Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report.

Traumatic thumb injuries often result in significant functional disability. With segmental bone loss, reconstructive options include antibiotic cement with delayed bone graft, revision amputation with webspace deepening, metacarpal distraction osteogenesis, index pollicization, bone flap, and free toe transfer. We present a case of a subtotal thumb amputation just distal to the metacarpal phalangeal joint resulting in loss of both soft tissue and a segmental bone defect of the proximal and distal phalanx. Reconstruction was initially performed with a chimeric bone free flap from the medial femoral condyle with a vastus medialis muscle cuff to provide soft tissue coverage. A revision soft tissue coverage procedure was required and a radial forearm free flap was utilized. His reconstruction restored his missing bone and soft tissue, and provided stability with sufficient grip strength and metacarpophalangeal function resulting in a satisfactory functional outcome.

Femoral nerve decompression and sartorius-to-quadriceps nerve transfers for partial femoral nerve injury: a cadaveric study and early case series.

OBJECTIVE: Partial femoral nerve injuries cause significant disability with ambulation. Due to their more proximal and superficial location, sartorius branches are often spared in femoral nerve injuries. In this article, the authors report the benefits of femoral nerve decompression, demonstrate the feasibility of sartorius-to-quadriceps nerve transfers in a cadaveric study, describe the surgical technique, and report clinical results. METHODS: Four fresh-frozen cadaveric lower limbs were dissected for anatomical analysis of the sartorius nerve. In addition, a retrospective review of patients with partial femoral nerve injuries treated with femoral nerve decompression and sartorius-to-quadriceps nerve transfers was conducted. Pre- and postoperative knee extension Medical Research Council (MRC) grades and pain scores (visual analog scale) were collected. RESULTS: Up to 6 superficial femoral branches innervate the sartorius muscle just distal to the inguinal ligament. Each branch yielded an average of 672 nerve fibers (range 99-1850). Six patients underwent femoral nerve decompression and sartorius-to-quadriceps nerve transfers. Four patients also had concomitant obturator-to-quadriceps nerve transfers. At final follow-up (average 13.4 months), all patients achieved MRC grade 4-/5 or greater knee extension. The average preoperative pain score was 5.2, which decreased to 2.2 postoperatively (p = 0.03). CONCLUSIONS: Femoral nerve decompression and nerve transfer using sartorius branches are a viable tool for restoring function in partial femoral nerve injuries. Sartorius branches serve as ideal donors in quadriceps nerve transfers because they are expendable, are close to their recipients, and have an adequate supply of nerve fibers.

Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada.

BACKGROUND: Overprescribing following surgery is a known contributor to the opioid epidemic, increasing the risk of opioid abuse and diversion. Trainees are the primary prescribers of these medications at academic institutions, and little is known about the factors that influence their prescribing. The authors hypothesized that differences in health care funding and delivery would lead to disparities in opioid prescribing. Therefore, the authors sought to compare the prescribing practices of plastic surgery trainees in the United States and Canada. METHODS: A survey was administered to trainees at a sample of U.S. and Canadian institutions. The survey queried opioid-prescriber education, factors contributing to prescribing practices, and analgesic prescriptions written after eight procedures. Oral morphine equivalents were calculated for each procedure and compared between groups. RESULTS: One hundred sixty-two trainees completed the survey, yielding a response rate of 32 percent. Opioid-prescriber education was received by 25 percent of U.S. and 53 percent of Canadian trainees (p < 0.0001). Preoperative counseling was performed routinely by only 11 percent of U.S. and 14 percent of Canadian trainees. U.S. trainees prescribed significantly more oral morphine equivalents than Canadians for seven of eight procedures (p < 0.05). Residency training in the United States and junior training level independently predicted higher oral morphine equivalents prescribed (p < 0.05). CONCLUSIONS: U.S. trainees prescribed significantly more opioids than their Canadian counterparts for seven of eight procedures surveyed. Many trainees are missing a valuable opportunity to provide opioid counseling to patients. Standardizing trainee education may represent an opportunity to reduce overprescribing.

Patient Reported Outcomes Following Lower Extremity Soft Tissue Sarcoma Resection with Microsurgical Preservation of Ambulation.

