Lumbar Artery Perforator Flaps: A Systematic Review of Free Tissue Transfers and Anatomical Characteristics.

BACKGROUND: The lumbar artery perforator (LAP) flap has gained popularity as a versatile flap in reconstructive surgery; however, few studies have analyzed salient characteristics of this flap. We set out to provide a comprehensive appraisal of free tissue transfers of LAP flaps with specific attention to anatomic features and clinical outcomes. METHODS: Using preferred reporting items for systematic reviews and meta-analyses guidelines, we identified clinical, radiographic, and cadaveric studies of LAP flaps and assessed outcomes, complications, and anatomic parameters, such as pedicle length, diameter, location, and course. RESULTS: A total of 254 articles were initially reviewed, of which 18 met the final inclusion criteria. Ten studies were primarily concerned with anatomic characteristics, and most clinical studies related to breast reconstruction. The operative durations varied between 4.8 and 9.2 hours. Partial and total flap losses were estimated at 2.6% and 7.6%, respectively. Acute revision rates ranged from 16% to 24% related to hematoma, arterial thrombus, and venous thrombus. Donor-site seromas were frequently encountered in breast reconstruction with an incidence of 17% to 78%. CONCLUSIONS: The LAP flap has demonstrated favorable outcomes in various reconstructive scenarios. The caudal perforators generally offer more pedicle length, greater pedicle diameter, and septocutaneous course and may be better suited for flap design. For breast reconstruction, the LAP flap is a useful alternative to abdominal-based flaps, and special attention should be given to optimizing pedicle length using interposition grafts and methods that minimize seroma formation at the donor site.

Preoperative Hypoglycemia and Hyperglycemia Are Related to Postoperative Infection Rates in Implant-Based Breast Reconstruction.

OBJECTIVES: Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk. METHODS: A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes. RESULTS: The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia (<70 mg/dL). CONCLUSIONS: The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population.

BACKGROUND: Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. METHODS: We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. RESULTS: Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range. CONCLUSIONS: Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.

Trends in open and endoscopic carpal tunnel release utilization in the Medicare patient population.

BACKGROUND: Surgical management of carpal tunnel syndrome (CTS) is performed with an open or endoscopic approach. Current literature suggests that the endoscopic approach is associated with higher costs and a steeper learning curve. This study evaluated the billing and utilization trends of both approaches. METHODS: A retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, IN) was performed for patients undergoing open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) from 2005-2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate (CAGR) were evaluated. RESULTS: Our query returned 1,500,603 carpal tunnel syndrome patients, of which 507,924 (33.8%) and 68,768 (4.6%) were surgically managed with OCTR and ECTR respectively (remainder treated conservatively). Compound annual growth rate was significantly higher in ECTR (5%) than OCTR (0.9%; P < 0.001). Average charges were higher in OCTR ($3820) than ECTR ($2952), whereas reimbursements were higher in ECTR (mean $1643) than OCTR (mean $1312). Both were performed most commonly in the age range of 65-69 y, females, and southern geographic region. CONCLUSIONS: ECTR is growing faster than OCTR in the Medicare population. Contrary to previous literature, our study shows that ECTR had lower charges and reimbursed at a higher rate than OCTR.

Persistent Median Artery Crossing and Continuing Distally as Ulnar Artery: Case Report.

The finding of a persistent median artery coursing superficial to the flexor tendons in the distal forearm is described.

A staging system for gluteal foreign body reaction to injectables.

BACKGROUND: Esthetic augmentation of the gluteal region can lead to complications including debilitating pain, infections, wounds, and scars. To our knowledge, a general consensus of staging and treatment guidelines for managing gluteal foreign body reaction to injectables has not yet been established. OBJECTIVE: The objective of this study was to develop a reliable staging system that can be used to implement a treatment algorithm for gluteal foreign body reactions. METHODS: A retrospective review of 40 patients treated for complications of gluteal injections between September 2010 and May 2014 was performed. Patient symptoms, imaging, and photographs were used to develop a staging system of disease. Institutional review board approval was obtained from the University of Miami Miller School of Medicine. Five independent observers reviewed the patients' documented symptoms and photographs. Using our staging system, the independent observers reviewed the patient cases at two separate time intervals. Intra- and interclass correlation coefficients (ICCs) were computed to assess the reliability for each of the observers. RESULTS: Seven patients were classified as Stage I, fifteen as Stage IIa, nine as Stage IIb, and nine as Stage III. The mean patient age was 34 years (21-50). Analysis of the independent reviewer results revealed ICC for each rater to range from 0.96 to 0.98, demonstrating high indexes of intra-rater reliability. CONCLUSIONS: Based on our statistical analysis, we found an excellent inter- and intra-observer reliability, indicating that the staging system is reproducible and reliable. A treatment strategy dependent on the stage can be implemented as a guideline to optimize functional and esthetic outcomes.

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand.

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.