Publications by authors named "Jason H Ko"

49 Publications

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis.

J Foot Ankle Surg 2021 Jul 7. Epub 2021 Jul 7.

Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address:

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.
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http://dx.doi.org/10.1053/j.jfas.2021.07.001DOI Listing
July 2021

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Hand Clin 2021 Aug;37(3):345-359

Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 675 North St. Clair Street, Suite 19-250, Chicago, IL 60611, USA. Electronic address:

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.
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http://dx.doi.org/10.1016/j.hcl.2021.05.002DOI Listing
August 2021

Assessment of Plastic Surgery Residency Applications without United States Medical Licensing Examination Step 1 Scores.

Plast Reconstr Surg 2021 Jul;148(1):219-223

From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; the Division of Plastic Surgery, University of Washington; the Department of Plastic Surgery, University of Pittsburgh Medical Center; the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine; and the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Hospital.

Summary: The United States Medical Licensing Examination announced the changing of Step 1 score reporting from a three-digit number to pass/fail beginning on January 1, 2022. Plastic surgery residency programs have traditionally used United States Medical Licensing Examination Step 1 scores to compare plastic surgery residency applicants. Without a numerical score, the plastic surgery residency application review process will likely change. This article discusses advantages, disadvantages, and steps forward for residency programs related to the upcoming change. The authors encourage programs to continue to seek innovative methods of objectively and holistically evaluating applications.
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http://dx.doi.org/10.1097/PRS.0000000000008057DOI Listing
July 2021

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene.

Plast Reconstr Surg Glob Open 2021 May 21;9(5):e3582. Epub 2021 May 21.

Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.

Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.
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http://dx.doi.org/10.1097/GOX.0000000000003582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140772PMC
May 2021

The Association between Away Rotations and Rank Order in the Integrated Plastic Surgery Match.

Plast Reconstr Surg 2021 Jun;147(6):1050e-1056e

From the Division of Plastic, Oral, and Maxillofacial Surgery, Duke University; the Department of Plastic Surgery, University of Pittsburgh; the Division of Plastic Surgery, Northwestern University; the Department of Plastic and Reconstructive Surgery, Johns Hopkins University; and the Section of Plastic Surgery, University of Michigan.

Background: Given the competition in the integrated plastic surgery Match, away rotations are ubiquitous among plastic surgery applicants to differentiate their applications. This study aimed to characterize how performing an away rotation affects rank order and Match outcomes for integrated plastic surgery programs.

Methods: An online survey was designed and distributed to the top 25 integrated plastic surgery programs in the United States as determined by Doximity. Programs were polled about away rotation structure, position of rotators on their 2018 to 2019 rank list, and composition of current resident classes.

Results: Twenty-five programs completed the survey (response rate, 100 percent). On average, programs interviewed 34.9 applicants (range, 22 to 50 applicants) and ranked 32.8 applicants (range, 10 to 50 applicants). Most "ranked-to-match" positions were occupied by home students or away rotators (60.9 percent). Rank order of home students, away rotators, and nonrotators varied significantly (p < 0.001), with median rank order of home students [5 (interquartile range, 1 to 9)] and rotators [14 (interquartile range, 6 to 27)] higher than nonrotators [17 (interquartile range, 10 to 29)]. Rank orders of away rotators tended to follow a bimodal distribution. Furthermore, 64.4 percent of integrated residents were either a home student or away rotator at their matched integrated program, with 20 percent of residency programs composed of greater than 70 percent of away rotators/home students across postgraduate years 1 through 6 classes.

Conclusions: For integrated plastic surgery programs, the majority of ranked-to-match students on rank lists and current residents were either home students or away rotators at their respective program. Performing well on an away rotation appears to confer significant benefit to the applicant applying in the integrated plastic surgery Match.
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http://dx.doi.org/10.1097/PRS.0000000000007984DOI Listing
June 2021

Imaging Review of Peripheral Nerve Injuries in Patients with COVID-19.

Radiology 2021 03 1;298(3):E117-E130. Epub 2020 Dec 1.

From the Department of Radiology (C.E.F., S.D.), Department of Physical Medicine and Rehabilitation (C.K.F.), Department of Neurology (C.K.F., I.J.K.), Division of Plastic and Reconstructive Surgery (J.H.K.), and Division of Pulmonary and Critical Care, Department of Medicine (J.M.W.), Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611; Shirley Ryan Ability Laboratory (formerly the Rehabilitation Institute of Chicago), Chicago, Ill (C.K.F.); and Department of Radiology, Johns Hopkins Hospital, Baltimore, Md (S.A.).

