Double fascicular nerve transfer for elbow flexion and extension.

Traumatic brachial plexus injuries are life changing, often leaving affected individuals with severe functional deficits. Recent advances in nerve transfers have allowed surgeons to improve elbow flexion, shoulder abduction, and prehension of the hand in some patients. We hypothesize that in a patient who lacks both biceps and triceps function, a double fascicular transfer may be the key to restore elbow flexion and extension. In three cadaver upper limbs, we transferred the expendable motor fascicle of the ulnar nerve to the biceps branch of the musculocutaneous nerve, and the expendable motor fascicle of the median nerve to the triceps (ulnar collateral) branch of the radial nerve. We evaluated the feasibility of this double nerve transfer via a medial approach, and elucidated the anatomy. The transfers were easily performed and were tension-free throughout full range of motion at the elbow. The triceps branch of the radial nerve that we utilized has a length of approximately 4.9 cm, and is best found between 3.5 and 6 cm from the anterior axillary line. We consistently identified a relatively avascular plane in the region between 7.5 and 11 cm from the anterior axillary line, which corresponds with the recipient sites of the medial head of the triceps. The distance between the triceps branch to the median nerve was an average of 2.5 cm. Transfer of expendable motor fascicles from the ulnar and median nerves to the biceps and triceps nerve branches can be successfully and consistently performed through a medial approach in a cadaver.

Resident selection of Hand Surgery Fellowships: a survey of the 2011, 2012, and 2013 Hand Fellowship graduates.

BACKGROUND: We desired information from the recent, current, and future matched hand surgery fellows regarding their residency training, number of interviews, position matched, cost of interviewing, influences, opinions on future hand training models, and post-fellowship job information. METHODS: Institutional review board approval was obtained from our institution to submit an online survey. An email was sent to the coordinators of all US Hand Fellowships to be forwarded to their fellows with graduation years 2011, 2012, and 2013, as well as directly to the fellows if their email addresses were provided. Data on the application process, relative importance of program attributes, and opinions regarding optimal training of a hand surgeon were collected. Statistical analysis was performed with respect to the training background and graduation year of the respondent. RESULTS: The survey was completed by 137 hand surgery fellows. Seventy-one percent of the survey responders were from an orthopedic residency background, 20 % from plastic, and 7 % from general surgery. Forty-four percent of all of the respondents matched into their first choice. The type of operative cases performed by the current fellows was most often selected as very important when making their rank list. Seventy-seven percent of the respondents reflected their personal preference in fellowship model to be a 1-year fellowship program. CONCLUSIONS: The field of hand surgery is unique in that it has residents from multiple training backgrounds who all apply to one fellowship. The current fellowship model allows for diversity of training and the possibility of obtaining a second fellowship if desired.

Pulmonary resection for non-small cell lung cancer in patients with prior spinal cord injury.

BACKGROUND/OBJECTIVE: We sought to determine the clinical course of patients with spinal cord injury (SCI) who subsequently developed bronchogenic carcinoma and underwent pulmonary resection. METHODS: A nationwide retrospective study was conducted of all veterans at Department of Veterans Affairs Medical Centers for fiscal years 1993-2002 who were diagnosed with SCI, subsequently developed non-small cell lung cancer, and were surgically treated with curative intent. Inclusion criteria included American Spinal Injury Association type A injury (complete loss of neural function distal to the injury site) and traumatic etiology. Data were compiled from national Department of Veterans Affairs data sets and supplemented by operative reports, pathology reports, progress notes, and discharge summaries. RESULTS: Seven patients met the inclusion/exclusion criteria and were considered evaluable. Five (71%) had one or more comorbid conditions in addition to their SCIs. All 7 underwent pulmonary lobectomy. Postoperative complications occurred in 4 patients (57%). Two patients died postoperatively on days 29 and 499, yielding a 30-day mortality rate of 14% and an in-hospital mortality rate of 29%. CONCLUSIONS: This seems to be the only case study in the English language literature on this topic. Patients with SCI who had resectable lung cancer had a high incidence of comorbid conditions. Those who underwent curative-intent surgery had high morbidity and mortality rates. Available evidence suggests that SCI should be considered a risk factor for adverse outcomes in major surgery of all types, including operations for primary lung cancer.