Fixing Hands, Breaking Backs: The Ergonomics and Physical Detriment of the Hand Surgeon

BACKGROUND

Work-related musculoskeletal disorders in surgeons have been well documented. Hand surgeons, however, represent a unique population of surgical subspecialists due to frequent use of operative magnification. Thus, we aim to examine the contributing factors, types, and frequencies of work-related musculoskeletal injuries experienced by hand surgeons.

METHODS

A Research Electronic Data Capture survey including 12 demographic and 13 Nordic Musculoskeletal Injury Questionnaire questions was emailed twice to all active members of the American Association for Hand Surgery (AAHS). Data collection remained open for 30 days.

RESULTS

Ninety-six of 1228 AAHS members (8%) responded. Respondents were predominantly attendings (88, 91.7%), male (67, 69.8%), in academic practice (48, 50%), and in the age range of 35 to 44 years (34, 35.4%). Sixty-nine respondents (71.9%) attribute discomfort to their profession. Pain (56, 82.4%) and stiffness (46, 67.6%) were the most frequent symptoms, most common in the neck and wrist/hand regions. Fifty-nine (61.5%) respondents had acute (<1 week) discomfort, with onset most frequently reported after surgery (45, 48.9%). Thirty-two (34.8%) of the respondents state they worry these symptoms will hinder their ability to perform surgery in future. Sixteen (16.7%) respondents sustained a musculoskeletal injury directly related to work. Exercise was the most popular nonmedical therapy, while over-the-counter medications were the most popular medical therapy.

CONCLUSION

The unique ergonomics of hand surgery, including frequent use of loupes and microscopes, appear detrimental to the surgeons' health and career longevity. Further research will allow for the development of preventative measures, with the goal of facilitating longer, more productive careers for hand surgeons.

Are Patient Demographics and Payor Status Associated With Practice Patterns in the Surgical Management of Carpal Tunnel Syndrome?

BACKGROUND

Open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR) are the 2 operative approaches used to treat carpal tunnel syndrome (CTS). This study aims to identify whether differences between OCTR and ECTR rates exist, and, if so, are these differences associated with patient demographics or hospital characteristics.

METHODS

The 2018 Nationwide Ambulatory Surgery Sample (NASS) was filtered for patient encounters including either OCTR or ECTR operations. All patients undergoing either OCTR or ECTR were included, regardless of surgical specialty. Patient demographics and hospital characteristics data, provided and predefined by the NASS database, were collected and compared between the 2 treatment groups.

RESULTS

A total of 180 740 patient encounters were collected for both procedure types (OCTR: 62.4% women, mean age, 58 years; ECTR: 62.2% women, mean age, 58 years). Patients from lower income zip codes were more likely to undergo OCTR (P < .001). Patients either self-paying (P < .008) or covered by Medicare (P < .001) or Medicaid insurance (P < .001) were also more likely to undergo OCTR. In contrast, patients who received care at academic centers and centers with >300 beds were more likely to undergo ECTR (P < .001). Patients <65 years old were more likely to undergo ECTR (P < .001), and patients > 75 years old were more likely to undergo OCTR (P < .001). In addition, ECTR was found to be more expensive, with average total charges $1568 greater than charges for OCTR (P < .001).

CONCLUSIONS

Significant differences exist in treatment strategies for CTS and are related to patient income, location, and primary payor status. Differences in OCTR and ECTR rates are also present, and are related to the size and academic status of hospitals.

Primary Repair versus Reverse End-to-Side Coaptation by Anterior Interosseous Nerve Transfer in Proximal Ulnar Nerve Injuries

BACKGROUND

Proximal ulnar nerve lacerations are challenging to treat because of the complex integration of sensory and motor function in the hand. The purpose of this study was to compare primary repair and primary repair plus anterior interosseous nerve (AIN) reverse end-to-side (RETS) coaptation in the setting of proximal ulnar nerve injuries.

METHODS

A prospective cohort study was performed of all patients at a single, academic, level I trauma center from 2014 to 2018 presenting with isolated complete ulnar nerve lacerations. Patients underwent either primary repair (PR) only or primary repair and AIN RETS (PR + RETS). Data collected included demographic information; quick Disabilities of the Arm, Shoulder and Hand questionnaire score; Medical Research Council score; grip and pinch strength; and visual analogue scale pain scores at 6 and 12 months postoperatively.

RESULTS

Sixty patients were included in the study: 28 in the PR group and 32 in the RETS + PR group. There was no difference in demographic variables or location of injury between the two groups. Average quick Disabilities of the Arm, Shoulder and Hand questionnaire scores for the PR and PR + RETS groups were 65 ± 6 and 36 ± 4 at 6 months and 46 ± 4 and 24 ± 3 at 12 months postoperatively, respectively, and were significantly lower in the PR + RETS group at both points. Average grip and pinch strength were significantly greater for the PR + RETS group at 6 and 12 months.

CONCLUSION

This study demonstrated that primary repair of proximal ulnar nerve injuries plus AIN RETS coaptation yielded superior strength and improved upper extremity function when compared with PR alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database

INTRODUCTION

Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay.

METHODS

The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05.

RESULTS

A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001).

