Axillary Brachial Plexus Block Compared with Other Regional Anesthesia Techniques in Distal Upper Limb Surgery: A Systematic Review and Meta-Analysis.

Background: Several regional anesthesia (RA) techniques have been described for distal upper limb surgery. However, the best approach in terms of RA block success rate and safety is not well recognized. Objective: To assess and compare the surgical anesthesia and efficacy of axillary brachial plexus block with other RA techniques for hand and wrist surgery. The attainment of adequate surgical anesthesia 30 min after block placement was considered a primary outcome measure. Additionally, successful block outcomes were required without the use of supplemental local anesthetic injection, systemic opioid analgesia, or the need to convert to general anesthesia. Methods: We performed a systematic search in the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CENTRAL. RCTs comparing axillary blocks with other brachial plexus block techniques, distal peripheral forearm nerve block, intravenous RA, and the wide-awake local anesthesia no tourniquet (WALANT) technique were included. Results: In total, 3070 records were reviewed, of which 28 met the inclusion criteria. The meta-analysis of adequate surgical anesthesia showed no significant difference between ultrasound-guided axillary block and supraclavicular block (RR: 0.94 [0.89, 1.00]; p = 0.06; I2 = 60.00%), but a statistically significant difference between ultrasound-guided axillary block and infraclavicular block (RR: 0.92 [0.88, 0.97]; p < 0.01; I2 = 53.00%). Ultrasound-guided infraclavicular blocks were performed faster than ultrasound-guided axillary blocks (SMD: 0.74 [0.30, 1.17]; p < 0.001; I2 = 85.00%). No differences in performance time between ultrasound-guided axillary and supraclavicular blocks were demonstrated. Additionally, adequate surgical anesthesia onset time was not significantly different between ultrasound-guided block approaches: ultrasound-guided axillary blocks versus ultrasound-guided supraclavicular blocks (SMD: 0.52 [-0.14, 1.17]; p = 0.12; I2 = 86.00%); ultrasound-guided axillary blocks versus ultrasound-guided infraclavicular blocks (SMD: 0.21 [-0.49, 0.91]; p = 0.55; I2 = 92.00%). Conclusions: The RA choice should be individualized depending on the patient, procedure, and operator-specific parameters. Compared to ultrasound-guided supraclavicular and infraclavicular block, ultrasound-guided axillary block may be preferred for patients with significant concerns of block-related side effects/complications. High heterogeneity between studies shows the need for more robust RCTs.

A Giant, Neglected Leiomyosarcoma on the Left Shoulder.

This paper examines the impact of delayed diagnosis and treatment on the prognosis of patients with leiomyosarcomas (LMS). We present a case study highlighting the consequences of neglected LMS, focusing on vascular involvement and metastatic potential. Our findings underscore the importance of early detection and intervention in improving patient outcomes. Additionally, we discuss the challenges associated with diagnosing rare skin LMS and the implications of limited access to medical screening. Through a comprehensive analysis of the literature, we elucidate the critical role of routine surveillance in detecting these malignancies at an earlier stage, thus facilitating timely intervention and potentially curative treatment. This study underscores the urgency of raising awareness among both healthcare providers and the general population about the significance of early detection and prompt management in mitigating the adverse outcomes associated with neglected LMS.

Approaching the Humerus, Elbow, and Proximal Forearm Using the Trimano Arm Holder.

Upper limb surgeons frequently encounter complex cases involving the proximal humerus, elbow joint, and proximal forearm, both in trauma and elective practice. Given the diverse pathology in these areas, various surgical approaches have been described, each with its advantages, limitations, and specific patient positioning requirements. We describe an operative technique that modifies the use of an existing, commercially available, dynamic pneumatic limb positioner, the TRIMANO FORTIS® (Arthrex, Maquet GmbH), for open and arthroscopic procedures of the elbow, proximal forearm, midshaft, and distal humerus. This technique offers simplicity, reproducibility, and enhanced surgical efficiency.

A comparative study between single injection (corner pocket approach) and double injection costoclavicular block: A randomized parallel arm, non-inferiority trial.

