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The American Society for Reconstructive Microsurgery (ASRM) sponsors the Godina Fellowship to expand the careers of talented early career microsurgeons. This study characterizes the scholarly impact and academic career outcomes of Godina Fellows. The ASRM provided a list of Godina Fellows since program inception (1993 - 2020). An Internet based search obtained demographic, academic pedigree, and scholarly impact metrics. Curriculum vitae were reviewed to characterize future career outcomes including academic leadership positions. Of the 28 Godina Fellows, most were men (96%) and from the United States (61%). The average age of selection was 44 â± â4 years. Training pedigrees consisted primarily of plastic surgery residency training (93%) followed by orthopedic surgery (3%) and otolaryngology (3%). 32% completed reconstructive microsurgery fellowship training, 25% completed hand fellowship training, and 32% had no sub-specialty fellowship training. A minority of Fellows had a PhD (32%) and Master's Degree (14%). The average h-index was 33 â± â11 resulting from 160 â± â90 peer-reviewed manuscripts cited 3998 â± â2516 times. At the time of selection, Godina fellows had an average of 65 â± â42 peer-reviewed manuscripts. Most selected academic careers (79%), including 43% serving as chief of a sub-specialty service line (25%) or chair of a division or department (18%). Godina Fellowship recipients make important contributions to the field of reconstructive microsurgery through research impact and leadership at academic departments.
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BACKGROUND: The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72 hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction. METHODS: The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays. RESULTS: One-thousand and thirty patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours-10 days, 18% from 10-30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared to those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications. CONCLUSIONS: Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion.
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Objective: Qualifications needed to achieve national leadership positions in hand surgery are poorly defined. This study compares the academic accomplishments, demographics, and training backgrounds of presidents elected to serve the American Society for Surgery of the Hand (ASSH) and the American Association for Hand Surgery (AAHS). Methods: The ASSH and AAHS provided names of elected Presidents (1990-2022, n = 64). Curriculum vitae and academic web sites were used to collect demographic, training, bibliometric, and National Institutes of Health (NIH) funding data of presidents. Results: Presidents were predominately male (95%), Caucasian (90%), and orthopaedic surgery residency-trained (66%). Only 9% were racial minorities (8% Asian, 2% Hispanic, and 0% African American). The average age at appointment was 59 ± 7 years old, which was an average of 23 years from completion of hand surgery fellowship. More presidents received plastic surgery residency training in AAHS than ASSH (50 vs. 19%). The most represented hand surgery fellowships were Mayo Clinic (14%), University of Louisville (11%), and Duke University (9%). Twenty-one presidents participated in a travel fellowship (33%). Thirty presidents served as Department Chair or Division Chief at time of election (47%). The average h-index was 34 ± 18 resulting from 164 ± 160 peer-reviewed manuscripts and was similar between the two organizations. Eleven presidents had NIH grant funding (18%) and there were no differences in procurement or funding totals between the two organizations. Conclusion: Presidents of American hand surgery societies obtain high levels of scholarly activity regardless of training specialty. Women and racial minorities remain underrepresented at the highest levels of leadership.
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Objective: Multiple pathways exist for hand surgery training in the United States. Plastic surgeons often select Orthopedic Hand Surgery Fellowships to complement their skills and bridge perceived deficiencies in bone and joint cases. This study aims to quantify the impact of this approach on operative hand experience. Materials and methods: Case logs were analyzed for plastic surgery residents and orthopaedic hand surgery fellows (2016-2017 to 2019-2020). Reported hand surgery cases were compared between residency and fellowship using Student's t-tests. In total, 606 plastic surgery residents and 393 orthopaedic hand surgery fellows were included in this study. One year of Orthopedic Hand Surgery Fellowship training afforded more than twice the volume of hand surgery cases than Plastic Surgery Residency training (886.1 ± 234.7 vs. 428.1 ± 147.2, p < 0.001). Results: Case categories with the greatest positive fold difference in case volume encountered during Orthopedic Surgery Hand Fellowship were tumor (138.2 ± 63.2 vs. 22.1 ± 11.8, p < 0.001), joint reconstruction (108.7 ± 21.6 vs. 18.8 ± 11.5, p < 0.001), nerve decompression (158.4 ± 63.1 vs. 53.0 ± 32.6, p < 0.001), Dupuytren's (18.4 ± 10.5 vs. 7.6 ± 6.4, p < 0.001), and fracture management (132.8 ± 21.7 vs. 59.6 ± 24.1, p < 0.001). Conclusion: Orthopedic Hand Surgery Fellowship training doubles the operative hand case volume encountered during Plastic Surgery Residency. Significant increases are especially encountered for select case categories including bone and joint cases.
