Intraoperative Nerve Stimulation as an Approach for the Surgical Treatment of Genitofemoral Neuralgia.

BACKGROUND Genitofemoral neuralgia is a pain syndrome that involves injury to the genitofemoral nerve and is frequently iatrogenic. We report intraoperative nerve localization using ultrasound, nerve stimulation, and the cremasteric reflex in the surgical treatment of genitofemoral neuralgia. CASE REPORT A 49-year-old man with a history of extracorporeal membrane oxygenation with cannulation sites in bilateral inguinal regions presented with right groin numbness and pain following decannulation. His symptoms corresponded to the distribution of the genitofemoral nerve. He had a Tinel's sign over the midpoint of his inguinal incision. A nerve block resulted in temporary resolution of his symptoms. Due to the presence of a pacemaker, peripheral nerve neuromodulation was contraindicated. He underwent external neurolysis and neurectomy of the right genitofemoral nerve. Following direct stimulation and ultrasound for localization, the nerve was further localized intraoperatively using nerve stimulation with monitoring for the presence of the cremasteric reflex. At his 1-month postoperative visit, his right medial thigh pain had resolved and his right testicular pain 50% improved; his residual pain continued to improve at last evaluation 3 months after surgery. CONCLUSIONS We report the successful use of nerve stimulation and the cremasteric reflex to aid in identification of the genitofemoral nerve intraoperatively for the treatment of genitofemoral neuralgia.

Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology (PROFILE): Updated Report 2012-2020.

BACKGROUND: In January of 2011, the U.S. Food and Drug Administration released a safety communication regarding the potential association between breast implants and anaplastic large-cell lymphoma (ALCL). In 2012, the American Society of Plastic Surgeons, The Plastic Surgery Foundation, and the Food and Drug Administration signed a cooperative research and development agreement to develop the Patient Registry and Outcomes for Breast Implants and Anaplastic Large-Cell Lymphoma Etiology and Epidemiology (PROFILE) patient registry. METHOD: This is an updated report of registry findings. From August of 2012 to August of 2020, 330 unique, suspected, or confirmed cases of breast implant-associated (BIA) ALCL in the United States were reported to PROFILE, including 144 cases newly reported since the 2018 publication. RESULTS: Median time from implantation of any device to BIA-ALCL diagnosis was 11 years (range, 2 to 44 years). At the time of presentation, 91% of cases had local symptoms and 9% had concurrent systemic symptoms. The most common local symptom was seroma, seen in 79% of patients. All patients had a history of a textured device; there were no patients who had a confirmed smooth-only device history. Approximately 11% of the reported cases were diagnosed with stage 1A disease (tumor-node-metastasis staging classification). CONCLUSIONS: The PROFILE registry continues to be an essential tool in unifying the collection of granular-level data pertaining to BIA-ALCL. These data emphasize the critical importance of detailed tracking of BIA-ALCL cases, and will contribute significantly to our understanding of the relationship between breast implants and ALCL.

An Update and Report Failure of Surgical Syndactyly Repair in Harlequin Ichthyosis.

Harlequin ichthyosis (HI) is a rare congenital skin disorder caused by irregular epidermal differentiation. Syndactyly in HI is associated with thick hyperkeratotic skin flexion and angulation deformity of the hand and fingers resulting in limited function of the upper extremity. Traditional syndactyly release is limited as full-thickness skin grafts typically used in reconstruction are composed of diseased skin and require donor sites in a patient predisposed for adverse wound healing. This case report is a follow-up to a previous viewpoint written about digital escharotomies in a newborn with HI and outlines a second and fourth webspace syndactyly release with a dermal substitute. Despite early evidence of adequate release and improved hand function, recurrence of syndactyly was observed within 4 months of surgical release. Our experience described within this case report may suggest the limitations and possible alternatives of surgical release of syndactyly in the HI population.

Current Management of Trigger Digit in Rheumatoid Arthritis Patients: A Survey of ASSH Members.

