Challenges for Women in Hand Surgery: Our Perspective.

Over recent decades, the prevalence of women in surgical subspecialties has increased. There has been a significant rise in the percentage of women entering integrated plastic surgery programs and an increase, albeit smaller, in women entering orthopedic surgery training programs. Although female membership in the American Society for Surgery of the Hand has steadily increased, women remain in the vast minority within this professional society and many others within the field of hand surgery. In addition to underrepresentation in positions of leadership, women face challenges such as imposter syndrome, bullying, unfavorable work structure for work-family balance, macro and micro-aggressions, and lack of mentors at a higher rate than their male colleagues. As awareness rises of the additional challenges that women in hand surgery face, we must directly address them to improve equity within our subspecialty.

Open Carpal Tunnel Release With a Z-plasty Rearrangement for Median Nerve Mononeuropathy Secondary to Traumatic Scar Contracture.

We present the case of a 56-year-old woman who developed carpal tunnel syndrome and palmar scar contracture secondary to a left-hand palmar laceration in a pedestrian versus motor vehicle accident. The patient underwent carpal tunnel release and a Z-plasty rearrangement to restore normal thumb movement. The patient reported significant improvement in thumb mobility, resolution of median neuropathy symptoms, and no pain along the scar at her three-month follow-up. Our case illustrates the effectiveness of a Z-plasty in relieving tension along scars and potential management for traction-type extraneural neuropathy arising from scar contracture.

Does resident autonomy in colectomy procedures result in inferior clinical outcomes?

BACKGROUND: The amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. METHODS: The Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. RESULTS: In total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P = .42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. CONCLUSION: Colectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency.

Treatment of Nonreplantable Total Thumb Amputation at the CMC Level Using Index Finger Pollicization.

BACKGROUND: Pollicization of the index finger is a rarely performed reconstructive option for patients with total thumb amputations with nonsalvageable carpometacarpal (CMC) joint and thenar muscles. Successful pollicization can provide basic grasp and pinch to help patients carry out activities of daily living. We present a retrospective review of 4 patients who underwent index finger pollicization for traumatic total thumb amputations. METHODS: A retrospective review of 4 cases of pollicization using an injured index finger for traumatic thumb amputation was performed. Patients available for follow-up were contacted for functional assessment. Outcomes including range of motion (ROM), grip strength, key pinch, 2-point discrimination, and Disabilities of the Arm, Shoulder, and Hand score were obtained. Functional thenar muscle and the CMC joint were absent in all cases. Injury mechanism was firework in 2 patients and crush in 2 patients. RESULTS: The time from injury to pollicization ranged from 8 days to 17 months. Follow-up time ranged from 10 weeks to 3 years. Three patients regularly used the pollicized thumb in activities of daily living such as writing. Tip pinch and lateral pinch along with grip strength were weak in all cases; the best recorded pinch strength was 24% and grip strength was 25% compared with the contralateral hand. The ROM of the pollicized thumb was limited. CONCLUSIONS: Index finger pollicization following total thumb amputation can be a viable last-resort option for patients. The pollicized digit acts as a sensate post and avoids further morbidity from the traumatized extremity.

Supervised independence in elective inguinal hernia repairs performed by surgical residents is not associated with compromised short clinical outcome or rates of reoperation for recurrence.

BACKGROUND: We evaluate the association between attending surgeon involvement and clinical outcome in elective inguinal hernia repairs performed by residents. METHODS: Patients undergoing initial elective unilateral inguinal hernia repair between 2004 and 2019 were identified using the Veterans Administration Surgical Quality Improvement Program Database. The level of attending surgeon involvement was categorized as active (attending scrubbed [AS]) or passive (supervising the resident's performance but not scrubbed [ANS]). AS and ANS herniorrhaphies were 1:1 propensity matched for patient demographics, comorbidities, surgical approach, resident postgraduate level, and year of repair. Rates of complication and recurrence for matched cohorts were compared by standard methods. RESULTS: 30,784 patients met inclusion criteria. 5136 (17%) repairs were performed without the attending scrubbed. On comparison of matched-cohorts, overall complication rates (1.7% vs 1.2%, p = 0.07) and rates of recurrence (1.9% vs 1.4%, p = 0.041) for patients undergoing herniorrhaphy AS were statistically similar to those performed ANS. CONCLUSION: Supervised independence in elective inguinal hernia repair performed by surgical residents is not associated with inferior clinical outcomes.

