Targeted muscle reinnervation (TMR) is a novel approach to postamputation neuroma pain; however, this has not been explicitly studied. The purpose of this study was to develop a TMR model in hind limb amputated rats. Ten hind limbs from 5 Sprague Dawley cadaver rats were used. Sciatic nerve, main branches of the sciatic nerve (common peroneal, tibial, sural), motor branches from the sciatic nerve to the biceps femoris and cauda femoris, gluteal nerve and its motor branches to the semimembranosus, and biceps femoris and femoral nerve were dissected to look for consistent nerve anatomy that can be used for TMR in the rat hind limb amputation model. Transfemoral amputation was performed and two types of coaptations were made: common peroneal nerve to motor branch to biceps femoris and tibial nerve to motor branch to semimembranosus. The total surgical time for the dissection, amputation, and coaptation of nerves was ∼90 minutes. A total of 100 nerves were dissected in 10 rat hind limbs. Anatomical dissections were straightforward to perform. Anatomy of the dissected nerves was consistent. Hind limb amputations were performed without damaging the target muscles and nerves. Nerve lengths were sufficient for coaptation without any tension. To the best of our knowledge, this is the first report on TMR model in hind limb amputated rats. This model will allow for mechanical, electromyography (EMG), and histological analysis for future assessment of neuroma prevention.
Background: The primary objective of this study was to identify patient-related and socioeconomic factors associated with the operative treatment of adult traumatic brachial plexus injuries (BPI) at two tertiary referral centres in a single metropolitan area in the United States. The secondary objective was to assess surgeon variability in operative treatment. Methods: Adult patients with traumatic BPI at two tertiary referral centres in a single metropolitan area from 2015 to 2019 were retrospectively identified. After applying exclusion criteria, 84 adult patients with traumatic BPI treated by 22 surgeons were included. Our response variable was operative treatment of the traumatic BPI. Bi-variate screen was performed, and multi-variable logistic regression analysis was used to identify factors associated with operative treatment. Surgeon variability was separately assessed using Fisher's exact test. Results: The mean age of the study cohort was 45 years, and 69% were male. The most common BPI pattern was a global injury (39%) followed by an upper trunk injury (23%). Thirty-eight patients (45%) underwent operative treatment for the traumatic BPI. Multivariable logistic regression analysis showed that younger age and out-of-state referral were associated with operative treatment. There was significant surgeon variation in the utilisation of operative treatment. Conclusions: Out-of-state patients had more than four times higher odds of operative treatment, suggesting a regional practise pattern in which BPI requiring surgery are referred from surrounding states to our tertiary centres. Supra-regional BPI centres may facilitate timely referrals for specialty care. High-quality outcomes research in BPI is needed to mitigate surgeon treatment variation. Level of Evidence: Level IV (Therapeutic).
Ganglion excision is performed for pain, functional impairment, or cosmetic reasons, with recurrence rates ranging between 9 and 20%. The aim of this study was to evaluate the recurrence and reoperation rates after ganglion excision, along with assessing patient-reported outcomes.
