Cast selection and non-union rates for acute scaphoid fractures treated conservatively: a systematic review and meta-analysis.

Cast selection for conservatively treated acute scaphoid fractures remains controversial. Cast options include short arm versus long arm, and those that include the thumb or leave it free. We sought to investigate the role of how cast choice affects nonunion rates after conservative management of scaphoid fractures. We searched PubMed, Embase, and Google Scholar from inception through July 14, 2020, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. We extracted information of interest, including cast type, and non-union rates at the end of the treatment period. We then performed a meta-analysis using the random-effects model. We identified seven relevant studies. Non-union was observed in 15 out of 156 (9.6%) with short-arm cast and 13 out of the 124 (10.5%) with long-arm cast (OR = 0.79, 95% CI [0.19, 3.26], p = 0.74). Non-union was observed in 18 out of 174 (10.3%) with thumb immobilization cast and 18 out of the 179 (10.1%) without thumb immobilization (OR = 0.97, 95% CI [0.49, 1.94], p = 0.69). In our study, short arm casting was proven non-inferior to long arm casting. Similarly, casts without thumb immobilization were equally as effective as casts with thumb immobilization in terms of non-union rates for acute scaphoid fractures treated non-operatively.

En Masse Excision and Curettage for Periarticular Gouty Tophi of the Hands.

Background: Despite increasing disease prevalence, there remains a paucity of data examining surgical treatments for gouty tophi. This article assesses en masse excision and curettage of articular tophi involving the hands and shows that carefully planned and precisely executed surgery can consistently alleviate pain, preserve function, and enhance the aesthetics of afflicted hands. Methods: A retrospective review was conducted of all consecutive patients who underwent surgical excision of tophaceous deposits from the upper extremity. All patients had an established diagnosis of gout and had been treated with urate-lowering medication. All tophi were substantive in size and were causing significant digital joint dysfunction and disfigurement with variable skin ulcerations. Results: The study group included 12 patients with 24 tophaceous deposits excised from the metacarpal and interphalangeal joints; 2 deposits were also concomitantly excised from the wrist and 2 from the elbow. The study group included 8 men and 4 women, with an average age of 67 years. Follow-up evaluation ranged from 2 to 15 years. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. All regained high levels of function, and all reported satisfaction with their outcome. On follow-up for as long as 15 years, recurrence has not been observed and secondary surgery has not proved necessary. Conclusions: This study indicates that surgical excision of articular tophi of the hands can provide long-term improvement in function and aesthetics with minimal risk of wound complications or recurrence.

Traumatic Complex Scaphoid Dislocation With Radial Carpal Disruption: A Case Report.

Background. Scaphoid dislocation with radial carpal disruption constitutes an extremely rare injury, and there are no clear guidelines for treatment. This article reviews a delayed presentation of this injury and its surgical management.

Dislocation of the metacarpophalangeal joint of the index finger requiring open reduction due to the presence of an intra-articular sesamoid bone.

Complex dislocation of the metacarpophalangeal joint of the index finger is rare and often requires surgical intervention. Here, we present a case of an index finger metacarpophalangeal joint dislocation requiring open reduction due to obstruction by a displaced volar plate and the intra-articular entrapment of a sesamoid bone. Surgical approach was performed dorsally, allowing easy visualization of the volar plate and sesamoid bone as well as minimizing risk to the radial digital nerve to the index finger. Postoperatively, the patient reported good functional return despite the delay in definitive management.

Acute Ulnar Neurapraxia and Carpal Tunnel Syndrome in the Context of a Distal Radius Fracture.

Distal radius fractures, carpal tunnel syndrome, and ulnar nerve compression are common causes of symptoms that result in patients presenting for hand evaluation. This is a unique case of a distal radius fracture leading to both carpal tunnel syndrome and ulnar nerve compression requiring urgent operative management.

Prevalence of a Septated First Dorsal Compartment Among Patients With and Without De Quervain Tenosynovitis: An In Vivo Anatomical Study.

