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OBJECTIVE: Spinal cord stimulation (SCS) is effective for relieving chronic intractable pain conditions. The Dorsal spInal cord STImulatioN vs mediCal management for the Treatment of low back pain study evaluates the effectiveness of SCS compared with conventional medical management (CMM) in the treatment of chronic low back pain in patients who had not undergone and were not candidates for lumbar spine surgery. METHODS AND MATERIALS: Patients were randomized to passive recharge burst therapy (n = 162) or CMM (n = 107). They reported severe pain and disability for more than a decade and had failed a multitude of therapies. Common diagnoses included degenerative disc disease, spondylosis, stenosis, and scoliosis-yet not to a degree amenable to surgery. The six-month primary end point compared responder rates, defined by a 50% reduction in pain. Hierarchical analyses of seven secondary end points were performed in the following order: composite responder rate (numerical rating scale [NRS] or Oswestry Disability Index [ODI]), NRS, ODI, Pain Catastrophizing Scale responder rate, Patient Global Impression of Change (PGIC) responder rate, and Patient-Reported Outcome Measure Information System-29 in pain interference and physical function. RESULTS: Intention-to-treat analysis showed a significant difference in pain responders on NRS between SCS (72.6%) and CMM (7.1%) arms (p < 0.0001). Of note, 85.2% of those who received six months of therapy responded on NRS compared with 6.2% of those with CMM (p < 0.0001). All secondary end points indicated the superiority of burst therapy over CMM. A composite measure on function or pain relief showed 91% of subjects with SCS improved, compared with 16% of subjects with CMM. A substantial improvement of 30 points was observed on ODI compared with a Asunto(s)
Dolor Crónico
, Dolor de la Región Lumbar
, Estimulación de la Médula Espinal
, Humanos
, Dolor de la Región Lumbar/terapia
, Dolor de la Región Lumbar/psicología
, Resultado del Tratamiento
, Estudios Prospectivos
, Dolor de Espalda
, Estimulación de la Médula Espinal/métodos
, Dolor Crónico/diagnóstico
, Dolor Crónico/terapia
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BACKGROUND: Spinal cord stimulation is a well-established modality for the treatment of chronic intractable pain. The safety and efficacy of various stimulation therapy designs have been demonstrated in multiple randomized controlled studies, oftentimes comparing an investigational device to an existing commercial therapy. In the real-world setting, data are lacking regarding selection of spinal cord stimulation (SCS) therapy, as waveform, pulse trains, and programming are not interchangeable among the devices. The purpose of this study is to help dissect a methodology for a patient centric multisystem trialing. METHODS: We conducted a single center, retrospective, open label observational chart review. Between June 2017 and June 2019, 83 patients underwent SCS trials. Devices from four commercially available systems were trialed. Patients were given the opportunity to trial up to three systems. If the patient reported 50% or more pain relief/functional improvement with the trial, they were able to choose which system they liked best and proceed with implantation. RESULTS: There were 82% (68/83) of patients who proceeded to permanent implant, with 72 patients electing to trial more than one stimulation paradigm. Of those, 62 trialed 2 SCS systems, whereas 11 trialed 3. During the SCS trials, loss of efficacy due to lead migration was 1.2% (1/83) and no infections occurred. The average pain score measured on the numeric pain rating scale (NRS), improved from 6.8 at baseline to 2.9 after implantation. CONCLUSIONS: Multisystem trialing is safe and effective in providing patients increased exposure to multiple commercially available SCS systems.
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Dolor Crónico , Estimulación de la Médula Espinal , Dolor Crónico/terapia , Humanos , Manejo del Dolor , Estudios Retrospectivos , Médula Espinal , Resultado del TratamientoRESUMEN
BACKGROUND: Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release. METHODOLOGY: A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes. RESULTS: The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003). CONCLUSIONS: Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.