BACKGROUND: Traditional dogma regarding management of rheumatoid arthritis (RA) patients with trigger digit symptoms holds that A1 pulley release should be avoided. Surgical release was thought to further destabilize the metacarpophalangeal joint. Biologic disease modifying anti-rheumatic drugs (DMARDs) have limited the development of hand deformities. Despite advances in RA treatment, many textbooks continue to discourage release of the A1 pulley in RA patients. The aim of this study was to determine if this belief is consistent with current trends in surgical management of trigger digits in patients with RA. METHODS: Active Members of the American Society for Surgery of the Hand (ASSH) were surveyed on their training and current practices as related to RA patients with trigger digits. RESULTS: Five hundred three surveys were completed (16% response rate). During training, 55% of ASSH Members were taught to avoid releasing the A1 pulley in RA patients. Seventy-one percent of respondents currently release the A1 pulley in RA patients with no preexisting deformities, no tenosynovial thickening, or if tenosynovectomy and flexor digitorum superficialis slip excision fail to relieve triggering. Forty percent reported that their practice has evolved toward more frequent release of the A1 pulley in RA patients. CONCLUSION: The majority of ASSH Active Members were taught during training to avoid surgical release of the A1 pulley in RA patients to prevent acceleration of finger deformities. Indications and contraindications for A1 pulley release are evolving along with the improved natural history of RA associated with the use of biologic DMARDs.

Chronic Distal Radioulnar Joint Instability.

The distal radioulnar joint is inherently unstable, relying primarily on ligaments for stability. Disruption of the joint-stabilizing structures can occur in isolation or concomitantly with osseous trauma. Instability can result from dislocations, fractures, ligament injuries, or malunions. Untreated instability alters wrist and forearm kinematics, leading to pain, weakness, and possibly arthritis. In chronic instability, the native ligaments may not be reparable, necessitating a reconstructive procedure.

Breast Implant Imaging Surveillance among U.S. Plastic Surgeons: U.S. Food and Drug Administration Recommendations versus Clinical Reality.

BACKGROUND: Device rupture is considered a major complication associated with breast implants. The U.S. Food and Drug Administration recommends magnetic resonance imaging (MRI) surveillance 3 years after implantation and then every 2 years, but adherence to these recommendations is poor. The authors identified current practice management for breast implant rupture surveillance by surveying practicing U.S. plastic surgeons. METHODS: An online survey of all active members of the American Society of Plastic Surgeons was performed. Questions analyzed imaging practice patterns related to breast implants. Logistic regression models were used to analyze determinants for radiographic imaging in breast implant patients. RESULTS: The survey had a response rate of 16.5 percent. For patients with breast implants, 37.7 percent of respondents recommended MRI at the recommended intervals. Fifty-five percent perform imaging only if there is a problem with the implant. Academic surgeons more frequently recommended MRI (56.3 percent and 39.3 percent; p = 0.0002). Surgeons with less than 5 years of experience are four times more likely to order MRI than surgeons with over 25 years' experience (60.8 percent and 28.1 percent; p < 0.0001). Furthermore, lower volume surgeons recommend significantly more MRI (45.2 percent and 27.3 percent; p = 0.001). Respondents are almost two times more likely to recommend MRI in reconstructive versus cosmetic patients (51.2 percent and 35.6 percent; p = 0.0004). CONCLUSIONS: MRI limitations include high costs, time commitments, and equipment constraints. Fewer than 40 percent of survey respondents suggest the recommended screening frequency to their patients; however, academic, low-volume, early-career surgeons are more likely to recommend MRI implant monitoring. Screening recommendations need to be evidence based and align with common practices to prevent undue system, provider, and patient burden.

Current indications for abdominal-based flaps in hand and forearm reconstruction.

Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.

Venous Flaps for Revascularization and Soft-Tissue Coverage in Traumatic Hand Injuries: A Systematic Review of the Literature.