Background Nontraumatic painful upper-extremity conditions (NPUCs) are largely age-related degenerations that affect the majority of adults. Most patients with NPUCs do not seek medical care and adjust on their own. Among those who do seek care, approximately 20% report risky substance use, defined as a consumption pattern that increases the risk of harm to physical or psychosocial health. In the context of NPUC, risky substance use is associated with more intense pain, emotional distress, disability, and opioid or other substance misuse (ie, cross-tolerance). Consequently, risky substance use is a significant modifiable risk factor for the progression and maintenance of chronic pain-related disability and comorbid psychopathology among patients with NPUCs. Objective This study aims to develop, adapt, and test the feasibility of the Web-Based Toolkit for Resilient Life Beyond Pain and Substance Use (Web-TIRELESS), a novel, asynchronous, and web-based mind-body intervention aimed at modifying maladaptive pain-coping behaviors in patients with NPUC and comorbid risky substance use. This study illustrates the proposed study design, methodology, and intervention content. Methods In aim 1, we will conduct live video qualitative interviews (n=20) with care-seeking adult patients with NPUC and comorbid risky substance use to inform the development and refinement of Web-TIRELESS and study procedures. In aim 2, we propose an open pilot study (n=12) of Web-TIRELESS with exit interviews and pre- and postintervention assessments to evaluate the feasibility, credibility, and acceptability of Web-TIRELESS and refine study procedures. Aim 3 consists of a pilot feasibility randomized controlled trial of Web-TIRELESS versus minimally enhanced usual care (n=50), both of which follow a web-based modality, to demonstrate the feasibility of recruitment procedures and data collection, as well as the feasibility, credibility, and acceptability of Web-TIRELESS and the control condition (adherence, retention, fidelity, and satisfaction), following prespecified benchmarks. Results Patient interviews (aim 1) concluded in May 2024 and qualitative analysis is expected to be completed in September 2024. Completion of aim 2 (data collection and analysis) is expected by June 2025. The completion of aim 3 and other study-related operations is anticipated by June 2027. Conclusions We will develop and test Web-TIRELESS, the first asynchronous mind-body intervention specifically adapted to enhance resilience in response to chronic pain among individuals with NPUCs and comorbid risky substance use. Results from this 3-aim study (feasibility, acceptability, and satisfaction of Web-TIRELESS) will be leveraged to inform a future efficacy randomized controlled trial of Web-TIRELESS versus the minimally enhanced usual care. Trial Registration ClinicalTrials.gov NCT06366633; https://clinicaltrials.gov/study/NCT06366633 International Registered Report Identifier (IRRID) DERR1-10.2196/64547
Background Total wrist fusion can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. This study aimed to investigate the overall complications and the factors associated with reoperation and soft tissue complication after total wrist fusion. Methods We retrospectively identified adult patients who underwent total wrist fusion using Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) and verified these by medical chart review. We included patients ( n = 215) who were treated at a single institutional system from January 1, 2002 to January 1, 2019. The mean age was 53.3 ± 15.0 years and the median follow-up was 6.1 years (interquartile range [IQR] =1.7-9.0). The most common indications for wrist fusion included inflammatory arthritis ( n = 66, 31%), degenerative arthritis ( n = 59, 27%), and posttraumatic arthritis ( n = 47, 22%). All wrist fusions were performed using a dorsal fusion plate or dorsal spanning plate, either with a local autograft ( n = 167, 78%), iliac crest autograft ( n = 2, 1.0%), allograft ( n = 7, 3.3%), a combination of both ( n = 16, 7.4%), or without a graft ( n = 23, 11%). We performed a multivariable logistic regression to evaluate factors associated with reoperation. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after total wrist fusion. Results Forty-one (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9-18). The indications included symptomatic implants ( n = 12, 27%), implant failures ( n = 8, 20%), infections ( n = 7, 17%), and nonunions ( n = 6, 15%). In multivariable analysis, total wrist fusion of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1-4.7, p = 0.033) was associated with a higher reoperation rate. Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas ( n = 8, 3.7%), observed blistering ( n = 5, 2.3%), and observed wound dehiscence ( n = 4, 1.9%). In multivariable analysis, smoking (OR: 2.5, CI: 0.95-6.4, p = 0.010) was independently associated with soft tissue complication after total wrist fusion. Seventy-two (33%) patients had a postoperative complication including symptomatic hardware ( n = 16, 7.4%), implant failure ( n = 11, 5.1%), infection ( n = 11, 5.1%), nonunion ( n = 8, 3.7%), and carpal tunnel syndrome ( n = 4, 1.9%). Conclusion Roughly one-third (33%) of the patients undergoing total wrist fusion experience a postoperative complication and 19% of the patients underwent a reoperation. Total wrist fusion of the dominant hand results in higher reoperation rates. The risk of a soft tissue complication after total wrist fusion is increased in smokers.
