Contralateral Extremity Research Articles

Functional outcome after endoscopic assisted release of the ulnar nerve for cubital tunnel syndrome: mid-to-long term results.

The aim of the study was to investigate functional and patient-rated outcome parameters after endoscopic assisted release of the ulnar nerve for cubital tunnel syndrome. One hundred of 204 consecutive patients between 2006 and 2011 met the inclusion/exclusion criteria. Fifty-one of these patients were recruited and evaluated clinically and by questionnaire testing retrospectively after a mean follow-up of 82months (range: 60-116). Neurological parameters (two-point-discrimination, application of Semmes-Weinstein monofilaments, Tinel's test), grip, and three-point pinch strength were not significantly different from the contralateral extremity at the time of examination, whereas key pinch strength was significantly weaker. Mean Disabilities of the Arm, Shoulder, and Hand score was 20.82. Patients' overall opinion was good/excellent for 78% of the study population. The examined surgical procedure proved to be as efficacious as open in-situ decompression regarding functional outcome with fewer post-operative complications. Regarding the results it might be postulated that grip strength and three-point pinch strength determination is not necessarily relevant for ulnar nerve evaluation. Endoscopic assisted release of the ulnar nerve is a reliable and safe treatment option for cubital tunnel syndrome with satisfactory mid-to-long term functional and patient-rated outcomes.

Spinal Cord Stimulation in Patients With Complex Regional Pain Syndrome: A Possible Target for Immunomodulation?

Complex regional pain syndrome (CRPS) is characterized by continued pain disproportional to the inciting event, sensory abnormalities, vasomotor and sudomotor disturbances, and motor and trophic changes. Inflammatory involvement has been demonstrated in past CRPS studies resulting in pain, swelling, and warmth. Currently, it is unknown whether spinal cord stimulation (SCS) has immunomodulatory properties. The aim of this study was to determine whether SCS has immunomodulatory properties in CRPS patients. The primary outcome parameters are cytokines (IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, IL-15, IL-17, TNF-α, IFN-γ), chemokines (IP-10 and Eotaxin), and growth factors (VEGF, PDGFbb, and basic FGF) from interstitial fluid of artificial skin blisters before (T0-baseline without SCS) and after SCS therapy (T1-40 Hz standard frequency stimulation and T2-preferred frequency stimulation). Secondary outcome parameters were baseline demographics, CRPS signs, symptoms, and phenotype (inflammatory, vasomotor, dystonia, or neuropathic). Results were analyzed by means of a MANOVA repeated measures design. After SCS, the expression of both pro- and anti-inflammatory cytokines decreased over time in both the CRPS affected extremity and the contralateral extremity. The levels of IP-10, Eotaxin, VEGF, and PDGFbb were also significantly reduced bilaterally. There were no significant changes in IL-6 and TNF-α before and after SCS. The sensory signs, symptoms, and phenotype improved after SCS. SCS in CRPS patients attenuates T-cell activation, improves peripheral tissue oxygenation and decreases anti-angiogenetic activity which results in diminished endothelial dysfunction and improved bloodflow. The possible immunomodulatory effects of SCS opens new therapeutic possibilities in diseases with the involvement of the immune system and vasomotor disturbances, and requires further research on these mechanisms of action.

Extra-Cephalic Involvement in the Syndrome of Parry Romberg

Parry-Romberg Syndrome (PRS) is an uncommon disorder characterized by a slowly and acquired progressive atrophy involving skin, soft tissue, cartilage, and bony structures. Accompanying atrophies of the other parts of the body are rarely reported. We report an extremely unusual case with PRS associated with contralateral lower extremity atrophy.

