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Background: The purpose of this study was to determine pain and functional outcomes following revision cubital tunnel surgery and to identify predictors of poor postoperative outcome. Methods: A retrospective cohort study was conducted of all patients undergoing revision cubital tunnel surgery over a 5-year period at a high-volume peripheral nerve center. Intraoperative findings, demographic and injury factors, and outcomes were reviewed. Average pain, worst pain, and impact of pain on self-perceived quality of life were each measured using a 10-cm visual analog scale (VAS). Function was evaluated using pinch and grip strength, as well as the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Differences in preoperative and postoperative pain, strength, and DASH were analyzed using nonparametric tests. Predictors of postoperative average pain were evaluated using odds ratios and linear regression analyses. Results: The final cohort consisted of 50 patients (mean age: 46.3 ± 12.5 years; 29 [68%] male) undergoing 52 revision ulnar nerve transpositions (UNTs). Pain VAS scores decreased significantly following revision UNT. Strength and DASH scores demonstrated nonsignificant improvements postoperatively. Worse preoperative pain and greater than 1 prior cubital tunnel procedure were significant predictors of worse postoperative average pain VAS scores. Conclusions: Patients can and do improve following revision cubital tunnel surgery, particularly as it relates to pain. Intraoperative findings during the revision procedure suggest that adherence to specific principles in the primary operation is key to prevention of secondary cubital tunnel syndrome.

Minimal clinically important differences (MCIDs) for the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) measuring pain have not been previously described using an anchor-based method after shoulder arthroplasty. The purpose of this study was to determine the MCIDs for these measures after shoulder arthroplasty for glenohumeral arthritis or advanced rotator cuff disease.Primary anatomic total shoulder arthroplasty (TSA), primary reverse TSA, or hemiarthroplasty was performed in 326 patients by 1 of 5 shoulder and elbow surgeons. The SST score, ASES score, and VAS pain score were collected preoperatively and at a minimum of 2 years postoperatively (mean, 3.5 years). The MCIDs were calculated for the ASES score, SST score, and VAS pain score using an anchor-based method.The MCIDs for the ASES score, SST score, and VAS pain score were 20.9 (P .001), 2.4 (P .0001), and 1.4 (P = .0158), respectively. Duration of follow-up and type of arthroplasty (anatomic TSA vs reverse TSA) did not have a significant effect on the MCIDs (P .1) except shorter follow-up correlated with a larger MCID for the ASES score (P = .0081). Younger age correlated with larger MCIDs for all scores (P .024). Female sex correlated with larger MCIDs for the VAS pain score (P = .123) and ASES score (P = .05).Patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score, a 2.4-point improvement in the SST score, and a 21-point improvement in the ASES score to achieve a minimal clinical importance difference from the procedure.

Purpose To evaluate intraoperative findings and outcomes of revision carpal tunnel release (CTR) and to identify predictors of pain outcomes. Methods We performed a retrospective cohort study of all adult patients undergoing revision CTR between 2001 and 2012. Patients were classified according to whether they presented with persistent, recurrent, or new symptoms. We compared study groups by baseline characteristics, intraoperative findings, and outcomes (strength and pain). Within each group, we analyzed changes in postoperative pinch strength, grip strength, and pain from baseline. Predictors of postoperative average pain were examined using both multivariable linear regression analyses and univariable logistic regression to calculate odds ratios of worsened or no change in pain. Results We performed revision CTR in 97 extremities (87 patients). Symptoms were classified as persistent in 42 hands, recurrent in 19, and new in 36. The recurrent group demonstrated more diabetes and a longer interval from primary CTR, and was less likely to present with pain. Incomplete release of the flexor retinaculum and scarring of the median nerve were common intraoperative findings over all. Nerve injury was more common in the new group. Postoperative pinch strength, grip strength, and pain significantly improved from baseline in all groups, apart from strength measures in the recurrent group. Persistent symptoms and more than 1 prior CTR had higher odds of not changing or worsening postoperative pain. Higher preoperative pain, use of pain medication, and workers' compensation were significant predictors of higher postoperative average pain. Conclusions Carpal tunnel release may not always be entirely successful. Most patients improve after revision CTR, but a methodical approach to diagnosis and adherence to safe surgical principles are likely to improve outcomes. Symptom classification, number of prior CTRs, baseline pain, pain medications, and workers' compensation status are important predictors of pain outcomes in this population. Type of study/level of evidence Therapeutic III.

