Treatment of complex extremity wounds with MatriDerm: first clinical experience in the US.

OBJECTIVE: Coverage of upper and lower extremity wounds with exposed vital structures such as tendon and bone is reliant on pedicled and free flaps. However, a population of patients with medical comorbidities or other social issues may not be suitable for flap coverage. We present the first in patient clinical experience in the US with MatriDerm (Billerbeck, Germany) for treatment of difficult extremity wounds, all with exposed bone or tendon. METHOD: MatriDerm dermal matrix has been popular in Europe for coverage of wounds. However, MatriDerm only received full approval for use by the US Food and Drug Administration (FDA) in 2021. Here we review our clinical experience. RESULTS: Locations (n=11) treated included forearm (n=1), hand (n=4), leg (n=3), and feet (n=3). Vital structures in wounds exposed included bone (n=3), bone and tendon (n=1), and tendon (n=7). Mean area of the wound treated was 59.2cm2 (range: 2 to 230). In our series, eight out of 11 wounds healed, with MatriDerm only (n=6) or following delayed skin grafting (n=2). Mean time to healing in the patients treated only with MatriDerm was 49 days (range 7 to 84). Mean time to split-thickness skin grafting in the remaining two patients was 44.5 days (range 32 to 57). CONCLUSION: MatriDerm has potential for treatment of complex extremity wounds, which would otherwise require flap coverage, in patients who are not good candidates for flap surgery.

Opioid Prescribing Practices Among Plastic Surgeons: Results of the 2019 American Society of Plastic Surgeons Opioid Survey.

BACKGROUND: Health care providers play an important role in the national opioid crisis with 40% of opioid-related deaths being attributed to prescription medications (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2018) and as many as half of the opioid pills prescribed after outpatient plastic surgery may go unused (Plast Reconstr Surg 2019;143:929-938). The purpose of this study was to provide broad foundational data regarding postoperative analgesic prescribing patterns among members of the American Society of Plastic Surgeons (ASPS) to facilitate inclusion of opioid data fields in the ASPS Tracking Operations and Outcomes for Plastic Surgeons database for longitudinal evaluation. METHODS: A survey regarding opioid prescribing practices was electronically distributed to a representative cohort of 2555 ASPS members. Two hundred seventy-nine responses (11% response rate) were received. RESULTS: The majority of respondents reported prescribing opioids following 1 or more types of cosmetic and reconstructive procedures (90.2% and 81.7%, respectively; p = 0.0057), most commonly oxycodone and hydrocodone. Most (61.9%) reported less than 5% of patients request an opioid refill. Nonopioid medications, most commonly acetaminophen and ibuprofen/naproxen, were also prescribed but less commonly so for cosmetic (80.7-85.8%) than reconstructive (86.3-91.5%) procedures. Local anesthetic was less commonly used for mastopexy (83.7%) than augmentation (91.8%, p = 0.02). CONCLUSIONS: Based on survey responses, potential areas of improvement to reduce opioid prescribing and use include provider education on the use of multimodal pain regimens including nonopioid medication and "as needed" rather than scheduled dosing, use of local anesthetic blocks, as well as patient education on opioid safety and proper disposal of unused medication.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps.

BACKGROUND: The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap. METHODS: Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed. RESULTS: A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder. CONCLUSIONS: Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture.

