Single-specialty management and reconstruction of necrotizing fasciitis of the upper extremities: clinical and economic benefits from a case series.

PURPOSE: Patients with necrotizing fasciitis are managed with multiple prompt, radical surgical debridements and critical care support. Debridement and reconstruction are often provided by different surgical teams. Anecdotally, single-specialty management seemed to be a more efficient management strategy. This study aimed to investigate and compare the outcomes of management by plastic surgery versus multiple disciplines through a retrospective economic and clinical analysis of patients with necrotizing fasciitis treated over 8 years. We also present 3 index cases for which our service functioned as the primary management team. METHODS: Necrotizing fasciitis cases evaluated and treated by our department, covering both Level I and Level II Trauma Centers, were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. The admission Acute Physiology and Chronic Health Evaluation II score was calculated for each patient. Three comparative index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail. RESULTS: Patients managed primarily by the plastic surgery service had equivalent Acute Physiology and Chronic Health Evaluation II scores to patients managed by multiple services for their necrotizing fasciitis, with the average score higher for patients managed by plastic surgery alone. In a case-matched series of upper extremity necrotizing fasciitis, the patients admitted directly to plastic surgery had shorter average lengths of hospital and ICU stays as well as decreased total number of procedures, resulting in decreased average total hospital charges. There were no amputations among the cases treated primarily by the plastic surgery. The patients also required smaller areas of reconstruction with skin grafting despite large initial areas of debridement compared to those whose reconstructive teams differed from the team performing the debridement. CONCLUSIONS: Improved economic and clinical outcomes-as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting-may be attainable when the surgeon eventually performing the reconstruction is involved early in management. We propose that, in the interest of improving patient care, a closer collaboration should be established between the reconstructive and primary managing teams.

Surgical Reconstruction for the Triphalangeal Thumb.

The triphalangeal thumb poses a complex reconstructive challenge to the congenital hand surgeon due to its rarity and variable anatomy. We discuss the available evidence, reporting clinical characteristics and outcomes of surgical reconstructive procedures of triphalangeal thumb alongside a representative case. The congenital hand surgeon must approach each patient with triphalangeal thumb individually to optimize the use of available tissues to maximize functional and aesthetic outcomes.

Vascularized Fibular Epiphyseal Transfer for Pediatric Limb Salvage: Review of Applications and Outcomes.

Vascularized fibular epiphyseal transfer (VFET) offers a functional advantage in pediatric limb salvage due to the preservation of growth potential and an articular surface for remodeling. This review summarizes the available evidence on the clinical characteristics and outcomes of pediatric reconstruction applying VFET at different recipient sites and with varying techniques. VFET was used to reconstruct the proximal humerus, distal radius or ulna, proximal femur, distal fibula, calcaneus, and mandible. Although most often harvested on the anterior tibial artery, VFET has also been performed using the peroneal artery, the inferior lateral genicular artery, and a dual pedicle. Recipient site flap inset most often involved fixation with plates and/or screws as well as soft tissue reconstruction using a retained slip of biceps femoris tendon. Outcomes included limb growth, range of motion, and strength. The most common reported complications were bone flap fracture and peroneal nerve palsy. The anterior tibial artery was the most applied pedicle with reliable limb growth, but with the added risk of postoperative peroneal palsy. Bone flap fracture most often occurred at the proximal humerus and femur recipient sites. Plate fixation and the combined use of allograft had lower instances of bone flap fracture. This review highlights how the anticipated dynamic growth and remodeling this free flap offers in the long term must be weighed against its complexity and potential complications.

Microsurgical Needle Retention Does Not Cause Pain or Neurovascular Injury in a Rat Model.

Approximately 20% of retained foreign bodies are surgical needles. Retained macro-needles may become symptomatic, but the effect of microsurgical needles is uncertain. We present the first animal model to simulate microsurgical needle retention. Given a lack of reported adverse outcomes associated with macro-needles and a smaller cutting area of microsurgical needles, we hypothesized that microsurgical needles in rats would not cause changes in health or neurovascular compromise. Methods: Male Sprague-Dawley rats (x̄ weight: 288.9 g) were implanted with a single, 9.0 needle (n = 8) or 8.0 needle (n = 8) orthogonal to the right femoral vessels and sutured in place. A control group (n = 8) underwent sham surgery. Weekly, a cumulative health score evaluating body weight, body condition score, physical appearance, and behavior for each rat was determined. Infrared thermography (°C, FLIR one) of each hindlimb and the difference was obtained on postoperative days 15, 30, 60, and 90. On day 90, animals were euthanatized, hindlimbs were imaged via fluoroscopy, and needles were explanted. Results: The mean, cumulative health score for all cohorts at each weekly timepoint was 0. The mean temperature difference was not significantly different on postoperative days 15 (P = 0.54), 30 (P = 0.97), 60 (P = 0.29), or 90 (P = 0.09). In seven of eight rats, 8.0 needles were recovered and visualized on fluoroscopy. In six of eight rats, 9.0 needles were recovered, but 0/8 needles were visualized on fluoroscopy. Conclusions: Microsurgical needle retention near neurovascular structures may be benign, and imaging for needles smaller than 8.0 may be futile. Further studies should explore microsurgical needle retention potentially through larger animal models.

Bilateral Calcaneus Transfers for the Treatment of Congenital Tibial Deficiencies: A Novel Surgical Technique and Case Report.

Tibial deficiency (also known as tibial hemimelia) is a rare condition with variable presentation. A 2-month-old patient presented with absent bilateral tibias. When the patient was 1 year, a novel reconstructive surgery was done. A bilateral fibular resection with pedicled calcaneus transfer was done, allowing for transfer of the calcaneus along with the overlying glabrous skin and soft tissues to the end of the femur. The patient was permitted to weight-bear after the 4-week postoperative follow-up. At the six-month follow-up, the patient was able to pull to stand and walk with assistance without any reports of pain.

Predictors of Patient Satisfaction in Hand and Upper Extremity Clinics.

Introduction Patient satisfaction is an important clinical marker for hand/upper extremity patients. Few studies have investigated the predictors of patient satisfaction in the clinic setting. Our objective was to analyze patient satisfaction surveys to explore factors that influence patient satisfaction. Materials and Methods We conducted a retrospective analysis assessing patient satisfaction in the hand/upper extremity clinics at our university medical center between 2012 and 2018. Patient satisfaction was assessed via Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Patient demographics, satisfaction scores, and clinic experience questionnaire responses were evaluated. Statistical analysis was conducted to identify significant trends. Results Between 2012 and 2018, 102 surveys were completed. Scores ranged from 5 to 10 with an average provider rating of 9.56. We found six factors significantly influenced patient satisfaction: adequate time was spent with the provider, provider showed respect, patient was seen by provider within 15 minutes of appointment time, provider listened sufficiently, patient received understandable medical instructions, and understandable medical explanations ( p < 0.05). Conclusion Achieving patient satisfaction is an important clinical marker in hand/upper extremity clinics. Patient satisfaction has defined predictors wherein various clinical factors can influence patient satisfaction and willingness to refer their provider to other patients.