Utilization of the gastrocnemius flap for post-traumatic knee reconstruction: a systematic review.

PURPOSE: High-energy injuries to the knee may lead to extensive soft tissue loss, fractures, and potential loss of extensor function. The gastrocnemius flap is a prominent reconstructive option for patients with injuries involving the knee and proximal third of the lower extremity. To the best of our knowledge, there has not been an informative review that has evaluated outcomes of patients who have undergone post-traumatic knee reconstruction with a pedicled medial or lateral gastrocnemius flap. The goal of this study is to assess outcomes in patients who have undergone gastrocnemius flap reconstruction after traumatic injuries to the knee. METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gastrocnemius, flap, knee, and traum*. RESULTS: A total of 204 studies were imported for screening, from which five papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were case series followed by retrospective chart reviews. In total, 43 patients with traumatic soft tissue knee defects were included with an average patient age of 27.28 years. All patients had successful and clinical viable flaps post-operatively, and there were a total of five patients who had complications. CONCLUSION: The gastrocnemius flap has demonstrated to be an effective option for individuals undergoing post-traumatic knee reconstruction. Infection rates, loss of mobility, and scarring represent a minority of complications that may be seen when this reconstructive technique is utilized. Still, additional randomized controlled trials and retrospective studies are required in order to further evaluate for other potential complications that may occur in this patient population.

Applying GPT-4 to the Plastic Surgery Inservice Training Examination.

BACKGROUND: The recent introduction of Generative Pre-trained Transformer (GPT)-4 has demonstrated the potential to be a superior version of ChatGPT-3.5. According to many, GPT-4 is seen as a more reliable and creative version of GPT-3.5. OBJECTIVE: In conjugation with our prior manuscript, we wanted to determine if GPT-4 could be exploited as an instrument for plastic surgery graduate medical education by evaluating its performance on the Plastic Surgery Inservice Training Examination (PSITE). METHODS: Sample assessment questions from the 2022 PSITE were obtained from the American Council of Academic Plastic Surgeons website and manually inputted into GPT-4. Responses by GPT-4 were qualified using the properties of natural coherence. Incorrect answers were stratified into the consequent categories: informational, logical, or explicit fallacy. RESULTS: From a total of 242 questions, GPT-4 provided correct answers for 187, resulting in a 77.3% accuracy rate. Logical reasoning was utilized in 95.0% of questions, internal information in 98.3%, and external information in 97.5%. Upon separating the questions based on incorrect and correct responses, a statistically significant difference was identified in GPT-4's application of logical reasoning. CONCLUSION: GPT-4 has shown to be more accurate and reliable for plastic surgery resident education when compared to GPT-3.5. Users should look to utilize the tool to enhance their educational curriculum. Those who adopt the use of such models may be better equipped to deliver high-quality care to their patients.

The Clinical Association between Carbon Monoxide Poisoning and Myocardial Injury as Measured by Elevated Troponin I Levels.

Carbon monoxide (CO) poisoning accounts for over 50,000 estimated emergency room visits and approximately 1200 deaths per year in the US. Despite the high prevalence, there is a paucity of data looking at the association between laboratory biomarkers and clinical outcomes. Our study investigates the association between myocardial injury as assessed by increased troponin levels and its effect on in-hospital outcomes in CO poisoning. A total of 900 sequential charts of patients presenting with CO poisoning between 1 January 2012, and 31 August 2019, at our tertiary center with regional hyperbaric chamber and burn unit, were reviewed. Of the 900, a total of 488 patients had elevated carboxyhemoglobin levels. Of these 488 patients, 119 (24.4%) also had blood troponin levels measured. Patients were stratified based on the presence or absence of myocardial injury as evidenced by highly sensitive serum troponin I (TnI) level > 0.5 ng/mL to determine if a correlation exists relating to myocardial injury and risk of major adverse events. Mean age was 51.2 years, 58.8% were males, 35.3% were non-White, and 10.1% were intentional CO poisonings. Comorbidities included hypertension: 37%, diabetes: 21%, smoking: 21%, hyperlipidemia: 17.6%, coronary artery disease: 11.8%, asthma: 5.9%, heart failure: 5%, atrial fibrillation: 4.2%, and chronic obstructive pulmonary disease: 4.2%. Myocardial injury occurred in 22 patients (18.5%) and was associated with increased likelihood of requiring intensive care admission (54.5% vs. 20.6%, p = 0.002) and intubation (40.9% vs. 14.4%, p = 0.008). TnI elevation was associated with higher in-hospital mortality (p = 0.008, OR 21.3) compared to patients without TnI elevation. Older age was independently associated with increased in-hospital mortality (p = 0.03, OR 1.08). When controlling for age, in-hospital mortality remained statistically significant (p = 0.01, OR 21.37). No significant difference was found with respect to age, comorbidities, gender, race, ethnicity, or hospital length of stay in patients with and without myocardial injury. Myocardial injury induced by CO exposure occurs frequently and adversely affects clinical outcomes. Further research is needed to help guide physicians in the management of CO poisoning and associated myocardial injury to improve patient outcomes.