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Hipoglucemia/complicaciones , Cuidados Preoperatorios/métodos , Infección de la Herida Quirúrgica/prevención & control , Trastorno del Dedo en Gatillo/cirugía , Glucemia/análisis , Femenino , Glucosa/uso terapéutico , Humanos , Hipoglucemia/sangre , Hipoglucemia/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Trastorno del Dedo en Gatillo/complicacionesRESUMEN
BACKGROUND: Highly cited publications are referred to as citation classics and can signify important contributions to a discipline. Although citation classics in plastic surgery have been identified, none were published before 1960. Citation classics in earlier periods may contain the historical roots or intellectual origins of the field. We set out to identify such scholarly works and analyze their characteristics. METHODS: A novel technique of citation analysis, referred to as reference publication year spectroscopy, was used to analyze the literature. The spectrogram revealed distinct peaks before 1960, which corresponded to 20 citation classics. These 20 references were then analyzed with respect to historical context, topic of interest, anatomical region, originality, and if authors were named for their findings (eponyms). RESULTS: Twenty distinct citation classics (published from 1851 to 1959) were identified, accounting for 430 literature citations. Salmon's "Arteres de la Peau" was the most cited reference, followed by Gillies' "Principles of Plastic Surgery" and Neuber's "Fat Grafting." The theme of angiosomes was highly represented. Most citation classics dealt with reconstruction of acquired defects (37%) and primarily focused on the head and neck regions (45%). Thirty-five percent of clinical studies were noted for their originality, and 5 studies earned their authors' eponymous distinctions. CONCLUSION: The roots of modern plastic surgery began in the late 19th century with early efforts to describe cutaneous vasculature. Historical studies that either establish principles or lead to an advancement in our reconstructive methods have the best chance of achieving classical status.
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Factor de Impacto de la Revista/historia , Publicaciones Periódicas como Asunto/historia , Procedimientos de Cirugía Plástica/historia , Cirugía Plástica/historia , Historia del Siglo XX , Humanos , EdiciónRESUMEN
INTRODUCTION: Regenerative peripheral nerve interfaces (RPNIs) are biological constructs which amplify neural signals and have shown long-term stability in rat models. Real-time control of a neuroprosthesis in rat models has not yet been demonstrated. The purpose of this study was to: a) design and validate a system for translating electromyography (EMG) signals from an RPNI in a rat model into real-time control of a neuroprosthetic hand, and; b) use the system to demonstrate RPNI proportional neuroprosthesis control. METHODS: Animals were randomly assigned to three experimental groups: (1) Control; (2) Denervated, and; (3) RPNI. In the RPNI group, the extensor digitorum longus (EDL) muscle was dissected free, denervated, transferred to the lateral thigh and neurotized with the residual end of the transected common peroneal nerve. Rats received tactile stimuli to the hind-limb via monofilaments, and electrodes were used to record EMG. Signals were filtered, rectified and integrated using a moving sample window. Processed EMG signals (iEMG) from RPNIs were validated against Control and Denervated group outputs. RESULTS: Voluntary reflexive rat movements produced signaling that activated the prosthesis in both the Control and RPNI groups, but produced no activation in the Denervated group. Signal-to-Noise ratio between hind-limb movement and resting iEMG was 3.55 for Controls and 3.81 for RPNIs. Both Control and RPNI groups exhibited a logarithmic iEMG increase with increased monofilament pressure, allowing graded prosthetic hand speed control (R2 = 0.758 and R2 = 0.802, respectively). CONCLUSION: EMG signals were successfully acquired from RPNIs and translated into real-time neuroprosthetic control. Signal contamination from muscles adjacent to the RPNI was minimal. RPNI constructs provided reliable proportional prosthetic hand control.