BACKGROUND: Previous studies have shown that ultrasound guided costoclavicular block may require a double shot to provide adequate, rapid sensory and motor blockade. In this trial, we hypothesized that if the corner pocket approach (between axillary artery and median cord) is used instead of the central approach (at the midpoint of the 3 cords) when performing single-shot costoclavicular block, the onset of blockade would be non-inferior to the double-shot technique. METHOD: Ninety patients undergoing upper limb surgery were randomized to 2 groups for ultrasound-guided costoclavicular block (CCB) at a tertiary hospital. One group received ultrasound guided single-shot CCB using the corner pocket approach and other received ultrasound guided double-shot - the first shot at the centre of the 3 cords and the second between the axillary artery and the median cord. An observer blinded to group assignment recorded blockade onset time (defined as the time required to achieve a minimal sensorimotor composite score of 14 out of 16 points). RESULTS: Of the 101 patients assessed for eligibility, 90 were recruited over period of 1 year (February 2022 to January 2023), with 45 in each group. Onset time was 22.1 ±â€¯3.1 min in the single-shot group and 22.4 ±â€¯2.9 min in the double-shot group. This difference was insignificant (P = .3). CONCLUSION: Time to onset of blockade and full anaesthesia are similar in single-shot corner pocket CCB vs double-shot CCB. Further studies are required to determine the minimum effective volume of local anaesthetic required for the described technique.

Artificial Intelligence Image Recognition System for Preventing Wrong-Site Upper Limb Surgery.

Our image recognition system employs a deep learning model to differentiate between the left and right upper limbs in images, allowing doctors to determine the correct surgical position. From the experimental results, it was found that the precision rate and the recall rate of the intelligent image recognition system for preventing wrong-site upper limb surgery proposed in this paper could reach 98% and 93%, respectively. The results proved that our Artificial Intelligence Image Recognition System (AIIRS) could indeed assist orthopedic surgeons in preventing the occurrence of wrong-site left and right upper limb surgery. At the same time, in future, we will apply for an IRB based on our prototype experimental results and we will conduct the second phase of human trials. The results of this research paper are of great benefit and research value to upper limb orthopedic surgery.

A Comparison Between Ultrasound-Guided Supraclavicular and Infraclavicular Approaches to Brachial Plexus Block for Elective Upper Limb Surgery.

BACKGROUND: Regional anaesthesia offers the anaesthesiologist, the surgeon, as well as the patient advantages over general anaesthesia such as being conscious through the surgery, avoiding multiple drugs, better haemodynamic stability, excellent postoperative analgesia, and faster per oral consumption post surgery. Compared with the axillary approach, the brachial plexus block at the level of the clavicle can anaesthetize all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve. AIM: The aim of the study was to compare the effect of both supraclavicular and infraclavicular brachial plexus blocks in terms of time taken for onset, performance, and block success. MATERIALS AND METHODS: Sixty patients undergoing below-elbow upper limb surgeries were randomized into two groups: (i) supraclavicular (Group S) and (ii) infraclavicular (Group I). All patients received 30ml 0f 0.5% bupivacaine as the local anesthetic of choice. The block performance time, time taken for onset of sensory and motor blockade, total duration of block, and hemodynamic parameters were observed. The block performance times and the onset of the sensory blockade were the primary outcomes while the duration of the block and hemodynamic parameters were secondary outcomes. Two two-tailed independent sample t-tests will be used to compare the variables. RESULTS: We observed that the block performance time for the infraclavicular block (mean 14.833 minutes) was longer than the supraclavicular block (mean 10.37 minutes). This was statistically significant with p <0.001. In terms of onset of sensory blockade, the infraclavicular group (13.667 minutes) had a quicker onset compared to the supraclavicular group (17.333 minutes). This was also statistically significant with p <0.001. The mean total duration of sensory and motor blockade was similar in both groups (p-value of 0.341 and 0.791 respectively) and there was no statistical difference. There was no hemodynamic instability or complications in our study. CONCLUSION: Ultrasound-guided infraclavicular block is a relatively safer technique when compared to the supraclavicular technique with faster onset. The time taken for administering the infraclavicular block can be reduced by repeated exposure to the technique.

Functional recovery of wrist surgery with regional versus general anesthesia: a prospective observational study.