Rare Case of a Cutaneous Fingertip Schwannoma: A Case Report and Review of Literature.

Background: Soft tissue masses of the hand are common and mostly benign, including ganglion cysts, glomus tumors, lipomas, and giant cell tumors of the tendon sheath. Schwannomas are benign nerve sheath tumors but are rarely found on the distal parts of the digits. The authors present a case of a schwannoma located at the tip of the finger. Methods: An otherwise healthy 26-year-old man presented because of a 10-year history of a slowly growing mass on the tip of his right little finger that significantly interfered with his right hand function. The patient underwent hand radiographs and surgical excision of the tumor. Results: Pathologic evaluation determined that the mass was a schwannoma with positive immunohistochemistry for S-100 and SOX-10. The patient reported complete resolution of symptoms associated with the tumor and his satisfaction with the surgical outcome. Conclusions: Imaging studies, such as radiographs, ultrasound, and magnetic resonance imaging, are critical in the diagnostic workup of soft tissue masses of the hand to better understand involvement of the tumor to musculature, vasculature, and other pertinent bony structures. Although quite common, schwannomas may be hard to differentiate from other soft tissue tumors, and a review of the literature demonstrates the importance of providers utilizing imaging and other diagnostics before proceeding to treatment.

Performance of ChatGPT on the Plastic Surgery Inservice Training Examination.

BACKGROUND: Developed originally as a tool for resident self-evaluation, the Plastic Surgery Inservice Training Examination (PSITE) has become a standardized tool adopted by Plastic Surgery residency programs. The introduction of large language models (LLMs), such as ChatGPT (OpenAI, San Francisco, CA), has demonstrated the potential to help propel the field of Plastic Surgery. OBJECTIVES: The authors of this study wanted to assess whether or not ChatGPT could be utilized as a tool in resident education by assessing its accuracy on the PSITE. METHODS: Questions were obtained from the 2022 PSITE, which was present on the American Council of Academic Plastic Surgeons (ACAPS) website. Questions containing images or tables were carefully inspected and flagged before being inputted into ChatGPT. All responses by ChatGPT were qualified utilizing the properties of natural coherence. Responses that were found to be incorrect were divided into the following categories: logical, informational, or explicit fallacy. RESULTS: ChatGPT answered a total of 242 questions with an accuracy of 54.96%. The software incorporated logical reasoning in 88.8% of questions, internal information in 95.5% of questions, and external information in 92.1% of questions. When stratified by correct and incorrect responses, we determined that there was a statistically significant difference in ChatGPT's use of external information (P < .05). CONCLUSIONS: ChatGPT is a versatile tool that has the potential to impact resident education by providing general knowledge, clarifying information, providing case-based learning, and promoting evidence-based medicine. With advancements in LLM and artificial intelligence (AI), it is possible that ChatGPT may be an impactful tool for resident education within Plastic Surgery.

Utilization of ChatGPT for Plastic Surgery Research: Friend or Foe?

On November 20, 2022, ChatGPT was made available to the general public free of charge. As a large language model (LLM), the software was able to process inquiries by users and generate text based on compiled datasets in a humanist manner. Due to the importance of research in the Plastic Surgery community, we set out to determine if ChatGPT could be utilized to produce novel systematic review ideas relevant to Plastic Surgery. Out of 80 systematic review ideas generated by ChatGPT, we found that the software was highly accurate in creating novel systematic review ideas. Beyond aiding in Plastic Surgery research, ChatGPT has the potential to be used for virtual consultations, pre-operative planning, patient education, and post-operative care for patients. ChatGPT may be a simple solution for the complex problems encountered in Plastic Surgery.