With surging numbers of patients with coronavirus disease 2019 (COVID-19) throughout the world, neuromuscular complications and rehabilitation concerns are becoming more apparent. Peripheral nerve injury can occur in patients with COVID-19 secondary to postinfectious inflammatory neuropathy, prone positioning-related stretch and/or compression injury, systemic neuropathy, or nerve entrapment from hematoma. Imaging of peripheral nerves in patients with COVID-19 may help to characterize nerve abnormality, to identify site and severity of nerve damage, and to potentially elucidate mechanisms of injury, thereby aiding the medical diagnosis and decision-making process. This review article aims to provide a first comprehensive summary of the current knowledge of COVID-19 and peripheral nerve imaging.
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http://dx.doi.org/10.1148/radiol.2020203116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709352PMC
March 2021

Targeted Muscle Reinnervation as a Solution for Nerve Pain.

Plast Reconstr Surg 2020 11;146(5):651e-663e

From the Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine.

Learning Objectives: After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fashion to treat existing pain.

Summary: Symptomatic injured nerves resulting from amputations, extremity trauma, or prior surgery are common and can decrease patient quality of life, thus necessitating an effective strategy for management. Targeted muscle reinnervation is a modern surgical strategy for prevention and treatment of neuroma pain that promotes nerve regeneration and healing rather than neuroma formation. Targeted muscle reinnervation involves the transfer of cut peripheral nerves to small motor nerves of adjacent, newly denervated segments of muscle and can be easily performed without specialized equipment. Targeted muscle reinnervation strategies exist for both upper and lower extremity amputations and for symptomatic neuromas of intact limbs. Targeted muscle reinnervation has been shown in a prospective, randomized, controlled trial to result in lower neuroma and phantom pain when compared to the historical gold standard of burying cut nerves in muscle.
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http://dx.doi.org/10.1097/PRS.0000000000007235DOI Listing
November 2020

Injury-prone: peripheral nerve injuries associated with prone positioning for COVID-19-related acute respiratory distress syndrome.

Br J Anaesth 2020 12 4;125(6):e478-e480. Epub 2020 Sep 4.

Shirley Ryan Ability Lab (Formerly the Rehabilitation Institute of Chicago), Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2020.08.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473147PMC
December 2020

Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey.

Plast Reconstr Surg Glob Open 2020 Jul 15;8(7):e2977. Epub 2020 Jul 15.

Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.

More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain.

Methods: PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores ( < 0.05).

Results: Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 [interquartile range (IQR), 41-52] for RLP Intensity, 56.7 (IQR, 51-61) for RLP Behavior, and 55.9 (IQR, 41-63) for RLP Interference. Similar scores were calculated for PLP parameters: 46.8 (IQR, 41-54) for PLP Intensity, 56.2 (IQR, 50-61) for PLP Behavior, and 54.6 (IQR, 41-62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP.

Conclusion: This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.
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http://dx.doi.org/10.1097/GOX.0000000000002977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413780PMC
July 2020

Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.

Clin Orthop Relat Res 2020 09;478(9):2161-2167

L. M. Mioton, G. A. Dumanian, N. Shah, C. S. Qiu, J. H. Ko, S. W. Jordan, Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying.

Questions/purposes: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])?

Methods: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery.

Results: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001).

Conclusions: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed.

Level Of Evidence: Level IV, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431223PMC
September 2020

A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation.

Plast Reconstr Surg Glob Open 2020 Apr 23;8(4):e2750. Epub 2020 Apr 23.

Department of Surgery, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Mass.

Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.
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http://dx.doi.org/10.1097/GOX.0000000000002750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209851PMC
April 2020

Cell Phone Application to Monitor Pain and Quality of Life in Neurogenic Pain Patients.

Plast Reconstr Surg Glob Open 2020 Apr 29;8(4):e2732. Epub 2020 Apr 29.

Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.