PURPOSE: Regional anesthesia may favour postoperative rehabilitation by inhibiting peripheral sensitization and secondary hyperalgesia. The literature on this subject is limited. In the present FUNCTION study, we sought to compare the functional recovery post orthopedic wrist surgery with regional versus general anesthesia. METHODS: We conducted a single-centre prospective observational cohort study in adult patients with a distal radial fracture. Functional recovery was assessed with validated psychometrics questionnaires (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Patient-Rated Wrist Evaluation [PRWE]), range of motion, and grip strength. We used a linear mixed regression model to assess the impact of the anesthesia technique on functional recovery. Postoperative pain and patient satisfaction were evaluated using a visual analog scale. RESULTS: We recruited 76 patients. At 12 weeks post surgery, there was no difference between the type of anesthesia and functional recovery with the QuickDASH (higher scores worse; regional anesthesia [RA], 22.7 vs general anesthesia [GA], 19.3; adjusted mean difference [aMD], -0.3; 95% confidence interval [CI], -9.6 to 9.0; P = 0.9) and PRWE (higher scores worse; RA group, 21.0 vs GA group, 20.5; aMD, -3.3; 95% CI, -12.1 to 5.6; P = 0.93) questionnaires. Range of motion, satisfaction, and postoperative pain were similar between groups. Right-hand grip strength was higher in the GA group. CONCLUSION: Regional anesthesia was not associated with improved functional recovery compared with general anesthesia. The dominance of the operated limb was a confusion factor in all evaluation modalities. Further research taking into account the dominance of the hand is necessary to establish the effects of regional anesthesia on functional recovery. STUDY REGISTRATION: ClinicalTrials.gov (NCT04541745); registered 9 September 2020.

RéSUMé: OBJECTIF: L'anesthésie régionale pourrait favoriser la rééducation postopératoire en inhibant la sensibilisation périphérique et l'hyperalgésie secondaire. La littérature à ce sujet est limitée. Dans la présente étude nommée FUNCTION, nous avons cherché à comparer la récupération fonctionnelle après une chirurgie orthopédique du poignet réalisée sous anesthésie régionale vs sous anesthésie générale. MéTHODE: Nous avons réalisé une étude de cohorte observationnelle prospective monocentrique auprès de patient·es adultes présentant une fracture radiale distale. La récupération fonctionnelle a été évaluée à l'aide de questionnaires psychométriques validés (questionnaires QuickDASH [Quick Disabilities of Arm, Shoulder and Hand] et PRWE [Patient-Rated Wrist Evaluation]), de l'amplitude des mouvements et de la force de préhension. Nous avons utilisé un modèle de régression linéaire mixte pour évaluer l'impact de la technique d'anesthésie sur la récupération fonctionnelle. La douleur postopératoire et la satisfaction des patient·es ont été évaluées à l'aide d'une échelle visuelle analogique. RéSULTATS: Nous avons recruté 76 personnes. Douze semaines après la chirurgie, il n'y avait aucune différence entre le type d'anesthésie et la récupération fonctionnelle selon le questionnaire QuickDASH (scores plus élevés les pires; anesthésie régionale [AR], 22,7 vs anesthésie générale [AG], 19,3; différence moyenne ajustée [DMa], −0,3; intervalle de confiance [IC] à 95 %, −9,6 à 9,0; P = 0,9) et PRWE (scores plus élevés les pires; groupe AR, 21,0 vs groupe AG, 20,5; DMa, −3,3; IC 95 %, −12,1 à 5,6; P = 0,93). L'amplitude des mouvements, la satisfaction et la douleur postopératoire étaient similaires entre les groupes. La force de préhension de la main droite était plus élevée dans le groupe AG. CONCLUSION: L'anesthésie régionale n'a pas été associée à une amélioration de la récupération fonctionnelle par rapport à l'anesthésie générale. La prédominance du membre opéré était un facteur de confusion dans toutes les modalités d'évaluation. D'autres recherches tenant compte du côté dominant au niveau des mains sont nécessaires pour déterminer les effets de l'anesthésie régionale sur la récupération fonctionnelle. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT04541745); enregistrée le 9 septembre 2020.

Optimal concentration of ropivacaine for brachial plexus blocks in adult patients undergoing upper limb surgeries: a systematic review and meta-analysis.

