Browsing by Author "Loewenstein, Scott N."

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    Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy
    (Sage, 2022) Loewenstein, Scott N.; Angulo-Parker, Francisco; Timsina, Lava; Adkinson, Joshua; Surgery, School of Medicine
    Background: Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons. Methods: We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care. Results: Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team. Conclusions: Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.
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    Comparison of Patient-Reported Outcomes after Local Flap Coverage versus Amputation for Complex Lower Extremity Trauma
    (Thieme, 2024-10-24) Bhagat, Neel; Drake, Connor; Dawson, Steven; Loewenstein, Scott N.; Knox, Kevin R.; Adkinson, Joshua M.; Hassanein, Aladdin H.; Bamba, Ravinder; Surgery, School of Medicine
    Background: There is a paucity of patient-reported outcomes (PROs) data in lower extremity salvage. Limb salvage can often be achieved with the use of local muscle flaps or fasciocutaneous flaps. The purpose of this study was to compare PROs of patients who underwent lower extremity salvage using local fasciocutaneous flaps or muscle flaps to lower extremity amputation. Materials and Methods: The outcomes of 61 patients that underwent lower extremity local flap reconstruction ( n  = 33) or amputation ( n  = 28) between 2014 and 2020 were recorded. Chart reviews were performed to collect perioperative data. Patients were contacted via telephone for participation in the survey portion of our study. PROs were recorded utilizing both the Lower Extremity Functional Scale (LEFS) and the 36-Item Short-Form Health Survey (SF-36). Results: Surveys were completed by 61 patients (response rate 59.2%). The mean time of survey after flap reconstruction or amputation was 2.7 ± 1.4 years. Recent trauma (within 90 days) was the most common indication for local flap coverage ( n  = 23). LEFS score and SF-36 physical functioning scores were significantly lower in patients who underwent muscle flaps compared with fasciocutaneous flaps ( p  = 0.021 and p  = 0.022). Muscle flap patients had similar LEFS and SF-36 scores to amputation patients, while fasciocutaneous flap patients had significantly higher LEFS ( p  = 0.01), SF-36 physical functioning ( p  = 0.031), physical role functioning ( p  = 0.031), and emotional role functioning ( p  = 0.047) scores than amputation patients. Conclusion: Patients who underwent local fasciocutaneous flaps for limb salvage reported higher PRO scores than those undergoing amputation, while patients undergoing muscle flaps reported outcomes similar to those undergoing amputation. PROs for muscle flap patients were significantly lower than those of fasciocutaneous flap patients. These data suggest that while fasciocutaneous and muscle flaps are both useful limb salvage procedures, fasciocutaneous flaps may confer advantages that result in improved patient-perceived outcomes. Further study is needed to better characterize outcomes in limb salvage.
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    The Effects of Postoperative Physician Phone Calls for Hand and Wrist Fractures: A Prospective, Randomized Controlled Trial
    (Cureus, 2022-02-14) Loewenstein, Scott N.; Pittelkow, Eric; Kukushliev, Vasil V.; Hadad, Ivan; Adkinson, Joshua; Surgery, School of Medicine
    Background: In this study, we sought to determine if postoperative physician phone calls following hand and wrist fracture surgery improve patient outcomes, satisfaction, and treatment adherence. Methodology: We prospectively enrolled 24 consecutive adult patients who underwent outpatient surgery for isolated hand and wrist fractures at a single, metropolitan, safety-net hospital over one year to receive an additional physician phone call starting on postoperative day one. We measured preoperative and postoperative Brief Michigan Hand Questionnaire (bMHQ) composite score, overall satisfaction on a five-point Likert scale, compliance with treatment recommendations, presence of complications, discharge instructions reading level, and clarity of discharge and follow-up instructions. The surgical team was blinded to the treatment arm. Results: The bMHQ score improved 26% after surgery; however, there was no difference in absolute score change between groups (12.2 vs. 6.5, p = 0.69). Most patients were satisfied throughout all stages of care, but postoperative satisfaction did not differ between groups (1.4 vs. 2.5, p = 0.21). There was a stronger correlation between patient hand function and satisfaction starting one month after surgery (R2 = 0.502, p = 0.002) than preoperatively (R2 = 0.252, p = 0.029). Immediately following surgery, most patients stated that discharge instructions were clear, and the average readability was below the average patient education level. Despite this, 13% removed their splint or Kirschner wires, 67% did not follow up within a week of recommendation, 62% did not complete postoperative treatment, and 33% had complications. Conclusions: Postoperative phone calls by physicians did not improve compliance with recommendations, patient-rated outcome measures, or clinical outcomes among our hand and wrist fracture patient population.