BACKGROUND: The use of the venous flap for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. First described in 1981, Nakayama et al demonstrated that a vein and overlying skin, or a venous flap, may be transposed from one area of the body to another with complete survival of the graft. The aim of this study was to conduct a systematic review of the literature to determine predictors of venous flap survival in traumatic hand injuries. METHODS: A literature search of PubMed, MEDLINE, and Cochrane Library was performed with emphasis on venous flap use in traumatic hand injuries. MeSH terms included: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand, and thumb. RESULTS: Forty-three articles were collected that contained data on 626 free venous flaps. Most patients were males (73.9) and injured their right hand (52.3%). The forearm was the most commonly used venous flap donor site (83.6%), and most of the skin paddles were 10 to 25 cm2 (41.1%). Arterial inflow was used in 93.1% of the flaps. Most venous flaps (79.6%) healed without superficial tissue loss or necrosis. Ninety-two (14.7%) flaps had partial loss while 36 (5.8%) flaps did not survive. CONCLUSION: The use of venous flaps for concomitant revascularization and soft tissue coverage of the hand permits good results with limited morbidity. The overall flap survival rate is nearly 95%. Younger patients whose flaps have arterial inflow and skin paddles of medium size (10-25 cm2) have the best chance for survival.

Dupuytren Disease Management Trends: A Survey of Hand Surgeons.

Background: Indication for intervention in Dupuytren disease is influenced by many factors, including location and extent of disease, surgeon preference, and comfort level with different treatment techniques. The aim of this study was to determine current Dupuytren disease management trends. Methods: A questionnaire was sent through the American Society for Surgery of the Hand to all members. In addition to demographic data, questions focused on indications for different procedural interventions based on location of disease, age, and activity level of the patient. Results: Approximately 24% of respondents completed the survey. Respondents were mostly orthopedic surgeons in private practice who do not work with residents or fellows. Respondents preferred collagenase over needle aponeurotomy and limited fasciectomy for primary Dupuytren disease involving only the metacarpophalangeal (MCP) joint. Limited fasciectomy was the preferred treatment for primary Dupuytren disease involving the MCP and proximal interphalangeal joints. For a patient amenable to any treatment option, the majority would use collagenase, although 87.1% felt that fasciectomy offered the longest disease-free interval. Furthermore, given the option of a young, working patient, 42.7% would use collagenase, while plastic and general surgeons were more likely to treat this patient with limited fasciectomy. More plastic surgeons (vs orthopedic) believe that limited fasciectomy yields the longest disease-free interval. For a patient amenable to any surgical option, orthopedic surgeons prefer collagenase, whereas plastic hand surgeons prefer a limited fasciectomy. Conclusion: There are several procedural options for the treatment of Dupuytren disease. This study details current practice patterns among hand surgeons and reveals the increasingly prevalent use of collagenase.

Management of Intravenous Infiltration Injuries.

BACKGROUND: Intravenous (IV) lines are ubiquitous in hospital settings. These lines can malfunction, leaking noxious contents into subcutaneous tissue. Existing literature describes invasive intervention and complex treatment protocols. These persist despite significant changes in the composition and administration of IV agents. The purpose of this study is to examine the consequences of IV infiltrations at a tertiary medical center to update protocols and treatment algorithms. MATERIALS AND METHODS: This study is an observational, retrospective chart review performed at a tertiary care medical center. All inpatient plastic surgery consultations for IV infiltration were reviewed from 2011 to 2017. Patients were included if IV infiltration was suspected or documented. Data were collected for each injury regarding patient demographics, substance, and intervention. RESULTS: The plastic surgery service evaluated 381 IV infiltration injuries from 2011 to 2017, with 363 meeting the criteria. Injuries per year progressively increased, with 32 consultations in 2011 and 102 consultations in 2017. The vast majority of injuries identified (91%) were treated with only elevation and observation. The minority consisted of wound care (7%) performed by nursing or any form of incision, aspiration, or antidote injection (2%) performed by the physician. Of the 363 injuries, the most common infiltrates were noncytotoxic (35%), radiographic contrast (27%), and known vesicants (18%). Interestingly, a large portion of consultations were requested by other surgical services (32%). CONCLUSIONS: Although there is an increase in expert involvement for cases of IV infiltration injuries, the vast majority of these injuries are managed with minimal intervention. This is most likely owing to recent changes that have decreased the potential for harmful infiltration. Contrary to existing literature, invasive intervention is almost never indicated.

