The International Medical Graduate Perspective in Hand Surgery: Legacy and Future Challenges.

International medical graduates (IMGs) have made significant contributions in the field of hand surgery in terms of bringing in skill, innovation, research, and leadership and have gone onto mentor the next generations of hand surgeons. In this article, we have highlights some such contributions. We also highlight various pathways that IMGs take to establish their practice in the United States and the various challenges and hurdles they face.

Spontaneous Midsubstance Rupture of the Flexor Digitorum Profundus Tendon of the Long Finger.

Closed flexor tendon injuries can often result from trauma that causes sudden forceful extension of an actively flexed digit. These closed tendon injuries commonly occur as avulsions in flexor zone I. Spontaneous midsubstance flexor tendon ruptures are rare, especially in the absence of an underlying pathology. Diagnosing such injuries accurately is challenging and critical. We present a case of a zone III spontaneous flexor tendon rupture of the long finger after forceful eccentric loading. Surgical exploration was performed, and the level of the rupture was identified during surgery. A side-to-side tendon repair technique was performed using a palmaris longus tendon graft. No underlying pathology to explain the rupture was found in this case. This report emphasizes the importance of considering spontaneous midsubstance ruptures, identifying the level of ruptures, and preoperative planning for such cases. It reviews the possible causes and treatment of spontaneous flexor tendon rupture.

Use of Integra® as a Temporizing Measure Before Definitive Flap Surgery in Mangled Extremities Requiring Revascularization.

Complex palm defects with devascularized digits often require vein grafts. This may need to be followed by a free or pedicled flap to resurface the tissue lost and also cover the vein grafts and the anastomosis. However, if the anastomosis fails, or there is marginal wound necrosis, the existing flap would be redundant and a different flap would be needed for coverage. In such situations, a novel approach would be to temporarily cover the anastomotic site with Integra® (Integra LifeScience Corporation, Plainsboro, NJ), until the digit and skin margin vascularity stabilize. This technique can be used to buy time and potentially lessen the need for pedicled or free flap coverage in the first instance. This should be taken into consideration as a viable alternative during revascularization in such cases. In this case report, we present two cases in which we used Integra® as a temporary cover over exposed vein grafts until vascularization was established and a more definitive flap coverage was done. We were able to place the flap directly over the Integra®. This allowed time to determine additional necrosis of the wound margins and the final size of the defect that required coverage. Other advantages of this technique are that Integra® is readily available, there is no donor site morbidity, and the silicone layer which is not directly in contact with the vein graft can be easily peeled off without any traction. A flap or skin graft can be done directly over the collagen layer of the Integra®. Also, having a collagen layer integrated over the vein graft can potentially obviate the need for a flap.

Icing the Muffin (Sponge): An Easily Reproducible and Cost-Effective Dressing Technique Used for Nipple Areola Reconstruction.

Nipple areola reconstruction is an integral part of breast reconstruction and serves as the "cherry on top" of the reconstructed breast. These delicate tissues need protection and stabilization. There are many techniques to dress skin grafts and the NAC. The ideal NAC dressing should not be bulky and should stent the nipple. Having less bulk enables the patient to wear a bra immediately after the procedure to reduce edema. We have developed a dressing for nipple areola reconstruction which has all these qualities and more. This is a very cost-effective, fast, and easy to perform technique. There have been no adverse outcomes, and it can be accomplished within a few minutes.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Impact of the COVID-19 Pandemic on the Practice of Hand and Upper Extremity Surgeons.

Objective The purpose of this study was to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the practice of hand and upper extremity surgeons. Methods We assessed how the pandemic affected the practice on multiple fronts including professional, personal, and practice aspects. The survey was conducted through an online questionnaire that had six sections: demographics, clinic, elective surgery, emergency surgery, urgent surgery, and human resources. The survey was sent to 586 Kleinert Society members who are all practicing hand and upper extremity surgeons. Results We received 35 responses from the United States and 53 from the rest of the world. Based on our findings, the clinic volume was reduced by >50% in the early stages, subsequently returning to a level that was 25-50% lower than pre-COVID-19 times in later stages. A corresponding decrease in elective surgeries was also noted. The need for preoperative COVID-19 tests added to the logistics of surgery, causing delays of three to six hours for emergency cases and >24 hours for urgent cases. The hand surgeons witnessed multiple furloughs, layoffs, and even COVID-19 infections among nursing and support staff. Most hand surgeons continued to perform urgent and emergency surgeries during the pandemic. The application of telemedicine was not popular and had multiple drawbacks. Hand surgeons are modifying their practice by adopting measures such as social distancing, reducing the clinic volume, and using personal protective equipment (PPE). Conclusions As COVID-19 is likely to prevail for the foreseeable future, these measures are here to stay. The initial reduction in the clinic and elective volume has improved but has not reached pre-COVID-19 levels, suggesting a slow recovery. As reopening measures will lead to more people rejoining employment, subsequently, more patients with hand-related conditions are likely to present to the clinics. Rapid COVID-19 testing and supply of PPEs will play a crucial role in the near future to enable hand surgeons to continue their service while taking care of their personal health.

The bilobed flap - a better option for soft tissue release in the management of Radial Club Hand.

OBJECTIVE: To establish that the bilobed flap as soft tissue release component for the radial club hand is superior to the z-plasty technique in type III and IV radial club hands. METHODS: This study was conducted at the Shifa International Hospital, Islamabad, Pakistan, from 2009 to 2015, and comprised patients with radial club hands operated by a single consultant plastic surgeon. Soft tissue release was performed at 08 months. The extremity was then casted for 08 weeks and kept in a long-arm cast for 3 to 6 months. RESULTS: Twelve radial club hands of 9 patients treated successfully during the study period showed good to excellent results. Z-plasty was used on the radial side to correct the soft tissue deficiency in 5(42%) hands, and a bilobed flap in 7(58%) hands for soft tissue rearrangement on the radial side. Of all hands, 1(8.3%) z-plasty flap developed partial flap necrosis and 1(8.3%) each developed infection and needed implant (Kirschner wire removal), which were dealt with efficiently with no long-term sequelae. CONCLUSIONS: The bilobed flap was found to be superior to the z-plastytechnique since the flap had better predictability and no tissue was wasted.

Congenital alveolar synechiae with cleft palate.

Congential maxillomandibular fusion or jaw adhesions is a rare entity. It is often associated with other congenital anomalies like cleft palate and is characterized by restricted mouth opening. This unusual presentation of congenital alveolar synechiae is highlighted in a 15 days old baby boy. Under inhalational anaesthesia his fibrocartilagenous adhesions were excised and endotracheal tube was then placed. Good recovery without any residual scars or adhesions and a 25 mm mouth opening was achieved.

Schwannoma of the brachial plexus; report of two cases involving the C7 root.

Brachial plexus schwannomas are rare tumors. They are benign nerve sheath tumors and only about 5% of Schwannoma arise from the brachial plexus. They pose a great challenge to surgeons due to their rare occurrence and complex anatomical location. We present two cases who presented with a supraclavicular swelling, that were proven to be schwannoma on histopathology.