Outcomes After Flexor Tendon Injuries in the Pediatric Population: A 10-Year Retrospective Review.

Background: Pediatric outcomes after flexor tendon repairs are variable, and evidence in the literature remains scarce. Methods: Repair of pediatric flexor tendon injuries was reviewed over a 10-year period (2005-2015). Data collection consisted of patient demographics, injury characteristics, anesthetic choice, repair technique, rehabilitation protocol, American Society for Surgery of the Hand Total Active Motion (TAM) scores, and complications. Results: There were 109 patients included in our study, with a total of 162 digits injured and 235 flexor tendon injuries. The mean age was 12 ± 4.6 years. The small finger (48 of 162; 30%) and the flexor digitorum profundus tendon (126 of 235) were the most commonly injured. The mechanism of injury was mainly from a knife (46 of 109; 42.2%) in zone II (82 of 159; 52%). Injuries were mostly repaired under general anesthetic (61 of 104; 56%). The Kessler technique was the predominant repair mechanism (111 of 225 repairs; 49%). Most patients (103 of 109; 95%) had excellent or good TAM scores with 5 postoperative ruptures reported. The most common complication was stiffness (17 of 121 complications; 14%), with most patients having no complications ( 74 of 109 patients; 68%). Patients were commonly immobilized (mean 8.4 ± 10.3 weeks) with a splint (93 of 109; 85%). There were 85 patients who followed a postoperative rehabilitation protocol for 12 ± 18 weeks. Patient demographics, time of repair, injury characteristics, anesthetic choice, and rehabilitation protocol were not significantly correlated with TAM scores or complication rates. Conclusions: Pediatric tendon injuries have good outcomes with no predictive factors identified. Surgical repairs performed under local anesthetic have similar outcomes without increased rates of complications, but remain underused in the pediatric population.

Neisseria elongata osteomyelitis: Literature review and case report in a 63-year-old male presenting with progressive right-handed redness, swelling and pain.

INTRODUCTION: Neisseria elongata, a gram-negative rod, has been identified in 23 cases of pathogenesis in the literature, of which only 2 were osteomyelitis. Here we report the third known case of isolated N. elongata cultures in a digital osteomyelitis. PRESENTATION OF CASE: A 63-year-old male with peripheral vascular disease and lower extremity wounds presented to his vascular surgeon with right-handed redness and pain requiring urgent surgical intervention. Irrigation, debridement, and partial thumb amputation were performed, followed by treatment with a 6-week course of antibiotics. DISCUSSION: N. elongata is a rare cause of osteomyelitis and unfamiliarity with the causal organism and rod-like morphology may delay diagnosis and treatment. CONCLUSION: Gram-negative coverage should be considered in high-risk populations with cellulitis to prevent progression to fulminant abscesses, suppurative tenosynovitis and osteomyelitis.

Complication rates of acellular dermal matrix in immediate breast reconstruction with radiation: A single-institution retrospective comparison study.

BACKGROUND: The use of acellular dermal matrix (ADM) in immediate breast reconstruction (IBR) continues to rise despite ongoing concerns with respect to increased complication rates. While the indications for radiation continue to broaden, it is essential to critically evaluate ADM's performance in its context. The purpose of this study was to review complication rates between patients reconstructed with and without ADM, who underwent IBR and radiation. METHODS: A retrospective review was performed for patients undergoing IBR and radiation from 2010 to 2019. Postoperative outcomes were compared between patients with and without ADM. RESULTS: Over a 9-year period, 130 patients underwent IBR and radiation (42% preoperatively and 59% postoperatively). For patients with preoperative radiation (36 ADM and 18 non-ADM), the average follow-up was 312 and 296 days, respectively. In this group, there was no difference in minor complications (25% ADM, 22% non-ADM, and p = 1.00) or major complications (31% ADM, 22% Non-ADM, and p = 0.52). For patients with postoperative radiation (53 ADM and 23 non-ADM), the average follow-up was 544 and 748 days, respectively. There was no difference in minor complications (21% ADM, 26% non-ADM, and p = 0.11) or major complications (21% ADM, 26% non-ADM, and p = 0.61). Multivariable logistic regression analyses showed no difference between ADM and non-ADM groups (OR 0.83, 95% CI 0.22-3.08, and p = 0.78). CONCLUSION: Despite increasing literature supporting the use of ADM in breast reconstruction, postoperative outcomes following radiation remain poorly understood. In the present study, we report no difference in overall complication rates between breasts reconstructed with and without ADM in an irradiated field. Nevertheless, the complication rate remains high, and future studies will be required to determine whether ADM-associated complications in an irradiated field outweigh the purported benefits.

A Randomized Controlled Trial Comparing Alloderm-RTU with DermACELL in Immediate Subpectoral Implant-Based Breast Reconstruction.