Inter- and intra-tester reliability of sensibility testing in healthy individuals

Static two-point discrimination (S2PD) and Semmes-Weinstein monofilament (SWM) tests are the most widely used tests for evaluation of sensory deterioration. It is a necessity to know the inter- and intra-tester reliability of these tests to determine the suitability of method. Another important point in evaluation of sensory deterioration is whether or not there is a reference point which can be compared with the test results. So, it is important to know the reliability of sensory evaluation tests on the healthy extremities. The aim of this study was to evaluate the inter- and intra-tester reliability of the S2PD and SWM tests applied to the fingers of healthy individuals. One hundred and sixty three healthy fingers from 83 individuals were included into the study. An experienced orthopaedic surgeon and a physiotherapist examined all the individuals separately. The reliability of the S2PD test was found to be little and low. The reliability of the SWM test was determined as low and moderate. The reproducibility scores of both tests were at a poor level. Therefore, in the evaluation of states with sensory deterioration, the use of the healthy contralateral extremities as a standard reference point could be considered unreliable. Prognosis, grading or follow-up of treatment should not be made according to the results of the S2PD and SWM tests only. It would be more correct to use these tests as a diagnostic tool rather than quantitative follow-up for neurological function in pathological conditions.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children.

We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes. Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years). All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively. Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children. Therapeutic V.

Reduction Techniques for Diaphyseal Femur Fractures.

Achieving and maintaining reduction in patients with a diaphyseal femur fracture may be difficult; therefore, thorough preoperative planning is required. To fully prepare for successful surgical management of diaphyseal femur fractures, surgeons must consider appropriate patient positioning and necessary tools, including surgical tables, traction devices, and instruments. Principles of acceptable reduction rely on the restoration of length, alignment, and rotation. Reduction of diaphyseal femur fractures should be attained in the least invasive manner, via percutaneous reduction techniques, if possible, to preserve fracture biology and promote successful fracture healing. Intraoperative assessment of reduction often requires imaging studies of the contralateral extremity as a reference. Intraoperative assessment for associated femoral neck fractures and postoperative clinical examination of the hip and knee are imperative to the successful management of diaphyseal femur fractures. Other reference modalities and clinical examinations are required in patients with bilateral diaphyseal femur fractures.

Neurophysiological mechanisms and functional impact of mirror movements in children with unilateral spastic cerebral palsy.

Mirror movements may be indicative of the underlying corticospinal tract reorganization in children with unilateral spastic cerebral palsy (CP). Future research will benefit from systematic investigations of the relationship between mirror movements and its pathophysiology. Mirror movements may be a potential biomarker for individualized medicine in children with unilateral spastic CP.

Dismounted complex blast injuries

Category: Trauma Introduction/Purpose: The United States Medical Corps has continued to evaluate and define the injury patterns of our service members in an effort to prevent injury and improve combat casualty care. The pattern of injury can be predicted by the mechanism of injury. One of the more recently described and studied mechanisms has been coined the ‘dismounted complex blast injury. This injury pattern involves traumatic amputation of at least one leg with a second injury involving another extremity in addition to an injury to either the pelvis, the abdomen, or the urogenital region. The purpose of this study was to better define and describe the injuries occurring to the non amputated extremity. Methods: This is a retrospectively review of data from the US and UK Joint Theater Trauma Registries (JTTR) of consecutive patients admitted to the UK Role 3 hospital at Camp Bastion, Afghanistan, from January 1, 2009, to February 29, 2012. Data was obtained from the US JTTR (Joint Theatre Trauma Registry). Each patient was assigned an Injury Severity Score (ISS) and an Abbreviated Injury Scale (AIS) score. Only those patients with an AIS of 3 or greater (a serious injury) were included. All xrays and CT scans were evaluated by two board certified orthopaedic surgeons and one board certified musculoskeletal radiologist. Fisher’s exact test was used to compare categorical data and binomial logistic regression was be used to compare proportions of types of injuries by traumatic amputation level observed. Results: There were 295 patients with lower extremity injuries identified. 201 had traumatic lower extremity amputations, 140 with bilateral lower extremity amputations, 61 with single leg amputations. The mean age was 23.38 +/-3.77 years. All were male. Below the knee amputation was the most frequent amputation type observed, representing 55.7% of the amputations (29/52), the next most frequent was the through knee amputation representing 25%. The least frequent was the through ankle amputation. The presence of a symes level amputation was associated with an 8.1% increase in the odds of the presence of a skeletal foot injury in the rear lower extremity. There was also an association found between AKA level amputation and skeletal injury in the contralateral upper extremity . Conclusion: This is among the first studies to correlate level of injury and associated musculoskeletal injury for the Afghanistan theater of operations. The results of this data set demonstrate that proximal lower extremity amputation levels are significantly associated with distal upper extremity skeletal injury. In addition, the Symes level of amputation is significantly associated with contralateral foot fractures. Amputation levels proximal to the ankle often present with associated Genitourinary injuries. Unique to this study is the demonstration of a significant association of upper extremity injury with a more proximal lower extremity amputation level .

