Techniques and Outcomes in Microsurgical Treatment of Posttraumatic Lymphedema: A Systematic Review.

BACKGROUND: The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL. METHODS: A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded. RESULTS: A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements. CONCLUSION: PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies.

Experience with ultrasound neurography for postoperative evaluation of targeted muscle reinnervation.

Targeted muscle reinnervation (TMR) was originally developed as a means for increasing intuitive prosthesis control, though later found to play a role in phantom limb pain and neuroma prevention. There is a paucity of literature describing the clinical course of patients with poor TMR surgical outcomes and the value of imaging in the postoperative recovery period. This report will illustrate the potential utility of ultrasound neurography to accurately differentiate TMR surgical outcomes in two patients that received upper extremity amputation and subsequent reconstruction with TMR. Ultrasound evaluation of TMR sites in patient 1 confirmed successful reinnervation, evident by nerve fascicle continuity and eventual integration of the transferred nerve into the target muscle. Conversely, the ultrasound of patient 2 showed discontinuity of the nerve fascicles, neuroma formation, and muscle atrophy in all three sites of nerve transfer, suggesting an unsuccessful procedure and poor functional recovery. Ultrasound neurography is uniquely able to capture the longitudinal trajectory of rerouted nerves to confirm continuity and eventual reinnervation into muscle. Therefore, the application of ultrasound in a postoperative setting can correctly identify instances of failed TMR before this information would become available through clinical evaluation. Early identification of poor TMR outcomes may benefit future patients by fostering the discovery of failure mechanisms and aiding in further surgical planning to improve functional outcomes.

Hand and finger, ultrasound-guided, percutaneous core needle biopsies: A safe procedure with high diagnostic accuracy.

Introduction/Purpose: To determine the diagnostic accuracy and complication rates of ultrasound-guided, percutaneous core needle biopsies of soft tissue masses in the hand and fingers. Methods: Reports from all ultrasound-guided procedures between 21 May 2014 and 17 March 2022 were queried for keywords including "hand", OR "finger", AND "biopsy". Patient demographics, lesion size and location, biopsy needle gauge and the number of cores obtained were recorded. The final pathology of the mass excision was then compared with the core needle biopsy (CNB) for each patient. Results: Sixty-six records were reviewed, and 37 patients met inclusion criteria. Maximum lesion diameter averaged 1.45 cm with a range between 0.4 and 4.3 cm. The frequency of needle gauges used was 14G (14%), 16G (24%), 18G (38%), 20G (11%) and 'not reported' (14%). The mean number of tissue cores obtained was 2.9 (SD 1.2; range 1 to 6), excluding nine cases that reported 'multiple'. The frequency of CNB diagnoses included tenosynovial giant cell tumour (TGCT) at 30%, ganglion cyst at 11% and epidermal inclusion cyst at 5%. CNB was 100% sensitive in detecting the three (8%) malignancies. Of the 37 tumours biopsied, 16 were surgically excised. One angiomyoma was originally diagnosed as a haemangioma on CNB, but all other histologic results were concordant for a diagnostic accuracy of 97%. Discussion: Small soft tissue masses in the hands and fingers, even those less than 1 cm, are often amenable to ultrasound-guided CNB. Performance under image guidance facilitates retrieval of core specimens adquate for histologic diagnosis with relatively few passes using higher gauge needles. Conclusion: Overall, ultrasound-guided CNB of the hand and fingers is safe and highly accurate in diagnosing soft tissue tumours. The accuracy is unrelated to the needle's gauge, the number of passes and the size of the lesions.

Soft Tissue Masses of the Hand: A Review of Clinical Presentation and Imaging Features.

More than 15% of all soft-tissue tumors arise in the hand. Because of the location of these tumors, even small abnormalities may be alarming to patients on presentation. Although the majority of lesions are benign and can be diagnosed solely by history and physical examination, additional imaging workup may be required to confirm a diagnosis or define anatomic extent of involvement. This paper aims to review the basic epidemiology, clinical presentation, imaging findings, and treatment options of the more common soft-tissue tumors of the hand.

