Faculty Bibliography

BACKGROUND: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery- and plastic surgery-based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. METHODS: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. RESULTS: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. CONCLUSIONS: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns.

PURPOSE: Local anesthetic is often used for perioperative pain control. Thrombin serves as a carrying medium for sustained release of antibiotics, chemotherapy, and growth factors. We tested the hypothesis that local anesthetic pain relief can be prolonged with the adjunct use of thrombin. METHODS: A prospective single-blinded clinical study was performed. Patients undergoing elective hand surgery inclusive of carpal tunnel release, excision of ganglion cyst, trigger finger release, and excision of mucous cyst under local block were enlisted. Before closure, patients received 1 of the following combinations: (1) control with oral analgesics, (2) 5 mL of 2% xylocaine, (3) 5 mL of 0.5% bupivacaine, (4) 2.5 mL of 2% xylocaine with 2.5 mL of 0.5% bupivacaine (XB), (5) thrombin with 5 mL of 2% xylocaine (XT), (6) thrombin with 5 mL of 0.5% bupivacaine (BT), and (7) thrombin with 2.5 mL of 2% xylocaine and 2.5 mL of 0.5% bupivacaine (XBT). There were 7 patients in each group, and patient demographics were similar between groups. Outcome measures included postanesthesia care unit (PACU) time, pain level, and number of pain pills required. RESULTS: Compared with oral analgesics alone, mean (SD) postoperative pain levels were reduced by 33.3% (8.9%) by xylocaine, 69.1% (8.7%) by bupivacaine, and 45.7% (9.4%) by XB. When thrombin was added, pain levels were further reduced by 69.9% by XT (P < 0.001), 23.1% by BT (P = 0.071), and 50.5% by XBT (P < 0.001) compared with their nonthrombin counterparts. In addition, PACU time was decreased by 34.8% by XT (P = 0.003) and 19.7% by XBT (P = 0.013) compared with xylocaine and XB, respectively. However, there was no difference in total pain pills needed between xylocaine, bupivacaine, and XB when administered with and without thrombin. CONCLUSIONS: The addition of topical thrombin to local anesthetic at the end of elective hand surgery provides for sustained postoperative pain control. Patients in this study who received thrombin and local anesthetic before wound closure had lower pain levels and were discharged from the PACU sooner than those who received local anesthetic alone. LEVEL OF EVIDENCE: Therapeutic level 2.

BACKGROUND: In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the composite primary endpoint of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke thereafter did not differ between carotid artery stenting and carotid endarterectomy for symptomatic or asymptomatic carotid stenosis. A secondary aim of this randomised trial was to compare the composite endpoint of restenosis or occlusion. METHODS: Patients with stenosis of the carotid artery who were asymptomatic or had had a transient ischaemic attack, amaurosis fugax, or a minor stroke were eligible for CREST and were enrolled at 117 clinical centres in the USA and Canada between Dec 21, 2000, and July 18, 2008. In this secondary analysis, the main endpoint was a composite of restenosis or occlusion at 2 years. Restenosis and occlusion were assessed by duplex ultrasonography at 1, 6, 12, 24, and 48 months and were defined as a reduction in diameter of the target artery of at least 70%, diagnosed by a peak systolic velocity of at least 3.0 m/s. Studies were done in CREST-certified laboratories and interpreted at the Ultrasound Core Laboratory (University of Washington). The frequency of restenosis was calculated by Kaplan-Meier survival estimates and was compared during a 2-year follow-up period. We used proportional hazards models to assess the association between baseline characteristics and risk of restenosis. Analyses were per protocol. CREST is registered with ClinicalTrials.gov, number NCT00004732. FINDINGS: 2191 patients received their assigned treatment within 30 days of randomisation and had eligible ultrasonography (1086 who had carotid artery stenting, 1105 who had carotid endarterectomy). In 2 years, 58 patients who underwent carotid artery stenting (Kaplan-Meier rate 6.0%) and 62 who had carotid endarterectomy (6.3%) had restenosis or occlusion (hazard ratio [HR] 0.90, 95% CI 0.63-1.29; p=0.58). Female sex (1.79, 1.25-2.56), diabetes (2.31, 1.61-3.31), and dyslipidaemia (2.07, 1.01-4.26) were independent predictors of restenosis or occlusion after the two procedures. Smoking predicted an increased rate of restenosis after carotid endarterectomy (2.26, 1.34-3.77) but not after carotid artery stenting (0.77, 0.41-1.42). INTERPRETATION: Restenosis and occlusion were infrequent and rates were similar up to 2 years after carotid endarterectomy and carotid artery stenting. Subsets of patients could benefit from early and frequent monitoring after revascularisation. FUNDING: National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions.

The proximal interphalangeal joint (PIP) joint is the most crucial joint for the functionality of a finger. For a child with complex injury of the hand every effort should be exercised to maximize function restoration. If the PIP joint is irreparably damaged, its reconstruction is indicated. The technique of autogenic heterotopic vascularized toe joint transplantation provides unique advantage of a composite transfer of skin, tendons, bone and joint alone with growth plate and its efficacy has been affirmed in children. It has been suggested that such transfers require intact flexor tendon to achieve satisfactory results, our experience however indicates quite the contrary. As evidenced by this report of a 7-year-old boy with abrasion and avulsion injury to his dominant right hand resulting in a complex defect with skin lose, extensor, flexor avulsion along with cominution of the PIP joint of his long finger. A surgical formulation of staged reconstruction scheme including an autogenic heterotopic vascularized toe joint transplantation led to complete functional restoration to his right hand. (c) 2011 Wiley-Liss, Inc. Microsurgery 2011

Peripheral nerve defects are common. The surgeon faced with these problems must provide the best functional recovery for the patient with the tools provided. The ideal nerve reconstruction would create a tensionless repair with direct coaptation. However, this is not always possible and other techniques must be employed. The alternatives to direct coaptation include nerve autografts, nerve conduits, and tissue-engineered constructs. This article reviews commonly used autogenous nerve grafts and conduits. Autogenous nerve grafts have been utilized in various techniques which include the trunk graft, cable graft, interfascicular graft, and vascularized graft. The nerve conduits reviewed fall into the category of autogenous biological conduits, nonautogenous biological conduits, and nonbiological conduits. New technologies are being developed to enhance peripheral nerve regeneration with the concept that conduits can be enriched and manipulated in the laboratory to promote regeneration of the peripheral nerve. Further clinical studies hold the promise of successful alternatives for treating peripheral nerve injuries