Elbow flexion and forearm supination strength in a healthy population

Despite the lack of representative data of a healthy population, many clinical trials concerning the measurement of postoperative elbow flexion or forearm supination strength use the contralateral side as a control. We hypothesized that there are no differences in elbow flexion and supination strength between the dominant and nondominant sides in healthy volunteers. The study was performed on a cross-sectional cohort of healthy subjects without any prior injuries or surgical interventions of the upper extremities. Isometric elbow flexion strength and supination strength were measured on both the dominant and nondominant sides. The results were analyzed for the entire group and subanalyzed for female vs. male, for different age groups, and according to handedness and regular practice of overhead sports. A total of 150 subjects (75 female and 75 male subjects; mean age, 44 ± 15 years [range, 18-72 years]) were included in this study. Within the entire collective, no significant differences concerning the elbow flexion strength between the dominant and nondominant sides could be detected, whereas the supination strength was 7% higher on the dominant side (P = .010). Women, right-hand-dominant subjects, and subjects who do not regularly practice overhead sports have a significant 8% higher supination strength on the dominant side compared with the nondominant side (P < .05). Left-hand-dominant subjects have an 8% higher elbow flexion strength on the nondominant right side (P < .05). Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides. The contralateral upper extremity cannot be used as a matched control without some adjustments.

Phase synchronization of skin blood flow oscillations in humans under asymmetric local heating

The hypothesis is proposed that an external local stimulus may cause a change in the phase relationships of oscillations in the peripheral skin blood flow of contralateral extremities. To test this assumption, the wavelet phase coherence of skin blood flow oscillations of the left and right forearms of 18 healthy volunteers of both sexes at rest and in response to unilateral local heating was investigated. An area of the skin of the left forearm was exposed to heat and the native blood perfusion in an area of the skin of the right forearm was recorded simultaneously. It was shown that an asymmetric local change of skin perfusion led to a significant change in the phase relationships of the blood flow oscillations in all the analyzed frequency ranges. A significant reduction of phase synchronization of oscillations of skin blood flow in the range of endothelial, neurogenic, and myogenic activity, as well as in the range of respiratory rhythm was revealed. In contrast, in the range of the cardiac rhythm, a significant increase in phase synchronization of the oscillations of the blood flow of contralateral skin areas of the forearm was detected.

Directing clinical care using lower extremity biomechanics in patients with ankle osteoarthritis and ankle arthroplasty.