Pediatric Pain and Pain Management After Ambulatory Plastic Surgery: Trends in the Age of Opioid Awareness.

BACKGROUND: Overprescribing by physicians has been shown to be a major contributor to the opioid epidemic. Although pediatric ambulatory plastic surgery patients are commonly prescribed opioids for postoperative pain control, there is a lack of evidence for their necessity. This study aimed to investigate the role of prescribed narcotics in the ambulatory pediatric plastic surgery setting. METHODS: All assenting patients/guardians, ages 0 to 17 years, who underwent an ambulatory plastic surgery procedure by 1 attending surgeon from March 2018 to March 2019, were asked to participate in the study. A questionnaire was distributed at the first postoperative visit to interrogate postoperative pain, management, and narcotic use. RESULTS: A total of 95 patients/guardians completed the questionnaire. Seventy-eight percent (74) of patients picked up the narcotic medication, with 33% (31) taking at least 1 dose of narcotics, and only 9% (9) taking 4 or more doses. Patients overall found no difference in efficacy of the narcotics versus nonprescription analgesics (3.93/5 and 4.31/5, P = 0.11). Age was a significant predictor, with older patients requiring more narcotics (odds ratio, 1.12; 95% confidence interval, 1.02-1.24; P = 0.019). The type of surgery a patient underwent was not a significant predictor of the amount of narcotic used. Few patients knew how to properly dispose of the excess narcotics, with almost 50% still having it stored in their homes. CONCLUSIONS: This study demonstrates that the majority of pediatric ambulatory plastic surgery patients do not require narcotic pain medications and experience adequate pain relief with over-the-counter analgesics. Importantly, education on proper disposal of narcotic medications may be a simple, yet effective target to decrease opioid availability for abuse.

Continuous External Tissue Expansion Closure Technique for Management of Forearm Compartment Syndrome Releases and Simple Upper-Extremity Wounds.

Upper-extremity wounds from various etiologies such as trauma and fasciotomies can prove to be problematic for the upper-extremity surgeon. These defects can result in considerable morbidity often requiring prolonged wound care and the eventual use of skin grafting from a separate painful donor site. Tissue expansion takes advantage of the viscoelastic properties of skin to provide additional tissue for reconstruction. The authors present a technique using a continuous external tissue expansion device for closure of upper-extremity wounds.

A Retrospective Review of Differences in Complication Rates between Dorsal Percutaneous and Mini-Open Surgical Fixation of Scaphoid Fractures.

Objective We retrospectively reviewed the complications of 80 cases of scaphoid screw fixation in acute fractures and early nonunions comparing dorsal percutaneous and mini-open approaches. Methods We performed a chart review of all patients who underwent surgical fixation of a scaphoid fracture or a nascent nonunion using a dorsal percutaneous or dorsal mini-open technique by a single surgeon. We collected data on patient demographics, including age and smoking status, time to surgery, fracture type, union, and the major and minor complications that occurred in each group. Fisher's exact tests were used to compare the complication rates between the groups. Results We identified 80 patients who underwent surgical fixation. Of these, 44 underwent percutaneous fixation and 36 underwent mini-open fixation. All fractures went on to heal. There was a total of five complications identified. There were no major complications in the percutaneous group, but one major complication in the mini-open group (a delayed union that eventually healed at 6 months). There were two minor complications in each group. There was no statistically significant difference in total, major, or minor complication rates between the groups. Conclusions This study suggests that a dorsal percutaneous surgical technique for scaphoid fracture repair does not affect the complication rate despite prior literature to the contrary. Both techniques analyzed produce excellent rates of union with very low complication rates. Surgeon-specific technique rather than operative approach or exposure may be responsible for previously reported complication rates in the fixation of scaphoid fractures. Level of Evidence This is a level III, therapeutic study.

Optimizing Successful Outcomes in Complex Spine Reconstruction Using Local Muscle Flaps.

