Focal Neurotoxicity Associated With Topical 5-Fluorouracil.

Topical 5-Fluorouracil (5-FU) is an antineoplastic chemotherapy drug used to treat precancerous and cancerous skin growths, such as actinic keratoses (AKs), squamous cell carcinoma in situ, and superficial basal cell carcinoma. The topical agent may rarely cause neurotoxic adverse effects. Multiple cases of systemic 5-FU and capecitabine chemotherapy-induced neuropathies have been reported. However, until now, the topical administration of the drug has not been reported to cause neurotoxicity. We present a case of an 83-year-old male who was prescribed topical 5-FU 5% cream to treat AKs on the left anterior scalp and returned weeks later with the development of focal neurotoxicity in the treatment area. He presented with focal paralysis of the left medial frontalis muscle, with initial loss of sensation followed by intermittent pain and paresthesias, persisting four months after the cessation of therapy. He was referred to a neurologist and received a diagnosis of supraorbital neuralgia. The temporal relationship of symptom onset and the localization of symptoms to the treated area strongly suggests that the medication contributed to the observed neurologic effects. These effects are more likely to be observed in patients with a genetic deficiency of dihydropyrimidine dehydrogenase (DPD), which is responsible for the majority of 5-FU degradation (80%), therefore potentially leading to toxic levels of unmetabolized 5-FU. Providers should be aware of the potentially neurotoxic effects of topical 5-FU in order to properly counsel patients and to consider this as a possible etiology of neurologic deficits in patients using this drug.

Soft Tissue Management of Partial Hand Amputation.

Conventional teaching in the management of partial hand amputations prioritizes residual limb length, often through local, regional, or distant flaps. While multiple options exist to provide durable soft tissue coverage, only a few flaps are thin and pliable enough to match that of the dorsal hand skin. Despite debulking, excessive soft tissues from previous flap reconstructions can interfere with residual limb function, prosthesis fit, and surface electrode recording for myoelectric prostheses. With rapid advances in prosthetic technology and nerve transfer techniques, patients can achieve very high levels of function following prosthetic rehabilitation that rival, or even outpace, traditional soft tissue reconstruction. Therefore, our reconstruction algorithm for partial hand amputations has evolved to the thinnest coverage possible, providing adequate durability. This evolution has provided our patients with faster and more secure prosthesis fitting with better surface electrode detection, enabling earlier and improved use of simple and advanced partial hand prostheses.

Outcomes After Use of the Induced Membrane Technique for Fractures of the Upper Extremity.

PURPOSE: The purpose of this study was to review a series of cases in which the induced membrane technique was used for fractures with segmental bone loss in the upper extremity. We aimed to examine patient indications, outcomes based on union rates, and complications associated with this technique. METHODS: An institutional review board-approved database at our institution was used to identify patients based on either diagnosis or procedure codes commonly used during the induced membrane treatment. The database was queried between 2003 and 2020 and included patients with segmental bone defects from acute trauma, nonunions, and infections. Demographic data, mechanism of injury, size and extent of the bone defect, treatment indication and methods along with intraoperative and postoperative complications were retrospectively reviewed. RESULTS: We identified 23 patients who met our inclusion criteria, including 15 patients with traumatic segmental bone loss and 8 patients with chronic nonunions and/or infections. Fourteen cases involving the bones of the forearm, 8 cases involving the metacarpals and 3 cases involving the phalanges were identified. Radiographic union was ultimately demonstrated in 21/23 patients (91.3%) with a median time to union of 20 weeks (range 13-29 weeks). A total of 10 patients required unplanned reoperation, with 4 nonunions requiring repeat plating and grafting procedures, and 1 patient ultimately underwent amputation for persistent infection. CONCLUSIONS: The induced membrane technique represents an effective treatment option for acute traumatic bone loss as well as chronic fracture nonunions. The technique has potential challenges, as 10 patients (43.5%) in our series required unplanned reoperations with 4 patients (17.4%) requiring a repeat intervention for persistent nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Percutaneous Treatment of Unstable Scaphoid Waist Fractures.