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The crises of climate change and biodiversity loss are interlinked and must be addressed jointly. A proposed solution for reducing reliance on fossil fuels, and thus mitigating climate change, is the transition from conventional combustion-engine to electric vehicles. This transition currently requires additional mineral resources, such as nickel and cobalt used in car batteries, presently obtained from land-based mines. Most options to meet this demand are associated with some biodiversity loss. One proposal is to mine the deep seabed, a vast, relatively pristine and mostly unexplored region of our planet. Few comparisons of environmental impacts of solely expanding land-based mining versus extending mining to the deep seabed for the additional resources exist and for biodiversity only qualitative. Here, we present a framework that facilitates a holistic comparison of relative ecosystem impacts by mining, using empirical data from relevant environmental metrics. This framework (Environmental Impact Wheel) includes a suite of physicochemical and biological components, rather than a few selected metrics, surrogates, or proxies. It is modified from the "recovery wheel" presented in the International Standards for the Practice of Ecological Restoration to address impacts rather than recovery. The wheel includes six attributes (physical condition, community composition, structural diversity, ecosystem function, external exchanges and absence of threats). Each has 3-5 sub attributes, in turn measured with several indicators. The framework includes five steps: (1) identifying geographic scope; (2) identifying relevant spatiotemporal scales; (3) selecting relevant indicators for each sub-attribute; (4) aggregating changes in indicators to scores; and (5) generating Environmental Impact Wheels for targeted comparisons. To move forward comparisons of land-based with deep seabed mining, thresholds of the indicators that reflect the range in severity of environmental impacts are needed. Indicators should be based on clearly articulated environmental goals, with objectives and targets that are specific, measurable, achievable, relevant, and time bound.
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Mineração , Biodiversidade , Ecossistema , Meio Ambiente , Conservação dos Recursos Naturais , Mudança ClimáticaRESUMO
BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.
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Articulação do Cotovelo , Fraturas Ósseas , Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Humanos , Feminino , Masculino , Adulto , Cotovelo/cirurgia , Estudos Retrospectivos , Articulação do Cotovelo/cirurgiaRESUMO
Free functional muscle transfer is an attractive option within reconstructive surgery when seeking to restore critical muscle function. The gracilis muscle has long been utilized for this purpose due to its expendability and consistent anatomy. Historically, survival of the skin overlying the distal one-third of the myocutaneous gracilis flap has been unpredictable. To address this, the myofasciocutaneous technique was developed, with prior studies demonstrating improved distal skin paddle viability with this approach; however, the mechanism is poorly defined. This study aimed to understand what factors contribute to survival benefit in myofasciocutaneous gracilis flaps. Using cadaveric dissections followed by latex dye injections, we discuss the creation of a deep fascial sheath that contains a rich vascular network and permits adhesion-free excursion at the recipient site. This study advances our understanding of the myofasciocutaneous gracilis flap and provides wider clinical applicability in free functional muscle transfer.
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PURPOSE: To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). MATERIALS AND METHODS: Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). RESULTS: After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008). CONCLUSIONS: ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.
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Falência Renal Crônica , Doença Arterial Periférica , Masculino , Humanos , Fatores de Risco , Medição de Risco , Resultado do Tratamento , Salvamento de Membro , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Extremidade Inferior/irrigação sanguínea , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Although palmar and digital soft-tissue resurfacing with intrinsic flaps may provide functional and aesthetic reconstruction, the donor site may result in a tight closure or need for a skin graft once the flap is raised. In this series, the "mini-shaped kiss flap" was used to increase the resurfacing efficiency and preserve hand function. METHODS: The mini-shaped kiss flaps, based on common palmar digital arteries (eg, princeps pollicis artery and ulnar palmar digital artery), were developed for the resurfacing of distal or proximal finger areas. The tiny skin paddles were "kissed" together and transferred as pedicled in proposed dimensions and shape. The flap size, donor/recipient site, perforator source, whether free or pedicled, surgical outcome, and donor-site morbidity were evaluated. RESULTS: Twenty mini-shaped kiss flaps were harvested for the purpose of palmar and digital resurfacing. The flap sizes varied from 3 × 1.2 cm to 5 × 2 cm. All 19 patients, aged 6 to 52 years (mean, 35 years), achieved successful reconstruction without major complications after 6- to 12-month follow-up. CONCLUSIONS: The mini-shaped kiss flap technique exhibited favorable surgical outcomes with excellent color and texture match to the recipient sites. The reverse midpalm, thenar, and hypothenar island flap can be raised at the cost of an unnoticeable linear scar with minimized functional compromise in the donor area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Traumatismos dos Dedos , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Lesões dos Tecidos Moles , Humanos , Retalhos Cirúrgicos/irrigação sanguínea , Transplante de Pele/métodos , Dedos/cirurgia , Dedos/irrigação sanguínea , Mãos/cirurgia , Retalho Perfurante/irrigação sanguínea , Lesões dos Tecidos Moles/cirurgia , Resultado do Tratamento , Traumatismos dos Dedos/cirurgiaRESUMO
BACKGROUND: The Plastic Surgery In-service Training Examination (PSITE) provides residents and faculty with an objective evaluation of hand surgery knowledge during plastic surgery residency training. The purpose of this study was to understand tested hand surgery concepts and references to optimize study efforts during plastic surgery residency. METHODS: We reviewed hand surgery questions on 6 consecutive PSITEs (2016-2021). Questions were classified by taxonomy and clinical subject area. Answer references were quantified by source and year of publication. RESULTS: A total of 235 questions tested hand surgery (16% of all PSITE questions) and 60 questions had an associated image (26%). Questions required direct level I-recall (37%), level II-interpretation (28%), and level III-medical decision-making skills (35%). The most frequently tested hand surgery topics were trauma (31%), reconstruction (20%), and functional problems (17%). There were 667 references to 130 unique journals. Journal of Hand Surgery (American volume), 34% and Plastic and Reconstructive Surgery (17%) were the highest yield primary sources. The median lag from publication to PSITE was 7 years (interquartile range, 7 years) with a mode of 2 years. Green's Operative Hand Surgery was the most referenced textbook (54% of textbook references). CONCLUSIONS: This study creates an objective benchmark for hand surgery knowledge training during plastic surgery residency. Efforts focused on the most commonly tested topics and references can enhance resident preparation in hand surgery.
