Narrow Results

The conventional hand tendon zones and subzones do not reflect the actual lengths covered by the involved locus of the tendon during full digital and wrist motion, which warrant reappraisal of the tendon zone concept. Because of the tendon excursions many lacerations should be regarded as multiple zone injuries. Furthermore, the length-spans of glide of the distal tendon stump and of the tendon junction (i.e. the glide zones of tendon injury and repair, respectively) are mostly not of the same length because, due to pulley release and bulkiness of the tenorrhaphy, the glide zone of tendon repair is shorter than that of tendon injury. Therefore, it would be practical to notate the glide zones of the lacerated tendon by indicating the anatomic position of the distal tendon stump and tendon junction in full extension and flexion. This data can be provided separately or along with the conventional tendon zones, e.g. II (A4–C2) or II–III (A2–PA), where A, C, and PA stand for the annular, cruciform, and palmar aponeurosis pulleys, respectively. The conventional tendon zone classification could be improved with a tendon glide zone concept. Documentation of the actual excursions of the distal tendon stump and of the tenorrhaphy interface would prevent misinterpretation of the actual level of tendon injury and repair.

Coronavirus disease-19 has affected million of people worldwide, constituting the biggest social, economic, and health crisis since World War 2. During this pandemic, the hospitals have become hot zones for the treatment of patients. Therefore, it is important to take the appropriate protective measures and ensure the physician’s health and, especially, those who work in the intensive care units and in operating rooms. In this letter, we are trying to make a discussion regarding the measures that should be considered by the healthcare workers who are facing this invisible enemy during their effort to provide their services in the surgery rooms.

Background: Osteoarthritis of the thumb base is the second most prevalent arthritis of the hand. Management is primarily conservative, consisting of analgesia, splinting, physiotherapy, and steroid injections. Surgery is considered when conservative measures fail.

Methods: The primary objective was to assess the safety and efficacy of the surgical interventions and therein, evaluate whether any superiority exists among the available interventions. Efficacy was evaluated by examining four parameters: pain, function, range of movement and strength of the joint postoperatively. Safety was determined by comparing the rate and severity of postoperative complications. A systematic search of MEDLINE (2014–2019), EMBASE (2014–2019), CINAHL (2014–2019) and CENTRAL (2014–2019) databases was carried out. Abstracts were screened for relevant studies. Randomised controlled trials were only considered.

Results: Eight studies were included in the quantitative synthesis. The procedures evaluated are: Trapeziectomy (T), trapeziectomy with ligament reconstruction (T + LR), trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI), trapeziectomy with allograft suspension (T + ALS) and joint arthrodesis (A). Low-moderate quality evidence suggests that T + LRTI yields better range of movement (palmar abduction) when compared with (T) alone; (SMD 0.61, 95% CI 0.22 to 1.00, random-effects, p = 0.002). Comparing adverse events showed that arthrodesis carries a greater risk of adverse events when compared with T + LRTI; (RR 0.33, 95% CI 0.17 to 0.61, random-effects, p = 0.0005). In addition, T + LRTI is preferred over arthrodesis by patients (OR 0.29 95% CI 0.09 to 0.95; p = 0.04). This difference was no seen in the other comparison groups.

Conclusions: It is difficult to declare with any degree of certainty which procedure offers the best functional outcome and safety profile. Results suggest T + LRTI yields good postoperative range of movement. Arthrodesis demonstrated an unacceptably high rate of moderate-severe complications and should be considered with careful consideration.

Background: The precise etiology of carpal tunnel syndrome (CTS) remains unclear. One of the accepted factors for CTS is the restriction of the median nerve. Previous reports using ultrasound had only observed and measured the movement of parts of the median nerve. In this study, we aimed to elucidate the difference in the movement of the entire median nerve in patients with CTS (before and after surgery) and healthy volunteers using a new measurement method.

Methods: We expressed the amount of movement of the entire nerve by a new method creating the motion area of the median nerve (MAMn) from an ultrasonographic video image on the computer. We compared the MAMn, the real MAMn (RMMn) (the value obtained by subtracting the nerve cross-sectional area from the MAMn), and mobile ratio (MR) (the value obtained from dividing the MAMn by the nerve cross-sectional area) between six wrists of six cases of CTS (before and at an average of 3.5 months after surgery) and six wrists of six healthy volunteers.