Background: The reported prevalence of a subcompartment housing the extensor pollicis brevis (EPB) tendon within the first dorsal compartment varies widely in the literature, especially regarding the rates of occurrence between genders and among those with and without De Quervain. Based on direct intraoperative observation, we hypothesized that the prevalence of a septated compartment is far greater than previously reported, particularly in those with De Quervain disease. Methods: A prospective analysis of consecutive patients who underwent first dorsal compartment release was carried out. Patients were divided into 2 groups: those with De Quervain tenosynovitis ("De Quervain" group) and a control cohort without a primary diagnosis of De Quervain ("non-De Quervain" group). The intraoperative findings of a single compartment or a separate subcompartment were recorded. The prevalence of a septated compartment was calculated and compared between genders and both patient groups. Results: A total of 102 consecutive patients were included, with a female predominance (74.5%). Overall, 79.4% of patients had a separate subcompartment for the EPB. In the De Quervain cohort, 89.1% had 2 compartments, while 71.4% of non-De Quervain patients had a subcompartment. Men and women had a similar rate of double compartments (80% and 82.4%, respectively). Conclusions: The prevalence of a septated first dorsal compartment is considerably higher than previously reported, most notably in patients afflicted with De Quervain tenosynovitis. This higher rate of septation occurs with a similar prevalence in both men and women. Owing to its consistent presence, the dual first dorsal compartment should be regarded as an expectant anatomical component of the normal wrist.

Osseointegrated Finger Prostheses Using a Tripod Titanium Mini-Plate.

BACKGROUND: Digital amputation is a common upper extremity injury and can cause significant impairment in hand function, as well as psychosocial stigma. Currently, the gold standard for the reconstruction of such injuries involves autologous reconstruction. However, when this or other autologous options are not available, prosthetic reconstruction can provide a functionally and aesthetically viable alternative. This study describes a novel technique, known as a tripod titanium mini-plate, for osseointegrated digit prostheses, and reviews the outcomes in a set of consecutive patients. METHODS: A retrospective review of patients who underwent 2-stage prosthetic reconstruction of digit amputations was performed. Demographic information, occupation, mechanism of injury, number of amputated fingers, and level of amputation were reviewed. Functional and aesthetic outcomes were assessed using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale and a visual analog scale (VAS) score, respectively. In addition, complications during the postoperative period were recorded. RESULTS: Seven patients were included in this study. Their average age was 29 years. Five patients had single-digit amputations and 2 patients had multiple-digit amputations. Functional and aesthetic outcomes were assessed using the Q-DASH score (average, 10.4) and VAS score (average, 9.1), respectively. One episode of mild cellulitis was seen at 24 months of follow-up. However, it was treated successfully with oral antibiotics. No other complications were reported. CONCLUSIONS: When autologous reconstruction is not suitable for digit reconstruction, prosthetic osseointegrated reconstruction can provide good aesthetic and functional results. However, larger series with longer-term follow-up are required in order to rule out the possibility of other complications.

Abdominal Contouring: Can the American Society of Anesthesiologists Classification System Help Determine When to Say No?

BACKGROUND: The purpose of this study was to determine whether the American Society of Anesthesiologists classification system could be used preoperatively to identify patients at high risk for complications after abdominal contouring. METHODS: Using the National Surgical Quality Improvement Program database from 2007 to 2012, patients undergoing abdominal contouring procedures were identified and stratified by American Society of Anesthesiologists class. The primary outcome was any complication within 30 days. Secondary outcomes included minor wound, major surgical, and medical complication. Adjusted odds ratios were calculated using logistic regression. RESULTS: A total of 3637 patients were analyzed; 14.6 percent of patients were class I, 59.1 percent were class II, 23.4 percent were class III, and 2.9 percent were class IV. Overall complication and mortality rates were 12 percent and 0.2 percent, respectively. There was a significant trend of increasing odds of any complication with increasing class (class I, OR, 1.0; class II, OR, 1.5; class III, OR, 2.5; class IV, OR, 5.6; p-trend < 0.001). This trend was seen consistently for minor wound complications, medical complications, and major surgical complications (p = 0.007, p = 0.005, and p = 0.001, respectively). CONCLUSIONS: The American Society of Anesthesiologists classification system, which is simple and universally applicable, appears to predict significant complications and can be used to rapidly screen patients before abdominal contouring. Furthermore, the authors' results can be used to inform patient-physician discussion about the risks incurred when undergoing these procedures based on their individual class. Together with optimization of high-risk patients, patient selection using American Society of Anesthesiologists classification may prevent complications and improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Update on Post-mastectomy Lymphedema Management.