BACKGROUND: One of the most feared complications following treatment of Dupuytren contracture is complex regional pain syndrome (CRPS). This study aims to provide a national perspective on the incidence of CRPS following treatment of Dupuytren contracture and identify patient factors to target for risk reduction. METHODS: Using the Truven MarketScan databases from 2007 to 2016, individuals aged ≥18 years who developed CRPS within 1 year of treatment of Dupuytren contracture were identified using the International Classification of Disease diagnosis code for CRPS. Predictor variables included: age, sex, employment status, region, type of procedure, and concurrent carpal tunnel surgery. Multivariable logistic regression was used to analyze outcomes. RESULTS: In all, 48 327 patients received treatment for Dupuytren contracture, including collagenase injection (13.6%); percutaneous palmar fasciotomy (10.3%); open palmar fasciotomy (3.9%); palmar fasciectomy with 0 (10.8%), 1 (29.2%), or multiple (19.6%) digit releases; or a combination of these procedures (12.8%). One hundred forty-five patients (0.31%) were diagnosed with CRPS at a mean of 3.4 months (standard deviation, 2.3) following treatment. Significant predictors of CRPS included female sex (odds ratio [OR], 2.02; P < .001), Southern region (OR, 1.80; P = .022), long-term disability status (OR, 4.73; P = .035), palmar fasciectomy with release of 1 (OR, 5.91; P = .003) or >1 digit (OR, 13.32; P < .001), or multiple concurrent procedures for Dupuytren contracture (OR, 8.23; P = .001). CONCLUSIONS: Based on national commercial claims data, there is a lower incidence of CRPS following treatment of Dupuytren contracture than previously reported. Risk factors identified should help with preoperative counseling and assist clinicians in targeting risk reduction measures.

Efficacy of Abductor Pollicis Longus Suspensionplasty Compared to Ligament Reconstruction and Tendon Interposition.

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher's exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

Engaging Patients to Ask More Questions: What's the Best Way? A Pragmatic Randomized Controlled Trial.

PURPOSE: Hand conditions are common, and often require a discussion of the tradeoffs of different treatment options. Our goal was to evaluate whether providing patients with a Question Prompt List (QPL) for common hand conditions improves their perceived involvement in care compared with providing patients with 3 generic questions. METHODS: We performed a prospective, single-center, pragmatic randomized controlled trial. We created a QPL pamphlet for patients with common hand conditions. New patients with common hand conditions were enrolled between April 2019 and July 2019 and were randomized into either the QPL group (with 35 hand-specific questions) or the AskShareKnow group (3 generic questions: [1] What are my options? [2] What are the possible benefits and harms of those options? [3] How likely are each of these benefit and harms to happen to me?). Both groups received the questions prior to meeting with their surgeon. We used the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient participation in decision-making, as our primary outcome. The maximum PICS score is 13, and a higher score indicates higher perceived involvement. RESULTS: One hundred twenty-six patients participated in the study, with 63 patients in the QPL group and 63 patients in the AskShareKnow group. The demographic characteristics were similar in the 2 groups. The mean AskShareKnow group PICS score was 8.3 ± 2.2 and the mean QPL PICS score was 7.5 ± 2.8, which was not deemed clinically significant. CONCLUSIONS: The QPLs do not increase perceived involvement in care in patients with hand conditions compared with providing patients with 3 generic questions. CLINICAL RELEVANCE: Various approaches have been evaluated to help improve patient involvement in their care. In hand surgery, 3 generic questions were no different than a lengthy QPL with respect to patient involvement in their care.

Development and Testing of a Question Prompt List for Common Hand Conditions: An Exploratory Sequential Mixed-Methods Study.

PURPOSE: A question prompt list (QPL) is a tool that lists possible questions a patient may want to ask their surgeon. Its purpose is to improve patient-physician communication and increase patient engagement. Although QPLs have been developed in other specialties, one does not exist for hand conditions. We sought to develop a QPL for use in the hand surgery clinic using a mixed-methods design. METHODS: We drafted a QPL based on prior work outside of hand surgery and then used an exploratory sequential mixed-methods design (both qualitative and quantitative methods) to finalize the QPL. Qualitative evaluation included both a written questionnaire completed by a patient advisory board, hand therapists, and hand surgeons, as well as cognitive interviews conducted with clinic patients using the tool. Revisions to the QPL were made after each phase of qualitative analysis. The final QPL was then evaluated quantitatively using the system usability score (SUS) questionnaire to assess its usability. RESULTS: A patient advisory board consisting of 6 patients, 5 hand therapists, and 6 hand surgeons completed the written questionnaire. Thirteen patients completed a cognitive interview of the QPL. We completed a content analysis of the qualitative data and incorporated the findings into the QPL. Twenty patients then reviewed the final QPL pamphlet and completed the SUS questionnaire. The resulting SUS score of 78.8 indicated above-average usability of the QPL tool. CONCLUSIONS: The QPL developed in this study, from the perspective of multiple stakeholders, provides a usable tool to engage and prompt patients in asking questions during their visit with their hand surgeon with the potential to improve communication and patient-centered care. CLINICAL RELEVANCE: This study provides clinicians with a QPL developed for use in the hand surgery clinic setting, aimed at facilitating more thorough patient-provider discussion.

