Soft Tissue Reconstruction for Upper Extremity Necrotizing Soft Tissue Infections.

INTRODUCTION: One of the main aspects of management for necrotizing soft tissue infection (NSTI) is surgical excision and debridement, which can result in large soft tissue defects. This study examined the reconstructive options and outcomes of patients with upper extremity NSTIs. METHODS: A retrospective chart review was performed on patients from a single institution who were diagnosed with an upper extremity NSTI between 2014 and 2019. Patient characteristics, infectious etiology, surgical debridements, reconstructive procedures, and secondary procedures were analyzed. RESULTS: There were 99 patients included in the study. The median size of the wound from the initial surgical debridement was 100 cm 2 (interquartile range, 300 cm 2 ). The mean number of debridements was 3.4. Seven patients underwent amputations, and 12 patients died. Most wounds were reconstructed via delayed primary closure (15 patients), skin grafting (16 patients), or a combination of the two (30 patients). Three patients underwent reverse radial forearm flaps, 1 patient underwent a groin flap, 3 patients underwent pedicled latissimus muscle flaps, and 2 patients underwent local flexor carpi ulnaris muscle flaps. Seven patients did not undergo any surgical reconstruction, and their wounds were managed with local wound care. Eight patients had complete or partial failure of their initial soft reconstruction requiring an additional operation, and 5 patients had secondary operations for neuromas and/or contractures. CONCLUSIONS: Overall, patients with upper extremity NSTIs survive and undergo successful reconstruction of their wounds. Few patients required additional procedures for reconstructive failure or sequela of their wounds.

Severe Fireworks-Related Injuries: Demographic Characteristics, Injury Patterns, and Firework Types in 294 Consecutive Patients.

OBJECTIVES: The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults. METHODS: We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older. RESULTS: Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died. CONCLUSIONS: Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries.

BACKGROUND: There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment. METHODS: Retrospective case series (2005-2015) of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn Center. Fireworks types, injury patterns (body region, injury type), operation, and permanent impairment were examined. RESULTS: Data from 294 patients 1 to 61years of age (mean 24years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admission and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was related to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe-injured patients experienced partial or complete permanent vision loss. Thirty-seven percent of hand-injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. CONCLUSIONS: Severe fireworks-related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury.

Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types.

PURPOSE: The purpose of this study was to characterize injury patterns and outcomes of fireworks-related hand injuries and determine if there was an association with certain fireworks types. METHODS: A retrospective cohort study was conducted on patients treated at a trauma center between 2005 and 2015. A total of 105 patients sustaining operative hand injuries due to fireworks were identified. Medical records were reviewed to identify injury patterns, treatment outcomes, and fireworks types. RESULTS: Eighty-eight patients (84%) sustained 92 thumb and/or first web space injuries. There were 12 thumb soft tissue-only injuries (13%) and 80 thumb fractures/dislocations (87%). Of these, there were 52 thumb carpometacarpal (CMC) joint dislocations (57%) and 36 thumb fractures outside the thumb CMC joint (39%). Fifteen hands (16%) sustained both thumb CMC joint dislocations and additional thumb fractures. Twenty-three hands (25%) required thumb revision amputation. The number of surgeries for acute reconstruction ranged from 1 to 7, with 17 patients (19%) requiring 3 or more. Sixty-three hands had deep first web space injuries, and 11 (17%) required flaps acutely for first web space reconstruction. Six hands required secondary reconstruction of a first web space contracture. An external fixator was applied to 6 hands to maintain the first web space; none of these required secondary web reconstruction. Excluding isolated pin removals and dressing changes under anesthesia, 19 patients (22%) required later-stage surgeries. Shells/mortars (59%) were the most common fireworks type causing injury. CONCLUSIONS: Among operative hand injuries, fireworks most commonly fracture the thumb, destabilize the thumb CMC joint, and deeply damage the first web space. The first web space requires particular consideration because deep injury may result in adduction contracture and require secondary reconstruction if not prevented. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison of Traditional and Skin-Sparing Approaches for Surgical Treatment of Necrotizing Soft-Tissue Infections.

Background: A skin-sparing approach for the treatment of necrotizing soft-tissue infections (NSTIs) removes necrotic tissue planes while leaving viable overlying skin. Subsequent closure of the spared skin may decrease the need for graft-based reconstruction, which is associated with contracture, pain, and deformity. This study compared the outcomes of a traditional approach (excision of overlying skin with diseased fascia) with that of a skin-sparing approach for patients with NSTI treated at a major metropolitan medical center. Methods: Demographic, clinical, and operative details for patients treated for NSTI between July 2012 and December 2016 at a single institution were reviewed retrospectively. Pre-operative and post-operative photographs were evaluated independently by three surgeons to determine reconstructive outcomes. Cohen's κ was used to assess inter-rater reliability. Multiple regression and Poisson regression models were used to assess the association between outcomes and the surgical approach. Results: A total of 487 patients were divided into two cohorts: Traditional approach (TA), treated between July 2012 and December 2014 (n = 230), and skin-sparing approach (SS), treated after January 2015 (n = 257). The mortality rate in the two groups was equal at approximately 10%. The median percentage of each wound closed by skin graft was significantly lower for the SS group than for the TA group (20% versus 90%; p < 0.0001) with a correspondingly higher median percentage of primary skin closure for the SS group (50% versus 0; p < 0.0001). Conclusions: Relative to traditional debridement, skin-sparing debridement for source control of NSTI results in significantly more wounds closed completely by delayed primary suture of existing skin flaps and a significantly lower overall wound percentage closed by skin graft, while demonstrating equivalent efficacy of source control and a similar low mortality rate.