BACKGROUND: Percutaneous techniques have been described for the treatment of nondisplaced scaphoid fractures, although less information has been reported about outcomes for unstable, displaced fractures. The aim of this study was to evaluate the union and complication rates following manual closed reduction and percutaneous screw placement for a consecutive series of unstable, displaced scaphoid fractures. METHODS: A total of 28 patients (average age, 27 years; 22 male/6 female) were treated for isolated unstable displaced scaphoid waist fractures. Closed reduction and percutaneous headless, compression screw fixation was successfully performed in 14 patients (average age, 32 years; 10 male/4 female), and the remaining 14 patients required open reduction. Patients who underwent percutaneous treatment were followed for radiographic fracture union and clinical outcomes. RESULTS: Thirteen of 14 fractures (93%) had clinical and radiographic evidence of bone union at an average of 2.8 months postoperatively. Average visual analog pain score at the time of union was 0.9. The average Quick Disability of the Arm, Shoulder, and Hand score at 2.5 years follow-up (range, 1.5-8.3 years) was 9.6 (range, 0.0-27.3). Complications included 1 case of nonunion and 1 case of intraoperative Kirschner wire breakage. CONCLUSIONS: Manual closed reduction followed by percutaneous headless, compression screw fixation was possible in 50% of patients who presented with acute unstable, displaced scaphoid fractures. This technique appears to be a safe and effective method when a manual reduction is possible, and it may offer a less invasive option when compared with a standard open technique.

Free Flap Functional Muscle Transfers.

Free functional muscle transfers remain a powerful reconstructive tool to restore upper extremity function when other options such as tendon or nerve transfers are not available. This reconstructive technique is commonly used for patients following trauma, ischemic contractures, and brachial plexopathies. Variable outcomes have been reported following free functional muscle transfers that are related to motor nerve availability and reinnervation. This article highlights considerations around donor motor nerve selection, dissection, and use of the gracilis muscle, and the surgical approach to performing a free functional muscle transfer to restore elbow flexion and/or digit flexion.

Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps.

OBJECTIVE: Successful foot and ankle soft tissue reconstruction is dependent on a clear understanding of the vascular supply to the foot. The aim of this study was to identify risk factors for reconstructive failure following foot and ankle free tissue transfer. METHODS: The authors retrospectively reviewed their 17-year institutional experience with 231 foot and ankle free flaps performed in 225 patients to determine predictors of postoperative foot ischemia and flap failure. Postoperative foot ischemia was defined as ischemia resulting in tissue necrosis, separate from the reconstruction site. RESULTS: Six (3%) patients developed postoperative foot ischemia, and 28 (12%) patients experienced flap failure. Chronic ulceration (P = 0.02) and an elevated preoperative platelet count (P = 0.04) were independent predictors of foot ischemia. The presence of diabetes was predictive of flap failure (P = 0.05). Flap failure rates were higher in the setting of an abnormal preoperative angiogram (P = 0.04), although the type and number of occluded arteries did not influence outcome. Foot ischemia was more frequent following surgical revascularization in conjunction with free tissue transfer and the use of the distal arterial bypass graft for flap anastomosis (P < 0.01). Overall, no differences were observed in foot ischemia (P = 0.17) and flap failure (P = 0.75) rates when the flap anastomosis was performed to the diseased artery noted on angiography, compared with an unobstructed native tibial artery. CONCLUSIONS: Foot and ankle free tissue transfer may be performed with a low incidence of foot ischemia. Patients with diabetes, chronic ulceration, and an elevated preoperative platelet count are at higher risk for reconstructive failure. © 2015 Wiley Periodicals, Inc. Microsurgery 36:276-283, 2016.

Sexual and Overall Quality of Life Improvements After Surgical Correction of "Buried Penis".