Aim of the Study: Brachial plexus block (BPB) is widely used for patients undergoing upper limb surgeries. Ropivacaine is the most commonly used local anesthetic for BPB. This study aimed to identify the optimal ropivacaine concentration for BPB in adult patients undergoing upper limb surgeries. Materials and Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched to identify randomized controlled trials (RCTs) that compared the effects of different concentrations of ropivacaine for BPB in adult patients undergoing upper limb surgeries. The primary outcomes were the onset time of sensory and motor block. RevMan 5.4 software was used for analysis. The GRADE approach was used to assess evidence quality. Results: Nine studies involving 504 patients were included. Compared to 0.5% ropivacaine, 0.75% ropivacaine shortened the onset time of sensory (WMD, -2.54; 95% CI; -4.84 to -0.24; <0.0001, moderate quality of evidence) and motor blockade (WMD, -2.46; 95% CI, -4.26 to -0.66; p = 0.01; moderate quality of evidence). However, 0.5% and 0.75% ropivacaine provided similar duration time of sensory (WMD, -0.07; 95% CI, -0.88 to 0.74; p = 0.81; high quality of evidence) and motor blockade (WMD, -0.24; 95% CI, -1.12 to 0.65; p = 0.55; high quality of evidence), as well as time to first request for oral analgesia (WMD, -1.57; 95% CI, -3.14 to 0.01; p = 0.5; moderate quality of evidence). Conclusion: Moderate-quality evidence suggested that, in terms of the onset time of sensory and motor blockade, 0.75% ropivacaine is a preferred concentration for BPB in upper limb surgeries. Systematic Review Registration: identifier CRD42023392145.

Assessing an Online Patient Decision Aid about Upper Extremity Reconstructive Surgery for Cervical Spinal Cord Injury: Pilot Testing Knowledge, Decisional Conflict, and Acceptability.

Background. While nerve and tendon transfer surgery can restore upper extremity function and independence after midcervical spinal cord injury, few individuals (∼14%) undergo surgery. There is limited information regarding these complex and time-sensitive treatment options. Patient decision aids (PtDAs) convey complex health information and help individuals make informed, preference-consistent choices. The purpose of this study is to evaluate a newly created PtDA for people with spinal cord injury who are considering options to optimize upper extremity function. Methods. The PtDA was developed by our multidisciplinary group based on clinical evidence and the Ottawa Decision Support Framework. A prospective pilot study enrolled adults with midcervical spinal cord injury to evaluate the PtDA. Participants completed surveys about knowledge and decisional conflict before and after viewing the PtDA. Acceptability measures and suggestions for further improvement were also solicited. Results. Forty-two individuals were enrolled and completed study procedures. Participants had a 20% increase in knowledge after using the PtDA (P < 0.001). The number of participants experiencing decisional conflict decreased after viewing the PtDA (33 v. 18, P = 0.001). Acceptability was high. To improve the PtDA, participants suggested adding details about specific surgeries and outcomes. Limitations. Due to the COVID-19 pandemic, we used an entirely virtual study methodology and recruited participants from national networks and organizations. Most participants were older than the general population with a new spinal cord injury and may have different injury causes than typical surgical candidates. Conclusions. A de novo PtDA improved knowledge of treatment options and reduced decisional conflict about reconstructive surgery among people with cervical spinal cord injury. Future work should explore PtDA use for improving knowledge and decisional conflict in the nonresearch, clinical setting. Highlights: People with cervical spinal cord injury prioritize gaining upper extremity function after injury, but few individuals receive information about treatment options.A newly created patient decision aid (PtDA) provides information about recovery after spinal cord injury and the role of traditional tendon and newer nerve transfer surgery to improve upper extremity upper extremity function.The PtDA improved knowledge and decreased decisional conflict in this pilot study.Future work should focus on studying dissemination and implementation of the ptDA into clinical practice.

Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus.

Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximally to the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008) but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cm from the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.

Uncommon configuration of intercostobrachial nerves, lateral roots, and absent medial cutaneous nerve of arm in a cadaveric study.

The intercostobrachial nerve (ICBN) originates from the second intercostal nerve's lateral cutaneous branch, while the median nerve (MN) typically arises from the brachial plexus's lateral and medial roots. The medial cutaneous nerve of the arm, a branch of the medial cord of the brachial plexus, often connects with the ICBN. Variations were observed during the dissection of a 50-year-old male cadaver, including MN having two lateral roots (LR), LR1 and LR2, joining at different levels. Three ICBNs innervated the arm in this case, with the absence of the medial cutaneous nerve of the arm compensated by branches from the medial cutaneous nerve of the forearm. Understanding these anatomical variations is crucial for surgical procedures like brachioplasty, breast augmentation, axillary lymph node dissection, and orthopedic surgery. Surgeons and medical professionals must be aware of these variations to enhance preoperative planning, minimize complications, and improve patient outcomes in these procedures.

Ultrasound-guided Retroclavicular Approach Versus Costoclavicular Approach of Infraclavicular Brachial Plexus Block for Upper Limb Surgeries.

