Monkeypox Presenting as a Hand Consult in the Emergency Department: Two Case Reports.

The ongoing outbreak of the monkeypox virus (now referred to as "mpox") was deemed a public health emergency by the World Health Organization in 2022. The United States now reports the highest number of mpox cases, with 29 980 cases and 21 deaths as of January 11, 2023. The most common presenting symptom is a pruritic, vesicular rash that commonly involves the hands. While covering hand call, our division has encountered 2 cases of mpox in the emergency department for which the chief complaint was a hand lesion. Because hand surgeons will be called upon to make an initial diagnosis, the purpose of these case reports is to describe the presentation, disease course, treatment, and outcomes of these mpox patients. These patients had both uncontrolled HIV as well as other sexually transmitted disease. Symptoms included painful vesicular hand lesions with ulceration and eventual central necrosis, followed by similar lesions on the face, trunk, and genital area. Diagnosis was made using nucleic acid amplification testing through polymerase chain reaction. The patients were treated with restoration of immunity through control of HIV as well as treatment of all secondary bacterial infections. One patient died in the hospital, and the other survived without any long-term defects.

Cross-institutional Virtual Mock Oral Examination: A New Paradigm?

Mock oral examinations (MOEs) are shown to be valuable in preparation for national board oral examinations. Although traditionally conducted in-person, improved technological advances have supported exploring virtual alternatives. Furthermore, the cornoavirus disease 2019 pandemic has necessitated virtual learning. We hypothesized that the virtual platform would improve and expand the MOE experience to include collaborative institutions while approximating a board examination environment. Methods: Sixteen senior plastic surgery residents and 14 faculty from three separate programs participated in a cross-institutional virtual MOE. Over a single day, each trainee was evaluated by two faculty from a separate institution on six scenarios, including digitally interactive photographs. Immediate postexamination debriefing with feedback was performed. All participants were subsequently invited to complete an anonymous survey regarding MOE experience, accuracy, and stress level, with responses graded on a Likert scale (1-5). Results: Twenty-three participants completed the survey, with 87% having prior MOE experience; however, only 26.1% of participants had virtual MOE experience. Most found the virtual platform more convenient (4.18 + 1.18; 5-far more convenient, 1-far less convenient) and less stressful (2.32 + 0.65; 5-far more stressful, 1-far less stressful) than in-person. All participants found the examination fair, and participants found the examination valuable (4.65 + 0.57) in preparing trainees for the American Board of Plastic Surgery oral examination. Conclusions: The majority of participants found the virtual MOE experience valuable and comparable to in-person. These results reinforce that a virtual MOE provides an acceptable alternative with greater convenience and improved cross-institutional collaborative efforts.

"Racing-stripe" Modification of Radial Forearm Free Flap: Technique and Experience (704 Consecutive Cases).

The radial forearm fasciocutaneous free flap (RFFF) has proven to be a versatile and reliable tool for the reconstructive microsurgeon when addressing soft-tissue defects. A significant drawback of the traditional RFFF is related to donor site morbidity and wound healing complications, especially when coverage of sizable defects is planned. The authors describe the "racing-stripe" modification of the RFFF (RS-RFFF) that involves harvesting a large segment of the deep forearm fascia with a narrow strip of skin overlying the radial vessels, thus allowing primary closure of the donor site. Methods: Retrospective chart review was conducted of a single surgeon's (E.G.M.) experience of patients who underwent RS-RFFF. Results: Seven hundred four RS-RFFFs were performed in 698 patients over a 19-year period (2000-2019) for lower extremity reconstruction (657 flaps, 93.3%), upper extremity reconstruction (32 flaps, 4.5%), and head and neck reconstruction (15 flaps, 2.1%). Wounds secondary to trauma were the most common reason for flap reconstruction (655 wounds, 93.8%). Five hundred four RS-RFFFs were used for soft-tissue defects of the foot (129 flaps, 18.3%), ankle (309 flaps, 43.9%), and heel (66 flaps, 9.4%; 27 of which provided coverage for Achilles tendon repair or exposure). There were three flap losses (0.4%). Limb salvage rate was 100% for extremity wounds. Forearm donor site wound complications were minimal. Conclusions: The RS-RFFF can be consistently and safely harvested and permits low-profile, reliable coverage of small-to-medium size soft-tissue defects. Primary closure of the donor site is possible in all cases, thus minimizing wound healing complications.

