Mitchell A. Pet

Does Targeted Nerve Implantation Reduce Neuroma Pain in Amputees

BackgroundSymptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.Questions/purposesWe asked: Does TNI (1) prevent primary neuroma-related pain in the setting of acute traumatic amputation and (2) reduce established neuroma pain in upper- and lower-extremity amputees?MethodsWe retrospectively reviewed two groups of patients treated by one surgeon: (1) 12 patients who underwent primary TNI for neuroma prevention at the time of acute amputation and (2) 23 patients with established neuromas who underwent neuroma excision with secondary TNI. The primary outcome was the presence or absence of palpation-induced neuroma pain at last followup, based on a review of medical records. The patients presented here represent 71% of those who underwent primary TNI (12 of 17) and 79% of those who underwent neuroma excision with secondary TNI (23 of 29 patients) during the period in question; the others were lost to followup. Minimum followup was 8 months (mean, 22 months; range, 8–60 months) for the primary TNI group and 4 months (mean, 22 months; range, 4–72 months) for the secondary TNI group.ResultsAt last followup, 11 of 12 patients (92%) after primary TNI and 20 of 23 patients (87%) after secondary TNI were free of palpation-induced neuroma pain.ConclusionsTNI performed either primarily at the time of acute amputation or secondarily for the treatment of established symptomatic neuroma is associated with a low frequency of neuroma-related pain. By providing a distal target for regenerating axons, TNI may offer an effective strategy for the prevention and treatment of neuroma pain in amputees.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Furlow palatoplasty for velopharyngeal dysfunction: velopharyngeal changes, speech improvements, and where they intersect.

Objective We investigated how Furlow palatoplasty changes velopharyngeal morphology and speech characteristics, as well as how the anatomical and clinical results might be related. We hypothesized that Furlow palatoplasty would result in measurable velar elongation, tightening of the genu angle, and retropositioning of the levator sling and that the achievement of these modifications might be associated with clinical speech improvement. Design Retrospective analysis of preoperative and postoperative videofluoroscopic and speech data. Setting Tertiary care center. Patients/Participants A total of 29 patients with velopharyngeal insufficiency in the setting of previous cleft palate repair or submucous cleft palate. Interventions Furlow palatoplasty for treatment of velopharyngeal insufficiency. Outcome Measures Lateral videofluoroscopy and perceptual speech examination were conducted preoperatively and postoperatively in order to measure velopharyngeal dimensions and speech quality. We describe anatomical and speech changes associated with the Furlow palatoplasty and undertake an exploratory analysis of the relationship between surgical changes to the velopharynx and clinical outcomes. Results Furlow palatoplasty results in significant velar elongation, increased acuity of the genu angle, and retropositioning of the levator sling. Postoperative speech improvement was identified on the three subscales of resonance, nasal emission, and stops/plosives. Speech improvement and the absence of need for reoperation were most consistently associated with tightening of the genu angle. Conclusions Furlow palatoplasty lengthens the palate, while both tightening and retropositioning the levator sling. These changes reflect transverse recruitment of lateral velar tissues, along with transverse tightening and anterior release of the muscle fibers, respectively. Levator tightening is most consistently associated with improved speech outcomes.

Reconstruction of the traumatized thumb.

Background: The goals of thumb reconstruction include the restoration of thumb length, strength, position, stability, mobility, sensibility, and aesthetics. It is a rare event when all of these objectives can be achieved, and prioritization should be based on the goals and functional demands of the patient. Methods: In this article, the authors review the most common reconstructive strategies for all types of traumatic thumb defects. Results: Replantation is approached first as the primary option for most amputations. Nonreplantable injuries are organized using a simple classification adapted from Lister, dividing thumb amputations into four functional categories: soft-tissue deficit with acceptable length, subtotal amputation with borderline length, total amputation with preservation of the carpometacarpal joint, and total amputation with destruction of the carpometacarpal joint. Within each category, relevant microsurgical and nonmicrosurgical reconstructive techniques are discussed, with a focus on appropriate technique selection for a given patient. Evidence and outcomes data are reviewed where available, and case examples from our own experience are provided. Conclusions: Given that available options now range from simple gauze dressings to complex microsurgical reconstruction, preservation of reconstructive flexibility is essential and should be facilitated by judicious preservation of intact structures. The divergence of available reconstructive pathways underscores the importance of knowing one’s patients, understanding their motivation, and assessing their goals. Only in properly matching the right reconstruction with the right patient will a mutually satisfactory result be achieved.

