Commentary: severe carpal tunnel syndrome.
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Carpal Tunnel Syndrome↗
Biomedical subjects
Kevin C Chung
Publications and source records attributed to Kevin C Chung.
Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists.
PURPOSE: Surgical management of rheumatoid hand diseases is controversial with large variation in practice pattern in the U.S. The purpose of this study is to evaluate the attitudes of hand surgeons and rheumatologists toward the effectiveness of rheumatoid hand surgery. METHODS: We designed a survey instrument to examine physicians' opinions about the effectiveness of different surgical treatments for rheumatoid hand deformities. The self-administered survey was mailed to a national random sample of 500 members of the American Society for Surgery of the Hand and 500 members of the American College of Rheumatology. RESULTS: Of survey responders, 82.5% of hand surgeons versus 34.1% of rheumatologists believe metacarpophalangeal joint arthroplasty improves hand function; 93.2% and 54.6%, respectively, believe prophylactic extensor tenosynovectomy prevents tendon rupture; and 52.5% and 12.6%, respectively, believe small joint synovectomy delays joint destruction. CONCLUSIONS: Rheumatologists view rheumatoid hand surgery as significantly less effective than do hand surgeons, which highlights the disagreements between the 2 specialties about the management of this clinical problem.
Arthritis, Rheumatoid↗
Upper-extremity sarcomas in the United States: analysis of the surveillance, epidemiology, and end results database, 1973-1998.
PURPOSE: Upper-extremity soft-tissue sarcomas are a rare disease with unclear epidemiology and evolving treatment strategies. Our purpose is to evaluate the incidence of upper-extremity soft-tissue sarcomas and the use of adjuvant radiotherapy in this patient population. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, a national population-based database, we identified all cases of primary upper-extremity sarcoma reported to the 9 national SEER registries in the Untied States from 1973 to 1998. RESULTS: Of the 1,286 upper-extremity soft-tissue sarcomas the average incidence rate is 2.2 cases/million/y, which has not changed significantly from 1973 to 1998. Caucasians' average incidence rate is significantly higher than African Americans' (incidence rate ratio [IRR] = 1.3, p =.02); and men are at a significantly higher risk compared with women (IRR = 1.3, p <.01). The use of adjuvant radiotherapy has increased significantly from 17% in 1973 to 47% in 1998 (p <.01). African-Americans, compared with Caucasians, are significantly less likely to receive adjuvant radiotherapy (odds ratio [OR] =.5, p =.01). CONCLUSIONS: The incidence of upper-extremity sarcomas has not changed significantly over the past 3 decades; however, the disease differentially affects the population with higher rates in Caucasians and men. Based on the results of this study the use of adjuvant radiotherapy is increasing but African Americans are less likely than Caucasians to receive this treatment for upper-extremity sarcoma.
Black or African American↗
Autonomic dysreflexia: a plastic surgery primer.
Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. Autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome.
Adult↗
Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons.
OBJECTIVE: Rheumatoid arthritis (RA) is a common cause of debilitating hand deformities, but management of these deformities is controversial, characterized by large variations in the surgical rates of common RA hand procedures. We conducted a national survey evaluating potential differences in physicians' management of RA hand deformities. METHODS: We mailed a survey instrument to a random national sample of 500 rheumatologists and 500 hand surgeons in the US. We evaluated physicians' attitudes toward the other specialties' management of common RA hand deformities and toward the indications for performing rheumatoid hand surgery. RESULTS: We found 70% of rheumatologists consider hand surgeons deficient in understanding the medical options available for RA, while 73.6% of surgeons believe rheumatologists have insufficient knowledge of the surgical options for RA hand diseases. However, 66.9% of surgeons and 79.5% of rheumatologists had no exposure to the other specialty during training. The 2 physician groups disagree significantly on the indications for commonly performed RA hand procedures such as metacarpophalangeal joint arthroplasty (p < 0.001), small joint synovectomy (p < 0.001), and distal ulna resection (p = 0.001). When physicians do not agree with others' management of RA hand deformities, only 62.4% of surgeons and 61.9% of rheumatologists relay their concern to the other specialty. CONCLUSION: Rheumatologists and hand surgeons have minimal interdisciplinary training, communicate with each other infrequently, and significantly disagree on the indications for RA hand surgery. Research must focus on the surgical outcomes of RA hand procedures and on improving communication between rheumatologists and hand surgeons.