Use of the Adductor Magnus Muscle Free Flap for Lower-Extremity Soft Tissue Coverage: An Alternative to the Gracilis Muscle Flap With Unfavorable Vascular Anatomy.

BACKGROUND: The gracilis muscle free flap has proven to be a dependable tool for the reconstructive microsurgeon for coverage of small- to medium-sized lower-extremity soft tissue defects because of its reliable anatomy, ease of elevation, and minimal donor site morbidity. We describe our experience with the adductor magnus muscle free flap which we have utilized in cases when confronted with the rare situation in which the dominant vascular pedicle to the gracilis muscle is insufficient or absent. METHODS: We conducted a retrospective chart review of a single surgeon's experience (EG Melissinos) over an 18-year period of all patients that underwent adductor magnus muscle free flap coverage for lower-extremity soft tissue injuries. RESULTS: Twenty-four adductor magnus free flaps in 24 patients were performed over an 18-year period (2000-2018). All of the adductor magnus muscle free flaps were performed with the initial intention of gracilis muscle harvest for lower-extremity soft tissue coverage. The most common wound etiology was motor vehicle collisions (8 patients, 33%). All of the adductor magnus free flaps were used for coverage of lower-extremity wounds in the following anatomic locations: distal third (10 patients, 41.7%), ankle (11 patients, 45.8%) and foot (3 patients, 12.5%). All flaps were successful. There were minimal donor site complications. Limb salvage rate was 100%. CONCLUSIONS: Use of the adductor magnus muscle free flap is a reasonable alternative to the gracilis muscle in cases when unfavorable gracilis vascular anatomy is encountered intraoperatively. It can be easily and safely harvested within the same donor incision and permits reliable coverage of small- to medium-sized lower-extremity soft tissue defects while avoiding the morbidity of a secondary donor site.

Effect of Anemia in Postoperative Outcomes of Autologous Breast Reconstruction Surgery.

BACKGROUND: The true effects of anemia on postoperative surgical outcomes in autologous breast reconstruction surgery are unknown. We intended to evaluate the effect of chronic anemia on surgical outcomes in autologous breast reconstruction surgeries using a large national database. METHODS: Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed autologous breast reconstruction surgery from 2012 to 2014. Univariate and multivariate regression analyses were performed to independently evaluate the effect of chronic anemia on postoperative outcomes. RESULTS: Totally, 55,839 patients underwent autologous breast reconstruction surgery (immediate: 40% vs. delayed: 60%) during this period. Overall, 6.0% of patients had chronic anemia at the time of surgery. Compared with patients without chronic anemia, patients with chronic anemia had a significantly higher complication rate (19.8% vs. 9.4%) and a longer mean length of hospital stay (5.4 vs. 3.7 days). Postoperative complications were significantly higher in patients with chronic anemia compared with patients without chronic anemia except for venous thromboembolism (VTE) and fat necrosis. Multivariate regression analyses demonstrated that chronic anemia was independently associated with an increased overall complication rate (adjusted odds ratio: 2.20). Also, multivariate regression analyses showed that chronic anemia was an independent risk factor of all the evaluated postoperative complications except VTE, stroke and fat necrosis. CONCLUSION: This study demonstrated that chronic anemia was a significant predictor factor of morbidity in autologous breast reconstruction including flap failure. Correction of anemia prior to breast reconstruction may help reduce poor surgical outcomes related to chronic anemia.

Predictors of blood transfusion in autologous breast reconstruction surgery: A retrospective study using the nationwide inpatient sample database.

