The Role of Electrical Stimulation in Peripheral Nerve Regeneration: Current Evidence and Future Directions.

The role of electrical stimulation in peripheral nerve regeneration is reviewed, including a brief background and proposed mechanism of action. Studies in animal as well as human models are reviewed. Current recommendations and future directions are addressed.

Flexor Tendon Injuries.

Flexor tendon injuries are complex, and management of these injuries requires consideration of the surgical timing, injury location, approach, and soft tissue handling. Complications are common, including adhesions, tendon rupture, infection, and a high reoperation rate for zone 2 repairs. Special considerations are given to chronic ruptures, concomitant fractures, and pediatric cases. We discuss current concepts that may improve patient outcomes.

Clinical Practice Guidelines to Support Capacity Building in Orthopaedic Surgical Outreach: An International Consensus Building Approach.

BACKGROUND: Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel. METHODS: We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it. RESULTS: An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques. CONCLUSIONS: As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs)1,2. It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs)3. Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources4-6. In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account7,8.

Successful topical treatment of human biofilms using multiple antibiotic elution from a collagen-rich hydrogel.

Chronic non-healing wounds significantly strain modern healthcare systems, affecting 1-2% of the population in developed countries with costs ranging between $28.1 and $96.8 billion annually. Additionally, it has been established that chronic wounds resulting from comorbidities, such as peripheral vascular disease and diabetes mellitus, tend to be polymicrobial in nature. Treatment of polymicrobial chronic wounds with oral and IV antibiotics can result in antimicrobial resistance, leading to more difficult-to-treat wounds. Ideally, chronic ulcers would be topically treated with antibiotic combinations tailored to the microbiome of a patient's wound. We have previously shown that a topical collagen-rich hydrogel (cHG) can elute single antibiotics to inhibit bacterial growth in a manner that is nontoxic to mammalian cells. Here, we analyzed the microbiology of cultures taken from human patients diagnosed with diabetes mellitus suffering from chronic wounds present for more than 6 weeks. Additionally, we examined the safety of the elution of multiple antibiotics from collagen-rich hydrogel in mammalian cells in vivo. Finally, we aimed to create tailored combinations of antibiotics impregnated into cHG to successfully target and treat infections and eradicate biofilms cultured from human chronic diabetic wound tissue. We found that the majority of human chronic wounds in our study were polymicrobial in nature. The elution of multiple antibiotics from cHG was well-tolerated in mammalian cells, making it a potential topical treatment of the polymicrobial chronic wound. Finally, combinations of antibiotics tailored to each patient's microbiome eluted from a collagen-rich hydrogel successfully treated bacterial cultures isolated from patient samples via an in vitro assay.

A New Model of Global Reconstructive Surgery Training With Reduced Carbon Footprint of Outreach.

This economic evaluation compares carbon dioxide emissions from air transportation for surgical mission trips vs team training trips.

Bard Versus the 2022 American Society of Plastic Surgeons In-Service Examination: Performance on the Examination in Its Intern Year.

Background: Bard is a conversational generative artificial intelligence (AI) platform released by Google (Mountain View, CA) to the public in May 2023. Objectives: This study investigates the performance of Bard on the American Society of Plastic Surgeons (ASPS) In-Service Examination to compare it to residents' performance nationally. We hypothesized that Bard would perform best on the comprehensive and core surgical principles portions of the examination. Methods: Google's 2023 Bard was used to answer questions from the 2022 ASPS In-Service Examination. Each question was asked as written with the stem and multiple-choice options. The 2022 ASPS Norm Table was utilized to compare Bard's performance to that of subgroups of plastic surgery residents. Results: A total of 231 questions were included. Bard answered 143 questions correctly corresponding to an accuracy of 62%. The highest-performing section was the comprehensive portion (73%). When compared with integrated residents nationally, Bard scored in the 74th percentile for post-graduate year (PGY)-1, 34th percentile for PGY-2, 20th percentile for PGY-3, 8th percentile for PGY-4, 1st percentile for PGY-5, and 2nd percentile for PGY-6. Conclusions: Bard outperformed more than half of the first-year integrated residents (74th percentile). Its best sections were the comprehensive and core surgical principle portions of the examination. Further analysis of the chatbot's incorrect questions might help improve the overall quality of the examination's questions.

Current Treatment Landscape for Dystrophic Epidermolysis Bullosa: From Surgical Management to Emerging Gene Therapies and Novel Skin Grafts.