Ankle osteoarthritis is a debilitating disease with approximately 50,000 new cases per year leading to skeletal deformity, severe and recurrent pain, cartilage breakdown, and gait dysfunction limiting patient mobility and well-being. Although many treatments (total ankle arthroplasty [TAA], ankle fusion [arthrodesis], and ankle distraction arthroplasty) relieve pain, it is not clear that these procedures significantly improve patient mobility. The goal of the research presented here is to summarize what is presently known about lower extremity gait mechanics and outcomes and to quantify the impact of ankle osteoarthritis and TAA have on these measures using an explicitly holistic and mechanistic approach. Our recent studies have explored physical performance and energy recovery and revealed unexpected patterns and sequelae to treatment including incomplete restoration of gait function. These studies demonstrated for the first time the extreme levels and range of gait and balance dysfunction present in ankle osteoarthritis patients as well as quantifying the ways in which the affected joint alters movement and loading patterns not just in the painful joint, but throughout both the ipsilateral and contralateral lower extremity. Through this work, we determined that relieving pain alone through TAA is not enough to restore normal walking mechanics and balance due to underlying causes including limited ankle range of motion and balance deficits leading to long-term disability despite treatment. The results indicate the need to consider additional therapeutic interventions aimed at restoring balance, ankle range of motion, and movement symmetry in order to improve long-term health and function. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2345-2355, 2017.

The Comprehensive High-level Activity Mobility Predictor-Sport (CHAMP-S)

The Comprehensive High-level Activity Mobility Predictor (CHAMP) is a reliable and valid outcome measure that assesses high-level mobility in Service Members (SM) with traumatic lower limb loss. The CHAMP has the potential to be used to assess current high-level mobility capabilities in healthy, athletic individuals, to determine those athletes that may be at risk for injury, can be administered throughout rehabilitation process, and can assist with return to play decision making for collegiate athletes that suffer lower limb injuries. PURPOSE: To develop the reliability and validity of the Comprehensive-High-Level Activity Mobility Predictor-Sport (CHAMP-S) in Division I Collegiate Football Players. METHOD: 206 student athletes participated in the study. 97 were tested at one time by three testers (two using the paper format and one using a mobile device application) to determine CHAMP-S interrater reliability. 115 had completed CHAMP-S, anthropometric measures, upper and lower limb power, speed, and agility measures and underwent correlation analysis. 206 underwent ANOVA followed by post hoc analysis to determine differences between CHAMP-S scores between different football positions. Twenty athletes who underwent season ending injury were administered the CHAMP-S every 4-5 weeks throughout rehabilitation to assess change in high-level mobility and determine return to sport. RESULTS: The ICC’s for the CHAMP-S items ranged from 0.90 (95% Confidence Interval, CI: [0.85, 0.93]) to 0.98 (95% Confidence interval, CI: [0.97-0.99]) for Single Limb Stance, Four-meter side step test, L-Test, and Illinois Agility Test. The CHAMP-S was significantly correlated with BMI, % Body Fat, Vertical Jump, Broad Jump, 40-yard dash, and shuttle run. The CHAMP-S demonstrated differences between linemen and skilled position players in all planes of movement. All 20 athletes returned to play safely and have not suffered re-injury to the ipsilateral or contralateral lower extremity. The athletes achieved 103% ± 5% (95-109%) of their baseline CHAMP-S score (p = 0.09). CONCLUSION: The CHAMP-S is a reliable and valid measure of high-level mobility in Division I Collegiate Football Players that can help determine differences by position and assist return to sport following lower limb injury.

Clinical utility of 99mTc-ubiquicidin (29–41) as an adjunct to bone scan in differentiating infected versus noninfected loosening of prosthesis before revision surgery

