Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review.

BACKGROUND: The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature. METHODS: An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns. RESULTS: Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure. CONCLUSION: This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate.

Port-Site Metastasis Identified on Prostate-Specific Membrane Antigen-Targeted 18 F-DCFPyL PET/CT After Robot-Assisted Laparoscopic Radical Prostatectomy.

ABSTRACT: Port-site metastasis is an extremely rare complication following minimally invasive oncologic surgery for prostate cancer. We present the case of a 74-year-old man who underwent robot-assisted laparoscopic radical prostatectomy followed by salvage radiotherapy. Despite treatment, he developed biochemical recurrence. However, there was no evidence of disease on CT and bone scan at a prostate-specific antigen of 4.6 ng/mL. Subsequently, 18 F-DCFPyL PET/CT revealed a solitary focus of intense uptake in the right rectus abdominis muscle that was felt to represent a port-site metastasis. Histopathologic evaluation with immunostaining following ultrasound-guided needle biopsy confirmed the presence of metastatic adenocarcinoma of the prostate.

Prospective Multicenter Randomized Controlled Trial Comparing Early Protected Movement and Splinting for Fifth Metacarpal Neck Fracture.

BACKGROUND: Fifth metacarpal neck fractures account for 20% of all hand fractures, yet there remains debate with respect to management, particularly when conservative treatment is initiated. The objective of this study is to compare functional and patient-reported outcomes (PROs) in patients treated with early protected movement or splint immobilization. METHODS: This national multicenter prospective randomized controlled trial compared 2 groups; elastic bandage with early protected movement versus immobilization with splinting. Demographic characteristics were collected at baseline. Functional outcomes (grip strength testing) and PROs (Brief Michigan Hand Questionnaire [bMHQ]) were collected at 4, 8, and 12 weeks post-intervention. Grip strength values of the injured hand were normalized to both the non-injured hand (at baseline), and the Canadian reference values. RESULTS: Thirty-seven participants from 5 Canadian centers were randomized into the splint (n = 21) or elastic bandage group (n = 16). There were no significant differences in the bMHQ score between the splint (52.1 ± 27.2) or the elastic bandage (46.6 ± 20.4) groups (P = .51). There were no differences in baseline grip strength between the splint (15.3 ± 8.9 kg) and elastic bandage (19.9 ± 7.5 kg) groups. At 8 weeks, the elastic bandage group had a significantly higher grip strength than the splint group (93% vs 64%, respectively: P < .05), when standardized as a percentage of the Canadian reference values. CONCLUSION: Patients with Boxer's fractures treated with early protected movement had better functional outcomes by 8 weeks post-treatment as compared to the Canadian reference values of those treated with immobilization and splinting. Providers should manage Boxer's fractures with early protected movement.

