Endoscopic Versus Open Carpal Tunnel Release: An Umbrella Review and a Meta-analysis.

INTRODUCTION: Whether endoscopic carpal tunnel release (ECTR) versus open carpal tunnel release (OCTR) has superior outcomes remains a controversial topic. Therefore, we sought to perform an umbrella review and meta-analysis to compare ECTR and OCTR with regards to (1) postoperative functional ability, (2) operative outcomes, and (3) time to return to work. METHODS: A PubMed, Scopus, and Cochrane database search was conducted for all meta-analyses comparing ECTR and OCTR performed between 2000 and 2022 in accordance to PRISMA and Joanna Briggs Institute guidance for umbrella reviews. The primary outcomes were as follows: (1) functional ability-symptoms severity, postoperative grip strength, postoperative pinch strength, 2-point discrimination, and pain; (2) operative outcomes-operation time, total complications, nerve injury, and scar-related complication; and (3) time to return to work. Quality was assessed using the Assessment of Multiple Systematic Reviews. Pooled analysis was performed to compare several clinical outcome measures between groups, depending on the availability of data using Review Manager Version 5.2.11. RESULTS: A total of 9 meta-analyses were included, 5 were of high quality and 4 were moderate quality. For functional ability, ECTR was associated with better pinch strength after 3 months (0.70, 95% confidence interval [CI] = 0.00, 1.40, P = 0.05) and 6 months (0.77, 95% CI = 0.14, 1.40, P = 0.02, I2 = 84%). For return to work, OCTR was associated with longer return to work compared with ECTR (-10.89, 95% CI = -15.14, -6.64, P < 0.00001, I2= 83%). There were no significant differences between OCTR and ECTR in the hand function, symptom severity, grip strength, pain, operation time, and total complications. CONCLUSIONS: In an umbrella review and meta-analysis of ECTR versus OCTR, ECTR was associated with a higher pinch strength, and a shorter time to return to work. Differences in major complications, such as nerve injury, were unclear due to statistical inconsistency and bias.

Reduced Access to Acute Hand Care and Potential Role of Telemedicine in Tennessee During the COVID Pandemic.

INTRODUCTION: Previous studies have identified that there is limited, although expanding, access to acute hand care in Tennessee. Because of the rapid changes that occurred in health delivery and access during the coronavirus disease pandemic, we reassessed access to acute hand care, with particular interest in the utilization of telemedicine to assess if this increased access. METHOD: We surveyed Tennessee hospitals listed by the Tennessee Hospital Association on their management of hand trauma and availability of telemedicine programs. Census data including population demographics such as race, age, income, and county size were merged with the survey data. Descriptive analysis was performed comparing the 2021 cohort with the historic 2018 cohort and between counties that had hand care versus counties that had no hand care. RESULT: Survey response rate was 71.4% (n = 80 of 112). Telemedicine was used in 80% of the hospitals for other specialties but was not used for hand care. Overall, counties that offered hand trauma care reduced from 60% to 26% from 2018 to 2021 ( P < 0.001). This change was associated with a significant reduction of acute hand care among counties that were classified micropolitan (from 56.3% to 6.7%, P < 0.01). Percentage of hand specialists on staff and 24/7 specialists availability remained low and were similar to the availability in 2018. CONCLUSIONS: There was a decrease of acute hand care access in Tennessee during the coronavirus disease pandemic despite widespread utilization of telemedicine for other specialty consults. Expansion of telemedicine in acute hand care, targeted to micropolitan areas, may help to reduce variability in access to care.

Can Diffusion Tensor Imaging Apparent Diffusion Coefficient Diagnose Carpal Tunnel Syndrome? A Systematic Review and Meta-Analysis.