The aim of this study was to evaluate the utility of Tc-ubiquicidin (Tc-UBI) (29-41) as an adjunct to an methylene diphosphonate (MDP) bone scan in differentiating septic versus aseptic loosening in patients with painful prosthesis posted for revision surgery. A two-vial cold kit of UBI (29-41) was prepared and utilized for the preparation of patient dose of Tc-UBI (29-41). Twenty two patients with painful hip or knee prosthesis and scheduled for revision surgery were included in the study. Overall, 370-555 MBq of Tc-UBI (29-41) was injected intravenously in all the patients. A blood pool image at 20 min after injection was followed by spot views of the suspected region of infection (target) and a corresponding normal area (nontarget) at 60 min. All patients underwent a routine Tc-MDP three-phase whole-body bone scan, followed by single-photon emission computed tomography/computed tomography of the prosthesis within a week of the Tc-UBI (29-41) study. For Tc-UBI scans, a visual score (0-3) was used to categorize studies as positive or negative, with scores of 0 (minimal or no uptake; less than soft tissue or contralateral extremity) and 1 (mild; equivalent to soft tissue or contralateral extremity) being considered negative and scores of 2 (moderate; uptake greater than soft tissue or contralateral extremity, but less than the liver) or 3 (intense; uptake greater than soft tissue or contralateral extremity and equivalent to the liver) being considered positive. The final correlation was on the basis of bacterial culture as the major criterion and the results of clinical tests, radiography, fluorine-18-fluorodeoxyglucose PET-CT, and three-phase bone scanning as the minor criteria. In all, 22 studies were carried out with Tc-UBI (29-41). Of these, 16 scans were considered positive and six were negative for infection foci. All negative scans were subsequently confirmed to be true negative. Adverse reactions were not observed during image acquisition and within 5 days after the study. The overall sensitivity, specificity, and positive and negative predictive values were 100, 85.7, 93.75, and 100%, respectively. A combination of an MDP bone scan and UBI scans was considered to yield maximum confidence toward reporting for the presence of infection. Patient dose of Tc-UBI (29-41) was prepared successfully and a simple quality control method to check radiolabeling yield was used at the hospital radiopharmacy. Tc-UBI (29-41) showed promise in localizing foci of infection, with optimal visualization at 20-60 min, for the evaluation of prosthesis loosening.

Abstract 88: Increased Incidence of Symptomatic Deep Venous Thrombosis Following Lower Extremity Flap Harvest for Abdominal and Perineal Reconstruction: A Case for Extended Surveillance

BACKGROUND: Postsurgical venous thromboembolism (VTE) remains a leading cause of hospital morbidity and data to support VTE prophylaxis guidelines in lower extremity flap surgery are currently lacking. The purpose of this study was to identify the incidence of symptomatic VTE in patients undergoing harvest of lower extremity flaps who received standard chemoprophylaxis while hospitalized to identify factors which could change postoperative prophylaxis guidelines. METHODS: One hundred twenty-seven consecutive patients undergoing unilateral lower extremity flap harvest from June 2011 to December 2015 were retrospectively evaluated for the development of VTE. Each patient had a flap harvested from the lower extremity and inset into the abdomen or perineum and not the ipsilateral leg/foot/ankle. All patients with symptomatic leg pain received bilateral ultrasonographic evaluation for VTE formation. The contralateral, non-operative leg served as an internal control. Sixty comorbidity-matched patients who underwent perineal tumor extirpation without reconstruction provided an external control. RESULTS: Sixty patients were male (47%) with mean age of 52 years. Mean follow-up was 339 days. All patients underwent flap reconstruction for an oncologic defect of the abdomen or perineum with 79% undergoing perineal reconstruction. Most patients underwent anterolateral thigh (41%) or gracilis flap (40%) harvest. Eleven patients developed VTEs in either leg (9%), for a total of 15 episodes of VTE. Of these, 10 were donor site (66%) and 5 were contralateral leg (33%). There was a non-significant trend towards increased odds for the formation of donor-site VTE when compared with contralateral lower extremity (OR:1.7;CI:0.80–3.4;p=0.15). Patients who underwent flap harvest had a 9 times higher odds of VTE formation when compared with their comorbidity matched controls who did not undergo flap reconstruction (OR:9.08;CI:1–82.6;p<0.05). CONCLUSIONS: The rate of VTE is higher than previously appreciated for reconstructive procedures of the perineum that utilize lower extremity flaps. Routine surveillance or extended prophylaxis may be warranted.

