Safety and Efficacy of Liposomal Bupivacaine Supraclavicular Nerve Blocks in Open Treatment of Distal Radius Fractures: A Perioperative Pain Management Protocol.

INTRODUCTION: Distal radius fractures (DRFs) are common fractures requiring surgical fixation. The literature varies regarding opioid prescribing habits, opioid consumption, and postoperative pain scores. We hypothesized that the preoperative administration of a liposomal bupivacaine (LB) supraclavicular nerve block would be safe and effective in controlling postoperative pain. METHODS: A standardized pain management protocol was implemented at a single institution from July 2021 to March 2022 for patients undergoing open reduction internal fixation of DRF. Protocol elements included a preoperative LB supraclavicular nerve block and a multimodal postoperative pain regimen. Primary clinical outcomes included postoperative pain scores and number of opioid tablets consumed. RESULTS: Twenty patients underwent a newly implemented protocol. The average age was 56 years. Mean number of oxycodone 5-mg tablets consumed was 4.1 (median, 2.5), and mean visual analog scale pain score at first postoperative appointment was 2.8. There were no incidences of missed acute carpal tunnel postoperatively. When compared with an institutional historical control (n = 189), number of opioid pills prescribed was reduced by 60% (21.4 vs 8.6 tablets, P < 0.0001), and no patients had unscheduled health care contact because of uncontrolled pain (22% vs 0%, P < 0.016). CONCLUSIONS: Liposomal bupivacaine supraclavicular nerve blocks are safe and effective in the treatment of postoperative pain after open reduction internal fixation of DRF. Patients consumed <5 oxycodone tablets on average, which is less than many recommend prescribed quantities (>20-30 tablets). Patients had low pain scores (2.8/10) at the first postoperative follow-up. To our knowledge, this is the first study demonstrating the utility of LB in this clinical setting.

Safety and Outcomes in Rereduction Mammaplasty: Single Institution Experience and Review of the Literature.

BACKGROUND: Reduction mammaplasty is commonly performed for symptomatic macromastia and is useful in achieving symmetry in unilateral breast reconstruction and oncoplastic surgery. Postoperatively, however, recurrent macromastia or asymmetry often develops. In the past, there has been concern about safely resecting additional volume and moving the nipple. We analyze our outcomes with regard to rereduction mammaplasty, (and discuss) these results in comparison to the current literature. METHODS: A retrospective review of patients undergoing rereduction mammaplasty at Emory Hospital from 2008 to 2014 was performed. Prior breast reduction and subsequent removal of additional tissue was required for inclusion. Patient demographics, pedicle selection, time from initial to rereduction, reduction weight, indications, and complications were recorded. RESULTS: Our review identified 37 patients who underwent rereduction mammaplasty. Thirty-four underwent unilateral and 3 underwent bilateral reduction. Average initial reduction weight was 483 g, and average rereduction weight was 226 g. Thirty reductions required nipple areolar complex repositioning; 25 used a superior pedicle, and 5 used a central mound. Eighty-three percent of the superior pedicle and 20% of the central mound reductions used the same pedicle. There were 5 complications reported; no cases of nipple necrosis were reported. CONCLUSIONS: With careful technique, rereduction mammaplasty is safe, reliable, and effective. Varying amounts of tissue may be excised, and the nipple may be moved safely with a short superior or central mound pedicle regardless of initial technique. Limited rereduction can be performed as early as 4 to 6 months.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure.

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

Radial Artery Reconstruction After Iatrogenic Cannulation-Related Occlusion: A Case Report.

A 59-year-old male, with a history of angiogram via the left radial artery during the workup for multi-trauma, presented to the hand clinic with a 14-day history of progressive critical ischemia in the left thumb and index finger, along with dry gangrene of the distal index fingertip. Radial artery occlusion was confirmed on imaging. The patient underwent radial artery thrombectomy, arterial reconstruction with vein graft, and amputation of the index fingertip. Postoperatively, perfusion to the thumb and index finger was restored, resulting in the resolution of associated pain and hypersensitivity. This case demonstrates the delayed presentation of ischemia following radial artery cannulation, which was successfully managed with radial artery thrombectomy and a saphenous vein graft.

A Perspective on Electrical Stimulation and Sympathetic Regeneration in Peripheral Nerve Injuries.

