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Introduction: Rotator cuff tears (RCTs) are a common source of pain in the shoulder girdle. There is still debate about the optimal treatment for older adults with RCTs. In clinical practice, patients who do not respond well to non-surgical management may still be eligible for operative treatment. In this study, we assessed the outcome of arthroscopic repair of RCTs in patients ≥60 years old. Material and method: A retrospective case series was conducted to include patients who underwent arthroscopic repair of RCTs from 1 January 2018 to 1 January 2021. The study included individuals aged ≥60 years who had radiologically confirmed RCTs (verified by MRI) and clinical findings including sleep-disturbing pain and reduced range of motion. Preoperative treatment included physiotherapy for at least 6 months and one subacromial corticosteroid injection. Results: Fifty-three RCTs were treated during the study period. After exclusion because of incomplete documentation, 45 patients remained. The mean age was 66 years and 80% had isolated supraspinatus tears and 25% had variable degrees of fatty infiltration (Goutallier grade 1-3) on MRI examination with positive tangent sign. There were no surgical site infections and three symptomatic re-ruptures (6%). At follow-up, (71%) reported no remaining sleep-disturbing shoulder pain. Abduction improved from 62° to 122°. Flexion improved from 68° to 135°. This study found that people aged 60 years and older who underwent repair of RCTs showed statistically significant clinical improvement in shoulder flexion and abduction with less sleep-disturbing shoulder pain. These encouraging results may contribute to the existing literature, favoring the choice of surgical treatment for symptomatic RCTs in this age group with failed nonoperative treatment. Conclusion: The arthroscopic repair of RCTs in patients 60 years and older yielded a substantial increase in shoulder flexion and abduction, significantly reducing sleep-disturbing shoulder pain. Postoperative complications were minimal. [ABSTRACT FROM AUTHOR]

Introduction: Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors. Methods: Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared. Results: A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P <.001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 – 34.199, P =.020). There were no significant differences in any adverse event (AAE) between procedures (P =.259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 – 1.128, P =.018). Conclusion: The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures. [ABSTRACT FROM AUTHOR]

Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia. We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics. Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens. Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens. Therapeutic II. [ABSTRACT FROM AUTHOR]

Background: Corticosteroid injection (CSI) has a relatively high benefit-to-risk ratio and is commonly administered to treat musculoskeletal conditions. However, perioperative CSI has been associated with an increased risk of postoperative infection. The literature suggests delaying surgery after CSI to minimize the risk of postoperative infection. We review the literature to summarize the most current knowledge on the association between perioperative CSI and infection rates for different hand and upper extremity procedures. Methods: Two independent reviewers conducted a literature search using PubMed and Web of Science databases (through October 1, 2022). The database searches used were (((injection) AND (infection)) AND (risk)) AND ((hand) OR (wrist) OR (elbow) OR (shoulder)). English-language articles were screened for infection rates associated with CSI given temporally around upper extremity surgery, focusing between 6 months preoperatively and 1 month postoperatively. Results: Nineteen articles including database queries and retrospective case-control or cohort studies were used after screening 465 articles. Most infection rates were increased in hand, wrist, elbow, and shoulder surgery between 3 months preoperatively and 1 month postoperatively. Intraoperative injection during elbow arthroscopy demonstrated increased infection rate relative to other upper extremity surgeries. Conclusions: Corticosteroid injection increased the risk of infection temporally around upper extremity surgeries; however, CSI provides benefits. The consensus regarding CSI timeline perioperatively has yet to be determined. The evidence supports an increased benefit-to-risk ratio when giving corticosteroids greater than 3 months preoperatively and greater than 1 month postoperatively for most upper extremity procedures, with relative contraindications within 1 month of upper extremity surgery. [ABSTRACT FROM AUTHOR]

Background: Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off." Methods: A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes. Results: A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P =.04 and 3.5 and 2, P =.002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels (P =.03). Conclusions: Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted. [ABSTRACT FROM AUTHOR]

Background: The lateral sagittal brachial plexus block is the most used method for pediatric upper extremity surgery, whereas the applications of costoclavicular brachial plexus block are limited. This study aimed to compare the lateral sagittal and costoclavicular approaches for the ultrasound-guided infraclavicular block in pediatric patients. Methods: Sixty pediatric patients aged 5...15 years undergoing hand or forearm surgery were randomly assigned to two groups. Group LS (n.ß=.ß30) received ultrasound-guided lateral sagittal block, and Group CC (n.ß=.ß30) received ultrasound-guided costoclavicular block. The block performing time, needling time, imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores were evaluated. Results: The needling time (82.90.ß...ß28.17 seconds vs. 64.77.ß...ß28.11 seconds respectively, p.ß=.ß0.004) and total block performance time (109.53 .. 29.75 seconds vs. 89.70 .. 29.98 seconds respectively, p.ß=.ß0.005) were significantly longer in Group LS than in Group CC. However, there was no significant difference between the groups in imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores (p > 0.05). Conclusions: Costoclavicular and lateral sagittal brachial plexus blocks resulted in similar anesthetics effects. Moreover, the costoclavicular method can be a better alternative to lateral sagittal as it has a shorter block performance time.