BACKGROUND: "Buried penis" is an increasing burden in our population with many possible etiologies. Although surgical correction of buried penis can be rewarding and successful for the surgeon, the psychological and functional impact of buried penis on the patient is less understood. METHODS: The study's aim was to evaluate the sexual satisfaction and overall quality of life before and after buried penis surgery in a single-surgeon's patient population using a validated questionnaire (Changes in Sexual Functioning Questionnaire short-form). RESULTS: Using Likert scales generated from the questionnaire and 1-tailed paired t test analysis, we found that there was significantly improved sexual function after correction of a buried penis. Variables individually showed that there was significant improvement with sexual pleasure, urinating, and with genital hygiene postoperatively. There were no significant differences concerning frequency of pain with orgasms. CONCLUSIONS: Surgical correction of buried penis significantly improves the functional, sexual, and psychological aspects of patient's lives.

Microvascular Anastomoses Using End-to-End versus End-to-Side Technique in Lower Extremity Free Tissue Transfer.

BACKGROUND: The decision to perform an end-to-end (ETE) or end-to-side (ETS) arterial anastomosis in lower extremity free tissue transfer has not been thoroughly evaluated in a large multisurgeon setting. The authors compared the reconstructive outcomes of lower extremity free flaps with ETE and ETS arterial anastomoses. METHODS: The authors retrospectively reviewed their 17-year institutional experience with lower extremity free flaps to determine whether ETE or ETS arterial anastomoses were associated with foot ischemic complications and flap failure. RESULTS: From 1996 to 2013, 398 patients underwent 413 lower extremity free flaps with ETE (66%) or ETS (34%) arterial anastomoses. The incidence of postoperative foot ischemia was 2% (n = 8). The flap failure rate was 11% (n = 45). The ETS technique was preferred in patients with fewer intact vessels to the foot (32% ETS for three-vessel runoff, 36% ETS for two-vessel runoff, and 50% ETS for single-vessel runoff) and when an intact recipient vessel was selected for anastomosis (60% ETS for intact vessel vs. 25% ETS for distally occluded vessel). No differences were observed in the foot ischemia (p = 0.45) and flap failure rates (p = 0.59) for ETE versus ETS arterial anastomoses. In subset analyses, the incidence of foot ischemia did not differ for either technique in the context of impaired vascular runoff or recipient vessel selection. CONCLUSION: No advantage was noted for ETE or ETS arterial anastomoses based on reconstructive outcomes. The choice of anastomotic technique in lower extremity free tissue transfer should be based on patient factors and the clinical circumstances encountered.

Current Concepts in Lower Extremity Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the existing principles for lower extremity reconstruction for both traumatic and ablative defects. 2. Understand the important factors for lower extremity reconstruction-based anatomical regions. 3. Discuss perforator flaps and their application in lower extremity reconstruction. SUMMARY: The Gustilo-Anderson open fracture classification is briefly reviewed. A comprehensive overview of the available flaps and methods for lower extremity reconstruction is provided.

Early Postoperative Complications following Gracilis Free Muscle Transfer for Facial Reanimation: A Systematic Review and Pooled Data Analysis.

BACKGROUND: Multiple studies have detailed promising smile restoration following gracilis free muscle transfer for facial reanimation but information detailing the potential complications is lacking. The aim of this study is to systematically review the literature to evaluate the reported complication rate associated with this procedure. We also aim to determine the most common occurring complications. METHODS: The PubMed, Embase, and Web of Science databases were queried with multiple search strategies for published articles between January 1950 and February 2013 that detailed gracilis free muscle transfer for facial reanimation. Title, abstract, and full text review was performed. Complications were defined as any reported, identifiable adverse outcome that required an alteration in treatment for correction. RESULTS: The literature search yielded 62 studies of gracilis free muscle transfer for facial reanimation. Overall, 36 articles (58%) reported whether or not a complication had occurred. The overall complication rate based on pooled proportions was 9.6% and the most commonly occurring complications were postoperative hematoma (3.6%) and infection (3.5%). CONCLUSIONS: Our data suggests that complications after gracilis free muscle transfer for facial reanimation may be underreported and this complex procedure may in fact be associated with significant adverse outcomes as high as 9.6%.