A Prospective Approach to Inform and Treat 1340 Patients at Risk for BIA-ALCL.

BACKGROUND: The increasing incidence and associated mortality of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has become alarming. However, many patients remain unaware of their risk for BIA-ALCL and may overlook early warning signs of the cancer. The authors aim to contact all breast implant patients at a single institution to educate them on the disease and provide screening and treatment as indicated. METHODS: All patients who had breast implants placed at Penn State Hershey Medical Center from 1979 to November of 2017 were mailed a letter to describe BIA-ALCL and to encourage a follow-up visit. Patient information regarding demographics, implant type, the number of calls and follow-up visits, physical examination findings, and patient decisions after being informed of the disease were recorded prospectively. RESULTS: One thousand two hundred eighty-four letters were mailed to 1020 patients (79.4 percent) with smooth implants and 264 patients (20.6 percent) with textured implants. Seventy-six calls were received and 100 patients (84 smooth and 16 textured) were evaluated within the first 2 months. Of the 16 patients with textured implants, nine are undergoing secondary surgery to remove or replace their textured device. CONCLUSIONS: Informing patients at risk for BIA-ALCL is an important endeavor. Patients educated on the disease will likely be diagnosed and treated earlier, which can prevent the need for adjuvant chemotherapy and/or radiation therapy and decrease mortality. The authors provide a method, supporting documents, and preliminary data to help other institutions contact their breast implant patients at risk for BIA-ALCL.

How Breast Implant Surface Type Is Influenced by Breast Implant-associated Anaplastic Large Cell Lymphoma: A Survey of the American Society of Plastic Surgeons.

INTRODUCTION: Breast implant selection is multifactorial and must assess risk profiles of the implants. Textured implants are available in an anatomically shaped form and are thought to have lower rates of capsular contracture. However, evidence is mounting that they carry a significantly higher risk of breast implant associated anaplastic large cell lymphoma. Given this relationship, we aimed to assess breast implant preferences and device selection for members of the American Society of Plastic Surgeons (ASPS). METHODS: An online survey of all active members of ASPS was performed. Questions analyzed the surgeons' demographic data as well as implant and tissue expander choices for patients receiving either breast augmentation or reconstruction. Logistic regression models of summarized data were used to assess surgeons' implant choices. RESULTS: The survey was sent to 5000 members and was completed by 824 for a response rate of 16.5%. Demographic data indicate a homogenous sampling of ASPS members from all geographical areas. A majority of surgeons reported that they perform 21-50 implant cases in the last year (n = 219, 28.5%), followed closely by surgeons performing greater than 100 cases (n = 194, 25.3%) and those placing between 51 and 100 (n = 189, 24.6%). Almost one-half of respondents (n = 361, 46.9%) stated that the majority (>50%) of the implants they placed were for cosmetic purposes. Conversely, 306 (37.9%) respondents stated that the majority of implants they placed were for reconstructive purposes and 102 (13.3%) respondents indicated equal placement of cosmetic and reconstructive implants. There were 40.9% (n = 318) surgeons who continue to use textured implants, whereas 59.1% (n = 460) report using only smooth implants. This data includes 47.7% (n = 363) of respondents who report switching to only smooth implants due to awareness of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). CONCLUSIONS: The incidence of BIA-ALCL continues to rise. All known cases have some link to textured implants. With equally efficacious alternatives available with smooth implants, surgeons and patients are altering their implant choices.

