Onycophagia, or nail-biting, is common in adults and children, but self-mutilating onycophagia is almost exclusively associated with nerve injury and psychiatric comorbidities, and may lead to osteomyelitis and flexor tenosynovitis. Cases with autophagy or autocannabalistic components are extremely rare, as are cases requiring proximal amputation. Behavioral interventions are rarely successful, but the literature supports psychiatric medication to decrease the onycophagic impulse. We therefore present a 70-year-old male with history of severe onycophagia, diabetic neuropathy, and vascular disease who developed sepsis from onycophagia-associated severe flexor tenosynovitis. He was found to have osteomyelitis of multiple digits and a large abscess extending through nearly every bursa of the hand and forearm, causing forearm compartment syndrome. After surgical treatment and antibiotic therapy, he returned for soft tissue infection and osteomyelitis of the opposite hand, again from severe onycophagia. He was definitively treated, diagnosed with obsessive-compulsive disorder by psychiatry specialists, and was started on medications to reduce onycophagia impulses. He unfortunately relapsed and required further amputation.

Background Heterotopic ossification (HO) is a rare but known complication of brain and nerve trauma, orthopedic trauma, and burns. Nerve compression due to HO is extremely rare; “bony cubital tunnel syndrome,” or compression of the ulnar nerve at the elbow due to HO, is an unusual presentation that requires special considerations for treatment. Case Presentation We present a 50-year-old man who presented to our hospital after vehicular polytrauma with associated car fire and prolonged extrication. He experienced extensive trauma, with all classically described risks for HO. He developed bony cubital tunnel syndrome, with ulnar neuropathy confirmed on electrodiagnostic studies, and underwent surgical decompression. Surgical decompression revealed circumferential encasement of the ulnar nerve in heterotopic bone, all of which was removed. He demonstrates appropriate recovery of nerve function. Literature Review All perineural HO should be excised early to prevent nerve injury, because excision within 4 months of development is linked to improved functional outcomes. Measures to prevent nerve compression by HO are all associated with delayed wound or bone healing and should be considered on an individual basis.

All perineural HO should be excised early to prevent nerve injury, because excision within 4 months of development is linked to improved functional outcomes. Measures to prevent nerve compression by HO are all associated with delayed wound or bone healing and should be considered on an individual basis.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Surgery HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2022 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Surgery journal

With the 1-portal technique for endoscopic carpal tunnel release, the incision is less tender and patients have less postoperative need for analgesics, and return to activities of daily living and work seems to be earlier. The literature also confirms an earlier return to work. Surgical time can be shorter as less time is spent in making and closing the incision.DescriptionThe 1-portal technique, as described by Agee et al., is performed with the patient under general anesthesia, supplemented with only a small amount of local anesthesia in the beginning to blunt the pain response during the incision. Then, once the patient is fully anesthetized, the endoscope is inserted, and the carpal ligament is visualized and incised. The incision is closed and the dressing is applied.AlternativesAnother surgical alternative is open carpal tunnel release. Nonsurgical alternatives include corticosteroid injection, splinting, nonsteroidal anti-inflammatory drugs, and ergonomics.RationaleThe incision is smaller and less painful than the incision utilized during open carpal tunnel release. There is less need for analgesia. Unlike the incision utilized during open carpal tunnel release, the incision in this procedure is not made in a weight-bearing surface of the hand and generally is not firm and tender. Studies also show an earlier return to work with this technique. The endoscopic technique is only for a primary release. Surgical intervention for recurrent carpal tunnel syndrome needs to be performed with the open technique. Because of the need for deep sedation, only patients who are healthy enough for general sedation are candidates for the 1-portal technique. The risk of nerve injury with this technique is higher than with open carpal tunnel release.Expected OutcomesGenerally, the patient will have very rapid resolution of the preoperative paresthesia. The incision typically heals very well; however, when closing the 1.5-cm incision with skin glue and Steri-Strips (3M), there may be cases of delayed wound-healing if the patient is overly physically active in the first 2 weeks after the procedure.Important TipsMake sure that the endoscope is properly set up and that the patient is supine and the arm is abducted 90° at the shoulder with the hand and forearm fully supinated. Seating of the surgeon and assistant(s) and placement of the monitor are important.Make sure that the patient is fully anesthetized, particularly when the endoscope is being used. If the patient moves during the endoscopic incision of the ligament, other structures (i.e., vessels, nerves, and tendons) could be injured.Difficulty with the insertion of the scope can result in injuries. The carpal ligament must be visualized with the scope prior to any attempts at cutting the ligament. Convert to an open procedure if there are any difficulties with endoscope insertion or visualizing the carpal ligament.