BACKGROUND: Regional anesthesia for an upper limb provides many advantages over general anesthesia, especially in orthopedic surgery. OBJECTIVES: This trial aimed to compare a retroclavicular approach to the infraclavicular brachial plexus with a costoclavicular approach in term of needle time, image time, and procedure time, and comparing both with the classic technique for upper limb surgeries guided by ultrasound. STUDY DESIGN: Prospective, randomized, single-blinded controlled trial. SETTING: Minia University, Faculty of Medicine, Anesthesia and Intensive Care Department. METHODS: Sixty patients of both sees with an American Society of Anesthesiologists  Classification of I and II, a BMI (kg/m2) of 20-35, aged from 18-60 years who were scheduled for a forearm or hand surgery under infraclavicular brachial plexus block were divided into 3 parallel equal groups. Group I (RC) received a retroclavicular approach.  Group II (CC)received a costoclavicular approach.  Group III (CT) received the classic technique. Procedure time, the sum of the imaging and needling times, was our primary outcome. Secondary outcomes were the motor and sensory block success rate 30 minutes postinjection of local anesthesia, duration of motor and sensory block, Visual Analog Score, first analgesic need, total analgesia requirements during the first postoperative 24 hours, and any complications. RESULTS: The procedure and needle times were significantly decreased in the retroclavicular group due to better needle visibility. There was no significant difference regarding sensory and motor block data. The VAS score in the first postoperative 24 hours showed no statistical significance. Regarding analgesic data and patient satisfaction, there was no statistical significance among the 3 studied groups. There were no complications in any of the used approaches. LIMITATION: Our trial did not include patients with a BMI > 35. CONCLUSIONS: The retroclavicular approach is superior because of its decreased procedure time and needle time than both the costoclavicular approach and classic approach.

Beyond the Brachial Plexus: Reapplication of the Thoracic Paravertebral Block for Upper Arm Fistula Surgery.

Patients requiring complex upper arm arteriovenous fistulas or grafts may not be suitable candidates for a single regional anesthesia technique and monitored anesthesia care because the necessary thoracic (T2) dermatomal area of the medial, upper arm remains spared by any solitary brachial plexus (C5-T1) technique. An infiltrative intercostobrachial nerve block can often be used in conjunction with a brachial plexus block; however, coverage may still be incomplete. This case report describes the use of a high thoracic paravertebral block in conjunction with a brachial plexus block to achieve adequate anesthetic coverage for an upper arm arteriovenous fistula creation procedure extending into the axilla. The result of this technique showed adequate coverage of the upper arm and demonstrates that paravertebral blocks are a reasonable adjunct for proximal upper arm arteriovenous fistula procedures.

A Unique Presentation of the Glenoid, Coracoid, and Proximal Humerus Fractures.

Fractures of the proximal humerus are common injuries with a bimodal age distribution. They usually present in younger patients after high-energy trauma and in elderly patients after lower-energy trauma. Fractures of the proximal humerus are rarely associated with concomitant fractures of the glenoid, and this is a complex injury pattern that indicates the presence of significant instability. Such injuries are usually treated surgically. Even more rarely, patients may present with proximal humerus fractures and fractures of the coracoid process. A male patient presented to our emergency department (ED) after a fall off the loading platform of his heavy goods vehicle (HGV), resulting in a right shoulder injury. During his initial assessment in ED, a computerised tomography (CT) scan demonstrated the presence of a comminuted proximal humerus fracture, a comminuted anterior glenoid wall fracture, and a coracoid process displaced fracture. Surgical fixation of all three fractures was undertaken in the same sitting. This is the first case described in the literature with a combination of the above injuries and serves as a reminder that as trauma complexity and incidence continue to increase, we should maintain a high index of diagnostic suspicion when dealing with such patients. Furthermore, we present our treatment approach for this case and the rationale behind it.

Thermal Imaging to Predict Failed Supraclavicular Brachial Plexus Block: A Prospective Observational Study.