CONCLUSION

National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

Local Infiltration of Tranexamic Acid in Breast Reduction for Symptomatic Macromastia

BACKGROUND

With a surge of tranexamic acid (TXA) use in the plastic surgery community and a constant demand for breast reduction for symptomatic macromastia, questions about the benefits and risks emerge. The aims of this study are to evaluate and compare outcomes of patients undergoing breast reduction while receiving local TXA as opposed to standard procedure without TXA and to assess intraoperative bleeding and operative time.

METHODS

A retrospective review of breast reductions at a single institution from June 2020 to December 2021 was performed. The breast was infiltrated with tumescent solution at the time of surgery, with or without TXA. The population was divided into 2 groups: the TXA receiving group and tumescent only group. Demographics, intraoperative bleeding, operative time, complications, and drain duration were compared between groups. T test and χ 2 test analyses were performed on IBM SPSS.TM.

RESULTS

A total of 81 patients and 162 breasts were included. Mean age among patients was 30 ± 13.44 years. Mean SN-N distance was 32.80 ± 3.62 cm. Average resected breast specimen weight was 903.21 ± 336.50 g. Mean operating room time was 159 minutes. Intraoperative blood loss and operative time were not statistically different between groups ( P = 0.583 and P = 0.549, respectively). T-junction dehiscence was lower in the TXA group ( P = 0.016). Incidence of suture granulomas was lower in the TXA group ( P = 0.05). Drain duration was statistically significantly higher in the TXA group ( P = 0.033).

CONCLUSIONS

No decreases in intraoperative blood loss, operative time, or hematoma were seen after local administration of TXA during breast reduction. The rate of overall complications was not increased by using TXA, and incidence of T-junction dehiscence was lower in the TXA group lending to TXA's relatively safe profile. More research is necessary to further elucidate the TXA-related benefits in standard breast reductions.

Primary Repair of Upper Extremity Peripheral Nerve Injuries: An NSQIP Analysis From 2010 to 2016

BACKGROUND

To identify the rate of 30-day complications after primary repair of upper extremity peripheral nerve injuries, associated diagnoses, and postoperative complication rate.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2010 to 2016. Current Procedural Terminology codes consistent with primary nerve repair of the upper extremity were identified and included in the analysis. Patient demographics, comorbidities, type of procedure (elective/emergent), wound class, operative time, and 30-day complications were recorded. Patients with isolated upper extremity nerve injuries (isolated) were compared with those with peripheral nerve injuries in addition to bone, tendon, or soft tissue injuries (multiple).

RESULTS

In all, 785 patients were identified as having upper extremity nerve repairs (0.16%). Of them, 64% were men and 36% were women; the average patient age was 40 years. The most common indication for surgery was injury to the digits (54% of cases). Thirty-day adverse events occurred in 3% of all cases. Isolated nerve injury occurred in 43% of patients, whereas 57% had additional injuries. The multiple injury group had a significantly higher complication rate compared with the isolated group (1% vs 4.5%) (P = .007). Repair of tendon at forearm or wrist was the most common concurrent procedure performed.

CONCLUSIONS

Thirty-day complications among upper extremity peripheral nerve injuries are low, accounting for 3% of cases. Return to the operating room accounted for nearly half of all complications. Patients in the multiple injury group accounted for more than half of these and had a significantly higher complication rate compared with patients with isolated nerve injuries.

Sauvé-Kapandji and Darrach Salvage Procedure Rates and Perioperative Parameters for Distal Radioulnar Joint Arthritis and Instability

BACKGROUND

Distal radioulnar joint (DRUJ) instability and arthritis are often painful and functionally limiting pathologies. Two common salvage procedures for DRUJ dysfunction are the Darrach and Sauvé-Kapandji (S-K) procedures. This study aims to provide an analysis of national Darrach and S-K procedure utilization rates and patient demographics.

METHODS

A national ambulatory surgery database, the 2018 Nationwide Ambulatory Surgery Sample, was filtered for Darrach and S-K procedure encounters. Data related to patient demographics and medical history, indications for DRUJ salvage, and concurrent hand/wrist procedures were collected.

RESULTS

Database analysis revealed 1044 Darrach and 223 S-K procedure encounters. Patients undergoing Darrach procedures were older (60 vs 57, P = .002) and more likely to be women (66.1% vs 54.6%, P < .05). Patients aged <35 years underwent S-K procedures at greater rates compared with Darrach (13.9% vs 8.6%, P < .05). Primary osteoarthritis proved to be the most common indication for DRUJ salvage (64.8%) compared with rheumatoid arthritis (23.2%) and post-traumatic osteoarthritis (12.0%). Darrach and S-K procedures were accompanied by a secondary procedure at rates of 64% and 41%, respectively. The most common secondary procedures were tendon transfer, implant removal, neuroplasty, nerve resections, and wrist arthroscopy.

CONCLUSIONS

Patient age and sex are associated with DRUJ salvage procedure selection. Sauvé-Kapandji procedures are used in higher rates in male and younger patient populations. Furthermore, primary osteoarthritis and rheumatoid arthritis are the main underlying pathologies for Darrach and S-K procedures.

A Leadership Perspective on the Plastic and Reconstructive Surgery Residency Application Cycle during the COVID-19 Pandemic

Introduction

The purpose of this study was to identify leadership perspective on the impact of COVID-19 Plastic and Reconstructive Surgery residency application cycle in 2020 and future implications.