Biological scaffolds must support a complex balance of resisting enzymatic degradation while promoting tissue remodeling. Thus, the purpose of this study was to evaluate the effects of in vitro enzymatic exposure on the mechanical properties of biological scaffolds. It was hypothesized that exposure to an enzyme solution would result in decreased tensile strength and that crosslinked scaffolds would resist enzymatic degradation more effectively than noncrosslinked scaffolds.Nine scaffolds were evaluated (four porcine dermis: Permacol™, CollaMend™, Strattice™, XenMatrix™; two human dermis: AlloMax™, FlexHD(®); two bovine pericardium: Veritas(®), PeriGuard(®); and one porcine small intestine submucosa: Surgisis™). Ten specimens (n = 10) were hydrated in saline at 37 °C and subjected to uniaxial testing to establish baseline properties. 50 specimens (n = 50) were incubated in collagenase solution at 37 °C for 2, 6, 12, 24, or 30 h (n = 10 each group) followed by uniaxial tensile testing.Tensile strength was significantly reduced after 30 h for CollaMend™, AlloMax™, Veritas(®), Strattice™, XenMatrix™, Permacol™, and FlexHD(®) (p0.01), while PeriGuard(®) demonstrated a slight increase in tensile strength (p = 0.0188). Crosslinked bovine pericardium (PeriGuard(®)) maintained greater tensile strength than noncrosslinked bovine pericardium (Veritas(®)) throughout all exposure periods (p0.0001). Similarly, crosslinked porcine dermis (Permacol™) maintained greater tensile strength than noncrosslinked porcine dermis (Strattice™ and XenMatrix™) throughout all exposure periods (p0.0001).Materials that deteriorate rapidly after in vitro enzymatic exposure may also deteriorate rapidly in vivo, particularly when exposed to a wound environment with elevated levels of matrix metalloproteinases. Permacol™, CollaMend™, Strattice™, FlexHD(®), and PeriGuard(®) survived the longest incubation period (30 h) and withstood mechanical testing. XenMatrix™, AlloMax™, Veritas(®), and Surgisis™ degraded more quickly and did not survive the longer exposure periods. Scaffolds that maintain strength characteristics after in vitro collagenase exposure may be advantageous for long-term hernia repair scenarios where elevated enzyme levels are expected.

Engineered skin must be mechanically strong to facilitate surgical application and prevent damage during the early stages of engraftment. However, the evolution of structural properties during culture, the relative contributions of the epidermis and dermis, and any correlation with tissue morphogenesis are not well known. These aspects are investigated by assessing the mechanical properties of engineered skin (ES) and engineered dermis (ED) during a 21-day culture period, including correlations with cellular metabolism, cellular organization and epidermal differentiation. During culture, the epidermis differentiates and begins to cornify, as evidenced by immunostaining and surface electrical capacitance. Tensile testing reveals that the ultimate tensile strength and linear stiffness increase linearly with time for ES, but are relatively unchanged for ED. ES strength correlates significantly with epidermal differentiation (p < 0.001) and a composite strength model indicates that strength is largely determined by the epidermis. These data suggest that strategies to improve ES biomechanics should target the dermis. Additionally, time-dependant changes in average ES strength and percent elongation can be used to set upper bound limits on mechanical stimulation profiles to avoid tissue damage.

This study sought to determine the validity and responsiveness of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in cubital tunnel syndrome.Consecutive patients with cubital tunnel syndrome treated by anterior ulnar nerve transposition between September of 2009 and December of 2011 were reviewed retrospectively. Questionnaires were completed preoperatively and 1.5, 3, 6, and 12 months postoperatively. The relationship of the questionnaire to measures of pain, health status (Short Form-8), and pinch and grip strength was evaluated using Spearman's correlation coefficients. Responsiveness of the questionnaire was analyzed using Cohen's effect size, and was compared with responsiveness of the physical examination, pain, and Short Form-8 measures.The final cohort included 69 patients with isolated cubital tunnel syndrome and 39 with concurrent cubital and carpal tunnel syndrome. Questionnaire scores correlated as expected with other measures. Moderate to strong correlations were observed with pain visual analogue scale and Short Form-8 scores, and weak to moderate correlations were observed with pinch and grip strength. Effect sizes for the DASH questionnaire were small (0.3) at 6 weeks and moderate (0.35 to 0.57) at 3, 6, and 12 months postoperatively in both groups. Pain visual analogue scale scores demonstrated large effect sizes (0.8) at all postoperative time points, whereas Short Form-8 and pinch and grip strength were poorly responsive.The Disabilities of the Arm, Shoulder, and Hand questionnaire is a valid measure in cubital tunnel syndrome, and is moderately responsive to change beyond 3-month follow-up.Diagnostic, II.

