Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity.

BACKGROUND: Recurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen conduits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy. METHODS: Patients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were retrieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome. RESULTS: The mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 postoperatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recurrent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group. CONCLUSIONS: Here we report on the novel technique of using a collagen matrix wrap in recurrent compression neuropathies with good success. The collagen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching.

Merkel cell carcinoma of the hand and upper extremity: current trends and outcomes.

Merkel cell carcinomas represent an uncommon yet aggressive skin cancer. We sought to identify changes in incidence and predictors of outcomes and survival of patients with Merkel cell carcinomas of the hand and upper extremity. The Surveillance, Epidemiology and End Results database was used to identify all patients with Merkel cell carcinomas of the skin located specifically in the hand and upper extremity. Overall, 5211 cases were identified in the period from 1986 through 2009. The age-adjusted incidence of Merkel cell carcinoma of the hand and upper extremity increased from 0.02 cases per 100,000 in 1986 to 0.14 cases per 100,000 in 2009. The mean age of these patients was 75 years and positive regional lymph nodes were identified in 33%. Rate of metastasis was 4.1%. Overall survival for the study cohort was 49%. Multivariate analysis identified tumor size >5 cm, positive regional lymph nodes and metastasis at diagnosis as independent predictors of mortality. The incidence of Merkel cell carcinomas has increased substantially over the study period. Overall survival for Merkel cell carcinomas of the body and hand and upper extremity is related to tumor size and extent of disease at time of clinical presentation. Merkel cell carcinomas of the hand and upper extremity tend to be diagnosed at an earlier stage with lower rates of regional and systemic spread, and subsequently have a higher overall survival rate.

Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery database.

PURPOSE: To ascertain trends in the surgical treatment of ulnar nerve compression at the elbow within the United States. METHODS: We analyzed the National Survey of Ambulatory Surgery to study trends in the treatment of cubital tunnel syndrome from 1994 to 2006. The National Survey of Ambulatory Surgery provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other. The data were then statistically analyzed for trends in treatment, utilization, and demographics. RESULTS: A total of 52,133 surgical procedures were recorded in the National Survey of Ambulatory Surgery for the treatment of ulnar nerve compression in 2006. This represents an increase from 26,283 in 1994 and 35,406 in 1996. In the 11 years from 1996 to 2006, the total surgical procedures on the ulnar nerve increased by 47%. Transposition went from 49% of all cubital tunnel procedures in the 1990s to 38% in 2006. In 2006, women were much more likely to have a simple decompression (70%) than a transposition or other technique. Decompression had a mean surgical time of 48 minutes, and transposition had a mean surgical time of 59 minutes. CONCLUSIONS: The percentage of transpositions used in the treatment of cubital syndrome has decreased to 37% in the last survey. Possible reasons include expanded indications or changing surgical preferences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Outpatient surgery and sequelae: an analysis of the AAAASF Internet-based quality assurance and peer review database.

Although Internet-based quality assurance and peer review data have demonstrated the safety of procedures performed in the outpatient setting through the analysis of outcomes, the future of patient care will be directed by evidence-based medicine. Large inpatient surgical databases have long existed to provide quality assurance and improvement data for the inpatient cohort of patients. The acquisition of large data sets related to surgical care can best be achieved through the Internet. When outcomes are analyzed in conjunction with the indications for a procedure and the manner that care was delivered, evidence-based medicine is the end product.

A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome.

BACKGROUND: Recurrent and persistent carpal tunnel syndrome is an uncommon but potentially difficult surgical dilemma. Many surgical treatment options have been described in the literature without comparative data on outcome. METHODS: A systematic review on recurrent carpal tunnel syndrome was performed for all articles from 1946 to 2012 in MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists from all identified articles. Twenty-three articles were screened and identified from the time period 1972 to 2012, representing two general treatment groups: decompression with flap interposition and repeated open decompression. A meta-analysis was then performed, generating forest and funnel plots of the data. RESULTS: In total, 294 patients from 14 studies in the flap arm of the meta-analysis had a weighted success rate of 86 percent (95 percent CI, 0.75 to 0.96), and 364 patients from nine studies in the nonflap arm had a weighted 75 percent success rate (95 percent CI, 0.66 to 0.84). Heterogeneity was statistically analyzed and revealed low heterogeneity with the I statistic. Forest plots were created and analyzed between subgroups, and chi-square analysis revealed a highly statistically significant difference (p = 0.001). The odds ratio of success in the nonflap group was 0.50 (95 percent CI, 0.33 to 0.75). CONCLUSIONS: Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression. The relevance of these data is pertinent to all hand surgeons, as they could have an impact on treatment guidelines for this relatively uncommon but problematic condition, but further prospective study is needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

The variation in the absence of the palmaris longus in a multiethnic population of the United States: an epidemiological study.

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Hypertrophic scarring in cleft lip repair: a comparison of incidence among ethnic groups.

BACKGROUND: Although hypertrophic scar (HTS) formation following cleft lip repair is relatively common, published rates vary widely, from 1% to nearly 50%. The risk factors associated with HTS formation in cleft patients are not well characterized. The primary aim of this retrospective study of 180 cleft lip repairs is to evaluate the frequency of postoperative HTS among various ethnic groups following cleft lip repair. METHODS: A retrospective chart view of patients undergoing primary cleft lip repair over a 16-year period (1990-2005) by the senior surgeon was performed. The primary outcome was the presence of HTS at 1 year postoperatively. Bivariate analysis and multivariable logistic regression were used to evaluate potential risk factors for HTS, including ethnicity, type and laterality of cleft, and gender. RESULTS: One hundred and eighty patients who underwent cleft lip repair were included in the study. The overall rate of postoperative HTS formation was 25%. Ethnicity alone was found to be an independent predictor of HTS formation. Caucasian patients had the lowest rate of HTS formation (11.8%) and were used as the reference group. HTS rates were significantly higher in the other ethnicities, 32.2% in Hispanic patients (odds ratio [OR]: 3.51; 95% confidence interval [CI]: 1.53-8.85), and 36.3% for Asian patients (OR 4.27; 95% CI: 1.36-13.70). Sex, cleft type, and cleft laterality were not associated with increased rates of HTS. CONCLUSIONS: Differences in ethnic makeup of respective patient populations may be a major factor influencing the wide variability of reported HTS rates. Consideration should be given to potential prophylactic treatments for HTS in susceptible ethnic populations.

Algorithmic approach to the management of hemangiomas.

Hemangiomas are a common benign vascular tumor that can occur in all parts of the body. These lesions can be a distressing sight for both patient and parent. This unique vascular tumor has characteristic phases of growth. Historically, these tumors have been treated nonoperatively, but with variable results. Often, the residual-resolved tumor produces contour defects, unpredictable scarring, and pigmentation problems. The authors devised an algorithmic diagram for treating hemangiomas based on a 30-year experience with treating these unique tumors. This step-by-step method delineates the thinking method that should be used when presented with a difficult hemangioma. This algorithmic method takes into account a multifactorial approach to management. This includes anatomic location, growth velocity, treatment response, expected outcome, and psychosocial considerations.