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Miembros Artificiales , Electromiografía/métodos , Regeneración Nerviosa , Procesamiento de Señales Asistido por Computador , Animales , Miembro Posterior/inervación , Masculino , Movimiento/fisiología , Músculo Esquelético/fisiología , Regeneración Nerviosa/fisiología , Nervios Periféricos/fisiología , RatasRESUMEN
BACKGROUND: Facial rejuvenation is an elective procedure commonly performed to combat the consequences of normal aging. The senior author's practice initially consisted of traditional facelifts with superficial muscular apopneurotic system plication and/or superficial muscular apopneurotic system flap. After the development of the minimal access cranial suspension (MACS) technique by Tonnard et al., the senior author transitioned to an almost exclusive MACS facelift practice. The purpose of this study was to determine the efficacy of the MACS technique versus the traditional facelift approach and objectively incorporate these results into practice. METHODS: A retrospective cohort study design was performed to identify all patients who underwent a facelift by the senior author between January 1, 2013, and December 31, 2015. Patient demographics, comorbidities, type of procedure, complications, revision surgery, and objective surgeon satisfaction were among the parameters recorded. This was compared with an historical cohort of the senior author's earlier experience. RESULTS: There was a statistically significant decrease in the use of the MACS facelift procedure between this study and the senior authors' seminal study. Within this study cohort, compared with conventional facelift, the MACS technique was done on younger patients, proved to have significantly shorter operative time, mean follow up, and allowed for additional concurrent non-facial procedures when compared with the traditional approach (all comparisons significant at P < 0.05). However, continued postoperative neck laxity, submental pleating, and periocular pleating were seen with the MACS technique. CONCLUSIONS: The current study shows that the MACS technique is better suited for young patients with lesser cervical bulk or laxity and provides an opportunity for concurrent nonfacial procedures. Objective assessment with recognition of the limitations of the MACS technique versus the traditional facelift approach has led to a change in the senior author's practice. Although the MACS lift incurs shorter procedure time and quicker recovery, it does demonstrate limitations when it comes to marked skin laxity and bulky necks/platysmal banding. Both techniques are used with in line with the respective limitations and advantages.
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Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Ritidoplastia/métodos , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Rejuvenecimiento , Estudios Retrospectivos , Sistema Músculo-Aponeurótico Superficial/cirugía , Colgajos QuirúrgicosRESUMEN
BACKGROUND: Poland syndrome typically presents as a unilateral congenital complete or partial absence of the pectoralis major muscle, variably with other associated anomalies. Reconstruction of the defect typically concentrates on aesthetic restoration with functional outcomes being unsuccessful or limited. We present an innovative means of true muscle transfer that provided functional benefit to increase upper extremity strength. CASE REPORT: A 16-year-old adolescent boy with Poland syndrome manifesting as left pectoralis major muscle agenesis wished to undergo functional reconstruction. He wanted to play on his high school football team, but could not meet the minimum weightlifting requirements. An ipsilateral latissimus dorsi muscle bipolar functional transfer was done with bone-anchored inset into the sternum and humerus so that muscle flexion would replace the absent pectoralis major. A progressive weight training program was then instituted postoperatively. At 9 months, a significant increase in left upper extremity strength was confirmed. The patient ultimately was able to surpass the weightlifting requirements for his high school football team, and joined the team. CONCLUSIONS: Our highlighted procedure restored functional outcome using both plastic surgical principles and orthopedic techniques for muscle and tendon repair: bipolar muscle transfer and load-bearing muscle inset. Heretofore, transfer of the latissimus for provision of pectoralis major function has not been reported. Functional reconstruction was possible due to stable, bipolar muscle transfer with load-bearing muscle attachments into cortical bone of the anterior sternum and anteromedial aspect of the humerus. The techniques described should be within the skill set of most plastic surgeons, so that functional restoration for those with Poland syndrome is possible and accessible.