Expanding Cosmetic Plastic Surgery Research With ChatGPT.

BACKGROUND: In the past 3 months, OpenAI, a San Francisco-based artificial intelligence (AI) research laboratory, has released ChatGPT, a conversation large language model. ChatGPT has the ability to answer user questions, admit to mistakes, and learn from users that are accessing the program. OBJECTIVES: Due to the importance of producing evidence-based research in plastic surgery, the authors of this study wanted to determine how accurate ChatGPT could be in creating novel systematic review ideas that encompass the diverse practice of cosmetic surgery. METHODS: ChatGPT was given commands to produce 20 novel systematic review ideas for 12 different topics within cosmetic surgery. For each topic, the system was told to give 10 general and 10 specific ideas that were related to the concept. To determine the accuracy of ChatGPT, a literature review was conducted with PubMed, CINAHL, EMBASE, and Cochrane. RESULTS: A total of 240 "novel" systematic review ideas were constructed by ChatGPT. We determined that the system had an overall accuracy of 55%. When topics were stratified by general and specific ideas, we found that ChatGPT was 35% accurate for general ideas and 75% accurate for specific ideas. CONCLUSIONS: ChatGPT is an excellent tool that should be utilized by plastic surgeons. ChatGPT is versatile and has uses beyond research, including patient consultation, patient support, and marketing. As advancements in AI continue to be made, it is important for plastic surgeons to consider the utilization of AI in their clinical practice.

Index surgery and ninety day re-operation cost comparison of robotic-assisted versus manual total knee arthroplasty.

INTRODUCTION: This study looks to compare early costs of index surgery and re-operations of robotic-assisted total knee arthroplasties (rTKA) and manual total knee arthroplasty (mTKA) re-operations within 90 days. MATERIAL AND METHODS: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was queried for patients undergoing rTKA and mTKA at our institution from January 1st, 2018, to March 31st, 2021. Primary outcomes were the day of surgery and overall encounter variable direct costs (VDC). Secondary outcomes included 90-day re-operations and costs. RESULTS: One thousand two hundred seventy-six (21.2%) patients were in the rTKA cohort, while 4740 (78.8%) were in the mTKA cohort. When comparing rTKA to mTKA, rTKA had higher median total encounter costs (p < 0.001) and higher encounter VDC costs (p < 0.001). TKA had higher day of surgery total VDC (p < 0.001), VDC supplies (p < 0.001), and VDC of post-op recovery (p < 0.001). Multivariate linear regression showed no relationship with age, BMI, OR time, or LOS with cost for rTKA or mTKA. CONCLUSION: Results from our study show that rTKA is associated with a higher index surgery costs, and no difference in 90-day re-operation costs. The main factor driving increased cost is supply cost, with other variables between too small in difference to make a significant financial impact. Future studies should focus on post-operative costs including readmission and episode of care costs and should consider cost to the payor as opposed to VDC. rTKA will become more common, and other institutions may need to take a closer financial look at this more novel instrumentation before adoption. LEVEL OF EVIDENCE: III, retrospective cohort.

Randomized Prospective Evaluation of Microblepharoexfoliation BlephEx as Adjunctive Therapy in the Treatment of Chalazia.

PURPOSE: Chalazia are benign eyelid lesions caused by the obstruction and inflammatory reaction of the meibomian glands. Demodex mites are one potential cause of chalazia leading to mechanical obstruction of the meibomian gland. In this prospective randomized study, we examine a novel approach to treating chalazia with the use of microblepharoexfoliation (MBE), an in-office lid hygiene technique that exfoliates the eyelid margins. METHODS: Fifty patients with clinical evidence of acute chalazion were enrolled in this study. Subjects were randomly assigned to a MBE plus lid hygiene group (23 patients, mean age 66.6 ± 16.6 years) or a lid hygiene alone group (27 patients, mean age 62.1 ± 14.4). The MBE plus lid hygiene group received MBE treatment and were evaluated 1 month after the baseline visit. The main outcome measured was the resolution of the chalazion at the 1-month follow-up visit. RESULTS: The lid hygiene plus MBE treatment group demonstrated a statistically significant resolution of the chalazion compared with the lid hygiene group alone ( P = 0.007; chi-square test). Among the MBE plus hygiene group, 87% of the patients had resolution of their chalazion as opposed to the lid hygiene alone group, which had 44% resolution. CONCLUSIONS: This is the first prospective, randomized clinical trial that demonstrated efficacy of MBE as a noninvasive adjunctive treatment method for chalazion resolution.