Results: During passive wrist flexion, the average MAMn, RMMn, and MR of healthy cases were 23.1 mm², 16.4 mm², and 3.52, respectively. The average MAMn, RMMn, and MR of cases of CTS were respectively 11.8 mm², 5.4 mm², and 1.86 preoperatively; and 16.2 mm², 7.3 mm², and 1.87, postoperatively. The MAMn, RMMn, and MR decreased more significantly in patients with CTS than in healthy volunteers (p < 0.01). The MAMn and RMMn increased postoperatively (p < 0.05), but the MR remained low.

Conclusions: The new measurement method revealed that the mobility of the entire median nerve was significantly restricted in cases of CTS compared to healthy participants. However, after surgery, nerve restriction was not restored despite improvements in symptoms, suggesting that decreases in nerve mobility contribute to CTS but are not a direct cause of symptoms.

Background: No consensus exists regarding the management of complete collateral ligament injuries of the proximal interphalangeal joint (PIPJ) of fingers.

Methods: We aimed to systematically review the outcomes of Acute (< 1 month) surgical repairs of these injuries. Outcomes assessed included Stability, Pain, Range-of-Motion and Return to Function. The Modified Coleman Methodology Score (MCMS) was utilised in critical appraisal.

Results: 70 patients with complete collateral ligament injuries of the PIPJ were identified in 5 studies. 49 were managed operatively and 21 non-operatively. All trials were methodologically flawed with a mean MCMS of 50.4, corresponding to a “Poor” Level of evidence.

Conclusions: Whilst acute surgical repair of complete collateral ligament injuries of finger PIPJs are a described viable management option with promising results, there is insufficient high-quality evidence to inform current practice. Based on the current literature, no evidence-based conclusions can be made regarding superiority of acute surgical repair over conservative management or one method of surgical repair over another. Further high level studies are required.

Background: An open approach is the gold standard for trigger finger (TF) release. However, this may be associated with infection and scar tenderness. Percutaneous trigger release is an alternative, but this can sometimes result in incomplete release and digital nerve injury, even with ultrasound (US) guidance. Limited-open TF release is an intermediate technique that uses a specially designed knife via a 2–3 mm incision. The aim of this study is to compare the outcomes of blinded versus US-guided limited-open TF release using the Yasunaga knife (Medical U&A, Inc., Japan).

Methods: About 138 fingers in 111 patients underwent limited-open TF release using the Yasunaga knife. Green classification was used to grade the severity of TF. Thirty-one patients had grade 3 TF and 80 patients had grade 4 TF. The TF was released in a blinded fashion in 60 patients and using US guidance in 51 patients. Outcome measures included residual triggering, contracture of the proximal interphalangeal joint, visual analog scale (VAS) for assessment of pain, Quick Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patel and Moradia grading of patient satisfaction. Complications were also recorded.

Results: Six patients had residual triggering in the blinded group, whereas it resolved in all patients in the US-guided group. This difference was statistically significant (p = 0.03). Patients in both groups showed significant improvement in VAS and Quick DASH score postoperatively. There were no significant differences between the two groups for these two outcomes. Patient satisfaction was graded as excellent by 20 patients and good by 30 patients in the US-guided group compared to eight excellent and 45 good in the blinded group.

Conclusion: The incidence of residual triggering was lower and overall satisfaction higher in patients who underwent US-guided limited-open TF release using the Yasunaga knife.

Level of Evidence: Level III (Therapeutic)

Background: Syndactyly is one of the commonly encountered congenital hand anomalies. However, there are no strict guidelines regarding the timing of surgical release. The aim of this study was to investigate the age and factors associated with syndactyly release in the United States.

Methods: A retrospective analysis of the California and Florida State Ambulatory Surgery and Services Databases for patients aged 18 years or younger who underwent syndactyly release surgery between 2005 and 2011 was performed. Demographic data that included the age at release, gender, race and primary payor (insurance) was collected. A sub-analysis was performed to compare the demographic characteristics between those patients undergoing syndactyly release before 5 years of age (‘Early Release’) and at (of after) 5 years (‘Late Release’).

Results: A total of 2,280 children (68% male, 43% Caucasian) were identified. The mean age of syndactyly release was 3.6 years, and 72.9% of patients underwent release before the age of 5 years. A significantly larger proportion of females (p = 0.002), and Hispanics and African Americans (p = 0.024), underwent late release compared to early release. Additionally, a significantly higher percentage of patients undergoing late release utilised private insurance (p = 0.005). However, the actual differences in gender, race and primary payor were small.