Peripheral nerve injuries (PNIs) are common and devastating. The current standard of care relies on the slow and inefficient process of nerve regeneration after surgical intervention. Electrical stimulation (ES) has been shown to both experimentally and clinically result in improved regeneration and functional recovery after PNI for motor and sensory neurons; however, its effects on sympathetic regeneration have never been studied. Sympathetic neurons are responsible for a myriad of homeostatic processes that include, but are not limited to, blood pressure, immune response, sweating, and the structural integrity of the neuromuscular junction. Almost one quarter of the axons in the sciatic nerve are from sympathetic neurons, and their importance in bodily homeostasis and the pathogenesis of neuropathic pain should not be underestimated. Therefore, as ES continues to make its way into patient care, it is not only important to understand its impact on all neuron subtypes, but also to ensure that potential adverse effects are minimized. This piece gives an overview of the effects of ES in animals models and in humans while offering a perspective on the potential effects of ES on sympathetic axon regeneration.

The lazy lateral incision: an innovative approach to the skin-sparing mastectomy.

The skin-sparing mastectomy has many advantages over a simple mastectomy, including preservation of the native breast skin, inframammary fold, and improved aesthetics for immediate reconstruction. The traditional transverse elliptical access incision is anterior on the breast mound, requires a second incision for previous biopsy sites, and provides restricted access to the axilla. We describe a novel mastectomy incision that improves scar appearance, improves access to the axillary contents, and reduces skin flap retraction. This incision starts at the nipple-areolar complex and extends laterally in a curvilinear fashion toward the axilla incorporating the biopsy scar along the way. This simple sinusoidal design results in an aesthetically superior alternative to the traditional linear mastectomy incision.

Persistent Median Artery Thrombosis Causing a Bifid Median Nerve and Carpal Tunnel Syndrome: A Case Report.

CASE: In this report, we describe a 41-year-old woman with symptoms concerning for acute carpal tunnel syndrome. Operative exploration resulted in resection of an aneurysmal, thrombosed, persistent median artery seen on preoperative imaging and full recovery by the patient. CONCLUSION: A persistent median artery is an uncommon congenital hand condition resulting from the failure of the median artery to regress, which can then travel through the carpal tunnel and be associated with a bifid median nerve, irritation of the nerve, and need for surgical exploration if it thromboses, which is rare. This should be considered in patients with acute median nerve compression, without other etiologies.

Early Experience with External Negative Pressure Delay in Free Anterolateral Thigh Perforator Flap Reconstruction.

Negative pressure therapy has been utilized in the treatment of open and closed wounds to increase blood flow and improve wound healing. More recently, external negative pressure has been shown to induce a noninvasive delay phenomenon in animal models by increasing vessel size and density within a planned flap, leading to improvement in flap survival. Although successful in animal models, this new method of delay has not been demonstrated in clinical practice. We present our initial experience with preoperative external negative pressure delay of free anterolateral thigh flaps in upper extremity reconstruction to detail the technique and safety profile of this innovative new technique. External negative pressure delay has the potential to provide results similar to those of traditional surgical delay, while being cost effective, safer, and more convenient for patients. More research is needed to investigate the clinical benefit and cost effectiveness of external negative pressure delay.

Pulp De-epithelialization for Venous Outflow Augmentation after Digital Replantation.

Traumatic amputation injuries account for a substantial portion of emergency department visits. This includes digital amputations that may be considered for replantation. Following surgery, venous congestion is the most common cause of replant failure. To address this, several methods have been proposed to augment venous outflow. In this article, a simple and straightforward method that can be utilized to establish or augment venous outflow in cases of venous insufficiency is described. This method entails de-epithelization of the replanted digit pulp skin with use of postoperative anticoagulation. The area can be further expanded or stimulated to increase bleeding as needed and is allowed to heal by secondary intention. This method allows for reliable venous outflow with relative ease of implementation.

Current Trends in the Management of Ballistic Fractures of the Hand and Wrist: Experiences of a High-Volume Level I Trauma Center.