Methods

A survey was sent to residency program leaders (RPL), consisting of program directors and division chiefs/chairs. The survey was sent weekly for a total of 4 weeks and remained open for a total of 28 days.

Results

156 Plastic and Reconstructive Surgery (PRS) residency program leaders (RPL) were emailed. Response rate was 24% (38/156). 68% were division chiefs/chairs and 42% were program directors. 10% were both division chiefs/chairs and program directors. 78% were male. 87% of RPLs reported changes in number of away rotations, of which 91% reported less away rotations. Only 27% of programs provided virtual away rotations (VAR), and 88% of RPLs were not comfortable writing letters of recommendation after VARs. 100% reported that VARs influenced whether an applicant received an interview. 24 RPLs (63%) reported no changes how they viewed applications due to the pandemic. However, 5 (13%) reported USMLE scores were more important, 4 (11%) reported research more important, and 4 (11%) reported LORs more important. 66% did not feel they relied heavily on home institution candidates. 76% found virtual interviews effective in evaluating applicants and 71% reported they would add virtual interviews to future interview.

Conclusions

During 2020-2021 PRS residency application cycle, fewer away rotations were offered, and formerly in-person activities were moved to virtual platforms. Virtual activities caused difficulty assessing candidates for many residency programs.

Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis

BACKGROUND

Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP).

METHODS

ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,² respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications.

CONCLUSIONS

Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.

A Comparison of Applicant and Resident Physician Demographics Among Surgical Subspecialties From 2009 to 2019: Trends in Gender and Underrepresented Minorities in Medicine

BACKGROUND

The purposes of this study were to compare applicant statistics to resident physician demographics among several surgical subspecialties (SSSs), to identify trends of gender and underrepresented minorities in medicine (UIM), and to evaluate current diversity among these specialties.

METHODS

Graduate medical education reports from 2009 to 2019 were queried to determine trends among programs. Further identification of gender and UIM statistics was obtained in 4 several SSSs: integrated plastic surgery, orthopedic surgery (OS), otolaryngology surgery (ENT), and neurosurgery (NS). These were compared with Association of American Medical Colleges data of residency applicants for the respective years.

RESULTS

Significant differences were seen among gender and UIM(s) of the applicant pool when compared with resident data. All specialties had significantly fewer American Indian and African American residents compared with applicants. Significant differences between applicants and residents were also found among Hispanic, Native Hawaiian, and female demographics. All SSSs had a significant positive trend for the percentage of female residents. Significant differences between specialties were identified among African American, Hispanic, and female residents. Orthopedic surgery and NS had significantly higher percentage of African American residents compared with ENT and integrated plastic surgery. Neurosurgery had significantly higher percentage of Hispanic residents compared with OS and ENT. Integrated plastic surgery and ENT had significantly higher percentage of female residents compared with OS and NS.

CONCLUSIONS

There has been significant increase in number of residency programs and resident positions since 2009. However, increase in female residents and UIM(s) among SSSs has not matched the pace of growth.

Open Reduction Internal Fixation of Distal Radius Fractures: Retrospective Cohort Analysis of the Geriatric Population Using the NSQIP Database

Background: Distal radius fractures (DRFs) are the most common upper extremity fractures with more than 600 000 cases per year in the United States and account for up to 18% of fractures in the geriatric population. The purpose of our study was to identify the influence of age on 30-day postoperative outcomes while adjusting for patient demographics and comorbidities. Methods: The National Surgery Quality Improvement Program database was queried for patients having undergone open reduction internal fixation (ORIF) of DRFs. Current Procedural Terminology codes 25607, 25608, and 25609 between the years 2007 and 2016 were collected and analyzed. Patients were divided into 2 groups: group 1, 18 to 64 years; and group 2, 65 years and older. Patient demographics; preoperative, perioperative, and postoperative variables; and complications were recorded and analyzed. Results: In all, 5894 patients were identified; group 1 consisted of 4056 patients aged <64 years, and group 2 consisted of 1838 patients aged 65 years and older. The total complication rate was 2.7% for all patients, 2.2% for group 1, and 3.4% for group 2. The most common complications included surgical site infection for group 1 and urinary tract infection for group 2. Univariate analysis demonstrated association between age ≥65 years and complication (hazard ratio, 1.55; 95% confidence interval, 1.12-2.14; P = .009). However, after controlling for statistically significant factors, age was not an independent predictor of complications (P = .685). Admission status, American Society of Anesthesiologists classification, operative time, renal failure, and bleeding disorders were independent predictors of 30-day complications across all patients. Conclusion: Our data suggest that patients aged 65 years and older without high-risk comorbidities should be offered ORIF of DRFs as their complication risk remains low.

Increasing Recognition of Community-Acquired, Non-Tuberculous Mycobacterial Infections of the Hand and Wrist

Background

In this study, we present our experience with community-acquired, culture-positive, non-tuberculous mycobacterial (NTM) infections of the hand and wrist and compare the clinical features, risk factors, diagnostic delays, and treatment outcomes among patients referred for surgical consultation at our institution over a five-year period.