Management of postoperative pain is a challenge for healthcare providers in all surgical fields, especially in the context of the current opioid epidemic. We developed a cell phone application to monitor pain, medication use, and relevant quality of life domains (eg, mood, mobility, return to work, and sleep) in patients with neurogenic pain, including those with limb loss. A literature review was conducted to define application length and design parameters. The final application includes 12 questions for patients with limb loss and 8 for patients with neurogenic pain without limb loss. Pilot testing with 21 participants demonstrates acceptable time to complete the application (mean = 158 seconds, SD = 81 seconds) and usability, based on the mHealth App Usability Questionnaire. We aim for our application to serve as an outcome measure for evaluation of an evolving group of peripheral nerve procedures, including targeted muscle reinnervation. In addition, the application could be adapted for clinical use in patients undergoing these procedures for neurogenic pain and thus serve as a tool to monitor and manage pain medication use.
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http://dx.doi.org/10.1097/GOX.0000000000002732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209850PMC
April 2020

Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation.

Plast Reconstr Surg Glob Open 2020 Jan 17;8(1):e2545. Epub 2020 Jan 17.

Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.

Neuromas are a debilitating peripheral nerve problem due to aberrant axon sprouting and inflammation after nerve injury. The surgical management of neuromas has for a long time been up for debate, largely due to lack of consistent, reliable outcomes with any one technique. We have found success utilizing targeted muscle reinnervation, a technique originally described in amputees that re-routes the proximal ends of cut sensory nerve stumps into the distal ends of motor nerves to nearby muscles. In doing so, the sensory nerve ending can regenerate along the length of the motor nerve, giving it a place to go and something to do. In this report, we describe our technique specifically for targeted muscle reinnervation of sural nerve neuromas that is applicable to both amputees and to patients with intact limbs. Sural nerve neuromas can occur after sural nerve harvest for reconstructive procedures and particularly after lateral malleolar incisions for orthopedic access to the calcaneus. By re-routing the sural nerve into a motor nerve of the lateral gastrocnemius muscle, we are able to manage a variety of sural nerve neuromas presenting anywhere along the course of the sural nerve and in a variety of clinical settings.
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http://dx.doi.org/10.1097/GOX.0000000000002545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015593PMC
January 2020

Management of Unreconstructable Saphenous Nerve Injury with Targeted Muscle Reinnervation.

Plast Reconstr Surg Glob Open 2020 Jan 17;8(1):e2383. Epub 2020 Jan 17.

Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.

Neuroma pain significantly impacts patient quality of life and is associated with unemployment, chronic opioid dependence, and depression. Targeted muscle reinnervation (TMR), a surgical technique that coapts proximal stumps of cut nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study was to describe the surgical technique for TMR of the saphenous nerve, while providing a retrospective review. Between January 2015 and December 2018, 18 patients underwent TMR of the saphenous nerve: 1 nonamputee patient with chronic pain after ankle surgery and 17 amputee patients (10 for relief of chronic postamputation neuroma pain and phantom pain and 7 at the time of amputation for of these symptoms). Six patients were lost to follow up; 2 patients had recurrent pain; and 10 patients had reduced or no pain after TMR surgery. TMR is a successful technique for the management of traumatic neuroma pain in both the amputee and nonamputee populations, and in this study, we describe the technique for saphenous nerve TMR.
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http://dx.doi.org/10.1097/GOX.0000000000002383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015600PMC
January 2020

Histologic Analysis of Sensory and Motor Axons in Branches of the Human Brachial Plexus.

Plast Reconstr Surg 2019 12;144(6):1359-1368

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine.

Background: The topographic distribution through histologic analysis of motor and sensory axons within peripheral nerves at the brachial plexus level is not clearly defined, as there has previously been little need to appreciate this microanatomy. A desire to better understand the topography of fascicle groups developed with the introduction of targeted muscle reinnervation.

Methods: Fourteen bilateral brachial plexus specimens from seven fresh human cadavers were harvested at the time of organ donation, and immunofluorescent staining of motor and sensory nerves with choline acetyltransferase and Neurofilament 200 was performed to determine whether a consistent somatotopic orientation exists at the brachial plexus level.

Results: There was significant variability in the number of fascicles at the level of the brachial plexus. Qualitative analysis of choline acetyltransferase staining demonstrated that although motor axons tended to be grouped in clusters, there were high degrees of variability in somatotopic orientation across specimens. The radial nerve demonstrated the highest number of total myelinated axons, whereas the median nerve exhibited the greatest number of motor axons. The ulnar nerve contained only 13 percent motor axons, which was significantly lower than the median, radial, and musculocutaneous nerves.