Venous Thromboembolism Prophylaxis in Plastic Surgery.

Background: In 2011, the American Society of Plastic Surgery (ASPS) formed the Venous Thromboembolism Task Force Report, which encouraged the use of the 2005 Caprini score and was amended in 2013. Still, there have been several studies that have questioned the validity of the Caprini score. As a result, the goal of this study is to present our experience with chemoprophylaxis in cosmetic patients compared with the current recommendations for venous thromboembolism (VTE) chemoprophylaxis endorsed by the ASPS. Methods: A retrospective analysis was conducted in all patients operated on by a single surgeon from 2006 to 2016. Exclusion criteria were surgery length >6 hours, patients with known hypercoagulable states, or a personal history of deep vein thrombosis (DVT)/pulmonary embolism (PE). Demographic data were collected and analyzed. Results: There were 1272 patients from a single institution who met the inclusion criteria. We determined that 71% of patient VTE scores were in the high to highest risk categories (n = 657), median age was 46 years, 79% of the population was Caucasian, 35% of patients had a body mass index of overweight or obese, and the average length of stay was 1 day. The rate of VTE in our patient population was found to be 0.08% (1 patient), which was uncomplicated and resolved with conservative therapy. Conclusions: This retrospective study found no significant difference in the incidence of VTE by providing chemophrophylaxis to patients without utilizing a scoring system. Our study suggests that the Caprini Scoring system might not be optimal in predicting VTE in patients undergoing aesthetic surgery.

Utilization of the Free Fibular Flap for First Metatarsal Reconstruction.

Beyond being aesthetically unpleasing, metatarsal defects have been known to lead to several patient concerns such as intermetatarsal malpositioning and metatarsalgia. There are several reconstructive techniques that have been utilized for reconstruction of bony defects in the foot, including the free dorsal toe flap and dorsal metatarsal perforator flap. Our institution has utilized the free fibular flap for surgical management pertaining to tarsal reconstruction. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes. A retrospective chart review was conducted at Beaumont Health System, Royal Oak for patients who underwent first metatarsal reconstruction with a free fibular flap between the years 2015 and 2022. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed. A total of two patients were isolated after chart review. Both patients were found to have tolerated the procedure well and had no intraoperative complications. In addition, all patients had clinically viable flaps and were satisfied with their surgical results. The free fibular flap may be used effectively in the management of metatarsal defects that have failed prior therapy. In our study, both patients who underwent surgical management with a free fibular flap were noted to have successful long-term results. With the right expertise and patient population, a free fibular flap can be highly successful in the repair of metatarsal defects.

Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis.

Ankle arthrodesis has become a common surgical procedure for individuals with end-stage ankle arthritis, chronic infection, and bony misalignment. Although arthrodesis is typically managed with arthrodesis in situ or realignment, reconstruction may be utilized for patients with more complicated cases that involve metatarsal defects. Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes. Methods: A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent ankle arthrodesis with a pedicled fibula flap for nonunion or avascular necrosis of the talus between the years 2014 and 2022. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed. Results: A total of six patients were isolated, with three patients undergoing a free fibula approach and three patients undergoing the pedicled fibula approach. All patients were found to have tolerated the procedure well and had no intraoperative complications. In addition, all patients had clinically viable flaps and were satisfied with their surgical result. Conclusions: Both free and pedicled free fibula flaps may be used effectively in the management of ankle arthrodesis in patients who have failed prior therapy. In our study, free fibula flaps were utilized in a medial approach, while the pedicled fibula flap was utilized in a lateral approach. With the right expertise and patient population, the free and pedicled fibula flaps can be highly successful in the repair of ankle defects.