Does Pandemic Crisis Mean Education Crisis? The Chicago Academic Plastic Surgery Collaborative Response to COVID-19.

SUMMARY: The health care crisis related to the spread of novel coronavirus (severe acute respiratory syndrome coronavirus 2) has created new challenges to plastic surgery education, mostly because of the decreased volume of procedures. The plastic surgery program directors in Chicago decided to act and identify ways to promote surgical education through citywide, multi-institutional, systematic clinical case discussions. Although the initiative has no impact on the surgical skill of the trainees, it was welcomed by residents and faculty and promoted clinical core knowledge in plastic surgery and collaboration among the institutions.

A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury.

BACKGROUND: Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs). STUDY DESIGN: We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication. RESULTS: There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching. CONCLUSIONS: In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.

Positive microscopic surgical margins: Is there an association with survival in resected small gastrointestinal stromal tumors?

BACKGROUND: Few studies evaluate the relationships between surgical approach, histologic margin, and overall survival in gastrointestinal stromal tumor. We test the hypothesis that margin positive resection is associated with compromised overall survival. METHODS: We queried the National Cancer Data Base to identify patients undergoing resections for gastrointestinal stromal tumors ≤3 cm in size between 2010 and 2015. Multivariable logistic regression was used to identify factors associated with positive microscopic margins on final pathology. Cox proportional hazard methods were used to evaluate factors associated with overall survival. RESULTS: 2064 patients met inclusion criteria; 135 (6.5%) had a microscopically positive surgical margin. On multivariable regression, minimally invasive approach was not associated with risk of a positive margin (OR 1.06 95% CI [0.71, 1.59]). On Cox analysis, positive margin status was not associated with OS (R1: 1.03, CI [0.46-2.31], reference R0). CONCLUSIONS: Positive microscopic surgical margins are not associated with compromised overall survival in patients undergoing resection of small gastrointestinal stromal tumors. Minimally invasive surgical approaches do not compromise oncologic outcomes in these cases.

The importance of the margin of resection and radiotherapy in retroperitoneal liposarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiotherapy on clinical outcomes in retroperitoneal liposarcoma have been underpowered. METHODS: We queried the National Cancer Database for patients undergoing resection of retroperitoneal liposarcoma from 2004 to 2016. Cox proportional hazards modeling stratified by tumor size was used to identify factors associated with overall survival. RESULTS: 4018 patients met inclusion criteria. 251 had small (<5 cm), 574 intermediate (5-10 cm), and 3193 large (>10 cm) tumors. Positive surgical margins were correlated with risk of death across all tumor size categories (<5 cm HR 2.33, CI [1.20, 4.55]; 5-10 cm HR 1.49, CI [1.03, 2.14]; >10 cm HR 1.30, CI [1.12, 1.51]). Adjuvant radiotherapy was associated with improved survival for patients with large tumors only (HR 0.75, CI [0.64, 0.89]). CONCLUSIONS: In retroperitoneal liposarcoma, adjuvant radiation is associated with improved survival only for patients with tumors larger than 10 cm. Radiation should be used sparingly in patients with smaller tumors. SUMMARY: The use of radiotherapy in the management of retroperitoneal sarcoma remains controversial. We isolated retroperitoneal liposarcomas only and identified a survival benefit from radiotherapy treatment only in tumors larger than 10 cm and only in the adjuvant setting.