Conclusions: There was no consistent somatotopic organization of motor and sensory axons of the mixed major nerves of the arm just distal to the brachial plexus, but clustering of motor axons may facilitate the splitting of nerves into primarily "motor" and "sensory" fascicles.
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http://dx.doi.org/10.1097/PRS.0000000000006278DOI Listing
December 2019

Prognostic value of needle electromyography in traumatic brachial plexus injury.

Muscle Nerve 2019 11 4;60(5):595-597. Epub 2019 Sep 4.

Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington.

Introduction: In this study we aimed to determine whether needle electromyographic assessment of voluntary motor unit recruitment in traumatic brachial plexus injuries could predict spontaneous motor recovery.

Methods: A retrospective study was performed on patients with brachial plexus injury affecting deltoid, supraspinatus/infraspinatus, and biceps brachii. The outcome measure was strength on manual muscle testing at least 1 year after injury. Good outcome was considered strength >3/5 on the Medical Research Council (MRC) scale.

Results: No muscles with no recruitment (n = 27) at 1-9 months improved to MRC 4/5 strength at a mean of 2.0 years postinjury. Twenty-five percent of muscles with discrete or severely reduced recruitment (n = 8) regained strength to >3/5 at a mean of 1.4 years postinjury (P = .047).

Discussion: Absent voluntary motor unit potential recruitment at 1-9 months predicted poor prognosis for spontaneous recovery. A high percentage of patients with discrete recruitment did not improve to >3/5 strength. These patients should be considered for early nerve transfer surgery.
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http://dx.doi.org/10.1002/mus.26684DOI Listing
November 2019

Successful treatment of a intra-articular infection.

Emerg Microbes Infect 2019 ;8(1):866-868

a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA.

A 78-year-old woman with a long-term ankle spacer with antibacterials developed an intra-articular infection. Treatment with systemic antifungal therapy plus an amphotericin B moulded cement spacer was successful.
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http://dx.doi.org/10.1080/22221751.2019.1625287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566482PMC
September 2019

Indications for Replantation and Revascularization in the Hand.

Hand Clin 2019 05 23;35(2):119-130. Epub 2019 Feb 23.

Northwestern University School of Medicine, NMH/Galter Room 19-250, 675 North Saint Clair, Chicago, IL 60611, USA.

The indications for upper extremity replantation are fluid, and it has long been appreciated that they change with time. Traditional strong indications for replantation include hand, thumb, or multiple digit amputation in adults, and almost any amputation in a child. Patients often desire replantation of single nonthumb digits based on aesthetic preference and personal/cultural values. Replantation in these situations is acceptable and rewarding, but individual consideration of patient, injury, and circumstantial factors is critical to avoid patient morbidity and unsatisfactory outcomes.
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http://dx.doi.org/10.1016/j.hcl.2018.12.003DOI Listing
May 2019

Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model.

J Hand Surg Am 2019 Mar 16;44(3):208-215. Epub 2019 Jan 16.

Division of Plastic and Reconstructive Surgery, Northwestern University, Chicago, IL. Electronic address:

Purpose: Conventional suture repairs, when stressed, fail by suture rupture, knot slippage, or suture pull-through, when the suture cuts through the intervening tissue. The purpose of this study was to compare the biomechanical properties of flexor tendon repairs using a novel mesh suture with traditional suture repairs.

Methods: Sixty human cadaveric flexor digitorum profundus tendons were harvested and assigned to 1 of 3 suture repair groups: 3-0 and 4-0 braided poly-blend suture or 1-mm diameter mesh suture. All tendons were repaired using a 4-strand core cruciate suture configuration. Each tendon repair underwent linear loading or cyclic loading until failure. Outcome measures included yield strength, ultimate strength, the number of cycles and load required to achieve 1-mm and 2-mm gap formation, and failure.

Results: Mesh suture repairs had significantly higher yield and ultimate force values when compared with 3-0 and 4-0 braided poly-blend suture repairs under linear testing. The average force required to produce repair gaps was significantly higher in mesh suture repairs than in conventional suture. Mesh suture repairs endured a significantly greater number of cycles and force applied before failure compared with both 3-0 and 4-0 conventional suture.

