Distal upper extremity function following proximal humeral resection and reconstruction for tumors: Contralateral comparison

Background: Most functional analyses after limb salvage operations about the shoulder have focused on proximal function with the assumption that distal function is largely unaffected. This analysis examines distal function objectively. Methods: Objective laboratory data regarding distal upper extremity strength after reconstructive procedures for tumors near the shoulder joint was collected over a 16-year period. Thirty-two patients were able to participate fully in the data collection at an average most recent follow-up duration of >3.5 years. Results: Statistically significant reductions on the involved side compared with the uninvolved side in grip, forearm pronation, forearm supination, elbow flexion, and elbow extension strength were documented (p<0.05). The magnitude of reduction in strength diminishes distally, with the greatest effect in this group of patients being observed in elbow extension, followed by elbow flexion, forearm supination, and forearm pronation. Grip strength consistently showed the least amount of strength reduction compared with the uninvolved side, even within resection and reconstruction groups. Subjective patient rating of dexterity was no less than 3 of 5. Ninety percent of patients rated their dexterity 4 of 5 (52%) or 5 of 5 (38%). Conclusions: Despite the insistence of “normal” function in the distal upper extremity after limb salvage procedures, complete normality is not maintained. However, the degree of maintenance of distal function appears to be high, especially for grip strength and forearm pronation strength, and patient satisfaction is acceptable.     

Reconstructive treatment of soft tissue sarcoma of the upper extremity

Limb-sparing surgery is currently the cornerstone of treatment for most patients with soft-tissue sarcoma of the upper extremity. To achieve the best outcome, the reconstructive surgeon must be part of a multidisciplinary team and is required to have a thorough understanding of the whole treatment concept. This article provides an update for the current surgical management of patients with soft tissue sarcoma of the upper extremity. Relevant nonsurgical aspects are also highlighted.     

Nerve reconstruction in the hand and upper extremity

In the management of traumatic peripheral nerve injuries, the severity or degree of injury dictates the decision making between surgical management versus conservative management and serial examination. This review explores some of the recent literature, specifically addressing recent basic science advances in end-to-side and reverse end-to-side recovery, Schwann cell migration, and neuropathic pain. The management of nerve gaps, including the use of nerve conduits and acellularized nerve allografts, is examined. Current commonly performed nerve transfers are detailed with focus on both motor and sensory nerve transfers, their indications, and a basic overview of selected surgical techniques.     

上肢透明细胞肉瘤的治疗

目的 探讨上肢透明细胞肉瘤的疗效.方法 对3例上肢透明细胞肉瘤患者采用了肿块扩大切除术进行治疗,并采用带蒂尺动脉腕上皮支皮瓣覆盖创面.结果 术后3例皮瓣全部存活,伤口Ⅰ期愈合.随访时间例1为2年,例2为4年,2例患者至今存活,局部肿块无复发,无局部和远处转移;例3患者于前臂中段截肢术后4个月死亡.结论 透明细胞肉瘤是一种高度恶性的软组织肿瘤,早期手术是主要的治疗手段.     

无转移肢体软组织肉瘤非计划性手术后再次手术的临床相关因素研究

背景:软组织肉瘤是一组包含50余种亚型的恶性肿瘤,手术彻底切除肿瘤是治疗无转移肢体软组织肉瘤的主要手段。如果初次进行了非计划性手术,后期治疗更加困难。目的:评价无转移肢体软组织肉瘤患者接受非计划性手术后再次手术时需要进行软组织修复重建的比例以及患者的预后情况。方法:回顾性分析2016年10月至2019年4月手术治疗的28例无转移肢体软组织肉瘤患者的资料,其中11例接受非计划性手术后再次手术,17例行计划性手术组。记录两组的软组织修复重建率、局部复发率、远处转移率及无瘤生存率等指标。观察终点为术后肿瘤复发、转移或非肿瘤引起的死亡。结果:所有患者均顺利完成手术治疗。非计划性手术后再次手术组软组织重建率为27.3%,高于计划性手术组的11.8%,但差异无统计学意义(P>0.05)。随访时间1~36个月,平均(16.3±9.3)个月。随访期间再次手术组肿瘤局部复发率、远处转移率和无瘤生存率分别为18.2%、9.1%、72.7%,计划性手术组上述指标分别为5.9%、11.8%、82.3%,两组比较差异均无统计学意义(P>0.05)。多因素分析结果表明手术方式为患者无瘤生存的独立风险因子(P<0.05)。结论:无转移的肢体软组织肉瘤接受非计划性手术后再次手术,短期内患者的预后不会受到初次手术的影响,但再次手术时需要进行软组织修复重建的可能性会增大。     