Methodology

We retrospectively identified patients on chart review who were diagnosed with culture-positive, extrapulmonary, cutaneous NTM infections between January 1, 2014, and December 31, 2018. Only patients with community-acquired NTM infections of the hand and wrist were included. Patient demographics, risk factors, location, diagnostic delays, NTM species isolated, treatment modalities, and treatment outcomes were collected and analyzed. These variables were further compared between patients who participated in fishing-related activities and those who did not.

Results

A total of 10 patients were identified with community-acquired NTM infections of the hand or wrist. Of these patients, eight (80%) were male, and six (60%) had participated in fishing-related activities prior to the initial presentation. The majority of patients had Mycobacterium marinum isolates (n = 6, 60%) and involved the hand (n = 8, 80%). M. marinum isolates were associated with a significantly shorter time to diagnosis (p = 0.02). All patients underwent surgical management with a prolonged course of postoperative antibiotics and were cured of their infection at the end of their treatment course.

Conclusions

Proper risk factor documentation and heightened clinical awareness are essential to reduce delays in the diagnosis of NTM skin and soft tissue infections and provide the best chance for curative therapy.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program

INTRODUCTION

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay.

RESULTS

The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21).

CONCLUSIONS

Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Evaluation of National Resident Matching Program and Electronic Residency Application Service Data in the Integrated Plastic Surgery Match

INTRODUCTION

The National Resident Matching Program and Electronic Residency Application Service provide data for tracking trends among applicants in each specialty over the past 5 years. The purpose of this study was to examine this information and determine sex and race/ethnicity distribution over the past 5 years.

METHODS

The National Resident Matching Program and Electronic Residency Application Service databases were surveyed for trends in the following categories: number of positions, number of applicants, percent of applicants per position, and number of applicants by sex and self-identified race/ethnicity. This information was analyzed graphically for visual representation of the changes in the field.

RESULTS

While there has been a steady increase in number of positions offered, there has also been a significant decrease in number of applicants, resulting in an increase in number of positions offered per applicant. While female and Asian applicants have increased in number, rates of applications from other diverse groups have remained stagnant.

CONCLUSIONS

The number of plastic surgery positions offered has increased, whereas the number of applicants has decreased, resulting in a reduction in the number of applicants per position. Lack of racial diversity remains a significant issue in the applicant pool.

Cost Analysis and National Trends in the Treatment of Thumb Basal Arthritis: Comparing Ligament Reconstruction/Tendon Interposition and Trapeziectomy/Hematoma Distraction Arthroplasty

BACKGROUND

Thumb basal arthritis (TBA) is a common form of arthritis characterized by wearing away of cartilage in the crarpometacarpal joint at the base of the thumb. The purpose of the study was to analyze cost trends of the 2 common surgical treatments options: ligament reconstruction/tendon interposition (LRTI) and trapeziectomy/hematoma distraction arthroplasty (THDA).

METHODS

The Vizient Clinical Data/Resource Manager electronic database was reviewed for the 3 treatment procedures of TBA from January 1, 2016, to December 31, 2019. Cases were placed into 1 of 2 categories: LRTI or THDA. Total and direct costs were averaged and compared nationally and regionally. One-tailed t test and Pearson correlation analyses were performed (P < 0.05 and r > 0.9 or r < -0.9 was considered significant).

RESULTS

A total of 28,887 total cases (26,405 LRTI, 2482 THDA) were analyzed. There was a 49% increase in number of surgical procedures to treat TBA between 2015 and 2018. Ligament reconstruction/tendon interposition (91%) had larger market share than THDA (9%). However, market share percentage of each procedure stayed the same over time. Trapeziectomy/hematoma distraction arthroplasty had lower average cost (US $4157) compared with that of LRTI (US $4446, P = 0.06) However, THDA had a significant positive trend in cost, increasing 14% in 4 years. In 2019, 30% of procedures performed were in the Midwestern United States, 27% Northeastern United States, 24% Southern United States, and 19% Western United States.

CONCLUSIONS

Most patients with TBA seem to be treated with LRTI. The market share seems to be greatest for LRTI and lowest for THDA nationally and regionally. Although the average cost for THDA was less than that of LRTI, this difference was not significant.

Cost Analysis and National Trends in the Treatment of Dupuytren Contracture Comparing Collagenase Injection, Needle Fasciotomy, and Open Fasciectomy Procedures

BACKGROUND

Dupuytren contracture (DC) is a common disorder characterized by progressive fibrosis of palmar fascia. This study analyzed cost trends of 3 common treatments for DC: fasciotomy, fasciectomy, and collagenase injection (CI)/cord manipulation.

METHODS

The Vizient Clinical Data/Resource Manager electronic database was reviewed for all procedures for the treatment of DC at participating hospitals in the United States (US) from October 1, 2015, to September 1, 2019. Cases were placed into 1 of 3 categories: (1) CI, (2) needle fasciotomy (NF), and (3) open fasciectomy (OF). Total and direct costs were averaged for each procedure and compared nationally and regionally. Temporal trends and specific market share were analyzed. One-tailed t test and Pearson correlation analysis was performed (P < 0.05 and r > 0.9 or r < -0.9 was considered significant).