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Músculos Pectorales/fisiología , Procedimientos de Cirugía Plástica/métodos , Síndrome de Poland/cirugía , Músculos Superficiales de la Espalda/cirugía , Adolescente , Humanos , Masculino , Músculos Pectorales/anomalías , Músculos Pectorales/cirugía , Síndrome de Poland/fisiopatologíaRESUMEN
BACKGROUND: The growth and acceptance of smartphones among clinicians has been remarkable over the last decade. Over 87% of doctors use a smartphone or tablet capable of running third-party software known as applications (apps). In the field of plastic surgery, apps have been designed for personal practice development, education, clinical tools and guidelines, and entertainment. This study reviews the literature on apps related to plastic surgery and determines the number and types of apps available. METHODS: A systematic review of the literature was performed to find articles written about plastic surgery applications. Queries were run in the Apple iPhone iOS App store and Google Play using the term "plastic surgery." Apps were reviewed for ratings, downloads, and cost. In addition, apps were categorized based on purpose. Categories include practice development, media/literature, clinical tool and guideline apps, or recreation. RESULTS: The literature search yielded 8 articles for review, 2 articles focused on categorizing apps and 6 articles focused on describing useful apps. Searching Apple's iTunes (iOS) store identified 273 and Google Play identified 250 apps related to plastic surgery; since 2013, a 62%, and 580% increase, respectively. The iOS store included practice development (46%), recreation (26%), media/literature (14%), and clinical tool and guideline (11%). Google Play store included recreation apps (44%), practice development (24%), clinical tools and guidelines (11%), and media and literature (9%). CONCLUSIONS: Apps related to the field of plastic surgery are increasing in prevalence. The content of these apps are variable, and the majority are intended for marketing and development of private practices. Apps linking to literature, texts, study materials, and clinical tools and guidelines are developed for both practicing plastic surgeons and surgical trainees. Finding "useful" apps takes time because searches are often complicated by a variety of apps.
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Aplicaciones Móviles , Teléfono Inteligente , Cirugía Plástica , Sistemas de Apoyo a Decisiones Clínicas , Humanos , Aplicaciones Móviles/economía , Aplicaciones Móviles/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Administración de la Práctica Médica , Procedimientos de Cirugía Plástica , Estados UnidosRESUMEN
We report a patient with a severe axial-radial-ulnar (ARU) fracture dislocation of the carpus, involving multiple intermetacarpal dislocations as well as divergent carpometacarpal dislocations involving the index, long, ring and small fingers and peritrapezoid and scaphotrapezial dislocations. She also had a degloving injury involving the dorsal hand. Emergent debridement followed by open reduction and internal fixation of all injuries was performed, followed by soft tissue management. At 6-year follow-up, the patient had adequate active range of motion with the ability to make a full fist and was able to use her wrist and hand for most activities of daily living. Disabilities of the arm, shoulder and hand (DASH) score was 47.5. Michigan hand outcomes questionnaire (MHQ) score was 66.8. Mayo wrist score was 65. Patient-rated wrist evaluation (PRWE) score was 42. Severe ARU fracture dislocations of the carpus can result in adequate functional recovery on long-term follow-up. Level of Evidence: Level V (Therapeutic).
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Luxaciones Articulares , Fracturas del Cúbito , Humanos , Femenino , Actividades Cotidianas , Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/cirugía , Fijación Interna de Fracturas , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugíaRESUMEN
Aim: Low Back Pain (LBP) is a prevalent condition. Spinal cord stimulation (SCS) has emerged as a more effective, long-term treatment compared to conventional medical management (CMM). The DISTINCT study enrolled and randomized chronic LBP patients with no indication of traditional spine surgery. This analysis focuses comparing study outcomes on patients initially randomized to receive CMM treatment and subsequently crossed over to SCS after 6 months. Purpose: To compare the therapeutic effectiveness and cost-efficiency of passive recharge burst SCS to CMM. Patients and Methods: A total of 269 patients were enrolled with 162 randomly assigned to SCS and 107 to CMM. The DISTINCT study design allowed a crossover to the alternative treatment arm after 6 months. Patients underwent a trial and received a permanent implant if they reported ≥50% pain reduction. Outcome analysis included pain (NRS), disability (ODI), catastrophizing (PCS), quality of life (PROMIS-29) and health care utilization. Results: Seventy out of eighty-one patients opted to cross over to trial SCS at 6M with 94% (66/70) undergoing a trial. Among those, 88% (58/66) reported a ≥50% or more pain relief and 55 received a permanent implant. At 12M visit, 71.4% reported a ≥50% pain improvement sustained at the 18M visit, with 24.5% (12/49) indicating a ≥80% improvement. Disability reductions (79% meeting the minimally important difference of a 13-point decrease), decreased catastrophizing, and significant improvements in all PROMIS-29 domains were noted. Furthermore, 42% of the patients reported decreased or discontinued opioid usage. Clinical benefits at the 12M visit were sustained through the 18M visit accompanied by a significant reduction in healthcare utilization and a $1214 cost savings. Conclusion: SCS demonstrates superior, long-term performance and safety outcomes compared to CMM therapy in LBP patients who received both CMM and SCS therapy. Additionally, SCS patients experienced reduced healthcare resource utilization and lower costs compared to those receiving CMM.