Magnetic resonance diffusion tensor imaging (DTI) can detect microstructural changes in peripheral nerves. Studies have reported that the median nerve apparent diffusion coefficient (ADC), a quantification of water molecule diffusion direction, is sensitive in diagnosing carpal tunnel syndrome (CTS). Five databases were searched for studies using ADC to investigate CTS. Apparent diffusion coefficient (measured in mm2/s) were pooled in random-effects meta-analyses. Twenty-two studies met criteria yielding 592 patients with CTS and 414 controls. Median nerve ADC were measured at the level of the distal radioulnar joint (CTS ADC: 1.11, 95% CI: 1.07-1.15, I2 = 54%; control ADC: 1.04, 95% CI: 1.01-1.07, I2 = 57%), pisiform (CTS ADC: 1.39, 95% CI: 1.37-1.42, I2 = 0%; control ADC: 1.27, 95% CI: 1.23-1.31, I2 = 59%), hamate (CTS ADC: 1.40, 95% CI: 1.36-1.43, I2 = 58%; control ADC: 1.27, 95% CI: 1.25-1.28, I2 = 47%), and as an combination of several measurements (CTS ADC: 1.40, 95% CI: 1.37-1.47, I2 = 100%; control ADC: 1.39, 95% CI: 1.24-1.53, I2 = 100%). Median nerve ADC is decreased in individuals with CTS compared to controls at the levels of the hamate and pisiform. ADC cut-offs to diagnose CTS should be established according to these anatomic levels and can be improved through additional studies that include use of a wrist coil.

The Impact of Dividing the Flexor Tendon Pulleys on Tendon Excursion and Work of Flexion in a Cadaveric Model.

PURPOSE: The A2 and A4 pulleys of the flexor tendon system have traditionally been considered critical components of efficient digital flexion. This dogma has recently been challenged. Using fresh human cadaveric hands and a model to measure force and excursion, we sought to clarify the clinical importance of releasing different pulleys. METHODS: Combinations of A1, A2, and A4 pulleys were released on the index, middle, ring, and little fingers of fresh, cadaveric hands. The excursion was measured as the distance the tendon was pulled by the motor to achieve palm touchdown. The force applied by the motor was constant (25 N); work was derived from the product of force and excursion (distance). The change in excursion and work needed to achieve palm touchdown before and after pulley release was measured. Excursion varies among digits and specimens at baseline; therefore, the percentage change from the intact state was used to compare groups. We compared A2 versus A1, A4 versus A1, A4 versus A2, A1 + A2 versus A2, and A1 + A4 versus A4. RESULTS: Isolated A2 or A4 release had the greatest individual impact on the excursion (4.77% ± 1.52% and 3.88% ± 1.93%, respectively). When A1 was released with A2 (9.90% ± 2.52%), the additional impact on the excursion was significant; however, when A1 was released with A4 (2.63% ± 2.81%), the impact was marginal. No clinically or statistically significant change in the work of flexion was detected. CONCLUSIONS: A1 release was clinically significant when added to A2 release but not when added to A4 release. Sacrifice of the A2 and A4 pulleys resulted in a statistically significant, but clinically negligible, difference in flexor tendon excursion. These data suggest that the A1 pulley should be preserved when other proximal pulley components are likely to be compromised. These data also add further support to the concept that the A2 pulley or the A4 pulley can be released as needed for optimal tenorrhaphy. CLINICAL RELEVANCE: During flexor tendon repair, the length of contiguous pulley release may have more impact on final tendon excursion than which specific pulleys are released.

Primary Sternal Osteomyelitis: A Case Report and Review.

Primary sternal osteomyelitis (PSO) remains a rare but morbid and challenging condition. Due to the limited reports of PSO in the literature, management of this disease continues to lack consensus. We present a case report highlighting how PSO remained, in our experience, refractory to medical management, and how operative intervention provided resolution, and a review of the literature.

Ulnar Nerve Compression due to Anconeus Epitrochlearis: A Case Report and Review of the Literature.

CASE: A 32-year-old right-handed surgeon presented with a history of intermittent pain at the right medial epicondyle, a mild Tinel's sign, and dysesthesia in the ulnar nerve distribution. Dynamic ultrasound demonstrated a hypertrophic anconeus epitrochlearis bilaterally, and chronic irritation of the ulnar nerve. Anterior release with myectomy of the accessory muscle was performed. No compressive symptoms were present at 1-year follow-up. CONCLUSIONS: The anconeus epitrochlearis is an often-underappreciated cause of ulnar nerve compression that can lead to significant functional impairment. Dynamic ultrasound is an excellent diagnostic modality, and anterior release with myectomy provides durable relief with minimal downtime.