RENSEIGNEMENTS GÉNÉRAUX: Les fractures du col du cinquième métacarpien représentent 20 % de toutes les fractures de la main, mais leur prise en charge ne fait pas l'unanimité, en particulier lorsqu'un traitement classique est instauré. L'objectif de cette étude consiste à comparer les résultats fonctionnels et les résultats déclarés par le patient traité au moyen d'une protection contre le mouvement instaurée de manière précoce ou d'une attelle pourimmobilization. MÉTHODOLOGIE: Cet essai multicentrique, national, prospectif, contrôlé et mené à répartition aléatoire a comparé 2 groupes recevant les traitements suivants: un bandage élastique et une protection contre le mouvement instaurée de manière précoce, d'une part, et une attelle pourimmobilization, d'autre part. Les caractéristiques démographiques ont été recueillies au début de l'étude. Les résultats fonctionnels (épreuve de force de préhension) et les résultats déclarés par le patient (questionnaire bMHQ [Brief Michigan Hand Questionnaire], question bref de Michigan portant sur les mains) ont été recueillis 4, 8 et 12 semaines après l'intervention. Les valeurs de la force de préhension de la main blessée ont été normalisées en fonction à la fois de la main non blessée (au départ) et des valeurs de référence canadiennes. RÉSULTATS: Trente-sept participants de cinq centres canadiens ont été répartis aléatoirement dans le groupe traité au moyen d'une attelle (n = 21) ou celui traité par un bandage élastique (n = 16). Aucune différence significative sur le plan du score bMHQ n'a été observé entre les groupes traité au moyen d'une attelle (52,1 ± 27,2) ou d'un bandage élastique (46,6 ± 20,4; P = .51). Il n'y avait aucune différence au chapitre de la force de préhension initiale entre le groupe traité au moyen d'une attelle (15,3 ± 8,9 kg) et celui traité par un bandage élastique (19,9 ± 7,5 kg). Après huit semaines, le groupe traité par un bandage élastique présentait une force de préhension significativement plus élevée que celle du groupe traité au moyen d'une attelle (93 % contre 64 %, respectivement: P < .05), après la normalizationdes valeurs en pourcentage par rapport aux valeurs de référence canadiennes. CONCLUSION: Les patients subissant une « fracture du boxeur ¼ traités au moyen d'une protection contre le mouvement instaurée de manière précoce obtenaient de meilleurs résultats fonctionnels huit semaines après le traitement, vis-à-vis des valeurs de référence canadiennes, que ceux traités par une attelle pourimmobilization. Les professionnels de la santé devraient donc prendre en charge les fractures de boxeur au moyen d'une protection contre le mouvement instaurée de manière précoce.

Identifying the top research priorities in postmastectomy breast cancer reconstruction: a James Lind Alliance priority setting partnership.

BACKGROUND: Major improvements in breast cancer treatment in the last decade include advancements in postmastectomy breast reconstruction (PMBR). Unfortunately, the studies in PMBR are primarily researcher or industry led with minimal input from patients and caregivers. The aim of this study is to use the James Lind Alliance (JLA) approach to bring together the patients, caregivers and clinicians in a priority setting partnership to identify the most important unanswered research questions in PMBR. METHODS: The JLA priority setting methodology involved four key stages: gathering research questions on PMBR from patients, caregivers and clinicians; checking these research questions against existing evidence; interim prioritisation and a final consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology. RESULTS: In stage 1, 3168 research questions were submitted from 713 respondents across Canada, of which 73% of the participants were patients or caregivers. Stage 2 confirmed that there were a total of 48 unique unanswered questions. In stage three, 488 individuals completed the interim prioritisation survey and the top 25 questions were taken to a final consensus meeting. In the final stage, the top 10 unanswered research questions were determined. They cover a breadth of topics including personalised surgical treatment, safety of implants and newer techniques, access to PMBR, breast cancer recurrence and rehabilitation. INTERPRETATION: Identification of the top 10 unanswered research questions is an important first step to generating relevant and impactful research that will ultimately improve the PMBR experience for patients with breast cancer.

Complete reversibility of pembrolizumab-induced eosinophilic fasciitis without corticosteroids: A case report.

Checkpoint inhibitor immunotherapy has recently started to play a fundamental role in the management of metastatic melanoma. It is however accountable for many undesirable adverse effects involving many organ systems. Eosinophilic fasciitis is a rare immune-related adverse effect associated to checkpoint inhibitors such as pembrolizumab and nivolumab. We report the case of a 25-year-old male who received pembrolizumab as a second-line therapy for metastatic melanoma. Approximately 8 months after starting the treatment, the patient developed signs and symptoms of eosinophilic fasciitis, including edema of his hands and lower legs, as well as joint limitation. Pembrolizumab was discontinued after 15 cycles because of symptom progression. The patient experienced complete resolution of symptoms 4 months after cessation of pembrolizumab and without corticosteroids. This case illustrates the reversibility of this immune adverse effect by discontinuation of the treatment, speculating that corticotherapy may not be needed in all cases.

