The Scratch-Collapse Test: Are Electrodiagnostic Changes Measurable?

INTRODUCTION: Carpal tunnel syndrome is commonly managed by hand and upper extremity surgeons. Though electrodiagnostics are considered the gold standard diagnosis, the scratch collapse test (SCT) was introduced to address uncertainty, despite remains controversial. To address this, we sought to identify if the SCT can correlate with EDS studies if the SCT can identify actual changes in measures of nerves. METHODS: We reviewed patients who underwent electrodiagnostic studies (EDX) and SCT for carpal tunnel syndrome (CTS). Demographic data as well as sensorimotor amplitudes, latencies, and velocities on nerve conduction and electromyography were collected. Analogous values based on SCT findings were analyzed for statistical significance. RESULTS: Three hundred fifty patients with CTS were included. Sensory and motor velocities and amplitudes were significantly lower in patients with a positive SCT. Motor values were independent of age, though younger patients had larger measured changes. Obese patients did not show any motor EDX changes with the scratch collapse test, though thinner patients did. All changes were seen in nerve conduction only. CONCLUSIONS: Carpal tunnel can be a difficult problem to diagnose as one study does not singularly determine the condition. The SCT was introduced to facilitate easier diagnosis. We demonstrate that the SCT correlates with changes on nerve conduction studies, especially in relation to decreased amplitudes and velocities, suggesting that it does identify changes in nerve with compression, specifically axonal, and myelin damage. These findings support the use of the SCT maneuver to evaluate and diagnose in appropriate patients.

Fascial Lengthening at the Time of Surgical Release for de Quervain's Tenosynovitis to Prevent Postsurgical Tendon Subluxation.

BACKGROUND: De Quervain's tenosynovitis is a relatively common, painful condition. Although commonly managed nonoperatively, some patients have recalcitrant disease, necessitating surgical release. Traditional surgical release for de Quervain's tenosynovitis with simple retinacular release can leave patients susceptible to first dorsal extensor compartment tendon subluxation. We present a stair-step flap technique that releases the first dorsal compartment while simultaneously preventing postoperative tendon subluxation via fascial lengthening. METHODS: All patients over the past decade who underwent surgical release with this technique were collected. Preoperative characteristics, surgical details, and postoperative outcomes were reviewed and aggregated as summary statistics. RESULTS: A total of 101 patients were found. Of these, 35 patients had isolated first dorsal compartment release. Tourniquet time for the total group was 1 hour and that for the isolated first dorsal compartment release subgroup was 20 minutes. The average follow-up was 590 days for the total group and only 440 days for the isolated first dorsal compartment release subgroup. No patients who underwent our novel technique experienced subluxation of the tendons postoperatively. One patient required oral antibiotics for a superficial cellulitis, and 1 patient had recurrent symptoms due to excessive scarring that resolved with scar massage and steroid injection. No patient required repeat operations. CONCLUSION: Our study demonstrates that first dorsal compartment release with a stair-step incision allows for closure of the compartment with a very loose sheath without subluxation and simultaneously provides satisfactory decompression. This procedure is safe and efficacious and can be considered a useful modification to traditional retinacular release alone. LEVEL OF EVIDENCE: Level III.

At What Time Interval After a Sharp Nerve Laceration Is Primary Nerve Repair No Longer Possible?

PURPOSE: The timeframe after a sharp nerve injury when nerve grafting becomes required remains unclear. A retrospective analysis was performed to determine the timeframe when primary repair of a sharp nerve laceration can no longer be performed and grafting becomes necessary. METHODS: All sharp nerve injuries in three regions of the hands and upper extremity-major nerves, common digital nerves, and proper digital nerves-treated between 2016 and 2021 were reviewed. Time from injury to repair, need for nerve grafting, length of graft, age, and associated injuries were collected and analyzed. RESULTS: A total of 313 nerve lacerations were included. Predictors of the need for grafting included time from injury to repair and level of injury. The odds ratio of time from injury in predicting the need for grafting was 1.04 for proper digital nerves, 1.05 for common digital nerves, and 1.18 for major nerves. Age and other injuries were not associated with increased rates of grafting. Only level of injury was associated with length of graft needed. CONCLUSIONS: Patients with sharp major nerve injuries required grafting more frequently after several days from injury, whereas primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury. This suggests that the window for primary neurorrhaphy may be as short as two days after injury for major nerve injuries, much shorter than for common and proper digital nerve injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Wassel VI Thumb Duplication With Triphalangeal Radial and Ulnar Thumbs: Anatomy and Surgical Reconstruction.

