The Impact of Microsurgery on the Treatment of Ring Avulsion Injuries.

BACKGROUND: Treating ring avulsion injuries continues to challenge the reconstructive hand surgeon. The complex operation draws from plastic surgery and orthopedic surgery principles to provide soft-tissue coverage, skeletal fixation, tendon repair, and neurovascular reconstruction. Furthermore, the application of microsurgical techniques has enabled the revascularization and replantation of completely avulsed fingers. METHODS: A retrospective review of 22 consecutive ring avulsion injuries (seven amputations, five replantations, and 10 revascularizations) from 1987 to 2015 performed by a single senior surgeon (D.T.W.C.) was conducted. RESULTS: Of these 22 ring avulsions, 10 revascularizations, five replantations, and seven amputations (five because of clinical factors, and two because of patient request) were performed. None of the 15 replantations and revascularizations resulted in loss of the ring finger or necrosis of the revascularized tip. CONCLUSIONS: With proper patient selection, appropriate level of injury identification, and meticulous surgical execution, the restoration of form and function to the hand is feasible in ring avulsion injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparative Accuracy of Clinical and Formula-Based Estimation of Resection Weight in Reduction Mammoplasty and Implications for Insurance Preapproval and Payment.

INTRODUCTION: Insurance companies use minimum resection weight, sometimes based on body surface area (Schnur sliding scale), as a criterion for preapproval and ultimately coverage of reduction mammoplasty. The purpose of this study is to compare the accuracy of subjective resection estimates and estimates calculated by published formulae versus measured resection weights, and to explore the impact of these estimates on insurance preauthorization and payment. METHODS: A retrospective chart review of bilateral reduction mammaplasties performed at a single academic medical center by seven plastic surgeons from January 2011 to December 2017 was performed. Patients undergoing oncoplastic reduction, simultaneous additional body-contouring procedures, or lacking complete data were excluded. A total of 762 patients were reviewed. Absolute and relative errors between preoperative estimate and actual resection weights were calculated. A subset of patients with requisite breast measurements (n = 579) was examined to compare formula-based with clinical estimates of resection weights. RESULTS: Median error was 105 g (14% normalized by resection weight). Frequency of underestimation (40.5%) and overestimation (55.7%) were similar. In 19% (n = 291) of reduced breasts, resection estimate was less than the Schnur requirement. For 5 (2.8%) of these patients, insurers denied coverage explicitly for this reason. Our surgeons' positive predictive value of estimate > Schnur was 86.6%. In 23% (n = 352) of breasts, resection was < Schnur requirement. No insurance claim was denied a posteriori due to resection weight less than Schnur. The formula proposed by Appel et al. produced the most accurate estimates, and is the most likely to produce an estimate < Schnur in nonobese women. Correlations between each surgeon's relative errors and years of faculty experience (r < 0.07) and number of reduced breasts (r = 0.0275) were very weak. CONCLUSIONS: Resection estimate accuracy varies among surgeons and does not appear to be affected by experience. Because insurers use resection estimates to determine preauthorization, this could be problematic, particularly for surgeons tending to underestimate. However, insurers are inconsistent in application of the Schnur requirement once surgery has been preapproved and its validity as a determinant of medical necessity is in question.

Freeze-cast Porous Chitosan Conduit for Peripheral Nerve Repair.

A novel freeze-cast porous chitosan conduit for peripheral nerve repair with highly-aligned, double layered porosity, which provides the ideal mechanical and chemical properties was designed, manufactured, and assessed in vivo. Efficacies of the conduit and the control inverted nerve autograft were evaluated in bridging 10-mm Lewis rat sciatic nerve gap at 12 weeks post-implantation. Biocompatibility and regenerative efficacy of the porous chitosan conduit were evaluated through the histomorphometric analysis of longitudinal and transverse sections. The porous chitosan conduit was found to have promising regenerative characteristics, promoting the desired neovascularization, and axonal ingrowth and alignment through a combination of structural, mechanical and chemical cues.

The Diagnosis and Management of Mallet Finger Injuries.

BACKGROUND: Mallet finger is a common injury of the extensor tendon insertion causing an extension lag of the distal interphalangeal joint. METHODS: We reviewed the most current literature on the epidemiology, diagnosis, and management of mallet finger injuries focusing on the indications and outcomes of surgical intervention. RESULTS: Nonoperative management has been advocated for almost all mallet finger injuries; however, complex injuries are usually treated surgically. There is still controversy regarding the absolute indications for surgical intervention. CONCLUSIONS: Although surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface as well as in all patients who develop volar subluxation of the distal phalanx, a significant advantage of surgical management even in those complicated cases has yet to be clearly proven.

Methods in obtaining split-thickness skin grafts from skin reduction surgery specimens.

BACKGROUND: To devise a method for obtaining bacterial culture-negative split-thickness skin grafts from specimens removed from living donors undergoing skin reduction surgery. METHODS: Specimens were obtained from patients undergoing abdominal skin reduction surgery in inpatient and outpatient surgical settings. Skin specimens were cleaned in a method adapted from the former Yale Skin Bank's methods. The specimens were attached to the autoclave container for the dermatome using towel clips or sutures to provide tension. Normal saline clysis was injected subdermally and a Padgett Electric Dermatome was used to obtain skin grafts. These were then photographed and discarded. RESULTS: Eight specimens were obtained from seven women and one man. The mean age was 46.6 years and mean weight at time of surgery was 87.7 kg. Bacterial cultures obtained from all specimens were negative. All procured grafts were transparent, with visible dermis, suggesting that they could be used in a clinical setting. CONCLUSION: Bacterial culture-negative split-thickness skin grafts can be obtained from skin reduction surgery specimens, offering a potential source of split-thickness allograft during regional or national shortages.

Benjamin Alcock and the pudendal canal.

The anatomy of the pudendal nerve is complex and difficult to visualize. Entrapment of the pudendal nerve is believed to occur in a canal, the pudendal canal or Alcock's canal, yet in the literature this term is used to refer to several different anatomic locations. We present a brief history of Benjamin Alcock, and we compare Alcock's original description of the pudendal canal with our findings from a cadaveric study. It is concluded that Alcock's canal for the pudendal nerve, as Alcock described it related to the pudendal artery, should be that portion of the pudendal nerve within the obturator internus fascia. This definition now permits future medical and surgical approaches to use the appropriate terminology for this anatomic location.