BACKGROUND: Lower extremity soft tissue sarcoma treatment has evolved from primarily amputation procedures toward limb salvage. This series assesses whether soft tissue sarcoma tissue defects, extensive enough to require microsurgical reconstruction, can reliably result in preservation of ambulation, as well as objectively evaluate functional outcomes utilizing a patient-reported validated scale. It will also look at whether immediate functional muscle reconstructions and tendon transfers can be successful at restoring ambulation, potentially expanding the indications for limb salvage procedures. METHODS: A retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completed at our institution (2009-2013). Patients were additionally asked to complete the Toronto Extremity Salvage Score(TESS) quality of life survey. RESULTS: Over a 5-year period, 23 patients (mean age: 53 years) underwent free flap reconstructions for 23 sarcomas (mean follow-up: 14 months). Seventy-eight percent of patients received neoadjuvant radiation. The thigh was the most common tumor site (61%) and three muscles were resected on average. Perforator flaps were most frequently used (61%), and functional muscle transfers or immediate tendon transfers were used in four patients. There were no flap take-backs or failures, and 22 patients achieved independent ambulation. Three patients in the series died, two from metastatic disease found postoperatively and one from local recurrence. A 74% response rate was achieved for the TESS survey, with a mean score of 83. CONCLUSION: Microsurgical reconstruction of lower extremity sarcoma defects enables preservation of independent ambulation. Restoration of function utilizing immediate functional microsurgical reconstructions and tendon transfers should be considered.

Canadian Plastic Surgery Resident Work Hour Restrictions: Practices and Perceptions of Residents and Program Directors.

BACKGROUND: The impact of resident work hour restrictions on training and patient care remains a highly controversial topic, and to date, there lacks a formal assessment as it pertains to Canadian plastic surgery residents. OBJECTIVE: To characterize the work hour profile of Canadian plastic surgery residents and assess the perspectives of residents and program directors regarding work hour restrictions related to surgical competency, resident wellness, and patient safety. METHODS: An anonymous online survey developed by the authors was sent to all Canadian plastic surgery residents and program directors. Basic summary statistics were calculated. RESULTS: Eighty (53%) residents and 10 (77%) program directors responded. Residents reported working an average of 73 hours in hospital per week with 8 call shifts per month and sleep 4.7 hours/night while on call. Most residents (88%) reported averaging 0 post-call days off per month and 61% will work post-call without any sleep. The majority want the option of working post-call (63%) and oppose an 80-hour weekly maximum (77%). Surgical and medical errors attributed to post-call fatigue were self-reported by 26% and 49% of residents, respectively. Residents and program directors expressed concern about the ability to master surgical skills without working post-call. CONCLUSIONS: The majority of respondents oppose duty hour restrictions. The reason is likely multifactorial, including the desire of residents to meet perceived expectations and to master their surgical skills while supervised. If duty hour restrictions are aggressively implemented, many respondents feel that an increased duration of training may be necessary.

HISTORIQUE: L'effet des restrictions des heures de travail des résidents sur la formation et les soins aux patients est un sujet très controversé. Jusqu'à présent, il n'y a pas d'évaluations officielles de cette réalité chez les résidents canadiens en chirurgie plastique. OBJECTIF: Caractériser le profil des heures de travail des résidents canadiens en chirurgie plastique et évaluer les points de vue des résidents et des directeurs de programme à l'égard de l'effet des restrictions des heures de travail sur la compétence chirurgicale, le bien-être des résidents et la sécurité des patients. MÉTHODOLOGIE: Les auteurs ont préparé un sondage anonyme en ligne qu'ils ont transmis à tous les résidents et les directeurs de programme en chirurgie plastique au Canada. Ils ont synthétisé les statistiques de base. RÉSULTATS: Au total, 80 résidents (53 %) et dix directeurs de programme (77 %) ont répondu au sondage. Les résidents ont déclaré faire une moyenne de 73 heures de travail hospitalier par semaine, faire huit quarts de garde par mois et dormir 4,7 heures par nuit lorsqu'ils sont sur appel. La plupart d'entre eux (88 %) déclarent une moyenne de 0 journée de congé après une garde, et 61 % travaillent ensuite sans avoir dormi. La majorité désire pouvoir travailler après une garde (63 %) et s'oppose à un maximum hebdomadaire de 80 heures (77 %). Par ailleurs, 26 % des résidents précisent avoir fait des erreurs chirurgicales et 49 %, des erreurs médicales qu'ils attribuent à la fatigue accumulée après une garde. Les résidents et les directeurs de programme s'inquiètent de la capacité des résidents à maîtriser les habiletés chirurgicales s'ils ne travaillent pas après les gardes. CONCLUSIONS: La majorité des répondants s'opposent aux restrictions des heures de garde. La raison est probablement multifactorielle, y compris le fait que les résidents souhaitent répondre aux attentes perçues et maîtriser leurs habiletés chirurgicales pendant qu'ils sont sous supervision. Si les restrictions des heures de garde étaient vigoureusement adoptées, de nombreux répondants croient qu'il faudrait allonger la formation.

