Randy Sherman

Tinel's sign and Phalen's test in carpal tunnel syndrome.

Tinels sign and Phalens test are two provocative tests used in the diagnosis of carpal tunnel syndrome. A review of the literature reveals a wide range of sensitivity for these tests. Analyzing the historical data and comparing these to the Tinels sign and Phalens test results of 100 individuals without carpal tunnel syndrome (200 wrists), we conclude that the Tinels sign is not useful in the evaluation of patients with carpal tunnel syndrome, whereas Phalens test, which has a greater sensitivity and specificity, can be of use.

Management of Chronic Deep Infection Following Rotator Cuff Repair

Background: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. Methods: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. Results: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. Conclusions: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

The Medical Mission and Modern Cultural Competency Training

BACKGROUND Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency. METHODS Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences. RESULTS One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence. CONCLUSIONS A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.

A biomechanical evaluation of a cannulated compressive screw for use in fractures of the scaphoid

The compressive force generated by a 3.5 mm ASIF cannulated cancellous screw with a 5 mm head was compared with that generated by a standard 3.5 mm ASIF screw (6 mm head), a 2.7 mm ASIF screw (5 mm head), and a Herbert screw. The screws were evaluated in the laboratory with the use of a custom-designed load washer (transducer) to the maximum compressive force generated by each screw until failure, either by thread stripping or by head migration into the specimen. Testing was done on paired cadaver scaphoids. To minimize the variability that occurs with human bone, and because of the cost and difficulty of obtaining human tissue specimens, a study was also done on polyurethane foam simulated bones. The 3.5 cannulated screw generated greater compressive forces than the Herbert screw but less compression than the 2.7 mm and 3.5 mm ASIF cortical screws. The 3.5 mm cannulated screw offers more rigid internal fixation for scaphoid fractures than the Herbert screw and gives the added advantage of placement over a guide wire.

MOC-PS(SM) CME article: treatment of flexor tendon laceration.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the preoperative assessment of the patient who presents with a flexor tendon laceration. 2. Understand the surgical options for flexor tendon lacerations based on location, type, and presence of concomitant injuries. 3. Understand the appropriate postsurgical treatment and therapy. 4. Understand the expected outcomes of operative repair and potential complications. Background: Flexor tendon laceration is one of the injuries most commonly encountered by the hand surgeon. Appropriate workup, treatment, and postsurgical therapy are essential to achieving favorable outcomes. Methods: The current literature on each aspect of acute flexor tendon injury diagnosis and repair was reviewed. Conclusions: A systematic approach to the evaluation and treatment of flexor tendon lacerations should adhere to basic principles of hand surgery with the intention of minimizing complications and offering patients the greatest chance of functional recovery. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

The role of humanitarian missions in modern surgical training.

Background: Surgical trainees have participated in international missions for decades and are now seeking out these experiences in record numbers. Resident participation in humanitarian service has been highly controversial in the academic plastic surgery community, and little evidence exists elucidating the value of these experiences. This report examines the impact of international volunteerism on surgical training. Methods: Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed 1 year after their experiences. Results: One hundred percent responded that participation in an international surgical mission had an overall positive impact on their lives, and 94.7 percent reported that they had achieved marked personal growth. Results demonstrate significant education in each of the Accreditation Council for Graduate Medical Education core competencies and insights into global health and cultural competency. One hundred percent “strongly agreed” that the Regan Fellowship was a quality educational experience, and 94.7 percent deemed the experience a valuable part of their residency training. Conclusions: Resident physicians are calling for more international health opportunities, and they should be generously supported. A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. Plastic surgery training programs can contribute mightily to global health and improved resident education by embracing and fostering the development of international humanitarian opportunities. A surgical mission experience should be widely available to plastic surgery residents.

Limb salvage for chronic tibial osteomyelitis: an outcomes study.

BACKGROUND The decision to undergo a limb salvage procedure is difficult and multifaceted. This study reviews the outcomes of patients with chronic tibial osteomyelitis who underwent limb salvage and hopes to enhance our understanding of the impact this complex procedure has on the patients ability to have a functional and fulfilling life. METHODS Forty-six patients, with at least 18 months follow-up, who had undergone limb salvage for chronic, refractory tibial osteomyelitis were evaluated. A modification of the Limb Extremity Outcomes Instrument was utilized emphasizing inquiries pertaining to quality of life. RESULTS Thirty-nine (85%) of the 46 patients were able to ambulate independently without pain. All patients younger than 45 years of age had successful outcomes. Thirty-one percent of the patients with a positive smoking history were failures, and 71% of all failures were smokers. CONCLUSION Limb salvage seems to be a satisfactory option for patients with chronic tibial osteomyelitis. A history of smoking and advanced age may have adverse affects and are relative contraindications.

Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, and ankle fusion.

Infection after fractures of the tibial plafond is a challenging problem that may even result in amputation. The current study evaluates a limb salvage protocol and the associated long term functional outcome in 6 patients (mean age 46 years) who were treated for infection after a fracture of the distal tibial metaphysis and plafond. Our limb salvage protocol included 3 stages: 1) radical debridement and stabilization of the ankle with a bridging external fixator, 2) soft tissue coverage with free muscle flaps, and 3) ankle fusion using iliac crest bone graft for filling the existing defects measuring 4.2 cm on average. At a mean followup of 5.5 years (range, 2–10.5 years), limb-salvage and eradication of infection was accomplished in all extremities. Fusion of the ankle joint was achieved in all patients, with one patient requiring a supplemental bone grafting procedure for delayed healing of the fusion site. All patients are able to walk without assistive devices and five of six patients are pain free. Limb salvage with free muscle flaps, bone grafting, and ankle fusion is a viable option for the treatment of infected tibial metaphysis and plafond fractures.

SALVAGE OF THE SEPTIC ANKLE WITH CONCOMITANT TIBIAL OSTEOMYELITIS

Five patients with concomitant distal tibia osteomyelitis and ankle sepsis with an open, draining wound were treated. All of the patients were men with an average age of 54.8 years. All of the bone infections were polymicrobial and had open draining wounds. A standardized protocol of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion was employed. All five fusions were successful on first attempt, with an average time to fusion of 3.5 months. All patients were free of infection at an average follow-up of 27 months. We believe our aggressive treatment protocol can salvage these extremities and preclude amputation in properly selected cases.

Results of Bone Grafting for Infected Tibial Nonunion

Thirty-two patients with infected tibial nonunions were treated, including 24 men and 8 women whose ages ranged from 21 to 72 years (mean, 40 years). Thirty of 32 patients had bone defects < 3 cm. Using the Cierney-Mader classification of osteomyelitis, 11 of 32 (35%) patients were Stage 4A, and 21 of 32 (65%) patients were Stage 4B. All patients had irrigation, debridement, and stabilization using an external fixation device. Twenty-seven (84%) patients had muscle transfers. The time between initial debridement and muscle transfer ranged from 3 to 24 days (mean, 4 days). Bone grafting was performed between 6 weeks and 8 months (mean, 8 weeks) after soft tissue coverage. Patients received intravenous antibiotics for 2 to 6 weeks (mean, 6 weeks). Twenty patients received anterior grafting, 10 received posterolateral grafting, and 2 received both. Followup times ranged from 12 to 49 months (mean, 28 months). Twenty-nine of the 32 (91%) patients had tibial unions between 3 to 10 months (mean, 5.5 months) after bone grafting. The 3 failed tibias united after posterolateral grafting. Infection was controlled in all 32 patients. Autogenous cancellous bone grafting using infection control principles is an effective means to treat infected tibial nonunions.