Background: Successful brachial plexus blockade produces sympathetic blockade, resulting in increased skin temperature in the blocked segments. This study aimed to evaluate the accuracy of infrared thermography in predicting failed segmental supraclavicular brachial plexus block. Methods: This prospective observational study included adult patients undergoing upper-limb surgery under supraclavicular brachial plexus block. Sensation was evaluated at the dermatomal distribution of the ulnar, median, and radial nerves. Block failure was defined as absence of complete sensory loss 30 min after block completion. Skin temperature was evaluated by infrared thermography at the dermatomal supply of the ulnar, median, and radial nerves at baseline, 5, 10, 15, and 20 min after block completion. The temperature change from the baseline measurement was calculated for each time point. Outcomes were the ability of temperature change at each site to predict failed block of the corresponding nerve using area under receiver-operating characteristic curve (AUC) analysis. Results: Eighty patients were available for the final analysis. The AUC (95% confidence interval [CI]) for the ability of temperature change at 5 min to predict failed ulnar, median, and radial nerve block was 0.79 (0.68-0.87), 0.77 (0.67-0.86), and 0.79 (0.69-0.88). The AUC (95% CI) increased progressively and reached its maximum values at 15 min (ulnar nerve 0.98 [0.92-1.00], median nerve 0.97 [0.90-0.99], radial nerve 0.96 [0.89-0.99]) with negative predictive value of 100%. Conclusion: Infrared thermography of different skin segments provides an accurate tool for predicting failed supraclavicular brachial plexus block. Increased skin temperature at each segment can exclude block failure in the corresponding nerve with 100% accuracy.

Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review.

BACKGROUND: Peripheral nerve block is a common anesthetic technique used during orthopedic upper limb surgery. Injection of local anesthetics around the target nerve inhibits the action of voltage-dependent sodium channels, inhibiting neurotransmission of pain impulses and providing motor immobility. Compared to general anesthesia, it could improve functional recovery by inhibiting nociceptive impulses and inflammation, thus reducing postoperative pain and immobilization and improving postoperative rehabilitation. This systematic review evaluates the impact of peripheral nerve block versus general anesthesia on postoperative functional recovery following orthopedic upper limb surgery. METHODS: We searched CENTRAL, MEDLINE, CINHAL, EMBASE, and Scopus trial databases from inception until September 2021 for studies comparing peripheral nerve block to general anesthesia. We collected data on functional recovery, range of motion, patient satisfaction, quality of life, and return to work. We pooled studies using a random-effects model and summarized the quality of evidence with the GRADE approach. RESULTS: We assessed 373 citations and 19 full-text articles for eligibility, and included six studies. Six studies reported on functional recovery, but failed to detect a significant superiority of peripheral nerve block over general anesthesia (3 RCT studies, N = 160; SMD -0.15; CI at 95% -0.60-0.3; I2 = 45%; p = 0.07; low quality of evidence and 3 observational studies, N = 377; SMD -0.35; CI at 95% -0.71-0.01; I2 = 64%; p = 0.06; very low quality of evidence). CONCLUSIONS: Current literature is limited and fails to identify the benefit of peripheral nerve block on functional recovery. More studies are needed to assess the impact on long-term recovery. Considering the potential impact on clinical practice and training, a prospective study on functional recovery is ongoing (NCT04541745). TRIAL REGISTRATION: PROSPERO ID CRD42018116298. Registered on December 4, 2018.

Myeloid sarcoma with ulnar nerve entrapment: A case report.

BACKGROUND: Myeloid sarcoma (MS) is relatively rare, occurring mainly in the skin and lymph nodes, and MS invasion of the ulnar nerve is particularly unusual. The main aim of this article is to present a case of MS invading the brachial plexus, causing ulnar nerve entrapment syndrome, and to further clinical understanding of the possibility of MS invasion of peripheral nerves. CASE SUMMARY: We present the case of a 46-year-old man with a 13-year history of well-treated acute nonlymphocytic leukaemia who was admitted to the hospital after presenting with numbness and pain in his left little finger. The initial diagnosis was considered a simple case of nerve entrapment disease, with magnetic resonance imaging showing slightly abnormal left brachial plexus nerve alignment with local thickening, entrapment, and high signal on compression lipid images. Due to the severity of the ulnar nerve compression, we surgically investigated and cleared the entrapment and nerve tissue hyperplasia; however, subsequent pathological biopsy results revealed evidence of MS. The patient had significant relief from his neurological symptoms, with no postoperative complications, and was referred to the haemato-oncology department for further consultation about the primary disease. This is the first report of safe treatment of ulnar nerve entrapment from MS. It is intended to inform hand surgeons that nerve entrapment may be associated with extramedullary MS, as a rare presenting feature of the disease. CONCLUSION: MS invasion of the brachial plexus and surrounding tissues of the upper arm, resulting in ulnar nerve entrapment and degeneration with significant neurological pain and numbness in the little finger, is uncommon. Surgical treatment significantly relieved the patient's nerve entrapment symptoms and prevented further neurological impairment. This case is reported to highlight the rare presenting features of MS.