BACKGROUND: Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. The literature shows that wound complication rates in this patient population approach 19 percent and, in very high-risk patients (i.e., prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or history of radiation therapy), as high as 40 percent and with reoperation rates as high as 12 percent. The authors investigated whether prophylactic closure of spinal wounds with muscle flaps improves outcomes. METHODS: A retrospective review was performed of 102 reconstructions (in 96 patients) in which spinal wound closure was performed by means of paraspinous, trapezius, or latissimus muscle advancement flaps by a single plastic surgeon (J.A.S.) from 2006 to 2014. Data regarding presurgical diagnosis, patient demographics, and incidence of postoperative complications were recorded. RESULTS: One hundred two reconstructions were included, with follow-up ranging from 2 to 60 months. Eighty-eight reconstructions were classified as very high-risk for wound complications, defined as those having prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or prior radiation therapy. Within the very high-risk group, there were six wound complications (6.8 percent), three of which (3.4 percent) required reoperation. CONCLUSIONS: In this study, there is a markedly lower rate (6.8 percent) of postoperative wound complications compared with historical controls after closure of spinal wounds with local muscle flaps in very high-risk patients. These data encourage safe and routine use of muscle flaps for closure in this cohort of patients undergoing spinal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vascular smooth muscle cell optimization of vasculogenesis within naturally derived, biodegradable, hybrid hydrogel scaffolds.

BACKGROUND: As vascularization represents the rate-limiting step in permanent incorporation of hydrogel-based tissue-regeneration templates, the authors sought to identify the material chemistry that would optimize endothelial cell adhesion and invasion into custom hydrogel constructs. The authors further investigated induction of endothelial tubule formation by growth factor supplementation and paracrine stimulation. METHODS: Hydrogel scaffolds consisting of combinations of alginate, collagen type I, and chitosan were seeded with human umbilical vein endothelial cells and maintained under standard conditions for 14 days. Cell density and invasion were then evaluated. Tubule formation was evaluated following basic fibroblast growth factor addition or co-culture with human aortic smooth muscle cells. RESULTS: Human umbilical vein endothelial cells demonstrated greatest cell-surface density and invasion volumes with alginate and collagen (10:1 weight/weight) scaffolds (p < 0.05). Supplementation with basic fibroblast growth factor increased surface density but neither invasion nor tubule formation. A significant increase in tubule content/organization was observed with increasing human aortic smooth muscle cell-to-human umbilical vein endothelial cell ratio co-culture. CONCLUSIONS: Alginate and collagen 10:1 scaffolds allow for maximal cellularization compared with other combinations studied. Growth factor supplementation did not affect human umbilical vein endothelial cell invasion or morphology. Paracrine signaling by means of co-culture with human umbilical vein endothelial cells stimulated endothelial tubule formation and vascular protonetwork organization. These findings serve to guide future endeavors toward fabrication of prevascularized tissue constructs.

Use of Integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid.

Keloids present a formidable clinical challenge. Surgical excision in conjunction with radiation therapy may decrease the chance of keloid recurrence. Split-thickness skin grafts, however, are more prone to failure in the setting of radiation. In this report, we present a patient with a recurrent auricular keloid who underwent excision and immediate Integra (Integra LifeSciences, Plainsboro, NJ) application, followed by high-dose rate brachytherapy and interval split-thickness skin graft placement. A 23-year-old woman with a history of a recurrent auricular keloid after previous surgical excision, corticosteroid injection, and radiation underwent reexcision of her keloid. Integra was used to cover the resultant exposed auricular perichondrium. The patient then received high-dose rate brachytherapy (1500 cGy) on postoperative days 1 and 2, followed by definitive split-thickness skin graft placement 3 weeks after her initial surgery. The patient recovered from all interventions without complication. There was no evidence of keloid formation 27 months after the interval split-thickness skin graft placement at either the auricular recipient or thigh donor sites. We report the first case of a 2-stage reconstruction of a recurrent auricular keloid (composed of keloid excision and placement of Integra in conjunction with high-dose rate brachytherapy, followed by interval split-thickness skin grafting), resulting in an acceptable cosmetic result without evidence of recurrence at long-term follow-up.