Introduction: With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself. Material and Methods: Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality. Results: The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was.44 (CI.18-.69, P <.01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was.96 (CI.78-1.14). The patients' ability to live independently in their own home had the highest impact on survival. Discussion: The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient. Conclusions: The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level. [ABSTRACT FROM AUTHOR]

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery. A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities. The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods. Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation. Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions. [ABSTRACT FROM AUTHOR]

Dexmedetomidine (DEX) provides a unique conscious sedation without respiratory depression. We examined the usefulness of intravenous (IV) DEX sedation combined with brachial plexus block for long-duration upper extremity surgery without an anesthesiologist. We retrospectively reviewed 90 limbs of 86 patients and measured the actual operative time course in detail. The adverse events and the patient-reported outcomes regarding intraoperative pain and depth of sedation were evaluated. The mean total time of the operation, tourniquet use, and the IV DEX sedation were 150 min, 132 min, and 117 min, respectively. The mean time between discontinuation of IV DEX sedation and completion of the operation was 51 min. The intraoperative adverse events involved bradycardia (21%), hypotension (18%), and oxygen desaturation (3%). The mean visual analog scale scores of pain during brachial plexus block, surgical site pain, tourniquet pain, and depth of the sedation were 23.4 mm, 0.14 mm, 4.2 mm, and 6.6 mm, respectively. Furthermore, 96% patients expressed a preference for receiving anesthesia as brachial plexus block with IV DEX sedation. Long-duration upper extremity surgery, even longer than 2 h, was feasible under brachial plexus block combined with IV DEX sedation without an anesthesiologist. For patients with low blood pressure and/or low heart rate, it is recommended to adjust the continuous infusion of IV DEX to less than 0.4 µg/kg/h. To ensure that the patients are able to promptly leave the operating room fully awake, IV DEX infusion should be stopped at least 30 min before finishing the operation. [ABSTRACT FROM AUTHOR]

Abstract Background Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure. We report a case in which thoracic spinal anaesthesia (T3–T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery. Case presentation A 15 years old man with distal radius fracture ORIF was scheduled to undergo remove of implant. His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential. We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg). Conclusions Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block.

The supraclavicular block (SCB) and the infraclavicular block (ICB) are introduced to meet upper extremity surgery, where the transducer or the insertion point is placed superiorly and inferiorly at the approximate midpoint of the clavicle, respectively. These two approaches are highly appealing since they clearly exhibited each cord and its associated anatomy. In addition, it directed the needle accurately with real-time imaging by ultrasound guidance. Therefore, it brought higher success rates and fewer complications. Numerous trials have recently been conducted to examine the SCB and ICB regarding the new approach, injection techniques, block dynamics, and complication of hemidiaphragmatic paresis. It was found that both approaches could improve block effectiveness and postoperative analgesia for upper extremity surgery, according to recent studies at the level of the clavicular brachial plexus block. However, there is still a lack of work comparing the clinical performance and effectiveness of both approaches with ultrasonography. This review aims to outline the current available data from clinical trials along with case reports about these two approaches and to describe the findings published in the literature during the previous 5 years. Based on these findings, we attempt to determine whether there exists a one-size-fits-all approach that has the potential to meet upper extremity surgery. [ABSTRACT FROM AUTHOR]

Cervical spinal cord injury (SCI) causing tetraplegia is extremely disabling. In such circumstances, restoration of upper extremity (UE) function is considered the highest priority. The advent of early nerve transfer (NT) procedures, in addition to more traditional tendon transfers (TT), warranted in-depth consideration given the time-limited nature of NT procedures. Potential surgery candidates may not yet have come to terms with the permanence of their disability. A mixed methods convergent design was utilized for concurrent analysis of the Aotearoa/New Zealand upper limb registry data from the clinical assessments of all individuals considering UE surgery, regardless of their final decision. The International Classification of Functioning, Disability and Health (ICF) taxonomy guided data interpretation during the three-phased study series. It was the integration of the findings using the Stewart Model of care drawn from palliative health that enabled the interpretation of higher order messages. It is clear the clinical assessment and selection processes in use require reconsideration given the complexities individuals face following onset of SCI. We draw attention to the higher order cognitive demands placed on individuals, the requirement for SCI peer involvement in decision making and the need for acknowledgment of interdependence as a relational construct when living with tetraplegia. [ABSTRACT FROM AUTHOR]

Background Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited. Methods The EMBASE database was queried with the search terms "targeted muscle reinnervation" OR "TMR" AND "outcomes" OR "patient outcomes." Clinical human studies in English were eligible for inclusion, yielding 89 articles. After rigorous exclusion criteria, a total of 13 articles were included in this review. Study data including geographic location, patient demographics, TMR indication, amputation level, number of nerve transfers performed, length of follow-up, and reported outcomes were extracted and analyzed. Results The included articles represent 338 patients (341 limbs). Average patient age was 47.4 years. Indication for amputation included trauma (n = 125), infection (n = 76) cancer/tumor resection (n = 71), ischemia (n = 18), failed Charcot reconstruction (n = 15), failed hardware (n = 9), burn (n = 4), and CRPS (n = 4). Five studies included upper extremity TMR only, two included lower extremity TMR only, and six included both upper and lower extremity TMR. TMR was performed in an immediate or delayed fashion, with an average of 2.2 nerve transfers performed per limb overall. Average length of follow-up was 22.3 months. In three studies, patients with phantom limb pain undergoing delayed TMR were found to have significant or trending toward significant reduction in pain after TMR using numeric rating scale and patient-reported outcomes measurement information system scales. One article reported 9/10 patients with improved or complete resolution of phantom limb pain after delayed TMR. Three studies found that patients undergoing immediate TMR had lower pain scores compared with non-TMR controls. Conclusion While there is evidence that TMR reduces neuroma-related pain and improves the quality of life for amputees, further outcomes studies are needed to study the patient experience with TMR on a larger scale. Establishing standardized, validated patient-reported outcomes assessment tools is critical to future investigation in this field. [ABSTRACT FROM AUTHOR]

Background: Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure. We report a case in which thoracic spinal anaesthesia (T3–T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery. Case presentation: A 15 years old man with distal radius fracture ORIF was scheduled to undergo remove of implant. His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential. We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg). Conclusions: Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block. [ABSTRACT FROM AUTHOR]