Prospective Clinical Trial Comparing Curettage and Cryosurgery to Curettage and Electrodesiccation in the Management of Minimally Invasive Basal and Squamous Cell Carcinomas [Formula: see text].

BACKGROUND: Basal and squamous cell carcinomas represent the most common cancers in North America. Their management is an important issue. OBJECTIVES: The evaluation of cure rates of minimally invasive cutaneous carcinomas with curettage-cryosurgery compared to curettage-electrodesiccation, as well as the assessment of the aesthetic appearance of scars. METHODS: This prospective trial randomized 117 patients 1:1 to treatments of curettage-cryosurgery or curettage-electrodesiccation. They were then followed at 6, 12, 18, and 24 months. RESULTS: At 12-month follow-up, only one (1/49) patient had a recurrence of cutaneous carcinoma in the curettage-cryosurgery group and none (0/43) in the curettage-electrodesiccation group. Farrington-Manning analysis with a 5% margin of error showed the non-inferiority of the first method (P = .04). For the aesthetic appearance of scars after 12 months, better results with curettage-cryosurgery procedure has been observed, but this was not statistically significant (P = .80 and P = .27 for evaluations of patients and clinicians respectively). LIMITATIONS: This study was mainly limited by its small sample size. CONCLUSION: We have demonstrated that curettage-cryosurgery compared to curettage-electrodesiccation for the treatment of minimally invasive carcinomas is noninferior (comparable) with regards to cure rates at 12-month follow-up. No significant difference has been demonstrated for the appearance of scars.

Feasibility of Implementing a Breast Reconstruction Database.

OBJECTIVE: To assess whether implementing a breast reconstruction database would be feasible in terms of time commitment, cost, and overall benefits in a tertiary-care hospital. METHODS: A survey was sent to 40 Canadian plastic surgeons who have a practice focused on breast reconstruction. The survey assessed demographics, practice characteristics, database use, and opinions on database construction. Univariate descriptive analyses were performed on all variables. RESULTS: Thirty-one surgeons responded to the survey (77.5%). Most were from Ontario (29.1%) and worked in an academic center (83.9%). Of all, 45.3% of surgeons performed more than 50 breast reconstructions yearly. Six (19.4%) surgeons utilized databases that were all started for quality improvement and research purposes. Databases included variables such as demographics, type of reconstruction, complications, surgeons involved, and type of implants. Data are input by research assistants (50%) for approximately 4.2 hours per month at a cost below 200$CAD per month. Databases are funded by research grants (50%), hospital funds (33.3%), and/or division funds (16.7%). Of the surgeons without databases, 60% have considered starting a database. Barriers include being too busy (72%) and impressions of the cost being too high (32%). Surgeons commonly felt that a database would be beneficial at their practice (80%), provincially (77.4%), and nationally (67.7%). CONCLUSIONS: Plastic surgeons are open to the idea of constructing a breast reconstruction database and that the costs and time required are lower than expected. Grants or integration with existing databases should be pursued on a provincial level first prior to pursuing a national database.