The importance of the margin of resection and external radiation in non-lipomatous retroperitoneal sarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiation on clinical outcomes of patients with non-lipomatous retroperitoneal sarcoma have been underpowered. METHODS: We queried the National Cancer Database to identify patients undergoing surgical resection of retroperitoneal sarcoma with non-lipomatous histology from 2004 to 2016. Multivariable logistic regression and Cox proportional hazards modelling with patients stratified by tumor size were used to identify factors associated with overall survival. RESULTS: 3,394 patients met inclusion criteria. 592 had small (<5 cm), 1,186 had intermediate (5-10 cm), and 1,616 had large (>10 cm) tumors. Use of either neoadjuvant or adjuvant radiotherapy was associated with improved survival for patients with intermediate (neoadjuvant HR 0.67, CI [0.46, 0.98]; adjuvant HR 0.61, CI [0.50, 0.76]) and large (neoadjuvant HR 0.50, CI [0.37, 0.68]; adjuvant HR 0.56, CI [0.47, 0.69]) tumors, while adjuvant radiation therapy was associated with a survival benefit for small-sized tumors (HR 0.67, CI [0.46, 0.99]). CONCLUSIONS: Radiation therapy is associated with an overall survival benefit in patients presenting undergoing resection of non-lipomatous retroperitoneal sarcoma.

Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures.

PURPOSE: To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures. METHODS: All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires. RESULTS: Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43° vs 58°), extension (46° vs 56°), and ulnar deviation (23° vs 29°) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture. CONCLUSIONS: Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Danger zones for flexor tendons in volar plating of distal radius fractures.

PURPOSE: To define a danger zone for volar plates using magnetic resonance imaging by analyzing the position of the flexor tendons at risk around the watershed line. METHODS: We analyzed 40 wrist magnetic resonance images. The location of the flexor pollicus longus (FPL) and index flexor digitorum profundus (FDPi) tendons was recorded at 3 and 6 mm proximal to the watershed line of the distal radius. We measured the distance between the volar margin of the distal radius and the FPL and FDPi tendons, and the coronal position of the tendons. RESULTS: At a point 3 mm proximal to the watershed line, FPL and FDPi were located on average 2.6 and 2.2 mm anterior to the volar margin of the distal radius. This distance increased to 4.7 and 5.3 mm at a point 6 mm proximal to the watershed line. The FPL and FDPi were located at 57% and 42% of the total width of the distal radius from the sigmoid notch at 3 mm from the watershed, and at 66% and 46% at 6 mm from the watershed. CONCLUSIONS: Surgeons should be aware of the close proximity of the flexor tendons to the volar cortex of the distal radius proximal to the watershed line and their radial to ulnar position. Three millimeters proximal to the watershed line, plate placement more than 2 mm anterior to the volar cortex or the use of plates thicker than 2 mm poses a high risk for directly contacting flexor tendons. CLINICAL RELEVANCE: This article may prove to be helpful in avoiding flexor tendon injury during volar plate fixation.

Predicting a safe screw length for volar plate fixation of distal radius fractures: lunate depth as a marker for distal radius depth.

PURPOSE: We hypothesized that the lunate depth as measured on plain lateral radiographs can be used to predict distal radius depth radially and ulnarly and serve as a useful reference for intraoperative screw placement in volar plate fixation of distal radius fractures. METHODS: Plain radiographs and magnetic resonance imaging (MRI) of the wrists of 30 patients were reviewed. The lunate depth and the maximal depth of the distal radius were determined from plain lateral radiographs. Depth of the distal radius, measured in quartiles, was determined from axial MRI images, and the lunate depth was obtained from sagittal MRI images. The depth of the distal radius in each quartile was then calculated related to the lunate depth. RESULTS: The mean depth of the lunate on plain radiographs and MRI was 17.5 mm and 17.4 mm, respectively. The depth of the distal radius from ulnar to radial was 18.4 mm, 20.2 mm, 19.4 mm, and 15.1 mm for the 1st through 4th quartiles, respectively. The depth of the distal radius is the least radially (4th quartile), with a mean 87% of the lunate depth, and greatest in the 2nd quartile, with a mean 116% of the lunate depth. CONCLUSIONS: The depth of the lunate as measured on plain radiographs can be used as a marker for drilling and placement of safe screw lengths during volar plate fixation of distal radius fractures. We recommend that surgeons use the lunate depth as an estimate for the length of their longest screw when fixing distal radius fractures with volar plate techniques to avoid extensor tendon irritation and rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Bacteriophage therapy for Staphylococcus aureus biofilm-infected wounds: a new approach to chronic wound care.