The proximal superficial femoral artery perforator flap: Anatomic study and clinical cases.

BACKGROUND: The upper thigh has provided multiple new soft tissue free flaps in recent decades, including the anterolateral thigh, anteromedial thigh, transverse upper gracilis, the profunda artery perforator, and superficial circumflex iliac perforator flaps. The purpose of this study is to describe a new, reliable free flap option in the upper thigh: the proximal superficial femoral artery perforator (p-SFAP) flap. METHODS: A cadaveric dissection study was performed to confirm clinical landmarks and evaluate pedicle characteristics. A retrospective review of patients who have received a p-SFAP free flap and surgical technique are described in detail. Eight patients (aged 27-85 years) underwent reconstruction with the p-SFAP flap involving six upper and two lower extremity defects. RESULTS: A consistent pedicle 6 to 8 cm in length was identified in all cadaveric and clinical limbs, emerging from under the lateral aspect of the sartorius muscle and entering the flap approximately 10 cm inferior and 4 cm medial to the anterior superior iliac spine. The perforator took origin off of the superficial femoral artery and femoral vein in all clinical cases. Arterial and venous diameters were 1.2-1.5 mm and 2.0-2.5 mm, respectively. There was one occurrence of partial flap necrosis and one case of complete flap loss. CONCLUSIONS: The p-SFAP flap represents a new, clinically relevant addition to the armamentarium of the reconstructive microsurgeon for use in small to medium sized defects. It can be harvested as a free flap and may have utility as a pedicled flap for groin and perineal reconstruction.

Fixation and Grafting After Limited Debridement of Scaphoid Nonunions.

PURPOSE: To evaluate a surgical technique of treating nondisplaced waist and proximal pole scaphoid nonunions without avascular necrosis (AVN). METHODS: We performed a retrospective review of all patients with nondisplaced, scaphoid waist or proximal pole nonunions without AVN treated with the following technique. Two K-wires are positioned along the scaphoid axis to stabilize the proximal and distal poles. Debridement with a curette or burr is performed parallel to the nonunion site until the K-wires are visualized and punctate bleeding of the proximal and distal fragments is encountered. The volar, radial fibrous union is left intact. Distal radius cancellous bone graft is packed into the nonunion site. A headless screw is placed perpendicular to the fracture and the K-wires are removed. RESULTS: Between 2012 and 2014, 12 patients (ages 13-29 y) with clinical and radiographic evidence (10 had computed tomography or magnetic resonance imaging; 2 had radiographs only) of scaphoid nonunion were identified (10 transverse waist and 2 proximal pole fractures). Median interval from injury to surgery was 38 weeks (range, 3 mo to 9 y). Four patients were active smokers and 2 had failed previous iliac crest bone grafting. All patients healed as confirmed by computed tomography. Average time to union was 14 weeks (range, 6-31 wk). Four patients had delayed union requiring a bone stimulator. All patients had resolution of pain and there were no complications. CONCLUSIONS: The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. We suggest that complete debridement of the nonunion is not essential to achieve union. In addition, pinning the proximal and distal scaphoid poles initially and maintaining the volar fibrous union of the scaphoid nonunion stabilizes the fracture fragments, increasing the technical ease of grafting and fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of synovial osteochondromatosis of the distal radioulnar joint with imaging features consistent with malignancy.

Synovial osteochondromatosis of the distal radioulnar joint is a rare entity with only 14 cases reported in the literature. Malignant transformation of synovial osteochondromatosis is the most worrisome complication of the disease. It has been described in joints such as the hip and knee but never for the distal radioulnar joint. We report a case of synovial osteochondromatosis of the distal radioulnar joint which presented with radiographic features which were worrisome for malignant transformation and required a comprehensive preoperative workup. Discussed are the preoperative management, surgical treatment, and a literature review of this rare disease.

Identifying self-perceived HIV-related stigma in a population accessing antiretroviral therapy.