OBJECTIF: Évaluer s'il est possible de créer une base de données de reconstruction mammaire dans un hôpital de soins tertiaires, compte tenu du temps, du coût et des avantages globaux. MÉTHODOLOGIE: Quarante plasticiens canadiens dont la pratique est axée sur la reconstruction mammaire ont reçu un sondage, qui évaluait les données démographiques, les caractéristiques de la pratique, l'utilisation de bases de données et les opinions sur la construction d'une base de données. Les chercheurs ont procédé à des analyses descriptives univariées à l'égard de toutes les variables. RÉSULTATS: Trente et un chirurgiens (77,5 %) ont répondu au sondage. La plupart provenaient de l'Ontario (29,1 %) et travaillaient dans un centre universitaire (83,9 %). Ainsi, 45,3 % des chirurgiens effectuaient plus de 50 reconstructions mammaires par année. Six chirurgiens (19,4 %) utilisaient des bases de données qui avaient toutes été lancées pour favoriser l'amélioration de la qualité et la recherche. Ces bases de données incluent des variables comme les données démographiques, le type de reconstruction, les complications, les chirurgiens en cause et le type d'implants. Les données sont saisies par des assistants de recherche (50 %) qui s'y consacrent environ 4,2 heures par mois, à un coût mensuel inférieur à 200 $CAD. Les bases de données sont subventionnées par des bourses de recherche (50 %), les fonds des hôpitaux (33,3 %) ou les fonds des divisions (16,7 %). De plus, 60 % des chirurgiens ne disposant pas d'une base de données avaient envisagé d'en lancer une. Les obstacles incluaient le fait d'être trop occupé (72 %) et l'impression que le coût serait trop élevé (32 %). Les chirurgiens avaient souvent l'impression qu'une base de données serait utile pour leur pratique (80 %), leur province (77,4 %) et le pays (67,7 %). CONCLUSIONS: Les plasticiens sont ouverts à l'idée de créer une base de données de reconstruction mammaire, et les coûts et le temps nécessaire sont moindres que prévu. Il faudrait chercher à obtenir des subventions ou à intégrer cette base de données à une base de données déjà en place à l'échelle provinciale avant d'en envisager une nationale.

Donor Site Morbidities of Iliac Crest Bone Graft in Craniofacial Surgery: A Systematic Review.

BACKGROUND: The iliac crest bone graft (ICBG) is criticized for high donor site morbidity. Recent research suggests this morbidity is related to the patient population for which the ICBG is harvested. This systematic review is the first to delineate the type and incidence of ICBG donor site complications in craniofacial surgery. METHODS: Two independent reviewers conducted a systematic review of multiple databases (MEDLINE, EMBASE, CINAHL, PEDRO, and Cochrane Central Register of Controlled Trials) from 1917 to 2017. All studies utilizing the ICBG for craniofacial indications were included. Donor site morbidities, including immediate and chronic pain, hematoma, seroma, infection, hypertrophic/painful scarring, nerve injury, muscle herniation, iliac crest fracture, and gait disturbance, were recorded. A weighted incidence for each morbidity, excluding immediate pain, was calculated. An average visual analog scale score was calculated for immediate pain. RESULTS: Forty-four studies, with 2801 patients, were included. Oral and maxillofacial (50%) and cleft reconstruction (40%) were the primary indications for surgery. Average immediate pain visual analog scale scores on postoperative days 1 and 14 were 6.3 and 1.3, respectively. The incidence of donor site morbidities was as follows: acute (45.7%) and chronic (1.5%) gait disturbance, acute (17.8%) and chronic nerve changes (1.4%), hypertrophic/painful scar (9.1%), chronic pain (3.1%), hematoma (2.2%), seroma (2.0%), infection (1.0%), iliac crest fracture (1.2%), and muscle herniation (0%). CONCLUSIONS: Chronic morbidity was lower than previously documented. Rare chronic morbidity illustrates that the ICBG remains a viable surgical option. The authors hope this review will facilitate surgical planning and informed consent.

Pyoderma Gangrenosum of the Breast After Mastopexy.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare, inflammatory, noninfectious skin disorder that is idiopathic in nature; however, it may occur as a rare complication of breast surgery. The mainstay of treatment is medical immunosuppression. CASE REPORT: This report describes the case of a 46-year-old woman who developed PG of both breasts following bilateral reduction mammoplasty and mastopexy. She was managed with a combination of medical immunotherapy and full-thickness skin grafts, which resulted in successful wound healing. CONCLUSIONS: This patient's positive outcome illustrates the use of skin grafts in combination with medical immunotherapy in the setting of PG. This approach, which differs from the common method of treating solely with medical immunotherapy, may provide a quicker and more satisfying result for the patient.

Undergraduate Plastic Surgery Education: A National Survey of Clerkship Directors.

