Journal of Hand and Microsurgery最新文献

Introduction  The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods  The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results  VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion  This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.

Over recent decades, the prevalence of women in surgical subspecialties has increased. There has been a significant rise in the percentage of women entering integrated plastic surgery programs and an increase, albeit smaller, in women entering orthopedic surgery training programs. Although female membership in the American Society for Surgery of the Hand has steadily increased, women remain in the vast minority within this professional society and many others within the field of hand surgery. In addition to underrepresentation in positions of leadership, women face challenges such as imposter syndrome, bullying, unfavorable work structure for work-family balance, macro and micro-aggressions, and lack of mentors at a higher rate than their male colleagues. As awareness rises of the additional challenges that women in hand surgery face, we must directly address them to improve equity within our subspecialty.

Introduction  Vessel repair in a chicken thigh is commonly used in microsurgery training model. The sciatic nerve is closely associated with the vessels and has been used for training nerve coaptation, which has different technical considerations from vessel anastomosis. We describe in detail the relevant surgical anatomy and training exercises that can be used with this model. Methods  With 32 fresh store-bought chicken thighs, 16 were used to analyze the gross and histological features of the sciatic nerve, and 16 were intended to create and perform training models. Results  The average visible length of the nerve in the thigh was 51 mm (standard deviation [SD] 2.57 mm). The average diameter of the nerve was 2 mm (SD 0.33 mm) and was largest at its proximal end (3.21 mm, SD 0.27 mm). The nerve consistently branched into two along the chicken thigh, with more branching subsequently. This simulation model is appropriate not only for the classical end-to-end epineural suture, but also for advanced exercises, in terms of longitudinal fasciculus dissection, mismatched size nerve transfer, injured nerve preparation, and vein conduit technique. Dyeing of nerve fascicles enhanced the visibility of nerve surface quality. Conclusion  The sciatic nerve in the chicken thigh is a suitable and accessible model for microsurgery training. The branching and fascicular patterns of the nerve lends itself well to both novice training and advanced simulation. We have incorporated this model into our training curricula.

Background  The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods  We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results  In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion  This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

Objective  To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods  We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results  The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p  < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p  < 0.01). Conclusion  The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non - rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

Objective  Microsurgery remains an integral component of the surgical skillset and is essential for a diversity of reconstructive procedures. The apprenticeship also requires overcoming a steep learning curve, among many challenges. The method of microsurgical training differs depending on the countries' regions and resources of their health care system. Methods  The Journal of Hand and Microsurgery leadership held an international webinar on June 19, 2021, consisting of a panel of residents from 10 countries and moderated by eminent panelists. This inaugural event aimed to share different experiences of microsurgery training on a global scale, identifying challenges to accessing and delivering training. Results  Residents shared various structures and modes of microsurgical education worldwide. Areas of discussion also included microsurgical laboratory training, simulation training, knowledge sharing, burnout among trainees, and challenges for female residents in microsurgical training. Conclusion  Microsurgical proficiency is attained through deliberate and continued practice, and there is a strong emphasis globally on training and guidance. However, much remains to be done to improve microsurgical training and start acting on the various challenges raised by residents. Level of Evidence  Level V.