Leila Katabi,1 Erica Stevens,1 Mona Ascha,2 Kavita Arora3,4 1Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA; 2Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA; 3Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, 44109, USA; 4Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, 27514, USACorrespondence: Kavita Arora, Department of Obstetrics and Gynecology, University of North Carolina, 101 Manning Drive, Chapel Hill, NC, 27514, USA, Tel +1 919-843-8295, Email kavita.shah.arora@gmail.comPurpose: Etonogestrel subdermal implants are a commonly used contraceptive device placed in the medial upper arm. Plastic and orthopedic surgeons may be consulted for difficult implant removals. We performed a case–control study comparing patients undergoing surgical and uncomplicated in-office removal at our institution.Patients and Methods: We identified patients who underwent operative removal of implantable contraceptive devices by plastic or orthopedic surgeons at our institution from January 2014 to October 2019. Patients who underwent uncomplicated office removal during the same time were compared. Demographic and surgical variables were collected, and descriptive statistics were calculated. Univariate and multivariate logistic regression was performed with surgical versus outpatient removal as the outcome of interest.Results: A total of 669 patients undergoing etonogestrel subdermal implant removals were identified during the five-year study period, of which thirteen patients required surgical removal (1.9%) and 326 were selected as uncomplicated removal comparisons. There were no significant differences in median (IQR) body mass index (BMI) (31.1 [28.2, 35.2] versus 29.3 [24.0, 35.1], p = 0.19), median (IQR) weight gain since device placement (5 [− 0.6, 14.7] kilograms versus 1.6 [− 1.2, 5.8] kilograms, p = 0.15), or length of time since device insertion (2.3 [0.8, 2.8] years versus 1.0 [0.4, 2.2] years, p = 0.17). Of those who needed surgical removal, the most common indication for implant removal was device expiration (n = 5, 38.5%). Devices placed by OBGYN attendings were less likely to require surgical removal (p = 0.02). Family medicine attendings were more likely to refer patients for surgical removal (p = 0.02). No significant findings were detected on univariate or multivariate regression. Among surgical removals, radiography was the most frequently used imaging modality. Implants were most frequently subdermal (n = 11, 84.6%) though intramuscular placement was also identified (n = 2, 15.4%). Only one patient had residual paresthesia along the length of the incision. No other complications were identified.Conclusion: We did not identify risk factors associated with the difficult removal of etonogestrel subdermal implants. Practitioners should consult upper extremity surgeons if they encounter difficult removals.Keywords: nexplanon, etonogestrel subdermal implant, upper extremity surgery, implantable contraception

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery. We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve. We included 2,114 patients. In our final model on the 2018–2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit. We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management. Prognostic II. [ABSTRACT FROM AUTHOR]

Background: Tourniquets are widely used in limb fracture surgeries. Controversies still exist about the pressure inflated, including unified tourniquet inflation pressure (UTIP) and personalized tourniquet inflation pressure (PTIP). This study evaluated the hemostatic effect between UTIP and PTIP based on systolic blood pressure (SBP) in extremity fracture patients., Materials and Methods: Patients with fresh extremity fractures requiring tourniquets during surgeries were prospectively enrolled and randomly assigned to the UTIP and PTIP groups. The inflation pressure was set to 250 mmHg for the upper extremities and 300 mmHg for the lower extremities in the UTIP group and SBP plus 50 mmHg for the upper extremities and SBP plus 100 mmHg for the lower extremities in the PTIP group. The primary outcome was a hemostatic effect evaluated by the surgeon (satisfied or dissatisfied). Other secondary outcomes included postoperative changes in limb swelling and tourniquet-related complications., Results: A total of 144 patients were enrolled and randomly assigned to the UTIP group or the PTIP group, and each group has 72 patients (36 upper limb and 36 lower limb). Totally, the hemostasis effect of the PTIP group was worse than that of the UTIP group by non-inferiority test. The hemostatic effect of upper limb fractures with SBP plus 50 mmHg for tourniquet inflation pressure was also worse than that with 250mmHg; however, there was no statistically significant difference between 300mmHg and SBP plus 100 mmHg in the lower limb group hemostasis effect due to a lack of power. Also, no difference was observed in the incidence of complications (p = 1.000) and postoperative changes in limb swelling during 2 days after surgery (upper limb: P1 = 0.546, P2 = 0.545; lower limb: P1 = 0.408, P2 = 0.857) between the PTIP and UTIP group., Conclusion: In the surgery of limb fractures, setting SBP + 50mmHg as tourniquet pressure may not be sufficient for upper limbs. Also, we found no difference between the SBP + 100mmHg and the unified 300mmHg for lower limb surgeries., (© 2024. The Author(s).)

Background: The purposes of this retrospective study were to determine the efficacy of interventional methods in control of intraoperative blood losses and investigate the perioperative complications., Methods: The cases of 44 patients in whom a giant upper extremity tumor had been operated between 2008 and 2022 were analyzed retrospectively. Of these, 29 patients were treated with interventional methods (Group A) and 15 were treated without (Group B). Group A was further divided based on the intervention methodss: Group C (combination of balloon occlusion and transarterial embolization [TAE], n = 11) and Group D (single TAE, n = 18). Within Group D, patients were categorized based on the timing of TAE relative to surgery into Group E (TAE on the same day as surgery) and Group F (TAE performed days before surgery). We compared demographic features, blood loss, ICU admission rates, and use of vasopressors during surgery., Results: We collected clinical records from 44 patients diagnosed with a giant upper extremity tumor who underwent surgery. Group sizes were as follows: A (29), B (15), C (11), D (18), E (7), and F (11). Tumor volumes in the interventional and non-interventional groups were similar (704.19 ± 812.77 cm³ vs. 1224.53 ± 1414.01 cm³, P = 0.127). Blood plasma transfusion was significantly higher in Group B compared to Group A (425.33 ± 476.20 ml vs. 155.90 ± 269.67 ml, P = 0.021). Although overall blood loss did not significantly differ between Group A and Group B (467.93 ± 302.08 ml vs. 1150 ± 1424.15 ml, P = 0.087), the rate of massive bleeding (defined as blood loss over 1000 ml) was lower in Group A (6.9% vs. 46.47%, P = 0.004). The proportion of minors (patients aged less than 18) in Group C was significantly higher than in Group D (27.7% vs. 0.00%, P = 0.045). The amount of RBC transfusion was also significantly higher in Group C compared to Group D (458.18 ± 292.22 ml vs. 164.44 ± 224.03 ml, P = 0.021). No significant perioperative complications were observed., Conclusions: Interventional techniques have been shown to reduce both blood loss and the necessity for blood transfusions in patients with large upper extremity tumors. Furthermore, no significant perioperative complications have been observed., (© 2024. The Author(s).)