An Overview of Skin Antiseptics Used in Orthopaedic Surgery Procedures.

Surgical site infections (SSIs) in orthopaedics are a common complication, with more than half a million SSIs occurring in the United States each year. SSIs can carry a notable burden for patients and physicians alike. Skin antiseptic solution plays an important role in preventing SSI. Many studies have looked at different skin antiseptic solution in preventing SSIs. Different surgical preps can decrease bacterial loads at surgical sites in varying degrees. Yet, the amount of bacterial load does not always correlate with a lower risk of infection.Chlorhexidine, for example, has been shown to cause markedly less SSIs compared with povidone-iodine prep in general surgery cases. Whereas chlorhexidine with alcohol may best work in the forefoot, iodine povacrylex with alcohol is equivalent in the spine. Conversely, joint arthroplasty SSIs were markedly decreased with a combination of preps. Because of all these differences, understanding which prep solution to use and when can be invaluable to the orthopaedic surgeons.

Late-Start Days Increase Total Operative Time in Microvascular Breast Reconstruction.

BACKGROUND: Prolonged operative time has been associated with increased postoperative complications and higher costs. Many academic centers have a designated day for didactics that cause cases to start 1 hour later. The purpose of this study is to analyze the late-start effect of microvascular breast reconstructions on operative duration. METHODS: A retrospective review was performed on all patients who underwent abdomina-based free flap breast reconstruction from 2007 to 2011 and analyzed by those who had surgery on late-start versus normal-start days. Patient demographics, average operative time, postoperative complications, and individual surgeon effects were analyzed. A Student t-test was used to compare operative times with statistical significance set at p < 0.05. A multivariate regression analysis was performed to control for potential confounders. RESULTS: A total of 272 patients underwent 461 free flap breast reconstructions. Twenty-one cases were performed on late-start days and 251 cases were performed on normal-start days. Patient demographics and complications were not statistically different between the groups. The average operative time for all reconstructions was 434.3 minutes. The average operative times were significantly longer for late-start days, 517.6 versus 427.3 minutes (p = 0.002). This was true for both unilateral and bilateral reconstructions (432.8 vs. 350.9 minutes, p = 0.05; 551.5 vs. 461.2 minutes, p = 0.007). There were no differences in perioperative complications and multivariate regression showed no statistically significant relationship of confounders to duration of surgery. CONCLUSION: Starting cases 1 hour later can increase operative times. Although outcomes were not affected, we recommend avoiding lengthy procedures on late-start days.

The Clinical Role of Intraoperative Core Temperature in Free Tissue Transfer.

BACKGROUND: Lengthy microvascular procedures carry hypothermia risk, yet limited published data evaluate the overall impact of core temperature on patient and flap morbidity. Although hypothermia may contribute to complications, warming measures are challenged by conflicting reports of intraoperative hypothermia improving anastomotic patency. METHODS: A retrospective review included all free flaps performed by plastic surgeons at an academic medical center from December 2005 to December 2010. Intraoperative core temperatures were measured by esophageal probe, and median values recorded over 5-minute intervals yielded a case mean (Tavg), maximum (Tmax), and nadir (Tmin). Outcomes included flap failure, pedicle thrombosis, recipient site infection and complications associated with patient, and flap morbidity. Analysis used Student t test, Fisher exact test, Probit, and logistic regression. RESULTS: Of 156 consecutive free tissue transfers, the median Tavg, Tmax, and Tmin were 36.5°C, 37.1°C, and 35.8°C, respectively. The flap failure rate was 7.7% (12/156) and pedicle thrombosis occurred in 9 (6%) cases. Core temperatures did not associate with overall flap failure or pedicle thrombosis but recipient site infection occurred in 21 (13%) patients who had significantly lower mean core temperatures (Tavg=36.0°C, P<0.01). Lower Tavg and Tmax significantly predicted recipient site infection (P<0.01 and P<0.05, respectively). Cut-point analysis revealed significant increases in recipient site infection risk at Tavg less than 37.0°C (P=0.026) and Tmin less than or equal to 34.5°C (P=0.020). CONCLUSIONS: Intraoperative hypothermia posed significant risk of flap infection with no benefit to anastomotic patency in free tissue transfer.

Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury.

BACKGROUND: This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population. MATERIALS AND METHODS: A retrospective review included patients admitted to a level I trauma center with HVI from 2000-2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity. RESULTS: A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036). CONCLUSIONS: Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.

Does scene physiology predict helicopter transport trauma admission?

BACKGROUND: Helicopter transport (HT) is necessary in the management of civilian trauma; however, its significant expense underscores the need to minimize overuse and inefficiency. Our objective was to determine whether on-scene physiologic criteria predict appropriate triage in HT trauma patients. METHODS: We performed a retrospective review of patients flown from the injury scene to the emergency department of a level 1 trauma center by a university HT service from January 2006 to December 2010. Demographics, mechanism of injury, scene revised trauma score (RTS), travel distance, trauma alert level, payer status, emergency department and hospital disposition, and injury severity scores were queried from the electronic medical record and Trauma Registry of the American College of Surgeons with similar data on patients admitted because of trauma by ground transport for comparison. Proper triage criteria were defined through by the American College of Surgeons Committee on Trauma. RESULTS: We identified 2522 HT patients. Of these, 1491 (59%) were properly triaged and 1031 (41%) were overtriaged. Univariate analysis revealed that the mean scene RTS was significantly higher for over- versus proper triage (7.68 ± 0.67 and 6.97 ± 1.57 respectively, P < 0.001). Neither the scene RTS nor travel distance predicted the triage criteria in a regression model (odds ratio 0.37, 95% confidence interval 0.16-0.85, and odds ratio 0.67, 95% confidence interval 0.60-0.74, respectively). Compared with ground transport, admitted HT patients had significantly more blunt trauma, lower scene RTSs, higher injury severity scores, more intensive care unit and ventilator days, a longer length of stay, and a greater travel distance and were more likely to be intubated (P < 0.001). CONCLUSIONS: The physiological criteria did not predict the triage status in HT trauma patients. Although >40% of HT patients were overtriaged, they were more severely injured and required greater institutional resources than did the ground transport patients. Overtriage by a helicopter transport program might be appropriate.

Re-evaluating the paradigm of early free flap coverage in lower extremity trauma.

Early free flap coverage in lower extremity trauma is a practice largely supported by research that may be outdated and is frequently impractical due to logistics, resuscitation efforts, and associated injuries. Our objective was to re-evaluate this paradigm to determine whether reconstructive timing impacts outcome in modern clinical practice. We reviewed 60 free flaps for traumatic lower extremity coverage from December 2005 to December 2010 by the plastic surgery service at an academic medical center. All reconstructions were >72-hours from injury, spanning from 3 days to 2.2 years. The overall failure rate was 13.3% (8/60). Statistical analysis yielded no significant associations between reconstructive timing and flap failure or morbidity, although there was a trend toward fewer failures among latest reconstructions (>91 days) compared to within 30 days (P = 0.053). These findings support that delays may be safely utilized to allow patient and wound optimization without negatively impacting outcomes in free tissue transfer.

Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction.

Patients undergoing microvascular reconstruction are often anemic from a combination of iatrogenic hemodilution and acute blood losses. No major clinical study describes the impact of preoperative anemia on free flap morbidity. The plastic surgery service at a high-volume academic center performed 156 free flaps among 147 patients from December 2005 to December 2010. One hundred thirty-two had a preoperative hemoglobin (Hb) or hematocrit (Hct), with mean values of 11.8±2.4 g/dL and 35.2%±7.0%, respectively. The overall failure rate was 9% (12/132), primarily from vascular thrombosis (6/12). Through logistic regression analysis, Hb and Hct were significant predictors of flap failure (P<0.005) and vascular thrombosis (P<0.05). Fisher exact test revealed a significant increase in failure risk at Hct level less than 30% (Hb<10 g/dL) (relative risk, 4.76, P=0.006), and probit analysis demonstrated an exposure-response relationship to decreased Hct level (P<0.005). These findings support that preoperative anemia could significantly impact free flap morbidity.