Background The Patient Acceptable Symptom State (PASS) is a symptom state that a patient considers acceptable. No prior study has determined the PASS for the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and the Visual Analog Scale (VAS) pain score after shoulder arthroplasty. The purpose of this study was to determine the PASS for the ASES score, the SST score, and VAS pain for patients treated with a total shoulder arthroplasty. Methods A total of 326 patients had a primary anatomic total shoulder arthroplasty (TSA) or primary reverse total shoulder arthroplasty (RSA) by 1 of 5 shoulder and elbow surgeons at 1 of 2 institutions. Each patient completed the SST, ASES score, and a VAS pain preoperatively and at a minimum of 2 years postoperative (average 3.5 years). The PASS value for the ASES score, SST, and VAS pain was calculated. Results The PASS for the ASES score, SST, and VAS pain was 76, 8.4, and 1.5, respectively. Neither hand dominance nor age had a significant effect on PASS for SST, VAS, and ASES ( P > .05). Gender had significant effect on SST and ASES scores with P -values of

Permanent/nonresorbable hernia repair materials rely on profibrotic wound healing, and repair sites are commonly composed of disorganized tissue with inferior mechanical strength and risk of reherniation. Resorbable electrospun scaffolds represent a novel class of biomaterials, which may provide a unique platform for the design of advanced soft tissue repair materials. These materials are simple, inexpensive, nonwoven materials composed of polymer fibers that readily mimic the natural extracellular matrix. The primary goal of the present study was to evaluate the physiomechanical properties of novel electrospun scaffolds to determine their suitability for hernia repair. Based on previous experimentation, scaffolds possessing ≥ 20 N suture retention strength, ≥ 20 N tear resistance, and ≥ 50 N/cm tensile strength are appropriate for hernia repair.Six novel electrospun scaffolds were fabricated by varying combinations of polymer concentration (10-12 %) and flow rate (3.5-10 mL/h). Briefly, poly(ε-caprolactone) (PCL) was dissolved in a solvent mixture and electrospun onto a planar metal collector, yielding sheets with randomly oriented fibers. Physiomechanical properties were evaluated through scanning electron microscopy, laser micrometry, and mechanical testing.Scanning electron micrographs demonstrated fiber diameters ranging from 1.0 ± 0.1 μm (10 % PCL, 3.5 mL/h) to 1.5 ± 0.2 μm (12 % PCL, 4 mL/h). Laser micrometry demonstrated thicknesses ranging from 0.72 ± 0.07 mm (12 % PCL, 10 mL/h) to 0.91 ± 0.05 mm (10 % PCL, 3.5 mL/h). Mechanical testing identified two scaffolds possessing suture retention strengths ≥ 20 N (12 % PCL, 10 mL/h and 12 % PCL, 6 mL/h), and no scaffolds possessing tear resistance values ≥ 20 N (range, 4.7 ± 0.9 N to 10.6 ± 1.8 N). Tensile strengths ranged from 35.27 ± 2.08 N/cm (10 % PCL, 3.5 mL/h) to 81.76 ± 15.85 N/cm (12 % PCL, 4 mL/h), with three scaffolds possessing strengths ≥ 50 N/cm (12 % PCL, 10 mL/h; 12 % PCL, 6 mL/h; 12 % PCL, 4 mL/h).Two electrospun scaffolds (12 % PCL, 10 mL/h and 12 % PCL, 6 mL/h) possessed suture retention and tensile strengths appropriate for hernia repair, justifying evaluation in a large animal model. Additional studies examining advanced methods of fabrication may further improve the unique properties of these scaffolds, propelling them into applications in a variety of clinical settings.