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INTRODUCTION: Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments. METHODS: The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria. RESULTS: The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis. CONCLUSIONS: There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.
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Introduction: Research suggests that sacroiliac joint (SIJ) dysfunction is responsible for 15% to 30% of reported low back pain cases. Recently, there has been an increasing interest in SIJ fusion using minimally invasive surgery (MIS) due to safety. Initially, devices designed for MIS were intended for lateral approaches. A minimally invasive sacroiliac fusion implant for use with a posterior approach has been developed and is regulated for clinical use under the regulatory framework required for human cells, tissues, or cellular or tissue-based products (HCT/Ps). Methods: A multi-center, prospective, single-arm study was launched after initial studies provided preliminary data to support safety, efficacy, and durability of this minimally invasive sacroiliac posterior fusion LinQ allograft implant (NCT04423120). Preliminary results were reported previously. Final results for the full participant cohort are presented here. Results: One-hundred and fifty-nine (159) participants were enrolled across 16 investigational sites in the US between January 2020 and March 2022. One-hundred and twenty-two (122) participants were implanted. At the 1-month follow-up, 82 participants satisfied all criteria for the composite responder endpoint, representing 73.2% of the study cohort. These results stayed consistent across the remaining study timepoints with 66.0%, 74.4%, and 73.5% of participants classified as responders at the 3-, 6- and 12-month follow-up visits, respectively. VAS scores were significantly reduced (p < 0.0001) and ODI scores were significantly improved (p < 0.0001). All domains of the PROMIS-29 were also significantly improved (all p's <0.0001). Only one procedure-related serious AE was reported in the study. Conclusion: These results suggest that the posterior approach LinQ Implant System is a safe and effective treatment for sacroiliac joint dysfunction at 12 months, with results that are favorable compared to outcomes reported for an FDA-cleared lateral approach.
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Background: Low back pain (LBP) is a highly prevalent, disabling condition affecting millions of people. Patients with an identifiable anatomic pain generator and resulting neuropathic lower extremity symptoms often undergo spine surgery, but many patients lack identifiable and/or surgically corrective pathology. Nonoperative treatment options often fail to provide sustained relief. Spinal cord stimulation (SCS) is sometimes used to treat these patients, but the lack of level 1 evidence limits its widespread use and insurance coverage. The DISTINCT RCT study evaluates the efficacy of passive recharge burst SCS compared to conventional medical treatment (CMM) in alleviating chronic, refractory axial low back pain. Methods: This prospective, multicenter, randomized, study with an optional 6-month crossover involved patients who were not candidates for lumbar spine surgery. The primary and secondary endpoints evaluated improvements in low back pain intensity (NRS), back pain-related disability (ODI), pain catastrophizing (PCS), and healthcare utilization. Patients were randomized to SCS therapy or CMM at 30 US study sites. Results: The SCS arm reported an 85.3% NRS responder rate (≥ 50% reduction) compared to 6.2% (5/81) in the CMM arm. After the 6M primary endpoint, SCS patients elected to remain on assigned therapy and 66.2% (49/74) of CMM patients chose to trial SCS (crossover). At the 12M follow-up, SCS and crossover patients reported 78.6% and 71.4% NRS responder rates. Secondary outcomes indicated significant improvements in ODI, PCS, and reduced healthcare utilization. Six serious adverse events were reported and resolved without sequelae. Conclusion: DISTINCT chronic low back pain patients with no indication for corrective surgery experienced a significant and sustained response to burst SCS therapy for up to 12 months. CMM patients who crossed over to the SCS arm reported profound improvements after 6 months. This data advocates for a timely consideration of SCS therapy in patients unresponsive to conservative therapy.