Maternofetal trauma in craniosynostosis

Background: Premature cranial suture fusion may prevent neonatal skull malleability during birth, increasing the risk of unplanned cesarean delivery and neonatal birth trauma caused by cephalopelvic disproportion. We sought to determine the incidence of perinatal maternofetal complications in cases of craniosynostosis. Methods: Records of children presenting with nonsyndromic craniosynostosis to a tertiary pediatric hospital from 1996 to 2012 were reviewed retrospectively with focus on birth history and birth-related complications. Results: Six hundred eighteen births were reviewed. Rates of cesarean delivery among mothers of children with craniosynostosis [n = 201 (32.5 percent)] exceeded the overall regional rate of 24.5 percent (OR, 1.50; p < 0.0001). Unplanned cesarean delivery occurred in 19.7 percent of births, and were most associated with nulliparous mothers, breech fetal presentations, and lambdoid or multisuture synostosis patterns. Eleven neonates (1.8 percent) exhibited cranial birth trauma, including cephalohematoma and subgaleal hematoma. Neonates with sagittal or multisuture synostosis patterns were more likely to suffer birth trauma and had a higher mean head circumference than those who did not (81st versus 66th percentile, p < 0.05). Conclusions: In the setting of craniosynostosis, birth trauma is increased—for mothers in the form of increased cesarean delivery risk, and for fetuses in the form of subgaleal and subperiosteal perinatal bleeding. Difficult maternal labor may be mediated especially by multisuture or lambdoid synostosis, whereas fetal birth trauma may be mediated to a greater extent by large head size. Prenatal diagnosis of craniosynostosis could influence decision-making in the management of labor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury

High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.

Traction neurectomy for treatment of painful residual limb neuroma in lower extremity amputees

Objectives: To describe the outcomes of traction neurectomy as a surgical treatment for symptomatic neuroma of the residual lower extremity and to identify clinical and/or demographic factors associated with an increased likelihood of persistent or recurrent pain after surgery. Design: Retrospective Cohort Study. Setting: Amputee clinic at a Level I Trauma Center. Patients: Inclusion required a history of transfemoral or transtibial amputation and a history of symptomatic neuroma(s) at the residual limb treated with traction neurectomy. Twelve months of clinical follow-up or the recurrence of neuroma-type pains was required for inclusion. Thirty-eight patients (63 nerves) comprised the study group. Intervention: Traction neurectomy for treatment of symptomatic neuroma. Main Outcome Measures: The primary outcome was the presence or absence of persistent or recurrent neuroma-type pain at last follow-up. The secondary outcome was reoperation for persistent or recurrent symptomatic neuroma. Results: Sixteen of 38 patients (42%) had recurrent or persistent neuroma-type pain at a mean follow-up of 37 months (range, 11–91 months), and 8/38 (21%) have undergone subsequent surgical treatment. Among the demographic and clinical features examined, only male gender was found to be a statistically significant predictor of persistent or recurrent neuroma-type pain. Conclusions: Traction neurectomy results in a high rate of persistent or recurrent neuroma-type and that surgeons should be cautious when considering it for the treatment of symptomatic neuroma of the residual lower extremity. Furthermore, efforts to identify better surgical and nonsurgical treatments for this problem are justified. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of scaphoid fractures

Learning Objectives: After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole. Summary: The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation.

BACKGROUND After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation. METHODS At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain. RESULTS Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08). CONCLUSIONS Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.

Commentary on "A Comparison of K-Wire Versus Screw Fixation on the Outcomes of Distal Phalanx Fractures".

We read with interest the retrospective comparison of K-wire and screw fixation of distal phalanx fractures. Although the authors have convincingly shown that many distal phalanx fractures can be reliably fixed using screws, this technique was associated with a 52% incidence of symptomatic hardware necessitating operative removal. At the authors’ center, this was associated with an additional cost of

Vascularized Composite Allotransplantation of the Elbow Joint: A Cadaveric Study

729 per instance. We suspect that at many centers, this price would be much higher—especially after accounting for both direct and indirect costs—because K-wires can be easily removed from the distal phalanx in clinic, whereas screw removal requires a trip to the operating room. So is this just the triumph of technology over reason? Our concern is whether the benefits of screw fixation over K-wire fixation outweigh the cost of frequent reoperation. The authors argue that the additional cost is justified by the significantly greater range of motion achievedwith screw fixation (60 vs 45 ). However, the design of this study and data presented do not support their conclusion that the outcomes after screw fixation are superior to those after K-wire treatment. This would require a randomized design or at least a demonstration of equivalency between the treatment groups. Although it was not commented on in the text, Table 2 offers specific evidence demonstrating that the groups comparedwere in factmeaningfully different: a significantly greater proportion of the patients treated with K-wires had fracture comminution (33% vs 5%, c 1⁄4 4.8, P 1⁄4 .028). This bias toward treating comminuted fractures with K-wires could alone account for the observed