Selective Ulnar Nerve Decompression, Capsular Branch Denervation, and Arthroscopic Debridement as a Unique Technique to Improve Quality of Life for Avascular Necrosis of the Distal Humerus and Radius in a Young Patient With ALL.

Avascular necrosis (AVN), one of the most common therapy-related and debilitating side effects of antileukemic treatment, can adversely affect a patient's long-term quality of life. Our case study presents a young woman with bilateral elbow AVN and hip AVN after acute lymphoblastic leukemia treatment, with a unique treatment strategy for her elbow pain. The treatment strategy included elbow joint denervation with arthroscopic debridement and distal humerus core decompression. The goal of this procedure was to improve symptomatic pain while retaining bone stock in the distal humerus hopefully allowing better function of the patient's elbow. This treatment may not only improve the quality of life in a young patient but also delay the need for future surgery. Our patient had improved pain relief in her elbow postsurgery. This procedure may be used for pain control and may have beneficial future implications in this limited population.

Geospatial Inefficiencies Associated With Digital Replantations at High-Volume Centers and Optimal Allocation Model for Centralization of Replantations.

PURPOSE: Digit replantation can improve dexterity, functionality, patient satisfaction, and pain following amputation, but rates continue to fall nationally. This study aimed to describe the effects of travel time and distance as barriers to high-volume hospitals, identify geospatial inefficiencies in the presentation of patients to replantation care, and provide an optimal allocation model in which cases are redistributed to select centers to reduce geospatial redundancies and optimize outcomes. METHODS: We reviewed the California Office of Statewide Health Planning and Development hospital discharge database to identify cases of digital amputation and determine outcomes of replantation. Using residential zip codes, risk- and reliability-adjusted multivariable logistic regression was used to assess the relationship of hospital volume and travel time on replantation success. Geospatial analysis assessed the travel burden of patients as they presented for care, and optimal allocation modeling was used to create a model of centralization. RESULTS: We identified 5,503 patients during the study period; 1,060 underwent replantation with an overall success rate of 70.2%. Ninety-three hospitals were found to perform replantations, of which only 4 were identified as high-volume hospitals. Patients routinely traveled farther to reach high-volume hospitals, and decreasing the travel time predicted a 15% increase in odds of replantation at a low-volume center. Twenty-one percent of patients presented to a low-volume hospital when a high-volume hospital was closer, and differencein payer type and race/ethnicity existed between those who presented to the closest center compared to those who bypassed high-volume centers. The optimal allocation modeling allocated all cases into 8 centers, which increased the median annual volume from 1 case to 9.6 cases and decreased patient travel time. CONCLUSIONS: Travel burden and geospatial inefficiencies serve as barriers to high-quality and high-volume replantation services. Optimized allocation of digital replantation cases into high-quality centers can decrease travel times, increase annual volumes, and potentially improve replantation outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Social Media Use Among Academic Hand Surgeons.

Purpose: Social media has become increasingly prevalent among the general population in the past decade. We examined the current prevalence of social media use among academic orthopedic-trained and plastic surgery-trained hand surgeons in the United States. Methods: All publicly available hand surgery faculty across the nation were analyzed for their public social media usage, including Instagram, Facebook, Twitter, LinkedIn, and personal websites. Comparisons of social media usage between orthopedic-trained and plastic surgery-trained hand surgeons, male and female academic hand surgeons, hand surgeons from different regions of the United States (East, West, Midwest, and South), and years of experience were analyzed. Results: A total of 469 academic hand surgeons were included. Among academic hand surgeons in the United States, LinkedIn was the most common platform used (40.3%), followed by Facebook (15.78%), a personal website (13.86%), Twitter (12.37%), and Instagram (4.05%). Plastic surgery hand surgeons had more of a presence than orthopedic hand surgeons on Instagram (8.26% vs 2.59%, P < .01)) and Twitter (19.01% vs 10.06%, P < .01). Male hand surgeons were more likely than female hand surgeons to use LinkedIn (41.19% vs 34.85%, P = .04). Southern (18.89%) and Eastern (14.36%) surgeons used personal websites more than Western (6.52%) and Midwestern (4.60%) surgeons (P = .03). Conclusions: Despite the widely known use of social media among plastic and aesthetic surgeons, this study shows the use of web-based marketing strategies to be quite rare in the academic hand surgery setting. Clinical Relevance: Our study shows that throughout the United States, academic hand surgeons use social media at low rates. We suggest that academic plastic surgery and orthopedic hand surgeons throughout the United States consider having a larger social media presence to expand advertising, improve patient education, and enhance networking among their practices. Social media can be a valuable tool and will likely only increase in popularity in the coming years.

Panniculectomy: Practical Pearls and Pitfalls.

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.

Acellular Dermal Matrices: Applications in Plastic Surgery.

Modern advances in tissue engineering have transformed the plastic surgeon's management strategies across a wide variety of applications. Comprehension of the fundamentals of biologic constructs is critical to navigating the available armamentarium. It is essential that plastic surgeons become familiar with some of the existing methods for utilizing biologics as well as the advantages and limitations to their use. In this article, the authors describe the basic science of biologics with a focus on acellular dermal matrices (ADMs), and review the recent evidence behind their use for a variety of reconstructive and aesthetic purposes. The review is organized by system and examines the common indications, techniques, and outcomes pertaining to the application of ADMs in select anatomic areas. The final section briefly considers possible future directions for using biologics in plastic and reconstructive surgery.

Optimal Pain Control in Abdominal Wall Reconstruction.

Lack of physician familiarity with alternative pain control strategies is a major reason why opioids remain the most commonly used first-line treatment for pain after surgery. This is perhaps most problematic in abdominal wall reconstruction, where opioids may delay ambulation and return of bowel function, while negatively affecting mental status. In this article, we discuss multimodal strategies for optimal pain control in abdominal wall reconstruction. These strategies are straightforward and are proven to improve pain control while minimizing opioid-associated side effects.

Smoking may be a harbinger of early failure with ultraporous metal acetabular reconstruction.

BACKGROUND: Smoking is considered a risk factor for surgical complications in total hip arthroplasty (THA) and has been linked to a higher rate of aseptic loosening in uncemented acetabular components. Acetabular reconstruction with newer ultraporous metals in both complex primary and revision THA has increased survivorship but it is unclear whether smoking affects survival of these implants. QUESTIONS/PURPOSES: We reviewed our early experience with THA using ultraporous acetabular components to assess the incidence and etiology of early failure and examine if any preoperative variables, including smoking, related to failure. METHODS: We used ultraporous acetabular components in 498 patients (534 hips), beginning with one case each in 1999 and 2004, 17 in 2005, and the majority from 2006 through March 2010. There were 159 complex primary and 375 revision cases. Of these patients, 17% were smokers (averaging 35 pack-years), 31% previous smokers (averaging 29 pack-years), 41% nonsmokers, and 1% unknown. Failure modes possibly related to smoking were infection, aseptic loosening, or periacetabular fracture and unrelated were dislocation and implant breakage. Minimum followup was 1 month (average, 32 months; range, 1-78 months). RESULTS: There were 34 cup failures (6%): 17 infections, 14 aseptic loosening, and one each liner breakage, dislocation, and periacetabular fracture. The failure rate (uncontrolled for potentially confounding variables) was 10% in both current (9 of 89) and prior smokers (17 of 167) and 3% in nonsmokers 8 of 271). CONCLUSION: With ultraporous metal technology in complex primary and revision THA, smoking, both past and current, may be a risk factor for early failure. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.