Skeletal muscle surrogates for the acquisition of muscle repair skills in upper limb surgery.

INTRODUCTION: The required fidelity of synthetic materials in surgical simulators to teach tissue handling and repair requirements should be as accurate as possible. There is a poor understanding of the relationship between choice of muscle surrogates and training outcome for trainee surgeons. To address this, the mechanical characteristics of several candidate synthetic muscle surrogates were measured, and their subjective biofidelity was qualitatively assessed by surgeons. METHODS: Silicone was selected after assessing several material options and 16 silicone-based surrogates were evaluated. Three of the closest samples to muscle (Samples 1.1, 1.2, 1.3) and one with inserted longitudinal fibres (1.2F) were mechanically tested in the following: compression and tension, needle puncture force and suture pull-out in comparison with real muscle. The four samples were evaluated by 17 Plastic and Orthopaedic surgeons to determine their views of the fidelity with regard to the handling properties, needle insertion and ease of suture pull-out. RESULTS: The mechanical testing showed the surrogates exhibited varying characteristics that matched some of the properties of muscle, though none recreated all the mechanical characteristics of native muscle. Good biofidelity was generally achieved for compression stiffness and needle puncture force, but it was evident that tensile stiff was too low for all samples. The pull-out forces were variable and too low, except for the sample with longitudinal fibres. In the qualitative assessment, the overall median scores for the four surrogate samples were all between 30 and 32 (possible range 9-45), indicating limited differentiation of the samples tested by the surgeons. CONCLUSIONS: The surrogate materials showed a range of mechanical properties bracketing those of real muscle, thus presenting a suitable combination of candidates for use in simulators to attain the requirements as set out in the learning outcomes of muscle repair. However, despite significant mechanical differences between the samples, all surgeons found the samples to be similar to each other.

Anatomic factors associated with partial distal biceps tendon tears: a comparative control study.

BACKGROUND: There is minimal literature on the anatomic factors associated with partial distal biceps tendon (DBT) tears. It has been proposed that a larger radial tuberosity size-and, therefore, a smaller radioulnar space during pronation-may cause mechanical impingement of the DBT predisposing to tears. We sought to investigate the anatomic factors that may be associated with partial DBT tears by retrospectively reviewing the DBT anatomy using 3-T magnetic resonance imaging (MRI) scans of elbows with partial DBT tears and a comparison group of normal elbows. METHODS: Two independent observers retrospectively reviewed 3-T MRI scans of elbows with partial DBT tears and elbows without visible pathology. Basic demographic data were collected, and measurements of radial tuberosity length, radial tuberosity thickness, radioulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardized technique. The ratio of radial tuberosity thickness to radial diameter and the ratio of radioulnar space to radial tuberosity-ulnar space were calculated. The presence or absence of enthesophytes and the presence of a single DBT vs. double DBTs were noted. RESULTS: This study included twenty-six 3-T MRI scans of 26 elbows with partial DBT tears and thirty 3-T MRI scans of 30 elbows without pathology. Basic demographic data were comparable between the 2 groups. The tear group showed statistically significantly larger mean measurements for radial tuberosity length (24.3 mm vs. 21.3 mm, P = .002) and radial tuberosity thickness (5.5 mm vs. 3.7 mm, P < .0001). The tear group also showed statistically significantly smaller measurements for radioulnar space (8.2 mm vs. 10.0 mm, P = .010) and radial tuberosity-ulnar space (7.2 mm vs. 9.1 mm, P = .013). The ratio of radial tuberosity thickness to radial diameter was statistically significantly larger in the tear group (0.389 vs. 0.267, P < .0001). There was a statistically significant positive correlation between partial DBT tears and the presence of enthesophytes (P = .007), as well as between partial DBT tears and the presence of 2 discrete DBTs rather than a single tendon or 2 DBTs that interdigitated prior to insertion (P < .0001). CONCLUSION: Larger radial tuberosities and smaller radioulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. Larger tuberosities and a smaller functional space for the DBT may lead to chronic impingement, tendon delamination, and consequent weakness, which ultimately lead to tears. Enthesophytes may be associated with tears for the same reason. The presence of 2 discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears. This study will help clinicians understand the pathogenesis of partial DBT tears.