BACKGROUND: The delivery of medical education has received increased attention in recent years due to ongoing time and financial constraints faced by medical educators. Given the recent calls to action by the Carnegie Foundation and Health Canada, an evaluation of the specialty education sector is warranted. To our knowledge, this is the first assessment of the Canadian plastic surgery undergraduate clerkship curriculum. METHOD: An anonymous electronic survey was distributed to the plastic surgery clerkship directors of all Canadian medical schools (N = 17). The survey consisted of Likert scales and open-ended short answer questions. Themes included general clerkship information, exposure characteristics, teaching characteristics, resource characteristics, and challenges and barriers faced by clerkship directors. RESULTS: Survey response rate was 88%. All responding schools offered a clerkship rotation of varying length in time (1-4 weeks). Students had the most exposure to breast surgery (100%) and general plastic surgery (100%) and the least exposure to aesthetic surgery (40%). Sixty percent of schools indicated the use of modern educational methods. Resources available for teaching students varied. Rotations received excellent feedback from medical students (67%). More than half of respondents would like to see a universal, nationally formulated plastic surgery clerkship curriculum. CONCLUSION: There is significant heterogeneity in the delivery of plastic surgery clerkship in Canada. A number of areas for improvement have been identified. We hope to establish a national plastic surgery clerkship task force to address the concerns raised here and improve the delivery of undergraduate medical education. Assessment of students based on a national curriculum may help in decision-making regarding plastic surgery program admissions by introducing an element of standardization to clerkship exposure.

HISTORIQUE: L'enseignement de la médecine retient davantage l'attention ces dernières années en raison des contraintes de temps et d'argent qu'affrontent les professeurs. Dans la foulée des récents appels à l'action lancés par la Fondation Carnegie et Santé Canada, une évaluation de l'enseignement des spécialités s'impose. En autant que les auteurs le sachent, il s'agit de la première évaluation du programme canadien de stages de premier cycle en chirurgie plastique. MÉTHODOLOGIE: Les directeurs de stage en chirurgie plastique (n=17) de toutes les écoles de médecine du Canada ont reçu un sondage électronique anonyme, formé d'échelles de Likert et de questions ouvertes aux réponses courtes. Les questions traitaient des renseignements généraux sur le stage, des volets auxquels les étudiants étaient exposés, des caractéristiques de l'enseignement, des caractéristiques des ressources et des difficultés et obstacles qu'affrontaient les directeurs de stage. RÉSULTATS: Le taux de réponse au sondage s'élevait à 88 %. Toutes les écoles répondantes offraient des stages de durées variées (de une à quatre semaines). Les étudiants étaient plus exposés à la chirurgie mammaire (100 %) et à la chirurgie plastique générale (100 %) et moins exposés à la chirurgie esthétique (40 %), et 60 % des écoles indiquaient utiliser des modes d'enseignement modernes. Les ressources offertes pour l'enseignement variaient. Les étudiants en médecine donnaient d'excellents commentaires sur les stages (67 %). Plus de la moitié des répondants aimeraient disposer d'un programme de stage national et universel en chirurgie plastique. CONCLUSIONS: Au Canada, les stages en chirurgie plastique sont très hétérogènes. Plusieurs secteurs à améliorer sont ressortis. Les auteurs espèrent créer un groupe de travail national sur les stages en chirurgie plastique pour étudier les préoccupations soulevées et améliorer l'enseignement de la médecine au premier cycle. L'évaluation des étudiants d'après un programme national pourrait contribuer à la prise de décision lors des admissions en chirurgie plastique, car elle ajouterait une certaine standardisation des stages.

Autologous Latissimus Dorsi Breast Reconstruction Flap Salvage: Microvascular Anastomosis with Serratus Branch.

Autologous breast reconstruction has become a standard option during the recovery of breast cancer survivors. Although pedicle damage is a rare complication of this procedure, extensive torsion or tension can lead to partial or total flap failure. We report a case of partial flap salvage after accidental transection of the pedicled blood supply within the intramuscular course of a latissimus dorsi musculocutaneous flap. This salvage technique involved microvascular anastomosis between the remaining vasculature of the latissimus dorsi pedicle and the serratus branch of the thoracodorsal artery and vein.