Microvascular Hand Surgery for Digital Ischemia in Scleroderma.

Periarterial sympathectomy and arterial bypass are microsurgical techniques which the literature suggests can provide improvement in digital pain and ulceration in patients with systemic sclerosis (SSc) who have persistent symptoms despite medication management. This review summarizes the relevant anatomy, medical therapies, operative techniques, and surgical outcomes and complications associated with the management of the vascular manifestations of SSc in the hand. Multidisciplinary collaboration between dermatology, rheumatology, and hand surgery can facilitate optimal medical and surgical management for SSc patients.

Extensive Hand Thermal and Blast Injury From Electronic Cigarette Explosion: A Case Report.

Background: As the use of electronic cigarettes rises, more reports of injuries related to device explosion are surfacing. Methods: Presented here is the case of a 35-year-old man sustaining extensive thermal and blast injuries to his hand when the device exploded while he was holding it. He required multiple surgeries involving groin flap coverage, tendon transfer, and nerve grafting to optimize his postinjury function. Results: While much of his hand function has been restored, he has continued deficits in range of motion and sensation as a result of the incident. Conclusions: With increasing numbers of such injuries, hand surgeons must be aware of the blast mechanism involved so as to avoid missing deep soft tissue injury or disruption of deep structures, as demonstrated in this case.

The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndrome.

BACKGROUND AND PURPOSE: Complex regional pain syndrome (CRPS) is a challenging complication after surgery or trauma. This study sought to determine the incidence of CRPS after a second inciting event in a previously unaffected extremity in patients with a history of an ongoing CRPS diagnosis in another extremity. METHODS: A retrospective review identified patients with CRPS seen in clinic over a 20-month period. The incidence of CRPS after subsequent surgery or injury in a previous unaffected extremity was determined and compared to an average incidence reported in the literature. RESULTS: Ninety-three patients had a diagnosis of primary CRPS. Nineteen (20.4%) developed CRPS in one or more additional extremity compared to the incidence of 23.4 per 100,000 (0.0234%) in the literature (odds ratio 1069.6, p<0.0001, 95% CI 562.0-2035.7). Twenty patients had a documented secondary injury or surgery in a second extremity. Fifteen (75%) developed secondary CRPS compared to a CRPS incidence rate of 6.4% following distal radius fracture, as determined by literature review (odds ratio 11.7, p<0.001, 95% CI 5.9-23.2). CONCLUSIONS: These result suggest that patients with a history of CRPS are more likely to develop secondary CRPS compared to the rates reported in the literature among the general population. IMPLICATIONS: Patients with a history of CRPS should be counselled that they may be at risk for developing secondary CRPS if they undergo surgery or sustain trauma to another extremity.

Nipple-areolar complex reconstruction and patient satisfaction: a systematic review and meta-analysis.

BACKGROUND: Nipple-areola complex (NAC) reconstruction transforms a mound of soft tissue into a breast and often marks the final stage of breast reconstruction after mastectomy. METHODS: A systematic review and meta-analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles were classified based on the nipple reconstructive technique-either composite nipple sharing or local flap with nipple-sparing mastectomy (NSM) used as a control. A standardized "Satisfaction Score" (SS) for "nipple appearance" and "nipple sensation" was calculated for each technique. A Fisher's exact test was used to compare the SS with local flap reconstruction with NSM. RESULTS: Twenty-three studies met the systematic review inclusion criteria. Nine NSM articles were identified with patient satisfaction data from 473 patients. The weighted average SS for NSM was 80.5%. Fourteen local flap technique articles were identified with satisfaction data from 984 patients and a weighted average SS of 73.9%. This was a statistically significant difference (P=0.0079). C-V and badge local flap techniques were associated with the highest SS, 92.6% and 90.5%, respectively. C-V and modified C-V flap technique was associated with a higher SS when compared to those using one or more other flap techniques (P=0.0001). CONCLUSIONS: While patient satisfaction with nipple reconstruction is high regardless of technique, it is higher with NSM. When NSM is not an option, local flap reconstruction with a C-V or modified C-V flap may be associated with higher satisfaction than alternative local flap techniques.