High-voltage electrical burn injuries: Functional upper extremity assessment

High-voltage electric injuries have many manifestations, and an important complication is the damage of the central/peripheral nervous system. The purpose of this work was to assess the upper limb dysfunction in patients injured by high-voltage current. The evaluation consisted of analysis of patients’ records, cutaneous-sensibility threshold, handgrip and pinch strength and a specific questionnaire about upper limb dysfunctions (DASH) in 18 subjects. All subjects were men; the average age at the time of the injury was 38 years. Of these, 72% changed job/retired after the injury. The current entrance was the hand in 94% and grounding in the lower limb in 78%. The average burned surface area (BSA) was 8.6%. The handgrip strength of the injured limb was reduced (p < 0.05) and so also that of the three pinch types. The relationship between the handgrip strength and the DASH was statistically significant (p < 0.001) as well as the relationship between the three pinch types (p ≤ 0.02) to the injured limb. The ability to perceive cutaneous touch/pressure was decreased in the burnt hand, principally in the median nerve area. These data indicate a reduction of the hand muscular strength and sensibility, reducing the function of the upper limb in patients who received high-voltage electrical shock.     

Characterisation and outcomes of upper extremity amputations

Background

The purpose of this study is to characterise the injuries, outcomes, and disabling conditions of the isolated, combat-related upper extremity amputees in comparison to the isolated lower extremity amputees and the general amputee population.

Methods

A retrospective study of all major extremity amputations sustained by the US military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, and the Physical Evaluation Board Liaison Offices were queried in order to obtain injury characteristics, demographic information, treatment characteristics, and disability outcome data.

Results

A total of 1315 service members who sustained 1631 amputations were identified; of these, 173 service members were identified as sustaining an isolated upper extremity amputation. Isolated upper extremity and isolated lower extremity amputees had similar Injury Severity Scores (21 vs. 20). There were significantly more non-battle-related upper extremity amputees than the analysed general amputation population (39% vs. 14%). Isolated upper extremity amputees had significantly greater combined disability rating (82.9% vs. 62.3%) and were more likely to receive a disability rating >80% (69% vs. 53%). No upper extremity amputees were found fit for duty; only 12 (8.3%) were allowed continuation on active duty; and significantly more upper extremity amputees were permanently retired than lower extremity amputees (82% vs. 74%). The most common non-upper extremity amputation-related disabling condition was post-traumatic stress disorder (PTSD) (17%). Upper extremity amputees were significantly more likely to have disability from PTSD, 13% vs. 8%, and loss of nerve function, 11% vs. 6%, than the general amputee population.

Discussion/conclusion

Upper extremity amputees account for 14% of all amputees during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts. These amputees have significant disability and are unable to return to duty. Much of this disability is from their amputation; however, other conditions greatly contribute to their morbidity.     