Epidermolysis bullosa is a genetic skin disorder characterized by blister formation from mechanical trauma. Dystrophic epidermolysis bullosa (DEB) is caused by mutations in the COL7A1 gene presenting as generalized blisters from birth, which can result in extensive scarring, alopecia, esophageal stenosis, corneal erosions, and nail dystrophy. This disease also often leads to pseudosyndactyly of the digits from the closure of webspaces, progressing to a "mitten hand" deformity. Although traditional and current treatment for DEB is largely supportive with wound care and iterative surgical pseudosyndactyly release, emerging gene therapies and novel skin grafts may offer promising treatment. Studies published in the early 2020s have used HSV-1 vectors expressing missing COL7A1 genes to restore collagen function. One of these treatments, B-VEC, is an HSV-1-based topical gene therapy designed to restore collagen 7 by delivering the COL7A1 gene, leveraging a differentiated HSV-1 vector platform that evades the patient's immune system response. Other work has been performed to retrovirally modify autologous keratinocytes, but limitations of this process include increased labor in harvesting and engineering autologous cells. This article provides an overview of DEB treatment with an emphasis on emerging gene therapies and novel skin grafts, especially as they pertain to pseudosyndactyly treatment.

Greening Hand Surgery: Targeted Measures to Reduce Waste in Ambulatory Trigger Finger and Carpal Tunnel Decompression.

BACKGROUND: Operating rooms (ORs) produce approximately 70% of hospital waste. Greening strategies in the OR aim to reduce the environmental impact of surgery while maintaining patient safety and outcomes. The aim of this study was to strategically reduce waste and cost associated with common ambulatory hand procedures by implementing a 3-stage "green case" plan over a 1-year period in a high-volume tertiary referral hand surgery division. METHODS: A 3-stage greening initiative for hand surgery was designed and implemented in ambulatory open carpal tunnel release (CTR) and trigger finger release (TFR) cases, including: (1) introduction of minor field sterility; (2) implementation of a lean and green minor hand surgery pack and reduced instrument set; and (3) elimination of gown use by surgeons and OR staff. Surgical supply usage and costs were tracked during the study period and compared with control. RESULTS: Each "green case" resulted in savings of $105 compared with the control cases from the preceding year, excluding cost savings associated with reduced waste processing. There was a 64% and 75% reduction in waste and costs after greening, respectively. This equates to a minimum institutional annual savings of $51 000 when used for CTR and TFR. There was no observed increase in surgical site infections or complications after the introduction of greening. CONCLUSION: Greening initiatives can be successfully implemented by surgeons to reduce waste and costs. With targeted greening of CTR and TFR procedures, we significantly reduced waste and decreased costs while maintaining patient safety and outcomes.

The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips.

Background The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

Assessment of a Synergistic Effect of Platelet-Rich Plasma and Stem Cell-Seeded Hydrogel for Healing of Rat Chronic Rotator Cuff Injuries.

Outcomes after repair of chronic rotator cuff injuries remain suboptimal. Type-1 collagen-rich tendon hydrogel was previously reported to improve healing in a rat chronic rotator cuff injury model. Stem cell seeding of the tendon hydrogel improved bone quality in the same model. This study aimed to examine whether there was a synergistic and dose-dependent effect of platelet-rich plasma (PRP) on tendon-bone interface healing by combining PRP with stem cell-seeded tendon hydrogel. Human cadaveric tendons were processed into a hydrogel. PRP was prepared at two different platelet concentrations: an initial concentration (initial PRP group) and a higher concentration (concentrated PRP group). Tendon hydrogel was mixed with adipose-derived stem cells and one of the platelet concentrations. Methylcellulose, as opposed to saline, was used as a negative control due to comparable viscosity. The supraspinatus tendon was detached bilaterally in 33 Sprague-Dawley rats (66 shoulders). Eight weeks later, each detached tendon was repaired, and a hydrogel mixture or control was injected at the repair site. Eight weeks after repair, shoulder samples were harvested and assigned for biomechanical testing (n = 42 shoulders) or a combination of bone morphological and histological assessment (n = 24 shoulders). Biomechanical testing showed significantly higher failure load and stiffness in the concentrated PRP group than in control. Yield load in the initial and concentrated PRP groups were significantly higher than that in the control. There were no statistically significant differences between the initial and concentrated PRP groups. The addition of the highly concentrated PRP to stem cells-seeded tendon hydrogel improved healing biomechanically after chronic rotator cuff injury in rats compared to control. However, synergistic and dose-dependent effects were not seen.