BACKGROUND: Ballistic fractures of the carpus and hand are routinely treated in large urban centers. These injuries can be challenging due to many factors. Various treatment options exist for these complicated injuries, but there are limited data available. This report analyzes patient demographics, treatments, and outcomes at a large urban trauma center. METHODS: All ballistic fractures of the hand and wrist of the patients who presented to a single center from 2011 to 2014 were retrospectively reviewed. Patient demographics, injury mechanism, treatment modalities, and outcomes were analyzed. RESULTS: Seventy-seven patients were identified; 70 were male, and 7 were female. Average age of the patients was 29.6 years. Seventy-five injuries were low velocity, whereas 2 were high velocity. Sixty-seven patients had fractures of a metacarpal or phalanx, whereas 4 had isolated carpal injuries. Six had combined carpal and metacarpal or phalanx fractures. Thirty-six patients had concomitant tendon, nerve, or vascular injuries requiring repair. Sixty-three patients underwent operative intervention, with the most common intervention being percutaneous fixation. Sixteen patients required secondary surgery. Eighteen complications were reported. CONCLUSIONS: The majority of patients in this report underwent early operative intervention with percutaneous fixation. Antibiotics were administered in almost all cases and can usually be discontinued within 24 hours after surgery. It is important to consider concomitant nerve, vascular, or tendon injuries requiring repair. We recommend early treatment of these injuries with debridement and stabilization. Due to lack of follow-up and patient noncompliance, early definitive treatment with primary bone grafting should be considered.

Indocyanine Green Angiography: A Helpful Tool for Intraoperative Assessment of Upper Extremity Perfusion.

Assessment of tissue perfusion can be a challenge for the hand surgeon. Indocyanine green (ICG) angiography has been shown to be a valuable adjunct to physical examination and clinical judgment when there is a concern for tissue perfusion. The use of this technology has risen sharply in recent years in reconstructive surgery. Applications of ICG angiography have been developed throughout the field of surgery, including breast surgery, free tissue transfer, bowel surgery, neurosurgery, and lymphatic reconstruction. In this study, we discuss the novel applications of ICG angiography within the field of upper extremity surgery, and provide specific case examples of its successful use.

Biomechanical analysis of the FlatWire Figure 8 sternal fixation device.

OBJECTIVE: To determine whether the FlatWire Figure 8 sternal fixation device (Penn United, USA) is mechanically superior to the current standard in sternotomy closure. DESCRIPTION: Unstable sternal closure using traditional steel-wire cerclage can increase postoperative pain, bony cut-through and wound dehiscence. The authors present the Figure 8 sternal fixation device to minimize these complications. Biomechanical properties of the device were compared with conventional steel wire sternal repair. EVALUATION: Using two constructs of both FlatWire and steel wire, pull-to-failure, Hertzian contact and cut-through were compared. Samples were tested to 500,000 cycles or failure. Cyclic comparisons were performed using log-rank t tests and Student's t tests for cut-through analysis. FlatWires were found to have superior biomechanical properties in all categories tested. CONCLUSION: The FlatWire provides superior biomechanical properties compared with conventional steel wire, which may lead to reduced sternal wound complications.

OBJECTIF: Déterminer si le dispositif de fixation du sternum FlatWire Figure 8 (Penn United, États-Unis) est mécaniquement supérieur à la norme actuelle pour la fermeture des sternotomies. DESCRIPTION: La fermeture du sternum au moyen du cerclage classique en fil d'acier peut accroître la douleur postopératoire, l'insertion osseuse et la déhiscence de la plaie. Les auteurs présentent le dispositif de fixation du sternum Figure 8 pour réduire ces complications au minimum. Les auteurs ont comparé les propriétés biomécaniques du dispositif à la réparation sternale classique à l'aide d'un fil d'acier. ÉVALUATION: Les auteurs ont comparé le test de tension, le contact hertzien et l'insertion du modèle FlatWire à celui du fil d'acier. Ils ont comparé les échantillons jusqu'à 500 000 cycles ou jusqu'à l'échec. Les comparaisons cycliques ont été effectuées au moyen de tests t de Mantel-Haenzel et de tests t pour l'analyse de tension. Le modèle FlatWire avait des propriétés biomécaniques supérieures dans toutes les catégories mises à l'essai. CONCLUSION: Le FlatWire a des propriétés biomécaniques supérieures à celles du fil d'acier classique, lesquelles peuvent réduire les complications de la plaie du sternum.