BackgroundPatient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptoms and limitations after upper extremity surgery. Our objective was to determine how these scores compare amongst patients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively.MethodsIn this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF], pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal anti-inflammatory drugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from 2014-2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression to assess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was used to identify patient and disease factors independently associated with PROMIS scores.ResultsSurgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42), or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient by Eaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater time-since-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37).ConclusionIn small retrospective comparative cohorts, surgery was not associated with better UEF, pain, or depression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.

Background Lower extremity reconstruction is challenging because of the need to restore form and function. Despite the many options for soft‐tissue coverage, little research has addressed combined tendon and soft‐tissue reconstitution. We present a series of patients undergoing lower extremity tendon reconstruction and wound coverage with a single free gracilis flap and its tendon. Methods We studied five patients (age range, 51–81 years) undergoing lower limb reconstruction for defects involving soft tissue and tendon between 1998 and 2016 in the senior author's practice. Wounds (all in the foot and ankle region) were caused by sarcoma ( n = 4) and Merkel cell carcinoma ( n = 1) and ranged from 6.5–10 × 8–12 cm. Donor tendons, 2–18 cm long, were used to reconstruct the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and extensor retinaculum. Patient characteristics and outcomes were reviewed retrospectively. Results Reconstructions used a gracilis muscle free flap and its tendon. Flap sizes ranged 5–6.5 × 11–14 cm. Complications were one case of cellulitis and one case of reoperation for flap thinning and tenolysis. All patients had at least 7 months of follow‐up (mean: 37 months; range: 7–104 months). At latest follow‐up, all patients were ambulatory. On average, patients resumed assisted ambulation 27 days postoperatively and unassisted ambulation 62 days postoperatively. Conclusions For complex wounds with soft‐tissue and tendinous defects, the gracilis muscle free flap may be a reconstructive option. We recommend it be considered as a single‐donor incision option for lower extremity reconstruction.

CASE:We describe a 13-year-old girl with bilateral symmetric eccrine angiomatous hamartoma (EAH) on the volar aspect of the wrists. The lesions were painless and had been enlarging progressively for 1 year; the enlargement of the nodule on the right wrist was more substantial than that on the left wrist. She had palmar hyperhidrosis, which has a known association with EAH.CONCLUSION:To our knowledge, bilateral symmetric EAH has been reported only 3 other times in the literature. In all 3 of these cases, the lesions were on the dorsum of the hands or the wrists. We believe that this is the first report of this rare presentation on the volar aspect of the wrist. The symmetry suggests that the lesions may be the manifestation of a systemic or mechanical cause.