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    Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery
    (Sage, 2022) Loewenstein, Scott N.; Bamba, Ravinder; Adkinson, Joshua M.; Surgery, School of Medicine
    Background: The purpose of this study was to determine the impact of upper extremity peripheral nerve blocks on emergency department (ED) utilization after hand and upper extremity surgery. Methods: We reviewed all outpatient upper extremity surgeries performed in a single Midwestern state between January 2009 and June 2019 using the Indiana Network for Patient Care. These encounters were used to develop a database of patient demographics, comorbidities, concurrent procedures, and postoperative ED visit utilization data. We performed univariate, bivariate, and multivariate logistic regression analyses. Results: Among 108 451 outpatient surgical patients, 9079 (8.4%) received blocks. Within 1 week of surgery, a greater proportion of patients who received peripheral nerve blocks (1.4%) presented to the ED than patients who did not (0.9%) (P < .001). The greatest risk was in the first 2 postoperative days (relative risk, 1.78; P < .001). Pain was the principal reason for ED utilization in the block cohort (53.6%) compared with those who did not undergo a block (35.1%) (P < .001). When controlling for comorbidities and demographics, only peripheral nerve blocks (adjusted odds ratio [OR], 1.71; P = 0.007) and preprocedural opioid use (adjusted OR, 1.43; P = .020) conferred an independently increased risk of ED utilization within the first 2 postoperative days. Conclusions: Peripheral nerve blocks used for upper extremity surgery are associated with a higher risk of unplanned ED utilization, most likely related to rebound pain. Through proper patient education and pain management, we can minimize this unnecessary resource utilization.
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    Parent Perspectives for Type B Ulnar Polydactyly Management
    (Sage, 2023) Goebel, Gunnar J.; Loewenstein, Scott N.; Adkinson, Joshua M.; Graduate Medical Education, School of Medicine
    Background: Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly. Methods: We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications. Results: The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants. Conclusions: Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.
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    Patient-Reported Outcomes and Factors Associated With Patient Satisfaction After Surgical Treatment of Facial Nonmelanoma Skin Cancer
    (American Medical Association, 2019-02-01) Sasor, Sarah E.; Cook, Julia A.; Loewenstein, Scott N.; Wooden, William A.; Cohen, Adam C.; Chu, Michael W.; Tholpady, Sunil S.; Surgery, School of Medicine
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    Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations
    (Sage, 2021) Loewenstein, Scott N.; Wulbrecht, Reed; Leonhard, Vanessa; Sasor, Sarah; Cook, Julia; Timsina, Lava; Adkinson, Joshua; Surgery, School of Medicine
    Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.
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    Risk for Persistent Peripheral Neuropathy After Repair of Brachial Artery Injuries
    (Cureus, 2022-03-09) Loewenstein, Scott N.; Rogers, Corianne; Kukushliev, Vasil V.; Adkinson, Joshua; Surgery, School of Medicine
    Background: Brachial artery lacerations are limb-threatening injuries requiring emergent repair. Concomitant peripheral nerve symptoms are often only identified postoperatively. This study evaluated the prevalence of peripheral nerve deficits among this population as the indications for early nerve exploration have not been definitively established. Methods: We reviewed all patients sustaining a brachial artery injury at one pediatric and two adult Level I Trauma Centers between January 1, 2007, and December 31, 2017. We recorded patient demographics, comorbidities, intoxication status, injury mechanism, concomitant injuries, type of repair, and intraoperative peripheral nerve exploration findings. Pre-and post-operative and long-term peripheral nerve function examination findings were analyzed. Differences between categorical variables were determined with Chi-square and Fisher’s exact tests. Results: Thirty-four patients sustained traumatic brachial artery lacerations requiring operative repair. Injury mechanisms included tidy (clean cut) laceration (n=11, 32%), gunshot wound (n=9, 26%), blunt trauma (n=8, 24%), and untidy laceration (n=6, 18%). Preoperatively, 15% had a normal peripheral nerve examination, 26% had localizable symptoms, 38% had non-localizable symptoms, and 21% were taken to the operating room without formal nerve assessment. Thirty-two percent underwent formal nerve exploration, and 81% underwent nerve repair. At an average follow-up of 2.5 years, 27% of patients underwent exploration, and 39% did not have localizable peripheral nerve deficits (p=0.705). Conclusions: Brachial artery injuries are associated with a clinically significant risk for long-term peripheral nerve symptoms. Early nerve exploration in patients with peripheral nerve symptoms after a brachial artery injury may be warranted, although there is no statistically significant likelihood for improved peripheral neurological outcomes.
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    Side-to-Side Metacarpal Fusion for Reconstruction of Bone Loss in the Radial Carpometacarpal Joints
    (Elsevier, 2021-07-28) Wu, Gerald J.; Loewenstein, Scott N.; Adkinson, Joshua M.; Surgery, School of Medicine
    We present a unique case of side-to-side metacarpal fusion for reconstruction after an isolated gunshot wound to the right hand of a 19-year-old woman. There was a traumatic segmental loss of the proximal right second metacarpal base with considerable comminution of the trapezium and trapezoid. Reconstructive options were limited because of the destruction of the distal carpus and carpometacarpal (CMC) joint. Digital ray amputation was offered but deferred because of patient preference. The reconstruction was performed via metacarpal fusion of the second metacarpal remnant to the third metacarpal base, bypassing the previously destroyed second CMC joint. The fusion of the second and third metacarpals offers acceptable results when the radial CMC joints are traumatized with extensive bone loss.