Contemporary solutions for the treatment of facial nerve paralysis.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Understand the most modern indications and technique for neurotization, including masseter-to-facial nerve transfer (fifth-to-seventh cranial nerve transfer). 2. Contrast the advantages and limitations associated with contiguous muscle transfers and free-muscle transfers for facial reanimation. 3. Understand the indications for a two-stage and one-stage free gracilis muscle transfer for facial reanimation. 4. Apply nonsurgical adjuvant treatments for acute facial nerve paralysis. SUMMARY: Facial expression is a complex neuromotor and psychomotor process that is disrupted in patients with facial paralysis breaking the link between emotion and physical expression. Contemporary reconstructive options are being implemented in patients with facial paralysis. While static procedures provide facial symmetry at rest, true 'facial reanimation' requires restoration of facial movement. Contemporary treatment options include neurotization procedures (a new motor nerve is used to restore innervation to a viable muscle), contiguous regional muscle transfer (most commonly temporalis muscle transfer), microsurgical free muscle transfer, and nonsurgical adjuvants used to balance facial symmetry. Each approach has advantages and disadvantages along with ongoing controversies and should be individualized for each patient. Treatments for patients with facial paralysis continue to evolve in order to restore the complex psychomotor process of facial expression.

Free flap reconstruction of the knee: an outcome study of 34 cases.

BACKGROUND: Open wounds around the knee joint can often be managed with local flaps; however, free tissue transfer may be required when local tissue options are unavailable or inadequate. Free tissue transfer around the knee can be challenging due to unique anatomic features of the joint. The outcomes of such procedures remain largely unreported. METHODS: We retrospectively analyzed 33 patients who underwent 34 free tissue transfer reconstructions to the knee from 1993 to 2010. Twenty-four flaps were composed of soft tissue only and 10 flaps included a bony component. Patient demographics, details of the defect, operative characteristics, and clinical outcomes were reviewed. Outcomes included rates of flap failure, flap reexploration, and limb salvage. RESULTS: Thirty-three (97%) of 34 flaps survived. One flap failed secondary to arterial thrombosis. In total, 6/34 flaps (18%) required reexploration (2 arterial thromboses and 4 venous thromboses). A wide variety of donor and recipient vessels were used. Vessel selection did not affect vascular reexploration. Overall, 88% of lower extremities were salvaged. Four of 10 (40%) patients receiving bone free flap reconstruction experienced delayed union and 2 (20%) of these required amputation for eventual nonunion. CONCLUSIONS: Free flap reconstruction of the knee has a high flap survival and limb preservation rate in threatened extremities. Flap survival rates in the knee are similar to reported rates elsewhere in the lower extremity. Despite flap survival, infected nonunions that occur after bone free flap reconstruction result in a high limb amputation rate.

Patient perceptions on physician reimbursement in plastic surgery.

BACKGROUND: Public perception on physician reimbursement may be that considerable payments are received for procedures: a direct contrast to the actual decline. We aim to investigate patient perceptions toward plastic surgeon reimbursements from insurance companies. METHODS: A survey of 4 common, single-staged procedures was administered to 140 patients. Patients were asked for their opinion on current insurance company reimbursement fees and what they believed the reimbursement fee should be. RESULTS: Eighty-four patients completed the survey. Patients estimated physician's reimbursements at 472% to 1061% more for breast reduction, 347% to 770% for abdominal hernia reconstruction, 372% to 787% for panniculectomy, and 290% to 628% for mandibular fracture repair. Despite these perceived higher-than-actual-fee payments, 87% of patients thought reimbursements should still be higher. CONCLUSIONS: Patients surveyed overestimated plastic surgery procedure fees by 290% to 1061%. Patients should be informed and educated regarding current fee schedules to plastic surgeons to correct current misconceptions.

Scaphoid nonunions treated with 2 headless compression screws and bone grafting.