BACKGROUND: Bacterial biofilms, which are critical mediators of chronic wounds, remain difficult to treat with traditional methods. Bacteriophage therapy against biofilm has not been rigorously studied in vivo. The authors evaluate the efficacy of a species-specific bacteriophage against Staphylococcus aureus biofilm-infected wounds using a validated, quantitative, rabbit ear model. METHODS: Six-millimeter dermal punch wounds in New Zealand rabbit ears were inoculated with wild-type or mutant, biofilm-deficient S. aureus. In vivo biofilm was established and maintained using procedures from our previously published wound biofilm model. Wounds were left untreated, or treated every other day with topical S. aureus-specific bacteriophage, sharp débridement, or both. Histologic wound healing and viable bacterial count measurements, and scanning electron microscopy were performed following harvest. RESULTS: Wild-type S. aureus biofilm wounds demonstrated no differences in healing or viable bacteria following bacteriophage application or sharp débridement alone. However, the combination of both treatments significantly improved all measured wound healing parameters (p < 0.05) and reduced bacteria counts (p = 0.03), which was confirmed by scanning electron microscopy. Bacteriophage treatment of biofilm-deficient S. aureus mutant wounds alone also resulted in similar trends for both endpoints (p < 0.05). CONCLUSIONS: Bacteriophages can be an effective topical therapy against S. aureus biofilm-infected wounds in the setting of a deficient (mutant) or disrupted (débridement) biofilm structure. Combination treatment aimed at disturbing the extracellular biofilm matrix, allowing for increased penetration of species-specific bacteriophages, represents a new and potentially effective approach to chronic wound care. These results establish principles for biofilm therapy that may be applied to several different clinical and surgical problems.

Intrafascicular stimulation of monkey arm nerves evokes coordinated grasp and sensory responses.

High-count microelectrode arrays implanted in peripheral nerves could restore motor function after spinal cord injury or sensory function after limb loss. In this study, we implanted Utah Slanted Electrode Arrays (USEAs) intrafascicularly at the elbow or shoulder in arm nerves of rhesus monkeys (n = 4) under isoflurane anesthesia. Input-output curves indicated that pulse-width-modulated single-electrode stimulation in each arm nerve could recruit single muscles with little or no recruitment of other muscles. Stimulus trains evoked specific, natural, hand movements, which could be combined via multielectrode stimulation to elicit coordinated power or pinch grasp. Stimulation also elicited short-latency evoked potentials (EPs) in primary somatosensory cortex, which might be used to provide sensory feedback from a prosthetic limb. These results demonstrate a high-resolution, high-channel-count interface to the peripheral nervous system for restoring hand function after neural injury or disruption or for examining nerve structure.

Limb transplantation and targeted reinnervation: a practical comparison.

Limb transplantation and targeted reinnervation are complimentary but very different approaches for restoring function to an upper limb amputee. This article reviews the advantages and limitations of both of these procedures, and highlights the reconstructive obstacles in the treatment of upper limb amputees.

Targeted reinnervation in the transfemoral amputee: a preliminary study of surgical technique.

BACKGROUND: Lower limb amputation is a common and growing problem in the United States. Current prosthetic technology is insufficient for transfemoral amputees to safely control their prostheses for demanding exercise such as stair climbing. Using a technique called targeted reinnervation, intuitive control of prosthetic devices has been achieved for upper limb amputees. To bring this technique to transfemoral amputees, a comprehensive understanding of the location of motor and sensory nerves is required. METHODS: Five lower limbs were dissected and the locations of motor points for 13 muscles of the thigh were documented, as was the location of the posterior femoral cutaneous nerve of the thigh. A transfemoral amputation was performed on one limb to demonstrate the targeted reinnervation procedure. The tibial and common peroneal divisions of the sciatic nerve were coapted to the motor points of the semimembranosus and biceps femoris, respectively. The posterior femoral cutaneous nerve was coapted in end-to-side fashion to the tibial nerve. RESULTS: The average number of motor points per muscle were as follows: sartorius, 4.75; rectus femoris, 3.25; vastus lateralis, 4.5; vastus intermedius, 4.5; vastus medialis, 4; adductor brevis, 2.3; adductor longus, 3; adductor magnus, 2.7; gracilis, 3; semitendinosus, 1.5; semimembranosus, 2.5; biceps femoris long head, 2.75; and biceps femoris short head, 1. CONCLUSION: The results of this study indicate that targeted reinnervation is technically feasible in a transfemoral amputee.