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BACKGROUND: The lower body lift (LBL) is a comprehensive body contouring procedure done after massive weight loss. Because of the magnitude of the operation and demands of subsequent care, it has traditionally been viewed as an inpatient procedure. However, it is believed that with surgical experience combined with fine tuning of perioperative and postoperative care, lower body lifting is safe as an outpatient in properly selected patients. METHODS: In this article, we retrospectively review and evaluate our series of 35 patients (19 outpatient and 16 inpatient), who have undergone lower body lifting after massive weight loss. Operative technique, perioperative management, and postoperative care are reviewed. RESULTS: Compared to the inpatients, the body mass index of the outpatients was significantly less: 24.99 compared to 30.89 kg/m, respectively (P = 0.002 χ value 7.886). Reoperations did not occur in any of the 19 outpatient LBL procedures, but were necessary in 6 of the 16 inpatients, all for wound closure (P < 0.001 χ value 25.811). No patient in either group had thromboembolic occurrences, clinically apparent hematomas, and none required transfusions. CONCLUSIONS: Outpatient LBL is safe and effective when performed on the properly selected patient. Avoidance of hospitalization has importance in minimizing nosocomial infections or other complications. There is also potential great influence on access to care due to reduced costs associated with outpatient surgery centers, compared to hospitals. As such, a financial barrier is alleviated to many who cannot otherwise afford these procedures after weight loss.
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Abdominoplastia/métodos , Procedimientos Quirúrgicos Ambulatorios , Nalgas/cirugía , Lipectomía/métodos , Obesidad , Muslo/cirugía , Pérdida de Peso , Adulto , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Selección de Paciente , Cuidados Posoperatorios , Complicaciones Posoperatorias/prevención & control , Estudios RetrospectivosRESUMEN
BACKGROUND: Necrotizing fasciitis (NF) most often is caused by bacterial infection while a fungal source has been reported in immunosuppressed patients. Early wide surgical resection remains the mainstay of treatment. Split thickness skin grafts are both versatile and easy to harvest, thus making them a long-established option for soft tissue reconstruction. CASE REPORT: A 55-year-old man was admitted for gunshot wounds. Purulence was noted at the central catheter site. Cultures grew Candida albicans. Antifungal therapy was initiated and debridement for NF of the neck and upper chest was performed. The patient underwent reconstruction using a split thickness skin graft obtained from the anterolateral thigh. CONCLUSIONS: Necrotizing fasciitis secondary to Candida species infection is exceedingly rare. We report an unusual case of candidal NF in a patient with no past medical history of immunocompromise. Patients with this type of infection can be successfully treated with aggressive surgical debridement and intravenous anidulafungin.
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Candidiasis/cirugía , Fascitis Necrotizante/cirugía , Trasplante de Piel , Infecciones de los Tejidos Blandos/cirugía , Candidiasis/diagnóstico , Fascitis Necrotizante/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Infecciones de los Tejidos Blandos/diagnósticoAsunto(s)
Implantación de Mama/efectos adversos , Implantes de Mama/efectos adversos , Neoplasias de la Mama/terapia , Carcinoma de Células Escamosas/etiología , Neoplasias Primarias Secundarias/etiología , Anciano , Mama/diagnóstico por imagen , Mama/patología , Mama/cirugía , Implantación de Mama/instrumentación , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Femenino , Humanos , Mastectomía Radical/efectos adversos , Neoplasias Primarias Secundarias/diagnóstico , Neoplasias Primarias Secundarias/cirugía , Radioterapia AdyuvanteRESUMEN
BACKGROUND: Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. METHODS: Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). RESULTS: A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. CONCLUSIONS: The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.
