Functional and Quality of Life Outcomes of a Hand Surgery Mission to Honduras.

Background: The objective of this study was to assess functional, quality of life, and satisfaction outcomes of a hand surgery short-term surgical mission (STSM) to Honduras, and determine whether patient demographics and surgery characteristics during a surgical mission correlate with outcome. Methods: A total of 63 patients who received upper extremity surgery at a week-long hand surgery STSM to Honduras in March 2013 participated in the study. A before-after study design was used. Before receiving surgery, participants completed the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and the Short Form 12 Health Survey version 2 (SF12v2). Four months postoperatively, participants completed the QuickDASH, SF12v2, and Satisfaction Survey. Results: The mean QuickDASH score significantly improved preoperatively to postoperatively. Demographics measures of age, sex, education, and income did not correlate with QuickDASH scores. Preoperative QuickDASH statistically significantly correlated with surgery type: Carpal tunnel patients had the highest scores (worst functioning). Postoperatively, mass excision and scar contracture/skin graft patients were correlated with the lowest scores. Carpal tunnel and tendon surgery patients showed greatest correlation with QuickDASH improvement. SF-12 scores revealed improvements in mental domains and declines in physical domains. Conclusions: Hand surgery performed during STSMs can result in significant functional improvement, regardless of socioeconomic status. Patients benefited from both simpler and more complex operations. Four months after surgery, general health-related quality of life measures showed improved mental indices. Measured physical indices declined despite improved QuickDASH scores. This may be due to the early general postoperative state. Further outcome research in STSMs in additional countries and specialties is required to expand our conclusions to other STSM contexts and guide best practices in STSMs.

Effects of a cyclooxygenase-2 inhibitor (rofecoxib) on bone healing.

In the study reported here, we determined the effects on bone healing of rofecoxib, one of the selective cyclooxygenase-2 (Cox-2) inhibitors that has been used for postsurgical analgesia, and compared these effects with those of nonselective ibuprofen and placebo. Each of 66 male rats received a closed, nondisplaced femoral fracture and was fed rofecoxib, ibuprofen, or placebo for 4 weeks. Results of postsacrifice evaluation showed gross nonunions in 64.7% of rofecoxib rats (P < .0001), 17.6% of ibuprofen rats (P = .007), and 0% of placebo rats. Compared with ibuprofen, rofecoxib was significantly more likely to produce nonunions (P = .007). Mean callus width was 8.9 mm (SD, 1.3 mm) for rofecoxib (P = .03), 8.9 mm (SD, 1.2 mm) for ibuprofen (P = .03), and 8.0 mm (SD, 1.3 mm) for placebo. Mean healing maturity (Goldberg classification) was 1.6 (SD, 0.7) for rofecoxib (P < .0001), 1.7 (SD, 0.8) for ibuprofen (P = .0001), and 2.7 (SD, 0.6) for placebo. Mean fracture angulation was 30.8 degrees (SD, 16.7 degrees) for rofecoxib (P = .003), 14.3 degrees (SD, 14.4 degrees) for ibuprofen (NS), and 13.4 degrees (SD, 10.3 degrees) for placebo. Mean histologic healing was 5.75 for rofecoxib (P = .02), 6.35 for ibuprofen (P = .05), and 8.25 for placebo. Cox-2 inhibitors should be used with caution when bone healing is necessary. Further study is warranted to determine whether the adverse effects occur in humans.

Combined fractures of the scaphoid and distal radius: a revised treatment rationale using percutaneous and arthroscopic techniques.

Revision of the treatment rationale for combined fractures of the scaphoid and distal radius is based on evolution of treatment goals. The trend toward early recovery of hand function requires rigid fixation of both fractures before the start ofa hand therapy program. It is clear that prolonged immobilization of the scaphoid fracture jeopardizes early motion protocols for the distal radius. The fixation of unstable distal radius fractures with volar locking plates appears to offer the most stable construct to permit early motion. Evaluation, reduction, and fixation should be accomplished without disruption of the uninjured ligaments required for stable motion or the soft tissue envelope required for healing. Minimally invasive or percutaneous techniques are the meth-ods required. The tools needed are a clear understanding of anatomy, minifluoroscopic imaging units, and small-joint arthroscopy instruments. Many investigators advocate these techniques for scaphoid and distal radius fractures. It is only natural that these techniques should be used for these combined injuries. The key to success is a three-step process: (1)percutaneous reduction of the scaphoid fracture and provisional stabilization with a guide wire placed along its central axis, (2) percutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to permit early motion, and(3) fixation of the scaphoid fracture. This final step is accomplished by dorsal percutaneous implantation of a cannulated headless compression screw along the central scaphoid axis. Dorsal percutaneous fixation of scaphoid fractures with headless compression screws and rigid fixation of unstable distal radius fractures with a volar lock-ing plate system offer the most secure fixation. This small series suggests that the goals of early recovery of hand function can be accomplished using percutaneous/miniopen techniques for fracture reduction with rigid fixation and minimal risks.

Repair of partial lesions with nerve grafting methods in the rat tibial nerve.

A partial nerve lesion and associated neuroma can be either left alone or repaired with a graft. A by-pass graft around the undisturbed lesion with end-to-side attachments might be a good alternative. This study in rats examines these strategies using walking-track analysis, muscle weights, and histology. After a tibial nerve partial lesion (3 mm) and a 21-day delay, the reexposed lesion was either not repaired, repaired with an interposed allograft, or a by-pass allograft. Functional results showed that all three groups had a steady improvement over the 8-week period, but without significant group differences. Gastrocnemius muscle ratios reflected intermediate atrophy. Axons regenerating through the lesion were more advanced than those which regenerated through the grafts and a neuroma was absent. The partial lesion can regenerate to an intermediate level without any intervention, including a by-pass graft, although the delayed repair strategy may have counteracted any potential benefits.

Assessment of recovery following a novel partial nerve lesion in a rat model.

Partial nerve lesions with a varying degree of retained function and often a painful neuroma pose a dilemma for the clinician. Surgical treatment of partial nerve lesion is perilous because of possible damage to intact axons and subsequent loss of retained function. We present a new rat model of a partial nerve lesion, allowing further study to improve treatment for this condition. A partial (50%) lesion of the tibial portion of the rat sciatic nerve was created and compared to standard crush and neurectomy control lesions. The extent of lost function and the progress of postoperative recovery following the three lesions were compared using serial walking track analyses and end-point muscle weight ratios for atrophy as outcome measures. All groups had tibial functional indices (TFI) significantly different from one another after 1 week. TFIs for the crush group returned to normal by 4 weeks, whereas the neurectomy group showed no recovery. The partial lesion group gradually improved, reaching a plateau of 44% by 7 weeks. Gastrocnemius muscle weight ratios for the partial, crush, and neurectomy lesions at 9 weeks were 0.63, 0.87, and 0.32, respectively. There was a strong correlation between the TFI and muscle weight ratios (r(2) = 0.89; P < 0.001) suggesting that these outcome measures are highly predictive of function. In conclusion, the partial lesion showed a gradual but incomplete functional recovery with a complementary degree of muscle atrophy. The model may prove useful in the evaluation of proposed treatments for partial nerve lesions and the associated painful state.