Correlation between preoperative Kimura inching studies and intraoperative findings during endoscopic-assisted decompression of the ulnar nerve at the elbow.

BACKGROUND: During the evolution of the senior author's technique of ulnar nerve transposition to in situ decompression for ulnar neuropathy at the elbow, nerve conduction studies (NCS) including the Kimura inching method were performed preoperatively in an effort to ensure that all potential sites of compression were investigated intraoperatively. The purpose of this study is to compare the results of the Kimura inching technique with the intraoperative findings noted during decompression of the ulnar nerve at the elbow. METHODS: The medical records of consecutive patients who underwent in situ decompression of their ulnar nerves combined with endoscopic examination between March and December of 2009 were retrospectively reviewed. The site of ulnar nerve compression noted using the Kimura inching technique was compared with the intraoperative findings. RESULTS: Twelve consecutive patients (four with bilateral symptoms) underwent endoscopic ulnar nerve compression in the study period for a total of 16 cases analyzed. In 12 cases, the Kimura method localized the site of compression to Osborne's bands and/or the aponeurosis of the flexor carpi ulnaris (FCU). Intraoperatively, compression was noted at Osborne's bands, the FCU aponeurosis, and/or the FCU) muscle proper in all 16 patients. There was partial or full correlation between the nerve conduction data and intraoperative findings in 13/16 cases. CONCLUSIONS: There was good but not perfect agreement between the NCS and intraoperative findings, perhaps because transcutaneous NCS are less accurate when a nerve is surrounded by muscle. The information obtained in this study is valuable when planning surgery to address ulnar nerve compression.

Technical use of synthetic conduits for nerve repair.

A review of the technique used for conduit repair of short peripheral nerve gaps.

Prospective measurements of intra-abdominal volume and pulmonary function after repair of massive ventral hernias with the components separation technique.

OBJECTIVE: To assess the effect of components separation on abdominal volume and pulmonary function after repair of hernias with loss of domain. SUMMARY OF BACKGROUND DATA: Immediate postoperative abdominal compartment syndrome is a feared complication after hernia repair in patients with a "loss of abdominal domain." Replacement of the viscera within an unyielding stiff abdominal wall may compromise the perfusion of the intestines, elevate the diaphragm, and interfere with ventilation. The components separation technique, used to repair these massive hernias, employs bilateral relaxing incisions in the external oblique muscle and fascia to approximate the rectus abdominis muscles in the midline. METHODS: Nineteen consecutive patients with large ventral hernias were enrolled. Intra-abdominal volumes were prospectively measured before and after hernia repair, using computer analysis of abdominal CT scans. Pulmonary function tests were similarly obtained before and after surgery. Statistical analysis was performed using paired student's t test. This study was registered at clinicaltrials.gov (ID# NCT00894582). RESULTS: Nine women and 10 men ages 24 to 76 with an average BMI of 30 kg/m had an average hernia size of 915 mL. Intra-abdominal volume increased significantly after separation of parts hernia repair from an average of 7640 to 8166 mL (P=0.01). Diaphragm height did not change significantly (37.1 cm to 37.5 cm, P=0.42). Intraoperative peak airway pressures remained within normal limits for all patients. Pulmonary function testing revealed no significant differences before and after surgery. CONCLUSIONS: The components separation repair technique acts to restore lost abdominal domain by increasing its volume, and can be performed on patients with large ventral hernias with acceptable outcomes and without measurable changes in pulmonary function.