RESULTS

A total of 22,974 total cases were identified. A total of 16,966 OF, 3962 NF, and 2046 CI were performed. There was a nearly a 4-fold increase in number of procedures to treat DC from 2015 to 2018. Market share percentage of each procedure stayed relatively similar over time. However, market share percentage differed between procedures. Needle fasciotomy had the lowest market share percentage approximately 7%. Collagenase injection had the highest average cost at US $4453.66 and was significantly higher than OF at US $3394.90 and NF at US $2010.75. Cost and distribution of procedures were further analyzed by geographic regions. In 2018, 32% of procedures performed were in the Northeastern US, 29% in the Midwestern US, 23% in the Southern US, and 16% in the Western US. Total number of Dupuytren procedures increased more than 300% in all regions across the US from 2015 to 2018. In every region, NF was the lowest cost intervention. Cost of OF and CI varied between regions and was often the most expensive intervention.

CONCLUSIONS

Treatment of DCs with NF seems to be the least costly treatment option. Needle fasciotomy seems to be the least commonly performed procedure. Regional data show variations in the cost of OF and CI. However, OF has the majority market share nationally and regionally. Although the cost of these procedures seems to vary regionally, the type of procedures being performed seem to be similar across regions.

Comparative Analysis of Open Reduction Internal Fixation and Closed Reduction Percutaneous Pinning of Hand Fractures: Single Academic Center Retrospective Review

PURPOSE

The purpose of our study was to compare postoperative outcomes between patients receiving closed reduction percutaneous pinning (CRPP) to open reduction internal fixation (ORIF) following metacarpal and phalanx fractures.

METHODS

A retrospective chart review was performed at a single academic center for all patients suffering a metacarpal or phalanx fracture and receiving either CRPP or ORIF between 2012 and 2018. Patients were divided into fracture mechanism, high-energy mechanism of injury, low-energy mechanism of injury, or unknown, and treatment of fracture with either ORIF or CRPP. High-energy mechanism of injury included gunshot wounds, motor vehicle crash, and blast injuries, whereas low-energy mechanism of injury included all other causes. Patient demographics, postoperative complications, 30-day readmission, and return to the operating room were recorded.

RESULTS

A total of 408 patients, with 524 fractures, were included in the study. There were 127 fractures that resulted from high-energy mechanisms and 394 fractures that resulted from low-energy mechanisms. Open reduction internal fixation was used to treat 299 fractures, whereas CRPP was used for 225 fractures. Among fracture fixation, there was a total of 8.4% complication rate with ORIF, accounting for 10.4% of complications, and CRPP accounting for 5.8%. Among the fracture mechanism, the high-energy mechanism of injury had a 21.3% complication rate, whereas the low-energy mechanism of energy was 4.3%. When comparing the above variables, only high-energy mechanism of injury was a statistically significant predictor of complications (odds ratio, 3.2; confidence interval, 1.5-7.0; P = 0.002). The average operating room time for the ORIF group was 124.82 minutes compared with 97.6 minutes for the CRPP group.

CONCLUSION

Patients with hand fractures corrected by ORIF appeared to have a higher postoperative complication rate. When the 2 procedures, ORIF and CRPP, were controlled for mechanism of injury, there was not a statistically significant difference in postoperative complication rate (P = 0.14). However, a fracture sustained by a high-energy mechanism was a statistically significant predictor of postoperative complications (P = 0.002).

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction

INTRODUCTION

Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction.

METHODS

The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded.

RESULTS

A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related.

CONCLUSION

Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.

High-Pressure Injection Injuries of the Hand: A 10-Year Retrospective Analysis at a Single Academic Center

INTRODUCTION

The incidence of high-pressure injection injuries of the hand is low. Although the occurrence is rare, the precarious progression of the injury exacts prompt surgical evaluation in order to avoid complications and amputation. The current study was devised in order to make comparisons to the current data, in addition to supplementing the literature with observations regarding clinical course and management.

METHODS

A multisurgeon, retrospective chart review from a single institution was performed. Inclusion criteria included cases involving a high-pressure injection injury to the hand that underwent surgical management. Patient demographics, injury details, and hospital course were all reviewed and recorded.

RESULTS

This retrospective review identified 20 cases meeting criteria, all of which involved males. The average age at time of injury was 39.7 years (range, 21-71 years). The incidence of injection injuries over a 10-year time period was 2.1 cases per year. The nondominant hand was injured in 11 cases (63%). The most common site of injury was the index finger with 11 recorded incidents (55%). Other reported locations included the metacarpal (40%) and small finger (5%). Occupational data included 10 construction workers, 5 painters, and 2 cleaning crew members, and 3 had nonmanual occupations. Paint was the most commonly injected substance with 17 reported cases (85%). On average, the delay until surgery was observed to be 21.9 hours (n = 16). Only 1 patient underwent surgery at 6 hours after surgery. The average number of procedures performed was 1.8 (range, 1-4). Hospitalization duration was on average 3.9 days (range, 1-9 days), and the average follow-up length was 69 days (range, 7-112 days). There were no identified cases that necessitated amputation.

CONCLUSIONS

This form of injury most commonly affects male, middle-aged laborers. Our study found very low amputation rates when compared with the current literature, despite observing longer delays to surgery according to current recommendations. Limited comparisons can be made from data regarding clinical course and management because of the small sample size of the current study and the limited published data. This indicates a need for further exploration and collection of data involving parameters such as clinical course and management.

