all cases, the pulp defects were successfully reconstructed with this flap. The average size of the donor flap was 3.9 cm2. At 6 months after surgery, the average static two-point discrimination value was 5.9 mm, the average moving two-point discrimination value was 5.0 mm, and the average Semmes-Weinstein monofilament score was 3.79. At 1 year postoperatively, the average Cold Intolerance Severity Score was 20. The percentage total active motion was measured at 99 percent 2 years after surgery. Conclusions: Because this flap does not sacrifice the proper digital nerve or dorsal branch of the nerve, the sensibility of the dorsal aspect of the proximal and middle phalanx can be preserved. This flap is cosmetically excellent, as it uses a donor flap similar to the injured fingertip and the donor scar can be hidden by adjacent fingers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.