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PURPOSE: Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss. METHODS: Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation. RESULTS: Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use. CONCLUSION: While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.
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The field of vascularized composite allotransplantation (VCA) has demonstrated remarkable advances since its inception with some excellent long-term results in a variety of graft types. However, unlike solid organ transplantation, it has yet to become mainstream. We therefore discuss strategies on ensuring long-term sustainability by addressing continued clinical developments of VCA to improve the risk-to-benefit balance, importance of public support, improved policy and financial support, and need for a bridge to the future of transplant surgery. There has been headway on all fronts and collaboration among the VCA centers for centralization of data and incorporation of patient voices will be essential for continued progress.
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Alotransplante de Tecidos Compostos Vascularizados , Humanos , Transplante Homólogo , Alotransplante de Tecidos Compostos Vascularizados/efeitos adversos , Alotransplante de Tecidos Compostos Vascularizados/métodos , Medição de Risco , Rejeição de EnxertoRESUMO
Background: Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint. Methods: A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts. Results: Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope. Conclusion: The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings. Level of Evidence: Level IV, retrospective case series.
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PURPOSE: While there are advantages and disadvantages to both processed nerve allografts (PNA) and conduits, a large, well-controlled prospective study is needed to compare the efficacy and to delineate how each of these repair tools can be best applied to digital nerve injuries. We hypothesized that PNA digital nerve repairs would achieve superior functional recovery for longer length gaps compared with conduit-based repairs. METHODS: Patients (aged 18-69 years) presenting with suspected acute or subacute (less than 24 weeks old) digital nerve injuries were recruited to prticipate at 20 medical centers across the United States. After stratification to short (5-14 mm) and long (15-25 mm) gap subgroups, the patients were randomized (1:1) to repair with either a commercially available PNA or collagen conduit. Baseline and outcomes assessments were obtained either before or immediately after surgery and planned at 3-, 6-, 9-, and 12-months after surgery. All assessors and patients were blinded to the treatment arm. RESULTS: In total, 220 patients were enrolled, and 183 patients completed an acceptable last evaluable visit (at least 6 months and not more than 15 months postrepair). At last follow-up, for the short gap repair groups, average static two-point discrimination was 7.3 ± 2.8 mm for PNA and 7.5 ± 3.1 mm for conduit repairs. For the long gap group, average static two-point discrimination was significantly lower at 6.1 ± 3.3 mm for PNA compared with 7.5 ± 2.4 mm for conduit repairs. Normal sensation (American Society for Surgery of the Hand scale) was achieved in 40% of PNA long gap repairs, which was significantly more than the 18% observed in long conduit patients. Long gap conduits had more clinical failures (lack of protective sensation) than short gap conduits. CONCLUSIONS: Although supporting similar levels of nerve regeneration for short gap length digital nerve repairs, PNA was clinically superior to conduits for long gap reconstructions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.
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Traumatismos dos Nervos Periféricos , Nervos Periféricos , Humanos , Nervos Periféricos/transplante , Estudos Prospectivos , Traumatismos dos Nervos Periféricos/cirurgia , Transplante Homólogo , Regeneração Nervosa/fisiologia , AloenxertosRESUMO
Free functional gracilis transfer is a technique for restoration of upper extremity function following brachial plexus injury, as well as muscle loss from traumatic, oncologic, and congenital causes. However, when used for the latter applications, a functional muscle as well as large skin paddle can be required. Historically, skin paddle size was limited by venous outflow of the gracilis flap, using 1 or 2 venae comitantes, and large unreliable skin paddles resulting in partial necrosis. Therefore, to restore form and function, we herein present a technique of free functional gracilis muscle harvest with inclusion of adjacent greater saphenous vein for inclusion of a large skin paddle with 2 venous drainage systems.
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Plexo Braquial , Músculo Grácil , Humanos , Músculo Grácil/transplante , Músculo Esquelético/transplante , Veia Safena/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Plexo Braquial/lesõesRESUMO
The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck. Methods: A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm2. The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture. Conclusion: The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.