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16-40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.

Reconstruction of the pediatric midface following oncologic resection.

BACKGROUND: Sarcoma is the most common midface malignancy in children. While first-line treatment in adults is resection, the challenges associated with resection and reconstruction of these tumors in children often lead to radiation therapy as primary treatment. This report highlights the feasibility and efficacy of midface reconstruction in the pediatric population after resection. In most cases, the same principles utilized in reconstructing midface defects in adults hold for the pediatric population. PATIENTS AND METHODS: From 2008 to 2013 seven pediatric patients underwent resection and reconstruction for maxillary sarcomas. These patients ranged in age from 18 months to 20 years. Five patients were reconstructed with six microvascular free flaps. Two patients received pedicled flaps. Follow-up ranged from 15 months to 4.5 years. Reconstructive, oncological, and functional outcomes were analyzed. RESULTS: Seven patients underwent eight reconstructions for sarcomas of the maxilla. Flaps utilized included vertical rectus abdominis, anterolateral thigh, fibula, and temporoparietal fascia. One flap was complicated by venous thrombosis but was successfully salvaged after thrombectomy and revision using vein graft. One patient developed recurrence after initial flap placement and required salvage resection and a second free flap. Six patients were judged to have good facial symmetry and tolerated a regular oral diet with normal or near-normal dental occlusion. CONCLUSIONS: Standard primary therapy for sarcomas of the maxilla in the pediatric population consists of nonsurgical management. However, a radiation-first approach is associated with significant morbidity and makes surgical salvage more difficult. Based on our experience, microsurgical reconstruction of the pediatric midface is safe and effective, and should be considered a first-line treatment option for midface sarcomas in children. In general, there is no significant area of departure between the principles that govern midface reconstruction in adults and children.

Asymmetric sternotomy and sternal wound complications: assessment using 3-dimensional computed tomography reconstruction.

OBJECTIVE: Wound complications after midline sternotomy result in significant morbidity and mortality. Despite many known risk factors, the influence of sternal asymmetry has largely been ignored. The purpose of this study was to assess the utility of 3-dimensional computed tomographic scan reconstructions to assess sternal asymmetry and determine its relationship with sternal wound infection. METHODS: A retrospective chart review was conducted for patients who underwent midline sternotomy and received a postoperative computed tomographic scan between 2009 and 2010. Cases were composed of all patients who had a sternal wound infection after undergoing sternotomy. Controls were randomly selected from patients without poststernotomy wound complications. Sternal asymmetry was defined as the difference between the left and the right sternal halves and was expressed as a percentage of the total sternal volume. RESULTS: Twenty-six cases were identified and 32 controls were selected as described earlier. The patients were similar in baseline characteristics and risk factors including age, sex, smoking status, diabetes, chronic obstructive pulmonary disease, preoperative creatinine, and operative time. Univariate factors associated with sternal wound infection include an asymmetry of 10% or greater, body mass index, and internal mammary artery harvest. In a multivariate logistic regression, independent predictors of sternal wound infection included an asymmetry of 10% or greater (odds ratio, 3.6; P = 0.03) and diabetes (odds ratio, 3.3; P = 0.0442). CONCLUSIONS: Our data suggest an association between asymmetric sternotomy and sternal wound infections. We recommend an assessment of sternal asymmetry to be performed in patients with sternal wound infection and if it is found to be 10% or greater, the surgeon should implement measures that stabilize the sternum.

Superficial temporal artery and vein as recipient vessels for scalp and facial reconstruction: radiographic support for underused vessels.

