Thin Profunda Artery Perforator Flap for Hand and Upper Extremity Coverage.

The profunda artery perforator (PAP) flap provides a good option for hand and upper extremity reconstruction. The reliable quality, caliber, and number of perforators in the posteromedial thigh support large flaps with long pedicles. The PAP flap has been widely used for breast reconstruction, although its use in the extremities has been slower to catch on due to the bulk and thickness of the subcutaneous tissue. The authors discuss evolution of thin flaps and our application of the thin and superthin PAP flap for upper extremity reconstruction.

Comparison of Aesthetic Outcomes of Epidermal Staples vs Sutures in Deep Epigastric Perforator Flap Breast Reconstruction.

Background: A secondary benefit of abdominally based autologous breast reconstruction may be improving the abdominal contour; however, poor scaring can lead to aesthetic dissatisfaction and complications. Although studies have demonstrated favorable aesthetic results and decreased operative time using dermal or subcuticular stapling (Insorb), no reports exist regarding epidermal stapling. Objectives: The aim of this study is to compare the aesthetic abdominal scar outcomes, closure time, and postoperative complications of abdominally based breast reconstruction patients who have undergone suture closure vs epidermal staple closure. Methods: A total of 217 patients who underwent abdominally based autologous breast reconstruction from 2011 to 2022 were included and retrospectively analyzed (staples = 41, suture = 176). Twenty-four patients' postoperative abdominal scar photographs were randomly chosen (staples = 12, sutures = 12) and assessed by 3 board-certified plastic surgeons using a modified patient observer scar assessment scale (POSAS) and visual analog scale (VAS). Closure time (minutes per centimeter) using staples or sutures was also analyzed. Results: The assessment of abdominal scars closed by epidermal staples revealed significant improvements in thickness (P = .033), relief (P = .033), surface area (P = .017), overall opinion (P = .033), POSAS score (P = .034), and VAS scar score (P = .023) in comparison with scars closed by sutures. Closing the abdominal wound with staples was significantly faster than closing with sutures (P < .0001). Staple and suture closure had similar postoperative complication rates. Conclusions: Abdominal donor-site scar quality may be superior and faster using the epidermal staple compared to traditional suture closure.

Hardware Salvage in the Lower Extremity after Flap Coverage: 10-Year Single Center Outcomes Analysis.

An unanswered question with open tibial fractures is whether the type of flap used affects hardware retention. Flap survival may not equate hardware retention or limb salvage. In this study, we performed a 10-year single institution review and analysis of all patients who had placement of hardware for open tibial fractures followed by flap coverage. Methods: Inclusion criteria consisted of patients who underwent pedicled or free flap coverage of Gustilo IIIB or IIIC tibial fractures requiring open reduction and internal fixation. Outcomes and complications were statistically analyzed based on flap type. Flap type was stratified into free versus pedicled flaps and muscle versus fasciocutaneous flaps. Primary outcome measures included hardware failure and infection requiring hardware removal. Secondary outcome measures included limb salvage, flap success, and fracture union. Results: Overall primary outcome measures were better for pedicled flaps (n = 31), with lower rates of hardware failure and infection (25.8%; 9.7%) compared with free flaps (n = 27) (51.9%; 37.0%). Limb salvage and flap success was not different comparing pedicled and free flaps. There was no significant difference in outcomes between muscle and fasciocutaneous flaps. Multivariable analysis showed that patients who had free versus pedicled flaps or muscle versus fasciocutaneous flaps had a higher chance of hardware failure. A formal orthoplastic team was established in the period from 2017 to 2022, after which flap numbers were higher and hardware failure less for pedicled and fasciocutaneous flaps. Conclusions: Pedicled flaps were associated with lower rates of hardware failure and infection requiring hardware removal. A formal orthoplastic team improves hardware-related outcomes.

Optimizing needle length and site choice for adult immunization.

BACKGROUND: Current recommendations for needle length and vaccination site for intramuscular deltoid vaccinations are backed by minimal data. AIM: To determine the ideal needle length and vaccination site for intramuscular deltoid vaccine administration. METHODS: 120 shoulder CT scans were evaluated and grouped by patient weight and sex as recommended by the United States CDC: Group 1, <60 kg, Group 2, 60-70 kg, Group 3, females 70-90 kg and males 70-118 kg, and Group 4, females > 90 kg and males > 118 kg. For each group, distance from skin to deltoid fascia and deltoid muscle width were measured at 2, 4, and 6 cm distal to the posterolateral corner of the acromion for 5 unique trajectories. Needle lengths of 0.625″, 1.0″, and 1.5″ were simulated at each site to determine inoculation location relative to the deltoid. RESULTS: For Group 1, a 0.625″ needle in the mid-lateral (ML) trajectory 4 cm distal to the posterolateral corner provided a perfect rate of successful inoculations (100 %). For Groups 2-3, a 1″ needle in the posterolateral (PL) trajectory 4 cm distal provided high rates (>80 %) of successful intramuscular inoculations with low rates of overpenetration (<15 %) while minimizing risk to the axillary nerve. For Group 4, a 1.5″ needle using the same strategy provided the highest rate of successful inoculations (96 %) and minimal overpenetration (4 %). Overpenetration was associated with more anterior and superior injection sites (P < 0.001 for both) for all needle lengths. CONCLUSIONS: The overall ideal injection site to maximize successful intramuscular vaccine administration, minimize overpenetration, and avoid axillary nerve injury is 4 cm distal to and in line with the posterolateral corner of the acromion, a site more posterior and inferior than current CDC recommendations. We caution against use of a 1.5″ needle for patients < 118 kg due to high predicted rates of overpenetration.

Prevalence of antimicrobial resistance in urine, blood, and wound pathogens among rural patients in Karnataka, India.

Background and objective: Antimicrobial resistance (AMR) is increasing in tertiary-care hospitals across India, which consumes more antibiotics than any other country. Microorganisms with novel resistance mechanisms, initially isolated in India, are now recognized worldwide. Until now, most efforts to stem AMR in India have focused on the inpatient setting. Ministry of Health data now suggest that rural areas are playing a more significant role in the pathogenesis of AMR than was previously appreciated. Thus, we conducted this pilot study to ascertain whether AMR is common in pathogens causing infections acquired in the wider rural community. Methods: We performed a retrospective prevalence survey of 100 urine, 102 wound, and 102 blood cultures obtained from patients who were admitted to a tertiary-care facility in Karnataka, India, with infections acquired in the community. The study population included patients >18 years of age who (1) were referred to the hospital by primary care doctors, (2) had a positive blood, urine, or wound culture, and (3) were not previously hospitalized. Bacterial identification and antimicrobial susceptibility testing (AST) were carried out on all isolates. Results: Enterobacteriaceae were the most common pathogens isolated from urine and blood cultures. Significant resistance to quinolones, aminoglycosides, carbapenems, and cephalosporins was noted among pathogens isolated from all cultures. Specifically, high resistance rates (>45%) to quinolones, penicillin, and cephalosporins were evident among all 3 types of culture. Among blood and urinary pathogens, there were high resistance rates (>25%) to both aminoglycosides and carbapenems. Conclusion: Efforts to stem AMR rates in India need to focus on rural populations. Such efforts will need to characterize antimicrobial overprescribing practices, healthcare-seeking behaviors, and antimicrobial use in agriculture in rural settings.