Direct Cost Comparison of Open Carpal Tunnel Release in Different Venues.

Background: The increased efficiency and cost savings have led many surgeons to move their practice away from the traditional operating room (OR) or outpatient surgery center (OSC) and into the clinic setting. With the cost of health care continuing to rise, the venue with the lowest cost should be utilized. We performed a direct cost analysis of a single surgeon performing an open carpal tunnel release in the OR, OSC, and clinic. Methods: Four treatment groups were prospectively studied: the hospital OR with monitored anesthesia care (OR-MAC), OSC with MAC (OSC-MAC), OSC with local anesthesia (OSC-local), and clinic with local anesthesia (clinic). To determine direct costs, a detailed inventory was recorded including the weight and disposal of medical waste. Indirect costs were not included. Results: Five cases in each treatment group were prospectively recorded. Average direct costs were OR ($213.75), OSC-MAC ($102.79), OSC-local ($55.66), and clinic ($31.71). The average weight of surgical waste, in descending order, was the OR (4.78 kg), OSC-MAC (2.78 kg), OSC-local (2.6 kg), and the clinic (0.65 kg). Using analysis of variance, the clinic's direct costs and surgical waste were significantly less than any other setting (P < .005). Conclusions: The direct costs of an open carpal tunnel release were nearly 2 times more expensive in the OSC compared with the clinic and almost 7 times more expensive in the OR. Open carpal tunnel release is more cost-effective and generates less medical waste when performed in the clinic versus all other surgical venues.

Opioid Sparing in Cleft Palate Surgery.

OBJECTIVE: This study aimed to determine whether intraoperative acetaminophen was able to decrease opioid consumption, pain scores, and length of stay while increasing oral intake in cleft palate surgery. DESIGN/SETTING/PATIENTS: One hundred consecutive patients with cleft palate who underwent a von Langenbeck or 2-flap palatoplasty and intravelar veloplasty at a tertiary medical center by the 2 senior authors from 2010 to 2015 were reviewed. INTERVENTIONS: Three intraoperative treatment groups were analyzed: intravenous (IV) acetaminophen, per rectal (PR) acetaminophen, and no acetaminophen. All patients received long-acting local anesthesia infiltration before incision. Additionally, all patients were admitted overnight and given weight-based per oral (PO) acetaminophen and oxycodone and IV morphine as needed based on pain scores. OUTCOMES MEASURED: The study outcomes included pain scores, opioid requirement, length of stay, and oral intake. RESULTS: The treatment groups were comprised of 40 patients who received IV acetaminophen, 22 PR acetaminophen, and 35 none. Concerning demographic data, there was no statistical difference between treatment groups. There was no statistically significant difference for opioid intake, although both IV and PR acetaminophen groups had decreased pain scores ( P = .029). There was no difference in oral intake ( P = .13) or length of stay ( P = .31) between treatment groups. CONCLUSION: In this study, intraoperative administration of acetaminophen was associated with decreased pain scores, but no opioid-sparing effect. As other studies have shown an opioid-sparing effect with postoperative acetaminophen, we recommend withholding the intraoperative dose and beginning therapy in the immediate postoperative period.

Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone.

BACKGROUND: The lateral arm flap is used for composite defects in need of vascularized soft tissue, skin, and bone. From its original description, the distal humeral metaphysis can be included with the flap, supplied by the periosteal extensions of the posterior branch of the radial collateral artery. We sought to reexplore the anatomy of the lateral arm to determine its utility as a donor site for vascularized bone. METHODS: Twelve fresh, silicone-injected cadaver dissections were performed. Arteriovenous anatomy, pedicle length and diameter, and anatomic variability as well as photo documentation was recorded. RESULTS: The distal extent of the deltoid, lateral intermuscular septum and lateral humeral epicondyle were identified before the dissection. A septocutaneous perforator was consistently located 10 cm proximal to the lateral humeral epicondyle, which could be used for a skin paddle to monitor. Harvest of a 1.5 cm × 2 cm corticocancellous bone graft was performed. Average pedicle length was 9.1 ± 1.1 cm, and average pedicle diameter was 1.74 ± 0.52 mm. The inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm were consistently identified and preserved. CONCLUSION: The predictable anatomy of the lateral distal humerus make it an ideal donor site for small segments of vascularized bone.