Arthritis, Rheumatoid↗
A systematic review of the outcomes of digital sympathectomy for treatment of chronic digital ischemia.
OBJECTIVE: To determine the effectiveness of digital sympathectomy for treatment of chronic digital ischemia, to provide information on outcomes of this surgical procedure, and to give recommendations for further investigations. METHODS: We conducted a systematic review of English language citations referring to digital sympathectomy published between 1966 and 2002 using Premedline and Medline. RESULTS: Multiple differences in surgical techniques, causes of digital ischemia, and outcome measurements among studies made comparisons of surgical outcomes difficult. We found that 14% of all patients required amputation and 18% of patients had ulcer recurrence. Some type of postoperative complication was reported in 37% of patients with systemic sclerosis. CONCLUSION: To best determine the effectiveness of this surgical procedure, we recommend that future studies are prospective, to include standardized pre- and postoperative measurements, stratify the study outcomes by diagnosis and disease duration, and have consistent postoperative followup intervals.
Adult↗
The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns.
OBJECTIVES: To evaluate variation in fusion, arthroplasty, and tenosynovectomy rates among rheumatoid arthritis (RA) patients across states; to evaluate associations between surgery rates and the density of hand surgeons; and to evaluate differences in treatment by sex of the patient. METHODS: Data were obtained from the 1996 and 1997 Healthcare Cost and Utilization Project database. The procedure codes for fusion, arthroplasty, and tenosynovectomy were matched to patients with the diagnostic code of RA, which provided the total number of procedures performed in each state. The smoothed estimates of the RA population for each state were derived from age/sex strata in the 1995 US census using age/sex-adjusted RA prevalence data from the Third National Health and Nutrition Examination Survey. The number of hand surgeons was from the 1996 American Society for Surgery of the Hand. RESULTS: Procedure rates across states varied from 9-fold to 12-fold for all 3 procedures. The rates of the reconstructive procedures-fusion and arthroplasty-were highly correlated in each state, but these 2 procedures were only moderately correlated with tenosynovectomy. Surgeon density and procedure rates were minimally correlated. Procedure rates differed by patient sex, with significantly more arthroplasty and fusion procedures performed in women. More tenosynovectomy procedures were performed in men, and they were also performed at a younger age in men. CONCLUSIONS: Significant large area variations are present in the surgical management of the rheumatoid hand, but the correlations between reconstructive and early intervention procedures are modest. These rate differences are not explained by the number of hand surgeons, disease prevalence, or demographic composition of the states. However, men are more likely to receive more aggressive early surgical interventions, and women are more likely to receive end-stage reconstructive surgery.
Adolescent↗
Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds.
The temporoparietal fascial (TPF) flap is a thin, pliable, and well-vascularized flap that is ideal for reconstructing hand defects. Conventionally harvested flaps, however, result in a large scar over the temporal fossa, which may be problematic in patients with male-pattern baldness. We describe an endoscopic technique for harvesting the TPF flap through a 4-cm preauricular incision to reduce donor site morbidity. Five TPF flaps were used to cover hand wounds. Three of the flaps were successful and there were no injuries to the frontal branch of the facial nerve in this series. Endoscopic harvest of the TPF flap is an ideal solution for covering medium-sized hand defects without potentially prominent scars in the temporal area.
Adult↗
Outcomes of multiple microvascular toe transfers for reconstruction in 2 patients with digitless hands: 2- and 4-year follow-up case reports.