Impact of Radiation on Implant-Based Breast Reconstruction in Prepectoral Versus Submuscular Planes

BACKGROUND

Postmastectomy implant-based breast reconstruction (IBR) in the setting of radiation (XRT) comes with a high risk of perioperative complications regardless of reconstruction method. The aim of study was to identify the effects of XRT on IBR using a prepectoral versus submuscular approach.

METHODS

A retrospective chart review was performed after institutional review board approval was obtained. Patients at a single institution who had 2-stage IBR from June 2012 to August 2019 were included. Patients were separated into 4 groups: prepectoral with XRT (group 1), prepectoral without XRT (group 2), submuscular with XRT (group 3), and submuscular without XRT (group 4). Patient demographics, comorbidities, and postoperative complications were recorded and analyzed.

RESULTS

Three hundred eighty-seven breasts among 213 patients underwent 2-stage IBR. The average age and body mass index were 50.10 years and 29.10 kg/m2, respectively. One hundred nine breasts underwent prepectoral reconstruction (44 in group 1, 65 in group 2), and 278 breasts underwent submuscular reconstruction (141 in group 3, 137 in group 4). Prepectoral tissue expander placement was associated with higher complication rates in the radiated group (38.6% compared with 34.0% submuscular) and lower complication rates in the nonradiated group (26.2% compared with 29.2% submuscular), although significantly less explants were performed in prepectoral group, regardless of XRT status. The 3 most common complications overall were contracture (15.1% radiated, 10.4% nonradiated), infection (18.4% radiated, 11.9% nonradiated), and seroma (15.7% radiated, 10.9% nonradiated).

CONCLUSIONS

Two-stage, prepectoral tissue expander placement performs clinically better than submuscular in nonradiated patients compared with radiated patients; however, no statistical significance was identified. Prepectoral had a significantly less incidence of reconstructive failure than submuscular placement regardless of XRT status. Future larger-scale studies are needed to determine statistically significant difference in surgical approach.

Epidemiology of Upper-Extremity Amputations Using the National Electronic Injury Surveillance System

BACKGROUND

Upper-extremity amputations can be devastating injuries that lead to lifelong disabilities. The purpose of our study was to review national data and identify populations at risk and injury patterns that could be targeted with prevention strategies.

METHODS

Data from the National Electronic Injury Surveillance System between years 2012 and 2018 were reviewed. Injuries affecting the upper extremity resulting in amputation were included. Patient demographics, anatomical location, mechanism of injury, level of care provided, and setting of injury were recorded. Descriptive was recorded and tabulated for each category.

RESULTS

There were 4,766 patients identified with amputations to the upper extremity from 2012 to 2018. The following categories are listed below: age in years, sex, race, anatomical location of injury, most common mechanisms of injury, disposition of patient, environmental location.

CONCLUSIONS

Our data show that male children younger than 10 years are at the high risk for finger amputations. In addition, the majority of these injuries occur in the home. This suggests that safety prevention in the home is a significant area in need of improvement. We recommend further research in areas of home safety and injury prevention to decrease the risk of the devastating injuries.

Practice Patterns Among Hand Surgeons According to Primary Residency Training: A National Surgical Quality Improvement Project Study

INTRODUCTION

Hand surgery fellowships accept applicants from 3 different residencies: general surgery, orthopedic surgery, and plastic surgery. Although all of these specialties culminate into a board-certified hand surgeon, each specialty receives drastically different training in residency, which can have effects on which procedures these surgeons feel comfortable performing in their own practices. This study aims to compare practice patterns and complication rates among hand surgeons by residency training.

METHODS

The National Surgical Quality Improvement Program database was queried between the years of 2014 and 2018 for all Current Procedural Terminology codes pertaining to upper-extremity surgical procedures performed below the elbow. Procedures not performed by a general, orthopedic, or plastic surgeon were excluded, as well as polytraumas. Procedures were then stratified by anatomic region, tissue type, and primary specialty of the attending surgeon. Data collected included the number of each procedure, patient complexity, and complications. Statistical analysis consisted of a t test for continuous variables, χ2 analysis for categorical variables, and linear regression analysis to compare complications rates between specialties.

RESULTS

A total of 76,980 unique cases were included in our analysis: 4979 (6.4%) at the elbow, 43,680 (56.7%) at the forearm/wrist, 23,284 (30.2%) at the hand, 1421 (1.8%) flaps/grafts, 285 (0.4%) vascular, and 3331 (4.3%) neurological. Orthopedics performed most (79.5%) of the procedures, whereas plastic surgeons and general surgeons performed 17.3% and 3.1%, respectively. There were also significant differences by anatomic location/type of procedure, with orthopedic surgeons performing 99.2% of procedures at the elbow but only 67.7% of procedures at the hand. Linear regression analysis showed general surgeons had the lowest complication rates.

CONCLUSIONS

Our data show significant differences in the number of upper-extremity surgeries performed by surgeons from each specialty at different anatomic locations.This could be due to differences in training during residency or proportionately more orthopedic surgeons being "full-time" hand surgeons. These data could affect hiring patterns in hospitals seeking hand surgeons depending on the variety of pathology encountered at that particular institution.

Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon

Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.