PURPOSE: To evaluate union and complication rates associated with the use of 2 headless compression screws and bone grafting for the treatment of scaphoid nonunions. METHODS: A total of 19 patients (18 male and 1 female) at an average age of 21 years were treated with open reduction and internal fixation with 2 cannulated, headless, compression screws for scaphoid nonunions. Bone grafting techniques included corticocancellous autograft from the iliac crest in 14 patients, capsular-based vascularized distal radius graft in 3, and medial femoral condyle free vascularized bone graft in 2. Patients were treated an average 19 months after the injury. Fracture nonunions were at the waist (n = 12), proximal third (n = 5), or distal third (n = 2) of the scaphoid. Dorsal (n = 7) and volar (n = 12) surgical approaches were used. RESULTS: All fractures had clinical and radiographic evidence of bone union at an average of 3.6 months. Postoperative computed tomography scans were available in 13 patients and showed union without evidence of screw penetration of the scaphoid cortex. No complications occurred in this series, and no revision procedures have been necessary. CONCLUSIONS: Our results indicate that the use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. A variety of bone grafting techniques can be used with this technique. The use of 2 compression screws may provide superior biomechanical stability and ultimately improve outcomes measured with future long-term comparative studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of scaphoid fractures in the athlete: open and percutaneous fixation.

Scaphoid fractures occur commonly in the athlete and should be treated with urgency to avoid undesired late complications. Magnetic resonance imaging may be helpful to make a prompt diagnosis so that an appropriate early treatment plan can be initiated. Cast immobilization in acute, nondisplaced scaphoid fractures seems to have an equivalent union rate to surgical modalities. Despite this, limiting the immobilization and time to union period in the athlete will allow earlier restoration of preinjury level function and eventual return to play. Percutaneous techniques with or without arthroscopy assistance have been advocated as less invasive surgical approaches that may have an added benefit in the athlete. Displaced and unstable fractures should be approached with a volar or dorsal open technique to achieve and confirm an anatomic reduction before screw placement.

Vascularized fibula-based physis transfer for pediatric proximal humerus reconstruction.

UNLABELLED: Free vascularized fibular transfer has become a standard procedure in upper extremity reconstruction after resection of osteogenic tumors. The authors present two rare pediatric cases of high-grade osteosarcoma resection of the proximal humerus. A free vascularized fibula autograft including the physis based on the anterior tibial artery and vein was used for reconstruction in a delayed (case 1) and immediate (case 2) approach. The main focus of the article is to describe the surgical technique, which is also presented in a series of intraoperative videos. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Lumbar decompression and fusion in a centenarian.

The incidence of chronic and debilitating conditions in the aging population is steadily increasing, and the treatment of extreme elderly patients with spinal conditions can be challenging. Spinal stenosis and spondylolisthesis can dramatically affect patient quality of life, and patients commonly seek a surgical solution for their condition. Many extreme elderly patients are cautioned against surgery secondary due to their high complication and in-hospital mortality rates when compared with younger patients. This article describes the oldest patient (101 years old) in the English literature with severe spinal stenosis and spondylolisthesis who underwent primary lumbar decompression and fusion. His symptomatology dramatically affected his quality of life, and he was denied surgical care at another institution secondary to his advanced age and high potential risks. A successful outcome was ultimately achieved, and he was able to return to a higher level of physical functioning and social participation prior to his death of unrelated causes 3 years later. This case questions the strict indications of surgery in less-than-ideal and extreme elderly surgical candidates. The authors believe that surgery should not be denied in extreme elderly patients who have failed conservative treatment modalities and continue to have functional impairments. Successful spinal surgery may allow extreme elderly patients an improved quality to the remainder of their life.

An evaluation of information on the internet about a new device: the cervical artificial disc replacement.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: The objective of this study was to investigate the authorship, content, and quality of information available to the public on the Internet pertaining to the cervical artificial disc replacement device. SUMMARY OF BACKGROUND DATA: The Internet is widely used by patients as an educational tool for health care information. In addition, the Internet is used as a medium for direct-to-consumer marketing. Increasing interest in cervical artificial disc replacement has led to the emergence of numerous Web sites offering information about this procedure. It is thought that patients can be influenced by information found on the Internet. METHODS: A cross section of Web sites accessible to the general public was surveyed. Three commonly used search engines were used to locate 150 (50/search engine) Web sites providing information about the cervical artificial disc replacement. Each Web site was evaluated with regard to authorship and content. RESULTS: Fifty-three percent of the Web sites reviewed were authorized by a private physician group, 4% by an academic physician group, 13% by industry, 16% were news reports, and 14% were not otherwise categorized. Sixty-five percent of Web sites offered a mechanism for direct contact and 19% provided clear patient eligibility criteria. Benefits were expressed in 80% of Web sites, whereas associated risks were described in 35% or less. European experiences were noted in 17% of Web sites, whereas only 9% of Web sites detailed the current US experience. CONCLUSION.: The results of this study demonstrate that much of the content of the Internet-derived information pertaining to the cervical artificial disc replacement is for marketing purposes and may not represent unbiased information. Until we can confirm the content on a Web site to be accurate, patients should be cautioned when using the Internet as a source for health care information related to cervical disc replacement.