A 6-year-old otherwise healthy girl presented with a Wassel VI duplication of the left thumb metacarpal and triphalangeal radial and ulnar thumbs. The patient underwent successful thumb reconstruction by transposition of the distal ulnar thumb onto the radial thumb metacarpal. To the best of our knowledge, this case report represents the first published anatomical dissection and surgical reconstruction of a Wassel VI duplication with triphalangeal radial and ulnar thumbs.

Assessing the Effect of Time from Injection of Collagenase to Manipulation on Success Rates in Dupuytren Disease.

PURPOSE: Dupuytren disease can be managed with an injection of collagenase Clostridium histolyticum enzyme followed by manual manipulation. Although the recommended time from injection to manipulation is 24-72 hours, patient and physician schedules may not accommodate this time frame. Therefore, we sought to study the impact of time from injection to manipulation on outcomes and complications of collagenase injection. METHODS: We performed a review of 309 patients who underwent an injection of collagenase Clostridium histolyticum for Dupuytren disease with manipulation at two, five, or seven days after injection. We compared preinjection and postinjection contracture angles as well as frequency of skin tears and tendon ruptures. RESULTS: Of the 309 patients, 207 underwent manipulation at two days, 32 at five days, and 70 at seven days. Patients had similar preinjection contracture angles. All patients demonstrated improvement in contracture after manipulation. Rates of skin tears and tendon ruptures were similar in all three groups. Significant predictors of complications included number of cords injected and history of previous collagenase injection, but not history of previous Dupuytren diagnosis. CONCLUSIONS: Although collagenase injection for Dupuytren disease is typically performed with plans for manipulation at 24-72 hours, postinjection manipulation could be performed as late as seven days without adversely affecting the frequency of skin and tendon complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Role of Antibiotic Prophylaxis in Primary and Secondary Implant-Based Breast Augmentation: A Systematic Review and Meta-Analysis.

BACKGROUND: The administration of antibiotic prophylaxis for implant-based breast augmentation (IBBA) is commonplace among many plastic surgeons. However, the current literature lacks evidence-based recommendations to support this practice. Although few studies have demonstrated a reduction in surgical site infection (SSI) and capsular contracture (CC) with antibiotics, these studies were underpowered and poorly designed. The aim of this study was to provide an updated comprehensive analysis of the literature to revisit the benefit of antibiotic prophylaxis. METHODS: A comprehensive literature search of PubMed, Embase, Web of Science, and Cochrane was performed from January 1989 to January 2022. Observational studies and randomized controlled trials (RCTs) involving primary and secondary IBBA and use of antibiotic prophylaxis were included. Primary outcomes included SSI and CC. Study quality and risk of bias were evaluated using standardized tools. A meta-analysis was performed for eligible studies. Trial Sequential Analysis was used to assess the need for future RCTs. RESULTS: A total of 5 studies (3 observational and 2 RCTs) with 2383 patients were included in this study. Rates of SSI ranged from 0% to 2.3%, whereas CC ranged from 0% to 53%. Antibiotic prophylaxis showed no benefit for both SSI (odds ratio, 1.77; 95% confidence interval, 0.76-4.13) and CC (odds ratio, 0.46; 95% confidence interval, 0.00-45.72). Trial Sequential Analysis demonstrated that further high-quality RCTs are needed. CONCLUSIONS: Antibiotic prophylaxis for IBBA failed to demonstrate improvements in SSI and CC in this comprehensive review. Current evidence was shown to be of low quality because of heterogeneity and high risk for bias. Further high-quality multicentered RCTs are warranted to fully evaluate the role of antibiotic prophylaxis for IBBA.

The Scratch-Collapse Test: A Systematic Review and Statistical Analysis.

BACKGROUND: The scratch-collapse test (SCT) is a provocative maneuver used to diagnose compressive neuropathies. Despite multiple studies supporting its use, the SCT remains a controversial point in the literature in regard to its exact clinical application. We performed a systematic review and statistical analysis to provide statistical data on SCT outcomes and elucidate its role in diagnosing compressive conditions. METHODS: We performed a systematic review of the literature according to Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. We extracted data of patients with outcomes on the SCT (yes/no) and on an accepted gold standard examination (electrodiagnostic studies). These data were analyzed using a statistical software program to generate the sensitivity and specificity values of the pooled data, as well as kappa agreement statistics. RESULTS: For patients with carpal tunnel, cubital tunnel, peroneal, and pronator compressive neuropathies, the overall sensitivity of the SCT was 38%, and the specificity was 94%, with the kappa statistic approximately 0.4. Sensitivity and specificity values were higher for cubital tunnel syndrome and peroneal compression syndrome but lower for carpal tunnel syndrome. Pronator syndrome was also examined, but the data were inadequate for analysis. CONCLUSIONS: The SCT is a useful adjunct in the armament of diagnostic tools for the hand surgeon. Given its low sensitivity and high specificity, SCT should be used as a confirmatory test, rather than as a diagnostic screening test. More analyses are needed to identify subtler applications.