Reverse Shoulder Arthroplasty in Patients With Amputation or Paralysis of the Contralateral Upper Extremity (One-Arm Patients)

BackgroundTheoretically, patients with only one functional arm secondary to contralateral amputation or paralysis will subject their only functional upper extremity to increased loads. This could become an issue after reverse shoulder arthroplasty (RSA). However, there are no reported data on the implant survival or function for patients with a nonfunctional contralateral upper extremity. ObjectiveTo report the outcomes of RSA in patients with contralateral upper extremity amputation or paralysis. DesignRetrospective case series. SettingTertiary university hospital. PatientsAll patients who underwent RSA between January 2004 and December 2013. MethodsOf 1335 RSA procedures performed, 5 patients had a minimum 2-year follow-up and nonfunctional contralateral upper extremity. There were 3 men and 2 women, with a mean (standard deviation) age and length of follow-up of 72.4 (7.5) years and 56.4 (24-132) months. Two of the patients had a contralateral upper extremity amputation, and the other 3 had contralateral upper extremity paralysis as a result of stroke, traumatic brain injury, and traumatic brachial plexus injury at birth. Main OutcomesPain, range of motion, functional scores (Simple Shoulder Test, American Shoulder and Elbow Society and Quick-Disability of the Arm, Shoulder and Hand), satisfaction, complications/reoperations, and radiographic loosening. ResultsRSA resulted in substantial improvement in pain (P = .008), forward flexion (P = .02), and external range of motion (P = .01). The mean (standard deviation) Simple Shoulder Test, American Shoulder and Elbow Society, and Quick-Disability of the Arm, Shoulder, and Hand scores were 9.8 (1.3), 82 (13), and 17.8 (13.4), respectively. The results were excellent in 3, satisfactory in 1, and unsatisfactory in 1 patient (due only to external rotation limited to 10°). Subjectively, all 5 patients felt greatly improved and stated they would undergo RSA again. There were no complications or reoperations. There were no shoulders with component loosening. ConclusionsRSA seems to be a safe, effective, and successful surgical procedure for patients with a nonfunctional contralateral upper extremity. Studies with larger sample sizes and longer follow-up will hopefully validate the present findings. Level of EvidenceIV

Morphology of the articular cartilage of the knee joint in rats with extraarticular femoral bone deformity

Objective: to assess the structural and functional state of the rat knee after modeling posttraumatic extraarticular deformation of the femur. Methods: experiment was performed in 39 white mature (6 months old) male rats. To model the deformation of varus (test group, 15 rats) after transverse osteotomy of the fe­mur, a bent angled rod was introduced into the medullary ca­nal, the control animal (15) was straight. The comparison group was intact rats (9) of the corresponding age and sex. After 1, 3 and 6 months. After the operation, histological examination was performed. Results: In 1 month after modeling the deformation in the articular cartilage of the knee joint, destructive changes of 1–2 degree according to OARSI were noted. In contralateral extremity, AC had a structure characteristic of the age norm. After 3 months a decrease in the width of articular cartilage (in comparison with intact group by 1.21 times, p < 0.01), loss of glycosaminoglycans, a violation of the structure and ordering of collagen fibers, accumulation of type I collagen was estab­lished. After 6 months the most pronounced disorders were found in the cerebral cortex on the medial condyle of the deformed femur — a 1.63 fold decrease in its width compared with the in­tact group (p < 0.001), in places the replacement with fibrous cartilage. Conclusions: in animals with simulated extraarticular deformation of the femur in the knee joint of the injured limb after 1 month revealed destructive changes that progressed with time. After 1 month the maximum manifestation of disorders was noted in the area of the femur surface under the patella, and after 3 and 6 months he medial condyle. In the articular cartilage of the knee joint of the contralateral limb, destruc­tive changes were recorded 3 months after the reproduction of the deformation, but the severity of the manifestations was less.