A socioeconomic analysis of surgical treatment of migraine headaches.

BACKGROUND: This study is meant to compare the direct and indirect cost of migraine headache care before and after migraine surgery and to evaluate any postoperative changes in patient participation in daily activities. METHODS: Eighty-nine patients enrolled in a migraine surgery clinical trial completed the Migraine-Specific Quality-of-Life Questionnaire, the Migraine Disability Assessment questionnaire, and a financial cost report preoperatively and 5 years postoperatively. RESULTS: Mean follow-up was 63.0 months (range, 56.9 to 72.6 months). Migraine medication expenses were reduced by a median of $1997.26 annually. Median cost reduction for alternative treatment expenses was $450 annually. Patients had a median of three fewer annual primary care visits for the migraine headache treatment, resulting in a median cost reduction of $320 annually. Patients missed a median of 8.5 fewer days of work or childcare annually postoperatively, with a median regained income of $1525. The median total cost spent on migraine headache treatment was $5820 per year preoperatively, declining to $900 per year postoperatively. Total median cost reduction was $3949.70 per year postoperatively. The mean surgical cost was $8378. Significant improvements were demonstrated in all aspects of the Migraine-Specific Quality-of-Life Questionnaire and the Migraine Disability Assessment questionnaire. CONCLUSIONS: Surgical deactivation of migraine trigger sites has proven to be effective for the treatment of severe migraine headache. This study illustrates that the surgical treatment is a cost-effective modality, reducing direct and indirect costs. Patients may also expect improvements in the performance of and increased participation in activities of daily living. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Detection of postoperative neurologic deficits using somatosensory-evoked potentials alone during posterior cervical laminoplasty.

BACKGROUND CONTEXT: The use of neurophysiologic monitoring during anterior and posterior cervical decompression procedures in patients with spondylotic myelopathy remains controversial. The ideal neurophysiologic monitoring modality of choice is also highly debated. PURPOSE: The purpose of this study was to evaluate the utility of neurophysiologic monitoring with only somatosensory-evoked potentials (SSEPs) in a consecutive series of laminoplasty procedures with regard to the detection of new postoperative neurologic deficits. STUDY DESIGN: Retrospective case series. PATIENT SAMPLE: Eighty consecutive patients who underwent a posterior cervical laminoplasty were reviewed. OUTCOME MEASURES: We analyzed intraoperative SSEP amplitude and latency changes from baseline with regard to the development of new postoperative neurologic deficits. METHODS: We retrospectively reviewed 80 patients who underwent a posterior cervical "open-door" laminoplasty with a standard SSEP neurophysiologic monitoring protocol. Intraoperative SSEP amplitude and latency changes from baseline ("alerts") were analyzed with regard to the development of new postoperative neurologic deficits. RESULTS: Baseline SSEP values were obtained in all patients. There were five (6%) procedures that had SSEP alerts. All alerts occurred shortly after the lamina was hinged open. Four patients with SSEP alerts developed new postoperative neurologic deficits, including three unilateral upper extremity motor and sensory deficits and one complete spinal cord injury. In the immediate postoperative period, our experience with SSEP monitoring demonstrated 4 true-positive, 75 true-negative, and 1 false-positive monitoring results. CONCLUSIONS: In this series of laminoplasty procedures, SSEP neurophysiologic monitoring had a high sensitivity and specificity for predicting new neurologic deficits in the early postoperative period. Somatosensory-evoked potentials are an effective tool for spinal cord monitoring when performing a posterior cervical laminoplasty procedure.