Iatrogenic Radial Artery Injuries: Variable Injury Patterns, Treatment Times, and Outcomes

Background: The radial artery is commonly accessed for arterial blood sampling, invasive blood pressure monitoring, and vascular access for cardiac catheterization. Iatrogenic radial artery injury is a rare complication with potentially devastating outcomes. The purpose of our study was to identify the timing of these injuries and define a treatment algorithm. Methods: A retrospective chart review of all patients with iatrogenic radial artery injuries were identified between the years 2008 and 2018. Patient demographics, mechanism of injury, interventions, and outcomes were recorded. Results: A total of 18 patients were identified with iatrogenic radial artery injury over a 10-year period. Fifty percent of these resulted from arterial line cannulation, and 50% occurred after transradial cardiac catheterization. Thirty-three percent resulted in radial artery pseudoaneurysm (RAP), and 66% had acute radial artery thrombosis (RAT). Eleven of the 18 patients underwent operative intervention. Of the 12 patients with RAT, 4 were treated with systemic anticoagulation for 3 months. All patients with RAP who were surgically treated had resolution of symptoms on follow-up evaluation. Of the patients with RAT, 2 had persistent sensorimotor deficits after treatment, and 1 patient had multiple necrotic fingers requiring amputation. Conclusion: Radial artery injuries are an uncommon but potentially devastating complication of common invasive procedures resulting in thrombosis, pseudoaneurysm, or overt hand ischemia. The treatment options vary depending on presenting symptoms.

Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction

BACKGROUND

Prior investigations of microsurgical breast reconstruction have not distinguished the effects of surgeon versus hospital volume and failed to address the effect of patient clustering. Our data-driven analysis aims to determine the impacts of surgeon and hospital volume on outcomes of microsurgical breast reconstruction.

METHODS

Nationwide Inpatient Sample (NIS) data from 2008 to 2011 was analyzed for patients who underwent microsurgical breast reconstruction. Volume-outcome relationships were analyzed with restricted cubic spline analysis. A multivariable mixed-effects logistic regression was used to account for patient clustering effect.

RESULTS

A total of 5,404 NIS patients met inclusion criteria. High-volume (HV) surgeons had a 59% decrease in the risk of inpatient complications, which became non-significant after clustering correction. For HV hospitals, there was a 47% decrease in the risk of inpatient complications (odds ratio = 0.53; 95% confidence intervals 0.30, 0.91; p = 0.021) that was statistically significant with the clustering adjustment. Neither the volume-cost relationship for surgeons nor hospitals remained statistically significant after accounting for clustering.

CONCLUSIONS

Hospital volume plays a significant impact on outcomes in microsurgical breast reconstruction, while surgeon volume has comparatively not shown to be similarly impactful. The complexity of care related to microsurgical breast reconstruction warrants equally complex and engineered health systems.

Remote Injuries and Outcomes After Distal Radius Fracture Management

BACKGROUND

Distal radius fracture (DRF) is a common fracture of the upper extremity. The role of concurrent injuries in patients treated for DRFs is poorly elucidated. The authors sought to determine whether remote injuries were associated with worse outcomes after management of DRFs.

METHODS

A retrospective cohort study including all consecutively seen patients by a university hospital hand service between 2010 and 2015. Preoperative radiographs were analyzed, and patients were managed by surgeon preference and evaluated postoperatively using pain scores. Remote injury was defined as any other injury sustained at the time of fracture not localized to affected extremity. Univariate analysis was performed to identify factors associated with risk of complication. A multivariate logistic regression analysis was performed, controlling for confounding factors.

RESULTS

A total of 181 DRFs in 176 patients were treated over the 5-year period of the study. Forty-eight (26.5%) of the fractures were managed nonoperatively with casting, 12 (6.6%) with closed reduction and pinning, and 119 (65.7%) with open reduction and plating. The mean follow-up was 5.2 months. The complication rate was 18.2%. The most common complication was persistent pain in 5 patients, followed by median neuropathy, loss of reduction, arthritis, and distal radioulnar joint instability. After controlling for age, body mass index, hand surgeon, and other confounders, remote injury was associated with a significantly increased risk of complications ( P = .04, odds ratio: 6.03, 95% confidence interval: 1.05-34.70).

CONCLUSIONS

Patients with remote injuries have a 6-fold increased risk of complications after DRF treatment. The additional risk in these patients should be considered during patient/family counseling and clinical decision-making in DRF management.

Upper extremity injuries associated with all terrain vehicle accidents: A multicenter experience and case review

BACKGROUND

All terrain vehicle accidents are a common cause of trauma admission and often associated with extremity injuries. However specifics of injury patterns to the upper extremity has not previously been described. A multicenter, retrospective study was conducted to determine the frequency and distribution of upper extremity injuries sustained from ATV accidents.

METHODS

Medical records of all patients presenting to two trauma centers with ATV related upper extremity trauma from 2001 to 2013 were reviewed. Patient records and radiographic data were analyzed for detailed extremity injury data. The identified injuries were classified by: anatomic location (shoulder, arm, elbow, forearm, wrist, hand) and structures involved (fracture/dislocation, amputation, nerve, artery, soft tissue). In addition, patient demographic information, length of stay (LOS), airway status, intensive care unit (ICU) stay, Glasgow coma scale (GCS), use of safety equipment, and associated injuries RESULTS: Two hundred seventy-seven patients with upper extremity injuries secondary to ATV accidents presented from 2001 to 2013. The frequency and distribution of ATV related upper extremity injuries classified by anatomic location demonstrated 18% of injuries involving the shoulder, 20% arm, 16% elbow, 18% forearm, 40% wrist, and 24% hand, with 30% of patients having injuries that involved more than one anatomic location. Injuries classified by structure involved indicated 73% of injuries were fracture/dislocations, 4% nerve injury, 2% vascular injury, and 36% soft tissue injury.