Objectives: The hourglass like constriction (HGC) of peripheral nerves is a characteristic pathological manifestation of Neuralgic Amyotrophy. Once identified, early surgical intervention is essential. However, the method of surgery is controversial, particularly regarding whether HGC needs to be excised. This study aims to explore the efficacy of early aggressive resection of HGC in the upper limb nerves., Materials and Methods: This retrospective study focuses on 13 nerves of spontaneous upper limb paralysis treated at our hospital from June 2019 to July 2023, in which HGC was identified during surgery. During surgery, epineurectomy and interfascicular neurolysis were performed on the constricted areas. Post-neurolysis, constriction excision was carried out if any of the following conditions were met: (1) A single constriction with constriction ≥75%. (2) Constriction combined with torsion. (3) The presence of ≥2 constrictions. Regular face-to-face follow-ups were conducted postoperatively., Results: Four cases with a single constriction of less than 75% underwent epineurotomy and interfascicular neurolysis; eight underwent constriction excision, of which four cases with a single constriction and associated torsion had direct end-to-end suturing after excision, and four had more than two constrictions treated with autologous sural nerve grafts. Postoperative follow-ups showed good recovery in all but one case, which had unique pathological features and had underwent only epineurectomy, showing moderate recovery., Conclusions: For early surgical treatment of HGCs in peripheral nerves of the upper limbs, if severe constriction, constriction combined with torsion, or the presence of more than two constrictions are identified during surgery, aggressive constriction resection may be a better option., Competing Interests: Declaration of competing interest Dandan Yang, Yao Wu, Long Zheng, Zhenzhi Wu, Xing Rong, Buguo Chen declare that they have no conflict of interest., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Currently, the gold standard of treatment for extremity soft tissue sarcoma (STS) is limb-sparing surgery. When the upper extremity is involved, the functional outcome is frequently poor. A 1-step resection and functional reconstruction would be advisable to obtain a fast recovery. Our study aims at retrospectively analyzing our case series of immediate nerves and tendons reconstructions of the upper limb after STS resection, while combining a review of the literature., Methods: A retrospective review was conducted on a consecutive series of patients who underwent an immediate functional reconstruction after STS resection of the upper limb between 2015 and 2022 among the IRCCS Foundation "Istituto Nazionale dei Tumori." The Disabilities of the Arm, Shoulder and Hand (DASH) score was considered the primary outcome. The obtained DASH scores were compared through groups that underwent different reconstructive procedures. The literature review was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) criteria among 3 databases (PubMed, EMBASE, and Cochrane) using the search parameters "(((upper extremity) OR (upper limb)) AND (functional reconstruction) AND (soft tissue sarcoma).", Results: Between 2015 and 2022, 52 patients required a functional reconstruction. The mean follow-up time was 49.63 months. The DASH score analysis reported a mean value of 44.1 ± 26.7. A statistically significant difference was found between groups who underwent different reconstruction techniques, whereas no difference was found regarding exposure to neoadjuvant radiation therapy. The literature review reported few articles focusing on immediate functional reconstruction after STS resection, and only 6 articles were included in the review., Conclusions: Our review aimed at reporting our case series of immediate functional reconstructions after STS of the upper extremity, which is currently the most substantial one reported in literature to set an effective baseline for further studies in the field., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

This study compared postoperative motor recovery between anterior spinal fusion (ASF) and posterior cervical foraminotomy (PCF) in patients with cervical spondylotic radiculopathy (CSR) who had motor deficits. From a database maintained by surgeons across 27 institutions, 227 patients undergoing primary ASF or PCF for CSR without myelopathy were evaluated. Among these, 106 patients with upper-limb motor deficits (manual muscle testing [MMT] grade 0-3) were observed for at least 12 months post-surgery. Data on preoperative and postoperative MMT grades were collected at 3, 6, and 12 months after surgery and at the final follow-up. The recovery of motor function was compared between the ASF and PCF groups using Kaplan-Meier curves and Cox regression analysis. While the overall excellent recovery rates (MMT grade ≥ 2) at the final follow-up were similar between the ASF and PCF group (74 % vs. 86 %, p = 0.15), the PCF group showed significantly faster motor recovery at 3, 6, and 12 months postoperatively, with recovery rates of 43 %, 63 %, and 82 %, respectively, compared to 18 %, 46 %, and 54 % in the ASF group (HR = 1.62, p = 0.031). These findings suggest that PCF may offer a quicker recovery of motor function and could be a more suitable surgical procedure than ASF for patients with CSR and motor deficits., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This article provides an overview of fundamental upper limb prosthesis concepts and componentry, including control systems (body-powered, externally powered, passive, and hybrid), sockets and suspension, and terminal devices., Competing Interests: Disclosures None of the authors have any commercial or financial conflicts of interest and any funding sources., (Published by Elsevier Inc.)