An Analysis of Complication Risk Factors in 641 Nipple Reconstructions.

Nipple-areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB-approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15-year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy-two patients with 641 nipple reconstructions were included with an average follow-up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant-based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant-based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.

Outcomes of Vacuum-Assisted Therapy in the Treatment of Head and Neck Wounds.

INTRODUCTION: Head and neck wounds can present a reconstructive challenge for the plastic surgeon. Whether from skin cancer, trauma, or burns, there are many different treatment modalities used to dress and manage complex head and neck wounds. Vacuum-assisted closure (VAC) therapy has been used on wounds of nearly every aspect of the body but not routinely in the head and neck area. This study was conducted to demonstrate our results using the VAC in the treatment of complex head and neck wounds. METHODS: This is an IRB-approved, retrospective review of 69 patients with 73 head and neck wounds that were managed using the VAC between 1999 and 2008. The wound mechanism, location, and size, length of VAC therapy, patient comorbidities, use of radiation, complications, and ultimate outcome were assessed. In this patient population, the VAC was utilized because the standard reconstructive ladder was not a good option or had previously failed. RESULTS: Sixty-nine patients with complex head and neck wounds were treated with the wound VAC. The mean age of the patients was 66 years, with a range of 5-96 years. Males outnumbered females in this study nearly 2:1. Eighty-six percent of patients had wounds secondary to cancer, 8% secondary to trauma, 3% secondary to infection, and 3% secondary to burns. The VAC was used as a dressing over skin grafts in 50%, over Integra in 21%, and over open debrided wounds in 29%. Wounds healed without complication in 44% of the skin grafts, 67% of Integra-covered wounds, and 71% of debrided wounds. Minor complications included failure of complete graft take, failure of granulation tissue formation in open debrided wounds, infection, and hematoma formation under skin grafts. Major complications included positive cancer margins requiring reexcision and death secondary to pulmonary embolism, sepsis, and metastatic cancer. Most complications resolved with dressing changes, repeat grafting, or the administration of antibiotics. CONCLUSIONS: Our results demonstrate that the wound VAC provides a reliable, effective, and durable dressing for a multitude of complex head and neck wounds. Additionally, it is a valuable tool when traditional surgical procedures are not a viable option.

The management of complications of small joint arthrodesis and arthroplasty.

Arthrodesis and arthroplasty are surgical options used for the management of pain, stiffness, deformity, and instability related to arthritis and traumatic injury of the small joints of the hand. Arthrodesis and arthroplasty come with a risk of postoperative infection. Superficial soft tissue infections can often be managed with oral antibiotics alone. Deep infections and osteomyelitis frequently require removal of hardware in addition to antibiotics and may require surgical revision once the infection is cleared. Selection of the most appropriate revision technique depends on the underlying cause of the initial failure, patients' functional and outcome needs, and surgeon preference.

Anteriorly positioned ulnar nerve at the elbow: a rare anatomical event: case report.

Two patients with an anteriorly positioned ulnar nerve at the elbow, identified during cubital tunnel release, are presented. Upon encountering an empty cubital tunnel, additional dissection found the ulnar nerve to course posterior to and to penetrate through the intermuscular septum 3 to 5 cm proximal to the medial epicondyle. It then ran anterior to the pronator-flexor mass before entering the forearm between the ulnar and the humeral heads of the flexor carpi ulnaris. Although a rare anatomical anomaly, an anteriorly positioned ulnar nerve is potentially an underreported finding. In individuals with cubital tunnel syndrome, diagnosis and surgical treatment may be negatively affected if the surgeon fails to recognize the aberrant anatomy. Upper extremity surgeons should also be mindful of this rare anomaly when performing elbow arthroscopy or medial epicondyle release to prevent inadvertent injury to the nerve.