Management of Brachial Plexus Birth Palsies: The Stanford Experience.

The start of Stanford's brachial plexus birth palsy (BPBP) experience dates back to 1983, when Dr. Vincent Rod Hentz visited Dr. Alain Gilbert on sabbatical. Since then, our principles of care for patients with BPBP have evolved based on our group's longitudinal experience caring for children with the entire spectrum of sequelae that arise in children with BPBP. We base our clinical decision making on frequent serial examinations and use intraoperative evoked potentials to guide surgical decisions. Here, we discuss our current principles on surgical indications, timing of surgery, and preferred techniques for secondary surgery in patients with BPBP.

The Impact of Virtual Reality on the Patients and Providers Experience in Wide-Awake, Local-Only Hand Surgery.

Purpose: Virtual reality (VR) is an emerging technology with the potential to enhance patient care by reducing pain and anxiety for a variety of medical procedures. The aim of this study was to evaluate an immersive VR program as a nonpharmacologic intervention to reduce anxiety and increase satisfaction in patients undergoing wide-awake, local-only hand surgery. The secondary aim was to assess providers' experience with the program. Methods: An implementation evaluation was employed to assess the experience of 22 patients who used VR during outpatient, wide-awake hand surgery at a veterans affairs hospital. We assessed the patients' anxiety scores and vital signs before and after the procedure as well as postprocedural satisfaction measures. The providers' experience was also assessed. Results: Patients who used VR exhibited lower anxiety scores after the procedure compared with what they exhibited before the procedure and had high satisfaction levels with their VR experience. Surgeons who used the system reported that VR improved their ability to teach learners and better focus on the procedure. Conclusions: Virtual reality, as a nonpharmacologic intervention, reduced anxiety and contributed to the patients' perioperative satisfaction with wide-awake, local-only hand surgery. As a secondary finding, VR positively impacted the providers' experience by increasing their ability to concentrate on tasks during the surgery. Clinical relevance: Virtual reality represents a novel technology that can reduce anxiety and contribute to a positive experience for both patients and providers during wide-awake, local-only hand procedures.

Capacity Assessment Tool to Promote Capacity Building in Global Orthopaedic Surgical Outreach.

BACKGROUND: A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building. METHODS: To develop the CAT-os tool, we utilized methodological triangulation-an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking. RESULTS: The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity). CONCLUSIONS: The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

Scoping Review of Hydrogel Therapies in the Treatment of Diabetic Chronic Wounds.

Chronic diabetic wounds are a significant issue that can be treated with topical hydrogel therapies. The aim of this study was to review the different compositions of hydrogel that have been developed and analyze their clinical relevance in the treatment of chronic diabetic wounds. Methods: We conducted a scoping review in which twelve articles were selected for review after applying relevant inclusion and exclusion criteria using a two-reviewer strategy. Data extracted from these studies was used to answer the following research question: What is the composition of hydrogels used to treat chronic diabetic wounds and how effective are they? Results: We analyzed five randomized controlled trials, two retrospective studies, three reviews, and two case reports. Hydrogel compositions discussed included mesenchymal stem cell sheets, carbomer, collagen, and alginate hydrogels, as well as hydrogels embedded with platelet-derived growth factor. Synthetic hydrogels, largely composed of carbomers, were found to have high levels of evidence supporting their wound healing properties, though few articles described their routine use in a clinical setting. Collagen hydrogels dominate the present-day hydrogel market in the clinical treatment of chronic diabetic wounds. The augmentation of hydrogels with therapeutic biomaterials is a new field of hydrogel research, with studies demonstrating promising early in vitro and in vivo animal studies demonstrating promising early results for in vitro and in vivo animal investigations. Conclusions: Current research supports hydrogels as a promising topical therapy in the treatment of chronic diabetic wounds. Augmenting Food & Drug Administration-approved hydrogels with therapeutic substances remains an interesting early area of investigation.

Tenolysis and Salvage Procedures.

Complications in flexor tendon repair are common and include tendon rupture, adhesion formation, and joint contracture. Risk factors include preexisting conditions, gross contamination, concurrent fracture, early unplanned loading of the repaired tendon, premature cessation of splinting, and aggressive early active range of motion protocols with insufficient repair strength. Rupture of a repaired tendon should be followed by early operative exploration, debridement, and revision with a four-core strand suture and nonbraided epitendinous suture. Wide-awake flexor tenolysis should be considered when adhesion formation results in the plateaued range of motion, and passive motion exceeds active motion. Two-staged reconstruction is recommended when injury results in excessive scaring, joint contracture, or an incompetent pulley apparatus.