The rising presence of xylazine in Philadelphia's fentanyl supply has led to various upper-extremity complications in individuals who inject drugs. Sociogeographic trends predict that our current local phenomenon will spread nationally. We aim to discuss the drug's impact on clinical presentation and patient care via a cohort of five patients with upper-extremity wounds related to drug use. Interventions included local wound care, revascularization, compartment release, free flap reconstruction, and amputation. Successful treatment of these patients, who are often in challenging psychosocial environments, requires an individualized and interdisciplinary approach including surgical services, infectious disease, wound care, addiction medicine, psychiatry, social services, and prosthetic services., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background:  Studies have shown a significant reduction in breast cancer-related lymphedema (BCRL) rates in patients undergoing complete axillary lymph node dissection (cALND) combined with immediate lymphatic reconstruction (ILR) using lymphovenous bypass (LVB).The purpose of this study was to determine if ILR with LVB at the time of cALND results in a decreased incidence of BCRL and its impact on patient quality of life (QOL)., Methods:  In this prospective cohort study, patients ≥ 18 years requiring cALND underwent ILR from 2019 to 2021. The primary outcome was bilateral upper limb volumes measured by Brørson's truncated cone formula and the Pero-System (3D Körper Scanner). The secondary outcome was QOL measured by the Lymphedema Quality of Life (LYMQOL) arm patient-reported outcome measurement., Results:  Forty-two patients consented to ILR using LVB. ILR was completed in 41 patients with a mean of 1.9 ± 0.9 lymphovenous anastomosis performed. Mean age of patients was 52.4 ± 10.5 years with a mean body mass index of 27.5 ± 4.9 kg/m 2 . All patients ( n  = 39, 100%) received adjuvant therapy after ILR. Mean follow-up was 15.2 ± 5.1 months. Five patients met criteria for lymphedema throughout the duration of the study (12.8%), with two patients having resolution, with an overall incidence of 7.7% by the end of the study period. Patients with lymphedema were found to have statistically significant lower total LYMQOL values at 18 months (8.44 ± 1.17 vs. 3.23 ± 0.56, p  < 0.001). A mean increase of 0.73 ± 3.5 points was observed for overall QOL average for upper limb function at 18 months compared with 3 months ( t  = 0.823, p  = 0.425)., Conclusion:  This study showed an incidence of 7.7% lymphedema development throughout the duration of study. We also showed that ILR has the potential to reduce the significant long-term adverse outcomes of lymphedema and improve QOL for patients undergoing cALND., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Supermicrosurgical lymphaticovenular anastomosis (LVA) is increasingly being recognized as a first-line treatment of limb lymphedema because it is minimally invasive and highly effective. Lymphoscintigraphy and indocyanine green (ICG) lymphography are the two most commonly performed diagnostic imaging examinations to establish the indication and plan the procedure for patients affected by limb lymphedema. In a small group of patients, the information between these two imaging tools can be discordant, showing different anatomical drainage pathways or the absence of drainage and dermal backflow in one examination and valid drainage pathways in the other. The purpose of this study is to examine the types of possible discrepancies between lymphoscintigraphy of the superficial system and ICG lymphography and to describe the surgical outcomes after LVA for patients presenting with such discrepancies., Methods: We retrospectively reviewed the data of all patients who underwent LVA for upper or lower limb lymphedema between July 2015 and July 2023. From this series, we identified a group of patients with nonconcordant imaging results from lymphoscintigraphy and ICG lymphography before lymphatic surgery. Nonconcordant findings were described in terms of "pattern discordance" and "pathway discordance." The surgical outcome was measured by the change in the mean circumference of the limb after surgery. The changes between the preoperative and postoperative limb measures were analyzed using the Student t test. P values < .05 were considered significant., Results: A total of 28 patients with limb lymphedema exhibited inconsistencies between preoperative lymphoscintigraphy of the superficial system and ICG lymphography. Among these patients, 14 experienced pattern discordance, 13 had pathway discordance, and 1 patient had both. After LVA, we observed a significant reduction in the average circumference of the affected limb in the analyzed group., Conclusions: The discrepancy in the information between lymphoscintigraphy and ICG lymphography in the preoperative study of patients affected by limb lymphedema is rare but possible. This phenomenon is still not fully explained; however, our results suggest that it does not correlate with the outcome of supermicrosurgical LVAs., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Novel surgical treatments for painful neuromas are increasingly used, but determining which provides the greatest benefit has been difficult due to the inconsistent use of outcome measures. We mapped the current literature of outcome measures used to evaluate peripheral nerve surgery for the management of symptomatic neuromas in patients who underwent an adult-acquired upper extremity amputation (UEA). Medline, Embase, Cochrane, and CINAHL were searched for primary research written in the English language from inception to February 2023. The search yielded 1137 articles, of which 35 were included for final analysis. Studies varied in their assessment of pain, health-related quality of life (HRQOL), neurotrophic measures, psychological and sensorimotor function, highlighting a consensus on crucial domains but also revealing significant heterogeneity in the use and application of outcome measures among primary studies. Our findings highlight the need to establish common standards that reflect the best evidence and unique needs of the UEA population. This includes developing a core outcome set, utilizing multi-center trials, and maintaining flexibility to adapt to ongoing advancements in patient-reported outcome measures (PROMs) research., (© 2024 The Author(s). Muscle & Nerve published by Wiley Periodicals LLC.)