BACKGROUND: Specific risk factors associated with the use of blood transfusions during and following autologous breast reconstruction are unknown. The purpose of this study was to evaluate the rate of blood transfusion in autologous breast reconstruction and identify independent risk factors of blood transfusion in autologous breast reconstruction. MATERIALS: A cohort of patients who had undergone autologous breast reconstruction was identified using the Nationwide Inpatient Sample database from 2012 to 2014 in the United States. Univariate and multivariate regression analyses were performed to identify independent risk factors of blood transfusion in this patient population. RESULTS: A total of 55,840 patients underwent autologous breast reconstruction surgery during this period. The overall rate of blood transfusion was 7.0%. Multivariate regression analysis showed that chronic anemia (adjusted odds ratio [AOR], 5.17), congestive heart failure (AOR, 4.07), free flap (AOR, 2.03), chronic kidney disease (AOR, 1.79), hypertension (AOR, 1.39), chronic lung disease (AOR, 1.23), diabetes mellitus (AOR, 1.21), non-teaching hospital (AOR, 1.20), and obesity (AOR, 1.12) were significant risk factors of blood transfusion. There was no association between age, race, liver disease, smoking, chemotherapy, or reconstruction-time on blood transfusion. Patients who received blood transfusion had a significantly higher overall complication rate, longer length of hospital stay, and higher costs than patients who did not receive blood transfusion. CONCLUSIONS: The rate of blood transfusion in autologous breast reconstruction is noticeable (7.0%). Improved awareness of these common risk factors can allow surgeons to identify patients with higher risk to attempt to mitigate complications.

Frequency and Predictors of 30-Day Surgical Site Complications in Autologous Breast Reconstruction Surgery.

BACKGROUND: Surgical site complication (SSC) is one of the known complications following autologous breast reconstruction. The aim of this study was to evaluate the frequency and predictors of 30-day surgical site complications in autologous breast reconstruction. METHODS: American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database was used to identify patients who underwent autologous breast reconstruction during 2011-2015. Multivariate regression analysis was performed to identify independent perioperative risk factors of SSC. RESULTS: Totally, 7,257 patients who underwent autologous breast reconstruction surgery were identified. The majority of the procedures were free flap (60%) versus pedicled flap (40%). The mean age was 51 years and the majority of patients were classified as American Society of Anesthesiologists (ASA)-II (60%) and 15% of patients had BMI>35. The overall 30-day SSC rate was 6.3%. The overall frequency of different types of SSC were superficial incisional infection (3.2%), wound dehiscence (1.8%), deep incisional infection (1.4%) and organ space infection (0.6%). BMI>35 (adjusted odds ratio [AOR]=2.38), smoking (AOR=2.0), diabetes mellitus (AOR=1.67) and hypertension (AOR=1.38) were significant risk factors of SSC. There was no association with age, ASA classification, steroid use, or reconstruction type. CONCLUSION: The rate of 30-day SSC in autologous breast reconstruction was noticeable. The strongest independent risk factor for SSC in autologous breast reconstruction was BMI>35. The type of autologous breast reconstruction was not a predictive risk factor for SSC. Plastic surgeons should inform patients about their risk for SSC and optimizing these risk factors to minimize the rate of surgical site complications.

Congenital aneurysm of the palmar digital artery: A case report and literature review.

Spontaneous arterial aneurysms of the hand are uncommon but are well-described in the adult population. In the pediatric population, however, congenital or true aneurysms of the hand are exceptionally rare. A case report and a literature review were performed for published cases of arterial aneurysms of the hand in the pediatric population. A 13-month-old child presented with an aneurysm of the common digital artery and underwent surgical excision without need for reconstruction. Literature review found 13 documented cases. Patient characteristics and management strategies were summarized. There are very few documented cases of hand arterial aneurysms in the pediatric population, with our patient being the third youngest ever reported. No cases were associated with hereditary disease, and aneurysm excision was performed in all cases. Our report highlights the need to include arterial aneurysm in a differential diagnosis when evaluating a pediatric patient with a palpable hand mass.