BACKGROUND: The choice of the recipient vessels for microsurgical reconstruction is based on proximity to the defect, vessel caliber, anatomic reliability, and ease of dissection. Traditionally in head and neck reconstruction, the superficial temporal artery and vein (STA/V) have been reserved as secondary recipient vessels. Others, including the facial artery (FA) and vein have been the preferred choice for facial reconstruction. METHODS: A retrospective analysis of all consecutive head and neck reconstructions using the STA/V by the senior author (E.S.G.) over a 5-year period was performed. Perioperative data were reviewed for all the patients. In a subset of patients, radiographic analysis was used to delineate STA and FA anatomy including vessel diameter and distances to standard anatomic landmarks. RESULTS: A total of 31 patients had 32 microsurgical reconstructions using the STA/V as recipient vessels. Radiographic analysis revealed no significant difference between the STA and FA diameters. The distances from the STA to the upper and middle face were significantly shorter relative to the FA, 64 versus 102 mm (p < 0.0001) and 72 versus 80 mm (p < 0.04), respectively. The distances from the lower face to the STA and FA were 56 and 30 mm, respectively (p < 0.0001). CONCLUSIONS: The STA/V can be used as first choice recipient vessels in head and neck reconstruction. Key features of these vessels include proximity to defect, acceptable caliber, predictable anatomic location, and relative ease of dissection. We recommend that the STA/V be considered recipient vessels of choice for reconstruction of defects of the face and scalp.

Neonatal mandibular distraction osteogenesis: converting virtual surgical planning into an operative reality.

Mandibular distraction osteogenesis (DO) has become an accepted method to manage severe cases of micrognathia-induced airway obstruction in neonates. Current imaging used to plan these procedures aids in surgical planning, but offers only a rough guide for the operating room. To our knowledge the following report offers the first description of virtual surgery used to guide DO in the mandible of a neonate. The plan provided a valuable link between the simulated procedure and the actual operative steps. Such technology can serve an important role in DO and offers objective guidance in device selection, vector planning and operative guide positioning.

Virtual surgical planning: a novel aid to robot-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Incidental detection of small renal masses has significantly increased over the last two decades with the advent of cross-sectional imaging. The shift in stage has been met with a shift in treatment modality because the preservation of renal parenchyma can prevent adverse outcomes. Robot-assisted laparoscopic partial nephrectomy (RALPN) needs significant surgeon expertise, and preoperative planning is imperative. PATIENTS AND METHODS: Between December 2010 and September 2011, virtual surgical planning (VSP) was used in consecutive patients with renal tumors that were suspicious for renal-cell carcinoma who were undergoing RALPN by a single surgeon. Three-dimensional (3D) reconstructions were examined and manipulated preoperatively, and an operative plan formulated. Intraoperative anatomy and preoperative 3D reconstructions were compared in real time. RESULTS: A total of 10 patients underwent RALPN with preoperative VSP. Average patient age at intervention was 54.6 years and average tumor size was 4.3 cm (range 1.7-7.5 cm). Tumor laterality was evenly distributed. Nephrometry score ranged from 5A to 10P, and final tumor pathology results revealed malignancy in 80%. No complications occurred intraoperatively, and an excellent correlation was noted between preoperative 3D reconstruction and intraoperative anatomy. All patients underwent a successful partial nephrectomy with no positive margins on final pathology results. Mean length of surgery was 232.9 minutes (range 156-435 min), and mean estimated blood loss was 370 mL (range 75-1800 mL). Warm ischemia time ranged from 20 to 50 minutes (mean 33.9 min). Data regarding postoperative renal function were available for six patients with an average loss of function of 9.5% (range 2%-17%). CONCLUSIONS: The implementation of this novel technology has significantly improved our ability to plan RALPN preoperatively. Tumor depth and complexity of tumor resection are assessed and the appropriate operative intervention and approach planned. Tumor proximity to vascular structures and collecting system were reliably predicted and therefore anticipated. Overall, these advantages created a safer surgical endeavor.