Background: The impact of infraclavicular versus supraclavicular nerve block on the analgesia for upper limb surgeries is unclear. This meta-analysis and systematic review aims to study the analgesic efficacy of infraclavicular versus supraclavicular nerve block for upper limb surgeries., Methods: We searched several databases including PubMed, EMbase, Web of science, EBSCO and Cochrane library databases from inception to December 2023, and randomized controlled trials (RCTs) assessing the effect of infraclavicular versus supraclavicular nerve block for upper limb surgeries were included. We excluded studies reporting other nerve block approaches. The methodological quality of the included studies was evaluated by the modified Jadad scale. Standard mean difference with 95% confidence interval (CI) was used to assess continuous outcomes. This meta-analysis was conducted by the fixed-effect model or random-effect model based on the heterogeneity., Results: Eight RCTs and 725 patients were included in this meta-analysis. Compared with supraclavicular nerve block for upper limb surgeries, infraclavicular nerve block was able to significantly increase duration of motor block (SMD = 0.34; 95% CI = 0.12 to 0.56) and decrease readiness for surgery (SMD = -0.43; 95% CI = -0.77 to -0.10), but showed similar duration of sensory block (SMD = 0.17; 95% CI = -0.05 to 0.39), block performance time (SMD = -0.14; 95% CI = -0.51 to 0.22), onset of sensory blockade (SMD = -0.13; 95% CI = -0.59 to 0.33) and onset of motor blockade (SMD = -0.17; 95% CI = -0.26 to 0.12). No high heterogeneity was seen among the included studies., Conclusion: Infraclavicular nerve block may be superior to control the analgesia for upper limb surgeries than supraclavicular nerve block., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To investigate the feasibility and effectiveness of ulnar cortex transverse transport technique in treating upper extremity thromboangiitis obliterans (TAO)., Methods: A retrospective analysis was conducted on the clinical data of 7 male patients with upper extremity TAO who were admitted and met the inclusion criteria between January 2019 and July 2022. The patients ranged in age from 32 to 50 years, with a mean age of 40.1 years. The disease duration ranged from 6 to 24 months, averaging 13.6 months. The smoking history ranged from 8 to 31 years, with a mean of 18.4 years. All patients presented with finger ulcers or gangrene, including 1 case affecting the thumb and index finger, 1 case affecting the index and middle fingers, 1 case affecting the middle and ring fingers, 1 case affecting only the ring finger, and 3 cases affecting the ring and little fingers. The preoperative visual analogue scale (VAS) score was 9.1±0.7. All patients underwent treatment with the ulnar cortext transverse transport technique. The wound healing time and the disappearance time of rest pain were recorded. The VAS score was used to assess the degree of hand pain before and after operation. Serum interleukin 6 (IL-6) levels were measured before operation and at 1 month after operation. Computed tomography angiography (CTA) of the affected limb was performed before operation and at 3 months after operation to evaluate changes in blood vessels. The clinical outcomes were evaluated at 1 year after operation based on the Patwa and Krishnan grading system., Results: All 7 patients were followed up 12-17 months, with an average of 13.7 months. All patients experienced successful healing of ulcers, with wound healing time ranging from 14 to 21 days, averaging 17.3 days. During the follow-up, no complication occurred, and there was no recurrence of ulcers. The disappearance time of rest pain ranged from 8 to 15 days, averaging 12.1 days. The pre- and post-operative (1-month) serum IL-6 levels were (25.1±5.9) pg/mL and (11.9±2.9) pg/mL, respectively, with a significant difference ( t =5.363, P =0.002). CTA examination at 3 months after operation revealed partial revascularization of upper extremity arteries and establishment of collateral circulation, showing significant improvement compared to preoperative status. The VAS scores at 1, 7, 28 days, and 6 months postoperatively were 6.4±0.8, 3.7±0.8, 0.6±0.8, and 0.1±0.4, respectively, all of which significantly improved compared to preoperative scores ( P <0.05). Furthermore, the VAS scores gradually decreased over time, with significant differences observed between postoperative time points ( P <0.05). At 1 year after operation, the effectiveness of all 7 patients were evaluated as excellent based on the Patwa and Krishnan grading system., Conclusion: The ulnar cortex transverse transport technique can improve blood circulation in the upper limb of patients with TAO, reconstruct microcirculation, inhibit inflammation, promote ulcer healing, and alleviate limb pain.

Importance: An upper-extremity approach for secondary access during transfemoral transcatheter aortic valve implantation (TAVI) may reduce clinically relevant secondary access site-related bleeding., Objective: To investigate the safety and efficacy of an upper-extremity approach compared with a lower-extremity approach in patients undergoing TAVI., Design, Setting, and Participants: The TAVI XS trial was a randomized clinical trial performed between November 28, 2022, and November 15, 2023, with a 30-day follow-up, in 4 TAVI centers in the Netherlands. Eligibility was determined first, and only those patients with severe aortic stenosis and no contraindication for upper- or lower-extremity secondary access were informed about the study and asked to participate., Intervention: Participants were randomized 1:1 between the upper-extremity approach (radial artery diagnostic access and upper-arm vein for temporary pacing lead placement) and lower-extremity approach (femoral artery diagnostic access and femoral vein for temporary pacing lead placement) for secondary access during TAVI., Main Outcomes and Measures: Primary end point was clinically relevant bleeding (Bleeding Academic Research Consortium type 2, 3, or 5) of the randomized secondary access. Secondary end points included any clinically relevant bleeding, time to mobilization, duration of hospitalization, secondary access failure, and procedural time., Results: Of a total of 324 eligible patients, 238 patients undergoing transfemoral TAVI (mean [SD] age, 79.4 [6.5] years; 150 male [63.0%]; median European System for Cardiac Operative Risk Evaluation II score, 2.2% [IQR, 1.5%-3.5%]) were included. The primary end point occurred in 5 of 119 patients (4.2%) in the upper-extremity group and 16 of 119 (13.4%) in the lower-extremity group (odds ratio [OR], 0.28 [95% CI, 0.10-0.80]; P = .01). Incidence of any clinically relevant bleeding was decreased in the upper-extremity group (25 of 119 [21.0%] vs 41 of 119 [34.5%] patients; OR, 0.51 [95% CI, 0.28-0.91]; P = .02). There was no difference in time to mobilization or duration of hospitalization. Secondary access failure (14 of 119 [11.8%] vs 1 of 119 [0.8%] patients; OR, 15.73 [95% CI, 2.03-121.69]; P = .001) and procedural time (60.0 [IQR, 39.0-88.0; 95% CI, 53.0-70.0] vs 48.0 [IQR, 34.0-64.0; 95% CI, 40.0-55.0] minutes; P = .002) were higher in the upper-extremity cohort., Conclusion and Relevance: In this randomized clinical trial of patients undergoing transfemoral TAVI, the upper-extremity approach for secondary access was associated with less clinically relevant access site-related bleeding compared with the conventional lower-extremity approach and should be considered to reduce periprocedural bleeding complications., Trial Registration: ClinicalTrials.gov Identifier: NCT05672823.

Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Peripheral nerve surgeries for compressive neuropathy in the upper extremity are generally successful. However, cases that either fail or have complications requiring revision surgery are challenging. During revision consideration, surgeons should perform a comprehensive preoperative workup to understand the etiology of the patient's symptoms and categorize symptoms as persistent, recurrent, or new in relation to the index procedure. Revision surgery often requires an open, extensile approach with additional procedures to optimize outcomes. Even with proper workup and treatment, clinical outcomes of revision surgeries are inferior compared to primary surgeries and patients should be well informed prior to undergoing such procedures., Competing Interests: Disclosure The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment., Competing Interests: Disclosure T.K.K. Chan has no disclosure. Dr K.C. Chung receives funding from the National Institutes of Health, United States and book royalties from Wolters Kluwer and Elsevier., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Reconstruction of bony defects is challenging. Most cases can be solved by means of nonvascularized bone grafts, either corticocancellous or cancellous. However, when the defect is long, there is a combined soft tissue defect, infection, a poor scarred bed, and when a piece of cartilage needs to be included, a vascularized bone graft is preferred. This article features a review of the most useful flaps for small and long defects in the hand and upper limb., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Upper extremity amputation can lead to significant functional morbidity. The main goals after amputation are to minimize pain and maintain or improve functional status while optimizing the quality of life. Postamputation pain is common and can be addressed with regenerative peripheral nerve interface surgery or targeted muscle reinnervation surgery. Both modalities are effective in treating residual limb pain and phantom limb pain, as well as improving prosthetic use. Differences in surgical technique between the 2 approaches need to be weighed when deciding what strategy may be most appropriate for the patient., Competing Interests: Disclosure T.A. Kung is the chief medical officer and cofounder of Blue Arbor Technologies, Inc, a prosthetics interface company. Otherwise, the authors have no commercial or financial conflicts of interest or any other funding sources related to this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Summary: Innovations in prosthetic devices and neuroprosthetic control strategies have opened new frontiers for the treatment and rehabilitation of individuals undergoing amputation. Commercial prosthetic devices are now available with sophisticated electrical and mechanical components that can closely replicate the functions of the human musculoskeletal system. However, to truly recognize the potential of such prosthetic devices and develop the next generation of bionic limbs, a highly reliable prosthetic device control strategy is required. In the past few years, refined surgical techniques have enabled neuroprosthetic control strategies to record efferent motor and stimulate afferent sensory action potentials from a residual limb with extraordinary specificity, signal quality, and long-term stability. As a result, such control strategies are now capable of facilitating intuitive, real-time, and naturalistic prosthetic experiences for patients with amputations. This article summarizes the current state of upper extremity neuroprosthetic devices and discusses the leading control strategies that are critical to the ongoing advancement of prosthetic development and implementation., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Limb amputation can lead to significant functional challenges in daily activities, prompting amputees to use prosthetic devices (PDs). However, the cognitive demands of PDs and usability issues have resulted in user rejections. This study aimed to create a Human Performance Model for Upper-Limb Prosthetic Devices (HPM-UP). The model used formulations of learnability, error rate, memory load, efficiency, and satisfaction to assess usability. The model was validated in an experiment with 30 healthy participants using a bypass prosthetic device. Findings indicated that the HPM-UP successfully predicted the usability of prosthetic devices, aligning with human subject data. This research proposes a quantitative approach to predict upper limb prosthetic device usability by quantifying each dimension and computationally connecting them. The model, available on Github and executable with Rstudio, could enable clinicians to assess and analyze the human performance of various commercial prostheses, aiding in recommending optimal devices for patients., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: American hospitals are required to provide price transparency data (known as a chargemaster) for medical services, which is intended to allow consumers to accurately estimate the cost of medical services. Our purpose was to identify hospital compliance in publishing chargemaster documents and to assess the price information published for common upper-extremity services and procedures., Methods: We performed a cross-sectional analysis of publicly available chargemaster data from 122 hospitals, which included the top-20-ranked Honor Roll hospitals from US News and World Report and 2 top-ranked hospitals from each state. Chargemaster files were accessed for each hospital, and price information was recorded for 10 common upper-extremity procedures including radiographs, injections, and surgeries. Mean procedural prices were compared between academic and nonacademic hospitals., Results: Chargemaster files were able to be accessed for 107 (88%) of 122 institutions. Price estimates for imaging studies were more frequently reported (73%) than those of procedures (23%-41%). With 50 hospitals reporting a price estimate, carpal tunnel injection was the most frequently reported procedure, whereas trigger finger release was the least frequently reported (41% and 23%, respectively). Wide price ranges were noted, with mean charges for a total shoulder arthroplasty listed as US $51 723 (range, US $247-US $364 024). Mean prices between academic and nonacademic hospital systems were similar., Conclusions: While most (88%) of the included hospitals have been compliant with publishing their price transparency files, price estimates for common upper-extremity procedures and imaging studies are inconsistently reported and, when present, demonstrate high levels of price variability between and within hospital systems., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Postoperative care is essential to upper extremity replantation success and includes careful and frequent monitoring of the replanted part. During this period, pharmacologic agents such as antithrombotic and anticoagulants may prevent complications such as arterial thrombosis and venous congestion. Dressings and therapy can also impact short- and long-term outcomes following replantation. This article reviews the literature to provide guidance for postoperative protocols following upper extremity replantation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Controversy exists regarding the role of specific etiology and mitigating factors in perioperative upper extremity peripheral neuropathy (PUN) development during oral and maxillofacial surgery (OMS) procedures., Purpose: The purpose of this study was to measure the association between upper extremity (UE) positioning and developing PUN in OMS operations., Study Design, Setting, Sample: The investigators implemented a retrospective cohort study. Patients referred to the Department of Oral and Maxillofacial Surgery at Jefferson Health who underwent orthognathic, telegnathic, or free flap surgery from April 2017 through December 2021 were identified. Exclusion criteria were age less than 13, revision surgery, ablative case without free flap reconstruction, incomplete medical record, pre-existing neuropathy, and UE position other than tucked or abducted., Predictor Variable: The predictor variable was UE position during surgery, which had 2 levels-tucked or abducted., Main Outcome Variable: The outcome variable was self-reported development of PUN, defined as new sensory and/or motor deficit in a nonoperated extremity diagnosed within 48 hours of surgery., Covariates: Demographic covariates included age, gender, and race. Perioperative covariates included American Society of Anesthesiologists physical status and body mass index (BMI). The operative covariate was general anesthesia (GA) duration., Analyses: Descriptive statistics were calculated. Shapiro-Wilk test was used to assess normality of the sample. Categorical variables were analyzed with Fisher's exact test. Continuous variables were analyzed with Mann-Whitney U test. Significance was defined at P < .05., Results: Of the 432 patients identified, 342 met inclusion criteria. Median (interquartile range) ages for the abducted and tucked cohorts were 40 (31) and 34 (28) years, respectively (P < .01). Males comprised 55.4% (n = 41) and 54.1% (n = 145) of abducted and tucked groups, respectively (P = .9). PUN frequency was 6.8% (n = 5) for abducted subjects and 3.7% (n = 10) for tucked subjects (relative risk 1.8, 95% confidence interval [0.7, 5.1]; P = .33). PUN was associated with gender (P = .01), American Society of Anesthesiologists status (P = .03), BMI (P = .01), and GA duration (P < .01) on bivariate analysis. When adjusting for covariates, only GA duration (P < .01) and BMI (P = .03) were associated with PUN development., Conclusion and Relevance: The findings suggest that PUN development during OMS procedures was not associated with UE position., (Copyright © 2024 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Nerve transfer for motor nerve paralysis is an established technique for treating complex nerve injuries. However, nerve transfer for sensory reconstruction has not been widely used, and published research on this topic is limited compared to motor nerve transfer. The indications and outcomes of nerve transfer for the restoration of sensory function remain unproven. This scoping review examines the indications, outcomes and complications of sensory nerve transfer. In total, 22 studies were included; the major finding is that distal sensory nerve transfers are more successful than proximal ones in succeeding protective sensation. Although the risk of extension of the sensory deficit with donor site loss and morbidity from neuromas remain a barrier to wider adoption, these complications were not reported in the review. Further, the scarcity of studies and small patient series limit the ability to determine sensory nerve transfer success. However, sensory restoration remains an opportunity for surgeons to pursue. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cerebral palsy (CP) in upper limb produces functional, aesthetic and hygienic issues, and is not always amenable to surgical procedures. We are reporting a single-center, long follow-up experience with tendon transfer in wrist and forearm CP. The CP cases who had undergone tendon transfer in hand, wrist and forearm in a 14-year period were evaluated for change in motion, function and cosmetic appearance and also assessed by Manual Ability Classification System (MACS), and Dash (Disability of Arm, Shoulder, Hand) scores. Forty-two spastic CP patients with a mean age of 19.81 (10-34 years, SD: 5.36) years with a mean follow-up of 5.5 (2-14) years, entered the study. 24 cases were GMFCS I or II and 18 were III or IV. Supination beyond neutral was seen in 48.5%, and improvement in MACS scores in all the cases. Improved 'grasp' and 'release' and keyboard use was seen in 50%, 71% and 87% respectively. The satisfaction from appearance and improved function of 83-96% correlated positively with GMFSC, MACS and DASH scores. Noticeable improvement in personal hygienic care was seen in only 52% of cases. Tendon transfer in well-selected spastic upper extremity CP cases results in long-time improved function, and limb appearance - correlating with initial GMFCS and MACS scores., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality., Research Question: There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients., Methods and Materials: An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness., Results: The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up., Conclusion: Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation. Level of evidence : IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