Long-term Outcomes following Operative Management of Pediatric Scapholunate Ligament Injuries.

Background Scapholunate (SL) ligament injuries are rarely diagnosed in children. This study reports the outcomes of surgically treated SL ligament injuries in patients younger than 18 years. Methods A retrospective review was performed on 20 pediatric patients with SL ligament injuries. Records were reviewed for preoperative and postoperative radiographic data, intraoperative findings, classifications of interosseous ligament injury, and postoperative course. Results Thirteen girls and seven boys sustained SL injuries requiring operative intervention and were followed for an average of 26 months. Magnetic resonance imaging (MRI) was performed in 15 patients, which revealed an SL tear in 7 patients. Arthroscopically, SL injuries were classified as Geissler grade III in 12 patients and grade IV in 5 patients. Based on the Mayo Wrist Score, nine patients had excellent or good results, while six demonstrated fair results. The mean wrist flexion-extension arc was 109 degrees, while the mean grip strength was 82% of the unaffected side. Patients treated >1 year following injury had significantly decreased grip strength and Mayo Wrist Score. Conclusion In this study, worse results were seen in children with a protracted course prior to treatment of an SL injury. A high index of suspicion is necessary to detect an SL injury in the younger age group and should be in the differential for those with persistent dorsal wrist pain, tenderness over the dorsal SL joint, and/or positive Watson's test. MRI may assist in diagnosis but is not definitive to rule out injury. Arthroscopy is valuable to determine the extent of injury.

Thinking Outside the Operating Room: Guidance on Designing a Safe and Effective Minor Procedure Room.

The minor procedure room (MPR) offers numerous advantages over the traditional operating room for performing many common hand surgeries. MPRs require less space, are subject to more practical architectural design standards, and facilitate more judicious use of disposable materials and unnecessary instruments than common hand surgeries. MPRs reduce costs to the system and patient at every step of the surgical workflow and improve efficiency by removing preoperative and postoperative monitoring requirements. Hand surgeons sometimes face resistance when attempting surgery in MPRs, often because of confusion about their design characteristics and capabilities. This article aims to clarify many of the major requirements for establishing an MPR and provide a guide to hand surgeons for performing safe, efficient surgery outside the operating room.

A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach.

BACKGROUND: Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs. METHODS: We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs. RESULTS: A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity. CONCLUSIONS: The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.

Biomechanical, Histologic, and Micro-Computed Tomography Characterization of Partial-Width Full-Thickness Supraspinatus Tendon Injury in Rats.

PURPOSE: Partial rotator cuff tears can cause shoulder pain and dysfunction and are more common than complete tears. However, few studies examine partial injuries in small animals and, therefore a robust, clinically relevant model may be lacking. This study aimed to fully characterize the established rat model of partial rotator cuff injury over time and determine if it models human partial rotator cuff tears. METHODS: We created a full-thickness, partial-width injury at the supraspinatus tendon-bone interface bilaterally in 31 Sprague-Dawley rats. Rats were euthanized immediately, and at 2-, 3-, 4-, and 8-weeks after surgery. Fourteen intact shoulders were used as controls. Samples were assessed biomechanically, histologically, and morphologically. RESULTS: Biomechanically, load to failure in controls and 8 weeks after injury was significantly greater than immediately and 3 weeks after injury. Load to failure at 8 weeks was comparable to control. However, the locations of failure were different between intact shoulders and partially injured samples. Bone mineral density at 8 weeks was significantly greater than that at 2 and 3 weeks. Although no animals demonstrated propagation to complete tear and the injury site remodeled histologically, the appearance at 8 weeks was not identical to that in the controls. CONCLUSIONS: The biomechanical properties and bone quality decreased after the injury and was restored gradually over time with full restoration by 8 weeks after injury. However, the findings were not equivalent to the intact shoulder. This study demonstrated the limitations of the current model in its application to long-term outcome studies, and the need for better models that can be used to assess chronic partial rotator cuff injuries. CLINICAL RELEVANCE: There is no small animal model that mimics human chronic partial rotator cuff tears, which limits our ability to improve care for this common condition.