Women's Experiences With Flap Failure After Autologous Breast Reconstruction: A Qualitative Analysis.

Clinical experience suggests that flap failure after autologous breast reconstruction can be a devastating experience for women. Previous research has examined women's experiences with autologous breast reconstruction with and without complications, and patients' experiences with suboptimal outcomes from other medical procedures. The authors aimed to examine the psychosocial experience of flap failure from the patient's perspective. Seven women who had experienced unilateral flap failure after deep inferior epigastric perforator flap surgery in the past 12 years completed semistructured interviews about their breast cancer treatments, their experiences with flap failure, the impact of flap failure on their lives, and the coping strategies they used. Interpretive phenomenological analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences and their meanings, was used to analyze the interview data. From these data, patient-derived recommendations were developed for surgeons caring for women who have experienced flap failure. Three main themes (6 subthemes) emerged: coming to terms with flap failure (coping with emotions, body dissatisfaction); making meaning of flap failure experience (questioning, relationship with surgeon); and care providers acknowledging the emotional experience of flap failure (experience of being treated "mechanically," suggestions for improvement). In conclusion, flap failure in breast reconstruction is an emotionally difficult experience for women. Although there are similarities to other populations of patients experiencing suboptimal outcomes from medical procedures, there are also unique aspects of the flap failure experience. A better understanding of women's experiences with flap failure will assist in providing more appropriate supports.

The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study.

BACKGROUND: Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors' objective was to determine whether providing a pamphlet would improve patients' ability to remember the risks of surgery. METHODS: Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source. RESULTS: There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01). CONCLUSIONS: Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients' ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Generalized Recalcitrant Pruritus as the Presenting Manifestation of Hypereosinophilic Syndrome.

BACKGROUND AND OBJECTIVE: Pruritus is a frequent occurrence in dermatology, and investigation is often unrevealing. The authors report the case of a 65-year-old man presenting with generalized recalcitrant pruritus as the presenting manifestation of hypereosinophilic syndrome. METHODS AND RESULTS: A 65-year-old man developed intractable pruritus. Results of polymerase chain reaction clonal rearrangement were positive and led to the diagnosis and treatment. The patient also developed massive pulmonary embolism, which can be caused by chronic eosinophilia. CONCLUSIONS: This case highlights the importance of investigating patients with pruritus and unexplained persistent eosinophilia. Hypereosinophilic syndrome must be included in the differential diagnosis, which in this case presented initially as intractable pruritus. Polymerase chain reaction clonal rearrangement was key in reinforcing the diagnosis.

Is it true that injecting palmar finger skin hurts more than dorsal skin? New level 1 evidence.

BACKGROUND: Since the first texts on local anesthesia were written in the early 1900s, it has been widely quoted and believed that dorsal finger skin is less sensitive to needlestick pain than volar finger skin. The result is that the most commonly used finger block for local anesthesia is the dorsal two injection technique. METHODS: In this study, the needlestick discomfort associated with dorsal and volar finger skin was compared in a group of 78 volunteers who had the long finger of both hands poked with a 25 G needle; one in the midline of the volar side and the other in the lateral web space of the dorsal side. Volunteers then completed a pain scale for each needlestick and ranked which technique they would prefer for future injections. RESULTS: We found that there was no significant difference in needlestick pain or preference of future needle location between the dorsal and volar aspects of the finger. CONCLUSIONS: We provide level 1 evidence that the needlestick of the SIMPLE block which has one needlestick on the volar side of the finger is not more painful than the needlestick of the dorsal finger block.

Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.

BACKGROUND: Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. METHODS: This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. RESULTS: One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. CONCLUSIONS: A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.

A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.

BACKGROUND: Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. METHOD: A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. RESULTS: In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. CONCLUSION: The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.