Proximal Plate Migration After Internal Fixation of a Pediatric Distal Radius Fracture.

We present a case of a 26-year-old right-hand-dominant male stage manager who underwent open reduction internal fixation of right open both-bone forearm fractures at the age of 13. The patient presented 13 years and 8 months later with proximal hardware migration, soft tissue erosion, and subsequent hardware exposure. The patient underwent hardware removal with resolution of pain and improvement in range of motion. To the best of our knowledge, this complication has not been published before.

Tendon Transfers, Nerve Grafts, and Nerve Transfers for Isolated Radial Nerve Palsy: A Systematic Review and Analysis.

INTRODUCTION: Isolated radial nerve palsy is a debilitating injury that may potentially be reconstructed with either tendon transfers, nerve grafts, or nerve transfers. Currently, there is no consensus on the optimal technique for reconstruction. We performed a systematic review and analysis to determine which surgical intervention provides the best clinical outcomes. METHODS: A systematic review was conducted according to PRISMA guidelines. Twenty-nine papers met inclusion criteria. Grading scales of function and strength were converted into a tripartite scoring system to compare outcomes between techniques. χ2 analyses were performed with a P value < .05. RESULTS: Seven hundred fifty-four patients were analyzed. Tendon transfers resulted in the highest percentage of good outcomes (82%) and the lowest percentage of poor outcomes (9%). Tendon transfers were superior to nerve grafts and nerve transfers for restoration of wrist extension. Nerve transfers for wrist extension were superior to nerve transfers for finger extension. Nerve grafts and nerve transfers had equivalent rates of good and poor clinical outcomes. CONCLUSIONS: This study analyzed reported outcomes of tendon transfers, nerve grafts, and nerve transfers for reconstruction of isolated radial nerve palsy. On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. Tendon transfers should be considered first-line reconstruction for isolated radial nerve palsy as nerve-based reconstruction is less predictable and reproducible.

Persistent Median Artery Thrombosis Causing a Bifid Median Nerve and Carpal Tunnel Syndrome: A Case Report.

CASE: In this report, we describe a 41-year-old woman with symptoms concerning for acute carpal tunnel syndrome. Operative exploration resulted in resection of an aneurysmal, thrombosed, persistent median artery seen on preoperative imaging and full recovery by the patient. CONCLUSION: A persistent median artery is an uncommon congenital hand condition resulting from the failure of the median artery to regress, which can then travel through the carpal tunnel and be associated with a bifid median nerve, irritation of the nerve, and need for surgical exploration if it thromboses, which is rare. This should be considered in patients with acute median nerve compression, without other etiologies.

Virtual Surgical Planning for Mandibular Reconstruction With the Fibula Free Flap: A Systematic Review and Meta-analysis.

BACKGROUND: The fibula free flap (FFF) remains the criterion standard for complex mandibular reconstruction. Surgeons have incorporated virtual surgical planning (VSP) into the reconstructive algorithm with the assertion that VSP increases operative efficiency and may improve clinical outcomes. To date, no large-scale studies have analyzed these claims. This study examines the literature and tests the hypothesis that VSP improves operative efficiency, clinical outcomes, and accuracy when compared with traditional techniques. METHODS: A systematic review was performed to identify articles utilizing VSP and traditional techniques for FFF-based mandibular reconstruction. Two reviewers independently assessed all articles for methodological quality using a validated instrument (weighted Cohen κ for interrater reliability = 0.70). Outcomes included operative time, length of stay, complications, and accuracy. Meta-analytic comparisons were performed using data from comparative studies using a random-effects model and differences of means analysis for outcomes measured on identical scales. RESULTS: One hundred thirty-one articles were identified, and 25 met the inclusion criteria: 12 were VSP only, whereas 13 were comparative. There were 241 VSP patients and 214 traditional patients available for meta-analysis. Patients undergoing reconstruction with VSP had a significant reduction in operative time by 44.64 minutes (95% confidence interval [CI], -74.69 to -14.58 minutes; P < 0.01) and demonstrated a mean trend toward shorter hospital admission (mean difference, -1.24 days; 95% CI, -4.00 to 1.52 days; P = 0.38). There was no statistical difference between cohorts for major (odds ratio, 1.03; 95% CI, 0.46-2.31; P = 0.95) or minor complications (odds ratio, 0.97; 95% CI, 0.54-1.71; P = 0.90). Insufficient data were available for cost analysis and accuracy. CONCLUSIONS: Virtual surgical planning-guided mandibular reconstruction with FFF is associated with significantly decreased operative time and a mean trend toward shorter hospital admission. While multiple studies reported a high degree of accuracy, no standard measurement was available for meta-analysis.