Conclusion: The majority of syndactyly releases were performed before school age, which is the primary goal in the management of syndactyly. While gender and racial disparities in the surgical treatment of syndactyly may exist, the differences in the present study were relatively small.

Level of Evidence: Level III (Therapeutic)

Background: There is no consensus for the appropriate surgical management of symptomatic chronic ulnar collateral ligament (UCL) injuries of the thumb. The aim of this study is to systematically review the treatment of chronic thumb metacarpophalangeal (MCP) joint UCL injuries to determine the optimal approach to treatment.

Methods: A systematic review of PubMed, Medline, Embase and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-Analysis (PRISMA) guidelines.

Results: Data from 11 studies using various surgical techniques in 245 thumbs were heterogenous and meta-analysis of results not possible. These data were qualitatively assessed. Direct repair, reconstruction with free tendon grafts and arthrodesis all demonstrated favourable outcomes with patient-reported outcome measures (PROMs).

Conclusions: Direct repair can be safely performed more than 2 months following injury. Arthrodesis may be considered in heavy manual labourers or those with osteoarthrosis. Tendon grafting is safe, yet the optimal type and configuration are yet to be determined for reconstructive methods.

Level of Evidence: Level III (Therapeutic)

Background: A flexion contracture (FC) of the proximal interphalangeal (PIP) joint can have a profound negative influence on daily activity. The outcomes of surgical release of the PIP joint in literature are based on small sample size studies done several decades ago. The aim of this study is to report the outcomes of surgical treatment for post-traumatic FC of the PIP joint and to identify factors that affect these outcomes.

Methods: This single institute retrospective study included patients from 2000 to 2020. We only included patients with post-traumatic FC of the PIP joint. We evaluated the demographic characteristics, cause of FC, surgical approaches and the various procedures conducted. We surveyed postoperative complications. During the study period, we asked about their current symptoms and evaluated their operative outcomes as excellent, good, fair or poor through the phone.

Results: The average FC recovery angle was 37.3°. The small finger was the most affected, and the most common cause of FC was a tendon laceration. The volar plate complex release was the most frequently conducted procedure. The FC improvement was positively correlated to the degree of preoperative FC. The more severe preoperative flexion–extension arc was presented, the more FC recovery was achieved after operation. Patients who underwent multiple procedures had a higher degree of preoperative FC, and better correction was achieved with multiple procedures than with a single procedure. The most critical complication was recurrence.

Conclusions: We were able to obtain average 37.3° of extension by surgical treatment. The more severe the FC presented before surgery, the greater the need for multiple procedures, however, this resulted in a significant increase in joint extension. Nevertheless, caution should be exercised regarding recurrence and could occur even with an experienced surgeon.

Level of Evidence: Level IV (Therapeutic)

Background: To restore distal radioulnar joint stability following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be necessary. Post-surgery rehabilitation is prescribed to restore wrist and hand function; however, no universally accepted or definitive rehabilitation protocol currently exists. The aim of this study was to survey hand and wrist surgeons regarding their recommended postoperative rehabilitation protocols following TFCC foveal repair surgery.

Methods: Australian hand and wrist surgeons were invited to complete a descriptive survey containing 10 questions. Questions included clinical recommendations for wrist and forearm immobilisation, range of motion (ROM) exercise timeframes and surgeon experience of TFCC rupture. Descriptive statistics and between-group (TFCC rupture vs. no-rupture) comparisons (Pearson’s Chi²) were calculated.

Results: Thirty-one surgeons completed the survey. Recommendations for post-surgery immobilisation ranged from ‘not required’ to 8 weeks (mode 6 weeks). Wrist and forearm ROM commencement time ranged from ‘immediately’ to ‘later than 8 weeks’ (mode 6 weeks). The most recommended orthosis was a ‘sugar-tong’ (57%). Thirty-seven percent (37%) reported experience of post-surgery re-rupture.

Conclusions: While surgeon recommendations varied, the majority recommended 4- to 6-week timeframe for immobilisation and ROM exercise commencement. Additional clinical research is recommended to evaluate whether postoperative rehabilitation decisions influence patient outcomes.

Level of Evidence: Level V (Therapeutic)

Automatic detection of the current task load of a surgeon in the theatre in real time could provide helpful information, to be used in supportive systems. For example, such information may enable the system to automatically support the surgeon when critical or stressful periods are detected, or to communicate to others when a surgeon is engaged in a complex maneuver and should not be disturbed. Passive brain–computer interfaces (BCI) infer changes in cognitive and affective state by monitoring and interpreting ongoing brain activity recorded via an electroencephalogram. The resulting information can then be used to automatically adapt a technological system to the human user. So far, passive BCI have mostly been investigated in laboratory settings, even though they are intended to be applied in real-world settings. In this study, a passive BCI was used to assess changes in task load of skilled surgeons performing both simple and complex surgical training tasks. Results indicate that the introduced methodology can reliably and continuously detect changes in task load in this realistic environment.