Strategies for Reconstruction of the Plantar Surface of the Foot: A Systematic Review of the Literature.

BACKGROUND: Reconstruction of the plantar surface of the foot is challenging because of its distinctive anatomy and microarchitecture. Unfortunately, no single coverage option meets the needs of all patients and defects. A comprehensive literature review is presented to better define available reconstructive options for resurfacing the plantar foot. METHODS: A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. The PubMed, Embase, and Scopus databases were queried for published articles. After the exclusion of duplicate records, 1624 articles were available for review. A total of 280 unique articles were included for analysis, with a total of 2684 individual reconstructions. RESULTS: Of the articles reviewed, 10 percent described a skin grafting technique, 53 percent described a locoregional flap, 32 percent described free tissue transfer, and 5 percent described multiple reconstructive methods. Isolated heel defects were the most frequently reconstructed subunit of the plantar foot (73 percent). The latissimus dorsi muscle was the most commonly used free flap, whereas the reverse sural artery flap was the most commonly used locoregional flap. Protective sensation was noted in most locoregional and free flap reconstructions, regardless of primary neurotization; however, improved two-point discrimination was noted when neurofasciocutaneous flaps were used. Complication rates varied widely, although rates of flap loss approached those of flaps performed at other anatomical sites. CONCLUSIONS: Numerous methods exist for reconstructing the plantar surface. Proper flap selection should be determined by the size of the defect, the availability of donor tissue, and the surgeon's experience and comfort with the reconstructive technique.

A comparison of Google Glass and traditional video vantage points for bedside procedural skill assessment.

BACKGROUND: This pilot study assessed the feasibility of using first person (1P) video recording with Google Glass (GG) to assess procedural skills, as compared with traditional third person (3P) video. We hypothesized that raters reviewing 1P videos would visualize more procedural steps with greater inter-rater reliability than 3P rating vantages. METHODS: Seven subjects performed simulated internal jugular catheter insertions. Procedures were recorded by both Google Glass and an observer's head-mounted camera. Videos were assessed by 3 expert raters using a task-specific checklist (CL) and both an additive- and summative-global rating scale (GRS). Mean scores were compared by t-tests. Inter-rater reliabilities were calculated using intraclass correlation coefficients. RESULTS: The 1P vantage was associated with a significantly higher mean CL score than the 3P vantage (7.9 vs 6.9, P = .02). Mean GRS scores were not significantly different. Mean inter-rater reliabilities for the CL, additive-GRS, and summative-GRS were similar between vantages. CONCLUSIONS: 1P vantage recordings may improve visualization of tasks for behaviorally anchored instruments (eg, CLs), whereas maintaining similar global ratings and inter-rater reliability when compared with conventional 3P vantage recordings.

Full-thickness Scalp Injury Due to Hair Braiding and Weave.

Full-thickness scalp necrosis secondary to hair weave placement is a rare but serious complication of a common hairstyle. The defects can be large and may necessitate complex reconstruction with hair-bearing tissue. We report on the case of a young woman with extensive scalp loss following tight spiral braiding. The case description illustrates this relatively unknown complication, its treatment, and possible preventative measures.

Clinical utility of CT angiography in DIEP breast reconstruction.

BACKGROUND: CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps. METHODS: Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation. RESULTS: A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT. CONCLUSION: CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated. LEVEL OF EVIDENCE: Level 3.

Multivariate predictors of failure after flap coverage of pressure ulcers.

BACKGROUND: Pressure ulcers are estimated to be present in more than one-third of patients with spinal cord injury. The rate of recurrence after flap surgery over last 50 years has ranged between 3 and 82 percent, with no trend toward improvement. This study seeks to identify and evaluate patient and operative characteristics associated with flap dehiscence and ulcer recurrence. METHODS: A retrospective chart review of all patients who underwent pressure ulcer flap coverage between 1993 and 2008 was performed. Thirty-one demographic and operative variables were collected. Multivariate logistic regression with generalized estimating equation was used to evaluate the effect of significant variables. The primary outcome was recurrence of pressure ulcer at the operative site. Secondary outcomes included flap line dehiscence and the need for operative revision. RESULTS: There were 88 recurrences of pressure ulcers after flap surgery (39 percent) of 227 operations performed on 135 patients. Thirty-six flaps (16 percent) had dehiscences necessitating return to the operating room. Hemoglobin A1c less than 6 percent and previous same-site flap failure were associated with both dehiscence and recurrence (odds ratios, 2.15 and 3.84; and odds ratios, 6.51 and 3.27). Younger age and albumin less than 3.5 were associated with early flap failure (odds ratios, 5.95 and 2.45). Ischial wound location correlated with late recurrence (odds ratio, 4.01). Patients with multiple risk factors had operative success rates that approached zero. CONCLUSIONS: Confirmation of adequate nutritional status and strict preoperative management of blood glucose may improve operative success rates. The authors propose that operative management should be approached with trepidation, if at all, in young patients with recurrent ischial ulcers.