Background Sarcoma treatment necessitates high-dose chemoradiation therapy and wide surgical margins that create wounds that are difficult to reconstruct. Many techniques have been developed to cover these defects, originating with muscle flaps such as the rectus abdominis and latissimus dorsi. The gracilis flap, which is best known in contemporary practice as a microneurovascular flap for functional reconstructions, is not usually considered a robust option for reconstruction after sarcoma extirpation. Methods We reviewed records of 22 patients (9 women) at our institution who underwent reconstructive surgery after sarcoma extirpation using gracilis flaps for soft-tissue coverage from 1998 to 2017. Neurotized gracilis flaps were excluded. The mean patient age was 51 years (range, 18-85 years), and mean length of follow-up was 53 months (range, 9-156 months). Patients had 7 tumor types, with fibrosarcomas and undifferentiated tumors being most common. There were 23 defects (mean size, 118 cm2 (range, 54-200 cm2)). Defects were located most commonly in the foot and leg (n=9 each), upper extremity (n=4), and head and neck (n=1). The primary outcome was the flap success rate. Secondary outcomes were rates of major complications (unplanned reoperations, infections requiring intravenous antibiotics, and amputations); minor complications (superficial infections, partial skin-graft loss, partial flap necrosis, fluid collections treated in the office, and cosmetic reoperations); and sarcoma recurrence. Results Twenty-one flaps (91%) survived. Six patients (27%) experienced a major complication, and 12 patients (54%) experienced a minor complication. There were 2 amputations, for a limb salvage rate of 91%. Conclusions This series shows that the gracilis is well suited to covering large, compromised wounds across diverse anatomic features, which are the hallmark of sarcoma resections. The high rate of limb salvage and minimal donor-site morbidity further support the use of this flap as a first-line option for sarcoma reconstruction.

Background Excision of extensive scar tissue (EEST) may be required in certain cases of revision reverse total shoulder arthroplasty (RTSA). Neurovascular structures are at a higher risk of iatrogenic direct injury in these cases. We describe a technique to expose and protect the musculocutaneous and axillary nerves in a series of revision RTSA cases that required EEST. Methods Between 2004 and 2013, 83 revision RTSA procedures were identified in our database. Of these, 18 cases (22%) who underwent concomitant nerve exploration for EEST preventing glenoid exposure, preventing reduction of the humeral component, or causing instability of the implanted RTSA, were included. All patients were observed for a minimum of two years or until reoperation. Patient-reported outcome scores (PROMs), range of motion (ROM), and complication rates were analyzed. Results Patients had significant pain relief and improvement in PROMs post-operatively. Two patients (11%) required another revision surgery because of infection (one patient with glenoid loosening; one patient with stem loosening). Two patients (11%) had instability successfully managed with closed reduction. Two patients (11%) had a clinically evident post-operative nerve injury. Both cases were neurapraxias (1 partial brachial plexopathy and 1 partial isolated axillary nerve injury) and experienced complete neurologic recovery at last follow-up. Conclusions Complete permanent nerve injuries resulting from direct surgical trauma during revision RTSA requiring EEST can be avoided using the technique presented here. Despite proper exposition of the nerves, partial temporary neurapraxic injuries may occur. Patients who underwent this procedure experienced significant improvements in shoulder pain and function with complication rates consistent to those previously reported in revision RTSA.

Transradial catheterization and cannulation are typically well-tolerated procedures, but they are associated with various vascular, infectious, and orthopedic complications. Potential complications include radial artery occlusion, hematoma formation, radial artery laceration, pseudoaneurysm, abscess formation, and compartment syndrome. Hand surgeons are commonly consulted to treat such complications. We review recent evidence available to guide decisions about nonsurgical and surgical interventions to treat and prevent the complications associated with transradial access procedures.

BACKGROUND:Traditionally, the gracilis free flap is used for coverage of small- to medium-sized wounds (<50 cm) or as a functional muscle transfer. The purpose of this study is to examine the use of the gracilis free flap in the reconstruction of large extremity wounds (>100 cm). METHODS:We retrospectively reviewed records of 34 patients who underwent extremity soft-tissue reconstruction using gracilis free flaps for wounds larger than 100 cm from 1998 to 2016. The primary outcome was overall flap success rate. Secondary outcomes were rates of major and minor complications. Mean defect size was 145 cm (range, 104-240 cm). Seven flaps covered defects greater than 175 cm. Indications were tumor extirpation (n = 18) and traumatic/posttraumatic wounds (n = 16). The most common time period for flap coverage was immediately (3 days or less) after the defect was created (n = 14). Most flaps were solely muscle (n = 28) and were used for lower extremity or foot coverage (n = 29). RESULTS:The overall success rate was 94%. Major and minor complications occurred in 5 and 13 cases, respectively. The most common major complication was unplanned reoperation (n = 5), and the most common minor complications were partial skin graft loss (n = 3), partial flap necrosis (n = 3), and planned recipient-site reoperation (n = 5). CONCLUSIONS:Reconstruction of large extremity wounds using the gracilis free flap showed a 94% success rate with few major complications.