Background: Ectopic pregnancy remains the most common cause of early pregnancy mortality, with management options differing according to clinical presentation and investigations. This audit aims to investigate the indications for medical and surgical management of ectopic pregnancy at a tertiary hospital network, in order to assess variances in practice and adherence to local hospital protocols.

Methods: A retrospective audit of the management of women with a diagnosis of ectopic pregnancy was performed over 12 months from July 2018 to June 2019, at three hospitals in the largest healthcare network in Victoria, Australia. Information collected included patient demographics, risk factors for ectopic pregnancy, pathology and radiology results, documented indication for surgery, and any complications of treatment. A subgroup analysis of data was done to investigate changes and deficiency in management of ectopic pregnancy compared to local hospital protocol.

Results: Over a 12-month period, 138 women were diagnosed with an ectopic pregnancy, of which 99 (72%) received surgical management and 39 (28%) received medical management. Four women within the medical group were excluded from analysis, one due to loss of follow-up and three patients who were diagnosed with nontubal ectopic pregnancies. About 94% (33/35) of women who received methotrexate were within hospital guidelines for medical management and 91% (32/35) were successfully managed without surgery. All women who received surgical management underwent a salpingectomy and 97% (96/99) had clear indications documented for surgery within local protocol.

Conclusion: Overall, the majority of women with ectopic pregnancy were treated according to local guidelines. Expectant management and the option of salpingostomy as a surgical alternative could be considered in the local guidelines. The dissemination of this clinical audit data is aimed at continuing clinical governance and improvements in outcomes.

The practice of thoracic surgery is a model of using a multidisciplinary approach to the care of patients, particularly in the area of cancer. These diseases include primary malignancies of the lung, esophagus, pleura, chest wall, airway and mediastinum; less commonly, metastatic deposits to the lung, pleura, chest wall and mediastinum require the thoracic surgeon's attention for diagnosis, for potential curative resection, or for palliative intervention. The optimal and efficient approach to diagnosing, staging, and managing patients with thoracic malignancies is constantly evolving, with the choices available to the patient becoming ever more complex. Yet, the care is moving toward personalization, based on certain factors such as demographics, staging characteristics, and biologic markers. Thus, the traditional roles of the individual disciplines managing these patients are constantly being challenged and are becomes less frequent. As a result of advanced imaging technologies and patient demand for ‘minimally invasive’ procedures, several disciplines are now providing overlapping services. The input from a wide range of these specialists demonstrates the importance of a multidisciplinary approach to optimize treatments and to streamline care. Weekly conferences are held to discuss these complex patients, and a list of those whose services are often required is listed in Table 1. This chapter will focus on the common diagnostic, staging, and therapeutic modalities that are available to the clinician taking care of the patients with non-small cell lung cancer (NSCLC). In particular the aspects of management that fall ‘in-between’ disciplines will be the focus of this discussion.

Over 95% of all oesophageal cancers are either adeno- or squamous cell carcinomas. With increasing growth they cause dysphagia, weight loss and bleeding. Diagnosis is made with endoscopy and biopsy, and staging is completed by endoscopic ultrasound, abdomino-thoracic CT scan and PET. The UICC TNM classification is used to stage oesophageal tumours, and in gastro-oesophageal junction tumours the anatomical classification described by Siewert is commonly used when planning surgical resection.

Patients with locally resectable tumours and no distant metastases are classified as curative candidates. For these patients the gold standard for treatment is surgery with or without neoadjuvant radio-chemotherapy. Tumours stage T2 or higher and/or N1 are usually considered for neoadjuvant treatment. Additional to the oncological staging, a risk analysis for each individual patient should be performed as oesophagectomy is associated with significant risks of morbidity and mortality. Co-morbidity, age and the number of surgical procedures performed by the treating institution are important predictors of outcome. Surgery is performed either with open, or minimal invasive techniques. The stomach is most commonly used conduit to replace the oesophagus, with a segment of large bowel an alternative in some individuals. Post-operative morbidity includes anastomotic leak, empyaema, chylothorax, and most importantly respiratory complications. After multimodal treatment, survival is between 20% and 40% at five years.