Two farmers who sustained amputations of all digits in the dominant hand had hand reconstructions with 3 toes from both feet. Both patients were monitored with hand function tests and validated outcomes questionnaires (Michigan Hand Outcomes Questionnaire and Short Form-36). Long-term follow-up data showed that both patients were able to use the reconstructed hands for activities of daily living and heavy manual farm labor. Until the immunologic problems associated with hand transplantation are solved, multiple toe transfer for total hand reconstruction is a reliable surgical treatment for these patients.
Activities of Daily Living↗
Intrafocal pinning of distal radius fractures: a simplified approach.
Distal radius fractures are not often treated by plastic surgeons. At the authors' institution, plastic surgery manages half of all traumas below the elbow, including distal radius and forearm fractures. This opportunity gives the residents a unique perspective for comprehensive training in treating upper extremity injuries. Because a distal radius fracture is the most common fracture of the upper extremity, the authors describe the use of intrafocal pinning as a simple and effective approach in the treatment of extra-articular distal radius fractures (Colles' fractures). They conducted a prospective study of 18 patients with Colles' fractures treated sequentially at their institution from 1998 to 2001 using this technique. They measured ulnar variance and palmar tilt of the distal radius at the time of injury, after closed reduction, immediately postoperatively, and 11 weeks postoperatively. Acceptable distal radius reduction aims to achieve at least neutral ulnar variance and 0-deg palmar tilt. Compared with closed reduction, they achieved superior anatomic reduction with intrafocal pinning: ulnar variance, +2.6 mm vs. -1.4 mm; palmar tilt, -13.3 deg vs. +2.1 deg). These results were stable at the 11-week follow-up. Intrafocal pinning is a valuable tool in the management of Colles' fractures. It is simple to perform and to teach, and it produces results that are superior to closed reduction alone.
Adolescent↗
Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries.
Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.
Adult↗
Evaluation of plastic surgery information on the Internet.
The Internet allows vast access to medical information. Unlike most plastic surgery literature, the Internet is a quagmire of unfiltered information, not subject to peer review. To assess the accuracy of medical information on the Internet the authors studied one commonly performed elective procedure, classifying and defining the information retrieved. Using the keyword "breast augmentation," the authors compiled a list of the first 300 web sites, obtained from six distinct search engines, yielding 215 unique sites. They devised an instrument to evaluate each site for its accessibility, relevance, and accuracy. Of the 215 unique web sites evaluated, 20 were inaccessible, 24 were irrelevant, and 41 contained no medical information. Of the remaining 130 sites, almost 34% contained false or misleading information. Errors pertained most often to the technical details of the operation, potential benefits, and risks. In addition, exaggerated claims concerning alternative breast enhancement regimens, adverse sequelae of silicone breast implants, and potential effects on lactation were also seen commonly. A considerable amount of information regarding breast augmentation on the Internet was either misleading or inaccurate. Physicians can assist their patients with specific guidelines to allow them to process information discerningly, thereby diminishing the likelihood that medical decisions are based on misinformation.
Health Education↗
Use of eight-hole titanium miniplates for unstable phalangeal fractures.
The authors present a series of 16 unstable phalangeal fractures (13 patients) treated by open reduction and internal fixation using the eight-hole titanium miniplate system from Synthes (Paoli, PA). Thirteen fractures were finger fractures whereas three were thumb fractures. Most fractures (n = 15) were crush injuries with concomitant soft tissue trauma. Six patients with finger fractures had good to excellent range of motion (total active motion > or =180). Two patients with thumb fractures had moderate range of motion (range of motion 70-97), whereas the remaining patient with thumb fracture had poor motion because the interphalangeal joint was destroyed. Complications included two cases of plate exposure because of insufficient soft tissue cover. Although no malunion occurred in this series, there was one case of delayed union. Three patients had extensor tenolysis to improve motion. The eight-hole miniplate system adds to the versatility of the many options available for fixation of unstable phalangeal fractures. Rigid fixation using this system is particularly helpful in initiating early motion in severely crushed fingers with concomitant soft tissue injury.