Conclusions: This ex vivo biomechanical study of flexor tendon repairs using a novel mesh suture reveals significant increases in average yield strength, ultimate strength, and average force required for gap formation and repair failure with mesh suture repairs compared with conventional sutures.

Clinical Relevance: Mesh suture-based flexor tendon repairs could lead to improved healing at earlier time points. The findings could allow for earlier mobilization, decreased adhesion formation, and lower rupture rates after flexor tendon repairs.
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http://dx.doi.org/10.1016/j.jhsa.2018.11.016DOI Listing
March 2019

Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation.

J Am Coll Surg 2019 03 8;228(3):217-226. Epub 2019 Jan 8.

Division of Plastic Surgery and Department of Orthopedics, Uniformed Services University-Walter Reed National Military, Bethesda, MD.

Background: A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain.

Study Design: A multi-institutional cohort study was conducted between 2012 and 2018. Fifty-one patients undergoing major limb amputation with immediate TMR were compared with 438 unselected major limb amputees. Primary outcomes included an 11-point Numerical Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behavior, and interference.

Results: Patients who underwent TMR had less PLP and residual limb pain compared with untreated amputee controls, across all subgroups and by all measures. Median "worst pain in the past 24 hours" for the TMR cohort was 1 out of 10 compared to 5 (PLP) and 4 (residual) out of 10 in the control population (p = 0.003 and p < 0.001, respectively). Median PROMIS t-scores were lower in TMR patients for both PLP (pain intensity [36.3 vs 48.3], pain behavior [50.1 vs 56.6], and pain interference [40.7 vs 55.8]) and residual limb pain (pain intensity [30.7 vs 46.8], pain behavior [36.7 vs 57.3], and pain interference [40.7 vs 57.3]). Targeted muscle reinnervation was associated with 3.03 (PLP) and 3.92 (residual) times higher odds of decreasing pain severity compared with general amputee participants.

Conclusions: Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.12.015DOI Listing
March 2019

Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.

Ann Surg 2019 08;270(2):238-246

Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, IL.

Objective: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain.

Summary Background Data: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain.

Methods: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function.

Results: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment.

Conclusions: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy.

Trial Registration: NCT02205385 at ClinicalTrials.gov.
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http://dx.doi.org/10.1097/SLA.0000000000003088DOI Listing
August 2019

Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis.

Microsurgery 2019 Jan 3;39(1):32-38. Epub 2018 Sep 3.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Background: Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis.

Patients And Methods: We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection.

Results: Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts.

Conclusions: These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.
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http://dx.doi.org/10.1002/micr.30368DOI Listing
January 2019

Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study.

Plast Reconstr Surg 2018 10;142(4):541e-550e

From the Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine.

Background: Targeted muscle reinnervation reroutes the ends of cut nerves to reinnervate small motor nerves of nearby muscles, with the goal of reducing neuroma pain and/or improving prosthesis function. Anatomical roadmaps for targeted muscle reinnervation have been established in the upper extremity and thigh, but not for the lower leg.

Methods: The major branch points of motor nerves and the motor entry points to muscles of the leg were dissected in five cadaver specimens. Leg length was defined as distance from the lateral femoral condyle to the lateral malleolus. The distances from the lateral femoral condyle to major branch points and motor entry points were recorded as percentages of leg length to identify targets for targeted muscle reinnervation.

Results: The tibialis anterior and extensor digitorum longus were both acceptable targets in the anterior compartment, with an average 4.4 motor entry points within 10 to 80 percent and 3.0 motor entry points within 20 to 80 percent leg length, respectively. The peroneus longus was the best target in the lateral compartment, with an average 5.8 motor entry points within 20 to 70 percent leg length. The gastrocnemius and soleus were both acceptable targets in the superficial posterior compartment, with an average 4.4 motor entry points within 0 to 40 percent and 6.2 motor entry points within 20 to 80 percent leg length, respectively for each muscle. The flexor digitorum longus was the best target in the deep posterior compartment, with an average 6.0 motor entry points within 30 to 90 percent leg length.

Conclusions: Targeted muscle reinnervation is technically feasible in the lower leg. This cadaveric study provides a roadmap for incision placement and identification of motor nerve targets.
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http://dx.doi.org/10.1097/PRS.0000000000004773DOI Listing
October 2018

Vascularized Composite Allotransplantation of the Elbow Joint: A Cadaveric Study.