This study identifies factors associated with self-perceived HIV-related stigma (stigma) among a cohort of individuals accessing antiretroviral therapy in British Columbia, Canada. Data were drawn from the Longitudinal Investigations into Supportive and Ancillary Health Services study, which collects social, clinical, and quality of life (QoL) information through an interviewer-administered survey. Clinical variables (i.e., CD4 count) were obtained through linkages with the British Columbia HIV/AIDS Drug Treatment Program. Multivariable linear regression was performed to determine the independent predictors of stigma. Our results indicate that among participants with high school education or greater the outcome stigma was associated with a 3.05 stigma unit decrease (95% CI: -5.16, -0.93). Having higher relative standard of living and perceiving greater neighborhood cohesion were also associated with a decrease in stigma (-5.30 95% CI: -8.16, -2.44; -0.80 95% CI: -1.39, -0.21, respectively). Lower levels of stigma were found to be associated with better QoL measures, including perceiving better overall function (-0.90 95% CI: -1.47, -0.34), having fewer health worries (-2.11 95% CI: -2.65, -1.57), having fewer financial worries (-0.67 95% CI: -1.12, -0.23), and having less HIV disclosure concerns (-4.12 95% CI: -4.63, -3.62). The results of this study show that participants with higher education level, better QoL measures, and higher self-reported standards of living are less likely to perceive HIV-related stigma.

Management of congenital midline cervical cleft.

Congenital midline cervical cleft (CMCC) is a rare developmental defect of the anterior neck normally characterized by an atrophic mucosal plaque with a cranial nipple-like skin tag, a short caudal sinus, and may be attached to a subcutaneous fibrous cord of variable length. Clinically, patients present at an early age with, white females being the most commonly affected population. In addition to aesthetic concerns, CMCC can prevent full extension of the neck, result in micrognathia and torticollis, predispose patients to infection, and can coexist with other clefting defects or cysts. Fewer than 50 cases have been published in the English-language literature. Herein, we report a case of CMCC that also presented with a mild contracture of the right sternohyoid muscle. The embryopathogenesis, histopathology, diagnosis, and treatment of this rare condition are also discussed.

Reconstructive or cosmetic plastic surgery? Factors influencing the type of practice established by Canadian plastic surgeons.

BACKGROUND: Some argue that the specialty of plastic surgery is facing a changing identity. Challenged by factors such as increasing competition in the cosmetic marketplace and decreasing reimbursement for reconstructive procedures, many American plastic surgeons have increasingly adopted cosmetic-focused practices. The present study investigated the currently unknown practice profiles of Canadian plastic surgeons to determine the reconstructive-cosmetic mix, as well as factors that influence practice type to determine whether a similar pattern exists in Canada. METHODS: An anonymous online survey regarding practice profiles was distributed to all 352 Canadian plastic surgeons with e-mail accounts registered with the Canadian Society of Plastic Surgeons and/or the Canadian Society for Aesthetic Plastic Surgery. RESULTS: The survey response rate was 34% (120 responses), of which 75% of respondents currently had a reconstructive practice and 25% had a cosmetic practice. Reconstructive surgeons had more educational debt following their training, spent more time on emergency call, academics and teaching and, when deciding which type of practice to establish, were more influenced by academic opportunities and less influenced by financial and nonfinancial metrics. Similarities between the groups included hours worked per week and academic achievements. CONCLUSIONS: The field of reconstructive plastic surgery appears to be thriving in Canada. While a transition from reconstructive to cosmetic practice is common, compared with their American colleagues, a greater proportion of Canadian plastic surgeons maintain reconstructive practices. Differences between reconstructive and cosmetic plastic surgeons are discussed.

HISTORIQUE: Certains prétendent que la spécialité de la chirurgie plastique subit un changement d'identité. Remis en question par des facteurs comme la concurrence croissante sur le marché de l'esthétique et le recul du remboursement des interventions reconstructives, de nombreux chirurgiens plasticiens américains se tournent vers une pratique de chirurgie esthétique. La présente étude portait sur le profil de pratique des chirurgiens plasticiens canadiens, jusqu'alors inconnu, afin de déterminer la combinaison entre la reconstruction et l'esthétique ainsi que les facteurs qui influent sur le type de pratique, de manière à d'établir si le Canada connaît une évolution similaire. MÉTHODOLOGIE: Les auteurs ont distribué un sondage virtuel anonyme au sujet des profils de pratique aux 352 chirurgiens plasticiens canadiens détenteurs d'une adresse de courriel auprès de la Société canadienne des chirurgiens plasticiens ou de la Société canadienne de chirurgie plastique et esthétique. RÉSULTATS: Le taux de réponse au sondage s'élevait à 34 % (120 réponses), dont 75 % avaient une pratique en reconstruction et 25 % en esthétique. Les chirurgiens reconstructeurs avaient une dette d'études plus élevée après leur formation, consacraient plus de temps aux appels d'urgence, aux tâches universitaires et à l'enseignement et, lorsqu'ils choisissaient leur type de pratique, étaient davantage influencés par les perspectives universitaires et moins par des calculs financiers et non financiers. Pour ce qui est des similarités entre les groupes, soulignons le nombre d'heures travaillées par semaine, les réalisations universitaires et le désir d'effectuer les interventions qu'ils préféraient. CONCLUSIONS: Le domaine de la chirurgie reconstructive semble prospère au Canada. Le passage d'une pratique de reconstruction à une pratique esthétique est courant, mais par rapport à leurs collègues américains, une plus forte proportion de chirurgiens plasticiens canadiens maintient une pratique reconstructive. Les différences et les similarités entre les chirurgiens plasticiens reconstructeurs et esthétiques sont exposées.