Adolescent↗
The prevalence of negative studies with inadequate statistical power: an analysis of the plastic surgery literature.
Studies published in the medical literature often neglect to consider the statistical power needed to detect a meaningful difference between study groups. Small sample sizes tend to produce negative results because of low statistical power. Studies that cannot make conclusive statements about their hypotheses can waste resources, deter further research, and impede advances in clinical treatment. The current study reviewed three of the most frequently read plastic surgery journals from 1976 to 1996 to determine the prevalence of inadequately (<80 percent) powered clinical trials and experimental studies that found no difference (negative studies) in the response variable of interest between comparison groups. The statistical power of 54 negative studies using continuous response variables was calculated to detect a difference of 1 SD (+/-1 SD) in means between the comparative groups. The power of another 57 negative studies with dichotomous response (yes/no) variables was calculated to detect a relative change in proportions of 25 percent and 50 percent from the experimental to the control group. It was found that 85 percent of the studies with continuous response variables had inadequate power to detect the desired mean difference of +/-1 SD. In studies with dichotomous response variables, 98 percent had inadequate power to detect a desired 25 percent relative change in proportions, and 74 percent had inadequate power to detect a desired 50 percent relative change in proportions. These results indicate that many of the studies in the plastic surgery literature lack adequate power to detect a moderate-to-large difference between groups. The lack of power makes the interpretation of the studies with negative findings inconclusive. Proper study design dictates that investigators consider a priori the difference between groups that is of clinical interest, and the sample size per group that is needed to provide adequate statistical power to detect the desired difference.
Animals↗
Are plastic surgery advertisements conforming to the ethical codes of the american society of plastic surgeons?
Cosmetic surgeons have increasingly come under fire for using advertisements that may be deceptive or intended for the solicitation of vulnerable consumers. However, aesthetic surgery is a growing business that relies heavily on advertising to survive. To prevent the use of deceptive advertisements, the American Society of Plastic Surgeons has developed a code of ethics for its physician members. We conducted a study to determine the prevalence of cosmetic surgery advertisements considered objectionable by the lay public. These advertisements were published in the Yellow Pages of the 10 largest U.S. cities. Because all of the advertisements in this study contained the American Society of Plastic Surgeons logo, we also determined whether its members are upholding the ethical code of advertising. We asked a convenience sample of 50 participants to rate 104 advertisements using four yes/no questions derived from the code of ethics and one overall yes/no question regarding whether the advertisement was objectionable. We obtained the mean percentage of "yes" responses for each advertisement, from the total sample, for each question. We found that the study participants felt that 25 percent of the advertisements used images of persons or facsimiles that falsely and deceptively created unjustified expectations of favorable results. The participants responded that 22 percent of the advertisements appealed primarily to the layperson's fears, anxieties, or emotional vulnerabilities. In addition, 18 percent of the advertisements were considered to be objectionable. Discretion is currently left up to physicians as to the ethical nature of their advertisements. Although the majority of American Society of Plastic Surgeons members uphold the ethical code of advertising, there are still a substantial number of published advertisements that the average consumer considers to be in violation of this code.
Adult↗
A simplified approach for unstable scaphoid fracture fixation using the Acutrak screw.
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Adolescent↗
Ipsilateral gluteal flap coverage of an exposed Achilles wound in a child.
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Achilles Tendon↗
Macrodystrophia lipomatosa: a reconstructive approach to gigantism of the foot.
Localized gigantism poses a challenging surgical dilemma, and it may be treated with amputation. This case report documents the application of a reconstructive approach to a severe case of pedal macrodystrophia lipomatosa in a 1-year-old girl. A series of 3 surgeries were designed to reduce the length, width, height, and overall bulk of the congenitally enlarged foot. The 3 procedures debulked the foot for normal ambulation and same-size shoe wear for both feet. The resulting functional and aesthetic improvements achieved through reconstructive treatment provided a desirable alternative to amputation.
Female↗