Ann Plast Surg 2018 Apr;80(4):438-447

Background: Surgical options for the unreconstructable elbow are limited to arthrodesis, total arthroplasty, or osteoarticular allograft reconstruction. Each of these options is limited by severe functional impairment and/or high complication rates. Vascularized allotransplantation of the elbow joint has the potential to mitigate these complications. In this study, we describe our technique for harvesting the elbow for vascularized joint transplantation and demonstrate the flap's vascularity using contrast angiography.

Methods: Anatomical studies were used to design and harvest a vascularized elbow joint flap pedicled on the brachial vessels in 10 cadaveric arms. Diaphyseal blood supply is provided by 3 nutrient arteries, and periarticular supply arises from the various collateral arteries of the arm and recurrent arteries of the forearm. The brachialis and supinator, and their respective nerves, were included as functional muscles because of their intimate association with critical vasculature. Tendinous insertions of the biceps and triceps, as well as the flexor/pronator and extensor origins, were preserved for repair in the transplant recipient. Both lateral arm and radial forearm flaps were preserved to aid in soft tissue inset as well as vascular/immunologic monitoring. Contrast angiography of each dissected specimen was performed to assess the location of the nutrient vessels and assess flap vascularity, as indicated by filling of the critical extraosseous and endosteal vessels.

Results: Angiographic imaging of 10 specimens demonstrated that this flap dissection preserves the nutrient endosteal supply to the humeral, radial, and ulnar diaphysis, in addition to the critical extraosseous arterial structures perfusing the elbow joint and periarticular tissues. From proximal to distal, these arteries are the musculoperiosteal radial, posterior branch of the radial collateral, inferior ulnar collateral, recurrent interosseous, radial recurrent, and the anterior and the posterior ulnar recurrent.

Conclusions: Vascularized composite allotransplantation of the elbow joint holds promise as a motion and function preserving option for young, high-demand patients with a sensate and functional hand, who would otherwise be limited by the restrictions of total elbow arthroplasty or fusion. In this study, we propose a flap design and technique for harvest and also offered vascular imaging-based evidence that this flap is adequately vascularized.
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http://dx.doi.org/10.1097/SAP.0000000000001292DOI Listing
April 2018

Management of Scaphoid Fractures.

Plast Reconstr Surg 2017 Aug;140(2):333e-346e

Chicago, Ill.; Seattle, Wash.; and Rochester, N.Y.

Learning Objectives: After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole.

Summary: The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.
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http://dx.doi.org/10.1097/PRS.0000000000003558DOI Listing
August 2017

Optimizing the Treatment of Burn Injuries of the Upper Extremity.

Hand Clin 2017 05;33(2):xiii

University of Michigan, 1500 East Medical Center Drive, Tabuman Center 2130, Ann Arbor, MI 48109, USA. Electronic address:

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http://dx.doi.org/10.1016/j.hcl.2017.02.001DOI Listing
May 2017

Acute Management of Hand Burns.

Hand Clin 2017 05 1;33(2):229-236. Epub 2017 Mar 1.

Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 North Saint Clair Street, Suite 19-250, Chicago, IL 60611, USA. Electronic address:

The hand is extremely susceptible to burn injuries, and hand burns can occur in up to 90% of all major burns. A thorough neurovascular examination of the hand should be performed in the acute setting. Escharotomies are required in patients with full-thickness or circumferential burns, when perfusion of the upper extremity is compromised. The decision for excision and grafting is based on whether the wound will heal in the first 2 to 3 weeks after the burn injury. Acute care and resuscitation are always importance in this patient population; subsequent care leads to optimal hand functionality and cosmetic long-term outcomes.
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http://dx.doi.org/10.1016/j.hcl.2016.12.001DOI Listing
May 2017

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation.

Injury 2016 Dec 19;47(12):2783-2788. Epub 2016 Oct 19.

Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States. Electronic address:

Background: After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.

Methods: At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.

Results: Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08).

Conclusions: Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.
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http://dx.doi.org/10.1016/j.injury.2016.10.004DOI Listing
December 2016

Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury.

Hand Clin 2016 May 10;32(2):191-207. Epub 2016 Mar 10.

Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, 675 N. St. Clair Street, Suite 19-250, Chicago, IL 60611, USA. Electronic address:

High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.
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http://dx.doi.org/10.1016/j.hcl.2015.12.007DOI Listing
May 2016
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