Management of pelvic heterotopic ossification post-myocutaneous flap reconstruction of a sacral pressure ulcer.

Heterotopic ossification (HO) is a process whereby lamellar bone forms in the soft tissues surrounding a joint. The most common type of HO is traumatic myositis ossificans, which develops following traumatic injuries, burns or arthroplasty. A variety of other forms of HO also exist, such as those associated with central nervous system injury and systemic forms that can manifest at other joints simultaneously. Clinically, patients can present with decreased range of motion, pressure ulcers, nerve compression, swelling, pain or asymptomatically. Symptomatic patients are most commonly treated with surgical debridement of the affected heterotopic deposits.Spinal dysraphism (SD) is a term describing a wide range of congenital malformations of the neural tube, ranging from spina bifida occulta to the more severe form, myelomeningocele. The cause of SD is multifactorial and has been associated with chromosomal disorders, teratogenic exposure and folate deficiency. Many patients with SD experience neuropathy below the affected neurological level, making them particularly susceptible to pressure ulcers. If these ulcers are severe and do not respond to conservative therapy, they often require surgical debridement and flap reconstruction - a clinical scenario that rarely results in HO.The present article describes a case involving a patient with pelvic HO following myocutaneous flap reconstruction of a pressure ulcer. The patient was successfully treated with oral bisphosphonate and aggressive physiotherapy.

Factors behind HIV testing practices among Canadian Aboriginal peoples living off-reserve.

The objective of this study was to examine factors associated with HIV testing among Aboriginal peoples in Canada who live off-reserve. Data were drawn for individuals aged 15-44 from the Aboriginal Peoples Survey (2001), which represents a weighed sample of 520,493 Aboriginal men and women living off-reserve. Bivariable analysis and logistic regression were used to identify factors associated with individuals who had received an HIV test within the past year. In adjusted multivariable analysis, female gender, younger age, unemployment, contact with a family doctor or traditional healer within the past year, and "good" or "fair/poor" self-rated health increased the odds of HIV testing. Completion of high-school education, rural residency, and less frequent alcohol and cigarette consumption decreased the odds of HIV testing. A number of differences emerged when the sample was analyzed by gender, most notably females who self-reported "good" or "fair/poor" health status were more likely to have had an HIV test, yet males with comparable health status were less likely to have had an HIV test. Additionally, frequent alcohol consumption and less than high-school education was associated with an increased odds of HIV testing among males, but not females. Furthermore, while younger age was associated with an increased odds of having an HIV test in the overall model, this was particularly relevant for females aged 15-24. These outcomes provide evidence of the need for improved HIV testing strategies to reach greater numbers of Aboriginal peoples living off-reserve. They also echo the long-standing call for culturally appropriate HIV-related programming while drawing new attention to the importance of gender and age, two factors that are often generalized under the rubric of culturally relevant or appropriate program development.

HIV/AIDS in Vancouver, British Columbia: a growing epidemic.

The prevalence of HIV in Vancouver, British Columbia was subject to two distinct periods of rapid increase. The first occurred in the 1980s due to high incidence among men who have sex with men (MSM), and the second occurred in the 1990s due to high incidence among injection drug users (IDU). The purpose of this study was to estimate and model the trends in HIV prevalence in Vancouver from 1980 to 2006. HIV prevalence data were entered into the UNAIDS/WHO Estimation and Projection Package (EPP) where prevalence trends were estimated by fitting an epidemiological model to the data. Epidemic curves were fit for IDU, MSM, street-based female sex trade workers (FSW), and the general population. Using EPP, these curves were then aggregated to produce a model of Vancouver's overall HIV prevalence. Of the 505 000 people over the age of 15 that reside in Vancouver, 6108 (ranging from 4979 to 7237) were living with HIV in the year 2006, giving an overall prevalence of 1.21 percent (ranging from 0.99 to 1.43 percent). The subgroups of IDU and MSM account for the greatest proportion of HIV infections. Our model estimates that the prevalence of HIV in Vancouver is greater than one percent, roughly 6 times higher than Canada's national prevalence. These results suggest that HIV infection is having a relatively large impact in Vancouver and that evidence-based prevention and harm reduction strategies should be expanded.