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Recuperación Mejorada Después de la Cirugía , Mamoplastia , Colgajo Perforante , Humanos , Mamoplastia/métodos , Mama , Atención PerioperativaRESUMEN
BACKGROUND: The most common presentation of cluneal neuropathy is ipsilateral low back and gluteal pain. Cluneal neuralgia has been described historically in surgical contexts, with much of the description and treatment related to entrapment and decompression, respectively. Treatment options for addressing axial low back pain have evolved with advancements in the field of interventional pain medicine, though clinical results remain inconsistent. Recent attention has turned toward peripheral nerve stimulation. Nonsurgical interventions targeting the superior and medial cluneal nerve branches have been performed in cases of low back and buttock pain, but there is no known review of the resulting evidence to support these practices. OBJECTIVES: In this manuscript we provide a robust exploration and analysis of the available literature regarding treatment options for cluneal neuropathy. We provide clinical manifestations and recommendations for future study direction. STUDY DESIGN: Narrative review. METHODS: This was a systematic, evidence-based narrative, performed after extensive review of the literature to identify all manuscripts associated with interventional treatment of the superior and medial cluneal nerves. RESULTS: Eleven manuscripts fulfilled inclusion criteria. Interventional treatment of the superior and middle cluneal nerves includes blockade with corticosteroid, alcohol neurolysis, peripheral nerve stimulation, radiofrequency neurotomy, and surgical decompression. LIMITATIONS: The supportive evidence for interventions in cluneal neuropathy is largely lacking due to small, uncontrolled, observational studies with multiple confounding factors. There is no standardized definition of cluneal neuropathy. CONCLUSION: Limited studies promote beneficial effects from interventions intended to target cluneal neuropathy. Despite increased emphasis and treatment options for this condition, there is little consensus on the diagnostic criteria, endpoints, and measures of therapeutics, or procedural techniques for blocks, radiofrequency, and neuromodulation. It is imperative to delineate pathology associated with the cluneal nerves and perform rigorous analysis of associated treatment options.
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Dolor de la Región Lumbar , Neuralgia , Nalgas/inervación , Nalgas/cirugía , Descompresión Quirúrgica , Humanos , Dolor de la Región Lumbar/cirugía , Neuralgia/cirugía , Nervios Periféricos/cirugíaRESUMEN
Sacroiliac (SI) joint arthropathy is the primary pain generator in approximately 15-25% of patients with axial low back pain and traditionally diagnosed with >50% pain reduction following an intra-articular injection localized to the inferior 1/3 of the SI joint. The conventional technique for accessing the SI joint encompasses a posterior approach with fluoroscopic guidance at 10-20° contralateral oblique angulation, and minor adjustments to this approach have been implemented with varying degrees of success. The authors present a novel technique for SI joint injection, infiltrating the middle third of the joint through an alternative far-contralateral oblique (FCO) approach, angulation between 20-40°. This approach theoretically endows easier access to the SI joint and at the very least provides another option for interventionalists in the diagnosis and treatment of sacroiliac joint pain. It can also be utilized to determine if a patient is a candidate for posterior percutaneous SI joint fusion. The authors sought to document this approach to ensure that it was both reproducible and safe, while recognizing the need for future studies.
Asunto(s)
Dolor de la Región Lumbar , Articulación Sacroiliaca , Artralgia , Fluoroscopía , Humanos , Inyecciones Intraarticulares/métodos , Dolor de la Región Lumbar/diagnóstico por imagen , Dolor de la Región Lumbar/tratamiento farmacológico , Articulación Sacroiliaca/diagnóstico por imagenRESUMEN
BACKGROUND: We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach. METHODS: Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper. RESULTS: There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm. CONCLUSIONS: Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.