BACKGROUND: The effectiveness of different acellular dermal matrices (ADM) used for implant-based reconstruction immediately following mastectomy is an important clinical question. A prospective randomized clinical trial was performed to evaluate the superiority of DermACELL over Alloderm-RTU in reducing drain duration. METHODS: Patients undergoing mastectomy with subpectoral immediate and permanent implant-based breast reconstruction were randomized to Alloderm-RTU or DermACELL. The primary outcome was seroma formation, measured by the duration of postoperative drain placement. Secondary outcomes included: post drain removal seroma aspiration, infection, redbreast syndrome, wound dehiscence, loss of the implant, and unplanned return to the operating room. RESULTS: 62 patients were randomized for 81 mastectomies (41 Alloderm-RTU, 40 DermACELL). Baseline characteristics were similar. There was no statistically significant difference in mean drain duration (p = 0.16), with a trend towards longer duration in the Alloderm-RTU group (1.6 days; 95%CI, 0.7 to 3.9). The overall rate of minor and major complications were statistically similar between the two groups; although patients with Alloderm-RTU had 3 times as many infections requiring antibiotics (7.9% vs. 2.5%) with a risk difference of 5.4 (95%CI -4.5 to 15.2), and twice as many unplanned returns to the operating room (15.8% vs. 7.5%) with a risk difference of 8.3 (95% CI -5.9 to 22.5) as DermACELL. CONCLUSION: This is the first prospective randomized clinical trial comparing the two most commonly used human-derived ADMs. There was no statistically significant difference in drain duration, minor, or major complications between DermACELL over Alloderm-RTU in immediate subpectoral permanent implant-based breast reconstruction post-mastectomy.

The effect of post mastectomy radiation therapy on breast reconstruction with and without acellular dermal matrix: a systematic review and meta-analysis protocol.

BACKGROUND: The widespread implementation of acellular dermal matrix (ADM) has broadened the reconstructive repertoire for alloplastic breast reconstruction. ADM's role in the context of postoperative radiation therapy remains unclear. The present review will evaluate whether ADM reduces complication rates in patients undergoing post-mastectomy radiation therapy (PMRT). METHODS: A healthcare librarian assisted in performing a search strategy of electronic databases MEDLINE (via Ovid), EMBASE, and CENTRAL. A combination of the keywords and Medical Subject Headings (MESH) to describe the various commercially available ADMs and terms for radiation therapy will be used. The search strategy will identify patients undergoing postoperative radiation following implant-based breast reconstruction and compare outcomes between those with and without ADM. Extracted data will include patient demographics, intraoperative data, and postoperative complications. Data on patient satisfaction and resource utilization will also be extracted if available. The references of selected works will be reviewed for additional studies meeting study criteria. Only peer-reviewed papers written in English will be included. The study data will be assessed for risk of bias and heterogeneity. Providing that sufficient studies can be identified, a meta-analysis will be performed. This review has been registered with PROSPERO (CRD42017056495). CONCLUSIONS: To date, the short- and long-term performance of ADM in the context of postoperative radiation remains unclear. The objective of the present review will be to critically evaluate the literature with the intention of improving postoperative outcomes in the context of mastectomy and radiation.

Treatment of Frostbite With Hyperbaric Oxygen Therapy: A Single Center's Experience of 22 Cases.

INTRODUCTION: Frostbite is well documented in the military and countries with extreme temperatures, and it is most likely due to increased exposure to cold temperatures and/or risk-taking behavior. Severity of injury depends on absolute temperature, wind chill, duration of exposure, wet or dry cold, immersion, clothing quality, and substance use. Hyperbaric oxygen therapy (HBOT) has been described as a treatment option but only in small case series. OBJECTIVE: The aim of this retrospective study is to describe the usage patterns, side effects, and outcomes of HBOT used as an adjunct to wound care at a single major Canadian university hospital. MATERIALS AND METHODS: A retrospective review of patients with frostbite injury admitted and treated with HBOT between January 2000 and March 2015 was performed. A total of 22 patients were studied. Available data included patient demographics, duration of exposure to cold temperature, severity of injury, time to HBOT, duration of therapy, side effects of therapy, concurrent therapies (dressing, anticoagulation, antibiotics), bone scan results, and consequent level of amputation. RESULTS: The cohort consisted mostly of men (18, 81.8%) and patient mean age of 40 years (range, 13-70 years). Ten patients (45.5%) were intoxicated at the time of injury, and psychiatric illness was implicated in 9 (40.9%) patients. Of the presented injuries, 17 (77.3%) had frostbite to the upper extremity. Bone scans were performed on 16 (72.7%) patients. In 4 patients, the absence of radiotracer activity correlated with a protective effect on subsequent amputation levels. All patients received anticoagulant therapy. Of the 22 patients, 16 (72.7%) experienced at least 1 side effect of HBOT, including otologic barotrauma, nausea, vomiting, anxiety, oxygen toxicity seizure, and myopic changes. All study patients recovered without permanent sequelae; it is unclear whether HBOT reduced soft-tissue damage or amputation rates. CONCLUSIONS: This is the largest cohort reported in the literature of patients with frostbite injuries treated with HBOT. Hyperbaric oxygen therapy may show positive impact on the demarcation level of frostbite and, despite the common side effects, it generally causes no long-term sequelae.