CONCLUSION

The most common upper extremity injuries experienced in ATV injuries were fractures/dislocations with one third of patients having injuries that involved more than one anatomical location. Less than half of the patients were documented as having worn safety equipment, illustrating a need for increased awareness and enacted of measures to improve safety and prevent accidents.

Modified percutaneous needle aponeurotomy for the treatment of dupuytren's contracture: early results and complications

BACKGROUND

The purpose of our study was to identify postoperative results and complications using a percutaneous approach to treat Dupuytren's contracture in a consecutive series of patients.

METHODS

A review of all patients with Dupuytren's contracture treated with percutaneous needle aponeurotomy (NA) from 2008 to 2010 was performed. Patient demographics, digits affected, and disease severity was recorded. Pre-operative total passive extension deficit (TPED) was calculated for each affected digit. TPED in the immediate postoperative period and at the time of most recent follow-up was measured. Treatment-related complications and incidence of disease recurrence were identified. Statistical analysis was performed using paired t-test. (Statistical significance p-value <0.05).

RESULTS

525 digits in 193 hands were treated with NA. 140 patients were male, average age was 65 years. The average preoperative TPED was 41° and the average immediate postoperative TPED was 1° (98% correction) (P=0.0001). The average TPED at 4.5 month follow up was 11 o (73% correction). Complications included infection in 3 patients and one case each of triggering, delayed flexor tendon rupture, complex regional pain syndrome and persistent numbness. Recurrence was observed in 62 digits.

CONCLUSION

Percutaneous needle aponeurotomy is an effective technique in the treatment of Dupuytren's contracture. Near complete correction of contracture was achieved and few complications were observed. Longer follow-up is needed to determine if these short-term results are maintained.

Outcomes of open and endoscopic carpal tunnel release: a meta-analysis

BACKGROUND

Currently, there are two genres of surgical treatment of carpal tunnel syndrome, open versus endoscopic. The goal of our study is to analyze published data by comparing outcomes of surgical treatment for carpal tunnel syndrome and determine if one approach is superior to the other (open versus endoscopic).

METHODS

A meta-analysis of retrospective series of Carpal tunnel release including >20 patients, with results measuring outcomes based on at least six of the following nine parameters (paresthesia relief, scar tenderness, two-point discrimination, thenar muscle weakness, Semmes-Weinstein/SW monofilament testing, return to work time, grip and pinch strength, and complications).

RESULTS

Endoscopic carpal tunnel approach showed statistically superior outcomes in eight of the nine categories investigated. Only in the category of complications (mean occurrence of 1.2 % in the open release versus 2.2 % in the endoscopic release group) was the endoscopic group inferior.

CONCLUSION

This suggests that the endoscopic release is superior to the open release, particularly in experienced hands.

Challenges of Randomized Controlled Trial Design in Plastic Surgery

Randomized controlled trials are the gold standard of evidence-based medicine. In the field of plastic surgery, designing these studies is much more challenging than in pharmaceutical medicine. Randomized trials in plastic surgery encompass several road blocks including problems shared with other surgical trials: equipoise, high cost, placebo issues and learning curves following the establishment of a novel approach. In addition, plastic surgery has more subjective outcomes, thus making study design even more difficult in assessing the end result.

Challenges of randomized controlled trial design in plastic surgery

Randomized controlled trials are the gold standard of evidence-based medicine. In the field of plastic surgery, designing these studies is much more challenging than in pharmaceutical medicine. Randomized trials in plastic surgery encompass several road blocks including problems shared with other surgical trials: equipoise, high cost, placebo issues and learning curves following the establishment of a novel approach. In addition, plastic surgery has more subjective outcomes, thus making study design even more difficult in assessing the end result.

Breast carcinoma metastatic to the gallbladder and urinary bladder

We present a patient with a history of infiltrating lobular breast carcinoma that metastasized to both the biliary and urinary tract after a ten year disease-free period following mastectomy and chemoradiotherapy. The patient presented with acute cholecystitis; imaging and histopathology revealed infiltrating lobular carcinoma of the gallbladder and urinary bladder. This report emphasizes the importance of long-term follow up in patients with a history of breast cancer and maintaining a high degree of suspicion for diagnosis of metastatic disease.

The distal superficial femoral arterial branch to the sartorius muscle as a recipient vessel for soft tissue defects around the knee: anatomic study and clinical applications

Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the reconstructive surgeon. Most of these defects can be managed using local or regional flaps alone. However, large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in soft tissue coverage and closure of large cavities. We describe a unique recipient vessel for microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through anatomic and clinical studies.

Management of vascular graft infections with soft tissue flap coverage: improving limb salvage rates--a veterans affairs experience

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide débridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with débridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive débridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful débridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.

Simultaneous double second toe transplantation for reconstruction of multiple digit loss in traumatic hand injuries

The objective of this study is to review a single institution's 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.