BACKGROUND:The standard of care for treatment of low-flow venous malformations (VMs) is percutaneous sclerotherapy. These lesions are seldom surgically resected, especially if the malformation is in an anatomically difficult location. Percutaneous sclerotherapy is safe and effective. However, the drawbacks to sclerotherapy are the need for repeated treatments and risks of skin ulceration, deep venous thrombosis, scarring/contractures, and nerve damage. Surgical resection can be difficult because of intraoperative bleeding, intraoperative lesional decompression, and difficulty in localization.METHODS:We describe our initial experience with 11 patients who underwent surgical resection of VMs located in the hand and forearm after preembolization of 27 total sites using n-butyl-cyanoacrylate or ethylene vinyl alcohol copolymer.RESULTS:Of the 11 patients treated, 5 had focal VMs, 3 had multifocal VMs, and 3 had diffuse VMs throughout the affected extremity. Four of the 5 patients with focal VMs were followed for at least 1 year, and no further treatment was required. All 3 of the patients with diffuse VMs have required ongoing treatment. No major functional impairments were reported, and there were no major procedure-related complications.CONCLUSIONS:Overall, embolization of the malformation before surgical resection facilitated localization, demarcation, and removal of the lesion.

Purpose Radial artery pseudoaneurysm is uncommon and mainly associated with radial artery cannulization for cardiac intervention or invasive hemodynamic monitoring. It is rarely seen as a result of intra-arterial recreational drug injection.Methods We present the case of a 35-year-old man with a 12-year history of intravenous drug use and 1-year history of intra-arterial drug use who developed radial artery pseudoaneurysm with a right long finger suppurative flexor tenosynovitis and subsequent acute radial-sided hand ischemia. Computed tomography (CT) angiography with three-dimensional reconstructions was used in diagnosis. We treated him with parenteral antibiotics followed by surgical debridement of his infection and removal of the infected pseudoaneurysm.Results Examination of the three-dimensional CT angiogram showed an unusual anatomical variant that likely predisposed him to isolated long finger flexor tenosynovitis.Conclusion Prompt diagnosis and treatment of pseudoaneurysm in this context is crucial to avoiding sepsis, hemorrhage, and irreversible ischemia. In rare cases, imaging can demonstrate an underlying anatomical variant that may be a predisposing factor.

Background: Carpal tunnel syndrome (CTS) can be treated with open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR). Our goal was to evaluate the safety and efficacy of ECTR versus OCTR in patients with severe CTS. We hypothesized that ECTR would be as safe and effective as OCTR in these patients. Methods: This was a retrospective cohort study of patients with severe CTS who underwent ECTR or OCTR by E. G. Deune between 2001 and 2014. Variables were patient age, sex, relevant medical history, alcohol and tobacco use, and preoperative electromyography and physical examination results. The primary outcome was patient-reported resolution of neuropathic symptoms at last follow-up. Secondary outcomes were surgical complications and need for reoperation. We compared the cohorts using Student’s t tests and chi-square tests. Results: We identified 138 cases of severe CTS in 126 patients who met our inclusion criteria. Thirty-nine cases were treated with ECTR and 99 with OCTR. Mean ages were 59 years (ECTR group) and 56 years (OCTR group). The population was 68% women, and 56% of cases involved the dominant hand. The distributions of age, sex, hand dominance, presence of relevant medical history, and alcohol and tobacco use did not differ significantly between groups. Treatment completely resolved CTS symptoms in 82% of ECTR cases and 39% of OCTR cases. Complication rates (all causes) were similar for both procedures. Recurrence was observed in 2.6% of ECTR cases and 10% of OCTR cases. Conclusions: ECTR is a safe and effective alternative to OCTR for patients with severe CTS.

Herein we present the case of a 78-year-old female who suffered a radial nerve injury following her third left shoulder arthroplasty. At first follow-up twoandahalfweeks following shoulder surgery, she presented with left arm weakness and profound, persistent hand weakness. This was diagnosed as complete radial nerve palsy.After threemonths, the patient still had no return of function. At that point, she became a candidate for tendon transfer surgery to remediate her complete radial nerve palsy. At six months post-arthroplasty, it was noted on exam that she unexpectedly regained weak wrist extension two weeks before her scheduled three tendon transfer surgery. The decision was made to proceed with a modified two tendon transfer procedure. Surgery is the most reliable treatment to restore function, but it must be tailored for each patient’s specific needs. A current assessment of the patient’s reconstructive needs must be performed to prevent overtreatment. We suggest referral for surgical evaluation,with emphasis on up-to-date clinical exam and functionality, as the typical course of action for patients with non-resolution of radial nerve palsy.

This case report describes the reconstruction of a segmental ulnar defect using a vascularized rib graft. A 27-year-old man was injured during military service by an improvised explosive device, resulting in bilateral through-the-knee amputations, left hand deformity, and a segmental left ulnar defect. After unsuccessful ulnar reconstruction with nonvascularized autologous bone and allograft bone substitutes, he presented to our institution. We removed the residual allograft fragments from the ulnar defect, harvested a vascularized left sixth rib with the intercostal artery and vein, secured the construct with internal hardware, and performed microanastomoses of the intercostal artery and vein to the posterior interosseous artery and vein. Postoperatively, he had a hematoma at the vascularized graft recipient site caused by anticoagulation therapy for his chronic deep vein thrombosis. Despite this, the rib graft successfully incorporated on the basis of radiographic and clinical examinations at 27 months. He had no pain and good function of the arm. The results of this case suggest that a vascularized rib graft for forearm reconstruction may be a viable option with minimal donor site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 37:160-164, 2017.

After axillary lymph node dissection (ALND), patients are cautioned against ipsilateral interventional procedures to avoid the theoretical increased risk of postoperative complications, particularly lymphedema. The authors' goal was to evaluate the complications of elective hand surgery after ALND. The authors reviewed patients presenting to their hand clinic from 1998 to 2011, selecting those with a diagnosis of breast cancer or melanoma and a history of previous ALND; the authors excluded those treated nonoperatively and those treated with elective surgery in the contralateral hand. Average age of the 22 patients meeting the criteria (20 with a history of breast cancer, 6 with preexisting lymphedema) was 53.9 years (range, 26.7 to 73.6 years) at the time of ALND and 63.1 years (range, 31.7 to 83.5 years) at the time of hand surgery. Average interval between surgeries was 9.2 years (range, 8 days to 37.3 years). Follow-up averaged 9.2 months (range, 8 days to 41.7 months). Fifteen patients were surveyed for long-term postoperative results (average surgery-to-survey interval, 4.3 years [range, 1 to 11.9 years]). Fifteen patients had uneventful postoperative recoveries, 4 had peri-incisional erythema requiring oral antibiotics, 1 had incisional pain and scarring, 1 had chronic wound-healing issues, and 1 had a dehiscence requiring a return to the operating room. In the 15 patients who completed the follow-up survey, there was no disease exacerbation in the 3 patients with preexisting lymphedema, and there were no new cases of lymphedema. Routine minor hand surgery did not result in lymphedema and did not increase existing lymphedema in these patients with previous ipsilateral ALND, but almost one-third of them had short-term complications in the postoperative recovery period.

To evaluate the impact of magnetic resonance neurography (MRN) on diagnostic thinking and therapeutic choices in patients with suspected peripheral neuropathy.

Background The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas. Methods Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS). Results Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps ( n = 6), free innervated myocutaneous flaps ( n = 1), and tendon transfers or grafts ( n = 6). Overall survival was 85 % ( n = 11) and disease-free survival was 77 % ( n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % ( n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work. Conclusions Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.