Salve and Burdock: A Safe, Effective Amish Remedy for Treatment of Traumatic Wounds?

BACKGROUND: Amish patients show a demonstrated preference for traditional, herbal remedies over modern medical interventions such as skin grafting. One such remedy is a mixture of Burn & Wound Ointment (B & W Ointment; Holistic Acres, LLC; Newcomerstown, Ohio) and steeped burdock leaves. Although both have demonstrated some antimicrobial and wound healing properties, burdock and/or the combination of B & W Ointment and burdock has never been studied to determine its purported ability to reduce pain, prevent infection, and accelerate wound healing. METHODS: A retrospective chart review was performed on 6 Amish patients treated with salve and burdock leaves instead of skin grafting following complex traumatic wounds to determine whether the traditional treatment incurred any patient harm. RESULTS: The time of wound epithelialization and healing complications were noted, among other data points. Time to full epithelialization ranged from 1 to 7 months. Time to full wound healing was proportional to wound size. CONCLUSIONS: Although the treatment presented here is unconventional, it did not cause harm to the patients studied.

Medically managed gout precipitating acute carpal tunnel syndrome.

BACKGROUND: The most common compressive neuropathy affects the median nerve in the carpal tunnel; it is typically chronic and progressive. Acute carpal tunnel syndrome (ACTS), on the other hand, is a less frequently encountered surgical emergency that usually occurs in the setting of trauma, such as a displaced fracture of the distal radius or carpal dislocation. To our knowledge, there are only two cases of acute carpal tunnel secondary to gout reported in the literature, with both being outside of the USA and the last case being over 20 years ago. We reviewed the literature describing acute carpal tunnel syndrome (ACTS) caused by gout and present a recent case of atraumatic ACTS caused, in part, by a tophaceous gouty mass. METHODS: Review of the literature consisted of a PubMed search of all articles in the English language using the following keywords: "Acute Carpal Tunnel Syndrome" and "Tophaceous Gout" and "Gout." RESULTS: We present the youngest reported case of atraumatic ACTS caused by tophaceous gout and the only reported case with a documented history of gout being actively medically managed with a uric acid lowering agent. This was successfully treated with an emergent extended carpal tunnel release, a complete flexor synovectomy, and excision of a gouty mass adhered to the carpal tunnel floor. CONCLUSIONS: Atraumatic ACTS secondary to gout is rare and has never been reported in a patient already being managed with uric acid lowering agents. Such a presentation requires rapid surgical exploration with release of the carpal tunnel, debridement of all gouty tissue, and increasingly aggressive adjuvant medical therapy.

Chamber identity programs drive early functional partitioning of the heart.

The vertebrate heart muscle (myocardium) develops from the first heart field (FHF) and expands by adding second heart field (SHF) cells. While both lineages exist already in teleosts, the primordial contributions of FHF and SHF to heart structure and function remain incompletely understood. Here we delineate the functional contribution of the FHF and SHF to the zebrafish heart using the cis-regulatory elements of the draculin (drl) gene. The drl reporters initially delineate the lateral plate mesoderm, including heart progenitors. Subsequent myocardial drl reporter expression restricts to FHF descendants. We harnessed this unique feature to uncover that loss of tbx5a and pitx2 affect relative FHF versus SHF contributions to the heart. High-resolution physiology reveals distinctive electrical properties of each heart field territory that define a functional boundary within the single zebrafish ventricle. Our data establish that the transcriptional program driving cardiac septation regulates physiologic ventricle partitioning, which successively provides mechanical advantages of sequential contraction.