Intraoperative Image-Guided Navigation in Craniofacial Surgery: Review and Grading of the Current Literature.

INTRODUCTION: Image-guided navigation has existed for nearly 3 decades, but its adoption to craniofacial surgery has been slow. A systematic review of the literature was performed to assess the current status of navigation in craniofacial surgery. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) systematic review of the Medline and Web of Science databases was performed using a series of search terms related to Image-Guided Navigation and Craniofacial Surgery. Titles were then filtered for relevance and abstracts were reviewed for content. Single case reports were excluded as were animal, cadaver, and virtual data. Studies were categorized based on the type of study performed and graded using the Jadad scale and the Newcastle-Ottawa scales, when appropriate. RESULTS: A total of 2030 titles were returned by our search criteria. Of these, 518 abstracts were reviewed, 208 full papers were evaluated, and 104 manuscripts were ultimately included in the study. A single randomized controlled trial was identified (Jadad score 3), and 12 studies were identified as being case control or case cohort studies (Average Newcastle-Ottawa score 6.8) The most common application of intraoperative surgical navigation cited was orbital surgery (n = 36), followed by maxillary surgery (n = 19). Higher quality studies more commonly pertained to the orbit (6/13), and consistently show improved results. CONCLUSION: Image guided surgical navigation improves outcomes in orbital reconstruction. Although image guided navigation has promise in many aspects of craniofacial surgery, current literature is lacking and future studies addressing this paucity of data are needed before universal adoption can be recommended.

Thyroid Dysfunction in Children Exposed to Iodinated Contrast Media.

CONTEXT: Iodinated contrast media (ICM) is routinely used in imaging studies and contains several 100-fold the recommended daily allowance of iodine. OBJECTIVE: To determine whether children exposed to ICM have a higher risk of iodine-induced thyroid dysfunction. DESIGN: This was a single-institution case-control study, examining patients with incident thyroid dysfunction aged less than 18 years from 2001 to 2015. Cases were matched 1:1 to euthyroid controls by age, sex, and race. SETTING: This was a single-institution case-control study occurring at tertiary care center. PARTICIPANTS: Cases were defined as those with thyroid dysfunction (by International Classification of Diseases, Ninth Revision diagnosis codes and/or 2 consecutive abnormal serum TSH values <6 mo apart). We analyzed 870 cases matched to 870 controls (64% female, 51% White). MAIN OUTCOMES MEASURES: Using conditional logistic regression, the association between ICM exposure and the primary outcome, thyroid dysfunction, occurring within 2 years of exposure was assessed. RESULTS: Sixty-nine patients received ICM, including 53 (6%) among cases and 16 (2%) among controls. The risk of incident hypothyroidism was significantly higher after ICM exposure (odds ratio 2.60; 95% confidence interval, 1.43-4.72; P < .01). The median interval between exposure and onset of hypothyroidism was 10.8 months (interquartile range, 6.6-17.9). In hypothyroid cases, the median serum TSH concentration was 6.5 mIU/L (interquartile range, 5.8-9.6). CONCLUSIONS: ICM exposure increases the risk of incident hypothyroidism in pediatric patients. Children receiving ICM should be monitored for iodine-induced thyroid dysfunction, particularly during the first year after exposure.

Characterization of PD-L1 Expression and Associated T-cell Infiltrates in Metastatic Melanoma Samples from Variable Anatomic Sites.