There is currently an overprescription of opioids, which may result in abuse and diversion of narcotics. The aim of this systematic review was to investigate opioid prescription practices and consumption by patients after upper extremity surgery. This review was registered a priori on Open Science Framework (osf.io/6u5ny) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search strategy was performed using MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases (from their inception to October 17, 2021). Prospective studies investigating opioid consumption of patients aged 18 years or older undergoing upper extremity surgeries were included. The Risk of Bias in Nonrandomized Studies of Interventions and Risk of Bias 2.0 tools were used for quality assessment. In total, 21 articles met the inclusion criteria, including 7 randomized controlled trials and 14 prospective cohort studies. This represented 4195 patients who underwent upper extremity surgery. Most patients took less than half of the prescribed opioids. The percentage of opioids consumed ranged from 11% to 77%. There was moderate to severe risk of bias among the included studies. This review demonstrated that there is routinely excessive opioid prescription relative to consumption after upper limb surgery. Additional randomized trials are warranted, particularly with standardized reporting of opioid consumption and assessment of patient-reported outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Brachial plexus block for hand and upper extremity procedures in the obese presents a unique set of technical challenges. The authors examined how obesity affects procedural success, quality of anesthesia, and patient satisfaction., Methods: Secondary analysis of a randomized control trial comparing the retroclavicular versus supraclavicular brachial plexus block for distal upper extremity surgery was conducted. Patients were randomized to supraclavicular or retroclavicular brachial plexus block groups in the original trial. In this study, the authors dichotomized patients by obesity to compare differences in outcomes., Results: Sixteen of 117 patients (13.7%) were obese. The groups were statistically well balanced in terms of baseline and operative variables. Obese patients had increased imaging time 2.7 minutes (95% confidence interval [CI], 1.44-3.92) versus 1.9 minutes (95% CI, 1.64-2.16), P value = .05; needling time 6.6 minutes (95% CI, 5.17-7.95) versus 5.8 minutes (95% CI, 5.04-5.74), P = .02; and procedure time 9.3 minutes (95% CI, 7.04-11.46) versus 7.3 minutes (95% CI, 6.79-7.79), P = .01. Block success and complications were not statistically significant. The visual analog scores during the block, at 2 hours, and 24 hours after were not statistically different. Patient satisfaction score among obese patients was 9.1 (95% CI, 8.6-9.6) versus 9.2 (95% CI, 9.1-9.4), P = .63., Conclusion: Findings from this trial suggest that despite an increased procedural difficulty, the use of both supraclavicular and retroclavicular brachial plexus blocks is associated with comparable quality of anesthesia, similar complication profile, equal opioid requirements, and similar patient satisfaction in the obese., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.