Faculty Bibliography

Targeted muscle reinnervation (TMR) is a procedure in which amputated nerves are transferred to motor branches of functionally expendable muscles, which can then serve as "biological amplifiers" of neurologic information. It is a technique that was developed with the primary intent of improving myoelectric prosthesis control in high level upper extremity amputees. Over time, TMR has been shown to confer significant benefits in terms of both residual and phantom limb pain and as such has become a powerful tool in neuroma management in amputees and non-amputees. This review first discusses general principles of amputation management in the upper extremity, including the different types of prosthetics that are available for these patients. The history, rationale, and evolution of TMR will then be outlined, followed by several relevant surgical principles. Finally, the current evidence for and against TMR will be reviewed. Robust data on the functional benefits are still needed, and future studies will continue to clarify its role in both upper and lower extremity amputees.

Regional blocks are being increasingly utilized for anesthesia for various orthopedic procedures. Several studies have shown that regional anesthesia has fewer side effects and improved postoperative pain relief compared to general anesthesia, but regional blocks are not without risks. We present case reports of 2 patients who experienced posterior shoulder instability, one of whom had a posterior shoulder dislocation, immediately in the postanesthesia care unit after undergoing hand surgery with regional anesthesia. This paper highlights the importance of being aware that patients might be at increased risk of shoulder instability after upper extremity regional anesthesia, and appropriate perioperative precautions should be taken.

Major peripheral nerve injuries are devastating and represent a very challenging clinical problem. Despite many years of advancement in peripheral nerve research, results so far have been fair at best, with only 50% of patients regaining useful function. Advancement of techniques in imaging, better understanding of the physiology of nerve recovery, improved repair and grafting options, and secondary reconstructive techniques, including tendon and nerve transfers, have helped facilitate a degree of more effective treatment. This article presents current concepts regarding the principles of management, expected outcomes, and new advancements in major upper extremity peripheral nerve injuries.

BACKGROUND:Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. METHODS:A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. RESULTS:= .04). CONCLUSIONS:While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.

PURPOSE/OBJECTIVE:Corticosteroid injections (CSIs) are commonly used in carpal tunnel syndrome; however, recent literature has demonstrated risk of postoperative infection associated with preoperative CSIs in other orthopedic fields. The aim of this study was to assess the relationship of CSIs and postoperative infection following carpal tunnel release (CTR). METHODS:A single-center retrospective review was conducted from 2010 to 2019 to identify patients who underwent CTR with subsequent antibiotic prescription for chart-documented wound infection. A demographically-matched cohort of 100 patients was identified for comparison. Information on patient demographics, comorbidities, injection history, and presence of postoperative infection was collected. RESULTS:Thirty-nine patients (0.67% of all CTR patients) were identified with postoperative infections, 3 of which (0.05% of all CTR patients) were deep infections. In the infection cohort, 16 of 39 (41%) patients received an injection prior to surgery, whereas 16 of 100 (16%) patients in the control cohort received an injection. History of CSI was significantly more common in patients with postoperative infection, and patients in the infection cohort had a significantly shorter average time from injection to surgery by approximately 55 days. CONCLUSIONS:Corticosteroid injections in the preoperative period are associated with postoperative infection after CTR. Proximity of injection to time of surgery plays a role, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Prognostic III.

Purpose/UNASSIGNED:To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries. Methods/UNASSIGNED:Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported. Results/UNASSIGNED:The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients. Conclusions/UNASSIGNED:CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS. Level of Evidence/UNASSIGNED:IV, therapeutic case series.

Over the past two decades, management of open distal tibial fractures has evolved such that a staged approach, with external fixation and débridement during the index procedure, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment of these complex injuries is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcome. The mechanism of injury, neurovascular status, size and location of soft-tissue injury, fracture pattern, and concomitant injuries in the polytraumatized patient should direct the treatment plan and anticipated outcomes. This review focuses on evaluation and management of these complex injuries with an emphasis on early aggressive débridement, principles of initial fracture fixation, and modern options for soft-tissue coverage, including local and free tissue transfer.