PURPOSE: Programmed death ligand-1 (PD-L1) tumor expression represents a mechanism of immune escape for melanoma cells. Drugs blocking PD-L1 or its receptor have shown unprecedented activity in melanoma, and our purpose was to characterize tumor PD-L1 expression and associated T-cell infiltration in metastatic melanomas. EXPERIMENTAL DESIGN: We used a tissue microarray (TMA) consisting of two cores from 95 metastatic melanomas characterized for clinical stage, outcome, and anatomic site of disease. We assessed PD-L1 expression and tumor-infiltrating lymphocyte (TIL) content (total T cells and CD4/CD8 subsets) by quantitative immunofluorescence. RESULTS: High PD-L1 expression was associated with improved survival (P = 0.02) and higher T-cell content (P = 0.0005). Higher T-cell content (total and CD8 cells) was independently associated with improved overall survival; PD-L1 expression was not independently prognostic. High TIL content in extracerebral metastases was associated with increased time to developing brain metastases (P = 0.03). Cerebral and dermal metastases had slightly lower PD-L1 expression than other sites, not statistically significant. Cerebral metastases had less T cells (P = 0.01). CONCLUSIONS: T-cell-infiltrated melanomas, particularly those with high CD8 T-cell content, are more likely to be associated with PD-L1 expression in tumor cells, an improved prognosis, and increased time to development of brain metastases. Studies of T-cell content and subsets should be incorporated into trials of PD-1/PD-L1 inhibitors to determine their predictive value. Furthermore, additional studies of anatomic sites with less PD-L1 expression and T-cell infiltrate are needed to determine if discordant responses to PD-1/PD-L1 inhibitors are seen at those sites.

PLEKHA5 as a Biomarker and Potential Mediator of Melanoma Brain Metastasis.

PURPOSE: Approximately 40% of patients with metastatic melanoma develop brain metastases. Our purpose was to identify genes aberrantly expressed in melanoma that might be associated with propensity for brain homing. EXPERIMENTAL DESIGN: We studied gene expression profiles in a cell line model of brain metastasis (cerebrotropic A375Br cells vs. parental A375P cells) and compared them with profiles of patients who developed early brain metastases and who did not. A tissue microarray containing 169 metastatic melanoma cases with variable time to brain metastasis was constructed to further study marker expression by quantitative immunofluorescence. An in vitro model of the blood brain barrier (BBB) was generated to evaluate potential mediators of brain metastases. RESULTS: PLEKHA5 was differentially expressed in both the A375 cell line model and patient samples subjected to gene expression profiling. At the protein level, by quantitative immunofluorescence, PLEKHA5 was associated with decreased brain metastasis-free survival. PLEKHA5 overexpression was not associated with other metastatic sites. Knockdown of PLEKHA5 decreases the viability of A375Br cells, inhibits BBB transmigration and invasion in vitro. Similar results were found with YUMUL cells, cultured from a patient with overwhelming brain metastases. PLEKHA5 knockdown did not affect the viability of A375P cells. CONCLUSIONS: PLEKHA5 expression in melanoma tumors was associated with early development of brain metastases. Inhibition of PLEKHA5 might decrease passage across the BBB and decrease proliferation and survival of melanoma cells both in the brain and in extracerebral sites.

PAX-8 expression in renal tumours and distant sites: a useful marker of primary and metastatic renal cell carcinoma?

AIMS: Immunohistochemical stains have greatly improved the diagnostic accuracy of renal cell carcinoma (RCC) for primary and distant tumours. We evaluate a marker that has recently been incorporated in clinical practice, PAX-8, in primary and metastatic RCCs. METHODS: Two distinct tissue microarrays were used, one consisting of over 334 renal tumours, 294 with adjacent normal kidney and the other with 40 matched nephrectomy and metastatic sites of RCC. PAX-8 expression was assessed by a method of quantitative immunofluorescence. RESULTS: PAX-8 was positive in 96% (146/152) of normal renal tissue and 83% (227/272) of renal tumours. PAX-8 staining was positive in clear cell, papillary and chromophobe tumours in 80% (165/207), 95% (39/41) and 100% (6/6) of samples, respectively. Overall, intensity of PAX-8 expression was significantly higher in RCC metastatic sites than in the primary site (p=0.0047), however, in matched sites there was no statistically significant difference in the proportion of positive versus negative specimens (p=0.274). CONCLUSIONS: As the role of molecular markers expands in the diagnostic algorithm, this study confirms that PAX-8 expression is a useful diagnostic marker for RCC. PAX-8 expression was found in the primary tumour and distant sites. Compared with normal tissue and other histological types, clear cell RCC has lower PAX-8 expression and is less frequently positive, therefore, the lack of expression does not exclude a tumour of renal origin.