Results of limb-sparing surgery with vascular replacement for soft tissue sarcoma in the lower extremity

OBJECTIVE: To evaluate limb-salvage surgery with vascular resection for lower extremity soft tissue sarcomas (STS) in adult patients and to classify blood vessel involvement. METHODS: Subjects were consecutive patients (median age, 56 years) who underwent vascular replacement during surgery of STS in the lower limb between January 1988 and December 2003. Blood vessel involvement by STS was classified as follows: type I, artery and vein; type II, artery only; type III, vein only; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database. RESULTS: Twenty-one (9.9%) of 213 patients underwent vascular resections for lower limb STS. Besides 17 type I tumors (81.0%), 3 (14.3%) type II and 1 (4.7%) type III STS were diagnosed. Arterial reconstruction was performed for all type I and II tumors. Venous replacement in type I and III tumors was performed in 66.7% of patients. Autologous vein (n = 8) and synthetic (Dacron and expanded polytetrafluoroethylene; n = 12) bypasses were used with comparable frequency for arterial repair, whereas expanded polytetrafluoroethylene prostheses were implanted in veins. Morbidity was 57.2% (hematoma, thrombosis, and infection), and mortality was 5% (embolism). At a median follow-up of 34 months, the primary and secondary patency rates of arterial (venous) reconstructions were 58.3% (54.9%) and 78.3% (54.9%). Limb salvage was achieved in 94.1% of all cases. The 5-year local control rate and survival rate were 80.4% and 52%, respectively. We observed a 5-year metastasis-free survival rate of 37.7% and found vessel infiltration and higher tumor grade (low-grade vs intermediate grade and high grade tumors) to be negative prognostic factors at univariate and multivariate analysis. CONCLUSIONS: Long-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of STS involving major vessels in the lower limb. Disease-specific morbidity must be anticipated. The classification of vascular involvement (type I to IV) is useful for surgical management.     

Core needle biopsy for diagnosis of extremity soft tissue sarcoma

Background: Classic teaching has advocated the use of open biopsy to diagnose and grade extremity soft-tissue sarcoma. Reported advantages of core needle biopsy include the minimal morbidity, cost, and time. The perceived disadvantage has been diagnostic inaccuracy. The objective of this study was to compare the diagnostic accuracy of core needle biopsy to incisional or frozen section biopsy for primary extremity masses suspicious for soft-tissue sarcoma. Methods: Patients presenting with extremity masses were identified from our prospective soft-tissue sarcoma database (malignant) and from the clinical information center (benign) between January 1, 1990, and December 31, 1995. Biopsy and subsequent resection data were collected from the pathologic records. Results: During this time, 164 primary extremity soft-tissue masses were evaluated before any biopsy. As the initial diagnostic approach, there were 60 core needle, 44 incisional, 36 frozen section, and 26 excisional biopsies. Two patients underwent two biopsy procedures. Ninety-three percent of the specimens obtained at core needle biopsy were adequate to make a diagnosis. Of the adequate core needle biopsy specimens, 95%, 88% and 75% correlated with the final resection diagnosis for malignancy, grade, and histologic subtype, respectively. Of the frozen section biopsy specimens, 94% were adequate, and accurate diagnostic results of malignancy were obtained with 88%. However, only 62% and 47% were correct for grade and histologic subtype, respectively, which was significantly different than the results obtained with incisional biopsy. The false-negative and false-positive rates for core needle biopsy were 5% and 0% for malignancy. Two core needle biopsy specimens graded low were found to be high, and one core needle biopsy specimen graded high was subsequently found to be low on final resection. Conclusions: When read by an experienced pathologist, the results of core needle biopsy provide accurate diagnostic information for malignancy and grade. Adequate core needle biopsy obviates the need for open biopsy and can be used for rational treatment planning. In the absence of adequate tissue, open biopsy is required. Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