In patients with locally advanced tumours, metastases, or who are unfit for surgery, definitive radio-chemotherapy is the treatment of choice. Standard treatment regimens include radiotherapy (50 to 60 Gy) and chemotherapy with 5-FU and Cisplatin. If stenosis or obstruction is present, adjuvant interventions such as stent placement, dilatation and argon plasma ablation may be used.

Management of liver neoplasia is a multidisciplinary endeavour. In the non-cirrhotic liver resectional surgery has a well-defined place in the management of primary liver tumours. In the cirrhotic liver, the approach to treatment of hepatocellular carcinoma depends on the severity of underlying liver disease and the size of the tumour. The best long term results are achieved with transplantation regardless of severity of liver failure, but the number and size of lesions is important. Liver resection can be used in any size lesion, but the extent of resection possible is dependent on the severity of liver disease. As with ablative methods, the tumour volume is an important prognostic factor. Colorectal cancer is the most common secondary liver cancer with a chance of cure following surgical resection. Surgical resection is becoming more aggressive, as more sophisticated techniques and increasing chemotherapeutic options allow removal of more advanced tumours. The role and timing of surgery, local ablation, chemotherapy and adjuvant chemotherapy are explored in the setting of both synchronous and metachronous disease. Surgical resection and the chance of cure is possible in a subset of patients with neuroendocrine liver metastases, but pharmacological and chemotherapeutic therapies are available if resection is not possible. Surgery is less applicable in non-colorectal, non-neuroendocrine tumours, but in some circumstances, it may be of benefit.

We use surgery along Brunnian links to relate, via a certain isomorphism, the Goussarov-Vassiliev theory for Brunnian links and the finite type invariants of integral homology spheres. To do so, we show that no finite type invariant of degree < 2n − 2 can vary under surgery along an (n + 1)-component Brunnian link in a compact connected oriented 3-manifolds, where the framing of the components is in .

Let X be a compact connected orientable Haken 3-manifold with boundary, and let M(X) denote the 4-manifold ∂(X × D²). We show that if (f, b) : N → M(X) is a degree 1 TOP normal map with trivial surgery obstruction in L₄(π₁(M(X))), then (f, b) is TOP normally bordant to a homotopy equivalence f′ : N′ → M(X). Furthermore, for any CW-spine B of X, we have a UV¹-map p : M(X) → B and, for any ɛ > 0, f′ can be chosen to be a p⁻¹(ɛ)-homotopy equivalence.

In this chapter, the humane use of animals in surgical research is described, with reference to Russell and Burch's The Principles of Humane Experimental Technique (1992) — commonly known as the 3R's of replacement, reduction, and refinement — as well as the ethical need for researchers to justify the experiment and take responsibility for the well-being of animals in their care. The basic role of animal ethics committees is also discussed. The chapter then describes in practical terms the preparation of the experimental animal for surgery; the techniques for anesthesia, including knock-down, intubation, and maintenance; and the drugs used for premedication before anesthesia, maintenance of anesthesia, and, most importantly, pre-emptive and postoperative pain relief. The monitoring of the experimental animal under anesthesia and during recovery is also discussed.

The following sections are included:

• INTRODUCTION

• AIMS, ADVANTAGES AND DISADVANTAGES OF LAMINOPLASTY

• INDICATIONS AND CONTRAINDICATIONS FOR LAMINOPLASTY

• TECHNIQUES OF LAMINOPLASTY AND THE SUPPLEMENTARY PROCEDURES
  • Unilateral Hinge Laminoplasty
  • Procedures Supplementary to Laminoplasty

• POSTOPERATIVE MANAGEMENTS AFTER LAMINOPLASTY

• RESULTS AND OUTCOME
  • Neurological Results
  • Roentgenographic Outcome
  • Long-Term Results (Fig. 8)
  • Complications

• REFERENCES

Neurologic deterioration after surgery is one of the most serious complications of surgery for cervical compression myelopathy. It is divided into two subgroups depending on the time of onset; early onset (i.e. regressions of onset within the first year after surgery) and late onset (more than one year after surgery). Early onset deterioration, of course, includes an accidental damage on neural tissue during surgery which can be prevented by meticulous operation or applying a procedure offering a wider visual field, such as subtotal corpectomy with strut bone graft (SCS). Use of a surgical microscope also provides superior illumination and magnification in a small surgical field. Management of direct complications are discussed in the other chapters, and here we describe the detection and treatment of unpreventable neurological complications.