Arteriovenous Hybrid Graft with Outflow in the Proximal Axillary Vein

The patency of long-term hemodialysis access in end-stage renal disease patients remains a significant challenge. Often these patients are affected with limited venous outflow options, requiring limb abandonment, and creation of new access in the contralateral arm. Vascular surgeons are familiar with the exposure of the proximal axillary artery via an infraclavicular incision. The axillary vein is easily exposed through this technique. The use of the hybrid Gore graft can make the venous anastomosis easier. A hybrid graft with its venous outflow placed in the proximal axillary vein can extend the options of upper extremity access procedures. We reviewed our early experience with this technique. A review of dialysis procedures at the Loma Linda VA was performed. All patients undergoing placement of arteriovenous grafts utilizing the Gore hybrid placed into the proximal axillary vein for outflow were identified. Outcomes in terms of primary and secondary patency rates were determined. Eight patients had placement of an arteriovenous hybrid graft in the proximal axillary vein via an infraclavicular incision. All patients had exhausted other options for hemodialysis access in the ipsilateral upper extremity. All grafts were used successfully for dialysis. The mean primary and secondary patency rates at 6months were 37.5% and 62.5%, respectively. One patient developed steal syndrome, requiring proximalization of the graft. Seven out of the 8 patients required secondary procedures including thrombectomy (n=16) and angioplasty (n=17). Placement of a hybrid graft in the proximal axillary vein is an effective and suitable option for patients who have exhausted arteriovenous access sites in the arm. This procedure can easily be performed in an outpatient setting with a low complication rate and allowing for preservation of the contralateral upper extremity for future use.

Is clinical measurement of anatomic axis of the femur adequate?

Background and purpose — The accuracy of using clinical measurement from the anterior superior iliac spine (ASIS) to the center of the knee to determine an anatomic axis of the femur has rarely been studied. A radiographic technique with a full-length standing scanogram (FLSS) was used to assess the adequacy of the clinical measurement.Patients and methods — 100 consecutive young adult patients (mean age 34 (20–40) years) with chronic unilateral lower extremity injuries were studied. The pelvis and intact contralateral lower extremity images in the FLSS were selected for study. The angles between the tibial axis and the femoral shaft anatomic axis (S-AA), the piriformis anatomic axis (P-AA), the clinical anatomic axis (C-AA), and the mechanical axis (MA) were compared between sexes.Results — Only the S-AA and C-AA angles were statistically significantly different in the 100 patients (3.6° vs. 2.8°; p = 0.03). There was a strong correlation between S-AA, P-AA, and C-AA angles (r > 0.9). The average intersecting angle between MA and S-AA in the femur in the 100 patients was 5.5°, and it was 4.8° between MA and C-AA.Interpretation — Clinical measurement of an anatomic axis from the ASIS to the center of the knee may be an adequate and acceptable method to determine lower extremity alignment. The optimal inlet for antegrade femoral intramedullary nailing may be the lateral edge of the piriformis fossa.

The frequency of De Quarvain Tenosynovitis, Trigger Finger and Dupuytren Contracture accompanying Idiopathic Carpal Tunnel Syndrome

Our aim in this study was to determine the frequency of Trigger finger, De quervain tenosynovitis and Dupuytren contracture in patients who underwent Idiopathic carpal tunnel release. The frequencies of trigger finger (TF), De Quervain tenosynovitis (DQ), and Dupuytren contracture (DC) on the same or contralateral extremity were evaluated in 430 patients who underwent surgery with a diagnosis for idiopathic carpal tunnel syndrome (ICTS) from January 2008 to August 2017. The mean age of patients was 54.6 (range, 40-68), and 348 were female while 82 were male. We identified 42 cases with TF (9.76%), 7 cases with DQ (1.62%), and 10 cases with DC (2.32%). We believe that our data could provide insight for the evaluation of the Turkish population.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

Background and Aims:The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.Material and Methods:A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score.Results:The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention.Conclusions:SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.