上肢屈曲性旋转撕脱离断伤的形成及功能挽救

目的探讨上肢轴向屈曲性旋转撕脱离断伤的形成以及侧胸和背部组织在功能挽救中的应用方式和疗效。方法2000年7月～2003年9月共收治6例上肢轴向屈曲性旋转撕脱离断伤患者,所有病例行一期再植或寄养再植。术后肩关节外展90°、肘关节屈曲100°位石膏或支具固定,6周后去除固定行功能锻炼。结果6例患者再植均顺利成活,随访3个月～2年,术后肩关节外展50°～90°,前屈50°～70°,后伸20°～30°,内收20°～40°;肘关节屈曲100°～140°,伸-20°～0°;重建术后3个月时屈肘肌力达Ⅳ～Ⅴ级。结论充分利用侧胸和背部组织特点进行分期、分层手术,解决创面覆盖和功能重建互相干扰的矛盾,是挽救严重轴向屈曲性旋转撕脱离断伤上肢,恢复其外形和功能的可靠方法。     

手指软组织肉瘤的创面修复与重建

目的 回顾性分析手指原发软组织肉瘤病例,判断在根治肿瘤的同时是否能实施保指以满足手指外观功能的需要.方法 收集2007年4月至2009年11月期间11例手指软组织肉瘤保指的患者,采取肿瘤广泛切除后,对创面覆盖选用第一掌背动脉皮瓣7例,第二掌背动脉皮瓣修复4例;其中5例合并肌腱缺损患者同期行肌腱移植修复,1例骨质缺损行髂骨移植术.结果 术后6例接受新辅助化学治疗,1例接受辅助放射治疗.术后随访时间14个月至5年,9例肿瘤无复发,1例术后14个月肺转移死亡,1例肺转移带瘤生存.术后皮瓣全部存活,1例局部复发行截指.术后1年手指外观满意度为81％,功能评分为8～15分,平均12.6分,优或良10例,占91％.结论 建议对手指软组织肉瘤有保指可能时应尽可能实施保指,并同期进行功能重建.     

Limb-sparing surgery with vascular reconstruction for malignant lower extremity soft tissue sarcoma

Background

The standard of care for lower extremity soft tissue sarcoma (STS) is limb-sparing surgery. A small subset of these patients will require concomitant vascular reconstruction to ensure adequate resection and to preserve limb viability and function. The aim of this study was to evaluate outcomes in these patients with respect to wound healing and postoperative functional status.

Outcome instruments for the assessment of the upper extremity following trauma: a review

Orthopaedic injuries are common among trauma patients and can result in long-term problems. Considerable data are available regarding functional outcomes following lower extremity trauma. There is, however, a paucity of data available for upper extremity trauma patients. Whilst currently available instruments appear to assess outcomes of relevance in trauma populations, the reliability, validity and responsiveness of these instruments have not been evaluated in the upper extremity trauma population. This paper reviews instruments designed for patient self-evaluation of musculoskeletal disorders of the upper extremity, and instruments used in an orthopaedic trauma population to assess functional recovery following injury. The Musculoskeletal Functional Assessment (MFA), Short Musculoskeletal Functional Assessment (SMFA), Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons Shoulder Scale (ASES-s), American Shoulder and Elbow Surgeons Elbow Scale (ASES-e), Patient Rated Elbow Evaluation (PREE), and the Patient Rated Wrist Evaluation (PRWE) were reviewed. Until research is published outlining the evaluation of assessment instruments in upper extremity orthopaedic populations, authors will need to conduct their own validation studies before investigating outcomes in specific trauma populations.     

绞扎性上肢损伤的修复与一期功能重建

目的 探讨上肢绞扎性损伤的修复与一期功能重建的方法及临床效果.方法 对6例上肢绞扎伤采用前臂切开减压,一期修复血管、神经、肌腱和肌腱移位功能重建术.结果 术后6例上肢全部存活,随访时间1～6年,平均18个月,患肢外形和功能满意.按中华医学会手外科学会上肢部分功能评定试用标准评定:优3例,良2例,差1例;优良率83.3％.结论 绞扎性上肢损伤为多种组织复合伤,伤情复杂,严格掌握手术适应证,采用显微外科修复技术,一期重建肌腱功能可获得较好的效果.     

Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors

Objectives

This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction.